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Full text of "Surgical applied anatomy"

COLUMBIA LIBRARIES OFFSITE 

HEALTH SCIENCES STANDARD 



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MANUALS 



FOR 



Students of Medicine 



SURGICAL APPLIED 
ANATOMY. By SIR 

FREDERICK TREVES, Bart., 

G.C.V.O., C.B., LL.D., F.R.C.S. Sergeant 
Surgeon-in-Ordinary to H.M. the King ; 
Surgeon-in-Ordinary to H.R.H. the Prince 
of Wales ; Consulting Surgeon to the London 
Hospital ; Late Lecturer on Anatomy at the 
London Hospital 

Fifth Edition, Revised by 

ARTHUR KEITH, m.d., f.r.c.s. 

Lecturer on and Senior Demonstrator of 
Anatomy at the London Hospital ; Examiner 
in Anatomy, Royal College of Surgeons, 
England, and University of Leeds ; formerly 
Examiner in Universities of Aberdeen, 
Cambridge, etc. 

ILLUSTRATED WITH IO7 FIGURES, INCLUDING 4. 1 IN COLOUR 




PHILADELPHIA 

LEA BROTHERS AND CO. 



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a 



r— ^ 



PREFACE TO THE FIFTH EDITION 

In the present edition the work has been carefully 
revised throughout ; certain sections have been 
rewritten, and much new matter has been added. 
Every effort has been made to bring each chapter 
of the book well up to date. Neither pains nor 
expense has been spared in the matter of illus- 
trations. Forty-three figures have been specially 
prepared for this edition ; fifteen of the former 
figures have been redrawn, and colours have been 
freely used to make the illustrations more effective. 
The editor is indebted to Messrs. S. J. A. Beale 
and E. H. Eainey for their assistance in the 
preparation of this edition. 

Arthur Keith. 

London Hospital Medical College, 
August, 1907. 



PEEFACE TO THE FIRST EDITION 

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

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

It must be owned also that all details in 
Anatomy have not the same practical value, and 
that the memory of many of them may fade with- 
out loss to the competency of the practitioner in 
medicine or surgery. It should be one other 
object, therefore, of a book having such a purpose 
as the present, to assist the student in judging 
of the comparative value of the matter he has 



x PREFACE 

learnt ; and should help him, when his recollection 
of anatomical facts grows dim, to encourage the 
survival of the fittest. 

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

I have assumed that the reader has some know- 
ledge of Human Anatomy, and have not entered, 
except in a few instances, into any detailed 
anatomical descriptions. The bare accounts, for 
example, of the regions concerned in Hernia I 
have left to the systematic treatises, and have 
dealt only with the bearings of the anatomy of the 
parts upon the circumstances of practice. The 
limits of space have compelled me to omit all 
those parts of the " Surgery of the Arteries " that 
deal with ligature, collateral circulation, abnor- 
malities, and the like.^ This omission I do not 
regret, since those subjects are fully treated not 
only in works on operative surgery, but also in 
the manuals of general anatomy. 

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

Frederick Treves. 
September, 1883. 



CONTENTS 



PART I.— THE HEAD AND NECK 



CHAPTER 

I.- 


PAGE 

—The Scalp 1 


II.- 


—The Bony Vault op the Cranium . . 17 


III.- 


—The Cranial Contents .... 31 


IV.- 




V.- 




VI.- 


—The ISTose and Nasal Cavities ... 94 


VIL- 


-The Face Ill 


VIII.- 


—The Mouth, Tongue, Palate, and Pharynx 137 


IX.- 





PART II.— THE THORAX 

X. — The Thorax ... 



195 



PART m -THE UPPER EXTREMITY 
XI. — The Region of the Shoulder . 

XII.— The Arm 

XIII. — The Region op the Elbow 
XIV.— The Forearm . . . . . 
XV. -The Wrist and Hand . 



214 
255 
263 

282 
290 



xii CONTENTS 

PART IV,— THE ABDOMEN AND PELVIS 

CHAPTER PAGS 

XVI. — The Abdomen 321 

XVII. — The Abdominal Viscera .... 358 
XVIII. — The Pelvis and -Perineum . . . 424 

I 

PART V— THE LOWER EXTREMITY 

XIX. — The Region of the Hip .... 478 

XX.— The Thigh 5l| 

XXI. — The Region op the Knee .... 523 

XXII.— The Leg ■ . . 550' 

i 

XXIII.— The Ankle and Foot 561 \ 



PART VI.-THE SPINE 

XXIV.— The Spine 600 

Index 623 



Surgical Applied Anatomy 



Part I.— THE HEAD AND NECK 

CHAPTER I 

THE SCALP 

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

The skin of the scalp is thicker than in any 
other part of the body. It is in all parts in- 
timately adherent, by means of the subcutaneous 
tissue, to the aponeurosis and muscle beneath it, 
and, from this adhesion, it follows that the skin 
moves in all movements of that muscle. The sub- 
cutaneous tissue is, like a similar tissue in the 
palm, admirably constructed to resist pressure, 
being composed of a multitude of fibrous bands 
enclosing fat lobules in more or less isolated spaces 
(Fig. 1, b). The density of the scalp is such, that 
in surface inflammations, such as cutaneous ery- 
sipelas, it is unable to present (except in a very 
slight degree) two conspicuous features of such 
inflammations, viz. redness and swelling. The skin 

B 



SURGICAL APPLIED ANATOMY LPart I 



is provided with a great number of sebaceous 
glands, which may develop into cystic tumours or 
wens, such cysts being more common upon the scalp 
than in any other part of the body. Being skin 
growths, these cysts, even when large, remain, ex- 
cept in rare instances, entirely outside the apo- 




Fig. 1 —Diagram showing the layers of the scalp and membranes of the 
R VJ; *brain in section. 

a, Skin; U, subcutaneous tissue with bail' roots and vessels; c, epicranium ; 
ii, subaponeurotic layer; e, pericranium; /, parietal bone; g, dura mater; 
/.-, arachnoid ; I, pia mater ; m, cortex ; n, in subdural space near a Pacchionian 
body projecting within the superior Longitudinal sinus. 

neurosis, and can therefore be removed without 
risk of opening up the area of loose connective 
tissue between the aponeurosis and the peri- 
cranium. 

There being no fatty tissue in any of the layers 
that cover the bony vault save in the subcutaneous 
layer, it happens that in cases of obesity the scalp 



Chap. I] THE SCALP 3 

undergoes but little change, the fat in the subcu- 
taneous tissue being limited by the dense fibrous 
structures that enclose it. For the same reasons 
fatty tumours of the^ scalp are very rare. The 
attachment of the hairs collectively to the scalp 
is so strong that there are many cases where the 
entire weight of the body has been supported by 
the hair of the scalp. Agnew records the case of 
a woman whose hair became entangled in the re- 
volving shaft of a machine. The hair did not give 
way, but the entire scalp was torn off from the 
skull. The patient recovered. I have seen a pre- 
cisely similar case in a girl aged 13. (Museum, 
R. Coll. Surgeons, 87 F.) 

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

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



4 SUKGICAL APPLIED ANATOMY [Part I 

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

The scalp is extremely vascular, and presents 
therefore a great resistance to sloughing and gan- 
grenous conditions. Large flaps of a lacerated 
scalp, even when extensively separated and almost 
cut off from the rest of the head, are more prone 
to live than to die. A like flap of skin, separated 
from other parts of the surface, would most prob- 
ably perish ; but the scalp has this advantage, that 
the vessels run practically in the skin itself, or 
are, at least, in the tissue beyond the aponeurosis 
(Fig. 1). Thus, when a scalp flap is torn up, it 
still carries with it a very copious blood supply. 
Bleeding from these wounds is usually very free, 



Chap. I] THE SCALP o 

and often difficult to arrest. This depends not 
so much upon the number of vessels in the part as 
upon the density of the tissue through which these 
vessels run, the adherence of the outer arterial 
wall to the scalp structure, and the inability, 
therefore, of the artery to retract properly when 
divided. 

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

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

The pericranium is but slightly adherent to 
the bone, except at the sutures, where it is inti- 
mately united (Fig. 1, e). In lacerated wounds 
this membrane can be readily stripped from the 
skull, and often, in these injuries, extensive tracts 
of bone are laid bare. The pericranium differs 
somewhat in its functions from the periosteum 
that covers other bones. If the periosteum be 
removed to any extent from a bone, the part from 
whence it is removed will very probably perish, 
and necrosis from deficient blood supply result. 
But the pericranium may be stripped off a con- 
siderable part of the skull vault without any 
necrosis, save perhaps a little superficial exfolia- 
tion, following in consequence. This is explained 
by the fact that the cranial bones derive their 
blood supply mainly from the dura mater, and are 
therefore to a considerable extent independent of 



6 SURGICAL APPLIED ANATOMY [Part I 

the pericranium. A like independence cannot be 
claimed for the periosteum covering other bones, 
since that membrane brings to the part it covers 
a very copious and essential contribution to its 
blood supply. This disposition of the pericran- 
ium is also well illustrated by its action in cases 
of necrosis of the cranial bones. In necrosis of a 
long bone, the separation of the sequestrum is 
attended with a vigorous periosteal growth of 
new bone, which repairs the gap left after the re- 
moval of such sequestra. In necrosis of the vault 
of the skull, however, no new bone is formed, as 
a rule, and the gap remains unrepaired. The 
general indisposition of the pericranium to form 
new bone in other circumstances is frequently 
illustrated. 

Abscesses in the scalp region may be situated 
(1) above the aponeurosis, (2) between the apo- 
neurosis and the pericranium, and (3) beneath the 
pericranium. Abscesses in the first situation must 
always be small and comparatively insignificant, 
since the density of the scalp tissue here is such 
that suppuration can only extend with the great- 
est difficulty. Suppuration, however, in the 
second situation (in the loose tissue beneath the 
aponeurosis) may prove very serious. The laxity 
of this tissue offers every inducement to the ab- 
scess to extend when once pus has found its way 
between the aponeurosis and the pericranium. 
Suppuration in this area may undermine the en- 
tire scalp, which in severe and unrelieved cases 
may rest upon the abscess beneath as upon a kind 
of water-bed. As in scalp wounds, the aponeu- 
rosis is often divided, and as suppuration may 
follow the injury, it will be seen that the chief 
danger of those lesions depends upon the spread- 
ing of such suppuration to the area of lax con- 
nective tissue now under notice. The significance 
of a small amount of bare bone in a scalp wound 
is not so much that evils will happen to the bone, 
but that the aponeurosis has been certainly 
divided, and the dangerous area of the scalp 



Chap. I] THE SCALP 7 

opened up. Suppuration, when it occurs in this 
area, is only limited by the attachments of the 
occipito-frontalis muscle and its aponeurosis, and 
therefore the most dependent places through which 
pus can be evacuated are along a line drawn 
round the head, commencing in front, above the 
eyebrow, passing at the side a little above the 
zygoma, and ending behind at the superior curved 
line of the occipital bone. The scalp, even when 
extensively dissected up by such abscesses, does 
not perish, since it carries, as above explained, its 
blood supply with it. The abscess is often very 
slow to close, since its walls are prevented from 
obtaining perfect rest by the frequent movement 
of the epicranial muscle. To mitigate this evil, 
and to ensure closing of the sinuses in obstinate 
cases, Mr. Hilton advises that the whole scalp be 
firmly secured by strapping, so that the movement 
of the muscle is arrested. 

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

Hseuiatoumta, or 1>iood tumours of the 
scalp region, occur in the same localities as ab- 
scesses. The extravasation of blood above the apo- 
neurosis must be of a limited character, while that 
beneath it may be very extensive. It fortunately 
happens, however, that the cellular tissue between 
the aponeurosis and the pericranium contains but 
very few vessels, and hence large extravasations in 
this tissue are uncommon. 

Extravasations of blood beneath the peri- 
cranium are generally termed cephalhsematomata, 
and are of necessity limited to one bone. They 
are usually congenital, are due to pressure upon 
the head at birth, and are thus most commonly 
found over one parietal bone, that bone being 
probably the one most exposed to pressure. Their 
greater frequency in male children may depend 
upon the larger size of the head in the male fcetus. 
Such extravasations in early life are encouraged 



8 SUEGICAL APPLIED ANATOMY [Part I 

by the laxity of the pericranium, and by the soft- 
ness and vascularity of the subjacent bone. 

In the temporal region, or the region corre- 
sponding to the temporal muscle, the layers of soft 
parts between the skin and the bone are somewhat 
different from those that have been already de- 
scribed as common to the chief parts of the scalp. 
There is a good deal of fat in the temporal fossa, 
and when this is absorbed it leads to more or less 
prominence of the zygoma and malar bone, and 
so produces the projecting " cheek bones ; ' of the 
emaciated. The temporal muscle above the zy- 
goma is covered in by a very dense fascia, the 
temporal fascia, which is attached above to the 
temporal ridge on the frontal and parietal bones, 
and below to the zygomatic arch. The unyielding 
nature of this fascia is well illustrated by a 
case recorded by Denonvilliers. It concerned a 
woman who had fallen in the street, and was ad- 
mitted into hospital with a deep wound in the 
temporal region. A piece of bone of several lines 
in length was found loose at the bottom of the 
wound, and was removed. After its removal the 
finger could be passed through an opening with 
an unyielding border, and came in contact with 
some soft substance beyond. The case was con- 
sidered to be one of compound fracture of the 
squamous bone, with separation of a fragment 
and exposure of the brain. A bystander, however, 
noticed that the bone removed was dry and white, 
and a more complete examination of the wound 
revealed the fact that the skull was uninjured, 
that the supposed hole in the skull was merely 
a laceration of the temporal fascia, that the soft 
matter beyond was muscle and not brain, and that 
the fragment removed was simply a piece of bone 
which, lying on the ground, had been driven into 
the soft parts when the woman fell. 

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



Chap. I] 



THE SCALP 



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

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



DREq/^A 



Sup .Tem.line 

Lambda 
Squamous Suture 



POST.DlV.OFfllD.MEn.AR- 
AsTEP-ION 

SupraMeatalTriamcle 
Lateral Sirtus 

IftIO 

Ext. Auditory /ieatus 
Occipital Art 




IflT. JUQULAR. VEIM 



Ext. Carotid Art 



Fig. 2. — Points to trephine for middle meningeal artery and lateral sinus- 

terior inferior angle of the parietal bone at a 
point 1| inches behind the external angular pro- 
cess of the frontal bone, and l| inches above the 
zygoma. In cutting down to expose this artery 
the following structures are met with in order : 
(1) The skin; (2) branches of the superficial tem- 
poral vessels and nerves ; (3) the fascia continued 
down from the epicranial aponeurosis ; (4) the 
temporal fascia; (5) the temporal muscle; (6) the 
deep temporal vessels; (7) the pericranium; (8) 
the anterior inferior angle of the parietal bone. 



10 SURGICAL APPLIED ANATOMY [Part I 

Trephining for meningeal licemorrhage and 
cerebral abscess. — At the anterior inferior angle 
of the parietal bone the anterior division of the 
middle meningeal artery lies with its companion 
veins in a deep groove or even canal in the bone. 
A fracture of the bone, which is comparatively 
thin in the region of the pterion, is apt to involve 
the artery, leading to a subdural haemorrhage, 
with consequent compression of the brain. The 
pterion lies 1\ inches behind and | inch above 
the notch of the fronto-malar suture— a point 
which can be readily felt (Fig. 2) ; Similar mea- 
surements — namely, 1\ inches behind and \ inch 
above — taken from the centre of the external 
auditory meatus — the meatal point, gives the posi- 
tion of the posterior inferior angle of the parietal 
bone (asterion), beneath which lies the highest 
point of the lateral sinus (Fig. 2). A trephine 
opening, f inch in diameter, made over the as- 
terion, will expose the lateral sinus, and give 
access to the temporo-sphenoidal lobe above _ it 
and the cerebellum below it. The posterior 
division of the middle meningeal, in the majority 
of cases, will be exposed by trephining at a point 
1 inch above the external auditory meatus. These 
measurements apply to the head of the average 
adult ; allowance must be made for youth and for 
the size and shape of the head. In finding the 
pterion the line is drawn backwards parallel to 
the upper border of the zygoma; in finding the 
asterion, the line is drawn backwards along the 
meato-inionic line (Fig. 2), which passes from the 
centre of the external meatus to the most promi- 
nent point of the external occipital protuberance 
—the inion. 

Intracranial abscess is often due to middle-ear 
disease, and is then very commonly found in the 
temporo-sphenoidal. lobe or in the cerebellum. It 
is estimated to be three times more common in 
the cerebrum than in the cerebellum. 

The abscess of the temporo-sphenoidal lobe is 
usually found in that part of the lobe which lies 



Ohap. I] THE SCALP 11 

over the tegmen tympani — a thin plate of bone 
which forms the roof of the tympanum and of the 
antrum of the mastoid. The level of the tegmen 
may be indicated thus (Fig. 3) : a point is taken 
above the meatus in line with the upper border of 
the zygoma; this suprameatal point is joined 
with the asterion, which lies, it will be remem- 
bered, 1^ inches behind and ^ inch above the 
meatus ; the anterior half of the above line corre- 
sponds to the tegmen tympani. A trephine open- 
ing made 1 inch above the level of the tegmen is 
the most likely to give access to a temporo- 
sphenoidal abscess. 

In dealing with an abscess of the cerebellum 
the best spot to select is, in the adult, 1^ inches 
behind the centre of the meatus and \ inch below 
the meato-inionic line. 

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

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

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

In trephining the skull generally, the compara- 
tive thickness of the cranial wall in various parts 
should be borne in mind (p. 30), and the large 
arteries of the scalp should be avoided if possible. 
In order to accommodate the instrument to the 



12 



SURGICAL APPLIED ANATOMY [Part I 



varying thickness of the skull, the pin of the 
trephine is not allowed to protrude more than 
iVth of an inch. The trephine should not be ap- 
plied over the frontal sinuses, which are often 
of large size in the aged, and should, when possi- 
ble, keep clear of the sutures, owing to the fre- 
quent exit of emissary veins at or about suture 
lines. The bone, moreover, at certain of these 
lines is of unequal thickness. Between the bones 
forming the sutures passes the sutural membrane. 




Upper Holamdic Poi/it 



Fissure of Rolamdo 



Parietal Eminence 

Parieto Occipital Fissure- 
Lambda 

For Lateral Ventricle 
Post. Ior/i 
Desc.Morm 
For Temp.Sp/ien Abscess 

Occipital Pole 
Iaiion 



Asterion 
T)vi panic Plate 
Suprameatal Triadcle 
Meatus 
Supra/i eatal Point , 

Fig. 3. — Diagram to show the position of the lateral ventricles, Island of 
Reil and temporal lobe. 

This structure blends with the dura mater, and 
laceration of it may conduce to meningitis. 

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



Chap. I] THE SCALP 13 

of deep parts. Its upper border, in its posterior 
three-fourths, corresponds to the floor of the mid- 
dle fossa of the skull, and marks the lower border 
of the temporal lobe of the brain which lies in 
that fossa (Fig. 3) ; the articular eminence, felt 
so plainly near its root, marks the point at which 
the middle meningeal artery _ perforates the base 
of the skull by the foramen spinosum (Fig. 2), and 
also the position of the Gasserian ganglion (Fig. 
26, p. 119) ; the post-glenoid spine is directly over 
the carotid canal (S. Scott). 

The vessels and nerves of the scalp.— The 
supraorbital artery and nerve pass vertically up- 
wards from the supraorbital notch, which is situ- 
ate at the junction of the middle with the inner 
third of the upper orbital margin. Nearer the 
middle line the frontal artery and supratrochlear 
nerve ascend. This artery gives life to the flap 
that in rhinoplasty is taken from the forehead 
to form a new nose. The temporal artery, with 
the auriculotemporal nerve behind it, crosses the 
base of the zygoma just in front of the ear. The 
vessel divides into its two terminal branches (the 
anterior and posterior) 2 inches above the zygoma. 
The branches of this artery, especially the an- 
terior branch, are often very tortuous in the aged, 
and afford early evidence of arterial degeneration. 
Arteriotomy is sometimes practised on the an- 
terior branch of this vessel. The superficial tem- 
poral vessels are very liable to be the seat of 
cirsoid aneurism, as, to a less extent, are the other 
scalp arteries. Cirsoid aneurism is more often 
met with in the superficial temporal arteries than 
in any other artery in the body. The posterior 
auricular artery and nerve run in the groove be- 
tween the mastoid process and the ear, and the 
occipital artery and great occipital nerve reach 
the scalp just internally to a point midway be- 
tween the occipital protuberance and the mastoid 
process. 

Certain of the emissary veins are of import- 
ance in surgery. These veins pass through aper- 



14 SURGICAL APPLIED ANATOMY [Part J 

tures in the cranial wall, and establish communi- 
cations between the venous circulation (the 
sinuses) within the skull and the superficial veins 
external to it. The principal emissary veins are 
the following : 1. A vein passing through the mas- 
toid foramen and connecting _ the lateral sinus 
with the posterior auricular vein or with an occi- 
pital vein. This is the largest and most constant 
of the series. The existence of this mastoid vein 
serves to answer the question, Why is it a com- 
mon practice to apply leeches and blisters behind 
the ear in certain cerebral affections 1 2. A vein 
connecting the superior longitudinal sinus with 
the veins of the scalp through the parietal fora- 
men. 3. A vein connecting the lateral sinus with 
the deep veins at the back of the neck through the 
posterior condylar foramen (inconstant). 4. 
Minute veins following the twelfth nerve through 
its foramen, and connecting the occipital sinus 
with the deep veins of the neck. 5. Minute veins 
passing through the foramen ovale, foramen of 
Vesalius, foramen lacerum medium, and carotid 
canal to connect the cavernous sinus with (respec- 
tively) the pterygoid venous plexus, the pharyn- 
geal plexus, and the internal jugular vein. 

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

Lastly, there is the well-known communication 
between the extra- and intracranial venous circu- 
lation effected by the commencement of the facial 
vein at the inner angle of the orbit. In this com- 
munication the angular and supraorbital veins 
unite with the superior ophthalmic vein, a tribu- 
tary of the cavernous sinus. The veins within the 
cavities of the nose and middle ear also communi- 
cate with those of the meninges. 

Through these various channels, and through 



Chap. I] 



THE SCALP 



15 



many probably still less conspicuous, inflammatory 
processes can spread from the surface to the in- 
terior of the skull. Thus we find such affections as 




Nerve areas of the face and scalp. 



a, a, Distribution of the first division of the fifth cranial nerve : a', nasal branch ; 

a", supratrochlear ; a'", supraorbital, 
n, b, distribution of the second division ; b', infraorbital branch j b", malar branch ; 

b"', temporal branch. 
c, c, distribution of the third division ; c', mental branch ; c", buccal branch ; c'", 

auriculo-temporal. 

1, area of great occipital; 2, of small occipital; 3, of great auricular; 4, of 

superficial cervical ; .% of third occipital. 

erysipelas of the scalp, diffuse suppuration of the 
scalp, necrosis of the cranial bones, and the like, 
leading by extension to mischief within the diploe, 
to thrombosis of the sinuses, and to inflammation 



16 SUEGICAL APPLIED ANATOMY [Part I 

of the meninges of the brain. If there were no 
emissary veins, injuries and diseases of the scalp 
and skull would lose half their seriousness. Mis- 
chief may even spread from within outwards along 
an emissary vein. Erichsen reports a case where 
the lateral sinus was exposed in a compound frac- 
ture. The aperture was plugged. Thrombosis and 
suppuration within the sinus followed, and some of 
the pus, escaping through the mastoid vein, led to 
an abscess in the neck. 

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

The scalp nerves, especially such as are branches 
of the fifth pair, are often the seat of neuralgia 
(Fig. 4). To relieve one form of this affection, the 
supraorbital nerve has been divided (neurotomy) 
at its point of exit from the orbit, and a portion 
of the nerve has been resected (neurectomy) in the 
same situation. Some forms of frontal headache 
depend upon neuralgia of this nerve. The inner 
branch of the nerve reaches the middle of the 
parietal bone ; the outer branch, the lambdoid 
suture. 

The lymphatics from the occipital and pos- 
terior parietal regions of the scalp enter the oc- 
cipital and mastoid glands ; those from the frontal 
and anterior parietal regions go to the parotid 
glands, while some of the vessels from the frontal 
region join the lymphatics of the face and end in 
the submaxillary glands (Fig. 35, p. 190). 



CHAPTER II 

THE BONY VAULT OF THE CRANIUM 

Position of the sutures. — The bregma, or 
point of junction of the coronal and sagittal 
sutures, is in a line drawn vertically upwards from 
a point just in front of the external auditory 
meatus, the head being in normal position (Fig. 2). 
The lambda, or point of junction of the lambdoid 
and sagittal sutures, lies in the middle line, about 
2\ inches above the occipital protuberance (Fig. 2). 
The lambdoid suture is fairly represented by the 
upper two-thirds of a line drawn from the lambda 
to the apex of the mastoid process on either side. 
The coronal suture lies along a line drawn from 
the bregma to the middle of the zygomatic arch. 
On this line, at a spot about 1^ inches behind and 
above the fronto-malar junction, is the pterion, the 
region where four bones meet, viz. the squamous 
bone, the great wing of the sphenoid, the frontal 
and parietal bones (Fig. 2). The summit of the 
squamous suture is If inches above the zygoma. 

In the normal subject all traces of the fon- 
tanelles and other unossified parts of the skull 
disappear before the age of two years (Fig. 6). 
The anterior fontanelle is the last to close, while 
the posterior is already filled at the time of 
birth. It is through or about the anterior 
fontanelle that the ventricles are usually as- 
nirated in cases of hydrocephalus. The needle 
is either entered at the sides of the fontan- 
elle at a sufficient distance from the middle 
c 17 



18 SURGICAL APPLIED ANATOMY [Part I 

line to avoid the longitudinal sinus, or is intro- 
duced through the coronal suture at some spot 
other than its middle point. It may be noted that 
in severe hydrocephalus the coronal and other 
sutures of the vault are widely opened. 

The condition known as cr»nio-tal>es, a con- 
dition assigned by some to rickets and by others to 
inherited syphilis, is usually met with in the verti- 
cal part of the occipital bone, and in the adjacent 
parts of the parietal bones, but especially in the 
posterior inferior angles of these bones. In this 
condition the bone is greatly thinned in spots, and 
its tissue so reduced that the affected district feels 
to the finger as if occupied by parchment, or, as 
some suggest, by cartridge paper. The thinning is 
mainly at the expense of the inner table and diploe. 
The pits are situated over the impressions of early 
formed convolutions. It is, on the other hand, 
about the site of the anterior fontanelle that cer- 
tain osseous deposits are met with on the surface 
of the skull in some cases of hereditary syphilis 
(Parrot). These deposits appear as rounded ele- 
vations of porous bone situated upon the frontal 
and parietal bones, where they meet in the middle 
line. These bosses are separated by a crucial de- 
pression represented by the frontal and sagittal 
sutures on the one hand and the coronal suture on 
the other. They have been termed " natiform " 
elevations by M. Parrot from their supposed resem- 
blance, when viewed collectively, to the nates. To 
the- English mind they would rather suggest the 
outlines of a "hot-cross bun." 

It is necessary to refer to the development ol 
the skull in order to render intelligible certain 
conditions (for the most part those of congenital 
malformation) that are not unfrequently met with. 
Speaking generally, it may be said that the base of 
the skull is developed in cartilage, and the vault 
in membrane. The parts actually formed in mem- 
brane are represented in the completed skull by 
the frontal and parietal bones, the squamo-zygo- 
matic part of the temporal bone, and the greater 



Chap. Ill THE VAULT OF THE CRANIUM 



19 



part of the expanded portion of the occipital bone. 
The distinction between these two parts of the 
skull is often rendered very marked by disease. 
Thus there are, in the museum of the Royal College 
of Surgeons, the skulls of some young lions that 
were born in a menagerie, and that, in consequence 
of malnutrition, developed certain changes in 
their bones. A great part_ of each of these skulls 
shows considerable thickening, the bone being con- 
verted into a porous structure ; and it is remark- 
able to note that these changes are limited to such 
parts of the skull as are formed in membrane, the 
base remaining free. In hydrocephaly and in the 
condition known as achondroplasia, it is only the 
bones formed in membrane which are unduly ex- 
panded. 

Among the more common of the gross malforma- 
tions of the skull also is one that shows entire ab- 
sence of all that part of the cranium that is formed 
in membrane, while the base, or cartilaginous part, 
is more or less perfectly developed — the condition 
of anencephaly. 

Meningocele is the name given to a con- 
genital tumour that consists of a protrusion of a 
part of the cerebral mem- 
branes through a gap in an 
imperfectly developed skull. 
When the protrusion contains 
brain, it is called an encepha- 
locele, and w r hen that pro- 
truded brain is distended by 
an accumulation of fluid with- 
in the ventricles, it is called 
hydrencephalocele. These pro- 
trusions are most often met 
with in the occipital bone, 
and next in frequency in the 
f ronto-nasal suture, while in 
rarer cases they have been 
met with in the lambdoid, 
sagittal, and other sutures, and have projected 
through normal and abnormal fissures at the 




Fig. 5. — The occipital 
bone at birth. 



20 



SURGICAL APPLIED ANATOMY [Part I 



base of the skull into the orbit, nose, and 
mouth. Their frequency in the occipital bone 
may be in some degree explained by a refer- 
ence to the development of that part. This 
bone at birth consists of four separate parts 
(Fig. 5), a basilar, two condylar, and a tabular 
or expanded part. In the tabular part, about 
the seventh week of foetal life four nuclei appear, 
an upper and a lower pair. These nuclei are 
to some extent separated by fissures running 
inwards from the four angles of the bone to meet 



/ietopic Suture 
.Frontal Eminence 




...BReqmatic Fontanelle 
...Coronal suture 

.SAqiTTAL 5UTURE 



-Parietal Eminence 
Sagittal Fontanelle 



LambdoidalFo/uahelle 

Inter Parietal 

Supra Occipital 



Fig. 6.— Skull of newly born child from above. 

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



Chap. II] THE VAULT OF THE CRANIUM 21 

membrane, the lower part from cartilage. The 
lateral fissures may persist, and may simulate frac- 
tures, for which they have, indeed, been mistaken ; 
or they may be so complete as entirely to separ- 
ate the highest part of the occipital bone from the 
remainder. The bone so separated is the os epactal 
of the French, the interparietal bone of some 
animals (Fig. 6). 

Parietal fissures. — In the developing parie- 
tal bone, fibres concerned in ossification radiate 
towards the periphery from two nuclei about the 
centre of the bone. An interfibrillar space, larger 
than the rest, is seen about the fifth month, to 
separate the loose osseous fibres which abut on the 
posterior part of the sagittal border from the 
stronger fibres which form the rest of this border 
(Pozzi). This is the parietal fissure (Fig. 6). It 
usually closes and leaves no trace, but it may per- 
sist in part as a suture-like fissure, and be mistaken 
for a fracture. If the fissure persists equally on 
the two sides an elongated lozenge-shaped gap is 
left, the sagittal fontanelle (Fig. 6). It is situate 
about an inch in front of the lambda, and occurs in 
over 4 per cent, of newly born children (Lea). The 
parietal foramina are remains of this interval. 

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

Necrosis is fairly common on the vault of 
the skull, and most often attacks the frontal 
and parietal bones, while, for reasons that 
are not very obvious, it is rare in the occi- 
pital bone. The external table is frequently 
necrosed alone, it being more exposed to injury 



22 SURGICAL APPLIED ANATOMY [Part I 

and less amply supplied with blood than is 
the internal table. From the converse of these 
reasons it happens that necrosis of the internal 
table alone is but rarely met with. Necrosis in- 
volving the entire thickness of the bone may prove 
very extensive, and in a case reported by Saviard, 
practically the whole of the cranial vault necrosed 
and came away. The patient was a woman, and 
the primary cause of the mischief was a fall upon 
the head when drunk. 

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

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

Mere local extension may also cause meningitis. 
In cases of necrosis of the external table the growth 
of granulation tissue from the exposed and vascu- 
lar diploe plays a very important part in aiding 
the exfoliation of the lamella of dead bone. 

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



Chap. II] THE VAULT OF THE CEANIUM 23 

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

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

The following anatomical conditions tend to 



24 SUBGtfCAL APPLIED ANATOMY [Part I 

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

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

In children the membranous layer between the 
sutures is of considerable thickness, but as age 
advances this membrane disappears and the bones 
tend to fuse together (synostosis). The sutures 
begin to be obliterated about the age of forty, the 
change commencing on the inner aspect of the 
suture, and appearing first in the sagittal suture, 
then in the coronal and lambdoid, and last in 
the squamous. As age advances, moreover, the 
skull bones become thicker owing to a deposit over 
the inner table to replace the diminishing brain, 
and lose much of their elasticity. They are, there- 
fore, more readily fractured in the aged than in 
the young. 

As a rule, in fracture, the entire thickness of the 
bone is involved ; but the external table alone may 
be broken, and may even be alone depressed, being 
driven into the cliploe, or, in the case of the lower 
frontal region, into the frontal sinus. The internal 
table may be broken without a corresponding frac- 
ture in the outer plate ; and in nearly all cases 
of complete fracture, especially in such as are at- 
tended with depression, the internal table shows 
more extensive splintering than does the external. 
There are many reasons for this. The internal 



Chap. II] THE VAULT OF THE CRANIUM 



25 



plate is not only thinner than the external, but is 
so much more brittle as to receive the name of the 
"vitreous table. A force applied to the external 
table may be extremely limited, and produce, as in 
a sabre cut, but a limited lesion. As the force, 
however, travels through the diploe it becomes 




broken up, and reaches the inner plate as a much 
more diffused form of violence. This is especially 
the case when parts of the outer table are driven 
in. Then, again, the internal plate is a part of a 
smaller curve than is the external plate ; and, 
lastly, Agnew assigns a reason for the greater vul- 




nerability of the inner plate that has reference 
to the general yielding of the bone. In Fig. 7* a b 
represents a section of a part of the vault through 
both tables, and c d and e f two vertical and paral- 
lel lines. Now, if force be applied to the vault be- 
tween these parallel lines, the ends of the arch, 



26 SUPGtfCAL APPLIED ANATOMY [Part 1 

A b, will tend to become separated, and the whole 
arch, yielding, will tend to assume the curve shown 
in Fig 8. In such case, the lines c d and e f will 
converge above and diverge below (Fig. 8), so that 
the violence would tend to force the bone particles 
together at the outer table and asunder at the 
inner table. 

Fractures of the vault are due to direct 
violence. The construction of the skull is such 
that the fracturing force is resisted in many ways. 
(1) When a blow is received on the vertex in the 
parietal region, the force tends to drive the upper 
borders of the two parietal bones inwards. Such 
driving-in of these borders must be associated with 
a corresponding outward movement of the inferior 
borders. This latter movement is forcibly resisted 
by the squamous bone and the great wing of the 
sphenoid, which overlap the lower edge of the 
parietal bone. Moreover, the force transmitted to 
the squamous bone is passed on to the zygomatic 
arch, which takes its support from the superior 
maxillary and frontal bones. This arch then acts as 
a second resisting buttress, and this transmission 
of force from the vertex to the facial bones is said 
to be illustrated by the pain often felt in the face 
after blows upon the top of the head. (2) If the 
upper part of the frontal bone be struck, the force 
is at once transmitted to the parietal bones, be- 
cause the upper part of the frontal bone (owing to 
the manner in which its border is bevelled) actu- 
ally rests upon the two parietal bones, so the same 
resistance is again called into action. If there be any 
tendency for the inferior parts of the bone to move 
outwards, as would certainly be the case while the 
mid-frontal suture existed, such movement would 
be resisted by the great wings of the sphenoid and 
by the anterior inferior angles of the parietal bones 
which embrace or overlap these parts of the 
frontal. Thus it will be seen that much depends 
upon the manner in which the corresponding edges 
of the frontal and parietal bones are bevelled. (3) 
Blows upon the occiput are less distinctly pro- 



Chap. II] THE VAULT OF THE CRANIUM 27 

vided for, and it must be owned that a by no 
means heavy fall is sufficient to break this bone. 
It must receive, however, much protection from 
its connections with the two parietal and tem- 
poral bones, and from its articulation with the 
elastic vertebral column. 

Fractures of the base of the skull may 
be due to (1) direct or to ^) indirect violence, or, 
most commonly of all, to (3) extension of a fracture 
from the vault. (1) The base has been fractured 
Iry direct violence due to foreign bodies thrust 
through the nasal roof, through the orbital roof, 
and through the base as it presents in the pharynx. 
The posterior fossa can also be fractured by vio- 
lence applied to the nape of the neck. (2) Of frac- 
tures by indirect violence the following examples 
may be given : Blows applied to the lower part of 
the frontal bone have been associated with no 
lesion other than a fracture of the cribriform 
plate or of the orbital part of the frontal, 
these parts being much disposed to fracture 
on account of their extreme tenuity. In 86 
cases of fracture of the base of the skull, the 
orbital roof was involved in 79, the optic foramina 
in 63, and the cribriform plates in nearly all (Rawl- 
ing). In falls upon the chin, the condyle of the 
lower jaw has been so violently driven against the 
glenoid cavity as to fracture the middle fossa of the 
skull. The force of a "knock-out", blow applied 
to the point of the chin produces concussion of the 
brain without fracture of the skull. When the body 
in falling has alighted upon the feet, knees, or but- 
tocks, the force has been transmitted along the 
vertebral column, and has led to fracture of the 
base in the occipital region. Such accidents are 
most apt to occur when the spine is kept rigid by 
muscular action, and the mechanism involved is 
precisely similar to that whereby the head of a 
broom is driven more firmly on to the broom-handle 
by striking the extreme end of the stick against 
the ground. The theory that the base is often 
broken by contre-coup is pretty generally abandoned, 



28 SUEGICAL APPLIED ANATOMY [Part I 

although there are a few cases that appear to sup- 
port the suggestion. Such a case was recorded by 
Mr. Hutchinson, and in it a fracture of the occipital 
bone was associated with a like lesion in the cribri- 
form plate, the intervening part of the skull being 
uninjured. (3) Fractures of the vault, and especi- 
ally linear fractures due to such diffused violence 
as obtains in a fall upo%the head, are very apt to 
spread to the base. In so spreading they reach the 
base by the shortest possible route, and without 
any regard to the sutures encountered or to the 
density of the bones involved. Thus, fractures of 
the frontal region of the vault spread to the an- 
terior fossa of the base, those of the parietal region 
to the middle fossa, and those of the occipital 
region to the posterior fossa. To this rule there are 
but few exceptions. To indicate more precisely the 
exact bones involved in these three districts, P. 
Hewett has divided the skull into three zones. The 
anterior zone includes the frontal, the upper part 
of the ethmoid, and the f ronto-sphenoid ; the 
middle, the parietals, the squamous and anterior 
part of the petrous of the temporals, and the 
greater part of the basi-sphenoid ; and the pos- 
terior, the occipital, the mastoid, the posterior 
part of the petrous bone, with a small part of 
the body of the sphenoid. 

In all fractures of the base there is usually a 
discharge of blood and of cerebro-spinal fluid ex- 
ternally. (1) In fractures of the anterior fossa the 
blood usually escapes from the nose, and is derived 
from the meningeal and ethmoidal vessels, or in 
greater degree probably from the torn mucous lin- 
ing of the nasal roof. To allow of the escape of 
cerebro-spinal fluid from the nose, there must be, 
in addition to the fracture in the nasal roof, a lacer- 
ation of the mucous membrane below that fracture, 
and of the sheaths of the olfactory nerves which are 
derived from the dura mater and arachnoid. A 
profuse discharge of cerebro-spinal fluid may take 
place through the nasal mucous membrane inde- 
pendently of injury. The discharge probably oc- 



Chap. II] THE VAULT OF THE CEANIUM 29 

curs along the sheaths of the olfactory nerves, and 
is caused by a lessened absorption or increased 
secretion of cerebro-spinal fluid. In many cases 
of fracture in this part the blood finds its way into 
the orbit, and appears beneath the conjunctiva. (2) 
When the middle fossa is involved, the blood 
escapes from the external auditory meatus, through 
a rupture in the tympanic membrane, and is de- 
rived from the vessels of the tympanum and its 
membrane, or from an intracranial extravasation, 
and in some cases from a rupture of the cavernous 
or petrosal sinuses. The blood may follow the 
Eustachian tube, and may escape from the nose or 
mouth, or be swallowed and subsequently vomited. 
To allow of the escape of cerebro-spinal fluid by the 
ear ("the serous discharge "), (a) the fracture must 
have passed across the internal auditory meatus; 
(b) the tubular prolongation of the membranes in 
that meatus must have been torn ; (c) there must 
be a communication between the internal ear and 
the tympanum ; and (d) the membrana tympani 
must have been lacerated. (3) In fractures of the 
posterior fossa an extravasation of blood may ap- 
pear about the mastoid process or at the nape of 
the neck, or may even extend into the cervical region. 

It may be added that in compound fractures 
of the vault associated with tearing of the dura 
mater and arachnoid, an escape of cerebro-spinal 
fluid has in a few rare instances been noted. After 
simple fracture of the vault in children a swelling 
may form at the injured part which fluctuates, be- 
comes tenser when the patient cries, and may pos- 
sibly pulsate synchronously with the brain. Such 
swellings are clue to a collection of cerebro-spinal 
fluid beneath the scalp, and indicate a coincident 
rupture of the brain membranes. 

Separation of sutures. — This condition, as 
the result of injury, is practically restricted to the 
young skull. In later life, force applied at the site 
of an obliterated suture may cause a fracture, 
which accurately follows the old suture line. Separ- 
ation of the sutures, independent of fracture, is 



30 SUEGICAL APPLIED ANATOMY [Part I 

very rare in the adult skull. In the few instances 
of such a condition the temporal bone has usually 
been the one displaced and the separation noted 
at the squamous suture. When associated with 
fracture, the coronal and sagittal sutures are those 
most frequently separated, and next in fre- 
quency is the lambdoid. 

The thickness of the skull cap varies 
greatly, not only in different parts of the same 
skull, but also in corresponding parts in different 
individuals. The average thickness is one-fifth of an 
inch. It varies with age ; at birth the parietal is 
less than T V inch ; at three years diploe appear, 
marking off the inner from the outer table of the 
skr: 11; in old people the parietal bone may be 
\ inch or \ inch in thickness. The thickest 
parts are at the occipital protuberance (where the 
section may measure half an inch), the. mastoid 
process, and the lower part of the frontal bone. 
The bone over the inferior occipital fossae and orbit 
is very thin, while it is thinnest over the squamous 
bone. Here. the bone may be no thicker in parts 
than a visiting card. The skull is also thinned 
over the sinuses and grooves for the meningeal 
vessels. It is especially thin over the anterior in- 
ferior angle of the parietal bone. It is important 
to remember in trephining that the inner table is 
not always parallel with the outer. 

Craniectomy. — This operation is carried out 
in cases of microcephaly in infants and chil- 
dren. It consists in the removal of a strip of bone 
from the vertex of the skull so as to give to the 
brain, as an American author expresses it, " more 
elbow room." The operation presumes that the 
arrest of growth in the brain is due to a retarded 
growth of the skull, but all the evidence at our dis- 
posal points to the arrest in the development of 
the brain as the primary lesion ; the condition of 
the skull being a consequence. In hydrocephaly 
the skull is seen to respond readily to the quick 
expansion of the brain ; if the growth of the brain 
is arrested, the skull remains small. 



CHAPTER III 
THE CRANIAL CONTENTS 

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

Sir C. Bell pointed out that the dura mater of 
the vault may be separated from the bone by the 
vibration produced by a blow. "Strike the skull 
of a subject with a heavy mallet ; on dissecting you 
find the dura mater to be shaken from the skull at 

31 



32 SUEGICAL APPLIED ANATOMY [Part I 

the point struck. Repeat the experiment on an- 
other subject, and inject the head minutely with 
size injection, and you will find a clot of injection 
lying betwixt the skull and dura mater at the part 
struck, and having an exact resemblance to the 
coagulum found after violent blows on the head." 
Tillaux has demonstrated that the adhesions be- 
tween the dura mater and the bone are particularly 
weak in the temporal fossae, the most usual site of 
meningeal haemorrhage. 

When blood is poured out between the dura 
mater and the bone in cases of fracture, the vessel 
that as a rule gives way is the middle menin- 
geal artery. In thirty-one cases of such 
haemorrhage, this vessel was the source of the 
bleeding in twenty-seven instances (P. Hewett). 
The vessel, having passed through the foramen 
spinosum, divides into two branches ; the anterior, 
the larger, runs upwards across the anterior in- 
ferior angle of the parietal bone and ascends the 
vault some distance behind the coronal suture ; 
the posterior runs backwards, with a horizontal 
sweep across the squamous bone, and takes the 
course of the second temporal convolution. (See 
Figs. 2, 3.) 

Mr. Jacobson has shown that the branches of the 
artery are more frequently ruptured than the 
trunk. The vessel is very frequently torn as it 
crosses the anterior angle of the parietal bone. 
There are many reasons for this : the bone where 
grooved by the artery is very thin ; the artery is 
often so embedded in the bone that fracture with- 
out laceration of the vessel would hardly be pos- 
sible ; and lastly, the particular region of the 
artery is a part of the skull peculiarly liable to be 
fractured. Mr. Jacobson shows that the artery may 
be ruptured by a force that does not fracture the 
skull, but merely leads to detachment of the dura 
mater. Failing this vessel, the most frequent 
source of extrameningeal haemorrhage is the 
lateral sinus, for reasons that will be obvious. 
Venous sinuses. — The flaccid-walled cerebral 



Chap. Ill] THE CRANIAL CONTENTS 33 

veins, which are compressed with each pulsa- 
tion of the brain, empty into the venous sinuses, 
rigid-walled cavities formed between the outer or 
periosteal and inner or supporting layers of the 
dura mater. At the points where the superior 
cerebral veins enter the superior longitudinal 
sinus, and w T here the temporo-sphenoidal and 
occipital veins join the lateral sinus, the arach- 
noid, elsewhere free from dura mater, is firmly 
adherent to it. From a surgical point of view 
the lateral is the more important sinus; and as 
it turns downwards beneath the mastoid process 
it comes into close relationship with the antrum 
and cells of the mastoid, from which a septic con- 
dition may spread to the sinus, setting up throm- 
bosis (see Fig. 20, p. 86). The lateral sinus is 
marked out by taking the following three points 
(see Fig. 2, p. 9, and Fig. 3, p. 12) : (1) The 
inion, (2) the asterion, (3) a point h inch behind 
the lower border of the meatus. When these 
three points are joined, the upper and anterior 
borders of the sinus are marked out. The sinus 
is 10 mm. wide. The : lateral sinus escapes from 
the skull to form the internal jugular vein in line 
with the anterior border of the mastoid process, 
but situated deeply beneath the parotid gland 
(Fig. 2, p. 9). A line drawn over the vault of the 
skull from nasion to inion marks the line of the 
superior longitudinal sinus; beneath the posterior 
third of the sagittal suture it may not keep exactly 
to the middle line, and in this part of its course 
it frequently shows lateral extensions or diverti- 
cula known as parasinoids. In the majority of 
cases the superior longitudinal ends in the right 
lateral sinus, which is hence commonly larger 
than the left. < The cavernous sinus, enclosing the 
internal carotid artery and sixth cranial nerve, 
with the third, fourth and greater part of the fifth 
embedded in its wall, is situated over the 
sphenoidal air sinus^ from which septic conditions 
may extend to it, giving rise to thrombosis. In 
such cases the eyes become prominent owing to the 

D 



34 SUEGICAL APPLIED ANATOMY [Part I 

distension of the ophthalmic veins, for the venous 
stream from the orbit flows through the cavernous 
sinus to reach the lateral sinus and jugular vein by 
means of the superior and inferior petrosal sinuses. 
Tumours of the pituitary necessarily compress the 
cavernous sinus. The relations between the inter- 
nal carotid artery and cavernous sinus are so in- 
timate that an arterio-venous aneurism has fol- 
lowed injury involving these parts. It will be 
seen also with what ease this sinus could become 
thrombosed in cases of inflammation within the 
orbit by the extension of the mischief along its 
great tributaries, the two ophthalmic veins. 

Between the dura mater and the arachnoid is 
the subdural space, which, like the pleural 
cavity, is merely a potential space, for in health 
the arachnoid is closely applied to the smooth 
inner surface of the dura mater^ A space is formed 
only when fluid, blood, or pus is collected between 
the two membranes (Fig. 1, p. 2). The subdural 
space contains a small amount of fluid, and acts, 
probably, like the pleural and peritoneal sacs, in 
preventing the effects of friction during the move- 
ments of the brain. 

A knowledge of the subarachnoid space is 
steadily becoming of greater surgical importance. 
The space which surrounds the spinal cord is in 
direct continuity with the subarachnoid spaces of 
the brain, and hence, when this space is tapped 
in the lumbar part of the spinal canal (Fig. 107, 
p. 612), the fluid situated in the subarachnoid 
spaces of the brain is also drained off (Fig. 9). In 
meningitis the cerebro-spinal fluid becomes turgid ; 
the subarachnoid space, or parts of it, may contain 
pus. In the spinal column the arachnoid is widely 
separated from the pia mater, hence the subarach- 
noid space is extensive. As the space passes into 
the skull it forms an expansion between the cere- 
bellum and roof of the fourth ventricle named the 
cisterna magna (Fig. 9); an opening in the roof 
of the fourth ventricle (the foramen of Majendie) 
allows the cerebro-spinal fluid in the ventricles of 



Chap. III1 THE CRANIAL CONTENTS 



35 



the brain to join that in the cisterna magna (Fig. 
9). On the base of the skull, in front of the medulla 
and pons, the spinal subarachnoid space expands 
into the cisterna pontis, which in turn becomes 
continuous with a large space situated on the base 
of the brain between the temporal lobes and under 
the inter-peduncular space — the cisterna basalis 
(Fig. 9). In this cistern are situated the circle of 
Willis, the third, fourth, and root of the fifth 



Calloso /1arcinal Space 

Supra Cauosal Space 

Splenium 
Velum Interpositun 

Pl/IEAL C.LAND 

Tentorium Cerebelli 

Aqueduct ofSylvius 
Four.™ Ventricle 
Foramen of/IajendiEt 
Cisterna macna 




Cut edge of Arachnoid 

Supra- CallosalSpace 

Lateral Ventricie; 

Genu 

Foramen of 
aionro 
Third 
entricle 

Sub Callosal 
Space 

Cisterna 
Basalis 

Optic 
/terve 
Pituitary 
Body 
_ Internal 
arotid art- 
Temporal L0B& 



iro /Ierve 



Cisterna Spinalis 



Cisterna Pontis 
^Cisterna /Iedullaris 
.Cisterna Spinalis 



Fig. 9. — Diagram of the cranial spaces containing cerebro-spinal fluid. 



nerves, the optic chiasma and tracts and infundi- 
bulum of the pituitary body. In basal meningitis 
it may become distended with pus. The inflam- 
matory adhesions which occur in the inferior 
medullary velum may lead to a condition of 
hydrocephaly by closing up the openings in that 
membrane. Over the convolutions of the brain 
the arachnoid is bound by the pia mater, which 
here serves as a loose subarachnoid tissue. Every- 
where extensions of the basilar cistern pass out 
with the arteries derived from the circle of Willis 
into the pia mater in the sulci of the brain. While 



36 SURGICAL APPLIED ANATOMY [Part I 

the interpeduncular part of the base of the brain, 
pons and medulla rest on these basal cisterns, the 
temporal and frontal lobes lie directly on the base 
of the skull ; the occipital lobe rests on the tentor- 
ium cerebelli. > The three poles of the brain— the 
frontal, occipital and temporal — are in direct 
contact with the meninges and skull, and are 
therefore the parts of the brain that are most 
liable to laceration in cases of injury to the head. 

The cerebro-spinal fluid prevents the ill effects 
that irregularities in the blood circulation might 
have upon the brain, situate as it is within an un- 
yielding cavity. If the great nerve centres near the 
lateral ventricles are swollen by congestion, they 
are not met by an unyielding wall, but merely dis- 
place some of the cerebro-spmal fluid through the 
foramen of Majendie, until such time as their cir- 
culation is normal again. When the healthy brain 
is exposed by a trephine opening it is seen to 
pulsate with each beat of the heart; if it does 
not pulsate, this shows that the pressure within 
the skull is higher than the arterial pressure 
(100-130 mm. Hg.); normally, as Hill has shown, 
the intracranial pressure is that of the blood- 
pressure in the veins (10-15 mm. Hg.). With each 
pulsation of the heart about 5 cm. of arterial blood 
is thrown into the skull, causing the ejection of a 
similar amount of venous blood by the jugular 
vein. 

Fluid may pass from the lateral to the third 
ventricle by the foramen of Monro ; from the third 
to the fourth ventricle by the aqueduct of Sylvius ; 
and from the fourth ventricle to the cisterna 
magna by the foramen of Majendie (Fig. 9). Many 
still share the opinion of Hilton that blockage of 
the aqueduct, or closure of the foramen of 
Majendie, or of the other two openings at the 
lateral angles of the fourth ventricle — (the fora- 
mina of Key and Retzius) — may prevent the exit of 
cerebro-spinal fluid from the ventricles and thus 
produce the condition of hydrocephaly. The fluid 
also drains into the veins of Galen, hence pressure 



Chap. Ill] THE CRANIAL CONTENTS 37 

on these may bring about a like result. It has been 
proposed to relieve the pressure within the lateral 
ventricles in cases of hydrocephaly by draining the 
cerebro-spinal fluid into the subdural space by 
means of a seton. It is absorbed under any pressure 
above that within the cerebral veins (Hill). If the 
brain, too, becomes enlarged by congestion, it is 
not met by unyielding bone, but rather by an ad- 
justable water-bed, and during its period of en- 
largement it merely displaces into the spinal part 
of the subarachnoid space some of the fluid that 
surrounds it. This mutual effect is well illustrated 
in a case reported by Hilton of a man with a frac- 
ture of the base, from whose ear cerebro-spinal 
fluid was escaping. The discharge of this fluid 
was at once greatly increased by expiratory efforts 
when the nose and mouth were held closed and the 
veins compressed in the neck. 

The surface relationships of the Drain 
(see Figs. 10 and 11). — The longitudinal fissure of the 
brain is indicated by a line drawn along the vertex 
from the glabella to the external occipital protu- 
berance. It is narrow in front, but as it contains 
the longitudinal sinus, which rapidly enlarges as 
it passes backwards, it becomes of considerable 
breadth behind, and as a rule lies somewhat to- 
wards the right of the median line, owing to the 
predominance of the left cerebral hemisphere. 
Between the external occipital protuberance and 
the ear, the lateral sinus bounds the lower level of 
the cerebrum and the upper of the cerebellum 
(Figs. 3 and 10). In front of the ear the upper 
border of the zygoma in its posterior three-fourths 
marks the lower border of the temporal lobe. The 
pole of the temporal lobe is f of an inch behind the 
outer margin of the orbit (see Fig. 3). The lower 
limit of the brain on the forehead may be indicated 
approximately by drawing a line from the glabella 
to the Sylvian point, ^ an inch above the upper 
margin of the orbit. The olfactory bulbs lie at 
the level of the nasio_n (Fig. 3). 

The cerebellum is best explored at a point 1^ 



38 



SUKGICAL APPLIED ANATOMY [Part I 



inch behind and | inch below the level of the 
external auditory meatus (see Fig. 3, p. 12). _ It 
is deeply placed, being covered by the insertions 
of the occipital muscles. 



FISSURE of ROLANDO. 



PARIETAL 
EMINENCE 



BREQMA 




r-NASION 



Fig. 10. — Showing the relation of the brain and sensori-motor areas of 
the cortex to the skull. {Modified from Quain.) 

The sensori-motor areas are shaded ; the leg and trunk areas with vert Lea] lines ; 
the arm and hand areas with lines slanting forwards; the face and mouth 
areas with lines slanting backwards; the tongue, pharynx, and larynx areas 
are stippled. The ascending frontal convolution, containing the areas which 
are strictly motor in function, is indicated by red lines. The motor centre for 
speech on Broca's convolution is shaded with horizontal lines. The "word- 
hearing" centre is indicated on the superior temporal convolution, and 
the' "word-seeing" centre on the angular convolution. The area shaded 
with horizontal lines on the posterior parts of the middle and inferior frontal 
convolutions is the centre for combined movements of I he head and eyes. 

Of the many methods which have been sug- 
gested for marking out the fissure of" Rolando, 

the most simple and accurate is the following : A 
point over the sagittal suture is taken midway 



Chap. Ill] THE CRANIAL CONTENTS 



39 



between the glabella and external occipital pro- 
tuberance. Half an inch behind the mid point 
terminates the upper end of the fissure (Fig. 
11). A line 3h inches long drawn downwards and 



Upper 
rolandic 


POINT 


MID POINT. 


PARIETO- 
OCCIPITAL 
FISSURE 




PAf^EMIN. 


LAMBDA./S 




X 



BRECMA. 



WON. 




Fig. 11. — Showing the lines which indicate the position of the principal 
fissures of the brain. 

Reid's base line is drawn from the lower margin of the orbit backwards through 
the meatal point. 



forwards from this point, at an angle of 67° to 
the line of the sagittal suture, will indicate the 
position of the fissure of Rolando in the adult. 
In the child the fissure is shorter and the con- 
tained angle is 5° smaller. The angle is easily 



40 SURGICAL APPLIED ANATOMY [Part I 

obtained by folding twice the corner of a square 
piece of paper and removing a fourth of the 
right angle. This line may not lie exactly oyer 
the fissure, for it varies somewhat in position 
according to the shape of head. The sensori- 
motor areas of the brain are mostly represented 
in the ascending frontal and parietal convolu- 
tions which bound the fissure of Rolando. The 
average width of each of these convolutions is 
J of an inch. The coronal suture is about 2 inches 
in front of the fissure of Rolando at its upper 
part and 1| inch at its lower. 

The fissure of Sylvius is indicated thus 
(Fig. 11) : — A point is taken 1| inch behind 
and \ inch above the fronto-malar junction, 
which is indicated by a distinct notch. This point 
on the temple overlies the anterior inferior angle 
of the parietal bone — the pterion. The pterion 
marks the junction of the three limbs of the 
fissure of Sylvius with its stem. A line drawn 
backwards and upwards from the pterion to a 
point | of an inch below the parietal eminence 
indicates the situation of the posterior horizontal 
limb or ramus (Fig. 11). If the parietal eminence 
be not well marked, then the fissure may be in- 
dicated by joining the fronto-malar notch with 
the pterion and prolonging the line thus formed 
straight backwards to the region of the parietal 
eminence, as shown in Fig. 3 (R. J. Berry). This 
ramus is bounded below by the superior temporal 
convolution, which contains in its middle third 
the "word-hearing" centre (Fig. 10). Above, it 
is bounded from before backwards by the basilar 
part of the inferior frontal convolution, the lower 
ends of the ascending frontal and parietal con- 
volutions, and the supramarginal gyrus. In the 
three parts first named are situated centres for 
movements of the tongue, larynx, pharynx and 
mouth. A penny piece placed directly behind the 
termination of the Sylvian line will cover the 
angular convolution in which the "word-seeing ;; 
centre is placed (Fig. 10). The parietal eminence 



Chap. Ill] THE CRANIAL CONTENTS 4,1 

covers the supramarginal convolution. The ascend- 
ing limb of the fissure of Sylvius is indicated 
by a line f of an inch long drawn upwards and 
slightly forwards from the pterion, while the short 
anterior horizontal limb is indicated by a line 
\ an inch long drawn forwards from the same 
point. Between the ascending and anterior limbs 
is situated the pars triangularis of the inferior 
frontal convolution in which the centre for 
" motor speech ,; is placed. Broca regarded the 
left inferior frontal convolution (frequently 
called Broca's convolution) as specially connected 
with speech, but recently Pierre Marie has pub- 
lished accounts of a number of cases of disease of 
this part in which speech was unaffected. The 
stem of the Sylvian fissure is \ an inch long and 
runs downwards and forwards under the great 
wing of the sphenoid (Fig. 10). The temporal 
pole lies below it. 

The four angles of the parietal bone have im- 
portant relationships to the brain. The anterior 
inferior angle covers the posterior part of the in- 
ferior frontal convolution and the anterior hori- 
zontal and ascending limbs of the fissure of Syl- 
vius. The anterior branch of the middle meningeal 
artery ascends beneath it. The anterior superior 
angle at the bregma covers the terminal part of 
the superior frontal convolution and the centre 
for movements of the hip. The posterior superior 
angle at the lambda lies oyer the upper part of the 
occipital lobe and \ an inch behind the parieto- 
occipital fissure. The posterior inferior angle 
covers the convexity^ of the lateral sinus and 
marks the lower limit of the cerebrum. In its 
anterior half the posterior limb of the Sylvian 
fissure lies beneath the squamous suture, but be- 
hind it passes entirely beneath the parietal bone. 
It will be thus seen that the parietal bone covers 
the whole of the parietal lobe, the posterior parts 
of the frontal and temporo-sphenoidal lobes, and 
the upper margin of the occipital. 

The inferior temporal convolution passes 



42 SURGICAL APPLIED ANATOMY [Part I 

backwards above the upper border of the zygoma 
and external auditory meatus and rests on the 
thin roof of the tympanum. Hence it is the_ most 
common site of abscess which may follow middle- 
ear disease. (Fig. 10.) 

The basal ganglia of the brain — the corpus 
striatum and optic thalamus — are capped on their 
outer aspect by the Island of Eeil. The Island 
lies buried in the anterior three-fourths of the 
fissure of Sylvius, and hence the surface markings 
for the fissure may be also used for the Island 
and the basal ganglia (see Fig. 3, p. 12). A 
half-circle, with a radius of ■§• an inch, drawn 
in front of the pterion, will indicate the anterior 
limit of the basal ganglia, while their posterior 
limit lies some distance in front of the point at 
which the lateral ventricles may be tapped (see 
Fig. 3, p. 12). That point is found thus : a 
line 5 cm. (2 inches) in length is drawn verti- 
cally upwards from the external auditory meatus ; 
the point for tapping the lateral ventricle lies 
2 cm. ( f of an inch) behind the upper end of 
this line ; a trochar thrust in there enters the 
lateral ventricle at the junction of the body with 
the descending and posterior horns. (Jenkins.) 

The sensori-motor areas of the brain. — A 
knowledge of the position of these areas is most 
important in enabling certain brain lesions to be 
localised and in guiding the surgeon in operations 
upon the cerebral cortex. 

Formerly these areas were believed to be situ- 
ated in the ascending frontal (precentral) and also 
ascending parietal (postcentral) convolution, but 
by stimulating more accurately the cortex of these 
convolutions in anthropoid apes, Sherrington and 
Griinbaum found that motor reactions were 
elicited only from the ascending frontal. The 
arrangement of the motor areas is shown in Fig. 
12 : in the upper third of the ascending frontal, 
passing also some distance on to the mesial aspect 
of the brain, the movements of the lower extremity 
and trunk are represented; in the middle third, 



Chap. IIIJ THE CRANIAL CONTENTS 



43 



those of the arm ; while in the lower third, those 
of the face, mouth, and larynx. Behind the fis- 
sure of Rolando, in the ascending parietal con- 
volution, are situated sensory areas corresponding 
to the motor areas in the ascending frontal con- 
volution. A tumour pressing on the surface of 
the brain first excites the cortex to action ; hence 
one situated over a motor area excites the move- 




Pirsf IzrnpoY^/^ 



Fig. 12.— Showing the localisation of motor areas in the precentral or 

ascending frontal convolution, and the sensory areas in the postcentral 

or ascending parietal convolution. 



ments represented in that area, or one over a sen- 
sory area excites the sensations represented there. 
Stimulation of the cortex is soon followed by its 
destruction and loss of function ; hence loss of 
movement or loss of sensation replaces the pre- 
liminary excitement. The symptoms produced by 
intracranial growths are apt not to be definitely 
localised, because even a small tumour may pro- 
duce widely distributed compression effects when 
it is situated within the rigid walls of the skull. 



44 SUEGICAL APPLIED ANATOMY. [Part I 

Conjugate movements of the eyes are represented 
in the cortex at the posterior end of the mid- 
frontal convolution (Fig. 12). There are also 
several primary sensory areas of cortex — areas 
connected with sight, hearing, and smell — which 
may be affected by intracranial lesions, and give 
signs which assist the surgeon to localise the seat 
of disease. The visual cortex is situated near the 
calcarine fissure and round the occipital pole; 
the " word-seeing " centre occupies the angular 
gyrus (Fig. 10) ; the auditory cortex lies in a deep 
or buried part of the superior temporal convolu- 
tion, while the "word-hearing" centre is ascribed 
to the middle third of this convolution. The ol- 
factory cortex is placed in the uncus, which is 
situated to the inner side of the temporal lobe. 
Tumours in the neighbourhood of the uncus, 
besides producing disturbance of the olfactory 
sensations, frequently give rise to " dreamy 
states." 

Of the brain generally little has to be said. 
In a surgical sense, it presents itself simply as 
a large mass of soft tissue that may be damaged 
by shaking as gelatine may be shaken in a case. 
As it is of very yielding structure, and does not 
entirely fill the cranial cavity, it may," as it were, 
be thrown about with the skull, and be damaged 
by collision with its walls. In contusion or bruis- 
ing of the brain it is noticed that the lesion is 
very much more frequently situate on the under 
surface, both as regards the cerebrum and cere- 
bellum, than in any other part (see p. 36). To 
this statement, however, there is the striking 
exception that those parts of the base of the 
cerebrum that rest upon the large basal collection 
of the cerebro-spinal fluid are the least often con- 
tused. These parts include the medulla, the pons, 
and the interpeduncular space. 

The brain is very lavishly supplied with blood- 
vessels. The main arterial trunks (vertebral and 
internal carotid) are both rendered tortuous be- 
fore entering the skull, with the object probably of 



Chap. Ill] THE CRANIAL CONTENTS 45 

diminishing the effects of the heart's systole upon 
the brain. On entering they are almost immedi- 
ately blended into an anastomosing circle (circle 
of Willis), which has the effect of equalising the 
cerebral circulation. Embolism of the middle 
cerebral artery leads to a wide-spread destruc- 
tion of the cerebral cortex. It supplies the third 
frontal, the upper and middle temporal, the angu- 
lar supramargpnal, and the lower two-thirds of 
the ascending frontal and parietal gyri. The only 
jd arts of the sensor i-motor areas which escape de- 
struction in such a case are those for the lower 
limbs and trunk. The anterior cerebral artery 
supplies these centres, the mesial surface of the 
frontal and parietal lobes, and the adjacent part 
of the cortex on the outer aspect. The occipital 
lobe and temporo-sphenoidal convolutions are 
supplied by the posterior cerebral artery. Liga- 
ture of one common carotid may produce no effect 
upon the brain, although the mortality afterthis 
operation is mainly due to cerebral complications. 
One carotid and the two vertebrals would appear 
to be able to bring enough blood to the brain, 
which blood will be as evenly distributed as 
hitherto by the circle of Willis. Both common 
carotids have been ligatured, or one carotid has 
been secured when its fellow of the opposite side 
has been occluded by disease, and no marked cere- 
bral disturbances have followed. In no case, how- 
ever, has the patient recovered when the interval 
between the closing of the two vessels was less 
than a few weeks. The vertebral arteries can 
carry a sufficient amount of blood to the brain 
if only the strain be thrown upon them gradu- 
ally, and the brain be allowed to accommodate 
itself slowly to the change. After ligaturing all 
four arteries in the dog, the anastomosis between 
the spinal and cerebral arteries within the fora- 
men magnum was sufficient to maintain life 
(Hill). Plugging of any of the smaller cerebral 
arteries by emboli, as a rule, leads at^ once to a 
marked disastrous result. Such embolism is met 



46 SURGICAL APPLIED ANATOMY [Parti 

with in surgery in connection with aneurism of 
the common carotid. In simply examining such 
aneurisms, a little piece of the clot contained in 
the sac has been detached, has been carried up 
into the brain, and has produced a plugging of 
one of the cerebral vessels. Thus, hemiplegia has 
followed upon the mere examination of a carotid 
aneurism, as in a case recorded by Mr. Teale, of 
Leeds. Fergusson ; s treatment of aneurism at the 
root of the neck, by displacing the clots by manip- 
ulation, has been abandoned on this same score. 
In the second case treated by manipulation by 
this surgeon, a case of subclavian aneurism, 
paralysis of the left side of the body followed at 
once upon the first handling of the tumour. 

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

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

Ligature of a cerebral vein usually leads to an 
atrophy of the cortex which it drains (Horsley). 
There is always one — sometimes more — anastomos- 



Chap. Ill] THE CliANIAL CONTENTS 47 

ing vein on the surface of the cerebrum, uniting 
the upper with the lower cerebral veins. The 
lower cerebral veins are four in number — three of 
them leave the temporal and occipital lobes to end 
in the lateral sinus; the other, the superficial 
Sylvian vein, ends in the sinus of the jsmall wing 
of the sphenoid. The temporal and occipital lobes 
cannot be lifted off the tentorium without rup- 
turing the veins joining the lateral sinus. 

Nearly all the veins of the cerebellum end in 
the lateral sinus; its arteries are derived from 
vertebral and basilar. Tumours in the cerebel- 
lum give rise to muscular weakness and inco- 
ordination, giddiness, and loss of balance. The 
vermis, or middle part of the cerebellum, is more 
directly connected with bending movements of the 
trunk, while the lateral lobes are concerned in 
the co-ordination of turning movements — move- 
ments made round the vertical axis of the trunk 
(Horsley). 



CHAPTER IV 

THE ORBIT AND EYE 

The orJbit. — The antero-posterior diameter of 
the orbit is about If inches (44 mm.), its ver- 
tical diameter at the base a little over l\ inches 
(31 mm.), and its horizontal diameter at the 
base about lj inches (37 mm.). The diameters 
of the globe are as follow : transverse, 24 mm. ; 
antero - posterior, 24"5 mm. ; vertical, 23 mm. 
(Brailey). The eyeball is therefore nearer to 
the upper and lower margins of the orbit than 
it is to the sides, and the greatest interval be- 
tween the globe and the orbital wall is on the 
outer side. The interior of the orbit is most con- 
veniently reached by incisions made to the outer 
side of the globe, and, in excision of the eyeball, 
the scissors are usually introduced on that side 
when the optic nerve has to be divided. In excis- 
ing the left eye, however, it may be more con- 
venient to divide the optic nerve from the inner 
side. The bones forming the floor, the roof, and 
the inner wall of the orbital cavity are very thin, 
especially in the last-named situation. Thus, 
foreign bodies thrust into the orbit have readily 
penetrated into the cranial cavity, into the nose 
and ethmoidal cells, and, when directed from 
above, into the antrum. In several instances, a 
sharp-pointed instrument, such as the end of a 
stick or foil, has been thrust into the brain 
through the orbit, and has left but little external 
evidence of this serious lesion. Nelaton mentions 

48 



Chap. IV] THE ORBIT AND EYE 49 

a case in which the internal carotid artery was 
wounded through the orbit. Certain cases of 
pulsating orbital tumour which depend upon a 
communication between the carotid artery and 
the cavernous sinus have a traumatic origin. 

A reference to the relations of the orbital walls 
will show that a tumour may readily invade the 
orbit by spreading (1) from the base of the skull, 
(2) from the nasal fossse, (3) from the antrum, 
and (4) from the temporal or zygomatic fossse.. 
In any of these instances the growth may enter 
the orbit by destroying the intervening thin layers 
of bone, and in tumours of the antrum this is 
the usual mode of entry. It may, however, ex- 
tend more readily from the cranial cavity through 
the optic foramen or sphenoidal fissure, from the 
nose through the nasal duct, and from the two 
fossse named through the spheno-maxillary fis- 
sure. After violent blows upon the temple blood 
has found its way into the orbit through the 
spheno-maxillary fissure, \ and has led to subcon- 
junctival ecchymosis. Distension of the frontal 
sinus by retained mucus or pus may lead to a 
prominent tumour at the upper and inner margin 
of the orbit, above the level of the tendo oculi, 
which may cause displacement of the globe down- 
wards, outwards, and forwards. The bones of the 
orbit are peculiarly apt to be the seat of ivory 
exostoses, which may in time entirely occupy the 
orbital cavity. 

The anterior third .of the outer wall of the 
orbit is formed by the temporal fossa (Fig. 13) ; 
the posterior two-thirds are separated from the 
middle fossa of the skull, which contains the tem- 
poral lobe, by the great wing of the sphenoid. 
Kronlein removes intraorbital tumours by open- 
ing the outer wall of the orbit in the temporal 
fossa. In a recent notorious case, in which a mur- 
derer attempted to commit suicide, the bullet 
entered the temporal fossa, perforated the outer 
wall of the orbit, and destroyed the eyeball, but 
left the brain untouched. The pole of the tem- 
E 



50 



SUEGICAL APPLIED ANATOMY [Part I 



poral lobe is situated from 2 to 2*5 cm. behind 
the outer margin of the orbit (see Fig. 3, p. 12). 

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



Ext. Tarsal Lie 
Conjunctiva 
Ext.Chcck, 
Ext-£ec 



Int. Tarsal Lie 
Lach. Sac 
Int. Check. Liq. 




Capsule of-Tbnon 
Temporal Fossa 



Ext. Rectus 



JLCapsule-opTenon 
Int. Rectus 
Optic aierve 

5 ME ATM 



Middle fossa 



Fig. 13. Diagram to show the arrangement of the capsule of Tenon and 
check ligaments. 

The eyeball is turned outwards so that the external check ligament is taut and 
the internal relaxed. 

" The capsule is a firm loose membrane spread 
over the posterior fths of the globe, the cornea 
alone being free from it. In front it lies under 
the ocular conjunctiva, with which it is intim- 
ately connected, and it ends by blending with 
that membrane close to the margin of the cornea 
(Fig. 13). Behind it fuses with the sheath of the 
optic nerve, where the latter pierces the sclerotic. 
The surface of the membrane towards the globe 
is smooth, and is connected to the eyeball by some 



Chap. IV] THE ORBIT AND EYE 51 

soft yielding areolar tissue. It thus forms a kind 
of dome for the globe, a species of socket or bursa 
in which it moves. The posterior surface of the 
capsule is in contact with the orbital fat. The 
tendons of the ocular muscles pierce the capsule 
opposite the equator of the globe (Fig. 13). The 
lips of the openings through which the four recti 
pass are prolonged backwards upon the muscles, 
in the form of sheaths, very much as the infundi- 
buliform fascia is prolonged upon the cord from 
the internal abdominal ring." Where the internal 
and external recti perforate, strong expansions 
of the capsule spread out to the inner and outer 
wall of the orbit. Because these expansions limit 
the action of the two recti they are known as the 
check ligaments (Fig. 13). They allow a side-to- 
side movement of the cornea to the extent of 
about 45°. The external check ligament is the 
stronger, and is attached to the outer wall im- 
mediately behind the external tarsal ligament; 
the attachment of the internal ligament is close 
behind the lachrymal sac. A prolongation of the 
capsule passes to the trochlea round the tendon 
of the superior oblique. The suspensory ligament 
of the eyeball stretches across the orbit like a 
hammock, _ supporting the eyeball. It is really 
a thickening of the under part of the capsule 
of Tenon, its attachment to the orbital walls being 
made by means of the internal and external check 
ligaments. When the upper jaw is removed the 
surgeon should take care to preserve the attach- 
ments of the suspensory ligament. If these be 
destroyed the eyeball will sink downwards. 

The intimate relations of the capsule of Tenon 
to the eyeball, conjunctiva, orbital muscles, and 
orbital walls has to be kept in mind where opera- 
tions are undertaken to remedy squint. From 
Fig. 13, it will be seen that after the tendon of 
a rectus muscle is cut through as it lies within the 
capsule of Tenon, the muscle still possesses, 
through the continuity of its sheath with the cap- 
sule, an attachment to the eyeball and conjunc- 



52 SURGICAL APPLIED ANATOMY [Part I 

tiva as well as to the orbital wall by the check 
ligament. Hence when the tendon of a muscle is 
completely cut it can still act on the eyeball ; its 
complete retraction is prevented by the check 
ligament. 

The orbit behind Tenon's capsule is occupied 
by a large quantity of loose fat, in addition to 
the ocular muscles, vessels, and nerves. It is by 
the absorption of this fat that the sunken eye 
is produced in cases of emaciation and prolonged 
illness. This tissue affords a ready means for the 
spread of orbital abscess. Such an abscess may 
follow injuries, certain ocular inflammations, 
periostitis, etc., or may spread from adjacent 
parts. The pus may occupy the entire cavity, dis- 
placing the eyeball forwards, limiting its move- 
ments, and causing, by interference with the cir- 
culation, great redness of the conjunctiva and 
swelling of the lids. 

Foreign bodies, some of them of remarkable 
size and shape, have lodged for long periods of 
time in the orbital fat without causing much 
trouble. Thus Lawson reports a case where a 
piece of an iron hat-peg, three inches long, was 
embedded in the orbit for several days without the 
patient being aware of it. A stranger case, in 
some ways, is that reported by Furneaux Jordan : 
" A man who was employed in threshing became 
the subject of severe ophthalmia. At the expira- 
tion of several weeks, the patient, whilst pressing 
his finger on the lower eyelid, suddenly ejected 
from a comfortable bed of warm pus a grain of 
wheat, which had shot forth a vigorous green 
sprout." The orbital fat affords also an excellent 
nidus for growing tumours. Fractures of the 
inner wall of the orbit involving the nasal fossae 
or sinuses may lead to extensive emphysema of 
the orbital cellular tissue. The air so introduced 
may cause the globe to protrude, may limit its 
movements, may spread to the lids, and will, in 
any case, be increased in amount by blowing the 
nose, etc. 



Chap. IV] THE ORBIT AND EYE 53 

The orbital muscles. — The four recti muscles 
end in thin, flat membranous tendons. The ten- 
don of the external or internal rectus muscle is 
frequently divided for strabismus. The width of 
the tendons varies from 7 mm. to 9 mm. They 
are inserted into the sclerotic near the cornea. 
The internal rectus is inserted 6'5 mm. from the 
corneal margin, the external 6*8 mm., the inferior 
7*2 mm., and the superior 8 mm. (Merkel). 

While the internal and external recti are pure 
internal and external rotators of the eyeball, the 
superior and inferior recti, owing to the line in 
which they pull, act as internal as well as up- 
ward and downward rotators. Their tendency to 
act as internal rotators is counterbalanced by the 
two oblique muscles, which serve as external as 
well as upward and downward rotators. 

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

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



54 SUEGICAL APPLIED ANATOMY [Part I 

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

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

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

In paralysis of the sixth nerve there is 
convergent strabismus, with consequent diplopia, 



Chap. IV THE ORBIT AND EYE 55 

and an inability to rotate the eye directly out- 
wards. Paralysis of the sixth nerve may be ac- 
companied by paralysis of the nerve to the in- 
ternal rectus of the opposite side, giving rise to 
conjugate deviation of the eyes. Such a condi- 
tion indicates a lesion in the nucleus of the sixth 
nerve, for although the fibres for the internal 
rectus pass out with the third nerve they take 
their origin with the sixth. 

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

In paralysis of the first division of the fifth 
there is a loss of sensation in all the conjunctiva, 
except such as covers the lower lid (supplied by 
the palpebral branch of the infraorbital nerve), 
loss of sensation in the globe, and in skin sup- 
plied by the supratrochlear and supraorbital 
nerves, and in the mucous and cutaneous surfaces 
supplied by the nasal nerve. The area of anaes- 
thesia is much less than the anatomical distri- 
bution of the nerve, owing to the extent to which 
cutaneous nerves overlap. No reflex movements 
(winking) follow upon irritation of the conjunc- 
tiva, although the patient can be made to wink 
on exposing the eye to a strong light, the optic 
nerve in this case transmitting the impression to 
the facial nerve. Sneezing also cannot be ex- 
cited by irritating the mucous membrane in the 
anterior part of the nose. Destructive ulceration 
of the cornea may follow this paralysis, due 
partly to damage to the trophic branches con- 
tained in the paralysed nerve, partly _to the anaes- 
thesia which renders the part readily injured, and 
partly to the loss of the reflex effect of the sensory 
nerves upon the calibre of the blood-vessels, 
whereby the inflammation is permitted to go un- 
controlled (Nettleship). 

In paralysis of the cervical sympathetic 
there is narrowing of the palpebral fissure from 



56 SUKGICAL APPLIED ANATOMY [Part I 

some drooping of the upper lid, apparent reces- 
sion of the globe within the orbit, and some nar- 
rowing of the pupil from paralysis of the dilator 
muscle of the iris, which muscle is suppliedby the 
sympathetic. The drooping of the upper lid may 
be explained by the fact that each eyelid contains 
a layer of unstriated muscle fibre. That in the 
upper lid arises from the under surface of the 
levator palpebrse, and is attached to the tarsal 
cartilage near its upper margin (Fig. 16, p. 73). 
This layer of muscle, which, when in action, 
would keep up the lid, is under the influence of 
the cervical sympathetic. The recession of the 
globe is supposed by some to be due to paralysis 
of the orbitalis muscle of H. Miiller. This muscle 
bridges over the spheno-maxillary fissure, is com- 
posed of unstriated fibres, and is innervated by the 
sympathetic. Contraction of the muscle (as pro- 
duced by stimulation of the cervical sympathetic 
in animals) causes protrusion of the globe, while 
section of the sympathetic in the neck produces 
retraction of the eyeball (CI. Bernard). No 
changes are observed in the calibre of the blood- 
vessels of the globe. The non-striated muscle 
maintains the intraorbital pressure, and thus 
assists in the return of blood from. the ophthalmic 
veins. In animals such as the ox, in which the 
veins of the orbit become dilated when the head 
is carried low, as in browsing, this musculature 
attains a great development. 

The globe : the cornea. — The thickness of the 
cornea varies from "9 mm. in the central parts to 
ri mm. at the periphery. One is apt to be a 
little deceived as to its thickness, and on intro- 
ducing a knife into the cornea, the instrument, 
if not entered at the proper angle, may be thrust 
for some little distance among the laminse of the 
part. In front the cornea is covered by stratified 
epithelium. When this layer has been removed 
by abrasion, a white deposit of lead salts may 
take place in the exposed corneal tissue in cases 
whore lead lotions are used. The bulk of the 



Chap. IV] 



THE ORBIT AND EYE 



57 



cornea, is made up of a great number of fibrous 
lamella?, between which are anastomosing cell 
spaces containing the corneal corpuscles. If the 
nozzle of a fine syringe be thrust into the corneal 
tissue, the network of cell spaces can be filled 
with injection (Recklinghausen's canals). When 
suppuration takes place within the proper 
corneal tissue, it is probably along these canals, 




Fig. 14. — A horizontal section of the globe through the middle. 

a, Cornea ; b, sclerotic ; c, choroid ; <7, retina ; «, lens ; J\ iris : <j, ciliary process and 
muscle ; //, canal of Sclilrimn. 

modified by inflammation, that the pus spreads, 
thus producing onyx. The cornea contains no 
trace of blood-vessels, except at its extreme peri- 
phery, where the capillaries of the sclerotic and 
conjunctiva end in loops. This lack of a direct 
blood supply renders the cornea prone to inflame 
spontaneously in the cachectic and ill-nourished. 
When inflamed, the tissue always becomes opaque. 
In the affection known as interstitial keratitis, 
blood-vessels from the arteries at the margin of 
the cornea penetrate into the substance of the 



58 SUEGICAL APPLIED ANATOMY [Part I 

cornea for some distance. As these vessels are 
some little way below the surface, and are 
covered by the hazy corneal tissue that is the re- 
sult of the disease, their scarlet colour is much 
toned down, and a strand of such vessels is called 
a " salmon patch." In the condition known as 
pannus, the cornea appears to be vascularised ; 
but here, owing to continued irritation, vessels, 
derived from the neighbouring conjunctival 
arteries, pass over the cornea just beneath its 
epithelial covering, leaving the cornea proper as 
bloodless as ever. The term arcus senilis is ap- 
plied to two narrow white crescents that appear 
at the periphery of the cornea, just within its 
margin, in the aged, and in certain morbid con- 
ditions. The crescents are placed at the upper 
and lower margins, and their points meet midway 
on either side of the cornea. They are due to 
fatty degeneration of the corneal tissue, and the 
change is most marked in the layers of the cornea 
just beneath the anterior elastic lamina, i.e. in 
the part most influenced by the marginal blood- 
vessels. In spite of its lack of a direct blood 
supply, wounds of the cornea heal kindly. The 
cornea is very lavishly supplied with nerves, esti- 
mated to be from forty to forty-five in number. 
They are derived from the ciliary nerves, enter 
the cornea through the fore part of the sclerotic, 
and are distributed to every part of the tunic. 
In glaucoma, a disease of which the phenomena 
depend upon greatly increased intraocular pres- 
sure, the cornea becomes anaesthetic. This depends 
upon the pressure to which the ciliary nerves are 
exposed before their branches reach the cornea. 
(See also Nerve supply of the eyeball, p. 63.) 

The sclerotic, choroid and iris. — The sclerotic 
is thickest behind, and thinnest about \ of an 
inch from the cornea. When the globe is rup- 
tured by violence it is the sclerotic that most 
commonly yields, the rent being most usually a 
little way from the cornea, i.e. in or about the 
thinnest part of the tunic. A rupture of the 



Chap. IV] THE OEBIT AND EYE 59 

cornea alone from violence is not common. The 
sclerotic may be ruptured while the lax conjunc- 
tiva over it remains untorn. In such a case the 
lens may escape through the rent in the sclerotic, 
and be found under the conjunctiva. At the point 
of penetration of the optic nerve the sclerotic is 
thin, and pierced by numerous holes for the pas- 
sage of nerve bundles. This weakened portion, 
the lamina cribrosa, plays an important part in 
glaucoma (p. 70). It gives the stippled appear- 
ance to the optic papilla. Brailey states that 
the lateral parts of the sclerotic are thinner than 
the upper and lower segments, the inferior part 
being the thickest and the external wall the thin- 
nest. It happens, therefore, that under the influ- 
ence of intraocular pressure the eye expands more 
laterally than in the vertical direction. It is 
mainly to the denseness and unyielding character 
of the sclerotic that must be ascribed the severe 
pain (due to pressure on nerves) experienced in 
those eye affections associated with increased in- 
traocular tension (glaucoma, etc.). 

The choroid is the vascular tunic of the globe, 
and carries its mam blood-vessels. Between the 
choroid and sclerotic are two thin membranes, the 
lamina suprachoroidea and lamina fusca, which 
are separated from one another by a lymph 
space. In injuries to the globe, therefore, ex- 
tensive bleeding may take place between these two 
coats, and indeed a like haemorrhage may be the 
result simply of a sudden diminution in the 
ocular tension produced by such an operation as 
iridectomy or cataract extraction. The choroid 
alone has been ruptured (usually at its posterior 
part) as the result of a blow upon the front of 
the eye. The choroid is one of the few parts of 
the body that may be the seat of melanotic 
growths. These growths are sarcomatous tumours 
containing a large amount of pigment, and occur 
only where pigment cells are found. In the 
choroid coat pigment cells are very abundant. 

The iris is, from its great vascularity, very 



60 SURGICAL APPLIED ANATOMY [Part I 

easily inflamed. From its relations to the cornea 
and sclerotic it happens that inflammation in those 
tunics can spread without difficulty to the iris. 
On the other hand, the vessels of the iris and 
choroid are so intimately related that inflamma- 
tions set up in the iris itself have every induce- 
ment to spread to the choroidal tunic. When the 
iris is inflamed its colour becomes altered, owing 
to the congestion of the part and to the effusion of 
lymph and serum that takes place in its substance. 
The swelling to which it becomes subject, together 
with the effusion, produce a blurring of its delicate 
reticulated structure, as seen through the cornea. 
Owing also to the swollen condition of the little 
membrane, the pupil becomes encroached on, 
and appears to be contracted, while the move- 
ments of the membrane are necessarily rendered 
very sluggish. If it be remembered that the greater 
part of the posterior surface of the iris is in actual 
contact with the lens capsule, it will be understood 
that inflammatory adhesions may readily take 
place between the two parts (Fig. 14). After iritis, 
therefore, it is common to find the posterior sur- 
face of the iris (most often its pupillary margin) 
adherent to the lens capsule by bands of lymph, 
either entirely or in one or more different points. 
Such adhesions constitute posterior synechise, the 
term anterior synechise being applied to adhesions 
between the iris and the cornea. In iritis also 
the lens may become involved, and the con- 
dition of secondary or inflammatory cataract be 
produced. 

The iris is not very closely attached at its inser- 
tion. Thus, in case of injury to the eye, it may be 
torn more or less from its attachments without any 
damage being done to the other tunics. The iris 
has been completely torn away in a few instances, 
and has escaped through a wound of the globe. 
The ciliary processes have been thus exposed. 
Congenital absence of the iris has been recorded. 
In cases of penetrating wounds of the cornea the 
iris is easily prolapsed. It is so delicate and yield- 



Chap. IV] THE ORBIT AND EYE 61 

ing a membrane that in performing iridectomy the 
necessary piece of the iris can be seized and pulled 
out through the corneal incision without offering 
sensible resistance. The membrane also derives 
much support from its contact with the lens, for 
in cases where the lens has been displaced into the 
vitreous, or has been removed by operation, the 
iris is observed to be tremulous when the globe is 
moved. Although very vascular, the iris seldom 
bleeds much when cut, a circumstance that is pro- 
bably due to the contraction of the muscular fibres 
that exist so plentifully within it. Sometimes the 
iris presents in its substance a congenital gap that 
runs from the pupil downwards and a little in- 
wards. This condition is known as coloboma iridis, 
and is due to the persistence of the " choroidal 
cleft." In other cases there can be seen, stretch- 
ing across the pupil, some shreds of the pupillary 
membrane. Normally this membrane, which is ap- 
parent for a few days after birth in some animals, 
is entirely absorbed before birth. 

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

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

2. The two long ciliary arteries (from the 
ophthalmic) pierce the sclerotic to the outer side 
of the optic nerve and run forwards, one on either 
side, until they reach the ciliary region, where they 
break up into branches that, by anastomosing, 
form a vascular circle about the periphery of the 
iris (the circulus major). From this circle some 



62 SUEGMCAL APPLIED ANATOMY [Part I 

branches pass to the ciliary muscle, while the rest 
run in the iris in a converging manner towards the 
pupil, and at the margin of the pupil form a 
second circle (the circulus minor). 

3. The anterior ciliary arteries (from the mus- 
cular and lachrymal branches of the ophthalmic) 
pierce the sclerotic (perforating branches) ^ about 
2-3 mm. behind the cornea, join the m circulus 
major, and give off branches to the ciliary pro- 
cesses, where they form copious anastomosing 
loops. These arteries lie in the subconjunctival 
tissue. Their episcleral or non-perforating branches 
are very small and numerous, and are invisible 
in the normal state of the eye. In inflammation 
of the iris and adjacent parts, however, these ves- 
sels appear as a narrow pink zone of fine vessels 
round the margin of *bhe cornea, that run nearly 
parallel to one another, are very closely set, and 
do not move with the conjunctiva. This zone is 
known as the zone of ciliary congestion, or the cir- 
cumcorneal zone. 

4. The vessels of the conjunctiva are derived 
from the lachrymal and the two palpebral arteries. 
These vessels, in cases of inflammation, are readily 
distinguished from thoselast described. They are 
of comparatively large size, are tortuous, are of a 
bright brick-red colour, can be easily moved with 
the conjunctiva, and as easily emptied of their 
blood by pressure. The differences presented by 
thesetwo sets of vessels serve in one way to dis- 
tinguish inflammation of the conjunctiva from that 
involving deeper parts. The conjunctival vessels 
around the margin of the cornea form a closer 
plexus of anastomosing capillary loops, which be- 
come congested in severe superficial inflammation 
of the cornea, and may then form a zone around 
the margin of the cornea, which can, however, be 
distinguished from the " ciliary zone " by the 
general characters just named. The retina has a 
vascular system^ of its own, supplied through the 
arteria centralis retinae, which is nowhere in 
direct communication with the choroidal vessels, 



Chap. IV] THE ORBIT AND EYE 63 

except just at the entrance of the optic nerve. 
Indeed, the outer layers of the retina which are in 
relation with the choroid coat are entirely destitute 
of vessels. Thus, when the central artery of the 
retina becomes plugged, sudden blindness follows, 
and as the meagre collateral circulation that is 
established by the minute anastomoses about the 
entrance of the nerve is quite insufficient, the re- 
tina soon becomes oedematous. A permanent plug- 
ging of the central artery means, therefore, a prac- 
tical extinction of the vascular system of the re- 
tina. In some cases of embolism only a branch of 
the retinal artery is plugged, the patient retaining 
vision except in that par,t of the retina supplied 
by the branch. The fovea centralis, the centre of 
acute vision, receives twigs from both the superior 
and inferior temporal branches of the arteria 
centralis retinae. 

In cases of haemorrhage between the choroid 
and retina the blood must come from the choroidal 
vessels ; and in haemorrhage into the vitreous, 
which often follows injury, the blood may be de- 
rived from the retinal vessels, since they run in the 
inner layers of that membrane, or from the vessels 
in the ciliary region. 

Nerve supply of the eyeball. — 1. The 
ciliary nerves derived from the lenticular ganglion 
and the nasal nerve pierce the sclerotic close to the 
optic nerve, and pass forwards between the sclero- 
tic and the choroid, supplying those parts. They 
enter the ciliary muscle, form a plexus about the 
periphery of the iris, and then send fibres into 
the iris, which form a fine plexus as far as 
the pupil. They send branches through the fore 
part of the sclerotic to the cornea. Thus the eye- 
ball obtains through these nerves its sensory fibres 
from the nasal branch of the first division of the 
fifth, its motor fibres for the ciliary muscle and 
sphincter iridis from the third nerve, and many 
sympathetic fibres, among which are those that 
supply the dilator muscle of the iris. 

2. The conjunctiva is supplied by four nerves : 



64 SURGICAL APPLIED ANATOMY [Part I 

above, the supratrochlear ; inner side, the inf ra- 
trochlear ; outer side, the lachrymal (all branches 
of the first division of the fifth) ; below, the palpe- 
bral branches of the second division of the fifth. 
As the ciliary nerves pass forwards between the 
choroid and the sclerotic, it will be seen that they 
are readily exposed to injurious pressure against 
the unyielding sclerotic in cases of increased intra- 
ocular tension. 

The sensation of the globe itself is derived solely 
from the first division of the fifth. In inflammatory 
affections of the globe, as in corneitis or iritis, be- 
sides the pain actually felt in the eye, there is 
pain referred along other branches of the first divi- 
sion of the fifth. The explanation of this fact has 
to be sought for in the common origin of the 
ophthalmic division from the upper sensory 
nucleus of the fifth nerve in the floor of the fourth 
ventricle. Not only are the nerve cells^ connected 
with the eyeball disturbed, but the neighbouring 
cells also are affected, and by a psychical error 
the pain is reflected along the nerves with which 
they are connected. There is pain over the fore- 
head along the supratrochlear, supraorbital, and 
lachrymal branches (circumorbital pain), and 
pain down the side of the nose following 
the nasal nerve. Or the pain may spread to 
the second division of the fifth, and discom- 
fort be felt in the temporal region (orbital 
branch of second division), or be referred to 
the upper jaw and teeth. These affections are 
associated also with much lachrymation, the 
lachrymal gland being also supplied through the 
first division of the fifth. Photophobia, or intoler- 
ance of light, is common in inflammatory affec- 
tions of the eye. In this condition there is spasm 
of the orbicular muscle, keeping the eye closed, 
or closing it on the least exposure to irritation. 
Although the orbicular muscle is supplied by the 
facial nerve, its nerve fibres are derived, not from 
the nucleus of the seventh but from the oculo- 
motor nucleus, situated near the upper sensory 



Chap. IV] THE ORBIT AND EYE 65 

nucleus of the fifth, and connected with it by 
reflex paths. Photophobia is most marked in 
superficial affections of the cornea, and is often 
much benefited by a seton in the temporal region. 
Inflammation of the iris and glaucoma are accom- 
panied by hyperesthesia and referred pains over 
the outer frontal and anterior temporal areas 
(Head). The nerve centres for the skin of this 
region and the eyeball are closely connected, a 
relationship which may explain the application 
of counter-irritation to the temples in eye disease. 
Inflammation of the cornea gives rise to no 
referred pains (Head). Strain of the ciliary 
muscle, which occurs with errors of refraction, is 
one of the commonest causes of headache leading 
to referred pains and areas of hyperesthesia over 
the mid-orbital region of the forehead. 

The relations between the nasal nerve and the 
orbital contents receive many illustrations in prac- 
tice. Thus, if the front of the nose be struck, or the 
skin over its lower part be irritated, as by squeez- 
ing a painful boil, profuse lachrymation will 
frequently be produced. Snuff, too, by stimulating 
the nasal branch of the ophthalmic nerve, often 
makes the eyes of the uninitiated to water ; and 
it is well known that there are many disturb- 
ances about the nose, and the anterior part of the 
nasal fossse, that can " make the eyes water." 
Herpes zoster often provides a remarkable illus- 
tration of the intimate relation between the nasal 
nerve and the eye. In this affection, when the 
regions of the supraorbital and supratrochlear 
branches of the first division are alone implicated, 
the eye is usually unaffected; but when the erup- 
tion extends over the part supplied by the nasal 
nerve, _ i.e. runs down the side of the nose, then 
there is very commonly some inflammation of the 
eyeball. In frontal neuralgia watering of the eye 
(irritation of the lachrymal branch) is very fre- 
quently met with. 

The dangerous area of the eye. — Penetrat- 
ing wounds of the cornea alone, or of the sclerotic 
F 



66 SURGICAL APPLIED ANATOMY [Part I 

alone, behind the ciliary region, are by no means 
serious : but wounds involving the ciliary body, 
or its immediate vicinity, are apt to assume the 
gravest characters. Inflammation in the ciliary 
region is peculiarly obnoxious, on account of the 
important vascular and nerve anastomoses that 
take place in the part. Indeed, as regards blood 
and nerve supply, there is no more important 
district in the eyeball. From the ciliary body 
also inflammations can spread, more or less 
directly, to the cornea, iris, choroid, vitreous, and 
retina. Plastic, or purulent, inflammation of the 
ciliary- body, after injury, is the usual starting 
point of sympathetic ophthalmia. In this terri- 
ble affection destructive inflammation is set up in 
the sound eye, which is, however, not usually 
involved until two or three months after the other 
eye has been injured. " Although at present the 
exact nature of the process which causes sym- 
pathetic inflammation is unknown, and though 
its path has not been fully traced out, it is cer- 
tain (1) that the change starts from the region 
most richly supplied by branches of the ciliary 
nerves, viz. the ciliary body and iris ; (2) that its 
first effects are generally seen in the same part of 
the sympathising eye ; (3) that the exciting eye has 
nearly always been wounded, and in its anterior 
part, and that decided plastic inflammation of its 
uveal tract is always present ; (4) that inflamma- 
tory changes have in some cases been found in the 
ciliary nerves and optic nerve of the exciting 
eye " (Nettleship). It is now generally believed 
that the sound eye is directly infected from the 
diseased one. The subarachnoid spaces which sur- 
round the optic nerves are in continuity at the 
chiasma, and offer a path whereby infection may 
spread from one eye to the other. 

The lens measures ^ of an inch from side to 
side, and \ of an inch from before backwards. 
All through life it slowly increases in size. It, 
together with its capsule, is in all parts perfectly 
transparent and perfectly non-vascular. The lens 



Chap. IV] THE ORBIT AND EYE 67 

may easily be loosened or displaced by partial 
rupture of its suspensory ligament, and may find 
its way into the anterior chamber, or, more com- 
monly, back into the vitreous. The lens, if dis- 
turbed, may swell, and by the pressure thus exer- 
cised cause great damage to the important struc- 
tures adjacent to it. The capsule is very brittle 
and elastic, and when torn its edges curl out- 
wards. It has to be lacerated in all cataract 
operations, and may be ruptured by many forms 
of violence applied to the eyeball. When the 
capsule is wounded the aqueous humour enters, 
and is imbibed by the lens fibres, which in conse- 
quence swell up and become opaque, thus produc- 
ing a traumatic cataract. In the various forms of 
cataract the whole lens, or, more commonly, some 
portion of it, becomes the seat of opacity. This 
often commences in the nucleus, and for a long 
while remains limited to that part; or it may first 
involve the cortex, and in such a case the opacity 
takes the form of a series of streaks that point to- 
wards the axis of the lens, and are dependent upon 
the arrangement of the lens fibres. " In so-called 
' concussion cataract,' where after a blow on the 
eye a part of the lens becomes opaque, it appears 
probable that the capsule has been very slightly 
torn opposite to the opacity " (Lawford). 

Of the retina it is only necessary to observe 
that its connection with the choroid is so slight, 
that it may easily be detached from that mem- 
brane by hsemorrhagic or other effusions, and may 
indeed be so detached by a simple blow upon the 
globe. Even when extensively detached it remains, 
however, as a rule, attached at both the optic disc 
and the ora serrata. The optic nerve as it passes 
from the brain receives its perineural sheath from 
the pia mater, and, in addition, two other sheaths : 
an outer from the dura mater, and an inner from 
the arachnoid. These sheaths remain distinct and 
separate, and the two spaces enclosed may be in- 
jected, the outer from the subdural, the inner from 
the subarachnoid space. Thus inflammatory affec- 



68 



SUEGMCAL APPLIED ANATOMY [Part I 



tions of the cerebral meninges can readily extend 
along the optic nerve to the optic disc through 
these spaces in the nerve sheath, while in cases of 
intracranial disease other than meningeal the 
mischief may extend from the brain to the disc 
along the interstitial connective tissue in the nerve. 




Fig. 15. — Section of globe, showing iris, lens, ciliary region, etc. 
(After Allen Thomson.) 

a, Cornea; b, sclerotic; c, lens; d, iris; e, ciliary process ; /, conjunctiva; fir, cana 
of Schlerain ; h, canal of Petit ; i, hyaloid membrane ; j, choroid covered by 
retina ; k, aqueous chamber. 



These connections may serve in part to explain the 
frequent association of optic neuritis with intra- 
cranial disease. Optic neuritis usually implies that 
the optic disc or papilla is inflamed, but in excep- 
tional cases the changes are limited to that part of 
the nerve behind the globe (retrobulbar neuritis). 
The length of the optic nerve within the orbit is 
28 to 29 mm. 



Chap. IV] THE ORBIT AND EYE 69 

The aqueous and vitreous humours. — 

The aqueous fills the space between the capsule 
and suspensory ligament of the lens and the cornea. 
The iris divides this space into two parts, the an- 
terior and posterior chambers. Since, however, the 
iris is largely in actual contact with the lens, it 
happens that the posterior chamber is repre- 
sented by a little angular interval between the 
iris, the ciliary processes, and the suspensory 
ligament of the lens (Fig. 15). The depth of 
the anterior chamber is 3'6 mm. The cornea 
at its circumference breaks up into bundles of 
fibres, which are partly continued into the front of 
the iris, and which constitute the ligamentum pec- 
tinatum iridis. Between the processes of this liga- 
ment there are intervals which lead into certain 
cavernous spaces called the spaces of Fontana. 
These spaces in their turn communicate with a 
large circular canal situate in the sclerotic close 
to its junction with the cornea, and known as the 
canal of Schlemm (Fig. 15, g). This space is in 
communication with the veins of the anterior part 
of the sclerotic, and thus through this somewhat 
complicated channel the aqueous chamber is 
brought into relation with the venous circulation 
This relation probably explains the ready absorp- 
tive powers of the aqueous. Thus, if pus finds its 
way into the anterior chamber (hypopyon) it is 
usually readily absorbed. The same applies to 
moderate extravasations of blood in the chamber, 
and the speedy removal of such effusions contrasts 
with the difficulty that is experienced in the absorp- 
tion of blood from the vitreous chamber. The 
treatment of soft cataracts by the " needle opera- 
tion " depends for its success upon the absorptive 
powers of the aqueous. In this procedure, the lens 
capsule having been torn through, and the cataract 
hrokenup with needles, the removal of the opaque 
debris is left to the aqueous, and it is not long be- 
fore its efficacy in that direction is seen. 

The vitreous takes little active share in 
ocular maladies. It may be secondarily affected in 



70 SUEGICAL APPLIED ANATOMY [Part I 

inflammation of adjacent parts, may be the seat of 
haemorrhages, and is often occupied by opaque 
bodies of various kinds. Foreign bodies have lodged 
in the vitreous for considerable periods without 
causing any symptoms. The muscse voHtantes that 
so often trouble the myopic are due to little opaque 
matters in the vitreous, and very often have exactly 
the appearance that the corpuscles of the vitreous 
present when seen under the microscope. 

The delicate transparent membrane which en- 
capsules the vitreous humour is known as the 
hyaloid membrane. The vitreous is readily separ- 
ated from the . retina except behind, opposite the 
disc where the artery to the lens enters in the 
foetus. 

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

Glaucoma is a disease the symptoms of which 
are all dependent upon an increase in the intraocu- 
lar tension of the globe. The increased tension is 
due to an excess of fluid within the eyeball, and 
this would appear to result from certain changes, 
seldom absent in the glaucomatous, that interfere 
with the normal escape of this fluid. Normally 
there is a constant movement of fluid through the 
pupil from the posterior to the anterior chamber. 
This fluid is derived mainly from the ciliary bodies, 
and in a less degree from the posterior surface of 
the iris. Atrophy of the epithelium on the ciliary 
body is said to lead to diminished tension^ From 
the anterior chamber the fluid can escape into the 
veins through the gaps in the ligamentum pectin- 
atum already alluded to (Fig. 15). It is remark- 
able that in nearly every case of glaucoma these 
gaps are occluded by the < complete obliteration of 
the angle between the periphery of the iris and the 
cornea, which angle is normally occupied by the 
ligamentum pectinatum. The importance of the 
peripheral part of the anterior chamber in relation 



Chap. IV] THE ORBIT AND EYE 71 

to the outflow of fluid from the eye is shown in 
many ways. If this part be blocked by the iris in 
perforation of the cornea, or by the lens in some 
dislocations of that body, increased tension of the 
globe is apt to follow. The relief given to glaucoma 
by iridectomy appears to depend upon the circum- 
stance that the operation practically opens up 
again these channels of communication from the 
aqueous, since the procedure, to be successful, 
should involve an incision so far back on the sclero- 
tic as to fully pass through the angle just alluded 
to. It is needful also that the iris should be re- 
moved quite up to its attachment, and that the 
portion resected should be considerable. 

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

The eyelids. — The skin over the eyelids is ex- 
tremely thin and delicate, and shows readily 
through its substance any extravasation of blood 
that may form beneath it. Its laxity, moreover, 
renders it very well adapted for certain plastic 



72 SURGICAL APPLIED ANATOMY [Part I 

operations that are performed upon the part. Its 
loose attachments cause it to be readily influenced 
by traction, and the shrinking of cicatrices below 
the lower lid is very apt to draw that fold away 
from the globe, and so produce the condition of 
eversion of the lid known as ectropion. The con- 
traction of the conjunctiva after inflammatory con- 
ditions, or after it has been subjected to destructive 
agencies, is prone, on the other hand, to curl either 
lid inwards towards the globe, and thus to produce 
entropion. Tlie lids present many^ transverse 
folds ; one of these on the upper lid, deeper and 
more marked than the rest, divides the lid into 
two parts, the part below being that which covers 
the globe, the part above being that in relation 
with the soft structures of the orbit. In emacia- 
tion the lid becomes much sunken in the line of 
this fold. Incisions should follow the direction of 
these folds. The lids are very freely supplied with 
blood, and are often the seat of nsevi and other vas- 
cular growths. ^ Rodent ulcer so frequently attacks 
this part that it was originally known as " Jacob's 
ulcer of the eyelid." 

The following layers are found in either lid in 
order : (1) the skin; (2) the subcutaneous tissue; 
(3) the orbicularis palpebrarum; (4) the tarsal 
plate and its continuation to the margin of the or- 
bit- r the < palpebral membrane; (5) the layer of 
Meibomian glands embedded in the plate ; and (6) 
the conjunctiva. In the upper lid the levator pal- 
pebrse is found passing to the tarsal plate. The 
subcutaneous tissue is very lax, and hence the lids 
swell greatly when oedematous, or when inflamed, 
and when the seat of haemorrhage. On this ac- 
count it is inadvisable to apply leeches to the lids, 
because of the extensive black eye" that may 
follow. This tissue is peculiar in containing no 
fat. At the edge of the lids are found the eye- 
lashes, the orifices of the Meibomian glands, and 
of some modified sweat and sebaceous glands. The 
secretion of these glands prevents adhesion of the 
edges of the lid. This edge, like other points of 



Chap. IV] 



THE ORBIT AND EYE 



73 



junction of skin and mucous membrane, is apt to 
be the seat of irritative affections. Being a free 
border also, the circu- 



l 



lation is terminal, and 
stagnation in the 
blood current is not 
difficult to produce. 
Sycosis, an inflamma- 
tion involving the hair 
follicles and some of 
the glands at the edge 
of the lid, is among 
the most common of 
ophthalmic affections. 
The common stye also 
is a suppuration in 
the connective tissue 
or in one of the glands 
at the margin. On 
everting the lid the 
Meibomian glands can 
be seen through the 
conj unctiva as lines 
of yellowish granules. 
The common tarsal 
cyst is a retention 
cyst developed in one 
of these glands. 

Two arteries sup- 
ply either lid : a pal- 
pebral branch of the 

Ophthalmic running Fig 1 . 16.— Vertical section through upper 

along the inner part, e y elid - ( After Waideyer.) 

nnrJ a hy^-nnh r»f +V10 «. Skin ; b, orbicularis ; ¥, its ciliary part : 

d/iiu. a, ui dutu UJ. i/iie c, involuntary muscle of eyelid repre- 

lachrymal along the senting part of the insertion of the 

, a . P R ,. , levator palpebrse; d, conjunctiva; e, 

OUter part OI each lid. tarsal cartilage ; /, Meibomian gland; 

F„. „ „ i a, modified sweat gland ; /(, eyelashes 

OUr nerves Supply v,' P ost-tarsalglands 

the upper eyelid, the 

supraorbital, the supratrochlear and infratroch- 
lear, and the lachrymal. One nerve supplies the 
lower lid, the infraorbital. Some of the lymph- 
atics of the eyelids enter the preauricular glands, 




74 SURGICAL APPLIED ANATOMY [Part I 

hence in cases of chancre of the lid the glandular 
enlargement has nearly always been noticed in 
front of the parotid gland (Fig. 35, p. 190). 

The conjunctiva. — The ocular Dart of this 
membrane is thin, covered with stratified epithe- 
lium very loosely attached, and not very exten- 
sively supplied with blood; the palpebral portion 
is thicker, covered with columnar epithelium more 
closely adherent, and more vascular. At the edge 
of the cornea the conjunctiva becomes continuous 
with the epithelium covering that tunic. The loose- 
ness of the ocular conjunctiva allows it to be freely 
moved about, and is of great value in some opera- 
tions, as, for example, in Teale's operation for 
symblepharon, where a bridge of conjunctiva, dis- 
sected up from the globe above the cornea, is drawn 
down over the cornea to cover a raw surface in con- 
tact with the lower lid. This lax tissue favours the 
development of oedema (chemosis), which in ex- 
treme cases may reach such a degree that the 
patient cannot close his eye. The vessels also, 
being feebly supported, are prone to give way 
under no great provocation. Thus, subconjunc- 
tival haemorrhages may occur from severe vomit- 
ing, or during a paroxysm of whooping cough. 
Blood also may find its way beneath the membrane 
in fractures of the base of the skull. Haemorrhages 
beneath the membrane are unlike other extravasa- 
tions (bruises), in that they retain their scarlet 
colour. This is due to the fact that the thinness 
of the conjunctiva allows oxygen to reach the blood 
and retain for it an arterial character. Severe 
inflammation of the conjunctiva^ may lead to con- 
siderable cicatricial changes, as is the case in other 
mucous membranes, and especially, perhaps, in 
the urethra. The contraction of the conjunctiva 
after destructive processes is apt to lead to en- 
tropion. If both the ocular and the corresponding 
part of the palpebral conjunctiva have been de- 
stroyed, the two raw surfaces left will readily ad- 
here ; the lid will become fused to the globe, and 
the condition called symblepharon be produced. 



Chap. IV] THE OEBIT AND EYE 75 

This condition concerns the lower lid, and is gener- 
ally brought about by lime or other caustics being 
accidentally introduced between the under lid 
and the globe. 

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

The lachrymal apparatus. — The lachry- 
mal gland is invested by a special fascia which 
separates it from the general cavity of the orbit; 
and, according to Tillaux, this little body can be 
removed without opening the greater space of the 
orbit. The gland may inflame, and become so en- 
larged as to appear as a tumour, which may dis- 
place the globe downwards and inwards, and press 
forwards the oculo-palpebral fold of conjunctiva. 
If an abscess forms, it most usually breaks through 
the skin of the upper lad. Cystis of the gland 
(dacryops) are due to obstruction and distension 
of some of its ducts. The normal secretion of the 
gland keeps the exposed surface of the eye moist, 
yet the gland may be excised without giving rise 
to any untoward effect. 

The lachrymal sac is situated at theside of the 
nose, near the inner canthus, and lies in a groove 
on the lachrymal and superior maxillary bones 



7fi 



SUEGICAL APPLIED ANATOMY [Part t 



(Fig. 17). On its outer side, and a little anteriorly, 
it receives the two lachrymal canaliculi. In front 
of the sac is the tendo oculi. If the two lids be 
forcibly drawn outwards this tendon can be readily 
felt and seen, and serves as a guide to the sac. It 




Lacm. Gland 
Plica Semiluaj. 
/^asioai 
Canaliculus 

1/mt. Tarsal Lie. 
Lac/i. 5ac 

/IasalDuct 



A1P /TEATUS 



Fig. 17. — Diagram of the lachrymal apparatus. 
The arrow points to the first molar tooth, showing the direction of the nasal duct 

can also be felt as it is tightened, when the lids are 
firmly closed. It crosses the sac at right angles, 
and at about the junction of its upper third with 
its lower two-thirds. A knife entered immediately 
below the tendon would about open the middle of 
the sac, and it may be noted that a lachrymal 
abscess, when about to discharge, always points 



Chap. IV] THE ORBIT AND EYE 77 

below the tendon. Epiphora, or overflow of tears, 
is due in the main to two causes : (1) to an obstruc- 
tion in any part of the lachrymal passages from the 
puncta to the opening of the nasal duct in the 
nose; (2) to any cause that removes the lower 
punctum from its contact with the globe, as may be 
the case in ectropion, in entropion, in swelling of 
the lower lid, etc. Facial palsy causes epiphora, 
because, the orbicular muscle being relaxed, the 
punctum falls away from the globe, and, more- 
over, the passage of the tears is no longer aided 
by the suction action effected by the muscle in the 
process of winking. The canaliculi may readily be 
slit up by a proper knife, and a probe can without 
difficulty be passed down the nasal duct from the 
lachrymal sac. 

The nasal duet is a little over £ an inch in 
length, and the probe that traverses it should pass 
downwards, and a little backwards and outwards, 
in the direction of the first molar tooth (Fig. 17). 
The nasal duct perforates the mucous membrane of 
the nose below the inferior turbinate process very 
obliquely, so that its inner wall acts as a valve. If 
this is destroyed by ulceration, as sometimes oc- 
curs in syphilis, the lachrymal sac may be inflated 
by blowing the nose. The bony nasal duct has a 
calibre which varies from 2*5 to 7*5 mm. in dia- 
meter ; the thick mucous membrane which lines 
it has a rich venous plexus in its submucous layer 
which readily swells and prevents the passage of 
tears when the duct is inflamed. The normal duct 
will take a probe measuring 35 mm. in diameter ; 
it must be remembered that the lumen of the duct 
is normally closed, and that its lining membrane 
possesses several transverse folds which may catch 
the point of a probe. Inflammatory conditions 
readily ascend from the nasal cavity to the lachry- 
mal sac through the nasal duct. 

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



CHAPTER V 
THE EAE 

The pinna, and external auditory meatus. 

— The pinna may be congenitally absent, or may 
be supplemented by supernumerary portions of the 
auricle, which may be situated upon the cheek or 
side of the neck. In the latter situation the so- 
called supernumerary auricle consists in an irregu- 
lar leaf of fibro-cartilage developed from the mar- 
gins of one of the lower branchial clefts. (See 
p. 193.) The tag-like supernumerary auricles that 
are found on the cheek just in front of the pinna 
or meatus are due to the irregular development or 
want of fusion of one or more of the six tubercles 
from which the pinna itself is developed. The pinna 
may present a congenital fistula dependent on a 
defective closure of the first branchial cleft. The 
position of this cleft is represented in the normal 
ear by the Eustachian tube, the tympanum, and 
the external auditory meatus, the pinna being 
developed from the integument bordering the cleft. 
In these congenital fistulse, when well marked, the 
pinna is cleft above or below the meatus. Some 
of the smaller and more superficial fistulse are due 
not to a defective closure of the branchial cleft but 
to want of complete fusion between certain of the 
tubercles from which the pinna is primarily de- 
veloped. Accidental removal of the pinna is 
usually associated with but comparatively little 
diminution in the acuteness pi hearing. 

The skin covering the auricle is thin and closely 

78 



Chap. V] THE EAR 79 

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

The external auditory meatus is about 
1| inches long. It is important to remember that 
the meatus is directed forwards as well as inwards ; 
to reach and expose the middle ear the surgeon 
takes the posterior wall of the meatus as a guide. 
The external meatus, the promontory, the cochlea, 
and the internal meatus lie nearly in the same line. 
The canal has a vertical curve about its middle, 
with the convexity upwards. To straighten the 
canal for the introduction of specula and other in- 
struments, the pinna should be drawn upwards and 
a little outwards and backwards. The osseous part 
forms a little more than one-half of the tube, and is 
narrower than the cartilaginous part. 

In the infant at one year, a third only of the 
meatus is formed of bone. The rest is cartilagin- 
ous. In a child of five or six years of age the bony 
and cartilaginous portions of the meatus are about 
of the same length (Symington). The meatus is re- 
latively as long in a child as it is in an adult. The 
narrowest portion of the meatus is about its mid- 
dle. The outer orifice is elliptical, with its great- 
est diameter directed from above downwards ; 
therefore specula should be elliptical in shape 
rather than round. The inner end of the tube, on 
the other hand, is slightly wider in the transverse 
direction. Owing to the obliquity of the mem- 
brana tympani, the floor of the meatus is longer 
than the roof. The cartilaginous segment of the 
tube presents many sebaceous glands that may be 
the seat of minute and very painful abscesses. It 
also presents numerous ceruminous glands, which 
secrete the cerumen of the ear, and which, when 



80 SUEGMCAL APPLIED ANATOMY [Part I 

their secretion is excessive, may produce the plugs 
of wax that often block the meatus and cause deaf- 
ness. In the cartilage of the floor of the meatus 
are certain fissures, fissures of Santorini. They are 
filled up with fibrous tissue. They permit of easier 
movement of the cartilaginous meatus. It is 
through these gaps in the cartilage that a parotid 
abscess may burst into the meatus. There are 
neither hairs nor glands in the lining of the bony 
part of the tube. 

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

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



Chap. V] THE EAR 81 

chin. Tillaux states that abscess in the parotid 
gland may spread into the meatus through the an- 
terior wall of the passage. The posterior wall separ- 
ates the meatus from the mastoid cells. Directly 
behind the posterior wall, at a distance of 12 or 15 
mm., is the lateral sinus (Fig. 20). The inferior 
wall of the bony meatus is very dense and substan- 
tial, and corresponds to the vaginal and styloid 
processes. 

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

Nerve supply. — The pinna is supplied by 
the auriculotemporal, great auricular and small 
occipital nerves (see Fig. 4, p. 15). Arnold's nerve, 
the auricular branch of the vagus, sends a twig to 
the back of the concha, near the mastoid process. 
The meatus is supplied mainly by the auriculo- 
temporal, with, in addition, a contribution from 
Arnold's nerve, which goes to the lower and back 
part of the canal, not far from its commencement. 
Arnold's nerve has been credited with a good deal 
in connection with the nerve relations of the ear. 
After a heavy dinner, when the rose-water comes 
round, it is common to see the more experienced 
of the diners touch the lower part of the back of 
the ear with the moistened serviette. This is said 
to be very refreshing, and is supposed to be an 
unconscious stimulation of Arnold's nerve, a nerve 

G 



82 SURGICAL APPLIED ANATOMY [Part I 

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

Ear coughing, ear sneezing, ear yawning. 

— It is not uncommon to have a troublesome dry 
cough associated with some mischief in. the 
meatus. Sometimes the mere introduction of a 
speculum will make the patient cough. A case 
is reported, where a troublesome cough persisted 
for eighteen months, and at once ceased on the re- 
moval of a plug of wax from the ear. In such cases 
the irritation is conveyed to the respiratory and 
cough centres in the floor of the fourth ventricle by 
Arnold's nerve, a small branch of the vagus. Gas- 
kell has shown that the vagus also contains the dis- 
associated visceral fibres of the fifth nerve. Hence, 
disturbances may be set up in the vagal nuclei 
through branches of the fifth nerve, such as the 
auriculo-temporal. The connection of the nerves 
of the external auditory meatus with the vagal 
nuclei also explains the sneezing or vomiting which 
is sometimes caused by the presence 'of foreign 
bodies in the external meatus. The same nerve 
connection also explains the occurrence of repeated 
yawning, sometimes set up by ear ailments. Irrita- 
tion conveyed along the inferior dental or lingual 
nerves may be referred along the auriculo-tem- 
poral. Hence the need to examine the tongue and 
lower teeth in cases of earache. Head has pointed 
out that disease of the ear, the tonsil, the tongue 
or the lower jaw may be associated with an area 
of tenderness in the skin along and below the jaw. 

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



Chap. V] THE EAR 83 

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

Membra na tympani. — This membrane is very 
obliquely placed, forming with the horizontal an 
angle of 45°. At birth it appears to be more nearly 



Fig. IS. — Section through the external meatus, middle ear, and Eustachian 

tube. (Tillaux.) 

a, External auditory meatus ; 5, attic of tympanum ; c, Eustachian tube ; 
d, internal auditory meatus; e, cochlea; /, ossicles; g, membrana tympani;- 
ft, styloid process. 

horizontal, although it is not really so. In cretins, 
and in some idiots, it is said to retain this apparent 
inclination. Owing to the sloping downwards of 
the bony wall of the meatus at its inner end, that 
wall forms with the lower edge of the membrane 
a kind of sinus in which small foreign bodies 



84 SURGICAL APPLIED ANATOMY [Part I 

may readily lodge (Fig. 18). The ring of bone to 
which the membrane is attached is deficient at its 
upper and anterior part. The gap so formed is 
called the notch of Rivini, and is occupied by loose 
connective tissue, covered by a continuation of the 
lining of the meatus, and through it pus may es- 
cape from the middle ear into the auditory canal 
without perforating the membrane. When the 
membrane gives way owing to a violent concussion 
transmitted through the air, it often gives way 
opposite the notch, its attachments here being ob- 
viously less secure than elsewhere. The membrane 
possesses but little elasticity, as shown by the very 
slight gaping of the part after it has been wounded. 
It is for this reason, among others, that perfora- 
tions made in the membrane by the surgeon heal 
so very rapidly. The membrane has been ruptured 
during tits of sneezing, coughing, vomiting, etc. 
The same lesion has followed a box on the ear, and 
even simple concussions such as that produced by 
a loud report. 

The umbo, or deepest point of the depression in 
the diaphragm, is just below the centre of the en- 
tire membrane, and corresponds to the attachment 
of the end of the handle of the malleus. The rest of 
the handle can be seen through the membrane dur- 
ing life. The head of the malleus is in no connec- 
tion with the membrane, being situated in the 
attic of the tympanum above the level of the mem- 
brane (Fig. 18). The segment of the membrane 
above the umbo is very freely supplied by vessels 
and nerves ; it corresponds to the handle of the 
malleus, and to the chain of ossicles, and is oppo- 
site to the promontory and the two fenestrse. The 
chorda tympani nerve also runs across this 
supraumbilical portion. The segment below the 
umbo, on the other hand, corresponds to no very 
important parts, and is less vascular and less sen- 
sitive. Paracentesis of the tympanum through the 
membrana tympani should therefore always be per- 
formed in the subumbilical segment. If performed 
above the umbo the knife may strike the incus and 



Ohap. V] THE EAE 85 

loosen that bone from its frail attachments, or 
the chorda tympani be cut, which would give rise 
to a paralytic secretion of saliva. The malleus 
and stapes are too firmly attached to be readily 
detached. 

The membrane is supplied by the stylo-mastoid 
artery and the tympanic branch of the internal 
maxillary, and obtains its nerve supply from the 
auriculo-temporal and vagus. 

A/1TRUM 

Ext.5emiCIRC.Ca/sal 
Vli^flERVE 
AUDITUS 

Fenestra Ovalis 
Tec mem Tympani 
Processus Cocm. 



PrOMO/STORY ^v^-v. ' 

PyRAMID V v" - S \ 

Fenestra Rotunda i \ \ 
/Mastoid Process 



Fig. 19. — The inner wall of tympanum and antrum. 

The position of the external semicircular canal and course of the facial nerve 

(vii.) are shown. 

The tympanum. — The width of the tympanic 
cavity, as measured from its inner to its outer wall, 
varies from 2 to 4 mm., poth to ^th of an inch. The 
narrowest part is that between the umbo of the 
membrana and the promontory. A fine rod thrust 
through the centre of the membrana tympani would 
hit the promontory of the inner wall of the cavity. 
Above the promontory is the fenestra ovalis, and 
below and behind it the fenestra rotunda (Fig. 19). 
Skirting the upper and posterior margin of the 
inner wall of the tympanum is the aqueduct of 




86 SURGICAL APPLIED ANATOMY [Part I 

Fallopius, containing the facial nerve. The wall of 
the aqueduct is so thin that inflammatory mischief 
can readily extend from the middle ear to the facial 
nerve. The upper wall is very thin, and but little 
bone separates it from the cranial cavitv. The 
suture between the squamous and petrous bones is 
found in this wall, and by means of the sutural 
membrane that separates the bones in the young, 
inflammatory changes may readily spread from the 



CJA/^ EATAL Tai A/MQ LE- 
UPRAMEATAL SPme 




Facial /Iebve 



Fig. 20. — Showing the position and relationships of the various parts of 
the middle ear. (See also Fig. 3, p. 12.) 

tympanum to the meninges. The petro-squamous 
suture unites at the end of the first year and usually 
contains the petro-squamous vein, a remnant of 
the primitive jugular. The floor is very narrow. Its 
lowest part is below the level of both the mem- 
brana tympani and the orifice of the Eustachian 
tube, and hence pus may readily collect in this 
locality (Fig. 20). It is separated by a thin piece 
of bone from the internal jugular vein behind, and 
from the internal carotid artery in front. Fatal 
haemorrhage from the latter vessel has occurred in 



Chap. V] THE EAE 87 

connection with destructive changes in this part of 
the ear. The posterior- wall in its upper part pre- 
sents the opening or auditus of the antrum of the 
mastoid. The antrum opens into the attic — that 
part of the tympanic cavity which is situated above 
the level of the membrana tympani (Fig. 20). 

The antrum of the mastoid (Figs. 19, 
20) lies above and behind the external auditory 
meatus. Implication of this space and of the mas- 
toidal cells, which open into it and surround it, 
forms one of the most serious complications of 
middle ear disease. It is large enough to contain 
a small bean, and is present at birth (Fig. 21), being 
developed with the cavity of the tympanum. It is 
closely surrounded by important structures. Its 
roof, formed by the tegmen tympani, a plate of 
bone only 2 mm. thick, separates it from the third 
temporal convolution. Small veins perforate the 
roof to join the petro-squamous vein, in the rem- 
nant of the suture of the same name. In the infant 
the communication is even more free, for this 
suture does not close until the end of the first year. 
The facial nerve passes downwards on its inner 
wall, where the antrum opens into the attic, and 
behind the facial nerve, also on the inner wall, is 
the external semicircular canal (Fig. 19). Facial 
paralysis or giddiness may follow operations on the 
antrum if the inner wall is injured. The superior 
and posterior borders of the meatus indicate the 
position of the facial nerve (Fig. 20) ; on the inner 
wall of the antrum, the nerve is situated 14 to 22 
mm. deep to the suprameatal triangle (Joyce). 
The antrum is separated behind from the lateral 
sinus and cerebellum by a plate of bone which 
varies in thickness from 3 mm. to 6 mm. The 
temporo-sphenoidal lobe, the lateral sinus, and 
the cerebellum are the common seats of secondary 
infection in cases of middle ear disease. At the 
mouth of the antrum and in the attic of the tym- 
panum are situated the incus, the head of the 
malleus and their ligaments, structures which 
may be diseased and require removal. 



88 



SUEGICAL APPLIED ANATOMY [Part I 



At birth the outer wall of the antrum is formed 
by the postmeatal process of the squamosal, a 
plate of bone 2 mm. thick (Fig. 21). In the child the 
antrum is comparatively superficial, and pus may 
easily escape or be evacuated. The suture between 
the postmeatal part of the squamosal and the 
petro-mastoid disappears in the second year of life 
and so shuts off a possible route that pus may take 
to reach the surface (Fig. 21). The outer wall of 
the antrum steadily increases in thickness until 

Squamosal 
Antrum 
Attic 



Post. I/nf. Fontanelle 




A/it Imp. Fo^tamelle 



Squamo/Iastoi 

5UTURE 

/iASToiD / T'TyAiPA/HicRinc; 

Drum 
stylomastoid forame/h 

Fig. 21. — The temporal bone at birth. 

The position of the antrum and attic is indicated. The squamo-niastoid suture is 
open and the mastoid process undeveloped. 



adult life, when the depth of the cavity from the 
surface of the bone is found to vary in different in- 
dividuals from 12 to 22 mm., about 16 mm. being 
its average depth. A shallow triangle {see Fig. 20) 
above and behind the meatus lies directly over the 
antrum and serves as a guide to its position. It 
may also be reached by following the junction of 
the posterior wall and roof of the external auditory 
meatus. The drill is entered 5 mm. behind the 
meatus and on a level with its upper margin. Its 
roof lies 5 mm. above the level of the meatus. The 
posterior auricular artery passes upwards behind 



Ohap. V] THE EAR 89 

the meatus, beneath the concha of the auricle, and 
lies within the field of any operation on the middle 
ear. 

The mastoid cells develop with the growth of 
the mastoid process, which appears as a definitely 
marked structure in the second year. Besides the 
antrum there are also some cells present even at 
birth (Young). Three varieties of the mastoid pro- 
cess are recognised, each of which is about equally 
common : (1) those in which the cells are large and 
communicate with each other and with the antrum, 
(2) those in which the central cells are large and 
communicate with the antrum, while the peripheral 
are small and closed, (3) those in which all the 
spaces are small and closed. The cells surround 
the antrum, and may pass backwards to the masto- 
occipital suture, forwards to the suprameatal 
region, upwards to the masto-parietal suture, and 
downwards to the apex of the mastoid. Inflamma- 
tory conditions may lead to a thickening of the 
walls of the mastoidal cells, and the bone may be- 
come so dense as almost to resist the chisel. Veins 
drain into the periosteum of the mastoid from the 
more superficial cells, and by these inflammation 
may reach the surface and give rise to oedema and 
swelling behind the ear. 

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

On the anterior wall of the tympanum is the 
opening of the Eustachian tube (Figs. 18 and 19). 
This tube is If inch long, and by opening into the 
pharynx serves to keep a proper supply of air in 
the tympanum, and so equalise the pressure upon 
•the two sides of the membrane. The floor of the 



90 SURGICAL APPLIED ANATOMY [Part I 

tympanum is below the level of the outer opening of 
the Eustachian tube. The line of direction of the 
tube lies almost exactly midway between the trans- 
verse and antero-posterior axes of the base of the 
skull. In the adult it inclines downwards, so as to 
form an angle of 40° with the horizontal. In the 
child this angle is only 10° (Symington). In adults 
fths of the tube is cartilaginous and Jth bony 
(Symington). On the outer side of the tube lie the 
tensor palati, the third division of the fifth nerve, 
and the middle meningeal artery. On the inner 
side are the retropharyngeal tissue and (quite pos- 
teriorly) the internal carotid artery. The pharyn- 
geal orifice of the tube is usually shut. During 
swallowing, however, it is opened by the action 
mainly of the tensor palati muscle. If the nose and 
mouth be closed and the cheeks blown out, a sense 
of pressure is produced in both ears. The hearing, 
at the same time, is dulled, and the change is due 
to the bulging out of the membrana tympani by the 
air thus forced into the tympanum. • This method 
of inflating the middle ear is known as Valsalva's 
method. 

In "Politzer's method" of passing air into the 
Eustachian tube, the patient's mouth is closed, 
while into one nostril the nozzle of a caoutchouc 
bag filled with air is introduced, and the nostrils 
are then held firmly closed. The patient is asked to 
swallow a mouthful of water, while at the same 
moment the bag is forcibly emptied, and the air, 
having no other means for escape, is thus driven 
into the open Eustachian tube. The surgeon listens 
for the little noise caused by the entrance of the 
air by means of a tube that passes between the 
patient's meatus and his own. Prolonged closure 
of the Eustachian tube leads to deafness, and thus 
impairment of hearing may follow upon great 
thickening of the mucous membrane of the tube due 
to the extension of inflammatory mischief from the 
pharynx. In the deafness associated with enlarged 
tonsils and postnasal growths, the hypertrophic 
change extends to the mucous lining of the tube, 



Chap. V] THE EAR 91 

and in the cases of many pharyngeal growths and 
nasal polypi, the orifice of the tube is mechanically 
obstructed. The near relation of the pharyngeal 
end of the tube to the posterior nares serves to 
explain a case where suppuration in the mastoid 
cells followed upon plugging of the nares for 
epistaxis. Infection may be carried up to the 
middle ear by means of the ciliated lining of the 
Eustachian tube; C. J. Bond found that indigo 
particles, which had been blown within the naso- 
pharynx, in a case of perforation of the drum, ap- 
peared afterwards in a discharge from the external 
meatus. 

The upper edge of the pharyngeal orifice of the 
tube is about \ an inch below the basilar process, 
\ an inch in front of the posterior wall of the 
pharynx, \ an inch behind the posterior end of 
the inferior turbinate bone, and \ an inch above 
the soft palate (Tillaux). In the foetus the orifice 
is below the hard palate; at birth on the same 
level. The form of the opening is that of a 
triangle. The opening of the tube is effected by 
the tensor palati, levator palati, and salpingo- 
pharyngeus. 

Just behind the elevation formed at the orifice 
of the Eustachian tube there is a depression in the 
wall of the pharynx, the lateral recess or fossa 
of Rosenmuller (Fig. 22, p. 101). It may be mis- 
taken for the orifice of the tube, and may readily 
engage the point of a Eustachian catheter. In 
cases in which the pharyngeal tonsil (Luscha's 
tonsil) is enlarged, this fossa on either side may 
be greatly deepened and made to form a narrow 
diverticulum. {See p. 153.) To^ pass the Eus- 
tachian catheter, the instrument is carried along 
the floor of the nares with its concavity down- 
wards, " until its point can be felt to drop over 
the posterior edge of the hard palate into the 
pharynx. The instrument should now be with- 
drawn until its point can be felt to rise again on 
the posterior edge of the hard palate ; having 
arrived at this point, the catheter should be 



92 SUEGICAL APPLIED ANATOMY [Part 1 

pushed onwards about 1 inch, and during its 
passage its point should be rotated outwards 
through a quarter of a circle. ' ; This manoeuvre 
should engage it on the orifice of the tube. 

Blood supply.— The tympanum is supplied by 
the following arteries : The tympanic of the in- 
ternal maxillary and internal carotid, the petro- 
sal of the middle meningeal, and the stylo-mastoid 
of the posterior auricular. The fact that some of 
the tympanic veins end in the superior petrosal 
and lateral sinuses gives another explanation of 
the frequent occurrence of thromboses of those 
channels in inflammatory affections of the middle 
ear. The petro-squamous vein, which crosses the 
roof of the middle ear, also receives branches 
from the antrum and attic and joins the lateral 
sinus behind and the meningeal veins in front 
(Cheatle). 

The lymphatics of the middle ear follow two 
routes. The majority pass along the wall of the 
Eustachian tube and end in the retropharyngeal 
lymphatic gland. Others reach the postauricular 
group of glands, situated over the mastoid process, 
by passing out beneath the lining membrane of 
the meatus and by other efferent channels which 
accompany the veins escaping by the superficial 
openings seen on the mastoid part of the temporal. 

The chorda tympani nerve, from its exposed 
position in the tympanum, is very likely to be 
damaged in suppurative disease of the middle 
ear ; and Urbantschitsch and Schulte have shown 
that such disease in this part may be associated 
with anomalies of taste. 

The osseous labyrinth is formed independ- 
ently of the other bony parts of the ear. Portions 
of this labyrinth have necrosed and have been 
expelled in recognisable fragments. In a case 
recorded by Dr. Barr the whole of the osseous 
labyrinth (the cochlea, vestibule, and semicircular 
canals) was removed entire as a necrosed frag- 
ment from the auditory meatus. Suppuration of 
the middle ear may spread to the inner ear, either 



Chap. V] THE EAR 93 

through the fenestra ovalis, in which the foot 
plate of the stapes is fixed by the strong annular 
membrane, or by the fenestra rotunda, which is 
closed by the membrana secundaria. From the 
inner ear the suppurative process may extend in- 
wards along the auditory nerve and meatus, thus 
reaching the large subarachnoid spaces at the base 
of the brain. 



CHAPTER VI. 

THE NOSE AND NASAL CAVITIES 

1. The nose. — The skin over the root, and the 
greater part of the dorsum, of the nose, is thin 
and lax. Over the alse, however, it is thick, very 
adherent to the deeper parts, and plentifully 
supplied with sebaceous and sweat glands. In- 
flammation of the integuments over the cartilagin- 
ous portion of the nose is apt to be very painful, 
and to be associated with much vascular engorge- 
ment. The pain depends upon the tenseness of the 
part, which prevents it from swelling without pro- 
ducing much pressure upon the nerves, while the 
engorgement depends upon the free blood supply 
of the region, and the fact that the edge of the 
nostril being a free border, the circulation there 
is terminal, and apt therefore to favour con- 
gestion. 

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

The integument of the nose is very well sup- 
plied with blood, and for this reason the part is 

n 



Chap. VI] NOSE AND NASAL CAVITIES 95 

well suited for the many plastic operations that 
are performed upon it. Wounds in this region 
heal kindly, and even the extensive wound made 
along the line between the nose and the cheek in 
removal of the upper jaw leaves very little de- 
formity. In many reported cases portions of the 
nose have been entirely severed, and have united 
to the face on being immediately re-applied. 

The skin over the root of the nose is supplied 
by the nasal branch of the first division of the 
fifth; as is also the skin over the alse and in 
the region of the nostril (Fig. 4, p. 15). The 
greater part of the side of the nose is supplied by 
the second division of the fifth, and is the seat of 
pain in neuralgia of that trunk. The fact that 
the nasal nerve is a branch of the ophthalmic 
trunk, and has intimate connections with the eye, 
serves to explain the lachrymation that often 
follows painful affections about the nostril, as, 
for example, when the edge of the nostril is 
pinched. 

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

The nasal bones are oftsn broken by direct 
violence. The fracture is most common through 
the lower third of the bones, where they are thin- 
nest and least supported. It is rarest in the 



96 SURGICAL APPLIED ANATOMY [Part I 

upper third, where the bones are thick and firmly 
held, and where, indeed, considerable force is 
required to produce a fracture. Since no muscles 
act upon the ossa nasi, any displacement that 
occurs is due solely to the direction of the force. 
Union takes place after these fractures with 
greater rapidity than perhaps obtains after frac- 
ture of any other bone in the body. In one case 
Vioted by Hamilton, " the fragments were quite 
firmly united on the seventh day." If the mucous 
membrane of the nose be torn, these fractures are 
a,pt to be associated with^ emphysema of the sub- 
cutaneous tissue, which is greatly increased on 
blowing the nose. The air in such cases is de- 
rived, of course, from the nasal fossae. In frac- 
tures of the upper third of the ossa nasi the 
cribriform plate may be broken, but it is ques- 
tionable whether this complication can occur 
when the fracture is limited to the lower third 
of the bones. The root of thp n nsft is a, favourite 
' pla.ce for meningoceles and e nce phaln r.pl ps, thp. 
protrusion escaping through the sutures between 
the nasal and frontal bones. Such protrusions^ 
when occurring in this place, are often covered 
by a thin and vascular integument, and have been 
mistaken for nsevoid growths. 

2. The nasal cavities.— The anterior nares 
have somewhat the shape of the heart on a play- 
ing card, and the aperture as a whole measures 
about.. 1| inches vertically, and a little less than 
Lj inches transversely, at its widest part. The 
plane of the nostril is a little below that of the 
floor of the nares. To examine the nasal cavities, 
therefore, the head should be thrown back, and 
the nose drawn upwards. The anterior nares can 
be well explored by the finger introduced into the 
nostril, and the nasal apertures are just so wide 
on each side of the septum as to allow the finger 
to be passed far enough back to reach another 
finger introduced into the posterior nares through 
the mouth. An effectual way of removing soft 
polypi in the adult is by tearing them away by 



Chap. VI] NOSE AND NASAL CAVITIES 97 

two fingers so introduced. The operation is a 
little rough. By the most gentle introduction of 
the finger into the nostril it is often possible to 
feel the end of the inferior turbinated bone. The 
anterior nares, and front of the nasal cavities, 
can be well explored by Rouge's operation. In 
this procedure the upper lip is everted, and a 
transverse cut made through* the mucous mem- 
brane into the soft parts that connect the upper 
lip with the upper jaw. The incision extends be- 
tween the second bicuspid teeth of either side. 
The soft parts connecting the upper lip and nose 
to the bone are divided without damaging the* 
skin, and the flap is dissected up until the nares 
are sufficiently exposed. 

The posterior nares. — If a little mirror, 
somewhat similar to that used in laryngoscopy, 
be cautiously introduced behind the soft palate 
through the mouth, and illumined from the mouth 
the following parts may, under favourable cir 
cumstances, be seen : the posterior nares, the sep- 
tum, the middle turbinated bone, part of the 
superior and inferior turbinated bones, and pari 
of the inferior meatus. The middle meatus is well 
seen, and also the Eustachian tube, and the 
mucous membrane of the upper part of the 
pharynx. 

This mode of examina tion is very riiffinii]f. fro 
carfyou t , and is known as poster i or rh inoscopy 
The parts just named can all be felt by the finger 
introduced behind the soft palate through the 
mouth. The posterior nares are often plugged to 
arrest severe bleeding from the nose, and in order 
to cut a proper sized plug it is desirable to bear 
in mind the dimensions of the apertures. Each 
aperture is of regular shape, and measures about 
ij an inch transversely by 1^ inch in the vertical 
direction in a well-developed adult skull. 

As regards the nasal cavities generally, it is 
well to note that the floor is wider at the centre 
than at either end, that the vertical diameter is 
greater than the transverse, and is also greatest 

H 



98 SURGICAL APPLIED ANATOMY [Part 1 

about the centre of the fossae. Forceps introduced 
into the nose, therefore, are most conveniently 
opened if opened vertically. The width of the 
fossae increases somewhat from above downwards ; 
thus the superior turbinated bone is only 2 mm. 
from the septum, while a space of from 4 to 
5 mm. intervenes between the inferior turbinated 
bone and the septum. _ The nasal cavity is so very 
narrow above the middle turbinated bone that 
that bone really forms the surgical roof of the 
nasal fossae. 

The shape and proportions of the nasal 
cavity in the child are peculiar. In the adult 
the inferior meatus is large, and constitutes the 
chief respiratory passage; in the young child 
the inferior meatus is relatively^ very small, the 
middle meatus affording the main space^ for the 
respiratory tide (Lack). The nasal cavities grow 
rapidly from the sixth to the eighteenth year ; 
during this period the permanent dentition is be- 
ing formed, necessarily causing an increase in the 
size of the palate and of the floor of the nose ; at 
the same time the development of the antrum of the 
maxilla leads to an increase in the vertical height 
of the nose, this increase affecting the lower or 
maxillary much more than the ethmoidal or olfac- 
tory part of the cavity. Growth of the nasa l 
rajntips a.nrl of thp fa,f»Pi ma.v hp Tr ra stp.d or vit i- 
ated bv an y obst ruction to thp. fr ^p p? ggg g a " f + ha 
hrpath through thp. nosp. ; thp. most r.omrno n r.a.-ns p 
Qf-obstruGtio n is the form ation of jaxlgnoids in \hf 
naao-pharynx. 

From a reference to the relations of the nasal 
fossae (Fig. 22) it will be understood that inflam- 
mation of the lining membrane (coryza) may ex- 
tend to the pharynx vid^ the posterior nares ; may 
extend up the Eustachian tube and cause some 
deafness ; may reach the lachrymal sac and con- 
junctiva through the nasal duct; and may extend 
to the frontal sinuses and the antrum, producing 
frontal headache and cheekache. These relation- 
ships are often demonstrated in a severe " cold 



Chap. VI] NOSE AND NASAL CAVITIES 99 

in the head." From the nearness of the nasal 
fossae to the cranial cavity it happens that menin- 
gitis has followed upon purulent inflammations of 
the nose. Foreign bodies of various kinds are 
often lodged in the nose, and may remain there 
for some years. Thus Tillaux reports the case oi 
an old woman, aged 64, from whose nose he re 
moved a cherry stone that had been there foi 
twenty years. 

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

The roof of each nasal fossa is very narrow, 
being only about ^ of an inch in width. It is 
mainly formed by the thin cribriform plate, but 
its width is such that the danger of the roof being 
penetrated by so large a substance as a pair of 
polyp forceps has been greatly exaggerated. The 
cranial cavity has, however, been opened up 
through the roof of the nose by penetrating bodies 
introduced both by accident and with homicidal 
intent. Meningitis has followed inflammation nf 

the nasal fos g^ the — inflammation extending 

through the cribriform plate. Through the peri - 
neural and perivascular sheaths the ^ lymphatic 

sy stern" of the nose is in rrmtinnity with that ni 

th e menin ges, and by these channels infection s 
may spread from the roof of the nose to the mem- 
branes of the brain . Fracture of this part also 
has been associated with very copious escape of 
cerebro-spinal fluid through the nostrils. A men- 
ingocele may protrude through the nasal roof. 
In a case reported by Lichtenberg the mass hung 



100 SURGICAL APPLIED ANATOMY [Part I 

from the mouth, having passed through a congeni- 
tal fissure in the palate. It was mistaken for a 
polyp, was ligatured, and death resulted from 
intracranial inflammation. 

The_ sgptmii is seldom qu ite — straight in 

adults; the deviation hm ng more nft.pn inwards 

the left . It is, however, straight in children, 
and remains so up to the seventh year. In adults 
the septum deviates in 76 per cent, of all persons. 
The deviation may follow an injury. It has been 
pointed out that a deviation of the septum may 
seriously interfere with the singing voice. The 
nose also is seldom quite straight, and French 
authors ascribe this to some deviation of the sep- 
tum, often dependent upon the practice of always 
blowing the nose with the same hand. If the 
deviation of the septum be considerable, it may 
more or less block one nostril, and, until the oppo- 
site nostril is examined, be mistaken for a septal 
tumour encroaching upon the cavity. The flat- 
tened nose in acquired syphilis is usually due 
to destruction of the septum and more or less 
implication of the adjacent bones. Workmen ex- 
posed to the vapour of bichromate of potash are 
liable to a peculiar perforation of the septum 
known as " bichromate disease." 

Outer wall (Fig. 22). — The inferior turbin- 
ated bone may interfere with the introduction of 
a Eustachian catheter if the curve of the instru- 
ment be too great. The anterior end of the bone 
is about | of an inch behind the orifice of the 
nostril. The opening of the nasal duct is about 
1 inch behind the orifice of the nostril, and about 
| of an inch above the nasal floor. This opening 
is usually slit-like and narrow. The nasal duct 
pierces the nasal mucous membrane in the same 
oblique and valvular manner as the ureter enters 
the bladder. The height of the inferior meatus is 
about | of an inch. The superior meatus is a 
very short and narrow fissure, and into its upper 
and fore part open the posterior ethmoidal cells. 
The middle meatus opens widely in front upon a 



Chap. VI] NOSE AND NASAL CAVITIES 



101 



part of the outer wall called the atrium, and 
unless care be taken to keep the point of any in- 
strument well towards the floor of the fossa, it 
is easier to pass the instrument into the middle 
than into the inferior meatus. Upon the wall of 
the middle meatus is a deep gutter (the hiatus 
semilunaris), which runs from above downwards 
and backwards (Fig. 22). Into this groove open 




aey Fossa 
oidal Sinus 



ey/scEAL Tonsil 

Lateral Recess 

Eustachian Tube 
Eustachian Cus/iion 
Atlas 



Soft Palate 



Fig. 22. — The outer wall of the nasal cavity. 

Tne greater part of the middle turbinate process lias been cut away to expose the 
hiatus, bulla and openings, a, b, indicate the two positions at which the 
opening of the antrum may occur. 

the infundibulum (the aperture of the frontal 
sinus), the anterior ethmoidal cells, and, near its 
posterior end, the antrum. The rounded aperture 
of the frontal sinus is usually situated in the 
anterior end of the hiatus, but not unfrequently 
it will be found in a recess above and in front of 
the hiatus. The anterior ethmoidal cells, usually 
two in number, may open into the hiatus, the 
infundibulum, or directly into the anterior part 
of the middle meatus. The opening of the antrum 



102 SURGICAL APPLIED ANATOMY [Part 1 

may occur below, instead of within, the posterior 
part of the hiatus semilunaris (Fig. 22). The 
upper boundary of the hiatus is formed by the 
bulla ethmoidalis ; its lower sharp prominent 
margin contains the uncinate process of the eth- 
moid. The middle ethmoidal cell is seen to open 
on the bulla, above the hiatus semilunaris. . The 
level of the hiatus within the nose may be indi- 
cated by the position of the internal tarsal liga- 
ment. The anterior end or beak of the middle 
turbinate process can be seen distinctly from the 
anterior nares, when the interior of the nose is 
illuminated by reflected light. 

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

The mucous membrane lining the nasal cavi- 
ties is covered by ciliated epithelium over the 
lower two-thirds or respiratory part; the upper- 
third — the olfactory part — is covered by columnar 
epithelium, while the vestibule is lined by strati- 
fied epithelium- It is very thick and vascular 
over the turbinate bones and over the lower 
two-thirds of the septum, while over the nasal 
floor and in the intervals between the turbinate 
bones it is very much thinner. The mucous 
membrane lining the various sinuses and the 
antrum is conspicuously thin and pale. The 
membrane is provided with many glands, which 
are most conspicuous over the lower and hinder 
parts of the outer wall and over the posterior 
and inferior parts of the septum. These glands 
may be the subject of considerable hypertrophy. 
They are capable of providing also a very copious 
watery secretion, which has in some cases of 
chronic coryza following injury been so free as 
to be mistaken for an escape of cerebro-spinal 



Chap. VI] NOSE ANt) NASAL CAVITIES 103 

fluid. There is also much adenoid, or lym- 
phoid, tissue in the nasal mucous membrane, 
which is the primary seat of the chief scrofulous 
affections thaj|invade this part. Sn think and lax 

JS f^ T " inv TTJTy niUCOUS Tn pr "hrnnp ovpt thi? Inwpr 

border and posterior extremity of the inferio r 
turbinnted bones that it forms a kind of soft 

p_TT3hinn J gnmptjrnpg na.Ued thp " fvnrbina tphodv. ' ' 

This condition is mainly due to the presence of a 
rich submucous venous plexus, the vessels of which 
run, for the most part, in an antero-posterior 
direction. "When turgid with blood it swells so 
as to obliterate the interval between the bone and 
the septum. When the seat of chronic inflam- 
mation, the mucous membrane over the inferior! 
bone may appear as a polypoid swelling. 

Polypi are often met with in the nose. They 
are of two kind s, the mucnus or myxo Tngfniiq 
polyp that springs usually from the mucous mem- 
brane beneath or over the middle turbinate, and 
thp fibrou s or Karno rnaf nii s — polyp that usually 
takes origin from the periosteum of the nasal 
roof or from that of the base of the- skull. Polypi 
of the latter kind spread in every available direc- 
tion. They expand the bridge of the nose, close 
the nasal duct and cause epiphora, depress the 
hard palate and encroach upon the mouth, in- 
vade the antrum and expand the cheek, grow 
down into the pharynx, pushing forwards the 
velum palati, and may penetrate even through the 
inner wall of the orbit. Such tumours may be 
exposed and removed by separating the posterior 
and inner attachments of the superior maxilla, 
turning it forwards, thus exposing the nasal 
cavity by detaching its outer wall. The bone may 
be replaced in situ after removal of the tumour 
(F. S. Eve). 

The blood supply of the nasal cavity is ex- 
tensive, and is derived from the internal maxil - 
lary ophthalmi a, and facial arteries . With 
regard to the veins, it may be noted that the 
^ethmoidal veins that come from the nose enter the 



104 SURGICAL APPLIED ANATOMY [Part I 

ophthalmic vein, while in children a constant com - 
munication exists between the nasal veins and the 
superior longitudinal sinus through the foramen 
csecum . This communication mayg^Jso be main- 
tained in the adult, These connexions may, in 
part, serve to explain the occurrence of intra- 
cranial mischief as a consequence of certain in- 
flammatory affections of the nasal cavities. 
Bleeding from the nose, or epistaxis, is a common 
and often a serious circumstance. Its frequency 
is to a great extent due to the vascularity of the 
mucous membrane, to its laxity, and to the fact 
that the veins, especially those over the lowest 
turbinate bone, form extensive plexuses, and pro- 
duce a kind of cavernous tissue. The epistaxis is 
often due, therefore, to interference with the 
venous circulation, as seen in cases of cervical 
tumour pressing upon the great veins, in the 
paroxysms of whooping cough, and the like. The 
beneficial effect of raising the arms in epistaxis 
is supposed to depend upon the extra expansion 
of the thorax thus produced, and the aspiratory 
effect thus brought to bear upon the cervical veins. 
The bleeding may be copious and long continued. 
Thus Spencer Watson reports a case where tlie 
epistaxis continued on and off for twenty months 
without obvious cause. Martineau mentions an 
instance in which 12 lb. of blood was lost in sixty 
hours, and Fraenkel records a case where 75 lb. 
of blood is said to have escaped from first to 
last. In several instances the haemorrhage has 
proved fatal. The seat of the bleeding is often 
not easy to detect, even when the examination is , 
post mortem. In many cases the bleeding point 
is situated on the septum, | an inch above and 
behind the nasal spine. 

The nerve supply of these parts is derived 
from the olfactor y nerve, and frorn" tjie first arid 
second divisions of the fifth nerve. The lachryma- 
tion that often follows the introduction of irri- 
tants into the front of the nares may be explained 
by the fact that that part of the cavity is sup- 



Chap. VI] NOSE AND NASAL CAVITIES 105 

plied freely by the nasal nerve, a branch of the 
ophthalmic trunk. As an example of transfer- 
ence of nerve force in the opposite direction may 
be noted cases where a strong sunlight falling 
upon the eyes has produced an attack of sneez- 
ing. Troubles involving the vagal centres, such 
as cough and bronchial asthma, have followed 
affections of the nasal cavities. The olfactory 
nerves are situated in the upper third of the 
cavity, and thus, in smelling intently, the indi- 
vidual sniffs deeply and dilates the nostril. The 
inability to dilate the nostril in facial paralysis 
may explain "the partial loss of smell sometimes 
noted in such cases . It is said (Althaus) that 
ajiosjiinsia, or loss of the sense of smell, when 
following upon an injury to the head, may be due 
to a rupture of the olfactory nerve fibres as they 
pass through the cribriform foramina. The olfac- 
tory roots cross the edge of the lesser wings of the 
sphenoid, and in falls on the forehead are liable 
to injury. The olfactory centre is situated in the 
hippocampal gyrus . 

Most of the lymphatics of the nasal fosses 
enter the retropharyngeal glands placed behind 
the pharynx, in front of the rectus capitis anticus 
major. Hence, as Fraenkel has pointed out, 
" retropharyngeal abscess may arise in conse- 
quence of diseases of the nose/' Other lympha- 
tics go to the submaxillary, parotid, and upper 
deep cervical lymph glands, and it is common to 
find these enlarged in nose affections, especially in 
the scrofulous. The lymphatics of the nose also 
communicate with those of the meninges through 
the cribriform plate. 

The nasal sinuses. — Of late years a know- 
ledge of the anatomy and relationships of the ac- 
cessory sinuses of the nose has become of the 
utmost importance to the surgeon. Over 15 per 
cent, of the subjects examined in the dissecting 
room of the London Hospital show disease of one 
or more of these sinuses ; St. Clair Thomson, quot- 
ing from German statistics, estimates that the 



106 



SUKGICAL APPLIED ANATOMY [Part I 



sphenoidal sinus is the seat of disease in 30 per 
cent, of individuals — probably an overstatement. 
The collective capacity of the accessory sinuses — 
the maxillary, frontal, sphenoidal, and ethmoidal 
— is more than twice that of the nasal cavity 
(Braune). 




Frontal SiauS 



AIasioa 



I/sfu/ndibulum 
Lacai.Sac 

AllD.TUfcBI/IATE- 

aIasal Duct 

ANTRUM 

1/iF- TuRBI/iAT& 



Fig. 23.— Surface markings of the frontal and maxillary sinuses. 

a, lj" above nasion ; b, on the supraorbital margin, at the junction of the middle 
and outer thirds; C, on the infraorbital margin to the outer side of the 
lachrymal sac ; d, on the centre of the cheek bone in line with the outer 
margin of the orbit ; e, over the second bicuspid ; r, over the last molar. The 
points a, b and Nasion give the surface position of the frontal sinus ; c, n, e 
f, that of the maxillary sinus 

The frontal sinus is extremely variable in 
size and shape. The surface markings shown in 
Fig. 23 indicate the average development in the 
adult ; the_ opening of i ts duct or infnrirlihnlnm 
is shown in Fig. 22. Large frontal sinuses do 
not necessarily imply large external prominences 



Chap. VI] NOSE AND NASAL CAVITIES 107 

over the glabella and superciliary eminences. One 
sinus may develop at the expense of the other, and 
the septum may be displaced. They are larger in 
men than in women. They are absent on one side 
in 9 per cent, of cases, and on both sides in 7 per 
cent. (Logan Turner). Bonv tumours o ftpn grow 
from the interior of these sinuses, and ar p known 
as. pn^st^s a s It is obvious that a depressed frac- 
ure may exist over a frontal sinus without the 
cranial cavity being damaged. In such cases the 
inspissated contents of the sinus have been mis- 
taken for brain matter escaping. Since the 
sinuses communicate with the nose, much emphy- 
sema may follow upon fracture of the sinus wall. 
Insects have found their way into these cavities. 
" Centipedes are particularly liable to be found 
in the frontal sinuses, where they may remain for \ 
years, the secretions of these cavities furnishing' 
them with sufficient nourishment " (Fraenkel).' 
Larvae have also been found here, and maggots 
that have developed within the nose have managed 
to make their way to the frontal sinuses. 

Trip, frontal sinns is ahspnt in parly nhildhoo^ . 
About the sixth year a bud of mucous membrane 
grows out from the anterior end of the hiatus, and 
gradually insinuates its growing extremity into 
the diploe of the frontal bone, separating the 
inner from the outer osseous table. It reaches its 
full size about the twenty -fifth year ; the stalk of 
the outgrowth becomes the infundibulum; it leads 
from the posterior part of the sinus. The infundi- 
bulum is | of an inch long, and runs downwards 
and slightly backwards to open at or near the 
anterior end of the hiatus semilunaris. Along the 
hiatus the secretion of the frontal sinus may be 
conveyed to the antrum, thus converting that 
cavity into a cesspool in cases of chronic suppura- 
tion of the frontal sinus (Fig. 22). The infundi- 
bulum is frequently tortuous, and even after the 
beak of the middle turbinate process is removed 
it is not easy to catheterise from below. Hence in 
cases of obstruction the frontal sinus is trephined 



i08 SURGICAL APPLIED ANATOMY [Part 1 

over the glabella, or at the superior internal angle 
of the orbit (Tilley), and a probe passed down- 
wards and slightly backwards to drain the sinus 
into the nose. The anterior ethmoidal cells com- 
monly open into the infundibulum, and hence are 
usually involved in any disease affecting the 
frontal sinus. The frontal diploic vein, which 
joins the frontal vein at the supraorbital notch, 
receives blood from the frontal sinus. By this 
channel infection may be disseminated in the 
frontal bone from disease of the frontal sinus. 

The sphenoidal sinus opens on th p rnn ^ ^ 
the nose behind the superior meatus ; it is de- 
veioped at the same period of life as the frontal 
sinus (Fig. 22). It is deeply placed, and not very 
accessible for operation when the seat of disease. 
It is frequently the seat of chronic suppuration 
set up by infections from the nose. Its anterior 
wall, which is comparatively thin, is situated be- 
tween V and 8 cm. from the lower margin of the 
anterior nares. Tilley recommends the mid point 
of the lower border of the middle turbinate as a 
guide to the opening of the sphenoidal sinus. A 
probe^ passed to this point from the floor of the 
anterior nares will, if passed straight onwards, 
reach the opening of the sinus at the depth men- 
tioned above — 7 to 8 cm. 

In close contact with the thin lateral wall of this 
sinus there are certain extremely important struc- 
tures^ Besides the cavernous sinus and internal 
carotid artery, the optic nerve and second division 
of the fifth nerve are in the closest contact, and 
may be affected in sinusitis (Fig. 26). On the roof 
is the pituitary body ; tumours of this body may 
invade the sinus. Its veins join the ethmoidal. 
The walls of the sinuses are thin and easily per- 
forated, as the following case, which occurred re- 
cently at the London Hospital, will show. A 
man stumbled forwards on his umbrella as he 
left a public-house in Whitechapel, the point 
entering his face above the bicuspid teeth. He 
walked to the hospital, and died three days after- 



Chap. VI] NOSE AND NASAL CAVITIES 109 

wards. The ferrule of the umbrella was found 
embedded in the pons, the point having traversed 
the antrum of Highmore and the sphenoidal sinus. 

The antrum exists at birth, but attains its 
largest dimensions in old age. The surface mark- 
ings for indicating its position on the face are 
given in Fig. 23. The walls of the cavity are 
thicker in children than in adults. Tummirs of 
various kinds ar e apt tn dp.vplop in this na.yity, 
and to distend its walls in various directions. 
Thus the growth breaks through the thin inner 
wall and invades the nose, it pushes up the roof 
of the cavity and invades the orbit, it encroaches 
upon the mouth through the floor of the antrum, 
and makes its way also through the somewhat 
slender anterior wall into the cheek. The densest 
part of the antrum wall is that in relation to the 
malar bone, and this part does not yield. There 
is little inducement for any growth to spread 
backwards, although it sometimes invades the 
zygomatic and pterygo-maxillary fossae. As the 
infraorbital nerve runs along the roof of the 
antrum, while the nerves of the upper teeth are 
connected with its walls, these structures are 
pressed upon in growths springing from the 
antrum, and thus neuralgia of the face and teeth 
is often produced. In tapping the antrum a spot 
is usually selected "j ust above the second bicus - 
pid ^ tooth", sinop thp. houp. is hp.rp thin and is con- 
veniently reached . In some cases it is sufficient 
to py tr act one of the molar teeth, since the fa ngs 
of t hese often e nt er the cavity of th e antruim The 
tooth usually selected is either the first or the 
third molar. Not unfrequently the antrum com- 
municates at its upper anterior part with the 
frontal sinus. 

The opening of the antrum is shown in Fig. 22 ; 
it is on a level with the roof of the cavity ; hence 
if pus_ be present it drains most freely when the 
head is turned so that the affected chamber is 
uppermost; the sphenoidal sinus empties most 
easily when the head is bent forwards ; the frontal, 



110 SUKGICAL APPLIED ANATOMT [Part 1 

when the head is thrown backwards. The cavity 
of the antrum is small if the inferior meatus is 
large or if the canine fossa of the face be well 
marked. The lymphatics of the sinuses drain 
into the retropharyngeal gland s! As the result of 
a fall, one of the upper teeth has been entirely 
driven into the antrum and lost to view. In one 
case, reported by Haynes Walton, an upper in- 
cisor was found lying loose in the antrum three 
and a half years after the accident that had 
driven it there. 



CHAPTER VII . ... 

THE FACE 

The parts of the face, other than those already 
dealt with, will be considered under the follow- 
ing heads : (1) The face generally; (2) the paro- 
tid region; and (3) the upper and lower Jaws 
and parts connected with them. The lips will be 
considered with the " cavity of the mouth ,; 
(chap. viii.). 

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

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

111 



112 SURGICAL APPLIED ANATOMY LPart I 

prominent bones, as the parts over the malar bone, 
the chin, and the upper lid, are struck by a 
blunt instrument or in a fall, the wound pro- 
duced has often the appearance of a clean incised 
wound, just as obtains in contused wounds of the 
scalp. 

The mobility of the facial tissues renders this 
part very suitable for the performance of plastic 
operations of various kinds, and their vascularity 
generally ensures a ready and sound healing. 
Although there is a large quantity of fat in the 
subcutaneous tissue of this region, yet fatty 
tumours are singularly rare upon the face. They 
appear, indeed, to avoid this region. Thus M. 
Denay reports the case of a man who had no less 
than 215 fatty tumours over different parts of 
his body, but not one upon his face. The face is 
peculiarly liable to be the seat of certain ulcers, 
especially the rodent and lupoid ulcer, and is the 
part most often attacked by " malignant pustule/' 
a disease transmitted to man from cattle afflicted 
with a malady known in this country as " mur- 
rain," and in France as " charbon. ,; 
* Blood supply. — The tissues of the face are 
very vascular, and are liberally supplied with 
blood-vessels in all parts. The finer vessels of the 
skin often appear permanently injected or vari- 
cose in the drunken, or in those who are exposed 
to cold, or are the subjects of certain forms of 
acne. Thus, nasvi, and the various forms of erec- 
tile tumour, are common about the face. For a 
like reason also wounds of the face, while they 
may. bleed readily when inflicted, are apt to heal 
with singular promptness and accuracy. All 
wounds, therefore, of this part should have their 
edges carefully adjusted as soon after the accident 
as possible. Extensive flaps of skin that have 
been torn up in lacerated wounds often retain 
their vitality in almost as marked a manner as 
do like flaps torn from the scalp. ExtensiVe in- 
juries to the face associated with great loss of 
substance are often repaired in a most remark- 



Chap. VII] THE FACE 113 

able manner, as has been illustrated in gunshot 
wounds where a considerable portion of the face 
and upper jaw has been blown away. The low 
mortality after severe injuries to the face is due, 
however, not only to the excellent powers of re- 
pair the part possesses, but also to the fact that 
the face contains no organs essential to life, that 
its bones are soft and thin and do not favour 
extensive splitting, and that there are several 
passages and cavities in the region through which 
discharges may escape. One of the most terrible 
instances of injury not immediately fatal is re- 
ported by Longmore : " An officer of Zouaves, 
wounded in the Crimea, had his whole face and 
lower jaw carried away by a ball, the eyes and 
tongue included, so that there remained only the 
cranium, supported by the neck and spine/' He 
lived twenty hours. 

The pulsations of the facial artery can be best 
felt at the lower border of the jaw, where the 
vessel crosses just in front of the anterior border 
of the masseter muscle. It is here covered only 
by the integument and platysma, and can be 
readily compressed against the bone or ligatured. 
The anastomoses of the artery upon the face are 
so free that when the vessel is divided, both ends, 
as a rule, require to be secured. The facial vein 
is only in contact with the artery near the lower 
border of the jaw ; on the face it is separated from 
it by a considerable interval. The vein is not so 
flaccid as are most superficial veins; it remains 
more patent after section, it possesses no valves, 
and communicates at one end indirectly with the 
cavernous sinus, and at the other with the inter- 
nal jugular vein in the neck. This vein has also 
another, but less direct, communication with the 
intracranial veins. It is as follows : the facial vein 
receives the " deep facial vein ;; from the ptery- 
goid plexus, and this plexus communicates with 
the cavernous sinus by means of some small veins 
which pass through the foramen ovale and the 
fibrous tissue of the foramen lacerum medium. 



114 



SURGICAL APPLIED ANATOMY [Part I 



These dispositions of the facial vein may serve 
to explain the mortality of some inflammatory 
affections of the part. Thus carbuncle of the face 
is not unfrequently fatal by inducing thrombosis 
of the cerebral sinuses, and a like complication 
may occur in any other diffuse and deeply extend- 
ing inflammatory condition. The unusual patency 
also of the facial vein favours septic absorption, 
and its direct communication with the great vein 




Fig. 24.— Sh owing the development of the face. (Modified from Merke . 

f.x.p., Part formed from the fronto-nasal process ; l., from its lateral and M.,from 
its mesial parts ; max., formed by the maxillary process ; man., formed by the 
mandibular process. 

in the neck may explain those abrupt deaths from 
thrombosis that have followed upon the injection 
of facial nsevi in infants. 

A reference to the development of the face 
assists to explain the distribution of the fifth 
nerve and the occurrence of certain abnormalities 
(Fig. 24). The face is developed from five pro- 
cesses, a mesial, the fronto-nasal, and two lateral 
— the maxillary and mandibular. The fronto- 
nasal process forms the middle part of the upper 
lip and the nose. It may fail to develop : thus 
the condition of cyclops is produced. It springs 



Chap. VII] THE FACE 115 

from the frontal region and carries with it a 
branch of the first division of the fifth, the nasal 
nerve. The second division of the fifth is the 
nerve of the maxillary process, while the third is 
that of the mandibular. 

JVerve supply.— The nerves of the face are 
very liberally distributed, the fifth being the sen- 
sory nerve, the facial the motor (Fig. 4, p. 15). 
It follows, from the great number of nerve fila- 
ments about the part, and the extensive sensory 
nucleus of the fifth nerve, that severe irritants 
applied to the face may set up a widespread nerve 
disturbance. Dr. George Johnson mentions a case 
where a piece of flint embedded in a scar on the 
cheek set up facial neuralgia, facial paralysis, 
and trismus, and induced a return of epileptic 
attacks. The positions of the supra- and infra- 
orbital foramina and of the mental foramen and 
of the exit of the corresponding nerves are indi- 
cated as follows : _ The supraorbital foramen is 
found at the junction of the inner with the middle 
third of the upper margin of the orbit. A straight 
line drawn downwards from this point so as to 
cross the gap between the two bicuspids in both 
jaws will cross both the infraorbital and mental 
foramina. The infraorbital foramen is a little 
over \ of an inch below the margin of the orbit. 
The mental foramen in the adult is midway be- 
tween the alveolus and the lower border of the 
jaw, and is a little over \ of an inch below the 
cul-de-sac of mucous membrane between the lower 
lip and jaw. At puberty the foramen is nearer 
to the lower border of the maxilla, and in old age 
it is close to the alveolus. The infraorbital nerve 
has been divided for neuralgia at its point of exit, 
the nerve being reached either by external incision 
or through the mouth by lifting up the cheek. In 
other cases the floor of the orbit has been exposed, 
the infraorbital canal (the anterior half of which 
has a bony roof) has been opened up, and large 
portions of the trunk of the nerve have been in 
this way resected. Meckel's ganglion has been 



116 SURGICAL APPLIED ANATOMY [Part I 

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

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

The nerve has been divided also before its entry 
into the mental foramen in the following manner : 
The mouth being held widely open, an incision is 
made from the last upper molar to the last lower 
molar just to the inner side of the anterior bor- 
der of the coronoid process, which can be clearly 
defined by palpation. The cut passes through the 
mucous membrane down to the tendon of the tem- 
poral muscle. The finger is introduced into the 
incision, and passed between the ramus of the 



Chap. VII j THE PACE 117 

jaw and the internal pterygoid muscle until the 
bony point is felt that marks the orifice of the 
dental canal. The nerve is here picked up with 
a hook, isolated, and divided. 

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

The trunk of the third division of the fifth 
nerve has been divided at the foramen ovale 
through a flap wound made in the cheek. Con- 
siderable damage of the soft parts results. The 
position of the foramen ovale may be marked on 
the surface of the head by taking a point on the 
lower border of the zygoma immediately in front 
of the eminentia articularis (see Fig. 26). 

When a sensory nerve is divided the area 
of analgesia which results does not correspond 
to its anatomical distribution. Thus, when the 
ophthalmic division of the fifth cranial nerve is 
cut, only a narrow strip of skin on the forehead is 
completely deprived of feeling, whereas from the 
anatomical distribution one would infer that the 
skin of the forehead and of the anterior half of the 
scalp should be involved (see Fig. 4, p. 15). If the 
second division is cut, the area of anaesthesia is 
confined to a narrow space between the orbit and 
the mouth ; on section of the third division, to a 
strip running downwards in front of the ear and 
along the course of the lower jaw (Head). 

Head has lately offered an explanation of the 
varying results which follow section of a sensory 
nerve. A nerve contains three kinds of sensory 
nerve fibres : (1) those subserving deep sensibility 
— endowing muscles, bones, ligaments, joints, and 
deep structures with the power to feel pressure and 
pain; (2) those subserving protopatliic sensibility^ 



118 



SURGICAL APPLIED ANATOMY [Part I 



by which the skin is rendered sensitive to prick 
and to temperature, if it be above 40° or below 
22° ; (3) those subserving epicritic sensibility — by 
which the skin is endowed with the power of feel- 
ing light touch — tested with such a substance as 
cotton wool — and finer degrees of temperature. 
Now, in the majority of instances, when a nerve is 
divided, the loss of epicritic sensibility corresponds 
in extent to the anatomical distribution of the 
nerve ; when the Gasserian ganglion is removed 
{see Figs. 4 and 25) the loss of epicritic sensibility 




Fig. 25. — The extent of loss of sensibility following (a) excision of the 
Gasserian ganglion ; (b) section of the second cervical nerve. {After 
H. H. Tooth.) 

In the area stippled black there is a loss of protopathic sensibility ; in that 
stippled red, of epicritic sensibility. 

corresponds to the area of distribution, but the loss 
of protopathic sensibility is less than the anatomi- 
cal area. It is evident that protopathic fibres from 
the second cervical nerve (Fig. 25) invade and sup- 
ply the area of skin furnished with epicritic sen- 
sibility by the fifth nerve. In the lower part of the 
face there is no overlapping of areas ; in the mental 
branch of the fifth, the epicritic and protopathic 
fibres are distributed to the same extent of skin. 
Thus the effects which follow section of a sensory 
nerve depend on the nature of the fibres in that 
nerve, and on the extent of skin to which each 
kind is exclusively distributed. 



Chap. VII] 



THE FACE 



119 



Excision of the Gasserian ganglion. — For cases 
of intolerable and intractable neuralgia Rose pro- 
posed the excision of the Gasserian ganglion. It 
is the sensory ganglion of the fifth nerve, and cor- 
responds to the ganglion on the posterior root of a 
spinal nerve. The nerve fibres of the fifth neces- 
sarily undergo degeneration when it is excised. 

The operation usually performed is the follow- 
ing (see Fig. 26) : An omega-shaped flap of skin is 
raised from the temples, having the zygoma at 



island of Ceil & 
Fissureoc Sylvius 
Deep Temp. Fascia 

Temp. Muscle 
First Temp. Fissure 
Uncus 
Dura Mater. 
Aid /Ie/iihqealArt 
Root of Zyqoma 
Ext Pteryqoid 
Mid ZiE/iinqEAL Art 
I/ht. Max. Art 
Masseter 
Ccronoid Proc 




Optic Tract 
Subarachnoid Space 
IV* 

Cavernous Simus 
Int Carotid Art. 



VI 



rb 



C.ASSER.IAN C.ANC.LION 

Sphenoidal Sinus 
3 rd Div. of V fh 
Lat. Recess of Phar. 
Eustachian Tube- 
Levator. Palatae 



Fig. 



-Coronal section to show the depth and relationships of the 
Gasserian ganglion. 



its base and the temporal ridge at its convexity. 
The tissues are reflected down to the floor of the 
temporal fossa. The superficial and deep temporal 
vessels have to be tied. A wide trephine opening is 
made in the squamosal and great wing of the 
sphenoid on a level with the upper border of the 
zygoma, and the dura mater exposed. This is 
usually followed by profuse haemorrhage from the 
middle meningeal vessels which cross the field of 
operation. The dura mater and the superimposed 
temporo-sphenoidal lobe are raised from the bone, 
when the third and second divisions of the fifth 



120 SURGICAL APPLIED ANATOMY [Part I 

nerve are brought into view as they escape by the 
foramen ovale and foramen rotundum. They are 
seen to spring from the Gasserian ganglion situ- 
ated over the apex of the petrous bone and on the 
outer wall of the cavernous sinus. The motor root 
which supplies the muscles of mastication lies 
under the ganglion and should not be cut. The 
ganglion is embedded in the dura mater and sur- 
rounded by a prolongation of the subarachnoid 
space (Meckel's space), which is necessarily opened. 
Only the part of the ganglion connected with the 
second and third divisions is removed, the part 
connected with the ophthalmic division being left, 
as it is firmly embedded in the outer wall of the 
cavernous sinus and in close proximity to the inter- 
nal carotid artery and the oculo-motor nerves. 
The hippocampal convolution containing the olfac- 
tory centre lies immediately over the ganglion 
(Fig. 26). 

The eminentia articularis at the base of the 
zygoma serves as a useful guide to the position 
of the ganglion ; when the middle fossa is opened 
and the temporal lobe raised up the ganglion will 
be found at a depth of 2^ inches and in the same 
coronal plane as the articular eminence, but at a 
higher level.* 

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

2. The parotid region. — The main part 
of the parotid gland is lodged in a definite space be- 

* For a full account of the anatomy of this operation see "The Surgical 
Treatment of Facial Neuralgia," by J. Hutchinson, jun. London, 1905. 



Chap. VII] 



ill i : iwci: 



121 



hind the ramus of the lower jaw (Fig. 27). This space 
is increased in size when the head is extended, 
and when the inferior maxilla is moved forwards, 







Fig. 27. — A horizontal section through one side of the face and neck just 
above the level of the lower teeth. (Braune.) 

a, Facial artery; b, facial vein; c, gustatory nerve; c?, inferior dental nerve and 
artery lying internally to the ascending ramus of jaw ; e, styloid process ; 
/, internal carotid artery: g, internal jugular vein, with the vagus, spinal 
accessory, and hypoglossal nerves to its inner side ; h, vertebral artery. 
Externally to the ascending ramus is shown the masseter ; internally to it the 
internal pterygoid • internally to the last-named muscle, the superior con- 
strictor and tonsil. 



122 SURGICAL APPLIED ANATOMY [Part I 

as in protruding the chin. In the latter movement, 
the increase in. the antero-posterior direction is 
equal to about f of an inch. It is diminished when 
the head is flexed. When the mouth is widely 
opened the space is diminished below, while it is 
increased above by the gliding forwards of the con- 
dyle. These facts should be borne in mind in 
operating upon and in exploring the parotid space. 
It will be found also that in inflammation of the 
parotid much pain is produced by all those move- 
ments that tend to narrow the space occupied by 
the gland. The obliquity of the ramus of the jaw 
in infancy and old age causes the lower part of the 
space to be, in the former instance relatively and 
in the latter instance actually, larger than it is 
in the adult. 

The gland is closely invested by a fascia derived 
from the cervical fascia. The superficial layer of 
the parotid fascia is very dense, continuous be- 
hind with the fibrous sheath of the sterno-mastoid, 
and in front with that of the masseter. Above it 
is attached to the zygoma, while below it joins 
the deep layer. The deep layer is slender, is 
attached to the styloid process, forms the stylo- 
maxillary ligament, and is connected with the 
sheaths of the pterygoid muscles and the pterygoid 
process. The gland is, therefore, encased in a dis- 
tinct sac of fascia, which is entirely closed below, 
but is quite open above. Between the anterior 
edge of the styloid process and the posterior bor- 
der of the internal pterygoid muscle there is a gap 
in the fascia, through which the parotid space com- 
municates with the connective tissue about the 
pharynx. It is well known that in postpharyngeal 
abscesses there is very usually a parotid swelling, 
and in several instances the pus, or at least some 
portion of it, has been evacuated in the parotid 
region. In these cases the matter most probably 
extends from the pharyngeal to the parotid region 
through the gap just described. From the disposi- 
tion of the fascia it follows that very great resist- 
ance is offered to the progress of a iiarotid abscess 



Chap. VII] THE FACE 123 

directly outwards through the skin. The abscess 
often advances upwards to the temporal, or zygo- 
matic fossae, in the direction of least resistance, al- 
though progress in that line is resisted by gravity. 
It frequently makes its way towards the buccal 
cavity or pharynx, or it may break through the 
lower limits of the fascia and reach the neck. It 
must be borne in mind that the gland is in direct 
contact with the cartilaginous meatus, with the 
ramus of the jaw and other bony parts, and is 
closely related to the temporo-maxillary joint. 
Thus, a parotid abscess has burst into the meatus, 
has led to periostitis of the bones adjacent to it, 
and has incited inflammation in the joint of the 
lower jaw. 

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

The most important structures in the gland are 
the external carotid artery, with its two terminal 
branches, and the facial nerve. The artery, as Til- 
laux has pointed out, is behind the ramus of the 
jaw, as high up as the junction of the inferior with 
the middle third of its posterior border. It then 
enters the parotid gland, and, passing a little 
backwards and outwards, comes nearer to the 



124 



SURGICAL APPLIED ANATOMY [Part I 



surface, and at the level of the condyle of the jaw 
breaks into its two terminal branches. The artery, 
therefore, does not enter the gland at its inferior 
border, and is not in actual relation with the 
parotid space at its lowest part. The vessel, more- 
over, is not parallel with the edge of the ramus, 
but passes through the parotid gland with some 
obliquity. 



Sup Temp.Art. 
Ext. Auditory /I eatus 
1/xf.Max.Ar.t 
Styloid Pp-OC. 
Facial /Ieeve 




^=^SPinAL Accessory /i. 

^SZd/ AlypoQLoasAL N. 
/X x/ 

Ste/nsom's Duct 

Ext Carotid Art 



AlypocLOsSAL /leave 
Qreat /Ior/i o/AlyOlD 



Fig. 28. — Surface markings of the facial, spinal accessory, and hypoglossal 

nerves. 

a, Mid point of anterior border of mastoid process ; b, point on anterior border oi 
seer no-mast oid, one inch below mastoid process ; c, mid point of posterior 
border of sterno-mastoid. Above b the transverse process of the atlas is 
indicated. 



At its point of exit from the base of the 
skull by the stylo-mastoid foramen, the facial 
nerve lies 1 inch deep to the mid point of the 
anterior border of the mastoid process ; a line 
drawn horizontally forwards from that point to 
the posterior border of the ascending ramus of the 
mandible marks the position of the main trunk of 
the nerve (Fig. 28). Within the gland, where the 
nerve divides into its temporo-facial and cervico- 



Chap. VII] THE FACE 125 

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

Section of the facial nerve causes paralysis of 
the buccinator and of all the muscles of expres- 
sion, the mouth being pulled towards the sound 
side and the eye remaining unclosed. To restore 
mobility to the face in cases of palsy, surgeons 
have, in a number of recent instances, sutured the 
facial to the trunk of a neighbouring nerve — 
the trunks selected being the spinal accessory and 
hypoglossal (Fig. 28). In the one case the muscles 
of expression are thrown into action when the 
trapezius and sterno-mastoid are used; in the 
other when the tongue is moved. In course of time 
the patient may become able to dissociate these in- 
conveniently combined movements. At its point 
of exit the facial nerve gives off its posterior 
auricular branch to the muscles of the ear and 
twigs to the posterior belly of the digastric and 
stylo-hyoid muscles. 

It follows, from the complex relations of the 
parotid, that its entire removal as a surgical pro- 
cedure is an anatomical impossibility. In open- 
ing a parotid abscess a cut is usually made over the 
angle of the jaw, and a director pushed upwards 
into the substance of the gland, after the plan ad- 
vised by Hilton. The gland is separated by a mere 
layer of fascia from the internal carotid artery, the 
internal jugular vein, the vagus, glosso-pharyn- 
geal, and hypoglossal nerves (Fig. 27). Thus, in 
stabs in the parotid region it may be difficult at 
first to tell whether the internal or the external 
carotid is wounded. It has been suggested that 
the cerebral _ hyperemia sometimes noticed in 
severe parotitis (mumps) may be clue to the 



126 SURGICAL APPLIED ANATOMY [Part I 

pressure of the enlarged gland upon the internal 
jugular vein. 

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

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

Stenson's duct (Fig. 28) is about %\ inches 
long, and has a diameter of |th of an inch, its 
orifice being the narrowest part. At the anterior 
border of the masseter muscle the duct bends 
suddenly inwards to pierce the buccinator muscle. 
The bend is so abrupt that the buccal segment of 
the duct may be almost at right angles with the 
masseteric. This bend should be taken into con- 
sideration in passing a probe along the duct from 
the mouth. The duct opens on the summit of a 
papilla placed on a level with the second upper 
molar tooth. The course of the duct across the 
masseter is represented by a line drawn from the 
lower margin of the concha to a point midway 
between the ala of the nose and the red margin of 
the lip. It lies about a finger-breadth below the 
zygoma, having the transverse facial artery above 
it and the infraorbital branches of the facial nerve 



Chap. VIII THE FACE 127 

below it. The duct has been ruptured subcutane- 
ously, leading to extravasations of saliva. Wounds 
of the duct are apt to lead to salivary fistulse. 
When the fistula involves the buccal segment of 
the duct it may be cured by opening the duct into 
the mouth on. the proximal side of the fistula. 
Fistula? of the masseteric segment are, on the 
other hand, very difficult to relieve^ At least one- 
half of the buccal part of the duct is embedded in 
the substance of the buccinator muscle. A salivary 
fistula over the masseter may involve the parotid 
gland itself, or that part of it known as the socia 
parotidis. Inflammatory conditions may spread 
to the parotid from the mouth along Stenson's 
duct. 

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

The superior maxilla (for antrum, see Nose, 
p. 109; for hard palate, see Mouth, p. 149). — This 
bone, on account of its fragility and the manner 
in which it is hollowed out, is very readily frac- 
tured. The fracture may be due to direct violence, 
as by a blow from a "knuckle-duster," or it may 
be broken by a force transmitted from the lower 
jaw through the teeth, as in cases of severe blows 
or falls upon the chin. It may be broken by a blow 
upon the head, when the chin is fixed, no other bone 
being damaged ; and, lastly, it may be crushed, as 
above stated, by the driving in of the malar bone. 
The displacement of the fragments depends upon 
the direction and degree of the force employed, 
no muscles having effect. The bone being very 
vascular, serious injuries, involving great loss of 
substance, are often wonderfully repaired. Its 
hollowness and the cavities that it helps to bound 
render it possible for large foreign bodies to be re- 
tained in the deeper parts of the face. Thus, 
Longmore reports "the case of Lieutenant Fretz, 
of the Ceylon Rifles, who was able to do his mili- 
tary duties for nearly eight years with the breech 
and screw of a burst musket lodged in the nares, 
part of the tail-pin and screw protruding through 



128 SURGICAL APPLIED ANATOMY [Part I 

the hard palate into the mouth." The bone may 
undergo extensive necrosis, especially in that form 
of necrosis induced in workers in match factories 
by exposure to the fumes of phosphorus. In one 
case (Med. Times, 1862) of necrosis following 
measles the mischief was limited to the p re-maxil- 
lary, or incisive bone. 

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

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

Soft parts divided: These may be considered 
under three heads : The parts cut (l) in the first 
incision; (2) in turning back the flap; and (3) in 
separating the bone. 

(1) The following are the parts cut in order 
from above downwards in the usual, or " median, " 
incision, an incision commencing parallel with the 
lower eyelid, and continued down the side of the 



Chap. VII] THE FACE 129 

nose, round the ala, and through the middle of the 
upper lip : Skin, superficial fascia, orbicularis pal- 
pebrarum, palpebral branches of infraorbital nerve 
and artery, part of lev. labii superioris, angular 
artery and vein, lev. labii sup. alseque nasi, later- 
alis nasi artery and vein, nasal branches of infra- 
orbital nerve, compressor naris, depressor alse nasi, 
attachment of nasal cartilage to bone, orbicularis 
oris, sup. coronary artery and vein, and mucous 
membrane of lip. Various branches of the facial 
nerve to the muscles may be cut. (2) In turning 
back the flap, the muscles above named _wi.ll be 
dissected up, together with the tendo oculi, if the 
nasal process is removed entire, the levator anguli, 
the buccinator, a few fibres of the masseter, and, 
on the orbital plate, the inferior oblique muscles. 
The infraorbital nerve and artery will be cut as 
they leave their foramen. In the flap itself will be 
the trunks of the facial artery and vein, the trans- 
verse facial artery, and the facial part of the facial 
nerve. (3) In separating the nasal process the lach- 
rymal sac and infratrochlear nerve will be dam- 
aged, and the nasal duct and external branch of 
the nasal nerve cut across. In separating the bones 
below, the coverings of the hard palate are divided, 
and the attachment of the soft palate to the 
palate bone, unless the removal of that process 
can be avoided. " Any attempt to dissect off and 
preserve the soft covering of the hard palate is 
futile" (Heath). Posteriorly, the trunk of the 
infraorbital nerve is again divided (this time 
in front of Meckel's ganglion), together with 
the posterior dental and infraorbital arteries, 
and some branches of the spheno-palatine artery. 
The deep facial vein from the pterygoid plexus 
will probably be cut, and, lastly, near the palate 
will also be divided the large palatine nerve and 
the descending palatine artery. 

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

The inferior maxilla ; fracture. — This bone 



130 SUEGICAL APPLIED ANATOMY [Part I 

is to a great extent protected from fracture by its 
horse-shoe shape, which gives it some of the pro- 
perties of a spring, by its density of structure, by 
its great mobility, and by the buffer-like interarti- 
cular cartilages that protect its attached extremi- 
ties. The bone is usually broken by direct violence, 
and the fracture may be in any part. The sym- 
physis is rarely broken, on account of its great 
thickness. The ramus is protected by the muscu- 
lar pads that envelop its two sides, and the coro- 
noid process is still more out of the risk of injury, 
owing to the depth at which it is placed and the 
protection it derives from the zygoma. The weak- 
est part of the bone is in front, where its strength 
is diminished by the mental foramen and by the 
large socket required for the canine tooth. It is 
about this part, therefore, that fracture is the most 
common. The bone may be broken near, or even 
through, the symphysis by indirect violence, as by 
a blow or crushing force that tends to approximate 
the two rami. Thus, the jaw has been broken near 
the middle line by a blow in the masseteric region. 
The amount of displacement in fractures of this 
bone varies greatly, and is much influenced by the 
nature and direction of the force. In general 
terms, it may be said that when the body of the 
bone is broken the anterior fragment is drawn 
backwards and downwards by the jaw depressors, 
the digastric, mylo-hyoid, genio-hyoid, and genio- 
hyo-glossus ; while the hinder fragment is drawn 
up by the elevators of the jaw, the masseter, inter- 
nal pterygoid, and temporal. It must be remem- 
bered that the mylo-hyoid muscle will be attached 
to both fragments, and will modify the amount of 
displacement. Fractures of the ramus are seldom 
attended with much displacement, muscular tissue 
being nearly equally attached to both fragments. 

In fractures of the body of the bone the dental 
nerve often marvellously escapes injury, a fact that 
is explained by the supposition that the bones are 
not usually sufficiently displaced to tear across the 
nerve. Weeks after the accident, however, the 



Chap. VII] THE FACE 131 

nerve has become so compressed by the developing 
callus as to have its function destroyed. 

One or both condyles have often been broken 
by falls or blows upon the chin. The gums being 
firm and adherent, it follows that they are usually 
torn in fractures of the body of the maxilla, and 
hence the bulk of the fractures in this part are com- 
pound. 

The temporo - maxillary articulation is 
supported by a capsule which varies greatly in 
thickness in different parts. By far the thickest 
part of the capsule is the external part (the exter- 
nal lateral ligament). The internal part is next in 
thickness, while the anterior and posterior por- 
tions of the capsule are thin, especially the former, 
which is very thin. Thus, when this joint suppu- 
rates, the pus is least likely to escape on the ex- 
ternal aspect of the articulation, and is most likely 
to find an exit through the anterior part of the cap- 
sule, although this part is to a great extent pro- 
tected by the attachments of the external ptery- 
goid muscle. Immediately behind the condyle of 
the jaw are the bony meatus and, a little to the 
inner side, the middle ear. In violent blows upon 
the front of the jaw these structures may be dam- 
aged, and it is interesting to note that the strongest 
ligament of the joint (the external lateral) has a 
direction downwards and backwards, so as im- 
mediately to resist any movement of the condyle 
towards the slender wall of bone that bounds the 
meatus and tympanum. Were it not for this liga- 
ment, a blow upon the chin would be a much more 
serious accident than it is at present. 

It follows, from the proximity of the joint to 
the middle ear, that disease in the articulation may 
be a result of middle-ear disease. In one case 
(Holmes's " System of Surgery"), suppurative dis- 
ease, spreading from the middle ear, not only in- 
volved the joint, but induced necrosis of the con- 
dyle of the lower jaw. The necrosed condyle was 
removed entire from the auditory meatus, into 
which- cavity it had projected. 



132 SUEGICAL APPLIED ANATOMY [Part I 

The movements of this joint are peculiar. On 
opening the mouth it will be observed that the 
condyle moves forwards and downwards upon the 
articular eminence, while the angle of the jaw 
moves in a backward and upward direction. The 
axis of the movement is a transverse line drawn 
between the inferior dental foramina ; thus, it will 
be seen that the inferior dental nerves enter the 
mandible at the point of least movement. The ex- 
ternal pterygoid muscles, by pulling the condyle 
upon the articular eminence, take the chief part 
in opening the mouth ; at the same time the chin 
is depressed by the contraction of the mylo-hyoid 
and digastric muscles. 

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



Chap. VII] THE FACE 133 

age remaining behind. On reaching its new posi- 
tion it is immediately drawn up by the temporal, 
internal pterygoid, and masseter muscles, and is 
thereby more or less fixed. A specimen in the 
Musee Dupuytren shows that the fixity of the lux- 
ated jaw may sometimes depend upon the catch- 
ing of the apex of the coronoid process against 
the malar bone. 

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

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

1. (a) In the anterior vertical cut: Skin, etc., 
orbicularis oris, inferior coronary and inferior 
labial vessels, branches of submental artery, leva- 
tor menti, mental vessels and nerve, some radicles 
of anterior jugular vein, (b) In the horizontal cut : 
Skin, etc., platysma, branches of superficial cer- 
vical nerve, branches of supramaxillary part of 
facial nerve, facial artery and vein at edge of mas- 
seter, and inframaxillary branch of facial nerve 
(not necessarily divided), (c) The posterior verti- 
cal incision would not go down to the bone, and 
would merely expose the surface of the parotid 
gland and part of posterior border of masseter muscle. 



134 SURGICAL APPLIED ANATOMY [Part I 

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

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

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

Deformities. — The lower jaw may be entirely 
absent, or of dwarfed dimensions, or incompletely 
formed. These conditions are congenital, and 
depend upon the defective development of the 
mandibular or first visceral arch, out of which 
the lower jaw is formed (Fig. 24, p. 114). They 
are often associated with branchial fistulse, super- 
numerary ears, macrostoma, and like congenital 
malformations. 

With regard to the nerves connected with the 
jaws, little need be said. The upper teeth are 
supplied by the second division of the fifth, the 
lower by the third. Some remarkable nerve dis- 
turbances have followed, by reflex action, upon 
irritation of the dental nerves. Thus cases of stra- 
bismus, temporary blindness, and wry-neck have 
been reported as due to the irritation of carious 
teeth. Hilton gives the case of a man who was 
much troubled by a carious tooth in the lower jaw 
(supplied by the third division of the fifth), and 



Chap. VII] THE FA.CE 135 

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

Caries of the teeth is frequently associated with 
areas of hyperesthesia on the side of the face and 
neck. The explanation of the reflection of pain 
set up by dental caries, to certain areas of skin, 
must be sought for in a close association of the 
central nerve nuclei, in which the cutaneous and 
dental nerves terminate. Disease of the peridental 
membrane does not give rise to referred pains 
(Head). 

The muscles of mastication are often at- 
tacked by spasm. When the spasm is clonic the 
chattering of the teeth, that is so conspicuous a 
feature in rigor, is produced. When the spasm is 
tonic the mouth is rigidly closed, and the condi- 
tion known as trismus, or lockjaw, is produced. 
Trismus is amongst the first symptoms of tetanus. 
It is also very apt to be produced by irrita- 
tion of any of the sensory branches of the third 
division of the fifth, since the motor nerve 
supply of the muscles themselves is derived 
from that trunk. Thus trismus is very common 
in caries of the lower teeth, and during the 
" cutting " of the lower wisdom tooth. It is 
much less common in affections of the upper 
set of teeth, since they are supplied by a more 
remote division of the fifth nerve. If the motor 
root of the third division of the fifth nerve 
be cut in excising the Gasserian ganglion, paralysis 
and atrophy overtake the muscles of mastication 
of the corresponding side. The muscles of the 
sound side, however, are still able to carry on the 
necessary movements of the jaw concerned in 
speech and mastication. 

Teeth. — As a test of age the following periods 
for the eruption of teeth are given by Mr. C. 
Tomes : Temporary teeth : Lower central incisors, 
six to nine months ; upper incisors, ten months ; 
lower lateral incisors and four first molars, a few 
months later ; then, after a rest of four or five 



136 SURGICAL APPLIED ANATOMY [Part I 

months, the canines; and, lastly, the second 
molars; the whole being in place by the end of the 
second year. Permanent teeth: First molars, sixth 
or seventh year ; next in order the lower central 
incisors, then the upper central incisors, and a 
little later the laterals, the eighth year ; first bicus- 
pids, ninth or tenth year; second bicuspids and 
canines, about the eleventh year, the lower preced- 
ing the upper; the second molars, the twelfth or 
thirteenth year ; the wisdom teeth, eighteen to 
twenty-live or later. 

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

The upper wisdom tooth is developed in the 
posterior border of the upper jaw, and the lower 
wisdom on the inner aspect of the ascending 
ramus. They may fail to come into position or re- 
main buried. They may give rise to deeply-seated 
and obscure abscesses which frequently point in 
the neck, at some distance from their seat of 
origin. 



CHAPTER VIII 

THE MOUTH, TONGUE, PALATE, AND 
PHARYNX 

The lips. — The principal tissues composing the 
lips have the following relation to one another, 
proceeding from without inwards: (1) Skin; (2) 
superficial fascia; (3) orbicularis oris; (4) coron- 
ary vessels; (5) mucous glands, and (6) mucous 
membrane. The free border of the lip is very sensi- 
tive, many of the nerves having end bulbs closely 
resembling tactile corpuscles. The upper lip is 
supplied with sensation by the second division of 
the fifth nerve, and the lower lip by the third divi- 
sion. Over these labial nerves a crop of herpes 
often appears (herpes labialis). The free border of 
the lower lip is more frequently the seat of epithe- 
lioma than is any other part of the body ; its lym- 
phatic vessels pass to the submental and submaxil- 
lary lymphatic glands (Fig. 35, p. 190). The lips 
contain much connective tissue, and may swell 
considerably when inflamed, or cedematous. They 
are very mobile, and are entirely free for a con- 
siderable extent from bony attachment of any 
kind. It follows that destructive inflammations of 
the lips, and such losses of substance as accom- 
pany severe burns, produce much contraction and 
deformity of the mouth. Contracting cicatrices, 
also, in the vicinity of the mouth are apt to drag 
upon the lips, everting them or producing kindred 
distortions. It is fortunate that the laxity of the 
tissues around the mouth, and the general vascu- 

137 



138 SURGICAL APPLIED ANATOMY [Part I 

larity of the part, greatly favour the success of the 
many plastic operations performed to relieve these 
deformities. 

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

The mucous glands in the submucous tissue are 
large and numerous. From closure of the ducts 
of these glands, and their subsequent distension, 
result the " mucous cysts " that are so common 
about the lips. "Hare-lip" is noticed below in 
connection with the subject of cleft palate. 

The buccal cavity. — The following points 
may be noticed in the examination of the interior 
of the mouth. In the floor of the mouth, on either 
side of the frsenum linguae, can be observed the 
sublingual papillae with the openings of Whar- 
ton's ducts. The duct of Bartholin (one of the 
ducts of the sublingual gland) runs along the last 
part of Wharton's duct, and opens either with it 
or very near it. Wharton's duct is singularly 
indistensible, and hence is partly explained the 
intense pain usually observed when that duct is 
obstructed by a calculus. The proximity of this 
duct to the lingual nerve may serve also to ac- 



Chap. Villi 



THE MOUTH 



139 



count for the pain in some cases. The submaxil- 
lary gland can be made out through the mucous 
membrane at a point a little in front of the angle 
of the jaw, especially when the gland is pressed 
up from the outside. On the floor of the mouth, 
between the alveolus and the anterior part of the 
tongue, is a well-marked ridge of mucous mem- 
brane, that is directed obliquely forwards and in- 
wards to the sublingual papilla near the frsenum 
(Fig. 29). It indicates the position of the sub- 
lingual gland, and also, so far as it goes, the line 
of Wharton's duct and the lingual nerve. These 
structures, with the sublingual artery, lie beneath 



CErti071V0-Ci.0SSUt 




UP. U/tCUAUS 
l/lMjflCUALIS 

AIyO-QlOSSUS 
Li/igual Artery 
Subungual Cla/io 
Sublingual Arter* 



CEflKWIVOID 
/1yLO-/1v0lO 

Digastric 



Fig. 



29. — Section across tongue and mandible to show the position of 
the sublingual gland and lingual artery. (After Poirier.) 



the mucous membrane between the gland and the 
side of the tongue. The ducts of the sublingual 
gland, some ten to twenty in number, open into 
the mouth along the ridge of mucous membrane 
just referred to. Ranula, a cystic tumour filled 
with mucous contents, is often met with over the 
site of the sublingual gland, and is due to the dila- 
tation of one of the gland ducts that has become ob- 
structed, or to an occluded mucous follicle. The 
mucous membrane of the floor of the mouth, as it 
passes forward to be reflected on to the gums, is 
attached near to the upper border of the jaw (Fig. 
29). Here also are situated some mucous glands 
which may become cystic. The genio-hyo-glossus 
is attached near the lower border. Between these 



140 SURGICAL APPLIED ANATOMY [Part I 

two parts (the mucous membrane and the muscle) 
there is, according to Tillaux, a small space lined 
with squamous epithelium. To this cavity the 
name of the sublingual bursa mucos'a is given. 
It is constricted in its centre by the frsenum 
linguae, and is said to be the seat of mischief in 
" acute ranula.' ; 

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

The coronoid process of the lower jaw can be 
easily felt through the mouth, and is especially dis- 
tinct when that bone is dislocated. It may be 
noted that a fair space exists between the last 
molar tooth and the ramus of the inferior maxilla, 
through which a patient may be fed by a tube in 
cases of trismus or ankylosis of the jaw. 

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

The gums are dense, firm, and very vascular. 
In the bleeding that follows the extraction of 
teeth much of the blood is supplied by them. The 



Chap. VIII] THE MOUTH 141 

gums are particularly affected in mercurial poison- 
ing, and are also especially involved in scurvy. 
In chronic lead-poisonmg a blue line often appears 
along their margins. This is due to a deposit of 
lead sulphide in the gum tissues, which is thus de- 
rived : Food debris collected about the teeth in 
decomposing produces hydrogen sulphide, which, 
acting upon the lead circulating in the blood, pro- 
duces the deposit. The blue line, therefore, is said 
not to occur in those who keep the teeth clean. 

The tongue.— On the under surface of tihe 
tongue, less than h an inch from the fraenum, the 
end of the ranine vein can be seen beneath the 
mucous membrane. Two elevated and fringed 
lines of mucous membrane may be seen on the 
under surface of the organ converging towards its 
tip. Thev^ indicate the position of the ranine 
artery, which is more deeply placed than the vein, 
close to which it lies. It is extremely rare for the 
tongue to be the seat of congenital defect. The 
author of the able monograph on the tongue iD 
Holmes's " System of Surgery '' has discovered 
only one instance of congenital absence of the 
organ. Fournier gives a case where the tongue 
was so much longer than usual that the chest could 
be touched with its tip while the head was held 
erect. 

In rare cases the frsenum linguae may be 
abnormally short, constituting the condition known 
as "tongue-tie," which is really a very uncommon 
affection. The fraenum when divided should be 
cut as near the jaw as possible, so as to avoid 
the ranine vessels. Division of these vessels in 
relieving tongue-tie has led to fatal haemorrhage, 
the bleeding being encouraged by the efforts of 
sucking. "If the frsenum and subjacent muscle 
fibres be too freely divided, energetic sucking on 
the part of a hungry child may tear the wound of 
these very lax tissues farther and farther open, 
until the tongue, having lost all its anterior sup- 
port, turns over into the pharynx, and is firmly 
embraced by the muscles of deglutition, which force 



142 SUKGICAL APPLIED ANATOMY [Part I 

it down upon the epiglottis, and the latter upon the 
larynx, until suffocation is produced * ; (Holmes's 
" System of Surgery," vol. ii). In complete anaes- 
thesia, as in that produced by chloroform, when all 
the muscular attachments of the tongue are re- 
laxed, the organ is apt to fall back and to press 
down the epiglottis, so causing suffocation. 

The tongue is firm and dense, but contains, 
nevertheless, a sufficient amount of connective 
tissue to cause it to swell greatly when inflamed. 
The surface epithelium is thick, and in chronic 
superficial inflammation of the organ it often be- 
comes heaped up, forming dense opaque layers, 
ichthyosis linguae, plaques des fumeurs, leucoma, 
etc. From the mucous glands, situated chiefly be- 
neath the mucous membrane near the base of the 
tongue, the mucous cysts are developed that are 
sometimes met with in this part. 

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

The tongue is well supplied with nerves, that 
endue it not only with the special sense of taste, 
but also with common sensation. According to 
Weber's experiments, tactile sensibility is more 
acute on the tip of the tongue than it is on any 
part of the surface of the body. It should be borne 
in mind that the lingual nerve supplies the fore 
part and sides of the tongue for two-thirds of its 
surface, whii'e the glossopharyngeal nerve sun- 
plies the mucous membrane at its base, and especi- 



Chap. VIII] THE MOUTH 143 

ally the papillae vallatae. In painful affections, 
situated in the area supplied by the lingual nerve, 
the patient is often troubled with severe pains 
deep in the region of the meatus of the ear, and 
an area of skin from the ear along the lower bor- 
der of the jaw may be tender (Head). The anterior 
two-thirds of the tongue is a derivative of the man- 
dibular arch, which also forms the anterior boun- 
dary of the meatus. Hence the nerve supply of 
the anterior part of the tongue from the third divi- 
sion of the fifth nerve and the reference of pain to 
its cutaneous termination. The posterior third of 
the tongue is derived from the second (hyoid) and 
third visceral arches and is associated with tender 
areas in the skin over the larynx (Head). Spas- 
modic contraction of the masticatory muscles is 
sometimes found to accompany painful lingual ul- 
cers when involving the region of the gustatory 
nerve. There would seem to be but little connec- 
tion between an abscess over the occipital region 
and wasting of one half of the tongue. But Sir 
James Paget reports the following case: "A man 
received an injury to the back of his head that was 
apparently not severe. In time the right half of 
the tongue began to waste, and continued to waste 
until it was less than half the size of the unaltered 
side. An abscess formed over the occiput, from 
which fragments of the lower part of the occipital 
bone were removed. After the removal of all the 
dead bone the tongue began to recover, and in one 
month had nearly regained its normal aspect." 
Here the atrophy was due to wasting of the lin- 
gual muscles produced by pressure upon the hypo- 
glossal nerve, which leaves the skull through the 
anterior condyloid foramen in the occipital bone. 
The case illustrates the importance of remember- 
ing even small foramina, and the structures they 
transmit. 

The tongue contains much lymphoid tissue, a 
considerable part of which (the lingual tonsil) is 
massed under the mucous membrane at the pos- 
terior part of the organ. Hypertrophy of this tissue 



144 SURGICAL APPLIED ANATOMY [Part I 

may lead to troublesome symptoms by interference 
with the proper action of the epiglottis. The lin- 
gual and pharyngeal adenoid tissue, with the ton- 
sils proper, form a complete ring of lymphoid 
tissue round the isthmus of the fauces. 

The lymphatics of the tongue are large and 
numerous, and offer a free channel for the dissem- 
ination of cancerous emboli. They are arranged 
in two systems : (1) Superficial, forming an ex- 
tremely rich plexus in the submucous tissue on 
the dorsum and sides of the tongue; (2) deep, ar- 
ranged as a network in the musculature of the 
tongue. These two systems are in free communica- 
tion ; Cheatle found that the genio-hyo-glossus 
muscle was a common site of secondary deposit in 
cases of cancer of the tongue. The lymph from 
these two systems is carried off by the following 
sets of efferent vessels : (1) the marginal or lateral 
vessels, which leave the submucous plexus on the 
side of the tongue and pass partly to the sub- 
maxillary group of glands and partly to the upper 
deep cervical group ; (2) the central vessels, which 
form between the two genio-hyo-glossus muscles 
and end in the upper deep cervical glands ; (3) the 
apical vessels, which end in the submental gland 
and in the upper deep cervical ; (4) the basal 
vessels from the posterior third of the tongue 
which terminate in the upper deep cervical 
group.* The tongue is one of the commonest 
sites for cancer, and the disease commonly affects 
the anterior two-thirds, which is derived from 
the mandibular arch. So is the lower lip, which 
also is a common site. Cancer spreads along 
the lymphatic vessels, which > for the greater 
part accompany the lingual vein and artery and 
pour their lymph and emboli in the upper deep 
cervical glands, behind and below the angle of the 
jaw. The normal paths are soon choked, and the 
lymph has to follow circuitous by-paths. The lym- 
phatic glands over the submaxillary gland, the 

* For a full account of the lymphatics see Poirier's "Lymphatics," 
translated by Cecil Leaf, 1903. 



Chap. VIII] THE MOUTH 145 

lymphoid tissue in that gland and in the sublin- 
gual, become the seats of secondary deposit. The 
submental gland may also be affected. 

In the strange congenital affection known as 
macroglossia the tongue becomes much enlarged, 
and in some cases may attain prodigious dimen- 
sions. The enlargement is primarily due to the 
greatly dilated condition of the lymphatic chan- 
nels of the organ (hence the name, lymphangioma 
cavernosum, proposed by Virchow), and to an in- 
creased development of lymph tissue throughout 
the part. The portion most conspicuously affected 
is the base of the tongue, where the lymphatics 
are usually the most numerous. 

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

Accessory glands about the tongue.— 
Streckeisen states that accessory glands, belong- 
ing to the thyroid body, are frequently found in 
the vicinity of the hyoid bone. They are also 
found in the basal part of the tongue, near the 
foramen caecum (Makins). Some may be super- 
ficial to the mylo-hyoid muscle, others may be just 
above the hyoid bone, and others in the hollow of 
that bone. Cysts lined with ciliated epithelium 
may sometimes be found in the same situations. 
All these structures are the remains of the neck 
of the central diverticulum which is protruded 
from the ventral wall of the pharynx in the em- 
bryo, and from which the isthmus and pyramidal 
parts of the thyroid gland are formed. The fora- 
men ececum on the tongue indicates the spot where 
this diverticulum leaves the pharynx. Ducts lined 
with epithelium have been found leading from the 
foramen csecum to accessory glands about the hyoid 
bone. It is probably from these glandular and 
epithelial collections about the hyoid bone that cer- 
tain deep-seated forms of cancer of the neck are 
developed. Some of these take the form of malig- 

K 



146 SUKGICAL APPLIED ANATOMY [Part I 

nant cysts described by the author (Path. Soc. 
Trans., 1886). 

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

In another series of operations the tongue has 
been reached, or the organ has been fully exposed, 
by an incision made between the hyoid bone and 
the inferior maxilla. More recently Kocher has 
exposed the tongue from the neck, and has reached 
it by an incision commencing near the ear and fol- 
lowing the anterior border of the sterno-mastoid 
muscle as far as the hyoid bone, whence it turns 
upwards along the anterior belly of the digastric 
muscle. This method allows free removal of the 
upper deep cervical glands, the lymphatic glands, 
and the tissue over and in the submaxillary and 
sublingual glands which form the seats of second- 
ary cancerous deposits. 

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

Bleeding from the stump of the tongue, after 



Chap. VIII] 



THE PALATE 



147 



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

When both Unguals have been ligatured in the 
neck (through the hyo-glossus muscle) before re- 
moving the tongue, bleeding still takes place from 
the dorsalis linguae branches of the lingual and 




Fig. 30. — Illustrating the relationship of the lateral incisor tooth to the 

palatal cleft. 

a, Normal hard palate. The premaxilla is stii>plecT ; the lateral incisor occurs in 

the suture between it and the maxilla. 
is, Double cleft Of palate, the lateral incisor being situated on the preniaxilla to 

the inner side of the cleft. The septum of the nose is exposed in the cleft 

between the maxillary bones, 
c, Double cleft palate, the lateral incisor being situated on the maxilla to the outer 

side of the cleft. 

from small branches of the ascending pharyngeal 
and facial arteries. 

The palate. — The arch of the hard palate 
varies in height and shape in different individuals, 
and it has been said that the arch is particularly 
narrow and high in congenital idiots . The outline 
of this arch is of some moment in operations upon 
the palate. 

Cleft palate. — In order to understand the 
various forms of cleft which occur in the palate 
and upper lip, it is necessary to review briefly the 
development of these parts ; for all forms of cleft 
palate and " hare-lip ' are due to an incomplete 
fusion of parts. In Fig. 30, a, the bony palate at 



148 SURGICAL APPLIED ANATOMY [Part I 

birth is shown to be made up of three elements, (1) 
the premaxillary, carrying the four incisor teeth, 
(2) the right maxillary, (3) the left maxillary, bear- 
ing the right and left canine and milk molars. 
These three parts are different in origin : the pre- 
maxillary part is developed in the mesial nasal 
process (Fig. 24, p. 114) ; the maxillary parts from 
the right and left maxillary processes. Fusion 
of the various elements to form the palate com- 
mences anteriorly and proceeds backwards. In 
the posterior two-thirds of the palate the maxillary 
processes fuse with each other in the median line, 
but in the anterior third they unite with the pre- 
maxillary part. Thus the line of fusion is 
T-shaped, the premaxillary part occupying the 
fork. In the majority of cases the cleft occurs in 
the position of the main stem of the T, or it may 
affect only the soft palate ; or it may extend 
forwards to the alveolus on one side or on both, as 
is shown in Fig. 30, b, c. The lateral incisor is 
developed in the groove between the premaxillary 
and maxillary elements; if the condition of cleft 
palate occurs, the developmental elements separate 
as growth proceeds ; the bud of the lateral incisor 
may adhere to either side of the cleft thus formed ; 
hence in some cases this incisor is found on the 
premaxillary process; in others, in the maxillary 
(see Fig. 30, b, c). Each premaxilla may show 
two centres of ossification, but the cleft is not, as 
is so often said, the result of the failure of union 
of two centres of ossification, but is due to the 
separation of the developmental parts of the 
palate. As growth goes on, the cleft becomes 
wider. 

The upper lip is developed from the same three 
elements as the palate (Fig. 24, p. 114) ; if the 
palatal cleft extends to the alveolus the lip is also 
affected, but a cleft on one or both sides of the 
lip may occur without a cleft of the palate. The 
premaxillary or median element of the lip is also 
bilateral, but it is extremely rare to find a per- 
sistent separation of its two parts. In cases of 



Chap. VIII] THE PALATE 149 

double hare-lip one sees occasionally two papillae 
on the lower lip, fitting into the clefts in the upper 
when the lips are in apposition. 

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

The main bl ood supply of thp. houp s of ^ flip. 
hard palate and of its mucous covering is derived 
from the descending palatine branch of the inter- 
nal maxillary artery . This vessel, which is 
practically the only vessel of the hard palate, 
emerges from the posterior palatine canal near 
the junction of the hard palate with the soft, and 
close to the inner side of the last molar tooth. 
The vessel runs forwards and inwards, to end 
at the anterior palatine canal. Its pulsations on 
the palate can often be distinctly felt. In dis- 
secting up muco-periosteal flaps from the hard 
palate, it is most important to make the incision 
in the mucous membrane close to, and parallel 
with, the alveolus, so that this artery may be in- 
cluded in the flap and its vitality therefore not 
be endangered. By such an incision, also, un- 
necessary bleeding is avoided. In dissecting up 
the flap it should be remembered that the artery 
runs much nearer to the bone than to the mucous 
surface. 

The soft palate is of uniform thickness, its 
average measurement being estimated, at about 5 
of an inch. When the soft palate is cleft, the 



150 



SURGICAL APPLIED ANATOMY [Part I 



edges of the fissure are approximated during 
swallowing by the uppermost fibres of the superior 
constrictor. This approximation may narrow the 
cleft to one-third or one-half of its previous size. 
The muscles that tend to widen the cleft are, in 
the main, the levator palati and tensor palati. 
It is necessary that these muscles should be 
divided before attempting to close the cleft by 
operation. The levator palati crosses the palate 
obliquely from above downwards and inwards on 
its way to the middle line, lying nearer to the 
posterior than the anterior surface of the velum. 
The tensor palati turns round the hamular pro- 
cess, and passes to the middle line in a nearly 

horizontal direction (Fig. 31). 
The hamular process can be 
felt through the soft palate 
just behind and to the inner 
side of the last upper molar 
tooth. There are three prin- 
cipal methods of dividing 
these muscles: (1) > Fergus- 
son's : A small knife, with 
the blade at right angles to 
the stem, is passed through 
the cleft, and is made to 
divide the levator palati by 
an incision on the posterior 
aspect of the palate, trans- 
verse to the direction of the 
muscle. The tensor is not 
divided in this procedure. 
(2) Pollock's : A thin narrow 
knife, with the cutting edge 
upwards, is introduced into 
the soft palate a little in front, and to the inner 
side, of the hamular process. The tendon of the 
tensor muscle is above the knife, and is cut as the 
knife is pushed upwards and inwards. The knife 
is inserted until its point presents at the upper 
part of the cleft. As it is being withdrawn, it is 
made to cut the posterior surface of the velum 




Fig. 31.— The muscles of the 
soft palate, from behind. 

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



Chap. VIII] THE PHAKYNX 151 

to a sufficient depth to divide the levator palati 
(Fig. 31). (3) Bryant's : Here the palate muscles 
are divided by a cut with the scissors that in- 
volves the entire thickness of the velum, the cut 
being at the side of the velum, and nearly parallel 
with the cleft. 

The blood supply of the soft palate is derived 
from the descending palatine branch of the in- 
ternal maxillary artery, the ascending pharyn- 
geal artery, and the ascending palatine branch 
of the facial artery. The latter vessel reaches the 
velum by following the levator palati muscle, and 
must be divided in the section made of this muscle 
in the procedures just described. 

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

The pharynx is about five inches in length. 
It is much wider from side to side than from 
before backwards. It is widest at the level of the 
tip of the greater cornua of the hyoid bone, where 
it measures about 2 inches. It is narrowest where 
it joins the gullet opposite the cricoid cartilage, 
its diameter here being less than f of an inch. 
The pharynx is not so large a space as supposed, 
for it must be remembered that during life it is 
viewed very obliquely, and erroneous notions are 
thus formed of its antero-posterior dimensions. 
The d istance from the arch of the teeth to the 
commencement ot tne gullet is about 6 to 7 innhps ^ 

p, Tnp.a.aurftTTlftnt that aVimilrj — Vip linrnp | n mind 

in extracting foreign bodies . Foreign bodies 
passed into the pharynx are most apt to lodge 
at the level of the cricoid cartilage, a point that, 
in the adult, is a little beyond the reach of 
the finger. The history of foreign bodies in the 
pharynx shows that that cavity is very dilatable, 



152 SURGICAL APPLIED ANATOMY [Part I 

and can accommodate for some time large sub- 
stances. Thus, in a case reported by Dr. Geoghe- 
gan, a man of 60, who had had for months some 
trouble in his throat for which he could not 
account, was supposed to have cancer. On ex- 
amination, however, a plate carrying five false 
teeth, and presenting niches for five natural ones, 
was found embedded in the pharynx, where it 
had been lodged for five months. The plate had 
been swallowed during sleep {Med. Press, 1866). 
In the Lancet for 1868 is an account of a mutton 
chop that became lodged in the pharynx of a 
gluttonous individual. The chop presented the 
ordinary vertebral segment of bone, together with 
1\ inch of rib, and was " pretty well covered 
with meat." Attempts to remove it failed, and 
it was finally vomited up. Dr. Hicks (Lancet, 
1884) reports the case of a woman who committed 
suicide by cramming half a square yard of coarse 
calico (belonging to her nightdress) into her 
mouth and throat. 

The walls of the pharynx are in relation with 
the base of the skull, and with the upper six cer- 
vical vertebrae. The arch of the atlas is almos t 
ex actly on a line wi th the" hard pa.1a.tp The axis 
is on a line with the free edge of the upper teeth. 
The termination of the tmarynx corresponds ^o 
the six t h cervical vertebra . The upper vertebrae 
can be examined, as regards their anterior sur- 
face, from the mouth. When the bones about the 
pharynx are diseased, the necrosed parts may be 
discharged by that cavity. Thus portions of the 
atlas and axis have been expelled by the mouth, 
as also have been some fragments of comparatively 
large size thrown off by the occipital and sphenoid 
bones. 

The mucous membrane of the pharynx is vas- 
cular, and readily inflamed; and such inflamma- 
tions are peculiarly dangerous, in that they may 
spread to the lining membrane of the larynx. 
The submucous tissue of the aryteno-epiglottic 
folds and of the neighbouring part of the pharynx 



Chap. VIII] THE PHARYNX 153 

is peculiarly loose, and in oedematous conditions 
the upper aperture of the larynx may be almost 
closed. 

Much adenoid tissue is distributed in the 
mucous membrane of the pharynx, and it is this 
tissue that is the primary seat of inflammation 
in scrofulous pharyngitis. A distinct collection 
of a d enoid tissue, stretches across the hinder wall 
of the pharvnx hRtwp.en the openings o? thft Eus- 
tachia n^ tubes. It is known as the pharyngeal 
tonsil. In and near the lateral recess, just be- 
hind the opening of the Eustachian tube, the 
lymphoid tissue forms a thick layer or mass (Fig. 
22, p. 101). This deposit of adenoid tissue may 
undergo hypertrophic change and the condition 
known as " adenoid vegetations ;; or " post-nasal 
growths ;; be produced. These growths may cause 
deafness, and may block the posterior nares. 
They need to be removed by operation. 

The tissue immediately outside the pharyngeal 
walls is lax, and favours the spread of effusion. 
Thus, in acute inflammation of the pharynx the 
effusion has been found to extend along the oeso- 
phagus, reaching the posterior mediastinum, and 
advancing even to the diaphragm. In the lax 
connective tissue between the pharynx and the 
spine abscess is not infrequent, due, as a rule, to 
caries^ of the vertebrae (postpharyngeal abscess). 
In this connective tissue, and opposite the axis, 
is also found a lymphatic gland that receives 
lymphatics from the nasal cavity and naso- 
pharynx. This gland may prove the seat of a 
suppuration. Such collections may so push for- 
ward the posterior pharyngeal wall as to depress 
the soft palate, or may cause severe dyspnoea 
by interference with the larynx. The matter may 
discharge itself through the mouth, or may reach 
the neck by passing behind the great vessels and 
the parotid gland, presenting ultimately beneath 
or at one border of the sterno-mastoid muscle. 

_ Many structures of importance are in relation 
with the lateral walls of the pharynx, the prin- 



154 SURGICAL APPLIED ANATOMY [Part I 

cipal being the internal carotid artery, the vagus, 
glossopharyngeal, and hypoglossal nerves (Fig. 
27, p. 121). The internal carotid is so close to 
the pharynx that its pulsations may be felt by 
the finger introduced through the mouth. These, 
and other deep structures in the neck, may be 
wounded by foreign bodies that, passing in at 
the mouth, have been thrust through the pharynx 
into the cervical tissues. The internal jugular 
vein is at some distance from the pharynx, especi- 
ally at its upper part (Fig. 27, p. 121). The 
styloid process, when prominent, and an ossified 
stylo-hyoid ligament, can also be felt at the side 
of the pharynx immediately behind the tonsil. 
In more than one case an ossified stylo-hyoid liga- 
ment has been mistaken for a foreign body, and 
an attempt made to excise it. Langenbeck has 
three times extirpated the pharynx for malignant 
disease, but without success. He reaches it from 
the neck through an incision that, beginning 
below the jaw, midway between the symphysis and 
angle, is carried over the great cornu of the hyoid 
bone, and ends close to the cricoid cartilage. The 
posterior belly of the digastric and the stylo-hyoid 
muscles are detached from the hyoid bone, while 
the omo-hyoid muscle, the lingual, facial, and 
superior thyroid arteries and the superior laryn- 
geal nerve are divided. 

The tonsil is lodged bet we en th e anterior and 
posterior palatine arches. It is in relation ex- 
ternally with the superior constrictor muscle, and 
corresponds, as regards the surface, to the angle 
of the lower jaw. It is questionable whether the 
enlarged tonsil, when it is the subject of other 
than malignant enlargement, can ever be felt 
externally. When hypertrophied, the mass tends 
to develop towards the middle line, where no 
resistance is encountered, and to effect but little 
change in its external relations. The mass, often 
mistaken for the enlarged tonsil in the neck, is 
formed of enlarged glands, situate near the tip of 
the great cornu of the hyoid bone, and overlying 



Chap. VITI] . THE PHARYNX 156 

the internal jugular vein. These glands receive 
the tonsillar lymphatics, and are almost invari- 
ably enlarged in all tonsil affections. The fact 
that these glands are so frequently the first to en- 
large when the cervical glands become tubercular 
points to the tonsil as a common site of primary 
infection. It must be remembered that many 
structures are interposed between the tonsil and 
the skin, and as the hypertrophied body projects 
freely into the pharygneal cavity, one would not 
expect that it could be readily felt, even were 
the interposed tissues less extensive than they are. 
The tonsil is closely enough attached to the 
pharyngeal wall to be affected by the movements 
of the pharyngeal muscles. Thus it is moved in- 
wards by the superior constrictor muscle during 
the act of swallowing, and may be drawn out- 
wards, on the other hand, by the stylo-pharyngeus 
muscle. The ease with which a tonsil can be 
reached depends, other things being equal, upon 
the extent to which it can be withdrawn by the 
stylo-pharyngeus, and upon the development of 
the anterior palatine arch, which, to some extent, 
hides the tonsil. A child with a prominent an- 
terior palatine arch, containing a well-developed 
palato-glossus muscle, and with a vigorous stylo- 
pharyngeus, can for a long time elude the tonsil 
guillotine. 

Deafness i s of ten complaine d o f when the tonsil 
is hypertrophie d. This is not due to closure of 
th ft F.iiRta^hifln tube hv t he direct pressure of the 
en larger] mass. Such pressure is anatomically im- 
possible. T-he —large tonsil may, however, af fect 
the patency of the tube, by disturbing the s oft 
pjki ate, and t hr ough it th e tensor pal ati muscle . 
which r s much con cerned in keep in g open the 
Enstflph ian tube . The deafness in these cases Ts 
probably due rather to an extension of the hyper- 
trophic process to the lining membrane of the 
tube than to any pressure effects, since it is 
usually not improved until some time after the 
tonsil has been removed. The tonsil tissue is for 



156 SURGICAL APPLIED ANATOMY [Part I 

the most part collected around a number of re- 
cesses. The decomposition of retained epithelial 
structures within those recesses produces the foetid 
breath often noticed in cases of enlarged tonsil, 
and probably incites the attacks of inflammation 
to which such tonsils are liable Calculi may 
form in these crypts and give rise to a spasmodic 
cough. In this case the glosso-pharyngeal nerve 
conveys the afferent impulse to the respiratory 
centre. 

The tonsil is very vascular, rece iv ing blo o d 
from the tonsillar and pala~tirip hran ohps n f thp 
facial arter y, from thp. descen ding pglat.inp hranr- h 
of the internal maxillary , from thp dorsal is lin - 
guae Of thp lingual, aild frnrn thp agpPnrlincr 

pharyngeal Hence the operation of removing 
the tonsil is often associated with free bleeding. 
The internal carotid artery is close to the 
pharynx, but some way behind the gland (Fig. 27, 
p. 121). The vessel is, indeed, about f of an inch 
posterior to that body, and is in comparatively 
little danger of being wounded when the tonsil 
is excised. The internal jugular vein is a con- 
siderable distance from the tonsil. The facial 
artery, in its cervical stage, is close to the tonsil. 
Of im po rtant cervical structures, the nearest to 
the ton si l is the gloss o- pha,ry ngp« I tipt-vp, The 
ascending pharyngeal artery is also in, close re - 
fation with it . Although of small size, bleeding 
from this vessel has proved fatal, as the following 
interesting case, reported by Mr. Morrant Baker, 
will show : A man, aged 23, fell when drunk, and 
grazed his throat with the end of a tobacco- 
pipe he was smoking at the time. He thought 
nothing of the accident. In two days he came 
to the hospital with what appeared to be an 
acutely inflamed tonsil. The tonsil was punc- 
tured, but nothing escaped save a little blood. 
Several haemorrhages occurred from the tonsil 
wound, and on the fourth day after the accident 
1 inch of the stem of a clay pipe was discovered 
deeply embedded in the glandular substance. It 



Chap. VIII] THE PHARYNX 157 

was removed, and the common carotid tied. The 
patient, however, never rallied from the previous 
severe haemorrhages, and soon died. The autopsy 
showed that the stem of the pipe, which had not 
been missed by the patient, had divided the as- 
cending pharyngeal artery (St. Bart.'s Hosp. 
Reports, 1876). 

The tonsil is often the seat of malignant 
fl£oj/)tj3.s. Such tumours have been removed 
through the mouth, but are more conveniently 
dealt with through an incision in the neck along 
the anterior edge of the sterno-mastoid ( Cheaper/ s 
qpftration). 



CHAPTER IX 

THE NECK 

Surface anatomy; tooiiy points.— The hyoid 
bone is on a level with the fourth cervical vertebra, 
while the cricoid cartilage is opposite the sixth. 
The upper margin of the sternum is on a level 
with the disc between the second and third 
dorsal vertebrae. (See p. 173.) At the back of the 
neck there is a slight depression in the middle 
line which descends from the occipital protuber- 
ance, and lies between the prominences formed by 
the trapezius and complexus muscles of the two 
sides. At the upper part of this depression the 
spine of the axis can be made out on deep pres- 
sure. Below this, the bony ridge formed by the 
spines of the third, fourth, fifth, and sixth cervi- 
cal, vertebrse can be felt, but the individual spines 
cannot usually be distinguished. At the root of 
the neck the spinous process of the vertebra 
prominens is generally very obvious. The trans- 
verse process of the atlas may be felt just below 
and in front of the tip of the mastoid process. 
By deep pressure in the upper part of the supra- 
clavicular fossa, the transverse process of the 
seventh cervical vertebra can be distinguished. 
If pressure be made over the line of the carotid 
vessels at the level of the cricoid cartilage, 
the prominent anterior tubercle of the trans- 
verse process of the sixth cervical vertebra 
can be felt. This is known as the " carotid tuber- 
cle." The carotid artery lies directly over it, 

158 



Chap. IX] THE NECK 159 

and in ligaturing that vessel some surgeons make 
important use of this tubercle as a landmark. If 
a horizontal section of the neck, in a muscular 
subject, taken about the level of the sixth cervical 
vertebra, be viewed, the whole of the body of the 
vertebra divided will be seen to lie within the 
anterior half of the section. 

The middle line. — In the receding angle be- 
low the chin the hyoid bone can be felt and its 
body and greater cornua well made out. About 
a finger's breadth below it is the thyroid cartilage. 
The details of this latter are readily distin- 
guished, and below it the cricoid cartilage, crico- 
thyroid space, and trachea can be easily recog- 
nised. The separate rings of the trachea cannot 
be felt. The trachea is less easily made out as it 
passes down the neck. As it descends it takes a 
deeper position, and at the upper border of the 
sternum lies nearly 1^ inches from the surface. 

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

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

The anterior jugular veins descend on either 
side of the middle line upon the sterno-hyoid mus- 
cles. They commence in the submaxillary region, 
pierce the fascia just above the inner end of the 
clavicle, and, passing beneath the origin of the 
sterno-mastoid muscle, end in the external jugu- 
lar. The inferior thyroid veins lie in front of 
the trachea, below the isthmus. 

The side of the neck. — Muscles.— The sterno- 
mastoid muscle, especially in thin subjects and 
when thrown into action, is a prominent feature 
in the neck. The anterior border of the muscle is 
very distinct. The posterior border is less promi- 
nent, especially at its upper part. A communi- 
cating branch from the facial vein generally runs 
along the, anterior border of the muscle to meet 
the anterior jugular vein at the lower part of 



160 SURGICAL APPLIED ANATOMY [Part I 

the neck. The interval between the sternal and 
clavicular parts of the muscle is generally well 
marked. If a needle be thrust through this in- 
terval, quite close to the clavicle, it would just 
touch the bifurcation of the innominate artery 
on the right side and would pierce the carotid 
vessel on the left. The posterior belly of the 
digastric muscle corresponds to a line drawn from 
the mastoid process to the anterior part of the 
hyoid bone. The anterior belly of the omo-hyoid 
follows an oblique line drawn downwards from the 
fore part of the hyoid bone, so as to cross the 
line of the carotid artery opposite the cricoid 
cartilage. The posterior belly can be made out in 
thin necks, especially when in action, running 
nearly parallel with and just above the clavicle. 
Although not taking quite the same direction, yet 
the posterior borders of the sterno-mastoid and 
anterior scalene muscles practically correspond 
to one another. 

Vessels. — The common carotid artery is repre- 
sented by a line drawn from the sterno-clavicular 
joint to a point midway between the angle of the 
jaw and the mastoid process. The vessel bifur- 
cates at the upper border of the thyroid cartilage, 
or not unfrequently nearly \ an inch above that 
point. The omo-hyoid crosses it opposite the 
cricoid cartilage, and at about the same level the 
artery is crossed by the middle thyroid vein. The 
line of the internal jugular vein is just external 
to that for the main artery. Both the artery and 
vein lie under the anterior border of the sterno- 
mastoid. The superior thyroid artery comes off 
below the great cornu of the hyoid bone, and 
curves forwards and downwards to the upper 
edge of the thyroid cartilage. The great cornu of 
the hyoid serves as an excellent guide to the lin- 
gual artery, which invariably forms a loop above 
the posterior end of that process before proceeding 
forwards beneath the hyo-glossus muscle (Fig. 28, 
p. 124). The facial artery is very tortuous, but its 
general course in the neck is represented *by a line 



Chap. IX] THE NECK 161 

drawn from the anterior border of the masseter 
at the lower border of the jaw to a point just 
above the tip of the great cornu, while the occi- 
pital follows a line that starts from the latter 
point and runs across the base of the mastoid 
process. 

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

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

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

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

Nerves. — The position of the chief superficial 
nerves of the neck may be fairly indicated by 
six lines, all drawn from the middle of the pos- 
terior border of the sterno-mastoid muscle. A line 
drawn forwards from this spot so as to cross the 
sterno-mastoid at right angles to its long axis 
corresponds to the superficial cervical nerve. A 
second line drawn up across the muscle to the 
back of the pinna, so as to run parallel with the 
external jugular vein, corresponds to the great 
auricular nerve ; and a third line, running along 
the posterior border of the sterno-mastoid muscle 
to the scalp, marks the course of the small ocel- 
li 



162 SUEGICAL APPLIED ANATOMY [Part I 

pital nerve. These lines, continued downwards, 
so as to cross the sternum, the middle of the clavi- 
cle, and the acromion, will indicate respectively 
the suprasternal, supraclavicular, and supra- 
acromial nerves. 

The spinal accessory nerve reaches the anterior 
border of the sterno-mastoid muscle at a point 
about 1 inch below the tip of the mastoid process. 
It emerges from beneath that muscle about the 
middle of its posterior border, crosses the pos- 
terior triangle, and passes beneath the trapezius 
between the middle and lower thirds of the anterior 
border of that muscle (Fig. 28, p. 124). 

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

The skin in the submaxillary region is lax 
and thin, and is often found of considerable value 
for making flaps in plastic operations about the 
mouth. The platysma myoides is closely con- 
nected with the skin, and to its action is due the 
turning-in of the edges of such wounds as are 
athwart the line of direction of the muscle. The 
amount of subcutaneous fat in the cervical region 
varies in different parts. In the suprahyoid 
region it is apt to undergo extensive development, 
producing the diffused lipoma known as " double- 
chin.'' 

The skin over the nape of the neck is very 
dense and adherent, and these two circumstances, 
in addition to the free nerve-supply of the parts, 



Chap. IX] THE NECK 163 

serves to explain the severe pain that often accom- 
panies inflammation in this region. Common car- 
buncle is very often met with behind at the root 
of the neck, in the middle line. 

When the sterno-niastoid muscle of one side is 
rigidly contracted, either from paralysis of the 
opposite muscle or from spasmodic contraction, 
or from some congenital defect, the condition 
known as wry-neck is produced. The position of 
the head in wry-neck illustrates ^ precisely the 
effect of the sterno-mastoid when in full action. 
The head is bent a little forwards, the chin is 
turned towards the sound side, and the ear on the 
affected side leans towards the sterno-clavicular 
joint. In many cases the trapezius and splenitis 
muscles are also affected. Spasmodic contraction 
of the muscle may be due to reflex irritation. 
Thus, it has accompanied inflammation of the cer- 
vical glands in the posterior triangle. Such in- 
flammation has irritated some branches of the 
cervical plexus, and the sterno-mastoid muscle, 
although it is supplied mainly by the spinal acces- 
sory nerve, receives a nerve from that plexus (viz., 
from the second cervical). The course of the re- 
flex disturbance in such cases is therefore not diffi- 
cult to follow. It is to be remembered, too, that 
the spinal accessory nerve passes between the 
upper two or three deep cervical lymph glands 
which may compress it. A like contraction has 
also been produced by direct irritation of the 
second cervical nerve in cases of disease of the 
first two cervical vertebrae. For the relief of some 
forms of wry-neck, the sterno-mastoid muscle is 
divided subcutaneously, as in an ordinary teno- 
tomy operation, about ^ an inch above its attach- 
ment to the sternum and clavicle. Two structures 
stand considerable risk of being wounded in this 
operation, viz., the external jugular vein lying 
near the posterior border of the muscle, and the 
anterior jugular which follows its anterior border 
and passes behind the muscle, just above the 
clavicle, to terminate in the first-named vein. 



164 SURGICAL APPLIED ANATOMY [Part I 

With common care, there should be no risk of 
wounding the great vessels at the root of the neck. 
For spasmodic wry-neck the spinal accessory 
nerve and the communicating branches of the 
third and fourth cervical nerves have been cut. 
The spinal accessory nerve is found at the an- 
terior border of the sterno-mastoid, 1 inch below 
the mastoid process. 

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

The cervical fascia. — The layers of fascia 
that occupy the neck, and that are known col- 
lectively as the deep cervical fascia, are dense 
structures, having a somewhat complex arrange- 
ment and a great amount of importance from a 
surgical point of view. This fascia limits the 
growth of cervical tumours and abscesses, and 
modifies the direction of their progress, but I do 
not think that its effect in this matter is quite so 
definite as is usually maintained. It is true that 
deep-seated cervical abscesses are often found to 
follow just such a course as the arrangement of 
the fasciae would lead us to suppose, while, on 
the other hand, instances are by no means un- 
common where the abscess or growth appears to 
ignore these membranes and adopt a course of 
its own. 

The deep cervical fascia may be divided into 
(a) the superficial layer, and (b) the deeper pro- 
cesses (see Fig. 32). 

(a) The superficial layer forms a complete in- 
vestment for the neck, and covers in all the cer- 
vical structures, except the platvsma and some 
superficial veins and nerves, with the complete- 
ness of a perfectly fitting cravat. It commences 
behind at the spinous processes of the vertebra, 
and, having invested the trapezius muscle, starts, 
at the anterior border of that muscle, as a single 



Chap. IX] 



THE NECK 



165 



layer, to cross the posterior triangle. Arriving 
at the posterior border of the sterno-mastoid 
muscle, it splits to enclose that structure, appear- 
ing again as a single layer at the anterior border of 
the muscle, from whence it passes to the middle 
line of the neck to join the fascia of the opposite 




Fig. 32. — Transverse section through the lower part of the neck, to show 
the arrangement of the cervical fascia (diagrammatic). 

a. Trapezius ; b, sterno-mastoid ; c, depressors of hyoid bone ; d, platysma ; e 
anterior spinal muscles ; /, scalenus amicus j </, carotid artery ; h, externa 
jugular vein: i, posterior spinal muscles; t, trachea, with gullet behind and 
thyroid body in front. 



side, entirely covering in on its way the anterior 
triangle. The part that occupies the posterior 
triangle is attached above to the mastoid process 
and superior curved line of the occipital bone, 
and below to the clavicle, so that the space is com- 
pletely closed in by the fascia in all parts, al- 
though, just above the clavicle, it is pierced by 
the external jugular vein on its way to the deeper 
trunks. Over the anterior triangle the fascia 



lm SURGICAL APPLIED ANATOMY [Part I 

is attached above to the border of the lower jaw. 
Behind that bone it passes over the parotid gland 
to the zygoma, forming the parotid fascia, while 
a deeper layer passes beneath the gland (between 
it and its submaxillary colleague), to be attached 
to points at the base of the skull. It is from this 
deeper part that the stylo-maxillary ligament is 
developed. In front the fascia is attached to the 
hyoid bone, and just below the thyroid body it 
divides into two layers again, one to be attached 
to the front of the sternum and the other to the 
back. Both these layers lie in front of the de- 
pressors of the hyoid bone, and they form between 
them a little space (which extends so far later- 
ally as to enclose the sternal head of the sterno- 
mastoid), the widest part of which is below, and 
which there corresponds in width to the thickness 
of the sternum. It will be perceived that, in 
dividing the sternal head of the sterno-mastoid, 
the operation is performed within this little cham- 
ber formed by the two layers just named, and it 
is well to note that the anterior jugular vein 
also occupies this chamber on its way to the 
external jugular trunk. This superficial layer of 
the fascia, considered generally, would oppose in 
all parts the progress of abscesses or growths to- 
wards the surface, and would encourage or com- 
pel them to take a deeper position. 

(6) The deeper processes. (1) From the super- 
ficial layer a process comes off near the anterior 
border of the sterno-mastoid muscle, which, pass- 
ing beneath the depressors of the hyoid bone, in- 
vests the thyroid body and front of the trachea, 
and passes down, in front of that tube and of the 
large vessels, to the fibrous layer of the peri- 
cardium. (2) The prevertebral fascia is a layer 
that descends on the prevertebral muscles behind 
the pharynx and gullet. It is attached above 
to the base of the skull, and, below, descends into 
the thorax, behind the oesophagus. Laterally, it 
joins the carotid sheath, and is then prolonged 
outwards and downwards over the scalene muscles, 



Chap. IX] THE NECK 167 

the brachial plexus, and subclavian vessels. It 
follows these vessels beneath the clavicle, where 
it forms the axillary sheath and becomes con- 
nected with the under surface of the costo-cora- 
coid membrane. (3) The sheath of the carotid 
artery and its accompanying vein and nerve is 
derived in part from fascia No. 1, and in part 
from fascia No. 2. 

The effects of this disposition of the fascia 
may be illustrated by noting the course probably 
taken by cervical abscesses in various positions. 
(1) An abscess in the posterior triangle will be 
bounded towards the surface by the superficial 
layer of fascia. Towards the floor, or deep part, 
of the triangle it will be bounded by the lateral 
portion of fascia No. 2. The abscess may extend 
some way under the clavicle until arrested by the 
union of the costo-coracoid membrane with fascia 
No. 2. It would readily extend under the edge 
of the trapezius muscle, and could pass beneath 
the sterno-mastoid muscle and carotid artery to 
the anterior and deeper parts of the neck. (2) 
An abscess in the anterior triangle in front of the 
depressors of the hyoid bone would probably come 
forward, owing to the thinness of the fascia in 
front of it; but, if pent up, it would tend to 
progress towards the anterior mediastinum or 
into the lateral parts of the neck in front of the 
carotid vessels. (3) An abscess behind the hyoid 
depressors and about the trachea or thyroid body, 
or in the immediate vicinity of the carotid ves- 
sels (an abscess situate, in fact, between the deep 
fasciae Nos. 1 and 2), would find itself in a nar- 
row strait, and after pressing much upon adja- 
cent parts would most readily spread downwards 
into the mediastinum. (4) An abscess immedi- 
ately in front of the spine, and beneath the deep 
fascia No. 2, might extend down into the posterior 
mediastinum, or move towards the posterior and 
lateral parts of the neck, following the brachial 
plexus, and so reach the posterior triangle, or 
even the axilla. 



168 SUEGlCAL APPLIED ANATOMY [Part I 

In many cases a cervical abscess has burst into 
the gullet, or trachea, and even into the pleura. 
In some instances the great vessels have been 
opened up. In one remarkable case reported by 
Mr. Savory {Med. Chir. Trans., 1881), not only 
was a considerable portion of the common carotid 
artery destroyed by the abscess, but also a still 
larger portion of the internal jugular vein and a 
large part of the vagus nerve. This, and like 
examples of the destructive action of some cervical 
abscesses, depend, no doubt, upon the unyielding 
character of the cervical fascia, which hems in 
the pus on all sides, and drives it to resort to 
desperate measures to effect an escape. " It is 
noteworthy/ 5 remarks Mr. Jacobson, " that com- 
munications between abscesses and deep vessels 
have usually taken place beneath two of the 
strongest fasciae in the body, the deep cervical 
fascia and the fascia lata " (Hilton's " Rest and 
Pain "). 

The apex of the lung* extends into the 
neck, and reaches a point from 1 to 2 inches 
above the inner half of the clavicle. A point 
between the sternal and clavicular heads of the 
sterno-mastoid and l\ inches above the clavicle 
will, in the majority of adults, mark the highest 
point of the apex and the position of the neck of 
the first rib. It lies behind the clavicle, anterior 
scalene muscle, and subclavian vessels. The right 
lung commonly extends higher up than the left. 

The pleura has been opened in careless opera- 
tions on the subclavian artery, and has also been 
torn in dragging deep-seated tumours from the 
base of the neck. The pleura and lung have been 
wounded in stabs of the neck and by fragments 
of bone in severe fractures of the clavicle. Cer- 
vical abscesses have opened into the pleura, and, 
apart from this, pleurisy has followed inflamma- 
tion of the cellular tissue at the root of the neck. 
Sibson's fascia, which is attached along the inner 
border of the first rib, strengthens the pleura over 
the apex of the lung. 



Chap. IX] 



THE NECK 



169 



Cervical ribs. — These structures have led 
to many errors in diagnosis, have been mistaken 
for exostoses, and where the subclavian artery is 
carried over them, which is usually the case (Fig. 
33), have led to the diagnosis of aneurism. They 
are met with at all ages and in both sexes, and 




jFlFTH CERV./lE&VE. 



hCarotid Tubercle 

TRAC/iEA 
zriElCHTrt Cerv./Ierve 
^-Cervical Rib 
J-Subclaviam Art. 
fCAROTiD Art. 

Sibson's Fascia 
l/iMOMiftATE Art. 

Clavicle 



[AIa/nubriuai 



Fig. 33. — Showing the relationship of the subclavian artery and brachia 
plexus to a cervical rib. » 

represent the cervical ribs of lower vertebrates. 
In most cases one such rib is found on either side 
of the seventh cervical vertebra ; sometimes it is 
movable, sometimes it is ankylosed to the vertebra 
and its transverse process. A rudiment is always 
present in the foetus. It may be very short, and 
represented only by a head, neck, and tubercle. 
Such forms have been mistaken for exostoses. 



170 SURGICAL APPLIED ANATOMY [Part I 

It may be long, and may then end free, or be 
joined to the first rib or the first costal cartilage 
by ligament, or even by cartilage. In such in- 
stances the subclavian artery passes over the 
cervical rib, its pulsations being very distinctly 
seen and felt. To the longer form of cervical ribs 
the scalenus anticus and the scalenus medius 
may be attached. Occasionally subjects of this 
anomaly complain of numbness along the ulnar 
side of the arm and hand, or of partial paralysis 
of the muscles of the hand. These symptoms are 
due to traction on the first dorsal nerve at the 
point where it crosses above the cervical rib 
(Thorburn). (See Fig. 33.) In thin subjects the 
rib can be seen as a distinct projection in the neck. 
Cut throat and wounds of the neck.— 
The skin of the neck is so elastic and mobile that 
it is readily thrown into folds when a knife, 
and especially a blunt knife, is drawn across it. 
Thus, in cases of cut throat several distinct skin 
cuts may be found that were all produced by one 
movement of the knife. The wound in cut throat, 
whether suicidal or homicidal, most frequently 
involves the thyro-hyoid membrane, next in fre- 
quency the trachea, and then the thyroid car- 
tilage. 

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

2. If the wound be across the thyro-hyoid space 
the following may be the parts cut : Anterior 
jugular vein; sterno-hyoid, thyro-hyoid, omo- 
hyoid muscles ; thyro-hyoid membrane ; inferior 
constrictor ; superior laryngeal nerve ; superior 



Chap. tx] THE NECK 171 

thyroid artery ; and if near the hyoid bone the 
trunk of the lingual artery may be cut. The 
pharynx would be. opened in a deep wound, and 
the epiglottis divided near its base. Division of 
the epiglottis in w r ounds in this situation is always 
a serious complication. 

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

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

In some cases of gunshot wound the vessels 
seem to have been actually pushed aside, and to 
have owed their safety to their mobility. Thus, 
in a case reported by Longmore, the bullet passed 
entirely through the neck from one side to the 
other. It passed through the gullet, damaged the 
posterior part of the larynx, but left the great 
vessels intact. In another recorded case a boy 
fell upon the point of a walking-stick. The end 
of the stick passed entirely through the neck 
from side to side, entering in front of one sterno- 
mastoid muscle and emerging through the sub- 
stance of the opposite one. It probably passed 



172 SURGICAL APPLIED AN ATOM'S [Part I 

between the pharynx and the spine. The boy, 
who left the hospital well in eighteen days, owed 
his safety to the laxity of the cervical connective 
tissue and to the mobility of the main structures 
in the neck. The structures of the neck are fixed 
laxly to allow movements of the larynx and 
tongue. 

In connection with the subject of wounds of the 
neck it must be remembered that the most im- 
portant part of the spinal cord can be reached 
from behind, through the gap between the atlas 
and axis. In this situation the cord has been 
divided by one stab of a knife, the instrument 
entering between the two bones. Langier gives 
some ingenious cases of infanticide where the 
lethal weapon was merely a long needle. The 
needle was introduced into the spinal canal be- 
tween the atlas and the axis, and the cord readily 
cut across. 

Wounds at the side of the neck have divided 
considerable portions of the brachial plexus with- 
out involving other structures. 

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



Chap. IXJ THE NECK 173 

The larynx and trachea.— The position of 
the larynx in the neck is influenced by age. In 
the adult the cricoid cartilage reaches to the lower 
part of the sixth cervical vertebra. In a child 
of three months it reaches the lower border of 
the fourth cervical, and in a child of six years 
the lower border of the fifth vertebra. At puberty 
it attains the adult position. The upper end of 
the epiglottis in the adult is opposite the lower 
border of the third cervical vertebra. With the 
laryngoscope the following parts may be made 
out (Fig. 34) : The base of the tongue and glosso- 
epiglottic ligaments ; the superior aperture of the 
larynx, presenting in front the epiglottis, at the 
sides the aryteno-epiglottidean folds (in which are 
two rounded eminences corresponding to the 
cornicula and cuneiform cartilages), and at the 
back the arytenoid commissure of mucous mem- 
brane. Deeply down can be seen the true and 
false vocal cords, the ventricle, the anterior wall 
of the larynx, a little of the cricoid cartilage, 
and more or less of the anterior wall of the 
trachea. If the glottis be very fully dilated 
the openings of the two bronchi may be dimly 
seen. 

The thyroid and cricoid cartilages and the 
greater part of the arytenoid are in structure 
hyaline, as are the costal cartilages. Like the 
last-named, they are liable to become more or less 
ossified as life advances. Ossification commences 
in the thyroid and cricoid cartilages at about 
the age of 20, and in either cartilage the process 
commences in the vicinity of the crico-thyroid 
joint. The arytenoid ossifies later. Ossification 
of the laryngeal cartilages is more marked in 
males than in females. The larger cartilages are 
liable to be fractured by violence, as by blows, 
throttling, etc. The thyroid is the one most fre- 
quently broken, and usually in the median line. 
The posterior superior angle of the thyroid car- 
tilage marks the position of the pyriform fossa, 
a wide recess 5 above and external to the aryteno- 



174 



SURGICAL APPLIED ANATOMY [Part I 



epiglottic folds (Fig. 34). Foreign bodies may 
be arrested in this fossa. 

The riiusi glottidis is the aperture between 
the true vocal cords and the vocal processes of the 
arytenoid, to which the cords are attached pos- 
teriorly. The cords are double the length of the 
processes, and are of a grey buff colour, owing 
to the elastic tissue, of which they are mainly 
composed, being apparent beneath the stratified 
epithelium. The rima is the narrowest part of 





Fig. 34. — The upper aperture of the larynx iu the open (a) and shut (k 

positions. 

A, Cushion of epiglottis; b, apices of arytenoids; c, aryreno-epiglottidean folds ; 
E, posterior aspect of cricoid ; p, false vocal cords; g, rima glottidis, between 
true vocal cords ; h, posterior border of thyroid cartilage ; i, tip of great born 
of hyoid. 

the interior of the larynx, and it is well to be 
familiar with its proportions in reference to the 
entrance of foreign bodies and the introduction 
of instruments. In the adult male the rima mea- 
sures nearly 1 inch (23 mm.) from before back- 
wards; from side to side, at its widest part, it 
measures about one-third of the length ; this dia- 
meter may be increased to one-half of the length 
in extreme dilatation. In the female and in the 
male before puberty the antero-posterior diameter 
is from 17 mm. The rima is widely opened dur- 
ing inspiration, owing to the action of the crico- 



Chap. IX] THE NECK 175 

arytenoideus posticus, while the vocal cords are 
approximated in speech under the influence of the 
crico-arytenoideus lateralis. 

The mucous membrane of the larynx varies 
in thickness in different parts, and in the amount 
of its submucous tissue. The membrane is thick- 
est, and the submucous tissue most abundant, in 
the following parts, taken in order of degree : 
The aryteno-epiglottidean folds, the mucous mem- 
brane of the ventricle, the false cords, and the 
laryngeal aspect of the epiglottis. These are the 
parts that become most congested and swollen in 
acute laryngitis : and the serious condition known 
as oedema of the glottis depends mainly upon 
effusion into the lax submucous tissue in the 
aryteno-epiglottidean folds. The lax condition of 
the mucous membrane of the aryteno-epiglottidean 
folds allows free movements of the arytenoid 
cartilages and complete closure of the upper 
aperture of the larynx (Fig. 34). The mucous 
membrane is firmly bound to the true vocal cords 
and covered by stratified epithelium, while the 
rest of the larynx is lined, like the trachea, with 
ciliated epithelium. Owing to the nature of its 
covering and exposure to friction, the true vocal 
cord is not an uncommon site of epithelioma. The 
affection known as " clergyman's sore throat " has 
an interesting anatomical basis. The mucous 
membrane of the larynx is well provided with 
mucous glands, whose function it is to keep moist 
the parts concerned in phonation. When an in- 
dividual speaks aloud for a long time the lining 
of the larynx tends to become dry, on account 
of the large amount of cold air that is drawn 
in directly through the mouth. To keep these 
parts moist the mucous glands have to exhibit 
increased energy, and in those who speak much 
in public the glands may in time become so over- 
worked as to inflame. It is the inflammation 
of these glands that constitutes the present affec- 
tion. The glands are not distributed equally over 
all parts of the larynx, but are most numerous 



176 SURGICAL APPLIED ANATOMY [Part I 

in the membrane covering the arytenoid cartilages 
and parts immediately about them, the base of 
the epiglottis, and the interior of the ventricle. 
It is in these parts, therefore, that the changes 
in chronic glandular laryngitis, or dysphonia 
clericorum, are most marked. 

Excision of the laryiix.— The entire larynx 
has been removed for carcinomatous disease, but 
the operation, although not immediately fatal, 
has not been followed by very satisfactory results. 
It is removed through an incision in the middle 
line. In this incision are divided the platysma, 
the fascia, and the anterior jugular vein. The 
larynx is separated from its connections, the fol- 
lowing structures being divided : sterno-thyroid, 
thyro-hyoid, stylo-pharyngeus, palato-pharyngeus, 
and inferior constrictor muscles, laryngeal 
branches of the superior and inferior thyroid 
arteries, superior and inferior laryngeal nerves, 
hyo-epiglottic and glosso-epiglottic ligaments. The 
larynx is then separated from the trachea, and is 
dissected off from below up. In separating the 
gullet and pharynx there is great risk of " button- 
holing " the former tube. Growths and foreign 
bodies may be removed from the larynx by the 
operation of thyrotomy: the two alse of the thyroid 
are separated along the middle line and pulled 
apart, thus exposing the interior of the larynx. 
In subjects over 45 years of age the cartilage be- 
comes ossified in the middle line, and will require 
division by a fine saw. It should be remembered 
that the vocal cords are attached on each side of 
the median line near the mid point of the anterior 
border of the thyroid cartilage, while just above 
them are fixed the false vocal cords and stalk of 
the epiglottis. 

The lymphatic vessels of the upper half of the 
larynx follow the superior laryngeal vessels and 
pass to the upper deep cervical glands. A small 
lvmphatic gland, the first to become the seat of 
secondary cancerous deposit, is situated below 
the horn of the hyoid on the thyro-hyoid mem- 



Chap. IX] THE NECK 177 

brane (Fig. 35, p. 190). The lymphatics of the 
lower half of the larynx accompany the inferior 
thyroid vessels and pass through lymph glands 
by the side of the trachea. 

Tracheotomy and laryngotomy. — The trachea 
is about 4^ inches in length, and from f to 
1 inch in its extreme width. It is surrounded 
by an atmosphere of very lax connective ; tissue, 
which allows a considerable degree of mobility to 
the tube. The mobility of the trachea is greater 
in children than in adults, and adds much to the 
difficulties of tracheotomy. In this procedure the 
windpipe is opened in the middle line by cutting 
two or three of its rings above, below, or through 
the isthmus of the thyroid gland. Since the 
trachea, as it descends, lies further from the sur- 
face, and comes in relation with more and more 
important structures, it is obvious that, other 
things being equal, the higher in the neck the 
operation can be done the better. The length of 
trachea in the neck is not so considerable as 
might at first appear, and, according to Holden, 
not more than some seven or eight of the tracheal 
rings (which number sixteen to twenty in all) are 
usually to be found above the sternum. The dis- 
tance between the cricoid cartilage and the sternal 
notch varies greatly, and depends upon the length 
of the neck, the age of the patient, and the posi- 
tion of the head. If 2 inches of trachea are ex- 
posed above the sternum when the head rests easily 
upon the spine, then in full extension of the head 
some | of an inch more of the windpipe will, as 
it were, be drawn up into the neck. According 
to Tillaux, the average full distance between the 
cricoid cartilage and the sternum is, in the adult, 
about 2f inches (7 cm.). The full distance in a 
child between three and five years is about 1^ 
inches (4 cm.), in a child between six and seven 
about 2 inches (5 cm.), and in children between 
eight and ten years about 2| inches (6 cm.). As 
may be imagined, the dimensions of the trachea 
on section vary greatly at different ages, and even 

M 



178 SURGICAL APPLIED ANATOMY [Part I 

in different individuals of the same age. This 
leads to the question as to the proper diameter 
of tracheotomy tubes. Guersant, who has paid 
much attention to this matter, says that the dia- 
meter of the tubes should run from 6 mm. to 
15 mm.* The tubes with a diameter of from 
12 mm. to 15 mm. are for adults. The tubes below 
12 mm. are for children, and are divided into 
four sets. 

No 1 i with a dia * 1 fi mm i is suitable for 1 11 +n 4 vears of a?P 
JSo - 1 - 1 meter of ] b mm " 1 children from f ±2 t0 4 years ot age> 

No. 2. ,, 8 mm. ,, 4 to 8 „ 

No. 3. „ 10 mm. „ 8 to 12 

No. 4. „ 12 mm. ,, 12 to 15 

For children under eighteen months the dia- 
meter of the tube should be about 4 mm. 

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

In cutting down upon the trachea in the 
middle line of the neck from the cricoid cartilage 
to the sternum the following parts are met with : 
Beneath the integument lie the anterior jugular 
veins. As a rule these veins lie some little way 
apart on either side of the median line, and do 
not communicate except by a large transverse 
branch which lies in the interfascial space at the 
upper border of the sternum. Sometimes there 
are many communicating branches right in front 
of the tracheotomy district, or the veins may 
form almost a plexus in front of the trachea, or 
there may be a single vein which will follow the 
middle line. Then comes the cervical fascia, 
enclosing the sterno-hyoid and sterno-thyroid 

* The reader may be reminded that 12 mm. = about I an inch, and 
6 mm., therefore, = about \ of an inch. 



Ohap. IX] THE NECK 179 

muscles. The gap between the muscles of opposite 
sides is lozenge-shaped, and is such that the 
trachea can be exposed without dividing muscle 
fibres. The isthmus of the thyroid usually crosses 
the second, third, and fourth rings of the trachea. 
Above it a transverse communicating branch be- 
tween the superior thyroid veins is sometimes 
found. Over the isthmus is a venous plexus, from 
which the inferior thyroid veins arise, while be- 
low the isthmus these veins lie in front of the 
trachea together with the thyroidea ima < artery 
(when it exists). The inferior thyroid vein may 
be represented by a single trunk occupying the 
middle line. In the infant before the age of two 
years the thymus extends up for a variable dis- 
tance in front of the trachea. At the very root 
of the neck the trachea is crossed by the innomi- 
nate and left carotid arteries and by the left 
innominate vein ; and lastly, abnormal branches 
of the superior thyroid artery may cross the 
upper rings of the windpipe. 

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



180 SURGICAL APPLIED ANATOMY [Part I 

from an unduly prominent thymus. In one case, 
in an infant, the end of a tracheotomy tube press- 
ing on the front of the trachea produced an ulcer 
that opened the innominate artery (Brit. Med. 
Jour., 1885). In introducing the cannula, if the 
tracheal wound be missed, it is easy to thrust the 
instrument into the lax tissue beneath the cervical 
fascia and imagine that it is within the windpipe. 

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

Foreign bodies often find their way into 
the air passages, and have been represented by 
articles of food, teeth, pills, buttons, small stones, 
and the like. They are usually inspired during 
the act of respiration, and may lodge in the 
superior aperture of the larynx, or in the rima, 
or find their way into the ventricle, or lodge in 
the trachea, or enter a bronchus. If a foreign 
substance enters a bronchus it usually selects 
the right, that bronchus having its aperture more 
immediately under the centre of the trachea than 
has the left tube. On one occasion, in a dissecting- 
room subject, I found two threepenny pieces lying 
side by side, in the right bronchus, so as to en- 
tirely block the tube. The danger of inhaled 
foreign substances depends not so much upon the 
mechanical obstruction they offer, as upon the 
spasm of the glottis they excite by reflex irrita- 



Chap. IX] THE NECK 181 

tion. A body may, however, lodge in the ventricle 
for some time without causing much trouble, as 
in a case reported by Desault, where a cherry- 
stone lodged for fcwo years in this cavity without 
much inconvenience to its host. In one strange 
case a bronchial gland found its way into the 
trachea by producing ulceration of that tube, was 
coughed up, and became impacted in the rima 
glottidis. The patient was saved from immediate 
suffocation by tracheotomy. Foreign bodies have 
been removed from the right bronchus through a 
tracheotomy wound. In this way MacCormac 
removed from the bronchus the blade of a tooth 
forceps. 

The thyroid body.— Each lobe should mea- 
sure about 2 inches in length, about 1^ inches in 
breadth, and § of an inch in thickness at its 
largest part. When distinctly beyond these 
measurements the thyroid may be considered to 
be enlarged. Its usual weight is between one and 
two ounces. Of its three surfaces, the _ anterior 
is covered by the infrahyoid muscles,^ its inner 
rests on the larynx and trachea, while its outer 
or posterior covers the carotid sheath. Its promi- 
nent posterior border is in contact at its lower 
part with the recurrent laryngeal nerve and 
oesophagus. Each lobe extends from about the 
middle of the thyroid cartilage to the sixth ring 
of the trachea. It is larger in females than in 
males, and the right lobe is usually larger than 
the left. In connection with these matters it may 
be noted that thyroid enlargements (bronchocele, 
goitre) are more common in females than in 
males, and in any case are more apt to be first 
noticed on the right side. The body being closely 
adherent to the trachea and larynx, it follows 
that it moves up and down during deglutition, 
and this circumstance is of the utmost value in 
the diagnosis of bronchocele from other cervical 
tumours. A strong process of cervical fascia (the 
suspensory ligament of Berry) binds the gland to 
each side of the cricoid cartilage, and has to be 



182 SUEGICAL APPLIED ANATOMY [Fart I 

severed before complete removal is possible. The 
thyroid when enlarged may distort and narrow 
the trachea, and this is all the more likely to be 
the case when the enlargement occurs rapidly, 
since the body is held down by the sterno-hyoid, 
sterno-thyroid, and omo-hyoid muscles. The en- 
larged gland is apt to press especially upon the 
veins of the neck, producing engorgement of the 
face and head, upon the sterno-mastoid muscle, 
and the other muscles named, upon the cervical 
nerves, and particularly the recurrent laryngeal. 
In some cases of dyspnoea produced by rapidly 
growing bronchoceles, Bonnet has proposed sub- 
cutaneous section of the muscles. Since the isth- 
mus must bind together the enlarging lobes of a 
bronchocele, Sir Duncan Gibb, on the other hand, 
proposed to divide the isthmus in cases where 
dyspnoea resulted. This operation he performed 
several times with great relief to the patient. 
The posterior or outer surface of the thyroid body 
being in contact with the sheath of the great ves- 
sels, it follows that the gland when enlarged may 
readily receive pulsations from those vessels. It 
generally touches also the lower part of the 
pharynx, and the upper part of the gullet behind, 
and enlargement in this direction may, in con- 
nection with the interference with the movement 
of the larynx in deglutition, serve to explain the 
difficulty in swallowing often noticed in broncho- 
cele. 

The isthmus of the thyroid gland is developed 
from a diverticulum which is protruded from the 
ventral wall of the pharynx in the embryo between 
the mandibular and hyoid parts of the tongue. 
The foramen csecum of the tongue represents the 
point at which the diverticulum grew out from 
the pharynx. From this foramen a duct (the 
thyro-glossal) may be found to lead to accessory 
gland masses about the hyoid bone. In the vicinity 
of this bone accessory glands and small cysts lined 
with epithelium are not unfrequently met with. 
These glands, together with the so-called pyramid 



Chap. IX] THE NECK 183 

or middle lobe, are the remains of the neck of the 
primitive diverticulum. The pyramid, which is 
nearly always connected to the hyoid bone by the 
levator fchyroideae, exists in 79 per cent, of the 
subjects examined (Streckeisen). The lateral 
lobes are developed from the fourth visceral clefts. 
The median diverticulum occasionally fails to 
join one of the lateral, in which case the isthmus 
is partially absent. Small accessory thyroid 
bodies are frequently present. 

The parathyroid bodies appear to play an 
essential part in the function of the thyroid. 
They are of the size of small peas, and have a 
structure similar to that of the suprarenal bodies. 
Two are usually found on each side, one at the 
lower pole of the lateral lobe, the other behind 
the lobe amongst the terminal branches of the 
inferior thyroid artery. Parathyroid bodies be- 
come less numerous as age advances, so that in the 
aged none may be found (Forsyth). 

Atrophy of the thyroid gland, or its destruc- 
tion by disease, is apt to lead to a general con- 
dition of the body known as myxozdema. The con- 
dition closely resembles cretinism, especially as 
met with in goitrous subjects. Myxcedema may 
follow the entire excision of the gland by opera- 
tion, and has been produced in monkeys by ex- 
perimental removal of the same. One prominent 
feature in myxcedema is the swelling of the sub- 
cutaneous tissues from an accumulation therein 
of a mucinoid substance. 

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

In excision of the thyroid gland a Y-shaped 



184 SURGICAL APPLIED ANATOMY [Part I 

median cut is usually made that divides the skin, 
fascia, platysma, and anterior jugular veins. 
The sternohyoid, sterno-thyroid, omo-hyoid, and 
portion of the sterno-mastoid have usually to be 
divided. The tumour is carefully separated. The 
capsule that invests the vascular gland must not 
be torn through. The thyroid vessels are liga- 
tured in situ before the removal of the mass. The 
superior thyroid reaches the gland at the apex 
of the lateral lobe and is there secured. The in- 
ferior thyroid artery enters the lower part of the 
lobe at its posterior # aspect. In securing this 
vessel, and in liberating the lower part of the 
tumour, the recurrent laryngeal nerve is in great 
danger of being damaged. The thyroidea ima 
artery, an extra vessel to the thyroid body, 
usually arises from the innominate, and is found 
in one subject out of every ten. 

The gullet commences opposite the sixth 
cervical vertebra, and pierces the diaphragm 
opposite the tenth dorsal vertebra. The point is 
marked on the back by the overlapping spine of 
the ninth dorsal vertebra. By placing the stetho- 
scope a little to the left of this spine, fluid may 
be heard to enter the stomach. It presents three 
curves : one is antero-posterior, and corresponds 
to the curve of the spinal column ; the other two 
are lateral. The gullet, commencing at the middle 
line, deviates slightly to the left as far as the 
root of the neck ; from thence to the fifth dorsal 
vertebra it gradually returns to the middle line, 
and finally it turns again to the left, at the same 
time passing forwards, to pierce the diaphragm. 
Its length is from 9 to 10 inches. Its transverse 
diameter has been carefully estimated by Dr. 
Mouton, by filling the gullet with plaster-of-Paris 
in^ situ, and then measuring the cast thus ob- 
tained. Dr. Mouton found that there were three 
narrow parts in the gullet, one at its commence- 
ment, one about 2| inches from that point, and 
a third where the tube passes through the dia- 
phragm. The diameter at each of these points was 



Chap. IX] THE NECK 185 

a little over | an inch (14 mm.); the diameter else- 
where was about f of an inch (17 mm. to 21 mm.)- 
Bv forcible distension the two upper narrow parts 
could be distended to a diameter of 18 to 19 mm., 
the lower part to 2b mm., and the rest of the gul- 
let to a diameter of nearly lh inches (35 mm.). 
It follows that foreign bodies when swallowed 
are most apt to lodge either at the commence- 
ment of the gullet or at the spot where it passes 
through the diaphragm. The same parts also are 
those most apt to show the effects of corrosives that 
have been swallowed. 

Among the relations of the oesophagus, the 
following may be noted as receiving illustration 
in surgical practice : The gullet is in nearly all 
its course in close relation with the front of 
the vertebral column. In the neck the trachea 
is immediately in front of it. In the thorax 
it has the left bronchus, left bronchial glands, 
pericardium, and left auricle in front of it, while 
the two vagi form a plexus on it. The left 
bronchial glands, when enlarged, may press on the 
gullet, adhere to it, or even cause localised soften- 
ing and diverticula to spring from it. The 
thoracic duct passes behind to reach the left side 
of the gullet in the upper part of the thorax, 
while in the lower part the aorta, at first to the 
left of the oesophagus, gradually becomes pos- 
terior to it. It is, moreover, partly in contact 
with both pleurae, but more especially with the 
membrane of the right side ; and, lastly, the re- 
current laryngeal nerve ascends between it and 
the trachea. (See Figs. 39 and 69, pp. 218 and 414.) 

Now, foreign bodies impacted in the gullet are 
very apt to lead to ulcerations that may open 
adjacent parts. Thus, in the Musee Dupuytren is 
a specimen showing a five-franc piece that had 
stuck in the gullet, and had produced an ulcer 
that had opened the aorta. In another instance 
a " smasher " swallowed a counterfeit half-crown 
piece. Eight months afterwards he died of 
haemorrhage. The coin had sloughed into his 



186 SURGICAL APPLIED ANATOMY [Part I 

aorta. In another case (Lancet, 1871), a fish-bone, 
lodged in the gullet opposite the fourth dorsal 
vertebra, had caused two perforating ulcers ; one 
on the right side had caused plugging of the vena 
azygos major, while the other on the left had made 
a hole in the aorta. Less frequently impacted 
foreign substances have found their way into the 
trachea and into the posterior mediastinum. Dr. 
Ogle reports a case {Path. Soc. Trans., vol. iv. ) 
where a piece of bone impacted in the gullet 
induced ulceration of an intervertebral disc and 
subsequent disease of the spinal cord. Carcinoma 
of the gullet, also, when it spreads, is apt to 
invade adjacent parts, and especially to open into 
the trachea or bronchi. If it spreads to the 
pleura, it will usually involve the right pleura, 
as being the membrane more in relation with the 
gullet. Cancer of the gullet has so spread as to 
invade the thyroid body, the pericardium, and 
the lung, and has opened up the first intercostal 
artery in one case and the right subclavian in 
another (Butlin's " Sarcoma and Carcinoma/' 
1882). 

The sensory nerve supply of the oesophagus 
comes mainly from the fifth dorsal segment of the 
cord (Head). In cases of cancer or burns of the 
gullet, pain is referred to the skin of this seg- 
ment (see Fig. 56, p. 333). 

(Esophageal malformations. — In the newly 
born the upper part of the oesophagus may end 
blindly, while the lower part commences by an 
opening in or near the bifurcation of the trachea, 
so that milk can only reach the stomach by first 
passing into the larynx and trachea. Death soon 
follows from suffocation or septic pneumonia. 
The condition is the result of a maldevelopment 
of the septum between the trachea and oesophagus. 
Hernial diverticula of the mucous membrane occa- 
sionally occur at the junction of the oesophagus 
and pharynx. They are usually named pharyngeal 
pouches, and protrude between the lower border 
of the inferior constrictor and commencement of 



Chap. IX] THE NEfitv 187 

the oesophageal musculature, opposite the cricoid 
cartilage. Since the pouch lies against the spine, 
it necessarily compresses the commencement of the 
oesophagus when it becomes filled with food. 

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

Oreat vessels. — The course, relations, and 
abnormalities of the great cervical vessels, to- 
gether with the operations whereby they may be 
ligatured, and the details pertaining to those 
procedures, are so fully given, not only in works 
on operative surgery, but also in the chief ana- 
tomical text-books, that nothing need be said upon 
the matter in this place. The bifurcation of the 
common carotid is a favourite locality for aneur- 
ism, being a point where some resistance is offered 
to the blood current. These tumours, also, are 
common at the root of the neck, where they are 
often due to extension of aneurismal disease from 
the aorta, although in many cases they have an in- 
dependent origin. It is in the neck that the treat- 
ment of aneurism by the distal ligature is most 
often carried out. There is no place in the body 
where Brasdor's operation can be carried out with 
the completeness with which it can be adopted 
in the neck. In this procedure a main trunk is 
ligatured on the distal side of an aneurism, no 
branches intervening between the sac and the liga- 
ture. The cure by this measure depends upon the 



188 SURGICAL APPLIED ANATOMY [Part I 

fact that blood does not continue to go to parts 
when once the need for blood in them is dimin- 
ished. Thus, after amputation at the hip joint, 
the femoral artery, having no need to carry to 
the stump the amount of blood it brought to the 
limb, often shrinks to a vessel no larger than 
the radial. When an aneurism low down in the 
carotid artery is treated by ligature of the vessel 
near its bifurcation by Brasdor's method, the 
blood, having now, as it were, no object in enter- 
ing the carotid trunk, soon ceases to fill the 
vessel entirely, and the artery (and in successful 
cases the aneurism) shrinks in consequence. 
Wardrop's operation, or the distal ligature of 
large branches for the relief of aneurism of a main 
trunk, is now, perhaps, quite limited as to its 
performance to the ligature of the carotid and 
subclavian arteries for innominate aneurism. 
Since in this procedure large branches come off be- 
tween the sac and the ligature, it is not easy to 
fully understand how the operation acts bene- 
ficially. It is assumed to owe its success to the 
same principle that underlies Brasdor's operation. 
The right carotid and subclavian have also been 
ligatured for aortic aneurism with some success, 
and here also the reason for the good effected by 
the operation is difficult to appreciate. It has 
been pointed out that the innominate artery lies 
more or less directly in the axis of the ascending 
aorta, while the left carotid and_ subclavian 
arteries arise at an angle to that axis, and it is 
upon this fact that reasons have been founded for 
selecting the vessels of the right side (Barwell). 
The matter is, however, complicated by the know- 
ledge that when vegetations are swept off the 
aortic valves they enter the left carotid with in- 
finitely greater frequency than they do the right. 
The whole subject, indeed, requires investigation. 
The cervical connective tissue being lax, aneur- 
isms in this part can grow and spread rapidly, 
and usually soon produce " pressure symptoms." 
As examples of these may be noted oedema and 



Chap. IX] THE NECK 189 

lividity of the face and of the upper limb from 
pressure upon the main veins, laryngeal symptoms 
from pressure upon the recurrent nerve or trachea, 
spasm of the diaphragm from pressure upon the 
phrenic nerve, damage to the sympathetic, and 
giddiness and impaired vision from anaemia of 
the brain. 

The vertebral artery has been ligatured with 
doubtful benefit in cases of epilepsy. It is sur- 
rounded by vasomotor nerves derived from the 
inferior cervical ganglion, which also are neces- 
sarily tied. The artery is reached through an in- 
cision made along the posterior border of the 
sterno-mastoid muscle just above the clavicle. The 
" carotid tubercle " {see p. 158) is then sought 
for, and vertically below it lies the artery, in 
the gap between the scalenus anticus and longus 
colli muscles. The procedure is surrounded with 
considerable difficulties. 

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

Air in veins. — The veins of the neck are 
under the influence of the respiratory movements. 
The veins do not collapse owing to attachments to 
the surrounding fasciae. During inspiration these 
vessels become more or less emptied; during ex- 
piration they become enlarged and turgid. With 
greatly impeded breathing they may attain for- 
midable size. Since ether usually causes some 
respiratory difficulty, it is seldom administered 
in operations on the neck. The only other veins 
that are under the influence of the aspiratory 
power of the thorax are the axillary vein and 
its larger tributaries. When any one of these 
vessels is wounded, and the wound is for the 



190 



SURGICAL APPLIED ANATOMY [Part I 



moment dry, air may very readily be drawn into 
it during the inspiratory act, just as air is drawn 




Fig. 35.— Showing the position of the lymphatic glands of the head and 
neck. The outlines of the sterno-mastoid (s.m.), trapezius (tr. ), 
internal jugular, subclavian, and right innominate veins are shown. 

1, Submaxillary glands, 1' area drained ; 2, suprahyoid glands, 2' area drained : 
3, parotid glands, 3' area drained; 4, postauricular glands, 4' area drained; 
5, occipital glands, 5' area drained ; C, in front of external jugular vein, marking 
position of the superficial cervical glands ; 7, laryngeal gland ; 8, 8, 8, upper 
deep cervical glands; 9,9,9, lower deep cervical glands; 10 gland receiving 
lymph from thyroid ; 11, superior mediastinal glands ; 12, axillary glands. 



Chap. IX] THE NECK 191 

into the trachea. The air causes embolism of the 
pulmonary capillaries. 

Valves in the veins of the neck. — The sub- 
clavian veins and their tributaries are liberally 
provided with valves, but the internal jugular has 
only one pair, situated at its termination in the 
innominate vein. There are no valves in the in- 
nominate veins nor in the superior vena cava. 
When the venous pressure within the^ thorax is 
greatly raised, as in lifting heavy weights, only 
the terminal valves of the internal jugular vein 
prevent the transmission of the pressure to the 
brain. In accidents which cause sudden compres- 
sion of the thorax, the head and neck may remain 
livid for days following the accident. The 
lividity is probably due to the jugular valves 
yielding, thus subjecting the capillaries of the 
head and neck to a higher pressure than they are 
able to withstand. 

The lymphatic glands of the head and 
neck are numerous, and arranged in the follow- 
ing sets (Fig. 35) : — 

(1) Submaxillary glands, 10 to 15 in number, 
situated at the lower border of the jaw beneath 
the cervical fascia ; (2) the suprahyoid, 1 or 2 
in number, situated between the chin and hyoid 
bone near the middle line; (3) parotid or pre- 
auricular set, situated in and over the parotid 
gland ; (4) postauricular, or mastoid, 2 to 4 in 
number, situated over the mastoid process; (5) 
occipital, 3 to 5 in number, over the insertion 
of the complexus muscle ; (6) superficial cervical 
glands, often absent, situated over the sterno- 
mastoid along the ^ external jugular vein; (7) 
laryngeal, 1 to 3 in number, below the great 
horn of the hyoid ; (8)_ the upper deep cervical set, 
10 to 20 in number, situated over the upper part 
of the internal jugular vein and bifurcation of the 
common carotid artery ; (9) lower deep cervical 
set, surrounding the terminal parts of the in- 
ternal jugular, subclavian, external jugular, and 
transverse cervical veins. This set becomes 



192 SURGICAL APPLIED ANATOMY [Part I 

continuous with the axillary and mediastinal 
glands. 

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

Scalp. — Posterior part = occipital and post- 
auricular glands. Frontal and parietal portions 
== parotid glands (Fig. 35). 

Vessels from the scalp also enter the super- 
ficial cervical set of glands. 

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

External ear = superficial cervical glands. 

Lotver lip = submaxillary and suprahyoid 
glands. 

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

Gums of lower jaw = submaxillary glands. 

Tongue. — Anterior portion = suprahyoid and 
submaxillary glands. Posterior portion = deep 
cervical glands (upper set). 

Tonsils and palate == deep cervical glands 
(upper set). 

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

Larynx, orbit, and roof of mouth = deep cer- 
vical glands (upper set). 

Nasal fossce — retropharyngeal glands, deep 
cervical glands (upper set). Some lymphatics 
from the posterior part of the fossae enter the 
parotid glands.*" 

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



Chap. IX] THE NECK 193 

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

Thoracic duct in the neck. — A point taken 
on the upper border of the clavicle, 1 inch from 
its sternal end, will mark the angle between the 
internal jugular and subclavian veins where the 
thoracic duct ends. At its termination the duct 
curves outwards over the scalenus anticus and 
phrenic nerve above its point of entrance where 
it is furnished with valves. It may be double 
or triple at its termination. Ligature of the duct 
is followed by no untoward symptoms, as a rule, 
a result which is due to the free anastomosis which 
exists between it and the lymphatics of the right 
side of the thorax and to communications with 
the azygos veins (Leaf). 

Branchial nstiihr. — Certain congenital fis- 
tula? are sometimes met with in the neck, which 
are due to partial persistence of one of the 
branchial clefts. These clefts are placed in the 
foetus between the branchial arches. The arches 
are usually described as five in number. The 
first lays the foundation for the lower jaw and 
malleus. From the second are developed the 
styloid process, the stylo-hyoid ligament, and 
lesser cornu of the hyoid bone. From the third are 
formed the body and greater cornu of the hyoid 
bone, while the fourth and fifth take part in the 
formation of the soft parts of the neck below the 
hyoid bone. The first cleft is between the first and 
second arches. " The cervical branchial fistulse 
appear as very fine canals opening into minute 
orifices in one or both sides of the fore part of 
the neck and leading backwards and inwards or 
backwards and upwards towards the pharynx or 
N 



194 SURGICAL APPLIED ANATOMY [Part I 

oesophagus ' ; (Paget). Their length is about lj to 
2£ inches, and their diameter varies from that of 
a" bristle to that of an ordinary probe. They 
usually exist about the line of the third or fourth 
cleft, and are most often met with just above the 
sterno-clavicular joint. Others are found about 
the level of the top of the thyroid cartilage at the 
anterior edge of the sterno-mastoid muscle. About 
some of these fistulse, or in spots where they com- 
monly open, flat pieces of cartilage may be found. 
The more prominent of these have been^ termed 
supernumerary auricles. Certain dermoid cysts 
of the neck arise from unobliterated branchial 
spaces, and it would appear also, that certain 
polycystic congenital tumours, occurring as one 
form of " hydrocele of the neck, ;J may be de- 
veloped from an imperfectly closed cleft. I have 
elsewhere detailed the dissection of one of these 
tumours that appeared to be associated with a 
partially closed second branchial cleft (Path. 
Soc. Trans., 1881). 

His has shown that many branchial fistulse and 
cysts are formed from the cervical sinus. The 
cervical sinus is produced in the neck of the em- 
bryo by a rapid growth in the second and third 
arches which causes them to grow backwards and 
overlap the fourth and fifth. The piece of epiblast 
thus included in the neck usually disappears, but 
it may persist and give rise to a cyst or, if open, 
to a fistula. The common fistula, that which opens 
above the sterno-clavicular joint, is derived from 
the cervical sinus. It is to be remembered that 
the branchial clefts are only depressions in the 
wall of the pharynx, not complete fissures. Hence 
fistulas rarely communicate with the pharynx. 

The ventricle of the larynx, as is normally the 
case in many apes, may become prolonged into a 
sac which passes into the neck through the thyro- 
hyoid membrane, thus forming a cervical air 
cyst or sac, 



Part II.— THE THORAX 



CHAPTER X 

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

In pigeou breast deformity the sternum and 
cartilages are rendered protuberant, so that the 
antero-posterior measurement of the chest is much 
increased, while a deep sulcus exists on either 
side along the line of junction of the ribs and 
their cartilages. It is by the sinking in of the 
parietes along the costo-chondral junctions that 
the protuberance is produced. 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 suction 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 

195 



196 SUKGICAL APPLIED ANATOMY [Part II 

the parietes yield most conspicuously in such 
cases, and by this yielding the deformity is pro- 
duced. 

Deformities of the chest result from abnor- 
mal curvatures of the dorsal part of the spinal 
column. The ribs are firmly bound to the verte- 
brae by the costo-vertebral and costo-transverse 
ligaments, and hence alteration in the position of 
vertebras is attended by changes in the costal 
series. Thus, when there is kyphosis in the dorsal 
region the upper part of the spine is bent for- 
wards and downwards, carrying with it the 
upper ribs and the sternum. The antero-posterior 
diameter of the thorax is thereby increased, but 
its vertical and transverse measurements are de- 
creased. When lateral curvature is produced in 
the dorsal region, the ribs, on the side towards 
which the bend occurs, are necessarily compressed, 
while on the opposite side they are separated. In 
scoliosis of the spine not only is a lateral curva- 
ture formed, but the vertebras undergo a rotation 
at the same time. The vertebral bodies move to- 
wards the convexity and their spines towards the 
concavity of the curvature (Fig. 36). The ribs on 
the concave side are carried forwards on the trans- 
verse processes and their angles open out, the side 
of the chest becoming flattened behind. On the 
other side (convex) the angles are unduly promi- 
nent, for the ribs are carried backwards at their 
vertebral extremities and bent inwards in front. 
The transverse diameter of the chest thus becomes 
oblique (Fig. 36). On the concave side the inter- 
costal spaces are diminished in size, the ribs even 
coming into contact, while on the convex side 
the spaces are increased in size. The thoracic 
viscera are necessarily distorted in shape and 
altered in position. 

The sternum.— The upper edge of the sternum 
corresponds to the disc between the second and 
third dorsal vertebrae, and the sterno-xiphoid 
joint to the middle of the tenth dorsal. In the 
foetus at full term the upper edge of the sternum 



Chap. X] 



THE THORAX 



197 



STERNUM 




AN OLE: 

Ari<;Le 

Fig. 36.— Showing the changes in the thorax 
which follow scoliosis of the spine. 
(After Redard.) 

The convexity of the spinal curvature is towards 
the right ; on that side the ribs are sharply bent 
at their angles. On the concave Cleft) side the 
ribs have an open angle. 



is opposite the middle of the first dorsal vertebra 
(Symington). A transverse ridge may be felt 
upon its anterior surface that- corresponds to the 
junction of the manubrium and gladiolus, and is 
in a line with 
the second costal 
cartilages. The 
skin over the 
sternal region is 
the part of the 
surface most fre- 
quently the seat 
of cheloid. The 
bone is rarely 
fractured, being 
soft and spongy, 
and supported by 
the elastic ribs 
and their cartil- 
ages, as by a 
series of springs. In the old, when the cartilages 
are ossified and the chest is more rigid, the tend- 
ency to fracture is increased. The sternum is most 
often found fractured in connection with injuries 
to the spine, although it may be broken by 
simple direct violence. The bone may be frac- 
tured by violent bending of the spine backwards, 
and by abrupt bending of it forwards. In the 
former instance the lesion is probably due to 
muscular violence, to the abdominal muscles and 
the sterno-mastoicl pulling one against the other. 
In the latter instance the lesion is commonly 
brought about by the violent contact of the chin 
with the bone. Dislocation may occur ^ at the 
sterno-manubrial joint. The manubrium in these 
injuries generally remains in situ, while the 
gladiolus with the ribs is displaced forwards in 
front of it. A considerable degree of respiratory 
movement takes place at this joint; only in very 
old people does it become obliterated by bony 
union. It possesses a distinct synovial cavity 
surrounded by strong fibrous and fibro-cartilagin- 



198 SURGICAL APPLIED ANATOMY [Part II 

ous ligaments. Malgaigne cites the case of a 
youth who, from constant bending at his work as 
a watchmaker, caused the second piece of the 
sternum to glide backwards behind the manu- 
brium. 

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

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

The ribs are placed so obliquely that the an- 
terior end of one rib is on a level with the pos- 
terior end of a rib some way below it in numerical 
order. Thus the second rib in front corresponds 
to the fifth rib behind, and the insertion of the 
seventh to the tenth. If a horizontal line be 
drawn round the body at the level of the inferior 
angle of the scapula, while the arms are at the 
side, the line would cut the sternum in front at 
the attachment of the sixth cartilage, would cut 
the fifth rib at the nipple line, and the ninth rib 
at the vertebral column. The second rib is indi- 
cated by the transverse ridge on the sternum 
already alluded to (angulus Ludovici). The lower 



Ohap. X] THE THOBAX. 199 

border of the pectoralis major leads to the fifth 
rib, and the first visible serration of the serratus 
magnus corresponds to the sixth. The longest rib 
is the seventh, the shortest the first. The most 
oblique rib is the ninth. 

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

Those most often broken are the sixth, seventh, 
and eighth, they being under ordinary circum- 
stances the most exposed. The rib least frequently 
fractured is the first, which lies under cover of the 
clavicle. In elderly people dying from phthisis the 
cartilage of the first rib is often found to be cal- 
cified and occasionally to be fractured. Fractures 
are more common in the elderly than in children, 
owing to the ossification of the cartilages that 
takes place in advancing life. When a rib is 
fractured, no shortening occurs, the bone being 
fixed both in front and behind, while vertical 
displacement is prevented by the attachments of 
the intercostal muscles. Thus no obvious de- 
formity is produced unless a number of consecu- 
tive ribs are the subjects of fracture. These bones 
have been broken by muscular violence, as during 
coughing, and in violent expulsive efforts such as 



200 SURGICAL APPLIED ANATOMY [Part II 

are incident to labour. In such instances the ribs 
are probably weakened by atrophy or disease. 

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

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

The intercostal spaces are wider in front 
(than behind, and between the upper than the 
lower ribs. The widest of the spaces is the third, 
then the_ second, then the first. The seventh, 
eighth, ninth, and tenth interspaces are very nar- 
row in front of the angles of the ribs. The first 
five spaces are wide enough to admit the whole 
breadth of the index finger. The spaces are 
widened in_ inspiration, narrowed in expiration, 
and can be increased in width by bending the body 
over to the opposite side. 

1 , Paracentesis is usually performed in the 
/sixth or seventh space, at a point midway between 
//the sternum and the spine, or midway between the 
/ anterior and posterior axillary lines. The seventh 
space can be readily identified by its relation- 
ship to the angle of the scapula; when the arm is 
by the side of the body this space is slightly over- 
lappedby the angle. If a lower space be selected 
there _ is danger of wounding the diaphragm, 
especially upon the right side. If the eighth or 
ninth space be selected the incision is made just 
externally to the line of the angle of the scapula. 
The trochar should be entered during inspiration, 
the space being widened thereby, and should be 
kept as near as possible to the lower border of the 



Chap. X] THE THORAX 2C1 

space, so as to avoid the intercostal vessels. Tap- 
ping of the chest through any space posterior 
to the angles of the ribs is not practicable, owing 
to the thick covering of muscles upon the thoracic 
wall in this place, and the fact that the inter- 
costal artery, having a more horizontal course 
than the corresponding ribs, crosses the middle 
of this part of the space obliquely. Beyond the 
angle the intercostal vessels lie in a groove on the 
inferior border of the rib forming ^ the upper 
boundary of the space. The vein lies immediately 
above the artery, and the nerve immediately below 
it. In the upper four or five spaces, however, the 
nerve is at first higher than the artery. Paracen- 
tesis of the thorax is occasionally followed by syn- 
cope or even death. It is difficult to account for 
such a result ; it may be a reflex inhibition of the 
heart set up during perforation of the parietal 
pleura, which is richly supplied by the intercostal 
nerves, or by injury to the lung, which is supplied 
by the vagus. 

Pus may readily be conducted along the loose 
tissue between the two layers of intercostal mus- 
cles. Thus, in suppuration following upon disease 
of the vertebrae, or of the posterior parts of the 
ribs, the pus may be conducted along the inter- 
costal spaces to the sternum, and may thus pre- 
sent at a considerable distance from the real seat 
of the disease. 

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

In some cases of long-standing empyema with an 
open sinus, all that part of the bony wall of the 
thorax w T hich corresponds to the outer boundary 
of the suppurating cavity is removed in order that 
the cavity may collapse and be in a position to 
close. This latter measure is known as Estlander's 
operation, or thoracoplasty. In some instances 
portions of as many as nine ribs have been ex- 
cised, and the total length of bone removed has 
reached 50 to 60 inches. 



202 SURGICAL APPLIED ANATOMY [Part II 

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

The internal mammary artery runs paral- 
lel to the border of the sternum, and about ^ an 
inch from it. It may give rise to rapidly fatal 
haemorrhage if wounded. The vessel may readily 
be secured in the first three intercostal spaces, and 
with some difficulty in the fourth or fifth space. 
It is most easily reached through the second space, 
and cannot be secured through any space below the 
fifth. 

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

Although the principal part of the breast rests 
on the pectoralis major, quite one-third of the 
gland crosses the outer border and rests on the 
serratus magnus within the axilla. It also covers 
the origins of the obliquus abdominis externus and 
rectus abdominis. In excision or inflammation 
of the breast it is important to bind the arm by 
the side to keep the parts from being disturbed 



Chap. X] THE THORAX 203 

by the pectoralis major. Peripheral processes of 
the gland and many of its deep lymphatics enter 
the pectoral sheath, hence the removal of this 
structure with part, or even all, of the pectoral 
musculature if complete extirpation of cancer is 
to be assured. The loose retromammary tissue 
which binds the mamma loosely to the pectoral 
sheath may be the seat of abscess, or sometimes of 
a bursal cyst. 

The nipple, in the male and in the virgin 
female, is situated on the fourth intercostal space, 
about | of an inch from the junction of the ribs 
with their cartilages ; after lactation the breast 
becomes pendent, and the nipple no longer serves 
as a guide to the intercostal spaces. The nipple 
contains erectile and muscular tissue, and_ is 
richly supplied by cutaneous branches ofthe third 
and fourth spinal nerves. The skin is pigmented, 
thin and sensitive, and often the seat of painful 
fissures and excoriations. In painful diseases of 
the breast, tender areas occur over the fourth and 
fifth spinal segments (Fig. 56, p. 333) (Head). 

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

It is through lymph channels that cancer 
spreads, and those of the breast, which is one of 
the commonest sites of cancer, are of especial im- 
portance if complete eradication of the disease is 
to be obtained. The lymph vessels are arranged in 
the following sets : (1) Perilobular, round the 
acini and lobules ; (2) periductal, round the lac- 
tiferous ducts ; (3) interlobar, situated in the 
interlobar septa and joining (4) the retromam- 



204 SUPGICAL APPLIED ANATOMY [Part II 

mary network with (5) the superficial mammary 
in the anterior part of the capsule. If the inter- 
lobar septa are invaded by cancer they contract, 
and through their cutaneous attachments cause 
depressions in the skin ; if the process invades the 
periductal vessels, the nipple is retracted. The 
mammary lymphatic system is connected with the 
subcutaneous network of vessels, to which cancer 
may spread, producing that variety of the disease 
known as cancer en cuirasse. Through communi- 
cations with the lymph channels of the pectoral 
fascia and muscle, cancer of the breast may spread 
to these structures. The gland then becomes 
firmly fixed to the deeply seated structures. The 
majority of the lymph vessels pass from the breast 
to the pectoral glands, six to eight in number, 
situated along the anterior border of the axilla, 
and to the central axillary set, twelve to fifteen 
in number, situated beneath the axillary tuft of 
hair and on the inner side of the axillary vein. 
From these two sets the lymph vessels pass to the 
deep axillary glands lying along the front and 
inner side of the axillary vessels. The deep axil- 
lary glands become continuous with the lower deep 
cervical glands. It is mainly along this path that 
cancer tends to spread, but vessels leave the inner 
segment of the breast and pass to the anterior 
intercostal glands situated in the upper four 
intercostal spaces and lying on each side of the 
internal mammary vessels, while occasionally a 
few vessels pass to the cephalic gland situated 
in the hiatus between the deltoid and pectoralis 
major muscles. Handley found a marked ten- 
dency for breast cancer to spread downwards in 
the lymphatics, passing to the epigastric triangle, 
where they perforate the belly wall to join lym- 
phatics both above and below the diaphragm ; it 
is probably owing to this communication that the 
liver is so often the seat of secondary deposit in 
cases of cancer of the breast. When the normal 
channels become clogged with cancerous emboli the 
lymph passes by circuitous paths. The subscapu- 



Chap. X] THE THORAX 205 

lar glands, surrounding the subscapular vessels on 
the posterior wall of the axilla, may become in- 
filtrated; through the lymphatics of the arm, 
which end in the central axillary glands, the 
structures round the shoulder may become the 
seats of secondary deposit, and through the com- 
munication between the lymph system of one 
breast with that of the other, across the sternum, 
a secondary deposit may even occur in the oppo- 
site breast (Stiles). 

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

The intercosto-humeral nerve pierces the cen- 
tral set of axillary glands. It becomes compressed 
when these glands are invaded by cancer, and 
pain is referred to the termination of the nerve 
over the posterior aspect of the arm above the 
elbow. Various parts of the brachial plexus may 
also become involved or the axillary vein or lym- 
phatics occluded, the arm being swollen and 
cedematous in consequence. 

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

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



206 



SURGICAL APPLIED ANATOMY [Part II 



breasts on the buttock or back, where they are 
occasionally found. 

2. The thoracic viscera. 

The lung*. — The apex of the lung rises in the 
neck from 1 to 2 inches above the inner half of 
the clavicle. Its highest point in the majority 
of adults lies 1| inch above the sternal end of 
the clavicle, in the interval between the sternal 

Pulmonary Apex 

iX LAV I CLE: 

Pleural Lime 
.Stereo- AIanub. Point 



/ilPPLE 

Uncovered Area 
5TER/10- ErtSIf ORN Poifll 



Pulmonary Line 

Pleural Line 
2" 




Apex Point 
Pulmonary Line 

Pleural Line 
2" 



Fig. 37. — Diagram showing the surface markings for the lungs and pleura. 

and clavicular heads of the sterno-mastoid muscle 
(Fig. 37). The anterior edges of the two lungs 
pass behind the sternoclavicular articulations, 
and meet in the middle line at the junction of the 
manubrium with the gladiolus. The edge of the 
right lung then continues vertically downwards 
behind the middle line of the sternum to the sixth 
chondro-sternal articulation, where it slopes off 
along the line of the sixth cartilage. The edge of 
the left lung keeps close to that of the right as far 



Chap. X] THE THORACIC VISCERA 207 

as the fourth chondro-sternal articulation, where 
it turns off to the left, following a line drawn 
from the fourth cartilage to near the apex of the 
heart (Fig. 37). Occasionally it does not diverge, 
but completely covers the pericardium up to the 
edge of the sternum. In the child, owing to the 
thymus, the lungs are more separated in front. 
The right reaches the middle line, but the left only 
reaches the left edge of the sternum (Symington). 
The easiest and also the most accurate method of 
indicating the lower border of the lung is the fol- 
lowing (Fig. 37) : A line is drawn along the sixth 
costal cartilaere from its sternal end to its heel; 
from the heel the line is carried horizontally 
round the body; it will be found to cross the 
median line behind, at, or near the eleventh dorsal 
spine (the anticlinal spine). The corresponding 
border of the pleura is not parallel to the lower 
border of the lung ; it is indicated by a line drawn 
along the seventh costal cartilage from its sternal 
end to its heel ; from there the line is continued 
to a point 2 inches above the lowest part of the 
subcostal margin and then prolonged horizontally 
to the median line behind where it crosses at or 
near the twelfth dorsal spine. Between the pul- 
monary line above and the pleural line below, the 
diaphragm is in contact with the chest wall, separ- 
ated only by the costo-phrenic reflection of the 
pleura. On the left side these lines commence at 
a variable distance from the sternum — 1 inch 
should be allowed for the pleura; 2-§- inches for the 
lung (Fig. 37). The pleura is in relation with 
the twelfth rib, but occasionally it descends | an 
inch or more below this point, and may be 
wounded in operations on the kidney (Fig. 65, 
p. 402). It extends lower down in the child than 
in the adult. The left lung descends to a slightly 
lower level than the right. 

In penetrating wounds involving the pleura^ 
air may enter the pleural cavity, producing 
pneumothorax, and this air may be subsequently 
pressed by the respiratory movements into the 




208 SURGICAL APPLIED ANATOMY [Part II 

subcutaneous tissues through the wound in the 
parietal pleura, and lead to surgical emphysema. 
The cohesion between the smooth pulmonary and 
parietal layers of pleura is such that occasionally 
collapse does not follow, but the intimate connec- 
tion between them makes it difficult for the pul- 
monary to escape when the parietal layer is 
wounded. In wounds of the lung without exter- 
nal wound, as when that organ is torn by a 
fractured rib, the air escapes from the lung into 
the pleura, and may thence pass into the subcu- 
taneous tissues through the pleural wound, thus 
producing both pneumothorax and emphysema. 

It is well to note that emphysema may occur 
about certain non-penetrating wounds of the 
thorax when they are of a valvular nature. In 
such cases the air is drawn into the subcutaneous 
tissues during one respiratory movement, and is 
forced by another into the cellular tissue, the valv- 
ular nature of the wound preventing its escape 
externally. When the pleural " cavity ; ' is opened, 
the lungs, owing to the amount of elastic tissue 
they contain, undergo some degree of collapse, but 
there is much misconception regarding the extent 
to which this takes place. Half the air in the 
lung, in some cases even two-thirds, is residual 
and cannot be expelled by the passive collapse of 
the lung; when the diaphragm is pushed up and 
the ribs are pulled down by the expiratory efforts 
of the muscles of the belly wall the thoracic space 
may be so reduced in size that the lung still more 
than fills it ; if the glottis be closed a hernia of the 
lung will occur through the wound in the chest 
wall. If, however, there is a valvular orifice into 
the pleural cavity, so that air can be sucked 
in but not expelled from it, every respiratory 
effort increases the amount of air in the pleural 
snace ; then compression of the lung and suffoca- 
tion quickly ensue. MacEwen is of opinion that 
collapse of the lung is prevented by the capillary 
attraction which exists between the visceral and 
parietal layers of the pleura. 



Chap. X] 



THE THORACIC YISCERA 



209 



In wounds of the lung the blood may escape 
in three directions : into the tissue of the organ 
(pulmonary apoplexy), into the bronchi (causing 
haemoptysis), and into the pleura (causing hsemo- 
thorax). In some instances the lung has been rup- 
tured without wound and without fracture to the 
ribs. These cases are difficult to interpret, and 




Right Int. Juc lilac Vewn 

Right Subclavian Ve 
Right Innoni- v ein 

5tep.no ManuB.Poin 

SuPERKDR VENACAV 

Pericardium 
RiCmt Auricle 

JRiCulC -VENTRICULAR 

q«.oovE 
Dome: 
,teknoE:nsiforn Line- 
mferioR Caval Point 
erno* cnsiforn poim 
nferiOR Vena Cava 



Left InnominateVein 

Arch op Aorta 
Pulmonary Artery 

Left Ventricle 

/ilPPLE- 
RlQHT VENTRICLE; 



Left Dome 
Apex Point 



Fig. 3S.— The relationship of the pericardium and heart to the sternum 

and ribs. 



probably the best explanation suggested is that 
put forward by M. Gosselin. This surgeon be- 
lieves that at the time of the injury the lungs are 
suddenly filled and distended with air by a full 
inspiration, and that the air, prevented from 
escaping by occlusion of the larynx, thus becomes 1 
pent up in the pulmonary tissue, and the lung not 
being able to recede from the superincumbent pres- 
sure, its structure necessarily gives way. 

Owing to the fineness of its capillaries, and to 
o 



210 SURGICAL APPLIED ANATOMY [Part II 

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

Lung cavities resulting from tuberculosis, gan- 
grene, or bronchiectasis have been successfully in- 
cised and drained, and the same measure has been 
applied to hydatid cysts of the lung. Deep in- 
cisions in the lung are followed by less haemor- 
rhage than might be expected from such a vascular 
organ. 

The trachea divides opposite the junction of 
the manubrium and gladiolus in front, and the 
fourth dorsal vertebra behind. 

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

The root of the lung and bronchi can be ex- 
posed by opening the dorsal wall of the thorax 
behind the vertebral border of the scapula. Rus- 
sell and Fox record the case of a boy in whom a 
pin, 3 inches long, had slipped head downwards 
within the trachea, and ultimately lodged in the 
lower division of the left bronchus. They resected 
part of the eighth rib from the back, pushed the 
lung forwards to expose the bronchus at the root, 
and removed the pin. The root of the lung re- 
quires to be steadied; through the pericardium it 
is intimately bound to the diaphragm and follows 
the movements of that muscle. In the case men- 
tioned above, the boy was able to leave the hospital 
I twelve days after the operation. 
•^ The heart and pericardium.— The position 
and extent of the pericardium may be indicated 
thus on the surface of the thorax (Fig. 38) : Three 
points are taken: (1) the apical, over the apex 
beat, in the fifth left intercostal space, 3^ inches 



Ohap. X] THE THOKACIC VISCERA 211 

from the sternum ; (2) the sterno-manubrial, mid- 
way between the insertions of the second costa] 
cartilages; (3) the inferior cava!, 1 inch to the 
right of the sterno-ensiform point and directly 
superficial to the termination of the inferior vena 
cava. When these three points are united by 
curved lines, as in Fig. 38, the area over the peri- 
cardium and its contents is marked out. The 
lower line crosses \ an inch or more below the 
sterno-ensiform point ; if a trochar be thrust back- 
wards in the angle between the ensiform process 
and seventh left costal cartilage, it enters the 
pericardium just above the diaphragm. Through 
this angle the pericardium may be drained ; by 
resecting part of the sixth and seventh cartilages 
its cavity may be explored. The right border of 
the pericardium is deeply placed and covered by 
the right lung (Fig.37); in health it should not 
project more than 1 inch beyond the right sternal 
border. 

Besides the auricles and ventricles the follow- 
ing parts are contained in the pericardium : The 
terminations of the inferior and superior venae 
cava?; the ascending aorta and pulmonary artery. 
The position of these parts, and of the arch of the 
aorta and its branches, is shown in Fig. 38. It 
will be observed that more than two-thirds of the 
anterior surface of the heart is made up of right 
ventricle and auricle ; consequently it is these ^ 
parts which are usually perforated in stabs of the// 
heart. / 

The heart may be exposed for operative treat- 
ment by removal of the terminal inch or more of 
the fourth and fifth left costal cartilages. The 
heart may be freely handled and sutured; the sur- 
geon's task is rendered difficult by its rapid 
motions and the respiratory movements of the 
pericardium and diaphragm. When the heart is 
wounded, blood escapes into the pericardium, lead- 
ing to compression of the auricles and the arrest of 
the inflow of blood. Hydrops of the pericardium 
may cause death in a similar manner. Other 



212 SURGICAL APPLIED ANATOMY [Part II. 

things being equal, a wound of the ventricle is 
less rapidly fatal than is a wound of the auricle, 
owing to the thickness of the ventricular wall, 
and to its capacity for contracting and prevent- 
ing the escape of blood. Death in cases of wound 
of the heart would appear in a great number of 
cases to be due to an impression upon the nervous 
centres rather than to actual haemorrhage. Many 
instances have been recorded to show that the 
heart may be very tolerant of foreign bodies in 
its substance. Thus a man lived for twenty days 
with a skewer traversing the heart from side to 
side (Ferrus). In another case a lunatic pushed 
an iron rod, over 6 inches in length, into his 
chest, until it disappeared from view, although it 
could be felt beneath the skin receiving pulsation 
from the heart. He died a year following, and 
the metal was found to have pierced not only the 
lungs but also the ventricular cavities (Tillaux). 
Wounds of the heart have been sutured, the in- 
sertion of the stitches causing only momentary 
disturbance of its action. Recently Travers 
sutured a wound of the right ventricle into which 
he was able to place three fingers to prevent 
haemorrhage. A propos of chest wounds, Velpeau 
cites the case of a man in whose thorax was found 
a part of a foil that entirely transfixed the chest 
from ribs to spine, and that had been introduced 
fifteen years before death. In the museum of the 
Royal College of Surgeons is the shaft of a cart 
that had been forced through the ribs on the left 
side, had passed entirely through the chest, and 
had come out through the ribs on the right side. 
The patient had lived ten years. 

Paracentesis of tlie pericardium.— As al- 
ready mentioned, the pericardium may be tapped 
or drained through the left costo-ensiform angle 
(Fig. 38). The extent to which it is covered by 
the left pleura and lung is extremely variable, 
but in the majority of cases it may be tapped in 
the left fourth and fifth spaces, up to 1 inch from 
the sternum, without injuring the pleura. The 



Chap. X] THE THORACIC VISCERA 2l3 

internal mammary artery descends in these spaces 
.7 an inch from the sternum, and divides, behind 
the seventh cartilage, into its superior epigastric 
and musculo-phrenic branches. 

The iiiediastiua. — Abscess in the anterior 
mediastinum may have developed in situ, or may 
have spread down from the neck. In like manner 
posterior mediastinal abscesses may arise from 
diseases of the adjacent spine, or lymphatic 
glands, or may be due to the spreading down- 
wards of a retropharyngeal or retro-oesophageal 
collection of matter. 

The azygos veins, commencing as they do below 
in the lumbar veins, and having more or less direct 
communications with the common iliac, renal, 
and other tributaries to the vena cava, are able 
to a great extent to carry on the venous circula- 
tion in cases of obstruction of the terminal part 
of the superior vena cava. In this they are as- 
sisted by the vense comites of the internal mam- 
mary artery and epigastric veins; the intraverte- 
bral veins also become greatly enlarged, and serve 
as anastomotic channels between the superior and 
inferior caval systems. 

These veins are apt to be pressed upon by 
tumours (such as enlarged gland masses) de- 
veloped in the posterior mediastinum, and to pro- 
duce in consequence some oedema of the chest 
walls by engorgement of those intercostal veins 
that they receive. Tumours growing in the pos- 
terior mediastinum may cause trouble by press- 
ing upon the trachea or gullet, or by disturbing 
the vagus nerve or the cord of the sympathetic. 
The numerous lymphatic glands which surround 
the trachea, bronchi, and oesophagus are often the 
seat of tuberculosis. They become adherent to 
these organs and may ulcerate into them. 

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



Part III.-THE UPPER EXTREMITY 

CHAPTER XI 

THE REGION OF THE SHOULDER 

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

Surface anatomy.— The clavicle, acromion 
process, and scapular spine are all subcutaneous, 
and can be readily felt. In the upright position, 
when the arm hangs by the side, the clavicle is, 
as a rule, not quite horizontal. In well-developed 
subjects it inclines a little upwards at its outer 
end.* In the recumbent posture, the weight of the 
limb being taken off, the outer end rises still 
higher above the sternal extremity. The degree 
of the elevation can be best estimated by a study 
of frozen sections. Thus, in making horizontal 
sections of the body, layer by layer, from above 
downwards, Braune found that by the time the 
sterno-clavicular articulation was reached, the 
head of the humerus would be cut across in the 
lateral part of the section (Fig. 39). 

The deltoid tubercle of the clavicle may, if 
large, be felt through the skin, and be mistaken 
for an exostosis. The acromio-clavicular joint lies 
in the plane of a vertical line passing up the 
middle of the front of the arm. A prominence is 
sometimes felt about this joint in place of the 

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

214 



Chap. XI] EEGION OF THE SHOULDER 215 

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

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

In thin subjects the outline and borders of 
the scapula can be more or less distinctly made 



216 SURGICAL APPLIED ANATOMY [Part III 

out, but in fat and muscular subjects all parts 
of the bone, except the spine and acromion, are 
difficult of access in the ordinary positions of the 
limb. To bring out the superior angle and verte- 
bral border of the bone, the hand of the subject 
should be carried as far as possible over the oppo- 
site shoulder. To bring out the inferior angle 
and axillary border, the forearm should be placed 
behind the back. The angle formed at the point 
of junction of the spine of the scapula and the 
acromion is the best point from which to take 
measurement of the arm, the tape being carried 
down to the external condyle of the humerus. The 
upper border of the scapula lies on the second 
rib, its lower angle on the seventh. 

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

When the arm hangs at the side with the palm 
forwards, the bicipital groove may be defined 
directly below the acromioclavicular joint. 

Just below the clavicle is a depression, the sub- 
clavicular fossa, which varies considerably in 
depth in different subjects. It is obliterated in 
subcoracoid dislocations of the humerus, in frac- 
tures of the clavicle with displacement, by many 
axillary growths, and by some inflammations of 
the upper part of the thoracic wall. In sub- 
clavicular or infracoracoid dislocation, the fossa 



Chap. XI] REGION OF THE SHOULDER 217 

is replaced by an eminence. In this region, at a 
spot to the inner side of the coracoid process, and 
corresponding nearly to the middle of the clavicle;, 
the pulsations of the axillary artery can be felt 
on deep pressure, and the vessel be compressed 
against the second rib. Just below the clavicle the 
interspace between the sternal and clavicular por- 
tions of the pectoralis major can often be made 
out. 

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

The axillary glands cannot be felt when they 
are in a normal condition. The central set lies 
beneath the axillary tuft of hair. 

The direction of the axillary artery, when the 
arm is raised from the side, is represented by a 
line drawn from the middle of the clavicle to the 
humerus at the inner side of the coraco-brachialis. 
A line drawn from the third rib near its cartilage 
to the tip of the coracoid process indicates the 
upper border of the pectoralis minor, and the spot 
where this line crosses the line of the axillary 
artery points out the position of the acromio- 



218 



SURGICAL APPLIED ANATOMY [Part III 



thoracic artery. A line drawn from the fifth rib 
near its cartilage to the tip of the coracoid process 
indicates the lower border of the pectoralis minor, 
and the position of the long thoracic artery which 
runs along that border. The line of the sub- 
scapular artery corresponds to the lower border 



2 1 \? 



,a T 







9 



r /•''£■' / / • ■' \ \ 



Fig. 39. 



f 8 

-Horizontal section of the body just below the upper border 
of the manubrium. (Braune.) 

a, Manubrium ; b, head of humerus ; c, clavicle ; d, first rib ; e, second rib ; /; third 
dorsal vertebra; g, spine of second dorsal; ft, pectoralis major; i, deltoid; 
j, infraspinatus ; fc, subscapularis ; I, coraco-brachialis and biceps : m, pectoralis 
minor ; n, serratus magnus ; o, intercostals ; p, semispinalis and undtifidus 
spina?; q, biventer cervicis and complexus ; r, longissimus dorsi; s, splenius 
colli ; t, rhomboideus ; u, trapezius ; v } sterno-thyroid ; w, sterno-hyoid ; 
T, thymus ; l, lung ; 1, left innominate vein ; 2, left carotid artery ; 3, left sub- 
clavian artery ; 4, vertebral artery ; 5, left subclavian vein ; G, cephalic vein ; 
7, phrenic nerve ; 8, vagus ; 9, transverse scapular artery. 

of the subscapularis muscle along which it runs, 
but the position of this border can only be ap- 
proximately indicated on the living or undissected 
sub j ect. 

The circumflex nerve and posterior circumflex 
artery cross the humerus in a horizontal line that 
is about a finger's breadth above the centre of the 
vertical axis of the deltoid muscle. This point 



Chap. XI] EEGION OF THE SHOULDEE 219 

is of importance in cases of supposed contusion 
of the nerve. These various indications of the 
positions of the main branches of the axillary 
artery are made while the arm hangs in its 
natural position at the side. 

The clavicle. — The skin over the clavicle is 
loosely attached, and is easily displaced about the 
bone. This circumstance may serve to explain 
why the skin so often escapes actual wound in 
contusions of the clavicular region, and in part 
explains the infrequency of penetration of the 
integument in fractures of the clavicle. The posi- 
tion of the supraclavicular nerves in front of the 
bone renders them very liable to contusion, and 
accounts for the unusual amount of pain that is 
said to sometimes follow blows over the collar 
bone. Tillaux believes that the severe pain that in 
rare cases persists after fracture of the clavicle is 
due to the implication of these nerves in the callus 
formed. The three nerves that cross the clavicle 
are branches of the third and fourth cervical 
nerves, and it is well to note that pain over the 
collar bone is sometimes a marked feature in 
disease of the upper cervical spine. This symp- 
tom is then due to irritation of these nerves at their 
points of exit from the spinal canal. A communica- 
tion between the external jugular and cephalic 
veins is occasionally seen to cross the clavicle. 

Beneath the clavicle the great vessels and the 
great nerve-cords lie upon the first rib. The vein 
is the most internal, and occupies the acute angle 
between the collar-bone and the first rib. It will 
be seen that growths from the bone may readily 
press upon these important structures, and that 
the vein, from its position, as well as from the 
slighter resistance that it offers, is likely to be 
the first to be compressed. These structures have 
also been wounded by fragments of bone in frac- 
ture of the clavicle. Fortunately, between the 
clavicle and these large nerves and vessels the 
subclavius muscle is interposed. This muscle is 
closely attached to the under surface of the bone, 



220 SURGICAL APPLIED ANATOMY [Part III 

is enveloped in a dense fascia, and forms one of 
the chief protections to the vessels in case of frac- 
ture. This interposing pad of muscle is also of 
great service in resection operations, as can _ be 
well understood. Braune states that by pressing 
the clavicle against the first rib in the dead body 
a stream of injection in the thoracic duct can, in 
some cases, be entirely arrested. Behind the 
clavicle the following structures may be noted ; 
viz., the innominate, subclavian, and external 
jugular veins, the subclavian, suprascapular, and 
internal mammary arteries, the cords of the 
brachial plexus, the phrenic nerve and nerve of 
Bell, the thoracic duct, the omo-hyoid, scalene, 
sterno-hyoid and sterno-thyroid muscles, and the 
apex of the lung. The sternal end of the bone is 
not far removed from the innominate or left 
carotid artery, the vagus and recurrent nerves, 
the trachea, and the oesophagus. 

These relations of the clavicle are given to show 
the dangers in the way of partial or. complete 
resections of the bone. The difficulties and risks 
of the operation increase as one progresses from 
the acromial to the sternal end. Resection of the 
acromial third of the bone is comparatively easy, 
but resection of the sternal portion is difficult 
and dangerous. The entire clavicle has been re- 
moved with success, and the operation has been 
followed by less impairment of the arm movements 
tt^an would be imagined. 

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

Fractures of clavicle. — The clavicle is more 



Chap XI] EEGION OF THE SHOULDER 221 

frequently broken than is any other single bone in 
the body. This frequency is explained by the fact 
that the bone is very superficial, is in a part ex- 
posed to injury, is slender and contains much 
compact tissue, is ossified at a very early period 
of life, and above all receives a large part of all 
shocks communicated to the upper extremity. The 
common fracture, that due to indirect violence, is 
oblique, and very constant in its position, viz. 
at the outer end of the middle third of the bone. 
So closely is the outer third of the clavicle bound 
by ligaments to the coracoid and acromion pro- 
cesses that it may be regarded as part of the 
scapula. Hence the impact resulting from a fall 
on the shoulder is transferred to the clavicle at 
the junction of its outer and middle thirds. The 
bone breaks at the point where the force is trans- 
ferred to the clavicle from the scapula. The posi- 
tion of the coraco-clavicular ligaments is no doubt 
of the greatest import in localising the fracture 
in this position, since a clavicle experimentally 
subjected to longitudinal compression does not 
break at this spot (Bennett). 

The displacement that occurs is as follows. The 
inner fragment remains unchanged in position, or 
its outer end is drawn a little upwards by the 
sterno-mastoid. It will be seen that any action of 
this muscle would be resisted by the pectoralis 
major and the rhomboid ligament. The outer frag- 
ment undergoes a threefold displacement. (1) It is 
carried directly do wti wards. This is effected mainly 
by the weight of the limb aided by the pectoralis 
minor, the lower fibres of the pectoralis major, 
and the latissimus dorsi. (2) It is carried 
directly inwards by the muscles that pass from 
the trunk to the shoulder, viz. the levator anguli 
scapulae, the latissimus dorsi, and especially by 
the pectorals. (3) The fragment is rotated in 
such a way that the outer end projects forwards, 
the inner end backwards. This rotation is 
brought about mainly by the two pectorals, as- 
sisted prominently by the serratus magnus. The 



222 SUEGICAL APPLIED ANATOMY [Part III 

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

Fractures due to direct violence are usually 
transverse, and may be at any part of the bone. 
When about the middle third they present the dis- 
placement just described. When the fracture is 
between the conoid and trapezoid ligaments no 
displacement is possible. When beyond these liga- 
ments, the outer end of the outer fragment is car- 
ried forwards by the pectorals and serratus, and 



Chap. XI] EEGION OF THE SHOULDER 223 

its inner end is a little drawn up by the trapezius. 
In this fracture there is no general displacement 
downwards of the outer fragment, since it can- 
not move in that direction unless the scapula go 
with it, and the scapula remains fixed by the 
coraco-clavicular ligaments to the inner fragment 
of the clavicle. 

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

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

A reference to the relations of the bone will 
show that important structures may be wounded 
in severe fractures associated with much displace- 
ment and with sharp fragments. Several cases 
are reported of paralysis of the upper limb (as a 
rule incomplete) following upon fracture of this 
bone. In some _ cases this symptom was due to 
actual compression or tearing of some of the great 
nerve cords by the displaced fragments. In other 



224 SURGICAL APPLIED ANATOMY [Part III 

cases the nerve injury, while due to the original 
accident, was yet independent of the broken clavi- 
cle. Paralysis of the biceps, brachialis anticus, 
and supinator longus, muscles supplied through 
the upper cord, may result from heavy weights 
being carried on the shoulder. Cases are reported 
of wound of the subclavian artery, of the sub- 
clavian vein, of the internal jugular vein, and of 
the acromio-thoracic artery. -In several instances 
the fracture has been associated with wound of the 
lung, with or without a fracture of the upper ribs. 

The clavicle begins to ossify before any bone in 
the body. At birth the entire shaft is bony, the 
two ends being still cartilaginous. The bone has 
one epiphysis for its sternal end that appears be- 
tween the eighteenth and twentieth year, and joins 
the shaft about twenty-five. It is a mere shell, is 
closely surrounded by the ligaments of the sternal 
joint, and cannot, therefore, be well separated by 
accident.'"" In cases where the clavicle is described 
as congenitally absent, the membrane-formed 
part of the bone is represented by a ligamentous 
cord ; the cartilage-formed extremities are repre- 
sented by bony nodules. 

Steriio-clavicular joint. — Although this is 
the onlv articulation that directly connects the 
upper limb with the trunk, yet it is possessed of 
such considerable strength that luxation at the 
joint is comparatively rare. The amount of move- 
ment in the joint deDends to a great extent upon 
the lack of adaptability between the facets on the 
sternum and the sternal end of the clavicle. The 
disproportion between these parts is maintained 
by the interarticular cartilage, which reproduces 
onlv the outline of the clavicular surface. The 
cavity of the joint is V-shaped, since the clavicle 
only touches the socket at its inferior angle when 
the arm hangs by the side. When the arm is 

* Mr. Heath {Lancet, Nov. is, 1882) reports a case which is probably 
vrainue. Tt concerns a lad, aged 14, who. when in the act of bowling at 

cricket, tore the clavicle away from its epiphyseal cartilage, which 
remained in sitv. The muscle producing the accident was apparently the 
pectoralis major. 



Chap. XI] REGION OF THE SHOULDER 225 

elevated, however, the two bones are brought in 
more immediate contact, and the joint cavity be- 
comes a mere slit. Thus, in disease of this articu- 
lation it will be found that of all movements of 
the joint the movement of the limb upwards is the 
most constant in producing pain. The joint is 
supplied by the suprasternal nerve. 

The movements permitted at this joint are 
limited, owing to the anterior and posterior 
sterno-clavicular ligaments being moderately 
tense in all positions of the clavicle. Movement 
forwards of the clavicle on the sternum is checked 
by the posterior ligament, and resisted by the an- 
terior ligament. This latter ligament is more lax 
and less substantial than is the posterior band. 
Its weakness serves in part to explain the fre- 
quency of the dislocation forwards. 

Movement of the clavicle backwards on the 
sternum is checked by the anterior ligament, while 
the passage of the head of the bone is resisted by 
the powerful posterior band. The movement is 
also opposed by the rhomboid ligament. To pro- 
duce, therefore, a dislocation backwards consider- 
able force must be used. Movement of the clavicle 
upwards on the sternum is checked by the rhom- 
boid ligament, the interclavicular ligament, the 
interarticular cartilage, and in a less direct man- 
ner by the two remaining ligaments of the joint. 
Thus it happens that dislocation upwards is the 
least common of the luxations at this articulation. 

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

These joints are liable to the ordinary maladies 
of joints, and it would appear that the disease 
may commence in, and be for some time limited 
to, only one of the synovial sacs. In time the 
whole articulation usually becomes involved, but 
even in advanced cases the mischief is sometimes 
restricted to the synovial cavity on one side of the 
cartilage. According to some authors, this joint 
p 



226 SURGICAL APPLIED ANATOMY [Part III 

is more frequently involved in pysemia than is any 
other. When effusion has taken place into the 
sterno-clavicular joint, and especially after sup- 
puration has ensued, the swelling usually makes 
itself evident in front, owing to the fact that the 
anterior sterno-clavicular ligament is the thinnest 
and least resisting of the ligamentous structures 
about the articulation. For the same reason the 
pus usually escapes from the anterior surface 
when it discaarges itself spontaneously. It may, 
however, make an opening for escape through the 
posterior ligament, and in these circumstances has 
found its way into the mediastinum. The rela- 
tions of this joint to the great vessels at the root 
of the neck should be borne in mind. In one case 
reported by Hilton a large abscess formed in the 
articulation, and the collection, receiving pulsa- 
tions from the subjacent artery (the innominate 
or right subclavian), was supposed at one time to 
be an aneurism. It is remarkable that disease of 
this joint never leads to ankylosis. This circum- 
stance may be explained (1) by the constant 
slight movement in the part, which prevents the 
diseased structures from being kept at rest, (2) 
by the occasional persistence of the interarticular 
cartilage, and (3) by the utter lack of adapta- 
bility of the two bony surfaces involved. 

Dislocations of the sterno-clavicular joint. 
— The clavicle may be dislocated from the sternum 
in one of three directions, which, given in order 
of frequency, are : (1) forwards, (2) backwards, 
(3) upwards. The relative frequency of these dis- 
locations can be understood from what has been 
already^ said as to the action of the ligaments in 
restricting movements. The displacement for- 
wards involves entire rupture of the capsule, and I 
more or less damage to the rhomboid ligament. 
The head of the bone, carrying with it the sterno- 
mastoid, rests on the front of the manubrium. 
The dislocation backwards may be due to direct 
or indirect violence, and has occurred spontane- 
ously in connection with the chest deformity in 



Chap. XI] REGION OF THE SHOULDER 227 

Pott's disease. The capsule is entirely torn, as is 
also the rhomboid ligament. The head is found 
in the connective tissue behind the sterno-hyoid 
and sterno-thyroid muscles. In this position it 
may cause severe dyspnoea, or dysphagia, by 
pressure upon the trachea or gullet. It may so 
compress the subclavian artery as to arrest the 
pulse at the wrist, or so occlude the innominate 
vein as to produce semi-coma (Fig. 39, p. 218). 
In one case the head of the bone had to be ex- 
cised to relieve a troublesome dysphagia. In the 
luxation upwards, due usually to indirect vio- 
lence, the head rests on the upper border of the 
sternum between the sterno-mastoid and sterno- 
hyoid muscles. It involves more or less complete 
tearing of all the ligaments of the joint, together 
with avulsion of the interarticular nbro-cartilage. 

The non-adaptability of the joint surfaces in 
this part serves to explain the ease with which 
these luxations are usually reduced, and the diffi- 
culty of retaining the clavicle in position after it 
is replaced. 

4 croon io-cl a vicul a .r joint. — This articulation 
is shallow, and the outlines of the two bones that 
enter into its formation are such that no obstacle 
is offered to the displacement of the clavicle from 
the acromion. The joint, indeed, depends for its 
strength almost entirely upon its ligaments. The 
plane of the joint would be represented by a line 
drawn from above downwards and inwards be- 
tween the two bones. This inclination of the joint 
surfaces serves to explain the fact that the usual 
luxation of this part takes the form of a displace- 
ment of the clavicle upwards on to the acromion. 
The capsule that surrounds the joint is lax and 
feeble, and it is partly from its comparative thin- 
ness that effusion into this joint, when it is the 
seat of disease, makes itself so soon visible. The 
joint, however, depends mainly for its strength 
upon the powerful conoid and trapezoid liga- 
ments. The effects of shock at this joint are les- 
sened by the presence of a partial nbro-cartilage 



228 SURGICAL APPLIED ANATOMY [Part III 

which projects between the bones from the upper 
part of the capsule. 

As the movements permitted in this joint may 
be impaired by accident or disease, it is well to 
note the part the articulation takes in the move- 
ments of the extremity. The scapula (and with it, 
of course, the arm), as it glides forwards and 
backwards upon the thorax, moves in the arc of a 
circle whose centre is at the sterno-clavicular 
joint, and whose radius is the clavicle. As the 
bone moves forwards it is important, for reasons 
to be immediately given, that the glenoid cavity 
should also be directed obliquely forwards. This 
latter desirable condition is brought about by 
means of the acromio-clavicular joint. Without 
this joint the whole scapula as it passed forwards 
with the outer end of the clavicle would precisely 
follow the line of the circle above mentioned, and 
the glenoid cavity would look in an increasingly 
inward direction. It is essential that the surface 
of the glenoid cavity should be maintained as far 
as possible at right angles to the long axis of the 
humerus. When these relations are satisfied, the 
humerus has the support behind of a stout sur- 
face of bone, and it is partly to obtain the value 
of this support that the boxer strikes out from 
the side, i.e. with his humerus well backed up by 
the scapula. If there were no acromio-clavicular 
joint the glenoid fossa would offer little support 
to the humerus when the limb was stretched for- 
wards, and a blow given with the limb in that 
position, or a fall upon the hand under like con- 
ditions, would tend to throw the humerus against 
the capsule of the shoulder joint, and so produce 
dislocation. Normally, therefore, as the scapula 
and arm advance, the angle between the acromion 
and the adjacent portion of the clavicle becomes 
more and more acute, and the glenoid fossa is 
maintained with a sufficiently forward direction 
to give substantial support to the humerus. * It 

* For an excellent account of the mechanism of these joints see 
Morris's " Anatomy of the Joints," p. 202 et se</. 1879. 



Chap. XI] REGION OF THE SHOULDER 229 

will thus be seen that rigidity of this little joint 
may be a cause of insecurity in the articulation 
of the shoulder, and of weakness in certain move- 
ments of the limb. 

Dislocations of the acroinio- clavicular 
joint. — The clavicle may be displaced upwards 
on to the acromion or downwards beneath it. 
Polaillon has collected thirty-eight cases of the 
former luxation, and six only of the latter. This 
disproportion is, in the main, explained by the 
direction of the articulating surfaces of the joint. 
Both luxations are usually due to direct violence. 
The dislocation upwards is very commonly only 
partial, and is associated only, with stretching 
and some trifling rupture of ligaments. In the 
complete form, where the end of the clavicle rests 
entirely upon the acromion, there is rupture, not 
only of the capsule, but also to a greater or less 
extent of the coraco-clavicular ligaments. In the 
complete dislocation downwards, also, there is a 
rupture of the capsule, with extensive tearing 
of the conoid and trapezoid ligaments. These 
luxations are usually easily reduced, but it 
will be understood, from the direction of the 
articular surfaces, that in the displacement up- 
wards it is very difficult to retain the clavicle in 
situ when once reduced. 

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

The infraspinatus and teres minor muscles are 
also enclosed in a distinct, but much denser, fascia 
that is attached to the bone beyond these muscles, 
and blends in front with the deltoid sheath so as 
to form a second enclosed space. The arrange- 
ment of these fasciae serves to explain the trifling 
amount of ecchymosis that usually follows upon 
fractures of the scapular blade. The extravasa- 



230 SURGICAL APPLIED ANATOMY [Part III 

tion of blood about the fracture is bound down 
by the fasciae over these muscles, and is unable, 
therefore, to reach the surface. 

Movements of the scapula. — In lifting the 
arm from the side to a vertical position over 
the head, the scapula undergoes a free rota- 
tory movement, its vertebral border passing 
from an approximately vertical to an approxi- 
mately horizontal position. At the commence- 
ment of the movement, until the arm has as- 
cended 35 degrees from the side, the angle of the 
scapula is practically stationary ; during this 
stage the scapula is fixed and maintained in posi- 
tion by the trapezius, rhomboids, and serratus 
magnus. If the trapezius is paralysed, as may 
result from accidental section of the spinal acces- 
sory nerve in removing glands from the neck, the 
angle and vertebral border project backwards, 
under the weight of the raised arm. When the 
arm passes beyond 35 degrees, the serratus magnus 
comes into action, and the angle of the scapula 
moves rapidly forwards. If the nerve to this 
muscle be paralysed (the nerve of Bell from 
5, 6, 7 c.) or if its antagonists — the rhomboids — 
which are also then in action, be paralysed (nerve 
from 5 a), then the angle and posterior border of 
the scapula become prominent or " winged " — 
evidence of the paralysis of these muscles. Thus 
"winging" of the scapula at the commencement 
of the movement indicates paralysis of the trape- 
zius ; if it occurs after the movement is well begun, 
then the serratus magnus is affected. 

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

The most common lesion is a fracture of the 
acromion process. This is often but a separation 
of the epiphysis. There are two, sometimes three, 



Chap. XII REGION OF THE SHOULDER 231 

epiphyseal centres for the acromion. Ossification 
appears in them about puberty, and the entire 
epiphysis joins with the rest of the bone from the 
twenty-second to the twenty-fifth year. Several 
cases of supposed fracture of the acromion united 
by fibrous tissue are probably but instances of an 
imperfectly-united epiphysis, and may have been 
independent of injury. In five bodies out of forty 
Symington found the acromial epiphysis united 
to the spine by a fibrous union, and from the 
statistics of other observers it appears that this 
is the case in quite 10 per cent, of adults. In 
fractures of the process much displacement is 
quite uncommon, owing to the dense fibrous cover- 
ing the bone derives from the two muscles attached 
to it. This dense periosteum also explains the 
circumstance that many fractures are incomplete 
and crepitus is often absent. When the fracture 
is in front of the clavicular joint, displacement of 
the arm is impossible. When it involves the joint, 
a dislocation of the collar bone is common. When 
behind the joint, the arm, having lost its sup- 
port from the thorax, is displaced in somewhat the 
same way as obtains in the common fracture of 
the clavicle. The coracoid process may present a 
genuine fracture, or may be separated as an 
epiphysis. As an epiphysis, it joins the main 
bone about the age of seventeen. The supra- 
glenoid tubercle, from which the long head of the 
biceps takes its origin, is part of the coracoid 
epiphysis. In spite of the powerful muscles at- 
tached to it, the displacement is usually slight, 
inasmuch as the coraco-clavicular ligaments are 
seldom torn. These ligaments, it may be noted, 
are attached to the base of the process. In some 
few cases the process has been torn off by mus- 
cular violence. 

Among the more usual fractures of the body of 
the scapula is a transverse or oblique fracture 
of its blade below the spine. Owing to the infra- 
spinatus, subscapulars, and other muscles being- 
attached to both fragments, none but a trifling 



232 SUKGICAL APPLIED ANATOMY [Part III 

displacement is usual. A fracture may occur 
through the surgical neck. The surgical neck is 
v epresented by a narrowed part of the bone be- 
hind the glenoid fossa, and in the line of the 
suprascapular notch. The smaller fragment will, 
therefore, include the coracoid process, the larger, 
the acromion. The amount of deformity in these 
cases depends upon whether the coraco-clavicular 
and acromio-clavicular ligaments are entire or 
torn. If they be torn, the smaller fragment and 
the entire limb are displaced downwards, and the 
injury somewhat resembles a subglenoid _ disloca- 
tion. From this, however, it is distinguished by 
the crepitus, by the ease with which the deformity 
is removed and the equal ease with which it re- 
turns, by the position of the head of the humerus 
in regard to the glenoid fossa, and by the con- 
spicuous fact that the coracoid process is displaced 
downwards with the limb. 

Tumours of various kinds grow from the 
scapula and mainly from the spongy parts of the 
bone, viz. the spine, the neck, and the inferior angle. 
The bone may be removed entire, with or without 
amputation of the upper limb. An interscapulo- 
thoracic amputation is usually performed for 
malignant tumours which involve structures in 
the neighbourhood of the shoulder-joint. In this 
operation the upper extremity, including the 
scapula and the clavicle beyond the origin of the 
sterno-mastoid, is removed. An elliptical incision 
is made in front and behind the shoulder, the 
upper end of the ellipse lying on the clavicle, the 
lower at the angle of the scapula. The operation 
is commenced at the clavicle so as to secure the 
axillary vessels. The artery is tied before the 
vein so that the limb may continue to empty its 
blood into the circulation. The main vessels to 
be noted in connection with this operation are the 
suprascapular at the superior border of the bone, 
the posterior scapular about the vertebral border, 
the subscapular running along the lower border 
of the subscapulars muscle, the dorsalis scapulae 



Chap. XI] REGION OF THE SHOULDER 233 

crossing the axillary edge of the bone, and the 
acromial branches of the acromio-thoracic artery. 

The axilla. —The axilla may be regarded sur- 
gically as a passage between the neck and the 
upper limb. Axillary tumours and abscesses may 
spread up into the neck, and in like manner cer- 
vical growths and purulent collections may extend 
to the armpit. The skin forming the base of the 
axilla is provided with many short hairs and 
with numerous sebaceous and sudoriparous glands. 
In this integument small superficial abscesses are 
often met with, that arise usually from suppu- 
ration of these glandular structures, and that are 
brought about by the friction of the skin against 
the clothing. Owing to the tendency of the axil- 
lary integument to become chafed and inflamed 
under friction, the axilla is not a good locality to 
select for the use of the mercurial inunction as 
applied in syphilis. Beneath the skin and super- 
ficial fasciae is the axillary fascia, and beyond this 
membrane is the axillary space. The connective 
tissue with which the axillary space is mainly 
occupied is very loose, and, while this laxity 
favours greatly the free movement of the arm, it 
at the same time permits of the formation of large 
purulent collections and immense extravasations 
of blood. 

It is important to remember the disposition of 
the fasciae about this region. There are three 
layers principally concerned. (1) The deep pec- 
toral fascia that covers in and encloses the pector- 
alis major. (2) The clavi-pectoral fascia that, 
adherent above to the clavicle, fills in the space 
between that bone and the pectoralis minor, then 
splits to invest this muscle, and joins the deep 
pectoral layer at the anterior fold of the axilla 
to form with it the axillary fascia. The upper 
part of this fascia is generally known as the costo- 
coracoid membrane. The whole membrane is some- 
times known also as the " suspensory ligament of 
the axilla," since it draws up the axillary fascia 
towards the clavicle, and is mainly instrumental 



234 SURGICAL APPLIED ANATOMY [Part Til 

in producing the " hollow " of the armpit. (3) 
The axillary fascia that is formed by the union 
of the two preceding fasciae, and stretches across 
the base of the axilla from its anterior to its pos- 
terior fold. It is thinnest under the axillary 
hairs. 

Abscess about the axillary region may be 
considered (1) when it is beneath the pectoralis 
major, or between the two pectoral muscles, and 
(2) when it is beneath the pectoralis minor and 
clavi-pectoral fascia, and therefore in the axillary 
space. (1) An abscess in this situation is placed 
between the deep pectoral and the clavi-pectoral 
fasciae, the latter separating it from the axillary 
space. Such an abscess undermines the great pec- 
toral, and tends to present either at the anterior 
margin of the axilla, or in the groove between the 
great pectoral and deltoid muscles, being guided 
thither by the attachment of the fasciae. (2) A 
purulent collection in the axilla may soon fill that 
space and distend it entirely. Its progress to- 
wards the skin is arrested by the axillary fascia, 
its progress backwards by the serratus magnus 
muscle, which, by its attachment to the scapula, 
hermetically closes the axillary space behind. In 
front the advance of the abscess is prevented by 
the pectoral muscles and clavi-pectoral fascia, 
while on the inner side is the unyielding thorax, 
and on the outer side the upper limb. The 
abscess, therefore, as it fills the axilla pushes for- 
wards the pectoralis major, more or less obliter 
ates the hollow of the armpit, thrusts back the 
scapula, and widens the angle between the serra- 
tus magnus and the subscapularis muscles. There 
is a great tendency, therefore, for unrelieved ab- 
scesses to extend upwards into the neck, that being 
the direction in which the least amount of resist- 
ance is encountered. From the neck the purulent 
collection may extend into the mediastinum. In 
one case an axillary abscess, set up by shoulder- 
joint disease, perforated the first intercostal space 
and set up fatal pleurisy. 



Chap. XII REGION OF THE SHOULDER 235 

In opening an axillary abscess, and, indeed, in 
most incisions into this space, the knife should 
be entered at the centre of the floor of the axilla, 
i.e. midway between the anterior and posterior 
margins, and near to the inner or thoracic side 
of the space. The vessel most likely to be damaged 
by an indiscreet incision are the subscapular, 
running along the lower border of the .subscapu- 
lars muscle ; the long thoracic, following the 
lower border of the small pectoral ; and the main 
vessels lying close to the humerus. The knife, if 
properly entered, should be midway between the 
two first-named vessels, and quite away from the 
main trunks. There is an artery (the external 
mammary) that sometimes comes off as the lowest 
branch of the axillary trunk, and crosses the 
middle of the axilla, to be distributed to the 
thorax below the long thoracic. This vessel would 
probably be wounded in the incision above named. 
The artery is, however, very inconstant, is small, 
and is not far below the surface. It is usually 
met with in female subjects. 

Lymphatic glands. — The axillary glands are 
numerous, and of much surgical importance. 
They may be arranged in four sets. (1) The 
greater number are placed to the inner side of 
the axillary vein beneath the axillary tuft of 
hair. This centred set of glands receives the 
lymph from the upper extremity and breast. Pain 
in the axilla which follows whitlow or any septic 
infection of the arm is due to inflammation of 
this group, which is pierced by the intercosto- 
humeral nerve. (2) The deep axillary set lies 
along the axillary vessels. It receives the lymph 
from the central set and becomes continuous with 
the lower deep cervical glands in the subclavian 
triangle (Fig. 35, p. 190). (3) Other glands lie 
upon the serratus magnus muscle on the thoracic 
side of the axilla, and just behind the lower bor- 
der of the pectoral muscles. They receive the 
lymphatics from the front of the chest, the princi- 
pal lymph vessels of the breast, and the superficial 



236 SURGICAL APPLIED ANATOMY [Part III 

lymphatics of the -abdomen as low down as the 
umbilicus. Their efferent vessels for the most part 
pass on to join the central set of glands. These 
glands will be the first to be enlarged in certain 
breast affections, and after blistering and other 
superficial inflammations, etc., of the chest and 
upper abdomen. Paulet has seen them affected 
in inflammation of the hand. The axillary pro- 
cess of the female breast is in contact with this 
set. (4) The remaining glands are situated at the 
back of the axilla, along the subscapular vessels. 
They are joined by the lymphatics from the back. 

It may here be convenient to note that one or 
two glands are commonly found in the groove 
between the deltoid and pectoralis major muscles. 
They receive some vessels from the outer side of 
the arm and a part of the shoulder and breast. 
The superficial lymphatics over the upper part of 
the deltoid go to the cervical glands (Tillaux), 
over the lower half to the axilla. The lymphatics 
from the supraspinous fossa follow the supra- 
scapular artery, and join the lowest cervical 
glands. The superficial lymphatics of the back 
that converge to the axilla are derived from the 
neck over the trapezius muscle, and from the 
whole dorsal and lumbar regions as far down as 
the iliac crest. 

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

The axillary vessels. — The axillary vein is 
formed by the union of the basilic with the two 
vense comites of the brachial artery. This union 
commonly takes place at the lower border of the 
pectoralis minor muscle, and the vein is therefore 
shorter than the artery. Sometimes the vein does 



Cimp. xij REGION OF THE SHOULDER 237 

not exist as a single trunk until just below the 
clavicle. This condition, when it exists, is very 
unfavourable to operations upon the artery, as 
many transverse branches cross that vessel to unite 
the veins that lie on either side of it. The axil- 
lary vein, being comparatively near the heart, is 
readily influenced as regards its contained blood 
by the inspiratory movement. Thus it happens 
that, in many instances of wound of the vessel or 
of its larger tributaries, air has been drawn into 
the venous canal and death has ensued. The en- 
trance of air into the main vein is perhaps aided 
by the circumstance that the costo-coracoid mem- 
brane (upper part of clavi-pectoral fascia) is ad- 
herent to the vessel, and thus tends to maintain it 
in a patent condition when wounded. This con- 
nection with the fascia is supposed by some to 
account in part for the furious bleeding that 
occurs from this vein when it is divided. 

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

Aneurism is very frequent in the axillary 
artery, a fact to be explained by the nearness of 
the vessel to the heart, by the abrupt curve it pre- 
sents, by its susceptibility to frequent and exten- 
sive movements, and by its liability to share in the 
many lesions of the upper limb. In violent and 



238 SURGICAL APPLIED ANATOMY [Part III 

extreme movements of the limb the artery may be 
more or less torn, especially if its walls are 
already diseased 

In ligaturing the first part of the axillary 
artery it is well to note that the pectoralis major 
has sometimes a cellular interval between two 
planes of muscle fibre, and this may be mistaken 
for the space beneath it (Heath). If the pector- 
alis minor has an origin from the second rib, it 
may more or less entirely cover the artery and re- 
quire division. The cord of the brachial plexus 
nearest to the artery may be mistaken for that 
vessel, or easily included in a ligature intended 
for it. A ready guide to the axillary vessels in 
this operation is to follow the cephalic vein. The 
anterior internal thoracic nerve appears between 
the vein and artery as it passes to the pectoralis 
minor. It also may be useful occasionally as a 
guide. 

In applying a ligature to the third part of the 
artery, it should be borne in mind that a mus- 
cular slip sometimes crosses the vessels obliquely, 
passing from the latissimus dorsi to join the pec- 
toralis major, coraco-brachialis, or biceps mus- 
cles. This slip may give rise to confusion during 
the operation, and may be mistaken for the 
coraco-brachialis. 

Brachial plexus. — When the shoulder is de- 
pressed the upper and middle trunks of the 
brachial plexus, formed by the fifth, sixth, and 
seventh cervical nerves, can be distinctly felt in 
the neck, passing from beneath the posterior 
border of the sterno-mastoid to enter the axilla 
just externally to the mid-point of the clavicle. 
The upper trunk, formed by the fifth and sixth 
nerves, is by far the most exposed to injury, for 
the reason that it rises higher in the neck than the 
middle and lower trunks ; hence when the neck is 
bent forcibly to the left, as when a burden is 
borne on the right shoulder, the upper trunk on 
the right side is subjected to a greater strain than 
the middle or lower cords. In cases of shoulder- 



Chap. XI] REGION OF THE SHOULDER 



239 



presentation at birth, or if the neck and shoulder 
be forced apart by accident, the upper cord is lia- 
ble to be strained or ruptured, resulting in what is 
usually described as Erb's palsy. _ It will be re- 
called that the suprascapular, circumflex, and 
musculo-cutaneous nerves are derived from this 
trunk; so are the nerves to the rhomboids and 



UPRASPINATUS 



SCAPU 




ACROMIO/i Proc 

Deltoid 
Capsule 
Bursa 

Epiphyseal Line:'. 

JoirtT Cavity 

CjLEttOlD LlQAME/^T 

—4- Capsule 

P05t.Cir.cu/mflex Art 

4_TeR.ES /iAJOR 

Triceps 



W 

Fig. 40. — Section of the shoulder-joint to show the relations of the 
capsule, epiphyseal line, and bursa. (After Poirier.) 

serratus magnus. The rupture, however, is usually 
distal to the origin of these nerves, and hence 
their muscles escape. The muscles affected in 
Erb's palsy are the supraspinatus, infraspina- 
tus, teres minor, deltoid, coraco-brachialis, biceps, 
brachialis anticus, and supinator longus; occa- 
sionally also the supinator brevis, extensor carpi 
radialis longior., and pronator radii teres. No 
sensory paralysis is observed in such cases. Curi- 
ously enough, section of the fifth cervical gives 
as wide an area of muscular paralysis as section 



240 SURGICAL APPLIED ANATOMY [Part III 

of the combined fifth and sixth (W. Harris). In 
complete rupture of the brachial plexus sensation 
is completely lost beyond the elbow, but in the arm 
and shoulder deep sensibility is retained (Sher- 
ren). The arm, in such lesions, retains intact the 
nerves received from the descending cervical and 
intercosto-humeral. 

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

The deltoid region. — This region, comprising 
as it does the " point " of the shoulder, is limited 
in all parts by the deltoid muscle. The deltoid 
covers the upper end of the humerus and the 
shoulder-joint (Fig. 40). Between the joint and 
the surface, therefore, are only the skin and super- 
ficial fascia, the deltoid in its sheath, and some 
loose connective tissue (the subdeltoid tissue) in 
which is found the great subacromial bursa. This 
subdeltoid tissue sometimes assumes the form of a 
distinct thick membrane, and may have an im- 
portant influence upon the localisation of puru- 
lent collections proceeding from the joint. The 
fatty tissue over the deltoid is a favourite seat 
for lipomata, and it is in this situation that the 
tendency of these growths to change their position 
is sometimes seen. Thus, Erichsen records a case 
where the tumour slid downwards from the 
shoulder to the breast. 

Emerging from the interval between the two 



Chap. XI] REGION OF THE SHOULDER 241 

teres muscles, and winding horizontally round the 
shaft of the humerus, quite close to the bone, and 
about the line of the surgical neck, are the circum- 
flex nerve and posterior circumflex artery. This 
nerve affords an example of an arrangement 
pointed out by Mr. Hilton, viz. that a principal 
nerve to a joint not only supplies the articular 
surfaces, but also some of the main muscles that 
move that joint, and the skin over those muscles. 
This nerve supplies the shoulder-joint, the deltoid 
and teres minor muscles, and the skin over the 
lower two-thirds of the shoulder and upper part 
of the triceps. This nerve is frequently damaged 
in injuries to the shoulder. It may be severely 
bruised by a simple contusion of the part, and 
this bruising may be followed by paralysis of the 
deltoid. It would appear, however, that damage 
to the circumflex is much less frequent after con- 
tusions of the shoulder than was formerly main- 
tained. It will also be readily understood that 
the nerve is often torn in fractures of the surgical 
neck of the humerus, in dislocations of that bone 
(especially the luxation backwards), and in vio- 
lent attempts at reducing such dislocations. The 
nerve, from its position, is very apt to be seri- 
ously pressed upon by growths springing from the 
upper end of the humerus. 

The shoulder-joint.— From one surgical point 
of view, joints may be divided into (1) those that 
depend for their strength mainly upon ligaments ; 
(2) those that are mechanically strong, and that 
derive their stability to a great extent from the 
arrangement of their component bones; and (3) 
those that rely for their support principally upon 
muscles. As an example of the first kind may be 
cited the sterno-clavicular joint, of the second 
form the elbow-joint, and of the third the 
shoulder-joint. The articulation the least prone 
to dislocation is the one that derives its strength 
from tough unyielding ligaments, while the one 
most often luxated belongs to the third variety, its 
strength being greatly dependent upon muscles 
Q 



242 SURGICAL APPLIED ANATOMY [Part III 

that may be taken by surprise, and that may them- 
selves, from disordered action, prove sources of 
weakness. These are, of course, not the only fea- 
tures in the etiology of dislocation. A great deal 
depends upon the amount of movement permitted 
in a given joint, and the degree of leverage that 
can be brought to bear upon its parts. 

The arch formed by the coracoid and acromion 
processes and the ligament between them forms an 
essential support to the head of the humerus, and 
is an important constituent of the articulation. 
With this arch the humeral head is in immediate 
relation, though not in actual contact (Fig. 40). 
In paralysis of the deltoid the head may be 
separated by some distance from the coracoid 
process, and Nannoni records the case of a child 
with old-standing paralysis of the deltoid, between 
whose humeral head and acromial vault four fin- 
gers could be lodged. It is well to note that at 
least two-thirds of the head of the bone are not 
in contact with the glenoid cavity when the arm 
hangs by the side, and Anger points out that in 
this position three-fourths of the circumference 
of the humeral head are in front of a vertical line 
drawn from the anterior border of the acromion 
process. In this posture, also, the head is wholly 
to the outer side of the coracoid process. The 
margin of the glenoid cavity is more prominent 
on the inner than on the outer side, while the 
strongest part of the margin and the broadest 
part of the fossa are below. This is significant, 
since it points to an attempt to strengthen a part 
of the joint that practice shows to be the weakest 
in the articulation, viz. the lower and inner por- 
tion of the capsule. It is at this place that the 
head of the bone leaves the joint in dislocation of 
the shoulder. 

The capsule of the shoulder- joint is very lax, 
and would lodge a bone-head twice as large as that 
of the humerus. According to Henry Morris, no 
one part of the capsule is constantly thicker than 
the rest, as is the case in the hip- joint. 



Chap. XI] EEGION OF THE SHOULDER 243 

Of the nursse about the joint, the subacromial 
bursa is the one most frequently the seat of disease. 
This sac, when distended with fluid, may be mis- 
taken for the results of chronic inflammation of 
the joint (Fig. 40). 

Experiment shows that the walls of this bursa 
may be actually torn in twists of the arm, especi- 
ally when either flexed or extended (Nancrede). 
When the sac is distended most pain is elicited in 
the position of abduction, for in this posture the 
bursal walls are normally folded up, so as to form 
a sort of collar in advance of the greater tuber- 
osity. When the walls are thickened and dis- 
tended by inflammation, abduction mustf press 
the bursa very forcibly under the acromion, and 
so cause pain. In elderly rheumatic people the 
sac sometimes communicates with the joint. The 
subscapular bursa may be regarded as an exten- 
sion of the synovial membrane of the joint between 
the terminal part of the muscle and the scapula. 
Pain elicited when the arm is rotated at the 
shoulder- joint may be due to disease in the joint, 
in the subacromial or in the subscapular bursa, 
for a movement then occurs in all three. 

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



244 SURGICAL APPLIED ANATOMY [Part III 

the great tuberosity being sooner brought in con- 
tact with the acromion. The intracapsular part 
of the tendon may disappear in cases of chronic 
rheumatic arthritis, owing to the friction against 
the abraded articular surface of the humerus. It 
acquires an attachment to the bicipital groove in 
such cases. 

Joint disease. — This articulation is liable to 
all forms of joint disease. The capsule, as just 
stated, is very lax, the articular surfaces being 
kept in apposition by the tonus of the surrounding 
muscles ; when chloroform is administered the sur- 
faces may be freely separated and examined. In 
joint disease, however, the effusion may effect a 
considerable separation of the two bones. Braune, 
having pierced the glenoid cavity through the 
supraspinous fossa, injected tallow at considerable 
pressure into the joint. When fully distended 
the humerus was found to be separated from the 
scapula by more than ^ an inch, and this may 
serve to explain the lengthening of the limb often 
noted in joint disease of this part with much 
effusion. When the greatest degree of distension 
of the capsule was reached the humerus became 
slightly extended and rotated inwards. It is 
significant that in shoulder-joint disease it is com- 
mon for the arm to be found close to the side, the 
elbow carried a little back (extension), and the 
limb rotated inwards. This position may also be 
due to the rigid contraction of the muscles about 
the joint that is usually observed. When such 
contractions exist it may be inferred that the 
powerful latissimus dorsi has a little advantage 
over its opponents, and may be answerable for the 
rotation in and slight projection backwards of the 
arm. The inner part of the epiphyseal cartilage 
is just within the capsule ; the outer, anterior, and 
posterior parts are entirely subperiosteal. It 
happens, therefore, that the pus in suppurative 
epiphysitis will find its way into the joint. 

There are two diverticula from the synovial 
membrane : (1) one that runs some way down the 



Chap. XI] REGION OF THE SHOULDER 245 

bicipital groove with the tendon ; (2) a cul-de-sac 
beneath the subscapulars formed by a communica- 
tion between the synovial cavity and the bursa 
under that muscle. When the joint is filled with 
effusion, the capsule is evenly distended and the 
shoulder evenly rounded. Special projections 
usually occur at the seats of the diverticula. Thus 
a swelling often appears early in the course of a 
synovitis in the groove between the pectoralis 
major and the deltoid muscles, and this swelling 
may appear bilobed, being cut in two by the un- 
yielding biceps tendon (Paulet). Fluctuation 
can best be felt by examining the uncovered part 
of the capsule in the axilla beyond the subscapu- 
lar muscle. When the joint suppurates pus 
usually escapes at one of the culs-de-sac just 
mentioned, most often through the one that fol- 
lows the biceps tendon. Pus may thus extend for 
some way along the bicipital groove. Pus escap- 
ing through the subscapular cul-de-sac is apt to 
spread between the muscle and the venter of the 
scapula, and to present at the lower and back part 
of the axilla. Purulent collections beneath the 
deltoid are nearly always conducted towards the 
anterior aspect of the limb, being unable to pro- 
ceed backwards owing to the denseness of the 
fascia covering in the deltoid and infraspinous 
muscle. In one recorded case, pus that had 
escaped from the shoulder-joint followed the 
course of the musculo-spiral nerve, and opened on 
the outer side of the elbow. _ 

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

The principal forms of luxation of the humerus 
at the shoulder are : 1. Subcoracoid, forwards and 



246 SURGICAL APPLIED ANATOMY [Part III 

a little downwards ; the usual form. 2. Sub- 
glenoid, downwards and a little forwards; rare. 
3. Subspinous, backwards ; rare. 

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

In all cases of dislocation at this joint the 
primary displacement is always downwards into 
the axilla. It is well known that dislocations at 
the shoulder are usually due to violence applied 
to the limb while the arm is abducted, or to severe 
direct violence forcing the bone downwards. Now 
when the limb is abducted the head of the humerus 
projects below the glenoid fossa, and rests and 
presses upon the inferior and least protected part 
of the capsule. The fibres of this portion of the 
capsule being tightly stretched in this position, 
it requires no extraordinary force to tear the 
ligament and drive the bone into the axilla. 

Thus it happens that in luxations at this joint 
the rent in the capsule is at its inferior and inner 
aspect, the humeral head lying beneath the sub- 
scapulars, which is always strained and some- 
times torn. The head of the bone, being thus 
driven downwards into the axilla, may, for cer- 
tain reasons, remain there (subglenoid form), or 
more usually it will be drawn forwards and in- 
wards by the powerful pectoralis major, aided 
by other muscles whose action is now less resisted 
and by the weight of the unsupported limb (sub- 
coracoid form) ; and lastly, the direction of the 
violence being applied markedly from in front, 
the head of the bone may be thrust backwards 
under the acromion or spinous processes (sub- 
spinous form). The overwhelming frequency of 
the subcoracoid variety is explained by the greater 



Chap. XI] REGION OF THE SHOULDER 247 

advantage at which those muscles act that draw 
the bone forwards, in comparison with those that 
would draw it backwards, and by the very trifling 
opposition offered to the passage of the head for- 
wards when compared with the substantial ob- 
stacles in the way of its passage backwards under 
the scapular spine. 

Features eommoit to all dislocations at 
tlie shoulder. — As the roundness of the deltoid 
depends to a great extent upon the presence be- 
neath it of the humeral head, and as in all these 
luxations (save perhaps in the slighter grades of 
the subspinous form) the head is removed practi- 
cally from its connection with the deltoid, that 
muscle is always more or less flattened. This 
flattening is augmented by the _ stretching of the 
muscle, which in some degree is constantly pre- 
sent. Stretching of the deltoid involves abduc- 
tion of the arm, and this symptom is fairly con- 
stant in all the luxations. The biceps being also 
more or less unduly tense, the elbow is found 
flexed and the forearm supinated. In every form 
there is some increase in the vertical circumfer- 
ence of the axilla, since the head, having left the 
glenoid fossa, must occupy some part comprised 
within that circumference. Again, Dr. Dugas 
has pointed out that " if the fingers of the in- 
jured limb can be placed by the patient, or by the 
surgeon, upon the sound shoulder while the elbow 
touches the thorax (a condition that obtains in 
the normal condition of the joint), there can be 
no dislocation ; and if this cannot be done there 
must be one, for no injury other than a disloca- 
tion can induce this physical impossibility." This 
depends upon the fact that in consequence of the 
rotundity of the thorax it is impossible for both 
ends of the humerus to touch it at the same time, 
and in luxation at the shoulder the upper end of 
the bone is practically touching the trunk. Lastly, 
from the position of the great vessels and nerves 
it will be seen that in the subcoracoid and sub- 
glenoid luxations the head of the bone may press 



248 



SURGICAL APPLIED ANATOMY [Part III 



injuriously upon those structures. Thus may 
result oedema of the limb and severe pain or loss of 
muscular power. The artery is usually saved by 
its greater elasticity ; but Berard reports a case 
of displacement forwards where the axillary 
artery was so compressed by the humeral head 
as to induce gangrene of the limb. 

The close connection of the circumflex nerve 
with the humerus renders it very liable to injury, 
especially in the subglenoid and subspinous forms 
of dislocation. 

Special anatomy of each form. — 1. Sub- 
coracoid. The articular head of the humerus lies 
on the anterior surface of the neck of the scapula, 
and the anatomical neck rests on the anterior lip 
of the glenoid fossa. The head is thus placed 
immediately below the coracoid process, and is 
in front of, internal to, and a little below, its 
normal site. The great tuberosity faces the empty 
glenoid cavity (Fig. 41). The subscapulars mus- 
cle is stretched 
over the head of 
the humerus, and 
is usually in some 
part torn. The 
s u p r aspinatus, 
inf rasp inatus, 
and teres minor 
are stretched or 
torn, or the great 
tuberosity may 
even be wrenched 
off. The coraco- 
brachialis and 
short head of the 
biceps are tense, 
and are immedi- 
ately in front of 
the head of the 
humerus instead of 
to its inner side. The 

41. — Subeoracoia cusloration of the , , „ , 

lmmerus. long tendon or the 




Pig. 



Chap. XI] REGION OF THE SHOULDER 249 

biceps is deflected downwards and outwards. It is 
sometimes, although rarely, torn from its groove. 
The deltoid is put upon the stretch. The pro- 
minence formed by the humeral head in the front 
of the axilla depends to some degree upon the 
amount of rotation. If the bone be rotated out, 
the projection is most distinct; but if rotated in, 
its head sinks into the axilla and is brought more 
in contact with the scapula than with the skin. 
The head of the bone being always carried a little 
downwards, some lengthening must in all cases 
really exist; but with the ordinary method of 
measuring the limb this lengthening may be re- 
placed by a normal measurement, or even by 
apparent shortening, if the head of the bone be 
carried a good deal forwards and inwards, and 
the limb be abducted. When the head has left 
the glenoid cavit}^, abduction tends to bring the 
external condyle nearer to the acromion, and these 
are the two points between which the measurement 
is usually taken. Thus the apparent length of 
the arm depends mainly upon the degree of abduc- 
tion of the humerus, or the obliquity of the axis 
of the bone. 

2. Subglenoid. — The head is below, and a little 
in front of and internal to, its normal position. 
It cannot go directly downwards, owing to the 
situation of the long head of the triceps, but 
escapes in the interval between that muscle and 
the subscapularis. The articular head rests on 
the anterior aspect of the triangular surface just 
below the glenoid fossa that gives origin to the 
triceps. The upper border of the great tuberosity 
is in close relation with the lower margin of the 
joint. It is generally stated, on the authority 
of Malle, that the circumstance which prevents 
the head of the bone from being drawn upwards 
is the entirety of the anterior part of the capsule, 
the rent being in the lower part only of that liga- 
ment. The subscapularis muscle is much stretched 
or torn, and the head usually lies beneath its ten- 
don, and upon some fibres of the disturbed muscle. 



250 



SURGICAL APPLIED ANATOMY [Part III 



The supraspinatus will be torn. The infraspina- 
tus will be stretched or torn, and the two teres 
muscles will not be much affected unless there be 
considerable abduction of the arm. The coraco- 
brachialis and biceps will be stretched, but owing 
to the amount of abduction usually present the 
biceps tendon is but little deflected from a straight 
line. The deltoid is greatly stretched, and its ten- 
sion serves to produce the extreme flattening of the 
shoulder and the great abduction common in this 
injury. Some lengthening is seldom absent, al- 
though it is always modified by the abduction that 
exists. 

3. Subspinous. — The head usually rests on 
the posterior surface of the neck of the scapula, 
the groove of the anatomical neck of the humerus 
corresponding to the posterior lip of the glenoid 
fossa. The head is thus placed beneath the 
acromion ; but it may be displaced still farther 
back, and may rest on the dorsum scapulae, and 
beneath the scapular spine (Fig. 42). The sub- 
scapulars tendon is drawn right across the 

glenoid fossa, and is 
often torn from its 
attachment. The head 
pushes back the hinder 
part of the deltoid, 
the infraspinatus and 
teres minor muscles. 
These latter cover the 
bone, and are stretched 
over it. The supra- 
spinatus is tense, asis 
also the biceps, while 
the teres major and 
latissimus dorsi are 
relaxed. The great 
pectoral is rendered 
unduly tense, and this 
serves in part to ex- 

-subspinous dislocation of P lai ? the rotation in- 
the humerus. wards oi the humerus, 




Chap. XI] EEGION OF THE SHOULDEE 251 

and the abduction forwards, that are usually ob- 
served, those movements being more or less unop- 
posed. The circumflex nerve is often torn. 

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

Fractures of the upper end of the 
humerus. — 1. Anatomical neck. The upper 
part of the capsule is exactly attached to the ana- 
tomical neck, and in this situation the fracture 
may run beyond the ligament and be partly extra- 
capsular (Fig. 40, p. 239). The lower part of the 
capsule is inserted some little w T ay below the ana- 
tomical neck, and in this position, therefore, the 
lesion must be intracapsular. From the line of 
attachment of the lower part of the capsule to 
the humerus, fibres are reflected upwards to the 
margin of the articular cartilage on the head of 
the bone. These fibres, if unruptured, may serve 
to connect the fragments. If entirely separated, 
the head of the bone must necrose, having no such 
source of blood supply as the head of the femur 
derives from the round ligament. It is easy for 
the small and comparatively dense upper frag- 
ment to be driven into the wide surface of can- 
cellous bone exposed on the upper surface of the 
lower fragment. When impaction occurs, there 
may be some flattening of the deltoid, since the 
head is rendered of less dimensions by that im- 
paction, and consequently causes a less projection 
of the deltoid. It may be possible to detect the 
impaction by examination through the axilla when 
the arm is fully abducted. The difficulty of ob- 
taining crepitus in non-impacted fractures will 
be obvious when the small size of the upper frag- 
ment is considered, together with its great 



252 SUEGICAL APPLIED ANATOMY [Part III 

mobility, and the obstacles in the way of so fixing 
it that one broken end may be rubbed against the 
other. 

The amount of displacement is to be measured 
by the laxity of the capsule. The usual deviation 
is a projection of the upper end of the lower 
fragment towards the anterior and inner side of 
the articulation, brought about mainly by the 
muscles attached to the bicipital groove. In no 
case could the two bone-ends overlap. 

2. Separation of the upper epiphysis. — The 
lower border of this epiphysis is represented by a 
line crossing the bone at the base of the great 
tuberosity and placed between the anatomical 
and surgical necks (see Fig. 40, p. 239). It would 
be fairly indicated by a transverse saw-cut 
through the widest part of the bone. The three 
component nuclei of this epiphysis (head, greater 
and lesser tuberosities) fuse together about the 
fifth year, and the entire mass joins the shaft 
about the twentieth year. The upper fragment 
may be carried and rotated a little outwards by 
the muscles attached to the great tuberosity, while 
the lower fragment is drawn inwards and for- 
wards by the muscles inserted into the bicipital 
groove. Thus, a part of the smooth upper erid of 
the lower fragment commonly forms a distinct 
projection below the coracoid process. In such 
case the axis of the limb would be altered, and 
the elbow carried a little from the side. Often, 
however, the displacement is solely in the antero- 
posterior direction, the lower fragment project- 
ing forwards. So wide are the two bone surfaces 
at the seat of injury that it is scarcely possible 
for them to overlap one another. 

3. Surgical neck. — The surgical neck is situ- 
ated between the bases of the tuberosities and the 
insertions of the latissimus dorsi and teres major 
muscles. A common displacement of parts is the 
following. The upper fragment is carried out 
and rotated out by the supra- and infraspinatus 
and teres minor. The upper end of the lower 



Chap. XI] REGION OF THE SHOULDER 253 

fragment is drawn upwards by the deltoid, biceps, 
coraco-brachialis, and triceps, inwards by the 
muscles attached to the bicipital groove, and for- 
wards by the great pectoral. Thus it forms a 
projection in the axilla, and the axis of the limb 
* is altered so that the elbow projects from the side. 
This displacement, however, is by no means con- 
stant. Pean, Anger, and others maintain that the 
usual deformity is a projection of the upper end 
of the lower fragment forwards, and that this 
deviation is due to the nature and direction of 
the violence, and not to muscular action. In some 
cases there is no displacement, the broken ends 
being retained in situ, probably, by the biceps 
tendon and the long head of the triceps. In at 
least one instance (Jarjavay) the lower fragment 
was so drawn upwards and outwards, apparently 
by the deltoid, as to nearly pierce the skin of the 
shoulder. Hamilton comes to the general con- 
clusion " that complete or sensible displacement 
is less common at this fracture than in most other 
fractures," and in this conclusion many surgeons 
agree. 

Amputation at the shoulder joint. — " Flap 
method " : " deltoid flap " (Fig. 43). In the 
outer flap are only the deltoid and a few small 
vessels derived from the acromio-thoracic and the 
two circumflex arteries. The cephalic vein and 
descending^ branch of the acromio-thoracic artery 
are in the inner flap. The anterior and posterior 
borders of the inner flap show portions of the 
deltoid muscle. Along its lower border from be- 
fore backwards are sections of the pectoralis 
major, the short head of the biceps and coraco- 
brachialis, the axillary vessels and nerves, the 
latissimus dorsi and teres major, the triceps, and 
the posterior portion of the deltoid. The trunks 
of the posterior circumflex artery and nerve are 
found divided on the posterior part of the surface 
of the flap, between the sections of the triceps 
and deltoid, and not far from the angle between 
the two flaps. 



254 



SURGICAL APPLIED ANATOMY [Part III 



Oval method (Spence). The parts cut and the 
order of their division are practically the same as 
obtain in the anterior and inferior borders of the 
two flaps made in the previous method. The an- 
terior incision, being a little more vertical than 




Fig. 43. — Amputation at shoulder-joint: flap-method. (Agatz.) 

a, Glenoid cavity ; It, deltoid ; c, long head of biceps ; d, pectoralis major ; e, biceps 
and coraco-brachialis ; /; latissimus dorsi and teres major ; g, triceps ; 1, axillary 
vessels ; 2, circumflex vessels ; 3, brachial plexus. 

is the gap between the two flaps, divides more of 
the pectoralis major and cuts the cephalic vein 
higher up. The posterior circumflex vessels and 
nerve are separated from the bone by the finger 
and are retained, one advantage of the procedure 
being that only a few of the terminal branches 
of that artery are divided. 



CHAPTER XII 

THE ARM 

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

Surface anatomy.— In women, and in those 
who are fat, the outline of the arm is rounded 
and fairly regular. It is less regular in the mus- 
cular, in whom it may be represented by a 
cylinder, somewhat flattened on either side and 
unduly prominent in front (biceps muscle). The 
outline of the biceps muscle is distinct, and on 
either side of it is a groove. The inner of the 
two grooves is by far the more conspicuous. It 
runs from the bend of the elbow to the axilla, and 
indicates generally the position of the basilic vein 
and brachial artery. The outer groove is shal- 
low, and ends above at the insertion of the deltoid 
muscle. So far as it goes it marks the position 
of the cephalic vein. 

The insertion of the deltoid can be well made 
out, and is an important landmark. It indicates 
very precisely the middle of the shaft of the 
humerus, is on the same level with the insertion 
of the coraco-brachialis muscle, and marks the 
upper limit of the brachialis anticus. It corre- 
sponds also to the spot where the cylindrical 
part of the humeral shaft joins the prismatic 
portion, to the point of entrance of the nutrient 
artery, and to the level at which the musculo- 
spiral nerve and superior profunda artery cross 
the back of the bone. 

255 



256 SURGICAL APPLIED ANATOMY [Part III 

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

The inferior profunda would be represented 
by a line drawn from the inner side of the 
humeral shaft at its middle to the back part of 
the internal condyle. The nutrient artery enters 
the bone at its inner aspect opposite the deltoid 
insertion, and the anastomotic vessel comes off 
about 2 inches above the bend of the elbow. 

The ulnar nerve follows first the t brachial 
artery, and then a line drawn from the inner side 
of that vessel, about the level of the insertion of 
the coraco-brachialis, to the gap between the inner 
condyle and the olecranon. The main part of the 
internal cutaneous nerve is beneath the inner 
bicipital groove, while the musculo-cutaneous 
nerve becomes superficial in the bend of the elbow 
at the outer margin of the tendon of the biceps. 

The arm. — The skin of the arm is thin and 
smooth, especially in front and at the sides. It 
is very mobile, being but loosely attached to the 
deeper parts by a lax subcutaneous fascia. In 
circular amputations of the arm this looseness of 
the integument allows it to be sufficiently^ drawn 
up by traction with the hand only. It is from 
the integument covering the anterior surface of 
the biceps that the flap is fashioned in Taglia- 
cozzi's operation for the restoration of the nose. 
The fineness of the skin of this part, and its free- 
dom from hairs, render it very suitable for this 
procedure. The scanty attachments of the skin 



Chap. XII] THE AEM 257 

of the arm allow it to be readily torn or stripped 
away in lacerated and contused wounds. Some- 
times in these lesions large flaps of integument 
are violently dissected up. The looseness of the 
subcutaneous tissues favours greatly the spread 
of inflammatory processes, while its comparative 
thinness allows of the early manifestation of 
ecchymoses. 

The limb is completely invested with a deep 
fascia, the brachial aponeurosis, as by a sleeve. 
The fascia is held down at the sides by the two 
intermuscular septa which are attached along the 
outer and inner margins of the humerus, running 
from the deltoid insertion to the outer condyle on 
the one side, and from the coraco-brachialis inser- 
tion to the inner condyle on the other. By means 
of this aponeurosis and its septa the arm is 
divided into two compartments, that can be well 
seen in transverse sections of the limb (Fig. 44, 
p. 261). These compartments serveto confine in- 
flammatory and hemorrhagic effusions. The an- 
terior of the two spaces has the less substantial 
boundaries, owing to the thinness of the brachial 
fascia as it covers the biceps. Effusions can 
readily pass from one compartment to the other 
by following the course of those structures that, 
by piercing the intermuscular septa, are common 
to both spaces. These are the musculo-spiral and 
ulnar nerves, the superior and inferior profunda, 
and anastomotic arteries. The principal struc- 
tures that pierce the brachial aponeurosis itself 
are the basilic vein, a little below the middle of 
the arm, the internal cutaneous nerve, about the 
middle, and the external cutaneous nerve, at the 
elbow. The two first-named are in the inner 
bicipital groove, and the last-named in the outer. 

The brachialis anticus is closely adherent to 
the bone, while the biceps is free. It follows, 
therefore, that in section of these muscles, as in 
amputation, the latter muscle retracts more con- 
siderably than does the former. It is well, there- 
fore, in performing a circular amputation, to 



258 SUEGICAL APPLIED ANATOMY [Part III 

divide the biceps muscle first, and then, after it 
has retracted, to cut the brachialis anticus. 

The brachial artery* — The line of this vessel 
has already been given. It is well to note that 
in the very muscular the artery may be over- 
lapped to a considerable extent by the biceps 
muscle. Compression of the brachial, unless per- 
formed carefully with the fingers, can hardly 
avoid at the same time compression of the median 
nerve. It must also be remembered that the in- 
ternal cutaneous nerve lies in front of the vessel, 
or close to its inner side, until it pierces the 
fascia; that the ulnar nerve lies along the inner 
side of the artery as far as the coraco-brachialis 
insertion ; and that behind the commencement of 
the vessel is the musculo-spiral nerve. The venae 
comites are placed one on either side of the artery, 
and communicate frequently with one another by 
short transverse branches which directly cross the 
vessel, and which may give trouble in operations 
upon the artery. If in ligaturing the artery at 
its middle third the arm rests upon any support, 
the triceps may be pushed up and mistaken for 
the biceps. If the incisions be too much to the 
inner side the basilic vein may be cut, or the 
ulnar nerve exposed and mistaken for the median. 
Tillaux states that in the operation a large in- 
ferior profunda artery has been taken for the 
brachial. Inasmuch as the median nerve often 
derives distinct pulsation from the subjacent ves- 
sel, it happens that in the living subject it has 
been confused with the main artery itself. 

Abnormalities in the arrangement of the 
brachial artery are so frequent (they occur in 12 
to 15 per cent._ of arms) as to be of surgical im- 
portance. It is not unusual to find a collateral 
branch (vas aberrans) arising from the upper 
part of the brachial or lower part of the axillary, 
passing down the arm, superficially to the median 
nerve, and ending in the radial or sometimes the 
ulnar artery. The vas aberrans may replace the 
brachial, in which case the artery will be found 



Chap. XII] THE ARM 259 

superficial instead of deep to the median nerve, 
and the profunda vessels arise from the remnant 
of the real brachial artery. This superficial 
brachial vessel may pass under the supra- 
condyloicl process, a hooked projection of bone 
which occasionally springs from the humerus, 2 
inches above the epicondyle. It is situated 
amongst the inner fibres of origin of the brachialis 
anticus. 

The iiiusculo-spiral nerve, from its close 
contact with the bone, which it crosses at the level 
of the deltoid insertion, is frequently injured and 
torn. Thus it has been damaged in severe con- 
tusions, in kicks, in stabs, in bites from horses, 
and very frequently in fractures of the humeral 
shaft; or the nerve may be sound at the time of 
fracture, and become subsequently so involved 
in the callus formed as to lead to paralysis of the 
parts it supplies. In a case reported by Tillaux, 
where paralysis followed some time after a frac- 
ture, the nerve was found embedded in callus, and 
on cutting some of the redundant mass away a 
good recovery followed. In several instances the 
nerve has been paralysed by the pressure of the 
head when a man has_ slept with his head resting 
on the arm in the position of full supination and 
abduction. It is said to be often paralysed in 
Russian coachmen who fall asleep with the reins 
wound round the upper arm. It has also been 
frequently damaged by the pressure of badly con- 
structed crutches, especially those that afford no 
proper support for the hand. Indeed, it is the 
nerve most often affected in " crutch paralysis," 
the ulnar being the trunk that suffers next in 
frequency. 

Fracture of the shaft of the humerus is 
usually due to direct _ violence. The shaft may, 
however, be broken by indirect violence, and of all 
bones the humerus is said to be the one most 
frequently fractured by muscular action. As ex- 
amples of the latter may be noted the throwing 
of a ball, the clutching at a support to prevent a 



260 SURGICAL APPLIED ANATOMY [Part III 

fall, and the so-called trial of strength known as 
" wrist-turning." When the bone is broken above 
the deltoid insertion the lower fragment may be 
drawn upwards by the biceps, triceps, and del- 
toid, and outwards by the last-named muscle; 
while the upper fragment is drawn inwards by the 
muscles attached to the bicipital groove. When 
the fracture is below the ■ deltoid insertion, the 
lower end of the upper fragment may be carried 
outwards by that muscle, while the lower frag- 
ment is drawn upwards to its inner side by the 
biceps and triceps. The deformity, however, as 
a rule depends much more upon the nature and 
direction of the force that breaks the bone than 
upon any muscular action. The displacements 
just noted may be met with, but usually they are 
quite independent of the relation of the deltoid 
insertion to the seat of fracture, and cannot be 
tabulated. The weight of the arm seldom allows 
of more than § of an inch of shortening. 

The humerus is more frequently the seat of 
non-union after fracture than is any other bone. 
This result is quite independent of the position 
of the fracture in relation to the nutrient artery. 
Hamilton's explanation is briefly this : The frac- 
ture is usually so adjusted that the elbow is 
flexed; this joint soon becomes fixed by muscular 
rigidity, and when any movement is made as if 
to flex or extend the forearm on the arm, that 
movement no longer occurs at the elbow- joint, but 
at the seat of fracture. Thus, if the arm be in 
a sling, and the patient allows the hand to drop 
by relaxing that sling, it is maintained that the 
bulk of that movement will take place about the 
fracture line. There are many objections to this 
theory. If true, the tendency to movement about 
the fragments would be the greater the farther 
the fracture is from the elbow- joint, but non- 
union is more common at the middle than at the 
upper third of the shaft. Probably many causes 
conspire to bring about non-union of fractures 
of this bone, among which may be mentioned the 



Chap. XII] 



THE ARM 



261 



imperfect fixing of the joint above the fracture, 
and the inadequate support afforded to the elbow, 
whereby the weight of the arm and of the splints 
tends to drag the lower fragment out of the 
proper line it should form with the upper frag- 
ment. The most effective cause would appear to 
be the entanglement of muscular tissue between 
the broken ends, for it must be remembered 
that the shaft of the bone is closely surrounded by 
muscular fibres that are directly adherent to its 
surfaces. Thus, in an oblique fracture the end of 
one fragment may be driven into the brachialis 
anticus, while the other end projects into the sub- 
stance of the triceps, and immediate contact of 
the bones may be consequently prevented. 

Amputation through the middle of the 
arm. — Circular method: The parts divided in 
this amputation are fully shown in Fig. 44. Flap 
method : Two 
flaps of about 
equal size and 
shape may be cut 
antero-posterior- 
ly, the arm being 
well rotated out- 
wards. In the an- 
terior flap would 
be the biceps and 
the greater part 
of the brachialis 
anticus, with the 
musculo - cutane- 
ous nerve between 
them, and a small 
piece of the tri- 
ceps from the 
inner side of the 
limb. The bra- 
chial vessels, the 
median and ul- 
nar nerves, and possibly the inferior profunda 
artery, are also found in this flap, about the 




Fig. 44. — A transverse section through the 
middle of the arm. (Braune.) 

a, Biceps ; b, coraco - brachialis ; c, brachialis 
anticus ; d, triceps ; 1, brachial artery ; 2, me- 
dian nerve ; 3, ulnar nerve ; 4, muscuio-spiral 
nerve. 



262 SUKGICAL APPLIED ANATOMY [Part III 

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



CHAPTER XIII 

THE REGION OF THE ELBOW 

Surface anatomy. — On the anterior aspect of 
the elbow are seen three muscular elevations. 
One, above and in the centre, corresponds to the 
biceps and its tendon ; while, of the two below and 
at the sides, the outer corresponds to the supina- 
tor longus and the common extensor mass, and the 
inner to the pronator radii teres and the common 
set of flexor muscles. The arrangement of these 
elevations is such that two grooves are formed, 
one on either side of the biceps and its tendon. 
The grooves diverge above, and join the outer and 
inner bicipital grooves, while below they meet 
over the most prominent part of the tendon, and 
thus form together a Y-shaped depression (Fig. 
45). The distinctness of these details depends 
upon the thinness and muscular development of 
the individual. In the inner of the two grooves 
are to be found the median nerve, the brachial 
artery and its veins; while deeply placed below 
the outer groove are the terminations of the mus- 
culo-spiral nerve and superior profunda artery, 
with the small radial recurrent vessel. The biceps 
tendon can generally be very distinctly felt. Its 
outer border is more evident than is its inner 
edge, owing to the connection of the bicipital 
fascia with the latter side of the tendon. Extend- 
ing transversely across the front of this region is 
a crease in the integument, the " fold of the 
elbow." This fold is not a straight line, but is 

263 



264 SURGICAL APPLIED ANATOMY [Part III 

convex below. It is placed some little way above 
the line of the articulation, and its lateral ter- 
minations correspond to the tips of the two con- 
dylar eminences. In backward dislocations of the 
elbow the lower end of the humerus appears about 
1 inch below this fold, whereas in a fracture of 
the humerus just above the condyles the fold is 
either opposite to the prominence formed by the 
lower end of the upper fragment, or is below it. 
This crease is obliterated on extension. 

At the apex of the V-shaped depression, about 
the spot where the biceps tendon ceases to be dis- 
tinctly felt, and at the outer side of that tendon, 
the median vein divides into the median basilic 
and the median cephalic. At the same spot also 
the deep median vein joins the superficial vessels. 
The median basilic vein can be seen to cross the 
biceps tendon, to follow more or less closely the 
groove along the inner border of the muscle, and 
to join, a little above the internal condyle, with 
the posterior ulnar vein to form the basilic trunk. 
The median cephalic, following the groove at the 
outer margin of the biceps, joins, about the level 
of the external condyle, with the radial vein to 
form the cephalic vein. The brachial artery 
bifurcates 1 inch below the centre of a line drawn 
from one condyle to the other; the^ point of 
division is opposite the neck of the radius. " The 
coronoid process of the ulna can be indistinctly 
felt, if firm pressure is made in the triangular 
space in front of the joint " (Chiene). The points 
of the two condyles can always be felt. The in- 
ternal condyle is the more prominent and the less 
rounded of the two. The humero-radial articula- 
tion forms a horizontal line, but the humero-ulnar 
joint is oblique, the joint surfaces sloping down- 
wards and inwards. _ Thus it happens that while 
the external condyle is only f of an inch (18 mm.) 
above the articular line, the point of the internal 
condyle is more than 1 inch (28 mm.) above that 
part (Paulet). From the obliquity of the joint 
surfaces between the ulna and humerus, it follows 



Chap. XIII] REGION OF THE ELBOW 265 

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

The joint line of the elbow is equivalent only 
to about two-thirds of the width of the entire line 
between the points of the two condyles (Fig. 46, 
p. 270). The prominence of the condyles forms a 
capital point d'appui for traction by encircling 
bands applied to the limb above the elbow-joint. 
At the back of the elbow the prominence of the 
olecranon is always to be distinctly felt. It lies 
nearer the internal than the external condyle. In 
extreme extension the summit of the olecranon 
is a little above the line joining the two condyles. 
When the forearm is at right angles with the arm, 
the tip of the process is below the line of the 
condyles, and in extreme flexion it lies wholly 
in front of that line. Between the olecranon and 
the inner condyle is a depression that lodges the 
ulnar nerve and the posterior ulnar recurrent 
artery. 

To the outer side of the olecranon, and just 
below the^ external condyle, there is a depression 
in the skin which is very obvious when the limb 
is extended. This pit is to be seen even in those 
who are fat, and also in young children. In it 
the head of the radius and radio-humeral joint 
can be felt, and can be well distinguished when 
the bone is rotated in pronation and supination. 



266 



SURGICAL APPLIED ANATOMY [Part III 



The pit corresponds to the hollow between the 
outer border of the anconeus and the muscular 
eminence formed by the two radial extensors of 
the carpus and the supinator longus. The highest 
point of the bone that can be felt ^ moving on 
rotation will correspond to the radius immedi- 
ately below the line of 
the elbow-joint, and is a 
valuable guide to that 
articulation. The upper 
limit of the elbow-joint 
reaches a line drawn be- 
tween the point of the two 
condyles. The tubercle of 
the radius can be felt just 
below the head of the bone 
when the limb is in the 
position of extreme pro- 
nation. 

The region of the 
el how. — The skin in front 
of the elbow is thin and 
fine, and is readily ex- 
coriated by tight bandag- 
ing and by improperly 
applied splints. The;$hin- 
ness of the skin allows the 
subjacent veins to be 
easily seen through the 
integuments, but the dis- 
tinctness with which these 
veins appear depends 
mainly upon the amount 
of subcutaneous fat. In 
the very stout they may 
be quite invisible, and it 
may be difficult or im- 
possible to render them 
evident by the usual means 
Tillaux points out that if 
suchpeople are bled a pellet of fat will often pro- 
ject into the wound and prevent the flow of blood. 




Fig. 45.— The left elbow from 
in front. 

a, Basilic vein ; b, cephalic vein ; 
o, on the ulna points to median 
basilic vein: d, on the radius 
points to median cephalic vein ; 
e, radial vein ; /, median vein ; 
0, posterior ulnar vein. The 
brachial artery passes behind 
the median-basilic vein, and 
divides into its radial and ulnar 
branches to the inner side of 
the radial neck. 

adopted in venesection. 



Chap. XIII] REGION OP THE ELBOW 267 

The arrangement of the superficial veins in 

front of the elbow, so as to form an M-shaped 
figure, is familiar, but it must be confessed that 
it is by no means constant (Fig. 45). So far as I 
have seen, it would appear that the precise M-like 
arrangement figured in most books is only present 
in about two-thirds, and perhaps in only one- 
half, of all cases. 

The median vein breaks up into the median 
cephalic and median basilic, just to the outer 
side of the biceps tendon, and, therefore, the 
latter vein passes in front of the tendon, of the 
brachial artery and its veins, and of the median 
nerve. From these structures it is separated by 
the bicipital fascia. The median basilic vein may 
cross the brachial artery abruptly, and be com- 
paratively free of it, except at the point of cross- 
ing, or it may run for some distance quite in 
front of the artery, or, crossing it early, it may 
lie parallel with the vessel, although at a different 
level, for the greater part of its course. As re- 
gards size, the median basilic is usually the 
largest of these veins, the median cephalic coming 
next, and the median itself third, while the ulnar 
and radial veins are the smallest of the series. 
These" - veins are liable to many abnormalities, 
some of the most conspicuous being in cases where 
the main arteries of the part also are abnormal. 
The deviation is more usual in the veins on the 
radial than in those on the ulnar side of the limb. 
Thus it is common for the radial or the median 
cephalic veins, or both, to be either very defec- 
tive or entirely absent.^ In spite of the relation 
the median basilic vein bears to the brachial 
artery, it is nevertheless the vein usually selected 
in venesection and transfusion. The reasons for 
its selection are these : it is usually the largest 
and most prominent of the veins, and the one 
the nearest^ to the surface ; it is also the least 
movable vein, and v the one the least subject to 
variation. The bicipital fascia forms an excel- 
lent protection to the brachial artery during 



268 SURGICAL APPLIED ANATOMY [Part III 

phlebotomy. • The density of that membrane 
varies, and depends mainly upon the degree of 
muscular development. In thin subjects the 
median basilic vein may receive pulsations from 
the subjacent artery. According to one observer, 
the walls of this vein are often as thick as those 
of the popliteal vein.^ The ulnar, radial, and 
median veins seldom yield enough blood on vene- 
section, since they are below the point of junction 
of the deep median vein, and thus do not receive 
blood from the deep veins of the limb. The 
brachial artery has, as may be supposed, been 
frequently injured in bleeding; and at the period 
when venesection was very commonly practised, 
arterio-venous aneurisms at the bend of the elbow 
were not infrequent. Since the principal super- 
ficial lymphatic vessels run with these veins, and 
since some of them can scarcely escape injury in 
phlebotomy, it follows that an acute lymphan- 
gitis is not uncommon after the operation, especi- 
ally when, the point of the lancet being unclean, 
septic matter is introduced into the wound. 

The internal cutaneous nerve, which usually 
runs in front of the median basilic vein, may be 
wounded in bleeding from that vessel. The in- 
jury to the nerve, according to Tillaux, may lead 
to " traumatic neuralgia of extreme intensity, 
and very chronic." A " bent arm " may follow 
after venesection, and Mr. Hilton believes this 
to be often due to injury to the filaments of the 
musculocutaneous nerve, especially to the inclu- 
sion of those filaments in a scar left by the opera- 
tion. The cutaneous branches of this nerve lie 
over the median cephalic vein. These peripheral 
fibres being irritated, the muscles supplied from 
the same segment of the cord (biceps and 
brachialis anticus) are caused to contract by re- 
flex action. Hence the bent arm. In one case he 
cured a bent arm following bleeding by resecting 
the old scar, which on removal was found to 
have included within its substance some nerve 
filaments. 



Chap. XIII] REGION OF THE ELBOW 269 

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

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

The ulnar nerve is, from its position at the 
elbow, very^ liable to be injured. It passes in a 
groove behind the internal epicondyle, and is 
crossed by a bridge of fibrous tissue which pre- 
vents its displacement. The nerve may pass in 
front of the internal condyle, and an instance 
is reported where the nerve slipped forward over 
that eminence whenever the elbow was bent 
(Quain). In cases where an abnormal brachial 
passes beneath a supracondyloid process the 
median nerve goes with the artery. In exposing 
the ulnar nerve (for nerve-stretching, etc.) behind 
the elbow the nerve may be found quite covered by 
an occasional muscle, the epitrochleo-anconeus. 

The elbow-joint. — The strength of this joint- 
depends not so much upon either ligaments or 
muscles as upon the coaptation of the bony sur- 
faces. The relations of the olecranon and coronoid 



270 



SURGICAL APPLIED ANATOMY [Part III 



processes to the humerus are such that in certain 
positions the strength of the joint is very con- 
siderable. 

The elbow, being a pure hinge-joint, permits 
only of flexion and extension. These movements 
are oblique, so that in flexion the forearm in- 
clines inwards, carrying the hand towards the 



Triceps 




OLECRAnO/S 



Ulha 



HUMERUS 

Biceps 

BRACKIALI5 ArtTICUS 

Capsule 

Sup. Lo/icus. 
Epipmysis of Trochlea 

ro/noid 

E-URSA 

Biceps 
Iaiterosseus Ae.t. 



Fig. 46. — Vertical section of the elbow-joint. 



The epiphyseal lines of the olecranon and trochlea are. shown in red. The joint 
is semi-extended. 

A, Usual cap-like epiphysis of olecranon receiving insertion of triceps ; B, occa- 
sional epiphysis forming the upper third of the olecranon. Three bursas are 
shown— over the olecranon, under the insertion of the triceps, and at the 
insertion of the biceps. 

middle third of the clavicle. If it were not for 
the obliquity of the joint line it would be possible 
for the hand to be placed flat upon the shoulder 
of the same side, but this movement is only possi- 
ble after some excisions of the joint, for in this 
operation the oblique direction of the articular 
surfaces is not reproduced. In extreme extension 
the ulna is nearly in a straight line with the 
humerus as regards their lateral planes, while 



Chap. XIII] REGION OF THE ELBOW 271 

in extreme flexion the two bones form an angle 
of from 30° to 40°. 

Bursa?. — Of the bursse about the joint the 
large subcutaneous bursa over the olecranon is 
very commonly found enlarged and inflamed 
(Fig. 46) ; and when inflamed may lead to exten- 
sive mischief in the limb. Its enlargement is 
favoured by certain employments involving pres- 
sure on the elbow ; thus, the disease known as 
" miner's elbow " is merely an enlargement of this 
sac. There is a bursa between the biceps tendon 
at its insertion and the bone, the relations of which 
to the nerves of the forearm are worth, noting. 
A case, for instance, is reported where this bursa 
became chronically enlarged, and by pressing 
upon the median and posterior interosseous 
nerves produced loss of power in the forearm 
(Agnew). There is a small bursa at the insertion 
of the triceps (Fig. 46). 

Of the ligaments of the elbow-joint, the an- 
terior and posterior are comparatively thin, and 
the latter especially^ soon yields to the pressure of 
fluid within the joint in disease of the articula- 
tion (Fig. 46). The internal lateral is the strong- 
est and most extensive of the ligaments of the 
part. From its rigidity, its extended attachment, 
and the fact that it serves to limit not only 
flexion and extension, but also any attempt to 
wrench the forearm laterally from the arm, it 
happens that it is the ligament that suffers the 
most often in " sprains " of the elbow. As this 
ligament is attached to the whole length of the 
inner border of the olecranon, it may assist in 
preventing separation of the fragments when that 
process has been fractured. 

Joint disease. — In disease of this joint the 
effusion first, and most distinctly, shows itself 
by a swelling around the margins of the ole- 
cranon. This is explained by the facts that the 
synovial cavity is here nearest to the surface, and 
that the posterior ligament is lax and thin (Fig. 
46). Some swelling is also soon noticed. about the 



272 SUEGICAL APPLIED ANATOMY [Part III 

line of the radio-humeral joint, and fluctuation 
in this situation serves to distinguish joint effu- 
sion from simple enlargement of the bursa beneath 
the triceps tendon. Deep-seated swelling may be 
noted about the front of the joint beneath the 
brachialis anticus, owing to the thinness of the 
anterior ligament; and lastly, about the external 
condyle. The density of the internal ligament 
prevents a bulging of the synovial membrane on 
the inner side. When the joint suppurates the 
pus will most easily reach the surface by travel- 
ling upwards and backwards between the humerus 
and the triceps, and the abscess points, therefore, 
very commonly at one or other border of that 
muscle. The pus may escape beneath the brachi- 
alis anticus in front, and discharge itself near the 
insertion of the muscle. The diseased elbow tends 
to assume the posture of semi-flexion, and it is 
interesting to observe that that is the position 
assumed by the joint when forcible injections 
are made into its cavity (Braune). The joint, in 
fact, holds the greatest amount of fluid when it 
is semi-flexed. As regards muscular rigidity of 
the elbow, due to reflex irritation from disease, 
it is well to note that all the nerves of the articu- 
lation supply muscles acting upon the joint, not- 
ably the musculo-spiral and musculo-cutaneous. 
The relation of the ulnar nerve to the joint serves 
to explain cases where severe pain has been felt 
along the forearm and in the fingers, in parts 
corresponding to the distribution of that nerve. 
The upper epiphysis of the radius and the greater 
part of the lower epiphysis of the humerus are 
intrasynovial, i.e. come within the capsule of the 
joint (Fig. 47). The comparatively small upper 
epiphysis of the ulna is only partly within the 
capsule (Fig. 46). 

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



Ohap. XIII] EEGION OF THE ELBOW 273 

wards, backwards, or outwards (in order of fre- 
quency). (3) Luxation of the ulna alone back- 
wards. 

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

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

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

(c) The commonest dislocation of the two bones 
together is backwards, the rarest is forwards. — 

s 



274 SURGICAL APPLIED ANATOMY [Part III 

In the former instance the movement is resisted by 
the small coronoid process, in the latter by the 
large and curved olecranon. For like reasons the 
luxation outwards is less rare than is the dis- 
placement inwards, since the articular surface of 
the humerus inclines downwards and inwards on 
the inner side, and thus affords a greater obstacle 
in that quarter. 

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

Dislocations of the elbow of all kinds may be 
partial or complete. More usually they are com- 
plete when in the antero-posterior direction, and 
partial when the luxation is lateral. 

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

(1) Displacement of both bones back- 
wards. — This may be effected during forced ex- 
tension. Here the point of the olecranon pressed 
against the humerus acts as the fulcrum of a lever 
of the second kind, with the result that the sig- 
moid cavity is forced away from the trochlea. 
The addition of violence to the forearm in a 
backward or upward direction would effect the 
actual displacement. This condition may be illus- 
trated by a fall, as in running, upon the fully 
extended hand. The lesion may also be produced 
by certain violent wrenchings of the limb. Mal- 
gaigne maintained that the particular kind of 



Chap. XIII] REGION OF THE ELBOW 275 

wrench most effectual in producing luxation was 
a twisting inwards of the forearm while the 
elbow was semi-flexed. In this way the internal 
lateral ligament was ruptured, and the coronoid 
process twisted inwards and downwards under 
the humerus, and the bones thus displaced back. 
This lesion would be difficult to effect while the 
joint was fully flexed. In the complete form the 
coronoid process is opposite to the olecranon 
fossa. It can hardly occupy that hollow (as some- 
times described), since the connection of the ulna 
to the radius, and the projection of the latter 
bone behind the outer condyle, would prevent it 
from actually falling into ■ the fossa. The an- 
terior and the two lateral ligaments are usually 
more or less entirely torn, while the posterior 
and the orbicular ligaments escape. The biceps is 
drawn over the lower end of the humerus, and is 
rendered moderately tense. The brachialis anti- 
cus is much stretched and often torn. The an- 
coneus is made very tense. Both the median and 
ulnar nerves may be severely stretched. 

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

Sprain of the elbow. — Mr. J. Hutchinson, 
jun., has shown that in young children, under 



276 SUKGICAL APPLIED ANATOMY [Part III 

five years, forcible traction of the limb in the 
supinated position may cause the radius to slip 
downwards, away from the orbicular ligament, 
which is displaced upwards. In such cases trac- 
tion is applied before the muscles of the elbow 
have had time to undergo their usual reflex con- 
traction, so that when the child is lifted by the 
hand all the weight falls upon the ligaments at 
the elbow instead of on the muscles. _ The only 
ligaments which resist such a dislocation are (1) 
the oblique ulno-radial ligament, (2) the _ lower 
fibres of the orbicular ligament which grip the 
head. Flexion of the elbow in the pronated posi- 
tion restores the ligament to its normal position. 
It is clear that this displacement is the anatomical 
basis of the common sprain of the elbow met with 
in young children, and usually due to violent 
traction of the hand. 

Fractures of the lower end of the humerus. 
— These are : (1) A fracture just above the con- 
dyles; (2) the "T-shaped fracture ' ; involving the 
joint; (3) fractures of the internal, and (4) of 
the external condyle; (5) fracture of the internal 
epicondyle ; and (6) separation of the lower epi- 
physis. All these fractures are more common in 
the young. 

(l) The fracture " at the base of the condyles," 
as it is sometimes called, is usually situate a little 
above the olecranon fossa, where the humeral 
shaft begins to expand. It is commonly trans- 
verse from side to side, and oblique from behind 
downwards and forwards. It is generally the re- 
sult of a blow inflicted upon the extremity of the 
elbow. Probably the tip of the olecranon driven 
sharply against the bone acts like the point of 
a wedge, and takes an important share in the 
production of the fracture. The lower fragment, 
together with the bones of the forearm, is gener- 
ally carried backwards by the triceps, and up- 
wards by that muscle, the biceps, and the brachi- 
alis anticus. The median or ulnar nerves, especi- 
ally the latter, may be severely damaged. 



Chap. XIII] REGION OF THE ELBOW 277 

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

(3, 4, and 5) For surgical purposes it is well 
to limit the term " condyle ,; to such ]oarts of the 
extremity of the humerus as are within the cap- 
sule, and the term " epicondyle '• to such parts 
of the lower projections of the bone as are with- 
out the joint. 

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

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

On account of its insignificant size, a fracture 
of the external epicondyle is scarcely possible. 
Fractures of the inner epicondyle are, however, 
quite common, the joint remaining f ree (Fig. 47). 
This epicondyle exists as a distinct epiphysis, 
which unites at the age of eighteen, and which at 
any time before that age may be separated from 
the bone by direct injury or muscular violence. 



278 



SUEGtCAL APPLIED ANATOMY [Part til 



Owing to the dense aponeurotic fibres that cover 
the part, much displacement of the fragment is 
uncommon. When displacement exists, it is in 
the general line of the common flexor muscles that 
arise from the tip of the process. In such cases 
the ulnar nerve, which lies behind the process, is 
often damaged. 

6. The lower epiphysis (Fig. 47).— In the car- 
tilaginous lower extrem- 
ity of the humerus, four 
ossific centres appear, 
one for each of the fol- 
lowing parts : capitel- 
lum, trochlea, internal 
and external epicon- 
dyles. The three centres 
named first unite to form 
the main epiphysis, that 
for the internal epicon- 
dyle remaining separate 
(Fig. 47). The epiphy- 
seal line is thus divided 
into two parts, and is 
irregular in form ; it lies 
both within and without 
the capsule of the joint 
(Fig. 47) ; Its position 
may be indicated by a 
line drawn from the 
upper border of the ex- 
ternal to the lower border 
of the internal epicon- 
dyle. The lower epiphysis joins the shaft at 
seventeen. Thus, after the age of seventeen the 
growth of the bone must depend upon the activity 
of the upper epiphysis, which does not unite until 
twenty. Excision of the elbow, therefore, after 
the sixteenth or seventeenth year, will not be fol- 
lowed by arrest of development in the limb, even 
if the epiphyseal line has been transgressed by 
the saw. Several cases are, however, reported of 
marked arrest of growth in the limb following 




Fig. 47. — Lower epiphysis of the 
humerus from behind. 

A, Centre for internal epicondyle ; b,c,d, 
united centres for the trochlea, 
capitellura, and external epicon- 
dyle ; e, b, epiphyseal line ; the 
capsular attachment is indicated 
by red lines. 



Chap. XIII] REGION OF THE ELBOW 279 

upon injuries to the lower epiphysis before the 
sixteenth year, and to the upper epiphysis before 
twenty. Since the greater part of the epiphyseal 
line is within the capsule, it follows that but 
little displacement, other than a slight movement 
backwards, is consequent upon the separation of 
the mass. 

Fractures of the olecranon are commonly 
due to direct violence, and in a few cases to severe 
indirect violence applied to the lower end of the 
humerus or upper end of the ulna. Instances of 
fracture by muscular action are few, and open 
to some question. The fracture is most commonly 
met with about the middle of the process, just 
where it begins to be constricted, and is usually 
transverse in direction. The amount of displace- 
ment effected by the triceps varies, and depends 
upon the extent to which the dense periosteum 
about the process and the ligaments that are 
attached to it are torn. The olecranon is de- 
veloped mainly from the shaft of the ulna (Fig. 
46). There is a scale-like epiphysis, however, at 
the summit of the process which joins the rest of 
the olecranon at the age of seventeen. Occasion- 
ally another epiphyseal centre occurs, giving 
origin to the upper third of the olecranon (Fig. 
46). In young subjects the scale-like epiphysis 
may be separated by violence, or the cartilagin- 
ous olecranon may be dissevered from the rest of 
the bone. The common fracture of the adult 
olecranon does not follow the epiphyseal line. 

Fracture of the coronoid process is an 
extremely rare accident. It is impossible to 
understand how the process can be torn off by the 
action of the brachialis anticus, as some main- 
tain, since that muscle is inserted rather into the 
ulna at the base of the projection than into the 
process itself (Fig. 46). Nor can it be separated 
as an epiphysis, as supposed by others, since it 
does not exist as such. 

Fractures of the head or neck of the radius 
are rare, and occur usually with dislocation or 



280 SUEGICAL APPLIED ANATOMY [Part III 

other severe injury. The head is commonly found 
split or starred, and the lesion, if limited to the 
head, could hardly be diagnosed. The upper 
epiphysis of the radius is entirely within the 
limits of the annular ligament, and could scarcely 
be separated in a simple lesion. It is a mere disc 
of cartilage joining the shaft at the age of seven- 
teen. When the neck is broken the upper end of 
the lower fragment is drawn well forwards by 
the biceps muscle. 

Resection of the elbow may be performed in 
many ways. In all procedures there is danger of 
injuring the ulnar nerve, and some little difficulty 
often in clearing the prominent internal condyle. 
If the knife be kept close to the bone, no vessel of 
any magnitude should be divided. The muscles 
most disturbed are the triceps, anconeus, supin- 
ator brevis, extensor carpi ulnaris, extensor carpi 
radialis brevior, and brachialis anticus. It is 
most important to preserve the periosteum over 
the olecranon, so that the triceps may still have 
some attachments to the forearm. Jt is never 
necessary to divide the insertion of the brachialis 
anticus, still less of the biceps, although some 
few fibres of the former muscle may be separated 
in removing the upper surface of the ulna. By 
the subperiosteal method the periosteum is care- 
fully peeled off from all the parts to be resected, 
and is preserved. By this means the triceps re- 
tains a hold upon the ulna, and the restoration 
of the joint is more complete. The functions of 
the joint may be well restored after resection, 
especially when performed by the subperiosteal 
method, but it would appear that after no method 
are the anatomical details of the joint repro- 
duced. Thus, in a successful case, the new joint 
will assume the bimalleolar form, and will re- 
semble the ankle- rather than the elbow-joint. The 
humerus throws out two malleoli on the sites of 
the normal condyles, and in the concavity between 
them the ulna and radius are received. Between 
the ulna and the humerus new ligaments form, 



Chap. XIII] REGION OF THE ELBOW 281 

and a new annular ligament for the radius is also 
developed. 

Position ol the main nerves at the elbow. 

— The musculo-spiral is found in front of the 
external epicondyle, under cover of the supinator 
longus, where it divides into posterior interos- 
seus and radial. The median is situated at the 
inner border of the brachial artery; the ulnar lies 
in a groove behind the internal epicondyle. 



CHAPTER XIV 

THE FOREARM 

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

282 



Chap. XIV] THE FOREABM 283 

cular, that indicates the posterior border of the 
ulna. The ulna is subcutaneous throughout its 
entire extent, and can be readily examined. The 
upper half of the radius is too deeply placed to 
be well made out, but the lower half of the bone 
can be easily felt beneath the skin. The course of 
the radial artery is represented by a line drawn 
from the outer border of the biceps tendon at the 
bend of the elbow to a point in front of the styloid 
process of the radius. The pulse is felt between 
the styloid process and tendon of the flexor carpi 
radialis where the artery rests on the lower ex- 
tremity of the radius. The middle and lower 
thirds of the ulnar artery follow a line from 
the inner condyle to the radial side of the pisi- 
form bone. The upper third would be repre- 
sented by a line drawn from the middle of the 
bend of the elbow to meet the first line at the 
junction of the upper and middle thirds of the 
inner border of the forearm. Such a line would 
be slightly curved, with its concavity outwards. 
The tendons, etc., that can be demonstrated at the 
lower extremity of the forearm will be considered 
in the description of the wrist. 

Vessels. — It is well to note the very free anas- 
tomoses that exist along the greater part of the 
limb between the ulnar and radial arteries. This 
fact was illustrated by a case under my care, some 
time ago, in the London Hospital. A seaman 
had inflicted upon his left forearm three deep 
transverse wounds across the front of the limb 
with a sharp knife. The wounds were about 
1^ inch apart. The radial artery was divided in 
each of the wounds, and that vessel, therefore, 
presented six cut ends. It would appear to be 
sufficient to ligature the proximal and distal ends 
of the wounded vessel, and to leave the two iso- 
lated portions of the artery, each about 1^ inch 
in length, alone. I applied ligatures to five of 
the divided ends, leaving the lower end of tho 
upper isolated piece of the artery untied, and 
watched the effect. During the course of the day, 



284 SURGICAL APPLIED ANATOMY [Part III 

when the man had rallied from the profound 
faintness due to the great loss of blood he had 
experienced, copious bleeding took place from this 
single unsecured end of the vessel, and it, of 
course, had also to be tied. 

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

The median nerve passes between the two 
heads of the pronator teres, and may possibly be 
compressed by that muscle when in vigorous 
action. At the wrist the median is between the 
tendons of the flexor carpi radialis and flexor 
sublimis digitorum; it lies deep to the tendon 
of the palmaris longus, which serves as a useful 
guide to its position. 

The bones of the forearm. — Transverse sec- 
tions of the limb at various levels show that the 
radius and ulna are in all parts nearer to the 
posterior than the anterior aspect of the ex- 
tremity (Figs. 48 and 49). This relation is the 
more marked the higher up the section. The two 
bones are nearest to the centre of the limb about 
the lower end of the middle third. At the upper 
part of the forearm the muscles are found mainly 
at the sides and in front. The lower the section 
proceeds down the limb, the less will the bones be 
covered at the sides, and the more equally will 
the soft parts be found distributed about the 
anterior and posterior aspects of the limb. It 
will be noticed that where one bone is the more 
substantial the other is the more slender, as near 
the elbow and wrist; and that it is about the 
centre of the limb that the two are most nearly of 
equal strength. The proximity of the two bones, 
and especially of the ulna, to the posterior aspect 
of the limb permits them to be easily examined 
from that surface, while it is from the same aspect 
that resections and other operations upon the 



Chap. XIV] 



THE FOEEAEM 



285 



bones are most readily performed. It will be 
understood, moreover, that in compound frac- 
tures, due to penetration of fragments, the wound 
is more usually on the posterior aspect of the 
limb. 

The important movements of pronation and 
supination take place between these bones, and 
round an axis cor- 
responding to a 
line drawn 

through the head 
of the radius, the 
lower end of the 
ulna, and the 
metacarpal bone 
of the ring-finger. 
In extreme pro- 
nation the radius 
crosses the ulna 
obliquely ; the two 
bones are almost 
in contact at the 
point of crossing ; 
the lower fibres 
of the inter osseus 
membrane and the 
posterior radio- 
ulnar ligament 
are tight. # "The 
chief influ- 
ence in check- 
ing supination is 
not _ to be found 
in ligament at all, but in the contact of the pos- 
terior edge of the sigmoid cavity of the radius 
with the tendon of the extensor carpi ulnaris, 
as it lies in the groove between the styloid pro- 
cess and the round head of the ulna " (H. Mor- 
ris). Of the two movements, supination is the 
more powerful. This is illustrated in many ways. 
In using a screw-driver or a gimlet the movements 
of pronation and supination are conspicuously 




n o 

Fig. 48.— A transverse section through the 
middle of the forearm. {Branny) 

a, Radius ; &, ulna ; c, supinator longus ; d, flexor 
longus pollicis ; e, flexor carpi radialis ; /, 
palinaris longus ; g, flexor sublimis digi- 
torum ; li, flexor carpi ulnaris ; i, flexor 
profundis digitoruiu ; k, extensor carpi 
ulnaris ; I, extensor indicis ; m, extensor 
minimi digit! ; n, extensor communis digi- 
torum ; o, extensor ossis and extensor 
secundi internodii pollicis ; q, extensor 
carpi radialis brevior ; r extensor carpi 
radialis longior ; s, pronator radii teres ; 
1, radial vessels and nerve ; 2, ulnar vessels 
and nerve. 



286 SURGICAL APPLIED ANATOMY [Part III 

involved, but the main force is applied during 
supination. It is significant that the thread of 
a corkscrew is so turned that it shall be inserted 
by supination rather than by pronation. 

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

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

Fractures of the forearm. — The two bones 
are more often broken together than is either the 
radius or the ulna alone. The radius, when 
broken alone, is usually fractured by indirect 
violence, since it^ receives more or less entirely 
all shocks transmitted from the hand. The ulna, 
on the contrary, is more often broken by direct 
violence, it being the more superficial and exposed 
of the two bones. For example, in raising the 
arm to ward off a blow from the head, the ulna 
becomes uppermost. When the two bones are 
broken together, the violence may be direct or 
indirect. Malgaigne reports a case where both 
bones were broken by muscular violence in a 
patient while shovelling earth. Here the bones 
probably were broken between the two opposed 
forces represented by the biceps and brachialis an- 
ticus above and the weight of the loaded shovel in 



Chap. XIV] THE FOREARM 287 

the hand below. When both bones are broken 
and the fractures are oblique, shortening may be 
produced by the united action of the flexors and 
extensors. The displacement varies greatly, and 
depends rather upon the direction of the violence 
than upon muscular action. Thus Hamilton 
says : " I have seen the fragments deviate slightly 
in' almost every direction." If union be delayed, 
the delay is usually in the radius, since it is the 
more mobile of the bones. 

When the radius alone is broken (1) between 
the insertions of the biceps and pronator teres, 
the upper fragment is flexed by the biceps and 
fully supinated by that muscle and the small 
supinator. The lower fragment will be pronated 
by the two pronators, and drawn in towards 
the ulna by means of those muscles. If such 
a fracture be put up with the hand midway 
between the prone and supine positions, the 
following evils result : the upper fragment is 
fully supinated by the muscles; the lower frag- 
ment is placed in the mid-position by the splints. 
It follows that the proper axis of the bone 
is not reproduced, and the use of the biceps 
and supinator brevis as supinators is entirely 
lost. Thus patients so treated usually recover 
with great loss in the power of supination ; and 
to avoid this ill result, ^ it is advised to put the 
limb up in full supination, so that the two frag- 
ments may unite in their proper axis, the upper 
fragment being supinated by the muscles, the 
lower by the splints. (2) When the fracture is 
between the insertions of the two pronators, the 
upper fragment may be carried a little forwards 
by the biceps and pronator teres, and drawn to- 
wards the ulna by the latter muscle. The lower 
fragment will be adducted to the ulna by the 
pronator quadratus, and its upper end will be 
still further tilted towards that bone by the 
action of the supinator longus upon the styloid 
process. 

When the ulna alone is broken, as, for example, 



288 SURGICAL APPLIED ANATOMY [Part III 

about its middle, the upper fragment may be 
drawn a little forwards by the brachialis anticus, 
while the lower fragment will be carried towards 
the radius by the pronator quadratus. 

The displacement, however, in all cases^ is in- 
fluenced as much by the direction of the violence 
as by the action of muscles. When the fragments, 
after fracture of one or of both bones, fall in 
towards one another, so as to meet across the 
interosseous space, attempts are sometimes made 
to separate the broken ends and to preserve the 
integrity of the space by the use of graduated 
pads. These pads, however, if supplied with 
sufficient force to separate the fragments, will 
probably compress one or both of the arteries of 
the limb, and cause great distress, resulting in a 
peculiar form of paralysis, due, it is believed, 
to the compression shutting off the blood-supply 
to the muscles. Subsequently the muscles undergo 
contracture. 

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

Amputation of the forearm. — In amputa- 
tion of the forearm by double transfixion flaps, 
at about the upper part of the middle third the 
parts would be cut in the following manner (Fig. 
48) : On the face of the anterior flap would be 
seen from without inwards the supinator longus 
(cut the whole length of the flap), then the flexor 
sublimis (cut to a like extent), and, lastly, the 
flexor carpi ulnaris. Between the supinator 
longus and the flexor sublimis the divided end of 
the pronator teres isseen; andbetween the flexor 
sublimis and the skin would lie the flexor carpi 



Chap. XIV] 



THE FOEEARM 



289 



radialis and the palmaris longus. t The latter 
would appear as a tendon at the inner border 
of the flap. In the angle between the two flaps 
would be found in front of the radius a little of 
the flexor longus pollicis, and in front of the 
ulna, the flexor profundus, the latter cut much 
the longer. Quite close to the radius, and for 
the most part behind it, would be the lowest 
part of the small supinator, while behind the ulna 
would be the cut fibres of the upper end of the ex- 
tensor ossis. On the face of the posterior flap would 
be seen from without inwards the extensor carpi 
radialis longior and brevior, the extensor com- 
munis, the extensor of the little finger, and the 
extensor carpi ulnaris. The radial artery will 
run the whole length 
of the anterior flap, 
and be cut near its 
outer border to the 
inner side of the supin- 
ator longus. The ulnar 
artery will be cut 
shorter, in front of the 
bone, and between the 
flexor sublimis and 
flexor profundus. The 
anterior interosseous 
vessels will be divided 
immediately in front of 
the interosseous mem- 
brane. The posterior 
interosseous vessels will 
be cut long, and will 
be found between the 
superficial and deep 
muscles. 

Fig. 49 shows the 
relation of the parts as 
they would be cut in 
a circular amputation 
of the limb through the lower third. 




Jl o 



Fig. 49. — A transverse section 
through the lower third of the 
lor ear in . (B raune. ) 

«, Radius ; b, ulna; c, supinator longus; 
cl, flexor longus pollicis ; e, flexor 
carpi radialis ; /, palmaris longus ; 
g, flexor sublimis digitorum ; h, 
flexor carpi ulnaris ; i, flexor pro- 
fundus digitorum ; j, pronator quad- 
ratus ; k, extensor carpi ulnaris ; 

1, extensor indicia ; to, extensor 
minimi digiti ; n, extensor com- 
munis digitorum ; o, extensor se- 
cundi internodii pollicis ; p, exten- 
sor primi internodii pollicis ; q, 
extensor carpi radialis brevior ; r, 
extensor carpi radialis longior, with, 
in front of it, the extensor ossis 
metacarpi pollicis ; 1, radial vessels ; 

2, ulnar vessels ; 3, median nerve. 



CHAPTER XV 

THE WRIST AND HAND 

Surface anatomy. — The following structures 
can be made out about the wrist : Commencing 
at the outer side, the lower extremity and styloid 
process of the radius can be well denned. The 
bone is here superficial in front and behind. The 
styloid process lies more anteriorly than does the 
corresponding process of the ulna, and also de- 
scends about \ an inch lower down the limb. 
The outer surface of the radius at the wrist is 
crossed by the tendons of the extensor ossis meta- 
carpi and extensor brevispollicis. These are very 
distinct when the thumb is abducted, and the slit- 
like interval between the two can be felt. About 
the centre of the front of the wrist is the pal- 
maris longus tendon, which is usually the most 
conspicuous of the tendons on this aspect of 
the joint. It will be found absent in quite 10 per 
cent, of wrists examined. It is rendered most 
prominent when the wrist is a little flexed, the 
fingers and thumbs extended, and the thenar and 
hypothenar eminences as much approximated as 
possible. A little to its outer side is the larger but 
less prominent tendon of the flexor carpi radialis. 
In the narrow groove between these two tendons 
lies the median nerve, and on the radial side of 
the flexor carpi radialis is the radial artery.* 

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

290 



Chap. XVJ THE WRIST AND HAND 291 

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

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

The ivrist-joint.—- r ]Lhe tip of the styloid pro- 
cess of the ulna corresponds to the line of the 



292 SURGICAL APPLIED ANATOMY [Part III 

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

There are several folds in the skin on the front 
of the wrist; of these, the lowest is the most dis- 
tinct. It is a little convex downwards, precisely 
crosses the neck of the os magnum in the line of 
the third metacarpal bone (Tillaux), and is not 
quite | of an inch below the arch of the wrist 
joint. It is about \ an inch above the carpo- 
metacarpal joint, and indicates very fairly the 
upper border of the anterior annular ligament 
(Fig. 53). 

The palmar surface of hand. — The palm is con- 
cave in the centre where the skin is adherent to 
the palmar fascia. This " hollow of the hand ; ' is 
of somewhat triangular outline, with the apex up- 
wards. On either side are the thenar and hypo- 
thenar eminences. At the upper end of the former 
eminence, a bony projection is felt, just below and 
internally to the radial styloid process, which is 
formed by the tubercle of the scaphoid and ridge 
on the trapezium (Fig. 53). The interval separat- 
ing these two processes of bone cannot always be 
made out. At the upper extremity of the hypo- 
thenar eminence is the projection of the pisiform 
bone, and just below it the unciform process can 
be identified. Below the hollow of the palm, and 
opposite the clefts between the four fingers, three 
little elevations are seen, especially when the first 
phalanges are extended, and the second and third 
are flexed. These correspond to the fatty tissue 
between the flexor tendons and the digital slips 



Chap. XV] THE WRIST AND HAND 293 

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




Fig. 50. -Surface markings on the palm of the hand. 
The thick black lines "represent the chief creases on the skin. 

Of the creases in the skin of the palm (Fig. 50) 
three require especial notice. The first starts at 
the wrist, between the thenar and hypothenar 



294 SURGICAL APPLIED ANATOMY [Part III 

eminences, and, marking off the former eminence 
from the palm, ends at the outer border of the 
hand at the base of the index finger. The second 
fold is slightly marked. It starts from the outer 
border of the hand, where the first fold ends. 
It runs obliquely inwards across the palm with 
a marked inclination towards the wrist, and ends 
at the outer limit of the hypothenar eminence. 
The third, lowest, and best-marked of the folds 
starts from the little elevation opposite the cleft 
between the index and middle fingers, and runs 
nearly transversely to the ulnar border of the 
hand, crossing the hypothenar eminence at the 
upper end of its lower fourth. An unimportant 
crease running obliquely from the third to the 
second fold gives to these markings the outline 
of the letter M. The first fold is produced by the 
opposition of the thumb, the second mainly by 
the bending simultaneously of the metacarpo- 
phalangeal joints of the first and second fingers, 
and the third by the flexion of the three inner 
fingers. The second fold, as it crosses the third 
metacarpal bone, corresponds approximately to the 
lowest point of the superficial palmar arch (Fig. 50). 
The third fold crosses the necks of the metacarpal 
bones, and indicates pretty nearly the upper limits 
of the synovial sheaths for the flexor tendons of the 
three outer fingers (Fig. 53). A little way below 
this fold the palmar fascia breaks up into its four 
slips, and midway between the fold and the webs 
of the fingers lie the metacarpo-phalangeal joints. 
Of the transverse folds across the fronts of the 
fingers corresponding to the metacarpo-phalangeal 
and phalangeal joints, the highest is single for 
the index and little finger and double for the 
other two. It is placed nearly f of an inch below 
the corresponding joint. The middle folds are 
double for all the fingers, and are exactly oppo- 
site the proximal interphalangeal joints. The 
distal creases are single, and are placed a little 
above the corresponding joints (1 to 2 mm., ac- 
cording to Paulet). There are two single creases 



Chap. XV] THE WRIST AND HAND 295 

on the thumb corresponding to the two joints, 
the higher crossing the metacarpophalangeal 
articulation obliquely. The free edge of the web 
of the fingers, as measured from the palmar sur- 
face, is about | of an inch from the metacarpo- 
phalangeal joints. The superficial palmar arch 
m ay be represented Ey a curved line across th e 
patm start ing from the pirifo rm bone and rum 
nmg in a line with the palmar border of th e 
thumb when outsti- etch ed_al, rig ht angles with t he 
" index flnge i\ The deep arch is beween ^ and £ 
an inch nearer the wrist, and its position may 
be accurately marked by a line drawn from the 
base of the fifth metacarpal to the base of the 
second, two easily distinguished points. The 
digital arteries bifurcate about ^ an inch above 
the clefts between the fingers (Fig. 50). 

The dorsal surface of the hand. — On the outer 
side of the wrist, when the thumb is extended, a 
hollow is obvious between the extensores ossis 
metacarpi and brevis pollicis and the extensor 
longus pollicis. French writers have termed this 
hollow " tabatiere ana^n^^." Across this 
hollow and beneath the tendons just named runs 
the radial artery. Under the skin over the space 
can usually be seen a large vein, the cephalic 
vein of the thumb. Across the space also runs 
the external division of the terminal branch of 
the radial nerve. In the floor of the " snuff-bo x " 
are th e scaphoid bone and the trapezium. The 
extensor longus pollicis crosses the apex of the 
first interosseous space. The sesamoid bones of 
the thumb and the joint between the trapezium 
and the first metacarpal bone can all be well 
made out. The latter articulation is situate in 
the floor of the " tabatiere." On the back of the 
hand the various tendons and the surface veins, 
too, can all be clearly distinguished. Between 
the first and second metacarpal bones is the Ursj^ 
clorsal i nterosseous muscle, w hich~ ^f5rms a c on-' 
s' picuOus prom i nence when th e thumb is pressed 
against the side of the index finger. The three 



296 SURGICAL APPLIED ANATOMY [Part III 

rows of knuckles are formed by the proximal bones 
of the several joints. 

The wrist and hand. — The skin of the palm 
and of the front of the fingers is thick and dense, 
while that on the back of the hand is much finer. 
The palm, the fronts and sides of the fingers, 
and the dorsal aspects of the last phalanges, all 
show an entire absence of hair and of sebaceous 
glands. These parts are, therefore, exempt from 
the maladies that attack hair follicles and their 
gland appendages. On the dorsum of the hand, 
and of the first and second rows of phalanges, 
there are numerous hairs and sebaceous follicles. 
Sweat glands are more numerous in the skin of 
the palm than in any other part. According to 
Sappey they are four times more numerous here 
than they are elsewhere. Krause has estimated 
that nearly 2_,800 of these glands open upon a 
square inch of the palm. Only about half the 
number are found upon the dorsum of the hand. 
The profuseness with which the palm may per- 
spire is well known, and is very marked in certain 
conditions. The cutaneous nerve-supply of the 
hand is very free. The nerves present Pacinian 
bodies, which are far more numerous in the hand 
than in any other part. With the exception of the 
tip of the tongue, a more acute degree of tactile 
sensibility is met with in the hand than elsewhere 
in the body. The most sensitive district is the 
palmar surface of the third phalanx of the index 
finger, while the least sensitive to tactile im- 
pressions is the dorsum of the hand. It may be 
said that the tips of the fingers are about thirty 
times more acute to the sense of touch than is the 
skin of the middle of the forearm, which is among 
the least sensitive portions of the integument as 
regards tactile influences. 

The subcutaneous tissue of the front of the 
hand, and especially of the palm, is scanty and 
dense, and somewhat resembles the subcutaneous 
tissue of the scalp in that the skin is closely ad- 
herent to it, and the fat it contains is arranged in 



Chap. XV] THE WRIST AND HAND 297 

minute lobules lodged in lacunae. Cutaneous 
ligaments bind the skin down at the creases of 
the palm and fingers. The subcutaneous tissue 
on the dorsum, however, is lax, and has but a 
frail association with the skin. Thus it follows 
that subcutaneous extravasations of blood are 
practically impossible in the palm and on the 
anterior aspect of the fingers, while they may be 
very extensive on the dorsum. In like manner 
oedema of the extremity is conspicuously marked 
upon the dorsal surface, while the palm remains 
comparatively free even in severe cases. The 
denseness of the integuments of the palm renders 
inflammation of the part extremely painful, 
owing to the tension that is so readily produced, 
whereas inflammation in the lax tissues of the 
dorsum may reach some magnitude without caus- 
ing great pain. The palm of the hand is well 
adapted to meet the effects of pressure and fric- 
tion. The cuticle is thick, the skin is adherent, 
and immediately beneath it lies the dense palmar 
fascia. This fascia efficiently protects the palmar 
nerves and the main vessels, while it must be 
noted that the front of the hand, and especially 
the palm, is singularly free from surface veins. 
Indeed, the great bulk of the blood from the hand 
is returned by the superficial veins on the dorsum 
of the fingers and hand. In like manner, the 
lymphatics of the palm, which form a rich sub- 
cutaneous plexus, join the large efferent lym- 
phatics on the dorsum of the hand. 

The form of the nail varies somewhat in in- 
dividuals, and, according to certain authors, 
there are special types of nail to be met with in 
some constitutional diseases. By the Hippocratic 
hand is meant a hand the tips of the fingers of 
which are clubbed and the nails of which are 
much curved. This condition would appear to be 
due to impeded circulation by retardation in the 
return of venous blood, and perhaps also to im- 
perfect oxygenation of that blood. It is most 
often met with in congenital heart disease, in 



298 SURGICAL APPLIED ANATOMY [Part III 

phthisis, empyema, chronic lung affections, and 
certain thoracic aneurisms. There are several 
forms of inflammation affecting the matrix of the 
nail and the soft parts immediately around it 
(onychia, paronychia). Such inflammations lead 
to great deformity of the structure itself. When 
a nail is thrown off by suppuration or violence 
a new nail is produced, provided any of the 
deeper epithelial cells are left. During conval- 
escence from certain illnesses {e.g. scarlet fever), 
a transverse groove will appear across all the 
nails. This groove indicates the portion of nail 
formed during the illness, and by watching its 
movement the rate of growth of the nail can be 
estimated. The nail grows at the average rate of 
a^nd of an inch per week; if the hand is im- 
mobilised by splints the rate of growth is retarded 
(Head). It may be noted that each digital nerve 
gives a special branch of large size to the pulp 
beneath the nail, and this explains the intense 
pain felt when a foreign body is thrust under 
the nail. 

The fascise. — Beneath the skin of the palm is 
the dense palmar fascia. This fascia gives almost 
as much strength to the hand as would so much 
bone, while its unyielding character, its com- 
parative freedom from vessels and nerves, render 
it well suited to withstand the effects of pressure. 
The fascia gives slips to each finger ; each slip 
sends fibres to join the digital sheaths of the 
tendons, the skin, and the superficial transverse 
ligament. In the disease known as Dupuytren's 
contraction, the palmar fascia, and especially its 
digital slips, becomes contracted. One or more 
or all of the fingers may be involved in the con- 
traction. The proximal phalanx is drawn or 
flexed towards the palm, and later the second 
phalanx becomes bent also. The skin is drawn 
in towards the fascia, since the two structures 
are normally connected with one another. Ex- 
periment shows that by dragging upon the fascia 
the proximal phalanx can be readily bent, and 



Chap. XV] THE WRIST AND HAND 



299 



also, but with less ease, the middle phalanx. The 
middle part of the palmar fascia represents the 
tendon of the palmaris longus in the hand. 

The structures of the palm are divided into ' 
three spaces by the fascia (Fig. 51). Thus the 
muscles of the thenar and hypothenar eminences 
are both enclosed in a thin fascia proper to each. 
The two spaces formed by these membranes are 



h (J \ \ 



Wo , if - 




Fig. 51.— Horizontal section of the hand through the middle of the 
thenar and hypothenar eminences. (Tillaux.) 

a, Metacarpal bone; &, Hist dorsal interosseous; c, palmaris brevis; d, abductor 
niin. diyriti : e, flexor brevis niiii. dig.;/ opponens min. dig.; g, flexor brevis 
poll.; //, abductor poll.; i, Opponens poll.; j, adductor poll.; fc, flexor long 
poll.: .', dorsal interossei: m, palmar interossei; ;/, flexor sublimis; o, flexor 

profundus j />, supeiUc. volae : q, median nerve, and (on inner side) ulnar artery 
and nerve ; r, deep palmar areli ; 1, palmar fascia ; l', outer septum ; :% inner 
septum: -4, deep fascia of palm. 

enclosed in all directions, and are capable, though \ 
only in a feeble way, of limiting suppuration 1 
when it commences in them. Between these two/ 
spaces is a third space, which is roofed in by/ 
the palmar fascia. This cavity is closed in at the) 
sides, but is open above and below. Above there/ 
is a free opening beneath the annular ligament 
and along the flexor tendons into the forearm, 
while below there are the seven passages provided 
for by the division of the palmar fascia. Of these 
seven passages, four, situate at the roots of the 



300 i SURGICAL APPLIED ANATOMY [Part III 

several fingers, give passage to the flexor tendons, 
while the remaining three correspond to the webs 
between the lingers, and give passage to the lum- 
bricales and the digital vessels and nerves. When 
pus, therefore, forms on the palm, beneath the 
palmar fascia, it cannot come forward through 
that dense membrane, but escapes rather along the 
fingers or makes its way up into the forearm. 
So rigid is the resistance offered by the palmar 
fascia, that pent-up pus will make its way through 
the interosseous spaces and appear on the dorsum 
of the hand, rather than come through the cover- 
ings of the palm. The passage of pus, however, 
towards the dorsum is resisted by a layer of fascia 
that lies deeply beneath the flexor tendons, and 
covers in the interossei muscles, the bones, and 
the deep palmar arch. This fascia joins on either 
side the fasciae enclosing the thenar and hypo- 
thenar " spaces " (Fig. 51). 

In opening a palmar abscess, when it points 
above the wrist, the incision should be in the long 
axis of the forearm, should be above the annular 
ligament, and is most conveniently made a little 
to the ulnar side of the palmaris longus, for a 
cut in this position would escape both the ulnar 
and radial arteries and also the median nerve. 

The tendons about the wrist are bound down 
and held in place by the annular ligaments. So 
dense is the anterior ligament, that even in ex- 
tensive abscess of the palm reaching into the fore- 
arm, and in severe distension of the synovial 
sheaths beneath the ligament, it remains firm, and 
will not yield. The lower border of the poster in r 
annular ligament corresponds to the u ppeT~~edge 
of the anterio r band, and these structures togeth er 
act the parE of the leather bracele t that the 
labourer sometimes wears arou nd his wrist, ah d 
that, in fact, takes the function of an additi onal 
ann ular ligame nt 

The fibrous slieatlis for the flexor tendons 
extend from the metacarpophalangeal joints to 
the upper ends of the distal phalanges. The pulp 



Chap. XVJ THE WRIST AND HAND 



301 



h 




of the third phalanx, therefore, rests practically 
upon the periosteum. Opposite the finger-joints 
the sheaths are lax and thin, and spaces may 
occur between the decussating fibres of the sheaths, 
through which the synovial membrane lining the 
sheath may protrude. It is, I believe, through 
this less protected part of the sheath 
that suppuration without often finds 
its way into the interior of the 
sheath. The sheaths in the rest of 
their course are dense and rigid, and 
when cut across remain, in virtue of 
this rigidity, wide open (Fig. 52). 
Thus, after the division of the sheath, 
as in amputation, an open channel is 
left leading into the palm of the 
hand, and offering the greatest 
facility for the spread of pus into 
that part. It is this rigidly open 
fibrous sheath that probably may ex- 
plain the frequency of suppuration 
in the palm after amputation of a 
part of a finger, and I am decidedly 
of opinion that some steps should be taken to 
protect or shut off this channel in any case where 
the sheath has been accidentally or intentionally 
divided. 

The tendons accurately fill the fibrous sheaths. 
A gangliform growth on the tendon as it enters 
the sheath, or a constriction of the sheath with an 
inequality in the tendon, gives rise to the con- 
dition known as " snap ; ' finger. Such a digit 
cannot be extended by will, but when pushed a 
little way " springs back with a snap like the 
blade of a pocket knife ,: (Abbe). " Congenital 
" of the little finger is very common 
degree. In marked cases, the prox- 
imal phalanx is hyper-extended and the middle 
flexed. Lock wood found in such a case that the 
condition was due to a contraction in the fibrous 
sheath in front of the joint. Contracted finger 
following whitlow is due to an adhesion of the 



Fig. 52. — Hori- 
zontal section 
through middle 
of second phal- 
anx. (TiUaitx.) 

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



contraction 
slight 



in a 



302 SURGICAL APPLIED ANATOMY [Part III 

tendons to their sheath. Paralytic contraction of 
the flexor muscles also brings about permanent 
contracture of the fingers. 

Synovial sacs and sheaths.— There are two 
synovial sacs beneath the annular ligament for the 
flexor tendons, one for the flexor longus pollicis, 
the other for the flexor sublimis and profundus 
tendons (Fig. 53). The former extends up into 
the forearm for about l\ inch above the annular 
ligament, and follows its tendon to its insertion 
in the last phalanx of the thumb. The latter 
rises about \\ inch above the annular band, 
and ends in diverticula for the four fingers. The 
process for the little finger usually extends to the 
insertion of the. flexor profundus tendon in the 
last phalanx. The remaining three diverticula 
end about the middle of the corresponding meta- 
carpal bones. The synovial sheaths for the digital 
part of the tendons to the index, middle, and ring 
fingers end above about the neck of the meta- 
carpal bones, and are thus separated by about \ 
to \ an inch from the great synovial sac beneath 
the annular ligament. Thus there is an open 
channel from the ends of the thumb and little 
finger to a point in the forearm some lh inch 
above the annular ligament. The arrangement 
explains the well-known surgical fact that ab- 
scesses of the thumb anu little finger are apt to be 
followed by _ abscesses in the forearm, while such 
a complication is not usual after suppuration in 
the remaining fingers. The synovial sac for the 
flexor tendons is narrowed as it passes beneath 
the annular ligament, and thus it happens that 
when distended with fluid or with pus, it presents 
an hour-glass outline, the waist of the hour-glass 
corresponding to the ligament. The two synovial 
sacs beneath the ligament sometimes communicate 
with one another. The tendon of the flexor carpi 
radialis perforates the insertion of the annular 
ligament to the trapezium; it is surrounded by a 
synovial sheath (Fig. 53). 

In one form of whitlow, that form where the 



Chap. XV] THE WRIST AND HAND 



303 



pus occupies the synovial sheaths of the tendons 
on the fingers (thecal abscess), the suppuration 
can often be seen to end abruptly where the sheath 
ends, when the index, middle, or ring finger is 
involved, viz. opposite the neck of the corre- 
sponding metacarpal bones. In another form of 



Flexor Digitorum 

Unciform 
Pisiform 
Wrist Folds 
Styloid Process 




Flex. Longus Pollicis 

Trapezium 
Ant. Annular Ligament 
Scaphoid 

Flexor Carp. Radialis 
Styolid Process 



Fig. 53.— The anterior annular ligament of the wrist and synovial 
sheaths of the wrist and hand. 

The creases of the hand are indicated by black lines ; the synovial sheaths are 

shown in red. 



whitlow (the abscess in the pulp at the end of the 
finger) the periosteum of the third phalanx is 
readily attacked, there being no intervening ten- 
don sheath over that bone. In this affection the 
bone often necroses and comes away, but it is sig- 
nificant to note that it is very seldom that the 
whole of the phalanx perishes. The upper part, 
or base, of the bone usually remains sound, and is 
probably preserved by the insertion of the flexor 



304 SUEGICAL APPLIED ANATOMY [Part III 

profundus tendon. It is also interesting to bear 
in mind that the base of the bone is an epi- 
physis that does not unite to the shaft until the 
eighteenth or twentieth year. 

The tendons do not lie free within the sac, but 
are bound to it by folds of synovial membrane in 
much the same way as the bowel is bound to the 
abdominal parietes by its mesentery. These folds 
may be ruptured in severe sprains, when the 
nutrient vessels for the tendon, which are con- 
tained in them, may be torn: Rupture is followed 
by effusion into the sac. These folds are almost 
absent within the digital sheaths, the slight liga- 
menta longa and brevia, near the insertion of 
the tendons, being their sole representatives. Syn- 
ovial sacs are lined by a squamous epithelium, and 
have extremely free communication with the lym- 
phatic vessels of the part. Hence the free absorp- 
tion of infective matter from such cavities. 

Beneath the posterior annular ligament there 
are six synovial sheaths for tendons, correspond- 
ing to the six canals formed by that ligament. 
The sheath most frequently inflamed is that for 
the extensores ossi metacarpi and brevis pollicis. 
It runs from a point about f of an inch above the 
radial styloid process to the first carpo-meta- 
carpal joint. The other sheaths reach above to 
the upper border of the annular ligament, that 
for the two radial extensors, however, beginning 
about | an inch above the ligament. The sheaths 
for the extensor communis and the extensor 
minimi digiti extend below to the middle of the 
metacarpus. That for the extensor indicis barely 
reaches the metacarpus. The other sheaths follow 
the tendons to their insertions. The synovial lin- 
ing and folds of these sheaths are injured in 
Colles' fracture of the radius. The tendons be- 
come adherent and fixed to their sheaths unless 
this be prevented by passive movements of the 
tendons. 

Blood-vessels and lymphatics.— The hand 
is very well supplied with blood, and indeed the 



Chap. XV] THE WRIST AND HAND 305 

finger pulp is one of the most vascular parts in 
the body. Cases arc recorded where the tip of the 
finger has been accidentally cut off, and has grown 
again to the limb on being immediately re- 
applied. The position of the palmar arches has 
been pointed out. Wounds of these arches, and 
indeed of most of the arteries of the palm and 
wrist, are serious, on account of the difficulty of 
reaching the bleeding point without severely 
damaging important structures, and on account 
of the free anastomoses that exist between the 
vessels of the part. The deep palmar arch may be 
wounded by a penetrating wound from the dor- 
sum, and indeed Delorme has pointed out that 
this arch may be ligatured from the dorsum after 
a preliminary resection of the upper part of the 
third metacarpal bone. It is well known that 
haemorrhage from either of the palmar arches can- 
not be checked by ligature of the radial or ulnar 
artery alone, on account of the connection of the 
arches with those vessels; and it is als o^ known 
that simultaneous ligation of tne tw"o~vessels may 
have no better effect, owing to the anastomoses 
between the palmar arches and the interosseous 
vessels. The anastomosis between the two palmar 
arches is well known, and is freely established 
both by the main vessels themselves and by the 
communion that exists between the digital arteries 
from the superficial arch and the palmar inter- 
osseous branches from the deeper vessels. In 
bleeding from the palm, the simultaneous ligature 
of the radial and ulnar arteries may also entirely 
fail in those cases where the arches are freely 
joined, or are more or less replaced by large and 
abnormal interosseous vessels, or by a large 
" median " artery. When either the radial or the 
ulnar part of the arches is defective, the lack is 
usually supplied by the other vessel ; and it is 
well to note that the deficiency is most common 
in the superficial or ulnar arch. Pressure ap- 
plied to the palm to arrest bleeding is apt to cause 
gangrene, owing to the rigidity of the parts and 
u 



306 SUKGICAL APPLIED ANATOMY [Part III 

the ease with which considerable pressure can be 
applied. 

The radial artery, as it curves round the back 
of the hand to reach the deeper part of the palm, 
is in close contact with the carpo-metacarpal 
joint of the thumb. This fact must be borne in 
mind in amputation of the entire thumb, and also 
in resection of the first metacarpal bone. The 
superficialis volae, if large, may bleed seriously. 
It adheres to the surface of the annular ligament, 
and may therefore be difficult to pick up when 
wounded. 

From the larger size and great number of the 
lymphatics about the fingers and on the dorsum of 
the hand, it follows that lymphangitis is more 
common after wounds of those parts than it is 
after wounds of the palm. 

The l>ones and joints. — The inferior radio- 
ulnar joint is supported by the powerful tri- 
angular fibro-cartilage, which forms the strong- 
est and most important of all the ligamentous 
connections between the two bones. The synovial 
sheath of the extensor minimi digiti sometimes 
communicates with this joint, and may therefore 
be involved when that articulation is diseased. 

The strength of the wrist-joint depends not so 
much upon its mechanical outline or its liga- 
ments as upon the numerous strong tendons that 
surround it, and that are so closely bound down 
to the bones about the articulation. Moreover, in 
the case of the wrist the long lever does not exist 
on the distal side of the joint. The anterior liga- 
ment of the wrist is the strongest ligament of the 
joint, while the posterior is the weakest. The 
former structure limits extension, and the latter 
flexion ; and in connection with this arrangement 
it is interesting to note that injury from forced 
extension is more common than from forced 
flexion. Thus, when a man falls upon the hand, 
he more usually falls upon the palm (forced ex- 
tension) than upon the dorsum (forced flexion). 
Owing to the thinness of the posterior ligament, 



Chap. XV] THE WRIST AND HAND 307 

together with the more superficial position of the 
hinder part of the joint, it follows that the effu- 
sion in wrist-joint disease is first noticed at the 
back of the hand. 

Movemeuts at the wrist take place as freely 
in the intercarpal joint (between the first and 
second row of carpal bones) as in the radio-carpal 
joint. The axis of the radio-carpal joint is such 
that in flexion the palm turns towards the ulnar 
side of the forearm ; while in flexion at the mid- 
carpal joint the palm moves towards the radial 
side. When movement takes place at both joints 
these tendencies are balanced and pure flexion is 
produced. The tendon of the extensor carpi ul- 
naris is placed anteriorly to the axis of the mid- 
carpal joint, but behind the radio-carpal, and 
therefore produces flexion in one joint and exten- 
sion in the other (Ashdowne). The muscles which 
act on the wrist exemplify the various parts which 
muscles play in producing a purposeful move- 
ment. A muscle may act as (1) a prime mover, (2) 
an antagonist, (3) a synergic muscle, (4) a fixation 
muscle. For instance, when the fingers are flexed : 
the deep and superficial flexors are the prime 
movers; the antagonists in action are the exten- 
sors of the fingers ; the flexors of the fingers would 
also produce flexion at the wrist were not the ex- 
tensors of the wrist also thrown into action as 
synergic muscles ; when the extensors of the fingers 
act, the flexors of the wrist contract; in flexing 
and extending the fingers the wrist can be ren- 
dered immovable by the flexors and extensors of 
the carpus, which then act as muscles of fixation. 
Thus a movement which appears simple results 
from the action of groups of muscles, and it is 
this complexity which makes the diagnosis of 
nerve lesions from a study of the action of mus- 
cles so difficult. What has been said of the muscles 
of the wrist applies equally to all the muscles 
of the body. (See Beevor's Croonian Lectures, 
1903.) 

But little movement is allowed in the carpo- 



308 SURGICAL APPLIED ANATOMY [Part III 

metacarpal joints of the first three fingers, but 
in the like joints of the thumb and little finger 
movements are free, and their preservation is of 
great importance to the general usefulness of the 
hand. The glenoid ligaments in front of the three 
finger-joints are firmly attached to the distal bone, 
and but loosely to the proximal. Thus it happens 
that in dislocation of the distal bone backwards, 
the glenoid ligament is carried with it, and offers 
a great obstacle to reduction. In flexing the 
middle and distal phalanges alone, it will be seen 
that the proximal phalanx is steadied by the 
extensor tendon as a preliminary measure, and in 
paralysis of the extensors, flexion of these two 
joints alone is not possible. 

Very few persons have the power of flexing the 
last finger-joint without at the same time bending 
the articulation above it; but in certain inflam- 
matory affections about the last phalanges the 
terminal joint is sometimes seen to be fixed in a 
flexed posture while the other finger-j'oints are 
straight. In the condition known as " mallet " 
finger the distal phalanx is fixed in a flexed posi- 
tion. The condition is due to a partial or com- 
plete rupture of the extensor tendon of the finger, 
commonly the result' of a blow over the terminal 
knuckles. 

Colles' fracture. — This name is given to a 
transverse fracture through the lower end of the 
radius, from \ to 1 inch above the wrist-joint. 
It is associated with a certain definite deformity, 
and is always the result of indirect violence, a 
fall upon the outstretched hand. There are good 
reasons why the bone should break in this situa- 
tion. The lower end of the radius is very can- 
cellous, while the shaft contains a good deal of 
compact bone. At about f of an inch from the 
articular surface these two parts of the bone meet, 
and their very unequal density greatly tends to 
localise the fracture in this situation. As to the 
mechanism of this lesion, many different opinions 
are still held, and a vast deal has been written 



Chap. XV] THE WRIST AND HaND 309 

on the subject. I subjoin Professor Ohiene's ac 
count of this lesion, because it may be taken as 
representing with admirable clearness the views 
most generally accepted at the present time as to 
the nature of this injury. Into the discussion 
itself I do not propose to enter. The deformity 
in Colles' fracture is entirely due to the displace- 
ment of the lower fragment. " The displacement 
is a triple one : (a) backwards, as regards the 
antero-posterior diameter of the forearm; (6) 
rotation backwards of the carpal surface on the 
transverse diameter of the forearm ; (c) rotation 
through the arc of a circle, the centre of which 
is situated at the ulnar attachment of the tri- 
angular ligament, the radius of the circle being 
a line from the ulnar attachment of the triangular 
ligament to the tip of the styloid process of the 
radius, (a) When a person in falling puts out 
his hand to save himself, at the moment the hand 
reaches the ground the force is received princi- 
pally by the ball of the thumb, and passes into 
the carpus, and thence into the lower end of the 
radius. If, at the moment of impact, the angle 
between the axis of the forearm and the ground 
is less than 60°, the line representing the direction 
of the force passes upwards in front of the axis of 
the forearm ; the whole shock is therefore borne 
by the lower end of the radius, which is broken 
off, and, the force being continued, the lower frag- 
ment is driven backwards. When at the moment 
of impact the angle is greater than 60°, the line 
of the force, instead of passing in front of the 
axis of the arm, passes up the arm, and the usual 
result is either a severe sprain of the wrist or a 
dislocation of the bones of the forearm backwards 
at the elbow-joint, (b) The carpal surface of the 
radius slopes forwards, and therefore the pos- 
terior edge of the bone receives the greater part 
of the shock ; there is, as a result, rotation of the 
lower fragment backwards on the transverse dia 
meter of the forearm, (c) The carpal surface 
of the radius slopes downwards and outwards 



310 SUEGICAr APPLIED ANATOMY [Part III 

to the radial edge of the arm ; therefore the radial 
edge of the bone receives the principal part of 
the shock through the ball of the thumb. As a 
result, this edge of the lower fragment is dis- 
placed upwards to a greater extent than the 
ulnar edge of the fragment, which remains firmly 
attached to the ulna by the triangular liga- 
ment." 

In over 50 per cent, of cases, the styloid process 
of the ulna is also broken by the force transmitted 
to it through the triangular fibro-cartilage (Mor- 
ton). By means of this rotatory displacement, the 
tips of the two styloid processes come to occupy the 
same level, or the radial process may even mount 
above the ulnar. In nearly every case there is 
some penetration of the fragments, the compact 
tissue on the dorsal aspect of the upper fragment 
being driven (by a continuation of the force that 
broke the bone) into the cancellous tissue on the 
palmar aspect of the lower fragment. It is only 
in very rare instances that the fragments are so 
separated as to ride the one over the other. In 
such cases the radio-ulnar ligaments are probably 
ruptured, and the wrist ceases to present the typi- 
cal deformity of a Colles' fracture. In studying 
the radiographs of 170 cases diagnosed as Colles' 
fracture, Dr. R. Morton found there was disloca- 
tion as well as fracture in 3 and separation of 
the lower radial epiphysis in 11 cases. This 
epiphysis is often separated by accidental vio- 
lence. It joins the shaft about the twentieth year. 
Its junction with the shaft is represented by a 
nearly horizontal line, and the epiphysis includes 
the facet for the ulna and the insertion of the 
supinator longus. 

Since the introduction of radiographic methods 
of examination, it has been found that many in- 
juries, formerly regarded as mere sprains, were 
really due to fracture or displacement of carpal 
bones or fracture of a metacarpal. The semilunar 
is most frequently displaced and the fifth meta- 
carpal most frequently fractured. 



Chap. XV] THE WRIST AND HAND 311 

Dislocations. — (1) At the wrist-joint. So 
strong is this articulation, for the reasons above 
given (p. 306), that carpo-radial luxations are 
extremely rare. For the same reasons, when they 
do occur they are usually complicated, and are 
associated with tearing of the skin, or rupture 
of tendons or fractures of the adjacent bones. 
The luxations of the carpus may be either back- 
wards or forwards, the latter being extremely 
rare. They would appear to be produced with 
equal ease by a fall upon either the front or the 
back of the hand. Bransby Cooper gives the case 
of a lad who fell upon the outstretched palms 
of both his hands : both wrists were dislocated, 
one backwards, the other forwards. 

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

(2) Some dislocations about the hand (os mag- 
num). In forcible flexion of the hand, the os 
magnum naturally glides backwards and projects 
upon the dorsum. In very extreme flexion (as in 
falls upon the knuckles and dorsum of the meta- 
carpus), this movement of the bone backwards may 
be such as to lead to its partial dislocation, the 
luxation being associated with some rupture of 
ligaments. In one recorded case this luxation 
was produced by muscular force. The patient, a 
lady, while in labour, " seized violently the edge 
of her mattress, and squeezed it forcibly." Some- 
thing was felt to give way in the hand, and the 



312 SURGICAL APPLIED ANATOMY [Part III 

head of the os magnum was found to be dislocated 
backwards. 

Dislocations at the metacarpophalangeal joint 
of the thumb. In this luxation the phalanx is 
usually displaced backwards, and the lesion is of 
interest on account of the great difficulty often 
experienced in reducing the bone. Many ana- 
tomical reasons have been given to explain this 
difficulty, which are well summarised by Hamil- 
ton in the following passage : " Hey believes the 
resistance to be in the lateral ligaments, between 
which the lower end of the metacarpal bone 
escapes and becomes imprisoned. Ballingall, 
Malgaigne, Erichsen, and Vidal think the meta- 
carpal bone is locked between the two heads of 
the flexor brevis, or, rather, between the opposing 
sets of muscles which centre in the sesamoid bones, 
as a button is fastened into a button-hole. Pail- 
loux and others affirm that the anterior ligament, 
being torn from one of its attachments, falls be- 
tween the joint surfaces, and interposes an effec- 
tual obstacle to reduction. Dupuytren ascribes 
the difficulty to the altered relations of the lateral 
ligaments, ... to the spasm of the muscles, and 
to the shortness of the member, in consequence of 
which the force of extension has to be applied very 
near to the seat of the dislocation. Lisfranc 
found in an ancient luxation the tendon of the 
long flexor so displaced inwards, and entangled 
behind the extremity of the bone, as to prevent 
reduction." Mr. Jonathan Hutchinson, jun., has 
recently investigated some cases and found that 
reduction is prevented by the fibro-cartilaginous 
plate on the palmar aspect of the joint. The 
plate is firmly attached to the phalanx and is dis- 
located with it. When subcutaneously divided 
from the extensor aspect of the thumb, the dis- 
location may be reduced with ease. 

\vnlsioii of one or more fingers may be 
effected by severe violence. In such cases the 
finger torn off usually takes with it some or all 
of its tendons. These tendons are practically 



Chap. XV] THE WRIST AND HAND 313 

drawn out of the forearm, and may be of con- 
siderable length. Billroth figures a case where 
the middle finger w r as torn out, taking with it the 
two flexor and extensor tendons in their entire 
length. When one tendon only is torn away with 
the finger, it is usually that of the flexor profundus. 

Amputation sit the wrist- joint by the cir- 
cular method. (See the author's " Operative 
Surgery/' In the dorsal wound will be cutthe 
following tendons : the extensores longus, indicis, 
communis, minimi digiti, and ulnaris, the radial 
nerve, and the dorsal branch of the ulnar nerve. 
The two radial extensors will be cut short in the 
radial angle of the wound, as will also be the ex- 
tensores ossis and brevis. The radial artery will be 
divided close to the radius. In the palmar wound 
will be found the ulnar artery, the superficialis 
volse, the ulnar and median nerves, the opponens, 
flexor brevis, and abductor pollicis in part, ihe 
flexor brevis, opponens, and abductor minimi 
digiti in part (the bulk of the opponens being- 
left behind on the hand), and the tendons of the 
flexor sublimis and flexor carpi radialis. The ten- 
dons of the flexor profundus and flexor longus 
pollicis are usually cut short close to the bones. 

Amputation of the thumb at the carpo- 
metacarpal joint by flaps. In the palmar flap 
will be cut the abductor, the short and long 
flexor, the opponens, and the adductor pollicis. 
The extensores ossis and brevis will be cut short 
in the posterior angle of the flap. The extensor 
longus and a considerable portion of the abductor 
indicis will be found in the dorsal flap. The 
vessels divided will be the two dorsal arteries 
of the thumb and the princeps pollicis. There is 
great danger, in this operation, of wounding 
the radialis indicis and the radial artery itself 
where it begins to dip into the palm. 

Nerve supply ot the upper limb. — The 
symptoms which follow a lesion to the nerves of 
the upper limb depend on the point injured. 
If the fifth spinal nerve be crushed between its 



314 SURGICAL APPLIED ANATOMY [Part III 

origin in the spinal cord and its exit from the 
intervertebral foramen, either from fracture or 
caries of the cervical vertebrae, the injury is fol- 
lowed by paralysis, partial or complete, of the 
rhomboids, spinati, deltoid, biceps, brachialis 
anticus, and supinator longus, but strangely 
enough the lesion is not accompanied by loss of 
sensation. Perhaps the fact that the posterior 
root of the fifth cervical nerve is very small may 
assist to explain this fact (W. Harris). Injury 
to the cord just above the origin of the eighth 
cervical vertebra will leave the skin of the ulnar 
half of the arm anaesthetic, while the muscles of 
the fingers, hand, and wrist, and some of those at 
the elbow and shoulder, will be paralysed. The 
fibres for the innervation of the various groups 
of arm muscles pass out in quite an orderly man- 
ner by the fifth cervical to the first dorsal nerve 
from corresponding segments of the cord. Those 
for the abductors of the shoulder pass out by the 
fifth; for the adductors by the sixth and seventh; 
for the flexors of the elbow by the fifth and sixth; 
for the extensors by the seventh and eighth ; 
for the extensors of the wrist and fingers by the 
sixth and seventh ; and those for the flexors by the 
eighth and first dorsal. _ It is important to remem- 
ber that a cervical spinal nerve makes its exit 
from the canal opposite the origin of the next 
spinal nerve. Further, the nerve to each muscle 
is made up of fibres derived from two or more 
spinal nerves. 

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

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



Chap. XV] THE WRIST AND HAND 



315 



V 



->. 1 



/ 



3 \ 



5\\ 



\\6 



IP 



6 Irl 



Fig. 54. — Cutaneous 
nerve supply of 
upper limb. 




Anterior aspect: l, Cervical plexus; 2, circumflex; 3, ext, cut. of muse, spiral; 

4, ext. cutaneous ; o, median ; 6, ulnar ; 7, int. cutaneous ; 8, n. of Wrisberg. 
I'v.itt-rinr aspect: 1, Cervical plexus; 2, circumflex; 3, int. cut. of muse, spiral; 

4, intercosto-humeral ; 5, u. of Wrisberg ; 6, int. cutaneous; 7. ext. cut. oi 

muse, spiral ; 8, ext. cutaneous ; 9, uluar ; 10, radial. 



316 SURGICAL APPLIED ANATOMY [Part III 

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

In the cutaneous nerve supply of the fingers, 
it must be remembered that on the palmar aspect 
the thumb, the two outer fingers, and the radial 
side of the ring linger are supplied by the median, 
the remaining one and a half fingers by the ulnar 
(Fig. 54). On the dorsal aspect, the thumb is 
supplied by the radial ; the index and middle 
fingers are supplied (as far as the base of the 
second phalanx) by the radial, and over the 
second and third phalanges by the median. The 
little finger and the ulnar side of the ring finger 
are supplied by the ulnar. The radial side of 
the ring finger, as far as the base of the second 
phalanx, is supplied by the radial, and the rest of 
this side of the digit by the median (Fig. 54). 
The cleft between the middle and ring fingers is 
occasionally supplied by the ulnar, or partly by 
the ulnar and partly by the radial. The roots 
and spinal segments to which these nerves belong 
may be ascertained from Fig. 54a. The roots are 
distributed in order of origin, the fifth cervical 
beginning on the radial or outer side of the 
shoulder and the second dorsal, or sometimes the 
third, ending on the ulnar or inner aspect of the 
upper arm. The hand is mainly supplied by the 
seventh. The neighbouring spinal nerves, as is also 
the case with ordinary terminal branches, overlap 
widely in their distribution. The area of anaes- 
thesia is much less than the area of anatomical 



Chap. XV] THE WRIST AND HAND 



D.lll' 




Fig. 54a. Showing the sensory distribution of the spinal nerves in the 

upper limb. 
The dotted lines indicate approximately the area of each nerve. No attempt is 
made to show the extent bo which the root areas overlap. (For the nerves 
supplying each area see Fig. 54.) 



318 SURGICAL APPLIED ANATOMY [Part III 

distribution. The nerves along the ulnar side of 
the arm are derived from cord segments which 
also give off sympathetic (sensory) nerves to the 
heart ; in angina pectoris the heart is really^ the 
cause of the pain, but the patient feels it on, 'and 
refers it to, the ulnar side of the arm. 

Paralysis of the muscnlo-spiral nerve.— 
When complete, the hand is flexed and hangs 
flaccid (" drop wrist "), and neither the wrist nor 
the fingers can be extended. The latter are bent 
and cover the thumb, which is also flexed and 
adducted. When attempts are made to extend 
the fingers, the interossei and lumbricales alone 
act, producing extension of the two distal 
phalanges and flexion of the proximal. Supina- 
tion is lost, especially if the elbow be extended 
so as to exclude the action of the biceps muscle. 
Extension at the elbow is lost, but there is practi- 
cally no loss of sensation unless the nerve is cut 
above the origin of its cutaneous branches. Sec- 
tion of the radial nerve in the upper part of 
the forearm gives no loss of sensation (Head and 
Sherren). 

Paralysis of the median nerve.— Flexion 
of the middle phalanx is impossible in every 
finger, as is also a like movement of the distal 
joint of the index and middle fingers. Partial 
flexion of the distal phalanges of the two inner 
digits is possible, the inner part of the flexor pro- 
fundus being supplied by the ulnar nerve. 
Flexion of the proximal phalanx with extension 
of the second and third can still be performed 
in all the fingers by the interossei. The thumb 
is extended and adducted, and can neither be 
flexed nor opposed. Bending of the wrist is only 
possible when the hand is forcibly adducted by 
means of the flexor carpi ulnaris, which is not 
paralysed. Pronation is lost. 

Section of the median or ulnar nerves 
at the wrist does not give rise to the results 
which one would expect from their anatomical 
distribution. Such lesions have been recently in- 



Chap. XV] THE WRIST AND HAND 



319 



vestigated by Head and Sherren. After section 
of the ulnar nerve in the forearm — taking this 
nerve as an example to explain their obseryations 
on nerves generally — they found that a certain form 
of sensibility, which they name epicritic, is lost 
over the area of anatomical distribution /Fig. 55). 
Over this area the patient is unable to distinguish 
light touch (tested by cotton wool) and degrees 
of temperature between 22°-40° C. In a small 
area of the fifth digit (see Fig. 55) neither pricks, 
very coM nor very hot things can be felt ; in this 
area, besides epicritic sensibility, there is also 





A 



B 



Fig. 55. — Results of section of the ulnar nerve (a, b), and of the median 
nerve (c, d). (Head and Sherren.) 

Black: Area in which epicritic and protopathic sensibilities are lost. 
Stippled : Area in which only epicritic sensibility is lost. 



lost another form which they name protopathic. 
But everywhere over the area of the ulnar nerve 
deep pressure is felt ; deep sensibility remains 
because the nerves which subserve it arise in the 
forearm and reach the fingers by the tendons. 
If the tendons are cut, deep sensibility also is 
lost. The effect of cutting any nerve depends on 
the nature of the fibres it contains ; a nerve may 
contain epicritic fibres for a small area and proto- 
pathic for a much wider, or vice versa. 

Paralysis of the ulnar nerve.— Ulnar flexion 
and adduction of the hand are limited. Com- 
plete flexion of the two inner fingers is impossible. 
The little finger can scarcely be moved at all. 



320 SURGICAL APPLIED ANATOMY [Part III 

The action of the interossei and two inner lum- 
bricales is lost. The patient is unable to adduct 
the thumb. 

In testing for paralysis of muscles in the hand 
it is extremely important to observe closely the 
muscles which flex, extend, abduct, and adduct 
the thumb. The ulnar border of the metacarpal 
of the thumb can be approximated to the radial 
border of the corresponding bone of the index 
finger by only two muscles — the adductor pollicis 
and first dorsal interosseus. These are paralysed 
when the ulnar nerve is cut. Their action may 
be simulated by the flexor longus pollicis, brevis 
pollicis, or opponens pollicis, but in such cases it 
will be observed that it is not the ulnar border 
but the flexor surface of the thumb which is moved 
towards the metacarpal bone of the index finger. 

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

The nerve supplying the humerus is the mus- 
culocutaneous. The radius and ulna are sup- 
plied by the anterior interosseous of the median. 
It may be taken as a general law that the nerve 
supply of a bone is the same as that of the muscles 
which are attached to it. 



Fart IV.— THE ABDOMEN AND 
PELVIS 

CHAPTER XVI 

THE ABDOMEN 

The abdominal parietes. — Surface anatomy. 
The degree of prominence of the abdomen varies 
greatly. The protuberance of the belly in young 
children is mainly due to the relatively large size 
of the liver, which occupies a considerable part 
of the cavity in early life. It also depends upon 
the small size of the pelvis, which is not only 
unable to accommodate any abdominal structure 
(strictly so called), but can scarcely provide room 
for the pelvic organs themselves. Thus in in- 
fancy the bladder and a great part of the rectum 
are virtually abdominal viscera. After long- 
continued distension, as, for example, after preg- 
nancy, ascites, etc.. the abdomen usually remains 
unduly prominent and pendulous. 

In cases of great emaciation it becomes much 
sunken, and its anterior wall appears to have 
collapsed. This change is most conspicuous about 
the upper part of the region. Here the anterior 
parietes immediately below the line of the costal 
cartilages, instead of being in the same plane with 
the anterior thoracic wall, may so sink in as to 
be almost at right angles with that wall on the 
one hand, and with the lower part of the ab- 
dominal parietes on the other. In such cases the 
abdominal walls just below the thoracic line may 
appear to be almost vertical when the patient is 
v 321 



322 SURGICAL APPLIED ANATOMY [Part IV 

in the recumbent posture. This change of sur- 
face is of importance in gastrostomy, since the 
subjects for that operation are usually much 
emaciated, and the incision has to be made close 
below the costal line. 

The position of the linea alba above the um- 
bilicus is indicated by a slight median groove, 
but no such indication exists below the navel. 
The linea semilunaris may be represented by a 
slightly curved line drawn from about the tip of 
the ninth costal cartilage to the pubic spine. 
In the adult it would be placed about 3 inches 
from the navel. Above the umbilicus the line is 
indicated on the surface by a shallow depression. 
The outline of the rectus can be well seen when the 
muscle is in action. It presents three " linear 
transversa," one usually opposite the xiphoid 
cartilage, one opposite the umbilicus, and a third 
between the two. The two upper of these lines 
are obvious on the surface in well-developed sub- 
jects. 

The site of the umbilicus varies with the 
obesity of the individual and the laxity of the 
abdomen. It is always below the centre of the 
line between the xiphoid cartilage and the pubes. 
In the adult it is some way above the centre of the 
body, as measured from head to foot, while in 
the foetus at birth it is below that point. It corre- 
sponds in front to the disc between the third and 
fourth lumbar vertebrae, and behind to the tip of 
the third lumbar spinous process. It is situated 
about | of an inch above a line drawn between the 
highest points of the two iliac crests. 

The anterior superior spine, the pubic spine, 
and Poupart's ligament are all conspicuous and 
important landmarks. The pubic spine is nearly 
in the same horizontal line as the upper edge of 
the great trochanter. It is very distinct in thin 
subjects. In the obese it is entirely lost beneath 
the pubic fat. In such individuals, however, it 
can be detected, when the subject is a male, by 
invaginating the scrotum so as to pass the finger 



Chap. XVI] THE ABDOMEN 323 

beneath the subcutaneous fat. In the female the 
position of the process may be made out by ad- 
ducting the thigh and thus making prominent 
the tendon of origin of the adductor longus mus- 
cle. This muscle arises from the body of the 
pubes immediately below the spine, and by run- 
ning the finger along the muscle the bony promi- 
nence may be reached. If the finger be placed 
upon the pubic spine it may be said that a hernia 
descending to the inner side of the finger will be 
inguinal, while one presenting to the outer side 
will be femoral. In the erect position of the body 
the anterior superior spine is a little below the 
level of the promontory of the sacrum, while a 
point taken over the junction of sternum and 
ensiform process — the sterno-ensiform point — is 
opposite the upper part of the tenth dorsal ver- 
tebra. This point can be readily recognised in 
even fat subjects by the depression below the 
sternal insertions of the seventh pair of costal 
cartilages, and, as will be seen presently, forms 
a valuable landmark. A point taken midway be- 
tween the umbilicus and sterno-ensiform — the 
mid-epigastric point — lies opposite the disc be- 
tween the first and second lumbar vertebrae and is 
a surface marking of great clinical utility 
(Addison). 

In that part of the back which corresponds to 
the abdominal region the erector spinse masses 
are distinct, and in any but fat subjects their 
outer edges can be well defined. Between these 
masses is the spinal furrow, which ends below in 
an angle formed by the two great gluteal muscles. 
Immediately behind the middle of the crest of the 
ilium is Petit's triangle, or the gap between the 
external oblique and latissimus dorsi muscles. 
The fourth lumbar spine is about on -a level with 
the highest part of the iliac crest. In counting 
the ribs it is well to commence from above, since 
the last rib may not project beyond the outer 
edge of the erector spinse, and may consequently 
be overlooked. 



324 SURGICAL APPLIED ANATOMY [Part IV 

The aorta bifurcates opposite the middle of the 
body of the fourth lumbar vertebra just to the 
left of the middle line about | of an inch below 
and to the left of the umbilicus. A line drawn 
on either side from the point of bifurcation to the 
middle of Poupart's ligament will correspond to 
the course of the common and external iliac 
arteries. The first two inches of this line would 
cover the common iliac, the remainder the ex- 
ternal. 

The coeliac axis comes off opposite the lower 
part of the twelfth dorsal vertebra, at a spot 
about lh inch above the mid-epigastric point, 
and that corresponds behind to the twelfth dorsal 
spine. The superior mesenteric and suprarenal 
arteries are just below the axis. The renal vessels 
arise about ^ an inch below the superior mesen- 
teric, opposite the mid-epigastric point. The in- 
ferior mesenteric artery comes off from the aorta 
about 1 inch above the umbilicus. The deep epi- 
gastric artery follows a line drawn from the 
middle of Poupart's ligament to the umbilicus. 
Along the same line may sometimes be seen the 
superficial epigastric vein. 

The abdominal " rings " will be referred to 
under Hernia (p. 339). 

Anterior abdominal parietes.— The si- in 
over the front of the abdomen is loosely attached 
in the region of the groin. It is more adherent to 
the deeper parts in the middle line than else- 
where, but not so adherent as to hinder the spread 
of inflammation from one side of the abdomen to 
the other. In cases of great obesity two transverse 
creases form across the belly, one crossing the 
umbilicus and the other passing just above the 
pubes. In the former of the two creases the navel 
is usually hidden from sight. In cases of anky- 
losed hip-joints transverse creases are often noted 
running across the middle of the belly. They are 
produced by the freer bending of the spine that 
is usually required in ankylosis, some of the 
simpler movements of the hip-joint being trans- 



Chap. XVII THE ABDOMEN 325 

ferred to the column when the articulation is 
rendered useless. 

After the skin has been stretched, from any 
gross distension of the abdomen, certain silvery 
streaks appear in the integument over its lower 
part. They are due to an atrophy of the skin 
produced by the stretching, and their position 
serves to indicate the parts of the parietes upon 
which distending forces within the abdomen act 
most vigorously. They are well seen after preg- 
nancy, ascites, ovarian tumours, etc. 

Beneath the skin is the superficial fascia, which 
over the lower half of the abdomen can be readily 
divided into two layers. The great bulk of the 
subcutaneous fat of this region is lodged in the 
more superficial of the two layers. In cases of 
great obesity the accumulation of fat is perhaps 
more marked beneath the skin of the abdomen 
than it is elsewhere. A layer of fat 6 inches in 
depth has been found in this region in cases of 
great corpulence. The superficial vessels and nerves 
lie for the most part between the two layers of the 
fascia, so that in obese subjects incisions may be 
made over the abdomen to the depth of an inch or 
so without encountering blood-vessels of any 
magnitude. 

The deep layer of the superficial fascia con- 
tains elastic fibres, and corresponds to the tunica 
abdominalis or " abdominal belt " of animals. 
It is attached to the deeper parts along the middle 
line as far as the symphysis, and to the fascia 
lata just beyond Poupart's ligament. In the in- 
terval between the symphysis and the pubic spine 
it has no attachment, but passes down into the 
scrotum and becomes the dartos tissue. Extrava- 
sated urine that has reached the scrotum may 
mount up on to the abdomen through this in- 
terval, and will then be limited by the deeper 
layer of the fascia. It will not be able to pass 
down into the thigh on account of the attachments 
of the fascia, nor, for a like reason, will it tend 
to pass over the middle line. In the same way 



326 SURGICAL APPLIED ANATOMY [Part IV 

emphysematous collections following injuries to 
the chest, when beneath the deeper layer of the 
fascia, receive a check at the groin, and lipomata 
also that grow beneath the membrane tend to be 
limited by the middle line and that of Poupart's 
ligament. 

The anterior abdominal parietes vary in thick- 
ness in different subjects. In cases of great 
emaciation the outlines of some of the viscera may 
be readily made out or even seen through the 
thinned wall. In some cases of chronic intestinal 
obstruction the outlines of the distended intestine 
are visible, and their movements can be watched ; 
in instances of obstruction of the pylorus the 
movements of the dilated and hypertrophied 
stomach can often be seen. The relative thickness 
of the abdominal wall in various subjects depends 
rather upon the amount of the subcutaneous fat 
than upon the thickness of the muscles. This 
muscular boundary affords an admirable protec- 
tion to the viscera within. By contracting the 
abdominal muscles the front of the belly can be 
made as hard as a board, and in acute peritonitis 
this contraction can sometimes be seen to produce 
a remarkable degree of rigidity. 

A blow upon the abdomen when the muscles 
are firmly contracted will probably do no injury 
to' the viscera unless the violence be extreme. The 
rigid muscular wall acts with the efficacy of a 
dense indiarubber plate. It may be bruised or 
torn, but it will itself receive the main shock of 
the contusion. 

The probable effect on the contained viscera 
of a blow upon the abdomen will depend upon 
many factors ; but, so far as the walls themselves 
are concerned, the effect greatly depends upon 
whether the blow was anticipated or not, and 
upon the extent of the padding of fat that is fur- 
nished to the parietes. If the blow be anticipated 
the muscles of the belly will be instinctively 
contracted, and the viscera at once provided 
with a firm but elastic shield. Thus the abdo- 



Chap. XVI] THE ABDOMEN 327 

minal muscles have been found bruised and torn 
while the viscera were intact, and, on the other 
hand, in cases probably where the muscles were 
inert or taken unawares, a viscus has been found 
to be damaged without there being any con- 
spicuous lesion in the belly wall. If the blow be 
anticipated also the body will probably be abruptly 
bent and the viscera be — as it were — removed from 
danger. 

Along the linea alba the abdominal wall is 
thin, dense, and free from visible blood-vessels. 
Hence in many operations upon the abdominal 
cavity the incision is made in the middle line. 
Along the outer border of the rectus muscle {i.e. 
about and just beyond the linea semilunaris) the 
parietes are also thin and lacking in vessels, and 
consequently that situation is well suited for an 
incision. Except in some operations on the 
kidney, stomach, or gall bladder, incisions are 
seldom so placed. In most cases it is a question 
of either opening the abdomen in the middle line 
or in one of the iliac regions. About 1 inch 
below the navel the two recti muscles are almost in 
contact, and here the linea alba can scarcely be 
said to exist, while above, the muscles remain 
apart, the linea alba being normally f of an inch 
wide. In pregnancy, obesity, and ascites the supra- 
umbilical part may become 2 or more inches wide, 
but the narrow infraumbilical part is unaffected; 
when this part of the linea alba widens the con- 
dition is known as divarication of the recti. 
When this is the case the contents of the abdomen 
bulge out between the recti when these two muscles 
are thrown into action, as when a patient at- 
tempts to assume the sitting from a supine 
posture unaided by the arms. Pellets of sub- 
peritoneal fat may grow through interstices in 
the linea alba and give rise to what are called 
" fatty hernise." 

The fibrous ring of the umbilicus is derived 
from the linea alba. To this ring the adjacent 
structures, skin, fascia, and peritoneum, are all 



328 SURGICAL APPLIED ANATOMY [Part IV 

closely adherent. The adhesion is such, and the 
amount of tissue between the skin and peritoneum 
is so scanty, that in operating upon an umbilical 
hernia it is scarcely possible to avoid opening the 
sac. 

The umbilicus represents the point where the 
lateral abdominal walls finally close. At the 
sixth week the opening is funnel-shaped and con- 
tains the yolk sac and a fold of the bowel to which 
it is attached. This condition may persist and 
give rise to a congenital umbilical hernia. In 
the foetus three vessels enter at the navel, and 
immediately separate on reaching the abdominal 
cavity, the vein passing directly upwards and the 
arteries obliquely downwards. Running down 
from the umbilicus in the middle line is also the 
remains of the urachus. In the foetus, the spot 
where the three vessels part company is about the 
centre of the navel, and it thus happens that in a 
congenital umbilical hernia the gut as it escapes 
separates the three vessels, which become to some 
extent spread over it. The congenital hernia, in- 
deed, works its way in among the structures of 
the cord and receives its main coverings from 
them. These hernise are fortunately rare, for in 
certain instances they extend some way into the 
cord, and in at least two reported cases the gut 
was cut across by the accoucheur in dividing the 
cord at birth.* As the abdomen increases in 
height the contraction of the two obliterated 
arteries and of the urachus drags upon the cica- 
trix and pulls it backwards and downwards. 
Thus, in the adult umbilical ring, as viewed from 
the inner side, the cords representing not only the 
obliterated arteries and the urachus, but also the 
vein, appear to start from the lower border of 
the cicatrix. In adult hernise, indeed, the gut 
escapes above both the obliterated arteries and 
the vein. The upper half of the cicatrix is thin 

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



Chap. XVI] THE ABDOMEN 329 

when compared to the lower half, and is sup- 
ported also by less firm adhesions. 

In some cases a fistula is found at the navel 
that discharges urine. This is due to a patent 
urachus. The urinary bladder is formed by a 
dilatation of the stalk of the allantois. The part 
below this dilatation becomes the first part of 
the urethra, that above becomes the urachus. In 
one instance of patent urachus the abnormal open- 
ing was 1 inch in diameter. The patient, a man 
aged 40, had a stone, which was extracted by 
passing the finger into the bladder through the 
opening at the umbilicus. 

Sometimes a fistula discharging faeces is met 
with at the navel. This depends upon the per- 
sistence of the vitello-intestinal duct, a duct that 
at one time connects the intestine of the early 
foetus with the yolk sac, and which generally dis- 
appears without leaving any trace. The per- 
sistent duct, when it occurs, is known as Meckel's 
diverticulum, and springs from the ileum some 
two or more feet above the ileo-csecal orifice. 
This fcetal relationship also explains the presence 
of a fibrous cord which is sometimes seen con- 
necting Meckel's diverticulum with the umbilicus. 
This fibrous cord may cause strangulation of the 
bowel. 

The position of the transverse intersections of 
the rectus muscle should be borne in mind. 
They adhere to the anterior layer of the rectus 
sheath, but not to the posterior. They are able, 
therefore, to some extent to limit suppurative 
collections and haemorrhages beneath the sheath 
on its anterior aspect. This muscle is often the 
seat of one form of " phantom tumour. ;; These 
tumours are mostly met with in the hysterical 
and hypochondriac, and when associated with 
some vague abdominal symptoms are apt to mis- 
lead. They are due to a partial contraction of 
the muscle, usually to a part between two inter- 
sections, and are said to be more common in the 
upper part of the rectus. When the fibres of the 



330 SURGICAL APPLIED ANATOMY [Part IV 

muscle are contracted the " tumour " is obvious, 
but when they relax it disappears. The phantom 
tumour, however, is not always a matter of little 
moment. It may be associated with grave disease 
within the abdomen, and be due to reflex muscular 
contraction, the starting point of such reflex act 
being in the viscera. These localised contractions 
may provide a clue to the seat of visceral disease. 
Thus the stomach derives its chief sensory nerve 
supply from the eighth dorsal segment of the 
cord; the section of the rectus between the upper 
and middle inscriptions is also supplied from 
this segment through the eighth dorsal nerve ; 
hence contraction of this section may be asso- 
ciated with disease of the stomach. The rectus 
receives nerves from the lower six dorsal nerves ; 
the section at the umbilicus is supplied by the 
tenth. 

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

Other vanishing tumours depend upon disten- 
sion of the intestines by flatus or by faecal 
matter. In great distension of the abdomen the 
fibres of the rectus may be much stretched, since 
they bear the brunt of the distending force. 
The direction of the fibres also renders them 
liable to be torn in opisthotonos, or extreme arch- 
ing of the back, or tetanus. Portions of the muscle 
have also been ruptured by muscular violence, as 
in vaulting. 

The lateral muscles of the front abdominal 
wall are separated from one another by layers 
of loose connective tissue. In the tissue between 
the internal oblique and transversalis are found 
the chief nerves and arteries. 

Everywhere the peritoneum is bound to the 
abdominal wall by subperitoneal connective 
tissue. In the pelvis this tissue is lax to allow 
the viscera of the pelvis — the bladder, rectum, 



Chap. XVI] THE ABDOMEN 331 

and uterus — to expand; so, too, over the iliac 
fossae and on the anterior abdominal wall for 
two inches above Poupart's ligament and the 
symphysis pubis ; but above this level and on 
the under surface of the diaphragm it binds the 
peritoneum down closely. The looseness of this 
layer greatly favours the spread of abscess, to 
the progress of which it offers little resistance. 
Such an abscess may spread from the viscera, 
especially from those that have an imperfect 
peritoneal covering, as, for example, the kidney, 
the vertical parts of the colon, etc. The laxity 
of this tissue has been of service in certain 
surgical procedures. Thus the external and 
common iliac arteries can be reached by an in- 
cision made some way to the outer side of the 
vessels and without opening the peritoneum. 
That membrane having been exposed in the 
lateral wound, the artery is reached by working 
a way with the finger through the subperitoneal 
tissue, and by actually stripping the serous mem- 
brane from its attachments. Ligature of the 
iliac vessels at the present day is usually effected 
through a direct incision which opens the peri- 
toneal cavity. The method just detailed belongs 
to pre-antiseptic days. The laxity of the sub- 
serous layer also favours that stretching of the 
peritoneum which occurs under certain circum- 
stances. 

Wounds of the abdomen may give trouble 
in their treatment, since, when inflicted, they 
may open up several layers of fascia and so lead 
to bagging of pus and to the spread of suppura- 
tion should an abscess follow the lesion. The 
constant respiratory movements of the belly walls 
do not favour that rest which is so essential to 
the healing of wounds. In penetrating wounds 
the contraction of the muscles may encourage the 
protrusion of the viscera, especially when the 
incision is transverse to the direction of the 
muscular fibres. In reducing small portions of 
protruded viscera it is quite possible to push 



332 SURGICAL APPLIED ANATOMY [Part IV 

them into one of the connective tissue spaces be- 
tween the muscles or into the subserous tissue in- 
stead of into the peritoneal cavity. In applying 
sutures to wounds involving the whole thickness 
of the parietes it is necessary that the threads 
should include the peritoneum, so that early 
healing of that membrane may be brought about. 
Without such precaution a gap may be left in 
the surface of the peritoneum which would 
favour the formation of a hernia in the site of 
the old wound. 

Blood-vessels. — The only arteries of any mag- 
nitude in the abdominal walls are the two 
epigastric arteries, some branches of the deep 
circumflex iliac, the last two intercostal vessels, 
the epigastric branch of the internal mammary, 
and the abdominal divisions of the lumbar 
arteries. The superficial vessels are of small 
size, although Verneuil reports a case of fatal 
haemorrhage from the superficial epigastric 
vessel. 

The superficial veins on the front of the 
abdomen are numerous, and are very distinct 
when varicose. A lateral vein, extending from 
the axilla to the groin, uniting the axillary and 
femoral veins, is often rendered in this way very 
prominent. The surface abdominal veins may 
take no part as alternative blood channels in 
cases of obstruction of the inferior vena cava. 
Clinical experience shows that these veins may 
be also enormously varicose in instances where 
the inferior cava is quite patent. In one case 
under my care there was extensive varicosity of 
the surface veins from the pectoral region to the 
groin that involved one side of the body only. 
It has been shown, moreover, that the valves of 
these vessels are so arranged that the blood in the 
surface veins above the navel goes to the axilla, 
while that in the veins of the subumbilical region 
runs to the groin. In the neighbourhood of the 
umbilicus these veins are connected with the 
portal vein in the liver through anastomotic 



Chap. XVI] 



THE ABDOMEN 



333 



venous channels in the falciform ligament of the 
liver (Sappey). 

As regards the surface lymphatics of the front 
of the abdomen, it may be said in general terms 
that those above the umbilicus go to the axillary 



Diaphragmatic 

Cardiac 
Oesophageal 



C.A5TRIC 

Mepatic 
mtestimal 
Colic 

Vesical 
Re/nalTesticular 



Fig. 56. — Showing approximately the areas of skin supplied hy spinal 
nerves on the anterior surface of the trunk. 

The areas are marked on the left side by dotted lines, and the number of the 
spinal nerve by which each is supplied is indicated. The nerves are shows 
on the right side. The red stippled areas show the regions to which pain in 
commonly referred in connection with visceral disease— according to the 
observations of Dr. .lames Mackenzie. The pain radiates towards the unen- 
closed part of each area. 

glands, and those below to the glands of the 
groin. 

IVerves. — The abdominal wall is supplied by 
the lowest six dorsal or intercostal nerves, and 
by the first lumbar nerve. These nerves run 
obliquely to the long axis of the abdomen down- 
wards and inwards from the sides to the middle 
line and hence are damaged more extensively in 
vertical than in oblique incisions. Their direc- 




334 SUEGICAL APPLIED ANATOMY [Part IV 

tion is represented by a continuation of the lines 
of the ribs : they are placed parallel to one 
another and at fairly equal distances apart. It 
is important to note that they supply not only 
the abdominal integument, but also the muscles 
of the belly, viz., the rectus, the two oblique 
muscles, and the transversalis. The segments of 
the spinal cord which supply the skin also 
innervate the underlying muscles, an association 
of great importance (Fig. 56). If a cold hand 
be suddenly placed upon the belly the muscles 
at once contract and the abdomen is instinctively 
rendered rigid. The safety of the viscera, at 
least so far as protection from contusions is con- 
cerned, depends upon the readiness with which 
the muscles can contract at the first indication 
of danger. As has been already stated, the 
viscera have a very efficient protection against 
the effects of blows when the belly muscles are in 
a state of rigid contraction. The sensitive skin 
acts the part of a sentinel, and the intimate asso- 
ciation of the surface nerves with the muscular 
nerves allows the warnings of this sentinel to be 
readily given and immediately acted upon. The 
rigidity of the muscles in certain painful affec- 
tions of the skin over the abdomen is often very 
conspicuous. I might instance the case of a 
man with a burn over the belly. While the burn 
is protected by the dressings the abdominal 
muscles are lax and the parietes move with the 
respiratory act. The moment the dressings are 
removed, the surface becoming painful, its spinal 
centre becomes excited and the muscles at once 
contract and the belly becomes rigid. 

It will be noticed that six of the abdominal 
nerves supply intercostal muscles, and are thus 
intimately associated with the movements of re- 
spiration. The abdominal muscles are of course 
-concerned! in the same movements. These asso- 
ciations are illustrated when cold water is sud- 
denly dashed upon the belly. The subject of 
such experiment at once experiences a violent 



Chap. XVI] THE ABDOMEN 335 

respiratory movement in the form of a deep 
gasp. When the abdominal muscles are firmly 
fixed the lower ribs are also rigid, and respiration 
is limited to the higher ribs and to the thorax 
proper. 

There are other practical points about these 
nerves. In caries of the spine, and in certain 
injuries to the column, the spinal nerves may 
suffer injury as they issue from the vertebral 
canal. This injury may show itself by modified 
sensation in the parts supplied by such nerves. 
Thus in Pott's disease the patient often com- 
plains of a sense of tightness about the abdomen, 
as if a cord were tied around it. This sense of 
constriction depends upon an impaired sensation 
in the parts supplied by a certain pair of nerves ; 
or, if the sense of constriction be wider spread, 
by two or more pairs of nerves. In other cases 
a sense of pain may take the place of that of 
constriction. It would hardly be believed that 
spinal disease has been mistaken for " belly- 
ache." But many such cases have been recorded. 
A child complains of pain over the pit of the 
stomach or about the umbilicus, and this feature 
may quite absorb for a while the surgeon's atten- 
tion. The abdomen is carefully poulticed, while 
the only mischief is in the vertebral column. 
Other symptoms, however, develop, and it be- 
comes evident that the pain is due to pressure 
upon the nerves supplying the skin over the 
epigastric or umbilical regions, and that that 
pressure is a circumstance in the course of spinal 
bone disease. A case came under my notice in 
which a man complained of intense and abiding 
pain over the stomach. The pain was made 
worse by food, and as all means used failed to 
relieve it, the abdomen was opened by an explor- 
atory incision. Nothing abnormal was dis- 
covered. A little later it became evident that 
the pain was due to a malignant tumour situated 
in the bodies of the dorsal vertebrae. There had 
never, before the operation, been any suspicion 



336 SURGICAL APPLIED ANATOMY [Part IV 

of spinal disease. The site of the painful part 
depends, of course, upon the position of the 
spinal ailment, and thus the cutaneous symptoms 
may serve to localise the caries in the vertebrae. 
Thus the skin over the " pit of the stomach " is 
supplied by the sixth and seventh dorsal nerves, 
and the tenth nerve is nearly in a line with the 
umbilicus. The position of the areas supplied 
by each spinal nerve on the trunk is shown in 
Fig. 56. The umbilicus may be at the upper or 
lower border of the area of the tenth, according 
to the individual, A spinal root may be cut and 
yet scarcely a trace of anaesthesia result owing 
to the overlapping of the nerve distributions. 

Not only may a lesion at the origin of a spinal 
nerve give rise to a pain referred by the patient 
to the abdomen, but, as may be readily understood 
from the fact that the nerves of the abdominal 
wall also supply the lower half of the thorax, 
thoracic lesions may also give rise to symptoms 
which are referred to the abdomen. Pain or tender 
areas in the upper part of the abdomen may be 
actually due to a pleurisy in the lower part of 
the thorax. 

Although the course of the spinal nerves in 
the body wall is oblique — following the axes of 
the ribs — yet in their final distribution they supply 
zones of skin which approximately pass horizont- 
ally round the body. This is due to the fact 
that the posterior primary divisions and lateral 
cutaneous branches, before they reach their areas 
of skin, descend to the same level as the anterior 
cutaneous nerves — the terminal branches of the 
anterior divisions. Indeed, the lateral cutaneous 
nerves of the lower segments, as the lower limb 
is approached, actually descend further than the 
anterior cutaneous nerves (Fig. 56). The hori- 
zontal arrangement of the skin areas is demon- 
strated bv the distribution of herpes zoster — a 
disease which is now ascribed to a lesion of the 
ganglia of the posterior roots. 

The nerves of the body wall have still more 



Chap. XVI] THE ABDOMEN 337 

important associations. The cord segments with 
which they are connected are also in communica- 
tion with the viscera of the abdomen and thorax 
through the sympathetic system. Hence diseased 
conditions in the abdominal viscera give rise to 
disturbances in the corresponding cord segments, 
and the brain, being accustomed to localise pain 
only along the spinal nerves, makes a mistake and 
refers the pain along the spinal nerve of the seg- 
ment disturbed. Not only is pain referred, but 
the skin supplied from the disturbed spinal seg- 
ments becomes tender, and through a study of 
these areas of tenderness, Head has been able to 
localise the visceral centres in the spinal cord, thus 
affording the surgeon a means for increased 
accuracy of diagnosis. The abdominal viscera 
are supplied from the sixth dorsal to the first 
lumbar spinal segments, the nerves passing to 
their destinations through the rami communi- 
cantes, splanchnic nerves and sympathetic 
plexuses of the abdomen. JSTo visceral nerves es- 
cape by the second, third, or fourth lumbar 
nerve roots, hence these are never the seats of 
visceral referred pains. The pelvic viscera are 
supplied from the fifth lumbar to the third or 
sometimes fourth sacral nerve through the nervi 
erigentes. 

It is important to remember, too, that there 
are three systems of nerves in the belly wall : 
(1) the nerves to the skin; (2) the nerves to the 
muscles (motor and sensory) ; (3) the nerves to the 
parietal peritoneum. Any one or all of these three 
sets may be the seat of referred pain, the most 
common being the muscular nerves. The pain 
elicited^ by pressure on the muscles or by move- 
ments is usually, but erroneously, regarded as 
situated in the diseased viscus. The tonus and 
condition of the muscles of the abdominal pari- 
etes are influenced by the condition of the 
viscera through the interconnection of their 
nerve systems in the spinal cord. 

The following are the segments with which 
w 



338 SURGICAL APPLIED ANATOMY [Part IV 

each viscus is connected (Head) : — Stomach, 6, 7, 
8, 9 D. ; intestine, 9, 10, 11, 12 D. ; rectum, 2, 3, 

4 S. ; liver and gall bladder, 7, 8, 9, 10 D. ; kidney 
and ureter, 10, 11, 12 D., 1 L. ; prostate, 10, 11 D., 

5 L., 1, 2, 3 S. ; epididymis, 11, 12 D., 1 L. ; testis 
and ovary, 10 D. ; appendages of uterus, 11, 12 D., 
1 L. ; uterus, 10, 11, 12 D., 1 L., 3, 4 S. 

This nerve relationship is illustrated in dis- 
ease in many ways. Thus, in acute peritonitis 
and in laceration of certain of the viscera the 
abdominal muscles become rigidly contracted, so 
as to insure as complete rest as possible to the 
injured parts. In acute peritonitis the belly is 
very hard, the respirations are purely thoracic, 
and so entirely do the cutaneous portions of 
these nerves enter into the situation, that the 
patient is often unable to tolerate even the most 
trifling pressure upon his abdomen. 

Congenital deformities of the abdomen.— 
At the end of the second month of development, 
part of the intestine projects through the widely 
open umbilicus within the cord when it is only 
covered by the transparent covering membrane of 
that structure. In the third month the intestines 
retreat within the abdomen, the cavity within the 
cord becoming obliterated and the umbilicus 
closed. The process of retraction of the intestine 
may fail or even an opposite process may occur — 
other contents being added to those normally 
found within the cord. Thus result the various 
forms of congenital exomphalos, which may vary 
in severity from a small hernia to a protrusion 
of the whole of the more movable viscera. One 
of the most remarkable deformities is that known 
as extroversion of the bladder. Here, not only is 
a part of the belly wall absent, but also a part of 
the genito-urinary apparatus. In complete cases 
there is an absence of the umbilicus and of the 
anterior abdominal wall below it. There is no 
symphysis pubis, an absence of the anterior wall 
of the bladder, of the principal part of the penis, 
and the whole of the roof of the urethra. The 



Chap. XVI] TEJE ABDOMEN 339 

scrotum, also, as may be expected from a refer- 
ence to the development of that part, is bifid. 

Hernia.— 1. Inguinal hernia. In this form 
of rupture the herniated bowel occupies the in- 
guinal canal for the whole or part of its entire 
length. This canal runs obliquely from the in- 
ternal to the external abdominal ring, and is 
about lh inch in length. It represents the track 
followed by the testis in its descent. It is, in 
a sense, apassage^ right through the abdominal 
wall, and is occupied by the spermatic cord. It 
is not a free canal, however, in the same sense as 
one would speak of an open tube, but is rather a 
potential one, a tract of tissue so arranged as to 
permit of a body being thrust along it. It is a 
breach in the abdominal wall, not a doorway ; 
a breach that is forcibly opened up and widened 
in the acquired forms of hernia. When a hernia 
occupies the inguinal canal it is covered in 
front by the integuments, the external oblique 
aponeurosis, and the lower fibres of the inter- 
nal, oblique and transversalis muscles. It rests 
behind upon the transversalis fascia, the con- 
joined tendon, and the triangular fascia ; over 
it arch the transverse and internal oblique 
muscles, while below it is the angle formed by 
the union of Poupart's ligament with the trans- 
versalis fascia. The herniated bowel is con- 
tained within a " sac," which is always formed 
of _ peritoneum. In congenital hernia the sac 
exists already formed as an abnormally patent 
" processus vaginalis." In acquired hernise the 
sac consists of that part of the parietal peri- 
toneum which the gut pushes before it in its 
descent. 

The external abdominal ring, half an inch ex- 
ternal to and above the pubic spine, is readily 
felt by invaginating the scrotum with the point 
of the finger, and then passing the digit up in 
front of the cord. If the nail be kept against the 
cord the pulp of the finger can readily recognise 
the triangular slit-like opening. Under ordinary 



340 



SURGICAL APPLIED ANATOMY [Part IV 



circumstances in adults it will just admit the 
tip of the little finger.* The internal ring is 
situate about \ an inch above Poupart's liga- 
ment, midway between the symphysis pubis and 
anterior superior iliac spine. This is the 
femoral point; it lies directly over the femoral 
artery as that vessel escapes from the abdomen 
beneath Poupart's ligament (Fig. 57). 



UnBiLlCUS 

4->- K LunBAB Vert. 

COfinO" Iliac Art 



Ext. Iliac Art. 
Rectus Abdominis 

DEEP ElPiCASTRiC Art. 
/lESSELBACtt'S TBIA/1CLE 

Course of Vas , 
Ext.Aboomiial Rimc 
5y/iPHysis 
Pubic 5pime 
QlMBECflATS Lica^e^t 
_ From rhe FemOBAl Ri/iC 



Course o/ vas 
#nd Cord 



Fig. 57. — Surface markings for the inguinal and femoral canals. 
a.s.s., Anterior superior spine of ilium. 

There are two principal forms of inguinal 
hernia, which can be best understood by a view 
of the anterior abdominal parietes from within. 
From such an aspect it will be seen that the 
peritoneum is marked by three linear ridges that 
run, roughly speaking, from the umbilicus to the 

In cases of congenital or acquired absence of the cord the external 
ring maybe almost, obliterated. Paulet quotes from Malgaigne the case of 
an old man wliu.se testicle had been removed iii infancy, and in whom the 
external ring was so small as to be scarcely recognisable. 




Chap. XVI] THE ABDOMEN 34] 

pelvic brim. One of these ridges follows the 
middle line from the navel to the symphysis and 
represents the urachus; a second, that may be 
indicated by a line drawn from the femoral 
point to the navel, represents the deep epigastric 
artery; while between these two, and much 
nearer to the epigastric vessel than to the middle 
line, is the line formed by the obliterated hypo- 
gastric artery. By means of these ridges the 
peritoneum is made to present three fossse, an 
external to the outer side of the epigastric artery, 
an internal between the urachus and the hypo- 
gastric artery, and a middle between the track 
of the latter vessel and the epigastric trunk. 
The internal ring (so called) is just to the outer 
side of the epigastric artery, and the site of 
the summit of the inguinal canal is indicated by 
a depression in the peritoneum (Fig. 57). When 
a hernia follows the inguinal canal throughout 
its entire length, it is called oblique, indirect, or 
external; " oblique " or " indirect ,; from its 
taking the oblique direction of the canal, " ex- 
ternal ;; from the position of its neck with refer- 
ence to the epigastric vessel. The coverings of 
such a hernia would be the same as those of the 
cord, viz., the skin, the superficial, inter- 
columnar, cremasteric and infundibuliform layers 
of fascia, the subserous tissue, and the peri- 
toneum. When the hernia escapes to the inner 
side of the deep epigastric artery, through the 
space known as Hesselbach's triangle, it is called 
a direct or internal hernia, for reasons that will 
be obvious. There may be two forms of direct 
hernia. In one form the gut escapes through the 
middle fossa above described, in the other 
through the inner fossa between the hypogastric 
artery and the outer edge of the rectus muscle. 
The middle fossa is nearly opposite to the sum- 
mit of the external ring. A hernia escaping 
through that fossa would enter the inguinal canal 
some little way below the point of entrance of an 
oblique hernia, and would have the same coverings 



342 SURGICAL APPLIED ANATOMY [Part IV 

as that hernia, with the exception of the infundi- 
buliform fascia. The first covering, indeed, that 
it would receive from the canal structures would 
be the cremasteric fascia. The inner fossa cor- 
responds, so far as the inguinal canal is con- 
cerned, with the external ring. A hernia escap- 
ing through this fossa would be resisted by the 
conjoined tendon and the triangular fascia. 
These structures are either stretched over the 
hernia so as to form one of its coverings, or the 
conjoined tendon is perforated by the hernia, or 
lastly the gut deviates a little in an outward 
direction so as to avoid the tendon and appear at 
its outer side (Velpeau). In any case the hernia 
is forced almost directly into the external abdo- 
minal ring. The coverings of such hernise are 
the skin and superficial fascia, the intercolumnar 
fascia, the triangular fascia and conjoined tendon 
(with the exceptions above mentioned), the trans- 
versalis fascia, subserous tissue, and peritoneum. 

An examination of the abdominal wall, apart 
from clinical experience, would lead one to sus- 
pect that the direct hernia would be more com- 
mon than the indirect, since the parietes are cer- 
tainly less resisting opposite Hesselbach's triangle 
than they are in the parts immediately external 
to the epigastric artery. Indeed, just to the outer 
side of the conjoined tendon the belly wall is 
remarkably thin. These conditions, however, seem 
to offer less facilities for the escape of a hernia 
than does the inguinal canal itself. The funnel- 
shaped depression in the peritoneum at the sum- 
mit of that canal seems to offer particular induce- 
ment for rupture, and there are, besides, certain 
congenital defects in the vaginal process of the 
peritoneum that render hernia almost unavoid- 
able along the inguinal canal. 

Direct versus indirect inguinal hernia. — 
The indirect hernia, as just hinted, may be con- 
genital, the direct is never congenital. In the 
congenital oblique hernia the outline of the in- 
guinal canal and the relations of the various 



Chap. XVI] THE ABDOMEN 343 

parts concerned are but little disturbed, and the 
differences between this form of rupture and the 
direct variety are conspicuous. The acquired 
oblique hernia, however, does not present such a 
contrast to the direct form as might be expected. 
In the first-named rupture, from constant drag- 
ging upon the parts, the internal ring becomes 
more or less approximated to the external ring, 
and the length of the canal, and consequently the 
obliquity of the hernia, are considerably reduced. 
Thus the axes of the two forms of rupture do not 
present such differences as to make their nature at 
once obvious. The direct hernia, however, on re- 
duction, will pass directly back into the belly, 
while the indirect will, even in old cases, take a 
slight but appreciable direction outwards. After 
the reduction of the direct hernia, the edge of the 
rectus muscle may be readily felt to the inner side 
of the aperture, the protrusion being, indeed, at 
the semilunar line. The direct hernia is usually 
small and globular, while the oblique rupture may 
attain large size, and tends to assume a pyriform 
outline. 

Forms of oblique hernia, depending* upon 
congenital defects in the " vaginal process.*" 
—The descent of the testis. It is well known that 
the testis in the foetus descends from the region 
of the kidney into the scrotum by a way through 
the abdominal wall that is afterwards known as 
the inguinal canal (see p. 339). 

Its descent is preceded by the passage into the 
scrotum of a process of the peritoneum, the 
vaginal process. The testicle usually enters the 
internal ring about the seventh month of fcetal 
life, and by the eighth month is in the scrotum. 
The testis is guided to its final resting place by 
the gubernaculum, a band of muscular fibres. 
This > band is attached below to the anterior ab- 
dominal parietes, to the pubes near the root of 
the penis, to the bottom of the scrotum, and to 
the tuber ischii and sphincter ani (Lockwood). 
The last-named attachments serve to explain the 



344 SUKGICAL APPLIED ANATOMY [Part IV 

occasional passage of the testis beyond the scrotum 
into the perineum (testis in perineo). In one 
example of this condition I found it necessary 
to divide a band passing from the tuber ischii 
to the testis before I could place the gland in the 
scrotum. 

Following the gubernaculum upwards, it is 
attached, first of all, to the vaginal process, which, 
therefore, descends before the testis, then to the 
gland and epididymis, and, lastly, to the peri- 
toneum about the bowel (caecum, ileum, or mesen- 
tery on the right side, and sigmoid flexure on the 
left side). 

The vaginal process is often found open at 
birth; one may infer from the observations of 
Zuckerkandl and of Sachs that, even in children 
three or four months old, the communication re- 
mains open in 30 to 40 per cent, of cases. The 
part of the processus vaginalis which surrounds 
the testicle becomes the tunica vaginalis, while the 
elongated tubular part between it and the internal 
abdominal ring is known as the processus funicu- 
laris. The manner in which the processus vaginalis 
is cut off is as follows. It becomes obliterated 
in two places, at the internal ring and at a spot 
just above the epididymis, the obliteration usually 
beginning at the higher point first. Supposing 
obliteration to have taken place at these two 
points, the vaginal process between them will be 
represented by an isolated tube. This soon 
shrinks, closes, and dwindles to an insignificant 
fibrous cord. It may, however, remain patent in 
part, and if fluid accumulates in this patent 
portion, an " encysted hydrocele of the cord " 
is produced. As regards the mode of closure, 
three contingencies may happen, each giving rise 
to a particular form of hernia: (1) the "pro- 
cess ;; may not close at all; (2) it may close at the 
upper point only; and (3) it may close at the 
lower point only. 

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



Chap. XVI] THE ABDOMEN 345 

Such a condition is called a congenital hernia. 
Here the intestine is found to occupy a large sac 
of the peritoneum, the open orifice of which is 
placed at the internal inguinal ring. The term 
" congenital ;; is misleading, as the hernia is 
very rarely present at birth, although it is com- 
mon in early life. 

(2) When the process is closed only at the in- 
ternal ring the unduly large tunica vaginalis 
is found to extend up to that orifice. If a hernia 
forms itf may invaginate the processus vaginalis. 
This is known as an infantile or encysted 
hernia. In such a case the tunica vaginalis lies 
in front of the sac, and therefore three layers of 
peritoneum would have to be cut through before 
the gut could be reached. The term " infantile ;; 
was given to this rupture because the first cases 
reported were met with in infants ; the term 
"encysted,"' because the hernial sac was con- 
sidered to be enclosed by the sac of the tunica 
vaginalis. 

(3) The funicular process may remain open 
from the internal abdominal ring to the top of 
the testicle and there end, the normal tunica 
vaginalis being beyond. Hernia into this process 
is called a hernia into the funicular process. 

In the first of these forms the testicle is quite 
enveloped in the hernia. In the second and third 
forms, as well as in the acquired form, it is to 
be felt quite distinct from the rupture, being 
actually behind and below it. Congenital hernia 
frequently occurs in cases of imperfect descent of 
the^ testicle ; this can be readily understood when 
it is remembered that the processus vaginalis is 
completely formed before the testicle passes into 
the inguinal canal. In such cases the processus 
remains open. In these instances the vaginal pro- 
cess may occupy the would-be canal, and along 
this process a hernia may descend. It is well 
known that the testicle may make its first appear- 
ance in the scrotum months and even years after 
birth. 



346 SURGICAL APPLIED ANATOMY [Part IV 

There is another possible congenital defect that 
may predispose to hernia, viz. an abnormally long 
mesentery. If, in the dead subject, the inguinal 
canal be opened up, and an attempt made to draw 
a piece of gut down from the abdomen into the 
scrotum, it will be found that this cannot be done, 
owing to the shortness of the mesentery. In any 
case of scrotal hernia, therefore, the mesentery 
must become lengthened, and it is a question 
whether or not an abnormally long mesentery may 
exist as a congenital defect, and so predispose tjie 
patient to rupture. More information is required 
upon the subject. 

The inguinal canal in the female is much 
smaller and narrower, although a trifle longer, 
than it is in the male. It is occupied by the 
round ligament, and offers such slight induce- 
ment to the formation of a rupture, that acquired 
inguinal hernia is as rare among females as it is 
common among men. In the female foetus a pro- 
cess of peritoneum descends for a little way along 
the round ligament. It corresponds to the pro- 
cessus vaginalis of males, and is known as the 
canal of Nuck. If this process remains patent, 
as it not unfrequently does, it may lead to a rup- 
ture that corresponds to the congenital hernia of 
males. Indeed, in quite early life the inguinal 
rupture is about the only form met with in 
female children, if exception be made of umbilical 
hernia. Not uncommonly the ovary is found as 
one of the contents of the hernial sac — for in the 
newly-born child the ovarv lies above the level 
of the pelvic brim and relatively near the internal 
abdominal ring. In all such instances of early in- 
guinal hernia the gut has travelled down a patent 
canal of Nuck. 

It only remains to be said, that in endeavour- 
ing to reduce an inguinal hernia by taxis the 
thi^h should be flexed and adducted, for in this 
position the abdominal parietes that bound the 
inguinal canal are the most relaxed. This posi- 
tion of the thigh affects the inguinal region 



Chap. XVI] THE ABDOMEN 347 

mainly through the attachments of the fascia lata 
to Poupart's ligament. 

In Herniotomy an incision is made along the 
middle of the tumour and in its long axis, being 
so arranged that its centre shall correspond to the 
external ring. The superficial external pudic 
artery is usually divided in the operation. It is 
impossible to distinguish the various layers of 
tissue that cover the hernia, the only one, as a 
rule, that is recognisable being the layer from 
the cremaster. In dividing the constriction it is 
usually recommended to cut upwards in all forms 
of inguinal hernia. The only vessel in risk of 
being damaged is the deep epigastric. In the 
oblique form of rupture an incision directly up- 
wards would quite avoid this artery; but in a 
direct hernia, where there is reason to suppose 
that the vessel is in close connection with the neck 
of the sac, it is well that the incision be directed 
a little inwards as well as upwards. It should 
be remembered that the incision required to re- 
lieve a constriction is, if properly applied, of the 
most insignificant character. 

2. Femoral hernia.— In this form of rupture 
the gut leaves the abdomen through the femoral 
ring and passes down into the thigh along the 
crural canal (Fig. 57). The name " crural canal " 
is given to the narrow interval between the 
femoral vein and the inner wall of the femoral 
sheath. Like the inguinal canal, it is a potential 
rather than an actual canal, and exists only when 
the sheath has been separated from the vein by 
dissection or by a hernial protrusion of some kind. 
The canal is funnel-shaped, about ^ an inch in 
length, and ends opposite the saphenous opening. 
A point taken on Poupart's ligament midway be- 
tween the pubic spine and femoral point lies 
directly over the femoral ring ; the centre of the 
saphenous opening is situated f of an inch below 
this point (Fig. 57). Femoral hernise are always 
acquired, and possess a sac, made by themselves 
out of the parietal peritoneum covering the crural 



348 SUKGICAL APPLIED ANATOMY [Part IV 

ring and its vicinity. The canal is larger in 
women than in men, and thus it happens that 
this species of rupture is much more common in 
the former sex. The tendency to this hernia in 
women appears also to be increased by the weak- 
ening effects of pregnancy upon the abdominal 
walls. As the gut descends it pushes in front of 
it its sac of peritoneum and the septum crurale 
(the name given to the subserous tissue that covers 
in the femoral ring) and enters the crural sheath. 
The adhesions of the sheath limit its downward 
progress when it has travelled about £ an inch, 
and it therefore passes forwards through the 
saphenous opening, pushing before it the cribri- 
form fascia. It then receives a covering from the 
superficial fascia and the skin. Owing to the 
rigidity of the structures about the femoral ring, 
the neck of the sac must always be small. For 
similar reasons its dimensions while in the femoral 
canal must of necessity be insignificant, but when 
once it has escaped through the saphenous open- 
ing the loose subcutaneous fasciae of the groin 
afford it ample opportunity for increase. When 
the hernia has passed through the saphenous open- 
ing it tends to mount upwards over Poupart's 
ligament, in the direction of the anterior superior 
iliac spine. Even when it overlaps the ligament 
considerably it can hardly be mistaken for an 
inguinal hernia, since it must always lie to the 
outer side of the pubic spine. The upward ten- 
dency of a femoral hernia has been variously 
explained. It has been ascribed to a supposed 
curve in the crural canal, the concavity of which 
is forwards. Scarpa believed it to receive its 
direction from the frequent flexion of the thigh. 
Probably one of the most important factors in 
the matter is the unyielding character of the 
lower edge of the saphenous opening. If an elas- 
tic capsule be dilated within the femoral canal 
it will be found to turn upwards and inwards 
oyer Poupart's ligament; the direction of expan- 
sion is determined by the circumstances just men- 



Chap. XVI] THE ABDOMEN 349 

tioned and by the yielding character of the an- 
terior wall of the femoral sheath. The hernial 
sac is superficial to Scarpa's fascia. 

Relations.- — When a hernia occupies the crural 
canal there are in front of it the skin and super- 
ficial fasciae, the iliac part of the fascia lata, the 
cribriform fascia, and the anterior wall of the 
crural sheath. Behind are the posterior wall of 
the crural sheath and pubic portion of the fascia 
lata, the pectineus muscle, and the bone. The 
boundaries of the femoral ring are, in front, Pou- 
part ; s ligament and the deep crural arch; behind, 
the bone covered by the fascia lata and the pec- 
tineus; on the inner side, the conjoined tendon, 
Gimbernat's ligament, and the inner part of 
the deep crural arch; on the outer side, the 
femoral vein in its sheath (Fig. 57). The sper- 
matic cord lies (in the male) just above the an- 
terior border of the ring, and the epigastric artery 
skirts its upper and outer part. The little pubic 
branch of this artery passes round the ring to 
ramify over Gimbernat's ligament. In two cases 
out of seven the obturator artery arises from the 
epigastric. In 10 per cent, of cases the abnormal 
obturator passes on the inner side of the femoral 
ring and is in danger of being wounded in opera- 
tions for strangulation ; in other cases the artery 
descends to the outer side of the ring or may cross 
it (R. Quain). In one instance where the vessel 
was placed internally to the femoral ring the pul- 
sations of the abnormal artery were felt before the 
parts were divided. In addition to the vessels 
about the ring there is also a pubic vein, which, 
ascending from the obturator vein in the thyroid 
foramen, enters the external iliac vein. Its rela- 
tion to the crural ring varies in the same way as 
the abnormal artery last named. 

The size of the femoral canal and the degree 
of tension of its orifices vary greatly with the 
position of the limb. If the thigh be extended, 
abducted, and rotated outwards, these parts are 
made very tense, while they are the most lax when 



350 SURGICAL APPLIED ANATOMY [Part IV 

the limb is flexed, adducted, and rotated inwards. 
It is consequently in the latter position that the 
thigh should be placed when taxis is being at- 
tempted. In herniotomy the incision is made 
along the inner side of the tumour, and is so 
arranged that its centre corresponds to about 
the upper part of the saphenous opening. The 
constriction is usually at the neck of ^ the sac, and 
caused by Gimbernat's ligament. It is divided by 
an incision directed upwards and inwards. 

3. Obturator hernia. — In this form the gut, 
pushing before it the peritoneum, the subperi- 
toneal fat, and the pelvic fascia, escapes through 
the obturator canal. The direction of this canal 
is, from behind, downwards, forwards, and in- 
wards. The inguinal is separated from the 
femoral canal by the inner part of Poupart's 
ligament; the femoral is separated from the ob- 
turator bv the horizontal ramus of the pubis. 

Beyond the canal the hernia may pass between 
the obturator membrane and the obturator exter- 
nus muscle and remain deeply placed, or it may 
make its way through the muscle or emerge above 
it and be then covered by the pectineus and adduc- 
tor brevis. The obturator artery is, as a rule, 
at the outer and posterior part of the sac. It is 
very rarely in front of it. The obturator nerve 
is generally found to the outer side of the sac, 
less commonly it is in front of it. The proximity 
of the nerve renders it very liable to be pressed 
upon, and pain along the nerve is often a marked 
feature of the rupture. The hernia presents be- 
neath the pectineus muscle, to the inner side of 
the capsule of the hip, behind and to the inner 
side of the femoral vessels, and to the outer side 
of the adductor longus tendon. Pain on moving 
the hip is generally a conspicuous symptom. The 
obturator externus may be made tense bv rotation 
inwards of the slightly abducted thigh. This 
hernia is much more common in females ; and it 
is worthy of note that the orifice of the obturator 
canal can be examined, to some extent, through 



Chap. XVI] THE ABDOMEN 351 

the vagina. Professor Wood reports a remarkable 
case where a hernial protrusion of a part of the 
adductor longus through a rent in the fascia lata 
was mistaken for an obturator hernia. 

1. Rare forms of hernia. — In perineal hernia 
the sac, covered by the recto-vesical fascia, escapes 
through the anterior fibres of the levator ani 
muscle, between the prostate and the rectum. In 
the ischio-rectal hernia the protrusion takes place 
into the ischio-rectal fossa. In pudendal hernia 
the sac lies in the posterior inferior half of the 
labium pudendi, escaping between the ascending 
ramus of the ischium and the vagina ; it has been 
mistaken for a cyst. In sciatic hernia the gut 
escapes through the great sacro-sciatic notch in 
front of the internal iliac vessels, above or below 
the pyriformis, and appears under the gluteus 
maximus muscle. As regards umbilical hernia, 
nothing remains to be added to what has been 
already said (p. 328), save that the sac from its 
position nearly always contains omentum, and 
may contain stomach. In lumbar hernia the gut 
escapes in front of the quadratus lumborum 
muscle, and appears on the surface through the 
triangle of Petit (the gap between the latissimus 
dorsi and external oblique muscles), and there- 
fore just above the highest point of the iliac crest. 
The sac must either force before it or (in cases of 
injury) come through the fascia lumborum and 
internal oblique muscles, since these structures 
form the floor of the triangle. The hernia may 
escape through the " upper lumbar triangle " — 
a gap near the last rib where the aponeurosis of 
the transversalis is covered only bv the latissimus 
dorsi. Macready (Lancet, Nov. 8th, 1890) has col- 
lected twentv-five examples of this hernia. Dia- 
vhraqmatic hernias may be congenital or acquired. 
The former variety is by far the more common, and 
is due to simple arrest in the development of the 
diaphragm and persistence of the original connec- 
tion between the thorax and abdomen ; the position 
of this connection is marked by the fibrous interval 



352 SUEGICAL APPLIED ANATOMY [Part IV 

between the muscular fibres rising from the last rib 
and those springing from the external arcuate liga- 
ment. The congenital form very rarely occurs on 
the right side, the development of the liver secur- 
ing the closure of the pleuro-peritoneal opening 
on that side. In the acquired form, which is 
usually the result of a crushing accident, the dia- 
phragm may be lacerated at any point, but in the 
majority of instances the lesion is situated in the 
left dome over the stomach. In an adult subject 
recently dissected by Dr. N. Paterson the ab- 
dominal contents of the left hypochondrium occu- 
pied the left pleural cavity ; there was a large 
aperture in the left dome ; the condition had not 
been recognised during life and apparently had 
given rise to no marked symptom. Of the organs, 
the stomach is the most frequently dislodged, then 
the transverse colon, omentum, small gut, spleen, 
liver, pancreas, and kidneys, in the order named 
(Leichtenstern). The hernia may escape through 
the foramen for the gullet, but never through that 
for the vena cava, nor through the hiatus aorticus. 
The parts commonly selected are the connective 
tissue intervals between the sternal and costal 
origins of the diaphragm in front and its verte- 
bral and costal origins behind. These hernise are 
more common in males. 

Femoral and inguinal diverticula. — Re- 
cently Mr. It. W. Murray has called attention to 
the frequency with which diverticula of peri- 
toneum are found over the openings of the femoral 
and inguinal canals. In 200 post-mortem ex- 
aminations he found 52 femoral and 13 inguinal 
diverticula and yet no hernia. In some cases the 
inguinal sacs may be formed from the processus 
vaginalis, but all the femoral forms and probablv 
the majority of the inguinal are caused by yield- 
ing of the fibrous tissue of the parietes over the 
femoral and internal abdominal rings. In these 
regions the peritoneum is so loosely bound to the 
abdominal wall that it may be evaginated by a 
low degree of intra-abdominal pressure. 



Chap. XVI] THE ABDOMEN 353 

Posterior abdominal parietes. — The lateral 
and posterior walls of the abdomen are lined in- 
side with two fasciae, the transversalis and iliac. 
The transversalis fascia lines the whole of the 
transversalis muscle, and is much thicker below 
than above. Above, it joins the fascia covering the 
diaphragm, while below it is attached to the iliac 
crest and to the whole of Poupart's ligament, save 
at that spot where it passes into the thigh to 
form the anterior layer of the crural sheath. The 
iliac fascia encloses the ilio-psoas muscle, the part 
over the psoas being the thinner. This part is 
attached on the inner side to the sacrum, and to 
the spine at the points corresponding to the psoas 
origin. Above, it is attached to the ligamentum 
arcuatum internum, and on the outer side to the 
anterior layer of the lumbar fascia along the 
outer edge of the psoas. Below, the fascia en- 
closes the iliacus, and is attached to the iliac crest, 
to the pelvic brim, and to Poupart's ligament, 
save at that part where the membrane passes be- 
neath the ligament to form the posterior wall of 
the crural sheath. It follows the ilio-psoas muscle 
to its insertion, and ends by blending with the 
fascia lata. 

The arrangement of these fasciae greatly influ- 
ences the progress and direction of abscess. Thus 
an abscess placed beneath the transversalis fascia 
will point either just above the iliac crest or Pou- 
part's ligament, or run down along the spermatic 
cord and distend the inguinal canal. 

The iliac fascia encloses the ilio-psoas in a 
very distinct osseo-aponeurotic space. Between the 
fascia and the muscle (especially its iliac division) 
there is a good deal of loose connective tissue, 
and thus every facility is offered for the progress 
of subfascial abscesses in this region. The osseo- 
aponeurotic space is practically closed on all sides 
within the abdomen, and is only open below where 
the fascia passes with its muscle into the thigh. 
This opening being at the most dependent part of 
the space, it follows that the psoas or iliac abscess 
x 



354 SUKGICAL APPLIED ANATOMY [Part IV 

very commonly points on the upper part of the 
thigh, just to the outer side of the femoral vessels. 
An abscess in the iliac fossa, although most likely 
to reach the thigh, might mount up to the superior 
attachments of the fascia, and point at the iliac 
crest or at the outer part of Poupart's ligament. 
Or it may disregard the inner attachments of the 
fascia and gravitate into the pelvis. If the 
patient should occupy for long the recumbent pos- 
ture, there is no reason why it should not extend 
upwards along the psoas muscle. 

The term iliac abscess, however, is often ap- 
plied to collections that are not within the space 
formed by the iliac fascia, but that are situated 
rather in the subperitoneal connective tissue. 
This tissue is very extensive and lax in the iliac 
fossa in order to allow the expansion of the 
peritoneum which necessarily attends the filling 
and emptying of the caecum, colon, bladder, 
uterus, and rectum. Large collections of puru- 
lent matter may form in it or may spread into it 
from the pelvis. Some distance above Poupart ; s 
ligament (1^ to 2 inches) the subserous tissue be- 
comes dense and the peritoneum closely bound 
down. Hence such abscesses remain in the iliac 
fossa, bulging out the abdominal wall just above 
Poupart's ligament, and occupying the angle 
formed by the union of the iliac and transversalis 
fasciae. In some cases they are disposed to extend 
into the pelvis. 

The abscess, when in the subserous tissue, is 
brought in close contact with certain of the vis- 
cera, especially with the caecum and sigmoid 
flexure, and into these portions of the colon it 
may open. Thus, I have seen a case of iliac 
abscess due to pelvic necrosis that opened into the 
sigmoid flexure, and at the same time discharged 
through sinuses about the groin. In this case 
some pus passed by the anus, while on the other 
hand some faecal matter escaped by the groin. 
Retroperitoneal abscesses in the pelvis (pelvic 
cellulitis) may mount up into the iliac fossae, may 



Chap. XVI] THE ABDOMEN 355 

appear as " iliac abscesses," and may ultimately 
discharge themselves by many openings in the 
lower parts of the anterior abdominal wall. 

It may be well to note that the common and 
external iliac vessels, the lymphatics, and the 
ureters are outside the iliac fascia, and rest upon 
its abdominal surface, while the anterior crural 
nerves and abdominal parts of the lumbar nerves 
are within the osseo-aponeurotic space. Thus the 
intrafascial abscess may, with little difficulty, 
reach the thigh by following the iliac vessels; 
while the subfascial collection would pursue the 
anterior crural nerve. 

A psoas abscess, or abscess within the fascial 
sheath of the psoas muscle, is usually due to spinal 
caries, although it may appear independently of 
that disease. If the lumbar spine be involved the 
matter can pass directly into the substance of the 
muscle, which it will more or less entirely destroy. 
If the mischief be in the dorsal spine, the matter 
gravitates along the front of the column until 
it reaches the diaphragm, which it pierces by an 
inflammatory process. It is now brought into re- 
lation with the heads of the psoas, and has to pass 
through a narrow strait. The pus, following the 
muscle, at last reaches the thigh, and usually 
points, just below the groin, to the outer side of 
the femoral vessels. The substance of the psoas 
may be completely replaced by an abscess cavity. 

The abscess, however, often shows much varia- 
tion. It may avoid the psoas, or leave it when 
once it has entered it, and make its way into 
the lumbar region to find an exit in the loin. Or 
it may extend into the iliac fossae and open above 
the groin, or mount up over the iliac crest and 
discharge in the gluteal region. It may pass 
along the inguinal canal and be mistaken for a 
hernia. It may sink into the pelvis, and may 
open into the bladder, or discharge itself through 
the great sciatic foramen, or through a sinus in 
the perineum. Some of the latter cases have led 
to much confusion in diagnosis, since there would 



356 * SURGICAL APPLIED ANATOMY [Part IV 

appear to be little connection between caries of 
the spine and a perineal abscess. 

Lumbar region. — The muscles that form the 
lateral and posterior walls of the abdomen, and 
that fill in the interval between the iliac crest and 
the lowest rib, are the external oblique and latis- 
simus dorsi, the internal oblique, the transver- 
salis muscle and fascia lumborum, the erector 
spinse and quadratus lumborum. The distance 
from the iliac crest to the tip of the nearest rib 
(usually the eleventh) varies from 3 to 7 cm, the 
average being 4'8 cm., a little less than 2 inches 
(Addison). 

The external oblique and latissimus dorsi mus- 
cles are separated by a small triangular interval 
below (the triangle of Petit), but above they over-, 
lap. The interval is best marked in women. The 
outer border of the erector spinse affords a useful 
landmark in the lumbar region. At the crest of 
the ilium the outer border of the quadratus lum- 
borum extends an inch beyond the erector spinse, 
but at the twelfth rib it lies an inch internally to 
that muscle (Fig. 68). The triangle of Petit is 
l\ to 2 inches beyond the erector spinas, or just 
behind the mid-point of the iliac crest. The sub- 
cutaneous tissue in the lumbar region is very 
extensive, and is a favourite locality for chronic 
abscess. The looseness and extent of the tissue 
also permit of large extravasations of blood. It 
is in the muscles and fascia along the spine in 
this region that the rheumatic affection known as 
lumbago has its seat. 

Between the last rib and the iliac crest is 
stretched the dense fascia lumborum, the posterior 
aponeurosis of the transversalis muscle. It is 
pierced near the rib by the last intercostal artery 
and nerve, and near the ilium by the ilio-hypo- 
gastric nerve and its accompanying artery. It is 
along these structures that an abscess may possi- 
bly find its way through the fascia in certain 
cases. The fascia divides behind into three layers, 
to enclose in definite spaces the quadratus and 



Chap. XVI] THE ABDOMEN 357 

erector spinas muscles, the middle layer passing 
between these two muscles to the tips of the trans- 
verse processes. Within these spaces or compart- 
ments suppuration may be for some time limited. 
A lumbar abscess commencing in some adjacent 
part, as in the spine or in the loose tissue around 
the kidneys, usually spreads backwards by pierc- 
ing the fascia lumborum or the quadratus muscle. 
It then finds its way through the internal oblique, 
and appears on the surface between the external 
oblique and latissimus dorsi muscles, and at the 
outer border of the erector spinse. 

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



CHAPTER XVII 

THE ABDOMINAL VISCERA 

The peritoneum. — Certain of the viscera, as, 
for example, the stomach, spleen, and small in- 
testines, are so closely invested with peritoneum 
that theycould not be wounded without that mem- 
brane being wounded also. Inflammatory affec- 
tions of such viscera are also very apt to involve 
the peritoneum. Other organs, such as the kid- 
ney, descending colon, pancreas, etc., are so im- 
perfectly covered with the serous membrane that 
a wound of those organs need not involve it, nor 
need it be implicated in even extensive inflamma- 
tory changes. Large abscesses may, for instance, 
form about the kidney and discharge themselves 
through the skin without any peritonitis being 
induced. Spontaneous perforation of the small 
intestine must involve the peritoneum, while, on 
the other hand, the duodenum and ascending 
colon may become perforated, and the matter 
escape into the subserous tissue without the serous 
membrane being in any way involved. It is note- 
worthy in connection with bacterial infection that 
it is singularly easy to set up inflammation of 
the peritoneum if the membrane be approached 
from its inner surface, but comparatively difficult 
if it be approached from without. Thus a small 
puncture of the membrane may, on the one hand, 
lead to fatal peritonitis, while, on the other, it 
may be extensively torn from its attachments 
(as in ligaturing the common iliac artery from 

358 



Chap. XVII] ABDOMINAL VISCERA 359 

the side) without any peritonitis following. Or, 
again, a little pus escaping on the inner surface 
of the membrane may lead to inflammation, while 
the outer surface may be bathed with pus for a 
long while (as in large perirenal abscesses) with- 
out any peritonitis being produced. Fluid is 
rapidly absorbed from the peritoneal cavity ; 
carmine particles are found within the thoracic 
duct seven minutes from their injection within 
the cavity; absorption takes place most rapidly 
in the subdiaphragmatic area (Dunbar and Remy). 
Inflammation of the peritoneum may lead to the 
formation of a great variety of bands and ad- 
hesions, beneath which pieces of intestine may be 
caught and_ strangulated. 

The peritoneum will allow of very consider- 
able stretching if only that stretching be effected 
gradually.^ This is frequently seen in cases of 
gradual distension of the bowel, in the formation 
of the sac in hernia, and in the growth of retro- 
peritoneal tumours. Abrupt stretching of the 
membrane leads to certain rupture of it. The 
parietal peritoneum may be ruptured by violence 
without damage to any of the viscera. 

The great omentum is, from its position, 
very apt to be wounded. In small wounds of the 
front of the belly it very often protrudes and acts 
as an excellent plug to prevent the escape of 
other and more important structures. It is often 
found in hernia, especially in umbilical hernia, 
where it is almost constant. Its limits vary, and 
it has an inclination to the left side. This 
depends upon the fact that the omentum is 
developed from the rnesogaster, and accounts for 
the fact that hernise containing omentum are 
much more common on the left side. The omen- 
tum, like the other parts of the peritoneum, is 
apt to inflame, and to contract adhesions to the 
neighbouring parts. These adhesions are often 
of the greatest service in limiting inflammatory 
and hsemorrhagic extravasations, by matting the 
bowels together and forming spaces between them. 



360 SUKGICAL APPLIED ANATOMY [Part IV 

In perforation of the bowels from disease, an 
opportune adhesion of the omentum over the aper- 
ture may prevent escape of the intestinal con- 
tents. 

Large masses of tissue may be nourished 
through an adherent omentum. Thus when the 
proper blood supply of an ovarian tumour has 
been cut off by twisting of its pedicle, the growth 
may be nourished through the omentum, if that 
structure is adherent to it. Rutherford Morri- 
son proposes to relieve congestion of the portal 
circulation by setting up an anastomosis between 
the omental vessels and the systemic circulation. 
When an adhesion between the omentum and 
parietal peritoneum is produced artificially, large 
anastomotic vessels open up and communicate 
with the vascular network beneath the parietal 
peritoneum, thus possibly relieving tension in 
cases of obstructed portal circulation. In cases 
of obesity fat collects conspicuously in the great 
omentum. In hernise the omentum generally con- 
tracts adhesions to the sac, and becomes irreduc- 
ible, or it may form a kind of second sac about the 
gut itself (" omental sac ,; ). The end of the omen- 
tum, by becoming adherent to distant parts, as to 
the pelvic viscera, may form itself into a firmly 
attached band, beneath which the bowel may be 
fatally strangled. In like manner the intestine 
has been strangulated through slits and holes that 
have developed in the omentum, usually as a re- 
sult of inflammatory adhesions. The functional 
meaning of the great omentum is by no means 
definitely established, but it undoubtedly increases 
the absorptive area of the peritoneum, and evi- 
dence is not lacking to show that it takes an active 
part in repelling bacterial invasions of the peri- 
toneal cavity. 

The mesentery. — The parietal attachment of 
the mesentery is liable to some variation. The 
point at which this attachment commences above 
is practically constant. It corresponds with the 
ending of. the duodenum, is about on a level with 



Chap. XVII] ABDOMINAL VISCEEA 361 

the lower border of the pancreas, and is just to 
the left of the second lumbar vertebra. (See p. 366.) 
From this point the insertion of the mesentery 
follows an oblique line that runs downwards 
and to the right, crossing the great vessels, and 
then ending in a somewhat uncertain manner on 
the right iliac fossa (Fig. 58, p. 363). The parietal 
attachment of the mesentery measures, as a rule, 
about 6 inches. From its oblique attachment it 
follows that, when haemorrhage takes place in the 
abdomen on the right side of the mesentery, the 
blood first is conducted into the right iliac fossa ; 
when on the left side, into the pelvis. This may 
explain the circumstance that collections of blood 
are more common in the right than in the left 
iliac fossa. 

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

The mesentery is relatively longest in infancy 

See " The Anatomy of the Intestinal Canal ami Peritoneum in Man " 
by the Author. London, 1SS5 



362 SUEGICAL APPLIED ANATOMY [Part IV 

and childhood, and a freer escape of the intestines 
from the abdomen is allowed in subjects under 
puberty. The disposition of the membrane per- 
mits also a freer downward excursion of the 
bowels on the right side, and this has been offered 
as an explanation of the undue frequency of right- 
sided inguinal hernise in childhood (Lockwood). 

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

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

Peritoneal spaces and communications. — 
Owing to the arrangement of the peritoneum the 
cavity of the abdomen is divided into a number 
of potential spaces which are connected together 
by certain definite communications or routes. 
Alimentary contents, pus, or blood escaping 
within the peritoneal cavity tend to collect in 
certain of these spaces and overflow into neigh- 
bouring spaces in well-defined directions. Some 
writers see in this arrangement of the peritoneum 
a resemblance to the watersheds of a country, and 
hence the potential spaces and routes are some- 
times spoken of as the " watersheds of the peri- 
toneum." The chief of these spaces are : (1) the 
lesser sac ; it communicates with (2) the subhepatic 



Chap. XVItj ABDOMINAL VISCERA 



3G3 



space by the foramen of Winslow ; this space is 
bounded above by the under surface of the liver 
and below by the duodenum, hepatic flexure of 
colon, transverse mesocolon, right kidney, and 
right costo-phrenic ligament (Fig. 58) ; (3) the 



Subphrenic Space 



Call Bladder 
Subhepatic 5pace 




Pericardium 
-A 

0E"5DT7r'0RIFICE. 



.Stomach 
Spleen 
/ 



Paracolic C,r 
Ileo-Colic Jiw 

ft/HT Sup I li 



.Spleaiic Flexure 
"Duode/io Je J. Flexure 



G 

Paracolic Groove 

Iliac Colon 
/ 

r> 



Fig. 58. 



-Diagram showing the average position of the abdominal viscera 
with their surface markings. (After Addison.) 

A, Stsrno-ensiform point; a 'a', sterno-ensiform line; b, mid-epigastric point; 
b'b', mid-epigastric or transpyloric line; c, umbilical point; c'c', umbilical 
line; d, mid-bypoffastric point; d'd', mid-hypogastric line; e,e, outer border 
of the right and left rectus abdominis ; F.Monro's point— on the fight spino- 
umbilical line at the outer border of tlie rectus abdominis. 

right subphrenic space between the diaphragm 
and liver ; it is bounded towards the middle line 
by the falciform and coronary ligaments; below 
it opens into the subhepatic space ; (4) left sub- 
phrenic space, between the diaphragm above 
and left lobe of liver and stomach below; it is 



364 SURGICAL APPLIED ANATOMY [Part IV 

separated from the corresponding right space by 
the falciform ligament ; below it communicates with 
(5) the perisplenic space; this space is bounded 
below by the splenic flexure and its mesocolon, 
the left costo-phrenic ligament and left kidney. 
These five spaces lie in the supra-omental region 
of the abdomen — above the transverse mesocolon ; 
below the transverse mesocolon there are two 
spaces, normally occupied by small intestine; (6) 
the right infra-omental, bounded above by the 
transverse mesocolon, below and to the left by the 
duodenojejunal junction and root of the mesen- 
tery ; (7) the left infra- omental, bounded above by 
the transverse mesocolon; it is separated from 
the right space by the duodenojejunal junction 
and mesentery of the small bowel. The remaining 
space — the eighth — lies in the pelvis, the recto- 
uterine in the female, the recto-vesical in the male. 
Communications between the supra- and infra- 
omental spaces exist only at the two extremities 
of the transverse mesocolon. Overflow from the 
subhepatic spaces tends to pass down the groove 
external to the ascending colon (right external 
paracolic groove) ; by that groove it reaches the 
iliac fossa ; from the iliac fossa, the pelvic space ; 
from the pelvis it may mount to the left infra- 
omental pouch, and from there the fluid matter 
may make its way to the left external paracolic 
groove and thence to the perisplenic space. In 
this description the writings of Barnard, Wallace, 
Box, Jenkins, and Maynard Smith have been 
followed. 

Surface markings of the abdominal vis- 
cera. —In Fig. 58 is shown the position of the 
abdominal viscera in an average individual, while 
in Fig. 59 is represented the position assumed by 
these viscera in a well-marked case of visceroptosis 
(Glenard's disease). Study of such cases, especi- 
ally by the aid of X-rays, shows the need of an 
accurate and simple method of indicating the 
normal position of the abdominal contents. The 
upper limit of the viscera is best indicated bv the 



Chap. XVII] 



ABDOMINAL VISCERA 



365 



sterno-ensiform point and line. The position of 
the sterno-ensiform point is indicated by a dis- 
tinct depression under the insertion of the seventh 




Fig. 59. — Diagram showing the position of the viscera in the condition 
of visceroptosis. 

a,a, [Sterno-ensiform line : it crosses above the fifth costal cartilage ; b,b, mid- 
epigastric line ; c,c, umbilical line ; n,D, mid-hypogastric line ; a, pericardium : 
b, stomach (greatly elongated and dilated) ; c, liver ; c', Riedel's lobe ; d, duo- 
denum ; e, CiBcum ; /, transverse colon ; g, rectum ; h, elongated gastro-hepatic 
omentum. 

pair of costal cartilages ; the sterno-ensiform line 
is drawn transversely on the body through this 
point and should cross the fifth pair of costal 
cartilages if the thorax is of normal shape. The 
right dome of the diaphragm, in the standing 



366 SURGICAL APPLIED ANATOMY LPart IV 

posture, reaches this line ; the left dome is 
£ an inch below it; in the supine position 
the domes rise upwards ^ an inch. The central 
tendon is \ an inch below the sterno-ensiform 
point. In visceroptosis the domes of the dia- 
phragm and viscera within them sink downwards 
until they lie 1 inch or more below their normal 
position (see Fig. 59). The mid-epigastric point 
is taken on the linea alba half-way between the 
umbilical and sterno-ensiform points; the mid- 
epigastric line (transpyloric plane of Addison) 
crosses the body at this point; it marks the level 
of the pylorus, pancreas, with the beginning and 
termination of the duodenum (Fig. 58). In vis- 
ceroptosis the parts sink until they reach the um- 
bilical line (Fig. 59). The umbilical line, drawn 
through the umbilicus, usually crosses somewhat 
below the highest point on the iliac crests ; the 
transverse colon and duodenum cross the abdomen 
above the line, the bifurcation of the aorta is 
below it. In visceroptosis the transverse colon 
and duodenum descend well below the umbilical 
line (Fig. 59). The mid-hypogastric point is taken 
on the linea alba half way between the umbilicus 
and symphysis pubis; it lies about 1 inch below 
the promontory of the sacrum. The mid-hypo- 
gastric line crosses the iliac colon in the left groin 
and the fundus of the caecum in the right. The 
outer border of the rectus abdominis (linea semi- 
lunaris) also serves as a useful guide ; at the point 
where it crosses the costal margin on the right 
side (right costo-rectal point) is situated the gall- 
bladder ; on the left side the greater curvature of 
the stomach emerges from the hypogastrium at 
this point (Fig. 58). A line drawn from the 
umbilicus to the right anterior superior iliac spine 
(spino-umbilical line) provides a useful guide to 
the ileo-C83cal region. Monro's point is situated 
on this line at the outer border of the rectus 
abdominis ; the ileo-csecal orifice lies to the right 
of Monro's point immediately below the spino- 
umbilical line. 



Chap. XVII] ABDOMINAL VISCERA 367 

The viscera arc maintained in position 

by the action of several structures, but by far the 
chief are the muscles of the abdominal wall — the 
external and internal oblique, transversalis, rec- 
tus abdominis, diaphragm and levator ani. By 
their contraction or tonus they maintain the vis- 
cera firmly pressed together ; in the upright pos- 
ture the weight of the upper viscera rests on the 
lower viscera. That the muscles are the chief 
agents in maintaining the viscera in position can 
be shown in many ways. In rising from the 
supine to the upright posture the upper viscera 
and diaphragm are seen in the living body (by 
aid of X-rays) to descend about ^ an inch. When 
the muscles and belly walls are cut away, and the 
dead body raised to the upright position, all the 
viscera drop downwards to the extent of 2 inches 
or more. The peritoneal ligaments, reflections, 
omenta, and mesenteries merely limit the degree 
of movement ; the viscera are freely movable to 
allow the extensive respiratory action of the dia- 
phragm. Besides the peritoneal, there are other 
visceral supports formed by vessels and their 
sheaths of connective tissue, such as the attach- 
ment of the liver to the diaphragm by the in- 
ferior vena cava, the kidneys and small intestine 
to the posterior abdominal wall by their vessels. 
It is only when the muscles of the belly wall are 
thrown out of action that any strain or weight 
falls on the peritoneal and vascular supports. 
The stomach — Its relationships are :— 

Above. 
Liver, small omentum, diaphragm. 

Behind 

Li front. 



(From left to right) dia- 
phragm, abdominal wall, 
liver. 



Stomach. 



Transverse -mesocolon, 
lesser sac, pancreas, 
crura, solar plexus, great 
vessels, spleen, left kid- 
ney, and suprarenal. 
Below. 
Great omentum, small intestines, transverse colon, gastro-splenic 
omentum. 

m The oesophagus perforates the diaphragm 
slightly to the left of the middle line and ends at 



368 SURGICAL APPLIED ANATOMY [Part IV 

the cardiac orifice of the stomach, 3 to 4 inches 
deep to the terminal inch of the seventh left costal 
cartilage. The pyloric orifice, permanently closed 
by its sphincter except when the contents of the 
stomach are passing to the duodenum, is situ- 
ated in the mid-epigastric line, about half-way 
between the epigastric point and the right costal 
margin (Fig. 58). Being situated under the quad- 
rate lobe of the liver and bound to the transverse 
fissure by the gastro-hepatic omentum, enlarge- 
ment or displacement of the liver necessarily 
causes a displacement of the pylorus; in cases of 
visceroptosis it may drop to the umbilical line 
(Fig. 59). Normally the lesser curvature is over- 
lapped by the liver, and the gastro-hepatic omen- 
tum is hid (Fig. 58), but when the stomach be- 
comes dilated, elongated, or falls down, the lesser 
curvature and gastro-hepatic omentum are ex- 
posed (Fig. 59). A curved line drawn from the 
position of the cardiac orifice (on the seventh 
costal cartilage, 1 inch from the sternum) to the 
position of the pylorus (mid-way between the epi- 
gastric point and right costal margin) indicates 
the normal position of the lesser curvature. While 
the lesser curvature is comparatively fixed, owing 
to the attachment of the gastro-hepatic omentum, 
the greater curvature is freely movable ; its posi- 
tion alters as the stomach is full or empty, con- 
tracted or relaxed. A curved line drawn from 
the position of the pylorus to the left costal mar- 
gin, so as to cross the linea alba 2 inches below 
the mid-epigastric line, will indicate the normal 
position of that part of the greater curvature 
which may be exposed in the epigastric space. 
Simple dilatation of the stomach leads to a low 
position of the greater curvature without altering 
the position of the lesser curvature ; in ptosis of 
the stomach both curvatures descend, but the 
greater descends most owing to dilatation being 
always present (Fig. 59). In ptosis the curva- 
tures become more vertical in position (Fig. 
59). The shape of the stomach depends on the 



Chap. XVII] ABDOMINAL VISCERA 369 

state of each of its three functional divisions. 
The fundus lies in the left hypochondrium ; 
it becomes continuous with the body of the 
stomach at or just abov3 the left subcostal 
margin (Fig. 58); the body joins the pyloric 
canal, the third division, about \\ inch from 
the pyloric orifice. The fundus is saccular in 
form and serves as a receptacle for the food ; it 
undergoes no active movements ; the body, on the 
other hand, is the part where digestive move- 
ments occur, and changes in shape are constantly 
taking place, but it is always more or less tubular 
in form. When empty it may be found in a con- 
dition of diastole or systole; if systolic it is 
usually covered by the transverse colon, and does 
not present when the epigastrium is laid open. 
The two extremities of the stomach are its most 
fixed points. The cardiac extremity is loosely 
fixed to the diaphragm by the oesophagus, lax 
pericesophageal tissue, and gastro-phrenic reflec- 
tions of peritoneum; the pyloric end is fixed to 
the liver and posterior abdominal wall by the 
gastro-hepatic omentum, by the hepatic branch of 
the coeliac axis and the tissue surrounding that 
vessel. The close relations of the stomach to the 
diaphragm and thoracic viscera serve in part to 
explain the shortness of breath and possible pal- 
pitation of the heart, etc., that may follow upon 
distension of the organ (Fig. 58, p. 363). The 
near proximity of the heart to the stomach is illus- 
trated by a case where a thorn (of the Primus 
spinosa), \ an inch long, had been swallowed and 
had then found its way through the diaphragm 
and pericardium into the wall and cavity of the 
right ventricle. 

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

The stomach rests behind on the lesser sac of 
the peritoneum, which plays the part of a bursa 
to it. Gastric ulcers rarely perforate into the 
lesser sac, but when they do the contents can only 

Y 



370 SUEGICAL APPLIED ANATOMY [Part IV 

escape by the foramen of Winslow, and may not 
be seen when the abdomen is opened. The sac 
is opened by incising the great omentum at the 
greater curvature of the stomach. 

The stomach has been frequently wounded. In 
most cases a fatal result rapidly follows upon 
these injuries, for the contents of the stomach 
escape into the peritonea! cavity and set up an 
acute peritonitis. The most certainly and rapidly 
fatal cases, therefore, are those in which the 
stomach was full of food at the time of the acci- 
dent. The empty stomach, being deeply placed 
and lying against the posterior abdominal wall in 
a collapsed state, is but little exposed to injury. 
A small punctured wound of the stomach need 
not be followed by escape of contents, since the 
loosely attached mucous membrane may escape 
from the wound and effectually plug it. This was 
illustrated many times in the Boer war, the viscus 
having been perforated by a Mauser bullet. The 
stomach has protruded through wounds in the 
abdominal walls, and has been returned, with no 
evil results following. In a few cases the belly 
wall in front of the stomach has been wounded, 
the viscus has protruded, its anterior wall has 
been wounded by the same injury that penetrated 
the parietes, and a fistulous opening leading into 
the stomach cavity _ has resulted. The best ex- 
ample of such cases is afforded by the well-known 
instance of Alexis St. Martin, the subject of so 
many physiological experiments. In this man the 
abdominal parietes in front of the stomach were 
torn away by a gunshot wound, a part of the an- 
terior wall of the stomach sloughed, and a per- 
manent fistula resulted. Dr. Murchison reports 
the case of a woman in whom a gastric fistula 
was produced by the continued pressure of a cop- 
per coin worn over the epigastric region. This 
coin was deliberately worn by the patient in order 
to excite a lesion that would arouse the sympathy 
of her friends. The pressure led to an ulcera- 
tion that finally opened up the stomach. In many 



Ohap. XVII] ABDOMINAL VISCERA 371 

cases the fistula has been due to ulcerative diseases 
commencing in the stomach itself and spreading 
outwards. 

Some remarkable cases have been recorded 
where foreign substances have been swallowed and 
have lodged in the stomach. Certain of these 
cases serve to illustrate the capacity of the 
stomach, and among the most striking is an in- 
stance where the viscus at death was found to 
contain thirty-one entire spoon-handles, each 
about 5 inches long, four half-handles, nine nails, 
half an iron shoe-heel, a screw, a button, and four 
pebbles. The whole mass weighed 2 lb. 8 oz. The 
patient was a lunatic. 

The pylorus has an average diameter of 16 mm., 
about that of a sixpenny-piece. It is normally in 
a closed state, and should, when open, be capable 
of taking the fore-finger. In spite of the narrow- 
ness of the pylorus, large substances that have 
been swallowed have been passed by the anus 
without trouble. Among these may be noted a 
metal pencil-case, 4| inches long, 10 ounces of 
garden nails, and fragments of crockery-ware 
swallowed by a lunatic ; a fork, a door-key, and 
other strange bodies. Needles and similar sharp 
substances that have been swallowed have travelled 
out of the stomach or bowels and have found 
their way to the surface at various points in the 
body. In a patient under my care at the London 
Hospital I extracted from beneath the skin, near 
the groin, a needle swallowed some months pre- 
viously. In a case reported in the Lancet a needle 
was extracted from the middle of the thigh six 
months after it had been swallowed, and like 
instances are recorded elsewhere. 

Hypertrophy may occur in the pyloric 
sphincter leading to a functional stenosis of the 
orifice. It occurs soon after birth, and its cause 
has to be sought for in the reflex mechanism which 
regulates it. Relaxation normally follows when 
the chyme expelled from the stomach has been 
neutralised in the duodenum. 



372 SURGICAL APPLIED ANATOMY [Part IV 

The lymphatics of the stomach pass mostly 
to the glands situated between the layers of 
the small omentum along the lesser curvature. 
Some also pass to the glands scattered along 
the greater curvature of the stomach. In can- 
cer of the pylorus, the glands along the lesser 
curvature are the first t6 become affected, and 
from these the disease spreads along vessels which 
accompany the coronary artery of the stomach to 
the coeliac glands near the commencement of the 
thoracic duct. Lymphatics also pass from the 
pylorus to the coeliac glands along the curve of 
the pyloric and hepatic arteries. Owing to a 
free communication between the lymphatics of the 
pylorus, pancreas, and liver, the disease fre- 
quently involves these organs. 

Oastrotosny and gastrostomy. — Gastrotomy 
consists in opening the stomach through the an- 
terior abdominal wall for the purpose of removing 
a foreign body, for making an examination, or 
for dealing with a simple or malignant ulcer ; 
gastrostomy, in opening the stomach in a like 
situation with the object of establishing a gastric 
fistula through which the patient may be fed in 
cases where the gullet is occluded by disease. The 
uncovered part of the stomach, accessible in these 
operations, is represented by a triangular area, 
bounded on the right by the edge of the liver, on 
the left by the cartilages of the eighth and ninth 
ribs, and below by a horizontal line passing be- 
tween the tips of the tenth costal cartilages (Fig. 
58). In the empty condition five-sixths of the 
stomach lies beneath the left hypochondriac region, 
only part of the pyloric end being exposed in the 
triangular area. The incision in these operations 
must be situate in this triangle, and may be made 
either parallel to, and about two fingers' breadth 
from, the free border of the costse, or along the 
left semilunar line. In the former incision the 
three flat muscles of the abdomen are cut through. 
In gastrostomy the stomach is not opened at the 
time of the operation, but is merely secured to the 



Chap. XVII] ABDOMINAL VISCERA 373 

wound, and a few days are then allowed to elapse 
so that adhesions may (orm. At the end of this 
time the viscus is opened. The opening must 
needs be very small. 

Resection of" the pylorus. — The pylorus is 
frequently the seat of cancer. As a means of re- 
lieving the patient, the whole of the diseased 
pylorus has been removed, and the divided ends 
of the stomach and duodenum united by sutures. 
The situation of the cancerous pylorus within the 
abdomen varies considerably, as the diseased part 
is very apt to shift its position. It is often found 
to have sunk down by its weight to a point below 
the umbilicus, and to have contracted adhesions 
to adjacent organs. The diseased part has to be 
isolated and the omental connections of the right 
end of the stomach freely divided. The vessels 
that are almost certainly divided are the pyloric, 
the gastro-epiploica dextra, and the gastro-duo- 
denal. The operation has not been attended with 
much success. The cancer is apt to become diffuse, 
to spread to adjacent tissues, and to lead to early 
lymphatic invasion of the greater and lesser 
omenta. 

Oastrectomy. — Considerable portions of the 
stomach have been excised in cases of cancer, and 
the entire organ has been removed (total gastrec- 
tomy) for the same cause. Up to the time of 
writing some fifteen examples of this operation 
have been recorded with more or less imme- 
diate death in five. Schlatter's first case of gas- 
trectomy, performed in 1897, died in fourteen 
months from secondary deposits. Ricord pub- 
lished a case in which he removed the whole 
stomach, the first piece of the duodenum, and 
part of the pancreas. The patient was alive and 
well eleven months after the operation (Gaz. des 
Hopitaux, March 22nd, 1900). It has yet to be 
shown that the operation is of genuine value. 
There is difficulty in uniting the gullet to 
the small intestine ; both vagi nerves are divided 
as they emerge through the diaphragm, and the 



374 SURGICAL APPLIED ANATOMY [Part IV 

solar plexus is apt to be roughly handled ; the 
operation is an extreme test for a weakened 
patient, and the after condition of those who 
survive is not free from distress. There is, how- 
ever, less disturbance of digestion than would be 
imagined. 

Other operations on the stomach. — 
Many other operations are performed upon the 
stomach which call merely for mention in this 
place. One of the most useful and the most fre- 
quently performed is gastroenterostomy. Here 
an opening (or stoma) is made between the 
stomach and the upper part of the jejunum. An 
opening has also to be made in the transverse 
mesocolon in order that the bowel may be applied 
to the posterior aspect of the stomach. In making 
the opening the middle colic artery and its larger 
branches are to be avoided. The operation is per- 
formed in cases of stenosis of the pylorus, in 
cases of dilatation of the stomach without much 
stenosis, in certain examples of ulcer, and in 
many other conditions. In the operation of 
pyloroplasty, a non-malignant stricture of the 
pylorus is divided and the pyloric passage thus 
made free. In gastroplication certain conditions 
of dilated stomach are dealt with by taking in a 
fold or pleat in the stomach wall and in thus 
lessening its capacity. 

The small intestines.* — The average length 
of the small intestine in the adult is 22^ feet, the 
extremes being 30 feet and 15 feet, the length, to 
a considerable extent, depending on the degree 
of contraction of the longitudinal muscular coat. 
In the foetus, at full term, the lesser bowel mea- 
sures about 9j feet. It is roughly reckoned that 
the first 8 or 9 feet of the adult bowel belongs to 
the jejunum, and the remaining 12 or 13 feet to 
the ileum. 

The division into jejunum and ileum is quite 
arbitrary. There is no one point where it can 

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



Chap. XVIIJ ABDOMINAL VISCERA 375 

be said that the jejunum ends and the ileum 
commences. When the small intestines are ex- 
posed by accident or operation, it is often diffi- 
cult, especially when there is abdominal disease, 
to recognise the upper from the lower part of the 
gut. It may be noted, however, that the jejunum 
is wider than the ileum (its diameter being £ of an 
inch greater than that of the ileum), and its 
coats are thicker and more vascular. If the gut 
be empty, and can be rendered translucent by 
being held against a light, the lines of the valvulse 
conniventes can be well seen. These folds are 
large and numerous in the jejunum, but become 
small and scanty in the upper ileum, and are 
wanting in the lower third of that bowel. In- 
juries of the jejunum are more serious than 
are those of the ileum, since an intestinal lesion 
is (other things being equal) the more serious the 
nearer it approaches to the stomach. The fatality 
of umbilical hernise probably depends in part 
upon the fact that the contained bowel is often 
jejunum. The coils of small intestine occupy no 
certain position in the abdomen. In the foetus, 
and during the earliest part of extra-uterine life, 
the bulk of the small intestine is placed to the left 
of the middle line. This is on account of the re- 
latively large size of the liver, to the weight of 
which the lesser bowel no doubt acts as a counter- 
poise. In the majority of adult bodies the small 
intestine is disposed in an irregularly curved 
manner from left to right. The gut, starting 
from the duodenum, will first occupy the contigu- 
ous parts of the left side of the epigastric and 
umbilical regions ; the coils then fill some part of 
the left hypochondriac and lumbar regions; they 
now commonly descend into the pelvis, re-appear 
in the left iliac quarter, and then occupy in order 
the hypogastric, lower umbilical, right lumbar, 
and right iliac regions. Before reaching the lat- 
ter situation they commonly descend again into 
the pelvis. 

Much interest attaches to the coils of small 



376 SURGICAL APPLIED ANATOMY [Part IV 

intestine that are found in the pelvis. These are 
the coils that are apt to become involved and ad- 
herent in cases of pelvic peritonitis, and that 
would probably form the protrusion in most cases 
of obturator, sciatic, and pudendal hernia. No 
small intestine occupies the foetal pelvis. The 
amount found in the adult pelvis depends mainly 
upon the state of distension of the bladder and 
rectum, and upon the position of the sigmoid 
flexure. The coils that are most usually found 
in this position belong to the terminal part of the 
ileum, and to that part of the intestine that has 
been already alluded to as possessing the longest 
mesentery ^ (page 360). The ileum is the part of 
the intestine that is most frequently found in 
inguinal and femoral hernise. It is also the part 
most usually involved in cases of strangulation 
by internal bands, by holes in the mesentery, etc. 
Of all the viscera the small intestines are the 
most exposed to injury, and at the same time it 
must be noted that by their elasticity, and by the 
ease with which their coils slide over one another 
and so elude the effects of pressure, they are the 
best adapted to meet such injuries as contusions 
and the like. A minute punctured wound of the 
small gut does not lead to extravasation of con- 
tents. The muscular coat contracts and closes the 
little opening. Thus, in excessive tympanitis the 
bowels are often freely punctured in many places 
with a fine capillary trochar, to allow the gas to 
escape, without any evil resulting. A case of in- 
testinal obstruction of sixteen weeks' duration 
is reported, in which the abdomen was punctured 
150 times {Boston Med. Journ.). If the wound 
be a little larger the loose mucous membrane be- 
comes everted or protruded through the wound 
and effectually plugs it. Gross found that a 
longitudinal cut in the small bowel 2^ lines in 
length was immediately reduced to a wound If 
lines in length by muscular contraction, and that 
the eversion of the mucous membrane in addi- 
tion to this contraction entirely sealed the open- 



Chap. XVII] ABDOMINAL VISCERA 377 

ing. Even the opening made in the intestine — 
for example, in the jejunum — by the penetration 
of a Mauser bullet may be attended by no escape 
of contents. A contracted empty piece of bowel 
becomes nearly twice as long when distended. 

Owing to the greater power of the circular 
layer of muscle a longitudinal wound gapes more 
than a transverse wound, and, in consequence of 
the greater muscular development of the jejunum, 
wounds of that part gape more than do those of 
the ileum. Transverse wounds gape most when 
inflicted across the free border of the gut, since 
in that place the longitudinal muscular fibres 
are thickest. 

In one remarkable case a man was stabbed in 
the belly. It was subsequently found that there 
was a small puncture in the ileum, which had been 
plugged by the mucous membrane and further 
secured by recent lymph. The man did well until 
the fourth day, when he died somewhat suddenly. 
It was then found that an intestinal worm 
(Ascaris lumbricoides) had worked its way 
through the wound, breaking down the adhesions, 
and had escaped into the peritoneal cavity. Ex- 
travasation followed, and thus the worm was the 
immediate cause of the man's death. 

The calibre of any portion of the small in- 
testine depends mainly upon the condition of its 
muscular wall. The tube may become much con- 
tracted when empty. In peritonitis and in cer- 
tain other conditions the muscular coat is para- 
lysed and the bowel becomes intensely dilated by 
gas (tympanites). 

Meckel's diverticulum. — From one to four 
feet from the end of the ileum is sometimes seen 
a diverticulum (Meckel's) that represents the 
remains of the vitello-intestinal duct (p. 329). 
It may be expected in 2 per cent, of the bodies 
examined. This diverticulum usually exists as a 
tube of the same structure as the intestine. Its 
length varies. It may sometimes extend as a 
patent tube as far as the umbilicus. It is more 



378 SURGICAL APPLIED ANATOMY [Part IV 

often but a few inches long, and may then end 
in a free conical or globular extremity, or in a 
fibrous cord. This diverticulum may cause in- 
testinal obstruction in many ways. Its end may 
contract adhesions, and beneath the bridge thus 
formed a loop of bowel may be strangled. It may 
twist itself about a piece of intestine so as to 
form a knot round it. It may, from its adhesions, 
so drag upon the ileum as to cause " kinking ;; 
of the tube at its point of origin. In more than 
one case it has been found in an external hernia. 
It may become invaginated and start an intussus- 
ception of the bowel. The lumen of the gut is 
often considerably diminished at or near the site 
of the diverticulum, and at this narrowing in- 
tussusception of the bowel may commence. 

The duodenum and fossa duodeno- 
jejunal! s.— The first portion of the duodenum is 
nearly horizontal. It measures about 2 inches in 
length and passes backwards from the pylorus to 
near the upper end of the right kidney. The 
second portion, about 3 inches in length, descends 
vertically in front of the inner border of the 
right kidney to the level of the third lumbar 
vertebra. The third portion, some 5 inches in 
length, crosses from right to left in front of the 
third vertebra, and then ascends for a short dis- 
tance on the surface of the left psoas muscle, to 
end in the jejunum to the left of the second 
lumbar vertebra (Fig. 58, p. 363). The first por- 
tion, which is movable, is invested by peritoneum 
in the same manner as the stomach. The second 
part is covered by peritoneum in front only, ex- 
cept at the spot where it is crossed by the trans- 
verse colon. The third part is also covered by 
peritoneum on its anterior aspect only, this mem- 
brane being, however, free of the gut where the 
superior mesenteric vessels cross it. A constric- 
tion, probably functional in nature, is usually 
found at the termination of the third stage. 

The end of the duodenum, the duodeno- 
jejunal bend, is very firmly held in place by a 



Chap. XVII] ABDOMINAL VISCEEA 379 

band of fibrous tissue that descends upon it from 
the left crus of the diaphragm and the tissue 
about the coeliac axis. This band is called the 
suspensory muscle of the duodenum (Treitz). It 
serves also to support the mesentery. In ptosis of 
the viscera the neck of the pancreas and duodeno- 
jejunal bend are the least displaced parts be- 
cause of their attachment to the posterior wall by 
the fibrous tissue round the cceliac axis and origin 
of the superior mesenteric artery. All sections of 
the duodenum have been ruptured by violence. 
Owing to its large non-peritoneal surface, the 
bowel, if approached from behind, may be 
wounded without opening the peritoneum. 

Brunner's glands occur in the first stage of the 
duodenum; their secretion probably protects this 
part of the gut against the acid chyme which 
is only neutralised as it reaches the second stage. 
It is probably because of the nature of its con- 
tents that the first stage of the duodenum is so 
frequently the site of ulceration ; over 90 per cent, 
of duodenal ulcers occur in the first stage (Collin). 
The ulcer may perforate and the contents escape 
into the subhepatic space, or adhesions may form 
to surrounding organs — the gall bladder, the liver, 
the head of the pancreas, the right kidney, or the 
hepatic flexure of the colon. A diverticulum is 
frequently found just above the entrance of the 
common bile duct (Rolleston), especially in cases 
of ptosis. Congenital constrictions of the duo- 
denum occur. 

Passing from the front of the terminal (as- 
cending) part of the duodenum^ a fold of peri- 
toneum is often seen, that joins the parietal 
peritoneum to the left of the piece of gut in ques- 
tion. This fold marks off a fossa of triangular 
outline, the orifice of which is directed upwards. 
I have found the fossa in about 50 per cent, of 
the bodies examined. It is called the fossa 
diiodeiio-jejmialis ; it is usually large enough 
to lodge the tip of the finger, and its opening lies 
just below the duodeno-jejunal bend (Fig. 60). 



380 



SURGICAL APPLIED ANATOMY [Part IV 



This fossa is the anatomical cause of mesen- 
teric^ mesocolic, meso gastric, or retroperitoneal 
hernia. The commencement of the jejunum presses 
into the fossa, enlarges its cavity, and ultimately 
separates the peritoneum from its posterior at- 
tachments. More and more of the small intestine 
passes into the increasing pouch, until at last, as 
in the case reported by Sir Astley Cooper and in 
many others, nearly the whole of the small intes- 




ferioh^meseWteriicmein 

W &s- li lib ~ 



DUODENAL FOLD 



Fig. 60.— The fossa duodenojejunalis. (Treves.) 

tine may be found lodged in an enormous median 
retroperitoneal sac, the mouth of which is the 
orifice of the fossa duodeno-jejunalis. The duo- 
denum can be seen to enter the sac and the end 
of the ileum to leave it. The sac usually extends 
downwards on the left side, and may reach the 
promontory of the sacrum. These hernise vary in 
size, but are as a rule large. The caecum and 
ascending colon have their normal position, but 
the transverse and descending parts of the colon 
are stretched over and displaced by the sac. The 



Chap. XVII] ABDOMINAL VISCERA 381 

renal artery is behind the hernia, and the in- 
ferior mesenteric artery is in front of it and to 
the left. A branch of this vessel, the colica sinis- 
tra, is near to the orifice of the sac in its lower 
part. Numerous modifications occur in the form 
and boundaries of this peritoneal fossa, and a 
hernia may enlarge in any direction, but usually 
towards the left, where it passes behind a peri- 
toneal fold containing the inferior mesenteric 
vein. 

Operations on the small intestine. — Enter- 
otomy is the operation of opening the small in- 
testine above some obstruction that threatens to be 
fatal or insuperable. An incision is made in the 
linea alba, below the umbilicus, or in one or other 
iliac region, as is considered more convenient. 
This if some 2 or 3 inches in length will prob- 
ably suffice. The peritoneum having been opened, 
a knuckle of small bowel close above the ob- 
struction is seized, secured to the parietal wound, 
and then opened. The small intestine has also 
been opened to remove impacted foreign bodies 
and large gall stones. In such cases the intes- 
tinal wound is usually closed immediately. 

E uterectomy. — Parts of the small intestine have 
been resected with success for various diseased 
conditions. In one case more than two yards of 
the small intestine was cut away on account of 
multiple stricture. The patient, a young woman, 
made an excellent recovery. Resections have also 
been successfully performed in cases of bullet 
wound or stab involving the lesser bowel, and in 
other injuries. Tumours of the gut have been 
removed by a partial resection. Non-malignant 
strictures of the bowel have been treated by in- 
cision and dilatation. 

The bowel above an obstruction has been con- 
nected to the bowel below an obstruction by the 
operation called intestinal anastomosis or short 
circuiting, « 

In uniting divided intestine by suture (enter- 
oraphy) it is essential that the serous coat of the 



382 SUEGICAL APPLIED ANATOMY [Part IV 

ends of the bowel should be brought together. 
This is best effected by the suture known as Lem- 
bert ; s, with the addition of a special and separate 
line of sutures for the mucous membrane. Ex- 
perience shows that if leakage occurs after re- 
section or suture of intestine it will most likely 
occur along the attachment of the mesentery. 
This circumstance is thus explained by Mr. An- 
derson : The two layers of the mesentery diverge 
as they approach the bowel, and so leave a tri- 
angular space, the base of which, averaging about 
1% ths of an inch in width, is formed by the un- 
covered muscular tissue. It is the existence of 
this bare piece of intestine that renders adjust- 
ment of the serous coat at the attachment of the 
mesentery a matter of some difficulty. 

The ileo-cseeal region. — The caecum is, to a 
certain extent, rudimentary in man, as it is also 
in the carnivora. In herbivorous animals it is of 
great size, and appears to serve as a reservoir for 
the elaboration and absorption of food. It has 
been said that the caecum in man exists as an 
anatomical protest against vegetarianism. The 
appendix persists as the remains of the larger 
caecum of lower mammals. In the human foetus 
it can be seen to be but the narrowed ex- 
tremity of a capacious caecum. The foetal type 
of caecum, which is very characteristic, may per- 
sist throughout life. From the point of view of 
evolution the appendix would appear to be becom- 
ing obliterated. Like other functionless parts 
that persist as developmental relics, it is very fre- 
quently the seat of disease, and it is worthy of 
note that such disease tends to cause the entire 
obliteration of the part (as after many forms of 
so-called appendicitis). 

It must be understood that the term ccecum is 
applied to that part of the colon that lies below 
the entrance of the ileum. The average breadth 
of the adult caecum is 3 inches, its average length 
(vertical measurement) 2| inches. The caecum 
normally contains gas, and gives a high, tym- 



Chap. XVII 1 ABDOMINAL VISCERA 



383 



panitic note on percussion ; Glenard found that in 
cases of ptosis of the viscera it was often con- 
tracted, and when palpated had the consistency 
of a sausage. 

The caecum is usually lodged in the right iliac 
fossa, and is so placed that its apex corresponds 
with a point a little to the inner side of the 
middle of Poupart ; s ligament. When distended 
with gas or faecal contents it occupies the whole 
of the right iliac fossa. The ileo-caecal orifice is 
situated immediately below the spino-umbilical 



MESO COLON 




ILEOCOLIC FOSSA 



BLOODLESS FOLD 



REXROCAECAL 

ILEOCECAL FOSSA 

Fig. 61. — The peritoneal fossae of the ileo-cEecal region. 



line and externally to Monro's point {see Fig. 58, 
p 363). 

A slightly distended caecum so located may be 
emptied by flexing the thigh upon the abdomen. 
The caecum is always entirely invested by peri- 
toneum. Its posterior surface is never in con- 
nection with the areolar tissue of the iliac fossa. 
The peritoneum is reflected from the commence- 
ment of the ascending colon on to the posterior 
parietes below the level of the iliac crest. A 
mobile caecum may hang over the pelvic brim, or 
occupy the pelvis, or even find its way into an 
inguinal hernia of the left side. The caecum is 
not unfrequently found in an inguinal or femoral 



384 SUKGICAL APPLIED ANATOMY [Part IV 

hernia of right side (csecal hernia). Such herniae 
are, except in a few rare instances, provided with 
a proper and complete peritoneal sac. Foreign 
bodies that have been swallowed are very apt to 
lodge in the caecum, and in that situation may 
cause ulceration and even perforation of the 
bowel, producing one form of typhlitis. In cases 
of faecal retention, also, 'the largest accumulation 
of faecal matter is very usually met with in the 
caecum, and upon that part of the bowel when 
distension is extreme the greatest strain usually 
comes. Stercoral ulcers (ulcers due to the pres- 
sure and irritation of retained faeces) are more 
often met with in the caecum than in any other 
part of the colon. Solitary follicles are numerous 
in the mucous membrane of the caecum, especially 
near the ileo-caecal orifice. Intestinal concretions 
also are not uncommon in this part. 

The caecum is susceptible of enormous disten- 
sion, provided that this be gradually effected, and, 
in certain instances, a dilated caecum has been 
found to occupy a large part of the abdominal 
cavity. When the abdomen is opened in any 
doubtful case of intestinal obstruction, the con- 
dition of the caecum is of great value in pointing 
to the seat of the obstacle. In stenosis of the 
colon it will be found greatly distended, while in 
obstruction of the small gut it will be empty, or, 
at least, in a normal condition. 

Three kinds of movement occur in the caecum : 
(1) a churning movement, which has been ob- 
served to commence within an hour of taking 
food ; (2) antiperistaltic movements which begin 
in the colon and end in the caecum; (3) pro- 
pulsive or emptying movements. Water is ab- 
sorbed, and the faeces commence to assume a solid 
consistency as they reach the transverse colon. 
The ileo-caecal orifice is guarded by a muscular 
sphincter (ileo-ccecal sphincter) ; it is innervated 
by the sympathetic system and regulates the 
escape of chyme from the ileum (Elliot and B. 
Smith) ; MacEwen has seen it in action in the case 



Chap. XVII] ABDOMINAL VISCERA 385 

of a soldier in whom a wide caecal fistula resulted 
from a gunshot injury. MacEwen also observed 
a secretion escaping from the mouth of the appen- 
dix, which is situated about 1 inch below the 
ileo-csecal orifice. 

The appendix varies in length. Its average 
measurement in the adult is 4 inches, the extremes 
being 1 inch and 6 inches. Its position varies, 
although, as a rule, it is seen to lie behind the 
end of the ileum and its mesentery, and to point 
in the direction of the spleen. It frequently also 
lies behind the caecum. I have seen the appendix 
so placed with reference to the bowel that it would 
have been encountered in a right lumbar colotomy. 
In such cases the appendix has been pushed be- 
hind the caecum and caught in the mesocolon 
during the later months of foetal life, when the 
colon migrates from the neighbourhood of the 
liver to the right iliac fossa.^ The appendix may 
hang within the pelvis and, in inflammatory con- 
ditions, contract adhesions to the ovary or other 
pelvic structures. I have found an inflamed ap- 
pendix adherent to the liver and another in the 
left iliac fossa. It has found its way down both 
the right and the left inguinal canals. 

The tip of the process may adhere to a neigh- 
bouring peritoneal surface, and thus forin a 
" band," beneath which a piece of small intestine 
may be strangulated. 

Foreign bodies occasionally lodge in the ap- 
pendix, and it is very often found to be occupied 
by a faecal concretion or calculus. These sub- 
stances excite inflammation, and, as a result, the 
appendix may become perforated. Troubles in 
the vermiform process are the most frequent 
causes of perityphlitis, a term applied to^ localised 
inflammation of the peritoneum in the vicinity of 
the caecum. 

The mesentery of the appendix (Fig. 61), whiph 

contains an artery derived from the ileo-colic, 

may be so short as to produce obstructive kinks 

in the appendix. The mucous lining is so crowded 

z 



386 SURGICAL APPLIED ANATOMY [Part IV 

with solitary lymphoid follicles as almost to oc- 
clude its lumen. Like other lymphoid structures 
these follicles begin to atrophy soon after adult 
life is reached. In some forms of appendicitis 
these follicles are involved. They are surrounded 
by lymph spaces, from which vessels pass to the 
lymph glands in the mesentery, especially to a 
group situated in the ileo-colic angle — the ileo- 
colic group ; others pass upwards behind the as- 
cending colon (Lockwood). It is probably through 
these latter vessels that infection passes from the 
appendix and gives rise to abscesses in the sub- 
diaphragmatic region. The muscular coat of the 
appendix is scanty, and through breaks in it the 
submucous tissue communicates with the sub- 
serous. 

It is in the ileo-csecal region that intussuscep- 
tion most frequently occurs. In this condition 
one part of the intestine is prolapsed or " tele- 
scoped " into the lumen of an immediately adjoin- 
ing part. In the ileo-csecal variety (the common- 
est form) the narrow ileum, and subsequently the 
caecum, are prolapsed into the colon. The ileo- 
csecal valve forms the summit of the protrusion 
or intussusceptum. By a gradual increase of 
the condition the intussuscepted bowel may at 
last reach the rectum, and the ileo-csecal valve 
has, in fact, been recognised protruding from the 
anus. In the ileo-colic variety (the rare form) 
the end of the ileum is prolapsed through the 
valve. The valve and the csecum remain in their 
normal situations, and the summit of the intus- 
susceptum is formed only by the ileum. In 
another variety, which is also common, the apex 
of the intussusceptum is formed by the fundus of 
the invaginated csecum. 

There are three fairly constant peritoneal 
fossae, which are sometimes the seat of hernia, in 
the ileo-csecal region (Fig. 61). They are (1) the 
ileo-colic, situated between the ascending colon 
and termination of the ileum; a fold containing 
the anterior caecal artery bounds it above; (2) the 



Chap. XVII] ABDOMINAL VISCERA 387 

ileo-csecal fossa, between the termination of the 
ileum and the caecum; it is bounded in front by 
the bloodless fold and behind by the mesentery 
of the appendix; (3) the retrocecal fossa, behind 
the caecum ; it is bounded on the right by the lower 
termination of the ascending mesocolon. 

The large intestine. — From the caecum tc 
the sigmoid flexure, this portion of the bowel is 
accessible to pressure except at the hepatic and 
splenic flexures, which are deeply placed. The 
hepatic flexure is under the shadow of the liver, 
and the splenic curve, which reaches a higher 
level, is behind the stomach (Fig. 58, p. 363). The 
position of the transverse colon can often be well 
marked out. It crosses the belly transversely , so 
that its lower border is nearly on a level with 
the umbilicus (Fig. 58). In cases of faecal accu- 
mulation, the outline of the colon, with the 
exception of the two flexures above named, may 
be distinctly defined. In distensions of the small 
intestine the belly tends to present the greatest 
degree of swelling in front, and about and below 
the navel. In distension of the larger gut, the 
front of the abdomen may remain (for a while at 
least) comparatively flat, while the distension will 
be most obvious in the two flanks and in the 
region just above the umbilicus. Tumours of the 
transverse colon, and of the lower two-thirds of 
the ascending and descending colon, can be well 
defined, even when of moderate size, and in cases 
of intussusception the progress of the mass along 
the colon can often be traced with great ease, and 
the effects of enemata and other methods of re- 
duction carefully watched. The diameter of the 
large intestine (excluding the rectum) gradually 
diminishes from the caecum to the sigmoid flexure, 
the diameter of the former being about 2^ inches, 
of the latter 1 1^ inch. The narrowest part of this 
segment of the bowel is at the point of junction 
of the sigmoid flexure with the rectum, and it is 
significant that it is at this point that stricture 
is the most common. 



388 SURGICAL APPLIED ANATOMY [Part IV 

The tendency to stricture increases as one pro- 
ceeds downwards from the caecum to the anus. A 
stricture is frequent in the descending colon, less 
frequent in the transverse colon, while in the 
ascending colon it is comparatively rare. Stric- 
tures are not uncommon about the flexures of the 
bowels.* 

The ascending and the descending colon are 
placed vertically. The average length of the as- 
cending colon in the adult (as measured from the 
tip of the csecum to the hepatic flexure) is 8 inches. 
The average length of the descending colon (from 
the splenic bend to the commencement of the sig- 
moid flexure) is 8^ inches. The descending colon 
is very little liable to variation, and is always 
found in a semi-contracted condition. That part 
of the descending colon which lies in the left 
iliac fossa, from the iliac crest to the left psoas 
muscle, is now distinguished as the iliac colon. 
In cases of non-descent of the csecum the ascend- 
ing colon may be absent (p. 385). I have 
pointed out that in 52 per cent, of adult bodies 
there is neither an ascending nor a descending 
mesocolon, and that a mesocolon may be expected 
on the left side in 36 per cent, of all cases, and 
on the right side in 26 per cent. These points 
are of importance in connection with the some- 
what uncommon operation of lumbar colotomy. 
The breadth of the mesocolon, when it exists, 
varies from 1 to 3 inches. The line of attach- 
ment of the left mesocolon is usually along the 
outer border of the kidney, and is vertical. That 
of the right mesocolon is, as a rule, less vertical, 
runs along the outer border of the kidney, and 
crosses its lower end obliquely from right to left. 

The transverse colon has an average measure- 
ment of 20 inches. It is not quite horizontal, 
since the splenic flexure is on a higher level than 
the hepatic flexure, as well as posterior to it, and 
always shows a number of bends, one occurring 
near its commencement and another near its end. 

* See "Intestinal Obstruction." By the Author. London. 1899. 



Chap. XVII] ABDOMINAL VISCERA 38«J 

Faecal masses lodged in the transverse colon have 
given rise to many errors in diagnosis. In some 
instances this part of the colon is displaced to- 
wards the pelvis, so that V- or U-shaped bends 
are produced. In such cases the point of the V 
or U may reach the symphysis pubis, while the 
two colic flexures occupy their proper situations. 
These deviations are described in detail in my 
work on Intestinal Obstruction. 

The right-hand part of the transverse colon 
is in intimate relation with the gall-bladder, and 
is commonly found to be bile-stained after death. 
In some cases where gall stones have been lodged 
within the gall-bladder, the walls of that struc- 
ture have ulcerated from pressure, the ulceration 
has involved the subjacent transverse colon, and 
thus a fistula has been established between the 
gall-bladder and the gut, through which large 
stones have been passed. Hepatic abscesses also 
have discharged themselves through the trans- 
verse colon. The transverse colon often finds its 
way into an umbilical hernia, and has been found 
to be concerned in many of the cases of hernia into 
the foramen of Winslow. 

The sigmoid flexure. — The segments of gut 
termed the sigmoid flexure and " the first part of 
the rectum ;; form together a single simple loop 
that cannot be divided into parts. This loop be- 
gins where the descending colon ends, and ends at 
the commencement of the so-called " second part 
of the rectum ;; ; at a spot, in fact, where the meso- 
rectum ceases, opposite about the third piece of 
the sacrum. This loop, when unfolded, describes 
a figure that, if it must be compared to a letter, 
resembles the capital Omega. It may well be 
termed the Omega loop, and the term rectum be 
limited to the short piece of practically straight 
gut that is now described as the second and third 
parts of the rectum. By the majority of anato- 
mists and surgeons the Omega loop is now named 
the " pelvic colon," although at birth and fre- 
quently in the adult it is not pelvic in position. 



390 SURGICAL APPLIED ANATOMY [Part IV 

The average length of the loop in the adult is 
1*7^ inches. The two extremities of the loop are 
about 3 or 4 inches apart. If they are approxi- 
mated to one another, as by contracting peri- 
tonitis at the root of the sigmoid mesocolon, a 
kind of pedicle is established, about which the 
loop may readily become twisted. Such a twist 
of the bowel constitutes a volvulus of the sigmoid 
flexure; and it may be here said that volvulus 
of the intestine is more commonly met with in this 
loop than in any other part of the canal. 

The line of attachment of the mesocolon of the 
Omega loop (the sigmoid mesocolon) crosses the 
left psoas muscle and the iliac vessels near their 
bifurcation ; it then turns abruptly down, and 
running nearly vertical, terminates at the middle 
line. 

In the left wall of this mesocolon, close to the 
point where it lies over the iliac vessels, a fossa 
is sometimes to be found. It is produced by the 
sigmoid artery, and is about l| inch in depth. 
It is called the intersigmoid fossa, and is the 
seat of sigmoid hernia (Fig. 62, mc). Two cases 
of strangulated hernia in this fossa have been 
recorded. 

The sigmoid flexure, or Omega loop, when 
empty, normally occupies the pelvis. When dis- 
tended this piece of bowel may become so enor- 
mously dilated as to reach the liver. The chief 
examples of extraordinary dilatation of the colon 
concern this loop. Faecal masses are very fre- 
quently lodged in the free end of the loop, and 
certain intestinal concretions have been met with 
in the same situation. 

I have shown by experiment that the " long 
tube," when introduced through the anus, cannot 
be passed beyond the sigmoid flexure in ordinary 
cases, and with a normal disposition of the bowel. 

In cases of congenital absence or deficiency 
of the rectum, the sigmoid flexure is often opened 
in the groin and an artificial anus established 
there. This operation, known as Littre's opera- 



Chap. XVII] ABDOMINAL VISCERA 



391 



tion, is, it must be confessed, not very successful. 
One difficulty has been said to depend upon the 
uncertain position of the sigmoid flexure in cases 
of congenital deformity, it being sometimes on the 
right side and sometimes in the pelvis at» the 
middle line. It is rarely, however, found in these 




Pig. 62. — Sigmoid flexure turned upwards to show the intersigmoid 
fossa. (Jonnesco.) 

s f, Sigmoid flexure ; a s, sigmoid artery ; 31 c, mesosigmoid fossa, \~a e, external 
iliac artery ; r, ureter in front of internal iliac vessels. 

positions. _ Out of 100 post-mortem examinations 
on young infants, Curling found the loop on the 
left side in eighty-five cases. Out of ten children 
who were operated on for imperforate anus, the 
loop was found in the left fossa in only one case 
(Montgomery). 

The sigmoid flexure is the part of the colon, 
opened in the operation of left iliac or inguinal 



392 SUEGICAL APPLIED ANATOMY ' [Part IS 

colotomy. In performing this operation the 
length of the sigmoid mesocolon and the conse- 
quent mobility of the coil are of much importance. 
The sigmoid flexure, when empty and contracted, 
can be felt through the parietes in moderately 
thin subjects. 

Congenital malformation of the colon. — 
These are of moment with regard to _ operative 
procedures. It may be very briefly said that in 
the foetus the small bowel occupies at one time 
the right side of the abdomen, while the large gut 
is represented by a straight tube that passes on 
the left side vertically from the region of the 
umbilicus to the pelvis. The caecum is at first 
situated within the umbilicus, and then ascends in 
the abdomen towards the left hypochondrium. It 
next passes transversely to the right hypochon- 
drium, and then descends into the corresponding 
iliac fossa. It may be permanently arrested at 
any part of its course. Thus the caecum may be 
found about the umbilicus, or in a congenital 
umbilical hernia, or in the left hypochondriac 
region (the ascending and transverse parts of the 
colon being absent), or it may. be found in the 
right hypochondrium, the ascending colon only 
being unrepresented. 

The whole of the large intestine has at one 
time an extensive mesentery, and in some rare 
cases this condition may persist throughout life. 
When it does persist, it may lead to one form of 
volvulus of the bowel. 

Lumbar colotomy. — The operation so named 
consists^ in opening the colon in the loin behind 
the peritoneum, for the purpose of establishing 
an artificial anus. The operation is performed, 
when possible, # upon the left side, in preference 
to the right, inasmuch as the descending colon 
ii nearer to the anus. The operation has, how- 
ever, been almost entirely superseded by iliac 
colotomy except in a few uncommon conditions. 
The position of the descending colon in the loin 
may be represented by a line drawn vertically 



Chap. XVIIJ 



ABDOMINAL VISCERA 



3&«? 



upwards from a point on the iliac crest 1 inch 
external to the outer border of the erector spinse. 
An incision is made across the centre of this line 
parallel to the last rib, and so planned that the 




Fig. 63. — Horizontal section through the body at the level of the 
umbilicus. {After Braune.) 

a, Spine of the fourth lumbar vertebra ; b, disc between third and fourth verte- 
brae ; c, umbilicus ; d, quadratus lumborum ; e, psoas ; /, external oblique, with 
internal oblique and transversalis muscles beyond ; g, rectus ; 'h, descending 
colon ; i, transverse colon ; j, aorta ; Jc, inferior vena cava ; I, ureter. 

centre of the incision corresponds to the centre of 
the line. The superficial tissues having been in- 
cised, the following structures are divided in 
layers in the following order (Fig. 63) : (1) The 
latissimus dorsi and external oblique muscles to 
an equal extent ; (2) the internal oblique in the 



394 SURGICAL APPLIED ANATOMY [Part IV 

entire length of the incision ; (3) the fascia lum- 
borum, with a few of the most posterior fibres, 
of the transversalis muscle; (4) the transversalis 
fascia. The quadratus lumborum will be^ exposed 
in the posterior inch or so of the incision, and 
usually does not need to be cut. At the seat of the 
operation the descending colon occupies the angle 
between the psoas and quadratus lumborum mus- 
cles, and the non-peritoneal surface is exactly re- 
presented by that part of the bowel that faces 
this angle (Fig. 63). Thus, if during the opera- 
tion the curved finger be placed in this angle, and 
the patient be rolled over to the left side, the 
bowel that falls into the finger cannot well be 
other than the descending colon. The gut is 
drawn forwards, stitched to the wound, and 
opened by a transverse cut. The width of the 
non-peritoneal surface varies from fths of an inch 
to 1 inch in the empty state, and may attain to 
2 inches or more in the distended condition 
(Braune). 

Iliac or iiagisiiial colotomy. — In this very 
common, excellent, and simple operation the sig- 
moid flexure is exposed and opened in the left 
iliac region. A line is drawn* from the anterior 
superior iliac spine to the umbilicus, and an in- 
cision some 2 inches in length is made at right 
angles to this line and at a distance of about 
l| inch from the point of the bone. The three 
muscles of the abdomen and the peritoneum hav- 
ing been divided, the loop of the sigmoid flexure 
is Drought into the wound, is secured, and is (at 
once or at a later period) opened. 

The caecum may be opened on the right side, 
and as a rule the most convenient incision is an 
oblique one placed externally to the deep epigastric 
artery. 

Colectomy consists in excising a portion of 
the colon. The caecum has been removed, and con- 
siderable segments of the rest of the large in- 
testine. ^ The m treatment of cancer of the colon 
by excision is attended with considerable sue- 



Chap. XVII J ABDOMINAL VISCERA 395 

cess. Portions of the ascending and descending 
parts of the colon have been excised through an 
incision in the loin, but colectomy is much more 
readily carried out through an anterior wound. 
I have reported a case in a young girl, in which 
I excised the whole rectum and anus, the sig- 
moid flexure, and the whole of the descending 
colon. The divided transverse colon was brought 
out at the anus. The child made a perfect re- 
covery. The parts removed are in the Museum of 
the Royal College of Surgeons. The operation 
of intestinal anastomosis or short circuiting is 
very frequently practised on the colon. Thus, in 
an obstruction on the descending colon incapable 
of removal, the transverse colon may be united 
to the sigmoid flexure. 

The liver. — The liver is moulded to the arch 
of the diaphragm, and lies over a part of the 
stomach (Fig. 64). Properly speaking, it has only 
two surfaces — a visceral surface, which in the 
upright posture rests on the stomach, duodenum, 
gastro-hepatic omentum, neck of the pancreas, 
hepatic flexure of colon, right kidney, and right 
suprarenal bodv; and a parietal surface, in con- 
tact with the diaphragm and anterior belly wall 
in the subcostal angle. As seen from the front it 
is triangular in outline, with its apex near the 
apex of the heart (Fig. 64); its upper border is 
best indicated by a line commencing at the apex 
beat (Fig. 64) and passing across the mid line 
\ an inch below the sterno-ensiform point : it 
ascends as it reaches the nipple line to the level of 
the sterno-ensiform plane. The lower border com- 
mences at the apex beat, crosses the mid line about 
1 inch above the mid-epigastric point, reaches 
the costal margin at the outer border of the 
rectus, and the remainder of its lower border 
corresponds to the costal margin as far as the tip 
of the eleventh rib. The liver is in contact with 
the right kidney along the lower margin of that 
rib (Fig. 68). For surgical purposes the liver in 
the right hypochondrium may be regarded as 



396 



SUEGICAL APPLIED ANATOMY [Part IV 



made up of three zones — an upper or pulmonary, 
a middle or pleural, and a lower or diaphrag- 
matic (Fig. 64). In the lower zone, which is 1| to 
2 inches wide in the mid-axillary line, the liver 
may be incised or explored ; in the middle zone, 
which is of equal width, the pleural reflection is 
encountered. In the erect posture the lower edge 
on the right side is about \ or \ of an inch below 



STEB/lO-EflSIF. LlAE 

Apex Poi/it 

Pulmonary Lime 

Pleural Line 

/Iepatic Duct 

Cystic Duct 

Pancreas 

Duodenum 

Alio Epiqastric Line 

Pylorus 

Stomach 

COMMON6lLEDUCT 
DUODENUM 




* ^ Linea Alba 

<*• " 

> Umbilical Line 

i 

lLlNEA5ENILUNARI5 



Fig. 64. — Diagram showing the position of the liver, gall-bladder, bile- 
ducts, and pancreas. 
The lower limits'of the pleura and lung are indicated. 

the margins of the costal cartilages. In the re- 
cumbent position the liver ascends about an inch, 
and is entirely covered by the costse, except at the 
subcostal angle. It descends also in inspiration 
and rises in expiration. 

The fundus of the gall-bladder approaches the 
surface behind the ninth costal cartilage, close to 
the outer border of the right rectus muscle (Fig. 
64). Its position is extremely variable ; it fre- 
quently occupies a position considerably below 
and external to the one mentioned. 



Chap. XVII] ABDOMINAL VISCERA 397 

The liver is retained in shape by, and moulded 
upon, the diaphragm above and the abdominal 
organs below. When removed from the body the 
shape is lost which it possesses clinically. It pre- 
sents many variations in form. One of the com- 
monest is a linguiform process, usually known 
as UiedeVs lobe, which projects from the margin 
of the right lobe under the tenth costal cartilage 
(Fig. 59, p. 365). It is found more frequently in 
women than in men, and may be mistaken for a 
floating kidney or an abdominal tumour. 

In the condition know as ptosis of the liver the 
organ slides from the dome of the diaphragm, 
and may descend to the level of the umbilicus or 
reach the iliac fossa (Fig. 59). With the descent 
there is also a rotation on its transverse axis, so 
that its diaphragmatic surface comes almost com- 
pletely to the front. In such a case the factors 
which maintain the liver in position have to be 
considered. They are : (l) its fixation to the 
diaphragm by the inferior vena cava and the 
fibrous tissue on the non-peritoneal posterior sur- 
face of the right lobe in the neighbourhood of 
the inferior vena cava. (2) The peritoneal folds, 
which include the right and left lateral, coronary, 
and falciform ligament, also attach it to the dia- 
phragm. These folds are lax, in order to allow 
the free movements of the liver which occur during 
respiration and in filling and emptying of the 
stomach. (3) The muscular abdominal walls. 
These keep the other abdominal viscera constantly 
pressed against the lower surface of the liver. 
The muscles constitute the chief means for main- 
taining the liver in position. In many women 
over forty the right lobe of the liver projects 
quite 2 inches below the eleventh rib, and as in 
the child, the extremity of the left lobe frequently 
comes in contact with, or even overlaps, the upper 
part of the spleen. 

The liver is more often ruptured from con- 
tusion than is anv other abdominal viscus. This 
is explained by its large size, its comparatively 



398 SURGICAL APPLIED ANATOMY [Part IV 

fixed position, its great friability of structure, 
and the large quantity of blood contained in its 
vessels. A normal liver will take its own weight 
of blood if its veins be injected at ventricular 
pressure (Salaman). Death in such injuries 
usually ensues from haemorrhage, since the walls 
of the portal and hepatic veins, being incorpo- 
rated with the liver substance, are unable to re- 
tract or to collapse. The hepatic veins also open 
direct into the vena cava, and, being unprovided 
with valves, could allow of the escape of an im- 
mense quantity of blood, if any retrograde cur- 
rent were established. The hepatic vessels are 
thin-walled, and it is almost impossible to liga- 
ture them, except by buried sutures. It is possi- 
ble for the liver to be ruptured without the 
peritoneal coat being damaged. Such injuries 
may be readily recovered from. The liver pre 
sents, behind, a fairly extensive non-peritoneal 
surface, at which rupture or wound may occur 
without extravasation into the abdominal cavity. 
From the relation of the liver to the right lower 
ribs, it follows that this viscus may be damaged 
when the ribs are fractured, and in some cases 
the broken ends of the bones have been driven 
through the diaphragm into the liver substance. 
Stabs through the sixth or seventh right inter- 
costal space, over the liver region, would wound 
both the lung and the liver, would involve the 
diaphragm, and open up both the pleural and 
peritoneal cavities. 

The intimate relation of the liver to the 
transverse colon is illustrated by a case where 
a toothpick, 4 inches in length, was found in 
the substance of the liver. It had worked 
its way there, from the colon, along an abscess 
cavity that connected the two viscera. The 
relation of the liver to the heart may be illus- 
trated by a case still more remarkable. In this 
instance a loose piece of liver, weighing 1 
drachm, was found in the pulmonary artery. The 
patient had been crushed between two waggons, 



Chap. XVII ABDOMINAL VISCEEA 399 

the liver was ruptured, and the diaphragm torn. 
A piece of the liver had been squeezed along the 
vena cava into the right auricle, whence it had 
passed into the right ventricle, and so into the 
pulmonary artery. The heart itself was quite 
uninjured. Portions of the liver may protrude 
through abdominal wounds, and are usually easy 
to reduce. In one instance of such protrusion the 
surgeon did not find the reduction easy, so he 
placed a ligature round the projecting part of 
the viscus, and then cut this obstinate portion 
of the liver off. The patient recovered. Con- 
siderable portions of the liver have been removed 
with success. It is remarkable from what grave 
injuries of the liver recovery is possible. Thus, Dr. 
Gann (Lancet, June, 1894) reports the case of a 
man of 28, who had a harpoon driven through the 
whole thickness of the right lobe of the liver, so 
that it projected at the posterior border. The 
blade was 7 inches long, and had two barbs. It 
was removed by operation twenty-eight hours 
after the accident, and the patient made a good 
recovery. 

f/roni a reference to the relations of the liver, 
it will be readily understood that an hepatic ab- 
scess may open into the pleura, and in some cases, 
indeed, the pus from the liver has been discharged 
from the bronchi. Thus, it has been possible for a 
patient to cough up some portion of his liver, 
although, of course, in a very disintegrated and 
minute form. Hepatic abscess may burst in one 
or other of the following directions, placed in 
order of their frequency : (1) into the right lung; 
(2) into the bowel; (3) upon the surface of the 
body. Such abscesses have, in rare cases, opened 
into the stomach. The liver is very frequently 
the seat of the secondary abscess of pyaemia, and, 
according to Mr. Bryant's statistics, abscesses in 
this viscus are more common after injuries to the 
head than after injuries elsewhere. They are 
rare in pyaemia following affections of the urinary 
organs, and are equally rare in the pyaemia after 



400 SURGICAL APPLIED ANATOMY [Part IV 

burns. Secondary deposits of tumours and ab- 
scesses are frequently limited to the right or to 
the left of a line drawn from the fundus of the 
gall-bladder to the inferior vena cava. This re- 
markable limitation is to be explained by the fact 
that the liver to the right of this line is supplied 
only by the right terminal division of the portal 
vein, while the part to the left receives blood only 
from the left division (Cantlie). 

The gall-bladder may be absent, as is the 
case with some animals, or reduced to a cica- 
trix from disease. Its mucous membrane has a 
peculiar reticulated, honeycomb appearance. It is 
often occupied by gall stones. These concretions 
are composed mostly of cholesterin, a normal con- 
stituent of bile, and vary in size from a hemp 
seed to a hen's egg. The escape of gall stones 
is rendered more difficult by the presence of 
a spiral fold of mucous membrane in the neck and 
duct of the gall-bladder. The gall-bladder, at its 
neck, forms an acute angle with the cystic duct, 
the spinal fold being necessary to keep the passage 
open. In the erect position the long axis of the 
gall-bladder is directed upwards and backwards, 
and the cystic duct downwards and forwards 
(Fig. 64). The cystic duct lies in the gastro- 
hepatic omentum, where it joins the hepatic to 
form the common bile-duct. It is accompanied by 
the cystic artery. The cystic veins pass directly 
into the liver and end in the portal capillary sys- 
tem. In cases of cystitis the part of the liver 
receiving the cystic veins is seen to be contracted 
or atrophied. 

A gall stone may be arrested in, and require 
removal from, any part of the cystic or common 
bile-ducts. The common bile-duct is 3 inches long, 
and its lumen ith of an inch wide, but by the pas- 
sage of the gall stones it may become three times 
its normal diameter. The upper half of the com- 
mon bile-duct lies in the gastro-hepatic omentum, 
in front of the foramen of Winslow, with the 
portal vein behind it and to the right. The 



Chap. XVII] ABDOMINAL VISCERA 401 

hepatic artery lies close to it on the left, and its 
branch, the superior pancreatico-duodenal, crosses 
the common bile-duct as it passes to its second 
or deeper stage. ' A stone arrested in the lower 
half of the duct is difficult of access. The duct 
lies buried between the head of the pancreas be- 
hind and the duodenum in front and to the outer 
side. It may be necessary in such a case to open 
the duodenum and extract the stone through its 
posterior and inner wall, or the duodenum and 
head of the pancreas may be turned forwards from 
the inner border of the right kidney, thus expos- 
ing the lower half (post-duodenal, stage) of the 
common bile-duct in the groove between the duo- 
denum and pancreas. The terminal half-inch is 
embedded in the wall of the duodenum and ends 
in the ampulla of Vater. At its termination it is 
surrounded by a sphincter which regulates the 
flow of bile. The lumen of the lower half of the 
duct is less than that of the upper half. Two 
lymphatic glands lie in the gastro-hepatic omen- 
tum by the side of the bile-duct, and have been 
mistaken for gall stones when calcified. 

The gall-bladder receives its nerve supply from 
the eighth and ninth segments of the cord (Head) 
through the great splanchnic and cceliac plexus. 
The intense colic caused by gall stones, believed 
to be due to spasm of the non-striated muscular 
coat of the bile-ducts, is reflected along the ninth 
dorsal nerve to the anterior abdominal wall. 
Stimulation of the sympathetic nerves causes the 
muscle of the cystic duct to contract, but relaxes 
that of the gall-bladder (T. R. Elliot). 

The gall-bladder and the bile-duct have been 
ruptured alone without rupture of the liver. The 
injury is rapidly fatal, owing to the escape of bile 
into the peritoneal cavity. Large gall stones may 
be passed direct into the bowel through a fistulous 
tract that has been established between the gall- 
bladder and the intestine. Gall stones have sup- 
purated out through the anterior belly wall, and 
have been removed from abscesses in the parietes. 
2 a 



402 



SUEGICAL APPLIED ANATOMY [Part IV 



Thus Dr. Burney Yeo reports a case where more 
than one hundred gall stones were discharged 
through a spontaneous fistula in the hypogastric 
region, 5 inches below the umbilicus. In cases 
where the bile-duct is occluded by gall stones, or 
by other causes, the gall-bladder may become 
enormously distended, and may form a tumour 



l/iFE-atOR Vena Cava 
■Stermi-Bisiform Li/ie- 

FUNDUS OFSTOMACfl 

Liver 
Oesophageal Orifice 

5PLEE/1 

Pulmonary l\ne 
Riq/it Suprarenal 

fllD-EPICASTR.IC LlflE 
Pl_E URAL LI/SE 

Pelvis of Kidney 
R-iq/jT Kid/hey 
Erector Spimae 

Asce/idinc Colon 

quadratus lumboeum 
Umbilical Line 
Ureter 

Post. 5up Iliac 5pm& 




Fig. 65. — The position and relationships of the abdominal viscera from 

behind. 

The lower limits of the pleura and lung are shown in red. 

extending some way beyond the umbilicus. So 
large a tumour has been formed that the mass has 
been mistaken for an ovarian cyst. The gall- 
bladder as it enlarges tends to follow a line 
extending from the tip of the right tenth car- 
tilage across the median line of the abdomen below 
the umbilicus. For the relief of this condition, 
cholecystotomy, or incision into the gall-bladder, 
has been performed. In this operation the in- 



Chap. XVII] ABDOMINAL VISCERA 



403 



cision or puncture is made over the most promi- 
nent part of the tumour. Impacted gall stones 
have been removed entire from the bile-duct 
through an incision so made, or the stone has been 
crushed in situ and extracted in fragments. 

In cholecystectomy the whole of the gall-blad- 
der is excised and the cystic duct closed. The bile 
finds its way into the intestine direct through the 
common duct. 

o f, 
h ^-^ i ST 




Fig. 66. — Horizontal section through upper part of abdomen. {Rudinger.) 



a, Liver; h, stomach; c, transverse colon; d, spleen; e, kidneys; /, pancreas 
<j, inferior vena cava ; h, aorta with thoracic duct behind it. 

In cholecyst enter ostomy a fistula is established 
between the gall-bladder and the intestine. The 
operation is carried out in cases in which there 
is an insuperable obstruction in the common duct. 
The gall-badder thus takes the place of the com- 
mon duct. 

The spleen. — The spleen is deeply situated in 
the left hypochondriac region, and in the normal 
condition cannot be palpated, being quite covered 
in front by the cardiac end of the stomach (Fig. 
65). It most closely approaches the surface in 
the parts covered by the tenth and eleventh ribs. 



401 SURGICAL APPLIED ANATOMY [Part IV 

Above this it is entirely overlapped by the edge 
of the lung. It is in all parts separated from 
the parietes by the diaphragm. " It lies very 
obliquely, its long axis coinciding almost exactly 
with the line of the tenth rib. Its highest and 
lowest points are on a level, respectively, _ with the 
ninth dorsal and first lumbar spines; its inner 
end is distant about 1^ inch from the median 
plane of the body, and its outer end about reaches 
the mid-axillary line ;; (Quain) _ (Fig. 65). It 
possesses three surfaces, gastric, renal, and 
phrenic, well shown in Fig. 66. 

A dislocated or floating condition of the spleen 
is rare. Its renal surface is fixed firmly to the 
upper half of the left kidney ; its gastric surface 
is kept in apposition to the stomach by the gastro- 
splenic omentum ; its upper pole is attached near 
the cardiac orifice of the stomach by a suspen- 
sory fold of peritoneum, while its lower rests on 
the costo-colic peritoneal fold, and has the tail of 
the pancreas and colon in contact with it. The 
tension of the abdominal walls exerts a general 
pressure on it through the other abdominal 
organs. When the spleen enlarges, as in ague, its 
crenated anterior border may be felt beneath the 
tenth costal cartilage. The movable or floating 
spleen is met with only in adults. > The organ may 
be so displaced as to reach the iliac fossa. 

Injuries. — Although extremely friable in struc- 
ture, the normal spleen is not very frequently 
ruptured. Its connections, indeed, tend to mini- 
mise the effects of concussions and contusions. 
When the spleen, however, is enlarged, it is very 
readily ruptured, and often by quite insignifi- 
cant violence. Thus, several cases have been re- 
corded of rupture of an enlarged spleen by mus- 
cular violence. For instance, a woman ruptured 
her spleen in an attempt to save herself from fall- 
ing, and another in springing aside to avoid a 
blow. The patients in each instance were natives 
of India, and the latter case gave rise to a charge 
of homicide. The spleen being extremely vas- 



Chap. XVII] ABDOMINAL VISCERA 405 

cular, it follows that ruptures of the viscus are 
usually, but not necessarily, fatal from haemor- 
rhage. It is well to note, in connection with this 
matter, that the spleen contains most blood during 
digestion. A case is reported, however, of a boy 
who met with an accident just after dinner, and 
who managed to walk some distance, although his 
spleen, as the autopsy revealed, was separated into 
three portions. He lived some days. In severe 
fractures of the ninth, tenth, and eleventh ribs 
the spleen may be damaged and lacerated. 

The capsule of the spleen contains muscular 
tissue, and must possess some contractile power. 
This fact may serve to explain cases of recovery 
from limited wounds of the organ, such as small 
gunshot wounds. In such lesions the capsule may 
contract and greatly narrow the hole in the viscus, 
while the track of the bullet or knife may become 
filled with blood-clot, and the bleeding thus be 
stayed. 

The spleen may be greatly enlarged in certain 
diseased conditions. The hypertrophied spleen 
may attain such dimensions as to fill nearly the 
whole abdomen, and in one case a cystic tumour so 
completely occupied both iliac fossae that it was 
mistaken for an ovarian cyst, and the operation 
for ovariotomy was commenced. 

Extirpation of the spleen has been suc- 
cessful in cases of abdominal wounds with pro- 
trusion of the viscus. It has also been performed 
with fair results in many cases of hypertrophied 
spleen, and of wandering spleen. The operation 
is not justifiable in cases of leukaemic enlargement 
of the organ, it having proved invariably fatal 
in such, instances. In cases of wounds with pro- 
trusion, the spleen is, of course, removed through 
the wound. In other instances the incision is 
usually made in the middle line, the most con- 
venient being one so arranged that the umbilicus 
corresponds to the centre of the cut. Some sur- 
geons prefer an incision along the outer edge of 
the left rectus muscle. The viscus is then slowly 



406 SUEGICAL APPLIED ANATOMY [Part IV 

pressed out of the wound. The great difficulty 
is with the gastro-splenic omentum, which has 
to be divided and its vessels secured. In drawing 
out the spleen there is much risk of tearing the 
splenic vessels, especially the vein. Special care 
has to be taken to avoid damage to the pancreas. 
The splenic artery, with its large accompanying 
vein, lies in the lieno-renal ligament, in contact 
with the tail of the pancreas below. 

The pancreas lies behind the stomach, in 
front of the first and second lumbar vertebrae 
(Fig. 64). It crosses the middle line behind the 
mid-epigastric line (Fig. 64). In emaciated sub- 
jects, and when the stomach and colon are empty, 
it may sometimes be felt on deep pressure, espe- 
cially in those who are the subjects of visceroptosis ; 
prolapse of the stomach leaves the pancreas ex- 
posed above the lesser curvature. It is in relation 
with many most important structures. So closely 
is it mixed up with the solar plexus that this 
structure is necessarily involved in any operative 
procedures on its head and neck. It has, I be- 
lieve, never been ruptured alone, and it could 
scarcely be wounded without the wound implicat- 
ing other and more important viscera. It has 
been found herniated in some very rare cases of 
diaphragmatic hernia, but never alone. The main 
duct (duct of Wirsung) usually terminates with 
the common bile-duct in the ampulla of Vater 
(Fig. 67, a), so that a gall stone arrested at this 
point may occlude both ducts or possibly cause 
a reflux of the bile within the pancreatic duct. 
Not uncommonly (in 30 per cent, of cases) the 
ampulla is partly (Fig. 67, b) or completely 
divided (Fig. 67, c), so that the orifices of the two 
ducts are separated ; in such cases occlusion of 
the termination of the bile passage leaves the pan- 
creatic duct free. A secondary duct (the duct 
of Santorini) is present in a more or less de- 
veloped condition in 50 per cent, of subjects. It 
may form a connection with the main duct, as in 
Fig. 67, a, or be merely a minute ductule, as in 



Chap. XVII] ABDOMINAL VISCERA 



407 



Fig. 67, b. The accessory duct opens nearer the 
pylorus, being f of an inch above the ampulla 
of Vater. The ampulla _ usually extends into a 
papilla which projects within the duodenum, but 
this papillated condition is not always present. 
Septic conditions may spread from the duodenum 
to the pancreas or gall-bladder by means of their 
ducts. 

The common bile-duct in its second stage lies 
between the head of the pancreas and the duo- 




Fig. 67. — Diagrams to show the variations in the manner of termination 
of the pancreatic and bile ducts. 

A, Form in which the common bile-cluctl(c, b, n) and main pancreatic duct (b) 
end in an ampulla (e). a. Duct of Santorini; i., ii., iii, first, second, and third 
stages of the duodenum. 

B, Form in which the ampulla is partly divided. The duct of Santorini is shown 

in its reduced form. 

C, Form in which the common bile-duct and pancreatic duct have separate 

openings into the duodenum. The duct of Santorini is absent. 

denum. It thus happens that in carcinoma of 
this part of the gland the duct may become en- 
tirely occluded and jaundice result. Or the duo- 
denum and even the colon may be more or less 
obstructed by pressure, or the neighbouring 
vessels be closed. Cancer of the pylorus may 
spread to the head of the pancreas by direct 
extension. The lymphatics of the two parts also 
freely communicate. 

The pancreas lies behind the lesser sac of the 
peritoneum, its anterior surface being covered by 
the posterior wall of the sac. It lies in front of 
the aorta, in the fork between the coeliac axis 



408 SURGICAL APPLIED ANATOMY [Part IV 

above and the superior mesenteric artery below. 
The portal vein passes upwards behind the neck 
of the gland. 

Certain remarkable cysts are sometimes de- 
veloped in the pancreas. They may attain great 
size and nearly fill the abdomen. 

The kidney. — Its relations are as follows : — 

In front. 

Right. Left. 

Visceral surface of liver. Fundus of stomach. 

Second part of duodenum. Descending colon. 

Commencement of transverse colon. Pancreas. 

Ascending colon. Spleen. 



Externally. 
Liver. 



Kidney. 



Externally. 
Spleen. 



Behind. 



Lower part of arch of diaphragm. 

Quadratus lumborum. Psoas. Transversalis. 

Last rib and transverse proeesses of upper two lumbar vertebra. 

The kidneys are deeply placed, and cannot be 
felt or distinctly identified when normal. They 
are most accessible to pressure at the outer edge 
of the erector spinse, just below the last rib (Figs. 
65 and 68). The dulness of the right kidney 
merges above in that of the liver, while on the left 
side it is impossible to distinguish between the 
dulness of the kidney and spleen. The right kid- 
ney lies usually lower down than does the left ; but 
even the lower pole of the right kidney is an 
inch above the crest of the ilium — or what for 
practical purposes is the same level — above the 
umbilical line (Fig. 58, p. 363). The simplest 
manner of indicating the position of a kidney is 
to mark out the position of the upper and lower 
pole and between those two points mark on the 
well-known form of the kidney. The lower pole 
of the right organ lies about \ an inch outside 
the prominent lateral border of the erector spinse 
and 1 inch above the iliac crest (Fig. 65) ; since 
the kidney is about 4 inches long and is situated 
obliquely — its long axis corresponding to that of 
the twelfth rib — its upper pole is sufficiently in- 



Chai). XVII I 



ABDOMINAL VISCERA 



409 



clicated, by taking a point 4 inches above and 
lh inch internal to the position of the lower pole. 
The spine of the eleventh dorsal vertebra — which 
may be identified when the patient bends by its 







f AV\\^ a>'\. ■♦t-^\V 



fit 





Fig. 68. — Showing the relationships of the kidney and colon in the 
lumbar region from behind. (Adapted from Merkel.) * 

p.l., Lower line of pleura ; xi., eleventh rib ; xil, twelfth rib ; 12th d.n., twelfth 
dorsal nerve ; 1st l.n.,, ilioinguinal and ilio-hypogastric nerves; a.b., vertical 
line representing position of descending colon (desc. c.) ; q.l., quadratus lum- 
borum ; e.s., erector spinas ; peritoneum (perit.) is shown reflected from the 
front of the kidney to the colon on the right side. 

anti-clinal direction and semilumbar form — is 
just below the level of the upper pole. On an 
average the left kidney lies \ an inch higher than 
the right (Addison). In many instances in the 

* The kidneys are represented in the position they assume when the 
body is turned on its face ; in the supine position they fall inwards and 
backwards into the position described in the text. In the subject 
figured above, the 12th rib is shorter than is common. 



410 SURGICAL APPLIED ANATOMY [Part IV 

female its lower end reaches the iliac crest, and 
may even go below it. Such positions are much 
less common in the male. The hilum lies about 
2 inches from the middle line, and is opposite to 
the first lumbar spine and usually in the gap 
between the transverse processes of the first and 
second lumbar vertebrae (Fig. 65, p. 402). In 
radiograms of the injected ureter, the shadow of 
the pelvis of the kidney is seen to fall across those 
of the transverse processes just mentioned, and 
also that of the last rib (Fig. 70, p. 418). 

The anterior surface is but slightly covered by 
peritoneum, being only in contact with that mem- 
brane in such parts as are not in relation with 
the cellular tissue at the back of the colon and at 
the back of the duodenum or pancreas. _ The ex- 
ternal border is more closely in connection with 
the peritoneum, while the posterior surface is 
quite devoid of that membrane (Figs. 65 and 66). 
Crossing the posterior surface of the kidney 
obliquely from above downwards and outwards 
are branches of the last dorsal nerve and of the 
first lumbar artery, together with the ilio-hypo- 
gastric and ilio-inguinal nerves (Fig. 68). Rup- 
ture of the kidney is more often recovered from 
than is a like lesion of any other of the more 
commonly injured abdominal viscera. This de- 
pends upon its extensive non-peritoneal surface, 
whereby the extravasation of blood and urine that 
follows the accident is very often entirely extra- 
peritoneal. The gland may be readily wounded 
from behind or from the loin, without the peri- 
toneum being injured. When the spine is much 
bent forwards, the kidney lies in the angle of the 
bend, at a part where the flexion of the column 
is the most acute. In extreme flexion, therefore, 
of the spine, it may be squeezed betweenthe ilium 
and the lower ribs. Thus, hematuria is not un- 
common after injuries to the back associated with 
extreme bending of the spine forwards, as when 
a heavy weight falls upon the bowed shoulders. 

The kidney is embedded in a large quantity 



Chap. XVII] ABDOMINAL VISCERA 411 

of loose fatty tissue constituting the perirenal 
capsule, and suppuration extending in this tissue 
constitutes a perinephritic abscess. Such an ab- 
scess may be due to disease of the kidney 
itself, to affections of the adjacent parts (spine, 
colon, etc.), or to injuries. The pus is at first 
in front of the quadratus 1 umbo rum, and then 
usually makes its way through that muscle or 
through the lumbar fascia. It then presents itself 
at the outer edge of the erector spinse, having 
passed between the adjacent borders of the ex- 
ternal oblique and latissimus dorsi muscles. It 
may, however, spread into the iliac fossa, or ex- 
tend into the pelvis along the loose connective 
tissue behind the descending colon and rectum, 
or open into the colon or bladder, or even into the 
lung. Most rarely of all does it perforate the 
peritoneum. Renal abscess usually opens upon 
the non-peritoneal surface of the gland. It may 
open into the adjacent colon. In one case a renal 
abscess, due to stone, made its way from the right 
kidney into the pyloric end of the stomach, so 
that a communication was established between 
those two organs. The perirenal fat is of much 
surgical importance, as its laxity permits of a 
ready enucleation of the organ. It is more abund- 
ant behind than in front. When this tissue has 
been destroyed or modified by inflammation, the 
kidney becomes fixed, and its removal a matter of 
great difficulty. This is illustrated by the re- 
moval of a large tuberculous kidney which has 
been long diseased. Besides the perirenal cap- 
sule, the kidney also possesses its proper capsule, 
which can be easily stripped from the normal 
orgam Incision of the capsule has been proposed 
to relieve congested conditions of the kidney. 

Movable kidney.— The kidneys, being closely 
applied to the diaphragm, necessarily follow its 
respiratory movements; in normal breathing the 
up and down excursion of the kidney is about 
h an inch in extent. The perirenal capsule in 
which the kidney is loosely embedded is merely a 



412 SUEGICAL APPLIED ANATOMY [Part IV 

specialised part _ of the subperitoneal connective 
tissue; above it is continuous with the dense sub- 
peritoneal tissue on the diaphragm, externally 
with the equally dense layer over the transversalis, 
internally it fuses with the sheaths of the in- 
ferior vena cava and aorta, while below it is 
continued downwards, as the lax subperitoneal 
tissue surrounding the ureter, to become con- 
tinuous with the corresponding tissue in the 
pelvis. Hence only downward displacements are 
possible. The perirenal capsule and the renal 
vessels, while they restrict and determine the 
direction of the renal movements, only come into 
action when the normal limits have been exceeded. 
The force which retains the kidneys in position is 
the intra-abdominal tension maintained by the 
musculature of the abdominal wall, by which 
the other viscera are compressed against the kid- 
neys. With the absorption of fat from the cap- 
sule the tissue of the perirenal capsule becomes 
more lax and the renal movements more free. 
Hence movable kidney is often met with in the 
badly nourished. It is far more common in 
women than in men. In the former sex the influ- 
ence of pregnancy appears to have especial effect, 
acting, probably, by dragging upon the peri- 
toneum, and by loosening its connections, as well 
as by inducing, after delivery, a general laxity 
of the abdominal walls. The right kidney is far 
more often movable than is the left, owing prob- 
ably to the displacing influence of the liver. I 
have recorded (in conjunction with Dr. Mac- 
lagan) three cases in which a movable kidney 
pressed against the neck of the gall-bladder and 
obstructed the flow of bile. The movable kidney 
can, of course, only be displaced within a seg- 
ment of a circle whose radius corresponds to the 
length of the renal vessels, and yet this displace- 
ment may be considerable. # 

The dragging pains which are felt with a 
movable kidney are due to a stretching of the 
renal plexus, which is connected with the solar 



Chap. XVII] ABDOMINAL VISCERA 413 

plexus and enters the kidney with the arteries. 
The kidney receives its nerve supply from the 
tenth, eleventh, twelfth dorsal, and first lumbar 
segments of the spinal cord through the small and 
lesser splanchnics (Head). Pain is referred to 
the wall of the abdomen along the sensory nerves 
derived from these segments. 

Abnormalities of the kidneys. — One, or less 
frequently both, kidneys may be misplaced. The 
left is more often out of place than the right, 
and may be found over the sacro-iliac synchon- 
drosis, or the promontory of the sacrum, or be 
discovered in the iliac fossa or pelvis. The mis- 
placed kidney is often misshaped. The kidney 
may exhibit a more or less extreme degree of 
lobulation, a condition present in the newly born. 
The ureter may be double. Supernumerary 
arteries are frequently present; cases have been 
recorded where such vessels, passing to the lower 
pole of the kidney, have caused constriction or 
kinking of the ureter. 

The two kidneys may be fused. " The lowest 
degree of fusion is seen in the horse-shoe kidney. 
The two kidneys are united at their inferior por- 
tions by a flat, riband-like, or rounded bridge of 
tissue, which crosses the vertebral column. In the 
higher degrees the two lateral portions approach 
one another more and more until they reach the 
highest degree, in which a single disc-like kidney, 
lying in the median line, and provided with a 
double or single calyx, represents complete 
fusion" (Rokitansky). When _ the two kidneys 
are united by a web of connective tissue, the con- 
dition is no bar to operation. There may be an 
entire absence of one kidney. The single kidney 
may he lateral or median in position. Henry 
Morris gives the following estimate of the fre- 
quency of these abnormal conditions : Congenital 
absence or extreme atrophy of one kidney may be 
expected in about one in 4,000 cases, the horse- 
shoe kidney in one in 1,600, and the single fused 
kidney in one in 8,000 cases. 



414 



SUKGICAL APPLIED ANATOMY [Part IV 



nc. Sinus 




LAR Vein 

1/IMOMlNATE art. 

Trachea 
« Oesophagus 

Vena Azyqos Major 
Right Luhc 
Thoracic Duct 
Diaphraqm 

Richt Kidney 
Ureter 
Spermatic Vessels 

nf. Vena Cava 
Bifurcation of Aorta 
Cluteus AIedius 
Psoas 
Rectum 

Sup. AIaemorrh.Art. 
Gluteus Maximus 



Fig. 69.— View of the kidneys, etc., from behind. (After RMinger.) 



Chap. XVII] ABDOMINAL VISCERA 415 

■ 5 j Operations on the kidney. — (1) Nephrotomy. 
Incision into the kidney for exploration, or the 
evacuation of pus. (2) Nephro-lithotomy. In- 
cision into the gland for the removal of a calculus. 

(3) Nephrectomy. Removal of the entire organ. 

(4) Nephroraphy. The operation of securing a 
movable kidney in its normal position. In the 
first, second, and fourth operations the kidney 
is reached through the loin by an oblique incision, 
such as is used in colotomy (p. 392), the cut, 
however, being carried a little farther backwards. 
In nephrectomy a like incision may be used. The 
cut is carried backwards about 1 inch over the 
erector spinse, and a part of the quadratus lum- 
borum will probably have to be divided. The 
costo-vertehral ligament, a specialised part of 
the middle layer of the lumbar fascia which 
binds the last rib to the tips of the upper 
two lumbar transverse processes, also falls in 
the line of the incision. The perirenal tissue 
is opened up, and the gland enucleated from 
the capsule of fat in which it lies. In 
some instances the last rib has been resected to 
obtain more space for the operation. The pleura 
reaches the neck of the twelfth rib and occasion- 
ally it descends as far as the transverse process 
of the first lumbar vertebra (Figs. 65 and 68). In 
one case the twelfth rib was rudimentary, and the 
eleventh rib was removed under the impression 
that it was the twelfth. The pleura was opened 
and death ensued. 

When the kidney is free from its fatty capsule, 
the vessels at the hilum are secured separately by 
ligatures. The numerous nerves to the kidney 
are no doubt included with the vessels. They con- 
stitute a surgical pedicle of the kidney. At the 
hilum the vein lies in front, the artery and its 
branches next, and the ureter behind and towards 
the lower > part. The artery is about the size of 
the brachial, and usually divides into four, five, 
or _ six branches before it reaches the kidney. 
This fact must be borne in mind if the structures 



416 SUEGICAL APPLIED ANATOMY [Part IV 

at the hilum are separately secured. One-third 
of these branches constantly enter the hilum be- 
hind the ureter and are liable to injury in ex- 
ploration of the pelvis of the kidney. The vein 
is also represented at the hilum by three or four 
branches. Accessory renal arteries may be present. 
Some may enter the upper end of the kidney or its 
anterior surface. In removing large renal tumours 
an abdominal incision is advised, the cut being 
made either along the corresponding semilunar 
line, and on a level with the diseased mass, or in 
the linea alba. The abdominal operation is the 
more usual one, and has the advantages of greater 
ease and rapidity in performance and gives an 
opportunity of examining the condition of both 
kidneys. In chronically inflamed conditions of 
the kidney — as, for example, in long standing 
tuberculous disease — the kidney becomes adherent, 
and on the right side is apt to become closely 
bound down to^ the vena cava. _ Much care is 
needed in clearing the great vein when so ad- 
herent. In removing a very adherent kidney the 
diaphragm has been torn. 

The ureters are strong tubes about 15 inches 
long, with thick muscular walls, and are placed 
entirely behind the peritoneum. The average 
width is that of a goose-quill. The ureter rests 
from above, downwards upon (1) the psoas muscle 
and the genito-crural nerve ; (2) the common iliac 
vessels on the left side, and the external iliac 
vessels on the right; (3) after passing downwards 
on the internal iliac artery it then enters the 
posterior false ligament of the bladder, and so 
reaches the bladder wall. In the female it passes 
through the base of the broad ligament, where the 
uterine artery loops over it f of an inch from the 
neck of the uterus. It rests on the roof of the 
upper part of the vagina before entering the 
bladder, and a calculus arrested in that stage may 
be distinctly felt. The narrowest part of the 
tube is the portion within the bladder walls, and 
when renal calculi pass along the ureter they are 



Chap. XVII] ABDOMINAL VISCERA 417 

often arrested at this point. There are two other 
narrow points at which calculi may be stopped : 
at its junction with the pelvis of the kidney, and 
where it crosses the pelvic brim. The ureters per- 
mit of great distension, and in certain cases of 
gradual dilatation they have attained a width 
equal to that of the thumb and even of the small 
intestine. Several cases are recorded of rupture 
of the ureter from external violence. When such 
an accident occurs a large urinary collection 
usually forms behind the peritoneum, which, lead- 
ing to suppuration, will produce a fluctuating 
tumour beneath the parietes. 

The ureter expands in the hilum of the kidney 
into a funnel-shaped cavity — the pelvis. This in 
turn divides into the calyces. In the pelvis or 
calyces, calculi are frequently lodged. The calyces 
are too narrow to admit an exploring finger. 
The ureter has been successfully resected and 
sutured. It is supplied by nerves from the renal 
plexus and by vessels from the renal, inferior 
vesical and subperitoneal plexus. 

In the search for impacted calculi by the aid 
of X-rays the following method will be found 
useful for indicating the course of the ureter. 
The pelvis of the kidney lies between the trans- 
verse processes of the two upper lumbar vertebrae 
(Fig. TO) ; its position on the surface of the body 
may be indicated by taking a point just internal 
to that used for the gall-bladder (p. 396). At 
the brim of the pelvis the ureter crosses at or 
near the bifurcation of the common iliac artery, 
a point which lies at the junction of the upper 
with the lower two-thirds of a line drawn from 
the aortic bifurcation to the femoral point (see 
Figs. TO and 57, pp. 418 and 340). Its pelvic 
course is curved (Fig. TO), the convexity of its out- 
ward bend lying \ an inch in front of the ischial 
spine. The vesical orifice is to be sought for in 
a skiagram at some distance above and internal 
to the pubic spines. Mr. Rigbj r has shown that 
the ureter may be exposed from behind through 
2 B 



418 



SUKGICAL APPLIED ANATOMY [Part IV 



the sacro-sciatic notch and calculi thus removed 
from it when the anterior operation is imprac- 
ticable on account of pelvic adhesions. He uses 
the ischial spine as a guide in finding the ureter. 
The nerve supply of the abdominal viscera. 
— Some account has already been given of these 



rIBAE 1/tRTEBOA 
IS OF KlDfEV 



ETEB 
MBIUCUS 

Aootic Bifurcation 




FtJrtDl!\5 ofUTERUS 

Ubetes 



Fig. 70.— Diagram to show the course of the ureters and position of the 

bladder, 

As they appear in a skiagram when they have been injected with a bismuth 
solution. The positions of the fundus of the uterus, Fallopian tubes and 
ovaries are also indicated. 



nerves and the spinal segments from which they 
are derived (p. 337). The abdominal viscera 
are mainly supplied by the sympathetic system 
through a series of remarkable plexuses. The 
most important of these is the solar, from which 
is more or less directly derived the nerve supply 
of the stomach, liver, spleen, kidneys, suprarenal 



Chap. XVII] ABDOMINAL YISCEEA 419 

capsules, pancreas, and such parts of the intestine 
as are in connection with the superior mesenteric 
artery. The solar plexus and its appendages re- 
ceive the splanchnic nerves and some branches 
from the vagus, while communications from the 
phrenic go to the hepatic and suprarenal plexuses. 
Through these nerves the calibre of the blood- 
vessels and the amount of blood in the abdomen 
are regulated. They contain not only sensory 
fibres for the abdominal viscera but constrictor 
and dilator fibres for the bowel. It may be well 
understood that an impression brought to bear 
upon extensive net-works with such wide central 
connections and with such important relations 
would produce considerable effects. These effects 
we see in the profound collapse, vomiting, and 
other grave symptoms that attend severe injuries 
to the viscera, and especially to those that are the 
most directly associated with these large plexuses. 
The descending colon and sigmoid flexure are sup- 
plied by the inferior mesenteric plexus, a cord 
that has but an indirect connection with the solar 
plexus : and this fact may serve to account for the 
less serious symptoms often seen in strangulation 
of the colon when compared with a like lesion 
of the small gut. The upper part of the colon, 
although supplied by the superior mesenteric 
plexus, is only supplied by that part of it that 
is most remote from the great centres, and it is 
a conspicuous fact that the nearer the lesion is to 
the stomach, the graver, other things being equal, 
are the nervous phenomena produced. It would 
appear that some lesion of these nerve plexuses 
is sometimes active in producing a remarkable 
pigmentation of the skin. This is seen in Addi- 
son's disease, a disease marked by a general bronz- 
ing of the surface, and usually associated with 
some disintegration of the suprarenal capsules. 
The very direct relation of these bodies to the 
solar plexus is well known. In pregnancy also, 
in abdominal tuberculosis, in cancer of the 
stomach, and in liver diseases, a pigmentation of 



420 SUEGICAL APPLIED ANATOMY [Part IV 

the face is sometimes seen, that may in such 
instances be probably ascribed to a disturbance 
of the great abdominal nerve centres. 

In some diseases of the liver and stomach 
" sympathetic ' ; pains are complained of between 
the shoulders or about the inferior angles of the 
scapulae. They commonly appear some distance 
below the angle of the scapula. The nerves for 
the stomach are derived principally from the 
seventh and eighth and those for the liver from 
the eighth and ninth spinal segments. The skin 
areas of these segments may become tender when 
the organs are diseased and to some point in 
these areas pain is referred (Fig. 56, p. 333). The 
shoulder-tip pain that often accompanies liver 
disease is situated in the area supplied by the 
fourth cervical segment, the same segment as sup- 
plies sensory fibres to the diaphragm and sub- 
diaphragmatic connective tissue through the 
phrenic nerves. It will be remembered that these 
nerves are distributed on the under surface of the 
diaphragm. 

There would seem to be but little connection 
between a disease in the sigmoid flexure and a 
pain in the knee, yet in cases of cancer in the 
flexure, and in instances where it has been dis- 
tended with fseces, such pain has been complained 
of. The pain is conveyed along the obturator 
nerve, which lies beneath the sigmoid flexure, 
and could be readily pressed upon by the gut 
when diseased. Pain arising from the small in- 
testine is usually referred to the neighbourhood 
of the umbilicus — the distribution of the tenth 
dorsal nerve (Fig. 56, p. 333). It seems remark- 
able that such pains should be restricted to so 
narrow an area, but a full explanation of this 
is to be found in the fact that the whole of the 
small intestine arises from an extremely small 
part of the embryonic alimentary tract. Pains 
along the groin (along the twelfth dorsal and first 
lumbar nerves) arise from many sources — from 
disease of the kidney, ureter, ovary, testicles, 



Chap. XVII] ABDOMINAL VISCERA 421 

Fallopian tubes, uterus, appendix, hip-joint, and 
from hernia?. 

The blood-vessels of the abdomen. — Some 
of the visceral branches of the abdominal aorta 
are of large size, and would bleed very copiously 
if wounded. Thus, the coeliac axis and the 
superior mesenteric artery are as large as the 
common carotid ; the splenic, hepatic, and renal 
vessels are about the size of the brachial; while 
the largest part of the inferior mesenteric trunk 
has dimensions equal to those of the ulnar artery. 
Aneurisms of the aorta are especially apt to occur 
at the coeliac axis, that being a point where a 
number of large branches are abruptly given off, 
and where the course of the circulation undergoes 
in consequence a sudden deviation. Although 
two, or in some places three, anastomotic arches 
occur between the branches of the superior mesen- 
teric artery before they form a final net-work in 
the bowel, yet embolism of a comparatively small 
branch may lead to gangrene of the gut (Lock- 
wood). 

When it is remembered that the lumbar glands 
lie about the vena cava and iliac veins, it will 
be understood that great enlargement of those 
bodies may cause cedenia from pressure. Gan- 
grene of the whole of the small intestine may 
result from an embolism of the portal vein. In 
a case reported by Mr. Barnard the embolism was 
caused by a constriction at the point where the 
vein passes behind the neck of the pancreas. The 
inferior vena cava has been ligatured success- 
fully ; amongst the collateral veins which enlarge, 
the chief are the azygos, epigastric, and intra- 
vertebral veins. 

A number of minute but most important anas- 
tomoses exist between some of the visceral branches 
of the abdominal aorta and certain of the vessels 
supplied to the abdominal parietes. These anasto- 
moses are situated behind the peritoneum, and 
mostly concern such viscera as have a fair surface 
uncovered by that membrane. The visceral 



422 SUEGICAL APPLIED ANATOMY [Part IV 

branches that join the anastomoses are derived 
from the hepatic, renal, and suprarenal arteries, 
and from the vessels supplying the lower part of 
the duodenum, the pancreas, the csecum, and the 
ascending and descending segments of the colon. 
The parietal vessels joining with the above are 
derived from the phrenic, lumbar, ilio-lumbar, 
lower intercostal, epigastric, and circumflex iliac 
trunks. In a case detailed by Professor Chiene 
{Joum. Anat. and Phys., vol. iii.) the cceliac 
axis and mesenteric vessels were plugged, but 
blood in sufficient amount to supply the viscera 
had reached branches of these arteries through 
their parietal communications. When the portal 
circulation becomes obstructed owing to disease of 
the liver, blood from the portal vein may pass 
into the systemic veins at the following points : 

(1) lower part of the rectum, from the superior 
to the inferior and middle hemorrhoidal veins; 

(2) at the oesophagus, from the coronary to the 
oesophageal veins; (3) in the falciform and round 
ligaments, from the portal vein to tributaries of 
the epigastric ; (4) in the subperitoneal tissue of 
the posterior wall of the abdomen, whereby the 
renal, phrenic, lumbar, and intercostal veins re- 
ceive blood from mesenteric, pancreatic, and other 
veins. By bringing about adhesions between the 
omentum or visceral peritoneum and the parietal 
peritoneum, as is done in the Talma-Morrison 
operation, new and large communications are 
formed between the portal and systemic venous 
circulations. Cases have been recorded of com- 
munications between the external iliac vein and 
the portal vein. These have generally been 
effected by the deep epigastric vein joining with 
a pervious umbilical vein in the vicinity of the 
navel. 

Thoracic duct. — The thoracic duct may be 
wounded in the course of removing tubercular 
glands from beneath the lower part of the left 
sterno-mastoid ; or, as in some reported cases, may 
be severed by a stab in the neck. In each case 



Chap. XVII] ABDOMINAL VISCERA 423 

lymph and chyle in large quantities escaped 
from the wound. The duct has been found to 
have been obliterated, and that, too, without pro- 
ducing any marked symptoms during life. It has 
been cut and ligatured during removal of glands 
from the supraclavicular triangle, with no bad 
result. Mr. Leaf has shown that the thoracic 
duct communicates freely with the azygos veins 
in the posterior mediastinum and with the lym- 
phatic vessels of the right side of the thorax and 
neck. It frequently serves as a channel for the 
spread of malignant tumours situated in the 
upper part of the abdomen. Enlargement of the 
inferior deep cervical glands in the left side of the 
neck niav be the first sign of cancer of the stomach 
(W. M. 'Stevens). 



CHAPTER XVIII 
THE PELVIS AND PERINEUM 

The mechanism of the pelvis. — Besides form- 
ing a cavity for certain viscera, a support for 
some abdominal organs, and a point for the at- 
tachment of the lower limb and of many muscles, 
the pelvis serves to transmit the weight of the 
body both in the standing and sitting postures. 
The transmission is effected through two arches, 
one available for the erect position, the other for 
the posture when sitting. When standing, the 
arch is represented by the sacrum, the sacro-iliac 
synchondroses, the acetabula, and the masses of 
bone extending between the two last-named points. 
If all other parts of the pelvis were to be cut 
away but these 2 the portions left would still be 
able to support the weight of the body, and would 
represent in its simplicity the arch through which 
that weight is transmitted. When sitting, tb? arch 
is represented by the sacrum, the sacro-iliac syn- 
chondroses, the tubera ischii, and the strong 
masses of bone that extend between the two last- 
named parts. Morris terms these two arches the 
femoro-sacral and the ischio-sacral. On examin- 
ing the innominate bone it will be seen that its 
thickest and strongest parts are such as are situ- 
ate in the line of these. ' When very considerable 
strength is requisite in an arch, it is continued 
into a ring so as to form a counter-arch, or what 
is called a tie is made to connect together the 
ends of the arch, and thus to prevent them from 

424 



Chap. XVIII] PELVIS AND PERINEUM 425 

starting outwards. By these means a portion of 
the superincumbent weight is conveyed to. the 
centre of the counter-arch, and borne in what is 
called the sine of the arch. The body and hori- 
zontal rami of the pubes form the tie or counter- 
arch of the femoro-sacral, and the united rami of 
the pubes and ischium the tie of the ischio-sacral 
arch. Thus the ties of both arches are united in 
front at the symphysis pubis, which, like the 
sacrum or keystone, is common to both arches. 
. . . . This explains how it is that so much 
strain is made upon the symphysis when any 
increased weight has to be supported by the pelvis, 
as in pregnancy ; why there is such powerlessness, 
with inability to stand or sit, in cases in which 
this joint is weakened or diseased; and why the 
anterior portion of the pelvis yields under the 
weight of the body and becomes deformed in 
rickets and mollities ossium." * The pelvic de- 
formity in rickets, it may be here observed, varies 
greatly according to the age at which the disease 
sets in, and the usual attitude of the child when 
it becomes affected. The deformity sometimes pro- 
duced in very young infants has been ascribed 
to muscular contraction (ilio-psoas, erector spinse, 
gluteus medius, etc.). In the rickety pelvis, par 
excellence, the two acetabula approach one 
another, the anterior part of the pelvis yields, so 
that the symphysis is pushed forward, and the 
cavity becomes greatly narrowed in its transverse 
diameter. In severe cases the anterior arch may 
practically collapse, and the horizontal rami of 
the pubes be for some little way parallel to one 
another. 

In the erect attitude the pelvis is so inclined 
that the plane of the brim of the true pelvis forms 
with the horizon an angle of from 60° to 65°; the 
base of the sacrum is about 3| inches above the 
upper border of the symphysis, while the tip of 
the coccyx is a little higher than its lower border. 

* Henry Morris on "The Joints," p. 116, where a most valuable 
account of the mechanism of the pelvis will be found. 



426 SURGICAL APPLIED ANATOMY [Part IV 

The centre of gravity of the whole body (adult) 
is at a spot just above the sacro-lumbar angle, 
and exactly over the mid-point of a line drawn 
between the heads of the femora. 

Fractures of the pelvis. — From what has 
been already said, it may be surmised that the 
weakest parts of the pelvis are at the symphysis 
and the sacro-iliac joints. The bones of these 
parts, however, are so very firmly knit together 
by powerful ligaments that it is very rare for 
these articulations to give way, fracture of the 
adjacent bones being more common. The com- 
monest fracture of the pelvis is in the weak 
counter arch, and involves the rami of both the 
pubes and the ischium. . The fracture is often 
associated with some tearing of ligaments about 
the sacro-iliac synchondrosis, and is met with in 
accidents due to the most varied forms of vio- 
lence. This last remarkable circumstance is thus 
explained by Tillaux. If the pelvis be compressed 
in (a) an antero-posterior direction, the main 
brunt of the force comes upon the weak counter 
arch, which fractures from direct violence. The 
force, continuing, tends to push asunder the two 
iliac bones, and so cause rupture of the anterior 
ligaments at the sacro-iliac joint. If the force be 
applied (b) transversely, the two acetabula tend 
to be pressed towards one another, the counter 
arch becomes more bent, and ultimately gives way 
by indirect violence. The violence, continuing, 
forces the two ilia towards one another, the strain 
then falls upon the sacro-iliac synchondrosis, and 
the posterior ligaments of that joint are apt to 
yield, or portions of the bone adjacent to the joint 
are torn away. In cases of falls, when the patient 
alights upon the feet or ischial tuberosities, it 
can be understood how in many instances the main 
arches will escape injury owing to their great 
strength, while the counter arch becomes frac- 
tured. Any part of the pelvis, including the 
sacrum, may be broken by well-localised direct 
violence. More or less of the iliac crest, the an- 



Chap. XVIII] PELVIS AND PERINEUM 427 

terior superior and posterior superior spines, 
have been knocked off. The first-named part may 
be separated as an epiphysis. It joins the bone 
at about the twenty-fourth year. In one case the 
anterior inferior spinous process was torn off by 
the rectus muscle during the act of running a 
race. The os innominatum has been broken into 
its three anatomical portions. This accident can- 
not take place after about the seventeenth year, 
since by that time the Y-shaped cartilage is 
usually fully ossified, and the three elementary 
bones are fully united. Before such consolidation 
occurs, abscess in the hip-joint not unfrequently 
makes its way through the cartilage into the 
pelvis. The acetabulum has been fractured, and 
the head of the femur driven through its thinnest 
part into the pelvis. In fractures of the pubes 
and ischium the bladder has been torn by the 
sharp fragments. In one case a loose piece of 
bone that had been driven into the bladder became 
the nucleus for a stone. The urethra and vagina 
also have been lacerated or seriously compressed 
by the displaced bones. In fractures of the 
sacrum the rectum has been torn, or has been so 
compressed by the lower fragment (which is al- 
most always carried forwards) as to be nearly 
closed. 

Special parts of the pelvis. Symphysis.— 
Separation of the bones at the symphysis without 
fracture has occurred from severe violence. Mal- 
gaigne reports three cases where the separation was 
brought about by muscular violence only, by ex- 
treme action of the adductor muscles of the two 
sides. The Sigaultean operation consisted in 
dividing the symphysis pubis in cases of con- 
tracted pelvis, with the idea of obtaining more 
room during labour, and of so avoiding Csesarian 
section. The union consists of fibro-cartilage and 
transverse peripheral fibrous bands. It varies in 
depth from lh to If inch, and may be divided 
subcutaneously, when the bones gape quite i an 
inch. It has been shown, however, that to gain 



428 SUKGICAL APPLIED ANATOMY [Part IV 

4 an inch in the anteroposterior diameter the 
bones must be separated to the extent of 2 inches. 
Such a separation involves laceration of the sacro- 
iliac ligaments, and more or less damage to the 
attachments of the pelvic viscera. 

The sacro-iliac synchondrosis may be the 
seat of disease. Normally, there is a synovial 
space and a slight degree of movement in this 
joint. As this joint lies in the line of the great 
arches of the pelvis, it follows that when inflamed, 
much pain is felt in the part, both when the 
patient is standing and when sitting. When 
abscess forms it tends to come forwards, owing to 
the anterior ligaments being slight while the pos- 
terior ligament is dense, thick, and of great 
strength. Having reached the pelvic aspect of the 
joint, the pus may occupy the iliac fossa, or gain 
the ilio-psoas sheath. Or it may follow the lumbo- 
sacral cord and great sciatic nerve and point in 
the thigh behind the great trochanter, or it may 
be guided by the obturator vessels to the inner side 
of the thyroid foramen, and ultimately appear at 
the inner side of the thigh. The abscess may, 
however, proceed backwards, and point over the 
posterior aspect of the joint. 

The nerve relations of this joint are important. 
It is supplied by the superior gluteal, by the 
lumbo-sacral cord and the first sacral nerve, and 
bv the first and second posterior sacral nerves 
(Morris). The lumbo-sacral cord and the obtura- 
tor nerve pass over the front of the joint, the 
former being very closely connected with the 
articulation. It will be understood from these 
relations that in sacro-iliac disease pain is 
felt over the sacral region (upper sacral nerves) 
and in the buttock (gluteal nerve). Much pain 
is also often complained of in the hip or knee- 
joint, and along the inner part of the thigh (ob- 
turator nerve). In one or two reported cases 
there has been severe pain in the calf and back of 
the thigh, with painful twitchings in the muscles 
of those parts (lumbo-sacral cord and connection 



Chap. XVIIIJ PELVIS AND PERINEUM 429 

with great sciatic nerve). Dislocation of the 
sacrum at this joint is prevented by the remark- 
able double wedge-shaped outline of the bone, and 
by the very dense ligaments that bind it in its 
place. The bone is set very obliquely, so that 
the weight of the body tends to force its base into 
the pelvis and tilt its apex upwards. The strong 
posterior sacro-iliac ligaments prevent the first 
movement, the great sacro-sciatic the second. 

Trendelenburg's operation. — In order to bring 
the two pubic bones and the deficient soft parts 
together in ectopia vesicas, Trendelenburg divides 
the sacro-iliae synchondroses on either side. The 
operation, which has been very succcessful, is 
limited to children between the ages of two and 
five. The distance between the anterior superior 
iliac spines has — in a child aged two and a half 
years — been lessened 2 inches by this operation. 

Sacro-coccygeal tumours. — The sacro-coccygeal 
region is very often the seat of congenital tumours, 
some of them of such a shape as to form " human 
tails " ; and to this part of the pelvis has also 
been found attached a third lower limb leading 
to the condition known as " tripodism." 

Parasitic foetuses are also frequently found 
attached to this segment of the spine. In many of 
the instances of attached foetuses the two in- 
dividuals have been joined together at this part 
of the column. Some of the sacro-coccygeal 
tumours contain epithelial cysts and fragments of 
skin, muscle, nerve, bone, cartilage, and mucous 
membrane. These strange masses spring from the 
anterior part of the coccyx, between it and the 
rectum. By some they are supposed to arise from 
coccygeal body, by others (Sutton) from the struc- 
tures known to embryologists as the postanal gut 
and the neurenteric passage. 

The sacro-coccygeal joint may be dislocated 
or diseased. In either affection great pain is kept 
up from the frequent movement of the part by the 
muscles attached to the coccyx (the gluteus niaxi- 
mus, coccygeus, levator ani, and sphincter). In 



430 SURGICAL APPLIED ANATOMY [Part IV 

the luxation the bone may project into the rectum, 
and thus give trouble. The joint and the parts 
about it may be the seat of such severe neuralgia 
(" coccygodynia ") as to require excision of the 
coccyx, or a free division of the structures that 
cover it behind. The joint and the fibrous tissue 
about it are supplied by the following nerves : the 
posterior divisions of the second, third, and 
fourth sacral, and the anterior and posterior 
divisions of the fifth sacral and coccygeal. In old 
age the coccyx becomes ossified to the sacrum. 

The floor of the pelvis and the _ pelvic 
fascia. — The outlet of the bony pelvis is occu- 
pied in the recent state by the following struc- 
tures from behind forwards : the pyriformis, the 
sacro-sciatic ligaments, the coccygeus, the levator 
ani, and the triangular ligament of the perineum. 
These form the floor of the pelvis. The three 
structures last named serve to separate the pelvic 
cavity from the perineum and provide a ham- 
mock-like support for the viscera of the pelvis. 

The walls and floor of the pelvis are lined by 
a fascia, the pelvic fascia, of which a brief general 
description may be given. This fascia is divided 
into two distinct parts, a parietal layer and a 
visceral layer, (l) The parietal layer begins at 
the brim of the true pelvis, to which it is at- 
tached. From this attachment it passes down 
along the pelvic wall, forming a lining for that 
part, covering in the obturator internus muscle, 
and becoming adherent below to the rami of the 
pubes and ischium, and to the tuber ischii. More 
posteriorly it gives a thin covering to the pyri- 
formis muscle. (2) The visceral layer comes off 
from the parietal along a ligamentous strand run- 
ning from the lower part of the symphysis pubis 
to the ischial spine and known as the white line. 
The bladder, prostate, and vagina are supported 
from the white line by the visceral layer of the fascia. 

Starting from this line the visceral layer passes 
down into the pelvis on the abdominal surface of 
the levator ani, and attaches itself to all the pelvic 



Chap. XVIII] PELVIS AND PERINEUM 431 

viscera with which it comes in contact, forming 
fibrous expansions or " ligaments/' that serve to 
hold the viscera in place. Were there no pelvic 
viscera, this layer of the fascia would be con- 
tinued evenly across the pelvic floor from one side 
to the other, just as the subperitoneal fascia is 
continued over the under surface of the dia- 
phragm. Having given " reflections ,; to the 
pelvic organs the visceral layer passes on, and, 
covering the opposite levator muscle, ends at the 
opposite white line. This visceral layer is usually 
known as the recto-vesical fascia. 

As regards the parietal division, it will be 
seen that that part of it above the origin of the 
visceral layer (i.e. above the white line) is in the 
pelvic cavity, while that part below the line is 
in the perineum. To this lower segment the name 
obturator fascia is commonly given. Now, the 
peritoneum lines some part of the pelvic floor, and 
covers a great part of the pelvic viscera. Be- 
tween this peritoneum and the visceral layer of 
the pelvic fascia is a good deal of loose connec- 
tive tissue. Inflammation may be set up in this 
tissue, may spread readily in it, and may of 
course lead to suppuration. Such suppuration 
will be limited to the pelvic cavity, and will be 
hindered from escaping from that cavity by the 
pelvic fascia. Inflammations of any extent so 
located^ are included under the term pelvic 
cellulitis. Suppuration, therefore, above the 
visceral layer of the pelvic fascia will be 
limited to the pelvic cavity, while that below 
this layer will be limited to the perineum, 
to either the urethral or the anal segment 
of that _ district. _ Thus it will be seen that 
the pelvic fascia is of much surgical importance. 
Wounds through the perineum that involve this 
fascia will_ be serious, in that they will open up 
the loose tissue on the pelvic aspect of the fascia 
in which inflammation so readily spreads, while 
unless the fascia be wounded the pelvic cavity 
cannot be said to have been opened. 



432 SURGICAL APPLIED ANATOMY [Part IV 

The fascia is so reflected upon the viscera that 
certain parts of them are excluded by the attach- 
ments of the membrane from the pelvic cavity. 
The parts so excluded are the prostate in the male 
and part of the vagina in the female. Over that 
part of the pelvic floor occupied by the rectum 
and over the rectum itself the pelvic fascia is so 
thin as scarcely to be distinguishable from the 
subperitoneal and loose pelvic tissue surrounding 
it. The rectum is loosely embedded, so that it 
may the more easily expand and contract; indeed, 
the only part which is at all firmly attached is the 
anal canal, which is fixed in the pelvic floor. 
Pelvic cellulitis, to use the term in the strict 
sense, means inflammation of the connective tissue 
between the pelvic , fascia and the peritoneum.* 
This connective tissue is chiefly situated between 
the anterior wall of the bladder and the pelvis, 
about the base and neck of the bladder, between 
the latter viscus and the rectum; and in the 
female, between the layers of the broad ligament 
and about the lower part of the uterus and com- 
mencement of the vagina. All this connective 
tissue is continuous, and inflammation in one part 
of it may spread to the other parts. In women 
the mischief is often found between the folds of 
the broad ligament, or in the hollow between the 
uterus and the rectum. As may be supposed, the 
abscess formed in such cases tends to mount up in 
the pelvis, being unable to escape below, and 
usually points in the inguinal region, or in the 
suprapubic region, having spread along the 
obliterated hypogastric artery (see p. 330). It 
may, however, open into one of the pelvic viscera 
or into the peritoneum, but both these termina- 
tions are rare. Out of thirty-seven cases of puer- 
peral pelvic cellulitis with suppuration, twenty- 
four burst externally, and for the most part in the 
inguinal region (McClintock). 

* Clinically the term pelvic cellulitis includes also pelvic peritonitis, 
and often inflammation of one or other of the viscera. Indeed, many- 
so-called oases of pelvic cellulitis are examples of localised pelvic 
peritonitis with or without suppuration. 



Chap. XVIII] PELVIS AND PERINEUM 433 

It should be borne in mind that the blood- 
vessels of the pur is are placed on the peritoneal 
aspect of the fascia. The branches of the internal 
iliac artery, therefore, that leave the pelvis, escape 
by piercing that membrane. The obturator artery 
is an exception to this rule, since it passes over 
the upper border of the parietal pelvic fascia 
(Cunningham). The nerves in the pelvis lie be 
hind or outside the fascia, and, therefore, the 
pelvic vessels and the pelvic nerves are, excepting 
the obturator, separated from one another by this 
layer of tissue. 

The male perineum. — The perineum is a 
lozenge-shaped space bounded by the symphysis, 
the rami of the pubes and the ischia, the ischial 
tuberosities, the great sacro-sciatic ligaments, the 
edges of the two great gluteal muscles, and the 
coccyx. A transverse line drawn across the space 
between the anterior extremities of the tubera 
ischii, and just in front of the anus, divides the 
perineum into two parts. The anterior part 
forms nearly an equilateral triangle, measuring 
about 3^ inches on all sides. It is called the 
urethral triangle. The posterior part is also 
somewhat triangular, contains the rectum and 
ischio-rectal fossse, and is called the anal triangle. 
The whole space measures about o\ inches from 
side to side, and about 4 inches from before back- 
wards in the middle line. The average antero- 
posterior diameter of the pelvic outlet in the male 
averages 3^ inches. This measurement in the un- 
dissected subject is increased to 4 inches by the 
curving of the surface. The average transverse 
diameter of the male pelvic outlet is 3i inches, 
and corresponds to the measurement of the perin- 
eum above given. 

The bony framework of the perineum can be 
felt more or less distinctly all round, and in thin 
subjects the great sacro-sciatic ligaments can be 
made out beneath the great gluteal muscle. The 
anus is in the middle line between the tubera 
ischii, its centre being about lh inches from the tip 
2 C 



434 



SUEGICAL APPLIED ANATOMY [Part IV 



of the coccyx. The raphe, a central mark or 
ridge in the skin, can be followed from the anus 
along the middle line of the perineum, scrotum, 




Fig. 11.— The male perineum. (After Rudinger.) 



a, Gluteus niaximus: b, semi-tendinosus and biceps; c, adductor magnus ; 
d, gracilis ; e, pyritormis ; /, obturator interims ; <j, quadratus femoris ; h, lev- 
ator ani ; i, external sphincter ; j, accelerator urinsB ; k, erector penis ; 
I, transversus perinei ; 1, great sciatic nerve ; 2, external liannorrhoidal vessels 
and nerve ; 3, superficial perineal vessels and nerves ; 4, pudic nerve (cut) 
and pudic artery; 5, pudendal branch <>f small sciatic nerve. 

and penis. No vessels cross this line, and, there- 
fore, in making incisions into the perineum this 
line is always chosen when possible. In the middle 
line, midway between the centre of the anus and 
the spot where the scrotum joins the perineum, is 



Chap. XVIII] PELVIS AND PEEINEUM 435 

the central point of the perineum. The two trans- 
verse perineal muscles, the accelerator urinse and 
the sphincter ani, meet at this point, which also 
corresponds to the centre of the inferior edge of 
the triangular ligament. The bulb is just in 
front of it, as is also the artery to the bulb, and 
in lithotomy, therefore, the incision should never 
commence in front of this spot. 

The perineal space is separated from the pelvic 
cavity by the levator ani muscles and recto-vesical 
fascia, as already mentioned. The depth of the 
perineum means the distance between the skin and 
the pelvic floor. This depth depends, to a great 
extent, upon the amount of fat under the integu- 
ment. It varies considerably in different parts, 
measuring from 2 to 3 inches in the hinder and 
outer parts of the perineum, and less than 1 inch 
in the anterior parts of the space. 

The ischio-rectal fossa is of pyramidal 
shape, its apex being at the white line, and its 
base being formed by the skin between the anus 
and the ischial tuberosity. It measures about 2 
inches from before back, 1 inch from side to side, 
and is between 2 and 3 inches in depth. Its 
boundaries are : on the outer side, the obturator 
internus muscle, covered by the obturator layer of 
the pelvic fascia ; on the inner side, the levator 
ani, covered by the anal fascia; in front, the base 
of the triangular ligament and the transversus 
perinei muscle; and behind, the gluteus maximus, 
great sacro-sciatic ligament, and coccygeus. The 
pudic vessels and nerves are on the outer wall, 
embedded in the fascia over the obturator muscle, 
and are placed about \\ inch above the lower 
border of the tuber ischii. 

The part of the rectum which occupies the 
space between the two fossae is supported by the 
levatores ani, external sphincter, and recto-vesical 
fascia. Its lateral wall is exposed for a distance 
of _ nearly 3 _ inches, its posterior wall for about 
1 inch (Quain). The fossa is occupied by a mass 
of fat which affords to the rectum the support of 



436 SUKGICAL APPLIED ANATOMY [Part IV 

an elastic cushion. This fatty tissue is badly 
supplied with blood, and this fact, in addition 
to the dependent situation of the part, and its 
exposure when the patient sits upon damp, cold 
seats, etc., leads to abscess being very frequent 
in the space (ischio-rectal abscess). These ab- 
scesses are hemmed in on all sides, soon fill the 
fossa, and then tend to discharge themselves in 
the two directions where the resistance is least, 
viz., through the skin and through the wall of the 
rectum. When this double discharge of the ab- 
scess has taken place, a complete fistula in ano is 
established. It is well to note that in all fistulce 
in ano the opening into the rectum is nearly 
always within \ an inch of the anus. An opening 
into the bowel higher up is resisted by the attach- 
ment of the levatores ani, by the anal fascia, and 
by the recto-vesical fascia. 

Crossing the space obliquely from its hinder 
part to the anus are the external hsemorrhoidal 
vessels and nerves (Fig. 71); crossing the an- 
terior and outer corner of the fossa are the 
perineal vessels and nerves, and about the pos- 
terior border of the space are the fourth sacral 
nerve and some branches of the small sciatic nerve. 
It will be readily understood, therefore, that 
ischio-rectal abscesses are associated usually with 
extreme suffering until they are relieved. The 
most severe pain is probably due to the stretching 
of the external hsemorrhoidal nerve by the abscess 
as it progresses towards the surface. In opening 
an abscess in the fossa the main structures to 
avoid are the rectum, the pudic and external 
hsemorrhoidal vessels. 

Anns. — (See p. 474.) 

The urethral triangle. — The skin of the peri- 
neum between the anus and the scrotum is thin, 
and shows very readily any extravasations of 
blood that may form beneath it. The superficial 
fascia is divided into two layers, of which the 
more superficial is quite unimportant, and con- 
tains what little subcutaneous fat exists in this part, 



Chap. XVIII] PELVIS AND PERINEUM 437 

The deep layer, known as the perineal fascia or 
fascia of Colles, is attached on either side to the 
rami of the pubes and ischium, and behind to the 
base of the triangular ligament. In front it be- 
comes continuous with the dartos tissue. This 
fascia, therefore, by its attachments forms with 
the triangular ligament a well-isolated aponeu- 
rotic space, containing the bulb with all that part 
of the spongy urethra between the triangular 
ligament and the attachment of the scrotum, the 
penile muscles, the transverse perineal muscles, 
vessels, and nerves, and the perineal vessels and 
nerves. When extravasation of urine follows 
upon a rupture of tne part of the urethra above 
named, the course of the escaping fluid is directed 
by the fascia of Colles. It fills the aponeurotic 
space. It is unable to gain the ischio-rectal fossa 
on account of the attachment of the fascia to the 
triangular ligament. The lateral attachments of 
this membrane prevent the urine from passing 
into the thighs. It is therefore guided into the 
scrotum, and there finds itself beneath the dartos 
tissue. It distends the scrotal tissues, and then 
mounts up on to the abdomen through the gap 
left between the symphysis pubis and pubic spine. 
It must be remembered that the fascia of Colles, 
the dartos tissue, and the deeper layer of the 
superficial fascia of the abdomen, are continuous, 
and merely represent different parts of the same 
structure. Pus or blood within this aponeurotic 
space would follow the same course if the effusion 
were extensive enough. The pain occasioned by 
such effusion can be understood when it is noted 
that the three chief sensory nerves of this region 
(the three long scrotal nerves) are included within 
the space. 

The triangular ligament has a depth of 
about 1^ inch in the middle line, and is formed 
of two layers, of which the posterior is derived 
from the pelvic fascia. The membranous urethra, 
surrounded by the compressor urethrse, lies be- 
tween the two layers, and runs about 1 inch below 



438 SUBGICAL APPLIED ANATOMY [Part IV 

the symphysis, and about f of an inch above the 
central point of the perineum (Fig. 72). The 
artery to the bulb passes inwards between the two 
layers about \ an inch above the base of the 
ligament and \\ inch in front of the anus. The 
dorsal vein and the terminal part of the pudic 
artery and nerve pierce the anterior layer of the 
ligament about \ an inch below the symphysis. 
In uncomplicated rupture of the membranous 
urethra, the urine extravasated would be limited 
to the space between the layers of the ligament, 
until subsequent suppuration had made a way 
for it to escape. When extravasation occurs be- 
hind the triangular ligament, the effusion may 
collect in the retropubic space if the pelvic fascia 
is ruptured (Deanesley), or it may pass back- 
wards by the side of the rectum into the cellular 
tissue of the pelvis. 

Just beyond the triangular ligament is the 
prostate, surrounded by its capsule, and the pros- 
tatic venous plexus (Fig. 72). In dissecting down 
from the surface to the prostate, we meet, as 
Cunningham has well pointed out, alternate strata 
of fascial and muscular tissue, forming seven 
layers in all, viz. (1) superficial fascia; (2) super- 
ficial perineal muscles; (3) triangular ligament 
(ant. layer) ; (4) compressor urethras muscle; (5) 
triangular ligament (post, layer) ; (6) levator ani 
muscle; (7) sheath of prostate. 

Stone in the bladder. — Stones of the bladder 
which were formerly removed by a perineal in- 
cision are now commonly crushed and washed out 
through the urethra by the operation of litho- 
lapaxy. This operation is carried out readily 
even in male children. If the stones are too 
large for crushing, the supra-pubic operation is 
performed to give sufficient room for extraction. 
Although the perineal operations are now but very 
rarely performed^ a description of the parts in- 
volved helps to give a proper conception of their 
important anatomical relationships. 

Lateral lithotomy. — The first incision, 2 or 



Chap. XVIII] PELVIS AND PERINEUM 



43d 




Fig. 72. — A vertical anteroposterior section of the male pel is 
(Braune). 



440 SURGICAL APPLIED ANATOMY [Part IV 

3 inches in length, is commenced just to the left 
of the middle line and just behind the central 
point of the perineum, i.e. about l\ inch in 
front of the anus. The incision is carried down- 
wards and outwards into the left ischio-rectal 
fossa, and ends at a point between the tuber ischii 
and posterior part of the anus, and one-third 
nearer to the tuberosity than to the gut. In the 
early part of this incision the staff may just be 
touched, as it lies in the membranous urethra, the 
incision becoming more and more shallow as the 
knife is withdrawn. The parts cut in the first 
incision are: (1) skin and superficial fascia; 

(2) transverse perineal muscle, artery and nerve ; 

(3) the lower edge of the anterior layer of the 
triangular ligament; (4) the external hsemor- 
rhoidal vessel and nerves (Figs. 71 and 72). 

In the second incision the knife, guided by the 
fore-finger of the left hand, is passed upwards 
behind the triangular ligament, is engaged in the 
groove on the staff as it lies in the membranous 
urethra, and then, having its edge turned towards 
the left tuber ischii, is steadily carried along 
the groove into the bladder. In this incision the 
parts divided are : (1) membranous and prostatic 
portions of urethra; (2) posterior layer of tri- 
angular ligament; (3) compressor urethrse; (4) 
anterior fibres of levator ani and left lateral lobe 
of prostate. The finger is then introduced along 
the staff into the bladder, the staff is removed, 
and, the forceps being inserted, the stone is ex- 
tracted, traction being made in the proper axis 
of the pelvis. 

Parts that may be wounded. — (a) In the first 
incision : (1) the bulb, or the artery of the bulb. 
These parts can be avoided by commencing the 
incision well behind the " central point/' and by 
causing the holder of the staff to draw it, the 
scrotum, and the penis well up. The staff should 
be held as close up under the pubes as possible. 
The bulb is very small in children, large in 
adults, and largest in old men. (2) The rectum 



Chap. XVIII. PELVIS AND PERINEUM 441 

may be cut if much distended, or if the incision 
be made too vertical or carried too far back. In 
all cases the gut should be well emptied by enema 
before the operation. (3) The pudic vessels can 
hardly be wounded unless the incision is very 
carelessly made, and the knife carried almost 
against the bone as it is being withdrawn, (b) 
In the second incision the knife may be passed 
beyond the prostate, and may so incise the vis- 
ceral layer of the pelvic fascia as to open up the 
pelvic cavity. It will be understood that the 
lateral lobe of the prostate may be cut freely 
without this cavity being endangered. The gland 
is enveloped by the pelvic fascia, but the incision 
made into the prostate is well below the superior 
reflection of the membrane. The incision in the 
neck of the bladder, therefore, must be strictly 
limited to the prostate. The prostatic plexus of 
veins cannot avoid being wounded. The left 
ejaculatory duct would be cut if the prostatic 
incision were carried too far backwards. 

In children the pelvis is relatively narrower 
than in the adult, the bladder is more an ab- 
dominal than a pelvic organ, and the neck of the 
bladder, therefore, is high up. The viscus, more- 
over, is very movable, and has less substantial 
attachments than has the adult's bladder. It thus 
happens that in forcing the finger into the bladder 
after the second incision, the viscus has actually 
been torn away from the urethra. In children 
the prostate is rudimentary, and thus more of 
the actual neck of the bladder itself has to be 
cut. From the small size of this gland, it hap- 
pens, too, that in some cases the knife has passed 
too far beyond the prostatic area, and has opened 
up the pelvic fascia. In children also the peri- 
toneum descends lower on the posterior surface 
of the bladder, and may be wounded by a careless 
operator. 

.Median lithotomy. — In this operation the 
knife is entered in the middle line, just in front 
of the anus. The staff has a central groove, and 



442 SUEGICAL APPLIED ANATOMY [Part IV 

the point of the knife should hit the instrument 
as near as possible to the apex of the prostate. 
As the knife is withdrawn the whole of the mem- 
branous urethra is incised, and a wound made 
in the median raphe of about \\ inch in length. 
The incision is made by cutting upwards. i\ 
probe is then introduced into the bladder, and, 
the staff being removed, the finger is passed into 
that viscus by steady dilatation of the parts, with 
some laceration of the prostate. The object in 
this operation is to enter the bladder with the 
least amount of cutting, and by dilatation rather 
than incision. 

Farts divided. — (l) Skin and superficial 
fascia ; (2) sphincter ani ; (3) central point of 
perineum ; (4) lower border of triangular liga- 
ment; (5) whole length of membranous urethra; 
(6) compressor urethrse. 

Advantages. — (1) The bleeding is much less 
than in the lateral operation, the slight vascu- 
larity of the raphe being well known. (2) The 
pelvic fascia is much less likely to be wounded 
if the bladder be entered by dilation rather than 
by incision, as in the lateral procedure. 

Disadvantages. — (1) The bulb is in great risk 
of being wounded. It must, however, be noted 
that wounds of the bulb in the middle line do not 
bleed readily, as a rule. (2) The amount of space 
obtained for the removal of the stone is very 
slight. (3) In children the operation in its in- 
tegrity is scarcely possible, since the prostate is 
quite rudimentary, and the slight attachments 
of the parts are such that, in using forcible dila- 
tation, the bladder may readily be torn from the 
urethra. If the incision be made upwards, and 
one linger be retained in the rectum, the risk of 
wounding the gut is not great. 

In lithotomy, and in other operations for reach- 
ing the neck of the bladder through the perineum, 
it should be remembered that the bladder lies at 
a depth of from 2| to 3 inches from the surface 
when the body is in the lithotomy position (Fig. 72). 



Chap. XVIII] PELVIS AND PERINEUM 443 

If the bladder is empty and the rectum full, 
the prostate, trigone and reflection of peritoneum 
are carried upwards and forwards; if the bladder 
is full and the rectum empty, the movement is in 
an opposite direction ; in fat people the bladder 
and peritoneum are carried away from the 
perineum. 

Suprapubic litliotoiny. — This operation has 
been revived of late years, and in cases in which 
litholapaxy is contraindicated has practically 
supplanted the two forms of lithotomy just de- 
scribed. In order to bring the summit of the 
bladder well above the symphysis, both bladder 
and rectum may be dilated. Into the former vis- 
cus, tepid water or bora^ic lotion is injected. It 
is found that in the adult 8 to 10 ounces is suffi- 
cient to ensure the desired distension. The rectum 
is dilated by some operators by means of a soft 
rubber bag. The gut, when thus distended, 
pushes forward the bladder, and gives it a firm 
basis upon which to rest. In the adult from 10 
to 14 ounces are usually introduced into the bag. 
Distension of the rectum alone will elevate the 
bladder, but may have no effect upon the reflection 
of peritoneum. In operating upon children the 
rectal bag is very seldom required, and many 
surgeons do not employ it in any case. In the 
case of a male child, aged five, the injection of 
3 ounces of water into the bladder caused the 
reflection of peritoneum to mount to more than 
1 inch above the symphysis. An incision, some 3 
inches in length, is made immediately above the 
symphysis in the median line. The bladder is 
exposed below the peritoneum, is drawn forwards 
by a hook, and opened. 

The bladder. — When empty the bladder is 
flattened and of triangular outline, and lies 
against the anterior wall of the pelvis. The 
empty bladder may be found in one of two condi- 
tions (as demonstrated by Dr. Hart in the adult 
female bladder). It may be small, oval, and 
firm, with its upper wall convex towards the 



444 SURGICAL APPLIED ANATOMY [Part IV 

abdomen. In vertical anteroposterior section the 
urethra forms with the cavity of the bladder a 
curved slit (the systolic empty bladder). It may 
be larger, and soft, with its upper surface con- 
cave towards the abdomen, and fitting into the 
concavity of the lower wall or surface. In the 
section named, the urethra forms, with the blad- 
der cavity, a Y-shaped figure, the two diverging 
limbs of the Y corresponding to the concavity 
named (the diastolic empty bladder). When 
moderately distended with an opaque solution 
and examined by the aid of X-rays it is seen to 
be conical in form, with its apex behind the sym- 
physis and its base or upper surface indented 
by the pressure of the abdominal viscera (Fig. 70, 
p. 418). As distension of the bladder increases, 
the summit of the viscus is brought more and more 
in contact with the anterior abdominal wall, the 
organ becoming also more convex on its posterior 
than on its anterior surface. This tendency for 
the summit of the distended bladder to press itself 
against the anterior parietes is of good service in 
tapping the organ above the pubes, and in supra- 
pubic lithotomy. When greatly distended it may 
reach the umbilicus, and may even touch the dia- 
phragm. The usual capacity of the organ is 
about one pint, but when fully occupied it may 
hold some quarts. When both bladder and rec- 
tum are quite empty the apex of the bladder and 
the prevesical reflection of the peritoneum are a 
little below the upper margin of the symphysis 
pubis. As the distended bladder ascends above 
the pubes it dissects the serous membrane from 
the parietes, and the layer so lifted off forms a 
cul-de-sac or fold of peritoneum between the 
upper part of the anterior surface of the bladder 
and the parietes. When the apex of the bladder is 
2 inches above the pubes the peritoneal reflection 
is probably not more than f of an inch above 
the same point of bone. When the apex of the 
bladder is midway between the umbilicus and the 
pubes there may be 2 inches (vertical) of the an- 



Chap. XVIII] PELVIS AND PERINEUM 445 

terior abdominal wall in the middle line and im- 
mediately above the symphysis devoid of peri- 
toneal lining. Thus it happens that the distended 
viscus may be readily tapped above the pubes 
without the peritoneum being wounded. As the 
bladder becomes distended, not only does it rise 
into the abdomen, but it extends also towards the 
perineum, diminishing the length of the prostatic 
and membranous urethra. In suprapubic litho- 
tomy that tendency to extend downwards is pre- 
vented by the rectal bag (p. 442). 

Between the anterior surface of the bladder 
and the symphysis, and shut in by the peritoneum 
above, is the retropubic or prevesical space, con- 
taining lax connective tissue (Fig. 73). The loose- 
ness of this connective tissue permits the bladder 
to readily ascend as it fills. In injuries to the 
pelvis and to the front of the bladder a diffuse 
inflammation may be set up in this tissue and 
assume serious proportions. I have reported a 
case where an extensive suppuration in this area 
followed upon aspiration of the bladder above 
the pubes, and led to death. Like suppuration 
has followed suprapubic lithotomy. In rupture 
of the anterior wall of the viscus or of the urethra 
above the triangular ligament the urine escapes 
into this district of cellular tissue ; a limited sup- 
puration may follow and recovery ensue. 

The bladder, although fairly fixed, has been 
found in inguinal, femoral, and vaginal hernise. 
In the erect position its neck (in the male) lies 
on a horizontal line drawn from before backwards 
through a point a little below the middle of the 
symphysis, and is placed about 1\ inch (3 cm.) 
behind that articulation (Tillaux). 

Relations to the peritoneum. — The anterior 
surface is entirely devoid of peritoneum, while 
the superior surface is entirely covered by that 
membrane. At the sides there is no peritoneum 
in front of, or below, the obliterated hypogastric 
arteries. On the posterior aspect of the bladder 
the serous membrane extends down as far as a 



446 SUKGICAL APPLIED ANATOMY [Part IV 

transverse line, uniting the upper parts of the 
two seminal vesicles, so that the upper ends of 
the vesicles are covered by peritoneum. This 
recto-vesical pouch of peritoneum in the adult ex- 
tends to within about 3 inches of the anus, and 
does not reach below a line 1 inch above the base 
of the prostate. Harrison Cripps gives the dis- 
tance of the pouch from the anus as 2| inches 
when the bladder and rectum are both empty, 
and as 3j inches when those viscera are distended. 
(See Bladder in the Child, p. 450.) 

Puncture of the bladder per rectum. — 
The base of the bladder is adherent to the rectum 
by dense areolar tissue over a triangular area 
the apex of which is formed by the prostate, 
the sides by the diverging seminal vesicles, and 
the base by the recto-vesical fold of peritoneum. 
This triangle is equilateral, and in the dissected 
specimen measures about l\ inch on all sides. 
It corresponds to the trigone on the inner surface 
of the viscus. It is through this triangle, and 
as near as possible to the prostate, that the blad- 
der is tapped when the operation is performed 
per rectum. The recto-vesical fold of peritoneum 
is raised, and is carried still farther from the 
anus when the organ is distended. 

Rupture of bladder.— The bladder may be 
ruptured by violence applied to the anterior ab- 
dominal wall apart from pelvic fracture or ex- 
ternal evidence of injury. Such a rupture can, 
however, hardly happen to the empty bladder ; 
it must be full or distended at the time of the acci- 
dent. It is very rare for the rupture to be on the 
anterior surface only. As a rule, the tear in- 
volves the superior or abdominal surface, and im- 
plicates the peritoneum. The injury, therefore, 
is very fatal (five recoveries out of seventy-eight 
cases). In some cases of vesical rupture the sur- 
geon has opened the abdomen and has stitched up 
the rent in the viscus with perfect success. The 
bladder may be torn by fragments of bone in 
fractures of the pelvis, or by violence applied 



Chap. XVIII] PELYIS AND PERINEUM 447 

through the rectum or vagina. A case, for ex- 
ample, is reported (Holmes's " System of Sur- 
gery ") of a man who fell upon a pointed stake 
fixed in the earth. The stake passed through the 
anus, pierced the rectum, and entered the bladder 
near the prostate. The patient recovered, the 
wound having been made in the triangular area 
on the fundus of the bladder alluded to above, 
and therefore outside the peritoneum. The viscus 
may be ruptured by an accumulation of urine, as 
seen in cases of congenital closure of the urethra 
in some infants. In the museum of the Royal 
College of Surgeons is a preparation of " the 
bladder of a woman which burst near the entrance 
of the ureter in consequence of neglected reten- 
tion of urine. ;; In neglected cases of stricture in 
the male the urethra gives way rather than the 
bladder, and an extravasation of urine into 
the perineum follows. A small puncture of the 
bladder, as, for example, that made by a fine 
trochar, is at once closed by the muscular con- 
traction of its wall. 

The mucous meintoraiie of the bladder is 
very lax, to allow of its accommodating itself to 
the varying changes in the size of the viscus. 
Over the trigone, however, it is closely adherent, 
and were it not so the loose mucous membrane 
would be constantly so prolapsed into the urethral 
orifice during micturition as to block up the neck 
of the bladder. When examined by the cystoscope, 
the mucous membrane is seen to be red and con- 
gested when the bladder is empty, pale and 
ansemic when the bladder is full (Newman). The 
trigone is bounded by three orifices, for the ure- 
thra and the two ureters, and forms an equilateral 
triangle, measuring about lh inch on all sides. 
It is here that the effects of cystitis are most evi- 
dent, and the unvielding character of the mucous 
membrane over the trigone serves in part to ex- 
plain the severe symptoms that follow acute in- 
flammation of that structure. Since the orifice 
of the urethra forms the lowest part of the bladder 



448 SUKGICAL APPLIED ANATOMY [Part IV 

in the erect posture, it follows that calculi gravi- 
tate towards the trigone, and are very apt to 
irritate that part of the interior. The same re- 
mark applies to foreign bodies in the viscus. The 
mucous membrane about the trigone and neck is 
very sensitive, whereas the interior of the re- 
mainder of the bladder appears to be singularly 
defective in common sensation. This can be well 
noted in using sounds and catheters. 

The sensory nerves for the bladder are de- 
rived mainly from two parts of the spinal cord, 
namely, the twelfth dorsal and first lumbar seg- 
ments, and the second, third, and fourth sacral 
segments. From the first source (through the 
hypogastric plexus) come the sensory nerves to 
the upper part of the bladder and the motor 
nerves which stimulate the internal sphincter and 
inhibit the expelling musculature ; from' the 
second source (through the nervi erigentes) the 
motor fibres which stimulate the expelling mus- 
culature and inhibit the sphincter. The trigone, 
having the same nerve supply as the penis and 
scrotum, gives rise, when injured, to pains which 
are referred along the perineal nerves. 

In the muscular coat of the bladder the 
fibres are collected in bundles which interlace in 
all directions. When the viscus becomes hyper- 
trophied these bundles are rendered very distinct, 
and produce the appearance known as " fascicu- 
lated bladder. " This simply means that the 
muscle of the bladder, having been unduly exer- 
cised to overcome some obstruction to the escape 
of urine, increases in size, as do other much- 
exercised muscles, and that increase serves to 
demonstrate the arrangement of the individual 
bundles. From distension the mucous membrane 
becomes bulged out between the unyielding muscle 
bundles, so that sacculi are formed, and the ap- 
pearance known as " sacculated bladder " is pro- 
duced. In some cases the parietes yield, especially 
at one part, and one large saccule is produced. 
In this way a sacculus may be formed which in 



Chap. XVIII] PELVIS AND PERINEUM 449 

time may become almost as large as the bladder 
itself, and give rise to the erroneus description 
of " double bladder," etc. 

The ureters run for f of an inch in the mus- 
cular wall of the viscus, and their oblique course, 
together with the action of the muscular _ tissue 
about them, tends to prevent regurgitation of 
urine. On cystoscopic examination it is seen that 
once or twice a minute each ureter contracts and 
expels a spurt of urine into the bladder ; be- 
tween these spurts the ureteric orifices are closed 
as if by a sphincter. If the ureter becomes con- 
tracted, as is the case if it is the seat of a tuber- 
cular ulceration, the vesical orifice of the ureter 
is pulled outwards (Fenwick). The mucous mem- 
brane is laxly attached and may be prolapsed 
within the bladder as a pedunculated body. In 
cases of retention the ureters become distended ; 
but this is due rather to accumulation of urine 
within them than to its reflux from the bladder. 
In cases of great distension of the bladder the 
neck of the viscus is opened up by the pressure 
from within, and the patient exhibits the feature 
of overflow of urine. 

The female bladder is less capacious than 
that of the male. Its neck is situate a trifle 
nearer to the symphysis than it is in the male, 
and lies in a horizontal line continued back from 
the lower border of the symphysis. There being 
no prostate, the neck of the bladder is very dis- 
tensible, and this fact, taken in connection with 
the shortness and dilatability of the urethra, 
allows of most stones being extracted by forceps 
without cutting. By simple dilatation, stones of 
a diameter of f of an inch have been removed. 
Through the dilated urethra the orifices of the 
ureters can be seen and examined. The intimate 
relation of the bladder to the vagina allows it to 
be examined well from the latter passage, and 
the comparative thinness of the dividing wall 
serves to explain the frequency of vesico-vaginal 
fistulse. Strange foreign bodies have been intro- 
2 D 



450 SURGICAL APPLIED ANATOMY [Part IV 

duced into the female bladder, such as hair-pins, 
crochet hooks, sealing-wax, penholders, and the 
like. 

The orifice of the ureter is 3 cm. from the cervix 
uteri, and 4 cm. from the vesical opening of the 
urethra. Its close relation to the cervix renders 
it liable to injury in supravaginal amputation of 
that part, and in certain operations on the 
uterus. 

r*! The bladder in the child is egg-shaped, and 
its vertical axis is relatively much greater than 
it is in the adult. The larger end of the egg- 
shaped cavity is directed downwards and back- 
wards. The fundus is developed and the pelvic 
position assumed about the fourth year (Birming- 
ham). The viscus is situated mainly in the abdo- 
men, the pelvis being small and very shallow. At 
birth the orifice of the urethra is on a level with 
the upper edge of the symphysis. Although the 
bladder projects so freely into the abdomen, its 
anterior wall is still entirely uncovered by peri- 
toneum. On the posterior wall the serous mem- 
brane extends lower down than in the adult, 
reaching the level of the urethral orifice at the 
time of birth, and the level of the prostate in 
young male children. The prostate is exceedingly 
small in children. Thompson states that at the 
age of seven years it only weighs thirty grains, 
whereas in subjects between eighteen and twenty 
it weighs two hundred and fifty grains. The 
bladder wall in the child is so thin that in sound- 
ing for stone it is said that a " click ' ; may be 
elicited by striking the pelvis through the parietes 
of the viscus. 

The prostate. — The prostate is situated about 
I of an inch below the symphysis pubis, and rests 
upon the rectum above the anal canal (Fig. 72). 
It is, therefore, placed within 1^ to 2 inches from 
the anus, and can be readilv examined from the 
bowel. The prostate is made up of two lateral 
lobes which fuse together in front of the urethra 
by a pubic commissure (Fig. 73) and behind by 



Chap. XVIII) PELVIS AND PERINEUM 



451 



two commissures, one above the common ejacula- 
tory ducts — the median commissure — and one be- 
low these ducts — the rectal commissure {see Fig. 
73, b, d). The part here named median commis- 
sure was formerly known as the median lobe — a 
name which is apt to mislead, for it is not a 
separate lobe, but, as already explained, merely 
a fusion of the two lateral lobes. Each gland 




Fig. 73.— A, Median section of the normal prostate ; B, similar section 
of enlarged prostate. 

a, a, Sphincter vesicae; b, median commissure; c, common ejactulatory duct ; d, 
rectol commissure ; e,e, constrictor urethras ; v, rectOr-urethral muscle ; u, Cow- 
per's gland ; n, ejaculator urinae ; I, internal sphincter of anus ; .t, external. 
sphincter of anus ; k, symphysis pubis ; L, retropubic space ; m, pubo- 
prostatic ligaments and sheath of prostate ; N, dorsal vein of penis ; o, pubic 
commissure ; p, corpus cavernosum ; q, urethra ; r, bulb. 



is made up of numerous branching tubular glands 
which are embedded in and surrounded by non- 
striated muscle and fibrous tissue. The glands 
end in the urethra — chiefly in the prostatic 
sinuses — but the use of their secretion is un- 
known. 

The secretion from the gland is discharged 
through the long and very narrow ducts of glands 
which are diffusely arranged as two lateral masses 
or lobes. In certain forms of prostatic irrita- 
tion, little white opaque threads, very much like 



452 SURGICAL APPLIED ANATOMY [Part IV 

short pieces of cotton, are found in the urine, 
and are actual casts of the prostatic ducts. 

The sheath and capsule of the prostate. — 

Owing to the success which has attended enuclea- 
tion as a means of treatment for enlarged pros- 
tate, much discussion has recently taken place 
concerning its ensheathing structures. The term 
capsule is now usually applied to the superficial 
fibro-muscular stratum of the gland, while the 
term sheath is applied to the enveloping fibrous 
structure derived from the pelvic fascia. In enu- 
cleating the gland everything within the sheath 
is removed. At only one part is the sheath in- 
timately adherent to the capsule, and that is 
along the anterior or pubic surface ; elsewhere 
it is free from it. Since the base of the prostate is 
applied to the bladder and uncovered by the 
sheath, while elsewhere it is enclosed, it follows 
that the sheath is most easily entered and the 
gland enucleated from the bladder. The sheath 
determines the course of a prostatic abscess. 

The prostatic abscess usually bursts into 
the urethra, that being the direction in which 
least resistance is encountered. If it does not 
enter the urethra, it will probably open into the 
rectum, there being only one layer of the pelvic 
fascia, and that layer not a thick one, between 
the two organs. This encasement of the gland 
in an unyielding membrane will serve, in part, 
to explain the severe pain felt in acute prostatic 
abscess. In acute prostatitis pains are referred 
over the tip of the last rib (tenth dorsal nerve), 
over the posterior iliac spine (eleventh dorsal 
nerve), or even to the soles of the feet (third- 
sacral nerve). It derives its nerve supply from 
the lower three dorsal and upper three sacral 
segments ; hence the widely distributed character 
of the referred pains (Head). 

Hypertrophy of the prostate. — The average 
measurements of the normal prostate are 1^ inch 
across at its widest part, and 1\ inch from be- 
fore backwards, or from apex to base. After the 



Chap. XVIII] PELVIS AND PERINEUM 453 

age of fifty-three the organ is very apt to become 
hypertrophied ; and, according to Sir Henry 
Thompson, this hypertrophy may be^ considered 
to exist when the gland measures 2 • inches from 
side to side, or when it weighs 1 ounce or more. 
The usual weight of the prostate is 6 drachms. If 
the enlargement mainly affect the lateral parts, it 
will be understood that the hypertrophy may at- 
tain considerable dimensions without retention 
of urine being produced. On the other hand, a 
comparatively trifling enlargement of the median 
commissure may almost entirely block the orifice 
of the urethra. As this part enlarges it pushes 
its way into the bladder through the urethral 
orifice, dilating and destroying the sphincter 
vesicae and forming a mechanical obstruction to 
the free passage of urine (Fig. 73, B). If the 
affection be general, the prostatic urethra is 
lengthened, and if one lateral lobe be more en- 
larged than the other, the canal deviates to one 
side. When the enlargement particularly affects 
the median commissure, the prostatic urethra, 
which is normally almost straight, becomes con- 
siderably curved, the curve being sometimes very 
abrupt. It is important to note that enlarge- 
ment of the median commissure alone can hardly 
be made out by rectal examination. The project- 
ing middle commissure, when viewed from the in- 
terior of the bladder, may appear as a distinct, 
well-rounded pedunculated or sessile growth. 

In the operation of prostatectomy this project- 
ing and most troublesome mass is removed 
through a suprapubic incision. Everything 
within the sheath of the prostrate — gland, urethra, 
common ejaculatory ducts — is enucleated by the 
surgeon's finger through the base of the bladder; 
the sheath then encloses a space which at first is 
filled witn blood and urine, but afterwards con- 
tracts to form a new urethra. The prostrate is a 
sexual organ, and its size and development de- 
pend on the presence and activity of the testes. 
Castration prevents its development or causes 



454 SUKGICAL APPLIED ANATOMY [Part IV 

atrophy if already developed. Removal of one 
testicle causes a partial atrophy, but section of 
the vasa deferentia has usually no effect (C. 
Wallace). Embedded in the sheath of the pros- 
tate, especially over the groove between the base 
of the prostate and neck of the bladder, is an ex- 
tensive plexus of veins, the prostatic plexus, into 
which enters the dorsal vein of the penis (Fig. 
73 A). This plexus is cut in lateral lithotomy, 
and it is through its vessels that septic matter is 
probably absorbed in cases of pyaemia following 
that' operation. Its lymphatics, which are 
numerous, pass to a group of glands on the wall 
of the pelvis, between the external and internal 
iliac arteries. 

The male urethra is about 8| inches in 
length (21 cm.), \\ inches being devoted to the 
prostatic urethra, f of an inch to the mem- 
branous, and 6^ inches to the penile or spongy 
portion. Between the ages of four and six years 
its length is 8 to 9 cm., and between ten and thir- 
teen years 10 to 11 cm. The canal may be divided 
into a fixed and movable part. The fixed part 
extends from the neck of the bladder to the 
posterior extremity of the penile urethra at the 
point of attachment of the suspensory ligament. 
The fixed part describes an even curve, fairly 
represented by the line of a " short curve " metal 
catheter. The two ends of the curve lie about in 
the same line, viz. one drawn across the lower 
end of the symphysis, and at right angles to the 
vertical axis of that articulation. The curve is 
formed around this line, its centre summit corre- 
sponding to a prolongation of the vertical axis of 
the symphysis, and to about the centre of the mem- 
branous urethra. This part of the tube lies about 
1 inch below the pubic arch. The movable portion 
of the urethra forms, when the penis is dependent, 
a second curve in the opposite direction, so that 
the whole canal follows somewhat the outline of 
the letter S. 
The prostatic portion of the urethra is nearly 



Chap. XVIII] PELVIS AND PERINEUM 455 

vertical. It" is surrounded by circular muscular 
fibres which may give rise to a spasmodic stricture 
(Fig. 73)- The sinus pocularis or uterus mascu- 
linus, in the floor of this part of the urethra, 
represents the united ends of the rudimentary 
Miillerian ducts. 

The penile or spongy portion of the urethra 
is surrounded by the erectile tissue of the corpus 
spongiosum urethrse, which is thickest on the 
under side of the canal. A very thin layer of 
erectile tissue surrounds the membranous urethra 
lying beneath the fibres of the compressor 
urethrse. 

In introducing a catheter it must be noted 
that while the instrument passes along the mov- 
able urethra, the canal accommodates itself to the 
catheter, but while traversing the fixed segment 
the instrument must accommodate itself to the 
unyielding canal. In introducing a catheter in 
the recumbent posture the penis is held vertically 
upwards, and in this way the curve formed by 
the movable urethra is obliterated. The instru- 
ment is best kept close to the surface of the groin, 
and over and parallel to Poupart's ligament. 
When the fixed urethra is reached, the handle of 
the catheter is brought to the middle line, and 
then, being kept strictly in the median plane of 
the body, is depressed between the legs, so that the 
front of the instrument may follow the natural 
curve of the canal. The greatest difficulty in the 
introduction is generally experienced at the point 
where the movable and fixed parts of the urethra 
meet; or, rather, in practice, at a spot a little 
behind this point, viz. at the anterior layer of 
the triangular ligament (Fig. 73). At this spot 
the tube abruptly becomes not only very fixed, 
but also very narrow, and a part of it is reached 
where muscular tissue is very abundant, and 
where _ resistance from muscular spasm is there- 
fore likely to be most marked. 

It thus happens that when a false passage has 
been made by a catheter in a case where no 



456 SUEGICAL APPLIED ANATOMY [Part IV 

stricture exists to offer a definite obstruction, the 
instrument is usually found to have left the canal 
just in front of the triangular ligament. 

Some other points in connection with cathe- 
terisation will be noted subsequently. 

The urethral canal must not be regarded 
as forming an open tube like a gas-pipe. Except 
when urine or an instrument is passing along it, 
the tube appears on section as a transverse slit, 
the superior and inferior walls being in contact. 
This fact should be remembered in amputation of 
the penis by the ecraseur. In the fossa navicu- 
lars the tube appears as a vertical slit. 

The prostatic part of the canal is the widest 
and most dilutable portion of the whole urethra. 
It is widest at its centre, having here a diameter 
of nearly \ an inch ; at the bladder end its dia- 
meter is about \ of an inch, while at the anterior 
extremity of this part of the urethra the measure- 
ment is a little less than \ of an inch. When 
small catheters are being introduced their points 
may lodge in the orifice of the utricle, unless the 
tip of the instrument be kept well along the roof 
of the canal. The ejaculatory ducts open into the 
prostatic urethra, and thus it happens that in- 
flammation of this part of the canal may spread 
back along those ducts to the seminal vesicles, and 
from thence along the vas deferens to the epididy- 
mis (Fig. 73). It is by spreading along these 
parts that inflammation of the testicle is set up in 
gonorrhoea involving the prostatic urethra, and 
it will be understood that a like inflammation 
may follow lateral lithotomy, impacted stone in 
the prostatic urethra, prostatic abscess, and the 
like. Stricture never occurs in this part. 

The membra?wus urethra is, with the exception 
of the meatus, the narrowest part of the entire 
tube. Its diameter is about | of an inch. It is 
fixed between the two layers of the triangular 
ligament, and is the most muscular part of the 
canal. It is at this spot, therefore, that what is 
known as " spasmodic stricture " usually occurs. 



Chap. XVIII] PELVIS AND PERINEUM 457 

In any case, the contraction of the constrictor 
urethra? often offers an appreciable amount of re- 
sistance to the passage of a catheter or sound 
(Fig. 73). 

The penile urethra is clilaed at either end, 
viz. at the parts occupying the bulb and the glans 
penis respectively. The diameter of the bulbous 
urethra is midway between that of the prostatic 
and membranous segments of the canal, while that 
of the greater part of the penile urethra is mid- 
way between that of the bulbous and membran- 
ous portions. It is in the bulbous urethra that 
organic stricture is the most commonly met with. 
The meatus measures from \ to \ of an inch, 
and therefore if a catheter will pass the meatus 
it will pass along an3^ part of the normal canal. 
Its aperture is very resisting, and has often to 
be incised to allow the larger instruments to 
pass. 

The narrowest parts of the urethra, therefore, 
are (1) at the meatus, and (2) in the membranous 
segment, especially at its anterior end. It is 
at these points that calculi passed from the blad- 
der are most apt to lodge. The widest portions 
of the canal, on the other hand, are at (1) the 
fossa navicularis, (2) the bulbous part of the 
urethra, and (3) the centre of the prostatic 
portion. 

Keegan has shown that the urethra of a male 
child two or three years of age will take a No. 9 
catheter. In boys between eight and ten years a 
No. 11 lithotrite may be passed. 

It will be obvious, therefore, that the operation 
of lithotrity may be performed upon quite young 
male children, and that fragments of crushed 
calculus of no small dimensions may be removed 
from the bladders of such patients by washing. 

The mucous membrane presents, in addition 
to many mucous glands, several lacunae, the ori- 
fices of which for the most part open towards 
the meatus. These lacunae are most numerous in 
the bulbous urethra, and occupy the floor rather 



458 SUKGICAL APPLIED ANATOMY [Part IV 

than the roof of the canal. In passing small 
catheters, therefore, the point of the instrument 
should be kept along the upper surface of the 
tube, so that it may not become engaged in any 
of these spaces. The largest lacuna, the lacuna 
magna, is situate in the roof of the fossa navicu- 
lars, and may readily engage the point of a 
small instrument. 

The urethra may be ruptured by the patient 
falling astride of some hard substance. In such an 
injury it is crushed between the hard substance 
and the pubic arch. The part of the canal, there- 
fore, that is most often damaged is the mem- 
branous segment, and the posterior part of the 
penile division. The more the body is bent for- 
wards at the time the perineum is struck, the 
greater is the length of penile urethra that may be 
crushed against the pubes. 

The female urethra is about \\ inch in 
length, and has a diameter of from \ to \ of an 
inch. It is capable, however, of great distension. 
In the erect position the canal is nearly vertical, 
and in the recumbent posture almost horizontal. 

Pewis. — The skin covering the bulk of the 
organ is thin and fine, and the subcutaneous tissue 
is scanty and lax. It follows, from the looseness 
of this tissue, that the skin is very distensible 
and movable. The latter fact should be borne 
in mind in circumcision, for in performing that 
operation the skin of the penis can be so readily 
drawn forwards over and beyond the glans, that 
if it is excised as far back as possible the greater 
part of the organ may be left bare. This applies, 
of course, mainly to children. The laxity of 
the submucous tissue permits the organ to be- 
come enormously swollen when cedematous, or 
when extravasated urine finds its way into the 
part. Over the glans penis the mucous mem- 
brane is so adherent that there is practically no 
subcutaneous tissue. It happens, therefore, that 
when Hunterian chancres appear on this part 
they can never be associated with other than the 



Chap. XVIII] PELVIS AND PERINEUM 



459 



most trifling induration, there being no tissue in 
which the thickening can develop. At the corona, 
on the other hand, the submucous tissue is lax 
and plentiful, so that the induration can readily 
form, and it is about this spot, therefore, that the 
syphilitic sore often attains its most characteristic 
development. The vascularity of the penis, and 
the rapid engorgement that ensues when the re- 
turn of its venous blood is impeded, serve to ex- 
plain the ready and extensive swelling of the 
organ that follows when any constricting band is 
placed about it. This should be borne in mind in 
tying in a catheter by securing it by tapes around 



Prepuc 
Corp.Caver/mos 

Q LA/IS 

Lacuna AIaqna 

Fossa AIaviculari 

Permanent AIea 

Primitive All 

Fig. 74. — Section of a penis showing a common form of hypospadias. 

The cross marks the point" where the tissue breaks down between the cloacal 
urethra and meatal ingrowth. 




the penis. The blood spaces in the corpus spongi- 
osum may be rendered indistensible from gonor- 
rhoeal inflammation w T hile those of the corpora 
cavernosa remain free. The corpus spongiosum 
then acts like the string of a bow during the erec- 
tion of the penis. Through the superficial lym- 
phatics disease may spread from the skin and 
meatal region of the penis to the inner of the in- 
guinal glands. Deeper vessels pass with the pros- 
tatic veins to the internal iliac group of glands 
on the lateral wall of the pelvis. Some vessels 
pass directly to the external iliac glands through 
the crural ring. The penis is often the seat of 
arrests of development, presenting a variety of 
appearances. Among them may be mentioned 
hypospadias, where the inferior wall of the 



460 SURGICAL APPLIED ANATOMY [Part IV 

urethra and corresponding part of the corpus 
spongiosum are wanting, and epispadias, where 
the superior wall of the canal and corresponding 
parts of the corpora cavernosa are more or less 
entirely deficient. In the condition of hypo- 
spadias two meati are present — one situated on 
the glans opening into a cul-de-sac which repre- 
sents the fossa navicularis, and another just 
behind leading into the urethra (Fig. 74). Here 
is seen the double origin of the male urethra — the 
part within the glans is formed by an ingrowth 
of epithelium from the surface of the glans, while 
the rest of th,e penile urethra is derived from the 
cloaca. At first the cloacal urethra opens by its 
own orifice (primitive meatus, Fig. 74), but in the 
course of development the ingrowth from the glans 
takes place to form the permanent meatus and 
fossa navicularis ; when this ingrowth opens into 
tne cloacal urethra the primitive meatus becomes 
closed. The frenum preputii is formed over it. 
The condition thus represented is one of ar- 
rested development. On the prepuce of such cases 
sebaceous glands are arranged in two pigmented 
oval groups — preputial ocelli (Shillitoe). 

Scrotum. —The skin of the scrotum is thin 
and transparent, so that in bruising of the parts 
the discoloration due to the extravasation of 
blood beneath the surface is readily and distinctly 
seen. It is also very elastic, and allows of great 
distension, as is seen in large scrotal hernise 
and testicular tumours. The integument of the 
part is indeed redundant, and the excision 
of a portion of it will hardly be missed. Even 
in gangrene of the scrotum, when both testicles 
have been exposed, the parts have been entirely 
restored without any inconvenient shrinking or 
contraction. The rugce on the surface of the scro- 
tum favour the accumulation of dirt, and the 
irritation set up by such accumulation may be 
the exciting cause of the epitheliomata that are 
not uncommon in this part. When the surface is 
sweating, the rugse tend to favour a retention of 



Chap. XVIII] PELVIS AND PERINEUM 461 

the moisture between their folds ; from this and 
other circumstances it happens that the scrotum 
is liable to eczema and to those syphilitic skin 
disorders that are often localised by irritation. 
The rugse are a sign of health, since they depend 
upon the vigorous contraction of the muscle fibres 
in the dartos tissue. In the enfeebled, or under 
the relaxing effects of heat, the scrotum becomes 
smooth and pendulous. In a simple incised 
wound, as in castration, the dartos is apt to turn 
in the edges of the skin and cause some difficulty 
in applying the sutures. This difficulty may be 
avoided by relaxing that tissue for a while by the 
application of a warm sponge to the wound. 

The subcutaneous tissue is lax and very ex- 
tensive, and permits of considerable extravasa- 
tions of blood forming beneath the surface. It is 
unadvisable, therefore, to apply leeches to the 
scrotum itself, since they may lead to an unde- 
sirable outpouring of blood beneath the skin, and 
to the appearance of a considerable ecchymosis. 
Leeches in testicular affections had better be ap- 
plied over the region of the cord. 

The scrotum, from its dependent position, and 
from the looseness and extent of its cellular tissue, 
is often the first part of the body to become 
cedematous in dropsy, and is apt to show that 
oedema in a marked degree. The scrotum also is 
the part most frequently the seat of elephantiasis, 
which is due essentially to a distension of the lym- 
phatic vessels and spaces of the connective tissue. 
The vitality of the scrotum is not considerable, 
and it therefore not unfrequently sloughs in 
parts when severely inflamed. For' this reason 
strapping should be applied with some care over 
the enlarged testis, for against the hard mass of 
the affected gland the integument of the scrotum 
can be subjected to considerable pressure when the 
strapping is tightly applied. _ In such a case I 
have seen the whole of one side of the scrotum 
slough from an indiscreet use of this familiar 
method of treatment. 



462 SURGICAL APPLIED ANATOMY [Part IV 

The laxity of the subcutaneous scrotal tissues 
is an essential feature in those operations for the 
radical cure of inguinal hernia where the fundus 
of the sac is invaginated, through an incision in 
the scrotum into the orifice of the inguinal canal. 
Lastly, the great mobility of the scrotum affords 
an admirable source of protection to the testicle ; 
for when the part is struck or squeezed the testis 
can slip about within the scrotum, as a smooth 
ball would within a loose indiarubber bag, and 
so very often eludes all injury. , 

The testicle may be retained within the ab- 
dominal cavity, or may lodge for varying periods 
of time, or for life, in the inguinal canal. It 
may, on the other hand, pass beyond the scrotum 
into the perineum, or may miss the inguinal canal 
altogether and escape through the femoral canal 
and saphenous opening on to the thigh. The 
testis proper is entirely invested by the visceral 
layer of the tunica vaginalis, except over a small 
part of its posterior border where the vessels 
enter. The epididymis is entirely covered by 
the serous membrane at its sides, is more or less 
so covered in front, but is free or uncovered 
along the greater part of its posterior border. 
It. is about the posterior border of the epididymis 
that the visceral layer of the tunica vaginalis 
joins the parietal layer. The posterior border of 
the testicle and of the epididymis — from globus 
major to globus minor— is bound by a reflection of 
serous membrane — the mesentery of the testicle. 
Instead of binding the whole of the posterior 
border, the mesentery may be attached merely to 
the lower pole of the testicle and globus minor ; 
on such a pedunculated attachment the testicle 
is apt to become strangulated by a twisting of its 
narrow mesentery. The more intimate and exten- 
sive connection of the serous tunic with the testis 
or gland proper serves in part to explain the 
greater frequency with which hydrocele appears 
in inflammation of this part of the organ, as 
compared with its occurrence when the epididy- 



Chap. XVIII] PELVIS AND PERINEUM 463 

mis is alone inflamed. It is owing to the reflec- 
tions of the tunica vaginalis that in cases of 
common hydrocele the testicle remains firmly set 
at the lower and posterior part of the swelling, 
and yet so extensively is the organ surrounded 
by that membrane that the position of the gland 
in the larger hydroceles is often difficult to deter- 
mine. In some cases the testicle occupies the front 
of the scrotum, the epididymis being placed an- 
teriorly, and the body of the gland being located 
behind it. The vas deferens descends also along 
the front of the cord. In these cases the testicle 
is just in the position it would occupy if it had 
been turned round upon its vertical axis. The 
condition is known as inversion of the testicle, 
and should be sought for in cases of hydrocele, 
as in several instances the testis has ^been pierced 
by the trochar when tapping collections in cases 
where the inversion existed. 

The proper gland tissue is invested by a very 
dense membrane, the tunica albuginea. The epi- 
didymis, on the other hand, lacks any such firm 
fibrous investment. The unyielding character of 
the tunica albuginea serves in great part to_ ex- 
plain the intense pain felt in acute affections 
of the testis proper, a degree of pain which is 
not reached when the less tightly girt epididymis 
is alone involved. It willbe understood also that 
in inflammation of the epididymis the part swells 
rapidly and extensively, while in a like affection 
of the body of the gland the swelling is compara- 
tively slow to appear. 

It should be borne in mind that the lymphatics 
of the scrotum go to the inguinal glands, those of 
the testicle to the lumbar. The testicle is de- 
veloped in front of the tenth dorsal vertebra, 
and receives its nerve supply from the tenth 
dorsal segment. Its nerves pass by the small 
splanchnics, solar and aortic plexuses, to the 
spermatic artery, on which they reach the gland. 
The epididymis receives its nerve supply from 
the pelvic plexus, along the vas deferens. 



464 SUKGICAL APPLIED ANATOMY [Part IV 

The spermatic cord, — The structures in the 
cord are (l) the vas deferens, (2) the cremaster 
muscle, (3) the spermatic and (4) cremasteric 
arteries, (5) the artery to the vas deferens, 
(6) the pampiniform plexus of veins, (7) the 
genito-crural nerve, (8) sympathetic nerve fibres, 
and (9) lymphatics. The vas deferens lies along 
the posterior aspect of the cord (Fig. ?5), and 
can be detected by the firm, cord-like sensation 
which it gives when pinched between the thumb 
and finger. Mr. Birkett (Holmes's "System") 
gives three cases of rupture of the vas deferens 




EE— 



Fig. 75. — Section of the left spermatic cord of an adult, at the level of 
the external abdominal ring, viewed from above. (From a specimen 
prepared by Mr. W. G. Spencer.) 

vd, vas deferens ; da, deferential artery ; dv, deferential veins ; sa, spermatic 
artery ; ca, cremasteric artery ; cm, cremaster muscle ; pp, pampiniform 
plexus. 

during severe and sudden exertion. The duct ap- 
pears to have in each case given way within the 
abdomen at some point between the internal ring 
and the spot where it approaches the ureter. Re- 
section of part of the vas has been practised to 
bring about atrophv of enlarged prostate, but has 
not proved successful. The size of the cremaster 
muscle depends mainly upon the weighty it has to 
suspend. In atrophy of the testicle it almost 
entirely disappears, while in cases of large slow- 
growing tumours of the gland it attains consider- 
able proportions. If in children or young adults 
the skin over the middle of the thigh just below 
Poupart's ligament be tickled the testicle of the 



Chap. XVIIIj PELVIS AND PERINEUM 465 

same side will usually be seen to be suddenly 
drawn upwards. The tickling concerns the crural 
branch of the genito-crural, while the motor nerve 
of the cremaster is the genital division of the same 
trunk. The interval of time that elapses between 
the irritation of the skin and the movement of 
the testicle has been appealed to as affording evi- 
dence of the state of nerve health and of the 
readiness with which nerve impulses are con- 
ducted. Of the arteries, the spermatic comes from 
the aorta and lies in front of the vas, the cre- 
masteric arises from the deep epigastric and lies 
among the superficial layers of the cord in its 
outer segment, while the deferential artery from 
the superior or inferior vesical lies by the side of 
the vas (Fig. 75). The first-named vessel is the 
size of the posterior auricular, and the two latter 
the size of the supraorbital. The spermatic artery 
divides into a number of branches as it reaches 
the testicle ; these branches pass to the inner side 
of the epididymis, which may be removed without 
interfering with the blood supply of the testicle. 
The three arteries of the cord are divided in 
castration, and may all require ligature. It is 
advisable to secure the vessels in sections, rather 
than adopt the clumsy plan of involving the whole 
cord in one common ligature. The veins are 
divided roughly into two sets. The anterior is 
by far the larger set, runs with the spermatic 
artery, and forms the pampiniform plexus. The 
posterior set is small and surrounds the vas, run- 
ning with the deferential artery. The veins of 
the spermatic and pampiniform plexus are very 
frequently varicose, and then constitute the affec- 
tion known as varicocele. Many anatomical 
causes render these veins liable to this affection : 
they occupy a dependent position, and the main 
vein is of considerable length, and follows a 
nearly vertical course ; the vessels are very large 
when compared with the corresponding artery, 
and so the vis a tergo must be reduced to a mini- 
mum : they occupy a loose tissue, and are lacking 
2e 



466 SURGICAL APPLIED ANATOMY [Part IV 

in support and in the aid afforded to other veins 
(as in the limbs) by muscular contraction; they 
are very tortuous, form many anastomoses, and 
have few and imperfect valves; they are exposed 
to pressure in their passage through the inguinal 
canal. The left veins are more frequently affected 
than the right. Mr. Spencer has shown that the 
veins in the left cord are always much larger 
than those of the right. It may also be pointed 
out that the left testicle hangs lower than the 
right ; that the left spermatic vein enters the left 
renal at a right angle, while the right spermatic 
vein passes Obliquely into the vena cava ; and that 
the left vein passes beneath the sigmoid flexure, 
and is thus exposed to pressure from the contents 
of that bowel. The congenital origin of vari- 
cocele is now very generally allowed. 

When the varicose veins are exposed by opera- 
tion it is impossible to isolate or even recognise 
the arteries. 

The female generative organs require 
but little notice in the present volume. The 
labia majora have the same pathological tenden- 
cies as has the scrotum, to which, indeed, they 
anatomically correspond. They are liable to 
present large extravasations of blood, are greatly 
swollen when cedematous, are prone to slough 
when acutely inflamed, and are the usual seats of 
elephantiasis in the female. A hernia may pre- 
sent in one or other labium (pudendal hernia), 
the neck of the sac being between the vagina and 
the pubic ramus. 

" On everting one of the labia minora and 
pressing the hymen inwards, a small red de- 
pression may generally be seen on the vulva, 
somewhat posteriorly. It leads to the orifice for 
Bartholin's gland ;; (Doran). This gland, an oval 
body about \ an inch in length, lies against the 
posterior part of the vaginal orifice, under the 
superficial perineal fascia, and covered by the 
fibres of the sphincter vaginae. It wastes after 
thirty. It corresponds to the gland of Cowper 



Chap. XVIIIJ PELVIS AND PERINEUM 467 

in the male (Fig. 73, p. 451). Both are apt to 
become the sites of chronic gonorrhoea! inflamma- 
tion. Abscess of the gland and cystic dilatation 
of its duct are not uncommon. 

The vagina is lodged between the bladder and 
rectum, while the upper fourth of its posterior 
surface is covered with peritoneum, and is there- 
fore in relation to the abdominal cavity. Thus it 
happens that the bladder, the rectum, or the 
small intestines may protrude into the vagina by 
a yielding of some parts of its walls and thus pro- 
duce a vaginal cystocele, rectocele, or entero- 
cele. 

The anterior wall of the vagina measures a 
little over 2 inches, the posterior wall about 3 
inches. The long axis of the canal forms an angle 
of 60° with the horizon, and is therefore almost 
parallel to the pelvic brim. The loose areolar 
tissue at the base of the broad ligament lies on 
each side of the upper extremity of the vagina. 
The ureter terminates in the bladder, on the upper 
part of the vaginal roof. 

The abdominal cavity may be opened through 
a wound of the vagina. In one or two instances 
of such injuries several feet of intestine have pro- 
truded through the vulva. In one reported case 
an old woman, the subject of a brutal rape, 
walked nearly a mile with several coils of the 
small bowel hanging from her genitals. 

From the comparative thinness of the walls 
that separate the vagina from the bladder and 
rectum, it happens that vesico-vaginal and recto- 
vaginal fistulas are of frequent occurrence. The 
vagina is very vascular, and wounds of its walls 
have led to fatal haemorrhage. It is very dilat- 
able, as can be shown when the canal is plugged 
to arrest haemorrhage from the uterus. 

The uterus weighs about one ounce. The 
uterine cavity and the cervical canal together 
measure about 2^ inches. This must be borne in 
mind when passing a uterine sound. The blood- 
vessels run transversely to the length of the 



468 SURGICAL APPLIED ANATOMY [Part IV 

uterus, so that a ligature may be placed com- 
pletely around the organ without affecting the 
circulation above or below. Ligature of the uterine 
artery has been practised to arrest the growth of 
uterine tumours. The artery rises from the in- 
ternal iliac \ an inch below the pelvic brim and 
passes to the neck of the uterus in the broad liga- 
ment. It is 2\ inches long and loops over the 
ureter midway in its course. It is reached by 
incising the broad ligament between the Fallopian 
tube behind and the round ligament in front. It 
is found in the loose areolar tissue under the 
wound. 

The lymphatics from the fundus of the uterus 
and appendages pass to the lumbar glands, a few 
also pass along the round ligament to the in- 
guinal glands. The lymphatics of the cervix, 
which is frequently the seat of cancer, pass to 
the internal iliac glands on the lateral wall of 
the pelvis. 

The unimpregnated uterus is very rarely 
wounded, owing its immunity to the denseness of 
its walls, to its small size, to its great mobility, 
and to its position within the bony pelvis. 

The ovary is so placed that the outer part of 
the Fallopian tube turns downwards externally to 
it. The more common position of the ovary may 
be indicated on the surface of the body by the 
line employed to mark out the course of the 
common and external iliac arteries — a line drawn 
from the aortic bifurcation to the, femoral point 
(Fig. 57, p. 340). The ovary lies internally to the 
mid point of this line (Fig. 70, p. 418). It lies 
in the angle between the external and internal 
iliac arteries and may be indistinctly palpated 
through the vagina. Its nerves come from the 
tenth dorsal segment of the cord. The sensory 
nerves for the cervix are derived from the lower 
sacral segments. The lymphatics of the ovary 
pass to the lumbar glands. The ovaries exert a 
very marked trophic influence on the breast; the 
hypertrophy of the mammae at puberty and in 



Chap. XVIII] PELVIS AND PERINEUM 469 

pregnancy depends on an internal secretion of 
the ovary (Starling). By their removal it was 
hoped that cancer of the breast might be arrested, 
but the procedure has not been followed by much 
success. At the brim of the pelvis the ovarian 
vessels lie within a fold of peritoneum, named 
the ovario- or infundibulo-pelvic ligament, for it 
is attached both to the ovary and to the infundi- 
bulum of the Fallopian tube. This ligament 
forms the outer part of the pedicle in ovariotomy. 

The rectum in the adult is situated entirely 
within the true pelvis, and presents three marked 
curves, one in the lateral and two in the antero- 
posterior direction (see p. 390). In the infant, 
however, a good deal of the rectum is in the 
abdominal rather than the pelvic cavity, the gut 
is nearly straight, and occupies a more or less 
vertical position. For these reasons, _ together 
with the fact that the sacrum is straight, the 
prostate small, and the connections of the bowel 
loose, prolapsus ani is much more common in 
children than in adults. Children are, besides, 
especially liable to such exciting causes of pro- 
lapse as worms and rectal polypi. 

The rectum commences in front of the third 
sacral vertebra and is about 5 inches in length. 
It is continuous with the pelvic colon, which is 
invested by peritoneum and supported by a 
mesentery. The serous membrane gradually 
leaves its posterior surface, then its sides, and 
lastly its anterior surface. Anteriorly, the peri- 
toneum, in the form of the recto-vesical pouch, 
extends in the male to within 3 inches of the anus, 
while on the posterior aspect of the gut there is 
no peritoneum below a spot 5 inches from the 
anus. Thus, in excision of the rectum, more of 
the bowel can be removed on the posterior than 
on the anterior part of the tube without opening 
the peritoneal cavity. It will be seen, also, that 
carcinomatous and other spreading ulcers are 
more apt to invade the peritoneal cavity when 
they are situated in the anterior wall of the 



4?0 StJEGtCAL APPLIED ANATOMY [Part IV 

intestine. The lower part of the rectum, distin- 
guished as the anal canal, is surrounded by the 
internal sphincter — an involuntary muscle con- 
tinuous with the circular coat. In the condition 
of rest the anal canal, which is directed down- 
wards and backwards, measures l\ inch, but 
during defsecation and when the patient bears 
down, it assumes a shallow annular form. The 
canal is firmly fixed to the levatores ani ; hence 
in prolapse it is the rectum above the canal which 
is extruded through the anus. Mr. Cripps has 
shown that the posterior edge of the levator ani 
forms a distinctly felt free border, which crosses 
the rectum, nearly at a right angle at a point 
from 1^ to 2 inches from the anus. 

By inserting the finger into the rectum the 
prostate and seminal vesicles can be readily felt 
and examined, and that triangular surface of the 
bladder explored through which puncture per 
rectum is made (p. 446). 

It will be understood that the prostate, when 
enlarged, may encroach upon the cavity of the 
rectum and greatly narrow its lumen (Fig. 73). 
The position of the seminal vesicles with regard 
to the bowel is such that in violent attempts at 
defsecation they may be pressed upon by the rectal 
contents, and so in part emptied, producing a 
kind of spermatorrhoea. Defsecation also often 
causes much pain in inflammatory affections of 
the prostate and adjacent parts. 

The anterior surface of the rectum in the 
female is in relation, so far as the finger can 
reach, with the vagina, and in examining the 
lower part of the rectum, it is convenient to pro- 
trude its mucous membrane through the anus by 
means of the finger introduced into the genital 
passage. 

The rectum is dilated, and is very distensible 
just above the anus. In faecal accumulations it 
may be distended to a considerable size, and 
strange foreign bodies of large dimensions have 
been found in the ampulla. Among the latter 



Chap. XVIII] PELVIS AND PERINEUM 471 

may be mentioned a bullock's horn, an iron 
match - box, and a glass tumbler. By anti- 
peristaltic movements of the colon, such bodies 
may be carried towards the caecum. Thus a case 
is recently reported by Alexander in which the 
handle of an umbrella, accidentally lodged in the 
rectum, was removed by the surgeon two weeks 
later from the hepatic flexure of the colon. Ex- 
periment has shown that when the rectum is dis- 
tended in the male, the recto-vesical fold of peri- 
toneum is raised, and the bladder is elevated and 
pushed forwards. In the female the fundus uteri 
is raised and pushed towards the symphysis. 
The rectum is artificially distended in suprapubic 
lithotomy, in order to bring the bladder into 
better position (p. 443). Normally the rectum is 
empty except during defalcation. Advantage of 
this circumstance is taken in operations for the 
cure of ectopia vesicae where the ureters are re- 
moved from the exposed bladder and implanted in 
the rectum. 

If the sphincter be very gradually dilated, the 
entire hand, if small, may be introduced into the 
rectum in both males and females. The circum- 
ference of the hand should not exceed 8 inches. 
By a semi-rotary movement, and by alternately 
flexing and extending the fingers, the hand can be 
insinuated into the commencement of the sigmoid 
flexure. Owing to the mobility of this part of 
the bowel a large extent of the abdomen may be 
explored through the bowel wall. The structures 
that can be readily felt are the kidneys, the aorta, 
the iliac vessels, the uterus and ovaries, the 
bladder and its surroundings, the pelvic brim, 
the sacro-sciatic foramina, the ischial spine, the 
sacrum, etc. In some subjects even a small hand 
cannot be passed beyond the reflection of the peri- 
toneum over the second part of the gut. In such 
instances the peritoneum offers a resistance like a 
tight garter, and prevents the farther advance of 
the hand without great risk of laceration of the 
parts (Walsham). 



472 SUEGICAL APPLIED ANATOMY [Part IV 

Owing to the constrained position of the hand 
and the cramping of the fingers, this method of 
examination has proved to be of but limited ser- 
vice. 

The attachments of the rectum by means of the 
pelvic fascia are not very firm; since, in some 
severe and rare cases of prolapse, all the walls 
of the gut may be protruded at the anus {see 
p. 431). In excision of the rectum, also, advantage 
is taken of this mobility. 

The mucous membrane is thick, vascular, and 
but loosely attached to the muscular coat be- 
neath. This laxity, which is more marked in 
children, favours prolapse, an affection in which 
the mucous membrane of the lower part of the 
rectum 'is protruded at the anus. The mucous 
membrane presents three prominent semilunar 
folds, about \ an inch in depth, which are placed 
more or less transversely to the long axis of the 
bowel. The first projects backwards from the fore 
-part of the rectum opposite the prostate, the 
second projects inwards from the left side of the 
tube opposite the middle of the sacrum, the third 
is near the commencement of the bowel on the 
right side. These rectal folds, especially when 
the gut is empty, may offer considerable resist- 
ance to the introduction of a bougie or long 
enema tube, and their position should be there- 
fore borne in mind. 

The vessels, and especially the veins, at the 
lower part of the rectum, are apt to become vari- 
cose and dilated, and form piles. The tendency 
to piles can in part be explained by the dependent 
position of the rectum, by the pressure effects of 
hardened faeces upon the returning veins, and by 
the fact that part of the venous blood returns 
through the systemic system (internal iliac vein) 
and part through the portal system (inferior 
mesenteric vein). This connection with the portal 
trunk causes the rectum to participate in the 
many forms of congestion incident to that vein. 
The veins of the rectum, also, can be affected by 



Char. XVIII] PELYIS AND PERINEUM 473 

violent expiratory efforts. For the last 4 inches 
of the bowel, moreover, the arrangement of the 
vessels is peculiar, and is such as to favour vari- 
cosity. The arteries, " having penetrated the 
muscular coats at different heights, assume a 
longitudinal direction, passing in parallel lines 
towards the edge of the bowel. In their progress 
downwards they communicate with one another at 
intervals, and they are very freely connected near 
the orifice, where all the arteries join, by trans- 
verse branches of considerable size ;; (Quain). 
The veins form a plexus with a precisely similar 
arrangement. The veins beneath the mucous mem- 
brane of the anal canal perforate the muscular 
coat of the rectum about 1 inch above the anal 
canal. At the point of perforation they are liable 
to be compressed. 

The lymphatics of the rectum pass to the in- 
ternal iiiac group of lymphatic glands on the 
lateral wall of the pelvis. Hence in cancer of the 
lower part of the rectum these glands and the 
vessels leading to them are the earliest seats of 
secondary infections. The lymphatics of the pel- 
vic colon pass to the glands in front of the sacrum 
and to others between the layers of the meso- 
rectum. 

The rectum may be most freely exposed from 
behind (Fig;. 71, p. 434). In Kraske's operation 
for the extirpation of cancer of the rectum an 
incision is made along the sacrum in the middle 
line, from the level of the posterior inferior iliac 
spine to the anus. A flap is turned out on the left 
side, including the skin and origin of the gluteus 
maximus. The attachments of the left sacro-sciatic 
ligaments, coccygeus, and levator ani, to the sacrum 
and coccyx are divided and turned outwards. 
The lateral and median sacral arteries and a 
plexus of veins are raised with the fibrous tissue 
from the anterior surface of the sacrum by a peri- 
osteal elevator. The left halves of the fourth and 
fifth sacral vertebrae, with the left half of the 
coccyx, are removed. The fourth, fifth sacral and 



4?4 SURGICAL APPLIED ANATOMY [Part IV 

coccygeal nerves are necessarily cut, but an at- 
tempt should be made to save the third sacral 
nerve, owing to the importance of its function. 
The rectum is then exposed, with the hsemor' 
rhoidal vessels and reflection of peritoneum. By 
opening the peritoneal cavity part of the pelvic 
colon may be brought into the wound. After the 
diseased part is removed, with the presacral and 
internal iliac lymphatic glands, the upper end of 
the rectum is brought down and sutured to the 
anal part. An attempt should be made to save 
the levator ani and third sacral nerve, in order 
that the integrity of the pelvic diaphragm may 
be maintained. The rectum is supplied with 
sensory and motor nerves from the second, third, 
and fourth sacral segments through the corre- 
sponding nerves. Some motor nerves are also 
derived from the lower two dorsal and upper 
lumbar segments. These nerves reach the rectum 
through the hypogastric and pelvic plexuses. 

Anus. — The skin about the anus is thrown 
into numerous folds, and it is in these that the 
ulcer or fissure of the anus forms. When the anal 
canal is closed the vertical columns of Morgagni 
meet. At their upper and at their lower ends 
they are united by small valvular folds of mem- 
brane, which prevent the escape of liquid contents. 
The lower valves may be torn by the passing 
scybalous masses, and from the rent thus caused 
a fissure of the anus may be produced (Ball). The 
extreme painfulness of these ulcers is due to the 
exposure of a nerve-fibre at their base, and to the 
constant contraction of the sphincter muscle that 
they excite. Relief is given by excising the base 
of the ulcer, so as to divide some part of the 
sphincter ; or by violently dilating the anus, so as 
to tear up the base of the ulcer and paralyse for 
a while the action of the disturbing muscle. Below 
the columns of Morgagni a fine white line surrounds 
the anus at the junction of the skin and mucous 
membrane, and indicates the interval between the 
external and internal sphincters (Hilton). 



Chap. XVIII] PELVIS AND PERINEUM 4?5 

The anus may be torn during defsecation, when 
the stools are hard. A case is reported of a 
woman who, during violent efforts at defsecation, 
felt something give way, and discovered faeces in 
her vagina. The recto-vaginal wall had ruptured 
2 inches from the anus. During labour the child's 
head has passed into the rectum, and has been 
delivered per anum. 

An imperforate anus is the most common 
congenital defect of the rectum. This condition 
represents an arrest of development. The forma- 
tion of the anus is a double process; first there is 
an ingrowth from the perineum, and secondly a 
downgrowth from the bowel, these two elements 
meeting and communicating near the upper end 
of the anal canal. In many cases of imperforate 
anus, only a thin anal membrane requires to be 
broken down to allow the free passage of faeces, 
but in other cases the defect is much greater, the 
anal canal, and even the rectum, being completely 
wanting. NTot unfrequently in such cases the rec- 
tum may communicate with the urethra in the 
male or with the vulval cleft in the female. This 
communication is due to the persistence of an 
embryonic condition. 

Nerves of pelvis and perineum. — The 
pelvic viscera are supplied by the pelvic plexus of 
the sympathetic. This plexus is joined by at least 
three spinal nerves, the second, third, and fourth 
sacral. 

It is well known that in certain affections of 
the bladder, rectum, prostate, etc., pain is felt 
along the perineum, in the penis, over the but- 
tock, and down the thigh. These parts are sup- 
plied by the pudic and small sciatic nerves, and 
the reason for the pain is explained by the origin 
of the sensory nerves for those organs from the 
same and adjoining segments of the spinal cord. 
The upper part of the rectum is provided with 
but_ little sensation, as illustrated by the passage 
of instruments, by the comparative painlessness 
of malignant and other growths high up in the 



476 SURGICAL APPLIED ANATOMY [Part IV 

bowel, and by the little inconvenience felt when 
the gut is distended with hardened faeces. From 
this apathy it has probably happened that, in the 
self-administration of enemata, patients have 
thrust the tube through the rectum into the peri- 
toneal cavity. The anal canal, on the other hand, 
is extremely sensitive. 

The nerve relations between the anus and the 
neck of the bladder are very intimate. Painful 
affections of the anus often cause bladder troubles, 
and retention of urine is very common after 
operations upon piles. Maladies, on the other 
hand, that involve the bladder neck are often 
associated with tenesmus and anal discomfort. 
This relation is maintained by the pelvic plexus, 
but mainly by the fourth sacral nerve. This 
nerve gives special branches direct to the neck of 
the bladder, and then goes to supply the muscles 
of the anus (the sphincter and levator) and the 
integument between the anus and the coccyx. 

The mucous membrane of the urethra, the mus- 
cles of the penis, and the greater part of the skin 
of the penis, scrotum, perineum, and anus, are 
supplied, from the second, third, and fourth 
sacral segments, by the pudic nerve. Thus, it 
will be understood that irritation applied to the 
urethra may cause erection of the penis (as illus- 
trated by chordee in gonorrhoea), or may produce 
contraction of the urethral muscles (as seen in 
some forms of spasmodic stricture). The disturb- 
ance caused by accumulated secretion beneath the 
prepuce in young children may provoke great 
irritability of the organ, and it is well known 
that painful affections of the perineum and anus 
may be associated with priapism. The distribu- 
tion of the third sacral segment in the perineum 
by means of the long pudendal nerve will explain 
the pain about the buttock and down the back of 
the thigh that is often complained of during the 
growth of perineal abscess and in painful affec- 
tions of the scrotum. This nerve crosses just in 
front of the tuber ischii, and may be so pressed 



Chap. XVIII] PELVIS AND PERINEUM 477 

upon by using a hard seat as to cause one-sided 
neuralgia of the penis and scrotum. It is also 
in close connection with the ischial bursa, and 
neuralgia of the same parts has been met with in 
cases of inflammation involving that structure. 

The testicle is supplied mainly from the tenth 
dorsal segment by the spermatic plexus. The kid- 
ney is also partly supplied from the same segment. 
This is illustrated by the pain felt in the renal 
region during neuralgia of the testicle, and by the 
pain felt in the testicle, the vigorous retraction 
of that organ observed in certain affections of the 
kidney, such as in acute nephritis, and in the 
passage of renal calculi. By means of the renal 
plexus the testicle is brought into direct com- 
munication with the semilunar ganglia and solar 
plexus, which receives some of the terminal fibres 
of the vagus. This communication serves to ex- 
plain_ the great collapse often noticed in sudden 
injuries to the testicle, and especially the marked 
tendency to vomit, _ so often observed in such 
lesions. _ So far as its nerves are concerned, the 
testicle is nearly in as intimate relation with the 
great nerve-centre of the abdomen as is a great 
part of the small intestine, and one would expect 
a sudden crush of the testis to be associated with 
as severe general symptoms as would accompany 
a sudden nipping of the ileum in a rupture. 
Such a resemblance in symptoms is actually to be 
observed in practice. 



PART V.-THE LOWER EXTREMITY 

CHAPTER XIX, 

, THE REGION OF THE HIP 

This region will be considered under the follow- 
ing heads : 1. The buttocks. 2. The region of 
Scarpa's triangle. 3. The hip-joint. 4. The upper 
third of the femur. 

1, The buttocks. — Surface anatomy. — The 
bony points about the gluteal region can be well 
made out. The crest of the ilium is distinct, as 
is also the anterior superior spine. The posterior 
superior spine is less evident, but can be readily 
felt by following the crest to its posterior termina- 
tion. This spine is on a level with the second sacral 
spine, and is placed just behind the centre of the 
sacro-iliac articulation. The great trochanter is 
a conspicuous landmark. It is covered by the 
fascial insertion of the gluteus maximus. Its 
upper border is on a level with the centre of the 
hip-joint, and is somewhat obscured by the tendon 
of the gluteus medius which passes over it. The 
comparatively slight prominence of the trochanter 
in the living subject, as compared with the great 
projection it forms in the skeleton, depends upon 
the completeness with which the gluteus medius 
and minimus fill up the hollow between the tro- 
chanter and the ilium. When these muscles are 
atrophied the process becomes very conspicuous. 
In fat individuals its position is indicated by a 
slight but distinct depression over the hip. 

If a line be drawn from the anterior superior 

478 



Chap. XIX1 REGION OF THE HIP 479 

spine to the most prominent part of the tuber 
ischii, it will cross the centre of the acetabulum, 
and will hit the top of the trochanter. This line, 
known as Nelaton's line, is frequently made use 
of in the diagnosis of certain injuries about the 
hip. McCurdy prefers a line drawn from the 
pubic spine ait a right angle to the median line 
of the body ; if the femur is normal in position 
the pubic line should cross at or just above the 
great trochanter. The mid-point of this line lies 
over the head of the femur. The anterior superior 
spine or crest of the ilium may be used as fixed 
points from which to estimate the degree of dis- 
placement of the great trochanter. 

The tubera ischii are readily felt. They are 
covered by the fleshy fibres of the gluteus maximus 
when the hip is extended. But when the hip is 
flexed, the processes become to a great extent un- 
covered by that muscle. The muscular mass of 
the buttock is formed by the gluteus maximus be- 
hind and by the gluteus medius and minimus and 
tensor vaginae femoris in front. The last-named 
muscle can be seen when in action, i.e. when the 
thigh is abducted and rotated in. 

The fold of the buttock crosses the obliquely 
placed lower border of the gluteus maximus. 
When the hip is fully extended, as in the erect 
posture, the buttocks are round and prominent, 
the gluteal fold is transverse and very distinct. 
When the hip is a little flexed, the buttocks be- 
come flattened, the gluteal fold becomes oblique 
and then disappears. Among the early symptoms 
of hip disease are flattening of the buttock and 
loss of the gluteal fold. These symptoms depend 
upon the flexion of the hip, which is practically 
constant in every case of the malady before treat- 
ment. It is incorrect to say, as some books still 
assert, that these changes are due to wasting of 
the gluteal muscles, since they appear at too early 
a period for any considerable muscular atrophy 
to have taken place. It is true that these symp- 
toms are much exaggerated by the wasting of the 



480 SUEGICAL APPLIED ANATOMY [Part V 

muscle that occurs later on in the course of the 
hip affection. 

With regard to the vessels and nerves of the 
buttock, if a line be drawn from the posterior 
superior spine to the top of the great trochanter 
when the thigh is rotated in, a point at the junc- 
tion of the inner with the middle third of 
that line will correspond to the gluteal artery 
as it emerges from the sciatic notch. A line 
drawn from the posterior superior spine to 
the outer part of the tuber ischii crosses 
both the posterior inferior and ischial spines. 
The former is about 2 inches and the latter about 
4 inches below the posterior superior process. The 
sciatic artery reaches the gluteal region at a spot 
corresponding to the junction of the middle with 
the lower third of this line. The position of the 
pudic artery as regards the buttock is not difficult 
to indicate, since it crosses over the ischial spine 
in passing from the great to the small sacro- 
sciatic foramen. The sciatic nerve is most easily 
found as it escapes from beneath the gluteus maxi- 
mus. When the thigh is rotated outwards, so that 
the great trochanter approaches the ischial tuber- 
osity, the nerve lies midway between these two 
bony points, but in the unrotated position it is 
found at the junction of the inner and middle 
thirds of a line joining them. 

The skin over the buttock is thick and coarse, 
and is frequently the seat of boils. From the 
appearance it presents in very fully injected speci- 
mens, it would appear that the blood supply is 
not quite so free as it is in many other parts of 
the surface. 

The subcutaneous fascia is lax, and contains 
a large quantity of fat. It is to this fat rather 
than to muscular development that the buttock 
owes its roundness and prominence. The enor- 
mous buttocks of the so-called " Hottentot Venus," 
whose model is in many museums, depend for 
their unusual dimensions upon the greatly in- 
creased subcutaneous fat. The amount of adipose 



Chap. XIX] REGION OF THE HIP 481 

tissue normally in the part renders the buttock 
a favourite place for lipomata. The laxity of the 
superficial fascia permits large effusions, both of 
blood and pus, to take place in the gluteal region, 
and ecchymoses of the buttock can probably reach 
a greater magnitude than is possible elsewhere. 

The deep fascia of the buttock, a part of 
the fascia lata of the thigh, is a structure of much 
importance. This dense membrane is attached 
above to the iliac crest, and to the sacrum and 
coccyx. Descending in front over the gluteus 
medius, it splits on reaching the anterior edge of 
the gluteus maximus into two layers, one of which 
passes in front of the muscle and the other behind. 
The gluteus maximus is thus enclosed, like the 
meat in a sandwich, between two layers of fascia, 
and the two lesser gluteal muscles are bound down 
within an osseo-aponeurotic space, which is firmly 
closed above, and only open^ below towards the 
thigh and internally at the sciatic foramina. Ex- 
travasations of blood may take place beneath this 
fascia without any discoloration of the skin to in- 
dicate the fact, the blood being unable to reach 
the surface through the dense membrane. Such 
extravasations may be long pent up, and, as they 
fluctuate^ may be mistaken for abscess. 

Deep inflammations beneath this fascia, and 
especially when beneath the gluteus medius, may 
be associated with much pain, owing to the cir- 
cumstance that the inflammatory effusions^ will be 
pent up between a wall of bone on one side and 
a wall of dense fascia and stout muscle on the 
other. Abscesses so pent up may travel for a con- 
siderable distance down the thigh before they 
reach the surface, and Farabeuf relates a case 
where a gluteal abscess travelled to the ankle 
before it broke. 

Under other circumstances the gluteal abscess 
may make its way into the pelvis through the 
sciatic foramina, or a pelvic abscess may escape 
through one of these foramina and appear as a 
deep abscess of the buttock. 
2F 



482 SUEGICAL APPLIED ANATOMY [Part V 

The thickened part of the fascia lata that runs 
down on the outer side of the limb between the 
crest of the ileum above and the outer tuberosity 
of the tibia and head of the fibula below, is 
known as the ilio-tibial band. This band is tightly 
stretched across the gap between the iliac crest 
and the great trochanter, and if pressure be made 
with the fingers between these two points, the re- 
sistance of this part of the fascia can be appreci- 
ated. It is obvious that in fracture of the neck 
of the femur, when the great trochanter is made 
to approach nearer to the crest, this band will 
become relaxed, and Dr. Allis (Agnew's " Sur- 
gery/' vol. i.) has drawn attention to this fascial 
relaxation as of value in the diagnosis of frac- 
tures of the femoral neck. 

The lower free edge of the gluteus inaximus 
is oblique, and ends some way below the transverse 
line of the fold of the buttock. 

It would appear that even this great muscle 
may be ruptured by violence. Thus Dr. Mac- 
Donnell (Brit. Med. Journ.,^ 1878) reports the case 
of a robust man, aged sixty-three who, while 
trying to lift a heavy cart when in a crouching 
position, felt something give way in his buttock, 
and heard a snap. He fell, and was carried home, 
when it was found that the great gluteal muscle 
was ruptured near the junction of the muscle with 
its tendon. 

At least three bursae exist over the great 
trochanter, separating that process from the three 
gluteal muscles respectively. The most extensive 
is that between the insertion of the gluteus maxi- 
mus to the ilio-tibial band and outer surface of 
the great trochanter. The bursa allows the great 
trochanter to move freely beneath the muscle 
during rotation of the thigh. When this sac is 
inflamed much difficulty is experienced in moving 
the limb, and the thigh is generally kept flexed 
and adducted. This position means absolute rest 
from movement on the part of the gluteal muscles, 
which, when acting, would extend and abduct 



Chap. XIX] REGION OF THE HIP 483 

the limb, and bring pressure to bear upon the 
tender bursa. 

There is a bursa over the ischial tuberosity 
that is often inflamed in those whose employments 
involve much sitting, the bursa being directly 
pressed upon in that position. This sac is the 
anatomical basis of the disease known in older 
text-books as "weaver's bottom" or "lighter- 
man's bottom." When enlarged this bursa may 
press upon the inferior pudendal nerve. 

The arteries and nerves of the buttock. — 
The gluteal artery is about the same size as the 
ulnar, and the sciatic as the lingual. The 
former vessel may sometimes be of much greater 
magnitude, and has led, when wounded, to rapid 
death from haemorrhage. Wounds of the gluteal 
vessels will probablv involve only the branches of 
the artery, since # the greater part of the main 
trunk is situate within the pelvis. Gluteal aneur- 
isms are not very uncommon, and with regard to 
the treatment of these tumours it may be noted 
that the gluteal artery, or, better, the internal 
iliac trunk, can be compressed through the rectum. 
Compression so applied has been adopted for the 
treatment of gluteal aneurism by Dr. Sands, of 
New York (Amer. Journ. Med. Sc, 1881), but 
without much effect. Aneurism of the commence- 
ment of the gluteal artery could hardly fail to 
provoke nerve symptoms, since the vessel runs be- 
tween the lumbo-sacral cord and first sacral nerve. 

Both the gluteal and sciatic arteries have been 
ligatured in the buttock, through incisions made 
directly over the course of the vessels. 

Henle has collected six cases where the femoral 
artery ran down along the back of the thigh to 
the "Dopliteal snace in company with the great 
sciatic nerve. The abnormal vessel was in each 
case formed by an enlargement of the comes nervi 
ischiadici, a branch of the sciatic artery. 

The great sciatic nerve is a continuation 
downwards of the main part of the sacral plexus. 
It is in this nerve that the form of neuralgia 



484 SUEGICAL APPLIED ANATOMY [Part V 

known as sciatica is located. A reference to the 
immediate relations of this nerve will show that 
it may readily be exposed to many external in- 
fluences. Thus, in the pelvis it may be pressed 
upon by various forms of pelvic tumour, and 
sciatica be produced in consequence. Its anterior 
surface is in close relation with some of the princi- 
pal pelvic veins, and according to Erb one form 
of sciatica may be traced to an engorged condi- 
tion of these vessels. Aneurism of certain branches 
of the internal iliac artery within the pelvis, 
sciatic hernia, and accumulation of faeces within 
the rectum, may all cause neuralgia ' of this im- 
portant trunk. It is said to have been injured 
also by the pressure of the foetal head during 
tedious labours, and to be affected by violent 
movements of the hip, a circumstance readily 
understood if the close relation of the nerve to 
the hip-joint be borne in mind. The nerve is also 
near enough to the surface to be influenced by 
external cold, and to this influence many forms 
of sciatica are. ascribed. At the lower edge of 
the great gluteal muscle the trunk is still nearer 
to the surface, and this fact receives illustration 
in a case reported in Ziemssen's Cyclopaedia, 
where paralysis of the nerve followed its com- 
pression by the contracting scar of a bed : sore. 

Nerve stretching - . — The great sciatic nerve 
has been frequently cut down upon and stretched 
for the relief of certain nervous affections of the 
limb (see rj. 480). In connection with this pro- 
cedure it is important to know how great an 
amount of traction may be brought to bear upon 
this and other nerves without the cord giving way. 
Trombetta, who has paid much attention to this 
matter, gives the following weights as those re- 
quired fa> ^ break the undermentioned nerves : 
great sciatic, 183 pounds; internal popliteal, 114 
pounds ; anterior crural, 83 pounds ; median, 83 
pounds; ulnar and radial, 59 pounds; brachial 
plexus in the neck. 48 to 63 pounds; and brachial 
plexus in the axilla, 35 to 81 pounds. (In each 



Ohap. XIX] REGION OF THE HIP 485 

instance fractions have been omitted.) It must 
be borne in mind, however, as pointed out by Mr. 
Symington {Lancet, 1S78), that in forcibly stretch- 
ing the great sciatic nerve the trunk may be torn 
away from its attachments to the soft spinal cord 
before a sufficient force has been applied to rup- 
ture the nerve at the point stretched. The same 
observation applies to other large nerve-cords, 
such as those of the brachial plexus, that are 
stretched at a spot not far from their spinal con- 
nections. The great sciatic nerve may be stretched 
by flexing the extended lower extremity on the 
belly. This measure "has served to cure certain 
cases of sciatica. 

The skin of the buttock is well supplied with 
nerves, and tactile sensibility is almost as acute 
in this part as it is over the back of the hand, 
while it is more acute than is like sensibility 
in such parts as the back of the neck, the middle 
of the thigh, and the middle of the back. The 
sensation of the gluteal integument is derived 
from a number of different nerves, and it may 
possibly interest a school-boy who has been^ re- 
cently birched to know that the painful sensations 
reached his sensorium through some or all of the 
following nerves : offsets of the posterior branches 
of the lumbar nerves, some branches of the sacral 
nerves, the lateral cutaneous branch of the last 
dorsal nerve, the iliac branch of the ilio-hypo- 
gastric nerve, offsets of the external cutaneous 
nerve, and large branches of the small sciatic. 
These nerves are derived from four spinal seg- 
ments — the twelfth dorsal, first lumbar, second 
and third sacral (Fig. 105, p. 597). The second 
and third sacral also supply the sexual organs, 
hence the physiological effects which may follow 
application of punishment to this part, as in the 
celebrated case of J. J. Rousseau. 

It should be remembered that the pelvic vis- 
cera can be readily reached through the sciatic 
foramina from the buttock. I once saw a case at 
the London Hospital of a man who was admitted 



486 SUEGICAL APPLIED ANATOMY [Part V 

with an apparently insignificant stab of the but- 
tock. He died in a few days, of acute peritonitis; 
and the autopsy showed that the dagger had 
passed througn the great sacro-sciatic foramen, 
had entered the bladder and allowed urine to 
escape into the peritoneal cavity. The rectum 
has also been damaged in injuries to the buttock, 
and Anger records a case of an artificial anus 
situate upon the buttock, that had followed a gun- 
shot wound, which, after involving the buttock, 
had opened up the csecum. It is by this route that 
Kraske's operation for resection of the rectum 
is performed and Rigby's operation on the ureter. 

2. The region of Scarpa's triangle. — 
Surface anatomy. The most important land- 
marks in the region of the groin, the anterior 
superior iliac spine, the spine of the pubes, and 
Poupart's ligament, are readily made out. To 
the two spines reference has already been made 
(p. 322). Poupart's ligament follows a curved 
line, with its convexity downwards, drawn be- 
tween these two projections. It can be felt in 
even stout persons, its inner half more distinctly 
than its outer, and even in very fat individualsits 
position is indicated by a slight furrow. Owing 
to its attachment to the fascia lata the ligament 
is relaxed, and rendered less distinct when the 
thigh is flexed and adducted, or when it is rotated 
in. The mid-point of a line joining the pubic 
with the anterior superior spine lies over the 
head of the femur and hip joint. In this position 
a crease is often to be seen crossing the groin 
(Holden). 

The sartorius muscle is brought into view when 
the leg is raised across the opposite knee, and the 
adductor longus is rendered distinct when the 
thigh is abducted, and the individual's attempts 
to adduct the limb are resisted. Even in the 
obese the edge of this muscle can be felt when 
it is in vigorous action, and the fingers can 
follow its border up to the very origin of the 
muscle, just below the pubic spine. 



Chap. XIX] EEGION OF THE HIP 48? 

The lymphatic glands in this region can some- 
times be felt beneath the skin, especially in thin 
children. The femoral ring lies behind Poupart's 
ligament 1 inch externally to the pubic spine (Fig. 
57, p. 340). The position of the saphenous open- 
ing is sometimes indicated by a slight depression 
in the integuments. It lies just below Poupart's 
ligament, and its centre is about li inch below 
and external to the pubic spine. In thin sub- 
jects the long saphenous vein can be often made 
out, passing to the saphenous opening. 

If a line be drawn from the femoral point 
(Fig. 57, p. 340) to the tubercle for the adductor 
magnus, on the inner condyle of the femur, when 
the thigh is slightly flexed and abducted, it will 
correspond in the upper two-thirds of its extent 
to the position of the femoral artery. Just below 
Poupart's ligament the femoral vein lies to the 
inner side of the artery, while the anterior crural 
nerve runs about \ of an inch to its outer side. 
The profunda femoris arises about li inch below 
Poupart's ligament, and the internal and ex- 
ternal circumflex vessels come off about 2 inches 
below that structure. 

The skin over Scarpa's triangle is, unlike that 
of the buttock, comparatively thin and fine. The 
looseness of its attachment, also., to the parts im- 
mediately beneath, permits it to be greatly 
stretched, as is seen in cases of large femoral 
hernise, and in certain inguinal tumours of large 
size. It may even give way under severe traction, 
as occurred in a case reported by Berne. The 
patient in this case was a child aged 11, the sub- 
ject of hip disease. The thighs were flexed upon 
the abdomen, and, forcible extension being ap- 
plied to relieve the deformity, the skin gave way 
just below the groin, and separated to the extent 
of some 2^ inches. Contracting scars in the region 
of the groin may produce a permanent flexing of 
the hip, and this result is not uncommon after 
deep and severe burns in this neighbourhood. It 
may at the same time be noted that horizontal 



488 SUEGICAL APPLIED ANATOMY [Part V 

wounds about the groin can be well adjusted by 
a slight flexion of the thigh. 

Instances are recorded where a supernumerary 
mammary gland, provided with a proper nipple, 
has been found located in the groin. Jessieu 
relates the case of a female who had a breast so 
placed, and who suckled her child from this 
part (see p. 205). In a few cases the testicle, in- 
stead of descending into the scrotum, has escaped 
through the crural canal, and made its appear- 
ance in Scarpa's triangle. It has even mounted 
up over Poupart's ligament after the manner of a 
femoral hernia, being probably urged in that 
direction by the movements of the limb. > 

The superficial fascia in this region is not 
very dense, and has little or no influence upon 
the progress of a superficial abscess. This fact 
receives extensive illustration, since the glands in 
Scarpa's triangle frequently suppurate, and yet 
the pus in the great majority of cases readily 
reaches the surface in spite of the circumstance 
that the denser layer of the superficial fascia (for 
in this region it is divided into two layers) covers 
in those glands, and should hinder the progress 
of pus towards the surface. Although the sub- 
cutaneous fat is not peculiarly plentiful in this 
region, yet Scarpa's triangle is a favourite spot 
for lipomata. It is in this place that the fatty 
tumour often exhibits its disposition to travel, 
and several cases are reported where such a 
tumour has started at the groin and travelled 
some way down the thigh. The journey is always 
in the direction of gravity, and rendered possible 
by the lax capsule of the tumour, by the loose- 
ness of the tissue in which it is embedded, and by 
the fluidity of fat at the normal temperature of 
the body. 

The fascia lata completely invests the limb, 
being, so far as the front of the thigh is con- 
cerned, attached above to Poupart's ligament, to 
the body and ramus of the pubes, and the ramus 
of the ischium. Its integrity is interrupted only 



Chap. XIX] REGION OF THE HIP 489 

by the saphenous opening. This fascia exercises 
some influence upon deep abscesses and deep 
growths. Thus a psoas abscess reaches the thigh 
by following the substance of the psoas muscle, 
and finds itself, when it arrives at Scarpa's tri- 
angle, under the fascia lata. In a great number 
of cases it points where the psoas muscle ends, 
but in other and less frequent instances its pro- 
gress is decidedly influenced by the fascia lata, 
and it moves down the limb. Thus guided, a 
psoas abscess has pointed low down in the thigh, 
and even at the knee, and Erichsen reports a case 
where such an abscess (commencing, as it did, in 
the dorsal spine) was ultimately opened by the 
side of tne tendo Achillis. 

The ilio-psoas muscle, being stretched, as it 
were, over the front of the hip-joint, and partici- 
pating in many of the movements of that joint, 
is peculiarly liable to be sprained in violent exer- 
cises. Between this muscle and the thinnest part 
of the hip capsule is a bursa, which not unfre- 
quently communicates with the joint. When 
chronically inflamed, this bursa may form a large 
tumour on the front of the thigh that may, ac- 
cording to Nancrede, attain the size of a child's 
head. To relieve this bursa from pressure when 
inflamed, the thigh always becomes flexed, and a 
train of symptoms is produced that are not unlike 
those of hip disease. The deep origins of the ilio- 
psoas lie behind the caecum and kidney, and may 
elicit symptoms from those organs when con- 
tracted. 

The sartorius is a muscle that, from its length, 
peculiar action, etc., one would hardly expect to 
find ruptured from violence, yet in the Musee 
Dupuytren there is a specimen of such a rupture 
about the middle of the muscle united by fibrous 
tissue. The adductor muscles, and especially the 
adductor longus, are frequently sprained, or even 
partially ruptured, during horse exercise, the grip 
of the saddle being for the most part maintained 
by them. " Rider's sprains," as such accidents 



490 SURGICAL APPLIED ANATOMY [Part V 

are called, usually involve the muscles close to 
their pelvic attachments. Much blood is often 
effused when the fibres are ruptured, and such 
effusion may become so dense and fibrinous as to 
form a mass that has been mistaken for a detached 
piece of the pubes (Henry Morris). The term 
'' rider ; s bone ;; refers to an ossification of the 
upper tendon of the adductor longus or magnus, 
following a sprain or partial rupture. Cases are 
reported where the piece of bone in the tendon 
was \ an inch, 2 inches, and even 3 inches long. 

Blood-vessels. — The femoral artery occupies 
so superficial a position in Scarpa's triangle that 
it is not unfrequently wounded. The vessel also 
has been opened up by cancerous and phagedenic 
ulcerations of this part, the occurrence leading to 
fatal haemorrhage. Pressure is most conveniently 
applied to the artery at a spot immediately below 
Poupart's ligament, and should be directed back- 
wards, so as to compress the vessel against the 
pubes and adjacent parts of the hip capsule. 
Lower down, compression should be applied in a 
direction backwards and outwards, so as to bring 
the artery against the shaft of the femur, which 
lies at some distance to its outer side. Pressure 
rudely applied by a tourniquet may cause phle- 
bitis by damaging the vein, or neuralgia by con- 
tusing the anterior crural nerve. 

From the proximity of the artery and vein, 
it happens that arterio-venous aneurisms follow- 
ing wounds have been met with in this situa- 
tion. Aneurism is frequent in the common 
femoral, and many reasons can be given why that 
vessel should be attacked. It is just about to 
bifurcate into two large trunks, its superficial 
position exposes it to injury, it is greatly influ- 
enced by the movements of the hip, and its coat 
may, if diseased, be damaged by those movements, 
if excessive. 

Phlebitis of the femoral vein has in many cases 
followed contusion of the vessel in its upper or 
more superficial part, and a like result has even 



Chap. XIX] REGION OF THE HIP 491 

followed from violent flexion of the thigh. The 
long saphenous vein is often varicose, and one 
form of the varicosity is said to depend upon con- 
striction of the vein by an unduly narrow saphen- 
ous opening. That varicose veins are, m the 
majority o± cases, of congenital origin is now 
very generally allowed. 

The anterior crural nerve lies on the ilio- 
psoas muscle, and it is said that neuralgia, and 
even paralysis of the nerve, may follow upon in- 
flammation of that muscle and upon psoas abscess. 
The superficial position of the trunk exposes it to 
injury. The genito-crural nerve (the nerve that 
supplies the cremaster muscle) gives a sensory fila- 
ment to the integument of the thigh in Scarpa's 
triangle. Irritation of the skin over the seatof 
this nerve, which is placed just to the outer side 
of the femoral artery, will cause, in children, a 
sudden retraction of the testicle. The same result 
is often seen in adults, also, on more severe stimu- 
lation. In this manner the condition of the second 
lumbar segment of the cord may be tested. 

The lymphatic glands in this region are 
numerous, and as they are frequently the seat of 
abscess, it is important to know from whence they 
derive their afferent vessels. They are divided 
into a superficial and a deep set. The superficial 
set, averaging from ten to fifteen glands, is ar- 
ranged in two groups, one parallel and close to 
Poupart's ligament (the horizontal series), the 
other parallel and close to the long saphenous vein 
(the vertical series). The deep set, about four in 
number, are placed along the femoral vein, and 
reach the crural canal. 

The inguinal glands receive the following lym- 
phatics : 

Superficial vessels of lower limb = vertical set 
of superficial glands. 

Superficial vessels of lower half of abdomen = 
middle glands of horizontal set. 

Superficial vessels from outer surface of but- 
tock = external glands of horizontal set. 



492 SUEGICAL APPLIED ANATOMY [Part V 

From inner surface of buttock = internal 
glands of horizontal set. (A few of these vessels 
go to the vertical glands.) 

Superficial vessels from external genitals = 
horizontal glands, some few going to vertical set. 

Superficial vessels of perineum and anus = 
vertical set. 

Deep lymphatics of lower limb = deep set of 
glands. 

The lymphatics that accompany the obturator, 
gluteal, and sciatic arteries, and the deep vessels 
of the penis, pass to the pelvis and have no con- 
nection with the inguinal glands. The only super- 
ficial lymphatics of the lower extremity which do 
not pass direct to the inguinal glands are those 
which drain the outer side of the ankle and pos- 
terior aspect of the leg. The vessels from these 
areas accompany the short saphenous vein and 
end in the popliteal glands ; the efferent vessels 
from these glands pass to the deep inguinal set. 

One of the deep glands lies in the crural canal 
and upon the septum crurale. Being surrounded 
by dense structures, it is apt to cause great dis- 
tress when inflamed and great pain when the hip 
is moved. In some cases, by reflex disturbance, 
it has produced symptoms akin to those of 
strangulated hernia. Some branches of the an- 
terior crural nerve lie over the inguinal lymph 
glands, and Sir B. Brodie reports a case in which 
these branches were stretched over two enlarged 
glands, like strings of a violin over its bridge, 
so that violent pain and convulsive movements 
were set up in the limb. 

The efferent vessels from the inguinal glands 
Dass through a chain of lymphatic glands stretch- 
ing along the course of the external and common 
iliac vessels. Three of these glands lie imme- 
diately above Poupart's ligament. The efferent 
vessels of the internal iliac group of glands, into 
which the pelvic lymphatics drain, join the chain 
along the common iliac vessels. The lumbar 
glands receive the lymph from the iliac groups 



Chap. XIX] EEGION OF THE HIP 



493 



and pass it on by the right and left lumbar trunks 
to the receptaculum chyli. 

Elephantiasis Arabum is more common in the 




Fig. 76. — Vertical section of the upper third of the thigh showing the 
structures in relationship with the hip-joint. {After Braune.) " 

Muscles.— 1, psoas ; 2, iliaeus ; 3, gluteus medius ; 4, glutens minimus ; 5, obturator 
interims ; 6, obturator externus ; 7, ilio-psoas ; 8, pectineus ; 9, adductor 
magnus ; 10, adductor brevis ; 11, gracilis ; 12. adductor tongus ; 13, vastus 
intemus ; 14, vastus externus. a, anterior crural nerve ; b, external iliac, 
artery; c. external iliac vein; d, obturator nerve; e, obturator artery; 
/, branches of obturator vessels to hip-joint ; g, internal circumflex vessels ; 
'/(, deep femoral vessels: i, branch of external circumflex ; j, bursa over sreat 
i rochanter ; k, reflections of capsule to neck of femur ; m, asc. ramus of pubes ; 
v, peritoneum ; o, iliac fascia. 

lower limb than in any other part, and leads to an 
enormous increase in the size of the extremity 
(Cochin or Barbadoes leg). Its pathology is in- 
timately concerned with the crural lymphatics. 
The lymphatics are obstructed by a small thread- 



494 SUEGICAL APPLIED ANATOMY [Part V 

worm, Filaria sanguinis hominis. The lymph ves- 
sels and lymph spaces in the connective tissue be- 
come greatly distended, and the elements of the 
connective tissue hypertrophied. 

The hip-joint.— The hip-joint is an articula- 
tion of considerable strength (Fig. 76). This 
strength depends not only upon the shape of the 
articulating bones, which permits of a good ball- 
and-socket joint being formed, but also upon the 
powerful ligaments that connect them and the 
muscular bands that directly support the capsule. 
These advantages, however, are to some extent 
counterbalanced by the immense leverage that can 
be brought to bear upon the femur, and the 
numerous strains and injuries to which the joint 
is subjected, as the sole connecting link between 
the trunk and the lower limb. 

The acetabulum is divided into an articular 
and a non-articular part. The former is of 
horse-shoe shape, and varies from 1 inch to \ an 
inch in width. The bone immediately above the 
articular area is very dense, and through it is 
transmitted the superincumbent weight of the 
trunk. The non-articular part corresponds to the 
area enclosed by the horse-shoe, and is made up 
of very thin bone. In spite of its thinness it is 
very rarely fractured by any violence that may 
drive the femur up against the pelvic bones, since 
no ordinary force can bring the head of the thigh- 
bone in contact with this segment of the os in- 
nominatum. 

Pelvic abscesses sometimes make their way into 
the hip-joint through the non-articular part of the 
acetabulum, and an abscess in the hip-joint may 
reach the pelvis by the same route. But both 
such circumstances are rare. In some cases of 
destructive hip disease the acetabulum may separ- 
ate into its three component parts. Up to the age 
of puberty these three bones are separated by the 
Y-shaped cartilage. At puberty the cartilage be- 
gins to ossify, and by the eighteenth year the 
acetabulum is one continuous mass of bone. The 



Chap. XIX] REGION OF THE HIP 495 

breaking up of the acetabulum by disease, there- 
fore, is only possible before that year. 

The manner in which the various movements at 
the hip are limited may be briefly expressed as 
follows. Flexion, when the knee is bent, is limited 
by the contact of the soft parts of the groin, and 
by some part of the ischio-femoral ligament; when 
the knee is extended the movement is limited by 
the hamstring muscles. Extension is limited by 
the ilio-femoral or Y ligament. Abduction, by the 
pubo-femoral ligament. Adduction of the flexed 
limb is limited by the ligamentum teres and ischio- 
femoral ligament, and of the extended limb by 
the outer fibres of the ilio-femoral ligament and 
upper part of the capsule. Rotation outwards is 
resisted by the ilio-femoral ligament, and especi- 
ally by its inner part, during extension, and by 
the outer limb of that ligament and the liga- 
mentum teres during flexion. Rotation inwards 
is limited during extension by the ilio-femoral 
ligament, and during flexion by the ischio-femoral 
ligament and inner part of the capsule. The 
structures which take the chief part in maintain- 
ing the integrity of the joint, however, are not 
the ligaments but the strong muscles which sur- 
round and act on the joint. Atmospheric pres- 
sure takes no part, for the fat at the transverse 
notch is readily drawn into the acetabulum to 
make good any space vacated by the femoral head 
in all normal movements of the hip-joint. 

Hip-joint disease—Owing to its deep posi- 
tion and its thick covering of soft parts (Fig. 76), 
this articulation is able to escape, to a great ex- 
tent, those severer injuries that are capable of 
producing aciite^ inflammation in other joints. 
Acute synovitis is indeed auite rare in the hip, 
and the ordinary disease of the part is of a dis- 
tinctlv chronic character. It follows, also, from 
the deep^ position of the articulation that pus, 
when it is formed in connection with disease, re- 
mains pent up, and is long before it reaches the 
surface. Suppuration in this region, therefore, 



496 SUEGICAL APPLIED ANATOMY [Part V 

is often very destructive. When effusion takes 
place into the joint, the swelling incident thereto 
will first show itself in those parts where the hip 
capsule is the most thin. The thinnest parts of the 
capsule are in front and behind; in front, in the 
triangular interval between the inner edge of the 
Y ligament and the pubo-femoral ligament, and 
behind at the posterior and lower part of the 
capsule. It is over these two districts that the 
swelling first declares itself in cases of effusion 
into the joint, and as these parts are readily ac- 
cessible to pressure, it follows that they corre- 
spond also to the regions where tenderness is most 
marked and is earliest detected. 

In chronic hip disease, certain false positions 
are assumed by the affected limb, the meaning of 
which it is important to appreciate. These posi- 
tions may be arranged as follows, according, as 
nearly as possible, to their order of appearing : 

(1) The thigh is flexed, abducted, and a little 
everted ; and associated with this there is (2) 
apparent lengthening of the limb and (3) lordosis 
of the spine ; (4) the thigh is adducted and in- 
verted, and incident to this there is (5) apparent 
shortening of the limb ; (6) there is real shorten- 
ing of the limb. 

(1). The first position is simply the posture of 
greatest ease. It depends^ mainly upon the ef- 
fusion into the joint. If fluid be forcibly injected 
into a hip-joint the thigh becomes flexed, abducted, 
and a little everted. In other words, the articula- 
tion holds the most fluid when the limb is in this 
position, and the patient places it there to relieve 
pain by reducing the tension within the capsule 
to a minimum. Flexion is the most marked fea- 
ture in this position. Its effect is pronounced. 
It relaxes the main part of the Y ligament, which, 
when the limb is straight, is drawn as an unyield- 
ing band across the front of the joint. Abduc- 
tion relaxes the outer limb of this ligament and 
the upper part of the capsule. Eversion slightly 
relaxes the inner limb of the Y ligament and the 



Chap. XIXj 



REGION OF THE HIP 



497 



ischio-femoral ligament. The latter movement is 
the least marked, since eversion, even in the flexed 
position of the joint, is resisted by the outer part 
of the Y ligament. Any but a moderate degree of 
abduction would be limited by the pubo-femoral 
ligament, especially as that band is rendered most 
tense when abduction is combined with flexion 
and rotation out- 
wards. The attach- 
ments of the psoas 
muscle are approxi- 
mated and its pres- 
sure over the joint 
relaxed. 

(2). The apparent 
lengthening is due to 
the tilting down of 
the pelvis on the dis- 
eased side, and is the 
result of the pa- 
tient's attempts to 
overcome the effects 
of the position just 
described. The limb 
is shortened by 
flexion and abduc- 
tion, and to bring A 
the foot again to the pi 
ground and to re 
store the 
parallelism of the 
limbs, the pelvis has 
to be tilted down on 
the affected side. Thus, an apparent lengthening is 
produced, which is seen when the patient lies upon 
a bed and the abduction is made to disappear. Real 
lengthening of the limb can scarcely be produced 
by the effusion into the joint. By forcible injection 
into the joint Braune could only separate the arti- 
culating surfaces about -,th of an inch. 

(3). The lordosis, or curving forwards, of the 
spine occurs in the dorso-lumbar region. It 
2g 




7,. — Diagram to show the mode of 
production of lordosis in hip disease. 

natural A - Femur flexed at hip, pelvis (represented 
by the dotted line) straight, and spine 
normal, b, The flexion concealed or over- 
come by lordosis of the spine; the pelvis 
rendered oblique. 



498 SUKGICAL APPLIED ANATOMY [Part V 

depends upon the flexion of the limb, and is the 
result of an attempt to conceal that false position, 
or at least to minimise its inconveniences (Fig. 
77). When the thigh is flexed at the hip by- 
disease, the lower limb can be made to appear 
straight by simply bending the spine forwards in 
the dorso-lumbar region without effecting the least 
movement at the disordered joint. Indeed, the 
movement proper to the hip is in this case trans- 
ferred to the spine. A patient with a flexed hip 
as the result of disease can lie on his back in bed, 
with both limbs apparently perfectly straight, he 
having concealed the flexion, as it were, by pro- 
ducing a lordosis of the spine. If the lordosis be 
corrected and the spine be made straight again, 
then the flexion of the hip reappears, although 
all the time the hip-joint has been absolutely 
rigid. This lordosis generally appears a little 
late in the disease, and after the limb has become 
more or less fixed in the false positions by con- 
traction of the surrounding muscles. 

(4). Sooner or later, in hip disease, the thigh 
becomes adducted and inverted, while it still 
remains flexed. The head of the femur then rests 
on the upper and posterior part of the acetabu- 
lum, quite half of it being outside the socket. 
This position has been variously accounted for. 
According to one theory, it is due to softening and 
yielding of some parts of the inflamed capsule. 
It is more probable that this false position, and 
especially the adduction, depends upon muscular 
action. The muscles about the joint are in a 
state of irritability. They are contracted by a 
reflex action that starts from the inflamed articu- 
lation, and since the adductor muscles are sup- 
plied almost solely by the obturator nerve, it is 
not unreasonable to expect them to be especially 
disturbed if_ the large share tfrat the obturator 
nerve takes in the supply of the hip be borne in 
mind. The whole matter, however, requires 
further investigation. 

(5). Apparent shortening of the limb is due to 



Chap. XIX] 



REGION OF THE HIP 



499 



tilting up of the pelvis on the diseased side, and 
bears the same relation to adduction that ap- 
parent lengthening bears to abduction. To over- 
come the adduction, and to restore the natural 
parallelism of the limbs, the patient tilts up one 
side of his pelvis (Fig. 78). It thus happens that 
a patient with his femur flexed and adducted by 
disease may lie in bed with both limbs quite 
straight and parallel, but with one limb obviously 



B 



B 




B 



Fig. 7S. — A, Parts in normal position. B, The adduction corrected by 
tilting up tlie pelvis. C, Femur adducted. 

AC, Line of pelvis ; ab, limb on diseased side : CD, limb on sound side ; E, the spine. 
It will be found that in Figs. B and C the angle at A is the same in the two 

cases. 

shorter than the other. The flexion in such a case 
is concealed by lordosis, and the adduction by 
the tilting of the pelvis. In some cases of simul- 
taneous disease in both hip-joints that has been 
indifferently treated, both thighs may remain ad- 
ducted. The limbs are unable, of course, to 
remedy their position by the usual means, when 
the disease is double, and consequently one limb 
is crossed in front of the other, and the peculiar 
mode of progression known as " cross-legged pro- 
gression ; ' is produced. 



500 SURGICAL APPLIED ANATOMY [Part V 

(6). The real shortening depends upon destruc- 
tive changes in the head of the bone, or upon 
dislocation of the partly disintegrated head on to 
the dorsum ilii, through yielding of the softened 
capsule and the crumbling away of the upper and 
posterior margin of the acetabulum. 

When hip disease commences in the bone it 
usually involves the epiphyseal line that unites 
the head of the femur to the neck. This line is 
wholly within the joint, and the epiphysis that 
forms the head unites with the rest of the bone 
about the eighteenth or nineteenth year (Fig. 76). 

When the bone is primarily involved the posi- 
tion of flexion and abduction with eversion may 
not be observed at all, there being no effusion at 
first into the joint. In such cases the limb be- 
comes at once flexed and adducted, and this pos- 
ture is probably due solely to muscular spasm, 
and to an attempt to prevent the head of the 
femur from pressing against the acetabulum, and 
so causing pain. 

It is well known that patients with hip disease 
often complain of pain in the knee. This referred 
pain may be so marked as to entirely withdraw 
attention from the true seat of disease. Thus I 
once had a child sent to the hospital with a sound 
knee carefully secured in splints, but without any 
appliance to the hip, which was the seat of a 
somewhat active inflammation. This referred 
pain is easy to understand, since the two joints 
are supplied from the same segments of the spinal 
cord. In the hip, branches from (1) the anterior 
crural enter at the front of the capsule ; (2) 
branches from the obturator at the lower and 
inner part of the capsule : and (3) branches from 
the sacral plexus and sciatic nerve at the pos- 
terior part of the joint. In the knee, branches 
from (1) the anterior crural (nerves to vasti) 
enter at the front of the capsule ; (2) branches 
from the obturator at the posterior part of the 
capsule ; and (3) branches from the internal and 
external popliteal divisions of the great sciatic 



Chap. XIX] REGION OF THE HIP 50l 

nerve at the lateral and hinder aspects of the 
joint. 

Pain, therefore, in the front of the knee, on 
one or both sides of the patella, has probably been 
referred along the anterior crural curve, and 
pain at the back of the joint along the obturator 
or sciatic nerves. 

In hysterical individuals joint disease may be 
imitated by certain local nervous phenomena, the 
articulation itself being quite free from struc- 
tural change. This affection most commonly 
shows itself in the hip or knee, and the " hys- 
terical hip," or " hysterical knee, ; ' takes a prom- 
inent place in the symptomatology of hysteria. 
It is not quite easy to understand why these two 
large joints should be so frequently selected for 
the mimicry of disease. Hilton has endeavoured 
to explain the fact upon anatomical grounds, 
having reference to the nerve supply of these 
joints in relation to the nerve supply of the 
uterus. The uterus is mainly supplied by an 
offshoot from the hypogastric plexus, and by the 
third and fourth sacral nerves. Now, the hypo- 
gastric plexus contains filaments derived from the 
lower lumbar nerves; and from the same trunks 
two nerves to the hip and knee (the anterior 
crural and obturator) are in great part derived. 
The great sciatic also contains a large portion 
of the third sacral nerve. The common origin of 
the joint and uterine nerves forms the basis 
of Hilton's explanation of the relative frequency 
of hysterical disease in the large articulations of 
the lower limb. The explanation, however, is un- 
satisfactory, since the uterus receives many of its 
nerves from the ovarian plexus, and the theory is 
founded upon the unwarranted supposition that 
all hysterical disorders are associated with some 
affection of the uterus or its appendages. More 
recently Head has revived a modified form of 
Hilton's theory. He explains the connection not 
through an anatomical association of nerves, but 
through an association of the centres from which 



502 SUEGICAL APPLIED ANATOMY [Part V 

nerves arise in the spinal cord. The spinal seg- 
ments from which the obturator nerve arises, the 
second, third, and fourth, contain no visceral 
nerves, and, therefore, cannot be associated with 
visceral conditions. On the other hand, the 
sacral segments from which the great sciatic nerve 
arises are those which supply the pelvic viscera. 

Fractures of the upper end of the femur 
may be divided into (1) fractures of the neck 
wholly within the capsule ; (2) fractures of the 
base of the neck not wholly within the capsule ; 
(3) fractures of the base of the neck involving the 
great trochanter ; (4) separations of epiphyses. It 
can be scarcely possible, apart from gunshot in- 
juries, to fracture the neck of the femur by direct 
violence, owing to the depth at which the bone 
is placed, and the manner in which it is protected 
by the surrounding muscles. The violence, there- 
fore, that causes the lesion is nearly always sup- 
plied indirectly to the bone, as by a fall upon the 
feet or great trochanter, or by a sudden wrench 
of the lower limb. 

(1). The true intercapsular fracture may involve 
any part of the cervix within the joint, but is 
most usually found near the line of junction of 
the head with the neck. This fracture is most 
common in the old, in whom it may be produced 
by very slight degrees of violence. The liability 
of the aged to this lesion is explained upon the 
following grounds : The angle between the neck 
and shaft of the femur, which is about 130° in 
a child, tends to diminish as age advances, so 
that in the old it is commonly about 125°. In 
certain aged subjects, as a result probably of gross 
degenerative changes, this angle may be reduced 
to a right angle. This diminution of the angle 
certainly increases the risk of fracture of the 
neck of the bone. There is often, also, in ad- 
vanced life, much fatty degeneration of the can- 
cellous tissue of the cervix with thinning of the 
compact layer. Dr. Merkel (Amer. Journ. Med. 
Sc, 1874) also asserts that in old persons there is 



Chap. XIX] REGION OF THE HIP 503 

an absorption of that process of the cortical sub- 
stance which runs on the anterior part of the neck 
between the lesser trochanter and the under part 
of the head. This process he calls the " calcar 
femorale," and maintains that it occupies the 
situation at which the greatest pressure falls when 
the body is erect. These fractures are but rarely 
impacted ; but when impacted, the lower frag- 
ment, represented by the relatively small and 
compact neck, is driven into the larger and more 
cancellous fragment made up of the head of the 
bone. The fracture may be subperiosteal, or the 
fragments may be held together by the reflected 
portion of the capsule. These reflected fibres pass 
along the neck of the bone from the attachment 
of the capsule at the femur to a point on the 
cervix much nearer to the head. " These reflected 
fibres occur at three places, one corresponding in 
position to the middle of the ilio-femoral liga- 
ment, another to the pectineo-femoral, and the 
third on the upper and back part of the neck " 
(Henry Morris). Fractures of this part very 
rarely indeed unite by bone. Blood is brought to 
the head of the femur by vessels in the neck of the 
bone, in the reflected parts of the capsule, and in 
the ligamentum teres. When the first two sources 
of blood supply are cut off by the fracture, the 
third does not appear to be sufficient to allow of 
great reparative changes taking place in the 
upper fragment. The fractures that heal by bone 
are probably either impacted, or subperiosteal, or 
not wholly intracapsular. 

(2). With regard to fractures at the base of the 
neck, it must be remembered that a wholly extra- 
capsular fracture of the neck of the femur is an 
anatomical impossibility. If the fracture is 
wholly without the capsule, then it must involve a 
part of the femoral shaft, and cannot be entirely 
through the cervix. In the front of the bone the 
capsule is attached to the femur along the 
intertrochanteric line, and strictly follows the 
line of junction between the cervix and the shaft. 



504 SURGICAL APPLIED ANATOMY [Part V 

Behind, the capsule is inserted into the neck about 
^ an inch above the posterior intertrochanteric 
line. It is therefore possible for a fracture of the 
neck to be extracapsular behind, but not in front, 
and many of these lesions at the base of the neck 
have this relation to the capsule. The Y liga- 
ment is so thick, being in one place about \ of an 
inch in thickness, that a fracture involving the 
base of the cervix may run between its fibres at 
their attachment, and be neither extra- nor intra- 
capsular. When fractures at the junction of the 
neck and shaft are impacted, the upper fragment, 
represented by the compact and relatively small 
cervix, is driven into the cancellous tissue about 
the great trochanter and upper end of the 
shaft. As a result of this impaction the tro- 
chanter may be split up, and the bones may be- 
come free again through the extent of this 
splintering. 

With regard to the symptoms of a fracture 
of the neck of the feimir, the following may 
be noticed : (a) The swelling often observed in 
the front of the limb, just below Poupart's liga- 
ment, is due either to effusion of blood into the 
joint or to projection of the fragments against 
the front of the capsule ; (b) the shortening is 
brought about by the glutei, the hamstrings, the 
tensor vaginae femoris, the rectus, sartorius, and 
ilio-psoas, the adductors, gracilis and pectineus ; 
(c) the eversion, or rotation outwards of the limb, 
is mainly due to two causes : (i.) the weight of 
the limb, which causes it to roll outwards, as is 
seen in persons insensible or asleep, the line of 
gravity passing through the outer part of the 
thigh; (ii.) the fact that the compact tissue on the 
posterior aspect of the neck is much more fragile 
than that on the anterior aspect. Thus the cervix 
is often more extensively fractured behind than in 
front, or the fracture may be impacted behind 
but not in front, and in either case the limb will 
tend to become everted. As a third cause may 
be mentioned the action of the ilio-psoas, the 



Chap. XIX] REGION OF THE HIP 



505 



adductor and pectineus muscles, and of the small 
rotator muscles, all of which will tend to roll the 
femur outwards. 

(3). Fracture of the base of the neck, involving 
the great trochanter. In this lesion the head, 
the cervix, and a part of the great trochanter 
are separated from the shaft and rest of the tro- 
chanter. 

(4). Separation of epiphyses. There are three 
epiphyses in the upper end of the femur : one for 
the head, which unites between eighteen and nine- 
teen ; one for the lesser trochanter, which unites 




Fig. 79. — Illustrating the ossification of the upper extremity of the 
femur and the condition of coxa vara. {After Elmslie.) 

a, The upper extremity at birth. 

b, ,, „ „ „ 2nd year. 

c, „ „ „ „ 4th year. 

jj, „ ,, „ of a femur from ' 

a subject of coxa vara. 

about seventeen ; and one for the greater tro- 
chanter, which unites about eighteen. The neck 
is formed by an extension of ossification from the 
shaft (Fig.' 79). The epiphysis for the head is 
secured against separation by being shaped like a 
cap, by its epiphyseal line being arranged trans- 
versely to the axis of the femur, and also by its 
intracapsular position. The epiphysis, however, 
is subject to a peculiar form of dislocation which 
gives rise to the condition of coxa vara. The 
epiphysis gradually tilts downwards so that the 
neck of the femur appears to sink under the 
weight of the body, coming to form an angle of 
90° or less with the shaft of the femur. It occurs 
in adolescents. Owing to the prominence of the 



506 



SURGICAL APPLIED ANATOMY [Part V 



trochanter and shortening of the limb which 
necessarily result, the condition may be mistaken 
for a fracture of the neck of the femur or a con- 
genital dislocation of the hip-joint. The great 
trochanter may be separated. The epiphyseal lines 
of the head and great trochanter are continuous 
until the neck is ossified (see Fig. 79). 

Dislocations of the hip. — These injuries are 
comparatively rare, on account of the great 
strength of the articulation, and when they occur 
in a healthy joint are always the result of a con- 
siderable degree of violence. A dislocation of the 



y- 5/iaped Cartilage 

ACETABULUM 

PuBES 

5yMPnysis 




C.RT TROCrtArtTER 



,2LyL-PECTIMEU3 

Adductor lohCus 
Capsulc 
Psoas 



Fig 80.— Congenital dislocation of the hip. 

From a specimen presented to the London Hospital Medical College Museum 
by Mr. Openshaw. It was obtained from a child aged 4 years. 

hip may be congenital, or may be spontaneously 
produced by muscular efforts, as shown in a few 
rare cases, or may be the result of disease of the 
articulation. Congenital dislocation of the hip- 
joint is due- in most instances to a failure in the 
development of the acetabulum. In such cases the 
acetabulum retains the shallow character seen 
during the second month of foetal life. The out- 
growth of the acetabular rim fails, especially in 
the iliac part. The acetabular cavity becomes 
filled up by the duplication of the capsule, which 
is unduly lax (Fig. 80). The round ligament may 
be intact or deficient. The head of the femur be- 
comes flat and the neck short, and the bone slips 
backwards on the dorsum ilii when the child 



Chap. XIX] REGION OF THE HIP S07 

learns to walk. The weight of the body is sup- 
ported by the muscles and ligaments round the 
hip-joint. If replaced the head again slips from 
the shallow cavity. In time osteophytic out- 
growths from the ilium lead to the formation of a 
new cavity. The deformity is evidently corre- 
lated with the development of the female sexual 
organs, for it is practically unknown in male 
children. 

In dislocations due to violence the head of the 
bone may be found displaced in four directions, 
producing the four regular dislocations of the 
hip. In two the head of the femur is posterior 
to a line drawn vertically through the acetabulum, 
and in the other two it is found anterior to that 
line. 

(1) Backwards and upwards. Head rests upon 
ilium, just above and behind acetabulum. The 
" dislocation upon the dorsum ilii." (2) Back- 
wards. Head rests upon ischium, and, as a rule, 
about on a level with the ischial spine. The " dis- 
location into the sciatic notch." (3) Forwards 
and downwards. Head rests on thyroid foramen. 
The " obturator or thyroid dislocation" (4) For- 
wards and upwards. Head rests upon the body 
of the pubes, close to its junction with the ilium. 
The ''''dislocation upon the pubes." 

The above arrangement represents also the 
order of frequency of these luxations, No. 1 being 
the most common dislocation of this part, and 
No. 4 the most rare. 

General facts. — In all these dislocations of 
the hip, (a) the luxation occurs when the limb is 
in the position of abduction ; (b) the rent in the 
capsule is always at its posterior and lower part; 
(c) the head of the bone always passes at first more 
or less directly downwards ; (a) the Y ligament 
is untorn, while the ligamentum teres is ruptured. 

(a) It is maintained that in all luxations at 
the hip, the pelvis_ and femur are in the mutual 
position of abduction of the latter at the time of 
the accident. The direction of the neck of the 



508 SURGICAL APPLIED ANATOMY [Part V 

femur and of the acetabulum, and the position of 
the cotyloid notch, all favour dislocation in the 
abducted posture. The lower and inner part of 
the acetabulum is very shallow, and the lower and 
posterior part of the capsule is very thin. In 
abduction, the head of the bone is brought to the 
shallow part of the acetabulum; it moves more 
than half out of that cavity ; it is supported 
only by the thin weak part of the capsule, and its 
further movement in the direction of abduction 
is limited only by the pubo-femoral ligament, a 
somewhat feeble band. In abduction the round 
ligament is slack, and in abduction with flexion 
both the Y ligament and the ischio-femoral liga- 
ments are also relaxed. In the position of abduc- 
tion, therefore, no great degree of force may be 
required to thrust the head of the bone through 
the lower and posterior part of the capsule and 
displace it downwards. 

(6) The above being allowed, it will be under- 
stood that the rent in the capsule is always at its 
posterior and lower parts. " Generally the rup- 
ture is jagged and irregular, but will be found 
to extend more or less directly from near the 
shallow rim of the acetabulum, across the thin 
portion of the capsule to the femur near the small 
trochanter, and then to run along the back of the 
ligament close to its attachment to the neck of the 
bone " (Henry Morris). 

(c) If the position of the limb at the time of the 
accident be considered, it will be seen that the 
femur will in every case be displaced downwards. 
There is, indeed, but one primary dislocation of 
the hip — a luxation downwards. The four forms 
given above are all secondary, the bone having in 
each instance first passed downwards before it 
moved to any of the positions indicated. This 
point has been ably demonstrated by Mr. Henry 
Morris, whose account of the anatomy of hip dis- 
locations is most valuable. The head having left 
the acetabulum, its ultimate destination will de- 
pend upon the character of the dislocating force. 



Chap. XIX] 



REGION OF THE HIP 



509 



" If the limb be flexed on the pelvis, and rotated 
inwards, or the pelvis be correspondingly moved 
on the thigh at the moment of displacement, the 
head of the femur will take a backward course 
and rest on the dorsum ilii or some part of the 
ischium. On the other hand, extension and out- 
ward rotation will cause the head of the bone to 
travel upwards and forwards, and what is called 
a dislocation on to the pubis will occur. _ . . . 
If the dislocation is neither accompanied nor 
followed by rota- 
tion or fixed 
flexion or exten- 
sion, the head of 
the femur will 
remain below the 
acetabulum, and 
will occupy the 
foramen ovale if 
it takes a slightly 
forward direction 
in its descent, 
or some position 
near the tuber- 
osity of the ischi- 
um if it leaves its 
socket in a back- 
ward and down- 
ward direction J ' 
(Henry Morris). 
(d) The Y liga- 
ment is never 
torn in any regu- 
lar dislocation. It is saved by its great density 
and the circumstance that it is probably more 
or less relaxed at the time of the luxation. The 
method of reducing these dislocations by manipu- 
lation > depends for its success mainly upon the 
integrity of the Y ligament, which acts as the 
fulcrum to a lever of which the shaft of the 
femur is the long arm and the neck the short. 
In the backward luxations the head is behind the 




Fig. 81. — Dislocation upon the dorsum ilii. 
(Bigeloiv.) 



510 



SURGICAL APPLIED ANATOMY [Part V 



Y ligament, and in the forward displacements in 
front of it. 

The anatomy of each form. — Nos. 1 and 2. 

The dislocations backwards (Fig. 81). The femoral 
head, having been displaced in the way; indicated, 
is carried towards the dorsum or sciatic notch 
by the glutei, hamstring, and adductor^ muscles. 
The bone having taken a general direction back- 
wards, the height to which it ascends • depends 
mainly upon the nature of the dislocating force, 
and also upon the extent of the rupture in the 

capsule and the 
laceration of the 
obturator internus 
tendon and other 
small external ro- 
tators. The dorsal 
dislocation is, 

therefore, a more 
advanced grade of 
the sciatic. The 
more extreme the 
flexion and inward 
rotation at the time 
of the accident, the 
more likely is the 
dislocation to be 
sciatic. More 

moderate flexion 
and inward rota- 
tion will produce a 
luxation upon the 
dorsum. In the 
dorsal luxation the 
head is above the 
obturator internus tendon, while in the sciatic 
form it is below it (Bigelow). Morris has been 
able to find but one case of direct dislocation of 
the femur backwards on to the ischium. In every 
instance it passes first in a downward direction, 
and then backwards. 

Bigelow states that there is no evidence to show 




Pig. 82. 



-Obturator or thyroid dislocation. 
{Bigelow.) 



Chap. XIX] REGION OF THE HIP 



511 



that the head of the femur has even been actually 
displaced into the sciatic notch. 

In these backward dislocations the ilio-psoas 
muscle is greatly stretched. The quadratics 
femoris, the obturators, the gemelli, and the pyri- 
formis are more or less 
lacerated. The pecti- 
neus is often torn, and 
the glutei muscles even 
may be rupture d_ in 
part. The great sciatic 
nerve may be compressed 
between the femoral 
neck and the rotator 
muscles, or between the 
head of the bone and 
the tuber ischii. In both 
of the backward luxa- 
tions there is shorten- 
ing, due to the circum- 
stance that the line 
between the anterior 
superior spine and the 
femoral condyles is les- 
sened by the displace- 
ment backwards of the 
bone, with the additional 
shortening in the dorsal 
dislocation brought 
about by the passing of 
the femoral head above 

the level of the acetabulum. The adduction and 
inversion in the main depend upon the position of 
the head and cervix, which must follow the plane 
of the bone upon which they lie. This position is 
maintained by the tense Y ligament. The damage 
done to the chief external rotators places them also 
hors de combat. The flexion is due to the tension 
of the Y ligament and of the ilio-psoas muscle. 

Nos. 3 and 4. The dislocation forwards. If 
the head after leaving the acetabulum simply 
moves a little forwards along the inner edge of the 




Fig. S3. 



-Dislocation upon the pubes 
(Bigelow.) 



512 SUKGICAL APPLIED ANATOMY [Part V 

socket, the thyroid luxation is produced (Fig. 82). 
If it goes farther and moves upwards, the pubic 
displacement will result (Fig. 83). The latter dis- 
location is therefore but an advanced form of the 
former. Whether the head will remain in the thy- 
roid foramen or ascend on to the pubes depends on 
whether extension and rotation outwards accom- 
pany the displacement. If these occur the pubic 
form is produced. In these injuries the pectineus, 
gracilis, and adductors will be more or less torn, 
while the ilio-psoas, glutei, and pyriform muscles 
are much stretched. The obturator nerve may be 
stretched or torn, and in the pubic luxation the 
anterior crural nerve may be involved. The ab- 
duction and eversion of the limb noticed in these 
luxations depend partly upon the position of the 
head of the bone, fixed more or less by the Y liga- 
ment, and partly upon the action of the gluteal 
muscles and some of the small external rotators, 
which are tightly stretched. The flexion of the 
limb is mainly due to the stretching of the ilio- 
psoas muscle. 

In the thyroid luxation the extremity is said 
to be lengthened. This lengthening is, however, 
only apparent, and is due to the tilting down of 
the pelvis on the injured side. In the pubic 
dislocation there is shortening, the head being 
carried above the acetabular level. 

Of the modes of reducing these dislocations by 
manipulation little can be said here. The more 
usual proceedings may be briefly summarised as follows : 
First. — Flex the thigh in the ad- \ 
ducted position in luxa- 
tions Nos. 1 and 2. To relax the 
Flex the thigh in the ab- f Y ligament, 
ducted position in luxa- 
tions Nos. 3 and 4. 
Secondly. — Circumduct out in^jTo bring back the 
Nos. 1 and 2. head to the rent 
c in the capsule by 
Circumduct in in the same route that 
JSTos. 3 and 1. ) it has escaped. 



Chap. XIX] REGION OF THE HIP 513 

Thirdly. — Extend in all cases. To induce the 
head to enter the acetabulum again. 

In reducing dislocations of the hip it may be 
noted that the internal condyle of the femur faces 
in nearly the same direction as the head of the 
bone. 

In amputation of the thigli at the hip- 
joint many methods may be employed. A com- 
mon procedure consists of a circular incision 
which divides the soft parts to the bone at the 
junction of the upper with the middle thirds of 
the thigh, and is combined with a vertical incision 
over the great trochanter, through which the 
upper extremity of the femur is exposed and 
the joint disarticulated. (See section, Fig. 76, 
p. 493.) Haemorrhage from the femoral, gluteal, and 
sciatic vessels is prevented either by compressing 
the termination of the abdominal aorta a little 
below and to the left of the umbilicus, or by en- 
circling the junction of the thigh and body with a 
loop of elastic bandage. The bandage must pass 
inside the ischial tuberosity to compress the con- 
tents of the sacro-sciatic foramen, over the groin 
to compress the femoral vessels, and above the iliac 
crest to prevent it from slipping downwards. In 
the circular incision the vessels divided are : the 
superficial and deep femoral, the second per- 
forating artery, descending branches of the ex- 
ternal circumflex arid sciatic vessels, and long 
saphenous vein ; the nerves divided are : the 
external, middle and internal cutaneous, the in- 
ternal saphenous, the deep muscular branches of 
the anterior crural, the obturator, the great and 
small sciatic ; the muscles divided are : the sar- 
torius, quadriceps extensor cruris, adductors 
magnus and longus, gracilis, and hamstrings. In 
the vertical incision (Fig. 76, p. 493) the ilio-tibial 
band and the insertions of all the gluteal muscles 
are divided to the bone. Communicating branches 
between the ascending and transverse branches of 
the external circumflex artery in front with the 
gluteal, sciatic and first perforating behind are 
2 H 



514 SURGICAL APPLIED ANATOMY [Part V 

cut. The capsule of the joint is divided, the head 
of the femur thrust from its socket, and the liga- 
mentum teres cut. The attachments of the follow- 
ing structures to the upper third of the femur 
have to be separated : the gluteus maximus, 
medius, minimus, pyriformis, gemelli, obturator 
internus and externus, quadratus femoris, ad- 
ductor magnus, brevis, pectineus, psoas and ilia- 
cus, with the capsular ligament. 

By the method of disarticulation at the hip- 
joint known as the anterior racket, no elastic 
tourniquet and no compression of the iliac vessels 
are needed. 

The vertical part of the racket-shaped incision 
is placed over the femoral vessels, and those ves- 
sels are secured by two ligatures each and are 
then severed between the ligatures. The circum- 
flex arteries are in the same way secured before 
division. 

If carefully performed, very little blood is lost 
in the anterior racket amputation. 



CHAPTER XX 
THE THIGH 

Under the term " the thigh ' ; it will be convenient 
to describe that part of the lower limb that ex- 
tends between the regions just described and the 
districts of the knee and popliteal space. 

Surface anatomy. — In muscular subjects the 
outline of the thigh is irregular, but in the less 
muscularly developed, who are provided with a 
good share of subcutaneous fat, the limb, in this 
section of it, is more or less evenly rounded. The 
prominence of the rectus muscle is noticeable on 
the front of the thigh, especially when the muscle 
is in action. To the inner side of this structure, 
and conspicuous along the lower half of the thigh, 
is the eminence formed by the vastus internus. 
The mass to the outer side of the rectus is com- 
posed of the external vastus muscle, and occupies 
the greater part of the limb in this region, being, 
however, more conspicuous below. 

Running down the anterior and inner aspect of 
the thigh, from the apex of Scarpa's triangle, 
is a depression which indicates the interval be- 
tween the quadriceps muscle and the adductors. 
Along this groove the sartorius lies. Over the 
surface of the vastus externus a longitudinal de- 
pression is often to be observed, formed by the 
pressure exercised bv the superimposed ilio-tibial 
band of the fascia lata. The hamstring muscles 
cannot usually be distinguished the one from the 
other above the popliteal space, nor is their 

515 



516 SURGICAL APPLIED ANATOMY [Part V 

separation from the adductors indicated. The 
separation, however, between them and the vastus 
externus is distinct, and corresponds to the posi- 
tion of the external intermuscular septum. The 
line of the femoral vessels has already been given 
(p. 487). The long saphenous vein follows in 
the thigh the course of the sartorius muscle, and 
may be represented on the surface by a line drawn 
from the region of the saphenous opening (p. 487) 
to the posterior border of the sartorius muscle 
at the level of the inner condyle of the femur. 
The long saphenous nerve follows the course of the 
femoral artery, lying first to the outer side of that 
vessel and then gradually crossing it. In the 
lower fourth of the thigh the nerve passes under 
cover of the sartorius muscle to the inner side of 
the knee, and is accompanied by the superficial 
branch of the anastomotic artery. A line drawn 
down the back of the limb from a point midway 
between the great trochanter and tuber ischii to 
the middle of the ham will correspond to the 
great sciatic nerve and one of its continuations, 
the internal popliteal (see p. 480). The great trunk 
usually bifurcates a little below the middle of 
the thigh. 

The skin of the thigh is coarse on the outer 
side of the limb, but internally it is thin and fine, 
and is apt to be readily excoriated by ill-applied 
bandages or splints. It is but loosely attached to 
the subjacent parts, a circumstance that greatly 
favours the performance of circular amputations . 
in this region. At one place, however, it is a 
little more adherent, viz. along the groove that 
separates the vastus externus from the hamstring 
muscles, and that corresponds to the outer inter- 
muscular septum. The laxity of the subcutaneous 
tissue favours extensive extravasations beneath 
the skin, and permits of large flaps of integu- 
ment being torn up in cases of injury to this part 
of the extremity. 

The fascia lata invests the limb at all parts 
like a tightly fitting sleeve. It is thickest at its 



Chap. XX] THE THIGH 517 

outer side, where it forms the dense ilio-tibial 
band. It is thinnest at the upper and inner as- 
pect of the thigh, where it covers the adductor 
muscles. It increases considerably in strength as 
it approaches the front of the knee, and attaches 
itself to the tibia and lateral margins of the 
patella. This fascia resists, especially at its outer 
part, the growth of tumours and abscesses, and 
limits deep extravasations of blood. It has occa- 
sionally been ruptured in part by violence, and 
through the rent so formed the subjacent muscle 
has bulged, forming what is known as a hernia 
of the muscle. This condition has been met with 
in the case of the quadriceps muscle, and also 
of the adductor longus. Such " hernise ,; are 
probably associated with some rupture of the fibres 
of the muscles implicated. Two deep processes 
of the fascia are attached to the femur, and 
form the outer and inner intermuscular septa. 
The outer septum separates the vastus externus 
from the biceps, and the inner the vastus internus 
from the adductors. Together with the fascia 
lata, these septa divide the thigh into two apo- 
neurotic spaces, which can be displayed in a 
transverse section of the limb. These divisions, 
however, are of little surgical moment, and the 
inner septum is often so thin and feeble that it 
could have but little effect in directing the course 
of an abscess. 

In circular amputations of the thigh the 
muscles are apt to retract a little unevenly, since 
some are attached to the femoral shaft while 
others are free. The muscles so attached are the 
adductors, vasti and crureus, while the free mus- 
cles are the sartorius, rectus, hamstrings, and 
gracilis. 

In spite of its great strength the tendon of the 
quadriceps may be ruptured by muscular violence. 
A good example of such an accident is recorded 
by Mr. Bryant (Med. Times, 1878). A man aged 
forty-two stumbled in the dark, and fell down a 
pit ten feet deep. On examination the tendon 



518 SURGICAL APPLIED ANATOMY [Part V 

was found to be torn across, and the gap above the 
patella produced by the rupture occupied no less 
extent than the lower third of the thigh. A some- 
what more remarkable accident is reported to have 
happened to the sartorius muscle. This muscle, 
just before its insertion into the tibia, gjives oft' 
an aponeurotic expansion from its anterior bor- 
der to the capsule of the knee-joint. In the case 
alluded to (Lancet, 1873), this expansion is said 
to have been ruptured, and the muscle itself to 
have been found dislocated backwards in conse- 
quence. The accident befell a man aged forty, 
who was squatting, in the position assumed by 
tailors, upon the floor of a waggon, when his com- 
panion tripped over him and fell across his bent 
knees. Something was felt to have given way 
near the ham, and on examination the above lesion 
was diagnosed. 

The femoral artery may be ligatured at any 
part of its course in the thigh, and the com- 
paratively superficial position of the vessel ren- 
ders it very liable to be injured. In the middle 
third of the thigh it lies beneath the sartorius in 
Hunter's canal. The thigh affords many instances 
of the remarkable way in which isolated branches 
of a main artery are often alone damaged. Thus, 
Langier relates the case of a man-cook, who, in 
running round a table, struck the upper and 
outer side of his thigh against the corner of it. 
This led to a subcutaneous rupture of the external 
circumflex artery. Unfortunately the extravasa- 
tion was cut into, and the patient, after being 
subjected to many modes of treatment, died from 
the effects of repeated haemorrhage. Dr. Butcher 
(Dub. Joum. Med. Sc, 1874) gives the case of a 
man who was stabbed in the thigh over the femoral 
vessels during a scuffle. Profuse bleeding fol- 
lowed, and it was found that the only vessel 
wounded was the internal circumflex artery, just 
at its point of origin from the profunda. The 
case was treated promptly and the man did well. 

Fractures of the femur. — The shaft of the 



Chap. XX] THE THIGH 519 

femur may be broken at any part, but the lesion 
is most common at the middle third of the bone, 
and least frequent at its upper third. If broken 
by direct violence the fracture is usually trans- 
verse, and if by indirect violence it is usually 
oblique. The probability of a fracture being due 
to direct violence diminishes in the bone from 
below upwards, while the probability of a lesion 
from indirect violence increases in the same direc- 
tion. Thus it happens that the fractures of the 
upper third of the bone are usually oblique, while 
those of the lower third are more commonly trans- 
verse. In the middle third the numbers of the 
transverse and oblique fractures are more nearly 
balanced. The femur has < often been broken by 
muscular violence, but it is doubtful if this has 
ever occurred in other than a diseased bone. In 
many of these cases the amount of force that 
breaks the bone is most insignificant. Thus Val- 
lin reports the case of a girl aged eighteen, de- 
scribed as robust, who broke the femur about its 
middle while in the act of mounting a table for 
the purpose of undergoing a vaginal examination. 
In oblique fractures in the upper third of the bone 
the line of fracture usually runs downwards and 
inwards, while in oblique fractures of the middle 
third the direction is more commonly downwards 
and forwards^ with a slight lateral inclination 
that is sometimes inwards and sometimes out- 
wards. Fractures of the lower third of the bone 
are discussed in connection with the region of the 
knee (chap. xxi.). 

_ With regard to fractures of the upper and 
middle thirds, the displacements of the fragments 
depend greatly upon the obliquity of the fracture. 
As a rule the lower fragment is drawn up behind 
the upper one by the hamstrings, aided by the 
rectus, gracilis, sartorius, tensor vaginae, and 
adductors, and is carried a little to its inner side 
under the influence of the last-named muscles. 
The^ lower end of the upper fragment usually 
projects forwards and a little backwards. This 



520 SURGICAL APPLIED ANATOMY [Part V 

is produced by the agency of the lower fragment, 
which tilts the upper piece of bone in the^ direction 
named. In the fracture of the upper third of the 
shaft the projection forwards of the upper frag- 
ment is aided by the ilio-psoas muscle. Thus the 
deformity produced in fractures of the femoral 
shaft is usually angular in character. The ever- 
sion of the foot noted in fractures of the femur is 
due to the weight of the limb, which causes the 
helpless member to roll out, aided probably by the 
action of the external rotator muscles. 

Certain spiral fractures (helicoidal fractures 
of Leriche) may be produced in the lower part of 
the shaft as the result of torsion. M. Fere finds 
by experiment that if the limb be carried forwards 
in front of the opposite knee, and the foot rotated 
outwards, a spiral fracture can be produced at the 
junction of the lower and middle thirds of the 
femur. A like fracture at the same level, but 
with the direction of the spiral reversed, can be 
produced by carrying the limb outwards and then 
rotating it inwards. 

Shortening of the limb after fracture.— 
It is doubtful if a fracture of the shaft of the 
femur can, after any treatment, become united 
without some shortening resulting, save in a few 
exceptional cases. It is important, in connection 
with this subject, to remember that the lower 
limbs may be normally of unequal length. Dr. 
Wight, of Brooklyn, has fully investigated this 
matter, and has arrived at the following con- 
clusions : (1) The greater number of normal lower 
limbs are of unequal length ; (2) the left limb is 
often longer than the right ; (3) the average in- 
equality of normal lower limbs is probably about \ 
of an inch ; (4) the average amount of shortening 
after a fracture of the femur that has been well 
treated is about f of an inch ; (5) in about one case 
in ten or eleven the two limbs will be found to be 
of equal length after the union of the fracture ; 
(6) one limb can never be a certain standard of 
length for the opposite limb. Dr. Garson, as a 



Chap. XX] THE THIGH 521 

result of the careful examination of some seventy 
skeletons, states that both the lower limbs are of 
equal length in only about 10 per cent, of all cases. 
He also found that the femur was more frequently 
the seat of variation than the tibia. 

Amputation of the tliigli. — In a circular 
amputation of the thigh about its middle the fol- 




2 $ 

Fig. S4. — Transverse section through the middle of the thigh. (Brawne.) 

«, Rectus fenioris; l>. vastus extemus; c, crureus; d, vastus internus; e, short 
head i if biceps; /. long head of biceps ; (i. seinitendinosus ; h, semimembra- 
nosus ; i, adductor niaguus ; j, gracilis ; k, adductor longus ; I, sartorius. 1, 
femoral artery : i', great sciatic nerve ; 3, great saphenous veiu : 4, middle 
cutaneous nerve: 5, external cutaneous nerve; 6, perforating branches from 
profunda ; 7, small sciatic nerve. 

lowing parts would be divided (Fig. 84) : the 
quadriceps, sartorius, gracilis, long and great ad- 
ductors, and the three hamstring muscles; the 
superficial and deep femoral vessels, the descend- 
ing branches of the external circumflex artery, the 
lower perforating vessels, and the long saphenous 
vein ; the main branches of the anterior crural 
nerve (middle cutaneous, internal cutaneous, and 
muscular, together with the long saphenous nerve), 
the anterior branch of the external cutaneous 



522 SURGICAL APPLIED ANATOMY [Part V 

nerve, the obturator, and the great and small 
sciatic nerves. Owing to the unequal manner in 
which the divided muscles retract, a simple cir- 
cular amputation is not well adapted for the 
thigh. A more convenient method of amputation 
is represented bv the elliptical method, the lower 
extremity of the ellipse being on that side of the 
limb on which muscular retraction is the more 
marked, i.e. on the posterior side of the thigh. 



& 



CHAPTER XXI 

THE REGION OF THE KNEE 

In this chapter will be considered the articulation 
of the knee, the soft parts about the joint, the 
popliteal space, the lower end of the femur, the 
patella, and the upper ends of the tibia and fibula. 

Surface anatomy. — In the front of the knee 
the patella can be distinctly felt and seen. Its 
inner border is a little more prominent than the 
outer. When the limb lies in the extended pos- 
ture, with the quadriceps relaxed, the patella can 
be moved to and fro, and appears to be but loosely 
attached. When the quadriceps is contracted the 
bone is drawn upwards, and becomes firmly fixed 
against the femur. In flexion of the joint the 
patella sinks into the hollow between the tibia and 
the intercondyloid notch, and is very firmly fixed. 
In this position some part of the trochlear surface 
of the femur can be made out above the patella. 
On each side of the knee-cap a hollow exists which 
may be completely filled up with fat in the obese. 

When the limb lies in the extended posture the 
ligamentum patellae is not to be very distinctly 
made out. It becomes a little more conspicuous 
in the flexed position, and is most prominent when 
the quadriceps muscle is vigorously contracted. 
The subpatellar pad of fat bulges outwards on 
each side of the ligament and may be mistaken 
by the inexperienced for fluid in the joint. 

On the inner side of the knee the following 
parts can be felt from above downwards : the 

523 



524 SURGICAL APPLIED ANATOMY [Part V 

• 
tubercle for the adductor magnus, and the tendon 
of insertion of that muscle; the inner condyle of 
the femur, which is very prominent, and forms 
the chief part of the rounded eminence on this 
aspect of the joint; and below this the inner 
tuberosity of the tibia. Between the two latter 
processes of bone, the interarticular line and 
semilunar cartilage are easily felt. On the outer 
side of the joint is the external condyle of the 
femur, which is much less conspicuous than its 
fellow of the opposite side, and below it is the 
corresponding tuberosity of the tibia, forming a 
marked prominence. Immediately in front of the 
biceps tendon the upper part of the external 
lateral ligament can be felt when the joint is a 
little flexed. Between the tendon and the patella, 
the lower part of the ilio-tibial process of the 
fascia lata can be detected as a prominent rounded 
band, descending to the external tuberosity of the 
tibia. It is most distinct when the knee-joint is 
forcibly extended by muscular action, and often 
stands out conspicuously beneath the skin. The- 
tubercle of the tibia and the head of the fibula are- 
both readily felt, and are nearly on the same level. 

The popliteal space only appears as a hollow 
when the knee is bent. In the extended limb the 
hollow is replaced by an evenly rounded eminence. 
The crease in the skin that passes transversely 
across the ham is some way above the line of the 
knee-joint. On the outer side of the space the 
biceps tendon can be very readily felt, especially 
when the muscle is in action. Just behind it, and 
along its inner border, lies the peroneal nerve. 
It can be rolled under the finger as it crosses the 
head of the fibula to pass beneath the peroneus 
longus muscle. On the inner side of the ham 
three tendons can be felt. Nearest to the middle 
of the space is the long prominent tendon of the 
semitendinosus. Internal to it is the larger and 
less distinct semimembranosus tendon, and still 
more to the inner side the gracilis may be made out. 

The popliteal vessels enter the ham obliquely 



Chap. XXI] EEGION OF THE KNEE 525 

at its upper and inner part, and under cover of 
the semimembranosus muscle. The outer border 
of this muscle is the guide to the upper portion 
of the artery. The vessels in their descent reach 
a point behind the middle of the knee-joint, and 
then pass vertically downwards. The termination 
of the popliteal artery is on a level with the lower 
part of the tubercle of the tibia. When the limb 
is flexed, the pulsations of the artery can be felt 
and the vessel compressed against the femur a 
little below its point of entry into the popliteal 
space. The upper articular arteries run trans- 
versely inwards and outwards just above the 
femoral condyles. The lower articular arteries 
are also placed transversely, the inner vessels run- 
ning just below the internal tuberosity of the 
tibia, and the outer just above the head of the 
fibula. The deep branch of the anastomotica 
magna descends to the inner condyle of the femur 
in the substance of the vastus, internus, and along 
the front of the adductor magnus tendon. The 
internal saphenous vein passes up along the back 
part of the internal condyle of the femur, and 
then follows the sartorius muscle to the thigh. 
It is just below the interarticular line that the 
long saphenous nerve usually joins the vein. The 
short saphenous vein follows the middle line of the 
calf just below the ham, and pierces the deep 
fascia at the lower part of the popliteal space. 
Tnis vessel is much less conspicuous than is the 
long saphenous vein, and is, indeed, not often to 
be seen unless varicose. 

_ The internal popliteal nerve descends in the 
middle line, and continues the line that marks the 
course of the great sciatic trunk. 

In their normal condition the popliteal glands 
are not to be felt. 

The limits of the synovial membrane of the 
knee-joint, and the position of the various bursa? 
about this articulation, will be dealt with in some 
of the subsequent paragraphs. 

The front of the "knee.— The skin over the 



526 SUKGICAL APPLIED ANATOMY [Part V 

front of the knee is dense and very movable. This 
mobility affords considerable protection to the 
knee-Joint, especially in stabs with bluntish in- 
struments, and in any injury where the gliding 
movement of the skin may direct the violence away 
from the articulation. The comparative looseness 
of the integument is sometimes utilised in the 
operation of removing so-called " loose cartilages ' ; 
from the knee-joint. It permits the incision into 
the joint to be very indirect, and, the skin being 
dragged out of place during the operation, it 
follows that, when the procedure is complete, the 
surface wound and that in the knee capsule no 
longer correspond. In flexion, the skin is drawn 
tightly over the patella, and, as is the case else- 
where, where the integument lies more or less 
directly upon the bone, a contusion over the knee- 
cap may produce a lesion precisely like an in- 
cised wound. 

In the Lancet for. 1877 is recorded the case of 
a very stout woman, aged fifty-seven, who, 'stum- 
bling on a hard road, fell upon her bent knee. 
The skin was burst across the front of the knee, 
and a wound was produced that was 7 inches in 
length, and was as cleanly cut as if made by a. 
scalpel. 

There is but little subcutaneous fat in front of 
the articulation, and thus it happens that in am- 
putations through the knee-joint the anterior flap 
is very thin, and is composed of little other than 
the simple integument. 

As blisters, and various forms of counter- 
irritant, are often applied to the front of the knee 
in cases of disease, it may be well to take note of 
the blood-supply of this part, and of the relations 
between the surface vessels and nerves and those of 
the joint. The vessels that give branches to the 
front of the knee, and are concerned in the 
suppjy of the part to which blisters are usually 
applied, are the anastomotic, the four articular 
branches of the ponliteal, and the anterior tibial 
recurrent. Now of these arteries, and especially 



Chap. XXI] REGION OF THE KNEE 527 

of the anastomotica magna and superior articular, 
it may be said that, shortly after their origin, 
they divide into two branches, or two sets of 
branches, one going to the surface and the other 
to the articulation of the knee and deeper parts 
about it. It may be supposed, therefore, that, in 
applying a counter-irritant in front of the knee 
for the relief of a joint affection, a greatly in- 
creased quantity of blood is drawn into the super- 
ficial divisions of the above-named vessels, and less 
blood is thereby left to flow by their deeper 
branches to the seat of disease. The skin over the 
front of the knee, the anterior parts of the joint, 
and the quadriceps is supplied from the third and 
fourth lumbar segments through branches of the 
anterior crural and obturator nerves. 

The superficial lymphatics in the region of the 
knee lie for the most part on the inner aspect of 
the joint, and follow the course of the long 
saphenous vein. Ulcers, and other inflammatory 
affections of the skin over the articulation, are 
more apt to be associated with lymphangitis and 
with enlargement of the inguinal glands when 
situate on the inner aspect of the joint than when 
placed in front or to the outer side of it. 

The bursae over the front of the knee. — (1) 
The patellar bursa is a large sac placed in front 
of the patella and upper part of the patellar liga- 
ment, and separates those structures from the 
skin. It is frequently divided by septa into 
superficial and deep compartments. It is very 
often found enlarged in those who kneel much, 
in housemaids, stonemasons, religieuses, etc. The 
parts about are well supplied with nerves, and 
hence much pain is usually associated with acute 
inflammation of this sac. It is in close contact 
with the patella, and, in one case reported by 
Erichsen, suppuration of the bursa led to caries 
of that bone (Figs. 85, 86, and 90). (2) There is 
a bursa between the patellar ligament and the 
tubercle of the tibia (Figc. 86). When inflamed, 
it causes more pain than is observed in affections 



528 SURGICAL APPLIED ANATOMY [Part V 

of the previous bursa, since it is firmly compressed 
between two rigid structures, the ligament and the 
bone. It is separated from the synovial cavity 
by the pad of fat that lies behind the patella. 
(3) The bursa between the quadriceps tendon and 
the femur will be considered in connection with 
the synovial cavity. 

The popliteal space. — The skin over the 
space is not so movable as is that over the front 
of the knee. When destroyed by injury, by burns, 
or by extensive ulceration, the contraction of the 
resulting cicatrix may lead to a rigidly bent 
knee. The skin in this place has also been rup- 
tured by forcible extension applied to the limb in 
cases of contracted knee. Beneath the skin and 
superficial tissue is the popliteal fascia, a dense 
membrane that covers in the space. It is but 
a continuation of the fascia lata of the thigh, 
and is continuous below with the fascia of the leg. 
It passes without bony attachment over the ham 1 
string muscles that bound the ham. This fascia 
limits, often in a very marked manner, the pro- 
gress of popliteal abscesses and growths towards 
the surface. Its unyielding character is fa prime 
cause in the production of the severe pain with 
which such collections and tumours are often 
associated. The popliteal abscess, unable to reach 
the surface, is encouraged to extend either up 
into the thigh or down the leg. The ham may 
hold a very considerable quantity of pus. Vel- 
peau has seen a case where a litre (1 pint, 15 oz.) 
of pus was evacuated from this region in a 
patient who presented before the operation but an 
insignificant swelling in the site of the collection. 
Duplay records two cases of ulceration of an ab- 
scess into the popliteal artery, and Ollivier an 
instance where the abscess, unable to find a way to 
escape, ultimately entered the knee-joint. 

Pus may reach the ham from the buttock or 
pelvis bv following the great sciatic nerve, or may 
extend from the thigh through the opening in the 
great adductor for the femoral vessels. 



Chap. XXI] REGION OF THE KNEE 529 

The Ii a in string muscles are frequently 
found contracted in neglected cases of knee-joint 
disease, and produce thereby more or less rigid 
flexion of the leg upon the thigh. Irritation from 
disease of the knee-joint may lead to contracture 
of the hamstring muscles. These muscles are sup- 
plied through the great sciatic nerve from the 
fifth lumbar segment, from which the knee-joint 
derives in part its nerve supply. Muscles on the 
flexor aspect of a bent joint undergo a permanent 
shortening if the position be maintained for a con- 
siderable space of time. 

Contraction of these muscles in knee-joint dis- 
ease tends not only to flex the knee but also to 
draw the tibia backwards, and produce in some 
cases a partial luxation. 

The hamstring tendons may be ruptured by 
violence, the tendon most frequently torn being 
that of the biceps. The muscles < are greatly 
stretched when the trunk is bent forcibly forwards 
at the hip-joint, the knee remaining extended. 
Extreme movement in this position has ruptured 
some of the fibres of this muscle. The difficulty 
experienced in touching the toes with the fingers 
while the knees are kept stiff depends upon the 
resistance offered by the stretched hamstrings. In 
tenotomy of the biceps tendon the peroneal nerve 
is in great risk of being wounded. It may be 
noted that contraction of the muscle tends to in- 
crease the distance between the tendon and the 
nerve, and to render the former more superficial. 
The peroneal nerve may be compressed by band- 
ages or garters applied too tightly over the head 
or neck of the fibula. 

The vessels of the ham.-— The popliteal ves- 
sels are, from their depth, but seldom wounded. 
It must be borne in mind that the lower part of 
the artery may be reached from the anterior 
aspect of the leg by an instrument passing between 
the tibia and fibula. Thus Spence reports the 
case of a farmer who received a wound in front 
of the leg, just below the knee, from the slipping 
2 i 



530 SURGICAL APPLIED ANATOMY [Part V 

of his knife while cutting a stick. It was dis- 
covered subsequently that the knife had entered 
the interosseous space and had wounded the pop- 
liteal artery at its bifurcation. It had indeed 
nearly severed the anterior tibial artery from the 
main trunk. 

The popliteal artery has been ruptured by ex- 
ternal violence, as when a wheel has passed over 
the region of the vessel. This artery is more fre- 
quently the seat of aneurism than is any other 
artery in the body, save only the thoracic aorta. 
In 551 cases of spontaneous aneurism, collected 
by Crisp, the popliteal vessel was the seat of the 
disease in 137 instances, the thoracic aorta having 
been affected in 175 of the cases. This marked 
disposition to aneurism depends upon many 
factors. The vessel is subjected to a great deal 
of movement, and often to very violent movement. 
Experiments upon the dead body show that the 
inner and middle coats of the vessel may be rup- 
tured by extreme flexion of the knee, and that a 
like rupture may in a smaller percentage of cases 
be brought about by forcible extension. More- 
over, except when the limb is in the position of 
extension, the popliteal artery is, like the thoracic 
aorta, much curved. Then, again, the vessel 
breaks up into two large vessels, and it is well 
known that the point of bifurcation of an artery 
is a favourite spot for aneurism. Lastly, the 
artery is supported only by the lax tissue of the 
popliteal space, and the support of strong muscles 
given elsewhere to so many large vessels is practic- 
ally absent. Some popliteal aneurisms have been 
successfully treated by flexing the knee and retain- 
ing the limb for some time in that position. That 
flexion can have a direct effect upon the lumen of 
the vessel is shown by the diminished pulse at the 
inner ankle produced by forcibly bending the leg 
upon the thigh. The artery and vein are so 
adherent that it is difficult to separate the two 
when applying a ligature to the arterial trunk. 
This adhesion must have been appreciated by any 



Chap. XXI] REGION OF THE KNEE 531 

who have taken pains to " clean " the artery in a 
dissection of the ham. 

The popliteal vein is a remarkably substantial 
vessel, and has walls so dense and thick that on 
section they often look more like the tunics of an 
artery. On the ground of this peculiarity, and of 
its close adhesion to its companion vessel, Tillaux 
asserts that " it is unlike any other vein in the 
economy/' It is worthy of note that the vein, 
although more superficial than the artery, is very 
rarely ruptured by violence. As a rule, the artery 
alone is torn. In a few cases both the vessels 
may suffer; but I can find no instance recorded 
of rupture of the popliteal vein alone. 

From the relations of the artery to the vein 
and nerve it will be understood that a popliteal 
aneurism may soon lead to oedema of the leg and 
to nerve symptoms depending upon pressure on 
the internal popliteal trunk. It has more than 
once also made its way into the knee-joint, with 
the posterior ligament of which the artery is in 
such close relation. 

The short saphenous vein lies almost in the 
middle line, and, not being usually apparent 
through the skin, may be divided in an incision 
made into the lower part of the popliteal space. 

The lymphatic glands in the ham are from 
four to five in number and are deeply placed 
about the great vessels. When enlarged they have 
been mistaken for aneurism and other popliteal 
tumours. They receive the deep lymphatics of 
the leg. A small gland is often met with beneath 
the fascia, close to the point of entry of the short 
saphenous vein. It receives some lymphatics that 
follow that vessel. 

The bmsae about the ham are usually seven 
in number, four on the inner side of the space 
and three on the outer. Inner side. — (1) A large 
bursa between the internal condyle of the femur 
and the inner head of the gastrocnemius and the 
semimembranosus. This is the largest bursa in 
the space, and after adult life it usually communi- 



532 SURGICAL APPLIED ANATOMY [Part V 

cates with the joint. It is, of all the bursas in 
this region, the one most often enlarged, and 
when affected may attain great size. In one re- 
ported case the sac measured 5 by 3.5 inches. 
In the extended position of the limb the enlarged 
bursa feels firm and resistant, but on flexion it 
becomes flaccid and can often be made to entirely 
disappear. Probably the slit-like communication 
between the bursa and the joint is closed when 
the posterior ligament is tightened by extension, 
and is opened when it is relaxed on bending the 
knee. In the latter posture the contents of the 
bursa can be reduced into the cavity of the knee- 
joint, and so the tumour disappears. (2) A little 
bursa between the semimembranosus tendon and 
the tuberosity of the tibia. Rather below the 
level of the knee there are two further bursas — (3) 
one beneath the insertion of the sartor ius, and 
(4) another beneath the insertions of the gracilis 
and semitendinosus. Outer side. — (l) A large 
diverticulum of the synovial membrane of the 
joint between the popliteus tendon and the ex- 
ternal tuberosity of the tibia. This diverticulum 
serves the purpose of a bursa, and may open into 
the tibio-fibular articulation, and so bring that 
cavity into connection with the knee-joint. (2) A 
bursa between the outer head of the gastrocnemius 
and the femoral condyle. It is not constant and 
is not connected with the articulation. (3) A 
bursa between the biceps tendon and the external 
lateral ligament. The peroneal nerve runs across 
this sac, a circumstance that may explain some of 
the pain experienced when the bursa is enlarged. 

It is not improbable that wounds in this region 
of bursae containing fluid have been mistaken for 
wounds of the joint, and the escaping serum for 
synovia. 

The kiico-joint. — This articulation is the 
largest in the body. The joint owes its great 
strength to the powerful ligaments that unite the 
two component bones, and especially to the muscles 
and fasciae that surround it. It derives no 



Chap. XXI] REGION OF THE KNEE 



533 



strength from the shape of the articular surfaces, 
since they are merely placed in contact with one 
another. In spite of its frequent exposure to in- 
jury, dislocations at the knee are extremely rare. 
The lateral ligaments are comparatively feeble, 
are tense in extension and relaxed in flexion. 
The laxity of these ligaments is such that partial 




Fig. 85. — Vertical section of normal knee-joint. (Braune.) 

a, Quadriceps; l>, semimembranosus: c, gastrocnemius; d. posterior crucial liga- 
ment ; c, ligamentum patellae ; /, bursa between quadriceps and femur. 



luxations of the tibia are possible without rup- 
ture of these bands, especially in cases where the 
joint is found slightly flexed after the accident. 
The crucial ligaments are very powerful, and are 
more or less tense in all positions of the joint. 
The anterior of these ligaments especially resists 
extension, forward displacement of the tibia, and 
rotation inwards of the leg. The posterior band 
resists flexion and displacement backwards of the 



534 SURGICAL APPLIED ANATOMY [fart V 

tibia. In the movement of extension the tibia 
slides a little forwards and is rotated a little out- 
wards. In flexion that bone glides backwards and 
rolls a little inwards. Extension generally is 
limited by the crucial and posterior ligaments; 
flexion by the ligamentum patellae and anterior 
part of the capsule, in addition to the crucial 
ligaments. Rotation is possible only in the flexed 
position. The thinnest part of the posterior liga- 
ment is the portion below the oblique fibres de- 
rived from the semimembranosus. If pus finds 
its way from the joint into the ham,_ it will 
probably escape through this part of the ligament. 

In the contracted knee associated with fibrous 
ankylosis, the chief contraction, so far as the 
joint tissues are concerned, is in the posterior 
ligament, in the lateral ligaments, and in the 
fibrous and fatty tissue between the former liga- 
ment and the posterior crucial band. 

The synovial membrane of the knee-joint ex- 
tends upwards as a large cul-de-sac above the 
patella and beneath the extensor tendon. This 
cul-de-sac reaches a point an inch or more above 
the upper margin of the trochlear surface on the 
femur, and is rendered very distinct when the 
joint is distended with fluid (Fig. 86). When the 
knee is bent the cul-de-sac is drawn down, and 
therefore this position of the limb is advised 
when operations are about to be performed upon 
the lower end of the femur. Above the synovial 
pouch is a bursa that separates the quadriceps 
tendon from the femur, and is usually over an 
inch in its vertical measurement (Fig. 86). From 
the examination of two hundred and sixty knee- 
joints in both infants and adults, Schwartz found 
that this bursa communicated with the synovial 
cavity in seven cases out of ten in young children, 
and in eight cases out of ten in adults. 

It will thus be seen that when this communica- 
tion exists, a stab over the femur, about 2 inches 
above the trochlear surface of the bone, or about 
the same distance above the top of the patella, 



Chap. XXI] REGION OF THE KNEE 



535 



when the limb is extended, will practically open 
the knee-joint. 

Cases are reported of extravasation of blood 
into this bursa that, although at first limited to 





I ill M 




mm 
m 



Fig. S6. — Vertical section of knee-joint distended with fluid. (Braunc.) 

a, Vastus externus ; b, crureus ; c, short head, ami d, long head, of biceps ; e, plan- 
taris ; /, gastrocnemius ; </, popliteus ; //, soleus ; i, tibialis posticus ; j, bursa 
patella?: k, liganientuni patella); I, liu-aniontmn mucosum ; in, anterior crucial 
ligament: n, external semilunar cartilage. 1, external popliteal nerve; 
2, popliteal artery. 

the sac, have, on rough handling, extended into 
the knee-joint, a circumstance leading to the sup- 
position that in some cases the orifice of communi- 
cation may be very small. 

The crucial ligaments, although more or less 
completely invested by the synovial membrane, 
are yet entirely outside the synovial cavity, and 



536 SURGICAL APPLIED ANATOMY [Part V 

divide the cavity behind into an outer and an inner 
condylar recess. The posterior ligament is con- 
tinuous with the posterior part of the capsule. 

The upper third of the patellar ligament is in 
relation to the synovial membrane, from which, 
however, it is separated by a pad of fat. The 
lower two-thirds of the ligament are in relation 
to the bursa and fatty tissue that intervene be- 
tween the band and the tibia. A knife passed 
horizontally backwards at the apex of the patella 
would, when the limb is extended, just miss the 
joint line between the femur and tibia, and would 
hit the latter bone (Fig. 85). If, however, there 
be any effusion in the joint, or the limb be a little 
flexed, a knife so introduced would pass between 
the two bones (Fig. 86). Fringes of the synovial 
membrane (the alar ligaments) fill the intervals 
between the articular surfaces of the patella and 
femur. Villous processes may grow out from 
them, become detached, and form loose bodies in 
the joint. That such processes should undergo 
chondrification and form cartilaginous bodies is 
not surprising seeing that the synovial lining is 
derived from the same tissue as forms the articular 
surfaces of the bones and is in reality merely a 
finely spread layer of cartilage covering a fibrous 
membrane. 

Joint disease—Owing to its superficial 
position the knee-joint is the articulation that is 
most frequently the seat of inflammation due to 
injury and exposure to cold. When distended 
with fluid, the effusion soon shows itself above 
and at the sides of the patella, by bulging for- 
ward the synovial sac, which is here more nearly 
in relation to the surface than it is elsewhere. 
Fluctuation is soon to be detected, and the patella, 
being pushed away from the femur, is said to 
" float *' upon the distending fluid (Fig. 86). 

The inflamed knee-joint, if left to itself, almost 
invariably assumes the flexed position. This may 
be explained upon three hypotheses, and it is 
probable that each of the three reputed factors 



Chap. XXI] REGION OF THE KNEE 



537 



takes part in producing this position in cases of 
disease. 

(1) The capacity of the joint is increased on 
flexion. The pain of acute synovitis is due mainly 
to the increasing distension of the joint with fluid, 
and it is natural that the patient should in- 
stinctively place the limb in the position in which 
the joint will hold the greatest amount of fluid, 
and in which the interarticular tension is reduced 
to a minimum. Braune found that the maximum 
capacity was reached when the knee was flexed 25°, 
and the minimum on complete flexion. 



Ti^Ans verse Lie, 



COROflARy Lie 



Exter/halSemil 

ArtT.CEUCIAL 

popliteus-, 
Ext.Lat.Lic^ 

5ICEP5 




LiQAMEmuM Patellae 
A/nt ftotzn 

kC0R0/iARy Liq. 

\ 

LilrtTERftALSEAflLU/IAR 

Cartilaqe 

Internal Lateral 
L.q. 



ST. Crucial Lie 
Post. Liq. 

Fig. ST.— Illustrating the fixation and movements of the semilunar 

cartilages. 

The positiou of the internal semilunar cartilage, when the tibia is rotated out- 
wards or femur inwards, is shown in red. 

(2) By flexing the limb, the more powerful 
ligaments (such as the ligamentum posticum, the 
posterior crucial and lateral ligaments) are re- 
laxed, while the ligaments rendered tense by the 
position are the patellar and the anterior part of 
the capsular, the latter of which is but a yielding 
membrane. 

(3) The sensory nerves of the joint being dis- 
turbed, contraction of muscles may be anticipated 
from reflex action, and of the muscles so excited 
the flexors may be expected to have the advantage, 
as being the more powerful and the more favour- 
ably placed for acting upon the articulation. 

Dislocation of the semilunar cartilages,— 



538 SURGICAL APPLIED ANATOMY [Part V 

One or other of these cartilages may be displaced 
from its attachments to the tibia, and become 
nipped or locked between that bone and the femur. 
The result is a sudden pain in the limb, associated 
with a fixing of the knee in a flexed position. 
The accident is usually brought about by a twist 
given to the leg when the knee-joint is more or less 
bent. In 200 cases of internal derangement of 
the knee-joint, Bennett found that the internal 
cartilage was affected in 155 cases and the external 
in only 45. The left knee was the seat of derange- 
ment nearly three times as often as the right, and 
the lesion occurred nine times more frequently in 
men than in women. In every one of twelve cases 
operated on by Marsh, the anterior extremity of 
the internal semilunar cartilage was found 
bruised and torn from its tibial attachment. To 
understand the liability to injury of the anterior 
part of the internal semilunar cartilage it is 
necessary to examine the manner in which it is 
maintained in position, the movements which it 
undergoes, and the strains to which it is sub- 
jected in active athletes — for it is amongst them 
that displacements most frequently occur. In the 
extended position of the knee, displacement is 
impossible, for the cartilages are immovably 
fixed by the coaptation of the articular surfaces, 
brought about by the tension of the ligaments and 
tonus of the muscles surrounding the joint. When 
the joint is partly flexed the internal cartilage is 
fixed by (1) its anterior horn attached to the tibia, 
above and behind the attachment of the liga- 
mentum patellae and outside the joint cavity (Fig. 
87) ; (2) by the transverse ligament to the anterior 
part of the external cartilage (Fig. 87) ; (3) by 
the coronary ligament to the capsule of the joint 
and internal lateral ligament; the anterior fibres 
of this ligament are the longest (Fig. 87). As the 
joint is flexed the cartilages, especially the in- 
ternal, glide backwards; if in this position the 
biceps brings about a sudden rotation outwards 
of the tibia, the anterior horn is carried forwards 



Chap. XXI] REGION OF THE KNEE 539 

and outwards with that bone, while the posterior 
is firmly fixed to the internal condyle of the 
femur by the internal lateral ligament, and thus 
a severe strain is thrown on the anterior part 
of the internal cartilage, which is brought into 
the position shown in Fig. 87. Its weakest point 
is in the thin inner crescentic margin of its an- 
terior third, and it is here that partial rupture 
usually occurs. The intense pain is due to the 
rupture and to the fact that the strain wedges 
the cartilage between the tibia and femur, thus 
forcing them apart and causing an instant and 
severe hyperextension of the unyielding liga- 
ments of the joint. The external cartilage is 
smaller than the internal, is rounder, is more 
movable, and possibly on these accounts is less 
likely to be " nipped ,; between the bones. It is 
attached in part to the femur through the pos- 
terior crucial ligament, and is grooved by the 
tendon of the popliteus, two factors which add 
to its security (Fig. 87). 

4>c ii ii- valgum, or knock-knee. — The appear- 
ances produced by this affection are familiar. 
When a person stands erect with the feet together, 
the tibiae are practically vertical, and the femora 
meet them at a certain angle. The degree of this 
angle depends, in normal subjects, to a great 
extent upon the relative width of the pelvis. In 
genu-valgum the tibiae cease to be vertical in the 
erect position ; their lower ends deviate more and 
more from the middle line, until the distance be- 
tween the two malleoli becomes considerable when 
the individual stands upright and when he is 
not concealing any of the deformity by rotating 
the limb. 

The progress of the genu-valgum may be di- 
vided into three stages. In the first stage there 
is a yielding or elongation of the internal lateral 
ligament, and of the fascial structures on the 
inner side of the joint. That the yielding of this 
ligament alone will permit of a lateral movement 
at the articulation being accomplished is illus- 



540 



SURGICAL APPLIED ANATOMY [Part V 



trated by cases of sprains of the knee, where the 
ligament has been torn, and where much lateral 
bending has been in consequence permitted. It 
is probable that the crucial ligaments yield also 
a little, and it is upon the posterior band at- 
tached to the internal condyle that the strain 
possibly first comes. In the second stage there 
is a contraction of the tissues on the outer side of 
the joint that have been relaxed by the new posi- 
tion of the limb. These structures are the ilio- 
tibial band of the fascia lata, the external lateral 
ligament, and the biceps tendon. This contrac- 





Fig. 88. — a, Normal femur ; b, femur in an advanced state of knock-knee, 
showing the enlargement of the internal condyle. The dotted line in 
each case represents the line of the epiphysis. 

tion tends to give permanency to the deformity. 
In the third stage the bones become changed. 
On the outer side of the joint the external con- 
dyle and the outer tuberosity of the tibia are 
pressed together, and through these bones the 
greater part of the weight of the body will be 
transmitted. As a result of the continual pres- 
sure the parts waste a little, and by their atrophy 
contribute not only to the extent of the deformity 
but also to its permanency. On the inner side 
the internal condyle tends to become separated 
from the tibia, and an interval to develop be- 
tween the two bones as the deformity advances. 
This interval is prevented from actually existing 



Chap. XXI] REGION OF THE KNEE. 



541 



«&-«$ 



by the development of the condyle, which enlarges, 
and so still maintains its contact with the tibia. 
Mikulicz has pointed out that " the alteration 
in length on the inner side of the femur arises not 
from alteration of the epiphysis, but is confined 
to the lowest part of the diaphysis." This state- 
ment also holds true for the tibia. This is shown 
in the diagram (Fig. 88), where it will be seen 
that the enlargement of the internal condyle is 
due almost entirely to increased growth in the 
diaphysis. The increased growth does not affect 
the antero-posterior diameter of the condyles. 
Hence, when the knee is flexed, all trace of the 
deformity disappears. 

The patella.— Fractures. This bone is more 
often broken by muscular violence than is any 
other in the body. Although the patella may 
be fractured by both mus- 
cular and direct violence, 
it would appear that the 
former is the agent that 
most often produces the 
lesion. Thus, in 127 cases 
of simple transverse frac- 
ture collected by Hamilton, 
he considers that muscular 
action was the cause of the 
injury in 106 instances. The Fi? S9 ._ Diagram " to show 

IOrm Or fracture due to mechanism of fracture of 

muscular violence is very *•"» patella by muscular 
uniform. It is nearly al- 

■ • i a, Line of action of ciuadriL'eps 

w ay s tr an s ve rs e , simp le , muscle ; &, femur ; c, tibia. 
and through ^ the centre of 

the bone, or just above that point or just below it. 
Fractures due to direct violence may present the 
same appearance, but they are more often starred, 
or oblique, or even longitudinal. Experiments upon 
the cadaver show that a simple transverse frac- 
ture about the centre of the bone cannot be pro- 
duced with any degree of certainty by a direct 
blow. The position of the knee that most favours 
fracture by muscular action is that of flexion. 




542 SURGICAL APPLIED ANATOMY [Part V 

When the knee is bent, the patella rests upon the 
femoral condyles along its transverse axis only. 
Nearly the whole of its upper half is unsupported 
behind, and the extensor muscle acts in a line 
nearly at right angles to the vertical axis of the 
bone. Thus, by violent contraction of the quadri- 
ceps, the patella may be snapped across the con- 
dyle as a stick is snapped across the knee (Fig. 89). 
As the fracture usually causes the patient to fall, 
it has been supposed that the contact with the 
ground, rather than any previous muscular 
action, may have caused the lesion. But, as 
Hamilton has pointed out, if a person falls upon 
the bent knee when the limb also is flexed upon 
the trunk, the part that comes in contact with 
the ground is not the patella, but the tubercle 
of the tibia. 

In the great majority of cases the lesion not 
only involves the bone but also the cartilage and 
fibrous structures that cover it respectively be- 
hind and in front; the synovial membrane also 
is torn, and the patella bursa opened up. Thus 
the synovial contents may come in actual contact 
with the skin. " It is anatomically possible, if 
the fracture involve only the lower and non- 
articular portion of the patella, and if the amount 
of the separation of fragments is slight, that the 
fatty tissue behind the apex of the patella, over 
which the synovial membrane is reflected, may 
save the latter from injury " (Henry Morris). 
In all cases where there is much separation of the 
fragments, the fibrous expansion attached to 
either side of the patella must be torn through. 
Indeed, none but a slight separation of the parts 
is possible until tnat expansion is ruptured. 
Braune has demonstrated this by experiment, by 
sawing through the patella without damage to 
the lateral ligamentous structures, and noting 
that but trifling separation of the fragments was 
possible until these structures had been divided. 
In stellate fractures, due to direct violence, these 
fibrous expansions from the extensor tendon may 



Chap. XXI] REGION OF THE KNEE 



543 



a 



be uninjured, and no separation of any magni- 
tude be permitted between the portions of the 
broken bone. 

The patella is more readily broken by muscular 
violence than is either the extensor tendon or the 
ligamentum patellae. In the flexed position it 
will be seen (Fig. 89) that the bone is placed 
at a considerable disadvantage when compared 
with the two other structures. Richet reports a 
case where violent contraction of the quadriceps 
caused the tubercle of the tibia to be torn away 
from the bone without any other lesion of the 
parts immediatelv concerned being produced. 

The patella may be congenitally absent. It is 
developed in the tendon of the quadriceps, re- 
maining cartilaginous until the end of the second 
year. Its sesa- 
moid nature is 
seen in the ten- 
dency to unite by 
fibrous rather 

than by bony 
union after frac- 
ture. It receives 
its