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ANATOMY

PK1NTKD HY

XPOTTISWOODE AND CO., NKW-STRKET SOl'AKH
LONDON

MANUAL OF ANATOMY

FOR SENIOR STUDENTS

EDMUND £OWEN, M.B., F.R.C.S.

SURGEON TO ST MARY'S HOSPITAL, LONDON, AND CO-LECTURER ON SURGERY

(LATE LECTURER ON ANATOMY) IN ITS MEDICAL SCHOOL

* In a practical point of "uieiti Anatomy i* of no use unless
it can be realised on the living body"1 — Francis Sibson

097

WITH NUMEROUS ILLUSTRATIONS

LONDON
LONGMANS, GREEN, AND CO.

AND NEW YORK : 15 EAST x6«> STREET
1890

TO THE MEMORY OF

FRANCIS SIBSON,

AND TO

SAMUEL ARMSTRONG LANE,

HIS EARLIEST TEACHERS

IN
MEDICAL AND SURGICAL ANATOMY,

THIS BOOK IS DEDICATED
BY

THE AUTHOR.

75810

PREFACE

WHEN about to vacate the Chair of Anatomy which, for twelve
years, I had occupied in the Medical School of St. Mary's Hospital,
I desired to leave some permanent record of my work which might
prove of interest and assistance to Senior Students.

Having always found it impracticable to draw a hard-and-fast
line between facts which bear upon the Science of Medicine and those
which chiefly concern the Practical Surgeon, I, a surgeon, have pre-
sumed in this MANUAL boldly to trespass upon the domains of the
Physician, as well as of the Specialist.

Most of the ground has, I am aware, been already covered,
especially as regards so-called Surgical Anatomy. But the entire
range of Anatomy has not hitherto, I think, been treated from the
point of view of the Senior Student, who, having quitted the dis-
secting-room, is in need of a volume which shall supply him with
such anatomical information, free of wearying detail, as is essential
for his successful and intelligent work in the Medical and Surgical
Wards, and in the Special Departments of his Hospital.

The books to which I have chiefly referred in writing this MANUAL
are those of Sibson, Tyler Smith, Ferrier, Gowers, and Ranney :
Holmes, Ch. Heath, and Juler ; Richet, Hilton, Holden, Quain, Gray,
Tillaux, Treves, and Bellamy.

As regards the illustrations, Messrs. Longman have kindly arranged
for my making use of many well-known blocks ; others have been

viii A Manual of Anatomy

obtained from private sources which are duly noted, and, lastly, some
have been specially prepared for me.

Though the reader will not find his attention distracted by foot-
notes, he will constantly meet with figures placed parenthetically in
the text, thus : (p. 67). They direct him to pages whence side-lights are
thrown upon the subject under consideration. It is by no means
necessary that he should always use them ; but it is thought that their
insertion may save him time in referring to the index, and induce
him to make his knowledge of the part the more thorough.

For much kind help in seeing the proofs through the press, my
warm thanks are due to Mr. J. Arthur Kempe, Demonstrator of
Anatomy at Queen's College, Birmingham.

LONDON : February 1890.

MANUAL OF ANATOMY

PART I

THE HEAD AND NECK

THE platysma myoides is a thin sheet of striated fibres between the
two layers of the superficial fascia. It arises from the fasciae of the
deltoid and pectoral regions, and is inserted into the bocjy of the lower
jaw and with the muscles at the commissure of the lips. Thus its
action is to depress the jaw and to draw down the corner of the mouth.
Being a muscle of (unhappy) expression, its nerve-supply is from (the
lower division of) the facial ; it also receives twigs from the superficial
cervical.

Relations. — Beneath it are the anterior and external jugular veins,
the superficial branches of the cervical plexus, and the infra-maxillary
nerve ; the deep fasciae ; deltoid, clavicle, pectoralis major ; sterno-
mastoid ; masseter ; facial vessels, and buccinator.

Passing from the shoulder towards the jaw, the line of the fibres
of the muscle is that of the external jugular vein, which is readily
seen through the thin muscle. When bleeding from this vein, the
surgeon must make his incision at right angles to the course of the
vein and across the fibres of the platysma, so that the blood may freely
escape through a widely open wound, and not become extravasated
beneath the muscle.

THE DEEP CERVICAL FASCIA

The deep fascia may be traced from the spinous process of the
seventh cervical vertebra and the ligamentum nuchag as a thin covering
to the trapezius ; having reached the anterior border of that muscle, it
is slightly reinforced by a layer from beneath it. This thickened layer

2 Musc/es of Head and Neck

then passes over the two posterior triangles, being attached to the
occiput and the mastoid process, and, having reached the hinder
border of the sterno-mastoid, splits to enclose it. At the front of that
muscle the two layers again join, and, covering in the anterior triangle,
the sheet blends in the middle line with that of the opposite side.

Over the posterior triangle the fascia is attached to the clavicle,
being there perforated by the external jugular vein, which had hitherto
lain between the deep fascia and the platysma.

In the anterior triangle it is attached to the lower jaw, and sends
an offshoot to the zygoma to cover the masseter. Another sheet
passes over the parotid gland, and an important slip from the angle
of the jaw to the styloid process — the stylo-maxillary ligament —
separates the parotid from the submaxillary gland.

In the front of the neck, where the deep fascia is attached to the
hyoid bone, it is thin, but as it descends it becomes thicker, and splits
into two layers, the more superficial of which is attached to the front
of the manubrium, whilst the deeper incloses the sterno-hyoid and
thyroid, and is connected with the back of the sternum. It also straps
the tendon of the omo-hyoid to the first rib. One offset from the
fascia beneath the sterno-mastoid joins with and strengthens the
carotid sheath, another intervenes between the sterno-thyroid and the
trachea (see 'Tracheotomy,' p. 131), which, descending in front of the
trachea and of the carotid vessels, unites with the pericardium.

Deeper than all these, a layer, the prcevertebral fascia, passes
behind the pharynx and cesophagus, which, binding down the rectus
anticus major, the longus colli, and the scaleni, descends with the
brachial plexus and the subclavian vessels to blend with the sheath of
the axillary vessels.

Suppuration beneath the deep fascia demands prompt drainage
or it may become diffuse, causing great damage to such tissues as
temporarily impede its course. At the front of the neck the pus ma)'
in time find its way to the surface, but it may be guided by the deep
fascia into the anterior mediastinum, and then possibly set up an
empyema. I once dissected a specimen in which the pus had found
its way into the subclavian vein, causing fatal pyaemia. When beneath
the deep fascia of the posterior triangle it may find its way into the
cesophagus or chest, or may wander in the track of the subclavian
vessels and set up an axillary abscess. The subject of post-
pharyngeal abscess is alluded to on page 210.

The trapezius arises from the inner third of the superior curved
line of the occiput, the ligamentum nuchas, and all the dorsal spines
and their supraspinous ligaments. The highest fibres descend, the
median pass horizontally, and the lowest ascend to their insertion intr>
the angle between the clavicle and the spine of the scapula. Thus
the muscle is attached to the back of the flattened part of the clavicle
and to the upper part of the spine of the scapula.

Sterno-inastoid ; Wry -neck 3

Acting with its fellow, it draws back and fixes the head and neck,
and raises, or depresses, and fixes the shoulders. Its nerve-supply is
from the spinal accessory, and also from the anterior divisions of the
third and fourth cervical nerves. Either with or without the sterno-
mastoid, the trapezius is apt to cause spasmodic wry-neck.

The Hgamentum nuchce ascends from the seventh cervical spine
to the external occipital protuberance, and gives attachment to fasciae
and muscles.

The sterno-cleido-mastoid is attached, as its name suggests, to
the sternum, clavicle (xXets-, ^XftSos-, clavis\ and mastcid process. The
sternal origin is by a tendon from the front of the manubnum ; and the
clavicular origin is by a wide mass of muscle and tendon from the upper
border of the inner end of that bone. The two heads are separated
by a narrow triangular interval, which corresponds with the common
carotid artery, the vagus, and the last part of the internal jugular.

The muscle is enclosed in a definite sheath of the deep cervical
fascia.

The two heads of origin slope upwards and backwards, and, having
blended a little below the middle of the neck, are inserted into the
mastoid process and into the superior curved line of the occiput. The
nerve supply is from the spinal accessory and the anterior divisions of
the second and third cervical nerves. The arterial supply is from the
occipital, the superior thyroid, through the descending branch (p. 28),
and the supra-scapular.

The anterior border of the muscle is the surgeon's guide in ligation
of the common, external, or internal carotid artery, and in cesophago-
tomy ; and the posterior border of its clavicular origin is the guide to
the subclavian artery.

The chief action of the muscle is to draw the head down to the
shoulder, and to turn the face to the opposite side. And this is neces-
sarily the attitude of the head and face in that form of wry-neck which
is secondary to contraction of the muscle. The common cause of
congenital wry-neck is rupture of one or both heads of the sterno-
mastoid during parturition, when the escaping head receives a vigo-
rous and natural twist ; the fibrous tissue by which the tear of the
muscular fibres is mended undergoes subsequent contraction. The
permanent drag upon that side of the face and head not only draws
down the corner of the mouth, the outer commissure of the eyelids,
and the side of the lower jaw, but also prevents the proper develop-
ment of the bones of that side of the face. In due course other muscles
and bands are shortened on the concave side of the neck, and the cer-
vical vertebrae become deformed.

Relations. — The sterno-mastoid is covered by the platysma ; the
external jugular vein ; lesser occipital, great auricular, and transverse
cervical nerves, and the deep fascia.

Beneath it are another layer of the deep fascia, the sterno-hyoid,

4 Muscles of Head and Neck

sterno-thyroid, and omo-hyoid muscles ; the posterior belly of the
digastric ; scaleni, levator anguli scapulas, and splenius ; the common,
and perhaps the beginning of external and internal carotid arteries ;
the internal and anterior jugular veins ; vagus ; descendens and com-
municantes noni ; spinal accessory ; cervical nerves ; occipital artery,
lymphatic glands, and the deep part of the parotid. Beneath the
muscle also, in contact with the scalenus anticus, are the subclavian
vessels and the phrenic nerve.

Though contraction of the cicatrix left after congenital rupture of
the muscle is the commonest cause of wry-neck, the deformity may
also be determined by ulceration of the cervical vertebrae, in which
case complaint will be made of peripheral neuralgias.

Tenotomy of the sterno-mastoid. — When the contraction of the
muscle is such that the head cannot be brought straight, both slips
of origin of the sterno-mastoid must be divided subcutaneously.

Operation. — The muscle having been put upon the stretch, a strong
and slender blade is passed close beneath each band in turn, the
section being made towards the skin. But the procedure is not devoid
of risk, as the anterior jugular (p. 36) or some other large tributary of
the subclavian or external jugular vein may be in the way of the knife.
Should this happen, the wound in the vessel is held wide open, on
account of the head being tightly dragged up, and thus air may pass
by the subclavian vein into the heart, where, being churned up with
the blood, it may cause a fatal arrest of the circulation.

As the anterior jugular and the subclavian are close behind the
clavicle, the risk of wounding an important vessel is diminished if
the tenotomy is done half an inch above that bone. The external
jugular descends close by the posterior border of the clavicular head
of the muscle.

Section of the clavicular part of the muscle may be conveniently
and safely effected by a free and open wound above and parallel with
the clavicle. In a case in which I recently operated by this method
I found the internal jugular vein so close beneath the contracted band
that, had I performed subcutaneous tenotomy, I could hardly have
failed to wound it. Subcutaneous surgery has no doubt played a use-
ful part, but at the present day it is an anachronism in many cases of
wry-neck and in most cases of club-foot.

When spasmodic contraction is deemed to be due to irritation of
the spinal accessory nerve, excision of half an inch of nerve as it is
entering the muscle may be resorted to with some hope of success

(P- 7i).

The levator anguli scapulae arises from the posterior tubercles
of the four upper cervical vertebrse, and is inserted into the upper
part of the vertebral border of the scapula. It is supplied by the
anterior divisions of the middle cervical nerves.

Relations of Omo-hyoid

THE DEPRESSORS OF THE HYOID BONE

The sterno-hyoid arises from the back of the manubrium and the
adjacent part of the clavicle, and, sloping towards the middle line, is
inserted into the lower part of the body of the hyoid bone.

The sterna-thyroid arises from the manubrium, just below the
sterno-hyoid, and, ascending under cover of that muscle, slopes slightly
backwards to its insertion in the oblique line on the thyroid cartilage.
This and the preceding muscle are often marked a little below their
insertion by a tendinous intersection. The net ye supply of these
two muscles is from the loop of the descendens and communicantes
noni.

Relations. — These muscles ascend from the anterior mediastinum,
and are under cover of the sterno-mastoid, the deep fascia, platysma,
and the anterior jugular vein. The omo-hyoid joins company with
them above on their outer side. They rest upon the trachea and the
lower part of the larynx ; the thyroid gland and its vessels ; the innomi-
nate, subclavian, and common carotid arteries, and the internal jugular,
subclavian, and innominate veins.

The thyro-hyoid continues the sterno-thyroid up to the body and
great cornu of the hyoid bone. It hides the passage of the superior
laryngeal vessels and nerve through the thyro-hyoid membrane, and
is itself covered by the sterno-hyoid and omo-hyoid. Its motor nerve
is a special branch of the hypoglossal.

The omo-hyoid ascends from the upper border of the shoulder-
blade (co/zo?) to the body of the hyoid bone, just external to the inser-
tion of the sterno-hyoid. It is a double-bellied muscle, the median
tendinous part being bound by a process of the deep cervical fascia,
beneath the sterno-mastoid, to the first rib. As the posterior belly
passes upwards and forwards to dip beneath the sterno-mastoid, it
forms the base of the occipital and the upper border of the subclavian
triangle ; in a thin person this belly may be seen at work in its
oblique position above the clavicle, especially when a deep inspiration
is taken. And as the anterior belly emerges from beneath the sterno-
mastoid and mounts to the hyoid bone it forms the upper boundary
of the inferior and the base of the superior carotid triangle.

The nerve-stipply is from the loop of the descendens and com-
municantes noni.

Relations. — Coming up from the shoulder-blade, the omo-hyoid is
covered by the trapezius, clavicle and subclavius, the deep fascia,
platysma, and integument, and it lies above the subclavian vessels,
the lower cervical nerves, and the posterior and middle scalenes. It
then passes beneath the sterno-mastoid and over the scalenus anticus
and the phrenic nerve, and over the sheath of the common carotid
with the internal jugular vein and the vagus. It subsequently rests

6 Muscles of Head ana Neck

upon the sterno-thyroid and thyro-hyoid, being covered by the platysma
and fascias.

The omo-hyoid crosses the carotid sheatli at the level of the fifth
cervical vertebra (see p. 23).

THE ELEVATORS OF THE HYOID BONE

The digastric arises posteriorly from the deep aspect of
mastoid process, and, therefore, under cover of the sterno-mastoid,
splenius, and tracheo-mastoid, but upon the outer side of the occipital
artery. And. as the parotid gland fills in the hollow in front of the
sterno-mastoid, it also lies over the posterior belly of the digastric.
This part of the muscle soon ends in a shining tendon, which, piercing
the fleshy stylo-hyoid, joins with the tendon of the anterior belly,
being bound down to the hyoid bone by the deep fascia.

Relations. — The posterior belly rests upon the stylo-glossus and
stylo-pharyngeus, the internal jugular vein, pneumogastric nerve, and
internal carotid artery ; the occipital artery and hypoglossal nerve ;
the external carotid, and the lingual and facial arteries, and then upon
the hyo-glossus (see p. 27). Its course is indicated by a line drawn
from the mastoid process to the body of the hyoid bone.

The anterior belly arises from a depression close against the
symphysis, and, passing downwards and backwards to the central
tendon, rests upon the mylo-hyoicl, being covered by skin, platysma,
and fasciae.

The posterior belly, with the stylo-hyoid, forms the upper limit of
the superior carotid, and the hinder limit of the submaxillary triangle.

Nerve-supply. — The anterior belly helps the mylo-hyoid in raising
and drawing forward the hyoid bone, and in depressing the jaw, and
receives its supply from the mylo-hyoid nerve. The posterior belly
acts with the stylo-hyoid in raising and drawing back the hyoid bone,
and, like that muscle, is supplied by the facial nerve.

The stylo-hyoid arises from the outer side of the styloid process
and is inserted into the body of the hyoid bone. It is pierced by the
tendon of the posterior belly of the digastric. Its course, actions, and
relations resemble those of the posterior belly of the digastric ; and its
nerve supply is identical.

The mylo-hyoid descends from the ridge at the back of the maxilla
to the body of the hyoid bone, the posterior border being free, whilst
the anterior is blended with its fellow in a median raphe.

Relations. — It is covered by the platysma and fasciae ; the anterior
belly of the digastric ; the mylo-hyoid nerve and artery ; the su
maxillary gland, and submental arteiy. Its deep surface helps to
form the floor of the mouth, and is in contact with the genio-hyoid,
genio-hyo-glossus ; the hypoglossal and gustatory nerves ; the deep
part of the submaxillary gland and its duct, and the sublingual

1st

Occipito-frontalis J

gland. It is supplied by the mylo-hyoid branch of the inferior dental
nerve.

The genio-hyoid lies upon the deep side of the mylo-hyoid, pass-
ing from the symphysis to the front of the body of the hyoid bone.
Along its posterior border is the genio-hyo-glossus, in whose action
and nerve supply (hypoglossal) it participates.

The occipito-irontalis may be taken as arising from the outer
part of the superior curved lines and from the neighbouring part of the
mastoid processes, and as inserted into the skin of the frontal region —
not into frontal bone itself, or it could have no action. The two
fleshy parts of the muscle are separated by a very thin intervening
aponeurosis, which covers the vertex, and gives origin at the side of
the head to the attollens and attrahens aurem. The tendon spreads
out into loose connective tissue upon the temporal fascia (p. 8). The
median fibres of the anterior part of the muscle blend with the pyrami-
dalis nasi, and the others with the corrugator and with the orbicularis.
The aponeurosis is very intimately blended with the skin — the student
may remember that in his first dissection he could not avoid removing
some of the aponeurosis with the skin, though he had no difficulty
whatever in separating the aponeurosis from the skull.

When pus or blood is effused upon the top of the head its situa-
tion is certainly beneath the aponeurosis — not between it and the
skin. A layer of loose connective tissue, the pericranium, intervenes
between the aponeurosis and the skull-vault, and it is over this that the
muscle and the scalp work. The scalp is readily torn down by accident,
or as one sees effected in the mortuary ; but when, during life, the
calvaria is thus laid bare the occurrence of necrosis is by no means
necessitated, as the nutrition of the outer table can be freely carried on
by the vessels of the diploe. When cleaned and readjusted, the scalp
promptly resumes its attachments and its office.

The action of the muscle is to raise the skin of the forehead in
horizontal wrinkles, as in expressing surprise ; the posterior fleshy part
may be able to draw back the scalp, and so help the anterior part.
Being a muscle of expression, it is supplied by the facial nerve, through
its posterior auricular and temporal branches. When one facial nerve
is paralysed the skin on that side of the forehead is destitute of wrinkles,
and remains strangely expressionless when compared with the other
half (p. 67).

The masseter arises from the zygomatic arch and is inserted into
the angle and ramus of the jaw. It is supplied by the third division of
the fifth nerve ; its action is to raise the lower jaw.

Relatio7is. — Between it and the integument are peripheral fibres
of the orbicularis palpebrarum, the zygomatici, risorius, and pla-
tysma ; the transverse facial artery ; Stenson's duct, and an offshoot
of the parotid gland (socia) ; and branches of both the divisions of
the facial nerve, and the facial artery and vein. On its deep surface

8 Muscles of Head and Neck

are the buccinator and the lower jaw. The parotid gland is
hind it.

The temporal fascia binds down, and gives origin to, the temporal
muscle. It is attached above to the temporal ridge, and below, in
two layers, to the zygomatic arch ; between these layers, and running
in a little fat, are the orbital branch of the temporal artery (p. 31) and
a twig of the temporo-malar nerve.

Upon the fascia are fibres of the orbicularis palpebrarum ; the
aponeurosis of the occipito-frontalis; the attollens and attrahens aurem ;
and the superficial temporal vessels and nerves.

The temporal muscle arises from the temporal fossa and also
from the temporal fascia, and, passing beneath the zygomatic arch, is
inserted into the coronoid process— down to the last molar tooth. Its
action is to raise the jaw and draw it backwards. Its nerve supply is
from the third division of the fifth.

Relations. — It is covered by the temporal fascia and the structures
lying thereon. Behind it are the masseteric vessels and nerves passing
through the sigmoid notch, and beneath is the floor of the temporal
fossa, with the deep temporal vessels and nerves.

The external pteryg-oid, pyramidal, arises from the outer side of
the external pterygoid plate and the great wing of the sphenoid, and,
running outwards and backwards, is inserted into the condyle of the
jaw and into the inter-articular fibre-cartilage. When the jaw is dislo-
cated the cartilage follows the condyle.

Action. — To advance and depress the jaw, and to carry it towards
the opposite side.

Relations. — Below it are the internal pterygoid, the inferior dental
vessels and nerve, and the gustatory nerve. The internal maxillary
artery winds round the muscle to enter the pterygo-maxillary fossa
between its heads.

T*he internal pterygoid arises from the inner surface of the external
pterygoid plate, and passes downwards, outwards, and backwards to
its insertion on the inner side of the angle of the jaw. Thus its action
is to raise the jaw, to thrust it towards the opposite side, and to
bring it forwards. Both pterygoid muscles are supplied by the thii
division of the fifth nerve.

Relations. — With the ramus of the jaw and the external pterygoi<
it roughly forms a triangular space through which pass the interne
maxillary vessels, the inferior dental vessels and nerve, and the gustatory
nerve.

Tetanus (re'rai/or, rfiW, strain}, a continuous spasm of the muscles
of the body, often begins in the maxillary region, so that the patient
cannot separate the teeth or swallow without great effort or choking.
This local tetanus is Mock-jaw 'or trismits (rpi£o>, creak, gnash A
teeth}.

IV*

;

Side of Neck

THE TRIANGLES OF THE NECK

The side of the neck may be represented as an oblong divided by
the sterno-mastoid into a superior and inferior triangle. (The student
will find it useful to practise drawing these tri-
angles and their subdivisions in outline, and
roughly filling in their chief contents.)

The posterior triangle has as its base that
part of the clavicle which is between the pos-
terior border of the sterno-mastoid and the
anterior border of the trapezius — the muscles
which form its sides — its apex being between
the occipital attachments of those muscles.
This triangle is divided by the posterior belly
of the omo-hyoid into an occipital and a sub-

rlavi'an trio r> n-1 ^ x> submaxillary triangle; 2,

Clavian triangle. superior carotid ; 3, inferior

The sides of the occipital triangle are carotid; 4, occipital; 5, sub-
formed by the borders of the trapezius and the

sterno-mastoid, the posterior belly of the omo-hyoid being its base. In
its floor, from above downwards, are the splenius capitis, levator anguli
scapulas, and the scalenus medius and posticus. It is covered by skin
and fasciae, and by the platysma inferiorly.

Superficial branches of the cervical plexus appear in the space,
namely, the lesser occipital, great auricular, and the superficial or trans-
verse cervical nerve (all of which wind round the posterior border of
the sterno-mastoid) and the supra-clavicular branches, which leave the
lower part of the triangle (v. p. 145). The spinal accessory nerve
traverses the middle of the triangle in its course from the sterno-
mastoid to the trapezius (p. 70), and the transverse cervical branch
of the thyroid axis (p. 233) crosses its lower part. The glandulas con-
catenates extend, deeply, along the posterior border of the sterno-
mastoid.

The subclavian triangle is bounded below by the clavicle, in
front by the posterior border of the sterno-mastoid, and above by the
posterior belly of the omo-hyoid. It derives its name and its import-
ance from the fact that the subclavian artery is usually tied in its
depths.

The more muscular the subject, the smaller is the triangle. It is
covered by the skin, fasciae, and platysma, and is crossed by the supra-
clavicular nerves. The external jugular vein (p. 35) pierces the deep
fascia just behind the origin of the sterno-mastoid, to end in the sub-
clavian vein, and it receives the suprascapular and transverse cervical
veins as it passes through the triangle. The suprascapular and posterior
scapular arteries also cross the space from beneath the sterno-mastoid.
The third part of the subclavian artery and the subclavian vein

10 Muscles of Head ana Neck

ery
us.

cross the floor of the triangle upon the first rib. and above the artery
the trunks of the cervical nerves slant down for the brachial plexus.
In front of the artery is the scalenus anticus, and behind the nerves
the scalenus medius. Some lymphatic glands lie in the space ; th
are apt to be enlarged in malignant disease of the mamma, ccsophag
and also of thestomach.

The anterior triangle is crossed obliquely by the anterior belly of
the omo-hyoid and by the posterior belly of the digastric, and is thus
divided into three triangles, which are named, from above downwards,
the submaxillary, and the superior and the inferior carotid triangles.

The submaxillary triangle is bounded above by the lower border
of the jaw, and by aline drawn from its angle to the mastoid process
below by the posterior belly of the digastric and the stylo-hyoid ; a:
in front by the median line of the neck.

It is covered by a skin, superficial fascia, platysma, and deep fasci
together with branches of the infra-maxillary (p. 67) and superfici
cervical nerves. Its floor is formed by the hyo-glossus, mylo-hyoi
and anterior belly of digastric.

The space contains the submaxillary gland, with the facial artery a
vein (p. 29) ; the mylo-hyoid nerve and artery, and the submen
branch of the facial artery. Behind the submaxillary gland is t
stylo-maxillary ligament, immediately behind which is the parot
gland. (For the anatomy of the parotid region see page 117.)

The superior carotid triangle is bounded behind by the stern
mastoid, above by the posterior belly of the digastric, and below by
the anterior belly of the omo-hyoid. It is covered by skin, superficial
fascia, platysma, and deep fascia, and is crossed by branches of the
superficial cervical and infra-maxillary nerves. Its floor is formed by the
thyro-hyoid and hyo-glossus, by the lower constrictors of the pharynx,
and by the upper part of the thyroid cartilage. It takes its name from
the fact that it contains the upper part of the common carotid and the
beginning of the external and internal carotids. In the triangle the
external carotid gives off the superior thyroid, lingual, facial, ascending
pharyngeal, and occipital branches. Corresponding venous tributaries
join the internal jugular, which, together with the vagus, is in the
carotid sheath. Additional contents of the space are the hypo-gloss
descendens and communicantes noni, and the superior laryngeal nerve
and a small piece of the spinal accessory nerve may be seen in t
highest angle, and of the recurrent laryngeal in the lowest angle, of t
space The sympathetic cord is behind the carotid sheath.

The inferior carotid triangle contains the lower cervical part of t
common carotid. Its boundaries are the sterno-mastoid, the anteri
belly of the omo-hyoid, and the median line of the neck. It is cove
by skin, platysma, and fasciae, together with branches of the superfici
cervical nerve.

As a matter of fact, the carotid artery is shut out of this triangle

Frontal Bone 1 1

the lower parts of the sterno-mastoid, sterno-hyoid, and sterno-thyroid,
though, with the internal jugular vein and the pneumogastric nerve,
it is popularly believed to be contained in it. Then, by only a very
little more imagination, the inferior thyroid artery, the recurrent laryn-
geal nerve (p. 70), and the cord of the sympathetic are seen within the
space— all of which are behind the carotid sheath. The trachea and
the thyroid gland are similarly given in the triangle.

THE BONES OF THE HEAD

The frontal bone. — The vertical part is marked by the frontal
eminences, which correspond to the frontal lobes of the brain. Below
them are the superciliary ridges, which are continuous internally with
the root of the nose. They correspond with the frontal sinuses and
give origin at their inner end to the corrugator supercilii and the
orbicularis. In the case of fracture the external table may be driven
into the sinus without the inner table being damaged, and on the man
coughing, or blowing his nose, air may escape into the scalp and cause
extensive emphysema.

The frontal sinuses are absent in childhood, and they are com-
paratively small in women. They communicate with the middle
meatus by the infundibulum. A chronic abscess of the sinus which
has opened externally must -be drained into the nose.

Below the superciliary ridge comes the margin of the orbit, with
the supra-orbital notch or foramen to the inner side of the middle.
As the supra-orbital vein traverses this notch it receives a small diploic
vein.

The supra-orbital arch ends at the strong external angular process,
which articulates with the malar, and the
temporal ridge ascends from it. This pro-
cess overhangs the fossa for the lachrymal
gland. The internal angular process
articulates with the nasal process of the
superior maxilla and the lachrymal ; a
hernial protrusion of the dura mater — a
meningocele— sometimes occurs at that
spot. Close behind the internal angular
process is the fossa for the pulley of the
superior oblique.

On the cerebral aspect, where the
lateral halves join, is a ridge for the attach-
ment of the falx cerebri, and the groove W

for the Superior longitudinal sinus. Anterior Meningocele (BRYANT).

The horizontal part of the frontal con-
sists of the thin plates for the roof of the orbit, the notch between them

The Bones of the Head

being filled by the cribriform plate of the ethmoid. There, also, a
meningocele may protrude. At the line of articulation with the ethmoid
are the ethmoidal foramina, by which the ethmoidal arteries and the
nasal nerve enter the cranium. Fracture of this part of the skull may
cause sub-conjunctival haemorrhage from the ethmoidal arteries, and
when this is associated with severe bleeding from the nose, and with
escape of sub-arachnoid fluid (which must not be taken for the effect
of a nasal catarrh), there is ample evidence of fracture having taken
place. The upper surface of the plates is marked by the orbital con-
volutions of the frontal lobes.

The frontal bone is developed in lateral halves.
The temporal. — The squamous part lies in the temporal fossa,
and its bevelled margin overlaps the parietal bone, whilst its lower
and hinder part is bounded by the posterior root of the zygoma. The
anterior root of the zygoma is the eminentia articularis, which is
covered by cartilage, and receives the condyle of the jaw when the
mouth is widely opened. Behind the eminentia is the glenoid fossa,
cleft by the Glaserian fissure through which the chorda tympani leaves
the middle ear ; a branch of the internal maxillary artery also tra-
verses it.

The front of the fossa, covered with cartilage, articulates with the
condyle of the jaw, and the hinder part lodges some of the parotid
gland ; a thin lamina of bone partitions it from the tympanic cavity
and the external auditory meatus. Thus < it is that a parotid abscess
may burst through the external ear. The inner surface of the
squamous portion is deeply grooved by the middle meningeal artery.
The mastoid portion scarcely .exists in childhood ; it is developed
with the petrous portion under the name of
petro-mastoid bone. But as puberty comes
on it is hollowed out into air-cells which
open into the back of the middle ear, their
mucous lining being covered with columnar
ciliated epithelium. It is by way of these
cells that tympanic suppuration sometimes
reaches the surface as a post-auricular
abscess, raising the skin and pushing the
pinna forward ; sometimes, however, the pus
finds its way into the external meatus, thus
the matter reaches the outer surface of the
membrana tympani without traversing it.
'« *e same way, in the case of fracture of
the base of the skull, blood may escape from
the external ear though the membrana, as shown by otoscopic exami-
nation, has not been damaged. In every case of suppuration in the
mastoid process the surgeon should be prompt in securing evacuation
by the gouge or trephine.

Fracture of Skull 13

In certain cases in which the Eustachian tube has been blocked,
the surgeon has endeavoured to ventilate the rmddle ear by making a
permanent drill-opening into the mastoid cells, but the proceeding is
dangerous, meningitis being apt to follow.

The mastoid foramen transmits- a large vein into the lateral sinus,
and a branch of the occipital artery for the dura mater ; and in acute
otitis, when every neighbouring vessel is engorged with blood, the
application of a few leeches behind the ear affords direct and imme-'
diate relief.

If matter be long pent up in the mastoid cells it may find its escape
into the cranial cavity and set up a purulent and fatal meningitis.
Moreover, the lateral sinus, which is close upon the inner side of
the cells, may become inflamed in the course of otitis media, and,
septic coagulation of its contents taking place, pyaemia ensues.

On the inner aspect of the mastoid process is a fossa for the origin
of the posterior belly of the digastric, and, more internally still, is the
groove for the occipital artery.

On the cerebral surface of the mastoid portion is the wide and
shallow groove for the lateral sinus (p. 39), into which the mastoid
vein is opening. When the question arises of trephining in the region
of the mastoid cells the surgeon must remember that the lateral sinus
specially grooves the front of the cranial aspect of the mastoid pro-
cess (Tillaux).

The petrous portion, hard as a stone (Tre'rpos), is wedged forwards
and inwards into the floor of the skull. Its base is between the
squamous and mastoid portions, and receives the external auditory
meatus, which is surrounded by . the outgrowth of the horse-shoe
auditory process, to the surface of which the cartilage of the pinna
is attached. Through the petrous portion winds the canal for the
internal carotid artery (p. 33) ; by the articulation with the occipital
the jugular foramen is enclosed.

The internal and middle ear are also contained within the petrous
bone, and the facial nerve winds through it from the internal auditory
meatus to its exit from the aqueductus Fallopii at the stylo-mastoid
foramen.

Fracture across this brittle bone may be followed by rupture of the
large vein and artery, and of the membrana tympani, and, further,
by bleeding from the ear. The perilymph may also escape from the
internal ear, diluting the blood, or staining the pillow long after
bleeding has ceased. The facial nerve having been torn across,
paralysis of the muscles of expression ensues.

On the anterior surface of the petrous bone is the upheaval which
is caused by the superior semicircular canal of the internal ear ; just
outside this is the thin plate of bone roofing in the middle ear. Nearer
to the middle line is the hiatus Fallopii, by which the petrosal branch of
the facial escapes from the aqueduct to join the Vidian nerve.

tones of tlie neat

The posterior surface shows the internal auditory meatus,
which pass the facial and auditory nerves in their arachnoid invest-
ment, and the auditory branch of the basilar artery. The facial nerve
enters the aqueductus above the sieve-like part of the end of the
canal through which the auditory filaments reach the internal ear.

The styloid process gives origin to small muscles for the pharynx,
hyoid bone, and tongue ; the piece of the deep cervical fascia which
separates the parotid and submaxillary glands (p. 2) is also attached
to it. The temporal bone is developed in four pieces : one for the
squamous, one for the petrous and mastoid, one for the tympanic
horse-shoe, and one for the styloid process.

The sphenoid. — The body is hollowed out into an air-chamber
which opens into the back of the superior meatus of the nose,
and on either side is a broad groove for the internal carotid artery
and the cavernous sinus (p. 40). The posterior part is connected
with the occipital bone by cartilage until the eighteenth year, after
which the union is osseous and perfect. The upper surface of the
great wing enters into the middle fossa, and is marked by the round
and oval openings for the second and third divisions of the fifth
nerve, and of the middle meningeal artery and vein. The outer
surface enters into the temporal and pterygoid fossas, and the anterior
surface forms most of the outer wall of the orbit.

The lesser wing forms the back part of the roof of the orbit, and
supports the frontal lobe. Its posterior border is lodged in the Sylvian
fissure of the brain. Between the two wings is the sphenoidal fissure,
which transmits the third, fourth, ophthalmic division of fifth, and the
sixth nerves, the ophthalmic vein, and some sympathetic filaments.
At the root of the process is the foramen by which the optic nerve and
ophthalmic artery enter the orbit.

The external pterygoid process is a wide plate which gives origin
to both the external and internal pterygoid muscles. The internal
process descends parallel with the vomer, and forms the outer wall of
the posterior nares. It ends below in the hamular process, round
which the tendon of the tensor palati is reflected. This hook-like
process is readily felt in the mouth (p. 107) ; to it are attached the
superior constrictor and the pterygo-maxillary ligament. The tensor
palati arises from the scaphoid fossa between the roots of the pterygoid
processes.

The ethmoid consists of a vertical plate which enters into the septum
of the nose, and of a horizontal, or cribriform, plate which forms
part of the anterior fossa of the skull, and on the under surface of which
are fixed the lateral masses. The front of the vertical plate extends
into the crista galli, between which and the frontal bone is the foramen
caecum, transmitting a vein from the nose to the superior longitudinal
sinus. At the side of the crista is the slit for the nasal nerve.
Through the cribriform plate descend the olfactory filaments, and

Occipital Bone 15

its outer border, where it articulates with the frontal, are the foramina
for the anterior and posterior ethmoidal arteries, the nasal nerve
accompanying the anterior vessel.

The lateral masses contain the anterior and posterior ethmoidal
sinuses, which open respectively into the middle and superior meatuses.
The superior and middle turbinated bones help to make up the mass.
They are covered with mucous membrane in which the olfactory
filaments are spread. The turbinated bones play the part of a re-
spirator, warming and moistening the inspired air, and filtering it
of solid particles. The outer wall of the lateral mass, the os planum,
forms part of the inner wall of the orbit.

The occipital bone has its vertical part greatly strengthened by a
protuberance (to which the ligamentum nuchag is attached), by an in-
ternal and external median crest, and by two curved lines, or groins,
which arch laterally from the external crest. The trapezius and
occipito-frontalis arise from the superior curved line, and the sterno-
mastoid and splenitis are inserted into it. Between the lines the
complexus and superior oblique are inserted ; the ' straight ' muscles
of the back of the head are attached to the lower line.

The condyles have their long diameter sloping forwards and
inwards, the movements at the occipito-atloid joints being only flexion
and extension. Between the condyles is the foramen magnum for the
transmission of the medulla oblongata and its membranes, the spinal
accessory nerves, and the vertebral arteries. At the front and outer
part of each condyle is the anterior condylar foramen for the trans-
mission of the hypoglossal nerve, and perhaps of a twig from the
ascending pharyngeal artery.

A vein may enter the lateral sinus through the posterior condylar
foramen. In front of the foramen magnum is the basilar process,
with a spine for the attachment of the superior constrictor of the
pharynx.

The cerebral surface shows the cruciform markings of the superior
longitudinal, the occipital, and the two lateral sinuses which meet at
the internal protuberance over which the torcular Herophili is placed.
The two superior fossae thus marked out are for the occipital lobes of
the cerebrum, the two inferior for the lobes of the cerebellum. The
lateral sinus, having grooved the vertical part of the occipital bone,
passes on to the posterior inferior angle of the parietal, the mastoid
portion of the temporal, and then to the jugular process of the occipital,
where it ends in the jugular fossa. The superior angle of the bone is
received between the parietal bones, and corresponds to the site of the
posterior fontanelle.

The upper surface of the basilar process supports the medulla and
pons. Its border is grooved by the inferior petrosal sinus passing
backwards to the jugular foramen, which also transmits the blood of
the lateral sinus to the internal jugular vein, and the glosso-pharyngeal,

iones 01

'eat

pneumogastric, and spinal accessory nerves. The under surf;
the basilar process is in the roof of the pharynx, and may be explored
by the finger in the case of suspected fracture of the base of the skull.
The bone is developed by seven centres : four for the vertical part,
which blend at the occipital protuberance, one for each condylar part,
and one for the basilar process.

The vertical part of the bone, as with those parts of the other
bones which form the wall and roof of the skull, is developed from
membrane, whilst the horizontal part, as is the case with those other
pieces which form the base of the skull, is ossified from cartilage.
This arrangement is to render the skull strong enough to protect the
basal ganglia during its passage through the pelvis.

Cranium bifidum occurs when osseous union in the occipital region

is incomplete, themembranes,
and perhaps some of the en-
cephalon, bulging backwards
through the median cleft.
(See Spina Bifida, p. 204.)

The parietal ( paries,
wall). — The convex surface is
marked by the curved tem-
poral ridge, above which
plays the aponeurosis of the
occipito-frontaljs, the tem-
poral muscle arising below
the ridge. Near the hinder
part of the superior border is
the parietal foramen, by
which a vein for the scalp
passes into the longitudinal sinus, accompanied sometimes by a twig
of the occipital artery.

The internal surface is marked by cerebral convolutions, especially
those of the motor area, and is deeply grooved by branches of the
middle meningeal artery, which lead upwards from the anterior inferior
angle. The posterior inferior angle is grooved for the lateral sinus,
and along the superior border runs the shallow groove for the longi-
tudinal sinus and the falx cerebri. Near this groove are depressions
for the Pacchionian glands — villous processes of the arachnoid ;
uninformed man might take these irregular nodules for tubercu
deposits. Some of them are deeply imbedded in the bone.

The posterior border articulates with the occipital in the lambdoid
suture. In weakly infants who lie much in the supine position, the
occipital bone may sink in between the parietals to such an extent as,
according to some observers, to cause cerebral irritation. The articu-
lation of the posterior inferior angle with the mastoid bone is often
thinned (cranio-tabes) in syphilitic and rickety children, imparting.

Occipital Meningocele.

Fontanelles : a, anterior
, posterior.

Superior Maxilla 17

to the finger and thumb the sensation of there being a parchment
patch in the skull-wall.

There is a fontanelle at each angle of the parietal bone, as may be
seen on p. 366, but those at the sphenoidal
and mastoid angles are comparatively un-
important. In the case of tubercular inflam-
mation attacking the membranes of the brain
in a child before the fontanelle is closed, a
bulging may be found at that region.

The superior maxilla is marked upon
the anterior surface by the ridge caused by
the fang of the canine tooth, which can be
felt even through the lip. Just external to
this is the canine fossa, from which the
levator anguli oris arises. Above the origin
to this muscle the infra-orbital nerve emerges
under cover of the levator labii superioris and of the orbicularis oris.

The orbital surface articulates behind with the vertical part of the
palate, internally with the lachrymal and ethmoid. It is separated from
the great wing of the sphenoid by the spheno-maxillary fissure, which
ends externally in the vertical, pterygo-maxillary fissure. Thus the
hinder part of the jaw has no direct articulations.

In a bony canal beneath the floor of the orbit run the infra-orbital
artery and the second division of the fifth nerve.

The under surface of the palate process is rough, and at the
front it may be marked by a delicate articulation which runs outwards
and forwards from behind the anterior palatine canals to the interval
between the lateral incisor and canine teeth ; it shows the limit of the
inter-maxillary bone. This segment
has a separate centre of ossification,
and is developed in connection with
the vertical plate of the ethmoid
and the vomer. In extreme cases
of hare-lip the inter-maxillary bone
adheres to the tip of the nose.

The antrum communicates with
the middle meatus by a small round
opening ; its inner wall is made up
by the vertical plate of the palate,
the lateral mass of the ethmoid, and
the inferior turbinated. The cavity
extends into the alveolar, malar,
and zygomatic parts of the bone, and is shut out from the orbit only
by a thin osseous plate. The roots of the first and second molar teeth
cause projections upon its inner wall. Abscess in the antrum may be
tapped by raising the lip and cheek in the neighbourhood of the canine

1 8 The Bones of the Head

fossa and drilling upwards and inwards ; but if the first or sec
molar be decayed it may be extracted, and the cavity opened by passing
a gimlet up the emptied socket.

Maligna?it disease often attacks the superior maxilla, and, entering
the antrum, grows at a great pace : advancing upwards, it raises, pushes
forward, and disorganises the eyeball; downwards, and it implicates the
palate and loosens the teeth ; inwards, and it blocks the nostril, and,
backwards, the pharynx. The only treatment likely to avail is exci-
sion of the superior maxilla. This operation is performed by making
an incision from the inner corner of the orbit down the side of the nose,
round the ala, traversing its cartilage, and through the middle of the
upper lip, the coronary artery being promptly secured. From the top
of the incision another is made horizontally outwards along the lower
margin of the orbit, and through the periosteum, which is then easily
raised from the floor of the orbit. The thick, irregular flap of the
cheek is turned outwards. The malar bone is then sawn across, and
the nasal process of the superior maxilla divided with bone nippers.
The central incisor having been previously extracted, the palate pro-
cesses of the palate and superior maxilla are nipped through, the soft
palate having been detached, and the loosened bone is then caught
with lion forceps and twisted out, the second division of the fifth nerve
and branches of the internal maxillary artery being torn across during
that procedure.

The soft palate remains behind. So also may the periosteum of the
orbit, the latter structure playing a useful part in the subsequent sup-
port of the eyeball. Indeed, after some weeks, if all go well, the chasm
is so filled up by contractions that there is little to indicate that so
serious an operation has been performed, the eye-ball keeping its place.

During the operation the following structures are divided', the
orbicularis oris, coronary artery, and labial mucous membrane ; lateral
nasal branches of the facial artery and vein, and branches of the infra-
orbital nerve passing to the nose ; the muscles which depress and dilate
the nostril. In raising the upper part of the flap the orbicularis palpe-
brarum, levator labii superioris, and levator anguli oris would be cut,
together with the infra-orbital nerve and artery, the angular branches of
the facial vessels, and branches of the facial nerve supplying the muscles.
The periosteum of the floor of the orbit and the origin of the inferior
oblique would be detached and raised. The more distant structures
detached are the buccinator ; the soft palate with the expansion from
the tensor palati ; the superior maxillary nerve in front of the fora-
men rotundum, and posterior palatine and dental branches of the
nternal maxillary artery. The muco-periosteum of the hard palate is,
of course, taken away with the bone. When the maxilhr arc narrow,
* V-shaped,' the palatine arch is contracted and the teeth appear in
great disorder. Not seldom, moreover, the deformity is associated
with mental deficiency.

Inferior Maxilla 19

The palate bone consists of a vertical and a horizontal part. The
former helps to close in the antrum and extends up into the floor of the
orbit. The horizontal part forms the back of the hard palate and of
the floor of the nose. Its under surface shows the ending of the pos-
terior palatine canal, and is also marked by a ridge for the attachment
of part of the tensor palati. To the posterior border is attached the
palatine aponeurosis, and from the posterior nasal spine arises the
azygos uvulae.

The lachrymal, somewhat of the size and thickness of a finger-
nail, rests upon the inner border of the orbital plate of the maxilla, and
helps to fill in the anterior ethmoidal cells. Its upper border articu-
lates with the frontal, and its anterior with the nasal process of the
maxilla. A vertical ridge upon the orbital aspect of the bone marks
off a groove, which, with a groove upon the nasal process, lodges the
lachrymal sac and the upper part of the nasal duct (p. 76). The tensor
tarsi arises from the bone just behind the groove.

The lachrymal bone is easily broken through in a clumsy attempt
to pass a style by the nasal duct, especially if the probe be held too
much in the horizontal position.

The inferior maxilla. — The outer surface of the body is marked
by an oblique line from which arise the muscles depressing the lower
lip and the angle of the mouth ; the platysma is inserted below this
line. The mental foramen is about half-way down the outer surface,
below the second bicuspid. The buccinator arises below the molar
teeth.

The outer surface of the ramies is covered by the insertion of the
masseter, and near the anterior inferior corner of this muscle the bone
is grooved by the facial artery (p. 29). The levator menti arises in
the incisive fossa.

An oblique ridge upon the inner surface of the body gives inser-
tion to the mylo-hyoid, and below it, running from the inferior dental
foramen, is the groove for the mylo-hyoid nerve and artery.

Below the ridge also are the fossae for the sub-maxillary gland
and for the origin of the digastric, the latter being just behind the sym-
physis. Separated from the digastric fossa by the anterior part of
the mylo-hyoid ridge are the genial tubercles, and to the outer side of
the genial tubercles, above the mylo-hyoid ridge, is a slight depression
for the sublingual gland. The pterygo-maxillary ligament and the
superior constrictor are attached to the inner side of the body just
below and behind the last molar tooth.

To the inner side of the angle the internal pterygoid is inserted, and
to the inner aspect of the coronoid process the temporal muscle. The
external pterygoid is inserted into the neck of the condyle.

The lower jaw is developed in lateral halves, chiefly from the car-
tilage (Meckel's) of the first or the mandibular arch. The halves
have a fibrous connection at the symphysisat birth, but this is ossified

2O The Bones of the Head

by the end of the first year. At birth the jaw is a ' mere shell of bone,'
with the sockets of the milk teeth, and until the teeth are cut there is
hardly any ramus. For a long while the alveolar part is larger than
the basilar, but in the adult these parts are of equal height, the mental
foramen being midway between the upper and lower borders of the
bone, the ramus passing up at a right angle. As old age advances the
teeth fall out, the alveolar process dwindles into a sharp and useful
cutting edge, covered with tough mucous membrane ; the mental fora-
men, in consequence, comes close to the upper border of the bone, and
the angle between the body and ramus widens out.

Dislocation ot the jaw may result from over-action of the depres-
sors in an attack of yawning, or from a blow upon the chin when the
mouth is wide open. The condyle is carried forward upon the emi-
nentia articularis, where it remains fixed, a wide hollow appearing in
front of the mastoid process, and the mouth being wide open and fixed
in that position. When the luxation is on one side only, the chin is
thrust over to the opposite side. The coronoid process may be caught
against the malar bone. The jaw is firmly fixed in the new position
by the contraction of, and strain upon, its elevator muscles.

Reduction is effected by making a fulcrum of the thumbs, well pro-
tected, between the molar teeth ; the symphysis being raised, the con-
dyle is unhitched, and, with a snap, the jaw resumes its proper position.
Simple pressure of the thumb downwards, backwards, upon the last
molar tooth, however, generally suffices, and it has this merit, that it
does not excite contraction of the temporal and internal pterygoid
muscles. Both in the dislocation and in the reduction the fibro-carti-
lage follows the condyle.

Fracture may occur in any part ; a common situation being a
little in front of the insertion of the masseter, in
which case the digastrics, mylo-hyoids, genio-
hyo-glossi, genio-hyoids, and platysmas may draw
the anterior part downwards and inwards, whilst
the other piece may be drawn upwards and for-
wards by the temporal, internal pterygoid, and
masseter. The line which the fracture has taken,
however, may greatly influence the displacement
of the fragments. The treatment consists in maintaining the fragments
in apposition until union is firm. This may be done by locking the lower
jaw against the upper by a moulded splint and a four-tailed bandage ;
but sometimes it is necessary to fix and steady the fragments by a
strong wire suture.

Resection may demand an incision along the lower border and
half-way up the back of the ramus — not too far, lest the facial nerve
be cut — the facial artery or arteries being promptly secured. The
muscles are detached to a great extent by using the blunt raspatory.
The genio-hyo-glossus, however, must be cut from the back of the

Temporo-Maxillary Joint 2 1

symphysis, and when this is done the tongue must be brought out by
a strong loop, lest it fall back against the glottis. As the surgeon pro-
ceeds to denude the angle and ramus, he keeps his knife or raspatory
close to the bone, lest he injure the internal maxillary artery ; its
inferior dental branch, with the vein and nerve, must be cut just as
they enter the substance of the bone. The mucous membrane and
the floor of the mouth (mylo-hyoid) and the sub-maxillary and sub-
lingual glands are detached early in the operation, and the ramus is
at last held merely by the ligaments of the joint and the insertions of
the temporal and external pterygoid ; these are easily severed, the
coronoid process being perhaps snipped off with much of the temporal
insertion.

Necrosis of more or less of the bone is generally the result of acute
inflammation, which may be caused by a bad tooth, or may occur in
the weakness left after measles or scarlet fever. The necrosis is due
to the fact that the lower jaw abounds in compact tissue, inflammatory
effusion quickly choking the vessels in the H aversian canals.

The temporo-maxillary joint belongs in man to the division
arthrodia ; in some animals, as the badger, it is a perfect hinge.
Entering into its formation are that part of the glenoid cavity which
is in front of the Glaserian fissure, the eminentia articularis, and
the condyle. Each surface is covered with articular cartilage, but
interposed between the upper and lower planes of the joint is a
sinuous layer of inter-articular fibro-cartilage, which, receiving some
of the insertion of the external pterygoid, closely follows all the
movements of the condyle. The external lateral and the capsular
ligaments are also attached to the fibre-cartilage. The external
lateral ligament, a strong and short band, descends from the tubercle
at the root of the zygoma to the neck of the condyle, being attached
also to the inter-articular fibro-cartilage, as just noted. The internal
lateral ligament is a long and unimportant band between the spine of
the sphenoid and the inner edge of the inferior dental foramen. The
internal maxillary artery and the inferior dental vessels and nerve
pass between it and the jaw. As Tillaux remarks, the external lateral
ligament of one side is the internal lateral ligament for the other.
The stylo-maxillary ligament is but a piece of the deep cervical fascia ;
it separates the parotid and sub- maxillary glands. The capsular
ligament, a loose and unimportant sac, is attached around the glenoid
cavity and the neck of the condyle.

There are two synovial membranes, one between the temporal bone
and the fibro-cartilage, and the other between it and the condyle.
They may communicate by a gap in the middle of the cartilage.

Supply.— The arteries are branches of the masseteric, and of the
vessels in the neighbouring parotid gland. The nerves come from the
masseteric and the auriculo-temporal of the third division of the fifth.

Movements. — The jaw is depressed by the platysma, mylo-hyoid,

The Bones of the Head

genio-hyoid, genio-hyo-glossus, and also by the external pterygoic
It is elevated by the masseter, temporal and internal pterygoid ;

advanced by the
pterygoids and the
superficial part of the
masseter ; and re-
tracted by the deep
part of that muscle
and the temporal.
The pterygoids im-
part the lateral move-
ments.

Relations of the
articulation exter-
nally are skin, fasciae,
and some of the pa-
rotid gland, but the
movements of the
condyle are readily
followed from the ex-
terior. Behind are the external auditory meatus, some of the parotid
gland, and the external carotid and its terminal divisions. Close above
and behind are the tympanum and the internal ear.

Permanent closure of the jaws may demand resection of the
condyle ; this is accomplished by making an incision along the lower
border of the zygoma, beginning over and through the posterior
border of the masseter, and continuing it back to the tragus. The
raspatory then thrusts down the branches of the facial nerve, part
of the parotid gland, and other tissues which hide the condyle ; the
neck of the condyle is then cut with a fine saw and drawn out with
some of the insertion of the external pterygoid, and perhaps with the
inter-articular fibro-cartilage.

Eminentiaa
2, condyle ;
cartilage.

THE ARTERIES OF THE HEAD AND NECK

The common carotid artery springs on the right side from the
division of the innominate, but on the left side it ascends from the
transverse part of the arch of the aorta.

Up to the level of the sterno-clavicular joint the left artery has
exceptional relations, but from this point to the upper border of the
thyroid cartilage, where the common carotids divide, the relations are
similar on the two sides.

The tboracic portion of the left carotid springs from the
transverse aorta, between the innominate artery and the left sub-

Common Carotid Artery 23

clavian, and ascends obliquely behind the manubrium to the clavicular
joint.

To mark out the root of the artery. — As the transverse sternal ridge
corresponds to the lower part of the transverse aorta (p. 1 79), a line
drawn across the manubrium at about a thumb's breadth above that
ridge marks the upper border of the arch. The innominate artery
springs from the middle of that line ; the left carotid, therefore, comes
from a little to the left of the middle of the line, and mounts to the
inner end of the clavicle.

To mark the course of the common carotid artery in the neck, the
shoulders should be raised and the head thrown back, the face being
slightly turned to the opposite side. A line is then drawn from the
sterno-clavicular articulation to the interval between the condyle of
the jaw and the mastoid process. This line, up to the level of the
upper border of the thyroid cartilage, corresponds to the common, and
above that to the external carotid.

The groove in the side of the neck running along the anterior
border of the sterno-mastoid is the surgeon's guide to the artery. The
higher that the vessel mounts in the neck, the more superficial it be-
comes, because the sterno-mastoid passes backwards from it, whilst
the sterno-hyoid and thyroid have left it upon the inner side. There-
fore the surgeon, who is free to choose, prefers to tie it in the upper
part of its course, that is, above the omo-hyoid, which crosses at the
level of the cricoid cartilage.

Remembering that all the large veins incline towards the right side
of the median line — the right side of the heart being the venous side
— the left internal jugular vein in its descent through the lower part of
the neck gradually gets to the front of the common carotid, whilst the
right vein slopes away from the outer side of its artery, to descend in
front of the right subclavian artery.

Rule. — Above the level of the diaphragm the large veins are upon a
plane anterior to the arteries ; below that level they are on a posterior
plane, with one exception (p. 356).

The carotid artery may be compressed with the employment of
a slight force against the transverse process of the sixth cervical
vertebra— the carotid tubercle. This may readily be made out a
little below the level of the cricoid cartilage, in the situation of
the carotid sheath, that is beneath the anterior border of the sterno-
mastoid.

The level of the fifth cervical vertebra is an important station
in the anatomy of the neck : it corresponds pretty nearly to the site
at which the omo-hyoid crosses the carotid sheath, and to the position of
the cricoid cartilage— thus marking the ending of the larynx and the
beginning of the trachea, the ending of the pharynx and the beginning
of the cesophagus. At that level also the inferior thyroid artery crosses
inwards behind the sheath of the carotid, whilst the sympathetic cord,

24 Arteries of Head and Neck

descending in front of that branch, distinguishes the spot with its middle
cervical or thyroid ganglion.

The carotid sheath contains, in addition to the common and the
internal and carotid artery, the internal jugular vein and the pneumo-
gastric nerve, the vein being to the outer side of the artery, and the
nerve between and behind them. These three structures are separated
from each other by delicate fibrous partitions. The sheath receives a
considerable accession from the deep cervical fascia.

The surgeon in seeking the artery should open the sheath upon the
inner, the arterial side, so as that the vein may not be in the way of
his needle.

irregularities. — The right common carotid artery may come from
a high or low division of the innominate, or as a separate branch from
the aortic arch. The two carotids may spring by a common trunk ;
or the left may come from the innominate, or from a left innominate
artery. The common carotid may divide as low as the cricoid carti-
lage, or may be continued as far as the hyoid bone. Sometimes the
common carotid gives off the superior thyroid branch.

Relations of the common carotid in the neck. — In front are
the skin, platysma, and fasciae ; the sterno-mastoid, and the beginning
of the sterno-hyoid and thyroid ; the omo-hyoid, which crosses at the
level of the fifth cervical vertebra ; the sterno-mastoid branch of the
superior thyroid artery, and the descendens noni lying upon the
sheath, as shown on page 27 ; the anterior jugular vein, and the
superior and middle thyroid veins running into the internal jugular.

Behind are the lower cervical vertebrae, covered by the longus colli
and the rectus capitis anticus major. Additional posterior relations
are the inferior thyroid artery, winding upwards and inwards (p. 233)
from the subclavian; the sympathetic cord, and the recurrent laryngeal
nerve.

Internally are the trachea and larynx, with a lobe of the thyroid
body and the inferior thyroid artery passing to it ; the oesophagus and
pharynx, and the recurrent laryngeal nerve ascending between the
trachea and oesophagus. Externally are the vagus and the internal
jugular vein.

In the thorax. — As the second part of the arch passes more from
before backwards than from right to left, and as the left carotid is
given off after the innominate and before the left subclavian, it neces-
sarily has the innominate a good deal in front of it and the subclavian
behind.

Additional anterior relations are the origins of the sterno-hyoid and
sterno-thyroid muscles ; the left innominate vein, running obliquely
across to join in the formation of the superior cava ; and the remains
of the thymus gland, which, in the child, is a very important relation
so far as regards bulk (v. p. 155).

Posteriorly are the trachea, oesophagus, and thoracic duct.

Common Carotid Artery 25

To the right is the innominate artery, and, slightly, the trachea;
and to tlie left is the left subclavian artery and the vagus, which in the
neck descended along the outer side of the carotid.

Aneurysm of the common carotid is likely to occur just below
its bifurcation. The pulsating tumour might be close by the side of,
and be mistaken for, an enlarged lobe of the thyroid ; but there is this
manifest distinction between the two: a thyroid tumour moves with the
larynx during deglutition, whereas the aneurysmal tumour does not.
The pressure effects of the aneurysm may be: upon the internal jugular
vein, causing headache, duskiness of the face, and cedema ; upon the
superior laryngeal nerve, causing cough; upon the recurrent laryngeal
giving rise to hoarseness, laryngeal spasm, or to paralysis of a vocal
cord ; upon the sympathetic cord, with the production of dilatation,
and, afterwards, of contraction of the pupil.

Ligation of the common carotid. — The subject lies supine, with
a block beneath the shoulders, so that as the head is thrown back, and
the face is turned to the opposite side, there may be more room, and
also that the sterno-mastoid and the other tissues at the front of the
neck may be made tense.

The surgeon then feels for the anterior border of the sterno-mastoid
and for the thyroid and cricoid cartilages. With his finger on the cri-
coid he knows where the omo-hyoid crosses the sheath.

To tie the artery above the omo-hyoid, a 3-in., or in a fat subject a
4-in., incision is made along the front of the sterno-mastoid, from the
level of the upper border of the thyroid cartilage, or even from just
below the angle of the jaw, dividing skin, superficial fascia, platysma,
and deep fascia. The head is then raised, so that the cord-like edge
of the sterno-mastoid may be slackened and drawn outwards. In ap-
proaching the sheath a branch to the sterno-mastoid from the superior
thyroid will be divided. The descendens noni may be seen and turned
aside, and the omo-hyoid maybe pulled downwards. The veins cross-
ing the sheath are drawn upwards or downwards, and the sheath is
opened on the inner side.

The aneurysm-needle is passed close to the artery, from without
inwards, extreme care being taken not to wound the internal jugular
vein, or to include the vagus in the ligature.

If ligation be required for aneurysm of the upper part of the
common carotid, the surgeon must seek the vessel below the omo-hyoid^
where, unfortunately, it is much more deeply placed. He makes an
incision along the anterior border of the sterno-mastoid from the
cricoid cartilage to the sterno-clavicular joint. The head having been
brought forwards, the sterno-mastoid is drawn outwards and the omo-
hyoid upwards, the sterno-hyoid and thyroid being drawn inwards.
The anterior jugular vein may need attention. If the operation
be performed upon the left side, and low down, the internal jugular
vein may be found bulging over, or even lying upon the artery. If

Arteries

'cad am

there is much difficulty in reaching the vessel the sternal origin of the
sterno-mastoid should be divided and turned outwards.

The collateral circulation would be carried on by the empty
branches of the external and internal carotids. Of the external the
following would prove useful : the superior thyroid with its fellow,
and with the inferior thyroid ; branches of the lingual, facial, super-
ficial temporal, and occipital, with their fellows of the opposite side ;
and the occipital, with the profunda cervicis and the vertebral. The
internal carotid would take in blood, by its anastomosis in the circle
of Willis, from its fellow, and from the vertebral.

The external carotid is destined, as its name implies, for the
external parts of the head ; therefore, in its ascent, its lies superficial
to the internal carotid, which is the direct continuation of the common
trunk. For convenience, in giving off the superior thyroid, lingual,
and facial branches, the external carotid bends forwards from its
origin, and thus it is at first superficial and anterior to the internal
carotid ; but, inclining backwards again, it ultimately lies superficial
to the internal trunk, and in the same line with it. Ascending into
the parotid gland, it ends by dividing into the superficial temporal
and internal maxillary.

Its course is marked by that part of the line, given on page 23
for the common carotid, which extends from the level of the upper
border of the thyroid cartilage to the fossa behind the condyle of the
jaw.

Relations. — Superficial to it are skin, platysma, and fasciae ; the
digastric and stylo-hyoid muscles, and the hypoglossal nerve; and
the lingual and facial tributaries of the internal jugular vein. In the
parotid gland it is crossed by the facial nerve, and in a muscular
subject its lower part is considerably overlapped by the sterno-
mastoid. The beginning of the external jugular vein is also super-
ficial.

Beneath it are the internal carotid and the intervening stylo-glossus
and stylo-pharyngeus, and the glosso-pharyngeal nerve ; and, lying
more deeply than the internal carotid, the superior laryngeal nerve.

Externally are the anterior border of the sterno-mastoid and the
commencement of the internal carotid ; and internally are the
pharynx and hyoid bone, and, just before its termination, the ramus
of the jaw.

Xiigation of the external carotid. — The patient is arranged as
for ligation of the common carotid (p. 25), and an incision is made
in the line of the artery, from just behind the angle of the jaw to the
level of the cricoid cartilage. The superficial fascia and platysma
having been traversed, the deep fascia is divided on a director ; then
the digastric, or the hypoglossal nerve, and some veins are seen
crossing obliquely. The sterno-mastoid must be pulled outwards, the
head having been raised, and the digastric must be drawn upwards.

External Carotid Artery 27

The veins must be gently drawn upwards or downwards, but if any
of them be absolutely in the way they must be tied in two places
and cut. The artery is then denuded, and the needle is passed from
without inwards, so that there may be no risk of wounding the sheath
of the internal carotid and jugular vein.

If it be only the lowest part of the artery which is exposed, the
surgeon must be careful not to tie the internal in mistake, for the two
vessels lie side by side. If he can see them both, he remembers that

Facial art.

Mylo-hyoid n.

Subment.art.

Com. car. art.

Digastric region. (HOLDEN.)

the external is anterior and becomes superficial to the internal;
one of them gives off branches ; it is, of course, the external. If the
hypoglossal nerve be seen touching one of the trunks it must be the
external carotid, for, at the level at which the nerve crosses, the internal
is too deeply placed for the nerve to touch it. Lastly, the surgeon
should see that compression of the artery, which he takes to be the
external carotid, arrests the temporal pulse.

If he seek the artery above the crossing of the digastric, he must

28 Arteries of Head and Neck

begin his incision in front of the tragus, and keep away from the
parotid gland, and avoid the branches of the facial nerve.

Collateral circttlation is established by the empty branches bring-
ing in arterial blood as follows : the superior thyroid, lingual, facial,
superficial temporal, and occipital from their fellows of the opposite
side ; the superior thyroid from the inferior thyroid of its own side ;
the facial by its anastomosis with the ophthalmic at the inner
corner of the orbit ; the superficial temporal by its anastomosis
with the supra-orbital of the ophthalmic ; and the occipital with the
profimda cervicis of the superior intercostal, and also with the
vertebral.

Branches. — The superior thyroid is given off in the superior
carotid triangle (p. 10), being covered by skin, superficial fascia,
platysma, and deep fascia. It runs upwards for a little, and then
downwards and forwards, under the omo-hyoid, sterno-hyoid, and
sterno-thyroid, to enter the thyroid body, where it anastomoses with
its fellow and with the inferior thyroid. It sends a twig across the
middle line below the hyoid bone, which anastomoses with its fellow,
and a branch, which descends obliquely over the sheath of the com-
mon carotid, to supply the sterno-mastoid, which is probably severed
in ligation of that artery. The superior laryngeal branch runs with
the nerve of that name, through the thyro-hyoid membrane, for the
interior of the larynx. The crico-thyroi d branch runs across the
crico-thyroid membrane to join its fellow. It is wounded in laryngo-
tomy.

The lingual artery is given off opposite the great cornu of the
hyoid bone, sometimes coming off in a common branch with the facial ;
it reaches the tip of the tongue as the ramne. In its course it not
only ascends, but passes deeply, running out of the superior carotid
triangle beneath the stylo-hyoid and digastric, and then under cover
of the hyo-glossus, where it rests on the middle constrictor of the
pharynx. It soon rests upon the genio-hyo-glossus, and ultimately
upon the lingualis, being then beneath the mucous membrane of the
tongue, by the side of the fraenum. Its position there must be re-
membered in dividing the fraenum, for if the scissors be clumsily
directed upwards it may very easily be cut. The ranine vein may
be seen through the mucous membrane on raising the tongue, but the
artery, which is more deeply placed, cannot be made out.

The lingual sends inwards a hyoid twig which anastomoses with
its fellow above the hyoid bone, and then a larger branch — the
dorsalis lingua — which ascends under the hinder part of the hyo-
glossus to the tongue, soft palate, and tonsil. It anastomoses with its
fellow in front of the epiglottis. The sublingual branch comes oft
just after the lingual has passed beyond the hyo-glossus. It supplies
the sublingual gland and the floor of the mouth.

legation of the lingual artery may be performed in the superior

Lingual Artery 29

carotid triangle, but, as its course and position are there subject to
variations, it is better to seek it at a spot where it is sure to lie, and in
the depths of an area with very definite boundaries : — The head being
thrown back, and the face turned to the opposite side, so as to get
the angle of the jaw out of the way, a curved incision is made from
behind the symphysis to just in front of the angle of the jaw, reaching
the middle of the side of the hyoid bone, through skin, superficial fascia,
and platysma. The deep fascia is then incised ; a large superficial vein
or two may need to be tied and cut. The lower border of the sub-
maxillary gland, which is then seen, must be detached with a director
and turned up out of the way. Then a very small triangle is made
out which is bounded above by the hypo-glossal nerve, behind by the
pearly tendon of the digastric, and in front by the posterior border of
the mylo-hyoid. The hyo-glossus forms the floor of this triangle.
Possibly the digastric tendon may have to be drawn down, the better
to expose the depths of the triangle. Then, with the director, the

Course of ling-, art. ; but underneath hyo-gloss. m. (SMITH and WALSHAM.)
Digast. in. Mylo-hyoid m. Hyo-gloss. in. Hypogloss. n.

\ \

hyo-glossus is scratched through close to the hyoid bone, and the
artery is laid bare, resting upon the middle constrictor.

The facial artery, given off in the superior carotid triangle, has to
turn over the maxilla in its course to the inner corner of the orbit,
where, as the angular artery, it anastomoses with the nasal branch
of the ophthalmic — itself a branch of the internal carotid trunk.
Winding out of the superior carotid triangle beneath the digastric and
stylo-hyoid muscles, it enters the sub-maxillary triangle, embedding
itself in the sub-maxillary gland. It then turns up over the maxilla, at
the anterior inferior angle of the masseter. It courses beneath the
platysma and the zygomatici, and rests upon the buccinator and the
elevators of the upper lip. It is accompanied by the facial vein, which
is thin-walled, and does not take the tortuous course of the artery. The
vein is posterior to the artery and passes superficially to the salivary
gland.

Below the jaw the facial artery gives off an ascending palatine and

30 Arteries of Head and Neck

a tonsillar branch, which, mounting by the internal pterygoid muscle
send twigs through the superior constrictor to the tonsil. The sub-
maxillary branches of the facial supply the salivary gland, and the
submental runs forward on the mylo-hyoid and supplies the chin and
the lip, anastomosing with its fellow.

Above the jaw the branches are : inferior labial and inferior
coronary, the latter lying between the mucous membrane and the
orbicularis, as does also the superior coronary. These three branches
anastomose with their fellows across the middle line, and the superior
coronary gives a branch to the septum of the nose. The lateral nasal
branches also anastomose with their fellows of the opposite side over
the ridge of the nose, and the angular, as already mentioned, joins
the nasal of the ophthalmic. The angular artery is upon the nasal side
of the lachrymal sac. The facial may be readily compressed or tied
as it passes over the lower jaw.

The occipital artery is a posterior branch of the external carotid
in the superior carotid triangle, out of which it passes under the
guidance of the digastric and stylo-hyoid to the interval bet -.veen the
transverse process of the atlas and the mastoid process. As the ex-
ternal carotid is anterior to the internal carotid, the occipital branch
has to cross the internal carotid and jugular vein. The hypoglossal
nerve hooks round the occipital artery. Arrived at the bony inter-
space just alluded to, the occipital artery necessarily lies under cover
of the sterno-mastoid, splenius capitis, and trachelo-mastoid, in addi-
tion to the origin of the digastric. It grooves the temporal* bone, and
then lies on the superior oblique and complexus, and ultimately pierces
the cranial origin of the trapezius. It ramifies in the scalp as high
as the vertex, anastomosing with its fellow and with the posterior
auricular and the superficial temporal arteries. At the back of the
head it is accompanied by the great occipital nerve. As it mounts
towards the vertex it crosses the middle of a line between the occipital
protuberance and the external auditory meatus, at which spot it can
readily be compressed.

Branches. — The occipital artery gives off muscular twigs ; an
auricular branch to the concha ; meningeal twigs through the posterior
lacerated foramen ; voAHtot princcps cervicis, which descends between
the complexus and semi-spinaliscolli to anastomose with the vertebral
and with the profunda cervicis of the superior intercostal arteiy. A
more superficial branch of the princeps runs beneath the border of the
trapezius, to communicate with the superficial branch of the transverse
cervical.

The posterior auricular springs from the carotid above tin-
crossing of the digastric, and, therefore, is not in the superior carotid
triangle. It is crossed by the portio dura, and mounts under cover
of the parotid gland to the crevice between the mastoid process and
the concha, giving twigs to the scalp and to the pinna, which anasto-

cle,
•ub-

Superficial Temporal Artery 31

•mose with the occipital and the superficial temporal. Its stylo-mastoid
branch enters the Fallopian aqueduct as the portio dura is leaving it,
and anastomoses with the petrosal branch of the middle meningeal.
It supplies the tympanum, the mastoid cells, and the three semi-
circular canals. In childhood a twig of this artery enters into an
anastomotic circle with the tympanic branch of the internal maxillary
upon the membrana.

The ascending pharyngreal is a slender and irregular branch
which mounts from the beginning of the external carotid, between the
internal carotid and the pharynx, to the base of the skull. It gives
pharyngeal, tonsillar, and palatine branches, and some meningeal twigs
which enter the skull through the middle, the posterior lacerated, or
the anterior condylar foramen.

The superficial temporal comes from the bifurcation of the
artery in the parotid gland ; it ascends over the zygoma, and soon
divides, upon the temporal fascia, into an anterior and a posterior trunk.

The anterior division anastomoses with the supra-orbital and
frontal branches of the ophthalmic, the posterior joining with its
fellow across the vertex, and with the posterior auricular and occi-
pital arteries.

Branches of the superficial temporal : — The transverse facial
emerges from the parotid gland and runs forwards over the masseter
between the zygoma and the duct of the gland, and anastomoses with
the infra-orbital branch of the internal maxillary, and with the facial.

The middle temporal dips through the temporal fascia to supply the
muscle and to anastomose with deep temporal branches. It also
sends forwards an orbital twig between the layers of the temporal fascia
which may anastomose with the lachrymal and palpebral branches of
the ophthalmic. Auricular branches anastomose with others upon the
pinna.

Arteriotomy. — ' Bleeding ' is sometimes done from the anterior
division of the artery, instead of from a vein, in the case of severe
ophthalmia or meningitis. For arteriotomy the main trunk of the
superficial temporal should not be selected, as it lies close to a large
tributary of the external jugular vein and by divisions of the facial
and auriculo-temporal nerves.

The anaesthetist conveniently feels the temporal pulse instead of
the radial during an operation. When there is an obstruction to
the flow of blood through the capillaries the anterior temporal artery
becomes elongated and extremely tortuous, and its pulsations are
apt to attract attention.

Haemorrhage from the branches of the superficial temporal, and ot
other vessels in the scalp, is often extremely troublesome to arrest, as
the vessels are incorporated with the surrounding fibrous tissue, and,
therefore, unable to retract and contract. A deep suture is the most
certain method of stopping the bleeding.

32 Arteries of Heaa and Neck

The internal maxillary, the larger terminal division of the
ternal carotid, hurries inwards and forwards from the parotid gland,
passing between the ramus of the jaw and the internal lateral ligament,
beneath the insertion of the external pterygoid. This constitutes the
first part of its course, and from it are given off the tympanic, middle
and small meningeal, and the inferior dental branches.

The tympanic branch mounts behind the condyle of the jaw to the
middle ear, which it enters by the Glaserian fissure. It forms an ana-
stomotic circle upon the membrane with the stylo-mastoid branch of
the posterior auricular. The middle meningreal enters the skull
through the foramen spinosum, passing between the heads of the
auriculo-temporal nerve (p. 63). It then divides. Its anterior
trunk runs in a tunnel or groove in the anterior inferior angle of the
parietal bone, and spreads in widely-reaching branches upon the convex
surface of the dura mater, and in grooves upon the frontal and
parietal bones. The posterior division winds backwards on the
squamous and parietal bones, to end, like the other, in the supply of
the dura mater and the cranium, and in anastomosis with its fellow
of the opposite side and other meningeal arteries. The middle
meningeal also gives a petrosal branch through the hiatus Fallopii,
which anastomoses in the aqueduct with the stylo-mastoid artery,
and sends branches through the great wing of the sphenoid into
the orbit and the temporal fossa.

The small meningeal passes into the skull through the foramen
ovale. The inferior dental enters the dental canal,* and divides
opposite the first bicuspid into a mental and an incisive branch. The
former emerges by the mental foramen, and anastomoses with the
inferior labial and submental branches of the facial, whilst the other
continues in the lower jaw, supplying the canine and incisor teeth,
and meeting its fellow across the middle line. Before entering the
maxilla the inferior dental gives off the mylo-hyoid branch, which
ramifies on the cutaneous surface of the mylo-hyoid muscle.

The second part of the artery lies in the triangle formed by the two
pterygoids and the ramus of the jaw ; it gives off deep temporal,
pterygoid, masseteric, and buccal branches. The anterior and pos-
terior deep temporals ascend b.eneath the temporal muscle, and ana-
stomose with the superficial and middle temporal arteries, and with
branches which enter the fossa from the middle meningeal and
ophthalmic arteries. As the masseteric twig runs outwards through
the sigmoid notch it supplies the maxillary joint. It anastomoses with
the facial and the transverse facial arteries. The buccal branch ana
stomoses upon the cheek with the facial.

The third part of the artery enters the spheno-maxillary fossa
But just before doing so it gives off a trunk from which the alveola
and infra-orbital arteries arise. The alveolar, ox posterior dental, dis
tributes branches upon the tuberosity of the maxilla for the gums

Internal Carotid Artery 33

and others which enter the bone for the molar and bicuspid teeth, and
for the antrum. The infra-orbital passes beneath the floor of the
orbit, and emerges from the foramen, beneath the levator labii supe-
rioris, to supply the tissues in the neighbourhood and to anastomose
with the facial. Whilst in the canal it sends branches up into the orbit,
and others down the anterior wall of the antrum — the anterior
dental — for the front teeth. The posterior or descending- palatine
branch leaves the spheno-maxillary fossa by a special osseous canal,
and turns forwards on to the under surface of the hard palate through
the posterior palatine foramen, which is on the inner side' of the last
molar tooth. It supplies the hard and soft palate and the tonsil.

A wound of this vessel may cause serious trouble in the operation
for cleft palate, and if pressure fail to stop the bleeding the canal
must be plugged by a sharp spigot of wood. The Vidian and the
pterygo-palatine branches run back to the pharynx and the Eustachian
tube ; the former may also send a twig into the tympanum. The nasal
or spheno-palatine branch enters the superior meatus, giving an off-
shoot to the septum of the nose, and twigs to the turbinated bones.

There is no venous trunk corresponding to the external carotid.

The internal carotid artery runs straight up from its origin at
the level of the upper border of the thyroid cartilage to the base of the
skull, which it traverses by the tortuous canal in the petrous bone.
It then turns forwards in the cavernous sinus, in the groove upon the
side of the body of the sphenoid, and upwards on the inner aspect of
the anterior clinoid process. Then, having pierced the dura mater
near the inner end of the Sylvian fissure, it divides into the anterior
and middle cerebral arteries.

Relations of the internal carotid in the neck. — Superficially
are the skin, platysma, and fasciae, the anterior border of the sterno-
mastoid, the posterior belly of the digastric and the stylo-hyoid,
with the hypo-glossal nerve and the occipital artery, and the lingual
and facial tributaries of the internal jugular vein ; the external
carotid and the stylo-glossus, stylo-pharyngeus, and the glosso-
pharyngeal nerve, and, as the artery approaches the petrous bone,
the parotid gland.

The artery rests upon the transverse processes of three upper
cervical vertebras and the rectus capitis anticus major ; the superior
laryngeal branch of the vagus ; and the superior cervical ganglion of
the sympathetic.

To its inner side are the pharynx and tonsil, and the ascending
pharyngeal artery. I have known of a case in which the stem of a
clay pipe, driven through the tonsil and the pharynx, caused a fatal
laceration of the internal carotid, and I have heard of another in which
an aneurysm of the artery, which pushed the tonsil inwards, was in-
cised under the belief that the swelling was a tonsillar abscess.

To its outer side are the internal jugular vein and the vagus.

34 Arteries of Head and Xcck

ternal

Its course in the neck corresponds to that given for the external
carotid (p. 23), but in that the external carotid is for the supply of
the exterior of the head, whilst the internal carotid is for the brain
and the orbit, the internal carotid lies deeper in its ascent.

The internal carotid takes its strange tortuous course through the
petrous bone and through the cavernous sinus in order that the rush
of blood from an energetic left ventricle into the delicate cerebral
capillaries may be softened down. The same arrangement also
obtains in the vertebral arteries in their sub-occipital ascent.

As the artery passes through the petrous bone it lies just in front
of the middle ear, being separated from it by merely a thin osseous
plate. It is accompanied by ascending filaments of the cervical sym-
pathetic. In certain morbid conditions its pulsations are unpleasantly
experienced by the auditory nerve.

As the artery winds along the inner wall of the cavernous sinus,
the sixth nerve rests on its outer side. In the case, therefore, of
aneurysm of that part of the artery the external rectus may be
weakened or paralysed. Sympathetic filaments surround this part of
the artery.

Branches. — A small tympanic twig comes off from the petrosalpart
of the artery, and anastomoses with the tympanic branches of the
internal maxillary and posterior auricular.

The ophthalmic, anterior, and posterior cerebral divisions
the internal carotid are described on pages 81 and 42.

The internal jugular vein corresponds to the internal and commoi
carotids.

THE JUGULAR VEINS AND THEIR TRIBUTARI1
VEINS OF HEAD AND NECK

The veins of the interior of the head and of the neck, like thos
of the lung, liver, kidney, uterus, and ovary, have no valves.

The facial vein begins as the angular at the inner corner of the
orbit, where it has an important communication with the ophthalmic
vein ; it descends obliquely towards the anterior inferior angle of the
masseter, lying behind the facial artery, and taking a straighter
course. Below the jaw it is joined by a considerable trunk of the tem-
poro-maxillary vein ; it continues beneath the platysma and fascia?,
and, passing across the external and internal carotids, ends in the
internal jugular. It brings down blood from the large median, frontal,
and from the supra-orbital veins, and from many tributaries corre-
sponding to the branches of the facial artery ; its communications with
the ophthalmic vein are of great importance.

The temporal is formed by the confluence of the superficial

il and

Veins of Head and Neck

middle temporal veins, and, in the parotid region, is joined by the
internal maxillary vein, which is bringing blood from the pterygoid,
palatine, and deep temporal regions. The temporo-mavillary vein
which is thus formed takes a short course in the parotid gland, and

i, Frontal ; 3, angular ; 4 and 5, facial ; 8, anterior jugular ; 9, temporal ; IT, internal maxil-
lary ; 12, temporo-maxillary giving branches to facial and external jugular ; 13, posterior
auricular ; 14, external jugular ; 16, transverse cervical ; 17, supra-scapular ; 18, occipital.
—PROF. THANE.

near the angle of the jaw gives off a tributary to the facial vein ; being
there joined by the posterior auricular vein, it forms the external
jugular. The last-named vein descends almost vertically beneath
the platysma and over the deep fascia, and, having passed obliquely

36 Jugular Veins

over the sterno-mastoid, turns down behind the clavicular origin of
that muscle to empty into the subclavian vein. Near its termination
it receives the transverse cervical (posterior scapular) and the supra-
scapular veins, which form an important plexus over the front of the
third part of the subclavian artery, and perhaps also the anterior
jugular vein.

The course of the external jugular vein is marked by a line from
the angle of the jaw to the back of the clavicular origin of the sterno-
mastoid. Thus it runs almost parallel with the fibres of the platysma.

The anterior jugular begins by the confluence of some submental
veins ; descending in a superficial course near the middle line of the
neck, it pierces the deep fascia just above the manubrium, and, passing
outwards beneath the sterno-mastoid, ends in the external jugular or
subclavian vein. In tenotomy of the clavicular part of the sterno-
mastoid there is risk of wounding the anterior jugular (p. 4). Short
transverse branches connect the two anterior jugular veins across the
middle line.

The internal jugular vein begins just below the posterior lace-
rated foramen by the confluence of the inferior petrosal and lateral
sinuses (p. 39). Thence it descends by the outer side of the internal
and common carotid arteries to join the subclavian vein in the forma-
tion of the innominate vein. Its relations are very similar to those of
the internal and common carotid arteries.

Lying in the carotid sheath, the vein is apt to overlap the common
carotid artery, and especially so upon the left side (p. 35) ; on the
right the end of the vein inclines somewhat to the outer side of the
artery. The end of the vein passes in front of the subclavian artery
in the first part of its course.

The tributaries of the internal jugular are the pharyngeal, facial,
lingual, superior and middle thyroid, and the occipital.

The occipital veins begin in a plexus at the back of the head, and,
running with the occipital artery, end in the internal jugular vein.

Cut throat. — The man who draws a razor across his throat with
suicidal intent, being probably right-handed, gashes the left side. If
the brunt of the shock is received by the thyroid cartilage, as often
happens, no serious harm may ensue. But if he happen to hit off the
thyro-hyoid space there is little to hinder the progress of the blade.
Thus, in addition to the skin, platysma, anterior jugular vein, cutaneous
nerves, and the deep fascia, the anterior part of the sterno-mastoid
may be traversed, and, more deeply, the external carotid, or its superior
thyroid or lingual branch, and the corresponding vein. The sterno-
hyoid, omo-hyoid, and the thyro-hyoid muscle and membrane and the
superior laryngeal nerve, might also be cut, and possibly the incision
might pass into the pharynx, wounding also the epiglottis.

To arrest the bleeding is the first treatment, and after that the man
must be propped up in bed with his head brought forward. Sutures

Cervical Lymphatic Glands 37

must be used with discretion, and for the most part only at the ends
of the gash, as to close the wound might be to lock discharges beneath
the deep fascia and to have them guided into the chest. Still, in these
days of antiseptic surgery, so much may be done to prevent suppuration
that the edges of the wound may in appropriate cases be sutured,
especially if tracheotomy have been resorted to. If there be a wound
of the trachea there is great risk of emphysema being set up if the
skin-wound is closely sutured. Death may result from entrance of
air into the veins. As deglutition disturbs the muscles and tissues
of the hyoid region, the man should be fed by a soft cesophageal tube.

lymphatic glands are scattered in the occipital and posterior
auricular regions. They are often enlarged in constitutional syphilis, in
inflammation of the scalp, and in otorrhoea. Other glands are found
in the parotid, zygomatic, buccal, and submaxillary regions.

The arrangement of the lymphatic vessels which enter the respec-
tive glands usually corresponds to that of the neighbouring veins.

The superficial cervical glands are grouped along the external
jugular vein, and in the subclavian triangle they receive communica-
tions from axillary glands, and tributaries from the windpipe and gullet.
They may be enlarged in malignant disease of the breast, and also of
the oesophagus and stomach.

The deep cervical glands are grouped along the internal jugular
vein ; they receive supplies from the mouth, pharynx, tongue, and
larynx, and from the tissues of the neck generally. They are in free
communication with the axillary and thoracic glands.

The course taken by the lymphatic vessels is often erratic and
peculiar ; those coming from the occipital scalp, for instance, may
enter glands beneath the anterior border of the sterno-mastoid, and
those from the right side of the tongue may pass to the glands of the
left side of the neck.

MEMBRANES OF BRAIN AND VENOUS SINUSES

The dura mater, though forming the internal periosteum of the
skull bones, is but loosely attached to them, except in the neighbourhood
of the sutures and foramina : thus it is often separated from them in a
considerable area by haemorrhage from the middle meningeal artery,
or by suppuration — the result of a blow on the head. It is firmly
attached at the base of the skull and at the margin of the foramen
magnum. From the foramen magnum it becomes continuous with the
dura mater of the spinal cord. Its outer surface is rough, and from
it small veins pass into the diploe. Its inner surface, paved with endo-
thelium, is smooth, and bounds the subdural space.

Tubular sheaths of the dura mater emerge with the cranial
nerves, and blend eventually with the external periosteum. In the

38 Venous Sinuses of Head

ded

neighbourhood of the superior longitudinal sinus the dura is stud
with granular elevations, Pacchionian glands, which are villous pro-
cesses of the arachnoid. They have been mistaken for tubercular
deposits.

The dura is continuous with the periosteum of the orbit through
the sphenoidal fissure and the optic foramen, and with the pericranium
through the sutures and foramina generally. And thus it happens in
the case of inflammation in the orbit, or of erysipelas of the scalp, that
secondary meningitis occasionally supervenes. If the meningitis im-
plicate the venous sinuses, coagulation of their contents results, and
pyaemia ensues.

The dura lines also the internal auditory meatus, and in the case
of fracture of the base of the skull extending across the petrous bone,
and rupturing the membrana tympani, subarachnoid fluid may escape
from the external ear in such quantities as to saturate the pillow ; the
lesion is not necessarily fatal, however, for the fluid is very rapidly
secreted.

The arachnoid forms a loose and delicate investment for the brain
and is continued down over the cord. The interval between it and
the pia mater constitutes the subarachnoid space, which is very roomy
over the base of the brain between the optic nerves and the pons, and
again between the cerebellum and the back of the medulla. By a
small opening in the pia mater in the latter situation the subarachnoid
space communicates with the interior of the fourth ventricle. This
opening is \\\z foramen of Majendie, and by it the serous fluid of the
subarachnoid space maintains its tidal communication with that of
the fourth, third, and of the lateral ventricles, constituting the so-
called cerebro-spinal circulation. Tubercular inflammation at the
base of the brain is apt to cause obstruction of this passage, and, as
a result, dropsy of the ventricles. A small quantity of fluid exists
between the dura and arachnoid — in the subdural space— but the chief
amount of the cerebro-spinal fluid is in the subarachnoid interval.
This fluid differs from ordinary serum in that it contains no albumen ;
it sometimes flows in very large quantities from the ear or from the
nose after fracture of the base of the skull.

A doubled cuff of arachnoid accompanies the facial nerve into
the auditory meatus, but, when after fracture of the petrous bone
the cerebro-spinal fluid escapes, this sheath need not be lacerated, for
the escape is not from the cavity of the arachnoid, but from the sub-
arachnoid space.

The sheath around the optic nerve becomes distended when a
tubercular deposit or a tumour is exerting pressure at the base of the
brain, and in such cases congestion occurs in the veins of the optic disc
— an evident and important sign.

The pia mater is a delicate fibrous network in which the vessels
break up before entering the brain-substance. It dips into the sulci,

Lateral Siuits 39

and turns in at the transverse fissure to form the velum interpositum
and the choroid plexuses. It adheres closely to the cerebral cortex,
whilst the arachnoid passes from convolution to convolution without
dipping into the sulci.

Falx and tentorium. — Sickle-shaped processes of the dura dip
between the hemispheres, down to the corpus callosum, and also be-
tween the lobes of the cerebellum ; and a horizontal layer, the tentorium,
forms a roofing to the cerebellum, and a support for the posterior lobes
of the cerebrum. The attachment of the tentorium may be marked by
a line from the external occipital protuberance to the external auditory
meatus.

Venous sinuses are formed by a splitting of the dura ; being part
of the vascular system, they are of course completely lined with a flat-
tened endothelium. They receive emissary veins from the skull, as
well as from the cerebrum and cerebellum.

The superior longitudinal sinus begins at the crista galli by a vein
which it receives from the nasal fossae through the foramen csecum.
The sinus grooves the middle of the frontal bone and the adjacent
edges of the parietals, and, descending on the occipital, communicates
with the torcular Herophili and turns, for the most part, into one of the
lateral sinuses. Trephining in the neighbourhood of the sinus may
give rise to serious bleeding, and should generally be avoided. The
vein which ascends to begin the sinus is in communication with the
vessels of the nose ; thus headache which is due to over-fulness of the
cerebral vessels may be relieved by epistaxis or by leeching the nose.
In its course the sinus receives the superior cerebral veins and a peri-
cranial communication through the parietal foramen.

The course of the sinus may be marked by a line beginning at the
root of the nose, passing up the middle of the forehead, backwards
along the interparietal suture, and to the external occipital protuberance.

The lateral sinuses carry the blood from the region of the in-
ternal occipital protuberance to the posterior lacerated foramen, and
so into the beginning of the internal jugular vein. After leaving
the occipital bone the sinus grooves the posterior inferior angle of the
parietal, and then the mastoid part of the temporal. As a rule, the
right sinus carries away the contents of the superior longitudinal,
whilst the left empties the straight sinus. In the case of injury, the
surgeon will be loth to trephine near the mastoid process ; but in the
case of disease he may have no choice. In its course the lateral
sinus receives the superior petrosal sinus, and at its termination in the
jugular vein the inferior petrosal. It communicates with the veins of
the pericranium by the mastoid vein^ and by small vessels which enter
through the posterior condylar foramen. The short mastoid vein
runs from the posterior auricular vein through the mastoid bone.
When, in the case of meningitis, leeches are applied behind the ear,
it is by this vein that the intracranial circulation is relieved. The

40 Venous Sinuses of Head

nearness of the sinus to the middle ear explains how in abscess of that
cavity septic thrombosis may occur.

The position of the lateral sinus is indicated by a line running
horizontally outwards from the occipital protuberance to within about
an inch of the external auditory meatus, and thence downwards to the
mastoid process.

The cavernous sinus, at the side of the body of the sphenoid,
receives the blood of the ophthalmic vein, which flows into it through
the sphenoidal fissure. It also receives cerebral veins. It is emptied
by the two pctrosal sinuses. On the inner wall of the sinus winds the
internal carotid artery, with the sixth nerve on its outer side, and in
the outer wall of the sinus are the third and fourth nerves and the first
division of the fifth. Tillaux alludes to some cases of aneurysmal
communication between the internal carotid and the sinus ; the signs
of such lesion are dilatation of the ophthalmic vein and a pulsatory
swelling behind the internal angular process of the frontal.

The inferior longitudinal sinus runs along the concave border of
the falx, and ends in the straight sinus, which latter passes along the
union of falx and tentorium to the torcular Herophili or into one of
the lateral sinuses. The straight sinus also carries blood backwards,
which the veins of Galen, emerging from beneath the corpus callosum,
have brought from the interior of the brain. The straight sinus also
receives veins from the upper surface of the cerebellum.

The veins of
the dip Joe do not
take their respec-
tive names pre-
cisely from the
bone in which
they ramify ; they
are not confined
to any individual
bone, but com-
municate across
the sutures. The
frontal diploic
vein joins the
supra-orbital as it
passes through
the supra-orbital
foramen. The
anterior temporal
comes chiefly
from the frontal bone, to end in a deep temporal vein, and the posterior
temporal emerges from the parietal bone to empty in the lateral sinus.
The occipital flows into an occipital vein or into the lateral sinus.

VEINS OF DIPLOE I

i, frontal ; 2 and 3, ant. temporal ; 4, post, temporal ; 5, occipital.

Emissary Veins 41

All these veins have irregular communications with those of the
pericranium and dura mater, and, being by their nature incapable of
contraction, they are very prone to carry septic matter into the blood,
in the case, for instance, of compound fracture of the skull. By means
of the supra-orbital and neighbouring branches, the facial vein is in
direct communication with the ophthalmic vein, and so with the caver-
nous sinus. ' Thus may be explained the thrombosis of the sinuses
which sometimes follows facial erysipelas.

Emissary veins are the short, open vessels which establish a de-
finite communication between the pericranial veins and the cerebral
sinuses. The mastoid emissary is a large link between the posterior
auricular or occipital vein and the lateral sinus, through the mastoid
foramen. The application of leeches behind the ear, as already
remarked, thus distinctly influences the intracranial circulation.

The parietal emissary passes through the parietal foramen, between
a pericranial vein and the superior longitudinal sinus. A small condylar
emissary runs from an occipital vein through the posterior condylar
foramen into the lateral sinus, and a short vessel ascends from the
pterygoid plexus to the cavernous sinus.

These emissary veins play an important part in septic wounds of
the scalp, rapidly carrying septic material into the intracranial sinuses,
and determining the onset of pyaemia.

The cerebral veins, which lie in the sulci, are thin-walled and
valveless, and are in communication with each other across the
middle line through the medium of the sinuses. The superior set of
them open from behind forwards into the superior longitudinal sinus,
the lower ones end in the cavernous, petrosal, and lateral sinuses.

The veins of the corpus striatum and of the choroid plexus emerge
from the velum interpositum, and, under the name of Galen's veins,
enter the straight sinus.

The cerebellar veins open into the straight, the lateral, and the
petrosal sinuses.

The pressure of venous blood within the skull is equalised by the
communication between the two cavernous sinuses by means of the
small circular sinus around the pituitary body ; by the transverse sinus
which runs across the basilar process ; by the communication between
the lateral sinuses at the torcular, and by the thin-walled veins upon
the surface of the brain which, destitute of valves, lie in the sulci and
communicate freely in all directions.

The arteries of the dura are anterior meningeal from the
ethmoidal of the ophthalmic, and others from the internal carotid ;
middle meningeal from the internal maxillary, entering by the foramen
spinosum, the small meningeal entering by the foramen ovale ; and
a twig or two from the ascending pharyngeal, through the middle
lacerated foramen. Posterior meningeal come from the vertebral and
from the occipital through the posterior lacerated foramen, and perhaps

42 Vessels of Brain

from the ascending pharyngeal, through the anterior condylar
men.

The veins, with the exception of the pair of middle meningeals,
which emerge by the foramen spinosum to join the internal maxillary
vein, end in the adjacent sinuses.

The middle meningreal artery ascends for a short distance in the
substance of the anterior inferior angle of the parietal, so that fracture
of that part of the skull is apt to be followed by haemorrhage between
the bone and dura mater. For the most part, the vessel is wrapped in
the dura, so that a rent of the membrane tears the vessel also, in
which case bleeding is also external to the dura. The looseness of
the attachment of the membrane to the vault of the skull allows the
formation of an enormous blood-clot outside the dura, the brain being
thereby gradually compressed. The nature of the compression is
readily suspected : thus, it is over the motor area ; the symptoms do
not follow immediately on the accident, as they would if the compres-
sion were due to depression of bone : they come on gradually after a
few days, and there is no rise of temperature such as would be
associated with the compression due to suppuration.

Being thus enclosed in bone and in the dura, there is little chance
of spontaneous cessation of bleeding when the artery is rent. The
haemorrhage being over the motor area, the progress of the clot can
be precisely noted. Trephining will be indicated, and on opening the
skull, if leakage from the vessel have not then ceased, there will be
little difficulty in finding and securing the torn vessel. >(Jacobson,
'Guy's Hospital Reports,' vol. xliii.)

The arteries oi the brain are derived from the internal carotid and
the vertebral, the former giving off the anterior and middle cerebral.

The anterior cerebral enters the front of the longitudinal fissure,
where it is joined with its fellow by the short anterior communicating
artery. It then winds on to the upper surface of the corpus cal-
losum, where it anastomoses with the posterior cerebral. It gives off
branches to the anterior perforated space (p. 53), to the anterior lobe,
and to the median surface of the hemisphere.

The middle cerebral, ' the artery of cerebral haemorrhage,' supplies
the motor area (p. 48). Entering the Sylvian fissure, it gives branches
to the island of Reil, through the anterior perforated space, to the
corpus striatum, and to those parts of the frontal and parietal lobes
adjacent to the fissure of Rolando. Thus, when the main artery of
the left side (p. 49) is plugged, there is right hemiplegia and aphasia,
and when the right vessel is plugged there is left hemiplegia. \Ylu-n
a branch only is blocked the motor paralysis is partial, and, perhaps,
temporary, as the anastomotic branches of the pia mater may in due
time repair the lesion. The left middle cerebral is said to be more
often plugged than the right, because, it is argued, a vegetation
is more likely to pass with the blood-stream into it than into that of

Circle of Willis 43

the right side. This statement, however, is not apparently borne out
by statistics ; probably more ' left ' cases are reported, because of the
interesting clinical feature — aphasia — being present. Acute rheuma- \
tism, gout, atheroma, morbus cordis, granular disease of the kidney, ]
syphilis, and injury are the chief causes of disturbance of arterial cir- V
culation in the motor area. And he who knows himself to be the subject
of one or more of these conditions should try to avoid everything likely
to put a strain upon his arterial system, such as running to catch a J
train, straining at stool, and so on.

The common seat of cerebral haemorrhage is in the neighbourhood
of the corpus striatum, and occurs from the good-sized branches which
run straight up from the beginning of the middle cerebral artery into
the lenticular and caudate nuclei ; probably it is the directness of the
course of these branches from the main trunk which causes them to
burst under the shock of the ventricular contraction.

The posterior communicating artery passes from the back of the
internal carotid to join the posterior cerebral. Just there, also, the
carotid gives off the antetior choroid twigs, which, entering the de-
scending cornu of the lateral ventricle, supply the hippocampus and the
choroid plexus.

The posterior cerebrals come off at the bifurcation of the basilar,
and wind round the crura to supply the occipital lobes, anastomosing
there with the middle and anterior cerebrals. The posterior cerebral
is joined by the posterior communicating from the internal carotid ; it
gives offsets to the optic thalamus, which enter by the posterior per-
forated space, and \hzposteiior choroid twigs, which pass beneath the
corpus callosum to the velum interpositum.

The circle of Willis is an arrangement for equalising the flow of
blood between the internal carotid and the basilar, and between these
trunks on the two sides of the middle line. Except for this arrange-
ment, ligature of the common carotid would probably be followed by
rapid degeneration of the brain. The vessels forming the circle are
the anterior communicating, anterior cerebral, internal carotid, posterior
communicating, posterior cerebral, and basilar. The circular arrange-
ment does not always suffice for carrying on the supply across the
middle line, for sometimes, as a direct result of ligation of the common
carotid, apoplexy or softening occurs. The walls of the cerebral
arteries are so thin that these vessels look like veins ; they inosculate
very freely in the pia mater, but their terminal branches do not ana-
stomose. This last fact accounts for the complete loss of function of
a part when its artery becomes plugged.

Within the circle are the lamina cinerea, optic commissure, in-
fundibulum and tuber cinereum, corpora albicantia, and posterior
perforated space.

The cerebellum derives its supply from the posterior inferior cere-
bellar of the vertebral, and from the anterior inferior and the superior

44 The EncepJialon

cerebellar of the basilar. The/^/j is supplied by small transverse
branches of the basilar, and the medulla by the anterior and posterior
spinal of the vertebrals, the anterior spinals becoming fused in their
descent into a slender median artery.

THE ENCEPHALON

The brain, which weighs 49^ oz. in the male and 44 oz. in the female,
is surrounded by a thin film of subarachnoid fluid, so that, floating on
a water-bed as it were, it may not be seriously shaken when one is
running or jumping. The violence may be so great as to fracture the
base of the skull, yet the layer of water saves the brain from con-
cussion, as is evinced by the man retaining perfect consciousness,
though he may die shortly after from other effects of the fracture.

There are many other natural provisions against rough inter-
ference with the delicate structure of the brain, such as the ' give ' in
the joints of the foot, knee, hip, and pelvis ; the curves of the tibia,
femur, and spinal column ; the fibro-cartilages of knee and spine ; the
arrangement of cancellated tissue of the bones, and so on. But some-
times, and especially when the subject is taken unawares, and so is
unable to arrange his muscles and joints to break the shock, the brain
is violently shaken in its bone-case, and, for a time, thrown out of work-
ing order. In common parlance, the man is ' stunned' ; the surgical
equivalent for the condition being * concussion?

The shock which causes concussion is apt to lacerate a meningeal
or cerebral vessel, the haemorrhage occurring either outside or inside
of the dura mater, the effect being compression of the brain, a much
more serious condition than simple concussion. The larger the vessel
torn, the more rapidly would the symptoms come on.

A deep longitudinal fissure separates the two cerebral hemi-
spheres and lodges the falx cerebri ; in its depths may be seen the
fibres of the corpus callosum crossing the middle line.

The lower limit of the cerebrum is approximately shown by drawing
a line from just above the supra-orbital ridge to the external auditory
meatus, and thence up to the external occipital protuberance.

As the protuberance marks the level of the lateral sinus (p. 39),
and, with it, the attachment of the tentorium, the cerebellum is neces-
sarily below the hinder part of this line.

The outer surface of the hemisphere is deeply cut by the fis-
sure of Sylvius, the beginning of which is at the front of the base of
the brain ; it lodges the lesser wing of the sphenoid, and the middle
cerebral artery, * the artery of cerebral haemorrhage ' (p. 42), winds
into it. The fissure quickly divides, one part running upwards for an
inch into the frontal lobe, the other extending backwards : these parts
are respectively the vertical and horizontal limbs of the fissure. The
horizontal limb cuts off the temporo-sphenoidal lobe below from the

Fissure of Rolando

frontal and parietal above. Within the beginning of the fissure is the
island of Reil, The posterior border of the lesser wing of the sphenoid
is lodged in the fissure.

The fissure of Rolando (central fissure] begins above near the
middle of the longi-
tudinal fissure, and
runs downwards and
forwards, almost to
the spot where the
Sylvian fissure bifur-
cates. It separates
the frontal from the
parietal lobe.

The situation of
the fissure of Ro-
lando on the vertex
of the skull is \ in.
behind the middle of
a line passing from
the root of the nose
to the occipital protu-
berance, from which
it slopes downwards A>
and a little forwards.

A simpler way of marking it on the shaven scalp is to draw a line
with an aniline pencil, from that part of the vertex which is directly
above the external auditory meatus, to the depression just in front of
the piece of cartilage (tragus) anterior to the meatus ; the fissure de-
scends along this line almost to the level of the Sylvian fissure (z/.z.).
The line thus drawn runs almost parallel with the coronal suture,
being about if in. behind it above, and i^ in. behind it below. But
the knowledge of the relative position of suture and fissure is of no
practical use to the surgeon, for the suture does not afford him a land-
mark when about to remove a tumour from the motor area ; the ani-
line mark upon the scalp is, however, of the greatest service. Though,
let it be remembered, the fissure of Rolando corresponds only to the
upper part of that mark.

The ascending frontal convolution runs for the width of the finger
in front of this line, and the ascending parietal mounts behind it.
From the front of the former convolution it is easy to map out the three
horizontal frontal convolutions.

The temporo-sphenoidal lobe is often the seat of abscess secondary
to suppurative otitis. It may be reached by the trephine applied two
inches above and behind the external auditory meatus. There are
more complicated ways of indicating the situation of this spot, but I
venture to say that they are not more precise.

, c, trephine-crowns over fissure of Rolando, R ; F 3, Broca's
Region. — After ERICHSEN.

The Encephahn

In operating, the trephine must not be applied at a lower level, lest
the lateral sinus be opened (p. 39).

The fissure of Sylvius runs backwards and upwards between the
frontal and the temporo-sphenoidal lobes. As the frontal lobe rests
upon the roof of the orbit, the fissure must start from just below the
level of the roof; it begins about \\ in. behind the external angular
process of the frontal bone, and runs to the parietal eminence — not
quite to its centre, for that is occupied by the supra-marginal gyms,
which takes its name from being ' above the end ' of the fissure.
The main fissure runs for about \ in. before it divides into its vertical
and horizontal limbs ; the former ascends for about i in., and the
latter runs backwards and upwards through about the middle of the
hemisphere.

The paricto-occipital fissure begins in the interior of the longi-

Outer Surface of Left Hemisphere. (GRAY.)

Cerebral Convolutions

tudinal fissure, and runs a short distance on to the convex surface of
the hemisphere between the parietal and occipital lobes.

This figure shows the relative position of the sutures of skull and the fissures of brain. (QUAIN.)

Lobes. — The frontal lobe reaches back to the fissure of Rolando ;
that part of it which rests in the anterior fossa of the skull constitutes
its orbital surface. The frontal lobe is marked by two horizontal
sulci which map it into superior, middle, and inferior frontal convolu-
tions, which, like the sulci, are directed from before backwards. Be-
hind these horizontal lobes is a vertical furrow, the transverse frontal
fissure, or, because it lies in front of the central (Rolando's) fissure, the
prce-central sulcus. The vertical convolution which lies between this
transverse frontal sulcus and the fissure of Rolando is the important
ascending: frontal convolution.

The infra-parietal fissure ascends for a while behind the fissure
of Rolando and then turns backwards, perhaps to join the parieto-
occipital fissure. The convolution between it and the fissure of Ro-
lando is the ascending parietal convolution, and below the fissure
of Rolando it becomes continuous with the ascending frontal convolu-
tion, the junction between their lower ends forming a thick flap which
has to be lifted up in order to expose the island of Reil. Acting thus
like a lid, the flap is called the operculum (operio, -ertum, cover, hide),
the convolutions of the island being the gyri operti.

The Encep/iti/on

Above, the ascending parietal convolution inclines backwards and
ends in the superior parietal lobule, which is continuous on the mesial
surface of the hemisphere with the quadrate lobule — which is just
behind the para-central lobule (p. 53). That part of the parietal lobe
which is above the end of the horizontal limb of the Sylvian fissure is
the supra-marginal lobule, and that which is just behind the ending is
the angular lobule. The former is covered by the parietal eminence.

The occipital lobe rests on the tentorium and is indistinctly mapped
into three horizontal lobules, called first, second, and third. This lobe
is continued into the parietal and temporo-sphenoidal lobes by four
small annectant convolutions.

The temporo-sphenoidal lobe lies in the middle fossa of the base of
the skull. It is limited above by the Sylvian fissure, and is mapped

fis-.Ro.

The Motor Area, after GOWEKS.

into first, second, and third convolutions (numbered from above down-
wards) by two antero-posterior fissures, the upper of which lies a little
below, and parallel with the horizontal limb of the Sylvian fissure.
Hence the upper furrow is called the paralle I fissure.

The motor area comprises the hinder part of the three frontal
convolutions, the convolutions bounding the fissure of Rolando, viz.,
ascending frontal and ascending parietal ; the continuation of the
latter into the superior parietal lobule ; and that part of the marginal
convolution which lies in front of the quadrate lobe — the para-central
lobe. This last-named lobe is formed where the ascending frontal and
parietal lobes blend above to prevent the fissure of Rolando entering
the longitudinal fissure. The whole of this area is supplied by the
middle cerebral artery (p. 42).

That part of the frontal lobe which lies in front of the coronal

Aphasia 49

suture, and which comprises the chief (anterior) part of the superior,
middle, and inferior frontal convolutions, constitutes the prce-frontal
region. It may be stimulated in experimental research, or destroyed
by injury or disease, without the occurrence of motor or sensory dis-
turbance.

Stimulation of various parts of the motor area causes definite
movements, on the opposite side of the body, of leg, arm, hand, or
face, whilst their complete destruction leaves the muscles paralysed.
As already remarked, this area is supplied by the middle cerebral
artery. This vessel, at its entrance to the Sylvian fissure, gives off
branches through the anterior perforated space to the corpus striatum,
so that this important ganglion may escape softening, when, on account
of a plugging of the more distant part of the artery, the cortical area is
degenerating.

The island of Reil, or the central lobe, lies deeply in the beginning
of the Sylvian fissure, and is seen on gently raising the apex of the
temporo-sphenoidal lobe. It is wedge-shaped, its apex corresponding
to the anterior perforated space, and its base being hidden by the
operculum. Its upper surface lies beneath the lenticular nucleus of
the corpus striatum ; its under surface is marked by some straight
radiating grooves into the gyri operti (or hidden convolutions).
Broca showed that the motor centres for speech are in the region of
the left island of Reil. The anterior perforated space is a grey
depression near the beginning of the Sylvian fissure, through which
twigs of the middle cerebral artery enter the corpus striatum,

Aphasia (a, privative, (pao-is, speech) means that a person has lost
the faculty of speech — it may be because he has lost the memory for
words, but then the disease is more properly called amnesia ( a, priv.,
pvrjo-is, remembrance) ; aphasia implies that he has the memory of
words, but that he has lost the power of co-ordinating the muscles
for articulating them. He knows the words, for he may be able
to write them, provided that he has not right hemiplegia also ; but
he cannot say them as he would like to, though he may be able to
pronounce certain words perfectly. This last fact proves that the
dumbness is very different from that of bulbar paralysis (p. 71).
Broca showed that in aphasia there is some serious disturbance with
the third left frontal convolution, near the island of Reil. This is
therefore, called Broca's region.

The defect may be due to a plugging of the middle cerebral artery,
to cerebral softening, haemorrhage, or to the pressure of some tumour
or effusion. The speech-centre is not always on the left side, it has
been shown clinically to be in the right third frontal convolution in the
case of a left-handed subject, but we are, generally, left-brained just
as we are right-handed. As regards the extremities, hemiplegia will
be upon the right side because of the crossing of the motor filaments
in the medulla.

50 The Encephalon

Were the hemiplegia to be on the same side as the cerebral lesion,
the explanation would be that, from an error of development, there
was no crossing in the pyramids, but that all the motor fibres had
descended uncrossed, like the fibres in the column of Tiirck (p. 215).
This element in the calculation, however, may practically be dis-
regarded.

In irritation of the motor area, as from meningitis or slight haemor-
rhage, there is twitching of the muscles of the opposite side, but when
the area is destroyed, as by abscess, injury, softening, or tumour, there
is complete paralysis of motion only on the opposite side, with sub-
sequent contracture of the muscles. The larger the area affected, the
more extensive the hemiplegia. Thus, in the case of softening in the
neighbourhood of the left fissure of Rolando, there will be right hemi-
plegia, right fac'iRl paralysis, and also aphasia. The softening is
usually caused by plugging of the middle cerebral artery, and, the area
of brain being suddenly deprived of its supply, the symptoms are much
like those of apoplexy.

Disease in the motor area, as already remarked, causes loss of
voluntary movements in the muscles of the opposite side ; and, as the
lateral columns of the cord become involved in a descending degenera-
tion (p. 222), spasm and subsequent rigidity of these muscles are
entailed. The degeneration may be traced by the microscope through
the crus cerebri, anterior pyramid, and the antero-lateral column of
the cord. There is no loss of sensation in these cases, unless, indeed,
the degeneration extends deeply into the hemisphere. When haemor-
rhage has occurred, and is continuing from a middle cerebral artery,
the patient should be propped up in bed, so as to retard somewhat
the leakage ; and it is a question whether in some of these cases con-
tinuous compression, or even ligation, of the common carotid might
not be resorted to with advantage.

Varieties of paralysis. — Paralysis of the arm with the leg consti-
tutes bracJiio-crural monoplegia ; the condition is a common one, for a
tumour implicating the upper part of the arm-centre need spread but
little to interfere with that of the leg. Perhaps the arm-centre might
first be attacked, and then, as the growth extended upwards, leg-para-
lysis would follow, and as it extended downwards facial paralysis and
aphasia would result.

The exact sitttation of the leg-centre is probably in the superior
parietal lobule and in the para-central lobule (p. 53). Thus, briefly,
the leg-centre is about the top of the fissure of Rolando.

Crural monoplegia means paralysis of the muscles of the lower
extremity only (ftovos, alone} that is, without any implication of the
muscles of the upper extremity.

Brachial. — The centres for the arm, hand, %n&fingers are extensive,
just as the movements of the limb are important and complicated ;
they are situated about the middle of the ascending frontal and ascend-

Motor Area tjr

ing parietal convolutions. The wrist and ringers have their centres in
the middle of the ascending parietal convolution, and the lowest of
them is close against the centre for the mouth and face. Watch a
man trying his very hardest to tie, or to untie a knotted cord, and
note how the muscles of the corner of his mouth and of his face are
at work. The vigorous motor impulse generated in the hand-centre is
brimming over and stimulating the neighbouring oro-facial centre.
Suppose that during this effort the branch of the middle cerebral
artery which supplies the hand-centre were to burst, there would at first
be a meaningless twitching of the hand and mouth, and, as the blood-
clot grew, the centres would become disorganised, and the man might
be left with brachio-facial paralysis— on the opposite side to the injury,
of course (p. 49). And thus it comes about that brachio-facial paralysis
is of more common occurrence than brachial monoplegia or facial
monoplegia. There is no anatomical boundary between the arm-
centre and the centres adjacent to it. In cerebral paralysis there will
be neither loss of consciousness nor sensation if only the motor area
be implicated.

Again, watch the demagogue upon the rostrum. The louder he
speaks, the more he throws his arm about, because the energy in his
speech-centre flows into the neighbouring hand-and-arm-centre. And,
as the speech- centre is upon the left hemisphere, it is the right arm
with which he gesticulates ; it is training only which makes the orator
use his left arm to vary the monotony of the brachial movement. I
do not know if the man whose speech -centre is upon his right side in
his oratory neglects the use of his right hand, but I expect that he does,
unless, indeed, he be a well-trained speaker.

Some untrained speakers, or ranters, throw out both arms in an
emphatic manner ; this is because the centres of the two sides are
held in association by certain commissural fibres. The need for such
fibres is evident ; were there none of that sort, the facial muscles of
one side, for instance, would be able to act without regard to those of
the other, expression being reduced to an absurdity. In very many
of our common acts, such as eating, talking, breathing, walking, it is
essential that the muscles on the two sides of the body be in harmonious
association, and the existence of commissural fibres by which this is
effected must not be overlooked when problems in paralysis are being
worked out.

Facial monoplegia is rare ; facial paralysis of cerebral origin usually
being associated with brachial paraplegia when the lesion spreads
upwards, or with aphasia when it implicates the base of the third
left frontal convolution.

The oro-lingual centres (which are at the lower end of the fissure of
Rolando) of one hemisphere are associated in their work with those
of the other side by certain cross-fibres ; for, as already suggested,
one does not use a lateral half of the tongue separately, nor does one

52 The Enceplialon

in eating or talking, for instance, confine the movements to one side
of the face. When, therefore, these centres are damaged on the one
hemisphere there is still some energy passing out to the opposite side
of the tongue, so that, as Ferrier remarks, we then find oro-lingual hemi-
paresis (napeo-is, relaxation) instead of paralysis. When the lesion is
in the left hemisphere the paresis of the right side of the tongue is
generally associated with aphasia, because, the lesion being in Broca's
region (p. 49), the centres for the muscles of speech — tongue, lips, palate,
and vocal cords — are also damaged.

Sometimes, as already remarked, the oro-facial paresis is associated
with brachial paralysis. The association of left hemiplegia with
aphasia may happen in the case of a left-handed man, that is to say, in
one whose right cerebral hemisphere has acquired the habit of perform-
ing the offices usually, by preference, carried out by the left.

It will simplify the problem of localisation if the student remembers
that the motor areas are inverted on the surface of the liemisphere —
like the landscape on the plate of the photographic camera. Thus the
centres for the muscles of the lower extremity are grouped about the
top of the fissure of Rolando, the arm-centres about the middle, and
the centres for the face and mouth, and for the muscles of speech, at
the bottom — near to the island of Reil. Thus it comes about in in-
complete hemiplegias that the leg and arm may be affected together
the face escaping ; that in another case the arm and face may be
affected without the leg ; and that aphasia is much more likely to occur
with paralysis of the right arm than of the right leg only, for the arm-
centres intervene between those of the muscles of articulate speech
and of the leg. (See illustration on p. 48.)

On the mesial surface of the hemisphere \S\htgyrusformcatU*
(or arched convolution), which begins near the anterior perforated spot
and arches round the corpus callosum to become continuous with

Corpus Striatum 53

the uncinate gyrus. Close above it is the convolution which lies along
the margin of the longitudinal fissure — the marginal convolution. It
begins at the anterior perforated space, and ends just in front of the
quadrate lobe. Between the gyrus fornicatus, or callosal convolution,
and the marginal convolution, is the calloso-marginal fissure.

The para-central lobe is chiefly formed by the top of the ascending
frontal convolution, which looks into the marginal convolution.

The quadrate lobe is the mesial surface of the parietal lobe ; just
behind it is the cuneate lobe of the occipital.

Jacksonian epilepsy is the convulsive attack, followed by tem-
porary paralysis, of a group of muscles, which results from irritation of
some part of the motor area. Chronic inflammation of the brain or
its membranes is a common cause of it, the inflammation being very
often the result of syphilis. Perhaps at first only one group of
muscles is affected, but as the irritation extends the neighbouring
parts of the cortex are implicated, and the convulsions become more
widely distributed. From what has gone before (p. 52) it is evident
that if the epilepsy begin as a facial spasm the muscles of hand and
arm will be next involved, and lastly those of the leg. When the last
group of muscles is first attacked those of the arm are likely to
follow suit, and ultimately those of the face. If the disturbance begin
in the arm-centres the muscles both of leg and of face are likely to
be involved subsequently.

The fibres from the motor area subsequently pass through the
corpus striatum and the internal capsule ; haemorrhage, therefore, in
either of these latter situations may cause extensive paralysis upon the
opposite side of the body. Indeed, the corpus striatum has been
called, on account of its associations, ' the motor ganglion,' the optic
thalamus, on the other hand, being ' the sensory ganglion.'

The sensory region of the cortex is posterior to the motor, and
in the case of a destructive lesion of the motor area, if there be
hemi-anaesthesia as well, it is certain that the injury is widespread, and
the chance of relief by trephining remote.

THE BASAL GANGLIA

The corpus striatum is a grey ganglion which is streaked, or
striated, by white fibres on their way down to the antero-lateral column
of the cord, through the superficial, or motor, part of the cms — the
crusta. These fibres reach the cortex through the fan-like corona
radiata. The presence of the vesicular tissue in the ganglion detracts
from its strength, and, being freely supplied with branches of the
middle cerebral, which enter it through the anterior perforated space,
it is often the seat of haemorrhage. Motor paralysis of the opposite
side results, just as if the lesion were in the motor area or in the crus.

Cerebral haemorrhage is generally the result of kidney-disease, as

54 The EncepJialon

explained on p. 348. At the autopsy of such a case the arteries are
found diseased, and therefore weakened, the left ventricle being hyper-
trophied and therefore strengthened.

Sometimes Nature hoists a danger-signal before the final apoplectic
fit occurs : such signals are headaches, epistaxis, and retinal haemor-
rhages which may be seen by ophthalmic examination.

The internal capsule consists of fibres from both the motor (crusta)
and sensory (tegmentum) tracts of the crus, which hold the cortex in
direct communication with the cord. Thus damage to the anterior
part of the internal capsule causes motor paralysis, and to the
posterior part loss of sensation, upon the opposite side of the body.
The paralysis in the former case is diffuse, and not confined to a group
of muscles as in the case of a cortical lesion.

The optic thalami lie behind the corpora striata, and nearer to the
middle line, being separated from each other only by the narrow third
ventricle. They receive fibres from the sensory tracts of the cord, which
reach them through the cerebral aspect of the crura — the tegmenta ;
each thalamus sends fibres into all parts of the cerebral cortex, and
these constitute the corona radiata.

The crura cerebri consist of fibres ascending from the cord, those
from its motor tracts being gathered in the superficial part, the crusta,
and those from the sensory tracts in the deeper part, the tegmcntum.
The former set pass, for the most part, through the corpus striatum and
internal capsule, to the motor area, by the corona radiata, whilst the
tegmental set pass to the thalamus and through the cororja radiata
to the sensory area of the cerebral cortex. Between crusta and teg-
mentum is a mass of grey cells, locus niger, through which the fibres
of the third nerve pass. Between the crura, as they diverge at the
front of the pons Varolii, is the posterior perforated space, by which a
group of vessels from the posterior cerebral arteiy reach the thalamus.
The tegmental fibres descend in the cord, in the direct (Tiirck's) and
in the crossed pyramidal tracts.

Hcemorrhagcinto the crus cerebri causes hemiplegia on the opposite
side of the body, and of the third nerve upon the side of the lesion,
provided that the inner fibres are involved.

Pons Varolii. — As the fibres descend from the crura to the medulla
they pass under cover of the middle commissure of the cerebellar
hemispheres, and, though the term ' pons' should only apply to the
bridging cerebellar fibres, still the word is usually applied to the
entire mass of the tuber annulare. As the fibres from both crura
descend through the pons, cerebral ha-morrhage in its substance
generally causes motor paralysis on both sides of the body, coma
following immediately, and death not being long delayed. But when
the haemorrhage is limited to one side there is hemiplegia upon the
opposite side of the body, but paralysis of fifth, sixth, and seventh
nerves upon the same side.

Medulla Oblongata 55

Though the pons consists chiefly of white fibres, it contains also
grey matter, and helps in co-ordinating muscular movements. There
also decussation of the fifth and of the seventh nerves takes place. If a
lesion, a small haemorrhage, for instance, occur above the crossing of
the facial fibres, there is paralysis of the opposite sides of face and of
the body, whereas if it be below the crossing the facial paralysis is
upon the same side as the lesion, whilst the hemiplegia is upon the
opposite side, for the motor fibres of the cord cross in the medulla.

Haemorrhage into the pons is usually accompanied by contraction
of the pupils.

The medulla oblong ata extends from the lower border of the pons
to the ring of the atlas. Its anterior surface lies upon the basilar
process of the occipital bone, and its posterior surface rests between
the hemispheres of the cerebellum. Being an enlargement of the
spinal cord, it consists of symmetrical lateral halves in which the
various columns of the cord can be traced. In front is the median
groove, which ends at the pons as the foramen caecum, and the posterior
median groove becomes widened out into the fourth ventricle, the
grey commissure of the cord being exposed in its floor. The anterior
columns of the cord are represented by the anterior pyramids ; the
bundles of fibres which decussate at the lower part of the groove
between the pyramids actually belong to the lateral columns — they
are called the crossed pyramidal tracts. The outermost fibres of the
pyramids do not cross — they constitute the direct pyramidal tracts.
(See SPINAL CORD, p. 213.)

The olive belongs to the lateral column. The restiform bodies
(restis, rope) are cord-like bundles of fibres continuing the posterior
column into the cerebellum ; they bound the fourth ventricle. The
posterior pyramid continues Goll's column along the median border
of the restiform body, and its fibres gradually pass into the restiform
body. In the exposed grey matter of the fourth ventricle descends a
narrow median groove, which at the apex of the ventricle was origi-
nally continued into the central canal of the cord.

The medulla oblongata is described by Ranney as ' the true nerve-
centre of animal life ' ; all the cranial nerves from the seventh to the
twelfth arise directly from it, whilst others can also be traced thither,
that is, to the floor of the fourth ventricle. It contains much grey
matter : its action, therefore, is ' largely reflex.3 Taking the nerves
arising from it in numerical order, we find the seventh controlling the
reflex movements of the facial muscles ; the ninth (glosso-pharyngeal),
of deglutition ; the tenth (pneumogastric), of respiration ; the eleventh
(spinal accessory), of the larynx and heart ; and the twelfth (hypo-
glossal), of the tongue.

The special centres of the medulla are respiratory, under the
influence of the pneumogastric, trifacial, and other afferent fibres.
* This centre also presides over the acts of laughing, sighing, sobbing,

56 The Encephalon

sneezing, and hiccough.' The efferent impulse leaves by the phrenic,
intercostals, spinal accessory, certain cervical nerves, and facial. Vaso-
motor centre, controlling the muscular coat of the large arteries of the
thorax, abdomen, and pelvis, through efferent impulses carried down
by the spinal cord, the dorsal nerves, and the'splanchnics. Dilatation
of these vessels follows section of the cord below the medulla. Cardio-
inhibitory, through which the heart is held under control by afferent
influences passing to the medulla, acceleration of the heart's action
following section of the vagus. The medulla contains also a centre
for deglutition, and one which, being stimulated, produces glycosuria
— the diabetic centre — and a salivary centre. Sugar and albumen may
be found in the urine in the case of lesion of the medulla.

Bulbar paralysis is the result of progressive degenerative changes
in the nuclei of origin of the hypoglossal, spinal accessory, vagus,
facial, and glosso-pharyngeal, which are near neighbours in the floor
of the fourth ventricle. The co-ordination of muscles of articulate
speech become gradually implicated, and the tongue and the muscles
of the pharynx lose their power. The disease used to be called labio-
glosso-pharyngeal paralysis ; the term bulbar paralysis is shorter, and
moreover indicates the seat of the primary lesion, in the ' bulbar ' end
of the spinal cord (see p. 71).

The aqueduct of Sylvius leads beneath the corpora quadrigemina
and posterior commissure from the top of the fourth ventricle into the
third. It is lined by a prolongation of the grey matter from the
fourth ventricle, in which are the nuclei of origin of the motor oculi
and patheticus.

When the basal ganglia are in physiological activity the vessels,
which enter them in great abundance, are filled full, and the ganglia
are increased in size. The corpora striata in their turgescence bulge
into the lateral ventricles, displacing some of the intra- ventricular fluid
which is secreted by the choroid plexuses, through the foramina of
Monro, into the third ventricle ; and the thalami, growing large,
squeeze fluid out of that ventricle through the aqueduct and into the
fourth ventricle, and so into the subarachnoid space. As an infant
with spina bifida excites himself, and cries, the brain evidently in-
creases in bulk, for the lumbar tumour becomes tense and swells up.
And as the brain quiets down again the cerebro-spinal fluid re-enters
the cranium, some of it, no doubt, passing into the third and lateral
ventricles by the apertures of Sylvius and Monro. In cases of dilatation
of the third lateral ventricles (internal hydrocephalus] Hilton1 found
that the communication between the ventricles and the subarachnoid
space was permanently blocked, so that the intra-cerebral fluid could
not escape. Sometimes the brain-tissue is represented by but a thin,
smooth film enclosing the 'water,' which has sometimes measured,/^/
mortem, twelve or twenty pints. In such cases the head may appear

1 Rest and Pain, 2nd edit. p. 28.

Cranial Nerves- 57

translucent — like a hydrocele. * In Cardinal's case this is said to have
been observed when the sun was shining behind him.' — (Fagge.)

Disease of the cerebellum is often associated with pain at the lower
and back part of the head, and with head-ache. There is also inco-
ordination of movement, so that the patient staggers ; he is often,
moreover, attacked with vomiting.

THE CRANIAL NERVES

No. i. — The olfactory is shown by development to be a diver-
ticulum from the cerebral hemisphere ; in fetal life it is hollow and
communicates with the lateral ventricle.

The external root of the nerve springs from the fissure of Sylvius,
near the anterior perforated space. This area is close to Broca's
region (p. 49), and so it comes about that aphasia is often associated
with an impaired sense of smell in the left nostril. The olfactory
filaments descend through the cribriform plate in groups for the mucous
membrane of the upper part of the septum and the roof, and of the
superior and middle turbinated bones. Odorous particles best reach
this area when the air in which they are suspended is ' sniffed ' up.
When, in nasal catarrh, swollen mucous membrane blocks the upper
part of the passages, and the sense of smell is lost, the patient has to
breathe by the floor of the nose or the open mouth.

The sense of smell may be entirely lost after a fracture extending
across the anterior fossa of the skull, or as the result of malignant
disease in the ethmoid region.

No. 2. — The filaments of the optic nerve pass out through the
commissure into the optic tracts, by which they arise from the optic
thalamus and the corpora quadrigemina. The tracts wind over the
crura cerebri.

The nerve passes out through the optic foramen in a special sheath
of dura mater, part of which blends with the orbital periosteum, whilst
the rest runs on to the sclerotic. The fibres of the nerve pass through
the lamina cribrosa of the sclerotic and spread out into the retina ;
those fibres which turn outwards, however, do not spread upon the
surface until they have reached the vertical meridian of the eye-ball.

In the optic commissure the most anterior fibres are inter-retinal
and the most posterior inter-cerebral ; some fibres pass from the
thalamus to the retina of the same side ; and, lastly, others pass
across from the thalamus of one side to the retina of the other. This
decussation is needed because the outer half of one retina works in
harmony with the inner half of the other. When we look to the
right, for instance, the image falls upon the inner part of the right
retina and the outer part of the left. (For the anatomy of the eye see
p. 82.)

58 T/ie Cranial Nerves

' When, therefore, the optic tract of either side is pressed upon, so
as to affect the entire thickness of the nerve, and thus to interfere with
the action of all the fibres, the temporal side of the retina of that eye
and the nasal side of the retina of the opposite eye will be rendered
blind.' l (Hemianopsia.} When the optic nerve is pressed upon, in
front of the commissure, as by sarcoma in the orbit, there is blindness
of the one eye only, and it will probably be associated with paralysis
of the third, fourth, or sixth nerves also, as they lie close together at
the apex of the orbit. If the decussating fibres alone be implicated in
the commissure, internal or nasal hernianopsia is found in each eye.
4 Double temporal hemianopsia indicates disease of each internal
carotid artery, with symmetrical lateral pressure upon the commissure.'
Severe pressure upon the commissure might cause blindness in both
eyes.

Optic neuritis, as determined by ophthalmoscopic examination, is
usually followed by atrophy.

No. 3. — The motor oculi arises from the grey matter surrounding
the Sylvian aqueduct (where the nerves of the two sides decussate),
and emerges from the inner side of the crus ; it then passes through
the outer wall of the cavernous sinus, and divides into two branches
which enter the orbit through the sphenoidal fissure, and between
the two heads of the external rectus. Coming away from the crus, the
third nerve traverses the narrow interval between the posterior cere-
bral and superior cerebellar arteries, so that if either of these arteries
become dilated at that spot ptosis occurs.

The upper division supplies the levator palpebra? and the superior
rectus ; the lower supplies the internal and inferior recti, the inferior
oblique, and, by the motor root to the lenticular ganglion, the ciliary
muscle and the sphincter fibres of the iris.

(The superior oblique is supplied by the fourth nerve, and the
external rectus by the sixth.)

Contraction of the pupil is effected through the third nerve :
when a strong light falls upon the retina a sensation is transmitted by
the optic nerve to the corpora quadrigemina, close to which, in the
Sylvian aqueduct, the third nerve arises. By this nerve a motor
impulse is carried to the lenticular ganglion, and so to the ciliary
muscle and iris.

In viewing- near objects both eye-balls are directed inwards,
the right and left internal recti acting in unison ; thus it becomes
necessary that the third nerves be associated at their origin, which
occurs, as already noted, in the grey matter around the Sylvian
aqueduct.

As the axes converge upon the near object the pupil must contract
so as to cut off peripheral rays ; it is expedient, therefore, that the
internal recti and the sphincter of the pupil be under the control of the

1 Applied Anatomy of the Nervous System, Ambrose L. Ranney.

Motor Oatli 59

same (the third) nerve. Also, when a near object is viewed, the rays
falling upon the eye are extremely divergent, and it is necessary that
the lens be rendered more convex to focus them ; this is accomplished
by the ciliary muscle, through the influence of the third nerve. Thus
the third nerve has entire charge of the accommodation for near vision ;
it converges the visual axes, contracts the pupil, and renders the front
of the lens more convex.

Dilatation of the pupil is affected by radiating muscular fibres in
the iris under the control of the sympathetic. The influence of the
sympathetic upon the pupil, it may be remembered, is exactly the
reverse of that upon a blood-vessel — when it is stimulated the pupil is
dilated, whereas a blood-vessel would be contracted.

The 'Argyll Robertson pupil,' as a symptom of posterior spinal
sclerosis, is thus explained : when the eye of a healthy man is directed
upon a distant object the pupil is dilated, and when he looks at a
finger, in front of his nose, for instance, the pupil is contracted ; also
when the eye is in shadow the pupil is dilated, but under the influence
of a bright light it contracts. In the case of the light, contraction of
the pupil is reflex ; but in the former case it is effected in accommoda-
tion (vide supra}. Now, in sclerosis the pupillary reflex — the contrac-
tion under the stimulus of light — is abolished, whilst the accommoda-
tion-contraction remains. Many other reflexes in addition to those of
the pupil are lost in locomotor ataxy as the result of degenerative
changes in afferent fibres.

When the third nerve is paralysed the upper eye-lid drops, the
levator palpebrae being unable to hold it up. The condition is called
ptosis (TTTCOO-I?, a falling ; 7rwrra>), and, the internal rectus being thrown
out of work, the external rectus holds the eye-ball in permanent
abduction (divergent squint}. The pupil is dilated and does not
contract to light, and accommodation for near vision is impossible.
Most of the muscles having relaxed their hold, the eyeball protrudes
between the Y\&s—proptosis (77/30, forwards, Trroxnr, falling). It cannot
be tilted upwards, inwards, nor downwards.

Likely causes of the paralysis are syphilitic inflammation or
deposit at the base of the brain, haemorrhage, tumour, and diphtheria.
When it is due to a lesion near the Sylvian aqueduct the paralysis
may be bilateral, and the fourth and the sixth nerves may be impli-
cated in due course. The roots of origin of the third nerve may also
be caught in a widely-spreading degeneration which causes labio-glosso-
pharyngeal paralysis (p. 56).

Double vision occurs when the recti act out of harmony, because
the associated areas of the retinae cannot be simultaneously directed
upon the object.

No. 4.— The patheticus, a thread-like nerve, comes round the crus
from its origin at the valve of Vieussens, and, passing along in the
outer wall of the cavernous sinus, and through the sphenoidal fissure,

60 The Cranial Nerves

enters the upper surface of the superior oblique. Fibres of the nerve
decussate in the grey matter around the Sylvian aqueduct, so that
there may be harmony in the action of the two superior oblique
muscles when the head is turned. When the nerve is paralysed and
the head is moved sideways, the eye of the paralysed side moves with
the head instead of being steadily fixed upon the object, and the
subject sees double — diplopia (8nr\ovs, double ; GIX//-, ton-os, eye).

No. 5. — The trifacial derives its name from its supplying the skin
of the face in three situations, namely, in the supra-orbital, infra-
orbital, and mental regions. It arises from the pons by two roots,
of which the anterior, or motor, is quite small ; the deep origin being
in the floor of the fourth ventricle.

The sensory part of the nerve expands on the apex of the petrous
bone into the Gasserian ganglion, from the front of which come the
ophthalmic and the superior and inferior maxillary nerves. The
motor root takes an independent course beneath the ganglion, and
eventually leaves by the foramen ovale to join the inferior maxillary
trunk, the first and second divisions of the nerve being purely
sensory.

Tic douloureux, or neuralgia of the fifth nerve or of one of its divi-
sions, maybe caused by pressure upon the main trunk, or upon its root-
lets in the floor of the fourth ventricle, or by pressure upon a trunk as it
leaves the skull — or elsewhere in its course. Sometimes the distress is
due to peripheral irritation of a single filament, as in a carious tooth,
and amongst more remote causes are cold, dyspepsia, and nervous ex-
haustion. The pain may shoot along the filaments of the supra-orbital
or supra-trochlear nerve, along a division of the temporo-malar, or the
branches of the superior maxillary nerve in the cheek, nose, or upper
lip ; or along the twigs to the teeth, the temple, chin, lower lip, or side
of tongue. On any branch of the nerve there may be a specially
painful spot which the patient can precisely indicate. Sometimes the
attack is associated with flushing or sweating of the surface, and
sometimes it clears up with a profuse secretion of tears, nasal mucus,
or saliva, showing, as Ranney remarks, the implication of the vaso-
motor filaments in the nerve. This association explains also the inflam-
matory changes which the skin of the affected region may undergo, and
also the falling out or blanching of the hair which are sometimes
associated with the neuralgia. When the4 tic 'is spreading, and is
associated with deep-seated headache and with paralysis of certain of
the motor nerves, a cerebral lesion may be suspected. Because there
is pain in the teeth it by no means follows that the teeth cause the pain,
and their extraction should not be hurriedly resorted to.

Clavus is that variety of neuralgia in which the pain, though limited
to a single spot, is so * intense ' that the patient (generally an hysterical
young woman) feels as if a nail (clavus] were being hammered into
her flesh and bone.

Trifacial Nerve 61

The ophthalmic division passes with the third and fourth nerves
along the outer wall of the cavernous sinus, and breaks up into frontal,
nasal, and lachrymal branches which enter the orbit through the sphe-
noidal fissure.

1^ frontal nerve lies under the middle of the roof of the orbit, and
divides into supra-orbital and supra-trochlear branches. The former
emerges by the supra-orbital notch, and, ascending beneath the orbicu-
laris palpebrarum in two divisions, passes through the occipito-frontalis
to supply the scalp, the outer set of filaments reaching back almost to
the lambdoid suture.

In the case of an injury to the trunk of the supra-orbital nerve, I
have seen a crop of vesicles on one side of the forehead and even
amongst the roots of the hair, just as vesicles occur, after intercostal
neuralgia, in the area of distribution of the affected nerve.

The supra-trochlear nerve escapes, as its name suggests, above the
pulley of the superior oblique, and supplies the skin and mucous
membrane of the inner end of the upper eye-lid, and the neighbouring
part of the forehead.

The nasal nerve reaches the inner wall of the orbit by passing
across the optic nerve, and enters the cranial cavity through the anterior
ethmoidal foramen, leaving it again by the slit at the side of the crista
galli. Descending in the nose, it gives branches to the front of the
septum, to the roof, and to the upper spongy bones ; it finally escapes
between the bone and the cartilage to supply the skin near the nostril.
In the orbit it gives off the sensory root to the lenticular ganglion, two
long ciliary to the ciliary muscle and iris, and the infra-trochlear branch
which supplies the skin and mucous membrane near the lachrymal sac.

The lachrymal nerve runs along the upper border of the external
rectus and ends in the lachrymal gland and the upper eyelid.

The lenticular ganglion lies at the apex of the orbit on the outer
side of the optic nerve. Its sensory root conies from the nasal, and its
motor from the third nerve ; its sympathetic twigs are from the
cavernous plexus. It gives off eight or ten short ciliary nerves which
pierce the back of the sclerotic to reach the ciliary muscle and iris.

Each division of the fifth nerve contains trophic filaments under
whose influence the nutrition of the integuments to which the trunk
is ultimately distributed is controlled. When the nerve is paralysed,
not only is there insensibility in the forehead, eyelids, and in the
conjunctiva and nose, in part, but these areas are apt to be the seat of
ulcerations ; conjunctivitis and corneitis may also occur, with escape of
the aqueous humour and lens, total destruction of the eyeball resulting.

In cases of intractable neuralgia it may be deemed advisable to try
the effect of stretching or of excising a portion of a nerve, but the treat-
ment is somewhat speculative ; if each division of the fifth nerve upon
the face were affected the operation could hardly succeed, for the cause
would then for certain be of central origin.

The Cranial Nerves

To reach the supra-orbital nerve a horizontal incision is made for
about three-quarters of an inch, just above the border of the orbit— the
skin, superficial fascia, orbicularis palpebrarum, and occipito-frontalis
being traversed. The middle of the incision should be just above the
supra-orbital notch, which can be made out by the finger. When
instead of a notch there is a complete foramen in the bone the site of
the nerve can be ascertained by pressure ; it emerges at the junction of
the inner middle thirds of the supra-orbital ridge.

When it is suspected that a person is shamming insensibility, steady
pressure should be kept up with the finger on the nerve, just over the
supra-orbital notch. No impostor could bear this for long, and he may
thus be conveniently and promptly tested.

The superior maxillary division leaves by the foramen rotundum,

SENSORY NERVES

1, Great Occipital.

2, Lesser Occipital.

3, Arnold's.

4, Great Auricular.

5, Auriculo-Temporal.

6 and 9, Temporo-Malar.

7, Supra-Orbital.

8, Supra-Trochlear.
10, I nfra-Trochlear.
TI, Nasal.

12, Infra-Orbital.

13, Buccal Branch of Inferior

Maxillary.

14, Mental.

(HOLDEN.)

runs across the spheno-maxillary fossa, and, coursing beneath the floor
of the orbit, emerges by the infra-orbital foramen under cover of the
levator labii superioris. It then spreads out into branches for the nose,
lower eyelid, and upper lip. It gives off an orbital branch which divides
into a temporal and a malar twig, which pierce the outer wall of the
orbit to supply the skin in the temporal and malar regions respectively.
Other branches of the trunk are the sensory root to Meckel's ganglion ;
the posterior dental, which forms a loop in the bone and gives off
twigs to the lining of the antrum, to the pulp-cavities of the molar
teeth, and to the gums.

The anterior dental runs down in the front wall of the antrum to
supply the incisors, the canine, and the bicuspids.

Trifacial Nerve 63

MeckePs ganglion lies in the spheno-maxillary fossa, being con-
nected with the under part of the superior maxillary nerve by the twigs
which constitute its sensory root. Its motor filament comes from the
facial through the Vidian nerve, and this also brings a sympathetic
communication from the carotid plexus. Branches from the ganglion
supply the nasal fossa, gums, soft palate and uvula, roof of mouth,
upper part of pharynx, Eustachian tube, tonsil, levator palati, azygos
uvulae, and palato-glossus and pharyngeus.

The infra-orbital nerve is found by dividing the orbicularis and the
levator labii superioris above the second bicuspid tooth. If it is desired
to remove the nerve, and also Meckel's ganglion, the course of the nerve
may be followed backwards by trephining the front of the antrum
and by breaking along the infra-orbital canal. The spheno-maxillary
fossa is thus reached, and the nerve is found emerging through the
foramen rotundum, near which it is to be cut with curved scissors.

The inferior maxillary nerve leaves by the foramen ovale, and
divides into an anterior and a posterior trunk. Most of the motor
root of the fifth nerve enters the anterior trunk, from which the follow-
ing branches pass off: the masseteric, which, in its course through
the sigmoid notch, supplies the temporo-maxillary joint ; deep tem-
poral, and pterygoid. It also gives a large buccal branch which
traverses the external pterygoid : this is not, however, the motor nerve
to the buccinator, for when the facial nerve is damaged that muscle
is completely paralysed (p. 67). This buccal branch of the inferior
maxillary is a sensory nerve, and ends in the supply of the skin and
mucous membrane of the cheek. Thus, when the motor part of the
fifth nerve is impaired there is paralysis of all the muscles of mastica-
tion on that side, with exception of the buccinator, which is supplied
by the seventh. Rut, nevertheless, mastication does not appear to be
much affected, as it is being efficiently carried on by the muscles of
the opposite side.

The posterior trunk of the inferior maxillary nerve gives off the
auriculo-temporal, gustatory, and inferior dental branches. The
auriculo-temporal embraces the middle meningeal artery between its
two heads of origin, it then turns up behind the condyle of the lower
jaw and beneath the parotid gland, giving off auricular and temporal
branches. The former supply the front part of the pinna and the
meatus, whilst the latter end in the skin of the temple. The auriculo-
temporal also gives twigs to the temporo-maxillary joint and the
parotid gland, and supplies the sensory root to the otic ganglion.

The gustatory nerve descends between the two pteiygoids, across
the superior constrictor, along the side of the tongue and to its tip,
lying just beneath the mucous membrane. It is a nerve of extremely
delicate but common sensation. It is joined in the pterygoid region
by the chorda tympani (p. 66), and upon the hyo-glossus by branches
of the hypo-glossal ; it gives branches to the anterior two-thirds of the

64 The Cranial Nerves

tongue, to the mucous membrane of the neighbouring part of the
mouth, and to the sublingual gland.

When the fifth nerve is paralysed (as also in the case of facial
paralysis, p. 68) the sense of taste on the tip of that side of the tongue
may be lost or impaired.

Division of the gustatory (or lingual] nerve may be expedient
in the case of intractable neuralgia in the anterior part of the
tongue, as in lingual cancer. The nerve runs between the internal
pterygoid and the ramus of the jaw, and then lies just beneath the
mucous membrane of the mouth. Its exact position may readily be
made out in one's own mouth by passing the tip of the index-finger
downwards and backwards from the last molar tooth, and thrusting it
outwards into the hollow beneath the prominent alveolar ridge ; when
the nerve is thus pressed against the bone the sensation is unmistak-
able. To make sure of dividing the nerve, it is best to take out about
half an inch of it, which is easily done when the mouth is held wide
open by a gag and the tongue is pressed down ; the mucous mem-
brane having been raised from over the hollow below the alveolar
process, the nerve may be hooked up by an aneurysm-needle and de-
liberately dealt with.

The inferior dental nerve descends between the lateral ligament
and the ramus of the jaw to the canal in the inferior maxilla. At its
origin it contains some motor filaments which it sends off to the mylo-
hyoid and the anterior belly of the digastric ; then, in the substance of
the maxilla, it supplies twigs to the teeth, and gives off the mental
branch, which emerges by the foramen under cover of the depressor
anguli oris. This branch is distributed to the mucous membrane and
s]f.m of the lower lip, and to the chin.

The mental foramen is below the second bicuspid, in the vertical
line of the supra- and infra-orbital foramina.

Irritation of filaments of the nerve in the pulp of some carious
tooth may give rise to disturbance in areas which are in anatomical
association : as, for instance, upon the front of the pinna, or in the ex-
ternal auditory meatus ; and thus it happens that the extraction of a
carious tooth may at once put an end to * ear-ache ' and ' face-ache.'

The application of intense cold (produced by the ether-spray) in
the region of the external auditory meatus has such a numbing effect
upon the trunk of the nerve that under its influence a tooth may be
extracted from the lower jaw without the usual pain.

Stretching or resection of part of the inferior dental nerve may be
needed in certain cases of inveterate neuralgia of the lower teeth. The
jaws being widely separated by a gag, a vertical incision is made
through the mucous membrane of the mouth, above and in front of
the insertion of the internal pterygoid (p. 8). Then, with a raspatory,
the mucous membrane is freely raised, and the nerve is found entering
the dental foramen. Unless the nerve be separated from the acconv

Facial Nerve 65

panying artery, free haemorrhage may occur if resection is being re-
sorted to.

The mental nerve, emerging through the foramen in the body of
the jaw in a line with the root of the second bicuspid, may be found
by an incision through the integument (the exact position of the fora-
men having been first determined by means of a sharp probe) and
through fibres of the depressor anguli oris and labii inferioris. Another
way of reaching the nerve is by freely incising the mucous membrane
as it is reflected from the lower jaw to the back of the lip, and working
carefully down with a director in the region below the second bicuspid.

When the fifth nerve is paralysed, and the patient puts a cup to his
lips, ' he feels only half of it ; it seems to him exactly as though it were
broken.' (Fagge.)

No. 6. — The abducens (because it supplies the external rectus) arises
in the floor of the fourth ventricle, and emerges between the anterior
pyramid and pons. It passes through the inner part of the cavernous
sinus, lying on the outer side of the carotid artery, and, entering the
orbit by the sphenoidal fissure, ends on the inner surface of the ex-
ternal rectus. At its origin this nerve does not decussate with its
fellow across the median line, as the third does, because the two
external recti have no experience of working in concert. When the
nerve is paralysed the eye-ball is drawn inwards, and the patient sees
a double image, because the yellow spots cannot both be placed
in focus unless the head be turned and tilted to make up for the
error (see p. 80). As he cannot abduct the eye-ball, he turns his
head. And in this, as in every other case of ocular paralysis which is
the result of cerebral lesion, the patient apologetically turns his head
towards the side of the cerebral lesion — he keeps looking towards the
cerebral damage, as it were.

No. 7. — The facial nerve arises, together with the sixth, from a
nucleus in the floor of the fourth ventricle, and leaves the medulla just
below the pons, through the groove between the olive and restiform.
It enters the internal auditory meatus with, but above, the auditory
nerve, and, passing into the aqueductus Fallopii, leaves the petrous
bone by the stylo-mastoid foramen. It then passes through the
parotid gland and divides into the temporo-facial and cervico-facial
trunks, which, by secondary divisions, form the pes anserinus.

Some of the fibres of origin of the two facial nerves decussate across
the middle line, and thus it happens that with a lateral pontine lesion
there may be paralysis upon the corresponding or upon the opposite
side of the face ; hemiplegia, moreover, may exist with facial paralysis
of the same or of the opposite side. The decussation takes place in
the pons, at the level of the apparent origin of the fifth pair. A lesion
anterior to this causes facial paralysis on the same side as the hemi-
plegia, that is, upon the opposite side to that of the lesion. But if
the lesion be behind this level ' crossed paralysis ' is produced— that

66 The Cranial Nerves

is to say, there is paralysis of the face muscles upon the side of the
lesion, with hemiplegia upon the opposite side of the body.

When cerebral haemorrhage, for instance, occurs within the anterior
part of the pons, the decussating fibres of the facial nerve are damaged,
together with fibres from the motor area which are passing down to
the crossing of the pyramids, and so facial paralysis is, like the hemi-
plegia, upon the side of the body opposite to the lesion. But when
the clot is formed in the lower part of the pons, the facial nerve upon
the side of the lesion is paralysed, whilst hemiplegia still occurs upon
the opposite side. ' Such clinical facts as these indicate that some of
the deep fibres of the facial nerve pass upward into the cerebrum.'
(Ranney.) Before the function of the portio dura was understood, Sir
Charles Bell once divided it for facial neuralgia ; its function was
thus at once manifested ; and, out of compliment to this experimental
physiologist, the peripheral effect of lesion of this nerve is called
Bell's paralysis.

In its course through the petrous bone the nerve gives off the
great petrosal branch, which runs in the Vidian as the motor root to
Meckel's ganglion, and so to the muscles of the soft palate. The facial
also gives off the chorda tympani, which passes across the upper part
of the membrana to leave the tympanic cavity by the Glaserian fissure.
This slender branch supplies the transverse lingualis, which narrows
and protrudes its own side of the tongue. When, therefore, the facial
nerve is damaged in the aqueduct, that side of the tongue cannot be
narrowed, and consequently, when, in protruding the tongue, the
opposite lingualis contracts, the paralysed side cannot advance in due
proportion, and so the tip of the tongue is pulled over to that side.

The chorda eventually joins the gustatoiy nerve (p. 63), and is
closely concerned with the sense of taste, perhaps through its associa-
tion with the submaxillary ganglion and gland.

Outside the stylo-mastoid foramen the facial nerve gives off the
posterior auricular branch for the hindermost of the muscles of facial
expression, namely the posterior belly of the occipito-frontalis and the
retraherts aurem. The main trunk then supplies the posterior belly of
the digastric and the stylo-hyoid.

The temporo-facial division, emerging from the parotid gland,
crosses the external carotid artery and breaks up into temporal, malar,
and infra-orbital branches. The temporal branches supply the attra-
hens and attollens aurem and the anterior belly of the occipito-frontalis,
the upper part of the orbicularis palpebrarum, and the corrugator. The
malar branches also send twigs to the orbicularis, and the infra-
orbital supply the buccinator and orbicularis oris, and the neighbour-
ing muscles of lips and nostrils.

The cervico-facial division breaks up into buccal and supra- and
infra-maxillary branches. The buccal branches cross the masseter to
supply the buccinator and orbicularis.

Facial Paralysis fy

The supra-maxillary nerve takes its name from its position upon
the lower jaw, and must not be confused with the superior maxillary
nerve, the large sensory trunk which emerges from the infra-orbital
foramen (p. 62). The supra-maxillary branches supply the platysma
and the small muscles of expression connected with the lower lip and
chin.

The infra-maxillary nerve is so called because it lies below the
jaw ; it supplies the platysma and joins with the superficial cervical
nerve (v. p. 145). It must
not be confused with the
inferior maxillary nerve

(P- 63).

When the facial
nerve is paralysed, as

in fracture of the petrous
bone, all the muscles of
expression on that side
of the face are paralysed,
and the wrinkles and
furrows of the skin are
smoothed out.

The forehead on that
side can be thrown into
neither horizontal (occi-
pito-frontalis) nor trans-
verse (corrugator super-
cilii) creases, and the
patient cannot close his

eye (orbicularis palpe- Branches of facUl nerve :-i, to occip. front ; a,post*uri-
brarum). I hllS even cular ; 3^ temporal brs. ; 4, malar brs. ; 5, infra-orb.

il ; 7, supra-maxillary ; " ' "

during sleep the cornea

remains exposed ; and

so, in such a case, to prevent inflammation, the lids had better be kept

approximated by strips of adhesive plaster. But when the paralysis

is of cerebral origin the orbicularis escapes, owing to the existence of

certain commissural fibres.

The tensor tarsi — the muscle which holds the puncta lachrymalia
against the eye-ball—being powerless, the tears fall over on to the cheek,
and, as the orbicularis can no longer wash them inwards, the eye-ball
becomes dry and irritable, though this may not occur if the patient
keeps it clean and moist by dragging down the lid with his finger.
The mouth, which is naturally balanced in the middle line, is now
dragged by the unopposed muscles over to the sound side of the
median line, as is particularly noticed when the patient laughs, for then
the muscles contract with greater energy.

On account of paralysis of the orbicularis oris, the saliva dribbles

68 The Cranial Nerves

out of the flaccid corner of the mouth and he cannot arrange his lips
for whistling (an excellent test) ; trying if he can spit is also a useful
though less delicate test. Articulation is impaired, and the flabby
cheek is puffed out with every deep expiration. Because the bucci-
nator cannot contract, food lodges in the cheek, from which the patient
has to clear it by his finger. He has no power to draw down that
corner of the mouth by the action of the depressor anguli oris and
platysma. Loud noises become distressing because of paralysis of
the muscles of the middle ear.

The soft palate and uvula are dragged from the affected side when
the nerve is damaged before it gives off the petrosal branches ; and,
the chorda tympani also being functionless, the tip of the tongue, as
already noted (p. 66), is drawn to the paralysed side, though not to
such an extent as may appear at first sight, the defect being exag-
gerated by the mouth being already drawn from the affected side.
The exact amount of the deflection of the tip of the tongue to-
wards the paralysed side is to be estimated by looking at the line
between the central incisors. The effect of the paralysis upon the
chorda tympani is often to pervert the taste. When the lesion is
below the coming off of the great petrosal the muscles of the soft palate
and uvula are not affected.

Partial facial paralysis is generally due to slight haemorrhage at the
origin of the nerve, and when associated with rigid arteries, hypertro-
phied left ventricle, and retinal degeneration, is sure evidence of a
coming haemorrhagic storm.

Facial paralysis is not always due to lesion at the root or of the
trunk of the nerve ; it may be the result of exposure near an open
window in a railway journey, or to a cold wind.

Stretching. — The facial, being a motor nerve, cannot be concerned
in facial neuralgia, but there are certain and obscure cases of facial
spasm in which it may be expedient to give the main trunk a specu-
lative jerk or two. In one such I saw my colleague Mr. Pye, operate
by a two-inch incision along the front of the mastoid process and the
topmost part of the sterno-mastoid, dividing skin, superficial fascia,
platysma, and deep fascia, layer by layer. Then the sterno-mastoid
was relaxed and drawn outwards, and, the parotid being drawn upwards,
the posterior belly of the digastric came into view ; along its anterior
border, and hurrying to the parotid gland, was the nerve, which was
then picked up and stretched by an aneurysm needle.

No. 8 is the auditory nerve ; it arises in the floor of the fourth
ventricle, and, emerging by the groove between the olive and restiform,
passes down the internal auditory meatus beneath the facial. At the
bottom of the meatus it breaks up into branches which are spread out
in the cochlea, vestibule, and semi-circular canals.

No. 9, the fflosso-pharyngreal, is distributed, as its name implies,
to the tongue and pharynx. It is a sensory nerve, but those fibres of

Pneumogastric Nerve 69

it which supply the hinder part of the tongue are concerned in the
special sense of taste.

Arising in the fourth ventricle, the nerve appears between the
olive and restiform, and leaves the skull by the jugular foramen. It
sends a branch (Jacobson's) to the tympanic plexus, and it enters into
the formation of the pharyngeal plexus (p. 138) by passing downwards
and forwards between the external and internal carotids. It gives
branches also to the stylo-pharyngeus and the tonsil.

No. 10, the pneumog-astric, or, as it might also be called, cardio-
pneumogastric, takes a long and wandering (vagus} course, and holds
the medulla in direct association with pharynx and oesophagus ; the
larynx, trachea, bronchi, and lungs ; the heart ; the cervical, thoracic,
and abdominal sympathetics ; and with the stomach, liver, and spleen.

It arises from the fourth ventricle and emerges between the olive
and restiform, and, having left the skull by the jugular foramen, runs
straight down, beneath and between the internal carotid artery and the
jugular vein, and then between the vein and the common carotid artery
(p. 24 ). Arrived at the root of the neck, it travels onward to the back
of the root of the lung, passing on the right side over the beginning of
the subclavian artery and behind the vein. On the left it descends
between the common carotid and subclavian arteries, behind the left
innominate vein, and over the transverse part of the aortic arch.

At the back of the root of the lung each nerve spreads out into the
posterior pulmonary plexus, from which fibres pass into the lung, in
company with sympathetic twigs.

From the back of the roots of the lungs the remnants of the vagi
are gathered up into two cords which descend upon the oesophagus
(plexus gulce], those of the left side passing, for the most part, on to
the front of the stomach, and those of the right on to the back of that
viscus. The former branches communicate with the hepatic plexus,
and the latter with the splenic and solar plexus.

As the vagus leaves the skull it gives off the auricular, or Arnolds
nerve, which enters the petrous bone near the jugular fossa, and leaves
it by the fissure between the external auditory meatus and the mastoid
process ; it supplies the skin behind the pinna, and the lining of the
auditory meatus. It is generally supposed that the stimulation of this
sensory filament by wetting the skin with cold water after a heavy
dinner stimulates the pneumogastric to renewed efforts at digestion.

Ear-cougrb. — An important fact in connection with Arnold's nerve
is that irritation of its branches, as by a plug of wax, or any foreign
body in the meatus, may set up uncontrollable cough. The probable
explanation is that there is a communication between this twig and
the filaments of the superior laryngeal branch.

Outside the skull the pneumogastric nerve receives the accessory
part of the spinal accessory. Some of the motor filaments which
are thus obtained pass out for the pharyngeal plexus, and others

7O The Cranial Nerves

leave by the superior laryngeal nerve. This important branch runs
downwards and forwards beneath the internal carotid, and then divides
into an external and an internal laryngeal branch ; the former supplies
the crico-thyroid and the inferior constrictor, whilst the internal branch
passes though the thyro-hyoid membrane to supply the arytenoideus
and the mucous membrane of the larynx.

Irritation of the superior laryngeal nerve in weakly children sets up
reflex spasm of the muscles of the glottis, and is thus concerned in
laryngeal asthma or laryngisimts stridulus.

The recurrent laryngreal nerve winds round the first part of the
subclavian artery on the right side, and the transverse aorta on the
left, and, ascending behind the common carotid and into the groove
between the trachea and oesophagus, enters the lower and back part
of the larynx. It gives off cardiac, cesophageal, and tracheal branches,
and supplies all the muscles of the larynx except the crico-thyroid.

Pressure upon this nerve by an aortic, innominate, subclavian, or
carotid aneurysm causes spasmodic contraction of the laryngeal
muscles, and sets up a dry and suggestive cough. Sometimes the
nerve is ' caught ' in epithelioma of the oesophagus.

When one recurrent laryngeal nerve is paralysed the vocal cord of
that side does not move ; the voice is ' uncertain/ or it may be entirely
lost, but the tidal air flows as usual. The abductor of the vocal
cord is especially affected, and in due course ' contracture ' occurs in
the unopposed adductor, the cord being held in a useful position for
phonation. Even when both nerves are paralysed there is no shortness
of breath, but the voice is then completely lost.

In their course through the neck and through the thorax the vagi
give off cardiac branches, which join with twigs of the left recurrent
laryngeal to end in the aortic and cardiac plexuses.

No. ii. — The spinal accessory consists of an ' accessory ' part
(which arises like the vagus and eventually blends with that nerve) and
of a ' spinal ' part. The latter arises from the anterior grey cornu of
the cord by several filaments, and, emerging from the lateral tract,
ascends between the ligamentum denticulatum and the posterior roots
of the five upper cervical nerves. It enters the skull by the foramen
magnum, and leaves again with the vagus. It then passes downwards
and backwards through the sterno-mastoid, which, with the help of
the second and third cervical nerves, it supplies, and it ends in the
trapezius. These two muscles derive a considerable supply from the
cervical nerves. But probably their chief motor influence comes from
the spinal part of the spinal accessory nerve, in order that there may
be harmonious working between two important muscles of elevation
and fixation of the sternum, clavicle, and scapula, and those of vocalisa-
tion.

That part of the nerve which is ' accessory ' to the vagus conveys
to it the motor filaments for the muscles of vocalisation : so actually

Labio-glossal Paralysis j\

the spinal accessory is the nerve of phonation. As the spinal and the
accessory parts of the eleventh nerve pass through the jugular foramen
they interchange filaments, and thus it is that the sterno-mastoid
and trapezius are in direct association with the muscles of the vocal
cords.

Peripheral or central irritation of the spinal part of the nerve may
cause spasmodic or tonic contraction of the sterno-mastoid and
trapezius ; rhythmic contraction and relaxation of those muscles of the
two sides cause the nodding movement so often seen in old persons —
nodding palsy.

Stretching, or partial resection, of the spinal accessory nerve may
be needed in certain aggravated cases of spasmodic contraction of the
sterno-mastoid. The nerve is sought as it runs beneath the anterior
border of the muscle, previous to piercing it, about two inches below
the mastoid process. The incision is made through skin, platysma,
and fasciae for about three inches along the front of the muscle, down-
ward from the mastoid process. The muscle is then relaxed by rais-
ing the head, and, its anterior border having been drawn outwards, the
nerve is seen entering it.

No. 12. — The hypoglossal is the motor nerve of the tongue; it
arises in the floor of the fourth ventricle, and emerges from the groove
between the anterior pyramid and olive, that is, in the line of the
motor roots of the cervical nerves. It leaves the skull through the
anterior condylar foramen, and descends with the vagus, between the
internal jugular vein and the carotid artery, to the level of the angle
of the jaw, when it passes forwards, over the internal and external
carotids, and over the hyo-glossus; then, sloping upwards beneath the
posterior tendon of the digastric, and under the mylo-hyoid, it ends in
the genio-hyo-glossus. It supplies also the stylo- and hyo-glossus, the
genio-hyoid, and, by a special branch, the thyro-hyoid.

It gives off the descendens hypoglossi (or descendens noni, when the
motor linguae is reckoned as the ninth nerve), which, joined by a com-
municating loop from the second and third cervical nerves, supplies the
depressors of the hyoid bone. This nerve lies upon the sheath of the
common carotid.

When one of the twelfth pair of nerves is paralysed the genio-
hyo-glossus of that side cannot help in the protrusion of the tongue,
which it should do by its posterior fibres ; so that, on the patient try-
ing to put out his tongue, the tip is carried over to the paralysed
side (p. 68). And this paralysed side is weak, flabby, and greatly
wasted.

Duchenne s disease, or glosso-labio-laryngeal, or labio-glosso-pha-
ryngeal paralysis, is the result of disease of that part of the medulla from
which the facial, glosso-pharyngeal, vagus, spinal accessory, and hypo-
glossal nerves arise. Another name for the disease is bulfcar paralysis,
because of the degeneration existing in the bulbar part of the cord.

/ 2 The Cranial Nerves

The compound names so well express the clinical features of the
disease that description is almost superfluous. The lips cannot seize
the solid food, nor prevent the fluids from flowing away, and, as they
are also helpless in vocalisation, speech is gravely affected.

The tongue is either protruded in a weak and trembling manner
or else lies flaccid in the mouth. In the latter case the voice is still
further altered ; and, as neither the tongue within, nor the buccinator
(p. 67) without, can keep solid food between the molar teeth, mastica-
tion is much impaired and the early stage of deglutition weakened.
The facial expression is altered in a characteristic manner.

The pharynx, moreover, cannot grasp such food as is conveyed to
it, and, in feeble attempts at swallowing, the food escapes again into
the mouth and perhaps from between the lips. The larynx being
thrown out of working order, the voice is still further altered and
weakened.

In every case of Duchenne's disease all these nerves are not
equally enfeebled ; the features of the paralysis necessarily vary with
the order in which the nuclei of the nerves are affected (v. p. 56).

THE EYELIDS AND CONJUNCTIVA

The so-called tarsal cartilages are thin plates of fibrous tissue
which form the foundation, or stiffening, of the eyelids. Their extremi-
ties are connected with the nasal process of the superior maxillae
and with the malar bones ; one border is near the edge of the lid, and
the other is attached to the margin of the orbit. The posterior surface
of the upper lid may be examined by turning the lid inside out, over
a probe laid on the outer surface of the lid, along the upper border of
the cartilage, the patient looking down so as to slacken the oculo-pal-
pebral fold of conjunctiva ; the stiff cartilage then holds the lid in the
everted position. The expanded tendon of the levator palpebrae is
inserted over the front of the upper tarsal cartilage.

Superficial to each cartilage is the (striated) orbicularis palpebrarum,
which is separated from the skin by a delicate fascia devoid of fat, and
which, therefore, is readily infiltrated in Bright's disease.

The orbicularis palpebrarum is the sphincter of the lids. It
arises from the inner corner of the orbit, and from the tendo oculi.
From this the pale, but striated, fibres of its palpebral portion pass out-
wards between the skin and the tarsal cartilages. The fibres of the
orbital part of the muscle are darker and coarser, and, like the others,
blend at the outer part of the orbit, where, however, they have no
important connection with bone. And thus it happens that when the
muscle contracts the outer commissure of the lids is drawn inwards,
so that the lachrymal secretion may be washed towards the inner
corner of the orbit and to the puncta lachrymalia. (If you rest your

Conjunctiva 73

finger over the outer end of the lids and then cause the orbicularis to
contract, the inward sweeping action of the muscle is manifest.)

It is supplied by the facial nerve.

The tendo oculi is for mooring the inner ends of the tarsal
cartilages. It is attached to the nasal process of the superior maxilla
anterior to the lachrymal groove, and passes outwards over the front of
the lachrymal sac, giving accessory fibres to the sac. It can easily be
felt when the lids are firmly drawn outwards ; the sac should always
be opened by incising just below the tendon.

Blepbaro-spasm (/SAe^apo, eyelids] is spasmodic contraction of
the orbicularis ; it may be caused by a piece of grit lodged under the
eyelid, in which case a sensory impulse is sent by a twig of the fifth
nerve upon the conjunctiva, which returns from the brain as a reflex
stimulus by palpebral twigs of the seventh ; or it may be caused by
conjunctivitis. When the spasm is inveterate, as it is apt to be in
strumous ophthalmia, it may be expedient to sevey the elliptical fibres
at the outer commissure.

As a result of blepharo-spasm, the free borders of the lids may be
' turned inwards,' entropion (ei>, in ; rporrrj, turn), against the front of the
eye-ball, so that the eyelashes irritate the cornea. This complication
is called trichiasis (0pi£, rpi/cos-, hair), and may demand not only the re-
moval of the eyelashes, but even some operation devised to everting the
edge, for producing, in fact, an artificial ectrophtm (e|, outwards, and
Tponr)) or eversion of the lids. It may be due to the contraction of
a scar of the face, to paralysis of the orbicularis, or to the weakness
of the muscle which is often found in old persons.

The levator palpebrae superioris arises just above the optic
foramen, and runs forwards beneath the roof of the orbit and the
frontal nerve, and above the superior rectus, to be inserted into the
front of the cartilaginous foundation of the upper lid.

It is supplied by the third nerve. The muscle is, as its name
implies, the opponent of the orbicularis palpebrarum, which is the
sphincter of the lids. It is supplied by the third nerve, and the lid con-
sequently droops, ptosis (TTTWO-IS, falling), when that nerve is paralysed.

On the posterior surface of the lids is the delicate mucous membrane,
the conjunctiva, which, reflected thence over the front of the eye-ball,
'joins together' the eyelids and the sclerotic. Like other mucous
membranes, it consists of a basement membrane, with vessels, nerves,
and connective tissue beneath it, and with epithelium on the free
surface.

The epithelium is for the most part columnar, but it gradually
becomes squamous as it approaches the free border of the lids. Over
the front of the cornea the conjunctiva is represented only by the layers
of epithelial cells, the most superficial of which are stratified.

Where it lines the lids it is thick and vascular, and is studded with
papillae, which, under the influence of chronic inflammation, become

74 Eyelids and Conjunctiva

enlarged, constituting the disease known as ' granular lids' So
loosely is the conjunctiva attached over the sclerotic, however, that
large extravasations of blood may occur beneath it. When this is
observed after a fall upon the head the question arises as to the
existence of a fracture extending across the anterior fossa of the base
of the skull, with laceration of the ethmoidal arteries.

At the inner commissure the conjunctiva forms a mucous fold, the
plica semilunaris, the homologue of the horizontal eye-lid of birds,
the membrana nictitans. On the inner side of this is the caruncula
lachrymalis — a collection of sebaceous glands beneath the conjunctiva.

Chronic conjunctivitis is sometimes spoken of as ' weakness of the
eyes ' ; certainly it is often found when vision is imperfect, as the con-
stant effort at accommodation is associated with increased flow of blood
to the orbit, and with lachrymation.

In the case of unhealthy children, the chronic condition may some-
times be successfully dealt with by counter-irritation at the temple or
behind the ear. Such beneficial effect has sometimes been inadver-
tently produced by piercing the lobe of the ear and inserting a ring, with
the inartistic idea of personal adornment, and thus it has come about that
* ear-rings are good for weak eyes.' The late Mr. Critchett told the writer
that some of his first success in practice was due to his having treated
chronic conjunctivitis by a slender seton behind the ear, * so that,' said he,
' friends remarked that my reputation hung on a thread ! '

Sometimes a thick triangular growth of the conjunctiva extends
from near one of the commissures towards the pupils ; it is- called a
pterygium (rrrepvyiov, a little wing), and, passing over the pupil, it ulti-
mately obscures the vision. It may have to be removed by the opera-
tion of transplantation.

The Meibomi an glands are arranged in pearly rows beneath the con-
junctiva, imbedded in the tarsal cartilages ; they can be seen on everting
the lids, and their minute orifices detected near the eye-lashes. Their
sebaceous secretion oozes upon the edges of the lids to lubricate the
cornea and to render it waterproof.

Should secretion be retained in one of the Meibomian follicles, a
small hard tumour is felt in the substance of the lid. It is called a
chalazion (^aXa^a, hail) or tarsal tumour. It is treated by everting
the lid and scooping out the contents of the cyst.

Supplementary sebaceous glands also open at the roots of the eye-
lashes, and, should one of them become inflamed, the condition is
known as hordeolum (hordeum, a barley-corn) or stye.

Supply. — The conjunct! val arteries are derived from the palpebral,
lachrymal, and other branches of the ophthalmic ; the nerves come from
the ophthalmic and infra-orbital parts of the fifth.

Haemorrhages beneath the conjunctiva which occur in an oldish sub-
ject after an attack of coughing or vomiting are suggestive of atheroma,
and sometimes come as warnings of an apoplectic storm.

Lachrymal Abscess 75

THE LACHRYMAL APPARATUS

The lachrymal gland, which is somewhat of the size and shape of
an almond, is lodged in the hollow under the external angular process of
the frontal bone. To reach the front of the globe, the tears have to
pass through the conjunctiva, which they do through half a score of
slender ducts, which open on the inner surface of the upper lid. Part
of the gland descends behind the lid, and its lower border rests over
the superior and external recti, and upon the eye-ball. Being thus
poured upon the upper surface of the globe, the tears fall over the
front of the eye-ball, washing it completely, whilst the contractions of
the orbicularis (p. 72) sweep them constantly inwards, in their course
to the puncta lachrymalia.

Its structure is like that of a salivary gland. It receives its supplies
from special branches of the oph-
thalmic nerve (p. 61) and artery,
and from the sympathetic.

The puncta lachrymalia are
the pin-point openings of the
superior and inferior lachrymal
canals, which lead from the inner
sixth of the margin of the lids to
the lachrymal sac. The punctum
may be seen on a small papilla on
everting the lid.

At first each canal runs for a
slight distance vertically away
from the border of the lid, then it
alters its course and enters the
lachrymal sac. The canal is com-
posed of delicate fibrous tissue, and of mucous membrane lined with
squamous epithelium.

The puncta are kept in position against the giobe of the eye by the
contractions of the small tensor tarsi, which is, really, a deep part of
the orbicularis. It arises from the lachrymal bone, behind the lach-
rymal sac, and passes with the canals to the eye-lids. If the punctum is
displaced it may be necessary to slit up the canal so that the tears
may flow away along the gutter which is then formed.

The lachrymal sac is the upper, dilated end of the nasal duct,
lying in the groove between the nasal process of the superior maxilla
and the lachrymal bone. It has the strong tendo oculi in front and
the tensor tarsi behind, whilst the lachrymal canals enter its external
aspect.

lachrymal abscess is the result of inflammation of the lining of
the sac ; it forms a swelling at the inner corner of the orbit which may

76 Lachrymal Apparatus

have a characteristic, hour-glass shape, on account of its bulging above
and below the tendo oculi, while its middle is constricted by the un-
yielding tendon.

A lachrymal fistula may follow its evacuation ; stricture of the
nasal duct, the result of chronic inflammatory thickening, is generally
associated with the fistula. The treatment of the stricture consists
in slitting up the inferior lachrymal canal, and thus finding an entrance
for a special probe into the sac. Before slitting up the canal, the
lower lid should be drawn firmly outwards so that the canal may be
made straight and direct. False passages may be made by the unscien-
tific use of the probe, through the lachrymal bone and into the ethmoid,
or between the cheek and the maxilla.

The nasal duct, £ in. long, descends in the groove in the maxillary
and the lachrymal bones, and against the inferior turbinated, to open
into the inferior meatus. Its direction is downwards, with a slight in-
clination outwards and backwards ; it is the unobliterated part of the
orbital fissure (v. p. 123) which ran from the side of the fronto-nasal
process through the mouth and into the orbit.

The sac and the duct are composed of fibrous tissue, and have a
mucous lining which is carpeted with columnar ciliated epithelium, like
that of the nose.

THE ORBIT

The long axes of the orbits diverge considerably, so that the field
of vision may be extended laterally. The inner wall is straight from
before backwards, but the outer wall runs outwards as well as forwards ;
this slope is taken advantage of in enucleation of the eye-ball, the curved
scissors being passed along the outer wall so as more easily to divide
the optic nerve.

Boundaries. — The floor is formed of the superior maxilla and the
malar and palate bones ; the roof by the frontal and the lesser wing
of the sphenoid.

The inner wall is composed of the nasal process of the maxilla,
the internal angular process of the frontal, lachrymal, os planum of
ethmoid, and body of sphenoid ; and the outer wall of the malar, the
external angular process of the frontal, and the great wing of the
sphenoid.

The roof is extremely thin, and if a child fall with a pencil upright
in his hand the point may be driven through into the anterior lobe of
the brain. In chronic hydrocephalus (p. 56) the fluid within the lateral
ventricles pushes down the frontal lobes and the roofs of the orbits
until they bulge into the orbits and thrust forwards the eye-balls. The
inner wall is also thin, and in roughly attempting to introduce a style
into the nasal duct a clumsy manipulator may thrust it into the ethmoid

Periosteum of Orbit jj

bone, and so into the nasal fossa. Below the floor of the orbit is the
antrum, and tumours from that region readily bulge into the orbit. Im-
mediately beneath the floor runs the superior maxillary division of the
fifth nerve (p. 62).

Through the inner part of the floor descends the nasal duct, close
to the outer side of which arises the inferior oblique. On the roof is a
depression, at the outer part, for the lachrymal gland, and at the inner
part is lodged the pulley of the superior oblique.

A large mass of yellow fat fills the back of the orbit, and forms a
soft bed against which the eyeball rests. In phthisis and other wast-
ing diseases this store of hydro-carbons is drawn upon and the eye
becomes sunken.

A periostitis, an erysipelas, or other inflammatory condition of or
about the orbit may spread by direct continuity of tissue through the
optic foramen or the sphenoidal fissure into the interior of the skull,
and there give rise to meningitis or to intracranial suppuration.
In the case, moreover, of septic phlebitis in the ophthalmic vein the
clot may extend into the cavernous sinus and set up fatal thrombosis.

The periosteum of the orbit is continuous through the optic foramen
and the sphenoidal fissure with the dura mater ; and anteriorly it
turns round to spread into the pericranium. As the fibrous offshoot
from the dura mater enters through the optic foramen to line the
orbit it gives a tubular investment along the optic nerve, which,
spreading out upon the sclerotic, is ultimately reflected from the antero-
lateral part of the eye-ball, behind the conjunctiva, to the margin of
the orbit, where it blends with the periosteum. By this arrangement of
the fascia the eye-ball is completely shut off from the back of the orbit.

A point of great surgical interest in connection with these fibrous
layers is that after removal of the superior maxilla (p. 18) the lower
periosteum becomes thickened and strengthened, and forms so useful
a floor to the orbit that there is but little permanent dropping of the
eye-ball ; the double vision which results from the first sinking of the
globe soon passes away.

The capsule of Tenon is that part of the orbital fascia which sur-
rounds the optic nerve and eventually spreads round the eye-ball.
It has already been described as sending a post-conjunctival offshoot
to the periosteum of the orbit, but, in addition, it sends back fibrous
sheaths around the muscles of the eye-ball, which are intimately
joined with their proper fascial investments.

The capsule of Tenon is connected with the sclerotic by delicate
filamentous tissue, and forms a smooth bed in which the globe moves
with absolute freedom. It is lined with endothelium, and is, in reality,
the outer wall of a large lymph-space, like the pleura or peritoneum.
The choroidal lymphatics enter the space around the venae vorticosae,
and the space itself is in communication, under the fibrous sheath of the
optic nerve, with the subdural and subarachnoid areas of the cranium.

78 Orbit

THE 'MUSCLES OF THE ORBIT

The levator palpebras superioris, the four straight muscles, and the
superior oblique one arise around the optic foramen ; the straight
muscles pass forwards, closely applied round the optic nerve, to
their insertion into the sclerotic about a quarter of an inch behind the
cornea. The third nerve supplies the superior, inferior, and internal
recti, the external one being supplied by the sixth. Acting together,
the straight muscles retract the eye-ball, whilst the oblique muscles
draw it forwards.

The external rectus of one eye acts in concert with the internal
rectus of the other.

If the long axis of the orbit were in the straight line with that of
the eye-ball, the superior and inferior recti would simply turn the
cornea upwards or downwards ; but, because these muscles pass for-
wards obliquely to their insertion, that is, in the axis of the orbit, they
turn the cornea slightly inwards as well. The inward inclination
caused by the superior rectus is counteracted by the action of the in-
ferior oblique, and that of the inferior rectus is checked by the superior
oblique.

The superior oblique passes forwards to the upper and inner
part of the orbit, where its slender tendon runs through a fibre-carti-
laginous ring which is lubricated by a delicate synovial membrane.
The tendon then passes downwards, outwards, and backwards, be-
tween the superior rectus and the sclerotic, to be inserted between the
superior and external recti, in the hemisphere of the globe behind the
transverse equator. The supply is from the fourth nerve, which has
been called * patheticus ' on the supposition that it supplied the muscle
which gave a ' pathetic ' turn to the eye-ball. The pulley can be
obscurely felt by thrusting the finger into the inner and upper part of
the orbit.

Chronic serous effusion into the synovial membrane of the pulley
causes a prominent cyst ; it is often seen in those beyond middle
life.

The inferior oblique arises from the superior maxilla just external
to the nasal duct, and, passing obliquely upwards, between the in-
ferior rectus and the floor of the orbit, and then between the sclerotic
and the outer rectus, is inserted just below the superior oblique, behind
the equator of the globe. It is supplied by the third nerve.

The action of the oblique muscles. — If an imaginary pin be
driven vertically through the centre of the globe, movement becomes
possible only in the horizontal plane, and the superior oblique, coming
from the inner side, to be inserted on the outer side of the globe,
behind the transverse axis, or equator, on contracting must draw the
posterior hemisphere inwards and so turn the cornea outwards.

Muscles of Orbit 79

Similarly, the inferior oblique, passing outwards and backwards, also
turns the pupil outwards.

If this imaginary pin be then thrust through the transverse axis of
the globe, the superior oblique, which is inserted behind the pin, coming
from above, turns the pupil downwards, whilst the other, coming from
below, turns it upwards. Thus the oblique muscles work in harmony
in turning the cornea outwards, but in antagonism in the upward and
downward movements.

To turn the cornea downwards it would not do for the inferior
rectus to act alone, or internal strabismus would result ; so the
superior oblique is called on to help the inferior rectus, abducting the
eye-ball at the same time, so as to neutralise the adduction of the
inferior rectus. Thus, the two muscles, acting together, merely turn
the globe downwards.

Conversely, the inferior oblique acts with the superior rectus, the
two muscles merely moving the eye to look upwards.

Thus even a simple movement of the front of the globe is not left
under the control of a single muscle. Inversion is effected by the in-
ternal rectus, with the superior and inferior recti ; emersion by the
external rectus and the two obliques ; elevation by the superior rectus
and the inferior oblique ; and depression by the inferior rectus, with the
help of the superior oblique.

When the external rectus is paralysed, abduction of the eye-ball is
limited. If the external rectus, say of the right eye, be paralysed,
there may be no double vision as the man looks towards the left, but
when he tries to look to the right, that is, to use his right external
rectus, the right eye-ball remains almost stationary, though the
left internal rectus directs the left eye-ball upon the object ; the result
is double vision. To save himself from this annoyance, the patient
keeps his head constantly in such a position that the useless muscle
may have no demand made upon it ; that is, he keeps his head con-
stantly turned towards the right, making, as it were, the left sterno-
mastoid do the work of the right external rectus.

When the paralysis of the external rectus is only partial, the man
expends an unusual amount of energy in inducing it to act ; but a
certain amount of this energy necessarily passes into the associate
muscle, the opposite internal rectus, which then overacts its part and
produces ' secondary deviation ' of that eye inwards.

When the right internal rectus is paralysed the face is apologeti-
cally turned to the left, so that the visual defect may not occur. So
also, due allowances being made, does it happen when a superior or
inferior rectus fails to act.

When the inferior oblique is paralysed the cornea cannot readily
be turned upwards and outwards ; indeed, it falls somewhat downwards
and inwards, and thus there is double vision. To correct the double
vision, the subject makes up for the defect of the oblique muscle by

8o Orbit

keeping the head in such a position that there is no work for the
inferior oblique to do ; thus he keeps the head tilted upwards and
outwards.

When the superior oblique is paralysed there is deficient abduction
and depression of the cornea, so the head is turned to that side and is
kept somewhat depressed.

Rule. — To enable the practitioner to detect the exact muscular
paralysis by merely looking at the patient's face, Dr. Ranney has
given this formula : ' The head is so deflected that the chin is carried
in a direction corresponding to the action of the affected muscle.'

Strabismus (squint) is that condition in which the visual axes are
not parallel. One eye or both eyes may be at fault. The commonest
form is that in which the axes are directed towards the nose— con-
vergent squint,

Upon the retina of the eye which deviates inwards the object falls
to the inner side of the yellow spot, and double vision is produced,
which, however, the person is able to educate himself to disregard.

To detect the squinting eye, the tip of the finger is held about
eighteen inches in front of the eyes. One eye promptly fixes on to it ;
the other wanders. Then a piece of ground glass is placed in front of
the eye which watched the object, and the wandering eye after some
hesitation becomes directed on the object. Then, on the observer
looking through the dull glass, the original working eye is found adrift.

As a rule, the subject of convergent strabismus has that congenital
defect — a shortness, it may be — of the eye- ball by which rays are not
brought to a focus until they have passed beyond the yellow spot.
Therefore his ciliary muscle has to struggle in a forced effort at ac-
commodation, so that the rays may be duly focussed. But accommo-
dation is closely associated with convergence (p. 58), and so the child in
due course has his eye-balls adducted. Thus the frequent occurrence
of convergent strabismus is fully accounted for.

With double convergent squint the object must fall to the inner
side of the yellow spot in both eyes, but the child acquires the art of
moving his head and arranging his eye-balls so that he can depend on
the image falling correctly on one eye — which, in due time, becomes
the ' working eye ' ; moreover, he at last takes no notice of the image
in the other eye. Thus, he is believed to squint with one eye only.
If the 'working eye' be covered, and he focus the object with the
' wandering eye,' which he can quite well do, and the ' working eye ' be
then uncovered, it is found to squint ; but it promptly turns on to the
object, as is its custom, and allows the other eye to get adrift again.

The treatment of convergent squint. — If the deviation be caused by
hypermetropia (p. 86) it will yield in due course to convex glasses. But if
the defect be permanent, subconjunctival tenotomy of the internal rectus
or recti is demanded.

The operation.— The lids having been fixed apart by the speculum,

Ophthalmic Artery Si

a fold of conjunctiva is pinched up, midway between the cornea and
the caruncle, and is divided with the scissors, the capsule of Tenon
being also opened. The tendon is then caught up by a blunt hook
and divided. Unless the capsule of Tenon be opened, the rectus
cannot be effectually dealt with. If after the operation the external
rectus overact its part, its tendon will also require division.

The ophthalmic artery is given off from the internal carotid, and
enters the orbit through the optic foramen, to the outer side of the
optic nerve. It then crosses the optic nerve, beneath the superior
rectus, to reach the inner wall of the orbit, and it eventually divides
into the nasal and frontal arteries near the lachrymal bone.

Branches. — The lachry mal runs above the external rectus, and ends
in twigs for the lachrymal gland and for the eyelids (the latter branches
anastomose with the palpebrals). From it some emissary branches
pass through the malar bone into the temporal fossa.

The arteria centralis retince imbeds itself in the optic nerve and
enters the eye-ball at the * blind spot.5

The supra-orbital emerges through the foramen of that name,
supplying the eyelid and the forehead, and anastomoses with the
superficial temporal artery.

The posterior ciliary branches pierce the sclerotic around the
optic nerve, and pass to the choroid ; but on either side of the nerve
one of them (long ciliary) runs on to pass between the sclerotic and
choroid to the ciliary muscle and iris.

The anterior ciliary are derived irregularly from the muscular
branches ; ' they form a vascular ring beneath the conjunctiva at the
fore-part of the eye-ball, and then pierce the sclerotic within a line or
two of the margin of the cornea,' having formed an interesting and
important anastomosis with the subconjunctival vessels.

The anterior ethmoidal artery passes with the nasal nerve through
the anterior ethmoidal foramen, into the anterior fossa of the skull,
where it gives off anterior meningeal branches to the dura mater, and
twigs through to the ethmoid cells and to the nasal fossa. The pos-
terior ethmoidal artery is smaller, and ends in the posterior ethmoidal
cells and in the nose. The ethmoidal arteries may be torn across in
fracture of the anterior fossa of the skull, and may cause suggestive
bleeding from the nose, or beneath the conjunctiva.

Two small palpebral branches are given off near the front of
the orbit. They supply the conjunctiva and the lachrymal sac, and
then run outwards beneath the orbicularis to anastomose with the
lachrymal.

The nasal artery ramifies at the root of the nose, anastomosing
with the angular branch of the facial, and so completes a link between
the internal and external carotids.

T\vt frontal artery turns on to the forehead near the root of the nose
where it anastomoses with its fellow of the opposite side.

Enucleation of the eye-ball. — The eye-lids are fixed asunder, and
the conjunctiva is opened near the cornea, and it, together with the
capsule of Tenon, is snipped with the scissors close to the cornea.
The straight muscles are then caught up by the strabismus hook and
severed, and the globe is pulled forwards. The scissors are then
passed along the outer, the oblique, wall of the orbit, and the optic
nerve is divided. Lastly, the attachments of the oblique muscles
and the ciliary vessels and nerves, and some loose connective tissue,
are divided.

Bleeding is checked by firmly bandaging into and over the orbit
a wrung-out sponge. The hard walls of the orbit usually render the
treatment of haemorrhage by plugging efficient. But, if the disease for
which the operation was performed were a tumour of extreme vascu-
larity, pressure may absolutely fail to arrest the bleeding. In a case
of this sort, in which I saw Mr. Richardson Cross, of Bristol, operate,
he had no alternative but to tie the common carotid, and with an
excellent result.

The ophthalmic vein begins in tributaries corresponding to the
branches of the ophthalmic artery, and slowly pours its contents
through the sphenoidal fissure into the cavernous sinus (p. 40).
Pressure upon the vein or upon the cavernous sinus by an inflamma-
tory deposit or a growth near the apex of the orbit delays the venous
return and causes distension of the tributaries of the vessel, intra-
ocular-injection, and a ' choking ' of the optic disc. Thus the condition
of the disc in the case of a supposed tumour of the base of the brain may
afford valuable information. But, though the pressure upon the vein
may be extreme, there may be no excessive injection if the condition
have come on slowly, as the facial vein communicates very freely with
the ophthalmic and relieves the intra-ocular pressure.

The nerves of the orbit are the optic ; third ; fourth ; ophthalmic
division of fifth ; sixth ; the temporo-malar branch of the second divi-
sion of the fifth, and the sympathetic.

THE EYE-BALL.

Five-sixths of the vascular and nervous layers of the eye-ball are
enclosed within a tough and opaque fibrous capsule, the sclerotic
(o-K\r)pos, hard, tough), which is directly continuous in front with the
cornea. It is strongest posteriorly, and it is strong again in front after
receiving the insertion of the straight muscles ; the intermediate part
is that which is most likely to yield to injury. It is covered in front
by the conjunctiva, and in the rest of its extent by the flattened epi-
thelium which lines the lymph-space in front of the capsule of Tenon.
Its inner surface is stained by the lamina fusca (fuscus, swarthy), the
delicate tissue which connects it with the choroid, across an inter-
mediate lymph -space.

Cornea; Arcus Senilis 83

The strands of the optic nerve riddle the sclerotic ^ in. into the nasal
side of the axis at the lamina cribrosa, at the centre of which is a
conspicuous opening, \heporus opticus,\>y which the arteria centralis
reaches the retina.

Although the sclerotic is extremely strong, nevertheless, as the
result of long-continued inflammation and intra-ocular pressure, the
choroid stretches and bulges through it under the name of staphyloma,
from the resemblance of the protrusion to a bunch of grapes (o-ra^uA??).

The cornea, the transparent part of the fibrous envelope of the
eye-ball, stands out like the convex glass in the front of a watch-case.
It is continuous peripherally with the sclerotic, by which it is some-
what overlapped. It is on account of this overlapping that in the
operation for cataract the surgeon makes his incision through the
sclerotic just beyond the cornea. As a matter of fact he divides the
bevelled edges of both sclerotic and cornea. Some operators, however,
make the incision entirely through the uncovered part of the cornea.

Sometimes a degenerative (fatty ?) change occurs at the periphery
of the cornea, rendering it white and opaque. As it is chiefly met
with in old persons, it is termed arcus senilis.

Structure. — The cornea consists of a central, thick fibrous layer,
which is covered in front by several layers of the epithelium of the
conjunctiva, and behind by a homogeneous elastic lamella, at the back
of which is the epithelium of the anterior chamber.

The fibrous foundation consists of about sixty lamellae connected
by a transparent cement ; in this cement delicate lymph channels
run, by which the nutrition of the cornea is carried on.

The nerves, represented only by the axis cylinders, come from the
ciliary branches, and pass between the lamellae. The cornea receives
no blood-vessels, but just beyond its periphery is an important circle
of conjunctival vessels which are engorged in corneitis or keratitis
(cornu, Kepas, horn, lantern ; and tils}. But, when keratitis advances
to ulceration, a branch of a ciliary or conjunctival artery may pass
boldly over the cornea to it. If the ulcer extend into the substance of
the cornea it may ultimately traverse the elastic and the endothelial
layer, and involve the escape of the aqueous humour. The pupillary
border of the iris, escaping with the stream, may protrude upon the
surface and there become glued by plastic effusion — synechia anterior
(a-wexysi a keeping together}. If the perforation be extensive, even
the lens and the vitreous may escape.

The cicatricial patch which eventually makes the site of an ulcer
may look like a little puff of smoke (nebula} upon the clear cornea ;
but if it be pearly white (Aeu*os) it is called leucoma. A central
leucoma blinds a most important area of the retina, and compels the
surgeon to let light through an artificial pupil (p. 88). After this
operation the white patch may be tattooed with a fine needle and
Indian ink, and so rendered unnoticeable.

G 2

84 Orbit

In the treatment of corneal ulcer atropine should be used, so that,
the pupil being dilated, the border of the iris may be unlikely to
prolapse. Then, to diminish the risk of the aqueous bursting through
the elastic layer, eserine must be used ; or paracentesis of the anterior
chamber may even be expedient. This operation is performed by intro-
ducing a slender blade through the sclero-corneal margin, taking
care that it does not pass between the layers of the cornea, and that,
in withdrawing it, the iris do not escape with the aqueous.

In the case of a perforation of the central part of the cornea,
atropine should be used, so that the pupillary border of the iris may
be secured against collapse. But if the wound be near the periphery
the pupil should be made to contract by eserene. If, however, a piece
of the iris be already prolapsed, and it be found impossible to return
it, it must be cut off flush with the cornea, the stump being tempted
to return by the use of atropine, or eserene, as the case may be.

With interstitial keratitis, which is often the result of inherited
syphilis, effusion takes place between the layers of the cornea, spoiling
its transparency, and giving it the appearance of ground glass.

If inflammation run on to the formation of pus between the layers,
and the corneal abscess be not promptly evacuated, it may cause
perforation. Sometimes the inflammation is attended with separation
of the lamellae, so that the pus sinks to their lowest part, where it forms
a collection, the form, size, and tint of which are like the little white
crescent at the root of the nail (ow£), and is therefore called onyx.

Similarly pus in the anterior chamber forms a small,, crescentic
abscess, but this may be distinguished from onyx by its altering its
position as the head is inclined to one side. The pus must be let out
by paracentesis.

The cornea is the most important of the refracting media, refraction
being the effect produced on rays of light passing from a rarer to a
denser medium. Should it be too convex— a somewhat frequent con-
genital defect— it overacts its part, and rays are brought to a focus before
they reach the retina. They have, therefore, to be somewhat scattered
before they reach the cornea by biconcave lenses. (Myopia, p. 86.)

On the other hand, should the cornea be abnormally flat, the antero-
posterior axis of the eye-ball is too short, and the rays have to be
collected, somewhat before reaching the cornea, by the aid of convex
glasses. (Hypermetropia, p. 86.)

If the curvature of the cornea be irregular, either in the vertical,
horizontal, or oblique diameter, the rays come unevenly to a focus,
some of them missing their mark, the error being called astigmatism
(a, priv., ort'y/Lia, mark}. Permanent unevenness with a resulting astig-
matism is more apt to follow the extraction of a cataract when the
incision is made through the cornea than when made through the
corneo-scleral tissue.

Sometimes the cornea grows thin and prominent, conical — it is not

A ccommodation 8 5

known why ; it is not from intra-ocular pressure, for the signs of that
affection are wanting. The earliest symptom is astigmatism.

The choroid is connected with the sclerotic by vessels and nerves,
and by delicate fibres which pass across the intervening lymph-space.
It is chiefly composed of blood-vessels, with pigment cells for absorbing
the diffused rays of light. The external set of vessels are the ciliary
arteries, and the venae vorticosas— - tributaries of the ophthalmic vein ;
the inner coat being composed of an extremely fine network of capil-
laries.

The ciliary processes, sixty or eighty in number, are continuous
posteriorly with the choroid, and intervene as a vascular, erectile fringe
between the ciliary muscle and the circumference of the lens. In
front they blend with the periphery of the iris. Their blood supply
is from the vessels of the choroid, and from the anterior ciliary
arteries.

The ciliary muscle is a narrow circle of unstriped fibres which,
arising from the line of junction of the sclerotic and cornea, pass
backwards to be inserted into the neighbouring part of the choroid.

Emmetropic (sound) eye ; parallel rays, a, a, come to focus on retina at b ; divergent rays, c,
would meet at focus, d, behind retina, but ' accommodation ' brings them to a focus at b.

(DlXON.)

Its action is to pull on the ciliary processes, and so to slacken the
suspensory ligament and the capsule of the lens, in order that the
elastic lens may again expand, and its convexity may be thus in-
creased for viewing near objects. Together with the other muscles
of accommodation, the internal, superior, and inferior recti, and the
sphincter fibres of the pupil, the ciliary muscle is under the control
of the third nerve.

The muscular act is known as 'accommodation5; it is associated
with contraction of the pupil, in order that the rays may pass through
the most convex, refracting part of the lens only. As the individual
can watch distant objects for a long while without tiring, his defect is
spoken of as ' long-sightedness.' But when reading small print his
eyes become bloodshot and tired, the fatigue of the ciliary muscle ex-
pressing itself, perhaps, as ' headache.'

In the case of the person who is born with the antero-posterior axis
too short, the life of the ciliary muscle is one constant struggle to collect
and focus the divergent rays. It frequently breaks down in the task

86 The Eye

after a long and enfeebling illness, such as scarlet fever, and then, for
the first time, it may be discovered that the person is hyperinetropic.

Myopic eye : axis too long ; parallel rays, a, a, brought to focus at b before reaching retina,
and eventually giving blurred image at b', b1 ; concave glass needed. (DixoN.)

With advancing age the power of accommodation naturally dimi-
nishes, whilst, at the same time, the lens grows flatter, so that the

Hypermetropic eye : axis too short ; parallel rays, a, «, tending to a focus at b, form circles
of dispersion on retina at b', b', but are brought to proper focus by the convex glass.

(DlXON.)

old man (Trpfo-fivs) is almost sure to be hypermetropic. "But, as the
loss of accommodation in his case is the result of age, and nojt of a con-
genital defect, it is called presbyopia.

Reference is made elsewhere (p. 58) to the fact that contraction
of the ciliary muscle is constantly associated with that of the internal
rectus — both muscles being supplied by the third nerve — and so it
comes about that the hypermetropic child who triumphs over the
defective depth of his eye-ball by a course of ciliary athletics is apt
to develop a convergent squint. It would, indeed, be a grave error to
perform tenotomy in such a case ; the child should be treated by convex
lenses.

In due course the myopic man finds such difficulty in securing bin-
ocular vision of near objects that he gets into the habit of using one
eye at a time.

Mr. Juler ' gives an excellent account of the anatomy of near-
sightedness — myopia (/uvco, cfose, o>^, eye — from the habit which myopic
people have of partly ' closing the eyes ' for distant vision), the defect
in which the eye-ball is too long, rays of light being brought to a focus
before the proper time. The defect usually comes on in childhood,
and is due to deficient strength in the ocular tunics, especially when
the child is busied with fine work, and in a bad light; he attempts to
obtain larger retinal images by keeping his head close down to

1 Ophthalmic Science and Practice, 1884, p. 333.

Myopia 87

the book ; then, that he may have binocular vision, the internal, the
superior, and inferior recti must be in constant contraction. This
causes the posterior, and unsupported, part of the feeble globe to
bulge, so that its length becomes increased. The strained and stoop-
ing position of the head compresses the cervical veins, and hinders
the return of blood from the eye-ball, which is already in a condition
of too great physiological activity, and in which there is also excessive
intra-ocular secretion.

That there is increased intra-ocular pressure is evidenced by the
fact that the choroid becomes so much flattened and thinned in the
neighbourhood of the optic nerve that a myopic crescent of the sclerotic
can be detected by the ophthalmoscope.

The treatment is first preventive : —

' Not with blinded eyesight poring over miserable books. '

Subsequently it demands the careful adjustment of concave glasses, so
that the rays of light may be rendered more divergent before they reach
the cornea.

The iris is the coloured circular curtain which floats in the
aqueous humour, in front of the lens, its central opening being the
pupil. By its circumference it is attached to the junction of the
sclerotic and cornea, and is continuous behind with the ciliary
processes.

Structure. — The iris is composed of delicate connective tissue,
the filaments being chiefly arranged in a radiating manner. Towards
the anterior part are a group of coloured cells, and behind is a dark
pigmentary layer, the uvea (uva, a bunch of grapes],

The posterior surface of the iris moves upon the front of the lens,
the narrow space between it and the periphery constituting the
posterior chamber of the aqueous. The anterior chamber is the
interval in front of the iris, and, like the posterior chamber, is virtually
a large lymph space.

The muscular tissue consists of a sphincter of plain fibres around
the pupil, and of a radiating series which extend through the width
of the iris. The sphincter set are governed by the third nerve, the
dilator fibres being under the influence of the sympathetic.

Up to the seventh month of foetal life a pupillary membrane occu-
pied the central opening of the iris. Its arteries were derived from
the arteria centralis retinae and from those of the iris. In the eighth
month the membrane begins to clear away from the centre, but occa-
sionally it persists after birth.

The vessels of the iris. — The long ciliary — one running on
either side of the optic nerve — eventually send an arterial circle
around the attached border of the iris, where they anastomose with
the short ciliary. Both sets then send twigs through the iris to make
an anastomotic circle round the pupillary border.

88 The Eye

The netves come from the lenticular ganglion (p. 58), bringing
motor influence from the third for the contraction of the pupil, and
from the sympathetic for its dilatation (p. 59). Thus, irritation of the
retina, the optic nerve, or the third nerve causes contraction of the
pupil, and of the cervical sympathetic, dilatation.

Iritis. — When the iris is inflamed its vessels are so engorged, and
its stroma is so infiltrated with effusion, that its bright colour is
changed to a rusty hue, and it is hindered in its work. Thus the pupil
but slowly contracts, even when a strong light is thrown upon the
retina. A pink circle appears just beyond the border of the cornea,
where the anterior ciliary arteries are bending inwards to the iris, and
are also anastomosing with the conjunctival vessels. This interesting
anastomosis is well shown in vol. ii. of ' Quain's Anatomy' (9th edition,
p. 403), by which it is easy to see that when the ciliary arteries are
engorged a ring of subconjunctival congestion is almost inevitable.

So full are the vessels that serum escapes into the aqueous, and
lymph oozes from the vessels and glues the iris to the capsule of the
lens — synechia posterior (awex*)*, holding together}. These adhesions
may be complete and permanent ; if, however, they be limited to certain
spots, and if, under the influence of atropine, the free part of the pupil-
lary border only be drawn away, the pupil becomes irregular. (The
atropine probably acts by paralysing the third nerve, and so allowing
the sympathetic filaments free play.)

The treatment of iritis demands the immediate application of atro-
pine, so that the sticky border of the pupil may be kept from adher-
ing to the capsule of the lens ; or that, adhesions having formed, they
may, if possible, be stretched and broken. Leeches should be applied
to the temple to relieve the engorgement of the ophthalmic vessels.
And, if the tension and pain persist, the distended anterior chamber
may be treated as the inflamed pericardial lymph-space is treated in
pericarditis, namely, by paracentesis.

When posterior synechia is permanent and universal, the aqueous
humour which is behind the iris can no longer flow through the pupil,
and, moreover, the iris itself is so disturbed by the attachment that
secondary attacks of inflammation are apt to recur (see GLAUCOMA
infra}.

An artificial pupil is, therefore, needed : — An incision is made
in the corneo-sclerotic margin (in the upper part, if possible, so that
the unsightly vertical pupil may be under cover of the lid), and the
pupillary border of the iris is gently dragged out of the wound by
delicate forceps which have been introduced into the anterior chamber ;
the piece of iris is then snipped off.

The lens, biconvex, is suspended in the capsule, just in front of
the vitreous, and behind the iris. Indeed, when the pupil is con-
tracted a considerable extent of the iris is touching the lens, and
even pushed forwards by it ; but during dilatation of the pupil there is

Cataract 89

no part of the iris in contact with the capsule. The posterior surface
of the lens is more convex than the anterior.

Structure. — The lens is composed of transparent fibres which are
connected by a clear cement. Diminution of the transparency con-
stitutes cataract (the etymology of the word is uncertain).

If the opacity be central, the eye is almost blind in a strong light,
as the contracted pupil admits light only over the opacity. Thus the
subject sees best when the pupil is dilated, as towards evening, or in
a fog or shade. In such circumstances the surgeon may content
himself with making an artificial pupil.

The old operation for senile cataract was to dislocate the lens into
the vitreous, where, however, it was apt to set up inflammatory
disease.

In young people an opaque lens is soft, and the surgeon treats it by
passing a needle through the cornea, tearing the capsule, and breaking
the front of the lens, so that the aqueous humour may further soften
it, and promote its complete absorption. In the adult, however, the
hard and opaque lens (which has a strong resemblance to an ' acid
drop ') must be removed by extraction.

In the operation of extraction a preliminary iridectomy is sometimes
done in order that the risk of iritis may be diminished, and also
that there may be a more ready escape for the lens. The anterior
part of the capsule is then lacerated with a ' cystitome,' and the
lens is very gently squeezed out of the sclero-corneal wound by
pressure delicately applied on the sclerotic, below the cornea. If the
cystitome be used with too much force, the lens is apt to be dislocated
into the vitreous ; and if, after the use of the instrument, too much
pressure be made upon the eye-ball the vitreous may be extruded.

The lens being removed, the rays of light meet at a focus very
far behind the retina, so that strong convex glasses are needed (p. 86).

The shape of the lens is regulated by the extremely elastic capsule
which contains it. This elasticity is shown by the way in which, when
it is scratched in the operation of extraction, the scratch becomes a
tear, and the tear a rent, so that the cataractous lens is set free. But
to ensure the ready escape of the lens the cataract should be fully
' ripe ' before its extraction is attempted, otherwise its escape may be
associated with that disagreeable phenomenon, the escape of the
vitreous. Moreover, if some of the * unripe ' cortical part of the lens
be left adhering to the capsule, it may in time become opaque, and
entail further operation for its removal.

The vitreous body forms a transparent mould for the eye-ball,
the retina being spread over the greater part of its circumference, and
the lens being supported by it in front. Probably there is running
throughout it a delicate reticular structure ; it also contains corpus-
cular elements which usually float unobserved, but which, under
certain conditions, can throw shadows upon the retina like gnats—

The Eye

muscce volitantes. In the foetus a slender canal through the vitreous
transmits a branch of the arteria centralis retinae to the lens, iris,
and pupillary membrane.

The canal of Schlemm is a narrow passage running all around
the eye-ball in the substance of the sclerotic, close to the attachments
of the cornea and iris. It is lined with endothelium, and, like the
anterior chamber, with which it is continuous, is part of the lymphatic

c, cornea ; cs, conjunctiva ; Ch, choroid ; R,
retina ; v, vitreous , le, ligamentum pec-
tinatum ; s, sclerotic ; A, aqueous ; a/>,
posterior chamber of aqueous ; s v, canal
of Schlemm ; ir, iris ; io, cut fibres of
sphincter of pupil ; /, lens ; c, capsule ;
«>, ciliary muscle ; dp, ciliary pro-
cesses ; 0, ora serrata ; h, hyaloid mem-
brane. (From QUAIN, by ALLEN
THOMSON.)

system of the eye-ball. Its office is to drain away the nutrient fluid
which the ciliary processes supply for the vitreous, and which enters
the posterior chamber of the aqueous by permeating the suspensory
ligament of the lens ; and, in addition, to carry off the tide of the
aqueous, which, coming also from the ciliary processes, leaks into the
anterior chamber between the lens and the free border of the iris — that
is, through the pupil.

These aqueous tides flow into the canal of Schlemm through the

Filtration Angle ; Glaucoma 91

lattice- work, ligamentum pectinatum (pectinatim, adv., like the teeth of
a comb], which occupies the narrow peripheral part of the anterior
chamber, between the cornea and the root of the iris. This important
crevice is, therefore, called the filtration angle. It becomes blocked
when, as the result of an excessive secretion of the vitreous, the ciliary
processes are thrust against the iris, and the iris is thrust against the
cornea. And its connection with the posterior chamber is, of course,
completely shut out when, as the result of iritis, the pupillary border, of
the iris is glued to the front of the capsule of the lens or to the posterior
surface of the cornea.

Whenever the tideway from the vitreous and the posterior chamber
into the anterior chamber is
blocked, the fluids collect behind
the iris and push it towards the
cornea, increase of the ocular
tension promptly taking place.

Thus, the tension may be in-
creased in the case of excessive
secretion from the ciliary pro-
cesses into the vitreous, and also
in that of a blockade of the filtra-
tion-angle. It is this increased
tension of theeye-ball which is
the essential feature of glau-
coma (yAavKos-, bluish-green).

Symptoms of glaucoma, in
addition to that of hardness of
the eye-ball : — Pain, on account
of the compression of the ciliary
nerves within the rigid sclerotic ;
advancement of the iris, as
already explained, and errors of
refraction, on account of the
grave interference with accom-
modation.

Then, if the media are clear
enough for the ophthalmoscope,
the veins at the fundus are seen
to be full and pulsating, because
the tension of the sclerotic prevents their emptying themselves ; and
the arteria centralis is found throbbing in its endeavour to force its con-
tents through the engorged capillaries. And the backward pressure
of the vitreous causes a manifest depression or even a cupping of the
optic disc, but in an acute case the general destruction of the tissues
may render this invisible. Atropine must not be used, as this causes
the ris still farther to encroach on the filtration-angle.

Iritis ; annular posterior synechia, aqueous
locked in behind iris, which, thus pushed
forwards, blocks filtration-angle and deter-
mines glaucoma. (PRIESTLEY SMITH.)

The Eye

Treatment.— Unless the tension be promptly relieved, the eye-ball
will be ruined. Eserine (Calabar bean), constantly dropped between
the lids, may help in this respect by contracting the pupil, and so
drawing the iris out of the way of the filtration-angle. But, if the
case be acute, iridectomy should be performed. This operation eases
the tension by allowing some of the aqueous to escape, and, moreover,
the section of the iris extending to its very root, the filtration-angle
is inevitably once more opened up.

From an eye cured of acute glaucoma by iri-
dectomy, filtration-angle being opened-
out. (PRIESTLEY SMITH.)

Tumour of iris ; filtration-angle blocked ;
secondary glaucoma. (PRIESTLEY
SMITH.)

Looking back, one can now appreciate the peril which a complete
anterior or posterior synechia entails (p. 88), and can also understand
why some surgeons prefer to preface extraction of the lens by an
iridectomy, lest iritis, synechia, and glaucoma should supervene. The
preliminary iridectomy, however, is by no means necessary.

(For the anatomy of the optic nerve see CRANIAL NERVES,

P- 570

The retina is the delicate expansion of the optic nerve. It is so
thin that the hue of the subjacent choroidal blood is clearly diffused
through it, and this, indeed, is all that can be made out in one's first

Blind Spot ; Yellow Spot 93

attempts at ophthalmoscopic examination. With a little practice,
however, the optic disc, the entrance of the optic nerve, is discovered,
whitish in appearance, on account of the absence of the choroid at the
point of its perforation, there being nothing behind that part of the
retina but the lamina cribrosa (p. 83). The ascending and descend-
ing divisions of the central artery and vein are then made out.

As the fibres cf the nerve radiate on to the front of the choroid
they leave a central depression in the disc, called the cup, and the
margin of the lamina cribrosa — the sclerotic ring — may often be seen
around the cup.

The optic disc is the ' blind spot' of the retina ; and, for that
reason, it is placed out of the way of the visual axis. The exact
centre is the most delicate and useful part of the field, and is known
as the yellow spot.

The nervous part of the retina extends to the ciliary processes,
where it ends as the ora serrata (ora, margin), but the retina is con-
tinued a little farther forwards by delicate fibrous tissue, even to the
capsule of the lens.

The retina depends entirely on the central artery for its blood-
supply, and on a few twigs from the choroid which enter at the optic
disc. If in disease of the aortic valve a small vegetation be detached,
and carried into (embolus) and plug the arteria centralis, the eye, or
part of it, becomes suddenly blind, for the retina is completely deprived
of its nutrition. Examination then shows the arteries and veins of the
fundus shrunken, whilst broken thrombi may be seen in the artery.
In Bright's disease haemorrhages are very apt to occur in the inflamed
and swollen retina (albuminuric retinitis).

The delicacy of the connections of the retina renders it liable to
detachment by injury and disease.

THE EAR

The external ear consists of the expanded pinna, composed of
yellow fibro-cartilage, and the auditory meatus.

The deepest part of the pinna is the concha (cockle-shell), at the
front of which is a cartilaginous plate which acts as a shield to the
meatus, on which grows a tuft of hair like the beard of a goat (tragus).
Behind this shield is another plate, the anti-tragus, below which is
the fibrous lobule. (A keloid tumour sometimes springs from the scar
which necessarily results from piercing the lobule for an ear-ring.)
The tragus and anti-tragus are separated by a deep incisura. The
margin of the pinna is the helix (eXi£, a spiral), and the groove be-
neath its incurved border is the fossa of the helix. Rather nearer
to the meatus is a thicker ridge, the anti-helix, which bifurcates above
to inclose \\\t fossa of the anti-helix.

94 The /:<rr

Beneath the skin are ligamentous and muscular slips, some of
which connect the pinna with the side of the head. The skin of the
pinna and of the meatus contains many sebaceous glands by which
the wax is secreted for lubricating the canal and for preventing the
entrance of insects. Sometimes it is secreted in excess, and forms at
last a plug which blocks the canal and causes deafness.

As the result of violence, blood may be extravasated beneath the
skin of the pinna, forming hamatoma auris, or the cartilage of the ear
may be crumped up and permanently disfigured. Both these con-
ditions may be found in vigorous and forward foot-ball players.

Passing down the meatus, the skin becomes gradually thinner, and
is at last blended with the periosteum. It forms also the outer layer
of the membrana tympani.

Supply of tne pinna. — The arteries are derived from the posterior
auricular and the superficial temporal. The veins take a correspond-
ing course.

The nerves. — The great auricular, from the second and third
cervical, supplies the lobule and the back of the pinna, the lesser
occipital also gives twigs to the occipital aspect of the pinna, as does
also the auricular branch of the pneumogastric. The auriculo-
temporal branch of the fifth supplies the outer aspect of the pinna.
The posterior auricular and temporal branches of the facial supply the
intrinsic muscles of the pinna. (It is noted elsewhere (p. 64) that pains
in the neighbourhood of the ear may be due to a lesion of the fifth
neive, and (p. 145) that pain at the back of the pinna may be the result
of cervical caries )

Muscles of the external ear. — The attollens, fan-shaped, arises
from the aponeurosis of the occipito-frontalis, and is inserted into the
front of the helix. The most anterior fibres of this muscle constitute
the attrahens. The retrahens passes from the mastoid process forwards
to the back of the concha.

Though the contemporary human anatomist hardly considers these
as muscles of expression, the suggestive fact, nevertheless, remains that
the facial nerve still supplies them : the retrahens by the posterior
auricular, and the attollens and attrahens by filaments from the
temporal division. The attollens may also receive a supply from the
lesser occipital nerve.

The external auditory meatus is an osseo-cartilaginous canal
about \\ in. long, and is directed forwards and inwards. At the bottom
of the concha its greatest diameter is vertical, but near the membrane it
is transverse ; the narrowest part is about the middle. It is developed
by the outgrowth of the tympanic bone (p. 12).

To make a thorough inspection of the canal, the pinna should be
drawn backwards, upwards, and a little outwards, the tragus being tilted
forwards. In the young child the meatus is extremely short ; the bony
wall is a subsequent development.

Tympanum 95

A foreign body in the ear may be detected by the speculum, and
perhaps extracted by appropriate forceps. If a stream of tepid water can
be got behind it, but obviously not otherwise, it may be washed out by
prolonged syringing, the stream being directed along the roof. A fine
stream is better than a full one, as it is more likely to pass behind the
foreign body. A large nozzle should not be used, lest, obstructing the
outflow, it produce so much tension as even to burst the membrana.
Rough syringing is always dangerous.

If the parts be much swollen the attempt at extraction should be
delayed until they have quieted down ; the foreign body may quietly
lie at the bottom of the meatus for months or years and cause no harm.
Possibly a hair-pin bent at the closed end, may happily bring it out,
but no rough efforts should be made, lest the membrane be torn. If
the case be urgent, the cartilaginous part of the meatus may be cut
half across from behind the concha, flat with the surface of the head,
when, the pinna being turned forwards, the body is found well within
reach.

If insects have entered the meatus, warm oil should be poured in.

Supplies. — The arteries of the meatus come from the posterior
auricular, internal maxillary, and superficial temporal. The veins run
to the external jugular, and the lymphatics to the glands near the
angle of the jaw.

The nerves come from the auriculo-temporal (p. 63), the great
auricular, and from the auricular branch of the pneumogastric. It is
owing to the presence of the last-named nerve that the introduction of
a speculum, or the presence of a plug of wax, sometimes sets up a
cough known as an ' ear-cougli ' (see p. 69), which may be accounted
for by the fact that the pneumogastric or the auriculo-temporal nerve
conveys an impression to the grey matter of the medulla which is to
the effect that some annoyance exists in the larynx — for which the
usual remedy is a cough. It is a sort of physiological equivalent of a
* printer's error.' The information conveyed by nerves is not invariably
true to the letter, and some have a worse character for veracity than
others — notably the obturator (p. 359) and the vesical nerves (p. 411).

Sometimes irritation of the auricular branch of the pneumogastric,
as by a plug of wax or by a foreign body, causes faintness, nausea, or
reflex vomiting, which entirely ceases on the cause being removed.

The tympanum is a minute cavity situated between the external
and the internal ear. Its outer limit are the membrana, and an osseous
surface upon which are the apertures of entrance and exit of the
chorda tympani (p. 66). Its inner wall is the bony partition which
separates it from the internal ear. The roof is formed by a thin plate
of bone separating it from the middle cranial fossa, and its floor
is another thin plate which shuts it off from the jugular fossa. In
front of it ascends the internal carotid artery, and at that aspect also
enter two tubes, the upper one transmitting the tensor tympani, and

9o 1 lie liar

the lower the Eustachian tube ; they are separated by the cochleari-
form process of bone. Behind the tympanum are the mastoid cells.

On the inner wall of the tympanum is an oval foramen which is
appropriately filled in by the oval plate of the stapes, but which other-
wise would open directly into the vestibule. Below this foramen is a
round one which leads towards the cochlea, but which is glazed with
a threefold layer, like a miniature membrana tympani (p. 97), the
innermost layer being the serous lining of the cochlea. Above the
oval foramen is a slight ridge which marks the passage of the facial
nerve in the subjacent aqueduct of Fallopius. The first turn of the
cochlea, bulging outwards, forms a projection, the promontory, upon
the inner wall ; and farther back is the pyramid, from the interior of
which the stapedius arises.

After the loss of the membrane the inner wall of the tympanum is
clearly shown by otoscopic examination, and Mr. McGill tells of a
case in which a minute bubble of air under a film of mucus upon that
part which is called the pyramid was for some time mistaken for the
glistening head of a pin, which, according to one account, had been
pushed into the ear.

The ossicles. — The head of the malleus, or hammer, articulates
posteriorly with the incus. Its tapering handle descends vertically
between the inner and middle layers of the membrana, the tensor
tympani being inserted into its upper end.

The top of the incus, or anvil, articulates with the head of the
hammer. Its short limb passes back to be lodged in the mastoid
cells, and the long one runs parallel with the handle of the hammer
to articulate, by the os orbiculare, with the head of the stapes, or
stirrup, the plate of which blocks the fenestra ovalis. The joints
between the ossicles are enclosed in delicate capsular ligaments, lined
with synovial membranes, and are liable to attacks of disease. Thus
chronic inflammation of the middle ear stiffens them, and so interferes
with the oscillation that deafness steadily advances. The subjects of
this troublesome complaint hear better when riding in a train or car-
riage, as the shaking of the vehicle imparts the needful vibration to the
chain.

The tensor tympani arises from the walls of the bony canal by
which it enters the tympanum, and is inserted near the root of the
handle of the hammer. It is supplied by a branch from the otic-
ganglion. Its action is to draw inwards, and so to tighten the mem-
brana ; at the same time it presses upon the perilymph and causes
a disturbance of the auditory filaments. When the buzzing in the
ear which is supposed to result from this pressure is constant, certain
aural orthopaedists have recommended a speculative tenotomy of the
muscle. An artilleryman, who is awaiting the firing of a big gun,
keeps his mouth open, so that the aerial concussion may rush along
the Eustachian tube as well as down the auditory meatus, and that

Middle Ear 97

the membrane may be evenly struck on each side ; at the same
time also he sets the tensor tympani in action so as to steady the
membrane ; otherwise the explosion may rend it.

The stapedius arises in a small pyramid of bone upon the inner
wall of the tympanum, and is inserted into the neck of the stapes. It
is supplied by a tympanic branch of the facial nerve. Its action is to
drive the plate of the stirrup farther into the oval foramen, and so to
compress the fluid in the vestibule.

The tympanum and the mastoid cells are lined by a delicate
mucous membrane, which is continuous with that of the pharynx
through the Eustachian tube. It covers the ossicles and the nerves,
and forms the inner layers of the membrana tympani. Its epithelium
is of the columnar ciliated variety.

Supply of tympanum. — Arterial twigs come from the internal
carotid, stylo-mastoid, internal maxillary, and middle meningeal. The
tympanic veins end in the petrosal and lateral sinuses, and in the
internal jugular. The nerve-supply is from Jacobson's branch of
the glosso-pharyngeal (p. 69) ; but Arnold's nerve also helps with
a delicate twig. The chorda tympani wraps itself in mucous mem-
brane as it hurries through the tympanum, passing between the handle
of the hammer and the long process of the incus, but it gives no
branch to the cavity. The lymphatics descend to glands behind the
angle of the jaw, and massage over them, downwards from the mastoid
process, may give much help in emptying mucus from the middle ear.

The membrana tympani is stretched obliquely at the bottom of
the external auditory meatus. In the adult its border is fixed in a
groove in the bone, but in the child to the tympanic ring. The ring
being deficient above, the attachment there is less firm — only to
the periosteum — and thus it may be unglued by a box-on-the-ear, or
by blood or pus escaping from the tympanum. (Tillaux.)

The membrane is composed of circular and radiating fibres, which
are covered on one side by a thin layer of skin from the external
auditory meatus, and in the other by the mucous lining of the middle
ear. Between this mucous membrane and the fibrous layer the handle
of the malleus descends as far as the centre, to which part it is
attached, drawing it slightly inwards at a sort of umbilicus. Its
arteries are derived from the tympanic branch of the internal maxil-
lary, and from the stylo-mastoid of the posterior auricular, which
ramify respectively upon the lower and upper parts. The auriculo-
temporal nerve endows it with sensibility.

Paracentesis of the tympanum may be required for the evacua-
tion of abscess from the middle ear ; also for the transmission of waves
of sound through a membrane which has become thickened and stiff
by chronic inflammation— the auditory nerve being known to be
healthy (p. 102). In this case it is often impossible to maintain the
desirable patency of the opening, whereas after the opening of a tym-

98 Hie Ear

panic abscess the wound in the membrane may obstinately refuse to
close ! Paracentesis should be performed through the lower part of
the membrane, so as to avoid the risk of wounding the handle of the
hammer and the chorda tympani, which are above the equator.

The instrument must be thrust through with great care, as the
inner wall is but y^-inch beyond the membrane. I once had a man
under my care whose child had roughly practised the operation on
him with a pair of scissors, and with such violence as to cut through
the facial nerve as it ran in the substance of the inner wall. The man
had complete facial paralysis (p. 67).

Polypi growing from the inner wall of the tympanum may cause
great local disturbance, and in due time may make their way through
the membrane and up the meatus ; they are usually associated with
much suppuration. Having been removed by snare or forceps, their
base must be kept down by astringents.

When there is a hole in the membrane, and the Eustachian tube is
clear, the subject can force air through it by blowing his nose hard.
But the existence of an opening by no means implies deafness. In-
deed, though the hammer and the anvil have escaped with the puru-
lent discharge, hearing may persist, provided that the plate of the
stirrup remains to close in the vestibular perilymph.

When the membrane has a large opening in it, and the Eustachian
tube is clear, the tympanum may be washed out into the pharynx by
sending a full stream of warm water down the auditory meatus, and in
cases of chronic suppuration this treatment may be advantageously
resorted to.

Artificial membrana tympani. — When the destruction of the
membrane has been so great as to lay the meatus into the tympanic
cavity, the hammer and the anvil having probably escaped, hearing
may be improved by passing a delicate plug of cotton-wool against
the inner wall of the tympanum, so that it presses against the head of
the stirrup, and conveys the sound-waves to the perilymph of the
vestibule.

Acute inflammation of the middle ear may be an independent
disease, or may be secondary to a < sore-throat.' As the muco-purulent
fluid collects in the chamber with unyielding walls the effect of pres-
sure becomes extremely serious : the first result may be noises in the
ear, because the stapes is driven against the vestibular perilymph ;
then come intense headache and pains of a bursting character, which,
increasing, may cause convulsions, delirium, and may be followed by
death.

There is tenderness around the meatus and over the mastoid pro-
cess. Swallowing causes pain by opening the inflamed Eustachian
tube and causing air to enter the tympanum. Movements of the jaw
also cause pain by disturbing the engorged tissues between the condyle
and the tympanum.

Tympanic Abscess 99

The pus may be absorbed, or may happily escape along the in-
flamed Eustachian tube ; but, if it be allowed to remain uninterfered
with in the tympanum, it may take its time in bursting through the
membrane, and may, but not necessarily so, leave the ear permanently
deaf.

Complications. — The abscess may burst through the roof of the
tympanum and cause meningitis, and an intra-cranial abscess, in the
neighbourhood of the petrous process and of the temporo-sphenoidal
lobe. Sometimes the matter burrows into the mastoid cells, in which
case its prompt escape may be helped by drilling behind the pinna,
or by cutting through the inflamed and softened mastoid process with
a gouge.

In the case of a boy who was recently under my care, the in-
flammation had extended from the tympanum throughout the entire
petromastoid bone, which came away as a large sequestrum without
implication of the internal carotid artery (which passes through it,
p. 13), but with, of course, total destruction of the portio dura, per-
manent facial paralysis resulting.

Extension of ulceration from the tympanum may involve the
carotid, or the jugular vein, fatal haemorrhage occurring through the
external meatus.

Suppuration from the petro-mastoid bone may reach the neck
and cause cervical abscess. If the inflammation extend downwards,
it may cause phlebitis in the internal jugular, and if downwards and
backwards to the neighbouring lateral sinus it may there set up an in-
flammation ; in both cases coagulation of the blood supervenes, and,
pieces of the septic thrombi being carried into the circulation, pyaemia
and metastatic abscesses result.

Cerebellar meningitis and abscess may follow extension of the
inflammation from the back of the tympanum and the mastoid cells.

The treatment of acute otitis demands the free application of
leeches behind the pinna and in front of the tragus, with subsequent
fomentations. If the membrane be found congested and bulging,
paracentesis must be promptly resorted to. If the mastoid cells be
apparently involved they should be freely opened.

The Eustachian tube, i^ inch long, leads into the pharynx from
the middle ear, at the level of the inferior meatus ; its direction
is forwards, inwards, and slightly downwards. Its posterior part is
osseous, being at the junction of the squamous and petrous portions
of the temporal bone. The anterior part is fibro-cartilaginous, and
ends by a trumpet-shaped expansion, from the lower aspect of which
the tensor and levator palati arise. Contraction of these muscles
during deglutition opens the tube and allows air to enter the tym-
panum. A 'singing in the ear' may often be made to disappear by
setting the tensor palati in action by swallowing, the inrush of air
causing the membraae to yield rwith a eHght? crack.- ;- -

H 2

ioo The Ear

The lining membrane of the tube contains mucous glands an
covered by columnar ciliated epithelium, except at the pharyngeal
opening, where it is squamous. The osseous part of the tube receives
its arterial supply from the vessels of the tympanum, and the carti-
laginous part from those of the pharynx. The lymphatics end in
glands about the angle of the jaw.

In the case of inflammation of the pharynx, the tube and the tym-
panum may be secondarily implicated, and when an acute inflammation
has travelled back, abscess may be set up in the middle ear. Thus
may be explained the destruction of the membrana tympani and the
permanent deafness which sometimes follow scarlet fever, or which, in
an unhealthy child, may result from acute tonsillitis.

On account of the tonsil being below the soft palate (p. in), and
the soft palate close below the opening of the tube, enlargement of the
tonsil may, indirectly, cause obstruction of the tube and deafness, but
more often the blockage is due to hypertrophy of the neighbouring
adenoid tissue, which is affected at the same time as the tonsil.

Obstruction oftbe Eustachian tube is usually caused by inflam-
mation. Air being then unable to enter the tympanum, the pressure
on the exterior of the membrane is in excess of that within. The result
is that the membrane and the malleus are thrust inwards, and, the incus
being forced against the stapes, there is a constant pressure against
the fluid of the vestibule ; this causes irritation of the terminal filaments
of the auditory nerve, which is recognised as a meaningless but annoy-
ing buzz or singing. ,

If the blocking of the tube be but slight, the singing may cease
after the act of swallowing, as these movements pull down the lower
end of the expanded opening of the Eustachian tube (p. 108) and allow
air to pass along. If this fail, success may follow on the person holding
the nose and blowing it hard, which effort may force the compressed air
beyond the obstruction, thrusting out the membrana tympani, and
drawing upon the plate of the stapes at the oval foramen. If this also
fail, the surgeon may pump air up the nostrils by Politzer's apparatus
at the instant that the patient swallows a mouthful of water, so that the
compressed air may be locked above and behind the soft palate and the
palato-pharyngei, and, instead of being dissipated down the oesophagus,
may find its way into the middle ear.

As a last resource the Eustachian catheter must be used. This
instrument, which is like a short and small silver catheter, is passed
lightly along the floor of the nose, with the point downwards, until it
touches the back of the pharynx. (It must not be allowed to enter the
middle meatus.) It is then withdrawn a little, the point being turned
outwards, and it should be felt to hitch against, and jump over, the
posterior edge of the cartilaginous expansion of the tube ; it is then
gently pushed upwards and outwards into the tube, after which it should
be felt to be in the firm fcrasp of the tabe, otherwise tho beak has not

Tnternal Ear 101

been brought forward enough, but is lodged in the space between the
posterior part of the opening and the back of the pharynx — the fossa
of Rosenmiiller.

The catheter being securely inserted into the tube, the surgeon
connects his own ear with that of the patient by a flexible stethoscope
and listens for the result of pumping air along the catheter. If the
obstruction be absolute no air is heard rushing into the tympanum ;
if the tube be abnormally dry the sound is harsh, and if the tube and
the tympanum contain mucus the air enters with a bubbling. But, if
the obstruction be suddenly overcome, the air enters with a rush, driv-
ing the membrane outwards with a slight click. If the membrane be
perforated the air escapes with a hissing sound.

If the catheter be so clumsily introduced as to tear the mucous
membrane, and if air be then pumped up with considerable force, tem-
porary emphysema of that neighbourhood may result.

The internal ear is a labyrinthine chamber hollowed out in the
petrous bone, and consisting of three parts, the vestibule, semicircular
canals, and the cochlea, which have a delicate lining for the secretion
of perilymph. The bony labyrinth contains a membranous labyrinth of
corresponding shape ; it is hollow and floats in the perilymph ; it, like-
wise, contains fluid, the endolymph. Thus, the auditory filaments, which
are spread out upon it, are securely placed between the peri- and the
endo-lymph. The membranous labyrinth is supplied by a small audi-
tory branch of the basilar artery, which enters by the internal auditory
meatus.

The semicircular canals occupy suggestive geometrical positions :
the superior is in a vertical transverse plane ; the posterior in a vertical
antero-posterior plane ; and the external one arches outwards in a
horizontal plane. Their function is probably for maintaining the equi-
librium of the head and of the body ; when they are diseased the
subject cannot keep upright.

When the amount of fluid in the labyrinth is excessive the patient
has sudden attacks of giddiness, headache, and sickness, and he
promptly falls in a definite direction. He may at first think that the
associated troubles, which are accompanied by deafness, are due to in-
digestion. The disease is named after M. Meniere, who first described
it, and, because of its associations, it is often spoken of as ' ear
vertigo.3

The auditory nerve passes down the internal auditory meatus and
breaks up into branches which run through small holes to the vestibule,
semicircular canals, and cochlea.

The waves of sound reach these terminal filaments by the mem-
brana tympani setting the ossicles in vibration, the oval plate of the
stapes imparting a similar movement to the perilymph, by which the
acoustic filaments are irritated. The nerve-filaments may also be set
in vibration by the conduction of sound through the bones of the skull.

102 The Ear

When a tuning-fork in vibration is placed on the vertex of the
head of a person with healthy ears, and one external auditory meatus
is then blocked, the sound is best heard on that side, as dissipation of
the waves along the meatus is prevented, and they are, therefore,
echoed again and again from the tympanic membrane to the perilymph.
When the deaf ear of a patient cannot hear the tuning-fork so placed
the auditory nerve must be at fault. When the 'deaf ear hears
the vibrations better than the other there is probably obstruction of
either the external meatus or the Eustachian tube, and treatment
may be hopefully undertaken, for the auditory nerve is evidently
healthy.

Development. — The pinna is formed by the fusion of six small
tubercles upon the integument at the end of the first visceral cleft,
which is between the mandibular and hyoid arches. The fusion, how-

Development of pinna from six tubercles. Supernumerary and persistent auricular
(After His.) nodules. (BLAND SUTTON.)

ever, is never absolutely complete, for those tubercles from which the
tragus, anti-tragus, and the lobule are developed assert their indepen-
dence throughout life. Occasionally the fusion is extremely incom-
plete, supernumerary auricles and pendulous growths near the meatus
resulting. (For a Note upon DEVELOPMENT it. p. 123.)

Sometimes the tragus-nodule is prevented from blending with the
elongated nodule just above it (from which the helix is formed) by
a recess of the epiblast which sinks between them and forms an
atiricular fistula. I saw such a case the other day, in which the in-
volution caused a fistula which ran beneath the superficial temporal
artery. From time to time it discharged a viscid secretion. It had
to be laid open and scraped out. (See also Trans. Soc. Med. Chir.
vol. Ixi.) Occasionally a similar fistula exists between the lower part
of the helix and the lobule, and sometimes the minute opening of one
of these fistulae becomes occluded, and the secretion collecting within
distends it into a dermoid cyst of pinna.

Occasionally the tubercles are joined over the meatus in an elon-
gated or confused mass which represents the pinna ; this malforma-

Orbicularis Oris

103

tion is likely to be associated with imperfect development of the
tympanic end of the first post-
oral cleft. Sometimes the
tubercles join over and hide
the meatus ; sometimes there
is neither meatus nor pinna.
On the other hand, by a sort of
carelessness, or, possibly, over-
zeal, on the part of Nature,
a supplementary pinna, or an
attempt at one, is sometimes
developed at the end of one of
the lower clefts.

The Eustachian tube and
tympanum ' are developed in
connection with the inner end
of the first post-oral cleft, while
the meatus externus and pinna

are formed On the OUtside, the Rudimentary pinna developed at dorsal end of

membranatympani being inter- third branchial deft. (BLAND BUTTON.)
posed between them. (Quain.)

THE MOUTH

The lips consist of striated fibres of the orbicularis and other
muscles covered on the outside by skin, and on the dental aspect by
mucous membrane which is continuous with that of the gums and
mouth. This entire mucous surface is covered with squamous epithe-
lium. Where the membrane is reflected from the middle line of the
upper and lower jaw to the lip, a prominent fold or frcenum occurs,
that of the upper lip being well-marked. Beneath the mucous mem-
brane of the lips racemose labial glands are placed ; and, should the
orifice of one of them be occluded, a labial cyst occurs ; sometimes
the glands become the seat of suppuration.

The orbicularis oris, a sphincter of striated fibres, consists of a
semi-elliptical portion in each lip ; the fibres of each piece blend and
cross at the corners of the mouth, where they join other muscles of
expression ; they become continuous externally with the anterior part
of the buccinator.

The orbicularis arranges the lips in whistling, and when the facial
nerve, which supplies it, is paralysed (p. 67) all efforts in that direction
are attended with characteristic failure. Contraction of the separate
halves of the muscle may spoil the plastic operation in hare-lip ; it
was to check this strain upon the wound that hare-lip pins were
formerly so much used. The employment of abundant fine sutures

IO4

The Mouth

at the front and back of the wound, and the judicious arrangement of
strips of waterproof strapping are now taking the place of the pins, the
use of which is apt to mark the lip with permanent scars.

Supply. — Below the region of the orbicularis the lower lip receives
the submental and inferior labial branches of the facial arteiy. The
coronary branches of the same artery pierce the orbicularis and form
a circle close beneath the mucous membrane. In operating for hare-
lip one suture should be passed beneath their cut ends. (There is no
superior labial artery : an upper lip which is long enough to need one
is an artistic defect.) The infra-orbital artery may help in the supply
of the upper lip, and the mental branch of the inferior dental in that
of the lower lip. The lymphatics pass to the submaxillary and to the
cervical glands.

The nerves are derived from the terminations of the superior
maxillary and inferior dental trunks ; the mental branch of the inferior
dental also helps in the supply of the lower lip.

Con

igenital MacrostomaanJ Supernumerary
Auricular appendage. (FERGUSSON.)

Macrostoma in a child six weeks old. (BLAND
SUTTON.)

Development. — The buccal cavity first appears as a depression
in the epiblast between the fronto-nasal process above, the superior
maxillary processes at the sides, and the mandibular plates (p. 105)
below. The mouth is then separated from the pharynx, but the par-
tition soon wears away at the region of the fauces. Sometimes the
hinder part of the mandibular fissure (M.F., p. 124) fails to be oblite-
rated ; a large mouth, macrostoma, then results.

Hare-lip. — The median part of the upper lip is formed by a flap
which descends, in connection with the fronto-nasal plate, from the
front of the cranium ; the lateral parts are developed from the cover-

Development of Lip 105

ings of the superior maxillary processes, which, extending inwards,
are eventually fused with the descending flap at a short distance from
the median line.

If a unilateral arrest of development take place, a single hare-lip
results ; if the arrest be symmetrical,
the cleft is double. The labial cleft
is thus to the side of the median line,
not in it, as it is in the hare. The
cleft may extend into the nostril ; or
may be represented by a mere notch
or depression at the border of the lip.
Sometimes a small triangular gap is
found continuous by its apex with a
vertical linear cicatrix, as if Nature
herself had attempted a plastic opera-
tion with partial success. Hare-lip
may be hereditary, several members Double hare-Ht% S™£?lla attached to
of the same family being disfigured

by it. Often it is associated with cleft palate, and the median piece of
the lip may be attached with the inter-maxillary bone to the projecting
nasal septum.1 In double hare-lip the inter-maxillary bone should
contain the four incisors, but more often it contains three, or two only.

Mr. Pitt's case of Median Hare-lip. Notch in pr?cess descendjng to

form median part of lip ; a
deepening of this notch gives
median hare-lip.

Fergusson taught that the lateral incisors were then lost in the cleft,
but, from development (p. 17), this explanation does not suffice.

The median part of the lip descends as a bifid process, and if the
gap between its lateral nodules be exaggerated, whilst their outer

1 From The Surgical Diseases of Children, Cassell & Co.

106 The Mon tli

borders are fused with the ingrowing maxillary parts, the fissure is
exactly median. This condition, however, is extremely rare.1

The operation for hare-lip consists in freshing the sides of the cleft,
freeing the maxillary attachments of the lip, and adjusting the cleft by
stitches and strapping, arrangements being made that the muscles do
not pull the edges asunder.

The cheeks, like the lips, with which they are continuous, consist
of skin and mucous membrane, with intervening muscular tissue,
namely, buccinator, zygomatici, platysma, and masseter. They con-
tain, also, a good deal of fat ; and beneath the mucous membrane are
minute salivary glands resembling those of the lips.

On the mucous lining of the cheek, opposite the second molar
tooth of the upper jaw, is a flat papilla upon which is the opening of
the parotid duct, which has just traversed the buccinator. To save
himself the annoyance caused by the flow of saliva during certain
dental operations, the dentist sometimes stuffs a piece of cotton-wool
between the upper jaw and the cheek so as to block the orifice of the
duct.

The buccinator arises from the alveolar process above the molar
teeth of the upper, and below those of the lower jaw ; and, posteriorly,
in the space between the jaws, from a fibrous seam connecting the
muscle with the front of the superior constrictor — the pterygo-maxillary
ligament. Thus the mouth is directly continuous with the pharynx.

Action. — The buccinator helps the man to ' blow his own trumpet ' ;
it is thus a muscle of expression, and is, therefore, under the control
of the facial nerve. Its chief office is to gather up the half-chewed
food which falls outwards from between the molar teeth, and to push
it again into the mill. When the facial nerve is paralysed the food
persistently collects in the cheek, whence the patient has to dislodge
it with his finger. So useless is the muscle in facial paralysis that
there can be no manner of doubt that the branches which the muscle
gets from the inferior maxillary nerve (p. 63) are but sensoiy.

Relations. — The muscle is covered by skin, superficial fascia, and
the muscles which draw the angle of the mouth downwards, back-
wards, and upwards ; it is crossed by the facial artery and vein,
and by branches of the facial and buccal nerves. Stenson's duct
passes through it opposite the second upper molar. A good deal of
fat is packed in between it and the anterior border of the masseter ;
in phthisis this is gradually consumed and the cheeks sink in. Behind
the muscle is the pharynx ; in front is the orbicularis, and lining it is
the mucous membrane of the mouth.

Pterygro-maxillary ligament. — The student is advised to pass
the tip of his index-finger behind, and a little to the inner side of, the
last molar tooth, where he will find a band beneath the mucous
membrane. The more widely the mouth is opened, the tighter the

1 See case reported by Bernard Pitts, "Z ancet, 1889.

Hard and Soft Palate 107

band becomes ; it is the pterygo-maxillary ligament. If traced up-
wards it is felt to be attached to a somewhat springy piece of bone,
the hamular process o>{ the internal pterygoid plate ; and traced down-
wards it is evidently connected with the inner and back part of the
lower jaw. From the front of this ligament the buccinator arises, and
from the back the superior constrictor.

If the student will be good enough to continue the examination by
bringing his finger upwards and forwards from the middle of the
ligament, keeping his nail upon the outer surface of the last molar, he
will feel the coronoid process of the jaw, separated from his finger,
however, by the buccinator, the insertion of the temporal muscle, and
the mucous membrane of the mouth. Then, lastly, if he will press
firmly below the lower end of the ligament he will make out the gus-
tatory nerve lying between the mucous membrane and the inner side
of the jaw ; firm pressure upon it causes pain (p. 63).

THE PALATE

The hard palate consists of the horizontal plates of the two
superior maxillae and of the palate bones ; posteriorly it is continued
into the soft palate by the palatine aponeurosis (W.). This surface
of bone is roughened for the more firm attachment of the muco-
periosteum. The muco-periosteum, which contains many glands, is
covered with squamous epithelium. A median raphe (pa<j>ri, seam} in
the mucous membrane of the hard and soft palate indicates their
development in lateral halves.

On the under surface of the palate bone is a ridge for the insertion
of part of the tensor palati, and at the outer end of the ridge is the
canal for the posterior palatine artery — that is, to the inner side of the
last molar tooth. Bleeding from this artery may be arrested by finding
the foramen with a sharp probe and then sticking a pointed spigot of
wood into the canal.

The arteries of the hard palate are derived from the internal
maxillary. The nerves come from the superior maxillary — Meckel's
ganglion.

The soft palate is firmly attached in front to the posterior border
of the hard palate, and from its sides pass off two folds of mucous
membrane, the anterior of which descends to the tongue and the pos-
terior to the pharynx, under the name of the anterior and posterior
pillars of the fauces. Between the anterior and posterior pillars the
tonsil is placed. The narrow passage between the two anterior folds
is the isthmus of the fauces. The mucous membrane covering the
pharyngeal aspect of the soft palate is thin, and, being continuous
with that of the nares, is covered with columnar ciliated epithelium ;
that upon the buccal surface is thick, and contains many mucous
glands. Its epithelial covering is squamous. Forming a foundation

io8 The Palate

for the soft palate, and attached to the posterior border of the hard, is
a strong aponeurosis which blends with the expanded tendon of the
tensor palati.

The chief of the muscles of the soft palate is the palato-pharyn-
geus, which there consists of two layers, between which are the levator
palati and the azygos uvulae. Passing downwards and backwards in
the posterior pillar of the fauces, it spreads out into the side of the
pharynx and along the posterior border of the thyroid cartilage. As
it descends from the outer border of the soft palate it is reinforced by
fibres arising from the lower part of the Eustachian tube ; these fibres
constitute the salpingo-pharyngeus (o-aA7riy£, trumpet], and, acting
from below, they open the tube during deglutition (p. 99).

The palato-glossus blends above with its fellow of the opposite
side on the under surface of the soft palate, and, passing down in the
anterior pillar of the fauces, is inserted in the side of the tongue.

The azygos uvul<z arises from the posterior nasal spine and de-
scends into the uvula.

The levator palati arises from the under surface of the petrous
bone and from the lower border of the Eustachian tube, and, entering
the pharynx above the upper border of the superior constrictor, is
inserted between the slips of the palato-pharyngeus.

The tensor palati arises from the scaphoid fossa at the root of the
internal pterygoid plate, and from the Eustachian tube ; descending on
the outer side of the inner plate, it ends on a tendon which is reflected
round the hamular process to be inserted partly into the ridge on the
under surface of the palate bone, and partly into the buccal aspect of the
soft palate. The reason for part of it being inserted into the hard palate
is that those fibres may be able to pull upon and open the Eustachian
tube during deglutition. This, indeed, may, after all, be the chief use
of the tensor palati.

Nerves. — The tensor is supplied by a branch from the otic ganglion.
The facial, through the Vidian and Meckel's ganglion, supplies the
levator and the azygos ; and the pharyngeal plexus probably supplies
the palato-glossus and palato-pharyngeus.

Supply.— The vessels of the soft palate are derived from the pos-
terior palatine of the internal maxillary, the ascending palatine of the
facial, and the ascending pharyngeal. The veins correspond. The
lymphatics pass to the glands near the angle of the jaw. The nerves
come from Meckel's ganglion and the glosso-pharyngeal.

Cleft-palate is the result of a want of union between the lateral
halves of the soft and perhaps of the hard palate also ; it generally
passes back through the tip of the uvula. At the front of the palate the
cleft leaves the middle line to pass through the articulation of the inter-
maxillary with the rest of the upper jaw (p. 17), and then, probably, to
finish off with a hare-lip (p. 105). When, as often happens, the median
cleft diverges on either side of the inter-maxillary bones, the incisor

Cleft Palate IOo

teeth may be found in an osseo-mucous tuft which is upon the tip of
the nose, and when the inter-maxillary bones are attached to the tip
of the nose (p. 17) the cleft is wide
in the extreme, as is shown in
the adjoining woodcut.

The palatine ingrowths from
the maxilla are a comparatively
late development of the bucco-
pharyngeal cavity, and when their
union fails to take place, on look-
ing into the mouth, a view is ob-
tained of the bright red membrane
covering the turbinated bones.
Many infants who are thus affected
die of inanition, as they can
neither suck, nor satisfactorily swallow the milk which is poured into
the mouth. For feeding they should be held upright, so that the milk
may drop directly into the pharynx.

If, as the child grows up, the cleft be so wide that merely a trace
of the maxillary plates exists, operative measures will be impossible,
but the mechanical dentist may eventually be able to mould a service-
able obturator (obturo, -am, stop up} to prevent the food entering the
nostril, and to improve vocalisation.

The plastic operation for cleft-palate consists in freshening the
edges of the cleft, detaching the muco-periosteum from the hard
palate, and incising it close along the inner border of the alveolar
process, so that the lateral flaps may be approximated, and secured by
stitches. The flaps must be as wide as possible, so as to contain many
branches of the posterior palatine artery, otherwise sloughing may occur.
The apeneurosis of the soft palate must be detached from the hard
palate, or the halves cannot be brought together. When the cleft in the
soft palate has been stitched up, the halves would be drawn asunder
again by the levator and tensor, and by the palato-pharyngeus of each
side, if these muscles were not divided. Their division is best effected
by a bold cut right through the outer part of the soft palate, in an antero-
posterior direction. In my experience, the freer these cuts, the greater
the prospect of the success of the operation.

In several cases lately I have operated with the child's head hanging
back over the end of the table, so that the blood may escape by the nasal
fossa and the anterior nares, rather than trickle into the larynx or oeso-
phagus. This position serves well also in the removal of nasal polypi
from the adult, especially if bleeding is likely to be free.

Deglutition.— In the first stage of the act the mouth is closed so as to
give the tongue and the muscles attached to the lower jaw a fixed point ;
then the food is pressed backwards by the tongue along the roof of the
mouth — the facial and the hypoglossal nerves being those which thus

no Deglutition

far are concerned. If the student will try to swallow with the mouth
open and the lower jaw unfixed, he will accomplish the act only with
difficulty ; but if he fixes the lower jaw by biting something, though
the mouth remains widely open, the act is readily accomplished.

In the second stage of deglutition the soft palate is raised by the
food being pushed against it by the tongue, and is fixed and tightened
by the levator and tensor ; the palato-pharyngei are also fixed, and, the
posterior wall of the pharynx being drawn forwards by the superior
constrictor, the back-way into the nares is completely shut off. (If
the soft palate be cleft or perforated, it is at this stage that the food
passes into the nose, to be ejected by the anterior nares.)

The larynx is now drawn forwards, and, the tongue being thrust
backwards, the glottis is protected beneath its hinder part, the epi-
glottis also being shut down.

In diphtheritic paralysis of the soft palate food passes through the
nostrils, or, at this stage of deglutition, if the muscles of the larynx and
tongue be not working in harmony, some ' goes the wrong way ' into
the larynx and sets up coughing, or, perhaps, food-pneumonia. To
avoid these risks, therefore, such patients must be fed by a soft catheter
introduced into the pharynx through the inferior meatus of the nose.

In the third stage the constrictors take charge of the bolus, and, the
larynx dropping, the food is carried from the posterior air-way, and
hurried down the oesophagus.

The nerves concerned in the reflex act of deglutition are first those
which convey the stimulus (afferent) to the medullary centre ; they
are palatine branches of the fifth, pharyngeal of glosso-pharyngeal, and
oesophageal of vagus. The efferent or motor nerves are the hypo-
glossal (for first stage), mylo-hyoid of inferior maxillary, and pharyn-
geal branches of vagus which have come from spinal accessory.

The uvula consists of a double layer of mucous membrane with
the azygos muscle included between them. Its office is not clearly-
known. Some compare it to a gargoyle which guides the mucus
from the nares to the back of the tongue and prevents its dripping
into the glottis. Others deem it to be needful to fill in the interval
between the posterior pillars of the fauces, and to block the naso-
pharyngeal straits during deglutition. Nevertheless, many are benefited
by its partial amputation.

In certain people it is greatly elongated ; and, its blood-vessels
being dilated after swallowing anything hot, or after smoking, it hangs
against and tickles the back of the tongue to such an extent as to set
up uncontrollable cough or retching. A medical friend of my own
who possessed a long uvula, and a strange aversion from the perform-
ance of even a slight operation upon himself, was through five consecu-
tive nights kept awake by a distressing uvula-cough. The ultimate
removal, however, of half an inch of the cedematous mass brought him
absolute and permanent relief.

A imputation of Tonsil 1 1 1

THE TONSIL

The tonsil is a lymphoid mass placed in the recess between the
anterior and posterior pillars of the fauces (p. 107). Its situation cor-
responds to the angle of the jaw, and when the gland is enlarged it
may cause a fulness in that neighbourhood. It is covered internally
by the mucous membrane of the mouth, and upon its free surface are
the openings of a dozen or fifteen crypts which extend into the sub-
stance of the tonsil. They have an epithelial lining, and upon the
deep side of their basement membrane are nodules of lymphoid tissue.

Relations. — In front is the fold of membrane enclosing the
palato-glossusj and behind is that enclosing the palato-pharyngeus ;
above is the soft palate, and below is the hinder part of the tongue.
On the outer side is the superior constrictor of the pharynx, and more
externally still are the internal carotid artery and the internal jugular
vein ; the vagus ; the sympathetic ganglion, and the ascending pharyn-
geal artery. As the internal carotid is not only external to the tonsil,
but also somewhat posterior to it, the jugular vein is still further away.

Supply. — The arteries are derived from the ascending pharyngeal ;
the ascending palatine and tonsillar of the facial ; the dorsalis linguae,
and the descending palatine of the internal maxillary. The veins
form a plexus which empties into the pharyngeal veins and so into
the internal jugular. The lymphatics pass to the glands below the
angle of the jaw, and into those beneath the sterno-mastoid. The
nerves are derived from the glosso-pharyngeal, and from descending
branches of Meckel's ganglion.

Hypertrophy. — When the tonsils are enlarged they project from
between pillars of the fauces, and may actually meet across the middle
line. There is difficulty in swallowing, and as the masses obstruct the
passage of air from the posterior nares the subject sleeps with his
mouth open, so that air may enter also by the mouth. His respira-
tion is always noisy, and at night he snores. Insufficient supplies of
air entering, the chest is badly developed, and the excessive atmo-
spheric pressure upon the exterior causes the child to become pigeon-
breasted. Because the mouth is constantly open, the face becomes
elongated, and because but little air passes through the nares the
nose is small and flattened from side to side, and the nostrils are very
narrow. Thus, the surgeon can often recognise the hypertrophy by
the aspect of the patient. The voice is ' thick.'

Being below the soft palate, whilst the opening of the Eustachian
tube is above it, the enlarged tonsil cannot actually occlude that open-
ing, but deafness is often associated with the enlargement because the
lymphoid tissue about the Eustachian orifice is simultaneously hyper-
trophied.

Amputation of the tonsil is best performed by dragging the mass

112 The Tonsil

towards the middle line of the fauces by toothed forceps, and then
slicing it off with a blunt-ended bistoury, the edge being kept in the
vertical plane. Should the point of a knife be directed outwards, the
whole depth of the tonsil and the superior constrictor might be
traversed, and the internal carotid wounded ; but such a disastrous
accident is very unlikely to happen. Occasionally a malignant ulcera-
tion of the tonsil implicates the artery.

Adenoid vegetations are the result of hypertrophy of the lymphoid
tissue, which, like scattered tonsillar elements, are placed in the
mucous membrane of the upper and back part of the pharynx, and
constitute a * pharyngeal tonsil.'

Quinsy (acute tonsillitis) is associated with difficulty of swallowing
and breathing ; pain extends along the Eustachian tube ; and because
the inflamed mass is moved in deglutition that act is painful. If
abscess have formed, or with the view of preventing its occurrence,
the tonsil should be punctured, from before backwards, by a guarded
bistoury ; or, as the tissue is very soft, the swollen tissue may be
painted with cocaine and the abscess opened by a backward thrust of
the dressing-forceps. With ordinary care, however, there is no risk
whatever of wounding the artery when operating upon the tonsil with
a knife.

The gums consist of a layer of mucous membrane which is closely
connected with the alveolar periosteum. The periosteum is continuous
with the thin layer in the sockets of the teeth, and when caries attacks
a tooth the inflammation may spread and give rise to a>sub-periosteal
alveolar abscess, or gum-boil. The pus being bound down by the
dense membrane, there may be much pain until the gum-boil breaks
or is lanced. Necrosis may follow this sub-periosteal suppuration.

For the stipply of the gums the vessels and nerves of the jaws,
teeth, palate, and lips contribute branches.

THE TEETH

The temporary teeth are, in each half-jaw, two incisors, one
canine, and two molars — giving a total of twenty. The permanent set
number thirty-two : thus, two incisors, one canine, two bicuspids, and
three molars.

The root of the third molar, or wisdom-tooth, shows but a trace
of fangs. It often issues clumsily and painfully through the tender
gum, and causes much swelling in the mouth and in the neighbouring
lymphatic glands. Sometimes the process is accompanied by profuse
suppuration.

Structure. — The chief part of a tooth is made of line branching
tubes of dentine, which imbibe nutriment from the pulp-cavity. The
pulp consists of connective tissue, cells, and twigs of nerve and
artery.

Syphilitic Teeth \ \ 3

Hexagonal rods of enamel cover the working part of the tooth and
protect the less durable dentine ; when they are worn away the den-
tine soon perishes.

The crusta pctrosa is a thin layer of bone which covers the hidden
surface of the tooth ; it contains rudimentary Haversian systems. In
old people outgrowths from it are apt to form large exostoses.

Development of the teeth. — In the second month the margin of
the rudimentary jaw is marked by a primitive dental groove ; the
enamel is developed from the epithelial lining of this groove. The rest
of the tooth grows up as a small papilla from the subjacent part of the
groove and eventually becomes capped with the enamel. Each rudi-
mentary and temporary tooth then becomes shut into a separate com-
partment of the dental groove, the small chamber constituting the
dentinal sac. The permanent teeth are developed in secondary
dentinal sacs which are budded off from the backs of the primary
sacs.

Eruption. — It is impracticable to remember when each tooth of
the two sets should be making its appearance, but every student
should know that the first tooth of the milk-set is cut in the seventh
month, and the first of the permanent set in the seventh year. The
lower teeth appear before the upper, and the eruption of the lower
central incisors should be taken as a hint that the child should be
weaned. In the first set the lateral incisors appear after the central,
and, at the end of the year, the first molars : then come the canines,
and, in the second or third year, the back molars.

As regards the permanent set, in the seventh year the first lower
molars appear. In the seventh and eighth years, respectively, the
middle and lateral incisors emerge. In the ninth, tenth, eleventh, and
twelfth years come the first and the second bicuspids, the canines, and
the second molars ; just before the subject comes of age he is supposed
to have cut his wisdom teeth.

It should be noticed that the temporary incisors, which are cut well
within the first year, must needs be formed and calcified many months
earlier, and that when hereditary syphilis attacks the mouth it is
powerless to affect them. In the first year or two, however, when the
congenital taint is exerting its prejudicial influence on nutrition, the
teeth of the permanent set are being developed. They, therefore, and
not those of the milk teeth, are de-
faced by the disease. Syphilitic teeth
are unevenly arranged, and their /J
narrowed cutting edge is marked by "
a crescentic notch. The « test-teeth '
of Hutchinson are the central, upper incisors of the permanent set.

If the teeth of the permanent set are very large, or the alveolar
processes are too small to hold them, one or more of them may fail to
reach the surface, and may migrate towards the antrum, or nasal fossa.

114 The Teeth

Its sac may then become distended into a so-called dcntigerous cyst.
In rare instances, as age advances and the jaw is less crowded, one of
these belated teeth may make its appearance, which phenomenon may
raise the vain anticipation of a third natural set of teeth.

When the teeth are irregularly crowded along the alveolus, a
judicious weeding out of some of them may effect a great improve-
ment. That there is considerable plasticity about the alveolar process
in a child is evidenced by the fact that a constant and vigorous thumb-
sucking causes repression of the lower incisors and an unsightly pro-
trusion of the upper. Cases are not rare in which the alveolar process
is drawn entirely out of the mouth by the contraction of an extensive
cicatrix left after a burn of the front of the neck.

When it happens that the jaws cannot be separated, the surgeon
must not propose the extraction of a tooth in order that the patient
may be fed : as the patient lies in bed fluid food poured between the
cheek and the back teeth readily finds its way into the mouth.

THE TONGUE

The tongue is a mass of intrinsic and extrinsic muscles covered
with a mucous membrane. It is connected with the floor of the mouth,
lower jaw, soft palate, epiglottis, and hyoid bone.

The mucous membrane consists of a basement membrane which
is elevated into papillae, depressed into glands, and covered with
squamous epithelium. Down the middle of the dorsum is the raphe,
which ends posteriorly in the foramen caecum.

Fixing the tongue to the middle of the lower jaw is a fold of
mucous membrane, the/«z#»w. Sometimes, as a congenital defect, it
is so short that the tip of the tongue is closely bound down behind the
gum, and sucking is performed with difficulty ; the infant is then said
to be tongue-tied. It is best treated by raising the tongue by inserting
the left index and middle finger, one on each side of the frasnum, and
then snipping the band below the fingers with blunt scissors. This
being done, the band is torn through and the front of the tongue freed.
As the ranine vessels run beneath the tongue, on either side of the
frsenum, there would be danger of cutting them should the scissors be

directed upwards. The old-fashioned
steel director is still made with a flat,
expanded, and cleft handle for raising
the tongue and shielding the ranine
vessels during division of the fraenum, but it is rarely used for that
purpose. That the ranine vessels are in danger of being wounded by
a clumsy operator is evident : the vein is readily seen through the thin
membrane at the side of the fraenum. Some children have a dangerous
trick of swallowing the tongue, and it may be necessary in such cases
to shorten the fraenum by a plastic operation.

Muscles of Tongue \ \ 5

An nicer may form at the frcenum of a little child whose tongue is
constantly being scratched in a whooping-cough over the serrated edge
of his lower incisors.

Of the papillce, the largest are the circumvallate, about ten in
number, arranged in two oblique rows which slope back to the foramen
caecum. The fungi 'form, skittle-shaped, are chiefly scattered over the
sides and apex of the tongue ; they are deep-red, and in scarlet fever,
when the tongue is coated with a yellow fur, they are conspicuous by
their bright colour. The filiform are arranged as a protective layer
over the anterior two-thirds of the dorsum.

At the back of the tongue there are many mucous glands and
crypts like those in the tonsil.

The fur upon the tongue is the result of desquamation of the
epithelium which is constantly taking place. When a person sleeps
with the mouth open the fur becomes dried by the air passing over it,
and the tongue gets hard and rough.

Muscles. — The genio-hyo-glossus, fan-shaped, arises from the
upper of the genial tubercles, and is inserted in the middle line of the
tongue from apex to base, into the pharynx, and into the hyoid bone.

Action. — Its anterior fibres retract the tongue, its posterior fibres
raise its base and help in protrusion ; they also increase the antero-
posterior diameter of the pharynx, and draw upwards the hyoid bone
and the pharynx.

When, during operation, the muscle is detached from the maxilla,
the tongue is apt to fall back, and, the epiglottis sinking, suffocation
may ensue.

Its nerve is the hypoglossal. When a patient under an anaesthetic
is breathing with stertor, his lower jaw should be raised, so that the
attachment of the genio-hyo-glossus may be pulled upon, and the
base of the tongue thereby drawn out of the pharyngeal air-way.

Relations.— -Its inner surface lies in contact with its fellow. Its
outer surface touches the inferior lingualis, the hyo-glossus, the
lingual artery and gustatory nerve, and the sublingual gland ; the
hypoglossal nerve enters its outer surface. Its inferior border rests
against the genio-hyoid, and its superior border lies just behind the
fraenum.

The hyo-glossus, an oblong muscle, arises from the body and
cornua of the hyoid bone, and is inserted into the side of the tongue.
It is supplied by the hypoglossal nerve.

Relations. — Its deep surface rests against the lingualis, genio-hyo-
glossus, and the middle constrictor of the pharynx. The glosso-
pharyngeal nerve turns under its upper and posterior corner, and the
lingual artery runs beneath it (p. 28). Superficially, it has the tendon
of the posterior belly of the digastric, the stylo-hyoid, and the hypo-
glossal nerve ; the gustatory nerve ; the mylo-hyoid, and the deep part
of the submaxillary gland and its duct.

I 2

1 1 6 The Tongue

The stylo-glossus arises from the tip of the styloid process and
from the stylo-maxillary ligament, and runs with the stylo-pharyngeus,
and the glosso-pharyngeal nerve, between the external and internal
'carotids, to blend with the upper part of the hyo-glossus and the lin-
gualis. It is supplied by the hypoglossal nerve.

The lin^uaiis, the intrinsic muscle, consists of four sets of striated
fibres, namely, a superior and inferior longitudinal, a transverse, and a
vertical. The inferior set, the more important, extend from the base
of the tongue, and even from the hyoid bone, to the apex, lying between
the hyo-glossus and the genio-hyo-glossus, the ranine vessels resting
upon them. They help in retraction of the tongue. The transverse
fibres pass from the median fibrous septum to the border ; their action
is to narrow, and thus help in protruding the tongue. The vertical
fibres help to flatten and curl up the tongue.

Supply of tlie tongue. — The arteries are the lingual of the external
carotid, and, perhaps, twigs of the ascending pharyngeal and ascend-
ing palatine. The veins run to the internal jugular. The lymphatics
end in the deep cervical and submaxillary glands.

Nerves. — The gustatory branch of the inferior maxillary, a nerve
of common sensation, is distributed to the mucous membrane at the
side and tip. The extremely delicate sense of touch of this nerve is
utilised by the dealer in precious stones when the eye alone cannot be
trusted. Neuralgia of the nerve is sometimes so severe in cancer of
the tongue as to demand its section (p. 64). The glosso-pharyngeal
is the special nerve of taste behind the circumvallate papillae. The
hypoglossal supplies all the muscles, except the lingualis, which re-
ceives its stimulus from the chorda tympani (p. 66).

Excision of the tongue. — A strong-looped suture is first passed
through each side of the tongue near the tip, the loops being dragged
forward and slightly asunder ; then the tongue is split with scissors
down the median raphe', and each half is detached from the jaw, and
from the floor of the mouth, by short snips with blunt-ended scissors.
The loop of the ecraseur is then passed far back, and fixed round one
half by a firm pin, and as the wire is slowly tightened up the mass is cut
through without loss of blood, the tough lingual artery being dragged
out entire. The evulsed artery is then tied and divided ; if necessary,
the other half of the tongue is then similarly treated. Sometimes one
of the lingual arteries is found quite small.

When the lymphatic glands and the jaw are implicated the opera-
tion is much more serious, and must be commenced by an incision
from the front of the sterno-mastoid down to the hyoid bone and up
to the symphysis, laryngotomy having first been performed. In one
case in which I thus proceeded in the removal of advanced cancerous
disease I had to tie the external carotid, and, before the operation
was finished, I had removed the side of the pharynx and the tonsil.
The structures divided in an ordinary excision are the mucous

Parotid Gland 1 1 7

membrane passing to the jaw, the floor of the mouth, the soft palate,
and the epiglottis ; the genio-hyo-glossus, hyo-glossus, stylo-glossus,
palato-glossus, and lingualis ; the lingual artery and vein ; the gusta-
tory, hypoglossal, and glosso-pharyngeal nerves.

Ranula (? dimin. Q{ rana, frog) is a collection of fluid in a mucous
gland in the floor of the mouth, or in the duct of one of the salivary
glands. The fluid, however, is not saliva ; it is thick and glairy, and
may be secreted again and again after incision and scraping of the
cyst, and after swabbing out the interior with glacial carbolic acid.
Simply to snip a piece out of the wall of the cyst rarely suffices for
obliteration, for on the collapse of the cyst the edges of the wound
fall together and unite, and the fluid begins again to collect.

THE PAROTID GLAND

The parotid gland (napa, near ; ovs, wro?, ear} is a compound
racemose gland, enclosed in a tough capsule which is obtained from
the deep fascia. It lies in the hollow which is bounded behind by the
sterno-mastoid, the mastoid process, and the external meatus ; in front
by the ramus of the jaw ; deeply, by the stylo-maxillary ligament, and
above by the zygoma.

This limited space, however, is not sufficient ; and some of the
gland passes deeply behind the condyle into the glenoid fossa,
and beneath the sterno-mastoid, against the digastric ; a little of it
extends over the sterno-mastoid, and a good deal of it spreads over
the masseter. A portion of the gland also is tucked beneath the
ramus of the jaw, and even between the pterygoid muscles. From
this (anterior) part the duct emerges, and connected with it is an acces-
sory piece of the gland, the soda parotidis. The gland is covered in
by a process of the deep cervical fascia (p. 2), the lower part being
also beneath the platysma.

Additional connections of the gland are as follows: — The external
carotid artery, having entered it, sends off the superficial temporal and
internal maxillary branches from its substance ; the posterior auricular
winds up between the gland and the mastoid process, and the transverse
facial emerges from its anterior border. The external jugular begins
in the gland by the confluence of the superficial temporal and internal
maxillary veins, and sends a branch through the deep part of the gland
to join with the internal jugular. The primary branches of the facial
nerve come through the front of the gland, and the auriculo-temporal
ascends beneath its upper end. Close beneath the gland are the
internal carotid artery, the internal jugular vein, and the vagus.

Supply.— Branches for the gland come off from the various arteries
in its substance, the blood being returned to the external jugular vein.
The lymphatics pass to superficial glands near the parotid, and into

1 8 The Parotid Gland

the glandulu: concatenate. The nerves are derived from the
auricular, auriculo-temporal, the facial, and the sympathetic.

The duct, stenson's, comes off from the anterior part of the gland,
and, crossing the masseter below the transverse facial artery, but above
the chief part of the facial nerve, pierces the buccinator opposite the
second upper molar. The duct consists of a strong fibrous coat with
a mucous lining covered with columnar epithelium.

To mark out the course of the duct, a line must be drawn from the
lower part of the concha to the middle of the upper lip. When the
jaws are tightly closed the duct may be made out by running the
finger up and down the front of the masseter.

In operations upon the cheek, care must be taken not to wound
the duct, as a salivary fistula may occur, which is a most troublesome
one to obliterate. Sometimes a small calculus blocks the duct, and a
dilatation then occurs upon the parotid side of the obstruction, the
cavity becoming distended at the smell or sight of food. It is often a
very difficult matter to extract the calculus from the dilated part of the
duct, as it may slip back towards the gland or into a pouch developed
behind the angle of the jaw, or even beneath the ramus.

When malignant disease has invaded the parotid gland extirpation
is impracticable, and an attempt to accomplish it is likely to entail
profuse haemorrhage, facial paralysis — and disappointment.

A specific inflammation (iniunps) is apt to attack the gland ; the
swelling causes a bulging close below the jaw, and when it is sym-
metrical it renders the face very broad. The movements ^of mastica-
tion disturb the gland and cause pain. In rare cases facial paralysis
is caused by pressure on the portio dura, and more rarely still deafness
or abscess supervenes. In the latter case the pus might find its way
into the external auditory meatus. Mumps is distinguished from
cervical lymphatic enlargement by the fact that the chief swelling is
above the angle of the jaw.

The submaxillary gland is placed in the submaxillary triangle
(p. 9) resting upon the mylo-hyoid, and covered by skin, superficial
fascia, platysma, and deep fascia, and by the overhanging border of the
jaw. The deep part of the gland turns round the free border of the mylo-
hyoid and rests on the hyo-glossus and stylo-glossus. Posteriorly, the
gland is separated from the parotid by the stylo-maxillary ligament, and,
anteriorly, from the sublingual by the mylo-hyoid. The hyo-glossus
separates the gland from the lingual artery (v. p. 27). The facial artery
runs through, and the vein over, the gland.

Wharton's duct comes up from the deep part of the gland, passing
between the sublingual gland and the genio-hyo-glossus to open on
a conspicuous papilla at the side of the fraenum. The beginning of
the duct rests upon the hyo-glossus, between the gustatory and hypo-
glossal nerves.

Supply.— The arteries and veins are branches of the facial trunks.

Nasal Fossa 119

The lymphatics end in the glands beneath the jaw. The nerves come
from the chorda tympani (p. 66) and from the branches of the sub-
maxillary ganglion.

The sublingual gland lies in a slight depression behind the jaw,
near the symphysis, and along the anterior border of the genio-hyo-
glossus. It is at the side of the fraenum, and, resting upon the mylo-hyoid,
is covered only by mucous membrane. The hinder part is in relation
with that piece of the submaxillary gland \vhich is tucked beneath .the
mylo-hyoid. The ducts (Rivinian\ a dozen or more, open separately
by the side of the frsenum, but some join Wharton's duct as it runs
between the sublingual gland and the genio-hyo-glossus.

Supply. — Its arteries come from the sublingual and submental ;
the lymphatics pass to the submaxillary glands ; the nerves come from
the gustatory.

THE NOSE

T\& foundation of the nose is made of the nasal processes of the
superior maxillae, the nasal bones, the nasal spine of frontal, and the
vertical part of the ethmoid. But, with the view of obviating fracture,
the rest of the organ is composed of small cartilaginous plates which
are connected with each other, with the adjacent bones, and with the
cartilage of the septum by fibrous tissue, as well as by skin and
mucous membrane. These small cartilages can be acted on by
muscles which raise, depress, dilate, or compress the nares under the
guidance of the facial nerve.

Supply. — The arteries come from the lateral nasal of the facial,
and from the superior coronary— the artery of the septum. The root
of the nose also obtains blood from the nasal branch of the ophthalmic
and from the infra-orbital of the superior maxillary. The veins enter
the facial and the ophthalmic. The lymphatics pass to glands behind
the ramus of the jaw. The nerves are branches of the facial (for the
muscles), of the infra-orbital, of the nasal, and the infra-trochlear.

The nasal fossa opens in front by the nostrils, and into the pharynx
by the posterior nares. The floor is formed by the superior maxilla
and palate bones, and the roof by the nasal and frontal bones, the
cribriform plate of the ethmoid bone, and the body of the sphenoid.

Syphilitic inflammation of the muco-periosteum of the nose in
childhood is apt to cause necrosis of the nasal bones, involving a
permanently sunken bridge.

As a result of imperfect ossification in the region of the anterior
and median part of the frontal bone, the membranes of the brain may
bulge forward and produce a mening-ocele. This defect is most often
found at the root of the nose, but on rare occasions the protrusion has
escaped by the cribriform plate of the ethmoid, and, having been

I2O The Nose

taken for and treated as a polypus, the base of the skull has been
lacerated and fatal meningitis has supervened.

Building up the outer wall of the fossa are the nasal process and
the body of the superior maxilla, the lachrymal, inferior turbinated,
the vertical plate of the palate, and the internal pterygoid process.
And entering into the formation of the septum, or inner wall, are the
triangular cartilage, the vertical plate of the ethmoid, and the vomer.
The septum often deviates so much to one side that that passage is
useless for respiration. The bulging may be taken for a tumour or an
abscess, but on introducing a probe or a finger into the free nostril
the condition is at once recognised. The septum may sometimes be
adjusted by force, but some cutting and trimming may be needed in
addition.

The mucous membrane, which closely adheres to the periosteum,
is continuous with that lining the pharynx, and, through the anterior
nares, with the skin. In the last-named region its epithelium is
squamous ; in the middle — the respiratory part of the fossa — it is
columnar ciliated, and in the region of distribution of the olfactory
nerve it is columnar, but not ciliated. The membrane is thick, and
is freely studded with mucous glands. Sometimes it is a good deal
hypertrophied over the lowest spongy bone, where it may possibly be
mistaken for a polypus.

The mucous membrane is easily stripped up from the septum, and,
as it is strong, an abscess beneath it may raise it to a considerable
extent before finding its discharge.

When, as the result of injury, the front cartilage is detached from
the bone, great pain may ensue from bruising of the nasal nerve,
which is escaping at the line of fracture (v. p. 62).

The nose has often a slight lateral inclination, and this may be
noticed for the first time after the receipt of a blow. The person may
then protest that it was previously quite straight. One of the greatest
living sculptors affirms, indeed, that the two sides of the head and face
are never symmetrical — unless in the case of professional beauties and
of others of a like intellectual capacity.

The inferior meatus runs along the entire length of the floor of the
nose, beneath the inferior turbinated bone. It receives towards the
front the nasal duct. It is along this meatus that the Eustachian and
the cesophageal catheters are passed.

The middle meatus occupies the posterior two-thirds of the fossa,
being above the inferior and below the middle turbinated bone. It
receives the opening of the antrum, and, through the infimdibulum, the
openings of the anterior ethmoidal and frontal sinuses.

The superior meatus occupies the posterior third of the cavity : it
is above the middle spongy bone. Into it open the posterior ethmoidal,
and, perhaps, the sphenoidal sinus.

Supply. --Arteries for the cavity come from the anterior and

Nasal Polypi 121

posterior ethmoidal branches of the ophthalmic ; and, in the case of a
fracture extending across the anterior fossa of the skull, these vessels
may be lacerated, and severe bleeding may occur from the nose.
The facial, and the spheno-palatine and the descending palatine of the
internal maxillary, also afford branches, and the superior coronary
sends a twig to the front of the septum. The veins correspond to the
arteries.

Of the lymphatics, some pass with the olfactory filaments into. the
subdural space, and others enter the glands near the angle of the
jaw.

Of the nerves, olfactory filaments are distributed to the roof and to
the inner and outer walls near the roof ; the nasal of the ophthalmic
gives sensory branches to the anterior part of the fossa, and the
anterior dental, Vidian, spheno-palatine, and descending palatine also
send in branches.

Chronic purulent discharge from one nostril is very apt to be caused
by necrosis or by the presence of a bead or a bean in the meatus.
Discharge from both nostrils is more likely to be the result of consti-
tutional disease. It may be treated by sending a gentle stream of
tepid water from an irrigator up one nostril whilst the patient breathes
through the open mouth ; the soft palate and the palato-pharyngei
(p. 1 08) then keep the nasal part of the pharynx shut off from the
ouccal tract, so that the lotion, turning round the back of the vomer,
flows out through the other nostril.

In two cases of necrosis high in the fossa I have successfully
performed Rouge's operation, which consists in incising the superior
labio-dental fold of membrane, and then detaching and everting the
lip and the soft parts of the nose. In this way exploration of, and
operation upon, the upper spongy bones can be most effectually carried
out.

Mucous polypi generally hang from the superior and middle tur-
binated bones, and are usually covered
with ciliated epithelium. They grow
in crops, and, blocking the nostril, ob-
struct respiration. Pressing outwards,
they may widen the nose, and, com-
pressing the nasal duct, may cause the
eye to ' water.' In inveterate cases,
when crop succeeds crop of polypi, it
may be expedient to draw out by the
forceps the middle and superior spongy
bones— taking care, of course, not to
damage the cribriform plate.

Bleeding- from the nose, if not the
result of fracture of the base of the
skull (p. 81), or of other injury, may be a general oozing from the en-

122 The Nose

gorged capillaries, in which case it comes as a relief, but it is a
be due to ulceration into an artery, in which case it is likely to occur
from the cartilage of the septum ; if so, prolonged pressure between
the finger and thumb may stop it at once. Pulmonary or cardiac
disease, by delaying the venous return, may be the cause of the
haemorrhage. The subject should keep erect, so as to help the venous
return, and he evidently should not blow his nose. Nor should he be
allowed to hang his head over a basin, as this attitude compresses the
jugular veins, and increases the venous engorgement (p. 36). The
vaso-motor centre may be stimulated by cold applied to the back
of the neck.

Plugging the nares may have to be resorted to if the bleeding
become very serious. If no better apparatus be at hand, a piece of wire
from a soda-water bottle may be bent into a suitable loop, and, having
been armed with a doubled string, may be passed along the floor of the
nose and down against the posterior wall of the pharynx. As soon as
the string appears below the level of the palate the loop should be
caught and brought out between the teeth, the wire being withdrawn
from the nose. Another piece of string should be fixed in the loop for
the subsequent drawing out of the plug, which should consist of a
small roll of lint, a little larger than the last joint of the patient's
thumb. This, having been secured in the loop, and having been
helped round to the back of the soft palate by the finger in the mouth,
should be drawn firmly into its place by pulling on the ends of the
string which hang from the nostril. Then a plug is thrust into the
nostril and tied in position by the two strings, the single string which
hangs out of the mouth being also fixed to the anterior plug.

The posterior plug, being firmly jammed in the oblong, bony frame
of the horizontal process of the palate bone, the internal pterygoid
plate, the vomer, and the body of the sphenoid, may set up necrosis if
it be too long retained.

Development. — The external nose is formed from a broad median
lappet which comes down from the cranium. Its central part forms
the tip of the nose, and, descending below the level of the nares, con-
stitutes the septum between them (the columella) and, lower down, the
lunula, or central part of the upper lip. The side of the nose is de-
veloped from the nasal process which comes down between the orbit
and the maxillary process.

The depression for the eye is continuous with the mouth through
an oblique cleft between the fronto-nasal and external nasal processes,
internally and above, and the maxillary plate externally and below ;
rarely does the entire fissure leading into the orbit remain uneffaced.
As remarked on p. 76, the nasal duct is the unobliterated part of this
cleft. (See also pp. 105 and 123.)

Branchial Clefts

123

A NOTE UPON DEVELOPMENT GENERALLY

From the external layer of the blastoderm (/SXaoros-, germ ;
iri)—\he epiblast — the entire nervous system, central and peripheral,
is developed, as are, also, the organs of sense, the cuticular covering
of the body and the lining of the mouth, together with its accesspry
glands.

From the hypoblast are developed the epithelium of the alimentary
canal and air-passages.

From the mesoblast come the bones, muscles, and vessels ; the

A, Embryo at three weeks ; i and 2,
cerebrum ; 3, fronto-nasal process ;
4, superior maxillary plate ; 5, eye ; 6,
inferior maxillary, or mandibular
plate ; 7, 8, and 9, second, third, and
fourth plates, or branchial arches, and
below each plate the corresponding
pharyngeal cleft. AA, i, 2. 3, and 5,
same as in A ; 4, lateral frontal or ex-
ternal nasal plate ; 6, sup. max. plate ;
7, mandibular ; 8, first pharyngeal
cleft, which becomes auditory passage ;
above and below 6 are seen the orbital
and mandibular fissures respectively.

B. i, Lower jaw; i', first post-oral cleft widening
out to form ext auditory meatus ; the second
cleft is still visible, but the third and fourth
clefts have become effaced, c, foetus at nine
weeks ; first pharyngeal cleft is now obliterated,
and the pinna, i', is beginning to grow up
around the unclosed dorsal end.

skin (not the epidermis) ; the alimentary canal (not the epithelium), and
the genito-urinary apparatus.

The facial part of the head is developed from bar-like growths from
the cranial base, some in front of, and some behind, the buccal cavity ;
the mouth, which is at first closed in, being a cleft between the facial
plates. The pre-oral plates are the median fronto-nasal (p. 105) and
the pairs of the lateral nasal and maxillary plates. The plates
behind the mouth (post-oral] are in five lateral pairs : the mandibular,
for the lower jaw ; the hyoid, for the upper part of the hyoid bone ; and
three pairs down the neck. The post-oral plates are sometimes
called branchial (flpny^ta, gills) from their corresponding to the gill-
plates of aquatic vertebrates.

The branchial clefts are the slits below the branchial plates, or the

124

Development

arches through which the cervical epiblast blends with the pharyn-
geal hypoblast. From the first cleft the Eustachian tube and tym-
panum are developed, the meatus auditorius grows from its hinder end,
and the pinna from the neighbouring integument (p. 102).

Branchial fistulae may be found in the middle line of the neck,
where the lateral arches have failed to meet, and down the side of the
neck, by the anterior border of the sterno-mastoid, where the blending
of the adjacent arches has been imperfect. Their most common
situations are shown in the adjacent sketch, which has been kindly lent

by Mr. Bland Sutton, to
whose Lectures in the
' Lancet' of 1888 the
reader will do well to
refer. These fistulas
lead by slender canals
deeply into the neck,
towards the pharynx,
with which they were
originally continuous.
Sometimes they are in
symmetrical pairs.
Paget has noticed that
their secretion is aug-
mented during bron-
chial or nasal catarrh.

Occasionally a small
pendulous nodule of
skin, or of skin and
cartilage, marks part of
the line of closure of
one of the clefts, just as
nodules grow at the end
of the first post-oral

A F, A F', situations of congenital auricular fistula: ; i, H, in, fissure to form the pill-

IV, external orifices of branchial fistulae, I being the ex- na, and Sometimes a

ternal auditory meatus ; OF, orbital fissure; M F, man- . ..

dibular fissure ; H H, lines of hare-lip ; c F, c F', show Similar nodule persists

median cervical fistulae. jn the mjddle line as a

clumsy representative of a needless raph^, by way of evidence of the
fusion of the plates in the middle line.

Derm old cysts, which are frequently found in the face, neck, and
pinna, are due to pieces of the epiblast in some of the clefts having
been closed in externally ; their epidermal lining secreting a seba-
ceous material, the cysts become conspicuous, and may in due course
demand removal. Sometimes the cysts contain hair and sebaceous
glands.

Thyroid Cartilage 125

THE LARYNX

The larynx is hung from the hyoid bone and the styloid process.
It is continuous with the trachea at the level of the lower border of the
fifth cervical vertebra. Above and in front is the tongue ; behind is
the pharynx, into which it opens by the glottis.

Standing out in the middle line of the neck, between the two sterno-
mastoids, it forms a groove in which lie the common carotid artery with
the internal jugular vein and the vagus.

The thyroid cartilage consists of the alas which unite in a promi-
nent angle, thepomum Adami, separated from the fascia and skin by
a small bursa.

On the outer surface of the ala a ridge runs downwards and for-
wards from the root of the superior cornu, for the insertion of the
sterno-hyoid and the origin of the thyro-hyoid. The inferior con-
strictor of the pharynx arises from the surface behind the ridge. The
inner surface of the ala is covered by mucous membrane, and, at the
retiring angle, gives attachment to the vocal cords and the thyro-
arytaenoid muscles. To the upper border is attached the thyro-hyoid
membrane. The crico-thyroid muscle and membrane are connected
with the lower border.

The posterior borders of the cartilage are widely separated, the
gap being filled in below by the cricoid and arytasnoid cartilages, and
they receive the insertion of the stylo-pharyngei. The width of the
lower part of the pharynx is maintained by the attachment of the
inferior constrictor to the posterior part of the alae. The posterior
borders lie close to the front of the middle cervical vertebras, and in
roughly pushing' the cartilage across the front of the vertebrae a moist
sort of crepitus is produced, which, being first noticed after an injury,
might possibly suggest fracture.

Fracture of the thyroid cartilage may result from violence. There
is difficulty and pain in coughing and swallowing, and there are swell-
ing and tenderness about the larynx. The patient should be kept on
his back and fed on enemata and liquid food; he should not be allowed
to talk. Tracheotomy may be needed if the injury and swelling are
great.

The cricoid cartilage, named from its resemblance to a signet-
ring (KptKo?), has its expanded part in the gap between the alas of the
thyroid, and its slender part in front, below the thyroid, with which it
is connected by the crico-thyroid membrane. Its lower border is at-
tached to the first ring of the trachea by a thin membrane. From the
posterior part arise the crico-arytasnoidei postici and the longitudinal
fibres of the oesophagus. The arytaenoid cartilages articulate with
the upper part of the expanded portion, and the inferior cornua of the

126 The Ldrynx

thyroid are hinged at the lower part of the side by capsular ligaments
and synovial membranes.

When more room is needed in tracheotomy it may be expedient to
divide the cricoid (vid. inf.}.

The arytsenoid cartilages are two small pyramids which articu-
late by their base with the upper and back part of the cricoid. Of
their three surfaces, the inner looks towards its fellow, and is covered
by mucous membrane ; the posterior is connected with its fellow by the
arytsenoideus, and the anterior receives the insertion of the thyro-
arytaenoid muscle.

To the anterior angle is attached the true vocal cord ; the external
angle receives the insertion of muscular slips which arise on the cricoid,
and the apex is connected with the corniculum laryngis, which is hidden
in the arytaeno-epiglottidean folds.

The epiglottis, shaped like an obovate leaf, is attached by its stalk
to the back of the thyroid, just above the vocal cords ; its anterior
surface is connected with the back of the hyoid bone by the hyo-epi-
glottic ligament, and with the base of the tongue by three bands of
mucous membrane — the glosso-epiglottidean folds. The posterior
surface looks towards the back of the pharynx during respiration ; but
when the larynx is hidden beneath the base of the tongue during de-
glutition, and the glosso-epiglottidean folds are relaxed, the epiglottis
falls over the laryngeal aperture, and its posterior surface is turned
downwards.

Structure. — The epiglottis is composed of yellow fibrp-cartilage,
which does not ossify, but the thyroid, cricoid, and arytaenoid cartilages
are apt, like the costal cartilages, to ossify as age advances.

The thyro-hyoid membrane is attached to the upper border of
the thyroid cartilage, and, ascending behind the hyoid bone, is con-
nected with its upper border, a bursa intervening between the mem-
brane and the back of the bone. On rare occasions this bursa be-
comes inflamed, or, being distended with fluid, forms a cyst. The
bursa is placed there in order that the thyroid cartilage may ascend
freely behind the hyoid bone during deglutition.

Through each side of the membrane run the superior laryngeal
vessels and nerve.

The crico-tnyroid membrane fills the interval between the cricoid
and thyroid cartilages, and is firmly connected with them in front ;
laterally, however, it ascends free on the inner side of the thyroid, and
becomes continuous above with the lower border of the true vocal cord.
The anterior part of the membrane is subcutaneous, but its sides are
covered by the crico-thyroid muscles. Upon it rests the anastomotic
loop between the two crico-thyroid or external laryngeal arteries.

The membrane is traversed in the operation of laryngotomy, and
sometimes the insertion of the tube fails to arrest bleeding from the
divided artery.

Vocal Cords 127

The superior aperture of the larynx is triangular, the base being
formed by the epiglottis, and the sides by the arytaeno-epiglottidean
folds and the arytaenoid cartilages. In the folds the cuneiform carti-
lages may be recognised.

The glottis (-yXcoo-o-a, -yXcorra, tongue, throat] or rima glottidis
(rima, chink) is the narrow triangular opening between the true vocal
cords and the bases of the arytaenoid cartilages. The apex of this
space is forwards, corresponding to the thyroid attachment of the cords.

In ordinary respiration the glottis is wide open, the arytaenoid car-
tilages being far apart, but in vocalisation, and when respiration is
forced, the space is narrowed.

The rima is the narrowest part of the larynx. In the adult male it
measures about an inch from before backwards.

The false vocal cords are folds of mucous membrane lying parallel
with and above the true cords ; they are attached in front to the retir-
ing angle of the thyroid, below the epiglottis, and behind to the front
of the arytasnoid cartilages. The interval between them is wider than
that between the true cords.

The true vocal cords are delicate elastic bands between the re-
tiring angle of the thyroid and the anterior angle of the arytasnoid
cartilage. They are covered with mucous membrane, continuous
below with the upper border of the crico-thyroid membranes. The
epithelium upon the true cords is squamous.

Between the true and false cords there is on each side a space, the
ventricle of the larynx, which is continued upwards for nearly half an
inch between the false vocal cord and the ala of the thyroid. It con-
tains a large number of mucous glands for lubricating the vocal cords,
for the membrane of the cords themselves is too delicate to contain
glandular tissue.

Muscles. — The crico-thyroid, triangular, arises from the side of the
cricoid cartilage and is inserted into the lower border of the thyroid.
Its action is to tilt the thyroid down to the cricoid (or the front of the
cricoid up to the thyroid), and so to tighten and elongate the cords.
It is supplied by the external branch of the superior laryngeal
nerve.

The posterior crico-aryteenoid arises from the back of the cri-
coid, and, passing upwards and outwards, is inserted into the outer
angle of the arytaenoid cartilage. Drawing this angle backwards, the
two muscles rotate the anterior angles outwards (abduction of cord)
and widen the glottis. ' They come into action during deep inspira-
tion. If paralysed, the lips of the glottis approach the middle line
and come in contact with each inspiration, so that severe dyspnoea
may be produced. Expiratory efforts, however, are not impeded, and
vocalisation is unaffected.' (Quain.)

The lateral crico-arytsenoid arises from the upper border of the
side of the cricoid, and, passing back, is inserted into the outer angle

The Larynx

of the arytaenoid. These muscles rotate the anterior angle
arytaenoids inwards, and thus approximate the cords.

The thyro-aryteenoid runs along the outer side of the true vocal
cord, being attached to the retiring angle of the thyroid, and to the an-
terior surface of the arytsenoid. Contracting, it shortens and slackens
the cord ; it is the antagonist of the crico-thyroid.

The arytaenoideus consists of bundles of striated fibres passing
from the back of one arytaenoid cartilage to the other. Its action is
to tilt the arytaenoid cartilages together and so to close the hinder
part of the glottis. It derives its motor filaments both from the
superior and the recurrent laryngeal branch of the vagus.

All the muscles of the interior of the larynx can act together as a
sort of sphincter; and so it happens that when the epiglottis is
destroyed by ulceration the patient can swallow without being choked.
He is safest, however, when bending his head well down and sucking

Vocal cord
Thyroid cart. —
Cricoid cart.

Glottis dilated. (HOLDEN.)

up the food by a tube, when it is taken to the oesophagus in the
zealous grasp of the constrictors.

Laryngismus stridulus (Xapuyyi^co, shout ; strideo, hiss] is a
spasmodic affection of the muscles of the cords in infancy ; it is also
called laryngeal asthma, and is often associated with spasmodic
contractions in the hands and feet. It is the result of some central
nervous irritation, and may be caused by indigestible food disturbing
the pneumogastric filaments in the stomach. Spasmodic asthma in
the adult may be caused by the pressure of aneurysmal or malignant
tumours upon the recurrent laryngeal nerves. The spasm generally
yields as carbonic acid poisoning comes on, but it may have to be
treated with chloroform inhalations, or, in the adult, by opening the
windpipe.

The mucous membrane of the larynx is continuous with that of
the pharynx and of the trachea. It is covered with columnar ciliated

(Edema of Glottis 129

epithelium below the false vocal cords ; above that it is squamous,
except in the lower half of the laryngeal aspect of the epiglottis, where
it is columnar ciliated. It contains many mucous glands, in some of
which the secretion may collect to form cystic tumours. About the
upper aperture the mucous membrane contains much loose connective
tissue, which becomes extensively infiltrated in oedema of the glottis.

(Edema of the glottis may be caused by boiling water having
been swallowed, or by laryngitis ; the serous infiltration of the sub-
mucous tissue resembles that of oedema of the prepuce or eyelid. The
onset is marked by cough, hoarseness, and dyspnoea. Scarification of
the swollen tissue may give relief, or a soft catheter may be passed
along the floor of the nose, and through the glottis, by which respira-
tion may be carried on ; but the surgeon must always be in readiness
to open the windpipe below the obstruction.

In acute laryngitis the vocal cords swell, and, vibrating amiss,
the voice becomes hoarse and the respirations noisy and difficult ; and
there is a 'brassy' cough. On account of the close proximity of the
pharynx, there is pain with deglutition. Unless relief be afforded, the
patient may die of suffocation ; indeed, laryngotomy or tracheotomy
may be early needed.

Supply. — The arteries are the superior and external laryngeal
branches of the superior thyroid, and branches of the inferior thyroid,
the blood being returned by the superior, middle, and inferior thyroid
veins. The lymphatics pass to the deep cervical glands.

The nerves are the superior, and the recurrent laryngeal branches
of the vagi, and filaments from the sympathetic. The superior
laryngeals supply the mucous membrane, and give off the external
laryngeal branches for the crico-thyroidei, and twigs to the arytys-
noideus. The recurrent laryngeal supplies all the other muscles, and
gives additional filaments to the arytasnoideus.

In making a laryngoscopic examination the observer should be
seated at a rather lower level than the patient ; the mirror should be
passed under the base of the uvula without having touched the tongue
or the pillars of the fauces, but even then its gentle application may
set up reflex vomiting (p. 70). The mirror being tilted, the epiglottis
is seen in its upper part, and the arytaenoid cartilages are seen in the
lower part ; but the vocal cord which is seen on the patient's right side
is actually the right cord. The cords appear white, and above them
are seen the false cords and the opening of the ventricle. The
arytaeno-epiglottidean folds are conspicuous objects ; the front of the
trachea is also seen, and possibly its division into the bronchi. Some-
times the wall of a thoracic aneurysm may be seen bulging into the
trachea.

An opening- in the windpipe is needed when the laryngeal
air-way is seriously blocked. Among the chief signs of urgency are
a sinking-in of the supra-clavicular, supra-sternal, and epigastric

130 77/r Larvn.v

regions ; a noisy passage of the air through the glottis ; and

tress which is associated with laboured and ineffectual attempts at

respiration.

The simplest operation is that of passing a tube through the crico-
thyroid space, but in the child this interval is far too narrow to serve,
so that the trachea has to be opened instead — tracheotomy always in
the child. Tracheotomy, moreover, is to be preferred in the adult
when the tube has to be left in permanently, as it is further away from
the vocal cords, and therefore less likely to set up inflammatory
thickening in that important region. Tracheotomy is also resorted to
in the adult when there is a foreign body below the cords.

In laryng-otomy the shoulders are raised, and the head is thrown
back and held perfectly square to the middle line. The surgeon feels
for the thyroid cartilage, and, a little below its prominent inferior
border, the arch of the cricoid. He then makes an inch incision
down the middle line, beginning it \ in. above the bottom of the
thyroid, and traversing skin, superficial, and deep fascine. Thus the
crico-thyroid membrane is readily exposed ; on it is the small arterial
communication between the two superior thyroids, which is generally
cut, but it rarely gives any troublesome bleeding. The membrane is
incised across the middle line, so as to secure a more easy introduc-
tion for the tube.

Thyrotomy. — For the removal of a foreign body from the larynx,
or for the clearing away of a crop of warty growths which impede
respiration, or for the more efficient dealing with intra;laryngeal epi-
thelioma, the thyroid cartilage may have to be split up the middle and
the halves turned asunder.

Tracheotomy having been first performed, the skin and fasciae are
divided down the middle line of the pomum Adami, the wound being
continued into that which is already made for the tracheotomy. The
incision through the thyroid cartilage must be kept exactly in the
middle line, as it has to hit the narrow interval between the anterior
ends of the vocal cords. To make more room, the thyro-hyoid and
crico-thyroid membranes should also be cut.

Removal of the entire larynx, a dangerous and unsatisfactory
operation, may be undertaken after a preliminary tracheotomy, due
provision having been made against the entrance of blood into the
trachea.

A median incision through skin and fasciae is made from the hyoid
bone to the top of the trachea, and, at the top of this, a transverse one.
Then, with the blunt end of a pair of scissors, the sterno-thyroid and
thyro-hyoid and other soft tissues are torn through, raised from the
larynx, and turned back with the skin, fasciae, and the sterno-hyoid and
omo-hyoid. The trachea is cut across just above the wound made
for the silver tube, and the cricoid end of the larynx is drawn forward,
and cleared by division of the recurrent laryngeal nerve and branches

Tracheotomy 1 3 1

of the inferior thyroid artery ; the oesophagus and the inferior con-
strictor of the pharynx and the lobes of the thyroid gland are also
detached.

The constrictor is then separated from the thyroid cartilage, and
the superior laryngeal vessels and nerve are divided.

THE TRACHEA AND BRONCHI

The trachea begins at the lower border of the fifth cervical
vertebra, and divides opposite the lower border of the fifth dorsal —
that is, a little below the transverse sternal ridge (p. 149). It is about
4 in. long and f in. wide, and consists of about sixteen horse-shoe
cartilages connected by elastic fibres, whilst in the tissue which fills
the deficiency in the cartilages at the back of the trachea is a trans-
verse layer of non-striated muscular fibres. Probably the trachea is
flattened behind so that it may not encroach upon the oesophagus and
impede deglutition ; a foreign body impacted in the oesophagus, or
malignant disease, may cause fatal dyspnoea. (For Mucous MEM-
BRANE, v. p. 195.)

Relations. — The most constant relation of the trachea is the
oesophagus, which is close behind it both in the neck and in the thorax.
In the lateral grooves between these tubes ascend the recurrent
laryngeal nerves. The common carotid arteries, the lobes of the
thyroid body, and the inferior thyroid arteries are also to the sides.
In the superior mediastinum (p. 154) the trachea descends between
the pleurae, a pneumogastric passing on either side of it to form the
oesophageal and the posterior pulmonary plexuses. The innominate
artery is somewhat to the right, and the beginning of the left carotid
to the left of the trachea.

In front are the skin and fasciae, the isthmus of the thyroid, and
the lowest thyroid artery and thyroid veins ; the sterno-hyoid and
sterno-thyroid, and some more deep fascia. Lower down the anterior
relations are the manubrium, the remains of the thymus, the left
innominate vein ; the second part of the aortic arch with the origins
of the innominate and left common carotid arteries, and the deep
cardiac plexus.

Supply. — The trachea derives its blood from the inferior thyroid
artery, and returns it by the lower thyroid veins. The lymphatics
pass to the deep cervical and the mediastinal glands.

The nerves are branches of the vagi, the recurrent laryngeals, and
the sympathetic.

Tracbeotomy. — The patient's shoulders are raised on a firm pil-
low, and the head is thrown straight back so as to draw up and steady
the trachea, and to give more room to the operator. The thyroid and
cricoid cartilages and the upper part of the trachea are then made out
by the tip of the index-finger.

The incision even in a child had better be free, from \\ to 2 in,

132 Tracheotomy

long ; it must be kept absolutely in the middle line and high up. ihe
lower down the neck that it is made, the deeper lies the trachea ; it
should, therefore, be begun over the lower border of the thyroid car-
tilage, and the surgeon should make it his object to open the very
highest rings of the trachea, and, if need be, the cricoid also. This
laryngo-tracheal operation does well in children, and, resorting to it,
the surgeon is certain to escape the dangers and difficulties which are
inseparable from the low operation.

Thyroid Cartiltujr _^

Orioo-thyroifi Membrane

9 ie Artery
Crusoid Cartilage.
Superior TJiyroid -vein

Infer. TJiyroid
Ji.rtcri<t tnnominata

Front of child's neck. (G RAY. )

The skin, superficial fascia, some tributaries of the anterior jugular
vein, and the deep fascia are divided. The narrow interval between
the sterno-hyoids is traversed with a director and forceps, and a second
layer of the deep fascia is then torn through.

The trachea, having thus been denuded, is caught and fixed by a
sharp hook, and a knife is plunged through the second or third ring,
and, the edge being directed forwards, a sufficient opening is made in
the upward direction for the tube. In old people the trachea 1 rings
may be ossified.

Though the surgeon prefers not to open the trachea until all bleed-
ing has been checked, he need not dread even free venous oozing ; for
as soon as air enters the lungs the right side of the heart empties itself

Tracheotomy 133

again, and the engorgement of the tributaries of the innominate veins
subsides.

In the high operation the surgeon opens the trachea above the
isthmus of the thyroid gland. A great deal is discussed about the
misfortune of wounding the isthmus ; for my own part, I never give
it a thought, but clear all the tissues from the front of the top rings
of the trachea by using a director and pair of dissecting-forceps. If
the isthmus happen to be across this track, and not easily displaced;
it must be sacrificed. But, if the surgeon proceed to open the trachea
below the isthmus, not only will he find it deeply placed, but he will
also be traversing the region of the important inferior thyroid veins
which descend from the isthmus to the innominate veins. Moreover,
should the left common carotid come from the innominate, should
there be a thyroidea ima, or should the left innominate vein cross
above the level of the episternal notch, as sometimes happens, the
complications might be extremely grave. He may even surprise
himself by coming against the apex of the thymus, which in young
children ascends well into the neck, as is shown by the figure on
pp. 132 and 155.

The metal tube should not be too much curved, lest its sharp end
impinge against the front of the trachea and set up an ulceration,
which may eventually implicate the left innominate vein, or the
innominate or common carotid artery, and entail a fatal haemo-
ptysis.

Fallacies in the operation.1 — ' The skin wound may be too low
and too short ; the trachea may have been dragged aside, or not
sufficiently incised, so that the tube . . . does not enter, but slips down
in front of it. The trachea may be altogether missed if the dissection
be not kept in the absolute middle line. If the wound in the trachea
be made with a dull scalpel, and without the little plunge, the mucous
lining may escape transfixion, the tube passing down between it and
the tracheal wall. If air do not pass through the tube, either naturally
or on compressing the chest, the chances are that the tube has not
been passed into the trachea. . . . The tube may be blocked with mucus,
or its aperture obstructed by false membrane. If the tracheal wound
be open, search should be made for a membranous cast of the trachea,
which might be drawn out by forceps. For thorough exploration, the
tracheal wound should be enlarged slightly upwards, and a pair of
forceps introduced. . . . Much more likely is it that the tube has
been passed down amongst the ribbon muscles at the front of the
trachea than that its end is blocked by a membranous cast of the
trachea.

* I know of a case in which, from the windpipe having been twisted
from its position, the tube was found post mortem to have been
introduced into the trachea through the cesophagtis ; and of another

1 From The Surgical Diseases of Children^ Cassell & Co., 1889.

134 The Bronchi

in which the tube had been dashed right through the trachea and into
the oesophagus ! '

The right bronchus (see also p. 194), about an inch long, slopes
downwards and outwards in the root of the lung, to enter opposite the
fifth dorsal vertebra. As the right lung is larger than the left (which
has to make room for the heart), the right bronchus is the larger, and,
having a greater intake of air, is the more apt to receive a foreign body.
Because the right bronchus is larger than the left, the tracheal septum
must of necessity be rather to the left of the median line.

The vena azygos major arches over the right bronchus in its course
to the superior cava.

The left bronchus has to run across the front of the third part of
the arch of the aorta before it can divide in the root of its lung. It
is two inches long; its diameter is less than that of the right. It
enters the lung opposite the sixth dorsal vertebra, about an inch
lower than the right. It passes in the root of the lung beneath
the aortic arch, and in front of the oesophagus (p. 139), the third
part of the arch, and the left auricle. This last relationship is of
considerable clinical interest, for when, under the influence of mitral
regurgitation, that auricle is greatly dilated, it may obstruct the flow
of air along the left bronchus. (For the structure of the bronchi sec

P- I95-)

A foreign body in the bronchus may be extracted by appropriate
forceps through a free opening made low in the trachea. For this
purpose it will be well to stitch the edges of the tracheal ^vound to the
skin as soon as bleeding has been arrested, so that the 'way into the
bronchus may be made more direct and easy. If the foreign body
were taken down at the end of an inspiration, the area of lung to
which the bronchus led would be tideless but resonant, but after a
while oedema and, perchance, suppuration would render it solid.

If attempts at extraction failed, the body might escape through
the tracheal wound, which should be stitched wide open ; or it might
escape through a localised thoracic abscess ; the pulmonary and costal
pleurae having become adherent, pneumothorax might not ensue.

THE THYROID GLAND

The thyroid gland consists of lateral lobes connected across the
second and third rings of the trachea by the isthmus. The outer sur-
face of the lateral lobes is convex ; their inner aspect is fitted on to the
side of the upper four or five rings of the trachea, the cricoid cartilage,
and the lower part of the thyroid cartilage. Often the isthmus extends
up to the level of the cricoid cartilage.

A slender pyramidal lobe sometimes mounts from the isthmus to
the hyoid bone. Sometimes the isthmus is very wide and descends
almost to the sternum — the tracheotomist should always endeavour to
operate above the isthmus.

Bronchocele 135

Relations. — The gland is covered by the deep fascia, the sterno-
hyoid, sterno-thyroid, and omo-hyoid, and laterally by the sterno-
mastoid. Beneath it is the sheath of the common carotid, and on the
inner aspect are the trachea and larynx, the oesophagus (on the left
side), and the pharynx.

The firm connection of the gland with the upper part of the wind-
pipe is a fact of great clinical importance ; when there is dilatation
of the vessels of one lobe a rounded tumour occurs in the groove
between the larynx and sterno-mastoid, which, pulsating with thrill and
expansion, strongly suggests aneurysm of the upper part of the common
carotid. On making the patient swallow, however, the tumour glides
up and down with the larynx : a carotid aneurysm is not influenced
by the movements of deglutition. An accessory thyroid gland is not
unknown.

Supply. — Arteries come from the superior, the inferior, and, some-
times, from the lowest thyroid branches. Of the veins, the superior
and middle enter the internal jugular, whilst the inferior descend in
front of the trachea as important tributaries of the innominates (p. 132).
The lymphatics enter the deep cervical glands.

Nerves. — Sympathetic filaments come from the cervical ganglia
along with the arteries, and other branches are derived from the external
and the recurrent laryngeals.

Structure. — There is a fibrous coat which sends in processes
dividing the gland into irregular lobules ; these consist of a gluey
material containing seed-like vesicles. The vesicles contain corpus-
cular elements and more of the glue, and, when greatly distended,
they cause cystic enlargement of the gland. Sometimes the cysts
contain serum, sometimes blood.

The probable function of the gland is * the control of the muci-
noid substances in the tissues of the body, and the manufacture of
blood-corpuscles.' (Horsley.) When the gland is atrophied, also when
its bulk is increased at the expense of its proper elements, mucin is
deposited in the connective tissues, as of the eye-lids, lips, and hands,
so that they become puffy and permanently swollen. This disease is
called myxoedema^ and it is associated with the presence of an excess
of colourless, and a diminution in the number of red, corpuscles of
the blood. Horsley has produced the same association of symptoms in
monkeys by removing the thyroid body. And in children who are
born without a thyroid body the symptoms occur, begetting the disease
known as sporadic cretinism, in which the subject is idiotic.

Enlargement of the thyroid gland, or bronchocele (jSpoy^os, wind-
pipe ; KrjX??, tumour], is called goitre in Switzerland, and, in England,
Derbyshire neck. The enlargement may be solid or cystic, lateral
or symmetrical. When the enlargement is due to dilatation of the
blood-vessels of the gland it is often associated with prominence of
the eye-balls and palpitation of the heart — Graves' disease — the pro-

136 The Thyroid (Jlaud

trusion being caused by dilatation of the blood-vessels in the back of
the orbit, and it may be that this dilatation is caused by pressure
upon the cervical ganglia of the sympathetic.
As a secondary result, ophthalmia and even
ulcerative corneitis may ensue.

The goitrous tumour may press upon the
trachea and flatten it, causing dyspnoea and
dysphasia ; if only one lateral lobe be enlarged
the windpipe and gullet may be pushed to the
opposite side. Extending laterally, the tumour
thrusts outwards the carotid artery and the in-
ternal jugular vein and the vagus, disturbing
the cerebral circulation. The voice is altered,
either from pressure upon the trachea or upon
Bronchoc^Tgoitrewith the recurrent laryngeal nerve. A large mass
dilated superior thyroid of the gland across the front of the neck im-
pedes flexion.

As regards operative interference, cysts may be tapped, but the
vascular thyroid enlargement which is associated with exophthalmos
had best not be interfered with. In no case should the entire gland be
removed, or myxcedema will be likely to supervene, unless perchance
an accessory thyroid should be present.

Division of the isthmus or removal of one lateral lobe may determine
atrophy of the rest of the enlarged gland ; when the chief trouble
is the dyspnoea the former operation should be resorted Jo. When
relief of dyspncea is sought by tracheotomy the surgeon should satisfy
himself that the tube is long enough to reach below the collapsed part
of the trachea, which may be very low down in the root of the neck.

The operation for removal of half of the gland is effected by a
longitudinal incision through the skin, superficial and deep fascia, all
bleeding vessels being secured ; then, the less the knife is used the
better : the surgeon should enucleate the mass with his finger and
a blunt raspatory. The vessels entering are secured by double liga-
tures before being cut. and the greatest care must be taken not to pick
up or damage the recurrent laryngeal nerve whilst the inferior thyroid
branches are being dealt with.

PHARYNX AND (ESOPHAGUS

The pharynx ((f>apvy£ = fauces'), closed above by the base of the skull,
opens at the level of the cricoid cartilage (fifth cervical vertebra) into
the oesophagus ; this is its narrowest part, its widest being near the
hyoid bone.

There are seven openings into the pharynx : the two posterior nares,
two Eustachian tubes, the mouth, larynx, and oesophagus.

When a mass of food is impacted in the pharynx it may cause suf-

Phatyu.r 137

focation by blocking the laryngeal opening, or by setting up a spasmodic
contraction of the muscles which close it.

The finger, thrust directly backwards along the dorsum of the
tongue, comes in contact with the body of the axis, and, when slanted
slightly upwards, with the anterior ring of the atlas. On thrusting it
somewhat downwards the body of the third vertebra is touched.

In the case of fracture or displacement of any one of these three
vertebrae valuable information may be obtained by digital exploration
through the mouth.

Relations of the pharynx. — Behind are the vertebral column
with the longus colli and rectus anticus major, and the layer of
prasvertebral fascia. Suppuration in this region constitutes post-
pharyngeal abscess (p. 210).

Laterally are the sterno-mastoid, the lobe of the thyroid, the com-
mon, internal, and external carotids ; the lingual artery ; the internal
jugular vein; and the vagus, glosso-pharyngeal and hypoglossal nerves.

Infro7it are the nares, mouth, tongue, hyoid bone, and larynx.

. The imiscular coat consists of three constrictors, which are gener-
ally described from below upwards, because the lowest is the most ex-
ternal. They are of striated tissue.

The inferior constrictor, the thickest of the three, arises from the
side of the cricoid cartilage, and from the thyroid cartilage behind
the oblique line. Its lowest fibres are continuous with those of the
oesophagus, and beneath them ascends the recurrent laryngeal nerve
(p. 70) ; the other fibres pass upwards and inwards to the median
raphe over the lower part of the middle constrictor.

The middle constrictor arises from the greater and lesser cornua
of the hyoid bone, and is inserted into the median raphe. Its lowest
fibres pass beneath the inferior constrictor, and its highest over those
of the superior constrictor, from which it is separated by the stylo-
pharyngeus. As the inferior constrictor arises from the thyroid carti-
lage, and the middle arises from the hyoid bone, the superior laryngeal
nerve, which traverses the thyro-hyoid membrane, necessarily passes
between their adjacent borders.

The superior constrictor arises from the internal pterygoid plate,
and from the pterygo-maxillary ligament, which takes it to the mylo-hyoid
ridge, from which also it arises, as well as from the side of the tongue.
The fibres curve backwards to be inserted into the median raphe.

Just beneath the base of the skull, where muscular fibres could be
of no use, the superior constrictor is deficient ; thus, above the upper
border of the muscle there is a gap, the sinus of Morgagni, through
which the levator palati, the Eustachian tube, and branches of the
ascending pharyngeal artery enter the pharynx.

The plan of the pharynx is like that of the canvas * wind-sail '
which is used on board ship to carry fresh air into the hold— it is closed
at the top and sides, whilst its anterior part is held wide open by being

138 Pharynx

attached to fixed points. The fixed points by which the front of the
pharynx is held wide open are the internal pterygoid plates and the
halves of the lower jaw ; the cornua of the hyoid bone and the alae of
the thyroid ; and the sides of the cricoid cartilage.

Ifot pharyngeal aponeurosis is a strong layer between the muscular
and mucous coats, which fills in the vacancy at the sinus of Morgagni;
it is connected with the occipital and petrous bones, and blends pos-
teriorly with the median raphe.

The mucous membrane is continuous with that of the nares,
mouth, tympanum, and larynx. It contains many racemose glands,
and a large amount of lymphoid tissue packed around follicular re-
cesses. A mass of this tissue extending across the back of the pharynx,
between the Eustachian tubes, constitutes the so-called pharyngeal
tonsil.

The epithelium of the respiratory part of the pharynx, that is, down
to the level of the floor of the nares, is columnar ciliated, but in the
rest of its extent it is squamous.

The pharyngeal bursa is a recess in the posterior part of the mucous
membrane which may reach up to the pharyngeal tubercle. Con-
stantly present in infancy, it generally disappears with growth.

Supply. — The arteries are derived from the ascending pharyngeal
of the external carotid, and the ascending palatine and tonsillar of the
facial. The internal maxillary and lingual arteries may also supply
small branches. The veins are tributaries of the internal jugular. The
lymphatics pass to the glandular concatenate, and, quickly conveying
septic matter from the surface of the pharynx, are a constant source
of anxiety to the cervical glands. Some of the lymphatics of the
pharynx also end in glands in front of the cervical vertebra?, which,
becoming enlarged, may even be felt through the back of the pharynx,
and which may be the starting-point of post-pharyngeal abscess,
especially in young children.

The pharyngeal plexus of nerves, from which the muscular and
mucous coats and the blood-vessels are supplied, is formed by branches
of the pneumogastric, superior laryngeal, glosso-pharyngeal, and
sympathetic. It is placed chiefly upon the middle constrictor.

A pharyngeal polypus may spring from the base of the skull, and,
dragging upon its stalk, may hang like a pear behind the soft palate,
pushing it forwards and obstructing deglutition as well as respiration.
It may be removed by a wire snare passed along the floor of the nares,
and guided by the finger in the mouth beneath and around the
pedunculated mass.

The stylo-pharyngcus arises from the base of the styloid process
and runs downwards and forwards between the external and internal
carotids, with the stylo-glossus and the glosso-pharyngeal nerve, and,
passing between the superior and middle constrictors, is inserted into
the sides of the wall of the pharynx and into the posterior border of

(Esophagus 139

the thyroid cartilage. It is supplied by the glossopharyngeal nerve.
With its fellow it raises and widens the pharynx in deglutition.

The oesophagus (oiVo, oiVo>, carry, $ay«i/, eat\ beginning at the fifth
cervical vertebra, runs almost straight through the lower cervical
region and the posterior mediastinum, and, passing through the
muscular opening in the diaphragm, ends at the level of the tenth
dorsal vertebra in the cardiac end of the stomach. It is ten inches
long. Both in the neck and in the chest it lies a little to the left of
the median line.

Its narrowest part is at the cricoid cartilage, and in that region,
therefore, a plate of artificial teeth or a mass of food is most likely to
be impacted ; the plate may generally be felt on grasping the gullet
between the finger and thumb.

Relations. — In tJie neck it has in front the flattened, membranous
wall of the trachea ; and, deviating somewhat to the left side, it has
also in front the left lobe of the thyroid body. In front also are the
left recurrent laryngeal nerve and the inferior thyroid artery, and the
sterno-mastoid. Sometimes the recurrent laryngeal nerve becomes
implicated in cancer of the oesophagus, the result being cough and
aphonia. Behind are the lowest cervical vertebrae, the longus colli
and the prae vertebral fascia (p. 2) ; and at each side are the thyroid
lobe, the common carotid sheath and its contents, and the recurrent
laryngeal nerves.

/// the thorax it has in front the trachea and the left bronchus ; the
left common carotid and subclavian arteries, the transverse aorta, and
the heart and pericardium. Indeed, the transverse part of the aorta
pushes the oesophagus a little towards the right, and, like the left
bronchus, may slightly indent it.

The relationship of the heart and pericardium is important, for
when the heart is greatly enlarged, or the pericardium dropsical, the
patient may not be able to swallow with comfort as he lies on his
back.

The crossing of the left bronchus is a favourite seat of epithelioma ;
should the malignant ulceration open into the bronchus, the contents
of the gullet would enter the air- way and cause septic pneumonia.

Posteriorly are the dorsal vertebra? and the longus colli, the right
intercostal arteries, the vena azygos, and the thoracic duct. And, just
before traversing the diaphragm, the thoracic aorta is also behind.

Laterally, on the left, are the aorta and the pleura; and on the right
are the pleura, the vena azygos, and, close by the diaphragm, the
aorta.

The vagi form \h.z plextis gulce upon the oesophagus, and from its

lower part the fibres of the left vagus descend chiefly in front, and

those of the right vagus behind to their distribution on to the stomach.

Thus the oesophagus, running almost straight through the thorax,

has the aorta winding round it : for the second part of the arch is in

1 40 (Esophagus

front of the oesophagus, and the thoracic aorta is to its left, but as the
large artery passes through the back of the diaphragm it is behind the
gullet, and slightly to its right side.

/;/ tJie abdomen the oesophagus runs a short and unimportant
course, being covered in front and behind by peritoneum ; in front
also is the left lobe of the liver.

structure. — The muscular coat consists of external longitudinal
and internal circular fibres, which, being continuous with the fibres
of the inferior constrictor above, are striated. Lower down, the muscle
is a mixture of striated and pale fibres, and in the lower half of the
oesophagus the fibres are entirely non-striated.

From the lower end of the oesophagus the longitudinal fibres pass
on as the longitudinal fibres of the stomach, the circular fibres of the
oesophagus becoming the oblique upon the cardiac end of the stomach.

The mucous membrane is extremely movable over the submucous
coat, and it is usually thrown into temporary longitudinal folds or rugiu.
The epithelium is thick and stratified.

Supply. — CEsophageal arteries come from the inferior thyroid, the
thoracic aorta, the intercostals, and, possibly, from the internal mam-
mary, also from the phrenic and gastric arteries. The veins take a
somewhat similar course.

The lymphatics enter the cervical and posterior mediastinal glands.
When cancer of the oesophagus, or even of the stomach, is suspected,
the glands at the root of the neck should be examined.

The nerves come from the two vagi and from the sympathetic
ganglia in the thorax.

Stricture of the oesophagus may be caused by the contraction ol a
scar left after swallowing corrosive liquids, and by malignant disease.
In either case the probang must be used with the greatest care, for the
walls of the dilatation which always exists upon the buccal side of
the obstruction are necessarily thin, and, being easily traversed,
the instrument may then wander into the posterior mediastinum, the
pericardium, or the pleura, and so determine a fatal inflammation.
Malignant ulceration of the gullet may open into the pleura and
determine the occurrence of pneumothorax and empyema.

Sometimes cesophageal obstruction is due to the pressure of an
aortic aneurysm, in which case rough instrumentation might cause an
immediate and fatal haemorrhage.

In malignant stricture gastrostomy (p. 223) has not proved a highly
satisfactory procedure. Probably it will eventually be considered
better surgery to pass a tube through the contraction before closure
is complete, and to allow it to remain there, so that the patient may be
fed with fluid nutriment, as recommended by Symonds.

CEsophagotomy may be needed for the extraction of a foreign
body. The patient's shoulders are raised, his head is thrown back,
and his face is turned to the right side. A three- or four- inch incision

Scalenns Anticns 141

is then made through the skin, platysma, and fasciae along the an-
terior border of the left sterno-mastoid, the middle of the incision
being over the foreign body. The head is then raised, as in ligation
of the common carotid (p. 25), and the sterno-mastoid is drawn out-
wards. The omo-hyoid is then seen crossing the carotid sheath, and
the sterno-hyoid and thyroid are passing inwards and upwards over
the trachea.

As the oesophagus is imbedded between the trachea and the
carotid sheath, the latter must be gently drawn outwards, and the
sterno-hyoid and thyroid and the trachea inwards, the omo-hyoid being
divided if necessary. The superior and middle thyroid veins "must be
tied and divided if they are in the way, but care must be taken not
to injure the thyroid body, the inferior thyroid artery, or the recur-
rent laryngeal nerve.

The position of the oesophagus may be definitely shown, if neces-
sary, by the introduction of a bougie or of curved forceps from the
mouth. Bleeding having been entirely arrested, the gullet is opened
and the foreign body extracted.

If the foreign body be impacted in the lower part of the oesophagus
— and it is apt to be lodged just before the diaphragm is traversed — it
may be extracted by gastrotomy, as demonstrated by Dr. Maurice
Richardson, of Boston, U.S.A.

In passing an cesophageal bougie a gag may be needed between
the teeth. Then the tube, being warmed and lubricated, is passed to
the back of the pharynx, and, guided by the left forefinger, is pushed
safely beyond the laryngeal orifice and down towards the stomach.
As it passes by the soft palate and fauces the patient chokes, but as
soon as the oesophagus is entered the choking ceases. It has happened
that a physician, administering beef-tea by the stomach-pump, injected
the trachea, and unfortunately set up a fatal pneumonia.

In diphtheritic paralysis of the palate the patient may conveniently
be fed by a soft catheter passed across the floor of the nose and into
the oesophagus.

THE PR^EVERTEBRAL MUSCLES

The scalenus anticus (o-KaX^j/oy, uneven) arises by a flat tendon
from the tubercle upon the inner border and upper surface of the
first rib, and, passing upwards and inwards, is inserted into the anterior
tubercles of the transverse processes of the third, fourth, fifth, and
sixth cervical vetebrae.

Relations.— -In front are the clavicle, and the subclavius, sterno-
mastoid, and omo-hyoid ; the subclavian vein ; the supra-scapular
and transversalis colli arteries and the phrenic nerve. Behind it are
the subclavian artery, the pleura, and the cords of the brachial plexus.
On its inner side, between it and the longus colli, is the vertebral

142 The Pr&vertebral

artery, and between its insertion and the origin of the rectus anticus
major is the ascending cervical artery.

The scaienus medius, the largest of the scaleni, arises from the
upper surface of the first rib behind the groove for the subclavian
artery, and at once begins to be inserted into the posterior tubercles
of the transverse processes, beginning at the seventh and mounting
to the axis.

Relations. — It lies behind the scaienus anticus, from which it is
separated below by the subclavian artery and the dome of the pleura,
and above by the cervical nerves. Behind it are the scaienus posticus
and the levator anguli scapulae. The nerve of Bell (p. 251), which is
formed in the muscle, emerges from its outer surface.

The scaienus posticus arises from the outer surface of the second
rib, and, ascending a little way behind the last muscle, is inserted into
the posterior tubercles of the two lowest cervical transverse pro-
cesses.

The scalene muscles incline the head and neck downwards and to
the side, or, acting from above, help in inspiration. They are supplied
by the anterior divisions of the lower cervical nerves.

The rectus capitis anticus major arises from the same points of bone
as those into which the scaienus anticus is inserted ; it is attached
above to the basilar process of the occiput. It is supplied by the upper
cervical nerves. In front of it are the pharynx, the sheath of the
internal carotid with its contents, and the sympathetic cord.

Appreciation. — The upper surface of the transverse processes of the
cervical vertebras are grooved for the comfortable transmission of the
cervical nerves ; the borders of the grooves end externally in the
anterior and posterior tubercles. The scaienus anticus is attached to
the anterior tubercles, and the middle and posterior scaleni are attached
to the posterior tubercles : therefore the cervical nerves emerge behind
the anterior scaienus, and in front of the other scaleni.

The origin of the anterior scalene is between two grooves upon the
first rib, and, as, according to the rule, the veins above the dia-
phragm lie in a plane anterior to the arteries, the subclavian vein is in
front of, and the artery behind, the origin of the muscle. The phrenic
nerve arises from the third, fourth, and fifth cervical nerves, that is, upon
the outer side of the scaienus anticus, and it must pass inwards to enter
the thorax, and this it does in front of the muscle ; and, as the second
part of the subclavian artery is behind the scaienus anticus, and the nerve
descends upon the inner border of the muscle, it passes in front of the
first part of the artery, but, to make its course as short as possible,
behind the vein.

The thyroid axis is given off in the first part of the subclavian
artery, and its supra- and posterior scapular branches must needs pass
outwards to their destination — they run in front of the anterior scalene
and the phrenic nerve.

Cervical Plexus 143

The inferior thyroid, coming off also from the thyroid axis, lies to the
inner side of the muscle till it turns inwards ; and the vertebral artery,
running up from the first part of the subclavian to the hole in the sixth
transverse process, is to the inner side of the scalenus anticus, which,
as already remarked, is inserted into the outer end of the transverse
processes.

THE CERVICAL NERVES

Though there are but seven cervical vertebrae, there are eight
cervical nerves, the first of which appears above the atlas, and the last
below the vertebra prominens. The anterior divisions of the first
four make up the cervical plexus, and those of the lower four join with
part of the first dorsal to form the brachial plexus.

The posterior primary divisions of the cervical nerves divide,
' for the most part, into an inner and an outer branch. But the
posterior division of the first, or sub-occipital nerve, does not divide ;
it emerges between the vertebral artery and the posterior arch of the
atlas, and supplies the obliqui, recti postici, and complexus. Some-
times it sends up a cutaneous branch to the back of the head, which
may be in great distress in the case of suboccipital disease.

The posterior trunk of the second is much larger than the anterior.
Its internal division is the great occipital, which, as its name implies,
is a large branch for the back of the scalp. Passing through the in-
sertions of complexus and the trapezius, it accompanies the occipital
artery, and communicates with the lesser occipital nerve. The external
division is distributed solely to the erector spinas.

The internal division of the third sometimes sends up an occipital
twig in addition to a branch for the skin of the nape of the neck.
The internal divisions of the fourth and fifth nerves give branches
to the erector spinse, as well as to the skin over the trapezius, whilst
those of the three lowest usually give off no cutaneous twigs.

The external divisions of the posterior cervical nerves are for the
muscles only.

The cervical plexus is formed by interlacements of the anterior
divisions of the first four cervical nerves. The anterior part of the
first) or sub-occipital nerve, is a slender branch, which winds forwards
from beneath the vertebral artery on the posterior arch of atlas, and at
the front of the first transverse process joins with a branch from the
second nerve. It ends in the supply of the recti laterales and antici.

The anterior part of the second winds round the vertebral artery
in its course from beneath the posterior ring of the atlas, and gives a
division to the first nerve and one to the third.

The anterior part of the third divides to join the second and the
fourth ; and the anterior part of the fourth, having received the last-
named branch, sends down a communicating twig to the fifth nerve,
which belongs to the brachial plexus.

144

The Cervical Nerves

The communications between the upper four cervical nerves take
place between the scalenus medius and levator anguli scapuke behind,
and rectus anticus major in front. They are under cover of the sterno-
mastoid, so that all their superficial branches emerge by the border of

RECT. CAP . LAT.

RECT. ANT . MAJOR
RECT. ANT. MINOR

TO SYMPATHETIC

TO SCALP & OCCIPITO-FPONTALIS
TO AURICLE* ATTOLLENS AUREM

AURICULAR
FACiAL

this muscle, and those which have an ascending or forward course pass
over that muscle.

The branches of the plexus are superficial and deep.

Superficial branches. — The lesser occipital, from the second cer-
vical nerve, winds upwards behind the sterno-mastoid, and, piercing
the deep fascia, supplies the skin between the areas of distribution of

Superficial Cervical Nerves • 145

the great auricular and great occipital. Thus, be it noted, both the
occipital nerves come from the second cervical— the lesser from its
anterior, and the greater from the posterior division. The lesser
occipital gives a branch to the back of the pinna.

i, Iransverse or superficial cervical nerve with its descending (2) and ascending (3) branches •
5, great auricular ; n, lesser occipital ; 15 to 18, supra-clavicular; 19, br. to trapezius :
20, spinal accessory; 23, post, auricular of facial ; 24, infra-maxillary of facial ; 25, great

The great auricular and the transverse or superficial cervical arise
from the second and third. The great auricular emerges on a lower

146 The Cervical Nerves

idinir

level than the lesser occipital behind the sterno-mastoid, and, winding
up over that muscle, reaches the parotid gland, giving branches to the
skin of the masseteric and the mastoid regions, to the back of the pinna,
and to the lobule.

The superficial cervical winds across the middle of the sterno-
mastoid, under the external jugular vein and the deep fascia, and,
piercing the fascia at the front of the neck, divides beneath the pla-
tysma into an ascending branch, which supplies the skin over the sub-
maxillary region, joining there with the infra-maxillary branch of the
facial, and a descending branch, which supplies the skin along the front
and lower part of the neck.

The supra-clavicular are the lowest and last of the superficial
branches ; they come from the third and fourth trunks, and emerge
from behind the sterno-mastoid. They descend in sternal, median,
and acromial branches to supply the skin of the pectoral and deltoid
regions. Sometimes one of the median set courses through the sub-
stance of the clavicle. In the case of fracture of the collar-bone
branches of these nerves may be bruised between the fragments, great
pain resulting.

The supra-clavicular nerves take the place of lateral cutaneous
branches of the first and second dorsal nerves.

When, as the result of caries, for instance, there is pressure upon
the posterior roots of the third and fourth nerves, peripheral pain
usually occurs in the area of distribution of these nerves : symmetrical
pains about the shoulders of a child should always direct attention to
the neck.

Peripheral neuralgias of the scalp, neck, pectoral region, or
sJioulder, are often caused by inflammatory pressure upon the
sensory roots of the nerve-trunks, and are often met with in disease
of the occipito-atloid joint, and in caries of the upper cervical verte-
bras. These pains are generally, but not always, in symmetrical
areas, whilst neuralgia which is due to pressure of a tumour outside the
spinal canal would be confined to one side, unless, indeed, it reached
across the middle line. A little girl who was brought to me with
mid-cervical caries suffered from darting pains across the front of the
neck, which she quaintly called ' belly-ache in the neck.' When
there is pressure upon the second nerve the pains in the area of the
lesser and greater occipitals are often called ' head-ache,' and when
those filaments of the second and third nerves which belong to the
great auricular are in distress the neuralgia may be called * ear-ache,'
or 'face-ache.' It is, then, of the greatest importance to know the
exact distribution of these nerves (see PINNA, p. 94).

Of the deep branches, some communicate with the sympathetic,
vagus, and hypoglossal; the second and third send down also com-
nninicantes hypoglossi (or noni) over the internal jugular vein to join
the descendens noni. Other branches pass to neighbouring muscles,

Phrenic Nerve 147

the most important of which are from the second and third for the
sterno-mastoid ; the influence of these nerves may render futile section
of the spinal accessory (p. 71) nerve in the case of spasmodic con-
traction of that muscle. The trapezius also receives branches from the
third and fourth, which, like the sterno-mastoid branch, communicate
with the spinal accessory.

The phrenic comes from the third and fourth, and receives a twig
also from the fifth nerve, that is, from the upper part of the brachial
plexus. It descends into the chest over the scalenus anticus and
the subclavian artery, and behind the vein. It then runs in front of
the root of the lung, between the pleura and pericardium, and supplies
the diaphragm on its under-surface, giving off pleural and pericardial
twigs in its course.

The left nerve is the longer, because it is pushed out of its course
by the pericardium ; it bears an important relation to the front of the
transverse aortic arch, whilst the right nerve descends on the outer
side of the innominate artery and the superior cava.

Filaments of the right phrenic pass under the coronary and falciform
ligament , into the substance of the liver; and it is probably through
their influence that, in disease of the liver, pain is referred to the point
of the right shoulder (p. 339). The phrenic chiefly comes from the
fourth cervical nerve, which also gives off acromial filaments in the
supra-clavicular nerves, as already noted.

In paralysis of the diaphragm, as after diphtheria, the phrenic nerve
may be galvanised on dragging the lower end of the sterno-mastoid
slightly inwards (so that the rheophore may be placed over the scale-
nus anticus, the outer border of which muscle corresponds to the
outer border of the sterno-mastoid), the other rheophore being placed
over the costal attachment of the diaphragm.

PART II
THE THORAX

THE thorax (6o>pa^ breast-plate) is enclosed by the dorsal vertebra.-,
the ribs, costal cartilages, and sternum ; its apex is bifid and extends
an inch and a-half above the first rib. The floor, formed by the dia-
phragm, is convex, and is higher on the right side than on the left by
the depth of a rib, being pushed up by the liver ; the centre is the
lowest part, being on the level of base of the xiphoid. On the right
side, after an ordinary expiration, the floor reaches the level of the
fifth rib in front, and, after a forced expiration, to the level of the fourth.
The lowest part of the floor extends from the base of the xiphoid to
the eleventh or twelfth rib (p. 196).

The sternum consists of the manubrium, gladiolus, and xiphoid ;
to the last piece the linea alba is attached. At the top of the manubrium
is a notch between the clavicles which receives the trachea in flexion of
the neck. Below and to the outside of this notch the cartilages of the
first ribs blend with the manubrium.

The downward slope of the first ribs brings the top of the manubrium
opposite the second dorsal vertebra, from which it is separated by the
space of two inches.

Down each lateral half of the sternum the pectoralis major arises,
and from the upper part of the front of the manubrium arises the
pointed tendinous head of the sterno-mastoid. At the back of the manu-
brium arise the sterno-hyoid and sterno-thyroid, and from the lower end
of the gladiolus the triangularis sterni. The diaphragm is attached
to the back of the xiphoid cartilage, and the linea alba to the tip.

The sternum is developed in lateral halves, together with the ribs,
in the mesoblastic layer, in curved plates extending from the vertebral
column. When these plates fail to meet along the middle line
the thorax is open in front, the condition being called cleft sfcr/nnn.
For an extreme case of this defect, with ectopia cordis, see p. 318.
Ectopia differs from cleft sternum in that not only is the sternum cleft,
but the want of fusion in the middle line implicates the soft tissues
as well as the bcne, the heart being out of place.

Intercostal Arteries 149

Where the manubrium joins the gladiolus there is a tratisverse
ridge which is easily felt on running the finger down the middle line.
The cartilages at the ends of the ridge are those of the second ribs.
In counting the ribs in a fat subject it is convenient to remember this.
The ridge corresponds also with the lower border of the second part of
the aortic arch.

Fracture of tJie sternum generally results from the chin being
forcibly doubled into the chest, as in a fall on the head, the springi-
ness of the ribs saving it from fracture from direct violence. Occa-
sionally the manubrium is dislocated forwards over the gladiolus.

Of the ribs, seven articulate with sternum, but the lower five do
not ; the eleventh and twelfth, being free anteriorly, are rarely broken.
The first rib is rarely broken, unless the clavicle, which protects it,
have first yielded. The ribs most often broken are the middle ones,
and the seat of fracture is generally in front of their angle. A rib may
be broken by direct violence, as by a blow with the fist, in which case
the salient angle is more apt to damag'e the pleura and lung, than
when the fracture is from indirect violence, as when a man is crushed
against a wall, in which case damage to the pleura and lung occurs
only when several ribs have been broken. When a man with fractured
ribs spits brig'ht and frothy, bloody sputa, there is evidently a wound of
the lung ; possibly also pneumothorax exists.

The groove along the lower part of the inner surface of the rib con-
tains the intercostal arteiy, with the vein above it and the nerve below,
passing between the inner and outer intercostal muscles ; to avoid
these, in puncturing the chest, the trocar should neither be introduced
through the upper part of the intercostal space nor through the lower,
where the collateral branch is coursing. In medio ttitissimus ibis.

The intercostal arteries come from the superior intercostal of the
subclavian, from the aorta, and from the internal mammary; they
anastomose freely with branches of the axillary and send emissaries
through the spaces to supply the mamma ; a wounded intercostal
artery may bleed into the pleural cavity (hcemothorax). If the skin
be also wounded the artery may be compressed by the finger passed
in under the rib.

The costal cartilage fits in a depression at the end of the rib ; the
other end articulates with the sternum, and, with the exception of the
first cartilage, which fuses with the manubrium, each chondro-sternal
joint has a synovial membrane. Indeed, the joints of the second and
third cartilages usually have each two membranes. As the result of
injury either end of a costal cartilage may be detached. Comparative
anatomy shows that the cartilages are anterior epiphyses.

The cartilages from the sixth to the ninth are connected with each
other by capsular ligaments lined by synovial membranes.

Most of the ribs articulate by their head with the bodies of two
vertebrae and with the intervertebral disc, being connected by the

1 50 The Thorax

stellate and info-articular ligaments, and by a capsule with two
synovial membranes.

The neck of the rib is connected with the front of the transverse
process by a strong interosscous ligament, and also with the trans-
verse process next above it by the anterior costo-transvcrse band,
which is continuous externally with the intercostal aponeurosis. The
tubercle is connected with the tip of the process by a capsule and
synovial membrane, and by the posterior costo-transverse ligament.

Pig-eon-breast is produced in rickety, soft-boned children when
inspiration is obstructed, as by enlarged tonsils — the contraction of
the diaphragm causes a partial vacuum in the chest which the pressure
of the external air helps to efface by thrusting inwards the weak costal
ends of the ribs, with the effect of making the sternum project.
Strengthening the child, removing the obstruction, and instituting
respiratory gymnastics, gradually diminish the defect ; no compression
of the prominent sternum should be used.

The Prussian army surgeons have been ordered to measure
narrow-chested recruits every four weeks. All are to be regarded as
narrow-chested the circumference of whose chest is less than half the
length of their bodies. Narrow-chested men whose chests are not
widened by drill are regarded as predisposed to tuberculosis.

The dorsal nerves, twelve on each side (the twelfth emerging
below the last dorsal vertebra), divide into an anterior and a posterior
trunk ; the former becomes the intercostal nerve, with the exception of
the first, the chief part of which passes up for the brachial rjlexus, only
a small intercostal branch being sent forward from it.

As the anterior divisions of the upper dorsal nerves run between
the intercostal muscles, and are half-way in their course, they give off
lateral cutaneous branches which pierce the outer intercostals and the
serratus magnus in the axillary line, and then divide ; the posterior
division supplies the skin over the region of the latissimus dorsi and
the scapula, and the anterior winds round the pectoralis major for the
mamma and the neighbouring integument, or, in the case of the lower
nerves, for the skin over the front of the abdomen.

The continuation of the intercostal nerve runs on and leaves the
space by the side of the sternum, piercing the origin of the pectoralis
major, and ending in the anterior cutaneous twigs.

The small, first intercostal nerve gives no lateral cutaneous branch,
but from the second a large undivided offshoot runs across the arm-pit
to end in the skin of the inner and back part of the arm. This is the
intercosto-numeral nerve, and it is often joined by the lesser internal
cutaneous. When the intercosto-humeral nerve is stretched by sup-
puration in the arm-pit, or is caught in the enlargement of axillary
glands which follows mammary scirrhus, neuralgia occurs in the area
of its distribution, down to the internal condyle.

In their course the intercostal nerves supply the parietal pleura ;

Intercostal Nerves 151

and thus it comes about that in inflammation of the upper part of
that membrane pain is sometimes felt along the inner side of the
arm.

The lower intercostal nerves, having reached the limit of the space,
pass onwards between the internal oblique and transversalis to the
sheath of the rectus, and, having pierced it and the rectus, appear as
anterior cutaneous nerves near the linea alba. The lower intercostal
nerves supply the oblique, the transverse, and the straight muscles of
the abdomen.

Thus, pain over the upper part of the abdomen may be due to
pleurisy, to pressure of thoracic tumours or of pleural collections of
fluid, to caries of the lower dorsal vertebrae, or to disease of the cord
above the lumbar enlargement.

The anterior division of the last dorsal nerve runs below the last
rib, in company with the first lumbar artery, in front of the quadratus
lumborum, and gains eventually the space between the transversalis
and the obliquus internus. Its peripheral branches (anterior cuta-
neous) end about half-way between the umbilicus and pubes. The
region of the ' pit of the stomach ' is supplied by the endings of the
sixth and seventh nerves. The nerve-supply of any part of the side
or front of the thoracic or thoracico-abdominal region is indicated by
continuing forward the lines of the intercostal spaces, and seeing which
of them runs into that particular area.

When a patient complains oft. pains over the upper part of the front
of the chest, the surgeon must not satisfy himself with tracing his finger
along the upper intercostal spaces and with examining the higher
dorsal vertebrae, but must carry his investigations also into the middle of
the neck, as the third and fourth cervical nerves (p. 145) furnish cuta-
neous branches to that neighbourhood as well as the dorsal nerves.

The lateral cutaneous branch of the last dorsal comes over the iliac
crest, through the internal and external obliques, and supplies the skin
of the fore part of the buttock, as far as the great trochanter.

Neuralgia in an intercostal nerve may be due to inflammation in
its fibrous elements, and may then be followed by a crop of vesicles
in the area of skin supplied by it. The disease is called herpes zoster
(fa>(rn;p, belt] or shingles (cingulum, girdle\ names which well describe
the arrangement of the eruption.

The posterior divisions of the dorsal nerves give off internal and
external branches. The internal branches of the upper six nerves
supply the erector spinas, and then send cutaneous twigs through the
trapezius ; all the external branches also give muscular twigs, but, in
addition, the lower six send twigs through to the skin of the infra-
scapular region.

According to Professor Griffith, the posterior branches descend
obliquely for the depth of several vertebras before ending in the skin,
and so it comes about that the line of herpes zoster is transverse and

152 The TJwrax

not oblique, and that the zone of anaesthesia in fracture of the spine is
horizontal.

The diaphragm, an important muscle of inspiration, arises from the
back of the xiphoid, the inner surfaces of the lower six ribs (where it
interdigitates with the transversalis), and, posteriorly, from the arcuate
ligaments. It also arises by two pointed crura, of which the right
descends rather lower than the left, namely, to the fourth lumbar
vertebra.

Roughly, the attachment of the phrenic plane may be marked by
a line extending obliquely round the trunk from base of the xiphoid
cartilage to the last rib.

According to Sibson, the central tendon descends about an inch
during inspiration, and with it descend the superjacent, and attached,
pericardium, the heart, and the base of the lungs. Sometimes, in
an anaemic subject, with the descent of the heart and the ascent of
the chest-wall during inspiration, the subclavian artery becomes so
stretched over the edge of the first rib that a bruit is heard there, the
radial pulse being lost at the very end of inspiration. That the bruit
is not the result of subclavian aneurysm is proved by causing the
patient to cease breathing after expiration, when the murmur disap-
pears and the radial pulse returns.

The openings in the diapliragiu are the osseo-aponeurotic notch in
front of the twelfth dorsal vertebra for the aorta, vena azygos major,
thoracic duct, and left sympathetic ; a tendinous one between the
right and central leaflets for the vena cava ; and a third, a$ oval one,
for the oesophagus and the vagi : this is muscular, being formed by
the decussation of the inner fibres of the crura.

Just on the outer side of the xiphoid there is an irregular gap in
the diaphragmatic fibres through which the superior epigastric artery
descends and some hepatic lymphatics mount to the mediastinal
glands. By this space also a diaphragmatic hernia may escape, and
through it the subperitoneal connective tissue joins that of the anterior
mediastinum. Along this loose tissue an anterior mediastinal abscess
may find its way into the epigastric region.

Because of the upward extension of the abdominal cavity within the
circle of the ribs, the liver, stomach, spleen, and kidneys might almost
be counted as thoracic viscera. In fracture of the lower ribs the pleura
and lung, as well as the peritoneum, liver, spleen, and kidney, may be
lacerated by broken bone.

Paralysis of the diaphragm embarrasses all the expulsive efforts,
and leaves respiration and vocalisation to be carried on almost entirely
by the intercostals.

In healthy inspiration the ribs ascend and the diaphragm is de-
pressed, the abdominal viscera being pushed downwards and forwards ;
but, the diaphragm being paralysed, when the patient takes a breath
the ribs ascend as usual, but the abdominal muscles, taking advantage

Mediastina \ 5 3

of the flaccid thoracic floor, push the viscera upwards, so that there is
an actual sinking in of the epigastric region.

The abdominal viscera press the diaphragm upwards as one lies
in bed : therefore the bronchitic patient often breathes better when
propped in the sitting posture.

Pleurodynia (TrAeupa, side ; oftwrj, pain) is pain in the chest-wall
which is not the result of pleurisy ; the chief merit of the term is in its
vagueness. Does it mean costal periostitis, muscular rheumatism,
intercostal neuralgia, or hepatitis ? Or is it the result of pressure upon
the posterior roots of some of the dorsal nerves of one side, or upon
nerves leaving the spine or entering the intercostal spaces ? For, after
all, pain is but a symptom of a disease, and sometimes a very mislead-
ing one.

Pains between the shoulders are often conplained of in dys-
pepsia, that is whenever the stomach is out of working order. They are
probably caused by the association of filaments of the great splanch-
nic (o-rrXa-yxwi, viscera, p. 224) with the solar plexus below, and with
the higher dorsal nerves above, these latter nerves giving dorsal
branches to the skin in that region. Similarly the pains about the
right shoulder in liver disease were formerly explained, but a better
reason for their occurrence is given on p. 147.

THE CAVITY OF THE THORAX

The upper opening- of the thorax transmits the apex of each
lung, which extends for i^ in. into the roof of the neck. In the middle
line pass the sterno-hyoid and sterno-thyroid muscles, the inferior
thyroid veins (p. 155), remains of thymus, the trachea and oesophagus
with left recurrent laryngeal nerve, and also, on the left side, the
thoracic duct.

A little removed from the middle line are the innominate artery, the
right vagus, and the left common carotid and subclavian arteries, with
the left vagus between them ; the two innominate veins ; the two
phrenic nerves ; cardiac filaments from sympathetic and from the
vagi ; the internal mammary and superior intercostal arteries descend-
ing into thorax ; part of the anterior division of the first dorsal nerve
mounting to the brachial plexus ; the longus colli and the cords of the
sympathetic.

THE MEDIASTINA

The mediastina are the spaces which ' stand in the middle ' (inedio,
std] of the chest, between the sternum and the spine, with the lung
and pleura on either side. The connective tissue which they contain
is liable to be the seat of suppuration.

The anterior mediastinum is the space between the pleurae in

1 54 The Thorax

front of the pericardium. It inclines, therefore, to the left. In front
of it are the sternum and the adjoining parts of the fifth, sixth, and
seventh cartilages. The triangularis sterni covers the anterior
boundary of the space and shuts out the internal mammary vessels.
It contains lymphatics ascending from the liver, and some small
lymphatic glands which are associated with the inner part of the
mamma (p. 203).

Abscess in the root of the neck readily finds its way into the
anterior mediastinum by following the trachea or the sterno-hyoid and
thyroid muscles.

The middle mediastinum contains the heart and pericardium, and
the arterial and venous trunks which the pericardium encloses ; the
roots of the lungs, and the various structures associated therewith ;
the vena azygos turning over the root of the right lung, and the
phrenic nerves.

The posterior mediastinum is limited by that part of the spine
which is behind the pericardium and the roots of the lungs. In it are
the third part of the arch and the thoracic aorta ; the oesophagus with
the vagi ; the azygos veins, the thoracic duct, and some lymphatic
glands, and the sympathetic chains with their splanchnic offshoots.

The superior mediastinum is defined by drawing an imaginary
horizontal plane from the transverse sternal ridge (p. 149) to the lower
border of the fourth dorsal vertebra. It contains the origin of the sterno-
hyoid and thyroid muscles, the remains of the thymus gland, trachea,
oesophagus, left recurrent laryngeal nerve, thoracic duct ; the trans-
verse part of the aortic arch with the origin of the innominate, left
carotid, and left subclavian arteries ; the innominate veins and the be-
ginning of the superior cava ; the phrenic, pneumogastric, and cardiac
nerves, and lymphatic glands.

The thymus (dvpos, soul, life) is a ductless gland lying between
the manubrium and the aortic arch ; in early life it ascends into the
root of the neck, in front of the trachea ; below it reaches to the peri-
cardium. It increases in bulk to the end of the second year, at which
time, as regards size, it is an important anatomical structure. (See
wood-cut on next page.)

Its arteries are derived from the internal mammary, and the in-
ferior and superior thyroid. The veins end in the internal mammary
and left innominate. The nerves come from the sympathetic.

The vena azygos major is the great link between the venae cavae.
Further, it receives the venous blood from the retro-cardiac region,
where, of course, no vena cava exists.

It begins by tributaries from the right lumbar and renal veins, or
from the inferior cava itself, and, passing through the aortic opening
of the diaphragm, ascends upon the right side of the spine to the
fourth dorsal vertebra, whence it turns forward over the root of the
right lung to enter the vena cava superior just as it is about to

Internal Mammary Artery 15 c

pierce the pericardium. It receives most of the right intercostal
veins, and, from the left side, the smaller azygos (v. p. 185),

When the inferior cava is blocked, as by an hepatic cancer, venous
blood from the lower part of the body finds a free collateral return to
the heart through the vena azygos major, which may thus become as
large as the thumb.

Thymus gland in a child of six m

(SAPPEY.)

i and 2, Right and left lobes ; 4, lung ; 6, thyroid ; 7 and 8, inf. thyroid veins ; o, com. car.
art. ; 10, int. jug. vein ; u, vagus.

The internal mammary artery, from the first part of the sub-
clavian (p. 228), enters the thorax behind the first costal cartilage, and,
descending behind the intercostal spaces, about £-inch from the border
of the sternum, divides behind the seventh cartilage into the musculo-
phrenic and superior epigastric. At first the artery lies behind the
subclavian vein and in front of the pleura, being crossed obliquely by
the phrenic nerve ; but, lower down, the triangularis sterni separates
it from the pleura.

norax

Its branches are : the comes nervi phrenici, to the diaphraj

mediastinal ; pericardial ; ster-
nal ; anterior intercostal, two to
each of the six upper spaces, to
anastomose with the aortic inter-
costals, and many perforating
branches which pass through
the pectoralis major for the
breast and the integument.

The inusculo-phrenic, the
outer of the terminal divisions,
slopes behind the sternal ends
of the lower spaces, under cover
of the diaphragm (which it sup-
plies), and gives off anterior
intercostals, like those described
above.

The inner division, the supe-
rior epigastric, passes through
the xiphoid gap in the diaphragm
(p. i 52) to enter the rectus ab-
dominis, in which it descends
to anastomose with the deep
epigastric of the external iliac.
A twig or two from it enter the
falciform ligament to anasto-
mose with branches of the hepa-
tic artery.

The internal mammary veins
end in the innominate veins.

Xiigation of the internal
mammary in its continuity may
be required when an oblique
wound, such as a stab, implicates
the trunk behind a costal carti-
lage, so that the surgeon cannot
secure it at the bleeding spot.
It may be reached by making a
two-inch incision from the side
of the sternum through the
middle of one of the higher
spaces. The skin, fascia:, and
pectoralis major having been
traversed, the aponeurosis is
seen which continues the exter-
nal intercostal muscle to the sternum. Then comes the internal inter-

Thoracic Duct 157

costal, and, in loose connective tissue, a little deeper, but in front of the
triangularis sterni, or pleura, is seen the artery with a vein on either
side. If the artery be tied in the second space, where the triangularis
sterni is not behind it, extra care must be given not to damage the
pleura in passing the aneurysm-needle.

The superior intercostal artery descends from the second part
of the subclavian in front of the neck of the first and second ribs to
supply the topmost spaces, which the aortic intercostals cannot con-
veniently reach. The artery lies behind the apex of the pleura and
against the anterior division of the first dorsal nerve as it ascends
to the brachial plexus. Its intercostal branches anastomose with the
internal mammary and with thoracic branches of the axillary.

It gives off theprofunda cervicis, which resembles the dorsal branch
of an aortic intercostal artery. Passing backwards between the seventh
cervical transverse process and the neck of the first rib, it eventually
ascends beneath the complexus, and anastomoses with branches of
the vertebral and with the princeps cervicis of the occipital (p. 30).

Of the superior intercostal veins the right turns down into the great
azygos, whilst the left passes across the second part of the aortic arch
to end in the left innominate vein.

The thoracic duct brings the chyle and lymph into the venous cir-
culation, with the exception of the lymph from the right side of head,
neck, and thorax, the right upper extremity, the right heart and lung,
and the phrenic surface of the liver. It is eighteen inches long, ex-
tending from the abdomen, through the thorax, and into the neck, to
the confluence of the left internal jugular and subclavian veins.

It begins on the front of the second lumbar vertebra in the recep-
taculinn chyli, a dilatation into which is poured the contents of the
lymphatics of the lower extremities, pelvis and abdomen, and of the
lacteals.

Relations. — The duct is placed behind the abdominal aorta, and
between it and the right crus. It enters the posterior mediastinum
through the aortic opening, and ascends on the bodies of the dorsal
vertebrae, between the thoracic aorta and the great azygos. As it
is reaching the back of the transverse aorta it inclines towards the
left, and, passing behind the oesophagus, ascends between it and the
left subclavian artery. Having thus reached the root of the neck, it
arches downwards and forwards in the gap between the carotid and
subclavian arteries, to end in the confluence of the internal jugular
and subclavian veins, on a plane anterior to the arteries.

At a post-mortem examination the duct is easily found, when the
pleura has been opened, by drawing the right lung towards the left,
and tearing through the parietal pleura along the right side of the
dorsal vertebrae. The duct is there lying in some loose connective
tissue between the great azygos and the oesophagus, whence it may be
traced upwards or downwards.

158 The Thorax

As it traverses the thorax it receives the lymphatics from the oeso-
phagus, trachea, left heart and lung, and from the left thoracic wall.

The right lymphatic duct, one inch long, brings the lymph from the
right side of the head, neck, thorax and heart, and from the right upper
extremity and lung ; it enters the confluence of the right internal
jugular and subclavian veins.

THE PERICARDIUM

The serous layer of the pericardium covers the heart and the first
i£ in. of the large vessels, and is thence reflected on to the interior of
the fibrous sac. It sends seven more or less complete tubular sheaths
round the vessels— a common one for the aorta and the pulmonary
artery, four for the pulmonary veins, one for the superior cava, and a
scanty one for the inferior cava, which last vessel enters the auricle
directly after coming through the diaphragm.

Laterally the pericardium is covered by the pleurae and lungs, the
phrenic nerves intervening between them. The anterior borders of
the lungs and the pleurae are also in front above, but, below, the peri-
cardium approaches the thoracic wall in an important triangular area
(p. 165) without the intervention of lung.

The close proximity of the pericardium and pleura explains the
frequency with which inflammation of one membrane follows that of
the other.

The external layer of the pericardium is of strong interlacing fibres,
and is firmly connected with the central tendon of the diaphragm.
Above, the fibrous sheath passes off in tubular prolongations which
blend with the outer coats of the transverse aorta and of the right and
left pulmonary arteries and veins, and of the superior cava. The lining
is of pavement endothelium.

The close association between heart, lungs, and diaphragm not
only causes a descent of the thoracic viscera during inspiration, but
even of the trachea, as may be easily recognised by laying the
finger on the larynx whilst a deep breath is taken.

When the pericardium is opened from the front the following struc-
tures are seen : the front of the right ventricle and the apex of the left ;
the right auricle and its appendix, and the appendix of left auricle ;
the root of the pulmonary artery, and a little of the aorta and of the
cavae.

Supply. — Pericardial twigs are derived from the aorta and from
the internal mammary, bronchial, oesophageal, and phrenic arteries.
Nerve-filaments come from the phrenic, the sympathetic, and the right
vagus.

At the beginning of an attack of pericarditis the lining membrane
is dry, and roughened from fibrinous deposit, and the heart no longer
moves noiselessly against the parietal layer, but rubs against it, pro-

Pericarditis

159

ducing a friction-sound. This sound may in time disappear from one
of three causes : from the deposit clearing up and leaving the surfaces
once more smooth and moist ; from adhesion occurring between heart
and pericardium ; or from effusion of serum collecting between and
separating them. In the last case the normal heart-sounds are, of
course, masked.

A pericardial friction-sound does not cease, as does a pleural rub,
when the patient holds his breath, but in either case the sound may
be exaggerated by pressure made by the end of the stethoscope ;
against such a fallacy the listener must be on his guard. On account
of the pain associated with pericarditis, the diaphragm and the lower
intercostals keep quiet in respiration, the work being done in the upper
thoracic region.

When the visceral and parietal layers of the pericardium are in-
flamed and sticky with lymph they may closely adhere. But often the
movements of the heart prevent
such adherence ; and the con-
stant unglueing of the opposed
surfaces renders each of them
rough or even shaggy.

In pericardial effusion the
area of absolute dulness is pear-
shaped, with the small end up-
wards ; whereas in hypertrophy
and dilatation of the heart (p.
175) the shape of the dull area
and the direction of its greater
diameter are transverse. In
pericardial effusion, also, the
left end of the dulness reaches
beyond the apex-beat — a most
important diagnostic sign— but
when the distending fluid is
abundant the heart is insulated
within it, and the apex can no
longer beat against the chest-
wall ; the cardiac sounds are
then practically drowned in the
fluid, and the apex-beat may be
altogether indistinguishable.

When the distension of the
sac is only partial, the area of
dulness may be made to shift

.,, *, ,. j •,• Effusion into pericardium, A ; lungs, B, B, pushed

its Site with the altered position aside> SdUrer, c, depressed. (SIBSON.)

of the patient (much as de-
scribed in abdominal ascites, p. 316). The lungs being thrust from the

i6o

T/ie Per it ~(ir< fin in

middle line and compressed, respiration is embarrassed, and the patient
is hardly able to move himself in his bed.

When the effusion is excessive the lower two-thirds of the sternum,
and the left cartilages, from the second to the seventh, are prominent,
the intercostal spaces are widened, and the area of cardiac dulness is
increased. In the young subject, with pliant chest-walls, the bulging
is more marked than in the adult.

As the patient lies in bed the effusion does not at first increase the
area of dulness, because it gravitates to the back of the sac — collecting
behind the heart ; but as the distension increases the lungs are pushed
aside, and the ascitic pericardium bulges against the chest-wall, giving
rise to a dull percussion-note as high, perhaps, as the first space, and
extending widely behind the right and left cartilages, and the xiphoid.

Effusion into pericardium ; lungs pushed aside ; .slight effusion into right pleura, v, vi, vn,
ribs in section. (BRAUNE.)

The diaphragm, liver, and stomach are, at the same time, thrust
downwards. In acute inflammation the sac may contain from twelve to
eighteen ounces of serum, but when the disease is chronic the fluid may
amount to three pints. In the latter case the left lung would be pushed
far out, and the tumour would bulge so much towards the abdomen

Paracentesis Pericardii 161

that there might be pain on pressing the epigastrium ; there would
be also a prominence of the sternum and of the left costal cartilages,
especially in young subjects. If, as the patient lies in bed, the water-
tumour press against the trachea, the dyspnoea may be relieved by let-
ting him sit up, so that the fluid may be brought forwards. Pressure
on the oesophagus may cause dysphagia, especially when the patient is
lying down ; and by bulging against the right auricle and superior
vena cava it may produce fulness of the veins of face and neck, with,
possibly, oedema.

In the treatment of acute pericarditis venassection and purgation
may be of great service by relieving the heart of some of its work.

Paracentesis pericardii may be necessary when the pressure of
the fluid seriously interferes with the heart's action.

The puncture may be performed in any part of the area of absolute
cardiac dulness, but the course of the internal mammary vessels at
half an inch from the border of the sternum must be remembered
(p. 156). The sternal end of the fourth or fifth space serves well. It
has been customary to operate on the left side, but I would urge that
the sternal end of the fourth right space is preferable, as the pericar-
dium is sure to be bulging there and the needle is less likely to
injure the heart.

In suppurative pericarditis the abscess must be thoroughly evacu-
ated and the cavity washed out and drained, the incision being made,
layer by layer through the fourth or fifth intercostal space, to the
outer side of the line of the left internal mammary artery. When the
pericardium is reached it should be drawn well forwards so that the
pus and the irrigation-fluid may not escape into the anterior medias-
tinum.

There is no definite sign by which adherence of the heart and peri-
cardium may be absolutely recognised, but in such cases the contract-
ing ventricles may be seen pulling-in the neighbouring intercostal
spaces, and even the lower end of the sternum and the adjacent car-
tilages.

THE HEART

The heart is, roughly, of the size of the closed fist of the individual ;
its weight averages 10 oz. It rests by its flat surface upon the dia-
phragm ; its base is directed upwards, backwards, and to the right,
opposite the four middle dor sal vertebra, and its apex points downwards
and to the left, beating against the fifth space. It lies behind the
lower two-thirds of the sternum, encroaching on the left side of the
thoracic cavity, and filling the space between the spine and the breast-
bone.

The heart is free within the pericardium, and between the latter
and the chest-wall the pleurae and lungs intervene, only a small
triangular part of the heart being uncovered by lung during inspiration.

162

The Heart

The heart is lowered in the cases of pulmonary emphysema, left
hydrothorax, large mediastinal tumours, and aneurysm of the aortic
arch ; also when the stomach and intestines are collapsed, as in
cesophageal stricture. It is raised in ascites, tympanites, and in the
case of ovarian, hydatid, or of other large abdominal tumours. It is
pushed to the left in the case of effusion into the right pleura, and
when the left pleura is water-logged the apex-beat may be found even
to the right of the sternum (p. 189). It maybe dragged to either
side by a contracting lung or by pleural adhesions.

The anterior part of the heart is chiefly the right ventricle, the left

ventricle being posterior.
The left ventricle has
much more work to do
than the right ; indeed,
its wall is of treble thick-
ness, and bulges into the
right ventricle ; thus,
when the heart is re-
moved from the body the
ventricles may be distin-
guished by gently pinch-
ing each between the
finger and thumb. Hav-
ing comparatively little
to do, the free border of

i, Wall of right vent., and 2, 3, wall of left.

the right ventricle is thin and sharp (margo acutus], whilst that of the
left ventricle is thick and rounded (margo obtusus). The left ventricle
extends beyond the right and forms the apex of the heart.

The apex-beat appears, ' two inches below the left nipple and one
inch to the sternal side,' as a gentle upheaval of the tissues of the fifth
space. In children the impulse is sometimes in the fourth space ; and
in the aged, on account of the stiffness of the large arteries, it may be
found in the sixth space.

The distinctness of the manifestation of the heart's impulse is due
to the great strength of the left ventricle (which forms the apex), to the
tilting of the heart forwards during systole, to the lengthening of the
aorta as the blood is impelled into it (causing the heart to descend
somewhat), and to the fact that there is no lung between the apex and
the chest-wall.

The impulse of the apex-beat is felt as the ventricle discharges its
contents into the large vessel, and resembles the ' kick ' of the rifle.
The impulse which is felt over the base is due to the energetic con-
traction of the thick ventricular mass. When the apex is covered with
lung, as in emphysema, the apex cannot reach the chest-wall, and the
cardiac impulse which is felt by the hand is then due to the contrac-
tion of the right ventricle. And, as remarked above, the apex-beat ;

To Mark out Heart 163

and even the basic impulse, are drowned in the case of abundant peri-
cardial effusion. When, as the result of old adhesions, the apex clings
to the hinder part of the pericardium, there may be no upheaval of the
fifth space during systole, but, with each contraction of the heart, the
space may actually recede, to thrill again or throb with ventricular
relaxation. Thus the apex-beat is synchronous with diastole— a some-
what rare phenomenon.

Displacement of apex-beat. — The apex-beat is raised when the
diaphragm is thrust up, as in ascites, tympanites, or abdominal tumour ;
it is depressed when the diaphragm is thrust down by emphysema, or
by fluid in the left pleura : in these circumstances also it is displaced
to the right, but the heart becomes more vertical as it sinks from the
left side. When the right pleura is full the displacement is to the left.
When the left lung is contracted the diaphragm is raised, and with it
of course, the apex-beat, which is manifested more to the left.

Even in the healthy subject there is a considerable amount of fat
about the grooves between the auricles and ventricles. When its
deposit is greatly increased it is spoken of as a fatty encroachment,
a much less serious condition than that in which muscular elements
have passed into fatty degeneration.

To mark out the heart upon the chest, first make a dot corre-
sponding with the apex, two inches below the left nipple and one inch
to the sternal side ; it is over the fifth space. Then draw a line to it
from the right side of the xipho-sternal joint ; this defines the flat side
of the right ventricle, which rests on the diaphragm ; it should be
slightly convex downwards, as the margin of the heart bulges a
little, as shown on p. 166.

From the right end of this draw another line, bowing outwards
half an inch from the right side of the gladiolus, to the top of the third
chondro-sternal joint. This shows the bulge of the right auricle.

From the top of the last line draw another horizontally across the
sternum and extending an inch to the left of the sternum ; this marks
the top of the auricles and the beginning of the great vessels.

It now remains to make a fourth mark from the left end of the
superior horizontal line to the dot which is over the apex ; this mark
must be bowed so as to indicate the left convex border of the heart.
The left and the flat borders must not meet at a point, but
should be well rounded off, like the apex itself, which their junction
represents.

The situation of the heart varies only slightly with change of
position of the subject, but when the diaphragm descends with in-
spiration the heart must, of course, descend also, though, resting on
the central tendon of the diaphragm — which moves less than do the
muscular domes — the change of position is not very great. The
elevation with inspiration is not so extensive as it seems to be, be-
cause in that act the thoracic cage is raised in front of the heart.

1 64 The Heart

The actual descent with inspiration is about one inch, whilst the

apparent descent is nearer two inches. (Sibson.)

Chief viscera of thorax and abdomen outlined on front of body. (GODLEE and THANE.) For
the back view see p. 333. See also figure on p. 295.

Superficial Cardiac Area

165

The superficial cardiac area is that part of the front of the heart
which is not separated from the chest-wall by lung. The larger the
lungs, the smaller that area : thus in
emphysema the heart may be entirely
covered by lung, but in phthisis,
where the lung-tissue is wasted, the
superficial cardiac area is extensive.
It is triangular — one side of the
space being formed by the straight
margin of the right lung ; the base
corresponds with the flat border of
the heart, resting on the diaphragm ;
and the third side by the sloping
margin of left lung, behind the fourth
left cartilage. During systole the
apex of the heart displaces the little
tongue of lung shown in the wood-
cut, and impinges against the fifth
space.

To mark out the superficial car-
diac area, draw the line, as given
above, from the xipho-sternal joint
to the apex — this gives the base of
the space ; draw a second down the
mid-sternum from the level of the
fourth cartilage to the xipho-sternal
Joint, to define the margin of the
right lung, and a third from the top

of this line to the apex. This border of the space usually slopes down
with the fourth cartilage or with the fourth space of the left side.

The tongue of lung which laps the apex of the heart is the lowest
part of the upper pulmonary lobe, and it easily slips aside for the con-
venience of the movements of the apex of the heart.

THE INTERIOR OF THE HEART

The endocardium is a serous layer which lines the cavities of the
heart, and is continued from them along the arteries and veins. Its
reduplication, with some fibrous tissue intervening, forms the valves.
It consists of pavement cells upon a stratum of connective tissue. In-
flammation of the endocardium (as in acute rheumatism) may cause
the growth of warts upon the cardiac valves. Endocarditis generally
occurs on the left, the hard-worked side, of the heart, and it is often
secondary to pericarditis, the inflammation having traversed the mus-
cular wall of the heart to reach the endocardium.

The rigrht auricle has a capacity of about two ounces. It consists

1 66

The Heart

of a sinus and an appendix. Into the upper part of the sinus, behind
and to the right side, the superior cava pours its contents in such a
manner that the blood, descending from it, falls against the opening into
the right ventricle. In the foetus this stream passes in front of, and
does not blend with, the wave of pure blood which is entering the
auricle by the inferior cava and leaving it by the foramen ovale.

Interior of right heart :

1, Sup. cava.

2, Inf. cava, with

hepatic veins.

3, Septum and fossa.

4, Pulmonary valve.

5, Tricuspid valve.

6, Pulmonary art.

7, Ductus art.

10, Left appendix.

11, Left ventricle.

The inferior vena cava opens into the lowest part of the auricle,
sending its blood upwards and inwards against the inter-auricular
wall, for this was the direction which it took in foetal life, passing
through the foramen ovale under the protection of the Eustachian valve.
This valve is a reduplication of the auricular lining, and is attached by
its convex border at the front of the inferior cava and just behind the
auriculo-ventricular opening.

The fossa ovalis is on the inter-auricular septum, and marks the
position of the foramen ovale by which, in the foetus, the pure blood

Left Ventricle 167

from the inferior cava passed into the left auricle ; the ridge around
the fossa is the annulus ovalis.

The coronary sinus collects the blood from the two coronary veins,
and returns it into the back of the right auricle ; its orifice, which is
guarded by an imperfect valve (Thebesian), is between the inferior
caval and the ventricular orifices. Some small cardiac veins open
independently by foramina Thebesii into the right auricle.

The auricular appendix has its wall strengthened by muscular
bands which are arrayed like the teeth of a comb— the musculi pec-
tinati.

The right ventricle has its flat side resting upon the diaphragm ;
its convex surface forms the chief part of the front of the heart, but it
does not quite reach to the apex. The auriculo-ventricular opening
is to the right side of its base, and is guarded by the tricuspid valve,
which lies behind the sternum between the third intercostal spaces.
The most important flap of the tricuspid valve is, of course, towards the
left, so that as blood is being driven into the pulmonary artery there
may be no risk of it flowing back into the auricle. Of the other seg-
ments one is anterior, the other posterior.

The bases of the flaps are attached to a fibrous ring around the
orifice, and blend with each other laterally. To the free borders of the
valve segments, and also to their ventricular surfaces, chorda tendinea
are attached, so that they may not be swept up into the auricle with
the stream of blood when the ventricle contracts. If the tendinous
cords were connected by their other end with the ventricular wall they
would become slack during systole — as the walls closed in upon their
contents — and the tension of the valves would cease. They, therefore,
lose themselves below on fleshy columns (musculi papillares), which
contract simultaneously with the ventricular wall, and thus they hold the
valves taut.

The pulmonary artery leads up from the conus arteriosus, and is
near to the interventricular septum — that is, on the left side of the roof
of the ventricle. Its mouth is guarded by semilunar valves, which are
placed behind the third left chondro-sternal joint.

The left auricle has an appendix like that of the right ; and
it overlaps the root of the pulmonary artery on the left side. In front
of the auricle are the aorta and the pulmonary artery. The four pul-
monary veins enter the back of the sinus, two to the right and two
to the left ; they have no valve. Behind the auricle passes the left
bronchus. On the inner wall is a depression marking the situation of
the foetal foramen ovale.

The left ventricle makes the chief part of the back of the heart,
only a small part of it being seen near to the apex on the anterior view,
but it reaches beyond the right ventricle and forms the apex. Its
opening into the left auricle is guarded by a valve of two flaps — like
a bishop's mitre — which is behind the sternum at the level of the third

1 68

The Heart

intercostal spaces, being behind, and a little to the left of the tricuspid
valve. The two flaps of the mitral valve are unequal, the larger and
stronger being placed to the right and in front, between the auriculo-
ventricular and the aortic openings. The segments are connected
with musculi papillares as in the right ventricle.

The aortic orifice is to the front of the ventricle and to the right
of the opening into the auricle. It is behind the sternal end of the
third left space, and is guarded by semilunar valves, like those at the
root of the pulmonary artery, than which, however, they are larger
and stronger. It is behind, and a little to the left of, the pulmonary
orifice.

The semilunar valves are folds of the lining membrane of the heart
over a foundation of fibrous tissue ; at the middle of the free border
of each is a fibrous nodule, the corpus Arantii. These nodules block
the centre of the aperture during diastole, when the valves fall to-
gether. The closed valve does not form a horizontal plane across the
root of the artery ; the convex surfaces of its segments bulge against
each other, and, the greater the strain, the greater the surfaces of con-
tact and the less the chance of regurgitation.

The sinus of Valsalva is the dilated part of the artery behind the
segments of the valve. When the ventricle ceases contracting, the
elasticity of the artery drives the blood into the three sinuses and
forces the valves together.

The coronary arteries are given off from the sinuses of Valsalva.
The right comes forward on the right side of the pulmonary artery, and
winds round the right auriculo-ventricular sulcus, sending one branch
down the posterior inter-ventricular groove to the apex, and another

1, Right ventricle.

2, Left ventricle.

3 and 4, Parts of right and
of left auricles.

5, Tricuspid valve.

6, Mitral valve.

7, Pulmonary artery.

8, Aorta.

9, Coronary artery.

between the back of the left auricle and ventricle. The left coronary
artery passes on the other side of the pulmonary artery, down the anterior

Position of Cardiac Valves 169

inter-ventricular groove, giving a transverse branch round the left auri-
culo-ventricular groove.

The coronary arteries give twigs to the large vessels as well as to
the auricles and ventricles. When they are diseased (atheroma) they
carry an insufficient amount of blood to ttie cardiac tissue, so that
fatty degeneration, together with faintness and pain (angina pectoris),
result. Should an embolus be carried into one of them, death may
immediately occur from paralysis of cardiac muscle.

The relative position of the chief cardiac orifices. — The
pulmonary artery and the aorta are developed together : they, there-
fore, lie close together ; but the aortic opening is behind the pulmonary
because the left ventricle is behind the right. Being close together,
the pulmonary orifice must be on the left side of the right ventricle,
and the aortic orifice must be on the right side of the left ventricle.
The right auriculo-ventricular opening, then, must be to the right of
the pulmonary aperture, and the left auriculo-ventricular opening must
be to the left of the aortic aperture. (See fig. on p. 168.)

The situation of the valves. — The aortic valves are behind the
sternal end of the fourth left space. The pulmonary are a little
higher — at the junction of the third left cartilage with the sternum.
The auriculo-ventricular orifices are behind the sternum at about the
level of the third intercostal spaces.

' Thus these valves are so situated that the mouth of an ordinary-
sized stethoscope will cover a portion of them all if placed over the
junction of the third intercostal space on the left side with the sternum.
All are covered by a thin layer of lung ; therefore we hear their action
better when the breathing is for a moment suspended.' (Holden.)

Occasionally a valve suddenly gives way during violent physical
exercise, or as the result of a blow over the front of the chest ; the
lesion causes enfeeblement of the circulation and shortness of breath.

THE SOUNDS OF THE HEART

The healthy heart-sounds are a long and a short one : lub dup.
Then comes a pause which is as long as the short, second sound ; and
then lub dup again. We may represent the rhythm by a series of
dactyls thus : — lub dup pause | lub dup pause.

And, if we divide the dactyl into eight equal parts, four parts will
be taken up by the first sound, two by the second, and two by the
pause. Thus : —

. .. 4, 5,6, 7,8
1st sound, 2nd, pause

ist sound, 2nd, pause-

The two ventricles dilate together and contract together, and the
auricles dilate together and contract together. Having divided the

Normal Heart Sounds

dactyl into eight parts (though, for the scheme of the sounds and
the pause, four would have served equally well), the eight divisions
are now needed for the demonstration of the workings of the auricles
and ventricles ; thus : —

Is- sound \an-sound\ .pause \

Ventricles Ventricles

contracting dilating

Thus, the auricles are filling during seven-eighths of the dactyl, and
are emptying their contents into the ventricles in the eighth part, and,
immediately after this emptying, the ventricles, which are now full to
the utmost, contract, and the auricles begin to fill again. As regards
the ventricles, they are contracting during the first four parts of the
dactyl and dilating during the remainder.

The first sound takes place with contraction of the ventricles and
is synchronous with the arterial pulse. It is due chiefly to the slam-
ming of the auriculo-ventricular valves, and partly, perhaps, to the rush
of blood out of the ventricles ; to the impulse of the apex against the
chest-wall, and to the rumble of the contracting ventricular walls.
With the first sound, then, the auriculo-ventricular gateways are shut,
and the aortic and pulmonary are open.

The short second sound is due to the sharp closure of the semilunar
valves, which takes place when the ventricles have finished their con-
traction, and the elastic coats of the pulmonary artery and aorta are try-
ing to drive the blood back into the flaccid ventricles. It is like the
noise which is caused by the vibration in a long, vertical, leaden pipe
when the tap, through which water is quickly flowing, is suddenly
turned off.

Take the hem of your handkerchief between the finger and thumb
of your left hand, and about 3 in. along in the straight line take it also
between the finger and thumb of the right hand. Now, by suddenly
separating the two hands after having slightly approximated them,
jerk the hem tight, and you get a long vibration or sound, some-
thing like that due to the sudden tension of the flaps of the auriculo-
ventricular valves. That represents the long first sound. Now, in a
similar way, snap the hem with the thumbs about an inch apart, and
you will imitate the short, ringing, second sound.

The fuller the large arteries, and the greater the pressure of the
blood down upon the semilunar valves, the louder, sharper, and more

Cardiac Murmurs iji

ringing is their slamming, and thus is explained the accentuation of
the second sound.

When an abnormal sound is heard over the heart, the first point is
to find if it is synchronous with ventricular contraction or not ; this is
settled by listening to the sound whilst the finger is laid on the radial
pulse. If the murmur be occurring with the ventricular contraction
it must be due either to obstruction to the outflow of blood into the
pulmonary artery or aorta, or to a reflux through an auriculo-ventri-
cular valve ; and if it be heard during diastole it must be caused by re-
gurgitation from the pulmonary artery or aorta, or by a difficult passage
from an auricle into a ventricle ; almost for certain it is due to re-
gurgitation, and, almost certainly, the regurgitation is from the aorta.

The aortic and pulmonary valves slam at the same time, making
the second sound, which should be heard over the carotids, being pro-
pagated along the aorta in the blood-stream. If it cannot be heard
in the neck the listener concludes that the aortic valves are unable to
slam together, and this loss of the second sound makes him suspect
aortic regurgitation (p. 173).

When the segments of the auriculo-ventricular valves do not slam
exactly together the first sound is spoken of as ' reduplicated. ' A
similar occurrence may be noticed as the lateral halves of a door- way
are pushed asunder ; if they swing back into the middle line at the
same instant a clear sound is heard, but if one of them lingers the
noise of the closure is blurred or reduplicated. When there is a want
of harmony in the closure of the aortic or pulmonary valves the second
sound is reduplicated.

Cardiac murmurs. —When the aortic or pulmonary orifice is
narrowed by chronic inflammation (endocarditis) or the presence of
warty excrescences (vegetations), the blood passes through it with a
scraping or whistling sound, called a bruit. Such bruit occurs, of
course, when the ventricle is contracting, and is, therefore, systolic.
(Systole, contraction ; o-uo-reAAa>, contract, aw with, oreAAco, send.
Diastole, dilatation ; 8ia, asunder, o-reAAco.)

A river flowing peacefully in its wide bed becomes excited as it
approaches the artificially narrowed passage under a bridge, and rushes
from between its piers with an audible sound. So it is with the
blood-stream which traversed a valve which has been made narrow and
rigid by disease, and then dashes into a roomy space. The murmur
is probably produced just after the blood has passed through the
straits. In the same way, when a stethoscope is placed over and made
to compress the common femoral artery, the bruit does not occur in
the compressed part of the vessel, but in the roomy part just beyond
the obstruction, where the blood-stream is opening out again.

The perfect working of a valve depends on the integrity of each
individual segment, and if the valve be so defective as to hinder the
passage of the blood its segments will probably fail completely to close

172 Disease of the Heart

the opening after the blood has passed through ; thus, some of it slips
back again (regurgitates) when the vis a tergo has ceased to act.
There are various ways of expressing this doubly imperfect condition :
the valve is ' stenosed ' (orei/os, narrow), and is also ' inadequate ' ; there
is 'obstruction' with 'insufficiency' also, and, therefore, regurgitation.
Thus there are systolic and diastolic murmurs. An aortic obstruction-
murmur occurs during systole, and a regurgitant murmur during diastole.
But aortic obstructive and mitral regurgitant murmurs occur at the
same time ; so also is it with pulmonary obstructive and tricuspid
regurgitant.

When the aortic or pulmonary aperture is both narrow and in-
competent there is a double murmur of obstruction during systole and
of regurgitation during diastole ; in the case of the aortic valve the
murmur of regurgitation accompanies or even takes the place of the
second sound, for the valve-segments have ceased to slam tightly
together. So also it would be with the pulmonary valve.

An auricle and ventricle both being dilated, the fibrous ring to which
the bases of the valves are attached is stretched, and, as the valves do
not at the same time grow larger, they are necessarily incompetent to
prevent regurgitation.

Disease of the tricuspid valve is so rare that we need not consider
the resulting murmur separately ; indeed, valvular disease of the right
side of the heart is quite uncommon ; but tricuspid regurgitation may
exist without valvular disease (v. z'.). In nineteen cases out of twenty,
valvular murmurs belong to the hard-worked left side of the heart — to
the mitral or aortic orifice, the inlet and the outlet of the left ventricle.
The natural inlet has become an outlet also : or the natural outlet
is obstructed. (Watson.)

A cardiac murmur, therefore, most likely exists in the left side of
the heart, and, as mitral obstruction is rare, it is either due to mitral
insufficiency or to aortic derangement. If the former, it occurs during
systole, and if it be due to aortic obstruction it will also be systolic, and
heard along the aorta (p. 173) ; if diastolic it will be due to aortic
insufficiency and will be heard over a more limited area.

A tricuspid regurgitant murmur when associated with aortic or
mitral disease is a ' friendly' sound, for it means that the right ventricle
is pumping some of its belated contents back into the right auricle, and
so is lessening the risk of pulmonary apoplexy. It obviously occurs
with ventricular systole-r-with the radial pulse ; it is best heard near
the xiphoid, but it is of rare occurrence. The murmur of tricuspid
obstruction is still more rare, and may be left out of consideration.

Notwithstanding the ' safety-valve arrangement' at the right aitri-
culo-ventricular opening, the energetic action of the right ventricle
sometimes throws more strain upon the pulmonary capillaries than they
could bear. Thus I have known of an athlete who, though apparently
in perfect health and strength, was liable to hemoptysis after any

Mitral Disease 173

unusual strain. Haemorrhage even in such circumstances should be
regarded with anxiety, though it may be merely of physiological
import. It is probable that the safety arrangement not only insures
the right side of the heart against strain, but also against disease.
A similar arrangement, desirable though it might seem, could not
exist at the left auriculo-ventricular opening, as the lungs would in-
evitably suffer by it.

Murmurs from disease of the pulmonary value are best heard over
the third left cartilage, that is over the valve ; they grow fainter
towards the apex. They are distinguished from aortic murmurs by
their occupying a limited area ; they certainly do not ascend into the
neck (p. 171). They are usually the result of congenital malformation.

When the left aurictilo-ventricular valve (mitral) is narrowed an
obstruction-murmur may be heard immediately preceding the ventri-
cular contraction. It is the presystolic murmur, and is of compara-
tively rare occurrence. When listening for it a finger should be kept
on the radial pulse, so that the observer may know exactly when to
expect it. The murmur runs with the blood-stream, and is heard over
the apex.

Mitral re gurgitation, a very common defect, occurs when the left
ventricle is pumping blood backwards through the incompetent auri-
culo-ventricular valve — the murmur, of course, takes place with systole.
It does not ascend into the large vessels at the root of the neck, as
does a systolic aortic murmur, but is loudest heard in those regions
where the ear can be approached to the left ventricle without the inter-
vention of the right ventricle, as in the neighbourhood of the apex ; also
below the left shoulder-blade, and behind the lower middle dorsal
vertebrae, the seventh and eighth (p. 166), for there the left ventricle is at
the back of the heart, and in that direction the blood is rushing. As
the left ventricle lies close over the stomach, a mitral murmur may often
be heard in the gastric region, with that peculiar metallic thrill which is
due to the vibrations passing across the stomach full of gas (v. p. 164).

The murmur of aortic obstruction is not best heard over the mid-
sternum, that is over the situation of the aortic orifice (p. 169), for at
this level the valve is deeply hidden behind the right ventricle and the
root of the pulmonary artery ; but the sound, being carried by the
blood-stream, is heard where the aorta comes near the surface, as
at the second right costal cartilage, behind the manubrium, in the
large vessels at the root of the neck, and along the dorsal spine. It
occurs with ventricular contraction, and is, therefore, synchronous
with the radial pulse. *

The murmur of aortic regurgitation is not well heard in the neck,
for the regurgitant blood is actually rushing away from that region,
back into the left ventricle. The carotids, however, which are half-
emptied before the ventricle contracts again, fill and throb visibly
with systole, especially when the patient sits or stands, as gravity in-

Disease of t/ic I f carl

creases the amount of the refluent blood. The regurgitation murmur
occurs immediately after the radial pulse, that is during ventricular
diastole, and is heard at the second right cartilage, over the valve,
along the left sternum, and down to the apex, replacing, possibly,
the second sound, or all of it but that which is due to the slamming of
the pulmonary valves. Now, for some obscure reason the regurgitating
blood does not always carry this murmur down to the apex, but, throwing
the sternum into vibration, it is well heard over that bone, for the
sternum is a good conductor of sound. When the regurgitation con-
tinues until the ventricle is actually ready to contract again the
murmur lasts until the first sound. This means that a little blood is
squeezing its way back during the whole time that the aortic valves
are shut. When the regurgitant murmur is a short one the valve
must be desperately out of order, allowing the arterial tension to send
plunging back as much blood as it likes, and all in a lump, as it were.
Thus the short-lived aortic regurgitant murmur is of much graver
import than that which persists up to the next ventricular contraction.
When the aortic valve permits regurgitation the arteries cannot be kept
full, and so it is that the radial pulse collapses during diastole. Then
when the ventricle contracts again blood is injected into the half-empty
vessel, and the water-hammer, or whipping pulse, is produced — a sign of
great clinical value.

When an aortic murmur lasts only through the first half of the
diastole, and the radial pulse is seen to expand and collapse rapidly,
regurgitation is extreme. But when it lasts through tke whole
diastole, and the collapsing pulse is not very visible, even on raising
the wrist, the valvular insufficiency is but slight. Aortic obstruc-
tion very often co-exists with aortic insufficiency ; then a ' see-saw '
murmur is produced.

Engorgement of the superficial cervical -veins occurs when the
right ventricle is much embarrassed, as in pulmonary emphysema ;
in mitral insufficiency ; in tricuspid insufficiency ; or when an
aneurysmal or other thoracic tumour presses upon the superior vena
cava or the innominate veins. The engorgement is less noticeable
when the head and neck are raised, as then gravity helps to empty the
veins. Inspiration relieves the cervical congestion ; but with each
expiratory act, and markedly in coughing, the intra-thoracic pressure is
increased, and the veins stand out fuller than ever along the neck,
showing a respiratory undulation imparted to their contents.

A definite venous pulse in the neck occurs when the right ventricle
is unable tp drive its contents through the lungs (p. 172) and some of
the blood escapes by the tricuspid valve into the right auricle, and
thence into the superior cava, the innominate and the jugular veins.
Regurgitation may occur through even a healthy tricuspid valve. As
already remarked, the right auriculo-ventricular orifice has a third flap
to provide for this safety-action ; through a healthy two-flap valve it

Cardiac Hypertrophy 175

could hardly take place, so that, had the right auriculo-ventricular valve
been on the pattern of the mitral, an overloaded right ventricle could
have found relief only by pulmonary haemorrhage. In the case of the
venous pulse the jugular veins can be seen rilling from below upwards.

The reflux blood passes straight into the right innominate vein, so
that the venous pulse is more perceptible on the right side of the neck.
The venous pulse is, of course, most marked in a case of tricuspid
dilatation, when the external jugular may be widely distended, throb-
bing as high as the angle of the jaw. Occasionally the pulsations
extend along the subclavian tributary of the innominate vein, and pass
down the superficial veins of the arm. Sometimes the tidal flow
passes backwards in the inferior cava, and through the hepatic veins,
so that if the liver happen to be at the same time congested and large
pulsations in it may be felt. Pulsation from tricuspid insufficiency has
also been found as low as the femoral vein.

Just before the systolic venous pulsation occurs, a much slighter
throb may be sometimes detected ; it occurs as the overloaded auricle
is struggling to empty itself into the ventricle, a portion of its contents
being forced up into the superior cava.

A respiratory pulse in the superficial veins of the neck is often
observable even in health, for during expiration the intra-thoracic pres-
sure is increased, and the veins are unable to empty themselves. Then,
with inspiration, their contents hurry into the right auricle, sucked,*as
it were, into the expanded chest, and their track is no longer visible.

Hypertrophy. — As the biceps of the blacksmith grows by constant
exercise, so does the wall of the heart by the continual effort to over-
come obstruction in the arterial circulation. When the obstruction
first occurs, the ventricle, unprepared for it, is unable to empty itself
of blood, and its cavity becomes dilated. Afterwards its wall begins
to thicken. Aortic obstruction (p. 1 73) becomes of comparatively little
importance when it is accompanied by hypertrophy of the left ventricle.
Thus, hypertrophy, which is always preceded by dilatation, is com-
pensatory for the dilatation, and for the thinning of the muscular wall.
With hypertrophy the impulse is excessive and 'heaving,' and the
cardiac region of the chest-wall may bulge, especially in a young adult.

The larger the heart, the more boisterous its action, and the more
extensive its impulse. Thus, hypertrophy may be recognised at a
glance, or by placing the hand over the front of the chest.

A greatly hypertrophied ' bovine ' heart may weigh twenty, thirty, or
even forty ounces, and, by pressing against the oesophagus (p. 139), may
impede deglutition. Even in the ordinary way the heart would compress
the gullet when the man is lying on his back, were it not swung in, and
held by the pericardium. If the heart be greatly enlarged, the left carti-
lages and ribs from the fourth to the seventh bulge, and, the lungs being
pushed aside, the dull area is increased, and the spaces are widened.

Hypertrophy of the rigrht ventricle occurs when there is diffi-

r/6 Disease of tJic Heart

culty in pumping blood through the lungs, as when the capillary a
is diminished by dilatation of the air-cells, as in emphysema and in
chronic phthisis, or by the compression of a pleuritic effusion. Ob-
struction at the pulmonary valve causes dilatation and hypertrophy
of the right ventricle, and so especially does incompetence of the
mitral valve, for the left ventricle then pumps blood back into the
left auricle, and the pulmonary veins cannot empty themselves ; the
pulmonary capillaries being overloaded, the right ventricle struggles
in vain to pass its blood onwards.

In these circumstances, the right ventricle may grow so large as
entirely to cover the left ventricle and to hide the apex-beat. The
impulse is felt over a large area, even up to the third left cartilage,
and down in the epigastrium. But when the heart is working with a
tremendous bustle, and the radial pulse is, nevertheless, poor, it is
evident that the right ventricle, not the left, is hypertrophied.

The left ventricle is dilated and hypertrophied when, Sisyphus-
like, it is struggling to force upwards its contents which are ever rolling
backwards though an incompetent aortic valve ; but these conditions
sometimes occur independently of valvular disease, as in the case of
athletes and others who are suddenly called upon for violent exertion.

In the case of severe aortic disease the left auricle remains over-
full, the pulmonary circulation is delayed, and the right ventricle be-
comes hypertrophied as well as the left. The grave lung-complication
does not occur so long as the left ventricle remains strong enough for
its extra work, but it comes on as soon as the walls begin to^ yield.

Delayed pulmonary circulation eventually causes hypertrophy of the
left ventricle as well as the right, as in emphysema ; the lungs being
full, the right heart is full, as are also the venous capillaries throughout
the body, and thus the left ventricle is obstructed in its work.

Hypertrophy of the left ventricle without dilatation occurs in
the case of simple narrowness of the aortic opening, and also in Bright's
disease, when there is an increasing difficulty in forcing blood through
the narrowed and rigid capillaries. In such circumstances hyper-
trophy must not be regarded as disease. It is, rather, Nature's remedy
for disease. It is ' compensatory,' and of excellent omen. How peri-
lous, on the other hand, is the state of the feeble individual who, with
aortic obstruction, has a dilating ventricle with walls so thin as scarce
to supply a perceptible apex-beat ! So long as the ventricle is equal
to its extra work all goes well ; but when it begins to fail the left auricle
becomes distended and the case becomes as serious as one of mitral re-
gurgitation, venous congestion occurring, as already described.

With aortic regurgitation (p. 1 73), dilatation precedes hypertrophy
and is inevitable ; in aortic narrowness there need be no dilatation of
the slowly thickening ventricle.

When the left ventricle alone is hypertrophied the impulse may be
found in the sixth, seventh, or eighth space, and outwards towards the

Effects of Mitral Disease 177

left axillary line : when the right ventricle is enlarged the impulse
extends to the right of the sternum. Displacement of the apex-beat
downwards and outwards at once suggests hypertrophy of the left
ventricle ; but an extensive impulse within the normal site does not
necessarily imply enlargement, it may be due to recession of the lung —
as in phthisis.

The extent of the hypertrophy cannot always be made out by
percussion, as the heart, instead of pushing the lung aside, may hide
beneath it.

Though the hypertrophied left ventricle labours and hurries to
force the blood onwards, it never gets complete mastery over the situa-
tion. The result is that when any extra demand is made it becomes
embarrassed, and the pulmonary veins, and the vessels of the lungs
generally, are over-filled, and aeration is retarded. Thus, shortness of
breath is a prominent sign of hypertrophy.

When the mitral valve is narrowed, also when it is incompetent, the
left ventricle has but a small quantity of blood to force into the aorta ;
thus, in mitral disease the left ventricle is the only part of the heart
which is not hypertrophied.

In valvular disease of the heart the prejudicial effects pass always
in the direction opposite to that of the normal blood-stream.

The auricles are dilated and their walls thickened when their labour
is increased by a narrowing of the gateway into the ventricle, or when,
from incompetence of that valve, the ventricle is able to pump some
of its blood the wrong way. In mitral regurgitation the left auricle
first enlarges, then the right auricle, on account of the obstruction in
the lungs, and then the right ventricle.

The dilatation of the left auricle may cause so much pressure upon
the left bronchus (which is close behind it, p. 194) as to obstruct the
flow of air through it.

With mitral insufficiency the hypertrophied and embarrassed heart
beats with such vigour against the chest-wall that recognition of the
exact murmur may be difficult. A thin layer of lung, however, acts
as a cushion and does away with the local excitement, and thus it is
that in these cases the murmur is often most distinct towards the
axilla. Sibson used to demonstrate this effect of the layer of lung on
the heart-sound by placing a piece of blotting-paper between the chest
and the stethoscope, and so diminishing the impulse-noise and bringing
out the murmur. ' A mitral murmur is a proof of mitral regurgitation,
but not of disease of the mitral valve ; it having been noticed in cases
in which post mortem examination revealed a healthy mitral valve.'

The effects of mitral disease. — Catarrhal bronchitis, and, later
on, cedema of the lung, haemoptysis, and pulmonary apoplexy, may
be caused by valvular disease of the heart, the pulmonary veins, and
the bronchial veins which open into them, being engorged, and the
lung ' splenified.' This condition occurs both when the mitral valve is

178 Disease of the Heart

narrowed, for then the left auricle is always over-full, and when it allows
regurgitation from the ventricle. Cough also is a sign of valvular dis-
ease, because the irregular passage of blood through the lungs worries
the pneumogastric filaments.

The lungs and the right auricle being distended, the inferior vena
cava is over-full and dilated, the liver becomes large and tender, and
' nutmeg' engorgement (p. 337) is produced. Later on, albuminuria,
and dropsy of the peritoneum, pleura, and pericardium, and oedema
of the legs, occur. The superior cava is also overloaded, and thus
cedema of eyelids, headache, and apoplexy are accounted for, as is also
the capillary congestion which gives rise to clubbing of the fingers.
The kidneys and spleen are also engorged and the urine is albuminous.
The albuminuria is the result of nephritis, for heart-disease causes
nephritis just as it does bronchitis ; but, the kidney being so much more
distant from the heart than the lungs, the student is apt to overlook
this pathological sequence.

The structure of an artery. — The innermost coat consists of a
layer of flat endothelium upon a bed of elastic fibres and connective
tissue (intiina). Next come alternating layers of circular elastic and
non-striated muscular fibres (media), and outside these more elastic and
connective-tissue fibres (adventitia). The internal and middle coats
break clean through and retract when a ligature is tightly applied, the
external, tough coat being puckered up. Inflammation is set up by
the operation, and the clot which forms becomes glued to the wall,
and in time nourished by the vasa vasorum and duly organised. The
narrow zone of artery which is girt by the ligature necroses, and is set
free by linear ulceration in the adjoining tissue, the fibrinous plug being
a safeguard against haemorrhage.

An artery is usually enclosed in a fibrous sheath, often with a vein
or with venae comites ; this sheath has to be opened up before the
ligature is applied. If the artery be too freely denuded in the opera-
tion, the vasa vasorum are needlessly destroyed and the vessel runs a
risk of sloughing.

A large artery, and especially so the aorta, has the middle coat
greatly thickened by elastic fibres, so that it may yield as the blood is
pumped into it, and then, when the semilunar valve is closed, may
exert continuous pressure upon the blood, forcing it onwards.

THE ARCH OF THE AORTA

The arch of the aorta springs from base of the left ventricle at the
level of the sternal end of the third left intercostal space.

The first part of the arch ascends obliquely forwards to the second
right costal cartilage.

l\cl<itions.—\\. is within the pericardium, and has /// front the |>ul-
artery, which comes from the anterior ventricle, and the

ArcJi 'of Aorta

right auricular appendix. Behind is the root of the right lung. To
the right are the superior vena cava and the right auricle, and to the
left is the pulmonary artery (v. p. 185).

The second part inclines backwards, and to the left, from the second
right cartilage, gently bending over the trachea, till it reaches the left
side of the fourth dorsal vertebra.

Relations. — /// front are the left pleura and lung, and the left
pneumogastric, phrenic, and cardiac nerves. The left innominate vein
may overlap it above, and the left superior intercostal vein ascends
obliquely in front to join the left innominate. Behind are the trachea,
oesophagus, thoracic duct ; the left recurrent laryngeal, and the deep
cardiac nerves. Above are given off the innominate, the left carotid,
and the left subclavian arteries ; the left innominate vein runs across
the roots of those arteries. Below are the bifurcation of the pulmonary
artery, the ductus arteriosus, and the left recurrent laryngeal nerve.

This part of the arch is badly named ' transverse,' as it runs almost
directly backwards from the second right cartilage.

Its upper border is about an inch below the episternal notch, and
corresponds with the tip of the third dorsal spine, and its lower border
is on the level of the transverse sternal ridge. But in feeble and small-
chested persons the transverse aorta may lie on the level of the top of
the manubrium ; in big-chested men it is placed much deeper — behind
the top of the gladiolus, for instance. Its concavity is, of course,
downwards, but there is a second concavity directed backwards and to
the right which is due to the vessel being bent round the trachea.

The third part of the arch is very short, extending only down the
left side of the fifth dorsal vertebra, which thus forms its posterior
relation. In front is the root of the left lung, and on the right side are
the fifth vertebra, and the oesophagus and thoracic duct ; on the left
are the lung and pleura.

To mark out the large vessels.— The aorta begins opposite the
sternal end of the third left space. Roughly, it is about as wide as the
thumb. It slopes upwards to the second right cartilage. Thence it
turns backwards, and slightly to the left, behind the manubrium, its
lower border corresponding with the ridge between the manubrium and
the gladiolus. The third part descends by the fifth dorsal vertebra,
rather to the left of the middle line.

From immediately behind the middle of the manubrium the inno-
minate artery and the left common carotid mount to their respective
sterno-clavicular joints. The left subclavian ascends a little to the
outer side of the left carotid.

The pulmonary artery, two inches long, ascends in the pericardium
from the right ventricle to the concavity of the aortic arch, where it bi-
furcates ; that is, it reaches from the third left chondro-sternal joint
(the situation of the pulmonary valve) to the second left chondro-sternal
joint.

180 Arch of Aorta

Irregularities of the aortic arch. — Sometimes the heart and
aorta, and the arterial and venous trunks associated with them, are
transposed, so that the apex beats on the right of the sternum, the
superior cava being on the left of the middle line, and the aorta arching
to the right. But the aorta may, by the development of the right fourth
branchial arch instead of the left, bend over to the right side, without
there being any other transposition of thoracic viscera.

The right subclavian artery may come from the back of the left end
of the arch, and reach the left scaleni by passing behind the trachea
and oesophagus.

There may be two innominate arteries ; the left carotid may come
from the (right side) innominate ; the two carotids may come off to-
gether, the subclavians arising on either side of the common trunk; the
left vertebral may come off as a fourth trunk between the left carotid
and subclavian ; both vertebrals may thus arise, making five trunks.
All four large trunks may arise separately, there being no innominate
artery. Further, the vertebrals may arise separately, whilst the innomi-
nate may be divided, making six. The left carotid coming from the
innominate may cross the windpipe dangerously near the knife of the
tracheotomist (p. 133).

On account of the enormous strain which is thrown on the beginning
of the aorta its wall is apt to yield, especially when weakened by disease
— arteritis. Aneurysm is thus produced. The very root of the aorta
being dilated, the valves fail to prevent regurgitation, and a diastolic
murmur occurs. The first part of the arch is more likely to yield than
the second, for the former is enclosed within the pericardium, whilst
the latter has its walls strengthened by the fibrous part of the pericar-
dium being blended with it. A fatal leakage of an aneurysm of the first
part may take place into or through the pericardium, but before this
happens certain pressure effects may be noticed; these, however, are not
so varied and suggestive as they are in aneurysm of the transverse arch,
for the tumour bulges forwards and usually bursts before it gets large.
When it reaches the chest-wall a pulsating swelling occurs near the
second or third right cartilage.

Tight-lacing, or tight clothing, especially about the neck and upper
part of chest, is apt to check the emptying of the large vessels and to
produce thoracic aneurysm.

The general effects of thoracic aneurysm are disturbance of the
action of the heart by the pressure upon cardiac and pneumogas-
tric filaments. Through the pneumogastric interference ' indigestion '
may be complained of. The growth of the tumour displaces the lung
and makes percussion dull. Later, there may be pain in the chest and
back, especially when the swelling impinges against the spine. Pres-
sure upon the root of the lung may cause dyspncea, with strange breath
sounds and cough. The patient may be unable to lie down in comfort,
as the tumour then weighs the more heavily against the trachea. The

TJioracic Aneurysm 181

arch is lengthened and the heart lowered, and the struggling left
ventricle is considerably enlarged. Circulation is delayed, and, an
imperfect supply of blood passing to the lungs, shortness of breath is
usually a prominent sign.

If the tumour happen to press upon and irritate a sympathetic
chain there may be dilatation of the pupil of that side (p. 88) ; contrac-
tion of the pupil suggests that the pressure is severe enough to paralyse
the sympathetic. In any case, the aneurysm is apt to cause inequality
of the pupils.

In aneurysm of the aortic arch the pulsation is exactly synchronous
with ventricular contraction ; and there may be a quiet space between
the region of the cardiac impulse and the abnormal pulsation. In
examining the tumour one hand should be placed flat over the pulsa-
ting area in front, whilst the other is laid between the shoulders during
expiration ; in this way the characteristic expansion may be best de-
tected. The sac may burst externally, or into the pericardium, pleura,
lung, trachea, cesophagus, mediastinum, spinal canal, or even into the
pulmonary artery itself.

Sometimes the chief and most characteristic symptom of the disease
is pain down the left arm, or at the left shoulder— an important clinical
fact which anatomy fails at present efficiently to explain.

Aneurysm of the first part is of the most frequent occurrence—
perhaps, as already remarked, because the second and third portions are
strengthened by the fibrous element of the pericardium. Another ex-
planation is that the blood from the left ventricle is, on account of
the obliquity of the heart, pumped forcibly against the outer side
of the first part, which it gradually stretches and weakens. The
aneurysm begins as a pulsating tumour in the second right space, close
to the sternum ; the apex-beat being displaced towards the left side.
The dilatation is apt to start in a sinus of Valsalva, the right for choice,
and it is, therefore, usually sacculated.

Aneurysm of the first part of the arch may press upon the superior
vena cava, and cause venous congestion of both sides of the head and
neck, and of both upper extremities ; indeed, a case is recorded by
Watson in which almost the whole of the blood coming from the head
and arms was returned by dilated epigastric veins into the external
iliacs, to reach the heart by the inferior cava. The obstructed return
of blood from the brain causes dizziness and headache.

Bulging backwards against the root of the right lung, the tumour
may obstruct the bronchus; and, pressing against the pulmonary artery,
it may cause a systolic bruit. Sometimes it produces absorption of the
ribs and sternum, and bursts at last into the pericardium, pulmonary
artery, or pleura, or through the thinning integument.

Aneurysm of the transverse aorta forms a pulsating tumour behind
the manubrium \vhich may even extend to the left of that bone. It may
press upon the trachea and cause dyspncea, cough, and harsh breathing;

1 82 Thoracic Ancutysin

upon the recurrent laryngeal nerve, altering the voice and paralysing
the muscles of the left cord (p. 70) ; upon the oesophagus, causing
dysphagia and suggesting stricture of the gullet (p. 139) ; upon the
thoracic duct, causing inanition ; upon the left innominate vein, pro-
ducing duskiness, venous congestion, and oedema of the left side of the
head and neck and of the left arm, and possibly causing at last absorption
of the manubrium. When the sac bulges into the episternal region the
case may be taken for one of aneurysm of one of the aortic trunks; and
the tumour may cause compression and even obliteration of the left
carotid or subclavian artery, thereby increasing the risk of error in
diagnosis. Should it bulge into the neck the resemblance to an
aneurysm of the innominate or common carotid may lead to error of
diagnosis.

More than once it has happened, unfortunately, that tracheotomy has
been resorted to for the relief of dyspnoea which happened to be caused
by pressure of an aortic aneurysm upon the trachea. When, however,
it can be made out that the dyspnoea is due to pressure upon the
left recurrent laryngeal nerve, the windpipe may be opened with ad-
vantage.

Aneurysm of the third part of the arch pulsates against, and may
bulge through, the vertebral ends of the middle ribs of the left side,
causing at first intercostal neuralgia and obscure dorsal pains sugges-
tive of caries ; then, reaching the spinal canal, it may determine para-
plegia ; and by pressing on the left pulmonary plexus, which is just in
front of it, may cause spasmodic attacks like those of asthma, so that
eventually air may entirely fail to enter the lung. It may press against,
and eventually burst into, the oesophagus, trachea, left bronchus, peri-
cardium, or pleura.

The innominate artery, \\ in., arises at the beginning of the trans-
verse aorta, behind the middle of the manubrium ; passing upwards
and to the right, it divides at the upper border of the right sterno-clavi-
cular joint, between the heads of the sterno-mastoid muscle.

Relations.— Separating it from the manubrium are the origins of
the sterno-hyoid and thyroid and the remains of the thymus gland ; it is
crossed by the left innominate vein and the right inferior thyroid veins.
Behind is the trachea. To tlic left are the trachea and the left carotid ;
and to the right are the pleura and lung, with the right innominate
vein and pneumogastric nerve.

Varieties. — The innominate artery may bifurcate in the thorax, or
it may pass into the root of the neck before dividing. Sometimes it
gives off the thyroidea ima, an irregular branch, to the lower part of
the thyroid body, which, however, is occasionally derived from the left
carotid, or from the transverse aorta itself. This little artery ascends
to the thyroid body on the front of the trachea, and may be wounded
in tracheotomy below the isthmus.

Xtigation of tbe innominate artery is a desperate operation, as

Innominate Artery 183

the trunk may happen to be altogether intra-thoracic — dividing low
down. In reaching it there may be alarming hasmorrhage from an
accidental or inevitable wound of the right inferior thyroid vein, or of
the left innominate vein ; or the right vein, or even the vena cava
itself, may be pierced by the aneurysm-needle working in the depths
of the wound — and in the dark. The pleura may be damaged and
become inflamed, or fatal secondary haemorrhage may occur on
account of imperfect plugging of the artery after the application of the
ligature. After tying the innominate, a ligature should also be placed
upon the common carotid artery so as to prevent the collateral circu-
lation interfering with the formation of firm clots.

Operation. — The shoulders are raised so that the head may be
thrown back with the view of pulling upon the carotid and raising the
innominate to the utmost, the right arm being drawn well down. The
root of the sterno-mastoid is to be raised by an L-shaped incision, one
limb of which runs down the anterior border, whilst the other detaches
at least the sternal head, each limb of the |_ being at least two inches
long. The skin, superficial fascia, platysma, and deep fascia are
divided, layer by layer, until the sterno-mastoid is reached. After re-
flection of the large muscle the sterno-hyoid and thyroid are divided
on a director, and the right inferior thyroid veins are seen and care-
fully hooked aside, or, if necessary, tied and severed.

The root of the carotid is then sought and followed down until the
innominate trunk is reached. The left innominate vein is then de-
pressed, the right being drawn downwards and to the right, and the
aneurysm-needle is gently passed from the venous, the pneumo-
gastric and pleural side — the outer side— upwards and inwards.

To find the channels by which collateral circulation may be estab-
lished, the best plan is to follow the empty trunk and to see what branches
from it, or from its divisions, are likely to meet with well-filled vessels.
Such branches quickly imbibe blood and bring it in the opposite direc-
tion to that in which they were accustomed to convey it — towards the
occluded part. Thus the right common carotid divides into the external
and internal carotids ; the external gives off the superior thyroid,
lingual, facial, occipital, temporal, and internal maxillary, which would
bring in blood from their fellows of the opposite side.

The internal carotid would bring blood by the anterior communi-
cating from the opposite side. The anastomosis through the posterior
communicating would not serve, as the posterior cerebral which it joins
has, because of the ligature, no blood to render ; it might, however,
obtain a little blood from the left vertebral through the basilar.

The subclavian trunk would be very serviceable : by the internal
mammary it would bring up blood from the aortic intercostals, the
deep epigastric of the external iliac, and the phrenics. The vertebral
would bring blood direct from the basilar and from branches of its
fellow of the opposite side. The inferior thyroid would bring in blood

184 Innominate Artery

from its fellow, but the supra- and posterior scapular arteries would be
useless. The superior intercostal helps by its anastomosis with the
first aortic intercostal, but its anastomosis with the occipital could not
serve ; by its thoracic branches, namely, the short, the acromial, the
axillary, the alar, and the long ; and by the ending of the subscapular
on the chest, all of which anastomose with aortic branches.

Aneurysm of the innominate artery causes a bulging to the
right of the manubrium, especially into the first right space. Eventually
it may cause absorption of the upper ribs of right side, and of the
manubrium, and appear as a pulsating tumour on the front of the chest.
It is often impossible to diagnose it from aneurysm of the ascending
aorta ; indeed, both of those trunks are often dilated at the same
time.

The dilatation interferes with the due filling of the trunks coming
from the innominate, so that the carotid and radial pulse of the right
side are altered. The left innominate vein (p. 186), and perhaps the
right also, is compressed ; the trachea is pushed towards the left side,
the voice is feeble, and respiration may be spasmodic and difficult.

The frequency of the occurrence of aneurysm of the innominate
artery may be due to the fact that the root of that vessel, together
with the right side of the first part of the arch, receives the shock
of the ventricular stroke.

Relations of the pulmonary artery. — A coronary artery comes
forward from the aorta on either side of its root. Springing from the
right ventricle, the pulmonary artery is at first in front of the aorta, but
as the first part of the arch ascends to the right the pulmonary artery is
soon found to its left side. As these two large trunks were developed
together, they lie in the same serous tube of pericardium. The bifur-
cation of the pulmonary artery is connected with the left side of the
concavity of the aortic arch by the ductus arteriosus.- (For Root of
Lung -u. p. 194.)

The thoracic aorta continues the third part of the aortic arch from
the lower border of the fifth (p. 179) to the twelfth dorsal vertebra,
where, passing through the diaphragm, it becomes the abdominal aorta.
At first towards the left side of the dorsal column, it gradually inclines
towards the middle line ; and, lying upon the spine, it has also a curve
with the concavity forwards.

Relations. — It rests upon the vertebral column and the left inter-
costal veins, and has in front some of the root of the left lung, the peri-
cardium and heart, and the oesophagus. To the left are the pleura and
lung; and just above the diaphragm the oesophagus also is to the left.
To the right are the oesophagus above ; the thoracic duct and vena
azygos major, and the spinal column.

Aneurysm of the thoracic aorta may extend backwards, causing
erosion of the vertebra? and ribs, producing spinal curvature ; irritating
the intercostal nerves, and causing ' pleurodynia,' or neuralgia in the

TJwracic Aneurysm

185

front of the chest and in the epigastric region. The peripheral pains
due to aneurysm are most likely on one side, whilst those due to spinal
caries are usually bilateral and symmetrical. Further, the aneurysm
of the thoracic aorta may appear as a pulsating tumour by the costal
angles. If it bulge forwards it presses upon the oesophagus, causing
dysphagia, or upon the lung, giving rise to shortness of breath, and to
the presence of a dull percussion-note. If it compress the thoracic
duct rapid wasting occurs. Pushing the heart forwards, it causes pal-
pitation and faintness, and an embarrassed circulation.

I, Aorta; n, pulmonary artery ; d' d', anterior jugular veins ; cc', internal jugulars; dd, ex-
ternal jugulars ; a a', innominate veins ; in, superior cava ; <?, great azygos ; IV, hepatics.
N.B.— All the veins are anterior to the arteries. (A. THOMSON.)

It may at last leak through an ulcerated patch upon the skin, or
may discharge itself into the oesophagus, pleura, or pericardium, or into
a bronchus ; or its contents may be extravasated along the posterior
mediastinum.

The branches of the thoracic aorta are bronchial, pericardial,
cesophageal, intercostal, and posterior mediastinal.

The intercostal arteries are nine on each side, the first and second
spaces being supplied by the superior intercostal of the subclavian

1 86

Innominate Veins

(p. 1 57). They pass out horizontally over the front of the external inter-
costal muscle, and behind the pleura. As the ribs slope downwards
the arteries soon reach the upper part of the space, where they run
between the intercostal muscles in the costal groove, the nerve being
below, and the vein above, the artery.

Each intercostal artery gives off a collateral branch, which courses
along the lower border of the space. In front the arteries anastomose
with the internal mammary (p. 156). They also anastomose with the
superior intercostal and with branches of the axillary, and with the
epigastric and lumbar arteries, and, at the back of the space, with the
bronchial arteries.

Each intercostal artery gives off a dorsal branch, and, in the female,
the third, fourth, and fifth send out branches to the mamma.

Section through bottom of fourth dorsal vertebra. I, H, in, iv, ribs ; i, trachea ; 2, oesopha-
gus ; 3, superior cava ; 4 is placed between first and third parts of aortic arch. (BRAUNE.)

The left innominate vein, 3 in., is formed behind the inner
end of the clavicle, in front of the beginning of the left carotid, by the
confluence of the subclavian and internal jugular veins ; lying on a
rather higher level than the transverse aorta, but sometimes overlap-
ping it, it is very near to the upper border of the manubrium, from
which it is separated by the sterno-hyoid and sterno-thyroid muscles
and the remains of the thymus gland.

The right innominate vein, I in., begins behind the end of the
right clavicle, and descends by the outer side of the innominate artery ;
on its right side are pleura and lung.

Inferior Thyroid Veins 187

The tributaries of the innominate veins are the vertebral, internal
mammary, and inferior thyroid ; in addition, the left vein receives the
left superior intercostal, which passes obliquely to it over the front of
the transverse aorta.

The inferior thyroid veins descend in front of the trachea, on either
side of the middle line ; the left ends in the left innominate, but the
right slopes over the front of the arteria innominata, to end at the con-
fluence of the innominate veins. These thyroid veins are important
in tracheotomy below the isthmus, and in ligation of the innominate
artery (p. 182).

The superior vena cava, 3 in., is formed by the junction of the
innominate veins, behind the first right chondro-sternal joint.

Course and relations. — It descends by the right side of the ascend-
ing aorta, behind the inner end of the first and second intercostal
spaces, to the right auricle. Just at its beginning it lies on the right
side of the innominate artery. To its outer side and in front are
pleura and lung. Behind it is the root of the right lung, over which
the vena azygos major is hooking to enter the vena cava (v. p. 185).

THE PLEURA

The pleura consists of an external fibrous and an internal serous
layer. It is a large lymph-space, and com-
municates by stomata with the adjacent

lymph- vessels. By its outer surface it ad- ^^£g^ / J|X
heres to the chest-wall, diaphragm, and peri-
cardium ; it surrounds the lung, passing in
between the lobes. The interval between
right and left pleurae is divided into the me-
diastina (p. 154).

There is actually no cavity between the
parietal and visceral layers, but, with a pene-
trating wound of the chest, or with rupture of
the lung, or with a fistulous opening from a
bronchus or cavity, air enters the pleural sac ;
the lung then collapses on account of the
elasticity of its wall, and that side of the chest
becomes tympanitic, and ceases to move in
respiration. This condition often follows
compound fracture of a rib.

The lower border of the pleura is marked
by a line passing obliquely from the costo-
xiphoid articulation to the vertebral end of
the twelfth rib, but the border of the lung does not descend quite so
far, not even in deep inspiration, nor does the pleura quite fill in the

Showing crevice between cos-
tal and phrenic pleura ; pul-
monary pleura ; phrenic and
hepatic peritoneum ; ribs, ix
to xn.

1 88 The Pleura

crevice between the chest- wall and the diaphragm. A sharp instrument
may pass through two layers of pleura in the costo-phrenic crevice,
and penetrate the diaphragm and liver without wounding lung, and
through such a wound a piece of omentum may even protrude.

The twelfth rib is covered by pleura, and in seeking the kidney
from the loin the surgeon, keeping his incision too near to the rib,
may open the pleura.

The apex of each pleura mounts \\ to 2 inches into the neck
(p. 164); and over the pleural dome the subclavian artery passes, in a
slight groove.

A peripleuritic abscess is one which forms between the chest-wall
and pleura; it is of limited extent, and is obviously very different from
an empyema (p. 190).

Inflammation of the pleura, or pleurisy, causes a 'stitch' in the
side, and produces a short cough. As the opposed surfaces become dry,
and roughened by fibrinous deposits, they rub against each other during
the movements of respiration, and produce * friction-sound or a vibra-
tion which may be appreciated even by the touch. The sound is lost
as the surfaces again grow moist and smooth, also when they become
glued together by plastic lymph, or when they are widely separated by
intra-pleural effusion. It is lost also whilst the patient holds his
breath, and this distinguishes it from a pericardial friction-sound,
which is, of course, uninfluenced by respiration (p. 158). The friction-
sound is like that which is often heard with a new saddle. The slower
and deeper the inspiration, the more jerky and prolonged the sound,
and it may usually be intensified by pressing the parietal pleura nearer
to the visceral by thrusting the finger between the ribs. When a class
of students are listening for the sound the first comers hear it best, for
the deep respiratory movements temporarily smooth down the rough
surfaces.

Movement causes pain, so the affected side of the chest hardly
stirs in respiration ; the fellow lung, therefore, does nearly all the re-
spiratory work, hurrying to accomplish it. The respiratory movements
are, therefore, quick, shallow, and almost unilateral ; they are best
noted by placing the hands flat on the ribs ; sometimes one side lags
or hardly moves at all.

The intercostal nerves supply not only the costal pleura, but also
the levatores costarum, the intercostals, and the flat muscles of the
abdomen. When, therefore, the parietal pleura is inflamed the nerve-
trunks are in distress, the patient is neither willing nor able to draw a
deep breath, and the utmost rest and comfort are required. The
pleuritic patient should not be allowed to converse, as this entails con-
siderable respiratory effort. Questions should be arranged so that
' yes ' or * no ' are the only answers needed.

Sometimes the pleuritic patient has pain and tenderness in the
epigastric region, on account of the trunks of the lower intercostal

Fluid in Pleura

189

nerves being implicated. Such peripheral pains are like those met
with in lower dorsal caries, but they are not usually bilateral. If pain
extend into the armpit or down
the inner side of the arm, the
explanation is to be sought in
the distribution of the lateral
cutaneous branches of the inter-
costal nerves, and especially of
the intercosto-humeral.

Hydrothorax. — As the re-
sult of pleurisy, serum oozes from
the capillaries of the pleura into
the cavity, rilling, perhaps, one
side of the chest, but hydrothorax
is apt to occur in disease of heart
(p. 178) and of kidney. The fact
of the pleura being a large lymph -
space accounts for the rapid ab-
sorption which 'water in the
chest' sometimes undergoes. If
there be only a small amount of
fluid in the chest there is a dull
percussion note behind as the
man lies supine, but as he is
turned on to his face the dulness may shift its position. As he sits up
the dull area is just above the diaphragm, front and back, the lung being
floated up. When the pleura is choke-full the intercostal furrows of
that side are effaced, the lung is driven into the costo-vertebral groove,
and the heart, as shown by the position of the apex-beat (p. 162), is
displaced right or left, as the case may be. The lung being com-
pressed, that area is absolutely dull on percussion ; the gentle breath-
sounds are lost, and the water-logged side of the chest scarcely moves
with respiration ; the air may be heard at the back, however, entering
and leaving the rigid tubes (bronchial respiration, p. 200). There is a
general bulging of that side of the chest. The patient obviously prefers
to be upon the heavy side ; and, as he speaks, the hand placed on the
chest detects absence of "vocal "vibration, for the fluid cuts off all the
sound-waves. The lung does not float on the fluid.

Some of the above signs equally apply to a solid thoracic tumour,
but a solid growth does not cut off the vibrations — a wooden carriage-
seat transmits vibrations, a water-cushion dissipates them.

In the case of effusion the liver and spleen are driven from the
shelter of the ribs and may be brought within reach of the fingers. The
full pleura may also bulge below the clavicle or in root of neck.

In left hydrothorax, as the diaphragm and phrenic pleura are
lowered, the pericardium, which is attached to the central tendon, also

Heart displaced vertically and to the right by
effusion into left pleura. (BRAUNE.)

190 The Pleura

descends, and, with it, the apex of the heart. At the same time the
pericardium and heart are displaced towards the right, so that the
apex-beat is felt in the epigastrium. If the heart be pushed still further
to the right it has to glide up over the liver, and thus the apex-beat
may be found in the fifth space, or even higher.

When the effusion is into the right pleura the apex-beat is neces-
sarily displaced towards the left.

Pressure upon the venae cavae keeps them constantly full, but as
soon as some of the fluid is withdrawn from the chest by paracentesis
the superficial veins empty themselves, the aspect of the patient im-
proves, and respiration is eased.

Sometimes the chest is found full of fluid without there having been a
pleurisy or any other disease to account for it; it is then probably caused
by the pressure of a malignant tumour upon the veins and lymphatics.

When the fluid is purulent the disease is called empyema (ei/,
within ; nvov, pus), and the pleural abscess, for such it is, may discharge
itself by a bronchus, into the peritoneum, or through the chest-wall
about the fourth or fifth space, outside the nipple-line and below the
border of the pectoralis major — a situation in which the chest-wall is
apparently weak ; or it may work its way to the sternum between the
planes of the intercostal muscles.

Tapping: the chest is best done just in front of the angle of the
scapula when the arm is by the side — through the middle of the fifth
space. If the contents be purulent, and the space narrow, it may sooner
or later be necessary to excise a piece of a rib, so as to ensure more
room for drainage, the periosteum being raised by a raspatory, and the
intercostal vessels being also turned out of the groove before the rib is
cut with the nippers. If the opening were made through a low space
— and especially if on the right side— there would be a risk of the
diaphragm rising so high as to block the tube. Indeed, it has even
happened that when an empyema has been incised too low down the
diaphragm has also been traversed, and that omentum has escaped
through the wound.

When the pleura has been evacuated, the lung, if not permanently
crippled, and bound down by adhesions, expands again. If it fail to
recover, and a pleural fistula persist, the ribs may have to be divided
in front of their angle, so that the side of the chest may collapse and
the suppurating pleura may be obliterated. But if this be not done the
obliteration may ultimately be effected by the rising of the diaphragm,
by displacement of the heart and sound lung, by a falling in of the
chest, and by lateral curvature of the spine ; the ribs become crowded
together on that side, whilst they are expanded like a fan upon the
sound side, the shoulder on the crippled side being depressed. The
effacement of the former pleural space is effected by the formation of
new fibrous tissue which has been developed out of the granulations
sealing the space.

Outline of Lung 191

Pneumothorax. — When the pleura is full of air (p. 187) the percus-
sion note is tympanitic, but as more air is pumped in at each expira-
tory movement the tension becomes so great that the air can no
longer vibrate and the sound becomes metallic. These sounds may be
imitated by slightly blowing out the cheeks and sharply striking one
of them with the finger-nail, and then again striking when they are dis-
tended to the utmost ; in the latter case the note is more metallic.

The most likely cause of pneumothorax is the opening up of a
vomica, but this is often provided against by the concomitant pleurisy
having glued together the visceral and parietal layers. Malignant
ulceration of the oesophagus sometimes lets air into the pleura, and
the same condition has followed a mediastinal emphysema which was
secondary to tracheotomy. (Fagge.)

In pneumothorax there is, as a rule, a certain amount of fluid in
the cavity as well as air (Jiydro-pneumothorax), and in either of these
conditions, the pleura being distended, the apex-beat may be displaced
right or left, as described in hydrothorax (p. 189).

THE LUNGS

In infancy the colour of the lungs is pinkish ; in adult life grey,
from the presence of particles of carbon ; and in those who have worked
in coal-mines it may be quite black (anthracosis).

The lung-tissue of the foetus, and of the newly-born child, unless
breathing has been instituted, is solid and sinks in water, but after
respiration it has become buoyant ; in this way it is determined whether
an infant found dead was still-born or not. Pieces of the lung from
which air has been dispelled by pneumonic exudation also sink in
water.

The apex of the lung mounts in the robust an inch and a-half
above the first rib, or an inch above the clavicle, into the region cor-
responding to the triangular interval between the posterior border of
the sterno-mastoid and the anterior border of the trapezius. The sub-
clavian artery grooves the front about £ in. below the very apex, being
separated from the lung by the parietal pleura. (See fig. on p. 164 )

The bases of the lungs reach much lower behind than in front, for
in front the diaphragm is level with the sterno-xiphoid joint. They are
concave, corresponding with the surface of diaphragm, and are de-
limited by an oblique line passing over the chest from the sterno-
xiphoid joint over the costal cartilages and above the last rib, and to
the spine. The base of the right lung is immediately above the liver,
the limit of its resonance and of hepatic dulness being clear and
definite. The base of the left is above the stomach, and it is generally
easy to define the area of the pulmonary resonance from the metallic
note of the stomach. Still, the student must guard against mis-

192 The Lungs

taking the metallic note of the distended and elevated stomach for
that of a pulmonary cavity or of a pneumo-
thorax.

IX The lower border of the lung descends

about an inch during inspiration, but in
emphysema, when the air-vesicles are per-
X manently dilated and inelastic, there is no
movement in the costo-phrenic crevice.

The thick, posterior border lies in the
costo-vertebral groove ; the sharp, anterior
border overlaps the pericardium. The inner
surface of the lung is concave, the root enter-
ing it nearer to the back than the front. The
thickness of the posterior border is well shown
on p. 1 86.

The left lung (20 oz.) has two lobes ; it is
narrower than the right, so as to leave a
hollow for the heart. The fissure between
the lobes extends from the spine of the sca-
pula (that is from the third rib behind) to the
base of the lung in front. The upper is the
anterior lobe.

The right lung (22 oz.) is the larger,
because it does not have to make room for
the heart ; but it is shorter on account of the presence >of the liver
beneath it ; it has three lobes, the third being sliced off the bottom of
the upper lobe by a fissure running upwards and forwards. The middle
lobe lies under cover of the fourth, fifth, and
sixth ribs, at the side of the chest, and in front
it reaches to the diaphragm.

It is important to remember that the fissure
between the upper and lower lobes extends from
the third rib behind (spine of scapula) to the
base of the lung in front. Thus, in pneumonia
of the lower lobe the dulness is found ending
abruptly at that oblique line, together with
the bronchial breathing and increased vocal
vibration ; above that line all is healthy. And
conversely, in phthisis, which has a prefer-
ence for the upper lobe, the dull percussion
sound posteriorly is above the spine of the

Pneumonia of lower lobe , . , .,

scapula only, whilst in front it extends down to
the diaphragm. The lower lobe is almost alto-
gether behind the upper lobe.
The lower dorsal vertebra: advance into the interior of the chest,
the ribs all the while receding, so that if a line be drawn across the

Right costo-phrenic crevice
seen from behind. A stab
of the liver through the gth
space would traverse four
layers of pleura and two of
peritoneum ; if through the
nth space the lung would
escape injury.

(2) of right lung ; dulnt
below spine of scapula,
front resonant.

Area of Lungs

193

chest, just in front of the vertebral column, as much lung is found

behind as in front of it. It is this

thick posterior part which becomes

sodden when a feeble person is

kept long in bed in the supine

position — Jiypostatic pneumonia.

Even after the deepest expira-
tion about 200 cubic inches of
' residual ' air, H, remain in the
lungs ; for convenience, another
loo cubic inches are 'reserved' in
ordinary respiration, the * tidal ' air
amounts to about 50 cubic inches
more, and when an additional 100
cubic inches of 'complemental' air
are inspired the lungs are full to
the utmost.

To mark the anterior border
of the lungr.— From the apices (p. 164) the anterior borders of the lungs

Complemental air

Tidal

Reserved

Residual

(HUTCHINSON.)

Area of lungs shaded ; heart in outline. (HOLDEN.)

194

1'lic Lungs

gradually incline inwards behind the sterno-clavicular articulation, and
the manubrium, to the middle of the transverse ridge on the sternum ;
they then descend together as far as the fourth cartilage. From this
level the border of the right lung descends straight to the end of the
gladiolus, whilst the other slopes outwards in a line from the fourth left
cartilage to a spot two inches below and one inch internal to the left
nipple — that is, to the apex of the heart — thus leaving a triangular
surface of the right ventricle uncovered by lung ; the size of this super-
ficial cardiac region (p. 165) is, of course, in the inverse ratio of the size
of the lung, being large in phthisis, small or effaced in emphysema.
There is scarcely any lung-tissue behind the manubrium, the narrow
space between it and the spine being occupied by the trachea and
oesophagus and the large blood-vessels ; but, as the aorta is fixed to
the back of the chest by its intercostal branches, when the sternum
advances in inspiration the edges of the lungs must then glide inwards
towards the middle line.

The root of the lung consists of the pulmonary veins, the pul-
monary artery, and the bronchus — in that order from before backwards.
From above downwards the order is : on the left side, artery, bronchus,
veins, but on the right side the bronchus is higher than the artery, the
veins being still below and in front. The left bronchus descends to a
lower level than the right in its course beneath the aortic arch. The
root of the lung has pleura in front and behind, constituting the broad
ligament, between the folds of which are the bronchial vessels, sym-
pathetic and pneumogastric filaments, and lymphatics anti lymphatic
glands.

Relations of the root of the lungr. — On the right side, in front,
are the ascending aorta and the descending cava, the vena azygos
major (v. p. 185) arching over the root to end in the vena cava.

On the left side the root lies in front of the oesophagus and the third
part of the aorta, and slopes beneath the aortic bend. Malignant
stricture of the oesophagus often occurs at the spot where it is crossed
by the left bronchus — perhaps as the result of pressure. In front of
the left bronchus is the left auricle (v. p. 177). The phrenic nerve and
the anterior pulmonary plexus are in front of each root, and the vagus
and the posterior pulmonary plexus are behind.

Infarction. — The branches of the pulmonary artery pass in with
the bronchi and continue to divide until the ultimate capillaries enter
their respective lobules ; if a clot be dislodged from one of the
systemic veins — say from an iliac vein, as after ' white leg ' — and
be carried into the right heart and into a pulmonary artery, by acting
as a plug it throws out of work all that area of lung which the artery
supplied. This area will be wedge-shaped, with the apex at the site
of the plug, and the base at the surface of the lung ; in conformity to
the arborescent distribution of the vessels, the base must reach the
surface, for there the capillaries end. The larger the embolic clot (ei>,

Hemoptysis ; H&matemesis 195

into ; /SaAXety, cast), the larger the vessel plugged and the more important
the resulting asphyxia. An embolus caught at the forking of an
artery does not completely block it, but allows a small quantity of blood
to pass beyond it ; this additional fluid coagulates in the capillaries and
eventually involves them in a hcemorrhagic infarction (infarcio, stuff- into,
in allusion to the engorgement of the tissue with blood). The anatomy
of infarction is the same whether it be in the lung, spleen, liver, kidney,
heart, coronary artery, or the brain ; but only in the lung can the
plug come from a systemic vein, for such, unless it be a very minute
one, must lodge in the lung. An embolus in any other viscus may come
from a pulmonary vein, from a vegetation detached from a mitral or
aortic valve, or from a fragment which has scaled from a diseased
artery — but not from one of the systemic veins. A patch of liver-
tissue may also be damaged by an embolus brought through the portal
vein. The infarcted area may slough, or become the seat of abscess,
or may quietly undergo decolouration and organisation. Pulmonary
infarctions are often associated with haemoptysis.

Sometimes, on the occurrence of an extensive pulmonary infarct, a
murmur which was previously heard on the right side of the heart dis-
appears, the vegetation which caused the murmur having been washed
off into a branch of the pulmonary artery.

The pulmonary veins, two from each lung, return the arterial
blood by separate openings into the left auricle ; they have no valves.
A vein comes from each lobe, and, as the third lobe of the right lung
belongs to the upper lobe, so the median pulmonary vein joins the right
upper vein.

In the root of the lung the veins are in front of the pulmonary
arteries and of the bronchi. The right veins pass behind the right
auricle and the ascending aorta, and the left pass in the root of the
lung, in front of the third part of the aortic arch.

Blood brought up from the lungs is necessarily mixed with air,
and is therefore bright-red and frothy ; it is alkaline, and is coughed up
(Jicemoptysis, at/xo, blood ; TTTUCO, spit). That issuing from the stomach
comes up with retching— it is dark, and often is mixed with food and
gastric juice ; it is, therefore, acid (hcematemesis — e/xeco, vomit).

When blood which has been coughed up is small in quantity it
usually comes from the bronchial capillaries, whilst severe bleeding is
usually due to a large artery in the lung having been eroded. But
even copious haemorrhages can occur from the bronchial capillaries,
just as fierce bleeding may occur from the capillaries of the nose.

The trachea consists of about sixteen horse-shoe cartilages. (For
the anatomy of the trachea see p. 131.) The mucous membrane is
covered with columnar ciliated epithelium, and contains in its depths
mucous glands and lymphoid tissue.

The bronchi resemble the trachea in structure, but the smaller ones
are not flat behind, the hor§e-shoe cartilages becoming complete circles.

196 The Lungs

The muscular tissue, which in the trachea lay only behind, in the small
bronchi completely encircles them, and may be traced even into the
divisions of the air-tube which are too small to possess any cartilage.
The columnar epithelium which lines the tubes is rarely expectorated,
even when bronchial catarrh is severe.

Ultimately the small bronchial tubes lose both cartilage and muscle
and expand into air-cells, which are lined with flattened epithelium.
Between these cells are crevices (stomata) which open into an alveolar
lymph-space ; through them germs, particles of soot or grit, may
reach the lymphatic vessels. The group of air-cells into which an
ultimate bronchial tube expands is cone-shaped and is called a lobule.
The lobules are distinct, and are separated by a delicate fibrous tissue
which is connected with the sub-pleural coat.

Emphysema (cv, in ; cfrvo-au, blow) is just that condition which
would be induced by inserting the nozzle of bellows into the trachea
and vigorously ' blowing into ' the lungs. Some of the air-cells burst,
and allow air to escape into the connective tissue of the lungs (extra-
vesicular or interlobular emphysema], whilst others are over-stretched,
and in some places many cells are blended into one large cell
(vesicular emphyse?)id], Interlobular emphysema is especially apt to
occur in the delicate chest of a child with severe whooping-cough.
When emphysema is imitated on the cadaver the anterior edges of
the lungs glide over the heart, and their bases depress the diaphragm,
liver, stomach, and spleen ; the ribs are raised, the upper ones notably
so, the chest becoming high and barrel-shaped, and the neck being
shortened by the elevation of the sternum, the first rib, and the clavicle.
And, if only the bones were soft enough, the expanding lungs would
make the spine bow forwards, rendering the subject round-shouldered.

The chest of the emphysematous man is hyper-resonant, even to
the twelfth rib, and on opening \\.post mortem the lungs do not collapse,
for much of their elasticity has been destroyed in the vesicular dilata-
tion, and the tubes are plugged with bronchitic mucus. The border of
the lung generally has, moreover, a bubbly fringe, and if during life
some of the bubbles had burst pneumothorax would have resulted.

The trombone-playe ', by his forcible blasts, over-stretches the air-
cells and becomes emphysematous. So does the man with chronic
cough, for emphysema is developed during expiration. But there is
an additional reason for the subject of chronic bronchitis being emphy-
sematous, for many of his small bronchial tubes become permanently
plugged, the lobules associated with them collapsing ; but at each inspi-
ratory act the chest must still be filled, so the adjacent lobules undergo
double expansion, for when a part of the lung is permanently thrown
out of working order the air-cells in the healthy neighbourhood struggle
to fill its place, and suffer in the act. The emphysema thus produced
is called vicarious ; it is likewise a constant accompaniment of chronic
pneumonia.

Emphysema ; Asthma

197

As contiguous cells coalesce, the intervening capillaries perforce
disappear, and the oxygenating area is diminished — thus, the large-
chested man is actually short of breath. The right side of the heart is
engorged, its ventricle is hypertrophied (p. 175), tricuspid regurgitation
occurs (p. 172), and with it a systolic, venous pulse occurs in the neck.
The venae cavas are overloaded, the face being dusky and livid ; piles
may occur, and later on dropsy ; the liver becomes nutmeggy, and
the urine may be albuminous. But, though the right ventricle is much
hypertrophied, the impulse is imperceptible, and its sounds are not
increased, for the heart is ' smothered ' by the expanded lungs.

Though the liver is depressed, it may not be conspicuous below the
ribs, for, the chest having been greatly enlarged from before backwards,
plenty of room is thus provided for it.

Occasionally the enlargement of the lungs is such that their in-
flated borders overlap each other behind the sternum. Such lungs
when removed from the thorax are sure to retain the prints of the ribs.

In extra-vesicular emphysema air may leak from the emphysematous
lung into the connective tissue of the chest and so find its way into
the subcutaneous tissue of neck and
trunk (general emphysema). On rare
occasions the parturient woman has,
in her violent straining, ruptured cer-
tain air-cells, and air having escaped
through the interlobular tissue has
found its way to the face and eyelids,
inability to see from between the lids
having suddenly supervened.

Both in emphysema and pneumo-
thorax there is a deficiency of breath-
sounds, and there is also a hyper-reso-
nance on percussion ; there is, however,
no difficulty in distinguishing the con-
ditions, as emphysema affects both
sides of the chest, pneumothorax only
one — bilateral pneumothorax being
incompatible with life. Indeed, when
both lungs are crippled by phthisis, and
ulceration of the wall of a vomica allows
air to escape into one pleura, death
may suddenly occur, the remains of the
other lung not sufficing for respiration.

Contraction of the muscular tissue

of the bronchi, from irritation of the pyo-pneumothorax. (DR. FENWICK.)
vagi, as in indigestion, causes spas-
modic asthma, which may also be produced by direct irritation, as in
the uraemia of Bright's disease. The nerve-irritation may also be

198 The Lungs

secondary to uterine disease. In the case of dyspepsia there is irri-
tation of the gastric filaments of the vagi, which, passing to the pul-
monary plexus, is reflected along the sympathetic filaments. An
asthmatic attack usually comes on suddenly, air being locked up in the
pulmonary vesicles, and the percussion-note becoming hyper-resonant.
Under the influence of an emetic, or of some special antispasmodic, the
muscular contraction yields, and air once more freely passes to and fro.
Though there is but little connective tissue in the healthy lung, as
the result of chronic interstitial pneumonia, or fibroid phthisis, large
quantities are formed, which ultimately undergo condensation and
atrophy (see cirrhosis of liver, p. 336). The disease may follow chronic
bronchitis, or may be due to the irritation caused by particles of coal
or grit (saw-grinder's phthisis). As the fibroid lung contracts, the walls
of the bronchi are dragged asunder and the tubes are dilated into enor-
mous cavities, under the atmospheric pressure (bronchiectasis : ppoyxos,
windpipe, eK-rao-o-co, draw out), the diaphragm rises, and the chest-walls
fall in. When the fluid which collects in these cavities is decomposed
it may be necessary to tap and drain them through the chest- wall.

In extensive bronchiectases the right ventricle is hypertrophied
(p. 175), and the veins are full even to the tips of the fingers, which are
usually clubbed.

Thus, in fibroid phthisis and in hepatic cirrhosis atrophy of the
new connective tissue ruins the"histological structure of, and obstructs
the flow of blood through, the viscus, but, whereas the cirrhotic liver
dwindles to insignificant proportions, the lung is unable to* do so, be-
cause, in obedience to the laws of atmospheric pressure, its exterior
must lie close to the parietal pleura. So great is the contracting force,
however, that, though the periphery of the lung cannot be pulled in-
wards, the bronchi, as just described, are widely stretched. The ' pull '
continues in each case, but it is easier for contracting elements in the
lung to drag the walls of the bronchi towards the surface of the lung
than the surface of the lung towards the interior of the bronchi : so the
tubes are opened out into large cavities.

In phthisis (0$to>, waste away) the lungs are small ; the chest as-
sumes the expiratory type, being low and flat ; the neck is long, because
the clavicle, the first rib, and the sternum have dropped ; and the ab-
dominal viscera hide in the phrenic dome. The shoulders are narrowed
and sloping, and the supra- and infra-clavicular regions are flat, on
account of the contracting fibrosis in the apices, and the percussion
note there is dull.

In phthisis, as in emphysema, the capillary area of the lungs is
diminished, and the right ventricle grows large in its constant stni^iji*
to get its contents passed through the degenerate pulmonary area.
But the lungs, though poor, remain honest, and decline to send forth
blood which is of inferior quality.

Branches of the pulmonary artery pass behind the bronchi to

Bronchial Vessels 1 99

end in fine capillaries between the air-cells. Indeed, the capillaries
bulge on each side into the cells, being covered only by their thin
epithelial pavement.

The bronchial vessels supply the machinery of the lungs, the
pulmonary vessels being occupied with aeration of the blood. The
bronchial arteries, two or three to each lung, come from the thoracic
aorta or the intercostals; the veins empty into the azygos trunks. The
lymphatics end in the bronchial glands, in the root of the lung.
These glands are often loaded with particles of carbon which have been
brought from the air-cells by the lymphatics. Often they are found
calcareous post mortem ; this is when they have been inflamed and
enlarged, the salts having remained whilst the softer elements were
absorbed.

The anterior and posterior pulmonary plexus supply pneumogastric
and sympathetic filaments.

EXAMINATION OF THE CHEST

Percussion is most conveniently carried out by striking the middle
finger of the left hand by tips of the partly flexed fingers of the right.
The character of the sound thus obtained reveals the comparative
density of the tissue beneath. Thus, over healthy lung the note is
clear, over cedematous lung it is comparatively dull, and over solid
lung, or over liver (with no lung intervening), it is absolutely dull.
With a good ear and a clever touch the exact area of heart, of a hepa-
tised patch of lung, of an aneurysm or a vomica, can generally be clearly
defined. But in the case of serious disease examination should be dis-
creetly carried out, lest the patient suffer from exposure, and lest his
chest be so shaken as to set up cough or bring on haemoptysis.

Percussion is resonant in the root of the neck, but the note is not
so clear as it is below the clavicles, because the apex of the lung is
small. Resonance should be good also along the middle of the cla-
vicle.

On the right side the note begins to get dull from below the fifth
rib, because of the decreasing volume of the lung over the liver. Below
the liver-dulness the tympanitic resonance of the intestines begins.

The note is clear over the manubrium, though there is no lung
behind that bone (p. 193) ; the resonance being due to vibration in ad-
jacent lung-tissue. But it is clearer along the gladiolus, though from
the fourth cartilage downwards, and to the left, comes the comparative
dulness of the cardiac area (p. 165). The resonance is greater on in-
spiration, as the border of the lung glides further over the heart. Below
the base of the left lung the tympanitic note of the stomach begins.

For the sake of comparison, the two sides of the chest must be
percussed symmetrically from the supra-clavicular regions downwards,
due allowance being made for the area of cardiac dulness. For per-

2OO Examination of CJiest

cussing the back, the patient should, if possible, sit up in bed, fold his
arms across the thighs, and bend forwards.

A strange, chinking, crack-pot sound may sometimes be heard on
percussing over a pulmonary cavity ; it is due to some of the air being
driven with each stroke into the opening of a bronchial tube. This
may be imitated by keeping the palms of the hands loosely closed
across each other, and then striking the back of one hand on the knee.
If the hollow between the hands be made air-tight, the crack-pot sound
is lost ; similarly the pulmonary cavity must have a clear bronchial
tube opening out of it, or it becomes an air-tight chamber and the sound
is lost.

Vocal fremitus is the thrill of the vibrating vocal cords which is
conveyed by the air in trachea, bronchi, and vesicles to the hands placed
upon the chest. The nearer to the larynx, the larger the bronchus and
the louder the fremitus. It is * damped ' by a thick layer of fat or
muscle upon the chest, and by air in the pleura ; whilst it is completely
drowned by pleuritic effusion (p. 189). Its absence from the back of the
lung, therefore, is a diagnostic sign between pleurisy with slight effusion
and pneumonia ; in the latter the vibrations are absolutely increased,
for the solid lung is a good conductor of sound. Returning fremitus
denotes absorption of fluid.

On listening at one end of a wooden beam whilst someone scratches
the other end with a pin, the scratches are heard with extraordinary
distinctness, for the solid material not only conveys the vibrations, but
magnifies them. Similarly in exudation into the lung the vopal fremi-
tus is exaggerated, provided always that the bronchial tubes are free
to convey the vibrations from the trachea to the lung-tissue.

A pulmonary cavity may act as a reservoir, or a sounding-board for
vocal vibrations (provided that it is not full of fluid), and thus vocal
fremitus may be increased, especially if the surrounding lung-tissue
be solid.

The healthy respiratory sounds vary with the site in which auscul-
tation is made. Thus, if the stethoscope be placed over the episternal
region, or over the spines of the lower cervical or upper dorsal verte-
bras, and the patient draw a deep breath, the air is heard rushing
through the trachea — this is tracheal respiration. It is a good deal
like the blow of air through a keyhole. If the stethoscope be placed
between the scapulas, or over the. sternum, the tidal blow is heard in a
less degree, termed bronchial, or tubular. In other parts of the chest
than over the trachea or bronchi the respiratory, or vesicular mur-
mur, or breath-sound is heard as a soft blow, which has been poetically
likened by Hughes to * the song of a gentle gale in the thick summer
foliage, or to the whisper of the retiring wave upon a sandy coast.'

When the pleura is full of air or liquid, and the lung lies collapsed
against the spine, air still enters and leaves the larger bronchi, and
so bronchial respiration is present in pneumothorax and empyema as

Voice-sounds 2OI

well as pneumonia. In collapse of the lung, however, the sound is
heard only at the back, whereas in consolidation it is found also at
the front of the chest, for solid lung is an excellent conductor. It is so
clear in the healthy child that when it is somewhat exaggerated in the
adult it is called ' puerile.'

When the lining of the small air-tubes is swollen, and the air does
not enter the vesicles freely, the vesicular murmur becomes ' harsh,'
and it is entirely lost when the lung is collapsed on account of the
pleura being full of air, serum, blood, or pus ; the space over which it
is heard is diminished in partial collapse of the lung, and when a
large tumour or a hypertrophied heart trespasses on the pulmonary
area.

When pneumonic exudation has made the walls of the vesicles
sticky, the air enters them with a fine crepitation, like that which is
heard when a small bunch of hair near the ear is rolled backwards and
forwards between the tips of the ringer and thumb.

When the lining membrane of the bronchi is inflamed, as in bron-
chitis, viscid or watery mucus is poured into the tube, and the air
passes through it in large bubbles, rhonchi (poyx°s, snoring) or
in smaller bubbles— rales.

The larger the tubes, the coarser the rales; and as death approaches,
and the patient has not the strength to clear his larynx, trachea, and
bronchi of the collecting mucus, the coarse bubbling of the air through
the fluid is popularly known as the * death-rattle.'

Prolonged expiration is due to obstruction in the bronchial tubes,
as from inflammation of the mucous membrane ; in the apex it is an
early sign of catarrh, and if also pus be spat it is a grave sign of phthisis.

Amphoric (amphora, a flagon) breathing is that heard when the air
enters a bronchiectatic or pulmonary cavity ; it is something like the
sound produced by blowing into an empty bottle.

Metallic tinkling is the sound produced by fluid vibrating in an
air-cavity which contains some fluid ; thus it is heard in large bronchi-
ectatic and pulmonary vomicae ; it is a kind of splash. It is probably
due to the echo in the cavity of the bursting of an air-bubble. ' It
nearly resembles the sound caused by shaking a pin in a decanter.'
(Hughes.) A metallic splash is also heard when a pleura containing
air and liquid (pyo-pneumothorax) is sharply shaken from beneath
(succussion}. The sound produced by air bubbling through the fluid
in a pulmonary cavity is termed cavernous.

The voice-sounds. — If the stethoscope be placed over the larynx
or trachea the voice is heard with extraordinary distinctness. This
sound is called, when it is heard over other regions of the chest than
that of the large air-tube, pectoriloquy (pectus, pectoris, breast ; loqtii,
speak). It means that the voice comes so straight to the ear that it
seems to be spoken in the chest itself, and not in the larynx ; and, as
healthy lung-tissue is a muffler of sound, pectoriloquism suggests

2O2 Examination of Chest

consolidation, for condensed lung-tissue is a good conductor (p. 189).
Bronchophony is a lesser degree of pectoriloquy.

Sometimes the voice sounds cracked, or like the bleat of a goat (m|,
aiyos, goat ; (frwvrj, voice) — aegophony. It is due to a break-up of the
sound-waves as they come splashing through a thin layer of fluid —
probably of pleural effusion.

Dyspnoea. — When the free entry of air is prevented, as in laryn-
geal diphtheria, or oedema glottidis, the inspiratory muscles work with
great energy, diminishing the intra-thoracic pressure ; and, as the
balance cannot be restored by air entering through the trachea, the
equilibrium is partially restored by the jugular, intercostal, and epi-
gastric regions falling in with each inspiratory effort.

THE MAMMA

The mamma in the female reaches from about the third to the
sixth rib. The nipple is over the fourth space, and points slightly
outwards and upwards for the convenience of the infant in the mother's
arms. As the ribs ascend in inspiration more than the breast, the
nipple which lay over the fourth space on expiration will be over the
fifth rib on inspiration. In emphysematous patients the nipple is
considerably higher than in the phthisical, for in the latter the chest
represents the type of expiration.

The developing breast at puberty is often tender and tingling.
With old age the gland becomes wasted, and, when this retrogressive
physiological change sets in, cancer is especially apt to invade the
tissue.

The breast is placed within the superficial fascia, and is connected
with the skin and with the deep fascia over the pectoralis major by
slender ligamentous fibres.

The nipple may be absent in the virgin, its future site being
surrounded by a pinkish zone, but in the second month of pregnancy
it begins to grow, and the areola darkens and extends until it forms a
deeply pigmented circle two inches in diameter. After parturition and
weaning, the pigmentation does not entirely clear away, so that
darkening of the areola is important as evidence of the first pregnancy
only.

The skin of the nipple is somewhat leathery, on account of the
fibrous tissue which it contains ; it is, moreover, rich in sebaceous
glands, which increase during pregnancy, to diminish the risk of
cracking and tenderness during suckling. Along the centre of the
nipple the milk-ducts (fifteen to twenty in number) ascend, and around
them are pale muscular fibres, to the contraction of which under
stimulation 4 erection ' of the nipple is due.

Structure. — The breast is surrounded by a fibrous capsule from

Breast and Nipple 203

which processes pass off to blend with the skin, whilst others enter
the gland, marking it out into separate lobes. Fat occupies the inter-
vals between the lobes, and thus it happens that large fat breasts may
be of less physiological value than those of a thin woman. A branch
of a milk-duct enters each lobe, sending off ramifications which are
connected with the small lobules. The ultimate lobule consists of
terminal expansions of the ducts into alveoli lined with cubical epi-
thelium, and surrounded with branches of blood-vessels, nerves, and
lymph-sinuses. As the duct approaches the surface the epithelium
becomes squamous. Chronic inflammation of the nipple and prolifera-
tion of its epithelial covering (eczema of the nipple} is often the starting
point of cancer of the breast. Squamous epithelioma is the nature of
the malignant growth in these cases, and it may eventually implicate
the entire gland.

The ducts descending from the nipple radiate through the gland,
and when an incision is made into the breast the scalpel should be
directed straight from the centre towards the periphery, so that it may
pass between and not across the ducts. During lactation a milk-duct
may be so distended with milk as to form a large tumour, galactocele ;
the condition is like an encysted hydrocele of the testis.

Supply. — The mammary arteries and veins are branches of the
long thoracic and other offsets of the axillary trunks, and of the internal-
mammary. The aortic intercostals also help in the supply.

Of the lymphatics, some few, from the inner side, pass between the
costal cartilages to enter the mediastinal glands; the others pass along
the border of the pectoralis major into the axillary glands.

The nerves come from the lateral cutaneous branches of the inter-
costals, and from the endings of the intercostal nerves themselves.

It has been suggested that the mammae are but modifications of
sebaceous glands, and sometimes during pregnancy enlargement of the
sebaceous glands in the axilla may be discovered, representing supple-
mentary mammas. Occasionally additional mammae and nipples exist,
either in the pectoral region or down the front of the abdomen.

In sdrrhus mamma a heterologous growth of fibres and cells forms
a hard mass, generally upon the axillary side of the nipple. The
malignant infiltration extends along the fibrous processes which
attach the gland to the surrounding tissues, and so the mass becomes
connected with the skin, the pectoral muscles, the chest, and even
with the pleura. Subsequently the new fibrous tissue atrophies, so
that the skin is dimpled and the nipple retracted.

Before the nipple is actually retracted it may show a slight but
highly suspicious deviation from its normal inclination. Retraction of
the nipple may also be due to atrophy of the new fibrous elements left
after chronic inflammation, corresponding to the contractions described
in cirrhosis of liver. The cut surface of the scirrhous mass becomes
concave on account of the further contraction of the fibrous tissue.

2O4 The Mamma

Contraction of the new elements of the breast causes so much
compression of the mammary tissues as to impede the return of blood
from the skin of the pectoral region, so that the superficial veins are
dilated and conspicuous, and the affected gland is even smaller than
the other. The lymph-channels running from the breast to the axil-
lary lymphatics are often invaded, and, like the glands themselves,
should be cleared away. When the scirrhus is situated to the sternal
side of the breast the axillary glands are involved later than when it
is to the outer side. In the former case the glands in the anterior
mediastinum are specially likely to be involved, and they may there
form an enormous tumour against the heart or lung.

Abscess may occur in the breast or in the loose connective tissue
superficial to or beneath it ; from the rapidity with which the tension
of the sensory nerves is produced, it is accompanied with much pain.
A sub-mammary abscess, if left to itself, is likely to point near the
anterior axillary fold. Hypertrophy is a multiplication of the normal
elements throughout the breast, and adenoma (aS^v, gland) is a
'chronic mammary tumour' of the normal cellular elements of the
gland in a bed of fibrous tissue. Cystic disease (serous) is due to the
dilatation of ducts or of lymph-spaces throughout the gland.

When a suckling woman has an abscess in one breast she ought
at once to wean the child, as putting it to the sound breast inevitably
causes physiological disturbance and irritation of the affected one.

In amputating the breast the arm should be abducted, so as to
tighten the integument and the pectoralis major. A semi-elliptical
incision is then made on either side of the nipple in a direction
towards the armpit, so that the axillary glands can be extracted by a
slight extension of the wound. It does not matter whether the upper
or the lower incision is made first. It is important, in operating for
cancer, that the whole of the gland and the nipple be taken away, even
if only a part be involved. After operation the arm should be fixed to
the side, and even when the wound is perfectly healed the arm should
be worn in a sling, so as to ensure rest.

In the newly-born child, whether male or female, the mamma
often contains a watery epithelial wreckage which looks like milk, and
on rare occasions this pent-up secretion determines inflammation and
suppuration.

THE SPINAL COLUMN

Spinabifida. — A vertebra has three primary centres of ossification,
two for lamina: and one for body. The lamina: are fused in the root
of the spinous process. If development be arrested the spinal canal
remains unenclosed posteriorly, the membranes with the cerebro-
spinal fluid bulging as a soft tumour. The defect is found most often
in the lumbar and sacral region, for there the lamina: are last ossified.

Spin a Bifida 205

It is possibly caused by an increase in the amount of cerebro-spinal,
subarachnoid fluid in the early development, whereby the coalescence
is prevented. The tumour is in the exact median line and has a firm
attachment. It is often associated with imperfect innervation of the
pelvic viscera, and with arrested development of the lower extremities.

When the child screams, some of the cerebral fluid is displaced
from the interior of the skull and into the spinal canal, the tumour
becoming more tense ; and by gentle compression of the tumour
some of the fluid can be squeezed into the cerebro-spinal canal, with
the effect of causing irregular muscular movements or even convul-
sions.

Sometimes the sac contains no nerve cords or branches ; some-
times the nerves are spread over its inner surface. The sac may be
lined by the substance of the cord itself, the serous fluid being con-
tained in the immensely dilated central canal of the cord. This is
likely to be associated with internal hydrocephalus (p. 56). If the cord
or the large nerves of the cauda equina be in the sac, they occupy the
median part.

Operative treatment is directed towards obliterating the communi-
cation with the interior of the spinal canal, and the more slender the
communication the greater the prospect of cure.

To put a ligature round the base of the tumour may be to set up a
meningitis spreading from the cord to the brain ; to tap and empty
the sac is to leave the brain high and dry, with no counterpoise to the
cerebral circulation ; and freely to inject a stimulating fluid may be
to excite meningitis and encephalitis, the child dying in convulsions.

The spinous processes of the upper cervical vertebras can just be
made out at the nape of the neck, especially that of the axis ; the spines
of the sixth and seventh are long, horizontal, and conspicuous. Indeed,
the spine of the seventh (vertebra promi?iens] sometimes juts out so
conspicuously as to suggest the appearance of angular curvature.

The dorsal spines are long, and overlap one another so as to pre-
vent extension in the chest region, otherwise the heart and lungs might
be interfered with in their work. The tip of a dorsal spinous process
descends well over the body of the vertebra below. The lumbar spines
are large and horizontal, and well hidden between the large masses
of the erector spinae.

In counting the spinous processes the seventh cervical is at once
recognised, with the sixth close above it, and the first dorsal just below.
The third dorsal spine corresponds with the root of the spine of the
scapula, and the fourth lumbar spine is on the level of the top of the
iliac crests.

In the cervical region the spinal cord may be readily injured by a
stab, but in the dorsal and lumbar regions it is well protected by the
imbricated laminae.

The transverse process of the atlas stands well out in the side of

206 The Spinal Column

the neck ; it may be dimly felt below, and just in front of the tip of
the mastoid process.

The transverse process of tJic sixth cervical vertebra is easily made
out at the root of the neck — the carotid tubercle (p. 23).

ligaments. — The bodies of the vertebrae are connected by the
strong anteiior and posterior common ligaments, the posterior being
lodged within the spinal canal and separated from the central part of
the body of each vertebra by the vena basis vertebrae.

Between the bodies are discs offibro-cartilage, the peripheral parts
of which are fibrous, whilst the central parts are pulpy and elastic.
The discs form about a fourth of the flexible part of the spine ; they are
flattened by prolonged standing. Thus, when a man rises from the bed
of sickness he is actually taller, perhaps by a third of an inch, than he
wras when he took to it. The height is also increased by the night's rest.

The articular processes are connected by capsidar ligaments and
synovial membranes, the laminae by the elastic ligamenta subflava,
the spinous processes by inter- and supra-spinous ligaments, and the
transverse processes by less important fibres.

The atlas is connected with the axis by two capsidar ligaments and
synovial membranes.

The transverse ligament stretches behind the odontoid process
from one lateral mass to the other, sending a slip up to the basilar
process of the occiput, and one down to the back of the body of the
axis ; thus its shape is cruciform. There is a synovial membrane
between the odontoid process and the anterior arch of thef atlas, and
another between the process and the transverse part of the cruciform
ligament.

The transverse ligament is less likely to give way from violence than
are the adjacent bones, but when it is softened by disease it may sud-
denly yield; the head then falling forwards, the medulla is compressed
against the back of the odontoid process, and sudden death results. In
caries of the high cervical vertebrae absolute rest in bed is the only
safe treatment.

The two anterior atlo-axoid ligaments are really part of the
anterior common ligament, and the posterior atlo-axoid is the repre-
sentative of the ligamentum subflavum.

Rotation is the only movement allowed between the atlas and
axis ; their joints are supplied by the vertebral arteries and the second
cervical nerves.

The condyles of the occiput articulate with the atlas by capsular
ligaments and synovial membranes, and in such a way as to permit of
nodding movements only. (Thus, a dumb person expresses ' yes ' at
the occipito-atloid joint, and 'no 'at the atlo-axoid.) The occipito-
atloid joints are supplied by the suboccipital nerves (p. 143) and the
vertebral arteries.

The two anterior occipito-atloid ligaments represent the anterior

Kyphosis.

Spinal Curvature 207

common ligament, just as the posterior occipito-atloid ligament repre-
sents the ligamentum subflavum. The posterior ligament is attached
above to the back of the foramen magnum, and is pierced by the verte-
bral arteries and the suboccipital nerves. In front it is
intimately connected with the dura mater as it descends
into the spinal canal.

The lateral ligaments pass between the transverse
process of the atlas and jugular eminence of the occipi-
tal bone.

The occiput is connected with the axis by an upward
prolongation of the posterior common ligament, which
blends at the front of the foramen magnum with the
cranial dura mater.

Beneath it are two cheek ligaments, which pass from
the tip of the odontoid process to the inner sides of the
occipital condyles, and a third slip which runs up to the
front of the foramen magnum.

When the weight of the head and the upper part of
the body is greater than the spinal column is able to
support it bends forwards in an exaggeration of the
normal curve of the dorsal region, just as the stalk, of
corn yields when the ear of wheat is large and full. In
the human subject the bending may be due to a deficiency of earthy
matter in the bony segments, as happens in the rickety child, or to a
settling down of the vertebrae and the intervening discs
from long-continued pressure, as in the rheumatic or old
and worn-out labourer. The curvature is dignified by
the name of kyphosis (KV^OS, bowed forwards}.

Iiordosis, or saddle-back (XopSoy, curved], is the
opposite condition, the trunk being thrown backwards
by exaggeration of the normal lumbar curve, the con-
cavity of which looks backwards. It is usually a com-
pensatory curve which the subject instinctively acquires
in order to keep the centre of gravity from being ad-
vanced too far, and unstable equilibrium being thereby
produced. Thus, it is found in pregnant women, who
are compelled to throw the shoulders backwards in
walking ; and, to a less degree, in the very fat man. It
is still better marked when caries of the high dorsal ver-
tebras has allowed the head and shoulders to fall for-
ward, and also when, from congenital displacement, the
heads of the femora are behind their normal position, as
figured on page 472.

Lateral curvature. — The commonest variety is that in which the
right shoulder is raised, the convexity of the lateral dorsal curve being

1 These and similar figures are from Erichsen's Surgery.

Lordosis.1

208

The Spinal Column

towards the right. The chest on that side, therefore, is 'full,' but on
the left the ribs are crowded together and the lung space is diminished ;
such a diminution may happen after em-
pyema, when the lung is permanently
collapsed. But, as a rule, the curvature is
caused by an uneven transmission of weight
down the spine, especially in girls who are
outgrowing their strength, and who sit or
stand long at lessons or work. The muscles
growing tired, the girl arranges her pos-
ture so that the ligaments, fasciae, and
articular processes, which are incapable of
feeling fatigue, may bear the strain.

Often the curvature is caused by a
difference in the length of the legs causing
the pelvis to be tilted.

In addition to this lateral bending
there is a strange rotation of the affected
vertebrae, the spinous processes being
tilted sideways into the concavity of the
lateral curve.

The proper way of dealing with the
ordinary case of lateral curvature is to
keep the girl as much as possible in the
fresh air, and to make her strengthen her
flabby muscles by exercises such as her
brothers delight in ; by not allowing her
to resume the vicious lolling attitudes,
and by employing massage and special

Lateral curvature; spinous processes J . " J *

rotated into concavities of curves, gymnastics. The worst * treatment ' is to
lock her up in a « spinal support.5 When

the lateral curvature is severe — that is when the bones have become
misshapen and the girl's growth has ceased — the condition is past
help.

Spinal caries ; angular curvature. — When the bodies of the ver-
tebrae, destroyed by caries (ulceration), begin to fall together, the spinous
processes are necessarily thrown backwards ; and if the disease be in
the dorsal segment the processes, which in that region are already very
prominent, stand out in a very conspicuous manner. But if the caries
be in the cervical or lumbar region the falling together of the bodies is
not at first accompanied by a corresponding projection of the spinous
processes, because the neck-region and the loin-region of the spine
are concave backwards. But instead of this the concavity is effaced.
Thus, in the cervical and lumbar regions a straightness of the spine is
as pathognomonic of vertebral caries as is the angular projection in
the case of dorsal caries. In every case the disease is accompanied

Spinal Caries

209

with stiffness of the region affected. In trying to stoop the patient
cannot bend his neck or back, and he stands with his hands on his
thighs or resting against a table or chair.

Normal curves.

Early lumbar caries ; normal Advanced dorsi-lumbar carit
curves effaced. angular curvature.

If the advance of the angular curvature be slow, the cord adapts
itself, and no pressure-effects are manifested. But if it come on rapidly,
or, coming on slowly, be extreme, motor paralysis results, because of a
projection taking place at the back of the bodies into the vertebral canal,
and impinging against the front, the motor area, of the cord (p. 215).
But, although a child may have complete muscular paralysis in his
lower extremities for many months, he may at last completely recover
movement ; the explanation being that much of the pressure has been
of the nature of inflammatory deposits, rather than of the bony pro-
jection. In the paraplegic child with angular curvature there is no
pressure upon the posterior aspect of the cord, so there is no loss of
sensation, and, the skin being well supplied, there is no special likeli-
hood of the occurrence of bed-sores, as obtains after fracture of the
spine.

With pressure upon the front of the cord, the knee and ankle
reflexes are exaggerated because the cerebral influence can no longer
descend to control them (p. 220). But if the pressure be upon the lumbar
enlargement, as may happen in caries of the lowest dorsal vertebrae,
there may be so much disturbance within the cord that the afferent
influence can no longer awaken the motor impulse, in which case the
knee-jerk and ankle clonus may be lost.

In the progress of caries, inflammatory thickenings press upon the
spinal nerves, causing characteristic peripheral pains in the area of
their distribution. When the disease is in the cervical region there may

210

Disease of Spine

be pains, possibly called ' head-ache,' over the area of the occipital
branches from the second cervical nerve ; or in that of the great auri-
cular from the second and third. A little girl suffered constant pain,
darting over the region between the chin and the sternum, which she
described as * belly-ache in the neck ' ; it arose from pressure upon the
trunk of certain nerves as they issued from the diseased region of the
column. The third nerve joins in the formation of the transverse super-
ficial cervical nerve, which supplies the skin over the front of the neck.
Pains due to caries of the atlas are generally confined to one side because
only one lateral mass, at any rate at first, is implicated.

If the disease be lower in the neck, symmetrical pains may be re-
ferred to the pectoral or deltoid regions, where the supraclavicular
branches are distributed, as shown in the figure on p. 145.

If the lowest cervical vertebrae be inflamed the nerve-trunks of the
brachial plexus are liable to compression, pain being referred to the
shoulders, elbows, or even to the fingers.

When the dorsal vertebrae are diseased neuralgia may be felt in
the intercostal nerves, or their peripheral branches. And when any
part of the lower half of the dorsal column is affected pain may be
referred to the epigastric or umbilical region, or even to the skin over
the ilium, where the lateral cutaneous branch of the last dorsal nerve
is distributed.

With lumbar disease the pains are referred to the ilio-hypogastric
and ilio-inguinal nerves, or the genito-crural or external cutaneous.

Pains in the front of the thighs, that is, over the region of the
anterior crural or obturator nerves, should direct attention to the neigh-
bourhood of the third and fourth lumbar vertebrae. If it happen that
the nerve-fibres destined for the long saphenous branch are irritated
as they leave the column, pains will be referred to the inner side of the
leg or foot, or to the ball of the great toe. Unfortunately obscure pains
are too often ascribed to rheumatism and gout. Symmetrical pains are
the result of central mischief, and generally of spinal disease.

Spinal abscess. — Spinal caries, like ulceration elsewhere, is usually
accompanied by suppuration, and, unless the disease be very quiet,
abscess forms in front of the vertebrae. Thus cervical caries gives rise
to post-pharyngeal abscess, the bulging against the back of the pharynx
causing difficulty in breathing and swallowing. The abscess has to be
opened, the patient inclining the head forwards for that purpose ; if the
abscess were allowed to burst spontaneously, the pus might be drawn
into the larynx, and the patient might die of suffocation or of septic
pneumonia.

Sometimes the abscess from cervical caries points in front of or
behind the sterno-mastoid, or follows the oesophagus into the posterior
mediastinum.

In dorsal caries the pus collects in the posterior mediastinum, from
which it may pass between the transverse processes to the back, there

Spinal A bscesses 2 1 1

to form a dorsal abscess. If it point forwards it may perchance open
into the oesophagus, trachea or bronchus, pleura or pericardium. Or
the pus may track forwards between the intercostal muscles, or between
the inner intercostal muscle and the pleura, to point at the side of the
sternum or of the rectus abdominis, or in some chosen part of the inter-
costal space. But more often it descends in the posterior mediastinum
till it reaches the diaphragm, which it traverses under the inner or
outer arcuate ligament : if under the former, to descend as a psoas
abscess ; if under the latter, to bulge as a lumbar abscess. When the
psoas abscess has passed beneath Poupart's ligament it usually bulges
on the outer side of the femoral vessels, and it not infrequently works
thence, inwards and backwards, following the internal circumflex, to
form a gluteal abscess.

In lumbar caries the pus generally collects beneath the iliac fascia
to form an iliac or psoas abscess. In the former case the tumour
bulges in the iliac fossa, probably to point above Poupart's ligament ;
in the latter case it finds its way beneath the ligament, and points in
Scarpa's triangle. In these cases, by pressing with one hand in the
iliac fossa and the other in the triangle, one can get a ' see-saw ' with
the fluid under Poupart's ligament, especially when the thigh is slightly
flexed.

But an iliac or a psoas abscess may push forwards and open into
the peritoneal cavity, the alimentary canal, or ureter, or may descend
into the bladder or ischio-rectal fossa, or, following the lumbo-sacral
cord and the great sciatic, through the great sacro-sciatic notch, to
form a gluteal abscess.

It frequently happens that pus which has descended beneath the
outer arcuate ligament, or which, in lumbar caries, has been collecting
anterior to or in the substance of the quadratus lumborum, escapes
backwards in the gap between the twelfth rib and the iliac crest to
form a lumbar abscess. In this course it passes through that weak
part of the abdominal wall which is bounded in front by the posterior
border of the external oblique, behind by the latissimus dorsi, and
below by the iliac crest — the triangle of Petit (p. 305). I have operated
for the cure of a reducible lumbar hernia in the case of a piece of bowel
escaping by the track of an old lumbar abscess.

Fractures and dislocations are fairly common in the cervical
region, where the vertebras are small and the range of movement is free.
Unless the lesion be associated with displacement of a vertebra, it may
pass unrecognised ; the most serious condition is that in which displace-
ment causes pressure upon the cord. When the displacement is con-
siderable the cord is torn across, or firmly compressed, and the symptoms
are immediate. If the displacement be but slight, there maybe no symp-
toms at first, but, as the local disturbance of the cord is followed by inflam-
mation, its functions become impaired and the symptoms manifested.
Thus, the patient is paraplegic (TrapaTrXr/^, struck badly), that is to say,

212 Disease of Spine

no messages can proceed from the brain to the muscles which are sup-
plied by nerves coming off below the injured spot ; sensation also is

lost (seep. 216). And
the trophic influence
for the skin being lost,
bed-sores are very apt
to appear. The pa-
tient, therefore, with
a broken back, is
placed upon a water-
bed, so that the weight
of his body may be
distributed evenly,
and not fall upon the
prominent parts only.
The bladder and the
lower bowel do not
work properly, be-
cause the reflex centre
(p. 218) is cut off from
cerebral control, and
retention of urine and

Fracture of spine ; cord lacerated. (A. SHAW.) . . . ,.

cystitis probably occur,

possibly the man has priapism (p. 216), and the reflexes, as explained
on page 219, are most likely exaggerated. The least touch upon the sole
may cause violent contractions in the quadriceps extensor ; but if the
displacement disorganise the lumbar enlargement these reflexes are
then lost, for the chain is broken. They may be lost too for a while

when the grey matter
has exhausted its
energy by frequent
discharges.

The spinal veins
consist of a ladder-
like network about
the neural arches of
the vertebrae ; of
anterior longitudinal
veins, which lie be-
hind the bodies and
receive the venae
basis vertebrae ; of
posterior longitudi-
nal veins, which are
also outside the dura mater, and which extend along the back of the cord;
and, lastly, of the veins of the cord itself, which pierce the dura mater,

Spinal Cord 213

to end in the surrounding spinal veins. The spinal veins empty into
the vertebral, intercostal lumbar, and lateral sacral veins. Hcemorrhage
from these veins, perhaps the result of injury, causes pressure upon the
cord and sudden paraplegia. Suspension in the treatment of diseases
of the spinal cord may possibly owe its value to the stimulus which is
thereby imparted to the circulation in the veins of the cord (p. 214)
and of the canal.

TOY fracture through sacro-coccygeal joint, v. p. 362.

THE SPINAL CORD

The spinal cord is the continuation of the encephalon towards the
trunk and extremities. It begins at the lower border of the medulla
oblongata, at the level of the first cervical vertebra, and extends to the
first lumbar, where it breaks up into the cauda equina. In early foetal
life it reaches to the very end of the spinal canal, but its subsequent
growth does not keep pace with that of the canal. Its average length
in the adult is i| ft. and its weight i£ oz.

It has two enlargements, one in the lowest cervical region, the other
in the lowest dorsal. From the cervical enlargement the nerves issue
for the brachial plexus, and from the lumbar enlargement emerge the
nerves for the lumbar and sacral plexuses. The cord is enclosed in
the pia mater, arachnoid, and dura mater, but even with these invest-
ments it does not nearly fill the canal, being separated from the bony
wall by a plexus of veins and by loose connective tissue. Partly to this
fact, and partly to its being suspended in cerebro-spinal fluid, does the
cord owe its comparative freedom from injury.

The dura mater is continuous with that lining the cranium, but it
does not act as periosteum, nor does it enclose venous channels. It is
firmly attached to the border of the foramen magnum and to the back
of the body of the axis. It forms a sheath to the cauda equina as far
as the top of the sacrum, and gives an investment to each nerve as it
passes out.

The arachnoid (apaxvrj, «§<>$•, ' fine as a spider's web ') intervenes
between the dura and pia mater, being continuous with that of the
brain. External to it is the sub-dural space, containing some cerebro-
spinal fluid, and between it and the pia mater is the sub-arachnoidean
space, the fluid of which is abundant, and which communicates with
that in the cerebral ventricles through an opening in the floor of the
fourth ventricle. In the case of a large spina bifida (p. 204) a distinct
wave of fluctuation may sometimes be obtained by compressing the
tumour with one hand whilst the other hand is over the anterior fonta-
nelle ; if, however, the pressure be made roughly, cerebral irritation
results.

The fluid of the spinal canal, be it clearly understood, is in the

214 The Spinal Cord

space between the arachnoid and pia mater — sub-arachnoidean ; in
the cranium the fluid is partly in the sub-arachnoid space and
partly in the cavity of the brain itself, the communication being through
the Sylvian aqueduct. When the fluid escapes from a spina bifida
the brain as well as the cord is drained, and, its support being lost,
fatal convulsions usually occur. The track of the fluid is first through
the foramen of Majendie and then through the aqueduct of Sylvius.

Inflammation of the membranes (/iefiy£) of the cord renders them
more thick (iraxvs)t the disease being called pachy-meningitis. The
thickening causes pressure on the posterior roots of the spinal nerves
and gives rise to peripheral pains (p. 209). This is common in caries
and in fracture of the spine.

On account of the cord ending at the first lumbar vertebra, the
lumbar and sacral nerves obviously cannot be given off at the level of
their exit from the inter-vertebral foramina. The high cervical nerves
have but slight obliquity, but from the dorsal enlargement the direction
of the nerves is almost vertical, the sacral nerves descending through
the entire length of the lumbar region.

The situation of the nerves in the canal. — The spine of the
vertebra prominens corresponds to the origin of the first dorsal nerve
from the spinal cord, the spine of the first dorsal to the origin of the
third nerve, and the fifth spine to that of the seventh pair. In fact, all
through the dorsal region the nerve emerges from the cord at the level
of the spine of the vertebra two above. The nerves of the lumbar and
sacral plexus arise in the interval between the eleventh dorsal and the
first lumbar spines — that is from the lumbar enlargement (v. p. 216).

In the cervical region the nerves take the number of the vertebra
above which they pass out, but in the other regions they pass out
below the vertebra whose number they bear, the reason being that
there are eight cervical nerves, but only seven cervical vertebras, the
first nerve emerging above the first vertebra.

In the brain the grey matter is for the most part on the exterior ;
in the cord it occupies a central position, and in transverse section it is
seen somewhat in the form of the letter H • A slender central canal runs
in it, opening above in the floor of the fourth ventricle. It is the ( per-
manent remains of the ectodermal canal from which the spinal cord is
developed.' Sometimes at birth it is enormously distended with fluid,
causing that variety of spina bifida known as syringo-myelocele (<rvpiy£,
pipe ; /iueXoy, marrow ; KijA?;, tumour).

The arteries of the cord, which first break up in a delicate network
in the pia mater, are derived from the vertebral (anterior and posterior
spinal), ascending cervical, intercostal, and lumbar. Of the veins, two
are found in the grey commissure, one on either side of the central
canal, and others in the anterior and posterior median fissures. They
are tributaries of the spinal veins.

Every spinal nerve arises by two roots, an anterior and posterior,

Spinal Nerves

215

the anterior containing motor, and the posterior sensory fibres. The
posterior, the larger root, has a ganglion upon it — just as has the
posterior or sensory division of the fifth cranial nerve. Just beyond
the ganglion, which lies in the inter-vertebral foramen, the roots join.
The mixed nerve then breaks into an anterior and a posterior primary
division, each of which contains both motor and sensory fibres. The
posterior primary divisions pass backwards to supply the erector
spinae and other muscles, and to carry sensory twigs to the back of the
head, neck, and trunk, whilst the anterior divisions end, for the most
part, in plexuses, except in the dorsal region, where they run forwards
in the intercostal spaces.

Nerve-roots. — The filaments of the anterior root arise from the
ganglionic cells in the anterior cornu
of the grey crescent and pass out
to the muscles. They are zmder
the control of the motor strands
descending from the brain in the
direct cohtmns of Tiirck and in the
crossed Pyramidal tracts.

In the posterior root, which is
afferent, or sensory, are also fila-
ments which preside over the nutri-
tion of the skin — trophic filaments
(rpe$o), nourish). Bed-sores are apt
to occur when the function of the
posterior roots is disturbed — as when
disease or pressure interferes with
the posterior columns. When the
anterior roots or columns, however,
are in distress, as in angular curva-
ture of the spine, dermal trophic
changes are conspicuous by their
absence.

Of the fibres of the posterior
root some straightway enter the tail
of the grey crescent, but others pass D.C\

\Q.C

into the pOSterO-extemal Column Of D c, direct cerebellar tracts ; c p, crossed

Burdach, as shown in the adjacent

diagram. All these sensory fibres

pass over into the opposite half of

the cord, and so up to the brain.

If, therefore, the right half of the

cord be destroyed, there is loss of

sensation in the parts below on the left side of the body, the motor

paralysis being on the right side, for the motor strands cross in the

medulla oblongata (p. 55) and not in the cord. In the case of a lesion

pyramidal tracts ; G, Coil's sensory
columns ; T, direct pyramidal (motor)
tracts — Turck's columns ; M, motor ;
s s', sensory roots of spinal nerve ; of
these sensory filaments some pass
through the posterior cornu of the grey
crescent, and some through postero-
external or Burdach's column. (After
RANNEY.)

216 The Spinal Cord

in the medulla above the level of the crossing in the pyramids, loss
of motion as well as of sensation occurs upon the opposite side of the
body.

Total transverse lesions involve, of course, complete loss of
motion and sensation on both sides below, and, the sensory nerves in
the proximal part of the cord, close to the lesion, being in distress, cir-
cumferential localised pains, ' girdle pains,' as they are called, result.
The area of the girdle-pains indicates which nerves are crossing in the
cord immediately above the damage, and points out the exact situa-
tion of the lesion. The girdle-pains which come on immediately after
a fracture of the spine are due to the pressure of the displaced verte-
bra upon the nerves which run almost vertically along the side of the
cord. The pains are referred by nerves which actually arise from the
cord at the level of at least one vertebra higher than that which is
displaced.

The region of the umbilicus is supplied by the tenth dorsal, and
the ensiform area by the sixth and seventh.

In complete transverse lesion of the middle of the lumbar enlarge-
ment the elements of the sacral plexus may be dissociated from
central control, whilst those of the lumbar are not interfered with.
Thus there may be anaesthesia along the outer side of the leg (from
external popliteal nerve) with hypera^sthesia along the inner (internal
saphenous of anterior crural). When the lower part of the cervical
enlargement is traversed there is anaesthesia over the whole of the
chest, and, on account of the implication of the fibres of the ulnar
nerve, there is numbness along the little finger (p. 253). If the cord be
seriously damaged by disease or injury at the level of the third and
fourth lumbar nerves, the anterior crural, obturator, and great sciatic
convey no stimulus, so that the quadriceps extensor, adductors, ham-
strings, and muscles of leg and foot are paralysed, whilst there is loss
of sensation in the thigh (except in area of distribution of the external
cutaneous), leg, and foot. The sphincter ani also ceases to act.

The reflexes in all these cases are altered ; most likely they are
exaggerated, for no cerebral control can reach the affected segment.

Priapism often follows fracture above the lumbar enlargement,
because, the cerebral control being lost, the reflex is exaggerated
and is in constant action. If the bladder be paralysed, the urine is
retained and undergoes decomposition, cystitis is the result, and, unless
the greatest care and cleanliness be observed, bed-sores occur.

If the lesion be at the level of the seventh dorsal, there will, in addi-
tion, be paralysis of the abdominal and lower intercostal muscles, the
area of insensibility reaching up to the level of the ensiform cartilage.

If at the level of \hzfirst dorsal nerve (seventh cervical vertebra)
all the intercostals cease to move, and the muscles and skin supplied
by that part of the first dorsal which enters the inner cord of the
brachial plexus are paralysed, the skin over the whole of the thorax,

Perineal and anal
muscles

r Neck and scalp

Neck and shoulder

Should*

Hand

Front of thorax
[• Ensiform area

Abdomen
(Umbilicus loth)

! Buttock, upper
j part

I Groin and scrotum

j (front)

.ThighH

outer side

front

, inner side

Leg, inner side
/Buttock, lower
part

-_/ Back of thigh

Lef ) except
-Dinner part

1 Perineum and
j anus

I Skin from coccyx
j to anus

Scapular

- Epigastric

Abdominal

Cremasteric
|- Knee reflex

Gluteal

Ankle clonus
Plantar

The approximate relation to the spinal nerves of the various motor, sensory, and reflex
functions of the spinal cord. (GowERS.)

218 The Spinal Cord

except in the area of distribution of the supra-clavicular nerves
(p. 146), becomes anaesthetic. (The phrenic nerve comes from the
third, fourth, and fifth nerves, chiefly the fourth, which passes out above
the fourth cervical vertebra.) When the lesion is in the mid-cervical
region the diaphragm acts imperfectly and the whole of the brachial
plexus is paralysed, as are, of course, all the nerves below. Death
rapidly closes the scene. At the second, third, or fourth cervical vertebra
the diaphragm, intercostals, and all other muscles of the trunk and
extremities are paralysed ; sensation may persist for a while in the
upper part of the neck and in the face, but immediate death is the
general result.

In the case of a man with a tumour of the dura mater, which
pressed upon the back of the cervical cord, giving rise to agonising
girdle-pains and paraplegia, Mr. Horsley removed the laminas of the
vertebrae, from the third to the sixth, opened the dura mater, and
successfully removed the growth.

It has been remarked elsewhere (p. 411) that the centre for micturi-
tion and defcecation is in the lumbar enlargement. When the cerebral
control is cut off, as in compression of the cord, the patient * passes
everything beneath him.' That is to say, he empties the bladder and
rectum without intent or even knowledge. As soon as the viscus gets
full the stimulus is conveyed to the grey matter of the cord and passes
out as a motor influence to the muscular tissue of the viscus. Let it
be remembered that these viscera, though containing non-striated mus-
cular tissue, are under cerebro-spinal and not merely sympathetic con-
trol. (See fourth sacral nerve, p. 378.) When the centre for micturition
is itself destroyed, as in extensive lesion of the lumbar enlargement,
or in disease of any part of the circuit, reflex is lost, and the bladder
quietly fills and overflows.

The grrey matter in a cross section of the cord is seen as two
crescents with their convex borders joined by a transverse band. This
commissure is exposed at the bottom of the posterior median fissure
by separating the lateral halves of the cord, but it is shut off from the
bottom of the anterior fissure by a trafisverse band of white tissue.

The posterior horn of the grey crescent tapers to the surface at the
postero-lateral fissure through which are issuing the sensory roots of the
spinal nerves. The anterior cornu is thick and tuberculated, and does
not reach the surface of the cord, the anterior roots of the spinal nerves
passing into it through the anterior column. That part of the lateral
half of the cord which the tapering posterior cornu cuts off constitutes
the posterior column, that part of it which lies close along the median
fissure being called the posterior median column or GolTs column.
Disease of this column gives rise to no known symptoms.

Large, multipolar, g-anglionic cells occupy the anterior cornu ;
they regulate the movements of the muscles, and preside over their
nutrition as well as over that of the muscles and bones. The trophic

Spinal Reflexes 219

s, a nurse ; rpe$o>, nourish) filaments from these cells run with the
motor nerves. Inflammation of these cornua is called anterior polio-
myelitis (TTO\IOS, grey; pveXos, marrow); it sometimes follows in the wake
of diphtheria, or, suddenly and obscurely occurring in a healthy child,
causes infantile paralysis. This condition may also occur in the
adult, however, as well as in the infant. When the cells are destroyed,
not only are the muscles flabby and useless, but, together with the
bones, their nutrition is affected and their development ceases, and
they no longer respond to Faradism. The excito-motory circuit being
broken, reflexes are lost, but, the posterior track of the cord being
uninterfered with, sensation is not impaired.

It does not follow that the paralysis after polio-myelitis will be
permanent. The cells which are placed in the centre of the storm-
region are often completely wrecked, while many of the outlying cells
receive only a passing shock. Sometimes after such a storm, in the
cervical enlargement, for instance, all the muscles of an upper extremity
are paralysed ; but the power of movement may return again in all,
with the exception, perhaps, of one small group of muscles. Some-
times only a single muscle is left permanently paralysed— the deltoid,
for instance.

In the early days of infantile paralysis there is often a tenderness
or a hyperaesthesia of the skin of the affected limb. The explanation
of this is that the storm-wave happened also to disturb the posterior
cornu, with which the posterior roots of the nerves are associated.

Progressive muscular atrophy differs from the paralysis just
considered in that it is the result of a slow degenerative change — not a
rapid inflammatory one — in the ganglionic cells. But, the motor and
trophic cells only being diseased, there is no loss of sensation in the
affected parts, though the muscles affected grow steadily smaller and
weaker.

Reflex action in cord. — The sensory impulse conveyed through
a spinal nerve passes by the posterior root into the grey crescent, and
then, traversing the large bi-polar cells of the anterior cornu, is con-
verted into a motor one, which is ' reflected ' by the anterior root of the
spinal nerve and causes certain muscles to ' act.'

Thus, if the sole of the foot be tickled during sleep — when the brain
has handed over general control to the reflex centres — the impulse is
transmitted through the crescent in the lumbar enlargement to the
motor filaments, certain muscles contract, and the foot is drawn away.
But if the man be awake the sensory impulse passes at once across
the grey commissure and up the opposite half of the cord to the brain,
where it is duly appreciated, and whence it is reflected as a motor im-
pulse by the pyramidal tracts, and then out by the anterior root to the
muscles. Or ' we can, if we wish, execute voluntarily a movement of
the leg quite the same as the reflex act. Moreover, we can exercise
some voluntary control over the reflex action and prevent the start of

22O The Spinal Cord

the leg.5 (Cowers.) If there be a serious flaw in any part of the
chain the reflex does not work, and if there be a break in the fibres
descending from the brain we cannot control it.

The reflexes are controlled by an inhibitory impulse descending
by the antero-lateral columns of the cord (pyramidal tracts). When
these columns are diseased the afferent impulse awakens in the grey
matter a motor wave of disproportionate vigour. The reflex is then
spoken of as ' exaggerated. ' Thus there is exaggerated knee-jerk when
the pressure of angular curvature interferes with the antero-lateral
columns of the cord.

Tetany, muscular spasms, limited and general convulsions— exagger-
ated spinal reflexes — are met with so frequently in young children
because the control-fibres of the pyramidal tracts are late in acquiring
due functional activity.

A reflex being lost, this question arises : 'Is there disease of the
postero-external column with which the sensory roots are associated,
as in locomotor ataxy ; or in the grey matter, as in antero-polio-
myelitis which had occurred in infantile or diphtheritic paralysis ;
or is there some degeneration affecting the anterior nerve-roots ? '
On account of the disturbance in the grey matter, exaggeration of a
reflex often precedes its abolition.

Special reflexes. — When the skin in the pubic region of the thigh
is stimulated, an impulse is conveyed by the ilio-inguinal nerve to the
lumbar enlargement, and thence by the genital branch of the genito-
crural to the cremaster, which, contracting, draws up the tesficle. This
is the cremaster reflex ; it is generally we. 11 marked in childhood. Its
absence in the adult does not necessarily imply disease. The * centre '
for this reflex is in the lumbar enlargement.

Other superficial reflexes are the plantar, gluteal, abdominal, epi-
gastric, and scapular.

It is unnecessary to describe each in detail, but one may say briefly
that by irritating sensory nerve filaments in any one of these regions
a gentle motor influence is duly passed out to the subjacent muscles
provided that the reflex chain be in working order. In the case of the
scapular reflex, irritation of the skin between the shoulder-blades sends
a quiver through the teres major. The reflex centre for the scapular
muscles is in the lower part of the cervical enlargement. When the
cerebral control is lost, or the segment of the cord within an indivi-
dual circle is excited by disease, the reflex is ' exaggerated.'

By trying one reflex after the other on each side of the body, and
duly comparing them, the condition of the cord in almost its entire
length can be ascertained.

The deep or tendon-reflexes are obtained by irritating the sensory
nerves of the muscles themselves. The muscle must first be placed
in a condition of moderate tension and then smartly struck or over-
stretched.

Tendon-reflexes

221

Patellar tendon-reflex. — The leg being crossed over the opposite
knee, and the ligamentum patellae being sharply struck with the inner
border of the hand, an afferent impulse is conveyed by filaments of the
anterior crural to the lumbar enlargement, and, being there converted
into a motor wave, the quadriceps femoris is set in action and the leg
is extended with a 'jerk.' Absence of the jerk is evidence of a flaw
either in the sensory fibres of the nerve, in the posterior column of the
cord, in the grey crescent, or in the motor filaments of the nerve. Thus,
it is lost in locomotor ataxy when the posterior external column is
sclerosed, and when in diphtheria or infantile paralysis there has been
a serious disturbance in the anterior cornu of the crescent. Some-
times it will manifest itself only when the patient occupies his muscles
and his attention by tightly linking his hands and trying to pull them
asunder {Jendrassi&s method].

The reflex is exaggerated in disease of the antero-lateral columns,
and when the control is lost in cerebral disease, as, for instance, in
hemiplegia.

Ankle-clonus (K\OVO$, any violent motion}. — When, the knee
being slightly bent, the foot is flexed to a right angle, and is then
kept in the over-flexed position by pressing the hand beneath the
metatarsal bones, rhythmic contractions and relaxations of the calf-
muscles ensue. Afferent and efferent branches (sural) of the internal
popliteal, associated in the lumbar en-
largement, constitute the reflex chain,
and tension in the muscle irritates the
nerve and stimulates immediate con-
traction. In the case of irritability of
the cord, a series of rhythmical con-
tractions are set up when the muscle
is merely held in the strained position
without any sudden flexion of the foot
being required to start them.

The ten do Achillis jerk is shown
by striking the tendon when the foot is
placed in the flexed position, and the
peroneal reflex is obtained in a similar
way when the foot is inverted.

In the upper extremity deep reflexes
may be searched in connection with
the triceps, biceps, supinator longus,
and wrist.

Transverse section of the cord.
— The anterior median column con-
sists of those fibres which come straight
from the anterior pyramid ; it is therefore called the direct pyramidal
tract. It is well to remember that it also bears the name of Tiirck.

Columns of the cord. (GRAY.)

222

The Spinal Cord

That part of the anterior column which is to the outer side of
Tiirck's column consists of fibres destined for the anterior roots of the
spinal nerves ; its strands, therefore, are for motor conduction.

In the lateral column are two strands of fibres, one of which passes
to the cerebellum, the direct cerebellar tract, the other being the crossed
pyramidal tract. The latter is composed of fibres which have crossed
in the decussation of the anterior pyramids of the medulla oblongata
(those fibres of the pyramid which have not so decussated passing down
in Tiirck's column). Thus, secondary to disease of the motor area of
the cerebrum — say of the right side — degeneration occurs in the right
direct (Tiirck's) tract and in the left crossed tract.

(The direct cerebellar tract is for the transmission of sensory im-
pulses, as indicated in the diagram on p. 215.)

Disease of the antero-lateral column causes loss of voluntary action
"of the muscles below, and, control from the brain being lost, the re-
flexes are exaggerated and a spasmodic contraction results — teta?ioid
paraplegia. But the muscles implicated are not wasted unless the
sclerosis extends into the anterior cornu, and
there is no loss of sensation or of co-ordina-
tion, for the posterior columns are still sound.
Children are specially subject to sclerosis of the
lateral column, the disease being generally called
spastic paraplegia. The child gradually loses
the power of walking, and as he is being exa-
mined a storm of reflexes may arise * his knees
are thrown up in bed and his thighs are violently
adducted. When he tries to walk a character-
istic spasm of the muscles of locomotion prevents
him, his heels being drawn up and his limbs
stiffened. All the reflexes are in excess, and that
•-* of the ankle is so strong that rhythmic contrac-
muscles tions are replaced by muscular rigidity. (The
reflex loops are entire, but the cerebral control
cannot travel down to them by the diseased motor paths.) Subse-
quently the muscles become contractured, the hands and feet are
* clawed,' and the patient is hopelessly bed-ridden.

As already remarked, the motor area of the brain is held in com-
munication with the anterior roots of the spinal nerves by means of the
pyramidal tracts— chiefly the crossed tract— with the intervention of
the large multipolar cells of the anterior cornu. And thus, if a muscle of
the arm, for instance, be paralysed, the fault may be in the motor area
of the brain, in a pyramidal tract, in the ganglionic cells, or in the
efferent filaments of the nerve.

Descending degeneration. — In the case of a lesion of the motor
area of the brain (p. 48) — say of the right side — degeneration descends
by the pyramidal tracts, those muscles being paralysed on the left side

Locomotor Ataxy 223

which are supplied by the cross fibres, and those on the right which
are supplied by the fibres of the direct tract, Tiirck's column. Thus
it is that a lesion on one side of the brain may be followed by paralysis
and contracture of muscles on both sides of the body. The degeneration
descending in the pyramidal tracts (as after hemorrhage in the motor
area of the brain), the muscles associated with them are not only
paralysed but also contractured, and if the disease extends into the
anterior horn of the grey crescent they also begin to atrophy.

The postero-external or BurdacKs column consists to a large extent
of fibres of the posterior roots of the nerves and of fibres that convey
tactile impressions to the brain. Under the guidance of the brain,
these fibres co-ordinate muscular movements. Thus, when the postero-
external columns are diseased the muscles are not paralysed, but they
act tumultuously, without co-ordination. There are also the peripheral
pains, impaired sensation, and the other characteristics of locomotor
ataxy. Later, as the sclerosis extends to the anterior cornua, mus-
cular weakness appears, with atrophy (p. 218). But when the anterior
cornua remain sound, whilst the posterior and lateral columns are
diseased, the nutrition of the muscles continues, though they become
weak because of the implication of the crossed pyramidal tract.
Thus locomotor ataxy (a, without ; ra^iy, order) is a want of harmony
in the working of muscles of locomotion, and is due to fibroid degene-
ration (sclerosis : oK\r)pos, hard) beginning in the columns of Burdach
and spreading into those of Goll. As the fibrosis is followed by atrophy
in the spinal or dorsal cord, the disease also bears the name tabes
dorsalis (tabeo, waste away}. Burdach's column being very closely
associated with the posterior roots of the spinal nerves — conveying
sensory impulses and co-ordinating movements — the sclerosing irrita-
tion of the sensory nerve roots accounts for the characteristic peri-
pheral ' lightning-pains ' of locomotor ataxy ; and as the strands are
pressed upon by the inflammatory thickening their power of co-ordi-
nating diminishes. Normal sensation is gradually lost, and the patient
cannot tell when his feet touch the ground. As the disease advances
the ataxic man can keep his muscles under nominal control only by
watching every step ; he stumbles and falls unless his path is light, and
with his eyes shut he cannot keep his balance. As he walks his feet
fly out in a meaningless manner, and in time the muscles of his hands
and arms become affected. The patella reflex is entirely lost because
the sensory impulse fails to reach or to traverse the grey crescent, and
erection of the penis, another reflex act, becomes in due course im-
possible. (For the state of the pupil, v. p. 59.)

THE SYMPATHETIC SYSTEM

The sympathetic system consists of two knotted cords along
the front of the vertebral column, which are joined together on the
anterior communicating artery (p. 42), and, at the tip of the coccyx, in

224 The Spinal Cord

the ganglion impar. From these knots, or ganglia, offshoots join the
spinal nerves, and branches pass off, frequently in intricate plexuses
along the neighbouring vessels. The chief office of the system is the
control of the non-striated muscular tissue of the blood-vessels, lym-
phatics, and hollow viscera, and it is through them that the calibre of
these vessels and viscera is regulated (asthma, p. 197).

In the cervical region the knots are represented by three ganglia
which lie behind the carotid sheath, the superior ganglion being a long
fusiform mass opposite the second and third vertebrae. The middle
ganglion is at the level of the inferior thyroid artery, and the lowest
•ganglion is near the neck of the first rib, whence it sends filaments
up with the vertebral artery.

From the superior cervical ganglion filaments ascend into the skull
with the internal carotid artery, to form the cavernous and carotid
plexuses, from which branches pass along the ophthalmic and the
cerebral divisions of the artery. Other offshoots of the cervical
ganglia accompany the branches of the external carotid, certain twigs
join the pharyngeal plexus (p. 138), and some descend to the cardiac
plexuses. Communications also pass to the spinal nerves.

The cardiac plexuses. — The superficial plexus is below the arch
of the aorta, and receives branches from the cervical part of the left
vagus and sympathetic, and from the deep plexus. The deep plexus
receives a large number of branches from the gangliated cords, and
also from the vagi in the neck. From these plexuses networks extend
along the coronary arteries and into the pulmonary plexuses.

In the thorax the sympathetic ganglia, lying near the heads of the
ribs, close behind the pleura, send branches to the dorsal nerves.
The upper six ganglia also give filaments to the thoracic aorta and to
the pulmonary plexus, and the lower six send down the splanchnic
(0-TrXuyxi/a, viscera} nerves to the viscera of the abdomen.

The great splanchnic is formed of offsets from the sixth to the
tenth, and, descending through the crus of the diaphragm, ends in
the semilunar ganglion and in the renal and supra-renal plexus.

The lesser splanchnic, from the tenth and eleventh, passes down to
the cceliac plexus, and the least splanchnic to the renal plexus.

In the abdomen the four or five pairs of ganglia send branches on
to the front of the aorta, and others over the common iliac arteries
to form the hypogastric plexus. The solar plexus, part of the aortic
network, is between the crura and behind the stomach, and sends
filaments along the chief visceral branches of the abdominal aorta,
under the names of supra-renal, renal, spermatic, cceliac, and superior
mesenteric plexuses. The solar plexus contains several ganglia, of
which the semilunar receive the ending of the great splanchnic
nerves.

The aortic plexus is that part of the network which sends off the
inferior mesenteric plexus ; it ends in the hypogastric plexus.

Ligaments of Clavicle 225

THE CLAVICLE AND SCAPULA

The clavicle articulates with the first costal cartilage, and, through
the medium of a fibro-cartilaginous disc, with the sternum. Its inner
two-thirds are almost cylindrical, and are concave on the posterior
aspect, so that when the shoulder is lowered the subclavian vessels
and the brachial plexus may not be pressed against the first rib.

The articulation between the clavicle and acromion forms the
shoulder ; the shoulder-joint is the articulation between the glenoid
cavity and humerus.

The rounded end of the clavicle is so firmly held down to the
first costal cartilage by the rhomboid ligament that dislocation of the
sternal end is extremely rare. It may occur, however, on to the front
of the manubrium, upwards, or backwards. In the last case the end of
the bone might so press upon the trachea as to demand a partial
excision of the bone. It might also press upon the end of the internal
jugular or the beginning of the innomimate vein, which are close
behind it.

The sterno- clavicular joint belongs to the class Arthrodia, and
its gliding movements are much increased by the presence of the
inter-articular fibro-cartilage which intervenes between the sternal
facet and the end of the clavicle. This disc effects, as part of its office,
the breaking of shocks transmitted by a fall upon the hand. Each
surface is covered by a synovial membrane, and these membranes
may join by a hole in the disc. The larger membrane is that between
the end of the clavicle and the disc, as it also lines the articulating
surfaces of the clavicle and the first costal cartilage. The joint is
enclosed by an anterior and a posterior ligament, and by superior fibres
(the inter-clavicular ligament] which run from clavicle to clavicle with
an intermediate connection with the supra-sternal notch.

In front of the joint is the sternal origin of the sterno-mastoid, and
behind are the sterno-hyoid and thyroid.

The rhomboid ligament is a strong band connecting the inner end
of the clavicle with the cartilage of the first rib ; it prevents extreme
elevation of the clavicle without a simultaneous effort at inspiration.
In front of it is the origin of the subclavius, and close behind it runs
the subclavian vein.

The outer third is flat, and articulates with the acromion by an
oblique facet. Dislocation of this joint rarely occurs, because strong
ligaments ascending from the coracoid to the clavicle (conoid and
trapezoid) are a firm bond of union ; the slope of the facets renders
upward luxation of the clavicle the only one possible. As the bones are
subcutaneous, the diagnosis is easily made out, but, though it may be

226

The Clavicle

readily reduced, it is often impossible to keep the clavicle in position
without obtaining, by a cutting operation, permanent ankylosis.

The joint has a synovial membrane and a capsule which is thick-
ened by superior and inferior fibres. Sometimes the joint is divided by
an inter-articular fibre-cartilage.

The conoid and trapezoid ligaments bind the outer third of the
clavicle to the coracoid process ; the conoid is behind and to the inner
side of the trapezoid, the base of the cone being upwards.

The chief muscles attached to the clavicle are the pectoralis major
in the cylindrical and the deltoid in the flattened part, in front, and
the trapezius behind the deltoid. The sterno-mastoid arises along the
sternal third of the upper aspect, and the subclavius is inserted into the
groove on the under surface.

Fracture of the clavicle usually occurs at about the middle of the
convex part, the cause being a fall on to the hand or shoulder.

Signs oj 'the fracture. — The shoulder at once drops, for there is now
nothing but the trapezius and the levator anguli scapulae to support the
weight of the arm. The dragging is so painful that the man usually
holds up the elbow in the other hand, and inclines his head to the
injured side. The collar-bone is intended not only to hold the shoulder
up, but to fend it from the chest. When, therefore, the bone is broken
the pectoralis major and minor, latissimus dorsi, subclavius, trapezius,
and rhomboids drag the scapula inwards, whilst the pectorals also drag
it somewhat forwards.

The inner fragment does not stir : the costo-clavicular '(rhomboid)
and the adjacent ligaments hold it firm. As the finger is run along
the broken bone the sternal fragment certainly does
seem to be displaced, but it is not. It is the outer
part that has fallen in beneath it.

The treatment consists in raising the elbow — and
with it the drooping scapula— and in bringing the
elbow across the chest, a large pad being placed in
the armpit. The pad acts as a fulcrum to the humerus
— a lever of the first order : when the elbow is drawn
inwards the scapular end of the bone is thrust out-
wards. The hand is laid flat over the opposite
breast, and the arm, forearm, and hand are secured
by a wide roller, or strapping, for about three weeks.
When the clavicle is broken outside the conoid
ligament there is usually no displacement, for the
shoulder-blade is still suspended by that ligament ;
there maybe some dropping of the shoulder, however.
Complications. — The broken bone may, if the
violence be great, wound the external jugular (p. 35), subclavian, or in-
ternal jugular vein, or even the subclavian artery. It may also lacerate
the brachial plexus.

Fracture of cla
vicle. (DHL; ITT.)

Fracture of Scapula 227

The sternal end of the clavicle has an epiphysis which begins to
ossify about the eighteenth year and joins the shaft a few years later.
Occasionally this epiphysis becomes

detached, when careful measurement //""jS^" ^"~- - "^^*

shows that the lesion is not a dislo- (£*r' "^^"^^tin ' fiT 'SntJ^ffi

Epiphysis, 2, of clavicle at sternal end.

In excision of the bone the peri-
osteum should be stripped off by the blunt raspatory, the knife being-
used only for the skin ; thus there is but little risk of wounding the sub-
clavian and supra-scapular vessels and the external jugular vein.

The scapula reaches from the second to the seventh rib. Its
spine at the base corresponds to the third rib, and marks the posterior
limit of the fissure between the upper and lower lobes of the lung
(p. 192). The subscapularis and serratus magnus intervene between
the scapula and the ribs. The bone is held in position by certain clavi-
cular ligaments, and by the trapezius, levator anguli, rhomboids, and
serratus magnus. The latissimus dorsi may be left out of the calculation,
as its connection with the inferior angle is but slight and inconstant.

Luxation of scapula is that condition in which the inferior angle
projects from the chest- wall. It is due, not to the angle having
slipped over the border of the latissimus, but to paralysis of that part
of the serratus which should hold the vertebral margin and the inferior
angle against the chest. Frictions, and electrical stimulations along
the nerve of Bell, usually efface the deformity.

The acromion and the coracoid processes have each two centres
of ossification ; they may become ' unglued,' especially so the latter,
by direct violence or muscular action. The coracoid is ossified on
to the rest of the scapula at puberty, the acromion at manhood.

After fracture of the coracoid the pectoralis minor, coraco-brachialis,
and short head of biceps drag at the loosened process, but are
unable to displace it materially, as the conoid and trapezoid ligaments
still fix it to the clavicle. The fracture is treated by flexing the elbow
(to slacken the biceps), and by drawing it across the chest (to take the
strain from the pectoralis minor and coraco-brachialis), and by fixing
the arm in that position for two or three weeks. The break may be
repaired by a ligamentous union. Probably not a few of the specimens
which are described as * ununited fracture of the coracoid ' are instances
of imperfect ossification, fracture, especially from violence, being of
rare occurrence. The only other fracture of the scapula which is of
anatomical importance is that of the neck, when the coracoid process
and the glenoid cavity are detached, and descend together with the
head of the humerus into the axilla. The injury is excessively rare ;
it is distinguished from simple downward dislocation of the humerus
by the fact that the contour of the shoulder is easily restored when
the arm is raised, though it recurs directly the support is removed.
In dislocation of the humerus the bone is firmly locked.

o 2

228

The Subclavian Artery

THE SUBCLAVIAN ARTERY

On the left side the subclavian arises from the left end of me
transverse part of the aortic arch, a little to the left of and behind the
left common carotid. Thence it ascends through the superior medias-
tinum (p. 154), and, arching over the apex of the pleura, passes behind
the scalenus anticus, just as it does on the right side.

Relations of the first part of the left subclavian. — It is much
longer and more vertical than that of the right. It has in front the
manubrium with the origin of the sterno-mastoid, and sterno-hyoid
and thyroid, a little of the left lung and pleura intervening. As the
artery ascends a little posterior to the left carotid the internal jugular
vein and vagus, descending along the outer side of the thoracic part of
the carotid, are on an anterior plane to the subclavian. The vertebral
and the subclavian vein, the beginning of the left innominate vein,
and the phrenic nerve, which has slipped down from the front of the
anterior scalene, are also in front.

Behind are the oesophagus and thoracic duct, and the longus colli.
The left carotid and the trachea are to the right side ; and as the
subclavian ascends it has the oesophagus also to the right. Because the
thoracic duct hooks forwards to the confluence of the jugular and sub-
clavian veins it lies close on the inner side of the artery.
The lung and pleura are to the outer side.

As already remarked (p. 184), aneurysm of the innominate artery is
of common occurrence, because that vessel receives much of the shock
of the contraction of the left ventricle ; on the other hand, dilata-
tion of the first part of the
subclavian is very rare.

The right subclavian
artery springs from the
innominate, behind the
sterno-clavicular joint, and
runs outwards and a little
upwards to the inner border
of the scalenus anticus,
where the second part
begins. It courses (first
part) above the level of the
clavicle, and, being some-
what horizontal, its rela-
tions are anterior, posterior,

I'lan of branches of right subclavian artery. (GRAY.) . . . _ .

superior, and inferior.

In front are the sterno-mastoid, sterno-hyoid, and sterno-thyroid ;
the internal jugular and vertebral veins, the pneumogastric and
phrenic nerves, and cardiac branches of the sympathetic.

Subclavian Artery 229

Behind are the recurrent laryngeal nerve, the sympathetic cord,
the longus colli, and a little of the pleura.

Below are the pleura and the recurrent laryngeal ; above, the verte-
bral branch is given off, and, below, the internal mammary.

The fact of the lung and pleura being somewhat behind the first
part of the right subclavian, but in front of the left, is explained by the
left artery not arising until the second part of the aortic arch had
passed well back.

legation of the first part of the right subclavian is performed by
raising a triangular flap, as in tying the innominate artery (p. 1 82). When
the sterno-mastoid and sterno-hyoid and thyroid are divided and
raised, the common carotid is to be followed down to the innominate,
and the first part of the subclavian is then to be denuded.

The aneurysm-needle is passed from before backwards.

The operation is difficult and dangerous, not only on account of
the depth at which the vessel is placed, but also on account of the
important structures which risk being wounded, namely, the internal
jugular and vertebral veins, the pleura and the apex of the lung, and
the pneumogastric, recurrent laryngeal, and phrenic nerves. If the
procedure be resorted to, the common carotid should also be tied, so
as to cut off most of the collateral supply and to diminish the risk of
recurrent haemorrhage.

Ligation of the first part of the left artery is well-nigh impracticable ;
the vessel is closely surrounded by important veins and nerves, whilst
the thoracic duct and the pleura are in the immediate neighbourhood.

The second part of the subclavian artery lies behind the sca-
lenus anticus, additional anterior relations being the clavicular origin
of the sterno-mastoid, the subclavian vein, and the phrenic nerve.

Behind are the apex of the pleura, and the scalenus medius.

Above are the cords of the brachial plexus, emerging between the
origins of the anterior and middle scalenus, and below is the pleura.

The second part may ba tied by cutting through the clavicular
origin of the sterno-mastoid, turning inwards the phrenic nerve, and
dividing the origin of the anterior scalene. There is, however, so
great a risk of damaging the phrenic nerve, the internal jugular vein,
and the pleura that the operation is very rarely resorted to.

The third part of the subclavian artery is comparatively
superficial in the posterior inferior triangle (p. 9). It rests upon the
first rib.

Above it are the omo-hyoid, and the cords of the brachial plexus.

In front are the platysma and the cervical fascia; the external
jugular, supra-scapular, and transverse cervical veins ; the subclavian
vein, though on a lower plane ; the clavicle and subclavius, and the
supra-scapular artery. Behind are the scalenus medius and the lowest
nerves of the brachial plexus.
; migration of the third part of the subclavian.— The patient lies

230 The Subclavian Artery

supine, with the shoulders raised and the head thrown back, the arm
being pulled down to the utmost, so as to lower the clavicle— the base
of the posterior inferior triangle : when the clavicle is raised, as in
axillary aneurysm, ligation is rendered much more difficult.

The land-marks are the clavicle, posterior border of sterno-mastoid,
and, possibly, the anterior margin of the trapezius, but this is not
generally defined. Perhaps the artery may be felt pulsating upon
the first rib. In a muscular subject the interval between the sterno-
mastoid and trapezius may be so small that much of the attachment
of the muscles may need section.

The skin is well drawn down, and an incision is made through it,
the superficial fascia, and the platysma for about 2^ to 3 in. along
the middle of the clavicle, beginning at the posterior border of the
sterno-mastoid. Then, when the skin is released, the incision is
drawn up along the superior border of the clavicle. The external
jugular vein is seen as it is about to pass through the deep fascia ; if
it be much in the way it must be tied in two places and divided.
The deep fascia, which, being attached to the upper border of the
clavicle, is not drawn down with the skin and platysma, is then divided
above the clavicle, and the finger is passed through it into the connec-
tive tissue in the depths of the subclavian triangle.

The first rib is then felt, and the scalene tubercle with the attach-
ment of the scalenus anticus — the outer border of that muscle lying
behind that of the sterno-mastoid. As this tubercle is at the inner
border of the rib, and as the subclavian artery passes 'behind the
muscle, the finger must be directed outwards and a little backwards
over the first rib, in order to feel the artery. The lowest cords of the
brachial plexus are close behind the artery, and on a rather higher
plane, resting upon the sloping rib ; they are apt to be picked up in
mistake for the artery. But even in the cadaver it is easy to make
out the difference, for on rolling the artery with the tip of the finger
upon the rib it is felt to be hollow and collapsing, the nerve being solid
and cord-like.

The artery having been freed by the cautious use of the director,
the aneurysm-needle is passed round it from behind, so that there
may be no risk of any of the plexus being enclosed in the loop. The
vein is well below the level of the artery, and behind the clavicle, and
is in but slight danger of being wounded. The operator does not
usually see the vein. Care must be taken that the point of the needle
is not thrust too much downwards, lest the dome of the pleura be
wounded.

On one occasion in which I was performing this operation a large
and dusky lymphatic gland appeared in front of the artery, and at first
sight looked like the swollen vein.

Some of the irregularities are mentioned on p. 180, the most
interesting of them being that in which the right subclavian is given off

Vertebral Artery

231

as the second or third trunk of the aorta, and reaches the scalenus by
winding behind the trachea and oesophagus. Sometimes the artery
passes in front of the scalenus anticus, and sometimes the vein passes
behind the muscle.

Compression of the subclavian may be effected by the surgeon
standing behind the patient, gripping the shoulder with his fingers,
and thrusting the thumb towards the first rib, down the outer border
of the sterno-mastoid, the shoulder and clavicle having been first drawn
down. In certain cases it may be expedient to compress the artery by
the aseptic finger introduced through an incision in the deep fascia.

Collateral circulation after ligation of the third part is carried on
by the service of the empty
branches of the axillary
artery. Thus, the superior
thoracic, acromial thoracic,
the long and the alar tho-
racic branches, and the
ending of the subscapular
bring blood from the supe-
rior intercostals, and from
intercostal branches of the
aorta and internal mam-
mary. The dorsalis scap-
ulae would help by its anas-
tomosis with the supra-
and posterior scapular
arteries, and the acromial
thoracic and the posterior
circumflex by their com-
munications with the
supra-scapular in the acro-
mial region.

The branches vi the first
part are the vertebral, in-
ternal mammary, and thy-
roid axis ; from the second
part comes the superior
intercostal.

The vertebral, arising
from the upper and back
part of the first portion,
makes a short ascent into

the transverse process of Inosculations of subclavi,n artery. (HOLDEN.)
the sixth cervical vertebra ;

it then passes through the transverse processes above this, and, taking
a peculiarly twisted course near the posterior ring of the atlas, enters

232 Branches of Subclavian Artery

the skull through the foramen magnum, joining with its fellow to form
the basilar.

Relations of the root of the vertebral artery. — As the vessel
comes off at the very beginning of the subclavian, it can be but a little
distance upon the outer side of the common carotid : as the internal
jugular vein descends upon the outer side of the carotid, and in
front of the subclavian artery, it lies just in front of the vertebral
artery.

The sealenus anticus slopes upwards and inwards from the front
of the second part of the subclavian to the anterior tubercle of the
transverse process of the sixth cervical vertebra, and the longus colli
is resting upon the front of the vertebrae : therefore the vertebral artery
ascends in the interval between those muscles.

The thoracic duct, turning downwards and forwards to the con-
fluence of the left internal jugular and subclavian veins, passes in front
of the root of the vertebral, and the inferior thyroid also winds to the
front. The vertebral vein, descending behind the end of the internal
jugular, to open into the beginning of the innominate vein, is also to
the front of the root of the vertebral artery.

As the artery courses with the vertebral vein through the trans-
verse processes it passes across the emerging cervical nerves, the re-
lative position of the structures being similar to the arrangement upon
the first rib, that is, the vein is anterior and the nerves are posterior
to the artery.

Ziig-atlon of the vertebral artery. — As the artery is ascending
on the inner border of the narrow sealenus anticus, and as the outer
border of that muscle corresponds to the outer border of the sterno-
mastoid, a vertical incision of 2^ or 3 in. down that border of the
sterno-mastoid must be only a little to the outer side of the vertebral
artery. From the lower end of this incision a second is to be made
inwards for about £ in. through the clavicular origin of the muscle.
Then, after the dexterous use of the end of the director, the artery is
exposed. The structures in danger are the phrenic and pneumogastric
nerves, the internal jugular vein, and the pleura and lung.

Branches of the vertebral artery (spinal] enter with the roots of the
spinal nerves to the cord and its membranes ; others pass out to the
muscles and anastomose with the occipital, and with the deep and the
ascending cervical arteries. Posterior meningeal branches ramify in
the cerebellar dura mater, and posterior and anterior spinal descend
along the medulla. The inferior (posterior) cerebellar is a good-sized
artery. (The branches of the basilar are referred to on p. 43.)

The vertebral vein begins outside the back of the skull and passes
down through the cervical transverse processes, in front of the vertebral
artery. Having traversed the sixth process, it descends on a plane
anterior to the first part of the subclavian artery, to end in the back of
the innominate vein. It may receive a tributary through the posterior

Branches of Thyroid Axis 233

condylar foramen, and it gathers many branches from the spinal cord
and column, and from the muscles of the neck.

The thyroid axis comes from the front of the first part of the artery,
and at once breaks into the inferior thyroid, and supra- and posterior
scapular branches I—-
The inferior thyroid, in order to reach the thyroid body, winds
beneath the sheath of the common carotid and the middle sympathetic
ganglion, at the level at which the omo-hyoid crosses the front of the
sheath — opposite the fifth cervical vertebra.

Ligation. — Sometimes this artery is tied in the case of enlargement
of the thyroid gland. An incision of 2 or 3 in. is made in front of the
lower part of the sterno-mastoid, and the vessel is then sought opposite
the cricoid cartilage.

Branches. — Unimportant twigs are given to the muscles in its
neighbourhood.

The ascending- cervical runs in the groove between the scalenus
anticus and the rectus anticus major, giving twigs to those muscles, and
others to anastomose with the vertebral in the spinal canal. Tracheal,
cesophageal, and laryngeal branches also pass off.

The termination of the inferior thyroid anastomoses with its fellow
of the opposite side, and with the superior thyroid artery in the lower
part of the thyroid body.

The supra-scapular artery passes outwards in front of the
scalenus anticus and phrenic nerve, and behind the clavicular origin
of the sterno-mastoid. And, as the supra-scapular notch is below the
level of the clavicle, the artery sinks behind the clavicle, where it lies
in front of the third part of the subclavian artery, and gives twigs
to the sterno-mastoid and subclavius. Then, winding on above the
ligament, it ramifies beneath the supra- and infra-spinatus muscles,
supplying the shoulder-joint, and anastomosing with the posterior and
the dorsal scapular (v. p. 231) arteries.

It sends a twig through the trapezius, on to the acromion process,
which anastomoses with the acromial thoracic.

The posterior scapular, in order to reach the vertebral border of
the shoulder-blade, runs across the root of the neck ; this course gives
it the alternative name of transversalis colli. The artery passes over
the phrenic and the scalenus anticus, and lies in the subclavian
triangle, but at a higher level than the.supra-scapular artery. It leaves
the triangle beneath the omo-hyoid, passing over the brachial plexus,
and reaches the anterior border of the trapezius, where it gives off the
superficial cervical branch, which anastomoses with the superficial
part of the princeps cervicis of the occipital (p. 30).

The continuation of the artery then descends along the border of
the shoulder-blade, beneath the levator anguli scapulae and the
rhomboids, anastomosing with the supra- and subscapular arteries, and,
in the neighbourhood of the rhomboids, with the posterior intercostal.

234 Branches of Subclavian Artery

The internal mammary is described on p. 155, and the superior
intercostal on p. 157.

The subclavian vein, the continuation of the axillary, begins at
the outer border of the first rib, and joins with the internal jugular
behind the sterno-clavicular articulation to form the innominate ; the
two innominates eventually join to form the superior vena cava, as
shown in the illustration on p. 185.

Chief relations. — The vein lies below and in front of the third
part of the subclavian artery, and behind the subclavius muscle and
the clavicle. It passes in front of the phrenic nerve and the scalenus
anticus, and over the apex of the pleura.

Its tributaries are the external and anterior (p. 35) jugulars.

The wall of the vein adheres closely to the fascia! sheath by which
it is invested, and, indirectly, to the clavicle and costo-coracoid mem-
brane, the vessel being expanded when the shoulder is brought
forwards. ' Hence care should be taken in operations about the root
of the neck or the shoulder in order to avoid the danger of air being
drawn into the circulation by movements of the limb.' (Quain.) If
this contingency should arise, the wound should be filled with water
whilst the opening in the vein is being sought.

235

PART III
THE UPPER EXTREMITY

Surface markings. — The clavicle (p. 225) is convex forwards in its
inner two-thirds and concave forwards in the outer third. Just where
it articulates with the acromion process it has a considerable upward
projection. The acromion process and the spine of the scapula are
easily traced towards the vertebral column, the base of the spine
corresponding to the third rib.

The meeting of clavicle and acromion constitute the shoulder. The
roundness of the shoulder is due to the presence of the large head of
the humerus and its tuberosities ; over this the deltoid is thinly spread.
After amputation at, or excision of, the shoulder-joint, the prominent
' shoulder ' remains, but the ' roundness of the shoulder' has vanished.

The lesser tuberosity is the inner ; between it and the outer, the
bicipital groove may be felt : it is exactly at the front of the head of
the bone when the arm is by the side and slightly rotated outwards.

The coracoid process is found on thrusting the fingers into the
space between the pectoralis major and deltoid, at about an inch below
the junction of the cylindrical and flattened parts of the clavicle. To
make sure that the fingers have not gone too far outwards and are
pressing against the lesser tuberosity of the humerus, the arm should
be rotated.

The course of the axillary artery may be indicated by a line from
the middle of the clavicle to the groove along the inner side of the
coraco-brachialis and biceps, the arm being abducted and rotated
outwards.

The prominent mass of the biceps in front of the arm suddenly tapers
into the strong tendon, from the inner side of which the bicipital fascia
may perhaps be made out as it expands over the muscles which are
arising from the inner condyle of the humerus.

Along the inner side of the biceps is the groove which is continued
down from between the axillary folds ; in it runs the brachial artery.
The inner border of this muscle is the guide in tying that vessel.
The muscle overhangs the artery.

236 The Upper Extremity

For compressing the brachial artery the assistant should stand
upon the outer side of the limb, and, passing the fingers round the
biceps and just beyond the surface-groove, should drag and hook the
artery with the tips of his fingers, and gently fix it against the bone.
Very little force is needed, only it must be properly directed— outwards.
At the back of the arm the triceps may be seen narrowing into its
insertion into the olecranon process. The course of the musculo-spiral
nerve may be shown by drawing the chalk from below the posterior
fold of the axilla downwards, backwards, outwards, and then forwards
to the front of the external condyle.

The condyiar ridges descend from the middle of the shaft to the
internal and external condyles ; the ulnar nerve may be felt as it
passes along the back of the inner ridge to the space between the
condyle and the olecranon. The inner ridge separates the biceps
and brachialis at the front from the triceps behind. The outer ridge
extends between the supinator longus and the long radial extensor, in
front, and the triceps posteriorly.

In a thin subject the internal intermuscular septum may be clearly
made out.

The external condyle is best examined on the forearm being fully
extended, when it is found in a depression which is bounded on the
inner side by the olecranon and the insertions of the triceps and
anconeus, and on the outer side by the mass of the supinator longus
and the extensors. In this depression, just below the condyle, is the
prominent margin of the bead of the radius, between which and the
condyle is a transverse groove corresponding to the elbow-joint.

In suspected fractitre of the radius^ if there be no impaction of the
fragments, the head of the bone does not rotate when the wrist is
being pronated and supinated. The student should practise this
method of examining the radius, the thumb or index-finger being
pressed firmly against the radial head.

A little above the internal condyle a small spur of bone is occasion-
ally met with ; it projects downwards, and beneath it the brachial
artery and median nerve may take an irregular course — as in the car-
nivora. It may be felt beneath the skin, and should not be taken for
an exostosis or any other morbid growth.

To measure the length of the arm, dot with ink the tip of each
acromion process, and each external condyle of humerus, and then
compare the two sides. To compare the forearms, dot the external
condyles as before, and the tip of each radial styloid process, and then
measure.

Between the chest and the arm is the depression corresponding to
the floor of the armpit ; when the arm is raised the axillary fascia is
tightened and the borders of the pectoralis major in front and the teres
major and latissimus dorsi behind become prominent. When the arm
is raised to the utmost, and the fingers are forcibly thrust towards

Phlebotomy 237

the apex of the space, the head of the humerus may be obscurely
felt.

The axillary line is the plumb-line descending, from the middle
of the first rib, between the axillary folds. In a deep inspiration the
chest-wall in front of it moves forwards whilst that behind it moves
backwards.

Superficial veins. — The anterior ulnar vein comes from the little
finger and the palm of the hand, and, receiving tributaries in its course,
is joined in the upper part of the forearm by \\\e posterior ulnar vein,
which begins on the back of the little finger as the "vena salvatella.
The common ulnar vein which is thus formed is soon joined by the
inner division of the median vein to form the basilic.

The radial vein comes from the back of the hand (where it has
large anastomotic arches with the posterior ulnar) and from the thumb ;
at the elbow it is joined by the outer division of the median vein to
form the cephalic.

Front of right elbow. (GRAY.)

The median vein ascends from the palm of the hand, and just before
it reaches the bend of the elbow it receives the communicating vein,
which brings blood from the venae comites of the radial and ulnar
arteries. It then divides into two short trunks, the outer of which joins
the radial to form the cephalic, whilst the inner flows into the common
ulnar vein to form the basilic. These short trunks are called from
their connections median-cephalic and median-basilic respectively.

Thus, the veins at the bend of the elbow are arranged in the form
of the letter M, with all the points prolonged.

The median-basilic is the vessel at the elbow which is generally
chosen for phlebotomy, for the simple reason that it is usually larger
than the median cephalic. It has this disadvantage, however, that
just beneath it runs the brachial artery ; but, as the bicipital fascia

238 The Upper Extremity

intervenes between these vessels, the artery is well protected from
injury by the lancet. Branches of the internal cutaneous nerve cross in
front of the vein.

Before using the lancet the surgeon should make out the exact
situation of the brachial artery, and should satisfy himself that that
irregularity does not exist in which the ulnar artery descends into the
forearm superficial to the group of muscles arising from the internal
condyle.

For the operation of venesection a tape should be tied round
the arm above the elbow, just tight enough to prevent the venous
return, but not to compress the artery, as I have known to happen.
The patient should hold something in his hand on which he can keep
exercising the flexors of his fingers, so as to hurry on the venous
return. The staff which was formerly used for this purpose has been
left in the keeping of the surgeon's old associate, the barber, who,
having now no other use for it, has decorated it in spirals of clean
and blood-stained tapes, and has fixed it over his shop-door as the
sign of his present craft.

If during phlebotomy the lancet traverse the vein and wound the
subjacent artery, and the lips of the adjacent wounds become glued
together, blood is pumped with each ventricular contraction into the
vein. Thus, not only the median basilic and the neighbouring veins
become distended and varicose, but they pulsate after the manner of
an aneurysm. The condition is called aneurysmal varix — it is a varix
with an aneurysmal pulsation.

But when the edges of the wound in the vein do not become glued
to those in the artery, and the blood collects in the intervening con-
nective tissue before entering the vein, a pulsating tumour (aneurysm)
exists in addition to the aneurysmal varix, the condition being called
varicose aneurysm.

Both these lesions may be treated by forcible flexion of the limb,
or, if that fail, by ligature of the artery above and below the wound.

The basilic vein is formed by the confluence of the median-basilic
and common ulnar, and, lying along the inner side of the biceps, super-
ficial to, but in a line with, the brachial artery, it pierces the deep fascia
below the middle of the arm. It then lies alongside of the brachial
artery, and joins its venae comites at the lower border of the tendon of
the teres major to form the axillary vein.

The median-cephalic vein ascends obliquely over the hollow between
the biceps and supinator longus, the musculo-cutaneous nerve lying
beneath it, but over the deep fascia. This vein when opened in
'bleeding' is said to be less easily compressed than the median-basilic
because of its lying over the intermuscular hollow.

The cephalic vein ascends superficially on the outer side of the
biceps, lying afterwards in the groove between the pectoralis major and
deltoid. It pierces the deep fascia just below the clavicle, and then,

Axillary Fascia 239

having traversed the costo-coracoid membrane (p. 240), runs over the
first part of the axillary artery to end in the highest part of the axillary
vein.

The cutaneous nerves. — In the pectoral region are supra-clavi-
cular branches of the third and fourth cervical nerves, the endings of
the intercostal nerves, and of their lateral branches. In the scapular
region of the chest the cutaneous nerves come from the posterior
divisions of the dorsal nerves, and from the lateral cutaneous branches
of the intercostals. In the deltoid region are the acromial twigs of
the supra-clavicular nerves, as shown on p. 145, and branches of the
circumflex.

Down the arm the superficial nerves come (on the inner side) from
the intercosto-humeral, the internal and the lesser internal cutaneous,
and the musculo-spiral ; and, on the outer aspect, from the circumflex
and musculo-spiral. (See Brachial Plexus, p. 249.)

The intercosto-humeral nerve, the lateral cutaneous branch of
the second intercostal, runs across the axilla to join the lesser internal
cutaneous in the supply of the skin as far as the inner condyle. Im-
plication of this nerve in cancerous invasion and in abscess of the
axilla causes neuralgic pain along the inner side of the arm. The
nerve is generally seen when the axilla is opened for the removal of
cancerous lymphatics in scirrhus mammas.

The axillary fascia is the deep and important layer which is
continued from the front of the pectoralis major, across the floor of the
space, and backwards over the latissimus dorsi. It is attached above
to the clavicle, and in front to the sternum and chest. At the lower
border of the pectoralis major it becomes continuous with the fascial
investment of the pectoralis minor, and so, indirectly, with the costo-
coracoid membrane and also with the sheath of the axillary vessels.
Below the armpit it is continuous with the fascia around the arm. It
is strong and well able to shut in an axillary abscess.

The deep fascia of the arm surrounds the limb, and is continuous
above with that covering the deltoid and pectoralis major. It is
strengthened by slips from the insertions of the deltoid, pectoralis
major, and latissimus dorsi, and gives off strong intermuscular septa to
the condylar ridges and condyles. The inner of these septa is pierced
by the inferior profunda and the anastomotica magna, the former vessel
being accompanied by the ulnar nerve. The musculo-spiral nerve
and superior profunda artery pass through the outer septum.

Below, the deep fascia of the arm is continuous with that of
the forearm, and is attached to the olecranon process, but it is not
attached to the head of the radius, or it would check its rotatory move-
ments.

The pectoralis major arises from the inner half of the clavicle,
the front of the sternum and the adjacent costal cartilages, and from
the aponeurosis of the external oblique. It is inserted into the outer

240 Region of Shoulder

lip of the bicipital groove, the clavicular part passing down in front of
and below the thoracic part of the muscle.

Relations. — The mamma rests upon its anterior surface ; therefore,
in the case of disease of that gland, the arm must be fixed to the side
for the sake of perfect rest. Behind it are the ribs and the intercostal
muscles ; the subclavius, the costo-coracoid membrane, the pectoralis
minor, the axillary vessels, and the brachial plexus. Its outer border lies
along the inner edge of the deltoid, an important interval separating
them near the clavicle. The cephalic vein is lodged in this inter-
muscular groove.

The pectoralis minor ascends from the third, fourth, and fifth ribs
and the intercostal fasciae to its insertion along the thoracic aspect of
the coracoid process. It lies beneath the larger muscle, and covers the
second part of the axillary vessels, and the brachial plexus. The lowest
border of the muscle is subcutaneous, and lies along the fifth rib.

Suppuration may occur between the two pectoral muscles or
beneath them both. In the former case the pus is likely to descend
to the lower border of the larger muscle and there to point. In the
latter case it may eventually break through the floor of the axilla, or
may ascend beneath the costo-coracoid membrane, and along the
course of the vessels and nerves, into the neck ; the abscess may
possibly find its way through the intercostal spaces unless promptly
evacuated.

Nerves. — The two pectoral muscles are supplied by the anterior
thoracic branches of the brachial plexus.

Bursee. — There may be a small bursa over the acromion or over
the outer end of the clavicle ; a large one between the deltoid and
shoulder-joint ; and small ones between the tendons of the infra-
spinatus and teres minor and the capsule of the joint, which may com-
municate with the interior of the articulation. The bursa sheathing the
tendon in the bicipital groove is a continuation of the synovial membrane
of the shoulder-joint. A separate bursa intervenes between the tendons
of the latissimus dorsi and teres major in the bicipital groove.

The costo-coracoid membrane is spread between the first rib,
clavicle, and coracoid process ; below, it blends with the fascia of the
lesser pectoral muscle, and with the sheath which the axillary vessels
have brought down from the fascia about the scalene muscles. The
membrane and the sheath of the vessels are pierced by the cephalic
vein in its course to the axillary vein, and by the acromial thoracic
artery.

The subclavius arises by a tendon from the cartilage of the first
rib, and is inserted into the groove on the under surface of the clavicle.
It is hidden by the origin of the pectoralis major, the costo-coracoid
membrane intervening. Beneath it are the subclavian vessels and
the brachial plexus, and when the shoulder is drawn down the muscle
closely overhangs the highest part of the axillary vessels.

'Luxation of Scapula' 241

The subclavian fossa corresponds to the interval between the
borders of the pectoralis major and deltoid at their clavicular origin ;
the greater the muscular development, the narrower this crevice. In
its depths may be felt the apex of the coracoid process, to the thoracic
aspect of which the narrowest part of the pectoralis minor is passing.
The second part of the axillary artery is beneath the lesser pectoral,
the first part being between its upper border and the outer edge of the
first rib. To the inner side of the artery is the vein, and to the outer
are the two cords of brachial plexus.

The serratus magnus arises by nine digitations from the eight
upper ribs, and, hugging the chest-wall, is inserted into the thoracic
aspect of the vertebral border of the scapula. The muscles bounding
the axilla anteriorly and posteriorly enclose it in front and behind,
and the axillary vessels and the cords of the plexus, in their passage
from the root of the neck, cross over the highest part of the muscle.

Its nerve-supply is from the nerve of Bell (p. 251), which descends
upon its axillary surface.

The action of the muscle is to steady the shoulder-blade, to draw
it forwards, and to keep its vertebral border and inferior angle close
against the chest. In paralysis of the muscle the angle of the scapula
projects like a rudimentary wing, and the fingers can be thrust up
between it and the chest-wall almost to the glenoid cavity. This
condition was formerly called ' luxation of the scapula.1 Over-action
of the muscle is the usual cause of the paralysis — I have met with it in
a nurse who spent most of her time in rubbing an old lady with
chronic pleurisy, and in a girl who was skipping all day long. When
the patient is told to raise the arm over the head the scapula is drawn
upwards and inwards by the elevator and by the rhomboids, for there
is nothing to keep it down to the side ; and, as the shoulder-blade
cannot be rotated, the superior angle fails to be tilted upwards and
the attempt at raising the arm fails.

The deltoid arises from the front of the clavicle, the acromion
process, and the lower border of the spine of the scapula, and is in-
serted halfway down the outer surface of the humerus. It is supplied
by the circumflex nerve and is sometimes paralysed after dislocation
of the humerus ; the power of abduction being then lost.

Relations. — It is covered by the skin and fasciae. Its inner border
rests against the outer edge of the pectoralis major, and in the groove
between these muscles lie the cephalic vein and the descending
branch of the acromial thoracic artery. Beneath it is a large bursa
which separates it from the shoulder-joint. The deltoid covers also
the coracoid process and its muscles, namely the pectoralis minor,
coraco-brachialis, and short head of biceps ; the coraco-acromial
ligament ; the upper end of the humerus with the subscapularis
inserted into the inner (lesser) tuberosity, and the supra- and infra-
spinatus and the teres minor into the greater ; the bicipital groove,

242 Region of Shoji/der

with the long head of the biceps, and the insertions of the pectoralis
major, latissimus dorsi, and teres major ; the anterior and posterior
circumflex vessels and circumflex nerve, and the outer and long heads
of the triceps.

Abscess in the shoulder-joint in the sub-deltoid bursa may reach
the surface by openings around the edges of the muscle, but the pus
rarely finds its way through the substance of the muscle.

The supra-spinatus arises in the supra-spinous fossa and is in-
serted into the upper part of the greater tuberosity. It passes over the
shoulder-joint, so, in sub-glenoid dislocation, it is tightly stretched,
and holds and firmly hitches the head of the humerus against the lower
rim of the socket. It is to relax this muscle that the arm is first
abducted in the scientific method of reduction.

The infra-spinatus and teres minor arise from the infra-spinous
fossa, and are inserted into the outer side of the greater tuberosity, the
teres minor being the lower of the two. They are external rotators.

The supra- and infra-spinatus are supplied by the supra-scapular
nerve ; and the teres minor is supplied by the ganglionic branch of
the circumflex.

The subscapularis arises from the vertebral two-thirds of the venter
of the scapula, and by tendinous intersections from the ridges ; it is
inserted into the lesser tuberosity and into the bone just below it. Its
tendon blends with the capsular ligament, but is separated from the
neck of the shoulder-blade by a bursa. It forms part of the posterior
wall of the axilla, and has resting upon it the origin of the coraco-
brachialis and biceps, and the axillary vessels and nerves. It is
supplied by the upper and middle subscapular nerves, and its action
is to roll the humerus inwards.

The teres major arises from the dorsal surface of the lower scapular
angle, and, passing on the inner side of the shaft of the humerus, is
inserted into the inner lip of the bicipital groove.

The latissimus dorsi arises from the back of the iliac crest, the
lumbar, and the lower six dorsal spines, and the lowest ribs (inter-digi-
tating with the external oblique). Its tendon curls round, and is inserted
in front of, that of the teres major, reaching the depths of the groove.
(Sometimes a muscular slip of the latissimus crosses over the axillary
vessels to be inserted with the pectoralis major.) These muscles
draw the humerus downwards and backwards, and rotate it inwards ;
they are supplied by the middle and long subscapular nerves.

Though the latissimus dorsi is the lowest muscle in the posterior
wall of the axilla', its tendon, which has curled round the teres major,
does not descend so far along the humerus. Thus the muscles forming
the back of the axilla are to be given in this order : subscapularis, teres
major, and latissimus dorsi ; but the artery lies on them in this order :
subscapularis, latissimus dorsi, and teres major.

Occasionally a bursa exists between the upper border of the latis-

Biceps

243

simus clorsi and the dorsal surface of the inferior angle of the scapula.
Like other bursae, it is liable to attacks of chronic inflammation, and
to distension by accumulation of its fluid contents.

The coraco-brachialis arises from the tip of the coracoid process
and is inserted halfway down the inner surface of the humerus, opposite
to the deltoid. It is supplied by the musculo-ctitaneous nerve, which
runs through it.

Relations. — It lies along the inner side of the biceps and the outer
side of the axillary and brachial artery. It is covered by the deltoid and
pectoralis major, and rests upon the muscles at the back of the axilla.

The biceps arises by its short head with the coraco-brachialis, and
by its long head from the top of the glenoid cavity, the tendon spread-
ing out into the glenoid ligament. This tendon then winds over the
upper end of the humerus, strapping it in its place, and, passing
between the tuberosities, escapes beneath the Capsule It carries with
it a prolongation of the synovial membrane into the bicipital groove,
along which an abscess in the joint may find its escape. The two
heads of the muscle join below the middle of the arm. The insertion
is into the back of the tuberosity of the radius, and a bursa, which is
sometimes inflamed and filled with fluid, intervenes between the
front of the tuberosity and
the tendon. By this back-
ward insertion the biceps
becomes a powerful supi-
nator. Its nerve-supply is
from the musculo-cuta-
neous.

From the inner side of
the tendon of the biceps
a strong slip, the bicipital
fascia, is given to join the
deep fascia over the muscles
arising from the inner con-
dyle. This fascia lies be-
neath the branches of the
internal cutaneous nerve,
and the median-basilic
vein, and separates them
from the subjacent brachial
artery, as shown on p. 237.

Relations. — Its upper
end is covered by the del-
toid and pectoralis major.
It rests on the muscles
which form the floor of the axilla, and on the brachialis anticus and
musculo-cutaneous nerve. Internally are the coraco-brachialis, median

Osteo-arthritis ; biceps adhering to head of humerus.

244 Th£ Upper Ann

nerve, and the brachial artery. Externally are the deltoid and supinator
longus.

Dislocation of the tendon of the long head of the biceps from the
groove occurs in chronic osteo-arthritis, when osteophytes grow about
the head of the humerus. When the articular disease is further advanced
the tendon may be frayed out or thinned and ruptured, and adhering
to one of the tuberosities. (' Med. Chirurg. Trans.,' vol. Iviii.)

The brachialis anticus arises from the front of the humerus and
the intermuscular septa, and is inserted into the coronoid process of
the ulna ; its action is, therefore, solely to bend the elbow. Its nerve-
supply comes from the musculo-cutaneous and sometimes also from
the musculo-spiral. Contracting with great energy, it may detach the
coronoid process, and if that process be broken off, as in dislocation
of the ulna backwards, some of the fibres of insertion may drag it
upwards.

Relations. — It is covered by the biceps, the brachial artery, and the
median nerve. The musculo-cutaneous nerve lies between it and the
biceps, and supplies them both. Its tendon lies close over the anterior
ligament of the elbow.

The triceps. — The long or middle head descends from below the
glenoid cavity ; the inner head arises from the back of the humerus
up to the level of the insertion of the teres major, and the outer head
up to the level of the teres minor. The three heads leave a passage
for the musculo-spiral nerve and superior profunda artery, and are in-
serted by a strong tendon into the top of the olecranon process, an
important slip running on to join the deep fascia at the back of the
forearm.

The scapular head of the muscle, descending between the teres
minor and major, divides the area which is bounded above by the teres
minor, below by the teres major, and externally by the humerus into a
quadrilateral space through which wind the circumflex nerve and the
posterior circumflex vessels, and a triangular one through which the
dorsalis scapulae artery passes.

A piece of the triceps is continued from the back of the external
condyle to the outer aspect of the olecranon under the name of
anconeus (p. 281). Both muscles are supplied by the musculo-spiral
nerve and are simple extensors of the elbow.

THE AXILLA

The axilla is the pyramidal space between the chest and the arm;
its apex reaches beneath the clavicle and into the neck. There is no
barrier between the root of the neck and the axilla, and pus readily
passes from one into the other unless escape be provided.

Boundaries. — The axilla is bounded in front by the pectoralis
major and minor; behind by the subscapularis, teres major, and

•

Axillary Artery 245

latissimus dorsi ; and on the inner side by the six upper ribs, the
intercostal muscles, and the serratus magnus. The base is covered
in by the deep fascia, which extends from over the pectoralis major
to the latissimus dorsi, and on to the chest-wall.

The space contains the axillary vessels and their branches ; the
brachial plexus and most of its branches ; the intercosto-humeral nerve ;
fat, and many lymphatic glands. The anterior and posterior folds
meet at the bicipital groove, the coraco-brachialis and biceps filling this
crevice.

The most important of the contents lie along the outer side of the
space ; against the inner wall there are merely the thoracic branches
of the artery and vein, the intercosto-humeral nerve, the nerve of Bell,
and lymphatics. Thus the surgeon may proceed with comparative
freedom in the removal of malignant glands or other tumours from
the thoracic side of the space, but along the humeral region he must
act with much deliberation.

To open an axillary abscess, a small incision should be made
with a scalpel through the deep fascia of the floor of the space, the
opening being subsequently enlarged by the director and dressing-
forceps, after the manner of Hilton. I have seen a paralysed serratus
magnus in a man whose axillary abscess had been opened by a bold
plunge of a surgeon's knife, the nerve of Bell having been severed. If
the ' plunge ' had been made into the outer part of the space instead
of into the inner, the vessels would probably have been wounded.

The axillary artery continues the subclavian from the outer
border of the first rib, through the apex and the outer part of the
space, and down to the lower border of the tendon of the teres major,
where the name changes to brachial. It lies to the inner side of the
shoulder-joint and the humerus, being separated from the former by
the insertion of the subscapularis. The narrow part of the pectoralis
minor crosses it in the neighbourhood of the coracoid process, and
divides it into three parts.

The first part of the artery extends from the first rib to the lesser
pectoral — a very short distance. The second part is shorter still,
being the mere width of the pectoralis minor just before its insertion.
The third part is much longer, reaching from the lower border of
the lesser pectoral to the lower border of the tendon of the teres
major.

To mark the course of the axillary artery, the arm should be
abducted and slightly rolled outwards, and a line drawn from the
middle of the clavicle to the groove on the inner side of the biceps.

Relations. — The surgeon takes a more liberal view of the relations
of an artery than is allowed to the student. The division of the artery
into three parts concerns him only to this extent : that the second
part, being under cover of both pectoral muscles, is inaccessible for a
ligature ; that the first part may be reached in the infra-clavicular

246 The Axilla

fossa (p. 241) ; and that the very end of the third part of the vessel is
comparatively superficial. He does not consider the relations of the
three parts separately, but regards the artery as a continuous trunk.

In front are the skin, superficial fascia and platysma, the deep
fascia, and the pectoralis major and minor. Just below the clavicle
the vessel is covered by the costo-coracoid membrane, and is crossed
by the cephalic vein. The subclavius also overhangs the beginning
of the artery, but in operations at that part the clavicle is raised, so
that the muscle may be out of the way. The formation of the median
nerve takes place over the third part of the artery.

Behind.— As the axillary artery is the continuation of the sub-
clavian, which rests upon the first rib, its beginning must needs rest
upon the first intercostal space and the top of the serratus magnus.
The nerve of Bell descends behind the beginning of the artery to
reach the chest-wall. The artery there rests upon the subscapularis,
the posterior cord of the plexus and its derivatives — the musculo-
spiral and circumflex — and on the tendons of the latissimus dorsi and
teres major. And, as the shoulder-blade does not lie flat against the
ribs, the artery crosses a gap in its course from the intercostal space to
the subscapularis.

To the inner side is the axillary vein in the whole of the course
of the artery, the inner cord of the plexus and its derivatives inter-
vening between the two vessels in the second and third parts of their
course.

To the outer side are the brachial plexus and the derivatives of the
outer cord, namely, the musculo-cutaneous and the outer head of the
median. At the lowest part of the artery the last-named nerve is to
the outer side, as are also the coraco-brachialis and biceps.

Branches. — The first duty of the axillary artery is to give offbranches
to the side of the chest. The further that the artery descends, the
wider is the gap between it and the chest, and the longer are its
thoracic branches. The first is the short one. The second is the
inner division of the acromiaJ -thoracic ; the third is" the long one. ; the
fourth is the alar ; the fifth is the subscapular, which is very largely
concerned in the supply of the serratus magnus and chest-wall. All
these arteries anastomose with vessels which are already between the
ribs — the superior intercostal of the subclavian in the back of the
highest spaces, and the aortic intercostals in the lower ; and the
anterior intercostals of the internal mammary in the front of each
space.

The acromial division of the acromial-thoracic runs through the
costo-coracoid membrane, and anastomoses in the region from which
it takes its name with branches of the supra-scapular and circumflex
arteries. A descending branch runs in the inter-muscular groove with
the cephalic vein. The Jong thoracic descends by the lower border
of the pectoralis minor to the chest, giving branches through to the

Axillary Artery 247

mamma. The alar thoracic supplies lymphatic glands as well as the
chest-wall, and its branches are useful in the collateral circulation.

The subscapular is a very large branch. It descends along the
axillary border of the muscle which gives it its name, and at last
reaches the chest- wall. It gives off a dorsal branch which passes on
to the scapula under cover of the teres minor and the infra-spinatus to
anastomose with the supra- and posterior scapular arteries of the thyroid
axis.

The circumflex arteries are named from their being ' bent around '
the surgical neck of the humerus. The anterior, the smaller, passes
outwards beneath the coraco-brachialis and biceps, and as it runs
across the bicipital groove it sends a branch up to the shoulder-joint.
It ends by anastomosing with the posterior circumflex, which emerges
from the axilla through the quadrilateral space bounded by the
humerus and the long head of the triceps at the sides, and the teres
minor and major above and below. It supplies the shoulder-joint
and the deltoid, and anastomoses with the preceding vessel, and,
on the acromion process, with the acromial-thoracic and the supra-
scapular.

Collateral circulation after ligation of the first part of the axillary
would be carried on as after ligation of the third part of the subcla-
vian (p. 231) ; and after ligation of the lowest part of the axillary
as after ligation of the brachial above the point of origin of the
superior profunda (p. 265).

The third part of the axillary artery may be reached and tied by
abducting the arm and rotating it outwards. The vessel lies in the
upward continuation of the brachial groove, nearer to the anterior
axillary fold than the posterior, and along the inner side of the coraco-
brachialis.

A three-inch incision is made through the skin and superficial
fascia from well up beneath the insertion of the pectoralis major
down into the brachial groove. The deep fascia is divided on a direc-
tor, the coraco-brachialis, which is the guide to the artery, being then
looked for and followed down. Some more fibrous tissue is traversed
by the director and forceps, and the median nerve is then turned out-
wards, and the axillary vein is gently separated from the inner side.
The internal cutaneous nerve may, perhaps, have to be drawn inwards ;
the ulnar nerve will be hidden by the vein as it lies between the vein
and artery, and it must be carefully excluded from the ligature, which
is passed from the inner side. Sometimes a fleshy bundle passes from
the latissimus dorsi over the artery, to be inserted with the pectoralis
major ; this might possibly be mistaken for the coraco-brachialis,
especially if the incision-wound were small.

Varieties. — Occasionally the axillary gives off the radial or ulnar
artery, or a slender i>as aberrans, to join the radial or ulnar below
the elbow. Sometimes a large branch runs by the side of the long

248 The Axilla

thoracic as an additional external mammary for the supply of the
gland.

The artery may be accompanied by two venae comites instead of by
the single venous trunk.

The axillary artery can be compressed in the lowest part, where
it is comparatively superficial, by thrusting the fingers under the pecto-
ralis major and gently driving the vessel outwards against the humerus,
under the coraco-brachialis and biceps.

It is not practicable to compress the beginning of the artery ; cir-
culation is easily arrested, however, in the subclavian instead.

Xiigation of the axillary artery may be performed in the first
part of its course (but, as the vessel can be here reached only with
danger and difficulty, the surgeon prefers to tie the subclavian, p. 229).
The arm having been drawn from the side, so as to raise the clavicle
and its muscle from the vessel, a slightly curved incision is made
below the inner three-fourths of the clavicle, through the skin, super-
ficial fascia and platysma, and the deep fascia, dividing a small super-
ficial vein, perhaps, which links the cephalic and the external jugular.
The cephalic vein is turned outwards from the pectoral muscle, which
is to be divided at its clavicular origin, and the finger then feels for
the pectoralis minor. The costo-coracoid membrane is torn through
with the dissecting-forceps and director, care being taken not to
wound the cephalic vein or the acromial thoracic artery as they
traverse the membrane.

Then a loose sheath surrounding the vessels is torn through, and
the artery is separated from the vein on its inner side and the brachial
plexus on the outer. The needle is passed from the vein-side. The
ligature is probably applied below the level at which the cephalic vein
crosses the artery.

Of the axillary lymphatic glands, some are placed along the
axillary vessels, and receive the lymph from the arm, whilst the
thoracic set, which lie along the lower border of the pectoralis
minor, receive their lymph from the mamma and the front of the chest.
Other glands, which are deep in the arm-pit, are associated with
the lymphatics of the back. A gland or two in the infra-clavi-
cular fossa (p. 241) receive lymphatics passing up with the cephalic
vein.

The superficial and deep lymphatic vessels for the most part follow
the veins ; those running up the fore-arm join a small group of lym-
phatic glands which are situated near the brachial artery, above the
inner condyle of the humerus.

In examining for enlarged lymphatic glands, as in suspected
scirrhus of the breast, the front of the fingers should be laid flat upon
the ribs, and the arm should be brought to the side so that the axillary
floor may be rendered slack. I have known the inner border of the
head of the humerus taken for an enlarged gland when the arm was

BracJiial Plexus 249

considerably abducted and the relaxed tissues allowed the fingers to
be thrust high into the space.

In enucleating glands which have become implicated in scirrhus
mammas the surgeon employs his fingers, not his scalpel, lest he
wound the large vessels ; but in tearing them out he runs the risk of
rooting a little alar thoracic artery from the main vessel. He must
proceed with very great care when removing glands from the outer
part of the space.

In the case of scirrhus mammae the surgeon cannot be sure that
there is no secondary implication of the glands until he has opened
up the fascia of the floor of the axilla and introduced his finger. It is
advisable, therefore, in every case of malignant disease to prolong the
incision into the arm-pit in the search for implicated glands.

The axillary glands are associated beneath the clavicle with those
at the root of the neck. When, therefore, the surgeon is considering
the advisability of operating in mammary cancer he should carefully
examine the supra-clavicular region as well as the arm-pit.

THE BRACHIAL PLEXUS

The brachial plexus is formed by the anterior divisions of the
fifth, sixth, seventh, and eighth cervical nerves, and by the chief part
of that of the first dorsal, which has come up in front of the neck
of the first rib. Resting in the grooves on the transverse processes of
the lower cervical vertebrae, the nerves emerge between the anterior
and middle scalene muscles, which arise from the anterior and posterior
tubercles of those processes, respectively. The subclavian artery also
lies behind the anterior and in front of the middle scalene : the plexus
is, thus, chiefly above the artery in the second and third portions of its
course, but the lowest strand of the plexus is partly behind it. In this
relative position the plexus and the artery descend beneath the cla-
vicle and the subclavius muscle into the axilla.

The anterior divisions of the fifth and sixth nerves join to form a
single cord, as do also the divisions of the eighth cervical and the first
dorsal, the division of the seventh passing on by itself.

On the outer side of the scalenus medius each of these three large
bundles splits into an anterior and posterior trunk, of which the anterior
trunks of the upper and middle unite to form the outer cord of the plexus.
The lower anterior trunk runs on independently as the inner cord, whilst
the posterior cord is formed, as might be anticipated, by the union of all
three posterior trunks.

In the top of the arm-pit these cords lie above the axillary artery ;
behind the pectoralis minor they lie, as their names express, one to the
outer side, one to the inner side of the vessel, and one behind it ; and
in the third part of the course of the artery they are breaking into their
terminal branches.

250

The B me J rial Plextis

The reason of there being a brachial plexus is probably this :
Certain muscles habitually work together. Thus, for example, the
biceps, brachialis anticus, and supinator longus bend the elbow. The
motor fibres for them arise together in the cervical enlargement, but
anatomically it may not be convenient for the fibres to reach all of
them by the musculo-cutaneous nerve ; some, therefore, are * switched
off' by the musculo-spiral. By adapting this theory to the different
groups of muscles the need appears for a great primary interlacement
at the root of the upper extremity.

The branches given off above the clavicle are twigs to the
scaleni, the levator anguli scapulas, rhomboids, longus colli, and sub-

.FROM 41!!

-CLAVIAN

UPRA-SCAPULAR

BH5 TO LONG
US COLLI
SCALEN

1ST DORSAL

EXT: ANT: THORACIC

UPPER SUB-SCAPULAR

.SUB*- SCAPULAR
CIRCUMFLEX

Plan of brachial plexus. (GKAV.

Musculo-spiral Nerve 2 5 1

clavius, the branch to the last-named muscle descending in front of
the third part of the subclavian artery. The fifth also gives a root to
the phrenic, which thus . comes from the fifth as well as from the third
and fourth cervical nerves.

The nerve of Bell arises from the fifth and sixth nerves in the sub-
stance of the scalenus medius, and enters the apex of the axilla lying
on the side of the chest. Coming out through the scalenus medius, it
lies behind the trunks of the plexus, and posterior also to the first part
of the axillary artery. It supplies the serratus magnus.

The supra-scapular nerve comes from the fifth and sixth after
their junction, and descends beneath the trapezius, and through the
supra-scapular notch, to supply the supra- and infra-spinatus, and the
shoulder-joint.

Below the clavicle the nerves given off are : the external and
internal anterior thoracic from the outer and inner cords, respectively,
to the pectoralis major and minor.

Three subscapular branches come from the posterior cord (which
is composed of fibres which are derived from the fifth, sixth, seventh,
and eighth cervical nerves, and from the first dorsal nerve) ; of these
three, the short subscapular supplies the subscapularis, the middle the
subscapularis and the teres major, and the long the latissimus dorsi.

The circumflex, from the posterior cord (formed as above), winds
with the posterior circumflex artery round the surgical neck of the
humerus, through the quadrilateral space (p. 244), to supply the
shoulder-joint and the deltoid. It gives off also a gangliform twig to
the teres minor, and many branches to the skin over the lower part of
the deltoid and the upper and back part of the arm.

The musculo -spiral, containing twigs of the fifth, sixth, seventh,
eighth, and first, continues the posterior cord from behind the third
part of the axillary artery, and winds in the spiral groove, with the
superior profunda artery, between the inner and outer heads of the
triceps, under cover of the long head. Piercing the external septum,
it lies between the supinator longus and the extensor carpi radialis
longior, on the outer side, and the brachialis anticus on the inner. In
front of the external condyle it divides into the radial and posterior
interosseous.

It gives off an inner cutaneous branch which descends to the
interval between the inner condyle and olecranon, and two outer
cutaneous branches which are distributed along the front and back of
the fore-arm, almost to the ball of the thumb.

It also sends branches to the triceps and anconeus, the supinator
longus and the extensor carpi radialis longior, and sometimes to the
brachialis anticus.

The radial nerve descends from the musculo-spiral along the
inner side of the supinator longus, and at about a third of the way
down the fore-arm joins company with the radial artery ; near the

252

The Brachial Plexus

outer side of this vessel it lies in the middle third of the fore-arm only,
for it then turns backwards beneath the tendon of the supinator longus
to become cutaneous a little above the wrist. It supplies the skin of the
thumb, the index and middle fingers, and the inner side of the ring-
finger as far as the first inter-phalangeal joint, the skin over the backs of
the second and third phalanges being supplied by the digital branches
of the median — except in the case of the back of the thumb, which
the radial supplies entirely.

The posterior interosseous nerve, the other division of the mus-
culo-spiral, gives a branch to the extensor carpi radialis brevior, and
then winds round the radius in the substance of the supinator brevis,
which it supplies ; it then descends between the superficial and deep
muscles at the back of the fore-arm, and ends in a gangliform enlarge-
ment on the back of the carpus. In its course it supplies also the
extensors communis digitorum, minimi digiti, and carpi ulnaris in the
superficial layer, and the extensors ossis metacarpi, primi et secundi
internodii pollicis, and indicis in the deep layer.

iviuscuio spiral paralysis may be caused by laceration of, or

injury to, the trunk as it winds
round the humerus ; or by
severe pressure, as by a chair-
back, by sleeping with the
head pressing the arm against
a hard pillow, or by a badly
padded crutch (cnutch-para-
lysis) ; often it is a symptom of
lead-poisoning, when it is pro-
bably due to interference with
the anterior cornu of the grey
crescent of the spinal cord.
There may be complete loss of

igers have been Hexed into palm, a, UT* A *o, f

they can be extended at first inter-phalangeal ability to extend the fore-arm,
joints by lumbricals and interossej, b, which
are supplied by ulnar and median nerves.

icture of

Paralysis of musculo-spiral nerve after fract

humerus; 'drop-wrist.' (EUCHSBN.) But
when fingers have been flexed into palm, a,

or, except for the action of the
biceps, to supinate it ; the ex-
tensors of the hand (drop-wrisf) and fingers are also powerless, and the
hand usually remains prone, with fingers flexed. Indeed, it is only by
the lumbricals and interossei acting on the second and third phalanges
that extension of the fingers can be in any way obtained, and even
then the first phalanx must be held and fixed, or else those little
muscles flex it to the palm. When the arm is raised above the head
the triceps has no power to extend the fore-arm. There is loss of
sensation in the region supplied by the radial nerve (vide supra}.

An interesting feature in the paralysis is that the grasp of the
fingers is enfeebled ; this is because the hand has fallen into the posi-
tion of flexion, and there is too much * slack ' in the flexor tendons.
(The best way to force a person to loose anything from the firmly

Ulnar Nerve 253

clenched hand is to forcibly flex the wrist ; by this trick the flexors are
slackened, and, the extensors of the fingers being tightened, the grasp
yields.)

The inner cord, which is composed of strands from the eighth cer-
vical and first dorsal, supplies, in addition to an anterior thoracic nerve
(vide supra), the ulnar, the inner head of the median, the internal
cutaneous, and the lesser internal cutaneous.

The internal cutaneous (eighth and first) pierces the deep fascia
at the middle of the arm, and gives off anterior branches which
descend in front of the median-basilic vein to supply the front of the
forearm nearly to the wrist, and posterior branches which wind behind
the internal condyle for the back of the fore-arm. The nerve also
sends twigs through to supply the skin on the inner side of the arm.

The lesser internal cutaneous (eighth and first) is joined by the
intercosto-humeral, and, piercing the deep fascia halfway down the
arm, is distributed to the skin over the inner head of the triceps.

The ulnar nerve (eighth and first) descends from the inner cord
along the third part of the axillary and the beginning of the brachial
artery ; but it gradually bears away towards the inner condylar ridge,
resting on the brachialis anticus and the inner head of the triceps,
in company with the inferior profunda artery. Having pierced the
inner septum, it descends to the hollow between the internal condyle
and the olecranon, entering the fore-arm there through the origin of the
flexor carpi ulnaris, and giving branches to the elbow-joint.

It then lies upon the flexor profundus digitorum, under cover of the
flexor carpi ulnaris, both of which it supplies, though the outer part of
the latter muscle also receives branches from the anterior interosseous
of the median.

Coming from behind the inner condyle, the nerve runs for some
distance before it joins company with the ulnar artery ; it does not
afterwards change its position, but runs close along the inner side of
that vessel close external to the pisiform bone, under the shelter of
which it passes over the annular ligament and into the palm. Like
the median nerve, it gives off & palmar cutaneous branch. Its dorsal
ctitaneous branch passes, after the manner of the radial nerve, beneath
a tendon (the flexor carpi ulnaris), and pierces the deep fascia to supply
the dorsal surface of the little and of half the ring-finger. The ulnar
nerve gives some twigs to the wrist-joint, and supplies the palmaris
brevis and the palmar aspect of the little and of half the ring-finger.

The deep palmar branch dips between the abductor and flexor
brevis minimi digiti, which, together with the opponens minimi
digiti, it supplies. Passing with the deep palmar arch, it then gives
branches to the two inner lumbricals and to all the interossei ; it ends
in the adductor and the deep half of the flexor brevis pollicis.

\T\ paralysis of the ulnar nerve adduction and flexion of the hand
are imperfectly performed ; there is wasting of the muscles forming

254 The Brachial Plexus

the ball of the little finger and of the muscular web between the meta-
carpal bones of the thumb and index-finger (abductor indicis, adductor
pollicis, and deep part of flexor brevis pollicis). All the metacarpal
bones become extremely prominent on the back of the hand, on account
of atrophy of the interosseous muscles. The patient is unable to
wrinkle the skin on the inner side of the palm (palmaris brevis) to
form the 'cup of Diogenes' ; he cannot span (abductor minimi digiti);
and he is able to bring the thumb towards the middle line of the hand
only by the action of the flexor longus pollicis, the muscles of the first
interosseous space being useless.

The two inner fingers are ' clawed] or, as it is also called, en griffe
— the two inner lumbricals and the interossei cannot flex the first pha-
langes nor extend the second and third (273) ; so the common extensor
keeps the first phalanges extended whilst the second phalanges are
kept slightly bent by the flexor sublimis. When this deformity is
extreme the metacarpo-phalangeal knuckles become hollowed, for the
extensor tendon is drawing back the first phalanx, and the interossei
and lumbricals are powerless to hinder it.

The median is formed by two trunks, one from the inner, the other
from the outer cord — fifth, sixth, seventh, eighth, and first— the two trunks
join over the front of the third part of the axillary arteiy. The nerve then
lies to the outer side of the axillary and the beginning of the brachial
artery, and, crossing the latter in the middle of its course, is found, near
the elbow, on its inner side, resting upon the brachialis anticus.

It enters the fore-arm between the two heads of the pronator radii
teres, and, crossing the ulnar artery, descends between the'superficial
and deep flexors of the fingers. Above the wrist, where the muscles
are ending in tendons, the nerve is exactly in the middle line —between
the flexor carpi radialis and the outermost tendon of the flexor sub-
limis, under cover, but slightly to the inner side of the palmaris longus.
It then passes beneath the annular ligament, and widens out prepara-
tory to dividing into digital branches.

In its course it supplies the pronator radii teres, flexor carpi radialis,
palmaris longus, and flexor sublimis digitorum. It gives off the an-
terior interosseous branch, which courses deeply, upon the membrane
supplying the flexor longus pollicis, the outer part of the flexor profun-

dus, and the pronator quadratus.
A palmar cutaneous branch also
comes from the median ; it pierces
the deep fascia, and descends over
the annular ligament,
i, Palmar branch ; 2, its filaments to pulp ; jn the palm the median nerve

3, its ungual twigs ; 4 and 5, distribution . a , ,

on dorsal aspect/ 1S flattened ; it rests on the tendons

of the superficial flexor, under the

protection of the palmar fascia, and gives branches for the three and
a-half outer digits, which, with the exception of those for the thumb,

Median Xeri'C 255

send twigs over the back of the second and third phalanges and to the
pulp of the nail.

The digital nerves lie beneath the superficial palmar arch, but in
the fingers they are superficial to the digital arteries. The median also
supplies the abductor, opponens, and the outer head of the flexor brevis
pollicis, and the two outer lumbricals.

Thus, the ring drawn over the 'ring-finger' couples together digital
branches of the median and ulnar upon the palmar aspect, and of the
radial and ulnar on the dorsal.

In paralysis of the median nerve the front of the fore-arm is wasted,
the supinator longus and flexor carpi ulnaris alone being unaffected.
The pronators are useless, as are also the special flexors of the fingers,
except the inner part of the profundus, which is supplied by the
ulnar. The second phalanges (flexor sublimis) cannot be flexed, nor
the ungual phalanges of the index- and middle fingers (outer part of
profundusj. The abductor pollicis being paralysed, the adductor (ulnar)
keeps the thumb well up against the index-finger, and wasting of the
muscles of the ball of the thumb becomes marked.

Flexion of the wrist has to be accomplished entirely by the ulnar
flexor, and by the inner part of the deep flexor of the fingers, the hand,
in consequence, being deflected to the ulnar side.

I have lately had a child under treatment whose median nerve was,
as seen during a subsequent operation, completely severed, yet there
was no loss of sensation of the skin of the hand or fingers. This pro-
bably was due to the presence of free communications between the
median and the ulnar and radial nerves, an arrangement wrhich may
prove as valuable in an emergency as the anastomotic loops between
veins or arteries. However, in paralysis of the median nerve in an
adult, loss of sensation must be expected in the outer part of the palm
(except over the ball of the thumb, where the radial is distributed),
in the front of the three and a-half outer digits, and also over the
backs of the last phalanges of those digits. The impaired nutrition
(trophic fibres, p. 215) in these areas is apt to be associated with
vesicles and sores, and with imperfect growth of the nails.

The musculo-cutaneous comes from the outer cord (fifth, sixth,
and seventh), and, leaving the third part of the axillary artery on its
inner side, passes obliquely through the coraco-brachialis to the space
between the biceps and brachialis, in which it descends almost to the
elbow. Piercing the deep fascia, it lies beneath the median cephalic
vein, and divides into an anterior and a posterior branch, which supply
the skin down to the ball of the thumb and over the back of the wrist.
The musculo-cutaneous nerve supplies the coraco-brachialis, biceps,
and brachialis anticus, the branch to the last-named muscle sending a
twig to the elbow-joint.

256 The Shoulder Joint

THE SHOULDER JOINT

The shoulder-joint is formed by the glenoid cavity and the humerus,
the articular surfaces being enclosed in a loose capsular ligament
which is attached just beyond the border of the glenoid cavity, and to
the anatomical neck of the humerus. Its strongest part is superiorly,
where it receives accessory fibres from the coraco-Jnnncral ligament.

In contact with the capsule axe the supra-spinatus above, the triceps
below, the subscapularis in front, and the infra-spinatus and teres
minor behind. Most of these muscles are blended with the capsule,
and thus play the part of ligaments. The axillary vessels and nerves
are to the inner side, separated from the capsule, however, by the sub-
scapularis.

Above the joint are the acromion process and the coraco-acromial
ligament ; to the inner side are the coracoid process and its muscles,
and covering all is the deltoid. A bursa underlies the deltoid, which
in rheumatic subjects is often in communication with the interior
of the joint through an opening in the upper part of the capsule.
Other openings in the capsule are those by which the bursa beneath the
subscapularis and that beneath the infra-spinatus communicate with
the synovial membrane of the joint. There is also a gap between the
tuberosities by which the tendon of the biceps and its synovial invest-
ment escape into the bicipital groove. When the subdeltoid bursa is
in communication with the synovial membrane of the joint, the open-
ing in the top of the capsule is occasionally so large that the head of
the humerus comes into extensive contact with the under aspect of
the acromion. In such cases a facet is produced, so that the appear-
ance presented after death is of an upward partial dislocation of the
humerus having existed. (See * Trans. Soc. Med. Chirurg.,' 1875.)

The glenoid ligament is the fibre-cartilaginous rim which gives a
pliable border to the glenoid cavity ; just inside the capsule it is lined
by synovial membrane. The origin of the long head of the biceps
blends with it above.

The synovial membrane lines the capsule and the glenoid ligament,
but, though reflected on to the joint-surfaces of the bones, it cannot
after birth be traced over their articular cartilages. It often com-
municates with the subdeltoid bursa, and usually so with bursie
beneath the subscapularis and the teres minor. It sends a tubular
process between the tuberosities to line the bicipital groove and to
lubricate the tendon.

Supply. — The arteries supplying the joint come from the supra-
scapular, the anterior and posterior circumflex, and the dorsalis
scapulae ; the nerves are derived from the supra-scapular and the
circumflex.

Movements. — The humerus is raised by the supra-spinatus and

Dislocations of Hnmcrns 257

deltoid, and depressed by the subscapularis, infra-spinatus, and teres
minor, and by the pectoralis major, teres major, and latissimus dorsi.
It is drawn forwards by the pectoralis major, coraco-brachialis and
biceps, and by the anterior part of the deltoid; backwards by the
posterior part of the deltoid, the teres major, latissimus dorsi, and
triceps.

The external rotators are the infra-spinatus and teres minor, and
the internal rotators are the pectoralis major, teres major, latissimus
dorsi, and subscapularis.

Elevation of the arm above the head is accomplished by the action
chiefly of the trapezius and serratus magnus, and other muscles which
rotate or fix the scapula ; without rotation of the scapula the arm cannot
be raised above the head.

In synovitis of the shoulder-joint there is impairment of move-
ment, and when the patient is stripped and the arms are raised the
scapula of the affected side moves with the humerus, its inferior angle
travelling forwards as the arm is abducted. If effusion occur there is
a deep-seated and elastic fulness beneath the deltoid.

If abscess form in the joint, the pus may escape by the offshoot
of the synovial membrane which descends along the bicipital groove,
and so the abscess becomes diffused in the subdeltoid tissue, whence
it will work its way to the surface beneath the anterior or posterior
border of the muscle, for it is not likely that the pus would approach
the skin through the substance of the deltoid. Sometimes the articular
suppuration escapes by the gaps which exist beneath the insertions of
the subscapularis and infra-spinatus. The sinuses leading to the dis-
eased joint may open through the infra-clavicular fossa at any spot
along the anterior border of the deltoid, or even into the axilla, or
along the posterior border of the muscle.

Dislocations of the humerus. — The great freedom of movement
which the humerus enjoys renders it specially liable to dislocation,
and when once the bone has slipped out of the shoulder-joint the
luxation is apt to recur.

The commonest cause of dislocation is a fall upon the elbow or
hand. When a man is falling he instinctively puts out his arm to
' break the fall.' This is done by the energetic contraction of the
supra-spinatus and deltoid, the axillary muscles at the same instant
contracting, so as to fix the arm. Then, partly by the shock trans-
mitted to the socket, and partly by the downward muscular pull,
the head of the bone tears through the lower part of the capsule.
Sometimes the head of the humerus rests in the axilla as a sub-
glenoid dislocation. But more often it is dragged by the muscles, or
thrust by the shock, into the sub-coracoid or even into the sub-
clavicular region.

If the elbow or hand happen to be advanced as well as raised
when the humerus tears through the capsule, the head of the bone

258 The Shoulder Joint

may easily slip from the axilla, and be dragged and thrust beneath
the origin of the infra-spinatus, to form a sub-spinous dislocation.
But, as in the other instances, the capsule is rent in the lowest
part.

As the roundness of the shoulder is due to the presence of the
head of the humerus, flatness of the shoulder is one of the characteristic
signs of dislocation ', the end of the acromion stands out conspicuously,
and the fingers may be thrust in beneath it towards the empty
socket.

The humerus is hung, as it were, by the insertion of the over-
stretched deltoid, and when its head is carried inwards, as in the sub-
coracoid dislocation, the lower end is necessarily thrust outwards.
So the man usually has his elbow abducted, and, the arm being thus
fixed, the hand cannot be laid upon the opposite shoulder whilst tJic
elbow is touching the chest. Lastly, the head of the bone may be
detected in the infra-clavicular hollow, in the axilla, or bulging in the
infra-spinous fossa.

Reduction of the dislocation is effected by first bending the elbow,
to take tension off the longhead of the biceps ; the arm is then drawn
from the side to relax the supra-spinatus, which is tightly stretched,
and to ' unhitch ' the margin of the humeral head from the border
of the glenoid cavity. The arm is then forcibly adducted over a firm
pad in the axilla, and thus, when the lower end of the humerus is
forcibly brought forwards and inwards, the upper end is tilted back-
wards and outwards against and into the socket.

This can also be effected by putting the shoeless heel or the knee
into the axilla, the patient in the latter case being in the sitting
posture, and by then using the lower end of the humerus as a lever —
the elbow being kept bent.

Sir Astley Cooper showed that the chief impediment to the
reduction is the supra-spinatus locking the head beneath the glenoid
cavity — hence the need of abduction in replacing the bone.

As the axillary vessels and the brachial plexus lie close on the inner
side of the head of the humerus, they are apt to be pressed upon in
subcoracoid or subglenoid dislocation ; thus the limb becomes cedema-
tous (from obstruction of the vein) and pulseless, or painful and numb
(from pressure against the artery or nerves).

In the case of an old-standing dislocation violent attempts to re-
duce the luxation by the heel in the axilla are apt to rupture the artery,
which by that time may have become adherent in its new bed, and
indirectly affixed to the head of humerus. It has happened also that
in such efforts to replace the bone fracture has occurred at the surgu-al
neck, or even that the heel has been thrust through the skin and
fasciae into the space. In the case of an old dislocation, therefore, it
is better to excise the head of the bone than subject the patient to such
serious risks.

Amputation at Shoulder 259

Excision of the shoulder- joint, or, rather, resection of the upper
end of the humerus, is performed by thrusting the point of a short,
strong scalpel through the deltoid in the space between the coracoid
and acromion, the ligament between these processes being also
traversed by it. The incision is continued three or four inches down
the limb.

The arm is then rotated outwards, so that the subscapularis may
be detached from the lesser tuberosity ; the capsule is opened up
in the bicipital groove, and the tendon of the biceps is raised from its
bed and hitched inwards over the lesser tuberosity, and well to the
inner side of the head. After this the arm is rotated inwards, and
the insertions of the supra-spinatus, infra-spinatus, and teres minor
are detached from the greater tuberosity. Some of the capsule has
then to be divided before the end of the bone can be thrust through
the wound and sawn off.

Amputation at the shoulder-joint is best performed by prolong-
ing the incision, which was made in the last operation, a little further
down the shaft of the bone. And, in those cases in which the surgeon
does not know whether the disease will demand resection or amputation,
he can begin by adopting the former method (short of sawing across the
humerus), and then, if necessary, go on to amputate, clearing the humerus
of the insertion of the muscles into the bicipital groove. The humerus
having been brought out through the wound, an assistant thrusts his
thumbs into the hollow whilst with his fingers on the outer side he com-
presses the blood-vessels ; the soft parts are then cut. Compression of
the subclavian artery in amputation at the joint is by no means satisfac-
tory, though it is often advised ; it is far better to grasp the vessel in
the shell of the soft parts as just described. (Compare this operation
with Furneaux Jordan's amputation at the hip-joint, p. 469.)

The tissues divided in the r:-:;\lcal cut are the skin, superficial and
deep fasciae ; the deltoid, and part of the coraco-acromial ligament,
and the capsule of the joint. Then, insertions of the subscapularis,
supra-spinatus, infra-spinatus, and teres minor ; the anterior circumflex ;
the pectoralis major ; latissimus dorsi and teres major. The trans-
verse incision sweeps through the skin, superficial fascia, cephalic vein,
filaments of the internal and lesser internal cutaneous, intercosto-
humeral, musculo-cutaneous, and circumflex nerves ; the deep fascia';
the coraco-brachialis and short head of biceps, the long head of biceps ;
the ending of the axillary vessels or the beginning of the brachial artery,
venae comites, and basilic vein ; the ulnar, internal cutaneous, median,
musculo-cutaneous and musculo-spiral nerves ; also some part of the
insertions of the pectoralis major, latissimus dorsi, and teres major, and
the lower end of the deltoid. Branches of the posterior circumflex
artery and of the circumflex nerve are cut in disarticulating, but the
main trunks of the circumflex nerve and the posterior circumflex artery
escape section.

s 2

260

77/i' II n merits

THE HUMERUS

The humerus has seven centres of ossification, that for the shaft
appearing very early in foetal life ; the head begins to ossify in the
second year, and the tuberosities in the third. The
lower end has four centres : for the radial head in the
second year, the internal condyle in the fifth year, the
trochlear surface in the twelfth, and the external con-
dyle in the fourteenth year.

The nutrient artery, from the brachial, running
towards the elbow, shows that the lower epiphysis joins
the shaft (at puberty) before the upper (at manhood).
But the prominent internal condyle, which begins to
ossify early, does not become united until the eighteenth
year.

Fractures. — The upper epiphysis may become
'unglued' at any time up to manhood, and that from
comparatively slight violence at times. There is usually
not much displacement, and if a small pad be placed
in the axilla, to prevent the pectoralis major, latissimus
dorsi, and teres major drawing the shaft inwards, and
the arm be fixed to the side, union quickly occurs.
The disturbance of the junction-cartilage, however,
may interfere with subsequent growth of the bone.

The surgical neck is slender and
is often the seat of fracture ; then if the
supra-spinatus be everting the upper
fragment, and the muscles of the axil-
lary fold be drawing the shaft inwards,
and, with the help of the deltoid, biceps,
coraco-brachialis, and triceps, upwards
as well, there maybe considerable over-
lapping of the fragments.

This is the classic form of the dis-
placement, though I venture to doubt
if, as is usually described, it is owing
to the action of the supra-spinatus that
the upper fragment is tilted outwards.
Indeed, unless the subscapularis, infra-
spinatus, and teres minor were in a
conspiracy of silence, how could the
Fracture of surgical neck. (GRAY.) supra-spinatus abduct the fragment ?

The displacement, if any there be

after the fracture, is as follows : the shaft of the bone is drawn upwards
and inwards, as already explained, and its upper end thus lies to the

Fracture of Surgical Neck 261

inner side of the scapular end of the bone, which, perchance, is hitched
outwards by the upper end of the shaft. The pectoralis major and
deltoid may have something to do with the displacement. This frac-
ture resembles somewhat a dislocation, but the presence of the head
in the arm-pit at once negatives it.

For treatment, a pad must be placed in the axilla, to thrust out the
lower fragment, and, as in the former case, the arm must be bandaged
against the side, and the shoulder protected by a stiff leather or gutta-
percha cap. An inside splint is of no possible value for steadying the
fragments, for the seat of fracture is high up in the axilla and out of
reach. When the upper end of the shaft-fragment is drawn inwards
the displacement may be recognised by thrusting the fingers up into
the arm-pit, and a biggish pad may be needed to keep the bone in
position. As this shaft-fragment is apt to be drawn upwards on the
inner side of the head-fragment, the elbow will require no support, for
that might be to still further elevate the shaft-fragment. Indeed,
when the overlapping is marked, it may be necessary to hang a shot-
bag upon the elbow, the wrist only being supported in the sling, so as
to bring down the end of the shaft-fragment.

In fracture of the upper end of the humerus the presence of the
head of the bone beneath the acromion process centra-indicates dis-
location, which the inward displacement of the shaft might at first sight
suggest ; and the fact of the head not moving when the elbow-end of
the bone is rotated is clear evidence of fracture.

Fractures of the lower end are specially liable to occur up to
puberty, a common form being that in which the epiphysis is carried
backwards from -the shaft together with the upper ends of the radius
and ulna. The appearance is much like that of dislocation of the
radius and ulna backwards, but in the latter injury the bones are
rigidly fixed, whilst in separation of the epiphysis pronation and supina-
tion are still possible, and flexion and extension also, if, by a little
gentle force, the epiphysis be brought into position. Such slight force
could not bring the dislocated bones into position. As soon as the
force is removed the elbow-end of the broken humerus slips back
again. If the sound fore-arm be extended the top of the olecranon
process is on a level with the condyles of the humerus ; the relative
position of these three pieces of bone is not disturbed in the case of the
fracture, but it is in dislocation, for the upper ends of the radius and
ulna are carried backwards and upwards behind the lower end of the
humerus.

A condyle may be detached without the joint being implicated,
but usually such a fracture extends obliquely into the articulation. The
internal cojidyle may be detached by violent action of the group of
pronators, or by a fall upon the elbow. The accident is most likely to
happen before the eighteenth year, when ossification on to the shaft
takes place ; this fracture does not extend into the joint. It should be

262 The Humerus

treated by flexing and pronating the fore-arm, so as to take all strain
from the loosened piece of bone.

The external condyle is not so likely to be detached as the internal,
as it joins the shaft earlier, and is not so prominent nor so much exposed
to injury. This fracture is likely to pass into the joint ; and in such a
case the elbow had better be put at a right angle and secured in a
moulded splint, in case of ankylosis occurring.

Non-union after fracture of the shaft of the humerus is specially
liable to occur unless the muscles which may move the fragments be
preserved in absolute rest. For this purpose the fractured shaft should
be fixed by an angular splint extending from shoulder to hand (so as
to keep the fore-arm quiet), whilst short splints should be secured
around the seat of fracture.

THE BRACHIAL ARTERY

The brachial artery is the continuation of the axillary, and, be-
ginning at the lower border of the tendon of the teres major, extends
along the inner and anterior aspects of the humerus to end opposite
the neck of the radius by dividing into radial and ulnar.

Its course may be marked out by a line drawn from beneath the
anterior axillary fold along the furrow on the inner side of the biceps
to the middle of the bend of the elbow.

Compression. — In its upper part the artery may be compressed
by dragging it outwards, against the bone, near the insertion of the
coraco-brachialis ; in the lower part it must be thrust backwards
towards the humerus, where the brachialis anticus is covering the bone.

Compression just above the elbow may be effected by forcibly
flexing the fore-arm. The mass of the muscles of the upper part of
the fore-arm then squeezes the vessel against the firm bed of the
brachialis anticus. (See how your own radial pulse is stopped in
energetic flexion of the elbow.) This is a useful method of treatment
in aneurysm in that neighbourhood, as well as a temporary measure
in the case of severe haemorrhage from a wound in the palm.

Relations. — Over the artery are skin, superficial fascia, the basilic
vein (which runs parallel with the artery), and, at the elbow, the
median basilic vein ; the deep fascia, and, between the artery and
the median basilic vein, the bicipital fascia ; the inner border of the
biceps, which overhangs the artery, and the median nerve which
crosses the middle of its course.

Behind are the insertion of the coraco-brachialis, the long and
inner heads of triceps, and the brachialis anticus ; and high up is the
musculo-spiral nerve turning inwards and backwards away from the
vessel. To the outer side are the shaft of the humerus, the coraco-
brachialis and biceps, and the median nerve in the upper part. To the
inner side are the internal cutaneous and ulnar nerves, and the median

Brandies of BracJiial Artery 263

in the lower part ; also to the inner side, but separated by the deep
fascia and the bicipital fascia, are the basilic and the median-basilic
veins. The artery has on either side a vena comes.

Brandies. — The superior profunda springs from the very begin-
ning of the brachial, and descends into the interval between the inner
and outer heads of the triceps, under cover of the long head, and thus
winds with the musculo-spiral nerve (p. 25]) to the outer condylar
ridge. It there passes through the external intermuscular septum and
lies between the supinator longus and the brachialis anticus, where it
anastosmoses with the radial recurrent. It Sends a branch to the
back of the external condyle, which anastomoses with the interosseous
recurrent, and another to the back of the internal condyle, which
anastomoses with the posterior ulnar recurrent, and the posterior
branches of the inferior profunda and anastomotica magna.

The nutrient artery to the medulla enters the bone near the
insertion of the coraco-brachialis, and courses towards the elbow. In
amputation just below the middle of the arm this vessel in the
medullary canal may require a touch with the thermo-cauteiy.

The inferior profunda comes off below the middle of the arm,
and runs with the ulnar nerve to the inner intermuscular septum, in
front of which a branch may descend from it to communicate with the
anastomotica magna and the anterior ulnar recurrent. The rest of the
profunda passes through the septum, lying on the inner head of triceps,
and anastomoses behind the condyle with the anastomotica magna,
superior profunda, and posterior ulnar recurrent.

Muscular branches are given off to the coraco-brachialis, biceps,
and brachialis anticus.

The anastomotica magna runs inwards on the brachialis anticus,
about an inch above the condyle, anastomosing with the inferior
profunda and the anterior ulnar recurrent ; some of it passes through
the septum and anastomoses with the inferior and superior profunda
and the posterior ulnar recurrent. Thus it anastomoses with every
neighbouring branch except the radial recurrent, which it is obviously
unable to reach without trespassing through the external intermuscular
septum.

Irregularities. — The division into radial and ulnar may take place
anywhere between the arm-pit and elbow, the two trunks descending
side by side. If after ligature of an unusually small brachial artery
pulsation continue in the radial or ulnar artery, search must be made
a little to the inner or outer side for a ' second bradiial?

At the bend of elbow there is a triangular fossa which is bounded
on the outer side by the supinator longus, and on the inner by the
pronator radii teres. The latter muscle slopes outwards, and the apex
of the space is at the approximation of these muscles, and to the outer
side of the fore-arm. The base is an imaginary transverse line drawn
through the condyles of the humerus. Covering the fossa are skin and

264 The Brachial Artery

superficial fascia, and the deep fascia with its reinforcement from the
inner side of the biceps-tendon — the bicipital fascia. The floor of the
space is formed by the brachialis anticus and by a little of the supi-
nator brevis. In the superficial fascia are the M-like arrangement of the
veins (p. 237) and many branches of the internal and musculo-cutaneous
nerves.

Contents. — The most prominent object in the space is the tendon
of the biceps ; and, as the brachial artery has lain on the inner side
of biceps all the way down the arm, it lies close to the inner side of
its tendon in this fossa. On either side of the artery is a small com-
panion vein, and well to the inner side is the median nerve.

In the fossa, at the level of the neck of the radius, the artery divides
into the radial and ulnar, which, consequently, begin their course
somewhat superficially. The radial artery leaves the space over the
insertion of the pronator teres, but the ulnar artery quickly descends
beneath the origin of that muscle and beneath the median nerve in its
oblique course to the inner border of the fore-arm. The radial recur-
rent artery is seen ascending to the crevice between the brachialis
anticus and the supinator longus. Under cover of the supinator
longus, and, therefore, scarcely within the space, is the radial nerve.
In a thin subject the posterior interosseous nerve may also be found
coining from the division of the musculo-spiral, but to see so much
the supinator longus will have to be pulled considerably outwards.

Xiig-ation of the brachial is the proper treatment for recurrent
haemorrhage after a deep wound of the palm, for it is impracticable to
search through the layers of nerves, tendons, and lumbricals to find the
bleeding point. It is also resorted to for aneurysms high in the fore-
arm.

Operation. — The patient is lying on his back with the arm abducted,
rotated outwards, and resting on a firm pillow. An incision is then
made for 2\ in. along the groove upon the inner side of the biceps.
In dividing the superficial fascia, the basilic vein, if seen, must be drawn
to one side. The deep fascia having been divided on a director, the
inner border of the biceps is looked for and drawn outwards. The
median nerve is probably lying over the arterial sheath, but if the
operation be performed high in the course of the brachial the IHTVI-
will be to the outer side ; if in the lower part, to the inner side. Heed
must be given not to tie the nerve instead of artery, nor to include it
with the artery in the ligature. A loose sheath is opened, and the
needle passed round the arteiy (the venae comites being avoided) from
the side of the median nerve, whichever that may be.

If ligation be required at the be ml of the cllnw, the vessel is found
by making a 2-inch incision along the inner side of the biceps tendon.

The lower limit of the incision reaches to the level of the internal
condyle, and will probably l>c just above and to the outer side of the
median-basilic vein. The bicipital fascia is divided on a director, and

Ligaments of Elbow 265

the artery is found between its venas comites, on the inner side of the
biceps tendon and close to the outer side of the median nerve. The
needle is passed from the inner, the nerve-side. Far to the inner side
is the pronator radii teres.

Collateral circulation. — If the artery be tied above the origin of
the superior profunda — that is, close below the ending of the axillary
artery — the superior profunda brings in blood from the well-filled
branches of the posterior circumflex, and thirsty muscular branches
help by their anastomoses with unnamed muscular branches which
are then given off in abundance directly or indirectly from the
axillary.

If the ligature be applied below7 the origin of the superior profunda
and above that of the inferior, the latter vessel will bring blood into
the empty trunk by its anastomosis with the former in the neighbour-
hood of the internal condyle. Empty muscular branches will bring
blood from unnamed and countless full ones ; and the anastomotica
magna, the posterior ulnar recurrent, and the radial and the inter-
osseous recurrents will also return blood from the superior profunda.

If the ligature be below both profunda^, the collateral circulation
will be maintained by muscular branches, as before, and by the empty
anastomotica magna, the anterior and posterior ulnar recurrents, and
the radial and interosseous recurrent returning blood from the well-
filled branches of the profunda: near the elbow-joint.

THE ELBOW JOINT

The elbow-joint is formed by the humerus, ulna, and radius, and the
only movements there permitted are flexion and extension. It is a
pure hinge-joint. The movements of pronation and supination take
place at the superior radio-ulnar joint, and, though the head of the
radius may then be touching the capitellum of the humerus, still these
movements must not be considered as movements of the elbow-joint.

As over-flexion is checked by the soft part of the fore-arm and arm
coming into mutual contact, and as over-extension is stopped by the
olecranon process impinging against its fossa in the humerus, the
(inferior mid the posterior ligaments are thin and mechanically un-
important. The former is attached to the humerus above the level of
the coronoid fossa, and below to the coronoid process and the orbicular
ligament. The posterior descends from above the olecranon fossa
to the border of the olecranon process.

The internal lateral ligament is a strong triangular bundle, the
apex of which is attached to the internal condyle of the humerus,
whilst the base spreads into the borders of the coronoid and olecranon
processes.

The external lateral ligament springs from just beneath the external
condyle, and is blended below with the orbicular ligament.

266 The Elboiv Joint

Neither is the external lateral ligament nor any other part of the
capsule of the joint, nor of the deep fascia, connected with the upper
end of the radius, for there must be no check to its rotation.

The capsule of the elbow-joint consists of the anterior, posterior,
and lateral ligaments in conjunction with all those intermediate fibres
which connect them with each other.

The synovial membrane lines the capsule and is reflected over
the articular surfaces of humerus, ulna, and radius ; it also lines the
lesser sigmoid cavity of the ulna, and the orbicular ligament, and is
wrapped around the neck of radius.

Relations of the elbow-joint. — In front is the brachialis anticus,
and more anteriorly are the tendon of the biceps, the brachial artery,
and the median nerve. Behind are the triceps and anconeus. In-
fernally are the origin of the pronators and flexors, the ulnar nerve,
and the inferior profunda artery. Externally are the supinator brevis
and the origin of the extensors, and towards the front are the superior
profunda artery and the musculo-spiral nerve dividing into the radial
and posterior interosseous.

The superior radio -ulnar joint is formed by the head of the radius
and the lesser sigmoid cavity of the ulna, the only movements allowed
at that joint being pronation and supination. The orbicular binds the
head and neck of the radius close against the ulna, and, forming the
medium of attachment for the anterior and the external lateral liga-
ments of the elbow-joint, allows free pronation and supination. The
synovial membrane is a prolongation from that of the elbows-joint.

Supply. — Branches of artery come from the superior and in-
ferior profunda ; the anastomotica magna ; the anterior and posterior
ulnar recurrents ; and from the radial and the interosseous rccurrcnts.
Nerve-twigs come from the ulnar and the musculo-cutaneous.

Dislocations at the elbow-joint. — In dislocation of both bones
backwards the olecranon process stands out like a heel behind the
albow, and the button-head of the radius can be made out through the
skin behind the external condyle. The coronoid process, if not broken
off, sinks into the olecranon fossa ; the brachialis anticus and biceps
are stretched round the lower end of the humerus, and the front of the
fore-arm is strangely short. The bones of the fore-arm being so firmly
fixed in their new position, flexion, extension, and rotation are impos-
sible, and on attempting to flex the joint the appearance becomes still
more characteristic.

To reduce this dislocation, the surgeon thrusts his knee into the
front of the elbow, steadies the humerus with one hand, and pulls on
the radius and ulna by grasping them above the wrist, and as he pulls
he flexes the fore-arm round his knee, so as to unhitch the coronoid
process. Thus the bones slip again into their position ; and there they
securely remain unless the coronoid process happen to be broken off,
in which case the luxation may recur. This recurrence suggests

Disease of Elbow-joint 267

separation of the lower humeral epiphysis, but this is excluded by
the fact that when the lesion has recurred the top of the olecranon
process is far above the horizontal line of the humeral condyles.

Other dislocations may take place, a not very uncommon variety
being that in which the head of radius tears through the front of its
orbicular ligament and the thin anterior ligament of the joint, and,
slipping up above the capitellum, rests against the front of the lower
end of the humerus. The characteristic features of the lesion are the
absence of the head of the radius from the pit below the external con-
dyle, and a mechanical impediment to full flexion of the joint, on
account of the radial head impinging against the front of the humerus.

In children the head of the radius is apt to be dragged out of the
orbicular ligament by a sudden pull upon the hand or fore-arm, the
elbow at once becoming swollen and tender. To replace the bone,
the elbow should be bent to a right angle, so that the head of the
radius may be brought close to the empty collar, and then, by firmly
and fully pronating, the bone is ' screwed' again into its place.

In synovitis there is a general fulness about the joint, with a bulging
on either side of the olecranon and of the insertion of the biceps, and in
the fossa below the external condyle, in which region the joint is com-
paratively superficial. The intra-articular effusion fixes the joint in a
position midway between flexion and extension, the greatest use as
well as the greatest comfort, moreover, being secured in this way ; later
on, the weight of the hand may carry the radius round to extreme
pronation — a most undesirable condition. At the commencement of
treatment, therefore, the elbow should be fixed at a right angle, and
only halfway pronated.

Abscess in the joint. — If suppuration occur the pus will be likely
to escape between one of the condylar ridges and the triceps, where the
capsule is thin and comparatively near the surface of the limb.

Excision of the joint is performed by an incision of three or four
inches through the triceps in the middle line, down to the bone, divid-
ing the skin, superficial and deep fasciae, the triceps, and the peri-
osteum over the olecranon process and down the prominent posterior
border of the ulna. By the aid of a raspatory the periosteum and the
triceps are peeled from the humerus, and the insertion of the muscle is
detached by a scalpel. In doing this the edge must be kept close to
the bone, all those fibres which run to their insertion in the deep
fascia being carefully preserved, so that trie muscle may retain as
much of its power of extension as possible. Chiefly by the raspatory,
and slightly by the knife, the origins of the muscles from the condyles
of the humerus are detached, but no transverse cuts are to be made,
lest, by chance, the ulnar nerve be wounded and useful bundles of
fibrous tissue be sacrificed. The ulnar nerve is raised from its bed
between the condyle and the olecranon and turned inwards, but the
operator ought not to expose it. If he do see it he has evidently

268 The Elbow Joint

been dissecting dangerously near to it. The lower end of the humerus
having been cleared of the attachment of the lateral and the anterior
ligaments, and other indefinite fibres, is thrust out of the wound and
sawn off. The olecranon process is cleared of the insertion of the
anconeus, and of fibres of origin of the flexor carpi ulnaris. The
lower part of the coronoid process is then cleared of the insertion of the
brachialis anticus (and of fibres of origin of the flexor sublimis digi-
torum), but as much as possible of the process and of the insertion of
the brachialis should be left ; the ulna is then sawn across. The head
of the radius is also removed. The arm had better not be fixed on a
splint after the operation, as the surgeon desires to obtain a fibrous
ankylosis, not a bony one as in the case of the knee, and, therefore,
the sooner that he begins to move it, the better.

THE FORE- ARM, WRIST, AND HAM)

Surface marking-s. — From the olecranon process the posterior
border of the ulna may be traced down to the styloid process, and
the head of the bone may be made out between it and the inferior
radio-ulnar joint. In the groove between the styloid process and the
head of the ulna runs the tendon of the extensor carpi ulnaris, and in
the gap corresponding to the radio-ulnar articulation passes the special
extensor tendon of the little finger.

The tendon of the flexor carpi ulnaris may be traced along the
front of the inner side of the fore-arm to the pisiform, and on flexing the
wrist, so as to slacken that tendon, the sesamoid bone may be moved
at its arthrodial joint with the cuneiform. Along the radial side of the
ulnar flexor tendon runs the ulnar artery, but its pulsations cannot be
made out as readily as those of the radial artery, first, because the
vessel is overlapped by the tendon, and, secondly, because the finger
compresses the ulnar artery not against firm bone, as in the case
of the radial, but against the less resisting mass of the flexor profundus
digitorum.

On the radial side of the groove in which the artery descends
are the tendons of the flexor sublimis, and in the middle line of the
wrist, and quite superficially, is the tendon of the palmaris longus.
Close to the outer side of the last tendon is that of the flexor carpi
radialis, immediately on the ulnar side of which is the median nerve —
under cover of the tendon of the palmaris longus. About \ in. ex-
ternally, in the groove on the ulnar side of the radial styloid process,
is the radial artery, which here rests upon the pronator qu.idr.itus, and
lower down on the radius itself. The tendon of the supinator longus
can just be made out descending to the root of the styloid process.

Proceeding outwards and backwards, one encounters the prominent
ridge of the tendons of the extensors ossis and primi, just beneath
which the radial artery and its veins are winding. The fleshy bellies

J)ti/in of Ham/ 269

of these muscles form a prominence on the back of the lower third of
the radius. Then comes the ' anatomist's snuff-box,' in the depths of
which are the tendons of the radial extensors, and on the inner side
of which descends the oblique tendon of the extensor secundi. Still
more internally pass the tendons of the extensor communis. The
radial styloid process descends considerably lower than that of the
ulna (p. 283).

At \hzfront of the wrist, between the lower end of the radius and
the root of the thumb, are the prominence of the scaphoid and the
ridge of the trapezium, and on the inner side, behind the movable
pisiform, is the cuneiform. (See fig. on p. 286.)

On the back of the Jiand zcce seen the venous arches from which the
radial and posterior ulnar veins ascend. The spaces between the
metacarpal bones are filled by the dorsal interosseous muscles ; the
chief of these is the abductor indicis, which, together with the adductor
pollicis, makes the thick mass between the first and second metacarpal
bones. When the ulnar nerve is paralysed these muscles waste and
the bones become strangely prominent.

At the front of the first metacarpo-phalangeal joint can be felt the
sesamoid bones in the heads of insertion of the flexor brevis pollicis.

In the ball of the thumb are the abductor, opponens, and the super-
ficial head of the flexor brevis pollicis, and in the ball of the little
finger are the abductor, flexor brevis, and opponens minimi digiti.

For the sake of strength and protection, the palm of the hand is
continued a short distance beyond the bases of the first row of
the phalanges.

The transverse creases of the palm. — If you gently flex the
fingers to the palm you will see a thick ruck of integument stand out
across the level of the metacarpo-phalangeal joints. This ruck is
bounded below by the short transverse furrows at the roots of the
fingers, and above by two well-marked creases which together stretch
right across the palm. The inner of these creases stands across the
heads of the fifth, fourth, and third metacarpal bones, the outer and
superior across the head of the index metacarpal bone. This second
crease would not be needed were all the metacarpal bones of the same
length ; but, the index metacarpal being shorter than the middle, a
fresh crease has to be started in the outer part of the palm.

If the skin and the subjacent soft parts of the palm were but a thin
layer, the transverse crease would correspond exactly to the line of
the metacarpo-phalangeal joint ; as it is, however, its thickness entails
a double crease, in order that the fingers may be bent. This ruck of
skin and fat plays a useful part in the hand of the oar's-man, cricketer,
and labouring man, shielding the heads of the metacarpal bones from
pressure ; the firmer the grasp, the thicker becomes the transverse pad.

When one understands the reason of the appearance of the trans-
verse fold of skin and fat, and appreciates its usefulness, one realises

2/O TJie Fore -anti, Wrist, and Hand

the fact that the creases themselves are not landmarks to the joints,
but that the line of the joints lies halfway between the palmar creases
and the creases at the roots of the ringers, that is along the middle line
of the tranverse fold.

The deep fascia offers a strong investment to the superficial
muscles of the fore-arm, and, dipping between them, supplies inter-
muscular septa from which they take additional origin. It receives
important accessory fibres from the insertions of the biceps and
triceps. It is attached along the posterior — the subcutaneous — border
of the ulna, and above it is continuous with the deep fascia of the arm;
below it passes to the front and back of the hand, being thickened to
form the annular ligaments.

The posterior annular ligament is firmly connected by transverse
fibres with the lower end of the radius, converting certain grooves into
tunnels for the passage of the tendons ; it slopes downwards, inwards,
and forwards to the cuneiform and pisiform bones.

The tendons at the back of the wrist. -Beneath the fascial
band are six canals for the extensor tendons, each being lined by a
separate synovial sheath : the outermost is for the extensors ossis
and primi ; the second is for the extensors radialis longior and brevior ;
the third, narrow and oblique, for the extensor secundi internodii ; the
fourth, wide and shallow, is for the extensors communis digitorum
and indicis ; the fifth, between the radius and ulna, is for the tendon
of the extensor minimi digiti ; and the sixth, at the back of the ulna, is
for that of the extensor carpi ulnaris.

Superficial to the posterior annular ligament are the radial and the
posterior ulnar veins, and the radial and the dorsal ulnar nerves.

The anterior annular ligament is the thickened band attached
to the prominences of the scaphoid and trapezium on the outer side,
and to the pisiform and unciform on the inner. It strengthens the bony
arch of the carpus, binds down the flexor tendons of the fingers, and
affords origin to certain muscles of the thumb and little finger.

Superficial to it pass the tendon of the palmaris longus, the palmar
cutaneous branches of the median and ulnar nerves, the superficialis
volae, and the ulnar artery and nerve.

Beneath it are the tendons of the flexors carpi radialis, sublimis and
profundus digitorum, and of the longus pollicis ; the median nerve and
the comes nervi mediani.

The palmar fascia, continuous above with the anterior annular
ligament and with the insertion of the palmaris longus, spreads more
thinly over the muscles of the ball of the thumb and of the ball of the little
finger. Its median piece is extremely thick, protecting the subjacent
branches of the median and ulnar nerves and the superficial palmar
arch. It sends slips to join the sheaths of the flexor tendons of the
four inner digits, also to the webs of the fingers, and to the transverse
ligament connecting the heads of the metacarpal bones.

Pronator Radii Tcrcs 271

Dupuytren's contraction. — Sometimes, as the result of pressure,
and especially in gouty men, the bands of the palmar fascia descending
to the ring and little
fingers become perma-
nently shortened, so that
those fingers are rigidly
bent into the palm, the
flexor tendons and the
joints being unaffected.
Subcutaneous division of
the contracted bands sets
the fingers free, but relapse
is apt to occur. The ad-
jacent woodcut, from Fergusson, shows that the skin also may be im-
plicated in the contraction.

The supinator longus arises from the upper two-thirds of the ex-
ternal condylar ridge of the humerus, and is inserted into the base of
the styloid process of the radius. Its chief action is to flex the fore-
arm ; as regards supination, all that it can do is to evert the pronated
fore-arm until the thumb points upwards. Its nerve-supply is from
the musculo-spiral.

Relations. — Just above its insertion it is overlaid by the tendons of
the extensors ossis and primi. It overlaps the brachialis anticus ; the
origin of the radial extensors of the wrist ; and the insertions of the
supinator brevis and pronator teres. Along its inner aspect are the
musculo-spiral and radial nerves, the anterior part of the superior pro-
funda, and the radial artery and its recurrent branch. In the upper
half of the fore-arm its fleshy, anterior border has to be everted in order
to expose the radial artery.

The pronator radii teres arises from the region of the internal
condyle of the humerus, and, by a small deep head, from the adjacent
part of the coronoid process of the ulna ; between these heads the
median nerve enters the fore-arm. The insertion is into the middle of
the outer surface of the radius. It is supplied by the median nerve.

Relations. — Superficial to it at its insertion are the supinator longus
and the radial nerve and artery. Its origin overlaps the brachialis
anticus, the anterior ulnar recurrent artery intervening. It rests on the
origin of the flexor sublimis digitorum. Along its ulnar border slopes
the flexor carpi radialis ; its outer border limits the triangle at the bend
of the elbow, and, therefore, is close to the inner side of the brachial
artery and its division into the radial and ulnar. The ulnar artery
passes beneath it, being separated there from the median nerve by the
deep head of the muscle.

The flexor carpi radialis arises from the inner condyle ; it ends
in a long tendon which passes through a separate compartment in
the anterior annular ligament, and through the groove in the trapezium,

2/2 77ft' Forc-nrui, \Vrist, tin//

to be inserted in the base of index metacarpal bone. The median
nerve supplies it.

Relations. — The fleshy part of the muscle is between the pronator
teres and the palmaris longus, and rests upon the flexor sublimis digi-
torum. The tendon is just slightly to the outer side of the middle line
of the fore-arm. Half an inch to its outer side, midway between it and
the tendon of the supinator longus, is the radial artery with its com-
panion veins ; and close along the inner side of the tendon, between
it and the outermost tendon of the flexor sublimis digitorum, and under-
neath that of the palmaris longus, is the median nerve.

The palmaris longus arises from the internal condyle, and its
slender tendon passes over the annular ligament to be inserted into
the palmar fascia. It is often absent. Like the next muscle, it is sup-
plied by the median nerve.

The flexor sublimis digitorum arises from the internal condyle,
coronoid process, and the oblique line of the radius; it is thin and wide
and lies beneath the three preceding muscles. About halfway down
the fore-arm it divides into four tendons, those for the middle and ring
fingers lying, as they pass beneath the annular ligament, superficial to
those for the index and little fingers. At the root of the first phalanges
each tendon is pierced by one from the flexor profundus, and then sends
a slip into either side of the middle phalanx.

Relations. — This flexor is mostly under cover of the foregoing
muscles, but some of its tendons are superficial between those of the
flexor carpi radialis, or palmaris longus, and the flexor carpi ulnaris.
The deep fascia sends down a linear septum between this muscle and
the adjoining flexor carpi ulnaris. It is by working through this sep-
tum that the surgeon seeks the ulnar artery in the upper part of its
course ; the septum is in the line extending from the internal con-
dyle of the humerus to the pisiform bone. Beneath the flexor sublimis
are the flexor profundus, flexor longus pollicis, the median nerve, and
the ulnar nerve and artery.

In the palm the tendons lie beneath the superficial parts of the
ulnar artery and median nerve, and, of course, beneath the deep fascia,
whilst they rest on the tendons of the flexor profundus and the lum-
bricals.

The flexor carpi ulnaris arises from internal condyle, the inner
border of the olecranon, and the posterior, the subcutaneous, border
of the ulna. Passing along the inner side of the fore-arm, it is inserted
into the pisiform and the fifth metacarpal bones, sending also a small
slip outwards, across the ulnar nerve and artery, to the front of the
annular ligament. Its nerve-supply is from the ulnar.

Relations. — Along its outer aspect are the flexors sublimis and pro-
fundus digitorum, and the ulnar nerve and artery ; indeed, the outer
aspect of the muscle is the ready guide to the ulnar artery in the lower
two-thirds of the course of that vessel. Between its humeral and

Lumbricals 273

olecranon heads the ulnar nerve enters the fore-arm, and in that same
interval is the anastomosis between the inferior profunda and posterior
ulnar recurrent, over the internal lateral ligament of the elbow.

The flexor profundus digitorum is a bulky muscle arising from
the upper two-thirds of the inner and anterior surfaces of the ulna, and
from the adjacent part of the interosseous membrane. Its four tendons
pass through those of the flexor sublimis, opposite the first phalanges,
and are inserted into the bases of the ungual phalanges. The nerve-
supply for its outer part is the anterior interosseous of the median,
and, for the inner part, the ulnar.

Relations. — Superficial to it are the flexors sublimis digitorum and
carpi ulnaris, the median and ulnar nerves, and the ulnar artery. The
flexor longus pollicis lies along its outer side, and in the deep and
narrow crevice between these muscles run the anterior interosseous
nerve and artery. On its inner aspect is the flexor carpi ulnaris.

The lumbricals arise from the tendons of the deep flexor in the
palm, and pass into the radial side of the common extensor tendons.
These muscles are much used by the piano-forte player. They extend
the first phalanx, and flex the second and third phalanges. The two
outer are associated with the tendons of that part of the deep flexor
which is supplied by the anterior interosseous nerve of the median,
and consequently derive their nerve-supply from digital branches of
the median, whilst the two inner are supplied by the ulnar nerve, which
has already supplied the inner part of the deep flexor, from which
come the tendons for the ring and'little fingers.

When the lumbricals are paralysed the metacarpal phalanges are
drawn backwards and the middle and terminal phalanges are flexed
into the palm.

i, metacarpal bone ; 2, tendons of flex, sublimis and, 3, profundus, bound down by fibrous
sheath ; 4, extensor communis ; 5, lumbrical muscle ; 6, interosseous muscle.

The flexor longus pollicis arises from the front of the radius
between the flexor sublimis and the pronator quadratus, and from the
adjoining part of the interosseous membrane. Its tendon passes over
the square pronator, under the annular ligament, and between the
heads of the flexor brevis pollicis, to be inserted into the base of the
ungual phalanx of the thumb. Its nerve is the anterior interosseous.

Superficial to it are the flexors carpi radialis and sublimis digitorum,
and the radial artery. Its ulnar border is separated from the flexor
profundus by the anterior interosseous nerve and artery.

274

The Muscles of Fore-arm

The pronator quadratus arises from the front of the lowest fourth
of the ulna and is inserted into the corresponding surface of the radius.
Its nerve is the anterior interosseous.

Relations. — It is covered by the tendons ot the flexors profundus
digitorum, longus pollicis, and carpi radialis, and by the radial artery
and its venae comites. The ulnar artery is widely separated from it
by the mass of the flexor profundus— tendon and muscle.

Of the synovial membranes beneath the anterior annular liga-
ment, one surrounds the tendons of the flexors sublimis and profundus
together with the median nerve as they pass beneath the ligament. As
the tendons lie in the fibrous sheaths on the front
of the first and second phalanges they are also
invested by synovial bursae, but these bursae are
distinct from the membrane beneath the annular
ligament. In the case of the little finger, however,
the synovial membrane from beneath the annular
ligament is directly continuous with that which
lines the digital sheath, as is shown in the adjoin-
ing wood-cut. The synovial sheath does not de-
scend on to the ungual phalanx, for at the base of
that bone the tendon of the deep flexor is inserted.
The outer synovial membrane beneath the annular
ligament accompanies the tendon of the flexor
longus pollicis down into the fibrous sheath along
the metacarpal bone and the first phalanx of the
thumb. The two large synovial bursae beneath the annular ligament
are separated from one another by the median nerve ; they extend into
the fore-arm about an inch above the annular ligament.

A reference to the wood-cut shows that a deep inflammation ot
the thumb or of the little finger is likely to lead to more serious
complications than that of the second, third, or fourth fingers, as, the
digital pouch of synovial membrane being implicated, suppuration may
extend beneath the annular ligament and up into the fore-arm. Some-
times the inner and outer pouches communicate above the wrist by a
tubular process across the median nerve, in which case a deep-seated
suppuration in the thumb may eventually implicate the sheath of the
flexor tendons of the little finger, the sheaths in the intermediate digits
being unaffected.

In the case of acute suppuration in one or other of these burs;i- it is
expedient to lay it freely open, dividing the annular ligament at the
same time. The purulent swelling bulges in the fore-arm and in the
hand, and, being constricted beneath the ligament, is somewhat of
hour-glass shape. When the sheath of one of the three middle digits
only is affected, it is better to incise the thecal abscess over the head
of the metacarpal bone than to slit open the sheath down the first and
second phalanges, with the risk of producing a stiff and comparatively
useless finger.

Usual arrangement
synovial sheaths
palm.

Ligation of Radial Artery 275

THE ARTERIES OF THE FORE-ARM

The radial artery comes from the bifurcation of the brachial
opposite the neck of the radius, and, though smaller than the ulnar, is,
by its direction, the direct continuation of the parent trunk.

Its course in the fore-ami may be markedly a line from the middle
of the bend of the elbow to the middle of the hollow between the
styloid process of the radius and the tendon of the flexor carpi radialis.
From this spot it winds round to the back of the wrist, and so into
the palm of the hand, to form the deep palmar arch.

Relations in the fore-arm. — It is covered by skin, superficial and
deep fasciae, and is overlapped by the anterior border of the supinator
longus. It rests upon the tendon of the biceps, the supinator brevis,
the pronator teres, the radial origin of the flexor sublimis digitorum, the
flexor longus pollicis, the pronator quadratus, and the radius.

To its outer side are the supinator longus, and, in the middle third,
the radial nerve.

Along its inner side is the pronator teres, and, after that, the flexor
carpi radialis. On either side runs a companion vein.

Branches in the fore-arm. — The radial recurrent ascends on the
supinator brevis to the interval between the supinator longus and the
brachialis anticus, where it lies against the musculo-spiral nerve, and
anastomoses with the superior profunda. This is the only artery at
the elbow which does not communicate with the anastomotica magna ;
the explanation being that these two branches are separated by the
large mass of the brachialis anticus.

Muscular branches are given off freely and irregularly.

The superficialis volee is given off close above the wrist, and runs
over the anterior annular ligament, or through or over the root of the
muscles of the ball of the thumb. Sometimes it joins in the formation
of the superficial palmar arch, but it often ends in the muscles of the
thumb. When this artery is large, the finger applied at the lower
part of the front of the wrist detects a ' double pulse.'

The anterior carpal runs inwards beneath the flexor tendons to
join a corresponding branch of the ulnar artery ; it lies in front of the
lower border of the pronator quadratus.

Ligation in the upper part of the fore-arm.— An incision of two
and a-half inches is made in the line of the artery through the skin
and the superficial and deep fasciae, when the longitudinal muscular
fibres of the supinator longus are exposed. The edge of this muscle
may, perhaps, be a little to the inner side of the incision, but when
the muscle is small the connective tissue over the vessel is at once
exposed. The border of the muscle is gently drawn outwards, and,
by working with the director through the bed of connective tissue,
the artery, with a companion vein on either side, is found lying

276 The Arteries of the Fore-ami

on the insertion of the pronator radii teres. The radial nerve will
probably not yet have joined company with the artery, or it may be
approaching it from the outer side, deeply hidden beneath the supi-
nator. The needle should be passed from the outer side, so as to
make sure of not taking up the nerve.

In the middle third of the fore-arm an incision made in the course
of the artery falls to the inner side of the supinator, and exposes the
vessel in the interval between that muscle and the flexor carpi radialis.
The artery is still between its venae comites, with the nerve close
on the outer side. From that side, therefore, the needle should be
passed.

Near the wrist the artery is quite superficial, lying along the
middle of the hollow between the tendons of the flexor carpi radialis
and supinator longus ; the latter, however, can hardly be made out as
it is approaching its insertion into the styloid process. A two-inch in-
cision being made through the thin skin and superficial fascia, the
deep fascia is divided on a director, and the artery is at once exposed,
together with its venae comites. The nerve has long since left the artery
to pass beneath the supinator longus towards the back of the hand
and fingers.

At the outer side of the wrist, the radial artery winds beneath
the extensor tendons of the thumb, over the external lateral ligament,
and over the scaphoid and trapezium. It lies beneath the integument
and fascia?, and beneath branches of the radial vein and of the radial
and musculo-cutaneous nerves in the hollow (often called the an<ilo-
misfs snuff-box), which is bounded above by the styloid process, below
by the root of the first metacarpal bone, externally by the prominent
tendons of the extensors ossis and primi, and internally by the oblique
tendon of the secundi. The course of the artery is shown by a line from
the tip of the radial styloid process to the inner side of the base of the
metacarpal bone of the thumb. The vessel is rather deeply placed.

The branches given off here are posterior carpal, the first dorsal
interosseous, or metacarpal, the dorsales pollicis, and the dorsal is
indicis. They are all small branches, and their courses are suffi-
ciently indicated by their names. The first dorsal interosseous artery,
like the others, is joined at the root of the space by a perforating
branch of the deep palmar arch, and at the cleft it turns forward to
communicate with the digital branch of the superficial arch.

Ligation maybe performed by a I \ in. incision downwards from
the styloid process ; branches of the radial vein and nerve are divided
with the superficial fascia. The artery is found between its com-
panion veins. The vessel is somewhat deep and inaccessible in this
hollow, and the operation for its ligation there is not so desirable as at
the front of the wrist.

In th« palm, the radial artery crosses the roots of the mc-ta-
iarpal bones; it has entered between the heads of the first dorsal

VI nar Artery 277

interosseous muscle (abductor indicis), and lies, therefore, very deeply
beneath the tendons of the flexor profundus and the lumbricals.

Its position on tJie surface may be marked by a transverse line an
inch nearer to the wrist than that which shows the situation of the
superficial palmar arch.

Branches. — The princeps pollicis descends between the abductor
indicis and adductor pollicis, and at the base of the first phalanx-
divides to supply the sides of the thumb.

The radialis indicis descends" between the same muscles to the
radial side of the index-finger, at the tip of which it anastomoses with
the outermost digital branch of the ulnar to complete the superficial
palmar arch.

Perforating; branches pass between the heads of the three inner
dorsal interosseous muscles to join the dorsal interosseous arteries,
and three palmar interosseous twigs descend to the clefts of the
fingers to communicate with the digital branches of the ulnar.

The ulnar artery is the larger division of the brachial, and,
beginning at the middle of the bend of the elbow, eventually reaches
the palm under the protection of the pisiform bone, to the radial side
of which it lies as it descends over the annular ligament.

To mark the course of the artery in the fore-arm, a slightly curved
line, with the convexity inwards, is drawn from the inner side of the
tendon of the biceps to a little above the middle of the fore-arm, and
from that spot, straight down the radial border of the flexor carpi
ulnaris, to the outer side of the pisiform.

In the curved part of its course the ulnar artery is burrowing
deeply beneath the pronator radii teres and company, and is occupy-
ing a position of more interest to the anatomist than the surgeon.
The surgeon does not attempt to reach the artery by cutting across
those muscles, but prefers to wait for it until it is approaching the
inner border of the upper part of the fore-arm.

Relations. — T\& guide to the artery is the flexor carpi ulnaris, but,
as just remarked, in the beginning of its course the artery is separated
from it by the group of muscles arising from the internal condyle,
namely, the pronator teres, flexor radialis, palmaris longus, and flexor
sublimis. To reach the flexor carpi ulnaris the artery does not pass
over this group, or it would be dangerously superficial, and it cannot
pass through it, so it passes beneath it. As it dips beneath the deep
head of the pronator teres the median nerve is passing between the
two heads of that muscle, therefore the median nerve is an additional
superficial relation to the beginning of the artery.

The manner in which the median nerve crosses the ulnar artery is
clear to the student when he traces on the surface of the fore-arm the
boundaries of the triangle, and places in their proper position the
tendon of the biceps, the brachial artery, and the median nerve. If
the line of the median nerve be then prolonged to the inner side of

278 The Ulnar Artery

the tendon of the flexor carpi radialis, it is seen to cross that of the
artery.

As the muscles narrow into their tendons the artery is found
nearer to the surface, between the flexor carpi ulnaris and the inner-
most tendon of the flexor sublimis digitorum, being then covered only
by the skin and the superficial and deep fascine, a branch or two of
the anterior ulnar vein and of the internal cutaneous nerve.

The ulnar artery rests upon, first, the brachialis anticus, and, in the
rest of its course, on the flexor profundus digitorum, a muscle which
is bulky enough to prevent the artery coming into relationship with
either the ulna or the square pronator.

The first definite external relationship is the innermost tendon of
the flexor sublimis.

On the inner side of the artery are the ulnar nerve and the flexor
carpi ulnaris, but these structures are not approached until the vessel
has completed its inward bend, that is, not until it has reached nearly
halfway to the wrist. The artery is accompanied by a small vein on
either side.

Branches. — The anterior ulnar recurrent ascends deeply in the
groove between the pronator teres and the brachialis anticus, to com-
municate with the anastomotica magna and the inferior profunda.

The posterior ulnar recurrent ascends behind the internal con-
dyle, and communicates with the posterior branches of the anasto-
motica magna, and with the inferior and superior profundas. It passes
between the origins of the flexors sublimis and profundus, and between
the heads of the flexor carpi ulnaris, lying against the ulnar nerve.

The common Interosseous speedily divides into the anterior
and posterior interosseous, the former of which descends upon the
interosseous membrane in the crevice between the flexor profundus
digitorum and the flexor longus pollicis. But, having reached the
pronator quadratus, it passes through the membrane to the back of
the fore-arm, where it anastomoses with the posterior interosseous
and the posterior carpal arteries. It gives off muscular twigs, and
the nutrient branches to the radius and ulna, the comes ncri'i mcdiani,
and branches to anastomose with the anterior carpal arch. The
branches to the radius and ulna run towards the elbow.

The posterior interosseous runs backwards between the oblique
ligament and the interosseous membrane, and then between the
adjacent borders of the supinator brevis and the extensor ossis. It
afterwards descends between the superficial and deep layer of muscles,
and ends in anastomosis with the anterior interosseous and the pos-
terior carpal arch. It gives off the interosseous recurrent branch,
which ascends between the external condyle and the olecranon process,
and beneath the anconeus, to anastomose with the superior profunda,
and perhaps with the posterior ulnar recurrent or the anastomotica
magna.

Superficial Palmar ArcJi 279

The anterior carpal joins in the anterior carpal arch beneath the
flexor tendons, and the posterior carpal winds beneath the flexor
carpi ulnaris, and then beneath the tendons at the back of the wrist,
to help form the posterior carpal arch. It gives off the dorsal inter-
osseous branches to the two inner spaces.

Iiig-ation of the ulnar artery. — In the upper part of the fore-arm
the artery cannot be reached by an incision in its course (p. 277), as
that would entail the division of the pronator teres and other muscles ;
it is sought, therefore, between the adjacent borders of the flexor sub-
limis digitorum and the flexor carpi ulnaris, by drawing a line from
the internal condyle of the humerus to the pisiform, and by making
an incision of 2j to 3 in. in that line, beginning' it ii in. below
the condyle. Probably this incision implicates the posterior ulnar
vein. The deep fascia is then exposed, and, beginning in the lower
end of the incision, the surgeon opens up with a director, or the handle
of the scalpel, the septum between those two muscles. This separation
is easily effected if it be begun below ; higher up the muscles are far
more closely connected with each other. The ulnar nerve is seen
lying on the flexor profundus digitorum, and after raising the flexor
sublimis and searching beneath it the artery is seen with its venae
comites.

For ligation of the ulnar artery in the middle of the fore-arm, or
nearer the wrist, a 2-in. incision is made close along the radial side
of the tendon of the flexor carpi ulnaris. A thickish layer of fascia
has to be divided, and the artery is found with its venae comites.
The nerve is between the vessels and the tendon ; the needle must
therefore be passed from the inner side.

At tlie wrist the ulnar artery continues over the annular ligament,
close to the radial side of the ulnar nerve and the pisiform bone. It
is covered by skin and superficial fascia with the transverse fibres of
the palmaris brevis, and by the inner part of the palmar fascia, which
is strengthened by a slip from the insertion of the flexor carpi
ulnaris.

in the palm the artery curves downwards and outwards from the
pisiform to make the superficial palmar arch, the convexity of which
is directed towards the fingers. The position of this arch is shown by
abducting the thumb and drawing a line across the palm at the level
of the inferior, or distal, border of the web of the thumb. Sometimes
the ulnar artery anastomoses at its outer end with the superficialis
volas, but the arterial anastomosis is more usually completed by the
communication with the radialis indicis at the tip of the index-
finger.

Relations of the superficial palmar arch. — It lies close beneath
the integument and the strong palmar fascia, and rests upon the
digital branches of the median nerve, and upon the tendons of the
flexor sublimis digitorum.

280 I>nitic/ics of (7//tir Artery

Crunches in the hand. — The profunda ulnaris clips between the
abductor and flexor brevis minimi digiti to complete the deep palmar
arch (p. 277) by joining with the radial.

Four digital branches come from the convexity of the superficial
arch. The innermost runs along the ulnar border of the little finger,
whilst the three others pass clown to the clefts, where they divide to
supply the adjacent sides of the four inner fingers. The outennost
branch joins the radialis indicis in the pulp of the index-finger, and. so
completes the superficial arch. These digital arteries descend straight
to the clefts, and thus lie in the lines of the interosseous spaces ; the
flexor tendons run in the lines of the fingers. In making exploratory
incisions the lines of the clefts must be avoided.

In the palm the arteries are superficial to the nerves, but along the
fingers the nerves are anterior.

At the clefts the digital arteries are joined by the palmar inter-
osseous branches of the radial, and by the dorsal interosseous twigs
of the posterior carpal arch.

Irregularities. — In the case of a high division of the brachial the
ulnar artery may reach the inner border of the fore-arm by passing
superficial to the group of muscles arising from the internal condyle,
lying sometimes superficial even to the deep fascia.

The comes nervi mediant is occasionally almost as large as the
radial or ulnar, and, accompanying the median nerve into the hand,
may enter into the formation of one of the palmar arches. Sometimes
it leaves its nerve and descends in front of the annular ligament.

As in the case of recurrent or obstinate hemorrhage from a wound
of the palm, it is quite possible that an irregular comes nervi may
be involved, and, as in every case collateral circulation between the
radial and ulnar arteries is extremely free, it is proper to tie the
brachial at once, rather than the radial and ulnar arteries, or one
of them singly.

THE BACK OF THE FORE-ARM

The extensor carpi radialis longlor arises from the lower third
of the external condylar ridge ; it has a long tendon which is inserted
into the base of the second metacarpal bone. Nerve , the musculo-
spiral.

The extensor carpi radialis brevior arises from the external
condyle by the common tendon, and is inserted into the base of the
middle metacarpal bone. Nerve, the posterior interosseous.

These two muscles lie beneath the supinator longus, and their fleshy
bellies project behind that muscle over the upper third of the radius.
Their tendons run together under the annular ligament in the wide
groove behind the radial styloid process, and are crossed by the
tendons of the thumb-extensors.

Back of Fore-ami 281

The extensor communis digitorum lies along the ulnar side of
the preceding muscle. Arising from the external condyle and from the
fascia investing it, it divides into tendons for the four fingers. These
pass in the shallow radial groove, together with the tendon of the
extensor indicis, lubricated by the one synovial membrane. As they
pass over the metacarpus the three inner tendons are connected with
each other by short slips. The tendons spread out and form the
posterior ligaments for the metacarpo-phalangeal joints ; at the next
joints they divide into three slips, of which the middle one is inserted
into the base of the middle phalanx, while the lateral slips pass on to
the base of the last phalanx ; in each case they act as posterior liga-
ments. Nerve, the posterior interosseous.

The extensor minimi digit! arises like the last muscle, along the
ulnar side of which it runs. Its slender tendon occupies a separate
compartment beneath the annular ligament, in the groove between the
radius and ulna, and is inserted in common with the innermost tendon
of the extensor communis. Nerve, the posterior interosseous.

The extensor carpi ulnaris arises from the external condyle,
between the extensor minimi digiti and anconeus, and passes along
the edge of the latter muscle to the posterior border of the ulna, along
which it also arises. Its tendon runs in the groove on the inner side
of the head of the ulna, behind the styloid process, under the annular
ligament, and is inserted into the base of the fifth metacarpal bone.
Its nerve-supply is from the posterior interosseous.

The anconeus (ay/cwi/, elbow) looks like a piece of the triceps which
has been cut off by the external condyle, from the back of which it
arises. It is inserted into the adjacent part of the olecranon process,
and a little way down the back of the shaft of the ulna. Being in its
origin, insertion, and action so like the triceps, it is naturally supplied
by the same nerve as the triceps, the musculo-spiral.

The muscles of the deep layer at back of fore-arm are directed
obliquely downwards and outwards, and intervene between the
posterior interosseous vessels and nerve and the back of the inter-
osseous membrane. The supinator brevis arises from the outer aspect
of the ulna, and surrounds the upper third or more of the radius.
The extensor ossis metacarpi arises from both bones, and the extensor
primi internodii pollids from the radius only ; these two muscles
form a projection at the back of the lower third of the radius as
they descend over the radial extensorsof the wrist to the groove on
the outer side of the styloid process. The former of them is inserted
into the base of the metacarpal bone, the latter into that of the first
phalanx of the thumb ; between the styloid process and the root of
the thumb they cross the radial artery ; serous effusion into their
synovial sheath is not of infrequent occurrence.

The extensor secundi arises from the ulna, and so, to reach its
insertion at the root of the ungual phalanx, it has to pass very

282 TJie Back of tJie Fore-arm

obliquely across the back of the wrist, where its tendon occupies a
deep and solitary groove on the ulnar side of that for the radial
extensors of the wrist. Its oblique tendon, which crosses the radial
artery just as it is entering the root of the first interosseous space, is an
important and conspicuous landmark. The extensor inditis arises
from the ulna ; its tendon passes with the tendons of the extensor com-
munis and is inserted with the outermost of them (v. p. 287).

All the muscles of the deep layer are supplied by the posterior
interosseous nerve.

Epiphyses of ulna.

The ulna begins to ossify at about the eighth week of foetal life, and
at birth ossification has extended from the shaft through the coronoid
and olecranon processes, with the exception of a shallow cap at the top
of the olecranon, which is still cartilaginous, and which does not begin
to ossify until the tenth year. This unimportant epiphysis joins the
shaft at puberty, but the lower end of the bone, which begins to ossify
in the fourth year, does not join until manhood.

Inflammation of the bursa which is placed between the skin and the
olecranon process constitutes ' miner's elbow ' ; I have seen it greatly
enlarged in a bill-poster, as the result of constant friction against the
walls and hoardings.

Epiphyses of radius.

The radius begins to ossify at about the eighth week, and at birth
only its ends are cartilaginous. The lower epiphysis begins to ossify
in the second year and joins at manhood ; the upper epiphysis ossifies
in the fifth year and joins at puberty.

Fracture may occur in any part of the fore-arm, but the most

common site is at the lower end of the radius — Colles's fracture. At
first view it seems unlikely that the stronger bone should oftenest break,
and that the fracture should be through the strongest part of that bone.
The explanation is simple : a man is falling and he puts out his hand
to break the shock. The hand being in the position of pronation, the

Colles's Fracture 283

shock is received by the scaphoid and the rest of the first row of the
carpus, and by the front edge of the lower end of the radius. The
result is that the carpal surface of the bone is cracked off, not straight,
as happens when the carpal epiphysis is detached, but obliquely,
the line of fracture being very near to the wrist-joint in front, but
reaching fin., or more, above it posteriorly. The continuance of
the shock which cracked off the end of the bone thrusts it, and the
carpus with it, upwards on to the back of the radius. As the inner
part of the carpus, and the ulna (which does not actually enter into the
formation of the joint), receive little shock, there is, as a rule, no
fracture or displacement on the ulnar side, further than that the head
of the ulna may be left prominent and conspicuous when the outer
part of the carpus is thrust upwards. Thus, the hand is found abducted

after the fracture and there is a considerable dorsal projection on the
lower end of the radius, and its styloid process is raised. (The figure
is after Erichsen.)

There is another explanation of the way in which the fracture occurs,
that is by the sudden and powerful dragging upon the front of the
the lower end of radius by the over-stretched anterior ligament of the
joint and the flexor tendons when, in the fall, the hand is thrown back.
The displacement of the carpal fragment is probably not in the least
influenced by muscular action, but is all mechanical.

As regards treatment of Colles's fracture, the hand must be dragged
forcibly downwards and adducted so as to replace the carpal fragment,
a pistol-shaped splint being then applied to keep it in the adducted posi-
tion, or some other form of splint which will keep the fragment in place.

Fracture of the radius between the insertions of the biceps and
pronator teres is a rare injury. The fact of the bone being broken is
detected by pressing with the thumb or the tip of the index-finger just
below the external condyle, and finding that the head of the bone does
not move in pronation and supination.

If the muscles exercised that important influence over the position
of fractured bones which is so often ascribed to them (but which I am
not prepared to admit), it is evident that the upper piece of the bone
would be flexed by the biceps and supinated by that muscle and the
supinator brevis, whilst the shaft of the bone would be rolled round by
the pronators teres and quadratus, and at the same time drawn towards
the ulna ; but this arrangement does not necessarily obtain.

284 The Radius and Ulna

As the upper fragment cannot be influenced by pad or splint, the
surgeon must direct his attention to the shaft-fragment, bringing it
into the best position by flexing the fore-arm and supinating it, so
as to relax the biceps.

When botb bones are broken, say at about the middle of the
fore-arm, the limb must not be put up with the hand either pronated
or half-pronated, as in that position the radius closely overlies the
ulna and there is risk of the four broken ends being solidly cemented
together with new bone. When the fore-arm is supinated the bones
are far apart ; therefore, as a practical surgeon once remarked, ' you
must arrange the limb so that the patient could spit into his hand.'
That is, the elbow is flexed so as to relax the biceps, whilst the fore-
arm is supinated and raised in a wide sling.

In dealing with a fracture in the fore-arm, the bandages must not
be tight, lest the superficial veins be compressed — which easily hap-
pens— or lest the circulation through the arteries themselves becomes
arrested, and pressure-sores or extensive gangrene supervene.

Fracture of the ulna. — As the result of direct violence or muscular
action the olccranon process may be broken off. The separation does
not take place through the epiphyseal cartilage, as this is a mere shell
of bone at the top of the process, but through the narrow part halfway
down the great sigmoid cavity. Sometimes the detached piece is
dragged up by the triceps, but at other times, when the surrounding
fibrous tissue is not much torn, there may be no displacement whatever.
The fracture is, of course, into the joint, and is occasionally fallowed by
arthritis and ankylosis. The union may be only of fibrous tissue, but,
to secure the best chance of solid repair, the elbow must be kept on
a straight splint for three weeks, so that there may be no dragging by
the triceps.

When a bone is broken in a synovial cavity, as in the case of the
olecranon process, the patella, and the neck of the femur, synovial
fluid bathes the fractured surfaces and often prevents their osseous re-
union. Non-union of the olecranon may leave the arm comparatively
useless, the fragment being drawn up the arm by the triceps, and the
power of extension being seriously interfered with. To remedy this
defect the joint may be laid open from behind, the surfaces of bone
freshened up, and the loose piece of the olecranon brought down and
fixed by wire sutures.

The coronoid process may be broken off in backward dislocation of
the bones of the fore-arm, or it may possibly be detached and drawn
up by the energetic action of the brachialis anticus. Like the last
injury, it is a fracture into the joint. The elbow has to be fixed by a
rectangular splint for three weeks. In this way the brachialis anticus
is kept in perfect rest, and the broken surfaces are approximated to
the utmost degree attainable.

Amputation in the fore -arm may be performed in the upper,

Interosseous Membrane 285

middle, or lower third. What may be called the ' favourite situation '
is just below the middle, so that the stump may be left under the
government of the pronator radii teres as well as of the supinator brevis
and its powerful ally, the biceps.

In amputation at the wrist the flap is dissected from the palm, and
turned back over the lower end of the radius and the triangular fibro-
cartilage. The head of the ulna and the membrana sacciformis are
not exposed or interfered with.

Below the level of the superior radio-ulnar joint the bones of the
fore-arm are connected by an oblique ligament which runs downwards
from the coronoid process of the ulna to the radius, just below the
tuberosity. Then begin the fibres of the interosseous membrane,
which are oblique in the other sense, namely, downwards and inwards.
Between the upper border of the interosseous membrane and the
oblique ligament is a triangular gap through which the posterior inter-
osseous vessels pass ; the nerve, however, reaches the back of the
fore-arm by passing round the outer side of the radius through the
supinator brevis.

Relations of the membrane. — Upon the front lie the origins of the
flexors profundus digitorum and longus pollicis, and deep in the interval
between them run the anterior interosseous vessels and nerve. The
pronator quadratus covers its lower third.

Upon the posterior surface rest the supinator brevis and the origins
of the three extensors of the thumb and of the index-finger. Because
of these oblique extensors covering the membrane, the posterior
interosseous vessels do not reach it, but the anterior interosseous
artery, which comes through above the pronator quadratus, and the
ending of the posterior interosseous nerve, lie upon it just above the
wrist.

The inferior radio-ulnar joint consists of the lesser sigmoid cavity
of the radius, and the head of the ulna. These surfaces are covered
with cartilage and lubricated with a loose synovial membrane (sacci-
formis}, and are connected in front and behind by short bands of
fibres.

Extending from the root of the styloid process of the ulna to the
lower border of the lesser sigmoid cavity of the radius is the triangular
Jibro-cartilage, which shuts the ulna out of the wrist-joint. The lower
surface of this cartilage articulates with the cuneiform, and is lubricated
by the synovial membrane of the wrist-joint. Sometimes the synovial
membranes above and below the joint blend through a hole in the carti-
lage. (See next page.)

The joint is supplied by branches of the two interosseous arteries
and nerves.

The wrist-joint is formed above by the radius and the triangular
inter-articular fibre-cartilage, and below by the scaphoid, semilunar,
and cuneiform bones, the last-named articulating with the fibro-carti-

286

The Wrist Joint

lage. It is an arthrodial joint, and is enclosed in a capsule consisting
of anterior, posterior, and lateral ligaments. The articular surfaces

are covered with hyaline cartilage
and are lubricated by a synovial
membrane which is special to this
radio-carpal joint, though it is some-
times in communication with the
membrane of the inferior radio-
ulnar joint, as remarked above.

The anterior ligament is at-
tached above to the anterior margin
of the radius and ulna, and below
to the front of the scaphoid, semi-
lunar, and cuneiform bones. The
posterior is a weaker band with
attachments very similar to those
just mentioned. The external
lateral ligament extends from the
tip of the styloid process of the
radius to the scaphoid, whilst the
internal passes from the tip of the
styloid process of the ulna to the
cuneiform and pisiform bones.

Relations. — In front of the joint
are the flexor tendons, an,d behind
are the extensor tendons. Over
the external lateral ligament the
radial artery winds, and close on the radial side of the flexor carpi
ulnaris are the ulnar nerve and artery. The median nerve is separated
from the anterior ligament by the flexor profundus.

Supply. — Branches of artery come from the anterior and posterior
carpal arches, the posterior interosseous, and the radial and ulnar. Its
nerves are branches of the ulnar and of the anterior and posterior inter-
osseous.

Dislocations of the wrist are very rare, although the articulation
does not seem particularly secure ; injury is far more likely to expend
itself in fracturing the radius. In dislocation the first row of the carpal
bones may be carried on to the back or front of the radius and ulna,
beneath the extensor or flexor tendons. The luxation is easily recog-
nised and reduced. The backward dislocation may look at first sight
like a Colles's fracture (p. 282), but in the fracture the styloid process of
the radius is displaced upwards and backwards with the carpus, whilst
in the dislocation it remains in its proper place, and projects beneath
the skin.

In opening a palmar abscess the scalpel must be used with great
caution, especially in the regions of the superficial and deep palmar

13.

Membrana sacciformis ; 3 and 4, lateral
ligaments ; 8, general synovial ravity
of intercarpal and carpo-metacarpal
joints ; 8', synovial bursa between unci-
form and fourth and fifth metacarpal
bones— is often separate; 9', synovial
cavity of first carpo-metacarpal joint.

(QUAIN.)

Synovitis of Wrist

287

arches, and, as shown elsewhere (p. 280), the lines of the clefts of
the fingers must also be avoided. Pus lying deeply must be reached
with the director ; but if an abscess have extended from the palm and
along the flexor tendons it may be necessary to slit boldly through
the anterior annular ligament.

In synovitis of the wrist there is a bulging all around the joint,
so that the depressions are effaced and the position of the tendons is
obscured. There is pain on moving the wrist, and also on pressing the
carpus against the radial socket or drawing the articular surfaces asun-
der. I have recently had two patients under my care who had at the
same time sub-acute inflammation of the wrist-joint and acute effusion
into the synovial membrane of the extensor communis digitorum. Doubt-
less in these persons there was a gap in the posterior ligament through
which the two synovial membranes were continuous. The fore-arm

E.M.D.

E.C.U.

Lister's excision of wrist.

and hand were secured in a moulded splint for some months, and the
disease completely subsided.

288 The Wrist Joint

Excision of the wrist-joint is very rarely needed ; it maybe per-
formed by straight lateral incisions, care being taken not to wound the
radial artery.

In lister's method the incision on the inner side of the joint is
made in the ordinary way, from two inches above the ulnar styloid
process down to the middle of the fifth metacarpal bone ; but the outer
incision is made in the line of the second metacarpal bone, and then
along the ulnar side of extensor secundi — the oblique tendon of thumb
(p. 287). This tendon and the radial artery are carefully raised from
the wrist, and the tendons of the carpi radialis longior and brcvior are
severed, as is also that of the carpi ulnaris. The flexor and extensor
tendons of the fingers are raised, the pisiform and the hook of unci-
form being detached ; the trapezium requires a snip from the cutting
pliers. The carpal bones, being cleared and separated, are taken out ;
the carpal ends of the radius and ulna, and of the metacarpal bones,
are laid bare and sawn off. It is evident that this latter part of the
programme cannot be carried out unless the tendons of the special
wrist-extensors had been previously divided, as they are inserted at
the base of the metacarpus ; but, when extracting the trapezium, the
tendon of the flexor carpi radialis is raised and saved. Personally, I
should not attempt the complicated operation, which I have thus briefly
sketched out, without carefully reading it up just before, and I deem it
unfortunate that the same indulgence cannot always be extended to
the student.

Much of the movement which apparently takes place at the radio-
carpal joint actually occurs in the mid-carpal articulation, the flexor
and extensors carpi radialis and extensor carpi ulnaris being inserted
into the metacarpal bones so that they may influence the wrist and
the transverse carpal joints at once.

The transverse carpal joint and tbe synovial membranes of
the carpus. — The lower surfaces of the scaphoid and semi-lunar bones
form a socket for the head of the os magnum, which articulates on
the outer side of the magnum with the trapezium and trapezoid, and
on the inner side with the cuneiform and uncifqrm, as shown in the
fig. on p. 286. The two rows of carpal bones are connected by anterior,
posterior, and lateral ligaments.

The transverse carpal joint is lubricated by a synovial membrane
which is distinct from that of the radio-carpal articulation ; it sends
processes between the bones of the second row which extend also
into the articulations of the trapezoid and magnum with the middle
metacarpal bones. A special synovial membrane is often found for the
joint between the unciform and the fourth and fifth metacarp.ils.
There are also separate membranes for the joints between the cunei-
form and pisiform, and the trapezium and the first metacarpal bone.
(The description here given differs somewhat from that figured on
p. 286.)

Phalangeal Joints 289

Supply. — The joints about the wrist are supplied by the endings
of the anterior and posterior interosseous arteries and by carpal
branches of the radial and ulnar. The nerves come from the ulnar
and the posterior interosseous.

The pisiform reflex is obtained by pressing the pisiform bone firmly
with the thumb on to the cuneiform bone, when, if the reflex chain be
entire, a motor impulse is promptly sent down to the palmaris brevis,
and the skin along the inner border of the hand is puckered in.

The metacarpo-phalangeal and the inter-phalangeal joints are
strengthened by lateral ligaments, and in front by a thick glenoid

Lines of incisions. (After SMITH and WALSHAM.)

ligament containing much fibrous tissue. There is no posterior liga-
ment, its place being taken by the extensor tendon. Each joint has a
synovial membrane.

290 Palm of Hand

In amputating a metacarpal bone its base should, if possible, be
left, as to remove it would be to open up a considerable extent of
synovial membrane (p. 286). But this remark does not apply to
the first metacarpal, which has an isolated joint with the trapezium.
In amputating this bone, however, the utmost care must be taken
lest, in attacking its base, the radial artery be wounded as it is pass-
ing to the root of the first space, as shown in the fig. on p. 287.

Amputation of the thumb at its joint with the trapezium may be
performed by a racket-shaped incision, the ' handle part ' of which
runs from the root of the metacarpal bone and down the dorsum,
whilst the ' loop part ' encircles the head of the bone. The three ex-
tensor tendons are cut, and the abductor, opponens, flexors brevis and
longus, and the adductor. The root of the first dorsal interosseous
muscle is detached. The radial artery must be very carefully guarded,
but its branches, the two dorsales and the princcps, must needs be
severed.

In amputating a finger or a phalanx a difficulty may arise in hit-
ting the articulation unless the finger be first
_ bent. The knife should be passed so as to strike
the middle of the head of the metacarpal bone,
not its dorsal aspect. The joint being traversed
from behind, a flap is cut from the flexor aspect.
It is important to remember that the prominence
of the knuckle is made by the head of the meta-
carpal bone or of the phalanx, and ,not by the
base of the phalanx ; unless this be understood, the operator may be
expending his time in useless cuts against the head of the metacarpal
bone or phalanx.

Ampliation through the first inter-phalangeal joint is apt to leave
the phalanx stiff and unmanageable, because it receives no insertion
either from the flexor or the extensor tendons. It is preferable,
therefore, to amputate through the middle of the second phalanx,
as the stump then retains the slips of the superficial flexor and of
the common extensor. But when only the first phalanx is left the
tendons may still find a cicatricial insertion and render the stump
extremely useful.

The metacarpal bones have a centre of ossification for the shaft
which appears at the eighth week of fcetal life, and one for the head
which appears in the third year ; they coalesce at manhood— 2Oth
year. The phalanges are developed on the same plan, except that in
them the epiphysis is at the base instead of the head.

The first metacarpal bone, let it be noted, has its epiphysis at its
base ; thus, developmentally, it is a phalanx.

Occasionally \hzfirst metacarpal bone is dislocated at its saddle-
shaped joint with the trapezium ; sometimes its epiphysis is detached,
in which case the appearance is a good deal like that of dislocation :

Dislocation of Thumb

291

careful examination and measurement, however, quickly clear up any
doubt.

The most important injury of the thumb is that in which the first
phalanx is dislocated backwards, the end of the metacarpal bone
slipping forwards between the heads of insertion of the flexor brevis
pollicis with its allied muscles, the abductor pollicis with the outer

X/*

head, and the adductor with the inner. The result is that the
more the surgeon pulls on the phalanges, the narrower the interval
between the heads of the flexor brevis becomes, the more tense are
those heads, and the firmer the grasp of the neck of the metacarpal
bone. Before attempting reduction, therefore, the metacarpal bone
should be thrust towards the palm, so as to slacken to the utmost the

292 Palm of Hand

abductor, flexor brevis, and adductor pollicis ; if manipulations then
fail it may be necessary to divide the abductor and the outer head
of flexor brevis before the phalanx can be replaced. Sometimes the
capsule of the joint or the intervention of the tendon of the long flexor
is the impediment to reduction.

The palmaris brevis arises from the inner part of the anterior
annular ligament, and is inserted into the skin along the inner border
of the hand, which it raises to form the cup of Diogenes. Crossing
over the ulnar vessels and nerve, it is supplied by the superficial part
of the ulnar nerve.

In the ball of the thumb the most superficial muscle is the
abductor pollicis, which arises from the annular ligament and is in-
serted with the flexor brevis into the outer part of the base of the first
phalanx, through the medium of a sesamoid bone.

The opponens is so named because its action is to 'place the
thumb opposite ' the other digits ; it is, therefore, inserted along the
outer side of the metacarpal bone itself. It arises from the annular
ligament and the trapezium, lying beneath the abductor.

The flexor brevis has a bulky origin from the annular ligament,
the trapezium, os magnum, and the bases of the second and third
metacarpal bones. Its outer head is inserted with the abductor, and
its inner with the adductor pollicis, into the sides of the base of the
first phalanx, through the medium of sesamoid bones. The tendon of
the long flexor passes down between its heads of insertion.

The adductor arises from the middle metacarpal bone*, and is in-
serted with the inner head of the short flexor.

Nerve-supply. — The muscles of the ball of the thumb are supplied
by the median, but the deep part of the flexor brevis, and the adductor
pollicis are supplied by the deep part of the ulnar nerve.

The muscles of the little finger are the abductor, flexor brevis, and
opponens. They arise from the pisiform region of the hand. Two of
them are inserted into the base of the first phalanx, and the opponens
is inserted into the metacarpal bone itself. They are supplied by the
deep part of the ulnar nerve.

Of the interossei, four are dorsal and three palmar. The former are
abductors, as is shown by looking at the outermost of them, which,
lodged between the first and second metacarpal bones, constitutes the
abductor indicis. The dorsal interosseous arise from two bones, and
between the heads of origin of each passes an artery. In the case of
the abductor indicis the artery is the radial, in the case of the others
it is the perforating of the deep arch. The interossei are inserted
partly into the bases of the first phalanges, helping to flex those
phalanges, and partly into the extensor tendons, helping, therefore, to
extend the second and third phalanges, as is shown on p. 273.

In the third month of fcetal life the flattened distal end of the lappet
or bud, A, B, from which the arm is developed, shows four notches, c

Web-finger 3 293

which, extending deeply, in a rough manner shape out the five
digits, as at D. Should arrest of development occur in this process of
cleavage, web-fingrers result.

This condition is often hereditary, and when the fingers are webbed
the toes are probably affected in the same manner. Further, it not
unfrequently happens that the webbing is associated with imperfect
mental development.

294 The Abdomen

PART IV
THE ABDOMEN

THE transverse measurement of the abdomen (abdo, I conceal) is
greater below than it is just beneath the diaphragm — and especially so
in women ; but in children, on account of the imperfect development
of the pelvis, the superior transverse diameter is the greater.

The boundaries are, laterally and anteriorly, the false ribs and
diaphragm, and the oblique, transverse, and straight muscles ; pos-
teriorly, the lumbar spine, the diaphragm, the lower ribs, quadratns
lumborum, and the lamellae of the transverse muscle. The expanded
ilia also help to enclose the cavity and support the viscera.

Though the diaphragm affords a definite limit above, the abdomen
is separated from the pelvic cavity only by the shifting planes of peri-
toneum, which, under the name of false ligaments, slope to the bladder
and rectum. Were the partition between the abdominal and pelvic
cavities less movable, the ascent of the distended bladder and of the
pregnant uterus would be impeded, and the descent of the coils of
small intestine into the pelvis, when those viscera are empty, could
not take place.

In cancer of the oesophagus or pylorus, on account of the emptiness
of the alimentary canal, the front of the abdomen is flat ; and in tuber-
cular meningitis, because of the irritability of the nervous system, the
bowels being empty and contracted, the depressed surface of the ab-
domen is * boat-shaped.'

For palpation of the abdomen, the patient should be lying on his
back, with the knees drawn up so that the abdominal wall may be
relaxed to the utmost, and when a very thorough examination is
to be made, precaution should be taken that the stomach, bowels,
and bladder are empty. When a tumour descends with inspiration and
rises with expiration its seat is in one of the abdominal viscera, and
not in the abdominal wall.

A line drawn around the trunk from the base of the ensiform
cartilage to the tenth dorsal spine suggests the upper limit of the
abdominal cavity, which ascends a good deal beneath the dome of the
diaphragm and under cover of the ribs and the base of the lungs.

Surface of Abdomen

295

Surface markings are made by the fleshy recti on either side of
the linea alba— the line of junction of the aponeuroses of the oblique
and transverse muscles. As the linea alba approaches the ensiform
cartilage its position is marked by a shallow depression, the ' pit of
the stomach.' Immediately behind this depression some of the liver
and stomach are placed, and there, if slightly enlarged, the border
of the liver may be felt. The linea alba contains no muscular fibres

Front of abdomen. (Modified from M'LACHLAN.)

or blood-vessels ; the site serves well, therefore, for abdominal section,
paracentesis, and supra-pubic operations on the bladder. Through this
line is a strong fibrous seam ; it gradually yields in extreme abdominal
distension until it is frayed out into a thin membrane. Thus, in
operating for ovarian dropsy the inner borders of the recti may be found
several inches asunder. Similarly, when the « pot-bellied,' rickety child
raises himself from the horizontal to the sitting posture, the intestines
are thrust forwards into a sausage-shaped protrusion along the

296 The Abdomen

median line ; and, as the child lies supine, one's fingers may be thrust
inwards through the chink.

The viscera immediately behind the linea alba are the left lobe
of the liver, stomach, transverse colon, great omentum, small intestine
and mesentery, and the distended bladder or pregnant uterus.

The linea semilunaris marks the splitting of the aponeurosis of
the internal oblique along the outer border of the rectus ; it extends
from the eighth costal cartilage to the outer end of the pubic crest.
Like the ' white line,' it possesses neither muscular fibres nor blood-
vessels ; it is the site of puncture when the ascitic patient is tapped
lying upon his side ; in that position the fluid falls against the one
flank, whilst the intestines float against the other and are thus out of
the way of the trocar. Through the linea semilunaris also the kidney
may be conveniently reached in the transperitoneal operation, or the
stomach opened.

Xiineae transversae. — Extending across the recti are several ten-
dinous intersections which show on the surface of a well-developed man
as slight depressions crossing from the white to the semilunar line ;
quadrilateral segments of the muscle stand in relief between them.
One of the lines is at the level of the umbilicus, one at the ensiform
cartilage, and a third midway between them. Sometimes a fourth is
found between the navel and the pubes. Occasionally a segment of
muscle between two of the lines has been mistaken for abscess or
tumour, and in hysterical subjects irregular contraction in them may
produce a variety of '•phantom tumour! ^

In a fat subject two transverse creases intersect the linea alba : one
at the umbilicus, the other a few inches above the pubes ; the bladder
may be conveniently tapped at the spot where the lower furrow crosses
the middle line. These furrows are the result of a folding of the front
of the abdomen in leaning forward and stooping, a certain amount of
the fat being absorbed by the constant pressure.

The superficial fascia consists of a fatty and of a deeper, mem-
branous layer, between which the main tributaries of the superficial
blood-vessels and the lymphatic glands are placed. The superficial
layer has slight connection with the abdominal aponeurosis except at
the umbilicus. In the female, just above the pubes, an extra deposit
of fat in the subcutaneous tissue produces an elevation, the mons
veneris.

The deeper layer of the superficial fascia is a firm, thin sheet, which,
coming on either side from the thoracic and lumbar regions, is attached
to the iliac crests, and along Poupart's ligament down to the pubic
spines. Thence it passes in a loose investment around the spermatic
cord, and helps in the formation of the scrotum. From the back
of the scrotum the membrane runs on to the outer lip of the pubic and
ischial rami (covering the crus and erector penis), and eventually
joins the base of the triangular ligament. On the median side of

Superficial Fascia 297

the spermatic cord the right and left sheets of the fascia are attached
to the pubic crest nearer to the symphysis, blending with each other ;
this layer also forms an investment for the penis ; on the scrotum and
penis it joins with the more superficial layer of fascia, which there loses
its fat and assumes non-striated muscular fibre instead. Some of its
fibres pass into the suspensory ligament of the penis.

When air is pumped, by the movements of expiration, beneath the
deep layer of the superficial fascia upon the chest, as after the fracture of
a rib, emphysema cannot descend beyond Poupart's ligament ; but if the
air pass superficial to this layer the emphysema might extend down
the thighs. When pus descends beneath this fascia it is guided to the
penis and scrotum, and not to Scarpa's triangle.

It is this deep layer of the superficial fascia which confines urine
which is extravasated after the urethra has been ruptured in front of
the triangular ligament. The urine cannot pass backwards into the
ischio-rectal fossa, or on to the thighs, because of the attachment of the
fascia to the base of the triangular ligament and the rami of the ischium
and pubes. It passes, therefore, around the scrotum and penis, along
the front of the spermatic cord, and up into the inguinal region. The
firm connection of the fascia to Poupart's ligament and to the iliac
crest prevents the fluid wandering down the front of the thigh or on to
the buttock. (In making free incisions for the escape of the extrava-
sating fluid, the surgeon must remember that a swelling along the
cord may possibly be due to the presence of an inguinal hernia.)

The anterior wall of the abdomen is freely movable over the
viscera, and offers so little resistance that, in a buffer-accident, liver,
stomach, intestine, or arterial trunk may be ruptured without the
surface of the body showing any bruise or discoloration. Moreover,
a blow in the epigastric region may be followed by immediate death
without the supervention of either external or internal ecchymosis ;
this result is probably due to concussion of the subjacent solar plexus.
It is asserted that hospital nurses used occasionally to adopt a rough
and ready method of abdominal compression in dealing with their
hysterical patients, by sitting upon them. In the female this is supposed
to affect the ovaries alone, but it is evident that the large abdominal
plexuses are all more or less influenced by it.

A house-surgeon should never refuse admission to the wards, at any
rate for a time, to a person who has received injury to the abdomen ;
it is impossible to say by outward inspection how serious it may be.

After the integument of the abdomen has been over-stretched, as
by an ovarian tumour, or pregnancy, it does not return to its original
smooth condition, but remains permanently flecked by whitish scars
called lima albicantes. These marks are, therefore, evidence merely
of antecedent distension of the abdomen, not necessarily of pregnancy.

The umbilicus (diminutive of umbo, boss of shield) is a fibrous
cicatrix in the linea alba, opposite the third lumbar vertebra ; it is the

298

The Abdomen

remnant of the gateway of the placental vessels. As the aorta bifurcates
at the left of \hzfourth vertebra, the origin of the two common iliac
arteries is represented by a spot about one and a-half inches below
and slightly to the left of the umbilicus ; thence to the middle of
Poupart's ligament the line of the common and external iliac arteries
can be chalked upon the surface ; the first two inches of the line belong
to the common, the rest to the external iliac artery.

In compression of the aorta the viscera should be empty and the
trunk flexed, so as to slacken the abdominal wall ; pressure is made
immediately below and to the left of the umbilicus. Higher than this
compression is less serviceable, as the ribs hold off the abdominal wall
from the spine. Moreover, at the higher level important viscera lie
in front of the aorta, and these might be damaged by the force
needed to arrest the circulation.

Umbilical hernia. — In early development the abdomen is wide
open in front, the lateral walls coming forward subsequently to join
along the median line. The part last closed in is at the umbilicus,
and this gap may persist after birth, the viscera being there covered
only by integument and peritoneum. A piece of bowel escaping by
the side of the hypogastric arteries may be accidentally tied or cut
with the navel-string. A bulky cord should, therefore, be carefully
dealt with, lest a loop of intestine be wounded and a faecal fistula
result ; it should be first emptied of bowel and then tied close to the
abdominal wall.

//.A.

H.K,

Diagram of back of um-
bilicus, showing linea
alba, remains of urachus,
u; obliterated hypogast.
arts., H A, and umb.

Embryo at loth week ; /, coil of intestine in umb.
cord ; Z', umb. vesicle. (A. THOMSON.)

vein, u v.

Umbilical hernia in childhood is merely the result of an arrested
development. In the adult the protrusion is not exactly at the navel-

Umbilical Hernia 299

scar — for that tissue is strong and resisting— but through the linea
alba either above or below the navel — most likely above it, but possibly
to one side of it. When a hernia takes place exactly at the navel
itself, it is generally through the upper part — that is, above the level
of the urachus and the obliterated hypogastric arteries — for this is the
weakest part of the scar.

The coverings of an umbilical hernia are peritoneum, sub-peritoneal
fat, transversalis fascia, and integuments ; but these tissues in time
become fused together into a single, thin layer. Umbilical hernia
occurs more frequently in women, and especially in those in whom the
umbilical region has been stretched and weakened by pregnancy, and
in those whose viscera are encumbered by the deposit of a large
amount of fat.

The abdomen may be mapped out into nine regions, as follows : —
A line is drawn around the body at the level of the two anterior
superior iliac spines, and a second, parallel to it, over the ninth costal
cartilages. These three zones are subdivided by two lines, parallel
to the linea alba, from the middle of Poupart's ligament to one of the
costal cartilages — probably the eighth.

These nine areas are, from above downwards, in the middle
line, epigastric (eTrt, over ; yaa-r^p, stomach), umbilical, and hypogastric
(VTTO, below) ; at the sides, hypochondriac (wro, xoi/Spot, cartilages),
lumbar (lumbi^ loins), and inguinal (inguen, groin) or iliac (;'//#,
flanks).

The viscera contained in each region are liable to variation ; for
instance, when the stomach is distended the colon is pushed far down,
and when that piece of intestine is distended it may ascend high
behind the ribs ; but, for the most part, the contents of each region are
as follows : —

Highest Zone.

Right hypochondriac. — Liver and gall-bladder ; pyloric end of
stomach (?) and duodenum. Hepatic flexure of colon and upper part
of right kidney, supra-renal capsule, and, probably, pancreas. (The
fundus of gall-bladder lies behind the ninth costal cartilage.)

Epigastric. — Part of liver and stomach ; transverse colon and great
omentum. Pancreas ; the large abdominal vessels and some of their
branches ; solar plexus.

Left hypochondriac. — Cardiac end of stomach, tail of pancreas,
spleen ; splenic flexure of colon ; upper end of kidney, supra-renal
capsule, and perhaps some of left lobe of liver.

Median Zone.

Right lumbar. — Ascending colon, descending duodenum, kidney ;
coils of small intestine, ureter.

Umbilical. — Transverse colon and duodenum, great omentum ;

3OO Regions of Abdomen

coils of small intestine. The bifurcation of aorta ; and bladder, or
stomach, when either viscus is greatly distended.

Left lumbar. — Descending colon, kidney, ureter, small intestine.

Lowest Zone.

Right inguinal. — Caput caecum coli and vermiform appendix ;
small intestine, especially ileum ; ovary, ureter, spermatic vessels.

Hypogastric. — End of omentum, rectum, small intestine and
pregnant uterus ; fundus of the child's bladder, and that of the adult
when the viscus is full.

Left inguinal. — Sigmoid flexure of colon, small intestine, ovary,
ureter, spermatic vessels.

In intestinal obstruction rolls of distended small intestine may
cause prominent elevations across the anterior wall of the abdomen.
These may be distinguished from the markings of the recti abdominis
by their irregular situation, and also by their extending beyond the limit
of the straight muscles ; moreover, abdominal distension effaces the
segmentation of the muscles.

Tight lacing greatly disturbs the relative position of viscera. It may
even cause indentation of the convex surface of the liver by the ribs, and
may thrust up the diaphragm until inspiration is imperfectly performed
and the capillaries give evidence of imperfect aeration.

The outline of an enlarged liver or spleen, a distended gall-bladder
or urinary bladder, may be traced upon the skin, and the upheaval
caused by a distended stomach may be detected by smoothing the
fingers gently over the abdomen.

The better to explore a lumbar abscess or an abdominal tumour,
the trunk must be flexed, and the knees drawn up, so that the abdominal
walls may be relaxed by the ascent of Poupart's ligament. For when
the thighs are flat upon the bed the fascia lata drags down Poupart's
ligament and tightens up the abdominal aponeuroses which are at-
tached to it, and so renders the depths of the abdomen inaccessible.

The pancreas crosses the aorta two or three inches above the
umbilicus, at the second lumbar vertebra ; pulsations may be trans-
mitted by it from the aorta to the fingers placed between the umbilicus
and the ensiform cartilage, especially in a thin subject. Pulsations
thus transmitted in a thin, though healthy, subject may suggest aneu-
rysmal or other tumour.

The superficial arteries of the abdomen come from the superior
epigastric artery of the internal mammary, and from the deep epigastric
of the external iliac. Twigs are also derived from the lower inter-
costal and the lumbar arteries, and from the superficial epigastric and
circumflex iliac branches of the common femoral.

The veins are tributaries of the internal saphenous, and of
the companion veins of the deep epigastric, lumbar, and intercostal
arteries. Between these surface- veins there is a free anastomosis ;

Dilatation of Surface Veins 301

thus, when a tumour of the liver blocks the inferior vena cava, some
of the blood from below finds its way into the intercostal, axillary, and
subclavian veins. In hepatic congestion also, and especially in cir-
rhosis, the portal vein may be greatly relieved by the anastomosis
of veins at the back of the liver with those of the abdominal wall.
Occasionally in cirrhosis the superficial epigastric and mammary veins
are enormously dilated.

Right nipple

Dilatation of super-
ficial epigastric and
internal mammary
veins due to ob-
struction of vena
cava. (From a
photograph. Dr.
SUCKLING.)

Umbilicus

Of the superficial lymphatics, those from above the level of the
navel enter the glands of the armpit, and those from below it pass to
the glands of the groin. Some of the lymphatics of the abdominal
walls are in correspondence with the lumbar and pelvic series, and
some pass to glands in the anterior mediastinum.

The cutaneous nerves are from the terminations of the lower inter-
costals, from the anterior divisions of the lower lateral cutaneous
branches, and from the ilio-hypogastric of the firstl umbar nerve. In
the case of pressure upon the parent trunks of these nerves, pain is
referred to their terminal filaments ; thus pain along the front of the
belly is a common symptom of spinal caries (p. 210). One or two
of these nerves may be implicated in inflammation — perineuritis —
when there is pain in the area supplied by them, and after a time a
series of vesicles may appear in the course of the nerve, the result
of impaired nutrition. This eruption, which may occupy the length

302 Abdominal Muscles

of one or two intercostal spaces, is herpes zoster (fao-T^p, a girdle),,
or shingles (cingulum, a belt).

Muscles. — The external oblique arises from the eight lower ribs
by as many digitations. The anterior part of this fleshy mass ends
on a wide aponeurosis which passes over the rectus to join the
aponeurosis of the opposite external oblique in the linea alba. The
hindermost part is muscular, and descends from the last rib, in a free
border, to be inserted into the anterior half of the outer lip of the iliac
crest. The shining aponeurosis is recognised during the operation of
ligation of an iliac artery. The fleshy part of the muscle extends very
slightly in front of a line running from the outer part of Poupart's
ligament vertically to the eighth costal cartilage.

Poupart's ligament is that part of the aponeurosis which stretches
over the iliacus and psoas, and over the femoral vessels, from the front
of the iliac crest to the pubic spine, and to which the fascia lata of
the thigh is fixed. It is imperfectly marked in women, but in man it
forms an important seam between the deep layer of the superficial
fasciae of the abdomen and of the front of the thigh, and between the
transversalis and iliac fasciae (see crural sheath, p. 313) and the fascia
lata. It also gives origin to the internal oblique and transversalis.
The direction of the ligament shows, of course, the direction of the
fibres of the muscle itself — downwards and outwards. Its inner end
is firmly attached to the pectineal line through the medium of Gim-
bernafs ligament, which is a triangular septum extending, in the erect
posture, almost horizontally between the pelvis and thigh.* Its base
is concave and free, and extends outwards as far as the crural
sheath.

Femoral hernia passes below Poupart's ligament, inguinal comes
out above it ; the neck of a femoral hernia is placed below and to the
outer side of the spine of the pubes, while an inguinal hernia is above
it, and to its inner side. The spine of the pubes is an important
landmark in the differentiation of the two herniae, and is specially
valuable in the case of a fat subject.

The structures beneath Poupart's ligament are the external
cutaneous nerve, iliacus, anterior crural nerve, psoas ; external iliac
vessels in crural sheath ; crural branch of genito-crural nerve, and
lymphatics passing from the thigh towards the pelvic glands.

Between those fibres of the aponeurosis of the external oblique
which are incorporated with the inner half of Poupart's ligament and
those which blend with the linea alba there is a triangular or oval gap,
the external abdominal ringr. The base of the opening is at the
pubic crest ; the outer, and lower, side is formed by Poupart's
ligament ; and the inner boundary is made by those fibres which run
downwards and inwards to the pubic symphysis. Certain transverse
fibres which stretch as a kind of lacing across the opening constitute the
inter-columnar fascia, a prolongation from which descends as a cover-

External Abdominal Ring 303

ing of the spermatic cord, and ot an oblique inguinal hernia. The
external abdominal ring, being the lower end of the inguinal canal,
transmits the spermatic cord or the round ligament. And, as the
spermatic cord is the more bulky of these two structures, the canal
and the ring are more capacious in the male than in the female, and
inguinal hernia, therefore, is more common among men than women.

Femoral hernia — a protrusion beneath Poupart's ligament — is
more common in women, the great breadth of the pelvis necessitating
a wide space below the ligament, which the iliacus and psoas, and the
femoral vessels, but indifferently block up.

In the case of a tumour in the upper part of the scrotum, if the
external ring contain nothing but the normal cord the swelling below
it can have no association with the abdominal cavity — it is not a
hernia. The tip of the ringer need not be made actually to enter
the ring by invaginating the scrotum and thrusting it up ; but in every
case of scrotal tumour the cord should be examined just below the
ring.

On account of the fascia lata being closely attached to Poupart's
ligament, tension of the fascia drags down the ligament and tightens
the aponeurosis of the external oblique. Therefore, before attempting
the reduction of an inguinal hernia, the thigh should be slightly flexed
and inverted. The hernia is rarely strangulated at the external ring,
because of the comparative slackness of its inner boundary ; the con-
striction is almost invariably in the neck of the peritoneal sac.

The internal oblique has its
fibres running upwards and inwards, ^
almost at right angles to those of
the external oblique, for the greater
strength of the abdominal wall ; the
directions of the fibres in the two
muscles are like those of the bars
of a lattice-work. The internal
oblique takes a fleshy origin from
the outer half of Poupart's ligament,
the anterior two-thirds of the iliac
crest, and the fascia lumborum, and
slopes upwards and forwards to be
inserted into the four lower costal
cartilages. As it approaches the
outer border of the rectus it becomes
aponeurotic, and then splits to en-
close the rectus. The anterior sheet
joins over the front of the rectus
with the. lamella of the external
oblique, to reach the linea alba, while the deeper layer passes to the
linea alba, along with the aponeurosis of the transversalis muscle

304 Abdominal Muscles

behind the rectus. Thus the sheath of the rectus is duly formed.
The lower part of the rectus is naked on its posterior aspect ; for in
the hypogastric region the internal oblique does not split, but, fusing
with the aponeurosis of the transversalis, passes over the rectus to the
linea alba and pubic crest. This fusion constitutes the conjoined
tendon of internal oblique and transversalis, which is attached just
behind the external abdominal ring. Except for this tendon backing
the ring, inguinal herniae would be much more common.

In its course from the outer half of Poupart's ligament to the pubic
crest the internal oblique does not arch clean over the cord ; some of
its lower border is carried down in front of the cord as looped mus-
cular fibres and connective tissue ; this is the cremaster or cremasteric
fascia (/cpf/xao-roy, hanging), and, like the inter-columnar fascia,
beneath which it is placed, it gives a covering to the cord and to an in-
guinal hernia ; over old herniae the cremaster is thick and conspicuous.
Under the stimulus of cold, the cremaster retracts the testicle ; its
nerve is derived from the genito-crural.

Posteriorly there is no free border to the internal oblique, as the
muscle there arises from the lumbar fascia.

The transversalis is named from the direction of its fibres. It is
the deepest of the flat muscles and arises from the inner surface of the
lower six ribs (where it inter-digitates with the diaphragm), from the
lumbar vertebrae, from the inner lip of the iliac crest, and from the outer
third of Poupart's ligament. The lateral part of the muscle is fleshy, but
as the fibres approach the linea semilunaris they are condensed into
an aponeurosis which passes with the posterior lamella of the internal
oblique behind the rectus, except in the lower part, where the trans-
versalis ends in the conjoined tendon, as already pointed out.

The loin-part of the muscle arises in three aponeurotic layers, of
which the most superficial is the strongest — the fascia lumborum —
it comes from the tips of the spinous processes. The middle sheet
passes between the erector spinae and the quadratus lumborum to the
tips of the transverse processes, and the anterior passes over the quad-
ratus to the front of the transverse processes, as shown in the figure
next above. The lowest border of the transversalis is free, arching
high over the cord, and giving no covering to it or to a hernia.

The separation between the flat muscles of the abdomen is indi-
cated by thin planes of connective tissue. In the neighbourhood of
the iliac crest the deep epigastric vessels course between the internal
oblique and transversalis, as shown on p. 156.

The rectus arises from the upper part of the pubes by a flat
tendon which quickly becomes fleshy, and, widening as it ascends, is
inserted into the front of the cartilages of the lowest true ribs. The
segmentation of the muscle has been already alluded to (p. 296),
and an account of the formation of its sheath is given above.

The lower part of the muscle is not inclosed in a sheath, its pos-

Lumbar Hernia 305

terior surface resting on the transversalis fascia. (For linece trans-
versce, see p. 296.)

When suppuration occurs in the substance of the rectus, the pus
may be confined between two of the transverse intersections ; but if
the abscess be below the level of the inferior segment the pus finds
its way down towards the pubes. Pus between the planes of the ab-
dominal muscles is directed towards the linea semilunaris and may
there reach the surface, but it may work its way do\vn to the iliac
crest, or along the inguinal canal, and into the scrotum. The starting
point of such abscesses is, usually, caries of the spine.

The quadratus lumborum is placed between the anterior and
middle layers of the lumbar aponeurosis of the transversalis muscle.
Three of its sides are attached, namely, to the iliac crest, the lumbar
transverse processes, and the last rib ; its outer border is entirely free,
and is a landmark in colotomy and in certain operations on the
kidney.

In front of it are the diaphragm arising from the external arcuate
ligament, the psoas, kidney, the ascending or descending colon
(according to the side), the anterior trunk of the last dorsal nerve, the
ilio-hypogastric and ilio-inguinal nerves. The anterior divisions of
the lumbar arteries, and the erector spinas, are behind it.

Lumbar hernia escapes on the outer side of the quadratus lum-
borum, taking, in addition to the covering from the peritoneum and
sub-peritoneal fat, the transversalis fascia ; it then causes a bulging of
the transversalis and internal oblique muscles, or passes through their
fibres, and escapes through the triangle oj Petit, bounded below by the
iliac crest, behind by the latissimus dorsi, and in front by the posterior
border of the external oblique. I have just recently had under
treatment a case of this sort, in which the hernia had emerged by the
track of a lumbar (spinal) abscess. The tumour was resonant on per-
cussion and reducible. Having returned it into the abdomen, I cut
down to the aperture, approximating its edges by deep sutures, having
thrust the sac within the abdomen. (' Brit. Med. Journal,' vol. i.
1888.)

The supply of the muscles of the abdominal wall is from the
anterior divisions of the lower intercostal and of the lumbar nerves,
notably by ilio-hypogastric, ilio-inguinal, and genito-crural. These
nerves run between the inner oblique and the transverse muscles to
the outer border of the rectus.

The blood-vessels are branches of the intercostals and lumbar ; of
the epigastric and circumflex iliac branches of the external iliac, and
of the internal mammary. The lymphatics are tributaries of lumbar,
pelvic, and mediastinal glands.

The transversalis fascia covers the peritoneal surface of the ab-
dominal wall ; it is distinct from the transversalis aponeuroses
(p. 304). Lining the transversalis muscle, it is attached along the

306

Abdominal Muscles and Fascia

inner lip of the iliac crest, and along Poupart's ligament. Below, it is
attached to the body of the pubes, covering the naked part of the
rectus, and the posterior layer of the sheath of that muscle ; it as-
cends as a thin sheet to lose itself in the phrenic vault. At the um-
bilicus it is firmly connected with the back of the linea alba. It is
joined with the iliac fascia (p. 307) along the outer half of Poupart's
ligament, but it descends free under the inner half of the ligament, in
front of the external iliac vessels, forming the anterior layer of the
crural sheath (p. 313). More internally, it is attached to Gimbernat's
ligament, where it is again connected with the iliac fascia. Just before
it passes beneath Poupart's ligament it is thickened and forms the
so-called deep crtiral arch, a structure of no special interest.

The parts of the fascia which are of greatest surgical importance
are the anterior layer of the crural sheath, and the process, like the
finger of a glove, which the testis carries in front of it in its descent.
This process is, at an early period of its development, much wider
above than below, like a funnel, and is called the infundibuliform
fascia. It entirely surrounds the spermatic cord, and the testicle lies
at the bottom of it. In the adult who has no inguinal hernia the
peritoneal aperture of the process is small and elliptical, constituting
the internal abdominal ringr. It is placed to the outer side of the

deep epigastric artery, about an inch above the middle of Poupart',
ligament, as is shown in the adjoining figure from Gray.

Iliac Fascia 307

As the transversalis fascia completely lines the antero-lateral
aspect of the abdominal cavity, no hernia can escape thence without
deriving a covering from it. The femoral variety takes an investment
from it under the name of the anterior layer of the crural sheath ;
the oblique inguinal hernia is, like the cord, invested by the infundi-
buliform process, and direct inguinal and umbilical herniae derive
special investments from it.

The coverings of an oblique inguinal hernia are, then, skin, two
layers of superficial fascia, intercolumnar fascia (of external oblique),
cremasteric fascia (of internal oblique), infundibuliform fascia, sub-
peritoneal fat, and the sac. In the female an oblique inguinal, labial
hernia may enter the labium pudendi ; it has the same coverings as a
scrotal hernia, except that there may be no representative of cremas-
teric fascia.

The iliac fascia is a strong investment for the iliacus and psoas ;
it is beneath the iliac vessels, and is connected above with the internal
arcuate ligament. Internally it is attached to the vertebral column
and to the brim of the true pelvis ; externally it meets the transversalis
fascia at the iliac crest and along the outer half of Poupart's ligament.
Passing down beneath the external iliac vessels, it forms the posterior
layer of the crural sheath, and on the inner side of them it joins the
transversalis fascia at Gimbernat's ligament. The branches of the
lumbar plexus are beneath it. (For crural sheath see p. 313.)

The iliacus arises from the iliac fossa and ilio-lumbar ligament,
and slightly from the capsule of the hip-joint, over which it passes to
its insertion into the tendon of the psoas and into the femur below it. It
flexes, adducts, and everts the thigh. It is closely covered in by the
iliac fascia and has in front the external cutaneous nerve, peritoneum,
caecum or sigmoid flexure (according to side), and, more internally,
the psoas and anterior crural nerve. It passes under Poupart's
ligament, a bursa intervening between it and the hip-joint. Lower
down, it is covered by the fascia lata, sartorius, and deep femoral
vessels.

The psoas arises from the bodies and transverse processes of the
last dorsal and the lumbar vertebrae, and from the intervening discs.
Its upper end extends beneath the internal arcuate ligament ; it
descends below Poupart's ligament and is inserted into the lesser
trochanter. Its action resembles that of the iliacus, but, in addition,
it acts upon the lumbar spine.

It is invested by the iliac fascia, and in its substance is the lumbar
plexus— the ilio-hypogastric, ilio-inguinal, and external cutaneous
emerge along its outer side, the genito-crural pierces it in front, the
obturator lies along its inner border, and the anterior crural is em-
bedded between it and the iliacus, which is on its outer and posterior
aspect. The vena cava, on the right, and the aorta, on the left, and,
lower down, the common iliac vessels, lie along its inner border.

x 2

308 Abdominal Muscles and Fascice

Additional anterior relations are the kidney, ureter, and renal and
spermatic vessels, peritoneum and colon, and, lower down, the external
iliac and common femoral artery. Behind it are the quadratus lum-
borum, the anterior division of last dorsal nerve, the anterior lumbar
arteries, the brim of pelvis, capsule of hip-joint, and the bursa. Below
Poupart's ligament the internal circumflex artery intervenes between
its inner border and the pectineus.

The iliacus and psoas are supplied by the anterior crural nerve.

The course taken by spinal abscess is greatly controlled by the
arrangements of fasciae and muscles. Pus from caries of the lower
dorsal vertebrae may find its way beneath the internal arcuate liga-
ment into the substance of the psoas —beneath the vertebral part of
the iliac fascia — and may descend beneath Poupart's ligament into the
front of the thigh. Pus from lumbar caries may pass at once into
that sheath, or, working behind the psoas, may enter the sheath of
quadratus lumborum (see p. 305), and point on the outer side of the
erector spinae (lumbar abscess) ; or it may infiltrate itself between the
large, flat muscles to point against the linea semilunaris, or it may
wander into the inguinal canal and so reach the scrotum. From the
lower lumbar vertebrae the matter may course under or through the
psoas, to get beneath that piece of fascia which binds down the iliacus,
and will then bulge in the inguinal region (iliac abscess), or, possibly,
on the front of the thigh. Or, sinking in the pelvis, it may find exit
by the great sacro-sciatic notch (gluteal abscess) or by the ischio-rectal
fossa. When suppuration occurs between the transversalis, muscle and
the transversalis fascia, or between that fascia and the peritoneum, there
is nothing to prevent the abscess extending across the middle line.

When the sheath of the psoas is filled by pus there is a fulness in
the iliac fossa, the furrow over Poupart's ligament being partially
effaced, and fluctuation being obtainable between the base of Scarpa's
triangle and the inguinal region — that is, beneath Poupart's ligament.
The thigh is kept flexed so as to diminish the pressure on the lumbar
plexus. The presence of matter in the psoas gradually determines
the absorption of the muscular tissue, and at last the sheath contains
only the lumbar plexus bathed in pus. Psoas abscess is almost in-
variably the result of spinal caries.

The sub-peritoneal fascia is a loose layer of connective tissue
and fat between the peritoneum and the transversalis and iliac fascia;.
It is thick in the loins, where it forms a soft bed for the kidneys. There
is a good deal of it also in the iliac fossae, where an unimportant
horizontal fold of it, the septum crurale, blocks the innermost com-
partment of the crural sheath. A loose investment from it surrounds
the cord, and gives an unimportant covering to inguinal hernia. (The
cover ngs of the hernia are, therefore, skin, two layers of superficial
fascia, intercolumnar cremasteric, and infundibuliform fascia: and sub-
peritoneal fat.)

Inguinal Canal 309

Small lobulated offshoots from this subserous layer are apt to pro-
trude through the iinea alba, and sometimes they grow into mushroom-
like masses which closely simulate omental hernioe. They differ from
omental hernia in that they are enclosed in no peritoneal sac ; but
this cannot be recognised until they are exposed by an incision, as in
an attempt to perform a radical operation for their obliteration. In
puerperal cellulitis inflammation spreads rapidly through the sub-
serous layer, and an abscess in it may open into the peritoneal cavity,
into an abdominal or pelvic viscus, or, passing outwards, may find
escape through the abdominal wall.

Anastomosis between parietal and visceral blood-vessels. —
In the sub-peritoneal tissue there is a delicate but general anastomosis
between the blood-vessels of those viscera which are on any particular
surface destitute of peritoneum, and those of the adjacent abdominal
wall. Thus, the hepatic vessels communicate with phrenic and inter-
costals ; renal and supra-renal with phrenic, intercostal, and lumbar ;
pancreatic and duodenal with phrenic and intercostal ; colic with
ilio-lumbar, circumflex iliac, lumbar and intercostal ; ovarian with
iliac ; haemorrhoidal with sacral, iliac, and pudic, and spermatic with
cremasteric and perineal. These important anastomoses explain the
value of cupping and leeching in hepatic and renal congestion, and in
ovaritis, epididymitis, and orchitis.

The inguinal canal is the tunnel, \\ in. long, through which the
spermatic cord descends. It runs obliquely, so that there may be
less chance of a piece of bowel entering it — in a similar manner the
ureter passes through the strata of the vesical wall, so that in disten-
sion of the bladder the sides of the passage may be pressed against
each other and regurgitation towards the kidney prevented.

The upper end of the inguinal canal is the internal abdominal ring,
about an inch above the middle of Poupart's ligament; the lower
end is the external ring, on the pubic crest. As the canal follows the
downward course of Poupart's ligament, the internal ring is further
from the middle line of the body than the external. Behind the canal
the deep epigastric artery runs in a direction upwards and inwards.
The artery lies, therefore, to the outer side of the external ring (but
at a much deeper level), and to the inner side of the internal ring, as
shown on p. 306.

Boundaries of the canat.—The floor is formed by Poupart's liga-
ment and the pubic crest. Posteriorly is the conjoined tendon.
Above are the arched border of the transversalis muscle and the
lower part of the internal oblique. In front are cremasteric and inter-
columnar fascise. Loosely investing the cord is the funnel-shaped
process of the transversalis fascia, which thus lines the canal.

3io

Inguinal Hernia

INGUINAL HERNIA

Oblique inguinal hernia follows the course of the spermatic cord
through the internal abdominal ring and along the inguinal canal.
Emerging on the outer side of the deep epigastric artery, it is also
called external inguinal hernia. It passes in front of the spermatic
cord, and may enter the scrotum or the labium.

If the protrusion be arrested in the inguinal canal, it is called
bubonocele, from its resemblance to a gland (povfav, gland; 107X17
tumour); its coverings then vary with the extent to which it has
advanced.

On account of the recent descent of the testis, and the imperfect
closure of the canal, oblique inguinal hernia is common in childhood ;
in the subsequent growth and development of the child it may be ex-
pected to disappear under the influence of a truss. This hernia passes
down into the funicular process of peritoneum which
accompanied the testis (see p. 429), and if it descend far
enough it comes in contact with the testis, lying above
and in front of it. Though this kind of hernia is fre-
quently met with in adults, it bears the name con-
genital, as expressive of its anatomical peculiarity. In
the female, congenital hernia descends in the canal of
Nuck (p. 390-

When the funicular process is closed only at the ab-
dominal end, a hernia in a sac of its own may descend behind the
tunica vaginalis, so that in front of the bowel there are three layers of

peritoneum, the two layers of the tunica,
and its own sac. This constitutes an
infantile hernia. If the sac of an in-
fantile hernia push its way into the top
of the open tunica the variety is called
encysted.

Occasionally an inguinal hernia in the
adult, though emerging through the ex-
ternal abdominal ring, has not passed
down with the cord, but has escaped from
the abdominal cavity through that part
of the anterior wall which is bounded externally by the deep epigas-
tric artery, internally by the rectus, and below by the inner end of
Poupart's ligament and the pubic crest. This space is Hesselbach's
triangle, and the hernia which passes through it is designated, from
the short and straight course which it takes to the surface of the body,
direct, or, from the position of its egress as regards the epigastric
artery, internal. The triangle is figured on p. 306.

The coverings of direct hernia vary according to the part of

Congenital her
nia ; x, testis.

Hernia behind
tunica vagi-
nalis, T v.

Encysted her-
nia into tu-
nica vagina-
lis, T V.

Inguinal Fossettes 311

Hesselbach's triangle through which it has escaped. If it have
escaped close on the inner side of the artery, that is, between the
artery and the outer border of the conjoined tendon, the coverings
are just those of oblique hernia, only the fascia transversalis taken
in front of it will not be the c infundibuliform process,' as that is the
piece of the fascia which specially surrounds the cord. A direct
hernia emerges on the inner side of the cord, and its neck is close
over the pubes, whilst the oblique runs as a pyriform mass from
above the middle of Poupart's ligament. On reducing a direct
hernia the external border of the rectus can be made out close on
the inner side of the short straight passage by which the protrusion
emerged.

If the direct hernia pass out nearer to the border of the rectus, it
bursts through the conjoined tendon, or carries it in front ; the cover-
ings are then peritoneum (the sac), subperitoneal fat, transversalis fascia,
conjoined tendon (unless it have passed through it), intercolumnar
fascia, superficial fasciae, and skin. This hernia pushes straight
through the abdominal wall, and occupies but the lowest and inner-
most part of the inguinal canal. It cannot take a twofold investment
from the internal oblique — it takes the internal oblique in the form of
conjoined tendon, instead of the cremaster.

The inguinal fossettes are three depressions in the inguinal
piece of the parietal peritoneum, caused by the ridge-like elevations
over the obliterated hypogastric and the deep epigastric (p. 306)
arteries. The innermost fossette is between the outer border of the
rectus and the ridge of the hypogastric artery ; the middle one is
between that ridge and the elevation caused by the epigastric artery,
and the outermost is external to the epigastric ridge — behind the in-
ternal abdominal ring. The external direct hernia passes through the
middle fossette, and the internal direct through the innermost.

The seat of stricture in an oblique inguinal hernia may be at
the external or internal abdominal ring, in which case the protrusion
may be returnable after division of the external oblique aponeurosis,
or the transversalis fascia, and without opening the peritoneal sac.
But the strangulation is almost invariably in the narrow neck of the
peritoneal sac itself, so that the operator generally has to open the sac ;
in doing this, discoloured serum escapes ; he then sees the bowel,
congested or plum-coloured, or black and gangrenous. Introducing
a strong, narrow, probe-pointed knife, on the flat, and turning its edge
against the constricting band, he makes a small incision directly
tip-wards. Thus he is sure of avoiding the epigastric artery, which
would be wounded if, in operating on a direct hernia, he were to cut
outwards, or, in an oblique hernia, inwards. As he does not always
know on which side of the artery the hernia has emerged, the rule to
cut upwards is invariable. Generally he can recognise a direct hernia
by its forming a rounded protrusion over the pubes. But an oblique

312 Inguinal Hernia

hernia of old standing may so drag down the epigastric artery as to
lie close to the pubes ; he may then mistake it for a direct hernia. In
every inguinal hernia, then, whether diagnosed as oblique or direct, the
strangulation is to be eased by an upward incision in the neck of the sac.

A strangulated inguinal hernia does not necessarily require a
cutting operation ; the surgeon may be able to return it by taxis (rn£t?,
an arrangement): he lays the patient supine, with the pelvis raised,
and he flexes the thigh and inverts it, to relax Poupart's ligament and
the abdominal wall ; then, taking the neck of the sac between the
fingers and thumb of his left hand — making them into a sort of funnel —
he endeavours to squeeze back the contents of the tumour. Years ago,
the patient was prepared for taxis by emetics, hot baths, tobacco
clysters, and even venaesection, with the view of diminishing general
and local resistance ; ether has happily rendered this treatment
obsolete. Before using taxis the patient should be kept on his back,
with pelvis raised, in hopes that, the vessels of the bowel being emptied
to the utmost, the mesentery may draw back the protruding knuckle.

Reduction en masse is the thrusting of the peritoneal sac and its
contents bodily within the abdomen,the strangulation not being relieved.
So symptoms persist ; and perhaps a tumour may be felt deep in the
iliac fossa. Moreover, the scrotum is found empty of sac. In such a
case the inguinal canal has to be opened up, the peritoneal cavity
explored, the mass brought down, the strangulation relieved, and the
bowel returned. Sometimes the sac and its contents get pushed up
between the peritoneum and the abdominal wall

If the constant wearing of a truss fail to prevent the descent of
a hernia, the radical treatment may be contemplated. The old
methods of performing the so-called radical ' cure ' were as complicated
in description as they were ingenious in execution ; they have now
given place to straightforward and simple operations on the principle
of occluding the neck of the peritoneal sac and partly closing the
external abdominal ring : an incision is made down the axis of the
tumour from the external ring, through skin and superficial fasciae,
intercolumnar, cremasteric, and infundibuliform fasciae, till the sac is
reached ; its contents are then returned, its neck, isolated from the
elements of the subjacent cord, is tied as high up as possible, and the
sac is cut away below the ligature. The wide mouth of the canal is
then partially occluded by lace sutures securely passed through the
pillars of the external ring.

The radical treatment is also usually performed after operating for
the relief of a strangulated hernia.

FEMORAL HERNIA

The external iliac vessels are continued into Scarpa's triangle,
beneath Poupart's ligament, between a prolongation of the transversalis

Femoral Hernia

313

fascia in front and of the iliac fascia behind. These two pro-
longations join on either side of the vessels, and the funnel-shaped
investment thus formed is the crural sheath ; it blends with the
connective-tissue sheath of the vessels about an inch below Poupart's
ligament.

Three compartments are made in the crural sheath by two antero-
posterior fibrous septa ; the outermost compartment contains the
common femoral artery, the middle the vein, and the innermost a
lymphatic gland. The anterior crural nerve, being beneath the iliac
fascia, cannot be within the sheath.

The innermost compartment is the femoral or crural canal ; it ex-
tends less than an inch into the thigh : from the base of Gimbernat's
ligament to the margin of the saphenous opening ; its abdominal
orifice, which is about large enough to admit the top of the little finger,
is overlaid by the peritoneum ; between it and the peritoneum is a
(practically) unimportant layer of sub-peritoneal connective tissue,
which, on account of its covering the aperture, is called the septum
crurale. See illustration on p. 306.

Relations of the crural canal. — In front is Poupart's lig'ament ;
behind is the pubic part of fascia lata covering the ramus of pubes and
the pectineus ; internally is Gimbernat's ligament ; and externally is
the common femoral vein, and, possibly, the irregular obturator artery.
Its apex reaches down to the top of the saphenous opening. The
spermatic cord, which lies along Poupart's ligament, is just above and
in front of the canal, and the deep epigastric artery, in its inward
ascent, lies external and superior to it.

Femoral hernia descends through the crural ring and down the
crural canal to the top of the saphenous opening. The bowel takes as
its coverings a sac of peritoneum ; then, probably, the sub-peritoneal fat
— under the name of septum crurale ; in the canal it derives an invest-
ment from the anterior wall of the crural sheath — that is from the pro-
longation of the fascia transversalis. Arrived at the lower limit of the
crural canal, the hernia comes forward through the saphenous open-
ing, taking the deep layer of the superficial or cribriform fascia, the
fatty layer, and the skin. Thus, the coverings from above downwards
are skin, two layers of superficial fascia, crural sheath, septum crurale,
and peritoneum.

The course of a femoral hernia is downwards, into the canal ;
then forwards through the saphenous opening ; and, lastly, upwards
towards Poupart's ligament or the iliac crest.

The hernia is superficial to and above the saphenous vein.

Before employing taxis the thigh should be flexed and slightly
inverted so as to relax the fascia lata, and especially its falciform
border, against which the bowel would otherwise be bruised. The
fingers and thumb of the left hand are arranged around the neck of
the hernia — to steady it — and the tumour is gently but firmly squeezed

314 Femoral Hernia

downwards, and backwards round the falciform process, and then
upwards through the crural ring.

The seat of the strangulation of a femoral hernia is at the rigid
margin of the crural ring, that is, outside the sac. Therefore, the
operator may expect to effect reduction, after easing this constriction,
with the hernia-knife, without opening the sac. He divides all the
coverings down to the sac by a vertical incision, and then slips the probe-
pointed bistouri through the crural ring, in front of the neck of the sac,
easing the constriction by a slight incision upwards and inwards, but
not too much upwards, lest he sever Poupart's ligament, and wound
the spermatic cord which lies along it, or the epigastric artery which is
above it. The fibres divided are those at the junction of Poupart's
and Gimbernat's ligaments.

Allusion is made elsewhere (p. 371) to those rare instances in which
the operator wounds an irregular obturator artery.

Perinea! and vaginal berniae are closely associated anatomi-
cally ; they pass down in front of the rectum. The former descends
in its peritoneal sac along the rami of the ischium and pubes to the
perineum through the levator ani, deriving a covering from the recto-
vesical fascia ; the latter simply bulges into the vagina.

Obturator hernia escapes through the upper part of the thyroid
foramen, where it would compress the obturator nerve, causing peri-
pheral neuralgia. (There is a good example of this hernia in the
museum of St. Mary's Hospital, No. C. d. 19). To ease the strangula-
tion of an obturator hernia, an incision would be made from the inner
third of Poupart's ligament vertically down the thigh for three or
four inches, dividing skin, superficial fascia, fascia lata— the common
femoral and the long saphenous veins being carefully avoided. Then
the pectineus would be exposed, and the interval between it and the
adductor longus would be carefully traversed. The short adductor
having been drawn downwards and inwards, the small protrusion
would be recognised. If it were necessary to enlarge the shallow
obturator canal, the obturator membrane might be incised by the
hernia-knife.

Hernia through the great sacro-sciatic foramen, like the varieties
just mentioned, is very rare.

THE CAVITY OF THE ABDOMEN

The peritoneum lines the abdominal cavity and is stretched
around (Ti-f/K, rcti/ftp) most of the viscera, its reflections constituting
' false ligaments.' The attachment to the abdominal walls is not very
intimate except in the neighbourhood of the umbilicus ; in the opera-
tion of ligation of an iliac artery the peritoneal pouch can be easily
stripped up from the iliac fossa ; whilst an abscess bursting through
the back of the liver, between the layers of the coronary ligament,

Peritonitis 3 1 5

may pass forwards between the peritoneum and transversalis fascia
to the middle line or even across it.

Except in the female, where the Fallopian tubes pierce it, the
peritoneum is a shut sac. It is lined by squamous endothelium, which
secretes a serous exudation so as to allow the coils of intestine to roll
freely over each other. In intestinal wounds and ulcerations plastic
peritonitis often prevents leakage of the contents of the bowel into the
general cavity. Thus, gall-stones may escape into the colon ; spinal
abscess may be discharged into small or large intestine, and peri-
caecal suppuration may be relieved through the groin with the occur-
rence of no more than a limited and conservative inflammation. By
the theory of inflammatory adhesions encysted peritoneal collections
are explained.

In peritonitis, on account of the swelling and tenderness, the
patient lies supine with his shoulders raised and his knees drawn up,
so as to relax the abdominal muscles and to ward off the weight of the
bed-clothes. As the inflammation extends to the muscular wall of
the intestine it paralyses it, and thus constipation sets in. Decom-
position of the contents of the bowel occurs, gas being evolved,
and tympanites resulting. To ensure complete rest for the inflamed
bowel, opium is administered. As the descent of the diaphragm in
respiration disturbs the inflamed membrane, respiration is carried on
entirely by the ribs and the intercostal muscles. The arms are often
thrown up and the hands placed behind the head, so as to give the
pectoral muscles a greater command over the ribs.

Inflammation of the peritoneum is accompanied by the deposit of
plastic material upon its surface, and when two areas of inflamed
membrane lie in quiet apposition the effusion may glue them perma-
nently together. But it often happens that before the effusion can be
thus organised the movements of the bowel itself, or of the abdominal
walls, gently drag the sticky surfaces apart, false bands and lengthened
fibrous adhesions being thus spun out. These bands offer a dangerous
snare to the neighbouring coils of bowel, and are a common cause
of intestinal obstruction, especially in the neighbourhood of the
uterus.

In the course of acute peritonitis the muscular coat becomes
implicated in due course ; the exudation into it and into the nerve
plexuses throws them out of working order, and the symptoms of
acute obstruction arise. It has happened to surgeons (besides my-
self) to open the abdomen for the relief of acute obstruction and to
find no other cause for it than acute peritonitis.

When a patient has intestinal muscular cramps — colic — it may be
at first a question whether his distress is due to peritonitis or not. If
the surgeon can move the flaccid abdominal wall freely over the bowel
there is no peritonitis. The peritoneal cavity is like a joint — when
the latter moves easily there is no synovitis.

316

The Peritoneum

On account of the close proximity of the peritoneum and pleura,
pleurisy sometimes sets up peritonitis. The intestines being inflated,
the diaphragm is so greatly raised that the heart and lungs work with
difficult)', and the patient is thereby much distressed. Sibson advised
that in such conditions a long flexible tube be passed into the stomach
or colon, or that gas be removed by puncture of bowel.

The pains of colic may be relieved by pressure, but in peritonitis
even the weight of the bed-clothes may be intolerable. In local peri-
tonitis a roughened serous surface, of the liver, for instance, may rub
against the parietal layer during respiration and so give rise to a
friction-sound.

The convalescent from peritonitis walks about with a stoop ;
standing up straight causes pressure upon the still tender sac.

Hernial sac.— As, with certain exceptions, the whole of the in-
testinal canal (in addition to its proper serous
coat) is enclosed within the general peritoneal
cavity, no knuckle of bowel can escape from the
abdomen without taking before it a pouch from
the parietal layer ; this constitutes the hernial
sac.

The great omentum, attached above to the
stomach and transverse colon, and descending
as an apron in front of the small intestine, is apt
to form part of the contents of a hernial sac ; it
escapes in front of the intestinfc through an
abdominal wound. When, at a herniotomy, bowel
and omentum are found in the sac, the bowel
should be returned first. Omentum is almost
certain to enter an umbilical hernia, and it may
have to be torn through before the strangulated
knuckle of bowel is reached. When the end of
the omentum is fixed in a hernial orifice, or has,
in some other way, formed an attachment to the
abdominal wall, it may strangle a coil of in-
testine ; a loop of bowel is sometimes caught in
a hole in the omentum. Malignant tumours are
apt to start from the pendulous folds.

Ascites (CUTKOS, a skin bottle) is effusion of
serous fluid into the peritoneal cavity. When
it is associated with dropsy of the body generally,
it is probably due to obstructed flow of blood
through heart, lungs, or kidneys. But when
peritoneal dropsy is unassociated with cedei
in other regions, obstruction is to be suspect<

in the liver, the serous fluid oozing from the congested capillaries
the tributaries of the vena portae. If the amount of effusion

Abdominal Dropsy 317

small, there is dulness in each flank, and resonance over the whole
antero-lateral aspect of the abdomen as the patient lies on his back —
the resonance being due to the inflated intestines floating on the fluid.
But on turning the patient upon the side the area of dulness changes.
Were the fluid enclosed in a cyst, as in ovarian disease, percussion
would be but little affected by change of position. If the patient sit up
or stand the area of dulness extends across the inguinal and hypo-
gastric zone, the higher regions becoming resonant. When the effusion
is excessive, resonance may be discoverable only behind the recti, as
the patient lies supine. The diaphragm is then pushed far up, and
respiration is short and thoracic. The patient may breathe more
easily in the sitting posture, for in that way the compressible intestine,
and not serum, lies against the diaphragm. (See figs, on p. 316.)

Tapping- the abdomen. — An enormously distended bladder has
sometimes been mistaken for ascites ; the rule, therefore, is to empty
the bladder before thrusting in the trocar. The puncture should be
made in the median or semilunar line (p. 296) ; as the fluid escapes
pressure is removed from the caval and other deep abdominal veins,
which now become distended, so that the heart is robbed of its accus-
tomed supply, and faintness comes on ; the descent of the diaphragm
also embarrasses the heart's action. Puncture through the semilunar
line of the recumbent patient is a satisfactory operation ; the patient
should be rolled a little on to the side selected. But if there be so
much distension that the rectus is flattened out and displaced, and
the situation of the semilunar line cannot be determined, it were
better to follow the usual English custom, and to operate in the exact
median line. There, for certain, no vessel will be injured or muscular
plane traversed. The patient sits over the edge of the bed, and the
puncture is made a few inches below the umbilicus ; as the fluid
escapes, a jack-towel, which was previously arranged round the trunk,
is tightened up, so that the risk of faintness may be lessened. Some-
times, when the serum is only partially drawn off, the flow is checked
by the omentum or a piece of intestine being carried against the end
of the tube ; the obstruction is to be overcome by passing a probe
down the cannula.

Development of intestines. — The early intestinal canal is a
straight cylindrical tube in the internal blastodermic layer ; it runs
in the long axis of the germ, and its ends are closed. As the growth
of the tube proceeds with great rapidity, it escapes in abundant coils
through the front of the abdomen, which is as yet not closed in. But
after the end of the second month energetic growth of the abdominal
walls takes place, so that the truant viscera are soon surrounded and
swept within the cavity. I have seen a new-born infant in whom
there had not been this subsequent growth of the parietes, so that not
only were the bowels protruding from sternum to pubes, but the
liver and the urinary bladder were also prolapsed. These viscera

318

Abdominal Viscera

were covered only by a thin and transparent membrane. A congenital
umbilical hernia is a slighter degree of the same arrest of develop-
ment, but with the growth of the child it usually disappears.

Ectopia viscerum, the result of imperfect development of chest and abdomen, a, liver ; />,
heart ; c , lung ; d, stomach ; e, spleen ; f, bowel ; <,»-, kidney ; //, chorion ; ;', amnion ; A;
umb. cord ; »i, placenta.

THE ABDOMINAL VISCERA

Stomach and intestine. — The stomach extends across the epi-
gastrium, between the two hypochondriac regions, but its position,
like its shape and size, is liable to considerable variation. (Sec
p. 164.)

Placed in the vault of the diaphragm, it has that muscle above and
in front of it, the liver intervening between its anterior surface and the
diaphragm towards the right side, whilst a wedge of lung descends
between the ribs and diaphragm in front of the stomach on the left
side. An additional anterior relation is the abdominal wall, close
behind which it lies. Behind are the vertebral column, crura of dia-
phragm, aorta, vena cava, and pancreas. Below it are the transverse

Stomach; Pylorus 319

colon and coils of small intestine. The left end fills in the hilnm of
the spleen and covers the kidney.

The heart is separated from the stomach only by the diaphragm,
and their close proximity goes far towards justifying the advice — * If a
patient complain of his " stomach " suspect heart-disease ; if he com-
plain of his " heart " suspect indigestion.' When the stomach is
excessively distended it thrusts down the transverse colon and small
intestine, and not only obliterates the depression below the ensiform
cartilage, but causes it and the left ribs and their cartilages to bulge
forwards ; it also thrusts upwards the liver, diaphragm, and heart.
Thus, flatulence may seriously interfere with the working of the heart
as well as of the lungs. Sometimes after a heavy meal, on account of
this elevation of the heart, the right side is so full of venous blood
that the capillaries of the brain and of the head imperfectly empty
themselves, the face becoming flushed and the cerebral circulation
disturbed ; respiration also is interfered with. The fuller the stomach,
the farther the liver is pushed up under the right arch of the dia-
phragm ; and when the stomach and the alimentary canal are empty,
as in cancer of the oesophagus, the liver sinks towards the epigastrium,
for it has lost much of its support ; the diaphragm also descends and
the heart is found on a very low level.

(The exact shape and size of the stomach may be made out by
percussion, after the patient has swallowed first some tartaric acid
and then some bicarbonate of soda. This method of examination
must not be employed if there be a question of gastric ulcer ; nor
indeed, is it often needed.)

Into the cardiac end of tJie stoinacJi the oesophagus opens without
any other valvular arrangement than that afforded by the muscular
fibres around the aperture by which the gullet passed through the
diaphragm. The opening is at about the level of the tenth dorsal
vertebra, a little to the left- behind the seventh costal cartilage.
The right end is continuous with the duodenum, the junction being
marked by a thickening of the circular fibres to form the pyloric valve
(TTiAj/, gateway), which, when the stomach is empty, lies behind the
liver, about a couple of inches below the gladiolus, and a little to the
right of the linea alba, at the level of the first lumbar vertebra. When
the stomach is distended the pylorus is thrust into the right hypo-
chondriac region, where it lies behind the right lobe of the liver and the
upper false ribs.

The upper border of the stomach is short and concave, and is fixed
to the liver by the gastro-hepatic omentum, between the layers of which
are the coronary artery and the vessels passing through the gateway
of the liver. From the lower, convex, border the great omentum hangs.
This border may descend even into the pelvis, as in the case of dilatation
due to pyloric stricture.

When a person goes to bed with an undigested meal in his stomach

320 The Stomach

the hard masses fall against the lesser curvature and the cardiac end,
and, irritating the pneumogastric, cause irregularity of the heart's action,
palpitation, and faintness, or, perhaps, asthma. After an attack of
vomiting the symptoms promptly subside.

Structure. — The stomach and intestine consist for the most part of
serous, muscular, submucous, and mucous coats. The muscular coats
consist of pale fibres arranged longitudinally, and, more deeply, in a
circular manner, the circular fibres being aggregated to form the
pyloric sphincter above and the internal sphincter ani below.

On the stomach the longitudinal fibres (continuous above and
below with those of the oesophagus and duodenum) are chiefly along
the two curvatures. The oblique fibres are deeply placed at the cardiac
end and are continuous with the circular fibres of the oesophagus.

The stomach is invested front and back by peritoneum, which
comes down in the gastro-hepatic omentum and is continued from the
lower curvature as great omentum.

The mucous membrane from the cardiac orifice of the stomach to
the anal part of the rectum is lined with columnar epithelium ; columnar
epithelioma is, therefore, the variety of malignant disease generally
associated with the alimentary canal.

When a piece of intestine is wounded, as in a stab in the abdomen,
the mucous membrane bulges through the wound in the serous and
muscular coats and so plugs the opening.

The arteries of the stomach come from the gastric, splenic (vasa
brevia and left epiploic), and hepatic (pyloric and right epiploic). The
veins are tributaries of the portal vein and run chiefly along the greater
curvature. They are often found much congested after death ; such
venous fulness is very different from the widely-spread congestion
of the capillaries found after irritant poisoning, and may be recog-
nised on opening the stomach and holding it up to the light. The
nerves are the pneumogastrics, and branches of the solar plexus ; the
left pneumogastric passing chiefly to the anterior surface. The lym-
phatics end in glands along the curvatures, and are associated with the
mediastinal glands, and indirectly also with those of the root of the
neck (p. 140).

Gastric catarrh interferes with digestion and causes a feeling of
fulness in the region of the stomach. The food undergoes decom-
position in the stomach, gas being evolved, and the patient is worried
with eructations, oppressed breathing, and cardiac disturbance, the
diaphragm being raised by the distended stomach. The inflammation
is chiefly along the greater curvature, so that discomfort occurs im-
mediately food is taken into the stomach ; whereas, in the case of
gastric ulcer, the lesion is probably near the lesser curvature, so that
pain does not come on so quickly after the meal. Though it is often
difficult to differentiate between catarrh and ulcer, an important sign is
that pain occurs only when food is in contact with the ulcer, so that

Gastric Ulcer 321

vomiting brings immediate comfort ; in catarrh the trouble is more
constant. With ulcer there is pain in the back, over the lower dorsal
spines, and, generally, blood is vomited.

Gastric ulcer is usually preceded by catarrh, the epithelial lining
being detached over small areas ; the ulcer is most liable to attack the
pyloric end of the posterior wall, near the lesser curvature. Should it
implicate a large branch of artery, fatal haemorrhage may result. In
haematemesis (e/^eo-t?, vomiting) the blood comes up in vomiting, not
in coughing ; it is not frothy or bright-coloured, but it is acid from
admixture with gastric juice ; blood from lung, pharynx, or nares may
find its way into the stomach and be voided by vomiting, so that blood
which is vomited is not necessarily the result of gastric haemorrhage.
If the ulcer cause perforation, the extravasated matter from the stomach
may come directly in contact with the solar plexus, death occurring
rapidly from shock or peritonitis, unless adhesions have glued the
margin of the ulcer to liver, pancreas, duodenum, or colon. On the
front of the stomach conservative adhesions are less likely to occur.
Sometimes, however, the ulcer opens harmlessly into the duodenum
or colon. If an ulceration be diagnosed upon the posterior wall, the
patient must be kept lying prone.

When ' ulcer ' has been diagnosed the diet should be of the lightest
kind, and the patient should be kept lying down, so that if, as often
happens, ulceration extend to the serous coat, local plastic peri-
tonitis may glue the treacherous area to the liver, general peritonitis
being thus averted. Grave collapse is the great sign of perforation,
and of extravasation of food having occurred into the peritoneal cavity.
To ensure absolute rest, no food whatever should be given by the
mouth.

Dyspepsia. — In disease of the heart, as also in cirrhosis of the liver,
there is impeded circulation, the vena portae being overladen, and
gastric catarrh and dyspepsia resulting. Thus it happens that ' indiges-
tion ' may be the most prominent symptom of morbus cordis. The
nerves of the stomach grow over-sensitive, and, as soon as food comes
in contact with them, there is discomfort, a feeling of fulness, or actual
pain, which may be relieved only by vomiting. As the patient gets
worse the food and glairy mucus which he vomits are streaked with
blood which has escaped from the over-loaded capillaries, and as the
disease still further advances the vomit consists of acid mucus and
darkened blood. This is the ' black vomit ' so often seen in the
dying.

Vomiting is accomplished by the abdominal muscles compressing
the stomach against the diaphragm and liver, the cardiac orifice being
relaxed. First a deep inspiration is taken, so that the diaphragm
may lie at its lowest level ; it is then fixed by the firm closure of the
glottis ; a patient with an opening in the trachea cannot vomit, as the
diaphragm cannot be fixed. The fuller the stomach, the easier is the

322

The Stomach

act, so that an emetic should be administered in plenty of warm water.
Vomiting may be caused by irritation of the pneumogastric filaments
in the pharynx as well as stomach, or even in the brain itself, as in
cerebral disease, or in a sea-voyage. Free expectoration of bronchial
mucus is excited by vomiting ; thus in certain chronic pulmonary con-
gestions an emetic is useful. In vomiting the tonsils are compressed
by the superior constrictor, and in acute quinsy an emetic may thus
effect the bursting of a tonsillar abscess, or, after amputation of tonsils,
may check troublesome oozing.

The close association between the stomach and brain is exemplified
by sea-sickness and by the vomiting which occurs on the return of
consciousness after cerebral concussion. But irritation of the gastric
filaments of the vagi is often misinterpreted by the brain as the re-
sult of pulmonary unrest ; and so arises the ' stomach cough.' When
vomiting is long-continued the bile-stained contents of the duodenum
are voided, and, later, the lower part of the small intestine is emptied ;
the ejecta then have a stercoraceous odour ; but in so-called ' faecal
vomiting ' the large intestine is not being emptied : this is prevented
by the ileo-caecal valve.

Eructation is that form of vomiting which is accomplished by the
muscular coat of the stomach alone without the help of the diaphragm
or of the abdominal walls.

Post-mortem digestion of the stomach affects its hinder wall, and
chiefly in those parts which depend on either side of the vertebral
column, that is where the gastric juice collects. The dissolution caused
by an irritant poison would not affect these pouches only and avoid
the rest of the lining of the stomach.

In stricture of the pylorus the stomach becomes much dilated,
and, as nutrition fails, the patient becomes so thin that the hardened
valve may be at last easily felt through the abdominal wall. If the
growth happen to lie over the aorta the pulsations are apparent above
the umbilicus, but the tumour feels solid and does not expand laterally
as an aneurysm would. Sickness comes on much later after food has
been taken in pyloric than in cardiac stricture, for in the former case
the food may remain in the stomach until, in the ordinary course, it
should be passing into the duodenum ; as it tries to force its way
through the pylorus pain may be intense. The stomach becomes
enormously dilated in pyloric stenosis and may spread through the
chief part of the abdominal cavity.

The condition of the stomach after death from pyloric stricture is
like that of the bladder in the case of enlarged prostate, or of the left
cardiac ventricle in aortic obstruction, the distended organ being not
only dilated, but considerably thickened.

Food accumulating undergoes decomposition, and the patient is
troubled with wind. If forcible dilatation of the contracted pylorus be
not considered expedient — and in some cases it has answered well —

Stomach; Small Intestine 323

the treatment should consist in careful dieting, and in the frequent
washing of the dilated viscus by means of a soft rubber-tube, a funnel,
and hot water.

Gastrostomy is, literally, cutting a mouth (arco/u-a) in the stomach,
and is resorted to in impassable stricture of the oesophagus, that the
patient may be permanently fed thereby. Cutting into the stomach, as
in the removal of a foreign body, is gastrotomy.

Gastrostomy may be done through the left linea semilunaris. The
incision is begun close below the ribs and is continued downwards
for 4 in. The peritoneum being opened, the left lobe of the liver
is seen ; behind it is the front of the stomach, which is then drawn
up and secured to the margin of the wound, where it soon becomes
fixed by adhesion of the opposed surfaces of peritoneum. (The
sacculated and movable transverse colon could best temporarily be
mistaken for the smooth and fixed stomach.) In performing gastro-
stomy the viscus need not be opened straightway, but may be fixed
to the abdominal wound for a few days by harelip pins to diminish
the risk of fluid entering the peritoneal cavity.

Another method of operating, and one which gives more room, is
by a three-inch incision which, beginning at about i£ in. to the left of
the linea alba, runs parallel to and about an inch below the cartilages of
the left ribs. The outer part of the rectus and its sheath, and, of course,
the oblique and the transverse muscle, are divided, the transversalis
fascia and the peritoneum are opened, and the lower border of the
stomach is brought to the wound and secured.

The stomach in all these operations is generally very small, and is
hidden beneath the left lobe of the liver, or high in the phrenic dome,
and the surgeon, seeing the transverse colon along his incision, is apt
to take it at first sight for the stomach. The appendices epiploicag
and the longitudinal bands, however, soon show that he must look
higher for the stomach, which he finds by passing his fingers round
the liver, up to the transverse fissure, and down the lesser omentum.
The great omentum descends from the lower border of the stomach.

Digital dilatation of the pylorus (Loreta) has been successfully
employed in cases of fibrous contraction, which is usually diagnosed
from the cancerous form by the lengthy and quiet course which the
disease has run, and by the absence of a definite tumour in the right
hypogastric or epigastric region. The stomach having been found
through the oblique incision just given, and the pylorus having been
drawn out of the wound, an opening is made on the anterior surface
of the lesser end, away from all large vessels, and, the pylorus being
steadied by the left hand, the right index and then the index and
middle fingers are gradually worked through the orifice. The wound
is then closed with Lembert's sutures and the stomach is dropped
back.

The small intestine is about 20 feet long, hung from the spinal

324 The Intestine

column in coils contained within the mesentery, though the duodenum,
which lies at the root of the transverse mcso-colon, has no mesentery.
The ileum is recognised by the comparative thinness of its wall, for it
does not contain valvulas conniventes, which abound in the jejunum to
thicken its mucous coat and increase its physiological activity. There
is no definite limit between jejunum and ileum, but, for convenience,
the jejunum is considered as making about two-fifths of the entire
length of small bowel (jejunum, empty ; ileum, * tAe ti/, twisted).

The duodenum is 10 in. long, and takes a horse-shoe bend
around the head of pancreas.

The first part ascends from the pylorus to the neck of gall-bladder,
and is 2 in. long ; like the pyloric end of stomach, it is covered
front and back by peritoneum, and is comparatively movable. In
front of it are the liver and neck of gall-bladder ; behind it are the
vena portae, and the hepatic artery and duct. Below it is the head
of the pancreas.

The second part is 3 in. long, and descends on the anterior
surface of the right kidney. In front of it is the ascending colon.
To the left is the head of the pancreas, the pancreatico-duodenal artery
lying in the crevice between them in front, and the common bile-duct
behind. This part is firmly fixed.

The third part measures 5 in., and passes transversely across the
spine at the level of the second lumbar vertebra to end in the jejunum.
Behind it are the aorta, vena cava, thoracic duct, and crura of dia-
phragm. In front the superior mesenteric vessels descend to enter the
mesentery ; they come out from below the pancreas, which viscus lies
along the upper border of the third part of the duodenum.

On account of the nearness of the gall-bladder, the duodenum is
usually stained by bile, and by this, when the 20 ft. of small in-
testines are removed at a post-mortem examination, the upper end
can be recognised at a glance.

Like the rectum, the first part of the duodenum is entirely sur-
rounded by peritoneum, the second piece being covered only in front,
and the third part being destitute of a serous coat.

The _;>///«//;« has a thick mucous coat, owing to the presence of the
valvulcE conniventes. The ileum is thin-walled (on account of the
comparative absence of the valvular), and is coiled chiefly in the right
iliac fossa, where it is about to end in the ciecum.

Peyer's patches are oval collections of solitary glands in the ileum,
arranged along the aspect which is opposite to the attachment of the
mesentery.

On account of the presence of the ileum in the right iliac fossa, the
physician gently presses his hand over that region to detect tender-
ness, and the gurgling of fluid, in enteric fever. When inflammation
extends to ulceration, fatal collapse and bloody stools may follow
the implication of a branch of artery, or perforation of the bowel may

Mesentery

325

determine peritonitis. The typhoid ulceration, like the Peyer's patch,
has its long axis with that of the bowel, whilst tubercular ulceration
generally extends across the long axis, that is, in the direction of the
blood-vessels which encircle the bowel.

A special outgrowth, iWeckel's diverticulum, is found about 2 ft.
above the ileo-caecal valve : it is the remnant of an early fcetal
canal, the vitelline duct, which extended from the interior of the ileum
through the umbilicus ; a loop of intestine is occasionally strangled
around it or its remnant Persistence of the duct may cause umbilical
fistula, or may involve a fatal snaring of a coil of bowel.

The arteries of the small intestine are the superior and inferior pan-
creatico-duodenal (from the hepatic and
superior mesenteric) and vasa intestini
tenuis (superior mesenteric). The pan-
creatico-duodenal, or the gastro-duodenal
(hepatic), is occasionally implicated in
duodenal ulcer following a severe burn.
The veins pass by the superior mesenteric
vein into the vena portse. The lacteah
and lymphatics course between the layers
of the mesentery to end in glands at its
base. The nerves come from the aortic
plexus of the sympathetic along the
mesenteric artery, together with pneumo-
gastric filaments.

On opening the abdomen in the case
of intestinal obstruction absolute size of
bowel is no guide to its recognition, for
small intestine may be distended to the
size of the forearm whilst the colon may
be no larger than the thumb. Also when
the colon is distended its three longitu-
dinal bands of muscular fibres are temporarily effaced. But the large
intestine may always be recognised by the presence of appendices
epiploicse, of which the small intestine is entirely destitute. The colon
may also be recog'nised by its comparatively fixed position in the lateral
and upper transverse parts of the abdomen.

The ileum occasionally shows offshoots, nearly as large as the
bowel itself, called cUverticula ; structurally they resemble the parent
bowel. They are generally hernial protrusions of the mucous mem-
brane through the muscular coat.

The mesentery (/Liecro?, middle ; ei/repa, bowel) is the thin doubling
of peritoneum by which the jejunum and ileum are surrounded, and
are hung from the vertebral column ; blood-vessels, lymphatics, and
nerves course between its layers. Its attached end is from four to six
inches wide, and slopes from the left side of the second lumbar vertebra

l>, duodenal ulcer after burn ; a,
pylorus ; c and d, bristles passed
through ulcerations in pancrea-
tico-duodenal arteiy and vein.
(HOLMES.)

326 The Large Intestine

to the right sacro-iliac synchondrosis. It is spread out like a fan,
and its intestinal border is about 20 ft. long. The measurement from
the spinal to the intestinal border is 4 or 6 in., and the question still
remains unanswered if, in a hernia, the mesentery was so deep as to
let the bowel slip into the inguinal or femoral canal, or if the fold was
pulled down and elongated by the emigrant bowel. The lymphatic
-lands at the root of the mesentery are prone to tubercular inflamma-
tion ; the disease may spread and glue together adjacent coils of
intestine, or may determine a suppurative peritonitis.

After resecting a piece of small intestine the edges of the tri-
angular gap in the mesentery must be carefully adjusted by sutures.

The end of the ileum, especially in children, is apt to slip through
the ileo-caecal valve, and, with the invaginated caecum, to be carried
along the colon and possibly through the anus. In a few happy cases
of this sort the invaginated bowel has sloughed off and the patient
recovered.

Forcible inflation of the lower bowel occasionally succeeds in un-
sheathing the piece when the adjacent serous surfaces have not become
too closely adherent by plastic effusion ; abdominal section, too, has
in rare instances availed (* Lancet,' August 4, 1888). Opium is the only
drug to be prescribed : absolute quiet is essential.

The colon, about 5 ft., ascends from the right iliac fossa through
the right lumbar into the hypochondriac region, passing in front of
the quadratus lumborum, kidney, and descending piece of duodenum
to the right lobe of the liver. Thence it turns across the top of the
umbilical region below the stomach ; reaching the spleen well behind
the stomach, it descends in front of the left kidney and quadratus, and,
at the end of the sigmoid flexure, is continued on as the rectum.
As it passes across the abdomen it lies over the vertebral column and
the large vessels ; aortic abdominal aneurysm is apt to burst into the
transverse colon. The transverse colon is often found in the sac of an
umbilical hernia. Gall-stones may escape into the hepatic flexure, and
renal or spinal abscess may be evacuated through the ascending or
descending parts.

The sigmoid flexure is apt, in habitual constipation, to be so laden
with faeces as to form a doughy tumour in the left iliac fossa. Some-
times a sigmoid loop swings over, producing that form of obstruction
known as volvulus. With obstruction so low in the bowel the abdo-
minal distension is extreme. In obstruction of the rectum the sigmoid
flexure may become an enormous faecal reservoir which occupies the
chief part of the abdominal cavity.

The ascending and descending colon are not generally entirely
invested with peritoneum ; the postero-internal strip is likely to be
bare, and it is through that part that the bowel is opened in lumbar
colotomy, as is shown on the next page.

The caecum, which as a rule is entirely surrounded by peritoneum,

Ferity phlitis 327

lies in the right iliac fossa, or rests upon the psoas ; it may even,
like the sigmoid flexure, hang over into the true pelvis. Above it is
carried on as the ascending colon,
and on its inner side the ileum enters
by the ileo-cascal valve. It is about
2^ in. deep and the same across.

The vermiform process, 3 or 4
in. long, and, completely ensheathed
by peritoneum, is curled up along the
left aspect of the caecum. Under its
serous coat are muscular and mucous
layers, as in the caecum itself. A shot-
corn, seed, or faecal concretion lodged
in the process may cause a localised
peritonitis and inflammation of the
neighbouring tissues generally ; the
condition is named perityphlitis (nepi,
around ; ruc^Aos, blind). The tissues
become matted together. In due
course ulceration or gangrene of the
process occurs, fasculent matter es-
caping, and suppuration advancing.
The disease is characterised by hard-
ness and tenderness deep in the right
iliac fossa. The inflammation of the
muscular coat of the bowel entails paralysis of its fibres, constipation
being the result. The constipation is beneficial in that it keeps the
parts at rest and encourages the formation of adhesions which may
shut the abscess out of the general peritoneal cavity ; opium, not pur-
gatives, should be prescribed, and leeches may be applied. The abscess
should be opened through the iliac fossa, or it may discharge into the
colon, or may wander into the pelvis ; its bursting into the peritoneal
cavity is always to be dreaded. Small hard masses are sometimes
found in the vermiform process, which, though much resembling
cherry-stones, are found on section to be formed of inspissated intestinal
secretion.

In two cases of acute peritonitis in children which were under my
care we found that the cause of the trouble was an ulceration over a
concretion in the root of the process. I ligatured and amputated the
process, and washed out the peritoneal cavity, but, unfortunately, the
children sank shortly afterwards. In the case of recurrent typhlitis an
exploratory laparotomy, and amputation of the vermiform process, may
be indicated ; it must be remembered, however, that the ureter lies close
in the neighbourhood and may possibly be implicated in the adhesions.

The surgery of the vermiform process is of far more interest than is
its anatomy.

Left lumbar colotomy. (HERBERT
ALLINGHAM.)

328 The Large Intestine

The ileo-ccccal valve is the chink by which the small intestine opens
into the large. Its lips are so joined that, the fuller the blind end of
the rolon becomes, the tighter they are approximated and the less
the chance of fluid passing back between them into the small intestine.
In faecal vomiting the contents of the large intestine do not regurgitate
through the valve, and in the treatment of intestinal obstruction by in-
flation of the bowel the air does not pass through the valve.

Serous coat of large intestine. — The caecum is entirely sur-
rounded by peritoneum ; 1 it is not, as it was formerly thought to be,
attached to the iliac fossa by a meso-ca:cum.

The ascending and the descending colon are completely invested
except on that aspect which lies against the quadratus lumborum,
whilst the transverse colon is covered on all aspects except where the
arteries enter. The sigmoid flexure, like the transverse colon itself,
is surrounded by a mesentery, and by this it hangs into the true pelvis.
The peritoneum entirely covers the first part of the rectum except
a strip on the sacral aspect ; the beginning of the second part is
covered only on the anterior and antero-lateral aspects, whilst the
rest of the second part and the whole of the third part is destitute
of serous covering. The fuller the colon becomes, the wider is the
surface devoid of peritoneum, and, conversely, the more empty it is,
the more complete is its mesentery7.

I have operated in a case of strangulated caecal hernia in which,
though the bowel had a complete sac, I was unable to pass the
finger round it, as one could have done, had an ordinary pie,ce of bowel
been down. The caecum was attached to the back of the sac. It is
said that the caecum can descend along the inguinal canal behind the
peritoneum, taking no peritoneum with it for its sac — such a hernia
must, indeed, be rare.

The appendices epiploicse are small tassels of peritoneum and
fat which are attached to the large intestine ; being only upon the
intra-peritoneal surface of the bowel, they can give no help to the
surgeon who is seeking for the colon through the loin, unless he be there
performing a transperitoneal operation.

The longitudinal muscular fibres are chiefly collected in three con-
spicuous bands, commencing at the vermiform appendix, and ceasing
at the end of the sigmoid flexure. When the large bowel is much dis-
tended the bands are less noticeable, but ordinarily they serve, as do
the appendices epiploicae, to distinguish the large from the small
intestine when the peritoneum is opened. The sacculation of the
colon is due to the comparative shortness of these bands. On account
of the difference in size and shape the percussion-note of the trans-
verse colon is of a higher pitch than that of the stomach.

The longitudinal bands are conspicuous only where the colon is
covered by peritoneum ; it is useless, therefore, to look for them as a

1 See Treves, I/ttntcrian Lectures, 1885.

Fcecal A ecu in illation

329

guide to the bowel when Amussat's post-peritoneal operation is being
performed.

Showing sites of faecal
accumulations : «, in
transverse colon ; b, in
ascending colon ; c, in
transverse colon, be-
tween the double lines ;
d, in sigmoid flexure.
(After BRIGHT.)

In faecal accumulation a large and hard, or doughy, mass may be
detected by careful examination ; it is best removed by persistent
massage and by enemata of soap and water. In the case of faecal
accumulation, as also of malignant tumour of the colon, pressure upon
the anterior crural, obturator, or other branch of lumbar plexus may
give rise to peripheral pains in loin, groin, or limb.

Intestinal obstruction is often caused by a piece of intestine
being snared by a band of old peritoneal inflammatory tissue in the
pelvis or abdomen, by a Meckel's diverticulum (p. 325), by a rent in the
mesentery or omentum ; by a twist, and in many other ways. The
small intestine is more often strangulated than the large, and chiefly
so because it is more movable ; though, as regards a twist (volvulus}^
the slackened folds of the sigmoid flexure are more frequently con-
cerned.

Intussusception is the passage of a piece of bowel into that next
below it, the invaginated piece having the two peritoneal surfaces
against each other ; indeed, these surfaces becoming firmly glued
together, the invaginated and inflamed piece of bowel may slough off,
and pass per anum, the patient recovering. A common variety of
this form of obstruction is that in which the ileum passes through the

330 Intestinal Obstruction

ileo-caecal valve ; ileum, valve, and caecum may all slip into the colon
and even hang into the rectum, so that in every case of obstruction
the finger should be passed into the anus. In most of these cases
bloody discharge occurs from the anus ; the piece of intussuscepted
bowel stimulates the ensheathing piece, and painful straining to pass
a motion (tenesmus) results. Where there is much faeculent or bloody
discharge there is not much inflation of the bowel. The intussuscepted
piece, like a ball of snow, grows larger as it travels onwards, and j^ivrs
rise to a tumour which may be felt through the abdominal wall, in the
course of the colon.

When obstruction is high in the small intestine the patient is sick
each time he takes anything into the stomach ; thus the amount of
urine must be greatly reduced ; moreover, he perspires profusely, the
skin doing some of the work of the kidneys. The more constant the
vomiting, the less must be the amount of gas in the alimentary canal ;
in some cases of obstruction high in the jejunum the abdomen is
flatter than normal. But as peritonitis sets in tympanites, of course,
supervenes. When the small intestine is inflated and the abdominal
walls are stretched the position of the transverse rolls may be felt and
seen behind the recti. These elevations must not be mistaken for the
natural segments in the muscles which occupy fixed and definite
situations.

When obstruction is low in the large intestine, as in the case of a
laden sigmoid flexure becoming twisted, or narrowed by malignant
constriction, there may not be much vomiting, but the Abdomen is
greatly distended by flatus, and there is resonance in the flanks — in
the course of the ascending and descending colon.

Borborygmi, or ventral rumblings, are caused by the irregular
passage of gas along the bowels, and are probably due to disturbance
of peristaltic action through the influence of the sympathetic system.
It is also by some irregular contraction of the circular fibres that a
piece of small or large intestine is slipped into and strangulated by a
piece of the bowel lower down (see also p. 329). The introduction of
food into stomach or rectum increases peristaltic action, so that nothing
but a little ice can be allowed in acute intestinal obstruction. Opium
is given to check peristaltic action. Strychnia is used in chronic forms
of constipation to excite peristalsis.

The arteries of the large intestine are ileo-colic, right colic, and
middle colic from the superior mesenteric, and left colic, sigmoidean,
and superior hrcmorrhoidal from the inferior mesenteric. (For the
supply of the rectum see p. 388.)

The veins are tributaries of the vena porta?, except those coming
from the lower end of the rectum, which open into the internal pudic
vein. The nerves come from the aortic plexus, and the lymphatics
enter the lumbar glands.

Xiittre's operation is making an artificial anus in the sigmoid

Colotomy 331

flexure through the anterior abdominal wall, and through that part of
the bowel which is covered with peritoneum. The operation is ex-
tremely simple, and, as the bowel is usually stitched to the skin wound,
and is there allowed to become glued by adhesive inflammation before
it is opened, the risk of peritonitis is very slight

A curved incision of about 3 in. is made in the iliac region with
the convexity towards the anterior superior iliac spine — much as
for ligation of an iliac artery (p. 295). But after the two obliques, the
transverse muscle, and the transversal! s fascia have been divided the
peritoneum is opened and the sigmoid loop brought up ; it is easily
recognised. Before it is stitched to the abdominal wound all its slack
folds should be drawn down, so that the artificial anus may be made
in the highest part and the risk of subsequent prolapse of bowel may
be diminished.

By drawing out a spur of the bowel evacuation can be completely
and permanently secured by the artificial opening ; unless this is done
merely a faecal fistula will be formed and much of the motions will
escape again per anum.

Amussat's operation is best performed upon the left side, as ob-
struction in the large intestine is likely to be in the sigmoid flexure or
rectum ; thus the artificial anus is made much nearer the end of the
canal than when the colon is opened on the right side, and faecal ac-
cumulation is the more effectually obviated. Before operating, the
surgeon inflates the bowel through the rectum, so as to steady it and
to widen out the strip which is destitute of serous covering. He feels
for the last rib and the iliac crest and makes his incision through the
intervening space.

A line is drawn up from \ in. behind the middle of the iliac crest
to the last rib, and a 4-in. or 5-in. incision is made across that line.

The outer border of the erector spinae is easily made out, and the
incision is begun, or ended, just over it — say i| to 2 in. from the spine.
(By the horizontal incision the lumbar arteries are avoided.) Skin and
fascia are divided, and the fleshy borders of the latissimus dorsi and
external oblique (figs, on pp. 303, 327) are notched ; the posterior part
of the fleshy internal oblique is freely incised on a director just as it
arises from the lumbar fascia, and the transversalis muscle, chiefly a
shining aponeurosis (fascia lumborum), though slightly fleshy at the front
of the wound, is opened up. Then the outer border of the quadratus
is bared, and, crossing from the front of it, the anterior division of the
last dorsal, or an upper lumbar nerve is seen. Next comes a quantity
of fat through which the surgeon carefully works with director and
forceps ; in front of this is the unimportant transversalis fascia, which
is to be carefully torn through. Then the lower end of the kidney is
felt, and the colon, which lies upon it, is traced down, and opened well
on its posterior and internal aspect. Unless the surgeon keep quite
to the back of the wound, he is apt to injure the peritoneum where it

332

Intestinal Obstruction

passes from the colon to the lateral abdominal wall. Such an injury
would be apt to prejudice the result of the operation. But if the

surgeon, after prolonged search for
the bowel, fail to discover it, it is
better for him deliberately to incise
the peritoneum and to bring up the
colon with his hooked finger, rather
than to blindly open some neigh-
bouring coil of small intestine which
he has encountered in the renal
region, through a rent in the peri-
toneum. I have known this accident
happen more than once, and, on the
other hand, amongst the most suc-
cessful cases of colotomy may be
some of those in which the peri-
toneum has been accidentally or
intentionally opened in the ' extra-
peritoneal ' operation.

If the colon happen to have a
short mesentery, or, practically, no
mesentery at all, Amussat's operation
is simple enough, but when the
mesentery is long, as sometimes
happens, it is absolutely impossible
to perform an extra-peritoneal colotomy.

Lumbar colotomy; peritoneum necessarily
opened. (HERBKRT ALLINGHAM.)

THE LIVER

The liver (50 oz.) is situated in the right hypochondriac and epi-
gastric regions ; it often extends also into the left hypochondriac region.
In the child (and in the adult when it is enlarged) it reaches to the
left false ribs, in front of the cardiac end of the stomach and spleen.

At birth it is very large, reaching across to the spleen, the umbili-
cal vein entering the longitudinal fissure in the median line of the body;
but with the subsequent growth of the child the proportionate size of
the liver diminishes, so that the left lobe lies behind the linea alba, the
round ligament and the falciform ligament being dragged towards the
right hypochondrium. In the adult, therefore, only the left lobe occu-
pies the epigastric region, and its border slopes downwards and to the
right, crossing the middle line about three inches below the base of
the xiphoid cartilage. (See illustration on p. 163.)

Normally, the highest level of the liver corresponds with the right
sixth or seventh rib ; for draining an empyasma on the right side,
therefore, the opening should not be lower than the fifth space. In
the case of a large abdominal tumour, and of great inflation of the

Viscera Outlined on Back

333

Chief viscera of thorax and abdomen outlined on back. (GoDLEE and THANE.) For the
front view, see p. 164.

334 The Abdominal Viscera

intestines, the liver is pushed up into and hidden in the dome of the
diaphragm.

Ordinarily the liver-dulness extends to the eighth rib at the side
of the chest, and, on account of the slope of the ribs, to the sixth rib
near the sternum ; near the spine, where the base of the lung comes
well down, the tenth rib marks the upper border of liver-dulness. At
the side of the chest the lower limit of dulness is the tenth or eleventh
rib. In emphysema the dull area is much diminished because of the
liver being shrouded by lung.

In the case of enlargement of liver, with ascites, Sibson used to
teach us to find the liver through the fluid by what he called 'dipping,'
that is, suddenly thrusting the tips of the fingers into the depths of the
right infra-costal region— splashing the fingers through the fluid.

A liver, uniformly enlarged, grows downwards, dropping by its own
weight, as it were ; but when its upper surface is the seat of hydatid
or malignant tumour, or abscess, it raises the diaphragm and the
thoracic viscera, and pushes the heart towards the left.

Relations. — The upper surface, smooth and convex, is directed a
good deal forwards, so as to lie against the six or seven lower ribs
and the abdominal wall ; its chief extent, however, occupies the phrenic
vault. And thus it happens that hydatid cyst or abscess is apt to
burst into pleura and lung. To the upper surface the base of the
falciform ligament is attached ; through the free border and the
depths of that ligament the umbilical vein, or round ligament, reaches
the transverse fissure.

Probably the liver is placed between the diaphragm and the ab-
dominal walls so that the movements of respiration may stimulate its
circulation. Certainly it often happens that when a free-living man is
suddenly laid on his back — say on account of a broken thigh-bone —
the portal circulation becomes congested, ' biliousness ' resulting.

Though usually hidden behind the ribs, the lower border of the
liver may descend within touch of the fingers on a deep inspiration
being taken, and in the epigastric region, even after expiration, its
border, overlapping the stomach and colon, may give a dull percus-
sion-note. It is also thrust down in the case of emphysema, hydro-
thorax, and other conditions involving distension of the right side
of the thorax ; and from tight-lacing it may descend even to the iliac
fossa. In hydatid or other tumour of the liver a more or less rounded
mass descends with inspiration ; the very weight of the liver, more-
over, keeps the area of dulness depressed. But when the right lobe
is implicated in abscess or hydatids the dull area ascends, the right
lung is encroached upon, and the heart is pushed upwards and to the
left. On the other hand, in phthisis and in collapse of lung the liver
ascends, so that even the right hypochondriac region is resonant on
account of the encroachment of inflated bowel.

When the peritoneal covering of the liver is roughened by intlam-

Loiver Surface of Liver

335

niatory thickening, the respiratory movements give rise to a friction
sound, just as in the case of pleurisy.

On account of the liver occupying the arch of the diaphragm, it is
overlapped in front, laterally, and behind by the sharp border of the
base of the lung. A horizontal stab may, therefore, pass through four
layers of pleura and two of peritoneum before the liver is wounded.
In a case of hydatid tumour of the upper surface of the liver, which I
was recently treating with Dr. Broadbent,1 we opened the pleura
through the seventh intercostal space, traversing also the diaphragm ;
we then fixed the hydatid cyst to the edges of the skin-wound by
hare-lip pins for a couple of days before incising and draining it, and
with an excellent result. The lung collapsed on the pleural cavity
being opened, but, the wound being sealed by adhesive inflammation,
it soon expanded again. (See figure on p. 192.)

The lower surface of the liver is mapped out by five fissures, arranged
in the shape of the letter H, into five lobes. In relation with this surface
are the right kidney and supra-renal capsule posteriorly, and the ascend-
ing part of duodenum and colon more to the front ; this surface also

R.L

L.L

R L, L L, right and left lobes ; L s, Spigelian ; L c, caudate ; LQ, quadrate ; p, portal fissure ;
uf, umbilical ; fdv, for ductus venosus ; gbl, gall-bladder ; vci, cava ; ig, gastric im-
pression ; c, position of cardia ; ic, impressio colica ; ir, impressio renalis ; id, impressio
duodenalis ; x, surface destitute of peritoneum. (From QUAIN.)

Transactions of the Clinical Society,

336 The Liver

overlaps the stomach. Suppuration in it is apt to find escape by way
of the stomach, duodenum, or colon.

The posterior border, thick and rounded, lies against the aorta and
the crura of the diaphragm. The two layers of the coronary ligament
which pass from* the upper and lower surfaces on to the diaphragm
leave this border destitute of peritoneum, and there, in a deep notch,
ascends the vena cava.

The hepatic tissue is extremely friable, and may be ruptured by a
blow which leaves no mark upon the surface of the body. As the result
of the injury, fatal haemorrhage may occur into the peritoneal cavity,
especially from the tributaries of the hepatic veins, which rest wide open,
on account of their intimate connection with the surrounding tissue.
The portal and hepatic veins are destitute of valves.

On account of the intervention of the pouch of peritoneum between
the liver and the abdominal parietes, leeches applied to the hypo-
chondriac region do not abstract blood directly from the liver, but in-
directly through the communication between the hepatic and phrenic
veins.

From the front and back of the transverse fissure the peritoneum
descends to the stomach as the lesser omentum, and between its layers
pass the portal vein (posteriorly), the hepatic duct (to the right), and
the hepatic artery (from the left) ; pneumogastric and sympathetic
filaments, and lymphatics, also enter the liver through this fissure.
These structures are loosely invested with fibrous tissue (Glisson's cap-
sule) which, sending offshoots between the lobules, makes a lattice-
work throughout the substance of the liver ; the threads of this lattice-
work eventually reach, and are connected with, the fibrous capsule of
the liver itself, which lies just beneath the peritoneum.

Cirrhosis. — As the result of chronic alcoholic irritation the fibrous
lattice throughout the liver becomes swollen, the liver itself growing
large and hard, and perhaps tender (hepatitis]. The patient is sick
and dyspeptic, and, on account of the flow of the bile from the
lobules being obstructed, the colouring matter is absorbed, and he
becomes jaundiced. If the irritation be still continued, hypertrophy of
the fibrous tissue results, and the subsequent contraction of this tissue
entails compression of the lobules and a puckering of the hepatic cap-
sule, rendering the surface nodular. Thus the liver becomes contracted,
hard, and fibrous, its surface growing rough and irregular. This is the
gin-drinker's, or hob-nailed liver ; it is hard and fibrous, and its surface
rough or tuberculated. (For the anatomy of the symptoms see p. 337.)

The substance of the liver consists of polygonal lobules— the size of
millet-seeds— which are composed of closely-packed hepatic cells.
The lobules are separated from one another chiefly by the inter-
lobular plexus of the vena portae, and by lattice offshoots from
Glisson's capsule ; in the contraction which follows the hypertrophy of
the fibrous tissue, the peripheral cells of the lobule are the first to

Hepatic Disease 337

atrophy on account of the compression. In the centre of the lobule
is the tributary of the hepatic vein (intra-lobular); between the peri-
pheral and the central part of the lobule is an intermediate zone, in
which the hepatic artery breaks up.

In disease of heart or lungs the escape of blood from the hepatic
veins into the vena cava is delayed, so that the central part of the
lobule, which contains the radicle of the hepatic vein, is engorged ;
and, on section of the tissue being made, the dark centre and the paler
periphery of the lobules give the appearance known as nutmeg-liver.
The peripheral cells are pale because they have undergone fatty
degeneration ; and the cells of the intermediate zone are stained
yellow by the stagnant bile.

In albuminoid disease the cells in the median zone of the lobule —
that is, in the region of the chief distribution of the capillaries of the
hepatic artery — are most infiltrated. In fatty degeneration the peri-
pheral cells of the lobule are earliest affected, as the fresh products
of digestion which are brought up by the vena portae first come in
contact with them.

As already remarked, the liver may become greatly enlarged in
heart-disease (p. 178), reaching even to the umbilicus, and this enlarge-
ment is often, as Dr. Wilks remarks, a great help to diagnosis. * A
medical man may be called to a patient for the first time, whom he
finds dropsical, with albumen in the urine, and a state of heart which,
from its weakness and the sounds of bronchitis, is not at once easy to
make out.' Is it a case of cardiac or of renal disease ? The former:
kidney disease does not cause hepatic enlargement, but morbus cordis
entails both that and bronchitis.

In albuminoid and fatty disease the liver may become enormously
enlarged. It makes room for itself partly by pushing up the dia-
phragm, but chiefly by thrusting the abdominal viscera downwards
and to the left, and by causing a bulging of the lower right ribs and
their cartilages. When hepatic enlargement does not implicate the
gland evenly throughout, as in abscess or hydatid cyst of right lobe,
the encroachment is chiefly towards the thorax, as already noted.

The portal vein (3 or 4 in. long) is formed behind the pancreas
by the confluence of the splenic and superior mesenteric veins ; it also
receives the venous blood from the stomach and pancreas. The
inferior mesenteric opens into the splenic vein, and the vein from
the gall-bladder into the portal vein. The inferior mesenteric vein
communicates upon the rectum with the haemorrhoidal plexus ; thus
hepatic congestion may be directly relieved by leeching the anal
region.

In hepatic cirrhosis (<ippos, yellowish) on section, the escape of
blood from the vena portse is retarded ; the portal capillaries are
engorged, and transudation of serum takes place. Thus, the lining of
the stomach becomes sodden, and the patient loses appetite and becomes

338

The Liver

dyspeptic. On getting out of bed in the morning he ejects from his
irritable stomach the acid fluid which has been collecting during the
night. As the disease advances he is frequently sick, and, owing to
rupture of the engorged capillaries, the vomit is mixed with blood.
The destruction of the peripheral cells of the lobule is necessarily

1, Vena portae, with tri-

butaries.

2, Superior mesenteric.

3, Intestinal.

4, Right colic.

5, lleo-colic.

6, Coronary.

7, Splenic.

8, Inferior mesenteric.

9, Left colic.
10, Sigmoid.

n, Superior haeinor-

rhoidal.
16, Inferior cava.

(From QUAIN.)

accompanied by diminution of the amount of bile, and, the muscular
coat of the bowel being less stimulated, constipation results.

The effect of the engorgement of the splenic vein is that the
spleen enlarges, and that the over-loaded veins of the rectum bleed
and become prolapsed. The venous blood along the entire in-

Symptoms of Cirrhosis 339

testinal tract is stagnant, and water escapes into the bowel and
causes diarrhoea, or into the peritoneal cavity, producing ascites (p. 316).
A dropsy which begins in the peritoneal cavity is generally due to
cirrhosis of liver. Haemorrhage may occur along the alimentary
canal, giving rise to black stools.

Because the blood cannot escape freely from the portal vein by the
usual route, it learns to reach the general circulation by going through
the veins of the abdominal wall, and through those upon the surface
of the liver. In the former case a chain of dilated veins may be seen
ascending from groin to chest ; in the latter case the collateral route
can be recognised only after death. (See the figure on p. 301.)

Hepatitis. — In acute inflammation of the fibrous tissue of the
liver there is a tender and deep-seated fulness in the right hypochon-
driac region, and the patient lies upon that side, so that there may be
no dragging upon the fibrous and peritoneal bands which keep the
heavy gland in its place.

When the right lobe is the chief part involved, and this is usually
the case, there is pain in the top of the right shoulder ; and, the left
lobe being implicated, there may ^ pain at the left shoulder. This,
as shown on p. 147, is due to the fact that filaments of the phrenic
nerves enter the substance of the liver ; the phrenic nerve comes
from the fourth, fifth, and sixth cervical nerves ; the fourth gives off
acromial twigs, and when the phrenic in the liver is implicated the
pain is reflected by those supra-clavicular nerves.

The movements of the diaphragm distress the liver and set up a
dry cough or a hiccough, and, by way of resting and protecting the
inflamed gland, the abdominal muscles, and especially the right rectus,
are rigid.

The figure on p. 192 shows how close the lung and the pleura
are to the liver and peritoneum ; and when there is pain in that
neighbourhood, with a short cough and shallow breathing, it may
be difficult to say promptly whether the base of the lung or the liver
is inflamed. But ' the ear will tell us, if we employ auscultation and
percussion, whether the contents of the chest or of the belly are
suffering : and my own experience has taught me that sharp pain,
with feverishness, occurring in the debatable ground of the right side,
denotes pleuritic inflammation far more often than it denotes hepatic.'
(Sir Thos. Watson.)

Acute hepatitis may end in abscess, and, the pus escaping, may
set up fatal peritonitis. But more often the inflammation glues the
liver to the stomach, bowel, or abdominal wall, a safe evacuation taking
place. The pus may also be discharged through the diaphragm
into the right pleura or into a bronchial tube, or even into the
pericardium.

A frequent cause of hepatic abscess is dysenteric inflammation of
the rectum, thrombi being carried through rootlets of the vena portas,

7. 2

340 T/ic Liver

which then lodge in the liver and become infecting foci. Sometimes
it follows surgical operations upon the lower bowel, or simple ulcera-
tions of the stomach or small intestine.

Jaundice is the result of the absorption of bile by the efferent
vessels of the liver. The vena portae carries up the elements of bile,
and the liver prepares that fluid from them. Thus, if the bile cannot
flow out into the intestine, as when a calculus blocks the hepatic or
common bile-duct, or a tumour presses upon them, the intra-hepatic
tension becomes so great that the blood-staining fluid has to be carried
away by the branches of the hepatic veins. The student is apt to
think that jaundice is always the prominent symptom of liver-diseases ;
but when the bile-secreting cells are destroyed, as in certain cases of
abscess and cancer, there is too little bile formed ; and if it be possible
to imagine malignant disease destroying all the liver-cells, it is certain
that no jaundice could occur, for no bile would be formed.

The hepatic circulation and the secretion of bile are under the
influence of the pneumogastric and sympathetic filaments, and when
the central nervous system is upset, not only may digestion be im-
paired or lost, but jaundice may occur. As an example of this, refer-
ence may be made to the brief clinical report of the lady in ' Twelfth
Night,' who, concealing her too great love, pined in thought and was,
in consequence, overcome by a ' green and yellow melancholy.'

The arterial supply is chiefly from the hepatic division of the
cceliac axis, whose branches pass with ramifications of the portal
vein, hepatic duct, and Glisson's capsule between the lobules. A small
quantity of blood also comes from the right phrenic.

The blood brought by the vena porta: and by the hepatic artery
is conveyed into the vena cava by the hepatic veins ; the descent of
the diaphragm at each inspiration compresses the liver and helps to
empty these capacious and valveless veins.

Of the lymphatics, some pass out by the transverse fissure to
glands between the layers of lesser omentum, whilst the superficial
ones join the anterior and posterior mediastinal glands.

The nerves are sympathetic filaments from the solar plexus, and
twigs of the pneumogastric and phrenic nerves. The pain in the
shoulder in hepatic congestion has been explained on p. 339.

The grail-bladder is pear-shaped ; its larger end reaches to the
sharp edge of the right lobe of the liver, just behind the ninth costal
cartilage. Its upper surface adheres to the liver ; the under surface
is covered by peritoneum, and overhangs the pylorus or the beginning
of the duodenum, and the hepatic flexure of colon. The stalk of the
pear extends upwards and backwards to the transverse fissure, where
it joins the common hepatic duct to form the common bile-duct,
which opens with the pancreatic duct into the second piece of the
duodenum. When a gall-stone blocks the cystic, or the common
bile-duct, the gall-bladder becomes distended, and may form a

Massage of Liver 341

tumour in the right hypochondrium — near the ninth cartilage. It may
readily be reached through the upper part of the left linea semilunaris,
fixed to the abdominal wound, and drained, the obstruction being re-
moved secundum artem.

A distended gall-bladder may open spontaneously into the stomach,
duodenum, or colon, or through the abdominal wall.

By persistent kneading, Dr. Harley has successfully dislodged
gall-stones which had blocked the duct. If by such artificial help the
torpid gall-bladder could be made to empty itself every day, there
would be little chance for the formation of concretions. When the
duct is blocked the gall-bladder is full, and its contents may be made,
by kneading, to play a useful part in dilating the duct and pushing
the concretion onward.

THE SPLEEN

The spleen (8 oz.) lies between the cardiac end of the stomach and
the ninth, tenth, and eleventh ribs, from which it is separated by the
arch of the diaphragm, a wedge of lung intervening between the dia-
phragm and the ribs. It is placed in the interval between lines which
continue the anterior and posterior folds of the left axilla, its long
axis corresponding with the length of the ribs. The tip of the spleen
lies beneath the apex of the eleventh rib ; its anterior border is gener-
ally notched.

The external surface is convex. The inner surface is concave, and
is secured to the stomach by the gastro-splenic omentum, between
the layers of which the vessels pass to the hilum of the spleen, and the
vasa brevia to the stomach. The hilum is one-third nearer to the
posterior border than the anterior ; the inner surface behind the hilum
is in relation with the tail of the pancreas, the kidney and its capsule ;
that in front with the convex surface of the stomach. Behind and
above is the diaphragm, and behind and below are the kidney and its
capsule, and in front and below is the splenic flexure of the colon.

Placed thus between the base of the lung, the stomach, and the
transverse and descending colon, the area of normal dulness of the
spleen varies according to circumstances, and in pneumo-thorax or
emphysema it may altogether disappear. When the left pleura is full
of fluid the spleen may descend considerably below the ribs. On
the other hand, when it is greatly enlarged it raises the heart and left
lung, and causes palpitation, coughing, and shortness of breath ; it
may extend also to the linea alba, and to the pelvic brim. Its
identity may be established by the characteristic notch in its front
edge ; its outline is not obscured by intestines floating in front of it,
as is the case with the kidney. Moreover, a suppurating or enlarged
kidney hides in the loin \ it does not encroach anteriorly as the spleen
does. Unless enlarged, the spleen cannot be felt by the fingers on
the surface of the abdomen, but by hooking them round the lowest

342 The Spleen

ribs, and making the patient take a deep breath, it may be often felt
in the child, especially if he be thin ; in the adult the healthy spleen
does not descend below the ribs, even on the deepest inspiration. The
spleen is temporarily enlarged during digestion, and permanently so
in cirrhosis of the liver (p. 337), in intermittent fevers, and in albu-
minoid disease ; in ague it may form an enormous mass, * ague-cake,'
which may weigh as much as 20 Ibs. The enlargement may be dia-
gnosed from an. ovarian tumour by its shape, and by the presence of
the notch, which may generally be made out.

Beneath the peritoneum is the fibrous coat, which sends trabecuke
into the interior to support the spleen-pulp.

The splenic artery is a large and tortuous trunk which reaches
the hilum by passing along the upper border of the pancreas, giving
branches to the pancreas and stomach in its course.

The vein runs close behind the pancreas to enter the vena porta?,
receiving in its course gastric and pancreatic branches, and the in-
ferior mesenteric vein. The lymphatics pass to glands in the hilum,
and eventually to the thoracic duct.

The nerves are derived from the solar plexus, and from the right
pneumogastric. The spleen is rich as regards its blood-vessels, but
poor as regards nerves.

Occasionally the spleen breaks from its moorings, and, dragging
its vessels and nerves, drifts towards the pelvis, causing so much dis-
comfort as to demand extirpation. This may be effected through the
left semilunar line. From buffer-accidents, and other injuries to the
abdomen, the spleen may be ruptured and fatal haemorrhage or peri-
tonitis supervene, with, perhaps, no bruising of the surface of the body.
When the lower ribs of the left side are heavily struck their broken
ends may be driven through the diaphragm and into the spleen.

THE PANCREAS

The pancreas (3 or 4 oz.) (nav uptus, all Jlesh) extends from the
epigastric into the left hypochondriac region, crossing the aorta and
the crura of the diaphragm at the level of the first and second lumbar
vertebrae. The superior mesenteric vessels, splenic vein, and the be-
ginning of the vena portas are also posterior to it.

Lying behind the peritoneum, the pancreas may be reached by
raising the great omentum and transverse colon and tearing through
the lower layer of the transverse meso-colon, which descends to form
the mesentery. Its head fits into the horse-shoe curve of the duo-
denum, the pancreatico-duodenal artery intervening between them in
front, and the common bile-duct behind.

The body of the pancreas lies behind the stomach ; its tail reaches
the hilum of the spleen, and lies in front of the left kidney and capsule.
Above are the coeliac axis and the splenic artery.

Relations of Kidneys 343

The duct leaves the substance of the gland at its head, and joins
with the common bile-duct to open into the duodenum.

The arteries come from the splenic, and from the pancreatico-duo-
denal loop of the hepatic and superior mesenteric. Its venous blood
enters the portal circulation. The nerves come from the coeliac plexus
of the sympathetic.

In enlargement of the pancreas, especially if the patient be thin,
the pulsations of the aorta are distinctly conveyed to the surface of the
body in the epigastric region.

THE KIDNEYS

The kidneys (each 5 oz.) are not quite on the same level, the right
being depressed half an inch by the intervention of the liver between
it and the diaphragm. On the under surface of the right lobe of the
liver there is a depression for the kidney and supra-renal capsule.
The kidneys lie against the outer border of the psoas, behind the peri-
toneum, in a bed of loose connective tissue and fat, and they rest upon
the slope of the diaphragm, the twelfth rib, and the quadratus lumborum.
Thus, they are about on a level with the last dorsal and the first and
second lumbar vertebrae. (See illustrations on pp. 164 and 333.)

Kidneys, ureters, ascend-
ing and descending
colon, from behind.
(HOLDEN.)

In front of the right kidney are the descending piece of duodenum
and ascending colon ; the descending colon lying on the front of the
left. The tail of the pancreas may also just touch the front of the
left kidney above, whilst the great end of the stomach is in anterior
relationship with it ; the spleen is above and to the outer side.

A horizontal line through the umbilicus passes just below the
normal kidneys, and a line drawn upwards from the middle of
Poupart's ligament parallel to the linea alba runs nearly through the
middle of each. On the posterior surface of the body their situation
can be marked a little way from thespinous processes, from just above
the last rib nearly to the iliac crest, the right being a little lower, and
the notch of each being directed towards the spine. Renal abscess
and calculi may escape through the loin.

Fissures and indentations of the surface of the kidney are often

344 The Kidneys

found in young children, and occasionally in adults ; they indicate the
development of the gland in lobules, which remain through life dis-
tinct from each other, separated by fibrous tissue. Sometimes the
kidneys are united by their lower ends across the aorta and vena
cava, forming a horse-shoe kidney.

The relative position of some of the chief abdominal viscera may IDC
remembered by such a system as this : — The stomach lies across the
middle line and is prolonged into the right hypochondriac region, being
continued on by the horse-shoe curve of the duodenum ; the head of the
pancreas fills in this duodenal curve, its body extending to the left, be-
hind the stomach ; its tail lies on the front of the upper part of the left
kidney, and touches the concave surface of the spleen, into which the
convex end of the stomach is fitting. As the tail of the pancreas passes
in front of the top of the kidney to reach the spleen, the kidney must
lie to the inner side of the spleen, and behind the stomach.

The peritoneum touches the front of the kidney, but does not give
it an investment. A movable kidney is one which, on account of the
looseness of its connection, can shift its position behind the peritoneum.
A floating kidney has a complete serous investment, and swings about
in the general peritoneal cavity at the end of a meso-nephron, tethered
only by its blood-vessels. Its movements vary with the position of the
subject, and also with respiration, and are often accompanied with un-
pleasant sensations and even pain. Tight-lacing, and the disturbance
of the abdominal walls and viscera associated with pregnancy, render
floating kidneys more common in women than men.

The removal of the kidney without wounding the peritoneum is, as
far as concerns the anatomy of the parts, so like Amussat's operation
(p. 331) that it is unnecessary here to describe it. The incision is made
nearer to the last rib than in colotomy, but, as the pleura sometimes
descends below the level of the twelfth rib, the knife must be used very
carefully. When the kidney is loosened from its bed the vessels and
ureter are ligated and divided, and the gland is taken out.

If the diseased kidney seemed to be too large to come readily
through the space between the last rib and the iliac crest, it would be
better to remove it through the corresponding linea semilunaris. In
that case the peritoneal cavity would be opened and the intestines
drawn aside, the peritoneum being traversed posteriorly on the outer
side of the colon, so as not to risk interference with the vessels passing
to and from the colon.

The fibrous capsule is a tough, thin layer which sends numberless
filamentous processes throughout the interior of the gland; their peri-
pheral attachment is noticed when the capsule is being stripped
off.

The hiliun leads into a cavity called the sinus of the kidney, into
which the dilated end— pelvis — of the ureter opens. The pelvis of the
ureter gives off three short primary divisions inj'umlibulti and

Structure of Kidney

345

quickly expand into calyces which, embracing the tops of the pyramids,
collect the urine. (For ureter, see p. 349.)

The function of the kidney is to get rid of the excess of water, with,
of course, certain excrementitious substances in solution ; it is thus
closely associated with the skin, with the mucous membrane of the
bowel, and to a certain extent with the lungs. When the diseased
kidney demands rest the skin and the bowels should be set to work
by diaphoretics and purgatives.

When a patient with acute intestinal obstruction is constantly
vomiting there is little or no fluid for the kidney to drain off, and
suppression of urine is noted ; and when a man is perspiring profusely,
or is racked with diarrhoea or cholera, he passes hardly any urine.
That which comes away in such cases is laden with excrementitious
materials and is consequently of high specific gravity.

Structure. — The cortical part consists of branching and coiled
tubules, and of ramifications of blood-vessels, in which the bases of the
twelve or twenty pyramids of the medullary part are received. These
pyramids consist of parallel bundles of uriniferous tubules, and are
partially separated from one another by offshoots of the cortical part,
through which the blood-vessels pass outwards from the hi him.

Fibrinous mould of tube entang-
ling epithelial and blood cells,
with, /', three crystals of lithic
acid in a case of acute desqua-
mative nephritis. (JOHNSON.)

i, a, br. of renal artery ; c, Mai-
pighian capsule ; e, e', efferent
vessel ending in plexus, /, on
tubule.

A uriniferous tubule begins in the cortex in a dilatation like a
Florence flask (Malpighian capsule), in which a branch of artery and
vein form a tuft (glomerulus\ from which the watery- part of the urine
transudes, to escape at last by the apex of the pyramid (papilla) into
the sinus of the ureter. The tubule has a continuous epithelial lining.
Blood in the urine may be due to rupture of the engorged vascular

;i» /'//<

mil,, i in- \ eii), a i hi emerging from the capsule, breaks up mt» a

plexus up. Hi Ihe lubllle, .Hid Illldei the ilillllelli e "I ihe epithelial lining

of die tube i id , 1 1 K II ol ihe .nl id , n| the m me in sn| ut ion. In t/t'\////,r/;/tr-
ti , v /!<•/>//> i//\ the epithelium is '.Ii ipped off, Iea\ m;^ the interior of the
lulu , nakrd ; (hen the mine i, , < mip.i i at i\ d \ destitute of salts, and is
of lou spn iln ;;ia\ llv. II the ^lollierull leinam, lio\\e\ei, tllele

idem \ of urine poured out) though oi io\\ ,p( -. m. gravity, in < ei iam

lib i moil, mould , in ,,i\f\ .ne loimd m the mine \\ith epithelial
tin oipoial. d \\ nh them.

I ho ,e lubes whose rpll hrhal III mi;.; ha . all rad\ brril shed the
md . le.n (aS -een in im.ioMopi. examination of the

III me , bill in oil ir i casts e|Hlhelial . el Is a lid 1 dood < ol |»i 1 ,' les are i III -
bedded 'l'h«- l.i I bad ailgUrj : lhe\ sho\\ that the tubes

are .nipped ami valueless, and that the patient i, m danger <>i n»n-

ehminalion o| ihe mine laltS.

Congestion. It ha . 'mm -ho\\ n e\|»ei nnentall\ that li;;alion ol (he

I ena I \ein. ail M • ihe e .. .ipe o| album 111 oils thud I loin the ( (invested renal

iimlaib , albumen oi hlnod appear, m the urine in mllam-

mation oi the kidneys, 01 m the more mechanical obstruction caused

b\ the pressure »l ;i gravid iileiu-., an aneiii \ sm, oi ( it her Inn nun upon
the \eiia • a\a or renal \ein. < longeStlOIl max ai 10 be due to delayd
.n. illation llmuijdi the Inn;; or the heail ; and, m II a

preparatOT) Stage tO mtlammalion, SO phthisis .md emplusema, initial
and a< 'i 1 1. dr.ra .-, .n «• « oimnon pre. m .. n , «,| nephiitr,. I .on;; < out inn
an. e ol . Qfige .lion ol the kidnr\ be-ets thi. kenin;; of the inter tubular
libioii, tissue, just as happen, also in the . a ,r . >| h\ri eon;;r,(ion ;
.ubsr.|i|rnlb ihr 1 1 ssi |e III ide I ; ; or, alioph\ and lhe(//v//.
//V/«-//V,Xv'r ///i; I' i'- piodll. rd.

Congestion ma\ be i.li.ved by \ena-.e. lion or by » nppm:; o\ . i
Ihr loins; m Ihr lallri.a.e lliioii;;h I he < 1 1 1 < < I anaM ol nos|s between
bian. In-. n| the luinli.il and ieii.il \ e, ., I , p. 309).

In Briffht'ft dUease the l.i.ln. \ ma\ be m. reased oi diminished m
a 6, the COltiCfJ p.ul ol the -land bem;.; . InelK alh . led. In om
the base, of the p\ lamids ale tin. kl\ i o\ eied \\ ith . oi te\, in the other

the\ approach verj m-.n i.» the sur&ce oi the ;;iami. ihe large

kidneys ma\ lo-ethei \\ei;:h twelve ounces, and the small ones bul

t \\ o ; the lonnei iniidit in due course have contracted into small

. II I hoti. ;.;land \,

II the mllammation be a. lite, the lenal . apiliai ie •., and <-. penally
the Malpijdnan lull,, .ne eii;;oi:;i d, and in pku es e\en burstini;, M>ine
ol the lubuU , beiii:; (linked \\ ilh blood and abundant epithelial ( elK,
\\lnls I others are bio. ketl \\ith libunous moulds oi ' cast

Contracted kidney. — As the u-.ult "I mll.imm.uion of the kuhu-y
ih. ie i. h\ pel ti oph\ d the .onnc(ti\e tissue pei\adim; the idand

then atio|di\ supervenes (<M* cii rhosii of liver, p, 136 .md, the tubules

ed. disarranged, and -.nan^led, ihe -land dwindles

Contracted Kidney 347

into a small cicatricial mass. The fibrous capsule is so firmly incorpo-
rated with the thickened trabeculas of the interior of the gland that at
the post-mortem examination it cannot be stripped off.

In the early clays of cirrhosis the new fibrous element of the kidney
is soft and vascular, but its subsequent contraction is only a matter of
time ; and during its progress, by pulling irregularly upon different
parts of the kidney, it throws the histological arrangement into com-
plete disorder, and, obliterating certain tubes, causes retention of their
secretion and a wide-spread cystic degeneration.

Renal dropsy. — When the kidneys are or have been inflamed,
their function, which is the excretion of urine, is necessarily impaired,
and the vessels generally, and the capillaries in particular, are over-
full. But from over-filled capillaries a certain amount of exudation is
sure to occur, and the result is that in renal disease serous transuda-
tion takes place into the lymph-spaces and into the connective tissues
generally. Thus, the eyelids and scrotum swell, the feet and ankles
become ' puffy,' and the legs pit on pressure ; the lungs become water-
logged, and dropsical effusions fill the pleura, pericardium, or peri-
toneum. Pulmonary oedema is a very common and serious complica-
tion of kidney disease ; so also is cerebral anasarca.

Because the feet are the lowest parts as the man walks or stands, the
uxlema first appears there. After the night's rest in bed the feet may
resume their normal size, the fluid being absorbed and deposited,
perhaps, in the face, which then becomes * bloated.' But, after the
patient has been up and about, the face improves again and the feet
in turn are enlarged. The serum actually trickles down through the
loose tissue, so that, as Watson remarks, a tight waistband may pre-
vent the descent of the fluid and keep the upper part of the body alone
oedematous, whilst if the patient lies constantly on one side that side
only is infiltrated. Dropsy of the submucous tissue of the air-
passagcs is frequently a cause of death.

Krec purgation is often useful in the case of dropsy, as it diminishes
the amount of fluid in the vessels and so encourages them to soak up
and utilise the extravasated serum.

l)io|)sy from liver-disease appears first as abdominal ascites,
whilst that from heart disease generally begins as anasarca in the legs.
It is quite impossible to draw a hard-and-fast line, however, between
these conditions. Indeed, kidney disease and heart disease often go
hand in hand, as it were ; for valvular disease of the heart begets
venous congestion of the kidney, which is a common cause of nephritis.
Thus the kidneys^being diseased, cannot work properly, so that impure
blood is being circulated, and the capillaries throughout the body
struggle to resist its passage through them, their muscular and fibrous
walls becoming thickened. To overcome this resistance the left
ventricle works with extra energy, and its walls increase in strength in
consequence, just as a blacksmith's biceps grows by exercise. As a

348 Disease of Kidney

part of this vascular change, the arteries lose their elasticity, and one
day, as the vigorous ventricle is straining to force some unusually
impure blood through the resisting capillaries, a vessel gives way,
perhaps in the brain, and the patient is attacked with apoplexy.

The effect of the impure blood upon the lungs is to cause cough,
bronchitis, and pneumonia ; upon the stomach, to cause dyspepsia, loss
of appetite, and vomiting ; upon the bowel, to set up diarrhoea ; and
upon the brain, to give rise to headache, convulsions, and coma.

Occasionally the uriniferous tubules become distended in number-
less spots by limpid urine, producing general cystic degeneration of the
gland. As a tubule bulges, the vascular tissue and the neighbouring
tubules disappear from pressure, the pyramids being first pressed
upon and wasted.

There is much truth in the saying that a man is as old as his
kidneys.

The practitioner should make it his rule to exatnine the urine of
every patient with obscure illness ; when it contains albumen or casts
he may expect to find the pulse hard and resisting, the temporal arteries
mobile and tortuous, the impulse of the heart increased, and its
apex-beat displaced outside the normal line. The kidneys of such a
patient should be rested to the utmost, by placing him upon a diet
without alcohol and poor in nitrogenous foods ; the bowels and skin
should be encouraged to eliminate by purgings and sweatings, and he
should be specially careful to avoid chills and violent exercise.

The kidney may be ruptured from a blow on the loin, btood escaping
into the surrounding tissues, and also into the ureter, where it is well
mixed with the urine. If a clot be carried into and plug the ureter,
urine may collect above it. (For Surgical Kidney see p. 410.)

Hydronephrosis. — If from congenital malformation of ureter,
bladder, or urethra, pressure of a tumour, clot, or stricture, there be
serious impediment to the outflow of urine, the fluid collects in the
interior of the kidney, and, by the mere effect of pressure, causes
wasting of all the proper renal tissue and converts the gland into a
mere water-bag.

A large and painless tumour, possibly yielding a sense of fluctuation,
fills the entire lumbar region, and, on aspiration, limpid urine is with-
drawn. For certain, the tumour is dull on percussion behind, but there
will be resonance in front if the colon intervene between it and the
anterior abdominal wall. The obstruction being overcome, an enor-
mous quantity of pale urine is passed and the area of dulness subsides,
the diaphragm descending and the coils of intestine passing outwards
to resume their proper place.

The fluid of hydronephrosis does not change its position as the
patient is turned ; this distinguishes hydronephrosis from ascites,
not from ovarian dropsy. In ovarian disease, however, there ma;
be some resonance in the loins, and the dulness is traceable in

Stone in t/ie Kidney 349

the pelvis. Ovarian disease begins below, and hydro-nephrosis works
downwards.

A large sarcomatous, cystic, or suppurating kidney may extend
across the middle line as well as fill the flank.

(For renal artery, v, p. 354 ; for renal vein, v. p. 349.)

The nerves of the kidney come from the sympathetic system of the
thorax (sphanchnic) and of the abdomen (solar plexus). Filaments
are also derived from the upper lumbar ganglia, and so the plexus
becomes associated with the upper lumbar nerves. Offshoots from
this network pass to the spermatic plexus.

The lymphatics enter the lumbar glands.

In renal calculus pains radiate widely on account of the extensive
communications of the nerves of the kidney. Thus, they strike along
the ureter to the bladder, causing frequent micturition ; and, descending
in the spermatic offshoot of the renal plexus to the testis, they may
so disturb its vaso-motor nerves as to set up orchitis. And, on account
of the association between the renal plexus and the upper lumbar
nerves through the higher lumbar ganglia, pains dart along the ilio-
hypogastric and ilio-inguinal nerves (of the first lumbar nerve), and
along the genito-crural (of the second) to the cremaster, so that
retraction of the testis is to be looked for in renal calculus. Neuralgia
may also extend along other branches of the lumbar nerves into the
thigh ; and irritation through the neighbouring solar plexus may cause
nausea and vomiting. The renal capillaries are bruised by the stone, and
the urine becomes bloody. At the end of the ureter the stone may be
for a while impacted, and by its presence it may cause obstruction of
the ureter and disorganisation of the kidney. It may sometimes be felt
fixed there, close to the bladder, by digital examination through the
rectum. The pains which have been caused by the stone scraping
along the ureter suddenly cease on its escape into the bladder.

In the case of disease of the second and third lumbar vertebrae,
with inflammatory pressure upon the posterior root of the second
lumbar nerve of one side, there would be dull pain in the back,
which would be increased by exercise, and possibly some tenderness
in the renal region, especially if abscess were forming. There would
be pain referred to the testis, and, on account of the irritation of the
genito-crural nerve, retraction of the testis. There might, moreover,
be increased frequency of micturition. Thus it is quite possible that
lumbar caries may be mistaken for renal calculus.

Ureter. — From the hiluin the ureter emerges, sloping downwards
and inwards ; it is behind the renal artery, the vein being in front of
both. Though the anterior surface of the kidney is the more convex,
and the upper end the larger, still the best way of telling the right kidney
from the left is by the position of the ureter, which is posterior to the
vessels and slopes downwards and inwards. -It is about fifteen inches
long, and, descending gently inwards, it rests upon the psoas and

35O Disease of Kidney

genito-crural nerve, being crossed superficially by the spermatic vessels,
which are inclining outwards, towards the internal abdominal ring.
Coils of small intestine — especially of the ileum— lie in front of the
right ureter, and the sigmoid flexure is anterior to the left. Entering
the true pelvis, the ureter passes over the common iliac artery close
to its division, or over the beginning of the trunks into which it
divides, and, having passed into the posterior false ligament of the
bladder, it enters that viscus by running obliquely through its base.
The right ureter descends on the outer side of the vena cava, and,
passing very near to the vermiform process, is sometimes glued to it
in perityphlitis. In the male the vas deferens curls round between the
side of the bladder and the ureter ; in the female the ureter descends by
the side of the neck of the uterus and the upper part of the vagina, and
in epithelioma of the cervix uteri the ureter may be implicated and ob-
structed. Psoas abscess has been known to discharge through the ureter.

Structure. — Inside a fibrous coat are two layers of non-striated
muscle, the outer of longitudinal, the inner of circular fibres ; more
deeply comes the mucous membrane lined with stratified epithelium.

The blood supply is from the vessels against wrjich it is placed in
its course, namely, renal, spermatic, internal iliac, middle and inferior
vesical ; so also with the veins.

The nerves come from the renal and the hypogastric plexus, and
from the filaments about the kidney, spermatic cord and rectum, and
indirectly, probably, from the lumbar plexus.

When a stone is passing down the ureter the pain ma? be intense,
localised in part to the region of the ureter, and radiating, after the man-
ner of renal colic, down to the bladder and penis, and even into the thigh.

The supra-renal body (2 drms.) is a ductless gland placed like a
cocked-hat upon the top of the kidney. Above the right capsule is the
liver ; above the left, and external to it, is the spleen. Posterior to
each is the beginning of the vault of the diaphragm. In front of the
left are the tail of the pancreas and the stomach.

Arteries come to the capsule from the aorta (supra-renal) and from
the renal, and twigs are derived also from the neighbouring diaphrag-
matic branches.

The right vein enters the vena cava ; the other, like the spermatic,
joins the left renal. The nerves come from the solar and renal
plexuses ; the lymphatics enter the lumbar glands.

Degeneration of the supra-renal bodies is associated with bron/ing
of the skin and with anaemia (Addison's disease).

THE ABDOMINAL AORTA

The abdominal aorta, the continuation of the thoracic, begins at
the twelfth dorsal vertebra, and divides into the common iliacs at the
left side of the fourth lumbar — that is, at a spot just below and to the left

A bdominal A orta 351

of the umbilicus. Above the umbilicus the aorta may be felt pulsating,
and may there be readily compressed in a thin subject

Sometimes the bifurcation is a little above, sometimes a little
below, the fourth lumbar vertebra.

Relations.— It rests upon the four upper lumbar vertebrae, the left
lumbar veins, and the beginning of the thoracic duct.

Anterior to it are the lesser omentum and stomach, pancreas and
splenic vein, left renal vein, the third part of the duodenum, and the
mesentery, and along its whole course is a dense interlacement of
sympathetic nerves. (The left renal vein, crossing to the vena cava
in front of the aorta, is the exception to the rule that above the dia-
phragm the large veins are in front of the large arteries, whilst below
it they pass behind.)

To the right side is the vena cava; this is separated from the
aorta above by the right crus, the beginning of the thoracic duct, and
the large azygos vein. To the left are the left crus and the psoas, the
tail of the pancreas, and the kidney.

Aortic aneurysm. — When injecting a subject for dissection through
the aortic arch, the abdominal aorta often gives way just where the
cceliac arises ; there, also, aneurysm is apt to form during life. It is
evidently a weak spot. When an aneurysm comes from the front of
the aorta a pulsating tumour is noticed in the epigastric or in the
upper part of the umbilical region ; but a tumour of the pyloric end of
the stomach, pancreas, or transverse colon may also give rise to this
symptom, for the abdominal aorta advances far towards the anterior
abdominal wall.

The aneurysm is best examined on flexing the trunk, so as to
slacken the abdominal wall, and by getting the patient to expire fully
so that the lower costal cartilages may sink. The bowels should
previously be well opened.

Pain in the back is a sign of the aneurysm ; for the sympathetic
filaments along the aorta are associated with the lumbar nerves
through the ganglia, and pain is reflected from these filaments to the
spinal trunks, and along the posterior divisions of those nerves to the
skin of the dorsi-lumbar region. A careless practitioner might satisfy
himself with calling such pains * lumbago.'

The aneurysm may, by disturbing the sympathetic plexus, pro-
duce indigestion and sickness ; or, by constant pressure, may cause
absorption of the bodies of the lumbar vertebrae, and may even bear
upon the roots of the lumbar nerves. Pressure may also cause per-
sistent neuralgia in the abdominal wall, testicle, groin, and thigh. The
tumour may bulge against the diaphragm, oesophagus, and stomach,
causing dyspnoea, dysphagia, and vomiting, and possibly a constant
pain in the epigastrium. In some cases the pains are less when the
patient lies upon his face, for then the tumour falls away from the
nerves. The tumour may compress the transverse colon ; it may thrust

352 The Abdominal Aorta

forward the liver and suggest hepatic enlargement ; should it impinge
against the vena cava, oedema of the legs may occur ; compression of
a renal vein may be followed by albuminuria. Briefly, it may be said
that if the tumour grow from the back of the aorta the pains are chiefly
lumbar ; if from the front the disturbance is chiefly visceral, and the
pains are abdominal and epigastric. The aneurysm may leak into the
peritoneal cavity, or behind it, forming an enormous, but pulseless,
blood-tumour ; or it may burst into the stomach, small intestine, or
transverse colon, or, causing absorption of the diaphragm, may enter
the chest.

Ijig-ation of the abdominal aorta may be effected through the
linea alba and the peritoneum, by separating the coils of intestine and
then gently tearing through the root of the mesentery. Or the vessel
may be reached without opening the peritoneum, as for ligation of
the common iliac, the pouch being dragged rather further upwards.
Should the patient survive, the collateral circulation would be freely
established, as described on p. 369, with the additional help of the
anastomosis of the lumbar arteries given off below the ligature with
those above, and of the inferior mesenteric (should the ligature be
placed above that vessel) with the superior mesenteric.

Branches. — The phrenics ascend obliquely over the front of the
crura to the vault of the diaphragm, where they anastomose with the
internal mammary and intercostal branches. The right phrenic also
gives twigs to the liver.

The cceliac axis arises opposite the top of the first lumbar vertebra,
which would place it about four inches above the umbilicus, and just
above the pancreas ; it has a semilunar ganglion on either side. It
divides into gastric, hepatic, and splenic trunks, of which, in the
child, the hepatic is the largest, but, as the proportionate size of the
liver decreases, the splenic becomes the largest.

The gastric (coronary) runs to the left end of the stomach, where
it gives branches to the oesophagus, and then doubles on itself to
descend in the lesser omentum to the pylorus, where it anastomoses
with the hepatic ; at the great end of the stomach it anastomoses with
the splenic.

The hepatic hooks forwards and upwards to reach the portal
fissure ; in its ascent in the lesser omentum it has the bile-duct to the
right and the vena portae behind. It divides into a right and left
trunk, the branches of which enter the lobes together with invest-
ments of Glisson's capsule. The right branch gives a twig to tl
gall-bladder. The branches of the hepatic are the pyloric to the less
curvature of the stomach, to anastomose with the gastric ; and the g«
tro-duodenal, which, descending behind the first part of the duodenui
divides into right gastro-cpiploic (which joins on the great curvatui
with the branch from the splenic), and the superior pancreatico-duc
denal, which winds round the head of the pancreas. This last-nai

Superior Mesenteric Artery 353

branch may be implicated in ulceration of the duodenum following
severe burn (p. 325).

The splenic runs along the upper border of the pancreas, behind the
stomach, and breaks up into several short trunks for the hilum of the
spleen and the great end of the stomach (vasa brevia). In its course
the splenic gives off the pancreaticoe parvce and a pancreatica magna,
and a large vessel, the gastro-epiploica sinistra, which runs in the root

4, Abdominal aorta.
I v, Inferior cava.
g, renal veins.
£•',£•", ureters.

//, A', spermatic veins.
;', com. iliac vein.
k, com. fern. vein.
/, int. saphenous.

5, renal arteries.

6, 6' spermatics.

7, 7' com. iliacs.

8, ext. iliac.

9, deep circumflexa

ilii.

10, internal iliacs.
12, deep femoral.

(A. THOMSON.)

N.B. -All the
lar-e veins -except
the left renal arc-
posterior to the arte-
ries.

of the great omentum, to meet the gastro-epiploic branch of the
lu'|>;itic along the greater curvature of the stomach.

The superior vicsentcric comes off close below the cceliac axis, just
behind the pancreas and splenic vein, and emerges between the pan-
creas and transverse duodenum. It gives off from its right side the
inferior pancreatico-duodenal branch ; and, passing between the layers

A A

354

The Abdominal Aorta

of the mesentery, it reaches the right iliac fossa, where it gives a
branch to the end of ileum and the beginning of colon, the ileo-colic.
The superior mesenteric has a slight convexity to the left, and from
this side are given off twelve or fifteen vasa intestini tenuis, which, by
dividing and anastomosing, form a series of arches, three or four deep,
from which twigs enter the wall of the jejunum and ileum. The
highest of the vasa anastomoses with the pancreatico-duodenal loop,
the lowest with the ileo-colic. The upper branch of the ileo-colic
anastomoses with colica dextra, which comes from the right side of the
superior mesenteric to supply the ascending colon. Higher up comes
off the colica media, for the transverse colon ; it anastomoses with
the colica dextra, and with the colica sinistra on the descending colon.
The colica dextra lies behind the peritoneum ; the colica media runs
between the two layers of the transverse meso-colon.

The supra-renals anastomose in the supra-renal capsule with
branches of the phrenic and renal arteries.

The renals arise just below the superior mesenteric, the right being
rather longer and higher than the left. Before entering the hilum
they give off twigs to the supra-renal capsule and ureter, and to the
bed of the kidney. The renal artery lies behind the vein, and in front
of the ureter, the right renal passing behind the vena cava. The
artery may be given off in several branches, and supplemental renals
are sometimes derived from a mesenteric or iliac trunk.

As the testis or ovary was developed just below the kidney, so the
spermatic or ovarian artery arises close below the renal. It is a
slender vessel which descends behind the peritoneum obliquely over
the psoas and ureter, the right lying also over the vena cava. In the
female the artery passes inwards between the layers of the broad
ligament to supply the ovary, and it gives off branches to the uterus,
Fallopian tube, and round ligament. By the last-named structure
some twigs of the ovarian artery may eventually reach the labium. In
the male the artery emerges with the other constituents of the sper-
matic cord, and may anastomose with the artery of the vas and with
the cremasteric branch of the deep epigastric.

Ths inferior mesenteric is given off within a couple of inches of the
bifurcation of the aorta, that is, rather more than an inch above the
umbilicus ; it passes over the left common iliac vessels to the upper
part of the rectum, down either side of which it sends a large branch,
the superior h&morrhoidal. Branches from these hnsmorrhoidals
pierce themuscular coat, and anastomose with the rectal twigs of
the internal iliac and internal pudic arteries. The inferior mesenteric
gives off the colica sinistra, which anastomoses on the descending
colon with the colica media above, and with the arteria sigmoidea
below. TIi3 colica sinistra lies behind the peritoneum, and in re-
moving tlvj kidney throjgh the peritoneum the gland should be reached
th? outer sicb of ths descending colon, so that the colica

Luschkcts Gland 355

may be avoided. The arteria sigmoidea, from the inferior mesenteric,
communicates with the colica sinistra above and with the superior
haemorrhoidal below.

The lumbar arteries, four on each side, run outwards, like the
intercostal arteries. They pass beneath the psoas and behind the
quadratus lumborum, and then between the inner oblique and the
transverse muscles. They anastomose with branches of the internal
mammary, deep epigastric, lower intercostal, ilio-lumbar, and deep
circumflex iliac arteries. They also give branches (spinal) along the
lumbar nerves, which supply the cauda equina, spinal cord, and the
vertebral periosteum ; and a branch (dorsal) which runs back between
the transverse processes for the erector spinas, and for the integument
of the loin.

The middle sacral passes from the bifurcation of the aorta down
the middle of the fifth lumbar vertebra, and the sacrum and coccyx ;
it gives branches to the anterior sacral foramina and to the rectum,
which latter anastomose with other haemorrhoidal arteries. On either
side the sacra media anastomoses with the lateral sacral branches,
and at the tip of the coccyx it supplies Luschka's gland.

The coccygeal, or Luschka's gland, at the tip of the coccyx, is a
pisiform tuft of small vessels derived from the ending of the sacra
media. It is surrounded by granular cells, and by a fibrous coat
which sends fine processes into the interior. Nerve-filaments enter it
from the ends of the neighbouring sympathetic chains. The gland is
of surgical importance in that it may be the starting point of certain
coccygeal, sacral, and pelvic tumours of infant life.

THE INFERIOR VENA CAVA

The inferior vena cava begins at the right side of the fifth lumbar
vertebra by the confluence of the common iliac veins. It ascends upon
the right side of the aorta, being separated from it above by the right
cms ; it deeply notches the back of the liver (where it receives the
hepatic veins), and, passing between the right and central leaflets of the
phrenic tendon, opens at once into the right auricle. The right renal
and lumbar arteries cross between it and the vertebrae. In front
of it are coils of small intestine and mesentery ; the right spermatic
artery ; transverse duodenum, pancreas, portal vein, and right lobe of
liver. To the right side are the kidney, ureter, psoas, and ascending
colon.

Its tributaries are the lumbar, which closely correspond in distribu-
tion with the lumbar arteries. The left lumbar veins are the longer,
as they have to pass beneath the aorta. The upper lumbar veins com-
municate with a vena azygos.

The right spermatic and supra-renal and lower phrenic veins end

A A2

356 The Vena Cava Inferior

in the vena cava ; the corresponding vessels of the left side pass into
the left renal vein.

The ovarian veins communicate freely with the uterine veins in the
broad ligament ; they end like the spermatic veins.

The renal veins begin at the hilum of the kidney and pass inwards
in front of the renal artery. The left vein is the longer ; it crosses in
front of the aorta, and receives the inferior phrenic, supra-renal, and
the spermatic or ovarian of the left side.

The hepatic veins return to the vena cava, by three or four large
trunks, the blood which was brought to the liver by the portal vein
and the hepatic artery. They enter the vena cava where it lies in
the notch at the back of the liver, between the layers of the coronary
ligament, and close below the diaphragm.

The descent of the diaphragm in inspiration, and especially so
during active exercise, compresses the liver and gently squeezes the
blood from its sluggish veins. (For portal system see p. 337.)

THE LUMBAR NERVES

The lumbar nerves break, like the other spinal nerves, into an
anterior and a posterior division ; the posterior passes between the
transverse processes and gives off an internal and an external branch.
The internal branch is small, and ends in the erector spinas ; the
external branch also supplies the erector, but the three upper branches
give, in addition, cutaneous twigs for the loin and buttock*

The lumbar plexus is formed by a descending (dorsi-lumbar)
branch from the twelfth dorsal nerve, and by the anterior divisions of
the first, second, and third lumbar nerves, and by most of that of the
fourth. It is lodged in the hinder part of the psoas, and is thus
anterior to the quadratus lumborum. The root-fibres for its nerve s
emerge from the lumbar enlargement of the cord.

In addition to a communicating twig to the second, the anterior
division of the first lumbar nerve gives off the ilio-hypogastric and
illo -inguinal branches, both of which pass outwards below the anterior
division of the last dorsal nerve, in front of the quadratus lumborum,
and then through the transversalis and into the interval between that
muscle and the internal oblique.

The ilio-hypogastric gives a branch through the oblique muscles
which passes over the iliac crest, to the skin of the buttock, and
another through the oblique muscles to the skin in the hypogastric
region.

The ilio-inguinal escapes through the external abdominal ring and
splits into a branch for scrotum or labium, and one for the skin over
the upper and inner part of Scarpa's triangle. In their course the
divisions of the first lumbar nerves supply the oblique muscles.

The first lumbar nerve lies below the first lumbar vertebra, and in

Lumbar Plexus

357

caries of that bone inflammatory pressure upon the posterior root of
the nerve is manifested by definite peripheral neuralgias— the patient
complaining of pains in the front of the belly, in each groin, or over
the hips.

The second nerve sends down a branch to the third, and divides
into the genito-crural and the external cutaneous, each of which, doubt-
less, derives a few filaments from the descending branch of the first.

The genito-crural descends on the front of the psoas, and breaks
into a genital and a crural division. The genital branch passes down
upon the external iliac artery, and eventually leaves the abdomen
through the inguinal canal, ending in the supply of the cremaster, or
over the round ligament. ' Retraction of the testis ' (p. 349) is effected
through the influence of this nerve. The crural branch passes beneath
Poupart's ligament and through the front of the crural sheath and the
fascia lata, and supplies the skin over the outer part of Scarpa's
triangle.

ILIO-HYPOGASTRIC

ILIO -INGUINAL

GENITO-CRURAL

EXT. CUTANEOUS

ANT. CRURAL

OBTURATOR

/ACCESSORY
\ OBTURATOR

The external cutaneous comes through the outer side of the
psoas, creeps beneath the iliac fascia, and emerges from the pelvis
below the outer end of Poupart's ligament. Then, slowly piercing the
fascia lata, it gives cutaneous branches to the buttock and to the outer
aspect of the thigh as low as the knee.

The third and fourth nerves, with the twig from the second, com-
bine to give off the anterior crural and the obturator.

358 The Lumbar Nerves

The anterior crural nerve emerges frcm the cuter side of the
psoas, beneath the iliac fascia, and lies between the psoas and iliacus,
both of which it supplies. Having passed beneath Poupart's ligament,
and beneath the outer part of the crural sheath, it divides, in the upper
part of Scarpa's triangle, into cutaneous and muscular branches.

The first-named branches are : the middle cutaneous, which pierce
the sartorius to end in the front of the thigh ; the internal cutaneous,
which cross the front of the superficial femoral artery for the inner side of
the thigh and even the upper part of the leg. Filaments of the internal
cutaneous nerve, beneath the fascia latajoin the middle cutaneous and
the internal saphenous nerve in the formation of the patellar plexus.

The largest of the cutaneous branches of the anterior crural nerve
is the internal saphenous, which crosses the artery obliquely from the
outer side and lies in front of it in Hunter's canal, but, though in the
canal, it is not within the proper sheath of the vessels. It leaves the
canal with the superficial part of the anastomotica magna, and, cours-
ing behind the sartorius to the knee, it pierces the fascia lata to lie by
the internal saphenous vein ; it ends at the ball of the great toe. It
gives branches to the obturator and patellar plexus and to the inner
side of the leg and foot.

Muscular branches. — In addition to those given off in the false
pelvis to the psoas and iliacus, the anterior crural sends a branch
beneath the crural sheath to the pectineus ; to the rectus, which gives a
twig to the hip-joint ; to the vastus externus, which reaches the interior
of the knee-joint ; to the crureus and sub-crureus (which, also, may
supply the knee-joint) ; and a large branch to the vastus internus,
which journeys with, but to the outer side of, the long saphenous nerve.
The sartorius may receive branches from the anterior crural as well
as from the middle cutaneous.

Neuralgia of the anterior crural may be due to central disease of
the cord, as in locomotor ataxy ; to pressure upon the posterior roots
as they leave the spinal canal, as in the case of spinal tumour,
meningitis, or lumbar caries ; to inflammation of, or abscess in, the
psoas ; to the pressure of enlarged lumbar glands, or of iliac aneurysm ;
to inflammatory thickening of the fibrous elements of the nerve, or to
reflected irritation, as in the case of hip-joint disease.

The strange way in which the ultimate branches of a nerve may be
distressed in the case of central pressure was well exemplified in a
child with spinal caries, whose chief symptom seemed to be sym-
metrical darting pains at the ball of each great toe— at the endings of
the internal saphenous nerves.

The obturator nerve descends along the inner border of the psoas,
and through the fork of the external and internal iliac arteries, and out
by the upper part of the thyroid foramen, above the obturator artery.
It divides into a superficial and a deep branch.

The superficial division passes down in front of the adductor brevis

Obturator Nerve 359

(behind the pectineus and adductor longus) and ends in the obturator
plexus, though it sometimes wanders thence to the skin on the inner
side of the upper part of the leg. In its course it gives a branch to the
hip-joint, and branches to the adductors longus and brevis, the gracilis,
and the pectineus. Its articular branch enters through the cotyloid
notch and is chiefly distributed to the ligamentum teres.

At the lower border of the adductor longus, beneath the sartorius, the
superficial part of the obturator nerve joins with branches of the internal
cutaneous and of the internal saphenous to form the obturator plexus.

The deep division of the obturator nerve enters the thigh through
the substance of the obturator externus, which it supplies, and descends
behind the adductor brevis and in front of magnus, supplying both those
muscles. It then passes through the large adductor into the upper part
of the popliteal space, and, after resting upon the popliteal artery, enters
the knee-joint, probably in company with the central articular artery.

Peripheral neuralgias are apt to disturb the obturator nerve in
disease of the hip, sacro-iliac, and mid-lumbar joints. Pain in the
knee, or the thigh over the region of the obturator plexus, is one of the
most usual and early symptoms of hip-disease. I cannot explain the
cause of this, but must content myself with calling attention to the fact
that the superficial division sends a twig to the ligamentum teres, and
that the deep division ends in the knee-joint. Analogous instances
of the transference of neuralgia are : pain at the end of penis, sympto-
matic of vesical calculus, and at the point of the shoulder, of aortic
disease or of hepatic disease. The fact of the obturator nerve
supplying also the sacro-iliac joint (Hilton) accounts for the pain about
the knee in disease of that synchondrosis. The weariness and aching
of the thighs and knees in lumbar caries is readily explained by the
effect of inflammatory pressure not only upon the obturator nerve but
upon other branches of the plexus situated in the diseased region of
the spine. The great feature in these pains is the symmetry of their
arrangement. The child complains of both thighs or knees aching.
When, after rest, the pains cease to be symmetrical, and are confined
to or chiefly felt upon one side, the formation of abscess in the sheath
of the psoas must be suspected.

The accessory obturator, an occasional branch of the third and
fourth nerves, runs along the inner border of the psoas, and out of the
pelvis over the horizontal ramus of the pubes and beneath the pectineus
which it supplies. It also gives a twig to the hip-joint, and then merges
its filaments with those of the superficial part of the obturator nerve.

The anterior division of the fifth lumbar nerve emerges below the
fifth lumbar vertebra, and is at once joined by a branch from the
fourth. The nerve thus formed is called the lumbo -sacral cord ; it
descends from the inner border of the psoas beneath the common iliac
vessels, and joins in the formation of the sacral plexus ; many of its
strands, however, pass out into the superior gluteal nerve.

360 The Pelvis

PART V
THE PELVIS

The innominate bone has three primary centres of ossification :
for ilium at third month of foetal life, ischium at fourth, and pubes at
fifth. During childhood these segments are
joined in the acetabulum by a Y-shaped carti-
lage, which, becoming softened and disinte-
grated in hip-joint disease, readily allows pus to
work through into the pelvis.

Five secondary centres appear at puberty :
in the Y-shaped cartilage (so that the three
parts of the bone are soon after fused together) ;
in the iliac crest, which, as a cartilaginous rim,
is sometimes detached by violence ; in the
anterior inferior iliac spine, which may be torn
off by energetic contraction of the rectus

femoris, or by direct violence ; in the ischial tuberosity, and at the
pubic symphysis. The bone is welded into a solid mass at about the
twenty-fifth year.

Weaver's bursa — The ischial tuberosity is separated from the
gluteus maximus by a large bursa, and in those who sit much, as
weavers, tailors, and coachmen, the sac may become inflamed, and may
suppurate.

The sacro-iiiac joint is formed by the auricular surfaces of the
sacrum and ilium, each of which is covered with a layer of cartilage.
The anterior sacro-iliac ligament is thin, the posterior is thick and
strong, and, in addition, contains a large amount of interosseous fibres.
The joint is supplied by branches of the gluteal and ilio-lumbar arteries,
and by nerves from the superior gluteal, the sacral plexus, and perhaps
from the obturator.

Disease of the joint may follow injury, or parturition, or may be
secondary to spinal caries. The local tenderness may be detected by
following the iliac crest round to the sacrum, and pressing below the
posterior superior spine.

In addition to the constant pain at the bottom of the back, there

Sacro-iliac Disease 361

may be peripheral f\ to the knee, on account of the

obturator n< ctimes giving a twig to the sacro-iliac joint, and to

the thigh, on account of associations between the nerves of that joint
and other branches of the sacral and lumbar plexuses. There is pain
on pressing the fronts of the iliac crests together, and defalcation may
distress. Abscess from the joint may open on to the back, or
into the pelvis, or into the sheath of the psoas, or into the rectum.

Ligament*. — The fifth lumbar vertebra is connected with the
sacrum by the ordinary ligaments of the vertebral column, but there
is in addition a strong intertransverse ligament which spreads down
into the lateral mass of the sacrum.

The ilio-lumbar ligament widens out from the tip of the last
lumbar transverse process along the back of the iliac crest, giving
origin to the quadratus lumborum.

The great sacro »ciatic ligament is attached by a broad base to
the posterior inferior iliac spine and to the side of the sacrum and
coccyx ; as it passes downwards and outwards it gathers up its
into a thick band which afterwards spreads along the inner border of
-,hial tuberosity, a falciform process being continued up the
ischial ramus. A good deal of the ligament is continued into the
origin of the hamstring muscles, especially the biceps. The ligament
bounds posteriorly the pelvic outlet and the ischio-rectal fossa, giving
origin to the glutens maximus, and closing in the lesser sacro-sciatic
foramen.

The tower »acro-*clatic ligament spreads from the ischial spine
into the side of the sacrum and coccyx, anterior to the attachment of
the greater ligament ; it closes in the great sacro-sciatic foramen, and
the internal pudic vessels and nerve wind round it

The rreat »acro-»datlc foramen transmits the pyriformis, and,
above it, the gluteal vessels and the superior gluteal nerve ; below it,
the sciatic and internal pudic vessels and nerves, and small branches
of the sacral plexus.

By the •mailer foramen the obturator internus and its nerve
leave the pelvis, and the internal pudic vessels and nerve re-enter on
their way to die ischio-rectal fossa.

The pubic •jrmpbjrsi* is enclosed by anterior, posterior, and
superior, and the sub-pubic ligaments.

Each osseous surface is covered by an oval fibro-cartilaginous
plate, and between these plates is an elastic pulp ; as pregnancy '
approaches a synovial membrane may be developed in the joint

Arterial twigs enter the joint from the obturator and deep epigastric ;
filaments of nerve come from the obturator.

The articulation of the fifth lumbar vertebra with the sacrum forms
the Mero-Tertebral angle, which may be felt by a long finger in the
rectum. It most not be taken for a stricture of the bowel, nor for a

362 The Pelvis

The sacrum is wedged between the haunch bones from above
downwards and before backwards, the better to break shock and
escape dislocation. Its lower end forms a slightly movable joint with
the base of the coccyx, a fibro-cartilage being interposed ; sometimes
these bones are welded together ; as the result of a fall on to the but-
tocks, or during parturition, fracture may occur and union fail to take
place. Subsequently, during defalcation, and in every other movement
of the coccyx, the last sacral nerve is subjected to painful contusions,
and removal of the coccyx may be demanded. This distressing disease
is called coccydynia. A subcutaneous section of the nerves irritated
or of the muscles moving the coccyx is far less likely to afford relief
than removal of the bone itself, which in these cases may be found
necrosed. That the bone is loose or dislocated may be readily made
out by taking the coccyx between the finger and thumb, the finger
being in the rectum. In women who have spent much time on horse-
back the coccyx is especially incurved and likely to be broken in labour.

Fracture of the pelvis is often associated with injury to the pelvic
viscera ; information can often be obtained as to the nature of the
fracture by digital examination through the rectum or vagina. The
treatment consists of rest in bed, the thighs being flexed, so as to
slacken the rectus femoris and the muscles of Scarpa's triangle, and a
band being fixed around the pelvis, if expedient.

Fracture often traverses the slender pubic and ischial rami, in
which case laceration of the urethra may occur. Blood in the urine
is a grave symptom in fracture of the pelvis ; a metal catheter should
be carefully introduced, but if that cannot be done the perineal urethra,
or the bladder itself, must be opened, lest extravasation of urine
take place. The patient must not attempt to micturate.

From great violence the head of the femur may be driven through
the acetabulum, or the pelvis crushed out of shape.

The festal pelvis is small, so as not to interfere with parturition, and
even after birth its development proceeds slowly up to puberty.
During infancy there is not room in it for the bladder, which, together
with the coils of small intestine and much of the rectum, are lodged in
the abdomen. Thus it is that the young child's abdomen bulges so
greatly ; and that in perineal lithotomy difficulty may be experienced
in introducing the finger into his bladder.

Deformities of the pelvis may be due to rickets or mollities
ossium. In each case the bones are soft, and, in rickets, as the grow-
ing child walks, sits, and stands, the weight of the body thrusts the pro-
montory of the sacrum towards the pubes at the expense of the conjugate
diameter of the brim. If such a child have her weak and bending
spine caged in an iron ' support,' the weight transmitted through the
soft pelvis is much increased and the pelvis rendered all the narrower.

In mollities ossium, which comes on after puberty, the haunch-
bones yield from the superimposed weight at their weakest part, that is

Pelvic Fascia

363

l-iterior Crura

in the rami of the pubes and ischium, until the pelvis becomes ' beaked '
or ' rostrated ' ; as the patient walks the acetabula are thrust inwards.
Thus, in the rickety deformity the pelvis is flattened from before back-
wards, and in that of osteo-malacia from side to side, the aperture
being tri-radiate.

The pelvis is also deformed when the bend of a lateral lumbar
curvature is continued into the sacrum. The sacral vertebras are rotated,
and are diminished in the concavity of the lateral curve ; and the
sacro-iliac joint is apt to be synostosed, the pelvis being tilted and
rendered obliquely ovate.

The pelvic fascia consists of various sheets which are all more or
less continuous with each other, but, because its arrangement is usually
studied in its various parts, the student often fails to understand it in its
general design and arrangement. The design of the fascia is to steady
and strengthen the
pelvic viscera, and to
shut the ischio-rectal
fossa out from the
general cavity.

The fascia lines
the circumference of
the pelvis, from the
pubes in front to the
sacrum behind, in
one continuous layer,
passing behind the
internal iliac arteries,
but in front of the
sacral plexus. From
the back of the pubes
it descends to the
prostate and neck of
bladder, constituting
the pubo-prostatic
ligament ; it also en-
closes the prostate
and joins the back of
the triangular liga-
ment. Passing from
the side of the pelvis,
the fascia slopes

down over the upper surface of the levator ani to form the true lateral
ligaments of the bladder, continuous, of course, with the pubo-prostatic
ligaments. Just behind the bladder it encloses the seminal vesicles
and joins with the piece of the opposite side in front of the rectum.
A little further back, but still over the levator ani, it loses itself upon

Obturator Fascia -

Internal Puttie Vessels ie-Neri't

The Pelvis

the side of the rectum, and, enclosing it, passes over the front of the
pyriformis and sacrum. Thus the pelvis is completely shut off from
the ischio-rectal fossae by the fascia passing on to the sides of the
rectum and bladder ; this sheet is the recto-vesical fascia.

At the level of the upper border of the levator ani the pelvic fascia
gives off two sheets, one of which is thin (anal fascia) and passes on
the under surface of the muscle to the lower end of the rectum, whilst
the other descends along the outer wall of the ischio-rectal fossa (obtu-
rator fascia] to cover the obturator internus, to be attached to the bony
and ligamentous margin of the pelvic outlet, and to join the posterior
layer of the triangular ligament. (The wood-cut is from Gray.)

THE PLANES OF THE PELVIS

Obstetricians have divided the true pelvis into three planes, and
have given each plane three diameters — antero-posterior or conjugate,

transverse, and obliqtie.

In the superior plane — the
brim of the true pelvis— the
conjugate diameter extends
between the sacro-vertebral
angle and the crest of the
pubes ; it, ab, is the shortest
diameter, 4 in., the transverse
diameter, tr, beingihe greatest,
Sin.

In the middle plane — the
pelvic cavity — the oblique dia-
meter, ob, is the longest, 5 in. ;
it extends from the middle of
the sacro-sciatic foramen to
the obturator membrane. The
antero-posterior diameter, be-
tween the middle of the sacrum
and the symphysis, is 4^ in.,
the distance between the ischial
tuberosities being 4-,' in.

In the inferior plane — out-
let— the diameter between the

tip of the movable coccyx and the pubic arch, cf, is 5 in. ; and, whilst the
diameter extending obliquely from sciatic ligament to ischial ramus
measures about 5 in., the interval between the tuberosities is but 4 in.

ab> superior, and c/: inferior plane; ed&nA kg,
axes of inlet and outlet.

Superior plane
Middle plane
Inferior plane

Transverse

. 5 in.

• 4*,,

• 4 „

OMique

4:,' i".
5 „
5 „

Antero-posterior

4 in.

Foetal Head 365

Thus, at the brim the longest diameter is the transverse, the
shortest is the antero-posterior. In the middle plane the oblique dia-
meter is the longest, and the shortest is the antero-posterior. At the
outlet the antero-posterior is the longest and the transverse the shortest

\j\-a.-.-.:-.:- ifpdvi :
«/. nteto-fXMtcri .-

: r •.."_• •: ' . -;

Axes. — A line, ed, drawn at right angles to the middle of the superior
plane shows the axis of inlet ; it extends between the navel and the tip
of the coccyx ; the axis of outlet passes from the sacro-vertebral angle
through the anus.

The spine of the ischium greatly influences the direction of the foetal
head during parturition.

The foetal head.— Though the base of the foetal skull is solidly
ped, to protect important nerves and ganglia, the vault is ex-
tremely compressible, the edges of the bones being bevelled, and con-
nected by membranous seams, so as to permit overlapping as the head
passes through the pelvic straits.

Where three or more sutures meet, the membranous seams are wide
and conspicuous, and the arterial pulsation which there exists gives
those areas the name of font ane lie*. There is a fontanelle at each
angle of the parietal bone, those in the middle of the coronal and
lambdoid sutures being extremely important ; by their shape and posi-
tion the finger of the obstetrician recognises the kind of head presenta-
tion with which he is dealing. (See fig. on p. 366.)

The anterior fontanelle is Kke the ace of diamonds ; the posterior
is triangular. The anterior is wide, but the posterior is encroached
upon by the close proximity of the corners of the three bones which
bound it In the case of chronic hydrocephalus the anterior fontanelle
may not be closed until after puberty. The lateral halves of the frontal
bone are connected by a loose suture which extends downwards from
the front of the anterior fontanelle ; it is the continuation of the sagitta

366

The Pelvis

measured by the obstetrician in the occipito-frontal
diameter, ab, in the occipito-mental, om, in the cervico-bregmatic, //,
and in the fronto-mental diameter, bm. The fronto-mental measure-
ment is small in the fcetus, because the jaw presents no teeth and the
ramus hardly exists.

Skull at birth, showing
lateral fontanelles :

a l>, occipito-frontal dia-
meter.

o in, occipito-mental.

/' in, fronto-mental.

1 1, cervico-bregmatic.

The measurements of these diameters are thus given : a b, 4^ in.,
om, 5 in., //, 3! in., bm, 3} in. of the male foetal head. Bregma (ftpcyfia)
means the ' top of the head ' ; in Latin the word is sinciput (semi,
caput}.

In parturition the long diameter of the head enters the superior
plane in the transverse diameter ; passing through the middle plane,
it occupies the oblique diameter, and it emerges through the inferior

Foetal head emerging
in ' first position ' ;
asterisk marks pre-
senting portion.

plane antero-posteriorly, the occiput under the pubic arch and the
face to the coccyx. Thus in its progress through each plane the long
diameter of the head occupies the longest pelvic diameter. The
adjacent sketch shows the head escaping through the outlet, its long

Parturition 367

diameter taking advantage of the wide sweep between the sub-pubic
arch and the movable coccyx. The head, as it were, screws itself
through the pelvis.

The soft parts are dilated by the descent of the amniotic bag, which,
under the contractions of the uterine and abdominal walls, plays an
important preparatory part. Hasty rupture of the membranes may
render the labour dry and tedious. When the os, the vagina, and
vulva are fully dilated, the membranes burst, the ' waters ' escape, and
the uterine walls contract with renewed vigour. The muscular tissue
of a feeble uterus may be stimulated by the administration of ergot ;
but this drug must not be- used until the os is wide open, or, in a vain
attempt to drive the foetus through the unyielding os, the uterus may
rupture itself. To aid the expulsion of the foetus, the nurse may advise
the woman to blow hard into a bottle ; in this way the lungs are filled,
the diaphragm is depressed and fixed, the abdominal cavity is dimin-
ished, and its muscles are set to work. By * holding her breath,' or
by hauling on a jack-towel fastened to the foot of the bed, the patient
fixes the diaphragm and ribs, and thus gives the oblique, transverse,
and straight muscles the greatest advantage. But the presence of the
head in the vagina excites strong reflex contractions which fatigue the
woman much less than voluntary acts would do. During the final ex-
pulsive act the escape of the contents of the rectum is almost inevitable.

When labour is threatening, the bladder and rectum should be
thoroughly evacuated to clear the way for the foetus, and to diminish
the risk of the occurrence of a rent or gangrenous perforation.

During the detachment of the placenta the large veins which run
obliquely into it through the muscular wall of the uterus are torn across,
but the immediate and energetic contraction of the muscle closes their
open mouths and prevents flooding. To check post-partum haemor-
rhage the inert uterus must be stimulated to contract by cold, by bi-
manual pressure, by ergot, or by electricity. The lingering attachment
of a piece of placenta checks contraction and is an incentive to bleed-
ing ; the uterus must at once be cleared.

Pelvic abscess, which may occur from cellulitis after parturition,
and from other causes, is associated with deep-seated tenderness and
fulness, and often with a bulging which may be made out through the
rectum or vagina. The abscess may break through into either of
these passages, or into the bladder or peritoneal cavity — or on to
the surface of the abdomen or pubes. It may be dealt with after the
manner of iliac abscess from spinal disease. In the case of the male
the contents of a pelvic abscess may follow the spermatic cord towards
the scrotum.

Pelvic hsematocele (at/za, blood \ KTJ\T], tumour] is a collection of
blood in the retro-uterine pouch, or in the sub-peritoneal tissue around
the uterus. The bleeding, which generally occurs at the time of
menstruation, is from some congested vessels of the generative organs.

368 The Pelvis

Unless the bleeding be furious and fatal, it trickles into \x>
pouHi (p. 390), where peritonitis adhecioiu may enclose it, CO
small intestine forming the roof of the cyst-wall. When the effusion
a peritoneal i' l:l:Hy be t v, eej, the layr-rs of the broad

ligament, and is due to the rupture of a varicose ovaria

, be diffused within the pelvis, in which case it may float the
Uterus out of the reach of the finger. In the ( ase of sub-pen1

, vacation, the ha-matoccle is Hi 'ed.

When the bleeding is into the peritoneal cavity there is sudden
and great shock; the pressure upon the front of the return causes
constant desire to defalcate, and the patient lies on her ba< k with the
knees drawn up. Suppuration may occur, the tumour discharging
itself by the rectum or vagina, or into the general peritoneal cavity.
The cavity may be evacuated by puncture through the vagina or
rectum, as the bulging may indicate.

THE COMMON ILIAC ARTERIES

The common iliac arteries come from the bifurcation of the aorta at
the left side of the fourth lumbar vertebra ; and as they divide opposite
the alae of the sacrum the right has to run the longer com
surface-marking see p. 164.) The artery begins about half an inHi
below and to the left of the umbilicus — in the line connecting the
highest points of the iliac crests. Each is about 2 in. long, and the
longer they arc the shorter are their terminal trm.

Relations. — The right Briery rests upon both common iliac-
upon their confluence to form the vena cava, and upon the fifth lumbar
\eitebra; the left similarly rests upon that vertebra, and upon the
left common iliac vein. (See fig. on p. 353.)

In front of each common trunk are the peritoneum and coil-, of
intestine, and close to the bifurcation is the ureter. Additional ani
i Hat ions on the left side are the beginning of the rectum, and the end-
ing of the inferior mesenteric artery in the superior ha-morrhoi<:

ween the common iliac arteries are the rectum and the left
common iliac vein. External to each trunk is the psoas, and, in
addition, on the right side are the ending of the right vein and the
lining of the cava.

Rule. --.piHmv the diaphragm the veins of the trunk are on a |
posterior to the arteries (except the renal), and inclining generally to
the venous, the i i;;ht, side.

Irreffularl tie*.— Tin- < ommon iliar artery may fall short of, or
exceed the average length of two inches. Sometimes the trunl.
off the middle sa< ral or the il'io lumbar artery.

Xiiration of the common lilac artery. — A curved iu< ision of 4$
or 5 in. i . mad«- ihiou ;;h the l.in and ',upcr!i< ial fasciae from the outer

Common Iliac Artery 369

side of the internal abdominal ring to the tip of the last rib, the con-
falling in front of the iliac crest. The external oblique (aponeur-
otic and fleshy) and the fleshy internal oblique and transversalis are
divided to the extent of the skin-wound ; between the last two muscles
a branch of the deep circumflex iliac artery, which runs in a little loose
connective tissue, may require attention. The transversalis fascia is
divided on a director and the peritoneum is gently dragged up by the
out-spread fingers, and with it, probably, the ureter and the spermatic

s. The external iliac artery is then made out, pulsating near
the pubes, and is followed upwards until the internal trunk is felt
descending into the pelvis ; the ligature is applied a little higher up.
During the operation the finger would be brought in contact with the
brim of the pelvis at the sacro-iliac articulation.

For the left artery the aneurysm-needle should be passed from
within outwards, but on the right side it must be passed from without
inwards. The veins are the important relations of the common iliac
arteries, and the ligature is passed always from the chief venous (the

-ide. As with the innominate artery (p. 185), the venous relations
of the right common iliac are of paramount importance.

The curved incision affords more room for the surgeon's fingers ; it
should not come further inwards than the middle of Poupart's ligament,
or the deep epigastric artery might be wounded ; it should not run too
close along the ligament and the iliac crest, or the deep circumflex artery
may be cut ; and it should not be too high above the ligament and crest,
or else the bag of the peritoneum is not so easily dragged up. A cleanly

Dr need not hesitate to tie the artery across the peritoneal

Collateral circulation would be established by those branches of

ernal and internal iliacs — all of them are empty — which ramify in

the neighbourhood of well-filled vessels. Thus, of the external iliac, the

deep epigastric would bring in blood from its fellow of the opposite

from the lumbar, lower intercostals, and the internal mammary •

whilst the deep circumflex would help by its anastomosis with the

lombai arteries.

The serviceable anastomoses of the internal iliac are, from the
anterior division, the middle haaaotihoidal with those of the opposite
side and with the inferior mesenteric ; vesical branches with those on
the other side of the bladder ; the artery of the vas deferens with the
spermatic ; vaginal with their fellows, uterine with their fellows and with
blanches of the aortic ovarian ; obturator with its fellow through the
pubic branch (0.306) ; internal pudic with its fellow through the inferior
haemorrhoidal, and perhaps with branches in the perineum and penis.

From die posterior division of the internal iliac there will be the
lumbar branch of the ilio-lumbar anastomosing with the lumbars of
the aorta, and the lateral sacral with their fellows of die opposite
:- .it- and • .:"-. the ~:.:r:. neda

• I

370 The External Iliac Artery

THE EXTERNAL ILIAC ARTERY

The external iliac artery continues the direction of the common
trunk, and extends from opposite the ala of the sacrum to the middle
of Poupart's ligament, where the name changes to common femoral ;
it is about 3^ in. long. (For surface-marking see p. 164.)

Relations. — Its most important relation is its vein, which lies to its
inner side, but which in the upper part of the artery is a good deal
posterior. The vas deferens, descending from the internal abdominal
ring towards the base of the bladder, is also an internal relation near
the pubes, and when the bladder is empty the pouch of peritoneum and
possibly some small intestine sink to the inner side. The beginning of
the rectum overlaps the artery of the left side (v. p. 353).

Externally is the psoas in its sheath ; but, as the artery descends,
the psoas gets beneath it, and at the pubes the tendon is directly
posterior. The anterior crural nerve is a good way on the outer side of
the artery, being separated from it by the iliac fascia and the mass of
the psoas.

Anteriorly are the bag of peritoneum with the intestines, and the
spermatic vessels sloping to the internal abdominal ring. The deep
circumflex vein coming from the iliac crest reaches the external iliac
vein by running over the front of the trunk near the pubes, and the
ureter may lie over the beginning of the artery ; so also does a branch
of the genito-crural nerve.

Above, the artery rests upon the vein, and, lower down, upon the
psoas. The iliac fascia separates the artery from the psoas, and, de-
scending behind it, forms the posterior layer of the crural sheath,
the transversalis fascia descending on the front of the vessels.

Branches, — The deep epigastric is given offclose above Poupart "s
ligament, and, running upwards and inwards to enter the sheath of
the rectus, passes behind the inguinal canal. The internal abdominal
ring is to its outer side, and the external ring is, ot course, well to its
inner aspect, and much nearer to the skin. (See fig. on p. 306.)

The course of the deep epigastric may be marked on tJic surface by
a line from the middle of Poupart's ligament, that is, from the end of
the external iliac artery, to the outer border of the rectus, about an
inch below the umbilicus ; and then straight up towards the ending of
the internal mammary (v. p. 1 56).

At first the epigastric artery lies on the peritoneal side of the
transversalis fascia where it is going to form the crural sheath,
there being nothing behind it but the peritoneum. Thru, piercing the
transversalis fascia, it lies upon the back of the rectus, which there has
no sheath ; and a little higher it enters and ascemU within the sub-
stance of the rectus. Above the level of the umbilicus it anuMonx'
with the ending of the internal mammary ; earlier in its course it

Deep Epigastric Artery 371

may also anastomose with the lumbar and intercostal arteries. The
vas deferens bends round the epigastric artery to reach the base of
the bladder.

Branches of the deep epigastric. — The pubic descends to the back
of the pubes, where it may anastomose with the branch of the opposite
side and with the pubic branch of the obturator (p. 306). In every three
or four subjects the latter anastomotic loop is of great size, and gives off
the obturator artery itself. The branch thus coining from the epigastric

Irregular obturator from deep epigastric, taking, A, safe course, close to vein and on outer side
of femoral ring, and, u, taking dangerous course on inner side of femoral ring. (GRAY.)

is called the irregular obturator artery, which generally dips down close
on the inner side of the iliac vein, so that the neck of a femoral hernia
would lie between it and Gimbernat's ligament, as shown herewith.
But now and then the hernia slips down between the irregular artery
and the external iliac vein, so that when the surgeon cuts upwards
and inwards to ease the strangulation, haemorrhage is unavoidable.
Before making that incision he could rarely inform himself of the pre-
sence of the vessel, but on the occurrence of the bleeding he would
quickly reduce the hernia, put his finger through the now empty crural
ring, and tiy to seize the vessel with catch-forceps ; or he might care-
fully dilate the opening and try to hook down the wounded artery.
He could not enlarge the wound by cutting, because of the important
surroundings.

The creniasteric branch supplies the coverings of the cord and
may anastomose with twigs of the spermatic, with the artery of the
vas, or with a branch of the common femoral.

The deep circumflex iliac arises near the deep epigastric and is
similarly placed between peritoneum and transversalis fascia ; running
outwards, it lies in the crevice between the iliac and transversalis fasciae
as they are attached along the outer part of Poupart's ligament (p. 1 56).
It then passes through the transversalis fascia and muscle to lie near
the iliac crest in the connective tissue between the internal oblique and
transversalis. It anastomoses with lumbar and lower intercostal
arteries ; with the iliac branch of the ilio-lumbar, and, over the iliac
crest, with the glutcal ; possibly also with the ascending branches
of the external circumflex.

B 13 2

372 The External Iliac Artery

The accompanying vein has to cross over the external iliac artery
to enter the main vein (v. p. 353).

Migration of the external iliac artery. — A curved incision of 3 or
4 in., with the convexity downwards and outwards, is made from a
little above and to the outer side of the middle of Poupart's ligament
to just above the front of the iliac crest. Integuments, muscles, and
fascia are divided, to the length of the skin wound, as detailed on
p. 369. The peritoneum is then gently drawn up, and the artery is felt
pulsating on the pubic ramus. The trunk is followed up for an inch,
and is then freed of a little connective tissue which attaches it to
its vein and to the sheath of the psoas. The aneurysm-needle is passed
from the venous, the inner, side. (For line of incision v. p. 295.)

In aged persons, and in those with diseased capillaries, the external
iliac artery is elongated and tortuous, and sometimes drops from the
inner side of the psoas to form a considerable loop into the true pelvis.

Collateral circulation. — The deep epigastric would bring in
blood from its fellow of the opposite side, and from the obturator, by
the anastomosis behind the pubes ; from the spermatic (aortic) through
the cremasteric branch ; from the lumbar and Iowa" intercostals, and
from the internal mammary (p. 1 56). The deep circumflexa would help
by its communications with the iliac branch of the ilio-lumbar, and
with thelower lumbar arteries.

Of the branches of the common femoral, the deep external pudic
might join with the superficial of the internal pudic. Of the deep
femoral, the anastomoses of the external circumflex with the gluteal
and the sciatic, of the internal circumflex with the sciatic and obturator,
and of the superior perforating with the sciatic would all help.

THE INTERNAL ILIAC ARTERY

The internal iliac artery descends from the bifurcation of the
common trunk, for about i£ in., to the great sacro-sciatic foramen,
where it divides into an anterior and a posterior trunk.

Relations. — In front are the peritoneum and rectum, and the
bladder and ureter. Behind are the internal iliac vein, the lumbo-
sacral cord, and the side of the sacrum, the anterior division of the
artery being continued over the sacral plexus and the pyriformis.

To the outer side is the brim of the pelvis, the obturator nerve, and
the external iliac vessels. Internally is the rectum.

Hypogastric arteries. — In the infant the internal iliac arteries are
so large that they seem to represent the divisions of the aorta itself,
the external iliacs coming off as mere branches. They give off twigs
into the pelvis, and run, but little reduced in size, along the brim of
the pelvis and up the side of the bladder to leave the abdomen at the
umbilicus, carrying impure blood to the placenta. Within the a,bdo-
men they are the hypogastric arteries, but outside they are the arteries
of the umbilical cord (v. p. 298).

Hypogastric Arteries 373

As already shown (p. 311), the hypogastric artery, in its ascent
between the peritoneum and the abdominal wall, causes a ridge-
like elevation of the peritoneum ; at the sides of the ridge are slight
depressions through either of which a direct inguinal hernia may pass.

After birth the hypogastric arteries dwindle into fibrous cords
which, pervious nearly up to the top of the bladder, constitute the
superior vesical arteries ; the middle vesical branches are derived
from the superior, whilst the inferior vesical comes as a special
branch from the anterior division of the internal iliac, and supplies
the base of the bladder, the prostate, and the seminal vesicle,
and gives off the artery of the vets deferens. This last-named and
thread-like vessel leaves the abdomen with the spermatic cord, and
may eventually anastomose with the spermatic artery. The vesical
arteries anastomose with each other and with their fellows of the
opposite side, and with the lower rectal, vaginal, and perineal arteries.

The uterine artery ascends between the layers of the broad liga-
ment, and anastomoses with the ovarian artery above, and with the
uterine vessels across the middle line, and below with the vaginal
arteries. The vaginal branch anastomoses with its fellow ; with the
uterine above ; and in front and behind with vesical and rectal
branches. The middle haemorrhoidal anastomoses with the ending
of the inferior mesenteric (p. 354) ; with its fellow of the opposite
side ; with the haemorrhoidal branches of the internal pudic and per-
haps lateral sacral, and with the vesical arteries.

The obturator artery runs forwards from the anterior trunk of
the internal iliac to the upper part of the obturator foramen, through
which it passes with, but below, the obturator nerve (p. 358). Before
emerging it gives off a pubic branch which anastomoses with its fellow,
and with the pubic branch of the epigastric (v. p. 306) behind the
pubes. The obturator may also give off a vesical branch, and a twig
to anastomose in the iliac fossa with the ilio-lumbar artery.

Outside the pelvis the obturator artery divides into a couple of
branches which, diverging, form an arterial circle around the thyroid
foramen ; the branch which runs inwards supplies the origin of the ad-
ductor muscles, and anastomoses with ascending twigs of the internal
circumflex. The outer division sends a branch to the hip-joint through
the cotyloid notch, and, supplying the muscles about the ischial
•tuberosity, anastomoses with the sciatic.

The irregular obturator artery has been described on p. 371, and
the internal pudlc on p. 441.

The sciatic is one of the terminal branches of the anterior trunk
of the internal iliac artery. It emerges below the pyriformis and
passes over the small rotator muscles between the ischial tuberosity
and the great trochanter to join in the upper part of the cruciform
anastomosis ; that is to say, it joins with the inner and the outer
circumflex and the superior perforating arteries. The sciatic also

374

The Internal Iliac Artery

anastomoses with the obturator artery. It is covered by the gluteus
maximus, which it freely supplies, anastomosing in it with the gluteal
artery. Before leaving the pelvis the sciatic artery may give off some
branches to the bladder and rectum ; but its first-named branch is the
coccygeal, which pierces the great sacro-sciatic ligament to supply the
lower part of the origin of the gluteus maximus and the integument
over it. The other named branch is the conies nervi ischiatici, which
enters the great sciatic nerve and anastomoses with the perforating
arteries and with superior muscular branches of the popliteal ; it is
an important branch in the collateral circulation.

To find upon the surface of the buttock the spot, at which the
sciatic artery is leaving the pelvis, see below.

The other terminal branch of the anterior division of the internal
iliac is the internal pudic artery.

The posterior trunk of the internal iliac gives off the gluteal artery,
which, passing through the upper part of the great sacro-sciatic notch,
at once divides into a superficial and a deep branch. The former
appears between the gluteus medius and pyriformis, and ends in the
supply of the gluteus maximus, anastomosing with the sciatic. The
deep part of the gluteal artery remains under
cover of the gluteus medius, and divides into
a superior and an inferior branch, both of
which run towards the interval between the
front of iliac crest and the great trochanter,
where they anastomose with ascending
branches of the external circumflex. The
upper branch runs close around the border
of the gluteus minimus, and, sending
branches through the medius, anastomoses
with the deep circumflexa ilii. The lower
branch may anastomose with the sciatic as
well as with the external and internal cir-
cumflex.

Surface-marking-. — The spot at which
the gluteal artery leaves the pelvis may be
marked on rotating the thigh inwards and
drawinga line, A G, from the posterior superior
iliac spine to the great trochanter. The
junction of the inner, A E, with the middle
third, E F, of this line gives the position of
the artery.

The pudic artery lies over the spine of
the ischium. To find it, draw a line, A D, from the posterior superior
iliac spine to the outer side of the tuber ischii, and take the junction of
the middle and lower thirds, C. The junction of middle and uppei
thirds, B, marks the point of emergence of the sciatic. (Holden.)

The following rationale may make this scheme more easily re-

Ligation of Internal Iliac 375

membered :-— The gluteal artery coming out of the pelvis above the
pyriformis is at a higher level than the pudic, which emerges below
that muscle. The line to cross its course must, therefore, be that
running from the posterior superior spine to the higher of the two
processes of bone, namely, to the great trochanter. The line for the
lower artery (pudic) runs to the lower land-mark — the ischial tuberosity.
Further, the higher artery is at the junction of the highest third with
the middle third of the upper line, the lower artery, the pudic, being at
the junction of the lower third with the middle third of the lower line.

Xiig-ation of the gluteal artery might be performed by making a
five-inch incision in the line just given, namely, from the posterior
superior spine of the ilium to the great trochanter, the body being placed
in the position which is adopted in the dissecting-room when the
buttock is being worked at. The coarse bundles of the great gluteus
having been reached and separated with a director, and the mass of
the muscle being traversed, the vessel is seen emerging above the
pyriformis. The limb is then raised to the level of the body, so as to
slacken the gluteus, and the ligature is applied as deeply as possible.

The ilio-lumbar artery passes upwards and outwards from the
posterior division of the internal iliac, and beneath the psoas, and, as
its name implies, divides into an iliac and a lumbar branch. The iliac
branch supplies the iliacus, and anastomoses with the circumflexa ilii
and with one of the lower lumbar arteries, whilst the lumbar branch
supplies the quadratus lumborum, and likewise communicates with the
lower lumbar arteries, and, perhaps, even, with the intercostals. The
lumbar branch sends a twig into the spinal canal. The anastomoses
of the ilio-lumbar artery are of great importance when the common or
internal iliac is tied.

The lateral sacral branch, or branches, run from the posterior
trunk of the internal iliac to the lateral part of the anterior surface of
the sacrum, whence anastomotic branches are sent to the sacra media,
to the branches of the opposite side, and to the rectum. Spinal
branches enter the anterior sacral foramina, and send out twigs on to
the gluteal region.

Iteration. — The internal iliac artery may be reached by a pro-
cedure like that described (p. 368) in the case of the common iliac ; the
external iliac is followed up until the bifurcation of the common trunk
is reached ; from that spot the internal iliac may be traced towards
the depths of the pelvis for about half-an-inch, and there tied. The
ureter would be raised from the artery in raising the peritoneum.
The vein is behind the artery.

Collateral circulation would be abundant, the following vessels
anastomosing across the middle line with their fellows of the opposite
side : from the anterior trunk, the middle haemorrhoidal, three
vesical, uterine, vaginal, obturator, and internal pudic ; and from the
posterior trunk, the lateral sacral.

In addition to these sources, the empty middle hasmorrhoidal

376 The Internal Iliac Artery

would receive blood from the inferior mesenteric; the uterine, from
the ovarian branch of the aorta ; the obturator, from the deep
epigastric and the internal circumflex ; the gluteal and the ilio-lumbar,
from the lumbar of the aorta, the circumflexa ilii, and the external
circumflex ; and the lateral sacral, from the sacra media. The empty
sciatic artery would probably bring blood from the cruciform anasto-
mosis, and the artery of the vas deferens (of the inferior vesical)
might possibly help by its anastomosis with the spermatic.

Sympathetic nerves of the pelvis. — The two knotted cords of
the sympathetic system are continued from the front of the last
lumbar vertebra upon the sacrum, internal to the foramina, till they meet
at last in front of the coccyx, in the ganglion impar. Each cord has
four or five ganglia which communicate with the sacral nerves ; several
branches pass on to the middle sacral artery, and others to the hypo-
gastric plexus — a network placed between the two common iliac arteries
in front of the sacral promontory. From this plexus numberless
branches descend on each side to form the pelvic plexus, where com-
munications take place with the third and fourth sacral (spinal) nerves.
Filaments also pass with every branch of the internal iliac artery ;
thus, the pelvic viscera and the penis (but not the testes, p. 432) are
supplied.

The sacra media comes off from the bifurcation of the aorta, and
descends between the two common iliac arteries over the last lumbar
vertebra, and down the sacrum ; it anastomoses with the lateral
sacrals of either side, and it ends in Luschka's gland. Ih its course
it gives twigs to the back of the rectum, which anastomose with other
haemorrhoidal branches.

THE LYMPHATIC GLANDS OF THE ABDOMEN AND PELVIS

are chiefly arranged along the abdominal aorta (lumbar glands] and the
trunks of the iliac arteries (pelvic glands\ those along the external iliac
being in association with the inguinal glands ; there are sacral glands
also, which quickly enlarge in cancer of the rectum. The pelvic
viscera are specially associated with the lymphatics which are grouped
along the internal iliac artery. The lumbar and pelvic lymphatic
vessels gradually reach the thoracic duct.

With malignant disease of the testicle, the lumbar lymphatic
glands may be so much enlarged as to form a palpable abdominal
tumour, which may, by compressing the vena cava, cause oedema in
the lower extremities.

THE ILIAC VEINS

The external iliac vein is the continuation of the common femoral.
The name changes at Poupart's ligament, where the vein, occupying
the middle compartment of the crural sheath, lies to the inner side

Veins of Pelvis 377

of its artery. The external iliac vein joins the internal opposite the
ala of the sacrum to form the common iliac.

Because of the general inclination of the veins towards the right,
the right external iliac vein in its ascent gradually sinks beneath the
corresponding artery ; whereas, on the left side, the vein keeps always
along the inner side.

The external iliac vein receives two tributaries just above Poupart's
ligament, corresponding to the branches of the artery, namely, the
deep epigastric and the deep circumflex iliac veins. The latter branch,
having come from the region of the iliac crest, reaches the iliac vein
by passing over the external iliac artery.

The internal iliac vein is formed by the confluence of the vense
comites of the branches of the internal iliac artery ; though, of course,
the single umbilical vein, which corresponds to the two hypogastric
arteries, has no concern therewith. These venae comites form a free
anastomosis about the vagina, uterus, rectum, bladder, and prostate ;
and the haemorrhoidal branches have an important communication
with the inferior mesenteric vein, that is, with the beginning of the
vena portas.

*R& prostatic plexus of veins is placed between the capsule of the
gland and the investment of the recto-vesical fascia. It is in free
communication with the vesical and the lower haemorrhoidal veins,
and receives anteriorly the dorsal vein of the penis, which enters it
through the triangular ligament (p. 413). The vesico-prostatic veins
are often much dilated ; they are liable to imflammation after lithotomy,
and they sometimes contain calcareous concretions— phleboliths.

The common iliac veins are formed opposite the ala of the sacrum,
by the confluence of the external and internal iliac veins ; and, passing
upwards and to the right, they unite at the right side of the fifth
lumbar vertebra to form the inferior vena cava.

The common iliac veins lie, at their commencement, to the inner,
the median, side of their respective arteries, and, to reach the right side
of the fifth lumbar vertebra, each must pass beneath the right common
iliac artery. Thus, in its ascent, the left vein is always on the inner
(right) side of the left artery, and it ultimately crosses the right artery
—on a posterior plane, of course. (See Rule, p. 368.) The beginning
of the right vein is slightly to the inner side of the right common iliac
artery, and, to reach the right side of the fifth lumbar vertebra, it has
to cross the right common iliac artery— on a posterior plane. In its
ascent, the right vein lies, for the most part, behind, and, ultimately,
as it swells out into the beginning of the vena cava, a little to the
outer side of its artery.

The student will best understand the arrangement of the iliac
arteries and veins by making an outline sketch of the aorta, the com-
mon, external, and internal iliac arteries, placing a figure 4 at the
division of the aorta— representing the fourth lumbar vertebra— and a

378 The Iliac Veins

5 to the outer side of the right common iliac artery, to mark the point
of origin of the cava. Then, with a blue pencil, let him place the ex-
ternal, and internal, and the beginning of the common iliac veins to
the inner side of their respective arteries. Having done that, let him
draw in the commencement of the cava. To continue the common
veins into the cava, he must bring the left vein away from its artery
and beneath the right artery, and send the right vein more quickly
beneath the right artery and even to its outer side.

Tributaries. — The sacra media vein conveniently falls into the left
common iliac vein as it crosses below the division of the aorta ; the
ilio-hnnbar vein enters the corresponding common iliac vein.

THE SACRAL PLEXUS

The sacral nerves descend from the lowest part of the lumbar en-
largement, which is at the level of the last dorsal vertebra, in the cauda
equina, and divide into an anterior and a posterior branch.

The posterior sacral nerves emerge by the posterior sacral fora-
mina and give internal branches to the origin of the erector spinae, and
external branches which form loops about the great sacro-sciatic liga-
ment, from which twigs pass through the origin of the gluteus maximus
to supply the skin of the hinder part of the buttock.

The sacral plexus is formed by the junction of the lumbo-sacral
cord with the anterior divisions of the first three sacraF nerves and
with part of that of the fourth. The fourth sacral nerve also sends
branches to the rectum, bladder, vagina ; to the coccygeus, levator ani,
and external sphincter, and to the skin near the side of the coccyx.

The anterior division of the fifth sacral is an unimportant twig
which passes out between the sacrum and coccyx, for the skin near
the coccyx, together with a still smaller nerve, the coccygeal.

Relations of the sacral plexus. — The plexus lies upon the sacrum
and pyriformis, and is separated from the rectum and bladder, and
from the divisions of the internal iliac artery, by the pelvic fascia.

The upper part of the plexus consists of the lumbo-sacral cord and
of the anterior divisions of the first and second and part of the third
sacrals, and forms chiefly the great sciatic nerve ; the rest of the third
and the part of the fourth forming the internal pudic. But, in addition to
these trunks, the plexus gives off the superior gluteal (from the lumbo-
sacral cord), the lesser sciatic, and the inferior gluteal, and muscular
branches to the pyriformis, obturator internus, gemelli, and quadratus
femoris. The nerve to the obturator internus runs round the ischial
spine, with the internal pudic nerve ; and the nerve to the quadratus
passes beneath the tendon of the obturator internus and the gemelli,
and gives a twig through the back of the capsule of the hip-joint.

The superior gluteal nerve comes from the lumbo-sacral cord,

Sacral Plexus 379

and emerges above the pyriformis ; it courses between the gluteus
medius and minimus, supplying them and the tensor fascias femoris.
Thus it is the motor nerve of the internal rotators of the thigh.

The inferior gluteal comes partly from the back of the plexus, and
partly from the lesser sciatic ; it supplies the gluteus maximus. The
two gluteal nerves are named from their situation as regards the pyri-
formis, one leaving the pelvis above and the other below that muscle.

The small sciatic nerve passes out below the pyriformis, under
cover of the glutens maximus, which it helps to supply. Its remaining
branches are cutaneous ; some of them curl round the lower border of
the gluteus maximus, to supply the skin over the buttock, whilst others,
descending^ pierce the fascia lata at various points to supply the skin
over the back of the thigh and the upper part of the calf. Another
branch, the long pudendal^ winds round the outer side of the ischial
tuberosity to the outer part of the scrotum or to the labium. Pain in
that region may be due to pressure upon the trunk of the long pudendal,
or the lesser sciatic, or upon that part of the plexus, or of the spinal
cord, from which the nerve-filaments arise.

The internal pudic nerve emerges below the pyriformis from 'the
lower part of the plexus, and, winding round the ischial spine, enters
the ischio-rectal fossa, where it divides into the inferior hcemorrhoidal
(which supplies the external sphincter and the neighbouring integu-
ment), \htperineal) and the dorsal nerve of the penis or clitoris. The
perineal nerve runs superficial to the pudic artery, in the outer wall of
the fossa, and gives off t\vo superficial branches to the scrotum and
the penis, and motor twigs to the anterior part of the levator and
sphincter ani, to the transverse muscle, and to the accelerator urinae
and erector penis. (See fig. on p. 440.)

The dorsal nerve of the penis ascends between the two layers of the
triangular ligament, where it supplies the compressor urethras, and then
passes through the anterior layer of the triangular ligament and the
suspensory ligament, and along the dorsum, to end in the glans penis
or clitoridis, and the prepuce.

Peripheral annoyance of the internal pudic nerve by a long or
adherent prepuce may set up reflex irritation of so general and serious
a nature as to entail want of co-ordination of the muscles of the ex-
tremity, paralysis, or other obscure nervous affections. Amongst the
commonest of the reflex results of phimosis are priapism, incontinence
of urine, and nocturnal emissions of semen.

The great sciatic nerve comes from the upper part of the plexus,
and, passing out below the pyriformis, and under cover of the gluteus
maximus, descends, shielded from pressure, in the hollow between the
ischial tuberosity and the great trochanter, over the small external
rotators, and on to the adductor magnus. It supplies the posterior
surface of the great adductor, and, just below the middle of the thigh,
divides into the two popliteal nerves.

380 The Sacral Plexus

Its course may be chalked by a line which connects the middle of
the hollow between the tuberosity and the trochanter with the top of
the popliteal space. It is crossed obliquely by the long head of the
biceps. The nerve supplies the biceps, semi-tendinosus, and semi-
membranosus. Its companion artery, the comes nervi ischiatici, is a
branch of the sciatic artery.

Sciatica is a painful condition of the large nerve, and may be due
to spinal disease, to intra- or extra-pelvic pressure, or to a chronic
inflammatory condition of the connective tissue in and around the
nerve-trunk. In due course it may cause wasting of the muscles and
stiffening of the joints. The neuralgia may sometimes be relieved by
massage along the back of the thigh, or by acupuncture.

Bloodless stretching of the nerve may be accomplished by flexing
the foot to a right angle, extending the leg on the thigh, and then
forcibly flexing the thigh upon the abdomen. A more efficient way of
stretching the nerve is through an incision of five or six inches down
the back of the thigh, extending downwards from the gluteal fold at a
point midway between the tuberosity and the great trochanter. The
incision passes through the superficial fascia (fat) and the fascia lata,
down to the upper part of the hamstring muscles. These muscles
are then drawn inwards, and the nerve is isolated from its bed of fat
and connective tissue and steadily hauled upon for some minutes, first
downwards, then upwards.

The internal popliteal nerve is much larger than the outer
division of the great sciatic, and it continues the original cdurse of the
great nerve. In the upper part of the ham it lies superficial and ex-
ternal to the popliteal vessels ; in the inter-condylar notch it is placed
directly over them, and at the lower border of the popliteus it is to
their inner side. Thence it is continued on as the posterior tibial.

The internal popliteal nerve gives off three branches to the knee-
ioint which accompany the superior and inferior internal articular, and
the azygos articular arteries. Muscular branches supply the gastro-cne-
mius, soleus, plantaris, and popliteus. The external saphcnous branch
descends between the bellies of the gastrocnemius, and, piercing the
deep fascia below the calf, is joined by a branch of the external popli-
teal. It passes below the outer malleolus with the short saphenous
vein, and ends on the dorsal aspect of the outer side of the foot and of
the little toe.

The posterior tibial continues the internal popliteal nerve from
the lower border of the popliteus to the inner ankle, where it divides
into the two plantars. For the first inch it is placed to the inner side
of the posterior tibial artery ; it then passes over the artery and lies
for the rest of its extent to the outer side. It is covered by the gastro-
cnemius and soleus, and by a second layer of the deep fascia, which
separates it from the soleus. It rests upon the tibialis posticus, the
flexor longus digitorum, the tibia and the ankle-joint. Behind the

Nerves of Leg and Foot 381

malleolus it has the artery and its venae comites close upon the inner
side, and the tendon of the flexor longus hallucis a little to its outer
side.

It supplies the tibialis posticus, flexor longus digitorum and flexor
longus hallucis, and gives an additional branch to the soleus. It also
gives off a plantar cutaneous branch for the inner border of the foot
(which pierces the internal annular ligament), and articular twigs to the
ankle-joint.

The internal plantar nerve is larger than the external, and comes
from the division of the posterior tibial midway between the inner
malleolus and the tuberosity of the os calcis, from under cover of the
abductor hallucis. It supplies the plantar surface of the inner three
and a-half digits (corresponding thus to the median nerve) ; the
branch for the inner side of the great toe pierces the deep fascia near
the middle of the inner side of the foot. The bed of the nail is
supplied by the plantar nerves. Muscular branches are given to the
abductor hallucis, flexor brevis digitorum, flexor brevis hallucis, and to
the two inner lumbricals.

The external plantar, like the ulnar nerve, gives off few digital
branches (to the little toe and the adjoining side of the fourth only),
and many muscular branches, namely, to the flexor accessorius (over
which it passes), to the abductor and flexor brevis minimi digiti, the
two outer lumbricals, all the interossei, the transversus pedis, and the
adductor hallucis.

The external popliteal or peroneal nerve descends close along
the inner side of the tendon of the biceps, and, winding below the
head of the fibula into the peroneus longus, divides into the musculo-
cutaneous and anterior tibial. It gives three branches to the knee-joint,
two of which accompany the outer articular arteries, and a recurrent
branch which ascends to the joint through the tibialis anticus ; some
cutaneous branches to the outer side of the leg, and the communicans
peronei to join the external saphenous.

The musculo-cutaneous nerve descends between the peronei
longus and brevis and the extensor longus digitorum, and divides into
two branches which pierce the fascia lata in the lower third of the
leg ; the inner of them supplies the inner side of the great toe and the
cleft between the second and third toes (leaving the first cleft for the
anterior tibial nerve), whilst the other division supplies the two outer
clefts (leaving the outer side of the little toe for the short saphenous).
Muscular branches pass into the peroneus longus and brevis.

The anterior tibial nerve gains the outer side of the corresponding
artery by passing through the origin of the extensor longus digitorum ;
afterwards it holds relations very similar to those of the artery.
Though the nerve may lie over the artery in some part of its course, it
is again to its outer side beneath the annular ligament, where it divides
into an inner and an outer branch, of which the former passes along

382

The Popliteal Nerves

the outer side of the dorsalis pedis artery, to the cleft between the
great toe and the next, whilst the outer branch ends in a ganglionic
thickening beneath the short extensor of the toes, which muscle it
supplies. Its other muscular branches are to the tibialis anticus,
extensor proprius hallucis, extensor longus digitorum, and to the con-
tinuation of the last muscle, the peroneus tertius.

When there is paralysis of the external popliteal nerve the patient
cannot flex or evert the foot, nor extend the toes. The foot remains
in the position of inversion and extension, the toes being curled towards
the sole ; as the patient walks the toes catch against the ground,
and progression is rendered difficult and dangerous. When there has
been complete section of the nerve, as may happen after careless
tenotomy of the biceps, sensation is impaired on the outer aspect of
the leg and the dorsum of the foot ; and, on account of the implication
of the trophic filaments, sores may occur in the skin of those neigh-
bourhoods.

THE RECTUM

This last part of the large intestine is by no means 'straight.' It
begins opposite the left sacro-iliac joint, and inclines to the middle of
the sacrum (first piece) ; then it follows the curvature of the sacrum
and coccyx (second piece), and afterwards it bends backwards for
\\ in. between the levatores ani, to end at the level of the external
sphincter (third piece). It measures about 8 or 9 in., and 'is capable
of enormous distension.

The curves taken by the rectum must be specially remembered in
the introduction of an enema-tube or bougie. An ignorant and clumsy
operator pushing an enema syringe directly upwards might injure the
prostate or the recto-vaginal septum, and entirely fail to irrigate the
bowel. And in the case of imperforate rectum, when the bowel is
being sought through the perineum, the dissection must be carried
well back along the sacro-coccygeal curve. In the young child, how-
ever, the rectum runs a comparatively straight course.

Though not properly a reservoir for fteces, the rectum is in some
cases accustomed to contain a large amount of accumulation, us is
often made out during digital exploration. In the healthy condition
of the bowel the presence offices is a stimulus to the muscular wall
to contract. But in the subject of habitual constipation the nerves
and muscle become degenerate, and cease to act. The scnsitivciu-ss
of the lining of the rectum is very slight at a little distance above the
inner sphincter, and thus it happens that the bowel may be over-
loaded with forces without the patient being in discomfort. In such a
case a doughy tumour may be found in the left lumbar and iliac
regions. The pressure thus exerted upon the iliac veins may cause
ia oi the left thigh and leg. The more diluted the bowel, the

Malformation of Rectum

383

A, depression for z
piece of rectum, R ; B,
bladder ; M, Meckel's
diverticulum ; CE, future
oesophagus ; P, pharynx ;
u, urachus.

more stretched and thinned is its wall ; the surgeon must proceed,
therefore, with the utmost gentleness in using the enema or scoop
when endeavouring to empty it. The muscular coat being greatly
stretched and enfeebled, there is no chance of a natural evacuation
taking place.

Development.— The blind end of the large intestine descending
into the pelvis is separated by a thick septum
from the surface of the perineum. Then a de-
pression at the site of the future anus deepens
upwards to form a short, shut sac ; at last the
septum is absorbed, and the pelvic and anal
pieces of the rectum become continuous. Thus,
the pelvic portion of the rectum is developed from
the hypoblast, whilst the anal portion is the result
of an involution of the epiblast.

Zmperforate rectum results from persist-
ence of the septum ; it may exist with a perfectly
formed anus. Should absorption of the septum
be incomplete, an annular constriction will be
detected an inch or so within the anus.

The close association of the rectum and
urinary bladder during development suggests
how, from arrest of development, the bowel may
open into the vagina or urethra, or on to the perineum.

In obstinate constipation in infants digital exploration of the
rectum must not be neglected, for, although the anus is well formed,

the pelvic portion of the large

intestine may not be deve-
loped, or may be represented

only by a cord descending

towards the perineum.

Xmperforate anus. —

Though the pelvic and anal

portions may be perfectly

developed, the orifice may

be occluded by a membrane

which may be easily broken

through.

Relations.— The upper

part of the rectum rests upon

the sacrum, the sacral plexus,

and the pyriformis. Coils of small intestine dropping down into the

recto-vesical pouch intervene between it and the distended bladder.

The uterus and vagina would also be in front of it (v. p. 389). The

ureters and various branches of the internal iliac artery lie against its

side. (There is no definite limit between the first and second parts of

c, rectum, opening into bladder, l> ; a. penis.

384 The Rectum

the bowel— the first part ends at the middle of the third vertebra of
the sacrum.)

The middle piece lies in the lower part of the sacro-coccygeal
hollow, with some of the pyriformis and sacral plexus behind it. In
its anterior bend rest the base of the bladder, the vesiculae seminales
and vasa deferentia, and the prostate gland, or the vagina and the
cervix uteri. This part of the bowel is securely fixed, and is very
capacious. It ends at the tip of the coccyx.

The third part, about \\ in., turns back from the prostate or the
vagina to the anus. It is surrounded by the (striated) external
sphincter ani, and has supporting and fixing it on either side the
levator ani with its two layers of pelvic fascia (p. 363). The urethra
is separated from it by the perineum or by the vagina. This is by
far the narrowest piece of the large intestine, but it is very dilatable,
nevertheless.

On introducing the finger about i £ in. into the rectum the apex of
the prostate gland can be felt, and just in front of and below this one
can detect the beak of the catheter in the membranous urethra ; and
should the instrument wander thence into a false passage its beak can
be felt just in front of the thin rectal wall. The finger can also ex-
plore the lobes of the prostate, detecting chronic hypertrophy, acute
inflammation, or the bogginess of a prostatic abscess. The vesicular
seminales and the vasa deferentia can also be searched for tubercular
or simple inflammatory enlargement ; and even a small stone may be
occasionally made out in the bladder or impacted at the orifice of the
ureter. Also the degree of distension of the full bladder may thus
be estimated. Information can also be obtained regarding fracture of
the coccyx, and of the connections of a sacral or pelvic tumour. In
the case of a tumour in the anterior wall of the rectum information
must be sought by thorough digital examination when a sound is in
the bladder, and the index-finger is in the vagina.

In supra-pubic operations upon the bladder that viscus is rendered
much more accessible by gradually distending an india-rubber bag pre-
viously inserted in the rectum. Thus the anterior wall of the bowel
and the base of the bladder are lifted up.

As remarked elsewhere (p. 386), a patulous condition of the anus is
a strong suggestion of the existence of stricture, and Mr. Bryant has
recently shown that a cavernous condition of the rectum — ballooning
he calls it — is of like clinical import. Having no work to do, the
muscular coat below the level of the stricture (which is then found high
in the rectum, or which exists in the sigmoid flexure) becomes relaxed,
and the wall widely yields all around the bowel.

Serous coat. — The arrangement of peritoneum is like that
obtaining in the duodenum — the first piece being almost completely
invested, the second part being covered in front, \\h,Ut the third
piece has no serous coat. In the rectum, however, it is only the

Rcctnin

335

beginning of the second piece that is covered in front, for the
peritoneum soon passes on to the back of the bladder, at the level
of the top of the vesiculas seminales, to form the recto-vesical pouch
and the posterior false ligaments of the bladder. The bladder is
readily punctured through the anterior wall of the rectum, between
the vesiculas seminales, without damage to the peritoneum.

^°~K v

A considerable extent of the rectum — perhaps some 3 or 4 in. —
may be removed for malignant disease, especially on the posterior
and postero-lateral aspect, without great risk of wounding the
peritoneum. At the front the peritoneum reaches to within about 3
or 4 in. of the anus, posteriorly it does not descend so low. In
excising the end of the bowel the levator ani is divided on each side,
and, for obtaining more room during the operation, the wound should
be prolonged to the tip of the coccyx. The rectum is then dragged
down by the vulsella.

The muscular coat consists of an outer layer of non-striated
fibres arranged longitudinally, and of an inner one of circular fibres.
The longitudinal fibres, which in the colon are found chiefly in three
bands, spread evenly around the rectum in a thickish coat. Just
within the anus the circular fibres are aggregated in a thick band

C c

386

The Rectum

nearly an inch deep, the internal sphincter ; its upper border forms a
definite ridge beneath the mucous membrane, and just above it an
ulcer or the opening of a fistula is often found.

The external sphincter (striated) is attached to the coccyx, and,
passing around the sides of the anus, its fibres join again to reach the
central tendon. It is under control of the will. It is supplied by
branches of the inferior hnemorrhoidal vessels and nerves, and by
twigs from the fourth sacral. It is advisable to forcibly dilate the
sphincter after operating for internal piles, as the temporary paralysis
which follows ensures perfect rest and freedom from spasm.

Fissure of the anus is a linear ulcer or crack which extends from
just within the anus to the exterior. On account of its passing across
the fibres of the external sphincter the sensory filaments in its depths
are disturbed after every act of defecation by the spasmodic contrac-
tion of the sphincter, whilst the anus itself is kept tightly occluded.
Hence the pain is intense, and it often lasts for hours after stool.
Before the ulcer can heal, temporary paralysis of the sphincter must be
obtained, either by forcible dilatation, or by section of the superficial
fibres. Spasmodic contraction of the sphincter may be due to the
presence of a fissure which is so small as to escape detection. By
obtaining the temporary paralysis of the muscle in an obscure case
relief may generally be secured.

Spasmodic contraction of the sphincter is very characteristic of
ulceration at or near the anus. Irritation of sensory filaments of the
internal pudic nerve involves a message of unrest to the grey matter of
the lumbar enlargement of the cord, which is there converted into a
motor stimulus leaving by those fibres of the nerve which supply the
muscle guarding the mucous orifice. Sometimes the pain is so severe,
and the sensory impulse is so energetic, that the adjacent cells in the
posterior part of the grey crescent are thrown into sympathetic vibra-
tion, and the patient complains of pains in the regions near those from
which the afferent nerves are coming ; thus he may have neuralgia
in the back (lumbago ?), down the thigh (sciatica ?), or along the scro-
tum. And^sometimes the efferent (motor) impulse is so severe that the
testicles may be drawn up, or the bladder spasmodically evacuated ;
vaginismus also may be set up, or contraction of the sphincter vesicae,
retention of urine being the result.

By inspection of the anus information may sometimes be obtained
as to the nature of rectal disease ; thus in the case of fissure it is tightly
closed, and only with difficulty can a search be made amongst the
muco-cutaneous folds and furrows. But when obstruction exists, as
in the case of simple or malignant stricture, or of a greatly enlarged
prostate, the sphincter becomes atrophied and weak from want of use,
and the anus flaccid and patulous. This is very characteristic. Even
in the case of annular constriction of the sigmoid flexure I have found
the anus flabby and patulous. (See also p. 384.)

Rectum and Anus 387

In making a digital examination of the rectum the firm os uteri
(felt through the anterior wall) must not be mistaken for ' tumour.'
If there be any doubt as to the nature of the mass one finger should
be passed into the vagina whilst the other remains in the bowel. Nor
must the sacro-vertebral angle be taken for a cartilaginous or malig-
nant tumour, or for some kind of rectal obstruction. A malignant
mass in the rectum, which is just beyond the reach of the finger as
the patient lies in bed, may sometimes be detected when the patient is
examinee, in the erect position and ' bears down.'

The dilatability of the anus, and the capacity of the rectum, have
occasionally tempted the surgeon to introduce his whole hand into the
lower bowel for exploration. The practice is dangerous, even when
the hand is small, as the bowel or its peritoneal covering may be torn,
whilst the practical result obtained is extremely problematical. More-
over, permanent paralysis may follow such rough dilatation of the
sphincter.

By the introduction of the hand after death — when permission
cannot be obtained for a sectio cadaveris — abdominal and even thoracic
viscera may be extracted for inspection.

When hcemorrhage takes place into the rectum no blood may escape
by the anus until the pressure within becomes so urgent that evacua-
tion can no longer be prevented by the external sphincter. Then an
enormous quantity of fluid and clot may come away. Faintness, with
a feeling of heat and fulness in the lower bowel after operation, suggest
haemorrhage, and demand the introduction of the finger.

The mucous membrane is but loosely attached by the sub-mucous
coat. It is thick and vascular, and when the bowel is empty is thrown
into folds. On account of the looseness of its connections it is apt to
prolapse, especially in the child who strains at stool on account of
vesical calculus, chronic constipation, or diarrhoea. Permanent trans-
verse folds have been described as existing where the bowel changes
its directions. They might possibly obstruct the introduction of a
tube ; their office is to allow free distension.

The mucous membrane of the large intestine is liable to dysenteric
inflammation and ulceration, and cicatrisation of these ulcers produces
stricture. The nearer the anus, the greater the liability to ulceration.
The disease probably begins in the solitary glands.

The epithelium is simple columnar ; a rectal epithelioma is, there-
fore, of the nature of columnar epithelioma ; sometimes the disease
appears as a cord-like constriction. The epithelium at the anus being
stratified, the malignant development from it is the squamous epithe-
lioma. In an epithelioma occupying both the rectal and anal mucous
membrane the elements might be of both varieties.

There is not always pain with cancer of the rectum, especially when
the disease is high up ; but even in this case distress comes on later
when the primary disease, or the lymphatic invasion, has involved the

c c 2

388 The Rectum

sacral nerves. Then there may be great pain in the back and along the
peripheral branches of the sacral plexus. In most cases there is a sense
of fulness of the lower bowel, on account of pressure upon its sensory
nerves, and, therefore, a frequent desire for evacuation. The motions
are often small and liquid, the solid part remaining behind as a harden-
ing mass. The sphincter is usually dilated. If the disease is too far
advanced for excision to be undertaken, comfort may be obtained and
life prolonged by diverting the faeces through an artificial anus in the
groin or loin.

Arteries. — The inferior mesenteric of the abdominal aorta lies
behind the upper part of the rectum (superior hccuwrrhoidal], and
then divides into a trunk for either side of the bowel. Branches are
thence given off which pierce the muscular coat and run in the sub-
mucous layer almost to the anus, anastomosing with those next de-
scribed. The middle hcemorrhoidah are derived from the internal
iliacs ; branches also come from the lower vesical and sacral, and from
the internal pudics within the pelvis ; they communicate with each
other and with the superior and inferior haemorrhoidals. The inferior
or external hamotYhoidal arteries come from the internal pudics in
the ischio-rectal fossa (p. 442). They anastomose with each other and
with the higher haemorrhoidal arteries. Their branches are divided
in lateral lithotomy, and also in the operation for anal fistula.

Veins. — The haemorrhoidal plexus is found in the lower part of the
rectum, in the mucous and submucous coats. It communicates with
the veins of the neck of the bladder and prostate. The branches are
destitute of valves, and the chief of them enter into the inferior mesen-
teric vein which ends in the splenic, itself an important tributary of the
vena portae (p. 338) ; others flow into the internal iliac and internal pudic
veins. Thus a noticeable communication is effected between the portal
and systemic circulation.

Piles are varicose haemorrhoidal veins ; when prolapsed from the
interior of the bowel they are covered with mucous membrane and are
apt to bleed ; external piles are tumours of the inferior haemorrhoidal
veins, and, possessing a thick (dermal) coating, they do not bleed. A
branch of a haemorrhoidal artery descends into the base of the internal
pile ; the pendulous tumour must therefore not be cut off unless this
vessel is first secured, either by a clamp or ligature. In freeing the
base of the pile for ligation the blades of the scissors must be passed
up parallel to the wall of the rectum, and between it and the pile. Any
condition which obstructs the return of the venous blood predisposes
to dilatation of these veins. Piles may, therefore, be symptomatic of
disease of the heart, lungs, or liver ; of stricture of the rectum ; of
habitual constipation, pregnancy, ovarian disease or abdominal tumour ;
of prostatic enlargement, or of vesical calculus.

The nerves of the rectum are derived chiefly from the inferior
mesenteric derivatives of the aortic plexus, and from the hypogastric

Nerves of Rectum

339

plexus, but important branches come from the fourth sacral nerve.
Paralysis of this nerve after injury to the lumbar spine may help to ex-
plain the sluggishness of the bowel in such cases. On account of the
close association of the nerves of the bladder and rectum, irritability
of the latter set may cause constant desire to micturate, whilst opera-
tions upon the rectum are apt to give rise to retention of urine.

The anus is supplied by branches of the internal pudic nerve.

The lymphatics end in the pelvic and lumbar glands ; those from
the anus enter the glands arranged along the course of Poupart's liga-
ment. Enlargement of the lymphatic glands may be caused by dysen-
teric or other non-malignant ulcerations of the rectum ; therefore, when
exploring the bowel in a case of ulceration, and feeling enlarged glands
against the sacrum, one must not jump to the conclusion that the
disease is malignant.

In the case of epithelioma of the anus the inguinal glands are first
enlarged, and subsequently the pelvic glands.

THE UTERUS

The uterus is about the size and shape of a small green fig ; the
large end is directed upwards and forwards, and the small end looks

a, anus ; cl, clitoris ; It, hymen ; /, labium ; n, nympha ; r, rectum ; u, uterus ; va, vagina.

downwards and backwards, to open into the vagina. Its anterior and
posterior surfaces are flattened. Its long axis corresponds with a line

390

The Uterus

passing from the navel to the coccyx — that is with the axis of inlet of
the pelvis (p. 364). In the normal state it is suspended within the true
pelvis ; thus it cannot be felt above the pubes ; during pregnancy it
ascends towards the anterior abdominal wall.

Relations. — The large end is surrounded by coils of small intestine.
Posteriorly is the rectum ; and into the recto-vesical pouch of peri-
toneum loops of jejunum and ileum descend. In front is the bladder,
and laterally are the ovaries and Fallopian tubes, between the layers
of the broad ligament. Inferiorly is the vagina, and lower still is the
perineum ; after rupture of the perineum the uterus sinks until the cervix
and some of the body hang permanently outside the vulva ; this is
prolapse of the uterus.

The presence of the uterus between the bladder and rectum divides
the recto-vesical cavity into the antero-uterine and the retro-uterine
pouches, each of which contains coils of small intestine ; the retro-
uterine cul-de-sac is commonly called Douglas's pouch, which may be
reached by the finger through the upper part of the back of the vagina.

When the bladder is distended the uterus is thrust backwards and
upwards ; w7hen the rectum is loaded it is pushed forwards.

The peritoneal covering- of the body of the uterus is complete on
the posterior surface ; indeed, the retro-uterine pouch descends con-
siderably below the level of the body covering the posterior part of the
cervix, which extends above the vagina, and the upper part of the back
of the vagina itself. Laterally, the recto-uterine pouch is bounded by
the ureters and the obliterated hypogastric arteries. Anteriorly the
peritoneum does not descend so far, but, leaving a small part of the
uterus bare below, passes forwards to the back of the bladder.

it, uterus ; c, cervix ; od, oviduct, and / and./?, fimbriated exty. ; /, round ligament ; e>, ovary,
and lo, its ligament ; po} parovarium, with small cyst, h.

The layers of peritoneum from the front and back extend laterally
to the side of the pelvis under the name of broad ligaments. The

Ligaments of Uterus 391

upper borders of these folds with the included uterus form a vertical
septum in the pelvis, whilst the lateral margins of the pouches con-
stitute the two anterior ligaments— vesico-uterine, and the two posterior
ligaments— recto-uterine. The blood-vessels, lymphatics, and nerves
of the uterus are placed between the folds of the broad ligament in a
good deal of loose connective tissue ; so are the ovary and its ligament,
the P'allopian tube, and the round ligament. The last-named is a
fibrous cord, five inches long, which is attached to the corner of the
uterus just below the Fallopian tube, and which passes through the
inguinal canal to spread out on to the tissues of the labium. In its
descent it carries a follicular process of the peritoneum, the canal of
Nuck, into which a piece of bowel, or even the ovary itself, may stray
(inguinal hernia, p. 310), and down which serous fluid may gravitate
(congenital hydrocele, p. 429). I have also seen an enormous encysted
hydrocele in this funicular process. Operations have been designed
for shortening these ligaments in the case of a backward tilting of the
uterus. It has likewise been thought that a forward tilting might
be due to a preternatural shortness of the ligaments.

The broad ligament, the vessels and nerves of the uterus and ovary
which are within the broad ligament, the Fallopian tube, and the round
ligament constitute the pedicle of an ovarian tumour. Unilocular
cystic tumours— not ovarian — are often found in the broad ligament.

The delicate sub-peritoneal tissue which connects the serous and
muscular coats of the uterus is liable to inflammation — peri-metritis —
but it may be impossible to distinguish this disease from inflammation
of the peritoneal coat itself.

Structure. — Beneath the sub-peritoneal coat is the thick wall of
non-striated muscular tissue, the fibres of which pass longitudinally,
obliquely, and transversely — the longitudinal fibres being chiefly
external. Numerous blood-vessels run through this coat to the
mucous membrane. Hypertrophic outgrowths from the muscular
tissue, with a mixture of fibrous tissue, constitute the uterine Jibromata
or myomata ; they may extend towards the cavity of the uterus, or
appear as upheavals beneath the serous coat ; the latter may grow
harmlessly into the peritoneal cavity. According to their size and
situation these tumours may prevent conception, arrest gestation, and
complicate parturition. The intra-uterine growths cause frequent
bleedings and constant distress, and should, if possible, be enucleated.
These tumours sometimes shrivel up, or detach themselves under a
long course of ergot ; and sometimes, after parturition, they undergo
involution with the rest of the uterine wall. Their presence may be
determined, and size estimated, by the bimanual method of examination,
and by the uterine sound. With one index-finger in the vagina and
the other in the rectum, further information as to the size and position
of a tumour may often be obtained. Sometimes a submucous tumour
growing into the cavity stretches its base into a slender pedicle and

392 The Uterus

hangs against or through the os uteri as a polypus. It is a source of
constant irritation, and the muscular wall of the uterus, in its attempts
to expel it, undergoes hypertrophy, like the left ventricle in aortic
obstruction or the bladder in prostatic disease.

The cervix is nearly an inch long, and ends in a transverse
aperture, something like the mouth of a tench, os tinea;. On account
of the backward slope of the cervix, the anterior lip is also inferior ; it
is also the larger, and is the first seen through the vaginal speculum.
The upper part of the cervix has a slight serous covering behind, but
none in front, as shown on p. 389.

The cavity of the cervix is fusiform, opening above by the
os internum, and into the vagina by the os externum or os tincae.
The mucous membrane in the cavity of the cervix is arranged in a
longitudinal and transverse pleat to allow for dilatation during preg-
nancy.

The epithelium of the interior of the cervix is columnar ciliated,
but that upon the outside is, like the epithelium of the rest of the
vaginal cavity, squamous.

Sometimes the squamous epithelium on the cervix ends quite
abruptly, being replaced by crops of projecting and close-set filiform
papillae. To the touch these patches are soft and velvety, and through
the speculum they appear florid and pathological. They may be
called phantom ulcers, and they deserve not that amount of personal
attention and treatment which are at times so assiduously bestowed
upon them. They are not the result of disease ; but when the surface
is persistently rubbed with lunar caustic a genuine ulceration is easily
made.

During pregnancy the cervix grows broad and soft, and is drawn
up from the cavity of the vagina, the os tineas being blocked by a plug
of mucus. From chronic disease it is at times enormously hypertro-
phied. Stricture of the neck may cause dysmenorrhcea and sterility ;
it may be dilated by graduated sounds. Dilatation may also be so
thoroughly effected as to allow complete introspection of the uterus,
and the enucleation of large tumours. The cervix is often the seat of
epithelioma which may extend to the body of the uterus, the vagina,
bladder, or rectum, so that faeces and urine escape by the vulva. It is
of the columnar variety. In the early stage the cervix maybe con-
veniently amputated by the dcraseur, but, later on, if operation be still
justifiable, the entire uterus and its appendages should be taken away,
cither with or without abdominal section.

The presence of cancer of the cervix does not necessarily prevent
conception, but if the disease be advanced natural delivery at the
full time is almost impossible. In such circumstances the abdomen
is opened through the linea alba, and the supra-vaginal part of the
uterus, with the fcetus, ovaries, and tubes, are removed ; this is Porrtfs
operation.

Uterine Vessels 393

The cavity of the uterus is small and triangular, the apex being con-
tinuous with the cavity of the cervix through the os internum, whilst the
superior angles receive the Fallopian tubes, or oviducts ; through the
oviducts the mucous membrane is directly continuous with the peri-
toneum ; hence, uterine injections escaping above may set up peritonitis.

A titerine sound^-A.^^.^ for about two and a half inches into the normal
uterus ; it is marked in inches and fractions of an inch. The elbow in

the sound is to render introduction more easy along the axes of outlet
and inlet of the pelvis. Its reckless use may cause abortion or inflam-
mation.

The mucous lining- of the uterus consists of a basement mem-
brane covered with a single layer of columnar ciliated epithelium. It
is continuous with the lining of the Fallopian tubes, and, through the
cervix, with that of the vagina. Its deeper layer is very vascular, and
rests upon the muscular layer without the intervention of a submucous
stratum. The surface of the membrane is smooth and closely studded
with the openings of tubular, glandular inflections of the basement
membrane. The membrane swells during menstruation, being then
partially cast off ; in certain cases of dysmenorrhcea nearly the whole
of the lining comes away in pieces, with loss of blood. Much of the
discharge in leucorrhcea comes from the tubular glands.

Vascular outgrowths of the mucous membrane may start into the
cavity and, growing downwards, become pedunculated. Such polypi
are a common source of haemorrhage and dysmenorrhcea.

Supplies. — The arteries come from the tortuous ovarian branches
of the aorta, and from the internal iliacs. They reach the uterus
between the layers of the broad ligament, and anastomose freely with
each other and across the median line They form a close and delicate
plexus in the mucous membrane, which eventually empties into venous
sinuses in the muscular wall. The uterine veins and ovarian veins
form a plexus in the broad ligament and enter respectively the in-
ternal iliac and the vena cava (right), or (left) the renal vein — like the
spermatic veins. They communicate freely below with the vaginal
veins also. The dense plexus of ovarian and uterine veins is liable to
dilatation.

The lymphatics pass from the mucous and muscular coats into a
delicate network beneath the peritoneum, and eventually enter the
pelvic and lumbar glands.

The nerves are derived from the hypogastric plexus, and from

394 '/'k' Uterus

branches coming with the ovarian and uterine arteries (aortic and iliac
plexuses) ; important twigs also come from the third and fourth
sacral nerves.

When an examination is made per vaginam but a few days after
conception the uterus is found hot and turgid as if formed of erectile
tissue. The finger may also feel the enlarged body of the uterus
through the front of the vagina, and the os is ' soft and cushiony.' The
surface of the abdomen becomes flatter and the navel is deepened ;
hence the proverb, ; En ventre plat, enfant il-y-a?

Os and cervix at third month Os and cervix at eighth month,

of pregnancy.

In the third month the abdomen shows enlargement ; in the fifth
month the uterus can be felt above the pubes, perhaps halfway to the
navel. There is no confirmation of the supposition that ' quickening '
is the result of a sudden ascent of the uterus. With advancing preg-
nancy souffles and pulsations are heard, and the movements of the
foetus may be felt and seen through the abdominal wall.

A few days before parturition the foetus sinks towards the pelvis,
preparatory to delivery.

The pregnant uterus may press against the renal veins, or may in-
directly irritate the kidneys, so that albuminuria occurs ; the legs, vulva,
hands, and face become cedematous, and unemic poisoning may be
obviated only by producing miscarriage. By pressure on the iliac veins
the haemorrhoidal plexus becomes congested and piles appear, and the
saphenous veins become varicose. On account of irritation of the
lumbar and sacral nerves, neuralgias and cramps occur. These con-
ditions may be relieved by recumbency. The bladder is apt to be
irritated and the rectum obstructed.

Development. — Early in foetal life an efferent duct descends from
the ovary (which is then near the kidney) ; the outer part of the duct
becomes the Fallopiair tube, whilst the part nearer the middle line
fuses with its fellow of the opposite to become the uterus. In some
of the lower animals the fusion of the tubes is less perfect than in the
human subject, so that the uterus remains bifurcated at the fundus —
iitcnisbicornis. The cavity of the normal human uterus (p. 390) shows

Uterine Flexions and Versions

395

this inclination towards the lower type, and in some instances, from

arrest of development, a double uterus results. The bicorned uterus

may be associated with

the halves of a vagina

which is divided down the

middle. Menstrual flow

may be pent up in one

of these chambers, the

condition being called

unilateral hcematokolpos

(KO\TTOS, womb}.

Flexions and versions
are apt to occur in the
flaccid uterus on account
of the inefficiency of its
ligamentous connections.
In 'flexion' the body of
the uterus is 'bent,' the
neck remaining in its
proper place. I n ' version ' the organ swings bodily ; either condition may
be caused by the weight of a fibrous tumour, or as a result of chronic
inflammatory thickenings and adhesions. On account of the strain
which is thus thrown on various pelvic nerves, versions and flexions
cause neuralgia and pains in the back. The introduction of the uterine
sound at once differentiates a version or flexion from a haematocele or
a uterine tumour.

Uterus bicornis ; os uteri and vagina double.

Anteversion. (G. HEWITT.)

Excessive attention is occasionally bestowed upon a womb which is
considered to occupy an incorrect position or plane : practice in uterine
orthopaedies has run a risk of being developed into too special an art.

396

Tlte Uterus

The spinal column bent this way or that does not necessarily want a
support, nor does the womb.

In ante version the finger in the vagina fails to find the cervix
at first, but eventually makes it out high up, and directed so much
backwards that the os lies against the posterior vaginal wall. Through
the anterior wall the finger detects the body of the uterus running
forwards as a firm ridge towards the pubes, the fundus pressing
against and irritating the bladder. The patient lying on her back,
the uterus may be pushed up by the finger through the front of the
vagina, and by the other hand working over the pubes. To keep it
then in position, the patient must lie constantly supine ; the bladder
may be kept full and a binder applied. If necessary, a uterine support
(a pessary) may be worn. It should not be left too long in position, or
it may cause ulceration. A pessary has been known quietly to work
its passage into the rectum, bladder, or uterus.

In anteflexion the fundus is bent forwards, with the result, if the
flexion be extreme, of irritating the bladder ; otherwise the symptoms
may be only those due to the impeded escape of the uterine fluids —
dysmenorrhcea. The displacement is apt to follow extensive rupture of
the perineum, for the bladder, having thus lost much of its support,
sinks, dragging with it the roof of the vagina and the uterus. It is said
that the displacement sometimes occurs when a woman jumps from a
height, carries too heavy a weight, or in some other way overtaxes the
attachments of the womb.

In retro version the fundus impinges against the rectifm, imped-
ing defalcation and causing
tenesmus. Retroversion is
apt to be found in women
who have borne children,
and especially so if, after
labour, they have been too
highly and persistently
bandaged and kept too
long lying supine. The con-
dition is detected both by
vaginal and rectal exami-
nation. In one case the
pressure against the rectum
was diagnosed as a 'malig-
nant obstruction,' for the
relief of which colotomy
was most unfortunately
performed.

In retroflexion the body is bent towards the sacrum, the fundus
filling into Douglas' pouch, where it may be felt by the finger in the
rectum or vagina ; the introduction of the sound shows that the mass
is not a uterine tumour or a hiumatocele.

Retroversion. (FARRE.)

Displacements of Uterus

397

Retroflexion. (G. HEWITT.)

Extreme prolapse, or procidentia of uterus. (FARRE.)

398 The Uterus

In procidentia, after rupture of the perineum, or as the result of a
yielding of attachments, the uterus sinks between the thighs, and in
due time its mucous covering, which is the everted vaginal lining,
becomes dry and tough like skin.

Haematocele. — The escape of the ovum from the ovary is associa-
ted with slight bleeding, but when this is unusually severe the blood
trickles down into the retro-uterine pouch (v. p. 389). A hasmatocele
may also result from a leakage from the veins of the Fallopian tube
or from the uterus. Eventually the blood may undergo coagulation.
By vaginal and rectal examination a doughy tumour is made out
which may compress the rectum and thrust the fundus uteri forwards ;
if the effusion be sufficient, a hypogastric tumour may be detected.
The collection may burst through the vagina or rectum, or it may be
absorbed or become inert. Frequently such collections have been
successfully tapped through the rectum.

Rupture of the pregnant uterus may be caused by violence, or by
muscular energy during labour, especially if the passage of the foetus
be impeded. The rent is generally near the junction of the neck and
body, but it may be so extensive as to allow the escape of the foetus
into the peritoneal cavity.

Flagging contractions of the uterus may be stimulated by the ad-
ministration of ergot, but this drug should not be given until the os is
so fully dilated as to offer no impediment to the passage of the foetus,
or rupture of the uterus might occur.

Reflexes. — The uterus has a strange and wide influence over the
person ; the word ' hysterical,' as applied to certain nervous phenomena,
is derived straight from vo-repa, the womb. Hilton went so far as to
ascribe the frequency of ' hysterical ' affections of the hip and knee-
joints to an association, through the sympathetic filaments, of the
ovarian and uterine nerves with the sciatic and obturator !

THE OVARY

The ovary has the shape of an almond, and weighs about \ oz. It
is placed between the layers of the broad ligament, being attached to
the corner of the uterus by a short, slender ligament just behind the
Fallopian tube ; externally it is joined to a fringe of that tube (v. p. 390).
It floats freely in the pelvis, but is apt to wander in childhood clown
the inguinal canal ; I once had occasion to operate for a strangulation
of the ovary through the crural canal. It may also be prolapsed into
the antero- or retro-uterine pouch, where it can be felt through the
vagina, movable and, perhaps, very tender.

It consists of a fibrous coat, tunica alhu^inea^ which sends delicate
processes into the interior to support the blood-vessels and the Graafian
follicles. The broad ligament invests it with a serous coat, tunica
vaginalis, which is covered with columnar epithelial cells.

Parovarium 399

The Graafian follicles are lined by the cellular membrana grami-
losa and contain fluid and an ovum ; as they ripen and approach the
surface of the ovary the fluid increases. During menstruation a follicle
bursts, the ovum escaping through the peritoneal coat and into the
Fallopian tube, through which it reaches the uterus. The burst follicle
is then filled with a yellowish substance, the corpus htteum, which
quickly shrivels up if conception have not taken place, but which grows
into an important mass if pregnancy have occurred ; the latter mass
is a true corpus luteinn, the former a false one.

Abscess in a follicle (suppuratii>e ovaritis] may burst into the peri-
toneum and involve it in a fatal inflammation.

Cysts of material 'like skin' (dermoid cysts) are often found in the
ovary, containing hair, fat, epithelium, teeth, and such like ; their origin
is congenital, and is probably due to an island of the external blasto-
dermic layer having become entangled in the middle layer, from which
the ovary is produced.

From a fetus of three
months :

a, uterus.

b, round ligaments.

c, Fallopian tubes.

d, ovaries.

e, remains of Wolffian
bodies. (See p. 390.)

The parovarium, or organ of Rosenmiiller, may be seen between
the ovary and the Fallopian tube by holding a fresh broad ligament
up to the light. It is about an inch wide and consists of a series of
tortuous tubes opening by one end into a slender canal, the duct of
Gaertner, whilst the other end is connected with the ovary. Doran has
counted as many as twenty-four of these tubes in the parovarium. They
are lined with cylindrical epithelium and contain a small amount of fluid,
which, increasing in amount, may form a ' cyst of the broad ligament.'

The parovarium is a remnant of the Wolffian body. The tubes of
the parovarium correspond to the vasa efferentia and coni vasculosi,
whilst the ovary represents the body of the testis.

Supply. — The ovarian arteries come from the aorta (spermatic) ;
in the broad ligament they anastomose freely with the uterine of the
internal iliac. As in the case of the testis, the veins form a pam-
piniform plexus, which ends in the caval or left renal vein.

The nerves come from the aortic plexus with the ovarian artery,
whilst others are derived from the pelvic plexus, and accompany
branches of the uterine artery.

Though malignant disease may attack the ovary, the common
form of ovarian tumour is due to a collection of fluid in dilated
Graafian follicles ; thus an enormous dropsy may be produced which

4OO The Ovary

has to be distinguished from abdominal ascites. When several
follicles are dropsical, mullilocular cystic tumours occur.

Both in ovarian and abdominal dropsy there is a rounded swelling
giving a wave of fluctuation on palpation. But as the patient lies
supine the ovarian tumour bulges more on one side, the area of
dulness on percussion varying little with change of position (v. p. 316).
If the tumour extend across the middle line, it pushes away the
intestine and renders the area absolutely dull ; whereas, in ascites,
there is generally some inflated bowel floating up under the umbilicus,
rendering percussion resonant. The finger in the vagina makes out
the semi-elastic tumour, and probably finds the cervix uteri swung
over to that side by the body of the uterus having been pushed over
to the opposite side by the tumour ; the uterine sound also shows lateral
deflection of the uterus ; but let it be remembered that miscarriage
is apt to follow the careless use of the sound. It should not be
introduced if there be the least chance of pregnancy existing — I kn<
of an instance in which a physician was spared the operation of ovari(
tomy itself by the patient giving birth to twins very early on
morning of the proposed operation.

When the diagnosis is between ovarian disease and pregnant
bimanual examination should be resorted to, the. os uteri and the
breasts should be examined, and the fcetal heart-sounds should be
listened for. If still there were doubt, time would certainly clear
it up.

A large ovarian tumour presses upon the bladder and irritates it ;
upon the rectum and obstructs it, producing haemorrhoids ; upon
the iliac veins, causing cedema of one lower limb. It may also irritate
the stomach, and, by pushing up the diaphragm, impede the action of
the heart and lungs. If it compress the ureter there will be renal pains
and albuminuria. The legs may be painful and greatly swollen. At
first the tumour occupies only one side of the false pelvis, but as it
ascends into the abdomen it passes to the middle line and evenly
occupies the cavity. By pressing upon the bladder it may entirely
efface that cavity, so that the urine runs away by the urethra as quickly
as it flows from the ureters.

Ovaritis, acute or chronic, may follow sexual and other irritations
of the vagina and uterus, just as epididymitis is caused by irritation of
the prostatic urethra. It is especially apt to follow specific (gonor-
rhceal) inflammation which has extended up the Fallopian tube. There
is pain in the back and down the inner side of the thigh, as inorchitis
and tenderness deep in the iliac region.

Ovariotomy. — The bowels should be empty, and a catheter should
be introduced into the bladder just before operating. The incision,
which need not measure more than a few inches, should be made in
the median line from an inch or so below the umbilicus. The parietal
peritoneum is then opened, and the cyst is seen and tapped ; and when

Fallopian Tube 401

it is sufficiently empty and flaccid, it is drawn out of the wound. The
pedicle is then transfixed, and, its spermatic vessels being securely tied
with the broad ligament, the cyst is then cut off. The other ovary
must be inspected ; if enlarged, it also should be removed. The sponges
and forceps are then carefully counted, and the wound is closed by
sutures which enclose the parietal peritoneum as well as skin.

THE FALLOPIAN TUBE

The Fallopian tube, 4 in., lies in the highest part of the free border
of the broad ligament ; it leads from the serous coat of the ovary into
the cornu of the uterus, with which it communicates by a minute orifice.
The ovarian end is trumpet-shaped and fringed, one of the fringes
serving to connect it with the ovary, as shown on p. 390.

Structure. — Its external coat is of peritoneum, and is derived from
the broad ligament. Then comes a muscular layer of longitudinal
and circular fibres ; and lastly the mucous lining, which is continuous
with the peritoneum at one end, and with the lining of the uterus at
the other. The epithelium is columnar ciliated. Through the tube
micro-organisms, septic matter, and vaginal douches may find their
way from the uterus into the peritoneal cavity.

The Fallopian tube depends for its supplies upon the vessels and
nerves of the ovary and uterus.

The functions of the ciliated epithelium are to sweep the ovum
into the uterus and to hinder the ascent of spermatozoa. When in-
flammation, possibly of gonorrhceal origin, has stripped the tube of
the epithelium, the descent of the ovum is retarded and the ascent
of spermatozoa little hindered, extra-uterine pregnancy being then
specially apt to occur. As a result of the original infection, on exami-
nation of patients who have died from the effects of tubal pregnancy,
old peritoneal adhesions are often met with. Such women have
commonly been sterile, because ' their procreative machinery was out
of gear.' (Lawson Tait.)

Rupture of the pregnant tube may occur into the peritoneal
cavity — a dangerous casualty— or between the layers of the broad
ligament.

Though the tube has normally a lumen only the size of a bristle,
it may become greatly dilated and may be converted into a mucous
or purulent cyst— hydro-salpinx or pyo-salpinx (o-aXyrty^, tube). The
elongated tumour of a dilated tube may be recognised by the finger
in the vagina. If allowed to remain, pain continues and great risk of
suppurative peritonitis, from the bursting of the tumour, is incurred.
The symptoms and treatment of pyo-salpinx have been clearly described
by Lawson Tait.

D D

4O2 Female Genito- Urinary Apparatus

THE GENITO-URINARY APPARATUS OF THE FEMALE

(An outline of the development of the parts is given on pp. 329
and 420.)

The labia majora are two large muco-cutaneous folds containing
fat, connected above the pubes in the mons Veneris, and tapering
inferiorly towards the posterior commissure of the vulva, about an
inch in front of the anus. They represent the lateral halves of the
scrotum, and occasionally the ovaries, after the manner of the testes,
pass into them from the inguinal canal. Inguinal hernia also may
descend into the labium, but ordinarily nothing enters the labial mass
but the round ligament of the uterus, the end of which then spreads
out into its fibrous tissue. Abscess frequently occurs in the labium,
and, on account of the looseness of the tissue of that part, oedema
extends rapidly and widely. If the pus be in the superficial layer of
the fascia (the fatty layer) it may be diffused towards the anus, thigh,
or abdomen ; but if it be beneath the deeper, or membranous layer,
it can pass only towards the abdomen.

The blood-vessels, lymphatics, and nerves of the labia correspond
to those of the scrotum (p. 426).

The labia minora, or nympnae, are mucous folds which join
above around the clitoris, and blend below with the inner surface of
the labia majora ; they contain much vascular tissue. They are apt to
be redundant, and to project outside the vulva, especially in children.
In certain adults, as among the Hottentots, they are often enormously
hypertrophied.

At the junction of the nymphas, and firmly attached to the pubic
and ischial rami by two crura, is the clitoris. It corresponds to the
corpus cavernosum of the penis, and is composed of erectile tissue.
Amputation of the clitoris may be required for malignant disease.

In some hysterical women this organ is in a state of chronic
erection ; micturition is then difficult, and there may be complete
(hysterical) retention of urine. (See also p. 406.)

The urethra has no connection with the clitoris, but opens into the
vestibule about an inch lower down ; its aperture, the nicatus urinarhts,
is somewhat raised, and, to the finger, feels as a depression in the
centre of a flat, round papilla. The urethra can be felt like a round
cord between the anterior wall of the vagina and the pubcs (?'. p. 389.)

Further down is the opening of the vagina, which, in the virgin
state, is partially occluded by the hymen. When the hymen has
been ruptured its situation is marked by papillary elevations, carun-
culae myrtiformes.

The hymen may form a complete diaphragm to the vagina, and
cause retention of menstrual discharge. The presence of a hymen is
not proof of the virginity of the subject, nor, on the other hand, can

46 3

ii^ absence be regarded as evidence of intercourse having occurred ;
sometimes, indeed, the hymen has to be incised in the parturient
woman.

kvulvo-vaginal gland \A placed on each side of the entrance to
the vagina ; it corresponds to Cov.per's gland, and discharges its
/on by a small duct opening in front of the hymen. The duct
is liable to inflammation and suppuration, often the result of sexual
or gonorrhea] irritation. The resulting abscess is hard, round, and
painful, and the muco-cutaneous covering is bright-red.

Masses of erectile tissue, bulbi vestibuli, are placed beneath the
mucous lining of the entrance of the vagina. They correspond to the
lateral halves of the bulb of the male urethra. From injury or other
cause, rupture of this tissue may occur, with the formation of a large,
dusky, blood-tumour —a pudendal hcEmatocele — which is more often
met with in pregnant women. The external abdominal ring being clear
shows that the pudendal swelling is not a hernia.

The blood-vessels and lymphatics of the labia correspond with
-otum and penis ; separate description of them is not
needed. The vein from the dorsum of the clitoris, however, joins
in a plexus around the urethra, which communicates with the
vaginal, vesical, and haemorrhoidal branches of the anterior division
of the internal iliac vein. The nerves are derived from the lumbar
plexus, the internal pudic, and the lesser sciatic, as in the male.

The urethra is about i \ in . long. It runs downwards and forwards,
parallel with, and imbedded in, the anterior wall of the vagina. The
narrowest part is the meatus urinarius. In the child the meatus is,
ount of the slight development of the pelvis and its viscera, far
within the opening of the vulva. The urethra is lined with mucous
membrane arranged in longitudinal folds and covered with scaly
epithelium. Next conies a submucous layer of white and elastic fibres,
and then a layer of erectile tissue and pale muscular fibres continuous
with those of the bladder. Around all, as the urethra passes through
the rudimentary triangular ligament, is the striated compressor urethrae.
Small vascular tumours grow from the mucous membrane of the
meatus urinarius ; their effect upon the patient is like that which
follows preputial irritation in the male ; they must be carefully searched
for and cut off.

The female urethra is extremely dilatable, and after the introduc-
tion of the finger in exploration of the bladder the paralysis quickly
•;s away.

n in the child the little finger of the surgeon may be gradually
introduced, or a large lithotrite used, and fragments of calculus ex-
•:. with merely a temporary incontinence of urine.

The vagina is the musculo-membranous passage which leads from

the vulva to the uterus. It follows the axis of the pelvic outlet, lying

behind the bladder and the urethra, in front of the rectum, and

u L> 2

404 The Vagina

between the levatores ani. Its curve must be remembered at the time
of introducing the speculum.

The prolonged pressure of the foetal head during a tedious labour
may cause a sloughing of the vaginal walls, opening the vagina into
the bladder or rectum, the result being vesico-vaginal and recto-vaginal
fistula respectively. Urine or flatus would not escape directly after
parturition, as in the case of a laceration, but would be delayed until
the slough had separated. The condition may eventually be remedied
by dilating the vagina with a speculum, vivifying the edges of the
fistula, and closing it by sutures.

In the case of a tumour implicating the anterior wall of the rectum,
its size and connections should be examined by one index-finger in the
bowel and the other in the vagina.

Structure of vagina, — With the exception of the slight peritoneal
connection (p. 389), the vagina has no serous coat, the most external
layer being of fibrous tissue, derived from the recto- vesical fascia.
Next comes a coat of non-striated muscular tissue, arranged for the
most part in a longitudinal and a deeper, circular layer. More inter-
nally is a thin coat of erectile tissue ; and, lastly, a lining of mucous
membrane covered with squamous epithelium. On the anterior and
posterior walls the mucous membrane is raised in a longitudinal ridge
with short transverse ridges passing from it. This arrangement is
chiefly for preparing the canal for the severe dilatation to which it is
submitted during parturition.

The orifice of the vagina is embraced by the striated sphincter
vaginae, which corresponds to the accelerator urinse in the male ;
its spasmodic contraction produces the condition known as vaginis-
mus ; it might possibly demand a speculum in the vagina for an
increasing length of time each day, the sphincter being thus tired out.
Sometimes, however, the spasmodic contraction is due to small sensi-
tive growths upon the mucous membrane ; a careful inspection of the
parts should be made under ether in every case before the adoption
of empirical treatment. The state of the ovaries and of the uterus
should also be enquired into.

After rupture of the perineum much of the support of the pelvic
organs is lost, and during defalcation and micturition the anterior wall
of the rectum or the posterior wall of the bladder is thrust down as a
flaccid tumour through the vulva, the condition being a rectocele or
vesicocele, as the case may be. The uterus itself may descend until
its neck and part of its body habitually remain outside the vulva. The
perineal rupture may extend right through the sphincter ani, making
of the vagina and rectum a vast cloaca.

Sometimes the vagina is divided in its length by a vertical septum,
the lateral halves of the cavity being associated with the halves of a
bifid uterus, as shown on p. 395.

The blood-vessels of the vagina are derived from the anterior

Female Bladder 405

divisions of the internal iliac trunks, and from the uterine branches.
The front and back of the vagina also derive twigs from the vesical
and haemorrhoidal vessels respectively ; and the entrance receives
twigs from the internal pudic. The lymphatics pass to the pelvic
glands. The nerves come from the vesical, haemorrhoidal, and uterine
ramifications, and from the hypogastric plexus itself.

As shown on p. 389, the upper part of the vagina is separated from
the rectum by the retro-uterine pouch of peritoneum, which thus gives
a partial serous covering to the vagina ; there is no peritoneum upon
the front wall. I have known the peritoneal cavity opened in paring
the edges of a fistulous communication between the upper part of the
vagina and the rectum, some shreds of omentum appearing in the
vagina. When epithelioma attacks the upper part of the posterior
wall of the vagina the peritoneal cavity is quickly invaded, fatal peri-
tonitis being entailed. A loop of small intestine may be driven in
this pouch to bulge into the upper part of the vagina, constituting a
'vaginal liernia.

The female bladder is placed behind the pubes and the triangular
ligament, and in front of the vagina ; and, when distended, it ascends in
front of the uterus, being separated from it by a pouch of peritoneum.
As there is no prostate gland, and as the base of the bladder is
separated from the concavity of the rectum by the vagina, there is no
pouch behind the vesical outlet in which urine can collect. The base
of the bladder can be thoroughly explored by the sound when the
index-finger is in the vagina, and in this way the presence of even
small papillomatous growths may be detected. But, as remarked
above, the finger may be conveniently passed into the bladder for the
purpose of examination.

On account of the size of the urethra, cystitis and vesical calculus
are rarely met with, and urethritis is uncommon. In crushing a stone,
the lithotrite should be placed to one side of the elevation which the
neck of the uterus may form at the back of the bladder.

The base of the bladder is closely adherent to the front of the
vagina, without, of course, the intervention of any peritoneum ; and
in amputation of the cervix uteri by the ecraseur it has happened that
part of the anterior vaginal wall and of the floor of the bladder have
been accidentally included in the noose and taken away. By the inter-
vention of the vagina and uterus between the bladder and rectum
the female bladder has less of a peritoneal coat than that of the male.
As in the male, there is no peritoneum on the anterior or antero-lateral
aspect.

For chronic and intractable cystitis free dilatation of the urethra
and irrigation of the bladder may be unhesitatingly performed, but
vaginal cystotomy can rarely be necessary.

Retention of urine in the female, except from hysteria, or after par-
turition, or after an operation upon the rectum, is rare, because of the

406 The Vagina

shortness and capacity of the urethra and of its immunity from gleet.
The signs of retention are inability to pass urine ; dribbling from over-
flow ; the presence of a rounded tumour — which may be made out
by palpation and percussion above the pubes and 1))' examination
per iHigimun. In a lady with every one of these signs it \\ as discovered
that an ovarian tumour grou-'mg centrally had compressed the bladder
until it could contain no urine, the 'overflow' bein^ the constant
escaping of the urine directly after its exit from the ureters.

Development. — Early in foetal life a hollow growth, like the finger
of a glove, starting from the hinder end of the rudimentary intestinal
canal, extends through a wide gap in the front wall of the abdomen.
On the closing in of the abdomen, the part of the diverticulum be-
tween the intestine and the umbilicus persists as the bladder ; a
small portion only (just behind the umbilicus) becomes obliterated,
and constitutes the superior ligament — the remains of the tirachits.
Then a partition grows downwards and forwards, and converts the
existing cloaca into two passages — the rectum and the urethra. Thus,
at birth the fusiform bladder is found in the abdomen rather than in
the pelvis ; it becomes rounded, and settles down, as the pelvis grows
capable of receiving it. In perineal lithotomy in young children the
knife must be thrust well upwards in order to open the bladder.

(For scheme of development see p. 383.)

In rare instances the obliteration of the urachus is delayed, so
that, after birth, urine, or even vesical calculi, may escape through the
opening at the umbilicus. Owing to an arrest of development the ab-
dominal walls may fail to meet in front, and, there being at the same
time an absence of the anterior wall of the bladder, the posterior wall
and base of that viscus bulge out as a bright vascular tumour. On it
may be seen the openings of the ureters and the trickling urine. The
term congenital hiatus better describes the deformity than does the
one more generally applied to it — extroversion of tlic bladder. It is
associated with absence of the pubic symphysis, the urethra being
represented by an open channel on the dorsum of an ill-developed
penis (epispadias). The front of the bladder being deficient, its
posterior wall and base are thrust forwards as a convex tumour by the
subjacent viscera.

THE MALE BLADDER

Relations. — When empty, the bladder lies deeply behind the pro-
state, triangular ligament, and body of pubes. When distended, it
mounts behind the recti abdominis and even to the umbilicus. Pos-
teriorly are the rectum and recto-vesical pouch ; into the pouch coils
of small intestine are falling ; lower down are the vesiculas seminales
and vasa differentia. Laterally are the pelvic walls, and around its

Male Bladder

407

sides and summit are intestinal coils. The base of the bladder is
fixed, and is close in front of the rectum. For further remarks upon
the relative position of the bladder and rectum reference may be made
to p. 385.

The bladder may be emptied by manual compression in those cases
in which retention is due to paralysis, provided there is no inflamma-
tion or other disease of the bladder, and no urethral obstruction.

Structure. — A partial serous coat. — The peritoneum passes from
the middle of the front of the rectum on to the back of the bladder,
just above the vesiculae seminales and the entrance of the ureters ;

Arrows showing rectal and supra-pubic puncture of distended bladder. (HOLDEN.)

thence it ascends over the postero-lateral surface, and, reaching the
hypogastric arteries and the urachus, is reflected on to the abdominal
wall. When the bladder is empty the recto-vesical pouch may come
within two inches of the anus, but when it is distended the pouch
stands at about four inches from the perineum. Thus, the base of
the bladder, the antero-lateral aspects, and the whole front surface
are destitute of serous investment, and puncture for the relief of
retention may be practised through the rectum (between the vesiculae
seminales) and above the pubes without risk of setting up peritonitis.
At the latter situation the instrument should be thrust boldly back-

408

The Bladder

wards, lest, as I have seen happen, it descend in the cellular interval
behind the pubes, and fail to enter the bladder.

In a fat subject the trocar may be introduced where the linea alba
is crossed, a few inches above the pubes, by the transverse crease.

The muscular coat consists of non-striated longitudinal fibres
chiefly at the front and back ; some of them are connected with the
prostate and also with the true ligaments ; chiefly towards the neck of the
bladder circular bands exist ; they are associated with the prostate and
form a kind of sphincter. When long-continued and extra work is

thrown upon the muscular
coat, as in the case of
old stricture, hypertrophy
results ; and sometimes a
pouch of the mucous
lining is forced through
a gap between the
thick muscular bands
and forms a herniated sac
in which a stone may be
lodged. Should a calculus
fall into such a sac, there
would be a sudden cessa-
tion of symptoms, and the
surgeon might thence-
forth fail to strike it. In
such cases examination by
the rectum should give
valuable assistance ; and
the stone might be suc-
cessfully removed by a

Stricture at bulb ; membranous urethra dilated ; bladder cnnra nnhir r>r»p»ratinn
thickened, and mucous membrane roughened. SUpra-pUblC Operation.

A definite band of

muscular fibres extends between the two ureters — the inter-uretal band
— and in cases of old-standing urinary obstruction it is recognised after
death as a prominent ridge bounding the front of a deep depression of
the mucous membrane.

The mucous coat, which is attached to the muscular by a layer of
connective tissue, is thrown into rugas which are effaced as the
bladder fills. But in the triangular part of the floor which intervenes
between the openings of the ureters and the beginning of the urethra
there are no rugae, the mucous coat being smoothly spread. This
area is called the trigone ; against it the stone is forcibly and pain-
fully driven during micturition. In certain conditions the mucous
coat is thrown into firm, permanent ridges, which, when the urine is
alkaline, may become encrusted with phosphates. The epithelium is
of a modified squamous type.

Retention of Urine 409

The uvula is a small sensitive elevation at the apex of the trigone ;
it is situated above the ' middle lobe ' of the prostate.

Ligaments. — The base of the bladder is firmly fixed by four
sheets of the recto-vesical fascia, two of which pass on to its side
along the upper surface of the levatores ani (p. 363), and two run on to it
more (p. 413) anteriorly from the pubes and prostate — the lateral and
pubo-prostatic ligaments, respectively. The urachus is reckoned as the
fifth true ligament. The &\t false ligaments are the various sheets of
the peritoneum which pass to or from the bladder. Thus the sides of
the recto-vesical pouch make two of them ; the lateral reflections of the
peritoneum from the side of the pelvis make two more, and the fifth
is that piece of the peritoneum which runs up behind the obliterated
hypogastric arteries and the urachus. The reflections of the peri-
toneum around the bladder steady it without absolutely fixing it ;
they also prevent coils of the intestine falling between the bladder and
the pubes.

Supply. — Blood is derived from the internal iliac, and especially
from that portion of it which, under the name of the hypogastric
artery, passed into the umbilical cord. The part which remains per-
vious after birth constitutes the superior vesical artery ; the middle
vesical is a branch of it. The inferior vesical branches come independ-
ently from the internal iliac, and from other neighbouring vessels,
such as the middle haemorrhoidal, sciatic, obturator, pudic, uterine,
and vaginal. The veins form an intricate plexus at the base of the
bladder with those of the lower part of the rectum, the prostate, and
seminal vesicles ; other branches pass at once into the internal iliac
trunk. The vesico-prostatic plexus of veins is enclosed within the
recto-vesical fascia.

The lymphatics communicate with the glands by the side of the
internal iliac artery.

The nerves are derived from the hypogastric plexus of the sym-
pathetic, and also from the sacral nerves, especially the fourth ; thus,
in the case of compression of the spinal cord, the patient may lose
not only the power of micturating, but also the consciousness of the
bladder being distended. The fact of the non-striated muscular tissue
of the bladder receiving filaments from a spinal nerve (fourth sacral)
is interesting and suggestive.

The subject of enlarged prostate sometimes finds that he can pass
water better when sitting on a cold seat, as in that way he is able to
stimulate the vesical nerves.

Retention of urine. —As the bladder becomes distended it ex-
pands laterally and also mounts behind the recti abdominis, lifting
the coils of intestine. Bowel cannot intervene between the bladder
and the abdominal wall, because of the reflection of the peritoneum
behind the urachus (v. p. 385) ; thus, the hypogastric and lower
umbilical region is full and rounded and dull on percussion. The

4io

The Bladder

base of the bladder is thrust down against the rectum, and, by digital
exploration, a semi-elastic and rounded bulging may be detected
against its anterior wall ; and, on gently striking the hypogastric
region, fluctuation may be detected by the finger in the bowel. When
the bladder is distended to the utmost, urine begins to leak out by the
urethra ; this overflow may continue for days or even months, the
patient believing that the viscus is efficiently emptying itself. Incon-
tinenceoj ' u rim -huhe adult thus generally means a bladder full and over-
flowing ; but in the child it suggests irritation. The more distended
the bladder the more thinly are the coats spread out, and the greater
the risk of rupture from injury. Over-distension may so stretch the
muscular coat as to produce temporary paralysis. Thus, when a
catheter is introduced the urine flows without force, and under the

influence of the diaphragmatic
contraction rather than of the
vesical wall. But when stricture
has long impeded micturition
the muscular coat of the bladder
i s found thickened from exercise.
In the same way the left ven-
tricle of the heart grows thick
and strong in the effort to force
blood through the arterial sys-
tem in Bright's disease.

In cystitis the mucous mem-
brane swells, and perhaps to
such an extent as to block the
openings of the ureters and
prevent the descent of urine. A
malignant growth may have
the same effect, and the ureters
may in time be dilated to the
size of apiece of small intestine.
If this change be slowly and
quietly brought about, the glan-
dular structure may almost en-
tirely disappear under pressure,
the kidney being represented by
a multilocular cyst into which its
fibrous framework is expanded.

Dilatation of ureters and disease of kidneys, the BUt more Commonly the result
result of enlargement of middle lobe of pro- of obstructed Outflow is the SC-
state. (ERICHSEN.) .

quence of pathological events

associated with the so-called surgical kidney, which are as follows : —

The bladder being distended, decomposition of the urine occurs,

and the inflammation of the mucous membrane extends along the

Stone in Bladder 4 1 1

ureters to the pelvis of the kidney, where suppuration also takes place
and where more of the decomposing urine is pent up. Inflammation
extends thence through the gland, the tissue of which becomes riddled
with foul and scattered abscesses. Sometimes one of these abscesses
bursts through the capsule and sets up perinephritic suppuration. The
decomposing urine is taken up by the blood, and the patient's breath
has a strong ammoniacal odour. On tearing off the capsule at the
post-mortem examination close adhesions are found in many places
and small cortical abscesses are opened up.

Vesical calculus. — The pressure of the stone against the nervous
filaments on the floor of the bladder gives rise to the sensation of the
bladder containing an uncomfortable amount of urine, and thus fre-
quency of micturition is an early sign. By nig'ht the boy wets the
bed, and even during the day he may be unable to hold his water. The
sacral plexus supplies the sensory filaments, and by the internal pudic
nerve it also gives twigs to the end of the penis, to which spot
pain is often referred. (Similarly pain is referred to the knee in dis-
ease of the hip, the obturator nerve supplying each articulation, p. 358.)
During micturition the stone is driven against the sensitive trigone, and
the effort at once becomes urgent and distressing ; so violent is it that
the boy runs to the closet lest in voiding the urine he also evacuate
the rectum. Prolapse of the lining of the rectum occurs ; and blood,
and, later on, pus, may be mixed with the urine. Should the stone be
driven against the urethral opening of the bladder, and so suddenly
check the outflow of urine, the boy may scream with agony, but in
time he finds that this distress does not occur when he micturates in
the kneeling or horizontal posture, as the stone then falls away from
the neck of the bladder.

The vesical sound should be formed of one piece of metal and
must possess a short and almost rectangular beak, so that the base of
the bladder, which may lie below the level of the prostate, may, with
every other mucous area, be thoroughly explored. (For lithotomy \ see
p. 443.) The floor of the bladder may be rendered more accessible to
the sound by raising it by the finger in the rectum, or by turning the
patient on to his side.

Probably there is a centre for micturition and defecation in the
lumbar enlargement : —

From the bladder and rectum sensory filaments carry upwards the
messages of unrest, but the reflex circle is not necessarily at once put in
motion, for education and habit have placed the centre under the con-
trol of the will. But when the brain has lost the control, as in fracture
of the dorsal spine, and in cerebral or medullary disease, the patient un-
consciously ' passes everything under him.' The afferent impulse from
the mucous membrane is converted into a motor impulse, which passes
to the muscular coat, urging its contraction, the sphincters being at
the same time relaxed. When the nerve-lesion is so great that the

412 The Bladder

centre is thrown out of working order, not only is the patient unaware
when the bladder is full, but no motor impulse is transmitted to the
muscular coat, and the bladder ' brims over.'

Extreme retention of urine may exist without causing distress when
the patient has become gradually accustomed to it, but sudden accumu-
lation from tension of sensory nerves, causes great agony. Chronic
retention may be mistaken for abdominal ascites. Before tapping for
the latter condition it is, therefore, the rule to pass a catheter. The
over-loaded bladder may also be mistaken for ovarian disease or
pregnancy. The distended bladder may be ruptured from violence.
If the rent implicate the postero-lateral aspect, peritonitis is very
likely to follow. If the rent be at the front or base of the bladder
the escape will be extra-peritoneal, cellulitis and abscess probably
occurring. As a rule the urethra gives way rather than the bladder,
perineal abscess being the result.

The chief signs of the intra-peritoneal rupture are inability to mic-
turate from the time of the injury ; onset of collapse on account of the
extravasation into the peritoneal cavity ; the bladder containing only
a little blood-stained urine whilst a long metal catheter may, perhaps,
pass through the rent until its beak is found behind the linea alba.
Lastly, warm water quietly injected into a ruptured bladder quickly
disappears. Abdominal section, suture of the wound, and flushings of
the peritoneum with a warm antiseptic solution, would be needed.

When ascites has been mistaken for retention of urine, the catheter
being introduced and the bladder being found empty, the practitioner
has sometimes imagined that the instrument was not thrust in far
enough, and has thereupon driven the beak of the instrument through
the posterior wall of the bladder, which would in such circumstances
fall near to the trigone, and has thus evacuated the peritoneal cavity of
serum.

In the case of an enormous calculus, or of villous disease, the bladder
may be opened above the pubes through an incision in the linea alba ;
but before performing this operation the bladder should be carefully
washed out and distended, and thrust bodily forwards and upwards
by the gentle inflation of an india-rubber bag in the rectum. Thus the
peritoneum is pushed high up and the bladder opened without difficulty
and without much danger. In the case of urgent cystitis from prostatic
enlargement a tube might be permanently worn above the pubes.

Through an incision in the perineum the finger can usually be
made to explore the whole of the interior of the bladder, its summit
and anterior wall being pushed downwards by the hand upon the
abdominal wall.

THE PROSTATE GLAND

The prostate is a mixture of fibrous tissue, non-striated muscle,
and of follicular gland-tissue. It is placed in front of the bladder (71720,

Relations of Prostate

413

), surrounding its neck. It is shaped like the ace of hearts, the
apex pointing against the triangular ligament. It is about the size of
a horse-chestnut, and consists of two lateral lobes and an intermediate
portion. The urethra runs through it, but nearer to the upper sur-
face. Additional relations are these : — The pubic symphysis lies above
and in front. Behind, in addition to the bladder, are the vesiculae
seminales and the vasa deferentia. Close below and behind is the
rectum, through which the index finger can define much of its outline.
Below it is the thick mass of the perineum. (See fig. on p. 385.)

9 8 44

1120

i, pubes ; 5, pubo-prostatic ligament ; 9, middle lobe of, 10, prostate ; 12, left vas ; 13, left
vesicula ; 14, com. ejaculatory duct ; 16, prostatic plexus receiving 17, dorsal vein of
penis ; 19, bulb ; 20, Cowper's gland.

Investments. — A fibrous capsule immediately surrounds the pro-
static tissue, and sends processes into its substance, being, indeed,
part of the gland. On the outside of this is a plexus of veins, which
is in communication with the veins of the bladder and rectum (vesico-
prostatic plexus) ; and at the front the plexus receives the dorsal vein
of the penis. This large venous plexus separates the fascial invest-
ment of the prostate from the fibrous coat of the gland. The veins
are often dilated, and occasionally contain calcareous matter ; they are
divided in lateral lithotomy, and then, in the adult, may be the source
of serious bleeding.

414

The Prostate

The prostatic plexus of veins empties on either side into the internal
iliac vein.

The arteries of the prostate come from the internal iliac, inferior
vesical, internal pudic, and inferior haemorrhoidal. An irregular in-
ternal pudic artery may run by the side of the prostate (p. 442). The
nerves are derived from the hypogastric plexus. The lymphatics enter
the chain of glands along the internal iliac artery.

Middle lobe.— At the upper and back part of the prostate, between
the lateral lobes, may be found a small, rounded lobe, ' intimately con-
nected with the other two, and fitting in between them and the bladder
and the adjacent part of the urethra. When prominent it corresponds
to the elevation in the urinary bladder, called the uvula ' (Quain). A
slight enlargement of the ' middle lobe ' upwards may cause serious
obstruction at the neck of the bladder, and will give increased length
to the urethra ; nevertheless, if the rest of the prostate be not hyper-
trophied, a digital exploration by the rectum may give no information
of the condition, the growth being into the bladder rather than towards
the rectum. In most cases, however, hypertrophy of the prostatic

tissue is general, and
can readily be esti-
mated per anum. If
the enlargement be
extreme, the bladder
is pushed upwards
and forwards, the
neck being increased
in length. To draw
off the retained urine,
a long catheter with
a sudden curve is
needed. In enlarge-
ment of the middle
lobe, a soft, elbowed

(coud^ catheter

answers well, the beak
readily surmounting the obstruction. Enlargement of the prostate

Hypertrophy of median and of lateral lobes of prostate; bladder
dilated and thickened ; ' prostatic ' catheter.

obstructs micturition, and necessitates the subject of it learning the art
of drawing off the residual urine by a catheter. Sometimes the patient
stimulates the bladder to contract by sitting upon a cold seat. Some-

Diseases of Prostate 4 1 5

times he finds that he can more completely empty it by getting on to
his hands and knees. The pressure of the tumour against the lower
bowel gives rise to the sensation that defaecation is not complete, and
may cause the patient to go to the closet to void the urine. On account
of the straining at micturition and at stool, the enlargement is apt to
cause piles. Pressure against the rectum may even obstruct defaeca-
tion, and render the sphincter flaccid and the anus patulous. The
subject of enlarged prostate usually avoids a soft-seated chair, because
the yielding cushion, forced up against the perineum, presses on the
hypertrophied masses. Pieces of enlarged prostate have often been
removed through a median perineal incision, and McGill has suc-
cessfully excised with scissors and forceps, by a suprapubic opera-
tion, portions of enlarged prostates which prevented micturition.
Probably in most cases in which a vesical calculus is associated with
enlarged prostate, suprapubic lithotomy should be resorted to in order
that, at the same time, the projecting middle lobe may be nipped
off, as advised by McGill.

Acute prostatitis is caused by extension of gonorrhceal inflam-
mation. The gland rapidly enlarges, and, blocking up the urethra,
causes retention. The patient is in dire distress, and neither hot bath
nor opium may afford relief. Examination by the rectum proves the
gland to be swollen and tender. With the utmost gentleness a soft
catheter should be passed and the water drawn off. Leeches may be
applied in front of the anus. Should suppuration follow, the prostatic
abscess will be likely to find its discharge into the urethra, bladder,
or rectum, or even through the perineum. The strong fascial covering
of the upper aspect of the prostate usually prevents the matter escap-
ing into the pelvis. Should the abscess break into the urethra, reco-
very is apt to be tedious, pus escaping during micturition, especially
towards the end of the act, when the gland is brought under the in-
fluence of the levatores ani. At other times by firm pressure in the
perineum and by appropriate manipulation, pus may be made to escape
from the meatus urinarius.

In chronic prostatitis enlargement may be detected per rectum;
there may be irritability of the bladder, and a feeling of weight in the
perineum. From the follicular glands of the prostate filamentous
casts are shed, which float in the urine like vermicelli.

THE MALE URETHRA

From the neck of the adult male bladder to the meatus urinarius is
about nine inches. The prostate contains the first inch and a-half ; the
next half-inch is between the two layers of the triangular ligament
(membranous portion, p. 413), and the remainder is surrounded by
the erectile tissue of the corpus spongiosum (p. 385). That piece of
the urethra which is inclosed in the enlarged portion of the corpus

4 1 6 The Urethra

spongiosum — upon the front of the triangular ligament — is the bulbous
portion.

Though usually represented in diagrams as a hollow cylinder, the
urethra has its roof and floor closely approximated ; it thus forms a
long valve to the bladder. Tt possesses, when the penis is flaccid, two
curves, of which the concavity of the posterior is turned upwards and
of the anterior downward. The hinder of the curves is permanent ;
the other is obliterated when the penis is raised, the urethral curve
being then like that of an ordinary metal catheter. The fixed part
of the urethra is the more likely to be ruptured by injury.

•

Wax cast of normal urethra : a, prostatic ; b, membranous ; c, spongy. (THOMPSON.)

The prostatic portion of the urethra lies nearer the upper surface
of the gland. It is wide and dilatable, especially in the middle, and
readily admits the passage of the finger during lithotomy. Extending
along the floor is the vent montanum, beneath which a tunnel, the
sinus pocularis, runs from before backwards for nearly half an inch.
This sinus is the homologue of the uterus, and the common ejaculatory
ducts open within it, or upon its margins. On each side of the veru
the floor is grooved by a prostatic sinus, which receives the secretion
of about a dozen follicular glands. These glands are the chief source
of that fluid which escapes from the urethra during strained defaeca-
tion, or under the expulsive efforts of the levatores ani at the end of
micturition. The hypochondriac imagines it to be semen, but micro-
scopic examination shows it to be destitute of seminal filaments. On
the theory that involuntary seminal emissions may be the result of
irritation about the veru montanum, close to the opening of the common
ejaculatory ducts, it has been recommended that the small mucous
area be touched with a strong solution of nitrate of silver. This
speculative treatment has, in the practice of some surgeons, been
believed to produce satisfactory results.

From the extension backwards of urethritis to the opening of the
common ejaculatory duct, or from its being bruised by the passage of
a catheter, or by an escaping fragment after lithotrity, inflammation
may extend along the vas deferens to the epididymis. That the trouble
is not ' metastatic orchitis ' is shown by the fact that the vas deferens
is tender and enlarged, whilst the body of the testicle is soft. Thus
the vas deferens may be enlarged to the size of a pen-holder. The
mild injection prescribed for a gleet should not be held accountable for

Male Urethra 417

the occurrence of the so-called swelled testicle, which generally comes
in a natural sequence of events.

The membranous portion is between the two layers of the
triangular ligament, at about an inch below the symphysis. Because
of the backward projection of the bulb, the floor is rather shorter than
the roof. Around the mucous lining is a thin erectile layer, continuous
behind with the tissue of the veru montanum and in front with that of
the corpus spongiosum. More externally are pale muscular fibres, and
around all is the compressor urethras.

The compressor urethrae is an arrangement of striated fibres
which sling up and encircle the urethra between the two layers of the
triangular ligament. It has a slender origin from the upper part of
each descending pubic ramus. It acts as a sphincter to the urethra,
and assists in erection by compressing the efferent veins of the corpus
spongiosum. Its nerve-supply is from the internal pudic.

Spasmodic stricture may be the result of energetic contraction of
the compressor urethras, but such spasm must be of short duration.
' I will tell you what spasmodic stricture often is. It is an exceed-
ingly useful excuse for the failure of instruments. It is " a refuge for
incompetence."' (Sir H. Thompson.)

Coiuper's glands lie below the urethra, between the two layers of
the triangular ligament. Their slender ducts pass forward — through
the anterior layer of the ligament — to open upon the floor of the
bulbous portion of the urethra.

The spongy portion measures about seven inches, the posterior
part being enclosed within the bulbous enlargement, the anterior
within the glans.

The bulbous part of the urethra is very capacious ; externally it
is covered by the accelerator urinae. There is also a considerable
dilatation, the fossa navictdaris just behind the meatus urinarius.
The meatus is the narrowest part of the canal ; often it has to be
incised to admit an instrument which readily passes along the rest of
the urethra. Such incision should be made towards the frasnum —
not upwards into the tissue of the glans.

The junction of the membranous and bulbous portions of the
urethra is also narrow. A slender catheter is apt to leave the canal
in a false passage through the floor, and to pass up below the prostate
and bladder. By the left index finger in the rectum the error is
immediately recognised ; it is less likely to happen if the beak of the
catheter be kept along the roof of the canal ; and if this rule be
observed the instrument is less likely to hitch against the front of
the triangular ligament, or to be caught in the sinus pocularis. A full-
sized instrument is less likely to be intercepted than a fine one.

Chronic inflammation (gleet) is apt to linger about the bulbous
part of the urethra, with the result that stricture is of frequent occur-
rence just in front of the triangular ligament.

K K

41 8 The Urethra

The association between gleet and stricture is briefly this : chronic
urethritis determines the deposit of plastic material in the submucous
coat ; this new tissue undergoes atrophy, the result being a con-
striction around the tube — a stricture. The stricture keeps up the
irritation and discharge, so that the only way of curing a gleet may
be by the gradual dilatation of the canal to its proper size. It may be
necessary to increase the size of the bougie up to No. 13 or 14 of
the English scale. The remarkable capacity of the normal urethra is
shown by the ease and safety with which Bigelow's enormous litho-
trites may be passed.

The follicular glands of Li lire are more freely scattered along the
floor of the spongy urethra ; but the largest of them, the lacuna inagna,
is yawning upon the roof of the fossa navicularis.

In an attack of urethritis, abscess may form in one of these follicles
and cause troublesome gleet. Sometimes the abscess breaks on the
under surface of the penis.

When the urethra is at rest its mucous membrane lies in longitudinal
rugae. It consists of a basement membrane covered by columnar
epithelium ; in the prostatic portion, and in the fossa navicularis, the
epithelium is laminated.

A calculus escaping from the bladder may be impacted in the
urethra, plugging the canal, it prevents micturition ; calculus in the
urethra is the most common cause of retention of urine in children.
But if the stone be too small to completely block the canal, it will
probably give rise to irritation and to incontinence of urine!

In passing a catheter the handle must not be depressed before
the beak has entered the depths of the perineum ; but if the handle
be not depressed soon enough, the beak will catch against the front of
the triangular ligament. The rule is to keep the beak of the catheter
along the roof of the urethra, thus the hitch may be avoided. On
partially withdrawing the catheter, and then depressing the handle, the
end glides over the obstructing ridge. But in the operation no force
should be used, lest the end of the instrument pass out of the urethra
and enter a false passage : — The instrument having been passed to
the very hilt, no water flows, only blood escaping ; moreover, the instru-
ment cannot be made to roll on its long axis, the point being still
tightly held, and, further, perhaps, the handle has swerved from the
middle line.

The error may be detected by introducing the finger into the
rectum, when the catheter will be found alarmingly near the bowel,
and it may be corrected by withdrawing the instrument— the finger
being still within the bowel — and re-introducing it at a higher level.
The accident may be followed by escape of urine on to the front of
the triangular ligament, and by perineal abscess.

If the handle of the instrument be too suddenly and too forcibly
depressed, a false passage is sometimes, though rarely, made through

Female Urethra 419

the roof of the urethra, just behind the triangular ligament, the beak
passing into the cellular interval between the front of the bladder and
the pubes. Blood might escape but no water, and the beak might be
clearly felt behind the abdominal wall. Digital exploration by the
rectum would not distinguish the catheter in the bladder.

Rules for catheterisation. — Be very gentle. Keep the beak of
the catheter along the roof of the urethra. When you can no longer
feel the beak in the perineum introduce your finger into the rectum,
as a guide and guard. Keep the handle in the exact median line,
and in depressing it mind that the beak does not catch against the
front of the triangular ligament. Learn, and remember against a
future occasion, the geographical peculiarities of that urethra. Should
spasmodic contraction of the compressor urethras obstruct the passage
of the instrument, pause until the muscle has yielded, and then gently
proceed with the operation.

Cock's operation. — When retention of urine results from stricture
of the urethra, that part of the canal which intervenes between the
prostate and the stricture is (see fig. on p. 408) distended ; if the end of a
scalpel be boldly introduced into it the bladder empties itself, and, rest
being secured, the stricture ultimately gives way. For the operation
the patient must be placed in the lithotomy position, and the finger
having been introduced into the rectum, and resting against the apex
of the prostate, the scalpel is thrust up to it, with the back towards
the rectum. The urethra is then opened from behind forwards. Urine
at once escapes ; if need be, a tube is easily passed into the bladder.

THE FEMALE URETHRA

The female urethra opens into the vulva about an inch below the
clitoris. It is an inch and a-half in length, and descends close in
front of the anterior wall of the vagina. Its coats consist of vascular
and elastic tissue, and of an abundant lining of mucous membrane,
which is thrown into longitudinal folds. The epithelium is transitional
and squamous. Passing through the somewhat indefinite triangular
ligament, the urethra is surrounded with the representative of a com-
pressor urethrae. It is extremely dilatable, and may, by careful
management, admit the index-finger for exploration of the bladder.
Even in the child a lithotrite may be safely passed along it, or a good-
sized stone removed through it, without more serious consequence
than a temporary paralysis (v. p. 389.)

To pass the female catheter without exposure of the parts,
cannot be done without practice ; the operation should be learnt upon
the cadaver. Descending from the anterior fourchette, the tip of the
left index-finger just touches the clitoris ; at about an inch further
down is a flat papillary enlargement, in the centre of which is the
urethral opening. The catheter is then run along the pulp of the

E E 2

42O

The Urethra

finger, which thus guides it to the meatus urinarius. In childhood
the meatus is, proportionately, very far back, and the sound is apt to
enter the vagina instead of the bladder. In case of doubt, a second
sound may be introduced into the vagina, or the finger into the
rectum.

Development For a considerable period of its existence the

fcetus remains sexless ; there is
a rudimentary penis or clitoris
(A, pc}, as the case may be ;
immediately below which is the
uro-genital orifice (c, ug). On
either side of this is a tegu-
mental fold (A, Is) ; should the
sex prove female, these folds
remain separate — the labia
majora ; but, should a male be
developed, they fuse in front of
the anus (D, j), to form the
scrotum. The median ridge
upon the scrotum — the raphe
— shows where the folds have
joined. The lips of the uro-
genital sinus remain as the

nympha? and enclose the clitoris above. The clitoris enlarges but
slightly. 'In the male the penis continues to enlarge, and the margins
of a longitudinal groove on its under surface gradually unite from the
primitive urethral orifice behind, as far forwards as the glans, so as to
complete the long canal of the male urethra, which is, therefore, a pro-
longation of the uro-genital sinus.' The corpora cavernosa, which are
at first separate, become fused together in the chief part of the penis,
but remain distinct against the pubes. In cases where the fusion of the
lateral halves of the body has been imperfectly accomplished, a deepish
dimple may persist in the skin of the middle line of the sacral or coccy-
geal region. Such a dimple is often associated with spina bifida.
Should the depression extend still more deeply, it might in time become
separated from the skin and remain as a closed sac beneath it ; then,
collecting epithelial elements in its interior, it would constitute a dennoid
cyst. Dennoid cysts are often met with in the sacro-coccygeal neigh-
bourhood.

Amongst the commonest of the twenty-four malformations which
arise from arrest of development of these parts are the following : —

Hypospadias (wro, beneath ; o-Trau, tear), from the floor of the
urethra having been apparently ' torn ' away. As the distal part of
the canal is the last to be closed in, the deficiency is of more frequent
occurrence towards the glans than along to the root of the penis. Some-
times the entire length of the floor is undeveloped. The urethral fissure

Hermaphroditism 42 1

may extend deeply into the perineum, the halves of the scrotum re-
maining separate. Occasionally, the urethra opens on to the surface
of the perineum at the site
of the uro-genital (c, ug)
aperture. In the case of
doubt arising as to the sex
of an imperfectly formed
subject, the probability is
that the subject is a male, in 'V(V
whom the process of deve-
lopment has been arrested.
(Epispadias, p. 406.) Oc-
casionally, during the fusion
of the halves of the scrotum,
and the closing in of the
urethra, the penis becomes
drawn down into and
blended with the scrotum,
so that the imperfectly de-
veloped subject is taken for
a female.

A glance at the adjacent
woodcut shows its close re-
semblance to fig. c above.
It represents the parts of an
imperfectly developed male,
who had ' lived in a state of
wedlock with three different
men.' (See Todd's Cyclo-

pcedia, vol. ii. p. 693.) The illustration closely represents also the
external genitals of a person whom I recently saw in consultation, who,
having been brought up as a female, was not aware of his true sex
until near twenty years of age.

In a case of doubtful sex the testes may often be pressed down from
the higher part of the inguinal canal ; their discovery at once shows the
child to be a male.

THE PENIS

The skin of the penis is thin ; its loose subcutaneous tissue is des-
titute of fat, and is quickly infiltrated and distended by serous or
urinary effusion. In case of a bulky hernia, or a large hydrocele, the
lax penile coverings are requisitioned to such an extent that the penis
is scarcely distinguishable in the full scrotal mass, its situation being
marked by a mere depression whence the urine escapes. The skin is
extremely movable, and in amputation of the penis it must not be
drawn too far forward, lest the body and root of the organ be denuded.

Hermaphroditism, the result of arrested development :
a, a, halves of scrotum ; b, penis ; c, perineal
fissure ; d, urethral aperture ;f,ft mucous glands.

422

The Penis

In anasarca the prepuce is specially enlarged, so that to find the en-
trance to the urethra it may be necessary to slit up the swollen fore-
skin along the dorsal aspect. (Edema may be due to the root of the
penis having been constricted by an elastic band or a string.

The prepuce of the new-born child is usually extremely long, but
in the course of subsequent development a proper proportion between
the parts is generally established.

Phimosis (</H/MO<», to close with a muzzle) implies that the prepuce
is so tight, or redundant, as to be incapable of
easy retraction. When the glans becomes
inflamed (balanitis, £aAai/o$-, acorn\ or a sore
occurs beneath the tight prepuce, circumcision
is indispensable. Hardened crusts of smegma
and calculi, which have escaped from the
bladder, may be lodged beneath a tight fore-
skin. Phimosis is very apt to cause inconti-
nence of urine (p. 379), especially in childhood.

I have seen the glans penis of an adult small and wrinkled from com-
pression of a foreskin which had been tight from birth. In later life
the effects of a chronic irritation of the glans from phimosis, and want
of cleanliness, are likely to be hypertrophy of the papillae in the form
of large and branching warts, which are not necessarily of venereal
origin, and a long continuance of the irritation may cause intractable
eczema and eventually epithelioma. I have recently cured a young
athlete of intractable and depressing seminal incontinence by removing
his long prepuce.

Phimosis may so obstruct the outflow of urine as to cause the
disease known as Surgical Kidney (p. 410).

For slight phimosis dilatation of the preputial orifice by a pair of
dressing forceps may suffice, but, if the measure prove inefficient, cir-
cumcision should be performed forthwith. At the time of operation
the furrow behind the corona should be completely exposed by break-
ing down adhesions, and all smegma should be cleared away.

When a prepuce with a small orifice has been retracted behind the
glans, it may remain caught in the corona,
the condition being called para-phimosis
(napa, beyond). The glans becomes greatly
swollen from the constriction, as does also
the lining of the prepuce, which has been
thus everted. The constricting band, which
is the preputial margin, is on the hindermost
depression. By gently but firmly compress-
ing the swollen tissues with the finger and
thumb of the left hand, they may be emptied
of blood, so that with the finger and thumb of the other hand the
glans may be pushed back again through the constriction. At some

Suspensory Ligament of Penis 423

time subsequently circumcision should be performed or para-phimosis
will recur.

A long prepuce is apt to give rise to < irritation of the bladder ' ; it
is the converse of the proposition of stone in the bladder giving rise
to an itching at the end of the penis. By day, the boy endeavours to
allay the symptoms by pinching the prepuce ; but by night, when the
brain is dormant, the voluntary movements suspended, and the super-
vision of the genito-urinary tract given over to the cells of the grey
matter of the cord, physiological mismanagement is apt to occur.
The sensory filaments which are distributed to the muco-cutaneous
tissue at the end of the penis are derived from the internal pudic trunk,
itself a branch of the sacral plexus (p. 379). The nerves of the
plexus lose themselves in the grey matter of a certain part of the spinal
cord, from which are passing out, through that same interlacement,
the efferent fibres, which are destined for the supply of the muscular
walls of the bladder. But more than this, the same colony of cells
receives the filaments which carry up sensations from the mucous
membrane which lines that viscus. It may be on account of the ex-
ceeding instability of the protoplasmic substance of those cells, or
that by education and design they are occupied with the care of
the bladder rather than of the end of the penis ; but in one way or
another they are induced to interpret the irritation of the filaments
coming from the latter and less important area as evidence of distress
from the bladder itself. For this disquieting condition they have
only one means of affording relief, and, putting it in force, the boy is
punished in the morning, perhaps, for wetting his bed.

Circumcision may be rendered a bloodless operation by gently
emptying the penis of blood, by compression, and then slipping an
india-rubber ring over its root. The prepuce being cut off, the mucous
membrane is torn back by two pairs of dressing-forceps and secured
by fine catgut sutures. Sutures are not absolutely necessaiy, but
they diminish the risk of secondary haemorrhage and promote rapid
healing. One suture should be passed deeply through the fraenum, for
thence haemorrhage is most likely to occur. The operation should
not be performed by passing a director under the dorsal aspect of the
foreskin and then incising ; for it has happened that the director has
been run along the urethra, and that the dorsal part of the gians itself
has been thus divided.

The frcenum contains an artery of good size, and if the band be
torn through during coitus, or if the artery be implicated in a venereal
ulceration, serious haemorrhage may result. A short fraenum may
cause discomfort, and may require division.

The suspensory ligament of the penis is attached above to the pubic
symphysis, and descends in a fan-shaped manner to surround the penis
in a thin aponeurotic layer, \vhich, under the name of fascia penis,
invests the vessels and nerves (p. 385). Pus forming beneath this fascia

424

The Penis

may be guided to the pubes and there point ; the abscess should not
be opened by incision along the median line, as the dorsal vessels
might so be wounded.

The corpus cavernosum acts as a support for the corpus
spongiosum, which lies in a shallow groove on its under surface. It
divides behind into two strong masses, the crura, which are firmly
attached to the inner surface of the pubic and ischial rami. The
anterior extremity of the crus is capped by the glans penis, which is
the enlarged end of the corpus spongiosum. The other end of the
corpus spongiosum forms an enlargement in the perineum, the bulb ;
it rests upon the front of the triangular ligament, where it encloses the
first part of the spongy urethra and is invested by the accelerator urin;c.
(See fig. on p. 440.)

The corpus cavernosum is bounded by strong fibre-elastic tissue
which contracts as the mass empties itself
of blood, and which prevents distension
beyond a definite limit. The interior is
partitioned off into numberless small spaces
by trabeculre, which interlace between the
fibrous coat and the pectiniform septum.
Pale, muscular tissue also exists in the
framework. The spaces freely communicate
with one another, and are occupied with
venous dilatations, which are supplied by
11, urethra; vt dorsal vein branches of the dorsal artery and of the

(single) ; a, n, dorsal artery f . _., i i j

and nerve. artery of the corpora cavernosa. The blood

is returned chiefly by veins, which emerge

near the corpus spongiosum and turn round the side of the penis to
end in the dorsal vein. The other veins leave the root of the penis
as tributaries of the internal pudic vein.

Bisecting the interior of the corpus cavernosum longitudinally is a
vertical fibrous partition, which is connected with the fibrous coat near
the dorsal and urethral grooves. The partition, which, viewed in pro-
file, looks like a comb, is called the pectin! form septum (pec fen, a
comb). This septum is incomplete towards the fore-end, in order that
the erectile tissue of one-half of the corpus cavernosum may be in free
communication with that of the other, so that, if by chance one iliac
or pudic artery be obstructed, distressing unilateral erection of the penis
may not occur. The corpus cavernosum, in rare instances, yields to
the blood-pressure within, and undergoes a kind of aneurismal dilata-
tion.

The urethra tunnels through the corpus spongiosum. Coming
through the triangular ligament, it enters the bulb, where it is some-
what dilated, and it ends in a vertical slit in the glans, the meatus
urinarius (v. p. 385.)

The structure of the corpus spongiosum resembles that of the corpus

Vessels of Penis 425

cavernosum, but the fibrous trabeculae are connected with the urethral
wall instead of with a median septum. The special arteries of the
spongy body — the arteries of the bulb — are derived from the internal
pudic trunk, and some branches of the dorsalis penis.

The dorsal vein begins in small branches, which emerge from the
prepuce and glans ; the trunk thus formed lies between the two arteries
in the shallow dorsal groove. It receives in its course tributaries from
the cavernous and spongy bodies, and, passing beneath the suspensory
ligament and through both layers of the triangular ligament, ends in
the prostatic plexus. Let this fact be well noted (77. p. 413.)

Most of the lymphatics end in efferent vessels, which course along
the dorsum to end in the inguinal glands ; a deeper set, however,
pass beneath the pubic arch to the pelvic glands. A lymphatic gland
is occasionally found near the suspensory ligament, where bubo and
abscess may occur as a result of a preputial or urethral irritation.

The nerves are derived from the superficial perineal and the
dorsales penis of the internal pudics ; the erectile tissue receiving-
additional branches from the hypogastric plexus of the sympathetic.

Priapism. — Under the influence of nervous impressions descend-
ing from the brain or spinal cord, or arising in the nerves of the penis
itself, or in some offshoot of the recto-vesical network of nerve-tissue,
much more blood is brought into the venous sinuses of the trabecular
tissue than is able to escape from them ; thus erection of the penis is
produced. The efflux is hindered by the expansion from the accelerator
urinoe extending over the dorsal vein, and by the erectors of the penis,
which compress the crura penis against the side of the pubic arch.
Erection may be caused by any local irritation, or by mental stimu-
lation acting through the erection centre in the grey matter of the
lumbar enlargement of the cord. This, as part of our moral training,
should be under cerebral control. When this control is cut off, as in
lesions above the lumbar enlargement, from fracture or disease, chronic
priapism is apt to occur.

When suppuration occurs in the body of the penis, the erectile
tissue is disorganised and the fibrous cavity distended with pus, which
readily makes its way across the pectiniform septum. Similarly, per-
sistent priapism may be due to extravasation of blood taking- place
during coitus. When suppuration is the cause of priapism, the power
of erection may subsequently be lost on account of the destruction of
the erectile tissue.

Forcible flexion of the erect organ may give rise to a species of frac-
ture, effusion of blood stiffening the penis and rendering it deformed.

When the urethra is inflamed, and serous effusion has taken place
into the tissue of the corpus spongiosum, a diminution of its elasticity
occurs, so that when the penis becomes erect the corpus cavernosum
is bent downwards by the sodden and rigid spongy body. The painful
condition thus produced is termed chordee (\op8f), bow-string).

426 The Penis

In amputation of the penis the skin should not be drawn too far
forward lest the stump of the organ be left raw. The corpus spongiosum
should be cut longer than the corpus cavernosum. The arteries di-
vided are the two upon the dorsum and the two of the crura ; they
may require ligatures.

When the penis is extensively implicated in epithelioma, and
the condition of the inguinal glands shows that the disease is at
present localised, removal of the entire organ is advisable. A sound
having been passed, the scrotum is split into lateral halves, the crura
of the corpus cavernosum are dissected from the pubic arch ; and the
posterior inch of the corpus spongiosum having been detached, the
penis is removed bodily, and the truncated urethra is diverted through
the posterior part of the scrotal wound.

THE SCROTUM

The scrotum (scorttim, skin) consists of the skin and the two layers
of the superficial fascia. Above, the scrotum is continuous with the
integuments of the abdomen and penis, and behind with those of the
perineum, the two layers of the superficial fascia being blended into a
single layer, which is destitute of fat. This fascia is thin, and contains
amongst its loose meshes bundles of unstriped muscular fibre, which
constitute the dartos (8ep&>, Saproy, flayed, from the skin-like ap-
pearance of the muscular fascia). The skin and dartos are closely
connected. Each testicle has its own fascial investment, but the two
pouches are connected along the middle line to form the septum scroti.
In the operation of castration, therefore, the opposite testis is not seen.
(See fig. on p. 385.)

Along the under part of the scrotum is a dark cutaneous seam or
ridge — the rapht which shows the line of fusion of the lateral halves
of the scrotum. The root of the scrotum covers the perineal part
of the urethra.

The superficial fascia of the scrotum, like that of the penis and
eyelid, is devoid of fat, and is readily infiltrated with serous effusion. In
this water-logged condition the scrotum may increase to an enormous
size ; in cellulitis, also, the parts rapidly swell, and gangrene of the
scrotum from erysipelas, or from extravasation of urine, is not uncom-
mon. The precise connections of the deep layer of the superficial
fascia, and the importance of that fascia in urinary extravasation, are
set forth on p. 439.

The arteries of the scrotum are derived from the superficial pudic
branches of the common femoral and from the superficial perineal
of the internal pudic. The veins are large, superficial, and tortuous,
and empty into the termination of the long saphenous and into the
internal pudic. They should be avoided in tapping a hydrocele. The
scrotal veins communicate with the spermatic veins.

Scrotum ; Testt's 427

The lymphatics pass to the upper set of the inguinal glands.
In malignant disease of the testis the inguinal glands are implicated,
usually only when the disease has invaded the scrotum. In hot
countries the lymphatics of the scrotum are often dilated and varicose.
The disease is probably due to the irritation of micro-organisms circu-
lating in the vessels. The effect of the disease is an enormous thicken-
ing of the integument, known as elephantiasis. Such tumours may
attain enormous size, weighing more than the patient himself. The
late Mr. Wordsworth assured the author that he saw one in the West
Indies which was computed to weigh 200 Ibs. ; the patient had been
' anchored ' to it for many years and declined separation by surgical
operation.

The nerves are derived from the ilio-inguinal (of the first lumbar),
the genital branch of the genito-crural (second lumbar) lying in the
cremaster ; the superficial perineal branches of the internal pudic,
and the long pudendal branch of the small sciatic.

In caries of the highest lumbar vertebrae, with inflammatory pres-
sure upon the afferent nerves, the patient may refer pain to the scrotal
region of one or both sides ; and, from an association between these
trunks and the renal and spermatic filaments of the sympathetic, there
may be similar complaints when calculi are passing down the ureter.
But, in the latter case, the neuralgic distress usually affects only one
side ; there might also be retraction of the testicle from stimulation of
the cremaster muscle.

The covering's of the cord and the testis beneath the skin and
superficial fascia (which together constitute the scrotum) are con-
sidered elsewhere (p. 307) ; they are the intercolumnar, the cremasteric,
and the infundibuliform fasciae, and, as regards the testis itself, the
peritoneum, or tunica vaginalis. The intercolumnar, cremasteric and
transversalis fasciae form a thin and close, but a comparatively un-
important, investment of the testis and cord, quite distinct from the
scrotum, on the one side, and the tunica vaginalis on the other.

THE TESTIS

Early in foetal development, two important tubular organs are found
in the abdomen by the side of the spinal column — the Wolffian bodies.
They probably play the part of rudimentary and temporary kidneys.
Before they are many weeks old they dwindle and make way for the
permanent kidneys, which appear from behind them, and for certain
organs of generation which appear in front of them. At this period
the foetus is sexless ; there is nothing in the structure of the genera-
tive organ to show whether it would be evolved into ovary or
testis (v. p. 399).

Then, just above the generative organ, a slender duct commences,
which descends in front of the temporary kidney to open into that

42 8 The Test is

part of the allantois which is to become the urinary bladder. This
duct will be either the vas deferens or the Fallopian tube.

The descent of the testis soon begins. This 'descent' is partly-
due to the growth of the upper part of the
body being out of proportion to that of
the lower part, and partly to the influence
of the giibernaculum testis, a soft, conical
structure which lies between the peri-
toneum and the psoas. Its apex is con-
nected to the testis, whilst its base passes
through the inguinal region to a threefold
attachment. Each division is said to con-
tain striated muscular tissue. The inner

piece ™ns to the p.ubic crest' the middie

piece loses itself in the depths of the
scrotum, whilst the outermost is attached
to Poupart's ligament near the inguinal
canal. Thus, the connections of the gubernaculum are those of the adult
cremaster (p. 304) ; indeed, Curling believed that this fcetal structure
eventually becomes the cremaster. The piece of the gubernaculum
which is attached to Poupart's ligament is supposed to guide the testis
into the canal, the pubic piece to draw it through the external abdo-
minal ring, and the scrotal piece to complete the descent.

The testis reaches the internal abdominal ring at about the seventh
month of fcetal life; during the eighth month it is working its way
along the inguinal canal, and at birth it has generally reached the
depths of the scrotum.

Abnormalities. — One or both testes may fail to reach the scrotum,
remaining within the abdomen or the inguinal canal, or wandering
into the groin or perineum. Beyond the limits of the deep layers of
the superficial fascia, beneath which they are placed, they cannot
stray. An inflamed testes in an unusual situation may be mistaken
for abscess. An undescended gland is likely to be of no physiological
value ; moreover, it is somewhat apt to be attacked with malignant
disease.

Whilst within the abdomen the testis is covered in front by peri-
toneum, and the accompanying diagrams show how the gland takes a
serous covering in front of it down into the scrotum. The lower end
of the funicular process eventually becomes detached from the rest of
the peritoneal sac, and persists as the tunica vaginalis. The rest
of the funicular process dwindles into a slender fibrous cord. The
closure of the abdominal end of the serous process should occur about
birth. The tunica vaginalis covers the front and sides of the testes,
and is reflected from the epididymis to the scrotum ; the laminated
epithelium lining it ensures a moist and glistening surface, which
allows the sensitive gland to escape injury in forcible abduction of the

Varieties of Hydrocele

429

thighs. The testis is not, like the heart, completely surrounded by
the serous tunic ; the posterior aspect is covered only by the

epididymis. Through the uncovered part of the testis the vessels
enter and leave, and through it an incision could be made into the
gland without wounding the serous sac. Occasionally the testis is
found with the tunica vaginalis at the back and the epididymis in
front, but this variation rarely occurs.

If, from arrest in the progress of development, obliteration of the
funicular process of peritoneum fail to take place, the serous fluid
which moistens the general peritoneal cavity may gravitate into the
tunica vaginalis, and give rise to a scrotal water-tumour (vSwp, water ;
KT^T;, tumour), a hydrocele. And, as this variety of hydrocele is
usually found at, or soon after, birth, it is distinguished by the adjective
congenital ; sometimes, however, it first appears in adult life. The
contents of this variety of hydrocele can be emptied into the abdominal
cavity by placing the patient on his back and raising the scrotum :

Congenital

Infantile

Funicular

Encysted

Vaginal

Varieties of hydrocele. (AsHBY and WRIGHT.)

but, as soon as he is put once more upright, the fluid comes trickling
down into the tunica vaginalis. Injecting such a hydrocele for radical
treatment might set up an extensive and uncontrollable peritonitis.
Treatment can only be expectant ; the obliteration of the funicular
process being aided by the constant pressure of a well-fitting truss.
It is not in itself a serious condition, but, by maintaining the patency
of the funicular process, it invites the descent of a piece of intestine.
(Congenital hernia, p. 310.)

If the funicular process be closed at its abdominal end but open
below, a collection of serum in the tunica vaginalis will distend the

43O The Testis

process up to the external ring; the swelling being conical or hour-
glass-shaped. It will differ from the variety just described, in that
the fluid cannot be squeezed up into the peritoneal cavity. This is
the Infantile nydrocele.

If the funicular process be obliterated both at its abdominal and
testicular end, but, remaining pervious between these spots, become
filled with accumulating serum, a firm oval or round swelling appears
in the course of the cord. This is encysted hydrocele of the cord.
Sometimes the swelling is, from extreme distension, as hard as is the
testicle which hangs below it ; and it is often just about the size of
that gland. It is then apt to be mistaken for a third testicle ; a
puncture by a grooved needle at once explodes the fallacy and removes
the swelling. The cyst does not contain spermatozoa, for it has no
association with the testis, being a derivative from the peritoneum.
If the cyst be as large as a pigeon's egg, diagnostic aid may be
obtained by the light-test.

As the funicular process descends in front of the cord, a congenital
hydrocele or hernia has the cord behind it. The finger shows the
external abdominal ring to be clear, and thus distinguishes the
encysted hydrocele of the cord from a hernia ; but if the cyst be
situated within the inguinal canal, the diagnosis may be difficult.
The history of the case shows that the swelling is not a strangulated
hernia; and, as in the other case, puncture with a fine grooved
needle solves the question. Encysted hydrocele in the canal of Nuck
(p. 391) is met with every now and then. ,

The commonest variety of hydrocele is that in which fluid collects
in, and distends, the isolated tunica vaginalis. The swelling is pear-
shaped, the stalk growing towards the external abdominal ring. The
testicle is, of course, towards the back of the cyst ; but, in tapping, it
is more important to know where it is not, than where it is.

Haematocele. — Sometimes in tapping a hydrocele a branch of
vein (spermatic?) is wounded, and blood oozes into the serous cavity
and quickly refills the sac ; but this time the cyst is opaque.

Structure. — The testis is composed of tubular gland tissue packed
in a tough, fibrous envelope, the tunica albuginca. Outside this is the
visceral layer of the tunica vaginalis, whilst upon its inner side, and
also supported upon the trabeculas which pass from its interior to
the fibrous septum at the back of the gland, is a close interlacement
of blood-vessels, which constitute the tunica vasculosa. A fibrous
partition — the corpus Highmorianum — separates a small piece at the
back from the rest of the gland. The somewhat conical spaces are
occupied by masses of coiled tubes, the lobuli testis, from which
straight vessels (vasa recta) convey the secretion to the network of
tubes behind the partition, the rete testis. From the rete the vasa
efferentia convey the semen through the upper part of the gland-
capsule into conical masses of tubes, the coni vasculosi, which make

Vas Deferens

up the globus major of the epididymis (eW, over ; didvpus, twin).

From the lower part of the globus major the body of the epididymis

tapers downwards, but it

thickens below into the

globus minor, from which

the vas deferens conveys

the semen to the common

ejaculatory duct, at the

base of the bladder.

Encysted hydrocele
of the testis results from
accumulation of fluid in
one of the coiled tubes of
the gland or of the epi-
didymis. The dilatation
may be extreme ; the fluid
differs from that of an
encysted hydrocele of the
cord (p. 430) in that it con-
tains seminal filaments.
Multiple cystic disease of
the testis is similarly pro-
duced, but, the proper
secreting tissue having
been destroyed, the fluid
may be destitute of sper-
matozoa.

The vas deferens lies ^ lobules ; c, vasa recta ; d, rete ; e, vasa efferentia ; f,

at the back of the COrd, coni vasculosi ; g, epididymis ; A, vas deferens ; i, vas

, . , , aberrans ; m, n, spermatic artery ; o, artery of vas,

and, picked Up between and/, its anastomosis with spermatic.

the finger and thumb,

feels like a piece of whipcord. It is nearly two feet long. Having
reached the upper opening of the inguinal canal, it bends downwards
and inwards around the deep epigastric artery ; and, lying close be-
neath the peritoneum, courses over the side of the bladder, lying to
the vesical aspect of the ureter and to the median side of the vesicula
seminalis, the duct of which it joins at the base of the prostate to enter
the prostatic urethra at the sinus pocularis (p. 413). In its course from
the internal abdominal ring it lies above the external iliac arteiy.
From the ring it descends alone, the spermatic vessels passing up to
the renal region. It consists of a mucous lining, a dense fibrous wall,
and a thick and firm intermediate coat of non-striated muscular fibres ;
the mucous coat is covered with columnar epithelium. The artery of
the vas is derived from one of the vesical branches, and, running
towards the testis, it anastomoses with the spermatic artery, as shown
in the adjacent figure.

432 The Test 2 s

A urethritis extending backwards may invade the openings of the
common ejaculatory ducts, and, spreading along their lining membrane,
may reach the epididymis and the body of the testis. That the in-
flammation travels by continuity of tissue is evinced by the swollen
and tender condition of the vas, which thus becomes as large as an
ordinary cedar pencil. The term 'gonorrhceal orchids' is incorrect ;
the condition is almost invariably ' epididymitis ' to begin with ; and
for some time the soft and unaffected gland may be found in front of,
but obscured by, the enlarged epididymis. Epididymitis may come on
in the course of a gonorrhcea or gleet when no injection or instru-
mentation has been employed ; the use of an injection has, as a rule,
nothing to do with its occurrence. Epididymitis is sometimes caused
by a slight damage to the mucous membrane of the urethra by the
passage of a lithotrite or by the removal of a fragment of stone.
At times, too, it follows the passage of a catheter or sound when, in
all probability, not the least abrasion of the mucous lining has
occurred.

In acute orchitis and epididymitis the pain is intense, on account
of the unyielding nature of the tunica albuginea. A few punctures of
the inflamed gland allow the escape of effusion into the tunica vagi-
nalis and afford almost immediate relief. Atrophy of the testis is apt
to follow acute inflammation, on account of the disturbance of nutrition
which was thereby caused.

At an early period of fcetal life there is no connection between the
vas deferens and the testicle, but, like the Fallopian tube, the vas begins
by an open and disconnected extremity ; so, through an arrest of
development, the vas deferens may end blindly in the spermatic cord,
without association with the testis ; each organ may, however, be in it-
self thoroughly developed. The developmental distinction between the
vas deferens and the testis proper explains the frequency with which
an inflammation of the vas deferens and epididymis may extend
itself in those structures without implicating the immediately adjoining
testicular tissue, as in the case of gonorrhceal epididymitis.

Vessels and nerves of the testis. As the testis was originally
formed in the neighbourhood of the kidney, the vessels and nerves which
supply it are all derived from, and kept in permanent communication
with, the corresponding systems of that neighbourhood (v. p. 353).

Thus, the spermatic artery comes from the abdominal aorta close
to the renal artery, whilst the right and left spermatic veins empty into
the vena cava and the left renal vein respectively. As the testis de-
scends, the artery becomes elongated, and by the time that the gland has
reached the scrotum the blood-vessel has become so long and slender
that the student who does not understand the development wonders
why the blood was not supplied by one of the iliac trunks or by some
artery which was still nearer to the scrotum.

In its downward course the spermatic artery lies behind the peri-

Varicocele ; Hcewatocele 433

toneum and rests upon the psoas and crosses very obliquely the
ureter and the external iliac artery. The right artery lies over the
inferior vena cava. Passing into the inguinal canal, the spermatic
artery joins in the formation of the spermatic cord, and communicates
with the cremasteric branch of the deep epigastric, and, when piercing
the back of the fibrous capsule of the gland, with twigs of the artery of
the vas deferens. Having entered the body of the testis through the
posterior part of the fibrous capsule of the testicle, the branches of the
spermatic artery spread out upon its inner surface, and upon the fibrous
septa in the interior. Sir Astley Cooper compared the vascular layer
to the pia mater, and called it the tunica vasculosa.

As the spermatic artery lies in the back of the cord near the vas
deferens, the probability is that it will have been separated from the
veins before the latter are ligated in the radical treatment of varico-
cele. If it be included in the ligature, atrophy of the testis is likely
to follow (vide infra}. But as the spermatic artery anastomoses with
the artery of the vas deferens, and with the cremasteric branch of the
deep epigastric, the testis does not depend entirely on the aortic branch
for its supply.

The spermatic veins return the blood from the tunica vasculosa,
and, leaving the gland through the back of the tunica albuginea, receive
branches from the epididymis. They are much twisted together and
communicate freely, and, though possessing valves, they maybe injected
in either direction. They are called the pampiniform plexus, from
their resemblance to the tendrils (pampinus) of a vine. They become
fewer as they ascend along the inguinal canal, and by the time that the
renal region has been reached there is usually but a single vein ; this
on the right side enters the inferior vena cava, on the left the renal vein.
In the development of the left testicle it would have been impractic-
able for its spermatic vein to pass over into the vena cava.

Within the abdomen the spermatic veins are behind the peritoneum,
and those of the left side take their course beneath the sigmoid flexure
of colon. When this piece of the bowel is habitually overloaded the
return by these veins is impeded, and the dilated veins form a tumour
— varicocele (varix, KrjXrj, tumour). A varicose vein is apt to burst
into the cavity of the tunica vaginalis, and so form an opaque blood-
tumour, hcematocele (ai/za, blood ; KTjAq, tumour). Rupture of a vein
into the cord may give rise to ' diffuse haematocele of the cord,' and
the extravasation may reach even to the renal region. Other reasons
have been suggested for varicocele usually occurring on the left side :
such as that the left spermatic vein is at times embarrassed in pouring
its blood, at a right angle, into the renal vein ; that, the left testicle
hanging somewhat lower than the right, the vein is longer and con-
sequently weaker.

In all probability there is some developmental explanation for the
occurrence of the varix upon the left side. Certainly most of the

F F

434 The Testis

subjects of varicocele are not liable to constipation. It is probably a
congenital defect, though its discovery is not made until puberty — that
is until the rapid development of the generative apparatus is taking
place.

The thickened and dilated veins feel just like ' worms in a bag.'
They give rise to a sensation of fulness in the cord, and up to the loin-
region. When they are much dilated before puberty they are likely
to prevent the due development of the testicle.

In the palliative treatment of varicocele the bowels should be
kept thoroughly open so as to remove pressure from the spermatic
vein ; the scrotum should be sponged daily with cold water to brace
it up, and to stimulate the dilated veins a suspensory bandage should
be used. A light truss may be worn over the external abdominal
ring, to prevent the downward pressure of the long column of venous
blood. If these gentler measures fail, it may be necessary to excise
an inch of the veins, having tied them above and below ; but, as the
spermatic artery may possibly be entangled amongst the veins, the
operation may be followed by atrophy of the testis, even if this have
not already been determined by the defect in the venous return. The
reason for excising a piece of the packet of veins is that after a mere
ligation their continuity may not improbably be re-established.

In the case of malignant disease of the testis the heavy mass
drags itself away from the external abdominal ring; in the case of
fluid collecting in the tunica vaginalis the fulness ascends along the
front of the cord towards the ring.

In all cases of disease of the testis the scrotum should be raised,
so as to diminish the vascular supply. The patient should lie on his
back when the epididymis or testis is acutely inflamed, with the scrotum
supported over the pubes.

The lymphatics commence in and upon the gland, and on the
surface of the tunica vaginalis ; they ascend in the cord to end in the
lumbar lymphatic glands. Unfortunately, when the surgeon is con-
templating the removal of the testis for malignant disease, he is
unable to inform himself whether the lymphatic glands are implicated
or not, because of their deep situation at the back of the abdominal
cavity. As a rule it is only when the cancer of the testis has invaded
the scrotum that the inguinal lymphatic glands are invaded, but in
rare instances it happens that they are implicated, and extensively
so, whilst the scrotal tissues are remaining sound. This is explained
by the lymphatic vessels of the testis having formed anastomotic
communications with those of the inguinal integuments — a communi-
cation resembling that which exists between the spermatic artery and
the cremasteric branch of the deep epigastric.

If there be much mechanical pressure upon the lymphatics or veins
of the cord, from malignant disease of the lumbar glands, or from any
other cause, the connective tissue of the cord may become infiltrated

Coverings of Spermatic Cord 435

with serum exuded from the congested vessels. This condition corre-
sponds to the oedema of the arm associated with malignant invasion of
the axillary glands ; it is called diffuse hydrocele of the cord, and is
more frequently described in books than observed in practice.

The nerves of the testis are derived from the aortic and renal
plexus, and it is probable that a few filaments from the communication
with the anterior trunks of the lumbar nerves pass down with the
sympathetic fibres. The free association of the spermatic nerves with
the great pre-vertebral system of the sympathetic system of the
abdomen explains the sickness, faintness, or collapse which may ac-
company a blow upon the testis, symptoms which occur also on rupture
of the stomach or kidneys. The pain extends into the loins, and the
patient is 'doubled up' ; that is, he slackens his abdominal muscles
so as to take all pressure from the inguinal canal and from the abdo-
minal plexus. The close association between the renal and spermatic
plexuses is further shown by the neuralgia -or the acute inflammation
of the testis which may be caused by the passage of a renal calculus,
and by the pain in the back which follows the injection of a hydrocele,
or the dragging of a tumour of the testis.

Leeching the front of the scrotum in acute epididymitis affords
relief through the anastomosis existing between the vessels of the
gland, the cord, the tunica vaginalis, and the scrotum ; the leeches
should be chiefly placed along the course of the cord.

The supervention of orchitis on mumps has not yet been satis-
factorily explained. All that is known is that there is a strange
association between the parotid gland and the testis, or the ovary,
and also with the inguinal and genito-urinary region generally
Parotitis sometimes follows operation on these parts — a parotitis
which is not, apparently, septicasmic in origin.

In castration the testis is thrust well forwards by the grasp of
the left hand, which is behind the scrotum, and an incision is made
from the external abdominal ring down to the bottom of the scrotum.
The cord is laid bare and raised, tightly ligated, and divided ; the
lower piece of the cord, the testicle, and the tunica vaginalis are then
enucleated. The structures divided to lay bare the cord are the skin
and the superficial fasciae (which latter, in the scrotal part of the
incision, constitute the dartos); the thin inter-columnar fascia derived
from the aponeurosis of the external oblique ; the cremasteric fascia
from the internal oblique ; the infundibuliform fascia from the fascia
transversalis ; and a little loose connective tissue. If the unobliterated
funicular process of peritoneum be encountered it must be tied along
with the cord. In reaching the cord, branches of the superficial
epigastric and external pudic arteries, and the cremasteric twig of the
deep epigastric artery, may be divided ; also some twigs of the super-
ficial perineal arteries. The ligature around the cord secures the
following blood-vessels : the spermatic artery, from the abdominal

436 The Test is

aorta ; the artery to the vas deferens, from one of the vesica arteries ;
and the spermatic veins, which communicate above with the inferior
vena cava, or (on the left side) with the renal vein. If the ligature be
tightly tied in a business-like way, with a clove-hitch and a half-hitch
over it, there will be no fear of the occurrence of bleeding within the
abdomen when the cord is retracted.

The vesicuise seminales are convoluted and sacculated tubes,
about 2 in. long, placed, like the arms of the letter V, beneath the tri-
gone of the bladder. They lie to the outer side of the vasa deferentia,
and in front of the second piece of the rectum (v. p. 413), through which
they may be made out by digital examination ; they can best be
examined when the bladder is full and is pressing them towards the
bowel. They are enclosed in an offshoot of the recto-vesical fascia
(p. 363), and their base is in contact with the recto-vesical pouch of
peritoneum. During the passage of a bulky motion the pressure
against the vesiculae may cause the escape of some of their con-
tents per urethram, and, the occurrence being noticed by a nervous
man, he at once fancies that he is the subject of ' spermatorrhoea.'
The anterior extremity of the vesicula seminalis joins the vas
deferens to form the common ejaculatory duct, which tunnels
through the back of the prostate to open in, or upon the margin of,
the sinus pocularis.

Placed between the bladder and rectum, the vesiculae depend upon
the inferior vesical and the middle haemorrhoidal vessels for their
supply ; a twig is also derived from the artery of the vas deferens.
Their nerves, which come from the hypogastric plexus, are in intimate
association with those of the adjoining viscera. The lymphatics com-
municate with the pelvic glands.

THE ISCHIO-RECTAL FOSSA

The ischio-rectal fossa is the pyramidal space between the ischium
and the rectum. Its base corresponds to the soft depression
at the side of the anus, whilst its apex reaches upwards to the
splitting of the pelvic fascia. It contains a considerable amount of
fat, which is much drawn upon in wasting diseases, so that a deep
hollow is then found on the surface. Its boundaries are internally
the rectum, the sphincter, and the levator ani, covered by the anal
fascia, as shown in the figure on p. 363, and, further back, a small
piece of the coccygeus ; externally are the ischial tuberosity, and
the obturator internus, covered by the obturator fascia, and the body
of the ischium. Behind are the tip of the coccyx and the great sacro-
sciatic ligament, over which lies the lower border of the glutens
maximus. In front is the base of the triangular ligament (v. p. 440).

Even when the fat which occupies the fossa has been dissected
out, the finger cannot be passed through he apex of the space into

Ischio-rectal Fossa 437

the pelvis, on account of a sheet of fascia which, coming from the
obturator fascia, slopes along the under surface of the levator ani to
the anus. This is the anal fascia. A stronger and much more
important layer of fascia also passes from the obturator fascia, over
the upper surface of the levator ani and the coccygeus, to lose itself
on the side of the rectum and bladder ; it is the recto-vesical fascia.
Behind the bowel the layers from the opposite sides of the pelvis
meet and invest the pyriformis and the sacral plexus, and between
the bladder and rectum the fascia invests the seminal vesicles. The
opposite sheets also form the lateral and anterior true ligaments
of the bladder, and also provide a special investment for the pro-
state and the prostatic plexus of veins. The most anterior part of this
recto-vesical fascia constitutes the pubo-prostatic ligament (p. 413).
The recto-vesical fascia helps the levator ani in preventing the abdo-
minal viscera sinking towards the ischio-rectal fossa ; it is at once a
sloping floor to the abdom n and roof to the fossa. In lateral lithotomy
the knife sometimes passes beyond the limit of the lobe of the prostate,
and, the ischio-rectal fossa being opened up into the pelvic cavity,
fatal cellulitis may occur.

The presence of abundant loose tissue in the fossa allows the de-
scent and expansion of the rectum during defaecation ; it is through the
tissue at the front of the fossa that the surgeon cuts to reach the pro-
state and the neck of the bladder in lateral lithotomy (v. p. 443). As
the return of venous blood from this tissue is aided neither by the in-
fluence of gravity nor by active pressure of surrounding muscles, the
part is extremely liable to congestion and inflammation, and especially
so in the subject of feeble circulation, embarrassed respiration (phthisis),
or of advancing disease of the liver. Inflammation may also be set
up by a wet seat, or by injury. If the inflammation be followed by
suppuration, isciiio rectal abscess is the result. A common cause of
ischio-rectal abscess is the escape of a foreign body, such as a fish-
bone, or of some hard fasces, through the lateral wall of the bowel.
Such perforation of the bowel may be preceded by an ulcer, especially
in the case of stricture of the rectum or of tuberculosis.

When suppuration occurs the abscess bulges at the side of the
anus, at the border of the gluteus maximus, or against the rectal wall.
In the last case there is great pain on defalcation, and on introducing
the finger into the bowel the fulness on its outer side is evident, and
perhaps fluctuation may thus be detected. In sitting the patient bears
all his weight on the opposite ischial tuberosity, resting upon the very
edge of the seat of the chair.

If left to itself, the pus will find exit either into the rectum or
through the skin at the side of the anus ; the surgeon should open such
an abscess through the base of the fossa, making his incision in a line
radiating from the anus : that is, parallel with the haemorrhoidal vessels.
The sooner that he opens it, the less will be the resulting chasm.

438 The IscJiio- Rectal Fossa

As the pus drains away the cavity contracts, until ii is represented
only by a narrow, thick-walled passage — a fistula — which, if 'complete,'
opens both into the bowel and on to the buttock. Such a fistula has
small chance of healing without operation, as at and after defalcation
its walls are constantly being dragged asunder towards the anus by
the sphincter, and from the anus by the levator. Gas may be driven
from the rectum into an internal or a complete fistula, rendering the
tissues of that neighbourhood emphysematous.

The structures divided in the operation for fistula are the
integument, the external sphincter ani, and the insertion of the levator
ani (both muscles are striated) ; the longitudinal and circular fibres
(internal sphincter) of the rectum (non-striated) ; the submucous and
mucous coats, and branches of the inferior hcCinorrhoidal vessels and
nerves. (See illustration on p. 440.)

(Fistula near the anus may be due to caries of the spine, p. 211.)

The Internal pudic vessels and nerve run in a tubular sheath
of the obturator fascia at a little more than an inch above the ischial
tuberosity, giving off the inferior hsemorrhoidal branches which cross
the base of the fossa to reach the neighbourhood of the anus. The
artery is accompanied by the dorsal nerve of the penis and the super-
ficial perineal branches.

The levator ani arises from the back of the body of the pubes and
from the inner surface of the ischial spine (below the origin of the
coccygeus) ; and between these points it arises from the pelvic fascia
where the oblique sheets are reflected downwards and inwards to the
rectum and bladder, and to the anus (v. p. 363). Between the two
levatores the rectum is suspended ; the muscles helping to form the
inner wall of the ischio-rectal fossae and to close in the pelvic outlet.
The muscle is inserted into the tip of the coccyx, and into the fibrous
line leading from it to the anus ; into the side of the third piece of the
rectum, between the pale fibres of its longitudinal coat and the striated
fibres of the external sphincter ; into the central tendon, and still more
anteriorly into the side of the prostate. The most anterior part of
the muscle is the levator prostatcc. In the female the vagina passes
between the levatores ani.

Relations. — The pelvic surface of the muscle is covered by the
recto-vesical fascia, and lies against the rectum and prostate. Be-
neath it are the anal fascia, the external sphincter, and the fat of the
fossa. Its posterior border lies along the lower edge of the coccygeus.

Supply. — Its vessels are derived from the inferior haemorrhoidal ;
its nerves come from the internal pudic and the fourth sacral.

THE PERINEUM

The outlet of the pelvis is diamond-shaped, the long axis extending
from the pubic symphysis to the tip of the coccyx. Its antero-posterior

Male Perineum 439

diameter averages 3^ in., its transverse 3| in. (vide Planes of Pelvis,
p. 364). If a line be drawn between the ischial tuberosities the space
is divided into the urethral and the anal triangles ; superficial to the
former are the tissues of the perineum ; the posterior is occupied by
the lower end of the rectum and the ischio-rectal fossae. Thus the
anterior triangle is subservient to genito-urinary functions, and the
posterior to the alimentary canal. For the most part these two func-
tions have separate and distinct sets of muscles, nerves, and vessels.

Surface markings. — In the middle line is a soft, antero-posterior
elevation, caused by the hinder part of the corpus spongiosum and
the bulb of the urethra ; over it is the median raphe. The rapJic is
not a trustworthy indication to the middle line, it is easily displaced
to one side or the other by inflammatory adhesions ; it is the embryonic
seam in which the integumental halves of the perineum were joined.
At the side of the urethral projection the finger can be thrust into a
shallow space beneath which the triangular ligament blocks the front
of the pelvic outlet ; more externally can be traced the rami of the
pubes and ischium. Passing forwards, the corpus spongiosum loses
itself within the base of the scrotum.

Beneath the skin is the superficial layer of the superficial fascia,
which is continuous with the non-striated muscular tissue of the
scrotum, laterally with the fat of the buttock, and behind with the fat
in the ischio-rectal fossa. This layer of fascia consists of loose con-
nective tissue with a little fat ; it has no deep connections.

The deep layer of the superficial fascia is thin and membranous ; it
loosely covers in the corpus spongiosum, and, passing forwards, enters
the tissue of the scrotum, becoming continuous with the clartos ; it
also invests the penis and passes up on to the abdomen, being attached
below to Poupart's ligament and to the iliac crest. Laterally, in the
perineum, this important fascia is attached to the pubic and ischial
rami ; posteriorly it loses itself on the base of the triangular ligament.
An incomplete and unimportant septum attaches the deep surface of
this fascia to the triangular ligament. (The student should demon-
strate the arrangement of this fascia, with a sheet of muslin, upon a
pelvis to which the ligaments are attached.)

When, in rupture of the urethra, urine is extravasated beneath this
fascia, it cannot pass backwards into the fossae, nor laterally on to the
buttocks, but, coursing along by the penis and scrotum, it ascends by
the spermatic cords to the iliac and hypogastric regions. In the dis-
secting-room air forced beneath the fascia takes the same course.

Perineal abscess. — Urine or pus locked in beneath this fascia
causes a tense bulging behind the scrotum and beneath its root ; as
the fascia is too dense to allow of fluctuation, the tumour may feel as
hard and solid as a cartilaginous growth. The pressure of the fluid
beneath the urethra drives the floor against the roof, rendering mic-
turition difficult, and the introduction of a catheter distressing and

440

TJie Perineum

dangerous. Sometimes the swelling is about the size of a filbert, and
it may feel almost as hard as one. The surgeon waits neither for
fluctuation nor redness, but deeply incises the perineum along the
middle line. A perineal fistula results, but this gets well as the stric-
ture, which was the original cause of the abscess, is dilated.

Right superficial, left

deep dissection :
a, anus.
6, bulb.

c, coccyx.

d, ischium.

<*, superficial fascia.
./, fat in ischio-rectal

fossa.
g, glutens maximus.

1, transverse muscle.

2, erector penis.

3, trans, artery.

4, int. pudic artery,
and 5, its haemor-
rhoidal branches.

6, first layer of triang.
ligament removed to
show artery of bulb
and Cowper's gland.

Beneath the deep layer of the superficial fascia, on either side, is a
muscular triangle, the base of which is formed by the tritiisvcrsi/s
pcrinci, which runs from the ischial tuberosity to the central tendon ;
at the outer side is the erector penis, which passes from the tuberosity
to the side of the corpus cavernosum, whilst in the middle line is the
accelerator urincc, surrounding the bulb, and sending its most posterior
fibres into the triangular ligament ; its most anterior fibres encircle the
corpus cavernosum, to blend with those of the opposite side over the

Internal Pit die Artery 441

dorsal vein. Beneath these muscles the triangular ligament stretches
across the sub-pubic arch. In lateral lithotomy, the surgeon, being
right-handed, plunges his knife through the muscular triangle on the
left side of the patient.

The superficial perineal vessels and nerves (from the internal
pudics) pass forwards over the triangle, getting beneath the deep layer
of the superficial fascia just where it is turning down to the base of the
triangular ligament.

To expose the triangular ligament in the dissection of the peri-
neum, the erector penis and the crus must be detached from the pubic
arch, and the transverse muscle removed ; and not only must the
accelerator urinas be dissected off, but the hinder end of the corpus
spongiosum should be also cut away, and with it, of course, the bulbous
part of the urethra. The chief use of the ligament is to steady
and support the urethra as it curves below the pubic symphysis. The
better to do this, it is composed of two aponeurotic sheets, which,
separated from each other by an interval of about one-third of an
inch, descend to blend with each other, and with the deep layer of the
superficial fascia, at the base of the triangle. The deeper layer of the
triangular ligament is joined also by the recto-vesical fascia.

The urethra pierces the two layers of the ligament about one inch
below the symphysis ; when running between them it is surrounded
by a striated sphincter, the compressor urethrse. The beak of a
catheter is apt to catch against the ligament unless the handle be well
depressed. Closer beneath the symphysis the dorsal vein of the
penis runs through the layers to join the prostatic plexus.

The endings of the internal pudic artery and nerve ascend between
the two layers of the ligament towards the dorsum of the penis ; they
have entered the ligament near its base, and close against the ischial
ramus. The short piece of the urethra enclosed in the triangular
ligament is the membranous part, and close below it are Cowper's
glands -(v. p. 413). The triangular ligament is very strong, and pre-
vents extravasated urine, and the contents of a perineal abscess, pass-
ing backwards to enter the pelvis. In addition to the parts already
enumerated between its two layers are the sub-pubic ligament ; a
short branch of the internal pudic artery to the bulb of the urethra,
and sometimes another transverse (deep) perineal muscle.

Cowper's glands are about the size of a pea ; they are lobulated,
and their ducts pass through the anterior layer of the triangular liga-
ment to open on to the floor of the bulbous part of the urethra, as
already noted, on p. 417.

The internal pudic artery is one of the terminal trunks of the
anterior divisions of the internal iliac ; leaving the pelvis below the
pyriformis, it winds round the ischial spine into the ischio-rectal
fossa, passing through the small sacro-sciatic foramen. In the fossa
it lies in a tube of the obturator fascia, an inch or more above the tuber

442 The Perineum

ischii. Then, passing along the ischial ramus, it enters between the
two layers at the base of the triangular ligament, and, ascending
almost to the symphysis, runs through the anterior layer of the liga-
ment, much diminished in size, as the dorsal artery of the penis.

Branches. — Inferior haemorrhoidal, which are given off as the
vessel lies under the obturator fascia : they pass inwards across the
ischio-rectal fossa to supply the tissues about the anus, and to ana-
stomose with their fellows of the opposite side and with the middle
haemorrhoidals (p. 388). They are wounded in lateral lithotomy and
also in the division of an anal fistula. The superficial perineal runs
in the muscular triangle, and under the deep layer of the superficial
fascia, to supply the various tissues of the perineum and scrotum; it
may anastomose with a pudic branch of the common femoral. The
transverse perineal passes inwards upon the muscle of the same
name, and anastomoses with its fellow ; it is apt to be wounded in
lateral lithotomy. The artery of the bulb is given off from the
main trunk as it ascends between the layers of the triangular
ligament ; it is a short thick vessel, and passes inwards to supply the
erectile tissue of the bulb and of the corpus spongiosum, giving, in
its course, a branch to Cowper's gland, and twigs to the membranous
urethra. The artery to the bulb should be well in front of the knife
in lateral lithotomy, but if, as sometimes happens, it be given off
earlier in the course of the internal pudic it would most likely be
severed. Should this accident occur, the bleeding might be controlled
by the self-holding forceps, by enlarging the wound and tying, by the
petticoated tube, or by compressing the pudic with the finger through
the wound against the ischial ramus.

The artery to the corpus cavernosum comes off, as one of the
terminals of the internal pudic, between the layers of the triangular
ligament. It is for the crus penis just what the artery to the bulb is
for the corpus spongiosum, namely, for the supply of its erectile
tissue. It courses in the cavernous body along the side 'of the
pectiniform septum.

The dorsal artery of the penis is the other terminal branch,
and, passing through the anterior layer of the triangular ligament,
and through the suspensory ligament of the penis, it courses by the
side of the vein, giving off branches to the corpus cavernosum, and
ending in the glans, where it anastomoses with its fellow. It supplies
the skin of the penis, even to the prepuce. Though there are two dorsal
arteries of the penis, there is but one dorsal vein.

Sometimes the pudic is not large enough to give off all these
branches ; ending as the artery to the bulb, its terminal branches are
then derived from an accessory internal pudic, which is either given
off from the internal pudic itself, before it passes out of the great
sacro-sciatic foramen, or else from the anterior division of the internal
iliac. This irregular vessel hurries along the floor of the pelvis

Lateral Lithotomy

443

below the bladder and beneath the side of the prostate, to reach the
penis by piercing the triangular ligament. In the operation of lateral
lithotomy such a vessel could scarcely escape division when the
incision is being made in the prostate.

In the female the pudic artery supplies the labia by its superficial
perineal branches ; the artery of the bulb enters the vaginal wall, and
the terminal branches, which are very small, supply the clitoris.

To mark the position of the internal pudic artery on the surface of
the buttock, see p. 374.

The internal pudic vein begins as the vein of the corpus caverno-
sum and receives branches corresponding to those of the artery, with
the exception of the dorsal vein of the penis, which runs straight
through the triangular ligament into the prostatic plexus, as shown
on p. 413.

For lateral lithotomy the grooved staff is passed and the stone

Lithotomy on curved staff. (FEKGUSSON.)

is struck, cither by it or by the sound — the former for choice, for then
the operator can be certain that the instrument is in the bladder ; the
patient is still lying supine. The assistant takes the staff, and the
patient is then placed in the lithotomy position. The surgeon feels
for the course of the pubic and ischial rami and the situation of the
bulb— taking his landmarks, gauging the space. He then introduces
his left index-finger into the anus, to feel that the staff has not
wandered into a false passage ; that the lower bowel is not loaded
with fasces, and bulging over the line of incision ; that the dilated
part of the empty rectum is not in undue danger of being incised ; to
learn, perchance, the situation of the stone, and to see that the
assistant is holding the staff according to his instructions. Then he

444 Lateral Lithotomy

makes a little stab — in the middle line of the perineum, just behind
the base of the scrotum and the bulb, and three-quarters of an
inch, more or less, according to the size of the patient, in front of the
anus. He cuts freely backwards and outwards, through the left
ischio-rectal fossa, to halfway between anus and tuberosity. Thus
far he has wounded skin, superficial layer of superficial fascia, and
deep layer, a few branches of the superficial perineal vessels and
nerves, and many twigs of the inferior haemorrhoidals, and also the
transverse vessels and nerve. After this he cuts towards the groove
of the staff through the anterior part of the wound, dividing a few of
the posterior fibres of the accelerator urina3, the base of the triangular
ligament, and within it the compressor urethras and the urethra itself.
The point of the knife being lodged in the groove, he slides the blade
into the bladder, slicing part of the left lobe of the prostate and its
investment of recto-vesical fascia, and dividing some of the prostatic
fibres of the levator ani, some of the prostatic plexus of veins, and the
neck of the bladder. Sometimes the common ejaculatory duct is also
wounded.

The neck of the bladder being opened, urine escapes from the
wound ; so the surgeon lays down the knife, puts the index-finger on
the naked staff in the membranous urethra, and artfully works it into
the bladder, dilating the wound in the process. He touches the stone.
Then he has the staff withdrawn, and, taking out the finger, he intro-
duces the lithotomy forceps, and catches and withdraws the stone
through the axis of outlet of the pelvis. He then re-introduces his
finger to see that there is not a second stone, and, bleeding having
well-nigh ceased, the patient's legs are brought down and he is taken
back to bed.

Cautions.— First, the surgeon must not stab the perineum too far
forwards or he will wound the vascular erectile tissue of the bulb ;
in tailing off the first incision he must not cut against the wall of the
ischio-rectal fossa or he will wound the internal pudic vessels and
nerve ; and he must not bring the incision too far inwards or he will
cut a hole in the wall of the rectum, which here is bulging over the
fossa. His deep incision must not be too limited or the staff will not
be sufficiently laid bare, and, in trying to introduce his finger into the
bladder (itself unopened), he may tear the urethra across, and push
the prostate and bladder bodily up into the pelvis. This is a frightful
calamity, and a not infrequent cause of 'blank lithotomy.' On the
other hand, he must not use the knife too freely, lest he cut through
the whole length of the prostatic lobe, and, widely wounding its fascial
investment, lay the ischio-rectal fossa, the neck of the bladder, and
the interior of the pelvis into one large space. Thus urinary infiltra-
tion and a fatal cellulitis and peritonitis would probably be set up.

On account of the high pelvic position of the bladder in boyhood,
lateral lithotomy is not an easy operation. To obtain confidence and

Female Perineum 445

dexterity in operating, the student and young surgeon should lose no
opportunity of rehearsing the operation on the cadaver, both of the
child and of the adult.

Median perineal cystotomy is the operation of cutting into the
bladder through the middle line of the perineum ; should the incision
be made for the extraction of a stone, the word ' lithotomy ' takes the
place of ' cystotomy.' Cystotomy is performed for exploration, and for
intractable inflammation of the bladder. Median lithotomy is an
excellent operation for the extraction of small stones or foreign bodies,
as no blood-vessel of importance is wounded ; it is an operation of dila-
tation rather than of cutting, and is thus performed : — A rectangular
staff with a median groove is passed into the bladder ; its elbow is
lodged in the membranous urethra, where it is readily felt through the
perineum when the patient is placed in the lithotomy position. The
surgeon makes an inch-long button-hole in the median line, down to
the elbow, and passes a steel director along the groove of the arm
and into the bladder. The staff is then withdrawn and the finger is
' screwed ' along through the membranous and prostatic urethra.
The stone is felt, and then the director is withdrawn and the forceps
are introduced.

The only parts incised are the skin and the superficial fasciae
for about an inch ; the base of the triangular ligament and the com-
pressor urethras and the membranous urethra. The prostatic urethra
is dilated, the prostate itself escaping the knife. The risk of haemor-
rhage may be disregarded. As the opening is made high up under
the pubes, where the arch is extremely narrow, this operation does
not serve for the extraction of a large stone.

The perineum of the female is much shorter than that of the
male, only about an inch intervening between the vulval and anal
openings. In the female the longitudinal lateral folds (labia majora)
fail to meet (in the male they are fused together to form the scrotum).
Thus, the vulva is a cleft between the lateral halves of an undeveloped
scrotum. The deep layer of the superficial fascia is continued along
the labia majora and the rami of the pubes up into the inguinal region
of the abdomen. The transversus perinei is but a rudimentary band ;
the erector clitoridis corresponds to the erector penis, and the sphinc-
ter vaginas represents the accelerator urinas ; the ' artery of the bulb '
supplies the vaginal wall. The triangular ligament supports the
urethra, much as in the male, and contains the compressor urethras,
but the base of the ligament is defective owing to the passage through
it of the vagina.

Tillaux cleverly demonstrates the closeness of the resemblance be-
tween the female and male perineum, by uncovering the muscular tri-
angle, and then splitting the bulb down the middle line, and separating
the lateral halves. The median cleft thus represents the vulva, and
the halves of the bulb of the urethra represent the bulbs of the

446

The Perineum

vagina, Cowper's glands becoming the vulvo-vaginal glands, and the
accelerator urinae the sphincter vaginae The two lateral triangles
now become insignificant by the half of the accelerator being displaced
outwards towards the erector penis (clitoridis). (See fig. on p. 440.)

Sometimes the perineum is ruptured during labour, the vulva
being torn through even into the rectum. If the woman be at once
laid upon her side, the knees being tied together, immediate union
may be secured. If, however, the repair be not thus established, the
surgeon waits until she has regained health and strength, when he
freshens up the torn surfaces and approximates them by sutures.

447

PART V
THE LOWER EXTREMITY

Surface markings. — The furrow corresponding to Pouparfs liga-
ment extends from the front of the iliac crest to the pubic spine. From
the spine the pubic crest may be traced inwards to the symphysis.
From the sub-pubic arch the rami of the pubes and ischium may be
followed to the ischial tuberosity.

When inquiring if a hernia be inguinal or femoral, the inner border
of the hand should be laid along the line of Poupart's ligament ; if the
protrusion be chiefly above the hand it is inguinal, if below, femoral,
for a femoral hernia comes up from the saphenous opening. The spine
of the pubes is above and to the inner side of a femoral hernia.

Below Poupart's ligament is a triangular depression corresponding
to Scarpa's triangle, and from its apex, which points downwards and
inwards, runs a shallow groove in which the femoral vessels and the
sartorius descend.

The line of the artery is drawn when the limb is slightly flexed
A

A B, Ne"laton's line ; c D, measurement from Bryant's belt-line to top of trochanter ; the line
A c should be continued round the body.

and everted, from the middle of the interval between the iliac spine
and pubic symphysis, to the inner femoral condyle. Roughly, but not

448 The

with precision, it may be said that the artery begins ' under the middle
of Poupart's ligament.' The artery is felt pulsating half an inch to
the inner side of the middle of the ligament.

Unless the subject be fat, the head of the femur may be felt ro-
tating in the middle of the base of Scarpa's triangle. It lies beneath the
crease which runs from the scrotum to the ilium. When the capsule
is distended this crease is partially effaced. The head of the femur
has the same direction as the inner surface (tuberosity) of the internal
condyle.

Iff elaton's line is drawn over the buttock from the anterior superior
iliac spine to the ischial tuberosity. In the sound limb it just touches
the top of the great trochanter, but when injury or disease has seriously
damaged the acetabulum or the joint, or the head or neck of the femur,
the top of the trochanter may be above that line. It is useful in cases
of doubtful dislocation, and of fracture of the neck of the femur.

Bryant's measurement is made when the patient is lying straight
and flat on his back. A string is passed across the front of the
abdomen at the level of the iliac spines, and another over the thighs
at the tops of the trochanters. These strings ought to be parallel ;
but if, from injury or disease, one trochanter be raised, the vertical
measurement, C D, between the lines is diminished on that side.

In measuring- a lower limb it is not expedient to pay too much
attention to a difference of one-fourth or one-third inch ; often, indeed,
the limbs are unequal in length from birth. In comparing lengths in
a child, a good plan is to lay him on his back, and, keeping the pelvis
flat and square, and the knees fully extended, to raise the soles of the
feet towards the ceiling. A slight difference in the level of soles or
of the inner malleoli is then at once manifested.

When measuring by a tape, the pelvis must first be arranged flat
and square ; a line is then taken from each anterior superior iliac
spine to the tip of the inner or outer malleolus, the limbs being straight
down, or, at any rate, in corresponding positions.

For the thigh, the measurement is made to the top of the patella,
or from the pubic spine to the adductor tubercle (p. 449). For the leg
alone, the tape is carried between the malleolus and the upper border
of the tibial head.

Between the front of the iliac crest and the great trochanter is the
thick mass of muscle consisting of the tensor fasciae femoris, and of
much of the gluteus medius and minimus — the three internal rota-
tors of the thigh. They are supplied by the superior gluteal nerv
(p. 378).

The tensor fasciae femoris arises from the outer side of the an-
terior superior iliac spine, and, passing downwards and backwards, is
inserted into the fascia lata about a quarter of the way down the
thigh, from which level the thickened ilio-tibial band descends to th
outer tuberosity of the tibia. This band receives two-thirds of the i

Surface Markings 449

sertion of the gluteus maximus, and may be traced upwards to the
front of the iliac crest.

Below the spine of the pubes is the cord-like tendon ot the adductor
long'us (p. 453) ; it is often extremely prominent in hip-joint disease,
but it very rarely needs division. Sometimes this tendon is par-
tially ossified (rider's bone}. Along the inner side of the thigh is the
rounded mass of the adductors longus, brevis, and magnus, covered
on their inner surface by the broad, ribbon-like gracilis. This group
of muscles is supplied by the obturator nerve. In a thin subject the
rigid and slender tendon of the adductor magnus may be detected
running to its insertion in the adductor tubercle on the upper part of
the inner condyle. Sometimes in men who spend much time on
horseback the insertion of this tendon is ossified into a rider's bone.
The tendon of the gracilis, which lies near that of the adductor magnus
is distinguished from it by the fact that it passes beyond the femur
and on to the tibia.

The spur-like projection of bone which gives attachment to the
tendon of the adductor magnus marks the level of the top of the
epiphysis, and also that of the highest part of the trochlear surface.
(Holden.)

Above the patella is a depression in which is the flat tendon of the
rectus femoris, and, deeper still, much of the quadriceps extensor.
Towards the outer side is the prominent ridge on the front of the
external condyle, bounding the trochlear surface. This ridge, which
should be carefully examined, is apparently quite subcutaneous, but, in
addition to the skin, it is covered by fascia lata, and by the expansion
from the vastus externus to the patella. An incision on to it opens
the synovial membrane of the knee-joint. The outline of the articular
margin of the external condyle may easily be made out below and
behind the outer border of the patella. This definite ridge is irregu-
larly covered by osteophytes in chronic osteo-arthritis, and in suspected
cases of that disease is always to be inspected.

On the inner side is the inner condyle of the femur ; it is larger
than the outer, but it does not project so markedly beneath the skin,
being covered by the fleshy mass of the vastus internus.

The tuber osities of the femur are the rounded projections upon
the sides of the condyles. They are behind the vertical axis of the
joint ; the lateral ligaments are attached to them, so that in their
descent they may be kept clear of the femur. Being behind the
vertical axis, the lateral ligaments check over-extension of the joint.
Below the joint are the tuberosities of the tibia. The level of the
articulation may be recognised by keeping the finger firmly pressed
below the tuberosity of the femur, and slightly bending or straighten-
ing the knee. In the crevice is the semilunar fibro-cartilage.

On either side of the patella is a depression which is quickly
effaced when effusion occurs in the synovial membrane of the knee ;

G G

45O The Thigh

so also are the hollows at the sides of the ligamentum patella. This
ligament is inserted into the lower part of the tubercle of the tibia.
The prominent part of this tubercle corresponds with the level of the
head of the fibula.

On the outer side of the knee, a little above the joint, are two
thick fibrous bands, one anterior to the other : the larger and posterior
is the tendon of the biceps, descending to the head of the fibula ; the
anterior is the ilio-tibial band of the fascia lata descending to the outer
tuberosity of the tibia (p. 448). Between these bands is a shallow groove
through which abscess in popliteal space is best attacked. The
external popliteal nerve (p. 381) may often be made out close to the
inner side of the biceps tendon ; it pierces the peroneus longus, at the
neck of the fibula, and ultimately divides into the musctilo-cutaneous
and anterior tibial trunks.

Tenotomy of biceps is often needed when a stiff knea is being
straightened. The strong and narrow blade must be introduced close
on the inner side of the tendon, feeling its way down, as it were, between
the tendon and the external popliteal nerve. Section of the tendon
is then accomplished by a sawing motion in the outward direction.
If the tendon were divided from without inwards there would be
considerable risk of the knife passing ' with a run ' through the last
bundles of fibres, and thus wounding the nerve.

When the joint is slightly bent, the fascia lata at the back of the
thigh and knee is relaxed, and the fingers can explore the popliteal
space, and also the slackened hamstring tendons. On* the outer
side is the biceps, and below and internal to it is a head of thegastro-
cnemius. On the inner side is the semi-membranosus, and a little
to the fibular side of that tendon is the slender tendon of the semi-
tendinosus. The tendon of the gracilis is more towards the front, and
is not always very readily made out, especially in a fat subject. Still
more to the inner side and to the front is the flat musculo-aponeurotic
sartorius ; its position is not marked by a tendon, but one can tell
where it is by following its course from the groove between the vastus
and the adductors, and noting, perhaps, a soft prominence caused
by the muscle as it passes over the side of the inner condyle. On the
fibular side of the inner hamstrings is the inner head of the gastro-
cnemius.

The superficial fascia consists of a fatty layer continuous with
that of abdomen and buttock, and with the dartos, and of a deeper
layer which is thin and membranous. The latter is beneath the
saphenous vein and the lymphatic glands of the groin ; it blocks up
the saphenous opening ; but at that situation it has so many perfora-
tions for blood-vessels and lymphatics that it is called cribriforui. It
is one of the coverings of femoral hernia.

The Internal saphenous vein begins in an arch with the external
or short saphenous on the dorsum of foot, and passes up in front

Internal Saphenous Vein 451

of the internal malleolus, by the inner and back part of the knee, and
up the front of the thigh between the two layers of the superficial
fascia. It pierces the cribriform fascia, and passes through the
saphenous opening into the common femoral vein. Before doing so
it receives the veins which correspond to the superficial branches
of the common femoral artery from the iliac, epigastric, and pubic
regions. A large tributary also joins it from the back of the thigh
by winding round the inner side of the limb.

As a result of pressure upon the inferior vena cava or the common
iliac vein — of ovarian tumour or in pregnancy — the saphenous becomes
dilated and thickened — varicose (varus, crooked) ; the valves being
rendered useless, a wound or ulceration of the vein may then cause
fatal bleeding. I have seen a bunch of varicose branches of the vein
form a very definite swelling at the base of Scarpa's triangle. The
tumour could be emptied by placing the man supine, and it recurred
only gradually when he got up again.

A femoral hernia by pressing against the common femoral vein
may so hinder the venous return that dilatation of the surface veins
and oedema of the limb may occur.

The inguinal lymphatic glands are placed between the two
layers of the superficial fascia ; they consist of two groups, one lying
along Poupart's ligament, the other along the saphenous vein.

The upper set receive lymph from the abdominal wall below the
level of the umbilicus ; absorbents from the penis, scrotum, and anus
also enter the innermost glands of this group, whilst those from the
buttock and outer side of the thigh enter the outlying ones. Some-
times lymphatics from the genitals enter the lower glands as well as
the upper.

The lower group receive the absorbents from the inner side of the
foot and leg, and from the thigh. Lymphatic vessels generally run
with the veins ; those, therefore, from the outside of foot and leg pass
with the external saphenous' vein, and end in the popliteal glands.

The lymph from all these glands ascends through the iliac and
abdominal glands towards the thoracic duct. Inflammation of a
gland is commonly called bubo (/3ou/3o>i>, gland). Practically it does
not matter in which direction the suppurating gland is opened provided
that the undermined and unhealthy skin be removed, and the gland-
capsule be scraped out. Infections conveyed from one gland to
another may involve the groin in sinuses which have to be opened up
before healing can take place. If a sinus run with the lymphatics
through the saphenous opening, and into crural canal, it must not
be laid open by bold incision but scraped out to its depths, and
drained by a short tube.

The fascia lata is attached to the iliac crest, Poupart's ligament,
rami of pubes and ischium, to the great sacro-sciatic ligament, the
sacrum and coccyx. It is especially thick on the outer side on account

GG 2

45 2 The TJiigh 3

of its receiving the insertion of the tensor fasciae femoris and two-
thirds of thegluteus maximus ; it passes as the ilio-tibial band (p. 450
from the iliac crest to the outer tuberosity of the tibia and head of
fibula. At the back of the thigh the fascia is thinner, and as it
ascends it gives one layer over gluteus maximus and one beneath.
Investing the lower part of the thigh, it is attached to the condyles of
the femur and sends intermuscular septa to the condylar ridges.

Covering in the popliteal space it is continued on as the deep
fascia of the back of the leg ; but from the front of the thigh it does
not reach below the knee, being gradually blended with the fibres
of the quadriceps extensor, and with the periosteal covering of the
articular ends of the bones. Guided by the fascia, abscess beneath
the gluteus maximus may wander down the thigh and through the
popliteal space into the calf.

The saphenous opening is about an inch below the inner end of
Poupart's ligament, but its site is not usually marked upon the surface
of the limb. It has a definite superior border formed by a sickle-
shaped (falciform} process, which, coming from the pubic spine, sweeps
outwards over the vessels to become continuous with that part of the
fascia which covers the pectineus, and which slopes upwards and out-
wards beneath the vessels to join the sheath of the psoas. This latter
part is \\\e pubic piece of the fascia lata ; it is on a plane posterior to
the outer piece, which, from its having come from the region of the
iliac crest, is called the iliac piece. (Note well that the iliac piece of
the fascia lata is not the iliac fascia, p. 307.) This arrangement of the
fascia lata in two planes which, though continuous below, are sepa-
rated by the thickness of the common femoral vessels above, is to
permit the saphenous vein to continuously discharge its contents into
the common femoral vein, even when the thigh is extended and
everted.

As the falciform process arches over the vessels it is connected with
the front of the crural sheath (p. 313).

When the thigh is extended and the fascia lata in the groin is
tight, and is dragging down Poupart's ligament, the falciform process
is rendered hard and sharp ; and when the thigh is flexed and rotated
inwards the process is slackened. In attempting to reduce a femoral
hernia without flexing the thigh, the bowel may be bruised against
the sickle-shaped band.

Femoral hernia (p. 3 12) descends in the innermost compartment of
the crural sheath, having the iliac part of the fascia lata in front of it,
and the pubic part behind. At about an inch below the ligament
the crural sheath ends by blending with the sheath of the vessels. As
a femoral hernia can descend no farther along the vessels than where
these sheaths blend, it bulges forwards through the saphenous opening,
taking the anterior layer of the crural sheath and the cribriform fascia
in front of it ; it then curls round the falciform process and on to the

Muscles of Thigh 453

front of the iliac piece of the fascia lata, along which it sometimes
travels to the iliac crest.

The sartorius arises from the anterior superior iliac spine, and
passes downwards and inwards over the iliacus and rectus, and the
anterior crural nerve. It then descends vertically over and between
the vastus internus and the adductor longus, covering the superficial
femoral vessels, passing over the adductor magnus, gracilis, long
saphenous nerve, and the internal lateral ligament of the knee. It is
inserted below the inner tuberosity of the tibia, and into the deep
fascia of the leg. It is supplied by the middle cutaneous and other
branches of anterior crural nerve. Lying in the groove between the
vastus and adductors it is the guide to ligation of the femoral artery,
both at the apex of Scarpa's triangle and in Hunter's canal. The
surgeon looks for its long parallel fibres as soon as he has incised the
fascia lata.

The rectus femoris arises from the anterior inferior spine of the
ilium, and from just above the acetabulum ; these heads join in a
tendon which soon spreads out into a bipenniform, fleshy mass, which,
lying over the deeper part of the quadriceps extensor (crureus and
vasti) is inserted with it into the patella.

Relations. — The origin of the muscle is deeply placed, lying upon
the capsule of the hip-joint, beneath the gluteus minimus, iliacus and
psoas, and the tensor fasciae femoris ; but in the rest of its extent it is
beneath the fascia lata.

When the muscle contracts with excessive energy it may break off
the anterior inferior iliac spine, or detach its epiphysis, or it may tear
through the lower tendon. If it be acting with the rest of the quadri-
ceps the patella may be broken across, or its ligament may be torn
through.

The adductor longus arises by a slender tendon from the front
of the angle of the pubes— just below the pubic spine — and passes
downwards, outwards, and backwards to the middle third of the linea
aspera. It separates the superficial from the deep femoral vessels ;
and, passing to its insertion behind the origin of the vastus internus,
it forms the postero-internal boundary of Hunter's canal. Behind it
descend the adductors brevis and magnus, and the anterior division
of the obturator nerve. Along its outer and inner borders are the
pectineus and the gracilis respectively.

The adductors longus and brevis and the pectineus are powerful
external rotators as well as adductors of the thigh ; they are supplied
by the obturator nerve, but the gracilis is a pure adductor, and is
supplied by the obturator nerve. The pectineus is as much a flexor
as an adductor, and is supplied both by the anterior crural and the
obturator ; the psoas is simply a flexor, and is therefore supplied by
the anterior crural only, or by twigs of the lumbar plexus.

454 Scarpa's Triangle

SCARPA'S TRIANGLE

Scarpa's triangle has its base at Poupart's ligament and its apex at
the junction of the upper with the middle third of the thigh, where the
sartorius passes over the inner border of the adductor longus. It is
covered by skin, two layers of superficial fascia, and by the fascia lata.
In the superficial fascia are the lymphatics and glands, branches of
the ilio-inguinal, genito-crural, and middle cutaneous nerves, and the
internal saphenous vein and its tributaries.

The floor of the triangle is formed by the iliacus, psoas, pectineus,
perhaps by a little of the adductor brevis, and by the adductor
longus.

The space contains the trunk of the common and superficial
femoral artery, which bisects the triangle, and the corresponding veins,
the deep femoral vessels and their branches, the anterior crural nerve
breaking up into branches, and the external cutaneous nerve near the
iliac crest.

Hunter's canal begins at the apex of Scarpa's triangle, and ends
at the opening in the adductor magnus. Thus it occupies the middle
third of the thigh. It is bounded on the outer side by the vastus
internus, and behind and on the inner side by the adductors longus and
magnus. It is roofed in by a fibrous expansion from the adductors
to the vastus, and over the roof lies the sartorius.

The canal contains the superficial femoral vessels in their proper
sheath, and the long saphenous nerve outside that sheath. The vein
is behind the artery, and slightly external to it ; and the nerve is
crossing over the sheath from the outer side. The nerve eventually
passes through the roof with the superficial part of the anastomotica
magna, a branch given off from the femoral whilst in the canal.

The femur winds round the main artery. — The femoral and
popliteal trunk of artery runs straight from the groin to the knee, lying
first to the front of the head of the femur, then to inner side of shaft,
and lastly behind it. In this changing position it is the femur that
winds round the artery, and not the artery round the femur.

The common femoral artery is the continuation of the external
iliac from beneath Poupart's ligament for about two inches into
Scarpa's triangle, where it divides into the superficial and the deep
trunk. As the superficial femoral is the direct continuation of the
common, it is convenient to take the relations of the trunk in its con-
tinuity. (Its course upon the surface has been given on page 447.)

Relations. — The artery rests upon the psoas, which separates it
from the capsule of the hip-joint ; upon the pectineus, the adductor
longus, (perhaps) brevis, and on the magnus. The deep femoral vein
is behind it in the triangle, and the superficial femoral vein is behind
it in Hunter's canal. Covering it are the skin and fasciae, sartorius,

Relations of Femoral Artery 455

the overhanging vastus internus, and the roof of Hunter's canal ;
also the long saphenous nerve, which, like the sartorius, crosses it
obliquely from the outer side.

To the outer side is the anterior crural nerve, and, lower down,
are its saphenous branch and the sartorius, also the vastus internus,
and, at the end of the canal, the superficial femoral vein. On the
inner side are the common femoral vein and the pectineus, then the
three adductors, and, further down, is the sartorius, which has
crossed it.

Note. — To the surgeon the most important relations of the artery
are the vein and the sartorius ; and, fortunately, by remembering the
position which the muscle occupies (which is sufficiently obvious) he
remembers also the situation of the vein, which is upon just the oppo-
site aspect of the artery. Thus, when the sartorius is entirely to the
outer side, as at the base of Scarpa's triangle, the vein is entirely to
the inner side. When the sartorius is gaining the front of the artery
from the outer side the vein is getting behind it from the inner side,
as towards the apex of the triangle. When the muscle is exactly over
the artery, as at the apex of the triangle, the vein is exactly behind
it ; and when, as in Hunter's canal, the sartorius is lying above and
to the inner side, the vein is beneath and to the outer side. Lastly,
when the muscle is quite to the inner side, as at the lower end of the
canal, the vein is quite to the outer side, in which relative position it
is found at the top of the popliteal space.

The relationship of the long saphenous nerve to the artery is the
same as that of the sartorius.

The branches of the common femoral artery are the three super-
ficial twigs which, coming through the cribriform fascia, pass between
the layers of the superficial fascia, towards, as their names respectively
denote, the epigastric region, over Poupart's ligament, the iliac region
(circumflexd), and the external ptidic region. The former branches
communicate with the deeper and larger vessels of the same name
(p. 370). The third branch passes to the scrotum or labium, and,
lying over the spermatic cord, is wounded in inguinal herniotomy
and in castration. A fourth branch, the deep external pudic, pierces
the fascia lata on the inner side of the thigh, and, ending like the last,
anastomoses with the superficial perineal artery.

The superficial femoral artery gives off various muscular branches,
and, in Hunter's canal, the anastomotica magna. This important
branch divides into a superficial part, which leaves the canal through
the roof, in company with the saphenous nerve ; and a deep part,
which passes obliquely across the lower end of the femur, under the
quadriceps extensor, giving branches into the articulation, and anasto-
mosing on the inner side with the superior articular of the popliteal,
and on the outer side with the superior external articular, the recur-
rent tibial, and the descending branches of the external circumflex.

456 Scarpds Triangle

The deep femoral artery (profunda femoris) comes off from the
back of the common trunk, an inch or two below Poupart's ligament,
and, passing at first outwards, winds downwards and inwards to the
adductor magnus.

Relations. — At first close beneath the superficial femoral vessels,
it is afterwards separated from them by the adductor longus, and the
deep femoral vein.

At its origin it touches the front of the iliacus ; afterwards it rests
upon the pectineus and the adductors brevis and magnus. On the
outer side is the femur, covered by the vastus interims, and on the
inner side are the adductors.

The branches of the deep femoral artery are the two circumflex
and the three perforating, which, as their names imply, are either bent
around the femur, or perforate the adductor magnus in their course to
the back of the thigh.

The external circumflex passes outwards through the divisions
of the anterior crural nerve, then under the sartorius and rectus,
and over the crureus. It divides into ascending branches which pass
under the tensor fasciae femoris to the space between the iliac crest
and the great trochanter, where they anastomose with the gluteal
and the circumflexa ilii.

Transverse branches pass backwards through the vastus externus
to anastomose with the sciatic, internal circumflex, and superior
perforating, completing the cruciform anastomosis ; and descending
branches run in the vastus externus to anastomose with the superior
external articular of the popliteal.

The internal circumflex leaves Scarpa's triangle between the
psoas and pectineus, and, passing below the obturator externus, and
above the adductor brevis, hits the interval between the quadratus
femoris and the adductor magnus, by which it enters the cruciform
anastomosis. When it is passing above the adductor brevis it gives
a branch to anastomose with the obturator artery, and to help in the
supply of the hip-joint. Another branch may pass by the tendon of
the obturator externus to anastomose with the gluteal and sciatic.

Of the perforating arteries, the first runs through or above the
adductor brevis to ' perforate ' the magnus. It joins in the cruciform
anastomosis, and communicates below with the second, which pierces
both brevis and magnus, and anastomoses with the first and with the
tJdrd, The third pierces the large adductor below the level of the short
one, and anastomoses with the second and with the termination of the
profunda, which comes through the magnus as a fourth perforating,
and anastomoses freely with the superior muscular branches of the
popliteal, and with the higher perforating branches.

The second perforating gives the special nutrient branch to the
medulla of the femur, which enters by the linea aspera in an upward
direction.

Ligation of Femoral Artery 457

Irregularities. — The common femoral artery may divide close
below Poupart's ligament, or as far down as the apex of Scarpa's
triangle ; in the latter case the circumflex branches come from the
common trunk. There may be two superficial femoral arteries. Oc-
casionally the femoral has been replaced by a giant sciatic artery
which has eventually become the popliteal.

The femoral veins. — The superficial femoral vein continues the
popliteal vein up through Hunter's canal, where it is lying external,
and then posterior to its artery ; through Scarpa's triangle where,
in its ascent, it gradually passes from behind to the inner side, until
it is joined, an inch and a half below Poupart's ligament, by the deep
femoral vein to form the common femoral. This last lies altogether
on the inner side of its artery, resting upon the pectineus. The
relations and the tributaries are much like those of the corresponding
arteries, with the exception that" the veins corresponding to the
branches of the common femoral artery enter the long saphenous vein,
itself a tributary of the common femoral.

Compression of the common femoral artery against the ilio-
pectineal eminence and over the head of the femur is easily accom-
plished by the thumb, the fingers grasping the great trochanter. If
the circulation have to be controlled for a considerable time, the part
should be first cleanly shaved, washed and dried, and then dusted
with starch powder, a shot-bag being placed over the backs of the
fingers, whilst the tips are laid along the artery. The necessary force,
which is not great, should be directed a little upwards towards the
pubic ramus.

The india-rubber tourniquet is applied by stretching it across the
thigh below the ischial tuberosity, crossing the stretched ends over a
pad in the groin, and taking them, spica-wise, front and back, to just
below the opposite iliac crest, where they are secured.

If compression be made lower down the thigh, by a screw-tourniquet
for instance, a pad (a rib-roller) should be laid over the artery, in the
groove between the quadriceps and adductors ; the pressure being
directed outwards against the femur.

legation of the common femoral has not been a popular opera-
tion, because the surgeon cannot be sure that the trunk is not divid-
ing high up, or that the circumflex trunks do not come from it. Then,
close above the ligature, the deep epigastric and the circumflex iliac
branches are given off, so that the risk of imperfect formation of the
clot and of recurrent haemorrhage is considerable. Ligation of the
external iliac has usually been the alternative operation, but in spite of
these objections ligation of the common femoral artery is often a very
proper operation.

To secure the common femoral, the skin being shaved and cleansed,
a two-inch incision is made from a spot midway between the iliac
spine and pubic symphysis, through the skin and superficial fascia

458 The Thigh

and fascia lata. Then the crural sheath is sparingly opened and the
artery is seen, to the outside of the vein. The needle is passed from
the inner side. The anterior crural nerve is far out of sight (p. 358).

Collateral circulation is established by the anastomosis of the
external circumflex with the gluteal, ilio-lumbar, and circumflexa ilii,
and with the sciatic branches in the cruciform anastomosis ; by the
anastomosis of the internal circumflex with the obturator, gluteal, and
sciatic ; of the superior perforating with the sciatic ; and of the per-
forating and superior muscular branches of the popliteal with the
comes nervi ischiatici.

Xiigration of the superficial femoral in Scarpa's triangle is per-
formed at ' a hand's breath ' (four inches) below Poupart's ligament — at
a spot in which the artery is comparatively near the surface, and distant
from the origin of any large branch. The line of the artery having
been taken (p. 447), or traced by the pulsations, as the limb lies
slightly flexed and everted upon a pillow, a three- or four-inch incision
is made with its mid-point over the chosen spot. In incising the
superficial fascia, the long saphenous vein, which is close on the inner
side, must be avoided ; the fascia lata is then divided on a director,
when the inner border of the sartorius is looked for, exposed, and
drawn outwards. The sheath of the vessels is thus brought into view
and is opened for ahput half an inch, along the aspect most distant
from the vein, which'is, of course, upon the side of the sartorius — the
outer side. Unless this point be attended to the thin-walled vein is
in great danger of being wounded. The vein may not be seen, as it
is behind the artery, though slightly to the inner side ; the aneurysm-
needle is passed from the inner side, close around the artery, threaded,
and withdrawn.

Migration in Hunter's canal is invariably performed in the case
of a punctured wound in that situation, and sometimes in the case of
aneurysm of the popliteal artery. A four-inch incision is made over
the line of the artery in the middle of the thigh, care being taken
to avoid the saphenous vein. The fascia lata having been divided, the
fibres of the sartorius are seen running evenly in the length of the
wound. Their direction distinguishes them from the oblique fibres of
the vastus internus and of the adductor longus. The muscle is then
drawn inwards, and the aponeurotic roof of the canal is exposed —
perhaps with the saphenous nerve and the superficial part of the
anastomotica magna passing through it. The roof is then divided on
a director for an inch or so, when the saphenous nerve is found rest-
ing upon the sheath of the vessels. This sheath is cautiously opened
for about a quarter of an inch, the artery is isolated, and the needle is
passed from the outer side— the side of the vein.

In seeking the artery in Hunter's canal the fallacy is apt to be in
making the incision too low down, so that the operator finds his wound
deepening against the tendons of the gracilis and the adductor magnust

Glu teal Region 459

Practically, Scarpa's triangle occupies the upper third of the thigh,
Hunter's canal the middle third, and the popliteal space the lowest
third.

After ligation of the superficial femoral the circulation is carried on
by the many unnamed, empty muscular branches of the femoral below
the ligature bringing in blood from muscular branches above it ; by
the deep part of the anastomotica magna bringing in blood from the
descending branches of the external circumflex ; by the superior
muscular branches of the popliteal anastomosing with the lower per-
forating arteries and with the comes nervi ischiatici (in a dissection
which I once made this was the most important collateral route) ; and
by superior external articular branches anastomosing with the external
circumflex.

As an anatomical exercise the following question may be
answered : — What structures are divided in a transverse section
across the middle of the thigh ? Ans. : Skin and superficial fascia,
and, in the latter, branches of the internal, middle, and external
cutaneous nerves, and of the lesser sciatic ; also the long saphenous vein
and lymphatics. The fascia lata, which is especially strong in the
region of the ilio-tibial band. The sartorius, rectus femoris, vasti
and crureus, and branches of the anterior crural nerve. The gracilis,
adductors longus and magnus, and the obturator nerve. Hunter's
canal, with the superficial femoral vessels and the saphenous nerve.
Descending branches of the internal and external circumflex vessels ;
the termination of the profunda vessels, and of a perforating artery.
The biceps semi-tendinosus and membranosus ; the beginning of the
internal and external popliteal nerves of the great sciatic ; perhaps
the comes nervi ischiatici, and ascending muscular branches of the
popliteal artery ; the femur and its periosteum.

The gluteal region. — Between the ischial tuberosity and the
great trochanter a shallow space can be made out by thrusting the
fingers into the glutens maximus. In its depth are the small external
rotators of the femur, and in the higher part of this space, under cover
of the rotators, is the capsule of the hip-joint. In the case of acute
effusion into the joint, a deep-seated fulness may be detected here,
which may be aspirated through the muscle.

It is difficult to show by marking on the rounded buttock the
position of parts which lie in the flat beneath it, and in attempting to
do so the student must work at first with the dry bones beside him.
He begins by tracing the iliac crest backwards to the posterior
superior spine, which overhangs the side of the sacrum ; descending
an inch, his finger is over and upon the sacro-iliac articulation ; in
sacro-iliac disease there are a swelling and tenderness at that spot.
A little below this is the posterior inferior spine. This spine, which
is at the lower part of the sacro-iliac joint, and may be easily made
out in a thin person, is to be the starting-point for a bold, sickle-shaped

460 The Thigh

line with its convexity towards the great trochanter, which marks the
great sacro-sciatic notch, and ends on the ischial spine. From the
ischial tuberosity arise the hamstring muscles, biceps, and semi-
tendinosus and semi-membranosus.

The sciatic nerves (p. 379) leave the pelvis below the pyriformis ;
the greater then descends between the trochanter and the tuberosity,
emerging in the mid-space from beneath the border of the glutens
maximus. It lies in this hollow so that it may be out of the way of
pressure in the usual sitting posture. If, however, one sits sideways
or on the edge of the chair, the nerve is compressed and numbness
and discomfort result. For nerve-stretching^ see p. 380 ; for the course
of the gluteal artery, see p. 374.

The gluteus maximus arises from the back of the ilium, sacrum,
coccyx, and sacro-sciatic ligament, and passes downwards and out-
wards; its thick and free lower border passes over the ischial
tuberosity, and is inserted below the great trochanter. The upper
two-thirds of the muscle glide as a strong, thin tendon over the
trochanter, and are inserted with the tensor fasciae femoris into the
ilio-tibial band. The muscle is separated from the tuberosity and
the trochanter by two bursae, and in men who sit a great deal, such
as coachmen, tailors, and weavers, the ischial burs a is apt to be greatly
irritated, and even to suppurate. The inflamed bursa has a very
unpoetic name. When the trochanteric bursa is inflamed the signs
may at first suggest hip-joint disease ; but there is no swelling of the
joint itself, and the femur may be rotated in the acetabiflum without
causing distress.

T\xt fold of the nates runs obliquely downwards and outwards in
the direction of the lower border of the gluteus maximus, with which,
however, it has no anatomical association. It is the result of the
creasing of the skin when the thigh is extended. When it is flexed
the crease and the fold disappear, which they would not do if their
presence had depended upon the existence of the border of the
muscle.

The pyriformi s may be depicted as passing downwards and out-
wards from the notch already marked out, to the top of the great
trochanter. It forms an elongated, triangular figure. Through the
notch, above the muscle, emerge the gluteal artery and the superior
gluteal nerve. As has already been shown (p. 374), the point of
emergence of the artery is at the junction of the upper and middle
thirds of a line running from the posterior superior spine to the top of
the great trochanter.

THE FEMUR

The femur generally changes its form with age ; in childhood
the neck is short and in an almost vertical line with the shaft. In adult
life it stands off at an obtuse angle, and often in old age, but by no

Development of Femur

461

means always, it passes inwards at a right angle from the shaft, the
head of the bone sinking even below the level of the top of the great
trochanter. At this time the compact wall becomes thinned, and
much of the cancellated tissue which it encases undergoes fatty
degeneration and absorption. Fracture of the femoral neck is, in such
circumstances, very apt to occur.

The femur has five centres of ossification ; the centre for the
diaphysis, or shaft, extends also into the neck. This
is an important exception to the rule that only the
epiphysis of a long bone enters into the formation
of a joint ; in the case of the hip some of the dia-
physis is enclosed within the capsule.

The knee-epiphysis begins to ossify in the ninth
month of fcetal life : a fact of importance in medical
jurisprudence. The head begins to ossify in the
first year, the great trochanter in the fifth, and the
lesser in the thirteenth year.

The epiphyses join the shaft, in the inverse order
of their development, at the seventeenth, eighteenth,
nineteenth, and twentieth years.

Increase in the girth of a bone depends upon
deposit in the periosteum ; increase in length by
growth in the junction-cartilages. As the lower
epiphysis of the femur is the last to join (twentieth
year), its integrity is very essential to the growth of Ossification of femur
the limb ; similarly, the scapular epiphysis of the
humerus(p. 260) is the important one in the growth of the arm. In ex-
cision of the knee-joint, the surgeon guards the lower junction-cartilage,
so as to diminish to the utmost the amount of the subsequent and
inevitable shortening of the limb.

Fracture of the femur may occur in any part of the bone;
reference will be made here to certain special varieties of fracture
only. Before manhood the lower epiphysis may be ' unglued ' from
violence, and the bellies of the gastrocnemius, which arise from the
condyles, may tilt the upper border of the epiphysis back into the
popliteal space and against the artery. If there be difficulty in
keeping the surfaces in apposition, as I have known to happen, the
knee must be kept slightly bent, and, if necessary, the tendon of
Achilles divided, so as to relax all muscular traction. Complete dis-
placement of these wide surfaces rarely occurs.

Fracture tJirough the epiphysis is apt to be followed by arrest of
growth of the bone, and by stiffness of the knee.

In fracture above the condyles of the fully ossified bone there
is often no displacement whatever, especially if the plane be trans-
verse ; but if it be oblique, the lower fragment is most likely thrust
backwards, the plane of fracture passing from behind, downwards and

462 The Femur

forwards, the gastrocttemius helping materially in the displacement
in the direction which the violence of the shock had first determined.
But if the line of fracture be from before, downwards and backwards,
there is neither gravity nor muscular action to unhitch the lower frag-
ment, and there is, therefore, no displacement, though the heavy shaft
of the femur may sink towards the mattress.

Mclntyre's splint, which is a double inclined plane hollowed out
for the thigh and leg, is very useful in the treatment of fracture above

the condyles, as, the knee being slightly bent, strain is taken from the
gastrocnemius and popliteus.

Signs of fracture of neck or shaft. — As the lever is broken the
limb cannot be raised, perhaps hardly moved, by the patient, and
there is probably deep-seated swelling, the result of effusion from the
torn vessels of the bone, medulla, periosteum, and adjacent muscles.

The weight, or natural inclination of the limb, carries it into
the everted position. This eversion is not due to 'the numerous
and strong external rotatory muscles ' (Sir A. Cooper), for it is as
characteristic of fracture of the middle of the shaft, that is below the
chief mass of those rotators, as it is of fracture of the neck. More-
over, though the external rotators are superior in number to the
internal rotators, they are not in strength.1 The eversion persists,
too, during anaesthesia, when muscular action is suspended, and I
have seen a woman with old fracture of the neck roll the limb inwards
at our request.

Fracture of left femur ; limb shortened and everted. (ERICHSEN.)

More influence is ascribed to muscles in affecting the position of
a limb after fracture than is their due. They are not constantly
contending on opposite sides of a bone in a sort of ' tug of war,'
ready to pull the fragment this side or that. If so, how is it that,

1 British Medical Journal, Nov. i, 1879.

Signs of Fracture of Femur" 463

when the patella is broken across, the leg is ndt immediately and
forcibly flexed, and that when the olecranon is separated the elbow is
not rigidly flexed?

A sound limb does not rotate on the long axis of the femur, but
on an imaginary axis which ascends through the mass of the adductors
to the centre of the femoral head. The centre of gravity of the limb
is far to the outer side of this axis, because the neck of the bone is
fending the shaft from the pelvis and from the other thigh. It is this
arrangement which makes eversion the natural position of the limb,
as occurs when one is at rest in the supine position. When the femoral
neck is broken, the impediment to further eversion is absent, and the
limb rolls into the characteristic position. Sometimes, though very
rarely, fracture of the femur is followed by inversion ; this is due to
the violence which effected the fracture having lifted the limb into,,
and temporarily left it in, that position.

Unless the line of a fracture in the shaft be transverse the lower
fragment is apt to be ' unhitched ' from the upper, and to be steadily
drawn upwards by the elastic pull of muscles, nerves, vessels, fasciae,,
and skin; thus shortening- is a sign of fracture. In children, how-
ever, in whom the plane of fracture is generally square, there is no
overlapping of the fragments, and therefore no shortening ; and, as
the neck of the femur is not directed much outwards, fracture of the
shaft is not characterised by eversion.

That the shortening after fracture is not due entirely to muscular con-
traction is evinced by the fact
that the amount of shortening-
is apt steadily to increase for
some time ; if it were due to
muscular contraction the short-
ening should be immediate,
and to the full. If the eversion
were due to muscular contrac-
tion, how is it that it generally
is to its full extent directly after
the injury, while the shorten-
ing, which some attribute to the
same cause, is but gradual ?

When the shaft is broken,
unless the surfaces are inter-
locked (impacted), when an
assistant rotates the limb, the
trochanter remains stationary.
And, if the fracture be in the
neck, the trochanter simply
rotates in its long axis ; it does not sweep in a semicircle as it does

Intra-capsular fracture.

when the sound limb is rotated.
Fracture of the neck is a

common injury in old subjects ; the

464

The Femur

violence which causes it may be trifling, for the bone is weak and the
shock of an unexpected step, or of a jarring, comes vertically across it.
The limb is at once everted, shortened, and useless, and swelling and
pain are at the hip. With such signs it is superfluous and unkind to
try to elicit crepitus.

The fracture may be within or outside of the capsule. In
the former case the shaft-fragment is tethered by the
ligament, and the shortening may not amount to more
than half an inch or so, but when the break is outside
the capsule there is, practically, no limit to the amount
of shortening, which may then amount to several
inches.

Union after intra-capsular fracture very rarely
occurs by bone, probably because, the fracture being in
the joint, the surfaces are constantly bathed in sero-
synovial fluid, instead of being wrapped in blood-clot,
as happens in fracture in any other part of the body,
with the exception of the patella, the olecnmon, and
the coronoid, which are all, be it noticed, instances of fracture into a
synovial membrane. To explain the failure of bony union by reference
to the age of the patient (upwards of fifty years) is incorrect, for if a
man of one hundred years break the shaft of his femur firm union
would be expected. To say, also, that the cause of non-union may be
want of apposition of the surfaces is wrong ; for months or years after
the injury we may find the surfaces closely applied, polished by friction
against each other, or closely connected by fibrous tissue. Neither is
the theory of imperfect blood-supply to the parts valid.

Extra-capsular
fracture.

Fracture below lesser trochanter ; upper fragment lilted forwards by psoas and iliacus.

(After HJND.)

Xn fracture below the lesser trochanter the lower fragment —
the chief part of the bone — drops by its own weight, and is pulled
upwards, as explained above, and rolled outwards ; the upper fragment
is tilted forwards by the psoas, iliacus, pectineus, adductor brevis, and
gluteus minimus ; thus there is often considerable overlapping, defor-
mity, and shortening. The injury cannot then be satisfactorily treated

Fracture of Femur 465

by the long splint, nor must any attempt be made to repress the upper
fragment by pad or bandage, lest a sharp end work through the

muscles, fasciae, and skin, and the fracture be rendered compound.
It may be dealt with, however, by keeping the patient in a slightly
sitting posture, so that, by flexing the trunk and pelvis on the femur,
the psoas and allied muscles may be relaxed to the utmost ; the knee

Double inclined plane ; the thigh piece Fracture of upper end of femur ; limb ar-

may be lengthened at A. ranged on double inclined plane.

being flexed over a well-padded double inclined plane. Bending the
knee takes the strain off the hamstring muscles, and raises the lower
fragment of the femur to the level of the upper.

Separation of the great trochanter may occur from muscular or
direct violence, but the fragment quickly becomes fixed again if the
limb be kept in absolute rest, the loose piece being steadied by a
bandage. The accident is apt to happen to the athlete whose femur
is not yet ossified throughout.

THE HIP-JOINT

The articular surfaces of the acetabulum and the head of the femur
are encrusted with a layer of permanent cartilage, which disappears
in chronic rheumatic arthritis. The dry surfaces of bone then become
worn by friction, the acetabulum becomes loose and shallow, and the
head of the femur flattened and worm-eaten. Or there may be a great
deposit of new, hard bone, which takes a beautiful polish from the
constant dry rubbing in the joint, so that it looks like porcelain.

466 The Hip- Joint

The capsule is attached beyond the border of the acetabulum. In
front it is extremely thick and descends to the intertrochanteric line,
but behind, where it is thin and membranous, it does not reach to
within a finger's breadth of the line. The anterior part is strengthened
by the ilio-femoral, or Bigelow's ' ligament, which descends like an
inverted Y from the anterior inferior iliac spine to the upper and lower
ends of the anterior intertrochanteric line. Fibres are reflected from
the lower end of the capsule up around the neck, these fibres strengthen
the periosteum ; thus, sometimes it happens that the neck is cracked
across without displacement occurring, the fragments being closely held
together by the thick periosteal covering.

There is often a perforation in the front of the capsule, between
the branches of the Y ligament, by which the synovial membrane of
the joint communicates with the bursa beneath the psoas. Around
the border of the acetabulum, just inside the capsule, is the fibro-
cartilaginous cotyloid ligament, which acts as a ' sucker ' around the
head of the femur which it tightly embraces, securing its position
by atmospheric pressure. It stretches across the cotyloid notch at
the lower part of the acetabulum under the name of the transverse
ligament, vessels and nerves entering the joint beneath it.

A synovial membrane lines the capsule and covers the neck of the
femur, but its continuity cannot be traced over the opposed articular
surfaces except in early fcetal life, as, under the influence of pressure,
it becomes absorbed.

The ligamentum feres is a hollow fibrous pyramid, which passes
between the margin of a depression at the bottom of the acetabulum
and the pit below and behind the centre of the head of the femur. It
is surrounded by synovial membrane. It is not an important struc-
ture ; sometimes it is represented by a mere shred. It is, of course,
ruptured in dislocation. Possibly its chief function is to act as a
cushion.

Relations of the hip- joint. — In front art the iliacus and psoas,
the pectineus, the straight head of the rectus femoris and some of the
gluteus minimus. Behind are the pyriformis, gemelli and obturator
internus, obturator externus, and quadratus femoris. Above are the
reflected head of the rectus and the gluteus minimus, and below are
the obturator externus and the outer border of the pectineus.

The anterior crural nerve and the common femoral vessels are
separated from the front of the capsule by the iliacus, psoas, and
pectineus ; and the sciatic vessels and nerves are separated from the
posterior aspect by the pyriformis, the gemelli and the obturator in-
ternus, and the quadratus femoris.

Supplies — Arteries come from the gluteal (above), the sciatic
(behind), the obturator and internal circumflex (below). Nerves enter
from the sacral plexus («. to quadratus), the great sciatic, obturator,
accessory obturator and anterior crural (». to rectus).

Hip- Joint Disease 467

Disease of hip-joint begins in the synovial membrane or bone,
the first result often being an acute effusion into the synovial mem-
brane. The joint is at once swollen, stiffened, deformed, and pain-
ful ; it is swollen, because effusion distends the capsule, causing it
even to bulge slightly into the buttock and into the base of Scarpa's
triangle. Thus, the psoas and the common femoral artery are
pushed forwards, the artery beating prominently beneath the skin ;
and the crease of the groin is obliterated by the general articular
fulness. The stiffening and deformity are caused by the great
intra-articular tension. Acute effusion into a joint always stiffens it.
This is readily shown in the case of the hip-joint by injecting fluid
into it from the pelvic side, when not only does the femur become
rigidly fixed, but it passes first into the position of slight abduction,
and then into that of flexion with inversion. Muscular action, as
explained by Hilton, has probably no direct influence on the assump-
tion of these positions, the limb taking them because, the joint being
full, more room is found for the fluid when the femur is so arranged. In
these positions, therefore, there is least tension of the sensory filaments
of the joint. It is the unyielding anterior part of the capsule which
determines the position of the limb.

The pain first complained of in hip-joint disease is on the inner
side of the thigh, above the pateHa, in the popliteal space, or at the knee
— that is, in the area of distribution of the terminal branches of the
obturator nerve (p. 358). The reason of this is not clearly understood.
The explanation usually given is that the obturator nerve supplies
the hip-joint, thigh, and knee, and that when one set of peripheral
fibres are irritated the trouble is referred to the area of distribution
of those of the other division. In a similar manner we find that, when
the bladder-branches of the sacral plexus are irritated by vesical
calculus, the painful area is at the end of the penis, where the peri-
pheral branches of the nerves supplying the bladder are distributed.

As the disease advances, the fulness of the groin and buttock
increases, and an abscess forms which bursts through the thin, posterior
part of the capsule.

The pus may then find its way under the gluteal muscles to below
the great trochanter, round by the obturator externus to the inner
part of Scarpa's triangle, beneath the great gluteus and into the upper
and back part of the thigh, or through the floor of the acetabulum and
into the pelvis. This last is by no means an uncommon event, and in
examining an old case of hip disease the surgeon must not fail to pass
his finger into the rectum so as to make a full exploration on the inner
surface of the os innominatum. The pus is not in actual contact with
the wall of the rectum, though it is felt by the finger (v. p. 363) close
to it ; it is separated by the periosteum of the os innominatum, the ob-
turator internus and obturator fascia, and the levator ani and its fasciae.
It is quite possible, however, that the pus may by pressure effect a

H i, 2

468

The Hip-Joint

thinning and an absorption of these tissues, and so escape through the
ischio-rectal fossa, or by the rectum and anus.

Occasionally the matter escapes by the perforation in the front of
the capsule^ finding its way into the bursa beneath the psoas, in which
case it may become extravasated upwards beneath the psoas and iliacus
and so give rise to secondary pelvic abscess and to caries.

Often when disease has passed away, the hip-joint is synostosed,
the femur being flexed and inverted. . The limb can then be brought
straight down only by tilting the pelvis forwards and arching the
loins (lordosis). The exact amount of the deformity is calculated by
correcting the lordosis, by raising the thigh, making the line which
connects the anterior iliac spines pass at right angles to the middle
line of the body (' squaring the pelvis] as it is called), and noting the
position which the limb thus assumes. If the ankylosis be in a very
faulty position, the limb may be brought straight by dividing femur
subcutaneously, below the great trochanter, with a keyhole saw.

Rectangular ankylosis following hip disease ; A, lordosis, thigh being brought down ; B, lor-
dosis effaced by raising thigh. (ERICHSEN.)

As the joint-disease advances, and ulceration attacks the femur and
acetabulum, the child finds that he can get greatest rest and quiet
when the flexed knee is steadied over the other thigh, and protected
from muscular startings and accidental movements by the other leg
and foot, with which he lifts and arranges the damaged member.
Thus the thigh becomes persistently flexed and inverted.

Dislocation of the femur, in the proper sense of the term, in hip-
joint disease never occurs. It sometimes seems to have taken place
when examination is made by Bryant's or Ne'laton's (p. 447) method,

Dislocation of Femur 469

but this is due partly to further excavation of the acetabulum, partly
to caries of the head and neck of the bone, and partly to the disease
having arrested growth at the upper epiphysis (v. p. 461). Often in
an advanced case of disease with apparent dislocation, as the surgeon
proceeds to excise the head of the femur, he finds that it has already
been carried away by molecular disintegration, the top of the great tro-
chanter being high above the acetabulum. Thus there is no head to
be dislocated, and no proper socket from which, or capsule through
which, it could be dislocated were it present.

Excision of head of femur may be performed through a long in-
cision over the great trochanter, or by one passing through the gluteus
maximus. The latter site offers advantages for drainage. The knife
should be used but little after the fascia lata has been traversed, the soft
parts being thrust aside and the muscles detached by a strong raspa-
tory. The bone may be divided above or below the great trochanter,
according to circumstances. If the bone be much diseased, and the
trochanteric part of the shaft be taken away, the following muscles
must be partially or entirely detached : — From the shaft the gluteus
maximus, vastus externus, crureus, and pectineus ; from the great
trochanter, the gluteus medius and minimus, pyriformis, gemelli and
obturators, and quadratus femoris ; from the lesser trochanter, the
psoas and iliacus.*

When excision is being performed for disease in childhood, the
great trochanter with the attachments of the gluteus medius and
minimus is frequently detached, but unless it be diseased it need not
be taken away.

Resection by the anterior vietJwd is performed by attacking the
joint between the tensor fasciae femoris and the glutei on the outer
side, and the sartorius and rectus on the inner, the Y ligament and the
front of the capsule being traversed.

Amputation at the hip-joint by transfixion is an operation of
the past ; Furneaux Jordan's method has superseded it. The latter
operation consists in making a vertical incision on to the femur from
above the great trochanter, and a third of the way down the thigh.
Bleeding vessels in this longitudinal wound are secured one by one. The
upper third of the femur is cleared of muscular attachments and dis-
articulated, the bared part being brought out of the wound by adduct-
ing the thigh. The assistant then grasps the hollow shell of the soft
parts, firmly compressing all the vessels in them, and the surgeon cuts
it with a circular sweep. The limb being thus amputated, the vessels
are leisurely secured ; the bleeding is very slight. In a case in which
I enucleated a femur from the periosteum, the upper fourth of a new
thigh-bone became developed in the long stump.1

Dislocations of the femur are rare, for the hip-joint is planned for

1 Proceedings of Med. Soc. Lond. vol. ix. p. 205.

470 The Hip-joint

exceeding strength. The head of the bone presses most forcibly against
the capsule during over-extension, but it is prevented bursting through
it, not only by the great thickness of that part of the capsule, but also
by the strap-like arrangement of the rectus femoris, psoas, iliacus, and
gluteus minimus, which are then tightened to the utmost over the
front of the joint.

Again, the strong, overhanging roof of the acetabulum is a sure
check against the head of femur escaping through the upper part of
the joint during forced adduction. I apprehend that the thigh-bone
would sooner break than that this could occur.

In abduction, however, the head of the femur partially rolls out of
the lower and unprotected part of the acetabulum ; and when abduction
is extreme, the bone escapes through the neighbouring and weak
part of the capsule, tearing a ragged hole in its inner aspect. The
ilio-femoral ligament remains entire, but the ligamentum teres is,
of course, torn through. The head of the bone may then remain just
below the acetabulum and form a dislocation into the obturator
foramen, the limb being stiff, a little lengthened and abducted.

Obturator dislocation ought to be the commonest variety of dis-
placement ; but when the bone is in the act of escaping, or has actu-
ally escaped, either the direction of the violence, spasmodic muscular
contraction, or a rotatory movement of the thigh or- the trunk causes
the bone to glide on to the dorsum ilii or into the great sacro-sciatic
notch.

The dislocation on to the dorsum ilii is the commoner result, the
smaller gluteal muscles being ploughed up, and the great trochanter
being rolled towards the front of iliac crest. Let the student take the
haunch-bone in one hand and the thigh-bone in the other and work
out these luxations for himself ; or, better still, let him use a moist
preparation of the joint with ligaments prepared, and he will thoroughly
understand them. He will find that in the dorsal dislocation the limb
must be shortened because the head now occupies a higher level.
That as the head has passed backwards the great trochanter is rolled
forwards, and, being raised, that it lies near the anterior superior iliac
spine. The upper end of the femur being thrust backwards, on to
the flat bone, its lower end must needs be advanced. Thus, the limb
is fixed, shortened (by two or three inches), and inverted. Fixation
characterises every dislocation ; a bone could hardly be as movable
when its end is out of its socket as it is when in it. As the patient
lies in bed, or attempts to stand, the flexed and inverted position of
the thigh carries the knee across the lower part of the sound thigh, the
ball of the great toe resting somewhere about the opposite ankle. But
it should not be thought that a man who has just dislocated his femur
stands up for inspection, as the sketches of some text-books might
suggest !

When the head of the bone is dislocated into tbe sciatic notch

Dislocation on to Pubes

the shortening is evidently not much — an inch or less ; the inversion
and flexion are also less, so that now the axis of the knee is only just
above the opposite one, the ball of the great toe is scarcely raised,
and the great trochanter is but little advanced towards the front of
the iliac crest, though still it is above Nelaton's line.

The head of the femur lies above the tendon of the obturator internus
in the high backward
dislocation,but below
it in the luxation
into the notch. In
either case, however,
the muscle and ten-
don may be lacer-
ated. If, as the bone
travels upwards from
the rent in the lower
part of capsule, it do
not rupture the ob-
turator internus, the
head may glide upon
its pelvic or upon its
gluteal surface. If
by the latter route,
it will rest in the
notch, for the tendon
over the front of the
neck prevents its
further ascent, but if
it slip in front of the
tendon it will reach
the dorsum ilii.

Dislocation on
to the pubes is rare.
The head of femur is
thrust up to the inner
side and in front of
the Y ligament, and
under the iliacus and
psoas, causing the
common femoral
vessels to be much

advanced and per- Congenital displacement of femora. (BRODHURST.)

haps arresting their

circulation. The anterior crural nerve also is stretched. The head is
raised about half an inch, and as it is advanced the great trochanter is
rolled back and the limb is everted. Thus are presented two of the

472 The Knee-joint

signs of fracture of the femur, shortening and eversion (p. 462), but the
dislocated limb is rigidly fixed, the great trochanter is absent from its
place, and the head of the femur is felt on the pubic ramus.

In each dislocation the ilio-femoral ligament remains entire, and.
impedes reduction — at any rate, when the attempt is made on the old
system of extension by pulleys and counter-extension by a band around
the perineum. But when the ligament has been first slackened, as
occurs when the thigh is flexed, a small amount of movement, if in the
right direction, suffices to get the head of the bone in its place again.
'After flexion, and perhaps circumduction (to enlarge the rent in the
capsule for the return of the femoral head), the reduction may be com-
pleted by rotation, or by extension of the thigh ' (Hamilton). This is
the anatomical or scientific method of restoring the bone.

As a result of congenital deformity of the acetabulum, and of the
hip-joint generally, the head of the femur rests upon the dorsum ilii,
the great trochanter being above Nelaton's line. On account of the
backward displacement of the femora, the centre of gravity of the body
is advanced, arid, in order to ensure stable equilibrium, the shoulders
have to be thrown back. Thus the defect is always associated with
lordosis, and especially so when it happens to exist on both sides of
the body. The buttocks are prominent and the lower limbs are small.
(For illustration see last page.)

THE KNEE-JOINT

The bones forming the knee-joint are the femur, tibia, and patella ;
their articular surfaces are enclosed in a capsule which is greatly
strengthened by fibrous expansions from the crureus and vasti, and
from the hamstring tendons.

The anterior ligament, or the ligamentum patellae, is the tendon of
insertion of the quadriceps.

The posterior ligament descends from above the condyles of the
femur to the back of the head of the tibia, and derives a strong acces-
sion from part of the insertion of the semi-membranosus. The popli-
teal vessels rest upon the posterior ligament.

The lateral ligaments, descending from the tuberosities of the
condyles, are placed behind the vertical axis of the knee, so as to
check over-extension. The inner band is wide, and descends several
inches down the hinder border of the tibial shaft. The outer passes to
the head of the fibula, over the tendon of the popliteus ; its upper end
may be felt beneath the skin, just in front of the tendon of the biceps,
the knee being slightly bent.

The crucial ligaments cross each other obliquely, and, becoming
locked together, specially check inward rotation of the leg. When,
in an old case of knee-disease, the surgeon is able to rotate the ex-
tended leg inwards, he knows that these ligaments are deeply impli-
cated, if not destroyed.

Synovial Membrane of Knee 473

The inter-articular fibro -cartilages are attached by their
cornua in front of, and behind the tibial spine, and their convex borders
are connected with the margin of the tuberosities of the tibia by short,
vertical fibres, which constitute the coronary ligament. The in-
ternal semilunar cartilage is firmly connected with the internal lateral
ligament, but the outer disc is separated from the external lateral liga-
ment by the tendon of origin of the popliteus which lies in a groove
upon it. The inner cartilage is, therefore, far less movable than the
outer ; still, if one of the discs become loosened and interfere with
the working of the joint, it is most likely the inner. I cannot explain
this paradox, except on the theory that the outer one is so movable
that it escapes injury from a wrench
which loosens the inner. Both sur-
faces of the semilunar cartilages are
covered with synovial membrane.

The synovial membrane, the
largest in the body, lines the capsule,
and, having ascended as a pouch for
about the width of four ringers, be-
neath the quadriceps, turns down over
the front of the femur. It forms also
shallow pouches on either side of the
patella and its ligament, and sends
a collar round the tendon of the pop-
liteus as it passes out of the joint.
A cushion of fat intervenes between
the ligamentum patella? and the mem-
brane which, in that region, sends a
pouch on to the crucial ligaments
(ligamentum mucosum) ; the free
borders of this pouch are the liga-
menta alaria. In the neighbourhood
of the crucial ligaments the membrane
has rudimentary fringes. When the
knee is extended, the top of the syno-
vial pouch is drawn up by the sub-
crureus working in harmony with the
crureus. This part of the cavity is apt
to communicate with a bursa higher
up the shaft of femur under the quad-
riceps ; that bursa may suppurate
without the membrane of the knee
being implicated.

It is sometimes remarked that, because the synovial pouch ascends
higher under the crureus when the knee is extended, one ought to keep
the limb bent in operating upon the front of the femur near the joint.

Vertical section of knee of young sub-
ject. (After THOMSON, from QUAIN.)
i, i, synovial membrane ; 2, lig.
mucosum ; 3, lig. patellae with, 4,
bursa behind it ; 5 and 6, crucial ligts.
Bursae are also shown in front of
tubercle of tibia, in front of patella,
and beneath crureus (z>. p. 478).

4^4 The Knee-joint

As a matter of fact, however, the limb has to be straight ; for when it is
flexed the patella is tightly dragged down below the condyles and the
quadriceps is so tense that it is impossible to work beneath it. The
cushion of fat behind the ligamentum patellae is made very apparent
when the knee is extended ; it is apt to be mistaken for abscess when
attention is directed to it in the case of knee-disease, so soft and
'fluctuating' does it seem to be.

The outline of the membrane may be traced upon the skin by
making a crescentic mark across the thigh, convex upwards, three inches
above the patella, with its horns descending in front of the femoral
tuberosities, and by then making a transverse line just above the apex
of the patella. The latter mark shows the lower limit of the membrane,
which does not cover the patella in its whole extent, but slopes from
it down to the front of the tibial head. The line is then to be kept close
along the top of the tibia and to skirt the femoral condyles below
the tuberosities (to which the lateral ligaments are attached). Having
crept through to the back of the articulation, the membrane ascends to
line the posterior ligament, and to cover the back of the condyles.

Synovitis causes effusion into the joint, and if the effusion be
rapid, the sensory nerves are suddenly stretched, great pain resulting.
The tension of the capsule is then extreme. But if the effusion be
gradual, as happens in chronic synovitis, there may be little pain, even
though the joint contain several ounces of fluid, and bulge high above
the patella, as the stretching of the nerves is slow and easy. At the
sides, where the lateral ligaments strengthen the capsule and prevent
it yielding, there is no bulging. Fluid collecting between the trochlear
surface and the patella floats the patella off that surface, and the knee
is slightly bent, as in that position there is more room for the fluid in
the articulation.

In effusion into the joint the fluid is obviously behind the patella,
whilst in effusion into the bursa patellae the fluid is in front of the bone,
obscuring, or even hiding, it.

When the knee is distended with fluid there is a bulging above
and at the sides of the knee-cap, under the quadriceps, and on either
side of the ligamentum patellae. As the patella is actually in the sub-
stance of the capsule, when the latter becomes distended the knee-cap
is carried forward or 'floated' from the trochlear surface, which it can
be made to touch by being thrust back through the fluid. By grasping
the front of the lower part of the thigh with the flat of the hand and
laying the fingers and thumb along the sides of the knee-cap, the fluid
may be made to bulge — even if only small in quantity — on either side
of the ligament ; and from this region it may be driven by pressure
with the other hand up again to the supra-patellar pouch, with a de-
finite fluctuation beneath the patella.

To open an abscess in the joint, a bold incision on one side, or on
both sides of the patella should be made ; if necessary, the incisions

Fracture of Patella 475

may be connected by another which traverses the ligamentum patellae.
Thus the patella is thrown up and the interior of the joint thoroughly
exposed. If further drainage yet be desired, an incision may be
made through the ligamentum posticum, and a drainage-tube passed
through the popliteal space between the popliteal vessels on the inner
side, and the external popliteal nerve and the biceps on the outer side.

If the articular abscess be not attacked it may burst through the
supra-patellar pouch, in which case the pus is extravasated not only
beneath the deep fascia but also beneath the quadriceps extensor.
Or, following the synovial sheath of the popliteus tendon, the
pus may escape into the floor of the popliteal space, and, guided
by the vessels, may find its way into the leg beneath the calf, or
upwards amongst the hamstring muscles. A favourite place for
articular abscess to point and break is (as the limb lies bent and
resting upon its outer side) along the outer edge of the patella or its
ligament. If it burst through the front of the lower part of the capsule
the pus will be extravasated over the front of either tibial tuberosity,
over the deep fascia, and between it and the superficial fascia of leg ;
thus the purulent extravasation is quite subcutaneous.

The patella is a sesamoid bone developed in the back of the
tendon of the quadriceps. Many tough fibres descend over the front
of the bone, whilst the posterior surface, covered by cartilage, arti-
culates directly with the condyles of the femur, without the interven-
tion of a synovial fold. The small bone does not touch the tibia,
but it is connected with its spine (p. 473) by the ligamentum patellce, a
strong band which is, virtually, the tendon of insertion of the quadri-
ceps; behind it there is a padding of fat. When the limb is loosely
extended the patella is freely movable, but when the joint is flexed
the quadriceps and its tendon are stretched, and the bone is firmly
imbedded in the depths of the trochlear groove, where it acts as a
shield to what would otherwise be an unprotected part of the articu-
lation.

Practure of the patella, which is almost invariably
the result of muscular violence, occurs when the knee is
partially bent, for then the bone is supported only across
its equator, on the trochlear surface of the femur. The
apex being firmly fixed by the strong ligament (as in
walking upstairs), and the quadriceps contracting with
great vigour, the bone is broken across, and necessarily
into the joint.

When anyone wishes to break a tolerably thick stick,
he puts it across his knee and suddenly pulls the ends
backwards ; transverse fracture of patella occurs in a very
similar manner, except that the force acts at the upper
end only, the other end being fixed. In the following scheme, from
' Lonsdale on Fractures,' B represents the patella supported at its

476 The Knee-joint

equator ; C, the ligament firmly holding it below, and A, the quadriceps
acting on it from above.

The quadriceps, continuing its action, then draws the upper
fragment of the bone from the lower ; the
lower does not move, being firmly fixed by the
ligament. The front of the capsule of the
joint is often much torn, and then, of course,
the separation of the fragments is wide. But
sometimes the force is only just sufficient to
break the bone, not to tear through the an-
terior expansion from the quadriceps, and
then it is very easy to overlook the lesion and
to diagnose merely a * sprain.' In every case
of obscure injury to the knee, the surgeon
should catch hold of the upper and lower
halves of the patella with his two hands, and
try if he can move one inwards and the other
outwards at the same time.

When the separation of the fragments is wide, the skin may be
pushed in between them till the fingers make out clearly the articular
part of the condyles of the femur. As the synovial membrane, the
bone, and the periosteum are all torn, blood, serum, and synovia are
quickly effused, and the knee is greatly swollen. This fluid has to be
aspirated before the fragments can be brought into apposition. The
knee is to be kept straight on a splint, so as to relax the* quadriceps,
and the limb is raised to remove all possible strain from the rcctus
femoris, which, coming from the pelvis, may possibly be dragging on
the upper fragment. The upper fragment is then to be coaxed down
towards the lower, and there steadied. Probably the fracture will be
repaired by ligament only, not by bone, for the reasons given on
page 464.

Suturing the approximated fragments with wire is a method of
treatment introduced by Sir Joseph Lister, as suitable for old-standing
and recent cases of transverse fracture. But though that eminent
surgeon showed several patients who had been thus successfully
treated, the operation, with its attendant risks, has not been generally
adopted in the case of recent fracture. In old cases, however, with
widely separated fragments, and a comparatively useless limb, the
joint may be opened and the edges of the bone freshened and approxi-
mated with a good chance of obtaining bony union, and, due care
being taken, the risks of the operation may well be run.

Even when the joint is opened, it may be necessary to divide the
tendon of the rectus femoris before the upper fragment can be brought
to the level of the lower fragment, which is immovably fixed by the
ligamentum patellae.

Dislocation of the patella is generally outwards, and the accident

Threefold Displacement of Tibia

477

is specially apt to occur in a knock-kneed subject, as the rectus femoris

then inclines a good deal inwards in its descent to its insertion. And

when it contracts with vigour it drags the patella a

little outwards. An unusual amount of this outward

movement lodges the bone on the front of the external

condyle. Sudden flexion of the limb generally suffices

to reduce the displacement ; but, if not, the leg should

be straightened to the utmost, the thigh being flexed

so as to slacken the rectus, when the bone can usually

be slipped into its place.

A characteristic threefold displacement of bead
of tibia occurs in cases of advanced and neglected
knee-joint disease. — The limb rests on the outer side
with the knee bent, this being the most comfortable
position ; and, as the ligaments become softened, the
weight of the leg causes it to sink outwards, so the
inner femoral condyle projects more and more, and
the outer tibial tuberosity slides outwards from beneath
its condyle. The flexion of the joint continuing, and
the biceps, gastrocnemius, and the other posterior
muscles contracting at times with a spasmodic start,
the head of the tibia is steadily pulled into the pop-
liteal space. Lastly, the weight of leg and foot in this
flexed and everted position of the limb causes external
rotation of the tibia. Thus the threefold displacement
of the tibial head is outwards and backwards, with
some external rotation. If the disease subside, the
knee, even thus deformed, may be extremely service-
able. At any rate, forcible straightening will not
improve the shape ; to attempt it is to make the tibia
slide still further back, or to detach the femoral or
tibial epiphysis. If the deformity be extreme, ex-
cision may be needed before the limb can be made
straight and useful.

A foreign body in the joint may be a piece chipped from a femoral
condyle or a semilunar cartilage ; a pendulous bud detached from
the synovial membrane, or an organised blood-clot. The substance is
apt to become suddenly caught between the femur and tibia, and* to
lock the joint. The sensory nerves are stretched and pained, and the
injury is likely to set up an attack of synovitis. The joint must be
opened at the side and the material extracted ; but if the trouble be
due to a loose fibro-cartilage (the inner most likely), the periphery of
the crescentic disc must be firmly sutured to the capsule, so as to
prevent further slipping.

Supply. — Arteries for the knee-joint come from the external
circumflex, the anastomotica magna, the popliteal (five in number,

Fracture of patella ;
stretching of liga-
mentous union.
(HOLTHOUSE.)

478 The Knee-joint

p. 482), and anterior tibial. The nerves are branches of the obturator,
anterior crural, internal popliteal (three), and external popliteal (two).

Pains about the knee may be due to local troubles, such as
disease of the synovial membrane, the bones, the epiphyses, or the
bursae (p. 473). But it may be due to some distant cause, such as
disease of the spinal cord, or its membranes, or of the column (p. 210) ;
to pressure upon the trunk of the anterior crural, obturator, or sciatic
nerve ; or to reflex irritation, caused by disease of the sacro-iliac or
hip-joint.

Bursae in the neighbourhood of knee-joint. — There is a large
one between the patella and the skin, and a small one between the
tubercle of the tibia and the skin. Either of these may become in-
flamed by continued pressure, the disease constituting housemaid's
knee. When the bursal inflammation is acute, the surrounding parts
are swollen, red, and hot, and the case looks like one of joint-disease.
In the latter case the swelling is behind the patella and its ligament,
whilst in bursal inflammation the effusion is in front of them. If sup-
puration occur the abscess should be promptly opened, lest the pus
find its way into the articulation. (See illustration on p. 473.)

A third bursa intervenes between the ligamentum patellae and the
upper part of the tubercle of the tibia. When acutely inflamed, this
bursa, bound down as it is, causes great pain, and bulges on either
side of the ligament. There is a bursa beneath each head of the
gastrocnemius ; that beneath the inner head often communicates with
the interior of the knee-joint, and also with another bursa which sepa-
rates the tendon of the semi-membranosus from the head of the tibia.
There are other bursaa between the internal lateral ligament and the
tendons of the sartorius, gracilis, and semitendinosus, and between the
external ligament and tendon of biceps. Lastly, there is the subcrureus
bursa, to which reference has already been made.

The superior-tibio fibular membrane may communicate with that
of the knee-joint.

The bursa under the inner head of the gastrocnemius and the in-
sertion of the semi-membranpsus is often full of fluid. When the knee
is extended the tendons are tightened and the tumour is made hard
and tense ; when it is flexed the outline of the tumour becomes less
definite. Sometimes fluctuation may be readily obtained between the
contents of this tumour and the over-abundant synovial fluid in the
joint. If the tumour be carelessly opened, septic inflammation spread-
ing from it may involve the knee-joint in acute disease.

The relative position of structures around the knee. — In front
the joint is almost subcutaneous. Behind are the popliteal vessels and
the internal popliteal nerve ; and on either side of them are the heads
of the gastrocnemius (the plantaris being with the outer), the semi-
tendinosus and membranosus, the biceps, and the external popliteal
nerve. Internally are the gracilis and sartorius, the internal saphenous

Knock-Knee 479

nerve, the superficial part of the anastomotica magna, and .the long
saphenous vein. (The origin of the poplitetis is within the joint.)

Knock-knee. — In the erect posture the tibiag are vertical, with
their heads close together ; but the heads of the femora are separated by
the width of the pelvis. The wider the pelvis the greater the separa-
tion of the femora above, and the greater the inward slant of the bones
to the knee. All of us, then, are a little ' in-kneed,' and women parti-
cularly so. So that the lower surfaces of the condyles may be on the
same level, the inner condyle must be the longer. Nevertheless, it is
not so prominent anteriorly as is the outer (p. 449). In a weakly, rickety
subject the internal lateral ligament is apt to stretch, over-growth of
the internal condyle consequently taking place, for some of the pressure
of the tibia against it is lost. Eventually the deformity becomes per-
manent.1

As the rectus femoris follows the axis of the femur, whilst the liga-
mentum patellae follows that of the tibia, when the muscle contracts it
is apt to drag the knee-cap over the external condyle ; outward dis-
location would happen still more often were it not for the presence of
that prominent flange limiting the trochlear surface externally.

In estimating- the amount of knock-knee the joint must be
completely extended, so that the lateral ligaments may be tightened
and the tibia firmly locked on the femur, for when these ligaments are
at all slack a little lateral and rotatory movement is enough to efface
the defect.

Operation for knock-knee has to be performed when gentler
methods cannot avail. In a young child forcible straightening often
succeeds without any cutting. In this operation the knee must be
first extended to the utmost so as to prevent rotation of the tibia as
the surgeon exerts his strength. It is not known exactly what occurs
in this process : perhaps the external lateral ligament yields a little ;
perhaps the inner femoral condyle undergoes some condensation ;
perhaps the epiphysis is slightly separated from the diaphysis on the
outer side. It is, however, a satisfactory procedure.

Ogston sliced off the inner condyle of the femur, and then, by
bringing the leg straight, shifted the loosened condyle upwards until
the lower surfaces of the condyles were on the same level. One great
disadvantage of this original operation was that, the knee-joint being
implicated, suppuration or stiffness was apt to ensue.

To obviate this risk, MacEwen partially divides the shaft of the
femur above the internal condyle, and completes the operation by
forcible fracture. He draws a transverse line a finger's breadth above
the external condyle, and a vertical one half an inch in front of the tendon
of the adductor magnus. At the meeting of these lines he makes
a small vertical incision on to the femur and introduces his osteotome,
which he then turns across the length of the femur, cutting the bone

1 For 'Anatomy of genu valgum ' see Journal of Anat. and Phys. 1879.

480 The Knee-joint

from the inner and back part. In this operation there is risk of
wounding the anastomotica magna, the superior or internal articular,
or even the popliteal artery itself. The articular artery, however,
ought to be well below the track of the osteotome, and the anastomo-
tica, running down close in front of tendon of the adductor magnus,
should be behind it.

The popliteus arises inside the capsule of the joint by a round
tendon from the front of a groove on the outer condyle of the femur.

The tendon passes between the external semilunar cartilage, which
it grooves, and the external lateral ligament. As it escapes beneath
the outer part of the posterior ligament it is enclosed in a prolongation
from the synovial membrane of the joint. It then spreads into a tri-
angular fleshy layer, which is inserted above the oblique line of the tibia.

The insertion is covered by an expansion from the attachment of
the semi-membranosus, and has resting on it the popliteal vessels, the
internal popliteal nerve, and the heads of the gastrocnemius. Its nerve
(from the internal popliteal) turns round its lower border to supply it
on the anterior surface.

Excision of the knee-joint is performed by making a deep, cres-
centic cut — convex downwards — from one tuberosity of the femur,
through the ligamentum patellae to the other tuberosity, and turning
up the flap of the quadriceps with the sesamoid bone in it ; for, unless
this bone is extensively diseased, it had better be left. The lateral and
crucial ligaments being divided, and the end of the femur cleared, the
knee is well bent, and the condyles are sawn off by directing the saw
vertically -to the head of tibia ; thus the risk of wounding the popliteal
artery is inconsiderable. As little as possible should be removed, so
that the line of the junction-cartilage may not be approached, or at
least implicated.

The head of the tibia is then thrust out of the wound and sliced off,
and the sawn surface adjusted and fixed ; but its sharp edge must not
be allowed to fall back on to the popliteal artery, or secondary
haemorrhage may occur, amputation being then needed. Provision
may be made for the free escaps of discharges through the cornua of
the incision, or by bringing a tube through the posterior ligament
the joint and out through the skin, passing it between the poplite
vessels and the external popliteal nerve.

THE POPLITEAL SPACE

The popliteal space is bounded above by the diverging
strings and below by the converging heads of the gastrocnemius.
It is covered in by skin and superficial fascia, and by the fascia lata.
The floor is formed by the lower fourth of the femur, the posterior
ligament of the knee-joint, and the upper sixth of the tibia, with the
popliteus.

Popliteal Space 481

In the superficial fascia ascends the external saphenous vein,

which, beginning in an arch on the dorsum of the foot, in communica-
tion with the internal or long saphenous vein, passes behind the
external milleolus, and be;ween the bellies of the gas'.rocneinius, to
pierce the fascia lata at the middle of the space. Like the long vein, it
receives tributaries just before traversing the deep fascia ; these are
cutaneous branches descending from the back of the thigh. Sometimes
when a tumour presses upon the popliteal or superficial femoral vein
these descending branches are engorged and dilated. There is a
communication between the vena? comites of the posterior tibial artery
and the external saphenous vein near the ankle, and a branch on the
thigh again links the two saphenous veins. The short saphenous nerve
accompanies the external saphenous vein between the bellies of the
gastrocnemius.

The cutaneous nerves of the space are branches of the small
sciatic.

In the undissected limb the space is small, as the muscles which
bound it closely overlap the artery. Thus, superficially, on the outer
side, are the biceps, the outer head of the gastrocnemius, and the
plantaris ; and on the inner side are the semi-membranosus and the
other head of the gastrocnemius.

The deep fascia is a continuation of the fascia lata, and it receives
slips from the hamstring tendons. Its density prevents digital explora-
tion of the depths of the space unless it be first slackened by bending
the knee.

Close on the inner side of the tendon of the biceps runs the external
popliteal nerve ; the internal popliteal nerve descends in the middle
line.

The popliteal artery enters the top of the space with the popliteal
vein. The fact of these vessels coming through the opening in ih)
adductor magnus, at the lower end of Hunter's canal, on the inner
side of the shaft of the femur, suffices to place them well on the inner
side at the top of the space. And, inasmuch as they are coming from
the front of the thigh, they are very deeply placed on their entrance
into the ham. Now, as the internal popliteal nerve is coming boldly
down the back of the thigh into the middle of the space, it necessarily
lies at first considerably external and superficial to the popliteal vessels.

The relative position of the vein and artery at the top of the
space is the same as (p. 454) in Hunter's canal— which actually ends
at the top of the space ; the vein is on the outer side of the artery,
and they are both resting upon the femur.

The passage from the crural to the sural (sura, calf) part of the
ham is the notch between the condyles of the femur, and it is far too
narrow to allow the nerve, the vein, and the artery to go through
abreast ; they are arranged, therefore, in single file, the vessels sti'l
being deeper than the nerve. In their preparation for the passage

I I

432 The Pop! it c.i I Space

the vein gradually mounts on to the artery ; and so, behind the plane
of the joint, the nerve is nearest the skin, the artery is upon the pos-
terior ligament, and the vein is lx-t ween the two.

Having emerged from the intercondylar pass, the three structures
spread out again, so that, as they rest upon the popliteus, the vein
has dismounted from the artery on to its inner side, whilst the nerve
is still more internal. At the lower border of the popliteus the artery
divides into the anterior and posterior tibials, and the nerve changes
its name to posterior tibial.

Xiigation of the popliteal artery is rarely performed, first be-
cause of the extreme depth of the vessel in the space, and secondly
because of an intimate fibrous adhesion which connects it with the
vein. It is, therefore, resorted to only in the case of a wound of the
artery, in every other case ligation of the superficial femoral being the
preferable operation.

The popliteal artery can, however, be reached without much diffi-
culty from the inner side, by a three-inch incision along the gap which
can be made out by the fingers just in front of the semi-membranosus
and gracilis, and behind the vastus internus and the tendon of the
adductor magnus.

The internal saphenous vein must be avoided, and, the fascia lata
having been divided on a director, and the sartorius having been
recognised and drawn backwards with the tendon of the gracilis, the
rigid tendon of the adductor magnus with the fleshy fibres of the
vastus internus are seen. The long saphenous nerve may also be
seen sloping backwards under the sartorius. The artery is looked
for by working towards the back of the femur with the forceps and
director. (The sartorius being to the inner side of the artery, the vein
is, of course, to the outer side.)

Branches of the popliteal artery.— Superior muscular, to the
hamstrings and the adductor magnus, which anastomose with the
ending of the deep femoral, with other perforating branches, and with
the comes nervi ischiatici. Inferior muscular (sural) to the muscles
of the calf. Five articular branches, each of which runs under or
through some important fibrous structure. The superior inferno/
articular winds under the tendon of the adductor magnus, to join the
•inastomotica magna, the superior external, and also the inferior
internal articular. The last-named branch passes under the internal
lateral ligament, in the groove below the head of the tibia, and anasto-
moses with the superior external articular, which passes under the
tendon of the biceps, and joins the descending branches of th< ex-
ternal circumflex, the anastomotica magna, and the superior internal
irticular.

The inferior external articular passes above the head of the fibu'a,
under the tendon of the biceps and the external lateral ligament. It
anastomoses with the inferior internal, and the superior external

Popliteal Aneurysm 483

articular branches, and with the anterior tibial recurrent. Each
inferior aiticular artery lies beneath a head of the gastrocnemius.
Toe central articular, or azygos, pierces the ligamentum posticum.

As their names imply, all these rive arteries are for the nutrition of
the articulation.

The popliteal vein begins at the lower border of the popliteus,
by the confluence of the venae comites of the anterior and posterior
tibial arteries, and possibly also of those of the peroneal artery. At
its commencement it is to the inner side of the artery, but as it as-
cends between the heads of the gastrocnemius, and between the con-
clyles of the femur, it lies superficial to, that is behind, the artery, and
in the upper part of the space it is to its outer side. Its tributaries are
the five articular, the external saphenous vein, and muscular branches
• — sural and crural.

The popliteal lymphatic glands, four or five in number, are
lodged in the loose connective tissue in the depths of the space, one
of them being generally placed upon the artery, which thus, when in-
flamed and enlarged, constitutes a pulsating tumour in the ham and
may be mistaken for an aneurysm.

The popliteal glands receive their lymph from the back of the leg,
he outer side of the foot, and from the lower part of the back of the
thigh. (Superficial lymphatic vessels usually run with the neighbouring
superficial veins.)

For the course and branches of the internal and external popli-
teal nerves see pp. 380 and 381, and for the obturator nerve in the
space see p. 359.

Aneurysm of the popliteal artery is of common occurrence, for,
as the artery is just behind the joint, it is constantly being bent and
straightened ; and, with arterial disease, a sudden and violent move-
ment of the knee is apt to crack the inner coats. The outer coat is
then dilated, and a pulsating tumour occurs in the ham ; this is best
examined when the patient is prone and the knee flexed, as the fascia
lata is then slackened and the depths of the space are rendered acces-
sible to the fingers. An enlarged lymphatic gland over the artery
would also give rise to a pulsating tumour, which, like aneurysm, would
be less prominent and would cease to pulsate, when the common
femoral was compressed, but it would not give that lateral impulse
which characterises aneurysm.

The aneurysm may compress the vein, and so cause congestion,
varix, and oedema of foot and leg, or even gangrene. Pressing upon
the internal popliteal nerve, it may set up peripheral pains and numb-
ness, and local insensibility. Causing stiffness of the knee, it is r.pt
to be taken at first for ' rheumatism.' Finally it may burst into the
joint, distending it with blood ; or its contents may be extravasated
from the popliteal space into the back of the thigh and leg. When
the artery bursts, pulsation ceases at the knee and in the posterior

i i 2

484 The Popliteal Space

tibial and dorsalis pedis arteries. Coldness and gangrene quickly
supervene, and amputation above the knee has to be resorted to.

The most certain method of treatment consists in ligation of the
femoral artery at the apex of Scarpa's triangle ; compression of the
common femoral and forcible flexion of the knee sometimes prove
successful. But, when an aneurysm is large and its walls are likely to
yield, the femoral must be tied at once.

Popliteal abscess may begin in one of the lymphatic glands, or
in the connective tissue of the space, and the pus may eventually find
its way into the joint, or amongst the muscles of the back of the thigh
or leg. The strength of the fascia lata delays its spontaneous escape
to the surface of the limb.

The abscess should be evacuated by incising the skin, super-
ficial and deep fasciae, in the groove between the ilio-tibial band and
the bicipital tendon, the director and dressing-forceps being used for
the deep part of the exploration. The lower end of the femur and the
depths of the space are readily accessible in this way, and without
risk of damaging important structures. The track being made in
front of the external popliteal nerve, all that the surgeon has to guard
against wounding is the superior external articular artery.

Sinuses left after the evacuation of an abscess may refuse to heal
unless the limb is kept in absolute rest in a splint ; and it may be well
to have the knee gently flexed.

In amputation at the knee-joint the long anterior flap, being
but poorly supplied with blood, is apt to slough. The mass of
condyles needs a very large flap. This flap is made by an incision
extending from one tuberosity of the femur down over the tubercle of
the tibia, and up to the other femoral tuberosity. The joint is opened
through the ligamentum patellae ; the lateral and crucial ligaments
are divided, and the knife is passed through to the back of the joint,
and, cutting downwards and backwards, severs the popliteus, the pop-
liteal vessels and nerves, the hamstring tendons, gastrocnemius, and
plantaris. As it descends behind the tibia and fibula, it detaches a
short posterior flap.

carden did a sort of 'Syme' (p. 499) at the joint, shaping the
ordinary oval, anterior flap, removing the patella, and cutting straight
back, making no posterior flap ; he removed the condyles just as Syme
sliced off the malleoli in the case of amputation at the ankle.

Gritti's is on the principle of a ' Pirogoff ' (500) ; it is much like
Garden's, but instead of the patella being removed, a slice is taken
from its articular cartilage, and the denuded surface is then turned
under the sawn end of the femur.

An excellent amputation at the knee is by lateral flaps, the scar
being eventually drawn up out of the vay of pressure, behind and
between the -xmdyles.

In the case of malignant disease in the leg it is safer to amputate

The ' Seat of Election ' 485

In the lower third of the thigh than through the joint, as all the lym-
phatic glands, which may possibly be invaded, are thus taken away,
and also the origins of the gastrocnemius, poplitcus, and plantaris,
and the bursas about the joint, any of which may be the seat of a
secondary and lurking malignancy.

Amputation at the ' seat ot election' was the favourite operation
years ago— before the days of Syme — in all cases demanding a sacri-
fice of the leg. The tibia was sawn just below the tubercle, and the
patient went about subsequently upon a kneeling-crutch, the cicatrix
being out of the way of all pressure. An improved and cheapened
system of artificial legs, and a greater conservatism in practice, have
now rendered the performance of this amputation of comparatively
infrequent occurrence, and the quaint title almost obsolete. The
surgeon now ' elects ' the amputation which involves the least mutila-
tion of the limb.

Method of operation at the seat of election. — With the left thumb
and index-finger the operator marks two spots on the sides of the
leg, two inches below the level of the tubercle, and from them he
shapes out liberal convex flaps of skin in front and behind. The
muscles are divided straight down to the bones ; the fibula is sawn,
and then the tibia, a piece being removed from the sharp crest of
the latter bone. The arteries requiring ligation are the anterior and
posterior tibial, and possibly the peroneal — and some large sural
branches.

THE LEG

The deep fascia on the front of the leg is thick, and gives origin
to the tibialis anticus, extensor longus digitorum, and peroneus tertius.
It is attached to the crest of the tibia, and follows the curve of the
external tuberosity on to the head of the fibula. Down the latter bone
it is attached indirectly by the septa which dip on either side of th'j
peroneus longus and brevis. Below it is attached to the malleoli,
forming the anterior annular ligament. The upper part of this
ligament is a horizontal band which binds down the extensor tendons
of the toes and the peroneus tertius. In addition, the tendon of the
tibialis anticus passes beneath it, invested in a synovial sheath. Just
below the bend of the ankle there is another, a vertical piece of the
annular ligament, under which three synovial sheaths descend, namely,
the one already mentioned, around the tibial tendon, a second invest-
ing the great toe extensor, and a third for the long extensor of the toes
and the peroneus tertius. This lower part of the annular ligament is
attached to the inner malleolus above, and to the front of the os calcis
below.

Beneath these ligaments pass also the anterior tibial vessels and
nerve, under cover of the extensor proprius hallucis, or, lower do\\n,

486

77/6' Leg

EX.L.D

between this tendon and that of the extensor longus digitorum, the
n^rve being to the outer side of the artery and its vcmc comitcs.

When effusion — the result of a sprain
or of gout, for instance takes place into
the synovial sheaths of the tendons about
the ankle, the outline of the tendons is
somewhat obscured, and flexion and ex-
tension of the foot are accompanied by
painful and strange creakings or crack-
lings in the sheaths.

At the back of the leg: the deep
fascia is continuous with the fascia lata
of the thigh, and receives some strengthen-
ing slips from the biceps, sartorius, grari-
lis, and semi-tendinosus. Over the ham,
where it is very strong, it is pierced by the
short saphenous vein. Lower down, it is
continuous with the sheet which covers
the peroneus longus and brevis, and it is
attached between them, and the solcus

Synovial sheaths^fronyf ankle. and flexQr longus hallucis, to the fibula.

Internally it is attached to the posterior

border of the tibia. It binds down the calf muscles. Another lay* r
of deep fascia, as remarked elsewhere (p. 490), passes across beneath
the soleus, binding down the tibialis posticus and the flexors longus
digitorum and proprius hallucis, covering also the posterior tibial
vessels and nerve.

Towards the inner ankle these two layers of deep fascia blend to
form the internal annular ligament, and are then lost in the deep
plantar fascia. This annular ligament passes from the inner malleolus
to the adjacent part of the os calcis, and binds down the structure*
behind the inner ankle. Most internally is the sheath for the tendon
of the tibialis posticus, which, like that of the tibialis anticus, has a
synovial investment of its own. Close to the outer side of this is another
compartment for the tendon of the flexor longus digitorum, with its
own synovial investment. Then comes a wide passage for the posterior
tibial artery with a vena comes on either side, and, a little farther out,
is the posterior tibial nerve. More externally still is the tunnel for the
tendon of the flexor proprius hallucis, with its synovial sheath.

The external annular litrament passes from the tip of the external
malleolus to the outer side of the os calcis, and binds down the ten-
dons of the peroneus longus and brevis and their common synovia]
sheath, the shorter tendon being anterior. The longer tendon is apt
to slip from its position and thereby to cause lameness and pain on
walking ; this accident may also happen to the tendon of the tibialis
posticus as it winds behind the inner malleolus.

Tendon of AcJiilles

487

The g-asfrocnemiiis arises from the condyles of the femur, and
spreads out into two bellies, of which the inner is the larger ; it is
inserted with the subjacent soleus into the tendo Achillis. The short
saphenous vein courses up between the bellies, separated from them
by the deep fascia. (For bursce, see p. 478.)

The soleus arises from the back of the head and the upper part of
the fibula, and from a tendinous arch over the ending of the popliteal
artery which carries it to the oblique line of the tibia, along which
it also arises, and down the middle third of the posterior border of
the tibia. The muscle lies beneath the gastrocnemius (the opposed
surfaces being aponeurotic) and joins with it in the formation of the
tendo Acnillis. This tendon is inserted into the lower part of the
posterior surface of the os calcis, a bursa intervening between it and
the upper part of that surface. It is most slender at about an inch
above the heel. The soleus covers the deep layer of muscles, the
posterior tibial vessels and nerve, and the peroneal vessels, all of
which are separated from the soleus by the second layer of deep
fascia.

The gastrocnemius flexes the knee, and, acting with the soleus,
extends the foot. The two muscles are supplied by the sural branches
of the internal popliteal nerve.

Achilies-tt- notomy.— The tendon may require section in talipes
equinus, in fracture of the tibia when there is difficulty in adjusting
the fractured surfaces, or in keep-
ing them in apposition, and after
subcutaneous osteotomy of a
bowed leg. For the operation,
the foot is flexed, so as to tighten
the tendon, and the slender knife
is introduced beneath its deep
surface. If the knife be directed
from the skin-surface of the ten-
don, there is a risk of dividing
the posterior tibial artery, and
especially so when the operation
is being done for talipes, as in
that case the tendon lies very
close behind the artery.

Rupture of the tendon may
occur with a sudden and painful
snap from muscular action, the
patient thinking that someone
has hit him above the heel. It
is treated by bending the knee
and extending the foot, the limb being kept in that position by a strap
which runs from a loop in the heel of a slipper to the back of a collar

488 The Leg

•which is fast2:ied above the knee. In certain cases of paralytic talipes
calcaneus a piece is cut out of the tendon, and the ends are spliced
together.

The flexor long-us hailucis is a large and very powerful muscle
arising from the lower two-thirds of the back of the fibula. Its tendon
passes over the tibia, to the outer side of the posterior tibial vessels
and nerve, and behind the ankle-joint ; it then grooves the back of the
astragalus, anc1, passing under the sustentaculum tali, runs between
the two heads of the flexor brevis hailucis to be inserted into the
lingual phalanx. To the outer side of the muscle are the fibula and
the soleus, to the inner side are the long flexor of the toes, the tibialis
posticus, and the posterior tibial vessels and nerve ; in its substance is
the peroneal artery. In the sole the tendon is united with that of the
flexor longus digitorum by a strong slip.

The flexor longus digitorum arises from the tibia below the
soleus. Its tendon lies in the groove behind the inner malleolus, with
that of the tibialis posticus, but in a separate synovia! sheath ;
and, passing through the sole, where it receives a slip from the tendon
of the long flexor of the great toe, it divides into four tendons which
are inserted into the ungual phalanges of the four outer toes. These
tendons perforate those of the flexor brevis digitorum. The posterior
tibial vessels and nerves rest upon the long flexor.

Tenotomy of the flexor longus is sometimes required in extreme
talpes equino-varus ; the tendon is then divided, together with that of
the tibialis posticus, by a wound made a little above the inner malleolus,
or, preferably, by an open incision nearer the sole of the foot. In the
former case, should the posterior tibial artery be accidentally punctured
or divided, the bleeding may be arrested by bandaging a firm pad over
the inner ankle, so as to compress the artery against the posterior
surface of the tibia. It is rarely necessary to enlarge the wound and
tie the vessel.

The tibialis i ostictn arises from the bick of the interosseous
membrane and from the adjacent surfaces of the tibia and fibula. The
tendon passes inwards on the tibial aspect of that of the flexor longus
digitorum, and rather to its inner side, and, running with that tendon
beneath the head of the astragalus, is inserted into the scaphoid and
internal cuneiform bones. It also sends back a slip to the sustentaculum
tali, and other slips to the outer cuneiform bones, the cuboid, and tin-
bases of the middle metatarsal bones. Thus it is an important struct ire
in supporting the transverse as well as the antero-posterior arch of the foo' .

The muscle is covered by the flexor longus digitorum on the inner,
and by the flexor longus hailucis on the outer side ; on it rest the
beginnings of the posterior tibial and the peroneal arteries, and the
posterior tibial nerve. At the ankle its tendon is the innermost, lying
in the same groove with that of the flexor longus digitorum, but in a.
separate synovial sheath.

Posterior Tibial Artery 489

Division of its tendon may be performed above the malleolus by
a puncture made close behind the posterior border of the tibia, which
is exactly halfway between the anterior and posterior aspects of the
limb ; or in the hollow between the tip of the malleolus and the tube-
rosity of the scaphoid. The latter is the better site for its division,
as there the tendon is quite subcutaneous, and out of the way of the
posterior tibial artery. But it is equally convenient for the surgeon to
divide it deep in the sole, by the same wound by which he cuts every
other fibrous structure which hinders his straightening the deformed
foot.

The three muscles of the deep layer of the back of the leg are
supplied by the posterior tibial nerve. They all extend the foot ;
two of them also flex the toes, whilst the third inverts the foot.

The posterior tibial artery is one of the trunks coming from the
bifurcation of the popliteal, at the lower border of the popliteus, the
other being the anterior tibial (p. 492). It divides under cover of the
abductor hallucis into the two plantars.

Its course may be marked by a line which begins about an inch
below the lower part of the ham, and ends in the mid-space between
the inner malleolus and the os calcis.

Relation s. — At its origin, and for an inch or two down, it rests on
the tibialis posticus, then on the flexor longus digitorum, and afterwards,
as the muscles narrow into tendons, and the tibia expands, it lies
upon the bone, and finally upon the posterior ligament of the ankle-
joint.

Posterior to it are the skin, superficial and deep fascia, the gastro-
cnemius and soleus ; the sub-soleus fascia (that is the second layer
of deep fascia) ; and the posterior tibial nerve, which crosses the artery
two or three inches below its origin.

70 the injter side are the tibial origin of the soleus, the first few
inches of the posterior tibial nerve, and, near the ankle, the tendons of
the tibialis posticus and flexor longus digitorum.

To the outer side is the fibular origin of the soleus, the flexor
longus hallucis, and, in the lower three-fourths of its course, the posterior
tibial nerve.

Venae comites, one on either side, join with each other by short
branches across the artery, and they ultimately flow into the popliteal
vein.

Xii?ation of the posterior tibial artery in the upper part of its
course is performed by bending the knee and extending the foot, so
as to slacken the deep fascia and the gastrocnemius, and by resting
the limb upon the fibular side. An incision of four inches is made
down the leg about a finger's breadth behind the posterior border of
the tibia, care being taken not to wound the long saphenous vein.
The deep fascia is then incised on a director, and the inner belly of the
gastrocnemius, if encountered, is turned outwards. The tibial origin of

4QO The Leg

the solcus, and that important second layer of deep fascia beneath it,
are divided in turn, and the artery is looked for at a considerable' dis-
tance outwards, where it lies upon the tibialis posticus or flexor longus
digitorum. The nerve is crossing it from the inner to the outer side,
so the needle had better be passed from the inner side.

A good deal of fibrous tissue may be met with on the deep aspect
of the soleus, which has to be traversed before that second layer of the
d«T|) fascia is seen. The division of the solcus should not be made too
close to the border of the tibia, or the operator will be apt to lose him-
self amongst the fibres arising from the periosteum ; thus he may
possibly detach the flexor longus digitorum from the tibia and work
outwards beneath it- -even into the substance of the tibialis posticus.

In the lower third of tne legr the artery may be tied by making
the incision midway between the inner border of the tendo Achillis
and the posterior border of the tibia, care being taken not to wound
the internal saphenous vein, which is, or ought to be, a good deal to the
front of the incision. Two layers of deep fascia again require division ;
the artery is found to the outer side of the tendons of the tibialis pos-
ticus and flexor longus digitorum, between its veins, the nerve being on
its outer side, as before. Still farther out is the tendon of the flexor
longus hallucis. The artery and its vena? comites, the nerve, and the
tendons are here spread out flat on the surface of the tibia. The needle
had better be passed from the outer side.

At the ankle the artery maybe reached through a two-inch in-
cision which curves round the inner malleolus, halfway between it and
the inner tuberosity of the os calcis. There is no fear of damaging the
internal saphenous vein. The layers of the deep fascia have here
joined to form the internal annular ligament, which has to be divided
on a director, when the artery is found laced in by fibres which form a
sort of sheath. It lies between its venae comites, with the large nerve
external to it. The needle had better be passed from the outer side.

Branches. — The peroneul is given off an inch below the border of
the popliteus ; resting at first on the tibialis posticus, it descends along
the inner border of the fibula, in the substance of the flexor longus
hillucis. It is covered, in addition, by the gastrocnemius, soleus, and
sub-soleus fascia. At about two inches above the ankle it divides into an
anterior and a posterior branch. The anterior peroneal reaches the front
of the leg through the interosseous membrane, and anastomoses with
the external malleolar and tarsal arteries. The posterior division
descends behind the outer ankle, and anastomoses with the branches
just enumerated, and also with the external plantar. Other branches
of the peroneal are muscular, nutrient to the fibula, and a transverse
communicating branch to join a similar vessel from the posterior
tibia!, which crosses about two inches above the ankle, under the flexor
s hallucis.

Irregularity. — Sometimes the peroneal is as large as the posterior

Artc:ies of Leg and Fact 491

tibial ks2lf, and it m iv practically take i';s place ; sometimes this large
artery passes through as the anterior psroneal to become the dorsalis
p^dis.

In addition to the p^roneal, the posterior tibial also gives off a
nulr'ent branch which runs downwards in the tibia ; tiiuscii lar branches ;
a communicating to join the corresponding branch from the peroneal,
and some infernal calcanean twigs which nourish the inner part of the
flap in Syme's amputation.

Collateral • ircuiation after ligation of the posterior tibial artery
below the origin of the peroneal would be carried on by numberless
muscular branches. Blood would also enter the empty trunk through
the communicating artery, and the other anastomoses frr m the pero-
neal ; through the plantar arch, and through other communications
with the anterior tibial and the dorsalis pedis.

Ligatio?i of the peroneal artery is required in the case of a punc-
tured wound, when the surgeon would have the track of the original
wound to guide him. Should he be called upon, however, to tie the
artery in its continuity, when there was no wound to guide him, he
had better make a four-inch incision between the bellies of the gastro-
cnemius, and, having traversed that muscle, the soleus, and the second
layer of deep fascia, secure the artery just previous to its entering the
long flexor of the great toe.

The internal plantar division of the posterior tibial artery runs
forward between the abductor hallucis and the flexor brevis digitorum,
and, arriving at the ball of the great toe as a small twig, ends by
anastomosing with the innermost digital branch. The internal
plantar is an unimportant trunk ; it takes no part in the formation of
the plantar arch.

The external plantar artery corner off from the bifurcation of
the posterior tibial, under cover of the abductor hallucis. It is a large
artery, and, having passed outwards between the flexors brevis and
accessorius, runs forwards between the former muscle and the abduc-
tor minimi digiti to the base of the fifth metatarsal bone. From that
situation it curves inwards across the metatarsal bones to the root of
the first interosseous space, where it joins the branch from the dorsalis
pedis to form the plantar arch. In this latter bend the artery lies
deeply beneath the long flexor tendons and the lumbricals.

The branches are calcanean, muscular, and cutaneous ; also three
posterior perforating, which mount through the roots of the three
outer interosseous spaces to join the interosseous branches of the
metatarsal artery, and four digital arteries, of which one runs along
the outer side of the little toe, whilst the others pass in the inter-
osseous spaces to divide at the three outer c'efts, to supply the toes,
and to inosculate by short anterior perforating branches with the end-
ings of the dorsal interosseous arteries. The innermost cleft, and the
inner side of the great toe, are supplied by the dorsalis pedis.

492 Anterior Tibial Artery

The tibialis anti jus .irises from the outer aspect of the tibia, the
deep fascia, and the interosseous membrane. It is inserted into the
internal cuneiform and the scaphoid bones. Its tendon has a syno-
vial sheath as it descends beneath the two bands of the annular liga-
ment. Its action is to flex and invert the foot ; its tendon often has
to be divided in talipes varus. The tenotomy is best performed just
below the front of the inner malleolus.

The extensor longus digltorurn arises from the outer tuberosity
of the tibia, the anterior surface of the fibula, and the deep fascia. Its
tendons are inserted into the second and third phalanges of the four
outer toes. The anterior tibial nerve comes through the upper end
of its origin. The peroneus terrius is continued from the lowest
part of this muscle, and is inserted into the dorsal surface of the base
of the fifth metatarsal bone.

The extensor prop.ius hallucfs (pollicis] arises from the middle
two-fifths of the front of the fibula, and from the interosseous mem-
brane ; it is inserted into the ungual phalanx of the great toe.

Course.— At first it lies on the outer side of the anterior tibial
artery, and to the inner side of the extensor longus digitorum between
that muscle and the tibialis anticus, and overlapped by them. It
then slowly crosses over the artery, and at the ankle its tendon lies to
the inner side of the artery.

The foregoing muscles are flexors of the foot ; they are supplied
by the anterior tibial nerve.

The peroneus longus and brevis arise down the outer side of the
fibula, the brevis being to the front of the longus and overlapped by
it. They lie between the extensor longus digitorum and the peroneus
tertius, to the front, and the soleus and flexor longus hallucis behind.
Their tendons groove the back of the external malleolus and the
outer side of the os calcis, the shorter tendon being above the peroneal
tubercle, and the longer below it. The shorter tendon is then inserted
into the outer side of the base of the fifth metatarsal bone, whilst the
longer runs forwards and inwards in the tunnel under the cuboid bone,
to be inserted into the tuberosity of the internal cuneiform and the
outer side of the base of the first metatarsal bone.

These two muscles, which are supplied by the musculo-cutaneous
nerve, extend and evert the foot, and in the case of extreme talipes
valgus their tendons require division behind the malleolus. The
external popliteal nerve divides in the substance of the longer muscle
just below the head of the fibula. The tendons have a common
synovial investment as they groove the malleolus.

The anterior tibial artery is one of the divisions of the popliteal.
It comes through the top of the interosseous membrane, and runs
clown thereon until it rests upon the front of the expanded, lower
end of the tibia. It afterwards lies upon the anterior ligament of the
ankle-joint, where it changes its name to dorsalis pedis.

Ligation of Anterior Tibial Artery 493

Its course is marked by a line from the inner side of the head of
the fibula to the middle of the front of the ankle.

Relations. — The artery is covered by skin, superficial and deep
fasciae, by the muscles between which it passes, and especially by the
extensor proprius hallucis, which, descending from the front of the
fibula to the great toe, crosses the artery a little above the ankle.
The anterior tibial nerve sometimes rests upon the artery.

On the inner side are the tibialis anticus, the tibia, and, near the
ankle, the tendon of the extensor proprius hal'ucis. On the outer side
are the extensor longus digitorum, the extensor proprius hallucis
(in the middle third of the leg), and the anterior tibial nerve.

Branches. — Recurrent, which ascends through the tibialis anticus
to the front of knee-joint, where it anastomoses with the lower arti-
cular branches of the popliteal, and perhaps with the anastomotica
magna. Muscular twigs, which, in addition, supply the skin. The
internal malleolar descends obliquely under the tendon of the
tibialis anticus, to anastomose near the inner ankle with twigs of the
posterior tibial (calcanean) and internal plantar. The external
malleolar passes beneath the tendons of the extensor longus digito-
rum and peroneus tertius to anastomose with the anterior peroneal,
and with tarsal branches of the dorsalis pedis. The supply of the
ankle-joint is partly derived from these branches.

A ligature may be applied in the upper or in the lower part of
the leg, but in the middle, where the great toe extensor is passing on
to, or is crossing over, the artery, it is obviously inconvenient to
attempt to secure the vessel.

X > the upper part of tha ley it is by no means easy to find the
vessel, on account of the depth at which it lies between the tibialis
anticus and the extensor longus digitorum. An incision having been
made through the skin and superficial fascia from the inner side of
the head of the fibula for three or four inches down the course of the
artery, the strong, deep fascia is exposed. Search is made for the
interval between the two muscles just mentioned. This is best
accomplished by working with the director, or handle of the scalpel,
in the lower part of the incision, where the space between the muscles
is commencing. Thus the muscles are parted from below upwards,
and are afterwards held asunder by spatulae. The finger may then
be passed upwards between the muscles, so as to make more room.
The artery is found on the interosseous membrane, with a com-
panion vein on either side. The anterior tibial nerve will probably be
seen coming through the origin of the long extensor of the toes, and
approaching the ou er side of the artery. The ligature, therefore,
may best be passed from the outer side.

Just abovj tn*^ ankle the vessel is expos 3d by an incision of
two inches and a half through the skin, superficial fascia, and deep
fascia. The deep fascia is here thickening into the anterior annular

494 Anterior Tibial Artery

ligament. The tibialis anticus tendon is well ti the inner side, and
that of the special extensor of the great toe, running along the artery
from its outer side, must be drawn outwards. The nerve is most
likely to the outer side, and from that side, therefore, the needle
should be passed, the artery having been isolated from its companion
veins. The great point in this operation is to keep close on the outer
side of th 2 tendon of the tibialis anticus, which is itself close to the
tibial crest.

The C'»Hater >l circulation after ligation of the anterior tibial
wjuld b2 c irried on through muscular and periosteal branches ; by
inosculations of its empty branches with branches of the anterior pero-
neal and the posterior tibial arteries through the malleolar, tarsal, and
metatarsal branches ; and by the junction of the communicating branch
of thedorsalis pedis with the external plantar in the plantar arch.

The extensor brevis digitorum appears as a firm elevation
through the thin skin on the outer side of the dorsum of the foot. It
arises from the front of the upper and outer part of the os calcis, and
from the anterior annular ligament. The innermost of its four ten-
dons is inserted independently into the base of the first phalanx of the
great toe, but the three other slips join with the three inner tendons
of the long extensor. Each of these conjoined tendons spreads out
and divides into three s'ips, of which the middle piece is inserted into
the base of the middle phalanx, whilst the lateral slips pass on to the
last phalanx.

Relations.- — The muscle is covered by a layer of deep "fascia, by
the peroneus tertius, and by the tendons of the extensor longus digi-
torum. It rests upon tarsal and metatarsal bones, the interosseous
muscles, and the outer, ganglionic, branch of the anterior tibial nerve,
which supplies the muscle as well as the tarsus. The dorsal artery
lies along its inner side, and the inner border of the muscle may just
overlap it. The innermost tendon crosses over the vessel in its
course to the first phalanx of the great toe. The innermost border of
the short extensor is the surgeon's guide to the artery.

The dorsalls pedis artery continues the anterior tibial from the
middle of the front of the ankle in the line which passes thence to the
cleft between, and the great and second toes. But, let it be well noted,
the dorsal artery itself does not reach this cleft ; a couple of inches
behind this, at the root of the first interosseous space, it divides into
the dorsalis Jiallucis and the communicating.

Relation*. — The artery rests upon the astragalus, scaphoid, and
internal cuneiform, and their dorsal ligaments. It is covered by \\\v
integument, superficial and deep fascia-, and by the innermost slip of
the extensor brevis digitorum. On the inner side is the special ex-
tensor of the great toe, and on the outer side are the long and short
extensors of the toes, and the anterior tibial nerve. On cither side is
a companion vein.

Ligation of Dor sal is Pedis 495

Xifg-ation of the dor alls pedis. — An incision of two inches is
made over the artery in the line running from the middle of the ankle
to the base of the first space, through the skin and the superficial
and deep fasciae. The tendon of the special extensor of the great toe
is not the guide to the artery, which is running at some distance on its
outer side ; the guide is the inner belly and tendon of the short ex-
tensor of the toes. This latter closely overlaps the dorsalis pedis, and
is beginning to cross it from the outer side. The artery is thus to be
looked for close on the inner side of, or just beneath, that part of the
extensor brevis digitorum, and a second layer of deep fascia, which
binds the artery to the tarsus, has to be divided before the vessel is
quite cleared. On either side is a vein, and to the outer is the an-
terior tibial nerve. The ligature is to be passed from the outer
side.

Branches. — Various tarsal branches anastomose with the malleolar
and plantar arteries, and the outermost of them may be also joined by
twigs of the anterior peroneal. The metatarsal branch runs over the
bases of the metatarsal bones, under the extensor brevis digitorum,
and gives off dorsal interosseous branches, which run along the three
outer spaces. These slender vessels divide at the clefts of the toes,
and receive there the anterior perforating branches from the digitals
of the external plantar. At the hinder end of the spaces the dorsal
interosseous arteries are joined by the posterior perforating twigs of
the external plantar. The outermost interosseous artery gives a
branch along the outer side of the little toe.

The dorsalis hallucis comes from the bifurcation of the dorsalis
pedis, and runs on the first dorsal interosseous muscle to the cleft, both
sides of which it supplies. It also sends a branch under the tendon of
the extensor proprius hallucis to the inner side of the great toe.

The communicating- branch descends between the heads of origin
of the first dorsal interosseous muscle to become continuous with the
external plantar, and so to form the plantar arch. It supplies also
the inner side of the great toe and the adjacent sides of the great and
second toes on their plantar aspect, the internal plantar artery failing
to reach so far forwards.

THE BONES OF THE LEG

The tibia has three centres of ossification, that for the shaft
appearing early in foetal life. The upper epiphysis consists of the
tubcrosities and the tubercle, and begins to ossify at birth. The
centre for the lower end appears in the second year and joins the
shaft soon after puberty. The upper epiphysis joins at manhood, that is
when the growth of the leg is perfected. The upper junction-cartilage,
therefore, has more concern with the growth of the bone than the
lower — for it is in active increase for several years longer — and must

496

Pott 'j Fracture

be jealously protected in excision of the knee. The tibial epiphyses
rarely become detached either by disease or injury.

The fibula also has three centres, the shaft beginning
to ossify soon after the tibia. The lower epiphysis begins
to ossify in the second year, as in the tibia. The upper
epiphysis begins to ossify in the fourth year, and joins at
manhood, as in the tibia. But the lower epiphysis, which
was the first to ossify, joins a little earlier. This is the
exception to the rule, that the epiphysis which ossifies
first joins last. The head of the fibula lies far back beneath
the outer tuberosity of the tibia, and is on a level with the
tubercle of that bone. Tailors often develop a bursa over
the external malleolus.

Fracture — From direct violence, as when a wheel
passes over them, the two bones may be broken at the
same level ; but when the fracture is the result of indirect
violence, as in a fall, they are likely to break in their
weakest parts, the tibia in its lower third, the fibula

near its neck.

Pott's fracture re-
sults from a sudden twist
of the foot, the internal
malleolus or the lateral
ligament giving way, and
the fibula breaking a few
inches above the ankle-
joint. The condition was
first described by Pott,
from whose * Chirurgical
Works ' the adjoining
wood-cuts are adapted.

With a violent twist of
the foot the lower end of
the fibula becomes a lever
of the first order : the ful-
crum being at the lower
tibio-fibular joint, the
power the outward thrust
against the external
malleolus, and the resist-
ance telling just where
the bone yields. This
spot is not the weakest
part of the entire bone,

for that is in the upper third, and can hardly be influenced by a twibt
at the ankle.

Potts Fracture

497

There may be no displacement with this fracture, but generally
the foot is everted, the astragalus being rolled outwards on its
antero-posterior axis, or even dislocated. Often the foot is rigidly
fixed in this everted position. Before trying to ' reduce ' it the knee
should be bent, so as to take all strain from the gastrocnemius. If it
still prove immovable, an anaesthetic may be required before the
soleus and the tibial
muscles permit of its
replacement. If, after
this, the parts cannot
be satisfactorily ad-
justed, it is advisable
to divide the tendo
Achillis, so as to in-
sure absolute quiet of
the calf-muscles. If
this be not done, the
leg should not be
fixed on a back splint,
as this keeps the knee
straight and the gas-
trocnemius in a state
of tension. Gypsum
or wooden side-
splints afford most
convenient support,
as then the knee can
be kept flexed and
the limb laid on the
outer side.

In putting up the fracture it is very necessary to keep the foot
flexed at a right angle, or else, when the man begins to get about
again, the toes will be stiffly pointing downwards, and he will not be
able to get his heel to the ground. He fancies that the leg is shortened
by an inch or two, but with frictions and manipulations the ankle
soon becomes flexed again. Sometimes, however, the surgeon is
compelled to divide the tendo Achillis before the elevated heel
can be brought down. Not infrequently his neglect to fix the foot,
at the outset of treatment, with the toes pointing to the ceiling, is the
cause of his lame patient ultimately resorting to a 'bone-setter,' who
by rough and sudden flexion of the foot breaks down adhesions, and
snatches a triumph from orthodox surgery.

It is quite possible to arrange the leg and foot in too straight a
line in adjusting a fracture near the ankle. It must be remembered
that the tibia is considerably bowed, and that the sole of the foot
naturally inclines a little inwards.

K K

Pott's fracture, showing rupture of internal lateral ligament.

498 Pott's Fracture

It is not always easy to recognise fracture in the upper two-thirds
of the fibula, for the bone is deeply shrouded by muscular attachments :
the soleus and flexor longus pollicus behind, the peroneus longus
and brevis on the outer side, and the extensors longus digitorum and
proprius hallucis in front. The unbroken tibia steadies the fragments
of the fibula, and prevents the surgeon obtaining crepitus.

The lower third of the fibula is subcutaneous in the interval
between the peroneus longus and brevis, behind, and the tertius and
extensor longus digitorum in front ; a break in this part of the bone
is, as a rule, easily detected.

THE ANKLE-JOINT

The ankle-joint is formed by the lower end of the tibia, the two-
malleoli, and the astragalus. The fibular malleolus descends to a
lower level than the tibial, therefore the outer articular surface of the
astragalus is larger than the inner.

The anterior and posterior ligaments are unimportant ; they
descend from the front and back of the lower end of the tibia to the
adjacent parts of the astragalus.

The internal lateral ligament is deltoid, spreading from the end
of the malleolus to the scaphoid, the sustentaculum tali, and, behind,
to the astragalus (see operation for club-foot, p. 503). There is a deep
part of this ligament between the tip of the malleolus and the adjacent
part of the astragalus. This deltoid ligament is crossed by the tendons
of the tibialis posticus and the flexor longus digitorum. The external
lateral ligament sends an anterior and a posterior band to the
astragalus, and a vertical one to the os calcis ; this last is crossed by
the tendons of the peroneus longus and brevis.

The synovial membrane of the ankle-joint lines the anterior,
posterior, and the lateral ligaments, and often sends up a slip into the
lower tibio-fibular joint.

Supply. — The vessels come from the anterior and posterior tibials,
the malleolar and the peroneals. The nerves are branches of the
internal saphenous and of the anterior and posterior tibials.

Structures around ankle. — Beginning in front and passing from
within outwards : the tibialis anticus, extensor proprius hallucis,
the anterior tibial artery between its companion veins ; the anterior
tibial nerve ; the extensor longus digitorum and the peroneus tertius.
The peroneus brevis and longus ; the flexor longus hallucis, the pos-
terior tibial nerve, and the artery with its companion veins ; the
flexor longus digitorum and the tibialis posticus. Behind all is the
tendo Achillis.

When articular effusion occurs, the capsule bulges under the ten-
dons at the front of the ankle, obscuring their outline and obliterating
the furrows between them. There is also a fulness around the malleoli,

Amputations at Ankle

499

and at the back of the joint, on either side of the tendo Achillis.
Such universal bulging is indicative of ankle-joint disease ; when
fulness in the neighbourhood is due to extra-articular causes it is
limited to one aspect, or, at the most, to two aspects of the ankle.

Excision of the ankle-joint may be performed by lateral incisions
which descend along the posterior borders of the malleoli, and by
prolonging them a little forwards so as to obtain more room. The
tendons are carefully turned back — the peroneus longus and brevis,.
and the tibialis posticus and flexor longus digitorum. The lateral
ligaments are divided ; the lower end of the fibula is sawn off, and
the lower end of the tibia is scraped or sawn, as may be expedient,
and the astragalus is thoroughly scraped over.

In Syme's amputation all the bones of the foot are removed, and
a flap is shelled from the back of
the os calcis which is flexed over
the ends of the tibia and fibula,
the malleoli having been re-
moved.

The land-marks for the ope-
ration are the tip of the external
malleolus, and a spot on the inner
side on exactly the same level,
which is below and behind the
tip of the inner malleolus. A large
scalpel is used. The heel-flap is

first cut by an incision connecting P I RO GO F F1'

these points, and passing under

the os calcis. It is sloped a little backwards, so that the flap is not
made needlessly long and cup-shaped. This incision divides every-
thing down to the bones : skin, superficial fascia, external saphenotis
vein and nerve ; deep fascia (external and internal annular ligaments) ;
the tendons of peroneus longus and brevis ; the posterior tibial vessels
and nerve ; the flexor longus hallucis ; the plantar fascia ; the points
of origin of the abductor hallucis, flexor brevis digitorum, and abductor
minimi digiti. Then the end of the os calcis is uncovered by carefully
peeling back the flap down to the bone, and round the point of the
heel, care being taken to make no ' button-hole.'

The second incision is carried straight over the front of the ankle-
joint, beginning and ending in the horns of the plantar incision. No
attempt is made at shaping a dorsal flap ; the knife is carried straight
across, down to the bones and into the ankle-joint. This incision
divides : skin, superficial fascia, internal saphenous vein and nerve,
and the musculo-cutaneous nerve ; the deep fascia (anterior, and part
of internal annular ligament) ; the peroneus tertius and the extensor
longus digitorum ; the anterior tibial nerve and vessels ; the extensor
proprius hallucis, and the tibialis anticus ; and, last or first, according-
ly K 2

/ 'SYME

LISFRAXC

500 SymJs Amputation

as the operation is on the right or left side, the tibialis posticus and
flexor longus digitorum, for these two tendons just escaped division
by the first incision.

The front of the foot bsing depressed, the articular ligaments are

easily divided, and the joint
traversed ; and the knife, pass-
ing along the upper part of the
os calcis, behind the tibia,
reaches and divides the tendon
of Achilles and the plantaris.
The ends of the tibia and
fibula are then sawn off.

The posterior tibial artery
lies just where the two in-
cisions meet, at the spot a little
below and behind the tip of
the inner malleolus.

When the operation is being
clone for disease of a child's
ankle, the epiphysis, which re-
presents the posterior part of
the os calcis, may be detached.
If so, it had better be dissected
out, as it is likely to be un-
sound (v. p. 508). „

The vitality of the flap
depends on the calcanean
branches of the posterior tibial,
the malleolar of the anterior
tibial, and the posterior
branches of the peroneal.

Lines of incisionsjor am^tations (After S> ,n plroffoff >. modification

of Syme's amputation, most of

that part of the os calcis which is behind the astragalus is cut off and
turned up, so that its sawn surface may become ossified on to the sawn
surface of the tibia. The incision in the sole, therefore, may be sloped
a trifle forwards, the plantar muscles, vessels, nerves, and tendons
being cut right through to the bones. The heel-flap, of course, is not
dissected up, but the back of the os calcis is sawn off after the ankle-
joint has been opened from the front. To ensure rest and perfect ap-
position of the sawn surfaces, the tendon of Achilles should be divided.

THE FOOT

The plantar fascia is very thick and strong where it is attached
to the tuberosities of the os calcis. Coming forwards, it spreads into

Sole of Foot 501

three pieces, of which the median is the strongest, and divides into
five slips which join the sheath of the flexor tendons of each toe.
These slips are strengthened by transverse fibres, under cover of
which pass the digital vessels and nerves. The lateral pieces of the
fascia blend with the middle piece, and with the deep fascia on the
dorsum of the foot. The outer piece covers the abductor minimi
digiti and extends to the base of the fifth metatarsal bone. The inner
piece covers the abductor hallucis.

Uses of the plantar fascia. — It strengthens the transverse as
well as the antero-posterior arches of the foot. It gives origin to the
three muscles in the superficial layer, the middle one being the flexor
brevis digitorum. It protects these muscles and the plantar vessels
and nerves, as when the bather treads on a broken bottle or a jagged
flint. (In company with other plantar structures, the fascia yields in
the case of flat-foot.)

The three muscles in the superficial layer of the sole are the abduc-
tors hallucis and minimi digiti, with the flexor brevis digitorum be-
tween them. They all arise from the deep fascia, os calcis, and
inter-muscular septa. The abductors are inserted into the base of
the first phalanx of the great and little toes, and the flexor brevis
digitorum is inserted, like the flexor sublimis in the hand (p. 272),
into the sides of the penultimate phalanges of the four lesser toes, its
tendons being pierced by those of the long flexor.

Tarsal ligaments. — The long plantar ligament passes from the
under surface of the os calcis to the ridge on the under surface of the
cuboid, converting the groove for the tendon of the peroneus longus
into a tunnel. It then spreads into the bases of the second, third, and
fourth metatarsal bones. The short plantar runs from the under and
anterior part of the os calcis to the cuboid behind the groove.

The internal calcaneo-cuboid is a short, strong band between the
inner and dorsal aspects of the bones. It forms the outer limb of the
V-shaped union between the first and second rows of the tarsus, the
inner limb being the superior calcaneo-scaphoid ligament, which
passes on to the dorsal surface of the scaphoid.

The inferior calcaneo-scaphoid ligament is a broad, strong band
between the sustentaculum tali and the tuberosity of the scaphoid.
The tendon of the tibialis posticus passes like a strap beneath it. Its
upper surface is lined by the synovial membrane from between the
astragalus and os calcis, and supports the head of the astragalus.
The front of the deltoid ligament blends with and supports it. It
is sometimes called the ' spring ligament/ and it is one of the first
structures to give way in flat-foot.

All these ligaments are necessarily divided in Chopart's amputa-
tion, which passes through the transverse tarsal joint.

The bony arches of the foot.— If the foot were a solid piece of
bone it would be very liable to fracture ; it would, moreover, possess

5O2 The Arches of the Foot

no elasticity, and man would walk heavily, ungracefully, and with
discomfort.

When in the erect position, the weight of the body is received and
transmitted by the inner tuberosity of the os calcis and by the heads
of the first and of the fifth metatarsal bones ; the plantar vessels,
nerves, muscles, and tendons occupy the intervening hollow, and are
there kept from pressure by the strong plantar fascia.

The antero-posterior arch is best marked upon the inner side ;
it is formed by the point of the os calcis, the astragalus, and the
scaphoid, cuneiform, and the three inner metatarsal bones. Great
elasticity is obtained by this arrangement. Along the outer side of
the foot the antero-posterior arch has not so much spring, but it is
extremely strong. It is composed of the os calcis, the cuboid, and
the fourth and fifth metatarsal bones.

The transverse arcfc is built up of the scaphoid, the internal
cuneiform, and the first metatarsal bones on the inner side, and of the
cuboid and the fourth and fifth metatarsals on the outer.

The integrity of the antero-posterior and transverse arches is
maintained by the keystone arrangement of the bones, by the dorsal,
interosseous, and plantar ligaments, and by the tendons and fascia.
The oblique tendon of the peroneus longus gives valuable support to
both the antero-posterior and the transverse arch ; so also does the
widespread insertion of the tibialis posticus.

Flat-foot. — Those who are not strong enough for the task and
who carry about heavy burdens, who are wearied by too much walk-
ing or standing, complain of dull pains up the legs, and of aching
feet. This is due to the stretching of sensory nerve filaments, and to
the fatigue of muscles, which, like the tibials, are trying to support
the sinking foot. Sometimes these aches are mistaken for rheumatic or
for ' growing' pains. Even if the deformity be but slight, the subject
is not fit for active work ; he tires after a long walk, and is, therefore,
unfit for soldiering, and for hard physical work generally.

In flat-foot the inferior calcaneo-scaphoid, the long and short
calcaneo-cuboid ligaments ; the plantar fascia ; the insertions of the
tibialis posticus and anticns, and of the peroneus longus, have all
yielded a little. The result is that the head of the astragalus rolls
downwards and inwards, whilst the tuberosity of the scaphoid, the
internal cuneiform, and the base of the first metatarsal bones sink to
the inner side of the sole. The condition may be treated by rest,
and by strengthening the tibial muscles, as by making the patient
walk on tiptoe and on the outer side of the feet. An ingenious
operation for flat-foot is that of opening the astragalo-scaphoid joint,
scraping away all the articular lamellae of cartilage and bone from its
interior, and, having arched the foot, inducing the raw surfaces of
astragalus and scaphoid to become ankylosed, in their tilted and im-
proved position.

Club-Foot 503

This operation should not be undertaken, however, until the gym-
nastic exercises have had a prolonged and patient trial.

Talipes (talus, ankle ; pes, foot), because, in the commonest variety
of club-foot, the patient walks on
the outer side of the ankle — this
variety is equino-varus, the
heel, or heels, being drawn up
(as in cquus\ and the soles being
turned inwards towards each
other, varits.

Before birth the feet are nor-
mally in this position, in order
that the embryo may be packed
in the smallest space ; the com-
pression of the uterine wall, in all
probability, causes the arrange-
ment. If, after birth, their posi-
tion be not improved by development, the retaining bands become
permanently shortened and the bones misshaped.

The structures which may require division in talipes equino-varus
are the tendo Achillis (and in slight deformity this may suffice), the
tibialis anticus, tibialis posticus, and flexor longus digitorum ; the
anterior part of the deltoid ligament, which is holding back the tuber-
osity of the scaphoid bone ; the inner part of the plantar fascia, and
possibly also the abductor hallucis. Indeed, every structure is to
be divided until the foot can be placed in the proper position. After
this it is fixed in a gypsum case till the wounds are soundly healed,
then massage is employed. There need be no anxiety about the non-
union of widely sundered tendon-ends, so long as they are not divided
in their synwial sheath. At the present day the tendons are divided
by a free incision in the sole, rather than above the malleoli, where
they lie in synovial sheaths and in the neighbourhood of important
vessels.

The tendon of Achilles is divided from before backwards an inch
above its insertion ; the tibialis anticus is divided from the outer (the
arterial side) just below and in front of the inner malleolus. The
tibialis posticus is divided between the tip of the inner malleolus
and the tuberosity of the scaphoid, and here also the anterior part of
the deltoid ligament may be severed. The other bands are cut
wherever they can be felt firm and resisting beneath the skin, and, as
remarked above, by a free incision, so that the surgeon may see wha:
he is doing ; subcutaneous tenotomy is often disappointing.

The flexor longus digitorum rarely needs section.

In the adult a wedge of bone has occasionally to be removed from
the upper and inner part of the tarsus, before the man can become a
plantigrade, or, better still, the astragalus is excised, as advised by Lund.

504 Deformities of Foot

Talipes valgus is not the same as flat-foot ; it is that condition
in which the outer border of the foot is drawn up by contracted
peroneal tendons. The condition is rare ; and rarer still is that in
which the peroneal tendons need division. Obviously it is wrong
to divide the tendon of the peroneus longus in mere flat-foot, for, as
remarked above, that tendon does much in supporting the arches of
the foot.

Students often experience a difficulty in remembering which is
talipes varus and which is valgus. They should think of the well-
known condition of knock-knee, or genu valgum, for genu valgum
is constantly associated with the flat-foot, the inner arch of the
instep having sunk ; flat-foot is also called spurious talipes valgus.
Talipes varus is tJic opposite condition, in which the inner border of
tJie foot is drawn up and the patient walks on its outer side. Often
in talipes varus corns form over the external malleolus, the cuboid,
and the base of the fifth metatarsal bone ; in those places also bursae
may be developed and become inflamed.

Every new-born child has a little * varus,' for this was the position
of the foot in utero.

Talipes calcaneus is the reverse of talipes equinus. In the
former condition the tibialis anticus and its associates may require
division ; in simple equinus Achilles-tenotomy may suffice. The
latter operation is common enough, the former is rarely needed.

In paralysis of the calf-muscles the heel may drop from stretching
of the tendon of Achilles, the patient becoming the subject of paralytic
calcaneus. In this condition an oblique segment may be removed
from the tendon, the cut surfaces being then spliced.

In equinus the first phalanx of the great toe, and the first phalanges
of the other toes, to a certain extent, are drawn up towards the dorsum
of the foot and even partially dislocated backwards. The reason of
this is that when the heel is elevated the toes are pointed down, and,
the distance between the origin and insertion of the long extensors
of the toes being increased, whilst the muscles themselves are not
lengthened, the toes are drawn into the position of extreme extension.
The long flexor still holds down the ungual phalanx.

If the foot be forcibly flexed the position of the toes is at once
improved, if not corrected.

Pes cavus is a rare congenital deformity, in which the heel is
drawn up by a contracted tendo Achillis, whilst the plantar fascia
shortens the foot and exaggerates the arch of the instep.

In pes cavus the tendon of Achilles and the plantar fascia may
require division.

Hammer-toe is a congenital deformity in which the first phalanx
of (generally) the second toe is drawn back, whilst the middle and
ungual phalanges are flexed. Thus the angle of the first inter-
phalangeal joint forms a prominent ' knee' which is constantly'pressed

Supply of Toes 505

upon by the upper leather of the boot or shoe. Careful padding
and strapping of the toe, or, in more extreme cases, division of the
tendons, sometimes cures this deformity, but when the lateral ligaments
have slipped behind the head of the metatarsal bone, nothing short of
excision of the head of that bone, or amputation of the toe, will effect a
cure. The deformity is often hereditary ; it is doubtful if wearing tight
boots is often accountable for it.

The inter-phalangeal articulations of the foot are like those of the
hand (p. 289).

The great mobility which naturally exists between the astragalus and
the scaphoid, and between the astragalus and os calcis, is necessarily
at the expense of the strength of the union between the astragalus
and those bones. So, as the result of great violence, the interosseous
(astragalo-calcanean) ligament may be ruptured, and the os calcis,
scaphoid, and the other bones of the foot shifted inwards, outwards,
or even in the antero-posterior plane. The dislocation of the foot is
called subastragaloid.

A modification of Syme's amputation is performed on this prin-
ciple : the heel-flap being made as usual, but the ankle-joint not
being opened. A short dorsal flap is made, the os calcis is removed
with the rest of the foot, and the heel-flap is brought round the
astragalus.

THE CUTANEOUS VESSELS AND NERVES OF THE FOOT

The venous arch on the dorsum receives tributaries from the backs
of the toes, and empties itself by the internal and external saphenous
veins. The direct communication between the saphenous veins
enables one of them to do the work of both when inflammation and
plugging have rendered its fellow impervious.

The arteries on the dorsmn of the toes are smaller than the plantar
digital branches. The three outer clefts, and the outside of the little
toe are supplied by the dorsal interosseous branches of the metatarsal
of the dorsalis pedis. The innermost cleft, and the inner side of the
great toe, are supplied by the dorsalis hallucis (p. 494).

On the under aspect the three outer clefts and the outer side of
the little toe are supplied by the digital branches of the external
plantar artery ; the innermost cleft and the inner side of the great
toe get branches from the communicating branch of the dorsalis
pedis.

Nerves.— The dorsum is chiefly supplied by branches of the
musculo-cutaneous, but the cleft between the great and second toes
receives the ending of the anterior tibial nerve, the inner side of the
great toe getting its branch from the musculo-cutaneous. Along the
outer side of the foot and little toe twigs are derived from the external
saphenous.

506 The Foot

The internal saphenous nerve supplies the inner border of the foot
nearly to the ball of the great toe, but no farther (p. 358).

In the sole the plantar nerves are distributed, the inner to three
toes and a half, and the external, like the ulnar nerve, to one and a
half. An additional plantar cutaneous branch comes through the in-
ternal annular ligament from the posterior tibial nerve.

In amputation of the great toe with its metatarsal bone the
ridge across the base of the first metatarsal is made out — the joint
with the internal cuneiform is close behind. A longitudinal dorsal
incision is made from half an inch behind this till the head of the
metatarsal bone is approached. The incision then divides to make a
racquet-shaped wound. The first metatarsal bone is then enucleated,
disarticulated, and removed, together with its two phalanges.

During the operation the fol hiving structures are divided : — Skin
and superficial fascia ; plantar fascia ; tributaries of the internal
saphenous vein, and branches of the internal saphenous, musculo-
cutaneous, anterior tibial, and internal plantar nerves ; the dorsalis
hallucis ; branches of the communicating, and of the internal plantar
arteries ; the extensor proprius hallucis ; the innermost tendon of the
extensor brevis digitorum ; the first dorsal interosseous muscle ; the
transverse ligament and muscle, the adductor, flexor brevis, and
abductor hallucis ; flexor longus hallucis ; tibialis anticus and peroneus
longus ; and fhe ligaments connecting the first metatarsal with the
internal cuneiform.

Care must be taken not to wound the communicating artery as it
dips through the root of the first dorsal interosseous muscle.

Amputation of the little toe with its metatarsal bone is per-
formed on a similar plan, the dorsal incision being begun behind the
articulation of the fifth metatarsal bone with the cuboid. The struc-
tures divided are tributaries of the external saphenous vein ; branches
of the external saphenous, musculo-cutaneous, and external plantar
nerves, and of the dorsal interosseous, metatarsal, and external plantar
arteries ; the outer part of the plantar fascia ; the outermost tendon
of the extensor longus digitorum and of the flexor longus and brevis
digitorum, and the fourth lumbrical ; the transversus pedis muscle
and ligament ; a plantar and a dorsal interosseous muscle, and the in-
sertions of the abductor and flexor brevis minimi digiti ; the peroneus
tertius and brevis, and the ligaments of the outermost tarso-meta-
tarsal joint.

The web of the toes reaches about an inch beyond the head of the
metatarsal bones. In amputation of a toe the web makes an excel-
lent covering for the head of the metatarsal bone, but, in amputation
of the great toe, the head of that metatarsal bone requires a large flap,
which is best obtained from the under surface. The head of this
metatarsal bone should, if possible, be preserved, on account of its
importance in standing and walking.

Choparfs A inputation

507

Bones of foot and synovial membranes.— The astragalus

articulates with the os calcis in two places, the interosseous ligament
intervening between the facets. Its head fits into the fossa at the
back of the scaphoid. The posterior of its two calcanean facets has a

Synovial membranes of ankle-joint and foot. (Qi'AiN.) .

synovial membrane of its own, but the membrane which lubricates the
anterior lines also the upper surface of the inferior calcaneo-scaphoid
ligament, and follows the head of the astragalus into the astragalo-
scaphoid joint.

Excision of the astragalus may be required in the case of caries, in
intractable dislocation of the foot, and in infantile paralysis and invete-
rate talipes equino-varus (Lund), with the view of keeping the sole
flat upon the ground. It is easily accomplished by a free incision
across the front of the ankle-joint, the anterior tibial vessels and
nerve, and as many of the neighbouring tendons as convenient, being
placed aside. The anterior and lateral ligaments of the ankle-joint
and the astragalo-scaphoid connection being severed, the bone is
1 dug out/ the interosseous astragalo-calcanean ligament having been
divided.

Chopart s amputation. — Much of the movement which apparently
takes place at the ankle-joint actually occurs between the astragalus
and scaphoid, on the inner side, and the os calcis and cuboid on the
outer side of the foot. These articulations constitute the transverse
or mid-tar sal joint ; the partial removal of the foot, known as Chopart's
amputation, is effected through it. In this amputation the flap is first
shaped out in the sole, the limits of the flap being the borders of the
sole laterally, and the roots of the toes in front. Thus all the soft
parts are raised in a thick flap to cover the naked ends of the

508 CJwparfs Aniptitation

astragalus and os calcis. A short dorsal flap is then made, the skin
and subjacent tissues being reflected up to the line of the trans-
verse tarsal joint. It is almost impossible to get the sole-flap too
large.

The land-marks. — The tuberosity of the scaphoid on the inner side ;
behind which the knife is introduced. On the outer side there is no
prominence showing the line of the calcaneo-cuboid joint, but that
articulation is surely opened by introducing the knife exactly midway
between the tip of the external malleolus and the tuberosity on the
base of the fifth metatarsal bone. The tendon of Achilles had better
be divided, so that the heel may be brought well down ready for sup-
porting the weight of the body.

Fallacies. — The mid-tarsal joint is not always easily found, the
surgeon opening the joint between the scaphoid and cuneiforms ; or,
on the outer side of the foot, plunging his knife into the hollow be-
tween the astragalus and os calcis, instead of into the calcaneo-cuboid
joint. The flap is apt to be cut too short, so that it does not cover the
articular surfaces ; this is especially apt to occur on the inner side,
where the head of the astragalus stands forth so boldly.

The dorsal artery and the two plantars and their branches will
require ligation.

The os calcis has an epiphysis into which the tendo Achillis is in-
serted ; this epiphysis is often detached in Syme's
operation. The os calcis articulates in front with
the cuboid ; this joint possesses a distinct synovial
membrane, as shown in the illustration.

The cuboid is on the outer border of foot, between

5 epiphysis. * " the os calcis and the fourth and fifth metatarsals. Its

joint with the metatarsals has a separate membrane.

The scaphoid articulates with the rounded head of the astragalus,
and in front with the three cuneiform bones. Its tuberosity bulges
into the sole on the inner side, and is the landmark behind which the
knife is kept in Chopart's, and also in the sub-astragaloid amputa-
tion.

The cuneiform bones. — The innermost has a large tuberosity
dipping into the sole, corresponding with that of the scaphoid. The
inner cuneiform articulates by a reniform facet with the base of the first
metatarsal, and has there a special synovial membrane. A strong
ligament holds the base of the second metatarsal bone against the
internal cuneiform. The middle and external cuneiforms articulate
with the second and third metatarsals ; the synovial membrane which
lines those joints passing back between the cuneiforms to Inbricate the
joints between them and the scaphoid. It also sends a prolongation
between the external cuneiform and the cuboid, and perhaps one be-
tween the scaphoid and cuboid. This arrangement is not shown in
the wood-cut.

Tarsus and Metatarsus

509

The metatarsai bones have a more or less rectangular base, for
articulation with the cuneiforms and the cuboid, and a rounded head
for the first phalanx. The first metatarsai, like a phalanx, has its
epiphysis at the proximal end.

Scheme showing ossification of tarsal bones, and of first and second metatarsai bones. (GRAY.)

There is a vertical ridge on the inner side of the base of the first
metatarsai which can be felt beneath the skin ; close behind this is
the joint with the innermost cuneiform. This joint is exactly in
the middle of the length of the foot, the arch of the foot being almost
entirely behind it. In flat-foot (p. 502), therefore, when the arch has
given way and spread out, the length of that part of the foot which is
behind this joint greatly exceeds that which is in front of it.

The base of the second metatarsai bone is firmly mortised amongst
the cuneiforms, and articulates with the middle cuneiform, its lateral
surfaces lying against the internal and external cuneiforms, a strong
interosseous ligament connecting it with the inner.

The third metatarsai articulates with the external cuneiform ; and
the fourth and fifth articulate with the cuboid. The base of the fifth
has a large tuberosity, which bulges behind the joint with the
cuboid, so, to hit the joint, as in Key's amputation, the knife must
be slipped behind that tuberosity and then brought forwards and
inwards.

The base of each of the three outer metatarsals articulates behind
by an oblique facet ; these joints have the same slant— backwards
and outwards — and the innermost of them is on the level of the joint
between the first metatarsai and the internal cuneiform.

To draw the line of the tarso-metatarsal joints upon the un-

5 1 o Bones of Foot

dissected foot, a dot is made close behind the ridge on base of the first
metatarsal bone, and another behind the tuberosity of the fifth, and
these dots are provisionally connected by an oblique line. Then the
shaft of the second bone is traced back into its expanded base amongst
the cuneiforms, and there a squared, but a slightly oblique, notch is
depicted. The latter part of this plan has to be made by estimation, as
the mortise cannot be actually felt. It is about a quarter of an inch
deep. It is shown on p. 507.

The tips of the index-finger and thumb are kept upon the inner
and outer landmarks of this tarso-metatarsal joint in Hey's and in
Xiistranc's operation. The latter amputation consists in disarticu-
lating all the metatarsal bones ; but in the amputation which bears
the name of the English surgeon the base of the second bone is
not disarticulated, but sawn across, or the internal cuneiform is
divided.

In Hey's and Lisfranc's amputation a very short dorsal flap is
raised, as in Chopart's operation (p. 500), whilst the sole of the foot is
made to supply the covering for the naked surfaces of the cuboid and
cuneiforms. This flap should be cut longer on the inner side, as the
surface of the internal cuneiform which it has to cover is deeper than
that of the cuboid. Branches of the two plantar arteries will require
ligation ; but the main trunk of the external, which crosses the roots
of the metatarsal bones, may just escape the knife.

Hallux valg-us. — As a result of wearing boots with narrow toes,

the great toe is thrust ' outwards,
until it may lie under or over the
neighbouring toes. The partial out-
ward dislocation of the base of the
first phalanx leaves the inner surface
of the head of the first metatarsal
bone prominent beneath the skin,
and unprotected from the pressure
of the boot. It is, however, the strain
upon the joint, not the pressure of
the boot, which sets up the trouble
and pain in the joint. The ap-
pearance presented by the great toe is something like knock-knee,
and is called hallux valgus. When the deformity is slight it may be
treated by wide-toed boots, and by wearing a pad of cotton-wool in the
first cleft. But, if it be severe, the shaft of the first metatarsal may
be divided, the distal part of the bone being so arranged that the
phalanges may lie in the direction of the inner border of the foot.

Unless the case be duly treated, the mucous bursa which is apt to
be developed by friction on the inner side of the head of the meta-
tarsal bone becomes inflamed. The large round and painful swelling
then produced is called bunion (3ouwy, mound}.

Stiff Great- Toe 5 1 1

Gouty inflammation is specially apt to attack the first joint of the
great toe : because it is a hard-worked joint, because it is far away
from the centre of circulation, and because wearing a boot has caused
the toe to be deflected so that the joint is not worked in the natural
manner.

In certain flat-footed adolescents the first joint of the great toe
becomes stiff and painful, or inconveniently flexed : the conditions are
called liallui rigidus and hallux flexus ; the cause is unknown,,
and the treatment is unsatisfactory.

INDEX

[Every dash ( — ) stands for a word in the line above it.]

ABD

abdomen, 294

— cavity of, 314

— dropsy of, 3x6

— injuries of, 297

— muscles of, 302

— regions of, 299

— superficial fascia of, 296

— nerves of, 301
vessels of, 300

— tumours of, 300

— viscera of, 318

relative position, 344

— wall of, 302
abdominal aneurysm, 351

— aorta, 350

— ascites, 316

— ring, external, 302
internal , 306

— wall, abscess of, 305, 308
abducens, 65

abnormality, see particular part
abscess, abdominal, 305

— axillary, 245

— of buttock, 211, 308, 452, 467

— cervical, 2, 210

— of hip-joint, 467

— iliac, 211, 308

— in prostate, 415

— in sheath of rectus, 305

— ischio-rectal, 211, 308, 437, 468

— lumbar, 211, 305, 308

— mediastinal, 154

— of liver, 339

— of scalp, 7

— palmar, 286

— pelvic, 308, 367

— perineal, 439

— peripleuritic, 188

— perityphlitic, 327

— popliteal, 450, 485

— post-pharyngeal, 210

— prostatic, 415

— psoas, 211, 308

— renal, 410

ANK

abscess, retro-phar'yngeal, 210

— spinal, 210, 308

— sub-peritoneal, 308

— thecal, 274
accelerator urinae, 440
accentuation of sound, 171
accessory internal pudic, 442
accommodation, 85
acetabulum, 360, 465
Achillis, tendo, 487

reflex, 221

acromion process, 227

— ligaments of, 226
Addison's disease, 350
adductors of thigh, 453
adenoid vegetations, in
adenoma mammae, 204
adenoma of breast, 204
segophony, 202
ague-cake, 342

air in veins, 4, 234
air-cells, 196

— passages, foreign body in, 130, 134
air, tidal, 193

amphoric resonance, 201

amputation, see special part

Amussat's operation, 331

anal fascia, 437

anastomoses, parietal and visceral,

309

anconeus, 244, 281
aneurysm, see special artery

— aortic, 1 80
angina pectoris, 169
angular curvature, 208
ani atresia, 383

— levator, 438

— sphincter, 386
ankle clones, 221
ankle-joint, 498

— effusion into, 498

— structures behind the, 486, 498
ankylosis of hip, 468

— of jaw, 22

514

A Manual of Anntoiuy

ANN

annular ligaments of ankle, 485

wrist, 270

annulus ovalis, 166
ano, n .tu l.i in, 438
iinterior crural nerve, 358

— interosseous artery, 278
nerve, 254

— tibial artery, 492

nerve, 383

nnthracosis, 191
antrum of Highmore, 17
anus, artificial, 330

— development of, 383

— epithelioma of, 387, 389

— fissure of, 386

— patulous, 386

aorta, abdominal, 398, 350

— arch of, 178

— ascending, 178

— thoracic, 184

— transverse, 179

— valves of, 168

disease of, 173

situation of, 169

aortic aneurysm, 180
apex-beat, 163
aphasia, 49
apoplexy, 50

appendices epiplofcjIB, 3-:K
aqueduct of Fallopius, 13
aqueous humour, 84
arachnoid, 38

arch of aorta, 178
arches of foot, 501
arcus senilis, 83
Argyll-Robertson pupil, 59
arm, surface of, 337
Arnold's nerve, 69
.n in i.i ccntralis, 81
arteriotomy, 31
artery, see special artery
— structure of, 178
articulation, see special joint
artificial anus, 330
arytaenoid cartilage, ia6
arytccnoidcus, 128
ascending cervical artery, 233
ascites, 316
asthma, 197
;r,ti|Mii.Uism, 84
astragalus, 507
atlas, 306

atlo-axoid joint, 206
atony of bladder, 410
atrcsia ani, 383
auditory meatus, external, 94

internal, 13

Mn-vr.68.

HkA

auditory vertigo, 101
auricle, left, 167
- iitdit, 165

— development of, 1O3
.mi ii ular nerve, 69

great, 145

posterior, 66

auriculo-temporal nerve, 63

am iculo-vcntricular orifices, 167, 169.
auscultation, 200
axilla, 344
axillary artery, 245
course of, 335

— fascia, 239

— glands, 248

- iinir, 237

— nerves, 249

— vein, 238, 246

206
a/.ygos artery, 157, 185

— vein, 154

back, pain in tin-, 210, 349, 351, 386
balanitis, 422

' ballooning' of rectum, 384
Land, ilio tibia!, 448, 453

IM 6 of skull, tincture of, jH, 7}
basilic vein, 338
I Jell, nerve of, 35 r
Bell's paralysis, 66

' lirlly-aclli1.' 3IO
bein I of elbow, 263

bieeps, of arm, 243

— of thigh, 450

— dislocation of, 224
bicipit.il lasei.i. 243
Bigelow's ligament, 466
bile-duct, 340

bladder, development of, 406

— extroversion of, 406

— female, 405

— hiatus of, 406

— inflammation of, 410

— irritation of, 423

— male, 406

— puncture of, 407

— rupture of, 413

— sacculation of, 408

— stone in, 411
b reding, 337
blcpharo-spasm, 73
blind spot, 93
borborygmi, 330
bi.ulii.il artery, 263

— — compression of, 336

— plexus, 349

Index 5 1 5

BRA CIR

brachialis anticus, 244 Garden's amputation, 484

brachio-cephalic artery, 182 cardiac disease, 171

brain, 44 ~~ murmurs, 17'

— arteries of, 42 — end of stomach, 319

— fissures, 47 — nerves, 224

— membranes of, 37 caries of spine, 206, 210

- :»graphy of, 45 carotid artery, common, 22

branchial clefts, 123 in thorax, 24

— fistula, 124 external, 26

tan* , 2->2 internal, 33

breath-sounds, 200 — sheath, 24

— thoracic, 315 — triangles, xo
bregma, 366 " — tubercle, 23
Bright's disease, 346 carpal arteries, 275
broad ligament, 390 carpal joints, 288
Broca | r«.-g;or., x> carpus, 286

bronchi, 134, 195 caruncula lachrymalis, 74

bronchial breathing, 200 carunculas: myrtiformes, 402

— glands, 199 castration, 435

— nerves, 199 cataract, 89

— '.•'-. •-.-*-:. • . i YJ catheter, male, passing a, 418
bronchiectasis 198 — female, passing a, 4x9
bronchitis, 198 — Eustachian, 100
Lror.'.r.o:,.'. ',:.•/, 202 caiheterisation, roles for, 4x9
broncbocele. 135 caoda equina, 213

Lrov. -;;.->. cava inferior, 355

bruits, 171 — superior, 187

Bryant's fine, 448 cavernous sinus, 39

bubo, 451 .•:.-.•..-<:-. of Mdrfb, 55

bubonocele, 310 cephaJhaematoma, 7

buccal nerve, 63 cephalic vein, 238

buccinator , i -X, cercbeflar arteries, 43

bulb of urethra, 417, 442 cerebellum, 57

b-ulbar ,'Aralyi::-, ^C, 71 cerebral circulation, 42

bunion, 510 — localisation, 48

burn, ulcer after, 325 — reins, 41

bttrsae about ankle, 486 cerebro-spinal fluid, 58

— buttock* 4^0 cerebrum, 44

— elbow, 282 cervical cord, 2x8

— hip, 468 — fascia, i

— knee, 478 — nerves, 143

— rimlacr, 240 — plexus, X43

— wrist, 270, 274 — vertebrae, 205

buttock, flattening of, cervicalis ascenoens, 233

cervix uten, 39^
ihcclt ligaments, 207
cheeks, xo6

ipa^ n-^«a^,«^^M ••^^•••^»*p»^, y*» cnest, 14^

i.'.';"^ r.':. 'vi —— tapping the xoo

canal, crural, 313 • bPfWl (OpeOMM, --,7

— Hunter's, 454, 458 chorda tympani, 66
~ ~ ixttuinal, 309 chordae tendinea?, 16

— of Nu-k, 2>r chordee, 425

— of Schlemro, 90 cteMtf, %-
canalimli, 75 ctuary arteries, 8x

capsule, of Glisson, 336 — nerves, 6x

— f Tn

ves, 6x
COMI ^5
of Wilbs, 43

\r*i>*wc, vi VIIIMIIU, 3;j» — :.rr.':-. -,i

— of Tenon, 77 — fHMOMI

— area, superficial, 165 drdeofWfll

L L2

516

A Manual of Anatomy

CIR

circumcision, 423
circumflex arteries of arm, 247
of thigh, 456

— iliac artery, 371

— nerve, 251
cirrhosis of liver, 336
clavicle, 225
clavus, 60
claw-fingers, 254
cleft palate, 108
clitoris, 402

club foot, 503
coccydynia, 362
coccygeal artery, 374

— gland, 355
coccygeus, 436
coccyx, 362
cochlea, 101

Cock's operation, 418
coeliac axis, 352
Colles's fracture, 282
colic, 315
colon, 326
colotomy in groin, 330

loin, 331

communicantes noni, 144
commissures, 54
concussion of brain, 44
condylar ridges, 236
condyles of femur, 449, 461

humerus, 236

congenital displacement of femur, 472

— hernia, 310

— hydrocele, 429

— sterno-mastoid tumour, 3
conjoined tendon, 304
conjunctiva, 73
constrictors of pharynx, 137
contractured muscles, 222
convolutions of brain, 45, 47
coracoid process, 235

ligaments of, 226

coraco-brachialis, 243
cord, spermatic, 433

— hydrocele of, 430

— spinal, 213
cornea, 83
corneitis, 84
coronal suture, 47
coronary arteries, 168

— sinus, 167
coronoid ligament, 226

— process, 284
corpus luteum, 399

— striatum, 53
costal cartilages, 149
costo-coracoid membrane, 240
cough, 95

Cowper s glands, 417
crack-pot sound, 200

DIP

cranial nerves, 57
cranio-tabes, 16
cranium bifidum, 16
creases of palm, 269
cremaster, 304
cremasteric artery, 371
crepitation, 202
cribriform fascia, 313, 450
cricoid cartilage, 125
crico-thyroid membrane, 126

— muscle, 127
crista galli, 14
cruciform anastomosis, 373
crural arch, deep, 306

— canal, 313

— nerve, anterior, 358

— sheath, 313
crutch paralysis, 252
crus cerebri, 54
crusta, 54

cuboid bone, 508
cuneiform bones, 508
curves of spine, 207, 209
cut- throat, 36
cyphosis, 207
cystitis, 410
cystotomy, 445
cysts, dermoid, 102, 124

— of breast, 204

— of kidney, 348, 410

— of neck, 124

— of testicle, 431

dartos, 426

' death rattle,' 201

deep crural arch, 306

defecation, involuntary, 218

deglutition, 109

deltoid, 241

dental artery, inferior, 32

posterior, 32

— nerve, inferior, 63, 64
dentition, 113

dermoid cysts, 102, 124, 399, 420
descendens noni, 71
descent of testis, 428
development, general remarks upon

123

diameters of pelvis, 364
diaphragm, 152
diastolic murmurs, 173
digastric muscle, 6

— region, 6, 27
dilatation of bronchus, 198
heart, 175

dimple near sacrum, 420
diploe, veins of, 40
diplopia, 59

Index

direct inguinal hernia, 310
diverticulum, 325
dorsal nerves, 150

— vein of penis, 425
clorsalis pedis, 494

— penis, 425, 442

— scapulce, 247
Douglas, pouch of, 390
dropped wrist, 252

dropsy of abdomen, 316, 347
— legs, 347

pleura, 189

scrotum, 426

Duchenne's disease, 71
duct, thoracic, 157
ductus arteriosus, 179
- • venosus, 335
duodenum, 324

— ulcer of, 325
Dupuytren's contraction, 271
dura mater, arteries of, 41

— of brain, 37

cord, 213

venous sinuses of, 37

dysentery, 339, 387
dyspepsia, 319, 321
dyspnoea, 202

ear, 93

— cough, 95

— development of, 102

— external, 93

— internal, 101

— middle, 95

— ring, 74
ear-ache, 94
ectopia, 318
ectropium, 73
ejaculatory ducts, 416
elbow joint, 265

— region of; 263

' election, seat of,' 485
embolism, 194
emissary veins of skull, 41
emmetropia, 85
emphysema, 196, 297
empyema, 190, 197
encephalon, 44
encysted hernia, 310

— hydrocele, 429, 430
endocardium, 165
entropium, 73
enuresis, 423
epiblast, 123
epicranial aponeurosis, 7
epididymis, 430
epididymitis, 432
epigastric artery, deep, 370
superficial, 455

FLE

epiglottis, 126
epilepsy, 53
epispadias, 406
epistaxis, 121
eructation, 322
eruption of teeth, 113
ethmoid bone, 14
ethmoidal arteries, 81
Eustachian tube, 99
eversion of femur, 463
extensors of ankle, 488

— of wrist, 280

external abdominal ring, 302

— auditory meatus, 94

— carotid artery, 26

— iliac artery, 370

— mammary artery, 248

— thoracic nerves, 251
extravasation of urine, 439
eye-ball, excision of, 82

— lids, 72

face, nerves of, 67, 145
facial artery, 29

— nerve, 65

— paralysis, 67

— vein, 34
faecal fistula, 298

— impaction, 329

fasces, incontinence of, 218
Fallopian tube, 401
false passage, 417
falx, 39
fascia lata, 451

— lumborum, 304
fauces, 108

femoral artery, common, 454

deep, 456

ligation of, 458

superficial, 454

— hernia, 312

— veins, 457

femur, development of, 461

— dislocation of, 469

— fracture of, 461
fibula, 496, 498
fifth nerve, 60
filtration angle, 91
finger, amputation of, 290
fissure of anus, 386

— of Rolando, 45

— of Sylvius, 44, 46
fistula, branchial, 124

— faecal, 298

— in ano, 438

— umbilical, 298
flat-foot, 502
flexors of ankle, 492
hand, 271

518

A Manual of Anatomy

FLE

flexors of leg, 487

— thigh, 453

— toes, 488

foetal circulation, 166

— head, 365

fold of buttock, 460
fontanelles, 365
foot, 500

— amputations in, 507

— arteries of, 491, 494

— muscles of, 494, 501

— nerves of, 381, 382, 505
foramen of Majendie, 38

Monro, 56

forearm, arteries of, 275

— dislocation of, 266

— muscles of, 271

— nerves of, 252

— surface of, 268

foreign body in air-passage, 134

ear, 95

gullet, 140

fossa, ischio-rectal,

— subclavian, 9, 229

• — of Rosenmuller, 101
fossettes, inguinal, 311
fourth nerve, 59
fracture, see special bone

— in a joint, 284
fraenum linguae, 114
friction-sound, 159
frontal artery, 81

— bone, ii

— sinus, ii

funicular process of peritoneum, 310,
428

— hydrocele, 429

Gaertner, duct of, 399
galactocele, 203
Galen, veins of, 40
gall-bladder, 340
ganglion, cervical, 224

— lenticular, 61
ganglionic cells, 218
Gasserian ganglion, 60
gastric catarrh, 320

— ulcer, 321
gastrocnemius, 487
gastrostomy, 323
gastrotomy, 323
generative organs, female, 389

male, 421

genito-crural nerve, 357
genu valgum, 479
Gimbernat's ligament, 302
glandulae concatenatae, 37
glans penis, 424
glaucoma, 91

HUM

glenoid cavity, 256
Glisson's capsule, 336
glosso-pharyngeal nerve, 68
glottis, 127
gluteal artery, 374

— bursae, 460

— nerve, 379

— region, 374, 459
gluteus maximus, 460
goitre, 135

Graafian follicles, 399
great auricular nerve, 145

— occipital nerve, 143

— toe, 506

Gritti's amputation, 484
groin, 447

gubernaculum testis, 428
gums, 112
gustatory nerve, 63
gyri operti, 49

haematemesis, 195, 321

haematocele, 367, 398, 430, 433

hoematokolpos, 395

haemoptysis, 195

hoemorrhoidal artery, 354, 373, 388,

442

haemorrhoids, 388
hallux rigidus, 511

— valgus, 510 *
hammer-toe, 504
hamstring muscles, 450
hand, 269

hamular process, 107

hard palate, 107

hare-lip, 104

head, bones of, ii

heart, altered position of, 162, 163

— diseases of, 171

— marked on surface, 163

— situation of valves, 169

— sounds of, 169
heel, sore,
hemiplegia, 50
hepatic artery, 340, 352

— duct, 340

— cirrhosis, 336

— veins, 340, 356
hepatitis, 339
hermaphroditisrn, 421
hernia, see special variety
Herophili, torcular, 40
Hesselbach's triangle, 310
Hey's operation, 510
hip-joint, 465

— disease of, 467

— dislocation of, 469
housemaid's knee, 478
humerus, development of, 260

Index

HUM

humerus, dislocation of, 257

— fracture of, 260

— rotators of, 257
Hunter's canal, 454, 458
hydrocele, 429

— encysted, of testis, 431

— of neck, 124
hydrocephalus, 56
hydronephrosis, 348
hymen, 402
hyo-glossus, 115

hyoid bone, depressors of, 5

elevators of, 6

hypogastric artery, 372

— plexus, 224
hypoglossal nerve, 71
hypostatic pneumonia, 193
hypermetropia, 86
hypertrophy, 175
hypoblast, 123
hypospadias, 420

ileo-caecal valve, 328
ileum, 324

iliac artery, common, 368
external, 370

— — internal, 372

— fascia, 307

— veins, 376
iliacus, 307

ilio-inguinal nerve, 356
ilio-lumbar artery, 375
ilio-tibial band, 448, 450, 452
imperf orate rectum, 383
incontinence of faeces, 218
urine, 410

incus, 96

infantile hernia, 310

— hydrocele, 430

— paralysis, 219
infarction, 194
inferior dental artery, 32
nerve, 64

— maxilla, 19, 20

— profunda, 263
infra-clavicular region, 241
infra-maxillary nerve, 67
infra-orbital artery, 33

— nerve, 62

infundibuliform fascia, 306
inguinal canal, 309

— fossettes, 311

— hernia, 307, 310

— lymphatics, 451

— nerves, 356
inhibitory influence, 220
innominate artery, 182

• — bone, 360
• — veins, 186

KNE

inter-articular fibro-cartilages, 473
intercolumnar fascia, 302
intercostal arteries, 156

— nerves, 151

intercosto-humeral nerve, 150, 239
intermaxillary bone, 17
internal abdominal ring, 306

— carotid artery, 33

— cutaneous nerve, 253

— iliac artery, 372

— jugular vein, 36

— mammary artery, 155

— maxillary artery, 32

— pudic artery, 438, 441
nerve, 379

— saphenous nerve, 358

vein, 450

interosseous arteries, 278

— membrane, 285

— nerves, 252, 254
irregular internal pudic, 442
intervertebral disc, 206
intestinal obstruction, 329
intestine, development of, 317

— large, 326

— small, 323
intracranial pressure, 50
intussusception, 329
iridectomy, 88

iris, 87

— structure of, 318
iritis, 88

ischio-rectal fossa, 363, 436
island of Reil, 49
isthmus of thyroid, 134

Jacksonian epilepsy, 53

Jacobson's nerve, 69

jaundice, 340

jaw, lower, 19

— upper, 17

jejunum, 324

joint, see special articulation

Jordan's amputation, 469

jugular vein, anterior, 36

external, 35

internal, 36

keratitis, 84

kidney, relations of, 343

— situation of, 333

— stone in, 349

— 'surgical,' 410
knee, bursae about, 478

— region of, 449
• — jerk, 221
knee-joint, 472

• amputation at, 484

520

A Manual of Anatomy

KNB

knee-joint, excision of, 480

— pains at, 478

— structures around, 478

— synovial membrane of, 474
knock-knee, 479

kyphosis, 207

labia majora, 402

— minora, 402
labial arteries, 104

— hernia, 307
labio-glossal paralysis, 71
lachrymal apparatus, 75

— artery, 81

— bone, 19

— nerve, 61
large intestine, 326

arteries of, 330

laryngeal nerves, 70
laryngismus stridulus, 128
laryngoscopy, 129
laryngotomy, 130
larynx, 125

— removal of, 130

lateral curvature of spine, 207

— sacral artery, 375

— sinuses, 39

— ventricles, 56
latissimus dorsi, 242
left auricle, 167

— ventricle, 167
leg, back of,

— fascia of, 485

— front of,
lens, 88

lenticular ganglion, 61
lesser occipital nerve, 144
levator anguli scapulae, 4

— ani, 438

— palati, 108

ligament, see special region
ligamentum nuchee, 3

— patellae, 450, 472
linea alba, 295

— semi lunar is, 296
lineae albicantes, 297

— trans versae, 206
lingual artery, 28
lingualis, 116
lips, 103

Lisfranc's amputation, 510

lithotomy, 443, 445

little finger, muscles of, 292

— toe, amputation of, 506
Littre's operation, 330
liver, 332

— pulsation in, 175

— stab of, 192, 335
lobes of brain, 45

MEM

lobule of ear, 93
localisation, cerebral, 45
locomotor ataxy, 223
locus per fora tus, 43, 49
longitudinal sinus, 39, 40
lordosis, 207, 468
lumbago, 210, 349, 351
lumbar aponeurosis, 304

— arteries, 355

— caries and renal calculus, 349

— fascia, 304

— glands, 376

— hernia, 211, 305

— nerves, 356

— plexus, 356
lumbo-sacral cord, 359
lumbricals, 273

lungs, outline of, 191, 193

— lobes of, 192
Luschka's gland, 355
lymphatics of abdomen, 376
groin, 451

neck, 37

macrostoma, 104
Maclntyre's splint, 462
Majendie, foramen of, 38
malar nerve, 62
malleoli, 496

malleus, 96 „

mammary gland, 202
margo acutus, 162
masseter, 7
mastoid cells, 12

— vein, 39
maxilla, inferior, 19

— superior, 17

excision of, 18

maxillary artery, 32

— nerve, inferior, 63

superior, 62

supra-, 67

measure, lower limb, 448

— upper limb, 236

meatus auditorius externus, 94
internus, 13

— of nose, 120
Meckel's diverticulum, 325

— ganglion, 63
median nerve, 253

— vein, 237

median basilic vein, 237

— cephalic vein, 238

— hare-lip, 105

— lithotomy, 445
mediastina, 153
medulla oblongata, 55
Meibomian glands, 74
membrana sacciformis, 285, 286

Index

521

MEM

membrana tympani, 97

artificial, 98

membranes of brain, 37

spinal cord, 213

meningeal arteries, 32, 41, 42
meningocele, 12, 16, 119
mesenteric artery, inferior, 354
superior, 353

— veins, 337
mesentery, 325

mesial surface of hemisphere, 52
mesoblast, 123
metacarpal bones, 290
metallic tinkling, 201
metatarsal bones, 509
micturition centre, 411
middle meningeal ; rtery, 32

— sacral artery, 355
miner's elbow, 282
mitral valve, 168

disease of, 173, 177

monoplegia, 50
Monro, foramen of, 56
mons Veneris, 296, 402
motor area of brain, 48, 52

— oculi, 58
mouth, 103

— development of, 104
mucous polypi, nasal, 121
mumps, 118
murmurs, cardiac, 171
muscae, 90

muscular atrophy, 219
musculi papillares, 167
- — pectinati, 167

musculo-cutaneous nerve, 255, 381
musculo-spiral nerve, 251

paralysis, 252

mylo-hyoid artery, 32

muscle, 6

nerve, 64

myopia, 86

nares, plugging, 122

— posterior, 122
nasal artery, 81

— duct, 76

— fossa, 119

— nerve, 61

— polypi, 121
nates, fold of, 460
neck of child, 132

— triangles of, 9

— venous pulse in, 174
Nelaton's line, 447
nephritis, 346

ninth nerve, 71
nipple, 202
nose, 119

— bleeding, 121

OVI

nose, development of, 122 .

note on development generally, 123

Xuck, canal of, 391

nutmeg liver, 337

nymphae, 402

oblique inguinal hernia, 307, 310

— muscles of abdomen, 302

orbit, 78

obturator artery, 373
irregular, 371

— fascia, 364

— hernia, 314

— nerve, 358

— plexus, 359
occipital artery, 30

— bone, 15

— nerves, 14

— sinus, 15

— triangle, 10
occipito-frontalis, 7
oculi tendo, 73
cedema of ankles, 178

eyelids, 72

glottis, 129

oesophagotomy, 140
oesophagus, 136
olecranon, fracture of, 284
olfactory nerve, 57
omen turn, 316
omo-hyoid, 5

onyx, 84
ophthalmic artery, 81

— ganglion, 61

— nerve, 61

— vein, 82
optic disc, 93

— nerve, 57

— thalamus, 54
orbicularis oris, 103

— palpebrarum, 72
orbit, 76

— fascia t f , 77

— muscles of, 78
orbital fissure, 76, 124
orchitis, 416, 432, 435
os calcis, 508

os innominatum, 360

— uteri, 392
ossicles, 96

osteo-arthritis, 243, 465
otitis, 98
ovariotomy, 400
ovaritis, 400

ovary, 398

— artery of, 354

— tumour of, 399

— veins of, 356
oviduct, 401

522

A Manual of Anatomy

PAC

Pacchionian bodies, 38
pains over chest, 153

— peripheral , 209
palate, cleft, 108

— hard, 19, 107

— soft, 107

muscles of, 108

palatine artery, 33
palm, 269

palmar arch, deep, 277
superficial, 279

— fascia, 271
palmaris brevis, 292
palpebral artery, 81
pampiniform plexus, 433
pancreas, 300, 342
paracentesis abdominis, 317

— pericardii, 161

— thoracis, 190

— tympam, 97
paralysis, cerebral, 50

— infantile, 219

— spinal, 222
paraphimosis, 422
paraplegia, 222
parietal bone, 16

— and visceral anastomoses, 309
parotid gland, 117
parovarium, 399

parturition, 366
patella, 475
patellar reflex, 221

— plexus, 358
patheticus, 59
pectiniform septum, 424
pectoralis major, 239

— minor, 240
pectoriloquy, 201
pedicle, ovarian, 391
pelvic glands, 376

— fascia, 363

— viscera, 382
pelvis, 360

— fracture of, 362
penis, 421

— arteries of, 442

— muscles of, 440

— nerves of, 379, 425

— vein of, 377, 425
percussion of chest, 199
perforating arteries, 456
pericarditis, 158
pericardium, 158
pericranium, 7
perineal abscess, 439

— hernia, 314
perineum, female, 445

— male, 438
peripheral pains, 209
peritoneum, 314

POS

peritonitis, 315
perityphlitis, 327
peroneal artery, 490, 491

— nerve, 381

— reflex, 221
peronei, 492

pes anserinus, 65

— cavus, 504
Petit's triangle, 305
petrosal nerve, 63

— sinus, 39
petrous bone, 13
Peyer's patches, 324
phantom tumour, 296

— ulcers, 392
pharyngeal artery, 31

— plexus, 138
pharynx, 136
phimosis, 422
phlebotomy, 237
phrenic artery, 352

— nerve, 147
phthisis, 198
pia mater, 38
pigeon-breast, 150
piles, 388
pinna, 93

PirogofFs amputation, 500
planes of pelvis, 364
plantar arch, 491

— arteries, 491 ,

— fascia, 500

— ligaments, 501

— nerves, 381
platysma myoides, i
pleura, 187
pleurisy, 188
pleurodynia, 153, 184
plexus gulas, 139
plica semilunaris, 74
pneumogastric nerve, 69
pneumonia, 192

— hypostatic, 193
pneumothorax, 191, 197
pons Varolii, 54
polio-myelitis, 219
popliteal artery, 481

— nerves, 380, 381
paralysis of, 382

— space, 480

— vein, 483
popliteus, 480
Porro's operation, 392
portal vein, 337
portio dura, 65

positions of cardiac valves, 169
post-pharnygeal abscess, 210
posterior auricular artery, 30
nerve, 66

— interosseous nerve, 252

Index

523

POS

posterior scapular artery, 233

— tibial artery, 489

nerve, 381

Pott's fracture, 496
Poupart's ligament, 302, 447
pregnancy, 394
presbyopia, 86
presystolic murmur, 173
priapism, 425

profunda femoris, 456
prolapsus ani, 387

— uteri, 397
pronator radii teres, 271

— quadratus, 274
prostate, 412

— veins of, 377
psoas, abscess of, 308

— muscle, 307
pterygium, 74
pterygoid muscles, 8
pterygo-maxillary ligament, 106
pubic artery, 371

— spine, 302
pudendal hernia, 307

— nerve, 379

pudic artery, external, 455

internal, 441

irregular, 442

— nerve, 379
pulmonary apoplexy, 195

— artery, 167, 184, 198

— plexus, 199

— valve, 167

— veins, 195
puncta lachrymalia, 75
puncture of bladder, 407
pupil, contraction of, 58

— artificial, 88
pyloric artery, 352
pylorus, 319

— dilatation of, 323

— stricture of, 322
pyo-pneumo-thorax, 197

quadratus lumborum, 305
quadriceps extensor, 453
•quinsy, 112

radial artery, 275

— nerve, 251

— vein, 237

radical treatment of hernia, 306
radio-carpal joint, 285

— ulnar joint, 266
radius, 282

— head of, 236
ranine artery, 28
ranula, 117
rectocele, 404

SCA

recto-vesical fascia, 363, 437

pouch, 384

rectum, 382

rectus abdominis, 304

— femoris, 453

recurrent laryngeal nerve, 70
reduction en masse, 312
reduplication of sound, 171
reflexes exaggerated, 209

— of cord, 219, 220

— lost, 220
Reil, island of, 49
region of Broca, 49
renal calculus, 349

— vessels, 354 356
respiration, 193
respiratory pulse in neck, 175

— sounds, 200
restiform bodies, 55
retention of urine, 409
retina, 92

retro-pharyngeal abscess, 210
rhomboid ligament, 225
ribs, 149

rider's bone, 449
right auricle, 165

— lymphatic duct, 158

— ventricle, 167
rima glottidis, 127

ring, abdominal, 302, 306
Rolando, fissure of, 45
root of lung, 194
round ligament, 402
Rosenmttller, fossa of, 101

— organ of, 399

rotators, internal, of thigh, 448

sac of hernia, 376
sacra media, 376
sacral dimple, 420

— nerves, 378

— tumour, 204
sacro-iliac joint, 360
sacro-sciatic ligaments, 361
sacro-vertebral angle, 361
sacrum, 362

saphenous nerve, external, 380
internal, 358

— opening, 452

— vein, long, 450

short, 481

sartorius, 453
scaleni, 141
scalp, 7

— arteries of, 30, 31, 81

— lymphatics of, 37

— nerves of, 62, 67, 145

— veins of, 35
scapula, 227

— luxation of, 241

524

A Manual of Anatomy

SCA

Scarpa's triangle, 454
Schlemm, canal of, 90
sciatic artery, 373

— nerves, 379, 390
scirrhus mammas, 203
sclerotic, 82
scrotum, 426

— development of, 420
' seat of election,' 485
see-saw murmur, 174
semilunar cartilages, 473

— valves, 168

sensory area of cortex, 53
septum crurale, 308, 313

— pectiniforme, 424
serratus magnus, 241
seventh nerve, 65
sheath of rectus, 304
shingles, 151, 302
shoulder, 225, 235

— bursoe at, 240

— dislocations, 258

— pains at, 339

— joint, 256
sigmoid flexure, 326
sinuses of dura, 39

Morgagni, 137

site of spinal nerves, 214
sixth nerve, 65
skull, fracture of, 13

— topography of, 45
small intestine, 324
snuffles, 121

soft palate, 107
solar plexus, 224
sole of foot, 500
soleus, 486
sounds of heart, 169

— morbid, 171
spasmodic stricture, 417
spastic rigidity, 222
spermatic artery, 354, 432

— cord, 431

— nerves, 435

— veins, 355, 433
spermatorrhoea, 416, 436
sphenoid bone, 14
sphincter ani veins, 212, 386
spina bifida, 204

spinal abscess, 210

— accessory nerve, 70

— arteries, 232

— cord, 213

— curvature, 207

— ligaments, 206

— nerves, 214

— reflexes, 219

— veins, 212
spine, 20

— caries of, 208

SYL

spine, ligaments of, 206

— of pubes, 302, 447, 453
spinous processes, 205
splanchnics, 224
spleen, 341

splenic artery, 353
spongy part of urethra, 417
stapedius, 97
stapes, 96
Stenson's duct, 118
sterno-clavicular joint, 225
sterno-hyoid, 5
sterno-mastoid, 3
sternum, 148
stiff great-toe, 511
stomach, 318
stomach-cough, 322
stone in bladder, 411

kidney, 349

strabismus, 80
stricture, 417
stye, 74

styloid process, 14
stylo-maxillary ligament, 2
subarachnoid space, 38
sub-astragaloid amputation, 505.
subclavian artery, 228

— fossa, 241

— triangle, 9

— vein, 234

subclavius, 240 *

subdural space, 38
sublingual artery, 28

— gland, 119
submaxillary triangle, 10

— gland, 118
sub-peritoneal fat, 308
subscapular artery, 247

— nerves, 251
subscapularis, 242
succussion, 201
superficial cardiac area, 165
superior intercostal artery, 157

— laryngeal nerve, 70

— maxilla, 17

— maxillary nerve, 62

— thyroid artery, 28

— vena cava, 187
supinatpr longus, 271

— brevis, 281

supra-clavicular nerves, 146
supra-maxillary nerve, 67
supra-renal bodies, 350
supra-orbital artery, 81

— nerve, 61

supra-scapular artery, 233
supra-trochlear nerve, 61

' surgical kidney,' 410
suspension in spinal disease, 212
Sylvius, aqueduct of, 56

Index

525

Sylvius, fissure of, 44, 46
Syme's amputation, 499
symmetrical pains, 210
sympathetic nerves, 223

of pelvis, 376

symphysis pubis, 447
synechia, 88

synovial sheaths at wrist, 274
synovitis of knee, 474

tailor's bursa, 360, 496

talipes, 503

tapping abdomen, 295, 296, 317

— pericardium, 161

— pleura, 190
tarsal cartilage, 72
tarso-metatarsus, 509
tarsotomy, 503
tarsus, 508

teeth, 112
tegmentum, 54
temporal artery, deep, 32
superficial, 31

— bone, 12

— fascia, 8

— muscle, 8

— nerves, 62, 67

— vein, 34

temporo-facial nerve, 66
temporo-maxillary joint, 20

vein, 34

temporo-sphenoidal lobe, 48
tendo oculi, 73

tendon of Achilles, 487

— reflex, 220
tendons of wrist, 270
Te"non, capsule of, 77
tensor palati, 108

— tympani, 96
tentorium, 39
teres muscles, 242
testis, 426

— vessels of, 432
tetanus, 8
thalami optici, 54
thigh, 447

third nerve, 58

thoracic aneurysm, 180, 184

— aorta, 184

— arteries, 156

— duct, 157

— nerves, 150
thorax, 148

— upper opening of, 153
thumb, amputation of, 290

— ball of, 269, 292

— dislocation of, 290

— extensors of 281

TUB

thymus gland, 154
thyro-hyoid membrane, 126

muscle, 5

thyroid artery, inferior, 233

— axis, 233

superior, 28

— body, 134

— cartilage, 125

— veins, 36, 185, 186

• inferior, 187

thyroidea ima, 182
thyrotomy, 130
tibia, 495

— threefold displacement of, 477
tibial artery, anterior, 492
posterior, 488

— muscles, 492

— nerve, anterior, 381, 382
posterior, 381

tic, 60

tight lacing, 300

tinkling, metallic, 201

toe, great, amputation of, 503

toes, supplies of the, 505

tongue, 114

— excision of, 116
tongue-centres, 51
tonsils, in
torcular Herophili, 39
torticollis, 3
trachea, 131
tracheotomy, 131
tragus, 93

tran sversalis muscle, 304

— fascia, 305

transverse cervical artery, 233
nerve, 145

— colon, 326

— section of cord, 221
trapezius, 2

trapezoid ligament, 226
triangle, at elbow, 263

— occipital, 9

— Scarpa's, 454

— subclavian, 9
triangles of neck, 9
triangular ligament, 441

— fibro-cartilage, 285
triangularis sterni, 148
triangle of Petit, 305
triceps, 244
tricuspid valve, 167

disease of, 172

trifacial nerve, 60
trigone, 408
trismus, 8
trochanter, bursa of, 460

— fracture of, 465
tube, EustaAian, 99

— Fallopiai, 401

526

A Manual of Anatomy

TUB

tuber annulate, 54

— ischii, 363

tunica vaginalis, 310, 428

tympani, membrana, 97

tympanum, 95

ulcer of duodenum, 325

stomach, 321

ulna, 282
ulnar artery, 277

— nerve, 253

— veins, 237
umbilical hernia, 298
umbilicus, 297
upper extremity, 235
urachus, 298, 406
ureter, 344, 349
urethra, female, 403, 419

— male, 415
urethral triangle, 439
urine, incontinence of, 423
uterine artery, 373
uterus, 389

uvea, 87
uvula, no

— of bladder, 409

vagina, 403
vaginal artery, 373

— hernia, 314, 405
vaginismus, 404
vagus, 69

Valsalva, sinus of, 168
valve, ileo-csecal, 328
valves of heart, 169
valvular disease, effects of, 177
varicocele, 433

varicose aneurysm, 238
Varolii, pons, 54
vas aberrans, 247

— deferens, 431
vasti, 453

veins at elbow, 237

— of Galen, 40

pelvis, 377

velum interpositum, 39
vena azygos, 154

— cava, inferior, 355
superior, 187

— portse, 337

ZYG

vena salvatella, 237
venae vorticosas, 85
venaesection, 237
Veneris, mons, 402
venous pulse in neck, 174.

— sinuses, 39
ventral hernia, 298
ventricles of brain, 38

heart, 167

vermiform process, 327
vertebra, fifth cervical, 23

— prominens, 205
vertebras, 205
vertebral artery, 231

— vein, 232
vertigo, aural, 101
veru montanum, 416
vesical arteries, 373
vesicocele, 404
vesicula seminalis, 436
vesicular breathing, 200
vestibule of ear, 101
Vidian artery, 33

— nerve, 63
vitreous, 89
vocal cords, 127

— fremitus, 200
voice-sounds, 201
volvulus, 326
vomiting, 321

water-hammer pulse, 174
Wharton's duct, 118
Willis, circle of, 43
wind-pipe, opening the, 129
Wolffian body, 399
Wrisberg, nerve of, 253
wrist-drop, 252

— tendons of, 270

— joint, 285

excision of, 287

tendons around, 270, 287

wry-neck, 3

yellow>pot, 93

zones, abdominal, 299
zoster, 302
zygomatici, 106

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