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PRACTICAL 
 
 MEDICAL ANATOMY 
 
 A GUIDE TO THE PHYSICIAN 
 
 m THE STUDY OF THE RELATIONS OF THE VISCERA TO EACH 
 OTHER IN HEALTH AND DISEASE 
 
 AND 
 
 IN THE DIAGNOSIS OF THE 
 
 MEDICAL AND SURGICAL CONDITIONS OF THE ANATOMICAL 
 STRUCTURES OF THE HEAD AND TRUNK 
 
 AMBROSE L. ^A^ITET, A.M., M.D. 
 
 ^ADJUNCT PROFESSOR OF ANATOMY, AND LATE LECTURER ON GEN ITO -URINARY AND MINOR SURGEKT 
 
 JN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF THE CITY OP NEW YORK; LATE SURGEON 
 
 TO THE NORTHERN AND NORTHWESTERN DISPENSARIES; RESIDENT FELLOW OF THE NEW 
 
 YORK ACADEMY OF MEDICINE, MEMBER OF THE MEDICAL SOCIETY OF THE COUNTY OP 
 
 NEW York; author of "the applied anatomy of the nervous system," 
 "a practical treatise on surgical diagnosis," "the essentials 
 
 OF ANAi-OMY," ETC., ETC. 
 
 NEW YOKK 
 WII,LIAM WOOD & COMPANY 
 
^cornell\ 
 
 Ur^iVERSITY 
 LIBRARY -^^ 
 
 GOPYRIOHT BT 
 
 WILLIAM WOOD & COMPAlTSr. 
 1882. 
 
I dedicate this Volume 
 
 MY WIFE, 
 
 to TH-hose discreet counsel, coTirage, laith, and loYing 
 
 companionship, I o'swe more than this 
 
 simple ackno-wledgment. 
 
INTRODUCTION. 
 
 T>R. Daewest, wlien lie wrote the preface to Ms " Zoonomia," stated 
 his proposed object in the following sentences : " A theory founded on 
 Nature, that should bind together the scattered facts of medical knowl- 
 edge, and converge into one point of view the laws of organic life, 
 would thus on many accounts contribute to the interests of society. It 
 would capacitate men of moderate abilities to practise the art of healiag 
 mth real advantage to the public ; it would enable every man of literary 
 attainments to distinguish the genuine disciples of medicine from those 
 of boastful effrontery or of wUy address ; and would teach mankind in 
 some important situations the knowledge of themselves." 
 
 To achieve pre-eminence in the discovery of a general law, or to 
 attain renown in science by the value of original investigation is an en- 
 viable as well as an uncommon privilege ; but in the voluminous litera- 
 ture of medical science, many a fact still remains which will bear 
 constant repetition, which is pregnant with practical value, and which 
 might otherwise be either forgotten by, or unknown to, the general 
 reader. Compilation is therefore not without some decided value, if 
 discreetly performed. 
 
 The anatomy of man must always be the groundwork of aU medical 
 knowledge, since by it alone are we able to understand the various 
 functions of the human frame, the symptoms of disease, and the ration- 
 ale of treatment. In our present enlightenment, physiology, histology, 
 and pathology are becoming so inseparable from the dry detail of mere 
 anatomical description, and the surgical bearings of the various struc- 
 tures are so intimately connected with general diagnosis, that it is no 
 longer possible, within the limited scope of a single volume, to present 
 to the general practitioner all the valuable points which can be daily 
 applied in the various departments of medicine. 
 
 To any one, f amihar with the earlier writers, the fact must, however, 
 be apparent, that, in spite of the rapid strides which are constantly 
 being made (through the aid of greater facilities for research, improved 
 apparatus, and new discoveries as to the application of general laws in 
 physics as a means of diagnosis), most of the fundamental facts, upon 
 whicli great stress is still laid, were known and skilfully used centuries 
 
VI INTRODUCTION. 
 
 ago. One, wlio attempts to establish priority to-day in almost any 
 braneli, is more than likely to find, in these earlier works, evidences of 
 previous thought in the same direction ; derived often from investiga- 
 tion pursued with a diligence that deserves more than simple praise, 
 when the difiiculties which then existed are considered. The use of 
 the special senses of the physician were then educated to a degree of 
 acuteness which few of our modem savants can justly claim for them- 
 selves. The expressions of the sick were once made a special study ; 
 the attitudes assumed in certain types of disease were carefully 
 noted and impressed upon the student ; the sense of touch was edu- 
 cated until the most trifling variation in the pulse, or the contour of the 
 various anatomical regions seldom escaped detection ; the anatomy of 
 the living subject was taught in those days in all its practical bearings 
 in connection with dissection ; and the student, by a constant repetition 
 of the more important anatomical guides, became familiarized with the 
 contents of surgical regions, the relations of the viscera to each other, 
 the value of the bony prominences, and the general plan of construction 
 which characterizes the biped from the quadruped, man from the lower 
 animals. Taste and smell were, to the physician of that time, faculties 
 which afforded practical points in diagnosis; and the secretions and 
 excretions of the body had not alone a physiological importance, but 
 were often used by the skilful physician as valuable aids to diagnosis. 
 
 It is, to my mind, a question if our present methods of medical in- 
 struction, as evidenced in our literature, do not tend to make the medi- 
 cal reader attach but a trivial importance to some of those aids which 
 made these men great and which cause their writings to be still re- 
 spected. Does it not tend to make us rely solely upon the later 
 science of auscultation and percussion in our examinations for obscure 
 diseases of the viscera, to the partial or utter disregard of many of the 
 outward symptoms which were then so carefully studied ; and to bring 
 into prominence chemical and microscopical analyses to the exclusion of 
 the special senses, when positive information upon subjects, to which 
 they are all equally applicable, is demanded ? 
 
 This volume is an indirect outgrowth of two courses of lectures 
 delivered by me before the students of the Medical Department of the 
 University of the City of New York, during the winters of 1879 and 
 1880, upon the anatomy of the circulatory and nervous systems, and one 
 in the spring of 1878, upon the anatomy of the viscera. Then more 
 than ever before, I realized that all practical points were received with 
 greed by the student ; in contrast to the apathy with which long de- 
 scriptive detail must necessarily be accompanied, unless, by illustration 
 it can be made clear that dry facts are not deficient in interest^ and that 
 
nrTBODUCTION. VU. 
 
 anatomy is not alone a mere preparatory drill to the practical branches, 
 hut a source of ever varying utihty in all the walks of professional life. 
 It struck me then that if anatomy could be so presented in all its de- 
 partments as to convince the medical reader that it could be made a 
 source, not only of pleasure at the time, but of unceasing benefit in 
 whatever direction his professional taste might call him, its study would 
 cease to be wearisome and its details no longer a task of memory. 
 
 The following pages, ' such as they are, have cost me many hours of 
 research to write ; and it is to be hoped they will afford some useful 
 hints to those who read them. As a prominent author puts it : " That 
 writer accomplishes the most, who gives his reader the inost knowledge, 
 and takes from him the least time ; " and I have not forgotten, in my 
 effort to make the work useful to all, the wise observation of him who 
 says " in the same meadow the ox seeks the herbage ; the dog the hare ; 
 and the stork, the lizard." 
 
 In deliberating upon the plan of arrangement of this work, the 
 question naturally arose how the subject could be best treated to sys- 
 tematize its study and at the same time to facilitate reference. It has 
 long been a custom with authors of works upon descriptive anatomy, 
 to exhaust each of the separate divisions of this subject before pro- 
 ceeding to the consideration of the next, thus treating in successive 
 chapters of osteology, arthrology, myology, etc.; while, in works de- 
 signed for use at the disseeting table, custom has modified the plan so 
 that we find all of the structures contained in special anatomical regions 
 so grouped as to furnish the student with a detailed description of the 
 vessels, muscles, nerves, etc., as they are met with in practical anatomy. 
 
 The object of this latter plan is obvious ; it furnishes the reader the 
 information for which he seeks, without the necessity of constant refer- 
 ence to different portions of the volume, which would not be afforded 
 by a general treatise. On the other hand, such a plan in a descriptive 
 treatise would tend to confuse the beginner, who is supposed to be 
 ignorant of anatomy, and even of the terms used in it, and who, very 
 properly, can best acquire a mastery of the general subject by a thor- 
 ough comprehension of each of the separate departments of anatomy in 
 their proper order ; and thus its utihty as a text-book would be impaired. 
 Furthermore, a different plan in a general treatise greatly f acihtates 
 reference, and thus adds to its popularity with the general medical 
 pubhc. 
 
 I have concluded, after much dehberation, to combine these two 
 methods, in the presentation of this work ; since, although, I can see 
 some defects in the arrangement which may cause others to disagree 
 
"Vlll INTEODUCTION. 
 
 with me in my decision, I believe that the aims of this volume wiU 
 be best promoted thereby. 
 
 As this work is not intended to be a treatise upon descriptive 
 anatomy, but rather a collection of hints which shall serve as a guide 
 to the study of the practioal hearings of the different portions of the 
 head and trunk upon the field of general medicine, only such points 
 win be touched upon as seem to the author worthy of incorporation 
 from a physiological, surgical, or medical point of view, or bearing, in 
 such a way, upon the boundless field of comparative anatomy as to add 
 to the interest of the reader in showing the object of the Creator in 
 causing man to so deviate from the type of the lower animals. 
 
 I have separated the description of the head and the neck, because, 
 anatomically, the latter region is only a portion of the trunk, although, 
 by so doing, the branches of some of the large arteries of the neck wOl 
 be described before the main trunks have been considered, which to 
 the beginner might possibly create confusion. But the same objection 
 appHes with equal force to all dissecting manuals ; and, as the present 
 volume presupposes some education on the part of its readers, it seems 
 to the author that the benefits which this arrangement afEords far out- 
 weigh its disadvantages. I have, however, followed the plan of gen- 
 eral text-books upon anatomy, as regards the grouping of such points as 
 pertain to the bones, muscles, vessels, and nerves, since, by so doing, 
 reference is greatly facilitated, and the danger of any important omis- 
 sions on the part of the author decreased. 
 
 In regard to the vessels, it is impossible to avoid reference to the 
 surgical anatomy of the more important trunks, in attempting to teach 
 the practical points pertaining to them ; while, as to the nerves of the 
 body, some hints that properly pertain to physiology and surgery can- 
 not be omitted, if the aim of this work is to be fully attained, although 
 the limited size of this volume will preclude the insertion of but scat- 
 tered hints in this direction. It is not to be inferred, however, that 
 this work pretends to cover the ground, either of physiology or of 
 operative surgery, since but a small portion of the former science treats 
 of the vessels and nerves, while the latter department embraces reme- 
 dial measures for every existing condition demanding surgical inter- 
 ference. 
 
 Again, when special bones are under discussion, and the attachments 
 of the muscles of each seem to indicate that memory will be assisted 
 by a reference to the action of some of these muscles which assist in 
 producing special types of deformity, in case of fracture of the bone, it 
 must not be forgotten that the bearing of anatomy upon the subject 
 ceases with the enumeration of those facts, and cannot possibly suggest 
 
INTEOD0CTION. IX 
 
 a discussion either of its symptoms or of the surgical appliances used 
 for its relief. 
 
 The points of practical utility which pertain to the integument are 
 •chiefly confined to the region of the head. Many of them are unques- 
 tionably due to the insertion of small sKps from the facial muscles into 
 the skin and subcutaneous tissues, but they are, nevertheless, constant, and 
 may often prove of great value. It is common with many authors of 
 the present day to either totally disregard the valuable points of diag- 
 nosis afforded by the face, or to stamp as visionary all points of diag- 
 nostic value which have been attributed by authors, in the past, to 
 special lines and wrinkles. While, perhaps, there may lae, in many 
 instances, sufficient ground for such scepticism, still the entire subject of 
 medical physiognomy should not, in my opinion, be totally disregarded 
 or pronounced absolutely worthless. If all our examinations of those 
 afBicted with diseases of the thoracic and abdominal viscera were con- 
 fined alone to a physical examination through the aids of percussion 
 and auscultation, without the opportunity of studying the physiognomy 
 of the patient, an iinf avorable prognosis as to the duration of Hf e would 
 frequently be pronounced ; when, could the brilhancy of the eye, 
 the expressions of the mouth, and the general facial characteristics of 
 the individual bespeak the vitality of temperament and the reactive 
 power which no physical examination could possibly determine, the 
 prognosis might appear less grave. I do not offer this as an apology 
 for the few scattered hints given as to the value of facial lines as a 
 means of diagnosis, or for the illustration of special types of counte- 
 nance afforded by disease. Each reader must for himself determine 
 to what extent the guides thus afforded by the earher investigators are 
 of value, and, by practical investigation, confirm some which have been 
 mentioned in this volume, and discard those which seem visionary or 
 hypothetical. 
 
 If tlie term "medical anatomy" be taken in its most restricted 
 sense, the title of this work is a misnomer. It has been written for the 
 use of the general practitioner, in his daily practice, with the hope that 
 it might present to him the study of anatomy from the stand-point of its 
 general interest and practical utihty, and afford him a means of refresh- 
 ing certain points which can be constantly applied, without entailing 
 upon him much descriptive detail. It is properly called "medical," 
 since it deals only with the head and the trunk, and the organs con- 
 tained within the cavities of the thorax and abdomen ; but it would be 
 insufficient for the wants of the general practitioner if it contained 
 only such points as could be applied to the diseases of the viscera alone. 
 I have, therefore, seen fit to incorporate many anatomical guides to the 
 
INTKODUCTION. 
 
 superficial, as well as the deeper structures, and to leave no region as 
 complete, until the various parts contained in it have been considered 
 in many of their practical relations, whether they be of a surgical or 
 purely medical character. I have furthermore incorporated such sug- 
 gestions as would tend to show a definite object in the construction of 
 the human frame, and, in many instances, have called attention to the 
 variations of the human body from that of the lower animals, when 
 such deviations could be explained as a wise provision on the part of 
 Nature. 
 
 Some portions of this work have already appeared in print in 
 various medical journals both in this country and in Europe, but they 
 have been altered and enlarged to meet the demands of this work ; 
 while the abundance of illustration will still further assist in making 
 the points more forcible and easy of comprehension to the reader. It 
 is not to be expected, nor is intended, that this work can serve all the 
 purposes of an extended anatomical treatise, since, of necessity, much 
 that pertains to the blood-vessels, nerves, and viscera has been omitted ; 
 but this objection applies with equal force to such valuable works as 
 those of Sibson and Hilton, each of which tills the place for which it 
 was designed. 
 
 I have used italics more frequently than would be deemed neces- 
 sary, or, perhaps, in good taste, if the book were simply intended to be 
 read from a stand-point of its general interest, and I have, in many 
 instances, divided the text into shorter paragraphs than is conducive to 
 the best appearance of the page, but this volume must, of necessity, con- 
 sist of fragmentary jottings, each of which brings out some individual 
 point of value, and the italics will greatly assist reference to different 
 portions of the text, when much time might be otherwise lost in seek- 
 ing for some special suggestion. 
 
 I have purposely omitted the illustration of anatomical statement 
 or of theory, by the details of cases, even where these rules may have 
 been applied by myself and others with benefit, and I have refrained 
 from dwelling, at any length, upon the methods of treatment employed 
 in the various diseases which have been discussed ; since I consider that 
 the anatomical character of the work should ever be kept uppermost in 
 the mind both of the author and the reader, and that any deviation 
 from the strict line of the task is to be deprecated rather than encour- 
 aged. It has been my earnest endeavor, as far as the limited size of 
 the volume would allow, to incorporate all that can be commended in 
 the works of authors in tlie same field, and to omit all that seemed 
 visionary or hypothetical. 
 
 If the work, as it stands, will help to verify that hackneyed phrase,. 
 
INTKODUOTION. XI 
 
 with which most courses of anatomical lectures are prefaced, but which 
 few of the listeners are ever able to appreciate, in ah of its bearings and 
 truthfulness of statement — "that anatomy is the foundation of all 
 medical knowledge " — ^the author will feel that his labor has not been 
 done in vain. 
 
 156 Madison Ave., New York City. 
 
TABLE OF OONTEE"TS. 
 
 pAas 
 In-jeoduction v-xi 
 
 PART I. THE HEAD. 
 
 Chapter I. The Bones of the Head— Their Points of Special Inter- 
 est 1-31 
 
 Abnormalities of the skull; General construction of the skull; Thick- 
 ness of the skull and its variations; Tablets of the skull and their 
 points of cHnioal interest; — Bony guides to intra-cerebral points of 
 interest; General rules for trephining; — Sutures of the skull, and 
 their clinical relations; — Occipital bone, its clinical relations; Sphe- 
 noid bone, its clinical relations; Frontal bone, its clinical relations; 
 Parietal bone, its clinical relations; Temporal bone, its clinical rela- 
 tions; The bones of the nasal fossa; — The base of the skull, and its 
 chnical relations; — Bones of the face and the clinical relations of 
 special parts; The orbit, its general construction and chnical rela- 
 tions; The nostril, its clinical relations; The upper jaw, its clinical 
 relations; The nasal bone, and the nasal arch; — the inferior maxillary 
 bone, and the teeth; — The cranium as a whole: Its buttresses and 
 their relation to fracture of the skull; — Variations in the form of the 
 skull: Skull of infancy; Skull of childhood; Skull of the two sexes; 
 Skulls of races and their variations: Mechanical deformities of 
 skulls; — Poise of the head, and the diagnostic value of deviations 
 from the normal attitude. 
 
 Chapter II. The Human Face in Health and Disease, and its Value 
 
 AS A Guide in Diagnosis 31-71 
 
 Medical physiognomy, its clinical importance; — Facial lines, and the 
 clinical significance of each: The transverse rugae; The oculo-frontal 
 rugse; The linea oculo-zygomatica; The linea nasalis; The linea labi- 
 alis; The linea coUateralis nasi; — Color of the face, and its changes in 
 disease: Flushing of face, its causes; Red patches on cheek; Pallor 
 (waxy, dusky, and leaden); Green discoloration; Light straw color 
 of face; Yellow discoloration of the face; Blue discoloration of the 
 face; Brown discoloration of the face. — Table of the forms of coun- 
 tenance met with in the more prominent diseases. —Special regions 
 of the face, and their modifications: The forehead, its clinical 
 aspects; The nose, its physiological interest and clinical aspects; The 
 eye, as an indicator of character and disease: The cornea, its clinical 
 aspects; The pupil, its clinical aspects; The eyeUd, its clinical aspects; 
 Squint of eye, its clinical aspects; Special types of the eye in dis- 
 ease; The ear, its clinical suggestions: Ear of gout; Ear of visceral 
 
XIV TABLE OF CONTENTS. 
 
 PAGE 
 
 cirrhosis; Ear of insane subjects; The cheek, its physiological and 
 clinical points of interest: Modifications with age; Physiological 
 functions; Variations in its color, and its significance; Surgical 
 aspectsofthecheek;The lips, their physiological and medical aspects : 
 Congenital deformities of the lips; Lips of the infant; Lips of the 
 aged; Lips, as indicators of pain; Pallor of lips, its significance; 
 Lividity of lips, its significance, — Deformities of the face — Congenital 
 defects: In region of the orbit; Absence of eyes; Union of orbits; De- 
 fects in eyelids; Defects in pupil, andotherstructuresof theeye; Total 
 absence of the face ; Median fissures of the face ; Absence ofnostrils; Ab- 
 sence of mouth; Double nose; Acquired defects — Herniaof the Brain; 
 Tumors in the region of the face; Ulceration (lupus, carcinoma, etc.); 
 Special types of face, and the clinical significance of each: ' ' Facies scro- 
 fulosa;" Face of idiots and imbeciles; " Facies Hippocratica;" "Facies 
 stupida;" "Pinched countenance;" Face of apnoea; Face of ansemia; 
 Eye of strumous ophthalmia; Eye, in iritis; Eye, in amaurosis; Eye, 
 in cataract; Abnormal attitudes of face and head from ocular paresis; 
 Eye, in chronic trachoma; Eye, in ptosis; Eye, in epicanthus; Eye, 
 in glaucoma; Eye, in anterior dislocation of the lens; Eye, in loco- 
 motor ataxia; Eye, in motor oculi paralysis; Head and face, in 
 hydrocephalus; Face, in thoracic affections; Face, in pneumonia; 
 Face, in emphysema; Face, in extreme dyspnoea, and the diseases 
 which tend to produce it; Face, in renal dropsy; Face, in chronic 
 abdominal diseases; Face, in valvular heart disease; Face, in Graves' 
 or Basedow's disease; Face, in cholera; Face, in chronic atrophy; 
 Face, in epilepsy; Face, in glosso-labial paralysis; Face, in general 
 paralysis of the insane; Face, in tetanus; Face, in chorea; Face, in 
 catalepsy; Face, in cretinism; Face, in crossed paralysis; Face, in 
 Bell's paralysis; Face, in trigeminal paralysis. 
 
 Chaptek III. The Blood- Vessels op the Head 71-110 
 
 Their clinical importance, in general — The lingual artery: its origin 
 and course; its ranine branch; the operation for ligation; its clinical 
 importance — The facial artery: its origin and course; its surgical 
 relations; its peculiarities and those of its branches; its siu'gical 
 anatomy; the operation for its ligation; its various anastomoses; — 
 The occipital artery: its origin and course; its peculiarities; its sur- 
 gical anatomy; — The posterior auricular artery: its origin and course; 
 its main branches; its peculiarities; — The ascending phaiyngeal 
 artery: its origin and course; its branches; its peculiarities; its sur- 
 gical anatomy; — The temporal artery: its origin and course; its 
 peculiarities: its surgical anatomy; — The internal maxUlary artery: 
 its origin and course; its various branches; its peculiarities; its sur- 
 gical anatomy; — The internal cai'otid artery: its origin and course; 
 its anatomical divisions; its peculiarities; its surgical anatomy; its 
 ophthalmic branch and its points of interest; the cerebral branches 
 and the areas of brain supplied by each; surgical anatomy of the 
 middle cerebral branch; aphasia, and its relation to embolism of the 
 middle cerebral branch; — The vertebral artery: its origin and course; 
 its various branches; its anastomoses; — The basilar artery: its course 
 and branches; its posterior cerebral branch;— The circle of Willis: 
 The vessels which help to form it; its nutrient branches given off to 
 
TABLE OF CONTEJSTS. XV 
 
 FAQE 
 
 tue bram;— The arterial supply of special regions of the head: Arte- 
 rial supply of the meninges; arterial supply of the tympanum; — 
 Hemorrhage, in general: Its varieties; Causes which modify it; 
 Causes which tend to prolong it; Symptoms due to hemorrhage; 
 Guides and suggestions as to the relief of hemorrhage. 
 
 The veins of the head — The cerebral sinuses: their formation and 
 the relative situation of each to the skull;— The veins of the exterior 
 of the skull: The facial vein; The temporal vein; The internal maxil- 
 lary vein; The temporo-maxillary vein; The posterior auricular vein; 
 The occipital vein;— Surgical aspects of the veins of the head. 
 
 Chapter rv. Special Regions of the Head, and the Points op Gen- 
 eral Interest Pertaining to Each 111-135 
 
 The temporal region — The Kar; its deformities; its follicles and their 
 clinical importance; the auditory canal; its curve; its relation to 
 foreign bodies; clinical significance of pus in the auditory canal; — The 
 membranatympani; rupture of; perforation of; — The mastoid process, 
 its construction and functions; trephining of ; — Middle ear; functions 
 of; cleansing of; — The wounds of the temporal rrgion; — Trephining 
 over the temporal region ;— Hernial protrusions in the temporal region, 
 through the lateral fontanelle; — Caries and necrosis of the temporal 
 region; escape of blood and cerebro-spinal iluid from the ear: their 
 clinical significance. 
 
 The region of the nose — Alterations in its cavities with age; — Prob- 
 ing of the nasal duct from below; — The cavities which communicate 
 with the nasal fossae;— Plugging of the posterior nares for epistaxis; — 
 Catheterism of the Eustachian tube;^Foreign bodies in the nose, the 
 symptoms produced, and the steps necessary for their extraction. — 
 Abnormal growths within the nose, their varieties and clinical points 
 of intei-est. 
 
 The region of the orbit — Results of injuries received in the region 
 of the eyebrow; — Opening of the frontal sinus; — Injuries to the nerves 
 of the orbit ; — Penetrating wounds of the orbit, and their possible 
 complications; — Extirpation of the eye, and its possible complica- 
 tions; — Amputation of the globe of the eye; — Tumors of the antrum 
 and their effects upon the orbit; — Clinical relations of the pulley for 
 the superior oblique muscle of the eye; — Probing of the lachrymal 
 canals and nasal duct; — The clinical relations between diseases of the 
 eye and nose; — Paralyses of the nerves of the orbit. 
 
 The region of the mouth — Surgical conditions of the cheek; Sali- 
 vary fistula; — The diseased conditions of the tongue; Furring of the 
 lateral half of the tongue from irritation of the trigeminus or glosso- 
 pharyngeal nerves; Operations for removal of the tongue; — Occlusion 
 of the salivary ducts; — Physiological functions and diseased condi- 
 tions of the soft palate; — Diseased states of the tonsil; Excision of 
 thetonsil; — Modifications of the teeth in congenital syphilis; — Dis- 
 eased conditions of the lower jaw; — Resection of the lower jaw; Fis- 
 sures of the hard palate; — False anchylosis of the lower jaw. 
 
XVI TABLE OP CONTENTS. 
 
 PART n. THE TRUNK. 
 
 PAGE 
 
 Chapter I. The Vertebral Column, its Physiological and Clinical 
 
 Points of Interest 136-165 
 
 The vertebrsB in general; Curves of the verfebral column and their 
 functions; The intervertebral disks; The movements permitted by 
 the spinal column; Changes in the length and shape of the spinal 
 column; The spinous processes, their varying lengths and their func- 
 tions; — The vertebrae as surgical guides; The third cervical, fifth 
 cervical, seventh cervical, third dorsal, eighth dorsal, ninth dorsal, 
 tenth dorsal, eleventh dorsal, twelfth dorsal, first lumbar, second 
 lumbar, third lumbar, fourth lumbar; — The relative points of origin of 
 the various spinal nerves; — The spinal canal, its variations in 
 size, its contents, and its surgical aspects; Dislocation of the cer- 
 vical vertebrae; The atlas and axis; The cervical rib; Peculiarities of 
 the sacral region; — Clinical points suggested by the vertebral column; 
 Variations in length of the neck; Variations in the mobility of the 
 spme with age; Caries of the vertebrae; Congenital and acquired mal- 
 formations; Spina bifida; Fractui-es of the vertebrae; Pain in spinal 
 lesions, and its clinical significance; Lesions of the spinal nerves fol- 
 lowing disease or injury of the vertebrae; Abnormal curvatures of 
 the spine; Pott's disease; Dislocation of the last lumbar vertebra 
 upon the sacrum ; Rosenthal's test for existing caries; Displacement 
 of the occipital bone from the atlas, and of the atlas from the axis; 
 Displacement of the transverse processes of the vertebrae. 
 
 Chapter II. The Neck and its Structures— their Clinical Aspects 155-185 
 
 Alterations in the curve of the neck with age; — Variations in its 
 length, and its medical aspects; The short neck, in disease; The long 
 neck, in disease; — The "Veins of the neck: Causes which tend to make 
 them prominent; Pulsation of the jugulars, its cause; Relation of the 
 veins of the neck to cyanosis; The vems of the neck in surgical ope- 
 rations; Air in the veins, its causes, mechanism of death, symptoms, 
 and treatment; — The muscles of the neck: The platysma; The omo- 
 hyoid; The scaleni; The levator anguli scapulae; The muscles of de- 
 glutition; The mechanism of deglutition in its three stages;— Clinical 
 points pertaining to the muscles of the neck; Paralysis of the sterno- 
 mastoid, and its symptoms; Paralysis of the trapezius, unilateral and 
 bilateral, and the symptoms of each; — Regions of special interest in 
 the neck: (1) The supra-clavicular region, its contents, effects of 
 wounds of, its relations to the lung, its nerves and vessels, its surgi- 
 cal guides; (2) The stemo-mastoid region, its boundaries, its contents, 
 effects of wounds of, its glands, and their enlargement; (8) Supra- 
 hyoid region, its contents, its relation to diseases of the pai-otid and 
 submaxillary glands; (4) Anterior cervical region, its boundaries, 
 contents, fasciae, surgical guides, its relation to the operations of 
 laryngotomy and tracheotomy, and diseases of the respiratory 
 organs, pharynx, and larynx; (5) The posterior cei-vical region, its 
 contents, effects of wounds of, its surgical and medical aspects; — 
 Points in the diagnosis of abnormal swellings in the neck: Glandular 
 tumors; Cystic Tumors; Fatty tumors; Suppuration; Malignant and 
 syphilitic gi-owths; Tumors of vessels; — The arteries of the neck: 
 
TABLE OF CONTENTS. XVll 
 
 PAGE 
 
 The subclavian artery, essentially a vessel of respiration, as shown 
 by its distribution; The internal maxillary artery, essentially a vessel 
 of mastication, as shown by its branches. 
 
 Chaptee III. The Bones of the Thoeax and theib Relations to the 
 
 Adjacent Structures 186-208 
 
 The dorsal curve of the spine and the anatomical peculiarities of that 
 region;— The ribs, a series of arches; The superior and inferior tho- 
 racic apertures, and the structures which pass through them; The 
 movements of the ribs and their effect upon the capacity of the tho- 
 rax; The customary subdivisions of the ribs; The costal cartilages, 
 and their functions; The attachment of the ribs and their obliquity; 
 The effects of direct and indirect violence to the ribs; The first rib, 
 and its surgical and medical aspects; The intercostal muscles, and 
 their functions; — The sternum: Its situation and functions; Its sub- 
 divisions; Its surgical guides; Its attachment to the clavicles; Its 
 modifications from mechanical causes; Congenital defects of; Medi- 
 cal aspects of the sternal region; Fracture of the sternum; Displace- 
 ment of the sternum;— The walls of the thorax, considered as a 
 whole: Congenital malformations; Acquired deformities; The modi- 
 fications dependent upon the sex; Rules for counting the ribs during 
 life; Relation of the nipple in health; Guide to the second rib; The 
 serratus magnus, as a medical guide; The scapula, as a medical 
 guide; The pectoralis major muscle, as a medical guide; Guide to the 
 sixth rib; Guides to the eleventh and twelfth ribs; The xyphoid car- 
 tilage, as a medical guide; — External guides to the thoracic viscera, 
 in health and disease: (1) The heart:— Rules to outline it upon the 
 chest; The areas of cardiac dulness; The apex-beat, and the diseases 
 which tend to modify its position; Means of examining for the apex- 
 beat; Tlie abnormalities of the apex-beat; The relation of the valves 
 of the heart to the chest-wall; Means of examining a patient for val- 
 vular defects; The precordial region, and its changes in the course of 
 certain diseases; Pericarditis, its effects on pulmonary displacement; 
 Cardiac hypertrophy, its effects on the lung; The heart-impulse, its 
 relation to pulmonary displacement; General diagnostic points re- 
 specting cardiac disease; (3) The limgs — Their position after death; 
 Their position during life; Their changes during respiration; The 
 apices of the lungs, and their surgical aspects; The anterior borders 
 of the lungs; The shape of the thorax as a guide to the amount of 
 lung-tissue; The chest of phthisis; The effects of pleuritic effusions 
 upon the lung and chest; The causes which tend to create variations 
 in the outline of the lung in reference to the chest-wall; Effects of 
 emphysema, all wasting diseases, pneumonic consolidation, pleurisy, 
 pericardial effusion, mediastinal tumors, and diaphragmatic displace- 
 ment, upon the normal pulmonary limits. 
 
 Chapter IV. The Chest and its Contained Organs 309-355 
 
 Medical subdivisions of the thorax and their boundaries; The supra- 
 sternal region and its contained organs; The superior sternal region 
 and its gross contents; The inferior sternal region; The supra-clavicu- 
 lar region; The clavicular region; The infra-clavicular region; The 
 
XVlll TABLE OF CONTENTS. 
 
 mammary region; The supra-scapular region; The scapular region; 
 The infra-scapular region; The inter-scapular region; The axillary- 
 region; The infrar axillary region; — Surgical points pertaining to the 
 thorax; Fractures of the ribs and the possible complications of such 
 an accident; The symptoms liable to be produced by fracture of the 
 ribs; Resection of the ribs for caries and necrosis; The evacuation of 
 fluid from the chest; The operation of tapping the pericardium; De- 
 formities of the thorax and their causes; Dislocations of the costal 
 cartilages; Punctured wounds of the chest and their dangers; Wounds 
 of the pleura, lung, and heart; Wounds in the sternal region and the 
 possible complications of such an accident; Abscesses of the 
 mediastina; Deformities of the sternal region; Surgical diseases 
 of the sternal region; Diseases of the mammary region; Cupping 
 of the costal region for pulmonary diseases; Spina bifida; Curva- 
 tures of the dorsal region of the spine; Effects of blows received 
 upon the back; Abnormal conditions of the diaphragmatic region 
 of the thorax; Laceration of the diaphragm; Wounds of the 
 diaphragm; Steps in making a diagnosis of hepatic abscess; 
 Abnormal positions of the diaphragm; Diaphragmatic hernia; Coun- 
 ter-irritation and depletion in the diaphragmatic region and its 
 effects; Protrusions of diaphragmatic growths; — The thorax con- 
 sidered as a whole; The typical inspiratory chest; The typical expira^ 
 tory chest; The alterations of the vertebral curves with inspiration: 
 The action of individual ribs on different portions of the lung; The 
 epigastric space; Thoracic expansion; The inspiratory movements of 
 the scapula; Causes of retraction of the chest-wall; Effects of intra- 
 thoracic hemorrhage; Suggestions as to the auscultation of the chest; 
 The normal relations of the spleen ; The piston-like action of the dia- 
 phragm and its objects; the changes in the thoracic organs with 
 inspiration; Symptoms of an adherent and crippled lung; changes in 
 the chest from emphysema; The areas of diffusion of the valvular 
 heart-murmurs; — The nerves of the thoracic walls; The nervous dis- 
 tribution to the pleura and its physiological deductions; Pain in the 
 axilla, an evidence of existing pleui'isy; Pain and tenderness in the 
 arm as a symptom of pleurisy; Pain between the shoulders a symp- 
 tom of disease within the mediastina; Pain near the angle of the 
 scapula, a symptom of disease of some of the digestive viscera; The 
 location of pain in cancer of the breast; The relation of the intercos- 
 tal nerves to the so-called "pleuritic stitch;" The relation of 
 the intercostal nerves to the restricted respiration exhibited in 
 pleurisy; — The muscles of the thorax: their general functions 
 and arrangement; Tlie intercostal muscles, a safeguard against 
 hernia of the thoracic viscera; The muscles of inspiration; The 
 diaphragm; The action of the intercostal muscles upon respi- 
 ration; Rule to determine the action of muscles; The auxUiary 
 muscles of respiration; The movements of the scapula; The factors 
 of the act of expiration; The muscles of expiration; The internal 
 intercostal muscles; The infra-costal muscles; The triangularis stemi 
 muscle; The pectoral muscles; The subclavius muscle; The serrati 
 muscles; The levator anguli scapulae muscle; The rhomboidei mus- 
 cles; — The clinical points afforded by the muscles of the thorax; Pa- 
 ralysis of the pectoral muscles, its causes and tests; Paralysis of the 
 
TABLE OF CONTENTS. XIX 
 
 .... PAQE 
 
 rhomboidei and levator anguli scapulse muscles; Paralysis of the 
 latissimus dorsi muscle; Paralysis of the serratus magnus muscle; 
 Paralysis of the dorsal muscles; — Clinical points afforded by the dor- 
 sal nerves: The pain of pleuritic inflammation, and its transmission 
 to the shoulder and arm; Pain high up between the shoulders, and its 
 causes; Pain low down between the scapulae, and its causes; Pain 
 in the "pit of the stomach,'' and its clinical significance; Pain in the 
 pectoral region, and its clinical significance; Abdominal pain, 
 caused by disease within the thorax; Intercostal neuralgia, its causes 
 and diagnostic symptoms; Mastodynia, its causes and diagnostic 
 symptoms; The effects of paralysis of the dorsal nerves. 
 
 Chapter V. The Bones of the Pelvis, and the General Plan of its 
 
 Construction 355-377 
 
 The general form of the pelvis; Its bones; The pelvic arch and its 
 mechanical construction; The obhquity of the pelvis to the spinal 
 column and its objects; The pelvis a support to the viscera as weU as 
 a sustaining arch; Enormous strength of the pelvis; The sacrum, a 
 key-stone to the pelvic arch; The joints of the pelvis and their func- 
 tions; The relation of the acetabulum to the line of gravity of the 
 trunk in the erect posture; The axes of the pelvis; The superior and 
 inferior straits of the pelvis, and their diameters; Objects of the 
 alterations in the diameters of the two pelvic straits; The differences 
 in the superior strait of the bony pelvis and that of the living subject; 
 — The differences between the male and female pelvis; The bones 
 themselves; The muscular prominences; The wings of the ilia; The 
 pelvic inlet; The pelvic cavity; the spines of the ischium; The pelvic 
 outlet; The pelvic foramina; The pubic arch; The tuberosities of the 
 ischia — The foramina of the pelvis: Their situation and functions; 
 The great sacro-sciatic foramen and the structures which pass 
 through it; The lesser sacro-sciatic foramen and the structures which 
 pass through it; The obturator foramen and the structures which pass 
 through it — The walls of the pelvis: The spine of the ischium and its 
 medical relations; The anterior pelvic wall; The lateral pelvic wall; 
 The posterior pelvic wall; — The separate bones of the pelvis: The os 
 innominatum; Its component parts; The ilium; Its functions; The 
 iliac fossa; The gluteal fossa; The anterior and posterior iliac spines; 
 The sacro-iliac joint; The ischium; its functions and general construc- 
 tion; its notches; The sacro-ischiatic ligaments and their functions; 
 The ramus of the ischium; The obturator foramen; The spine of the 
 ischium and its medical and surgical relations; The tuberosity of the 
 ischium; its functions and lever-like action upon the trunk; The 
 ischium as a part of the pelvic cavity; The ischium as a part of the 
 acetabulum; The pubes; its subdivisions; its body and rami; The 
 pubic arch and its variations in the sexes; The medical and surgical 
 relations of the body of the pubes; The symphysis pubis and its won- 
 derful construction; The spine of the pubes as a surgical guide to 
 hernia; The muscles attached to the rami of the pubes; The sacrum; 
 Its various functions; Its triangular form; Its curve and its modifica- 
 tions in the sexes; The sacral canal and its cUnical aspects; The sacral 
 foramina and their clinical aspects; The sacro-Uiac symphysis; The 
 articulation of the sacrum and the last lumbar vertebra; — The chni- 
 
yy TABLE OF CONTENTS. 
 
 PAGE 
 
 cal points pertaining to the region of the pelvis: The acetabulum and 
 the construction of the hip-joint; The relation of perforation of the 
 acetabulum to complicating diseases of the pelvic organs; The ante- 
 rior superior spine of the ilium, its use in diagnosis of fracture of the 
 pelvis, in the fixation of the sacro-iliac joint; In the diagnosis of 
 morbus coxarius; In the measurement of the lower limb; Eule for 
 measuring the length of the lower limbs; The anterior superior spine 
 of the ilium and its surgical aspects; Nelaton's guide; Winslow's 
 guide to the trochanter of the femur; The spine of the pubes as a 
 surgical guide; Guide to the hip-joint; The posterior superior spine 
 of the ilium as a surgical guide; The third spine of the sacrum as a 
 surgical guide; The tuberosity of the ischium as a surgical guide; 
 The fold of the nates; The apex of the coccyx; Guide to the gluteal 
 artery; Guide to the ischiatio artery; Guide to the pudic artery; The 
 surgical aspects of the gluteal region. 
 
 Chapter VI. The Abdomen — its Viscera, and the Surgical Guides 
 
 TO Important Structures of that Region 278-315 
 
 The dilliculties encountered in examining the abdominal cavity for 
 the purposes of diagnosis; — The medical subdivisions of the abdomi- 
 nal region; The epigastric zone; The umbilical zone: The hypogastric 
 zone; The subdivisions of each zone; The right hypochondriac 
 region, and its contents; The epigastric region, and its contents; 
 The left hypoohoudriao region, and its contents; The umbUioal 
 region, and its contents; The right lumbar region, and its contents; 
 The left lumbar region, and its contents; The hypogastric region, 
 and its contents; The right iliac region, and its contents; The left 
 iliac region, and its contents; — The exterior of the abdomen: Its 
 shape, elevations, and depressions, and modifications in health; Its 
 movements, and the causes which tend to modify them; Betraction 
 of the abdomen, and its causes; Enlargement of the abdomen, and 
 its causes; Abnormalities of the superficial veins of the abdomen; 
 Abdominal pulsation, and its causes; The linea alba, and its clinical 
 aspects; The umbihcus, and its clinical aspects; The organs which 
 bear relation to the anterior wall of the abdomen; Causes which tend 
 to modify the relative position of the various organs; The points to 
 be gained by inspection in abdominal examinations; The value of 
 abdominal palpation in diagnosis, and the methods of employing it; 
 Percussion of the abdomen, its modifications in health, and the clin- 
 ical significance of dull, flat, and tympanitic percussion notes. Aus- 
 cultation of the abdomen, and the points in diagnosis to be deter- 
 mined by its use; — Special portions of the abdominal wall possessing 
 a surgical interest: The crural arch; The inguinal canal; The exter- 
 nal and internal abdominal rings; The contents of the inguinal canal; 
 The deep epigastric artery; The abdominal muscles, and the peculi- 
 arity of arrangement of their fibres; — The abdominal viscera: The 
 changes of the viscera with respiration; The stomach, its' normal 
 direction and situation; The results of its distention upon the heart, 
 liver, intestines, and brain; Rules for ascertaining its size by percus- 
 sion. The Liver; Its constant alteration of position; Its modifica- 
 tions in disease; Its displacement in thoracic disease; Its normal 
 percussion limits; The anatomical guides to its upper limit; Its rela- 
 
TABLE OF CONTENTS. XXI 
 
 PASE 
 
 tions to the chest-wall. The Spleen; Its situation in health; Evi- 
 dences of its enlargement; Its discrimination from gastric cancer, 
 diseases of the omentum, enlargement of the left lobe of the liver, 
 fsecal impaction of the colon; Enlargements of the left kidney, and 
 ovarian tumors of the left side; Difficulties in palpation of the 
 spleen. The Pancreas; Its normal situation; Palpation of, through 
 the abdominal walls; The diseases with which it may be confounded 
 by the physician. The intestinal canal; The situation of each of its 
 different portions within the cavity of the abdomen; The Large 
 Intestine, and its medical and surgical aspects; The steps required in 
 colotomy; Typhlitis, and its diagnosis; The clinical aspects of the 
 contents of the right iliac fossa; Tympanites, and the normal func- 
 tion of air in the intestine; The mesentery, and its diseases. The 
 Kidneys; Their normal situation; Guide to the pelvis of the organ; 
 Palpation of the kidney; The movable kidney, and its diagnosis; The 
 differential diagnosis of renal dulness; Calculi of the kidney; Hydro- 
 nephrosis, and the causes which produce it; Means of determining 
 the kidney area when ascites exists. The Bladder; Its normal posi- 
 tion, and its modifications with age; Diagnosis of retention and 
 overflow; The bladder in paralysis; Diagnosis between a distended 
 bladder and a gravid uterus. The Uterus; Its changes in pregnancy; 
 Auscultation of the pregnant uterus; The foetal heart-sounds and the 
 murmurs to be confounded with them; Abnormal states of uterus 
 producing enlargement of the organ; Uterine displacements. The 
 Ovaries; Their normal situation; The direction of their growth when 
 the seat of diseased conditions; Diseases which are to be confounded 
 with such enlargements. The Nerves of the abdomen and pelvis; 
 Their clinical aspects; The ilio-hypogastric nerve; The ilio-inguinal 
 nerve; Neuralgia of the ilio-hypogastric and ilio-inguinal nerves, and 
 the diagnostic points of tenderness of each; The nervous supply of 
 the skin covering the abdomen; The nervous supply of the peritonae- 
 um; Nervous sympathy between the peritonseum and the abdominal 
 walls; The pudio nerve and its functions; The physiology of erection 
 and sexual orgasm; Physiology of the ejaculation of urine from the 
 urethral canal; The nervous symptoms produced by rectal dis- 
 eases; The small sciatic nerve, and its clinical aspects. — The points of 
 surgical interest pertaining to the abdominal region: The normal 
 openings in the abdominal walls; Their relation to hernial protru- 
 sions; The effects of abdominal enlargements upon the anterior wall 
 of that cavity; Arrested development of the abdominal walls; Extro- 
 version of the bladder; Wounds of the abdominal parietes; Contu- 
 sions of the abdomen, and the possible complications of such acci- 
 dents; Concussion of the abdomen, and its results; Tapping of the 
 abdomen for ascites; Enlargement of lymphatic glands as a guide to 
 abdominal disease; The inguinal canal. Inguinal hernia; Its forms; 
 The diseases liable to be confounded with it; The caput Medusse, its 
 clinical aspects; UmbUical hernia; Arrested descent of the testicle; 
 Femoral hernia; The abdominal aorta; Its relation to the exterior of 
 of the abdomen; The line of incision to reach it; The common iliac 
 arteries; Their normal length and situation; The iliac region of the 
 abdomen; Its congenital defects; Its relation to colotomy; Abscess; 
 faecal impaction, caries, and hernia; The region of the loins; Lateral 
 
XXll TABLE OF COlfTBNTS. 
 
 FAGB 
 
 spinal curvature; Spina bifida; Wounds of this region, and their 
 results; Fracture of the spines of the lumbar vertebrae; Hernial pro- 
 trusions of this region; Psoas abscess; Urinary renal fistulas; The 
 operation of nephrotomy; Ligation of the abdominal aorta in this 
 region; Cupping of the loins, and the explanation of its efEeots upon 
 renal congestion; — Foreign bodies in the alimentary canal, and their 
 effects: Abscesses of the abdominal cavity; Intestinal obstruction, 
 its causes, symptoms, and diagnosis; Perityphlitis, its causes and 
 diagnosis; Injuries to the diaphragm; Diaphragmatic hernia, its 
 symptoms and causes; The points of discrimination between this 
 form of hernia and tumors of the mediastina. 
 
PRACTICAL 
 
 MEDICAL ANATOMY. 
 
 PART I. 
 
 CHAPTEE I. 
 
 THE BONES OF THE HEAD. 
 
 It is a fact to be regretted that the study of the bony framework 
 should be so often made one of dry detail to the medical reader, espe- 
 cially as it is usually the first subject which, as an aspirant for medical 
 honors, the student is obliged to encounter, and it too often tends to cast a 
 shadow over the bright visions which his fancies had painted, as its 
 perplexities increase. 
 
 Sir Charles Bell was in the habit of frequently employing the living 
 subject as one of the most efficient means of teaching anatomy, and the 
 points which he thus impressed upon his pupils were furthermore made 
 matters, not only of information, but of practical interest, by the con- 
 stant application of the regions discussed to the needs of the physician 
 in his daily associations with the sick. 
 
 There are many well-known facts in anatomy which can be taught 
 without the aid of dissection; and many of those well versed in theoreti- 
 cal anatomy, and who could, if necessary, pass a satisfactory examination 
 upon the subject, would utterly fail if compelled to point out many of 
 the structures upon the cadaver, concerning which they think them- 
 selves familiar. Holden recognized the necessity of this method of 
 demonstration of anatomy upon the living subject, and the need of 
 guidance, which the general profession accepted, when he published his 
 "Surgical and Anatomical Landmarks;" and the success of the effort has 
 justified its republication in one of our popular text-books. 
 
 In this chapter it is my aim to direct attention to such points upon 
 the cranial bones as seem capable of being applied to the general 
 practice of medicine and surgery; and I shall endeavor to so apply 
 them as to once more recall scattered points which may have been known 
 
23 PRACTICAL MEDICAL ANATOMY. 
 
 and forgotten, and, if possible, suggest means by which this information 
 may be fixed in the memory. It is not to be expected that many origi- 
 nal ideas will be presented, as the researches of the greater anatomists 
 have left little to be added, iVhich can help to make this line of study 
 attractive, to which a claim of originality can justly be laid; but much 
 that is old will bear repeating with profit, and many facts which are now 
 scattered throughout text-books will be rendered more useful if compiled. 
 The entire skull is sometimes deficient at the time of birth, and the 
 term "acrania" was applied by Beclard' to this condition; while the 
 term " anencephalia " was also applied by him to those forms of arrested 
 development of the skull where the base only is present. 
 
 Fig. 1.— The skull. 1, frontal bone; 2, parietal bone. The line or ridge below these numbers is 
 the outer limit of the origin of the temporal muscle; X, coronal suture uniting the frontal and 
 parietal bones; 3, occipital bone— the figure is placed at the lower end of the lambdoidal suture, 
 uniting the parietal and occipital bones; 4, greater wing of the sphenoid bone; 5, is placed just 
 above the upper edge of the temporal bone as it lies upon the parietal ; 6 , is on the lower part of 
 the temporal bone where the zygoma joins it; the oval opening a little lower down is the entrance 
 to the bony canal of the ear; 7, mastoid portion of the temporal bone; the pointed projection in 
 front of it is the mastoid process; 9, the opening of the nasal cavity; 10, inner wall of the orbit, or 
 the lachrymal bone : 11 , the malar bone close to its junction with the zygoma ; 12, superior maxil- 
 lary bone ; 13, ramus of the lower jaw ; 14, body of the lower jaw. 
 
 We find that the orifice of the ear nearly corresponds, in the normal 
 skull, to the level of the fioor of the cerebrum; so that the height of 
 the skull above this point indicates, in general, the relative amount of 
 brain possessed by an individual. If a string be made to pass from one 
 external auditory meatus to the other over any part of the calvaria, the 
 development of that portion of the brain to other portions can be approx- 
 imately determined. 
 
 The bony skull-cap is not often symmetrically developed upon its two 
 lateral halves. The frequency of this lack of symmetry may be appreci- 
 ated by examining the impressions of heads taken by any of our prominent 
 
 1 Elements of General Anatomy (Togno's translation). Philadelphia, 1880. 
 
BONES OF THE HEAD. O 
 
 hatters. No two skulls have identical measurements or contour, since, 
 although faces are never alike, mechanical causes may furthermore alter 
 the shape of the head. This is eTidenced to a marked degree in certain 
 Indian tribes, where the heads of the young are mechanically compressed. 
 In the head we have the bony framework of the cranium and face 
 covered by its soft tissues. We have its numerous cavities, ridges, 
 depressions, prominences, and foramina. In its soft tissues ramify many 
 of the more important nerves and vessels of the body, while, within its 
 cavities, are contained the organs which afford the special senses of sight, 
 smell, hearing, and taste, and also the brain with its ganglia, its pro- 
 tective coverings, its vessels, and the nerves by which it performs its 
 various functions. 
 
 FiQ. 2. — ^Drawing of base of skull, introduced to show the want of correspondence between cer- 
 tain parts of the base of the skull and of the brain. (After Hilton.) 
 
 We find these various component parts so nicely adjusted, as to 
 weight, that the head is almost perfectly balanced upon the spinal col- 
 umn, and so articulated to the trunk, as to facilitate the motions of 
 flexion, extension, and rotation without injury to any of its structures. 
 
 It is my intention, in this chapter, to treat of those practical points 
 which are afforded by the osteology of the head alone, and to show in 
 how many ways the study of this portion of human anatomy may con- 
 stantly suggest to the physician new thoughts of value. 
 
 THICKKESS OF THE SKULL. 
 
 The skull-cap is not of equal thickness in all its parts; neither is it 
 of the same thickness in all individuals. It is thicker at the occipital 
 protuberance than elsewhere, and thinnest over the temple. Holden's' 
 
 ' Surgical and Anatomical Landmarks. London, 1876. 
 
■4 PEACTICAL MEDICAL ANATOMY. 
 
 rule for trephining should never be forgotten: " Think you are operat- 
 ing upon the thinnest skull ever seen, and thinner in one half of the 
 circle than the other." 
 
 Trephining the cranium should be regarded as an operation always 
 fraught with danger, ' and only to be performed from absolute necessity. 
 The following general rules " should guide in deciding the question: 1st, 
 In diffused injuries to the cranium and its contents all operative inter- 
 ference is unjustifiable; 2d, in simple fractures, with or without depres- 
 sion, operative interference is only called for when marked and persistent 
 symptoms of local compression of the brain exist; 3d, in compound com- 
 minuted fractures, with or without brain symptoms, the depressed 
 hones should be elevated and the fragments removed, with the object 
 of taking away known sources of irritation to the membranes, a common 
 cause of encephalitis; 4th, in all cases of local traumatism of the cranium, 
 
 Fig. 3.— Iron arrow-head impacted ia le£b temporal bone, without Assure. No. 5908, Sec. 1, A. M. M. 
 
 of fracture, or other injury, followed by clear clinical evidence of local 
 inflammation of the bone and persistent symptoms of hrain irritation or 
 suiosteal suppuration, the operation should be undertaken. 
 
 Old people often suffer absorption of the diploe, and are thus espe- 
 cially liable to present very thin skulls. 
 
 The exterior of the skull-cap does not correspond absolutely to the 
 eminences and depressions of the interior surface, but it bears, in some 
 cases, a resemblance to its general outline. Phrenology cannot there- 
 fore, be more than an approximate science. 
 
 The thickness of the skull-cap seems to be modified somewhat by the 
 exposure of the head to the effect of the sun, as it is usually very thick 
 in the Egyptian, and in other races where the head is generally uncov- 
 
 ' Erichsen: Science and Art of Surgery. Philadelphia, 1860. 
 'T. Bryant: Practice of Surgery. London, 1872. 
 
BONES OF THE HEAD. 
 
 ered; while it is liable to be very thin and soft in the Persian race, and 
 in other races where the head is covered with a turban from infancy. ' 
 
 TABLETS OF THE SKULL. 
 
 The middle tablet of the skull-cap (diploe) is abundantly supplied 
 with veins. It is not infrequent that a,, suppurative phlebitis of these* 
 yeins is created by wounds received upon the head, even when the scalp 
 is not lacerated, or symptoms of depression of the skull exist. Such an 
 occurrence usually results in disintegration of the blood-clots formed 
 within the inflamed veins, which are carried downward to the heart, and 
 are then thrown into the arteries, only to act as emboli and induce infarc- 
 tion and metastatic abscesses in the various viscera. This probably 
 explains vhj pycemia sometimes occurs in closed wounds, where no oppor- 
 tunity seems to be afforded for the absorption of any poisonous miasm 
 generated from decomposing pus. ' 
 
 Outer tablet. Inner tablet. 
 
 Figs, i htd 5.— Fissure of the outer table, with depression o£ the inner. (U. S A. Med. Museum, 
 No. 24. From Circular No. 6.) 
 
 The tablets of the skull difEer in their relative densities, the inner 
 tablet being extremely brittle, the middle being spongy and vascular, 
 while the outer tablet is more yielding and tenacious than the inner. 
 Outhrie ' states that sabre-cuts of the head, making only an incision of 
 the outer tablet, may splinter and depress the inner tablet over a large ex- 
 tent of surface. 
 
 The large number of cases in which the inner tablet has been frac- 
 tured when the outer tablet has been uninjured, seems to prove that the 
 brittleness of the inner tablet, as well as the fact that it is the last to feel 
 the blow inflicted, tends to render it especially liable to fracture. It is, 
 therefore, important that all forms of injury of the head be examined for 
 evidences of local pressure upon or lesions of the adjacent brain-substance, 
 even if no superficial injury to the bone can be detected. 
 
 The aperture of exit of a bullet is always larger than that of its 
 
 ' Holden: Human Osteology. London, 1876. 
 
 ' See article on Pyaemia by the author ; Annals of Anatomy and Surgery. 
 Brooklyn. November, 1881. 
 
 'Guthrie: Commentaries, Lect. xviii. 
 
6 
 
 PEACTICAL MEDICAL ANATOMY. 
 
 entry," and in gun-shot wounds of the skull, the most damage to sur- 
 rounding parts may thus be confidently sought for at that point. 
 
 It is also a well-known fact that some forms of injury to the bony 
 vault of the head are followed by an enormous increase over the average 
 tUckness of the skull-cap at the seat of injury, and thus a valuable point 
 •in diagnosis is sometimes afforded, when, from defective memory on the 
 part of the patient, or other causes, the seat of former traumatism can- 
 not be absolutely defined. 
 
 Outer plate. Inner plate. 
 
 Pigs. 6 and 7.—" Punctured " gunshot fracture caused by a pistol ball. (U. S. Army Med. Mu- 
 seum, No. 1673. From Circular No. 6.) 
 
 GUIDES TO INTEA-CEEEBRAL POINTS OE INTEREST. 
 
 A line, drawn from the external angular process of the frontal bone 
 to the external auditory meatus, corresponds closely to the level of the 
 floor of the anterior and middle lobes of the brain ; while one, drawn from 
 the external auditory meatus to the occipital protuberance, corresponds 
 to the level of the base of the posterior lobe of the cerebrum, and to the 
 upper surface of the cerebellum. 
 
 The level of the floor of the brain, in front, corresponds to a line 
 drawn transversely across the forehead, about one-quarter of an inch 
 above the supra-orbital arch. 
 
 The lowest level of the cerebellum cannot be defined upon the living 
 subject by any given rule. It depends entirely upon the extent to which 
 the occipital fossa bulges into the neck. It is this variation which pro- 
 duces the peculiarities of outline of the back and lower portion of the 
 skull in different individuals. The longitudinal sinuses of the brain 
 may be injured by any wound in the median line of the cranium, above 
 the level of the occipital protuberance, since these venous channels are 
 formed by the separation of the two layers of the falx cerebri. It was an 
 old practice among the earlier physicians to leech the nose to relieve con- 
 gestion of the brain, and it is recognized that epistaxis is often a great 
 relief in cases of congestive headache. This circumstance is explained by 
 the anatomical fact that the veins of the frontal sinus communicate, 
 through the foramen caecum, with the superior longitudinal sinus of 
 
 ' Erichsen: Science and Art of Surgery. Philadelphia, 1860. 
 
BOJ^ES OF THE HEAD. 7 
 
 the brain.' In the tiger, cats, and other of the feline race, the partition 
 between the lateral halves of the cerebrum, corresponding to the falx 
 cerebri of man, is not fibrous in character, but is composed entirely of 
 bone. 
 
 The lateral sinuses correspond, for a part of their course, to a line 
 drawn from the mastoid process to the occipital protuberance, but that 
 portion of the lateral sinus which is indicated by a groove in the postero- 
 inferior angle of the parietal bone, may be defined by measuring one inch 
 from the anterior border of the mastoidprocess, on a line with the zygoma. 
 The tentorium cerelelli, in man, supports the posterior lobe of the brain 
 and protects, it from the injuries which must, of necessity, often occur 
 from concussion, if it rested upon bone. In the earnivora and other 
 mammalia, the tentorium cerebelli is ossified. 
 
 Pi'om my late work upon the applied anatomy of the nervous system 
 I quote as follows: " In the year 1861, Broca invented a scientific method 
 of determining the relations of different parts of the cerebrum to the ex- 
 terior of the skull, which consisted of driving pegs through the skulls of 
 animals and of cadavers, holes having been previously bored through the 
 bone in order to prevent fracture and injury to surrounding parts. The 
 skull-cap was then removed with extreme care, and the convolutions which 
 were wounded were thus determined. It was discovered by this observer 
 that ihQ fissure of Rolando, whose relation to the coronal suture was then 
 unknown, lay obliquely ; and that its upper extremity could be placed, 
 with great accuracy in man, at a point situated /orf«/ millimetres behind 
 the coronal suture. This fissure was particularly studied on account of 
 its relation to the motor region of the cerebral cortex, and its exact rela- 
 tion to the exterior of the skull was, therefore, of great importance. 
 The same observer was also able to prove that the external parieto-occipital 
 fissure of the cerebrum lay under the lambdoidal suture of the cranium. 
 In 1873, the experiments of Heftier and Bischoff were added to those of 
 Broca, while Turner followed with his researches in 1874, and Per6 in 
 1875. The drawings which Turner furnished were admirable in their 
 way, but are, to my mind, hardly adapted to the purposes of the surgeon, 
 since the guides which the bony prominences of the skull afford are not 
 brought into such prominence as to be readily comprehended by the 
 casual reader. If the surgeon is to utilize the valuable researches of the 
 investigators above named (and several most brilliant surgical operations 
 have already been performed from the light which the newly-acquired 
 knowledge of the topography of the cerebrum has afforded), certain bony 
 prominences of the skull must be designated as of importance as guides 
 to the special convolutions and fissures of the brain. Now, there is one 
 line which is easily drawn upon the head of the living subject (the alveolo- 
 condyloid plane of Broca), upon which certain perpendicular lines may 
 
 ' Quain: Human Anatomy. London, 1849. 
 
8 PKACTICAL MEDICAL ANATOMY. 
 
 be described, intersecting certain bony points, which can be utilized as 
 guides to parts whose situation is now positively known. This base line 
 should be a straight one, and should intersect the tip of the mastoid pro- 
 cess and the line of the cusps of the teeth of the upper jaw. ' 
 
 ''This is the natural posture of the human skull when the lower jaw 
 is removed and the skull placed upon a table; hence it is a plane admi- 
 rably adapted for the study of the guides, which will be given, upon the 
 skeleton in the office of each practitioner, previous to an operation. 
 Furthermore, a skull can easily be painted upon its exterior so as to 
 bring the lines designated as important into prominence, and thus assist 
 the surgeon in the review of those points which possess special value. 
 The contribution of Fer§ is, to my mind, the best of all the authors 
 named, since it presents the points most needed by the surgeon in a 
 
 Fio. 8. — Outline of Skull resting upon the Alveolo-Condyloid Plane of Brooa ; modified by 
 Seguin from Topinard (''Anthropology"). 
 Vertical line A, or auriculo-bregmatic. Line 9-10, drawn parallel to the plane of Broca. 
 Upon this line, at a distance of 45 mm. posterior to the bregma, a vertical line, 1-3, will pass 
 through the upper (inner) end of the fissure of Kolando, b, b, and through the posterior extremity 
 of the thalamus opticus (c). A third vertical line, 3.4, drawn at 30 mm. forward of the bregma, 
 will pass through the fold of the third frontal gyrus (a), and through the head of the nucleus 
 caudatus (d). The horizontal line, 7-8, at i& mm. below the bregma (scalp), indicates the upper 
 limit of the central ganglia. The third horizontal line, 5-6, passing through the external angular 
 process of the frontal bone and the ocoipito-parietal junction, approximately indicates the course 
 of the fissure of Sylvius, and serves for measurements. At 18 or 20 mm. behind the external 
 angular process on this line is the speech centre of Broca ; 5 to 8 mm. behind the intersection of 
 3-4 and 5-6 is the beginning of the fissure of Sylvius, and at 28 or 30 ram. behind this intersection 
 is the lower end of the fissure of Rolando, b, b, placed a, little too far baclc in the out. At X 
 (near 6), near the median line, is the location of the occipito-parietal fissure. 
 
 1 This author places the line as intersecting the condyle of the occipital hone ; 
 but, as this cannot be felt in the living subject, and as it closely corresponds to 
 the tip of the mastoid process, I, have modified the guide so as to simplify its 
 exact situation upon the exterior of the skull. 
 
BONES OF THE HEAD. 9 
 
 practical way; and his guides are so tersely and clearly stated in Fig. 8 
 that it would be useless to attempt to improve upon it. It will be 
 perceived in the plate, introduced to make these guides more apparent 
 than a mere verbal description, that the line described, viz., the alveolo- 
 condyloid plane of Broca, is used as a base-line upon which to erect 
 perpendiculars at distances which can be accurately measured upon it ; 
 and that these perpendicular lines intersect certain regions which, from 
 facts previously recorded, are of the greatest importance. 
 
 "With this plate as a guide, and a thorough knowledge of the 
 facts comprised in cerebral anatomy and physiology, it is not out of the 
 bounds of possibility to definitely locate the existence of lesions in certain 
 * portions of the human brain, to map out their situation upon the exterior 
 of the skull, and to reach them with surgical means of relief, provided 
 the case be one which would justify such a measure. When Broca has 
 been successful in trephining directly over an abscess of the third frontal 
 convolution, which was suspected, and when successful cases have been 
 reported of trephining of the skull for fragments of the inner tablet which 
 were compressing the ascending gyri of the frontal and parietal lobes, 
 thus causing paralysis, have we not every reason to hope that the day is 
 coming when the rules governing this operation will be those based upon 
 science rather than upon empiricism, and when the surgeon will owe 
 his success to the researches of the physiologist and the labors of the 
 pathologist? 
 
 " There are certain suggestions which may be thrown out in this con- 
 nection, which are safe ones to follow in cases where the propriety of 
 surgical relief is called into question. These may be stated in the form 
 of propositions, which are of necessity based upon physiological and 
 pathological investigations. 
 
 "1. If the injury sustained, provided the case in question be one of a 
 traumatic origin, be situated over the motor area of the cortex, the 
 presence of ancesthesia in combination with motor hemiplegia is a contra- 
 indication to attempts at surgical relief; This symptom (anaesthesia) 
 probably indicates some injury to the posterior third of the internal cap- 
 sule, or to the white substance of the hemispheres; hence the lesion is 
 probably too extensive to be relieved by trephining. 
 
 "2. If the sensory region of the cortex be involved, and paralysis or 
 convulsive movements occur, an operation is contra-indicated; since the 
 lesion has either been so extensive as to extend to the motor area, or has 
 torn or compressed the cerebrum at a point removed from the apparent 
 seat of injury. 
 
 "Z. The occurrence oi paralysis on the same side as that upon which 
 the injury was received is always a contra-indication to any surgical pro- 
 cedure at the seat of injury, since it indicates some lesion of the opposite 
 side, probably dependent upon transmitted force {contre-coup). 
 
 "4. The completeness of the paralysis may be often taken as a guide 
 
10 PBACTIOAL MEDICAL ANATOMY. 
 
 to the amount of injury done to the cerebrum : if the paralysis be very 
 profound, the chance of success from trephining is extremely small, 
 since the injury has probably affected parts deeper than the cortex 
 centres. 
 
 "5. The appearance of paralysis of any of the special nerves of the 
 cranium, or the development of the symptoms due to lesions of the 
 base of the brain or of the basal ganglia, such as the Cheyne-Stokes 
 respiration,' choked disk, and vomiting, may be regarded as contra-indi- 
 cations to surgical interference. 
 
 " 6. When an injury to the skull is followed, after a lapse of some 
 weeks, by aphasia, the diagnosis of abscess of the base of the third 
 frontal convolution, or possibly involving the island of Eeil, or the white 
 substance situated between the third frontal convolution and the base of 
 the cerebrum,' may be safely made. In such a case, the operation of 
 trephining, as performed by Broca, affords a strong probability of relief. 
 
 "7. Cases of injury which ave followed immediately by aphasia are 
 strongly diagnostic of either a spicula of bone or the pressure of a clot in 
 the neighborhood of the centre of Broca. The former condition would 
 be strongly in support of surgical interference, since it would probably 
 continue to create pressure or irritation until removed, while the pressure 
 of a clot might also be relieved by trephining. 
 
 " 8. If the region over the fissure of Rolando be subjected to apparent 
 injury, and the symptoms of some of the special types of monoplegia 
 appear (affecting the muscles of the face, arm, leg, or any of these com- 
 bined), or even the occurrence of a slight form of he?niplegia follow, 
 successful trephining may be reasonably expected. The presence of 
 anaesthesia, as before mentioned, would, however, still be a strong contra- 
 indication to such a step, since it would prove that the lesion was proba- 
 bly of too deep a character to be benefited by the simple removal of a 
 button of bone, as the posterior third of the internal capsule would proba- 
 bly be found to be impaired. It must be also remembered that the motor 
 paralysis, of whatever kind it may be, must be confined to the side of the 
 body opposite to the seat of injury, if benefit is to be expected. The 
 type of monoplegia which exists may often be used as a guide to deter- 
 mine the extent of the lesion as well as its situation.'" 
 
 SUTURES OF THE CEANIUH. 
 
 The coronal suture (frontal-parietal) separates the frontal bone from 
 
 ' A respiration whose rhythm steadily increases and then decreases in a short 
 interval of time, described in 1818 by Cheyne, and by Stokes in 1846. 
 
 ' E. C. Seguin, Medical Record, 1878. 
 
 'The motor centres situated in the ascending frontal and parietal convolu- 
 tions, and the various forms of monoplegia will be found described in the late 
 work by the author, The Applied Anatomy of the Nervous System. N. Y., 
 1881. 
 
BONKS OF THE HEAD. 
 
 11 
 
 the parietal bone of either side. In the coronal suture, the middle por- 
 tion is formed by the frontal bone overlapping the parietal," while, at 
 the sides, the parietal bone overlaps the frontal; a provision which 
 manifestly is intended to prevent displacement of the bones. 
 
 The lambdoidal suture (parieto-occipital) also extends, like the coro- 
 nal, transversely across the head, separating the posterior borders of each 
 parietal bone from the occipital bone. Its relation to the external pari- 
 eto-occipital fissure of the cerebrum gives it an importance as a surgical 
 guide (see p. 8). 
 
 The frontal suture separates the two lateral halves of the frontal 
 bone until ossification is perfected between them. It is, therefore, situ- 
 ated in the median line of the forehead. In one out of every eleven 
 cases of adult skulls found in the catacombs at Paris, the frontal suture 
 remained unobliterated. ' 
 
 Fig. 9.— Bones of the skull separated at the sutures. 1, Frontal bone; 2, parietal bone; 3, occi- 
 pital bone; 4, temporal bone; 5, nasal bone; 6, malar bone; 7, superior maxillary bone; 8, lachry- 
 mal bone; 9, inferior maxillary bone. 
 
 The masto-parietal suture separates the posterior inferior angle of the 
 parietal bone from the mastoid portion of the temporal bone. In the 
 mastoid suture, small isolated bones called " Wormian bones " are chiefly 
 found. ^ 
 
 The squamous suture separates the parietal bone, and the great wing 
 of the sphenoid bone, from the squamous portion of the temporal bone. 
 It consists, therefore, of two portions, viz.: the " squamo-parietal" and 
 the " squamo-sphenoidal" sutures. 
 
 ' Flower (as quoted by Holden). 
 
 ' Leach (as quoted by Holden). This fact is also described by Eustachius and 
 Paracelsus. The name is applied to these small bones from Olaus Wormius, a 
 physician of Copenhagen. 
 
12 PRACTICAL MEDICAL ANATOMY. 
 
 The sagittal suture runs from the frontal to the superior angle of 
 the occipital bone, and lies in the mesial line of the skull. At either end 
 of it, lie the two largest fontanelles, viz., the anterior and the posterior. 
 The edges of the parietal bones which form this suture are very much 
 serrated, except opposite the parietal foramina, where these serrations 
 are much less prominent. ' 
 
 The sutures of the cranium are of great practical interest fgr the 
 following reasons: 
 
 1. Because they may be mistaken for a fracture, as was done by Hip- 
 pocrates himself." 
 
 2. Because, in any form of injury to the skull, it is not advisable to 
 trephine over the normal situation of a suture, as the emissary veins usu- 
 ally pass through them; besides, they are often in the immediate proxim- 
 ity of large venous sinuses. 
 
 3. Because they enable us definitely to locate the position of any por- 
 tion of the head of the child during labor. 
 
 OCCIPITAL BONE. 
 
 The basilar process of the occipital hone is within reach of the finger, 
 when introduced behind the soft palate until it touches the base of the 
 skull (the position of the patient being the same as when the posterior 
 nares are to be explored). It is often the seat of attachment of polypi 
 within the pharynx, and a positive diagnosis can thus be made by the 
 sense of touch, if sight or the laryngoscopic mirror detect the existence 
 of such a tumor, and its point of attachment is a matter of doubt. 
 
 The upper surface of this process, although situated within the 
 cranial cavity, affords support to the medulla oblongata. This important 
 ganglion does not, however, rest upon the bone itself, since a thin layer 
 of cerebrospinal fluid is interposed, like a water-bed, to prevent injury 
 to it in case of concussion being transmitted to the head through the 
 spinal column.' 
 
 The strength of the ligaments which bind the head to the verte- 
 bral column do not alone prevent its dislocation, since the dee'p cups 
 of the atlas hold the condyle of the occipital lone firmly in place.'' 
 
 The centre of the condyles upon which the head moves may be defined 
 by a line which shall connect the tips of the two mastoid processes of the 
 temporal bones. It is thus easy to designate their position on the living 
 subject. 
 
 The condyles of the occipital bone are much longer than the articulat- 
 ing cups of the atlas, and thus permit the forward and backward 
 
 ' Broca: Osteologie du Cr4ne, 1873. 
 
 ° Celsua (as quoted by Holden, Human Osteology). 
 
 " Hilton : Best and Pain. New York, 1879. 
 
 ^ Darling and Ranney : Essentials of Anatomy. New York, 1880. 
 
BONES OF THE HEAD. 13 
 
 motion of the head, while deepfossw behind the condyles allow an extra 
 amount of motion in the backward direction, so that vision can be directed 
 perpendicularly as well as horizontally. 
 
 The occipital protuberance, being the thickest portion of the skull, 
 is seldom fractured by violence received upon that point; but the same 
 force, by being transmitted, may create fractures either of the base or 
 anterior portions of the skull. 
 
 THE SPHENOID BOKE. 
 
 This bone, being situated at the base of the skull, cannot be studied 
 upon the living subject, in all of its parts, although the pterygoid pro- 
 cesses form the outer wall of each nasal cavity, and can, therefore, be 
 seen with the laryngoscopic m'irror, and felt by the finger when thrust 
 upward behind the soft palate. 
 
 It is not devoid of surgical interest, however, in spite of its situation, 
 and plays a most important part in the general plan of the construc- 
 tion of the head, since it acts as a point of meeting of all the but- 
 tresses ' of the skull ; while its pterygoid processes, furthermore, sup- 
 port the bones of the upper jaw, and thus greatly assist in making the 
 attachment of the face to the cranium firm and immovable. This latter 
 process, moreover, affords attachment to the powerful pterygoid muscles, 
 which help to grind the food, and also to the tensor palati muscle, which 
 is an important factor in the act of deglutition." 
 
 The little hook (hamular process) at the end of the internal ptery- 
 goid plate, around which the tendon of this latter muscle so beautifully 
 plays, can be felt within the mouth, when the finger is crowded along 
 the upper jaw, close to the commencement of the soft palate and in 
 the immediate vicinity of the last molar tooth. 
 
 The twelve foramina of the sphenoid bone afford a means of exit, 
 from the cavity of the cranium, for the nerves of the eye itself, and of 
 the ocular muscles^ and, also, for the great nerve of sensation of the face 
 (trigeminus or fifth nerve) ; while the middle meningeal and ophthalmic 
 arteries are also thus enabled to reach their respective points of distribu- 
 tion. It can, therefore, be readily understood why fractures of this bone 
 may create impairment of any one of these nerves or vessels ; and the 
 situation of the bone itself, in addition to the numerous foramina within 
 it, renders such an accident extremely common, when a force is trans- 
 mitted to it from any portion of the cranium,^ or even from the face, 
 since it acts as a buttress to the upper jaw. 
 
 ' See page 26 of this volume. 
 
 ^ See Essentials of Anatomy : G. P. Putnam's Sons, N. Y. , 1880 ; and also 
 the late work of the author : The Applied Anatomy of the Nervous System, 
 N. Y., 1880. 
 
 ^ The reader is referred to page 26 of this volume, where the buttresses of the 
 skull are discussed in their relation to the so-called " fracture by eontre-coup." 
 
14 rRACTICAL MEDICAL ANATOMY. 
 
 The body of the sphenoid bone is hollowed out into a large chamber, 
 which contains air, and, like the cayities of the frontal sinuses, the 
 mastoid cells, and the antrum of either side, tends to lighten the weight 
 of the skull, in addition to other functions. 
 
 This cavity is often extended into the basilar process of the occipital 
 bone. In birds. Nature forms most of the bones on this plan, and 
 often causes the respired air to communicate with the cavities so formed, 
 since the heated air still further reduces the weight of the body, and 
 thus assists in their flight. The owl has enormous air-chambers in the 
 frontal region, which accounts for the prominence of the forehead. In 
 those types of birds to which the power of very rapid motion is afforded, 
 every bone, even to the tips of the claws, is hollowed out. 
 
 The mucous lining of the cavity of the sphenoid communicates with 
 that of the nasal chambers — a point often of importance in diagnosis of a 
 fracture of the base of the skull, as will be shown in a later chapter. 
 The relations of the large venous sinuses at the base of the skull to the 
 body of the sphenoid bone (see page 20) may also possibly help to 
 explain some of the symptoms of those fractures of the base of the skull 
 which involve the sphenoid to a greater or less extent. 
 
 EKONTAL BONE. 
 
 The orbital plates of ih.e frontal bone are often absorbed in the aged, 
 and large holes in them may frequently be discovered. Their extreme 
 thinness renders any form of punctured wound of the orbit liable to 
 be complicated with injury to the frontal lobe of the brain." The arch 
 of the orbital plate is not uniform in all skulls; and, if gi'eat, the 
 frontal lobes of the brain are proportionately small. In the monkey 
 tribe, this is very apparent. 
 
 In the frontal bone, after puberty has been reached, the tablets of 
 the skull-cap begin to separate, thus leaving a cavity called ^e frontal 
 sinus, whose situation is usually indicated by a jDrominence of the fore- 
 head. It is a point of surgical value, that the frontal sinus may not 
 always be proportionate to this eminence ; and, in rare cases, this emi- 
 nence may be entirely absent, in case the sinus be formed by a recession 
 alone of the inner tablet of the skull. "Wounds of the forehead over 
 the sinus may break the skull without injury to the brain. Small 
 insects have been known to enter this cavity through the nose. The 
 sense of pain in the frontal region, which accompanies nasal catarrh, 
 has been explained by some authors as an extension of the inflamma- 
 tion to the mucous membrane which lines this cavity. 
 
 Blumenbach mentions the case of a lady (Poulet ascribes this case 
 to Mar6chal, of Metz) in whose frontal sinus a centipede managed to 
 
 ' Holden: Human Osteology. London, 1876. 
 
BONES OF THE HEAD. 15 
 
 pass, after entering the nostril. It gave her intense pain, and was 
 expelled alive one year afterwards during an attack of sneezing.' 
 
 The larvas of insects, especially those of the horse-fly, not infrequently 
 are found in the frontal cells of animals." 
 
 Sir Charles Bell ' reports a case, where a patient, who had slept in 
 barns, had a corn insect enter the frontal sinus, and which was event- 
 ually discharged as a worm. 
 
 Fractures of the skull, over the frontal sinus, may cause fragments 
 of bone to be discharged by the nose, and loss of smell is often pro- 
 duced by such accidents. Emphysema of the tissues ' about the fore- 
 head may be produced during attacks of sneezing or coughing, if the 
 outer wall of the frontal sinus be injured, and air be thus allowed to 
 escape. 
 
 In some tribes (especially the Australians), where the frontal sinuses 
 are imperfecty developed, a want of resonance to the voice is produced." 
 Musket-balls have been found within the frontal sinuses." 
 
 The enormous air-chambers in the head of the elephant, situated in 
 the frontal region, explain why musket-balls may be shot into the cranium 
 of that animal without apparent injury, unless it happen to wound the 
 hollow at the root of the nose (at which place the encasement of the 
 brain is very thin), or chance to enter the orbit. This arrangement, 
 constituting an approach to a double skull, is a protective one on the part 
 of Nature, since the falling of trees, etc. , to which dangers this animal is 
 constantly subjected, would otherwise be liable to produce fatal injuries. 
 
 The extent of the frontal sinuses differs in races and with age. They 
 may reach, in extreme development, a depth of one inch, and extend 
 more than half-way up the forehead. t 
 
 Wounds of the frontal region are especially dangerous to life for four 
 reasons: first, on account of nerves which may be wounded; second, from 
 the danger of meningeal inflammation; third, from the fact that the 
 frontal vessels, being derived from the same trunks as those of the cere- 
 brum, may induce similar changes in the brain; and, fourth, because the 
 shock may create a tendency to inflammatory effusions upon the menin- 
 ges, or within the ventricles. ' 
 
 The danger of this class of wounds was recognized by the ancients 
 who attributed it to injury of the " Galea Capitis," ' which, from its 
 white color, they mistook for nerve-tissue. 
 
 ' Holden, op. cit. 
 
 ^Poulet: A Treatise on Foreign Bodies in Surgery. New York, 1880. 
 
 ' System of Surgery. London, 1836. 
 
 "Hyrtl: Topog. Anatomie, 1857. 
 
 'Amman: De Loquela, 1700 (as quoted by Holden). 
 
 'Guthrie: Commentaries on Surgery. London, 1853. 
 
 'Blandin: Anat. Topog., 1834. 
 
 8 Another name for the tendon of the occipito-f rontalis muscle. 
 
16 PKACTICAL MEDICAL ANATOMY. 
 
 The internal angular process of the frontal bone is used as a guide to 
 detect the reflected tendon of the superior oblique muscle of the eye, 
 which can be felt by pressing the finger beneath this process, and should 
 always be carefully avoided in operations in the vicinity of the orbit. 
 
 PARIETAL BONE. 
 
 The sutures of the parietal ho-ne are wonderfully adapted by Nature 
 to prevent displacement inward, since they are bevelled upon alternate 
 sides. It is, therefore, impossible to injure the brain in this region 
 without a fracture having previously occurred. ' 
 
 There are six portions of the cranium where ossification is delayed 
 and where the pulsations of the brain may be felt. These spots are 
 called fontanelles, since the brain pulsations were first likened to the 
 bubbling of a spring. The fontanelles are called the anterior, poste- 
 rior, and lateral of either side;' and they exist at the points where the 
 angles of the several bones eventually meet. The anterior is quadrilat- 
 eral, and is formed by the two parietal bones and the two halves of the 
 frontal bone. The posterior is triangular, and is formed by the two 
 parietal and the occipital bones. The lateral are usually nearly filled at 
 the time of birth. 
 
 These openings are of value to the obstetrician in determining, by the 
 sense of touch, the position of the child's head during the first and second 
 stages of labor. 
 
 TEMPORAL BONE. 
 
 On the whole, the skeleton of the temple is thinner than that of the 
 preceding region, and its external and internal periostea, which are united 
 to each other by fibrous bands and emissary veins, adhere to it more 
 firmly, because there are here more sutures. 
 
 The temporal region, although the bone encasement of the skull is 
 extremely thin in that locality, is seldom fractured by direct violence, as 
 it is so thoroughly protected by muscular tissue. Blows which are 
 received, however, upon the region of the orbital arch frequently cause a 
 fracture of the temporal done, and in this way a spicula of bone has been 
 known to wound the middle meningeal artery, which lies in close relation 
 with the interior surface of that bone. Sucli a form of injury, if followed 
 by symptoms referable to the brain, would probably indicate a fracture 
 of the temporal region of the skull, and, possibly, a complicating hemor- 
 rhage from the artery mentioned, even if no direct injury to the orbital 
 arch could be discovered. 
 
 The mastoid process is intended chiefly to afford additional leverage to 
 the muscles destined to act upon it. 
 
 ' Horner: Treatise on Anatomy. Philadelphia, 1830. 
 ''Vogel: Diseases of Children. 
 
BONES OF THE HEAD. 17 
 
 The presence of the lateral fontanelle, in the region of the mastoid 
 process of the temporal bone, renders a protrusion of some part of the 
 encephalon possible at this point; and tumors situated in this yicinity 
 should, therefore, be examined with the special object of ascertaining 
 any possible connection with the brain before operation." 
 
 The mastoid process contains numerous cells, which communicate 
 with the cavity of the middle ear. It has occasionally to be trephined in 
 cases of suppurative otitis, in order to aSord an exit for the infiltrated 
 pus. Its cells are constantly filled with warm air, which enters the tym- 
 panum through the Eustachian tube, and thus render the bone lighter 
 than if it were not thus excavated. These cells are undoubtedly an aid 
 to the full development of the sense of hearing, since they increase the 
 space in which the vibrations of the air, contained within the middle 
 ear, may be diffused. 
 
 It was formerly the practice to open these cells in the mastoid process 
 as a remedy for deafness, dependent upon obstruction of the Eustachian 
 tube, since, by so doing, air was freely admitted to the cavity of the 
 tympanum. The operation fell, however, into disrepute, from the 
 death of the physician of the king of Denmark (Just Berger), who was 
 himself made a subject for the operation. 
 
 In wounds r^eived close to the region of the mastoid process, severe 
 Tiemorrliage is often occasioned, on account of the close proximity of 
 large vessels to that portion of the temporal bone; while, in this region, 
 caries, necrosis, and exostoses are extremely liable to occur during the 
 tertiary form of syphilis. 
 
 The groove between the skin covering the mastoid process and the 
 back of the ear is a frequent site for that form of ulceration which 
 accompanies the scrofulous diathesis. 
 
 The mastoid process transmits, through the "mastoid foramen," a 
 vein which communicates with the lateral sinus of the brain. This 
 explains why leeches behind the ears relieve congestion of the brain or 
 its coverings. 
 
 The abnormalities in length of the styloid processes of the skull, 
 which are occasionally found, are dependent upon an ossification of the 
 stylo-hyoid ligament. 
 
 The supra-mastoid ridge on the side of the skull is so extensively 
 developed in the negro race that it might possibly be mistaken for an 
 acquired deformity. 
 
 The post-glenoid process of the temporal bone is intended by Kature 
 as a protection against backward dislocation of the condyle of the lower 
 jaw. It is much more extensively developed in the negro race and 
 gorilla than in the European. 
 
 ' See A Treatise on Surgical Diagnosis. By the author. New York, 1880. 
 2 
 
18 PEACTICAL MEDICAL ANATOMY. 
 
 The external auditory canal is narrowest at about its middle point.' 
 For that |i-eason, foreign bodies which enter the ear are apt to be pushed 
 beyond this constriction during attempts at removal, and thus additional 
 difficulty in the extraction is afforded. In addition to this fact, the 
 natural moisture of the ear may cause some foreign bodies to swell, and 
 thus render their removal a matter of great difficulty. This subject will 
 receive further consideration in a subsequent chapter. 
 
 The temporal fossm are largest in the carnivorous animals, as their 
 size depends upon the relative strength and development of the temporal 
 muscles. In some animals, the temporal muscle almost, entirely covers 
 the cranium. 
 
 The zygomatic arch is modified, as to its size, in all animals, by the 
 development of the muscles of the jaw and the character of the teetli 
 which exist. It is most strongly marked in the carnivora, where it 
 is arched both in a horizonal and a vertical direction, so as to afford 
 abundant room for the play of the temporal muscle; while in the ant- 
 eater, which has no teeth, the zygomatic arch is incomplete." 
 
 Between the zygoma and the ear can often be felt the pulsations of 
 the main trunk of the temporal artery. 
 
 When it becomes necessary to trephine over the temporal region, a 
 suggestion has been made by a prominent author,' i(> make a "V" 
 shaped flap, whose apex should look toward the ear, and which should 
 be allowed to remain attached, while the other portion of the flap is dis- 
 sected from the bone, thus preserving the fibres of the temporal mus- 
 cle from being unnecessarily injured, and greatly facilitating in the 
 subsequent union of the flap. 
 
 THE NASAL FOSSA. 
 
 The external aperture of the nose lies on a plane below the bony floor 
 of the nasal fossa.* The nose has, therefore, to be pulled upward, to 
 allow of a free inspection of the inferior meatus for polypi or foreign 
 bodies. Since the perpendicular axis of the inferior meatus is much 
 greater than the transverse, forceps introduced into the nose, for the 
 purpose of removing either a growth or foreign body, should be opened 
 in the longest axis of the fossa. ° 
 
 The turbinated hones serve to afiord a large expanse of surface for the 
 distribution of the nerves of smell (olfactory). They are, therefore, 
 studded with grooves and canals, through which the nerves come down 
 from the cribriform plate of the ethmoid to spread themselves out upon 
 the mucous membrane of the nose. In man, they only form a single 
 
 ' Poulet: Foreign Bodies in Surgery. New York, 1880. 
 
 " Holden: Human Osteology. London, 1875. 
 
 'Blandin, op. cit. ■'Holden: Human Osteology. London, 1875. 
 
 * Daxiing H,nd Ramiey: Essentials of Anatomy. New York, 1880. 
 
BONES OF THE HEAD. 19 
 
 curve; but in animals, where the sense of smell is greatly developed, 
 they often make rolls within rolls, like a sheet of parchment which has 
 been rolled together. In the seal, they are arranged as individual and 
 parallel plates, and of great number, so that 130 square inches of surface 
 has been computed to exist in each nostril. 
 
 An arrest in the progressive ossification of the perpendicular plate 
 of the ethmoid bone occasions the deformity known as the "pug nose.'' 
 
 The roof of the nose is extremely thin, being formed only of the crib- 
 riform plate of the ethmoid bone, so that perforation of the brain is 
 extremely easy to be performed at this point. The old Egyptians were 
 in the habit of first removing the brain through the nose with an iron 
 hook before commencing the process of embalming,' and subsequently 
 the cavity of the cranium wa'S filled with drugs through the same 
 channel.^ 
 
 An anatomical peculiarity of the skull of the negro race is often 
 exhibited in the nasal fossa, as a fourth meatus, which lies above the 
 superior turbinated bone. 
 
 The bony edge of the anterior nares is a guide to the lower orifice of 
 the nasal duct, which appears as a minute slit, about one-quarter of an 
 inch behind the bony edge of the nose, on a level with the inferior tur- 
 binated bone. The nasal duct is usually probed from above downward, 
 in case the escape of the tears is obstructed, as its lower opening is diffi- 
 cult to reach, especially as it is situate upon the outer wall of the inferior 
 meatus of the nose. ' 
 
 The vomer is not always felt to be in the median line, as it is often 
 deflected toward either the right or left side. Cases are recorded where 
 such an abnormality, when associated with a tumefaction of its mucous 
 covering, has been mistaken for a polypus of the posterior nares, and 
 attempts at its removal have been made. The edge of the vomer may be 
 felt in examining the posterior nares with the finger. To accomplish 
 this, the head must be thrown as far back as possible, in order to bring 
 the upper and posterior part of the pharynx below the level of the soft 
 palate, and the finger should be pushed upwarcf behind the palate, and 
 hooked forward till it enters the posterior nares. This step ,has a prac- 
 tical value in estimating the size of a plug (usually one inch long and six 
 lines wide), to arrest epistaxis, and in the diagnosis of polypi of the pos- 
 terior portion of the nasal fossa. When the nasal fossa is considered in 
 a subsequent chapter as a special surgical region, other points of interest 
 
 ' Herodotus: Euterpe, chap. 86, 87, 88 (as quoted by Holden). 
 
 ° Holden states that in the collection of Egyptian skulls brought from Thebes 
 by Prof. Flower, of London, every one showed the cribriform plate of the eth- 
 moid bone destroyed. 
 
 ^ Homer, op. cit. Broca: Osteologie du Crlne, 1875. 
 
20 
 
 PBAOTICAL MEDICAL ANATOMY. 
 
 will be given; and the practical utility of a knowledge of its anatomical 
 formation will be made more apparent to the reader. 
 
 BASE 0¥ THE SKULL. 
 
 In fractures of the Use of the skull, blood and cerebro-spinal fluid 
 may flow from the ear of the affected side. If the latter escape, it 
 indicates that the petrous portion of the temporal bone has been 
 fissured,' and the dura-mater sheath to the auditory and facial nerves 
 has been also lacerated." 
 
 In this form of injury, as well as in diseases of the ear, the facial 
 nerve may be implicated, since it passes through a canal (the aquseductus 
 Fallopii) in the petrous portion of the temporal bone; and this explains 
 why we sometimes have paralysis of the Tnuscles of one side of the face 
 
 Fio. 10.— Base of the sknU. 1, Palate plate of superior maxillary bone ; 2, alveolar ridge of supe- 
 rior maxillary bone; 3, palate plates of palate bone; 4, posterior palatine foramen; 6, vomer; 6, 
 Internal pterygoid plate of the sphenoid bone; 7, external pterygoid plate of same; 8, hamular 
 process of same; 9, entrance to posterior nares; 10, scaphoid fossa; 11, zygomatic fossa; 12,glenoid 
 Eossa; 13, mastoid process; 14, styloid process; 13, foramen ovale; 16, foramen spinosum; 17, caro- 
 tid canal; 18, basilar process of occipital bone; 19, foramen magnum; 20, condyles of occipital 
 bone; 21, jugular fossa; 23, jugular process of occipital bone; 33, auricular fissure; 24, styloid pro- 
 cess of temporal bone; 26, posterior condyloid foramen: 26, external occipital protuberance. 
 
 under these circumstances. Pressure on this nerve, at its escape from 
 the bone, as in case of tumors, parotid abscess, etc. , may also produce a 
 like effect. 
 
 In fracture at the base of the skull, blood often escapes from the 
 
 ' Presoott Hewitt. See also article by Dr. Buck, Medical Record, 1880. 
 
 * It is asserted by some authors that if blood escape from the ear after an 
 injury, not only must the petrous portion of the temporal bone be fractured, but 
 that one of the large venous sinuses of the dura-mater must be also in direct com- 
 munication with the seat of fracture. 
 
BONES OF THE FACE. 21 
 
 nose. This is due to the fact that the air-cells in the body of the sphenoid 
 ione are lined by a prolongation of the mucous membrane of the nose; 
 and any fracture which involves the body of the sphenoid bone is liable 
 to be associated with hemorrhage from the nostril. 
 
 Ecchymosis of the lower eyelid is a symptom very frequently associ- 
 ated with fracture of the base of the skull. This discoloration is subcon- 
 junctival in character, and appears, as a rule, within the first twenty-four 
 hours after the accident. It may be explained as an infiltration of blood 
 from the nasal cavity into the orbit; or by an escape of blood into the 
 orbit, through the spheno-maxillary fissure, in case some one of the 
 numerous vessels which enter the cranium at its base are involved. It 
 may also occur if the orbital plate of the frontal bone be involved, or 
 when blood escapes through the sphenoidal fissure into the orbit. 
 
 BOIJES OF THE FACE. 
 
 Much of the character exhibited in the face depends upon the superior 
 maxiUary and inferior maxillary bones. In them the teeth are inserted, 
 which contribute much to fill out the cheeks and to modify the character 
 
 FiQ. 12.— ADtero-lateral view of th» skull. 1, Frontal bone; 3, parietal bone; 3, temporal bone; 
 4, sphenoid bone; 5, psilatebone; 6, sup. max. bone; 7, malar bone; 8, lachrymal bone; 9, nasal 
 bone; 10, Inf. maxillary bone; o, frontal portion of orbit; 6, part of temporal fossa; c, malar por- 
 tion of orbit ; d, mastoid process ; e, lef t orbft ; /, sup. maxillary portion of orbit ; gr, infra-orbital fora- 
 men; h, mental foramen; i, symphysis; j, ramus; fc, coronoid process; I, condyle; m, angle of jaw. 
 
 of the mouth, while most of the muscles of expression are also attached 
 to them. 
 
 THE ORBITS. 
 
 The orbits are surrounded, at the facial margin, by a very strong 
 
22 PEACTICAL MEDldAL ANATOMY. 
 
 ring of bone, while tlieir upper wall is as thin as parchment. The 
 mechanical object of thus protecting the exposed portion of the orbit 
 from injury is still further shown by the strong ridge of bone which runs 
 from the zygoma. It is thus almost impossible to directly crush in the 
 orbit, except the most extreme Yiolence be used. 
 
 The axes of the orbits are so directed that, if prolonged backward, 
 they would meet at the sella turcica. This divergence gives to the eye 
 a range of vision greatly in excess of that which would be afforded were 
 the orbits directed in the antero-posterior plane. 
 
 The muscles of the eye are enabled to retract it within its socket, and 
 tlms to still further protect it from violence. 
 
 Injuries from pointed instruments within the orbit may produce 
 death from injury to the hrain. 
 
 THE NOSTRILS. 
 
 The septum between the nostrils is seldom exactly in the median line, 
 and this should not be considered as a deformity unless one nostril be 
 seriously occluded. ' 
 
 The lower edge of the superior and middle turbinated bones can be 
 made visible by widely dilating the nostril. This is of importance in 
 attempting to include the pedicle of a polypus within the grasp of a 
 forceps.'' 
 
 THE UPPER JAVr. 
 
 The second- molar tooth of the upper jaw is a guide to the orifice 
 of the duct of the parotid gland (Steno's), which can be seen in the 
 mouth as a small papilla on the mucous membrane of the cheek. 
 
 A line drawn from the interval between the two bicuspid teeth to the 
 point of junction of the inner and middle thirds of the supra-orbital 
 ai'ch, will cross the supra-orbital and infra-orbital foramina, and, if 
 prolonged downward, will intersect the mental foramen. This point is 
 of value in dividing nerves for facial neuralgia. The division of the 
 main trunks of either the third, fifth, or seventh nerves, in removing 
 tumors or other operations upon the face, is apt to cause distortion of 
 the features or loss of sensibility.' But in nearly every instance, as any 
 deep incision must necessarily divide some portions of the nerves of the 
 part, the surgeon can do little more than bear in mind the importance of 
 avoiding them, if possible, or, at least, of not excising their trunks if 
 they should be divided, as union may possibly restore their function.' 
 
 Modifications in the configuration of the hard palate often affect the 
 tone of the voice. On the hard palate can often be felt the pulsation of 
 
 ' Holden: Human Osteology. London, 1875. 
 
 ^ Gross: System of Surgery. 
 
 ^ Homer: Special Anatomy. Philadelphia, 1830. 
 
 * H. H. Smith: Treatise on Neuroma. Dublin, 1848. 
 
BONES OF THIS FACE. 23 
 
 the posterior palatine artery, which escapes at the inner side of the last 
 molar tooth. 
 
 A pin introduced in the centre of the crucial suture of the hard palate 
 would touch five bones, the fifth one being the vomer. 
 
 The fact that no muscles are attached to the hard palate except at its 
 posterior margin, and the density of its investing structures, are a suflB- 
 cient mechanical explanation why fractures in this vicinity are seldom 
 associated with displacement. 
 
 The last molar tooth is a guide to the introduction of a tube into the 
 mouth, in case of tetanic fixation of the jaw requiring forced alimenta- 
 tion, since a space exists between that tooth and the ramus of the jaw 
 sufiiciently large to admit a tube of moderate size. 
 
 The cavity of the superior maxillary bone (the antrum ' or " maxillary 
 sinus") is the frequent seat of disease. Within if may be developed 
 either solid or cystic tumors, and pus not infrequently accumulates. The 
 close relation of the different walls of this cavity to important structures 
 gives to these growths more than a passing interest. 
 
 If the inner wall becomes expanded, the nostril may be occluded ; if 
 the lower wall, the roof of the mouth may be depressed; while the inferior 
 maxillary nerve, which runs above it, may be pressed upon if the upper 
 wall is affected, and the orbit may furthermore be so encroached upon 
 as to greatly displace the eye. If the posterior wall be crowded back- 
 ward, the zygomatic fossa will be encroached upon, and tumors have thus 
 created a marked swelling in the region of the temple." Finally, the an- 
 terior wall may become prominent, and thus greatly distort and disfigure 
 that side of the face. 
 
 The walls of the antrum are thicker in the child than in the adult, 
 and for that reason the growth of tumors within that cavity will be liable 
 to progress more rapidly after puberty than before. Suppuration of the 
 antrum arises not infrequently from decay of the teeth, or from a failure 
 to remove a nerve within a tooth after it has been killed by caustics pre- 
 vious to filling a cavity, since the putrefying nerve creates gas, which es- 
 capes from the end of the fang, and thus causes suppuration in and 
 about the alveolar process. 
 
 The antrum is the largest of the air cavities of the head.' A large- 
 sized musket-ball has been known to remain loose within it for years, and 
 in some instances such balls have been known to escape through the roof 
 of the mouth.' 
 
 Drake ° reports a case where a woman endeavored to explore the cavity 
 
 ' Galen: Epitome Operum, 1643. 
 
 ■i Highmore (as quoted by Holden). 
 
 » Blandin : Anat. jTopog., 1834. 
 
 * Guthrie: Commentaries. London, 1855. 
 
 '•• Jargavay : Anatomie chirurgicale. 
 
 •■ As quoted by Holden. 
 
24 PBAOTICA.L MEDICAL, ANATOMV. 
 
 of the antrum through a socket of a tooth with a quill pen, and, to her 
 horror, introduced the whole six inches of its length by its assuming a 
 spiral direction within the cayity, and thus curling upon itself. She 
 sought medical assistance, supposing it had entered her brain. 
 
 The antrum should be tapped in case of its distention from fluid 
 either within the mouth, at a point situated one inch above the margin 
 of the gum, covering the first molar toojh, or that tooth having been 
 drawn, puncture of the antrum should afterward be made through the 
 socket ; or, in case it is deemed important to preserve the teeth, puncture 
 through the canine fossa, as recommended by Desault, or through the 
 molar tuberosity, as recommended by Lemorier, can be performed. 
 
 THE NASAL BONES. 
 
 The nasal bones, although slight and small in themselves, from an 
 arch of enormous strength, whose buttresses are the superior maxillary 
 bones, and whose centre is supported by the spine of the frontal bone. 
 The feats of supporting great weights, such as a ladder with an adult on 
 the top, as seen in the circuses, attest to the strength of this method of 
 construction. 
 
 It is for this reason that fractures of the nasal bones are usually asso- 
 ciated with a fracture of the perpendicular plate of the ethmoid bone, and 
 occasionally with a fracture at the base of the skull. 
 
 THE INEEKIOR MAXILLAEY BONE. 
 
 The lower jaw in man consists of one bone, but in the serpent it con- 
 sists of two symmetrical bones Joined by an elastic band or ligament, 
 which allows them to be separated in a lateral direction to a great extent. 
 It is by means of this arrangement that the serpent is able to swallow its 
 prey, which is often as large or even larger than its own body. In man, 
 however, this bone is very strong, so as to perform mastication even 
 of hard substances, and its points for muscular attachment are rough 
 and prominent, to afEord the firmest possible union between the bone 
 and the power which moves it. 
 
 The absorption of the sockets (the alveoli), which is natural in the 
 old, constitutes a disease when it occurs in youth or middle life. Such 
 an absorption is liable to occur in cases of long salivation, scurvy, or 
 purpura, and a premature age of the jaws is produced. 
 
 The teeth are not fitted directly into a bony socket, since a very vas- 
 cular and elastic periosteum is interposed between the tooth and its recep- 
 tacle in the alveolar process of the jaw. This membrane not only serves 
 to nourish the tooth, but its elasticity tends also to break shocks trans- 
 mitted through the teeth to the facial bones. It is the shrinking of this 
 periosteal covering of the tooth that causes the socket to become too 
 large in old age, so that the teeth become loose. 
 
 AVlien the jaws are closod, we see that each tooth is opposed by two 
 
BONES OF THE FACE. 25 
 
 teeth in the other jaw, being an evident attempt on the part of !N"ature to 
 render the loss of any one tooth hardly perceptible in the act of mastica- 
 tion. 
 
 Each external cusp of the lower teeth fits into the hollows between 
 the cusps of the teeth of the upper jaw, and thus insures a more perfect 
 adaptation of the grinding surfaces. 
 
 The two condyles, or articulating surfaces of the lower jaw, are not 
 directed absolutely backward, but are placed at such an angle that, if 
 their long axes were prolonged, they would intersect each other at the 
 anterior edge of the "foramen magnum." This is to facilitate the 
 rotary movements necessary for the mastication of our food. 
 
 Each condyU of the lower jaw can be felt in front of the ear, on 
 motion being attempted. It can be felt to move forward when the 
 mouth is held wide open, and return when the mouth is closed, thus 
 affording the grinding motion demanded during mastication of food. 
 
 The ramus of the lower jaw partially protects the external carotid 
 artery from injury, since the artery enters the parotid gland close to its 
 posterior border. 
 
 The symphysis of the lower jaw, within the mouth, is a guide to 
 divide the genio-hyo-glossus muscle, in case the tongue has to be drawn 
 far out of the mouth to remove tumors of that organ, or in case it is 
 divided as a means of cure for stammering. 
 
 The coronoid process of the lower jaw can be felt at the lateral and 
 posterior part of the mouth. Its inner surface is a guide, in some cases, 
 for puncture of a deep temporal abscess, since pus burrows between it and 
 the tuberosity of the superior maxillary bone. 
 
 An attempt has been made to decide as to the character of food indi- 
 cated by Nature for the best nutrition of an animal by the character of 
 his teeth. It does not always hold good, however, as, while man would 
 seem adapted to masticate both vegetable and animal food, the bat 
 species have incisors, canines, and molars, and still some are purely 
 frugivorous, while others live entirely on insects. The monkey tribe 
 also has large canines, yet they live exclusively on vegetables. 
 
 The angle of the loiver jaw marks a region of special surgical interest, 
 since the temporal, temporo-maxillary, facial, external jugular and inter- 
 nal jugular veins can be found in the immediate vicinity. Hence the 
 necessity of caution in operating in this region. 
 
 THE CKAliriUM AS A WHOLE. 
 
 Holden, in his work on osteology, lays great stress upon the relative 
 situation of the various buttresses of the different regions of the cranium, 
 since, "like aU other arches, the cranium transmits a shock toward its 
 buttresses." 
 
 Thusf the frontal hone is supported by the malar bones and the 
 
26 PRACTICAL MEDICAL ANATOM.V. 
 
 wings of the sphenoid; the parietal hones by the temporal bones; the 
 occipital hone by its entering the base of the skull and adjoining the body 
 of the sphenoid. 
 
 It may, therefore, often be possible to predict the direction of the 
 course of a fracture, produced by transmission of a force applied to the 
 vault of the cranium, by a knowledge of the exact seat at which the 
 force was first applied; and, by a thorough familiarity with the surgical 
 bearings of the special cranial foramina, and the parts which lie in close 
 contact with the different portions of each of the cranial bones, to predict 
 symptoms which may be subsequently developed. 
 
 By far, the greater proportion of the blows received by the head is 
 applied to the parietal region. This bone rests upon the temporal bone, 
 which is weakened by the following cavities and foramina : the meatus 
 auditorius externus and internus, the tympanum, the cochlea and semi- 
 circular canals, the aquaeductus Fallopii, the Jugular fossa, the carotid 
 canal, the opening of the Eustachian tube, the Glasserian fissure, and 
 other smaller canals. It is, therefore, extremely probable that a fracture 
 of the parietal bone will extend in a direction to involve some of these 
 special portions of the temporal bone. 
 
 It has been argued in the past, by Malgaigne, Velpeau, and Beclard, 
 that the analogy between the head and a sphere will account for many 
 of the phenomena of transmitted force, producing the so-called " frac- 
 ture by contre-coupj" and since, a sphere, when struck smartly, is most 
 apt to break at the point immediately opposite to the point where the 
 blow was received, such an analogy would theoretically indicate a like 
 efEect within the skull. Practical observation seems to have proved this, 
 however, to be a fallacy, and the defect in the analogy will account for 
 the error in deduction. 
 
 The skull is in no respects a sphere; on the contrary, it can, with far 
 more reason, be compared to an arch, and all mechanical deductions on 
 the latter basis will approximate far more closely to the facts presented 
 by Nature than upon the previous hypothesis. It is the buttresses of the 
 arch, all of which converge toward the body of the sphenoid bone as a 
 centre, that feel, first and chiefly, the effects of transmitted force, and 
 most "fractures by contre-coup" will be found to affect, not antagonistic 
 portions of the cranium, but the supports of that portion of the vault 
 which is injured. 
 
 VARIATIONS IN THE FORM OF THE SKULL. 
 
 An external view of the head may show variations in its form. These 
 may be due either to age, sex, national characteristics, or mechanical 
 causes. 
 
 The shuU of the infant is large in its occipital region; while its frontal 
 region is imperfectly developed; and the face is extremely small^in com- 
 
BONES OF THE FACE. 
 
 27 
 
 parison with the skull, being usually only one-eighth of the entire weight. 
 The sutures are usually separated or imperfectly closed, and the fon- 
 tanelles are apparent. 
 
 In cliildhood, the face increases in its relative size, reaching one-quarter 
 to one-third the weight of the skull; and the frontal and parietal regions 
 also develop rapidly, giving the head a more symmetrical appearance. 
 
 The skull of the female is characterized by the following peculiarities: 
 
 1. The bones are individually smoother, lighter, and smaller. 
 
 2. The /ace is smaller in proportion to the skull. 
 
 3. Ihe frontal sinuses are smaller than in the male. 
 
 4. The parietal region is very large in compaiison with the frontal 
 
 and occipital regions. 
 
 5. The jaws are much narrower than in the male. 
 
 5 
 
 Fig. 12. Fig. 18. 
 
 Fig. 12.— View of the head showing the fontanelles. (After Byford.) 
 
 Fig. 13 shows the longitudinal and vertical diameters of the fcetal head. 1, 2, Occipito-frontal; 
 3, 4, occipito-mental ; 5, 6, traohelo-bregmatic; 7, 8, fron to-mental. (After Byford.) 
 
 Camper ' first pointed out the variations in the skulls of different races, 
 
 and showed the modifications which ensued as civilization advanced. 
 
 The more important points to which he called attention were as follows: 
 
 1. The smallest skulls are found in the Hindoo and the ancient 
 
 Peruvian races. 
 3. The largest skulls are tound in the Caflre and Scandinavian races. 
 3. The skulls of all rude tribes are characterized chiefly by the fol- 
 lowing deviations from those of the civilized races: 
 
 (a) Prominent temporal regions. 
 
 (b) Extremely wide zygomatic arches. 
 
 (c) " " anterior nares. 
 
 (d) Extreme length and strength of the jaws. 
 
 (e) '' "of the incisor teeth. 
 
 (/■) Obliquity of the incisor teeth to each other when approximated 
 
 (in contrast to the right angle found in civilized nations). 
 (g) Prominence of the points of muscular attachments. 
 
 ' Anatomy and the Arts, London, 1831. 
 
28 PE ACTIO AL MEDICAL ANATOMY. 
 
 Among the deviations in form, dependent upon mechanical causes, 
 may be enumerated: 
 
 1. Non-closure of the sutures (as in chronic hydrocephalus). 
 
 2. Imperfect ossification (as in rickets). 
 
 3. Excessive development. 
 
 4. Irregularities in shape, dependent upon a premature obliteration 
 
 of the sutures (synostosis). 
 
 5. Acquired distortion, from compression, etc. (as in the flat-head 
 
 Indian tribe). 
 
 6. New growths. 
 
 POISE OF THE HEAD AND THE DIAGNOSTIC VALUE OF DEVIATIONS 
 EEOM THE NORMAL ATTITUDE. 
 
 No part of the osseous system of man affords more striking evidence 
 of his adaptation for the erect attitude than the cranium. The vertebral 
 column forms a right angle with its base, and thus affords it a direct 
 support. The condyles, or points of articulation, are situated very near 
 to the centre of its base, by which arrangement little active muscular 
 power is required to maintain it in equilibrio. In this respect the human 
 cranium differs from that of other animals, in whicli the condyles 
 are usually placed much further back, esj)ecially in those animals where 
 the head is suspended by an elastic structure (the ligamentum nuchse) at 
 the extremity of a spinal column which lies horizontally. 
 
 The head, as has been observed, consists of two distinct portions, the 
 cranium and the face; the one being intended to contain the brain — the 
 organ of the mind — and the organ of hearing; the other to inclose the 
 organs of sight, smell, and taste. The more the organs of smell and 
 taste are developed, the greater is the size of the face and the greater its 
 relative proportion to that of the cranium. On the contrary, the larger 
 the brain, the greater must be the capacity of the skull, and the greater 
 its proportion to the face. 
 
 On this principle, a large cranium and a small face indicate a large 
 brain, with a restricted development of the sense of smell and taste ; but 
 a small cranium and a large face mark an opposite conformation. This 
 point is of special value to the naturalist, insomuch as it affords him a 
 means of relatively estimating the faculties, instincts, and capabilities of 
 different individuals, as well as of different classes of animals. 
 
 Camper suggests a simple rule to estimate tlie proportion of the cra- 
 nium to that of the face. 
 
 If a line be drawn upward from the side of the chin to the most prom- 
 inent part of the forehead, it will form an angle with a horizontal line 
 drawn hachtvard over the external auditory foramen from the margin of 
 the anterior nares; thesm of the angle so formed will indicate the degree 
 of development of the cranium and brain, as compared with that of the 
 face and the organs of sense. 
 
BONES OF THE FACE. 29 
 
 As examples of this, these lines are so nearly coincident in the croco- 
 dile as to form scarcely any appreciable angle; while, in the horse, it 
 measures 23°; in the dog, 20° to 35°; in the orang-outang, 56° to 60°; 
 and in the European adult, from 85° to 95°. Thus, ve find man at the 
 top of the scale of all of the animate beings, and distinguished from the 
 rest as well as by his external conformation as by his physical and moral 
 attributes and his internal organization. 
 
 The head js capable of direct movement only in one of three direc- 
 tions, viz., forward, backward, and a rotary movement. By means, how- 
 ever, of the cervical vertebree, which have great mobility, the head may 
 also be given a lateral inclination, and the forward and backward move- 
 ment of the head may be thus greatly increased. The different atti- 
 tudes assumed by the head have not only a physiological interest, but also 
 a diagnostic value. By permitting a free and unrestricted use of the 
 head, mankind is afforded a scope of vision equal to that of those animals, 
 where the absence of such latitude of movement requires that the eye 
 shall have such a prominence as to permit it to cover all points with dis- 
 tinct vision without motion of the head. Furthermore, were it not for 
 this mobility of the head and neck, hearing would also be rendered far 
 less acute in man than in those animals who are provided with larger and 
 movable ears. 
 
 The physiological acts of prehension of food and its mastication, the 
 sucking of liquids through a tube, the swallowing of food after mastica- 
 tion, and that part of normal respiration which is performed in the larynx 
 and hyoid region, are all materially assisted by movements of the head. 
 
 Much of the grace of movement which characterizes some individuals 
 depends upon the carriage of the head as weJl as that of the trunk and 
 extremities. The idiot " may often be told by the motions of the head 
 alone. 
 
 In convulsions, the head is usually inclined to one side, from the 
 destruction of the proper balance between the antagonistic power of 
 the corresponding muscles on the side opposite those then in active 
 exercise. In hemiplegia the same effect is produced, since the loss of 
 nerve power affects only the muscles of one side. In dislocation of the 
 cervical verteircB, although an infrequent accident, the head is usually 
 inclined from the mesial line of the trunk; and in glandular swellings, 
 and large cicatrices from burns of the lateral aspect of the neck, a me- 
 chanical impediment is often produced to an erect poise of the head, 
 which may demand surgical relief. 
 
 The head is'b&D.t forward in mme types of vertebral malformations: 
 in case of large growths upon the neck or shoulders, in emphysema, in 
 the cicatrices of burns affecting the anterior portion of the neck, and in 
 
 ■ Connelly: Med. Times and Gazette, 1861-3. 
 
30 
 
 PBA.OTIOAL MEDICAL ANATOMY. 
 
 many conditions of tlie spinal column, muscles, or vessels, which render 
 the erect position painful. 
 
 In almost all diseases resulting in extreme dyspnwa,^ such as croup, 
 laryngismus stridulus, laryngeal obstruction from foreign bodies, new 
 growths, or paralysis, growths in the neck, asthma, pneumo-thorax, heart 
 lesions, etc., the head is, as a rule, thrown lachward to afford an unob- 
 structed channel for air through the mouth, nares, and pharynx. The 
 same attitude will be also pereeired in tetanus, cerebro-spinal meningitis, 
 and brain affections of children." 
 
 As in some cases of deformity, resulting from permanent contraction 
 of the muscles which affect the attitude of the head, a knowledge of the 
 muscles which are involved may prove of service, I append a list" of the 
 muscles, which may assist in the various forms of distortion. 
 
 Forward by 
 Rectus cap. ant. major. 
 " " " minor. 
 Stemo-mastoid. 
 Platysma myoides. 
 
 THE HEAD MAY BE MOTED. 
 
 Badkward by 
 Eectus cap. post, major. 
 " " " minor. 
 Complexus. 
 Splenius capitis. 
 Obliquus cap. sup. 
 Trachelo-mastoid. 
 Part of trapezius. 
 
 Laterally, by 
 Platysma. 
 Stemo-mastoid. 
 Part of trapezius. 
 Splenius capitis. 
 
 " colli. 
 Trachelo-mastoid. 
 Complexus. 
 
 Assisted {when the lower 
 
 jaw is fixed) by 
 Mylo-hyoid. 
 Genio-hyoid. 
 Genio-hyo-glossus. 
 Digastric. 
 
 Certain muscles, which act alone upon the neck, may also assist in 
 displacement of the head from its normal attitude, among which may be 
 chiefly enumerated the longus colli, the scaleni muscles, the levator anguli 
 scapula, the omo-hyoid, and some of the deep muscles of the back. The 
 result of the contraction of any of the muscles enumerated must depend 
 entirely upon the associate muscles in contraction, and upon the exciting 
 cause; since, if either muscle acts in common with its fellow of the oppo- 
 site side, the result will differ materially from that produced by the con- 
 traction of the same muscle or muscles acting without its fellow. 
 
 ' Niemeyer, Corfe, Chas. BeU, Lavater. 
 
 > Vogel: Diseases of Children. New York, 1870. 
 
 ' Sharpey and Quain: Anatomy. Phila., 1849. 
 
THE HUMAN FACE IN HEALTH AND DISEASE. 31 
 
 CHAPTER II. 
 
 THE HUMAN FACE; ITS MODIFICATIONS IN HEALTH AND 
 DISEASE, AND ITS VALUE AS A GUIDE IN DIAGNOSIS.' 
 
 The extent to T.'hich the anatomy of the head, as studied from the 
 standpoint of physiognomy, may suggest points of practical value to the 
 physician or surgeon, has not, in my opinion, received sufficient con- 
 sideration in the popular text-books of the day. From the British and 
 Foreign Medical Review of 1841, I quote the following sentence: 
 ' ■ Medical physiognomy is, in many instances, a source of diagnosis which 
 seldom fails the practitioner who is himself well versed in it; and we be- 
 lieve that much of the exquisite tact in discrimination of disease, which 
 distinguishes some practitioners and which others can never attain, de- 
 pends upon the vivid perception of an eye and ear habitually familiar 
 with the lineaments, the tone, and the gestures of disease." Among the 
 earlier authors, who were ignorant of many of the present methods of 
 determining the condition, size, and position of organs, since the art of 
 auscultation and percussion is a growth of later date, the study of the 
 human countenance formed a very important part of the preparatory drill. 
 The followers of Hippocrates and Galen were rendered perfect in their 
 perceptive faculties. The former gave to us, in his masterly work, de- 
 scriptions of the symptoms of disease which are still considered classic, 
 while the latter, in his essays on the "Temperaments,"' is equally care- 
 ful to note the most trivial alteration either of the face or posture. 
 
 There seems to be a gi-owing tendency of late to regard the rational 
 symptoms of disease as subordinate to the results of a physical examina- 
 tion, and of but little value in themselves, except as confirmatory evi- 
 dence. Authors frequently render the description of the symptoms of 
 disease so terse and indefinite, that but few of the readers of the later 
 medical or surgical works could precisely picture to themselves the ap- 
 pearance of a sufferer from any of the maladies, with the pathology and 
 physical symptoms of which they may be thoroughly familiar. It is not 
 infrequently the experience of the most erudite of the profession to be 
 amazed at the gift, which is possessed by some less scholarly brother, of 
 making a diagnosis, which seldom errs, without the aid of the thermome- 
 
 ' This article originally appeared in the N. Y. Med. Journal, and I am indebt- 
 ed to Messrs. Appleton for the use of the cuts then made to illustrate it. 
 ' Kuhn's edition. 
 
32 PKACTIGAL MEDICAL AKATOMY. 
 
 ter or the stethoscope; and many an old nurse, long accustomed to spend 
 weary nights in watching the sick, can often render a prognosis which 
 seems little short of inspiration when her utter ignorance of all medical 
 knowledge is considered. 
 
 Despite the fact that some of our best authors have denounced the 
 attempts of DeSalle, Jadelot, and Seibert to establish certain facial lines 
 and wrinkles as of positive value in diagnosis, and have pronounced all 
 such statements as a mere fantasy, still no one of large experience can 
 deny that the face may at times afford most positive and valuable infor- 
 mation. 
 
 In 1806, Lavater ' published his work upon this subject, in which he 
 discusses at great length the diagnostic value of general physiognomy. 
 Subsequently, Sir Charles Bell wrote upon the subject from a purely ana- 
 tomical point of view, and, in 1834, published his "Essays upon Expres- 
 sion. "_ Baumgaertner •' added his contribution to the subject in 1839 
 and Laycock,' in 1863, published his course of lectures, with illustrations, 
 which were designed to show the various types of diathesis, and their 
 bearing upon the general development. Corfe, in 1867, published a 
 series of contributions in the Medical Times and Gazette, in which the 
 subject was studied from a clinical point of view, and not only the 
 entire field of facial expression, but also that of general physiognomy, 
 was pointed out to the student, so far as the cases under consideration 
 illustrated any points of special interest. Eothergill,* Southey {Lancet, 
 1878), S. Wilks" and Jonathan Hutchinson, have also been earnest 
 workers in the same field. 
 
 Darwin's great work upon the expression of the emotions in animals, 
 and the contributions of Connelly ° upon the typical shades of expression 
 peculiar to the insane, may well be read by those who question the util- 
 ity of this much neglected department of science. The careful study of 
 the expressions of the face, and the modifications which age produces 
 in it, is at least very advantageous in furnishing a normal standard by 
 which deviations in disease may be studied. I quote from the most 
 excellent treatise of Blandin ' the following sentence: "Those who 
 neglect or seek to ridicule this mode of investigation, prove only one 
 thing, that they study pathology without a proper knowledge of anatomy 
 and physiology, upon which the former is founded. The morbid expres- 
 sions of the face are an extremely useful, and often the only guide of 
 
 ' L'Art de counaltre lea Homines par Physiognomie. Paris, 1808-'7. 
 
 2 Atlas, 1839. 
 
 a Med. Times and Gazette, 1863, Vol. i. 
 
 * Principles of Therapeutics, 1880. 
 
 •^ Essays on the Temperaments. 
 
 «Med. Times and Gazette, 1862. 
 
 ' Anatomie Topographique, 1834. 
 
THE HUMAiT FACE IN HEALTH AND DISEASE. 
 
 33 
 
 the medical practitioner, in the case of a yery young child that can tell 
 nothing in regard to its sufferings." 
 
 It is with a yiew to systematize and arrange the collected inyestiga- 
 tions of the authors previously named, and to bring within the compass 
 of a single article such practical information as the aitatomy of the face 
 may afEord the practitioner, that I am led to draw professional attention 
 to this subject once more. 
 
 " The physiognomy of the sick presents innumerable shades of expres- 
 sion. It may assume the yarious conditions expressive of sadness, dejec- 
 tion, attentiveness, indifEerence, uneasiness, or terror; it may, at times, 
 be smiling; occasionally menacing or wandering; and sometimes show 
 a series of changes in rapid succession." ' 
 
 Fig. 14, — The Transverse Eugse. 
 
 These yarious conditions of the countenance may not only be the 
 direct result of the influence of the ever-varying passions upon the mus- 
 cles of the face, as is the case in health, but they may also be classed 
 as morbid phenomena, each of which possesses some special significance. 
 Chomel" lays great stress upon these variations of countenance, and 
 endeavors to point out the special diagnostic value of each. 
 
 Facial Lines astd "Wrinkles. — The theories of De Salle, Jadelot, 
 and Seibert ' as to the diagnostic value of facial lines and wrinkles have 
 had their share of support from time to time; while they have also been 
 considered by some authors as speculative and destitute of any value. The 
 existence of these marks may be attributable to one of two conditions, 
 viz., a disappearance of the fat from the subcutaneous tissues of the 
 face, or the abnormal contraction of certain facial muscles, dependent 
 
 • Williams: Principles of Medicine. Philadelphia, 1844. 
 ' Legons de clinique med. Paris, 1834. * Williams, op. cit. 
 
 3 
 
34 
 
 PRACTICAL MEDICAL ANATOMY. 
 
 upon some apparent irritation of the motor neryes supplying the affected 
 muscles. It is important, in using these lines and wrinkles as guides 
 in diagnosis, that the discrimination be made between those lines which 
 are natural to the face of the sufferer and those which are developed as 
 a result of the disease. For the reason that the face of the adult is 
 always more or less marked by lines, ' it must be evident that these lines 
 are a more reliable guide in the infant than in later life, if their diag- 
 nostic value remains unquestioned. Without entering into a discussion 
 as to the merits of the question, I give the theories advanced, for what- 
 ever interest and value they may possess to the reader. The wrinkles of 
 the face may be classified into six groups, as follows : 
 
 (1.) The Transverse Rugm. — These are situated upon the forehead, 
 and are formed by the action of the occipito-frontalis muscle. They are 
 thought to be expressive of an extreme amount of pain, arising from 
 causes outside of the cavities of the body. 
 
 Fig. 15.— The Ooulo-frontal Eugse. 
 
 (3.) The Oculo-frontal Rugm. — These extend vertically from the 
 forehead to the root of tlie nose, and are formed by the corrugator su- 
 percilii muscles. They are thought to express distress, anxiety, anguish, 
 and excessive pain from some internal cause. It is said that they farther- 
 more indicate an imperfect or false crisis; and that, in attacks of acute 
 diseases, an impending efflorescence and sometimes a fatal termination 
 may be indicated by their occurrence. In those types of headache where 
 the pain is very excessive, these rugae may exist simultaneously 'With the 
 ones previously described. It is stated that, when the former rugae meet 
 the latter abruptly, during the course of an acute disease, some serious 
 lesion of the brain, or its coverings, is developing. 
 
 ^ Blandin, op. cit. 
 
THE HUMAN FACE IN HEALTH AND DISEASE. 
 
 35 
 
 (3.) The Lijiea Oculo-zygomatica. — This line (the line of Jadelot) 
 extends from the inner angle of the eye downward and outward, passing 
 across the face below the malar bone. It is said to indicate, in children, 
 a cerebral or nervous affection; ' and, in adult life, some disease of the 
 genital organs, masturbation or venereal excess. 
 
 (4.) Tlie Linea Nasalis (Line of De Salle).— This line extends from 
 the upper border of the ala nasi downward, in a direction more or less 
 curved, to the outer edge of the orbicularis muscle. This line is said to 
 be strongly marked in phthisis and in atrophy. Its upper half (the linea 
 nasalis proper) is thought to be a reliable indication of intestinal disease, 
 if extensively developed and prominent; the lower half (the linea buc- 
 
 PiQ. 16.— The Line of Jadelot. 
 
 calls) is supposed to indicate the existence of some disease affecting the 
 stomach. It is claimed by Peiper that, when this line appears conjointly 
 with the line of Jadelot, it may be regarded as a positive indication of 
 worms in children, if a peculiar fixed condition of the eye exist and a 
 pallor of the face be present. 
 
 (5.) The Linea Labialis. — This line extends downward from the 
 
 ' Vogel: On Diseases of Children. New York. 
 
36 
 
 PKAOriOAL MBDIOAL ANATOMY. 
 
 angle of the mouth till it becomes lost in the lower portion of the face. 
 It is usually developed in connection with those diseases which render 
 breathing laborious or painful, and is more common in children than in 
 the adult as a sign of diagnostic value. 
 
 (6.) The Linea Qollateralis Nasi. — This, line extends from the nose 
 downward to the chin, in a semicircular direction. It lies outside the 
 linea buccalis, the linea nasalis, and the linea labialis. It is thought to 
 be a reliable guide to diseases of the thoracic and abdominal viscera.' 
 
 Color of the Page. — The color of the face is subject to variations 
 which, to the eye of the mfedical adviser, afford unquestioned aid in 
 
 Fig. 17.— The Line of De Salle. 
 
 diagnosis. Flushing of the face, as evidenced by a diffused redness 
 which is of a transient character, is very common in women suffering 
 from irregularity of the menstrual period and during the menopause. In 
 plethora, especially after exertion or excitement, an unnatural redness 
 of the face may occur, associated with symptoms indicative of cerebral 
 hyperasmia. Pressure of tumors, either of the neck or thorax, upon the 
 sympathetic nerve may create an abnormal dilatation of the capillaries, 
 thus resulting in a redness of the skin, with an increase of temperature 
 of the affected region; while section of the sympathetic nerve, although 
 a rare form of accident, would result in a like condition. " Red patches 
 occur on the cheek during an attack of croupous pneumonia. In wast- 
 
 'Corfe, Med. Times and Gaz. , 1867. 
 " M. Foster: Text book of Physiology. 
 
 London, 1878. 
 
THE HOMAiT FACE IN HEALTH AND DISEASE. 
 
 37 
 
 ing affections of a chronic character, especially of the lungs, such as 
 phthisis, cancer, etc., a circumscribed redness over the malar hones, 
 known as the "hectic flush," is usually present. It may occasionally 
 affect only one cheek/ where only one lung is diseased. Pallor of the 
 face is the rule during convalescence from any severe disease, and in 
 patients long deprived of sunlight.' A waxy pallor exists in chronic 
 Bright's disease, which renders the skin almost transparent. In the 
 chill of fevers and malarial attacks, a dusTcy paleness is usually perceived; 
 
 Fig. 18.— The Linea Collateralis Nasi. 
 
 while in cases of hemorrhage, where the loss of blood has been suflB- 
 cient to produce constitutional effects, the pallor of the face assumes a 
 peculiar leaden color, ' A greenish tint is present in profound attacks 
 of anasmia and during chlorosis,' giving to the, face an appearance sim- 
 ilar to that of imperfectly bleached wax. 
 
 Malaria and cancer are often manifested by a light straw color of 
 
 ' Stille: General Pathology. Philadelphia, 1848. 
 
 '' Williams, op. cit. 
 
 ' Sir Charles Bell: Treatise on Surgery. London, 1836. 
 
 < Niemeyer: Text-book of Practical Medicine. New York, 1881. 
 
38 
 
 PBAOTIOAL MEDICAL ANATOMY. 
 
 the face, although it may occasionally result in the deep yellow of jaun- 
 dice.' In the early stages of jaundice, the sclerotic coat of the eye and 
 the corners of the mouth first show the yellow color, although the dis- 
 coloration soon tends to become diffused over the entire face. A blue 
 tinge exists in those cases where the venous return to the right heart is 
 obstructed, or where, from any cause, the oxygenation of the blood ia 
 imperfectly performed. It occurs, therefore, in cyanosis, asphyxia, the 
 fevers, certain diseases of the pulmonary organs which interfere with 
 the circulation, and in diseases of the heart which render its action weak 
 or imperfect. In cases of poisoning from nitrate of silver, the skin 
 assumes a still deeper blue tint than in those cases above mentioned, and 
 the staining is permanent. In Addison's disease of the supra-renal cap- 
 sules, a darTc-brown color of the skin results, which may be either uni- 
 form or in isolated spots, and, in severe cases, almost rival the pigmen- 
 tation of the negro. The redness of erysipelas is usually accompanied 
 by an oedema which renders the face intense and shining, and often 
 causes a markedly altered expression of the countenance. 
 
 The face is the seat of many of the eruptions, some of which are confined 
 almost exclusively to it, while others are usually found in that region 
 before they appear elsewhere. It would exceed the limits of this chapter 
 to enter into the description of the characters which stamp each of the 
 various eruptions, since they can be easily learned by reference to any of 
 the special treatises. 
 
 Corfe suggests as a guide to the student in physiognomy the follow- 
 ing table, which designates the prevailing changes in the complexion of 
 the face in the course of the more common disorders. While it is not 
 possible to construct any table which shall give all the information 
 desired upon so important a subject, still this one may prove of some 
 valiie as a means of aiding the memory: 
 
 In cerebral disease the countenance is lethargic. 
 
 livid. 
 
 dusky and distressed, 
 dusky and flushed, 
 pale and anxious, 
 pale and thm. 
 sallow and thin, 
 yellow and thin, 
 thin, puffy, and anaemic, 
 anxious and dragged, 
 sallow and haggard. 
 
 Marshall Hall " thus describes a countenance which he considers typ- 
 ical of the acute form of dyspepsia: " This affection is accompanied by 
 some paleness or sallowness, and a dai-k hue about the eye. The lips are 
 
 ' Reynolds: System of Medicine. London, 1871. 
 ' On Diagnosis. London, 1817. 
 
 In emphysema 
 
 In pulmonary oedema 
 
 In pneumonia 
 
 In pleurisy 
 
 In phthisis 
 
 In malignant disease. 
 
 In icterus 
 
 In renal disease 
 
 In peritonitis 
 
 In uteriue disease 
 
THE HUMAN FACE IN HEALTH AND DISEASE. 39 
 
 slightly pale and livid. The cutaneous vessels exude a little oily perspi- 
 ration, and the muscles of the face, and especially of the chin and lips, 
 are affected with a degree of tremor, particularly on any hurry or sur- 
 prise, or on speaking." 
 
 The hue of the skin may be deepened, resembling that of plethora, in 
 the condition of atheroma, associated with a gouty heart. 
 
 The condition of cyanosis, if met with in babies, indicates a congenital 
 malformation of the heart or some imperfection in its development. It 
 is, therefore, a most serious symptom. 
 
 A purplish color of the face, when associated with rapid respiration 
 and other symptoms of phthisis, suggests a bad prognosis, as it indicates 
 extensive disease. 
 
 When, in young subjects, the face appears vascular, and the features 
 "blurred as to their outlines," especially if the lips and alse of the nose 
 appear full and prominent, mitral disease may be reasonably suspected. 
 In adults, a similar condition is met with among women at the meno- 
 pause, and it is to be explained as the result of a semi-paralysis of the 
 vaso-motor nerves associated with low arterial tension. ' 
 
 An unnatural smoothness of the skin of the face of adults in middle 
 life, if a marked pallor co-exists, may often be a guide to the detection of 
 chronic Bright's disease. The skin is usually dry, and perspiration is 
 excited with difficulty. 
 
 Phthisis often produces a pallor with a peculiar greasy, unctuous skin; 
 the same may be also met with in aortic disease. 
 
 The dry, anaemic, and "parchment-like" skin tightly drawn over the 
 face, and showing a tortuous and visibly pulsating temporal vessel, if seen 
 in the old, usually indicates changes in the viscera; but, when met with 
 in young men, syphilis may be strongly suspected to exist. 
 
 The Fokehead. — Fothergill ' thus clearly puts the clinical aspects of 
 this region: " The forehead is important. When well vaulted it forms a 
 part of the nervous diathesis. When broad and rather low, it usually 
 goes with a stalwart frame and a bulky body. The lofty brow is usually 
 accompanied by a thin flank and a 'weasel-belly' — indeed, with small 
 digestive viscera, and a liability to indigestion; the broad, low brow goes 
 usually with a square abdomen, large digestive organs, and good assimi- 
 lation — with gout looming in the distance, or even actually present. It 
 may be protuberant from excessive ossification of the centres of the fron- 
 tal bones, and this is apt to be found with defective development of the 
 rest of the bones, and wide fontanelles, as seen in hydrocephalic infants. 
 It is also seen ia the rachitic forehead. ' The head of the child in rickets 
 is generally unusally large, the vertex flattened, and the forehead promi- 
 nent, broad, and square, with considerable expansion at the centres of the 
 parietal bones.' Sometimes the sutures remain open; at other times they 
 
 ' Semeiology. New York, 18S1. 
 
40 
 
 PEACTICAL MEDICAL ANATOMY. 
 
 are closed prematurely, and then the growth of the cranium is arrested, 
 and the child remains a child in intellect, or is a cretin or an idiot. 
 Imbecility, however, is not always accompanied by a small cranium. In 
 strumous children with a syphilitic taint, the forehead may become 
 protuberant and project in front of the face. Here the arrested develop- 
 ment of the facial bones intensifies the deformity. In some cases, the 
 forehead carries with it a moral significance. There is the broad, ebur- 
 nated forehead, the forehead Jeremiah recognized when he said, ' Thou 
 hadst a whore's forehead, thou refusedest to be ashamed.' The woman 
 with this forehead will deny pregnancy with the most unblushing effron- 
 tery; and is utterly untruthful when anything connected with morals is 
 involved. Then the forehead may manifest one single copper-colored 
 spot, pathognomonic of syphilis. Ulceration of the forehead is always 
 syphilitic, except when the result of a wound. The scars are equally 
 significant and suggestive. " 
 
 FiQ. 19.— Acquired deformity of the nose and mouth. 
 
 The Nose. — The nostrils are of some practical interest from a medi- 
 cal point of view. They dilate forcibly and rapidly in difficult respiration, 
 when produced by disease;' and itching of the nostril is regarded by 
 many authors as a valuable diagnostic sign of intestinal worms." The 
 nose seldom points directly forward, being, as a rule, slightly inclined 
 toward the right side. This fact is explained by Beclard as the result of 
 the habit of wiping the nose with the right hand, since, in left-handed 
 
 ' Sir Charles Bell: 
 " Peiper, op. cit. 
 
 Essays on Expression. London, 1824. 
 
THE HUMAN FACE IN HEALTH AND DISEASE. 41 
 
 people, the opposite deflection exists. Tlie nose of a face perfect in its 
 outline should be one-third of the length of the distance from the root of 
 the hair to the chin; but, in certain races, the variation from this rule 
 affords a special physiognomy. The integument which covers the nose is 
 very firmly attached to the muscles underneath it by a cellulo-fatty layer. 
 Blandin ' lays great stress upon this fact as explaining the inf requency of 
 cedema of this region, and as an effort on the part of Nature to preserve 
 the uniformity of contour of the nose, which would be seriously impaired 
 by any local swelling of the face, were the skin over the nose loosely 
 attached. The nose is extremely vascular; hence the custom of surgeons 
 to replace severed portions of the organ, even if completely detached, with 
 a hope of obtaining union. Among the ancients, amputation of the nose 
 was practised upon the criminal classes, and the operation of rhinoplasty 
 was first suggested as a means of relief for those so disfigured. 
 
 The redness of the nose after an attack of crying indicates a connec- 
 tion between the sympathetic supply of the capillary vessels of the nose 
 and that of the capillaries of the lachrymal apparatus; hence any form of 
 irritation of either of these localities is liable to be accompanied by symp- 
 toms referable to the other.''' Injury to the nose, resulting in fracture, 
 often kaves a permanent facial deformity, and, even when no evidences 
 of serious injury can be ascertained by external examination, cerebral 
 symptoms are liable to follow, as fracture of the base of the skull may 
 result, from a transmission of the force through the perpendicular plate 
 of the ethmoid bone.' Vascular tumors of the region of the nose are not 
 uncommon, while a prominence of the capillary vessels of the nose is met 
 with in the aged as the result of a defect in the contractile power of their 
 coats. ' 
 
 Marked elevation of the nostril is regarded by some authorities ° as an 
 indicator of pain within the cavity of the thorax. 
 
 In pysemia, there is either a singular absence of all expression, or a 
 countenance which exhibits a stupid indifference to all surroundings. 
 
 When a sunken bridge to the nose exists, there is suggested at once a 
 strong probability of inherited syphilis; and this is still further confirmed 
 if the patient has had the "snuffles " in infancy. 
 
 Over-indulgence in alcohol gives to the tip of the nose a redness and 
 a tendency to small tuberosities upon that region; while chronic indiges- 
 tion or constipation, especially if associated with disease of the pelvic 
 viscera, may produce a similar result in women. 
 
 The Eye. — " It may appear to many a superfluous task to attempt to 
 judge of the character of an individual by a glance at his face, but, what- 
 ever may be thought of the possibility of laying down strict rules for such 
 
 ' Op. cit. ? Blandin, op. cit. 
 
 " Holden: Human Osteology. London, 1855. 
 
 ■• Beclard, op. cit. ' Marshall Hall, op. cit. 
 
42 
 
 PEACTICAL MEDICAL ANATOMY. 
 
 judgment, it is a fact of every-day occurrence that we are, almost without 
 reflection on our part, impressed favorably or u nf a vorably with the temper 
 
 Fig. 30. — Deformity from a burn. 
 
 and talents of others by the expression of their countenance. The 
 face acquires its expression also from bodily habits, injuries, and from 
 
 1^ ^\^^ 
 
 Fig. 21.— Deformity of the eyes from a bum. 
 
 intellectual or sensual pursuits, m that we may pass from the lofty and 
 expanded forehead, with the sm.all, well-formed mouth, of the philoso- 
 
THE HUMAN FACE IN HEALTH AND DISEASE. 43 
 
 plier, down to tlio sliallow front and protruded muzzle of the negro, 
 whose habits are more bestial than those of the animals he chases for the 
 support of his life." ' 
 
 The intimate communications between the second, the fifth, the 
 seventh, and the sympathetic nerves, through the media of the ciliary, 
 otic, and Meckel's ganglia, would lead us to expect that the eye should 
 exhibit, in its altered appearance, the derangement of internal structures. 
 " When a glance of this organ is caught, what a field of mute expression 
 is open to the mind! This silent and instructive index of the whole 
 man may be bright or dull, heavy or clear, half shut or unnaturally open, 
 sunken or protruded, fixed or oscillating, straight or distorted, staring or 
 
 Zgr. 
 
 if 
 
 
 
 A" 
 G 
 
 FiQ. 23. Fig. 23. 
 
 Fig. 28.— The external appearance of the normal eye and eyelids; 2, 2, cilia or eyelashes; 3, 
 inner canthus; 4, outer canthus; 5, puncta lachrymalia; 6, caruncula lachrymalls; 7, semilunar 
 fold. 
 
 Fig. 23.— Showing the appearance of the blood-vessels in conjunctivitis. 
 
 twinkling, fiery or lethargic, anxious or distressed; again, it may be 
 watery or dry, of a pale blue, or its white turned to yellow." ' 
 
 I quote the following suggestions from Fothergill's late pamphlet on 
 Semeiology: "The cornea may be affected, and is chronically inflamed by 
 syphilis about puberty, and until about seventeen. Under proper treat- 
 ment it may clear up; but if neglected, permanent opacity may result. 
 At the union of the cornea and the sclerotic a ring is sometimes seen; 
 this is the arcus senilis. It indicates advancing age, as its name implies; 
 but it is necessary to have clear ideas on the subject, else error may arise. 
 There are two forms of arcus: one very suggestive and of evil omen; the 
 other without any significance. The latter being the more pronounced 
 of the two, careless observers have often been misled. To take the inno- 
 cent form first may be well. It is very distinct, with sharply-defined 
 outlines and a clear cornea. It is calcareous in its nature, and is very 
 common in hale old people; especially persons with light-blue eyes. It 
 
 ' C!orfe, op. cit. 
 
44 PBACTICAL MEDICAL ANATOMY. 
 
 corresponds to the bony plates found in birds at the point of attachment 
 of the cornea to the sclerotic. It has no significance; but the other form 
 tells of tissue-decay. This arcus has badly defined edges; while the 
 cornea is hazy and cloudy from fat-granules being scattered throughout 
 it. It is more pronounced under the eyelids, where the arcus is often to 
 be seen very distinctly, when scarcely recognizable in that portion which 
 is exposed to light. It is often well, then, to lift the upper eyelid when 
 in doubt; as when the question arises as to whether or not there be fatty 
 degeneration in the fibres of the heart. Arcus is a bow: annulus a ring. 
 It is arcus senilis, not annulus senilis. Then as to the pupils. Some- 
 times the iris is the seat of inflammation; and the formation of a tubercle 
 at the inner or free edge of the iris is common in syphilis. Then the 
 pupils may be of unequal size. Contraction of one pupil is often found 
 in aneurism of the aorta. When the pupils are both contracted, and 
 severely contracted, then the suspicion of opium poisoning is aroused, or 
 indulgence in cough-lozenges containing opium." 
 
 The pupils may be contracted or widely dilated, insensible to or 
 
 Fia. 24. — Countenance of mania. Fio. 35. — Cduntenance of chron'c mania. 
 
 intolerant of light, oscillating or otherwise, unequal in size, or changed 
 from their natural clearness of outline. " The noble arch of the brow 
 speaks its varied language in every face of sufiEering humanity. It may 
 be overhanging or corrugated, raised or depressed; while the lid of the 
 eye, an important part of this vault, exhibits alternations of puffin ess or 
 hollowness, of smoothness or unevenness, of darkness or paleness, of 
 sallowness or brown discoloration, of white or purple. Lines intersect 
 this region, and the varied tints are perpetually giving new color, new 
 feature, new expression, by their shadows." ' If the frontal muscle a.cts 
 in connection with the corrugator supercilii, an acute deflection upward is 
 given to the inner part of the eyebrow, very different from the general 
 action of the muscle, and decidedly expressive of debilitating pain, or of 
 discontent, according to the prevailing cast of the rest of the countenance. 
 
 ' Corfe, op. cit. 
 
THE HUMAN FACE IN HEALTH AND DISEASE. 
 
 45 
 
 An irregularity of the pupils of the two eyes indicates, as a rule, pressure 
 upon nerTe-centres or upon the motor oculi nerve. In adynamic fevers, 
 the eyes are heavy and extremely sluggish, and are, as a rule, partially 
 covered by the drooping eyelid; while in certain forms of mania they 
 are seldom motionless. ' This latter peculiarity is also often noticed in 
 idiocy. 
 
 The inner surface of the eyelid is a valuable guide to detect the pres- 
 ence of anaemia, since it shows a pallor which is in mai'ked contrast to the 
 redness of health. 
 
 Fig. 26.—" Bell's Paralysis." (Modified from Ctorfe.) 
 
 The eye is apt to be vascular after an excessive indulgence in alcohol. 
 In Bright's disease, a small collection of fluid may often be detected beneath 
 the conjunctiva, which might be mistaken for a tear; it can be moved, 
 however, while a tear cannot be without causing its disappearance. 
 
 ' Connelly, Med. Times and Gaz., 1861-'2. 
 
46 PRACTICAL MEDICAL ANATOMY. 
 
 A squint of the eye is a most significant clinical point in hydrocepha- 
 lus of infants. It may, at first, be slight, but it tends to become per- 
 sistent as the disease advances. Internal squint often indicates the pres- 
 ence of a congenital or acquired hyperopia. 
 
 In the so-called "Bell's paralysis," due to failure of the facial nerve, 
 the eyelids stand wide open and cannot be voluntarily closed, since the 
 orbicularis palpebrarum muscle is paralyzed. This condition may be 
 further recognized, if unilateral, by a smoothness of the affected side, 
 since the antagonistic muscles tend to draw the face toward the side oppo- 
 site to the one in which the muscular movement is impaired; an inability 
 to place the mouth in the position of whistling, since for this act the two 
 sides of the face must act in unison; loss of control of saliva, which 
 dribbles from the corner of the mouth; and a tendency to accumulation 
 of food in the cheek, since the buccinator muscle no longer acts. 
 
 Fig. 87. Fig. 28. 
 
 Fig. 27.— Appearance of kerato iritis with adliesions. 
 Fig. S8.— Appearance of keratitis, the opacity partially occluding the pupil. 
 
 When the third pair of nerves are affected upon either side, the upper 
 eyelid cannot be voluntarily raised, for the levator palpebrse muscle fails 
 to act; and the eye is caused to diverge outward, since the external rectus 
 muscle, not being supplied by the third pair, and having no counter- 
 balancing muscle,- draws the eye from its line of parallelism with its 
 fellow. In photophobia, attempts to open the eye create resistance on 
 the part of the patient, since the entrance of light causes pain; while, as 
 death approaches, or in the state of coma (save in a few exceptions), the 
 eyes are usually open. In cardiac hypertrophy, an unusual brilliancy of 
 the eye is perceived, ' since the arterial system is overfilled from the addi- 
 tional power of the heart. A peculiar glistening stare exists during the 
 course of scarlet fever, which is in marked contrast with the liquid, ten- 
 der, and watery eye of measles." Many diseases of the eye itself tend to 
 greatly alter the normal expression of the face. Prominently among 
 these may be mentioned cataract, glaucoma, cancer, staphyloma, exoph- 
 
 ' Loomis: Lectures on Diseases of the Respiratory Organs, Heart, and Kid- 
 neys. New York, 1874. 
 
 - J. Dugan, quoted by Haviland Hall: Differential Diagnosis. Philadelphia 
 
 1879. 
 
THE HUMAN PAGE IN HEALTH AND DISEASE. 
 
 47 
 
 thalmus, iritis, conjunctivitis, amaurosis, episcleritis, pterygium, strabis- 
 mus, etc., but the special peculiarities of each need not be here described. 
 Abnormalities of the pupils may afEord the practitioner material aid 
 in diagnosis. The pupils are found to be dilated during attacks of dys- 
 pnoea and after excessive muscular exertion,' in the latter stages of 
 anaesthesia, and in cases of poisoning from 
 belladonna and other drugs of similar ac- 
 tion. A contracted state of the pupils 
 exists during alcoholic excitement, in the 
 early stages of ansesthesia from chloro- 
 form, and in poisoning by morphia and 
 other preparations of opium, physostig- 
 min, chloral, and some other drugs. Par- 
 alysis of the third cranial nerve creates a dilated condition of the pupil of 
 the same side, since that nerve controls the circular fibres of the iris. 
 Spinal sclerosis often produces a failure on the part of the pupil to respond 
 
 Fio. 89.— Pterygium. 
 
 Fio. 30.— Partial staphyloma of the comea. 
 
 FiQ. SI.— Total staphyloma of cornea. 
 
 to light, but it still contracts when accommodation of vision for near 
 objects is demanded. 
 
 Growths within the deeper portions of the orbit tend to create a dis- 
 placement of the eye forward, and thus to cause an apparent increase of 
 that organ in size. A similar condition may also result from abscesses 
 or the growth of tumors within the cavity of the antrum. In the so- 
 called Basedow's disease,' an abnormal prominence of the eyes accompa- 
 nies a simultaneous enlargement of the thyroid gland. 
 
 The eyelashes, if abnormal, not only in themselves create deformity, 
 but also, by causing irritation of the conjunctiva, produce an alteration 
 in tlie normal expression of the eye. 
 
 The Eaks. — "The ear is often instructive. It may contain otolites, 
 pathognomonic of gout. . Or as Professor Laycook insisted, the lobe may 
 be red, full, and glistening, as if the stretched skin was about to crack. 
 
 ' M. Foster: Text-Book of Physiology, third edition. London, 1879. 
 ' F. von Niemeyer: Text-Book of Practical Medicine. Translated by Hackley 
 and Humphrey. New York, 1869. 
 
48 PEACTICAL MEDICAL ANATOMY. 
 
 This is common in gouty persons in middle age. As nutrition fails, the 
 lobe may become wrinkled. It goes with the skin of the face to a great 
 extent. A wrinkled ear-lobe with a face seamed with wrinkles usually 
 goes with extensive but very chronic visceral cirrhosis. Here the skin is 
 very dry and imperspirable. Then the ear may be deformed by othae- 
 matoma, most commonly seen in the general paralysis of the insane. A 
 discharge from the ear should always claim careful attention; chronic 
 otorrhoea not rarely ends in meningeal inflammation and death." ' 
 
 The Cheek. — The cheek is capable of a great variety of movement. 
 During the reception of liquid or solid food into the mouth, it is of the 
 greatest assistance, since by its movements the two acts are greatly 
 facilitated; during mastication, the buccinator muscle helps to force the 
 food between the jaws, which are brought into apposition and rubbed 
 together; and, finally, the cheek can act as an important factor in pro- 
 ducing that peculiar type of countenance which is so strongly indicative 
 of the desire of taking nourishment. The respiratory motions of the 
 cheek are manifested in the acts of gaping and blowing, and in the exhi- 
 bition of intense passion, in which the malar region is markedly in 
 sympathy with a general excitation of the whole respiratory apparatus. 
 
 " The cheek may become the mirror of the souh When the feelings 
 are gay, it is drawn outward and upward; but, when the mind is de- 
 pressed or saddened, it is drawn obliquely downward. If these move- 
 ments be carefully noted, it will be perceived that the movable point of 
 the cheek is situated in the immediate vicinity of the naso-labial groove." 
 This is due to the fact that the attachments of several of the small facial 
 muscles at about this point tend to draw the anterior part of the cheek 
 outward from the line of this groove. It may be noticed, as a matter of 
 interest, that, when the mental impressions are slight and trivial, no 
 traces of their effect upon the face are left upon the cheek; but, when 
 they are of a serious or prolonged character, deep and permanent grooves 
 are formed, which are of interest to the physiognomist as an indication 
 of the temperament, and to the medical adviser as often of positive value 
 in diagnosis. "In the young child, the cheek, which is at nearly the 
 same instant alternately moistened with a tear or decked with a smile, 
 preserves in the healthy state the roundness which marks that happy age; 
 but in the adult, the cheek, on the contrary, presents numerous lines and 
 wrinkles, and this appearance becomes still more apparent as old age ap- 
 proaches."" There are, however, 'lines in the cheek of the aged which 
 should not be mistaken for evidences either of the temperament or of 
 disease, since they are produced simply by the apjjroximation of the jaws. 
 Lavater,' in his work upon physiognomy, locates most of the sentiment 
 
 ' Fothergill: Semeiology. New York, 1881. 
 
 ' Blandin, op. cit. ' Op. pit., Hunter's edition. 
 
THE HUMAN FACE IN HEALTH AND DISEASE. 
 
 49 
 
 of the face in the cheek, and draws comparisons between the base and 
 jealous face and that which is generous and noble, as a support to his 
 theory. 
 
 " The color of the cheek varies much, both as a direct result of the 
 passions and from special diseased conditions, which have been mentioned 
 previously in this article. In fear and envy, the cheek is usually pale 
 and colorless, while in love, embarrassment, or anger it is often uncom- 
 monly red. To the physiologist, these changes are a beautiful exhibition 
 of the sympathy which exists between the mind and the circulatory and 
 respiratory systems, which are seldom influenced except simultaneously. 
 The changes in the cheek which affect expression, like the respiratory 
 motions, depend chiefly upon the influence of the facial nerve; and thus 
 
 Fig. 32.— Deformity of the cheek, nose, and lips, from 
 a bum. 
 
 Fig. 33 — Hare-lip complicated by a fissure 
 of the hard palate. (After Buck.) 
 
 it is that children and females, in whom the nervous system is is generally 
 more susceptible to impressions, also present, to the greatest degree, more 
 or less transient modifications of the cheek. The cheek suffers a diminu- 
 tion in its fat as age advances, and when the teeth have been lost the 
 approximation of the jaws forces the redundant cheek outward; and its fiac- 
 cidity, from the loss of fatty tissue, throws it into folds, which are not 
 present in the face of the infant.'" 
 
 The cheek approaches a triangular form in the infant, but it becomes 
 quadrilateral when the teeth are developed; and in the old man, as the teeth 
 are lost, it again returns to the triangular form as in infancy. The fact 
 
 ' Blandin, op. oit. 
 
50 
 
 PRACTICAL MEDICAL ANATOMY. 
 
 that the maxillary sinus is Tery imperfectly developed in the child, and 
 gradually increases as age advances, explains to a great extent why the 
 triangular form tends to become quadrilateral; and the frequency of ab- 
 normal protrusions of this region is explained by growths or the accumu- 
 lation of fluid within this cavity. The changes in the cheek produced by 
 advancing years are also illustrated in its color. " In the child, the bright 
 rose tint, which accompanies exertion and frequently the hours of sleep, 
 bespeaks health and general activity; but in adult age this coloring tends 
 to disappear, and in old age the cheek often assumes a striated redness, 
 which is due to an abnormal dilatation of the capillary vessels, especially 
 the veins.'" The vascularity of the cheek renders the occurrence of erec- 
 tile tumors common in this region ; and the elasticity of the tissues affords 
 
 Fio. 34.— Ulcerated epithelioma o£ the lower lip. (After Hamilton.) 
 
 an anatomical explanation of the little disfigurement which follows the re- 
 moval of large portions of the cheek, in case surgical interference is 
 demanded from any cause. 
 
 The Lips. — Certain deformities of the face are common in the region 
 of the lips and mouth. Among these may be mentioned the condition of 
 deficient closure, which is the normal condition of the hare, and to which 
 the term "hare lip " is applied. This deformity may be as associated with 
 that of fissure of the hard palate, and often with imperfect development 
 of the soft palate; and thus not only is the countenance impaired, but 
 the power of sucking, natural to the infant, destroyed, and the articu- 
 lation of words subsequently rendered imperfect. The vascularity of 
 
 ' Blandin, op. cit. 
 
THE HUMAN FACE IN HEALTH AND DISEASE. 
 
 51 
 
 the ]ips renders the development of erectile tumors of this region not in- 
 frequent; while hypertrophy of the tissues forming the lips may occur as 
 one of the types of facial deformity. 
 
 The lips of the young child are very much longer in proportion to the 
 face than those of the adult, and their increased length renders the act of 
 sucking easier to the infant than if the teeth were present, since the lips 
 can be made almost to cross each other and thus closely embrace the nip- 
 ple. When the teeth are formed, the excessive length of the lips dimin- 
 ishes and the expression of the face is thus greatly altered; while, in the 
 old man, as the teeth are lost, the lips again become very long, which ac- 
 counts for their projection forward when the mouth is closed, and which 
 gives to the face of those advanced in years the peculiar pouting expres- 
 sion so often seen. ' The excessive length of the lips in the aged f urther- 
 
 FiG. 35 Fibro-cystic tumor of the frontal and orbital Fig. 36.— Warty tumor of tlie eyelid. 
 
 regions. 
 
 more acts as a hindrance to mastication, and often renders the articula- 
 tion of words extremely indistinct. 
 
 In sickness, if the angle of the mouth be depressed, pain and languor 
 may be read; and, when the corrugator supercilii muscle cooperates with 
 the depressor muscles of the mouth, acute sufEeriug is proclaimed.' 
 
 Extreme pallor of the lips is observed in excessive hemorrhage, in 
 purpura, in chlorosis, etc. ; deep lividity denotes a defective oxygenation 
 of the blood, and occurs chiefly in diseases of the lungs, heart, and 
 larynx; while pale lividity occurs in cases where the circulation of the 
 surface is languid or imperfect. ' In painful affections of the abdominal 
 organs, the upper lip is usually raised and stretched over the gums or teeth, 
 so as to give a diagnostic expression to the countenance, which is con- 
 
 ' Blandin, op. cit. 
 
 » Corfe. 
 
 ' Marshall Hall, op. cit. 
 
52 
 
 PRACTICAL MEDICAL ANATOSTr. 
 
 sidered by some as of great value. In anasarca of the face, the lips, eyes, 
 and cheeks are most affected, since the subcutaneous cellular tissue in these 
 regions admits of distention more readily than in those regions where it is 
 not so loose. 
 
 Dbfoemities of the Face. — ^Among the extraordinary deformities of 
 the orbital region, may be casually mentioned those rare cases of absence 
 of the eyes, and the union of the two orbits, as reported by Tenon and 
 Bartholine. The eyelids may also be foujid deficient or united at birth- 
 and occasionally turned in or out, when the skin and the conjunctiva are 
 
 Fia. 37.— Lipoma of the nose. (After Hamilton .) 
 
 of unequal length. The last type of deformity is most frequently the re- 
 sult of cicatrization of the tissues of the face, following an injury; while 
 adhesions of the eyelids to the globe of the eye may be either a congenital 
 defect or the result of inflammatory processes. The pupils may be ab- 
 sent at birth, or may be partially incomplete;' while deformities of this 
 aperture may also be acquired as the result of adhesions between the iris 
 and the cornea or the crystalline lens, or as the result of an operation in 
 which portions of the iris are excised for the relief of glaucoma. 
 
 The entire absence of the face at the time of birth has been recorded 
 
 ' Blandin, op. cit. 
 
THE HUMAN FA.OB IN HEALTH AND DISEASE. 
 
 53 
 
 by Lecart, Curtius, and B6clard; while in numerous instances the median 
 ])ortions of the face have been absent, or the existence of deep central 
 fissures in the face has been detected. Cases are on record where all 
 evidences of the existence of the nostrils are absent, termed " anarina ; " 
 those where the mouth has been found absent, termed " astomia ; " and 
 those where a double nose has existed, as recorded by Beclard. In these 
 abnormalities, as in those where the cranium has been partially or totally 
 wanting, an arrest of the process of development at an early stage of foetal 
 life must have occurred, the date of which in pregnancy may be roughly 
 estimated by the extent and situation of the deformity. In cases of senile 
 atrophy of the forehead, the bones are sometimes completely absorbed, 
 and hernia of the encephalon may thus be spontaneously produced. 
 
 Pig. 38 - 
 
 -Erectile tumor of the lips. (After 
 Hamilton.) 
 
 FlQ. 39.— Congenital hypertrophy of the tongue. 
 (Aft«r Buck ) 
 
 Tumors of the face always create a deformity, which is confined to 
 the anatomical region afEected; some of which have already been referred 
 to in this article in the treatment of certain of the special features. Many 
 conditions of the face, which may properly be spoken of as deformities, 
 are dependent upon disease. Some of those which affect the eye and its 
 appendages, and others which are due to injury of nerves of to disease of 
 nerve centres, will be described later on, among the special types of phy- 
 siognomy which are of interest in their bearing upon general diagnosis. 
 Severe types of ulceration, as it occurs in lupus and carcinoma, often 
 create so extensive a destruction of tissue as to give rise to hideous de- 
 formities, but they have no special bearing upon the diagnosis of the ex- 
 isting disease. 
 
 Special Types of Face. — Many of the specific forms of disease 
 have their special physiognomy. As examples of this fact, "scrofulous 
 children inherit either a velvety skin, dark-brown complexion, dark hair, 
 
54: PBACTIOAI. MEDICAL ANATOMY. 
 
 dark brilliant eyes, and long lashes, with the lineaments of a face finely 
 drawn and expressive; or a fair complexion, thick and swollen nose, broad 
 chin, teeth irregular and developed late, inflammation of the Meibomian 
 glands, scrofulous ophthalmia, eruptions of the head, nose, and lips, and 
 enlarged cervical glands." ' 
 
 The facial expression of idiots and imbeciles is described by Dr. Lang- 
 don Down at length. The following quotation " is an abbreviation of his 
 investigations: " Their eyes are oblique, and the face simulates the Mon- 
 golian type. There are semilunar folds of skin at the internal canthus 
 of the eye (the third eyelid of the bird). The lips are thick, especially 
 the lower one; they are often marked by transverse fissures; also, they 
 are often deficient in muscular power, so that the saliva dribbles. The 
 angle of the jaw is obtuse, while the ears are placed usually far back. 
 The mouth is arched, the tongue large, rugous, and fissured, while its 
 papillse are enlarged." 
 
 Hippocrates" describes a characteristic expression, which has been 
 called after him the "facies Hippocratica," in which the eyebrows are 
 knitted, the eyes are hollow and sunken, the nose is very sharp, the ears 
 are cold, thin, and contracted, with marked shriveling of the lobules; the 
 face is pale and of a greenish, livid, or leaden hue; and the skin about the 
 forehead is tense, dry, and hard. This type of countenance is a most 
 fi'cquent indicator of impending death from chronic disease, or in an 
 acute form of disease which has been unusually prolonged. 
 
 The "facies stupida" is distinguished by a dulness of expression, 
 which is its chief characteristic. A peculiarity exists as regards the eyes, 
 which are extremely dull, and resemble those seen in alcoholic stupor. 
 This type of countenance is identical with the so-called "typhoid face," 
 since it is most frequently met with either in connection with typhoid 
 fever or with the typhoid condition associated with some other disease.* 
 
 Another type of countenance to which attention is frequently drawn 
 is called the "pinched countenance." It can be produced artificially by 
 exposure to cold, and is characterized by an apparent decrease in the size 
 of the face, with a contracted and drawn expression of the features, and 
 pallor or livid color of the skin. It is said to exist most frequently in the 
 course of acute peritoneal inflammation. 
 
 " In the long list of diseases which tend to shut off the supply of air to 
 the lungs more or less suddenly, and in those accidents, such as chok- 
 ing, strangulation, smothering, drowning, etc., where the same effect is 
 accomplished, the symptons of apnoea are manifested in the face by flushing 
 and turgidity, at first, and, later on, by a livid and purplish color. The 
 
 ' Williams, op. cit. 
 
 "^ J. Milner Fothergill: Semeiology, 1880. 
 
 * Prognostics (Adams's translation). 
 
 *Finlayson: Clinical Diagnosis. Pliiladelphia, 1878. 
 
THE HOMAN FACE IN HEALTH AND DISEASE. 
 
 56 
 
 veins of the neck become markedly swollen, and the eyes seem to pro- 
 trade from their sockets. A loss of consciousness, and possibly convul- 
 sions, precedes death." ' 
 
 The countenance of extreme anaemia is seen in those cases where, 
 from sudden or gradual hemorrhage, the prognosis is rendered alarming. 
 The phenomena which attend this mode of dying are pallor of the face, 
 with a peculiar leaden or clay-like hue," cold sweats, dimness of vision, 
 dilated pupils, a slow, weak, irregular pulse, and speedy insensibility. 
 With these symptoms are frequently conjoined nausea, restlessness and 
 tossing of the limbs, transient delirium; a breathing which is irregular, 
 sighing, and, at last, gasping; and convulsions before the scene closes. 
 
 Kg. 40.— Face after Hemorrhage. (Modffled from Corfe.) 
 
 The expression of the countenance is typically marked in certain of 
 the inflammatory diseases of the eye.' " In strumous ophthalmia, the 
 child's brow is knit and contracted, while the ala nasi and the upper 
 lip are drawn upward. Those muscles which tend to exclude the light 
 from the inflamed organ, without shutting out the perception of external 
 objects, are called into action; thus producing a peculiar and distinctive 
 gi'in. In severe cases, the child will sulk all day in dark corners, or, if 
 compelled to stay in bed, will bury the face in the pillow, since the exclu- 
 
 ' Watson: Practice of Physic (Condie's edition). 
 
 ' Sir Charles Bell, op. cit. 
 
 ' Haynes "Walton: Operative Ophthalmic Surgery. 
 
 Philadelphia, 1853. 
 
56 PRACTICAL MEDICAL ANATOMY. 
 
 sion of all light tends greatly to diminish the suffering. If brought to 
 the window, the eyes are shaded with the hands or the arms; and, if the 
 eye be opened, a profusion of hot, scalding tears will enter the nose and 
 gire rise to sneezing, or flow over the face and cause excoriation of the 
 adjoining parts." This special intolerance of light seems to be a chief 
 characteristic of this type of trouble, since it is often out of proportion to 
 the redness which indicates the extent of the inflammation present. In 
 catarrhal ophthalmia, the inflammation seems to be confined to the con- 
 junctiva and the Meibomian follicles. The eyelids are glued together by 
 the lashes, which are bathed in the excessive secretion of the conjunctiva or 
 of the inflamed follicles; and a redness of the surface of the eye, with some 
 pain and uneasiness, is the only other symptom of special diagnostic value. 
 The condition of iritis is characterized by a redness of the sclerotic; a 
 change in the color of the iris, and in its general appearance, as compared 
 with the healthy eye; an irregularity in the pupil, produced by adhesion 
 of the iris to the adjacent structures; possibly immobility of the pupil, 
 as the result of such adhesions; and a visible deposit of coagulable lymph. 
 The pupil, in acute iritis, seldom dilates in the dark, on account of the 
 intense congestion which exists,' audit is usually smaller than that of 
 
 the unaffected eye. Some pain and ex- 
 cessive photophobia are usually also 
 present in attacks of acute iritis. There 
 is something vei-y peculiar in the expres- 
 sion of the countenance of a person suf- 
 fering from amaurosis, by which alone 
 the physician may almost recognize the 
 disease. " Such a patient enters a room 
 with an air of great uncertainty as to 
 movement, the eyes are not directed 
 
 Fig. 41.— Showing the radiate char- . ,...i ,.j 
 
 aoter of the overloaded blood-vessels toward surroundmg objects, the eyelids 
 in iritis, and also the irregular pupu. ^j-e wide Open, and the patient seems gaz- 
 ing into vacancy. This unmeaning stare of the face is due, in great 
 measure, to an absence of that harmony of movement and expression 
 which results largely from the information obtained by the exercise of 
 vision."" This seeming stare at nothing is not observed in patients 
 who are blind in consequence of opacity of the crystalline lens or of 
 its capsule, i. e., in consequence of cataract. They, on the contrary, 
 while they cannot see, still seem to look about them, as if they were 
 conscious that the power of sight remained in the retina, although 
 the perception of objects was shut out from it. Patients afflicted with 
 cataract, who cannot detect the existence of a gas jet or a candle in a 
 dark room, are not fit subjects for operation, as the existence of trouble 
 
 ■ See the experiments of Mosso, quoted by Michael Foster, 
 * Watson, op. cit. 
 
THE HUMAN FACE IN HEALTH AND DISEASE. 57 
 
 behind the lens may safely be surmised; since the periphery of the lens 
 seldom becomes opaque to such an extent as to prevent the perception 
 of light by the retina, even if the outline of objects cannot be per- 
 ceived. 
 
 It is a fact well known among oculists, and one which often helps them 
 materially in diagnosis, that the defects of vision, occasioned by impair- 
 ment in the power of the muscles which control the eyeball, cause the 
 patients unconsciously to assume a position of the head ' which tends to 
 assist them in the use of the afEected eye. So diagnostic are some of the 
 attitudes assumed by this class of afflicted people that the condition which 
 exists may be told at a glance as the patient enters a room, by one thoroughly 
 familiar with the diseases of this important organ. The explanation of 
 this tendency on the part of this class of patients, lies in the fact that any 
 loss of power in the ocular muscles immediately shows itself in the per- 
 ception of every object, as it were doubled; and it is to overcome these 
 double Images that patients almost instantaneously discover their ability 
 to get rid of the annoyance by some special attitude which, of course, 
 depends upon the muscle which is weakened or paralyzed. 
 
 It wiU be necessary, in order to make you clearly understand the 
 mechanism of this peculiarity, that the separate action of the six muscle 
 which directly act upon the globe of the eye be considered. 
 
 The action of each of the ocular muscles may be given, then, as 
 follows, with the proviso that many of the motidns of the eye are not 
 the result of the contraction of any single muscle, but often of a number 
 acting either in unison or successively. 
 
 The superior oblique muscle turns the eye downward and outward. 
 
 The inferior oblique muscle turns the eye upward and outward. 
 
 The superior rectus muscle turns the eye upward and inward. 
 
 The inferior rectus muscle turns the eye downward and inward. 
 
 The internal rectus muscle turns the eye directly inward. 
 
 The external rectus muscle turns the eye directly outward. 
 
 This statement as to the above muscles reveals nothing which would 
 not be immediately suggested by the insertion of each, with the excep- 
 tion of the superior and inferior recti muscles, which, besides the 
 action their situation would naturally suggest, tend also to draw the 
 eyeball inward, on account of the obliquity of the axis of the orbit and 
 the same obliquity of the muscles, since they arise at the apex of the 
 orbit. The action of the oblique muscles is, as any one familiar with 
 their origin and insertion would naturally surmise, to control the oblique 
 movements of the eyeball. 
 
 Now, as soon as any one of these six muscles beomes pressed upon 
 
 • An extract from the author's late work, The Applied Anatomy of the Nerv- 
 ous System. New York, 1881. 
 
58 PRACTICAL MEDICAL ANATOMY. 
 
 and weakened by the presence of tumors, inflammatory exudation, syphi- 
 lis, or other causes, the patient at once perceives double wiages, and in 
 order to get his eye into such a relative position with that of the healthy 
 side as to enable them both to focus upon the same object in a natural 
 manner, the patient soon learns to so move his head as to compel the 
 two eyes to look in parallel directions. 
 
 A very simple rule can be suggested by which the reader may be enabled, 
 not only to tell in what direction a patient will move his head in case any 
 special muscle be rendered weak or utterly useless, but also to diagnose 
 the muscle afEected, when youlook at the patient, without any knowledge 
 of his history. The rule may be thus stated : 
 
 In paresis of any of the ocular muscles, the head is so deflected from 
 its normal position that the chin is carried in a direction corresponding to 
 the action of the affected muscle. 
 
 Thus, in paresis of the external rectus,' the chin would be carried 
 outward toward the injured muscle, while in paresis of the internal 
 rectus muscle the head would be turned away from the side on which the 
 muscle fails to act. In case the superior oblique muscle is impaired, the 
 chin would be carried downward and outward, while in the case of the 
 inferior oblique muscle the chin would have to be moved upward and 
 outward to benefit the vision of the patient. The superior and inferior 
 recti muscles, when impaired by disease or other causes, would likewise 
 create a deflection of the head in a line corresponding to that of their 
 respective actions. 
 
 When a congenital, zonular cataract exists, the child will give evi- 
 dence of its presence by the peculiar method employed to obtain a clear 
 perception of any given object which is held in the hand: instead of look- 
 ing at it in the ordinary manner, the child moves the object constantly 
 before the eyes so as to obtain a view of the object, as it were by sections, 
 since light can only enter the chamber of the eye through the periphery 
 of the lens. This act is so characteristic as to be considered as almost 
 pathognomonic of this congenital defect. These patients also frequently 
 carry the head with the chin depressed so as to admit light through the 
 periphery of the lens, and thus to gain the aid of distinct vision in their 
 movements. 
 
 Children sufiering from glioma of the retina will often exhibit a 
 yellowish or reddish metallic lustre, which apparently comes from the 
 depth of the eye. 
 
 ' While this statement would be absolutely tiTie in theory in all cases, we 
 must acknowledge, as a clinical fact, that patients learn to utterly disregard the 
 image in the affected eye when the internal or external rectus is the seat of 
 paresis, and to use the normal eye only for the purposes of vision, thus rendering 
 this attitude of the head less diagnostic than when the oblique muscles are 
 affected. 
 
THE HUMAN FACE IN HEALTH AND DISEASE. 59 
 
 A person suffering from chronic trachoma (granular eyelid) will 
 manifest the diseased condition by a peculiar drooping of the upper lid^ 
 which gives a somewhat sleepy expression to the face. In some of the 
 pictures of Shakespeare, this type of countenance is markedly depicted. 
 
 In ptosis, the upper lid falls over the eye, in proportion to the degree 
 of the paralysis, giving the eye a more or less closed appearance. When 
 the upper lid falls so that its margin reaches the limit of the pupil, the 
 patient will often throw the head backward when endeavoring to per- 
 ceive an object directly in front of him. 
 
 One of the peculiarities of cataract, especially if it be nuclear or not 
 fully mature, may be noticed in the attitude of the head as the patient 
 enters the consulting room, since the chin will frequently be depressed in 
 order to admit light above the opacity in the lens. This is in marked 
 contrast to the attitude assumed by patients suffering from atrophy 
 of the optic nerve, who do not depress the chin, but exhibit the blank, 
 unmeaning stare which is so typical of that condition. 
 
 An exceedingly peculiar expression of countenance is observed in those 
 patients suffering from epicanthus, since the palpebral fissure is smaller 
 than normal and the canthus is brought closer to the limits of the cornea 
 than in health. If the condition be bilateral and confined to the inner 
 canthus, the eyes have the appearance of being too widely separated. 
 
 In glaucoma, the eyes have a peculiarly dull appearance, which is 
 largely the result of a corneal opacity, while a greenish discoloration of 
 the eye will be perceived in the advanced stages accompanied by an 
 engorgement of the veins of the sclerotic. The eye will also be unnatu- 
 rally hard and resistant to the touch. 
 
 A dislocation of the lens into the anterior chamber of the eye will 
 usually be manifested by a bright zone near to the junction of the cornea 
 with the sclerotic. This is due to the direct reflection of light from the 
 periphery of the dislocated lens. 
 
 In locomotor ataxia (provided that the eilio-spinal centre be affected 
 by the sclerosis), a peculiarity of the pupil may often be recognized, 
 since it will be small in size and will not respond to light. On care- 
 ful examination, however, it will be perceived that a certain amount 
 of movement in the pupil occurs when the patient is directed to accom- 
 modate the vision to some near object. The methods employed in the 
 examination of such patients may be found by a reference to most of the 
 later text-books on nervous diseases, as this condition is now considered a 
 valuable diagnostic point when locomotor ataxia is suspected. 
 
 The dilated pupil, which results from paralysis of the motor oculi 
 nerve, is not so wide as that resulting from the use of atropine, and is 
 associated with external strabismus and occasionally a slight protrusion 
 of the eye as the result of a relaxation of its muscles. 
 
 When the tears flow constantly over the cheek, some defect or strict- 
 
60 
 
 PRACTICAL MEDICAL ANATOMY. 
 
 ures of the nasal duct maybe suspected, provided that the puncta lachry- 
 malia are not turned away from the globe of the eye from any cause. 
 
 "The countenance of chronic hydrocephalus is, perhaps, the most 
 typical of any of the conditions to which the attention of the physician 
 or surgeon is directed. In it the frontal bone is tilted forward, so that 
 the forehead, instead of slanting a little backward, rises perpendicularly or 
 even juts out at its upper part and overhangs the brow. The parietal 
 bones bulge above toward the sides, the occiput is pushed backward, and 
 the head becomes long, broad, and deep, but flattened on the top. This, 
 at least, is the most ordinary result. In some instances, however, the 
 skull rises up in a conical form like a sugar-loaf. Not infrequently the 
 
 Fia. 42. — Deformity from compression of liead, simulating that of hydrocephalus. 
 
 whole head is irregularly deformed, the two sides b?ing unsymmetrical. 
 Some of these rarer varieties of form are fixed and connate, others ai-e 
 owing, probably, to the kind of external pressure to which the head has 
 been subjected. "' While the skull may be rapidly enlarging, the bones of 
 the face grow no faster than usual, perhaps not even so fast, and the 
 disproportion that results gives an odd and peculiar physiognomy to the 
 unhappy subjects of this calamity. They have not the usual round 
 or oval face of childhood. The forehead is broad, and the outline of the 
 features tapers toward the chin. The visage is triangular. The great 
 disproportion in size between the head and the face is diagnostic of the 
 disease, and would serve to distinguish the skull of the hydrocephalic 
 child from that of a giant. In acute cerebral diseases, the countenance 
 is either wild and excited or lethargic and expressionless." 
 
 ' Watson, op. cit. 
 
 ' Sir Charles Bell, op. cit. 
 
THE HUMAN FACE IN HEALTH AND DISEASE. 61 
 
 Thoracic affections are all accompanied by more or less change in 
 the color of the face; whereas the alteration in the natural hue of the 
 features is so slight in abdominal diseases, that both the intellect and 
 complexion remain unaltered up to the final struggle, though the pinched 
 and dragged features express the acute sufferings of the patient. "In 
 pneumonia, the countenance is inanimate; the cheek, of a dusky hue, 
 with a tinge of red; the eyelid droops over the globe; the brow is over- 
 hanging; the lips are dry, herpetic, and of a faint claret color; the chest 
 is comparatively motionless, but the abdomen exhibits-evidences of activ- 
 ity; the skin is hot; and the respiratory acts are usually about double the 
 normal number, while the pulse is markedly accelerated. In cases where 
 dyspnoea is extreme, the patient, entirely regardless of what is going on 
 about him, seems wholly occupied in respiring; is unable to lie down, 
 and can scarcely speak; and the face becomes expressive of the greatest 
 anxiety, while the expanded nostrils and their incessant movement indi- 
 cate pulmonary distress." " 
 
 Fig. 43. — The hydrocephalic head (different views). 
 
 In emphysema, the face is not only dusky but ansemic; the eyes are 
 wide open, as the patient gazes at you; the dusky redness of the lips 
 bespeaks the lack of proper oxygenation of the blood; the neck is thrown 
 backward, and the mouth is slightly open, while the cheek is puffed out 
 during the expiratory act; the distended nostril and the elevated brow 
 stamp the case as one of dyspnoea; while the coldness of the skin shows 
 that no acute inflammatory condition is present. If we see, in addition 
 to these facial evidences of disease, the deformity of the chest which has 
 been termed the " barrel-shaped " thorax, the shrugged shoulders, and 
 the absence of that expansive movement so well marked in normal res- 
 piration, auscultation and percussion can hardly make the diagnosis 
 more positive. 
 
 There are certain facial conditions, which so clearly tell, to the stu- 
 dent of physiognomy, of the existence of that most prominent sign of 
 many pulmonary and cardiac diseases, dyspnoea, that it may be well to 
 
 ' Watson, op. cit. 
 
62 
 
 PKA.OTICAL MEDICAL ANATOMY. 
 
 enumerate the alterations from the normal countenance which chiefly indi- 
 cate this condition. In all cases where excessive dyspncBa is present, the 
 brows will usually be found to be raised; the eyes will be full, staring, and 
 clear; the nostril will be dilated, and often it may be seen to move 
 with each respiratory act; ' the mouth will commonly stand partly open, 
 while its angles will be drawn outward and upward; the upper lip 
 will be elevated, so aa to show the margins of the teeth; and the 
 utterance of the patient will be monosyllabic, as the rapidity of breath- 
 ing renders the utterance of long sentences a matter of extreme difficulty. 
 When we add to these symptoms those of imperfect oxygenation of the 
 
 Fig. 44.— Countenance of Emphysema. (Modified from Corfe.) 
 
 blood, as is met with in all conditions where the free entrance of 
 air is in any way interfered with, we can better understand how the 
 clear eye becomes stupid, as coma approaches, from the carbonic-acid 
 poisoning, and the face cyanotic from the venous tinge of the blood. It 
 thus becomes possible for the reader to picture to himself the counten- 
 ance which must exist in such conditions as acute laryngitis, spasmodic 
 and true croup, thoracic tumors (which cause pressure upon the lungs or 
 
 ' Lavater, op. cit. ; Sir Charles Bell: Anatomy of Expression. London, 1824. 
 
THE HUMAN FACE IN HEALTH AND DISEASE. 
 
 63 
 
 trachea), and the various conditions of the lung itself, which impede 
 the entrance of air to the organ, but are not of inflammatory origin, and 
 have, for that reason, no distinctive physiognomy. 
 
 In cases where renal dropsy has stamped its characteristic marks 
 upon the countenance, we may perceive the signs of dyspnoea, due to 
 the accompanying oedema of the lungs, in the corrugated forehead, the 
 raised eyebrow, the dilated and waving nostrils; the corners of the mouth 
 will be found to be drawn downward and outward, expressive of some 
 disease of the abdominal cavity; the eye will be full and anxious, indic- 
 ative of suffering long-continued and borne with patient calmness;' the 
 conjunctiva may present that pellucid and bleb-like condition so often 
 
 Fig. 45. — Cardiac Dyspnoea. (Modified from Corfe.) 
 
 seen in thi.i type of disease, and an oedema of the eye may greatly alter 
 its appearance; finally, the waxy pallor of the complexion and the pasty 
 and bloated cheeks show the profound ansemia of the patient. 
 
 " Chronic diseases of the abdominal cavity are usually characterized 
 by a languor of the eye and an absence of that flash of alarm so peculiar to 
 the acute forms of abdominal trouble;" ' and, if attended with steadily 
 increasing danger to life, the corrugated brow and eyelid, the retraction 
 of tlie cheek, tlie dragged and elongated nostrils, the depressed angles 
 of the mouth, the protruded chin, and the parted lips, with the teetli 
 firmly clinched behind them, still further proclaim the seat of the disease.'' 
 
 ' Corfe, op. cit. 
 
 ° M. Louis, quoted by Marshall Hall, op. cit. 
 
61 
 
 PEACTICAL MEDICAL ANATOMY. 
 
 The pale face, stamped with the signs of anxiety and distress; the 
 head raised upon two or three pillows, and the trunk similarly supported; 
 the knitted brow, which bespeaks the cerebral disturbance; the nostrils, 
 waving to and fro with each breath; and the jugulars which, as they lie 
 exposed in the throat, show by their pulsation or unusual distention 
 that the Talves of the heart are acting imperfectly; all may be found in 
 endocardial or pericardial inflammations, or in conditions of the heart 
 dependent upon chronic valvular disease. ' 
 
 The countenance of each of the continued fevers is liable to receive a 
 modification from the existence of a complication, usually with some 
 morbid affection of the head, the viscera of the thorax, or of the abdo- 
 
 FiQ. 46. — Face of a Patient with Obstruction at the Pyloric Orifice. 
 
 men; the dejection produced by the latter of which is among the most 
 important objects in the clinical study of these diseases. ' In scurvy, the 
 dirty ashy hue of the skin and its characteristic dryness; the blue and 
 bleeding gums; the emaciation and the frequent indurations of the 
 intermuscular tissue of the cheeks; the sunken eyes, surrounded by a 
 blue ring; and the livid tinge of the lips, make the diagnosis positive at 
 once. 
 
 In G-raves's or Basedow's disease, a peculiarity of the eye is produced, 
 due to its partial protrusion from the orbit, probably from an increase of 
 the intra-orbital fat, which stamps the disease beyond a possibility of 
 error in diagnosis. In many cases, the inability to approximate the lids, 
 
 ' Corvisart: Diseases of the Heart, Gates's translation. Boston, 1812. 
 ' Marshall Hall, op. cit. 
 
THE HUMAN FACE IN HEALTH AND DISEASE. 
 
 65 
 
 and an absence of power to move the eye, on account of the paralysis of 
 the muscles from the stretching which they hare undergone, furnish evi- 
 dence also of disease of that organ which enhances the facial deformity. 
 
 In Asiatic cholera, and in children during attacks of profuse diar- 
 rhcea, the eyeballs sink into the orbit, a dark ecchymosis appears in the 
 region of the eyes, the lower eyelid forms a prominent fold in the 
 region of its attachment to the cheek, the nose is pointed and sharp, and 
 the lips, normally ruddy and full, become thin and sharply outlined . 
 These changes are chiefly dependent upon a rapid emaciation, which fol- 
 lows the withdrawal of a large proportion of the water from the tissues. ' 
 
 Fio. 47. — Cancer of the Abdominal Cavity. (Modified from Corfe.^ 
 
 In chronic atrophy, the entire absence of adipose tissue in the subcuta- 
 neous structures causes the skin to become loose and corrugated; while 
 various muscles become prominent from contraction (chiefly the frontalis, 
 the corrugator supercilii, and the levator labii superioris).'' Thus the so- 
 called " senile face " or " Voltairean countenance " is produced, which is 
 seldom to be mistaken in the child. ' 
 
 Among the diseases of the nervous system, there are certain types of 
 physiognomy which are so characteristic as to be of the most positive 
 value in diagnosis. Thus, in the attacks of epilepsy, " the neck at flrst 
 
 ' Vogel, op. cit. 
 
 ' Marshall Hall, op. cit. 
 
66 
 
 PKACTIOAL MEDICAL, ANATOMY. 
 
 becomes twisted, the chin raised, and brought round by a series of jerks 
 toward one shoulder. The features are greatly distorted. The brow is 
 knit; the eyes are sometimes fixed and staring, at other times rolling 
 about in the orbit, and again turned up beneath the eyelid, so that the 
 cornea is covered and only the white sclerotic is to be seen; the mouth is 
 twisted to one side and distorted; the tongue is thrust between the teeth, 
 and, caught by the yiolent closure of the jaws, is bitten, often seyerely: 
 
 Fig. 48.— Countenance of melancholia. 
 
 Fig. 49. — Countenance of dementia. 
 
 and the foam which issues from the mouth is reddened with blood. The 
 turgescence of the face indicates obstruction of the venous circulation; 
 the cheeks become purplish and livid, and the veins of the neck are vis- 
 ibly distended." ' 
 
 The expressions of the countenance which are produced by paralysis 
 of any of the special nerves of the face have striking peculiarities whicli 
 enable the skilful anatomist to easily detect the nerve affected. It is 
 
 important to remember that, if paralysis of any 
 nerve be the result of any form of external in- 
 jury, a danger is presented in the form of 
 tetanus, which should be guarded against by 
 a quick comprehension of the existing malady 
 and by all known precautions, applied with 
 judgment based on the anatomical course and 
 relations of the nerve affected. It is also well 
 to bear in mind the fact, that any form of severe 
 external violence about the face may, by causing 
 a fracture of the bones through transmission 
 of the force applied, cause injury to some 
 special nerve whose course may lie far distant 
 from the apparent seat of injury. It is not infrequent to find a fracture 
 of the superior maxillary bone followed by symptoms indicative of 
 a foreign body within the cavity of the antrum; and symptoms of 
 
 Fio. 50.— Countenance of paresis. 
 
 ' Watson, op. cit. 
 
THE HtJMAN FACE IN HEALTH AND DISEASE. 67 
 
 irritation of the nasal mucous membrane, or neuralgia of some of the 
 principal nerve-trunks distributed to the face, may likewise follow such 
 an accident. Violence to the vault of the skull may produce not only 
 cerebral lesions and their subsequent evidences in the face and body, but 
 also types of local paralysis,' produced by injury to some of the more im- 
 portant nerve-trunks at their point of escape from the skull, in case the base 
 of the skull has been injured." 
 
 "A slight tremor of the lips; a hesitation of utterance; a partial loss 
 of power over the lips and tongue, which seem to have lost their grip, as 
 it were, over the consonants; a characteristic stillness of all the muscles 
 of expression; and a slight disparity in the pupils are the predominant 
 features of the early stage of development of the general paralysis of the 
 insane." ' In those rare cases where the facial nerve of both sides is im- 
 paired, symptoms similar to those mentioned above exist, except the 
 tongue has its normal capabilities of movement, save in the perfect articula- 
 tion of the labial consonants only, and that a complete absence of facial 
 expression is present. " An open mouth; a loss of control over the saliva, 
 which constantly dribbles; an awkwardly moving or motionless tongue; 
 and an indistinct articulation render the labio-glosso-laryngeal paralysis 
 of Trousseau and Duchenne easy of detection.'" In the so-called Bell's 
 paralysis, ' which has been described in previous pages of this article, the 
 patient cannot laugh, weep, or frown, or express any feeling or emotion 
 with one side of the face; while the features of the other may be in full 
 play. " One-half of the aspect is that of a sleeping or dead person; while 
 the other is alive and merry. This incongruity would be ludicrously 
 droll, were it not so frightful and distressing." 
 
 "When, in the human subject, the hypo-glossal nerve is impaired, either 
 as a special type of paralysis or during an attack of hemiplegia, the power 
 of protrusion of the tongue from the mouth in a straight line is lost, and 
 that member becomes deflected toward the side which is paralyzed, since 
 the genio-hyo-glossus muscle is unopposed. A disease of rather rare oc- 
 currence, in which the hypo-glossal nerves of both sides are paralyzed, 
 and, in addition, the orbicular muscle of the mouth, and, not infre- 
 quently, the intrinsic muscle of the larynx, is described by Duchenne; " 
 and it has since been written upon, by most of the later authors, under 
 the names of glosso-labio-laryngeal paralysis, glossoplegia, etc. In this 
 type of disease, the tongue lies motionless and trembling in the floor 
 
 ' Holden, op. cit. 
 
 ' The reader is referred by the author to his late treatise: The Applied Ana- 
 tomy of the Nervous System. N. Y., 1881. 
 
 * W. H. Gairdner, Article on Medical Physiognomy, in Finlayson's Clinical 
 Diagnosis. 
 
 ■• Finlayson, op. cit. ' Sir Charles Bell, op. cit. 
 
 * De I'electrisation localises. Paris, 1861, 
 
68 PEACTICAL MEDICAL ANATOMY. 
 
 of the mouth, if all power of motion be paralyzed; but, if paresis 
 only exists, it can be imperfectly protruded with diflaculty, and is trem- 
 blingly and slowly retracted. If one side be affected, the sound side 
 becomes full and prominent, in comparison with the affected side, when 
 called into action. The peculiar trembling character of the. movement 
 of the tongue, in bilateral paresis, is observed in every motion which the 
 patient attempts to perform with that organ, and all the motions are 
 slowly and imperfectly accomplished^ 
 
 The most important effects of the paralytic state of the muscles are 
 shown in attempts at mastication and speech. The food is no longer 
 properly placed between the teeth; is with great difficulty carried to the 
 back part of the mouth; and frequently regurgitates into the mouth, 
 when attempts are made to swallow. The saliva is secreted in large quan- 
 tities, and swallowed with extreme difficulty, so that the patient is con- 
 stantly obliged to expectorate. 
 
 During the fit of exacerbation, in an attack of tetanus, the aspect of 
 the sufferer is sometimes frightful. The forehead is corrugated and the 
 brow knit, thus expressing the most severe type of bodily suffermg; the 
 orbicularis muscle of the eye is rigid, and the eye itself staring and 
 motionless; the nostril is widely dilated, indicating extreme dyspnoea; 
 the corners of the mouth are drawn back, exposing the teeth, which are 
 firmly clinched together; and the features, as a whole, have a fixed and 
 ghastly grin — the so-called " risus sardonicus." During such paroxysms, 
 as in those of epilepsy, the tongue is liable to become protruded between 
 the teeth and be severely bitten. 
 
 In chorea, the facial muscles participate in the general eccentricity of 
 movement. Watson ' thus describes the peculiarities of this strange affec- 
 tion; "The voluntary muscles are moved in that capricious and fantastic 
 way in which we might fancy they would be moved, if some invisible 
 mischievous being, some Puck or Robin Goodfellow, were behind the 
 patient and prompted the discordant gestures. With all this, the artic- 
 ulation is impeded: there is the same perverse interference with the mus- 
 cles concerned in the utterance of the voice. By a strong figure of 
 speech, the disorder might be called ' insanity of the muscles.' " 
 
 In catalepsy, the patient lies often with eyes open and staring, yet 
 without expression indicative of life; more like a wax figure or a corpse 
 than like a living subject. The features may be made to assume any ex- 
 pression, no matter how absurd, as the tissues have their normal pliability; 
 and they will remain so placed until again mechanically altered. This 
 same peculiarity is also present in the muscles of the extremities, and 
 forms one of the distinguishing tests of the disease. The mental facul- 
 ties are in abeyance, and all power of voluntary motion is lost. The 
 sensibility of the body seems also to be lost. 
 
 ' Op. cit. 
 
THE HUMAN PACE IN HEALTH AND DISEASE. 
 
 69 
 
 The deformities of face and intellect which seem to be the result 
 of residence in special atmospheric conditions, or certain well-defined 
 localities, are illustrated in that race of people found in Valais and the 
 adjoining cantons of Switzerland, called " cretins." Many of these 
 wretches are incapable of articiilate speech; some are blind, some are deaf, 
 and some suffer from all of these privations. " They are mostly dwarf- 
 ish in stature, with large heads, wide vacant features, goggle eyes, short 
 crooked limbs, and swollen bellies. The worst of them are insensible to 
 the decencies of Nature, and in no class of mortals is the impress of hu- 
 manity so pitiably defaced. They are usually the descendants of parents 
 afflicted with goitre." ' 
 
 Rq. 51.— Partial Paralysis of the Facial Nerve from Disease near the Pons Varolii. (Modified from 
 
 Oorfe.) 
 
 In that long list of pathological conditions in which the brain may be 
 subjected to more or less compression of its substance, there are certain 
 signs of positive value in diagnosis which may often assist the medical 
 practitioner to locate the disease. Thus, in depressed fracture of the 
 inner tablet of the skull, where the signs of external injury are absent; in 
 abscess within the cranial cavity; during the course of meningeal inflam- 
 mations; in apoplexy; in the development of intra-cranial tumors, etc.. 
 
 •Watson, op. cit. 
 
70 PEACTIOAL MEDICAL ANATOMY. 
 
 the eyelids will usually be closed and immovable; the pupils generally di- 
 lated or irregular, and always sluggish and less sensitive to light than in 
 nealth; the breathing will be slow and stertorous if coma exists; the spe- 
 cial senses will be in abeyance; and the temperature "will be either normal 
 or increased. The evidences of a paralyzed condition of certain of the 
 cranial nerves may also exist, and thus afford an additional means of de- 
 termining the exact seat of the disease. A rigidity of certain muscles, if 
 present, usually denotes some special irritation of the nerves which supply 
 them, and it is, therefore, seldom pi'esent in cerebral softening, but fre- 
 quently so in those cases where paralysis is produced by pressure upon 
 nerve-centres, or when descending sclerosis affects individual nerve-fibres 
 arising from the seat of the lesion. In cases where the fifth cranial nerve 
 has been impaired by pressure, injury, or disease, the prominent symp- 
 toms are a redness of the conjunctiva on the side of the face supplied by 
 the affected nerve; insensibility of the cornea, nostril, and tongue on the 
 same side; a dulness of hearing; a partial or complete loss of smell, sight, 
 and occasionally of taste also in the anterior two-thirds of the lateral half 
 of the tongue; and a diseased state of the gums, similar to that observed 
 in scurvy. 
 
 A paralysis of one side of the face, if associated with a hemiplegia of 
 the opposite side of the body (crossed paralysis), is one of the most valu- 
 able signs of a lesion in the upper part of the pons Varolii. The facial 
 paralysis may be confined to the motor oculi, trigeminus, or facial nerves. 
 
 While many typical varieties of countenance, which are of value to 
 the diagnostician, have been omitted, since the limits of a single chapter 
 have possibly been already over-stepped, still it is to be hoped that the 
 facts mentioned, although they are but fragmentary jottings, may tend 
 to kindle among the medical profession a renewed interest in a subject 
 which is rapidly being lost sight of, ind the value of which is often 
 ignored. It is not to be expected that sight alone can guide the medical 
 attendant to unerring diagnosis; but that it may prove of the greatest 
 value as an aid, cannot, I think, be disputed. It is to be remembered 
 however, that a direct perceptive faculty, like that of touch, hearing, or 
 smell, grows with use, and is capable of unlimited development. As with 
 the musician, an instrument which at first produced discords becomes 
 under skilful hands, one of melody; so the enlightened and accomplished 
 practitioner may often see at a glance wh*, to one unaccustomed to note 
 facial changes or to interpret their meaning, would escape detection, un- 
 less a special effort be made to note and record systematically the pecu- 
 liarities of each particular feature and anatomical region of the face and 
 the records afterward studied, as the mai-iner studies his chart before ho 
 attempts to direct his vessel through channels with which he is not per- 
 fectly familiar. 
 
THE BLOOD-VESSELS OF THE HEAD. 71 
 
 CHAPTER III. 
 THE BLOOD-VESSELS OF THE HEAD. 
 
 The blood-Tessels of the head require, possibly excepting those of the 
 neck, more constant study on the part of the surgeon than those of any 
 other region. They are in such intimate relation with nerves and impor- 
 tant organs that surgical interference, unless scientifically performed, is 
 especially dangerous, and may be followed by most disastrous results. 
 
 In addition to this source of anxiety, a large proportion of the wounds 
 received, which are apt to create injury to neighboring vessels, are situ- 
 ated about the head; and cancerous tumors, or those of a malignant type 
 which are liable to be associated with hemorrhage during their ulcerative 
 stage, are especially common about the face. 
 
 Cirsoid aneurisms of the scalp, vascular tumors of the orbit, or injury 
 to the meningeal or cerebral vessels from depressed fracture of the cranial 
 bones, also require, when present, the best practical anatomical knowl- 
 edge for their successful treatment, and they are not infrequently met 
 with by the surgeon. 
 
 It is my plan, therefore, to take up, as has been done with the bony 
 points of interest, those vessels which are most frequently brought to the 
 notice of the medical practitioner, requiring some steps of relief; and to 
 show, so far as the limits of a small work will allow, the points pertaining 
 to each, which are of practical value or which afford useful information. 
 
 One difficulty arises, at this point, from the attempt to place the neck 
 where it properly belongs, viz. , with the trunk, of which it is, anatomi- 
 cally, a part. Some of the vessels which are distributed to the head 
 arise from the carotid arteries within this region, although the distance 
 through which the vessel passes, in the neck, may often be very short, 
 and, in many cases, of no practical importance. To give a clear descrip- 
 tion, however, of the lingual, facial, occipital, and ascending pharyngeal 
 arteries, their points of origin must be mentioned, and their course traced 
 hastily, until the region of the head is reached, when all important 
 details pertaining to each will be carefully reviewed. To fail to do so 
 would be liable to leave the reader in doubt as to some points pertaining 
 to these vessels; while to attempt to consider, in the description of the 
 neck, only a minor portion of some important vessel, when the rest was 
 treated of elsewhere, would certainly thwart the aim of the author, and 
 embarrass the reader. The slight encroachments, therefore, upon the 
 
n 
 
 PEACnOAL MEDICAL ANATOMY. 
 
 neck as an anatomical region, which may be noticed in the pages of this 
 chapter, is not an eyidence of a lack of systematic arrangement, but a 
 step that seems demanded in order to insure perspicuity. In fact, the 
 head may, in some senses, be held to include all those parts above the 
 level of the hyoid bone, since the structures above that point are properly 
 its own. 
 
 THE UNGUAL AETBBT. 
 
 This vessel may be wounded, in cases of cut throat, near to its point 
 of origin. It is a frequent source of hemorrhage in ulcerations about the 
 
 Fig. 52. — Deep view of the carotid, subclavian, and axillary artenes and their branches; the 
 large muscles in the front of the neck and chest having been divided or removed ; 1, vertebral 
 artery; 2, subclavian artery; 3, 4, axillary artery; 5, commencement of the brachial artery; 0, 7, 8, 
 branches going to the shoulder ; 9, branch going to the pectoral muscle ; 10, long thoracic artery ; 
 11, 12, subscapular arteiy; 13, 14, common carotid artery; 15, external carotid artery; 16, internal 
 carotid artery; 17. 17, thyroid axis and thyroid gland; 18, superior thyroid artery; 10, lingual axi&ry; 
 ' 20, facial artery; 21, inferior labial artery; 22, coronary artery; 2.3, occipital artery; 24, xiosterior 
 auricular artery; 25, superficial temporal artery; 25, internal maxillary artery; 27, transverse 
 facial artery. 
 
 tongue. It may be also involved in punctured wounds of the floor of the 
 mouth or the lateral aspect of the tongue. 
 
 Its ranine brancli is very superficial, and may often be seen as a tor- 
 tuous pulsating vessel, running from the base toward the apex of the 
 
THE BLOOD-VESSELS OF THE HEAD. 73 
 
 tongue, on its lateral border, near to the floor of the mouth. The lin- 
 gual artery is tied to relieve hemorrhage of any of its branches, and as a 
 palliative measure in case of some tumors of the tongue, in order to check 
 the progress of the disease. It has been tied as a preparatory step to 
 removal of the tongue. ' The guide to the artery is the greater cornu of 
 the hyoid bone. 
 
 In division of thefrcenum of the tongue in children, serious hemor- 
 rhage is liable to occur if the ranine vessels, which almost meet at this 
 point, be severed. It is, therefore, of importance to remember that, in 
 surgical interference in this locality, the tissue should ie torn rather than 
 cut, except in dividing the mucous membrane, which should be done 
 with care and with scissors directed away from the tongue and made 
 blunt-pointed. 
 
 Operation for Ligation. 
 
 The steps of the operation for the ligation of this vessel are rendered 
 difficult, first, by occasional irregularity of its point of origin; second, by 
 the yielding nature of the tissues upon which it rests; third, by its depth 
 from the surface, and, fourth, by its relations to important structures. 
 The operation, however, possesses great advantages over that of ligating 
 the external carotid or the common carotid trunk; which is too often 
 practised, not only for tumors of the tongue, but also in cases of uncon- 
 trollable hemorrhage from the tongue or wounds in the mouth. 
 
 A straight incision should either be made obliquely downward and 
 backward, extending from a point one inch anterior to the greater cornu 
 of the hyoid bone for a distance of about two and a half inches; or a double 
 incision is preferred by some, the second lying in the line from the tragus 
 of the ear to the sterno-clavicular articulation. This should be one and 
 a half inches in length, and its centre should correspond to the level of 
 the greater cornu of the hyoid bone; while the first incision should meet 
 the second, and extend along the upper border of the hyoid bone. 
 
 The skin and platysma being carefully dissected, and the underlyinq 
 veins avoided, the artery will be found contained within the lingual 
 triangle, whose boundaries are as follows: above, the digastric muscle; 
 lelotv, the hyoid bone, and, externally, the external carotid artery. 
 
 The hypo-glossal nerve, as it crosses the external carotid artery, lies 
 just above the lingual's point of origin; and the thyro-hyoid branch of 
 this nerve crosses the lingual artery on its way to the muscle of the same 
 name. 
 
 The artery will, in the large majority of cases, be found in close rela- 
 tion to the hyoid bone among the loose areolar tissue at the bottom of tiie 
 wound. 
 
 Care must be taken, in applying the ligature to the vessel, that the 
 
 ' See report of J. W. Howe in Med. Record, Sept. 10th 1881. 
 
74 PEAOTIOAL MEDICAL ANATOMY. 
 
 pharynx ie not opened, as its walls form the floor upon which the artery 
 rests. 
 
 The Teins met with in this operation are often a source of serious 
 embarrassment to the operator. They may include either the internal 
 jugular or its lingual and facial branches. 
 
 THE FACIAL AKTBET. 
 
 This Tessel arises most frequently at a point about one inch from the 
 bifurcation of the common carotid. Its point of origin is, therefore, 
 above that of the lingual artery, from which it is usually separated by 
 about one-quarter of an inch. 
 
 It is usually the largest branch of the external carotid artery. Its 
 course may be divided into a cervical and & facial portion, for convenience 
 of description. The cervical portion, starting from the point of origin 
 of the facial, passes obliquely forward and upward beneath the body of 
 the lower jaw to the submaxillary gland, in which it lies, imbedded in a 
 groove upon its superior and posterior border. 
 
 The facial portion begins at the submaxillary gland, the artery curv- 
 ing upward over the body of the jaw at the anterior inferior angle of the 
 masseter muscle, ascending forward and upward across the cheek to the 
 angle of the mouth, then passing up the side of the nose, and, finally, 
 terminating at the internal can thus of the eye under the name of the 
 " angular artery." 
 
 The facial artery, in both its cervical and facial portion, is remark- 
 able for its tortuosity. This is evidently demanded in order to permit of 
 the muscular movements required in the performance of the acts of 
 deglutition, mastication, articulation, and expression, without incurring 
 a danger of compression or stretching of the supplying vessels. 
 
 Relations of the Facial Artery, 
 
 In the cervical portion the artery is at first superficially situated, being 
 covered only by the integument, fascia, and platysma muscle, but it soon 
 passes underneath the stylo-hyoid and digastric muscles, and becomes 
 partially imbedded in the submaxillary gland. 
 
 In its facial portion, it can at first be easily perceived by its pulsa- 
 tion, where it passes over the body of the lower jaw, since it lies very 
 superficially, being covered only by the integument and the platysma 
 muscle. It is at this point, therefore, that compression of this vessel can 
 be most effectually made, in case of hemorrhage from any of its branches 
 upon the face. During its course across the cheek, it is covered by the 
 integument and a deposit of fat, until it reaches the angle of the mouth, 
 when it receives the platysma and zygomatic muscles as additional cover- 
 ings. It rests, in its passage to the angle of tlie mouth, upon the buccin- 
 ator, the levator anguli oris, and the levator labii sujJerioris muscles. 
 
THE BLOOD-VESSELS OF THE HEA.D. 
 
 75 
 
 During its entire course, the facial vein accompanies it, but, unlike the 
 artery, it is not tortuous; upon the face, it is separated from it by a con- 
 siderable interval, and lies to the outer side of the artery. 
 
 The branches of the facial nerve, distributed to the various muscles 
 of the face, cross the artery; and the infra-orbital nerve (a terminal 
 branch from the fifth cranial nerve) lies beneath it, being separated from 
 it by the fibres of the levator labii superioris muscle. 
 
 Peculiarities of the Facial Artery and its Branches. 
 The facial artery, in about twenty-five per cent of all subjects,' arises 
 
 Fig. B3. — Diagram showing the facial artery and the position and size of the parotid and sub- 
 maxillary glands (two-flf ths the natural size) ; p, the larger part of the parotid gland ; p', the small 
 part which lies alongside the duct on the masseter muscle ; d, the duct of Steno before it perforates 
 the buccinator muscle; a, transverse facial artery; n, n, branches of the facial nerve emerging 
 from the gland; /, the facial artery passing out of a groove in the submaxillary gland and ascend- 
 ing on the face; am, superficial larger portion of the submaxillary gland lying over the posterior 
 part of the mylo-hyoid muscle. 
 
 by a trunk in common with the lingual. It occasionally also arises in 
 common with both the lingual and the superior thyroid arteries. 
 
 It varies in its point of origin, being often raised above its normal 
 
 'Wyeth: Essays on Surgical Anatomy. New York, 1879. 
 
76 
 
 PKAOTIOA.L MEDICAL ANATOMY. 
 
 level, when it is thus forced to descend to reach the angle of the lower 
 jaw. This latter variation exists in nearly one-third of the cases, al- 
 though the artery may not necessarily be markedly displaced. 
 
 The facial artery varies also in its size. As a rule, however, it is the 
 largest of the branches of the external carotid. 
 
 Variations in the extent of its distribution are also not infrequently 
 
 
 Fig. 54.— The arteries of the face and soalj (After Gray.) 
 
 present. Thus, the facial artery, in rare cases, is absent upon the face, 
 having its point of termination at its submental branch. In cases of 
 greater frequency, it is arrested upon the face before it reaches its normal 
 point of termination. In both of these conditions, the ophthalmic arteries 
 are proportionally developed, as a rule, upon the corresponding side of 
 the nose and in the orbit; and the transverse facial and the internal max- 
 illary arteries are also frequently enlarged. 
 
 The tranches of the facial artery exhibit occasional peculiarities. 
 
THE BLOOD-VESSELS OF THE HEAD: 
 
 77 
 
 The ascending palatine branch maybe transferred to the external carotid, 
 or may be of too small size to supply the soft palate, in which case the 
 ascending pharyngeal artery is usually excessively developed. 
 
 The tonsillar branch may be altogether wanting. The submental 
 branch occasionally arises from the lingual, and, in infrequent cases, the 
 facial artery sends branches of supply to the sublingual gland in place 
 of the lingual artery. 
 
 Surgical Anatomy. 
 
 In eases of severe wounds of the lip causing serious hemorrhage, the 
 results of pressure upon the facial of the wounded side, where it crosses 
 the body of the lower jaw, are unsatisfactory, and, in a short time, Mwa- 
 vailing. This is due to the remarkably free anastomosis existing between 
 its branches with other sources of vascular supply. 
 
 It is always advisable in such cases, therefore, to firmly evert the lip, 
 compressing it between the fingers, and to apply a ligature to the bleed- 
 ing point, if practicable. In operations for the removal of growths about 
 the mouth or lips, it is customary to use firm compression of the wounded 
 part between the fingers as a means of controlling hemorrhage, rather 
 than to resort to pressure over the main trunk during the process of 
 excision of the diseased part. 
 
 The situation of the vessels of the lips (being nearest to its mucous 
 surface), and the necessity of perforation of the orbicularis oris muscle 
 by the vessel, in order to reach that situation, furnishes us an important 
 practical point in arresting hemorrhage in wounds of the lip requiring 
 sutures. In this class of cases, the sutures should always be passed nearly 
 through the entire thickness of the lip, extending nearly, if not quite, to the 
 mucous surface, since, by so doing, the vessels are subsequently partially 
 compressed by the sutures, and the cut surfaces are more closely and 
 neatly adapted to each other. 
 
 The angular artery (the terminal branch of the facial) has a point of 
 practical surgical interest connected with it from its distribution to the 
 lachrymal sac, since it passes along the inner border of the orbit to 
 reach it; in cases of operation for lachrymal fistula, the sac should, 
 therefore, be opened upon its external portion, in order to avoid wound- 
 ing this vessel. 
 
 Operation for Ligation. 
 
 The facial artery may be ligated at its point of crossing over the 
 body of the jaw (the anterior edge of the masseter muscle), if wounded 
 upon the face, or, if the step be demanded, as a surgical procedure for 
 the relief of a tumor of the face, deriving its nutrition from the facial 
 artery. If, however, the tumor or wound implicate the cervical portion 
 of the vessel, the artery must be tied at or near it^ point of origin from 
 
78 • PBACTIOAL MEDICAL AifATOMY. 
 
 the carotid. If the former operation be performed, the seat of the artery 
 can easily be detected by its pulsation; and, as it lies extremely super- 
 ficially, it requires but an incision made along the body of the jaw, the 
 skin of the neck being first drawn upward to bring the cicatrix in the 
 neck, the division of the platysma fibres, and the encircling of the artery 
 by a ligature. 
 
 If the artery is to be tied near to its point of origin, an incision 
 along the line of the carotid should be made with its centre correspond- 
 ing to a, -point otie- quarter of an inch above the level of the hyoid hone. 
 The posterior belly of the digastric muscle will be exposed, after divid- 
 ing the integument, fascia, and the platysma, and the veins which lie in 
 close but varying relations to the vessel at its point of origin must be 
 carefully avoided. This muscle (the digastric) lies above the facial 
 artery, at its origin, but soon crosses it; while the hypo-glossal nerve lies 
 below it, and in close relation to its point of origin. The ligature is best 
 passed from below upward, to avoid the nerve and the veins which lie 
 anterior to the artery. 
 
 Anastomosis of the I^acial Artery. 
 
 The facial artery, through its numerous branches, anastomoses with 
 the following vessels : 
 
 (1) The opposite facial, through branches reaching the median line of 
 the body. 
 
 r infra-orbital 
 J nasal 
 
 I inferior dental 
 post, palatine 
 
 (3) The lingual, through its sublingual branch. 
 
 (4) The internal carotid, through its ophthalmic branch. 
 
 (5) The temporal, through its transverse facial branch. 
 
 (6) The ascending pharyngeal, in the pharynx and soft palate. 
 
 By means of the fourth anastomosis, the internal and external carotids 
 have a free point of collateral circulation; while the second group of anas- 
 tomosis serves to establish a free communication between the superficial 
 and deep branches of the external carotid artery. 
 
 THE OCCiPITAL AETEBY. 
 
 This vessel arises at a point on the posterior aspect of the external 
 carotid, nearly opposite to the point of origin of the facial artery or 
 about one inch distant from the bifurcation of the common carotid 
 trunk. Its point of origin corresponds, therefore, nearly to the lower 
 border of the digastric muscle. Near its origin, as it dips downward, it 
 becomes covered' by the stylo-hyoid muscle and the posterior belly of the 
 digastric. The posterior portion of the parotid gland also covers it in this 
 
 (3) The internal maxillary, through its 
 
 branches. 
 
THE BLOOD-VESSELS OF THE HEADt 79 
 
 locality, and the hypo-glossal nerve winds around it, passing in a direction 
 from behind forward. The course of this artery is long and "winding, 
 passing, at first, anterior to transverse processes of the cervical vertebrES, 
 in a direction nearly perpendicular, then turning sharply in the interval 
 between the transverse process of the atlas and the mastoid process of 
 the temporal bone, and passing in a horizontal direction along the outer 
 part of the base of the skull, till it reaches the occiput, where it becomes 
 again directed upward and ramifies beneath the integument. Its calibre 
 is, on the average, the sixth in point of size, as compared with the eight 
 branches of the external carotid artery. On its way upward, after pass- 
 ing underneath the parotid gland, this artery crosses the internal carotid, 
 the internal jugular vein, and the spinal accessory and pneumogastric 
 nerves. 
 
 In its horizontal portion, it is covered by the sterno-mastoid, digas- 
 tric, splenius, and trachelo-mastoid muscles, and rests upon the com- 
 plexus, superior oblique, and the rectus capitis posticus major muscles. 
 Injuries to this portion are, therefore, infrequent. 
 
 As it ascends upon the occiput, it passes through the cranial attach- 
 ment of the trapezius muscle, and follows a tortuous course over the 
 occiput as high as the vertex, where it divides into numerous small 
 branches. This artery is the main source of hemorrhage in wounds of 
 the scalp, in the posterior portion of the skull. 
 
 Peculiarities. 
 
 The occipital artery, though usually arising opposite the facial, is 
 sometimes given off from the external carotid, above or below that point. 
 The extreme limits of origin vary, between one inch and three-eighths, 
 and one-quarter of an inch above the bifurcation of the common carotid. 
 
 It is occasionally derived from the internal carotid, and, in rare cases, 
 it may arise from the inferior thyroid artery (a branch of the subclavian). 
 It also arises often in common with the ascending pharyngeal and the 
 posterior auricular arteries. The occipital artery sometimes passes over 
 the trachelo-mastoid muscle instead of beneath it, but, in the rarest 
 instances, does it ever pass external to the sterno-mastoid muscle. 
 
 The posterior auricular artery and some pharyngeal arteries are occa- 
 sionally derived from the occipital. 
 
 Surgical Anatomy. 
 
 The occipital artery bears a most constant relation to the hypo-glossal 
 nerve, which winds around it at about the point of origin of its sterno- 
 mastoid branch, and is then carried forward to its distribution within 
 the substance of the tongue. 
 
 This has been explained as a possible effort on the part of Jfature to 
 protect this nerve from tension during the protrusion of the tongue, since 
 
80 PEACTIOAL HEDICAL ANATOMY. 
 
 it is forced to descend from the anterior condyloid foramen before becom- 
 ing looped around the vessel, and thus ample opportunity for great lati- 
 tude of motion is afforded and a proportionate ability to endure strain 
 from the elasticity of the artery, which would be absent were it wound 
 around a bony prominence. 
 
 The artery may be ligated underneath the scalp where it is superfi- 
 cial, or, if necessity demands it, near its point of origin, or beneath 
 the margin of the digastric muscle. The operation differs little from 
 that required to ligate the facial,' in case the artery requires to be tied 
 within the neck. 
 
 In cases of pulsating or vascular tumors of the scalp, attempts at liga 
 tion of the supplying vessels often are associated with great difficulty 
 from the density of the tissues which invest them. 
 
 THE POSTEEIOE AURICUIAE ARTEKT. 
 
 This is a vessel of small size, which arises from the posterior aspect 
 of the external carotid in the vicinity of the apex of the styloid process; 
 this point being nearly two inches from the centre of bifurcation of the 
 common carotid artery. 
 
 It ascends along the styloid process of the temporal bone, in close 
 relation with the parotid gland, till it reaches the point of junction 
 between the cartilage of the ear and the mastoid process ' of the temporal 
 bone. At about this point, the artery is crossed ly the facial nerve, and 
 \\ie spinal accesory nerve passes iehind it, at about the same point. It 
 then divides into two branches, an anterior and a posterior, the former of 
 which anastomoses with the posterior division of the temporal ai-tery, 
 and the latter communicating with the occipital artery. 
 
 The stylo-mastoid ° branch of the posterior auricular artery enters the 
 foramen of that name in the temporal bone when it bears the closest rela. 
 tion to the facial nerve as it escapes at that foramen after passing 
 through the aquaeductus Pallopii. This vessel in young subjects gives 
 off a small branch which, after passing through the Glasserian fissure, 
 joins with the tympanic branch of the internal maxillary artery and 
 forms a vascular circle around the external auditory meatus, from which 
 vessels ramify upon the membrana tympani. These may be a source of 
 hemorrhage in wounds of that important part of the ear mechanism. 
 
 Peculiarities. — The posterior auricular artery is frequently very small 
 in size, and sometimes gives off no auricular branch. It is occasionally 
 also a branch of the occipital artery. 
 
 ' See page 77 of this volume. 
 
 ' One of the arteries which is liable to be injured in wounds of the mastoid 
 region. See page 17. 
 
 ^ For the special importance of this trunk, see the vascular supply of the ear. 
 
THE BLOOD-VESSELS OF THE HEAD. 81 
 
 THE ASCEl«rDIN-G PHAKTNGEAL AETEKT. 
 
 This vessel arises from the external carotid at a point situated, on the 
 average, about six-tenths of an inch from, the centre of bifurcation of the 
 common carotid. It is a long, slender vessel of small size placed near its 
 point of origin, deeply in the neck and on a plane posterior to the 
 branches of the external carotid previously mentioned. It is given oflE 
 from the posterior surface of the external carotid artery and ascends 
 nearly vertically ietween the internal carotid and the lateral wall of the 
 pharynx till it reaches the base of the skull (lying upon the rectus capitis 
 anticus major muscle.) 
 
 It divides into three sets of branches of distribution, as follows : 
 
 1st. Those distributed to muscles and nerves and directed outward. 
 
 3d. Those distributed to the pharynx, which pass toward the median 
 line of the body. 
 
 3d. Those distributed to the meninges of the brain, which pass verti- 
 cally upward till they enter the cavity of the cranium. 
 
 The external set of branches are numerous small vessels, some of 
 which supply the hypo-glossal nerve, the pneumogastric nerve, the first 
 cervical ganglion of the sympathetic, and the lymphatic glands of that 
 region. 
 
 The internal set of branches ramify between the superior and middle 
 constrictor muscles of the pharynx which they supply, and are distributed 
 also to the stylo-pharyngeal muscle and the mucous membrane of 
 the pharynx. The largest of the pharyngeal branches passes inward, 
 running upon the superior constrictor muscle of the pharynx and sends 
 ramifications to the Eustachian tube, tonsils, and soft palate. This 
 vessel frequently is abnormally developed in case of small size or the 
 absence of the ascending palatine branch of the facial artery. 
 
 The arrangement of the branches of this ascending pharyngeal artery in 
 the soft palate is as follows: After passing the superior constrictor muscle, 
 the palatine branch divides into two twigs, one of which arches over 
 the upper margin of the soft palate on its anterior surface and just beneath 
 its mucous membrane, while the other arches over the inferior border of 
 the palate in the same relative position, and thus the branches of the two 
 sides complete two arterial arches. 
 
 The meningeal branches are the terminal branches of the ascending 
 pharyngeal artery. They consist of several small vessels which enter the 
 cavity of the cranium through foramina in the base of the skull. 
 
 One, the posterior meningeal branch, passes through the jugular 
 
 foramen (foramen lacerum posterius) in company with the jugular vein 
 
 and the spinal accessory, pneumogastric, and glosso-pharyngeal nerves 
 
 which escape through the same foramen, and also with the inferior 
 
 6 
 
82 FKACTICAL MEDICAL ANATOMY. 
 
 meningeal IrancJi of the occipital artery, which enters the skull at the 
 same point. 
 
 A second branch passes through the foramen basis cranii (foramen 
 lacerum medium) in company with the internal carotid artery, the large 
 petrosal nerye, and some veins, although the foramen is largely filled with 
 cartilage. 
 
 A third branch occasionally is found to pass through the anterior 
 condyloid foramen, in company with the hypo-glossal nerve which escapes 
 through the same foramen. 
 
 These branches, after their entrance to the cavity of the skull, are all 
 distributed to the dura mater. They may, therefore, prove a source of 
 hemorrhage in depressed fracture of the skull, or in the operation of 
 trephining. 
 
 Peculiarities. 
 
 The ascending pharyngeal artery varies considerably in its place 
 of origin from the external carotid. It occasionally arises at the imme- 
 diate point of bifurcation of the common carotid, or it may, in extreme 
 limits, arise from a point varying from one inch to one inch and a half 
 distant from that point. It is a most constant branch of the external 
 carotid, but in about eight per cent of cases,' it is either a branch from a 
 trunk in common with the occipital or derived from some other source, 
 as the occipital or internal carotid arteries. 
 
 In rare cases,'' two pharyngeal arteries have been observed, arising 
 from the external carotid. 
 
 Surgical Anatomy. 
 
 The ascending pharyngeal artery is occasionally wounded in operations 
 about the tonsils or the posterior wall of the pharynx, although its small 
 size seldom renders the hemorrhage severe. One reported case of fatal 
 hemorrhage is, however, on record. 
 
 THE TEMPORAL AETEET. 
 
 This vessel is the smaller of the two terminal branches of the external 
 carotid artery, and having a direction similar to that vessel, it seems to 
 be its apparent continuation upon the external surface of the skull. It 
 usually arises at a point slightly helow the condyle of the loioer jaw, and 
 passes upward : while, at this point also, the other terminal branch of the 
 external carotid artery (the internal maxillary) sinks under the inferior 
 maxillary bone. This point of origin is, however, imbedded within the 
 substance of the parotid gland, and contained in an interspace between 
 the neclc of the condyle of the lower jato and the external auditory meatus. 
 
 As the artery is continued upward upon the face, it soon reaches the 
 
 'Wyeth, op. cit. 'Gray: Anat. Descriptive and Surgical. 
 
THE BLOOD-VESSELS OF THE HEAD. 83 
 
 cutaneous surface of the zygoma (near to its root), where it may be easily 
 compressed. About two inches above the zygomatic arch, it divides into 
 two terminal branches, the anterior and posterior temporal arteries, 
 which again divide and subdivide and ramify beneath the integument on 
 the side and upper part of the head. 
 
 As it crosses the zygoma, it is covered by the attrahens auris muscle 
 and a dense fascia which is given off from the parotid gland. 
 
 Peculiarities. 
 
 The temporal artery is frequently tortuous. This is most marked, 
 however, in the aged. It occasionally gives off a branch of large size 
 which runs to the upper part of the orbital arch. By joining with the 
 ophthalmic, it may furnish large frontal arteries which ramify over the 
 forehead. 
 
 The branches of the temporal, especially the transverse facial branch, 
 often present certain peculiarities of origin and distribution. Thus the 
 transverse facial artery sometimes supplies the place of the facial. It 
 occasionally arises from the external carotid. It presents marked varia- 
 tions in its size, and is especially liable to be large if the facial artery be 
 defective or absent. 
 
 The parotid branches vary also in their number, size, and situation of 
 origin. 
 
 Surgical Anatomy. 
 
 In cases of excessive vascular supply to the orbit, eye, or meninges, 
 ligature of the temporal has sometimes been performed, although the 
 anterior temporal is usually the branch selected. 
 
 The relations of the temporal artery as it passes over the zygomotic arch 
 are important to remember. It is here covered by the temporal fascia, 
 which is extremely dense and inelastic, and is crossed by one or two 
 veins. It is also closely related to two large nerves, the facial, and 
 auriculo-temporal. It is on account of the temporal fascia that bleeding 
 from the temporal artery should not be performed, since it not only 
 prevents a free escape of blood, but also, from its inelasticity, renders 
 the stoppage of the flow of blood difficult if compression only be used. 
 
 Again, puncture of one of the veins lying above the artery is liable to 
 generate either a varicose vein, an aneurismal varix, or a varicose aneu- 
 rism. ' Injury to one of the neighboring nerves would result either in 
 paralysis of the facial muscles or in severe neuralgic pains, if the auriculo- 
 temporal nerve was not perfectly severed or its structure completely 
 destroyed. 
 
 The anterior temporal artery, on the contrary, is subcutaneous and 
 
 ' For points of difierential diagnosis between these affections, see my woik on 
 Surgical Diagnosis. N. Y., 1880. 
 
84 
 
 PEACTIOAL MEDICAL ANATOMY. 
 
 free from many of the objections associated with the main trank in case 
 ligation is demanded. It is a vessel of large size and should be selected 
 for ligature, or the operation for bleeding, in preference to the main 
 trunk. 
 
 The pulsation of the vessel should be the guide to the incision made 
 to expose it, recollecting that the anterior temporal passes from a point 
 nearly two inches above the root of the zygoma toward the forehead, in a 
 direction nearly horizontal, for the first portion of its course. 
 
 Fig. 55.— The internal maxillary artery, and its branches. (After Gray.) 
 THE INTEKNAL MAXILLAKT AETEKT. 
 
 This vessel is the deep terminal Iranch of the external carotid, and 
 which, in point of size, if not in direction, is a continuation of that 
 vessel. 
 
 It pursues a winding course under cover of the ramus of the inferior 
 maxillary lone from its point of origin, where it is concealed by the 
 parotid gland, until it reaches the spheno-maxillary fossa, where it 
 furnishes its terminal branches. It may be considered physiologically as 
 the artery of mastication,^ since it supplies the structures pertaining to 
 that act. 
 
 For the sake of greater facility in describing and arranging the 
 
 ' Hilton: Best and Pain. N. Y., 1879. 
 
THE BLOOD-VESSELS OF THE HEAD. 85 
 
 numerous brandies which this vessel gives off, and to present in a clearer 
 form the general course of the vessel, it has long been customary with 
 anatomists to divide this artery into three portions, as follows : . 
 
 1st. The maxillary portion. 3d. The pterygoid portion. 3d. The 
 sjpheno-maxillqry portion. 
 
 The maxillary portion extends from its point of origin in the parotid 
 gland to the anterior border of the internal lateral ligament of the lower 
 jaw. In this portion, the artery lies horizontally, and is situated between 
 the internal lateral ligament of the jaw and the ramus of the jaw. The 
 artery here lies parallel with the auriculo-temporal nerve, and crosses 
 the inferior dental nerve (both branches of the inferior maxillary division 
 of the fifth pair), and is situated beneath the narrow portion of the 
 external pterygoid muscle. 
 
 The second or pterygoid portion of the artery is defined by the connec- 
 tion of the vessel to muscles through its muscular branches. In this di- 
 vision, the artery rests upon the outer surface of the external pterygoid 
 muscle, and is covered partially by the ramus of the jaw and the 
 lower part of the temporal muscle. The direction of this portion of the 
 artery is obliquely forward and upward. 
 
 The third or spheno-maxillary portion is again in close connection 
 with the superior maxilla; and is contained in a fossa which that bone 
 helps to form, termed the spheno-maxillary fossa. The artery enters this 
 fossa through an interval between the two heads of the external pterygoid 
 muscle, at which point it lies in close relation to Meckel's ganglion, and 
 it is in this fossa that its six terminal branches are given off. 
 
 This artery possesses less surgical interest than those situated more 
 superficially, as it is protected from injury by the base of the skull and 
 the bones of the face. 
 
 Its middle meningeal branch, however, is of surgical importance, since 
 it may be injured in fractures of the skull or in the operation of trephin- 
 ing. 
 
 Peculiarities. 
 
 The place of origin of the internal maxillary artery is very constant, 
 except in those cases where the external carotid presents either an in- 
 crease of or decrease from its normal length. 
 
 In rare instances, however, it has been seen to arise from the facial 
 artery. 
 
 The course of the artery often differs froni that described as the nor- 
 mal one. It may pass between the two pterygoid muscles, or perforate the 
 external pterygoid at its centre; or it may be bound to the posterior mar- 
 gin of the external pterygoid plate of the sphenoid bone, in which case 
 either a notch or foramen for the artery can be detected. 
 
 In cases, when the internal carotid artery has been found to be absent, 
 large branches from the internal maxillary have been detected which 
 
86 PRACTICAL MEDICAL ANATOMY. 
 
 have passed through the foramen rotundum and the foramen ovale and 
 thus supplied its place. In such an abnormality, ligation of this artery, 
 or of the external carotid would greatly decrease the Uood-supply of the 
 train. 
 
 The middle meningeal branch occasionally gives off a lachrymal branch, 
 but otherwise the branches present few peculiarities worthy of special 
 mention. 
 
 Surgical Anatomy. 
 
 The cavity of the orbit may sometimes become the seat of suppura- 
 tive inflammation, either as the result of traumatism or the extension of 
 inflammation from the eye or its appendages, or from the antrum or the 
 temporal or parotid regions, by means of the blood-vessels passing through 
 the zygomatic fossa. Such a condition is liable to produce death by ex- 
 tension of the inflammation to the brain or the cavernous sinus. Such 
 remarkable cases as that reported by Blandin, where a fracture of the 
 neck of the condyle of the lower jaw was followed by a protrusion of the 
 eye and rapid death can easily be explained by the remarkable anastomo- 
 sis which exists between the vessels of the zygomatic fossa and those of 
 the orbit, while that type of wound which results in hemorrhage from the 
 internal maxillary artery or some of its branches is seldom alrrested by 
 even a ligature of the common carotid trunk, on account of the extent of 
 the collateral circulation in this vicinity. In wounds of the hard palate 
 which is chiefly supplied by this artery, it is frequently difficult to con- 
 trol hemorrhage on account of the density of the tissues in which the 
 vessels are imbedded. It was for this reason that Dupuytren urged cau- 
 terization of bleeding points in the roof of the mouth in preference to 
 attempts at ligation. Within the cavity of the mouth the soft palate 
 hangs loosely at its posterior portion, and was undoubtedly designed by 
 Nature to act chiefly as a valve to close the posterior nares and upper por- 
 tion of the pharynx. It not infrequently happens, however, that the soft 
 palate has to be divided in order to remove large polypi of the throat or 
 nasal cavity. This operation is, however, associated with little hemor- 
 rhage and the damage is easily repaired, thanks to Roux and Graefe, by 
 the steps of staphylorrhaphy. 
 
 In amputating an elongated or hypertrophied uvula, little hemorrhage 
 is experienced, thus further showing the limited blood-supply of the soft 
 
 THE IKTEENAL CAEOTID AKTEKY. 
 
 . This vessel which supplies the eye and brain, is remarkable for the 
 number of curvatures that it presents in the different portions of its course. 
 These curvatures are explained as an effort on the part of Nature to offer a 
 mechanical obstruction to a rapid current of blood entering the brain, 
 
THE BLOOD-VESSELS OF THE HEAD. 87 
 
 since increased friction is thus produced and much of the danger to rup- 
 ture of the cerebral capillaries from excessive heart's action is thus obviated. 
 
 The artery is usually studied, as to its course and relations, by dividing 
 it into four distinct portions. First, the cervical portion, including all 
 of the artery below the carotid canal; second, the petrous portion, in- 
 cluding that part of the artery which lies within the carotid canal; third, 
 the cavernous portion, which includes that portion of the artery lying 
 within the cavernous sinus; and, fourth, the cerebral portion, or the bal- 
 ance of the artery before it divides into its terminal branches. 
 
 The internal carotid artery, as before stated, is distributed to the 
 brain, and also to the eye and its appendages, hence its surgical import- 
 ance. In point of calibre it equals that of the external carotid artery. 
 
 Cervical portion. This portion of the artery varies much in its length, 
 being dependent, not only upon the point of bifurcation of the common 
 carotid artery which sometimes varies, but also upon the stature of the in- 
 dividual. At its point of origin this vessel is easily accessible, being 
 superficially placed within the superior carotid triangle and lying on the 
 same level with but behind the external carotid. 
 
 Petrous portion. The internal carotid artery within the petrous por- 
 tion of the temporal bone, ascends perpendicularly for a short distance, 
 then inclines forward and inward near to the inner side of the Eustachian 
 tube, and again ascends as it passes from the carotid canal into the cavity 
 of the skull. In this portion the cavity of the middle ear is in the closest 
 relation, being separated from the artery only by a thin lamella of bone, 
 which, in the young subject, is cribriform, and, in old age, is often nearly 
 deficient from absorption; it can therefore be wounded by puncture 
 through the ear. The artery is separated from contact with the bony 
 walls of the carotid canal by an investing tubular process of the dura 
 mater; but it has, in direct contact with it, the carotid plexus of nerves, 
 which are derived from the sympathetic system. Fracture of the petrous 
 portion of the temporal bone seldom involves the artery on account of 
 its protective sheath derived from the dura mater. 
 
 Cavernous portion. On passing out of the carotid canal, the internal 
 carotid artery, which has now entered the interior of the skull, ascends 
 a short distance to reach the body of the sphenoid bone where it enters 
 the cavernous sinus,^ having first perforated the layer of dura mater 
 which forms the outer boundary of that venous channel. 
 
 ' Within this sinus the following relations are important and may be shown by 
 the following diagram: 
 
 Internally. Externally. 
 
 Internal carotid artery. Third cranial nerve. 
 
 Sixth cranial nerve. Fourth " " 
 
 Carotid plexus of nerves. Ophthalmic division of the fifth 
 
 cranial nerve. 
 
88 PE ACTIO AL MEDICAL ANATOMY. 
 
 Within this sinus the artery has relations with the third, fourth, fifth, 
 and sixth cranial nerves and is invested by the lining membrane constitut- 
 ing the sinus. It remains within this venous cavity, till the anterior clinoid 
 process of the sphenoid bone is reached, when the course of the artery is 
 suddenly deflected upward. Perforating the layer of dura mater forming 
 the upper or cerebral wall of the cavernous sinus, it is then received into 
 a sheath of the arachnoid membrane, and from this point its fourth anato- 
 mical division may be said to commence. 
 
 Cerelral portion. This portion of the internal carotid artery lies to 
 the outer side of the optic nerve, having the third cranial nerve (motor 
 oculi) external to it, and extends to the inner extremity of the fissure 
 of Sylvius, which separates the frontal and temporal lobes of the cerebrum. 
 It may be said to commence at that point where the artery pierces the 
 cerebral wall of the cavernous sinus. 
 
 I have entered thus into detail as to the course of this artery, from the 
 point at which it entered the carotid canal, as its relations may have a 
 practical bearing upon fractures of the base of the skull (see page 20), 
 and, in cases of carious disease of the petrous portion of the temporal 
 bone, the artery may possibly become involved. 
 
 Peculiarities. 
 
 The internal carotid varies in its length on account of abnormalities 
 0^ the common carotid, and also from variations in the length of the 
 neck. It also takes its origin occasionally from the aortic arch, and, in 
 rare instances, it has been observed to lie nearer the median line of the 
 body at its point of origin than the external carotid. 
 
 This vessel may be extremely tortuous instead of straight, for the 
 greater portion of its length; and cases are on record where the absence of 
 this artery has been discovered. In one of these cases the internal max- 
 illary artery supplied its place with two abnormal branches which passed 
 through the foramen rotundum and the foramen ovale. 
 
 The internal carotid artery may also occasionally give off branches in 
 its cervical portion. 
 
 Surgical Anatomy. 
 
 Hemorrhage may occur from wounds involving the internal carotid 
 artery. These wounds usually occur from a stab received in the neck, or 
 gun-shot wounds involving the deeper structures of the neck. It 
 may also be wounded by deep penetrating wounds received within the 
 mouth, as of falling upon a pipe, pencil, etc., when held in the mouth; 
 from a thrust of a foil or pointed weapon; or from a bullet wound re- 
 ceived within the mouth. In cases of operations about the tonsil, as 
 during its removal, incision for abscess, etc., the internal carotid may 
 possibly be wounded and fatal hemorrhage ensue. 
 
THE BLOOD-VESSELS OF THE HEAD. 
 
 89 
 
 Cases of death from ulceration into this vessel in severe attacks of sup- 
 purative tonsillitis are on record.' 
 
 The ophthalmic artery arises from the internal carotid, near the ante- 
 rior clinoid process of the sphenoid bone, and passes forward to supply 
 the eye, the orbit, and portions of the face. 
 
 It escapes from the cavity of the skull through the optic foramen, and 
 is here placed below and to the outer side of the optic nerve, which also 
 enters the orbit by the same foramen. 
 
 Te^^r/a^ 
 
 Jbipr* Oeiht^ 
 
 JLjtieriev JSUttia^ 
 
 £»atmBT ^E3imi 
 
 ,EffmaZ Civntiki 
 
 Fia. 56.— The ophthalmio artery and its branches, the roof of the orbit having been removed. 
 (After Gray.) 
 
 "Within the orbit, this vessel passes across the nerve, and thus reaches 
 the inner side of the same. It then runs horizontally forward to the 
 inner angle of the eye, passing, on its way to this point, under the lower 
 border of the superior oblique muscle, and divides, at the internal angle 
 of the eye, into two terminal branches: VaQ frontal and the nasal, which 
 are distributed upon the face. 
 
 In its course, it gives off numerous branches, which are destined to 
 
 ' Blandin, op. cit. 
 
90 PK ACTIO AL MEDICAL ANATOMY. 
 
 supply the eye and its appendages. These branches are usually diyided, 
 for conyenience of description, into an orbital and an ocular group, the 
 former sending its blood only to the parts forming the orbit, while the 
 latter is distributed to the globe of the eye and its muscles. 
 
 The laclirymal branch is the first, and, perhaps, the largest of the 
 branches of the ophthalmic artery. 
 
 It is given off in the immediate yicinity of the optic foramen and not 
 infrequently before the ophthalmic artery enters the orbit. 
 
 It is a long branch, and passes forward beneath the periosteum of 
 the roof of the orbit until the external rectus muscle is reached. It then 
 accompanies the lachrymal nerye along the upper border of the external 
 rectus muscle, and, guided by it, reaches the lachrymal gland, to which 
 it is distributed by numerous branches. 
 
 Terminal branches afterward escape from this gland, and are dis- 
 tributed to the conjunctiva and upper eyelid. 
 
 The lachrymal artery anastopioses with 
 (1) The deep temporal artery by a malar branch which passes through a 
 
 foramen in the malar bone. 
 (3) The transverse facial artery through a malar branch which also per- 
 forates the malar bone and escapes upon the cheek. 
 
 (3) The middle meningeal artery, through a branch passing backward 
 
 through the sphenoidal fissure, being distributed upon the 
 dura mater. 
 
 (4) The palpebral arteries, through its terminal branches in the upper 
 
 eyelid. 
 
 Peculiarities. — The lachrymal is occasionally derived from the middle 
 meninge,al artery, or from one of its anterior branches. 
 
 The supra-oriital hranch of the ophthalmic artery arises from that 
 vessel at a point where the artery lies immediately above the optic nerve. 
 It rapidly rises to the roof of the orbit, thus lying above all the muscles, 
 and, in company yj'i'Ca.^h.^ frontal nerve, passes forward, between the peri- 
 osteum and the levator palpebrse, to the supra-orlital foramen, where 
 both the artery and nerve escape. 
 
 After its exit, the artery divides into a superficial and a deep branch, 
 which supply the pericranium, the muscles, and the integument of the 
 forehead. 
 
 The ethmoidal arteries are two in number: & posterior and an anterior. 
 The former, which is of small size, passes through the posterior ethmoidal 
 foramen in the inner wall of the orbit, and, after giving some small 
 branches to the posterior ethmoidal cells, enters the skull. After sup- 
 plying the dura mater by its meningeal branches, it here sends its ter- 
 minal filaments (nasal branches) through the foramina of the cribriform 
 plate of the ethmoid bone, in company with filaments of the olfactory 
 nerve, into the nasal fossse. Thus, hemorrhage from the nose may 
 deplete both the meninges and the orbit. 
 
THE BLOOD-VESSELS OF THE HEAD. 91 
 
 The anterior ethmoidal artery passes through the anterior ethmoidal 
 foramen, in company with the nasal division of the ophthalmic nerve, 
 and, after supplying the anterior ethmoidal cells and ih.Q frontal sinuses, 
 it then enters the cranium. Within the skull, this artery, like the pos- 
 terior artery, gives off a meningeal branch to the dura mater of the 
 anterior fossa of the skull, and a nasal branch, which escapes at the crib- 
 riform plate of the ethmoid bone into the cavity of the nose. 
 
 'YhQ palpebral arteries are two in number: a superior and an inferior, 
 since they correspond to the lids which they are destined to supply. 
 
 They usually arise by a common trunk in the neighborhood of the 
 pulley of the superior oblique muscle, but both arteries may have a direct 
 point of origin from the ophthalmic artery. 
 
 They encircle the eyelids near their free margins, forming a superior 
 and an inferior arch, which lie between the tarsal cartilages and the orbi- 
 cularis palpebrarum muscle. 
 
 The superior palpebral artery anastomoses at the outer side of the 
 orbit with the orbital branch of the temporal artery, while the inferior 
 palpebral artery anastomoses at the inner side of the orbit with the orbital 
 branch of the infra-orbital artery (a branch of the internal maxillary). 
 From this last anastomosis a branch is given ofE, which supplies the 
 mucous membrane of the nasal duct as far as its inferior meatus. 
 
 T^hQ frontal artery, one of the terminal branches of the ophthalmic, 
 passes from the orbit at its inner angle, and, ascending upon the fore- 
 headj supplies its pericranium and the muscles and integument of that 
 region. 
 
 The nasal artery, the other terminal branch of the ophthalmic, 
 takes its course forward above the tendon of the orbicularis muscle, to 
 the root of the nose, where it ramifies and anastomoses freely with the 
 nasal and angular branches of the facial artery. 
 
 The ciliary arteries are divisible into three sets: the short, long, and 
 anterior ciliary branches. 
 
 The short ciliary vessels vary from twelve to fifteen in number, and, 
 as they pass forward to reach the posterior part of the sclerotic coat of 
 the eye, almost completely inclose the optic nerve. They pierce the 
 sclerotic at the posterior portion of the globe of the eye, about one or two 
 lines from the circumference of the optic nerve, and are distributed to 
 the choroid coat and the ciliary processes of that organ. 
 
 The long ciliary arteries, two in number, also enter at the back part 
 of the eye, but pass forward between the sclerotic and the choroid 
 coats, one on each side of the eyeball, till they reach the ciliary liga- 
 ment, where they divide into branches. These branches form two arte- 
 rial circles, one around the circumference, and the other around the free 
 margin of the iris, which are connected by intermediate branches of com- 
 munication, passing through the substance of the iris. 
 
 The anterior ciliary arteries are often derived from some of the mus- 
 
92 
 
 PEACTICAL MEDICAL ANATOMY. 
 
 cular branches of the ophthalmic artery. They form an arterial circle 
 around the fore-part of the eyeball, within a line or two of the circum- 
 ference of the cornea. 
 
 All of these arteries anastomose within the eyeball. 
 
 The arteria centralis retincB is one of the smallest branches of the 
 ophthalmic artery. It pierces the sheath and substance of the optic 
 nerve, and runs imbedded within it until it reaches the retina, where it 
 ramifies, its branches extending forward until the ciliary processes are 
 reached. 
 
 C«<**^^ 
 
 ^ 
 ^ 
 
 Flo. 57.— Vascular territories of the superior cerebral surface. (After Duret.) 
 
 The dotted lines indicate the territories of the anterior, middle, and posterior cerebral arteries. 
 
 In the foetus, a small vessel passes directly through the vitreous 
 humor, within the posterior chamber of the eye, and is distributed to 
 the posterior surface of the capsule of the crystalline lens. 
 
 The CEEEBKAL branches of the internal carotid artery are four in 
 
THE BLOOD-VESSELS OF THE HEAD. 
 
 93 
 
 number, viz., the anterior cerebral, the middle cerebral, the posterior 
 communicating, and the anterior choroid arteries. 
 
 The anterior cerebral artery arises from the internal carotid, at the 
 inner extremity of the fissure of Sylvius. It passes forward, in 
 company with its fellow of the opposite side, in the longitudinal fissure 
 which separates the two hemispheres of the cerebrum, and gives off, soon 
 after its origin, a communicating branch, two lines in length, which con- 
 nects the two arteries, called the anterior communicating artery. ' This 
 branch forms the anterior boundary of the circle of Willis. 
 
 E^fiwrfaT comroK . /Iscmding frrnital cunvDlution 
 
 S-fronlal c^aivotutfon. j 
 
 Il^l'fron.tal eonvqlation. 
 Ascending iparietal cmirolTi 
 
 Jccipital 
 v/Tartdo- sphenoidal &, spheaoidal artenes 
 lAscending"paiielal artery" 
 
 Fig. 58. — Distribution of the middle cerebral SiTt&cY— partially schematic. (After Cbarcot.) 
 
 ■. frontal Brandi 
 Ascending frontal artery J 
 
 The anterior cerebral arteries, after curving around the anterior part 
 of the corpus callosum (the great transverse commissure of the brain), 
 ramify upon its inner surface, and anastomose at the bottom of the cen- 
 tral part of the longitudinal fissure with the posterior cerebral arteries. 
 By these vessels are supplied the following parts from behind forward : 
 (1) the third ventricle; (3) the upper surface of the frontal lobes of the 
 brain; (3) the anterior perforated space, and, through it, the corpus stri- 
 
 ' For relation of this portion of the circle of Willis to the optic nerve and its 
 effect on vision, the reader is referred to the author's late work: The Applied 
 Anatomy of the Nervous System. New York, 1881. 
 
94 PEACTICA.L MEDICAL ANATOMY. 
 
 atum; (4) the optic and olfactory nerves; (5) the inferior surface of the 
 frontal lobes of the hemispheres, and (6) the corpus callosum.' 
 
 The middle cerebral artery is the largest branch given off from 
 the internal carotid, and is in a direct axis of continuation with the 
 main trunk of that vessel. It is contained in the fissure of Sylvius (which 
 separates the frpntal and parietal lobes and the parietal and temporo- 
 sphenoidal lobes of the cerebrum), and within it, this artery divides into 
 three branches: an anterior branch, which supplies the pia mater investing 
 the frontal lobe; a posterior branch, which supplies the pia mater invest- 
 ing the parietal lobe, and a middle branch, which is distributed to the 
 Island of Keil (a collection of gray matter, called the central loie, within 
 the fissure of Sylvius). This vessel gives off a few branches also which, 
 after penetrating the anterior perforated space, are distributed to the 
 corpus striatum. 
 
 Surgical Anatomy. 
 
 The middle cerebral artery, especially that of the left side, is, by far, 
 the most common seat of embolic obstruction, since the upward current 
 of blood finds a nearly straight channel from the aortic arch to this vessel. 
 The left side is the more frequently affected, since the common carotid 
 of that side arises from the arch of the aorta at such an angle as to favor 
 the entrance of foreign bodies floating in the blood-current; while the 
 innominate artery, on the right side, leaves the aorta at an angle directed 
 away from the main current, and, for that reason, frequently escapes the 
 entrance of foreign bodies, in spite of its large calibre. 
 
 The symptoms produced by the entrance of an embolus into the mid- 
 dle cerebral artery, or one of its branches, are chiefly dependent upon 
 impairment of nutrition in the parts to which that artery distributes its 
 blood. Thus we usually have sudden paralysis (most frequently of the 
 right side of the body, since the left middle cerebral artery is most com- 
 monly affected). Aphasia is also a prominent diagnostic symptom, 
 since the nutrition to the Island of Reil and the third frontal convolution 
 is impaired. '^ Consciousness is often i-etained, since no compression of 
 nerve-centres is produced; and, from collateral circulation, the paralysis 
 may show a marked improvement soon after the attack. If recovery 
 from the paralysis takes place, it usually indicates an absorption of the 
 embolus through a process of fatty degeneration. ' 
 
 ' See functions of these parts and their bearings on diagnosis in the chapter 
 on the Brain in the author's late work: The Applied Anatomy of the Nervous 
 System. 
 
 " For the location of the centre of articulate speech, and the clinical types of 
 aphasia, the reader is referred to the late work by the author: The Applied Anat- 
 omy of the Nervous System. 
 
 ' See my work on Surgical Diagnosis. New York, 1880. 
 
THE BL00D-YES8BLS OF THE HEAD. 95 
 
 The distinctive symptoms between embolism and apoplexy, proTidecI 
 the attack is not immediately fatal, are best grouped as a differential 
 diagnosis 
 
 Apoplexy. Embolism. 
 
 The attack, if serious, but not im- Under the same conditions, con- 
 mediately fatal, is accompanied by sciousness is liable to be present dur- 
 ooma and insensibility. ing the attack. 
 
 The indications of cerebral compres- The indications of cerebral ansemia 
 
 sion are present, as shown by the f ol- exist, as shown by the following symp- 
 
 lowing symptoms: toms: 
 
 The breathing is stertorous. The respirations are normal (as a 
 
 rule). 
 
 The face is flushed. The face is pale. 
 
 The pulse is full and slow. The pulse is rapid and feeble. 
 
 The pupils are irregular. The pupils are uniform. 
 
 No aphasia exists (as a rule). Aphasia is diagnostic. 
 
 The paralysis is slow in improvement. The paralysis usually improves slight- 
 ly within twenty-four hours. 
 
 The arteries are often felt to be The arteries are normal, 
 atheromatous. 
 
 No cardiac lesion exists if the attack The aortic and mitral valves are usu- 
 
 be uncomplicated, ally found to be abnormal. 
 
 A history of previous high living A history of previous rheumatism 
 
 is usually present. and endocardial inflammation is gen- 
 erally detected. 
 
 Both may have been preceded by similar attacks; but in each a 
 recurrence is liable to take place, even should no previous history of 
 a former attack exist. 
 
 The posterior communicating artery arises from the back part of the 
 internal carotid, and serves to join it with the posterior cerebral branch 
 of the basilar artery. This artery completes, by this anastomosis, the 
 arterial circle at the base of the brain termed the "circle of Willis." 
 The size of this artery not only varies in different subjects, but is fre- 
 quently larger upon one side of the body than upon the other. It may, 
 in some cases, present itself as a small branch of the internal carotid, 
 while, in others, it may be of such large dimensions as to give the appear- 
 ance of an abnormal origin of the posterior cerebral artery from the 
 internal carotid trunk. 
 
 Hemorrhage within the cavity of the cranium may occur in one of 
 three situations: (1) between the bones and the internal periosteum; (2) 
 between the dura mater and the parietal layer of the arachnoid, and (3j 
 into the brain tissue or upon its surface. 
 
 TEETEBKAL AETERT. 
 
 The point of origin of the vertebral artery has a direct surgical 
 importance, since upon its proximity to a ligature placed around the 
 first portion of the subclavian, depend, to a great extent, the chances 
 
96 PEACTIOAL MEDICAL ANATOMY. 
 
 of recovery. In dissections made by Dr. John A. "Wyeth," of New York, 
 upon an equal number of males and females, the average distance of 
 the origin of the vertebral was about one-third of an inch from the 
 inner border of the scalenus anticus muscle toward the median line, upon 
 the right side of the body, while upon the left side it was almost inva- 
 riably present at the point of abrupt change in the course of the subcla- 
 vian as it arches over the first rib, which, however, corresponds to 
 nearly the same relative point. The left vertebral artery is usually the 
 larger in calibre, and at its point of origin its axis lies more nearly in 
 the direct line of the current of blood than that of the right side, which 
 perhaps accounts for the increased size of the left vertebral artery. 
 
 This artery, after its escape from the subclavian artery, ascends 
 through a foramen in the transverse process of each cervical vertebra, 
 and, after pursuing a winding course, enters the skull through the fora- 
 men magnum, and terminates in front of the medulla oblongata, by 
 uniting with its fellow of the opposite side to form the basilar artery. 
 The singular course of this vessel, which has been thus generally indi- 
 cated, requires a more precise description. 
 
 The artery first enters a foramen in the base of the transverse pro- 
 cess of the sixth cervical vertebra, and subsequently passes directly 
 upward through a foramen similarly situated in each of the cervical 
 vertebrae until the axis is reached. It here inclines outward, in conse- 
 quence of the greater width of the atlas, to reach the foramen in the 
 transverse process of that bone. It then passes through this last-named 
 foramen, and, winding backward behind the articular process of the 
 atlas, runs along in a deep groove on the upper surface of the posterior 
 arch of that bone, and, piercing the occipito-atloid ligament and the dura 
 . mater, enters the skull through the foramen magnum of the occipital 
 bone. 
 
 This artery, previous to its entrance to the skull, is contained within 
 a triangular space, which is bounded by the rectus capitis posticus major 
 internally, the obliquus capitis superior externally, and the obliquus 
 capitis inferior below. 
 
 While within the canal formed by the transverse processes of the ver- 
 tebra, this artery is accompanied by a plexus of sympathetic nerves and 
 the vertebral vein, which lies in front of the artery. The cervical nerves 
 arising from the spinal cord and escaping from the intervertebral fora- 
 mina, lie behind the artery, so that, at these points of escape for the 
 nerves, the artery is placed between the vertebral vein and the cervical 
 branches of the cerebro-spinal system. As the artery passes through the 
 triangle just named and bounded, it is covered in by the rectus capitis 
 posticus major and the complexus muscles. 
 
 Within the cavity of the skuU, as the artery winds around the medulla 
 
 > Sui-gical Essays. New York, 1879. 
 
THE BLOOD-VESSELS OF THE HEAD. 
 
 97 
 
 oblongata, it is located between the hypo-glossal nerve and the anterior 
 branch of the sub-occipital nerve. 
 
 Branches. — The branches of the vertebral artery may be divided into 
 two sets: (1) Those given off within the neck, and (2) those given off 
 within the cranium. 
 
 Cervical Branches. Cranial Branches. 
 
 Lateral spinal. Posterior meningeal. 
 
 Muscular. Anterior spinal. 
 
 Posterior spinal. 
 Inferior cerebellar. 
 The lateral spinal branches enter the cavity of the spinal axis by pass- 
 ing through the intervertebral foramina. They chiefly pass along the 
 side of the spinal cord, close to the roots of the spinal nerves, and sup- 
 ply the meninges of the cord, but some branches are distributed directly 
 to the posterior surface of the bodies of the cervical vertebrse. 
 
 The muscular branches are given off near the articular process of 
 the atlas, and supply the deeply seated muscles of the cervical region and 
 anastomose with the occipital and deep cervical arteries. 
 
 The posterior spinal arises at an obtuse angle from the vertebral 
 artery after its entrance to the cavity of the cranium. It passes back- 
 ward around the medulla oblongata to reach the posterior portion of the 
 spinal cord, where it descends and inosculates with small vessels, accom- 
 panying the cervical and dorsal nerves through the intervertebral fora- 
 mina. It can be traced as low down as the cauda equina at the second 
 lumbar vertebra. This artery, at its commencement, gives off an ascend- 
 ing branch, which extends to the side of the fourth ventricle of the 
 brain. 
 
 The anterior spinal artery is larger than the preceding branch of the 
 vertebral. It descends obliquely in front of the medulla till ib reaches 
 the border of the foramen magnum, where it unites with the artery of 
 the opposite side to form a common trunk. This single vessel then 
 descends along the front of the spinal cord for a short distance only, since 
 the small artery, called the anterior median artery (see Pig. No. 59), 
 which apparently runs from one end of the spinal cord to the other, is, 
 in reality, formed by a series of small vessels, which enter the spinal canal 
 through the inter-vertebral foramina at the different regions of the spinal 
 column. 
 
 These anastomosing branches are derived as follows: 
 
 (1) Prom the vertebral and ascending cervical arteries in the neck. 
 
 (2) " " intercostal arteries in the dorsal region. 
 
 1 lumbar ] 
 
 ilio-lumbar I arteries, in the lumbar region, 
 lateral sacral 
 
 This chain of anastomosing vessels is placed beneath the pia mater of 
 
 7 
 
98 PB ACTIO AL MEDICAL ANATOMY. 
 
 tlie spinal cord and along the anterior median fissure. Its numerous 
 branches supply the pia mater and the substance of the cord, and send 
 branches to the cauda equina. 
 
 The posterior meningeal artery (occasionally two branches) is given 
 off from the vertebral near to the foramen magnum. It supplies the 
 falx cerebelli, and ramifies between the dura mater and the bone in the 
 posterior fossa of the skull. 
 
 The inferior cerebellar artery is the largest branch of the vertebral 
 (although occasionally a branch from the basilar), and arises near to the 
 pons Varolii. It passes first between the hypo-glossal and pneumo-gastric 
 nerves, then crosses the restiform bodies, and reaches the under surface of 
 the cerebellum. Here two branches are given off, one of which passes in 
 through the notch between the two hemispheres of the cerebellum, while 
 the other ramifies over the inferior surface of that portion of the brain, 
 and at its edge anastomoses with the superior cerebellar arteries which 
 supply its upper surface. 
 
 This artery, by means of small branches, supplies blood to the cho- 
 roid plexus within the substance of the brain, in the vicinity of its fourth 
 ventricle. 
 
 THE BASILAR AETEET. 
 
 A single trunk, formed by the union of the two vertebrals in the 
 median line, is so called from its lying upon the basilar process of the 
 occipital bone. It extends from the posterior to the anterior border of 
 the pons Varolii, lying underneath the arachnoid, and is, therefore, in 
 its length equal to the breadth of the pons. 
 
 Branches. — It divides at its anterior termination into two branches: 
 the posterior cerebral arteries, and in its course gives off the anterior 
 cerebellar, the posterior cerebellar, and transverse branches. It also gives 
 unnamed branches to the substance of the pons Varolii. 
 
 The transverse branches of the basilar artery are several in number ; 
 one of these accompanies the auditory nerve within the internal auditory 
 canal, and is called the auditory artery. It is subsequently distributed 
 to the labyrinth of the ear. Other of the transverse branches are dis- 
 tributed to adjacent portions of the brain. A large transverse branch 
 receives also a special name, being called the anterior inferior cerebellar 
 artery. It is distributed to the anterior part of the under surface of the 
 cerebellum. 
 
 The superior cerebellar artery arises from a point near to the termi- 
 nation of the basilar artery, in fact, so close to the point of bifurcation 
 that many anatomists describe the basilar artery as dividing into four 
 terminal branches instead of two. 
 
 Each superior artei-y of the cerebellum turns, immediately after its 
 origin, behind the third nerve, then enters the groove between the pons 
 Varolii and the eras cerebri, then winds around the crus, opposite the 
 
THE BLOOD-VESSELS OF THE HEAD. 99 
 
 origin of the fourth nerve, to reach the upper border of the cerebellum, 
 where it divides into its branches, and is distributed to the upper sur- 
 face of that division of the brain. 
 
 Branches are given off from this artery also to the pineal gland and 
 velum interpositum. 
 
 The posterior cerebral artery is larger than the preceding branch of 
 the basilar, and is separated from it by the third nerve, which, lies between 
 the two arteries at their point of origin. It turns backward, at first 
 parallel with the last-named vessel, and then runs outward and upward 
 upon the under surface of the posterior lobe of the cerebrum, till it 
 nearly reaches the posterior extremity of the corpus callosum. This 
 artery divides into numerous branches and anastomoses with the anterior 
 and middle cerebral vessels. 
 
 Near its point of origin, it receives the posterior communicating 
 branch of the internal carotid, and the two posterior cerebral arteries 
 thus form portion of the circle of Willis, which will be described in sub- 
 sequent pages of this work. 
 
 Fio. 59.— A diagram of the circle of Willis. (After Wilson.) 1, carotid artery; 2, the ophthalmic 
 artery divided across; 3, the middle cerebral artery; 4, the anterior cerebral aitery; 5, the anterior 
 communicating artery; 6, the posterior communicating artery; 7, the vertebral artery; 8, posterior 
 meningeal artery; 9, posterior spinal artery; 10, the two anterior spinal branches, uniting to form 
 a single vessel; 11, the inferior cerebellar artery; 13, the basilar arteiy, giving off transverse 
 branches to either side. 
 
 The posterior cerebral artery gives off a posterior choroid branch, 
 which, like the anterior choroid branch of the internal carotid, is distrib- 
 uted to the interior of the brain. It sends filaments to the velum inter- 
 positum and the choroid plexus. 
 
100 
 
 PB ACTIO AL MEDICAL ANATOMT. 
 
 CIRCLE OF WILLIS. 
 
 A remarkable anastomosis exists between the vessels at the base of the 
 brain, by which the circulation, not only of the brain, but also of all the 
 structures entering into the formation of the head and neck, may, to a 
 great extent, he equalized, and any obliteration of one or even two of the 
 larger vessels may be speedily remedied by a corresponding enlargement 
 of the others. This anastomosis, which is known as the "circle of Wil- 
 lis," results from a series of communications between the following 
 branches: (1) The two anterior cerebral arteries are connected by the 
 anterior communicating branch. (2) The internal carotid arteries of 
 either side are united to the posterior cerebral arteries by the posterior 
 
 .1" " 
 
 Verte'b.ArtEriEa. 
 Fig. 60.— Scheme of arterial circulation at the base of the enoephalon, intended to show the 
 origin of the nutrient arteries which arise from the circle of Willis. (After Charcot.) 
 
 communicating branches. (3) "JlhQ posterior cerelral arteries themselves 
 arise from a single trunk, viz. : the basilar artery, and (4) the anterior 
 cerebral arteries are direct branches of the internal carotids. Thus from 
 before backward we perceive the anterior communicating artery, next 
 the two anterior cerebrals, next the internal carotid trunks, next the two 
 posterior communicating arteries, next the two posterior cerebral arte- 
 ries, and finally the basilar artery, where the last-mentioned vessels 
 converge. ' 
 
 ' For a discussion of tlie bearings of tiie circle of Willis upon defects 
 
 m vision. 
 
THE BLOOD-VESSELS OF THE HEAD. 101 
 
 AETEKIAL SUPPLY OF SPECIAL KEGIONS OF THE HEAD. 
 
 In recapitulation of the arteries derived from the principal yascular 
 trunks of the head, it may be of service to the surgeon or the medical 
 practitioner to recall in a tabulated form the various sources of vascular 
 supply to special structures which have at times great surgical interest 
 and importance. 
 
 The MEKiKGEs OF THE BBAiK AND SPINAL COED receive arterial 
 blood from the following sources:' 
 
 (1) The anterior meningeal artery (a branch of the internal carotid). 
 (3) The middle " " ( " " intei:nal maxillary) . 
 
 (3) The small " " ( " " internal maxillary). 
 
 (4) The posterior " " ( " " vertebral artery). 
 
 (5) The inferior " " ( " " occipital artery). 
 
 (6) Small branches which are not specially named, but still distributed 
 
 to the meninges. Among these, the more important ones are : 
 
 (a) Branches to the meninges from the ascending pharyngeal. 
 
 (b) " " " " " lachrymal. 
 
 (c) " " " " " posterior ethmoidal. 
 {d) " " " " " anterior ethmoidal, 
 (e) " " spinal meninges from the vertebral artery. 
 
 Of these branches, the anterior meningeal artery and the meningeal 
 branches of the two ethmoidal and lachrymal arteries supply the anterior 
 fossa of the skull, the middle and small meningeal, and some branches 
 of the ascending pharyngeal, which enter the skull at the foramen basis 
 cranii, supply the middle fossa, while 
 
 The tympanum" receives its blood chiefly from the following sources; 
 
 (1) The tympanic branch of the internal maxillary which enters at the 
 
 Olasserian fissure. 
 
 (2) The tympanic branch of the internal carotid which enters through 
 
 a small foramen within the carotid canal. 
 
 (3) The stylo-mastoid artery (a branch of the posterior auricular) which 
 
 enters the aquseductus Pallopii through the stylo-mastoid foramen. 
 
 (4) The Vidian artery (a branch of the internal maxillary, which passes 
 
 through the Vidian canal and accompanies the large petrosal 
 nerve through the hiatus Pallopii. 
 
 (5) The petrosal branch of the middle meningeal artery, which enters 
 
 at the hiatus Pallopii. 
 
 (6) Branches from the ascending pharyngeal artery, which enters along 
 
 the Eustachian tube. 
 
 see chapter on Optic Nerve, in the Author's late work: The Applied Anatomy of 
 the Nervous System. N. Y., 1881. 
 
 ' Darling and Ranney. Essentials of Anatomy. New York, 1880. 
 
 ' Darling and Ranney, op. cit. 
 
102 PKACTICA.L MEDICAL ANATOMY. 
 
 HEMOKRHAGB. 
 
 To die of repeated hemorrhages, while perhaps the most painless of 
 deaths, is the most awful. With each succeeding hemorrhage, dissolution 
 is so distinctly intimated, and the patient so conscious that his strength 
 is fast ebbing, that he clings to life. The most resolute are overcome 
 with an anxiety which they cannot conceal, and look around for some 
 one to delay, at least, the fatal moment. 
 
 ■ But if there be a sudden hemorrhage from a vessel opened in an ope- 
 ration, or from an aneurism, or from some wound, the arteries of which 
 cannot be discovered, there is immediate danger of death to the patient 
 even while in the hands of the surgeon. Those who have witnessed the 
 agitation of such scenes can best judge of the importance of this sub- 
 ■ ject. 
 
 John Bell,' in his essay on hemorrhage, though undoubtedly influ- 
 enced by the defective means of arrest then existing, closes a paragraph 
 with these words: " Were this one danger removed, would not the young 
 surgeon go forward in his profession almost without fear ? " 
 
 I question if even our present enlightenment has entirely dispersed 
 this element of anxiety. 
 
 Hemorrhage is usually classed into three distinct varieties : 1st. Arte- 
 rial, as indicated by a bright- red color of the blood and an intermitting 
 flow; 2d. Venous, as indicated by a continued flow and'darker color; 3d. 
 Parenchymatous, as indicated by a general oozing from the capillaries of 
 an injured surface. 
 
 Causes primarily modifying Hemorrhage. 
 
 The amount of hemorrhage is modified, at first, by the number of ves- 
 sels wounded, and by the smoothness of the cut surface. 
 
 This latter element is especially important in vessels of large calibre, 
 since an injury with a dull instrument, or the rending of a vessel from 
 violence, leaves the mouth in a condition to offer more or less resistance 
 in itself to the rapid escape of blood, independent of the changes which 
 occur in the coats of the wounded vessel subsequent to its injury. 
 
 Causes tending to prolong Hemorrhage. 
 
 There are, however, other causes which may modify hemorrhage later 
 on, and, 'bj prolonging it, tend to greatly increase the danger to life. 
 Under this head I would mention : 
 
 1st. Gravity. 
 
 2d. High temperature, whether in the wound or surrounding atmo- 
 sphere, by delaying coagulation. 
 
 3d. Muscular expiratory efforts, especially in wounds of the neck. 
 
 4th. Obstruction to a free venous return. 
 
 ' Treatise on Surgery. London, 1821. 
 
THE BLOOD-VESSELS OF THE HEAD. 103 
 
 5th. Obstructed or delayed contraction of vessels, as occurs in hepatic 
 hemorrhage; from the teeth; from the nutrient artery of bone; from dis- 
 ease of the yessel; and from atony of a vessel. 
 
 6th. Diseases of Hood, preventing coagulation or assisting exudation, 
 as in vicarious hemorrhage, purpura, yellow fever, etc. 
 
 7th. Congenital anatomical defects in the construction of vessels. 
 Wilson's case,' coats only one-half normal thickness. Blagden's case,'' 
 transparent coats — died from the pulling of a tooth. Wachsmuth's case 
 — death from a ruptured hymen. 
 
 Symptoms due to hemorrhage. — When a patient suffers from the impet- 
 uous bleeding of some large artery, from a ruptured aneurism or wounded 
 viscera, the face at once becomes deadly pale, a dark circle around the 
 eyes is perceived, the lips change to a blackish hue, and the extremities 
 become rapidly cold. The patient faints, revives but to be conscious of 
 his danger, and faints again. The voice is lost; there is an anxious and 
 incessant tossing of the arms, with that restlessness which is the sign of 
 the approaching end. The head is suddenly raised, gasping as it were 
 for breath, with inexpressible anxiety depicted on the countenance. The 
 tossing of the limbs continues; convulsive sighs are drawn; the pulse flut- 
 ters, intermits from time to time, and the patient often expires sud- 
 denly. 
 
 The countenance is not of a transparent paleness, but of that clayey 
 and leaden color which the painter represents in assassinations and bat- 
 tles; and this tossing of the limbs, which is commonly represented as the 
 sign of a fatal wound, is indeed so infallible a sign of death, that I have 
 never known any one to I'ecover who had fallen into this condition. 
 
 Treatment. — In the early centuries, when hemorrhage was with diffi- 
 culty controlled, and the percentage of mortality from this source enor- 
 mous, superstition frequently accompanied the defective surgical means 
 at that time in vogue. Thus we find Wolffius Sennertus, Michael Mer- 
 cates, and Gottfried Moebius, in the sixteenth century, extolling the 
 application of toads behind the ear and in the arm-pits, as a means of 
 arresting hemorrhage. 
 
 Plunging bleeding members into the abdomen of a living fowl had its 
 adherents. The use of hot magnetic ore, boiling oil of turpentine, vit- 
 riol, and corrosive sublimate were also among the cruel practices of the 
 day. The actual cautery can be found described as early as Galen. Al- 
 bucasis, in his work on surgery, devotes fifty-eight chapters to the cautery 
 and its uses. All possible designs and shapes were wrought from iron to 
 meet the various emergencies, and plates of them published, and the spe- 
 cial advantages of each extolled. Ked-hot knives were first suggested by 
 "Pabricius Ab Aquapendente " as a valuable improvement on former 
 customs for the immediate arrest of hemorrhages during amputation. 
 
 ' Lancet, 1840. « :JIed. Chir. Trans., vol. viii., p. 224. 
 
104 PRACTICAL MEDICAL ANATOMY. 
 
 In the reign of Henry IV., Ambrose Pare first advocated ligature, 
 with rules and directions not unlike those of the present day; but for a 
 century it was used with great caution, and met with much disfavor. 
 
 Petit, in 1730, urged a compress and bandage at the stump to modify 
 the shape of the clot, and invented the tourniquet, known by his name. 
 In 1733, Petit's experiments of the efEect of astringents on mutton were 
 made in his endeavor to discover artificial means to harden the clot with- 
 n a stump by local applications. 
 
 Pouteau, soon after, advocated the ligature of nerves with the vessel 
 to stimulate the swelling of tissues, and thus cause compression of the 
 vessel. Subsequently torsion became developed by Amussat, Velpeau, 
 and Thierry. Ligature and its mechanism have been fully explained by 
 Jones. Tourniquets have been modified and improved by Signorini, Skey, 
 and hosts of others, and the study of collateral circulation investigated to 
 a high degree of perfection by Mannoir, Porta, and Stilling. 
 
 Transfusion has also been added, of the literature of which Blundell's 
 essay probably best deserves mention. Acupressure, devised by Simpson 
 in 1859, has proved also a valuable contribution to this branch of sur- 
 gical investigation. 
 
 I close the subject of hemorrhage by enumerating certain general rules 
 of treatment, which seem to me to meet all possible indications. 
 
 1st. Always ligate the bleeding vessel, in moderate hemorrhage, 
 when convenient to do so; the form of ligature used depending on the 
 choice of the operator. 
 
 3d. Use compression over the wound or on the main trunh, in mode- 
 rate hemorrhage, when ligature of the wounded artery is inconvenient. 
 3d. In violent hemorrhage enlarge the wound and tie the artery. 
 4th. As a rule, never attempt ligation except when bleeding actually 
 exists. 
 
 The exceptions to this rule are: 1. In exposed vessels of large calibre 
 
 demanding ligature as a safety measure. 3. In delirium tremens 
 
 following an injury. 3. When necessity for transportation exists. 
 
 5th. Ligature should, as a rule, be applied at the Heeding point, and 
 
 not remote from it. 
 
 The reasons for this general statement being: 1. That collateral cir- 
 culation may otherwise keep up the hemorrhage. 2. The bleeding 
 vessel may not be the main trunk. 3. There exists in certain 
 localities additional danger as you approach the heart. 4. Gan- 
 grene is liable to occur, in case subsequent ligature of the wound 
 shall be required. 
 6th. Use the external wound as a guide to your incision to reach the 
 vessel — except when the wound exists on the side opposite to the vessel 
 injured, when a probe may be cut down upon. 
 
THE BLOOD-VESSELS OF THE HEAD. 
 
 105 
 
 Vfch. Always use the greatest precaution to avoid needless loss of 
 blood in reaching the vessel, until the finger can compress it. 
 
 8th. The artery, when found, should be tied above and below the 
 wounded portion, and at a bifurcation three ligatures should be used. 
 In case the lower end cannot be discovered, use compression in the 
 
 wound as a substitute for ligature. 
 9th. A ligature should not be placed close below a large branch, since 
 a clot may not form and secondary hemorrhage occur. 
 
 10th. In r«cMrH«^ hemorrhages the treatment should depend on the 
 eoor of the blood and the severity of the hemorrhage. 
 
 If the hemorrhage springs from the proximal end of the artery: 1. 
 Tie, if possible. 2. Amputate, if necessary. 3. Use styptics and 
 compression, if both are impossible. 
 
 Fio. 61.— The superficial veins of the head and neck. 1, sterno-mastoid muscle; a, facial vein ; 
 6, anteFior temporal vein; c, transverse facial vein; d, posterior auricular vein; e, internal maxil- 
 lary vein; /, external jugular vein; g, posterior external jugular vein; A, anterior jugular; k, in- 
 ternal jugular vein. Many of these veins will be more apparent to tlie reader by consulting the 
 succeeding figures. 
 
 11th. Amputation is preferable to ligature: 1. When great swelling 
 of the limb renders ligation difiBcult. 2. When exhaustion of the patient 
 forbids further search for the vessel. 3. When competent assistance is 
 needed and not attainable. 
 
 12th. In case a large vessel is injured, without actual hemorrhage, 
 heat and flannels to the limb are indicated as a preventive measure. 
 
 13th. In case an aneurism is the seat of hemorrhage — provided the 
 aneurism is traumatic in its origin — it sliould be treated on the same 
 principles as if it were a wounded artery. 
 
106 
 
 PEAOTIOAL MEDICAL ANATOMY. 
 
 VEINS OF THE HEAD. 
 
 The veins of the head may be divided into two sets, viz., the superficial 
 veins, comprising those of the cranium and face; and the internal or 
 cerebral veins. The latter include (1) the cerebral veins proper, (2) those 
 channels formed by the dura mater (the cerebral sinuses), and (3) the 
 veins of the diploe or middle tablet of the skull-cap; while the former 
 correspond in their name and general direction with the arteries which 
 have been described in previous pages. 
 
 The Cerebral Sinuses. Many points of interest pertaining to the 
 cerebral sinuses and the veins of the diploe have already been mentioned in 
 connection with certain bony points on the exterior aspect of the skull,' 
 
 "T'-f-l 
 
 
 Fig. 62.— a diagram of the venous sinuses of the dura mater, as seen on a vertical section 
 through the cranium. 
 
 1, The superior longitudinal sinus (single). 2, The inferior longitudinal sinus, formed by the 
 under border of the falx cerebri (single). 3, The straight sinus, connecting the two longitudinal 
 sinuses and receiving the ven^ Galeni of the brain (single). 4, The torcular IIeropkili(y7me cup) 
 where the sinuses of the dura mater converge. 5, The lateral sinuses, showing the curve which is 
 made by the sinus of each side. 6, The superior petrosal sinv^, connecting the cavernous and the 
 lateral sinuses of the same side. 7, The inferior petrosal sinus, assisting the lateral sinus of the 
 same side to form the jugular. 8, The cavernous sinus, communicating with the two petrosal 
 sinuses of the same side and with the ophthalmic vein, anteriorly. 9, The jugular vein, formed by 
 the lateral and the petrosal sinuses. 10, The occipital sinus, passing downward to the foramen 
 magnum. II, The vence Qaleni, of the velum interpositum. IS, The vein which passes through 
 th& foramen ccecum, and thus allows of communication between the nose and the superior longi- 
 tudinal sinus. 
 
 which need not be repeated, as they can easily be found by reference to 
 the first chapter of this volume, or to the index, in case any special point 
 needs to be referred to; but the general situation of the cerebral sinuses 
 has not been, as yet, discussed in all its practical bearings. 
 
 The cerebral sinuses are channels formed by the sepm-ation of the dura 
 
 ' Pages 5 and 7. 
 
THE BLOOD-VESSELS OF THE HEAD. 
 
 lOT 
 
 mater, for the transmission of the venous blood from the supplying ves- 
 sels of the brain and its coverings. They are fifteen in number, and may 
 be divided into five single and five pairs of sinuses. The two diagram- 
 matic di-awings will help to show the relative situation of each far better 
 than a long description. 
 
 In this second drawing, the sinuses which are situated at the base of 
 the skull only are shown, and the points of communication between them 
 are also made evident. Two of the five single sinuses are shown to be 
 situated in the middle of the base of the skull, while the remaining three 
 
 ^<«*^ - > s --■•.> 
 
 Fio. 63. — A diagram of the venus sinuses of the dura mater, as seen on a horizontal section 
 through the cranium. 
 
 1, The torcular Berophili, where six sinuses join, 8, The lateral sinuses. 3, The occipital 
 sinuses^ passing downward to the foramen magnum. 4, The superior petrosid sinuses^ running 
 along the upper border of the petrous portion of the temporal bone. 5, The inferior petrosal 
 sinus, running along the posterior border of the petrous portion of the temporal bone. 6, The 
 transverse sinus, connecting the petrosal sinuses (single). 7, The cavernous sinuses. 8, The circu- 
 lar sinus, connecting the two cavernous sinuses (single). 9, The commencement of the internal 
 jugular vein. 10, The ophthalmic vein, communicating witla the cavernous sinus of the samo side. 
 II, A small vein joining the occipital and the inferior petrosal sinuses of the same side. 13, A vein 
 passing through the anterior condyloid foramen to join the lateral sinus. A, The anterior fossa 
 oftheskull. B, The middle /ossa of the skull. C, The posterior /ossa of the skull. FM,The/oro- 
 men magnum, FS, The frontal sinus. 
 
 have already been shown in the preceding diagram. The five double 
 sinuses are shown upon both charts, and thus their relative position to 
 each other and to adjacent parts can be better understood than if only 
 one diagram was used. 
 
108 
 
 PEACTIOAL MEDICAL ANATOMY. 
 
 It will be perceived, by reference to the above diagrams, that the 
 sphenoid bone is in close relation with both of the cavernous sinuses, and 
 also with the circular sinus which invests the margins of the " sella tur- 
 cica" or "pituitary fossa;" hence the liability of injury to some of these 
 venous channels in fracture at the base of the skull. ' The temporal bone 
 
 FiQ. 64.— The veins of the head and neck. (After Gray.) 
 
 also, which is frequently fractured by transmitted force (for reasons men- 
 tioned on page 26), lies in relation with the petrosal sinuses and a part 
 of the lateral sinus; while the parietal bones are each in contact with the 
 
 ' See page 20 of this volume. 
 
THE BLOOD-VESSELS OE THE HEAD. 109 
 
 superior longitudinal sinuses at their upper border, and the occipital 
 bone, with hoth lateral and ioth occipital sinuses, and a portion of the 
 superior longitudinal sinus. 
 
 The Veins of the Exterior of the Skull. 
 
 The Teins of the face and cranium are six in number, yiz. , the facial, 
 temporal, internal maxillary, temporo-maxillary, posterior auricular, and 
 occipital. 
 
 The facial vein passes obliquely downward across the side of the face, 
 in a line extending from the inner angle of the orbit to the anterior mar- 
 gin of the masseter muscle. It lies to the outer side of the facial artery 
 and is less tortuous than that vessel. 
 
 It commences at the angle of the eye, being formed at that point by 
 the junction of two vessels, called the angular and frontal veins; it ter- 
 minates in the neck, beneath the cervical fascia and the platysma mus- 
 cle, by uniting with a branch of the temporo-maxillary vein, to form a 
 large trunk, which empties into the internal jugular vein. 
 
 It collect's blood, during the upper half of its course, from the soft 
 tissues of the anterior portion of the face, and, below the jaw, from the 
 tonsil, soft palate, submaxillary gland, and the tongue. 
 
 The temporal vein corresponds, in respect to the course of its tributa- 
 ries, to the branches of the artery of the same name. Its main trunk 
 accompanies the artery, and eventually unites with the vein accompany- 
 ing the internal maxillary artery, to form the temporo-maxillary vein. 
 It collects blood from the scalp, the temporal muscle, parotid gland, the 
 ear, and the side of the face (through the transverse facial vein). 
 
 The i7iternal maxillary vein is of large size, and receives, as tributa- 
 ries, veins corresponding to the branches of the arteries of the same 
 name, viz.: the middle meningeal, deep temporal, pterygoid, buccal, 
 palatine, and inferior dental veins. It passes behind the angle of the 
 lower jaw, and unites with the temporal vein to form the temporo-max- 
 illary vein. 
 
 The temporo-maxillary vein divides into two branches in or below the 
 substance of the parotid gland, one of which joins the facial vein, and 
 the other is continuous with the external jugular. It receives, near its 
 point of division, the posterior auricular vein. 
 
 The posterior auricular vein commences from a plexus at the side of 
 the cranium, passes behind the ear, and empties into the temporo-maxil- 
 lary vein. It receives the stylo-mastoid vein, whose surgical importance 
 depends upon its carrying blood from the aquseductus Fallopii. 
 
 The occipital vein commences at the back part of the vertex of the 
 skull, from a plexus of small veins, and follows the course of the occipi- 
 tal artery. It usually terminates, on account of the depth to which it 
 passes in the neck, in the internal jugular. As it passes over the mas- 
 toid process, it receives the mastoid vein, whose surgical importance has 
 been already mentioned on page 7. 
 
110 PKACTIOAL MEDICAL ANATOMY. 
 
 The veins of the head have one very important surgical aspect, which 
 has not, as yet, been mentioned; and the same remarks are also equally 
 applicable to those of the neck and the axilla. I refer to the entrance 
 of air into the veins, and its transmission to the heart. This distressing 
 accident has never, to my knowledge, occurred, except in operations in 
 one of these three surgical regions. 
 
 The dangers liable to result from thrombosis of the veins of the head, 
 especially those of the diploe, have been already discussed on page 5 of 
 this volume. 
 
 The extension of facial erysipelas to the meninges of the brain prob- 
 ably takes place by means of the communication between the veins of the 
 scalp, through the diploe and sutures of the skull, and those of the face 
 by means of the ophthalmic vein, which traverses the orbit. 
 
 In ligation of arteries, the veins frequently embarrass the operator by 
 their over-distention. They 'can be made to collapse by pressure over the 
 distal portion of the vein; and too much care cannot be taken in avoid- 
 ing cutting a large vein, in this region, unless it be previously tied in two 
 places and cut between the ligatures. 
 
 As the return of blood, through the veins of the head, is assisted, to 
 a great extent, by gravity, the valves within them are less frequent than 
 in those of the extremities, where gravity tends to retard the circulation in 
 the veins.' Even those valves which exist in the veins of the head are 
 imperfect, since it is possible to make a satisfactory injection of them, 
 through the superior vena cava, which would be impossible, were the 
 valves capable of occluding their entire calibre. 
 
 The emissary veins, described by Santorini, are probably one of the 
 most frequent means by which inflammations upon the exterior surface 
 of the skull are transmitted to the meninges; and it is to these veins 
 alone that Beclard attributes the escape of blood from the ear in case of 
 fracture at the base of the skull, involving the petrous portion of the 
 temporal bone. Cambournac, Blandin, and others have also laid great 
 stress upon the emissary veins, as the anatomical explanation of the pro- 
 duction of meningeal or cerebral hemoi-rhage by wounds of the skull not 
 resulting in fracture. 
 _____ . j 
 
 ' Struthers: Jugular Venesection. 
 
SPECIAL, EEGIONS OF THE HEAD. 
 
 Ill 
 
 CHAPTER IT. 
 
 SPECIAL REGIONS OF THE HEAD. 
 
 Thbkb are eevtain practical points pertaining to the anatomy of the 
 head which can be given, in detail, only by considering special regions 
 whose anatomical construction brings them constantly to the notice of 
 the physician. 
 
 It has been the custom with almost all authors upon topographical 
 anatomy to follow some special plan as to the division of the head into 
 regions, based either upon those landmarks which Nature has herself de- 
 
 CJH 
 
 FiQ. 65.— Section through the external meatus and the ear at the point of junction o£ the carti- 
 age of the auricle, CC, with that of the auditory canal. (After Henle.) A small portion of the 
 upper wall of the latter remains as a narrow band, CM ; CM , lower wall of the cartilage of the 
 external meatus: H , spine of the helix; L, lobe of the ear; *, fibrous lip of the border of the osse- 
 ous meatus; 1, epicranius temporalis muscle ;S, levator aurioularis; 3, temporal muscle; 4, upper 
 wall of the osseous canal; 5, cavity of the tympanum: 6, membrana tympani; 7, stapes bone; 8, 
 vestibule; 9, meatus auditorius intemus and acoustic nerve; 10, lower wall of the osseous meatus; 
 11, parotid gland. 
 
 iined, or upon a jDhysiological connection between the various structures. 
 To follow in detail such a chart as Blandin recommends would increase 
 
112 
 
 PEAOTICAL MEDICAL ANATOMT. 
 
 the scope of this volume beyond its proper limits, while it would conflict 
 in many ways with the general plan of its construction. I shall, there- 
 fore, call attention, under this heading, only to such practical points as 
 pertain to the temporal, orbital, nasal, and buccal regions, since other 
 portions of the head have been treated of in previous pages. 
 
 TEMPORAL EEGION. 
 
 In the temporal region, the ear pften presents numerous anomalies. 
 The pinna may be flattened or some of its prominences excessively 
 developed. The lobule may be absent or adherent to the skin, while 
 the auditory passage may be abnormally short or narrow, and, in some 
 
 Fig. 66. — Method of holding the ear speculum in position. (After Eoosa.) 
 
 cases, entirely obliterated. The ancients, deceived by the false idea that 
 the cartilage of the ear was endowed with excessive sensibility, considered 
 injuries to the pinna to be extremely serious; and some have even spoken 
 of fracture of this portion, evidently mistaking an incised wound of the 
 cartilage for such an accident. 
 
 The follicles of the external canal may, if morbidly developed, result 
 in small encysted tumors; and inflammation of the external ear or of the 
 auditory canal iS rendered extremely painful by the close adhesion of the 
 skin to the subjacent parts. If the external ear be removed, the hearing 
 is markedly impaired, but is not entirely lost. 
 
 The curve of the auditory canal explains the necessity of drawing the 
 
SPECIAL BEGI0N8 OF THE HEAD. 
 
 113 
 
 pinna upward when we wish to examine it, since we thus remove the 
 curve, which does not extend to the osseous portion of the canal. In re- 
 moval of foreign bodies by instruments, it should be borne in mind that, 
 if the instrument has only one blade, it must be carried down upon the 
 lower toall of the canal, since we can thus introduce it more deeply be- 
 fore arriving at the membrana tympani, as this portion of the canal is the 
 longer; but, if the instrument has two blades, one should be introduced 
 below and the other above, as the vertical diameter of the canal is lon- 
 ger than the transverse, and the foreign body will be, for this reason, less 
 pressed upon, and a greater space for the instruments will be afEorded to 
 pass inward and embrace it. 
 
 FiQ. 67. — Mode of using the aural speculum and reflecting mirror. 
 
 Whenever it is desired to remove an insect from the ear, the head of 
 the patient should be inclined to one side, and the meatus filled with any 
 mild oil, which may be retained in the ear a few minutes, simply by keep- 
 ing the head in the inclined position. The oil thus occupying the tube 
 closes the respiratory pores of the creature, and soon either kills it or 
 8 
 
114 PBACTICAL MEDICAL ANATOMY. 
 
 causes it to seek the surface to obtain air or escape, when it may be 
 seized or subseqently washed out with a syringe or tepid water. Espe- 
 cially if inflammation exists, this latter mode should be practised, since 
 this condition increases the sensibility of the part and renders the intro- 
 duction of instruments painful. 
 
 If the foreign body should be a hard substance, and one not capable 
 of absorbing water, then the best plan of removing it will be to wash it 
 away by the force of a stream of water thrown in on one side of it, aad 
 made to fly outward from the resistance created by the surface of the 
 membrana tympani to the entrance of the water. 
 
 Cases have been reported by Sabatier, Blandin, and others, of menin- 
 gitis having been produced from foreign bodies which have been lodged 
 in the external auditory canal and which have withstood all attempts at 
 removal. 
 
 It is a well-recognized fact that foreign bodies in the ear sometimes 
 create symptoms of a cerebral type which may occasion alarm even with 
 those having a large experience in ear diseases. It is always advisable, 
 therefore, to examine the ear for foreign bodies, if any symptoms be I'e- 
 ferred to that region. 
 
 The escape of pus from the auditory passage, which often occurs, may 
 arise from its own lining membrane, or come from the tympanum 
 or the mastoid region. The auditory passage is partly membranous 
 on its posterior wall, and this anatomical fact explains how abscesses of 
 the mastoid or parotid regions sometimes point in this canal. 
 
 The membrana tympani is sometimes broken by loud noises, as is not 
 infrequently the case with cannoneers; and perforation may also be pro- 
 duced by the pressure of accumulated and hardened wax in the external 
 auditory canal, and sometimes by the pressure of the handle of the malleus. 
 Artificial puncture of the membrana tympani is sometimes performed (as 
 first suggested by Cooper in 1800) to allow the introduction of air into 
 the cavity of the middle ear when the Eustachian tube is obliterated,' or 
 for the purpose of evacuating pus during attacks of suppurative inflam- 
 mation of the tympanum. 
 
 The operation of opening the mastoid process, as a means of relief for 
 that obstinate form of deafness produced by permanent occlusion of the 
 Eustachian tube, was first suggested by Jasser, a Prussian surgeon, who 
 thus hoped to establish a permanent and free entrance of air to the cavity 
 
 ' The presence of air, having the same density and moisture, on both sides of 
 the membrana tympani is essential to the proper perception of sound, as that 
 membrane thus vibrates freely and accurately records the number of vibrations 
 peculiar to each individual note. 
 
 The closure of the Eustachian tube prevents the entrance of air to the middle 
 ear from the mouth; hence the abnormalities in hearing perceived when a catarrhal 
 inflammation creates a tumefaction of its lining membrane, as often occurs 
 during an attack of influenza. 
 
SPECIAI, EEGIONS OF THE HEAD. 
 
 IIJ 
 
 of the middle ear by means of the mastoid cells, and urged, as its chief 
 advantages, the facts that no anatpmical difficulties existed to the 
 operation, and that the membrana tympani was left intact. The unfor- 
 tunate accident of erysipelas in the case of Just Berger (physician to the 
 king of Denmark) brought serious criticism on Koelpin, of Copenhagen, 
 who performed the operation upon that distinguished man, and the ope- 
 ration fell into disrepute. 
 
 It is a fact worthy of mention in this connection, that the mastoid 
 cells are absent in childhood, and are not fully developed until middle 
 life. 
 
 Fig. 68,— Method of syringing the ear. (After Roosa.) 
 
 The intense pain which is present in suppuration of the middle ear 
 is produced by compression of the sensory nerve filaments, since most 
 of the walls of that cavity are bony; hence we find in those cases an ab- 
 normal outward protrusion of the membrana tympani, which is a symp- 
 tom of great diagnostic value; and, if not surgically relieved by puncture, 
 spontaneous perforation of the drum is liable to follow, and repair of the 
 damage often becomes difficult. 
 
 Pages have been written on most of the aural operations, but with a 
 tendency to confuse and embarrass, rather than encourage the reader. 
 Washing out the internal and external auditory tubes, with perforation 
 of the membrana tympani, or, perhaps, the mastoid cells, really consti- 
 
116 PEAOnOAL MEDICAL ANATOMY. 
 
 tutes the greater portion of aural operative surgery, and all are easily ex- 
 ecuted. For this reason, the steps of catheterizing the Eustachian 
 tube will be found appended in the description of the nasal cavity as a sur- 
 gical region; -while the steps necessary in the operation of opening the 
 mastoid process can easily be ascertained by reference to any work on sur- 
 gery. The dangers from the surgical relations of this process will be given 
 in full detail later on in this chapter. 
 
 Wounds of the temporal region, even if not very deep, may be at- 
 tended with profuse hemorrhage, especially when they are situated near 
 the auditory passage, and the temporal artery may possibly have to be 
 tied to arrest it. 
 
 The whole of the temporal region may be rendered prominent by 
 tumors of the antrum which have perforated its posterior wall, passed 
 through the zygomatic fossa, and thus encroached upon the temple. 
 
 Trephining should never be performed in this region unless the case 
 absolutely demands it, since the thickness of the soft parts which cover 
 the bone renders the operation a difficult one, and, because the skull is 
 extremely thin in this^ portion, the brain is therefore liable to be 
 wounded. The proximity of the middle meningeal artery is an addi- 
 tional reason why the operation should not be performed in this region, 
 unless circumstances render it imperative. 
 
 In the region of the mastoid process, the lateral fontanelle may be 
 abnormally large, or late in closing, and thus a hernia of the encephalon, 
 whether of the cerebrum or cerebellum, may occur through this opening. 
 Such cases, however, are fortunately infrequent. "Wounds in the vicinity of 
 the mastoid process may be attended with profuse hemorrhage if the cut- 
 ting instrument pass either in front of or behind it, since large vascular 
 trunks are in close relation to it, both anteriorly and posteriorly. 
 
 Caries and necrosis of the temporal region are frequently the result 
 of syphilis, and exostoses may also be developed from the same cause. 
 The occurrence of necrosis usually indicates that the disease has affected 
 the pericranium, and separated it from the bone, thus destroying its 
 nutrition. It is a curious fact that the cranial bones are seldom repro- 
 duced after removal of the entire thickness of the skull-cap; and this 
 seems to indicate that the dura mater does not take the place of a true 
 periosteum, since it sends few vessels into the bone, which is chieily 
 nourished by tlie pericranium, and, for this reason, the calvaria shows lit- 
 tle if any tendency to reproduce bone-tissue. 
 
 In trephining over the mastoid process — and the same statement is 
 applicable to other regions of the skull — the liability of injury to some of 
 the emissary veins, which pass chiefly through the sutures of the skull, 
 affords a danger of meningeal inflammation; hence all sutures should be 
 looked upon as points of danger in trephining. 
 
 The simultaneous escape of blood and cerebro-spinal fluid from the 
 auditory canal may be regarded as a most positive indication that the pe- 
 
SPECIAL KBGIONS OF THE HEAD. 
 
 117 
 
 rous portion of the temporal bone has been fractured (see page 20); 
 although blood alone may exist after an injury without a fracture having 
 occurred. 
 
 FiQ. 69.— Outer wall of the left nasal cavity, covered by the mucous membrane ; 1, frontal 
 bone; 2, left nasal bone; 3, upper jaw; 4, body of the sphenoid bone; 6, projection of the mem- 
 brane covering" the upper spongy or turbinated bone; 6, that of the middle; 7, that of the lower; 
 8, opening of the Eustachian tube going to the middle ear ; 9, inferior meatus. 
 
 KEGIOK OF THE NOSE. 
 
 The cavities of the nostrils are much narrower in the infant and the 
 aged than in middle life. In the infant, this narrowness is due to im- 
 
 Fia. 70.— Transverse vertical section of the nasal cavities, seen from behind: 1, part of the 
 frontal bone; 2, crista galli ; 3, perpendicular plate of the ethmoid bone; between 4 and 4 the 
 «thmoid cells ; 5, the right middle spongy or turbinated bone ; 6, left lower spongy bone ; 7, vomer ; 
 8, malar-bone; 9, maxillary sinus or antrum of Highmore; 10, its opening into the middle meatus 
 or passage. 
 
 perfect dcTelopment of the nasal cavity in the transverse direction; while 
 in the aged, an excessive development of the turbinated bones tends to 
 
118 
 
 PBACTIOAL MEDICAL ANATOMY. 
 
 occlude both the superior, middle, and occasionally the inferior meatus 
 of the nose. 
 
 The prominence on the ascending process of the superior maxillary- 
 bone may be used as a guide for inserting aprohe into the lower opening 
 of the nasal duct. In performing this operation, a probe which is pro- 
 perly curved is introduced along the floor of the nostril, with its point 
 looking outward. When it has penetrated for the distance of an inch, it 
 is generally withdrawn with the point in close contact to the outer wall 
 of the nasal fossa, until it is arrested by the prominence above mentioned ; 
 the probe is then depressed and carried a little inward, and, by a vibratory 
 
 Fig. 71.— Introduction of Eustachian catheter. 
 
 (After Eoosa.) 
 
 motion, the instrument is made to penetrate the nasal duct, passing un- 
 derneath a valve of mucous membrane, which partially occludes its lower 
 orifice. Probing of the nasal duct through the nostril is now seldom re- 
 sorted to on account of the valve of mucous membrane which occludes 
 its mouth. 
 
 The cavities of the nasal fossae communicate, in the superior meatus, 
 with the sphenoidal sinus and the posterior ethmoidal cells; in the mid- 
 dle meatus, with the frontal sinus, the cavity of the antrum, and the an- 
 terior ethmoidal cells; while, into the inferior meatus, the nasal duct opens. 
 The inferior meatus is of importance to the surgeon in the operations of 
 
SPECIAL KEGI0N8 OF THE HEAD. 
 
 119 
 
 plugging the posterior nares, dilating the nasal duct from below, cathe- 
 terizing the Eustachian tube, and removal of polypi or foreign bodies. 
 
 In plugging the posterior nares, should the surgeon not be able to ob- 
 tain Bellocq's canula, he may readily carry a ligature through the nostril 
 and mouth by means of a common elastic catheter, the ligature being 
 passed through the eye of the instrument, the latter being withdrawn after 
 the pellet is in position. After the lapse of several hours, the lint in front 
 of the nostril should be removed by the fingers or forceps, and that from 
 
 Fia. re.— A section of the nose, mouth, soft palate, uvula, tonsil, pharynx, upper part ot the 
 oesophagus, and trachea, showing the route taken by the Eustachian tube catheter along the infe- 
 rior meatus and floor of the nostril into the orifice of the Eustachian tube. (After Allen.) 
 
 the posterior nares displaced, either by pressing it into the throat by a 
 probe, when it may be drawn out by the thread left attached to it for 
 this purpose, or it may be removed by simply employing the end of the 
 ligature left in the mouth. 
 
 When, the position of the orifice of the Eustachian tube is recollected, 
 it will be seen that the introduction of a catheter into the mouth of that 
 
120 VEACTICAL MEDICAL ANATOMY. 
 
 tube is a simple operation, though the verbiage in which it has often been 
 described tends to create a belief in its being difficult. 
 
 The patient is seated with the head thrown slightly backward and 
 firmly supported, while the surgeon takes the catheter in his right hand, 
 and, after oiling it, introduces it into the nostril on the side to be dilated. 
 Then, keeping its point on the floor of the nostril, and its convexity 
 upward and inclined against the septum of the nose, he slides it back- 
 ward till it reaches the soft palate, as may be readily told by the sense of 
 touch transmitted along the instrument, or by the patient making a 
 slight gulp or effort to swallow. At this moment the surgeon should 
 turn the point of the catheter upward and outward by rotating it a quar- 
 ter of a circle, and then, by a slight movement forward and backward, 
 he may slip it into the tube with as much, if not more ease, than a cath- 
 eter can be made to enter the bladder. When the proper position of the 
 instrument is insured, it will at once be known by its steadiness, and 
 also by the sensation of the patient. 
 
 Foreign bodies in the nostril may be extVacted either from the front, 
 or pushed back into the throat, according to the proximity to one or 
 other of these orifices. As they seldom fill up the entire space of the nose, 
 a curette, or curved pi'obe, or Leroy's instrument for removing fragments 
 of calculi from the urethra, may generally be passed to one side of the 
 article, so as to enable the operator to draw it forward. If jammed 
 between the inferior turbinated bone and the septum, gentle pressure, 
 from above downward, by crowding it upon the floor of the nostril, will 
 facilitate its subsequent removal, either by the instruments above named, 
 or a polypus-forceps, or common dressing-forceps. If, however, the 
 foreign substance should be a piece of ribbon or something similar, which 
 has been stuffed high up in the cavity of the nose, washing out the nos- 
 tril by a stream of water with a syringe will often dislodge one end, and 
 thus enable the operator to seize and draw it out with the forceps. 
 
 During attacks of sneezing, coughing, laughing, or fright, at the time 
 an attempt at deglutition is being made, foreign bodies in the throat may 
 be forcibly driven into the postero-superior part of thenaresj and similar 
 instances are recorded during attacks of vomiting, although vomited 
 matters are usually expelled from the nose with little difficulty, in case 
 they chance to enter. 
 
 Metallic rings have been forced into the nostril through the pharynx' 
 during attacks of sneezing; and cherry pits and other substances have 
 been introduced by attacks of vomiting, and some have remained there 
 undetected, until ozsena caused a careful examination of the nares to be 
 made.'' 
 
 Foreign bodies can also be thus forced into the Eustachian tube, as 
 reported by Fleischmann, where a grain of barley became so lodged, and 
 
 Hickman Lowndes. " Poulet, op. cit. 
 
SPECIAL EEGIONS OF THE HEAD. 
 
 121 
 
 created ringing in the ears, a sensation of hair in the fauces, and inter- 
 ference with hearing. 
 
 It is well known that horse-flies are particularly prone to deposit their 
 larTse in the nasal fossae of animals, and that, after their maturity, the 
 animals which are hatched are often thus enabled to enter some of the 
 air-chambers of the head. In countries where leeches abound, they are 
 occasionally introduced into the pharynx with water drank from pools, 
 and they thus are enabled to crawl upward and lodge themselyes in the 
 nasal fossa, where they are often detected only by the epistaxis which they 
 
 FiQ. 73. — Section of the head, showing the divisions of the ear, and the naso-pharyngeal cavity 
 (after a photograph— Eudinger) ; 1, cartilage of external auditory canal; 2, osseous auditory canal; 
 3, 4, membranse tympani; 5, cavity of the tympanum; 6, dilator muscle of the Eustachian 
 tube; 7, levator palati muscle ; 8, mucous membrane of the pharyngeal orifice of the tube; 9, left 
 membrana tympani; 10, handle of the malleus and short process; 11, tensor tympani muscle; 13, 
 mucous membrane of the membranous portion of the tube, perforated by a needle ; 13, levator 
 veil palati muscle; 14, mucous membrane of the posterior surface of the pharynx; 15, mucous 
 membrane of the pharynx, attached to the lower surface of the body of the sphenoid bone; 16, 
 sphenoidal sinus; 17, hypophysis cerebri and its relations to the cerebral arteries and the cavern- 
 ous sinus. 
 
 create. They are extracted by salt douches or medicated injections, which 
 
122 
 
 PEACTIOAL MEDICAL ANATOMY. 
 
 cause them to loosen their hold and drop into the inferior meatus, where 
 they can be reached. 
 
 The presence of any form of foreign body in the nose creates a feeling 
 of irritation, which is indicated by an uncontrollable desire to forcibly 
 pass air through the nose and a peculiar stinging pain and sneezing, 
 which the patient seldom becomes deprived of, no matter how long the 
 foreign substance be retained. By its irritation, such an accident may 
 destroy smell, since an offensive ozaena is usually produced if the foreign 
 body be long retained; or, it may occlude the nasal duct by compression, 
 and thus induce symptoms referable to the eye or the lachrymal appa- 
 ratus, or create necrosis or caries of the bones of the nasal fossa, with the 
 many symptoms dependent upon those conditions. 
 
 The subject of foreign bodies of the nasal fossa has much of interest 
 which cannot be here given, and to such as seek for further information 
 the admirable work of Poulet is recommended.' 
 
 Fig. 74. Fio. 76. 
 
 Fig. 74.— Fibrous polpyus of the nose. (After Hamilton). 
 FiQ. 73.— Deformity of the nose from polypi of large size in both nostrils. 
 
 Swelling of the mucous membrane of the nasal cavity may partially or 
 completely occlude its calibre and thus affect the tone of the voice and 
 perhaps occasion dyspnoea; while a similar swelling in the region of the 
 lower orifice of the nasal duct may so occlude that canal as to prevent the 
 escape of the tears through their natural channel and thus cause them to 
 flow over the cheek. 
 
 Abnormal growths within the nasal fossa may be either mucous polypi 
 which are localized hypertrophies of the mucous membrane or the sub- 
 mucous tissue; fibrous polypi, which spring from the periosteum, and 
 
 ' A Treatise on Foreign Bodies in Surgery. New York, 1880. 
 
SPECIAL REGIONS OF THE HEAD. 
 
 123 
 
 are composed chiefly of bundles of fibrous tissue; cartilaginous growths, 
 which spring chiefly from the septum of the nose and the frontal or eth- 
 moidal cells; osseous tumors; sarcomata; and cancer. 
 
 The mucous type of polypus rarely, if ever, springs from the septum 
 of the nose, but usually arises from the mucous lining of the superior or 
 middle meatus, or the inferior turbinated bone. In rare cases they may 
 arise from the roof of the nasal fossa, or eyen from the frontal sinus,' and 
 may occasionally be so extensive as to hang into the pharynx. 
 
 The fibrous type of polypus, on the contrary, may grow from any part 
 of the walls of the nasal fossa, but is most frequently attached to the ba- 
 silar process at the base of the skull, and, for that reason, is usually found 
 within the upper portion of the pharynx, behind the uvula. 
 
 The tissues which invest the turbinated bones may undergo a genuine 
 hypertrophy and thus seriously occlude the cavity of the nose. Such cases 
 can be best relieved by removal of the hypertrophied mass by the 6craseur, 
 or actual cautery. 
 
 Fig. 76. —Vertical section of right orbit. (After Stellwag.) 
 KEGION OF THE ORBIT. 
 
 Injuries in the vicinity of the eyebrow may be regarded as particularly 
 liable to be followed by serious results. Death has resulted in such cases 
 from a fracture at the base of the skull; and an accompanying amaurosis 
 from injury to the optic nerve is frequent in such cases. Besides these 
 two sequelae, an emphysematous condition of the forehead may occur if the 
 frontal sinus be opened, and fistulse may remain, through which air may 
 be forcibly blown if the nose be held. A case is on record where, after 
 such an accident, the patient could blow out a candle through an opening in 
 the forehead which communicated with the frontal sinus. The supra-or- 
 
 ' Mackenzie : Diseases of the Nasal Cavity. London, 1880. 
 
124 
 
 PRACTICAL MEDICAL ANATOMY. 
 
 bital nerve which escapes from the orbit by a foramen underneath the 
 eyebrow may also be pressed upon by fragments of bone and thus become 
 the seat of a tormenting neuralgia, or, by creating reflex symptoms in 
 
 Fig. T7.— Relation of the various parts of the eye. ii, cornea; i, iris; p, anterior chamber of 
 eye; I, lens of eye; z, ciliary muscle; v, vitreous humor of eye; n, optic nerve entering eye and 
 sending its fibres into the retina; s, sclerotic coat of eyeball; 1, 2, 3, muscles which move the eye- 
 ball and upper eyelid. 
 
 other nerves which communicate with the fifth pair, cause manifestations 
 of a diseased condition of other parts of the head and face. ' 
 
 Penetrating wounds in this region may pass above or below the globe 
 
 Fio. 78.— Section of the orbit and cranium. 1, 2, 3, 4, 5, 6, muscles which move the globe and 
 upper eyelid; a, optic nerve; b, c, d, e, the trigeminus nerve and its branches; /, motor oculi 
 nerve; g, abducens nerve; A, ophthalmic artery. 
 
 of the eye, or aSect the globe itself. If the eye itself be injured, 
 it may be destroyed either as a direct result of the accident or by iiiflam- 
 
 ' Eanney, Medical Gazette, New York, October 30th, 1880. 
 
SPBOIAl, REGIONS OF THK HEAD. 
 
 125 
 
 ma^ion follomng it; while, if the eye be not destroyed, opacities of the cor- 
 nea or lens may result, foreign bodies may be deposited within its chambers, 
 the iris may be lacerated, and many other unfortunate conditions ensue 
 which may impair to a greater or less extent the functions of the eye and 
 lead to subsequent changes of a more or less serious character. 
 
 Wounds exterior to the globe of the eye are not as serious in their 
 results, except in those cases where the penetrating instrument has passed 
 deeply within the orbit and has injured (1) the orbital arch and the adja- 
 cent brain tissue, (3) the internal or external bony walls of the orbit, (3) 
 the important nerves and Tessels situated in the sphenoidal fissure, or (4) 
 by penetrating still more deeply, the vessels of the zygomatic fossa. In 
 
 Fig. 79. — Cyst in the region of supra-orbital ridge, cloEing the eye. 
 
 this latter region, all wounds are especially serious, for the following 
 reasons: first, because such wounds necessarily presuppose that the pierc- 
 ing instrument, before arriving there, has passed either through the cheek, 
 the temple, the parotid, region, or the orbit; secondly, because it is almost 
 impossible for the branches of the internal maxillary artery or its main 
 trunk to escape injury, while Meckel's ganglion and the superior maxil- 
 lary nerve may also be wounded; and thirdly, because the collateral cir- 
 culation between the branches of the internal maxillary artery with the 
 surrounding vessels is so extensive that, even if the common carotid 
 artery be tied, the other vessels are liable to produce fatal hemorrhage. 
 
 In extirpating the eye, we must guard against plunging the instru- 
 ment too deeply, in order to avoid injury to the nervous and vascular 
 structures of that region; besides, if roughly introduced, the scissors 
 
126 
 
 PEAcnOAL MEDICAL, ANATOMY. 
 
 might be forced into the sphenoidal fissure, or even through some por- 
 tion of the bony wall of the orbit. 
 
 In those cases where amputation of the globe of the eye is performed 
 in preference to extirpation, the globe should be cut behind the ciliary 
 body in such a manner as to prevent the escape of the vitreous humor 
 and cause the formation of a stump adapted for the insertion of an 
 artificial eye. ' 
 
 Elevation of the floor of the orbit by a tumor of the antrum, or the 
 pressure of an abnormal growth or suppuration behind the globe of the 
 eye, may cause a protrusion of the eyeball from its socket — a condition to 
 which the term " exophthalmia " is applied. In case the exciting cause 
 of such a condition be a vascular tumor, ligation of the internal carotid, 
 or even of the primitive carotid, may be demanded. 
 
 Fig. 80.— Complete Ptosis. 
 
 Within the orbital region, the operations of division of certain 
 branches of the fifth cranial nerve, for the relief of neuralgia, are per- 
 formed, whose steps in detail will be found given in most of the general 
 treatises on the art of surgery. 
 
 TJie pulley, through which the tendon of the superior oblique muscle 
 of the eye plays, is situated at the upper and inner angle of the orbit, and 
 in close proximity to the internal angular process of the frontal bone. 
 Care should always bo taken, in operating in the orbit, that this loop be 
 not severed, as the action of the superior oblique muscle would thus be tem- 
 porarily destroyed, and its permanent impairment rendered probable. 
 
 ' Blandin, op. cit. 
 
SPECIAL KEGIONS OF THE HEAD. 
 
 127 
 
 Abnormalities in the condition of tlie pupil, and deviations from the 
 normal power of vision dependent upon anatomical defects, have pre- 
 viously been considered, as far as anatomy has any direct bearing upon 
 them, in other articles of mine which treat of the second, third, fourth, 
 and sixth cranial nerves. ' 
 
 The lachrymal apparatus, which comprises the lachrymal gland, the 
 lachrymal canals, the lachrymal sac, and the nasal duct, often creates a 
 necessity for surgical interference in the region of the orbit. In those 
 
 Fio. 81.— Introduction of the lachrymal probe. (After Stellwag.) 
 
 •cases where the removal of the lachrymal gland is demanded, an incision 
 through the upper lid is usually made, and the gland is then dissected 
 from the surrounding parts. The loss of secretion of the gland is, in a 
 measure, supplied by the increased action of the conjunctiva; the mucus 
 secreted being generally sufficient to assist the action of the lid over the 
 eyeball. 
 
 In contraction of the puncta lachrymalia, the lachrymal canals, or the 
 nasal duct, it occasionally becomes necessary to either dilate them by a 
 probe or to wash them out by means of a syringe. In performing either 
 of these operations, that eyelid, in whose punctum the instrument is to 
 be passed, must first be drawn toward the temple, since by so doing the 
 normal curve of the lachrymal canal is straightened, and the introduction 
 
 ' See New York Medical Gazette, October 16th, 23d, 30th, 1880. A more com- 
 plete resume of the subject can be found in a late treatise by the author: The 
 Applied Anatomy of the Nervous System. N. Y., 1881. 
 
128 PEAOTIOAL MEDICAL ANATOMT. 
 
 of an instrument is thus greatly facilitated. If the canal is simply to be 
 washed out, the nozzle of the syringe (Anel's syringe is perhaps the best) 
 is introduced into tlie punctum and the fluid forced into the canal with 
 the finger, while the other punctum is compressed to prevent regurgitation. 
 If the fluid does not pass out of the syringe as freely as the orifice should 
 permit, withdraw the point a little, and, by again passing it forward, any 
 duplicature of the lining membrane of the canal may, as a rule, be easily 
 aToided. 
 
 In introducing a probe through the lachrymal sac and nasal duct, the 
 instrument should first be introduced with the handle of the probe paral- 
 lel with the border of the lids, and the point gradually moved toward the 
 inner canthus of the eye till it reaches the lachrymal sac. In some cases 
 incision of the larychmal canal may be required. The handle of the in- 
 strument should now be elevated from the horizontal to nearly a perpen- 
 dicular direction, when, on carrying the handle obliquely forward, the 
 point of the probe will pass readily through the nasal duct and escape 
 at the inferior meatus of the nostril. 
 
 It is a somewhat remarkable fact to a novice that a large probe will 
 pass with greater facility than a small one. This is explained by the 
 liability of a reduplication of the mucous lining of the canal, unless it be 
 fully distended. 
 
 The intimate nervous communication which exists between the nasal 
 mucous membrane and the lachrymal apparatus explains why irritation 
 of the nose is so frequently followed by an excessive flow of tears; and, 
 for that reason, any excessive action of the lachrymal gland should always 
 suggest to the surgeon a careful examination of the nasal cavity, in case 
 no cause can be discovered in the region of the orbit. 
 
 The passage of the third, fourth, ophthalmic branch of the fifth, and 
 sixth cranial nerves through the sphenoidal fissure, and of the optic nerve 
 through its own foramen, explains why any pressure created by abnormal 
 growths within the cavity of the orbit is so liable to be followed by symp- 
 toms dependent upon paralysis of some of these nerve-trunks, and, to one 
 familiar with the course of these nerves, such symptoms often indicate the^ 
 possible situation of the exciting cause. ' 
 
 KEGION OF THE MOUTH. 
 
 Within the cavity of the mouth, the bones which help to form it, the 
 mucous membrane which lines it, and the nerves and vessels which are 
 distributed to it, have been considered in previous pages and many prac- 
 tical points noted which will require but casual mention here, since they 
 can be referred to under each of these respective heads. The cheeks 
 
 ' For the symptoms created by pressure upon or destruction of these nerves, 
 the reader is referred to the late work of the author: The Applied Anatomy of 
 the Nervous System. N. Y., 1881. 
 
SPECIAL REGIONS OF THE HEAD. 
 
 129 
 
 tongae, tonsils, and soft palate, howeyer, present points of interest both 
 to the surgeon and medical practitioner. 
 
 In the child, the region of the cheek is particularly liable to gangre 
 nous and ulcerative processes, while, in the adult, tumors are not infre- 
 quent in this region. Its physiological functions, in the acts of respiration, 
 mastication, blowing, and sucking, are seriously impaired by any cause 
 which tends to create interference with the conducting power of thS fa- 
 cial nerve. 
 
 The situation of Steno's duct gives to wounds of the cheek a surgical 
 importance, since, if that duct be wounded, the escape of saliva between 
 the edges of the wound may create a salivary fistula upon the face, and 
 prove a source, not only of disfigurement and annoyance to the patient, 
 but one which it is often difficult for the surgeon to relieve. 
 
 Fig. 82.— The soft palate and tonsils, as seen from the mouth. 
 
 The tongue may present conditions of increase in its size as the result 
 of hypertrophy or tumors, which sometimes prevent mastication, and in 
 rare cases may so completely fill the mouth as to render breathing diffi- 
 cult. Its excessive vascularity renders wounds of the tongue a source of 
 serious hemorrhage, which frequently requires ligation of the lingual 
 artery; hence the caution given by surgical authors to inexperienced 
 opeirators in performing the trivial operation of the division of the frse- 
 num of the tongue in children. A peculiar condition of the tongue, in 
 which a furring of its lateral half is detected, may often be a point of 
 great diagnostic value, since it indicates irritation of some of the branches- 
 of the fifth cranial nerve or the glosso-pharyngeal nerve. Thus, Hilton 
 reports a case where furring of the posterior portion of the lateral half of 
 the tongue followed an attack of tonsillitis from irritation of the glosso- 
 9 
 
130 
 
 PKACTIOAL MEDICAL ANATOMY. 
 
 pharyngeal nerves; and another where the remoTal of a decayed molar 
 tooth caused the disappearance of a similar condition affecting the ante- 
 rior half of the lateral part of the tongue, which had for a long time with- 
 stood all other methods of treatment, since the irritation of the fifth 
 nerye had not been relieved. Bransby Cooper reports a case where the 
 furred tongue persistently remained upon one side after fracture of the 
 
 Fig. 83.— Sketch of a tongue furred only on the left side, resulting from a decayed and painful 
 second molar tooth in the upper jaw on the same side of the head. (After Eilton ) 
 
 base of the skull involving the foramen rotundum; and a similar case 
 recorded by Hilton was produced by disease of the Gasserian ganglion, 
 which was detected at the autopsy. Such cases as these cannot fail to 
 
 Fig. 84. Fig. 85. 
 
 Fig. 84.— Incisions in Eeg^ioli's operation. (After Hamilton.) 
 Fio. 85.— Tongue drawn out. (After Hamilton. ) 
 
 excite interest in the reader and to impress the importance of the bear- 
 ings of nervous distribution as an aid in diagnosis. ' 
 
 In operations for the removal of tumors of the tongue, if situated 
 
 ' Ranney, New York Medical Gazette, October and November, 1880. 
 
SPECIAI^ EEGIONS OF THE HEAD. 131 
 
 near to its base, an incision through the soft tissues forming the floor of 
 the mouth is sometimes required in order to permit the tongue to be 
 drawn below the chin and thus be more completely exposed. Care should, 
 however, be exercised, after the soft tissues have been divided, to pre- 
 vent the tongue falling or being drawn backward over the superior 
 opening of the larynx. This can be easily accomplished by passing a 
 loop of silk through the tip of the organ, by which its movements can be 
 easily controlled. 
 
 If we look beneath the tongue at the attachment of its frsenum, the 
 openings of the ducts of the sublingual glands can be perceived, and the 
 orifices of the submaxillary glands (ducts of Wharton) can be detected as 
 two small papillae on the anterior margin of the frsenum. A swelling is 
 often produced underneath the tongue by occlusion of the sublingual 
 ducts, to which the term " ranula " is applied, since such a tumor is nor- 
 mal in the frog. The saliva also sometimes deposits sabulous matter, and 
 gives rise to concretions, which are usually situated in the ducts them- 
 selves. 
 
 The palate is composed of two portions, the hard or bony structure 
 formed by the palate-plates of the superior maxillary and palate bones, 
 and the soft palate, which is composed of mucous membrane and muscles. 
 The soft palate extends across the back of the mouth from side to side, 
 being attached to the posterior margin of the hard palate above, while its 
 inferior or free margin presents, at its centre, the projecting uvula, which 
 is from half to three-quarters of an inch long in the healthy state. 
 
 The physiological action of the soft palate is chiefly confined to its 
 valve-like obstruction to the upper portion of the pharynx during the act 
 of deglutition, which thus prevents the regurgitation of food, and espe- 
 cially that of liquids, into the posterior nares during the contraction of 
 the constrictor muscles of the pharnyx. It also modifies to some extent 
 the intonation of the voice, as is demonstrated in those cases where it is 
 congenitally defective. It is abundantly supplied with mucous follicles, 
 which afford an anatomical explanation of the peculiar appearance which 
 that portion presents when inflamed, since it is then covered by an exces- 
 sive secretion of mucus, which frequently gives it a whitish color. 
 The muscles of the palate play an important part in its movements, and 
 in the various operations for fissure of the palate, a close study of the ac- 
 tion of these muscles is essential to a successful result; since, frequently, 
 some of them have to be divided in order to insure a close approximation 
 of the edges of the wound by suture. 
 
 The palate may be the seat of hypertrophy, as occurs chiefly in elon- 
 gation of the tonsil; of ulceration, as is particularly liable to occur during 
 the first stages of secondary syphilis, and in scarlet fever and small-pox; 
 and of tumors, both of the benign and malignant character. It may 
 be made to lulge forward into the mouth by nasal polypi which protrude 
 into the pharnyx, by fungoid gi'owths from the neighboring regions, or 
 
132 
 
 PBACTICAL MEDICAL ANATOMT. 
 
 by retro-pharyngeal abscess, which is usually dependent npon caries of the 
 cervical vertebrss. Perforation of the soft palate is liable to create con- 
 siderable difficulty in the swallowing of liquids, in case the abnormal open- 
 ing be of appreciable size. Most of the movements of the soft palate are 
 produced by means of the glosso-pharyngeal nerve, or branches from 
 Meckel's and the otic ganglion. Paralysis of the soft palate is therefore 
 sometimes associated with paralysis of the pharyngeal, lingual, and labial 
 muscles; hence, deglutition and articulation often become simultane- 
 ously embarrassed. 
 
 Many points of interest pertaining to the hard palate have been already 
 given in connection with the bones," and need not be repeated here. 
 
 The tonsils are small bodies situated between the anterior and poste- 
 
 FiQ. 86.— Complicate hare-lip. (After Buck.) 
 
 rior pillars of the fauces upon either side. They contain a central cavity, 
 and are in close relations to some of the large vessels of the neck. Dur- 
 ing attacks of chronic inflammation, or, repeated attacks of quinsy, sore 
 throat, effusions of lymph into the parenchymatous structure of these 
 glands sometimes produce an induration and permanent enlargement, 
 which may be mistaken for scirrhus. The continuance of such an en- 
 largement being a source of constant irritation, renders these patients 
 extremely liable to inflammation of the throat on the slightest change of 
 temperature; and, to relieve the sensibility, after the failure of all 
 other means, an operation for their removal may become necessary. Sup- 
 puration within the tonsil, especially of both sides, if simultaneously 
 attacked, may so close the fauces as to render deglutition impossible and 
 even respiration difficult, unless the accumulated pus be evacuated by 
 incision. The famous case reported by Desault, in which the carotid ar- 
 
 ' See pages 33 and 23 of tliis volume. 
 
SPECIAL EEGIONS OF THE HEAD. 133 
 
 tery was punctured by an incision made into the tonsils, should lead all 
 careful surgeons to remember that, in case extirpation of the tonsil be 
 attempted, only that portion should be excised which projects beyond 
 the free harder of the stylo-glossus muscle, and that incisions should 
 always be made with extreme care. 
 
 The occlusion of the ducts which open into the cavity of the tonsil 
 may sometimes result in the formation of calculi within the gland, as 
 was first described by Celsus. 
 
 The modifications of the teeth produced by congenital syphilis have 
 been made the subject of careful observation by Jonathan Hutchinson. 
 He writes: It is very common to find all the incisor teeth dwarfed and 
 
 Fio. 87.— Enlarged tonsils and elongated uvula. 
 
 malformed. Sometimes the canines are affected also. These teeth are 
 narrow, and rounded, and peg-like; their edges are jagged and notched. 
 Owing to their smallness, their sides do not touch and interspaces are 
 left. It is, however, the upper central incisors which are the most relia- 
 ble for purposes of diagnosis. When the other teeth are affected, these 
 very rarely escape, and very often they are malformed when all the others 
 are of fairly good shape. The characteristic malformation of the upper 
 central incisors consists in a dwarfing of the tooth, which is usually both 
 narrow and short, and in the atrophy of its middle lobe. This atrophy 
 leaves a single broad notch (vertical) in the edge of the tooth; and 
 sometimes from this notch a shallow furrow passes upward on both 
 anterior and posterior surface nearly to the gum. 
 
 This notch is usually symmetrical. It may vary very much in degree 
 in different cases; sometimes the teeth diverge, and at others they slant 
 toward each other. In any case in which this malformation was as 
 marked, I should feel no hesitation in pronouncing the possessor of 
 
134: 
 
 PKACTICAi MEDICAL ANATOMY. 
 
 the teeth to be the subject of inherited syphilis, even in the abseijce of 
 any other testimony. I hare neyer yet seen such teeth, excepting in 
 patients of this class. In the majority of cases, however, the condition 
 of the teeth is only sufficient to excite suspicion, and not to decide the 
 question. 
 
 The remoyal of portions of the superior maxillary bone, or, in severe 
 cases, of the bone itself, is demanded by the growth of tumors, usually of 
 a fungous or malignant character, and their encroachment on the sur- 
 rounding bony structure of the mouth. Probably the earliest reference to 
 the removal of this bone which is known to have been recorded is that of 
 Acoluthus, a surgeon of Breslau, who is stated by Gensoul' to have remov- 
 ed a portion of the upper jaw on account of a tumor in 1693, although 
 Jourdan, in 1768, removed a portion of the antrum, and Dupuytren, in 
 1830, a portion of the alveolar process of the bone. This operation may 
 
 Fio. 88.— Hypertrophy of lower Up. 
 
 be demanded as a means of relief for extensive disease of the antrum 
 which depresses the roof of the mouth; for large polypi of the nose, as is 
 reported by Mott in "Velpeau's Surgery;" and for extensive necrosis or 
 malignant growth. The severity of the operation and the deformity 
 which must ensue if the entire bone be removed, renders it evident that 
 this operation should never be performed except in cases where no other 
 means of relief is possible. 
 
 The lower jaw may be resected either partially or entire, although the 
 latter operation may justly be regarded by surgeons as a most formidable 
 
 ' Paris, 1833. 
 
speciaij eegions of the head. 
 
 135 
 
 one. It was first performed by Graefe and Walther of Bonn, and 
 lias since been repeated by Dupuytren, Delpech, Oarnoclian, and others ; 
 but it is still a question whether the evils resulting from the loss of the 
 entire inferior maxilla should not forbid its use. 
 
 In those instances where extensive necrosis of the lower jaw has 
 occurred from phosphorus poisoning, or where tumors have so involved 
 portions of the bone as to impair its usefulness or endanger other parts, a 
 partial resection of bone will often accomplish relief with less difficulty 
 to the surgeon than if the entire bone be removed, and with far less evil 
 to the patient. 
 
 In consequence of the effect of fissure of the hard palate upon the 
 tone of the voice, as well as upon the enunciation of words, it becomes 
 desirable to attempt its closure by uniting the two halves as soon as the 
 individual is able to assist the operator in the efforts required for its 
 execution; but in those extreme cases where such union is impossible, 
 mechanical appliances can often be made which will, to a certain extent, 
 obviate the annoyances of the deformity. 
 
 False anchylosis of the lower jaw, dependent upon cicatrization or 
 contraction of the soft parts, may exist to such an extent as to demand 
 subcutaneous division of the masseter muscle. A case was reported by 
 Dr. Schmidt, in 1841, where a young lady, in consequence of an exten- 
 sively ulcerated throat when a child, had not been able to open her 
 mouth for a period of twelve years, so that the end of the little finger 
 could be inserted, and where recovery followed the division of the 
 masseter muscle. Dr. Mott, in his edition of " Velpeaa's Surgery," treats 
 of this condition for the first time as a special type of disease, and 
 reports seventeen cases where the. condition was treated by forcible 
 dilatation by various mechanical devices. 
 
 It may be advisable in this connection to call attention to one 
 of the axioms of John Hilton in reference to the nervous association 
 which exists between the joints and the muscles which move them,' since 
 by this useful guide some local seat of irritation may possibly be detected 
 in such cases which will account for fixation of the jaw, and, when pro- 
 perly relieved, may be followed by a complete return of mobility without 
 recourse to severer methods. This would, of course, not apply to any 
 form of fixation dependent upon cicatricial tissue. 
 
 ' Every nerve distributed to the muscles which move a joint sends a filament 
 to the joint itself, and supplies the integument over the insertion of each of the 
 muscles which move it. 
 
136 PEACTICAL MEDICAI, ANATOMY. 
 
 PART II. 
 
 CHAPTER I. 
 
 THE TRUNK. 
 
 The bony framework of the trunk serves as a connecting link 
 between that of the iipper and lower extremities, while it also serves to 
 support the head. It must be evident also, to any one who studies the 
 design of Nature in the general plan of construction of the human 
 frame, that this part of the body serves many purposes; and there is 
 hardly an isolated portion which is not suggestive of the wonderful 
 adaptability of man to the various acts which he is called upon to 
 perform. This parb of the skeleton affords protection to the spinal 
 cord and all of the viscera; the large arterial trunks; the veins which 
 convey the blood from the extremities, the abdominal and pelvic 
 viscera, the head and lungs, to the chambers of the heart; the impor- 
 tant nerves which govern the movements necessary to respiration and 
 the functions of the viscera; and the lymphatic vessels, which are con- 
 cerned in the process of absorption of the nutritive elements of the food. 
 To its numerous surfaces and bony points are attached some of the most 
 important muscles, which are not only designed to act in harmony with 
 the muscles of the extremities in preserving the equilibrium of the body 
 and in the proper performance of locomotion, but also to directly assist in 
 the respiratory act, in parturition, in the act of vomiting, and in the eva- 
 cuation of the normal secretions, when any obstruction to their free escape 
 exists. The lower portion of the trunk, the bony pelvis, is so modified 
 from the type of the lower animals as to afford support as well as protec- 
 tion to the organs of the abdomen, while the vertebral column is a source 
 of constant wonderment to the anatomist from the beauty of its construc- 
 tion and the simplicity of its arrangement. 
 
 In studying the bones of the trunk, the vertebral column will first be 
 considered, then the bones of the thorax, and finally the bones of the 
 pelvis. It will be perceived that the cervical region of the spine, as well 
 as the structures whicli enter into the formation of the neck, are treated 
 of as portions of the trunk rather than as a separate anatomical region, 
 since many of its organs are properly but parts of the thoracic viscera 
 and the alimentary canal, and since its vessels can be studied to better 
 advantage, in their practical aspects, by grouping them with the larger 
 
THE VERTEBRAL COLUMN. 
 
 137 
 
 trunks from which they spring or into which they empty. Furthermore, 
 the nerves of the neck are, in a measure, those also of the trunk, since 
 their most important actions are confined to parts below the superior 
 opening of the thorax,, and to treat of 'only a limited portion of each 
 would tend to create confusion and possibly to impair the general utility 
 of the plan of this work. 
 
 After considering the bony frame-work of 
 the neck, thorax, abdomen, and pelvis, those 
 special clinical points pertaining to each of . 
 these regions in which anatomy has any spe- 
 cial bearing, will be discussed. Thus, the 
 external landmarks to all of the important 
 structures will be given: the modifications 
 from the normal contour of special regions, 
 which are indicative of disease, and may 
 prove of value to the diagnostician; the 7nus- 
 cles, and their physiological actions and sur- 
 gical importance; and the course of the cuta- 
 neous nerves, where pain, as a symptoni, is 
 an anatomical guide to disease of certain 
 well-defined localities. 
 
 THE VERTEBRAL COLUMK 
 
 The intermediate link, which serves to 
 coAnect the head with the bones of the lower 
 extremity, consists of a series of bones called 
 "vertebraB,"' since they allow of the bending 
 and turning of the body, and two lateral 
 bones, the ossa innominata, which are inter- 
 posed between the spinal column and the femur 
 of either side. The vertebrae are so articu- 
 lated together as to form three graceful curves, being bent forward in the 
 region of the neck, backward in the region of the chest, and again for- 
 ward in the loins. Between each of these bones is interposed a plate of 
 cartilage (the intervertebral disks), whose functions are to act as so many 
 
 Fig. 89.— Lateral view of the 
 bony skeleton of the trunk. 
 
 'The number of the vertebrse is given by different authors as twenty-four 
 and twenty- six. If the latter number be taken, the sacrum and coccyx are 
 included, which are properly parts of the pelvis. The twenty-four vertebrae 
 comprise seven cervical, twelve dorsal, and five lumbar. The length of the neck 
 cannot be used as a means of approximately estimating the number of cervical 
 vertebrse in animals, since Flower states, in his work on the Osteology of the 
 Mammalia, that the whale, which apparently has no neck, has the same number 
 as the giraffe. 
 
138 
 
 PKACTICAL MEDICAL ANATOMY. 
 
 elastic springs which shall tend to break the force of any shock trans- 
 mitted to the vertebral column and thus to the head. In the whale, 
 these disks are of extreme size, and are often found upon the seashore of 
 northern countries, having become separated from the vertebrae and thus 
 carried to the beach. Cases are reported where they have been used by 
 shipwrecked sailors as plates.' The curves of the vertebral column 
 
 >'Vi 
 
 
 Fig. 90. Fig. 91. 
 
 Fig. 90.— The spinal column as seen from the left side. C 1 to 7, the seven cervical vertebrae; 
 D 1 to 18, the twelve dorsal vertebrae; L 1 to 5, the five lumbar vertebrae; S 1, the sacrum; Co 1 to 
 4, the four bones of the coccyx. 
 
 Fig. 91.— The spinal column as seen from behind. The same figures and letters of reference as 
 in cut No. 90 are used. 
 
 serve the following purposes: (1), they contribute to the wonderful 
 
 ' Queckett: Lectures on Histology. London, 1853. 
 
THE VEETEBEAL COLUMN. 139 
 
 strength of the spine,' since its curres are alternating; (3), they convert 
 the spine into an elastic structure and thus afford a springy pillar upon 
 which the head shall rest, rendering the danger of severe jarring of the 
 brain a minimum;" (3), the curves are so arranged as to favor the lodg- 
 ment of organs, since the cavity of the chest is greatly enlarged thereby, 
 and the weight of these organs is still kept within the line of the centre 
 of gravity — a fact to be considered in the arrangement of muscles, as 
 less power is required to preserve the proper balance; (4), the curves 
 are so gradual as to prevent the possibility of compression of the spinal 
 cord, which might occur were there are any abrupt angles to the canal ; 
 (5), the curve of the cervical and dorsal regions adds greatly to the 
 beauty of outline of the body, while the cervical curve facilitates the 
 movements of the neck. 
 
 The curves of the vertebral column are due, in great measure, to the 
 variations in thickness of the intervertebral fibro-cartilages, but partly 
 also to the relative thickness of the bodies of the vertebrae of the differ- 
 ent regions, and to the tension exerted by the ligamenta subflava, which 
 connect the laminte of the different vertebrae together. 
 
 The spinal column is capable of movement in one of four directions, 
 viz., flexion, extension, lateral movement, and torsion. The first two are 
 freest in the neck, least free in the dorsal region, and less free in the 
 loins than in the neck. This is largely due to the fact that the spines of 
 the dorsal vertebra overlap each other, particularly from the fourth to 
 the eighth, and that the articular processes of the dorsal vertebrae are 
 nearly perpendicular, so that movement is prevented; while, in the cervi- 
 cal region, the articular processes are oblique, the intevertebral disks 
 thick, and the spinous processes of the third, fourth, and fifth are pur- 
 posely made short and horizontal. The lumbar vertebrae have also thick 
 intervertebral disks, which allow of movement between their spinous 
 processes; and the articular processes are so placed as to allow of a limited 
 liiovement. Flexion and extension of the spine are freest between the 
 third and sixth cervical vertebrae, between the eleventh dorsal and 
 second lumbar, and again between the last lumbar vertebra and the 
 sacrum.' The lateral movements of the spine are very free in the neck, 
 so as to allow of an easy carriage of the head, and in the loins, so as to 
 permit of movement of the trunk. The movement of rotation of the 
 spine is confined almost exclusively to the lumbar region, and it is this 
 power of movement that enables the head to be rotated beyond the 
 
 ' EoUin and Magendie have mathematically calculated the value of these 
 curves, and estimate the strength of the coluam aa sixteen times that of a 
 straight one. 
 
 ^ Holden: Human Osteology. London, 1878. 
 
 * In cases of tetanus, or in those feats of the acrobat where the body is made 
 to rest upon the head and the heels alone, this point is admirably shown. 
 
140 
 
 PEACTIOAL MEDICAL ANATOMY. 
 
 ability of movement of the atlas upon the axis, through a participation 
 of the trunk. ' 
 
 The intervertebral disks are soft and of a pulpy consistence in the 
 central portion, but firm at the edges, and they thus tend to form a ball- 
 and-socket joint which permits of a certain amount of movement in 
 every direction between the vertebrae which they separate. By the 
 weight of the body they are compressed, so that at night the height of an 
 individual is often diminished some fraction' of an inch from the 
 
 measurement taken after a night's repose.' 
 
 Upon each side of the spines of the verte- 
 brae may be perceived a deep groove ' for the 
 strong muscles of the back. If we look 
 at the spinal column from the front, we 
 can perceive that the transverse processes 
 of the atlas are very long, so that the 
 muscles which rotate the head can gain 
 additional leverage. An enlargement of 
 the column can be detected at the lower part 
 of the cervical region, so as to form an ex- 
 panded base for the neck, and a diminution 
 in the width of the column can be detected 
 in the dorsal region in order to afford more 
 room for the lungs. A slight lateral curva- 
 ture in the dorsal region may often be per- 
 ceived, which is attributed by some authors 
 to the excessive use of the right arm, since 
 its concavity is usually toward the left side. 
 This point should be remembered as a fre- 
 quent and natural deformity, when diagnos- 
 ing a lateral curvature as the result of dis- 
 
 Fio. B2. —Lateral curvature 
 and rotation. (After Hamilton.) 
 
 ease. 
 
 Along the entire length of the spinal column, on its posterior aspect, 
 the spinous processes form a prominent bony ridge, which may be felt 
 through the skin of the back even in the fattest people, and which is occa- 
 
 ' Holden suggests an admirable way to demonstrate this point : "Sit upright, 
 with your head and shoulders well applied to the back of a chair; the head and 
 neck can be rotated to the extent of 70°. Lean forward, so as to let the lumbar 
 vertebrae come into play; you can then turn your head and neck 30° more." 
 
 ' This diminution in the height may vary from a scarcely perceptible shrink- 
 age to one-third, or even one-half of an inch. 
 
 ' A habit of leaning toward one side may make a permanent deformity by 
 destroying the elasticity of these cartilages. Thus, a distortion of the spine may 
 not always indicate disease. 
 
 * This groove is narrowest at the junction of the last dorsal and first lumbar 
 vertebrae (the weakest part of the back), and widest at the sacrum. 
 
THE VEKTEBKAL COLUMN. 
 
 141 
 
 sionally prominent during life. It will he noticed that the spine cannot 
 be felt in the cervical as distinctly as in the dorsal and lumbar 
 regions, for the following reasons: (1) on account of its curve, (2) on 
 account of the attachment of an elastic ligament (the ligamentum 
 nuchae) which extends from the head to the last cervical Tertebra, and 
 assists the muscles in supporting the head at a right angle to the spine, (3) 
 from the fact that the spines of the third, fourth, and fifth cervical ver- 
 tebra are made shorter than the rest so as to admit of free extension of 
 the neck, (4) on account of the muscles which tend to render the long 
 spine of the axis less prominent than it would otherwise be. In a mus- 
 cular subject, the spines of the vertebrae of the dorsal and lumbar regions, 
 instead of being prominent as they are in the skeleton, lie in a median 
 
 Fig. 
 
 Fig. 94. 
 
 Fig. 93.— Fully developed caries. (After Hamilion.) 
 Fig. 94.— Lateral curvature. (After Hamilton.) 
 
 depression or groove, which extends the entire length of the back and 
 is caused by the prominence of the erector spinas muscles upon either 
 side of the spines. 
 
 The vertebrcB as surgical guides. 
 
 It frequently happens that it is desirable to determine the exact sit- 
 uation of some special Tertebra, since valuable guides are thus obtained to 
 important structures; this can be done most readily by first applying 
 sharp friction along the groove over the spinous processes of the vertebrae. 
 
142 PKAOTIOAL MEDICAL ANATOMY. 
 
 ■when tlie points of the spines will be made prominent as small red marks 
 (since they come close to the skin), and can then be readily counted. 
 
 There are certain vertebrae which are of special yalue to the physi- 
 cian, since they stand as landmarks to guide him to the seat of other 
 parts of the body. Thus, the third cervical vertebra corresponds to the 
 following parts: (1) the opening of the larynx,. (2) the bifurcation of the 
 carotid artery, (3) the point of origin of both the external and internal 
 carotid arteries, (4) the situation of the superior cervical ganglion of the 
 sympathetic nerve. The fifth cervical vertebra is a guide to the following 
 parts: (1) the lower opening of the larynx, (2) the beginning of the tra- 
 chea, (3) the lower end of the pharynx, (4) the upper opening of the 
 oesophagus, (5) the middle cervical ganglion of the sympathetic nerve. 
 Finally, the second lumbar vertebra corresponds to the following parts: 
 (1) the termination of the duodenum, (2) the commencement of the je- 
 junum, (3) the lower border of the pancreas, (4) the upper root of the 
 mesentery, (5) the point of origin of the superior mesenteric artery, (6) 
 the commencement of the thoracic duct, (7) the opehing of the ductus 
 communis choledochus into the intestine, (8) the coTnmencement of the 
 vena porta, (9) the termination of the spinal cord, (10) the point of origin 
 of the Cauda equina, (11) the attachment of the crura of the diaphragm, 
 and (12) the situation of the receptaculum chyli. 
 
 In addition to these three vertebrse, which are of special value as 
 guides to more than one part of the body, may be mentioned the seventh 
 cervical, whose long spine is a guide to the level of the apex of the lung 
 in the male, since, in the female, it extends higher up; the third dorsal 
 at whose level the aorta reaches the spinal column, the trachea bifurcates, 
 and the apex of the lower lobe of the lung is found; the eighth dorsal, 
 which indicates the lower level of the heart and that of the central tendon 
 of the diaphragm; the ninth dorsal, at which level the upper edge of the 
 spleen is found in health, and where also the oesophagus and vena cava pass 
 through the diaphragm; the tenth dorsal, which corresponds to the lower 
 edge of the lung, the spot where the liver comes to the surface posteriorly, 
 and the situation of the cardiac orifice of the stomach; the eleventh dor- 
 sal, guiding the student to the normal situation of the lower border of 
 the spleen, and to the upper part of the kidney; the twelfth dorsal, which 
 marks the lower limit of the pleura, the passage of the aorta through the 
 diaphragm, and the situation of the pyloric end of the stomach; the 
 first lumbar where the renal arteries are given oS., and where the pelvis 
 of the kidney may be found; the third luiJibar whicli corresponds to 
 the level of the umbilicus, and the lower border of the kidney; and, 
 finally, the fourth lumbar which marks the point of bifurcation of the 
 abdominal aorta into the two common iliac arteries, and which lies on 
 a level with the highest part of the ilium. 
 
 It may be of value to the physician in examining the chest, or endeav- 
 oring to locate the exact situation of any particular point upon the chest, 
 
THE ■VEETEBEAL COLUMN. 
 
 143 
 
 to remember that the spine of the tliivd dorsal vertebra is on the same 
 level as the commencement of the spine of the scapula; that the spine of 
 the seventh dorsal vertebra lies on a level with the inferior angle of that 
 bone; and, finally, that the spine of the last dorsal vertebra is on the level 
 with the head of the last rib, which may be used as a guide to certain 
 surgical operations, upon some of the abdominal viscera. 
 
 Between the difEerent vertebrte are placed /oramiMa, through which 
 the spinal nerves escape from the spinal canal to reach the parts which 
 each is destined to supply. It is often useful to know the vertebrse, oppo- 
 site to which the nerves of any special region arise from the spinal cord, 
 since the point of origin does not always correspond to the foramina of 
 escape. The following guides may be furnished by the vertebrse, to 
 locate the seat of lesions of the spinal cord, which are affecting any special 
 nerves or sets of lierves. 
 
 Fig. 95.— Side-view of chest, showing the course of the sixth and seventh dorsal nerves, a, 
 course of the sixth nerve ; b, course of the seventh nerve. ''After Hilton.) 
 
 The interval between the occiput and the sixth cervical spine, marks 
 the limits of origin of the eight cervical nerves; that between the sixth 
 cervical and the fourth dorsal spine,' marks the origin of \kiQ first six 
 dorsal nerves; between the eleventh and twelfth dorsaj spines, the five 
 ■ lumbar nerves arise as tli^ upper part of the cauda equina; while the 
 origin of the five sacral nerves corresponds to a single vertebra, the 
 twelfth dorsal spine. ♦ 
 
 ' It should be remembered that the spines of the vertebrce are not always in a 
 precisely straight line, but that in persons possessing the greatest strength, an 
 occasional deviation of single vertebrae, either to the right or the left, may exist. 
 It is by knowing these natural defects that we can guard ourselves against error 
 in diagnosis. 
 
Ui 
 
 PEACTIOAL MEDICAL ANATOMY. 
 
 The spinal canal which is inclosed by 
 the vertebrse extends throughout the en- 
 tire length of the spinal column, and 
 contains the spinal cord, and the lumbar, 
 sacral, and coccygeal nerves, after the 
 spinal cord has terminated in the cauda 
 equina. The vertebrse so overlap each 
 other, posteriorly and at the sides, that 
 it would be extremely difiScult for any 
 cutting instrument to injure the spinal 
 cord, except between the occiput and the 
 arch of the atlas, where animals are usual- 
 ly "pithed,"' and in the lumbar region, 
 where a cutting instrument might possi- 
 bly injure the lumbar or sacral nerves. 
 The spinal canal is larger in the neck and 
 the luonbar regions than in the dorsal, 
 which fact is explained on two grounds: 
 first, because there are two enlargements 
 present on the spinal cord (where the 
 large nerves of the upper and lower ex- 
 tremities arise), which demand increased 
 space, and second, because the dorsal , 
 region does not admit of much motion, 
 and therefore the spinal cord requires 
 less room to insure its safety from pres- 
 sure than in the neck, or lumbar regions, 
 where the movements of the spinal col- 
 umn are more extensive. 
 
 The vertebrse are so interlocked, by 
 their spinous and articular processes, as 
 to render the danger of dislocation of any 
 bone extremely slight; in fact such an 
 accident would be impossible in the dorsal 
 and lumbar regions without- a fracture of 
 the processes having first occurred; but, 
 in the cervical region, such cases have 
 been reported, and specimens of it are 
 
 Fig. 96.— Longitudinal section o£ a head, spine, etc., on right side of the median line. (After 
 Hilton.) The body recumbent, a, pons Varoli^; b, medulla oblongata; c, spinal marrow, terminat- 
 ing opposite the space between the first and second lumbar vertebrte; d, base of the skull formed 
 by occipital and sphenoid bones; e, atlas, or first cervical vertebra; /, axis, or second cervical ver- 
 tebra, with its ascending or odontoid process interposed between the altas and the medulla oblon- 
 gata; TO, thin pillow placed under occiput; n, thicker pillow, supporting the hollow of the neck, 
 so as to prevent the second vertebrafallingbackwardupon the medulla oblongata; o, six lumbar 
 vertebrcB as found in the body dissected; p, sacrum. 
 
 ' The deficient bony protection of the medulla oblongata between the occiput 
 
THE VEBTEBEAL COLUMN. 
 
 145 
 
 shown in some of the larger collections of osteological curiosities. 
 Sudden and forcible rotation of the neck may be followed by such a dislo- 
 cation, and Boyer reports a case where a lawyer was made the victim to 
 this accident in attempting to see a person entering a door behind his 
 chair. 
 
 The excessive length of the transverse processes'ot the atlas afEords one 
 of the many examples of a provision of Nature to increase the leverage 
 of muscles and thus to add to their power, since the inferior oblique 
 muscles of the neck are thus enabled to rotate the head with grfeater ease 
 than if the transverse processes were of the same length as those of the 
 other cervical vertebrae. 
 
 Fig. 97.— Sketch of a dissection, showing the head falling forwards, as happens in some cases of 
 destruction of the ligaments, associited with disease of the joints between the atlas and aids and 
 occipital bones. The head and atlas inclining forward, and leaving the second vertebra in its 
 proper position, crush the medulla oblongata upon the odontoid process of the second vertebra, 
 and so cause sudden or instant death; a, pons VaroUi; 6, medulla oblongata; c, spinal marrow; d, 
 base of skull, formed by occipital and sphenoid bones; e, atlas, or first cervical vertebra; /, axis, 
 or second cervical vertebra, with its ascending odontoid process. These bones are here shown 
 widely separated, as the result of the division of the ligaments between them. (After Hilton.) 
 
 The transverse ligament, which serves to retain the odontoid process 
 of the axis in close relation to the atlas, is an important structure, since 
 it protects the medulla oblongata from the pressure upon it which would 
 otherwise be exerted by that process of bone when the head is bent for- 
 ward; hence the fatal consequence of rupture of that ligament when 
 
 and the atlas seems to be known among the criminal classes, as several murders 
 have been perpetrated by forcing an instrument through this interval. (Blandin.) 
 10 
 
146 PRACTICAL MBDICAL ANATOMY. 
 
 hanging is scientifically performed upon a criminal. In spite of the 
 strength of this ligament and the deep groove in the odontoid process in 
 which it fits, it occasionally slips out of its place with fatal results to 
 the patient. Such a case is reported by Petit ' of a child that was killed 
 by being lifted by the head, while Holden '' reports another, where a lady 
 was carrying her child upon her shoulders, and the child, losing its bal- 
 ance, clung to the mother's neck in falling, and drawing it suddenly back- 
 ward, caused instantaneous death of the mother from rupture of this liga- 
 ment. Such displacement is more liable to occur in the child than in the 
 adult, since the ligaments are weak and liable to be more relaxed." 
 
 The seventh cervical vertebra has, in rare instances, a cervical rib de- 
 veloped in connection with it, which is analogous to the cervical ribs 
 found in some animals; such an abnormality has been mistaken for a 
 bony tumor of the vertebral column, as it is not often movable, being 
 frequently attached to the first rib, when present. 
 
 In the sacral region, the posterior sacral foramina are directly opposite 
 to the anterior openings, so that it is possible for a pointed instrument to 
 enter the cavity of the pelvis and thus wound some of the pelvic viscera; 
 while the spinal canal is also incomplete posteriorly in the lower part of 
 that bone, which thus enables the putrid secretions of bed-sores to enter 
 that canal and create symptoms of spinal inflammation. 
 
 POINTS OF CLINICAL INTBBEST PERTAINING TO THE VEKTEBEAL 
 
 COLUMN. 
 
 The number of the cervical vertebrae may, in rare cases, be decreased 
 to six; this is one of the numerous evidences which the human frame 
 often shows, of a tendency to return to the type of the lower animals, 
 since only one mammal ■* has more than seven vertebrae. Although the 
 neck may appear to be long, in phthisical subjects, and short in those of 
 a full habit, the variation is due chiefly ° to the shape of the upper por- 
 tion of the body, which resembles the condition present after a full in- 
 spiration in those where the neck is short, while it is comparable to the 
 condition of the healthy chest after a full expiratory effort in those 
 where the neck is long. It was formerly and still is believed by some 
 that the shortness of the neck indicates an additional danger to the sub- 
 ject from apoplexy in later life; basing this belief on the fact that the 
 
 ■ As quoted by Holden and others. 
 
 ^ Human Osteology, London, 1878. 
 
 ^ In addition to this explanation, Blandin mentions an anatomical fact pertain- 
 ing to the odontoid process of the axis, which may prove an important factor in 
 this accident; viz., that it is much shorter in the child than in the adult and thus 
 more I'eadily allows the transverse ligament to slip over its apex. 
 
 •• The " bradyphus tridaetylus." 
 
 " It may be also due to an increase in the thickness ot the intervertebral disks 
 and the bodies of the vertebrse themselves. 
 
THE VEETEBBAL COLUMN. 
 
 147 
 
 head is thus brought more closely in 
 relation to the heart, and the capil- 
 lai'y vessels of the head are there- 
 fore subjected to a greater pressure 
 than if the head were more widely 
 separated from the trunk. 
 
 In advanced age, the movements 
 of the s}nne often become seriously 
 impaired, especially in the region of 
 the neck, on account of a rigidity of 
 the muscles which act upon the ver- 
 tebrae. In the aged and also in the 
 very young, caries of tlie cervical 
 region of the spinal column is not 
 an uncommon afEection; and, as pus 
 usually forms at the seat of the cari- 
 ous process, the pharynx is apt to be 
 partially or even completely occluded 
 by the bulging forward of a soft fluc- 
 tuant tumor, and thus serious dys- 
 pnoea may ensue unless the pus be 
 evacuated. It may be safely stated 
 that a large proportion of the so- 
 called " retro-pharyngeal abscess" 
 which is met with in the ordinay 
 practice of the physician, due to 
 this carious process, is confined chiefly 
 to the cancellous tissue of the bodies 
 of the cervical vertebrae. 
 
 The spinal column may present 
 congenital, as well as acquired mal- 
 formations. Cases have been report- 
 ed where the upper half of the cervi- 
 
 FiG. 98.— The condition of spina bifida. (After 
 Hilton.) a, dura mater; 6, external arachnoid; 
 c, internal arachnoid; d, space occupied by cere- 
 bro-spinal fiuid ; e, torcular Herophili ; /, spina 
 biiida tumor; g, spinal marrow closely invested 
 by pia mater; h, separate ligaments fixing tlie 
 anterior parts of dm-a mater to the second, third, 
 fourth, and fifth portions of sacrum. (There are 
 other delicate ligaments passing separately from 
 the posterior part of the dura mater to the arches 
 of the sacrum and lumbar vertebras, not shown 
 in this sketch. The considerable space which 
 exists naturally between the dura mater and , AM/Si 
 
 the vertebras, occupied by the rachidian veins and CjK- 
 
 areolar tissue, is also omitted.) t, in the transverse section, indicates the position of the spinal 
 nerves entering their dura-matral sheath. The posterior halt of the dura mater is accurately vej- 
 resented as much thicker than the anterior half; its structure is more dense and more elastic. 
 
14:8 
 
 PEACTIOAl MEDICAL ANATOMY. 
 
 cal region of the spinal column has been found wanting at the time of 
 birth — a condition to which Beclard applies the term " atrachelo-cepha- 
 lia;" also, where the entire cervical region has been wanting, as well as the 
 upper extremities — a condition called by the same author "abrachio- 
 cephalia." The spinous processes of the Tertebrse may be deficient at the 
 time of birth — ^the condition of " spina bifida " — and a tumor, whose size 
 depends upon the extent of the imperfection in the spinal column, will 
 be presented in the median line of the trunk, posteriorly, which will be 
 fluctuant, as a rule, since it will contain the cerebro-spinal fluid. The 
 free communication which the cerebro-spinal fluid has with the ventricles 
 of the irain ' will explain why pressure over these tumors is apt to cause 
 brain symptoms, and why injections of medicinal agents into the cavity 
 of the tumor is certainly a questionable procedure, and one of great 
 danger. 
 
 ANTERIOR. 
 
 POSTERIOR. 
 
 Fig. 99.— This diagram lias been introduced to sliow the arrangement of the different membranes 
 and spaces as they are beUeved to exist in the spinal column ; 1, 1, dura mater passing down to end 
 on the sheath of the nerves; 3, 2, layers of arachnoid forming, 3, cavity of arachnoid; 4, 4, pia 
 mater ending on nerve-sheath; B, B, ligamentum dentioulatum; 6, gray matter of spinal cord; 7, 
 delicate areolar tissue found in the sub-arachnoid spacebetween the arachnoid and pia mater; 8, 
 anterior and smaller, 9, posterior and larger, roots of spinal nerve; 10, 10, similar tissue to 7. 
 (After HUton.) 
 
 Fracijires of the verteircB may result from direct injuries to the spine, 
 or from a force indirectly applied, as in case of falls upon the feet, knees, 
 pelvis, or head. In the first set of causes, viz., those producing fracture 
 from direct violence, the injury is, of necessity, received upon the hack; 
 since the spine is most thoroughly protected in front by the soft tissues. 
 
 ' The cerebro-spinal fluid performs for the cerebro-spiaal axis (the brain and 
 spinal cord) the functions: (1) of diverting the vibratory motions of the bones of 
 the skull from the brain, in case of violence being perceived; (3) it isolates the va- 
 rious nerves passing through the same cranial foramina; and (3) it regulates the 
 internal pressures required to properly counterbalance the blood-pressure in the 
 vessels of the brain and cord, and thus tends to bring back the internal ganglia 
 of the brain to a state of quiescence after their state of vascular activity. 
 
THK VEBTEBEAL COLUMN. 
 
 149 
 
 This class of injury, almost without exception, results in a complicating 
 dislocation of the vertebrae in addition to the fracture received, since the 
 anterior ligamentous attachments of the bodies to each other are rup- 
 tured by the direct force of the blow^ which causes an alteration of the 
 spinal curve; while at the same time the spinous processes and the 
 laminae of the vertebrae are comminuted, on account of the compression 
 exerted in endeavoring to resist such an alteration of the spinal axes. 
 
 In the second class, viz., those forms of fracture dependent upon a 
 force applied indirectly to the spinal column, the fracture is found to be 
 situated, as a rule, at a distance from the point where the force was ap- 
 plied. Dislocation of the vertebrae will generally be absent in this class 
 of fracture, but the articular processes will be often comminuted, and the 
 spinous and transverse processes frequently broken. In very severe 
 cases, however, where the force transmitted through the spinal column 
 
 Fig. 100. Double lateral curve. (After Hamilton. Fiq. lOi.—Quadruple lateral curve. (After 
 
 Hamilton.) 
 
 is of a violent character, the hodies of the vertebra may be com- 
 minuted (although the amount of cancellous tissue in their interior ena- 
 bles them to stand great compression without comminution), and thus a 
 most serious form of displacement may result, which is liable to produce 
 pressure upon the spinal cord and destroy life, if the displacement be 
 above the origin of the phrenic nerves. 
 
 The symptoms of fracture of the spine may be either local in charac- 
 ter, or referable to compression of, or injury to the spinal cord. The 
 local symptoms will probably consist of crepitus, deformity, detached and 
 movable fragments, local ecchymosis, and local pain. The spinal sijmp)- 
 tonis will vary with the seat of fracture and the portion of the cord 
 which has been compressed or otherwise injured. Thus, if above the 
 origin of the phrenic nerve, death may ensue from respiratory paralysis, 
 provided that both of the lateral halves of the spinal cord are simultane- 
 ously injured. If above the origin of the lumbar and sacral nerves, 
 
150 PRACTICAL MEDIOAL ANATOMY. 
 
 symptoms of paralysis of the limbs and pelvic organs will be apparent. 
 The paralysis of the muscles may be of the hemiplegia or the paraplegic 
 type, according as the pressure upon the spinal cord affects one lateral 
 half only, or both lateral halves of the cord; or, possibly, even local pa- 
 ralysis may result, if special spinal nerves be injured, and the spinal cord 
 escape. 
 
 In some cases, where dislocation of the vertebrae exists, in connection 
 with fracture of the spine, extension of the vertebral column, by means 
 of the suspension of the patient if practicable, will often reduce the dis- 
 location, and, possibly, an audible click will be heard when the reduction 
 is effected. The results of injury to the spinal column depends more 
 upon the severity of the spinal symptoms, produced by the injury to the 
 spinal cord, than the situation or extent of the fracture. 
 
 Carious disease of the dorsal and lumbar regions of the spine is ex- 
 
 FiG. 102.— Kyphosis. (After Hamilton.) Fia. 103.— Lordosis. (After Hamilton.) 
 
 tremely common in children. As regards the causes which conspire to 
 create this condition, I must personally disagree with many of the dis- 
 tinguished authors on surgery, in the opinion that scrofula is generally 
 found to exist in those so affected. To my mind, we can far more intel- 
 ligently trace the exciting cause of this affection to muscular exhaustion, 
 due to exercise persevered in after fatigue, or to some slight accident 
 which is either unacknowledged by the child or overlooked by both the 
 child and its parents. I am inclined to think that no case of spinal dis- 
 ease of an acute or chronic type ever occurred without some form of 
 wrench or strain to the tissues forming the affected joint or joints; not 
 that I am disposed to deny that scrofula probably predisposes to a debil- 
 ity of constitution which favors inflammatory processes, and in this way, 
 and to just that extent, may be regarded as a predisposing cause, but I 
 have never yet met with a case where my conviction as to the traumatic 
 origin of the affection was not strengthened rather than diminished. 
 
THE VEKTEBKAL OOLUMN. 151 
 
 Diseases of the spine may begin in the bodies of the vertehrce or in the 
 intervertebral substance. The traumatic theory of origin seems to favor 
 the latter as the most frequent seat of origin of this type of disease, since 
 it has been found by some of our best observers that all forms of injury 
 to the spinal column tend to create a partial or complete separation of 
 the intervertebral cartilages from the bodies of the vertebrae, and thus to 
 interfere with their nutrition. 
 
 The joam which is associated with spinal disease is due to an irritation 
 of the spinal nerves which escape from the foramina between the laminae 
 of the vertebrae, and are therefore placed in close relation both to 
 the bodies of the vertebrae and the intervertebral substances, both of 
 which have been discussed as the most probable points of origin of this 
 affection. It is often possible, by a thorough knowledge of the course 
 and distribution of these spinal nerves, and by a general law, which is given 
 by Hilton, to trace the symptom of localized pain to its exciting cause, 
 and thus to make an early diagnosis of a diseased condition of parts, 
 which may be far removed from the seat of pain, and whose recovery de- 
 pends upon this recognition in the early stages of the disease. The rule 
 to which I refer may be thus quoted: "In disease of the lower cervical, 
 dorsal, and lumbar regions of the vertebral column, the pain is usually 
 expressed symmetrically; that is, on both sides alike. It is often not so, 
 however, when the disease lies between the occiput and the atlas, or 
 between the first and second ceiwical vertebras." ' As examples of the 
 utility of this guide to the diagnosis of spinal affections by means of 
 symmetrical pain, a constant ^aw in the pit of the stomach is a frequent 
 indicator of disease in the region of the point of origin of the sixth and 
 seventh dorsal nerves from the spinal cord; while pai^tw the scalp cover- 
 ing the back part of the skull, in the region of the nape of the 'neck, is 
 often a guide to disease of the spine between the atlas and the axis, since 
 the great occipital nerve, which supplies that region of the scalp, arises 
 between these vertebrae. 
 
 The subject of pain, as a guide to the situation of spinal lesions, is 
 one which requires a most thorough knowledge of anatomy to properly 
 appreciate its advantages or to skilfully apply its precepts. It would be 
 out of the province, as well as the scope of a small volume like the pres- 
 ent one, to attempt to give to the reader more than a general idea of how 
 the nerves which arise from the spine can be utilized by the physician, 
 not only in making a brilliant diagnosis in some instances, but in skil- 
 fully treating and relieving the symptoms of others. Every student of 
 
 ' The explanation of this peculiarity of the iirst and second cervical vertebrae, 
 as given by Hilton, rests in the anatomical fact that the number of separate joints 
 between these bones enables the disease to frequently remain unilateral ; while, 
 in the case of all the other vertebra;, the disease rapidly spreads throughout the 
 bodies of those bones, and thus becomes a bilateral affection. 
 
152 PKACTICAL MEDICAL ANATOMY. 
 
 medical anatomy should first become most thoroughly familiar with the 
 seat of origin of the spinal nerves and the guides to them, as afforded by 
 the spinous processes of the vertebral column (see page 143). He should 
 next acquire the general course and distribution of those nerves which 
 are distributed to the muscles of the trunk and the integumentary cov- 
 ering of the thorax, and abdomen ; and also the general course of 
 those nerves which supply the muscles, joints, and skin of the upper 
 and lower extremities. When this has been mastered, he should learn to 
 regard pain as a symptom which can be traced along the well-defined 
 course of the nerve which supplies the region where the pain is perceived, 
 remembering that pain is usually felt at i\iQ peripheral extremity of the 
 nerve, and not in its central portion, or near its point of origin ; and he 
 should always trace the course of the affected nerve, carefully noting the 
 presence or absence of anything along the course of the nerve which might 
 create pain, until the seat of disease is reached. One axiom, which 
 is given by Hilton, cannot be too often repeated to those who hope to use 
 the method which has been described, with success, viz., " That superft- 
 cial pains on both sides of the tody, which are symmetrical, inipli/ an 
 origin or cause, the seat of which is central or bilateral, and that unilat- 
 eral paiti implies a seat of origin which is one-sided, and, as a rule, on 
 the same side of the body as the pain. " 
 
 We have now considered the results of fractures, dislocations, and 
 diseased conditions of the vertebral column, and the means of diagnosis 
 which are afforded us by anatomy, both in the recognition of the existing 
 condition and in the localization of the disease, • as far as this line of 
 study can guide us, without entering into the consideration of the 
 minute structure of the spinal cord and the nerve-centres, and the phy- 
 siological functions of the various parts. We have seen that pain may 
 be used as a guide to the proper recognition of the early stages of disease 
 of the vertebrae ; that deformity may be produced as the result of frac- 
 ture or dislocation, and that the seat and the results of a force applied 
 to the spine are capable of being explained on anatomical grounds, when 
 the construction of the vertebral column is mastered ; that the effects of 
 pressure upon the spinal cord may be revealed as a type of jmralysis, 
 either of the lateral half of the body (hemiplegia), of the lower half of the 
 body (paraplegia), or of the lower portion of one lateral half of the bo4y 
 (hemi-paraplegia) ; and, finally, that the tnotor power of the muscles 
 may be affected, the sensation of the parte alone affected, or that both 
 motion and sensation may be impaired or destroyed. ' 
 
 The normal curvatures of the spine have been discussed to some 
 
 ' Pressure on or disease of the posterior part of the spinal cord produces symp- 
 toms referable to the sensation of the parts to which the paralyzed nerves are dis- 
 tributed ; while pressure upon or disease of the anterior portion of the cord 
 interferes chiefly with the motor nerves distributed to the muscles. 
 
THE VERTEBRAL COLUMN. 
 
 153 
 
 some extent in the pages descriptive of the articulations of the vertebrse 
 with each other, as certain points were thus made clear by showing a design 
 on the part of Nature ; while the effects of abnormal curvatures upon 
 the intercostal spaces and the general configuration of the thorax will be 
 found mentioned in connection with the bones of that region. These ab- 
 normal curvatures are most commonly the result of carious disease of the 
 bodies of the vertebrae, and its attendant suppuration, or of a relaxation 
 of the ligaments and absorption of the intervertebral disks of cartilage. 
 They are met with in children who have been subjected to some severe 
 muscular strain or injury (possibly of so slight a character as to have 
 been forgotten or purposely concealed) ; also in those who have long as- 
 sumed a reclining position of the trunk toward one side, as in sitting over 
 a desk; and in the weak and debilitated. The various methods now 
 adopted to support the head and spine in an erect attitude, and the bene- 
 fits derived from their use, seem to warrant the 
 belief that the causes of the disease are largely 
 mechanical, and that a relief from pressure of 
 the vertebrse upon each other effects a cure. 
 
 In that condition, called " PoWs disease," 
 the bodies of the lower dorsal and upper lumbar 
 vertebrse undergo carious degeneration, and the 
 pus which forms follows the psoas muscle down- 
 ward to its point of insertion, and thus escapes 
 at the upper part of the thigh (on its inner as- 
 pect), where it forms 'a fluctuant tumor which 
 may be mistaken for a femoral hernia, and other 
 surgical conditions of that region.' 
 
 Dislocation of the last lumbar vertebra upon 
 the sacrum, in a forward direction, occasionally 
 occurs to such an extent that, while it does not 
 seem to imperil life to any marked degree, an 
 impediment to parturition is produced; because the superior aperture of 
 the true pelvis is shortened in its antero-posterior diameter. In case 
 such a cause of dystocia is suspected, a bony projection can be felt by the 
 :finger through the vagina or rectum, which juts out into the pelvic cav- 
 
 When the bones composing the vertebral canal are the seat of carious 
 degeneration, and the exact limit of the disease, or even its existence, is 
 involved in doubt, a practical test has been suggested by Rosenthal, by 
 which not only the existence of the affection, when the symptoms are ob- 
 scure, but also its extent and situation can be determined with an approach 
 
 Fig. 104. 
 
 ■Caries of the spine, 
 (After Hamilton.) 
 
 ' The author would respectfully refer his readers to his treatise on Surgical 
 Diagnosis, N. Y., 1880, for the points of discrimination between this affection 
 and several others which are liable to be confounded with it. 
 
154 PBACTICAL MEDICAL ANATOMY. 
 
 to accuracy. This test consists in passing, along the sides of the vertebral 
 column, a pair of electrodes attached to a Paradic battery of considerable 
 power. Under these circumstances, if there be any caries, or inflammation 
 of the vertebrae tending toward caries, the seat and extent of the disease 
 will be at once manifested by a burning and stabbing pain which will 
 often cause the patient to scream or start, since the passage of the electric 
 current through inflamed bone-tissue is extremely painful. While some 
 of the later authors are not yet willing to concede this symptom as a posi- 
 tive evidence of carious degeneration, still they are agreed, almost unani- 
 mously, that the absence of pain on the application of the galvanic cur- 
 rent may be regarded as conclusive evidence that no disease of the vertebrae 
 exists. 
 
 Dislocations of the spine are of infrequent occurrence, but such an 
 accident may occur either as the result of violence to or disease of the 
 vertebrae, without the presence of a complicating fracture. In two cases, 
 reported by Lassus and Paletta, the occipital bone has been displaced 
 from its articulation with the atlas; the first of these lived six-hours, hav- 
 ing sufEered a laceration of the vertebral artery, which lies in extremely 
 close relation with both bones, as it passes between them, while the second 
 survived five days. Dislocations of the axis from the atlas have been al- 
 ready mentioned as possible, and some remarkable cases have been cited 
 to illustrate the form of accident which is most liable to produce it (see 
 page 146). It has been stated by some authors that cases of this character 
 have been relieved by a reduction of the dislocation, by placing the head of 
 the patient between the hands, and the knees of the surgeon against the 
 shoulders of the sufferer, and thus, by drawing and twisting the head, 
 the odontoid process has been replaced; but such a statement seems 
 to me incredible, since, if the accident had really occurred and the 
 odontoid process had once become displaced, death would inevitably take 
 place before surgical relief could be of benefit. I am inclined, therefore, 
 to believe that these cases are properly those of concussion of the spinal 
 cord with a severe sprain of the neck, injuring its muscles or stretching 
 its ligaments. A rare form of accident is occasionally met with, in 
 which the transverse process of some of the cervical vertebrae is displaced, 
 upon one side only; thus causing the head to be turned toward the oppo- 
 site side and rendered immovable, while marked pain is present at the 
 seat of displacement, and a ridigity of the neck is produced. In such 
 an emergency, forcible extension of the head, and rotation afterward, will 
 tend to reduce the displacement, which will usually be indicated by that 
 peculiar snap with which all dislocations are liable to be associated when 
 replaced. 
 
THK NECK AKD ITS STBUOTUBES. 155 
 
 OHAPTEE II. 
 
 THE NECK AND ITS STRUCTURES. 
 
 THE REGION' OF THE NECK, AS A WHOLE. 
 
 The bones of the neck have already been considered as a part of the 
 vertebral column, with the exception of the hyoid bone, which seiTes as a 
 point of attachment for the root of the tongue; the membranous struc- 
 tures which connect it with the larynx; the muscles situated in the an- 
 terior portion of the neck; and those which serve to raise the hyoid 
 bone and the larynx, during the second period of the physiological act of 
 deglutition. 
 
 In the foetus and also in the aged,' the anterior outline of the neck as- 
 sumes a curve with its concavity looking toward the spinal column; but, 
 as the parts fill out, the line assumes more nearly a perpendicular direc- 
 tion in childhood and middle life." The length of this region varies, 
 not only in individuals, but also with the position of the head; it is 
 more delicate in the female than in the male, and its prominences and de- 
 pressions are therefore more apparent. The length of the neck is caused 
 to vary by alterations in the thickness of the intervertebral disks of fibro- 
 cartilage; partly by an increase in the thickness of the bodies of the verte- 
 brae themselves; and, finally, by the formation of the upper portion of the 
 chest, since the neck is apparently shortened during each inspiratory act 
 and lengthened during expiration. An actual increase or decrease in its 
 length is therefore produced by those types of thorax which more closely 
 resemble the conditions either of a full inspiration or a full expiration. 
 For this reason, the long neck is most often associated with that 
 type of chest which is flat in the supra-mammary region; where the clavi- 
 cles are prominent; the upper intercostal spaces widened, and the lower 
 spaces narrow; and where the sternum is depressed (the typical expiratory 
 chest). Such a condition of the chest always denotes a lack of robustness 
 of constitution, and, often, a tuberculous tendency; and, for that reason, 
 long necks are not the best evidence of animal vigor or of long life. 
 
 On the other hand, the short neck — ^while it may most often be found 
 
 ' Blandin: Anat. Topog. Paris, 1836. 
 
 ^ In the male adult, when the pomum Adami is extensively developed and 
 prominent, the line of the anterior portion of the neck is often rather convex 
 than straight; while in those afflicted with goitre (enlargement of the thyroid 
 gland) the same condition is present to an exaggerated degree. 
 
156 
 
 PRACTICAL MEDICAL ANATOMY. 
 
 with the typical inspiratory form of chest, and thus probably indicate 
 great vigor and strength of temperament — is thought to render its posses- 
 sor liable to the danger of apoplexy in later life, on account of the close ap- 
 proximation of the brain to the heart, and the additional strain to the 
 cerebral vessels, due to this fact. That the length of the neck is modi- 
 fied by the position of the head is too well-known by surgeons to need 
 more than a mere mention, since all the operations upon the neck demand 
 that the head be so placed as to assist the operator in rendering certain 
 muscular guides tense, and relaxing other muscles, when additional space 
 is required. The old rule, quoted by Blandin,' is valuable to those whose 
 surgical experience is limited: "Place the head so that the part to be 
 operated upon shall be opposed to the motion toward which the whole 
 inclines." 
 
 Fio. 105.— Muscles of the head and neck: 1. 1 , the two portions of the occipito-frontalis muscle; 
 2, 2, 3, three muscles (more largely developed in animals) which move the ear; 4, orbicularis pal- 
 pebrarum, the muscle which closes the eyelids; 5-7, muscles of the nose; 8, orbicularis oris, the 
 muscle which puckers the lips; 13, masseter muscle; 14, platysma myoides, abroad thin muscle 
 which gives motion to the skin overlaying it; 15, sterno-cleido-mastoid muscle; 16, trapezius; 17, 
 18, muscles which raise the shoulder-blade, or, when it is fixed, draw the head to either side. 
 
 The neck is rendered short during an advanced stage of emphysema, 
 since the chest, being forced to contain more than the normal amount of 
 air (inspiration being a labored act as well as expiration), the shoulders 
 are permanently i-aised and the upper portion of the thorax is rendered 
 prominent, thus shortening the neck. In phthisis, on the contrary, the 
 expansion of the thorax is reduced, to an extent proportionate to the 
 amount of lung-tissue involved; and, in severe cases, the neck therefore 
 
 ' Op. cit. 
 
THE NECK AND ITS STRU0TUKE8. 
 
 15T 
 
 becomes markedly lengthened on account of the flattening of the supra- 
 mammary region, and the sinking of the bones of the shoulder. 
 
 Many of the structures of the neck are of practical interest from a 
 medical point of view. The pharynx, larynx, trachea, oesophagus, and 
 thyroid gland are the seat of medical diseases, in contra-distinction to 
 those which are properly classed as surgical affections; while the various 
 diseases of internal organs are often evidenced by alterations in the arte- 
 ries, veins, muscles, nerves, glands, and fascise of this region. 
 
 THE VEINS OE THE NECK AND THEIR POINTS OF INTEKEST. 
 
 The veins of the neck, which lie superficially and can thus be watched 
 during life, show variations in their size which are of great value to the 
 physician. In the sitting posture, the law of gravity assists to empty these 
 veins, except during the act of expiration, when the sinking of the chest- 
 wall and the pressure exerted upon the mediastina, causes the down- 
 ward flow of blood to be temporarily arrested, and thus the veins are 
 made prominent from their over-distention. N"ow, there are certain 
 conditions of the internal organs of tlie thorax which tend to make such 
 an impairment to the venous return of the blood through the superior 
 vena cava permanent, among which may be mentioned extensive em- 
 physema, lesions of the tricuspid valve of the heart, thoracic aneurism, 
 tumors of the mediastina, cardiac dilatation or greatly enfeebled heart's 
 action, extensive effusions into the pleural or pericardial sacs, collapse of 
 the lung from the entrance of air into the pleural cavity, cancer of the 
 oesophagus within the thorax, and many other causes which directly or 
 indirectly would tend to impede the entrance of blood to the cavity of 
 the thorax, or tliat of the right auricle. 
 
 The veins of the neck may exhibit, liowever, variations in the amount 
 of blood which they contain, irrespective of disease; thus, in the acts of 
 speaking, singing, or coughing, the superficial veins may swell enorm- 
 ously, from the prolonging of the expiratory effort (which arrests the 
 venous return to tlie heart), and from the force wliich is employed by the 
 muscular system to produce the effort.' There is more blood in the 
 veins of the neck during the contraction of the heart than during its 
 period of repose; more in the recumbent position than when we sit up; 
 more when we are warm than when we are cold; and more during anger 
 or excessive mental activity than when cold and impassive.' If the veins 
 
 ' So apparent is this fact during the singing of high notes that the swelling of 
 the veins in the neck can often be seen among professionals on the stage, even 
 by the audience; and the extent of the venous engorgement may often be seen to 
 vary with the pitch of the note. Probably the abdominal muscles tend to force 
 the diaphragm upward and thus to crowd the blood in the superior vena cava to 
 the upper part of the thorax. 
 
 'Sibson: Medical Anatomy. London, 1868. 
 
158 PRACTICAL MEDICAL, ANArOMY. 
 
 be filled from any pressure due to disease, the afEected side of the thorax 
 may often correspond with the side of the neck upon which the veins are 
 the more distended; while an equal distention of the veins during both 
 inspiration and expiration is most commonly met with in those acute 
 types of inflammation of the bronchial tubes, where the respirations are 
 shallow, or in pulmonary congestion, pneumonia, emphysema, etc. 
 
 The large veins of the neck may be seen to pulsate synchronously with 
 the systole of the heart, when the tricuspid valve allows the blood to re- 
 gurgitate into the right auricle to so marked an extent as to cause the 
 heart-impulse to travel as a wave along the column of blood in the supe- 
 rior vena cava, and thus to the veins of the neck. This symptom is, 
 therefore, of the greatest value in deciding as to the condition of the right 
 auriculo- ventricular opening and the valve which tends normally to 
 occlude it; and, since this valve usually does not become insujficient with- 
 out previous disease of the lungs or of the mitral valve, an important 
 guide is thus afforded the diagnostician in locating the primary cause 
 either in the lung or the left heart. 
 
 The veins of the neck are filled with blood from the venous sinuses of 
 the brain and from the superficial and deep veins of the head and face; 
 for this reason any obstruction to the free escape of blood from these latter 
 veins, if long continued, produces a cyanosed condition of the face, and, 
 often, Irain symptoms, as the result of passive hypersemia of that organ, or 
 of carbonic acid poisoning. The face of the sufferer from emphysema man- 
 ifests, in a most striking way, the cyanotic condition of the face;' and 
 vertigo, specks before the vision, noises in the ears, and fulness in the 
 bead are liable to be produced by coughing or the slightest exercise in 
 this class of patients, illustrating the effect of an increase of the hyper- 
 semia of the brain. ^ The turgidity of the face, bleeding at the nose, ver- 
 tigo, and possible convulsions of whooping-cough again illustrate the 
 effect of the prolonged paroxysm of coughing upon the venous circulation 
 of the head and brain; while the frequent attacks of fatal apoplexy, 
 which are produced by fits of anger, exercise, or intense excitement, in 
 those whose arteries have become weakened by atheromatous changes, 
 may be due, in part, to the impeded return of venous blood to the tho- 
 rax, thus creating an indirect increase of the pressure in the arteries. 
 
 The veins of the neck are a frequent source of embarrassment to the 
 surgeon, since, in those diseases where respiration is greatly interfered 
 with, the veins swell enormously, and often so cover the parts which the 
 surgeon is endeavoring to reach, as to require some steps which shall obvi- 
 ate the difficulty. As a rule, simple compression over the vein, at that 
 angle of the wound which lies nearest to the head, will cause it to col- 
 lapse, but sometimes it becomes necessary to apply a ligature to it, and 
 
 "See page 61 of this volume. 
 
 Tioomis: Diseases of the Respiratory Organs, Heart, and Kidney. New 
 Yorl£, 1880. 
 
THE NECK AND ITS STRUCTURES. 159 
 
 subsequently to divide it. It should always be remembered that, in the 
 region of the neck especially, there is great danger of the entrance of air 
 into the severed vein, unless- a double ligature be first applied, and the 
 vein severed between the points ligated. 
 
 This distressing accident has always occurred, as far as my research 
 has extended, in operations about the head, neck, or axilla. 
 
 Experiments on animals by Morgagni, Valsalva, Bichat, and Nysten, 
 have shown death to arise in the dog from an injection of three cubic 
 inches of air into the jugular vein, and in the horse from three ordinary 
 human expirations. 
 
 Bichat, in his experiments, concluded that even one bubble might re- 
 sult in death; but his associate investigators — Bell, Magendie, Amussat, 
 Cormack, Wattman, Nysten, and Eriehsen — do not verify such a conclu- 
 sion. Death seems to depend not only upon the amount of air intro- 
 duced, but the rapidity of the injection seems also greatly to influence it. 
 
 In medicine, however, we have only to deal with the spontaneous ad- 
 mission of air into venous cavities, dependent upon a thoracic vacuum 
 existing both within the pleuritic and pericardial sacs, and occurring dur- 
 ing the act of inspiration. There has been much discussion, and many 
 theories have been advanced as to the exact physiological condition pro- 
 duced by the entrance of air into veins, and the mechanism of its action 
 as a cause of death. 
 
 Bell's theory argued that death w^as the direct result of air upon the 
 medulla oblongata. Cormack ascribes death to distention of the right 
 heart alone, without abnormal valvular or pulmonary conditions. Erich- 
 sen ' denies both of these conclusions, and claims that death results from 
 obstruction in the pulmonary capillaries from the frothy condition of the 
 blood, which resists the vis-a-tergo of the heart. This theory has had 
 great support; is based upon extensive experiments and pathological re- 
 search; and, where small quantities of air enter veins, probably is correct. 
 
 Moore," however, in his paper on this subject, advocates an explana- 
 tion, in which the valvular element is brought out as the most important 
 factor, and which certainly merits attention. He states his explanation 
 "briefly as follows: 1. Air, from its light density and compressibility, on 
 entering the right ventricle, fails to close the wet tricuspid valve during 
 the ventricular systole. 2. During the following diastole of the heart, 
 the -iir enters, or, rather, floats, into the pulmonary artery. 3. During 
 the second ventricular systole, the wet pulmonary valves also fail to close, 
 and adhere to the sides of the vessel. 4. The succeeding diastole now 
 draws blood into the ventricle fi-om both the auricle and the lungs. 
 5. The cardiac systole returns the blood again to its original situation. 
 
 • Science and Art of Surgery. Philadelphia, 1878. 
 ' Holmes' Surgeiy. New York, 1870. 
 
160 PEAOTICAL MEDICAL ANATOMY. 
 
 as botli the tricuspid and pulmonary yalves are open, and thus the circu- 
 lation becomes arrested. 
 
 These two latter explanations probably cover the mechanism of death, 
 the former being the most plausible when the amount of air in the heart 
 cavities is small, the latter when a large quantity of air is suddenly intro- 
 duced. 
 
 In 1818, Beauchesne reported the first case of this accident occurring 
 during the removal of a tumor of the right shoulder, the internal jugular 
 vein being wounded. The patient lived fifteen minutes. 
 
 Subsequently cases were reported by Dapuytren, Delpech, Castara, 
 Eoux, Ulrick, Mirault, Warren, Mott, Malgaigne, Begin, Erichsen, 
 Cooper, Clemot, and others. Some of those recovered; some met almost 
 instant death; some died of pneumonia from bronchial irritation at a 
 later date. In all of these cases, however, an abnormal condition of the 
 opened vein existed, characterized by a failure to collapse, termed by the 
 French "canalisation." 
 
 This abnormal condition may be produced either artificially or by 
 some anatomical changes. Artificial canalization may result from one 
 of four conditions, viz., 1. Tension of the aponeuroses, holding the mouth 
 of a vein open. 2. Veins opened by platysma contraction. 3. Traction 
 on the pedicle of a tumor. 4. Vein, at an angle of the wound, opened by 
 traction on the flaps. The abnormal anatomical conditions producing 
 canalization are: 1. Indurated cellular investments about the vein. 
 2. Induration or inflammatory thickening of the venous coats. 
 
 Thus, in Beauchesne's case, traction existed; in Delpech's, hypertro- 
 phy of axillary vein; in Castara's, section occurred during traction; in 
 Eoux's, section occurred during traction; in Ulrick's, the vein was in- 
 closed in a tumor; in Mirault's, the vein was inclosed in a tumor; in War- 
 ren's, tension from the position of the arm existed; in Mott's, the facial 
 wm was made tense from the position of the head; in Malgaigne's, the 
 vein was inclosed in the tumor; in Begin's, the jugular vein was tense 
 from traction. 
 
 When air is allowed to enter into the veins of a dog by section, there 
 occurs; 1. A hissing noise, with gurgling at the mouth of the vein. 
 2. Struggles during the subsequent inspirations. 3. A churning noise 
 at the apex of the heart during tlie ventricular systole, with a bubbling, 
 thrilling, and rasping sensation on palpation. 4. The circulation be- 
 comes feeble, but the heart's action remains forclMe. 6. The animal 
 becomes unable to stand, rolls over, utters a few plaintive cries, is con- 
 vulsed, extrudes its fseces and urine, and dies. In man, however, there 
 are additional symptoms given us by the expressions of the patient; 
 thus, the patient experiences a terrible constriction in the thorax imme- 
 diately after the air enters; screams, moans, and subsequently whines as 
 the symptoms increase. The pulse early becomes imperceptible; the 
 heart's action labored; convulsions come on rapidly; and death usually 
 
THE NECK AND ITS STBUCTUKES. 161 
 
 occurs. Still, in Mirault's case, three or four hours elapsed before death; 
 in Clemot's, several hours; in Beauchesne's, fifteen minutes; in Eoux's 
 and Malgaigne's, death from pneumonia ensued; while in Erichsen's and 
 Cooper's cases, recovery took place. 
 
 As prevention of this accident is of vital importance, the following 
 suggestions may be of value: 1. Always close the mouth of any open ves- 
 sel instantly, both on the proximal and distal end, and compress every 
 vein before cutting it. 3. Avoid raising any tumor or the shoulder in 
 operations about the neck, head, or axilla, without protecting the large 
 veins by pressure. 3. Compress between the wound and thorax, if a cause 
 for fear exists, during alterations in the position of patient or tumor. 4. 
 Bandage the chest and abdomen tightly to prevent gasping respirations, 
 which tend greatly toward this accident. . 
 
 As to the plan of actual treatment, after the accident has occurred, 
 many suggestions have been offered, though their value will depend some- 
 what on the views held as to the mechanism of death. Thus, Moore ad- 
 vises a supine position, to allow the blood to fall to the lacJc part of the 
 heart, and thus raise the tricuspid valves. Others advise the head low 
 and the feet high, to relieve the anaemia of the medulla. Mercier sug- 
 gests compression of the femorals, axillaries, and abdominal aorta, for the 
 same object; but this is objected to by others on account of the necessity 
 of venous return, which is retarded by this method. Warren advises 
 either Heeding from the temporal artery, tracheotomy, ©r stimulants, as 
 the indications seem to demand, with galvanic shocks across the chest in 
 case the heart's action seems to fail. Gerdy compresses the chest, hoping 
 to expel or facilitate the passage of air through the lungs. In apparently 
 fatal cases, Amussat and Blandin recommend suction of air from the 
 heart, by means of a catheter passed into the open vein, or into tlie right 
 jugular, if the former be impossible, with compression of the chest at the 
 same time. Magendie and Roux advocate suction alone. ReidandCormack 
 suggest the opening of the right jugular vein to relieve the right auricle. 
 
 Many of these plans have to me serious objections. Compression of 
 the chest, after the accident has occurred, seems useless, and increases 
 the pulmonary obstruction. Bleeding from the temporal artery depletes 
 the already empty arteries. Tracheotomy only relieves a secondary 
 symptom (dyspnoea). Brichsen lays great stress. on artificial inflation of 
 the lungs to overcome the obstruction in the pulmonary capillaries, and 
 suggests that mechanical respiration be kept up after this procedure, us- 
 ing at the same time ammonia to the nostrils. 
 
 Artificial respirations, with the mouth and nostrils closed, have been 
 suggested as a remedial measure, the object being to expel air from the 
 heart by the vein through which it entered. Finally, injections of warm 
 water into the heart cavity, to render the valves movable, and subsequent 
 artificial respiration to keep up the cardiac action, is resorted to and re- 
 commended by Moore as a remedy in the severe type of cases. His steps 
 11 
 
162 PRACTICAL MEDICAL ANATOMY. 
 
 for this operation are as follows: 1. Raise the head during the injection, to 
 allow the air to escape through the fluid. 2. Open some vein in the neck, 
 and evacuate its blood, to further assist the escape of the air. 3. Avoid 
 throwing in additional air with the syringe. 4. Inject with force enough 
 to FILL, but not distend the heart cavities. 5. Inject two ounces at 
 a time, with velocity enough to raise the wet valves which are adherent 
 to the walls of the heart. 6. Stimulate the heart's action, during the 
 operation, by galvanism and artificial respiration. 
 
 THE MUSCLES OE THE NECK AKD THEIB EITNCTIONS. 
 
 When t\Q platysma muscle is in action, it draws down the lower lip, 
 and thus tends to widen and open the mouth. This action is a frequent 
 cause of the expression of melancholy, as mentioned on page 36, but it 
 may also be seen in those cases where the patient gasps for breath, owing ' 
 to extreme difficulty in respiration, and is then a most formidable and 
 dangerous symptom. It is by means of this muscle that the lateral 
 wrinkles of the neck, which can occasionally be produced at will, are 
 chiefly created. 
 
 In thin nec~ks, a delicate cord may often be perceived which runs 
 transversely across it, parallel with the clavicle but slightly above its upper 
 border, and which may be seen to rise and fall with the movements of the 
 chest during respiration. This is the posterior belly of the omo-liyoid 
 muscle, which is attached to the cervical fascia, and by it to the apex of 
 the lung. Daring inspiration, this muscle renders the cervical fascia 
 tense, and thus tends to raise the apex of the lung, co-operating with the 
 scaleni and sterno-mastoid muscles of that side of the neck to assist in the 
 perfect performance of that act. If we trace the nervous supply to this 
 muscle, we will find that it derives motor power from three sources, viz., 
 the cervical plexus, the pneumogastric, and the hypoglossal; thus indi- 
 cating that the muscle is destined to assist m three important functions.' 
 By means of the filaments derived from the cervical jjlexus, it is capable 
 of acting in the various movements of the neck, in perfect harmony with 
 the other adjacent muscles; by means of the filaments from the pneumo- 
 gastricj it is placed under the control of the nerve of respiration, and thus 
 acts in harmony with the respiratory muscles, while the filaments from 
 the hypoglossal nerve bring its action into perfect accord with the mus- 
 cles of the tongue, most of which are chiefly attached to the hyoid bone. 
 
 The scaleni muscles, the levator anguli scapulm, and the omo-hyoid are 
 the chief muscles of the neck concerned in respiration;" hence to the 
 physician and the physiologist they possess an importance which the 
 muscles that simply control the movements of the head or neck do not 
 
 ■ John Hilton, op. cit. 
 
 ' Porter: Surg. Anat. of Larynx and Trachea. Bums: Anatomy of Neck and 
 Head. 
 
THE NECK AlTD ITS STETJCTUEES. 163 
 
 have. By the scaleni muscles the first and second ribs are made a point 
 of resistance for those muscles which act upon the remaining ribs during 
 inspiration; but to accomplish this effect the spinal column has to be also 
 made a fixed point from which the scaleni muscles can act upon the two 
 upper ribs. It can thus be perceived that the scaleni muscles can also be 
 made to act from the ribs in case the spinal column is to be moved; and 
 the neck can be deflected by them toward the side upon which the muscles 
 in action are situated, if those of one side act alone, but, if those of both 
 sides act simultaneously, the spine will be kept erect. 
 
 Fio. 106.— Prevertebral muscles; 1, basilar process of occipital bone; 2, anterior aspect of cervical 
 vertebras: 3, commencement of dorsal vertebrae; 4, longus colli muscle; 5, scalenus anticus mus- 
 cle, arising from first rib; 6, scalenus medius muscle arising from the first rib; 7, scalenus posticus 
 muscle arising from the second rib; 8, the rectus capitis anticus major muscle; 9, rectus capitis 
 anticvis minor muscle; 10, rectus capitis lateralis muscle; 11, styloid process of temporal bone. 
 
 The table of muscles acting upon the head (see page 30) may prove 
 of assistance in explaining the mechanism of production of some of the 
 distortions of the head and neck which are not infrequently met with. 
 
 The muscles of the tongue, pharynx, soft palate, and those of the 
 supra-hyoid region are chiefly concerned in the act of deglutition. Per- 
 haps no better way can, therefore, be devised to illustrate to the reader 
 the various functions of these muscles, than by giving a hasty sketch of 
 that act in its different stages, and the muscles which assist to produce it. 
 I quote, therefore, from my late work upon the nervous system. 
 
 The Act of Deglutition and its Mechanism. 
 
 For convenience of description, it has been the custom of physiologists 
 to divide the act of deglutition into three distinct periods. The first 
 period comprising the passage of the bolus of food through the mouth. 
 
164 
 
 PEAOTIOAL MEDICAL ANATOMY, 
 
 which is under the control of the voluntary muscles; the second, the 
 passage of the bolus through the isthmus of the fauces and the phar- 
 ynx; the third, the passage through the oesophagus to the cavity of the 
 stomach. 
 
 In the first period, the food is first seized by the lips, then forced be- 
 tween the jaws by the tongue and the buccinator muscles; and by the 
 teeth it is not only masticated, but is also mixed with the salivary se- 
 cretion. When the food is ready to be swallowed, the mouth is first 
 closed, as the act is performed with extreme difficulty when the mouth is 
 open, since the tongue cannot properly act upon the bolus . The tongue now 
 becomes widened, so as to offer a large surface to the bolus of food, and, 
 with the bolus placed behind it, is pressed backward along the roof of the 
 mouth. In case the food to be swallowed happens to be in a liquid form. 
 
 Fia. 107.— Anterior view of the naso-pharyngeal space; on one side the mucous membrane has 
 been dissected away (after Lusohta). 1, septum; 3, middle; 3, lower turbinated bone; 4, tuberosity 
 of the pharyngeal oriflce of the Eustachian tube; 6, soft palate: 6, uvula; 7, stylo-pharyngeus mus- 
 cle; 8, levator-palatl; 9, palatp-phaiyngeus muscle. (Ziemssen.) 
 
 the tongue is so curved that its edges curl upward, while its dorsum is de- 
 pressed in the centre, thus forming a longitudinal groove along its entire 
 length, and the soft palate is so closely applied to the base of the tongue 
 as to admit of a sucking fdrce. 
 
 The importance of the tongue during this period of the act of swal- 
 lowing, cannot be overestimated. Animals, in which the tongue has 
 been paralyzed by section of the ilerves of that organ, exhibit the utmost 
 distress in their efforts to bring the food to the back portion of the mouth, 
 and are forced to so toss the head as to bring tlie force of gravity to their 
 
THE NECK AND ITS STRUCTUEES. 
 
 165 
 
 aid.' Drinking also becomes even more interfered with, and the tongue 
 is no longer used to help in the act, but various devices are used to bring 
 the fluid where the reflex act of the fauces will help to carry it to the 
 stomach. If it were not for the fact that, after removal of the tongue for 
 local disease, the stump was of sufficient length to be of great assistance 
 
 Fio. 108.— Anterior view of the muscles of the pharynx and palate after removal of the tongue, 
 hyoid bone, and larynx as far as the posterior segment of the thyroid cartilage (Luschka) ; A, apo- 
 neurosis of the soft palate; B,th3Toid portion of the palato-pharyngeus muscle; C, arch-like con- 
 nection of the levator palati muscle; D, azygos uvula; F, G, bundle of constrictors in posterior wall 
 of pharynx; H, pharyngeal portion, and K, palatine portion of palato-pharyngeus muscle; L, 
 glosso-pharyngeus muscle; M, hyo-pharyngeus muscle; N, posterior segment of thyroid carti- 
 lage ; 1, aponeurosis of the thyro-pharyngeo-palatine muscle ; below which are the longitudinal fibres 
 «f the oesophagus springing from it. (Cohen.) 
 
 ' "We see this also marked, but to a less extent, in patients afflicted with glosso- 
 labial paralysis. 
 
166 PRACTICAL MEDICAL ANATOMY. 
 
 in controlling the bolus of food, such an operation would be a question- 
 able procedure. 
 
 In the second period of deglutition, tlie bolus of food, by being 
 crowded against the soft palate, tends to raise it; and the leTator palati 
 muscle further assists in retaining the palate in this elevated position, 
 while the superior constrictor muscle of the pharynx causes the posterior 
 wall of the pharynx to bulge forward and thus to meet the uvula. The 
 posterior nasal openings are thus mechanically closed to the entrance of 
 the food into the chamber of the nose, preparatory to the series of reflex 
 movements which are to ensue, for the purpose of forcing the bolus-down- 
 ward into the oesophagus and thence into the stomach. 
 
 The larynx is now suddenly raised, so as to bring the superior open- 
 ing of that organ underneath the base of the tongue, which has been 
 crowded backward during the first period, in order to force the bolus 
 against the soft palate, and whose soft structure renders it admirably 
 adapted to mould itself to the irregularities of outline of the laryngeal 
 opening. By this position of the tongue, the epiglottis is also applied 
 over this opening,' and the entrance of food into the larynx is further- 
 more protected against, by the approximation of the vocal cords by means 
 of the adductor muscles of the larynx. The muscles which thus raise the 
 larynx are the anterior belly of the digastric, the mylo-hyoid, the genio- 
 hyoid, the stylo-glossus, and some of the fibres'of the genio-glossus. 
 
 Simultaneously with the elevation of the larynx, the palato-pharyngei 
 muscles contract and raise the lower end of the pharynx, thus shortening 
 the length of that organ and tending to draw the pharynx over the bolus 
 of food very much as a glove is drawn over the finger; while, at the same 
 time, the curve of the posterior pillars of the pharynx is thus made 
 straight, and, by the approximation of these muscles to the sides of the 
 uvula, the opening of the pharynx into the nares is now completely oc- 
 cluded. 
 
 The constrictor muscles of the pharynx now come into play, contract- 
 ing in succession from above downward; the posterior pillars of the fauces, 
 by their approximation, prevent the bolus from again entering the mouth; 
 and the bolus of food is thus forced to enter the oesophagus. 
 
 Now it is apparent that most of these movements are of a reflex char- 
 acter and are excited by the presence of the bolus of food, which passes- 
 out of voluntary control as soon as it passes the anterior pillar of the 
 fauces, at which point the second period of deglutition may be said to 
 commence. Every reflex act presupposes some sensory filaments to con- 
 vey the impression to the brain, and certain motor filaments to transmit 
 
 ' It was formerly supposed that the epiglottis was the chief instrument in pre- 
 venting the entrance of food into the larynx, but the large number of cases where 
 the epiglottis has been removed and no difficulty in deglutition apparently pro- 
 duced have thrown much doubt as to its importance. 
 
THE NECK AND ITS STKUCTURES. 167 
 
 the impulses to the muscles destined to act upon the bolus; and it is now- 
 believed that the glosso-pharyngeal nerve possesses both of these sets of 
 fibres, as well as those controlling the special sensation of taste. This 
 nerve may then be considered as a nerve of taste, a nerve of motion to the 
 pharyngeal muscles, and the true "excitory nerve" of the act of degluti- 
 tion. 
 
 The importance of the soft palate in the act of deglutition is particu- 
 larly shown during the swallowing of liquids, since it has to be closely 
 applied to the base of the tongue in order to allow of a partial vacuum 
 within the cavity of the mouth, and thus to draw the fluid along the fur- 
 row formed by the curving upward of the edges of the tongue. This fact 
 is clinically shown by patients affected with paralysis of the velum, who 
 experience great diflficulty in swallowing liquids; since the fluid is liable 
 to escape through the nose. A case is reported by Berard of this charac- 
 ter, where a young lady was obliged to free herself from all observation 
 whenever she attempted to drink, as the escape by the nostril was so pro- 
 fuse as to occasion embarrassment. 
 
 The prevention of the entrance of food into the cavity of the larynx, 
 as has been mentioned, is insured, (1) by the base of the tongue, (3) by 
 the epiglottis, and (3) by the approximation of the vocal cords; but that 
 such accidents do still happen from attempts at inspiration * during eating 
 is attested to by the violent coughing excited, and by the instantaneous 
 expulsion of the foreign substance, unless it should chance to become 
 mechanically arrested in the larynx. Longet accounts for the symptoms 
 excited by such an accident as the result of an exquisite sensibility pos- 
 sessed by the mucous lining of the upper part of the larynx. It is well 
 attested that the danger of entrance of fluids into this organ is far greater 
 than in the case of solids, and the act of gargling is especially liable to be 
 followed by such an occurrence, since the larynx is much wider open than 
 in the act of deglutition. In the administration of anesthetics to pa- 
 tients who have eaten largely before the hour appointed for surgical relief, 
 a great danger of the entrance of vomited matbers into the- cavity of the 
 larynx is encountered, since the sensitiveness of the mucous lining is de- 
 stroyed, and the expulsive efforts of Nature are often wanting.' 
 
 The third period of the act of deglutition is confined to the oesopha- 
 gus, through which the bolus has to pass to reach the stomach. The 
 downward movement of the bolus is assisted by alternate contraction of 
 
 ' As occurs during attacks of laughing, hiccough, etc., when food is present 
 in the mouth, or during too hasty an effort to consume food. 
 
 ^ In cases where this accident occurs the tongue should be forcibly drawn out 
 of the mouth, so as to puU up the epiglottis, and the foreign body extracted by 
 the finger if possible, or, if not, the patient should be held by the feet, and thus 
 by shaking the patient, gravity may help to dislodge it. I once saved the life of 
 a patient by this means when all others had failed, and fatal asphyxia seemed 
 imminent. 
 
168 PKAOTICAT^ MEDICAL ANATOMY. 
 
 the longitudinal fibres of the tube, which shorten it and tend to draw its 
 walls upward over the bolus, and contraction of the circular fibres, which 
 constrict the tube and force the bolus downward. The fact that gravity 
 has little, if anything, to do with this downward movement is proven by 
 the fact that the position of the body does not seem to affect it, while 
 acrobats are often known to perform the feat while standing upon the 
 head or hands. The time consumed in the passage through the oesopha- 
 gus was estimated by Magendie ' as about two minutes in animals, but it 
 is probably much shorter in man; although we are often conscious of a 
 delayed termination of the act, and are forced to hasten it by the drink- 
 ing of fluids, as most of us can attest. It is probable that this peristaltic 
 action of the oesophagus, like that of the intestinal canal, is partly con- 
 trolled by the nervous influence of the sympathetic system, although the 
 pneumogastric nerves have also an extensive distribution to this organ.' 
 
 Deglutition is essentially a reflex act, save in its first period, when 
 volition plays an important part. It cannot take place unless some 
 stimulus is applied to the mucous lining of the fauces; and those appar- 
 ently voluntary acts of deglutition, which are produced when no food is 
 within the mouth, are undoubtedly due to the swallowing of saliva, or to 
 irritation of the fauces by the base of the tongue itself. When we tickle 
 the fauces, we can see all of the act of deglutition, confined to the second 
 period, artificially produced, and this irritability of the fauces is so 
 extreme in some persons as to render any attempt to examine the throat 
 one of difficulty, and often a cause of reflex vomiting. So important is 
 the education of the throat to enable the patient to tolerate the presence 
 of instruments, that all surgical procedures upon the larynx, if performed 
 from within the mouth, require often months of training to enable the 
 patient to assist the operator in a step, whose execution may be a matter 
 of a few seconds only. All forms of local applications are used to insure 
 an anaesthetic condition of these parts, and the internal administration of 
 medicinal agents is furthermore often required to render such procedures 
 within the canity of the larynx possible. 
 
 That the centre for the reflex act of deglutition is confined to the 
 medulla oblongata is proven by experiment on animals whose brain has 
 been entirely removed with the exception of the medulla, when irritation 
 of the fauces will still continue to produce all the movements of the 
 second stage of that act. 
 
 Clinical Points Pertaining to the Muscles of the Neclc. 
 
 The separate muscles or groups of muscles may exhibit evidence of 
 impairment in their motor power — paresis; or a total loss of motor power 
 
 ' Journal de Physiologie. 
 
 ' Michael Foster regards this third act of deglutition as more closely dependent 
 on the central nervous system than the movements of the intestinal tract, and at- 
 tributes it to reflex action due to the bolus. 
 
THE NECK AND ITS STRUCTUEE8. 169 
 
 — paralysis. As examples of this fact, the two large superficial muscles 
 of the neck, the sterno-mastoid and the trapezius, both of -which are 
 supplied from the same source — the spinal accessory nerve — may be 
 affected with a loss of power either simultaneously or separately; and 
 symptoms will thus be produced which are of so positive a character that 
 the existing condition can easily be diagnosed by any one familiar with 
 the action of the afEected muscle. 
 
 If the sterno-mastoid muscle be afEected upon one side only, the head 
 will be held in an oblique position, with the face directed toward the 
 affect-ed side, on account of the action of the unopposed mu-scle. ' The 
 chin will be slightly elevated, and the head cannot be voluntarily turned 
 toward the healthy side, although little force is required to place it in 
 its proper attitude by the hand of the physician. Since other muscles 
 assist in the rotation of the head, this unnatural position of the head is 
 not carried to an extreme extent, being still opposed by the muscles 
 which retain their normal power of movement. To make the diagnosis 
 positive, place the hand underneath the chin of the patient, and instruct 
 him to flex the head upon the chest while you resist his effort to do so, 
 when the muscular belly of the healthy side will become prominent, and 
 and that of the paralyzed side will not; thus affording the physician the 
 best possible means of estimating, not only the existence of the condition, 
 but also the extent of the paralysis. When unilateral paralysis of this 
 muscle has remained for some time, the opposite muscle assumes 
 a state of contracture, which causes the obliquity of the head to be 
 more difiBcult to mechanically overcome. If the muscles of loth sides are 
 paralyzed, the head is no longer held in an oblique position, but is pointed 
 straight forward; while rotation of the head, especially if the chin be 
 simultaneously raised, is performed with some difiSculty by means of other 
 muscles. The same absence of the prominence of the muscles during 
 attempts to flex the head under resistance will be present upon both sides 
 instead of pne only, as before mentioned; and a leanness of the neck may 
 be apparent, if the muscles have progressed far toward the condition of 
 atrophy, as the result of disuse or disease of the motor cells of the spinal 
 cord. 
 
 If the trapezius be the seat of paresis or paralysis, the deformity will 
 be chiefly confined to the scapular region. This bone appears to be drawn 
 downward and forward from its normal position. Its inferior angle is 
 tilted inward, and thus is in closer relation to the spines of the vertebral 
 column than in health, while its upper portion is farther removed from 
 the spine. The weight of the arm, assisted by the action of the rhom- 
 
 ' AVhile torticollis is most commonly due to contraction of the sterno-mastoid 
 muscle, it may be produced also by disease of the cervical vertebras, by the cica- 
 trices following deep burns of the skin of the neck, by paralysis of the muscles 
 (as in hemiplegia), by congenital malformation, by tumors of the neck, and by 
 other causes. 
 
170 PRACTICAL MEDICAL ANATOMY. 
 
 boideus and levator anguli scapulas muscles, tends to draw the acromion 
 downward and forward, and, in consequence of this, the clavicle projects 
 away from the antei'ior part of the chest; the supra-clavicular fossa ap- 
 pears deeper than normal; and the posterior angle of the scapula can be 
 felt in the posterior portion of that space with an unusual degree of dis- 
 tinctness. Since this muscle is supplied from more than one source, the 
 condition of paresis is more common than that of paralysis, and hence the 
 position of the scapula may be modified to some extent by the nerves 
 affected. 
 
 In this condition, voluntary elevation of the shoulder is limited; or, 
 at least, is afEected by other muscles than in the normal state. It is this 
 fact that accounts for the enormous increase in the size of the omo-hyoid 
 muscle, which sometimes becomes so enlarged as to resemble the anterior 
 border of the trapezius muscle in the state of firm contraction. The 
 relative actions of these two muscles afford us a clue to decide as to 
 which of the two is the cause of the prominence, provided the history of 
 such a case is unknown, since the omo-hyoid muscle tends to raise the 
 superior and internal angle of the scajiula, and thus tends also to deepen 
 the supra-clavicular fossa, because it acts upon the clavicle, causing it to 
 stand off from the wall of the thorax: while the trapezius muscle elevates 
 chiefly the acromial end of the scapula, and thus tends to draw the whole 
 bone toward the vertebral column, and to render the supra-clavicular 
 fossa less deep, since the clavicle is approximated to the chest-wall. 
 
 The elevation of the arm above the horizontal line of the shoulder is 
 chiefly effected by the movements of the scapula, in which the bone is 
 caused to revolve, as it were, upon a pivot in the centre of its body, thus 
 causing the inferior angle to recede from the vertebral column, while the 
 upper and internal angle is brought m ore closely i n relation with it. Now, 
 to effect this movement, the tra2)ezius muscle is the most important factor, 
 since its fibres act upon the acromion process, which is, in this case, the 
 end of a long arm of a lever; and, when this muscle is paralyzed, a most 
 characteristic effect upon the elevation of the arm toward the head is 
 presented from the absence of this powerful factor in the movement. 
 
 When both of the trapezii muscles are simultaneously paralyzed, these 
 anomalies are present upon both sides of the body. Both shoulder blades 
 having fallen outward and forward, the back has an appearance of being 
 excessively rounded in a transverse direction, and the head is maintained 
 in an erect position with more difficulty than in health, since it tends to 
 sink upon the chest. When we consider that paralysis of the trapezii 
 muscles may be associated with a lesion which impairs the free action of 
 the spinal-accessory nerve of either side, we can better appreciate whv in 
 such cases, the internal branch of that nerve may become affected and a 
 difficulty produced in sioallowing (due to paresis of the constrictor 
 muscles of the pharynx); a loss of or huskiness of voice (due to laryngeal 
 paralysis); and a peculiar nasal tone of the voice (due to the paresis of 
 
THE NECK AND ITS STRUCTURES. 
 
 171 
 
 tlie velum palati) may also exist as a further evidence of the impairment 
 of this important nerve. ' 
 
 REGIOlfS OF SPECIAL INTEKEST llf THE NECK. 
 
 In the supra-clavicular region of the neck, a ■wound may produce most 
 serious consequences, and even prove immediately fatal, if the sub- 
 clavian artery, which lies within this space, be opened, or the vein ivhich 
 accompanies it be punctured. The supra^scapular vessels and also the 
 transverse cervical artery and vein, both of which cross the neck in this 
 region, may be the source of most alarming hemorrhage, if wounded. 
 This latter vessel is so situated that the fragments of a broken clavicle 
 
 Tracheal carti- 
 lage. 
 
 Thyroid gland— -■ 
 
 Iieft recurrent \ 
 laryng'l nerre ) 
 
 Body of the! ..'^ 
 vertebra^ f ''^ 
 
 Thyroid gland. 
 
 ( Right recur- 
 -< rent laryngeal 
 ( nerve. 
 (Esophagus. 
 
 Apex of right 
 lung. 
 
 Fig. 109, — Transverse section through the neck at the lower surface of the first dorsal vertebra 
 (After Braune.) 
 
 may cause perforation of its coats, if driven backward with violence. I 
 have seen paralysis of the upper extremity follow an injury to this region, 
 from severing of the main cords of the Iracliial plexus: and even a slight 
 injury sustained by these nerves may create neuralgic pains which are ex- 
 tremely severe and may be felt in the arm, forearm, or hand. It 
 is possible for the brachial plexus to be injured even if the wound received 
 be situated far back in the neck, at the posterior limit of this spaced es- 
 pecially if the instrument be carried slightly forward. The phrenic nerve, 
 which crosses the scalenus anticus muscle and thus lies between the 
 subclavian artery and vein, may be severed, if the wound be carried inward 
 near to the median line of the neck; in which case, a sudden diflSculty in 
 respiration will be the symptom that wUl indicate the character of the in- 
 jury, as the diaphragm will no longer act upon that side. 
 
 ' For the full explanatioii of these symptoms, the reader is referred to the late 
 work of the author : The Applied Anatomy of the Nervous System. Xe-w York, 
 1881. 
 
172 PRACTICAL MEDICAL ANATOMY. 
 
 In this region of the neck, the apex of the lung rises above the 
 level of the first rib, especially at the end of a full inspiration; and, in 
 case the shoulder happens to be depressed, it is quite possible for a pointed 
 instrument to pierce the lung through the neck. I was once called to see 
 a patient, who was suffering from a marked emphysema of the tissues of 
 the neck, following a puncture of the supra-clavicular region, just above 
 the clavicle, and, on questioning him, I ascertained that he was holding 
 his breath after a full inspiration, at the tina^ of the accident. While I 
 have never met with a reported case of pneumo-thorax from such an acci- 
 dent, I can see no anatomical reason why the air from the apex of the 
 lung cannot enter the pleural sac, and thus produce those alarming symp- 
 toms of dyspnoea and collapse which often follow such a perforation. Fi- 
 nally, it is possible for the axillary artery to be injured in this space, pro- 
 vided the instrument inflicting the wound pass slightly below the level of 
 the depressed clavicle, and in the direction of the shoulder. 
 
 In phthisis, during the later stages, when cavities have formed and 
 decomposing pus within the lung is creating the so called " hectic fever" 
 by its absorption, the deep lymphatic ganglia of the supra-clavicular space 
 are not infrequently found to be enlarged; this has been explained by 
 Blandin' as the result of the communication of the lymphatic vessels of 
 the lung with these ganglia. Should these ganglia ever be found to be 
 the seat of suppurative inflammation, a practical point is afforded by the 
 aponeurosis of this region; which indicates that early incision should be 
 made, in order to prevent the accumulated pus from burrowing under- 
 neath the aponeurosis and thus entering the axilla. 
 
 The tierves from the cervical plexus, which ramify in the skin of this 
 region, and descend from above in nearly a perpendicular direction, 
 suggest a point in making incisions; since, if made in a perpendicu- 
 lar direction, less danger of dividing these sensory nerves exists, and thus 
 an annoying pain, which is often referred to the region of the shoulder 
 (because the supra-acromial nerve is derived from the same source), may be 
 avoided. Blisters may be also applied, in this space, to affect the trunks 
 of the brachial plexus, since it lies nearer the skin here than elsewhere. 
 
 It frequently becomes necessary to compress the axillary artery in 
 this, space, when wounds of a serious nature occur close to the shoulder- 
 joint; this can be best performed by first depressing the clavicle and 
 drawing the tip of the shoulder forward, when the finger can be crowded 
 behind the clavicle, and the pulsations of the artery can be felt, it 
 may be caught between the finger and the first rib, and thus held until 
 surgical relief is procured. Another method much in use consists 
 in wrapping a large key in a handkerchief, and using that as a wedge 
 between the clavicle and the first rib, but it is greatly inferior to the fin- 
 
 ' Op. cit. 
 
THE NECK AND ITS STETTCTUEES. 
 
 173 
 
 ger of a strong man, since the artery does not want to be pushed down- 
 ward, but rather backward and inward against the unyielding surface 
 of the rib itself. It once became my privilege to thus save the life of 
 a patient, when the emergencies of the case rendered ligation of the 
 bleeding vessel impossible, without additional assistance being procured. 
 It may be well here to call the attention of the reader to the fact that, 
 in the case of aneurism of the axillary artery, the clavicle is usually so 
 raised as to render this means of compression diflBcult, and often impos- 
 sible. When, in the experience of such men as Sir Astley Cooper, 
 attempts to so control the artery have signally failed, it is well to be fore- 
 warned. One other important structure within this space deserves men- 
 tion : I refer to the external Jugular vein.' It is deeply situated at the 
 inner border of the sterno-mastoid muscle, and hence may be here com- 
 pressed against the first rib in case it chance to be wounded, or, when 
 bleeding exists from some of its tributaries; but it is too deeply situated 
 for superficial wounds to reach it. 
 
 In those rare cases, where the subclavian artery requires compression, 
 a superficial incision through the skin and cervical fascia will often 
 enable the finger to press the artery, either against the first rib, the 
 middle scalenus muscle, or the transverse process of the seventh cervical 
 vertebra; but, in some cases, the artery can be controlled without such 
 an incision being made, the steps differing but little from those given to 
 compress the axillary artery. 
 
 Certain surgical guides of value pertain to this region. ° The poste- 
 rior border of the sterno-mastoid muscle is a guide to the external jugu- 
 lar vein; and, by putting this muscle into action, that vein may be 
 rendered prominent. It is well to remember also that the posterior bor- 
 der of the sterno-mastoid muscle corresponds to the outer border of the 
 scalenus anticus muscle, which is the guide to the subclavian artery. 
 The course of the external jugular vein corresponds to a line drawn from 
 the angle of the jaw, where the vein commences, to the middle of the 
 clavicle, where it terminates. 
 
 Sterno-Mastoid Region. 
 
 The sterno-mastoid muscle, which crosses the neck obliquely from the 
 mastoid process above, to the sternum below, is the great surgical land- 
 mark of the neck. In its middle portion, the anterior border slightly 
 overlaps the common carotid artery; while, at the root of the neck, the 
 muscle divides into two fasciculi of insertion, which are called the sternal 
 and clavicular. Between the sternal borders of the muscles of the two 
 sides, close to the superior opening of the thorax, is seen a depression, 
 
 ' See flg. 64 of this volume. 
 
 ^ For the effects of paralysis of the trapezius muscle upon this region, the 
 author would refer the reader to page 169. 
 
174 PKAOTICAL MEDICAL ANATOMY. 
 
 called the "fonticulus gutturis," which has a marked respiratory move- 
 ment when the breathing is rendered difficult from any cause; but it may 
 be absent in those young subjects whose necks are abundantly sup- 
 plied with adipose tissue in this locality. Between the sternal and cla- 
 vicular insertions of this muscle, another depression exists upon either 
 side of the neck, which has even a greater importance than the one pre- 
 viously mentioned, since a puncture through this opening might result 
 in death from injury done to the common carotid artery, if the instru- 
 ment were directed slightly inward, or to the internal jugular vein, if 
 directed slightly outward. In those cases where the two insertions of 
 this muscle have to be divided, as occurs in attempts to ligate the first 
 portion of the subclavian artery, and, as some authors have suggested, 
 for the relief of deformities due to its abnormal contracture, the operator 
 cannot be too strongly impressed with the close proximity of large veins 
 to the under surface of this muscle, and the great caution which should 
 always be used in passing a director underneath the muscle previous to 
 dividing it. 
 
 It follows from these remarks that all wounds of the lower portion 
 of the sterno-mastoid region must be extremely dangerous, since, if not 
 very superficial, the common carotid and subclavian arteries may be 
 involved; and the iniertial jugular and suhclavian veins, as well as the 
 phrenic, pneumogastric, and sympathetic nerves, are structures whose 
 injury is followed by serious consequences. In the middle portion of the 
 sterno-mastoid region, the cervical plexus of nerves may be involved, if 
 the injury penetrate much deeper than through the skin; while, in the 
 upper part of this region, the occipital vessels and the verteiral artery 
 are extremely liable to be wounded." The peculiar curve which is taken 
 by the vertebral artery between the atlas and the axis, renders this ves- 
 sel especially liable to be opened by a wound near the head, involving 
 the posterior part of the neck, since it throws the artery out on a level 
 with the tips of the transverse processes of these vertebras. 
 
 The sterno-mastoid muscle may be pushed outward by enlarged gang- 
 lia, and by abscesses of the supra-sternal and supra-clavicular regions, 
 which, by following the deep cervical fascia, often burrow underneath this 
 muscle. 
 
 ' Foreign bodies in the pharynx oocasionally demand a division of the struc- 
 tures of the neck, when they cannot be removed tln-ough tlie mouth, and 
 are so imbedded in the walls of that organ as to expose the patient to a risk 
 of perforation of some of the large blood-vessels of the neck, which lie in close 
 relation to the lateral wall of the pharynx. They may also create abscess of the 
 surrounding structures, even when the danger of directly wounding tlie neigh- 
 boring vessels is improbable; and they may thus do damage to the important 
 nerves of the neck, or, by creating a weakness of the walls of the blood-vessels, 
 produce a fatal hemorrhage by their rupture. 
 
THE NECK AND ITS BTKUOTITKES. 
 
 1Y5 
 
 Supra-Hyoid Region. 
 
 In the supra-liyoid region, the submaxillary gland may become the 
 seat of disease, while, above the hyoid bone, the parotid gland may also 
 attract the attention of the practitioner, since it may become affected 
 "vvith a degeneratiye process, and demand removal. The proximity of 
 several superficial lymphatic glands in the region of the parotid may 
 occasion a diseased condition of these superficial structures, to be mistaken 
 for disease of the parotid gland itself — a point that should be well deter- 
 mined by a study of the anatomical relations of the parotid and a most 
 thorough examination of the patient. It is a clinical fact that the sali- 
 vary glands are less frequently affected with degenerative changes than 
 any of the glandular structures of the body, and it is stated most posi- 
 tively by Velpeau that these changes are always secondary to the disease 
 of neighboring lymphatic structures. It has never been my privilege to 
 remove the parotid gland for disease, but it is stated by some of the lead- 
 ing authorities that the removal of a diseased parotid is much easier than 
 in the healthy state, since the gland is not infrequently incapsulated, 
 and, when not so, is so contracted and hardened as to greatly alter its 
 normal relation to the surrounding parts, so that a part may be superfi- 
 cial which, in health, is deeply situated. The operation was first per- 
 formed by Warren, of Boston, in 1798, and has been since performed by 
 a few of the leading surgeons of Europe, and by Mott, McClellan, Hor- 
 ner, White, and some others of our own country.' 
 
 Anterior Cervical Region. 
 
 The omo-hyoid muscles of the two sides form the outer boundaries of 
 a broad triangular space, which stretches across the front of the neck ; 
 whose base corresponds to the upper border of the two clavicles and the 
 upper border of the sternum, and whose apex corresponds to the hyoid 
 bone. In its central portion, which corresponds to the median line of the 
 neck, lie the sterno-thyroid and sterno-hyoid muscles. This space is 
 covered by a strong fascia, the deep fascia of the neck, which is firmly 
 attached to its apex and base, and is rendered tense during the acts 
 of speaking, coughing, singing, and other expulsive or violent mus- 
 cular efforts. It is evidently intended as a wall of support to the deeper 
 veins of the neck, when they are rendered turgid by any act which tends 
 to impede the return of venous blood to the thorax. 
 
 In the region of the hyoid tone, which lies nearly on the same level 
 as the lower jaw, when the head is carried at a right angle to the spinal 
 column as it should be in health, a depression can be perceived above the 
 prominence of the thyroid cartilage, the so-called ''pomum Adami." 
 This corresponds, anteriorly, to the attachment of the apex of the 
 
 ' Velpeau collected thirty-five cases, and H. H. Smith fifty-three cases of 
 entire removal of this gland. 
 
176 
 
 PBA.OTICAL MKDIOAL ANATOMY. 
 
 epiglottis to the thyroid cartilage, and to the thyro-liyoid ligament -which 
 joins tlie larynx to the hyoid bone; hence, as this is the most frequently 
 selected place for cut-throat from the ignorance of apatomy by those of 
 suicidal tendencies, the hyoid bone and the greater part of the epiglottis 
 lie in the upper portion of the wound. The hyoid bone has been frac- 
 tured by the strong grasp of the garroter." Its cornua serve as a guide to 
 the lingual artery of either side, where that artery lies within the lingual 
 triangle, so that it is usually felt for, in operations to tie that artery in 
 
 Thyroid carti- 1 
 lage. j 
 
 Crico-thyroid I 
 membrane and >- 
 arteiy. ) 
 
 Cricoid cartilage — ■ 
 
 Superior thy- 1 
 
 roid vein. J " 
 
 Inferior thy- 1 
 roid vein. J ■ — 
 
 \ 
 I 
 
 
 1 \ \ lifi, ,M{^jiiB5ili^iS\ W.I 
 
 Innominate ar- 
 tery. 
 
 }- 
 
 Thyroid body. 
 (Isthmus.) 
 
 FiQ. 110.— Surgical anatomy of the laryngo-tracheal region. (Gray.) 
 
 case of Wounds of the mouth and the tongue, or in cut-throat, where it 
 has been divided. This artery is occasionally tied for the relief of tumors 
 of the tongue, or to control excessive hemorrhage from severe types of 
 ulceration of that organ. The proximity of the hypoglossal nerve (to 
 sever which would cause paralysis of the tongue upon that side), and the 
 large veins which lie in close relation to the vessel, render the operation 
 one of difficulty even to the cautious surgeon. 
 
 When we place the finger upon the side of the larynx, below the level 
 of the prominence of the thyroid cartilage, the "pomum Adami," we 
 can easily perceive the pulsations of the common carotid artery, since it 
 does not bifurcate into the external and internal carotid arteries until it 
 reaches the level of that prominence. We can thus understand how 
 
 ■ Holden: Human Osteology. London, 1878. 
 
THE NECK AND ITS STEUCTUEES. 
 
 1Y7 
 
 wounds of the superior carotid region are liable to involve the common 
 carotid trunk or even the external or internal carotids, since they 
 lie quite superficially at this point; and the internal jugular vein and 
 the pneumogastric nerve, which are inclosed in the same sheath with 
 the common carotid, may also be injured. It is not usually mentioned 
 by authorities that effusions of blood or accumulations of pus may 
 extend from this region of the neck into the mediastina of the tho- 
 rax, by following the cellular layer which invests the large blood-ves- 
 sels at the root of the neck, which is often extremely loose. It is possi- 
 
 Mastold process. 
 Jugular vein, cut off. 
 Ganglion of the trunk. 
 Internal branch o£ the spinal accessory. 
 Pharyngeal branch o£ the pneumogastrio. 
 Superior laryngeal nerve. Lnerve. 
 
 Internal branch of the superior laryngeal 
 External branch of the superior laryngeal 
 Left pneumogastrlc nerve. [nerve. 
 
 Thyro-hyoid mtiscle. 
 
 Cardiac branch of the left pneumogastrlc. 
 
 Right pneumogastrio nerve. 
 
 Cardiac branch of the right pneumogastrio. 
 
 Right recurrent laryngeal nerve. 
 Left recurrent laryngeal nerve. 
 
 Ductus arteriosus. 
 
 Fio. 111.— Laryngeal branches of the pneumogastrio nerve in the newly-born child. (Heule.) 
 
 ble for enlarged glands of this region to press upon the sheath of thq 
 common carotid. Andral ' reports a case where the pneumogastrio nerve 
 was so atrophied by pressure from a gland, that the patient died from 
 dyspnoea which was gradually developed, and which, in the latter stages 
 ofthe disease, was intense. 
 
 The anterior region of the neck presents, in the median line, the 
 following parts from above downward: the hyoid bone, the depression 
 beneath it, the thyroid cartilage of the larynx, the crico-thyroid depres- 
 sion, the cricoid cartilage of the larynx, the rings of the trachea, and 
 
 13 
 
 ' As quoted by Blandin. 
 
178 PKACTICAL MEDICAL ANATOMY. 
 
 the thyroid gland. In the infant, the thymus gland rises into the lower 
 portion of the neck, but, in the adult, it atrophies and almost entirely 
 disappears, so that nothing can be seen of it above the upper border 
 of the sternum. Most of the parts above mentioned can be seen or felt 
 by a most superficial examination, and they all have some important 
 surgical bearings which should not be unfamiliar even to the physician 
 who might hesitate to employ them. 
 
 The hyoid bone has already been discussed in the first pages of this 
 chapter. It should, however, be remembered that its greater cornu is 
 the guide to the lingual artery, and that, as it affords attachment to the 
 base of the tongue, it is an important agent in raising the larynx during 
 the second stage of deglutition, and in protecting its superior opening, 
 since the epiglottis is prevented from being displaced. 
 
 The thyroid cartilage of the larynx forms the protective investment 
 of the cavity of that organ, and also acts as a firm point of attachment 
 for the vocal cords and the muscles which tend to regulate their position 
 and tension, during the acts of respiration, singing, and talking. In 
 the male adult, the anterior and upper part of the thyroid cartilage 
 increases in size, thus forming a prominence seen in most necks, called 
 the "pomum Adami," while between it and the hyoid bone, a bursa is 
 placed to facilitate the movement of the thyroid cartilage beneath the 
 hyoid bone during the second stage of the act of deglutition.' If we 
 examine the thyroid cartilage carefully with the finger, through the 
 integument and muscles which cover it, we can usually map out the 
 outline of its upper and lower borders and its superior and inferior 
 cornua. The superior border is the guide to the point of bifurcation of 
 the common carotid artery into the external and internal carotids, which 
 lie upon the same level, while it also corresponds to the level of 
 the third cervical vertebra. Upon the lateral aspect of this cartilage, 
 the lateral lobes of the thyroid gland can be felt; and, since this gland 
 rises and falls with each respiratory effort, it can be easily distinguished 
 from any abnormal growth of that region of the neck. The thyroid 
 cartilage is seldom, if ever, ojoefled to relieve impeded respiration, since 
 the attachments of the vocal cords and the apex of the epiglottis in the 
 median line render such a step contra-indicated. On the upper and front 
 part of the thyroid gland, near the upper border of the thyroid cartilage, 
 can be felt the pulsations of the superior thyroid artery, which ramifies 
 upon it. This pulsation is used as another surgical test to discriminate 
 between the gland in case it be enlarged, and a tumor of new-formation. 
 In cases of inflammatory diseases of the interior of the larynx, pressure 
 ■upon the thyroid cartilage will often give pain ; hence it is the custom 
 with some physicians to use this cartilage as a means of confirming or 
 excluding the presence of such conditions within the laryngeal cavity. 
 
 ' For tho details of the mechanism of this act, see page 163 of this volume. 
 
THE NECK AND ITS STBUOTUEES. 179 
 
 The cricoid cartilage is a point of interest both to the surgeon and the 
 physician, since its superficial situation renders it always capable of being 
 felt by the finger, even in babies whose necks are usually short and often 
 extremely fat. It is the great external landmark to the air-passages, and 
 a guide also to the upper opening of the oesophagus, which is partially 
 attached to it posteriorly. Since it lies on the level of the fifth cervi- 
 cal vertebra, it may be of use in determining the relative situation of 
 other parts to the spine. Again, if a transverse line be drawn across the 
 neck at the level of the cricoid cartilage, it will intersect the point at 
 which the omo-hyoid muscle crosses the sheath of the common carotid 
 artery, and, since the artery is usually ligated either just above or just 
 below that muscle, this cartilage is a valuable surgical guide to the seat 
 of election. 
 
 The depression between the thyroid and cricoid cartilages is easily 
 felt through the tissues which cover it in front, but it does not extend 
 far to either side of the median line, and cannot, therefore, be felt well 
 at the side of the larynx. It is in this space, which in health is covered 
 by the crico-thyroid membrane, that a tube is generally inserted, ' in those 
 cases where suffocation from any cause appears imminent. Since it lies 
 below the level of the vocal cords, the objection urged against the open- 
 ing of the thyroid cartilage does not hold good in this case, and the 
 operation is to be preferred to that of tracheotomy, if it can be as easily 
 performed. Unfortunately, however, the distance between the cricoid 
 cartilage and the upper border of the sternum is greatly under-estimated 
 by the majority of observers, since it is scarcely one and a half inches in 
 an adult, when sitting with the head in an easy and normal posture. If 
 the head be thrown well backward, the length of this interval may be 
 increased to about two and one-quarter inches. Now, when suffocation 
 becomes imminent, the trachea and the larynx move up and down with 
 great rapidity during the struggle for breath; the veins of the thyroid 
 body, which descend in front of the neck, are enormously swollen and 
 bulge outward as if about to rupture; the head is usually flexed upon the 
 chest, in order to afford all possible room for the parts; and thus the 
 space between the larynx and the sternum is rendered extremely short, 
 and when the head is raised to see the larynx, the dyspnoea is increased, 
 to a paroxysm. It can thus be understood how an opening between the 
 cricoid and thyroid cartilages is hot always practicable, and that trache- 
 otomy is often the easiest means of affording relief. 
 
 The trachea, or the main air-tube, extends from the cricoid cartilage 
 or the fifth cervical vertebra to its bifurcation into the right and left 
 bronchus in the thorax, at a level of the third dorsal vertebra. It is able 
 to bear external pressure without collapsing, by the cartilaginous rings 
 
 ' The operation of " Laryngotomy," as distinguished from that called " Tra- 
 cheotomy," where the rings of the trachea are divided to insert the tube. 
 
180 PE ACTIO AI, MEDICAL ANATOMY. 
 
 which give it form; and these rings are often of importance as a means of 
 locating the position and relations of certain portions of the tube. In 
 the neck, not more than seven or eight of these rings are present, and 
 none of them can be felt externally. This is accounted for by the fact 
 that the trachea becomes more and more deeply situated as it passes 
 downward, and because the isthmus of the thyroid gland covers the 
 second, third, and fourth cartilages. Moreover, the thymus gland pro- 
 jects upward into the neck of children, and thus adds an additional 
 source of difficulty in determining the situation of the rings by the sense 
 of touch. 
 
 So rapidly does the trachea recede from the surface of the neck that, 
 on a level with the upper border of the sternum, in an adult whose neck 
 is short and fleshy, fully one inch and a half would intervene. I quote 
 the following sentence from Holden, since it expresses the result of my 
 own experience, and possibly that of many of my readers: 
 
 "In the dead subject, nothing is more easy than to open the trachea; 
 in the living, no operation may be attended with greater difficulties." 
 
 In addition to the obstacles mentioned on the preceding page, the 
 thymus gland may be present; there may be a middle thyroid artery to 
 cause unexpected hemorrhage, and the left innominate vein may cross 
 the trachea unusually high up in the neck. It is a rule, therefore, with 
 all good surgeons to divide the trachea as high up as possible, even cut- 
 ting through the cricoid cartilage in children, when found necessary. It 
 is also very important that all incisions should be made in the middle 
 line of the neck — " the line of safety." ' 
 
 • The operation of traoheotomy dates back to the early period of Antyllus — 
 A. D. 340 — who performed it several times. It is not alone used as a remedial 
 measiire for inflammatory affections, since foreign bodies may become lodged in 
 the air-passages and require removal. It is usually preferred by surgeons to the 
 operation of laryngotomy, since it presents fewer dangers and many additional 
 points of advantage in its performance. To those not familiar with the points of 
 the operation, it may be of advantage to state that the opening of the trachea is 
 usually followed by a. paroxysm of coughing, due to the entrance of cold air into 
 the tube, during which little or nothing can be done; but, as it soon tends to pass 
 off, when the first stimulus of the air ceases to be felt, the symptom is not so se- 
 rious as is often supposed by spectators, who often imagine that the patient is in 
 immediate danger of death. In spite of the ease with which the operation is per- 
 formed upon the cadaver, I regard it as one that should not be attempted except 
 by a practitioner possessing skill and some surgical experience. In some cases, I 
 have seen the flow of blood excessive; and Desault was once compelled to aban- 
 don the operation from this cause alone, while Eoux only saved a patient by apply- 
 ing his mouth to the opening of the trachea, and thus sucking the blood from the 
 tube. Such cases should be remembered when we hear the operation spoken of 
 as but on a par with venesection, in point of diiHculty. As regards the indica- 
 tions for surgical interference in the air-passages, I believe that the presence of a 
 foreign body in the trachea is always a justification for the step, although I am 
 aware that such foreign bodies have been known to remain in the tube for years 
 without destroying life; but I am still of the belief tliat the operation is worse 
 \ 
 
THK NECK AND ITS STKUCTUEB8. 181 
 
 Posterior Cervical Region. 
 
 The posterior region of the neck is largely filled witli muscles and 
 strong elastic ligament — the ligamentum micliEe. In the quadruped, this 
 ligament is of enormous size, and acts as a powerful elastric spring to ex- 
 tend the head and neck after it has been flexed by muscles. The fact, 
 which has been mentioned in connection with the description of the 
 Twtebral column, that the 'spinous processes of the middle cervical verte- 
 brae are purposely made short to allow of the motion of the neck in a 
 backward direction, explains why they are indistinctly felt through the 
 muscles which cover them. It might be well to again call attention to 
 the reason why dislocation is more common in the cervical vertebrae than 
 in the dorsal and lumbar regions, and why it is possible to produce death 
 by a pointed instrument, in this region of the spine, when such an ac- 
 cident is impossible in the dorsal vertebrae, but such points can be recalled 
 by referring to that portion of this volume which treats of the spinal 
 column. 
 
 Wounds of the region of the nucha are not dangerous as long as they 
 are superficial, since only a slight hemorrhage may be produced which 
 can, as a rule, be checked by compression or by a ligature ; but, if deep, 
 such wounds may be very serious and immediately fatal, since the instru- 
 ment may penetrate the sub-occipital fossa, or between the atlas and the 
 axis. The vertebrae are rarely broken in this region, since they are more 
 thoroughly protected by muscles than in any other part of the spine, and 
 
 than useless in membranous croup, unless the step be taken before the inflammar 
 tory process has extended beyond the limits of the larynx. In two hundred and 
 forty-five cases where the operation was performed for the relief of this latter 
 malady, one hundred and eighty-eight died, which is a mortaUty of about seventy- 
 five per cent; while in twenty-nine cases of tracheotomy performed in the healthy 
 tube for the extraction of foreign bodies, only one fatal case was reported (as col- 
 lected by Henry H. Smith: Operative Surgery, Philadelphia, 1852). Such a 
 remarkable difference in the percentage of mortality certainly seems, to point to 
 the presence of previous disease of the tube as modifying the results of the opera- 
 tion; and to sustain the objection which I raise against the unnecessary delay of 
 the operation, when it seems indicated, as well as its uselessness after the exuda- 
 tion has extended down the tube.' 
 
 I should advise the practitioner to be guided somewhat by the severity of the 
 disease in deciding this momentous question; and, in case a hereditary tendency 
 .to croup existed in the family, especially if some of the family had previously died 
 from such an attack, I should deem an early operation justifiable, as affording a 
 better prospect of recovery than purely medical aid. I should regard the operation 
 as unjustifiable, in any case, where the symptoms of asphyxia were alarming and 
 the blood already so thoroughly impregnated with carbonic acid as to render the 
 nerve-centres sluggish; since the patient would not probably react, and the fatal 
 issue would rather be hastened by the shock and loss of blood. 
 
 Tracheotomy has been performed for oedema of the larynx, but it is not justi- 
 fied, in my opinion, until scarification has been thoroughly resorted to. 
 
182 PEACTIOAL MEDICAI, ANATOMY. 
 
 since the short ipinous processes render them less liable to be affected 
 by a blow which would tend to do them violence. 
 
 From a strictly medical point of view, this region has a particular in- 
 terest, from the fact that it is the one most frequently selected by 
 furuncles and anthrax. The intense pain which all forms of local swell- 
 ings of this region are liable to produce, is explained by the close adhe- 
 sions of the integument to the subjacent tissues. "When- it becomes 
 necessary to apply counter-irritation to this region (since it is the one most 
 used to affect the brain and the upper portion of the spinal cord for 
 reasons mentioned in the first chapter of this volume), care must be taken 
 not to wound the muscles or the nerves, as I have known tetanus and 
 death to follow the simple application of a seton in the nape of the neck. 
 The ramifications of the occipital artery, and, sometimes, of the trans- 
 verse cervical artery, may be wounded in this region, but simple compres- 
 sion will usually arrest all danger of serious hemorrhage. Severe sub-occip- 
 ital abscess may sometimes occur, which may denude the skull of ■'ts 
 periosteum and thus lead to necrosis of the cranial bones. The con- 
 stant tendency to movement of these parts is mentioned by Hilton ' as the 
 physiological explanation why such abscesses tend to remain chronic, 
 and to discharge their products through long and tortuous sinuses ; he 
 therefore lays great stress upon the necessity of absolute rest, insured by 
 adhesive straps applied to the shaved scalp in such a manner as keep the 
 muscles in a state of enforced repose, while the apertures of the sinuses 
 are left unobstructed. I should suggest, from my own experience, the 
 introduction of drainage tubes to further insure the free escape of the 
 secretions, since absolute rest to the parts is thus more completely insured. 
 
 POINTS IN" THE DIAGNOSIS OE ABNOEMAL SWELLINGS IN THE EEGION 
 
 OE THE NECK. 
 
 When any abnormal swelling of the neck is perceived, it becomes the 
 duty of every physician to ascertain, by every known means which is at 
 his command, the exact boundaries of the new-growth, and such other 
 points pertaining to it as shall enable him to determine its character. Its 
 general shape and position will often enable him, at once, to connect it 
 with certain structures which have been 'discussed as entering into the 
 construction of the neck; although its shape may still further assist him, 
 in many cases, to determine its character. Thus, if it appear nodular 
 and irregular in shape, it may be suspected that the glandular structures 
 of the neck are involved; although this cannot be considered as essential 
 to the development of such a growth, since effusions into surrounding 
 parts may so alter the shape of the tumor as to mask its origin. Smootli 
 and globular swellings, if markedly circumscribed, are usually of the en- 
 cysted or fatty character. Changes in the color of the skin covering the 
 
 ' Rest and Pain. N. Y., 1879. 
 
THE NECK AND ITS STEDCTUEES. 
 
 183 
 
 growth may often be observed, such as a diffused redness, when suppura- 
 tion is present and is approaching the surface; ablueness or ^prominence 
 of the veins of the surface, as exists often in inalignant growths and in 
 venous enlajgements; and a tendency toward ulceration, as exists in 
 malignant or syphilitic deposits. Again, the tumor ma.j pulsate, if situ- 
 ated over an artery, or if aneurismal in character; when the pulsation 
 should be carefully studied to ascertain if it is simply a rising and falling 
 movement (as would be present if a tumor rested upon a vessel), or an 
 expansive pulsation, indicating that the tumor received an impulse 
 directly from the heart, which is transmitted in every direction (as in 
 aneurism). Moreover, the pulsation may be made to cease, if a tumor 
 simply rests upon a large blood-vessel, by displacing it from such associa- 
 tion, which would be impossible if the artery were itself dilated. ' 
 
 Fig. 112.— Kbro-cystio growth. (After Hamilton.) 
 
 Palpation of the growth may enable the physician to detect the pres- 
 ence or absence of fluid, since fluctuation can often be positively felt even 
 when the tissues covering the tumor are of some thickness; while the sen- 
 sibility, the hardness or softness, the character of pulsation, and the ex- 
 tent and amount of its attachment to surrounding tissues may be thus 
 determined. A very hard tumor is often found to be associated with 
 scirrhus, especially if the skin be puckered over it; and sometimes those 
 albuminous deposits, which are also malignant in character, may be dense 
 
 ' Should the reader seek further information as to the differential diagnosis of 
 aneurismal sacs and the other forms of tumors of the various anatomical regions 
 of the body, the author would respectfully refer them to his more exhaustive 
 work on Surgical Diagnosis. 
 
184 
 
 PBACTIOAL MEDICAL ANATOMY. 
 
 to the touch. Fatty' tumors are of a peculiar doughy feel, and are mov- 
 able and painless to the touch; they are also lobulated, as a rule, and are 
 liable to become pedunculated, as the skin is stretched by their weight. 
 Fibrous tumors are generally firm and resistant to the touch; are usually 
 freely movable in the surrounding tissues; are painless, and grow slowly. 
 Glandular tumors are very hard and elastic, unless undergoing suppura- 
 tion; are extremely movable; are multiple, as a rule (lying in the course 
 of the lymphatic chains which accompany the deep and superficial veins) ; 
 and are often associated with a scrofulous or syphilitic history. 
 
 Fig. 113.— Fibro-oellular tumor of the neck and back. 
 
 Finally, the use of the hypodermic needle will often enable the physi- 
 cian to determine positively the character of the contents of any tumor 
 which fluctuates, thus often deciding as to the best course to pursue in 
 treating it. 
 
 DISTRIBUTION OF THE ARTERIES. 
 
 In connection with the vessels of the neck, which we have been dis- 
 cussing in reference to special regions, it may not be deemed a digression 
 if I call attention to those points, so admirably taken by Hilton, as re- 
 gards a definite plan of distribution of the branches of special arteries. 
 In previous pages, we have, from time to time, spoken of practical points 
 of interest pertaining to most of the prominent arteries of the head and 
 neck, although no attempt has been made to systematically describe the 
 arterial system of those regions; and it seems proper that so simple and 
 admirable a statement as that of Hilton should not be omitted, if this 
 work is to add to the general intelligence of the practitioner of medicine 
 as to the anatomical construction of the head and trunk. I therefore 
 quote from his book ■ the following general statements pertaining to the 
 subclavian artery: 
 
 Rest and Pain, 1879. 
 
THE NECK AND ITS STEUCTOEES. 185 
 
 "I point out that the branches distributed from the subclavian artery, 
 apart from its continuation to the upper extremity, are distributed lor 
 one simple purpose, viz., to supply all the parts concerned directly and 
 indirectly in the process of respiration; that is the simple object of the 
 distribution of the subclavian artery. Thus: 
 
 " The vertebral, besides supplying other parts, is distributed to that por- 
 tion of the spinal marrow from which the phrenic, spinal accessory, and 
 posterior thoracic — all important nerves of respiration — take origin. 
 
 " The internal mammary supplies the sternum, cartilages of the ribs, 
 origin of the pectoralis major, phrenic nerve, diaphragm, and the upper 
 half, or respiratory portion, of the abdominal muscles. 
 
 " The superior intercostal artery goes to the first and second ribs. 
 Now, the first is the most important of all the other ribs in the respira- 
 tory function, as it forms the fixed point for the action of the intercostal 
 muscles in elevating the chest. 
 
 " Of the branches of the thyroid axis, the inferior thyroid builds up the 
 trachea, a tube essentially connected with respiration, and sends a branch 
 upward (ascending cervical),' which accompanies and nourishes the phre- 
 nic nerve, and constitutes, in fact, an ascending comes nervi phrenici. 
 The transverse cervical supplies the trapezius, and the posterior border 
 of the scapula with the muscles attached to it, all of which may be con- 
 sidered accessoiy to respiration. The supra-scapular supplies the clavi- 
 cle and scapula, both of which are rendered respiratory by the attachment 
 they give to accessory respiratory muscles." 
 
 The same author again illustrates the distribution of the internal 
 maxillary artery as one which is destined to show a presiding function 
 over the parts employed in mastication, explaining, in a very ingenious 
 ■way, the object of those branches which are apparently disconnected with 
 the masticatory apparatus, as branches which are designed to complete 
 the ossification of those bony parts to which the muscles of mastication 
 are attached, and others as are designed to nourish the nerves which con- 
 trol their power of movement. Unfortunately, however, the entire arte- 
 rial system cannot be thus clearly divided into groups, whose function is 
 well defined, without including branches from difEerent trunks; although 
 even this point is used by the renowned author, above quoted, as a proof 
 of some Bj}ecisb\ physiological action of the part to which the distribution 
 of the arterial, as well as the nerve trunks, can afford us a clue, if we 
 study N'ature in the proper spirit, believing that no structure is carelessly 
 placed or constructed without a plan. 
 
 1 A branch of the superior intercostal artery, one of the points of collateral cir- 
 culation after ligation of the common carotid artery or the subclavian artery in 
 its first portion. See Darling and Ranney: Essentials of Anatomy. N. Y.,1880. 
 
186 
 
 PBACTICAI/ MEDIC Ai ANATOMY. 
 
 OHAPTEE III. 
 
 THE BONES OF THE THORAX. 
 
 The framework which contains the heart and lungs is formed by the 
 dorsal vertebrse, behind; the twelve ribs upon either side, which form a 
 portion of the posterior, the lateral, and a part of the anterior wall; and 
 the sternum, in front. The dorsal vertebrae have been already considered 
 in connection with the other parts of the vertebral column, and little of 
 
 Fig. 114. Fio. ug. 
 
 Fig. 114.— Front view of the bones of the chest; 1, the manubrium of the sternum; 2, body of the 
 sternum; 3, ensiform cartilage; 4, first dorsal vertebra; 5, twelfth dorsal vertebra; 6 and 7 are 
 opposite the first and second ribs on the left side; 9 and 10, false, or floating ribs, which have no 
 cartilaginous connection with the sternum ; 11, 11, are placed over two of the costal cartUages 
 
 Fig. I15.-The bones of the thorax, seen from behind: 1,1, the spinous processes of the first'and 
 twelfth dorsal vertebrse ; a, 2, laminaj of the same vertebras ; 3, 3, transverse processes of the verte- 
 brae; 4, 4, points where the first and tenth ribs articulate with corresponding transverse processes 
 of vertebrae; 5, angle of the third rib. 
 
 practical interest remains to be added. The backward curve of the spine 
 iu this region serves to increase the antero-posterior diameter of the chest 
 and thus to afford more room for the lungs; while the immoMlity of this 
 portion of the spine'tends to prevent the possibility of compression of the 
 organs of the chest or of the important structures contained in the medi- 
 astina. Its ridigity also is of special value in affording a fixed point of 
 resistance for the muscles of respiration, and in completing the arch of 
 
THE BONES OF THE THOEAX. 187 
 
 the ribs with a key-stone, which should resist all tendency to displacement, 
 in case of violence being received upon the anterior part of the che'st. 
 The bearing -which the dorsal curve of the spine has upon the results oi 
 direct force when applied to the spine has been mentioned in previous 
 pages, but it can well be again repeated, to call attention to the wise pro- 
 vision which Nature always takes to guard against injury to any organ 
 contained within a bony cavity, by so arranging the parietes of that cavity 
 as to present the most eflectual and, at the same time, the simplest me- 
 chanical device, which shall combine strength, lightness, and perfect 
 symmetry. 
 
 The eibs, if their cartilages be included, form a series of arches which 
 extend from the dorsal vertebrae forward to the sternum; and, as they suc- 
 cessively increase in length from above downward as far as the seventh 
 rib, and then steadily decrease in their length, the shape of the chest 
 is caused to lulge in its middle part, and to be constricted at its upper 
 and lower openings. The upper aperture ' is open and gives passage to 
 blood-vessels, nerves, the trachea, the oesophagus, the thoracic duct, the 
 apices of the lungs and three muscles; while the lower opening, which is 
 open in the skeleton, is closed, in the recent subject, by a thin flat mus- 
 cle, the diaphragm, which separates the thoracic and abdominal cavities, 
 and which has openings for the passage of the (Esophagus, the aorta, the 
 vena cava ascendens, the thoracic duct, and the pneumogastric and 
 splanchnic nerves." This muscular partition is not flat but vaulted, 
 with its convexity looking upward, so that the lungs extend farther down 
 near the surface of the chest, than in its central portion. The ribs have the 
 power of movement in an upward and downward direction; they can in- 
 crease the loidth of the chest, since they turn outward as they are raised, 
 and also its depth, since the sternum is raised with the ribs and is therefore 
 thrown forward. The diaphragm, by its contraction, can also increase 
 the height of the thoracic cavity, since it becomes more nearly a horizon- 
 tal partition when contracted than when at rest. 
 
 The _^rs^ seven rils are called the " true ribs, " since they are dii'ectly 
 attached to the sternum by means of costal cartilages of their own; while 
 the "false ribs,'" viz., the eighth, ninth, and tenth, are attached to the 
 costal cartilage of the seventh; and the last two, or " floating ribs '" are 
 
 ' This opening usually measures about two inches from before backward, and 
 three and a half inches in its transverse diameter. When it is remembered that 
 Borae forty different parts of the human frame pass through this small opening, 
 it will be apparent that the surgical conditions of the first rib, the first dorsal 
 vertebra and the upper part of the sternum have more than a common importance. 
 
 ' The parts enumerated cover only the more important structures which pass 
 through the floor of the thorax. Some twenty-six different structures can be in- 
 dividually enumerated. 
 
 2 Called "diaphragmatic ribs" by Sibson. 
 
 ^ A misnomer, since they are extremely movable only after death. 
 
188 PEAOTIOAL MEDICAL ANATOMY. 
 
 only tipped with cartilage and are not attached at their outer end. In rare 
 instances, a thirteenth rib is present in man; thus resembling the con- 
 struction of the chimpanzee, who has the thirteen upon each side, but 
 the same number of vertebrae as man. 
 
 The costal cartilages are a direct continuation of the ribs between their 
 anterior extremities and the sternum, and are a mechanical device on the 
 part of Nature to render the arches of the ribs more elastic than they 
 would be if composed entirely of bone: they thus permit of the movement 
 of the ribs during respiration, while their inherent elasticity favors the 
 return of the ribs after they have been raised during inspiration and they 
 thus act as mechanical agents in expiration. In addition to this impor- 
 tant function, these cartilages give to the chest-walls an ability to with- 
 stand violence when directly applied to it, far in excess of that which bone 
 alone would possess, since they enable the ribs to yield to the blow: thus 
 any force received upon the sternum is immediately distributed to fourteen 
 elastic arches which extend backward to the vertebrae (the seven true ribs 
 of each side, and their cartilages) and by this means its efEects are 
 greatly modified. Blows of the most severe character can thus be received 
 by the chest with comparative impunity, especially during a, full inspira- 
 tion, since the muscles of the chest also tend to assist the bones to bear the 
 shock; but when the lungs are emptied of air, as in expiration, the relax- 
 ation of these muscles renders the danger of direct violence greater than 
 when the ribs are raised, because the arches are more oMiquely placed in 
 reference to the spinal column, and since they then possess no muscular 
 support. Notwithstanding these wise provisions on the part of Nature, 
 the sternum is occasionally broken by direct violence, as in that case re- 
 ported by Dupuytren, where the life of a man, supposed to have been 
 killed by a falling beam, was saved by the timely discovery and reduction 
 of such a fracture. 
 
 The vertebral extremity of each rib is placed higher than the sternal 
 end; since, if both ends had been placed upon the same level, the upward 
 movement of the ribs during inspiration would have been rendered im- 
 possible. The head of the rib is the fulcrum upon which it moves, and, 
 if its attachment to the spinal column be carefully examined, it will be 
 perceived that it is articulated to and wedged between two vertebrae. 
 This arrangement insures the rib against the possibility of dislocation 
 from the spinal column, while, at the same time, the intervening disk of 
 fibre-cartilage acts as a spring to break the force of any blow transmitted 
 along the rib. 
 
 There are two important portions in each rib at its vertebral end, 
 called "the tubercle " and " the angle; " the former of which articulates 
 with the transverse process of the vertebra which supports the rib, and 
 thus tends to make it still more securely fastened to the spilhal column 
 while the latter indicates the point where the rib makes a sharp curve for- 
 ward. The angles of the ribs are placed more and more distant from the 
 
THE BONES OF THE THOEAX. 189 
 
 tubercle, as we trace them from above downward; and this is found to be 
 the strongest part of the bone, since it is forced to bear the greatest strain 
 in case of violence, and because the angle demands an increase in the 
 compact tissue. It is at the angle, or very close to it, that fractures of the 
 ribs occur when due to violence received upon the anterior surface of the 
 chest, as when the chest is compressed. 
 
 In this kind of fracture, viz., by indirect violence, the broken ends of 
 ribs are forced outward and away from the pleural covering of the lung, 
 so that complications of the pulmonary organs are infrequent; while, in 
 those forms due to direct violence, as from a blow, the kick of some ani- 
 mal, etc., the ribs are usually driven directly inward at the seat of injury, 
 or near it, and thus the pleura is extremely liable to be wounded or the 
 lung-tissue may be involved. This fact explains why pleuritic efEusion, 
 pneu mo-thorax, pulmonary hemorrhage, pneumonia, and emphysema may 
 follow such an accident, and probably endanger the life of the patient.' 
 
 The ribs are the most vascular hones of the body; hence the rapidity 
 of union in case of fracture, and probably also their great elasticity. 
 The vessels of the bone are placed in a groove upon its lower border, and 
 a practical point is thus suggested to the physician in performing the 
 operation of tapping the chest for fluid, as the upper lorder of the rib 
 should be taken as a guide in the introduction of the trocar, lest the ves- 
 sels be wounded and blood escape into the pleural cavity. Another prac- 
 tical point suggested respecting this operation is the importance of 
 drawing up the shin of the chest before introducing the trocar, since, 
 when the instrument is withdrawn, the skin glides over the orifice of the 
 puncture from its elasticity and from the force of gravity, and thus air is 
 prevented from entering the pleural sac. 
 
 The first rib' is the strongest of all, since it is so situated as to be 
 obliged to support the upper part of the sternum and the clavicles; and, 
 as before mentioned, it forms a boundary of the superior opening of the 
 thorax, and, therefore, bears relation to all of the structures which pass 
 through it. "When these structures have been enumerated, one can see at 
 a glance that a fracture of this rib, which, fortunately is extremely rare 
 on account of its great strength and situation, is a very grave accident 
 from the nerves and vessels which lie in close relation to it; while the 
 fact that it is the starting-point of motion of all the other ribs in the 
 act of inspiration, and that this function is arrested by its fracture, gives 
 the accident another and possibly as important an aspect. The struc- 
 tures which pass in more or less close relation to this rib are as follows: the 
 
 ' For the differential diagnosis of each of these affections from other, surgical 
 conditions having points of resemblance to them, the reader ia referred to the 
 Treatise on Surgical Diagnosis, written by the author. New York, 1880. 
 
 ' The tubercle of this rib is used by surgeons as the bony guide to the subcla- 
 vian artery, in operations for the ligation of that vessel. 
 
190 PE ACTIO AL MEDICAL ANATOMY. 
 
 large arteries of the neck (carotids and subclavians'), as well as the two 
 internal mammary arteries, the two superior intercostals, and the arteria 
 thyroidea ima; the large veins (jugulars, subclayians, innominata, and 
 inferior thyroids); important nerves (pneumogastrics, phrenics, cardiacs, 
 first intercostals, and sympathetic) ; and other important structures (the 
 trachea, oesophagus, thymus gland in the child, the apices of the lungs 
 and their investment of the pleura, and the thoracic duct).' 
 
 Between the ribs are spaces, called " intercostal," which, in the recent 
 subject, are filled by the intercostal muscles. These muscles comprise 
 an external and an internal set, which differ in their function, since 
 their fibres are directed antagonistically so as to cross each other like a 
 letter X in each intercostal space. The internal intercostal muscles 
 tend to depress the ribs and thus to act as aids to expiration, while the 
 external intercostal muscles help to raise the riis, and are, therefore, 
 classed as inspiratory muscles. The arrangement of the fibres of these 
 muscles serves to render openings, due to separation of the fibres, impos- 
 sible, and thus to prevent hernia of the pulmonary organs through the 
 parietes of the chest. The same arrangement of fibres is still more 
 beautifully shown in the abdominal muscles, which are even more liable 
 to protrusions of viscera, as the bony support is absent; and which 
 are, therefore, even more carefully protected by the fibres of the muscles. 
 The intercostal spaces are widest at the anterior extremity of the ribs, 
 where they become joined to the costal cartilages, and they are narrow- 
 est where they join the spinal column. 
 
 The STEKHUii occupies the anterior part of the chest, and serves as 
 a completing portion of the bony framework of the thorax. It is ossi- 
 fied, in contrast to the costal cartilages which lie adjoining it, in order 
 to be better adapted to the protection of the important organs and blood- 
 vessels which lie behind it, while, at the same time, it thus serves as a 
 firm point of origin for some of the most important muscles of the 
 trunk. " 
 
 If the bone be carefully examined, four faintly marked transverse lines 
 can be seen, which are the traces of the original division of the bone into 
 five pieces. The most prominent line of the four can often be felt 
 through the skin, and is used as a guide to determine the exact situation 
 of the second rib. The upper portion of the bone serves to afford artic- 
 
 ' Occasionally the innominate artery, upon, the right side of the body. 
 
 ' The abnormalities of the veins, and of the large arterial trunks given off 
 from the aortic arch, render it impossible to positively state the exact relations of 
 the first rib in any individual case; it should also be remembered that the ribs of 
 the right and left side differ somewhat in their relations. Many unimportant 
 structures which pass through the superior thoracic opening have been omitted, 
 since no practical value is associated with some of them. 
 
 ' Three pairs of the neck; four pairs of the abdominal waU; two internal 
 muscles; and the pectoralis major of either side. 
 
THE BONES OF THE THOEAX. 
 
 191 
 
 ulation for tlie clavicle, one of the most important joints of tlie body, 
 while its lower end, the xyphoid cartilage, affords attachment to the mus- 
 cles which form the anterior wall of the abdominal cavity. The artic- 
 ular surface upon which the inner end of the clavicle revolves^ has, in 
 the fresh state, a saddle-shaped appearance (concavo-convex), which 
 gives to that bone a great latitude of motion with little danger of dislo- 
 cation, so that, although the end of the clavicle is much larger than the 
 surface upon which it moves, it is seldom displaced, even when subjected 
 to a severe form of violence, but is very commonly broken. '• 
 
 The length ' and shape of the sternum vary with different individu- 
 
 Bi 
 
 Fig. 116.— The sternum, or breast-bone ; A, the bone as seen from the front ; 1 to 7, point to where 
 the costal, or rib cartilages, are attached; 8, manubrium; 9, body or gladiolus; 10, ensiform carti- 
 lage; 11, the notch seen between the ends of the collar-bones; 12, place where the right clavicle or 
 collar-bone is attached; B, the right edge of the sternum. 
 
 als.'' It may be bent backward in those persons who constantly bend the 
 trunk, as shoemakers, and thus the heart may be pressed upon; while the 
 xyphoid cartilage is often bent backward in workmen who hold tools 
 against the pit of the stomach, such as carpenters, etc. The first and 
 second portions of the sternum do not, as a rule, become joined; since 
 a certain amount of motion, at that point, tends to assist the movements 
 of respiration. It is the line of junction between these portions of the 
 bone that has been mentioned above as a guide to the centre of the 
 second rib. 
 
 The sternum may remain cleft at the time of birth, thus leaving the 
 
 'The upper border of the sternum lies on a level with the second dorsal ver- 
 tebra. ' It is shorter in the female than in the male. 
 
192 PEACTICAI, MEDICAL ANATOMY. 
 
 thoracic organs almost naked; and it may also be fractured, either by 
 direct violence or by muscular action. Ohaussier reports two such cases, 
 where this bone was fractured during parturition, by the patient resting 
 upon the head and heels; and Paget and Gurlt each report ; case pro- 
 duced by endeavors to lift weights with the teeth, when the body was 
 bent backward. Billard was once obliged to perform gastrotomv, in 
 order to raise a displaced fragment of the sternum, which was producing 
 alarming symptoms from the pressure created. 
 
 The region over the sternum is ft frequent seat of venereal tumors 
 and ulceration, from its superficial and exposed situation; while caries is 
 a frequent disease of this bone. So estensive may this carious process 
 be that the entire bone has been removed by Boyer and Genouville, and 
 even as far back as the time of Galen, large portions of it have been 
 excised. In those cases where ligation of the arteria innominata is 
 demanded, it may be necessary to traphine the sternum to reach the ves- 
 sel; and Lsennec even proposed this step as preparatory to puncture of 
 the pericardium, when greatly distended with fluid. The relation of 
 the sternum to structures within the cavity of the thorax will be consid- 
 ered later on in this volume. 
 
 PRACTICAL POIKTS OF IITTEEEST PEETAIKINQ TO THE WALLS 
 OF THE THOEAX. 
 
 The thorax may be entirely absent at the time of birth, when imper- 
 fect development of the foetus has existed, to which condition the term 
 " anthoraco-cephalia " ' is applied; but, when the upper half only is 
 absent, the term " apectoro-cephalia " is used. The intercostal spaces 
 may be rendered very narrow by lateral curvatures of the vertebral col- 
 umn, especially upon the side which corresponds to the deflection;' and 
 the chest- wall may even be indented iDy the abnormal pressure so created 
 upon one side, and caused to lulge outward upon the opposite side. In 
 that disease of children called rickets, these lateral curvatures of the 
 dorsal region of the spine are very common; and, as a clinical fact, the 
 left side seems to be the most frequent seat of the curve. Indentation 
 of the chest may not be due alone to spinal curvature, since localized 
 injuries of a severe character may drive the chest- wall inward; while cer- 
 tain diseases of the lungs may create a retraction of the thorax by inter- 
 fering with the expansion of that organ during the act of inspiration, 
 thus causing the atmospheric pressure, which is constantly acting upon 
 the outer wall of the chest, to become an agent in producing a permanent 
 deformity. Thus, in old pleurisies, after the fluid has been absorbed, 
 the bands of adhesion, formed in consequence of the inflammatory pro- 
 cess, may tie down the lungs in some unnatural position, and in this way 
 
 ' A term used by B^clard. 
 
 » Blandin: Anat. Topog. Paris, 1832. 
 
THE BONEB OF THE THOKAX. 
 
 193 
 
 prevent its full expansion; again, in fibrous phthisis, the increase in 
 the fibrous tissue of the lung may not only impair its expansibility, but 
 even diminish its size by its ^eady contraction, thus causing an incom- 
 plete filling of the cavity of the chest; while cancer, atelectasis, and pul- 
 monary gangrene, although infrequent as compared with those diseases 
 previously mentioned, may sufficiently impair the expansion of the lung 
 as to induce a thoracic deformity. 
 
 Fig. 117.— Mode of applying the chest-measurer. (After Sibson.) 
 
 Measurements of the two lateral halves of the chest will usually show 
 a difference in the two sides, the right being from one-haJf to one and a 
 half inches larger than the left. In tla.Q female, the upper ribs are more 
 movable than in the male, thus accounting for the heaving of the chest 
 seen in the woman, while the breathing of man is most prominently 
 shown by abdominal movement (a point not without value in counting 
 the respirations of a patient when covered with a sheet). This modifica- 
 tion of movement in the female is to allow of pregnancy, without inter- 
 ference to breathing, which would certainly occur if the upper ribs were 
 immovable. The sternum of the female chest is shorter than that of the 
 13 
 
194 PEACTICAL MEDICAL ANATOMY. 
 
 male, so as to make more room in the abdominal cavity for the displaced 
 organs during pregnancy. The upper opening of the thorax is also larger 
 in the female than in the male. 
 
 As the chest-wall covers many important structures, in addition to 
 the lungs and the propelling organ of the circulation, it is of great impor- 
 tance that the various guides to these parts be considered. 
 
 ETTLES FOR COUNTING THE EIBS DURINa LIFE. 
 
 It is not difficult to count the ribs in those subjects who have little 
 adipose tissue or restricted muscular development, but in fat people the 
 difficulties become increased. It is by means of these bony arches, pass- 
 ing forward from the spinal column toward the sternum, that we are en- 
 abled to map out the position of the thoracic organs during life, and thus 
 detect abnormalities which are often of great value in determining cer- 
 tain diseased conditions. 
 
 It has already been mentioned that the obliquity of the ribs caused 
 some difficulty in determining the rib which corresponds to any given 
 point on the surface of the chest, since the same rib is not on the same 
 level in any two regions; hence, in the guides which will now be enume- 
 rated, only those are made prominent which are of daily use to the skil- 
 ful diagnostician or the surgeon. 
 
 The nipple of the male, in a very large proportion of cases, corresponds 
 to the interval between the fourth and fifth ribs, and lies about three- 
 qifarters of an inch external to their cartilages. The nipple does not 
 correspond to the same point on the chest during inspiration as it does 
 during expiration, since the ribs move underneath the skin of the mam- 
 mary region; and the suggestion may, therefore, be given to take a record 
 of the relative situation of this point at the end of expiration, when it may 
 be found to lie as low as the fifth rib. In emphysema, the ribs may be so 
 raised as to bring the sixth rib at this point; while, in phthisis, the ribs 
 may be so far displaced downward as to bring the sixth rib four inches 
 below the nipple, especially upon the affected side.' 
 
 The guide to the second rib, in front, has already been mentioned as 
 the prominent ridge which crosses the sternum between its upper and 
 middle portions (the manubrium and the gladiolus). The guide to the 
 fifth rib most commonly used is the lower border of the pectoralis major 
 muscle. 
 
 On raising the arm, the first serration of the serratus magnus muscle, 
 which can be perceived below the axillary fold, serves as a guide to deter- 
 mine the position of the sixth rib; while the succeeding serrations corre- 
 spond successively to the seventh, eighth, and ninth ribs. 
 
 The scapula covers the ribs, from the second to the seventh inclusive, 
 upon the posterior surface of the thorax. 
 
 ' Sibson: Medical Anatomy. London, 1869. 
 
THE BONES OF THE THOKAX. 
 
 195 
 
 When a tape is tied around the chest, on a level with the nipple, it 
 will intersect the sixth rib, at a point midway between the sternum and 
 the spinal column. As this is the point usually selected for aspiration of 
 the chest for fluid in the pleural sac, it affords a very easy way of guiding 
 the practitioner in introducing the trocar, remembering the importance 
 of drawing up the skin so as to have a valvular opening after its with- 
 drawal, in order to prevent the entrance of air into the pleural cavity. 
 
 The eleventh and twelfth rids can be felt, even in corpulent subjects, 
 by the finger, as two bony projections, outside of the erector spinas mus- 
 cle, which are directed downward and outward. 
 
 It is important to remember that the slope of the ribs causes the cor- 
 responding vertebra to lie on a higher plane than the rib, if any point be 
 
 
 
 Fig. lis.— The heart and its vessels: 1, right ventricle; 2, left ventricle; 3, pulmonary arteiy; 4, 
 ascending arch of aorta; 4 , descending arch o£ aorta; 6, right auricle; 6, left^auricle; 7, vena cava 
 superior; 7 , left vena innoioinata; 8, vena cava inferior. 
 
 referred to its anterior extremity; the end of the sternum, therefore, cor- 
 responds to the level of the tenth dorsal vertebra, while the junction of 
 the third rib with the sternum corresponds to the sixth dorsal vertebra. 
 
 EXTERNAL GUIDES TO THE THOKACIC VISCERA AND THEIE DISEASES. 
 
 The hbaet. The outline of this important organ may be thus drawn 
 upon the exterior of the chest: "1. Mark a point on a level with the third 
 costal cartilage (upper border), one half inch to the right of the border 
 of the sternum; and a second point on the same level, but one inch to the 
 
196 
 
 PBAOTICAI, MEDICAL ANATOMT. 
 
 left of the sternal border. Connect these two j'oints by a line, and you 
 have the situation of that portion of the lase of the heart where the pul- 
 monary artery and the aorta escape, and where the superior vena cava 
 enters the right auricle. %. Mark a point two inches below the left nipple 
 and one inch to the left of the border of the sternum; this represents the 
 situation of the apex of the organ. The interval between the fifth and 
 sixth ribs, in front, corresponds to about the same level. 3. Mark an- 
 other point at the lowest part of the right edge of the sternum, before 
 the xyphoid cartilage is formed, and connect it with the point rgpresent- 
 ing tlie apex by a line slightly curved downward; this line will designate 
 that part of the heart which rests upon the central tendon of the dia- 
 
 FiG. 1 19.— Outline of the heart, its valves, and the lungs. (After Holden.) 
 
 phragm (where the inferior vena cava perforates that muscle to enter the 
 right auricle). 4. Now connect the right extremities of the lower and 
 the upper lines previously drawn, by a line slightly curved with its con- 
 vexity pointing toward the right, and you will have the outline of the 
 right aitricle. 5. To complete the outline of the heart you have now to 
 draw a line curved toward the left side of the body, which shall pass 
 close to the nipple but not embrace it, and which shall connect the left 
 extremity of the superior line to the point representing the apex of the 
 organ.'" 
 
 ' Holden: Surgical and Medical Landmarks. London, 1876. 
 
THE bONKS OF THE THOBAX. 197 
 
 By reference to figure 119 it will be seen that the surface of the heart 
 is covered, in part, by lung tissue, on its anterior aspect; so that percus- 
 sion over the precordial region of the chest yields two varieties of sound; 
 the one called deep cardiac dulness, being present over the portion cov- 
 ered by lung tissue; the other called superficial cardiac dulness, being 
 confined to the uncovered part. It will be also perceiyed that the right' 
 auricle of the heart, and a slight portion of the arch of the aorta, pass 
 beyond the limit of the right border of the sternum, so that a pointed 
 instrument, if passed close to that border through the third or fourth 
 intercostal space, might wound the lung and auricle; if passed through 
 the second intercostal space, the aorta could be punctured; while, if it 
 entered the_^?-s^ intercostal space, the superior vena cava might be opened 
 above its point of termination in the right auricle. 
 
 The apex of the heart is made to strike the chest-wall during each 
 contraction of the ventricles, on account of the spiral direction of the 
 muscular fibres, which form the walls of those cavities, and any deviation 
 from the normal seat of the apex-beat may be of great value in determin- 
 ing either alterations in the size of the heart, or in the diagnosis of some 
 obscure affection which mechanically tends to displace it. The normal 
 seat of the apex-ieat does not correspond with the seat of the apex in a 
 state of rest, since the heart shortens during its systole; it should be found 
 to exist, in healtli, at a point situated about one inch lelow the left nipple 
 and midtvay betiveen the edge of the sternum and a line dropped from the 
 nipple. ' 
 
 The conditions which tend to displace it may be thus enumerated, as 
 such a table may help the practitioner to make a diagnosis when the symp- 
 toms render the existing condition obscure. 
 
 Hypertrophy of the 
 left ventricle of the 
 heart. 
 
 Dilatation of the left 
 ventricle of the 
 heart. 
 
 Emphysema of the 
 lungs (especially of 
 the left side). 
 
 Mediastinal tumors. 
 
 Aortic aneurism. 
 
 Pleuritic effusion. 
 
 ' Loomis: Physical Diagnosis. New York, 1878. Guttmann: Physical Diag- 
 nosis. New York, 1880. 
 
 The heart-beat may be displaced dotoniuurd by - 
 
198 
 
 PBAOTIOAL MEDICAL ANATOMY. 
 
 The heart-beat may be displaced upward by 
 
 The heart-beat may be displaced to the left by 
 
 Wasting of the pulmo- 
 nary organs. 
 
 Any form of abdominal 
 tumor of the left 
 side (if sufficiently 
 large). 
 
 Tympanites. 
 
 Ascites. 
 
 Cancer of stomach. 
 
 Cancer of left lobe of 
 the liver. 
 
 Fluid in right pleural 
 
 sac. 
 Emphysema of right 
 
 lung. 
 Hypertrophy of left 
 
 heart. ' 
 Pleuritic adhesions, 
 drawing the heart 
 out of place. 
 Fluid in left pleural 
 
 sac. 
 Emphysema of lower 
 
 lobe of left lung. 
 Abdominal tumors (if 
 large and confined to 
 left side). 
 Pleuritic adhesions. 
 Hypertrophy of right 
 ventricle. 
 
 In fat people, and in females possessing large breasts, it is often diffi- 
 cult to detect the exact situation of the apex-beat; and in cardiac dilata- 
 tion the same difficulty is still more marked, as the heart-fibres are too 
 weak to throw the apex with any force against the chest- wall. It is cus- 
 tomary, therefore, to use both the eye and the sense of touch to determine 
 the situation and the character of the apex-beat, the palm of the hand 
 being applied to the chest, and the patient being requested to incline the 
 trunk well forward, if the beat be indistinct, in order to throw the heart 
 
 The heart-beat may be displaced to the right by ■ 
 
 ' In hypertrophy of the heart, the apex-beat is displaced diEEerently when the 
 left ventricle is alone involved, from that form where the right ventricle has been 
 increased in size as the primary result of obstruction to the pulmonary circula- 
 tion; in the former, the apex-beat is carried downward and to the left, while in the 
 latter, downioard and to the right. (Sibson, Guttman.) 
 
THE BONES OF THE THOBAX. 
 
 199 
 
 nearer to the surface of the chest by the aid of gravity. la the female, 
 the breast has often to be raised in order to get the palm in sufficiently 
 close proximity to the chest-wall as to distinctly feel the apex-beat; while 
 the tips of two or more fingers are often employed in place of the palm, 
 when any difficulty is present in definitely locating the point of the 
 impulse. The eye is employed by the diagnostician in examining the 
 heart, not only for the purpose of determining the point of the impulse, 
 but also for the sake of ascertaining the character of the beat and the 
 extent of its diffusion. Thus, in children with hypertrophy of the heart, 
 the precordial region is perceived to bulge forward, probably from the 
 too forcible impulse on the imperfectly ossified ribs, and the vibratory 
 
 \V, 
 
 C -t:^ 
 
 --7 
 
 "\ 
 
 I 
 
 
 
 
 
 . - , ^ ^ M M -^ 
 
 
 Fio. 120.— Hypertrophy of left ventricle. Heart in situ, a, the mammary line; 6, vena cava 
 superior; c, aorta; d, bulb of pulmonary artery; e, right auricle; /, right ventricle: s, left auricle; 
 h, left ventricle (normal circumference) ; 0, the hypertrophic ventricle. (After Eindfleisoh.) 
 
 wave is transmitted over its whole surface; while, in the case of a dilated 
 heart, a slight undulatory movemenb is all that sometimes can be per- 
 ceived, and the heart-beat may be so feeble, in some cases, as to be in- 
 capable of being detected either by sight or touch. 
 
 The valves of the heart bear relations to the anterior wall of the 
 thorax which should be at the^erfect command of any one who hopes or 
 aims to be skilful in diagnosis, since the direction of transmission of cer- 
 tain abnormal sounds, called "murmurs,"' which are indicative of some 
 abnormality of the valve over which it is heard, is of great value in decid- 
 
 ' For the area of diffusion of the various heart-murmurs, see subsequent 
 pages. 
 
200 PEAOnCAL MEDICAL ANATOMY. 
 
 ing as to their cause; and the situation of the point where the sound is 
 most intense often enables the physician to tell which valve is affected, 
 and thus to give an accurate prognosis. I am led, therefore, to make the 
 anatomical guides to the normal situation of each of the four valves of 
 the heart more prominent than if they were simply incorporated in the 
 reading text, by placing them also in the form of a table, as follows: 
 
 AoETic Valve.— Behind the left edge of the sternum, at the third 
 intercostal space. 
 
 PiTLMON-AKT Valtb. — Junction of the third rib and the left edge of 
 the sternum (nearer the chest- wall than the aortic valve.) ^ 
 
 Tricuspid Valve. — Behind the sternum, on a level with the fourth 
 costal cartilage. 
 
 f.3 
 
 .' I 
 A 
 
 -'-•'7.5 
 
 
 
 ---- //v6 
 
 
 
 
 ---'V'^7 
 
 
 ---'/k 
 
 - --' /,''8 
 
 
 
 ':-'''// 
 
 ^-~'' //9 
 
 s , — -' /'; 
 
 \ '--. '".1 
 
 \r:://i<> 
 
 '-:—.' "■ — ' 
 
 Fio. 121.— Hypertrophy of right ventricle. Heart in situ. Description as in the preceding fignre. 
 The contours of the hypertrophic right ventricle are indicated hy dots. (After Eindfleisch.) 
 
 MiTEAL Valve. — One inch to the left of the sternum, on a level with 
 the third intercostal space. 
 
 In a series of clinical lectures given by Dr. Latham,' the following 
 practical rule was given and it has since been extensively quoted: " Make 
 a circle of two inches in diameter round a point midway between the 
 nipple and the end of the sternum. This circle will define, sufficiently 
 for all practical purposes, that part of the heart which lies immediately 
 behind the wall of the chest, and is not covered by lung or pleura." Now 
 all of the valves of the heart lie outside of this area and are covered by a 
 thin layer of lung-tissue; hence all heart-sounds are heard with far 
 greater distinctness when the patient is instructed to stop breathing. 
 
 ' As quoted by Holden: Landmarks, Medical and Surgical, 
 
THE BONES OF THE THORAX. 201 
 
 The precordial region of the chest is greatly altered in case of pericar- 
 dial effusions, since the lower two-thirds of the sternum is rendered 
 prominent, as well as the left costal cartilages from the second to the 
 seventh, all of which are more widely separated than in health. The 
 effects of abnormal conditions of the heart or its investing sac upon 
 the walls of the thorax differ from those dependent upon pulmonary 
 changes, in that the former tend to create a localized enlargement, 
 confined to the precordial region, and in exact proportion to the extent 
 of the pressure created upon the sternum and the ribs, while the latter 
 tend to create modifications in the chest, which are analogous to those 
 produced by either inspiration or expiration, and which are symmetrical 
 if both sides be equally diseased, or confined to one side of the chest, if 
 only one lung be impaired. The effect of pressure, due to alterations of 
 
 ■<::.y /-:;:-•' 
 
 Fio. 182. — Dia^am showing the pericardial sac partially filled with fluid, and plastic exudation 
 upon the two surfaces of the pericardium above the level of the fluid. (After Loomis.) 
 
 the heart or pericardium, upon the anterior surface of the chest, is much 
 more marked in childhood than when occurring during adult life, since 
 the sternum then consists of three bones which are connected by carti- 
 lage, while the ribs themselves and their cartilages are also more yielding. 
 In pericarditis the fluid first finds its way backward, and, as long as 
 it is insufficient to create any decided pressure upon the lung, tends to 
 ascend in the pericardial sac; but as the effusion increases, the lungs 
 gradually become crowded more and more to one side, so that the exposed 
 pericardium, when fully distended, lies immediately behind the sternum 
 and rises to the level of the second costal cartilage. When the formation 
 of this fluid is rapid, the shape of this sack resembles a cone, with its apex 
 
202 PRACTICAL MEDICAL ANATOMY. 
 
 pointing upward where it is attached to the walls of the aorta; but when 
 the fluid forms slowly, the pericardium is distended in a lateral direction 
 by the weight of the fluid, and the sac is thus widened to so great an 
 extent as to often crowd the lungs so far backward as to render them 
 completely hidden when the thorax is opened, while the left lung may be 
 forced also to ascend, thus bringing its lower portion far higher than in 
 health.' 
 
 When the heart itself undergoes enlargement, it does not tend, as a 
 rule, to displace the lung to any marked extent, but rather to prolong 
 itself downward and to the left side; hence the alteration in the position 
 of the apex-beat," and its value as a means of diagnosis (see page 197). 
 
 The extent and force of the heart-impulse is unquestionably modified 
 greatly by the extent of the area uncovered by lung-tissue, since the 
 impulse has a more direct effect upon the wall of the thorax when the 
 lung-tissue between it and the surface of the chest is diminished. We 
 may attribute the feeble impulse of the heart of those that are strong and 
 robust rather to an ability to fully expand the lungs than to any inherent 
 weakness of the heart itself, or the tissues external to the chest (al- 
 though the latter may be one of the possible causes); while, in the feeble 
 and emaciated, an abnormally forcible impulse may lead the physician to 
 estimate the heart-power as fully up to the normal standard, when it is 
 in reality extremely weak, and yields the strong impulse chiefly because 
 the lungs have receded from between the heart and the chest, and the 
 thin chest-wall more readily transmits the vibration. 
 
 A peculiar symptom is often afforded, in phthisis, by the shrinking of 
 the lung from between the pulmonary artery and the chest-wall, in the 
 form of a short, sharp, diastolic impulse, felt in the second intercostal 
 space, and exactly synchronous with the second sound of the heart. The 
 size of the area which is covered by the vibrations produced by the apes, 
 
 ' From twelve to eighteen ounces of fluid can be injected into the pericardial 
 sac, in the state of health, and, hence, in acute pericarditis, the amount of fluid 
 present cannot greatly exceed that amount. In a case of chronic pericarditis, 
 however, three pints of fluid has been removed by Sibson. "We can better under- 
 stand, therefore, why the gradual accumulation of fluid will alter the shape of the 
 pericardial sac more than a rapid development, since, not only is the quantity 
 formed much greater, but the walls of the sac ai-e exposed to a constant stretch- 
 ing process by the additional weight of the fluid, 
 
 ^ The position of the apex-beat of the heart upon the surface of the chest un- 
 questionably differs when the right or left heart is alone involved, but the effect 
 of hypertrophy of the right ventricle upon the position of the apex-beat seems to 
 be a subject upon which authors disagree. Thus Sibson gives it as situated be- 
 hind the xyphoid and lower part of the sternum; Guttmann, as carried to the 
 right, often as far as the left edge of the sternum; Loomis, as carried upward and 
 to t/ie Ze/i (if total eccentric hypertrophy exists); while my own experience in- 
 cKnes me to believe a downward and' inward displacement to be the most com- 
 mon indication of this condition. 
 
THE BONES OF THE THOKAX. 
 
 203 
 
 if increased, does not necessarily indicate a hypertrophied condition of 
 that organ, since the absence of lung-tissue may make a feeble heart yield 
 an impulse widely diffused. ' A point which will generally enable the 
 physician to discriminate between the forcible impulse of a weak heart, 
 which has become uncovered from shrinking of the lungs, and that of a 
 hypertrophied heart, may be afforded by the statement that the former 
 impulse is never carried downward below the normal situation of the im- 
 pulse, but is rather raised, Avhile the latter impulse is always found below 
 the proper level. 
 
 The Lungs. — It must be remembered, in examining the position of 
 organs in the cadaver, that the viscera do not occupy the same rela- 
 tive position to the walls of the thorax and abdomen as they do during 
 
 Fig. 123.— The lungs, and the middle mediastinum with its contained structures. (After Gray.) 
 
 life, since the act of expiration is usually the last one of life, and this 
 last forcible expulsive act is in marked contrast to the tranquil expiration 
 of the healthy subject.' As before stated, each act of inspiration pro- 
 duces changes in the contour of the chest; the clavicles an.d ribs are 
 raised; the sternum is caused to project forward; the upper costal carti- 
 lages are caused to assume nearly a right angle with the sternum; the 
 upper ribs are made to approach each other, while the lower ribs are more 
 widely separated; the cartilages of the false ribs are spread outward so as 
 to cause a widening of the abdominal space between them: the effect of all 
 these phenomena being to widen, deepen, and raise the chest, to shorten 
 
 ' Sibson, op. cit. 
 
204: PKACTICAL MEDICAL ANATOMY. 
 
 the neck, and to caifte an apparent increase in the length of the abdo- 
 men. During the act of expiration, the position of all of the above-men- 
 tioned parts is exactly reversed; the ribs and sternum descend; the spaces 
 between the upper ribs are widened, while they are diminished below; the 
 costal cartilages of the false ribs are again approximated, and the abdom- 
 inal space between them is narrower; the neck is lengthened; and the 
 whole chest made narrow and flat; and the abdomen is apparently short- 
 ened.' It is, therefore, evident that during life the whole of the internal 
 organs are hept in a state of perpetual motion, since, as the chest rises 
 with the inspiratory act, the diaphragm goes downward, dragging with it 
 the lungs and the heart, and pushing the abdominal organs from beneath 
 it. If we examine the respiratory movements of an animal whose viscera 
 have been exposed without destroying its normal functions, this move- 
 ment seems much greater than it really is, since the ribs and organs move 
 in contrary directions, and thus give a deceptive appreciation of the act- 
 ual descent of the internal organs. 
 
 The apex of each lung rises into the neck for a distance of one and a 
 half inches, and slightly higher in the female than in the male, on ac- 
 count of the increased size of the superior aperture of the thorax; hence, 
 wounds of the neck are liable to be followed by the entrance of air into 
 the surrounding tissues, when the seat of the injury is low down near the 
 root of the neck, and especially if the person was inspiring when the in- 
 jury occurred. 
 
 The anterior border of the lung of either side runs parallel with the 
 other behind the sternum, from the level of the second costal cartilage 
 to that of the fourth, but below that point the edges diverge; hence, the 
 great blood-vessels of the thorax, as well as the aortic and the pulmonary 
 valves of the heart, are covered with lung-tissue. The divergence of the 
 anterior border of the lungs is due largely to the position of the heart, 
 and the line of each of the two borders is therefore not symmetrical; that 
 of the right side following the direction of the cartilage of the sixth rib,' 
 while that of the left side crosses the heart below the cartilage of the 
 fourth rib. On the sides of the chest, the lungs of either side can be 
 found as low as the eighth rib; while behind, the posterior border of the 
 base of each lung may usually be found to correspond to the tenth rib. 
 It must be remembered, however, that these limits are increased downward 
 about one and a half inches during a full inspiration. 
 
 The shape of the thorax may be often taken as a guide to the amount 
 of lung-tissue and the general robustness of the individual; since the 
 upper ribs are placed closely together in the strongest type of frame, and 
 the lower ribs widely separated. During an attack of acute bronchi- 
 
 > For these suggestions I am indebted to Sibson in his great work previously 
 referred to. 
 
 » See Fig. 119 on page 196 of this volume. 
 
THE BONES OF THE THOBAX. 
 
 205 
 
 tis, or in persons where emphysema has developed, the chest assumes the 
 appearance of a deep inspiratory effort; the neck is short; the sternum 
 and clavicles are higher than normal; the lower intercostal spaces are 
 wider than the upper; the spaces between the cartilages of the false ribs 
 are increased by the outward movement of the cartilages, and the abdo- 
 men is thus widened below the xyphoid appendix of the sternum; while 
 the scapulae may also be raised far above their proper level. 
 
 The typical chest oi phthisical disease' resembles closely that condi- 
 tion described as seen after a forcible expiration, and it thus makes a 
 marked contrast to the emphysematous chest, which, as before stated, is 
 analogous to the condition of a full inspiratory effort. In this class of 
 subjects, we find the upper portion of the chest flattened and narrowed. 
 
 Fia. 124.— A diagram of the respiratory organs' 1, thyroid cartilage ot the laiynx; 2, criooiii 
 cartilage of the same; 3, 8, trachea, bifm-cating (at 4) into the right and left bronchi (5 and 6) ; 7 to 
 14, ramifications of the bronchi within the lungs; 15, the bases of the lungs, showing their concave 
 form. 
 
 the neck long, the upper ribs widely separated, the lower ribs near 
 together, and the abdominal space between the cartilages of the false ribs 
 narrowed by their approximation. It is not uncommon to find these 
 changes more marked upon the side most affected, since the lung is ren- 
 dered inexpansible in proportion to the extent of the disease, and both 
 lungs are not symmetrically impaired, as a rule. 
 
 ' Life insurance examiners pay great attention to the configuration of the 
 chest as a means of estimating the risk of insurance. While exceptions may ex- 
 ist to the rule, a flat, narrow chest, with limited expansion, is not indicative of 
 long life. 
 
206 PRACTICAL MEDICAL ANATOMY. 
 
 When an extensive pleuritic effusion is developed ' upon one side, the 
 chest manifests its presence by a fulness and prominence of the affected 
 side, which causes it to present a contrast to the side where the lung is 
 performing its proper function; the ribs are separated by the pressure of 
 the fluid within the pleural sac, and the intercostal muscles, which form 
 a hollow between the ribs in health, are forced outward to the level of the 
 ribs themselves, thus rendering their borders more difi&cult of detection. 
 The respiratory movement of the chest is greatly diminished on the af- 
 fected side, and may be entirely absent; while the opposite side, being 
 compelled to perform excessive labor, frequently shows an exaggeration 
 of the normal movement. If the absorption of the fluid is followed by 
 adhesion of the pleural surfaces, thus binding the surface of the lung to 
 the wall of the chest, and rendering its inflation difficult, the affected 
 side may be made to resemble the expiratory type so well marked in 
 
 Fig. 125.-A diagram showing the pleural cavity completely filled with fluid, the lune beine 
 compressed. (After Loomis.) 
 
 phthisis, and the chest-wall may, in severe cases, be retracted so as to 
 leave positive deformity. 
 
 The normal outline of the lungs upon the wall of the chest, as de- 
 scribed in a previous page (see page 304) is not a constant one, but may 
 be modified by disease Cf the lungs themselves; of the pleura; of the heart 
 and its sac; of the large blood-v essels of the thorax, or even of the abdo- 
 
 ' The physical signs usuaUy given in text-books to determine pZewWKc e#u- 
 sion from pneumonic consolidation of the lung, must not be considered as incap- 
 able of modification. I think, in at least one-third of all the cases which I ex- 
 amine, that bronchial breathing is heard below the upper border of the fluid 
 (instead of the absence of all respiratory sounds as we are led by text-books to ex- 
 pect); and voice sounds are also often transmitted by the fluid. The rational 
 symptoms are, therefore, of the greatest value in the diagnosis of pleurisy. 
 
THE BONES OF THE THORAX. 
 
 207 
 
 minal aorta, if near the diaphragm; of the bronchial glands; and of the 
 abdominal organs. 
 
 Causes of Displacement of the Lungs in their Relations to the Walls 
 
 of the Thorax. 
 
 In emphysema, since the lungs are abnormally expanded, the outline 
 of the lungs is similar to that perceived during a full inspiration ; 
 hence the borders will be found to hare been extended downward some 
 one and a half inches below the normal limit of expiration, and the 
 pressure created within the thorax crowds the lung-tissue between the 
 chest-wall and the heart, thus forcing that organ out of its normal posi- 
 tion in the chest in a downward direction. If only one, side be affected to 
 a marked degi-ee, the heart may be displaced laterally and downward. 
 
 In all wasting diseases, and especially in phthisis, the lungs tend to 
 diminish in size and to assume a higher position in the cavity of the 
 thorax; hence the lower limit of the lung, as revealed by percussion, may 
 be raised as high as the fifth intercostal rib in front, and the heart may be so 
 uncovered, as a result of the shrinking of the lungs, as to present a marked 
 increase in the area of superficial and deep cardiac dulness (see page 197). 
 The apex-heat of the heart may be also raised to a slight extent, as the 
 result of diminished pressure of the lung, and the elasticity of the arch 
 of the aorta, which acts as a partial support for the heart. 
 
 In pneumonic consolidation, the lung-tissue becomes so much increased 
 in weight that it tends to sink lower in the thorax than it would in 
 health; while the opposite lung, being called upon to perform the labors 
 of both, becomes excessively inflated during each inspiration, and, there- 
 fore, its lower border sinks proportionally in the chest. We can thus 
 explain the clinical fact that, in pneumonia, the lower limits of pulmon- 
 ary percussion are often carried below the normal line. 
 
 In pleurisy, the lung is caused to float upon the fluid in the pleural 
 sac, and, as it increases, the lung becomes gi-adually compressed and solid- 
 ified; hence the percussion note of lung- tissue is, at first, raised, but the 
 character of the note is soon changed, since the air is expelled from the 
 lung on account of the compression, and it therefore often becomes diflBcult 
 to map out the line of the fluid and where the lung-tissue begins. Besides 
 this direct cause of the displacement of the normal outline of the lung, the 
 fluid can indirectly cause an alteration in the position of the opposite lung 
 by creating a displacement of the heart (see page 198). 
 
 lu. pericardial effusion, the lung-tissue is forced away from the anterior 
 surface of the pericardium when sufficient fluid, has accumulated to create 
 lateral pressure upon the lungs. Hypertrophy and dilatation of the heart 
 cavities may also cause an alteration in the limits of pulmonary percussion, 
 since a force is thus created which tends to displace the adjoining 
 viscera. 
 
 All forms of mediastinal tumors (especially aneurism of the aortic 
 
208 PEACTICAi MEDIOAJC ANATOMY. 
 
 arch) are frequently manifested by an early alteration in the relative posi- 
 tion of the anterior borders of the lungs, behind the sternum. The lungs 
 may, in severe cases, be entirely forced out from behind the sternum, 
 and the bone itself become destroyed by the pressure upon it which 
 eventually impairs its nutrition. 
 
 Finally, the outline of the lungs may be affected in their relation to 
 the wall of the thorax by all those conditions of the abdomen which 
 tend to raise the diaphragm beyond its proper limits. Among these con- 
 ditions may be mentioned tympanites, ascites, large abdominal tumors 
 which reach the diaphragm, extensive ovarian dropsy, cancer of the liver 
 and of the stomach, and tumors of the diaphragm itself. In some 
 exceptional cases of cancer, or of starvation, the abdominal organs waste 
 so rapidly from defective nutrition as to produce a perceptible falling of 
 the diaphragm; in these cases, the lungs would likewise tend to sink down- 
 ward, and thus the limits of pulmonary percussion would be extended 
 in the same direction. 
 
THE CHKST AND ITS CONTAINED OKGAWS. 209 
 
 CHAPTER lY. 
 
 THE CHEST AND ITS CONTAINED ORGANS. 
 
 THE TOPOGKAPHY OF THE WALLS OP THE THORAX, ASTD THE CONTENTS 
 OF THE VARIOUS REGIONS OF THE CHEST. 
 
 The parietes of the thorax have been more commonly subdivided by 
 anatomists into the anterior or sternal region; the lateral, or costal region; 
 and the posterior, or dorsal region. For the purposes of more accurately 
 defining the situation of lesions of the thoracic viscera, it is the custom, 
 however, with purely medical authors to subdivide the chest-wall still 
 more extensively. Thus, the anterior of the chest is divided, by the bony 
 outline of the sternum itself, into three portions, a central and two lateral 
 portions; the former of which is again subdivided into the "supra-ster- 
 nal," the "superior sternal," and the "inferior sternal " regions, while 
 the lateral regions are each subdivided, from above downward, into the 
 "supra- clavicular," the "clavicular," the "infra-clavicular," the mam- 
 mary," and the "infra-mammary" regions. 
 
 The side of the chest is divided into the "axillary," and the " infra- 
 axillary" spaces or regions; while the back of the chest is furthermore 
 divided into a central space, called the " inter-scapular region," and a 
 lateral region on each side, which is usually subdivided into three spaces, 
 called the "supra-scapular," the " scapular," and the infra-scapular" 
 regions. 
 
 Although it is not important or perhaps advantageous to the surgeon 
 to thus subdivide the chest surface into so many difEerent regions, since no 
 object can be gained, except from a medical point of view, by so doing; 
 still it is of great value to the physician (who aims to excel in the discri- 
 mination between diseases of the thoracic viscera and the stages of ad- 
 vancement which any of those diseases have reached), to have the contents 
 and boundaries of these various regions of the chest most thoroughly at 
 his command. It is as an aid to such a knowledge, that I append the 
 boundaries of each, and the various parts which lie in relation to that 
 portion of the internal surface which corresponds to each of the regions 
 above named. 
 
 The suPEA-STERNAL REGION has already been considered, to some ex- 
 tent, as one of the regions of the neck, rather than as belonging to the 
 chest; but, since it contains some structures which are of special interest 
 to the physician in connection with the diseases of the thorax, it is 
 14 
 
210 
 
 PBACTICAL MEDICAL ANATOMV. 
 
 again repeated. It lies above the sternum, and is bounded by the anterior 
 edge of the sterno-mastoid muscle of either side. It contains the trachea, 
 the arteria innominata (on the right side and at its lower angle), and, oc- 
 casionally, the arch of the aorta, when it rises unusually high. 
 
 The SUPERIOR STERNAL EEGIOK lies ovcj the sternum, ahove the line 
 of the loioer lorder of the third rii. It contains the anterior border of 
 the lung of either side, which nearly meet above this level; also, the as- 
 cending and transverse portions of the aortic arch; the pulmonary artery, 
 for its entire length; and the bifurcation of the trachea (situated on a level 
 
 Fig. 126.— The anterior region, the bouudaries of its subdivisions, and the organs corresponding 
 to these subdivisions. (After Loomis.) 
 
 with the second rib in front, or third dorsal vertebra, behind). By refer- 
 ence to a cut on page 196, it will be seen that the aortic and pul- 
 monary valves of the heart are in close proximity to the borders of this 
 region. 
 
 The INFERIOR STERNAL REGION Corresponds to that portion of the 
 sternum which lies Moto the third rib. Upon the right side only, does 
 the anterior border of the lung extend throughout the entire length of 
 this space (see cut on page 196), since the left lung is deflected over the 
 heart. The greater part of the right ventricle of the heart, a smaller 
 part of the left ventricle, and a part of the auricles, lie behind this por- 
 
THE CHEST AND ITS CONTAINED ORGANS. 211 
 
 tion of the sternum; while the tricuspid and mitral yalves of the heart 
 are sibuated within this region (see page 200). The attachment of the 
 central tendon of the diaphragm to the pericardium, a part of the left 
 lobe of the liver, and a part of the stomach are also contained in this 
 space. 
 
 In connection with the regions pertaining to the sternum, it will not 
 be inappropriate to consider that space between the reflections of the 
 pleurse of the right and left lung, called the " anterior mediastinum." 
 This space is not directed parallel with the median line of the sternum, 
 but rather slants obliquely toward the left side, on account of the heart. 
 It is, therefore, important to remember that the pleura of the right lung 
 projects beyond the middle line of the sternum, in the region of the third 
 or fourth rib, and might thus be wounded by puncture, apparently out 
 of the line of the lung. 
 
 The suPRA-CLAVicuLAK EEGiON' is a triangular space which has 
 already been considered at some length in connection with the neck (see 
 page 170),but it may again be recalled as it bears relations to the thoracic 
 viscera. It is a triangle, whose base corresponds to the clavicle, its upper 
 border to a line drawn from the outer third of that bone to the upper 
 part of the trachea, and its inner border to a perpendicular line drawn 
 through the sterno-clavicular joint. It contains the apex of the lung, 
 upon either side; also, the subclavian and the carotid arteries;' and the 
 subclavian, external jugular, transverse cervical, suprascapular, and inter- 
 nal jugular veins." 
 
 The OLATicuLAK EEGiou- Hes behind the inner three-fifths of the 
 bone. It is in close relation to the subclavian artery and vein; to the 
 arteria innominata on the right side near to its inner extremity; to the 
 carotid and 'subclavian arteries on the left side, at its inner extremity;' 
 and to lung-tissue on both sides for nearly its whole length. 
 
 The iNFEA-CLATiouLAK EEGiON is bounded by the lower edge of the 
 claYicle, above; the third rib, below; the edge of the sternum, internally; 
 and by a line drawn perpendicularly from the point of junction of the 
 outer and middle thirds of the clavicle, externally. The contents of this 
 space differ on the two sides of the chest. On the right side, the superior 
 lobe of the lung, the right bronchus (on a level with the second rib), 
 the superior vena cava and a small portion of the aortic arch (lying close 
 to the border of the sternum) are found. A pin introduced at the junc- 
 tion of the upper border of the third costal cartilage and the sternum, on 
 the right side, would pierce the arch of the aorta; while one, introduced 
 
 ' Whether the carotid artery or the jugular vein which accompanies it can be 
 included in this space depends on the limit placed as the internal boundary of the 
 space. 
 
 ' Since they arise from the arch of the aorta, upon the left side of the body^ 
 and from the innominate artery upon the right side. 
 
212 
 
 PKACTICAl. MEDICAL ANATOMY. 
 
 at the edge of the sternum and through the second intercostal space 
 of the same side would wound the superior Yena cava, after first perfor- 
 ating the lung, before that vein entered the pericardium. ' On the left side. 
 
 Fia. 127.— The posterior region, the boundaries of its subdivisions, and the organs corresponding 
 to these subdivisions. (After Sibson.) 
 
 ' See plate on page 196. 
 
THE CHEST AND ITS CONTAINED ORGANS. 213 
 
 the superior lobe of the left lung, the left bronchus, and the pulmonary 
 artery are to bo found in this space. The two large yessels (the aorta and 
 pulmonary artery) are each to be found behind the second costo-sternal 
 articulation, on the right and left side of the sternum, respectively. 
 
 The MAMMAET EEGiois' is bounded by the third rib above; by the 
 lower edge of the sixth rib below; by the edge of the sternum internally; 
 and by a continuation of the line marking the external border of the 
 infraclavicular region on the outer side. On the right side of the body, this 
 space contains the attachment of the right side of the diaphragm as high 
 as the seventh rib; the liver and diaphragm as high as the fourth interspace; 
 a small part of the right auricle, close to the sternum, on a level with the 
 fourth and fifth ribs, and the edge of the lung of that side which extends 
 downward behind the sternum to the sixth rib, when it is reflected in a 
 direction nearly parallel to the inferior border of this region. On the 
 left side of the body, this space covers lung-tissue only as far down as the 
 lower border of the fourth rib, since the heart causes the lung to leave the 
 .sternum at the fourth costo-sternal articulation; the exposed portion of 
 the heart is contained in this region, and a small portion of the apex of 
 the right ventricle. 
 
 The STJPEA-SCAPULAE EEGioif Corresponds to the supra-spinous fossa 
 of the scapula, and covers lung-tissue. It begins at the level of the sec- 
 ond rib and extends downward as far as the limits of the spine of the 
 scapula. It covers lung-substance on each side of the body. 
 
 The SCAPULAE EEGiOK extends from the spine of the scapula to the 
 lower angle of that bone. It therefore corresponds to the infra-spinous 
 fossa. It covers lung-tissue throughout its entire extent. Its lower 
 border corresponds to the level of the seventh rib. 
 
 The INFRA-SCAPULAE REGION extends from the line connecting the 
 inferior angle of the scapula and the seventh dorsal spine to the level of 
 the twelfth rib below. It is bounded internally by the spinous processes 
 of the vertebrae; and, externally, by the line dropped perpendicularly 
 from the angle of the scapula. This space is occupied by lung-tissue as 
 far down as the level of the eleventh rib; but, below that point, the liver 
 substance approaches the surface, on the right side, while, on the left side, 
 the intestine fills the inner part of this space, and the spleen the outer 
 part. The thoracic aorta lies to the left of the spinal column; and a 
 small portion of the kidney can be found, on each side, close to the 
 spinal column — but slightly more upon the left than on the right side. 
 
 The iNTEE-scAPULAE EEGiON compriscs that space between the inner 
 border of the scapula and the spinous processes of the vertebra, upon 
 each side of the body. It, therefore, extends from the second to the 
 sixth dorsal spines. It contains, if both sides be considered as forming 
 only one space, the trachea, the main bronchi, the bronchial glands, 
 lung-tissue, the oesophagus, the descending portion of the arch of the 
 
214 
 
 PEACTICAL MEDICAL ANATOMY. 
 
 aorta, a part of the thoracic aorta, and the other structures which are 
 contained in the posterior mediastinum. , , -, . ,, 
 
 The AXiLLAET KEGiON extends from the external border o± the 
 mammary region, in front, to the external border of the scapular region 
 behind. It includes the axillary space which hes aboYC the line, and 
 those portions of the chest which lie both in front of, and behind it. It 
 corresponds to the upper lobes of the lung of the corresponding side; and 
 the main bronchus of each lung can be found deeply seated m this 
 
 space. 
 
 The INERA-AXILLAKT REGION is limited,' in front, by the mfra-mam- 
 mary region; above, by the axillary region; and, behind, by the infra- 
 scapular region. It is limited, below, by the edges of the false ribs. 
 
 Flo. 133. 
 
 Fig. 129. 
 
 Fio. 128, Anterior, and Fia. 129, Posterior view ot the normal limits and intensity of dulness on 
 percussion; P, pulmonal sound; C, cardiac sound; H, hepatic sound; S, splenic sound; G, gastric- 
 sound (here the stomach is moderately distended with air) ; E, enteric pound. In the anterior view 
 the intestines are tolerably free from air, except CO, colic sound, from distended colon. The de- 
 scending colon and rectum are filled, and sound dull. HU, humoral soimd, over a distended blad- 
 der; M, muscular, and O, osteal sounds. (After Piorry.) 
 
 This region contains, on both sides of the body, the sloping edge of the 
 lung, which is lowest in the posterior region of the chest. On the right 
 side, the liver helps to fill up this region; while, on the left side, the 
 stomach and spleen are present. 
 
 SURGICAL POINTS OF INTEREST PERTAINING TO THE THORAX. 
 
 Fractures of the ribs may be the result of direct or indirect 
 violence applied to the chest. The situation of the fracture is greatly 
 modified by the type of injury which produces it, as has already been dis- 
 
THE CHEST AND ITS CONTAINED OKGANS. 215 
 
 cussed somewhat at length on page 189 of this volume; and the danger of 
 serious complications, from injury done to the thoracic viscera hy the 
 fractured ribs is much greater when that injury is due to direct violence 
 than when produced from simple compression of the chest. Almost all 
 forms of direct violence tend to drive the cliest-wall inward at the point 
 where the blow is received; and thus the pleura, the lung, the dia- 
 pliragm, or the heart and pericardium may be injured by the fragments, 
 if not by the blow itself. Such an accident may, therefore, become the 
 cause of death, since hemorrhage, pleurisy, pneumonia, emphysema, 
 pericarditis, myocarditis, aneurism, or peritonitis may be developed; and 
 the respiration may, in rare cases, be greatly interfered with if the dia- 
 phragm be badly torn. It is infrequent to find these complications 
 present, in fracture of the ribs from indirect violence, since, as before 
 stated, the fragments art usually directed outward, and thus away from, 
 rather than toward, the organs of the chest. During the contraction of 
 tlae abdominal muscles, in the forcible expulsive efforts of parturition, 
 the ribs have been known to be fractured; while I have seen the same 
 accident occur in exercising upon the parallel bars of a gymnasium. 
 
 Any of the ribs may be broken,, but the first and second are so thor- 
 oughly protected by the bones of the shoulder and the muscles of the 
 chest that they are seldom fractured; but, if so, a most serious accident 
 exists. Why this region should have any special dangers can be more 
 easily understood by referring to page 189. The lower ribs are also 
 comparatively exempt from fracture, since their mobility renders them 
 capable of withstanding a much greater shock than the middle ribs wliich 
 are firmly attached to the sternum in front, and to the vertebral column 
 behind. Age seems to have a marked influence upon the liability of 
 fracture of the ribs from any lorm of indirect violence, since the elasticity 
 of the bones has become impaired. One practical point in the relief of 
 fractures of the ribs is suggested by the physiological action of these bones 
 during the acts of inspiration and expiration; since the constant move- 
 ments of the chest interfere, not only with the union of the fragments, 
 but also greatly increase the pain, which is experienced by sufferers from 
 this accident. As soon as the patient has been seen and the existence of 
 a fracture positively diagnosed, by an abnormality or irregularity of the 
 rib, the presence of crepitus, and abnormal mobility of the fragments, the 
 chest should be firmly compressed by strips of adhesive plaster, applied 
 after a full expiratory effort; thus the broken ribs are held immovable 
 during the process of repair, and the pain, experienced previous to the 
 application of these strips, is greatly diminished. I am inclined to favor 
 the application of these adhesive strips to the entire circumference of the 
 chest at the seat of fracture, rather than an attempt to leave the unin- 
 jured side free to expand with inspiration, since I find, in most cases, 
 that the latter is impracticable. The plaster used should be free from 
 substances which will create an irritation of the skin and should be spread 
 
216 PBACTICAL MEDICAL ANATOMY. 
 
 on twilled muslin or canton flannel, rather than on ordinary muslin, to 
 render it incapable of stretching. 
 
 The ribs have occasionally to be resected for extensive caries or necro- 
 sis of these bones, and for tumors developed in connection with the ribs. 
 The old opinion, that such a step was demanded to relieve the pleura from 
 a source of irritation, has been somewhat modified of late, since the 
 danger of pleuritic inflammation is rather increased by such surgical 
 interference than avoided. Fortunately, the occurrence of extensive dis- 
 ease of the ribs is not so common as to bring this question prominently 
 before the mind of the surgeon. Cloquet and Berard, as well as Vel- 
 peau, report marvellous cases where the ribs have been excised so as to 
 expose the pulsations of the heart (and one, where the whole fist could be 
 inserted into the opening through the thoracic wall) without causing 
 death to the patient; but the danger of compression of the lung by the 
 air introduced into the pleural cavity is not to be considered as but one of 
 the most extreme significance, as regards the life of the patient. 
 
 The evacuation of fluid from the cavity of the chest — the operation of 
 "paracentesis thoracis'' — is among the most ancient of all surgical pro- 
 cedures; being referred to as far back as the time of Hippocrates. It is so 
 commonly performed, at the present time, by those who do not claim 
 distinction for surgical skill, that it can hardly be classed as more than 
 one of the common methods of relief, in those cases where pus or fluid 
 has accumulated in the cavity of the pleura. I have also seen it per- 
 formed for the evacuation of a large abscess of the lung itself, with good 
 results. It is indicated in all cases where the compression of the lung by 
 fluid in the pleura has progressed to such an extent as to interfere with 
 the subsequent absorption, after the inflammatory process has subsided; 
 and also, in all cases, where the danger of perforation of the walls of the 
 thorax seems imminent, by collections of pus either within the pleural 
 sac or external to it. The aspirator has afforded the practitioner a means 
 of emptying such cavities with little, if any, danger of the entrance of 
 air; and the step has, therefore, lost the chief element of danger which 
 formerly deterred surgeons from frequently employing this method of 
 relief. The space between the fourth and fifth, or the fifth and sixth 
 ribs,' is usually selected for puncture, and the needle should be intro- 
 duced close to the ujjper harder of the rib, in order to avoid the inter- 
 costal vessels, and also in the central line of the axillary space, for the 
 same reason. It is my custom to puncture one rib higher upon the right 
 side than upon the left, as the liver is liable to be wounded if the 
 
 ' Verdue, Desault, and Boyer recommended the lower portion of the chest for 
 tapping; while Lsennec advised the puncture to be made at the central portion of 
 the chest, so as to assist drainage, while the patient was lying down. The valvu- 
 lar flap and incomplete evacuation now renders the question of future drainage 
 of no importance. 
 
THE CHEST AND ITS CONTAINED OKGANS. 217 
 
 puncture be made too low down upon that side; although, in case 
 no adhesions exist, that organ is probably displaced downward by 
 the fluid, if it be large in quantity. I prefer to have the patient in a 
 sitting posture, as the weight of the column of fluid, aboye the seat of 
 puncture, assists in its escape; and, as the lung tends to expand from 
 above downward, as the fluid is withdrawn, that organ is therefore less 
 liable to be injured by the needle. In case of tapping the chest for fluid 
 in the pleura, it is my rule to be governed by the sensations of the pa- 
 tient, as to the amount which shall be withdrawn at any one time; always 
 withdrawing the needle as soon as the patient ceases to experience relief, 
 or begins to feel unpleasant effects from the decrease of pressure upon the 
 lung. A valvular opening should always be insured by drawing the skin 
 of the chest upward before the needle is introduced, since it tends to 
 return to its normal position as soon as the needle is withdrawn, and 
 thus covers the opening. In this way, the possibility of the entrance of 
 air into the chest is greatly diminished. 
 
 The operation of tapping the pericardial sac, for fluid within its cavity, 
 has not, as yet, seemed to meet with the approval of surgeons, although 
 some forcible arguments can be urged in its favor. The constant move- 
 ment of the heart within the sac, and the liability to puncture or lacera- 
 tion of that organ by the needle, seems to render the operation one of far 
 greater danger than that upon the pleura. 
 
 The deformities of the thorax which are met with as a result of rachi- 
 tic affections of the spinal column,, and from the effect of atmospheric 
 pressure upon the chest-wall, when the expansion of the lung does not 
 keep pace with the rapidity of absorption of fluid within the pleural sac, 
 have already been mentioned in the previous pages of this chapter (see 
 page 193). 
 
 The lower costal cartilages are sometimes caused to glide over each 
 other, thus constituting a trivial kind of dislocation. The direction of 
 the upper ribs, where one of the surfaces looks upward, renders a wound 
 made by a pointed instrument more liable to enter the chest if it come 
 from above downward; while, from an opposite arrangement, the lower 
 ribs are most likely to be perforated by pointed instruments held in a . 
 horizontal direction. 
 
 In wounds of the chest by pointed instruments, it should always be 
 remembered that the seat of the puncture modifies the danger, in case the 
 instrument enters the chest; and a reference to the contents of the differ- 
 ent topographical regions (see cuts on pages 310 and 313) will enable the 
 reader to ascertain the various structures which are liable to be involved 
 in any of the different parts of the thorax. A peculiarity in the course 
 of the intercostal arteries affords a point of some practical interest. 
 These vessels are protected by a groove in the lower border of each rib, 
 for the middle portion of their course only, since they are uncovered by 
 bone both in the posterior and anterior portions of the chest; hence they 
 
218 PEACTICAL MEDICAL ANATOMY. 
 
 are seldom wounded in the axillary region, but they may be in the parts 
 anterior or posterior to it. The internal mammary artery ' may also be 
 wounded, if an instrument pierce the chest-wall in the vicinity of the 
 sternum, while the heart cavities, the pulmonary artery, the aorta, and 
 the superior vena cava may also be opened. 
 
 The dangers of wounding either the lung or the pleura have already 
 been mentioned in previous pages. If the pleura only be wounded, an 
 inflammation of that membrane may be excited; or, if the opening allow 
 of the entrance of air into the cavity of that sac, the lung may be imme- 
 diately collapsed, and the most alarming dyspnoea, and even symptoms of 
 shock of a dangerous character, may be excited from so suddenly depriv- 
 ing the patient of the use of one lung. If the lung be wounded, a rapid 
 pneumonia may develop, or hemorrhage may occur from the injury 
 done to the vessels of that organ, which will probably escape from the 
 mouth, although it may enter the pleura. Emphysema of the connective 
 tissue between the lobules of the lung may occur, if sufficient air escape 
 through the wound in the lung; or a similar condition of the pleural 
 cavity may result, as before described, if the air be allowed to freely com- 
 municate with it by means of the lung. It might be possible for abscess 
 of the lung to follow such an accident, if the damage inflicted injured the 
 tissues to such an extent as to induce suppuration. Should the instru- 
 ment penetrate the middle mediastinum, the phrenic nerve might be 
 severed, and thus extreme dyspnoea might be created, irrespective of the 
 pulmonary lesion; but the nerve is placed too deeply to be so wounded 
 without the lung itself was pierced. 
 
 "Wounds of the region of the sternum are of a most serious character, 
 as can be seen when the important functions of the parts which are con- 
 tained wit?hin it are considered. This region is so filled with vascular 
 organs that the penetration of a sharp instrument may produce death 
 from puncture of the pericardium, the right cavities of the heart, and the 
 pulmonary artery; while, if it go still more deeply, the left cavities of the 
 heart and even the arch of the aorta may be opened. The mediastinum 
 lies behind the sternum, except upon the left side and in the dependent 
 portion of the chest, where it is in relation with the ribs for a short dis- 
 tance; it could, therefore, be penetrated at this point by a sharp instru- 
 ment without the sternum being pierced, but not elsewhere. 
 
 The relation of the internal mammary artery to the under surface of 
 the sternum, especially that of the left side, renders the sternal region a 
 source of hemorrhage, in those cases where the wound has been too super- 
 ficial to affect the other sources of hemorrhage which have been already 
 mentioned above. It was this danger that chiefly influenced Senac in 
 
 ' This artery is most apt to be wounded in its upper portion, on account of the 
 width of the upper intercostal spaces, the size of the vessel, and the fact that it 
 is removed by about two lines from the edge of the sternum. 
 
THE OHEST AND ITS CONTAINED OEGANS. 219 
 
 giving his rule as to the seat of election for puncture of the pericardium, 
 (third intercostal space, two inches from the middle line of the sternum), 
 since he preferred to wound the pleura rather than run the danger of 
 hemorrhage from the internal mammary artery (as would probably occur 
 if Leennec's ' method were followed). 
 
 Abscesses not infrequently form in the mediastina and are thus pro- 
 perly mentioned in connection with this region. They may be of local 
 origin, or the result of burrowing of pus from the region of the neck; 
 since the deep cervical fascia may prevent the pointing of such accumu- 
 lations at the seat of their formation, and the fluid be forced to find some 
 other means of outlet. I recall a case where pus had thus escaped into 
 the cavity of the thorax and pointed at the xyphoid cartilage of the ster- 
 num. The most common cause of such accumulations of pus within the 
 cavity of the mediastina is disease of the dorsal vertebrae. Carious 
 degeneration of these bones may give rise to very large collections of 
 pus which are particularly prone to infiltrate the loose connective tissue 
 which invests the aorta, and thus to travel downward, in the posterior 
 portion of the chest; while, in occasional instances', the pus may escape 
 from the cavity of the thorax by means of the aortic opening of the dia- 
 phragm, into the cavity of the abdomen. 
 
 It is not infrequently observed, when any cause of sympathetic irri- 
 tation is present, affecting the bronchial or oesophageal glands, that so 
 gi-eat an amount of tumefaction is created in them as to possibly produce 
 dysphagia from pressure upon the oesophagus, or dyspnoea from pres- 
 sure upon the trachea or the main bronchi, or possibly the phrenic nerve; 
 and, in case they proceed to suppuration, they may evacuate their con- 
 tents into the oesophagus, the right or left bronchus, the pleural sac of 
 either side, or even into the pericardium. 
 
 The effects of aneurismal tumors of the aortic arch or the descend- 
 ing portion of that vessel will be considered in some detail in later 
 pages of this work treating of the viscera of the thorax, but it may be 
 here suggested to the mind of the reader that such tumors are liable to 
 produce a local deformity of any of the regions of the chest, and espe- 
 cially of the sternal region, by absorption of the bones as the direct result 
 of long-continued pressure. 
 
 In the region of the sterniim, some curious deformities are occasionally 
 observed at the date of birth. It has been found to be congenitally cleft 
 or absent in its middle portions, thus leaving the pulmonary organs and 
 the pericardium almost naked. The xyphoid cartilage may be cleft, or 
 bifurcated, as an evidence of imperfect or arrested development. As 
 
 ' The suggestion made by Laennec, in case of fluid in the pericardium requir- 
 ing evacuation by surgical means, was to trephine 6ver the lower portion of the 
 Btei-num and tap the sac where it could be felt to fluctuate, and as low down as 
 possible. 
 
220 
 
 PKACTICAL MEDICAL ANATOMY. 
 
 before mentioned, certain occupations may produce acquired types of 
 deformity; thus, in shoemakers, the xyphoid cartilage may be so depressed 
 as to impinge upon the heart from the constant attitude assumed in that 
 occupation, while, in carpenters, the same efEect is perhaps more fre- 
 quently noticed, from the habit of using tools which are pressed upon 
 this region in order to brace them firmly against the materials upon 
 which they are employed. Severe blows upon this portion of the bone 
 may result in a depressed fracture, as in Billard's case, where gastrotomy 
 was required to replace it. 
 
 It is a well recognized fact that this region is a common seat of vene- 
 real growths and ulceration, probably on account of its superficial situa- 
 
 FiG. 130.— A diagram of the important structures within the thorax and neck. (After Wilson.) 
 1,3, 3, arch of aorta; 4, thoracic aorta; 5, artei'ia innominata; 6, common carotid artery; 7, subcla- 
 vian artery; 8, axillary artery ; 9, brachial artery; 10, right pneumogastric nerve; 11, left carotid 
 artery; 12, left subclavian artery; 13, left pneumogastric nerve; 14, 15, 16, 17, pulmonary artery; 
 18, right pulmonary Veins; 19, left pulmonary veins; 20, trachea; 21, 23, right and left bronchus; 
 23, intercostal arteries. 
 
 tion; and caries and necrosis is, occasionally, so extensively developed in the 
 sternum as to require removal either of portions of the bone or the bone 
 itself, as is reported by Galen, Genouville, and Boyer. This bone some- 
 times requires trephining, when the innominate artery is to be reached ; 
 and it has been suggested by Lsennec as a step to be performed previous 
 to puncture of the pericardial sac. ' 
 
 ' Senac's rule for puncturing the pericardium is to introduce the trocar in the 
 third intercostal space, at a distance of two inches from the middle line of stemum. 
 
THE CHEST AND ITS CONTAINED ORGANS. 221 
 
 Behind the upper portion of the sternum, there is little or no space 
 left for the presence of lung-tissue, since the trachea and the large blood- 
 vessels are in close relation to it. Just below its upper margin, the left 
 innominate vein crosses the sternum to join that of the right side and 
 thus form the superior vena cava. The large branches which arise from 
 the arch of the aorta lie immediately behind this large vein; while deeper 
 still, the trachea may be found, dividing into the right and left bronchus 
 at a point corresponding to the junction of the first and second bones of the 
 sternum, or on a level with the third dorsal vertebra. Behind all of these, 
 lies the oesophagus. The arch of the aorta seldom reaches the upper 
 border of the sternum, but may be found, as a rule, to extend to within 
 one inch of that point; so that the aorta usually lies upon the trachea 
 just above its point of bifurcation. If we draw a line upon the sternum, 
 from the middle of the junction of the manubrium with the gladiolus 
 to the right sterno-clavicular joint, it will indicate the course and extent 
 of the arteria innominata. 
 
 The mammary region is a frequent seat of surgical affections. Ab- 
 scesses often develop in this gland, during lactation, in consequence of 
 some obstruction in the lacteal ducts. Benign tumors are also common 
 in this region; and the seat of election manifested by scirrhus is prover- 
 bially the breast of the female. This fact seems to indicate that the con- 
 stant irritation of the nipple during nursing, and the prominence of the 
 breasts which exposes them to a greater liability to external forms of 
 injury, are factors which tend to account, in some degree at least, for 
 this affection. 
 
 The costal region of the chest has already been somewhat exhaustively 
 considered, when the dangers of fracture of the ribs were discussed, and 
 the surgical treatment of fluid within the pleural and pericardial sacs, by 
 aspiration.' There is, however, another point of interest suggested by 
 the distribution of the nerves and blood-vessels to this region that will 
 tend to explain the efificacy of certain well-recognized methods of treat- 
 ment. It is customary to apply both wet and dry cups over the surface 
 of the chest, as well as blisters of large size, when we wish to make any 
 decided impression upon the pleura. Such remedial measures are 
 employed for the relief of the pain of pleurisy, as well as for neuralgic 
 attacks affecting the intercostal nerves; and they are also frequently ad- 
 vised as a means of assisting in the absorption of inflammatory effusion, 
 within the cavity of the pleura. Now, if they are to be attended with any 
 b&nefit, such measures must be based upon some anatomical explanation; 
 and we find a simultaneous distribution of both vessels and nerves from 
 common trunks to the skin and the pleura of the corresponding side, as 
 our justification for such a plan of treatment. I am frank to state that 
 I have never yet been able to see how the lungs can be markedly relieved 
 
 ' See p. 216 for the steps of this operation and its indications. 
 
222 PBAOTICAL MEDICAL ANATOMY. 
 
 by the local abstraction of blood from the surface of the chest, since the 
 bronchial yessels are only for the purpose of nutrition of those organs 
 and. carry but a small proportion of the actual blood contained, and hence 
 abstraction of blood from the chest must first afEect the amount of blood 
 in the aorta itself, before it can affect the bronchial vessels, which 
 are themselves but minor factors in the general pulmonary circulation. I 
 do not believe that the intercostal, vessels nourish the lung substance, 
 although they do the pleura; and to afEect the amount of blood in the 
 lung itself, general depletion ■would be of as much, if not of more avail 
 than any attempt to reach the lung through the blood-vessels of the 
 thorax. If we accept the results of those experiments of Cammann, who 
 proved that the pulmonary and Ironchial vessels of the lung do not com- 
 municate (by injecting into the bronchial and the pulmonary arteries 
 ■ two fluids which would generate a gas when they came in contact with 
 each other, and thus create an inflation of the lung), we are still more 
 fortified in the position which we have taken, as to the absurdity of at- 
 tempting to reach the pulmonary circulation by any type of local depletion. 
 
 The explanation of the arrest of pain by local abstraction of blood is 
 supposed to rest in the relief of the pressure, upon the nerve trunks or 
 filaments, created by the over-distended vessels; while its effect upon the 
 absorption of inflammatory effusions within the pleural sac is based 
 upon a similar relief to the over-distended blood-vessels, which ramify 
 Tipon the surface of that membrane, and which are unable to absorb rap- 
 idly on account of the sluggishness of their current. I am inclined to 
 think, however, that a moderate withdrawal of, the fluid by the aspirator, 
 thus relieving the excessive distention of the sac, hastens the process of 
 absorption after an attack of sub-acute pleurisy, more than blood-letting, 
 dry cups, or blisters to the chest." 
 
 In the region of the back, the walls of the thorax may present the 
 condition of spina bifida. This is characterized by the appearance of a 
 fluctuant tumor, of varying size, dependent upon an arrest of develop- 
 ment of the spinous processes of the dorsal vertebrae and a protrusion of 
 the membranes of ^he spinal cord through the opening so produced; thus 
 forming a tumor which fluctuates, since it usually contains the cerebro- 
 spinal fluid. The size of this tumor depends upon the extent of the 
 abnormal opening, and the amount of protrusion of the membranes. 
 The shape of the tumor is usually oblong, with its long axis parallel with 
 the axis of the vertebral column, on account of the shape of the opening 
 through which the membranes escape. The contents of these tumors 
 explain the fact that pressure upon them may cause the fluid to again 
 return to the spinal canal, or possibly to enter the ventricles of the brain" 
 in excess, and so create brain symptoms. 
 
 ' For the details of this operation see p. 216. 
 
 ' The functions of this fluid are to equalize the pressure within the brain, 
 
THE CHEST AND ITS CONTAINED OEGANS. 223 
 
 Curvatures of the dorsal region of the spine may follow the condition 
 of rickets, when the lateral curye normal to this region '.may be increased 
 to such an extent as to constitute a deformity; or, in cases less frequently 
 met with, the posterior curve of the spine may be increased. In tabes 
 dorsalis, however, which acts upon the bodies of the vertebrae, consisting 
 of a tuberculous change in the bones, the flexion most often seen in 
 the dorsal region consists of a curve from behind forward. 
 
 When a person falls forcibly upon the back, the projection of the 
 ribs beyond the spinous processes of the dorsal vertebrae affords a partial 
 protection to this portion of the spine, although the dorsal vertebrae are 
 more liable to be struck in such an accident than the cervical or lumbar, 
 on account of the curve of that region, which rather favors than avoids 
 violence. Nature has, however, compensated for this risk by so inter- 
 locking the processes as to render the movement of this region a limited 
 one, and external violence is therefore capable of doing less damage here 
 than it would elsewhere. A practical point is afforded (in those cases where 
 suppuration and deep abscess follow a blow received on the spine) by the 
 vertebral apaneurosis, which tends to prevent the pus from pointing, 
 and favors its infiltration into adjoining parts; such abscesses should, 
 therefore, be incised early. 
 
 Wounds of this region cannot cause a dangerous hemorrhage, provided 
 the designated region be confined to the spinal column proper, since it is 
 almost impossible for a pointed instrument to penetrate into the spinal 
 canal, and the muscular structures are not supplied with vessels of large 
 calibre. The absence of large arterial trunks from the exposed surfaces 
 of the body is one of those wise provisions on the part of Nature, by 
 which she guards the important parts of the frame from those injuries 
 which we are constantly liable to receive from without. 
 
 The diaphragmatic region of the thorax may be lacerated during any 
 iorm of violent exertion, especially in those cases where the patient has fallen 
 from a great height and has made extra exertions to save himself. Such 
 lacerations are usually met with upon the left side, since the liver tends 
 to support the right side of the diaphragm, while the left side is com- 
 paratively unsupported. 
 
 The diaphragm may be wounded through the costal, lumbar, costo- 
 iliac, or dorsal regions. The convexity of the muscle brings its central 
 
 when the amount of blood in that organ suffers variation, as in the respiratory- 
 act. It also protects certain parts of the brain from injury (see page 148). 
 
 ' For details of this lateral curvature, which is normal to the majority of 
 adults, see page 140. 
 
 The guides to the thoracic viscera, which are afforded by the spines of the 
 dorsal vertebrae, are of great importance to the diagnostician; they may be 
 found mentioned in connection with the description of the bones of the vertebral 
 column (page 142) and also in the enumeration of the contents of the special to- 
 pographical regions of the chest (page 141). 
 
224 
 
 PRACTICAL MEDICAL ANATOMY. 
 
 portion far above its seat of attachment to the margins of the chest and 
 the dorsal Tertebrse, while its position is never constant, since it moves up 
 and down with respiration. In those cases where abscess of the liver is 
 aspirated, the diaphragm is usually pierced by the needle before it enters 
 the liver substance; and the obscure sense of fluctuation, by which the 
 knowledge of the existence of deep abscess of this organ is gained, is best 
 perceived by crowding the tijJS of two or three fingers into the space 
 between the seventh and eighth ribs and giving an impulse to the left 
 lobe underneath the xyphoid appendix of the sternum, thus using the 
 muscular tissue of the diaphragm as a part of the conducting medium. 
 Blows received below the margin of the ribs, if acting obliquely from 
 below upward, may cause an injury to the diaphragm. 
 
 Fis. 131.— Lower part of the chest, showing the diaphragm: a, sixth dorsal vertebra; c, ensi- 
 form cartilage of the breast-bone; d, the aorta, cut across, lying in front of the spinal column; d\ 
 the aorta appearing below the arch formed by the pillars of the diaphragm ; c, oesophagus (cut 
 across) descending through the tendon in the centre of the diaphragm ; /, opening for the passage 
 of the inferior vena cava; 1, central tendon of the diaphragm ; 4, 5, rightandleftmuseularportions. 
 of the diaphragm ; 6, 7, the pillars of the muscle arising behind from the lumbar vertebrae; 8,8, 
 10, 30, internal intercostal muscles ; 9. 9, external intercostal muscles. 
 
 The condition of pregnancy, or the presence of any form of abdominal 
 tumor, if very large, may tend to displace the diaphragm upward, even 
 above the limits of a full expiratory effort; hence a practical point in 
 tapping the chest, when such a complication exists, viz., to select a higher 
 point for perforation than in the normal subject. 
 
 Numerous cases are on record where the omentum, and even the 
 intestine, has been forced through the some of the openings of this mus 
 
THE CHEST AND ITS CONTAINED ORGANS. 
 
 225 
 
 cle; a severe type of hernial protrusion may thus exist, without its 
 presence being suspected, unless the aids of auscultation and percussion 
 be brought to bear upon the case. ' 
 
 The diaphragm is an important muscle from a physiological stand- 
 point, since not only is inspiration largely controlled by its contraction, 
 but a suction action upon the blood in the inferior vena cava is thus pro- 
 duced,'' which greatly assists in causing the return of the venous blood 
 from the lower extremities and the abdominal viscera to the right auricle 
 of the heart. In addition to these functions which are being constantly 
 employed, and which are necessary to the life of the individual, the dia- 
 phragm is an important factor in the acts of hiccough, laughter, yawning, 
 sobbing, and sneezing. 
 
 That portion of the muscle which invests the oesophagus, just before 
 it enters the cavity of the stomach, is also endowed with a sphincter-like 
 action upon that tube, and the regurgitation of food from the cavity of 
 the stomach is thus prevented during each inspiratory act, when the 
 abdominal organs are crowded downward, and pressure is thus exerted 
 upon the stomach which lies in close relation to that muscle. 
 
 The contraction of the diaphragm^ is supposed by Blandin to pre- 
 dispose toward the development of hernia of the floating viscera through 
 that muscle, since it is brought in closer relation to them than when 
 relaxed; this statement may hold good as regards those openings which 
 are situated in the tendinous portion of the muscle, but I question if the 
 effect of muscular contraction does not act as a barrier to such protrusions 
 through the muscular openings, as they must of necessity be diminished 
 in size. It is possible for the diaphragm itself to become protruded 
 through the infra-sternal space, if it is itself affected with local growths. 
 
 ' For the Bymptoms which indicate such a hernial protrusion through the 
 diaphragm, and tlie means of discrimination between it and tumors situated low 
 down in the mediastina of the chest, the author would respectfully refer the 
 reader to his work on Surgical Diagnosis, where the points are given in the form 
 of tables of differential contrast. 
 
 ' The pericardial sac is attached, above, to the walls of the large blood-vessels 
 escaping from the heart, and, below, to the diaphragm; hence each inspiratory 
 act tends to elongate this sac, and thus to assist the expansion of the heart cavi- 
 ties which, in turn, suck blood from the ascending vena cava, rather than from, 
 the descending vena cava, where gravity assists in emptying it. V 
 
 ^ The compression exerted by the contraction of the diaphragm upon the liver, 
 and possibly also upon the upper viscera of the abdomen, unquestionably tends to 
 empty the blood-vessels of those organs; and it is claimed by Sibson that this is 
 one of the forces which assist in forcing the blood into the inferior vena cava, 
 and thus in propelling the current of blood in that vessel toward the right auricle 
 of the heart. This effect, is, however, of less importance than it would be if 
 these large veins were supplied with valves to prevent regurgitation; and the 
 suction force of respiration must, therefore, be considered as paramount. 
 15 
 
226 FKACTICAL MEDICAL ANATOMY. 
 
 When the diaphragm is the seat of inflammation,' a pain is often felt 
 in the region of the neck and the top of tJie shoulder ; and the same phe- 
 nomena may he observed when the visceral layer of the pleura is involved. 
 This can be explained as a transmission of sensation through the 
 phrenic nerve to its points of origin (the third, fourth, and fifth cervical 
 nerves), and a reflex irritation of the descending filaments of the cervical 
 plexus, which afford sensation to the integument of the region of the 
 shoulder and clavicle. A point of diagnostic value in inflammation of 
 the diaphragm is afforded in a difficulty of respiration; while the so-called 
 "sardonic laugh " is mentioned by some authors as diagnostic of this 
 snecial type of 'disease. 
 
 The base of the chest is the spot usually selected for the application of 
 leeches or Misters in case of inflammation of the diaphragm, since the 
 vessels and nerves which supply the lower intercostal spaces are distrib- 
 uted, in part, to the diaphragm itself. It should be remembered, how- 
 ever, that this rule does not apply to similar conditions of the liver, since 
 the venous blood, which is sent to that organ by the portal system, comes 
 nearest to the surface of the body in the region of the anus; while its 
 arterial supply is derived from the abdominal aorta, and empties into the 
 portal vessels. 
 
 The relative position of tlie diaphragm to the walls of the thorax is so 
 inconstant' that it may be well to here recall some scattered points which 
 are of too practical a character to be forgotten. It has been akeady stated 
 in connection with the variations perceived in the situation of the apex 
 beat of the heart, as well as in other places of the preceding portion of 
 this volume, that the diaphragm -could be displaced both iipward and 
 downward;' that, exclusive of its modified form during inspiration and 
 expiration, the muscle is the passive subject of certain diseased con- 
 ditions which tend to affect its relative position to the adjoining parts; 
 and, finally, that these variations have a practical bearing upon the prog- 
 nosis of penetrating wounds of the chest, as well as to the operation of 
 paracentesis thoracis. Since emphysema is usually a bilateral disease, the 
 diaphragm is crowded downward upon both sides when that affection is 
 markedly developed; and thus the position of the abdominal viscera, as 
 
 • As may occur from an extension of a, pleurisy, pneumoijia, pericarditis, 
 hepatitis, or disease of the chest-wall, or mediastina. 
 
 ^ Birds, lizards, and snakes breathe by the movement of the ribs alone, the 
 diaphragm being either absent or subsidiary.— Sibson: Medical Anatomy. 
 
 The "false i-ibs" are sometimes called the "diaphragmatic ribs," since they 
 afford attachment for that muscle. Sibson considers the term ' ' false ribs " as a 
 misnomer, since they affect respiration to the same extent as the true or sternal 
 ribs. 
 
 2 On page 197 a table is given to show the causes of a displaced apex-beat of 
 the heart. This same table will also assist the reader to properly understand 
 the causes of displacement of the diaphragm. 
 
THE CHEST AND ITS CONTAINED ORGANS. 227 
 
 well as that of the heart, is materially altered. Collections of fluid within 
 the pleural sacs may also displace the diaphragm downward, and, with it, 
 the adjoining viscera of the afEected side. I haye seen the liver almost 
 entirely displaced from its relations to the chest-wall, lying free within 
 the cavity of the abdomen, from a very extensive effusion of the right 
 side of the pleura. The diaphragm may also be raised by any tumor of 
 the abdominal viscera if sufficiently large to effect it; and one side may 
 be more displaced than the other if tiie pressure be confined to one-half 
 of the muscle. Thus an abscess, or any form of tumor of the liver will 
 cause an encroachment upon the right side of the chest more than upon 
 the left, and the heart may be crowded to the left side rather than 
 upward; while tumors of the cardiac end of the stomach, the spleen, the 
 left kidney or ovary, and other forms of abdominal tumors, may produce 
 a diminution of the left side of the thorax, while the right side may be 
 normal. 
 
 THE THOKAX CONSIDERED AS A WHOLE. 
 
 It has been shown in previous pages that the walls of the thorax are 
 purposely made flexible and capable of movement, in order to allow of 
 respiration; that the capabilities of movement of the different parts are 
 somewhat modified in the sexes; that the cavity of the thorax can be 
 shortened and lengthened, both by the movements of the ribs and that 
 of the diaphragm; that the thoracic organs move downward while the 
 ribs ascend, and upward when they descend; that the neck is encroached 
 upon by the inspiratory movements of the thorax; that the intercostal 
 spaces are differently affected by the movements of inspiration and expi- 
 ration, in different parts of the thorax; that certain diseased conditions 
 of the thoracic viscera have a marked effect upon these points previously 
 mentioned; that the chest- wall affords the physician a means of mapping 
 out the relations of the viscera to each other in health, and often furnishes 
 pathognomonic evidences of diseased conditions of viscera; and, finally, 
 that many surgical guides are afforded by the bones and soft tissues of 
 the thorax, which are capable of various applications in medicine as well 
 as in operative procedures. 
 
 The cervical and dorsal vertebral form curves which are relatively in- 
 creased during inspiration, and thus the length of each of these two seg- 
 ments of the spinal column is shortened. 
 
 The five upper ribs act exclusively upon the upper hie of the lungs and 
 have no bearing upon the lower lobe or the diaphragm; while the sixth, 
 seventh, and eighth ribs act in common and co-operate with the dia- 
 phragm in affecting the lovrer lobe of the lung. The steady increase of 
 the length of the ribs from the first to the eighth tends to explain why 
 the lower part of the sternum is pushed farther forward during inspira- 
 tion than the upper part of the bone, as well as why the dorsal curve of 
 the vertebral column- is increased. The fourth, fifth, and sixth ribs have 
 
228 
 
 PEACTICAL MEDICAL ANATOMY. 
 
 a curye whose convexity looks downward; the seventh rib is straight; and 
 the eighth and ninth ribs have a curve whose convexity looks upward. ' 
 The epigastric space, contained between the seventh and eighth costal 
 cartilages, is widened in inspiration, and narrowed during expiration; 
 and these cartilages and their articulation to the lower end of the sternum 
 have been compared to the limbs of a pair, of compasses which expand 
 and converge with the respiratory act. 
 
 In the majority of males, the thoracic expansion during tranquil inspi- 
 ration is about one-twentieth of an inch, and the abdominal expansion 
 about one-third of an inch; while in the female, the thoracic expansion is 
 increased oyer the previous measurement, and the abdominal expansion 
 is decreased. Up to the age of fourteen, the two movements are alike in 
 the two sexes. The abdominal expansion during inspiration is produced 
 by the descent of the diaphragm. 
 
 Fio. 133. FlQ. 133. 
 
 Fio. 132.— The stethometer of Dr. Quain— half the real size. (After Quain.) 
 Fio. 133.— Mode of applying the instrument when the string is used. (After Quain.) 
 
 It is customary with specialists, in the diagnosis of lung affections, to 
 estimate by actual measurement the amount of expansion upon each side 
 of the chest during tranquil breathing and forced inspiration, and to 
 judge by the comparison of the measurements of the respective sides how 
 great an impairment of inflative power either lung manifests. This same 
 conclusion can be roughly drawn by instructing the patient to stand erect 
 with the arms hanging loosely at the sides of the chest, and with the back 
 toward you. If you now watch the movements of the scapulm, during a full 
 inspiratory effort, and again during tranquil breathing, you will perceive 
 that these bones move outward from the spinal column, just in propor- 
 tion to the amount of expansion of the chest upon that side; since the 
 serratus magnus muscle is attached to the ribs anteriorly, and posteri- 
 orly to the posterior border of the scapula, and acts (since no resistance 
 is afforded by the movable scapula), as a band over the expanding 
 
 ' This is admirably depicted in the plates of Sibson's great work. 
 
THE CHEST AND ITS CONTAINED ORGANS. 
 
 229 
 
 chest, wMcli moTes the scapula in the exact proportion to the increased 
 circumferential measurement of that side. 
 
 When pus is formed within the chest, the wall of the diaphragm is 
 crowded downward toward the cavity of the abdomen, and the space be- 
 tween the upper surface of that muscle and the inner surface of the ribs 
 is very much enlarged. The lung may form adhesions in this abnormal, 
 position and then, if the patient recovers from the pus formation, the 
 costal region is liable to become retracted. 
 
 It is asserted by Valentine that, when Hood accumulates within the 
 cavity of the chest, after it descends to the most dependent part of the 
 thoracic cavity, it is liable to pass into the cellular tissue and thus create 
 an ecchymosis in the loins. Should this accumulation of blood occur 
 within the cavity of either pleura, such an infiltration could not occur 
 without it first passed through that membrane; hence such an ecchymosis, 
 as mentioned above, is not a constant symptom of thoracic hemorrhage. 
 
 In auscultation of the chest, it should be remembered that the upper 
 part is much thicker, posteriorly, than the lower portions on account of the 
 scapulae, which render it difficult to perceive sounds created in that region 
 
 Fio. 134.— Mode of application of the chest-measurer, attached to brass rods, bent at right angles, 
 when the patient is in the horizontal posture. (After Sibson.) 
 
 with the same distinctness as in other parts; while, in the lower portion 
 of the chest, especially in the sternal region, the presence of the stomach 
 and liver are liable to so alter the percussion note as to create marked 
 variations, especially if the former organ be filled with solid food, or dis- 
 tended with gas. Percussion is used in the latter locality to determine 
 the condition of the subjacent abdominal organs rather than to detect 
 pulmonary disease. If the condition of the lung in its lower part be a 
 matter to be decided, the side of the chest is the proper point for explora- 
 tion, since the walls of the thorax are thin, and since the lung comes 
 into close contact with it especially during a full inspiration. In the 
 sternal region we are enabled oftentimes to determine by percussion and 
 auscultation the condition of the contents of the organs contained within 
 the mediastina. 
 
 The relation of the spleen to the lateral wall of the chest, upon the 
 left side of the body, should not be forgotten in percussing the chest, low 
 
230 PKAOTICAL MEDICAL ANATOMY. 
 
 down in the infra-axillary space of that side. This organ, in a state of 
 health, cannot le felt below the free border of the ribs. It extends from 
 the upper border of the ninth to the lower border of the eleventh rib, 
 and its presence is only to be detected by percussion oyer the side of the 
 chest, since it is imperceptible in the anterior or posterior portions of the 
 thorax, unless enlarged by disease. The remarkable prevalence of mala- 
 rial affections of late, in all of which the spleen is usually very much in- 
 creased in size, renders the size of this organ far in excess of its proper 
 limits in the majority of cases examined in many regions of our country. 
 
 When we run, we inhale sixteen times as much air in a given period of 
 time as during tranquil respiration. A deep breath is always drawn 
 before every form of expulsive effort; we therefore see it precede an attempt 
 to sneeze, cough, laugh, or cry violently; before the act of vomiting, 
 since the diaphragm then acts as a fixed wall for the abdominal muscles 
 to crowd the stomach against; before the expulsion of faeces, or urine, 
 if any obstacle to its free escape exists; and, finally, before each labor 
 pain. 
 
 The descent of the diaphragm " acts as a piston," since its effect is to 
 lengthen the lungs and the pericardial sac, both of which rest upon it as 
 the floor of the chest. This muscle may be regarded as consisting of 
 three distinct portions, each of which has a different function and differ- 
 ent anatomical relations, and which can be employed either in combina- 
 tion or separately, if emergencies arise to demand it.' The right portion 
 lowers the liver and lengthens the right lung; the left portion acts upon 
 the lung of that side and tends also to depress the stomach, the spleen, 
 and the left kidney; while the central portion draws the pericardial sac 
 downward and depresses the left lobe of the liver, the stomach, the 
 pancreas, and the intestine. The right and left portions do not have the 
 the same inclination within the thorax, because the pericardial sac and 
 the heart tend to displace the lung of that side; and the same difference in 
 the inclination of the two sides is stated by Sibson to exist during the 
 contracted state of that muscle. 
 
 During the inspiratory effort, the larynx, trachea, and main bronchi 
 are drawn downward, on account of the descent of the diaphragm; and 
 the same effect is produced upon the pulmonary vessels and the aortic 
 arch, on account of the displacement of the pericardium and the traction 
 so exerted upon the large blood-vessels. Note, therefore, that the respira- 
 tory play of the contents of the thorax is not alone confined to the lungs 
 and pericardium, since all the more important parts of both the respira- 
 tory and circulatory apparatus are likewise affected. 
 
 "When any marked difficulty to the entrance of air to the lungs exists, 
 as in laryngeal obstruction, pressure upon the trachea or bronchi, etc., 
 the lower part of the chest will be observed to sink inward, rather than 
 
 ' Sibson, op. cit. 
 
THE CHEST AND ITS CONTAINED OEGANS. 231 
 
 to rise as it does in health, and the abdomen will proportionally protrude, 
 since the diaphragm puts on an extra effort to create suction. In emphy- 
 sema, the sternum is caused to project forward, and the dorsal curve of 
 the spine is markedly increased, thus giving the chest a peculiar "barrel 
 shape "; moreover, the expansive motion of the chest is lost (since the 
 lung fails to collapse during expiration), and the whole chest rises and falls 
 like a solid structure. The organs of the abdomen are displaced down- 
 ward, and the heart is pushed out of place, as evidenced by an abnormality 
 of the apex-beat. The description given by Sibson of the appearance of 
 a chest, in which one of the lungs is so impaired as to be rendered 
 useless, is so complete that I quote it entire. 
 
 " "When one lung is crippled, as from constricting adhesions, the oppo- 
 site lung being developed, the contracted side presents the type of expi- 
 ration, the expanded side that of inspiration. On the affected side, the 
 shoulder slopes; the shoulder-blade drops close to the spine. The ribs 
 are hollow and diverge below the clavicle, and crowd together and 
 lengthen at the side, so as to cover the stomach or liver which encroaches 
 on the lung. The seventh cartilage comes close to the linea alba. The 
 nipple in relation to the ribs is high. The lung shrinks so as to uncover 
 and draw toward it the heart, which beats more to the left or right side, 
 accordingly as the left or right lung is affected. The diaphragm is high. 
 Percussion is dull, respiration bronchial, vocal vibration feeble. The 
 heart-sounds are loud and diffused; the respiratory movements are re- 
 strained. On the developed side, the shoulder is high; the scapula is 
 raised away from the spine. The spine is curved toward this side. The 
 ribs converge and are full below the clavicle; diverge, rise, and shorten 
 at the side, so as to uncover the liver or stomach, which is encroached 
 upon by the lung. The seventh costal cartilage diverges from the linea 
 alba. The nipple in relation to the ribs is low. The lung expands so as 
 to cover and displace the heart. The diaphragm is low. Percussion is 
 resonant, respiration exaggerated, vocal vibration strong. The heart- 
 sounds are feeble or inaudible, the respiratory movements are increased." 
 
 Many points of value in the auscultation of the heart are afforded by 
 the chest. I have already pointed out the situation of the different 
 valves, in the state of health ; and a hasty description of the area of 
 diffusion of the various heart-murmurs will not be out of place in the 
 general r6sum6 of the chest- wall. 
 
 MiTEAL Obsteuctivb Muemue. — This sound is heard with the 
 most distinctness over a limited area confined to the region of the apex 
 of the heart, as can be determined by the apex-beat upon the surface of 
 the chest. It is not usually diffused. It is never heard on the dorsal 
 surface of the chest. 
 
 MiTEAL Reguegitant Mukmue. — This sound is heard with the 
 greatest intensity at the apex of the heart. It is diffused to the left of 
 the apex-beat, and is heard with almost the same intensity between the 
 
232 
 
 PRACTICAL MEDICAL ANATOMY. 
 
 fifth and eighth dorsal verteircB hehind, as it is in front. The diffusion 
 oyer the cardiac area of the chest is limited, as a rule, to a circle of 
 about two inches in diameter, whose centre corresponds to the heart- 
 impulse upon the wall of the chest. 
 
 AoETic Obstuctive Muemuk. — This sound, like the regurgitant 
 murmur heard at this valve, is widely diffused, both along the carotid 
 arteries, and also down the sternum as far as the xyphoid cartilage. 
 The point where the sound is most intense is usually at the base 
 of the heart over the seat of the valve (see page 200), but it may often be 
 heard with equal intensity at other points. 
 
 Fio. 135.— Diagram showing the areas of cardiac murmurs. These several areas correspond to 
 the difflerent spaces marked by the dotted lines, and a capital letter designates each area. A, the 
 area of mitral murmurs; B, of aortic; C, of tricuspid; and D, of pulmonic. (After Gairdner.) 
 
 Aortic Keguegitant Muemuk. — Like the preceding sound, this 
 murmur has a wide area of diffusion. It extends into the carotid arteries 
 and down the sternum. Both of the aortic murmurs are the most widely 
 diffused of all the cardiac sounds, and they may be heard at great distances 
 from the heart, occasionally at the lower angle of the scapula. The 
 aortic murmurs are to be distinguished by their relation to the sounds of 
 the heart, and by their diffusion into the blood-vessels of the neck, 
 rather than by any positiveness of area. 
 
THE CHEST AND ITS CONTAINED OEGANS. 233 
 
 Pulmonic Murmurs.' — The obstructiTe and regurgitant murmurs 
 of this valve are much less frequent than those" of the left heart. They 
 are heard with the greatest intensity over the seat of the valve, but the 
 point may be situated an inch lower down. They are inaudible at the 
 apex, and along the sternum. They are never heard in the neck, nor 
 along the course of the large blood-vessels. On account of the super- 
 ficial situation of the valve, these murmurs are usually louder than 
 those produced at the aortic orifice. 
 
 Tricuspid Murmurs. — The area of these murmurs corresponds to 
 that portion of the heart which is uncovered ly lung-tissue (see page 197). 
 They are rarely audible above the third rib, and are usually loud, on 
 account of the superficial situation of the valve. They are heard with 
 the greatest intensity at or near the xyplioid cartilage of the sternum. 
 They are infrequent, escept as a secondary result of hypertrophy or dila- 
 tation of the right ventricle. The regurgitant murmur is the one which 
 usually exists. Jugular pulsation is one of the strongest diagnostic 
 symptoms of the existence of this latter condition of the tricuspid valve. 
 
 THE NERVES OE THE THORACIC WALLS. 
 
 Some admirable suggestions are made by Hilton,'' as to the distribution 
 of the nerves to the walls of the thorax, which will not only assist to 
 explain some of the peculiar forms of pain felt within the chest, but also 
 certain practical points as to their significance and methods of relief. I 
 quote from him the following sentences : 
 
 "We observe that the same intercostal nerves which supply the inter- 
 costal muscles moving the ribs, supply also the serous membranes lining 
 the thoracic parietes, and the skin over those different but physiologi- 
 cally associated structures, in order to produce harmonious and concerted 
 action during the varied states of respiration. Here, then, we have the 
 pleura representing the synovial membrane of a joint, the intercostal 
 muscles representing the muscular apparatus connected with and moving 
 a joint, the cutaneous branches of the nerves spread over the intercostal 
 muscles, assimilating in their arrangement to the cutaneous branches 
 which supply the skin over the insertions of the muscles moving the 
 joint. 
 
 " But this physiological anatomy, without some application to prac- 
 tice, would, perhaps, be scarcely worth dwelling upon. 
 
 "Pleurisy of the pleura costalis, at the upper part of the chest, is 
 often accompanied by pain and tenderness of the skin, not only over the 
 seat of the pleurisy, but also in the axilla, and over the front of the 
 
 ' A slight regurgitation of blood at the pulmonary orifice is considered' as the 
 normal condition by some authorities. 
 2 Op. cit. 
 
234 
 
 PBAOTIOAL MEDICAL, ANATOMY. 
 
 shoulder, resulting from the course and the peripheral distribution of the 
 intercostal nerves. 
 
 " It will be recollected that some filaments of the intercostal nerves 
 pass through the walls of the chest to the skin covering it, and that some 
 cross the axilla, and are then distributed to the skin of the front of the 
 shoulder and the inner side of the upper arm; hence the pain and tender- 
 ness in these parts resulting from pleurisy. 
 
 " It may be noticed that persistent pain on the surface of the upper 
 and posterior part of the chest and upon the anterior part of the sternum 
 is not infrequently associated with disease of the heart and large Mood- 
 vessels. Indeed, I think I might generalize on this part of my subject, 
 and make an artificial division of the back into three compartments. 
 First, high up between the shoulders, where permanent pains — pains of 
 nervous continuity — as a rule, coexist with /iisease of the heart, aneurism 
 
 Fie. 136. 
 
 Fig. 187. 
 
 Figs. 136 and 137. — Anterior and posterior outlines of the trunk, for marldng more readily the 
 results of percussion and auscultation. (After Bennett.) 
 
 of the aorta, disease at the bifurcation of the trachea and bronchi, 
 diseased glands, or stricture of the oesophagus within the posterior medi- 
 astinum; second, between the middle andlower part of the scapula, and a 
 little lower down, where the existence of like pains are most frequently 
 associated with disease of the abdominal digestive viscera, and, I think, 
 with the transverse colon, through the medium of the great splanchnic 
 and intercostal nerves; third, the surface in the lumbar region, where the 
 pains are more distinctly associated with local disease in the loins, such 
 as disease of the ascending or descending colon, the kidneys, lumbar 
 lymphatic glands, spermatic nerves, and testicles. 
 
 " Patients suffering from cancer of the breasts often complain of pain 
 in the back, between the shoulders, or on the side of the chest, and some- 
 times down the inner side of the arm, and across .the axilla. In such 
 cases, we not infrequently find cancer tubercles under the pleura costalis, 
 or cancerous glands in the axilla, or in the posterior mediastinum. Such 
 
THK CHEST AND 1TB CONTAINED ORGANS. 235 
 
 remote sympathetic pains occurring a long way from the real disturbing 
 cause are explained by the course of the intercostal neryes. 
 
 " I would venture, hypothetically, to apply the following explanation 
 to the painful effects resulting from the local application of cold air upon 
 the peripheral branches of the intercostal nerves. I believe that the local 
 influence of cold air may be sufficient to explain the occurrence of stitch, 
 or that cramp in the muscles of the chest which prevents a full inspira- 
 tion, by inducing tonic or spasmodic contraction of the intercostal muscles 
 which are supplied by the same nerves (the intercostals) which supply the 
 skin upon which the cold is applied. This explanation will hardly be 
 deemed untenable, when I remind you -that if a patient faints, we, 
 anxious to excite respiration as quickly as possible, throw cold water over 
 the face, or denude the chest, and flip its surface with a wet towel, and 
 throw cold water abruptly upon the walls of the chest. And we do it for 
 what purpose? It cannot be for the direct application of cold to the mus- 
 cles themselves. It must be for the purpose of exciting the muscular 
 apparatus which moves the walls of the chest, through the medium of 
 the local application of cold to the cutaneous nerves. 
 
 " May not the irritation of an inflamed pleura bring. on a congested 
 condition of the muscles between the ribs, and thus engender the limited 
 breathing and the painful cramps and stitches from which such patients 
 sufEer, in addition to that which results directly from any local inflamma- 
 tion of the pleura, and which induces pleuritic patients to limit their 
 respiration as far as possible to the action of the diaphragm? This spas- 
 modic contraction of the intercostal muscles, induced by the inflamma- 
 tory condition of the pleura, is precisely analogous to what we see in joint 
 disease. When the synovial membrane is inflamed, the joint is always fixed 
 and rigid and difficult to move. If the pleura be inflamed, we ought not 
 to be surprised if we find its muscular apparatus in a like condition, 
 excited to powerful contraction and a spasmodic condition from the asso- 
 ciation between the synovial membrane and the muscles." 
 
 All physicians must have observed, in cases of pleurisy, that if the 
 patients be asked to take a full breath, to raise the ribs and expand the 
 lungs, they cannot do so without suffering pain; this is surely very sug- 
 gestive of the importance of rest, and points to the value of strapping 
 the chest in cases of acute or chronic pleurisy, with or without frac- 
 tures of ribs ; for it not only keeps the ribs quiet, but prevents any 
 friction of the pulmonary pleura upon the inflamed pleura costalis. 
 
 These observations, of course, suggest another practical lesson — never 
 to allow a patient suffering from pleurisy or pneumonia to talk or 
 answer questions except by monosyllables, so as to avoid a full inspira- 
 tion. Let the patient write all of his or her wishes upon a slate. 
 
 Many practical points pertaining to the nerves will be given in sub- 
 quent pages, which treat of the effects of paralysis of the individual 
 muscles which act upon the bones of the thorax. 
 
236 
 
 PBACTICAL MEDICAL ANATOMY. 
 THE MUSCLES OB THE THOEAX. 
 
 The bones wliich compose the thorax are supplied with muscles 
 which serve as a means of producing the various movements of the thorax 
 in respiration, and also in so adapting the relative position of that part of 
 the body to the other parts as to meet all the requirements of Nature. 
 Furthermore, some of these muscles — chiefly the intercostals — serve to 
 
 
 Fia. 138.— Muscles of the neck, chest, and abdomen. 1, 1, on the right side— the number rests 
 over the platysma myoid muscle, on the left over the steTno-mastoid ; 2, sterno-hyoid; 3, 3, upper 
 and lower bellies of the omo-hyoid; 4, levator anguli scapuIsB; 5, front border of the trapezius; 6, 
 deltoid; 7, upperpart of the triceps; 8, 9, the teres muscles; 10, latissimusdorsi; 11, pectoralis ma- 
 jor; 12, part of the peetoralis minor; 13, serratus magnus muscle; 14, external oblique muscle of 
 the abdomen; 15, 15, the upper part is placed over the xyphoid cartilage at the end of the breast- 
 bone, the lower one at the navel ; 16, on the symphysis pubis, is placed between the outer opening 
 of the inguinal canals; 17, the tendinous aponeurosis of the external oblique muscle; 18, part of 
 the gluteus medius; 19, tensor vaginse femoris (which renders tense the tendinous envelope which 
 ensheathes the muscles of the thigh and renders them compact when in action) ; 20, rectus femo- 
 ris; 21, eartorius; 22, part of the iliacus and psoas muscles; 23 to 25, muscles which aid in draw- 
 ing the thigh inward and forward. 
 
 fill up the spaces between the ribs themselves, and thus are a protective 
 measure against hernial protrusions of the thoracic viscera, as well as 
 
THE CHEST AND ITS CONTAINED OKGANS. 
 
 237 
 
 mechanical aids to movement. The direction of the fibres of these latter 
 muscles seem to confirm this fact, since they are so arranged that the 
 fibres of the external set shall cross those of the internal set at nearly a 
 right angle, thus rendering a separation of these fibres, of sufficient size 
 to allow of visceral protrusion, next to impossible. 
 
 The muscles which are chiefly concerned in respiration are not all those 
 of the thorax, since some of the neck and some of the abdomen may be- 
 come most important factors in that process. It would certainly be a 
 great omission, if the muscles of respiration were not enumerated in this 
 work, in which so much has already been said of the inspiratory and ex- 
 piratory efforts and their results upon the bones of the thorax and the 
 viscera; and they are of interest to the physician, not only from the im- 
 portant aid which they furnish in performing many other acts besides those 
 of breathing, but also because the paralytic state of- certain individual 
 muscles is often a most direct guide to the physician in determining the 
 seat of fhe lesion which is the cause of the paralysis. 
 
 The muscles of inspiration are thus admirably classified in the work 
 of a prominent author:' 
 
 'Diaphragm. 
 Scalenus anticus. 
 Scalenus medius. 
 Scalenus posticus. 
 External intercostals. 
 Sternal portion of the internal 
 
 intercostals. 
 Twelve levatores costarum. 
 
 {Serratus posticus superior. 
 Sterno-mastoideus. 
 Levator anguli scapulas. 
 Trapezius (its superior por- 
 tion"). 
 Pectoralis minor. 
 Pectoralis major (its inferior 
 
 portion). 
 _ Serratus magnus. 
 The action of the diaphragm, as an inspiratory muscle, has been al- 
 ready considered at some length; while the effects of the scaleni muscles' 
 upon the first and second ribs have been touched upon in previous pages. 
 It may be well, however, to again state that, by the scaleni, the sternum 
 is raised and the two upper ribs are made an immovable point from which 
 the muscles can act upon the other ribs. 
 
 MTJSCLES OF OEDINAKT INSPIKATIOH. 
 
 OKDIN-AET AUXILIARY MUSCLES. 
 
 EXTKAOKDIKART AUXILIARY MUSCLES. 
 
 ' A Text-book of Human. Physiology, Austin Flint, Jr. 
 ' See p. 163 of this volume. 
 
 New York, 1879. 
 
238 
 
 PEAOTIOAL MEDICAL ANATOSIT. 
 
 As regards the intercostal muscles, there seems to have been a greater 
 difference of opinion between authors of note as to their action than in re- 
 gard to any other muscles of the human body. The decision of Beau and 
 Maissiat was based on extensive experimental research, and has been con- 
 firmed by Onimus and Sibson, viz., that the external intercostals raise the 
 ribs and are therefore inspiratory muscles; while the internal intercostals, 
 for the greater part, depress them and are expiratory muscles, I know 
 
 Fio. 139.— The outer layer of muscles of the back, shoulder, and hip. C, transverse process of 
 the atlas; D, first dorsal vertebra; L, first lumbar vertebra; S, sacrum; Co, coccyx; a, acromion; 
 6, base of scapula; i, crest of ilium; 1, upper part of sterno-mastoid muscle; 8, muscle which raises 
 the scapula; 3, 8, upper and lower ends of trapezius muscle; *, half of the oval tendon belonging 
 to the base of the trapezius muscle ; 4, 4, latissimus dorsi muscle ; 6, infraspinatus muscle ; 0, teres 
 minor muscle; 7, teres major muscle; 8, middle or acromial part of the deltoid muscle; 9, hind 
 part of the external oblique muscle of the abdomen; 10, gluteus medius muscle; 11, ll", gluteus 
 maximus muscle; 12, biceps muscle; 13, semitendinosus muscle; 14, adductor magnus muscle; 15, 
 gracilis muscle. 
 
 of no better rule to govern the question of the action of any muscle in 
 dispute than the following: "Every muscle tends to bring the points of 
 its origin and insertion more closely together, and acts upon that point 
 
THE CHEST AND ITS CONTAINED ORGANS. 239 
 
 which offers the least resistance to its action." Now, in the case of the 
 intercostals, the ribs must be brought more closely together by each set, 
 since the muscles are placed between the ribs, and the only point to de- 
 cide is, which point — the vertebral or the sternal extremity of the rib — 
 affords the greatest resistance to the action of the two sets. 
 
 The action of the twelve levatores costarmn cannot possibly be mis- 
 taken, since they act from the transverse processes of the twelve dorsal 
 vertebrae upon the upper borders of the ribs, and thus must tend to raise 
 them. 
 
 The auxiliary muscles of inspiration are capable of acting upon the 
 ribs, when some other part of the iody is made a fixed point, or, if the 
 vertebrse be the fixed point, they are capable of acting either upon the 
 head or upper extremity, depending of course upon their insertion. 
 These muscles are brought into action in respiration, only when the 
 movements of that act are exaggerated, as after exercise, and they cease 
 to act when tranquillity has been restored. In those cases, however, where 
 any obstruction to the free entrance of air to the lung is interposed from 
 any cause, all the muscles which can in any way afEect the expansion of 
 the chest are called into action — the principal ones of this class being put 
 down in the table as the "extraordinary" muscles of inspiration. Most 
 of these muscles can be brought into play and made to act upon the chest 
 by a simple act of volition; but, as they are chiefly inserted into the scapula, 
 the arms must be made a fixed point in order to enable them to affect the 
 ribs. This tends to explain the position which is assumed in all suffo- 
 cative diseases, such as asthma, capillary bronchitis, laryngeal obstruction, 
 etc. ; where the anxious countenance, the position of the head (whicli is 
 thrown forcibly backward), and the firm grasp of the hand upon some im- 
 movable object, with the arm extended, so as to made the shoulder- 
 blades immovable, all bespeak pulmonary distress. ' 
 
 The movement of the scapula upon the chest during the inspiratory 
 act has already been explained as the effect of the serratus muscle upon 
 the scapula, which, although in the relaxed state, still causes the shoulder- 
 blade to move on account of the increased circumference of the chest; but, 
 in very labored respiration, this outward movement observed m passive 
 respiration becomes changed in character. The scapulse are then seen to 
 be raised, on account of the force exerted by the upper fibres of the tra- 
 pezius and the levator anguli scapulte muscles, although the pectoralis 
 minor also assists in this movement by drawing the coracoid process for- 
 ward, and the lower fibres of the pectoralis major as well, by acting upon 
 the arm. The serratus magnus muscle becomes a most powerful agent 
 in expanding the chest, provided that the shoulder-blades are made im- 
 movable by some position of the arm, forearm, and hand, which shall af- 
 ford it a fixed point from which to act upon the ribs. 
 
 • For all the facial evidences of dyspnoea, see p. 63, 
 
240 PEAOnOAL MEDICAL ANATOMY. 
 
 We have not considered the muscles which coiitrol the movements of 
 the nostril as those of inspiration, altliough they properly belong to that 
 group, since they are unimportant in man; but, in the horse, and 
 other animals where the nose and mouth do not communicate, and where 
 all the respired air must, of necessity, pass through the nostril, paralysis 
 of the facial nerve, which supplies these muscles with the power of move- 
 ment, causes death from sufEocation. 
 
 It will be seen, on looking at the preceding table of the muscles of in- 
 spiration, that five of them are properly muscles of the neck, rather than 
 those of the thorax; while, by referring to the table of the expiratory 
 muscles, it will also be perceived that all of the auxiliary muscles are 
 those of the abdomen. I have thought it best, in spite of the apparent 
 lack of system in the construction of this portion of the work, to discuss 
 these muscles to some extent in this chapter upon the thorax, since it is 
 impossible to give the reader a clear conception of the respiratory acts 
 (whose effects we have discussed before the. acts themselves), without en- 
 croaching to some extent upon adjoining regions. 
 
 Expiration may be considered as dependent upon one of three causes, 
 as follows: 
 
 1. The influence of the elasticity of the lung-tissue. 
 
 2. The elasticity of the thoracic walls, and especially of the costal 
 cartilages. 
 
 3. Muscular action, so directed as to diminish the transverse and 
 antero-posterior diameters of the chest, by depressing the ribs and the 
 sternum, and the vertical diameter of that cavity, by crowding up the 
 abdominal viscera beneath the diaphragm. 
 
 It might be also possible to consider the law of gravity as one of the 
 forces of expiration in the reclining posture; since it would then assist the 
 abdominal organs to return to the position which they occupied before 
 the diaphragm contracted. The elasticity of the ribs and the effect of 
 the costal cartilages upon expiration have already been considered, and it 
 now remains to enumerate those muscles which are properly considered 
 as effecting the expulsion of air from the lungs after a full breath has 
 been taken. 
 
 If we follow the author' from whose work the previous table was 
 quoted, the expiratory muscles are as follows : 
 
 Osseous portion of internal in- 
 MUSCLES or TRANQUIL OK OBDiiTAET tercostal musclcs. 
 EXPIRATION. Infracostal muscles. 
 
 Triangularis sterni. 
 
 ' Austin Flint, Jr., op. cit. The table is somewhat modified. 
 
AUXILIAET MUSCLES OF EXPIKATION. < 
 
 THE CHEST AND ITS CONTAINED OKGANS. 241 
 
 ' Serratus posticus inferior. 
 Obliquus abdominis externus. 
 Obliqnus abdominis internus. 
 Transversalis abdominis. 
 Sacro-lumbalis. 
 Quadratns liimborum. 
 
 The internal intercostal muscles thus appear for the second time, and 
 now as expiratory muscles, while, before, they were enumerated as 
 inspiratory muscles. This apparent inconsistency is due to the fact that 
 the portion of each muscle, which is situated between the bony ribs, acts 
 from the point of greatest resistance — the vertebral extremity; while the 
 sternal portion of each muscle acts from the point of greatest resistance 
 to its fibres — the sternum itself — and thus tends to assist the inspiratory 
 muscles. This statement is fortunately not one of theory only, since tlie 
 observations of Sibson have confirmed it upon the human subject, when 
 he found that the osseous fibres are elongated when the chest is distended, 
 and shortened when it is collapsed; furthermore, the experiments of 
 numerous physiologists upon the respiratory act in living animals, whose 
 details are too long for repetition, also confirm it. 
 
 The triangularis sterni 7nuscle tends to draw the second, third, fourth, 
 and fifth ribs, to which its fibres are attached, toward the ensiform carti- 
 lage, the point of greatest resistance, and thus acts as an agent in dimin- 
 ishing the capacity of the chest. There has never been any doubt 
 among physiologists as to the action of this muscle. 
 
 The infracostal muscles connect the ribs of the lower portion of the 
 chest, at the posterior part of the thorax. They act from below, since 
 the last ribs are made rigid by the muscles of the back during life, 
 although they are extremely movable after death — Whence the term " float- 
 ing ribs" is a misnomer. 
 
 Before passing to the consideration of some of the clinical points sug- 
 gested by the muscles of the thoracic walls, let us consider the other 
 actions which the muscles already mentioned assist in, and such other 
 points as are of general interest to the practitioner. 
 
 The arm, having been raised from the side of the chest, is returned to 
 its former position by the combined action of the pectoralis major, the 
 teres major, and the latissimus dorsi. The former muscle, if acting 
 singly, tends also to draw the arm across the chest — a position of great 
 advantage in auscultating the regions on the posterior aspect of the thorax. 
 Beneath it lie the thoracic branches of the axillary artery, while its 
 lower border marks the floor of the axillary space. 
 
 The pecioralis minor muscle depresses the point of the shoulder, since 
 it draws upon the coracoid process of the scapula, while it also assists in 
 bringing the scapula inward to the chest- wall. 
 
 Tlie suhclavius muscle also assists in depi-essing the shoulder, but it 
 16 
 
24:2 PRACTICAL MEDICAL ANATOMY. 
 
 does so through the medium of the clavicle. In all positions of the 
 upper extremity, where the shoulder is rendered immovable, it and the 
 two preceding muscles are enabled to change the direction of their action, 
 and thus to affect the size of the thorax. 
 
 The serratus magnus muscle, as before mentioned, acts as an inspira- 
 tory muscle when the shoulder is i;endered immovable; it can, however, 
 through its lower fibres, so act upon the lower angle of the shoulder-blade 
 as to assist the trapezius in supporting weights upon the shoulder, pro- 
 vided the thorax is kept inflated by being simultaneously raised and made 
 immovable. 
 
 The levator anguli scwpulm muscle tends to raise the scapula, after it 
 has been depressed by the lower fibres of the trapezius muscle, and it 
 thup assists inspiration; it may also act upon the cervical portion of the 
 spine and assist in flexing the neck toward the same side as the muscle. 
 
 The serrati muscles act upon the ribs since the vertebrae act as the 
 fixed point from which the force is exerted. The serratus posticus supe- 
 rior raises the ribs, and thus becomes an aid in inspiration; while the 
 inferior muscle tends to depress the ribs, and thus becomes an expiratory 
 muscle. 
 
 The rliomloidei muscles, when acting together upon the shoulder-blade, 
 tend to draw the bone toward the spinal column — a movement seen when 
 a person endeavors to overcome a tendency to '*' round shoulders. " 
 
 The actions of the trapezius muscle are numerous. It may act upon 
 the head or the scapula. Thus the head may be drawn to one side, if one 
 muscle acts, or directly backward, if both m.uscles act from the scapula 
 and the dorsal vertebrae; it may help to raise the shoulder when the head 
 is fixed and its upper fibres only act, as in inspiration and the act of sup- 
 porting weiglits upon that part, or, finally, it may produce a partial ro- 
 tation of the shoulder-blade, as in the act of raising the arm above the head. 
 
 The latissinius dorsi muscle acts upon the arm, tending to draw it 
 backward and inward; if the arm be fixed, it assists inspiration by rais- 
 ing the ribs, and it may be of use in movements of the entire trunk, as 
 in the act of dragging the body, in the efforts to climb or to walk on 
 crutches. 
 
 Clinical Points pertaining to the Muscles of the Thorax. 
 
 Many of the muscles, whose actions we have been considering, 
 may present clinical features as the result of paralysis, either of a type 
 where several participate in a general hemiplegic condition, or where the 
 loss of power is confined to some individual muscle or set of muscles. 
 Nearly all of the muscles of the thorax may be independently and sep- 
 arately paralyzed, and, in many instances, great care in the examination 
 of the patient is demanded to fully ascertain in what particular muscle 
 the function is abolished. The investigations of Duchenne have afforded 
 
THE CHEST AND ITS CONTAINED OKGANS. 243 
 
 US the means of making a diagnosis of these affections whicli are mark- 
 edly in advance of previous knowledge in this direction. 
 
 The pectoral muscles maj be independently paralyzed when the ante- 
 rior thoracic nerves' are afEected. These nerves are rarely alone involved, 
 and this type of paralysis is therefore usually an accompaniment of par- 
 alysis of some other muscles. It may occur from some form of 
 
 Fig. 140.— The muscles of the back, after the removal of the trapezius, latissimus dorsi, deltoid, 
 gluteus maximus, and external obUque muscles. The muscles are: 1, splenlus capitis; 3, levator 
 anguli seaputo; 4 and 5, the rhomboid major and minor muscles— these move the shoulder-blade 
 and help to fix it when the arm is being used; 6, part of the erector spinse muscle; 8, S , the lower 
 serrated muscle, the action of which is to pull the ribs downward; 9, the internal oblique muscle 
 of the abdomen; 10, supraspinatus muscle; 11, infraspinatus muscle (partly seen in the foregoing); 
 the white space between is the spine of the shoulder-blade, terminating in the acromion (a) ; 12, 13, 
 teres minor and major muscles; 14, serratus magnus; 15, gluteus medius muscle; 16 to 19, muscles 
 which are inserted into the great trochanter of the femur; 20, part of the adductor magnus muscle. 
 
 traumatism which has caused an impairment of the brachial plexus 
 either entire or in part; in connection with an attack of hemiplegia; and 
 in progi-essive muscular atrophy due to some lesion of the spinal cord. 
 
 ' Branches of the inner and outer cords of the brachial plexus, given oflf in the 
 axillary space. 
 
244: PKACTIOAL ilBDIOAL ANATOMY. 
 
 Paralysis of these muscles is recognized at once by the impairment or 
 total loss of power in adducting the arm, and by an inability of the 
 patient to grasp the opposite shoulder with the hand of the para- 
 lyzed side, or to offer any resistance to passive abduction of the arm. 
 The subclavicular fossa may be markedly deepened, if atrophy of the 
 paralyzed muscles has taken place, and the ribs and intercostal spaces 
 will be easily mapped out in this region. The anterior wall of the axilla 
 may be so atrophied as to present simply a fold of loose integument, 
 through which the subjacent parts can be felt. 
 
 When the rhomboidei and the levator anguli scapulcB muscles 
 are paralyzed,' little alteration in the position of the shoulder-blade from 
 that of its fellow can be detected. It is often difficult, therefore, for one 
 unaccustomed to the detection of local forms of paralysis to recognize 
 this condition. The chief diagnostic symptom, by which this condition 
 can be determined, is an inability to produce the forced elevation of the 
 shoulder of the affected side — the position assumed in supporting weights 
 upon that part. When the trapezius muscle is simultaneously affected 
 and has undergone atrophy, the shoulder-blade cannot then be drawn 
 toward the vertebral column . 
 
 The latissimus dorsi mtcscle, which is supplied by the subscapular 
 nerve, ^ is independently paralyzed only in cases of extreme rarity. It 
 does occur, however, in connection with progressive muscular atrophy, as 
 a subordinate symptom, much more commonly than as a special type of 
 disease. In either case, little or no deformity is observed as the result of 
 a loss of power in this muscle, provided the arm hangs loosely at the side 
 of the chest; it is only when the arm has been raised that the power of 
 bringing it forcibly downward, or of firmly adducting the arm, when 
 hanging at the side, indicates a local affection of that muscle. A marked 
 difficulty is also experienced in placing the Itend upon the buttock, and 
 the shoulder cannot be drawn as forcibly downward as in health ; the 
 contrast between the muscles of the two sides will often be of advantage 
 to the physician, if the paralysis be unilateral. 
 
 The serratus magmis muscle is more often affected with isolated 
 paralysis than perhaps any muscle of the thorax. This muscle is, and 
 always has been, one of the greatest interest to the physiologist, since it 
 is a most important factor in many complex movements; and a most 
 extensive literature exists as regards its nerve-supply, its action, and its 
 points of clinical interest. Berger, Weisner, Duchenne, and others have 
 left little to add as regards the anatomy of this muscle or the diseases 
 which imjoair its usefulness. 
 
 ' Supplied by nerves given off by the brachial ple.vus, above the line of the 
 clavicle. 
 
 ' A branch of the poi^teiior cord of the brachial plexus, given off in the axillai-y 
 space. 
 
THK CHEST AND ITS CONTAINED OKGANS. 245 
 
 This muscle is supplied with motor power by the long or 2}Osterior 
 thoracic nerye/ whose superficial situation renders it particularly liable 
 to be involved in many forms of injury, while the extreme length of its 
 course necessarily subjects it to further dangers, since it passes through 
 the surgical region of the axilla as well as the neck. These two facts 
 possibly explain the gi"eater relative frequency of paralysis of this muscle 
 as an independent disease over the others which have previously been 
 discussed. Thus, direct injury is often the cause of this affection, as 
 from carrying heavy weights upon the shoulder, contusions, blows, or 
 severe concussion of the shoulder, bullet-wounds, stab-wounds of the 
 neck, etc. Cases have been reported where this muscle has been para- 
 lyzed from over-exertion of the muscles of the shoulder and neck, as in 
 mowing, puddling, shoe-making, rope-making, etc., and these instances 
 may tend to explain why this disease is more frequent in men than women, 
 "and why the right side is more commonly affected than the left. In 
 addition to these causes, this form of local paralysis has been known to 
 follow exposure to draughts of cold air, sleeping on the damp ground, 
 and as a sequel to typhoid fever. This muscle is not affected, as a rule, in 
 those forms of general paralysis dependent upon the spinal or cerebral 
 lesions, and, if it is so affected, it forms but a minor symptom in compari- 
 son with the others present. It may accompany progressive muscular 
 atrophy of the muscles of the back and shoulder-blade. 
 
 When this disease is developing, severe neuralgic pains are often ex- 
 perienced in the regions supplied by the supra-clavicular nerve (a branch 
 of the cervical plexus). A difficulty is soon noticed by the patient in 
 performing certain movements, which induces him to seek medical advice. 
 Now, if these movements are studied from an anatomical stand-point, it 
 will be seen that the normal action of this muscle is confined chiefly to 
 the movements of the scapula and the elevation of the arm above the line 
 of the shoulder; and it is in the position and capabilities of movement of 
 the shoulder-blade that we must expect to find evidences of this type, of 
 paralysis. "We find the scapula somewhat raised and approximated to the 
 spinal column when the arm hangs at the side; its inferior angle is carried 
 inward, thus indicating a partial rotation of that bone; and the shoulder- 
 blade seems to stand off from the chest-wall, especially at its inferior 
 angle, giving the bone an undue prominence in this locality.'' When 
 movement of the arm is attempted, the effect of the paralysis becomes 
 much more marked, since the patient finds himself utiahle to raise the 
 arm above tlie level of the shoulder, since the rotation of the inferior angle 
 
 ' Arising by two heads, derived from, the fifth and sixth cervical nerves. 
 
 ^ This is due to the antagonism of the rhomboid muscle, the trapezius, and 
 levator angttli scapulae, which are no longer counteracted by the serratus 
 magnus. If these muscles ai-e also aflEected, either by paralysis or atrophy, this 
 deformity becomes much less marked. 
 
246 PBAOTICAL MEDICAL ANATOMY. 
 
 of the scapula and the elevation of the bone which are necessary to 
 that movement cannot be performed. 
 
 If the arm be raised to the level of the shoulder (a movement produced 
 by the deltoid muscle alone), the inner border of the scapula, instead of 
 being removed farther away from the spinal column, is approximated 
 toward it; and, if the serrati muscles be both paralyzed, the shoulder-blades 
 will thus be caused to almost touch each other. "When we place the arm 
 in this raised position, and carry it forward, the shoulder-blade becomes 
 so separated from the wall of the chest that the hand may often be laid 
 in the fossa which intervenes between it and the bone; this affords a very 
 marked contrast to the position of tlie scapula of the healthy side, which 
 is closely applied to the chest when the arm is so placed. Should both 
 sides be -simultaneously paralyzed, this same position of the arms produces 
 a hollow between the scapulse, in which the rhomboid muscles of either 
 side distinctly project as muscular cords. , 
 
 There are other symptoms of this affection, which are strongly diag- 
 nostic, although the previous points render an error in diagnosis improb- 
 able: among these may be mentioned an inability to cross the arm in 
 front of the chest; impairment of the power of resistance to forcible re- 
 traction of the shoulder; and a difficulty in delivering a forward blow 
 with the affected arm. As has been mentioned in previous pages, the 
 serratus muscle only affects inspiration when the scapula is made a fixed 
 point by means of the upper extremity; it can be, therefore, understood 
 that no effects upon ordinary respiration are noticed in this type of para- 
 lysis. , 
 
 The dorsal muscles are sometimes affected with paralysis, either of a 
 partial or complete character; and thus the movement, the power of fixa- 
 tion, and the ability to maintain an upright position of that portion of 
 the spine may be affected. In youth, various degrees of weakness of the 
 dorsal muscles are observed which are confined to the distinct regions of 
 the spine or which may be distributed to its entire length, and these may 
 be either unilateral or bilateral. It is thus that spinal curvatures are 
 sometimes produced; and the exciting cause may be traced to some 
 injury, rheumatic affection, or some form of local inflammatory disease. 
 There are various degrees of these paretic conditions, leading to manifold 
 varieties in the amount and extent of the ensuing deformity, and in the 
 ability of the patient to rectify the deformity by a voluntary effort. The 
 condition where the spinal curve is increased in a backward direction 
 (paralytic kyphosis) is usually most marked in the dorsal region, and pre- 
 sents a most diagnostic deformity; while, if the muscles be paralyzed on 
 one side only, all gTades of lateral curvature (paralytic scoliosis) are liable 
 to be developed. 
 
 In some cases of the paretic conditioB, the dorsal muscles of the neck 
 are simultaneously affected with those of the dorsal or lumbar regions. 
 If such a condition be present, the head can no longer be carried erect 
 
THE OHKST AND ITS CONTAINED 0KGAN8. 247 
 
 and tends to sink forward, as soon as fatigue of the muscles takes place; 
 the patient can still raise it by a peculiar swinging raotion, and may then 
 be able to retain it, by using the muscles of the anterior region, in a posi- 
 tion where the head is inclined backward and the chin elevated. This 
 latter position and the means by which the head is brought to assume the 
 attitude are both highly diagnostic. 
 
 CLINICAL POIKTS AEFOKDED BT THE DOKSAL IfERVES. 
 
 TBe nerves which arise from the dorsal region of the spinal cord may 
 afford the physician essential aid in diagnosis. 
 
 While it will not be possible to give all the information upon so im- 
 portant a subject in a small volume like the present one, the following 
 points taken from the author's more extensive treatise* on that special 
 department of anatomy may prove of value as a general resume of the 
 symptoms afforded by the nerves of this region. 
 
 " The distribution of the dorsal nerves to the costal layer of the pleura 
 is a fact of great physiological interest. Hilton draws an analogy between 
 the pleura and a synovial membrane of a joint; and the intercostal mus- 
 cles are also compared by him to those moving a joint. Thus this author 
 adduces further proof of his general law of nerve-distribution, since the 
 skin of the chest, the intercostal muscles, and the pleura are supplied 
 from the same source. In pursuing this same line of i-easoning (and the 
 analogy is not a strained one from a physiological stand-point), the abdom- 
 inal muscles might also be included among the list of muscles which 
 move the ribs; and the nerve-supply to them also would thereby be 
 explained by this same axiom, viz., that the nerves which supply a joint 
 supply the muscles which move it and the skin over the insertions to 
 those muscles. 
 
 " It should be recollected that some of the filaments derived from the 
 upper intercostal nerves cross the axillary space and supply the integu- 
 ment of the arm. The ' nerve of Wrisberg ' is perhaps the most impor- 
 tant of these branches. It may thus be understood why the pain of pleu- 
 ritic inflammation may be carried to and felt m the region of the axilla 
 and inner arm, and why distinct points of tenderness to pressure may 
 sometimes be detected in these regions when the disease is confined to 
 the trunk. 
 
 "Prom the suggestions thrown out as to the physiological impor- 
 tance of nerve distribution, and from the fact that the pleura is supplied 
 from the same nerve sources as the respiratory muscles and the integu- 
 ment of the chest, abdomen, and inner arm, some important clinical les- 
 sons may be drawn. Patients, suffering from pleurisy, suffer a pain in 
 the costal muscles which compels restricted movement of the ribs, and 
 which limits the respiratory function largely to the diaphragm. Now, 
 
 ' The Applied Anatomy of the Nervous System. N. Y., 1881. 
 
248 PBACriOAI, MEDICAL ANATOMY. . 
 
 these painful cramps and stitches are independent of the pain arising alone 
 from the inflamed pleural surface, and tlie diminution of the respiratory 
 movement is due to a partially contractured state of the muscles of the 
 chest, as is demonstrated by the fact that patients cannot draw a long 
 breath if asked to do so. Hence, we may reasonably conclude that Nature 
 has so distributed the nerves to the pleura as to enable that serous mem- 
 brane to control the muscles which create movement of the adjacent cos- 
 tal surfaces, and thus to insure its quietude during the stages of inflam- 
 mation or of repair. It is wisely suggested by Hilton, in this conneTition, 
 that we learn a lesson in the treatment of such cases from Nature herself, 
 viz., ' never to allow a patient, suffering from pleurisy or pneumonia, to 
 talk except in monosyllables, so as to avoid a full inspiration.' 
 
 "The diagnostic value of pain is well exemplified in the region of the 
 thorax. Persistent pains high iq] between the shoulders are strongly in- 
 dicative of diseases of the heart, aneurism of the arch of the aorta, stric- 
 ture of the oesophagus, and anything which would tend to create pressure 
 within the posterior mediastinum. ' If we meet with persistent pain in the 
 space lying betioeen the middle of the scapula and the lumbar region of the 
 spine, we may have good ground to suspect the existence of some disease 
 of the abdominal digestive viscera, the pain being carried to the surface 
 probably by means of the splanchnic nerves. " It is not uncommon for 
 disease confined to the transverse colon to manifest itself in the form of 
 persistent pain in the lower intercostal region. 
 
 " The frequent occurrence of cancer in the mammary region renders its 
 detection one of importance in its early stages, while, in the later stages, 
 tlie pleura and the glands of the axilla and mediastina may be secon- 
 darily affected with cancer tubercles. Now, in these conditions, the 
 presence of pain in the back, between the shoulders, in the side of the 
 chest, or down the inner side of the arm, may possibly afford invaluable 
 aid in diagnosis. 
 
 " The distribution of the sixth and seventh intercostal nerves to the 
 skin over the J) lY of the stomach maybe a useful fact to remember in 
 making a diagnosis of the cause of pain in that region, since, by tracing 
 the course of these two nerves from before backward, and observing the 
 healthy or unhealthy condition of the structures near to which the nerves 
 would pass — as the pleura, ribs, oesophagus, aorta, etc. — we may at last 
 reach the spine as the seat of the disease which is producing pain in a 
 region far remote from the cause to which it is really due. It is by no 
 
 ' John Hilton, op. cit. 
 
 ^ The great splanchnic nerve is connected above with the fourth, fifth, and 
 sixth dorsal nerves, and below with the solar plexus and thence with the stomach, 
 duodenum, liver, pancreas, and intestines. It seems probable, therefore, that the 
 pain experienced in the region of the scapula, by patients afflicted with disease of 
 the digestive organs, is referable in some way to the greater splanchnic nerve. 
 
THK CHEST AND ITS CONTAINED OKGAN6. 249 
 
 means uncommon for spinal afEections of the mid-dorsal region to mani- 
 fest themselves by a pain ■which is distressing, and referred to the pit of 
 the stomach; and such an origin is rendered still more probable if present 
 on both sides of the median line, since symmetrical pains are especially 
 characteristic of central origin. Should such a pain exist, and a marked 
 relief ensue when the patient is in a recumbent posture, the probability 
 of spinal origin is still more distinctly suggested. 
 
 "It has been stated that pains which are confined to one side of the 
 body are usually indicative of an exciting cause which is confined to the 
 same side, rather tlian of diseased conditions of the central nerve ganglia. 
 It is therefore customary, with those most familiar with the steps neces- 
 sary to reach a scientific diagnosis, to search for some cause upon the 
 same side of the body, in case a pain exists which is not symme- 
 trically developed upon both sides. I have known the diagnosis of- 
 aneurism within the thorax to be discovered by a pain, which was one- 
 sided, and which was the only symptom which the patient was conscious 
 of, where the existence of the tumor would probably have gone on unde- 
 tected but for this valuable guide. A constant pain in the back is one of 
 the most positive signs of aneurism of the coeliac axis, and I question if 
 the diagnosis of aneurism of the aorta in any part of its course should 
 ever be made unless this symptom can be detected. 
 
 " Pain in the region of the pectoral muscle may indicate some cause 
 referred either to the third or fourth cervical or the first dorsal nerves; 
 hence we must look in two different localities for the exciting lesion. 
 The distribution of the cervical nerves to the fascia covering the anterior 
 portion of the chest is not safficiently well recognized by the profession 
 at large, and doubtless many cases have been a source of anxiety to the 
 physician which could have been easily explained, had this point been 
 impressed upon them. 
 
 "The distribution of the lower intercostal nerves to the integument 
 covering the upper part of the muscles of the abdomen may be useful in 
 diagnosis, since pain in this region of the abdomen may be created by 
 pressure of fluid in the pleural cavities, and by other lesions situated 
 above the line of the diaphragm. Is it not probable, therefore, that 
 many cases of this character have misled the medical attendant who has 
 referred the symptom of abdominal pain to organs within the cavity of 
 the abdomen when the exciting cause was to be sought for within the 
 chest or in the course of the lower intercostal nerves? Certainly, success- 
 ful treatment depends upon accuracy in diagnosis; and the application of 
 the laws of nerve distribution to fine discriminations in the appreciation 
 of symptoms is a guide whose value and utility is not generally known. 
 
 " When we have our attention called by a patient to a pain, no matter 
 where its situation may chance to be, we are positive that it can be 
 traced to the nerves supplying the part. Here, then, we have a direct 
 guide to follow which will usually lead us, if we are anatomists, to the 
 
250 PRACTICAL MEDICAL ANATOMY. 
 
 source of the pain. As an example of tliis, and they are too numerous 
 to mention in detail, there is one symptom in. spinal disease which stands 
 out prominently, and I might say solicits our proper appreciation of it, 
 and that is a fixed and local pain upon the surface of the body, with or 
 without exacerbations, and often without any local increase of tempera- 
 ture at the seat of the disease. I feel quite certain that through the 
 medium of this one symptom alone, if properly employed, morbid condi- 
 tions of the spine may be often diagnosed long before any palpable de- 
 formity exists, and a cure often effected by simple rest. 
 
 "It is in connection with the nerves of the dorsal region that pain is 
 a more valuable guide than in almost any other portion of the body. The 
 subjacent viscera, occupying the thoracic and abdominal cavities, are 
 constantly manifesting diseased conditions by pain of a superficial charac- 
 ter, through the intimate communications which exist between the 
 splanchnic and dorsal nerves, at spots often far removed from the exciting 
 cause. It is natural that the medical attendant, unless his attention has 
 been directed to this fact, will attribute the pain to some fanciful cause 
 in the locality of that pain, or to some general diagnosis of neuralgia, 
 malaria, etc., when an anatomical knowledge might direct him aright 
 both in diagnosis and treatment. "We know that liver disease may be oc- 
 casionally manifested by a pain in the region of the right shoulder, that 
 gastric and intestinal disorders frequently produce a constant pain in the 
 back between the scapulae, and that tumors of the viscera may produce 
 like results by pressure upon the splanchnic nerves or the solar plexus of 
 which they form a part. Without such a knowledge and its satisfactory 
 explanation, would we be apt to refer such pain to causes so remote? 
 Would we look for causes of abdominal pain in the region of the thorax, 
 without the knowledge that the lower intercostal nerves supplied the ab- 
 dominal muscles? The lessons taught by anatomy are of a most practical 
 character, and worthy of the study even of those old in the practice of 
 physic. If a patient complains of pain on the surface of the body, it 
 must be expressed by the nerve which resides there; there is no other 
 structure that can express it, and somewhere in its course of distribution, 
 between its peripheral filaments and its central point of origin from the 
 encephalon or the spinal cord, the precise cause of this pain expressed 
 upon the surface must be situated. 
 
 Intercostal Neuralgia. — " Those forms of neuralgia which have their 
 seat in the nerves which arise from the dorsal region of the spinal cord 
 are grouped under the term ' dorso-intercostal ' neuralgia. The exact 
 seat of the pain varies not only with the special nerve affected, but also 
 with the branch of the nerve which seems to manifest the most irritation. 
 Thus, if the upper two nerves are involved, the pain may extend to the 
 arm as well as the trunk; if the posterior branches of the dorsal nerves 
 be alone involved, the pain will be perceived in the back and loins; and, 
 finally, if the anterior branches be alone the seat of pain, it will be con- 
 
THE CHEST AND ITS CONTAINED ORGANS. 251 
 
 ned to the intercostal spaces and the anterior region of the chest. It is 
 rare to find the anterior and posterior branches of any dorsal nerve simul- 
 taneously affected with neuralgia. The anterior branches are usually the 
 ones which sufEer, and the pain assumes a type which is properly called 
 ' intercostal. ' 
 
 " Intercostal neuralgia is more common in women than in men, and 
 chiefly affects weak, hysterical, and anaemic subjects. It appears often 
 in those who are convalescing from some severe type of disease. The 
 causes to which this form of neuralgia can be traced include exposure to 
 cold or dampness, anatomical changes in the nerves themselves, diseases 
 of some of the adjoining organs (especially in connection with phthisis), 
 embarrassment to the venous return of the affected region, dilatation of 
 the venous plexuses of the interior of the vertebral canal, aortic aneu- 
 risms (which lead to absorption of the vertebrae or ribs), all possible dis- 
 eases of the vertebrae themselves and also of the ribs, diseases of the 
 spinal cord, and malarial affections. 
 
 "This form of neuralgia is most common upon the left side, and 
 Henle has attributed this clinical fact to the arrangement of the intercos- 
 tal veins of the left side which relatively tends to impede the return of 
 blood upon the left in contrast to the right side. From the extensive list 
 of causes which have been given — and many of the subdivisions of each 
 have been omitted — it can be readily understood that, to make an accu- 
 rate diagnosis as to the etiology of intercostal neuralgia, is never possible 
 without a most thorough physical examination of the subjacent organs, 
 the bones of the thorax, and the conditions of the soft tissues. 
 
 " The symptoms of this disease are generally confined to the anterior 
 and lateral walls of the trunk, more rarely to the back and the loins. 
 The area of the pain indicates the nerves affected, which is often a point 
 of great value in searching for the cause. While the pain is of a burn- 
 ing, dull, and persistent character for the greater part, yet it is charac- 
 terized by paroxysms of tearing and lancinating pains which follow the 
 course of the nerves affected with a remarkable precision. The violence 
 of these pai-oxysms may be . very great, so as to cause syncope. All 
 respiratory motions, such as sneezing, coughing, blowing the nose, etc., 
 increase the pain, and the skin is sensitive to the slightest pressure; even 
 the weight of the bedclothes distressing the patient, although firm pres- 
 sure may sometimes afford relief. While the paroxysm is active, the 
 patients sit with the body inclined toward the affected side, and their 
 faces indicate the most extreme anxiety. They neither dare to speak 
 loudly nor to take a deep inspiration, on account of the pain induced by 
 such efforts. 
 
 " In intercostal neuralgia, as in most other forms, there are certain 
 points which are particularly sensitive to pressure, and are of gi'eat aid in 
 confirming the diagnosis. These points comprise, first, one near to the 
 vertebral column {vertebral point), where the nerve emerges from the 
 
252 PRACTICAL MEDICAL ANATOMY. 
 
 intcr-Tertebral foramen; secondly, one at about the middle of the entire 
 course of the nerve, corresponding to a line dropped from the centre of 
 the axillary space {lateral point), where the lateral branch emerges 
 beneath the integument; and, thirdly, one in front, near to the sternal 
 border {anterior or sternal point), where the anterior perforating branch 
 emerges beneath the skin. 
 
 " For some unknown reason, the intercostal nerves, when inflamed, 
 are particularly liable to be associated with the appearance of that form 
 of skin disease called 'herpes zoster.' This may or may not be accom- 
 panied by neuralgic symptoms, but is a valuable sign of a neuritis of the 
 nerve supplying the region affected. 
 
 " The diagnosis of intercostal neuralgia can often be made only with 
 extreme difficulty. That rheumatic afEection of the muscles of the chest, 
 commonly called 'pleurodynia,' is often confounded with it, and the 
 diagnosis is to be made chiefly by the presence of the localized points of ten- 
 derness mentioned, and the rapid disappearance of all symptoms in the 
 course of a few days, which is seldom observed in true intercostal neural- 
 gia. Pleui-isy is to be differentiated by its physical symptoms from this 
 disease; and angina pectoris is to be told by the phenomena presented by 
 the heart and pulse, as well as by the sense of impending death, threat- 
 ened suffocation, intense anxiety, and the fact that the pain frequently 
 shoots down the left arm. 
 
 " Neuralgia of the Mammary Gland {Mastodynia). — The skin over 
 the mammary gland is supplied by the anterior and lateral branches of 
 the second, third, fourth, fifth, and sixth intercostal nerves, and by some 
 filaments derived from the supra-clavicular nerves, while the glandular 
 structure itself is supplied by the lateral perforating branches of the 
 fourth, fifth, and sixth intercostal nerves. This region is especially 
 liable to an extreme form of neuralgia, first described by Sir Astley 
 Cooper under the name of 'irritable breast.' So intense is the pain in 
 some cases of this affection that it is compared to the sensation of cutting, 
 tearing, or stabbing the part with a knife. It is usually paroxysmal in 
 character, and generally of short duration, although such attacks may 
 last for some hours. 
 
 " This affection seems to be associated with pregnancy, anemia, chlo- 
 rosis, hysteria, and the development of neuromata upon the nerves of this 
 region. It may be persistent and remain for years, and is particularly 
 obstinate to treatment. 
 
 " The detection of painful points is to be looked for in the region of 
 the escape of the nerves, which supply the part, from the inter-vertebral 
 foramina; and, in some instances, tlie existence of similar points may be 
 detected upon the breast, near the nipple, and upon the sides of the 
 gland. The attacks are particularly liable to exacerbate during the men- 
 strual periods, and, during the height of the paroxysm, the pain may be 
 
THE CHEST AND ITS CONTAINED ORGANS. 253 
 
 transmitted by otlier nerves into the neck, down the arm, and oTer more 
 extended areas upon the chest and back. 
 
 " Paralysis of the Dorsal Nerves. — The dorsal muscles control, to a 
 great extent, the movements, fixation, and upright position of the verte- 
 bral column, but these conditions require such a complexity of muscular 
 action that it is often difiicult, in case of paralysis, to exactly decide as to 
 the muscles which are affected. Various degrees of weakness of the dor- 
 sal muscles are often present in youth, sometimes on one side and some- 
 times on the other, and occasionally affecting the whole back to a greater 
 or less extent. 
 
 "These paretic states are dependent upon rheumatic affections, dis- 
 eases or injuries to the vertebral column, disturbances of the motor 
 regions of the cerebrum, lesions of the various ganglia of the encephalon, 
 and lesions of the kinesodic system of the spinal cord. In paraplegia, the 
 motor paralysis often extends upward to the muscles of the trunk; while, 
 in progressive muscular atrophy, the muscles of the dorsal region are not 
 infrequently involved. 
 
 " If the muscles of both sides of the back be paralyzed, the spinal 
 column gradually tends to assume the condition of a posterior curvature 
 (paralytic kyphosis), and the deformity is usually most marked in the 
 dorsal region, as the lumbar and cervical regions exhibit it to a less de- 
 gree on account of their anatomical peculiarities. If the extensor mus- 
 cles of the back be extensively affected, the spinal column forms an 
 equable curve, as if the body were bent forward as in old age, and the 
 patient becomes unable to voluntarily straighten the trunk to its normal 
 posture. When passive straightening is attempted, the spine is easily 
 brought into its proper curve, and this is a point of diagnosis between 
 paralytic kyphosis and the deformity dependent upon structural disease 
 of the vertebrae or a state of muscular contracture. 
 
 " The muscles most frequently affected are the sacro-lumbalis and tho 
 latissimus dorsi. If they be paralyzed upon one side only, the deform- 
 ity assumes the type of scoliosis, as a lateral curvature is produced by the 
 muscles of the unaffected side. In this case, as in the one before cited 
 the patient is unable to rectify the deformity by any voluntary muscular 
 effort, although the spinal curve can be easily removed by simple exten- 
 sion. 
 
 " When the extensor muscles of the lumbar region are markedly im- 
 paired, the attitude assumed by the patient is very characteristic. It 
 consists of a bending of the upper portion of the trunk in a backward 
 direction, so as to compensate for the bending forward of the lumbar 
 vertebrae; this bending of the thorax backward brings the upper part of 
 the body behind the centre of gravity of the whole body, and the balance 
 is preserved exclusively by the action of the muscles of the abdomen. 
 When the body is brought too far forward, it sinks and falls, as the lum- 
 bar muscles fail to support it in an erect posture. The patient cannot 
 
'254 PRACTICAL MEDICAL ANATOMY. 
 
 then bring the trunk into its former posture -without the use of the hands, 
 which are employed in a sort of climbing process, the hands being placed 
 upon the legs; a series of peculiar movements of the shoulders and trunk 
 then follow, which are employed to assist the arms in tossing the trunk 
 backward to an extent sufficient to allow the abdominal muscles once 
 more to support it. This difficulty in bringing the trunk above the level 
 of the lower limbs is typical of this condition, but there are still other 
 additional points of diagnostic value. The lumbar region presents a deep 
 hollow, the head is bent forward in standing or walking, and the trunk 
 may be seen to have a remarkable oscillating movement when the patient 
 "walks. When the patient sits down, the upper portion of the body seems 
 to sink, and the spine presents a condition of kyphosis. In fact, it seems 
 hardly possible that the condition can be mistaken by one well versed in 
 anatomy. " 
 
THE PELVIC B0NB8. 365 
 
 CHAPTER V. 
 THE PELVIC BONES. 
 
 THE PELVIS. 
 
 This portion of the trunk is called "the pelvis" from its resemblance 
 to a basin, as the derivation of the word implies (neXvS — a bowl). We 
 thus find it spoken of by older English works by the name of "the 
 basin," while the French commonly apply the term " le bassin " to this 
 part. It serves as a connecting link between the spinal column and the 
 femur of either side, and its construction is such (as will be shown later 
 on) as to afford the greatest sustaining strength in a vertical direction, 
 as well as to afford a large expanse of surface to support the viscera of the 
 abdomen. It would naturally be supposed that this portion of the frame 
 of bipeds would differ markedly from that of the quadruped, since, in the 
 atter class of animals, the pelvis has little if anything to do in supporting 
 the weight of the abdominal viscera, while much of the weight of the trunk 
 is supported by the upper extremities, thus decreasing the weight borne 
 hy the pelvis. This supposition is borne out by comparative anatomy, and 
 no part of the skeleton shows a more wonderful adaptation to the functions 
 -which it is destined to perform than the bony pelvis of the human race. 
 If we saw off the wings of the ilia, leaving the spinal column and femurs 
 •attached to the pelvic bones, a fact is disclosed which is either unknown or 
 imperfectly appreciated by the majority of anatomical students, viz., that 
 the ossa innominata and he sacrum form a most wonderfully constructed 
 arch, which rests upon e head of e'ther femur, at its lower portion, as 
 its columns of support, and whch is completed by a key-stone, the sa- 
 crum, at its upper part. So perfectly constructed is this arch that it 
 would be next to impossible for a force applied to the lower extremities 
 to seriously disarrange it, as the bones are so dovetailed as to render it 
 a piece of perfect workmanship, while the joints between the component 
 parts afford a certain degi'ee of elasticity which further increases its 
 strength, and which prevents a transmission of shocks to the regions 
 above the arch which are supported by it. It is the presence of this arch 
 which compels the pelvis to be placed at an oblique angle to that of the 
 spinal column, since the bones composing it must be placed directly un- 
 derneath each other so as to have the greatest strength — an arrangement 
 which will be seen to exist when the pelvic bones have been properly 
 
256 
 
 PRACTICAL MEDICAL ANATOMY. 
 
 sawn, as described above, but which is otherwise not so apparent, since 
 the projecting wings of the ilia tend to hide it. 
 
 In addition to the function of the pelvic bones as a sustaining arcli 
 for the portions of the body above the level of the sacrum, it has other 
 equally important functions to perform, which require special modifica- 
 tions of theSe bones. In order to support the viscera of the abdomen, 
 thus forming a bony wall at the dependent part of the trunk, the ilia are 
 expanded into prominent wings, and thus a great strain is taken from 
 the soft tissues which form the anterior and posterior wall of the abdomen, 
 which would otherwise be compelled to sustain the weight of these organs. 
 The expansion of these bones also affords a certain additional leverage for 
 
 Sacru». 
 
 Fio. 141.— The arch of the pelvis. Tlie wings of the ilia have been sawn through, in order to 
 show the direct support of the body upon the femur of either side. (After Holden.) 
 
 the muscles which are attached to them, thus assisting them in their re- 
 spective actions; and also in providing room for the attachment of the 
 successive layers of muscles of the abdomen and the thighs. 
 
 The pelvis is so constructed that its centre of motion upon the head 
 of the femur (the acetabulum) is nearly in the middle of a line drawn from 
 the tip of the tuberosity of the ischium to the highest part of the crest 
 of the ilium; it is thus cnpable of. becoming a lever of the first order 
 (where the fulcrum is in the middle and the power and resistance at either 
 end) in all of those movements where the trunk is bent upon the thighs, 
 as in the act of stooping, since the weight of the body is thus the resist 
 ance to be overcome, the fulcrum or movable point is in the acetabulum, 
 
THE PELVIC BONES. 257 
 
 ■while the power comprises the ham-string muscles which are attached to 
 the tuberosity of the ischium. 
 
 Before considering the points of interest presented by the separate 
 bones which form tlie pelvis, it may be of advantage to review such practi- 
 cal points, pertaining to the pelvis as a whole, as will enable us to more 
 thoroughly appreciate the special points which will come up during the 
 description of the os innominatum, the sacrum, and the coccyx. It will 
 therefore be necessary to call the attention of the reader: 1. To the 
 mechanism of the arch of the pelvis and the points of its construction; 3. 
 To the obliquity of the pelvis to the spinal column; 3. To the respective 
 axes of the pelvis; 4. To the diameters of its two outlets; 5. To the 
 differences which may be observed between the pelvis of the male and fe- 
 male; 6. To its foramina. 
 
 1. The arch formed by the pelvic bones has already been alluded to 
 in a previous page, but its construction has not been given in detail. It 
 is more properly a ring than an arch, since the bones which form it& sides 
 the ossa in nominata) are also joined at the lower portion, while they are 
 
 Fig. 142.— The lateral'view of the interior of the pelvis, showing the sacro-sciatic ligaments and 
 foramina. (After Byford.) 
 
 separated by a key-stone (the sacrum) at the upper portion. Thus the 
 femur of either side really articulates with a ring of bone interposed be- 
 tween it and the vertebral column above, which is so strongly constructed 
 as to be incapable of being crushed except by the most extreme violence, 
 and whose component parts cannot well be dislocated. As an evidence 
 of the marvellous strength of this bony ring, Holden records a case where 
 a wagon containing over five tons burden passed over the pelvis without 
 producing a fracture, which could never have occurred were it not for this 
 arrangement of the bones. The key-stone of this arch or ring, the sa- 
 crum, by its shape, is a mechanical wedge to force the parts into close ap- 
 position, since it constantly supports the superincumbent weight of the 
 head, trunk, and upper extremities, and is driven downward, and at 
 the same time backward, since it is set obliquely to the lumbar vertebrae. 
 17 
 
258 
 
 PEACTICAL MEDICAL ANATOMY. 
 
 Now wlaen this bone is examined more in detail, it will be- perceived 
 that the bone is so bevelled as to prevent it from being dislocated from the 
 ossa innominata in a backward direction; while the ossa innominata are 
 lipped over the front of the sacrum so as to prevent it from becoming dis- 
 placed in a forward direction. The dovetailing of the articular surfaces of 
 the sacrum with that of the os innominatum of the two sides is an addi- 
 tional precaution against the possibility of the key-stone of the arch be- 
 coming displaced by any form of external violence. It will be noticed, 
 also, that the ring or arch of the pelvis is so directed as to bring the line 
 of pressure of the weight of the trunk in a plane perpendicular to the 
 heads of the thigh-bones, and that this is no accidental arrangement is 
 proven by the additional fact that the cavity of the acetabulum is made 
 thicker at the point of bearing of the femur in the erect attitude than 
 elsewhere, so as to strengthen the line of pressure which passes through 
 the axis of this arch. 
 
 Fia. 143.— The pelvic outlet, showing the diameters of the same. (After Byford.) 
 
 In addition to this pelvic ring of bone which supports the weight of 
 the trunk in the erect or standing posture, there are two lateral arches, 
 one upon each side of the pelvis, designed to support, the same weight 
 during the sitting posture. Each of these arches runs from the pubes, in 
 front, to the ilium, behind; and the summit of each is the tuberosity of 
 the ischium. The eifect of the three joints in the main pelvic ring, viz., 
 the symphysis pubis and the sacro-iliac joint of either side, in breaking 
 the force of any shock transmitted from the bones of the lower extremity, 
 has been already mentioned, but can be repeated to advantage, since the 
 object of such joints is not alone for the purpose of allowing of movement 
 of the pelvic bones during parturition. 
 
 2. If we trace the line of gravity of the trunk downward, we will 
 perceive that it passes through the centre of the acetabulum, and thus 
 directly through the heads of the thigh bones; while the obliquity of the 
 sacrum to the spinal column is so great that it forms almost a right angle 
 with the axis of gravity. In the standing position, the tip of the coccyx 
 is thus placed about half of an inch higher than the symphysis pubis. 
 
THE PELVIC BONES. 
 
 259 
 
 3. The axis of the pelvis to the line of gravity of the trunk, or to a 
 perpendicular passing through the centre of the acetabulum, is about 
 140° in the male, and 144° in the female. It can thus be understood 
 that the axis of the superior plane of the pelvis is not directed perpendic- 
 ularly, but is inclined forward, as well as upward, so that, if drawn 
 through the exact centre of the plane of the superior opening of the pel- 
 vis, a line would extend from the second bone of the coccyx to the umbili- 
 cus. The axis of the outlet would begin at the promontory of the sacrum, 
 and pass through the middle point between the tuberosities of the ischia; 
 while the axis of the curve of the pelvic cavity, the curve of Oarus, corre- 
 sponds closely to that of the inner surfaces of the sacrum and coccyx. 
 
 4. The superior and inferior openings of the pelvis are of special 
 importance to the obstetrician, since they are subject to great variations 
 in their measurements as the result of congenital abnormalities, or 
 acquired defects following rickets, malacosteon, anchylosis of some of the 
 
 \ 
 
 Fia. 144.— Axes of superior and inferior straits, and pelvic cavity. (After Byford.) 
 
 joints, or abnormal growths afEecting the bones. The superior strait 
 (the name applied to the upper opening of the true pelvis) differs some- 
 what in its measurements when the soft tissues are present from those of 
 the bony pelvis, but a great diversity of opinion exists among difEerent 
 authors as to the normal diameters; and the same statement holds good 
 in reference to the inferior strait, since the coccyx is more movable in 
 some periods of life than in others, and since the pubic angle is not 
 always the same, even in the female sex. It would hardly be of sufficient 
 importance to enter into the statements of the more prominent authors 
 upon this subject, since the variations are not so wide between them as 
 to cause any serious discrepancy; and a general rule may be given which 
 will be approximately accurate and which will be much more easy to 
 retain in the memory than if the diameters be given in varying fractions 
 
260 
 
 PEACTICA.L MEDICAL ANATOMY. 
 
 of an inch. This rule may be stated as follows: " The diameters of the 
 superior and inferior openings of the female pelvis are the same, if it be 
 remembered that the superior strait is the longest in its transverse diam- 
 eter, and the inferior strait in its antero-posterior diameter; these diam- 
 eters are four inches for the shortest, four and a half inches for the 
 oblique, and five inches for the longest diameter of either opening.'" 
 
 It will thus be seen that the diameters of each opening form a 
 sequence with a variable quantity of one-half of an inch, and that the 
 oblique diameter of each opening is the same, viz. , four and a half inches. 
 The change in the diameters also shows that the longest diameter of the 
 superior opening, the transverse, becomes twisted, as it were, into the 
 
 FtGr. 145.— Intended to show the alteration in the length of the transverse and dia§^onal measure 
 ment of the pelvic cavity by the rectum and muscles at the brim. R, the rectum ; M, M, muscles. 
 (After Byford.) 
 
 antero-posterior diameter of the inferior opening, thus giving the cavity 
 of the pelvic bones such a gradual change in its measurements as to partly 
 assist in the rotation of the head of the child in its passage through the 
 space between the two openings, the inlet and the outlet. There are 
 other elements which tend to produce this important movement of rota- 
 tion of the head of the matured foetus, without which no child could ever 
 be born, which "will be considered in subsequent pages when difEerent 
 parts of the os innominatum are considered, but this change in the diame- 
 ters of the two straits of the pelvis is an important one, in explaining the 
 
 ' As given by Prof. T. G. Thomas in his course of iectures on Obstetrics in 
 
 1870. 
 
THE PELVIC BONES. 361 
 
 inclination of the lateral planes of that bony cavity, ■whose importance in 
 the mechanism of the act of labor is now taught by every lecturer on 
 obstetrics. 
 
 5. The pelvis of the male differs from that of the female in many 
 respects, which are evidences of design on the part of Nature and which 
 are so marked, as to enable the anatomist to discriminate between the two. 
 These points of difference may be thus stated: 
 
 a. The bones of the female pelvis are much lighter than those of the 
 male, and the muscular prominences are much less marked, thus giving 
 them a smoothness which the male pelvis does not present. It can be 
 easily understood why such a difference should naturally exist, since the 
 absence of prominent ridges of bone, where the muscles are attached, 
 favors the act of parturition; while the muscular structures of the female 
 are called into action less frequently than those of the male, and the 
 weight of the parts moved is proportionally less, thus demanding smaller 
 muscles and less roughening of the bones at the points of their attach- 
 ment. 
 
 Fig. 146.— Male pelvis seen from above. 
 
 h. The wings of the ilia are more widely separated, causing the 
 marked increase in the width of the hips of the woman over that of the 
 male, and the whole pelvis is broader from side to side, while the spines 
 of the ilia are more widely separated. 
 
 c. The inlet to the pelvis is m.uch larger in the female than in the 
 male, and is more nearly circular in shape, on account of the diminished 
 prominence of the sacro- vertebral angle. This provision assists in an easy 
 engagement of the foetal head in the first stage of labor; and a serious 
 impediment to labor is occasionally produced by a projection forward of 
 the sacro-vertebral angle, thus causing an alteration in the shape of the 
 pelvic inlet. 
 
 d. The cavity of the female pelvis is very shallow and is more capacious 
 than that of a male; both of which tend to render the passage of a foetus 
 more easy than if deep or narrow. The spines of the ischia do not pro- 
 ject into the cavity as in the male, since an obstruction to labor would 
 then exist; and the obturator foramen is larger in the male pelvis, since 
 
262 PEAOTIOAI, MEDICAL, ANATOMY. 
 
 the female needs a bony wall to assist in directing the foetal head during- 
 its rotation within the cavity of the pelvis. 
 
 e. The outlet is more expanded, since the pubic angle is greater in the 
 female than in the male, and is more dilatable, because the coccyx becomes 
 anchylosed late in the female, and admits of movement during labor 
 which greatly increases the size of the lower pelvic aperture* The edges 
 of the puMc arch are everted in the female pelvis, in order to prevent 
 injury to the soft parts during the expulsive efforts of the second stage of 
 labor; while the tuberosities of the ischia are very tvtdely separated, thus 
 increasing the lateral diameter of the bony outlet. 
 
 6. The foramina of the pelvis are of importance, both from a purely 
 anatomical point of view, since they allow of the exit and entrance of 
 structures which perform important functions, and also from a practical 
 stand-point, as they may become the seat of hernial protrusions and the 
 means of escape of abnormal collections of pus within the pelvic cavity. 
 They comprise the greater and lesser sacro-sciatic,' and the obturator 
 foramina of either side, the latter of which is, however, partially closed 
 by the obturator membrane. With the exception of the obturator, these 
 foramina each transmit a muscle, which thus escapes from within the 
 pelvic cavity in order to act upon the femur, while other important 
 structures are also afforded a means of egress, in case they are to 
 supply parts external to the pelvis, or of ingress, in case their region of 
 distribution be the perinaeum. Now, as all the large blood-vessels and 
 nerves which are destined to supply the different regions of the lower 
 extremity escape from one of these three foramina upon either side, the 
 relation of each of these foramina to the surrounding parts and the 
 structures which are transmitted by each becomes of great interest not 
 only to the surgeon but also the physician, since in many ways the 
 relation of the main nerve-trunks and the important blood-vessels can be 
 utilized in diagnosis. The parts which pass through the foramina of the 
 pelvis can be stated as follows : 
 
 'The gluteal vessels. 
 
 The superior gluteal nerve. 
 
 The pyriformis muscle. 
 
 The pudic vessels and nerve. 
 
 The sciatic vessels and nerve. 
 
 The nerve to the obturator 
 internus muscle. 
 
 Through the great sacro-sciatic foramen. 
 
 ' These are not foramina, properly speaking, in the os innominatum, since 
 the greater and lesser sacro-sciatic ligaments help to convert simple notches in the 
 bone into complete foramina. 
 
THE PELVIC BONES. 
 
 263 
 
 Through the lesser sacro-sciatic foramen. < 
 
 'The obturator internus mus- 
 cles. 
 
 The pudic vessels (re-enter- 
 ing)- 
 
 The pudic nerve (re-enter- 
 
 iiig)- 
 
 ( The obturator vessels. 
 Through the oUurator foramen. | ^he obturator nerve. 
 
 It will be perceived, on looking at the tables given above, that the 
 pudic vessels and nerve escape from the pelvic cavity by the greater 
 sacro-sciatic foramen, and immediately re-enter it by means of the lesser 
 sacro-sciatic foramen, having thus passed external to the spine of the 
 ischium which separates these two foramina. This peculiarity, of course, 
 naturally suggests some necessity for so marked a deviation from the rule 
 which Nature usually adopts, viz., to send the nerve-filaments and the 
 blood-vessels in the most direct route to their destination, unless the 
 function of the part so supplied is thereby imperilled; and, as no branches 
 are given oflE, either by the nerve or the artery during its passage between 
 the points of exit from and entrance to the pelvic cavity, the spine of the 
 ischium, around which the nerve and vessels wind, seems to be designated 
 as a point to be especially avoided in its relation to the interior of the 
 pelvis. 
 
 Starting with this guide, afforded by Nature, as to the importance of 
 this bony prominence, we would naturally expect to find it directly con- 
 cerned in some function which would be liable to cause serious injury 
 to either a blood-vessel or a nerve, if placed in relation with its internal 
 aspect; and we find the explanation, at once, in the important function 
 which this bony point has upon the complete performance of the second 
 stage of labor. During the passage of the foetal head through the 
 maternal pelvis, this point in that bony canal is severely impinged upon; 
 and it is claimed by many authors on obstetrics that this point marks 
 one of the most important agents in producing the rotation of the head 
 of the child which is essential to its delivery. Now, if this be the case, 
 it at once becomes evident, should the pudic vessels and nerve pass 
 along the inner surface of this bony prominence instead of on the outer 
 side of it, that the compression exerted by the head of the child during 
 the second stage of labor would so affect these parts as to cause serious 
 impairment of their function; and it would thus be possible for terrible 
 hemorrhage to occur if the artery should chance .to be lacerated; for gan- 
 grene of the perinaeum to result, if the artery be so long compressed as 
 to shut off the nutrition to the parts supplied by that artery; for paraly- 
 sis of the perinseum (whose functions in the female are almost vital to 
 the life of the patient, since its destruction makes existence a constant 
 burden), if the pudic nerve should be destroyed; and for severe neuralgic 
 seizures in that region if the nerve be injured but not destroyed. 
 
264 PRACTICAL MEDICAL ANATOMY. 
 
 I can conceive, therefore, of no greater proof of the wisdom of our 
 construction than this simple device exhibits, since untold ills to the sex 
 which bear the cherished names of Mother, Wife, and Daughter, would 
 be inevitably entailed, were such a provision against danger wanting. 
 
 The femoral opening, which lies below Poupart's ligament, is not prop- 
 erly a foramen of the pelvis. It will be found discussed in all its practi- 
 cal and anatomical aspects in those pages which treat of the anterior wall 
 of the abdominal cavity. 
 
 The pelvis may be divided into a true and & false pelvis; the former 
 including that portion which invests the bony canal or cavity of the pel- 
 vis and which is situated below the pectineal line; while the latter in- 
 cludes the expanded wings of the ilia, and thus presents an incomplete 
 bony investment, since its anterior wall is deficient between the two ante- 
 rior superior spines of the ilia, while a similar opening exists between 
 the postero-superior spines of the ilia. Certain portions of the true pelvis, 
 viz., its brim or inlet, its cavity, and its lower opening or outlet, have 
 already been described, but it yet remains to give the measurements of 
 the different walls of the true pelvis. 
 
 The anterior wall is extremely short, being but one and a half to two 
 inches in depth, and consists of the body of the pubes. It is made 
 extremely short in comparison with the depth of the lateral or posterior 
 wall, since the occiput of the foetal head is forced to rotate underneath 
 this arch during the second stage of labor and there to act as a point of 
 motion during the subsequent delivery of the head through the inferior 
 opening of the pelvis (the completing part of the second stage of labor). 
 
 The lateral wall of the true pelvis is somewhat broken by the sacro- 
 sciatic foramina, but it measures about three and a half inches in depth. 
 
 Th-Q posterior wall of the true pelvis, if measured along the inner sur- 
 face of the concavity of the sacrum, differs in its length in the two sexes, 
 since, as before stated, the sacrum of the male is longer, narrower, and 
 more curved than that of the female. It is customary, therefore, to find 
 this portion of the pelvis about five and a half inches in depth in the male 
 and about foui- and a half inches in the female. The necessity of an 
 alteration in the female pelvis from the type of the male in this region 
 is shown by the fact that it would be impossible for the male pelvis to 
 perform the requirements of child-bearing on account of the curve of the 
 sacrum which would offer a mechanical obstruction to the movement of 
 rotation within the cavity of the pelvis, while it would also so diminish 
 the size of the pelvic outlet as to markedly interfere with the mechanism 
 of the escape of the fcetus; hence the type of pelvis resembling that 
 which would be normal in the male, becomes, when met with in the fe- 
 male, a cause of surgical interference in ease of impregnation having 
 taken place. 
 
 Having now considered the pelvis as a whole, we are better prepared 
 to consider the separate bones which enter into its formation, and to study 
 
THE PELVIC BONES. 
 
 265 
 
 the construction of each, so far as points of practical utility are af- 
 forded, or the special objects which are attained by the deviations from 
 the type of the lower animals, go to prove the wisdom of the Creator. 
 
 THE OS INNOMINATUM. 
 
 This bone, the chief one composing the pelvis, since it and its fellow 
 form all of the pelvic ring, with the exception of the key-stone to the 
 arch, the sacrum, still goes as the bone '" without a name," although the 
 separate parts which compose it are specially designated. Tlie three 
 parts which compose it are called the "ilium," the "ischium," 
 and the " pubesj" and they are entirely separate bones during the years 
 of childhood, although they become united, in adult life, into one bone. 
 The first piece mentioned (the ilium) is so called because it supports the 
 flank (ilia); the second, because it supports the trunk while in the sit- 
 ting posture, since its derivation implies " the buttock;" while the third is 
 named from the fact that hair appears on that region. It is a curious 
 fact that these three portions of the os innominatum should enter into 
 the construction of its main cavity, the acetabulum,^ with which the 
 femur articulates, and which has, therefore, to support the entire weight 
 of the trunk and the upper extremity, when the subject stands erect. 
 
 The ilium is situated above the line of the "true pelvis." It is so 
 constructed as to form a broad expanse of bone surface for the support 
 of the viscera of the abdomen, while it is also intended to give a powerful 
 leverage to the muscles which are attached to it. This latter function is 
 particularly important in the case of those muscles which tend to 
 balance the pelvis upon the head of the femur. The attachment of the 
 glutei muscles is made doubly strong by the presence of roughened lines 
 upon the exterior surface of the bone, since these muscles are essential to 
 the biped in order to maintain the erect posture of the trunk upon the 
 extremities; hence the contrast in the attitude of a horse taught to stand 
 upon his hind legs from that of man or monkey, in which the extensor 
 muscles are more powerfully developed. 
 
 The fossa which exists in the internal surface of the ilium, the "iliac 
 fossa," is one of the distinguishing characteristics of the human skeleton. 
 It is intended as a support to the viscera of the abdomen, which are con- 
 stantly tending toward displacement downward from their weight alone. 
 When this fossa is turned to the light it will be perceived that a remark- 
 able thinness of the bone exists at the bottom of this fossa, which would, 
 at first, seem as a refutation of this theory as to its function; but, when 
 the bone is placed in its proper relations to the surrounding parts, it will 
 at once become evident that the thin portion of the bone is outside of 
 the line of gravity and does not therefore have to sustain weight, and 
 
 ' So-called from its resemblance to a wine-cup. The ilium forms about two- 
 fifths of it, the ischium about two-fifths, and the pubes, the remaining one-fifth. 
 
266 PRACTICAL MEDICAL ANATOMY. 
 
 hence Nature dispenses with unnecessary bone-tissue at this point in 
 order to save all weight, for the muscles to act upon, which is not abso- 
 lutely required. 
 
 Another fossa is formed by this portion of the os innominatum which 
 is called the " gluteal fossa," and which is situated upon its exterior sur- 
 face. It is intended to afford additional room for the lodgment of the 
 glutei muscles which are very extensively developed in man, for reasons- 
 previously given. The presence ' of the iliac and gluteal fossae gives to 
 the ilium, when viewed from above, a convexity outward in its anterior 
 part, and a concavity inward in its posterior part, thus causing it to as- 
 sume a curve similar to an elongated letter S. 
 
 The anterior harder of the ilium presents two bony prominences called 
 the anterior-superior and the anterior-inferior spines, for the attachment 
 of muscles of the thigh; and beneath the latter, a deep groove or notch, 
 around which the iliacus muscle and the accompanying psoas muscle pass 
 to be inserted into the femur. Still lower down the ilium joins the 
 pubes, thus forming the so-called pectineal eminence which is of interest 
 from the fact that the femoral artery passes over it to reach the thigh, 
 and against which it can be compressed, in case of hemorrhage from 
 an opening below that point. 
 
 On the posterior border of the ilium, similar bony prominences exist, 
 called the posterior-superior and the posterior-inferior spines, which serve 
 for the attachment of ligaments; while below them, the notch of the 
 ischium, which assists to form the great sacro-sciatic foramen, may be 
 perceived, through which many important structures pass, as mentioned 
 on page 263. As we pass downward from this point, we meet the spine 
 of the ischium, separating the greater sacro-sciatic from the lesser sacro- 
 sciatic notch, the latter of which is also transformed by a ligament into a 
 complete foramen, for the transmission of important parts. 
 
 The articular surfaces of the os innominatum pertain to the ilium and 
 the pubes. The ilium joins the sacrum posteriorly, and thus assists to 
 complete the. arch of the pelvis, while the pubes joins with its fellow in 
 front, to form the "symphysis pubis." The sacro-iliac joint is wonder- 
 fully constructed to prevent any possible displacement of the bones which 
 form it, since the integrity and strength of the pelvic arch, upon which 
 so much depends, is thus insured. This fact is clinically illustrated as 
 well as by the anatomical construction of the joint itself, since, while an 
 inflammation of the sacro-iliac synchondrosis is one of the most uncom- 
 mon of accidents, and one which requires the most extreme form of vio- 
 lence to create it, I have never seen nor do I know of a well authenticated 
 case where these bones have suffered a dislocation. This joint is provided 
 with a layer of interposed cartilage, shaped somewhat like a human ear, 
 which acts as a buffer to break the force of any shock transmitted to the 
 joint; while the bevelling of the sacrum prevents it from being forced 
 away from the ilia in 'a backward direction, and a lipping of the ilia over 
 
THE PELVIC BONES. ' 267 
 
 the sacrum in front prevents it from being forced out of place into the 
 cavity of the pelvis. ' Besides these mechanical safeguards against dis- 
 placement, the ligaments of the joint are so strong that, as before said, 
 the most extreme violence is required to create sufficient stretching of 
 them as to induce inflammatory action within the joint, setting entirely 
 aside the possibility of displacement. I once met with a case where a lad 
 fell from a high fence, while his feet were firmly wedged between the iron 
 spikes pi-ojecting from the top, in which the sacro-iliac joint was so 
 strained as to produce disease of that articulation, but the violence was so 
 severe as to create amazement that the limbs were not torn from their 
 attachment to the ossa innominata." 
 
 • The ISCHIUM is that portion of the os innominatum upon which the 
 trunk is supported while the subject is in the sitting posture. As men- 
 tioned in a previous page, the prominent portion, or tuberosity of the 
 ischium, is supported upon two projections of bone which form a lateral 
 arch upon the side of the pelvis; so that the weight of the trunk is borne, 
 while the subject is sitting, upon two lateral arches, whose curve is di- 
 rected downward, and which are capped by the tuberosities of the ischia 
 upon either side. The object of such an arrangement is evidently to dis- 
 tribute the weight more evenly over the entire pelvis. 
 
 The ischium is marked posteriorly by the two notches which assist to 
 form the greater and lesser sacro-sciatic foramina, and also by the spine 
 of the ischium, which separates these notches and which is of great im- 
 portance to the obstetrician. The special points of interest which per- 
 tain to these three localities have already been referred to in those pages 
 descriptive of the pelvis in general, and need not be again repeated. It 
 is of importance, however, in this connection to call attention to the liga- 
 ments which convert the notches of the ischium into complete foramina, 
 the sacro-ischiatic ligaments, since they serve other important functions 
 as follows: 
 
 1. They contribute to the fixation of the sacrum as the key-stone of 
 the pelvic arch, by their great strength and inelasticity. 
 
 3. They afford a larger surface for the attachment of the gluteus 
 maximus muscle, which contributes chiefly to form the buttock, than the 
 OS innominatum could itself afEord. 
 
 3. They assist in forming the floor of the pelvic cavity, and thus help 
 to sustain the weight of the pelvic organs without adding much to the 
 weight of the pelvis. 
 
 4. They convert the notches of the ischium into complete foramina 
 for the transmission and protection of those structures which are forced 
 to escape from or enter the pelvic cavity in the gluteal region. 
 
 ' For a full description of the construction of this pelvic arch, see page 256. 
 
 * For the dififerential diagnosis between sacro-iliac disease and disease of the 
 hip- joint, the author would respectfully refer the reader to his work on Surgical 
 Diagnosis. New York, 1880. 
 
268 PEACTICAL MEDICAL ANATOMY. 
 
 The ramus of the ischium, by joining with the ramus of the pubes, 
 helps to complete the anterior portion of the lateral arch, upon which 
 the tuberosity of the ischium is placed; while it also assists to form the 
 obturator foramen, which allows of and fayors movement of the fcetal 
 head within the cayity of the pelyis during labor, since it is covered with 
 a membrane which naturally yields more than would a solid wall of bone. 
 In addition to this object. Nature has also lightened the weight of the pel- 
 yis by providing this opening, while the membrane which covers it in 
 the recent subject affords an equally effective attachment for muscles. 
 
 The S]]ine of the ischium affords attachment to the lesser sacro-ischi- 
 atic ligament, the gemellus superior muscle, the coccygeus, and a part of 
 the levator ani. It should not be forgotten that the internal pudic artel(y, 
 vein, and nerve pass over this bony prominence, since they thus manage 
 to avoid the possibility of pressure during parturition;' and, in very thin 
 subjects, it might be possible to compress the pudic artery against this 
 portion of the ischium, should hemorrhage occur, of a serious character, 
 from wounds of the perinseum, or during the operation of lithotomy. 
 
 The tuberosity of the ischium has already been mentioned as present- 
 ing a mechanical arrangement, in reference to its attachment to the other 
 portions of the os innominatum, which admirably fits it to act as the 
 chief point of support of the trunk during the act of sitting; but its 
 other functions which have as yet been omitted, are possibly of even 
 greater importance in controlling the various attitudes which the trunk is 
 called upon to assume, in its relations to the thighs. Since it is the 
 most dependent portion of the human pelvis, when the trunk is sup- 
 ported by the lower extremities in the erect attitude, it becomes one'end 
 of a lever" when the trunk is flexed upon the thigh, as in the act of stoop- 
 ing; the weight of the trunk, head, and upper extremities becoming the 
 resistance, the hip-joint being the fulcrum, and the powerful ham-string 
 muscles which are attached to the tuberosity of the ischium being the 
 power which raises the weight. It can be readily understood, therefore, 
 why the muscular attachments to this prominence of bone are roughened 
 to afford a firm attachment to the pelvis, since they have to control a 
 great weight with a short leverage. The great sacro-ischiatic ligament, 
 whose functions have been already referred to, is also attached to the 
 tuberosity of the ischium; while the pudic vessels and nerve lie about one 
 inch and a half anterior to its inner margin. " 
 
 The internal surface of the ischium is smooth, since it helps to form 
 a portion of the pelvic cavity. It has a gentle slope toward the lower 
 
 1 See page 263. 
 
 ' This lever is one of the first order, since the fulcrum is in the middle, the 
 power at one end, and the weight at the other. 
 
 ' This may be used as one of the surgical landmarks of the pelvis, in determ- 
 nining the situation of the pudic vessel in the living subject. 
 
THE PELVIO BONES. 
 
 269 
 
 opening of the pelvis, and it is this portion of the os innominatum which 
 is the chief cause of the rotation of the fcetal head during its passage 
 through the cavity of the pelvis. It is this rotation that constantly 
 tends to bring the long axis of the head of the child in relation with the 
 longest axis of the maternal pelvis, after its engagement at the superior 
 opening." Prom this surface of the ischium, the obturator internus 
 muscle lakes a large portion of its origin. The tendon of this muscle 
 passes out of the pelvis by winding around the lesser sciatic notch, to 
 be inserted into the femur, thus using this depression as a pulley. 
 
 The external surface of the iscliium assists to form the acetabulum, 
 but, as the ilium and pubes also enter into its formation, thjs cavity will 
 be considered after the separate bones have been individually described. 
 It gives attachment to muscles which act upon the femur and the 
 leg; but they have no bearing upon the medical anatomy of the trunk, 
 and are, therefore, out of the scope of this volume. 
 
 The PtTBES is that portion of the os innominatum which helps to form 
 the front of the pelvis. It is usually divided into a body and two 
 branches, called "rami," one of which lies horizontally," and connects 
 the body to the ilium; while the other descends to Join the ramus of the 
 ischium and thus completes the inferior boundary of the obturator fora- 
 men. The ramus which connects the body of the pubes with the ilium — 
 the so-called "horizontal ramus " — assists to form a part of the true pelvis, 
 and also the upper boundary of the obturator foramen, while the so-called 
 " descending ramus " leaves a gradually increasing space between it and 
 its fellow of the opposite side, the "arch of the pubes." 
 
 It has been already stated that the arch of the pules differs in its 
 angle in the two sexes, since more room is required between the rami of 
 the pubes in the female than in the male, in order to facilitate the deliv- 
 ery of the head of the foetus. It will also be observed that the edges of 
 this portion of the pubes are sloped outward to excess in the female, 
 — another evidence of the adaptability of the sexes to the functions for 
 which they were designed. We can also see, in this region, the grooves 
 which are provided for the attachment of the crura of the penis in the 
 male pelvis, and for the crura of clitoris in the female pelvis. 
 
 The iody of the pules is of great interest to the anatomist, and also 
 to the surgeon, since it assists to form the joint in front of the pelvis, 
 called the "symphysis pubis," while it is also the region where hernia 
 most frequently develops, and, therefore, one of special surgical impor- 
 tance. In the construction of the symphysis, every precaution has 
 
 ' See page 263. 
 
 'The terms "horizontal ramus" and "descending ramus" are only correct 
 when the pelvis is held so that the plane of the superior strait is horizontal. 
 During life, when the pelvis is very oblique, the terms are absurdly incorrect, 
 since they might be reversed with an approach to accuracy. 
 
370 PRACTICAL MEDICAL ANATOMY. 
 
 been taken to insure strength and elasticity. The bones haye not been 
 placed in direct apposition, but a plate of cartilage some three-eighths of 
 an inch in thickness has been interposed as a bufEer against shocks trans- 
 mitted from below by the thigh-bones. This arrangement is strongly 
 analogous to the separation of the vertebrse by means of the inter- 
 vertebral disks, and is one of the devices found in every joint which is 
 exposed to the liability of excessive strain, or severe shocks. We see also 
 that the symphysis is provided with strong ligaments which are arranged 
 in front, behind, below, and above the bones of either side. 
 
 Upon the body of the pubes is a small prominence of bone which 
 is called the spine of the pubes, on account of its pointed shape. 
 This little bony prominence is one of the most important surgical guides 
 in the human body, since it acts as a point of attachment for Poupart's 
 ligament. It is not in accordance with the plan previously adopted, to 
 discuss here the subject of hernial protrusions of the inguinal and femo- 
 ral regions, since they will be found to be fully discussed in the chapter 
 upon the anterior wall of the abdomen; but it can be stated in this con- 
 nection, that the ligament of Poupart is the great dividing line between 
 the inguinal canal and the femoral opening, and that since it is attached 
 to the spine of the pubes, that bony prominence becomes a most valuable 
 guide in determining the character of all hernial protrusions in the imme- 
 diate neighborhood of Poupart's ligament. 
 
 The muscles which are attached to the body or the rami of the pubes 
 are inserted into the thigh-bone, and are of interest chiefly in their rela- 
 tion to the movements of the hip-joint, and to their effect upon fracture 
 of the femur. They do not properly belong to those regions of the body 
 which possess special interest of a purely medical character; and the sur- 
 gical points, to be readily understood, would require more space than the 
 limits of this work will allow of. 
 
 The SACRUM forms the key-stone to the pelvic arch, and supports 
 the weight of the trunk, head, and upper extremities. It also completes 
 the cavity of the pelvis, since its interior surface forms the posterior 
 boundary of that space. It will be seen, on viewing the spinal column 
 laterally, that the sacrum forms a rounded angle with the last lumbar 
 vertebra, thus giving rise to the so called " promontory of the sacrum." 
 The object of this angle is evidently a double one, since it increases the 
 capacity of the cavity of the pelvis, and also serves to assist in breaking 
 all shocks transmitted from the pelvis to the spinal column. 
 
 The triangular form of the bone renders it admirably adapted for 
 its use as a key-stone to an arch, since it prevents its displacement down- 
 ward between the ossa innominata, while its sides are so bevelled as to 
 render its displacement in a backward direction impossible. It is also 
 held still more securely in place by a lip derived from the ilium of either 
 side, which laps over it anteriorly. 
 
 The bone is curved and not straight; otherwise we would be un- 
 
THE PELVIC BONES. 271 
 
 uuable to sit, on account of a projecting bone similar to a tail seen in 
 animals, but lacking its flexibilitJ^ It is composed of five vertebra so 
 amalgamated as to form one bone, although the evidences of most of the 
 constituent parts of a vertebra are to be discerned upon its surfaces. 
 
 This bone is pierced for its whole length by the sacral canal, which 
 is a continuation of the canal of the spinal column and which affords 
 protection to the sacral nerves, which subsequently form the sacral 
 plexus after their escape from it. It is also provided with five anterior 
 and fi,ve posterior foramina upon either side, which afford exit for the 
 sacral nerves and which are so placed as to allow a pencil of small size 
 to be passed through both the anterior and its corresponding posterior 
 foramina in the skeleton; hence it might be possible, during life, for a 
 small pointed instrument to be plunged into the pelvic cavity through 
 the sacral region, and thus inflict a most serious wound. 
 
 The sacral canal is not completely invested with hone for its entire 
 length, since the spinous processes and a part of the laminae of the last 
 two sacral vertebrte are often deficient, thus leaving the posterior part of 
 the canal open. This anatomical fact is used by some authors to explain 
 the serious spinal symptoms which occur in connection with bed-sores, 
 since it is certainly not impossible for the putrid secretions of such local 
 sores to enter the spinal canal and set up inflammation of the spinal cord 
 or its coverings. 
 
 The joint between the sacrum and the ilium of either side is often 
 called "the sacro-iliac symphysis," in contradistinction to the pubic 
 symphysis. This point is one of the most secure of the body, since 
 every mechanical device has been employed by Nature to so dovetail the 
 bones as to prevent dislocation. It is occasionally so wrenched by acci- 
 dents of the most extreme character, as to excite an inflammatory pro- 
 cess, to which the term " sacro-iliac disease " is applied, and which 
 affords many symptoms in common with a similar condition of the hip- 
 joint. 
 
 The articulation of the sacrum with the last lumbar vertebra is so con- 
 structed as to admit of a slight amount of rotation, since the articular 
 processes of the sacrum are directed backward and inward, and are made 
 concave. They are also set very wide apart, so as to afford as broad a 
 base as possible upon which the spinal column could rest. 
 
 CLINICAL POINTS PEKTAINING TO THE EEGION OF THE PELVIS. 
 
 We have now considered the peculiarities of the construcbion 
 of the pelvic arch, the variations which exist in the sexes, the 
 diameters and axes of the different portions of the pelvis, the func- 
 tions which this portion of the human skeleton is designed to perform. 
 
 ' Beclard reports such a case as having been presented to his notice, in which 
 the pelvic organs were transfixed by the penetrating instrument. 
 
272 PEACTICAL MEDICAL ANATOMY. 
 
 and the Yarious points of interest which each of the separate bones of the 
 pelvis present to the anatomist. There still remain, however, the aceta- 
 bulum and other bony points whose clinical bearings have not been 
 fully shown; and certain medical and surgical landmarks, which pertain 
 to this region and which are of the greatest value to the diagnostician. 
 
 The acetaiulum, so called from its fancied resemblance to a wine-cup, 
 is the socket in which the head of the femur is so articulated as to permit 
 of the various movements of the hip-joint. It is formed by a part of 
 each of the three subdivisions of the os innominatum, the pubes forming 
 the smallest portion; and it is directed downward and outward, in the 
 erect attitude, so as to bring the bearing of the pelvis directly upon the 
 head of the thigh-bone. It will also be noticed that the part'formed bv 
 the ilium, which is at its uppermost part, is thickened in excess over the 
 other parts of the cavity, since, in the erect attitude, this portion is sub- 
 jected to the greatest strain, as it supports the weight of the entire trunk, 
 the head, and the upper extremity. That this is an arrangement spe- 
 cially provided for the biped, is proven by comparing the pelvis of the 
 quadruped with that of man. The margin of this cavity is not a contin- 
 uous ring of bone, since a notch exists in its lower part, the cotyloid 
 notch, for the transmission of blood-vessels and nerves to the interior of 
 the joint; but this incompleteness of the bony margin is unimportant, 
 from a mechanical point of view, as no strain comes upon that part of 
 the circumference, and as the notch is converted into a foramen by a 
 ligament which supplies the absence of bone. ' The acetabulum appears 
 deep in the skeleton, but it is made still deeper, in the recent subject, by 
 a ring of fibro-cartilage which surrounds its margin, the cotyloid liga- 
 ment, whose function is to embrace the head of the femur more closely 
 than the bony cavity could possibly do," while it also deepens it, and thus 
 renders the articulating surface increased. 
 
 When we look into the bottom of the acetabulum, in the recent state, 
 we will perceive that it is everywhere incrusted by cartilage except at the 
 lower part; and, at that portion, an irregular excavation exists. This 
 excavation is for the purpose of allowing free movement of the ligamen- 
 tum teres within the cavity of the joint, and it is partly filled also by fat. 
 and fringe-like projections of the synovial membrane. The most internal 
 part of the cavity, when the person stands erect, is extremely thin, and 
 is almost translucent in the skeleton; hence it is that severe concussions, 
 transmitted to the pelvis by means of the lower extremities, are liable to 
 
 ' The transverse ligamfent of the hip-joint. 
 
 ' The cotyloid ligament of tlie hip-joint acts as a " sucker" upon the head of 
 the femur and thus tends to prevent displacement of that bone. So perfect is 
 the construction of this joint, that, when all the muscles and also the capsular 
 ligament have been severed, atmospheric pressure will still support the weight of 
 the entire lower extremity, unless the acetabulum be perforated from within the 
 pelvis, when it will immediately drop. 
 
THK PELVIC BONES. Si 73 
 
 be followed by symptoms of injury to the pelvic organs, as the bladder, 
 rectum, vagina, uterus, urethra, etc., as this portion of the acetabu- 
 lum may be fractured. 
 
 The anterior superior spine of the iliiom is an important point in the 
 detection of disease of the iliac bone or of the sacro-iliac joint. In case 
 a fracture of the os innominatum is suspected to exist, pressure over this 
 bony prominence upon the two sides of the pelvis will often enable tlie 
 physician to detect the presence of crepitus, while mobility of the frag- 
 ments can be sometimes perceived. In a similar way, pressure made over 
 this point upon the two sides, will enable the physician to control the 
 movement within the -sacro-iliac joint, in case disease of that articulation 
 is suspected, since the os innominatum of the affected side is thus ren- 
 dered immovable and no longer allows motion at the hip-joint to create 
 movement in the sacro-iliac articulation. This bony point is one of the 
 greatest importance in the discrimination between the conditions of mor- 
 bus coxarius and sacro-iliac disease, since movement of the liip may cre- 
 ate pain referable to the gluteal region in either case, while concussion on 
 the end of the femur of the affected side will also create pain referable to 
 the same region in both diseases. Now, if the ossa innominata be ren- 
 dered immovable by pressure made upon the anterior superior spines of 
 the ilia, no pain will be experienced in hip-joint disease, since the force 
 is not perceived by the inflamed surfaces of the affected joint; while, on 
 the other hand, the same pressure will cause the inflamed surfaces of the 
 sacro-iliac articulation to be approximated and thus increase the pain, if 
 any exists, or produce it, if previously absent. Should, however, the 
 pressure be so applied to the pelvis as to separate the inflamed surfaces of 
 the sacro-iliac joint, while, at the same time, the os innominatum of the 
 side corresponding to the affected joint be prevented from participation 
 in the movements at the hip-joint, movement of the thigh upon the 
 pelvis will no longer create pain; a point of the most positive kind in the 
 diagnosis of this diseased condition. 
 
 It is customary with surgeons, in examining the lower limb for sus- 
 pected fracture, to measure between the anterior sujoerior spine of the 
 ilium and the internal malleolus, and thus to detect the presence or ab- 
 sence of sTiortening by comparing the measurement so obtained with that 
 of the corresponding limb, and the same steps are, or should be, taken 
 by careful practitioners in case of recovery from a fracture of the lower 
 extremity, in order to properly record and appreciate the results of treat- 
 ment. Now it is a fact, to which almost every surgeon of experience will 
 attest, that it is the rarest of coincidences to find any three or four men 
 agree in the measurements of a leg, even when made in each other's 
 presence and at the same time, and this is to be attributed, not to the 
 carelessness of the -observers or the desire on the part of any one present 
 to increase or diminish the existing deformity, but to a lack of method in 
 properly performing this very simple procedure. If we are to expect 
 18 
 
274 PBACTICAL SIEDICAL ANATOMY. 
 
 perfect accuracy in such measurements, we must insure two important 
 factors: first, that the points to which the measurements refer are abso- 
 lutely the same, and, secondly, that the two points are immovable. We 
 can effect both of these if we will use the following rule: — ^Use a tape 
 which is inelastic, and so crowd the finger tips underneath the lony prom- 
 inences as to render it impossible for either end of the tape to move up- 
 ward; if the tape is tightly drawn between the fingers in this position, 
 error is impossible. 
 
 The anterior superior spine of the ilium is also used as a point of mea- 
 surement in the detection of displacement of the head of the femur from 
 the acetabulum. The so-called " Nglaton's guide " which is employed for 
 tlii.3 purpose is thus applied: A line is first drawn from the anterior supe- 
 rior spine of the ilium to the most prominent portion of the tuberosity 
 of the ischium. This line should pass through the centre of the cavity 
 of the acetabulum, if properly drawn, and should also cross the top of the 
 trochanter of the femur, in the living subject, provided the thigh be 
 semi-flexed and slightly adducted;' so that all of the trochanter which 
 projects behind or above that line indicates the extent of the displace- 
 ment due to dislocation or fracture. 
 
 The drawing of such a line as suggested by Nelaton is not always 
 easy in a fat subject where the bony prominences are often detected with 
 some difficulty; hence it is custom'ary with surgeons to use their hands 
 as a means of estimating the relative distance of the trochanter from the 
 anterior superior spine of the ilium by placing the thumbs upon that 
 latter point and feeling with the fingers for the edge of the trochanter. 
 Thus Winslow says, in his work upon the structure of the human body, 
 " Feel whether the injured member answers to the sound." 
 
 The spine of the 'pules is often used as a guide to determine 
 whether the trochanter of the femur is normal in its relation to the 
 pelvis, since that bony prominence lies on the same level as the top of the 
 trochanter, in the erect attitude. This prominence of the pubes is the 
 most reliable guide to the external abdominal ring, and it is therefore 
 often appealed to as a means of discrimination between femoral and in- 
 guinal hernia, the spine lying to the outside of the sac of inguinal 
 hernia, and to the inner side of the sac of the femoral variety. It 
 is sometimes difiicult to feel the spine of the pubes through the 
 subcutaneous fat of the abdominal wall, but this difficiilty can be 
 most readily overcome by slipping the finger up along the upper portion 
 of the scrotum or labium, when the subcutaneous fat is forced away from 
 the pubes and its spine distinctly felt. The subject of hernia will, how- 
 ever be fully discussed in the chapter upon the wall of the abdomen. 
 
 ' The rule given as to the application of Nelaton's test has been modified by 
 the author, since he has found that the test, as originally described by its 
 originator, does not hold good unless the thigh be in a state of semi-flexion and 
 slight adduction^ 
 
THE PELVIC BONES. 275 
 
 Below the line of Poupai-t's ligament, a, fold in the groin may be per- 
 ceived when the thigh of a recent subject is flexed upon the abdomen. 
 This fold is one of importance, since it lies directly over the hip-joint; 
 and it is often used by surgeons as a guide in inserting the knife in am- 
 putation of the leg at the hip-joint, since if the knife be inserted at one 
 end of this furrow and brought out at the other end, the ccqjsule of the 
 hip-joint is almost of necessity opened, a point of the gTeatest importance 
 in performing this operation with rapidity and ease. Furthermore, if 
 the hip-joint become the seat of effusion, as occurs in the first stages of 
 morbus coxarius, this furrow is usually obliterated; hence the value of this 
 fold in the diagnosis of diseases of the joint underneath it. If we press 
 firmly at a point just below this furrow, we can detect the presence or 
 absence of tenderness in the hip-joint; a diagnostic sign often of the 
 commencement of inflammatory action. 
 
 When we examine the gluteal region of the living subject, we can 
 detect the following bony landmarks: 1, the posterior superior spines of 
 the ilium; 3, the spines of the sacrum ; 3, the tuberosities of the ischia ; 
 4, the apex of the coccyx, situated in a deep furrow leading toward the 
 anus. 
 
 The posterior superior spine of the ilium is a guide to the sacro-iliac 
 joint, since it lies on a level with the middle of that articulation ; and it 
 is at this point that direct pressure, when the patient is lying upon the 
 abdomen, reveals disease of this joint, as the inflamed surfaces are thus 
 brought into closer apposition, and pain is therefore produced. It is 
 opposite this point also that the bifurcation of the common iliac artery 
 takes place within the pelvis, while the internal and external iliac arteries 
 naturally arise from the same point. 
 
 The third spine of the sacrum denotes the lowest level to which the 
 cerebro-spinal fluid, whose function has been mentioned in a previous 
 portion of this work, descends; hence it would be an impossibility for a 
 spina bifida to appear below this level, even if the spinous processes of the 
 sacrum were congenitally absent throughout its whole length. 
 
 The tuberosities of the ischia can be felt through the gluteus maximus 
 muscle which covers that bony prominence upon either side. Nature has 
 considerately protected these supports of the trunk, in the sitting pos- 
 ture, by a large collection of fat, and a bursa which is placed between 
 this deposit of fat and the bone: hence the weight is distributed through 
 a cushion of fluid, fat, muscle, and skin. It is considered as indica- 
 tive of health when this portion of the body is firm and rounded in 
 form, when the subject is in the standing posture, since, in the infirm, 
 the soft tissues of this region tend to become loose and flaccid, while 
 wasting of this region is a frequent accompaniment of disease of the 
 hip- joint. So important is the comparison of the so-called "fold of the 
 nates " of the two sides, when the presence of morbus coxarius is sus- 
 pected, that it is considered as one of the most valuable guides in the 
 
276 PKAOTICAL MEDICAL ANATOMY. 
 
 detection of that disease, since its direction and character is often greatly 
 altered.' This fold is also a guide to the situation of the great sciatic 
 nerve, which we can reach by pressing deeply between the tuberosity of 
 the ischium and the great trochanter of the femur. This situation of the 
 nerve protects it from injury, while it also tends to explain why the sit- 
 ting posture is liable to produce a sense of numbness in the leg and foot, 
 if the trunk be long inclined toward one side, as it frequently becomes 
 pressed upon. 
 
 The ai)ex of the coccyx forms the posterior boundary of the perineal 
 space, while the tuberosities of the ischia, the sacro-ischiatic ligaments, 
 and the rami of the pubes and ischia help to complete its boundaries. The 
 coccyx is liable to displacement, in occasional instances, so as to impinge 
 upon the rectum. Its mobility and late anchylosis to the sacrum has already 
 been mentioned as peculiar to the female, since it is thus enabled to 
 modify the size of the inferior opening of the pelvis. In some rare 
 instances, the coccyx becomes the seat of a neuralgic affection, and sub- 
 cutaneous division of the muscles attached to it becomes demanded in 
 order to prevent its motion. 
 
 In connection with the region of the buttock, there are two important 
 vessels whose course is admirably defined by certain bony points which 
 have been discussed in the previous page; these are the gluteal and the 
 pudic arteries. These vessels, especially the latter, have to supply parts 
 with blood which are of the utmost importance in the construction 
 of the body: probably no region is of greater importance, from an ana- 
 tomical, physiological, and surgical stand-point, than the perinseum of 
 the male or female. It is important to every physician, therefore, that 
 he be acquainted with the surgical guides to these vessels, in case any 
 type of injury called either for compression or ligation of them. 
 
 The gluteal artery escapes from the pelvis by the great sacro-sciatic 
 foramen in company with its nerve. Its point of escape may be desig- 
 nated upon the surface of the hip by drawing a line from the posterior 
 superior spi?ie of the ilium to the trochanter of the femur, after the foot 
 has been rotated inward; the artery lies at the junction of the upper and 
 middle thirds of this line. 
 
 The ischiatic artery also escapes from the cavity of the pelvis by the 
 same foramen as the gluteal, and can be found, at its point of escape, 
 about one-half of an inch lower down than the gluteal artery; hence the 
 same line will answer as a guide for both of these vessels. 
 
 The pudic artery and its nerve, as previously mentioned, escape from 
 
 ' The diagnosis of morbus coxarius, and a careful and accurate discrimination 
 between it and the m.any other conditions which closely simulate it in its various 
 stages, is of the utmost importance before treatment be attempted. The author 
 would refer his reader to his work on Surgical Diagnosis, where all the points 
 of contrast and the latest means of diagnosis of hip-joint disease are given in full 
 detail. 
 
THE PKI.VIC BONES. 277 
 
 the greater sacro-sciatic foramen and enter at the lesser sacro-sciatic 
 foramen, thus passing over the exterior surface of the spine of the 
 ischium, upon which it may be compressed in a thin subject. The guide 
 to it consists of a line drawn from the posterior stqjet'ior spine of the 
 ilium to the oiiter side of the tulerosity of the ischium, since the point of 
 junction of its middle and loxuer thirds lies directly over this vessel. It 
 may also be remembered with profit that the ischiatic artery lies in close 
 relation to the pudic at its escape from the pelvis, but nearer to the 
 middle line of the hip. 
 
 Now, the situation of these vessels has more than a purely surgical 
 importance. When we sit upon a hard and unyielding support, the 
 weight^ of the superincumbent parts is borne by the bony prominence 
 of the ischium, and all pressure is, therefore, taken from the lateral por- 
 tions of the gluteal region; but, when we sit upon cushioned chairs, the 
 soft tissues become pressed upon, and the arteries, veins, and nerves of 
 the glirteal region are forced to bear a compression which may result in 
 the development of disease. It is stated by Holden that the compression 
 of these vessels tends to create congestion of the pelvic organs and the 
 development of hemorrhoids and uterine disorders, while the same author 
 makes use of the following statement : "A celebrated accoucheur used 
 to say that the fashion of high waists, tight lacing, and easy chairs 
 brought him many thousands a year." 
 
278 l-BACTICAI, MEDICAL ANATUMY. 
 
 CHAPTER VI. 
 THE ABDOMEN, ITS VISCERA, AND SURGICAL GUIDES. 
 
 Is previous chapters of this volume, we have discussed the bones which 
 assist to form the cavities of the thorax, abdomen, and pelvis, and we are 
 , now prepared to consider the organs of the two last cavities, as well as 
 such points of practical value as are suggested by their relations to each 
 other, or to the soft tissues which help to complete the walls of the abdo- 
 men and the floor of the pelvis. Many hints have already been thrown 
 out, when the bones of the vertebral column and of the pelvis were under 
 consideration, relating to the organs of the abdomen, which will bear 
 repetition here; but a careful study of the external contour of the abdom- 
 inal walls is required in order to fully grasp all of the guides which are of 
 use to the physician in determing abnormalities of the organs beneath them. 
 There are elements of difficulty in the examination of the abdominal cav- 
 ity for abnormalities of its contained organs which are not present in 
 similar efforts made in reference to the lungs and heart, or the contents 
 of the mediastina. These difficulties have been very clearly stated by my 
 colleague. Professor A. L. Loomis in his excellent work on " Physical Diag- 
 nosis,"' and I cannot do better than to give aresumS from him, as follows: 
 
 First. Thoracic diseases involve the examination of only one or two 
 organs; while an abdominal affection may require for its diagnosis an exam- 
 ination of ten or twelve organs. 
 
 8ecojid. The action of the thoracic organs is regular and rhythmical, 
 and their contents unvarying; while the action of the abdominal organs 
 is irregular and intermittent, since it may be distended with fluids, air, 
 or solid material, or be entirely empty. 
 
 Third. The organs of the abdomen are loosely packed in a cavity 
 whose walls are distensible; this allows of gi-eat alterations in the relative 
 situation of any organ to surrounding parts. In addition to this cause 
 of uncertainty, the abdominal organs vary in size during health. The 
 uterus (normally the smallest organ of the abdomen) may in pregnancy 
 become the largest of them all; the spleen alters its size with the vascu- 
 lar engorgement of the alimentary canal; and the bladder is constantly 
 enlarging and decreasing in its size, as the urine accumulates or is voided. 
 
 Dr. Bright, one of the pioneers of abdominal investigation as a means 
 of scientific diagnosis, suggested the mapping out of this region of the 
 
 ' Lessons in Physical Diagnosis. N. Y., 1880. 
 
THE ABDOMEN AND ITS VISCEBA. 
 
 279 
 
 Pig. 147.— View of the abdominal organs from in front. (After Lnschka.) The numerals are 
 placed upon the respective ribs. I, The stomach, whose outline is represented darker than those 
 of the surrounding parts; II, Duodenum; IH, Ileum; IV, Colon; V, Sigmoid flexure. 
 
280 PKACTICAL MEDICAL ANATOMY. 
 
 trunk into well-defined subdivisions, and a careful study of tlie content 
 of each in the state of health. These subdivisions are now comnaonly 
 employed by most of our anatomical teachers, and are essential to the 
 examination of the abdomen for diseased conditions, as they help (by a 
 knowledge of the contents of each) to make our inferences more certain. 
 Dr. Sibson has shown, in his excellent work upon medical anatomy, that 
 the abdominal organs are altered, in their relations to each other, during 
 the acts of inspiration and expiration by the displacement downward dur- 
 ing the contraction of the diaphragm, and their return to their former 
 position during its relaxation. While this displacement must of neces- 
 sity be most marked in the organs which occupy the upper regions of the 
 abdomen — the liver, stomach, and spleen — still the fact further illus- 
 trates the difficulties which are encountered by the physician in abdomi- 
 nal examinations. 
 
 ANATOMICAL SUBDIVISIOSTS OF THE ABDOMEN. 
 
 By a reference to the cut, showing the lines which mark the abdomen 
 into regions, it will be perceived that the space between the lower ribs 
 and the pelvis — the abdomen — is not of the same height in all of its 
 parts. The notch beneath the xyphoid cai'tilage <ot the sternum is 
 formed by the diverging cartilages of the lower ribs, which tend to sepa- 
 rate with inspiration and approach each other during expiration, thus 
 causing the abdomen to apparently shorten and lengthen as the ribs 
 move upward and downward. 
 
 The EPiGASTEic ZONE compriscs that part of the abdominal cavity 
 which lies above an imaginary line connecting the extremities of the 
 tenth ribs. An imaginary plane passing through the abdominal cavity 
 at this level will intersect the first or second lumbar vertebrae, and 
 the organs contained within it must be situated between the level of such 
 an imaginary plane and the under surface of the diaphragm. The 
 extremity of the tenth rib can usually be felt in the living subject as a 
 distinct projection on its convex border; hence it is a guide easily de- 
 tected. The diverging lines formed by the free borders of the ribs of 
 either side subdivide this zone into three regions, called the epigastric, 
 and the right and left hypochondriac regions. 
 
 The UMBILICAL ZOHE includes that portion of the abdominal cavity 
 which extends from the epigastric zone, above, to an imaginary plane 
 passing through the abdomen on a level with a line which shall connect 
 the two anterior-superior spinous processes of the ilia. Such a plane 
 would intersect the second or third sacral spine. 
 
 The HTPOGASTBio ZONE lies below the umbilical, and is bounded 
 upon either side by Poupart's ligament, and, in the middle, by the upper 
 margin of the pubes. As it embraces all of the lower portion of the abdo- 
 men, it includes the cavity of the true pelvis and its contained organs. 
 The subdivision of the umbilical and hypogastric zones is marked by two 
 
THE ABDOMEN AND ITS VISCERA. 
 
 281 
 
 vertical planes which are supposed to pass tlu-ough lines on either side 
 which shall intersect the spines of the pubes and the points on the tenth 
 ribs previously designated as indicating the lower level of the epigastric 
 zone. The names, rigid and left lumbar regions, are applied to these 
 parts of the umbilical zone which lie external to these planes, while the 
 hypogastric zone is subdivided into the middle or puiic, and the right 
 and left iliac regions. 
 
 Now a study of the diagrammatic cut previously referred to will enable 
 the reader to appreciate the contents of each of these regions in health; 
 and thus assist him to detect the presence or absence of any abnormality 
 
 Fig. 148. — A diagram showing the different regions of the abdomen, and the organs contained 
 in each, which are visible on the removal of the abdominal walls. (After Loomis.) 
 
 in individual cases, when sufiScient dexterity in auscultation, percussion, 
 and palpation has been acquired by practice. The following tables will 
 perhaps further enable the reader to follow this diagrammatic chart, 
 while it may also assist him in memorizing the various contents of the 
 individual localities. 
 
 'The right lobe of the liver. 
 The angle formed by the ascending 
 and transverse colon. 
 
 j The greater portion of the duodenum. 
 
 I The upper part of the right kidney 
 
 1^ and its supra-renal capsule. 
 
 The right hypochondriac region. 
 
PBA.OTIOAL MEDICAI, ANATOMY. 
 
 The epigastric region. 
 
 The left hypochondriac region. 
 
 The umbilical region. 
 
 The right lumbar region. 
 
 The left lumbar region. 
 
 The hypogastric region. 
 
 The right iliac region. 
 The left iliac region. 
 
 Left lobe of the liver. 
 Part of the right lobe of the liver. 
 Gall-bladder. 
 
 Pyloric orifice of the stomach. 
 The commencement of the duode- 
 num. 
 A portion of the colon 
 The pancreas. 
 The abdominal aorta. 
 The coeliac axis. 
 
 The cardiac end of the stomach and 
 a very large portion of that organ 
 when in a state of distention. 
 The angle formed by the transverse 
 
 and descending colon. 
 The spleen. 
 A small portion of the left kidney 
 
 and its supra-renal capsule. 
 The transverse colon, omentum, and 
 convolutions of the small intestine. 
 The mesentery and its glands. 
 The abdominal aorta. 
 The inferior vena cava. 
 'The caecum and ascending colon. 
 The lower and middle portions of the 
 
 right kidney. 
 Some convolutions of the small in- 
 testine. 
 A portion of the ureter. 
 The descending colon. 
 The larger part of the left kidney. 
 The ureter. 
 
 Some of the small intestine. 
 ' The bladder, in children. 
 Portions of both ureters. 
 Convolutions of the small intestine. 
 The uterus and its appendages, 
 f The vermiform appendix of the colon. 
 ) The iliac Tessels. 
 [ Part of the caecum, 
 j The sigmoid flexure of the colon. 
 I The iliac vessels. 
 
THE ABDOMEN AND ITS VISOEKA. 383 
 
 THE EXTEKIOR OF THE ABDOMEN. 
 
 Having mastered the contents and boundaries of these different 
 regions, we are prepared to consider the appearance whicli the abdomen 
 of the healthy subject presents to the eye of the educated physician. 
 "When, the subject is placed upon the back, with the head and thorax 
 raised and the legs and thighs slightly flexed so as to relieve the muscles 
 of the abdomen of undue tension, we perceive that the shape of the ab- 
 domen is oval and that it is marked by elevations and depressions which 
 correspond to the abdominal muscles, the subjacent viscera, and the 
 navel, which sometimes protrudes and again may present a depression. 
 
 In children, it is relatively larger to the chest than in adults; while in 
 women, it is usually more rotund and broader in its lower part than in 
 the male sex. Its density is modified by the condition of the abdominal 
 muscles, the pliability of the skin, and the condition of the lungs, since it 
 is rendered most tense during a full inspiratory effort by the displacement 
 of the viscera and the elevation of the lower ribs. 
 
 It may be seen to perform movements which are synchronous witli 
 respiration; and these are more marked in males than in females, on 
 account of the expansibility of the upper ribs in women, and also from 
 the customs of the two sexes as to dress. Abnormalities of movement may 
 be an indication of disease, as the movements are exaggerated in those 
 conditions which interfere with the full expansion of the lungs — such 
 as pleurisy, pericarditis, pneumonia, emphysema, mediastinal tumors, 
 etc. — while they are, as a rule, markedly diminished in peritonitis, and 
 other diseases of the abdomen which are accompanied by severe pain. 
 
 Retraction of the abdomen may indicate extreme emaciation, in which 
 the omental fat ,has been absorbed for the nuti'ition of the patient; it 
 often exists markedly in cerebral diseases, especially in the tuberculous 
 meningitis of children. In lead poisoning, the abdominal walls may be 
 rigid and unyielding, resembling a board . A uniform enlargement may 
 accompany ascites, tympanites, and tumors of the ovary of extreme size; 
 while an irregular enlargement may exist in tumors, when hypertrophy 
 of organs is present from the accumulation of gas in some isolated por- 
 tions of the intestine, from aneurismal enlargements, from hydatids, and 
 other causes. 
 
 The superficial veins of the abdomen may present abnormalities which 
 have a clinical value. Their engorgement is often a valuable guide to 
 those diseases which tend to obstruct the return circulation of blood 
 through the liver or the portal vein; hence we may expect to meet with 
 it in connection with the abdominal tumors which press upon that vein, 
 enlargement of lymphatic glands in the transverse fissure of the liver, 
 cancer of the stotnacli, duodenum, or liver, hepatic abscess, waxy degen- 
 eration of that organ, hydatids of the liver, cirrhosis, portal thrombo- 
 sis, etc. The same condition may exist from obstructed circulation in 
 
284 PKACTICAI^ MEDICAL ANATOMY. 
 
 the inferior vena cava, as a result of regurgitation at the tricuspid orifice, 
 since the portal vessels are thus engorged from interference with the 
 escape of blood into the vena cava. 
 
 In those cases where the tricuspid valve is insufficient, and the pulsa- 
 tion of the right ventricle of the heart is transmitted into the venae cavse, 
 abdominal pulsation (which may be mistaken for an aneurismal throb), 
 may be detected over the liver in the right hypochondriac and epigastric 
 regions, since the engorged portal and hepatic veins may transmit the 
 pulsations of the heart itself to the tissue of the liver. 
 
 In the median line running from the xyphoid cartilage to the pubes 
 is a white line — the linea alba — which marks the point of union of the 
 aponeuroses of the muscles which form the anterior abdominal waU. Its 
 white color indicates the absence of vessels of large size, and this fact, 
 coupled with the fact that it is the thinnest part of the abdominal wall, 
 renders it the seat of election in incisions made for the removal of intra- 
 abdominal growths, or in supra-pubic lithotomy, while it is the point 
 usually selected for tapping the distended bladder and the fluid of ascites. 
 
 In the median line may be seen the umbilicus or navel. This point 
 is rather nearer the pubes than the ensiform cartilage, and is placed 
 slightly above the centre of the height of the individual; it usually corre- 
 sponds to the level of the third lumbar .vertebra, although the obesity of 
 any subject may tend to bring it to a lower relative plane. When it be- 
 comes necessary to compress the abdominal aorta, the point selected is 
 usually situated about one inch below and a little to the left of the navel, 
 since the aorta is most easily controlled at the fourth lumbar vertebra. 
 Pressure made above the umbilicus would find the aorta farther from the 
 surface of the abdomen and there would also be a danger of compressing 
 structures which might endanger life. In very corpulent subjects, the 
 navel is often crossed by a transverse line or fold of integument, and a 
 similar fold often exists in front of the pubes; in tapping such a subject, 
 it should be remembered that the linea alba is the line of greatest safety. 
 
 As we descend along the linea alba from the ensiform cartilage, the fol- 
 lowing organs lie in contact with the anterior wall of the abdomen: 1. 
 The left lobe of the liver which crosses the line at a distance of two or three 
 fingers' breadthbelow the xyphoid cartilage; 2. The stomach, which lies in 
 close contact with the abdominal wall below the edge of the liver, when 
 in a state of moderate distention, while, if fully distended, it may occupy 
 the whole space between the lower edge of the liver and the navel; in a 
 state of contraction (when empty), it lies behind the liver upon the pan- 
 creas, and may give rise to a hollow — the pit of the stomach — which cor- 
 responds to the region filled by it when moderately full; 3. The middle 
 part of the transverse colon (which occupies a space about two or three 
 inches in a vertical direction according to its distention) crosses just 
 above the level of the umbilicus; 4. Finally, below the navel, lie the con- 
 volutions of the small intestine, the omentum, and also the bladder, when 
 
THE ABDOMEN AND ITS VISCERA. 
 
 28g 
 
 Fig. 149. — A diagram to show the condition of excessive dilatation of the stomach, the intestines 
 having Bhpped beneath it. (After Penzoldt.) a, cardiac end of stomach; 6, the pylorus; between 
 the two run the greater and lesser curvatures; the former extends at its most inferior part to be 
 low the umbilicus ; c, the enlarged duodenum ; e, the first convolution of the jejunum ; the shading 
 around d represents the pancreas ; /, shows the abnormal course of the colon. 
 
286 
 
 PBACTiOAL MEDICAL ANATOMY. 
 
 in a state of distention, but not when empty and contracted. It will 
 be perceived that the hollow organs vary in their relative position to the ' 
 abdominal walls when distended or empty, while, as has been mentioned 
 in preceding pages, the stomach and colon are also affected by the condi- 
 tion of the diaphragm in inspiration and expiration. "When any of these 
 organs gain in their weight by hypertrophy, tumors, cancer, etc., an 
 additional source of displacement below their proper level in the cavity 
 of the abdomen is present, since gravity tends to drag them downward 
 during the erect posture. 
 
 The close relation of the peritonaeum to the linea alba, and in fact to 
 the whole of the anterior wall of the abdomen, gives to all wounds 
 through the abdominal parietes a surgical importance far in excess of 
 the simple danger attached to incisions in other parts. When the blad- 
 der is empty, this serous coat of the organs lies in close relation to the 
 whole length of the anterior wall, but, when the bladder is greatly dis- 
 tended with urine, the peritoneum is raised, and thus separated from 
 the linea alba halfway to the umbilicus; this anatomical fact explains 
 why the supra-pubic operation for stone in the bladder can be performed 
 without injury to the peritonaeum, and why the distended bladder can 
 be tapped above the pubes without great risk. It is always advisable in 
 performing this latter operation, to insert the needle as close to the 
 upper border of the pubes as possible, and to use the vacuum chamber 
 to assist in withdrawing the urine through the small trocar, as less dan- 
 ger of subsequent infiltration exists, and as the organ can be completely 
 emptied without changing the position of the patient. I have per- 
 formed this operation daily upon a patient when the introduction of a 
 catheter was impossible, without exciting any inflammatory symptoms. 
 Percussion becomes an indispensable aid in determining whether the 
 bladder is distended, and should always be practised before aspiration is 
 attempted, since the case may be one of suppression of urine rather than 
 of simple retention. 
 
 Before we leave the median line of the abdomen, let us review the 
 points which may be gained in this locality by the ordinary means 
 employed in such examinations, viz., inspection, palpation, percussion, 
 and auscultation. The general rules which will be given in this connec- 
 tion apply with equal force to all the other regions of the abdomen, 
 although the organs examined must, of necessity, change Avith each 
 locality. 
 
 Inspection enables us to estimate the size of the abdomen, its respira- 
 tory movement, the evenness or unevenness of its surface, the presence 
 or absence of local enlargements, the pliability and color of the skin, the 
 size of the superficial veins, the amount of fat, the presence of abnormal 
 folds or lines on the abdomen, etc., etc. 
 
 Palpation should be made with the patient upon the back, with the 
 head and thorax raised and the thighs sliglitlv flexed. It should never be 
 
THE ABDOMEN AND ITS VISOEBA. 287 
 
 performed with the finger tips, as they tend to excite muscular contrac- 
 tion, but with the palm of the hand, and with a slow, firm, undulating 
 motion. Both hands may be used, and the pressure may be continuous 
 or alternating. In some instances, the erect posture or an attitude where 
 the body is inclined forward, will assist the diagnostician in palpation of 
 this region. Since the most valuable information is gained through 
 palpation and percussion, it is important that the various regions be 
 carefully and thoroughly explored. Mensuration by the graduated tape 
 may assist palpation in determining the relative size of different regions 
 of the abdomen, and the increase or decrease of existing lesions, as a case 
 is watched during its stages of development. 
 
 Percussion of the abdomen ' requires a familiarity with the difEerent 
 notes afforded by the various organs in health, to be of much value in diag- 
 nosis; but, when these are once gained, the note affords us most positive 
 evidences of the size and condition of the structures over which percus- 
 sion is made. The chief notes obtained in the regions of the abdomen 
 are of the dull, fiat, and tympanitic quality. The former is present 
 where the organ is solid, but is either overlapped or in proximity to 
 the intestines which contain air ; the second is detected over solid struc- 
 tures which are so separated from the intestine as to yield a note subject 
 to no modification from its contained air — as the central part of the 
 liver, spleen, and kidneys; while the latter is present over the intestines 
 and stomach, since they contain air and have thin walls. Plat percussion 
 will also be present over fluid, as in ascites, except the intestines happen 
 to be displaced by it or float upon its surface; it can thus be found over 
 the distended bladder, the enlarged uterus, fluid ovarian cysts, aneuris- 
 mal tumors, etc. Some diseased conditions have a characteristic percus- 
 sion note, but the scope of this work does not admit of a discussion of 
 all the field of physical diagnosis. Of late, some experiments have been 
 made by my friend Dr. McBride,' of this city, which seem to point to the 
 extensive employment of wooden stethoscopes, combined with percussion, 
 as ^ more certain way of deciding as to the exact limits of viscera which 
 are overlapped by intestine, than simple percussion alone; his experi- 
 ments upon the cadaver seem to prove that the most skilful could not 
 detect delicate shades of distinction with the naked ear which were very 
 distinct when a wooden stethoscope was applied over the seat of percussion 
 or at a spot slightly removed from it. 
 
 Auscultation is of value in detecting the foetal heart, the bruit of 
 aneurismal tumors, the gurgling of imprisoned intestine, and the utero- 
 placental murmur when pregnancy is suspected. 
 
 Now, in the median line, we may feel the free edge of the liver midway 
 between the xyphoid cartilage and the umbilicus, and possibly the head 
 
 ' The reader is referred to the cuts on page 214. 
 ' Archives of Medicine, 1880. 
 
288 PBACTIOAL MEDICAL ANATOMY. 
 
 of the pancreas, when the patient is emaciated; we may detect the size 
 of the stomach and the situation of the colon and small intestine by per- 
 cussion; we may discover the distended bladder or the enlarged uterus 
 by three of the methods, viz., sight, touch, and percussion; while hear- 
 ing may enable us to detect the foetal heart and the placental bruit. In 
 this region, the abdominal aorta lies in close relation to the spinal col- 
 umn, and hence deeply placed; but we can still often perceive the pulsa- 
 tion of aneurismal tumors and the enlargement of the vessel by palpation; 
 we may be able to map out its exact dimensions by auscultatory percus- 
 sion; and, finally, the aneurismal bruit may be detected by auscultation, 
 which confirms the diagnosis. Cancer of the stomach may present itself 
 to the touch as a tumor of the median line, and by dragging the organ 
 downward, greatly alter its area of resonant percussion; when the tumor 
 cannot be felt, auscultatory percussion may enable us to detect an abnor- 
 mal area of deep dulness. The coeliac axis is often the seat of aneuris- 
 mal disease, when a tumor will be probably detected, by some of the 
 means mentioned, high up near the diaphragm. The head of the pan- 
 creas ' has been mistaken for disease of the transverse colon and for ab- 
 dominal aneurism involving the aorta. 
 
 Upon the exterior of the abdomen, other points may be specially 
 designated as of importance to the jshysician besides those mentioned in 
 the median line. Prominent among these may be enumerated: 1, certain 
 bony prominences which have been discussed in their clinical relations 
 when the bones of the pelvis were described; 2, the crural arch, or Pou- 
 part's ligament; 3, the abdominal rings; 4, the inguinal canal, with its 
 contents; 5, the epigastric artery. 
 
 The line which corresponds to the crural arch or Poupart's ligament 
 is revealed, in most subjects, as a crescentic-like furrow in the skin, at the 
 junction of the thigh and abdomen, its curve being a gentle one, whose 
 convexity looks downward, extending from the anterior spine of the ilium 
 to the spine of the pubes. As the inguinal canal lies immediately above 
 Poupart's ligament, and as the external and internal abdominal rings are 
 but the two openings of this canal, the furrow indicated may serve as a 
 valuable guide to any one of these parts. 
 
 The inguinal canal connects the two abdominal rings and lies parallel 
 with and immediately above Poupart's ligament. Its most anterior open- 
 ing — the external abdominal ring — is situated immediately above the spine 
 of the pubes; hence the importance of this bony prominence in the diag- 
 nosis of hernial protrusions through this opening. It is an oval aperture, 
 whose long axis is directed obliquely downward and inward, and is formed 
 by the two diverging pillars of the ring, the point of meeting of these 
 pillars being concealed by the intercolumnar fascia. Its size varies 
 slightly in different subjects, but the forefinger can generally be intro- 
 
 ' Sir Wm. Jenner, Med. Gaz., 1869. 
 
THE ABDOMEN AND ITS VISOEEA. 289 
 
 duced into the normal aperture of the adult. The most direct way of 
 examining this opening for the purpose of determining its size or the 
 presence of hernial protrusions, is to slip the finger tip under the thin 
 skin of the scrotum, and follow up the spermatic cord till the finger per- 
 ceives the crest of the pubes and the sharp margins of the ring itself. 
 The other opening of the inguinal canal — the internal abdominal ring — 
 cannot be felt with the finger unless the inguinal canal is excessiyely 
 dilated. Its situation may be determined by measuring two-thirds of an 
 inch abore Poupart's ligament, at a point midway between the anterior 
 superior spine of the ilium and the symphysis pubis. It will thus be 
 perceived that the name of the opening refers to the portion of the abdo- 
 men with which the opening communicates* rather than to its relation 
 with the mesial line of the trunk, since the external ring is the most 
 internal. 
 
 The length of the inguinal canal in the well-formed adult varies from 
 one and a half inches to two inches, according as we include the openings 
 or not; while in the child, the inner ring is situated almost directly 
 behind the external opening, thus making the canal much shorter and 
 less oblique. The growth of the pelvic bones, which causes a separation 
 of the anterior spines of the ilia, tends to draw the soft tissues outward 
 and thus to affect the internal ring more than the external, since the 
 latter is securely fastened to the pubes. 
 
 Within the inguinal canal may be felt the spermatic cord, which 
 escapes from the external abdominal ring and supports the testicle, while 
 the vas deferens, which is the functional duct of that organ, may be felt 
 in the posterior part of the cord, since it can be distinctly separated from 
 the other component parts. Within this canal, the testicle may become 
 lodged during its descent from the abdomen into the cavity of the scro- 
 tum, thus causing a tumor which maybe mistaken for a hernia; the intes- 
 tine and omentum may be protruded; and, finally, the peritoneal fluid may 
 gravitate into it from defective closure of the tunica vaginalis, creating a 
 fluctuating sac. 
 
 The spermatic veins are sometimes ligated for the relief of varicocele, 
 and it is of great importance that the surgeon become so familiar with 
 the "feel" of the vas deferens as to distinguish between it and the adja- 
 cent Teins. A patient lately shot and killed a physician who ligated the 
 vas deferens by mistake and thus produced impotency. 
 
 The deep epigastric artery, which is of special interest from its close 
 relation to the interioi* surface of the abdominal wall in the immediate 
 neighborhood of the inguinal and femoral canals, may be severed in sur- 
 'gical attempts to relieve strangulation of a hernial protrusion at any of 
 the openings in the vicinity of Poupart's ligament. Its course can be 
 mapped out upon the wall of the abdomen by drawing a line from a point 
 corresponding to the inner border of the internal abdominal ring (whose 
 situation has been already giyen) to the central portion of the rectus ab- 
 19 
 
290 
 
 PEACTICAL MEDICAL ANATOMY. 
 
 dominis muscle and thence upward toward the xyphoid cartilage. The 
 rule generally given to students in operating for strangulated hernia of 
 the inguinal region, is to "cut upward and slightly inward." 
 
 ThQJilres of the abdominal muscles exhibit, to a marked degree, the 
 simplicity of arrangement which Nature always takes to insure against pos- 
 sible accidenj;. If we examine the three abdominal muscles — the external 
 and internal oblique, and the transversalis — we will see that the fibres of 
 each are directed in such a manner as to oppose each of the other two, 
 and thus to render the danger of an aperture occurring by a separation of 
 the muscular fibres extremely small if not impossible. It is, therefore, the 
 most uncommon of accidents to find a hernial protrusion of the contents 
 of the abdomen through its walls, except 'at some one of the normal 
 openings, unless some prcTious diseased condition or traumatism has 
 weakened the resisting power of the muscles. 
 
 THE ABDOMINAL VISCERA. 
 
 The study of the situation and relations of each of the abdominal vis- 
 cera is essential to the appreciation of diseased conditions. The investi- 
 gations of Sibso.n ' have shown that, when the lungs were artificially in- 
 flated, the relations of the viscera in a recent subject became so altered 
 from the state in which they are usually represented in anatomical works, 
 as to make the study of visceral relations one of great difficulty and pro- 
 portionate interest. He discovered that the organs of the abdomen, like 
 those of the thorax, were constantly changing their situation, due to the 
 combined influences of gravity and diaphragmatic pressure during each 
 inspiratory effort, and that, in some instances, this unceasing activity was 
 an agent in the proper performance of their physiological function. It 
 may, therefore, add to the general interest of this volume to note some of 
 the more important features which each organ of the abdomen presents, 
 and the guides which will be found most reliable in attempting to decide 
 as to the presence or absence of disease. The general steps of a physical 
 examination of this portion of the trunk have been given ' in previous 
 pages and need not be here repeated. 
 
 The Stomach. — This organ presents greater variations in size than any 
 of the abdominal viscera, excepting the uterus. It may, when empty, 
 resemble a piece of curved intestine, and in this state its long axis is 
 nearly vertical (a fact not generally recognized). When fully distended, 
 its long axis becomes nearly horizontal, and it projects far below the free 
 edge of the liver. Its large or " cardiac " end occupies the left hollow of 
 the diaphragm, and is separated from the anterior abdominal wall by the 
 liver; hence this latter organ occupies the greater part of the epigastric 
 space. When empty, the cardiac part of the stomach does not fill the left 
 
 ' Medical Anatomy. London, 1879. 
 ^ See page 286 of this volume. 
 
THE ABDOMEN AND ITS VISCEEA. 291 
 
 hollow of the diaphragm; convolutions of the small intestine, and the 
 transverse arch of the colon may thus fill its place, while the spleen may slip 
 in behind the stomach. The apex of the heart and the lower part of the 
 left ventricle actually overlap the cardiac end of the organ; hence the 
 pain referred to the heart, and the palpitation after a flatulent meal. 
 The distended stomach may so compress the heart cavities as to interfere 
 with the return of venous blood from the head; this explains the occur- 
 rence of stupor, epileptic fits, and coma, after eating excessively of indi- 
 gestible food.' The distended stomach may, by compressing and empty- 
 ing the blood from the liver, so distend the right auricle of the heart as 
 to produce the swollen veins of the neck and forehead seen after eating 
 to excess, since the return of venous blood from the head is thus im- 
 peded; and, by creating a difiiculty in the movements of the diaphragm, it 
 is further possible for the stomach, when distended, to impair the useful- 
 ness of the lungs. Patients afEected with dyspepsia usually labor under 
 the delusion that they are suffering from disease of the heart, from the 
 palpitation, cardiac pain, and symptoms of impeded return of venous 
 blood. If we percuss over the stomach when the patient lies upon the 
 back, the note is resonant, since the food contained in it gravitates to its 
 most dependent part, but, if the patient be in the erect posture, the food 
 fills the part of the organ which lies below the free border of the liver, and 
 a dulness takes the place of the former resonance; this point is of prac- 
 tical value in estimating the size of the stomach or of the liver, since the 
 trunk should not be raised, if we hope to get resonant percussion over the 
 entire area of the stomach. ' 
 
 The Liver. — This organ is extremely variable, both in point of size 
 and in its relative position to other parts. Its position within the abdo- 
 men is greatly afEected by the filling of the lungs during inspiration, when 
 it is displaced downward by the diaphragm; while the ribs are raised at 
 the same time, thus apparently adding to the downward displacement. 
 For this reason we find the liver low in the abdomen in those subjects 
 who have a robust development of the chest, and high in those whose 
 chests are contracted and the lungs small. Distention of the intestine 
 by air tends also to add to the upward displacement of the organ, and 
 the size of the stomach, as well as its distention, is also liable to markedly 
 afEect its position within the abdomen. This displacement of the liver 
 during each inspiratory act has a physiological function, since the com- 
 pression of the organ by the diaphragm tends to squeeze the blood from the 
 hepatic vessels, and thus to favor the return of portal blood to the right 
 auricle of the heart at a time when the heart cavities are best adapted to 
 receive it, as the lungs are expanded and the chest enlarged, thus reliev- 
 
 ' Sibson reports a case where a fit always occurred after eating pork. 
 ' The cuts on pages 279 and 285 depict the relations of the stomach to adjoin- 
 ing viscera in its normal and abnormal conditions. 
 
292 
 
 PEACTICAL MEDIOAL ANATOMY. 
 
 ing the heart of undue pressure and favoring the reception of large quan- 
 tities of blood. The play of the liver, stomach, intestine, and, to a less 
 extent, of the spleen and kidneys, during respiration, and the alternate 
 compression and expansion which they necessarily undergo, since they 
 are all more or less elastic, constitutes a 'perpetual- churn inff motion, 
 which unquestionably assists in the proper performance of their physiolo- 
 gical functions. When the stomach is empty, the liver may be found 
 to reach the left hypochondrium, while, when distended, it may be 
 crowded upward and to the right; the intestines, when empty, favor its 
 fall, while, when they are distended, the liver may be raised; emphysema 
 
 Fio. 150.— A diagram to sliow the normal position of the liver within the abdomen, and the ex- 
 tent of its enlargement in disease, as well as the areas in which pressm'e from such enlargements 
 would be exerted. 
 
 and fluid in the right cavity of the pleura tend to create a downward dis- 
 placement; finally, in phthisis, when the lungs are seriously impaired and 
 their full inflation rendered impossible, the liver may be found so high 
 as to be completely behind the ribs. When the liver is the seat of malig- 
 nant disease, an abscess, or hydatid cysts, the diaphragm is raised, the 
 right lung is encroached upon, and the heart is displaced to the left of 
 the thorax, and is also raised; but, when congested, or increased in size 
 by fatty or waxy degeneration, the organ tends to sink in the abdomen 
 and to present a marked increase below the ribs without encroaching 
 to any marked extent upon the thoracic cavity. 
 
THE ABDOMEN AND ITS VISCEEA. 
 
 293 
 
 The extent to vrhioh the liver may be detected below the margin of 
 the ribs may indicate either disease of that organ or some abnormal con- 
 dition of neighboring structures. Thus, the liver may be found to lie 
 in close contact with the abdominal walls (without any enlargement of 
 the organ itself) from pressure of pleuritic or pericardial effusion, or 
 when the conditions of emphysema or mediastinal growths are present; 
 while the same displacement may exist when the intestinal canal" is empty 
 or the stomach collapsed. We can understand from these facts why the 
 pain and sense of oppression created by a diseased liver may be referred 
 either to the costal walls or to the abdominal parietes, and why the fric- 
 
 FiG. 151.— The volume of the liver in various diseases. 5-10, Eibs. I, Position of the diaphragm 
 in the highest degree of tumefaction of the liver (carcinoma). II, II, Normal position of the 
 diaphragm. II, in. Relative dulness III, Position of the diaphragm at the anterior wall of the 
 chest, at the same time the line of dulness of the normal liver. IV, Edge of liver in cirrhosis. V, 
 In the normal liver. VI, Fatty liver. VII, Amyloid liver. Vm, Cancer, leukaemia, adenoma. 
 All of proportional size. (After KindHeisch.) 
 
 tion-sound heard over a local peritonitis at the seat of the liver may simu- 
 late a pleurisy when that organ has risen high up in the thorax, thus lying 
 entirely behind the ribs. The pain produced by diseased conditions of 
 the liver may be referred to the right shoulder; a fact whose explanation 
 lies in the anastomoses of fibres contained within the splanchnic nerves, 
 with the cervical and brachial plexuses. 
 
 From the facts which have been given in reference to the situation of 
 the liver within the cavity of the abdomen, it is plain that no organ offers 
 more opportunities for error in diagnosis, if the physician is not skilful 
 
294 
 
 PKACTICAL MEDICAL ANATOMY. 
 
 in percussion and thoroughly familiar with the note of lirer dulness. It 
 is not sufficient for one to ascertain by palpation and percussion tlie lower 
 limit of the organ alone, since the entire organ may be displaced down- 
 ward without any disease of its structures; but the upper limit of the 
 organ must also be determined, and, by comparing the two lines of dul- 
 ness thus obtained, the thickness of the liyer may be estimated and the 
 question of increased Tolume of the organ decided. It is well, therefore, 
 to start with some preconceived idea of the usual limits of liver dulness 
 in the state of health, since due allowances can be made in special cases 
 for displacement. 
 
 It percussion be made over the thorax from the right nipple down- 
 ward, the dulness of liver tissue will usually be reached at about the fifth 
 intercostal space; while the line will reach to nearly the level of the 
 xyphoid cartilage in the median line, and to the seventh rib in the axil- 
 lary space. Now, this upper line of dulness tells you whether the liver 
 is displaced upward or downward, or is normal in its position; and the 
 lower limit of hepatic percussion will decide, by comparison with the line 
 first mapped out upon the chest, whether the liver is of its normal thick- 
 ness, decreased, or increased. The normal liver should measure about 
 three inches in thickness in the median line in front; about four inches 
 in the line dropped through the right nipple; four and a half inches in 
 the centre of the axillary space; and, finally, about four inches in the 
 dorsal region. 
 
 Sibson puts the tipper limit of the liver in the region of the level of 
 the eighth dorsal spine, and he designates the tenth dorsal spine as the 
 guide to the point of contact of the liver with the wall of the abdomen 
 posteriorly. The lower edge of the liver, in front, corresponds closely in 
 health to the free border of the ribs, and it is customary to employ pal- 
 pation along this free border in determining the character of the liver 
 edges, the presence of nodosities, etc. If this be employed, the patient 
 should relax the abdominal wall, and the fingers should be crowded well 
 beneath the ribs until the edge of the liver can be readily perceived. 
 The lower border of the liver can be perhaps more readily felt in the epi- 
 gastric space, midway between the xyphoid cartilage of the sternum and 
 the umbilicus, where even the untutored hand can hardly fail to detect it. 
 
 The upper surface of the liver being convex and overlapped by the 
 edges of the right lung, while its highest point is beneath the dome of 
 the relaxed diaphragm, it becomes evident that a wound of the right side 
 of the chest with a pointed instrnment,' between the sixth and seventh 
 ribs, would first penetrate the right lung, then the diaphragm, and, 
 finally, the tissue of the liver itself. 
 
 ' Many facts of clinical interest pertaining to the liver have been already dis- 
 cussed in those pages which treat of the relations of the thoracic walls to the 
 organs beneath. 
 
THE ABDOMEN AND ITS VISCEEA. 
 
 295 
 
 The Spleek. — This organ, when healthy, is subjected to all the 
 modifications in position which have been enumerated as afEecting the 
 liver and stomach, and they are the mechanical results of about the same 
 general causes. Although a deep inspiration may tend to displace it 
 downward, it rarely, if ever, is thus pushed below the free border of the 
 costal cartilages; hence the spleen, if normal in size, cannot be felt by 
 the hand under any of the varying cirpumstances of life. In those con- 
 ditions where the spleen enlarges, the organ expands chiefly in an ante- 
 rior direction, thus gradually passing more and more in front of the 
 axillary line, but, while it grows also in a downward direction, it seldom 
 appears below the costal cartilages (even when quite large) except at the 
 end of a full inspiration, when it can sometimes be felt. It may be 
 
 Fig. 152.— Diagram representing the different areas occupied by the spleen in its various enlarge- 
 ments into the abdominal cavity. (After Bright.) 
 
 regarded as a most positive evidence of an enlarged spleen, even when 
 percussion leaves the examiner in doubt as to the exact size of the organ, 
 if a solid mass can be felt to protrude fi-om underneath the costal carti- 
 lages of the left side during a full inspiration, and to recede with expira- 
 tion.' There seems to be more uncertainty in the minds of many prac- 
 titioners as to the anatomical situation of the spleen than of any other 
 organ; I have often witnessed percussion made in the space below the ribs 
 and above the ilium by intelligent men for the purpose of estimating the 
 size of the spleen which was suspected to be enlarged. It should be 
 remembered that the organ lies on the left side beneath the ribs, and that 
 
 ' Sibsor Medical Anatomy, 
 zette. 186i, 
 
 London, 1879. Sir W, Jenner: Medical G-a- 
 
296 PEAOTICAL MEDICAL ANATOMY. 
 
 percussion should be made, with the patient lying upon the right side, 
 only in the axillary line from the level of the ninth rib downward, if its 
 size is to be accurately determined. Auscultatory percussion (as described 
 on page 287) will often enable the examiner to detect delicate shades of 
 splenic dulness when the unaided ear might fail to perceive it. 
 
 It is important to discriminate between splenic enlargement and (1) 
 cancer of the stomach, (3) abcess of the abdominal wall, (3) diseased 
 omentum, (4) enlargement of the left lobe of the liver, (5) fascal accumu- 
 lation in the colon, (6) disease of the left kidney, and (7) ovarian tu- 
 mors.' 
 
 In the first instance, the line of dulness will be circumscribed, and 
 firm percussion will yield a resonant percussion note, since air is contained 
 in the cavity of the stomach; in the second, the tumor will be detected 
 by palpation and will fluctuate when the pus becomes superficial; in the 
 third, the line of dulness will be carried to the right and across the abdo- 
 men, and cannot be traced backward or upward beneath the ribs, while the 
 growth will be nodular and uneven; in the fourth, the line of dulness 
 will be carried to the right and join liver dulness; in the fifth, the action 
 of enemata and cathartics will prove the only way of making a positive 
 diagnosis; while, in the sixth and seventh, the history of the patient, 
 sex, and the situation of the growths will aid in their discrimination. 
 
 The six lower ribs and cartilages protect the liver, stomach, and 
 spleen during expiration, all of which organs rest upon the muscular 
 fibres of the diaphragm, in front of the lower ribs and the wedge of the 
 lungs at the posterior portion of the thorax. These viscera, therefore, 
 occupy the hindermost part of the body, and, as the wedge of the lungs 
 descends during the inspiratory act, they are displaced forward as well as 
 downward, since the lungs are interposed between the chest-wall and the 
 diaphragm. This forward displacement of the spleen, liver, and stomach 
 constitutes one of the most striking eflects of the inflation of the lungs, 
 although in the case of the spleen, the forward movement is less marked 
 than that of descent, while in the case of the stomach, the forward move- 
 ment is in excess. 
 
 The doubt that still exists as to the physiological functions of the 
 spleen creates difficulties in the diagnosis of affections of that organ, 
 since few symptoms of a general character point directly to disease of its 
 substance. Its isolated position furthermore tends to render palpation 
 almost impossible, except when excessively enlarged, and the presence of 
 adjacent organs, which may, at times, contain solid matters, renders the 
 detection of the exact outline of splenic dulness on percussion a point of 
 difficulty. Some of the points of diagnosis between an enlarged spleen 
 and other conditions which simulate it have been considered in a previous 
 page. 
 
 ' A. L. Loomis: Lessons in Physical Diagnosis. N. Y., 1878. 
 
THE ABDOMEN AND ITS VISCEEA. 
 
 297 
 
 The Pancreas. — This organ, whose right extremity or "head" is 
 embraced by the curving duodenum (and whose duct, in common with 
 that of the liver, opens into the cavity of that portion of the alimentary 
 canal) lies transversely across the abdomen behind the stomach. It crosses 
 in front of the abdominal aorta and the bodies of the lumbar vertebrae, 
 usually on a level with the first or second. If the organ is normally situ- 
 ated, therefore, it should be found about two inches above the navel and in 
 the median line of the abdomen, l^ow it is only under the most favorable 
 circumstances that abdominal palpation can detect the pancreas, since the 
 subject has to be emaciated, all omental fat absent, and the abdominal 
 organs empty; in this case, firm and deep pressure may enable the edu- 
 cated touch to map out the outline of the pancreas. In an interesting 
 article written by Sir William Jenner,' the point was made that in some 
 few instances the normal pancreas had been mistaken for aneurism of the 
 abdominal aorta (since pulsation had been communicated to it from the 
 close proximity of that vessel), and also for disease of the transverse arch 
 of the colon. The difficulties in reaching it even under favorable circum- 
 stances, and the infrequency of such conditions, render the organ one of 
 little clinical interest. 
 
 The Intestinal Canal. — All of the space below the umbilicus is 
 occupied by the convolutions of the intestine, the jejunum lying nearer 
 to the navel; hence the fatality which is associated with umbilical hernia. 
 The coils of the ileum are situated lower in the cavity of the abdomen. 
 If we view the subject posteriorly, the duodenum may be said to wind 
 around the head of the pancreas on a line situated in the space between 
 the spines of the last dorsal and first lumbar vertebrae, being contiguous 
 to the point of entrance of the vena porta into the liver at its transverse 
 fissure, and the hepatic artery as it emerges from the same organ. From 
 this point, the duodenum descends along the side of the ascending vena 
 cava, then curves to the left and crosses the aorta at the level of the second 
 lumbar spine, then ascends along the left side of that vessel, and disap- 
 pears among a mass of convoluted intestine. 
 
 The large intestine lies superficially in the anterior part of the abdo- 
 men, and for the greater portion of its course it is accessible to pressure; 
 hence hardened faeces can usually be detected by external manipulation, 
 if the physician be familiar with its general course. The cfficum and the 
 ilio-caecal valve lie in the right iliac fossa, the ascending colon passes 
 through the right lumbar region in nearly a vertical direction, lying over 
 the kidney of that side; the transverse colon crosses the abdomen, in a 
 horizontal direction, two or three inches above the navel; the descending 
 colon descends through the left lumbar region, lying in front of the kid- 
 ney of that side, and finally, the sigmoid flexure occupies the left iliac 
 fossa. Faecal matter in the ascending colon and sigmoid flexure may be 
 
 Medical Gazette, 1869. 
 
298 
 
 PKACTIOAL MEDICAL ANATOMY. 
 
 mistaken for malignant disease, and, if in the csBCum, the diagnosis 
 between it and perityphilitis is often difiQcult. A tumor in the ahdomen 
 
 Fio 153 -view of the abdominal organs from behind. (After Lusohka.) I, Stomach. H, Duo- 
 denum III, Ileum. IV, Colon. V, Sigmoid flexure. VI, Bectum.-The vertebrffi are numbered 
 according to regions, and the ribs are numbered from above downward. The relative situation of 
 the lungs and kidney to adjacent structures is also shown. 
 
THE ABDOMEN AND ITS VISCEEA. 299 
 
 may be apparent when the transverse portion of the colon is so distended, 
 while, if it be confined to the point of junction between the transverse 
 and descending portions, the diagnosis between it and enlarged spleen 
 can only be made by the use of repeated injections of olive oil, ox-gall, or 
 other enemata, or the employment of cathartics. On the right and left 
 side of the body, the colon is uncovered by peritonaeum, below the kidney 
 and above the crest of the ilium, and it is in these two situations that the 
 operation of colotomy is performed for the relief of malignant disease or 
 congenital absence of the rectum. 
 
 Holden' gives the following landmarjcs for this operation: " 1, the last 
 rib, of which we feel the sloping edge ; 2, the crest of the ilium ; 3, the 
 outer border of the erector spinas muscle. The incision should be about 
 three inches long, midway between the rib and the ilium. It should 
 begin at the outer border of the erector spinas muscle, and should slope 
 downward and outward in the direction of the rib. The edge of the 
 ' quadratus lumborum ' muscle, which is the guide to the colon, is about 
 one inch external to the edge of the ' erector spinas,' or three full inches 
 from the lumbar spines. The line of the gut is vertical and runs (for a 
 good two inches) between the lower border of the kidney and the iliac 
 crest." 
 
 In typhlitis, the presence of a tumor, which bears a resemblance to a 
 sausage in its general outline, may be detected in the right iliac fossa, 
 since impaction of faeces in the caecum is usually the result of a paralysis 
 of the muscular fibre of the gut, which follows catarrhal inflammation. 
 The presence of the ileo-caecal valve in the right iliac fossa further assists 
 in producing impaction of faeces in that region of the abdomen more 
 commonly than elsewhere, and the direction of the colon may also be 
 taken as another factor, since the contents of the bowel have to oppose 
 the force of gravity in order to reach the transverse colon. 
 
 The right iliac fossa is the most frequent seat of tenderness, to pres- 
 sure or manipulation of the abdomen, in typhoid fever and its allied con- 
 ditions. This may be accounted for by the presence of the solitary glands 
 and Peyerian patches of the intestine in great abundance in the lower part 
 of the ileum, near to the ileo-caecal valve: since, in typhoid fever, these 
 glands, and the patches of Peyer especially, are the seat of morbid changes 
 of the greatest pathological interest, resulting in ulceration of the intes- 
 tine and a liability to perforation. 
 
 That distressing condition, and one which oftentimes has a clinical 
 value of the greatest significance — tympanites — is the result of over-dis- 
 tention of the intestine with accumulated gas. A certain amount of air 
 is always present in the intestinal canal, since, by it, Nature protects the 
 coats of the intestine from injury; the air keeping the canal inflated and 
 thus separating the walls from each other, while it also enables the intes- 
 
 ' Surgical Landmarks. 
 
300 PEAOTICAL MEDICAL ANATOMY. 
 
 tine to bear considerable compression or even violence without the walls 
 being brought into contact or their structure impaired. 
 
 The mesentery, which contains glands, blood-vessels, lymphatic vessels, 
 and connective tissue, in addition to the peritonaeum which forms it, may 
 be the seat of tumors of a simple fatty or malignant type; while, in the 
 course of a severe type of typhoid fever, each of the mesenteric glands 
 may enlarge to the size of a walnut or even a hen's egg. The danger 
 which exists in this disease from manipulation of the abdomen (since 
 perforation of the peritoneal coat may be induced, and death from shock 
 or peritonitis ensue) renders it .unwise to attempt to search for these 
 tumors as a confirmatory point in the diagnosis. 
 
 The KiDiq^EYS. — These organs lie on either side of the body in the 
 back part of the abdominal cavity, on the quadratus lumborum and psoas 
 muscles, in a space defined by the two lower dorsal and the two upper 
 lumbar spines. It is customary to find the right kidney placed about 
 three-quarters of an inch lower than that of the left side, as the liver 
 tends to push it further down into the abdomen. During a deep inspira- 
 tion, the diaphragm depresses the kidneys of each side about half an inch 
 below the situation mentioned above as a normal one; this movement be- 
 ing transmitted indirectly to them by means of the liver, stomach, and 
 spleen. The first lumbar spine is regarded as perhaps the best guide to 
 the level of the pelvis of the kidney, although the outer extremity of the 
 last floating rib is the point usually selected for aspiration of the pelvis 
 for pus, or retained secretion in hydronephrosis. 
 
 Despite the statements made by some authors that the kidneys can be 
 felt, in some cases where the abdominal walls are flaccid, by bimanual 
 manipulation (one hand being placed on the anterior and the other on the 
 posterior surface of the abdomen, so as to include the- organ between 
 them), I am frank to say that I have never been able to feel certain that 
 I could detect the outline of the kidney even under the most favorable 
 conditions, provided it was of normal size and in its proper position 
 within the abdomen. I believe that bimanual palpation, as described above, 
 is of use in deterniining the amount of renal tenderness which exists in 
 any given case, but I rely more upon auscultatory percussion than on 
 touch to determine the exact outline of the organ. 
 
 , ' These organs are retained in their place partly by connective tissue and 
 partly by means of the blood-vessels connected with them. They are 
 sometimes movable within the abdomen — the so-called " movable kidney" 
 . — and, if on the right side, such a tumor is to be diagnosed from an 
 enlarged gall-bladder, an ovarian tumor, or omental disease, while, if on 
 the left side, it may be confounded with an enlarged spleen, impacted 
 faaces, an ovarian growth, or malignant disease. 
 
 Care should always be used in the discrimination between the normal 
 outline of renal dulness and the dulness afforded by an enlarged liver or 
 
THE ABDOMEN AND ITS VISCEEA. 
 
 301 
 
 spleen, or an accumulation of feces within the colon. It can be made to 
 disappear, by gentle pressure, so that it cannot be felt. 
 
 The kidneys may be increased in size by calculi within the pelvis of 
 either organ, which tend to the development of pyelitis and thus con- 
 vert the kidney into a bag of pus; by cancerous and tubercular deposits; 
 by the formation of hydatid cysts within its substance, and by the 
 obstructed escape of its normal secretion — the condition known as hydro- 
 nephrosis — the result of obstruction to the ureter by calculi or pressure. 
 
 i«^ 
 
 
 
 111 I < 
 
 
 Fig. 154. — The structures which lie deep within the abdomen. 1, the abdominal aorta; 2, the 
 phrenic vessels; 3, the diaphragm; 4, the coeliac ajds; 5, the superior mesenteric artery; 6, the 
 renal artery ; 7, the spermatic arteries ; 8, the inferior mesenteric artery ; 8, the lumbar arteries of 
 either side; 10, the common iliac arteries; 11, the internal iliac arteries of either side; a, X3T)hoid 
 appendix; 6, inferior vena cava cut across; c, cesopha£:us cut across; d and e, psoas muscles; /, 
 kidneys; g, ureters; ft, bladder; i, rectum, lying behind the bladder. 
 
 an abnormal course of the renal artery which encircles the ureter like a 
 cord, the presence of a congenital valve-like flap in the pelvis of the kid- 
 ney, or the development of tumors of the ureter itself. Disease of the 
 supra-renal capsule may also tend to create an enlargement of the organ 
 and thus confuse the diagnostician. In determining the size of the kid- 
 ney by percussion, the patient should be placed upon the abdomen and 
 chest, so as to allow any fluid, if present, to gravitate to the most 
 
302 PKACTICAL MEDICAL ANATOMY. 
 
 dependent portion, and thus to float the intestine in the region of the kid- 
 neys, and to surround them with viscera whose resonant percussion assists 
 greatly in enabling the physician to detect the outline of renal dulness. 
 
 The Bladder. — The position of this organ, when empty, cannot be 
 determined by any of the means employed in the physical exploration of 
 the abdomen. When it is fully distended, it rises above the pubes nearly 
 as high as the umbilicus, carrying the peritonaeum with it, and thus sep- 
 arating that membrane from the linea alba below that level. A smooth 
 oval tumor is thus formed above the pubes, which may distend the 
 whole of the hypogastric region, and its outline is easily made out by 
 contrasting the tympanitic resonance of the intestine upon either side 
 of it with the dulness on percussion obtained over the fluid contents 
 of the organ. Since, in infants, the bladder normally assumes a higher 
 plane than in the adult, a smaller quantity of urine can be perceived by 
 percussion over the hypogastrium. The only thing liable to be con- 
 founded with the distended bladder are the gravid uterus in the female 
 and extensive malignant disease of either sex, and the employment of 
 the catheter will remove all doubt at once. 
 
 When the bladder has become impaired in its contractile power from 
 the atony of over-distention, local inflammation of the organ, or the 
 paralysis which accompanies some forms of spinal affections, an inconti- 
 nence of urine often occurs from an overflow of the highly distended 
 bladder which is too often mistaken for a true incontinence, the physi- 
 cian supposing erroneously that the bladder is empty, since the urine 
 flows off continuously. Such cases as these are always subjects for an 
 examination of the bladder by catheterism, and the only hope of relief 
 depends on the regular use of this instrument until the bladder can regain 
 its normal power of contraction, provided it is not permanently impaired. 
 Patients afflicted with true paralysis of the bladder often apparently regain 
 control of it, since the urine is voluntarily but hastily expelled; such an 
 occurrence must be considered, however, as an evidence of increased 
 reflex excitability of the spinal cord, in which case the presence of the 
 accumulated urine creates a reflex spasm of the organ, and the physician 
 should be extremely guarded in giving a favorable prognosis. 
 
 The Uteeus. — The unimpregnated uterus, although its fundus 
 reaches the lower part of the hypogastric region, is still inaccessible to 
 the touch and its outline cannot be made out by percussion. It is only 
 after impregnation has produced such an increase in the size of the organ 
 as to bring it well above the pelvic cavity that physical examination is of 
 aid in diagnosis. As early as the second month of pregnancy, the upper 
 limit of the uterus may 'be detected by percussion just above the pubes, 
 but it is still too small to be felt; by the fourth month, however, the 
 increase in the womb begins to be very perceptible, both to sight and 
 touch, while percussion is a valuable aid in accurately determining the 
 steady increase in the area of dulness as gestation progresses. 
 
THE ABDOMEN AND ITS VISOEEA. 
 
 303 
 
 After the fifth month, auscultation becomes even more reliable as a 
 means of determining pregnancy, since the foetal heart and the placental 
 bruit maybe then detected. To properly auscultate the uterus, the woman 
 should be placed upon the back with her thighs flexed, so as to relax the 
 wall of the abdomen, and, in some instances, it is well to rotate the 
 patient to the side, so as to draw the womb away from contact with the 
 pelvic arteries, if the question of transmitted sound from an aneurism be 
 worthy of consideration. I always prefer the stethoscope to the naked 
 ear for this purpose, as the sound can then be limited to a circumscribed 
 area. The special chai-acters of the placental bruit, the funic souffle, 
 and the fcetal heart can be ascertained by a reference to the excellent 
 work of my colleague, Prof. Loomis,' and to other similar works. 
 
 FiQ. 155.— Section of the pelvis showing the relations of the organs.— 1, pubis; 2, peritoneal cot- 
 eringto the uterus; 3, bladder; 4, urethral canal ; 5. meatus urinarius; 6, labiamajora; 7, vagina; 
 8, OS uteri; 9, fibrous structure of the uterus; 10, anus; 11, rectiim; 13, aorta; 13, sacrum. (After 
 Byford.) 
 
 It may be well to mention here that \hQfmtal heart-sounds may be 
 confounded with the pulsations of the aorta and iliac arteries of the 
 mother, and, in the early months of pregnancy, this pulsation may even 
 render the heart-sounds of the foetus inaudible. Twin pregnancies may 
 often be detected by heart-sounds heard over the womb at distant points, 
 and by an absence of synchronism between the two pulsations. If the 
 pulsations be heard below the line dividing the enlarged uterus in its 
 
 ' Lessons in Physical Diagnosis. 'Wm, Wood & Co., 1880. 
 
304 
 
 PEAOTIOAL MEDICAL ANATOMY. 
 
 centre, a vertex presentation may be suspected, while, if above this ima- 
 ginary line, the probability of a breech presentation is a strong one. The 
 foetal heart may be absent in pregnancy when the foetus is dead^a point 
 not to be forgotten in discriminating between pregnancy and other 
 tumors of the abdomen. The character of the foetal heart during labor 
 may often be a valuable guide to the time when instruments are demanded 
 to save the life of the child, since, if feeble and intermitting, impending 
 death of the foetus is indicated. 
 
 There are many abnormal states of the uterus which cause enlarge- 
 ment of that organ, and which require the most careful study of symp- 
 
 FiG. 150,— Diagram showing the gradual enlargement of a tumor of the right ovary till it fills a 
 large portion of the abdominal cavity, forcing the intestines into the lumbar region. (After 
 Bright.) 
 
 toms, as Tvell as the aid furnished by palpation, percussion, and auscul- 
 tation, to make an accurate diagnosis; buf these are too numerous to 
 decribe here in detail, and the author respectfully refers his reader to his 
 more exhaustive work upon Surgical Diagnosis for all the points of dif- 
 ferentiation between them. 
 
 The various disjjlaoements of the uterus, while associated with many 
 symptoms of a serious character, are not to be determined by abdominal 
 examination, although the use of one hand applied to the abdomen may 
 prove of great assistance in some instances when combined with vaginal 
 or rectal touch. The points of diagnosis of these more common disorders 
 of the uterus cannot, tlierefore, be incorporated in this volume. 
 
 The OvAiiiES. — In the normal state, these organs lie within the cav- 
 
THE ABDOMEN AND ITS VISOERA. 305 
 
 ity of the pelvis, and cannot be pereeired by abdominal exploration; it is 
 only when they have become enlarged from disease and been forced out 
 of the pelvic cavity into the abdomen, thus displacing adjacent organs 
 from their normal situation, that they become a source of error in diag- 
 nosis, and often of great perplexity tp the physician. When they are of 
 small size but still large enough to be perceived through the abdominal 
 walls, they are confined to the iliac fossa of the side corresponding to the 
 organ afEected; as they continue to grow, they gradually reach the median 
 line; still later, the tumor seems to fill the entire width of the abdomen, 
 and the point from which it started becomes a subject of the greatest 
 diflBculty to determine, except from the history of the patient. The pre- 
 ceding diagram will show the positions assumed by such a tumor in dif- 
 ferent stages of its growth. 
 
 These tumors are liable to be confounded with enlargements of the 
 uterus, such as pregnancy, fibroid tumors, etc., hydatids of the omen- 
 tum, ascites, enlargements of the spleen, liver, and kidney, and fsecal 
 accumulations within the intestine. The differential diagnosis of these 
 affections will be found arranged in tables for ready reference in another 
 work by the author. ' 
 
 CLIliriCAL POIU"TS PBETAIWING TO THE KERVES OF THE ABDOMElf AND 
 
 PELVIS. 
 
 The ilio-hypogastric and ilio-inguinal nerves are sometimes the seat of 
 a severe form of neuralgia. It may be produced by disease of the lumbar 
 vertebrae, structural changes in the parts investing the lumbar plexus, 
 pelvic diseases, exudations in the substance of the psoas muscle, strains, 
 contusions, exposure, and an hysterical condition. The pains are usually 
 of a paroxysmal character, and radiate in the course of these nerves; they 
 are of a lancinating type, and often extremely severe. Painful points 
 may be detected in one of the following regions, or possibly in all of them: 
 1, a lumbar point, near the spinous processes of the lumbar vertebrse; 3, 
 an iliac point, near to the middle of the crest of the ilium, where the ilio- 
 hypogastric nerve pierces the transversalis muscle; 3, a. hypogastric point, 
 slightly above the external ring, where the ilio-hypogastric nerve pierces 
 the aponeurosis of the external oblique muscle; 4, an inguinal p)oint; and 
 5, points upon the scrotum or labium. It is stated by Notta'' that this 
 type of neuralgia may be occasionally accompanied by an increase in the 
 sexual appetite, and a spasmodic contraction of the cremaster muscle. 
 
 This form of neuralgia is to be diagnosed from rheumatic myalgia of 
 the longissimus dorsi and sacro-lumbalis muscles; and from those types 
 of chronic affections of the uterus which induce pain in the back. It 
 might also be possibly mistaken for an attack of renal or biliary colic. 
 
 ' A Practical Treatise on Surgical Diagnosis. New York, 1880, 
 ' As quoted by Erb. 
 20 
 
306 PRACTICAL MEDICAL ANATOMY. 
 
 The diagnosis will be made chiefly by the "puncta dolorosa" ' previously 
 described, by the course of the pain, and by its intense paroxysmal and 
 lancinating character. 
 
 The nerves which are distributed to the skin of the abdominal walls 
 may be considered as comprising tyo distinct sets, based on the physio- 
 logical action of the abdominal muscles which are supplied by them. Ac- 
 cording to Hilton, the abdomen may be divided, on a line corresponding 
 with the situation of the umbilicus, into an upper or respiratory portion, 
 and a lower or abdominal portion. The upper or respiratory portion is 
 supplied, in great part, by the lower intercostal nerves, which are distri- 
 buted also to the muscles of the chest, and which, if taken with the other 
 intercostal nerves as a group, are essentially respiratory in their function. 
 The lower or abdominal portion of the abdomen is supplied chiefly by the 
 ilio-hypogastric nerve, although the ilio-inguinal, the genito-crural, and 
 the posterior branches of the lumbar nerves assist in furnishing motor 
 power to the muscles of that region. 
 
 The subjacent peritonsum is unquestionably supplied from the same 
 sources of nerve-power as the muscles and skin of the individual regions 
 of the abdomen, and it is considered probable, by the author above 
 quoted, that the spinal nerves which are distributed to the skin, muscles, 
 and parietal peritonaeum may be also associated with the visceral layer 
 underneath, by means of communications with the sympathetic nerve. 
 The abdominal muscles unquestionably assist the colon in its endeavors 
 to force the fseces, by its peristaltic action alone, throughout its length, 
 since the force of gravity has to be overcome in its ascending portion, 
 and the curves of the sigmoid flexure in its terminal portion. It would 
 therefore be an additional confirmation of a general nerve distribu- 
 tion, if the distribution of the abdominal nerves to the intestinal cover- 
 ing of peritonseum could be fully verified; since the structures which 
 assist in moving the adjacent organs — the abdominal muscles — would be 
 supplied from the same source as the organs as well as the skin over those 
 muscles. 
 
 A careful study of the distribution of the various branches of the 
 pudic nerve will show that it is the source of motion to the muscles of 
 the perinseum and urethra, and of sensation to the integument of the 
 peringeum, scrotum, labium, penis, and the mucous covering of the cli- 
 toris, as well as that lining the urethral canal. The friction made upon 
 the cutaneous nerves of the external genital organs in the acts of sexual 
 intercourse and masturbation creates a reflex act within the spinal cord, 
 which maintains the turgidity of the penis and clitoris during the first 
 portion of those acts; and, later on, a series of muscular contractions in the 
 perineal muscles and the involuntary muscular fibre of the urethral canal 
 
 ' A name applied by Valleix to the spots of extreme local tenderness found 
 along a course of a nerve which is the seat of neuralgia. 
 
THK ABDOMEN AND ITS VISCERA. 307 
 
 are produced, which assist in the expulsion of semen in the male and the 
 secretion of the glands of Bartholin in the female. That this is the true 
 explanation of emission is eyidenced by the fact that onanism is most 
 effectually prevented by blistering the cutaneous covering of the penis 
 and the mucous covering of the clitoris. 
 
 In some cases of fracture of the spine, in the dorsal region, where a 
 part of the spinal marrow is left intact below the seat of fracture, you 
 may be able, by repeatedly pinching the skin of the scrotum and penis, 
 to produce spasmodic contractions of the muscles of the perinaeum and 
 urethra, and often to effect a turgidity of the genital organ to such a 
 degree as to make it resemble an imperfect erection or priapism. ' 
 
 The ejaculation of the last few drops of urine from the ui-ethra is un- 
 questionably effected by a reflex act through the sensory and motor fibres 
 of the pudic nerve, in consequence of the irritation produced in the sen- 
 sory fibres of the urethral mucous membrane from pressure of the urine 
 or the contact of its saline ingredients. 
 
 It is not uncommon for rectal disease to produce sympathetic mani- 
 festations in the genito-urinary organs, in the form of neuralgic pains, 
 involuntary emissions, incontinence of urine, etc. ; such effects can only 
 he explained by the distribution of the pudic nerve to the integument 
 about the anus (and, I believe, to the walls of the rectum also), which 
 allows of reflex motor impulses to be sent from the spinal cord, in response 
 to rectal irritation, to the genito-urinary organs and perineal muscles. 
 
 The recognition of the perineal branch of the small sciatic nerve is 
 sometimes important in practice. If you care to trace this nerve upon 
 the dead subject, you will find that it escapes from beneath the perineal 
 border of the gluteus maximus muscle, runs along the outer portion of 
 the perinseum, and, finally, sends cutaneous filaments to the sides of the 
 penis. The perineal region is also supplied by the perineal branches of 
 the pudic nerve, which escape posteriorly to those of the sciatic, from 
 beneath the same muscle. Now, either of these two nerves may be the 
 cause of a pain referred to the perinseum and the penis, and their points 
 of escape from beneath the gluteus maximus muscle are so placed as to 
 render them frequently subjected to pressure from sitting upon hard or 
 uneven seats. It is thus possible for pains, referred to the penis, to be 
 wrongly attributed to diseases of the bladder, calculus in the bladder, 
 urethral troubles, and all other types of disease which are commonly in- 
 dicated by more or less pain in that locality, when the cause may be 
 found and correctly diagnosed by following up the course of the perineal 
 branch of the small sciatic. Such a case is reported by Hilton," where 
 prominent surgeons of Europe, among them Mr. Key, had diligently and 
 unsuccessfully searched for the cause of a pain (referred to the penis). 
 
 ' Hilton, op. cit. 
 
 = Rest and Pain. London, 1876. 
 
308 PJBACTICAL MEDICAL ANATOMY. 
 
 along the course of the pudic nerve, and where the patient had been 
 treated for disease of the bladder; a careful examination subsequently re- 
 vealing the true cause to be a spot of hardened tissue pressing upon the 
 perineal branch of the small sciatic nerve, which was cured (as well as the 
 pain which it created) by the application of nitric acid over the seat of 
 thickening. It is, therefore, well to remember the course of this branch, 
 as well as those of the pudic nerve, when investigating for the cause of 
 pain in the penis or periuEeum. 
 
 POINTS or SUEGICAL INTEREST PEETAIlfril<rG- TO THE EEGIOJT OE THE 
 
 ABDOMEN-. 
 
 There are numerous 0]}enings through the abdominal walls, among 
 which may be mentioned the inguinal canals, the femoral canals, several 
 through the diaphragm (which may be regarded as the superior wall of 
 the abdomen, as well as the floor of the thorax), and numerous small 
 openings for the passage of vessels in various parts of the abdominal 
 parietes. It is through some of these openings that the viscera, in most 
 cases, pass and form hernial protrusions. The looseness of the cellular 
 tissue which closes many of these openings rather predisposes to such 
 displacements, but, in contrast, their oblique direction, which is similar to 
 that of the j)assage of the ureters through the walls of the bladder, seems 
 an evident attempt of Nature to guard against such protrusions. 
 
 When a person tends to become very fleshy, adipose tissue is formed in 
 these canals, which helps to destroy the elasticity of the parts; hence, 
 when these subjects suddenly lose their fat, hernia is easily produced, as the 
 adipose tissue which filled the openings in tlie parietes is gone. In cases 
 of extreme obesity, the fat deposited on the outside of the abdominal 
 walls may, by its weight alone, so draw the muscles and skin downward, 
 as well as the subjacent peritoneum, as to form a true sac into which the 
 viscera will protrude. Tliis same condition is observed in pregnancy, 
 when the weakened walls of the abdomen are unable to sustain the 
 weight of the intestine and uterus. 
 
 The anterior region of the abdomen may, in some rare cases, be par- 
 tially or entirely deficient from an arrest of development; we see this in 
 those cases of so-called extroversion of the bladder, in which the bladder 
 appears as a red tumor of the hypogastrium, which allows urine to 
 trickle through its walls. In most of these subjects, the genitals 
 are malformed or deficient. The intestine and other viscera may 
 escape through such a congenital opening, if the abdominal wall is 
 extensively involved. 
 
 Wounds of the anterior abdominal wall are always serious, because 
 the cicatrix which follows is weaker than the injured wall, thus tending 
 toward hernial protrusions. Penetrating wounds have an additional 
 danger from the liability of wounding some of the viscera, and the lower 
 their situation in the abdomen, the greater the liability of some of the 
 
THE ABDOMEN AND ITS VISCKEA. 309 
 
 yiscera escaping from the wound, since the weight of the superincumbent 
 organs adds to the tendency to displacement; hence, the rule among sur- 
 geons to always divide these wounds upward instead of downward. 
 
 Contusions of the abdomen may produce either rupture of the mus- 
 cles, extravasation of blood, rupture of the peritoneum, rupture of the 
 diaphragm, rupture of the stomach or intestine, lacerations of the liver 
 and spleen, rupture of the gall-bladder, or lacerations of the kidney 
 and ureter. If uncomplicated by injury to the subjacent viscera, they 
 may result in abscess or recovery. 
 
 Death has occurred from concussion of the solar and cardiac plexuses 
 without any internal lesion being discovered. Concussion of this region 
 may be received from flying missiles (such as cricket balls); from blows 
 received during an altercation, from falls upon the abdomen, and the 
 passage of heavy bodies over the body. 
 
 True wounds of the abdomen may be superficial or deep, and asso- 
 ciated with protrusion of or injury to the viscera lying beneath the 
 wound. They may occur from sharp and pointed instruments, from 
 being impaled upon iron spikes, caught upon iron hooks, tossed by the 
 horns of cattle, injured by bits of glass, china, or missiles, or by the bites 
 of carnivorous animals. They may produce serious internal hemorrhage 
 even when the viscera escape injury. 
 
 The anterior wall of the abdomen is often tapped for ascites in the 
 linea semilunaris at the outer side of the rectus muscle, or in the median 
 line, since both of these localities are less vascular than other parts. The 
 danger of wounding the bladder, if the trocar is inserted in the median 
 line near to the pubes, should not be forgotten, and the abdomen should 
 not be tapped below the level of the umbilicus, as a rule. In all opera- 
 tions upon the abdomen, the incisions should be made in a line more 
 nearly horizontal than vertical, since the vessels of the abdominal walls 
 have a transverse direction in most instances. An exception to this rule 
 may be made to incisions made in the linea alba. 
 
 In disease afEecting the portion of the abdomen below the umbilicus, 
 the lymphatic glands of the groin are usually enlarged, while, if above 
 the umbilicus, the glands of the axilla are liable to manifest enlargement. 
 
 The inguinal canal is larger in the male than in the fejnale, and 
 inguinal hernia is therefore more common among the male sex. The 
 extent to which the internal structures of the abdomen pass through this 
 canal modifies the appearance of the tumor; since, if the hernia does not 
 pass through the external abdominal ring, the condition may be con- 
 founded with enlarged lymphatic glands of the groin: while, if it passes 
 the external ring, it may enter the scrotum. The different forms of in- 
 guinal hernia are named from their general direction through the walls 
 of the abdomen, from their contents, and from the relation of the neck 
 to the deep epigastric artery. The points of differential diagnosis between 
 the different forms, and between hernia of the inguinal region and bubo. 
 
310 PKAOriCAL MEDIOAL ANATOMY. 
 
 hydrocele of the spermatic cord, and the femoral variety can be fou A 
 in a form adapted for ready access, in a treatise by the author referred 
 to in previous pages. ' 
 
 The anterior wall of the abdomen is the seat of incision to reach the 
 larger blood-vessels of the abdomen and pelvis — ^the aorta and the exter- 
 nal and internal iliacs — but the steps taken to reach each of them, with the 
 special advantages claimed for the several incisions advocated, can be best 
 obtained from any of the later works on operative surgery. 
 
 The region of the umbilicus is often marked by an engorgement of 
 veins, giving to that region a peculiar blue color — the so-called "caput 
 Medusae " — which is pathognomonic of some obstruction to the portal cir- 
 culation, and to be explained as an effort on the part of Nature to es- 
 tablish a collateral circulation with the superficial veins of the abdomen. 
 In the fcetus, this region is imperfectly developed in some instances, thus 
 causing a hernia at the normal seat of the navel — the condition called 
 " exomphalos. " The same condition may be developed after birth, since 
 the linea alba is perforated by numerous vascular openings, which 
 are nearer together in the child than the adult. In females who have 
 borne many children, the normal openings in this region become dilated; 
 hence the frequency of hernial protrusions in this locality. 
 
 The testicle may be arrested within the inguinal canal during its de- 
 scent into the scrotum, and thus give rise to a tumor of that region 
 which might easily be mistaken for a hernia. 
 
 The escape of omentum or some convolutions of intestine below the 
 arch formed by Poupart's ligament — the so-called " femoral hernia " — is 
 much more common in women than in men, in which respect it makes a 
 striking contrast to hernia of the inguinal region. These protrusions 
 tend to curl upward, after they escape from the saphenous opening of 
 the thigh, and thus appear to lie above the level of Poupart's ligament, 
 so that they often afford extreme difficulty in deciding as to their char- 
 acter. Such a diagnosis is most important, as the methods employed in 
 reduction of the femoral and inguinal varieties differ, and the steps of 
 surgical relief are modified by the anatomical relations of the neck of the 
 sac. 
 
 The aorta divides into the right and left common iliac arteries at a 
 point situated about one and a half inches below the umbilicus. Perhaps 
 a more reliable guide to the seat of its bifurcation may be given by mapping 
 out the level of the highest point in the crest of the ilium, and determin- 
 ing where it would cross the median line of the abdomen; a slight dis- 
 tance to the left of this point of crossing will lie immediately over the 
 bifurcation. If a line be drawn from the highest point of the iliac crest 
 to that portion of the groin where the pulsations of the femoral artery can 
 be felt (a slight curve outward being given to the lino), it will correspond 
 
 ' A Practical Treatise on Surgical Diagnosis. N. Y., 1880. 
 
THE ABDOMEN AND ITS VISCEKA. 311 
 
 to the course of the common iliac and external iliac arteries. The point 
 where the femoral artery can be most easily detected by its pulsations lies 
 rather nearer the spine of the pubes, in the region of Poupart's ligament, 
 than the spine of the ilium. It is in the exact curve of this line, if 
 properly drawn, that the incision, first suggested by Cooper for the liga- 
 tion of the external iliac artery, is made; and, if the incision be carried 
 upward beyond the anterior spine of the ilium for a greater distance, the 
 same opening will allow of the ligation of the common iliac artery. 
 
 The length of the common iliac artery may be given as about two 
 inches in the majority of subjects, but it admits of extreme variations. 
 Holden records, as the result of a large number of dissections made in 
 reference to this point, that the length of this vessel varied from three- 
 quarters of an inch to three and a half inches, and that it seemed to be in 
 no way influenced by the height of the individual. 
 
 The iliac region may be entirely deficient at the time of birth, and the 
 corresponding limb is usually wanting in these cases. The sigmoid, flex- 
 ure of the colon has been brought to the surface in this region on the left 
 side, by Duret and others, and an artificial anus formed, although the 
 operation in Buret's hands seems to have involved wounding of the peri- 
 tonasum; this might, however, be avoided by opening the gut on its poste- 
 rior surface where the peritonasum does not invest it. The hypogastric 
 artery has been ligated in this region, and the operations upon the exter- 
 nal and common iliac vessels are most commonly performed in the region 
 of the crural arch. Caries of the ilium and of the bodies of the lumbar 
 vertebrae may result in sub-peritoneal abscess in this region, which 
 usually point upon the inner aspect of the thigh, near to the insertion of 
 the psoas muscle. Feecal impaction in tlie caecum and the lower part of 
 the ascending colon may show itself as a "sausage-shaped" tumor of the 
 right side which indents on firm pressure. The condition of hernia, 
 which is most common in this region, has been already considered at 
 some length in previous pages. 
 
 The region of the loins may manifest a lateral curvature of the verte- 
 brae in rickets, usually in antagonism to the deflection perceived in the 
 thorax. It may also exist in those subjects who are accustomed to carry 
 heavy weights upon the shoulder. Spina bifida may exist, if the spinous 
 processes of the vertebrae are so deficient as to permit an extrusion of the 
 investing membrane of the spinal cord. Wounds of this region wi th pointed 
 instruments may possibly enter the spinal canal and sever the cauda equina 
 or the lower end of the cord itself, thus producing severe symptoms. The 
 superficial and exposed position of the spines of the lumbar vertebrae ex- 
 plains their frequent fracture. Such fractures are liable to produce not only 
 paralysis of the lower limbs (provided the spinal cord or its nerves are impli- 
 cated), but also impairment or actual loss of the control of the pelvic organs. 
 Lumbar hernia has been seen by Petit, Cloquet, an others; the protrusion 
 occurring at the point between the limits of the external oblique and the 
 
312 PKAOTICAIi MEDICAL ANATOMY. 
 
 latissimus dorsi muscles, since this point offers less resistance to pressure 
 than the surrrounding parts. Oases are on record of the occurrence of 
 urinary renal fistula in this region. Abscesses may form either in the 
 ■tissues forming the posterior wall of the abdomen, or as a result of caries 
 of the bodies of the lumbar vertebrse, perinephritis, simple contusion, or 
 phlegmon. The condition known as "psoas abscess" is usually due to 
 disease of the lower dorsal and upper lumbar vertebrse, and the pus so 
 formed may follow the psoas muscle and point at the inner aspect of the 
 thigh; hence it is to be confounded in some cases with a femoral hernia. 
 The operations of "nephrotomy," in which the kidney is removed, and 
 that upon the colon for the establishment of an artificial anus in case of 
 malignant disease of the lower bowel, are both performed in this locality. 
 It is possible to ligate the abdominal aorta without opening the perito- 
 nseum by a vertical incision made in the loins on the outer side of the 
 sacro-lumbalis muscle; but, although in dogs the aorta can be tied with- 
 out necessarily destroying life, the operation in man afEords little, if any, 
 hope to the patient. 
 
 It is customary to apply wet and dry cups to the loins in order to 
 relieve those conditions of the underlying kidney which are associated 
 with marked engorgement. The explanation of the efficacy of this step 
 lies in the anastomosis which exists between the superficial lumbar vessels 
 and the vessels of the renal capsule, so that blood is directly abstracted 
 from the kidney by drawing it to the surface at this point. A practical 
 point is suggested in this relation, viz., to apply dry cups in preference to 
 the actual abstraction of blood by means of wet cups, since the former 
 tend to increase the rapidity of the circulation in the vessels of the lumbar 
 region, and thus act as a long-continued remedial measure, while the 
 latter affords a benefit for a time, but one which ceases when the opened 
 vessels have become choked by blood-clots. 
 
 Foreign bodies which are proof against the action of the intestinal or, 
 gastric juices are often introduced into the stomach either by accident or 
 design. The foreign bodies which have been more commonly detected, 
 include bullets, fruit-stones, coins, pebbles, marbles, hair, string, oats, 
 pins, fish-bones, etc. The results of the introduction of such foreign 
 bodies vary with the size, shape, and character of- the body introduced. 
 Small, flat, or oval bodies may be passed throughout the length of the 
 intestinal canal, and thus voided without delay, pain, or other symptoms 
 of disturbance. If hair, string, or other similar substance be present 
 within the stomach, they may attain an immense size from the accumu- 
 lation of food and mucus, and thus not only prevent their own expulsion, 
 but create serious symptoms by causing ulceration or even perforation of 
 the organ. Irregular-shaped or globular bodies often become arrested at 
 the pyloric orifice of the stomach, or, provided they pass that outlet, they 
 are liable to become again impacted at the ileo-caecal valve. Sharp or 
 pointed bodies are best voided by plentiful eating and the avoidance of 
 
THE ABDOMEN AND ITS VISCEEA. 313 
 
 cathartics, since, by so doing, the foreign body is more liable to become 
 inclosed in the abundance of fsecal material. Needles, when swallowed, 
 often penetrate the walls of the alimentary canal, and are sometimes 
 transported to distant parts before their removal. 
 
 Abscess of the abdominal region is sometimes dependent upon an 
 artificial aperture in some part of the alimentary canal. It may arise 
 from perforation of the bowel, as the sequel of simple ulceration of its 
 coats, from the lodgment of a foreign body in the intestine, from 
 ulceration of the gall-bladder, from stricture or malignant disease of the 
 bowel, and finally, from fsecal impaction, as a result of muscular atony or 
 paralysis, dependent upon preyious catarrhal inflammation 'of the intes- 
 tine. 
 
 Perhaps no subject pertaining to the abdominal cavity has more inter- 
 est to the operative surgeon than intestinal obstruction. The results of 
 opening the abdominal cavity for the relief of such cases have been so 
 remarkable, and the diagnosis is so often one of extreme difficulty, that 
 I feel that this work would be incomplete without some reference to it. 
 Intestinal obstruction may develop suddenly or slowly. The symptoms 
 of the two varieties vary somewhat with the suddenness of the attack, 
 but even more with the exciting cause and the seat of obstruction. 
 
 Sudden impairment of the normal calibre of the intestine may result 
 from the following causes: 1, foreign bodies, either artifically introduced 
 or formed within the gut; 2, congenital stricture, or some other mal- 
 formation of the intestine; 3, twisting of the intestine, a condition 
 termed "volvulus;" 4, the presence of peritoneal adhesions, acting as a 
 ligature around the intestine; 5, invagination of the intestine, called 
 "intussusception," as the result of intestinal tumors, worms, or other 
 causes not understood; 6, thickened peritoneal covering or mesenteric 
 attachment of some old hernial protrusion; 7, strangulation of a hernia 
 from the sudden forcing down of new intestine into the sac, cedema of 
 the surrounding soft tissues, or muscular spasm at the point of constric- 
 tion. 
 
 Gradual impairment of the normal intestinal calibre may result from 
 the following causes: 1, tumors pressing upon the intestine, and thus 
 gradually occluding it by the slow development of the growth ; 2, sim- 
 ple stricture of the bowel, from ulceration, injury, etc. ; 3, malignant 
 disease of the bowel, occluding its normal calibre; 4, tubercular perito- 
 nitis, by creating pressure on the intestine by the deposit; 5, abscess; 
 from traumatism of the abdominal walls; 6, obstinate constipation or 
 impaction of faeces; 7, inflamed and thickened intestine as the result of 
 injury. 
 
 The chief symptoms by which intestinal obstruction may be recog- 
 nized during life are: 1, a tumor, which may be detected by careful pal- 
 pation, of the abdomen, and which usually indents on firm pressure, if 
 due to impacted fseces; 3, a pain which is usually local and deeply seated, 
 
314 PEACTIOAL MEDICAL ANATOMY. 
 
 and most marked over the situation of the tumor; 3, a dull percussion 
 note over the tumor or the seat of obstruction in case the tumor cannot be 
 felt; 4, obstinate constipation which withstajids all attempts at removal; 
 6, vomiting, which, when stercoraceous in character, is pathognomonic 
 of obstruction; when it occurs late in the attack, it may often be a 
 guide to some obstruction low down in the intestinal canal; 6, tympanitic 
 distention of the abdomen is liable to be very marked if the large intes- 
 tine be occluded, but it is less prominent when the small intestine is the 
 seat of obstruction; 7, in those cases which are of sudden advent, some 
 authorities lay great stress upon the symptom of "visible peristalsis," as 
 indicative^of intestinal obstruction. 
 
 The connective tissue about the cfficum may become the seat of sup- 
 purative inflammation — the condition known as "perityphlitis " — when a 
 tumor will usually be detected in the right iliac fossa, which is to be dif- 
 ferentiated from the condition of typhlitis and faecal impaction in the 
 caecum and ascending colon. It occurs from traumatism, pyaemia, ulcer- 
 ation of the vermiform aptpendix, tlie extension of inflammation from 
 surrounding parts, etc. It is accompanied by numbness of the right 
 lower extremity, an inability to raise the right thigh, a deep-seated pain 
 in the iliac fossa, fluctuation and suppuration, and a tympanitic percus- 
 sion note over the tumor when the patient lies upon the back, since the 
 inflated caecum lies over it. 
 
 In rare cases, the viscera of the abdomen may be protruded through 
 some of the normal openings in the diaphragm, or that muscle may be 
 lacerated, and thus allow of their escape into the cavity of the thorax. 
 A want of the proper muscular tone may, in some instances, allow of 
 such a protrusion without either a dilatation of the normal openings or 
 laceration of its muscular fibres. It may follow a fall from a height, 
 the passage of heavy weights over the abdomen, or even a sudden spasm 
 of the muscles forming the abdominal walls, caused by a sudden slip or 
 a slight fall. If the diaphragm be extensively lacerated, a violent pain 
 js usually produced, and the stomach, transverse colon, omentum, or 
 small intestine may be crowded upward into the thorax and possibly rup- 
 tured. In all hernial protrusions in this region, irrespective of their cause, 
 the chest will usually be rendered prominent on the side where the 
 organs are displaced ; the heart may be pushed out of its normal relations 
 to the chest-wall, respiration may be seriously impaired, the respiratory 
 murmur will be absent .over the hernial protrusion, vomiting and thirst 
 will be developed, and death may follow from rupture of the displaced 
 viscera, strangulation of the part, compression of the structures within 
 the thorax, pleurisy, or peritonitis. If the intestine be protruded into 
 the thorax, a resonant percussion note may be detected low down in the 
 mediastinal region; while, if the more solid viscera be forced upward, 
 the percussion note will be dull, and the diagnosis between a diaphrag- 
 matic hernia and some form of mediastinal tumor will be difficult. Auscul- 
 
THE ABDOMEN AND ITS VISCERA. 
 
 315 
 
 tation over the seat of the suspected hernia may yield a gargling sound, 
 provided the intestine be displaced, and intestinal embarrassment may 
 further assist in the diagnosis. If strangulation be developed, the her- 
 nial protrusion will probably be followed by symptoms of a general peri- 
 tonitis, and the same may also be produced rapidly, if the protruded 
 organ has undergone rupture. 
 
INDEX, 
 
 Abdomen, abscess of, 313 
 
 aneurism of, 288 
 
 anterior wall of, organs in 
 relation with, 284 
 
 auscultation of, its value in 
 diagnosis, 387 
 
 auscultatory percussion of, 
 287 
 
 changes in, during respira- 
 tion, 290 
 
 concussion of, and their re- 
 sults, 309 
 
 congenital deficiency of, in 
 the iliac region, 311. 
 
 contusions of, and their re- 
 sults, 309 
 
 enlargement of, its causes, 
 283 
 
 epigastric region of, its con- 
 tents, 283 
 
 epigastric zone of, its con- 
 tents, 280 
 
 examination of, difQculties 
 of, 278 
 
 expansion of, in inspiration, 
 238 
 
 exterior of, 283, 284, 285. 
 
 external ring of, 288 
 
 hernial protrusions of, 308 
 
 hypogastric region of, its 
 contents, 282 
 
 hypogastric zone of, its con- 
 tents, 280, 381 
 
 iliac region of, its surgical 
 aspects, 311. 
 
 iliac regions of, their con- 
 tents, 282 
 
 incisions in, rules for, 309 
 
 internal ring of, 289. 
 
 its viscera and surgical 
 guides, 278 
 
 left hypochondriac region of, 
 its contents, 383 
 
 Abdomen, lumbar regions of, their con- 
 tents, 283 
 lymphatics of, enlargement 
 
 of, a guide to diagnosis, 309 
 mensuration of, ^ts value in 
 
 diagnosis, 387 
 modifications in, density of, 
 
 283 [330 
 
 muscles of, their functions, 
 muscles of, their peculiar 
 
 arrangement, 290 
 nerves of, 305, 306, 307, 308, 
 
 309 
 organs of, causes of displace- 
 ment of, 286 
 pain in upper part of, its 
 
 clinical significance, 249 
 percussion of, its value in 
 
 diagnosis, 387 
 percussion sound of, diagram 
 
 of, 314 
 points of surgical interest 
 
 pertaining to, 308 to 315 
 pulsation of, 284 
 regions of, 278, 280 
 respiratory movements of, 
 
 their clinical aspects, 388 
 retraction of, its causes, 383 
 right hypochondriac region 
 
 of, its contents, 381 
 rules for inspection of, and 
 
 its uses, 286 
 rules for palpation of, and its 
 
 uses, 886, 387 
 size and appearance of, in 
 
 sexes, 383 
 steps for examination of, 283 
 superficial veins of, their 
 
 clinical aspects, 283 
 surgical aspects of, 308 to 315. 
 tapping of, 384, 309. 
 umbilical region of, its con- 
 tents, 383 
 
318 
 
 INDEX. 
 
 Abdomen, umbilical zone of, its con- 
 ' tents, 2S0 
 viscera of, 290 to 303 
 wall of, abscess of, 296 
 walls of, deficiency of, 308 
 walls of, excessive relaxa- 
 tion of, 308 
 walls of, openings in, 808 
 wounds of, in regions of 
 
 loins, 311 
 wounds of, its results, 308, 
 309 
 Abdominal diseases, countenance of, 63 
 Abrachio-cephalia, 148 
 Abscess of abdomen, 313 
 
 of dorsal region of chest, 223 
 of mediastina, 177 
 psoas, 153, 312 
 retro-pharyngeal, 132, 147 
 sub-occipital, 183 
 Acetabulum, 265 
 
 construction of, 372 
 cotyloid ligament of, func- 
 tion of, 372 
 cotyloid notch of, 272 
 variations in thickness of, 
 272, 273 
 Acrania, 3 
 
 Addison's disease, characteristic discol- 
 oration of, 38 
 Air in veins, 159, 160, 161, 162 
 Amaurosis, its clinical characteristics, 
 
 56 
 Anarina, 53 
 
 Anesthetics, their effects upon degluti- 
 tion, 167 
 Anencephalia, 3 
 Aneurism, abdominal, 383 
 
 thoracic, its effects on nor- 
 mal limits of lung, 307 
 thoracic, effects of, on veins 
 
 of neck, 157 
 thoracic, effects of, 219 
 Aneurismal bruit, 288 
 Angina pectoris, pain of, 253 
 Anthoraco-cephalia, 193 
 Anthrax, 182 
 
 Antrum, its relation to nasal fossa, 118 
 of Highmore, its surgical im- 
 portance, 33 
 of Highmore, surgical diseases 
 of, 33, 34 
 
 Antrum, of Highmore, tapping of, 34 
 tumors of, involving temporal 
 region, 116 
 Anus, leeching of for hepatic disease, 
 
 326 
 Aorta, abdominal, 288 
 
 abdominal, compression of, 284 
 abdominal, external guide to, 
 
 310, 311 
 abdominal, incision for ligation 
 
 of, 310 
 abdominal, ligation of, from be- 
 hind, 312 
 Apectoro-cephalia, 192 
 Aphasia, its relations to injuries of the 
 
 skull, 10 
 Apnoea, 54 
 Apoplexy, 158 
 
 symptoms of, 95 
 Arch, zygomatic, its variation in ani- 
 mals, 18 
 Arcus senilis, its two forms, 43 
 Arterial hemorrhage, 102 
 Artery, angular, 77 
 
 anterior cerebral, 93 
 anterior communicating, 93 
 anterior temporal, 83 
 ascending palatine, 77, 81 
 ascending pharyngeal, its dis- 
 tribution to meninges, 81, 83 
 ascending pharyngeal, peculi- 
 arities of, 82 
 ascending pharyngeal, surgical 
 
 anatomy of, 82 
 auditory, 98 
 axiUary, compression of, 173, 
 
 173 
 axillary, injury of, through the 
 
 neck, 173 
 basilar, 98 
 bronchial, 222 
 centralis retinae, 93 
 cerebellar, inferior, 97, 98 
 cerebellar, posterior, 99 
 cerebellar, superior, 98, 99 
 choroid, posterior, 99 
 ciliary, anterior, 91, 93 
 ciliary, long, 91 
 ciliary, short, 91 
 common carotid, 173, 176, 177, 
 179 [of, 178 
 
 common carotid, bifurcation 
 
INDEX. 
 
 319 
 
 Artery, common caxotid, wounds of, 
 174 
 common iliac, length of, 311 
 communicating posterior, 99 
 deep epigastric, guide to, 289, 
 
 290 
 deep temporal, 90 
 epigastric, deep, 288, 289 
 ethmoidal, 90, 91 
 external carotid, 177 
 facial, 74 
 
 facial, anastomoses of, 78 
 facial, ligation of, 77 
 facial, peculiarities of, 75, 76 
 facial, relations of, 74, 75 
 facial, surgical anatomy of, 77 
 frontal, 89, 91 
 gluteal, 263, 363 
 gluteal, guide to, 376 
 hypogastric, ligation of, 811 
 internal carotid, 86, 87, 88, 177 
 internal carotid, peculiarities 
 
 of, 88 
 internal carotid, surgical anat- 
 omy of, 88 
 intei-nal mammary, 185 
 internal mammary, wounds of, 
 
 218 
 internal maxillary, 84 
 internal maxillary, anasto- 
 moses of, 125 
 internal maxillary, peculiari- 
 ties of, 85 
 internal maxillary, physiologi- 
 cal distribution of, 184, 185 
 internal maxillary, surgical 
 
 anatomy of, 86 
 internal maxillary, wounds of, 
 
 125 
 lachrymal, 90 
 lingual, 73 
 lingual, guide to, 176 
 lingual, ligation of, 78 
 lingual, wounds of, 176 
 median, anterior, 97 
 middle cerebral, 93, 94 
 middle cerebral, surgical anat- 
 omy of, 93, 94 
 middle meningeal, 86, 90 
 middle meningeal, its relation 
 to fracture of temporal bone, 
 16 
 
 Artery, middle meningeal, its relation 
 to trephining, 116 
 
 posterior meningeal, 97, 98 
 
 nasal, 89, 91 
 
 occipital, 78, 183 
 
 occipital, ligation of, 80 
 
 occipital, peculiarities of, 79 
 
 occipital, surgical anatomy of, 
 79, 80 
 
 occipital, wounds of, 174 
 
 ophthalmic, 89 
 
 palpebral, 90, 91 
 
 posterior auricular, 80 
 
 posterior auricular, peculiari- 
 ties of, 80 
 
 posterior communicating, 95 
 
 pudic, compression of, 368 
 
 pudio, guide to, 376, 277 
 
 pudic, its medical aspects, 263, 
 263 
 
 pudio, wounds of, 268 
 
 pulmonary, 223 
 
 ranine, 73 
 
 sciatic, 263, 263 
 
 sciatic, guide to, 276 
 
 spinal, anterior, 97 
 
 spinal, lateral, 97 
 
 spinal, posterior, 97 
 
 stylo-mastoid, 80 
 
 subclavian, 174 
 
 subclavian, compression of, 173 
 
 subclavian, guide to, 173 
 
 subclavian, physiological dis- 
 tribution of, 184, 185 
 
 superior intercostal, 185 
 
 superior thyroid, 178 
 
 supra-orbital, 90 
 
 supra-scapular, wounds of, 171 
 
 tonsillar, 77 
 
 transverse cervical, wounds of, 
 171, 182 
 
 transverse facial, 90 
 
 temple, peculiarities of, 88 
 
 temporal, 83 
 
 temporal, surgical anatomy of, 
 83,84 
 
 vertebral, 95, 96, 185 
 
 vertebral, wounds of, 174 
 Arteries, iliac, ligation of, 310, 311 
 of circle of Willis, 99, 100 
 of meninges of brain and 
 spinal cord, 101 
 
320 
 
 INDEX. 
 
 Arteries of tympanvun, 101 
 Ascites, 283 
 Astomia, 53 
 Atrachelo-cephalia, 148 
 Axis, displacement of, 145, 146 
 
 Back, muscles of, paralysis of, 246 
 
 pain in, a symptom of aneurism, 
 
 249 
 pain in, from intercostal neural- 
 gia, 250 
 Basedow's disease, countenance of, 64 
 BeUocq's canula, 119 
 Bladder, alteration in positions of, with 
 age, 303 
 catheterism of, 303 
 distention of, diagnosis from 
 gravid uterus and cancer, 
 303 
 extroversion of, 308 
 overflow of, 303 
 paralysis of, 303 
 percussion over, 286 
 stone in, supra^pubic opera- 
 tion for, 286 
 tapping of, 286 
 Blood-vessels of head, 71 
 Bone, atlas, dislocation of, 154 
 axis, dislocation of, 154 
 coccyx, tip of, its normal posi- 
 tion in the erect attitude, 258 
 ethmoid, arrest of ossification of 
 
 the perpendicular plate of, 19 
 ethmoid, cribriform plate of, 19 
 frontal, 14 
 frontal, fracture of orbital plate 
 
 of, 21 
 frontal, internal angular process 
 of, its surgical importance, 16 
 frontal, its buttresses, 25, 26 
 frontal, orbital plates of, their 
 
 surgical relations, 14 
 hyoid, 175 to 178 
 hyoid, fracture of, 176 
 hyoid, its functions, 155 
 inferior maxillary, 24 
 inferior maxillary, angle of, its 
 
 surgical relations, 25 
 inferior maxillai'y, condyles of, 
 
 axes of, 25 
 inferior maxillary, coronoid pro- 
 cess of, its surgical relation, 25 
 
 Bone, inferior maxillary, false anchy- 
 losis of, 135 
 
 inferior maxillary, its modifica- 
 tion in the serpent, 24 
 
 inferior maxUlary, necrosis of, 
 135 
 
 inferior maxillary, ramus of, its 
 surgical relations, 25 
 
 inferior maxillary, resection of, 
 134, 135 
 
 inferior maxillary, rotary and 
 grinding movements of, 25 
 
 inferior maxillary, symphysis of, 
 its surgical importance, 35 
 
 innominatum, 265 
 
 ischium, spins of, 361 
 
 ischium, spine of, its medical as- 
 pects, 363 
 
 ischium, spine of, its relation to 
 vessels and nerves, 263 
 
 ischium, tuberosity of, in the 
 sexes, 262 
 
 occipital, 13 
 
 occipital, basilar process of, its 
 surgical aspects, 12 
 
 occipital condyles of, 13, 13 
 
 occipital, dislocation of, 154 
 
 occipital, its buttresses, 26 
 > parietal, 16 
 
 parietal, its buttresses, 26 
 
 parietal, its sutures, 16 
 
 sacrum, a key-stone to pelvis, 
 257, 258 
 
 sacrum, precautions against dis- 
 locations of, 258 
 
 sphenoid, 13 
 
 sphenoid, foramina of, their sur- 
 gical relation, 13 
 
 sphenoid, fracture of body of, 21 
 
 sphenoid, pterygoid process of, 
 its functions and surgical rela- 
 tions, 13 
 
 sphenoid, sinus of, its relations 
 to fracture of skull, 14 
 
 superior maxillary, 22 
 
 superior maxillary, a guide to 
 nasal duct, 118 
 
 superior maxillary, cavity of, its 
 surgical importance, 33 
 
 superior maxiUary, operation 
 upon, 134 
 
 temporal, 16 
 
INDEX. 
 
 321 
 
 Bone, temporal, its fracture, 16 
 
 temporal, its numerous forami- 
 na, 36 
 temporal, its styloid and poste- 
 rior glenoid processes and their 
 function, 17 
 temporal, mastoid process of, its 
 
 surgical re ations, 16, 17 
 vomer, its surgical importance, 
 19 
 Bones, ilia, wings of, 261 
 
 nasal, their arch, and its unu- 
 sual strength, 24 
 nasal, their relation to fracture 
 
 of the base of the skuU, 24 
 of the face, 21 
 of the pelvis, 255 
 of the skull, 1 to 31 
 of Wormius, 11 
 turbinated, their modifications 
 
 in animals, 18, 19 
 turbinated, hypertrophy of mu- 
 cous covering of, 123 
 turbinated, in the aged, 117 
 turbinated, superior and middle, 
 22 
 Brachial plexus, wounds of, 171 
 Brain, carbonic-acid poisoning of, symp- 
 toms of, 158 
 counter-irritation of, Ih diseases 
 
 of, 182 
 guides to level of floor of, 6 
 hernia of, in the aged, 53 
 injuries of, rules for trephining 
 
 for, 4, 9, 10. 
 meninges of, arteries of, 101 
 meninges of, erysipelas of, 109 
 surgical guides to component 
 
 parts of, 6, 7, 8. 
 vascular territories of, 92 
 Breast, cancer of, seat of pain in, 248 
 Broca, alveolo-condyloid plane of, 8 
 
 speech centre of, guide to, 8 to 10 
 Brow, its clinical aspects, 44 
 
 Calvaria, non-reproduction of, 116 
 
 Campa, angle of, 28, 29 
 
 Canal, auditory, abnormalities of, 112 
 auditory, curve of, 112 
 auditory, escape of blood from, 
 116 
 
 Canal, auditory, escape of cerebro-spi- 
 nal fluid from, 116 
 auditory, escape of pus from, its 
 
 clinical significance, 114 
 auditory, foreign bodies in, 113 
 auditory, foreign bodies in, ef- 
 fects of, 114 
 auditory, osseous portion of, 113 
 auditory, removal of insects 
 
 from, 113, 114 
 external auditory, its relation 
 
 to foreign bodies, 18 
 inguinal, 288 
 
 inguinal, its surgical aspects, 289 
 intestinal, its medical aspects, 
 
 297 
 spinal, 144 
 Canals, lachrymal, dilatation of and 
 
 syringing of, 127, 128 
 Caries of temporal region, 116 
 Cartilage, cricoid, its surgical aspects, 
 179 
 thyroid, 177, 178 
 Cartilages, costal, dislocations of, 217 
 costal, their functions and 
 clinical aspects, 188 
 Carus, curve of, 259 
 Catalepsy, countenance of, 68 
 Cataract, congenital, 59 
 
 congenital, its characteristic 
 
 phenomena, 58 
 of adults, 56 
 Caecum, 397 
 Cells, ethmoidal, their relation to nasal 
 
 fossa, 118 
 Cerebellum, its relation to the occipital 
 fossa, 6 [10 
 
 Cerebral cortex, motor centres of, 9, 
 Cerebro-spinal fluid, 148, 275 
 
 -spinal fluid, its function, 222, 
 223 
 Cerebrum, external guides to fissures 
 of, 7 
 external guides to limits of, 
 
 6 
 floor of, guide to, 3 
 guide to limits of basal gan- 
 glia of, 8 
 injuries to, from wounds of 
 
 orbit, 22 
 injuries over motor areas 
 of, 9 
 
322 
 
 rsnzx. 
 
 Cheek, changes in, produced by age, 49 
 color of, 36, -37. 49 
 gangrene of, 129 
 its physiological and clinical as- 
 pects, 48, 49 
 ulceration of, 129 
 TascnlarirT of, its relation to 
 erectile tumors, 49 
 CJhest, absces of dorsal region of, 223 
 acctunulations of blood in, symp- 
 toms of, 229 
 accumulations of pus in, results 
 
 of, 229 
 anatomical snbdiTiaons of, 209 
 auscultation of, 229 
 asHlary region of, contents of, 
 
 214 
 bulging of, 192 
 clavicolar r^ion of, contents of, 
 
 211 
 clinical sobdiTisions of, 209 
 congenital defects of, 192 
 coEiractionof, itscauses,l&2 193 
 copping of, its physiological as- 
 pects. 221, 222 
 deformities of, 192. 217 
 diaphragmatic region of, its 
 medical and smgical aspects, 
 22-3. 224. 225 
 during expiration, 2(>4 
 expansion of, 22S 
 fluid in, aspiration of, 216, 217 
 in empfajsema, 231 
 in nckets. 192 
 in the female, 193. 194 
 indentation of, 1^3 
 inferior sternal region of, con- 
 tents of, 210, 211 
 infra-aTJllarf i^ion of, con- 
 tents of, 214 
 infra-davlcular F^on of, con- 
 tents of, 211, 212 
 infra-scapular region of, contents 
 
 of, 213 
 inspiratory efforts of, effects of, 
 
 230. 231 
 
 inter-scapular region of, con- 
 tents of. 213, 2.4 
 
 its modifications in respiration, 
 227 
 
 location of heart mormurs upon, 
 
 231, 232. 2:53 
 
 Chest, mammary n^ion of, contents 
 of, 213 
 
 mammary region of, medical as- 
 pects of, 221 
 
 measurements of, 193 
 
 measarements of, its diagnostic 
 Talue, 22 ^ 
 
 muscles of, 236 
 
 muscles of, paralysis of, 242. 243. 
 244. 24-5, 246 
 
 of phtjiisis, 20-5 
 
 on full inspirataon, 203. 204 
 
 pain in, from intercostal neural- 
 gia, 250 
 
 percTiSaion sounds of, diagrams 
 of, 214 
 
 precordial region of, in hyper- 
 trophy of heart, 199 
 
 praecordial r^on of, in pericar- 
 ditis, 2'jl 
 
 punctured -sronnds of, dangers 
 of, 217, 21;. 219 
 
 retraction of, 192 
 
 r^piratory movements of, ef- 
 fects of on organs. 204 
 
 respiratory movements of, in 
 the two sexes, 193, 194 
 
 scapular r^ion of, contents of, 
 213 
 
 sternal r^ion of, its medical 
 aspects, 192, 221 
 
 superior sternal region of, con- 
 tents of, 210 
 
 supra-clavicnlar region of, con- 
 tents of, 211 
 
 supra-scapular r^jon of, con- 
 tents of, 313 
 
 supra-sremal r^ion of. contents 
 of, -09, 210 
 
 tapping of, 1^9 
 
 viscera of. external guides to, 
 193 
 
 wounds of dorsal region of, 223 
 Clieyne-St okes respiration, its relations 
 
 lo injury of the skull, 10 
 Choked disk, its relations to injuries of 
 
 thesknll, 10 
 Cholera, countenance of, 65 
 Chorea, countenance of, 6S 
 Circle of Vri::is. 99. 100 
 Cc-ccyx, apex of, its medical aspects. 
 276 
 
INDEX. 
 
 323 
 
 Colon, fascal accumulation in, 296 
 its medical aspects, 297 
 transverse, 284 
 Colotomy in iliac region of abdomen,! 
 311 
 steps of, 399 
 Column, spinal (see vertebrsej 
 Coma, after eating, 291 
 Convulsions due to air in the veins, 160 
 Cord, spermatic, 289 
 Cornea, its changes and their clinical 
 
 significance, 43 
 Coughing, its effects on veins of neck, 
 
 157 
 Cranium, congenital absence of, 53 
 
 its buttresses, 25 
 Cretins, countenance of, 69 
 Crural arch, 288 
 Cut throat, 176 
 
 Cyanosis in infants, its clinical signifi- 
 cance, 39 
 
 Deglutition and its mechanism, 163, 164, 
 165, 166, 167, 168 
 stages of, 163, 164 
 Bementia, countenance of, 66 
 Diaphragm, an inspiratory muscle, 237 
 displacements of, 224 
 displacements of, causes 
 
 of, 336, 237 
 hernia of, 225 
 hernia through, 314 
 inflammation of, symp- 
 toms of, 326 
 its physiological functions, 
 
 325 
 laceration of, 233, 314 
 piston-like action of, 230 
 seat of abstraction of blood 
 
 from, 226 
 tumors of, 225 
 wounds of, 233, 334 
 Disks, intervertebral, 137, 138, 140 
 Duchenne's disease, countenance of, 67, 
 
 68 
 Duct, nasal, 118, 137 
 
 nasal, its lower opening, 19 
 
 nasal, probing of, 138 
 
 nasal, probing of, from below 
 
 upward, 118 
 Steno's, 139 
 Steno's, guide to, 33 
 
 Duct, thoracic, 187 
 
 Wharton's, 131 
 Duodenum, 297 
 Dyspnoea, causes of, 63 
 
 countenance of, 61, 63 
 Dystocia, a cause of, 153 
 
 Ear, auditory canal of, abnormalities 
 of, 113 
 cartilage of, its medical and surgi- 
 cal aspects, 113 
 congenital abnormaUties of, 113 
 construction of, plate of, 111 
 discharge from, its clinical sig- 
 nificance, 48 
 drum of, perforation of, 114 
 drum of, rupture of, 114 
 drum of, spontaneous perforation 
 
 of, 115 
 escape of blood from, 116 
 escape of cerebro-spinal fluid 
 from, its clinical significance, 
 116 
 examination of, 113 
 external, foreign bodies in, 113 
 external, removal of, 113 
 external, removal of insects from, 
 
 113, 114 
 external, canal of, infiammation 
 
 of, 113 
 external, canal of, tumors of, 113 
 in general paralysis of the insane, 
 
 48 
 in gout, 47, 48 
 in visceral cirrhosis, 48 
 lobule of, abnormalities of, 113 
 middle, suppuration of, 115 
 orifice of, as a surgical guide, 2 
 otolites of, 47 
 relations to the naso-pharyngeal 
 
 cavity, 131 
 syringing of, 115 
 Embolism, symptoms of, 94, 95 
 Emphysema, 158, 383 
 
 chest in, 231 
 countenance of, 61 
 its effects on normal lim- 
 its of lung, 307 
 its effect on veins of 
 
 neck, 157 
 neck in, 156 
 shoulders in, 156 
 
324 
 
 INDEX. 
 
 Epicanthus, 59 
 
 Epigastric space, its clinical import- 
 ance, 228 
 Epiglottis, 178 
 
 its relations to deglutition, 
 166 
 Epilepsy after eating. 291 
 
 countenance of, 65, 66 
 Epistaxis, 90 
 
 its relation to congestive 
 headache, 6 
 Eustachian tube, catheterization of, 116 
 
 tube, closure of, 114, 115 
 Exostoses of temporal region, 116 
 Exophthalmia, 126 
 Expiration, causes of, 240 
 
 muscles of, 240 
 Eye, amputation of, 126 
 
 bony protection of, 22 
 
 changes in, from growths in orbit 
 
 or antrum, 47 
 deformities of, produced by local 
 
 affections, 46, 47 
 extirpation of, dangers in, 125 
 general construction of, plate of, 
 
 124 
 in amaurosis, 56 
 in Basedow's disease, 47 
 in Bell's paralysis, 46 
 in Bright's disease, 45 
 in cardiac hypertrophy, 46 
 in cataract, 56, 59 
 in chronic trachoma, 59 
 in epicanthus, 59 
 in glaucoma, 59 
 in glioma of the retina, 58 
 in mania and idiocy, 45 
 in measles, 46 
 in motor oculi paralysis, 59 
 in photophobia, 46 
 in ptosis, 59 
 in scarlet fever, 46 
 its value in diagnosis, 41, 42, 43 
 
 44, 45, 46, 47 
 lens of, dislocation of, 59 
 muscles of, action of, 57 
 of iritis, 56 
 
 paresis of muscles of, effects of, 
 
 57, 58 [46 
 
 squint of, its clinical significance, 
 
 various results of injuries to, 124, 
 
 125 
 
 Eyes, absence of, 52 
 
 Eyebrow, effects of injuries in region 
 
 of, 123 
 Eyelashes, abnormalities of, 47 
 Eyelids, arteries of, 91 
 
 deformities of, 53 
 
 Pace, absence of, 52 
 
 anasarca of, 52 
 
 blue color of, its clinical signifi- 
 cance, 38 
 
 bones of, 21 
 
 brown color of, its clinical signifi- 
 cance, 38 
 
 central fissures of, 53 
 
 color of, its clinical significance, 
 37 
 
 cyanosis of, 158 
 
 deformities of, 52, 53 
 
 erysipelas of, extension of, to 
 brain, 109 
 
 expressions of, table of, 38 
 
 fiushing of, its clinical signifi- 
 cance, 36 
 
 greenish color of, its clinical sig- 
 nificance, 37, 38 
 
 Hippocratic, its clinical signifi- 
 cance, 54 
 
 in apoplexy, 95 
 
 in catalepsy, 68 
 
 in cholera, 65 
 
 in chorea, 68 
 
 in chronic abdominal diseases, 63 
 
 in chronic atrophy, 65 
 
 in dementia, 66 
 
 in Duchenne's disease, 67, 68 
 
 in embolism, 95 
 
 in emphysema, 61 
 
 in epilepsy, 65, 66 
 
 in excessive dyspnoea, 61 
 
 in fevers, 61 
 
 in glosso-labio-laryngeal paraly- 
 sis, 67, 68 
 
 in Graves' or Basedow's disease, 
 64 
 
 in melancholia, 66 
 
 in paresis, 66 
 
 in pneumonia, 61 
 
 in renal disease, 63 
 
 in scurvy, 64 
 
 in strumous ophthalmia, 55, 56 
 
 in tetanus, 68 
 
INDEX. 
 
 325 
 
 Face, in valvular heart-lesions,. 64 
 
 its modifications in health and 
 disease, and its value as a guide 
 in diagnosis, 31 
 lines of, their diagnostic value, 
 
 33, 34, 35, 36 
 modifications in color of, in dis- 
 ease, 36, 37, 38 
 of apnoea, and its causes, 54, 55 
 of. Cretins, 69 
 of extreme ansemia, 55 
 of idiots and imbeciles, 54 
 of scrofulous children, 53, 54 
 "pinched," its clinical signifi- 
 cance, 54 
 red patches of, its clinical signifi- 
 cance, 36, 37 
 senile, its clinical significance, 
 
 65 
 special types of, 53-70 
 " stupid," its cUnical significance, 
 
 54 
 tumors of, 53 
 ulceration of, 53 
 various expressions of, 33 
 vascularity of, in young and old 
 
 subjects, 39 
 Voltairean, 65 
 
 yellow color of, its clinical sig- 
 nificance, 38 
 FsBcal impaction, 311 
 Fascia, deep cervical, its functions, 175 
 Fever, typhoid, abdominal changes in, 
 
 399, 300 
 Fevers, countenance of, 64 
 Fissure, external parieto-occipital, ex- 
 ternal guides to, 7, 8 
 of Rolando, external guide to, 
 
 7,8 
 of Rolando, its relation to mo- 
 tor region of cerebral cor- 
 tex, 7 
 sphenoidal, its surgical as- 
 pects, 135 
 Fistula, salivary, 139 
 Fontanelle, lateral of skull, its rela- 
 tion to hernia of the brain, 116 
 Fontanelles of skull, 16 
 Fonticulus guttei-is, 174 
 Foramen, great sacro-sciatic, its con- 
 tents, 362 
 infra orbital, guide to, 33 
 
 Foramen, lesser sacro-sciatic, its con- 
 tents, 263 
 mental, guide to, 33 
 obturator, its contents, 263 
 obturator, its variations in 
 
 the sexes, 261, 262 
 optic, 89 
 supra-orbital, 90 
 supra-orbital, guide to, 33 
 Foramina, intervertebral, 143 
 of pelvis, 356, 263 
 of sacrum, their surgical re- 
 lation, 371 
 of sphenoid bone, their sur- 
 gical relation, 13 
 sacral, 146 
 Forehead, clinical manifestations of, 
 39, 40 
 senile atrophy of, 53 
 Fossa, gluteal, its medical aspects, 266 
 iliac, its medical aspects, 265, 
 nasal, 18 [266 
 
 nasal, anterior bony edge of, its 
 
 surgical importance, 19 
 subclavicular, changes in, in 
 
 paralysis, 244 
 supra-clavicular, in paralysis of 
 
 trapezius muscle, 170 
 temporal, its variation in ani- 
 mals, 18 
 zygomatic, its relation to wounds 
 of the orbit, 135 
 Fracture, by contre-coup, 13, 26 
 Funic souffle, 303 
 Furuncles, 183 
 
 Gall-bladder, perforation of, 313 
 Gallia capitis, 15 
 
 Ganglion, Gasserian, its relation to 
 tongue symptoms, 130 
 Meckel's, 133 
 otic, 133 
 Gland, lachrymal, 137 
 
 lachrymal, removal of, 137 
 parotid, removal of, 175 
 submaxillary, 175 
 thymus, 178 
 thyroid, 178 
 
 thyroid, in dyspnoea, 179 
 thyroid, isthmus of, 180 
 Glands, axillary, enlargement of, a 
 guide to diagnosis, 309 
 
326 
 
 INDEX. 
 
 Glands, bronchial, enlargement of, 
 symptoms of, 219 
 inguinal, enlargement of, a 
 
 goide to diagnosis, 309 
 in transverse fissure of liver, 
 
 enlargement of, 283 
 lymphatic, of supra-scapular 
 fossa, their clinical relations, 
 172 
 oesophageal, enlargement of, 
 
 symptoms of, 219 
 of mesentery, enlargement of, 
 300 
 Grlaucoma, 59 
 Glioma of retina, 59 
 Glosso-labio-laryngeal paralysis, coun- 
 tenance of, 67, 68 
 Gluteal region, bony landmarks of, 275 
 Graves's disease, countenance of, 64 
 
 Head (see also SkuU, Cranium, and 
 Face). 
 air cavities of, plate of, 117 
 air chambers of, foreign bodies 
 
 in, 121 
 attitude of, in dorsal paralysis, 
 
 246, 247 
 attitude of, in paralysis of dorsal 
 
 nerves, 254 
 attitude of, in paralysis of stemo- 
 
 mastoid muscle, 169 
 attitudes of, in ocular paresis, 57, 
 
 58 
 blood-vessels of, 71 
 causes of distortions of, 29, 30 
 diagnostic value of the devia- 
 tions from the normal attitude 
 of, 28 
 exterior of, veins of, 108 
 interference with venous circu- 
 lation of, from pressure of 
 stomach, 291 
 muscles creating movements of, 
 
 80 
 of chronic hydrocephalus, 60 
 poise of, in the normal skull, 28 
 possible movements of, 29 
 physiological and diagnostic 
 
 value of attitudes of, 39, 30 
 relative proportions of the cra- 
 nium and face, and its physio- 
 logical value, 38 
 
 Head, special surgical regions of, 111 
 temporal region of, exostoses of, 
 
 116 
 temporal region of, caries and 
 
 necrosis of, 116 
 temporal region of, its surgical 
 
 aspects, 113 
 temporal region of, prominence 
 
 of, its causes, 116 
 temporal region of, trephining 
 
 of, 116 
 veins of, 105 
 
 veins of, surgical aspects of, 109 
 veins of, valves of, 110 
 Heart, 195 [160 
 
 action of, when air enters veins, 
 apex-beat of, 197 
 apex-beat of, causes of displace- 
 ment of, 197, 198 
 apex-beat of, in the female, 199 
 apex-beat of, in fleshy subjects, 
 
 198 
 apex-beat of, in hjrpertrophy, 
 
 198, 203 
 
 areas of deep and superficial 
 
 dulness, 197 
 cavities of, effects of air in the 
 
 veijis upon, 159, 160 
 disease, countenance of, 64 
 enlargement of, 202 
 foetal, 303 
 
 hypertrophy of, 199, 200 
 impulse, modifications of, 203 
 impulse, when uncovered by 
 
 lung, 203 
 injection of, during life, 163 
 mitral valve of, 158 
 mapping out of, on surface of 
 
 chest, rules for, 195, 196 
 pain in, from pressure of 
 
 stomach, 391 
 palpitation of, from pressure of 
 
 stomach, 391 
 tricuspid valve of, its effect on 
 
 veins of neck, 157 
 use of eye in determining condi- 
 tion of, 199 
 valves of, their normal position, 
 
 199, 200 
 
 valvular murmurs of, their 
 areas of diffusion, 331, 232, 
 233 
 
INDEX. 
 
 327 
 
 Heart, venous return to, effect of dia- 
 phragm upon, 235 
 ■wounds of, 218 
 Hemorrhage, amputation after, 105 
 
 cranial, situations of, 95 
 from the ear, 110 
 from the tongue, 129 
 in contusions of skull, 
 
 110 
 in fracture of skull, 110 
 modifying causes of, 102 
 of temporal region, 116 
 of mastoid region, 116 
 prolonged, causes of, 102 
 recurrent, 105 
 symptoms of, 102, 103 
 treatment of, 103, 104, 
 
 105 
 varieties of, 102 
 Hemiplegia following injuries to the 
 
 skull, 9, 10 
 Hemiparaplegia, its relations to spinal 
 
 disease, 152 
 Hepatic pulsation, 284 
 Hernia, diaphragmatic, 314 
 
 diaphragmatic, its differential 
 
 diagnosis, 314, 315 
 femoral, 310 
 femoral and inguinal, diagnosis 
 
 of, 274 
 inguinal, 309 
 lumbar, 311, 312 
 strangulated, of inguinal re- 
 gion, rule for incision of, 290 
 thoracic, 314 
 Hernial protrusions of abdomen, 308 
 Hiccough during deglutition, 167 
 Highmore, antrum of, its surgical im- 
 portance, 23 
 antrum of, surgical diseases 
 
 of, 23, 24 
 antrum of, tapping of, and 
 its surgical diseases, 24 
 Hip- joint, effusion in, 275 
 
 guide to, 275 
 Hooping cough, effects of, 158 
 Hydrocephalus, chronic, 60 
 Hydronephrosis, 300 
 
 its causes, 801 
 Hypochondriac region of abdomen, 281, 
 
 282 
 Hypogastric region of abdomen, 282 
 
 Ileum, 297 
 
 Iliac regions of abdomen, 282 
 
 Ilium, 365 
 
 anterior border of, 266 
 anterior superior spine of, 274 
 anterior spine of, its medical 
 
 and surgical aspects, 273 
 caries of, 311 
 its functions and medical 
 
 aspects, 265 
 posterior border of, 266 
 posterior superior spine of, 275 
 Inguinal canal, 288 
 Inspiration, muscles of, 237 
 Intercostal neuralgia, diagnostic points 
 of tenderness of, 252 
 neuralgia, pain of, and its 
 
 causes, 350, 251, 255 
 spaces, modifications of, 192 
 Intestine, air in, function of, 299 
 
 causes of obstruction of, 313, 
 
 314 
 foreign bodies in, 812 
 large, 397 
 
 perforation of, 300, 813 
 rupture of, in thorax, 815 
 situation of different portions 
 
 of, 297 
 strangulation of, in thorax, 
 815 
 Intestinal obstruction, its causes and 
 
 symptoms, 313, 314 
 Iris, arteries of, 91 
 Iritis, 56 
 
 its clinical characteristics, 56 
 Ischium, 265 
 
 functions of, 267 
 internal surface of, its rela- 
 tions to parturition, 368, 269 
 lateral arches of, 267 
 notches of, 267 
 ramus of, its medical aspects, 
 
 268 
 spine of, its medical aspects, 
 
 268 
 tuberosity of, its anatomical 
 
 importance, 268 
 tuberosity of, its medical 
 aspects, 275 
 
 Jaw, lower (see Bone, inferior maxU- 
 
 lary). 
 
328 
 
 INDEX. 
 
 Jaw, upper (see Bone, superior maxil- 
 lary). 
 
 Jejunum, 297 
 
 Joint, hip, effusion in, 275 
 
 hip, surgical guide to, 375 
 sacro-iliac, its construction, 266 
 sacro-iliao, surgical guide to, 275 
 sterno-clavlcular, peculiarity of, 
 191 
 
 Jugular pulsation, 233 
 
 Kidney, aspiration of, 800 
 calculi in, 301 
 cancer of, 801 
 enlargements of, 296 
 movable, its differential diag- 
 nosis, 800 
 tubercular disease of, 801 
 Kidneys, enlargement of, their differen- 
 tial diagnosis, 300, 301 
 guides to, 300 
 
 movements of, during respi- 
 ration, 800 
 palpation of, 300 
 their normal situation, 300 
 Kyphosis, 150 
 
 paralytic, 246, 253 
 
 Larynx, 175, 176, 177, 178, 205 
 
 alterations in, during degluti- 
 tion, 167 
 foreign bodies in, 167 
 in dyspnoea, 179 
 inflammatory diseases of, 178 
 its construction and functions, 
 
 178 
 vocal cords of, 179 
 Laughing during deglutition, 167 
 Lead poisoning, 283 
 Leg, measurement of, for suspected 
 
 shortening, 373, 274 
 Ligament of Poupart, 288, 289 
 
 of Poupart, a surgical guide, 
 275 
 Ligaments, sacro-sci^tic, their func- 
 tions, 267 
 Ligamentum nuchse, its functions, 181 
 Line of De Salle, 35, 36 
 
 of Jadelot, 35 
 Linea alba, its clinical aspects, 284 
 Lines, collateral nasal, of face, their di- 
 agnostic value, 36 
 
 Lines, labial, of face, their diagnostic 
 value, 85, 86 
 nasal, of face, their diagnostic 
 
 value, 35 
 oculo-zygomatic, of face, their 
 
 diagnostic value, 35 
 of sternum, 190 
 Lips, changes in color of, their clinical 
 significance, 50, 51 
 deformities of, 49 
 in abdominal pain, 51 
 in the aged, 50 
 of the child, 50 
 tumors of, 50 
 Liver, abscess of, 327, 283 
 
 abscess of, aspiration of, 224 
 abscess of, diagnosis of, 234 
 cancer of, 283 
 cirrhosis of, 383 
 
 compression of, during inspira- 
 tion, 291 
 difficulty in diagnosis in diseases 
 
 of, 293, 294 
 diseased conditions of, 292 
 displacements of, 293 
 its relations to stomach, 292 
 its relations to the intestinal con- 
 ditions, 292 
 its relations to thoracic condi- 
 tions, 293 
 its variations in size and posi- 
 tion, 291 
 palpation of, 294 
 percussion note of, its modifica- 
 tions, 294 
 pulsation in, 284 
 seat of abstraction of blood from, 
 
 226 
 upper displacement of, 291 
 ■wounds of, 294 
 
 wounds of, in aspiration of chest, 
 216, 317 
 Loins, cupping of, its medical aspects, 
 312 
 pain in, from intercostal neural- 
 gia, 250 
 surgical aspects of, 811, 312 
 wounds of, 311 
 Lordosis, 150 
 
 Lumbar regions of abdomen, 282 
 Lung, 303 
 
 after death, 203 
 
INDEX. 
 
 329 
 
 Ltmg, after inspiration, 203 
 
 anterior border of, ita limits, 
 
 204 
 apex of, its clinical aspects, 304 
 apex of, wounds of, 173 
 displacements of, abdominal 
 
 causes of, 208 
 expiratory effort of, effects of, 
 
 on veins of neck, 157 
 in pleuritic effusion, 206 
 wounds of, 318 
 Lungs, capillaries of, their relation to air 
 in the veins, 159 
 diagram of, 205 
 normal outline of, modifications 
 
 of, its causes, 206, 207 
 outline of, on chest-wall, 196 
 percussion notes of, 214 
 shallow respirations of, effects 
 
 of on veins of neck, 158 
 wedge-like action of, on abdom- 
 inal viscera, 296 
 
 Mastodynia, its causes and symptoms, 
 353 
 painful, diagnostic points 
 of, 253 
 Mastoid cells, 115 
 
 Meckel, ganglia of, wounds of, 125 
 Mediastina, abscesses of, 319 
 
 their contents, 303 
 tumors of, their effects on 
 normal limits of lung, 
 307 
 wounds of, 218 
 Mediastinum, anterior, 311 
 Medulla oblongata, centre of degluti- 
 tion, 168 
 its relation to air in veins, 159 
 Melancholia, countenance of, 66 
 Membrana tympani, perforation of, 114 
 
 tympani, rupture of, 114 
 Membrane, crico-thyroid, 179 
 Mesentery, diseases of, 300 
 Monoplegia, following injuries to the 
 
 skull, 10 
 Motion, paralysis of, in spinal disease, 
 
 153 
 Mouth, absence of, 53 
 
 as a surgical region of the head, 
 138 
 Murmurs of aortic valve of heart, 233 
 
 Murmurs of mitral valve of heart, 231, 
 233 
 of pulmonic valves of heart, 
 
 233 
 of tricuspid valve of heart, 
 
 233 
 valvular, of heart, their areas 
 of diffusion, 231, 232, 233 
 Muscle, digastric, 166 
 
 genio-glossus, 166 
 
 genio-hyoid, 166 
 
 infra-costal, 241 
 
 latissimus dorsi, 241 
 
 latissimus dorsi, paralysis of, 
 353 
 
 latissimus dorsi, paralysis of, 
 symptoms of, 344 
 
 levator anguli scapulae, 163, 
 342 
 
 levator anguli scapulae, paraly- 
 sis of, symptoms of, 344 
 
 levator palati, 166 
 
 mylo-hyoid, 166 
 
 obturator extemus, 363 
 
 obturator intern us, 262 
 
 omo-hyoid, 175, 179 
 
 omo-hyoid, its formation and 
 nervous supply, 163 
 
 palato-pharyngeus, 166 
 
 platysma, 162 
 
 pectoralis major, 241 
 
 pectoralis minor, 341 
 
 pyriformis, 363 
 
 sacro-lumbalis, paralysis of, 253 
 
 scalenus, 162, 163 
 
 serratus magnus, 242 
 
 serratus magnus, in inspiration, 
 239 
 
 serratus magnus, paralysis of, 
 symptoms of, 244, 245, 246 
 
 stemo-mastoid, a surgical 
 guide, 173, 174 
 
 stemo-mastoid, paralysis of, 
 symptoms of, 169, 170 
 
 sterno-hyoid, 175 
 
 sterno-thyroid, 175 
 
 stylo-glossus, 166 
 
 subclavius, 241 
 
 superior constrictor of pha- 
 rynx, 166 
 
 superior oblique, of eye, its re- 
 lation to wounds of orbit, 126 
 
330 
 
 INDEX. 
 
 Muscle, trapezius, 243 
 
 trapezius, bilateral paralysis of, 
 symptoms of, 170, 171 
 
 trapezius, paralysis of, symp- 
 toms of, 169, 170 
 
 teres major, 241 
 
 triangularis sterni, 241 
 Muscles, action of, general rule to deter- 
 mine, 238, 239 
 
 auxiliary, of inspiration, 239 
 
 constrictor, of pharynx, 166 
 
 intercostal, action of, 238 
 
 intercostal, arrangement of, 
 190 
 
 intercostal, internal, 241 
 
 longus colli, 163 
 
 of abdomen, course of fibres 
 of, 290 [280 
 
 of abdomen, their functions, 
 
 of back, 243 
 
 of back, paralysis of, symp- 
 toms of, 246 
 
 of chest, 336 
 
 of expiration, 340 
 
 «f inspiration, 237 
 
 of neck, clinical points pertain- 
 ing to, 168, 169, 170, 171, 172 
 
 of neck, in respiration, 162 
 
 of neck, paralysis of, 168, 169 
 
 of neck, paresis of, 168 
 
 of nostril, in respiration, 240 
 
 of palate, 131 
 
 of pharynx, 165, 166 
 
 of soft palate, 163, 165 
 
 of supra-hyoid region, 163 
 
 of tongue, 163 
 
 pectoral, paralysis of, 243 
 
 prevertebral, 163 
 
 recti, of head, 163 
 
 rhomboidei, 342 
 
 rhomboidei, paralysis of, 
 symptoms of, 344 
 
 rigidity of, in sclerosis of 
 nerve-fibres, 70 
 
 scaleni, 236 
 
 serrati, bilateral paralysis of, 
 symptoms of, 246 
 
 serrati postici, 342 
 
 Nares, posterior, plugging of, 119 
 Nasal cavity, hypertrophy of mucous 
 membrane of, 123 
 
 Nasal cavity, its changes with age, 117 
 fossa, meatuses of, and their 
 
 communications with adjoin- 
 ing parts, 118 
 fossa, its bones, 18 
 Nates, its medical aspects, 377 
 
 fold of, its surgical aspects, 375, 
 
 376 
 Neck, abscess of, 172, 174, 177 
 
 abscesses of, treatment of, 183 
 aneurism of, 183 
 anterior region of, 175 
 arteries of, distribution of, 184, 
 
 185 
 cancer of, 183 
 counter-irritation of, in diseases 
 
 of brain and spinal cord, 182 
 deep fascia of, 175 
 emphysema of, from wounds of 
 
 lung, 173 
 fluid tumors of, 183 
 glands of, 174 
 in dyspnoea, 179 
 in emphysema, 156 
 in phthisis, 156 
 
 in stemo-mastoid paralysis, 169 
 its contour in different periods of 
 
 life, 155 
 length of, alterations in, and 
 
 their causes, 155 
 length of, its modifications with 
 
 positions of the head, 156 
 long, its clinical significance, 155 
 muscles of, acting upon the 
 
 head, 30 
 muscles of, clinical poiuts per- 
 taining to, 168, 169, 170, 171, 
 
 173 
 muscles of, functions of, 163, 163, 
 
 164 165, 166, 167, 168 
 muscles of, in respiration, 162 
 muscles of, paralysis of, 168, 169 
 muscles of, paresis of, 168 
 pain in, relation to thoracic and 
 
 abdominal disease, 336 
 posterior region of, 181 
 short, its clinical significance, 
 
 155, 156 
 special regions of, 171 
 stemo-mastoid region of, 173 
 structures of, 157 
 supra-hyoid region of, 175 
 
INDEX. 
 
 331 
 
 Neck, supra-clavicular region of, 171 
 
 tumors of, diagnosis of, 182, 183, 
 
 184 
 veins of, circulation in, 157 
 veins of, their points of interest, 
 
 157, 158, 159 
 veins of, wall of, support of, 175 
 wounds of, posteriorly, 181 
 Necrosis of temporal region, 116 
 Nelaton's guide, 274 
 Nephrotomy, 312 
 Nerve, anterior thoracic, 243 
 
 axiom of distribution of, 135 
 exoitory, of deglutition, 167 
 facial, its relations to physiologi- 
 cal functions of the cheek, 129 
 fifth cranial, 128 
 fifth cranial, division of branches 
 
 of, 126 
 fifth cranial, injuries of, 124 
 fifth cranial, its relation to fur- 
 ring of the tongue, 129 
 fourth ciauial, 128 
 genito-crural, 306 
 glosso-pharyngeal, 167 
 glosso-pharyngeal, its relation to 
 
 furring of the tongue, 129 
 glosso-pharyngeal, its relation 
 to movements of the palate, 
 132 
 hypo-glossal, 163, 176 
 ilio-hypogastric, its medical as- 
 pects, 305 
 ilio-inguinal, its medical aspects, 
 
 305 
 long thoracic, paralysis of, 
 
 symptoms of, 245 
 lumbar, 306 
 obturator, 263 
 ophthalmic, 128 
 of sexual sensation, 306, 307 
 of Wrisberg, 247 
 phrenic, 174, 185 
 phrenic, wounds of, symptoms 
 
 of, 171 
 pneumogastric, 162, 168, 174, 
 
 187 
 pneumogastric, its coiirse and 
 
 clinical aspect, 177 
 posterior thoracic, 185 
 posterior thoracic, paralysis of, 
 of, symptoms of, 245 
 
 Nei-ve, pudic, 262, 263, 268 
 
 pudic, its physiological and 
 
 medical aspects, 306, 307 
 sciatic, 262 
 
 sciatic, its medical aspect, 276 
 spinal accessory, 170, 185 
 splanchnic, 187 
 
 subscapular, paralysis of, symp- 
 toms of, 244 
 superior gluteal, 262 
 superior maxillary, woun.s of, 
 
 125 
 supra-clavicular, neuralgia of, 
 
 245 
 supra-orbital, injuries of, 123, 
 
 124 
 sympathetic, 174 
 third cranial, 128 
 Nerves, cervical plexus of, 174 
 
 dorsal, paralysis of, causes and 
 
 symptoms of, 258, 254 
 lower intercostal, 306 
 of abdomen, 305, 306, 307, 808 
 of muscles of abdomen, their 
 
 medical aspects, 306 
 of peritonaeum, their physio- 
 logical relations, 306 
 spinal, their relations to verte- 
 brae, 143 
 Neuralgia, intercostal, diagnostic points 
 of tenderness of, 252 
 intercostal, pain of, and its 
 causes, 250, 251, 252 
 Nipple as a surgical guide,' 194 
 Nose, a surgical region of the face, 117 
 cavity of, tumors of, 123 
 clinical manifestations, 40, 41, 42 
 deformities and tumors of, 41, 52 
 diseases of, their relation to lach- 
 rymal apparatus, 128 
 external aperture of, 18 
 foreign bodies in, 120, 121, 122 
 fossae of, in infant and in the 
 
 aged, 117 
 fourth meatus of, 19 
 fracture of, its complications, 41 
 hemorrhage from, 90 
 leeches in, 131 
 leeching of, to relieve congestion 
 
 of brain, 6 
 inferior meatus of, its clinical re. 
 lations, 118, 119 
 
332 
 
 INDEX. 
 
 Nose, inferior meatus of, its relation to 
 foreign bodies, 18 
 its relation to escape of tears, 122 
 its relation to voice, 122 
 polypi of, 122, 123 
 polypus of, 23 
 pug, 19 
 redness of, 41 
 roof of, and its surgical interest, 
 
 19 
 sunken bridge of, 41 
 tuberosities of, in male and fe- 
 male, 41 
 Nostril, excessive dilatation of, its clin- 
 ical significance, 40 
 itching of, its clinical signifi- 
 cance, 40 
 Nostrils, absence of, 53 
 
 (Esophagus, 187 
 
 cancer of, effects of on 
 
 veins of neck, 157 
 in deglutition, 167, 168 
 peristaltic movements of, 
 168 
 Omentum, diseases of, 296 
 Ophthalmia, strumous, 55, 56 
 Orbit, axes of, 32 
 
 as a surgical region of the head, 
 
 123 
 diseases of, their relation to 
 
 paralyses, 128 
 its relation to tumors of the an- 
 trum, 126 
 its surgical relations, 21, 32 
 penetrating wounds of, 124, 135 
 vascular tumors of, 126 
 Orbits, union of, 52 
 Orbital arch, its relation to temporal 
 
 fracture, 16 
 Ovaries, direction of growth of, when 
 diseased, 805 
 in disease, 305 
 in health, 304, 805 
 
 Pain, a guide to diagnosis, 249 
 
 bilateral, its clinical significance, 
 
 151, 153 
 between shoulders, clinical as- 
 pects of, 248 
 between the shoulders, high up, 
 its clinical significance, 234 
 
 Pain, between the shoulders, low down, 
 its clinical significance, 334 
 from diseases of digestive viscera, 
 
 334 
 in aneurism of cceliac axis, 349 
 in cancer of mammary region, 
 
 348 
 in diseases of abdominal digestive 
 
 viscera, 248 
 in diseases of liver, 393 
 in dyspepsia, 391 
 in fracture of ribs, 315 
 in heart, after eating, 391 
 in liver disease, 350 
 in lumbar region, its clinical sig- 
 nificance, 234 
 in mediastinal disease, 234, 248 
 in mastodynia, 252 
 in the neck, its relation to thora- 
 cic and abdominal disease, 226 
 in neuralgia of ilio-hypogastrio 
 
 and ilio-inguinal nerves, 305 
 in penis, its causes, 307, 308 
 in pit of stomach, its clinical sig- 
 nificance, 151,-248 
 its relations to vertebral disease, 
 
 151, 
 in renal and biliary colic, 305 
 in rheumatic neuralgia, in mus- 
 cles of back, 305, 306 
 in scalp, its relations to spinal dis- 
 ease, 151 
 in shoulder, its relation to abdom- 
 inal and thoracic disease, 226 
 in spinal affections of the mid- 
 dorsal region, 249 
 in upper part of abdomen, its 
 
 clinical significance, 249 
 of angina pectoris, 253 
 of diaphragmatic hernia, 314 
 of disease in posterior mediasti- 
 num, 334, 235 
 of intercostal neuralgia, and its 
 
 causes, 250, 351, 252 
 of intestinal obstruction, 813, 814 
 of perityphlitis, 814 
 of pleurisy, 333, 334 
 of pleurodynia, 252 
 produced by rectal disease, 307 
 unilateral, its clinical significance, 
 151, 152 
 Palate, hard, 131 
 
INDEX. 
 
 333 
 
 Palate, hard, bones of, 23 
 
 hard, fracture of, 23 
 
 hard, imperfect development of , 
 
 effects of, 135 
 hard, its effects upon voice, 22 
 hypertrophy of , 131 
 in deglutition, 167 
 its displacement from nasal 
 polypi and fungoid growths, 
 131, 182 
 movements of, 132 
 muscles of, 131 
 paralysis of, 132 
 perforation of, 132 
 soft, 131 
 
 soft, its follicles, 131 
 soft, its relation to voice, 131 
 tumors of, 131 
 ulceration of, 131 
 Pancreas, 288 
 
 a source of error in diagno- 
 sis, 297 
 palpation of, 297 
 its normal situation, 297 
 Paracentesis thoracis, 189, 216 
 Paralysis, crossed, its cUnical signifi- 
 cance, 70 
 from injuries to skull, its 
 relations to tx-ephining, 9, 
 10 
 glosso-labial, 165 
 of muscles of chest, 243, 244, 
 245,246 
 Paraplegia, 253 
 
 its relations to spinal dis- 
 ease, 152 
 Parenchymatous hemorrhage, 102 
 Paresis, countenance of, 66 
 Pharynx, foreign bodies in, 174 
 Pelvis, a lever for movements of the 
 trunk, 256 
 a support to the abdominal vis- 
 cera, 256 
 angle of, 255 
 anterior wall of, its variations 
 
 in the sexes, 264 
 arch of, 255, 257 
 axes of, 257, 259 
 bones of, 255 
 cavity of, 261 
 
 congestion of organs of, from 
 pressure on gluteal region, 277 
 
 Pelvis, diameters of, 257, 259, 260 
 
 diameters of, abnormalities of, 
 
 259 
 false, 264 
 
 foramina of, 257, 262 
 functions of, 255 
 inclination of, to spinal column, 
 
 259 
 inlet of, 261 
 joints of, and their functions, 
 
 258 
 lateral arches of, 258 
 lateral wall of, 264 
 ligaments of, 257 
 line of gravity of, 258 
 of female, 261, 262 
 of male, 261 
 
 outlet of, in the sexes, 262 
 posterior wall of, its variations 
 
 in the sexes, 264 
 pubic arch of, in the sexes, 262 
 region of, clinical points per- 
 taining to, 271, 272, 273 
 ring of, 257 
 
 sacro-vertebral angle of, 261 
 straits of, abnormalities of, 259 
 strength of, 255, 257 
 superior and inferior straits of, 
 
 259 
 true, 264 
 
 variations of, in sexes, 257, 261, 
 262 
 Percussion sounds of chest and abdo- 
 men, diagrams of, 214 
 Pericardial dulness, 201 
 Pericarditis, 201, 283 
 
 its effects on chest-wall, 
 
 201 
 its effects on normal limits 
 of lung, 207 
 Pericardium, aspiration of, 217 
 
 fluid in, from chronic in- 
 flammation, 202 
 its effects on veins of 
 
 neck, 157 
 its suction action upon 
 blood in the inferior 
 vena cava, 225 
 tapping of, 220 
 Peritoneum, its relations to linea alba, 
 
 286 
 Peritonitis, 283, 300 
 
334: 
 
 INDEX. 
 
 PerityphUtis, 298, 399 
 
 its causes and symptoms, 
 314 
 Pharynx, irritability of, its relations to 
 removal of laryngeal 
 growths, 168 
 Phthisis, its effects on normal limits of 
 lung, 307 
 neck in, 156 
 Placental bruit, 303 
 Pleura, effusions of, effects of on veins 
 of neck, 157 
 extension of effusion in, evi- 
 dences of, 306 
 inflammation of, pain of, 233, 
 
 234 
 nerves of, physiological distri- 
 bution of, 233 
 nervous supply of, 347 
 vrounds of, 318 
 Pleurisy, 283 
 
 cause of local stitch of, 235 
 its effects on normal limits of 
 
 lung, 207 
 pain of, 233, 234 
 regions of pain in, 247 
 respiration of, 235 
 strapping in, 235 
 Pleurodynia, pain of, 252 
 Plexus, brachial, seat for counter-iiTi- 
 tation of, 172 
 brachial, wounds of, 171 
 cervical, 174 
 cervical, wounds of, 173 
 choroid, 98 
 Pneumonia, 283 
 
 countenance of, 61 
 its effects on normal limits 
 of lung, 207 
 Pomum Adami, 175 
 Pott's disease of the spine, 153 
 Poupart's ligament, 388, 389 
 
 ligament, a surgical guide, 
 275 
 Process, basilar, of occipital bone, 13 
 
 internal angular, of frontal 
 bone, its surgical relations, 
 16 
 mastoid, its cells, functions, 
 
 and surgical relations, 17 
 mastoid, its relation to hemor- 
 rhage, 116 
 
 Process, mastoid, its relation to hernia 
 of the brain, 116 
 mastoid, its relations to vessels 
 
 and its diseases, 17 
 mastoid, trephining of, 116 
 mastoid, trephining of, for 
 
 deafness, 114, 115 
 odontoid, of axis, 145 
 posterior glenoid, of temporal 
 
 bone, 17 
 pterygoid, of sphenoid bone, 
 
 18 
 styloid, of temporal bone, 17 
 Psoas abscess, 153, 312 
 Ptosis, 59 
 Pubes, 365 
 
 arch of, in female, 369 
 rami of, 369 
 
 spine of, a surgical guide, 274 
 spine of, surgical relations, 270 
 symphysis of, construction of, 
 269, 370 
 Pulley of superior oblique muscle of 
 
 the eye, 126 
 Pulse of air in veins, 160 
 Puncta lachrymalia, contraction of, 127 
 Pupil in motor ocular paralysis, 59 
 
 in tabes dorsalis (locomotor 
 ataxia), 59 
 Pupils, abnormalities of, 47 
 absence of, 53 
 changes in, 44, 45 
 contracted, causes of, 47 
 deformities of, 52 
 dilated, causes of, 47 
 in spinal sclerosis (tabes dor- 
 salis), 47 
 Pyelitis, 301 
 
 Ranula, its cause, 131 
 Eegnoli, operation of, 180 
 Renal disease, countenance of, 63 
 Respiration, its effects on abdominal 
 
 viscera, 390, 292 
 Rib, angle of, 188 
 
 eighth, guide to, 194 
 
 eleventh, 195 
 
 first, relations of, 189, 190 
 
 first, surgical and medical aspects, 
 189, 190 
 
 ninth, guide to, 194 
 
 second, guide to, 190 
 
INDEX. 
 
 335 
 
 Rib, seventh, guide to, 194 
 sixth, guide to, 194, 195 
 tubercle of, 188 
 twelfth, 1«5 
 
 vertebral extremity of, 188 
 Eibs, 187 
 
 action of, on different portions of 
 
 lung, 227, 228 
 causes which tend to raise the, 
 
 194 
 curves of, 227, 228 
 diaphragmatic, 187 
 false, 187 
 floating, 187 
 fractures of, 188, 189 
 fractures of, causes of, symptoms 
 
 of, 214, 215 
 fractures of, complications of, 
 
 189 
 movements of, 187 
 obliquity of, its clinical import- 
 ance, 194 
 pain in fracture of, 315 
 resection of, 216 
 
 restricted movements of, in pleu- 
 risy, 247 
 rules for counting, during life, 
 
 194 
 true, 187 
 Eidge, supra-mastoid, of temporal bone, 
 
 its surgical aspect, 17 
 Rosenthal's test for caries of vertebrae, 
 
 153, 154 
 Eugse, oculo-frontal, of face, their 
 diagnostic value, 34 
 transverse of face, their diag- 
 nostic value, 34 
 
 Sac, lachrymal, 127 
 Sacro-Uiac symphysis, 371 
 
 synchondrosis, its construc- 
 tion and function, 266 
 Sacrum, canal of, its relation to spinal 
 disease, 371 
 curve of, 370 
 
 foramina of, their surgical re- 
 lation, 271 
 form of, 270 
 promontory of, functions of, 
 
 270 
 third spine of, a surgical guide, 
 275 
 
 Salivary concretions, 131 
 Santorini, veins of, 110 
 Scapula, a guide to the ribs, 194 
 
 movements of, 239 
 ScapulsB, movements of, during respi- 
 ration, their medical aspects, 238, 229 
 Scoliosis, paralytic, 246, 253 
 Scurvy, countenance of, 64 
 Sensation, paralysis of, in spinal dis- 
 ease, 153 
 Shoulder, attitude of, in paralysis, 344, 
 245, 246 
 pain in, from liver disease, 
 
 250 
 pain in, its relation to abdom- 
 inal and thoracic disease, 
 326 
 progressive muscular atrophy 
 of, 245 
 Shoulders, in emphysema, 156 
 
 pain between, clinical as- 
 pects of, 248 
 Singing, its effects on veins of neck, 157 
 Sinus, circular, 107 
 
 frontal, effects of injuries to, 123 
 frontal, effect of wounds of, 14, 
 
 15 
 frontal, its relation to cerebral 
 
 sinuses, 6, 7 
 frontal, its relation to nasal fossa, 
 
 118 
 frontal, its relations to voice, 15 
 frontal, its surgical relations, 14, 
 lateral, 106, 107 [15 
 
 longitudinal, inferior, 106 
 longitudinal, superior, 106 
 maxUlary, its surgical import- 
 ance, 23 
 occipital, 106, 107 
 petrosal, inferior, 106, 107 
 petrosal, superior, 106, 107 
 sphenoidal, its relation to nasal 
 
 fossa, 118 
 sphenoidal, surgical aspects, 14 
 straight, 106 
 transverse, 107 
 Sinuses, bilateral of dura mater, 107 
 cerebral, 106 
 
 cerebral, their relation to fron- 
 tal sinus, 6, 7 
 lateral of skuU, external guides 
 to, 7 
 
336 
 
 INDEX. 
 
 Sinuses, longitudinal of brain, their re- 
 lations to injury of the cra- 
 nium, 6 
 single, of dura mater, 106, 107 
 Skin, of Addison's disease, 38 
 of Bright's disease, 37, 39 
 of chlorosis, 87 
 of dyspeptics, 38 
 of phthisis, 39 
 " parchment," 39 
 Skull, air-chambers of, 14, 15 
 base of, 30 
 bones of, 1 to 31 
 Campa's angle of, 38, 39 
 congenital deformities of, 3 
 diploe of, its surgical aspect, 5 
 fontanelles of, 13, 16 
 fracture of, and its probable 
 
 course, 36 
 fracture of, its relation to tongue 
 
 symptoms, 130 
 fractures of base of, its symp- 
 toms, 30, 31 
 its buttresses, 25 
 mechanical deformities of, 28 
 occipital protuberance of, 13 
 of childhood, its peculiarities, 37 
 of female, its peculiarities, 37 
 of the different races, their pe- 
 culiarities, 37 
 of the infant, its peculiarities, 36 
 paralysis after injuries to, 9, 10 
 sutures of, their relations to 
 
 trephining of, 116 
 tablets of, 5 
 
 tablets of, their relative densi- 
 ties, 5 
 variations in the form of, 36 
 wounds of frontal regions of, 
 dangers of, 15 
 Skull-cap, absorption of, 4 
 
 effects of injury to, 6 
 hypertrophy of , at seats of 
 
 injury, 6 
 lack of symmetry of, 3 
 thickness of, variations of, 
 3,4 
 Spermatic cord, 289 
 Spina bifida, 148, 222, 375, 311 
 
 bifida, its relations to ventricles 
 of brain, 148 
 Spinal column (see vertebra) 
 
 Spinal curvatures due to paralysis, 
 
 346 
 Spleen, diseases of, differential diagno- 
 sis of, 296 
 displacements of, 295 
 enlargements of, 230 
 in malarial affections, 295 
 limits of, dulness of, 395, 396 
 normal relations of, to chest 
 
 wall, 339, 330 
 normal position of, 395 
 palpation of, 395, 296 
 percussion of, 395 
 Steno's duct, 139 
 Sternum, deformities of, 319, 330 
 dislocation of, 193 
 fracture of, 192 
 its medical aspects, 192, 230 
 its surgical and medical as- 
 pects, 190, 191 
 lines of, 190 
 
 malformations of, 191, 193 
 xyphoid appendix of, as a 
 medical guide, 195 
 Stomach, 388 
 
 cancer of, 283, 288, 396 
 
 dilatation of, 285 
 
 foreign bodies in, 313 
 
 its medical aspects, 291 
 
 its modifications in position, 
 
 290, 291 
 its position in abdomen, 290 
 percussion of, practical hints- 
 respecting, 291 
 pit of, 284 
 pit of, pain in, its clinical 
 
 significance, 248 
 relation of, to abdomen, 384 
 Stupor after eating, 291 
 Suture, coronal, 10 
 
 coronal, its relation to fissure of 
 
 Rolando, 7, 8 
 frontal, 11 
 lambdoidal, 10 
 
 lambdoidal, its relation to ex- 
 ternal parieto-occipital fissure 
 of cerebrum, 7, 8 
 masto-parietal, 11 
 of cranium, surgical interests. 
 
 pertaining to, 13 
 sagittal, 13 
 squamo-parietal, 11 
 
INDEX. 
 
 337 
 
 Suture, Bquamo-sphenoidal, 11 
 
 squamous, 11 
 Swallowing, difficulty in, 170 
 Symphysis pubis, its relative position 
 to tip of coccyx, 258 
 
 Tears, when escaping from the cheek, 
 
 their clinical signiiicance, 60 
 Teeth, absorption of sockets of, 34 
 
 as an indicator for the character 
 
 of food required, 25 
 cusps of, 25 
 decay of, its relation to tongue 
 
 symptoms, 130 
 in syphilis, 133, 134 
 their adaptation to the bony sock- 
 ets, 24 
 their plan of arrangement to 
 assist in mastication, 24, 25 
 Testicles, arrest of descent of, 310 
 Testis, arrest of, in inguinal canal, 289 
 Tetanus, 183 
 
 attitude of, 139 
 countenance of, 68 
 Thorax, bones of, 186 
 floor of, 187 
 shape of, a guide to health, 204, 
 
 205 
 surgical points of interest of, 
 
 314 
 upper aperture of, 187 
 Thrombosis, portal, 283 
 Tongue, amputation of, 165 
 
 frsenum. of, division of, 129 
 furring of, in one lateral half, 
 its clinical significance, 129 
 hemorrhage from, 129 
 hypertrophy of, 139 
 in deglutition, 164 
 paralysis of, its effects on de- 
 glutition, 164, 165 
 tumors of, 139, 130, 131 
 Tonsillitis, cause of death in, 89 
 Tonsils, 132 
 
 calculi of, 133 
 
 diseases of, 133 
 
 extirpation of, 133 
 
 relation of, to carotid arteries, 
 
 132, 133 
 suppuration of, 133 
 Tooth, first molar, its surgical relation, 
 24 
 
 Tooth, last molar, its surgical import- 
 ance, 23 
 Trachea, 179, 205 
 Tracheotomy, 179, 180 
 
 its indications, 181 
 obstacles to, 179, 180 
 Trachoma, 59 
 
 Trephining, general rules for, 4, 9, 10 
 Holden's rule for, 4 
 of temporal region, 18 
 Triangle, vertebral, 96 
 Trunk, bony framework of, 136 
 
 attitude of, in dorsal paralysis, 
 
 253, 254 
 general construction of, 136, 
 
 137 
 posterior region of, and its 
 contained organs, 212 
 Tube, Eustachian, catheterism of, 119, 
 130 
 Eustachian, foreign bodies in, 
 Tumors, abdominal, 283 [120 
 
 mediastinal, 283- 
 mediastinal, effects of, on 
 
 veins of neck, 157 
 of the kidney, 296 
 of the mediastina, their effects 
 on normal limits of the lung, 
 207 
 of the neck, diagnosis of, 183, 
 
 183, 184 
 of the ovary, 896, 305 
 Twin pregnancies, diagnosis of, 303 
 Tympanites, 383, 399 
 Tympanum, arteries of, 101 
 Typhlitis, 299 
 
 Typhoid fever, abdominal changes in, 
 299, 300 
 
 Umbilical region of abdomen, 383 
 Umbilicus, its clinical aspects, 284 
 
 parts below, 284 
 Urinary fistulse, 312 
 Uterus, auscultation of, 303 
 
 displacements of, 304 
 
 in pregnancy, 802 
 
 in pregnancy, diagnosis from 
 abdominal tunaors, 304 
 
 in the normal state, 302 
 
 Valve, aortic, of the heart, its normal 
 position, 300 
 
338 
 
 INDEX. 
 
 Valve, mitral, its normal position, 200 
 ileo-ca3cal, 297 
 pulmonary, its normal position, 
 
 200 
 tricuspid, its normal position, 
 
 200 
 tricuspid, regurgitation at, 284 
 Vas deferens, 289 
 Vein, angular, 109 
 
 auriculo-posterior, 109 
 
 external jugular, guide to, 173 
 
 facial, 108 
 
 frontal, 109 
 
 internal jugular, 177 
 
 internal jugular, wounds of, 174 
 
 internal maxillary, 109 
 
 occipital, 109 
 
 ophthalmic, 107 
 
 pudic, 268 
 
 subclavian, 174 
 
 temporal, 109 
 
 temporal, of maxillary, 109 
 Veins, air in, 109 
 
 air in, causes of death in, 159 
 160 
 
 air in, method of prevention of, 
 161 
 
 air in, symptoms of, 160, 161 
 
 air in, treatment of, 161 
 
 an embarrassment to ligation of 
 arteries, 110 
 
 canalization of, 160 
 
 emissary, their relations to tre- 
 phining of mastoid region, 116 
 
 emissary, of Santorini, their sur- 
 gical aspects, 110 
 
 of exterior of skull, 108 
 
 of the head, 105 
 
 of the head, surgical aspect of, 
 109 
 
 of the head, thrombosis of, 109 
 
 of the head, valves of, 110 
 
 of the head and neck, distention 
 of, after eating, 291 
 
 of the neck, circulation in, 157 
 
 of the neck, conditions which 
 affect amount of blood in, 157, 
 158 
 
 of the neck, entrance of air in, 
 159, 160, 161, 162 
 
 of the neck, in surgical opera- 
 tions, 158, 159 
 
 Veins of the neck, prominence of, 
 causes of, 157 
 of the neck, pulsation of, its 
 
 causes, 158 
 of the neck, their points of inter- 
 est, 157, 158, 159 
 portal, circulation of, effects of 
 
 inspiration upon, 291 
 spermatic, their surgical aspects, 
 
 389 
 superficial, of abdomen, their 
 clinical aspects, 283 
 Venm Gallinse, 106 
 Venous hemorrhage, 102 
 Vei-tebree, 137 
 
 abnormal curvatures of, 153 
 as surgical guides, 141, 143 
 caries of, 147, 150 
 caries of, causes of, 150 
 caries of, Rosenthal's test 
 
 for, 153, 154 
 cervical abnormalities of, 
 
 146 
 cervical, dislocation of trans- 
 verse processes of, 154 
 curvature of, in dorsal re- 
 gion, 223 
 curvature of, in rickets, 311 
 cui-ves of, and their func- 
 tions, 137, 138, 139 
 curves of, modifications of, 
 
 in respiration, 237 
 diseases of, relations of pain 
 
 to, 151 
 deformity of, in fracture and 
 
 dislocation, 153 
 diseases of, their most fre- 
 quent points of origin, 
 151 
 dislocation of, 144, 153, 154, 
 
 181 
 dislocation of last lumbar, 
 
 upon sacrum, 153 
 fractures of, 148, 149, 150, 
 
 181 
 foramina between, 143 
 lateral curvature of, 140 
 lumbar, caries of, 311 
 malformations of, 147, 148 
 movements of, 139 
 rotation of, 140 
 spines of, 140, 141 
 
INDEX. 
 
 339 
 
 Vertebrae, their relation to points of 
 origin of spinal nerves, 143 
 transverse processes of, 145 
 Voice, huskiness of, 170 
 loss of, 170 
 nasal tone of, 170 
 Vomiting, its relations to injuries of 
 the skull, 10 
 
 Whooping cough, effects of, 158 
 
 Wmis, circle of, 99, 100 
 Winslow's guide to trochanter of fe- 
 mur, 274 
 Worm^ian bones, 11 
 Wrisberg, nerve of, 247 
 
 Zone, epigastric, of abdomen, 280 
 
 hypogastric, of abdomen, 380, 
 
 381 
 umbilical, of abdomen, 280