Q^^bl>\ \^i^ (£nlnmbxa llniupraity I in tl|r (Etty of '^tm Inrk ^£itUvnut library APPLIED SURGICAL ANATOMY REGIONALLY PRESENTED FOR THE USE OF STUDENTS AND PRACTITIONERS OF MEDICINE GEORGE WOOLSEY, A.B., M. D. FKOFESSOR OF ANATOMY AND CLINICAL SURGERY IN THE CORNELL UNIVERSITY MEDICAL COLLEGE. SURGEON TO BELLEVUE HOSPITAL, ASSOCIATE SURGEON TO THE PRESBYTERIAN HOSPITAL, FELLOW OF THE AMERICAN SURGICAL ASSOCIATION AND OF THE NEW YORK ACADEMY OF MEDICINE With 125 Illustrations, mostly colored LEA BROTHERS & CO. NEW YORK AND PHILADELPHIA, 1902 GIFT Entered according to the Act of Congress in the year 1902, by LEA BROTHERS & CO., In the OflSce of the Librarian of Congress. All rights reserved. PREFACE. Tin: study of Anatomy is relieved of much of its difficulty when it is approached on the practical side. Isolated details do not appeal to the faculty of interest, but when they are set forth in their natural relationship, and tlieir practical application is pointed out, the mind grasps and recollects them with facility. As Anatomy is the most basic of all the medical sciences, a working knowledge of its data is indispensable for the study and practice of scientific medicine and sur- gery. The author has endeavored to embody these principles in the present work, and to do it in such a manner as to answer the needs of both students and practitioners. The plan of the work has been developed from twelve years' experience in teaching Anatomy. The author believes the form of presentation he has followed to be the best for didactic lectures, and that descriptive Anatomy is most advantageously learned from text- books and in the dissecting room. The regional and topographical method of treating Applied Anatomy is likewise the most convenient for clinical purposes. It is scarcely necessary to state that in order not to exceed the proper limits of a book designed for clinical and didactic purposes a most careful selection had to be made from the vast aggregate of knowledge constituting the modern science of anatomy. If in parts the text may appear quite as much like an anatomical surgery as a surgical anatomy, it is because of the author's belief that this is the best way to complete the study of anatomy and to begin the study of surgery. The author desires to acknowledge his indebtedness to the excellent words of Joessel, Tillaux, Merkel and others, both for anatomical facts, the methods of their presentation, and for numerous illustra- tions. An original work on such a subject can no longer be written, nor would it have as much value as a volume duly recognizing the vast fund of information accumulated bv tireless investigators. A single author can only hope to contribute a fair proportion of original knowledge and to present a chosen aspect of the science in a clear and practical manner. 117 East 36th St., New York, June, 1902. iii Digitized by tine Internet Arciiive in 2010 witii funding from Columbia University Libraries http://www.archive.org/details/appliedsurgicala1902wool CONTENTS. CHAPTER I. THE HEAD AND NECK. Page. The Head 17 The Scalp 18 The Temporal Region .... 24 The Bony Cranium .... 25 Construction and Lesions of the Cranial Bones 28 Fractures of the Skull . . 30 The Contents of the Cranium. . 83 The Cerebral Membranes 33 Localization of Cerebral Functions 40 Cranio-cerebral Topography . 43 The Ear . . . " . 47 The Auricle and the External Auditory Meatus 47 The Middle Ear .... 52 The Mastoid Antrum . 54 The Eustachian Tube . 56 The Face . 59 Region of the Orbit and Eye. — Eyelids 59 The Lachrymal Apparatus 63 The Orbit and its Contents 65 The Nose and Xasal Fossfe . 72 The Accessory Sinuses of the Nose 80 The Face 82 The Parotid Region 88 The Jaws 92 The Temporo-mandibular Joint 96 The Lips 98 The Tongue and Floor of tlie ^louth 102 The Pahite . . . . 107 Tlie Tonsils ..... 111 The Pharynx 113 The Neck 117 The Sterno-mastoid Muscle . 118 The Occipital and Subclavian Triangles 120 The Submaxillary Triangle . 132 The Carotid Triangles . 126 The Hyoid Bone .... 130 The Larynx ..... 132 The Trachea .... 135 The Thyroid Gland 138 The Deep Cervical Fascia 141 I^ymphatics of the Head and Neck 144 Embryology of the Neck 145 VI CONTENTS. CHAPTER II. THE UPPER EXTREMITY. The Region of the Shoulder . Anterior Region of the Shoulder The Posterior or Scapular Region The External or Deltoid Region The Shoulder Joint The Axilla . The Region of the Arm . The Region of the Elbow The Elbow Joint . The Forearm The Region of the Wrist The Hand and Fingers Page. 147 149 155 157 159 167 170 174 177 183 187 193 CHAPTER III. THE THORAX. The Thoracic Walls The Breast The Diaphragm The Contents of the Thorax The Pleura . The Lungs The Trachea in the Thorax The Pericardium . The Heart . The Aorta . The Thoracic Duct The CEsophagus . 201 208 212 214 214 218 222 223 225 228 232 233 CHAPTER IV the abdomen. The Anterior Abdominal Wall Vessels and Nerves of . Operations and Incisions The Regions of the Abdomen The Umbilicus and Umbilical Hernia . The Inguinal Region and Inguinal Hernia The Inguino-Femoral Region and Femoral The Posterior Abdominal Wall The Iliac Region The Lumbar Region The Abdominal Cavity The Peritoneum . The Abdominal Viscera The Stomach The Small Intestine The Large Intestine Ileociecal Region The Colon The Liver The Gall-Bladder and Ducts Hen 236 239 249 253 255 257 260 269 274 274 279 284 284 290 290 297 306 306 314 319 325 CONTENTS. VI 1 The Spleen . The Pancreas The Kidneys The Ureters The Adrenals Vessels of the Abdomen Nerve Supply of the Abdominal Viscera Page. 329 332 333 339 341 342 343 CHAPTER V. the pelvis and perineum. The Pelvis The Lining of the Pelvis The Viscera of the Pelvis The Eectum The Bladder The Prostate The Seminal Vesicles . The Vas Deferens The Female Pelvic Genital Organs The rterus . The Ovary . The Fallopian Tubes . The Broad Ligaments . The Eound Ligaments . The Vagina . The Female Urethra External Genitals The Female External Genitals The Male Urethra The Penis The Scrotum The Testis . The Perineum . The Ischio-rectal Region CHAPTER VI. 345 354 358 358 365 373 376 378 379 379 385 388 389 391 392 395 397 397 398 405 409 412 417 424 the lower extremity The Hip The Gluteal Region or Buttocks The Region of Scarpa's Triangle The Hip Joint The Thigh The Region of the Knee The Knee Joint The Leg .... The Ankle The Ankle Joint . The Foot .... 426 426 430 434 445 449 453 460 465 468 472 The Spine The Spinal Cord . CHAPTER VTT. THE SPINK. 484 491 APPLIED SURGICAL ANATOMY. CHAPTER I. THE HEAD AND NECK. THE HEAD. General Considerations. — The head is auatomically the most essen- tial and most complex part of the body. It is of great practical interest, for even its smaller parts are of importance to the life and well-being of man. In individuals of medium height and weight the head measures g of the body height in men and ^^ in women, and ireifjhs Jy of the body weight in men (4 k.g.) and -^^ in women (3.G k.g.). The larger the individual so much smaller is the head as com- pared with the total height and weight. When the face looks directly forward the external auditory meatus and infraorbital margin are in a horizontal plane. Such a position, the one most naturally assumed, is maintained by the posterior neck muscles and not by gravity, for the line of the latter lies in front of the transverse occipito-atlantoid axis of motion. As compared with the human skull that of the hir/her apf'.s (chim- panzee, orang, etc.) shows marked differences, /. e., the projection of the muzzle, the greater size and forward position of the face, the greater size of the intermaxillary bones, the backward and oblique ])o- sition of the foramen magnum, etc. Idiots'' skulls approximate those of the lower animals in many respects, i. e., large face, small cranium, etc. The head shows a tendency to asj/mmetri/. One error often com- pensates for another and one is often astonished in the examination of the separate parts to find considerable deformity whose existence escapes a general observation. Indivitlual ditferences in the head are marked, as they are elsewhere in the body, but we are accustomed to ob- serve them more closely as they are the essential marks of individuality. But besides the individual differences there are those of sex, age and race. Thus the female skull looks immature, resembling that of a child, and is smaller, lighter, broader and less high, the face and lower jaw are smaller and the vertex is flattened. The circumference of the skull at birth is greater than that of any other part of the body. The skull at birth is characterized by the large size of the cranium and the small size of the face and the base; the absence of 2 17 18 THE HEAD AND NECK. the mastoid process, the diploe and all ridges ; the presence of the anterior fontanelle and the prominence of the frontal and parietal eminences. It resembles more closely the skull of the lower animals than does the adult skull. During the fird seven years the skull grows very rapidly, at first more or less equally. During the first dentition the fontanelles close, the face broadens and enlarges, the jaws lengthen and the zygomatic arches project. Later the base of the skull lengthens and the face becomes deeper and somewhat longer. By the seventh year some parts have attained their growth, /. e., the foramen magnum, the petrous portion of the temporal bone, the width of the body of the sphenoid and of the cribriform plate. Near the approach of puberty a second period of active growth begins, the face is elongated from the increased height of the nasal fossae, alveolar arches and second teeth and the expansion of the air sinuses. In lutev years the latter continue to expand, up to old age, the crests and ridges develop and the frontal region elongates. In old age the skull atrophies, becoming thinner, lighter and perhaps smaller by absorption on the surface and redeposit on the interior. The face becomes smaller by the loss of the teeth and the absorption of the alveolar processes. The racial differences although marked in typical examples shade into each other. According to one classification we may distinguish : (Ij the prognathous or long-headed type, with projecting jaws and teeth, as in the negro, (2) the pyramidal or broad, flat-faced type, with narrow forehead, as in the Mongolian or Esquimaux and (3) the oval type of the European, with the length of (1), or even more, and the breadth of (2), but the teeth do not project as in (1) nor the zygomatic arches as in (2), and the forehead is full, laterally, and high. Again skulls are classified as I. Dolicocephallc, or "long-headed," in which the occipital lobes overlap the cerebellum and II. Brachycephalic, or " short-headed," in which the occipital lobes do not extend so far backward. Each division is subdivided into ortJiognat/wus in which the jaws and teeth do not project and prognathous in which they do. Other peculiar forms of skull are on the border line of pathological deformities, depending upon the premature closure of a certain suture whicli prevents the growth of the skull at right angles to that suture and forces it to grow in other directions, if at all. By the same process, extended to several sutures, raicrocephalus may result. The latter may be the result or cause of idiocy, in the latter case justifying operation (craniectomy). THE SCALP. The soft parts covering the vault of the skull are arranged as in no other part of the body. There are five layers : (1) The skin, (2) the subcutaneous fatty tissue, (3) the occipito-frontalis muscles and aponeurosis, (4) the subaponeurotic areolar tissue, and (5) the peri- cranium. The first three layers are so intimately blended Avith one TJIK SUBCUTAl^EOVS TISSUE. 19 another, especially over the aponeurotic portion of the occipito-frontalis, that they form virtually a single layer, the scalp (see Fig. 1). SUBCUTANEOUS TISSUE APONEUROSIS SUBAPONEUROTIC TISSUE PERICRANIUM -SAGITTAL SUTURE — PARIETAL BONE -^TWO LAYERS OF DURA — LONGITUDINAL SINUS FALX CEREBRI Frontal section of scalj) and skull through the sagittal suture and the superior longitudinal sinus. 1. The skin of the scalp is thicker than that in most regions of the body and is thicker behind than in front. The liair is so strongly attached to the scalp that it has supported the weight of the body in many instances since the days of Absalom, as for example where it is caught in revolving machinery belts and the body is drawn after it. The entire scalp has also been torn oif in such accidents. The hair should always be shaved around scalp wounds, otherwise it is impossible to make and keep them clean. Although the roots of the hairs may extend deeply into the subcutaneous fatty tissue the numerous seba- ceous glands associated with them are superficial in the skin. These may develop into sebaceous tumors or wens which are more common here than in any other part of the body. Owing to their superficial position, external to the aponeurosis, they are easily and safely removed. Care must be taken however in removing suppurating sebaceous cysts not to divide the aponeurotic layer on account of the danger of infec- tion of the loose tissue i)en('ath. 2. The subcutaneous tissue, 5-0 mm. in thickness, is composed of a great number of strong fibrous bands closely binding together the skin and aponeurosis and forming a multitude of small compartments enclosing lobules of fat. On account of this disposition of the fat it follows that fatty tumors are rare and that there is but little increase of it in obesity, though a perceptible decrease exists after long sickness. The falling out of the hair in such cases may be partly due to this fact. The arrangement of this subcutaneous tissue, like that in the palm, admirably adapts it to resist jiressure. It makes the densitv of the scalp such that in surface inflammations, as in erysipelas, the scalp 20 THE HEAD AXD NECK. swells but slightly, is but little reddened and is extremely painful. It attaches the skin so closely to the aponeurosis and muscle that the former moves with all the movements of the latter. Furthermore this layer contains the vessels which supply the three layers of the scalp. These vessels are closely connected with the fibrous partitions of this layer so that in wounds of the scalp the vessels which are divided are unable to retract or contract, hence hemorrhage is free and is not spontaneously arrested. Tumors situated external to the aponeu- rosis move with the scalp ; immovable growths are probably beneath the aponeurosis. 3. The aponeurosis occupies the space between the two muscular portions of the occipito-frontalis, in front and behind. It extends down laterally over the temporal fascia as a cellular layer, and over the zygomatic arch without attachment to it. 4. The subaponeurotic areolar layer is a layer of loose connective tissue whose looseness serves, like a serous membrane, to facilitate the movement of the scalp upon the pericranium, a condition which is more marked in the young than in the old. This looseness of attach- ment allows the gaping of scalp wounds and the ready separation of large flaps of scalp by injuries, operations, scalping by Indians or in autopsies. It is known as the dangerous area of the scalp, for its loose structure allows the wide and rapid spread of inflammation and pus, posteriorly as far as the superior curved line, anteriorly to the superciliary ridges, and laterally to or even below the level of the zygoma. Wounds or incisions which extend through the entire scalp and open into this layer are much more serious than more superficial ones on account of the more serious consequences of infection. This layer contains but few blood vessels which cross it to enter the peri- cranium, otherwise large eff*usions of blood would be far more common here than they are. 5. The pericranium is remarkable for its slight adherence to the bone except along the sutures, where it is attached to the suture mem- brane and is thus continuous with the dura, as it is also at the foramina. Hence inflammation of the pericranium may extend by continuity to the dura at the foramina and sutures where the two become continuous. It follows also that the ])ericranium may be widely stripped up from the underlying bone in extensive scalp wounds. Such an injury is of less importance than we would expect from analogy with similar injuries of the periosteum elsewhere. The skull bones seldom necrose under such circumstances, for they derive their main blood supply from the vessels of the diploe and dura. For a similar reason loss of bone in the vault of the adult skull due to injury, necrosis or opera- tion, is as a rule not repaired, for neither the pericranium nor the dura reproduce bone as does the periosteum. Vessels of the Scalp. — The vascularity of the scalp is greater than that of any other part of the surface. Flaps of scalp, however large and extensively stripped up, almost always live, for the scalp carries its own blood supply, which enters at the pedicle of the flap. Slough- Tllh: EMISSARY VEINS. 21 ing and gangrene from pressure are rare owing to the density of the scalp tissue in which the vessels run. Unlike other regions of the body, where vessels of any size are subfascial, the vessels of the scalp lie in the subcutaneous tissue alone. The arteries come from the occipital, posterior auricular and super- ficial temporal branches of the external carotid and from the supra- orbital and frontal branches of the ophthalmic. Each vessel converges upward toward the vertex of the skull and anastomoses freely with the adjoining ones and with its fellow of the opposite side. It follows that incisions should be planned as far as possible to radiate from the vertex, or, if horseshoe-shaped, to have the base below and the free end toward the vertex. To prevent hemorrliage during an operation rubber tubing may be tightly drawn around the base of the scalp, or to diminish it overlapping, interrupted, temporary sutures may be applied between the incision or flap and the base of the scalp, from whence the arteries pass upward. The frontal urtery emerging at the inner angle of the orbit on each side, enters at the base of and supplies the flap that is taken from the forehead to form a new nose in rhino- plasty. The temporal artery with the aiiriculo-temporal nerve behind it ascends between the condyle of the jaw and the external auditory meatus over the posterior root of the zygoma and divides into its anterior and posterior branches 1| to 2 inches above the latter. It presents in a high degree the tortuosities of the arteries of the head, especially its anterior branch, and, in the aged, it affords early evidence of arterial sclerosis. It is the most frequent situation for cirsoid aneurism and is more frequently wounded than almost any other artery of the body. The posterior auricular artery and nerve run in the angle between the ear and the mastoid process. The occipital artery ascends a finger's breadth behind the mastoid process and reaches the scalp, with the great occipital nerve a little internal to a point midway between the mastoid process and the occipital protuber- ance. These arteries all share the peculiarity of being subcutaneous instead of being subaponeurotic. The emissary veins connect the dural sinuses with the superficial veins at certain points through apertures in the skull and hence are of considerable practical importance. They afford a channel for the spread of inflammation from the surface, to the sinuses or meninges, thereby causing sinus thrombosis or meningitis, as in cases of ery- sipelas and su|)purati<>n of the scalp or necrosis of the cranial bones. Their presence adds greatly to the seriousness of injuries and diseases of the scalp. They also assist in equalizing the intracranial pressure and for this puri)ose are most developed in early life, during the period of i)rain growth. The most constant and important of the emissary veins connecting with the veins of the scalp are: (1) the vein passing through the mastoid foramen which connects the lateral sinus with the occipital (or posterior auricular) vein ; (2) the vein passing through the posterior condylar foramen which connects the sigmoid sinus with the deep 22 THE HEAD AXD XECK. veins at the back of the neck ; (3) the vein passing through the parietal foramen which connects the superior longitudinal sinus with the veins of the scalp. The inastoid emissary vein accounts for the practice of blood letting or blistering behind the ear in some cerebral affections and for the oedema behind the mastoid process in lateral sinus thrombosis. For the other emissary veins see any descriptive anatomy. The veins of the scalp are also connected by many minute veins with the veins of the diploe. The latter are not well developed until after the tenth year when the diploe develops and they are separate for each bone until the ossification of the sutures (Testut). The veins of the diploe communicate, the anterior two (frontal and anterior temporal) with the surface veins (su])raorl)ital and deep temporal), the posterior two (posterior temporal and occipital) with the lateral sinus. The anastomosis between the angular and su})raorbital veins at the inner angle of the orbit affords a free communication between the extra- and intracranial circulation, as the supraorbital vein through the oph- thalmic is a tributary of the cavernous sinus. Thus we see the number of channels, and there are other less conspicuous ones, through which inflammation can spread from the surface to the interior of the skull. The lymphatics of the scalp may be divided into three groups: (1) The occipital emptying into the suboccipital nodes ; (2) the posterior parietal emptying into the mastoid nodes, and (3) the anterior parietal and frontal which empty into the parotid nodes. Some vessels from the frontal region end in the submaxillary nodes. A knowledge of these regions and their nodes is of service in the diagnosis of scalp troubles in which they are affected. With regard to the nerves which sujiply the scalp it is only neces- sary to say that those which are branches of the fifth nerve are not infrecjuently the seat of neuralgia, especially the supraorbital nerve, less often the auriculo-temporal. The former emerges from the orbit at the supraorbital foramen or notch, at the junction of the inner and middle thirds of tlie supraorbital margin. Here it maybe readily found and divided or resected in some forms of obstinate frontal headache due to neuralgia of this nerve. The inner branch reaches back to the middle of the parietal bone, the outer branch as far as the lambdoid suture. Wounds of the scalp do not gape unless the aponeurosis or muscle is divided. Those wounds gape most which are transverse to the muscle fibers, next those transverse to the aj)oneurotic fibers, and those gape least which are parallel with them, /. e., antero-posterior. As the seal]) is firmly stretched over the hard bone beneath, contused wounds often appear as cleanly cut as incised wounds. Wounds resem- bling incised wounds may also be produced from within by the sharp edge of the superciliary ridge when struck by a blunt object. Bleeding from scalp wounds is very free and unless j)roperly treated very prolonged. There is little or no tendency to the spontaneous arrest of hemorrhage, for the arteries, owing to their adhesion to the tissues of the scalp, are unable to retract or contract when divided, HJEMATOMATA. 23 and it is by this process that hleedino; is ordinarily sj)ontaneously arrested. This adhesion and the density of the scalp account for the difficulty of tyintr a blcedintj; artery in the scalp, iience to arrest heni- orrhuf^e we often de])end upon pressure, a suture passed beneath the vessel or upon suturing the edges of the wf)un(l firmly togetiier. For- tunately, as we have seen above, there is very little (langer of slough- ing on account of pressure. In addition to the arrest of bleeding we have ((I think of the ])ossil)ilities of inflammation in scalp wounds. Inflammation or abscess in the scalp nuw occur in one of three situations, (1) in the subcutaneous tissue, (2) between the aponeurosis and the pericranium, and (3) beneath the pericranium. Abscesses of the first variety are small and spread only with the greatest difficulty in the dense tissue. In the second situation inflammation or abscess may be very serious on account of its easy spread in the loose tissue and the danger of the infection extending within the cranium. In- flammations of this kind may follow scalp wounds involving the apo- neurosis and the chief danger of these wounds lies in such inflamma- tions. The inflammation may undermine the entire scalp and is limited only by the attachments of the aponeurosis as given above. The scalp does not perish even in the most extensive cases, as it carries its own blood supply, but the wounds which lead to the abscess or are made to relieve it are often slow to heal, as the abscess walls fail to obtain perfect rest owing to the movements of the occipito-frontalis muscle. Abscess beneath the pericranium is limited to the surface of one bone as this membrane is adherent to the suture membrane. It is most often the result of necrosis of the cranial bones. Haematomata of the scalp may be classified in the same manner as abscess. They occur most frequently outside of the aponeurosis in the subcutaneous tissue which contains the greater part of the blood ves- sels. In this situation the extravasation of blood is usually small and sharply limited by the density of the tissues and is confined to the area where the tissues are lacerated by violence. Such extravasations of blood produce a tumor on the surface whose thin edges become hard from the coagulation of the thin layer of blood while the thicker center remains soft for a time. A firm sharp margin often separates these two parts which may lead to a mistake in diagnosis by mistaking it for the margin of a fracture of the skull and the soft center for the depression of an area of the skull. This error may be avoided by observing the projection of the blood tumor on the surface and bv moving the scalp back and forth, when the supposed depressed area moves with the scalp over the surface of the skull. Owing to its poverty in blood vessels the loose tissue beneath the aponeurosis is not often the seat of a hematoma except as the result of fracture of the skull. When they occur here they may attain a large size and may similarly present hard edges and a soft center, sinuilating depressed fracture, from which they cannot be distinguished by moving the scalp. Extravasations of blood beneath the pericranium are limited in area to one bone and may be diagnosed by this fact. Tlu'v are commonly 24 THE HEAD AND NECK. called cephalhematomata, are usually congenital in origin, due to pres- sure on the head at birth, and hence are more frequent in males owing to the larger size of the head. They are most common over the parietal bone and on the right side, which is most exposed to pressure. Besides these blood tumors beneath the pericranium others occur rarely which have a different origin and are distinguished by disap- pearing on pressure, in whole or in part, or even in the upright pos- ture. Such tumors according to their position are connected either with the veins of the diploe or the dural sinuses through an opening which may be the result of injury, disease or congenital defect. When communicating with the superior longitudinal sinus they are median and receive a faint pulsation from the brain. THE TEMPORAL REGION. The temporal region varies in some respects from the scalp proper as to the soft parts covering it. The limits of this region may be taken to be the upper border of the zygomatic arch, the external audi- tory meatus and the base of the mastoid process below and the curved superior temporal ridge above. The latter ridge connects the base of the mastoid bone with the external angular process of the frontal bone and rises 7 to 8 cm. above the level of the zygomatic arch. This region corresponds to the temporal fossa and its upper limits may be determined by making the temporal muscle to contract. The various layers of soft parts common to this region and the occipito-frontal are identical above, where they really form a part of the scalp, but change in character below. Thus the skiu, below, is less dense, less thick and less adherent to the subcutaneous tissue and is wanting in hair below and in front. The subcutaneous tissue, below, becomes loose and resembles that elsewhere in the body and the arteries are no longer intimately adherent to its septa. The aponeurosis passes down over the zygoma onto the cheek, becoming loose, thin and lamellar. Tiie loose subaponeurotic tissue is like that above, but loosely connects the aponeurosis with the temporal fascia instead of with the pericranium. Tlie temporal fascia, whose form represents exactly that of this region, is very dense and unyielding, so that in the case of an injury reported by Denonvilliers a lacerated wound of this fascia was at first mistaken for a fracture of the skull. In its lower third it is double, enclosing fat and the orbital branch of the temporal artery between its two layers, which are attached to the outer and inner aspects of tlie upper border of the zygomatic arch. Between it and the bone is an osseo-apoueurotic space which is deepest in front (2 J cm.) and narrows behind and above until we reach the attachment of the fascia to the bone. This space lodges the temporal muscle and deep temporal ves- sels and nerves. It is hermetically closed above by the attaclnnent of the fascia to the temporal ridge, while below it is directly contiuuous with the zygomatic fossa, so that surgically the two fossae form but a single region. Hence abscess, etc., in the temporal fossa is prevented SURFACE LANDMARKS. 25 by the firm fascia from opening above the zygoma and tends to extend downward into the zygomatic fossa and the neck. Owing to the density of the fascia pathological collections beneath it do not show on the surface. As in the scalj), inflammatory ])rodiicts or blood may collect in the subcutaneous or subaponeurotic layers, in which situations they may be wholly above the zygoma or sink in part below its level. Subcu- taneous effusions lie external to the zygomatic arch while those beneath the fascia are internal to the arch. In the temporal region the peri- cranium is much thinner and more adherent to the bone while the dura is less so than it is above, hence subpericranial extravasations are rare while epidural extravasations are more common than elsewhere. As the muscle is sei)arated from the fascia in the lower third of this region by a mass of fat, continuous with the abundant masses in the zygomatic fossa, we see that there are three distinct layers of fat between the surface and tiie muscle : (1) Subcutaneous, (2) inter- fasciai, (3) subfascial. This fat diminishes in wasting diseases, giving a sunken appearance to the temporal region, and bringing the zygo- matic arcli and the malar bone, below and in front, into prominent relief. The mastoid region, corresponding to the triangular mastoid proc- ess, is covered by the same layers as the occipito-frontal but the skin, subcutaneous, aponeurotic and subaponeurotic tissues are altered as in the lower temporal regions so as to resemble the similar layers else- where in the body. The pericranium is very thick and adherent and is more like periosteum elsewhere. THE BONY CRANIUM. Surface Landmarks. — Those that can be determined through the overlying scalp are of the most surgical importance in relation to cranio-cerebral topography. The external occipital protuberance, or inion, is readily felt in the median line. It is the thickest part of the vault and corresponds about to the torcular Herophili on the inner sur- face. The glabella, the median smooth area between the superciliary ridges of the frontal bone, can be felt just above the notch [lumon) at the naso-frontal suture. The external angular process of the frontal bone at the outer end of the supraorbital ridge is readily felt. Measure- ments are taken from its upper and outer part. It should not be con- founded with a projection on the back of the frontal process of the malar bone below it. The zi/f/onuitic arch, the cvtcniaf (tudiforif meatus and the mastoid proceas can all be readily seen or felt. The upper branch of the })osterior root of the zygoma {supramaHfoid crest) running into the posterior part of the temporal ridge can be felt above and behind the external auditory meatus. The parietal eminence is used as a landmark but is not a well marked one. To determine it the scalp should be shaved, and it c^m be more accurately determined when the skull is bared. It is more ]irominent in young skulls. In addition to these pali)able or visible landmarks and by means of 26 THE HEAD AND XECK. them we can determine the position of the sutures. The bregma, the site of the anterior fontanelle where the sagittal and coronal sutures meet, lies at the intersection of the median line with a vertical line drawn from ajwint just in front of the external auditory meatus. The coronal suture lies in a line from the bregma to the middle of the zygo- matic arch. The pterion Avhere the frontal parietal and great wing of the sphenoid meet, lies on this line about 1| inches behind the exter- nal angular process of the frontal and about the same distance above the zygoma. The sar/itfal suture is median and extends between the bregma and the lambda. The latter corresponds to the posterior fon- tanelle and is about midway between the bregma and inion (external occipital protuberance), or 2| inches above the latter. The parietal foramen is about 4 cm. above the lambda. The lanibdoid suture }oms the sagittal at the lambda and extends thence along a line drawn to the posterior end of the base of the mastoid process, or it may be rep- resented by the ])osterior two-thirds of a line from the lambda to the apex of the mastoid. The aster ion, at the postero-inferior angle of the parietal bone where the lambdoid and parieto-mastoid sutures meet, lies on the last-mentioned line 1| inches behind the meatus and on a level with the zygoma. The summit of the squamous suture is about 2 inches above the zygomatic arch. It should be remembered that tlie frontal suture, between tlie two halves of the frontal bone, some- times persists, and should not be mistaken for a fracture. The sutures, besides interlocking in a serrated or dentated manner, are bevelled alternately at the expense of the outer and inner aspect. Thus in the coronal suture the frontal overlaps the parietal above and is overlapped by it below. In injuries to the skull diastccsis or separa- tion of the bones at the sutures occurs in but a very small percentage of cases and then usually in connection with an extensive fracture. It is naturally more common in young than in adult skulls. The squa- mous suture is the one where diastasis is most common, or when asso- ciated with fracture, the sagittal and coronal sutures. The suture membrane in young skulls is thick and vascular so that a surface in- flammation may travel through it to the internal surface of the cranium and vice versa. In hi/drocephalus the sutures, especially those around the parietal bone, become \videly separated and the fontanelles form large openings whose closure is much delayed. The posterior fonta- nelle is normally closed at birth and the anterior during the second year, up to which time it acts as a safety valve for the rapidly varying intracranial pressure. It may persist much longer, even to adult life. As the sutures with their membranes allow the rapid growth of the skull their premature closure prevents the growth of bone in a line at right angles to them, Tiiis causes a deformity in sliape of the skull or, if more general, a small size (microcepJudus) of the skull which may bo the cau.se or the result of arrested brain development or idiocy. If it be the cause of idiocy microcephalus calls for craniec- tomy to allow for the growth of the brain. Such premature ossifica- tion may be due to rickets. CONDTTroyS DEPENDiyCi rPOX ERRORS OF DKVKLOPM EST. 27 The sutures may assist slightly to break tiie force of sliocks and diminish the liability of fracture, hence the latter would seem more likely to follow a slight injury after the closure of the sutures, which occurs at varying })eriods after middle life. This closure begins, as in the long bones, at the end of the suture last ossified, /. r., near the fontnnelles and occurs lirst in the sagittal, last in the squamous suture. It is said to begin when the weight of the brain ceases to increase and may be complete by the age of 80 (Tillaux). The M^orinldn honen occur in varying numbers and sizes along the sutures, most often in the lambdoid suture, and may be mistaken for fragments due to fracture. One of these bones, the cpiptcric bone, is found at the pterion and usually joins the great wing of the sphenoid, of which it may be thought to be a broken fragment. It may be met with in trephining for the middle meningeal artery. In craniofahes, ascribed to rickets or inherited syphilis, the skull is deformed by the premature ossification of the sutures, the occiput is flattened by the pressure of the heavy head resting largely on this part, and the upper ]iart of the occipital and adjacent jiarts of the parietal bones are thickened, with here and there a thinning on the inner surface, so that in places a mere shell of bone or an entire absence of bone may exist. Conditions Depending upon Errors of Development. — The frontal, ]iarietal, scpiamous ])ortion of the tem])oral and the part of the occipital al)ove its highest curved line are ibrmed in membrane, the base of the skull in cartilage. The entire absence of that part formed in membrane is occasionally found as an anomaly. The squamous ]iortion of the occipital bone is ossified from four centers, a ]")air above the highest curved line and a pair below. The u])j)er pair may form a separate bone, the inter pari vial bone of the lower vertebrates, and the suture between this and the part below should not be mistaken for a fracture. More commonly there ])ersist two lateral fissures, as at birth, or median fissures between the lateral centers, and these fissures also should not not be mistaken for fractures. Certain tumors of congenital origin, containing cerebral contents and called cephaloceles or " cerebral hernia?," occur as the result of de- fective development. They are usually situated in the median line and most often in the occipital, next in frequency in the naso-frontal region. Occipital cephaloceles generally occur through a median fissure in the occipital bone, either above or below the external occipital pro- tuberance ; anterior or .^iincipital ccj/lialocrlrs through the naso-frontal suture. INIore rarely such tumors occur through other abnormal aper- tures, especially at the base of the skull. When the sac of a ce}ihalo- cele, which is formed by the outer cranial membranes, contains cerebro-spinal fluid alone the tumor is ealJiMl a meningocele, when it contains brain substance an encephalocele. A hydrencephalocele is an encephalocelc containing a cavity filled with lluid which is often con- nected with the cerebral ventricles. The parietal fissure is a narrow gap extending from the jiarietal 28 THE HEAD AND NECK. eminence to the sagittal suture about an inch in front of the lambda. It is often seen about the fifth month of foetal life as a cleft between the radiating ossific spicules but it usually closes. When present on both sides the lozenge-shaped gap is known as the sagittal fontaneUe. The fissure should not be mistaken for a fracture. Construction and Lesions of the Bones of the Cranial Vault. In the adult these bones are composed of compact outer and inner tables and an intervening cancellous-like layer, the diploe. This is not present in children's skulls and does not form until about the tenth year. The blood supplii of these bones is contained largely in the diploe which receives but little blood from the vessels of the pericranium, more from those of the dura. Some of the consequences of this we have already seen (p. 22). The veins of the diploe empty into both the dural sinuses and the surface veins. As the vessels of the diploe com- municate with those of the dura and the dural sinuses, inflammatory lesions of the bone may extend to the sinuses and lead to sinus throm- bosis, with the danger of pyaemia, or to tlie dura and cause pachy- meningitis. Inflammatory lesions of the bones commonly lead to caries or necrosis, which is fairly common on the vault of the skull and most often in- volves the frontal and parietal bones. Owing to its poorer blood sup- ply and its exposure to injuries the external table is more often involved alone than the internal table. Syphilis and tuberculosis are not uncommon causes of caries or necrosis of these bones, many cases result from injury, especially when the wound is infected, and but few cases are spontaneous or idiopathic. Besides the special dangers, mentioned above, of sinus thrombosis and meningitis, pus may collect between the bone and dura and cause compression of the brain, but fortunately the collection of pus here is not common. When the disease of bone involves the whole thickness of the skull the pulsa- tions of the brain may be seen or felt in the gap produced. Necrosis and separation of extensive areas, even of the entire vault (Saviard), has been reported. A peculiarity of necrosis of the cranial vault is that no involucrum is formed and the bone is not reproduced. As a rule stripping up of the dura is not followed by necrosis. The average thickness of the bones of the cranial vault is | of an inch but tliis is liable to wide variation in different parts of the same skull and in different skulls. Thus it is very thin and translucent in the squamous portion of the temporal, the anterior inferior angle of the parietal and in the inferior or cerebellar fossse of the occipital squa- mosal ; while it is very thick at the occipital protuberance, the mastoid process, the lower part of the frontal bone, and along the ridges that bound the grooves for the superior longitudinal, the lateral and occip- ital sinuses. Again the inner surface of the cranium is marked by depressions or grooves : (1) For the cerebral convolutions, (2) for the dural sinuses, (3) for the meningeal arteries (especially the middle INFL. 1 MM A TOR i ' L h'SIOXS. 29 meningeal) and (4) for the Pacchionian bodies. Hence the inner and outer tables of the skull are not parallel with one another. These facts should be borne in mind in trephining. The pin of the trephine should not be made to penetrate over I of an inch and in many regions ^-g of an inch. The instrument should not Ijc applied over the course of the sinuses, over the position of the frontal sinuses (often of large size in the aged) nor over the position of the middle meningeal artery unless it is desired to expose these parts. As the suture membrane blends with tiie dura the trephine should not be applied over the sutures for fear of wounding the dura. From time to time the groove made by the trephine should be tested in its entire circumference by a probe to see if it is through where the bone is thin- nest. The bleeding in a trephine wound comes almost exclusively from the diploe. The skull presents certain stronger ridges or buttresses where the bones are thicker or stronger and between which they are thinner and more readily fractured. These buttresses pass from the vault to the base at the foramen magnum and serve to unite the two parts into one solid framework. Thus one buttress is represented by the median part of the frontal, the ethmoid, the body of the sphenoid and the basilar portion of the occipital. This antei-ior buttress is continuous along the middle line of the vertex with the posterior buttress which passes through the occipital protuberance and crest to the foramen magnum. Two lateral buttresses exist, the anterior represented by a Fig. rrcpanition of skull, showiag Uie principiil nrclu's of strength or biittres.-.i'8 of resistance. (Thomp- son, /. <•., after Uoi-iiiiAU aiiil 1-'klizkt.) 30 THE HEAD AND NECK. ridge of bone from the vertex to the exterior angular process of the frontal and thence through the great wing to the body of the sphenoid, the posterior running through the parietal eminence, mastoid process, posterior part of the petrous bone and the jugular process to the occip- ital condyle/ The bones of the skull and the skull as a Avhole are elastic. This elasticity is greater in the infant than in the aged but even the adult skull is less brittle than commonly supposed. The yielding character of the infant's skull is shown in the artificial deformity of the flat- headed Indian, produced by pressure, and it has been asserted (Gueniot) that in infants considerable deformity may be produced by the weight of the brain, by allowing them to lie always upon one side. In addition in the infant there is much cartilage and membrane be- tween the bones. Hence the skull of an infant is not easily fractured. The probable eifect of a blow is to indent the skull. During delivery the infant's skull, most often the parietal bone (right parietal in L. O. A. presentations) may be flattened by pressure against the sacral prom- ontory or by the use of the forceps. Though a hemorrhage (cephal- hcematoma) often occurs beneath the indented area real fracture is rare. Fractures of the Skull. Besides its elasticity the following anatomical conditions of the skull lessen its liability to fracture, the rounded form favoring glancing blows, the density and mobility of the scalp, the composition of the skull by a number of bones separated by sutures and suture mem- branes which act to a slight extent as buffers, and the mobility of the head on the spine. Although as a rule the entire thickness of the bone is involved in fractures of the skull yet the external table alone may be broken or even depressed into the diploe or into the frontal sinuses. More rarely, the internal table may be fractured without injury of the outer table. The latter injury can only rarely be diagnosed by the symp- toms (vomiting, convulsions, etc.). Fracture of the internal table alone can be explained and illustrated as follows : An injury causing fracture tends to flatten out the skull over the area where the violence is applied and is like bending a barrel hoop so as to straighten it. Like the barrel hoop it gives way first on the inner or concave surface and if the force is not continued this surface alone may be broken. For the same reason in complete fractures the inner table is fractured first. In addition this inner table is most extensively fractured in most cases for (1) it is thinner and more brittle (hence called the " vitreous table"), (2) the force as it travels from the outer table through the diploii to the inner table passes in a radiating manner so as to reach the inner plate in a more diffused form, (3) the inner table is a ])art of a smaller circle and (4) as the force tends to flatten out the arch the 'Dupluy and Keclus, Vol. III., p. 461. FRACTURES OF THE BASE. 31 bony particles of the outer table are forced together and t;»ose of the inner table asunder. In general, fracture of the vault occurs from a given violence when the limit of its ela.-ticity is excoccled, as illustrated in the straightening of a barrel hoop. Fractures of tlie vault are due to lied. When a con- siderable force is applied over a limited area this area of the skull is usually depressed. When it is applied over a large surface (as in falls from a height) the entire globe of the skull is compressed or flat- tened in the direction in which the force acts, and lengthened or pulled apart in a direction at right angles to this. Two forms of fracture may result: (1) A "compression fracture" at the point where the skull is pressed together by the direct violence, and (^2) a " bursting fracture " where the skull has been lengthened and pulled a.-under. The latter form is due to indirect violence and occurs more often at the base than on the vault of tlie skull. The symptoms and danger of fractures of the vault depend ver\' largely on the coucomitant l)rain lesions : (1) Concussion, (2) contu- sion of the brain, (3) intracranial hemorrhage. Fractures of the (an- poral region are in general more serious than similar fractures of the rest of the vault, for the middle meninyeal artery is often injured and the resulting hemorrhage causes compression of the brain. The escape of cerehro-spinal fluid from a fracture of the vault is not common, though it has been observed in compound fractures and in simple frac- tures in children (resulting in a fluctuating tumor beneath the scalp). It indicates injury of the dura. It is interesting to note how the construction of the skull resists the fracturing force in many ways. A blow on the vertex in the parietal region tends to drive the upper borders of the parietal bones inward and the lower borders outward. The latter tendency is resisted by the overlapping great wing of the sphenoid and the scjuanious bone. The latter is buttressed by the zygomatic arch and this in turn by the malar and the bones of the face, hence the pain in the face said to be felt in falls or blows on the top of the head. When the frontal suture exists a tendency of the lower part of the frontal bone to be Ibrced outward in blows on the median parts of the frontal is simihirly resisted by the overlapping arterior inferior part of the parietal and the great wing of the sphenoid. A blow on the upper part of the frontal bone is transmitted to the parietal on which this ]>art of the frontal bone rests owing to the bevelling of the upper part of the contuary su- ture. Blows on the occiput are less safeguarded by anatonncal arrange- ments, except by its articulation with tlie elastic vertebral column. Gaseous tumors beneath the scalp have been described as a sequel to fractures of tiie skidl in which one of the cavities containing air has been involved in the fracture, /. c, the various sinuses, mastoid cells, etc. Fractures of the base may be due to (1) direct violence, (2) indi- rect violence, and (3) extension of a fracture of the vault. Fractures of the base by direct viofencc occur in ca.ses where a foreign body is 32 THE HEAD AND NECK. forced through the orbital, nasal or pharyngeal roof or through the nape of the neck in the posterior fossa. They are not common. One form of fracture of the base by indirect violence is illustrated by the fracture of the cribriform plate of the ethmoid or the orbital plate of the frontal by a blow on the root of the nose or the lower part of the frontal bone ; and by the fracture of the glenoid fossa by the condyle of the jaw driven violently upward, as in fells or blows on the chin. In this manner the condyle has been actually thrust into the cranial cavity (Chassaignac). Again, in falls upon the buttocks, less often upon the feet or knees, the force has been transmitted along the vertebral column, especially when it is kept rigid by muscular action, and has resulted in the frac- ture of the base in the occipital region, often in a " ring fracture " around the foramen magnum. A similar fracture may possibly result from a blow on the head just as the handle of a hammer may be driven in either by a blow on the end of the handle or by one on the head of the hammer. The mechanism of the majority of fractures of the base has been much discussed. The former theory that many were the results of contrecoup, or a focusing of the force at the opposite pole to that struck, has been abandoned. Possibly a very few cases may be so explained though perhaps better as " compression " or " bursting" frac- tures. Aran and others showed that very many fractures of the base were fractures by irradiation, i. e., the result of fractures of the vault spreading to the base by the shortest route irrespective of the sutures, hence fractures of the frontal region spread to the anterior fossa, those of the parietal region to the middle fossa and those of the occipital region to the posterior fossa. This was especially the case in linear fissures, the result of diffused violence, as in falls upon the head. In general when the violence is not excessive Felicet found that these frac- tures seem to run in the weaker areas between the ridges or buttresses (see p. 29). These explanations do not fit all cases or even the majority, as well as does that of "compression" and •' bursting" fractures (see p. 31). As seen above the latter are indirect fractures and probably comprise most of the fractures of the cranial base. Fractures due to bursting (/. c, most fractures of the base) run parallel to the axis of pressure, those due to compression run at right angles to this axis. Fractures of the base run in the direction of the violence that inflicts the injury or parallel to it. Hence, given the direction of the force and the point struck, we can fairly well predict the course of a fracture of the base. Bursting fractures are most likely to occur where the skull is weakest which is at the base, owing to the numerous foramina, etc. (Figs. 3 and 4). In fractures of the base there is usually a discharge of blood and often o{ cerebrospinal fluid externally. In the majority of basal frac- tures the petrous bone is involved and especially that part which is weakest, which lies in the plane passing through the middle ear, the internal ear and the internal auditory meatus. In such cases the tym- panic membrane is commonly ruptured and this allows of the escape PLATE 1 FIG. 3. FIG. 4. Illustrating lines of iDursting force in basal fractures. (Wahl. FIG. SUP. LONGITUDINAL , n p. LONGITUDINAL SPHENOPA RIETAL SINUS INF. PETRO- SAL SINUS SUP. PETRO- SAL SINUS Interioi' of the base of the skull covered by dura, showing the sinuses, nerve exits and tentorium. Ci-anial nerves are numbered in Roman figures. (Merkei.) THE CEREBRAL MEMBRANES. 33 of blood from the ear, a symptom so common in fractures of this region of the base. This blood may be derived from the vessels of the tym- panum and its membrane or from an intracranial source, sometimes from the rupture of one of the sinuses about the petrous bone. If the membrane is not ruptured the blood may pass through the Eustachian tube and escajw? at the nose or mouth. In addition to bleeding from the ear the flow of cerebro-spinal fluid is sometimes observed. This occurs when the dura and arachno d, or their tubular prolongation in the internal auditory meatus, are torn by the fracture, which connects the subarachnoid space with the tympanum whose membrane is lac- erated. A free .sorouH dlscharf/c may (teeur from the ear after an injury to the head, without fracture. It escapes through a rupture in the tympanic membrane and may be derived from the mastoid cells or it may be blood serum. In fractures of the anterior fossa the blood escapes into the nose, mouth or orbit. In the latter case it produces a subconjunctival ecchymosis, rarely an exophthalmus. Bleeding into the nose may run back into the mouth and in bleeding either into the mouth or nose the blood may be swallowed and subsequently vomited. When bleed- ing from the nose or mouth occurs as the result of a basal fracture the latter involves the cribriform plate or the body of the sphenoid. In bleeding from the nose the greater part of the blood probably comes from the torn mucosa of the nasal roof. If there is a discharge of cerebro-spinal fluid from the nose there must be a laceration of the nasal mucosa and of the dura and arachnoid. In fracture of the base in the posterior fossa of the skull the blood may appear as an extrav- asation about the mastoid process or the nape of the neck. The symptoms and serious nature of basal fractures depend upon the eoneoinitant intracranial lesions. Meninejitis, due to infection of a fracture of the base which opens into a cavity connected with the air, is rare as a cause of death as compared with the intracranial lesions due to the injury. The base of the skull is rather inaccessible to oper- ations on accouut of its location. Owing to a lack of reparative vitality, repair after fractures of the skull is very slow and bony union occurs only when the fragments are separated by a very small interval. The new bone is produced mostlv by the diploe and more by the dura than by the pericranium. When there is any considerable loss of substance the oj^ening is not filled in with bone save for a narrow strip around the edge. After recovery from diastasis in a child the growth of bone is not interfered with. THE CONTENTS OF THE CRANIUM. The Cerebral Membranes. The tough fibrous dura may I)c dividid into an outer periosteal layer and an inner or supporting layer. This corresponds to its twofold function, on the one hand as an endosteum and on the other as a 3 34 THE HEAD AND NECK. protective covering of the brain. These layers are inseparable over the greater part of their extent, but the inner separates from the outer layer to form the cranial sinuses and the processes, like the falx and tentorium, which help to support and protect the brain. (See Fig. 1.) The adhesion of the outer layer to the bone increases with age and in chronic inflammation of the bone or the dura, but is less intimate in acute inflammations. It varies in different parts of the skull. Over the vertex and, according to Tillaux, particularly in the temporal fossae the dura is comparatively loosely attached, except along the sutures where it is more adherent. This loose attachment allows a probe to be passed a considerable distance between the bone and the dura, if the sutures are avoided, and large extravasations of blood or pus may occur here and lead to compression of the brain. Such ex- travasations are often limited to one bone by the adhesion along the suture lines, but not necessarily, especially in the case of purulent col- lections. The adhesion of the dura to the bone is largely due to the passage of small blood vessels from the meningeal vessels of the former to nourish the bone. The bone can live however if the dura is stripped off and after loss of bone the loss is not repaired by the dura. In the majority of traumatic cases the cause of cerebral compression lies out- side the dura in the epidural space or is due to the bone itself. As pointed out by Sir C. Bell the clara of the vault may be separated from fJtehonehy a blow and if this occurs during life the corresponding epidural area is occupied by a clot from the rupture of many small ves- sels that pass from the dura to nourish the bone. If a larger vessel is ruptured the hemorrhage may gradually strip off more and more of the dura so that a clot is formed which gradually causes local or general symptoms of compression. The stripping up of the dura may be dem- onstrated on the cadaver by striking a blow and then injecting the blood vessels. The vessel which by its rupture is most often (Sofo more or less) the cause of serious or fatal epidural compression is the middle meningeal artery, in the temporal fossa. This is the cause of the more serious results of fracture in this region. This vessel is for the most part closely wrapped by the outer layer of the dura so that it is ruptured in any tear of the latter, in fracture of the skull. It may also be torn without fracture, for in the great wing of the sphenoid and the antero- inferior angle of the parietal it is often lodged in a bony canal or a groove whose open side is smaller than that of the artery so that if by a blow the dura is here stripped from the bone the artery is torn at the point where the canal or deep groove prevents it from being stripped back with the dura. When after a blow over the position of this vessel symptoms of compression, not present at first, come on after an interval and gradually increase ruj)ture of this artery or some of its branches is probable. As it lies in ])art over the cortical motor area motor para/i/ses arc likely to occur from local compression. As such cases get progressively worse and end fatally, operation with turning out the clot and plugging or tying the vessel is imperatively demanded. THE SUBDURAL SPACE. 35 Hence the importance of knowing the position and course of this vessel. (See Fig. 7.) Tlie trunk of the artery passes outward and forward for a short ijut variable distance from the foramen spinosum, through which it enters the skull. It has tv)o main branches of which the larger (interior one runs upward and forward across the antero- inferior angle of the parietal bone and continues in a groove a little behind the coronal suture, giving off' branches which run upward and backward. Tne posterior hranch runs backward across the sfjuamous bone and then upward and backward over the ])osterior part of the parietal bone. Although it may be possible by a single trephine open- ing to expose both branches of the artery yet such an opening must be low down on the temporal fossa and below the common site of injury of the vessel, which is in the anterior branch near the pterion, where the groove is often very deep or converted into a canal. When the groove is so arranged fracture here without laceration of the artery would hardly be possible and this thin part of the skull is particularly liable to be fractured. If we trephine and ligate the artery too low an anasto- motic branch from the orbit may join the artery above the jioint of liga- tion and below the ])oint of rupture and thus continue the hemorrhage. To expose the anterior branch of the middle meningeal artery a trephine opening or iK)ne flap is made just behind the pterion (see p. 20) ; or two fingers' breadth above the zygoma and a thumb's breadth behind the frontal process of the mnlar bone (Vogt) ; or 3-4 cm. behind the latter point on a level with the supraorbital margin (Kronlein). As the artery lies enclosed in the firm dura or in the bone the chance of spontaneous arrest of bleeding is slight. At the hui^e of the skull the dara is closely adherent to the bone so that epidural extravasation can scarcely occur, and in fractures of the base the dura is likely to be torn, allowing the escape of cerebro-spinal fluid. The dura smoothes over some of the inequalities of the base and passes out through the foramina of the skull with the cranial nerves to become continuous with the nerve sheaths as well as with the pericranium on the outer surface of the skull. Its inner surfaceh smooth owing to the layer of flat endothelial cells which covers it. The subdural space, or the potential interval between the dura and the arachnoid, contains a small amount of //m/^/ and probably serves to prevent friction of the surface of the brain during its movements, like the pleural and other serons sacs. The hemorrhage m pachymeninr/itis hemorrh(/r/ica occurs in this space, into which a considerable effusion may occur without marked sym{)toms on account of its wide diffusion. Following an injury extravasations of l)lood into this space are very common and the blood so effused is liable to shift its position and per- haps suddenly cause dangerous symptoms by gravitating to the vicinity of the pons, cerebellum and medulla. Similarly, during operations upon the brain, l)lood, pus or irrigating fluid may enter this space and gravitate toward the medulla or sj)inal ciinal. Hence care should be taken in evacuating and irrigating cerebral abscesses to avoid the pas- sage of the fluid into this space and to secure its Escape extracranially. 36 THE HEAD AND NECK. The subdural space communicates with the abundant lymphatics of the dura and from the latter pathogenic organisms may invade this space. Normally the inner surface of the dura is not connected with the arachnoid except by a few and very delicate processes, hence on open- ing the dura any adhesions which prevent the probe or finger passing freely between it and the brain are pathological. The fibrous folds formed by the reflection of the inner or proteotive layer of the dura (falx cerebri, tentorium cerebelli, etc.) are of little surgical interest but they are important in preventing the compression of the two hemispheres by each other, and of the isthmus of the brain and the cerebellum by the cerebrum. The sinuses of the dura are formed by the separation of the inner from the outer layer on the surface or by the separation of two folds of the inner layer on the folds or processes of the dura. (See Fig. 1 .) They are lined by an epithelial layer continuous with the inner layer of the veins. Their walls are rigid and non-collapsible so that when wounded bleeding is not spontaneously arrested. Certain sinuses are of especial surgical interest and their position is of importance because in certain operations we wish to avoid them, in others to expose them (Fig. 5). The superior longitudinal or sagittal sinus extends in the median line from the foramen caecum anteriorly to the torcular Herophili, opposite the external occipital protuberance, posteriorly. As the tor- cular is usually to the right of the median line the posterior and larger part of the sinus is also rather more to the right of the median line. Through the foramen ccecum it communicates with the veins of the nasal mucosa, hence epistaxis may directly relieve cerebral congestion and infective organisms from lesions of the nasal septum may thus enter the sinus. It also communicates with the scalp by the emissary veins passing through the parietal foramina so that it may become in- fected from erysipelas or other septic diseases of the vertex. This sinus receives the veins from the median and upper surface of the cerebrum and communicates with the basal sinuses through the anas- tomosis of the superior cerebral with the middle cerebral and Sylvian veins. As the blood of the superior longitudinal sinus usually passes into the right lateral sinus and that of the straight sinus into the left lateral sinus, it follows that the right lateral sinus is usually the larger and receives the blood from the surface of the brain while the left sinus drains the central ganglionic portions. The course of the lateral sinuses is represented by a line from the external occipital protuberance to the upper margin of the external osseous meatus or the base of the mastoid process. (See Fig. 9.) It is usually slightly convex upwards and crosses the asterion, from whence to the jugular foramen it is called the sigmoid sinus, on account of its crooked S-shaped course. The sharp downward and inward bend, or gemi, of the sigmoid sinus on the mastoid bone is convex forward. It reaches forward to a point \ to \ of an inch behind a coronal plane through the posterior border of the external osseous meatus and is on a level with the upper part of the meatus. The genu on the right THE CAVERSorS SIXUS. 37 side extends slightly further forward and outward than on the left and this fact may possibly account for the supposed greater frequency of intracranial complications following otitis media on the right side. The genu of the sigmoid sinus receives groups of veins from the tym- panum and the mastoid antnnii and cells, through which infection may spread to the sinus and cause thrf)nil)osis. The course of the sigmoid sinus, where it is accessible to opera- tion, corresponds to two lines ; the upper and more superficial part to the posterior fj of a line from the asterion to the up])er margin of the external osseous meatus, the vertical part to the upper ^^ of a line from the parieto-squamo-mastoid junction (or the middle of the base of the mastoid) to the tip of the mastoid (see also Fig. 7). An opening may be made into the genu, the part of the sinus most often affected, at a point half an inch behind the posterior wall of the bony auditory canal between the levels of its roof and floor. Between these levels the upper and more superficial part of the sinus is | inch (sometimes as little as ^v, inch) from the surface and is thus more superficial than the antrum, while its lower ])art lies more deeply. The sigmoid sinus is connected with the surface veins through two emissary veins, the mastoid and the posterior condylar. The mastoid vein joins the occipital and through this the deep cervical, or occasion- ally it joins the posterior auricular. It may become thrombosed from sinus thrombosis or its foramen may give vent to extradural pus in the cerebellar fossa. The posterior condylar vein is the larger and more constant of the two, contrary to what is usually stated. It joins the deep veins at the back of the neck and its foramen may drain extra- dural pus in the bottom of the cerebellar fossa, setting up a deep in- flammation or abscess in the up])er part of the back of the neck which causes swelling and tenderness on pressure here. These two emissary veins and the occipital sinus may convey infective matter from the lateral and sigmoid sinuses to the heart and lungs so that ligation of the internal jugular vein does not afford complete protection against this accident. The u])jier and posterior end of the sigmoid sinus lies at the junction of the n)iddle and anterior thirds of the cerebellum so that the latter may be exposed in front of the sinus, though preferably behind it. The pdriefo-sfjiKiino-iiuistoid Juitcfion corresponds to the point where the superior ])etrosal joins the sigmoid sinus and where the upper border of the jK'trous joins the mastoid bone. The cavernous sinus extending from the sphenoidal fissure to the apex of the jx'trous bone receives and is, as it were, the continuation of the oj/hf/Ki/iiiic vein. The fact that the latter anastomoses with the facial through the nasal vein exjilains why an infiammation near the facial vein, like a carbuncle of the upper lip, is more serious than a similar condition on the lower lip, as the former may extend along the veins and set up a cavernous sinus thrombosis. This sinus also com- municates with the pteri/(/oi(} p/exiis by means of the ophthalmic and Vesalian veins through which infective matter may pass from one to the other. The intimate relation between the carotid artery and the 38 THE HEAD AND NECK. cavernous sinus accounts for the fact that arterio-venons aneurism has followed injury of these parts. In such cases the orbital cavity is distended with a pulsating tumor consisting of the dilated o]>hthalmic veins which protrude the eyeball. As the dural sinuses are rigid, non-collapsible, ever-patent tubes and the jugular veins into which they empty are alternately distended in expiration and collapsed in inspiration this aspiration would involve the sinuses unless there were some inechaniwi to prevent it. If the sinuses were thus aspirated and the blood of the brain suddenly pro- pelled forward to compensate for that withdrawn there would be a disturbance of brain function, a sudden faintness or lack of brain power on each deep inspiration. The entire sinus arrangement ensures a regular even flow as seen in the entrance of the middle and posterior cerebral veins obliquely into the longitudinal sinus against its current, thus damming it back,^ and especially in the traj)-/ike passage of the sigmoid sinus into the jugular bulb. The roof of the lowest portion, near the end of the sigmoid sinus, is on or below the level of the floor of its entrance into the jugular bulb and the roof of the latter is much above the whole of the lower end of the sigmoid sinus so that an ar- rangement like a plumber's trap is formed to prevent aspiration of the sinus. This aspiration is further prevented by the entrance of the inferior petrosal sinus into the jugular bulb so that this sinus alone, if any, would feel the eftects of aspiration. Furthermore by pouring its blood into the jugular bulb from a large reservoir, the cavernous sinus, there is no absolute collapse of the internal jugular with the conse- quent difficulty in reestablishing the flow. Between the two layers of the dura and occupying a depression on the iipj^er surface of the apex of the petrous bone and the adjoining cartilage filling the middle lacerated foramen, is the crescentic Gasserian ganglion. This with the roots of two of its branches, the superior and inferior maxillary divisions of the fifth nerve, is sometimes removed for intractable neuralgia. The best method of operation is the osteo- plastic Hartley-Krause method by which an ii^-shaped flap of l)one and soft parts, having its base on a level with the zygomatic arch, is turned down exposing the dura. The latter is then se])arated from the floor of the middle fossa of the skull until the two branches named above are ex])osed and traced up to the ganglion. To expose the latter the outer layer of the dura must be divided. Its close relation to the in- ternal carotid artery and the cavernous sinus as well as to the middle meningeal artery must be borne in mind, and the latter artery may also give trouble in the bone flaj). A small vessel nc('onij)anying the infe- rior maxillary nerve has occasionally caused troublesome hemorrhage. The delicate arachnoid is closely applied to the pia, over the top and sides of the head, l)ut does not dip in between the convolutions. The subarachnoid space is scarcely recognizable over the upper surface, though present, while over the posterior two-thirds of the base (in the ' For further interesting particulars consult Macewen, Diseases of tlie Brain and Spinal Cord, p. 35. THE BRAIN. 39 posterior and middle fossae) it is large and contains the larger part of the cerebral cerebro-spinal fluid. The latter serves as a water bed for the important i)arts of the brain resting npon it, while the less im- portant frontal lobes rest directly upon the bone, covered by dura. This arrangement of the fluid protects the posterior parts of the base of the brain from the effects of injury, either direct or by contrecoup, while the base of the frontal lobes is not infrequently injured by com- ing in violent contact with the irregular orbital plates. The cerebro- spinal fluid differs from blood serum in its very small percentage of albumin. The cerebral and spinal subarachnoid spaces communicate freely with each other through the foramen magnum and with the cavity of the cerebral vesicles through \.\\e Joraiiwn of Mdfjcndic, in the lower ])art of the roof of the fourth ventricle. Hence the cerebro- spinal fluid may also serve to equalize the intra-cranial pressure by being ])artly forced out from the ventricles through the foramen of Matrendie when the nerve centers in the walls of the ventricles are congested and down into the spinal canal if the general intracranial pressure is increased, as in cases of congestion from irregularities in the blood circulation. In case the foramen of Magendie is blocked by a tubercular deposit or the })ressurc of a cerebellar tumor fluid may accumulate in the ventricles and result in internal hydrocephalus. Lumbar puncture as a diagnostic and therapeutic measure depends upon this intercommunication and flow of the cerebro-spinal fluid from one part to another. In operations on the base of the brain, or on a spina bifida, etc., the draining away of cerebro-spinal fluid may deprive the medulla of its water bed and cause it to rest directly upon bone, so as even to interfere with its functions. The subarachnoid space is continued around the optic nerve in the orbit where it may even become cystic by being shut oflP from the rest of the space. Over the other cranial nerves the arachnoid is continued only a short distance and becomes fused with the nerve sheath, but fluid injected into the subarachnoid or subdural space passes along the nerves as far as the limbs. Without any direct channel fluid may also pass from the subarachnoid to the sul)dural space and even from the former into the longitudinal sinus through the Pacchionian bodies, which are arachnoid villi and project in some cases into the sinus. The ara(!hnoid is not considered as an entity in the pathology of meningeal inflammation. The intimate relations of the pia and brain, the former closely eover- ing the surface and dipping into the substance of the brain as an investment of its blood vessels, siiows that a certain degree of encepha- litis is necessary with lepto-meningitis. The li/injilidfics of the pia open into the subarachnoid space. I./ittle need be said of the brain itself, apart tVom the facts of cere- bral localization and cranio-cerebral topography, except that surgically it is a large soft vascular mass that do(\s not completely All the cranial cavity and hence may be injured i)y shaking or by being thrown about and collidin()ral convolutions. According to some a sensory cortical area (faclile and inii.seular fieiim- tions) is found in the posterior part of the motor area, the posterior central convolution, and the area just behind this, but if present here CRAyiO-CEREBRAL TOPOGRAPHY. 43 this area is not coextensive with the motor area. ^lotor paralysis of cortical orifj'i 11 is often independent of anjcsthesia and wiien the latter coexists it may be due to a dynamical distiirijancc and is usually more temporary than the motor paralysis. According to Fernierand others, lesions of the cortex in the falciform lobe, esj^ccially in the hipjwcampal region and the gyrus fornicatus (Horsley), cause more permanent ansesthesiie, and this region is connected by association fibers with the motor area. The motor and sensory tracts are separate in the nerves, cord, cms and internal capsule and we would hardly expect them to be found together in the cortex. A large part of the cortex is thus seen to be wanting in known function. Of this portion Flechsig has described four areas in the adult, not present in the infant, whose structure is similar and differs from that of other parts. These areas lie in the frontal, temporal and posterior jKirt of the parietal lobe and in the Island of Reil and are called mental or a.'imciatioa centers because they join together the activ- ities of the various organs of sense. These and other unnamed areas of the cortex are probably related to the higher forms of intellectual activity, for the full play of which a general integrity of the whole brain is necessary. But a disease in any one of the parts does not cause the loss of any one mental faculty. Thus very considerable damage or loss of substance has involved the frontal lobes without a serious disturbance of the mental powers. The function of the ('orpora str'mta and optic ihalami is'undetermined. Lesions of them cause no definite symptoms unless they involve the tracts in the internal capsule. The crura cerebri, pons and medulla contain the centers of the cranial nerve nuclei and transmit the motor and sensory tracts to the cord. Hence lesions in them cause cranial nerve palsies on the same side and motor and sensory paralyses of the opposite extremities. Lesions of the crura involve especially the third cranial nerve, those of the pons, the fifth, sixth and seventh. The cerebellum controls the equilibrium of the body so that a staggering gait and vertigo result from lesions of it, especially of its median lobe. The medulla contains, in addition to the centers named above, the respiratory and vaso-motor centers and the inhibitory center of the heart, also the reflex centers for deglutition, sneezing and coughing, etc. Uj)on the above local symjitoms we are dependent for our diagnosis of the location of a lesion. In order to be able to expose by opera- tion that part of the brain where the lesion is thus located we must be able to locate certain of the fissures of the l)rain on the surface of the heatl. Cranio- Cerebral Topography. 1. TIte Relation of the lira in as a Whale la the~ Stnll. — The lower limit of the cerehruni is approximately indieati'd by a line slightly convex upward, about one third of an inch al)(>ve the sujn'aorbital margin, crossing the temi)()ral crest half an inch above the external 44 THE HEAD AND NECK. angular process of the frontal bone, thence somewhat convex down- ward and forward to just above (J inch) the external auditory meatus and from here to the external occipital protuberance, just above the lateral sinus (see p. 36). Below the latter part of the line lies the cerebellum. Each cerebral hemisphere extends up to the superior longitudinal sinus (see p. 36), just to one side of the median line. 2. As to the fissures the localization of the fissures of Rolando and Sylvius, and perhaps also of the jmrieto-occipital fissure, enables the sur- geon to expose all the cortical areas whose function is definitely known. Fig. 8. BREGMA F. OF ROLANDO PAR. OCCIP. FISSURE Cranio-cerebral topography, showing relation of brain and .sonip of the fissures and convolutions to thf sutures and bony landmarks. The Fissure of Rolando. — Measure in the median line the dis- tance between the root of the nose (nasion) and the external occipital protuberance. Half an inch behind the center of this line (or 55/100 of the distance back from the nasion) represents the point where the continuation of this fissure meets the median line. From this point a line drawn downwards and forwards at an angle of 67 degrees with the median line lies over the fissure of Rolando. This is about 3| inches long and commences half an inch or so from the median line. In its lower third the fi.ssure becomes a little more vertical than this line. The upper end of the fissure of Rolando may also be found by drawing Reid's base line from the infraorbital margin through the THE FISSURE OF SYLVIUS. 46 center of the external auditory meatus and erecting a perpendicular from the posterior border of the mastoid process. Where the latter line reaches the median line gives us the point from which to draw the fissure of Rolando as before. Or it may be drawn from this point to the point where another ]icrpendicular to the base line, just in front of the external auditory meatus, intersects the fissure of Sylvius (Reid). This intersection lies on the anterior perpendicular line about two inches above the external auditory meatus. According to Le Fort the direction of the fissure of Rolando is also represented by a line con- necting the ujipermost point of this fissure, as determined by either of the preceding methods, with the middle of the zygomatic arch. The lower end of the fissure of Rolando is about half an inch above the fissure of Sylvius and one inch behind the junction of that fissure with its vertical limb. The lower end of the fissure of Rolando is about one inch (28 cm.), the upper end two inches, behind the coronal suture. The upper end is about at the center of the sagittal suture. The two central convolutions take up about an inch on each side of the fissure of Rolando. Fir;. 9. MID. POINT. EXT. ANG. PROCESS. GLABELLAR. PAR. OCCIP. FISSURE Cranio-cerebral topography, showing the relation of the fissiiies of Rolando and Svlvius, tlie middle mpiiingeal artery and the latoral sinus to tht' Iniidniarks and sutures of tbe head. The fissure of Sylvius is represented on the surface by a line from a point (pteriou) 1 ] inches horizontally behind the external angular process to a point ■[ of an inch below the most prominent point of the 46 THE HEAD AND NECK. parietal eminence. The anterior | of an inch of this line represents the main fissure, the rest of the line the horizontal limb. The short vertical limb ascends for an inch just behind the lower end of the coronal suture from the junction of the main fissure with its horizontal limb, or from a point two inches horizontally behind the external angular process. The fissure of Sylvius is about four inches long, its anterior part is just above (Horsley), below or in the line of the squamous suture. Around its hind end lies the supramarginal gyrus to which the parietal eminence fairly accurately corresponds. Below the Sylvian fissure lies the first temporal gyrus. The anterior part of the fissure slants gently, the posterior part more sharply upwards. Fig. 10. Superior frontal jis2v.re. End of cnUov)- marginal fii>sut e. Infei lor ftontal lobe Parieto- occipital fissure. w Fiasure of Sylvius. Drawing to illustrate crauio-cerebral topography. (Macalister.) Taken from a cast prepared by Professor Cuuuinghani. The parieto- occipital fissure lies | to jV of an inch in front of the lambda (Horsley) or where the fissure of Sylvius continued would reach the median line (or a little below this). It separates the parietal and occipital lobes and runs outwards on the external surface of the brain for about an inch. THE EXTERNAL AUDITORY MEATUS. 47 It may be added tliat the coronal suture lies over the posterior extremities of the three frontal gyr'i, the sulci separating which may be represented as follows: the .superior by a line drawn backwarp from the supraorbital notch parallel with the median line, the inferior by the frontal part of the temporal ridge. It should be remembered that the sulci and gyri are never precisely alike and that their relations to the surface vary slightly in different individuals, but as we expose a considerable area in most cases, the desired area is sure to be exposed and can be recognized by its relation to the sulci and, in the juotor area, by electrical stimulation. THE EAR. The pinna, auricle or external ear, is formed by a partial fusion of six small tubercles on the skin at the end of the first visceral cleft. In connection with this cleft are developed the Eustachian tube, tympanum and external meatus. A supplemental rudimentary pinna is sometimes formed at the end or margins of one of the lower clefts, appearing cougenitally as an irregular mass of fibro-cartilage on the side of the neck. AVlien the fusion of the six tubercles is less com- plete than usual, a tag-like mpermuaerary auricle may be present on the cheek just in front of the ear, or fistulce or fissures of the auricle may occur. The more marked congenital fistulse may be due to de- fective closure of the first branchial cleft. A dermoid cyst of the pinna may result if the opening of such a fistula closes. The framework of yello\v elastic cartilage gives the ear its essential shape which varies greatly in individuals and is largely influenced by heredity. A hcematoma may occur between the skin and the cartilage of the ear and is most common among athletes, such as football players, boxers, or prize fighters, and among the insane. The resulting deposit and contraction of new connective tissue, especially when the accident recurs as in the left ear of prize fighters, causes the markings of the ear to be obliterated and replaced by a wrinkled flattened surface, a condition sometimes known as prize fighter\s ear. Curiously enough a fine antique bronze statue of a boxer discovered in Rome in 1885, and some other antique statues, show this same condition of the left ear. The auricle is so finnli/ attached to the skull by the cartilaginous meatus that the body of average weight maybe lifted from the ground by the ears. The removal of the pinna is followed as a rule by com- paratively little diminution of hearing. As there is but little subcu- taneous fatty tissue between the skin and the cartilage the blood cesi^els of the ear are not well protected against cold so that the ear is often the seat of gangrene from frost bite. As the trunk of the po.'. The external auditory meatus in the adult is about 1 inch in length, of M'hich ^ belongs to the cartilaginous and I to the bony jwrtion. 48 THE HEAD AND NECK. In the infant the bony part is a mere ring and the cartilaginous por- tion is relatively longer and nearly straight, which renders an exami- nation easier. Owing to the obliquity of the drum membrane the inferior and anterior walls are longer than the superior and posterior respectively. Its general direction is inward and forward, but in passing from without inward the outer end slopes upward, the inner part downward so that the center of the canal is the highest point of an upward con- vexity. Furthermore the outer part inclines sharply forward and then bends backward while the bony or inner portion inclines gently forward again. Hence to straighten the canal to introduce a speculum and be able to see the entire membrane the pinna is pulled upward to straighten the upward curve and backward to straighten the antero- posterior curves. The external meatus, the promontory, the cochlea and the internal meatus lie nearly in the same line. Fig. 11. _FENESTnA OVALIS CLOSED BY STAPES Vertical section through the external auditory meatus and tynipannm, passing in front of the fenestra ovalis. (Gkkrish, after Testut.) Diameters. — The outer end is elongated vertically, the inner end slightly transversely, while the middle part is circular. On these differences depend the two forms of ear specula, the one round which fits the narrow circular median part of the canal, the other oval which fits and fills the outer part of the canal. The latter admits more light at the outer end, the former has a larger lumen where it reaches the bony portion. The osseous part is narrower than the cartilaginous FOREIGN BODIES IN THE EAR. 49 and tlie narrotvest part of the canal is at the junction of the middle and inner thirds. The cartilaginous portion of the meatus has a partial //•a//i.?Mwyt of elastic fihro-airtllafje, continuous with the pinna. This cartilage forms hut ^ of the circumference, is incomplete above and behind and tails off as it passes inward to become attached to the lower tiiird of the margin of the osseous meatus. This attachment is by dense fibro- elastic tissue wdiich allows of the shifting of position of the pinna on traction. The cartilage presents clefts or fissures (f.ssures of San- torini) on the floor of the meatus, which are filled with fii)rous tissue. They permit of easier movement of the cartilaginous meatus and allow the spread of inflammation or an abscess from the parotid gland below into the external meatus or vice versa. The skin lining the outer part of the cartilaginous portion is sup- plied with numerous Iiairs, which help to keep out dust and insects, and with sebaceous glands which may be the starting point of small, circumscribed but very painful abscesses. The ceruminous or wax glands, resembling modified sweat glands, stud the skin covering the cartilaginous meatus, and their secretion, "ear wax," is thought to be a defense against dust and the intrusion of insects. When this wax is secreted excessively it may produce plugs which cover the drum membrane or block the meatus and so produce deafness which, curi- ously enough, usually comes on suddenly and is continuous. The skin lining the osseous portion is intimately blended with the periosteum and contains only a few wax glands. The skin of the meatus is liable to eczema and may become inflamed (otitis externa), giving rise to a profuse muco-purulent discharge. In addition to small, circumscribed, glandular abscesses a less common but more serious and more diffuse form may occur beneath the periosteum. This may spread out onto the surface of the mastoid, beneath the periosteum, or it may extend downward into the parotid rt^gion, through the fissures of the cartilage or a (jap in the floor of the osseous portion. This gap is exj)lained as follows. The osseous ])ortion is largely formed by the outward growth of the tympanic ring, at first in two lateral tubercles which meet in the floor, leaving an opening mesial to their junction, which may some- times ])ersist. J*<>li/j'i may grow from the soft linings of the canal and exostoses from its bony walls. Foreign bodies are often lodged in the meatus and inav be very difficult of extraction. More damage has Ix'en done in manv cases by blind or forcible! attempts to remove the foreign body than bv leaving it in place. The ear drum and tym|)anum have been injured in such attempts at removal, while on the other hand, eases are reported where foreign bodies have remained in the ear from thirty to sixty years without harm. The extraction should only be attempted bv means of approjiriate forceps or a blunt hook, while the body is seen and the instruments guided to it through a sjieculum ; or by means of a stream of tepid Nvater forcibly injected through the narrow nozzle of a svringe so as to get behind the body and force it out. 4 50 THE HEAD AND NECK. The relations of the external auditory meatus, especially its bony portion, are of practical importance. The superior wall is in relation with the middle fossa of the skidl and is separated from it by a bony plate 4-5 mm. thick, and sometimes thinner. Hence long-continued subperiosteal inflammation or bone disease in the meatus may extend to the meninges or the brain, without necessarily first involving the tym- panum. Posteriorly the meatus is in relation with the mastoid j^rocess and, at its inner end, with the mastoid antrum. From the latter the meatus is separated by a thin plate of bone, sometimes defective, so that inflammations of the one may extend to the other and inflamma- tion in the antrum may often cause a swelling or bulging of the pos- tero-superior aspect of the inner end of the meatus. The inferior wall is in relation with the portion of the parotid gland occupying the back of the glenoid fossa and, as stated above, a congenital gap may occur here which permits the ready extension of inflammation from the one to the other. The anterior wall is in relation to the temporo-maxillary joint and may be fractured l)y the condyle of the jaw in falls upon the chin. As a result of this injury there may be considerable bleeding from the ear, as also in case the drum membrane is ruptured, hence this symp- tom does not necessarily indicate fracture of the base of the skull. The proximity of this part to the joint helps to explain the pain of move- ment of the jaw when the meatus is inflamed, but this is also explained by the two parts being supplied by the same nerve (auriculo-temporal). Nerve Supply. — The anrieuIo-temporaIsup\)\ies. parts of the meatus and the outer surface of the pinna. The f/reat auricular and small occipital also supply the pinna, while Arnold's nerve supplies the back of the concha and the lower and back part of the outer portion, of the canal. Arnold's nerve, a small branch of the vagus, has been nick- named " alderman\s nerve " from the following circumstance : It is said that diners after a heavy dinner were wont to touch the back of the ear with a napkin moistened with rose water. This is said to be very re- freshing by reason of the stimulation of Arnold's nerve and thereby, reflexly, of the main branch of the vagus, which supplies the stomach. The irritation of the meatus by a plug of wax, the introduction of a speculum, the presence of a foreign body or of an inflammation may give rise to symptoms which are explained as reflexes. Thus ear-coughing and ear-sneezing arc reflexes, through Arnold's nerve, of the branches of the vague supplying the lungs. Vomiting has been caused in like man- ner by an irritation through Arnold's nerve of the gastric branches of the vagus. In ear-yaivning the irritation is conveyed through the auric- ulo-temporal nerve to other branches of the fifth nerve which supply the muscles of the jaw. Again, other branches of the same division of the fifth nerve sujiply the lower teeth (inferior dental) and the tongue (gus- tatory); a circumstance that may account for the frequent association of earache with toofJiarhe or disease in the anterior two-thirds of the tongue. The tympanic membrane is placed so as to face obliquely outward, downward and slightly forward. The obliquity with the horizontal plane is 30°-50° at birth and 40°-45° in the adult. According to THE TYMPAXIC MEMBRA XE. 51 Fick the more vertical the membrane the more sensitive is it to sound and it has been observed to be less oblique in musicians than in those lacking; in a taste for music. Owing to the inclination of the mem- brane and the sloping downward of the inner end of the canal an acute- angled sinus is formed between the two where small foreign bodies, pus and other fluids are likely to collect. The membrane is nearly circular but slightly longer vertically (10 mm.) than horizontally (9 mm.). Its shape however is somewhat irregular for above and an- teriorly, where the tympanic ring is interrupted by a slight recess, the notch of Rivini, the membrane extends to the margin of the tympanum. This portion of the membrane, limited below by two small fibrous bands connectiuy; the two ang^les or corners of the notch of Rivini with the sh(jrt process of the malleus, bulges outward instead of in- ward and is thin and lax, hence called by Shrapnell memhrana fiaccida, and is known as ShrapnelC s membrane. This from its thinness may be readily ruptured by a blow and through it pus may escape from the middle ear without perforating the membrane proper. The inward bulging of the tympanic membrane is due to the position of the long process or handle of the malleus which is embedded between the circular and radiating fibers of the membrane. The center or umbo of this depression is slightly below the center of the membrane and, as may be seen from either side, corresponds to the slightly flat- tened end of the handle of the malleus. A section of the membrane below the umbo shows this part to be slightly convex externally. When pathological products such as mucus, pus, etc., are pent up in the tympanum the inward bulging is diminished or even replaced by an outward one. On the other hand, when the Eustachian tube is occluded and no air can reach the tympanum the atmospheric pressure on the outside of the memljrane increases the inward V)ulging to such an extent that the stapes is constantly pressed inwards and a ringing in the ear is produced. Fig. ]2. POS. FOLD LONG PROCESS OF ■Nr.u^| br ^ N c'^ '|SH O RT PROCESS kLLEUS SHRAPNELL'S MEMBRANE ANT. FOLD OF MEMBRANE PROMONTORY — ^ LIGHT CONE Otoscopic image of right ear dniiu. ( Tkbti-t. ) The otoscopic image of the membrane as seen through an ear speculum is that of a round or oval, concave surface, pearl gray in color with 52 THE HEAD AND NECK. sometimes a violet or yellowish brown tinge and with the following markings. Extending from a little in front of the upper pole down- ward and a little backward to the umbo is seen the handle of the malleus. At the upper end of this, and near the circumference of the membrane, is a whitish point, the short process of the malleus. Behind and parallel Avith the handle of the malleus, but less distinct and not as long, is seen the long process of the incus. Extending downward and forward from the umbo is the ''light cone/' a whitish cone-shaped area of vary- ing shape and size where the light thrown in is reflected back, owing to the inclination and curvature of the membrane. Pathologically this light cone may be wanting when a perforation occupies its posi- tion, when it is bulged outward or the surface dulled by an inflamma- tion of the membrane. Sometimes the chorda ti^mpani nerve may be seen crossing transversely near the upper end of the handle of the malleus. The promontory may also be seen behind the umbo. Practically we may divide the membrane into the parts above and below the umbo. The section above the umbo corresponds to the ossicles, their muscles and ligaments, the chorda tympani, the foramen ovale and the promontory. The greatest vascularity is in this part, the blood vessels being especially prominent on each side of the handle of the malleus. The section of the membrane below the umbo corre- sponds to no important parts and is less vascular and less sensitive than the upper segment ; hence paracentesis is usually practiced here and for the additional reason that the lower incision affords the better drainage of the tympanum. It is noticeable however that the floor of the tympanum is at a lower level than the lower end of the mem- brane so that perfect drainage cannot be secured in the upright posi- tion. As the membrane consists of a framework of circular and radiat- ing fibers of connective tissue, covered internally by mucous membrane and externally by epidermis, it possesses little elasticity ; hence incisions do not gape much and heal readily, often before it is desired, so that paracentesis may need to be repeated. In case of spontaneous perfora- tion from ulceration the wider opening resulting may heal slowly and sometimes not at all. But an opening in the membrane does not necessarily produce much deafness. The arteries supplying the membrane are derived from the stylo- mastoid and the tym|)anic branch of the internal maxillary, the latter supplying mostly the part below the umbo, the former that above it. The aiiri('ulo-f('nipor((l nerve supplies the membrane. The tympanum or middle ear is a narrow cleft-like cavity inter- vening between tlie external meatus and the internal ear. It is sepa- rated from the former by the ear drum, the vibrations of which are transmitted to the internal ear by a chain of three ossicles which cross this narrow s])ace. It contains air which reaches it from the pharynx through the Eustachian tube and it connects })osteri<)rly with the mas- toid antrum and cells. Its mucosa is ciliated except where it covers the membrane, the ossicles and the promontory, where it is thin and squamous. It measures 15 mm. in height and length, above it is 5-6 THE JVMI'AXU.V OR MIDDLE EAR. 53 mm. broad, below 4 ram,, and the umbo and promontory are only separated by 1-2 mm. It projects above the upper limit of the membrane where it widens out somewhat and is called the tympanic attic. The cavity lies o/jliijueli/ so that its outer and inner walls look outward, downward and forward. On its inner wall, opposite the umbo, is the promontort/, above this the fenestra ovalis and below and behind the latter the fenestra ro- tuitda. The fenestra ovalis leads into the vestibule and is closed dur- ing life by the stapes. In the angle between the roof and the inner wall, and appearing as a sligiit convexity above the fenestra ovalis, is the facial canal (aqueductus Fallopii) transmitting the facial nerve. The wall of this canal is very thin, especially in infants in whom it may be defective. This fact accounts i'ov facial paralysis in the course of chronic otitis media, especially in children. The floor of the tympanum is like a narrow gutter below the level of the ear drum and hence drainage of the tympanum is not perfect after paracentesis of this membrane. The floor is only separated from the jitf/alar and carotid fossre by a thin plate of bone and fatal hemor- rhage from the carotid has followed necrosis of this bony plate. The outer wall consists chiefly of the membrane, but is partly osseous and presents the apertures of entrance and exit of the chorda tyrnpani nerve which lies beneath the mucous membrane of this wall. This nerve crosses the upper part of the membrane internal to the handle of the malleus. If affected in connection with otitis media its irrita- tion causes prickling of the end of the tongue, its destuction unilateral loss of taste in the anterior two-thirds of the tongue. The roof or tegmen tympani is a very thin layer of bone which separates the tympanum from the middle fossa of the skull. Defects are sometimes found in the tegmen so that in cases of otitis media inflam- mation may spread from the ear to the meninges or the brain by ex- tension directly through such defects or after necrosis of the thin bony plate, or indirectly along small veins passing through the tegmen to the sigmoid and superior petrosal sinuses. The petro-squamous suture forms the outer boundary of the tegmen, the emincntia arcuata over the su))erior semicircular canal and the groove leading to the hiatus Fallopii form the inner boundary. The suture is generally obliterated by the end of the twelfth year, before which time inflammation may readily spread through the suture mem- brane from the tympanum to the meninges. The suture not infre- quently remains open longer. Fracture of the tegmen and rupture of its closely adhering meml)ranes causes an escape of cerebro-spinal fluid into the middle ear. The tegmen is continuous with the roof of the antrum behind and slopes downward in front to become continuous with the roof of the Kustaciiian canal. The posterior wall at its upper end, on a level with the tympanic attic, presents the irregularly triangular opening into the antrum, and below this there are sometimes smaller openings directly into the mastoid cells. 54 THE HEAD AXD XECK. As the result of chronic inflammatory changes i\\e joints of the ossicles may become stiffened so that they do not readily transmit slight vibra- tions. It is in such cases of partial deafness that the hearing is better in a noisy place, like a crowded street or a railway train, for the result- ing vibrations are sufficient to set the ossicles in vibration and the additional vibrations, due to the voice, are more readily transmitted to the internal ear. When the malleus and incus are removed and the membrane is freely perforated a considerable degree of hearing may be retained, the vibrations being transmitted directly to the stapes through the aperture in the membrane. The tympanum communicates with surrounding parts by many apertures, both large and small, through which pathological processes may extend in various directions. The mastoid antrum, variable in size but about as large as a pea, lies behind the attic of the tympanum into which it opens. The pas- sageway is frequently on a higher level than the floor of the antrum, so that drainage into the tympanum from the antrum is not well pro- vided for and fluid is apt to gravitate into the mastoid cells which communicate with it. As the facial canal descends on the inner wall of this passageway one must keep to the outer wall of the passage in operations, in order to avoid the nerve. It follows also that the antrum lies behind the facial nerve. The antrum lies nearer the outer surface of the skull than the tym- panum and is covered externally by the descending plate of the squamous bone, between the temporal ridge and the masto-squamous suture. This plate may present defects at birth, exposing the antrum. The masto- squamous suture, which is wide in infancy, persists frequently till puberty, occasionally through life, and traces of it are also found in the adult in the shape of foramina, etc., through some of which minute veins pass from the antrum and tympanum. Inflammation travelling along these veins may set up a periostitis on the mastoid. As long as this suture remains uuossified inflammation may spread and pus find a free outlet to the surface from the tympanum and antrum, an occur- rence not infrequent in children. Operations confined to this plate of the squamosal, i. e., above the masto-squamous suture, are safe as regards injury to the sigmoid sinus or the facial canal. Roughly speaking the level of the antrum corre- sponds to that of the upper half of the external osseous meatus and the passage between the tympanum and the antrum corresponds to the postero-superior quadrant of the meatus. Hence the operation of opening the antrum is commenced in the bone just behind this quad- rant, where Macewen has pointed out the existence of what he calls the suprameatal triangle. This occurs in 99.5 per cent, and is well marked in 94.G per cent, of cases. It is usually a depressed area, sometimes a slightly prominent one. It is bounded above by the pos- terior root of the zygoma, below by the postero-superior quadrant of the external meatus and behind by a line drawn vertically from the posterior border of the meatus. The opening is to be made at the latter line, the base of the triangle, and is to be carried inward, with a THE MASTOID .\^rnf\^f. 55 slight inclination forward, parallel with the hony external auditory canal, the direction of which may be determined by a probe passed into it i)Osteriorly between the skin and the l)ony wall. At this point of entrance the outer wall of the antrum is aiiout 2 mm. tliici: in the infant, 1 cm. at nine years (Symington) and 1^ cm. (| inch) or less in the adult, while the inner wall averages f of an inch from the sur- face in tiie adult. Hence in infants pus in the antrum can readily reach the surface or be readily evacuated by operation. As the in- crease of growth of the mastoid involves principally the outer part the antrum becomes more and more deeply placed. Fk;. 13. etAPO" INTERNAL INTERNAL JUGULAR CAROTID VEIN ARTERY AQUEDUCT OF FALLOPIUS Coronal section of the right temporal boue, passing through the Kiistaehian tube and the uiidille of the tympanum. Both surfaces of the section are shown, the parts being hinged on the line zz. (Gerrish after Tkstut.) The other relations of the antrum are of great importance iu case of inflammation extending int(» this cavity or of operations to evacuate the pus. Such inflammations readily extend into the antrum from the tympanum on acconnt of the free opening between them and the con- tinuity of their lining mucosa. The nuiro.sa of tiie antrum is thin and not ciliated. Tiie roof or tegmcn antri is a very (liin plate (about 1 mm.) of bone continuous with but at a little higher level than the tcgmen tympani. Inflammation may readily extend through this thin roof to the meninges, causing meningitis, or into the neighboring brain, caus- ing an al)scess of the temjxtro-sphenoidal lobe or of the cerebellum. The lower border of the posterior root of the zygoma indicates the level of the roof of the antrum and a few lines above this is the base 56 THE HEAD A^D XECK. of the brain. That part of the anterior antral wall separating the antrum from the inner end of the external auditory canal is thin and sometimes defective so that pus from the antrum has been known to escape directly into the meatus and inflammation of the antrum may be shown by a bulging of the postero-superior aspect of this part of the canal. Postero-internally the antrum is in close relation with the sigmoid sinus, 5-7 mm. intervening in the infant. The rear of the antrum may be freely and safely exposed as far as its outer covering by the descending plate of the squamous extends. Development. — The antrum is present and nearly of full size at birth while the mastoid cells are developed later. The mastoid process is present at birth but does not become pronounced externally until about the second year and it continues to grow for many years. The mastoid celts are developed with the process but at first are like spaces of cancellous bone; the true air cells do not appear until after puberty. The cells of the mastoid continue to enlarge and extend well into adult life, when they may reach superiorly within half an inch of the squamo-parietal suture, anteriorly over the external meatus, posteriorly to the masto-occipital suture, and rarely beyond it. The antrum is surrounded by mastoid cells on all sides but its roof. Most of the mastoid cells open directly or indirectly into the antrum and are lined by a mucosa continuous witii and similar to that of the antrum, hence in inflammation of the latter the former are secondarily involved. Suppurative inflammation of the mastoid antrum and cells is one of the most important complications of middle ear disease. Some of the more distant inferior cells are diploic spaces filled with red marrow, and have no direct connection with those above, but in case of inflammation the thin septa between may become disintegrated.' InternaUy the mastoid cells come in very close relation to the sigmoid groove. Onlv a thin osseous layer separates them and occasionally this is defective. As this layer is perforated, opposite the sigmoid bend, by minute veins leading from the mastoid antrum and cells to the sigmoid sinus thrombosis of the latter may result from inflamma- tion in the former. In cases where the outer surface of the mastoid is perforated, as the result of a fracture, or a congenital, atrophic, or pathological loss of substance, emphysema may occur and form a tumor-like bulging [pneumatocele) over the mastoid, the air coming from the mastoid cells. The Eustachian tube, connecting the tympanum with the naso- pharynx, measures 1| inches in length in the adult, and half of this in the infant, in whom it is also wider. Its direction is forward with an inclination of 45° inward and 40" downward in the adult, while in the infant its downward inclination is only 10°. These facts ex- plain tlie readiness with which inflammation spreads from the pharynx to the middle ear and pus or injected fluid in the middle ear escapes ' According to ZiickerkanfU the mastoid cells are entirely air cells in 36.8 per cent., entirely diploic in 20 per cent., and partly air partly diploic cells in 42.2 per cent, of all cases. THE KUSTACHIAN TUBE. 57 into the pharynx. As the tube is shorter, wider and more liorizontal in iiif(int>i and young chihlren inlhitnination spreads more easily from the piiarynx to the tympanum in young sul)jects. Tiie tipapan'w orifice of the tube is on a level with the roof and inner wall of the tympanum and, as it is on a higher level than the floor, it does not serve well for drainage, A straight instrument passed through the tube and on through the tympanum would strike the jf)int between the ineus and stapes and pass into the antrum. In the adult the posterior onc-foiirlh of" tube is l>oi\>i, the rest is cartilaginous, the point of junetion, in the petro-squamous angle, being the narrowest part of the tube. At the same point the tube bends slightly, though for practical purposes it may be regarded as straight. In the middle of its course it lies close to and parallel with the carotid artery, which is internal to it. The lumen of the bony portion is always open, that of the cartilaginous part is merely poten- tial and is only open during the act of swallowing when air may pass from the pharynx to the tympanum and equalize the atmospheric pres- sure on the two sides of the membrane. When the tube is obstructed, as by inflammation or a thickening of the mucosa or by pressure upon its pharyngeal orifice, the pressure on the outside of the membrane is in excess, so that the latter is thrust inward and presses the stapes against the fluid of the vestibule which causes an annoying buzzing or singing. If the obstruction is but slight the singing may cease after an act of swallowing, or, failing in this, by a forcible expiration while the nose and mouth are kept closed ( Valsalva's method) or by forcibly inflating the nose and naso-pharynx by a rubber bag whose outlet is held in one nostril while the patient swallows a mouthful of water as the bag is compressed {Politzer's method) or, finally, by infla- tion through a Eustachian catheter passed into the pharyngeal orifice of the tube. These jihenomena are readily explained by the awttomicrd structure of the cartilaginous part of the tube which is made of a plate of car- tilage folded on itself, the two borders of which are joineil l)v fibrous tissue on the outer aspect of the tube to complete the lumen. To this fibrous portion are attached the tensor palati and palato-pharyngeus, so that when they act in raising the ])alate or in deglutition the tube is o])ened by their pulling the fibrous portion away from the cartilag- inous portion. 80 in swallowing or any act involving the elevation of the palate the Eustachian tube is opened. Advantage is taken of this by artillerymen, who hold open and breathe through the mouth when a loud report is expected. When we breathe through the open mouth the palate is kept elevated and eonse([uently the Kustaehian tube is kept open so that the vibrations of the air on the membrane may be equalized by reaching it from both sides. Thus not only the painful shock of the loud report is avoided, but even the danger of rupturing the membrane. The trumpet-shaped pharyngeal orifice, the largest part of the tube, is vertically elongated and is marked by a prominent ridge above, in 58 THE HEAD AXD NECK. front and behind. Its position is about at the center of the lateral aspect of the naso-phari/iur, its upper border being about equidistant and half an inch from the roof of the pharynx above, its back wall behind, the level of the palate below and the end of the inferior tur- binate bone in front (Tillaux). It lies nearly directly above the pos- terior margin of the aponeurosis of the soft palate and looks downward, inward and forward. At birth it is at or below the level of the palate. With a knowledge of its position, and remembering that it is bounded above and at the sides by a projecting cartilaginous rim and is open below, we pass a Eustachian catheter in one of several ways : (1) After passing it through the inferior meatus of the nose with its beak downward until it touches the posterior wall of the naso-pharynx the beak is turned outward and the catheter is slowly withdrawn until it is felt to glide over the projecting posterior rim of the opening when it is turned still farther until the beak, and the ring on the handle, point to the outer cauthus of the eye. (2) After reaching the posterior wall of the naso-pharynx the beak is turned inward and the catheter withdrawn until its beak catches on the posterior border of the nasal septum when the catheter is rotated through a semicircle so that the beak gliding over the upper surface of the soft palate enters the Eusta- chian orifice on its lower or open side. The curve of the catheter is such that when the curved portion catches on the septum the tip will be far enough behind the margin of the hard palate to enter the Eu- stachian orifice. We may also withdraw the catheter with its beak down until the latter catches on the posterior margin of the hard palate and then rotate outward through 90°, but this plan is not so sure on account of the difficulty of distinguishing between the pos- terior margins of the hard palate and of the aponeurosis of the soft palate. Just behind the prominence caused by the pharyngeal orifice is a depression in the wall of the pharynx, the fossa of Rosenmuller. This may be mistaken for the opening of the tube, for it may readily engage the tip of the catheter, and it is the principal cause of error in passing the catheter. When the catheter is in Rosenmiiller's fossa, the patient gives a sudden start when air is forced through it, but when the catheter is in the Eustachian tube the surgeon can hear the entrance of air into the ear by means of a tube passing between the patient's meatus and his own. This fossa is greatly deepened when tlie pharyngeal (Luschka's) tonsil, internal to it, is enlarged. In cases of denfncsfi associated with In/pertrophy of the /oh.sjV, which lies below the soft palate, the pressure of the enlarged tonsil itself may possibly be the cause of the obstruction of the tube, but the latter is more often due to the associated hypertropiiy of the neighboring adenoid tissue and of that in the mucosa of the tube near the orifice, The movement of the cilia of the epithelium which lines the tube is toward the pharynx. The lymphatics of the external and mid- dle ear and of the Eustachian tube enter glands near the angle of the jaw. REGKfS Tin: OF ORBIT AM) EYE. 59 THE FACE. Region of the Orbit and Eye. The eyebrows are composed of layers similar to those of the scalp except that the subcutaneous layer contains but little fat and the mus- cular layer includes throe intersecting muscles, the corrugator super- cilii, the occipito-frontalis and the orbicularis palpebrarum muscles. Incisions made here should be parallel to the long axis of the eyebrow so that the cicatrix may be hidden in the hairs. Blows or falls may produce a icound made l)y the supraorbital margin cutting through from within and often appearing like an incised wound. The eye- brows, especially their inner end or head, correspond to the frontal sinuses. The outer end or tail of the eyebrows, at the level of the ex- ternal angular process, is a favorite situation for dermoid cyffs, which are here due to a portion of skin being shut in below the surface in the closure of the outer end of the orbito-nasal fissure. Such cysts are beneath and do not involve the skin and often indent the bone. The hairs of the eyebrows help to shade the eyes, to protect them from dust and to deflect the perspiration of the forehead beyond their limits. The corrugator muscle is supplied by the facial nerve and is affected in facial paralysis. The lymphatics of the outer half run to the parotid nodes, those of the inner end to the submaxillary nodes. The eyelids (Fig. 14) serv^e to cover, protect and keep moist the eyes. Examining the component layers successively we find that (1) the skin is very thin and delicate so that extravasation of blood beneath it shows through as a ^^ black eye" almost at once. It presents numer- ous transverse /oW.s- in line with which all incisions in the lid should be made. These folds are most marked beyond the tarsal cartilages and in the ujij)er lid one deeper than the rest (superior palpebral fold), divides the lid into two parts, a lower smoother tarsal portion covering the globe, and an upper more wrinkled orbital portion covering the soft parts of the orbit. The folds of skin are due to its laxity and its lo<)se attachment to the muscular layer by (2) a thin layer of fatless connective tissue. The laxity of the skin makes it well adapted for plastic operations. By reason of its loose attachment it is readily affected by the traction of cicatrices below the lower lid which draw the latter away from the globe and thus produce ectropion or eversion of the lid. Epitlielioma frequently attacks the lids and may in time produce ectropion. The skin contains some pigment which helps to protect the eye from bright light, and the yellowish plaques sometimes seen in the skin in old people, especially near the inner canthus, are due to an accumulation of sebaceous matter in the numerous sebaceous glands. 3. The orbicularis palpebrarum, or sphincter muscle of the lids, by its action, closes the lids, raising the lower and depressing the upper one. As it is attached internally to the firm tendo oculi its contrac- tion draws inward the outer commissure which is attached externally by the less firm external tarsal ligament. This inward motion of the 60 THE HEAD AND NECK. eyelids helps to wash the lachrymal secretion towards the inuer canthus and the puncta lachrymalia. The contracture of the muscle {blepharo- spasm) closes the lids continuously and may reach such a degree as to invert the free border of the lids (entropion), the pressure of which may occasion ulceration of the cornea. The muscle is supplied by the facial nerve in paralysis of which the ability to wink or close the eye- lids is lost. Fig. 14 i^Sr fc,*^ ^-* •* *< ^' I. tod ^ * *r UPPER MARGIN OF ORBIT /&-- ADIPOSE TISSUE LEVATOR PALPEBR>E SUPERIORIS MUSCULAR TENDON OF LEVATOR FORNIX OF CON- JUNCTIVA MEIBOMIAN GLANDS TARSUS GLAND OF MOLL Upper lid in sagittal section. (After Merkel. ) 4. Separating the muscle from the tarsi is a thin, loose connective tissue layer. This is readily hifiltrated by oedema, inflammatory or bloody exudation, etc., which cause a rapid and considerable swelling of the lids. In the puffiness of the lids so common in Bright's dis- ease and some other conditions the swelling is largely in this layer. This layer also includes fibers from the fibrous expansion of the levator palpebrfe muscle in the upper lid and of the corresponding rectus muscle in both lids. THE EYELIDS. 61 5. The stiff plates of closely felted connective tissue called the " tar -al cartilages" form the framework of those parts of the lids which cover the globe. The opposing maiyiini are free, except internally and externally where they unite to form the cmit/ii, the other margins are connected with the periosteum at the margin of the orhit by the pal- pebral faacia. The latter covers the soft i)arts of the orbit and is firm enough to prevent an extravasation within the orbit from reaching the surface of the eyelids. The breadth of the upper tarsus (10 mm.) is about double that of the lower and opposes the examination of the inner surface of the u|>per lid while the inner surface of the lower lid is readily exposed by drawing down that lid. To expone the inner surface of the upper lid, as in the search for foreign bodies, we direct the patient to look down and then seize the eyelashes and the edge of the lid and evert it by raising up the free border while the upper end of the lid is pressed down by a match, small pencil, etc. Attached to the upper border of the upper tarsus and the anterior surface just below this point is the levator muscle "which raises this lid. As it is supplied by the third nerre this lid droojvs (ptosis), -when that nerve is paralyzed. Incisions to reach the cavity of the orbit are made beyond the limits of the tarsi; through the palpebral fascia, usually that of the upper lid. The two tarsi, where they join internally and externally, are connected with the inner and outer orbital margins by the palpebral lif/aments. Of these the inner, tendo oculi, is attached by two limbs to the two ridges bounding the lachrymal groove and thus embraces the lachrymal sac to which it is an important guide. It lies in front and external to the lachrymal sac at the junction of its middle and upper thirds and can be made ])rominent by drawing the lids outwards. 6. The conjunctival mucous membrane adheres closely to the back of the tarsi [palpebral conjunctira). This part of it is thick, red and vas- cular and its degree of redness, in the absence of inflammation, is taken as an indication of the presence or absence of aniemia. In (/ranular lids the little elevations known as granulations are due to enlarged nodules of adenoid tissue, mucous follicles and j)apill8e. From the contraction of the new connective tissue found abundantly in the mem- brane in such conditions the edge of the lids may be inverted (entro- pion). The rich sensory nerre >^Hpplii, from the ophthalmic division and the infraorbital branch of the tilth nerve, e\j)lains the excpiisite pain caused by conjunctivitis or the presence of a foreign body.' The conjunctiva is reflected from the back of the lids onto the sur- face of the globe, the anterior third of which it covers. The ]>()int of this reflection is called the fornix. The uj>pcr fornix is the deeper, extending above the corres{)onding tarsus to the junction of the inferior three-fourths with the superior fourth of the upper lid. Hence iiwisioux to reach the orbital contents are made in the upper fourth of the lid so as to avoid the conjunctiva. The external canthus ' After tlie operation of removal of the (•'(i.iHrridii (/(Dif/lion tlie loss of sensjition of the conjunetivii renders tlie presence of the dust and foreign i)odies painless, but at the same lime the latter set nj) an inflammation of the conjunctiva so that the eye has to be kept closed and protected. 62 THE HEAD AND NECK. is several millimeters from the outer margin of the orbit and the con- junctiva extends beneath the lids here as an external cul de sac or fornix. It is in one of the cul de sacs, superior, external or inferior, that foreign bodies are likely to be lodged. To discover and remove such bodies the inferior and external fornices can be readily explored by drawing the lids downward or outward respectively, while the upper fornix may be explored by everting the lid as described above, or the foreign body may often be removed by pulling down the upper lid so that its inner surface is wiped off on the outer surface of the lower lid. At the inner canthus, which reaches to the inner margin of the orbit, is an island of modified skin, the caruncle, and external to this the conjunctiva presents a small vertical semilimar fold, the homo- logue of the third eyelid or membrana nictitans of birds. The conjunctiva covering the fornices and globe (ocular conjunctiva) is thin and loosely attached so that it is freely movable, which is of great value in some operations. Some of the vessels seen through the ocular conjunctiva belong to the underlying sclerotic, as can be shown by their remaining stationary when the conjunctiva is moved over them. This part of the conjunctiva has but little vascularity, unless it is inflamed, so that the white color of the sclerotic shows through it. The looseness of the subconjunetival tissue over the globe favors the development of (edema, which may reach such an extreme degree that the eye cannot be closed, and the cornea is partly or entirely covered. It also favors the occurrence of subconjunctival ecchymoses which may be due to the giving way of one of the poorly supported vessels, as in severe vomiting or a paroxysm of whooping cough, or to an extravasation from a fracture of the base of the skull involving the orbital roof. One peculiar feature of subconjunctival ecchymoses is the fact that they retain their scarlet color, owing to the thinness of the conjunctiva which allows the air to reach the blood and keep it oxygenated. Although the conjunctiva is normally very thin it may hypertrophy in the form of a vascular triangle (pterygium) the base of which is directed toward one of the canthi, the apex to and finally over the pupil. The arteries of the eyelids, derived from the lachrymal and palpe- bral branches of the ophthalmic, form arches near the borders of the tarsus in the connective tissue layer beneath the muscle. The veins enter into branches of tlie ophthalmic at the outer canthus and into the veins of the face at the inner canthus. Thus the veins of the eyelid and through them those of the face communicate with the cavernous sinus through the ophthalmic vein, so that an infection of the eyelid or face is capable of causing sej)tic thrombosis of the cavernous sinus. The free border of the eyelids, averaging 30 mm. in length, consists of a ciliary portion (outer five-sixths) and a lachrymal portion (inner one- sixth) separated by the projecting papilla on which is the punctum. The ciliary portion is flattened and 2 ram. thick. The two or three rows of obliquely implanted hairs which it presents anteriorly may occasionally project internally and irritate the conjunctiva and cornea. PLATE I I. FIG. 15. LACHRYMAL SAC TFNDO OCULI CANALICULUS CARUNCLE PUNCTUM TENDO OCULI, RE- FLECTED PORTION MUSCLE OF HORNER Horizontal section of lacrymal sac passing through the tendo oculi. Diagrammatic. (Testut.) THE LACHRYMAL M'l'Ml ATI'S. 63 This may be due to a vicious iuiplantation (trichiasis) or to a general inversion of the border (entropion). Intlaniuiation in the hair follicles, their sebaceous glands or the Meibomian glands, but especially in the sebaceous glands, constitutes a " sti/e." The secretion of the Meibo- mian (/lands lubricates the cornea and renders it waterproof. When this secretion is retained in one of the glands it gives rise to a 'tarsal tumor.'' The border of the lid with its sluggish terminal circulation, its junction of sivin and mucous membrane, its moist surface and numerous glands is frequently the seat of troublesome inflamma- tion. The Lachrymal Apparatus. — The lachrymal gland reaches to within a few millimeters of the anterior orbital margin at the upper and outer angle and lies between the superior and external recti. It is enclosed in a fibrous capsule derived from the orbital periosteum so that, according to Tillaux, it may be opened or removed, without opening the post-ocular space, by incising the periosteum at the margin of the orbit and stripping it off from the roof until we reach a point just above the gland. Cysts, tumors and abscesses may occur here. A lower accessory portion of the gland lies above the outer third of the upper conjunctival fornix where also the ducts of the gland open. From this point the tears, neutral in reaction, fall over the front of the eyeball, flusliing it of dust, etc., and are swept inward to the puncta by the contractions of tlie orbicularis muscle. Each papilla curves backward to the surface of the eye and presents at its summit the punctum or commencement of the canaliculus (Fig. 16). The position of the puncta in close apposition with the eye is well adapted for draining off the tears wliich collect here. Sometimes the puncta are displaced forward so that the tears collect and overflow {epiphora) onto the cheek. This may occur when the lower punctum only is displaced, as in swelling of the lid, entropion or ectropion. Among the causes of the latter is a relaxed condition of the orbicularis, present in old age or in facial paralysis when this muscle is paralyzed, for the puncta and inner margin of the lids are held in apposition with the surface of the globe by a specialized part of the orbicularis muscle, known as the muscle of Horner or the tensor tarsi. This muscle arises from the lachrymal bone behind the posterior or reflected limb of tlie tendo oculi and from the latter and is attached to the back of tlie inner end of the tarsi as far as the papilla?. By drawing inward and back- ward the outer end of the tendo oculi and thereby the tarsi, it may also compress the lachrymal sac. It may also help to open or keep open the canaliculi (Fig. lo). The loicer punctum is slightly external to and Uirger than the upper and both are held open by a firm fibrous ring. The canaliculi run at first vertically and then bend sharply and run nearly horizontally in- ward, a point to be remembered in passing a stylet or in injections. Obstruction of the ])tnu'ta or canaliculi, due to inflammation or to com- pression by an inflammation, etc., external to tiiem is ant)ther cause of the overflow of tears. 64 THE HEAD AND NECK. The lachrymal sac, lodged in the lachrymal groove just internal to tiie inner cantlius, receives the canaliouh antero-externally and has the following ((Oidmarks. The inner ridge bounding the lachrymal groove is continuous with the inferior orbital margin and can be palpated. By drawing the eyelids externally the tendo oculi can be seen and felt crossing in front of the sac at the junction of the upper and middle thirds. Consequently it is below the tendo oculi and external to the above ridge that we incixe to open the antero-external aspect of the lachrymal sac in case of lachrymal tumor, to give vent to pus or to introduce instruments. A lachrymal abscess always points below the tendon. In introducing stylets, etc., it is important to know the course and direction of the lachrymal sac and its continuation, the Fig. 16. PCNING OF CANALIC. NTO LACHRYMAL SAC NF. ORIFICE OF NASAL DUCT IMF. TURBINATE BONE Transverse obIi(iue section ilnough nasal canal, viewed fnmi in front. (Tkstut.) nasal duct. These together are not quite straight, but slightly curved so as to be concave posteriorly and are directed downward, backward and slightly outward. Together they average a little over one \nrh in length (2G mm.) of which the sac represents the upper two-fifths. Lachrymal tumor is usually due to a chronic inflammation and thicken- ing of the lining mucous membrane. It forms a swelling at the inner corner of the orbit and its evacuation is occasionally followed by a lachrymal fistula. Varts to be readily injured as there is no sensation an,s SINUS TH«o;*"0 ^^ OPENINGS OF POSTERIOR ETHMOIDAL CELLS External wall of right nasal fossa, parts of the turbinates having been cut away to show the orifices of the siiiii-si's which open into the meatuses. (tiiCKUisil, after Tkstct. ) ments along the inferior meatus. Tiie latter is the icided part of the nasal fossne, measuring about one half inch. Its greatest height (three fourths inch) corresponds to the opening of the ndsal duct, which is about 1 to 1-| inches behind the nostril. This t)pening lies just beneath the attached border of the inferior turbinate bone at the meeting of its anterior fourth, Avhich is slanted sharply downward and forward, and its posterior three fourths, which are slanted more gradually down- ward and backward (see also ]>, ().")). The sharp downward slant of the anterior fourth of the inferior turbinate bone renders the height of the inferior meatus but little in front and less here than it is behind. Hence itifipired air is not so apt to enter this meatus, expired air more apt to. This tendency is increased by the downward direction of the 78 THE HEAD AND NECK. nostrils, the consequent upward current of inspired air, the wide fun- nel-shaped anterior end of the middle meatus (tJieafrii(m) Sind the nar- rowed posterior end of this meatus. This explains the fact that we smell inspired air, for it passes through a meatus (middle) part of whose walls is supplied by the olfactory nerves, as well as the fact that we do not smell expired air, for it passes largely through the inferior meatus which the olfactory nerv^es do not reach. Also if we wish to smell an object we dilate the nostrils and sniff up the air which thereby is carried into the upper olfactory part of the fossse. The anterior end of the middle turbinate bone inclines upward so that it reaches the level of the inner canthus of the eye. This upward incliuation makes the middle meatus open up widely in front iuto the atrium, into which au instrument, introduced through the nostril, passes more readily than into the inferior meatus, unless care is taken. About the center of the middle meatus is the slit-like opening of the antrum, about one incli above the floor of the nasal fossa and nearer the roof than the floor of the antrum. This opening is at the lower end of a deep groove, the infundibulum, which curves downward and backward, beneath the attached margin of the superior turbinate bone, from the opening of the canal leading from the frontal sinus. Into this groove open also the anterior ethmoid cells. The mucous membrane varies in different parts of the nasal fos- sse. Behind the vestibule the nasal fossa is divided into an upper olfactory region including the middle and upper turbinate bones and the up})er third of the septum, which is covered by columnar epithe- lium, and a lower respiratory region including the rest of the fossa, which is covered by columnar, ciliated epithelium. On the outer wall between the turbinate bones and on the floor the mucosa is thin, else- where it is thick and vascular, especially over the turbinate bones. This thickness over the turbinates is largely due to the abundant sub- mucous venous j)lexus, the meshes of which run mostly antero-poste- riorly. The mucous membrane extends in a fold beyond the inferior turbinate bone in front, behind and below. Over this bone the veins of the thick mucosa form a kind of cavernous or erectile tissue. This may swell up rapidly from engorgement of the veins so as to come in contact with the septum and this contact is in itself a source of irri- tation. The rapid shrinkage of this "erectile body" when a caustic like chromic acid is applied to it is very striking. The acinous glands of the mucosa, secreting for the most part a thin watery fluid, are most numerous over the inferior turbinate bone and the middle and posterior parts of the fossae. They account for the profuse secretion in coryza. The normal function of this secretion appears to be to moisten the inspired air, that of the great vascularity of the mucosa to warm ti)e inspired air. Adenoid tissue is abundant in the mucosa of the posterior part and is continuous with that of the nasopharynx. Several of the openings found in the bony fossae are closed by the mucosa. From the relations of the nasal fossae and the continuity of its mucosa with that of other parts it follows that infkrni- THE NERVE SUPPLY. 79 matioii of this mucosa (coryza) may spraul tliroiitrh tlie ])osterior iiares to the ])liarynx and to the Eustachian tubes, tliroui^h the nasal duct to the lachrymal sac and conjunctiva and through the iniundibulum to the frontal and maxillary sinuses and the ethmoid cells. One or more of these extensions is often exempliiied in a coryza. Swollen turbinate bones may be mistaken for mucous polypi whicii are common in the nose and usually arise from the inferior or middle turbinate bones. They often grow in crops, block the fossae and may press upon and widen the nose or obstruct the opening on its outer wall. They may be removed with the snare or polypus forceps, care being taken not to damage the cribriform plate in case of liigh attach- ment. The fibrous and sarcomatous polypi take origin as a rule from the periosteum of the roof of the nose or piiarynx and spread in all directions. The blood supply of the nose is derived from three sources, the ophthalmic, facial and internal maxillary. The veins, in addition to accompanying the arteries, communicate with the superior longitudinal sinus through the foramen ctecum in children and sometimes in adults. This communication and that with the cavernous sinus through the ophthalmic veins help to explain intracranial complications in some cases of inflammation of the nasal cavities. Bleeding from the nose, or epidaxis, may be due to fracture or other injury, general oozing of the vascular mucosa, ulceration or venous con- gestion, as in cardiac or pulmonary disease. In the latter case the patient should be kept erect to aid venous return and the raising of the arras is recommended on account of the resulting expansion of the thorax and its aspiration upon the cervical veins. In some cases the bleeding is vicarious. The tdcerafions are apt to be on the septum, where they should be sought for. Nose bleed may be profuse and long continued; as much as 75 lbs. of blood has been lost altogether (Frankel), and it has continued for twenty months on and off (Spencer Watson). If it resists local applications pft>(jf/i)u/ of the nares or nasal fossiB (p. 7")) may have to be employed to arrest a fatal result, which has occasionally occurred. The great vascularity of the nasal mucosa accounts for the frequent occurrence of epistaxis. The lymphatics communicate through the cribriform plate with the subdural si)ace and also enter the submaxillary, parotid and retro- pharyngeal nodes. Abscess of the last-named nodes may therefore be due to disease of the nose, and in lymphadenitis of the cervical nodes we are forced by exclusion in many cases to assume, if not to prove, that the source of infection was in the nose or naso]iharyux. The nerve supply, apart from the olfactory nerve whose distribu- tion has been given above, is from the first and second divisions of the fifth iierre. The nasa/ bnowh of the opJdhulmie division of the fifth nerve supjilies theantero-su})erior part of the nasal fossa? and ex- plains the following reflexes in connection with other branches of this division of the nerve ; i. e., the kichri/nuition that may follow a pun- gent odor and the sneezing from looking at bright sunlight. In tlie 80 THE HEAD AND NECK. former case the irritation is referred to the lachrymal branch of the same division and in the latter case it is referred from the nerves of the orbit to the nasal branch. Sncczhuj also follows the direct irrita- tion of the nerves of the nose by chemical or mechanical irritants like snuff or dust or the abnormal contact of the septum and outer wall of the nose. Carious accidents have occurred during violent acts of sneezing. Thus Treves mentions fracture of the ninth rib, disloca- tion of the shoulder, and rupture of all the coverings of a large fem- oral hernia. The lodgment of foreign bodies in the nose is quite common. That they may remain in some cases for long periods of time without caus- ing much trouble is illustrated by a case reported by Tillaux of an old woman from whose nose he removed a cherry stone that had lodged there for twenty years. When they remain long they may become encrusted by calcareous matter and thus form rhinoliths which are most common in the lower meatus. In some cases of chronic purulent dis- charge from one nostril the cause may be the presence of a bean, bead, button or other foreign body in the nose. The nasal douche may be used in more than one way. Thus with the head lowered a little and the mouth open the nozzle of the irriga- tor is introduced into one nostril and the fluid flows out of the other after passing from one fossa to the other behind the posterior nares. This is possible from the fact that in breathing through the mouth the palate is elevated so as to continue in line with the nasal floor behind the posterior nares and shut off the nasal fossa from the pharynx. But at the same time the Eustachian tube is opened by the same mech- anism that raises the palate and there is some danger of infection being carried into it. Again, with the head tilted slightly backward, the douche may be allowed to flow back until it reaches the pharynx, the mouth being kept closed. The Accessory Sinuses of the Nose. The frontal sinuses do not exist at birth but their evolution occurs between tiie seventh and twenty-first year. Tliey may be considered as developed from the diploe and hence lie between the inner and outer tables of the skull, or they may be considered as prolongations of the ethmcjid cells. They are situated above and external to the nose, above and internal to the orbits, and beneath and in front of the cranial cavity. They lie on either side of the glabelhi and behind the .super- ciliary ridges whose prominence they form. But the absence of these prominences does not necessarily imply absence of the sinuses as they may extend backward only. The orbital and cranial walls of the sinuses are formed by thin l>ony lamella?. The sinuses are divided into two lateral halves by a scptma, often incomplete and sometimes want- ing, which is median inferiorly but deviates to one side above. Sometimes they are so small as to be scarcely noticeable, at other times they may be large enough to contain two or more ounces, or to contain a foreign body of some size. In old people these sinuses may THE ANTRUM OF HIGHMORE. 81 enlarge as the brain shrinks. Well-developed sinuses may extend 2 inches upward, 1^ inches outward and nearly as far backward. In injury to this re<^ion there may be a depressed Jrcictare without damage to the cranial cavity, in which case air may be forced through the opening on blowing the nose and cause frothing of the blood if the fracture be compound, or subcutaneous emphysema in a simple fracture. In the adult therefore fracture here is less serious than elsewhere on the skull, as the brain case may be spared. The frontal sinuses are lined by a pah-, thin, loosely adherent lan- cosa continuous with that of the nose, through the infundibula, and liable to extension of iaiiammation from the nose. Hence the frontal headache in some cases of coryza, ozoena, etc. The mfundibular pas- sage is d('e|)ly placed near the inner wall of the orbit and opens into the infinulibular groove about on a line with the tendo oculi. By the swelling of the mucosa of the infundibulura its lumen is tem])orarily occluded. When pus forms we have empyema of the frontal sinus or sinuses. P^ventually in such cases the walls give way at their weakest point, which in 90 per cent, of cases is the orbital roof, and the abscess discharges through the inner half of the upper lid. Occasionally the posterior wall of the sinus is eroded and perforated, giving rise to a subdural abscess or pachymeningitis, or in some cases meningitis or brain abscess. The frontal sinuses require openhif/ by the chisel, burr or trephine in cases of empyema and may be reached by a vertical incision which avoids the vessels and nerves of this region. This incision is made in the median line to open both sinuses or laterally, cither internal or external to the supraorbital notch, to open a single sinus. The rees- tablishment of drainage into the nose is most desirable. In some curious cases insects like centipedes, larvfe and even mag- gots have found their way into the frontal sinuses; in the latter case setting uj) a violent septic iiiHamniation. Bony tumors may grow from the fibrous hiycr lining the deep surface of the mucosa. The antrum of Hig-hmore or maxillary sinus (Figs. 16 and 19) is present at birth, but continues to grow until old age when its walls become very thin. It occu])ies the body of the maxilla and is ]iyramidal in s/iajjc with its base internally toward the nasal fossa. Its anterior or facial wall is the thickest but the most accessible so that the upeninc/ of an empyema of the antrum is usually made on this surface above the first or second molars, after incision of the mucous membrane where it is reflected from the gums to the cheek. Inflannnation and iinjiyema of the antrum may be due to the diseased root of a tooth, especially that of the first and second molars. The roofs of the latter teeth often cause a prominence in the lower j>artof the antrum and may even pro- ject uncovered into it. In diseased conditions the sockets of almost any of the teeth may eonnnunicate with it. M'hcn the diseasetl root of a first or second molar is drawn it may open :uid drain the antrum from its lowest ])oint but this method of drainage as an operation of choice has the disadvantage that it allows food particles to enter the 6 82 THE HEAD AND NECK. antrum. Behind the antrum is the sphenomaxillary fossa (Fig, 19) con- taining Meckel's ganglion, to remove which the route through the antrum, after resecting its facial and zygomatic walls, has been tried. The upper wall separating it from the orbit is very thin so that tumors of either of these cavities readily extend into the other. As this wall contains the infraorbital nerve, in a groove and canal, and the anterior and posterior walls contain the nerves of the upper teeth, tumors, etc., which press upon these walls are likely to cause neuralgia of the face and teeth. The inner wall or base corresponds to the outer wall of the nose in the inferior and middle meatuses, in the latter of which at the lower end of the infundibular groove is the orifice of the antrum. As this is above the middle of the cavity it is not arranged for drain- age. Sometimes, in perhaps 10 per cent, of cases, there is another opening a little further back which is pathological in many cases. This wall is so thin as to be readily perforated. The mucosa of the nasal fossa is continuous with that of the antrum and in this way inflammation may extend from the nose to the antrum. The mucosa of the antrum resembles that of the frontal sinus but is somewhat more vascular and more richly supplied with mucous glands. The latter are quite prone to cystic formation whereby the antrum may be partly or wholly filled, a condition sometimes erroneously called dropsy of the antrum. Tumors of the upper jaw may originate in the antrum or grow with great rapidity on entering it, and in either case they distend its ivalls. Thus, pushing up the roof, they invade the orbit, and breaking through the thin inner wall, they obstruct the nasal fossa. They also protrude through the bottom of the antrum onto the roof of the mouth and form a projection on the cheek. The only treatment for such conditions is the excision of the upper jaw. In one case of fracture of the anterior wall of the antrum under my care emphysema of the cheek was present and was increased on blowing the nose. Occasion- ally the antrum is subdivided by bony septa into recesses or separate chambers. As to the sphenoidal sinuses little need be said except that like the other sinuses of the face they serve the purpose of lightening the face so that in spite of its growth the equilibrium between the anterior and posterior parts of the head at its articulation with the spine is not disturbed. Also, like the maxillary sinus, it may have some effect on the quality of the voice, acting like a sounding box. Fracture through them leads to bleeding from the nose and may establish a communication between the latter and the cranial cavity. Dense ex- ostoses occur within them as within the frontal sinuses. THE FACE. This region, apart from the eyebrows, eyelids and nose, already studied, and the parotid region and lips, to be considered later, we will study layer by layer. The lower limit of this region and the boundary between it and the neck is the lower border of the lower jaw. 77//; SUBCUTAyEOUS LAYER. 83 The skin of the face is for the most pari thin, line and very vas- cular. Its rdsculariti/ is seen in the ready flushing of the cheeks, in bhishintj; and fever ; in the free bleeding and rapid healing of wounds or incisions; in the varicose or injected condition of its fine vessels in those exposed to cold and in the subjects of alcoholism and acne ; and in the common occurrence of nsevi and various forms of vascular tumors. As the shin is richly supplied with sebaceous and sweat glands it is a favorite site for acne and sef>areoi(,s cysts. The latter sometimes re(j[uire the use of the knife to avoid a more disfiguring scar. The skin of the face is also a favorite situation for the development of epitheiloiiia and lupus. Over the chin, from the median line to the posterior border of the depressor angularis muscle, the skin ])artakes of the character of that of the scalp, or more nearly that of the eye- brows, for instead of a fibroadipose subcutaneous layer, as in the scalp, we have muscle fibers of several intersecting muscles attached to the skin interspersed with small pellets of fat. Here too as in the scalp the skin is thick and dense and contains numerous hairs and seba- ceous glands, and the arterioles, adherent to the parts through which they pass, are difficult to seize wath the artery clamp. When the skin of this part or that covering the malar bone is struck by a blunt in- strument or in a fall a wound may be produced simulating an incised wound, as is also the case with the scalp. The subcutaneous layer is in general lax so that on the one hand it favors the spread of inflammations, oedema, etc., and on the other hand it increases the mobility of the skin and renders it suitable for the various plastic operations done here. In iwdammation or oedema the face may be greatly sw^ollen and in the latter condition the swell- ing first appears, as a rule, in the loose subcutaneous tissue of the lower lid. The quantity of fat in the subcutaneous tissue varies in different parts and under varying circumstances. Thus it is espe- cially abundant in the cheeks, or those lateral regions corresponding to the area lined by the mucous membrane on the inner surface. It is firmer and more abundant in children and well nourished persons, more scanty in old age and after wasting diseases, as indicated by hollow cheeks and prominent cheek bones. Fatty tumors are exceed- ingly rare here. In this layer lie the main blood vessels of the face, the principal branches of the facial nerve, (in front of the anterior border of the masseter), a lyuiph node near the lower border of the mandible and the facial muscles of expression. The facial artery, where it crosses the lower border of the mandible at the antero-inferior angle of the mas- seter, lies just anterior to its vein and is covered by the skin and platysma only. Here its pulsations can be easily felt and it can be readily compressed against the bone or ligated. In passing towards the angle of the mouth and the ala of the nose and thence up beneath the nasofacial groove it describes the arc of a curve whose cord is formed by the straightor and more superficial facial vein. The free communication of the latter with the cavernous sinus througii the 84 THE HEAD AND NECK. ophthalmic vein explains the danger of intracranial complications like sinus-thrombosis, in case of septic processes of the face, such as car- buncle, erysipelas, malignant pustule, etc., especially when they occur near the course of the facial vein, along which they may spread as a phlebitis or periphlebitis. MaUgnant pustule, a disease transmitted from cattle, attacks the face, on account of its free exposure, more often than any other part (even the hands). Also in the young a form of gangrene, cancrum oris, some- times attacks and extensively destroys the soft parts of the cheek to such an extent that in some cases the jaws may be firmly closed by the contraction of the resulting scar. Owing to the free blood supply ex- tensive flaps in ])lastic operations, or even those torn up in lacerated wounds, keep their vitality in a very remarkable manner. As the anastomosis is very free between the two sides of the foce or two ad- joining l)ranches of the artery both ends of a divided facial artery must be sought and tied to check bleeding. The lymph node near the vessels as they cross the border of the mandible, is often enlarged in cases of alveolar periostitis, etc., from dental caries. Abscess in this region not infrequently originates in this way. The Nerves. — The branches of the facial nerve are nearly hori- zontal in direction. They anastomose and form plexuses with the in- fraorbital, mental and buccal branches of the fifth nerve. The facial nerve supplies the muscles of expression, hence in facial paralysis there is a lack of expression on the side ])aralyzed, the lines of the face are flattened out and the surface is smoother than normal. The cause of the paralysis may be within the brain, in the passage of the nerve through the skull, in the aqueduct of Fallopius, or external to the skull. The si/mptoms help us to determine the position of the lesion according as one or another branch, given oif along its course, is affected or not. Thus, if the palate can not be elevated or shortened on the side paralyzed, the lesion is thought to be internal to the genic- ulate ganglion from which the great superficial petrosal nerve passes to Meckel's ganglion and, according to many, from thence by pala- tine branches to the levator palati and azygos uvula? muscles. On the contrary, if these muscles act the lesion is thought to be distal to the geniculate ganglion. Again, if the taste is lost on one side of the front of the tongue the lesion is ])roximal to, if it is not lost it is distal to, the origin and giving off of the chorda ti/mpani branch in the lower part of the Falh)pian aqueduct, for this branch conveys taste fibers from the glossopiiaryngeal nucleus to the tongue. Just below the aqueduct there is given off the posterior anric}dar branch which supplies the posterior belly of the occipitofrontalis and the retrahens and attollens aurem so that these muscles are paralyzed if the lesion is proximal to this branch but not if it is distal to it, and so on. As the orbicularis palpebrarum, frontaHi< and corrugator supei^dlii muscles are not involved in facial jiaralysis due to a lesion of the cortical facial center, it is probable that the fibers which supply them reach the facial nerve from the oculomotor nucleus. Also the involve- MECKEL'S GANGLION. 85 meat of the orbicularis oris iu bulbar paralysis and the close associa- tion of the movements of the lips and tongue suggest that tiiis muscle is supplied from the /if/pof/fossrff nucleus through the facial. The cliiej features of facial paralysis are the inability to wink or close the eye, so that the cornea is always exposed, the dripping of tears over the cheek (see p. 63), a flabby cheek between which and the gums food lodges, the inability to whistle or pucker the mouth and an expressionless corner of the mouth, with or without partial loss of taste and paralysis of the palate muscles. Elrctrieitij can be applied to the nerve or its branches ; to the undivided trunk by an electrode pressed as deeply as possible between the mastoid process and the cartilaginous auditory meatus. Below its exit from the stylomastoid foramen the facial nerve is accessible to surgical procedure through a curved incision in front of the mastoid process and the sternomastoid muscle. The latter is retracted backward and the parotid gland forward, and by blunt dis- section the styloid process is reached, behind which tiie nerve emerges. Though the main trunks of the sensory nerves belong to the deepest layer of the face their filaments pass through the subcutaneous layer to reach the skin. To complete the study of the nerves of the face they are best considered here. They are branches of the fifth nerve and three such branches concern the region under consideration. The infraorbital branch of the maxillary (second) division of the fifth nerve, after passing along a groove and then a canal in the floor of the orbit (and the roof of the antrum), emerges on the face at the infraorbital foramen. This is situated at the nj^per end of the canine fossa, one third of an inch below the inferior margin of the orbit, near the junc- tion of its middle and inner thirds and in a vertical line from the interval between the two upper bicuspids or from the second bicuspid. When, as sometimes occurs, it is the seat of an obstinate neuralgia it may be reached and resected either by incising the mucous membrane above the bicuspids and separating the soft parts from the bone, or by a curved or angular cutaneous incision below the orbit. By lifting up the contents of the or])it from its floor the nerve is exposed in the bony groove in which it lies and that part of it may be resected which lies between the groove and the foramen. The small arterial branch accompanying the infraorbital nerve may usually be disregarded. Meckel's ganglion has often been resected ibr certain neuralgias of the second tlivision of the fifth nerve by following the infVaorl)ital nerve backward. Thus, after incixiiu/ through the lip and along the nasolabial and nasofacial grooves, a flap of skin is turned up and the anterior wall of the antrum <)])oned, ujt to the infraorbital foramen. The bony canal and groove of the nerve is then laid open from beneath and, following the nerve, the posterior wall of the antrum is trephined, opening into the sphenoniaxillarj/ fossct. (Fig. 17.) This exposes the triangular reddish ganglion one fifth of an inch in diameter, lying below the main nerve. The terminal branches of the internal maxillary artery are in close relation to the ga!iglion. External to it is the 86 THE HEAD AND NECK. external pterygoid muscle, internal to it the vertical plate of the palate bone and the sphenopalatine foramen. Behind the ganglion the nerve trunk can be followed back to the foramen rotundum. The mental branch of the inferior dental trunk of the mandibular division of the fifth nerve emerges at the mental foramen, below the interval between the two lower bicuspids or below the second bicuspid. It is thus seen to lie in the same vertical line with the infraorbital foramen and if this line is continued upward it strikes the supraorbital notch or foramen. Hence these three branches of the three divisions of the fifth nerve emerge through bony openings in the same vertical line. The mental foramen in the adult is midway between the lower and the alveolar borders of the jaw, in the aged near the latter, in the infant near the former. It may be exposed by a cutaneous incision or by one through the gingivolabial fold of mucous membrane, remem- bering that the foramen lies one third of an inch below this fold. The main trunk of this nerve, the inferior dental, may be exposed for exsection at its entry into the inferior dental foramen in one of several ways. The foramen, it should be remembered, is about equi- distant from all four borders of the ramus, that is about the center of the inner surface. Surmounting the foramen in front is the mandibu- lar spine to be used as a landmark when we expose the nerve at its entrance into the foramen. This is done from within the mouth by incising the mucous membrane from the last upper molar to the inner side of the coronoid process, thus exposing the tendon of the temporal muscle. The finger is then introduced backwards between the ramus of the jaw and the internal pterygoid muscle till the mandibular spine is felt. Thereupon the nerve is hooked forward by a blunt hook, iso- lated from its accompanying vessels and divided, or a piece cut out of it. From the outside we may expose the nerve by an angular incision of 3 cm. upward and 5 cm. forward from the angle of the jaw. The periosteum of the borders of the ramus is divided to the same extent and then stripped up from the inner surface until the mandibular spine is reached. Again it may be exposed l)y resection of the angle or posterior border of the ramus of the jaw, or by a vertical incision over the middle of the ramus, retracting Stenson's duct upward, separating the fibers of the masseter, dividing the periosteum in the same line and trephining or chiselling through the center of the ramus. In all external vertical incisions great care must be taken to avoid Stenson's duct and the facial nerve. The buccal nerve (Fig. 21) is another sensory branch of the fifth nerve, sometimes aifected by neuralgia which is felt in the skin and mucosa of the cheek and lips. It may be exposed from within or without the mouth. As the nerve courses forwards on the inner sur- face of the temporal muscle, near its insertion on the coronoid process, it is only covered by the mucous meml)rane, buccinator muscle and fatty tissue, so that it may be exposed by dividing the latter layers vertically behind the last molar. From the outside it may be exposed by a transverse incision of 5 cm. over the course of Stenson's duct (see p. 87). PLATE V. FIG. 21. TEM PORAL MUSCLE BUCCAL NERVE EXTERNAL PTERYGO MUSCLE MASSETER MUSCLE INFERIOR DENTAL NERVE BUCCINATOR MUSCLE LINGUAL NERVE Zygomatic fossa and adjacent parts as seen when exposed from the vestibule of the mouih. (Zuckerkandl. ) STENSON'S DUCT. 87 Stenson's duct and accompanying nerves are retracted npward or downward, the fatty tissue (Biciiat's lobule) between tlie buccinator and masseter is removed or retracted and the nerve is seized opposite the insertion of the temporal muscle, about 2^ cm. behind the ante- rior border of the masseter. In this or anv operation on the face transverse incisions are preferable and vertical incisions objectionable because of the danger of wound- ing important structures having a transverse course. These are the branches of the facial nerve, already mentioned, and the duct of Sten- son whose course is given below. This, the excretory duct of the parotid gland is beneath the deep fascia, -which forms the next of the several layers of this region. This fascia is continued forward from the parotid gland, of which it forms the sheath. The two layers of the parotid sheath unite and form the fascial covering of the masseter and, in front of this, of the buccinator. Beneath the masseteric fascia lie the branches of the facial nerve which (except the buccal branches) pierce it at the anterior border of the muscle. Stenson's duct, one eighth of an inch in diameter, extends forward for 2 to 2?, inches from the anterior border of the parotid gland to the opening of the duct on the buccal mucosa, opjjosife the crown of the second molar, 4 mm. below the reflection of the mucosa from the gums to the cheek and about 33 mm. behind the angle of the mouth. The course of the duct is a finger's breadth or three quarters of an inch below the zygoma or in a line from the tragus of the ear to the mid- point of the upper lip. The posterior or masseteric portion crosses the middle of the masseter, having the socia pjarotidis above or superficial to it, the transverse facial artery above it, and the buccal branch of the facial nerve below it. It then bends sharply inward through the fat of the cheek to the buccinator muscle through which the anterior or buccal portion runs obliquely forward and then for a short distance between the muscle and the lining mucosa to its termination. The bends in its course should be remembered, for in passing a probe through it they should be straightened out by pulling forward the angle of the mouth. The course of the duct should be particularly remembered so as to avoid it in any incision in the cheek, for its divi- sion may be followed by an obstinate salivary fistula. This is particu- larly troublesome in the posterior or masseteric portion where the only successful conservative treatment is an anastomosis between the divided ends, a difficult matter on account of its small size. In the anterior or buccal portion of the duct a salivary fistula may be successfully treated by stitching the proximal end of the duct into an ojiening in the buccal mucosa, made by incising through the buccinator, behind its normal opening. The duct is surrounded by a fibrous sheath continued forward from the jiarotid sheath and by a fibrous sheath of its own. ]^oth of these sheaths leave it where it penetrates the buccinator and there become continuous with the fascial covering of this muscle. Jujiatamation may travel back along the duct from the buccal cavity to the gland, 88 THE HEAD AND NECK. in case of stomatitis in the former. It is not unlikely that this is the route of infection in some cases of acute parotitis complicating acute infectious diseases. Hence the importance of antiseptic mouth washes in these conditions. Between the buccinator and its fascia and behind Stenson's duct is a group of deep buccal or molar glands which may be the origin of cysts or adenoma. They are opposite the last two molars. Behind these and filling the space between the buccinator and the masseter is 2k pad of fat, the buccal fat pad or ^' Bichat's lobule." This is quite constant, even in emaciated conditions, but if it be absorbed in wast- ing diseases a marked hollow of the cheek is produced in front of the masseter. A swelling, from lipoma or ah.sce.Hs in this situation, points in the mouth, as it is beneath the buccal fascia. In case of abscess it is to be noticed that this fat is continuous with the fat and loose areolar tissue in the temporal and zygomatic fossse and that which covers the upper part of the pharynx. The mucous inembrane lining the buccinator is thin and directly adherent to the muscle without sub- mucous tissue between. The Parotid Region. This is bounded superficially in front by the posterior border of the mandible; behind by tlie mastoid process and sternomastoid muscle; above by the auditory meatus, the condyle of the jaw and the posterior part of the zygoma ; below by a line from the angle of the jaw to the sternomastoid muscle, outlined by a thickened band of the cervical fascia. The surgical anatomy of this region is most important on account of the important parts in relation or contiguity with the paro- tid gland which occupies it. This gland is lodr/ed in a narrow and deep but well-defined space, the parotid compartment, which is bounded as follows : behind by tlie sterno- mastoid, the posterior belly of the digastric and the mastoid process; in front by the posterior border of the ramus of the jaw, covered by the masseter and internal pterygoid muscles ; above by the external auditory meatus and the posterior part of the glenoid fossa ; beloia by the stylomaxillary ligament which separates the parotid from the posterior end of the submaxillary gland ; internally by the styloid process and its muscles, which separate it from the internal carotid and internal jugular, with their accompanying nerves, and, in front of these, from the loose tissue around the pharynx. Internal to the parotid si)ace and in front of and below the tip of the mastoid may be felt the transverse process of the atlas, covered in part perhaps by the posterior belly of the digastric. Within these limits the i)arotid is enclosed within a distinct sheath which is derived from the deep cervical fascia. At the anterior border of the sternomastoid the fascia which has formed the sheath of the muscle, divides into two layers, one of which passes internal and the other external to the gland. These layers unite in front of the gland to become continuous with the fascia covering the masseter ; and below the gland they unite along the thickened band between the angle of PLATE VI FACIAL NERVE PAROTID APONEU- ROSIS, SUPERFIC LAYER FIG. 22. RO- LLARY LOID OCESS D ITS USCLES Horizontal section through the left parotid connpartment. Diagrammatic. Arrow indicates the pliaryngeal opening of the compartment. (Testui. ) FIG. 23. EXT. AUDITORY CANAL )"'„„. \ STYLOID PROCESS PAROTID APON EU- ROSIS, SUPERFIC. LAYER Frontal section through the right parotid compartment to show its relations. Dia- grammatic. Arrow indicates the pharyn- geal opening of the compartment. (Testui.) THE PAROTID REGION. 89 the jaw and the sternomastoid muscle. From tliis hand the inner layer passes inward and upward on the outer aspect of the styloid proc- ess and its muscles, forming the sheath of these muscles and l)ecoming attached to the styloid process. Interna/ It/ the parotid sJiedi/i is (Icficicnt in front of the styloid proc- ess, between it and the internal pterygoid muscle, where an uncovered prolongation of the gland projects inward into relationship with the pharyngeal wall in front of the great vessels, etc. Plence r/iwc.s.s or tumors of the parotid are unopposed by the slieath in spreading inward toward the pharynx. Conversely in postpharyngeal abscesses tiiere is often a parotid swelling and sometimes the abscess evacuates through the parotid. Anteriorly there is a process of the gland, socia parotidis, prolonged forward a variable distance on the surface of the masscter, above or overlying Stenson's chict, and, like tlie latter, covered by a prolongation of the parotid sheath. In inflammation or tumor of the parotid therefore the swelling may extend forward onto the surface of the masseter. Superior/ 1/ the sheath is incomplete, being attached externally to the inferior border of the zygomatic areh and the outer part of the cartilaginous auditory meatus, internally to the base of the styloid process, the free border of the vaginal process and the Glaserian fissure. Hence between the outer and inner layers of the sheath superiorly tlie gland is in direct contact, without intervening fascia, with the external auditory meatus and the posterior part of the glenoid fossa. This accounts for the ease with which i)ijiamiacdions of the parotid extend to the external auditory meatus or the periosteum of the adjacent bones (see also pp. 49 and 50). As a portion of the gland occupies the posterior part of the glenoid fossa it comes in direct relation with the capsule of the temporomandib- nlar joiid and explains in part the pcdn of moving the jaw in cases of parotid inflammation, like mumps, abscess, etc., and the occasional extension of inflammation of the gland to the joint. The pain is also accounted for by the fact that the anterior limit of the parotid com- partment is formed by the movable ramus of the jaw and the masseter and internal pterygoid muscles covering it, so that in movements of the jaw, like retraction or ojiening, the space is encroached u})on and the gland pressed upon by the ranuis or its angle and the pain of an inflamed parotid is aggravated. The fact that the .s/ze of the parotid compartment, and especially that of its superficial boundaries, is (dtered by the position of the jaw, which occui)ies a groove on its anterior surface, should also be remem- bered in operations on this narrow region in which we need all the space available. Thus it may be /xcrcfr.sYY/ antero-posteriorly by about tluve eighths of an inch by a simple protrusion of the jaw and to a certain extent by extension of tiie head whereby the sternomastoid is separated from the ramus. It is uarnnred in the opposite movements. In opening the mouth it is narrowed inferiorly but widened superiorly by the gliding forward of the condyle. The obliquity of the ramus in infancy and old age widens the lower part of the space. 90 THE HEAD AND NECK. The strength of the fascia superficial to the parotid offers much re- sistance to the spontaneous opening of a parotid abscess in this direc- tion. In addition to the directions indicated above an abscess may also extend downward to the neck, upward into the temporal fossa, or forward toward the buccal cavity, internal to the ramus where the sheath is weaker and is penetrated by the carotid. Pus within the gland may also occasionally escape along a vessel or nerve where it perforates the investing fascia. From the inner surface of the enveloping fascial sheath fibrous proc- esses extending inward divide the gland into lobules and support the vessels and nerves which pass through it or supply it. To these trabecuke the vessels adhere so intimately that it is practically impos- sible to remove the gland and spare the vessels. Although the 7ierve trunks are less intimately adherent, yet in the living subject, especially where the entire gland is occupied by a tumor, it is impracticable if not impossible to remov^e the gland and spare the nerves also. This fibrous framework is the seat of the inflammation in the specific parotitis known as mumps. Acute parotitis also occurs as a compli- cation in septic or pyaemic conditions ; during acute infectious diseases, such as typhoid fever and more rarely pneumonia, and after injuries and diseases of the abdomen and pelvis. Abscess formation is to be expected in such conditions and the pressure on the small vessels may occlude them and cause a necrosis of the lobules of the gland supplied by them. Contained within and passing through the gland are many important structures. The facial nerve passes forward through the gland from the postero-internal aspect with an inclination outward and slightly downward. Its entry into the parotid corresponds to the point where the anterior border of the mastoid meets the external auditory meatus. It ^/e.9 superficial to the main arterial and venous trunks and breaks up, after an undivided course of about 2 cm. into a plexus which emerges at the anterior border of the gland, after being joined by branches of the auriculotemporal nerve. The latter sensory branch of the inferior maxillary division of the fifth nerve passes from within upward and outward through the upper part of the gland to emerge at its upper border. Thence it crosses the root of the zygoma be- tween the ear and the temporal artery where it may be exposed and resected. The pain of a parotitis and of some parotid tumors may be referred along the course of tiie auriculotemporal nerve. The pres- ence of the latter and of the great auricular nerve, supplying the gland with sensation, within the unyielding parotid fascia accounts for the severity of this pain. The external carotid artery lies undercover of the ramus of the jaw up to the junction of the middle and lower thirds of its posterior border where it enters the internal or deep surface of the parotid quite ante- riorly. Thence it continues through the upper three fourths of the gland in a direction upward, outward and slightly backward to behind the neck of the condyle of the jaw, where it has become more super- THE PAROTID REGION. 91 ficial and divides into its two terminal branches. These (jranche^, together with the posterior auricular and sometimes the occipital, are within the parotid at their commencement. Within the gland the artery is aeparated from the interna/ carotid, and the accompanying internal jugular vein, vagus, glossopharyngeal, hypogastric and sym- pathetic nerves, by the styloid process and its muscles, the parotid fascia and a varying thickness of gland tissue. It may be difficult at times to tell the source of arterial hemorrhage in a deep parotid wound. But in general, if the source of the bleeding can not be found and both ends tied, it is best to expose and tie the external carotid first and then if necessary the internal carotid, not the common carotid. It is evident from its relations that the styloid proc- ess is a most important landmarh in extensive operations on the parotid for it indicates its inner boundary, the position of its prolongation toward the pharynx and of the deep vessels. The temporomaxillary vein lies superficial to the artery and usually divides within the panjtid into its two divisions, one of which continues dow-nward to the lower border of the gland to become the external jugular while the other, passing downward and forward, joins the internal jugular. The number, size and deep situation of the vessels in the narrow and deep parotid region accounts for the gravity of wounds of this region when one of the vessels is injured. From the circumference of the surface of the gland many of the contained nerves and arteries take their exit ; posteriorly the posterior auricular artery, superiorly the auriculotemporal nerve and the super- ficial temporal artery, anteriorly the transverse facial artery and the branches of the facial nerve as well as Stenson's duct. Both superficial to and within the substance of the gland are a num- ber of lymph nodes which receive lymph from the temporal and frontal regions of the scalp, the outer part of the eyelid, the orbit, the cheek, the nasal fossa, the nasopharynx, the external auditory meatus and the intracranial parts. They empty into the deep and superficial cervical nodes. These lymph nodes when enlarged form one variety of parotid tumor. The sources from which they derive their lympii supply should be examined for the presence of lesions, in diagnosing between lymphatic enlargements and other parotid tumors. Abscess on the surface or within the gland may be due to an inflammation of these nodes. The deep nodes are found especially along the carotid artery. Tumors of the parotid are not uncommon and mixed tumors, con- taining cartilaginous, myxomatous and fibrous portions, occur quite often among them. In addition there are malignant tumors or malig- nant degeneration of benign tumors. It is a striking fact that the testis, in which metastases after mumi)s are quite common, is also one of the few other soft parts where cartilage occurs in tumors. The henign tumors are often encapsulated and involve only a portion of the gland so that their extirpation may be readily accomplished and the facial nerve, perhaps somewhat disjilaood, may be sj,ared in whole or in part. It has been much discussed whether the entire gland can be or should 92 THE HEAD AND NECK. be removed when involved in a new growth, especially a malignant one. The operation is difficult, but it certainly can and should be done if the tumor is confined within the capsule of the gland. It is to be expected that the facial nerve must be sacrificed, but the result of this is often not so distressing as might be expected. I have found the operation entirely feasible in a recent case of removal of the entire parotid involved in a recurrent endothelioma. Tiie external carotid and external jugular are tied in the earlier stages of the operation for the bleeding is very free from the arterial branches, including the tem- poral, internal maxillary, posterior auricular, and transverse facial arteries and the branches supplying the gland. Incimons over the parotid for minor conditions should be transverse so as to avoid the branches of the facial nerve. The upper and lower jaws are both susceptible to phosphorus necrosis among those who work with phosphorus, as in match factories, but it is almost confined to those with carious teeth. I have also seen it in an old colored man who took phosphorus internally for a long time to keep up his sexual vigor. There is usually an osteoplastic periostitis resulting in the production of osteophytes, which themselves are liable to necrose. The upper jaw or maxilla is .supported or buttressed above and internally by the articulation with the frontal and nasal bones, above and externally by the vertical portion of the malar, behind by the pterygoid process, externally by the zygomatic arch, internally by the articulation with the opposite maxilla in the hard palate. Thus sup- ported it is not very often fractured but it may be by direct or indirect violence. In the latter manner the shock is usually transmitted through the lower jaw as in a fall or blow, more rarely through the head while the chin is fixed, sometimes through the malar bone which, on account of its density, is seldom fractured but may be driven into the upper jaw. Fracture by direct violence may be due to a direct injurv over a circumscribed area or to the violent extraction of a tooth. The maxilla is partly protected from direct violence by the prominence of the nose internally and the mahir bone externally. When the ivall of the antrum is fractured it may be much depressed, depending upon the direction and degree of the force. Whether it is depressed or not subcutaneous emphysema may occur and is increased on blowing the nose. In other cases pain referred to the dental or infraorbital nerves may lead to the diagnosis ; thus in one case my attention was first called to a fracture through the infraorbital margin and canal by pain in the nerve. Althougii the maxilla is very vascular, yet its periosteum, like that of the skull, is not likely to form new iione so that there is no repro- duction after necrosis. The infraorbital margin is the favorite seat of tubercular periostitis and osteomyelitis of the maxilla. The fact that the maxilla is connected witii the surrounding bony parts at four poi)its is important to remember in its excision, which is undertaken in case of malignant tumors, etc. (1) The connection with EXCISION OF THE UPPER J A W. 93 the malar bone is divided by a wire or ciuun saw passed through the fore part of the sphenomaxillary fissure after raising up the perios- teum of the orbital floor. (2) The nami proccs.s, together with the lachrymal bone and the orbital plate of the ethmoid, is divided by the bone forceps whose blades are introduced into the nasal fossa and the orbit below the tendo oculi. In some cases most of the orl)ital floor may be left, the section passing just behind or sometimes below the orbital margin. (3) The hard palate, by which the opposite maxilla and palate bones are connected together, is divided by a saw or bone forceps after extracting a central incisor and dividing and strijjping up the muco-periosteum on its under surface. (4) Its connection behind with the pterygoid process and the intervening palate bone, as well as Avith muscular attachments (external pterygoid), are freed by twisting the bone, to ((raid unnecessary injury to the branches of the internal maxillary artery. Before this last step in the removal of the jaw it is well to cut the infraorbital nerve at the back of its groove in the floor of the orbit and to divide the connection of the fioft palate with the back of the hard palate on the aifected side. The bony connections are divided in the order named. To ra7j0.sc the maxilla /or excision the soft parts are divided down to the bone along the lower margin of the orbit to the side of the nose, thence in the groove between the nose and the cheek and the nose and the lip to the ridge on the side of the filtrum of the lij) and down this ridge through the lip. In this inci.sio)i the following ncrve.s a)id vcssek are cut in the following order from above downwards ; the palpebral branches of the infraorbital vessels and nerve, angular artery and vein, lateralis nasi vessels, nasal branches of the infraorbital nerve and the superior coronary vessels. Several small branches of the facial nerve may also be cut. Notice that no large vessels are divided in the soft parts and the same may be said of the bone section, though the opera- tion may appear bloody from the many small branches divided. The attachment of the lateral cartilages of the nose to the bone are divided, thus opening up the anterior nasal orifice. The flap is then turned, back, keeping close to the bone if the soft parts are not involved and in any case taking care to preserve the facial artery and vein and to avoid Stenson^s duct. The latter may be acconijilished by remembering its course and dividing the mucous membrane close to the gums so as to avoid the orifice of the duct, 4 mm. above this point. The division of the mucous niend>rane may be left toward the last to avoid the flow of blood into the mouth. In rare cases, but not as a rule, the muco-periosteum of the palate may be spared by dividing it close to the alveolar margin, strijiping it up and subsequently suturing it to the mucosa of the cheek, thus roofing over the oral cavity. The s/cin flap is well nourished by the facial and transverse facial vessels and is supplied by the facial nerve. The scar is almost imperceptible in time. By stripping nj) the periosteum of the orbital floor the con- tents of the orbit are spared, but the origin of the inferior oi)liquc muscle is detached. In dividing the nasal process of the maxilla and the 94 THE HEAD AND XECK. lachrymal bone the lachrymal sac or the naml duct will be cut across. If the nasal process is removed high up the origin of the tendo oculi is included. In the last step of twisting oif the maxilla the descend- ing palatine artery and great palatine nerve are severed. In some cases where the tumor involves only a part of the maxilla, most com- monly the alveolar process, the excision may be partial, sparing in such a case the orbital floor and margin. Again temporary resection of the maxilla is practiced to gain access to the nasopharynx in order to remove polypi situated there ; or to expose the orbit, sphenomaxillary or temporal fossae in order to remove tumors or excise nerves situated in these parts. In temporary resection the alveolar arch and palcde are left undisturbed , the section passing into the nose above them ; the connection with the malar bone is sev- ered and, after another horizontal section is made from the orbit to the nasal fossa, tlie bone flap is turned inward as on a hinge, breaking the nasal process, and is replaced at the end of the 0})eration. The lower jaw or mandible is more often fractured than any other bone of the face, in spite of its free mobility, the buffer-like interartic- ular cartilages and its horseshoe shape, which gives it increased elas- ticity. It may be broken by direct or indirect violence. In the latter case the pressure increases the curve until it gives way, usually at its weakest point near the symphysis. It is more often fractured by direct violence and in this case also most often near the sympjhysis. The line of fracture may be nearly vertical, especially when at or near the symphysis, or more oblique, in most cases of fracture further back. The displacement depends upon the position and direction of the fracture and the direction of the force. In general the elevator mus- cles attached to the ramus draw the posterior fragment upward, forward and outward while at the same time the depressor muscles, digastric, mylohyoid and geniohyoid draw the anterior fragment backward, downward and inward. In case of a fracture of the ramus itself the muscles attached to it hold the fragments together. In double frac- tures, which are quite common, the intermediate fragment may be dis- placed downward and backward. The displacement in fractures of the body of the bone is usually plainly visible in the difference oi level of the teeth. Although, owing to the firm character and close attachment of the gums to the bone, fractures of the body of the lower jaw are almost always compounded in the mouth and are thus exposed to bacterial infection, these fractures generally do well if kept in good pjosition. This we may accomplish by splinting the lower against the upper jaw by the pressure of bandages, preferably with an interdental ^tpHid. inter- vening. A fracture posterior to the mental foramen may injure the inferior dental nerve so as to be very painful and sometimes to cause anaesthesia of the lower lip and chin, supplied by its mental branch. The nerve escapes injury more often than one would suppose and it has been in rare instances compressed later on by the callus. EXCISIOy OF THE LOWER ./.111'. 95 Speech is interfered with on account of the attachment of the muscles of the tongue and the floor of the mouth to the jaw. If the attach- ment of the genioglossus is displaced backward in a fracture or is divided in excision of the jaw some trouble may be experienced from the tongne fdUing backward and blocking the pharynx. The condi/le is occasionally broken on one or both sides by direct blows or blows on the chin, and I have seen an oblique fracture of the ramus running from behind downward and forward and separating the region of the an(//e from the rest of the bone. Fractures of the alveolar process are common in connection with pulling teeth. The lower like the upper jaiv may be the seat of ma/ignant fumoi's, especially sarcoma, w'hich as well as extensive necrosis may call for excision of half of the jaw, more or less. Excision of the entire jaw is rare. Epulis, usually a sarcoma of the alveolar process of the lower or upper jaw, may be excised from within the mouth, well within sound tissue. In excising half of tJie mandible an incision is made down to bone along its lower border, commencing a little beyond the median line. It is not necessary to extend it up the back of the ramus and if this is done it should not extend more than 2 cm. for fear of wounding the facial nerve or even Stenson's duct. Except in large tumors it is not necessary to incise vertically through the lower lip. The horizontal incision divides the facial vessels at the antero-infe- rior angle of the masseter, also some branches of the facial and super- ficial cervical nerves. If the lip is incised in the median line the anastomoses between the inferior coronary, inferior labial and sub- mental vessels of the two sides are divided. The bone is then freed of its muscular attachments, keeping close to the bone. Except when there is a malignant growth, which has reached to or developed from the surface, the jaw may often be excised snbperiosteally, largely by blunt dissection. In this connection Tillaux has called attention to the im- portance and the feasibility of preserving the periosteum covering the angle and adjoining parts which connect together the attachments of the masseter and internal pterygoid muscles. The entire jaiv has been reproduced after subperiosteal removal. It is sometimes difficult even with much depression to free the at- tachment of the temporal muscle which, it should be remembered, is attached to the margins and the inner surface of the coronoid process. The tip of the latter is sometimes cut off with the bone forceps in place of detaching the muscle. As to the condi/lc it is best at the last to twist it ofl' instead of cutting the capsule and the insertion of the external pterygoid, on account of the danger of wounding the internal maxillary artery as it winds around the neck of the condyle. The inferior dental vessels and ncrrc and their mylohyoid branches are of course divided close to the inferior dental foramen. In lan/e tumors care should also be taken to avoid the salivary glands, the external carotid artery, the temporomaxillary vein and the lingual and auriculo- temporal nerves. Cysts and /('//jo/-.s'of the jaws may also develop from the tooth germs. In a central sarcoma or other tumor jxi in from pres- 96 THE HEAD AND NECK. sure on the dental nerves may be one of the earliest symptoms noticed. Congenifalli/, and depending upon defective development of the first branchial arch, the jaw has in rare cases been cleft at the symphysis, incompletely formed or entirely absent. Temporomandibular Joint. — The condyle can be seen and felt as a slight projection immediately in front of the tragus of the ear, from which point it can be seen and felt to move forward and downward onto the articular eminence when the mouth is widely opened. In dislocation the condyle passes forward and upward from the eminence into the zygomatic fossa The depression which is seen and felt in place of the normal projection in front of the tragus is a valuable sign of dislocation, especially Avhen it is unilateral. The honi/ external auditory meatus is immediately behind the joint and in falls or blows on the chin the condyle may be driven upward through the glenoid fossa fracturing the base of the skull or backward fracturing the ante- rior wall of the meatus. In the latter way only is a posterior dis- location possible. The direction of the fibers of the only strong liga- ment of the joint, the externcd lateral, is downward and backward so that it resists the backward movement of the condyle and thus pro- tects the wall of the meatus from more frequent injury. Dislocation of this joint is permitted in the foricard directly only, with the above exception. It occurs only when the mouth is ividely open and the condyle is on the eminentia articularis from which it is pulled forward by the external pterygoid in violent yairning, laughing or vomiting, in dentists' operations, and in the violent introduction into the mouth of large objects. When the condyle is pulled in front of the articular eminence it c/lides upward along the inclined surface in front of the eminence and is pulled up by the elevator muscles. The jaw however can not be closed but is held icidely opened and the fixity of this position and the difficulty of reduction is explained in different ways. (1) The direction of the fibers of the external latercd ligament is reversed in the new position of the condyle and the attempt to close the jaw now puts this ligament on the stretch. The same is true of an attempt to push the jaw backward, for it has to pass downward to pass beneath the articular eminence. A doimward as well as backward pressure is therefore necessary in the reduction of the dislocation and this can be eflfected with the least tension of the external ligament if the jaw is at first kept widely open or even opened more widely. It is not true, however, as is sometimes stated, that the external lateral ligament is relaxed when the mouth is wide open but rather the reverse, for the ligament is tightened by depression of the jaw and by the downward gliding onto the articular eminence more than it is relaxed by the fi)rward movement of the condyle. (2) In the comi)ined hinge and sliding movement of the jaw the con- dyle moves forward, the angle backward and the axis of motion, or the part which moves least, is about the center of the ramus, or at the infe- rior dental foramen. Hence the vessels and nerves which enter this foramen are not subject to traction and displacement as they other- DISLOCATIOX OF TIIK LOWER JAW 97 wise would he. The line of action of the masseter and internal pterygoid muscles normally passes upward and forward in front of this axis. AVhen however the jaw is dislocated forward the line of action of these muscles is displaced somewhat backward with the angle, while the axis of motion is displaced in front of it. (Fig. 24.) Hence while normally the action of these muscles is to elevate the front of the jaw and depress the angle, in a dislocated jaw their action is to elevate the angle and depress the front of the jaw, /. e., to open it. That the muscl€>t are .yja.siiioflical/ij contracted, from their lieing injured or put on the stretch or from pressure or traction on their nerves can be readily felt. According to Tillaux a dislocation is produced when in a vio- lent opening of the mouth the axis of motion is carried in front of the line of muscular action. In a dislocation the condyle may be said to be held bv a balance of forces between the external lateral lioament Fig. 24. DIRECTION OF EXT. LATERAL LIGAMENT INTERAHTIC. FIBRO- CARTILAGE LINE OF ACTION OF ELEVATOR MUSCLES AXIS OF MOVEMENT OF DISLOCATED JAW AXIS OF MOVEMENT g OF JAW Figure to show the relation of the line of actiou of tlie niasseter ami internal ptervcoid muscles to the axis of movement of the lower jaw in its normal position and in dislocation. The Jotted line rej)- resents the position of tne dislocated jaw. (Tillaux.) pulling upward and backward, and the muscles pulling upward and forward. (3) It is possible in rare cases, as in the specimen in the Musee Dupuytren, that the apex of an unusually lone/ cnronoid process may be caught against the malar i)one and resist reduction. In dislocation the Jihrocdrti/df/c may pass forward with the condyle or it may remain behind in the glenoid fossa and in the latter case the anterior part of the capsule may be torn. The posterior part of the capmie is much stretched and often torn. The dislocation may occur on one or both sides. 98 THE HEAD AND NECK. The lower jaw is sometimes held firnihi cloned. This may be due to a tonic spasm of the muscles of mastication, a condition known as trismus or lockjaw. This may be an early symptom of tetanus or a rejie.v symptom due to the irritation of one of the sensory branches of the fifth nerve, especially those of the lower teeth. The nerve to the muscles of mcustication is the only motor branch derived from the fifth nerve. Again the firm closure of the jaw may be due to a cicatricial con- traction following a cancrum oris or other large loss of substance of the cheek or to an anchylosis of the temporomandibular joint. In the latter case an excision of the neck of the condyle is done to secure a false joint. The two lips unite laterally at the cominissures to enclose a trans- verse aperture (the buccal orifice) popularly called the mouth, but the latter term should apply to the cavity to which the opening leads. The lips consist of the following layers: (1) Skin closely adherent to (2) a muscular layer (orbicularis oris), (3) labial mucous glands among which are the coronary vessels and (4) mucous membrane. The thick skin joins the mucous membrane along the free border by an intervening ^^ vermilion border,''^ or dry mucous membrane, which is remarkable for its sensitiveness and the frequent occurrence of epithe- lioma, especially on the lower lip. This border on the upper lip pre- sents a median tubercle, the remains of the free extremity of the fronto- nasal process. From this tubercle up to the columna nasi is a shallow groove, the filtrum, bounded by two low ridges along which vertical* incisions are carried if it is desired to show as little scar as possible. The muscular fibers run mostly parallel with the buccal orifice, hence incisions to open abscesses, etc., should be horizontal, for a vertical in- cision is followed by considerable retraction of the edges. Into the orbicularis oris are inserted most of the muscles of expression. The glandular layer is formed of racemose glands resembling the salivary glands. It may hypertrophy as a whole, thickening the lip, or the individual glands may form retention cysts. On a vertical sec- tion of the lips this layer protrudes while the muscular layer retracts. The coronary arteries are embedded in this layer close beneath the mucosa and nearer the free than the attached margin of the lips, about one half inch from the former. Bleeding from them may be easily 'prevented or stopped by pressure of the fingers or a temporary ligature. In .suturing vertical incisions of the lip, as in harelip operations, one suture should be passed behind both ends of the artery, between it and the mucosa, to check the hemorrhage. The coronary arteries can re- tract freely into the loose tissue in which they lie so that bleeding is often spontaneously arrested. As the superior coronary artery sends a branch to the septum nasi, compre.mon of the artery may check nose bleed. The vascularity of the lips, from the coronary and other arteries, accounts for the frequent presence of nsevi and other vascular tumors as well as for the ready healing of the many plastic operations per- formed to relieve deformities and fill the gaps left by the removal of HARELIP. 99 new-growths about the mouth. The success of these operations is also favored by the laxity and mobility of the tissues about the mouth. The vessels of the two sides of the lips anddomose freely, hence both ends of a divided vessel should be tied. The connection of the veins through the facial and ophthalmic, with the cavernous sinuses should be remembered in inflammatory conditions of the lips. The lymphatics pass to the submaxillary and suprahyoid nodes so that these nodes may be involved and re/(?/.sWe/7&f/-.s, of which the tongue is composed, is a comparatively small amount of connective tissue. It is note- worthy that cellulitis or inflammation of this tissue [c/lo.ssitis) is uncom- mon ; but when it does occur the tongue may swell greatly so as to threaten asphyxia by pressing down the epiglottis. Owing to the firm texture of the tongue and its thick mucosa abscess in its substance feels like a solid tumor. Foreign bodices may easily become embedded in the tongue. The tongue is not attached or anchored by ligaments but by its extrinsic muscles, to the mandible by the genioglossi, to the styloid ])rocess by the styloglossi and to the hyoid bone. Hence, in anaesthesia, when the muscles become relaxed, the tongue is liable to drop back by its own weight and press down the epiglottis so as to close the opening into the larynx. This tendency may be diminisjied by placing the patient's head on the side, so that gravity does not tend to force the tongue backward; or it maybe counteracted by pulling the tongue forward either directly, by the tongue forceps, or indirectly, by protruding the THE ToyauK. 103 jaw, by pressing forward heJtind fhe rami, and thereby pulling the tongue through the genioglossi. The tongue normally overhangs the entrance of the larynx, thereby hiding it, hence if the tongue is drawn too far forward it exposes the larynx and favors the passage of food or other fluids into it. Similarly when, in operations on the tongue or in excision of the fore part of the lower jaw, the genioglossi muscles are divided the tongue is liable to drop back if the patient lies upon his back. Hence precautions are taken to have the patient lie upon the side, to fasten the tongue forward by suturing its base to the mental region and to thread the tongue with a silk suture, whereby it may i)c pulled forward as occasion requires, until adhesions form whicii I'asten it in position. Fsa. 25. Under surface of tongue and the sublingual space, showing openings of salivary ducts. The mucosa of the left side is partly removed, aud shows the rauine artery, the lingual nerve, and the gland of Blaudiu. (OEKKisH, after TKsifi.) The tongue is also connected by mucosa with the alveolar arch and by folds of mucous membrane with the ei)iglottis, the soft palate (enclosing the palatoglossus muscle) and the back of the symphysis of the jaw. The latter is a median fold known as the fraenum linguae which normallv ends some distance short of the tii) of the tdnjruc. In rare instances this frsenum extends to the tij> or is abnormally short so as to restrict the movements of the tongue. This condition of "tongue- tie " may prevent the infant from sucking well or, later in life, interfere with articulation and necessitate (//r/.s/o/j of the fnenum. This may •be done after lifting up the tongue by tiie fingers or the back end of a 104 THE HEAD AND XECK. grooved director, which is made for the purpose. In such cases the free edge of the frfeiiuin shoidd be divided close to the jaw so as to avoid the ranine veins on the under surface of the tongue, and the freenum may be torn loose as much as required. If tliere is any bleed- ing in such cases it is encouraged and not checked by the infant's nursing. The ranine veins just mentioned are plainly seen beneath the mucosa of the under surface of the tongue, less than half an inch from and on eitlier side of the fraenum. The ranine arteries lie a little more later- ally and more deeply phiced, beneath fringes of mucous membrane which converge toward the tip. Surface of the Tongue. — It is the bright red color of the fungiform papillae, scattered along the sides and tips of the tongue, contrasted with the coating of the rest of the tongue, which produces the so-called " .■ duct. It can be readily /e/^ by the finger pressed against the inner surface of the jaw in a direction downward and backward from the last molar tooth. Branches of the superior laryngeal nerve reach the root of the tongue near the e})igl()ttis. The part of the floor of the mouth between the tongue and the alve- olar arch is covered by mucous membrane, reflected from the tongue to the gums, and is divided into two symmetrical halves by the frrenum of the tongue. On either side of the latter are two well-marked ridges directed backward and outward, due to the presence of the sublingual gland. Along these ridges the ten to twenty ducts of the gland open and at the anterior ends of the ridges, on either side of the frsenum, we notice the papilhv. on which arc the orifices of Wharton's duct. The duct of Bartholin, from a group of lobes of the sublingual gland, opens with or near Wharton's duct. Wharton's duct passes obliquely forward and inward for 5 cm. from the deep lobe of the submaxillary gland, near the posterior border of the mylohyoid. It accompanies the lingual nerve, crossi))g (djove the THE PALATE. 107 latter, wliich inclines inward to the tongue, and it lies beneath and behind, or internal to, the sublingual gland. Its walls are thin but not distensible so that when it becomes blocked by an impacted calculus the jjuin from tension is intense as it cannot become rapidly or largely dilated to form a cystic tumor. Such a cystic tumor is known as ranvila, a term applied to cysts of varied origin filled with mucous contents and situated under the tongue or in the floor of the mouth. Typical ranula is a retention cyst of the mucous glands ; according to Recklinghausen most frequently of those that lie beneath the tip of the tongue. Other cysts in this situation are classed as ranula, including retention cysts of the sub- lingual gland ducts or of Wharton's duct. The presence of Fh'isclmann''s sidjlinf/ual bursa is denied by most authorities, but according to Tillaux it is the seat of the acute or rapidly formed ranula, which sometimes occurs. Tillaux describes it as follows. It is triangular in form, situated between the genio- glossus muscle and the mucous membrane which is reflected from beneath the front and sides of the tongue to the floor of the mouth. Its apex lies at the end of the frsenum on the under surface of the tongue and its base at the sublingual gland, which separates the mucosa from the srenioslossus muscle. It is constricted in its center by the frsenum and reaches back on either side to the first or second molar tooth. Incision alone will not cure a ranula, for after the incision heals the cyst refills. Its lining membrane must be dissected out as far as possible and the edges of what is left sutured to the. opening in the mucous membrane. Congenital dermoid or branchiogenic cysts in the floor of the mouth, between the tongue and the lower jaw, may resemble ranula. They are due to the imperfect closure of the first branchial cleft or arch. Cysts or solid tumors deeply seated in the tongue or in the vicinity of the hyoid bone may develop from the thyroglossaJ duct, leading from the foramen ceecum. In this manner ]3robably some of the deep-seated forms of cancer and cancerous cysts of the neck are formed. When the mouth is widely opened the pterygomaxillary ligament can be readily _/V// beneath the mucous membrane and can be seen as a prominent fold running obliquely downward behind the last molar teeth. The loose connective tissue in the floor of the mouth between the mylohyoid muscle and the mucous membrane, together with that in the submaxillary region, is involved in the septic inflammation known as Ludwig's angina. The Palate. — The hard palate separates the mouth from the nose, hence when it is cleft these two cavities communicate. Its form is determined by that of the horseshoe-shaped alveolar arch which borders it. Normally the greatest width about equals its length, but this relation varies widely. Normally it presents a flat arcli, abnor- mally a high and narrow one. The latter form is said to be common in congenital idiots and often occurs in the two halves of a cleft j>alate, especially in complete clefts. This is a fact of importance in the 108 THE HEAD AJSD NECK. closure of the cleft, for in such cases the flaps, when brought down to a more horizontal position, are ample to meet and be sutured in the median line. These flaps consist of the entire soft parts which cover the bony framework and are composed of a firm pale mucosa fused with the periosteum so that they can not be separated. This dense, tough muco-periosteum is thickened by the many glands contained between its two layers except in the median line. Posterior to the anterior palatine foramen a median raphe indicates the formation of the palate from two lateral halves). The muco-periosteum is supplied principally by the posterior pala- tine artery which lies near its deep surface and passes forward, at the junction of the palate and the alveolar process, from the lower opening of the posterior palatine canal, internal to the last molar tooth. The two pi'inclpal dangers of operations for the closure of a cleft of the hard palate are hemorrhage and gangrene of the flaps, both due to a division of the posterior palatine artery or its branches which pass inward to supply the muco-periosteum. Hence this division should be avoided and the artery and its branches pjreserved in the flap for its nourish- ment by making the lateral incision, bordering the flap, along the base of the alveolar process, outside the course of the artery. The nerves come from Meckel's ganglion. The soft palate is of about the same length as the hard palate but it is broader than it is long, and about one quarter of an inch thick. Its sides are merged into the pharyngeal wall. The anterior third of the soft palate contains the palate aponeurosis which is always ^zrm and tense so that, as it is continuous in position and direction with the hard palate, it is often hard to distinguish it from the latter by the touch, as in passing a Eustachian catheter (see p. 58). The aponeurotic portion does not share in the movements of the posterior or muscular portion of the soft palate. The tendon of the tensor pcdati muscle is connected with this aponeurosis which is already tense and can scarcely be made much more so. Indeed it is probable that the principal action of this muscle, certainly of those fibers attached to the fibrous portion of the Eustachian tube, is to open that tube. Such an opening occurs wdienever the palate is raised, as in swallowing, and on this fact de- pends the Pollitzer method of inflating the middle ear (see p. 57). The levator palati and azygos uvulce muscles were formerly thought to be supplied by the facial nerve, through the great superficial petrosal and Meckel's ganglion, and hence to be affected by paralysis of the facial nerve when the lesion is mesial to the geniculate ganglion. It is questionable whether this is the source of their nerve supply which is now traced through the pharyngeal plexus from the spinal accessory nerve. These two muscles are embraced in the palate by the two heads or layers of the palafopJtaryngeus. The fibers of the pahdo- glosHUH form the most inferior layer of those which make uj) the sub- stance of the soft palate. * All the muscles named, except the azygos uvuhe, join those of the opposite side in the median line and hence by their contraction tend to THE SOFT PALATE. 109 widen a deft of the palate ov pull apart the sutures introduced to close it. According to some the levator and tensor palati are the chief agents drawing asunder the sutured cleft. To p recent this interference with the success of the operation many resort to free antero-])osterior incixions through the palate along the side of each half, to divide the muscles. In place of this a tenotomij of one or more muscles, espe- cially the levator palati and palatopharyngeus, has been employed by others. Billroth broke ojf' the liamular process and displaced it inward together with the tensor palati tendon which winds around it, in order to relax the latter, with good results. The hamular j)rocesscan ha felt to the inner side and behind the last upper molar tooth. Woltf thinks the soft palate is best relaxed by separating the muco-periosteum from the bony hard palate as in operations to close clefts of the latter. In any case the aponeurosis must be freed from its attachment to the pos- terior border of the bony hard palate to allow the anterior part of the soft palate to come together readily. The posterior t-wo thirds of the soft palate, the portion behind its aponeurosis, forms tiie velum pendulum palati proper or the movable curtain which in breathing through tlie nose hangs down in the isth- mus of the fauces and shuts off the mouth from the pharynx, and in deglutition or breathing through the mouth is raised to a horizontal position to shut off the buccal portion of the pharynx from the naso- pharynx, to prevent food entering the latter in swallowing. Hence in paralysis of the palate, as sometimes occurs after diphtheria and from other causes, the palate can not be raised, the nasopharynx is not shut off and fluids are liable to regurgitate through the nose. The elevation of the palate during breathing througli the mouth is taken advantage of in one form of nasal irrigation (see p. 80). When the palate is elevated it is enabled to shut oflP the buccal from the nasal portion of the pharynx by the contraction of the superior constrictor muscle which narrows this part of the pharynx and brings forward its posterior wall. The azygos uvulaj passes into the uvula and by its contraction shortens and raises it. Elongation of the uvula is largely due to hypertrophy of the part near the tip, beyond the muscle. When elongated it may touch the base of the tongue or produce cou^diino- in the supine position by irritating the back wall of the pharynx. It may be readily snipped off if necessary. From the base of the uvula two folds of mucous membrane pass off on either side in an out- ward and downward direction, the anterior and jxistcrior pillars of the fauces. The anterior folds cover the palatoglossi and incline forward. The space between them forms the isthmus of the fauces, the opening between the mouth and the pharynx, and i6h(*und(d bv tiie tongue be- low and by the palate above. In deglutition, after the food is passed into the pharynx, the isthmus is closed i)y the contraction and ajiproxi- mation of its pillars and the elevation of the back of the tongue to the palate, to shut off the mouth from the pharynx. The posterior folds cover the palatopharyngei and incline somewhat backward. As the latter approach nearer to one another than tiie anterior piHarstiiey 110 THE HEAD AND XECK are readily seen behind them. Between the two pillars of each side lie the tonsils (see p. 111). The blood supply of the soft palate is derived from the ascending palatine branch of the facial, the palatine branch of the ascending pharyngeal artery and the descending palatine branch of the internal maxillary. The lymphatics of the palate enter the internal maxillary or deep facial nodes, on the side of the superior constrictor just behind the pterygomaxillary ligament, and thence pass to the deep cervical nodes. The sensory nerves come from Meckel's ganglion and the glossopharyngeal. The latter nerve probably supplies the scattered taste buds found on the under surface of the palate. The terms pala- table, to tickle the palate, etc., are not without physiological founda- tion in fact, though the tongue is the principal organ of taste. Development (see also p. 99). — The palate is formed by the junction in the middle line of the palatal processes of the superior maxillary processes which grow backward and inward to separate the mouth from the nose. This union begins in front about the eighth week of f(]etal life and is completed posteriorly in the ninth and tenth weeks. Throughout the hard palate this line of union is joined from above by the frontonasal process, forming the septum of the nose, to the lower and anterior angle of which are attached the intermaxillary bones. These bones join the palate processes of the maxiilre along suture lines passing forward and outward from the anterior palatine foramen to the interspace between the canine and lateral incisors of each side, so that they contain the four incisor teeth. Congenital cleft palate is an error of development, a failure of fusion of the parts of which the palate is formed. In the soft pa/ate the clefi is median and single; in the hard palate, as far forward as the anterior palatine foramen, it is nearly or quite median in position but is called unilateral or bilateral according as one or both palatal processes fail to join the vomer, which is formed by the median frontonasal process. If the cleft is unilateral it communicates with the nasal fossa of one side, if bilateral with both nasal fossse and the free border of the vomer appears in or above the cleft. In one case I observed entire absence of the nasal septum, which occurs occasionally. In front of the anterior palatine foramen the cleft in extending through the alveolar border is always unilateral or bilateral, never median. If the cleft is bilateral the intermaxillary bones are entirely separate from the maxillse and, supported on the end of the nasal septum, they often protrude forward and appear to be suspended from the end of or beneath the nose. Such forms are usually accompanied by a double harelip ; the unilateral cleft of the alveolar process is as a rule associated with a single hare- lip, occasionally with a double one. In unilateral clefts the alveolar process of the intermaxillary bones may be on a line with the alveolar process across the cleft or it may project in front of it. According to Kolliker and others, the cleft in the lip and alveolar process is between the frontonasal process and the superior maxillary process, i. e., between the intermaxillary bones and the maxilla or PLATE VI r FIG. 26. lOR PA LA- FOSSA PREMAXILLARY SUTURE POSITION OF LATERAl CLEFT OF HARD PALATE DESCENDING PALA- TINE ARTERY Hard palate, showing the course of the arteries and of the lateral clefts. (Modified from Merkel.) FIG. 27. INT. JUGU- LAR VEIN INT. CAROTID ARTERY -f LONGUS COLLI MUSCLE TEMP-MAXILLARY VEIN PAROTID EXT. CAROTID ARTERY^ STYLO-HYOID &. STYLO- — PHARYNG. MUSCLES PHARYNGO-MAXILLARY SPACE INT. PTERYGOID MUSC INF. DENTAL FORAMEN RAMOS MASSETER FACIAL ARTERY LYMPH NODE PALATO-PHARYNGEUS MUSCLE SUP. CONSTRICTOR M. "TONSIL PALATO-GLOSSUS MUSCLE FORAMEN C/ECUU Horizontal section through the commissure of the lips and the tonsils. The section passes through the odontoid process and shows the pharyngo-maxillary space. (Merkel.) THE TONSILS. HI between the lateral incisor and canine teeth. But Albrecht regards it as between the frontonasal and the lateral frontal processes. lie as- sumes four intermaxillary bones, two on either side, and holds that the cleft is between the two of either or both sides, that is between the central and lateral incisors. His views have been largely confirmed by others. Both views are probably correct and the position of the clefts is not alwavs constant. There are clefts between the lateral incisor and canine teeth, others between the lateral and central incisors, but more often the lateral incisor is wanting, which was formerly explained by saying that it was " lost in the cleft." In bilateral clefts through the alveolar process the protruded intermaxillary bones as a rule contain the germs of the central incisors only. Cleft palate varies greatly in extent. Rarely it may involve the uvula only or merely the middle of the soft palate. A cleft of the soft palate often exists without any in the hard palate, or at most only in the posterior part of it ; but clefts of the hard palate rarely occur without one in the soft palate. In rare cases the intermaxillary bones may be entirely absent and the coexisting double harelip appears as a large median gap. Where there does not appear to be enough tissue to fill the gap of a cleft palate I have tried with excellent results the plan of chiselling through the palate processes along the inner border of the alveolar process, crowding inward the former, packing the gap so formed to keep the palate processes in their new position and after six or eight weeks completing the operation in the usual way. The usual operation consists in broadly freshening both edges, dissect- ing up afJap of inuro-periosteum on each side as far as the alveolar process, where it is limited by an incision along the base of the proc- ess (p. 108), and then bringing together and suturing tlie edges. It seems better to treat some bad clefts of the palate by an obturator fastened to the six-year molars. Such obturators, if well made, give an excellent functional result as far as speech and swallow- ing are concerned. Infants with cleft palate can usually nurse from a bottle if a large nipple is used which fills up the cleft. But later on articulation is very imperfect and the voice very nasal in tone. The tonsils are lymphoid masses situated in the triangular recesses between the pillars of the fauces and the base of the tongue. The floor of this recess is formed by the pharyngeal aponeurosis and the superior constrictor muscle, on which each tonsil rests and by which it is separated from the pharyngomaxillary space. The latter lie.s be- tween the lateral wall of the pharynx internally, the internal ptery- goid muscle externally and the upper cervical vertebra? posteriorly and contains fat and loose cellular tissue. Zuckerkandl sh(»wed that it was divided by the styloglossus and styl(>i)haryngrus inusclos into an anterior chamber, contiguous to the tonsil, and a posterior chamber con- taining in its hindermost part the internal carotid artery the internal jugular vein and their accompanying nerves. (Fig. 27.) 112 THE HEAD AND NECK. Quinsy, which is a peritonsillitis or an inflammation around the tonsil, is confined in most cases to the anterior chamber of this space and only rarely extends to the posterior chamber, in which case the internal carotid might possibly become eroded as reported in a few cases. The peritonsillar inflammation in the anterior chamber meets no obstacle in extending outward as far as the internal pterygoid muscle, but then further swelling projects inward toward the mouth in the line of least resistance. A quinsy is v.^iia//// opened through the soft palate just above the tonsil and the wounding of the internal carotid is out of the question for in the adult it lies 3 cm. behind this point in the normal state and probably twice as far when the parts are bulged forward by the in- flammation. In children the distance is relatively even greater, though of course actually somewhat less. As the internal carotid is at least 1.5 to 2 cm. behind the tonsil there is even less danger of its being wounded in tonsillotomy for no puncture is then made. A wound of the artery has probably never occurred from tonsillotomy or opening a peritonsillar abscess, though several cases are recorded where the artery has become eroded in a peritonsillar inflammation. It is in operations on the lateral aspect of the pharynx that the internal caro- tid is in danger of being wounded. The external carotid artery, 2 cm. from the lateral perijihery of the tonsil, is still more out of the way, lying external to the muscles aris- ing from the styloid j^rocess. The ascending pharyngeal artery is nearer the tonsil than the internal carotid, and gives a branch to it, but lies behind it in the pharyngomaxillary space and its main trunk is not exposed to injury in tonsillotomy. In one of the very few cases where fatal bleeding followed this operation the tonsillar branch of the facial was proved to be the source of hemorrhage. Bleeding from the ascending pharyngeal artery has proved fatal in a case re- ported l)y Mr. INIorrant Baker, but it did not follow tonsillotomy but a wound due to a pipe stem driven through the tonsil. According to Merkel the source of severe arterial honorrhage after tonsillotomy, etc., is in most cases the faded artery which, as it passes between the digastric and styloglossus muscles, may take a sharp S-shaped bend, which comes very close to the lateral surface of the tonsil. The position of the tonsil corresponds superficially to the angle of the jaw but, owing to the intervening structures, enlargement of the tonsil other than malignant cannot be felt externally. AYhat is felt and mistaken for the tonsil is an enlargement of the lymph nodes here which regularly accompany affections of the tonsil. Enlarged or hjiper- tropjliied tonsils project in the line of least resistance toward the median line where they may even meet and cause difficulty in swallowing. As the projecting mass of hypertrophied tonsils also narrows the pharyn- geal passageway between the nose and the larynx the subject of such hypertrophy sleeps with the mouth open, to get more air, and usually snores. The throat therefore becomes dry and inflamed. In such cases the chest is badly developed, from insufficient suj)])ly of air, and THE PHARYNX. 113 becomes i)igeon-breasted if the subject has rickets. The nose is also small and flattened, as little air passes through it, and the voice is thick. As the Hoft palate intervenes between the ton»il and the EuHtachian tube the deafness coni[)lained of in such cases is not due to direct pressure, which is anatomically impossible, but to a coexidincj hyper- trophy of the adenoid tissue about and within the Eustachian tube. It is possible, however, that the hypertrophied tonsil by pressing up the soft palate may relax the tensor tympani muscle and thus hinder its opening the tube. In the inflammation known as folficalar ton.si/lifis the openings of the twelve or fifteen crypts on the free internal surface of the tonsil are filled with a yellowish-white deposit composed of desquamated epi- thelium, leucocytes, bacteria, etc. The decomposition of retained epithelial structures and food debris within the crypts of an enlarged tonsil may give rise to foul breath and to the repeated attacks of in- flammation to wdiich such tonsils are liable. The attachment of the tonsil to the muscles of the pharynx renders deglutition jjainful in acute inflammations of the tonsil because of the movements conveyed to the latter by the movements of the pharynx. Thus the superior constric- tor moves it inward and the stylopharyngeus outward. The action of the latter in drawing the tonsil outward, combined with a prominent anterior faucial pillar may make it difficult to reach the tonsil with the tormllotome . The latter should be introduced backward and slightly downward, for this is the direction of the long axis of the tonsil, -which normally measures about one inch. Its postero-inferior end is some- times hard to inspect. Although the blood supply is from multiple sources the uninflamed tonsil is not very vascular so that it often bleeds but little on removal, but it may give rise to troublesome hemorrhage if removed when in- flamed. The arterial supply comes from the tonsillar and ascending palatine branches of the facial, the descending palatine branch of the internal maxillary, the dorsalis linguae branch of the lingual and branches of the ascending pharyngeal. The veins form the tonsillar plexus on the outer side of the gland, which joins the ]iharyngeal plexus. The lymphatics of the tonsil enter the submaxillary nodes near the angle of the jaw, which are usually involved in afl'ections of the tonsil and may be readily felt. The nerves come from ^Meckel's ganglion and the glossopharyngeal nerve. The latter as it winds around the palatopharyngeus is in such close relation to the tonsil as to be in some danger of injury in operations on or about the tonsil. The tonsil is not infrequently the seat of malignant new-groirths^ sarcoma and epithelioma, on account of which it is removed with a wide margin of healthy tissue, either through the mouth, after splitting the cheek or dividing the jaw, or through the neck by a lateral pharyngotomy. The pharynx extends from the basilar process of the occipital bone to the lower part of the cricoid cartilage, which is opposite the sixth 8 114 THE HEAD AND NECK. cervical vertebra, when the neck is neither flexed nor extended. It is 4| inches Jong, much wider transversely than antero-posteriorly, widest opposite the hyoid bone (about If inches) and luirroirexi (14 mm.) at tlie lower end where it is continuous with the oesophagus. Hence foreign bodies which reach the pharynx are most likely to be arrested at the latter point which is a little beyond the reach of the finger, for it measures six inches from the incisor teeth. The latter measurement should be remembered in passing oesophageal bougies to determine the position of a stricture, and it should be added to the length of the oesophagus (9^ inches) to determine the distance from the teeth to the stomach. The variety of foreign bodies reported as arrested in the pharynx is very great. Perhaps the most common are large masses of food swallowed gluttonously, a frequent occurrence among the insane. Treves cites a case reported by Dr. Geoghegan where a tooth plate containing five teeth and surrounding five others was lodged in the pharynx for five months and caused trouble which was first supposed to be cancerous. Stones, coins, etc., are also arrested here and strang- est of all, live cat fish are said to have jumped into the mouths of bathers in India and to have become impacted in the fauces. When the foreign body is a large one it may block the laryngeal opening and thereby cause suffocation. As corrosive ft aids pass the narrowest point more slowly than the wider parts the corrosive action is more intense and the resulting cicatricial contraction more marked at the lower end of the pharynx than it is above. The pharynx is complete behind and at the sides, where its musculo- membranous walls separate it from the surrounding parts. It is in- complete in front where it presents the openings of the posterior nares above, the faucial opening into the mouth below and still lower the upper orifice of the larynx. The froid of the ])harynx is held wide open by its attachment to the following fixed points, the internal ptery- goid plate, mandible, hyoid bone and thyroid and cricoid cartilages. Relations of the Pharynx. — The posterior wall of the pharynx is in front of the bodies of the up])er five cerfical rerte/jrrc. The anterior arch of the atla.s is on a feref tinth the j)(date, and behind the mouth one can palpate the anterior surface of the bodies of the second and third cervical vertebrae, and in this w^ay determine the existence of a fracture or dislocation of these vertebrae. Owing to their distance from the incisor teeth it is difficult to satisfactorily palpate the fourth and fifth cervical vertebrae. Necrosed portions of the upper cervical vertebrae have been discharged through the mouth. In caries of the upper cervical vertebrae, which is most common in children, a retro-pharyngeal abscess may form in the loose tissue sepa- rating the posterior pharyngeal wall from the prevertebral fascia. A lipnph. node situated in this loose tissue opposite the axis receives lymph vessels from the hind part of the nasal cavity, the roof of the pharynx and the prevertebral muscles, and may also be the starting point of such an abscess. These abscesses may push forward the posterior RELATKjyS OF THE I'll ART NX. 115 pharyngeal wall so as to depress the soft palate, or, if they extend further downward, they may cause dyspncea by obstructing the open- ing into the larynx. They may open or be opened through the mouth or on either side of the sternomastoid after passing behind the great vessels and the parotid gland. If they discharge spontaneously into the pharynx during sleep the pus may be inspired and cause suffoca- tion or set up a septic pneumonia. Abscess in this loose retropfiari/n- (jedl tissue may descend along the a?soi)hagus into the posterior medias- tinum even to the diaphragm. This loose tissue serves the purpose of a serous cavity and allows the free movements of the pharynx. Fig. 28. EUSTACHIA TUBE THYBO-HYOID BURSA THYBO-HYOIO MEMBRANE THYRO-HYOIO MUSCLE FAT IN FRONT OF EPIGLOTTIS THYROID CAR- TILAGE SPHENOIDAL SINUS PHARYNGEAL TONSIL PHARYNGEAL RECESS /.:y^;,\^\\ ANTERIOR ARCH ['■■'V . , \.-\\ OF ATLAS AHYTENO-EPI- GLOTTIC FOLD ARYTENOID MUSCLE Sagittal section of tlie pharynx, etc. (Zl'CKERKaxdl.) The lateral walls of the pharynx are in close relation with the //i^<'/-- nal carotid arteries and their accompanying nerves (ninth, tenth and eleventh and sympathetic nerves) so that the pulsations of the artery may be felt through the pharyngeal wall and the artery may be wounded by foreign bodies thrust through the wall. The internal jugular vein is less exposed to injury from such causes, as it is more laterally placed. The >iti/loid process and its muscles, the inner end of the jxirotid (/land and the upper end of the tin/roid r/land are also in relation with the lateral walls of the pharynx. If (pifhelionui involves 116 THE HEAD AND NECK. a part of the pharynx, as occasionally happens, with or without inva- sion of the tonsil, it may be reached through an incision on the side of the neck. In such cases it is well to tie the external carotid, and, in order to reach the upper end of the pharynx, a division or temporary resection of the jaw may be made. The loiver end of the pharynx may also be reached by subhyoid pharyngotomy through the thyrohyoid mem- brane, an operation which also exposes the portion of the larynx above the glottis. The nasopharynx, or the upper part of the pharynx which is above the level of the palate and behind the posterior nares, is entirely respiratory in function. Accordingly its epithelium is ci/iated and it is shut oif from the lower or buccal portion, during the act of swallow- ing, by the elevation of the soft palate. The superior constrictor does not reach to its upper end at the sides as the constriction of this part serves no purpose. The space above the curved upper border of the superior constrictor, the sinus of 3Iorgagni, is occupied by the thick- ened upper end of the pharyngeal aponeurosis, which lies internal to the constrictor muscles. Through this space pass the Eustachian tube and the levator palati muscle. In Politzer's method of inflating the middle ear the nasopharynx is shut oflP from the parts below by the act of swallowing, in which the palate is raised, so that the air forced into the nose finds no exit except through the Eustachian tube. The nasopharynx is very rich in lymphoid or adenoid tissue and a mass extending around its posterior wall between the orifices of the Eustachian tubes is known as the pharyngeal orLuschka's tonsil, which is often hypertrophied. Reaching from this point forward the mucosa of the roof and upper part of the pharynx is rich in similar tissue which, when hypertrophied, gives rise to nasopharyngeal adenoids. The lat- ter obstruct the posterior nares ; compress the openings of the Eusta- chian tubes ; cause mouth breathing, frequent colds, running of the nose, lack of development of the nose and the body of the maxillse ; aifect the voice ; are a common cause of deafness and otitis media and are often associated with mental apathy and dullness. After puberty they tend to diminish and the nasopharynx also becomes more capa- cious ; but before this time they should be removed, if well marked, to avoid the evil consequences. We have already seen the position of the openings of the Eustachian tubes (see p. 58) and of Rosenmiiller's fossa (recessus infundibuliformis) just behind it. The latter lies beneath the tip of the petrous bone and if the pharyngeal tonsil is enlarged this fossa may be reduced to a narrow fissure. The pharyngeal bursa is the jiharyngeal end of the diverticulum that forms the hypophysis cerebri and is present in infancy but has generally disappeared in adult life. It is a median recess 0])ening below tlie pharyngeal tonsil and reaching upward toward the pharyngeal tubercle. J, The roof and posterior wall of the nasopharynx is formed by the obliquely sloped under surface of the basilar process of the occipital bone and the thick layer of ligaments and fibrous tissue which fills in THE NECK— ANTERIOR MEDIAN REGION. 117 the angle between the occipital bone and the vertebne. From this fibrous tissue, or the periosteum, spring the nasopharyngeal polypi which may be pedunculated or sessile, benign or sarcomatous and which occur most often in male children. Even when benign they may by their growth fill up the nasopharynx, depress the soft palate, become pro- longed into the nasal fossie, the maxillary sinuses and even through the sphenopalatine foramen and they may possibly erode the base of the skull. Their reinoval if pedunculated may be secured Ijy a wire snare orgalvano-cautery loop introduced tiii'ough the nose, through a tempo- rary resection of the maxilla, a division of the palate and in many other ways. After about twenty years of age they grow much less rapidly or not at all and are even said to atrophy, hence the removal of a small one at this time may be unnecessary as far as its mechan- ical obstruction is concerned. The lower part of the pharynx is funnel-shaped, narrowing to its narrowest point at its lower end. All below the nasopharynx is lined by stratified epithelium. The fan-shaped conslridor muscles overlap one another from below upward. Beneath the inferior constrictor passes the inferior laryngeal nerve, between the inferior and middle constrictors the superior laryngeal nerve and artery pierce the thyro- hyoid membrane to reach the larynx and between the middle and superior constrictors the glossopharyngeal nerve and the stylo- pharyngeus muscle pass downward and inward. The stylo- and palatopharyngei both elevate the pharynx, the former also widens it and the latter narrows very strongly the isthmus of the fauces and helps to shut off the mouth from the pharynx in the second act of deglutition. The lymphatics of the pharynx pass to the upper deep cervical nodes whose enlargement may depend upon an inflammation or some other affection of tlie i)harynx. The lymphatics of the upper part of the pharynx first pass through the postpharyngeal node. THE NECK. The neck or the passageway between the head and the thorax is subject to wide vari(dions as to its lengfJi, size and shape. The abun- dance or lack of adipose tissue is largely responsible for the increase or decrease of size and for the rounded or angular shape. In extension of the neck its anterior part is lengthened and in flexion is shortened so that the distance of its movable parts from the sternum or the lower jaw varies as does also the relation of these jiarts to the vertebra\ Hence in giving the relative jiosition of its landmarks the neck is sup- posed to be in the position midway between flexion and extension, /.<'., the natural upright position, unless otherwise stated. Landmarks and Surface Markings. Anterior Median Region. — In the receding angle of the chin the hyoid bone and its great eornua can be made out. The body of the bone 118 THE HEAD AIsD NECK. is on a level with the fourth cervical vertebra and nearly on a level with the angles of the jaw. The upper borders of the cornua are guides to the lingual arteries which run just above them. Below the hyoid bone is the thyrohyoid membrane which corresponds posteriorly with the epiglottis and the upper aperture of the larynx. It is limited inferiorly by the thyroid cartilage which is one finger's breadth below the hyoid. The parts of the thyroid cartilage and the cricothyroid space between it and the cricoid cartilage below can be readily made out. The pro- jection of the thyroid angle is much more prominent in males after puberty, but the cricoid is always to be made out. It correspoiids to the upper end of the sixth cervical vertebra, to the junction of the pharynx and oesophagus and of the larynx and trachea and to the crossing of the 'common carotid by the omohyoid muscle. Below the cricoid the trachea may be felt but its individual rings can not be distino-uished. As it descends it becomes less easily felt, for ;it is covered more deeply by the lower thicker part of the neck so that at the episternal notch, on a level with the disc between the second and third thoracic vertebrae, it lies nearly 1| inch from the surface. The thyroid gland cannot be distinctly felt unless enlarged. On deep pressure opposite the cricoid cartilage, over the line of the carotid artery, the prominent anterior tubercle of the sixth cervical vertebra can be felt and the artery can be compressed against it, as advised by Chassaignac. Hence it is called the carotid tubercle or Chassaignac's tubercle. As the omohyoid crosses the carotid at this point the latter is more superficial and more easily compressed above it. In the median line at the back of the neck there is a slight depression between the prominences which are due to the trapezius and complexus muscles on either side. At the upper end of this depression is the occipital protuberance, a little way below this the spine of the axis can be felt on deep pressure and below this the spines of the third, fourth, fifth and sixth vertebrae can be felt as a bony ridge but not as indi- vidual spines. The spine of the vertebra prominens (seventh cervical) can be very plainly felt and represents the low^er limit of the neck. In some cases the sixth spine is unusually prominent so that it can be distinctly felt and may l)e mistaken for the seventh spine. At the side of the neck the transverse process of the atlas may be felt just below and in front of the tip of the mastoid process and in the upper part of the supraclavicular fossa the transverse process of the sev- enth cer viced vertebra can be felt on deep pressure. The angle between the submental region and the neck corresponds about to the hyoid bone and is continued as a groove and a crease in the skin backward and upward beneath the angle of the jaw to the subauricular depres- sion in front of the mastoid, behind the jaw and below the ear. In very fat subjects it may not be present. The groove corresponds to Kocher's incision for the upper cervical triangle. The sternomastoid muscle is altogether the most important land- mark of the neck. It is prominent in thin subjects and when thrown into action. Its anterior border is the thicker and better marked and THE STh'RXOMASTOlI) .MUSCLE. 119 along it runs a communicating branch from tlic facial to tiic anterior jugular vein in the lower part of the neck. Extending from the tip of the mastoid to a point just internal to tiie sternoclavicular joint, this border overlies the coiniiion (•(irotid and is the f/nide for iiki/iii/ iiici.slons. The sheath of the muscle which is derived from the superficial layer of the deep cervical fascia is thicker near the middle of the muscle than below or above. Tiie trianc/ular interval between the sternal and clavic- ular heads o^ the muscle is very evident in thin subjects. Beneath the lower end of this interval, /. c.,just above the sternoclavicular joint, lies the common carotid on the left and the bifui'cation of the in- nominate artery on the right side, and on both sides the margin of the pleura and lungs at a deeper level. The action of the sternomastoid of one side is to flex the head for- ward and to the side of the muscle and rotate it to the opposite side. The fibers from the sternal fasciculus cross superficial to those of the clavicular portion so as to be inserted behind them above. The cla- vicular portion produces the lateral flexion, the sternal portion the rota- tion. This difference of action is important and is illustrated in torticollis or wryneck, a condition often congenital, sometimes acquired and due to a contracture or spasmodic contraction of one muscle or the paralysis of the opposite one. The congenital cases are due most often to an injury at birth, too great traction on the after-coming head or the pressure of the forceps. A haematoma forms within the sheath of the ruptured or injured muscle and the injured part is replaced by fibrous tissue, or the pressure of the extravasation causes an ischa?mic degeneration and contracture. According to some the latter may occur from pressure in utero. The deformity may not be noticed for some time after birth and increases with the cicatricial contraction of the injured muscle and cervical fascia and with the diminished growth of the muscle. In this form of wryneck the treatment is division of the tnusclc. This was formerly practiced subcutaneoaslf/ 2 cm. above its lower end in adults, 1 cm. above in children, so as to avoid the anterior jugular vein which passes beneath the lower end of the muscle to join the external jugular, which lies along its posterior border. The latter vein is generally out of danger as only the sternal portion of the mus- cle is usually divided, for it is the rotation due to this portion which is particularly characteristic of torticollis. The great vessels are not in danger as they are here overlapped by the sternohyoid and sternothyroid muscles. The open division is far preferable as every- thing can be divided that prevents the correction of the deformity including the contracted sheath and the cervical fascia. It should l)e done before secondary changes in the vertebrie and soft parts have taken place. Spastic wryneck may be due to a reflex irritation. The spinal acccssort/ nerve together with filaments from the anterior divisions of the second and third cervical nerves supplies the muscle. In such forms of wryneck the spi)ial accessor}/ is often excised and may be exposed where it reaches the anterior border of the muscle, 1 to H 120 THE HEAD AND NECK. inch below the tip of the mastoid. This nerve traverses the mnscle about the junction of its upper and middle thirds, emerges at the posterior border a little above its middle, crosses the posterior triangle and passes under the trapezius on a level with the seventh cervical spine. It supplies the latter in conjunction with the third and fourth cervical nerves. In some severe cases of spastic wryneck the trape- zius and other muscles at the back of the neck are involved and be- sides the spinal accessory the upper four cervical nerves may require resection. Besides forming a guide for the incision in many operations the sternomastoid divides the antero-Iateral region of the neck, in front of the trapezius muscle, into two triangles. These primary surgical triangles are sahdivided into several smaller surgiccd triangles by muscles which are also_ of service as landmarks in operations on the neck. These triangles bounded by and containing landmarks are of practical use, for their contents can be located with reference to these boundaries and landmarks. The posterior triangle (Fig. 29) is subdivided by the posterior belly of the omohi/oid into an inferior or subclavian and a superior or oc- cipital triangle. The occipital triangle bounded by the sternomastoid in front, the trapezius behind and the omohyoid below contains com- paratively little of practical importance. The superjicicd cervical nerves appear at the posterior border of the sternomastoid. The small occip- ital, great auricular and transverse cervical nerves emerge just above the center of the muscle, the first running up to the scalp near the posterior border of the muscle, the second across the muscle to the back of the ear, the third straight forwards across the muscle. Lines drawn from the middle of the posterior border of the muscle to the sternum, the middle of the clavicle and the acromion represent the course of the suprasternal, supraclavicular and supraacromial nerves. The xpinaJ areessori/ crosses this triangle as described above. The subclavian triangle (Fig. 29) corresponds about to the wide depression above the clavicle, the supraclavicular fossa, which is well marked except in stout subjects and infants. In some fractures of the clavicle this fossa may be obliterated or even replaced by a prominence. This triangle is bounded below by the clavicle, above by the posterior belly of the omohyoid and in front by the posterior border of the sternomastoid. The posterior belly of the omohyoid can be made out in thin necks and especially when in action. It runs along a little above the clavicle, inclining somewhat upwards as it passes forwards to pass beneath the sternomastoid. The posterior border of the latter can be made out when in action. The attachment of its clavicxdar portion varies in width and in some cases, especially in muscular sub- jects, it encroaches on the subclavian triangle so as to require division in operations in this region. At a deeper level the posterior border of the scalenus anterior mus- cle roughly corresponds to that of the sternomastoid though it has a somewhat different direction. Hence we may say that there are two PLATE VI 1 1 FIG. 29. SPINAL ACCES- SORY NERVE SERRATUS ym MAGNUS — i™^' MUSCLE POSTERIOR SCAP. ARTERY SCALENUS MEDIUS MUSCLE PH RENIC NERVE BRACHIAL PLEXUS SUPRASCAP. ARTERY LONG THORA- CIC NERVE The occipital and subclavian triangles. The head is turned away to the left and the clavicle is strongly de- pressed. (The posterior scapular artery is unusually deep and has separated unusually early from the superficial cervical artery.) (Zuckerkandl. ) THE SUBCLAVIAN ARTERY. 121 triano;]es of which the deeper is bounded in front by the scalenus ante- rior. The phrenic nerve lies in front of this muscle and crosses it ob- liquely, being directed toward the lower end of its inner border, where it passes behind the subclavian vein. This nerve co//i/)U'nc^.s- about the level of the hyoid bone and \sJon/ial hi/ brandies from the third and fourth cervical. It lies deeply and descends underneath the sterno- mastoid, being about midway between its two borders at the level of the cricoid cartilage. Crossing the subclavian triangle in a line from the angle of the jaw to the center of the clavicle is the external jugular vein. It crosses the sternomastoid obliquely to reach its posterior border, the lower third of which it follows. The lower dilated end or '' sinua" of the vein, between a point 1?, inches above the clavicle, where it pierces and is adherent to the deep cervical fascia, and its entrance into the sub- clavian vein in front of the scalenus anterior, receives the transverse cervical and suprascapular veins. These veins sometimes present a plexiform arrangement in the subclavian triangle and may render more difficult the operations in this triangle. Owing to its adherence to the deep cervical fascia the " sinus " of this vein remains patent and is liable to admit air when it is opened. At the base of the triangle the suhclavian artery describes a curve from the sternoclavicular joint to the center of the clavicle, the highest point of the curve rising }j to \ inch above that bone. On the left side the artery lies more deeply and does not rise so high in the neck as on the right side. At the outer border of the sternomastoid and just above the clavicle the pidmtion of the artery may be felt and it may be compressed against the first rib by pressure downward and backward, when the arm is drawn downward. Normally the artery does not rest directly upon the rib but is slung, as it were, one fourth inch or more above it between the scaleni anterior and medius. The artery may be ligated in its third portion ; wh.ich lies in this triangle external to the scalenus anterior, Ijy an incision about four inches long a finger's breadth above the clavicle. The layers divided in reaching the artery are the following : (1) Skin ; (2) scanty subcutane- ous connective tissue ; (3) platysma ; (4) second connective tissue layer with fat; (5) superficial layer of deep cervical fascia, from the sheaths of the sternomastoid and trapezius ; (G) third layer of loose connec- tive tissue ; (7) middle layer of deep cervical fascia, forming the sheath of omohyoid and connected with the sul^clavian vein ; (8) fourth layer of connective tissue in which lie the lymph nodes, the end of the external jugular vein, the subclavian artery and vein and their branches, and the brachial plexus, etc. The e.rfcrnal jxirjxdar vein (see above) should be nd between two ligatures as should also the supra- scapular vein. The siiprascaindai- and transverse cervical hranc/te.^ of the subclavian artery run outward parallel with the clavicle, the f»)r- mer behind, the latter just above it where its pulsation may usually be felt. The suprdclavicidar nerves descend in front of this triangle. The subclavian vein lies at a lower level, below, internal to and in front 122 THE HEAD AND NECK. of the artery and under cover of the clavicle. To avoid injury to the vein the aneurism needle should he passed from below and in front. At the inner end of this triangle the siibdavkin vein is separated from the artery by the scalenus anterior. Behind the latter the artery lies in contact with and grooves the dome of the pleura and the apex of the lung. These structures should be carefully avoided in passing the ligature. Strict asepsis should be observed to avoid inflammation of the pleura and empyema. The pjleura has also been opened in removing deeply seated tumors of the base of the neck and, together with the lung, has been wounded in stab Avounds of the neck and by bony fragments in severe fractures of the clavicle or first rib. Abscess in this part of the neck has opened into the pleura and pleurisy lias also followed cellulitis of this part. Hernia of the lung into the neck during violent paroxysms of coughing has been reported. For the position of tlie lung and pleura in the root of the neck see p. 215. The brachial plexus can be /eft and, in very thin subjects, even seen in the subclavian triangle. Its upper limit is shown by a line from the side of the cricoid cartilage to a point a little external to the middle of the clavicle. It lies just above the subclavian artery, its lowest cord being partly behind the artery, and it emerges like the artery from between the anterior and middle scalene muscles. Hence it is exposed and may serve as a guide in ligating the subclavian artery. It has occasionally happened that a cord of this plexus has been included in the ligature in place of the artery but the mistake is evident from the continued pulsation in the arteries of the arm. The third portion of the artery is the seat of election for ligature for it is more superficial and has no branches and fewer vital relations. The second part lies deeply behind the scalenus anterior on which lies the phrenic nerve. It includes the highest point of its curve, gives off one branch (superior intercostal) and is in close relation with the pleura. The first portion is crossed in front by the internal jugular, vertebral and the commencement of the innominate veins, and on the right side by the pneumogastric and a loop of the sympathetic nerve. On the left side the thoracic duct arches over it. The subclavian vein is below and in front of it and gives off three large branches. Below and behind it are the pleura and lung and, on the right side, the recurrent laryngeal nerve. Hence and because of its deep situation it is not well suited for the application of a ligature. After ligature of the second and third portions of the subclavian the collateral circulation is established and carried on principally through the anastomoses, (1) of the suprascapular and posterior scapular with the acromiothoracic, infra- and subscapular and dorsalis scapulae ; (2) of the superior intercostal, aortic intercostal and internal mammary with the long thoracic and the scapular arteries ; (o) of small branches in the axilla. Cervical ribs occur usually on both sides, sometimes on one side only. As a rule they are articulated with the seventh cervical vertebrce and its transverse process but sometimes they are fused with it. They may THE SUBMAXILLARY TRIANGLE. 123 be very short, when they are often mistaken for exostoses, or they may extend well forward and be connected by bony, cartilaginous or fibrous union with the first rib, its cartilaije or the sternum. In such cases the suhc/(iri(in (/rfrr// and hraoJual jtle.vus pass over them and the anterior, and sometimes the middle, scalene nuiscle is attached to them. The distinct pnlmtion of the artery at a high level in such cases may lead to a diagnosis of anearism and in fact the latter condition seems to be not uncommonly associated M'ith cervical ribs. The rib may form a distinct projection in thin persons but as a rule it causes no si/nijjfom.s. Sometimes however the circulation in the arm and the function of the branches of the brachial plexus is interfered with, apparently as the result of pressure by the ribs or of the sharp bend in the artery, and hence i-enKiral of the ril) is indicated. The anterior cervical triangle, in front of the sternomastoid, is subdivided by the digastric muscle above and the anterior belly of the omohyoid below into three smaller triangles. The submaxillary triangle, or the upper one of these three, is bounded above by the lower border of the jaw and the line of this con- tinued back to the mastoid process, below by the posterior belly of the digastric muscle and the hyoid bone, in front by the median line. It corresponds to the s; prahyoid rer/ion of some authors. That part of its posterior angle behind the thick fascial band from the sheath of the sternomastoid to the angle of the jaw, belongs to and has been described under the parotid region. The posterior belly of the digastric muscle coincides with a line from the mastoid process to a point just above the junction of the great cornu and body of the hyoid bone. In the normal position of the head this region lies in a nearly hori- zontal plane which accounts for the rarity of wounds here. When the head is extended, as it is in operations on this region, the latter is oblique from above downward and inward. In incisions into it we meet the following layers in succession, (1) skin; (2) platysma, with a con- nective tissue layer on either side ; (3) the superficial layer of the deep cervical fascia forming a sheath for (4) the submaxillary gland ; (5) the muscular floor of the triangle with vessels and nerves covered by a deeper layer of fascia which is attached to the hyoid bone and the mylohyoid ridge and forms a sheath for the digastric muscle. The platysma is quite closely co)inected with the skin, so that the ed(/e^ of wounds crossing the course of the muscle are likely to be turned in. Owing to the loose tissue beneath the muscle the skin and ]>latysma may l)e readily used as a //a/> and the tlaj) so formed can be freely dis- placed to cover defects in the lower lip and lower part of the face. But to cover defects in the lips or cheek such flaps possess the disad- vantage of not beinir lined bv mucosa so that the final results are dis- appointing, owing to the adhesions and contraction of the flap (see p. 99). The amount of Jut between the skin and deep fascia is very variable. There is often a diffuse deposit of fat, especially in the area between the chin and the hyoid bone, |)roducing the so-called double or triple ehin, thus converting the normal concavity of this region into a convexity. 124 THE HEAD AND NECK. The superficial layer of the deep fascia splits to enclose the suh- maxillary gland in a fibrous .sheath and is adherent to the lower border of the jaw and to the hyoid bone. It is continuom laterally with the sheath of the sternomastoid and of the parotid gland and in the median line with the similar layer of the opposite side. It is connected with the thick fascial band from the sternomastoid to the angle of the jaw, which separates the submaxillary from the parotid sheath. The submaxillary gland differs from the parotid in that its fibrous septa are not closely connected with the inside of its sheath, but it is separated from its sheath by loose connective tissue so that it can be readily enucleated. The submaxillary gland is seldom inflamed pri- marily, though of all salivary glands it is most frequently the seat of calculi, which by obstructing the duct may produce sudden, recurring attacks of acute, painful sicelling of the gland, sometimes accompanied by suppuration. The contents of the submaxillary gland sheath of the most practical importance are the lymph nodes on the surface of the gland which receive lymphatics from the lips, the fore part of the tongue, the floor of the mouth, the nose, the forehead, the nasal half of both eyelids and the submaxillary and sublingual glands. Hence these nodes may be affected in any inflammatory affection or malignant new-growth of these parts, and the enlarged or broken-down nodes require opening or removal according to circumstances. When these lymph nodes are removed it is often impossible to spare the gland, especially in can- cerous conditions, and the entire contents of the digastric triangle are then removed together. In this procedure the most important rela- tion of tiie gland is with the facial artery which grooves its postero- superior part passing from its deep surface to the border of the jaw just in front of the masseter. The general direction of the tortuous facial artery is between the latter point and its origin just above and outside the tip of the great cornu of the hyoid bone, passing be- neath the posterior belly of the digastric in its course. The facial vein, usually separated from the artery by the submaxillary gland, the pos- terior belly of the digastric, the stylohyoid muscle and the hypoglos- sal nerve, crosses superficial to the artery to become more posterior at the border of the jaw. The submental branch, given off from the artery beneath the gland, runs forward on its deep surface. (Fig. 30.) When enlarged the posterior extremity of the gland, grooved by the facial artery on its deep and superior aspect, may overlap the external carotid from which it is separated by the posterior belly of the digas- tric, the stylohyoid and the band from the sternomastoid to the angle of the jaw. The gland lies partly hidden beneath the mandible. Its accessory portion and duct (Wharton's) (see page lOG), pass forward in the floor of the ujouth on the deep surface of the mylohyoid. Notice the close relation between this region and the floor of the mouth ; in- flammatory affections may spread from one to the other behind the mylohyoid. In this connection it should be remembered that the commonest cause of abscess in the submaxillary region is dented caries PLATE IX FTG 30. The salivary glands. The right half of the body of the mandible has been removed. GL.W., gland of Weber. GL. B., gland of Blandin. (Gerrish, after Testut.) POSTERIO BELLY OF DIGASTRIC MUSCLE HYPOGLOSS NERVE GREAT CORNU OF HYOID LINGUAL Tfi, ANGLE, WITH COURSE OF LING. ARTERY COVERED BY HYO- GLOSSUS Submaxillary triangle and the deep relations of the submaxillary gland. Dotted white line indicates the posi- tion of the gland, dotted red line the course of the lingual artery beneath the hyoglossus. (Testut. ) FIG EXT. CAROT ARTERY GLOSSO- PHARYNG. POST. AURIC NERVE ARTERY OCCIPITAL ARTERY SPINAL ACCES- SORY NERVE HYPOGLOSSAL NERVE INTERNAL CAROT. ARTERY DESCENDENS NONI N. LINGUAL VEIN COMMON FACIAL VEIN INGUAL ARTERY UP LARYNGEAL NERVE, INTER- NAL BRANCH. UP LARYNGEAL NERVE EXTER- NAL BRANCH Structures of the upper part of neck in the superior carotid and submaxillary triangles. The sternomastoid muscle is retracted somewhat backward, the digastric is divided and the omohyoid removed. (Zuckerkandl.) IHE LINGUAL VESSELS AND TRIANGLE. 125 followed by alveolar |)eriostitis of the mandible (see pages 100-1 j. In- flammation of the submaxillary gland and of the lymph nodes within its sheath, or the abscess resulting therefrom, is more circumscribed than the last-mentioned abscesses and in opening submaxillary ab- scesses it should be remembered that the facial vessels and their branches are beneath the sheath and not exposed to injury. The two bellies of the digastric below and the jaw above frame a deep irianf/Ie lodging the submaxillary gland. The Jioor of this tri- angle is formed by the mylohyoid and hyoglossus muscles from be- fore backward. Passing forward on the latter muscle i.-, the Injpo- glossal nerve accompanied by the ranine vein. The lingual artery has much the same course, at a somewhat lower level, but it lies beneath the hyoglossus and upon the genioglossus muscle. This artery, arising opposite the tip of the great cornu of the hyoid, runs forward just above that process and is usually ligated in the "lingual triangle." This triangle is bounded above by the hypoglossal nerve, in front by the posterior border of the mylohyoid and behind and below by the pos- terior belly of the digastric. (Fig. 31.) It is readily exposed on turning up the submaxillary gland. The lingual artery is here readied by separating the more or less vertical fibers of the rather thin hyo- glossus muscle, at right angles to which it runs. It is accompanied by one or several venre comites. To include the dorsalis Ihir/me branch it has been advised by Fara- boeuf and others to ligate the first jjortion of the artery, behind the hyoglossus muscle near whose posterior border this branch is given off and passes upward. For this purpose the end of the great cornu of the hyoid bone is our guide, to which the posterior fibers of this muscle are attached. This part of the artery is crossed by the hypo- glossal nerve, the facial and lingual veins and the digastric and stylo- hyoid muscles. The sublingual artery, usually given off at the anterior border of the hyoglossus, may sometimes arise in the lingual triangle and might then be ligated in place of the trunk, so that the circulation on the same side of the tongue would not be controlled by the ligature. This is probably not the common cause of hemorrhage in operations on the tongue after ligation of the lingual but rather an anomali/ wherein the lingual on one side is small and its place is taken by a large branch from the opposite lingual. Underneath the deep fascia in the median line beneath the chin and lying on the mylohyoid muscle are two or three /i/inii/i nodes which receive vessels from the middle of the lower lip and the chin and may be enlarged in affections of these parts. The submaxillary gland and its surrounding lymph nodes are com- paratively superfieiak and may be easily /•mc/(f(/ for removal or for elevation to expose the lingual triangle, by a cn.rred incisin)! from just below the angle of the jaw to the body of the hyoid bone and up toward the symphysis. Kocher's so-called "normal incision" for the upper lateral cervical triangle passes from in front of the tip of the 126 THE HEAD AND NECK. mastoid to the middle of the hyoid bone and lies just below the digas- tric and the other suprahyoid muscles. It avoids important nerves, for those crossing it can be retracted posteriorly, and it crosses the point where the branching of the great vessels occurs. The subhyoid region is divided into the two carotid triangles by the anterior belly of the omohyoid muscle. The latter follows a line from the side of the body of the hyoid at its lower border to the anterior border of the sternomastoid at the level of the cricoid cartilage, where it crosses in front of the common carotid and behind the sterno- mastoid. The superior carotid triangle is bounded behind by the sterno- mastoid, above by the posterior belly of the digastric and below and in front by the anterior belly of the omohyoid. Its floor is formed by the thyrohyoid, hyoglossus and inferior and middle constrictors of the pharynx. It contains, beneath the skin the platysraa and the superficial and middle layers of the deep cervical fascia, the lower portion of the external carotid with the commencement of its lower five branches and, beneath the anterior margin of the sternomastoid, the upper end of the common carotid and the lower part of the internal carotid. The superior thyroid artery arises a little below the great cornu of the hyoid and runs downward and forward to the back part of the thyroid cartilage and the upper and outer part of the thyroid body. It is superficial only at its commencement. Beneath it is the superior laryn- geal nerve whose internal branch, with the superior laryngeal branch of this artery, pierces the thyrohyoid membrane. Its sternomastoid branch, arising about half an inch from its origin, crosses the upper end of the common carotid to reach the sternomastoid muscle. The occipital artery, arising at the same level as the facial (p. 124), but from the posterior aspect of the artery, passes upward and backward to the interval between the mastoid process and the transverse process of the atlas. It finally enters the scalp with the great occipital nerve midway between the mastoid process and the external occipital protu- berance and follows thence the line of the lambdoid suture. The facial and lingual branches have already been referred to. The inferior carotid triangle is bounded above by the anterior belly of the omohyoid, behind by the sternomastoid and in front or mesially by the median line. The carotid triangles are so called from their containing the carotid vessels which strictly speaking are in great part behind these triangles under cover of the anterior border of the sternomastoid. The Great Vessels. — The line of the carotid is from the sterno- clavicular joint to a point midway between the angle of the jaw and the mastoid process. The common carotid extends up to the upper border of the thyroid cartilage, on a level with the third cervical vertebra, where it bifurcates into the external and internal carotids. At its point of bifurcation it presents a slight dilatation which is the most com- mon situation for aneurisms, for there appears to be some resistance to the blood current here. Such an aneurism may demand the proximal THE COMMOX CAROTID ARTERY. 127 iujature of the carotid. The carotid, having no collateral Ijranches, is also the vessel in which the didal ligature (Basador's method) is best adapted. It is most often ])racticcd for aneurisms in its lower part, where they are not uncommon. As there are no collateral ijranches between the aneurism and the ligature the latter, by occluding the artery, prevents the blood ])assing through the aneurism. Wardrop's operation, or the distal ligature of large branches for aneurism of a main trunk, has been tried here and is now limited to the ligature of the carotid and the third portion of the subclavian for aneurisms of the innominate or, occasionally, of the aorta. But as there are large branches given off from the first and second portions of the subclavian, which under the conditions present can scarcely l)e ligated, the success of this method is not so great as it might otherwise be. The common carotid is now ligated mainly for aneurism or wound of the artery itself The external or internal carotid, instead of the com- mon carotid, is now lir/ated to check hemorrhage from their branches due to wounds, to prevent hemorrhage in the removal of neoplasms and to check the growth of the latter. One objection to ligature of the common carotid is the occasional effect on the brain, but as a rule the two vertebrals and the opposite carotid with their free anastomosis in the circle of Willis are sufficient to obviate this. The rouiuion carotid may be secured at any part in the neck but the place of election is just above the omohyoid, where it is superficial, being covered only by the skin, platysma and superficial and middle layers of the deep cervical fascia. The incision is carried along: the anterior border of the sterno- mastoid with the center opposite the cricoid cartilage. A communi- cating vein between the facial and the anterior jugular veins may be met with in the line of incision. After incising the superficial layer of the cervical fascia along the anterior border of the sternomastoid we meet the omohyoid crossing obliquely the line of incision at the level of the cricoid cartilage. Then, incising the middle layer of the cervical fascia above the omohyoid in the same line, we expose the carotid sheath which is here crossed by the sternomastoid arteri/ and sometimes by the superior thyroid veins. The middle thyroid veins may also cross it here but usually with the omohyoid muscle. A valuable guide to the artery, about the crossing point of the omo- hyoid and about 2} inches above the clavicle, is the carotid tidjrrc/c or anterior tubercle of the sixth cervical vertebra, directly over which lies the artery and against which it may be compressed. This tubercle serves also as a guide to the vertebral artery which lies on the transverse process of the seventh cervical vertebra just be- low it, cro.s.sfd bji the inferior thyroid artery and, on the h'ft side, by the thoracic duct. It is less often tied than formerly. Jieloir the omo- hyoid the carotid artery lies more and more deeply, as we follow it to the base of the neck, being overlapped in front by the sternohyoid and sternothyroid muscles and to some extent by the thyroid body, especially if the latter is enlarged. Near its hirer end the anterior 128 THE HEAD AND NECK. jugular vein crosses in front of it and the inferior thyroid artery and recurrent laryngeal nerve behind it. The carotid sheath, (Jerired from the deep layer of the deep cervical fascia, encloses the internal jugular rei)i and the vagus nerve in addi- tion to the artery. The sheath should be opened from the inner side to avoid the thin-walled vein which is external and, being nearly twice the size of the artery, overlaps the latter anteriorly. On the right side the rei)i, which is commonly larger than that on the left, be- comes a little separated from the artery at the root of the neck while on the left side the vein overlaps the artery still more at this point. Although each of the three occupants of the sheath has its own special investment there is danger of wounding the vein in passing the aneurisni needle and to avoid this danger the latter is passed from without inward after carefully separating the vein and artery. In exposing the sheath of the carotid the descendens noni nerve is found in front of it, inclining gradually from the outer to the inner side. Care should be taken to avoid it as it supplies the infrahyoid muscles. It is sometimes found within the sheath. As before stated the external carotid is now ligated for many condi- tions for which the common carotid was formerly tied. Thus it is ligated for wound or aneurism of its branches, as a preliminary measure in certain operations (like excision of the parotid, maxilla, etc.) and as a palliative measure in malignant neoplasms to starve them or prevent hemorrhage. For the latter purpose excision is more effective than ligature. Ligature, and especially excision, of the external carotid is less easy but safer and more satisfactory than ligature of the common carotid. The line of the external carotid inclines forward from the line of the sternomastoid to reach a point beneath the augle of the jaw. In the natural position, when the angle of the jaw about touches the sterno- mastoid, the line of the artery nearly corresponds to the anterior border of the muscle, but in the extended position of the head, in which the operation is done, the line of the artery is from the angle of the jaw to the sternomastoid at the upper border of the thyroid cartilage. The incision for ligature or excision may be made in this line or across it, in the line of Kocher's normal incision (p. 125), In its loirer part the artery is corapariatively superficial, being covered by the same layers which cover the upper part of the common carotid (p. 127), but it soon becomes more d('ej)ly j^laced and passes beneath the digastric and stylohyoid muscles and then internal to and within the parotid gland. Below the digastric, which crosses it about IJ inch above its commencement, it is crossed by the hypoglossal nerve and below this by the facial and lingual veins, usually as a common trunk which is often joined by the superior thyroid vein. The place of election for ligature is between the superior thyroid and the lingual branches, or opposite the tip of the great cornu of the hyoid bone. Through the same incision the four lower branches of the external carotid can be ligated at their origin. ASPIRATION OF A HI INTO VEINS. 129 In the first part of its course the external carotid is situated internal (mesial) and anterior to the internal carotid, in the loose connective tissue in whicli both are lodged, hence the (juestion may arise whether the vessel exposed is the internal or external carotid. The following jjointi< help us to ditifinf/ui.sh the external carotid, (1) the presence of branches ; (2) the stoppage of pulsation in its branches from compres- sion of the artery; (3) contact with the hypoglossal nerve which crosses it just below tlie origin of the occipital l)ranch, and (4) its near rela- tion to the great cornu of the hyoid. In paiA^hich are drained into each group of nodes. Deep structures in red, superficial in black. ( F. H. Gerrish.) EMBRYOLOGY OF TJIIC NECK. 145 puny the internal jugular vein and are arranged m trro seta, Xha upper about and above the bifurcation of the carotid and the lower set below. They receive all the lym])haties of the head and neck directly or indi- rectly by receiving the lymphatics from the superficial set and those from tiie other groups which do not em])ty wholly into the latter. At the base of the neck they communicate with the mediastinal, subcla- vian and axillary nodes. Of the deep set the nodes near the bifurcation of the carotid often first show enlargement, but in most cases where the nodes are exposed by operation many more are involved than expected and a chain of glands, gradually decreasing in size, leads from the position of the visible tumor. Therefore in reniovincj cervical li/mphadenorna the operation often proves more extensive and formidable than ex])ected. They may be con- siderably enlarged without detection by j)alpation and we often feel them without suspecting their real size or numbers. In removing them their relation to the internal jugular vein is of great importance, as they may be adherent to it and difficult to separate from it, espe- cially when involved secondarily to cancer. With the exception of a few, like the superficial cervical group, the cervical lymph nodes lie beneath the deep fascia. They may also be enlarged in the rare cases of lymphoi^arcoma, and the peculiar affection known as Ho(lgkin\'i dis- ease. Although in most cases of involvement of the lymph nodes the infection comes from the same side of the body as the enlargement, yet in exceptional cases it comes from the opposite side. Thus exception- ally when one side of the tongue is the seat of epithelioma the opposite submaxillary nodes are involved. Embryologically the neck is formed by the coalescence of five visceral or branchial arches separated by four furrows or branchial clefts. These clefts, seen on the surface, correspond to a like number of inner clefts or pharyngeal pouches on the walls of the pharynx, separated from the outer clefts by a thin chiding niemhrane, composed of a layer of entoderm and one of ectoderm. Of these arches and clefts the first arch forms the lower and upper jaws, the incus and the malleus ; the second the stapes, the styloid process, the stylohyoid ligament and the lesser corn u of the hyoid bone; the third forms the body and great cornu of the hyoid ; the fourth and fifth form no special structures. The first outer cleft forms the external ear, the corresponding inner cleft the middle ear and Eustachian tube and the closing membrane between them forms the membrana tympani. The fourth inner cleft forms the lateral lobes of the thyroid gland and the tissues adjacent to the second cleft take jxirt in forming the posterior third of the tongue and the middle portion (isthmus) of the thyroid gland. If the lower branchial arches do not fuse together, as they normally should in the second month of fa>tal life, the corres])onding cleft remains partly open as a so-called branchial fistula. These may be lateral or median in position and complete or incomplete. In the case of complete fi.stukr the closing membrane gives way and there is a narrow canal lined by mucous membrane, leading from without back- 10 146 THE HEAD AND NECK. ward, inward and upward for 1^ to 2| inches. The internal opening of such a fistula is in the lower part of the pharynx or in the posterior palatine arch near the tonsil. The external opening varies in position according to the cleft which remains open, being most often near the sternoclavicular joint, in the region of the fourth cleft, or at the an- terior or posterior border of the sternomastoid near the larynx, in the second or third cleft. Incomplete Jistulce open either externally or internally in the same position as one end of a complete fistula. Near the external opening of a fistula, or in spots where they commonly open, a protruding fold of skin may be found and above it a cartilag- inous mass is sometimes to be felt. As the external ear is formed by the fusion of six similar nodules at the outer end of the first visceral cleft, the more prominent of these are called supernumerary auricles. Median fistulse of the neck, or tracheal fistulae, are rare and if incom- plete and internal may give rise to air tumors. Congenital dicerticula of the (esophagus are probably always incomplete lateral branchial fistulte of the neck. From obstruction of the external or internal opening of a fistula or from a portion of the wall of the cleft shut in by the closure of the arches, dermoid and branchiogenic cysts may be formed. Such shut-in portions of the epithelial tissue may be the nucleus of the rare primary carcinomas of the neck. CHAPTER 11. THE UPPER EXTREMITY. The upper extremity, the organ of prehension and touch, is notable for its rnobiUty, which is due to the freedom of movement of its joints and its many muscles. Its only bony connection Avith the skeleton of the trunk is through the clayicle. In the upright position the upper extremity reaches to the middle of the thigh, the right being stronger and ^-1 cm. longer as a rule. The greater deyelopment of the right upper extremity depends, accord- ing to Hyrtl, on the arrangement of the blood supply which is more abundant and comes more directly from the heart on the right side. The anomalous origin of the right subclayian as the last branch of the aortic arch is associated, according to the same author, with left- handeduess and the greater development of that side. THE REGION OF THE SHOULDER. This comprises the upper part of the extremity and reaches down to the insertion of the pectoralis major and latissimus dorsi muscles. Surface Landmarks and Markings. — The clavicle, acromion proc- ess and spine of the scapula can be readily /tV^ suhcutaneousli/. The clavicle is not quite horizontal, but inclines slightly upward at its outer end in the erect position and even more so in the reclining position when the weight of the arm no longer pulls it down. The upper sur- face is only covered by skin and platysma and the anterior and pos- terior surfaces are more or less readily palpable. The deltoid tubercle of this bone may be felt if large and may even be mistaken for an exostosis. The sternal end is large and prominent especially in mus- cular subjects and the outer or acromial end is often enlarged and projects above the level of the acromion so that it should not be mis- taken for a dislocation at the acromioclavicular joint. The latter joint is in the vertical line passing up the middle of the arm anteriorly. The angular prominence which can be felt externally at the junction of the acromion and tiie sj)ine of the scapula is the best point from which to measure the arm down to the external condyle. Tlie latter point, the tip of the acromion and the radial styloid process are all in the same line when the arm hangs at the side and the palm looks forward. A\ hen tile arm hangs at the side the upper angle of the scapula corre- sponds to the upper border of the second rib, the lower angle to the seventh intercostal space and the vertebral end o( the spine of the scapida to the third intercostal space, to the interval between the third and 147 148 THE UPPER EXTREMITY. fourth thoracic spines and to the fissure between the upper and lower lobes of the lung. The vertebralborder of the scapula may be made prominent by carry- ing the hand as far as possible over the opposite shoulder, the axillary border and inferior angle by placing the forearm behind the back. The prominence of the slioidder is due to the acromion process, but the roundness ]\M^i below this depends upon the prominent great tu- berosity of the humerus covered by the deltoid muscle. Hence this roimdness gives way to a flattening when the underlying bony bolster is removed, as in a dislocation of the shoulder, or is diminished in bulk, as in an impacted fracture of the anatomical neck. The head of the humerus can be felt high up in the axilla, especially when the arm is abducted, which brings the head in contact with the loM'er part of the joint capsule. The lower margin of the glenoid cavity can also be felt high up in the axilla below and internal to the humeral head. The head and internal condyle of the humerus and the styloid process of the ulna are in the same line. This relation of the head and internal con- dyle, beingconstant in all positions of the arm, is of value in the diag- nosis of injuries about the shoulder and in reducing dislocations. In thin subjects the two tuberosities of the humerus and the bicipital groove between them can be felt beneath the deltoid, especially on rotating the humerus. The bicipital groove looks directly forward when the arm hangs at the side with the palm of the hand looking forward. The groove between the deltoid and pectoralis major, distinguish- able in most cases, contains the cephaUc vein and, more deeply, the humeral branch of the acromiothoracic artery. The upper end of this groove widens out into a triangular infraclavicidar fossa, the base of the triangle being formed by the clavicle. On deep pressure here the Goracoid process can be felt just beneath the margin of the deltoid and a little below the clavicle. The depression of the infraclavicular fossa is obliterated in suljcoracoid dislocations of the humerus, in some fractures of the clavicle with displacement, in some axillary tumors, in lymphatic enlargements and in inflammations along the upper part of the axillary artery. It is re])laced by a prominence in intracoracoid dislocations of the humerus. If the muscles are relaxed we may detect the pulsation of the axillary artery by pressure in the infraclavicular fossa below the middle of the clavicle and we may also compress the artery against the second rib. By a vertical incision through the center of the coracoacroniial ligament the shoulder joint is opened and the biceps tendon is encountered. Hence in resection of the shoulder joint the coracoid process is a landmark for the incision. The anterior border of the axilla is formed by the lower margin of the great pectoral muscle which passes from the sixth costal cartilage to the outer bicipital ridge and nearly follows the line of the fifth rib. The anterior and posterior axillary borders are well marked, especially when the arm is abducted to an angle of about 45° and the muscles form- ing these borders arc contracted, in which position the depression of the FRACTURE OF THE CLAVICLE. 149 axilla is deepest. As the arm is raised to and above the horizontal line the axillary depression becomes shallower by reason of the pro- jection into it of tha humeral head, the approximation of the anterior and pi^sterior axiUary folds and tlie projection of the coracobrachial is muscle along the hnnioral side of the axilhi. Wlicn the arm is brought nearly to the side the thoracic wall bounding the axilla internally can be explored as high up as the third rib. The axillary lymph nodes on this or on the outer side cannot be felt unless they are enlarged. Topography of Some of the Deeper Parts. — When the arm is abducted the course of the axillary artery is represented by a line from the ceuter of the clavicle to the groove along the inner border of the coracohrachialis muscle. The latter muscle comes well into view when the huuierus is rotated a little outward. The position of the pectordli.i ininor muscle is outlined, by two lines, converging from the upper border of the third and the lower border of the fifth rib, just external to their cartilages, to the coracoid proc- ess. The position of the acromiothoracic artery is indicated by the point Avhere the upper line crosses the course of the axillary artery and the long thoracic (irtcry runs in the lower line. When the arm hangs at the side the circumflex nerve and posterior circumflex artery wind around the humerus under the deltoid about a finger's breadth above the center of the vertical axis of the latter. A finger's breadth below this point the dorsalis scapulas artery crosses the axillary border of the scapula. For convenience of study we may divide the shoulder into four regions. (1) The anterior or clavicular region ; (2) the posterior or scapular region ; (3) the outer or deltoid region (including the shoulder joint) ; (4) the axilla. 1. The Anterior Region of the Shoulder. This is also called the clavicular region because the clavicle forms its bony framework. The skin over this region is loosely attached and hence freely movable, a fact which explains why it usually escapes being wounded in contusions and which partly accounts for the rare occur- rence of penetration in fractures of the clavicle. It must also be care- fully put on the stretch in tlie incision for subclavicular ligation of the axillary artery. The supraclavicular nerves, the cutaneous nerves of this region, in their passage in front of the middle third of the clavicle are liable to contusion, and such an injury explains the occasional severe i)aiu after blows on the clavicle. According to Tillaux the severe pain which occasionally persists after fractures of the clavicle is due to the involvement of these nerves in the callus. Fracture of the clavicle is one of the commonest forms of fractures, a lact diw to its su[)erfic'ial position, its slender form and the circumstance that it receives a large share of almost all shocks which involve the upper extremity. Such fractures are more often due to indirect than to direct violence. Among the indirect fractures the 150 THE UPPER EXTREMITY. great majority are at the outer end of the middle third (i. e., the middle two inches) of the bone, for the reason that this is the most slender and most sharply curved part and also the meeting point of the two curves and of the more fixed outer third with the more movable inner two thirds. In this connection it may be noted that the clavicle breaks in such cases by the exaggeration of its normal curves. The direction of the fracture is accordingly usually obliquely inward, downward and backward. As to the displacement that occurs it should be borne in mind that the clavicle serves as a kind of outrigger to hold the shoulder and upper extremity away from the thorax. When this support is broken the shoulder with the outer fragment is naturally displaced inward and sinks downward by its own weight. The inward displacement also causes the shoulder to 8wing forward so that the common displacement of the inner end of the outer fragment is downward , inward and forward. The outer end of the outer frag- ment is also rotated forwards. This outrigger action of the clavicle may be illustrated by a bar supporting a sign from a building, the outer end of the bar being also supported by a chain from a point higher up on the wall, the chain representing the trapezius, etc. If the bar breaks the outer end with the sign falls downwards and inwards. But this is not the only and perhaps not the most important cause of the displacement, the other causes being the continuance of the force pro- ducing the fracture, the direction of the fracture and the action of the muscles. Thus in transv'erse fractures there may be no such displace- ment, but instead of it an upward angle, due to the sinking of the shoulder, or no displacement at all, especially in green-stick fractures. Again if the oblique direction is much inclined backward the inner end of the outer fragment may be forced behind or simply below the inner fragment and not in front of it. Among the muscles the pectorals and latissimus dorsi pull the outer fragment inward and downward. The outer end of the outer fragment is rotated forward by the pectorals and the serratus magnus. The inner fragment, if dis- placed at all, is pushed up by the outer fragment beneath it, rather than pulled up by the sternomastoid. Owing to the inward displacement of the outer fragment causing the fragments to overlap, there is necessarily a considerable shortening which may nearly equal in extreme cases one third the length of the bone, or two inches. As this shortening is difficult to remedy com- pletely it follows that some shortening remains permanently after fracture of the clavicle more often than after any other fracture save that of the femur. Tiiis shortening causes some narrowing and rounding of the affected shoulder. It follows from the nature of the displacement that reduction is to be obtained and maintained by carrying the shoulder upward, outward and backward. Upward pressure on the elbow carries the shoulder upward and, with a pad in the axilla as a fulcrum and the arm as a lever, inward pressure at the elbow forces the shoulder outward. Some shortening and deforinifi/ usually persists and any forward dis- COMPLICATIONS OF FRACTURE OF THE CLAVICLE. 1'">1 placement of the outer fragment may be particularly hard to keep reduced unless the patient is willing to lie perfectly flat on the back for three weeks or so. In this rcriiriihent posifion the weight of the arm no longer drags the shoulder downward and the weight of the shoulder and the pressure of the body on the scapula, forcing its outer border outward and backward, pull the outer fragment outward and backward better than any form of bandage. The mobility of the clavicle and the number of strong muscles attached to it explain the difficulty of applying a satisfactory fixed dressing and the tendency of the callus to become excessive. In fraeture of the outer third, which is more often transverse than oblique, there may be no ilisjj/dci'menf or an angular one due to the forward and inward turning of the outer fragment. The clavicle may be broken by muscular violence, probably by the clavicular fibers of the pedoralix major and dcUo'uJ. These tend to draw the clavicle dowuM'ard and forward, in which position the outer fragment is displaced in such cases. These fractures are most often in the middle third. Violent movements of the limb forward and inward or upward appear to be the commonest cause. Occasionally the frac- ture is due to a sudden depression of the arm by which the clavicle is bent over the first rib. Fractures by direct violence are most apt to be transve)^se and may occur at any point, but most frequently at the middle or outer third. Green-stick fracture, or fracture without rupture of the periosteum and hence without much displacement, occurs more often in the clavicle than in any other bone. This is partly due to the fact that such frac- tures occur in childhood and more than half the fractures of the clavicle are said to occur before the age of five. According to Kronlcin frac- ture of the clavicle in children takes the place of dislocation of the shoulder by direct violence later in life. The periosteum at this age is also very thick and loosely cdtached. Notwithstanding the absence of deformity, and the failure of diagnosis that may result, the callus is often excessive, owing to the stripping up of the ac- tive periosteum. T\\e firmness of the periosteum, l)ut es])ecially the presence beneath the clavicle of the suhclavius uiuscle enveloped in a dense fascia, are largely accountable for the rare oceurrence of the complications of frac- tures of the clavicle, which consist of injuries to the vessels, nerves and lung. xUthough the vessels and nerves lie beneath the clavicle in the angular interval between it and the first rib in the following order from within out, subclavian vein, artery and brachial plexus, injuri/ to the arteri/\s not recorded, unless of such a nature as to produce sub- sequent aneurism, and only a few cases of injury to the vein and brachial plexus arc on record. The vein from its position, as the most internal of these structures in the acute angle between the clavicle and the first rib, and from its slighter resistance is likely to be the first to be com- pressed. Injury to the infertud jur/ular vein, lying behind the clavicle, has also been recorded. I have recently seen a case of paralysis of 152 THE UPPER EX'I REMIT Y. the arm following a fall on the shoulder where the brachial plexus was found reduced to a mass of connective tissue, apparently from com- pression by the clavicle, though no fracture of the clavicle resulted. Injury to the lung by a fragment of the clavicle, as evidenced by emphyseina, has been observed in a few cases and in other cases the emphysema was apparently due to a wound of the soft parts. The interposed pad of the suhclarius muscle is of great service in resection of the clavicle, rendering the operation easy in the outer two thirds while behind the sternal third are the innominate or left carotid artery, the brachiocephalic and internal jugular veins, the vagus, re- current and phrenic nerves, the thoracic duct and the trachea. A little more externaUy the external jugular vein, the suprascapular vessels and the apex of the lung lie behind the clavicle. In case of enlargement of the clavicle the resection of its inner third may be a matter of consid- erable difficulty, though in case of necrosis with thickening of the peri- osteum the operation may be extremely easy. In any excision of the clavicle the operation is rendered much easier and safer if it can be done subpcriosteally. The restoration of the clavicle after subperiosteal resection is sometimes very complete, but even when no new bone forms the removal of the entire clavicle is followed by far less alteration in position and impairment of motion of the shoulder than would be ex- pected from its function as a support and outrigger for the shoulder. So striking is this in some cases as to lead one to question whether the displacement in fracture of the clavicle is not mostly due to the other factors, /. e., continuation of the force producing the fracture, muscular action, and the direction of the fracture. Avulsion of the entire upper extremity has occurred in a number of cases, especially in machine accidents. Apart from the sternoclavic- ular articulation only muscles hold the upper extremity to the trunk and if the clavicle is fractured only the rupture of muscles, vessels and nerves is necessary in avulsion. The Sternoclavicular Joint. — The lack of adaptability between the bony surfaces forming this joint accounts largely for the amount of motion that occurs here. When the arm hangs at the side the clavicle is in contact with the socket only at its lower angle, rendering the cavity V-shaped. This allows the elevation of the shoulder in which position the bones are in more immediate contact. Accordingly in disease of this joint the motion of elevation of the shoulder is that which produces the most ])ain. Dislocation of the clavicle from the sternum is rare on account of the strength of the ligaments that bind them together. It may be com- plete or incomplete and occurs in the (1) forward, (2) backward and (3) upward direction, in the order of frequency. The relative fre- quency of these three varieties depends upon the relative strength of the ligaments that resist them and that restrict the movements of tlie joint. Thus dislocation forward is resisted by the posterior and an- terior ligaments and the weakness of the latter serves partly to explain the relative frequency of the forward dislocation. The head of the thp: sternoclavicular joist. 153 bone, (Vixplacexl forward and usually inward and downward, rests on the niamtl)riuin and carries with it the sternomastoid musele. Dislocation backward is rcsisfrd by the same ligaments and in addi- tion the strong rhomboid ligament. It may be due to direct or indirect violence, more often the latter, the force pressing the shoulder forward and inward. The Jiead of the bone, li/inf/ Ijeliind the sternum and probably between it and the sternothyroid muscle, frequently jjre.sses upon the trachea causing dysi)no?a, less often upon the cesophagus causing dysphagia. In the region occupied by the displaced head of the bone are most important vessels and nerves, but the cases recorded show no serious pressure upon them. The head of the bone has been excised in one case to relieve troublesome dysphagia. In complete dis- locations either forward or backward the head of the clavicle is usually also displaced downward and in all complete dislocations it is as a rule displaced inward also. In addition to the ligaments resisting backward dislocation, dis- location upward is resisted by the interclavicular ligament and the inter- articular cartilage ; hence the rarity of this form, which implies a tearing of all the ligaments. It is usually c/»e to forcible depression of the shoulder, the first rib acting as a fulcrum so that the inner portion of the clavicle is elevated. The violence continuing forces the head inward and upward behind the sternal portion of the sternomastoid. The lack of adaj)tability of the joint surfaces serves to explain the ease of reduction and the difficidtif of retention in most cases of luxation in this joint. The recumbent position and various forms of dressing which act on the clavicle through the shoulder, as in fracture of the clavicle, have been employed. In connection with these the injection of 50 per cent, alcohol, or a similar fluid, with the object of producing a mass of connective tissue around the joint as a sort of new capsule, has occasionally been found useful. The sternoclavicukir joint is liable to the ordinary diseases of joints and, according to some, is more often involved in pysemia than other joints. As the synovial sac is divided into two by the interarticular cartilage, disease may commence in and be limited to one sac, but as a rule the entire joint (both sacs) become involved. Owing to the fact that the anterior sternocfavicidar ligainent is the thinnest and iceakest pjart of the capsule swellinr/ is as a rule first evident in front and, when spontaneous perj'oration occurs, the pus usually escapes anteriorly. If, as may happen, it escapes through the posterior ligament it may readily reach the mediastinum. The notable fact that the disease of this joint never results in anchylosis is due chiefly to the entire lack of adapta- bility of the two bony surfaces and, to a less extent, to the constant slight movement here and the occasional persistence of the interartic- ular cartilage. The importance of bearing in mind the r(7rt//o».s' of this joint to the great vessels behind it is illustrated by a case reported by Hilton in which a large abscess in the joint received pulsation from the subjacent subclavian or innominate artery and was first thought to be an aneurism. 154 THE UPPER EXTREMITY. The acromioclavicular joint depends for its strength iipou its lic/aiiients, for its shallow flat joint surfaces are beveled from above downward and inward and offer no obstacle to the uptvard dislocation of the outer end of the clavicle. This fact explains why this is the common form of dislocation in this joint. The capsule and ligaments of the joint proper are lax and weak so that effusion into the joint is soon visible. It is the strong coracoclavicular ligament (coronoid and trapezoid) upon which the strength of the connection between clavicle and scapula depends. The upward dislocation of the outer end of the clavicle may be com- plete or partial and in tiie former case the coracoclavicular as well as the acromioclavicular ligaments are torn, in the latter case the former may be torn or merely stretched. In complete dislocation the outer end of the clavicle rides up above the acromion and may be displaced outward over the latter. The cause is usually a blow upon the point of the shoulder, probably associated with a vigorous contraction of the tra- pezius, whereby the clavicle is prevented from becoming depressed with the acromion. The rarity of downward or subacromial dislocation of the outer end of the clavicle is explained by the oblique direction of the joint surfaces. The cause in most cases was direct violence applied to the outer end of the clavicle. Whereas reduction is commonly easy in both forms, retention is diffi- cult, as there is nothing in the shape of the bones to hold them together and the ligaments are torn. In the common upward form upward pressure of the shoulder through the arm and downward pressure on the outer end of the clavicle are accomplished by various retentive dressings but the necessary continuous retention is very difficult. As in dislocation of the sternoclavicular joint the injection of irritants, like 50 per cent, alcohol, to stimulate periarticular connective tissue formation which afterwards contracts and helps to hold the bones together, I have found useful, especially in the incomplete forms. Some patients are seriously disabled by this accident, others but little. In this connection it may be noticed that the movements of this joint allow the glenoid cavity to maintain or alter its rehdire position in the movements of the shoulder around the sternoclavicular joint as a cen- ter. Thus in raising the arm, forward or laterally, the extent of this movement is much increased by the elevation of the glenoid cavity, the scapula moving on an antero-posterior axis through this joint. Again as the shoulder moves forward for a blow or shove or in a fall upon the hand the glenoid cavity is turned forward, so that it may be as nearly as possible at right angles to the long axis of the iiumerus which it can thus best support. In this way a strong forward ''blow from the shoulder" is possible. Otherwise the strain comes upon the capsule of the shoulder and tends to dislocate it. This forward posi- tion of the glenoid cavity is due to a movement of the scapula on a vertical axis passing through this joint. Im])airment of this joint by accident or disease may therefore cause a limitation in certain move- ments of the u})per limb or an insecurity of the shoulder joint. THE POSTERIOR OR SCAPULAR RFJilOS. 155 Subclavicular Soft Parts. — The interspace between the aferiKd and clavicular portion.s of the jx'cforalis major can often be distinguislied on the surface just below the clavicle. The sternal portion is often removed in whole or in part in the operation for carcinoma of tlie breast. The clavicular portion is the more superficial of the two. The pectoral fascia is firmly connected with the pectoralis major. AVe may usuallv be sure that we have divided the pectoralis major when we reach a cellular layer, though Heath describes a cellular interval which sometimes lies between two planes of its muscle fibers and may be mis- taken for the space beneath it. On removal of tiie pectoralis major we expose the pectoralis minor from whose upper border a strong fascia, tlie clavipectoral fascia, extends up to and is continuous with the sheath of the subclavius muscle and thence is connected with the clavicle and coracoid process. It is continuous with the sheath of the axillary vessels and the deep cervical fascia. The upper part of this fascia, between the coracoid process and the first rib, is particularly firm and is named the costocoracoid. membrane. This fascia is pierced by the cephalic vein, the acromiothoracic artery and the anterior thoracic nerve and covers the first portion of the axillary vessels and the bra- chial plexus. The clavipectoral fascia splits to enshcath the ijcctoralis minor and unites below it into a single triangular sheet which extends laterally to the sheath of the coracobrachialis and inferiorly to the floor of the axilla, the hollow of which it serves to preserve, hence the name " suspeusorj/ ligament of the axilla.''^ The axillary vein lies below and internal to the artery which it overlaps, owing to its greater size. Hence when the axillary artery is tied in its first portion the aneuriam needle is passed from the vein side, or lielow, to avoid injury to the vein. The axillary artery is crossed in front by the cephalic vei)i in its passage to reach the axillary vein, but it is separated from this vein by the clavipectoral fascia. A part of or the entire cephalic vein occasionally crosses in front of the clavicle to join the external jugular vein. One of the cords of the bracliial plexus lies in contact with and on the same plane as the artery and may be and has been mistaken for it in ligation of the artery. These main vessels and nerves are surrounded by more or less areolar and fatty tissue containing lymphrdic vessels and nodes which may be involved secondarily to those of the axilla with which they are continuous. They communicate with the supraclavicular nodes above. Along this areolar tissue deep infection and al>scess may extend from the neck to the axilla and vice versa. The Posterior or Scapular Region. The skin covering this region is firm and there is but little subcu- taneous tissue. The thick deep fascia, by its attachment to bone around the origin of the supra- and iufra-spiuatus and the teres minor muscles wliicli it covers, encloses them in an osseo-aj/o neurotic eomixirfment, o}>en only toward the insertion of the muscle on the great tuberosity of the humerus. Hence in case of abscess under these fasciae or ecchvmosis 156 THE UPPER EXTREMITY. from fracture of the scapula the pus or blood cannot readily reach the surface, but follows the muscle sheaths to the humeral head and appears under the head of the deltoid. The firitmcHS of this fascia is such that it is difficult to decide whether dense tumors growing from it are con- nected with the fascia or the bone. The scapula is Iwld in place by the coraco- and acromioclavicular ligaments and by the serratus mag- nus, rhomboids, trapezius and levator scapulae muscles. The so-called ^'winged scapu/a," or luxation of the scapula, in which the lower part of or the entire vertebral border projects backward from the chest wall is due to pcn'd/ysi.s of the lower part or the whole of the serratns magnus muscle, which is supplied by the long thoracic nerve. Fracture of the body of the scapula is comparatively rare, owing to the mobility of the bone, its thick muscular covering, the elasticity of the ribs beneath and the soft muscular pad of the subscapularis and serratus magnus between it and the chest wall. In case of fracture the fragments are splinted by the muscles attached on both sides of it, which prevent much displacement. The acromion is 7nore exposed to injury and fracture than other parts of the bone. Some consider many cases of supposed fracture of the acromion as examples of epiphyseal separa- tion from the spine, which may occur before the twentieth year, when the epiphyseal union ossifies. But clinically most cases are found to be nearer the end of the acromion, i. e., just in front of the acromio- clavicular joint. The dense fibrous tissue, which covers this process and is derived from the two muscles attached to it (deltoid and tra- pezius), and its dense periosteum help to explain why much displace- ment is uncommon and why many fractures are subperiosteal and crep- itus is wanting. When the fracture is in front of the acromioclavic- ular joint the deltoid may pull the fragment slightly downward, but there can be no displacement of the scapula and arm. When the fracture is behind the joint the scapula may still be connected by the coracoclavicular ligaments to the clavicle and there can be but little if any displacement of the arm. Bony union is said to be the excep- tion. It should be remembered that in some cases the union of the acromion and spine does not ossify, so that the presence of motion and a fibrous union between these two parts does not necessarily imply fracture or an epiphyseal separation. Fracture of the coracoid process may occasionally occur as a result of violence or muscular action. Usually it is only one of several frac- tures resulting from severe violence. In some cases the line of frac- ture, being near the base of the process in the line of the epiphyseal cartilage, which ossifies during the fifteenth year, has suggested that the case was one of epiphyseal separation. Although three powerful muscles are attached to the coracoid process displacenient is usually slight owing to the attachment of the coracoclavicular ligaments which are seldom torn. The rare fracture of the surgical neck of the scapula involves the separation of the coracoid process and tlie glenoid fossa, together with the triceps attachment, from the rest of the bone. The arm is displaced. J THE EXTERNAL OR DELTOID REGION. 157 downward as in a .subglenoid dislocation, but the eoracoclavicular, coracoacromial and spinoglenoid ligaments are usually untorn and limit the displacement. It is easily distinguished from dislocation of the humerus by crepitus, the ease of reduction and the equal ease of recurrence of the displacement. Tumors of various kinds, especially osteoma, enchondroma and sarcoma, grow from the scapula and require partial or complete excision. In partial excision those parts which are of special impor- tance for the function of tlic arm — /*. e., the glenoid fossa, coracoid and acnjiuion processes, should be preserved if possible. The entire bone is removed with or without the arm in sarcoma. In malignant tumors of the upper end of the humerus and some sarcomas of the axilla the upper extremity, scajuda and outer two thirds of the clavicle are removed (interscapulotboracic amputation of the arm), after first ligat- ing the subclavian artery. The latter renders the operation bloodless except for the posterior scapular artery along the vertebral border and the suprascapular artery in the supra- and infraspinatus fossse, these arteries being branches of the first portion of the subclavian. In complete excision of the scapula (without ligature of the subclavian) the subscapular artery, which runs along the lower border of the sub- scapularis muscle and gives off the large dorsalis scapuke branch cross- ing the axillary border onto the infras])inatus fossa, must also be taken into account. This branch of the axillary artery aiia.Htontoses v'lih the posterior scapular and suprascapular branches of the subclavian and is an important factor in the collateral circulation after ligature of the third portion of the subclavian or the first portion of the axillary artery. The anastomoses on the acromion between the suprascapular branch of the subclavian and the acromiothoracic and circumflex branches of the axillary assist in this anastomosis. For re-section of the scapula a horizontal incision along the spine and a vertical one along the verteV)ral border (Ollier's) are very serviceable. The suprascapular nerve is a branch of the fifth cervical and receives a branch from the third and fourth cervical nerves, from which is derived the phrenic nerve. The latter also communicates with the nerve to the subclavius and these two connections explain the rejlex rrkitio)is between the diai)hragm or liver and the shoulder, i. c., hiccough from inflammation of the shoulder and pain in the right shoulder in perihepatitis, etc. The External or Deltoid Region. This is equal in extent to that of the deltoid muscle which covers the upper end of the humerus and the muscles inserted into it, the shoulder joint, the coracoid process and its muscles and the coraco- acromial ligament. The sidjcutaneous fatty layer over the deltoid is often well developed and is a favorite situation for lipoma. The deep Jascia ensheaths the deltoid and is closely bound to it. In subglenoid or subcoracoid dislocation of the shoulder the head of the humerus no longer bolsters out the deltoid, so that the latter is flattened and hangs 158 THE UPPER EXTREMITY. straight down from the acromion process, which is thereby rendered more prominent aiid angnlar. Moreover the attachments of the del- toid being more widely separated than normal the muscle is put on the stretch which still further flattens the region and causes a notch or fold at the insertion of the muscle. To relax the deltoid the dislo- cated arm is usually held in the abducted position. If this position is exaggerated, so that the deltoid is very lax, the fingers may be thrust beneath the acromion into the gap left by the dislocated head of the humerus and in thin subjects the glenoid cavity may even be felt. The deltoid region may he flattened and a depression be felt beneath the acromion in certain cases where the head sinks away from its socket owning to paralysis and. atrophy of the muscle, which is supplied by the circumflex nerve. (Fig. 40.) This nerve lainds around the surgical neck of the humerus a little above the posterior circumflex artery, which is two inches below the acromion. This nerve may be torn, bruised or stretched in dislocations of the shoulder, in violent attempts at their reduction and in fractures of the surgical neck of the humerus, and it may very rarely be bruised in contusion of the shoulder. As it also supplies the shoulder joint an inflammation of the latter extend- ing along the nerve may cause a neuritis and lead to paralysis of the muscle (Erb). This nerve also gives oif a cutaneous branch which, winding around the posterior border of the muscle, supplies the skin over its lower third (and below it). Thus, according to Anger, we may test the sensibility of this cutaneous branch after dislocations of the shoulder and thereupon base our prognosis as to the future condi- tion of the muscle, for it is not infrequently paralyzed temporarily or permanently. The deltoid is not the only abductor of the arm, being assisted by the supraspinatus, but in paralysis of the deltoid the power of abduc- tion is slight. In excision of the shoulder joint the nearer the incision is made to the anterior border of the deltoid the less of the muscle will be paralyzed by cutting its nerve supply and the smaller will be the branches of the posterior circumflex artery to be divided. Beneath the deltoid, in the layer of loose connective tissue which facilitates the movements of the underlying head of the humerus, is the subdeltoid or subacromial bursa, which still further facilitates these movements. As its name implies this bursa also extends beneath the acromion process and this portion is sometimes partly separated from the subdeltoid portion by a constriction. Beneath the bursa are the great tul)erosity of the humerus and the supraspinatus tendon, but there is )io comviunication ivith the joint unless in dislocation when the supraspinatus tendon is ruptured. This bursa may hold about an ounce when distended with fluid, as it sometimes is, causing an undue prominence of the deltoid. In case of abscess of this bursa the pus may reach the surface at either edge of the muscle, usually the ante- rior edge, rarely through it. From the point of view of operative incision the shoulder joint is o)dy covered by the skin, the deltoid and the capsule. PLATE XV FIG. 4-0. SUBSCAPULAR ARTERY CIRCUM FLEX NERVE POSTERIOR CIRCUM- FLEX ARTERY ■•■ USCULO-SPIRAL NERVE SUPERIOR PROFUN DA ARTERY Posterior region of the shoulder"; right side. (Joessei.) THE SHOULDER JOINT. 159 The shoulder joint is one that relies for its fifrenrjth largely upon the surrounding niu.selcs, a variety of joint most fiablr fo fJix/omtion. The laxity of the capsule and the fact that the articular surfaces are held together by atmospheric pressure is shown by the admission of air into the joint, dissected free of its muscular covering. Thereupon the head of the humerus falls away from the glenoid cavity by a considerable interval. The same occurs in cases of old standing paralysis of the deltoid. The acromion and coracoid processes, and the coracoacromial ligament connecting them, form an arch above the joint, protecting it but separated from it by the interposed tendon of the supraspinatus and the capsule. The muscles strengthening the capsule are the subscapularis in front, the supraspinatus above and the infraspinatus and teres minor behind. The tendons of these muscles are blended vith the capsule in their pas- sage to the small and great tuberosities of the humeral head. They are continuous with one another and are assisted in supporting the joint by the long head of the triceps below and the long head of the biceps above. The latter tendon in its passage through the bicipital groove, which is converted into a canal by the transverse ligament, is accompanied bv a tubular pyrolonfjaiion of the synovial membrane form- ing a kind of vaginal sheath for it. There is another constant gap in the capsule by which the synovial sac communicates with the sub- scapular bursa, a large pouch between the upper part of the subscapu- laris and the root of the coracoid process together with the adjoining part of the neck of the scapula. The crescentic gap leading from the joint into the bursa lies just in front of the upper end of the inner margin of the glenoid cavity, between the superior and middle gleno- humeral bands. A bursa beneath the infraspinatus rarely communi- cates with the joint. In addition the capjsule is unprotected antero- inferiorly between the subscapularis and the long head of the triceps, where the head can be felt by the hand in the axilla. The axillary vessels and nerves (Fig. 41) lie to the inner side of the joint, separated from it by the subscapularis tendon. In joint di.seasewith eifusion the shoulder appears full and rounded by reason of the dis- tended capsule, which may cause a separation of the two bones of more than one half inch (Braune). In artificial distension the arm becomes slightlv extended and rotated i)iivard, a position commonly found in joint disease and perhaps due to the rigid contraction of the muscles, of which the latissimus dorsi may have a sliglit advantage and be responsible for the extension and inward rotation. Special prom- inences occur in the bicipital and subscapular diverticula. Thus a swelling often appears at an early stage /// thr groove between the deltoid and great pectoral muscles. This swelling is sometimes bilobed on account of the unyielding biceps tendon. Fluctuation can best he felt through the axilla, at the uncovered part of the capsule below the sub- scapularis. If sup|>uration occurs the jius usutdli/ escajjes through one of the diverticula, most often the one around the biceps tendon. In the latter case it may extend some distance along the bicipital groove. 160 THE UPPER EXTREMITY. If it escapes through the subscapular bursa it is apt to spread between the muscle aud the scapula and point at the lower and dorsal part of the axilla. Although the shoulder joint is liable to all forms oi' Joi)it disease the latter are not particularly common here. As the result of disease the various forms of anchi/Iosis occur and in such cases Tillaux has suggested division of the clavicle and the formation of a false joint to afford freer movement. The long tendon of the biceps strengthens the upper part of the joint, keeps the humerus against the glenoid cavity, and prevents it from being pulled down when the arm is abducted. It is rarely ruptured and seldom displaced from its groove unless one of the tuberosities is torn away, as occasionally occurs in dislocation of the shoulder. The inner margin of the glenoid cavity is the stronger and more prominent, especially below, a fact which indicates an attempt to fortify a weak part of the joint where the head most often leaves the socket in dis- location. AVhen the arm hangs at the side the glenoid cavity looks outward and forward, nearly midway between the sagittal and frontal planes of the body, and at least two thirds of the head of the humerus are not in contact with it. The entire head is to the outer side of the cora- coid process in this position. The glenoid fossa is less than half as large as the articular portion of the head of the humerus on horizon- tal section and about two thirds as large on vertical section. Thus a considerable portion of the head of the humerus is always in contact with the capsule and in abduction of the arm to 90° the head of the bone presses against and puts on the stretch the lower unprotected part of the capsule, between the subscapularis and triceps tendons. It is in this position, with or without outward rotation, that dislocation of the shoulder is most likely to occur. In abduction of the arm to a right angle the great tuberosity abuts against the upper edge of the glenoid cavity and the upper end of the outer aspect of the humerus against the coracoacromial arch. Further (ibduction is due to the rotation of the scapula, but if the latter is kept from rotating by being held mechanically or by a muscular spasm (serratus raagnus) and if the motion of abduction is continued a neiv center of motion is formed at the point of contact of the hu- merus with the coracoacromial arch and the head is forced down against the lower and inner tense part of the capsule, rupturing it. Such is the common mechanism of dislocation in cases due to indirect or to muscular violence. The infrequency of the injury in i\\e first two decades of life is inter- esting in connection with Kronlein's theory that in this period fracture of the clavicle is the equivalent of dislocation of the shoulder by direct violence, and dislocation of the elbow the equivalent of dislocation of the shoulder by indirect violence. Dislocations of the shoulder are as numerom as all other disloca- tions combined, ])erhaps more so. This frequency is fully explained by (1) the structure of the joint (the shallowness of the glenoid fossa, DISLOCATIONS OF THE SHOULDER. 101 the large size of the humeral head, the freedom of motion, the long leverage of the arm, the laxity of the capsule and its dei)endence upon the muscles for its strength) ; and {'!) the exposure of the shoulder to indirect and direct violence. Dislocations of the shoulder are clas- sified, according to the dinplacemeid of the humeral head, into (1) anterior or subcoracoid, the common form, (2) downward or sub- glenoid, not common, (.">) backward or subacromial, rare, and (4) up- ward or supraglenoid, very rare. Only the first two forms demand our consideration. In subcoracoid dislocations the head of the humerus escapinrj through thf rent in tiie antcro-inferior part of the capsule is displaced primarily downward and somewhat forward. Indeed some downward displacement is necessary to allow the head to get beneath the coracoid. But the further downward displacement is resisted by the untorn part of the capsule (outer and anterior parts) whose attachment to the ana- tomical neck serves as a new center of motion, so that when the elbow is lowered after abduction has ceased, the head rises along the inner side of the joint. This secondary displacement to a final position, ap- proximately beneath the coracoid (subcoracoid), is also partly effected by the contraction of such mnticle.s as the i)ectoralis major, latissimus dorsi and deltoid. The extent of this secondary inward displacement is determined largely by the resistance of the untorn portion of the capsule, the continuance of the dislocating violence, and the degree of contraction of the adductor muscles. Thus the head maybe displaced internal to the coracoid process, giving rise to the subvariety " intra- coracoid." In the subcoracoid form the Jiead of the bone lies behind the coraco- brachialis and the short head of the biceps and against the edge of the glenoid fossa or the side of the neck of the scapula just internal to it. In the intracoracoidal variety it lies farther back on the neck and against the serratus magnus, having passed behind the muscles arising from the coracoid process. The head is thus internal, anterior and a little inferior to its normal position. The anatomical neck may rest on the anterior lip of the glenoid cavity. The subscapularis muscle is sometimes pressed inward and separated from the scapula by the interposed humeral head, but in many cases it is torn from its lower border upward to a greater or less extent. Thus tiie subscapularis may intervene in whole or in part between the coracoid process and the head, or the latter, escaping in front of the muscle, may lie close against the beak of the coracoid, behind the coracobrachialis and short head of the biceps. The attachment to the humerus of the sapra.ytinatKs is j>rol)ably often torn, that of the infra- spinatus less often, or, in place of this rupture of the tendon, the great tuberosity may be torn off. This latter accident is of importance be- cause it opens the way for the long biceps tendoti to escape from its groove, slip over the head and become engaged between the head and the glenoid cavity, wliere it may offer a serious obstacle to reduction. The rupture or avulsion of the s}ij>r(i- and infrasj)iii(dus foidons, and 11 162 THE UPPER EXTREMITY. their consequent retraction under the acromion, may impair the subse- quent motion of the joint by their loss of control over the humerus. They may become interposed between the head and its socket, so as to oppose reduction, or they may open up the subdeltoid bursa and favor the recurrence of dislocation by lengthening and weakening the cap- sule. The axillary vessels and nerves are pressed inward and sometimes ruptured. In the subglenoid variety the head usually re.sis against the flat- tened upper end of the axillary border of the scapula on the inner side of the triceps tendon, the latter preventing its displacement directly downwards. It thus lies below and a little internal and anterior to its normal position. It also lies beneath the subscapularis tendon, which is much stretched or torn. The rent in the capsule differs from that in the subcoracoid form in not extending so far upward along the anterior edge of the glenoid cavity. The resistance of this untorn anterior part of the capsule seems to be what prevents the head from reaching the subcoracoid position, although in some cases this dislocation may be transformed into a subcoracoid by movements of the arm or even by muscular action. The supraspinaius and often the infraspinatus are torn from their attachments, or the tuberosity is avulsed from the humerus. The cause of the subglenoid form has almost always been a forcible elevation of the arm. The symptoms in both forms are mainly due to the absence of the head from its normal position, the presence of the head in an abnormal position and the consequent altered position or action of the muscles. The absence of the head from its socket accounts largely for the flatten- ing of the deltoid region and, in the subcoracoid form, the empty glenoid socket can be felt through the axilla. In the subglenoid form we can feel the head tlirough the axilla, lying below the glenoid fossa i— 1 inch below the coracoid process, while in the subcoracoid form it forms a hard prominence of the anterior axillary wall, just below the coracoid process, and causes a fullness of the outer part of the infraclavicular fossa. The axis of the arm prolonged upward passes below or internal to the glenoid cavity. The deltoid is stretched by the increased separa- tion of its attachments, and this not only increases the flatteidnc/ of the deltoid region and the prominence of the acromion but causes the arm to be abducted, Avhich is more marked in the subglenoid variety as the deltoid is more stretched. As the head is displaced somewhat downward in both forms, viea,s- urement from the angle of the acromion to the external condyle of the humerus should show lengthening as compared with the opposite limb. But owing to the relativ^e position of these two points of measurement in a plane external to that of the glenoid cavity, abduction causes a measured shortening in the normal arm and nuich more so in the dis- located arm, when the head is displaced more or less inward. Hence the measured lengthening will depend on the degree of abduction and may be altogether wanting or replaced by shortening, though seldom so in the subglenoid form, in spite of its greater abduction, on account REDUCTION OF DISLOCATfOX OF SHOULDER 163 of its greater lengthening. The elbow can not be made to touch the thorax for, on account of the rotundity of the thorax, both ends of the straight luimerns can not touch it at the same time, and in a dis- location of the shoulder the head of the bone is ])ractically touching the thorax. The diagnosis between subcoracoid and subglenoid dis- locations can usually be readily made from the differences noted in the symptoms given above. Reduction. — The obstacles to this may be the tension of the untorn portion of the capsule, opposing the movement of the head toward the socket, the approximation of the sides of the rent in the capsule, the interposition of portions of the capsule or of the biceps tendon, the contraction and rigidity of the muscles, the edge of the glenoid cavity and, rarely, the interposition of the subscapularis tendon. The most frequent obstacles are the opposition of the anterior part of the capsule and the contraction of the muscles and these, as well as most other obstacles, may be avoided hi/ abduction and outirard rotation. of the arm. Traction in this position, with or without direct pressure on the head toward the glenoid cavity, is successful in the great majority of cases. Success in methods employing traction is also largely depen- dent upon the efficient /.ua//o/i of the scapula by the surgeon, his assist- ant, bandages or apparatus. Stimson ' has lately successfully employed a modification of this method by exerting continued traction by a weight on the abducted arm, the latter passing through a hole in a canvas cot. The continued traction of the weight tiring out the mus- cular contraction, reduction occurs painlessly and spontaneously within six minutes. Traction npioard, though formerly emjiloyed, is objection- able on account of the risk of increasing the laceration of the capsule and of injuring the axillary vessels by stretching them around the head of the humerus. Although this method is theoretically suggested by the position of the head in the subglenoid variety yet on account of the risks mentioned trial should first be made of direct reposition by pressure on the head, or this combined with traction in the abducted position. In the methods of reduction by manipulation, rotation inward has long been em])loyed to turn the head of the bone into the socket opposite to which it had been brought by traction. Inward rotation constitutes the last step in the pure manipulative method now most in use, that of Kocher. In Kocher's method the flexed elbow is pressed against the side (adduction) and rotated ontward until the forearm points directly outward ; the arm, rotated outward, is then carried forward and sline of the best methods (^racket method) of amputation or disarticulation at the shoulder joint and it allows an excision to he followed by an amputa- tion if the case demands it. The vertical incision is carried d(nvn to the level of the axillary fold and then curved outward through the lower part of the deltoid and around the posterior and inner part of the arm and then upward under the anterior axillary fold to end in the verti- cal incision. In the vertical incision the cephalic vein and branches of the acromiotlioracic artery are ligated. After division of the lower part of the deltoid this muscle, with the trunk of the posterior circum- flex artery and the circumflex nerve, can be readily raised from the bone by blunt dissection exposing the head, around which the capsule is divided. Then the muscular tissues on the inner side, with the vessels and nerves they contain, are divided after separating them from the bone from above downward to the level of the skin incision. In this step the main vessels may be controlled by an assistant com- pressing them in the inner flap between the thumb and fingers of both hands, or they may he previousiy ligated through the skin incision. In freeing the insertions of the teres muscles we must keep close to the bone to avoid the circumflex nerve, which passes back between them to supply the deltoid, the chief muscle of the stump. The Axilla. This pyramidal space between the chest and the arm may be regarded surgically as a passageway between the neck and the upper extremity by which tumors or abscesses may extend from the one to the other region. Boundaries. (Fig. 41.) — The anterior wall (Fig. 42) of the axilla is formed by the pectoralis major with its sheath, the pectoral fascia, and the pectoralis minor with its sheath, the clavipectoral fascia. From the outer border of the pectoralis minor, where the two layers of its sheath reunite, this clavipectoral fascia extends across in front of the axilla as a triangular sheet to become continuous with the sheath of the coracobrachialis. The lower border or base of this fascia is connected with the axillary fascia and helps to hold up the latter and preserve the hollow of the arm pit. The posterior axillary wall (Fig. 43) is formed by the subscapu- laris, latis?scn complained of after the ap])lication of a tourniquet. The lymph vessels are largely superficial. Most of these 15—18 accompany the basilic vein where they can readily be seen as a band of red striie in lymphangitis. A lymph vessel usually accompanies the cephalic vein. The musculospiral nerve in its passage along the musculospiral groove is in close contact with the bone and hence may be injured in con- tusions and wounds and especially in fractures of the humeral shaft. It FRACTURE OF THE SHAFT OF THE HUMERUS. 173 may also escape injury at the time of fracture to be subsequently involved and conipresucd in the callus. In many cases an o])eration has become necessary to free it from the canal of callus or bone in which it is compressed. It has also been paralyzed by the pressure of the head restinletely surrounded, the two fragments being driven into muscular masses on opposite sides of the bone ; (2) the defective imnioJiilizafion of the fragments due largely to the im])crfect fixation of the joints above and below. Ac- cording to Hamilton the flexed elbow soon becomes stiff by reason of muscular rigidity so that the movement of the forearm in flexion and extension of the elbow imparts a horizontal or lateral movement to the upper end of the lower fragment. ]5ut this alone cannot account for the condition for it would cause a greater movement of the frag- ments of fractures high up in the shaft and non-union is more common in the middle third. 174 THE UPPER EXTREMITY. Amputation of the Arm. — /// the lower half the circular amputation is best. The division and retraction of the skin has been ah-eady referred to. As only the biceps has no attachment to the bone it retracts most and requires separate division a thumb's breadth below where the other muscles are divided, at the edge of the retracted skin. After division of the muscles and continued retraction of the soft parts the fleshy cone may again be divided at its base, at the level of the fully retracted skin. Above the middle of the arm the biceps, long head of the triceps, deltoid and coracobrachialis may all retract considerably and unequally, hence amputation by long anterior and shorter (one half of anterior) posterior flaps has some advantages. The brachial artery should be in the posterior flap. The principal arteries cut are the brachial (with the median nerve), the superior profunda on the postero-external aspect (with the musculospiral nerve) and in the lower half of the arm the inferior profunda on the inner aspect (with the ulnar nerve). (Fig. 44.) In the flap method all the principal arteries divided are in the posterior flap. To reach the humerus for removal of sequestra, etc., incision along the outer border is jn-eferable, for the musculospiral nerve is the only structure which need be avoided. THE REGION OF THE ELBOW. The limits of this region may be arbitrarily assigned as two or three fingers' breadths above and below the " fold of the elbow." The elbow sflatfcncd from before backward. Surface Markings and Landmarks. (Fig. 45.) — In. front are visible three iniisrular elevations, one on the outer side corresponding to the brachioradialis and the extensor group, one on the inner side corre- sponding to the pronator radii teres and the flexor group, and one in the center corresponding to the biceps. The two lateral elevations con- verge and meet below, enclosing between them a depression, the cubital fossa, into which the biceps tendon is felt to sink toward its insertion. From this fossa tieo grooves forming a V are continued upward along the two sides of the bicepst endon, to become continuous with the bicipital grooves of the arm. The details are distinct only in thin or muscular subjects. The biceps tendon is plainly felt, especially along its outer border, the inner border being covered by the bicipital fascia. The ''fold of the elboK^ is a transverse crease in the skin of the front of the elbow extending transversely, with a slight convexity downward, between the two condyles. Hence it is some little ways, 2-4 cm., above the joint line. It is obliterated in extension and not constant in position so that it is not of great service as a landmark. It may be of some use, as employed by Malgaine, to diagnose between an ordinary dislocation of the elbow and a supracondylar fracture of the humerus, the lower end of the humerus projecting below this fold in the former and the lower end of the upper fragment forming a prominence above it in the latter. PLATE XVIII FIG. A^ CEPHALIC VEIN MOSCULO-SPIRAL BRACHIALIS MUSCLE BICEPS MUSCLE ■ ^ (- ■ y MUSCULO-CUTA- — <--^,^ - / ' ^/ NEOUS NERVE 'vT ^^'^'^7-^t BRACHIAL APONEUROSIS EXT. INTERMUS- CULAR SEPTUM TRICEPS MUSCLi BRACHIAL /ARTERY ,M E O I A N /^ NERVE ^^^ _BASI Lie ^^ VEIN -JLNAR NERVE I NT. INTERMUS- CULAR SEPTUM Cross section through the niiddle of the right arm of a female. Upper segment viewed froni below. (Tillaux.) FIG. 43. NTERNAL CUTANEOUS NERVE BRACHIAL ARTERY CEPHALIC VEIN EXTERNAL CUTANEOUS NERVE AND MEDIAN VEIN MEDIAN BASILIC VEIN Front of right elbow; superficial view. (Joessel.) TOPOGRAPHY OF THE ELBOW. 175 The two condyles are plainly felt, the inner and more prominent one even in conditions of extreme swelling. About 2 era. below the more rounded external condyle the rounded Itcad of tlic radian can Ije felt, especially on rotating the forearm. In extension of the elbow a marked depression indicates the position of the head of the radius and corresponds to the interval between the brachioradialis and the anconeus muscles. The two humeral coikUjIch are //; the same trans- verse line with one another and, when the arm is extended, with tlie tip of the plainly felt olecranon proceHn. When the elbow is flexed the tip of the olecranon comes to lie below the intercondylar line. Thet^e relations are of great importance in differentiating dislocation from supracondyloid fracture, for in the latter case they are preserved, in the former they are altered. Furthermore in full extension the point of the olecranon is nearly in the same transverse vertical plane with the two condyles, while in dislocation it is displaced backward. The ole- cranon does not lie midway between the two condyles but nearer the internal condyle, by 12 to 15 mm., so that the groove between the ole- cranon and the inner condyle is narrower as well as deeper than that between the olecranon and the outer condyle. Neither the coronoid process or tlie radial tubercle can be distinctly felt in ordinary subjects. Topography. — The joint line of the elbow is only about two thirds (4 cm.) of the width between the condyles and, while it nearly cor- responds externally with the lateral limit of the condyle, its inner end is some distance (nearly 2 cm.) external to the internal condvle. This partly accounts for the prominence of the internal condyle. The line of tlie humeroradial joint is horizontal and can be felt between the hciid of the radius and the external condyle, that of the kumeroulnar joint slopes obliquely downward and iuAvard so that the inner end of the trochlea is 1 cm. below the outer end. The obliquity of the humero- ulnar joint makes the axis- of the extended forearm to diverge outward at an angle of 6°, accounting for the "carrying function." It also makes the hand to be carried up toward the face in flexion, unless the forearm is supinated. The ulnar nerve, lying in the deep and narrow depression between the olecranon and the internal condyle, is exposed to injury by pressure against its hard bed. Pressure on it gives the peculiar numbness and tingling of the ulnar side of the hand, etc., and is known as hitting the " funny bone." It was wittily remarked that it was so named because it bordered on the humerus. The nerve may lie in h'out of the internal condyle or slip in front on flexion of the elbow (Qnain). It is particularly imjwrtant to avoid if in exri.^io}i of the elbow by keeping close to the bone in its neigliborhood. In a case of anchylosis of the elbow with much overgrowtii of bone, due to a bad fracture, I have found the nerve in a bony canal. The brachial artery lies in the inner of the two grooves in front of the elbow, just internal to the pearly white biceps tendon, which is an excelk'nt guide to it, and rather more external to the median nerve. It passes under the hicipitid fascia where it hifureatcs about half an inch 176 THE UPPER EXTREMITY. below the center of the bend of the elbow. It may be compressed by for- cible flexion of the joint so as to diminish or even stop the radial pulse. Accordingly (incari^m)< here, more frequent in blood-letting days, have been treated by compression, by flexion of the elbow. In tiie fully extended position the artery is somewhat flattened beneath the bicipital fascia so as to lessen the radial pulse, or even to stop it in the hyper- extension possible with fracture of the olecranon or dislocation of the elbow. It has been ruptured by the forcible straightening of a stiif, bent elbow. The median vein is joined by the deep median vein and divides into the median basilic and median cephalic in the depression at the apex of the V (e«6/^«/ /o.sscf). The median haxUie vein cro.s'.s'/?ir/ superficial to the biceps tendon and fascia comes to lie in the inner groove where it joins the posterior ulnar vein a little above the internal condyle, forming thereby the basilic vein. Similarly the median cephalic, pass- ing up in the outer groove, forms the cephalic vein by joining the radial vein about the level of the external condyle. An M-shaped figure is thus formed by the veins in front of the elbow, but this typical arrangement is by no means constant, occurring only in about 50 per cent, of cases. But in almost all cases a com- municating vein crosses the biceps tendon and fascia obliquely, and therefore overlies the brachial artery, and this vein is usually large enougli for venesection or intravenous infusion. The median basilic vein or its substitute may cross the artery trans- versely or obliquely or it may run nearly parallel with it, in front of it or to one side. Of all the veins in front of the elbow the median basilic is usually the largest, the most prominent, the nearest the surface and the one least subject to variation. Hence it was the one most often chosen for venesection in blood-letting days, and now is often chosen for intravenous infusion, in spite of the fact that it is separated from the artery beneath by the bicipital fascia only. This membrane, whose density depends upon the muscular development, is an excellent pro- tection to the artery, but on account of the blind method of venesection formerly employed it is not strange that the artery was often wounded, giving rise to aneurism or arteriovenous aneurism, the latter being more common at the elbow than anywhere else. The median cepJialic is therefore safer, but with open exposure of the vein, as for intra- venous infusion, it seems scarcely possible to wound the artery. Of the cnfaneoHs )u'rres at the elbow the e.vtenad cutaneous passes l)eliind the median cephalic vein, the anterior division of the internal cutaneous passes behind or (less frequently) in front of the median basilic. Hence the latter nerve or its branches may be wounded in opening the median basilic vein, an injury that, according to Tillaux, may lead to intense and chronic neuralgia. Small twigs of the external cutaneous nerve may cross in front of the median cephalic and the injury to these branches, or ])ossibly the main trunk behind the vein, and their inclusion in the scar may lead, according to Mr. Hilton, to a reflex contraction of the elbow, due to the contraction of the biceps THE ELBOW JOIST. 177 and brachialis muscles which are supplied by it. He has cured the condition by resection of the scar which was found to have included some of the nerve filaments. The HUperfic'ud lyiajjhatics accompanying the veins, lying in front of them, and are most numerous on the antero-internal aspect of the elbow. Situated in front of the intermuscular septum, an inch above the internal condyle, is the cpifrcjc/i/cdr lymph uodc (sometimes two nodes), the lowest node in the upper limb. It may become inflamed in any injury or inflammation of the ulnar side of the hand and fore- arm and the inner two or three fingers, from whence it receives lymph vessels. Around the elbow-joint is an cvfcnsive and free a na.stomosis between branches of the superior and inferior profunda and the anas- tomotica magna, from the brachial above, and branches of the anterior and posterior ulnar, posterior interosseous and radial recurrent from the ulnar, interosseous and radial arteries below. This anastomosis provides a codtdercd oirrahdion in case of ligature of the brachial or in aneurism at the elbow. The skin about the elbow is thin and fine in front, where it is readily excoriated by tight bandages or poorly applied splints ; it is thicker and less sensitive behind. Although the thin skin in front allows the veins to be clearly seen through it, yet in subjects with much subcu- taneous fat it may be difficult or impossible to see them. Between the skin and the olecranon is a mhcidancouH bursa, not infrequently the seat of a bui-sdi.s with the accumulation of serum or of pus. Occupations involving pressure on the elbow favor bursitis here, of which " miners elbow" is an example. The elbow joint depends for its: strength largely ujjon the shape and relation of the bones forming it, reinforced by the overlying muscles and the lateral ligaments. Only flexion and extension are permitted ; the presence of hderal motion shows that the ligaments are torn or stretched as in dislocation or tubercular disease and hence is a sign of some lemon of the joint. The internal lateral is the strongest and most important ligament of the elbow and, as it resists lateral strain as well as limits flexion and extension, it suffers most often from sprains and dislocations. Its attachment to the entire inner border of the great sigmoid cavity of the ulna prevents the wide separation of the frag- ments in fracture of the olecranon for part of it is attached above and part below the line of fracture. The anterior and posterior parts of the capsule are the weakest, especially the posterior portion which presents two pouches, one on either side of the olecranon. As this is also the most superficial part of the joint the effusion in joint disease is first noticed as a fiurtiading su-el/in(/ here. The line of the radio- humer(d joint also shows some swelling at an early stage and here, or in the pouches on the sides of the olecranon, especially the external one, the joint may be aspirated or injected. Beneath the brachialis a dcey>- seated bulging of the thin anterior part of the capsule is also observed in cITusion into the joint. Normally tiie joint surfaces are in contact in all positions, but if the soft parts are divided the radius and humerus 12 178 THE UPPER EXTREMITY. separate by a slight interval when the capsule is incised, readily allow- ing the knife to enter the joint in exarticulation. In case of suppuration in the joint the capsule is (il:ch/ to r/ive loay at its weakest point, pjostero-superiorh/. The pus thus comes to lie between the triceps and the humerus, burrows between them and points at either border of the muscle. In other cases it may perforate the thin anterior ligament beneath the brachialis and point near the inser- tion of the latter. The diseased elbow is usually held in a position of seiaiHexion, a position assumed when the joint is forcibly injected (Braune), for in this position it holds the most fluid. In disease however the position is probably due to a reflex contraction of the biceps and brachialis mus- cles, supplied by the musculocutaneous, which is the principal nerve of the joint. Owing partly to the accurate coaptation of the ulna and humerus anchylosis of the elbow after injury, disease or even disuse in a fixed position is not uncommon. Sudden forcible straightening of an anchylosed elbow entails some danger of rupture of the brachial artery at the bend of the elbow. If the elbow is anchylosed in a straight or semi-flexed position, the anchylosis should be broken up or the elbow excised, for in this position the arm is not only useless but in the way. In excision of the elbow joint the three most important muscles in re- lation to it, which act on it and therefore must be preserved, are the biceps, brachialis and triceps. The insertions of the first two are readily preserved. The ulna may be divided low enough to remove the entire coronoid process without sacrificing the insertion of the brachialis into the tuberosity at its lower end. The usual and best incision is a longitudinal one through the triceps which is then separated from the ulna on either side of the incision by longitudinal cuts close to the bone (subperiosteally) in order, as far as possible, to leave the tri- ceps insertion in connection with the periosteum of the hone below the point of section. The strong expansion from the outer margin of the triceps tendon should always be saved as it enables the triceps to retain a hold on the forearm. In freeing the parts about the internal condyle great care should be taken to avoid injury to the ulnar nerve lying be- hind it, by making whatever incisions are necessary close to bone and longitudinal. The nerve should not be seen. Another nerve in some danger of injury when the upper end of the radius is being bared is the posterior interosseous as it winds around the radius in the supina- tor muscle. It is wise to remove two inches of bone (including both humerus and forearm bones) to avoid the danger of re-anchylosis. In connection with excision in young subjects under 17 (when the humeral epiphyseal line ossifies) it may be noted that the principal growtJi in length of the humerus occurs at the upj)er end. Dislocation of the elbow is more common than that of any single joint save the shoulder. It is most common (85 per cent.) //( the first tiventy years of life when, according to Kronlein, it is the equivalent injury of dislocation of the shoulder by indirect violence. SYMPTOMS AND SIGNS OF ELBOW DISLOCATIONS. 179 Dislocation of both bones of the forearm backward is the (i/jjicti/ j'oniiy being by far the most euinmon. It is usually due to a fall on the out- stretehed hand by which the elbow is hyjjciextended and often a/xlucted. It is only in hyperextension that the beak of the olecranon presses against the bottom of the olecranon fossa. It then serves as a fulcrum so that by continued hyperextension the ulna is torn as it were from the humerus. The internal lateral ligament is thereby torn, usually at its insertion into the humerus, the external lateral ligament is usu- ally torn or detached from the humerus and the rent extends across the thin anterior ligament. These lateral ligaments oppose hyperextension and lateral motion and are the strongest bonds holding the l)ones together. Hence when they are torn the violence continuing forces the coronoid process far enough backw-ard to be pushed up behind and above the trochlear surface, opposite to or into the olecranon fossa. Associated Injuries. — The orhicu/ar Ufjainent is rarely injured and a partial preservation of the external lateral ligament may affect the atti- tude of the limb, adducting it, and render reduction difficult. The hrach'ialis is stretched, sometimes lacerated and rarely torn across. The biceps is rendered tense and occasionally slips around the outer condyle. The median and ulnar nerves may be greatly stretched. The tip of the internal condyle is often torn off and may be displaced upward with the internal lateral ligament. A common lesion of practical importance is the .stripping up of the periosteum at the hack of the external condyle. If the dislocation remains long unreduced new bone is here produced which interferes with the extension of the elbow by impinging on the radius. As complications there may he fracture of the coronoid process, olecranon, head of the radius (partial or complete) and the shaft or lower extremity of the radius. Symptoms and Signs. — The crucial signs, on which alone the diag- nosis should rest, are the relative positions of the two condyles, the olecranon and the head of the radius, as determined by })alpation. The olecranon is displaced backward and upward, the backward dis- placement being more marked in flexion, the upward in extension. The head of the radius can he felt and perhaps even seen under the skin behind the external condyle and to the outer side of the olecranon. In addition the elbow is usually flexed at an angle of about 135° but may be extended or even hyperextended, the lower end of the humerus causes a fullness in front (below the crease of the elbow), the forearm appears -shortened in front and broadened above, its axis may be devi- ated to either side, flexion and extension are limited and painful and latcnd motion exists. Reduction is often accomplished by flexion and traction, using the knee in the bend of the elbow as a fulcrum and to produce traction. In this method the coronoid process has to pass down behind and then below the trochlea and to do this the ulna must be separated from the humerus by more than half an inch, the height of the coronoid process. This can only occur when the laceration of the ligaments and soft parts is extensive or, as often happens, is made so by the process of 180 THE UPPER EXTREMITY. reduction. It also requires simultaneous elongation of the mus- cles of the front and back of the arm. Forcible pronation may facili- tate it. A method more in line with the principle that a dislocated bone should be returned along the route by which it was displaced with the least possible additional rupture of the soft parts, is the method by traction upon the extended or hyperextended forearm ; followed by flexion of the elbow or by direct pressure forward on the upper ends of the radius and ulna and backward pressure on the lower end of the humerus. Ax to other fornu of dis/oc((flon at the elbow it may be noted (1) that both bones are more often dislocated together than separately for the radius and ulna are connected by powerful ligaments, the radius and humerus are not. (2) That antero-posterior displacements are much more common than lateral ones on account of the lateral width and the antero-posterior narrowness of the joint, the absence of lateral movement and the presence of antero-posterior movement, the feeble- ness of the antero-posterior ligaments and muscular support and the strength of the lateral ligaments and the support afforded by the lateral muscles. (3) That the rarest dislocation of both bones is for- ward, for it is resisted by the large strong olecranon process. (4) That if but one bone is dislocated it is most often the radius, for it is less strongl}' connected with the humerus and more exposed to indirect violence through the hand. Dislocation of the radius alone may occur in the forward, backward or outward direction, usually forward. In luxation of the radius for- ward the head of the bone arrests flexion of the elbow at or near 90° by im])act upon the humerus. It may be due to direct violence from behind, extreme pronation with traction, or to falls upon the pronated or supinated hand while the elbow is hyperextended. The elbow is slightly flexed, almost always pronated and often abducted. Reduction may usually be accomplished by traction combined with supination, adduction and direct pressure upon the head of the radius but it is sometimes resisted or recurrence favored by the interposition of a por- tion of the capsule or the torn annular ligament between the head of the radius and the humeral condyle. Dislocation of the radius by elongation or the " Suhluxatioji of the radius of young eJiUdren" is an injury quite common between the ages of one and three, less common up to six, and is due to forcible traction on the extended elbow, possibly combined with adduction as in lifting a child or holding it when it stumbles. Symjitonis. — The child cries with pain, refuses to use the elbow, which is slightly flexed ; the wrist is pronated, and there is tenderness over the head of the radius. Passive motion is free except for supination. The injury consists in the escape of the anterior portion of the radial head below the orbic- ular ligament and is readily reduced by forcible su]>ination with pres- sure backward on the head of the radius followed by flexion of the elbow. It is sometimes spoken of as sprain of the elbow. FRACTURES ABOUT THE ELBOW. 181 Luxation of the nlita alone is usually backward but may rarely be forward or inward. Although all kinds of dislocations of the elbow have been described as complete or incompldc the differences are often inconsiderable and unimportant. Incomj)lete forms are more liable to occur in the lateral tiian in the antero-posterior varieties. Fractures of the /oicer end of the humerus are more common than those of the upper end or the shaft and are more common in young suh^ ject.s than in adults. Various forms occur, rendering a differential diagnosis necessary and often difficult. A. Supracondyloid fractures or fractures above the condyles are due to cio/enee, acting as a rule through the bones of the forearm, y>/-ef.^- ing the lower end of the humerus (1) bachicard, by the partly flexed fore- arm or possibly by hyperextension (''extension fractures"), (2) for- ward from beliind ( " flexion fracture " ) or (3) inward ( " adduction fracture"), (1) is oblique from behind downward and forward (the common form ; (2) is oblique in the opposite direction and (o) is oblique from above and externally downward and inward. Forms (1) and (2) may 1)C transverse or oblique from side to side. The character and extent of the di.^placcment vary with the direction of the fracture. In the common fomi (1) the lower fragment with the bones of the forearm is displaced backward and upward by the original violence aided perhaps by the triceps, Ijiceps and brachialis muscles. Hence the sharp lower end of the upper fragment projects forwards and the deformity rcsendjlc.s a dislocation, from which it may be distinguii^ of the arm the idnar nerve is almost necessarily cvposed on its ulnar side, while in ligating the radial artery the radial nerve is not exposed as it lies further to the radial side and is connected with the sheath of the brachioradialis. Among the arterial anomalies of practical interest may be mentioned : (1) the perforation of the deep fascia by the radial artery in the middle or lower third of the forearm and its subcutaneous course around to the back of the first interosseous space. It can be easily injured in its subcutaneous }X)rtion and if the radial pulse is sought in its usual place it is weak, being furnished by the smaller superficialis volse branch. (2) In case of a high origin of the ulnar artery, from the axillary or brachial, it usually pierces the fascia and becomes superficial a little above the elbow and thence, passing under or sometimes over the bicipital fascia, its course in the upper third of the forearm is superficial, covered by the fascia as a rule but some- times not. FRACTURES OF THE RADIUS AND ULNA. 185 Skeleton of the Forearm. — Of the two Ijones the ulna is tlie strongest and extends furtliest above, the radius below, and the two are most nearly of equal strength about the center of the limb. In all parts the two bones are iiefircr the posterior than the anterior aspect and especially so in the upper part. They are nearest the center of a section of the limb in the lower end of the middle third. On account of the posterior position of the bones, especially the ulna, they are best examined or reached for excision on this aspect ; also fractures are most readily compounded posteriorly. The two bones approach one another above and below and arc separated in the middle, the separa- tion being widest a little below the middle of the forearm. In supi- nation both bones are parallel, in pronation they are crossed. The interosseous space is narrowest in pronation, widest midway between pronation and supination, hence the latter position is maintained in most fractures of the forearm. In pronation and supination the ulna remains stationary, the radius revolving around it describes half a cone whose apex is above in the center of the radial head and the base below. Supination is the stronejer of the two movements, thus in using a screw driver, gimlet, or cork screw the main force is applied during supination. In ordinary pronation and supination there is some flexion and extension of the elbow and rotation of the shoulder in addition to rotation of the radius. The oblique ligament helps to hold the radius in contact with the humerus through the medium of the ulna. The obliquity of the fibers of the interosseous membrane (from above and without downward and inward) makes the ulna share with the radius in the strain of the latter in resting on or pushing with the palm and communicates to the radius the force imparted to the ulna in a blow from the shoulder. Fractures of the shafts of the radius and ulna may be due to direct, indirect or rarely to muscular violence. Fracture of the ulna alone, the more superficial and exposed of the two bones, is almost invariably the result oi' direct violence such as a blow on the arm raised to protect the head, for in this position the ulna becomes uppermost. Fracture of the radius alone is also generally due to direct violence but is more often the result of indirect violence than fracture of the ulna, for it receives all shocks transmitted from the hand. According to Malgaigne ^^green-stick fracturci'^ are more common in the forearm than elsewhere. The displacement varies greatly with the direction of the fracture and the fracturing force so that we may find overriding, lateral or angular displacement. In some cases it is afeeted by muscular action. Thus in fracture of the radius alone above the insertion of the pronator teres the upper fragment may be fully supinated by the biceps and supinator (brevis) while the lower fragment is maintained by the splints in the usual position midway between supination and pronation. If union occurs with the fragments in these relative positions the power of ."tupination will be lost as the supinators can act no further. The same result may follow after fractures of both bones. Another im- 186 THE UPPER EXTREMITY. portant ^ cm. above articular surface. Upper segment of the section. (Tillaux.) THE REGION OF THE WRIST. 187 front of the interosseous membrane is the anteri(n' interosseous artery and, with the median nerve in the posterior layer of the sheath of the flexor sublimis, is the median artery, sometimes of large size. Pos- teriorly between the deep and superficial layers of muscles is the posterior interosseous nerve and artery. In the upper two thirds of the arm, where the muscular masses cover the bones at the sides and the limb is more flattened and conical, ampu- tation bij antcro-podcrior fidps is more suitable. The anterior fiap con- tains the brachioradialis and the flexor muscles, the posterior fnp the extensor muscles. The anterior flap is more sul)stantial, as the bones He nearer the posterior surface. The radial artery with the radial nerve run the whole length of the anterior flap and are cut near its outer border, internal to the brachioradialis. The ufn((r artery is cut at a higher level, in front of the ulna and between the superficial and deep flexors. The anterior interosseous artery is cut short just in front of the interosseous membrane, the posterior interosseous is cut long between the superficial and deep muscles. The principal ney^es are good guides to the corresponding vessels. It may be noticed in this connection that the ulnar artery gives ofl^ the interosseous trunk one inch below the bifurcation of the brachial, which occurs opposite the upper part of the neck of the radius. As the chief pronators are the pronators teres and quadratus and the flexor carpi radialis and the chief supinators are the biceps and supi- nator (brevis), it follows that in amputation above the insertion of the pronator teres (the middle of the arm) the radius will become supi- uated and its further rotation lost. THE REGION OF THE WRIST. This region may be artificially limited, according to Tillaux, by planes two fingers' breadth above and below the radiocarpal joint. Surface Markings and Landmarks. — The radial and ulnar styloid ■processes can always be made out and are the most important lantl- marks for examination of or operations on the wrist. The radial styloid process, a finger's breadth above the thenar eminence, is more anterior and descends one half inch lower than that of the ulna. Partly on account of this fact abduction is less free than adduction of the hand. The radial styloid is commonly ca/T/'a/ upwai-d i)i Colles's j'ractn re so as to be on a level with or above the ulnar styloid, a point of diagnostic importance. Just beneath the radial and ulnar styloid processes one enters the radiocarpal joints the line of irhieh is concave inferiorly and rises 1 cm. above that connecting the styloid processes. In pronation of the forearm the xhuir styloid jtrocc^s is less distinct and the bony prominence at the back of the ulnar side of the wrist is due to the head of the ulnar. The ulnar styloid process is most plainly felt in supination, at the inner and posterior aspect of the wrist, to the inner side of the extensor carpi ulnaris tendon. In front of the wrist are several skin creases of which the hueesf and most distinct is slightly convex downward and is about 1 cm. 188 THE UPPER EXTREMITY. below the radiocarpal joint (Tillaux). If the line of this crease is continued around the back of the wrist it crosses the neck of the os magnum in the line of the third metacarpal bone. This point is felt as a depression in extension of the wrist, but is replaced by a promi- nence, the head of the os magnum, in flexion of the wrist. This crease also indicates fairly well the upper border of the anterior annular Uf/ament, which corresponds to the lower border of the posterior annu- lar ligament. Above the thenar and hyjwthenar eminences is a slight depression which in Colles's fracture forms a marked angular depres- sion and serves as an excellent sign of this injury, according to Tillaux. About and below the point where the flexor carpi radialis tendon crosses the lower skin crease, a bony rid(/e can be felt, formed by the tubercle of the scaphoid and the ridf/e of the trapezium. Correspond- ing to this level at the base of the hypothenar eminence the pisiform can be still more readily felt. Below the head of the ulna at the back of the wrist the cuneiform bone may be felt as a slight prominence. Topography. The Front of the Wrist. — On the radial side in the (jroove between the tendons of the brachioradialis and flexor carpi radialis, which is most marked when the wrist is flexed, can be felt the radial artery. This is very superficial, lying just beneath the fascia and hence easily exposed, compressed or wounded. It is here that the pulse is taken and arterial sclerosis looked for. To the ulnar side of the flexor radialis tendon is the most prominent tendon of this region, that of the pxdmaris longus. It is made most prominent when the wrist is partly flexed, the thenar and hypothenar eminences adducted and the fingers extended. It is near the center of the wrist. In the groove between the two last named tendons, or beneath the tendon of the palmaris longus, is the median nerve covered by the deep fascia. As the palmaris longus is not seldom wanting the/<:'.TOr carpi radifdis tendon is the better guide to the nerve, which lies between it and the flexor sub- limis. On the ulnar side the flexor carpi ulnaris can be felt extending to the pisiform bone. It is made most prominent by slight flexion of the wrist and adduction of the little finger. In the groove to its radial side, between it and the more deeply placed flexor sublimis tendons, lie the ulnar artery and nerve, the latter close to the ulnar side of the artery. The artery and nerve are covered by a deep and a superficial layer of the deep fascia of the forearm but pierce the deep layer, which is connected with the sheath of the flexor sublimis, just above the anterior annular ligament in order to pass in front of the latter. The synovial sheath for the superficial flexors and that for the long flexor of the thumb extend up the wrist above the annular ligament for 1^ to IJ inches. (Fig. 47.) The structures above named at the front of the wrist lie upon or in front of the pronator quadratus muscle. At the outer aspect of the wrist the outer surface of the radius is crossed by the tendons of the extensor ossis metacarpi pollicis and ex- tensor brevis pollicis. These tendons are made very prominent by extension and abduction of the thumb, in which position they bound ex- ternally a depressed triangular space, the '^ snuff box space" or " taba- PLATE XX. FIG. 48. EXTENSOR COMMU- NIS DIGITORUM EXTENSOR MINIMI DIGITI EXTENSOR CARPI ULNARIS EXTENSOR OSSIS METACARPI POLLICIS EXTENSOR BREVIS POLLICIS EXTENSOR LONGUS POLLICIS EXTENSOR CARPI RADIALIS BREVIS EXTENSOR CARPI 3IALIS LONGUS Synovial membranes of tendons on the dorsum of the forearm and hand, artificially distended. (Gerrish, after Testut.) THE WRIST JOIST. 189 tiere anatomique" of French writers, whose ulnar boundary is formed by tlie extensor longus pollicis tendon. The foor of the .ijj«ice is formed by the scaphoid and trapezium with their dorsal ligaments over which, and beneath the above tendons, runs th^ rfidial artery in its course from just below the apex of the styloid process to the back of the first interosseous space. The artery is here covered by two layers of fascia the deeper of which holds it close to the carpal bones. Sub- cutaneously the radial vein and branches of the radial nerve cross this space, the latter vertically, so that incisions to reach the artery should be iiKide rrrficfd/y. The tendon-^ which cross the outer and dorsal sur- faces of the lower end of the radius oceiipy grooves bounded by ridrjes of which that on the radial side of the groove for the extensor longus pollicis is prominent subcutaneously. The groove for this tendon in- dicates the center of the combined dorsal and external surfaces of the radius and corresponds about to the interval between the scaphoid and semilunar bones. Between the two grooves for the extensors of the thumb is one, sometimes divided by a low ridge, for the short and long radial extensors of the wrist. On the dorsal surfaca of the wrist on the ulnar side of the extensor longus pollicis is a shallow groove for the extensor communis and ex- tensor indicis, next to this and between the two bones a groove for the extensor minimi digit! and between the head and styloid process of the ulna a groove for the extensor carpi radialis. The order and relations of the tendon.^ at the wrist are given in detail as they are not infrequently severed in wounds and require fen- don .suture, for which an accurate knowledge of their position and rela- tions is essential, though when necessary the distal part of a tendon may be grafted onto another muscle with good results. The .S-/.1- grooves, for the tendons at the back and outer side of the wrist, are converted into as many osseoaponeurotic canals by the poste- rior annular ligament, which binds down the tendons and prevents their displacement in hyperextension of the wrist. This ligament is con- tinuous with and a thickening of the fascia of the dorsum of the forearm and hand. In these six canals the tendons are surrounded by .synovia/ sheaths. (Fig. 48.) The sheaths of the three carpal extensors and the extensor ossis metacarpi pollicis f.rtcnd to or nearly to the insertion of their tendons, that of the extensor indicis is very short, the sheaths of the other tendons extend a varying distance onto the dorsum of the hand. All the sheaths begin above near the upper border of the annular liga- ment except those of the radial extensors which commence a little lower down. The sheath of the extensor ossis metacarpi and extensor brevis pollicis is the one most often inflamed in the so-called trno-syno- fitis crepitans. This is accompanied by swelling, j)ain and crepitation on motion and is due to injury or unusual use of those muscles. The Wrist Joint. — The .strength of tiie radiocarpal, or wrist joint, (hpcnd.s Upon the number of .strong (Igamrnts and tcndon-s that surround it, the absence of a long lever on its distal side and the nearness of the numerous small bones and joints of the hand among which movements 190 THE UPPER EXTREMITY. and shocks are distributed. Its movements are largely supplemented by those of the mediocarpal joint. In the wrist joint proper extension is most free and its strongest ligament is the anterior which limits hyper- extension. It is noteworthy that the commonest injury is from forced extension, for in falls one naturally falls upon the palm, the wrist being extended, rather than upon the dorsum, the wrist being flexed. The dorsal ligament is so thin and superficial that swelling is first noticed at the back of the wu'ist in efi'usiou into the joint. In disease of the joint the latter is held midway between flexion and extension as the tendons at the front and back balance one another. If the wrist joint is injected one notices, especially on the dorsum, little hernial pro- trusions of the synovial membrane from which are derived most of the ganglia which are so common in this situation. At first these com- municate with the joint, but as a rule this communication becomes obliterated as the pedicle becomes lengthened. This pedicle may often be followed by dissection as a fibrous cord connecting the ganglion with the surface of the joint capsule. Similar protrusions are to be found on the synovial sheaths of the tendons, but these are much less often the starting point of ganglia. Dislocations of the wrist are rare, for in the common form of vio- lence, due to a fall on the palm, the joint is protected by the strong anterior ligament and fracture of the lower end of the radius almost invariably results. The dislocation is usually forward, less often back- ward, of the carpus on the forearm. It is usually due to great violence and hence is often compound and sometimes complicated by rupture of tendons or fracture of adjacent bones. I hav' e recently seen a compound backward dislocation in which the semilunar bone projected forward through the anterior wound, and was almost entirely detached. Both forms may be due to violence applied to the flexed or extended wrist. The deformiti/ of backicard dislocation closely rexendiles that of Collet's fracture but in the former the swelling in front of the wrist extends further down and ends more abruptly, that at the back of the wrist is more sharply outlined at its upper border. In addition the hand is usually more flexed and less movable in dislocation. In tiie inferior radioulnar joint the triatigular fibrocartilage is the principal ligament and the strongest ligamentous connection between the two bones. The synovial cavity of this joint is usually separate from that of the radiocarpal joint. Dislocation of this joint, apart from that sometimes observed in connection with Colles's fracture, is very rare. It is usually forward or backward of the ulna. In the latter form it is usually due to exaggerated pronation, so that the hand is pronated and supination is interfered with. The forward form has been due to direct violence and the wrist may be pronated or supinated and rotation is difficult. The ulna is prominent at the front or back of the wrist according to the form of dislocation. Some surgeons have thought that tlie injury described above (p. 180) as subluxation of the head of the radius in young children is a dislocation of the lower end of the ulna. COLLES'S FRACTURE. 191 CoUes's fracture is one through the lower end of the radius from I to 1 inch above its articular surface, at or near the point where the compact tissue of the shaft joins the cancellous tissue of the lower extremity, which appears to be a weak spot. It is one of the com- iiioned Jracturcii and is most frequent in the elderly. The direction is transverse, usually with a slight obliquity upward and backward and sometimes with a moderate slant upward and outward. The lower fragment usually shows a moderate backward (tiKplacement with considerable backward and often some outward rotation. Thus the articular surface looks downward and backward instead of downward and forward as normally. Iinpudion of the upper fragment into the cancellous tissue of the dorsal and lateral part of the lower is the rule, and coinininidion of the lower fragment is frequent. In addition the ulnar styloid process may be fractured by avulsion by means of the internal lateral ligament rather than by the fibrocartilage. The deformity in typical cases is characteristic. The prominence on the dorsum over the lower fragment, due to its backward displace- ment and rotation and to swelling, gave origin to the name, given by Velpeau, " silver fork fracture," on account of the resemblance of its outline as seen from the radial side. The end of the idna is veri/ proniuient in front on account of the displacement upward, backward and somewhat outward of the lower fragment of the radius and of the carpus which preserves its relations with it. The prominence in front over the lower end of the upper fragment is mostly due to swelling of the soft parts. The radial styloid is displaced up to or above the level of the ulnar styloid and the transverse creases in front of the wrist are deepened. Crepitus and abnormal mobility are not present in cases with marked impaction and may not be easily recognizable in other cases. The cause of Colles's fracture is almost always a fall upon the palm of the hand. The mechanism is neither simple nor constant and has been and is still much disputed. (1) The fracture is due to a crush- ing of the cancellous tissue between the carpus and the shaft, the weight of the body being received in the long axis of the radius while it is within 30° of the vertical. (2) The axis of the radius being more oblique and not in line with the fall the force is dcconijiosed, part of it passing up the shaft in the long axis of the radius and part acting transversely to break the bone at its weakest point. The back- ward rotation and displacement of the lower fragment indicates the direction of this latter part of the force, (o) The fracture is due to a cross-strain exerted on the lower end of the radius through the strong anterior ligament, made tense by hyperextension of the hand. The bone is broken by avulsion on the princi])le that a stout ligament is stronger than cancellous bone, so that the latter gives way first. Most fractures are j)rol)ably produced in one or the other of the first two ways. There is no doubt that it can be and sometimes is produced by avulsion. This theory rests upon experiments on the cadaver and is supported by many French and German writers on surgical anatomy (Tillaux, Joessel, etc.). 192 THE UPPER EXTREMITY. Epiphyseal separation is probably more often due to this mechan- ism. The cpipki/siK joins the shaft in the twentieth year ; it includes the insertion of the brachioradialis and the facet for the ulna. The line of the epiphyseal cartilage is nearli/ horizontal and may be intra- syuovial internally. Arrest of growth of the radius has followed epiphyseal separation in young subjects. Complete reduction of the displacement in Colles's fracture is often difficult but is essential to prevent permanent deformity and to insure perfect function. It is noteworthy that the X-ray shows a decidedly lower position of the articular surface of the radius as compared with that of the ulna in the female than in the male. Amputation at the wrist joint is rareli/ performed. Its principal object is to save the movements of pronation and supination. In most cases of injury it will either be necessary to amputate higher or it will be possible to save more, even a finger, which is most desirable. In cases of disease the necessary skin covering is involved and the move- ments of rotation are often lost from the disease. In general, ampu- tations in which the bones are left covered with cartilage are objection- able, as the latter has almost no reparative action. The elliptical method, resembling that by long palmar flap, is the best. In it the cicatrix is dorsal, the stump is covered by the tough and well-nourished tissues of the palm and the styloid processes are well covered. The great retract ibil it y of tJie ski)i on the dorsum, due to the looseness of the subcutaneous tissues, should be remembered. Disarticulation is easier from the dorsum. The radied artery is cut at the outer end of the dorsal wound, the ulnar at the inner end and the superjicialis voice at the outer portion of the palmar flap. Excision of the wrist includes the removal of the carpal bones and usually the articular ends of the bones of the forearm and meta- carpus. As the joints are covered and protected by strong tendons which move the wrist and fingers and which (save those of the pal- maris longus and flexor carpi ulnaris) are surrounded by synovial sheaths, the incisions are planned so as to spare these tendons and their sheaths as far as possible. Including that of the pisiform there are seven separate synovi(d sacs in the joints of the wrist and carpus. It is important to spare the radial artery which is close to the first carpometa- carpal joint (dorsally) the deep palmar arch (see p. 197) and if possi- ble the annular ligaments. In Ollier''s method the dorsoradial incision is along the radial border of the extensor indicis tendon, between it and that of the extensor longus pollicis, the ulnar incision is along the inner side of the extensor carpi ulnaris. The pisiform bone may usually be left and the trapezium should be when possible. Unless the subperiosteal method is employed, and this is often difficult, the tendons of the extensors and flexors of the carpus are severed or detached. Another simple and satisfactory method is to split the hand between the second and third metacarpal bones, between the trapezius and OS magnum and between the scaphoid and semilunar by an incision between the extensor indicis and the extensor communis tendons. THE HAXD AM) FINGERS. V33 THE HAND AND FINGERS. Surface Markings and Landmarks. Palmar Surface. — Between the thenar eminence on tlie radial side and the hypothenar eminence on the ulnar side is the " ho//o>r of the lianci/' a concavity of a somewhat triangular outline. Its apex is above and it is limited below by tliree little elevations opposite the clefts between the fingers. These eleva- tions are due to the projection of the fatty tissue between the flexor tendons and the digital slips of the palmar fascia, which form the grooves between these elevations. The hollow of the hand is more marked in the position of flexion and in muscular subjects. The bony prominences at the proximal ends of the thenar and hypothenar emi- nences have already been referred to. Fig. 49. SUPERFICIAL^-! PALMAR ARCH DEEP PALMAR ARCH ULNAR ARTERY RADIAL ARTERY Position of the principal creases of the palmar surface and of the jmlmar arches. Three of the many creases in the skin of the jxi/m deserve notice. The first murks off the thenar eniinonce from the hollow of the ])alm. It starts at the wrist and ends at the radial border of the palm at the base of the index finger. The second starts on the radial border, at 13 194 THE UPPER EXTREMITY. or just below the last, and crosses the palm obliquely inward and up- ward to the hypothenar eminence. The third and lowest starts from the elevation opposite the cleft between the first and second fingers and runs obliquely to the ulnar border. The first is due to the opposition of the thumb, the second to the flexion at the metacarpo-phalangeal joint of the index and middle fingers, the third to the similar flexion of the inner three fingers. Topographically the second fo/d, where it crosses the third metacarpal bone, is just below the lowest point of the superficial pal- mar arch, and the third fold crosses the necks of the metacarpal bones, roughly indicates the upper limit of the synovial sheaths of the mid- dle and ring fingers, and lies a little above the division of the palmar fascia into its digital slips. The metacarpophalangecd joints lie about midway between this fold and the webs of the fingers. The uppermost of the folds across the front of the fingers separate them from the palm, and are on a line with the webs of the fingers and 12—15 mm. below the metacarpophalangeal joints. The upper of the middle series of folds are opposite the first iuterphalangeal joints and the lowest set of folds are 2^ mm. above the second iuter- phalangeal joints. On the thumb the two creases correspond to the two joints, the upjier crease crossing the joint obliquely. Dorsal Surface. — The proximal ends of the first and fifth meta- carpal bones are prominent and can be readily felt. A line slightly concave downward, joining the upper ends of these and 1 cm. below the lowest skin crease in front of the wrist, indicates the line of the carpometacurpcd joints. When the fingers are flexed, the prominence.^ of the liiuckles are formed by the proximal bone of Fig. 50. g^ch joint (Fig. 50), so that the joint line lies be- low the prominences by one twelfth inch in the distal, one sixth inch in the middle and one third inch in the proximal joints. The first dorsal inter- osseous muscle forms a prominence between the first and second metacarpal bones, when the thumb is adducted. The skin of the palm and of the palmar surface Outline to show the i* ii j? • j/ • 7 i i 1 -ii i. 1 • relation of the bent ot the Hugers IS thick and dcusc and without hairs iines.'''^\h°e*''shadrd o^' sebaccous glands. Beneath the epidermis, which epiphyses'^^'^^*^"* ^^^ '^^ particularly thick, small subepidermal abscesses often develop. The .s7:/** of the dorsum of the hand is much thinner and down to the second or third phalanges is supplied with nu- merous hairs and sebaceous follicles and hence is liable to furuncles and other lesions associated with these .structures. The shin of tlie pcdm is more abundantly supplied with sireat glands than any other part of the body, four times more so, according to Sappey. Hence the profuse per- spiration that may occur here, as is well known. The Pacinian bodies and tactile corpuscles in connection with the free cutaneous nerve sup- ply are more numerous on the palmar aspect than elsewhere in the body. The palmar aspect of the third phalanx, especially that of the index finger, is most sensitive and, with the exception of the tip of the THE PALMAR FASCIA. 195 tongue, possesses more acute tactile sensibility than any other part. The dorsum of the hand, on the contrary, is but little sensitive to tactile sensation. The area around the upper end of the nail is liable to superficial subepidermal abscesses ("run around" paronijcliid) which develop quickly. The subcutaneous tissue on the palmar aspect intimately connects the overlying skin with the underlying fascia in the palm, and with the tendon sheaths in the fingers. Hence subcutaneous inflammatory or bloody extravasations and oedema are practically impossible here, while on the dorsum, where the subcutaneous tissue is lax and abundant, swelling and oedema may be very marked. For the same reason wounds do not gape on the palmar surface but gape widely on the dorsum. The denseness of the skin and underlying parts on the palm renders inflammation very painful on account of the tension caused by the inflammatory products, while on the dorsum the reverse is the case. Another particular in Avhich the coverings of the palm rescndjle the scalp is in the arrangement of the subcutaneous fat, the lobules of which are contained in small fibrous compartments of the subcutaneous tissue. This arrangement of the skin and underlying tissues of the palm adapts it to resist the eflfects of pressure and friction. Thus the ulnar border of the palm is much used in resting on the hand and in hammering movements, and it is noteworthy that the soft parts here are singularly free from large nerves. The palmar aspect is singu- larly //re //-oy/j large surface veins, which are abundantly found on the dorsum of the hand. The lymph vessels, on the contrary, are more numerous on the palmar surface of the hand and fingers. The palmar fascia, in its central portion beneath the hollow of the palm, is very dense and thick and is triangular in form. Its uprpjer end is connected with the lower border of the annular ligament and of the CI palmaris longus, of which it is the degenerated distal end. Its lower end or haxc splits into four slips which join the fibrous tendon sheaths of the fingers and send fibers to the skin, and deep transverse ligaments. The digital vessels and nerves and the lumbricales emerge in the inter- val between these slips. The denseness of the fascia well protects the soft parts beneath. Dupuytren's contracture is a peculiar contraction of the palmar fascia and its slips, especially those going to the ring and little Jingcrs. It occurs especially in men after middle life and may be associated with traumatism. It gradually flexes the first and then the second phalanges onto the palm. The tendons are not involved but between them and the thickened projecting cord-like slips of fascia, which are connected witli and wrinkle the skin, is a layer of fatty connective tissue. Laterally the palmar fascia is continued as a thinner layer over tiie thenar and hypothenar eminences. A fibrous membrane connects the deep surface of the palmar fascia, on each side of the central por- tion, with the interosseous fascia covering the palmar interossei. In this way two latcnd (thenar and hypothenar) and a central compart- 196 THE UPPER EXTREMITY. ment are formed. Suppuration commencing in any of these spaces may be limited to that space for a time but the membranous septa are thin and may soon yield. The central compariment i.s coufinuous above, beneath the annular ligament and along the flexor tendons, with the wrist and forearm. It is continuouft below irith the sheaths of the flexor tendons and the three intervals between the digital slips of the fascia which correspond to the webs between the fingers. Hence pus in the central compartment of the palm makes its way up into the forearm or down along or between the fingers. The resistance offered by the palmar fascia is so firm that rather than perforate it pus makes its way through the interosseous spaces to the dorsum, though this course is resisted by a layer of fascia covering the deep palmar arch and the interossei muscles. This fascia joins the membranes separating the central compartment of the palm from the thenar and hypothenar compartments in front of the third and fourth metacarpal bones re- spectively. Practically abscesses of the palm may be divided into those in front of and those behind the palmar fascia. Abscesses in front of the fascia, whether subepithelial or subcutaneous, are small, confined to the palm and very painful, but the pain is limited to the palm. Sub- fascial abscess may spread to the fingers, wrist and forearm or to the dorsum, which is usually much swollen. The pain is intense and is felt along the course of the nerves. In openiiu/ abscesses of the palm and in all operations on the palm the incision should be vertical, parallel with the tendons and digital nerves and above or below the superficial palmar arch (see p. 197). If an incision is required in the wrist it should be vertical and to the ulnar side of the palraaris longus tendon, where it will avoid the uhiar and radial arteries and the median nerve. The fibrous sheaths of the flexor tendons extend from the metacarpo- ])halangeal joints to the upper ends of the last phalanx at the insertion of the profundus tendons. Tliere being no intervening fascia here, the skin and subcutaneous tissues are connected with these sheaths in tlie same intimate way as with the fascia in the palm. The sheaths arch across the front of the phalanges between their lateral margins and thus form semicylindrical canals which lodge the synovial sheaths. The fibrous sheaths are dense and rigid so as to remain open when cut, so that in amputation of the fingers an open channel leading up to the palm is left for the spread of infection. Opposite the joints of the fingers the sheaths are thin and lax, leaving spaces between their obliquely decussating fibers through which the synovial lining may ])rotrude and suppuration may find its way into the interior of the sheath. Two synovial tendon sheaths are found in the palm, the outer for the flexor longus jjollicis, the inner for the superficial and deep flexors of the fingers. These extend up beneath the annuhir ligament, where tliey are constricted, and for about 1} inches above it into the wrist. Inferiorly the outer one extends to the insertion of the flexor longus pollicis, the inner one to the insertion of the flexor profundus of the PLATE XXI FIG. 51. , MEDIAN NERVE \ SHEATH OF FLEXOR CARPI RADIALIS ULNAR NERVE PALMAR SHEATH OF FLEXOR TENDONS OF FINGERS TENDON OF FLEX. \ j / jl SUBL. DIGIT TENDON OF FLEX. Tendon sheaths and muscles of the pah"nar surface of the left hand. (Joessel.) THE PALMAR ARCHES. 197 little finger and to about the middle of the metacarpal bone for the otiier three fingers, but further down on the tendons of the ring finger than on those of the other two. On the ring, middle and index fingers the dif/ifa/ si/novial slicatJis commence opposite the heads of the metacarpal bones and extend to the insertion of the profundus tendons, being contained within the fibrous sheath. (Fig. 51.) They are thus separated by one fourth to one half inch from the main palmar syno- vial sheath of the flexor tendons. Hence operations on and inflamma- tion of the thumb and little finger are more serious than of the oth«r fingers, for inflammation in the former may more readily spread to the synovial sac of the palm, causing a swelling here, which is constricted beneath the annular ligament and is expanded again in front of the wrist. This is seen, not infrequently, in case of felon of these two fingers. As the two sheaths may communicate normally or patholog- ically inflammation may spread from the thumb to the little finger or vice versa, giving rise to a horseshoe-shaped swelling. The two pal- mar sacs may be the seat of cysts which show the characteristic form of the sacs. In case of tubercular inflammation here and in the sheaths of the extensor tendons at the back of the wrist the sheaths are filled with fibrinous masses known as rice bodies. The superficial palmar arch (Fig. 49) lies beneath the palmar fas- cia and suj)erficial to the flexor tendons. Its course is represented by a line, slightly convex downward, commencing at the radial side of the pisiform bone and crossing the palm in line with the palmar aspect of the thumb, when abducted at rigiit angles with the index finger. This line should be (a-oided if possible /// incisions in the palm. The deep arch (Fig. 49) lies about one half inch nearer the wrist, in front of the bases of the metacarpal bones, and beneath the deep or interosseous fascia. It is nearer the dorsal than the palmar surface and is more liable to injury from the former aspect. The bifurcation of the digital arteries occurs about one half inch above the webs of the fingers. The blood suppli/ of the fingers is very abundant, the pulp of the fingers being one of the most vascular parts of the body. It is owing to this fact that in so many cases the tip of the finger, accidentally cut off, has grown on again when reapplied at once. Wounds of the palmar arches and their branches are serious on account of the dijficidty of cliwking tike Iwuiorrhage. This is due to the danger of damaging important structures of the palm and to the free anastomosis, whereby ligature of either the radial or ulnar or both does not control the bleeding, for the arches anastomose with each other and with the carpal arches, which communicate with the two inter- osseous vessels above. Hence the two ends of the divided artery should be secured if possible but, if the wound is deep or narrow, pressure may often arrest the bleeding. The possibility that pressure may cause gangrene, owing to the rigidity of the parts, should be borne in mind. Beneath the superficial arch and superficial to the flexor tendons is the median nerve in the groove between the long flexor of the thumb 198 THE UPPER EXTREMITY. and the flexors of the fingers. The nerve supply of the hand and fingers is of interest and practical importance. Cutaneous Nerve Supply (Figs. 52 and 53). Palmar Surface. — The palm is supplied by the median and ulnar nerves M'hich anastomose with one another. The palmar aspect of the little and the ulnar side of the ring finger are supplied by the ulnar, that of the other fingers by the median. On the dorsum of the baud the radial and ulnar nerves supply its radial and ulnar sides respectively, and anastomose with one another. The dorsal aspect of the thumb is supplied by the radial nerve as is that of the index and the radial side of the middle finger, as far as the second phalanx. The dorsal branch of the ulnar nerve supplies the dorsal aspect of the little, ring and ulnar side of the middle fingers as far as the second phalanx. In some cases the con- tiguous halves of the dorsum of the first phalanx of the ring and middle finger is supplied by the radial nerve or partly by the radial and partly by the ulnar. The dorsal aspect of the second and third phalanges of the four fingers are supplied by branches from the nerves supplying their palmar surfaces. The occasional apparently contradictory results of nerve lesions are due to the above mentioned variation (on the ring and middle fingers) and to the anastomoses between the nerves on the dorsal and palmar surfaces of the hand. Thus the loss of sensation is often quite slight in comparison to the area supplied and the same facts, and not " immediate union," probably explain the cases where sensation has returned within a few hours after suture of one of the nerves. Motor Nerve Supply. — The ulna supplies the interossei, adductor pollicis, inner head of the flexor brevis poUicis and the two inner lum- bricales, as well as the muscles of the hypothenar eminence and the inner half of the flexor profundus. Hence paralysis of the ulnar \sfol- loired by inability to adduct the thumb (adductor), to flex the last phalanx (profundus) or the first (interossei) of the two inner fingers, or to extend their last two phalanges (interossei). The latter two fingers are therefore held in the position of extension of the first pha- lanx (common extensor) and flexion of the second phalanx (flexor sub- limis). The muscles of the hypothenar and ulnar part of the thenar eminence are jiaralyzed and become atrophied. As the median nerve supj)lies the rest of the long flexors and those thumb muscles not supplied by the ulnar, and also the two outer lum- bricales, its paralysis {^followed, by inability to flex the second phalanx of all fingers, the last phalanx of the middle and index fingers, to flex or abduct the thumb, to pronate the hand and to flex the wrist, except by means of the flexor carpi ulnaris. The thumb is held adducted and extended. Flexion of the first phalanges with extension of the last two can be performed in all fingers by means of the interossei. On the dorsum of the hand the extensor tendons are united together by connecting slips so that it is difficult to extend one without the neighboring finger. The index finger can be extended alone most readily, next the little finger, for they are joined by only one band to PLATE XXir. FIG. 52. Cutaneous nerve supply of the upper limb, ventral aspect. (W. Keiller.) PLATE XXII FIO. 63. Cutaneous nerve supply of the upper limlD, dorsal aspect. (W. Keiller.) DISLOCATION OF THE FINGERS. 199 the tendon of the neighboring finger. The ring finger is extended alone with the most difficulty. The extensor tendons serve the place of posterior ligaments for the three joints of the fingers. When the last two phalanges alone are flexed, the first is steadied by the extensor tendons so that in paralysis of the latter this movement is not possible. When a finger is torn out it takes with it one or more tendons, most often the flexor profundus tendon if only one is avulsed. Felon or wMtlow is an inflammation usually commencing on the palmar aspect of the terminal phalanx, in the soft parts, tendon sheaths or periosteum. However it begins, unless it is promptly incised, it is /iaUe to extend to the synovial sheath of the tendon or to the periosteum. The latter is readily attacked as it is not covered by the tendon sheath beyond the base of the terminal phalanx. As the result of the involvement of the periosteum the bone often necroses, but usually only the terminal part for the base, which is an epiphysis not uniting with the shaft till about the eighteenth year, is protected by the insertion of the flexor profundus tendon. When the synovial sac is involved the abscess extends to the end of the sac opposite the head of the metacarpal bone, except in case of the thumb or little finger in which it may extend into the palm, beneath the annular liga- ment and up into the wrist, etc. (see p. 196). Bones and Joints. — In fracture of the metacarpal bones but little displacement is allowed as they are splinted to the neighboring bones by the interosseous muscles. The carpometacarpal joints of the first three fingers allow of but little motion, that of the little finger and es- pecially that of the thumb allow more free motion. The preservation of these joints is of great importance to the usefulness of the hand. Under all circumstances as much of the thumb as possible and a por- tion of the fingers or hand, to oppose it, should be saved, to preserve the forceps or grasping function of the hand. Dislocations of the metacarpophalangeal and interphalangeal joints arc coiiiiuDii. Dislocation of the first phalanx of the thumb back- ward is the nioHi important on account of its common occurrence and the frequent difficulty in its reduction. The latter has been explained in many ways ; the button-holing of the head of the metacarpal bone between the two sets of muscles which center in the sesamoid bones, the entanglement of the long flexor tendon around the neck of the metacarpal bone, the intervention of the anterior glenoid ligament be- tween the two joint surfaces, etc. The latter explanation is thought by Farabreuf to cover most cases. The f/lenoid lif/amcnt is torn from the metacarpal bone, to which it is loosely attached, but remains fixed to the phalanx and is carried back with it. If now the thumb is straight- ened, as it may be, and traction is made in this position the muscles attached to the sesamoid bones pull the ligament back and if the phalanx is brought back into place by traction, the glenoid ligament lies between the joint surfaces with its anterior face apj>lied to the head of the metacarpal bone. In any case traction in the straightened posi- tion should never be employed in reduction for fear of ciianging a 200 THE UPPER EXTREMITY. simple into a " complex dislocation," bat rather traction in the hyper- extended position. According to Stimson the resistance to reduction is due to the torn edges of the anterior ligament drawn closely across the metacarpal bone behind its head. This condition is frequently found on arthrotomy performed to reduce the dislocation, and a slight nicking of the tense edge makes reduction easy. As it is important to know from wJticJi spinal nerves the various nerves of the arm spring and the muscles supplied by them are inner- vated, for the purpose of diagnosis of nerve injuries of the upper limb, the following table is added. Nerves. — Suprascapular nerve and circumflex, 5, 6, C; posterior thoracic (nerve of Bell) and musculocutaneous, 5, 6, 7, C; internal cutaneous and ulnar, 8, C, 1, D.; lesser internal cutaneous (nerve of Wrisberg), 1, D.; musculospiral, 5, 6, 7, 8, C; median, 6, 7, 8, C, and 1, D.; nerve to rhomboids, 5, C; nerves to subscapularis and teres major (upper and lower subscapular), 5 and 6, C; nerve to latissimus dorsi (middle or long subscapular), 7 and 8, C. The entire hrachialplcxns may be ruptured or, more commonly, torn away from its attachments to the cord, or one or more of its cords, primary divisions or branches may be torn, stretched or compressed. The cutaneous distribution of the nerves of the arm is shown in the accompanying cuts. CHAPTER III. THE THORAX. I. THE THORACIC WALLS. Shape and Size. — The (uhilt f/iora.r, covered bv the soft parts, appears conini/, with its base above and its apex below and flattened from before backwards. Its circumference at the apex of the axilla is considerably greater in the male than that at the level of the nipple or at the base of the xiphoid process. In the fenw.le the circumference at the nipple is nearly as great as that at the axilla and the latter is considerably less than the similar measurement in the male. //; flie pldhUical the upper circumference is less than the lower (Hirtz). The senile thorax is narrowed above and lengthened so as to be conical with the base below. This is due to a sinking of the front of the ribs, due to the relaxed tone of the muscles. //( the Jaius it is flattened later- ally, the antero-posterior diameter being the greater. In the infant at birth the thorax is short, nearly circular on cross section and conical, with its base below. These differences in the infant are due, respec- tively, to the more horizontal position of the ribs, the absence of the angles of the ribs and the greater size of the liver, as compared with the lungs. The rcrticfil diainctcr of the posterior wall is over twice that of the anterior wall in the median line (31.5 cm. to 15.5 cm.) and the verti- cal diameter of the side of the thorax is longer than that of the poste- rior wall. The Jwif/Jit of the thorax increases with that of the body but not proportionally, the tran,werse diameter increases less and the (iiifcro-jHtsfcrior (Jidiiictcr still less. The greater height of the bodv is largely due to the length of the lower extremities. However a too small circumference of the thorax in a tall subject is thought to indi- cate a predisposition to phthisis. In the Prussian army those whose chest circumference is less than half the body height are regarded as narrow-chested and predisposed to tuberculosis unless the chest is widened by drill. The thorax of the female is relatively smaller than that of the male, is less flattened and more rounded. The tiro h(ilrej< of the thorax i\V(} usuaWy loisi/iniiietriral, \hc right measuring more (1 to 1 1 cm.), owing to the greater use of the right side. When the soft parts covering it have been removed the thorax is seen to be conical in shape with the apex above. Hence the lung ca- pacity is not indicated by the breadth of the shoulders but rather by the size of the base df the neck. Abnormal and Pathological Forms of the Thorax. — Occupation may atl'ect the sliape as by the pressure of tools depressing the ster- 201 202 THE THORAX. num and flattening the thorax. Corsets may so press in the lower ribs as to make the thorax spindle-shaped, or even smaller below than above. In pigeon breast the sternum and costal cartilages are pro- truded in relation to the ribs, like the sternum of a bird. It occurs especially in rickety children, in whom the long bones are not prop- erly ossified, particularly at their epiphyseal junction, as at the costo- chrondral. In such a case there is often obstruction in the respira- tory passages, due to adenoids or hypertrophied tonsils, so that in inspiration the air can not enter the chest fast enough to make the air pressure within equal to the atmospheric pressure without the thorax. Hence the weakest part, or that along the costo-chondral line, is pressed inward, making the sternum relatively prominent. In rickets the enlargement of the ends of the ribs along this line is often pal- pable and sometimes visible, receiving the name of " rickety rosary." Two opposite pathological types of thorax may be distinguished. The emphysematous type or the type of permanent inspiration is like that seen in pulmonary emphysema. The chest is barrel-shaped, enlarged in circumference but shortened vertically. As it is in the position of inspiration at all times the capacity of the chest can not be much increased. An approach to this type is normal as adult life advances. The type of permanent expiration or the phthisical typ)C (habitus j)aralyt- icus) is the opposite of the above. The chest appears flattened and lengthened. It may predispose to phthisis or be the result of it. The upper part of the thorax is especially contracted. Again in anterior and lateral curvatures of the thoracic spine the thorax is deformed. In anterior curvature of the spine (usually the result of Pott's disease) the sternum is thrust forward and the ribs are more oblique, approaching the pelvis so that the free ribs overlap the iliac crests. In lateral curvature the ribs on the convex side of the curve are more separated from one another than normal, those on the concave side more pressed together and sometimes so depressed as to touch or even overlap the iliac crests. Owing to the rotation of the vertebrae the ribs on the convex side bulge posteriorly on account of the prominence of their angles, and the scapula is carried back with them, making a "hump" on that side. On the concave side, usually the left, the front of the chest is abnormally prominent. As a result of pleuritic or pericardial effusions, aneurism, tumors, etc., the tJiora.v may become protruded and it may become sunken in from retraction of an adherent lung, etc. Such protrusions and retractions may involve a part or the whole of one half of the thorax. The internal configuration of the thorax is somewhat heart-shaped owing to the forward projection of the vertebral bodies, wliich renders the internal sagittal diameter but 1 cm. more than one half the same measurement externally. Owing to the backward projection of the angles of the ribs and the fact that the line of gravity descends in the cord of the backward curve of the thoracic vertebrae there is nearly as much space within the thorax behind the line of gravity as there is in front of it. Hence the erect position is easily maintained without LANDMARKS OF THE THORACIC WALLS. 203 the excessive muscular action which is necessary in animals in which these conditions do not prevail. Furthermore, in the human sul)ject, the backward projection of the angles of the ribs on either side to about the level of the vertebral spines renders possible the supine posi- tion, which is not possible in animals, as in them the spines project mesiallv without the corresponding lateral projection of the ribs. The thorax is bounded //( front by the sternum, costal cartilages and the spaces between them, laferaUy by the ribs and intercostal spaces, behind by the thoracic vertebrae and the posterior ends of the ribs and intercostal spaces. The bony thorax rorcr.s several of the ab- dominal viscera in addition to the thoracic, hence, besides the thoracic cavity proper, it bounds part of the abdominal cavity, the two being separated by the obliquely placed diaphragm (see p. 212). The latter therefore forms the convex floor of the thoracic cavity proper. The (ipiccx of f/ic hinfjx and pleural cavities extend through the small superior aperture of the thorax, as well as the trachea and oesophagus and the vessels, nerves and muscles which pass between the neck and thoracic cavity. This superior aperture connects the neck and thoracic cavity. It is formed bi/ the first ribs, first thoracic vertebra and the top of the sternum, is kidney-shaped, and slanted slightly downward from behind forward. It nietmires 2^ inches from behind forward and 4^ transversely. To assist in the topography of the chest we distinguish certain vertical lines in addition to the median line, /. e., the .sfcnial line along the side of the sternum, the mammary line through the nipples, the axillary line midway between the anterior and posterior axillary lines, which are drawn through the lower ends of the anterior and posterior axillary folds, and the xcapnlar line drawn through the inferior angle of the scapula. The parasternal line is midway between the sternal and mammary lines and the costoclavicular line connects the sterno- clavicular joint with the tip of the eleventh rib. Landmarks of the Thoracic Walls. — In i\\Q median line anteriorly the top of the sternum corresponds to the cartilage between the second and third thoracic vertebra3, the junction of the manubrium and body of the sternum is indicated by a readily palpable, prominent, trans- verse ridge which is continuous with the second costal cartilages. This is the easiest and most reliable point to start from in counting the ribs. It corresponds to the lower part of the fourth thoracic vertebra. The junction of the body and cnsiform process of the ster- num is readily palpable as a ridge, for the cnsiform is at a deeper level than the sternal body. This junction corresj)onds to the articu- lation of the seventh costal cartilage with the sternum, and to the ninth thoracic vertebra behind. It is also on a level with the lowest point of the fifth rib. Laterally the ni])j>le lies on a level with the anterior end of the fourth rib (Hyrtl), or in the finirth space, tiearly one inch external to the costal cartilages. The virgin breast covers the ribs from the third to the sixth. The lowest point of the seventh rib (the junction of the rib and costal 204 THE THORAX. cartilage) lies in the mammary line. The costochondral junction of the ribs above the seventh lie internal to this line, that of the lower ribs extci-nal to this line, in an oblique line extending downward and outward. The lower border of the pectoralis major corresponds to the fifth rib, the first visible i-.jrration of the serratus magnus to the sixth rib. Fosferior/i/ the scapula covers the ribs from the second to the seventh (sometimes the eighth). Owing to the obliquity of the ribs we find in a sagittal section in the mammary line that the first rib in front corresponds to the fourth rib behind, the second to the sixth, the third to the seventh, etc., each rib below the first in front corre- sponding to the fourth one lower in the series behind. The Layers of the Thoracic Wall, — The skin over the sternum is a favorite locality for keloid (/rouiJis. Gummata are also often found in the soft parts covering the sternum, especially the periosteum. The subcutaneous tissue of the thoracic wall may be the seat of extensive einplnisciiKt in some fractures of the ribs or in perforating wounds of the thorax. The sternum is very variable in lemjih and is often not in propor- tion to the height of tlie body. I have seen the sternum 10| inches long in a man of average height. In women the sternum, and espe- cially its body, is relatively shorter than in men. The holes or clefts in the lower part of the sternum, due to defects in its development from two lateral halves, may give pus an entrance to or an exit from the mediastinum. After a median division of the sternum the two halves may be retracted so as to expose the great vessels in the mediastinum for ligation. It may be trephined to open mediastinal abscess or for pericardial paracentesis. The sternum may be frdctured by direct violence, as by the violent contact witii the chin, or by indirect violence, as by the traction of the muscles when the body is forcibly bent backward. The fracture is usually transverse and occurs most often at or near the juncture of the manubrium and body, near the narrowest part of the bone. The body of the sternum with the ribs is commonly displaced forward. The lesion is often a di.slocu\ . EXT. INTERCOSTAL FASCIA EXT. INTERCOSTAL MUSCLE — PERIOSTEUM Vertical section of the sixth intercostal space at the junction of its posterior and middle thirds. (Tillaux.) THE INTERCOSTAL NERVES. 207 by the protection afforded by tlie periosteum and the fact that ihe fragments are rarely displaced. Owing to the protection of the rii)s, in the greater part of their course, the intercostal arteries are seldom wounded, but if wounded they are difficult to secure without injury to the pleura. Paracentesis may be done with care in any space within the limits of » the ph-ura were fluid can be diagnosed. It is usually ])cr- formed in the sixth, seventh or eighth spaces and midway between the axillary lines, where the overlying muscles are thin, or near the ])os- terior axillary line, or just outside the angle of the scapula, where the latissimus dorsi must be punctux'ed. Especial care must be taken in the lower spaces, like the ninth in the posterior axillary line, not to puncture the diaphragm. The needle or trochar is entered near the upper border of the rib, to avoid the main intercostal vessels, and in inspiration, for the spaces are then wider. The same rules apply to incision.^, which however can be made in the lowest spaces with greater safety than puncture, as they are not made blindly. The intercostal veins accompany the arteries, lying above them. Those in the upper six or seven spaces anastomose with the branches of the axillary vein. (Braune.) The subcutaneous veins of the thorax form an anastomosis between the axillary and the femoral veins, usually through the superficial epigastric veins (see the veins of abdominal wall). The internal mammary artery runs a finger's breadth from the sternal margin behind the cartilages and interspaces. It is .^(qjd rated from flic pleura in the upper two spaces by the endothoracic fascia, which is here thicker than elsewhere, and in the succeeding four si)aces by the triangularis sterni muscle. As it is a vessel of some size serious or fatal hemorrhage may follow its injury, and the bleed- ing is most likely to occur internally into the pleural cavity. As wounds of this artery are uncommon its ligation is seldom called for but may be done in one of the three or four upper spaces. Below this the spaces are so narrow as to require resection of the cartilages. The third space is preferable as this is wider in front than the fourth and the pleura is protected by the intervention of the triangularis sterni and not merely by the endothoracic fascia, as in the second. On either side of the artery, especially mesially, we may find sternal lymph nodes. The intercostal nerves (or anterior divisions of the thoracic nerves) lie below the arteries in their course behind the lower border of the ribs, though they are at first above them in the upper four spaces. They ■'rh' in all directions on the pec- toral muscle, the failure of such mobility indicates deep extension of the growth in cancer of the breast. This mobility may be tested after the muscle is made firm by its contraction. At the same time the breast moves somewhat Avith the movement of the muscle, hence the arm should be held at rest in inflammation of the gland. 14 210 THE THORAX. It is most important to remember that small glandular extensions may pass from the base of the gland to and even through the pectoral fascia so as to lie upon or in the muscle. It follows that every operation of excision of the breast for cancer, to be thorough, should remove this fascia and the surface, if not the entire thickness, of the underlying pectoral muscle. Similarly the fibrous trabecn/re [suspcnsori/ U/<'(//■« of both pleural cavities and the pericardium are closely connected with the diaphragm, the ^''/wVo/zDo/f more loosely. The under surface of the heart resting on the central tendon of the diaphragm explains the presence of the heart beat in the epigastrium, and its ex- aggeration in hypertrophy of the right ventricle. The liver, stomach, spleen, pancreas, kidneys and supraronals are in contact Avith the under surface of the diaphragm, the lungs and heart with the u]i])er surface. The diaphragm is supplied by the phrenic nerves in paralysis of which respiration is carried on almost entirely by the intercostals and 214 THE THORAX. the epigastrium sinks instead of protruding on inspiration, as the dia- phragm no longer pushes the abdominal viscera downward and for- ward. In action the diaphragm increases the vertical diameter of the thorax but as it also raises the lower six ribs it increases the other two diameters in the lower part. When fixed in the position of inspiration by the closure of the glottis, it assists the abdominal mus- cles in expulsive efforts, defecation, parturition, etc., by pressing down the abdominal viscera and holding them there. The abdominal vis- cera press the diaphragm upward in the supine position, hence many patients with dyspnoea breathe better in the sitting posture. The Pleura. The pleura of each side is a large serous sac or lymph f! oiichii.i Ptdm. y. ref«s \ \ \ (I real coroH. cfii Foramen for cesophagna Thoracic contents seen ri'om beliind. (Joessel.) THE PERICARBimf. 223 innominate vein, the innominate and left carotid arteries and the trans- verse arch of the aorta. It bifurcfdca behind the lower border of the aortic arch at about the level of the junction of the first and second pieces of sternum, or of the inner end of the spine of the scapula. Hence abnormal sounds produced at the tracheal bifurcation, or in the primary bronchi, can best be heard between the shoulders at this level. Surrounding the bifurcation of the trachea are twenty to thirty hroiicliUil (i/iiip}i iiodcs^ which are fref]Uontly diseased and may press upon and narrow the trachea or adhere to and ulcerate through it. Stenosis of the trachea from syphilitic lesions or from aneurisms of the aorta or the great vessels are apt to occur at the upper or lower ends of the trachea. Of the two bronchi the rif/ht is the larger, so that the dividing ridge between the two bronchi lies to the left of the median line and the trachea seems to lead more directly into the right bronchus. Hence, and by reason of the greater intake of air, foreign bi which corresponds to that part of the anterior surface overlapped by lung and sternum. Owing to the modification of the percussion note by the sternum and the margin of the right lung the right border of the heart cannot be definitely determined. As the heart dullness merges into that of the liver below, the loirer border cannot be determined by percussion, but may be con- structed by continuing the lower border of the right lung through the sternoxiphoid junction to the apex of the heart. The left border alone is tolerably accessible to percussion and by this we determine changes in the size and position of the heart. Laterallij the heart is in contact with the lungs, separated by the pericardium, pleurte and phrenic nerves. It encroaches more on the left side of the cliest and the left lung, so that two thirds of the heart are on this side. Only the right auricle and a small part of the left auricle and right ventricle are on the right side of a median vertical 15 226 THE THORAX. plane. The auricles lie above, behind and to the right of the mass of the ventricles and correspond to the sixth, seventh and eighth thoracic vertebrae. But between the heart and the thoracic spine lies the pos- terior mediastinum, containing the oesophagus, thoracic duct, aorta and azygos veins. The apex, belonging solely to the left ventricle, is directed downward, forward and to the left and strikes the chest wall in systole in the fifth space 3^ inches from the median line, or two inches below and one inch internal to the nipple. The apf.i* 6e«^ may be likened to the recoil of a gun. Topography. — The heart, as projected onto the chest wall, may be mapped out as a triangidar figure, whose upper truncated angle repre- sents the base of the heart, from which the great vessels are given off. The latter is represented by a line across the sternum at the level of the third cartilages, somewhat higher on the left than on the right, and projecting one half inch to the right and nearly one inch to the left of the sternum. The lower border, margo acutus, formed by the right ventricle, is drawn from the apex to the junction of the sixth (or seventh) right costal cartilage with the sternum, crossing the sternum near the costoxiphoid junction. This line is nearly horizontal behind the sternum, slightly convex downward to the left of it. The left border, margo obtusus, formed by the left ventricle, and the right border, formed by the right auricle, are completed by lines convex laterally which con- nect the left and right ends of these two lines, representing the base and the lower border. The right border projects one to two fingers' breadths from the right sternal margin or one and one half inches from the middle of the sternum. The auriculoventricular groove runs from the third left to the sixth (or seventh) right chondrosterual junction. The pulmonary orifice is the most superficial. It lies behind the sternal end of the left third costal cartilage, but the sound of the closure of the valve is transmitted upward with the blood stream and is heard most plainly in the second left space, close to the sternum. The aortic orifice is a little below and to the right of the latter, behind the left half of the sternum, opposite the third space. The mitral orifice is just to the left of and behind the latter, behind the left border of the sternum and opposite the third space or the fourth cartilage. Notwithstanding the close proximity of these two most important valves of the left heart, there is clinically no diffi- culty in distinguishing their respective sounds, for they are transmitted in the line of the blood stream, so that the sound of the mitral closure is best heard near the apex of the heart, that of the aortic at the sternal end of the second right intercostal space. The points of greatest intensity of the valvular sounds are much more superficial than the valves themselves, especially the mitral valve, which lies furthest posteriorly, behind and a little to the left of the aortic valve. The tricuspid valve lies behind the middle of the sternum about the level of the fourth space. Displacements of the Heart. — The position of the heart varies slightly with its systole and diastole and with the position of the body. PLATE XXVI FIG. 59. ^SCAUENUS ANTICUS '3 ,//V*)^l PULMONARX Relation of heart and great vessels to the anterior chest wall. (Joessel.^i WOUNDS OF THE HEART. 227 In cJilldren the apex is higher, in t/te aged lower than the position given alcove, the differenee between the two amounting to a full inter- costal space. The heart is e/erafed in case of ascites, tympanites or tumors of the abdomen which raise the diaphragm, and depressed in case of effusion into the pleural cavity, emphysema, large aoi-tic aneurism and mediastinal tumors. If the effusion is on one side only, the heart is disij/dccd to tJic ojjjjo.sde Hide. Effusions on the left side especially may dis})lace the heart to such an extent as to disturb the circulation and to displace the apex to or beyond the right margin of the sternum. The heart may also be pulled to either side by a con- tracting lung or pleural adhesion. The dcHcent of the heart in inspi- ration (about one inch) is not as great as it is made to appear by the elevation of the ribs in front of it. In cases of tranapoaition of the vh'icera the apex beat is found on the right side, and the position of the heart is correspondingly altered. The heart's position is affected by its enla/'f/ement. This is usually at first in the nature of a dilata- tion, and then the walls begin to thicken or hypertrophy to compensate for the dilatation. Hence an aortic obstruction, that may for instance be the cause of the dilatation, may be of comparatively little im])(tr- tance if there is compensatory hypertrophy of the left ventricle. The ill effects on the heart in valvular heart disease always extend in the opposite direction to that of the blood stream. The heart is supplied by the ric/ht and left coronary arteries, the first branches of the aorta, given off from the anterior and left posterior sinuses of Valsalva respectively. They run in the auriculoventricular and interventricular grooves and are exposed to injury in wounds of the heart. Atheroma of these arteries causes a poor blood supply of the heart, which may result in fatty or fibroid degeneration of the heart muscle, or in angina pectoris. An embolus in one of them may cause sudden death from paralysis of the heart muscle. The size of the heart is roughly speaking that of the closed fist, the weight varies greatly, averaging 266 to 292 grams. The size and weight of the heart increase up to advanced life and are one sixth less in the female. A physiological hypertrophy, especially of the left ven- tricle, occurs in pregnancy. Wounds of the heart most often involve the anterior surface, and hence concern the right auricle and ventricle and the left coronary artery and its accompanying vein, in the anterior interventricular groove. Wounds in the third, fourth and fifth spaces close to the right of the sternum are liable to injure the rif/ht auride, those in the same spaces to the left of the sternum the rif/lit ventricle. Wounds of the auricles are more serious and more raj)idly fatal than those of the ventricles owing to the thicker walls of the latter and their capacity to contract and prevent the escape of blood. For a similar reason wounds of the right ventricle are more serious than those of the left. Owing to the pf)sition of tiie pleura and its relation to the pericardium, a wound of the normal heart, unless it penetrates the sternum at certain points, must also pierce the pleura, hence blood is apt to be found in 228 THE THORAX. the left (more rarely in the right) pleural cavity. Wounds of the nor- mal heart, except over the area of cardiac flatness, involve also the anterior margin of the lung, hence air may escape into the pericardial as well as into the pleural cavity. Wounds of the heart are not as instantly fatal as commonly supposed. If death occurs at once it is usually due to interference with the heart's action by the presence of blood which has escaped into the pericardium, and not to the effect of the injury on the cardiac nerve centers. Patients with apparently fatal cardiac injuries have lived for some time and others have survived to die of other causes. In a few cases the foreign body causing the injury has been found on post-mortem encapsulated within the heart muscle. Punctured wounds of the ventricle, especially of the left ventricle, may be recovered from. Needles have not infrequently been found imbedded in the heart muscle, having often worked their Avay there from a nearby situation. Operations for cardiac injuries appear to afford a better prognosis than if no operation is done. The superior vena cava may be wounded by a stab wound in the first or second right interspace close to the sternum. The Aorta. The first or ascending portion of the aorta extends upward, forward and to the right in the axis of the heart. It lies behind the sternum and passes from the aortic orifice, behind the left half of that bone opposite the third space, to the upper border of the right second chondrosternal junction. It reaches to within about 1 cm. of the root of the innominate artery and lies irithin the pericardied sac, cov- ered by the sheath of the serous pericardium common to it and the pulmonary artery. Hence an aneurism of this part, before it attains a large size, very commonly bursts into the pericardium, causing sud- den death. The relations of the aorta are of importance in connection with the pressure symptoms of aneurism of its different parts. Aneurism, so common in the aorta when its walls are affected by disease, is most likely to involve the ascending part for this is not strengthened, like the arch, by the fibrous layer of the pericardium blending with it. Moreover it is the first part to receive the impulse of the cardiac systole. This impulse is felt especially along its right side where there is a normal bulging of the wall, the great sinus of the aorta, from which the current is reflected as it w^ere toward the left into the arch. Aneu- rism of the ascending portion usually bulges to the right and forward. Hence it presses on the superior cava on the right, causing congestion of the head, upper extremities and chest wall, and on the sternum in front from which it is normally separated by the overlapping right lung and the remains of the thymus gland. The pulmting tumor first appears in the second right sj^ace but, after erosion of the sternum, this and the upper right cartilages may bulge forward. If the tumor is directed backward it may press upon the right pulmonary artery, which lies behind it, or on the right bronchus behind the artery, caus- THE ARCH OF THE AORTA. 229 ing a deficient blood and air supply to the right lung and consequent dyspncea. Again the aneurism may start from one of the .s-innsr.s of Va/.salv(i, usually the right or anterior one, as the regurgitation of blood after systole occurs particularly here. Such a tumor, usually sacculated, projects chiefly forward and to the right, pressing on the pulmonary artery in front and the right auricle and superior vena cava on the right. The f/reat sinus of the ascending aorta projects a slight and varying degree to the right of the sternum, depending partly on the breadth of the sternum, and might be wounded in the second right Sj)aco. The arch of the aorta is badly named the transverse portion of the arch, for \iB principal direHion is backward, from about one fourth inch behind the sternum, at the second right chondrosternal junction, to the left side of the body of the fourth thoracic vertebra. Its fron.s- rcrse course corresponds only to about the width of the sternum. The downwardly directed concavity or lou-er border corresponds to the junction of the manubrium and body of the sternum. It is also con- cave to the right and posteriorly. Its convexity or upper border cor- responds to the level of the third thoracic spine, the middle of the first costal cartilages, the middle of the manubrium or a point about one inch below the episternal notch. In feeble and small-chested persons it may reach nearly to the top of the sternum or in big-chested men it may occasionally lie li to 2^ inches below it. It is covered in front l)v the margins of the right and left pleune and lungs and, between their diverging margins, by the remains of the thymus gland. Toward the left side the left vagus and phrenic nerves cross in front of it The left reeiirrent laryngad nerve arches beneath and then behind it, just to the left of the remains of the ductus arteriosus, which connects the arch inferiorly with the angle of bifurcation of the pulmonary artery, or the root of its left branch. The root of the left lung, including the left bronchus, pulmonary artery, etc., lies below it, Behind-it is the lower end of the trachea, just above or at its bifurcation, the cesophagus, thoracic duct, and the left recurrent laryngeal nerve. Its upper border is overlapped by the left innominate vein, Avhich covers the roots of its three branches which are given off above, from its convexity. A consideration of these relations will indicate the jjressure si/nip}toin.'< of an aneurism, which depend upon its position and the direction of its extension. The most common situation is on the posterior or right ((.sped, where it may press upon the trachea, causing dyspnoea, couj^h and harsh breathing, and on the left recurrent laryngeal nerve paralyz- ing the left vocal cord, altering the voice and so simulating laryngitis that tracheotomy has sometimes been done. Owing to its pressing more heavily upon the trachea in the reclining position the patient may be unable to lie down with comfort. Extending further backward it may press upon the (esophagus, causing dysphagia and simulating (esopii- ageal stricture, or upon the thoracic duct, causing inanition. Kvtcnsion foru-ard would involve the sternum and give rise to a pulsating bulging tumor, or press upon the left vagus or phrenic nerves. In case otexfen- 230 THE THORAX. sion downward the pressure may impede the circulation through the pulmonary artery, and especially its left branch, causing dyspnoea or ev^en cyanosis from the scanty oxidization of the blood. It may ob- struct the left bronchus, causing cough, dyspnoea and left-sided harsh and diminished breathing, or finally, it may affect the left recurrent laryngeal nerve. Upward extension of the tumor causes pressure on the left innominate vein, resulting in serious congestion of the left side of the head and neck and the left upper extremity, or upon one or more of the primary branches of the aorta, compressing or even oblit- erating them, and causing inequality of the carotid or radial pulses on the two sides. The tumor may extend up into the root of the neck, resembling aneurism of the innominate, left carotid or subclavian arteries, and cause difficulty in diagnosis. Aneurisms of the ascending aorta and the arch of the aorta are liable to lower the heart and to disturb the heart's action by pressure upon the cardiac plexuses. They may burst into any of the cavities or hollow tubes with w'hich they are in con- tact, causing a sudden fatal hemorrhage. The percussion note may be dull over a considerable area, owing to displacement of the lungs laterally. Most descriptive text-books speak of a short third or descending portion of the arch, but there is no sufficient reason for separating this from the descending thoracic aorta, which extends from the fourth thoracic vertebra to the aortic orifice of the diaphragm, opposite the twelfth vertebra and slightly to the left of the median line (Joessel). Superiorly it lies to the left, inferiorly in front of the thoracic spine, superiorly to the left and inferiorly behind and to the right of the oesophagus, and superiorly to the left and at its lower level in front of the thoracic duct. Furthermore it passes behind the root of the left lung, grooves this lung near its posterior border, and lies behind the pericardium and to the left of the vena azygos major. Aneurism of this part may press npjon and obstruct any of the above-mentioned parts, erode the spine and the vertebral ends of the left middle ribs, cause pressure upon and neuralgia of the corresponding left thoracic nerves, and bulge posteriorly to the left of the spine as a pulsating tumor, sometimes of enormous size. It may eventually burst on the surface or into the oesophagus, left bronchus, pericardium, pleura or posterior mediastinum. Variations. — The arch of the aorta is liable to occasional variations in its position and direction, with or without transposition of the vis- cera, and to frequent variations in the number and arrangement of its primary branches. These variations may decrease the number of pri- mary branches to two or increase them to four, five or six.' These anomalies are to be explained by abnormalities in the embryonic derelop- ment of these parts from the ventral and dorsal stems and the bran- chial arches. The only variation of much surgical interest is the ^ For the above variations see Henle's Anatomy (1868), Vol. HI., pp. 203 ot seq. ; Morris' Anatomy, 2d ed., pp. 471, 472, etc. THE SPLANCHNIC NERVES. 231 origin of the carotid, usually the left, from the innominate stem of the opposite side, in which case it may cross the trachea so as to be in danger of injnry in traciieotomy. Xot infrequently the ritjht aahelarian arises from the left end of the arch and passes behind the trachea and oesophagus to reach its normal position. The innominate and left common carotid, given off immediately be- hind the middle of the manubrium, mount thence to the right and left sternoclavicular joints, tiie former artery dividing opposite the upper border of the right joint. The innominate artery (1^ to 2 in. long) has the left innominate and right inferior thyroid veins in front ; the right innominate vein, pneumogastric nerve, pleura and lung to the right ; the trachea behind and to the left, and the left carotid artery to the left. These relation-s, and the occasional origin from it of the thyroidea ima artery, are of importance in the diagnosis of aneui-ism of this artery from the pressure symptoms, and in its ligation for aneu- rism of its branches, successful reported cases of which are on the in- crease. The dangers of the operation itself lie in the imj)ortant struc- tures in relation with it and in the difficulty of an adequate exposure, which may be facilitated by osteoplastic resection of the manubrium (Bardenheuer), or better by a longitudinal median section of the sternum, or its upper half, and the lateral retraction of the divided edges, whicii exposes the mediastinum and its contents. The pulmonary artery, in its course from the third left to the upper border of the second left chondrosternal junction, projects more or less beyond the left border of the sternum in the second space, where it is exposed to injury. Similarly on the right side the superior vena cava, from its origin behind the sternal end of the first costal cartilage to its termination behind that of the third cartilage, lies just to the right of the sternum and ascending aorta, and is exposed to injury in the mesial ends of the first and second spaces. The left innominate vein crosses transversely behind the manubrium, just above the aortic arch and just below the episternal notch, and in children and cases of high position of the aortic arch it may project above the bone so as to be exposed to injury in a low tracheotomy or in some thyroidectomies. The azygos veins are of practical importance on account of the free collateral circulation they afford between the inferior and superior cava?, in case of obstruction of the former. This is due to their connection with the liuubar, ilio-lumbar, common iliac and renal veins. The great, small and least splanchnic nerves, derived from the fifth to ninth, the tenth to eleventh, and the twelftli thoracic sympathetic ganglia respectively, are connected with the lower thoracic nerves, which supply the abdominal ])arietes. As they pass to the solar and renal plexuses, which supply the abdominal viscera, they account for the rejlcxes between the abdominal viscera and parietes (see p. 251), and for the pain in some diseases of the liver and stomach, in the region between and over the scapula^ supplied by the dorsal branches of the thoracic nerves, which are connected with the splauchnics. Pressure of thoracic tumors or ancuri,^ms upon the sympathetic may cause 232 THE THORAX. dilatation of the pupil of that side, from irritation of the nerve, or con- traction of the pupil, from paralysis of the nerve. As some filaments of the right phrenic nerve pass to the solar plexus and liver, the pain over the tip of the shoulder in liver disease may be explained as a reflex in the acromial filaments from the third, fourth and fifth cervical nerves from which the phrenic is derived. The Thoracic Duct. This is about eighteen inches lone/ from its commencement in the abdomen in the recepfacii/u)a cJu//i, opposite the second (or first) lumbar vertebra, to its termination in the neck in the posterior part of the angle of union of the subclavian and internal jugular veins, and is mostly contained within the thorax. Here, after passing through the aortic opening of the diaphragm behind the aorta, it lies between the latter and the vena azygos major in the posterior mediastinum up to the level of the fifth thoracic vertebra where it inclines to the left behind the oesophagus, the aortic arch and the left common carotid artery. Thence in the superior mediastinum it lies between the oesophagus and the left pleura, behind the left subclavian artery and in front of the vertebral artery. After ascending through the superior thoracic aper- ture into the lefi side of the neck as high as the seventh cervical verte- bra, it arches outward, forward and downward over the apex of the pleura, in front of the subclavian artery, the scalenus anticus muscle and the vertebral vein and behind the left internal jugular vein and the carotid artery, becoming external to the latter. (Fig. 60.) The hif/hest point of the arch of the thoracic duct normally reaches the level of the transverse process of the sixth cervical vertebra. Although in the thoracic cavity it may be pressed upon by tumors and aneurisms and its rupture is reported by Krabbel in a case of fracture of the ninth thoracic vertebra, followed by a chylous effusion of more than a gallon in the right pleural cavity, it is in the neck that its surgical in- terest lies. Here it has been u-ounded by stab and bullet wounds and in extensive operations for tumors or tubercular glands of the neck. The near neighborhood of many vital parts would render rapidly fatal most injuries of the duct, unless received during a surgical operation. Under normal anatomical conditions operative injury is very unlikely as the duct does not rise above the level of junction of the two great veins, but it not infrequently rises higher and has been found as high as 5| cm. above tlie sternum (Dietrich). When injured it has been successfully sutured in a few cases and its leakage has been checked by clamps or packing. Its obliteration has occurred without producing any marked symp- toms, though experimental ligation in dogs has been followed by rupture of the receptaculum chyli or other fatal lesions. A double perfect valve at its entrance into tlie vein guards against regurgitation of lymph or the entrance of blood. It may enter the veins as a delta. It receives the lymph and chyle from all parts of the body except the right upper extremity, the right side of the chest, head and neck and PLATE XXVI I FIG. 60. THORACIC_ DUCT VERTEBRAL VEIN BRACHIAL PLEXUS SUPERFIC. CER VICAL VEIN SUBCLAV. LYMPH ^^ TRUNK SUBCLAV. AF.TERV // Topography of the thoracic duct in the neck. (Zuckerkandl.) THE LUMEN OF THE (ESOPHAGUS. 233 the convex surface of the liver, which is returned by the right lymphatic duct to a corresponding point of the veins on the right side. Its injury is of less moment. The CEsophagus. Like the thoracic duct the (t'.so{)liagiis is contained partly in the neck and abdomen but mostly in the thoracic cavity, in the superior and posterior mediastina. Ti)e lei-ei of flie roiiimeuceiiiciit of the fx'sophagus, as the continuation of the pharynx, depends, like that of the trachea, on the position of the head and neck and varies from the fifth to the sixth or seventh cervical vertebrae. In a position midway between flexion and extension of the neck its upper end, beliind the lower border of the cricoid cartilage, is opposite the sixth cerrico/ i-ertehra. Its lower eiul passes through the diaphragm, opposite the tenth thoracic vertebra, to end in the stomach, opposite the eleventh vertebra. Its length (23 to 2G cm.) averages 9 J to 10 inches, which with the dis- tance of its upper end from the upper incisor teeth, 6 in., makes the average distance from the latter to the stomach \b\ to 16 in. (17 cm, in the new-born (Mouton). The length of the cervical portion, i. r., above the episternal notch or the second thoracic intervertebral disc, averages 5 to 7 cm. and ranges between 4| and Si cm. (Tillaux), vary- ing w^ith the length and position of the neck. Its direction (Fig. 58) is not straight. It inclines to the left in the neck but is pressed back to the median line by the left end of the aortic arch, opposite the fourth thoracic vertebra. Below this it again curves slightly to the left, so that its diaphragmatic orifice is normally somewhat to the left of the median line and to the left and in front of the aorta. In the sagittal plane it follows the curved line of the vertebrfe to the fourth thoracic vertebra, below which it gradually leav^es the vertebrae and passes more vertically to its diaphragmatic orifice. None of its curves are of sufficient extent or degree to inter- fere with the passage of bougies or instruments. The lumen of the oesophagus, except during the act of swallowing or vomiting, is always closed in the cervical portion, sometimes closed and sometimes open in the thoracic portion, according as the stomach is full or empty of gas or fluid. The caliber of the oesophagus, which is the narrowest section of the alimentary canal, varies and presents three constricted parts, one at its commencement, another 7 cm. below, and the third at its passage through the diaphragm, 22 cm. below. The latter is not a narrowing of the tube itself but is due to the fibers of the diaphragm which surround it and form a kind of canal for it. The loivest constriction is the narroircst, measuring 12 ram. in (liamcfer as compared to 14 mm. for the upper two, but it is )norc distensible, allowing of rapid dilatation to 22 mm., the other two to 18 or 19 mm. It follows that in a normal oesophagus a bougie 14 mm. in diameter should pass easily, otherwise there is a stenosis, and that in dilatinc/ the cesophagus an instrument of IS mm. diameter should be the limit. In the neir-l)orn the caliber of the oesophagus is 4 mm. On account of a spasmodic muscular contraction the introduction of a bougie may be 231 THE THORAX. hindered at the upper end of the oesophagus and lower down it may be suddenly held in the same way. During the muscular spasm the sound should be left at rest, as the attempt to force it increases the spasm. Owing to the firm relations in front of and behind the oesophagus, /. e., trachea and vertebrae, it is less distensible in these directions than laterally, as seen in sword swallowing. Accordingly some olive-tipped bougies are made flattened. Any foreign body which w^ill pass the upper two narrow points will probably pass the lower one. Foreign bodies are therefore most likely to be arrested at the upper end of the oesophagus, or the lower end of the pharynx, where the predominance of striped muscle tissue in the walls often allows of their being returned to the mouth by a spasmodic muscular action. If this fails they may be removed by some form of oesophagus forceps, as may also those bodies arrested at the second narrow point, which begins 3i cm. and is narrowest 7 cm. below. If the forceps fails to remove a body arrested at the second constriction the alternatives present of pushing it down to the stomach or remov- ing it by an external oesophagotomy. Strictures of the oesophagus, both malignant and cicatricial, are most likely to be found at one of the constricted points. The cica- tricial variety occurs most frequently at the narrow points because the corrosive fluid swallowed takes slightly longer in passing these points and hence acts more intensively on the oesophageal wall, caus- ing deeper ulceration and greater subsequent contraction. Cancerous stricture is most common at the upper or lower ends, and in the latter case the symptoms are not infrequently referred to the upper end. The lymphatics enter the mediastinal and cervical lymphatic nodes so that if cancer of the oesophagus is suspected we should examine the nodes at the root of the neck. The relations of the oesophagus are especially important at the nar- roir points where lesions are likely to occur and in the neck where oesophagotomy is done and where other operations and injuries may concern it. The second constriction is about behind the aortic arch and foreign bodies arrested here have idcerated. through into the aorta, causing immediate and fatal hemorrhage. Thus a five-franc coin (Mus6e Dupuytren), a fish bone (Lancet, 1871), etc., have been re|)orted ulcerating into the aorta, and a piece of bone impacted in the oesophagus has been reported (Ogle, in Path. Soc. Trans., Vol. IV.) ulcerating into an intervertebral disc and setting up a fatal disease of the cord. Aneurism of the aortic arch or descending aorta may press upon the oesophagus and simulate stricture of its lumen. A bougie passed under such conditions may penetrate the sac and bring on a sudden fatal bleeding. Similarly an impacted body or an epithelioma has ulcerated into the lower end of the trachea, the left bronchus or the right pulmonary artery, which also lies in front of the oesophagus. An instrument passed in case of a carcinomatous stricture of the oesophagus may readily pierce the softened wall of the tube and penetrate the trachea or left bronchus, setting up a septic pneu- PLATE xxvn r. FIG. 61. STERNUM RIGHT AURICLC V. CAVA SUP. RT. PHHENI L AURICLC SERRAT. MAJ. Transverse horizontal section of tlie body at the level of the 8th thoracic vertebra. (Joessel.) THE RELATIONS OF THE (ESOPHAGUS. 235 monia, or it may wound the aorta, pericardium, pleura, etc., with a fatal result. The contiguity of the esophagus with the membraneous wall of the trachea and with the left l)ronchus explains the effect of foreign bodies in the one producing symptoms of obstruction referable to the other, so that tracheotomy has been done for a foreign body in the oesophagus. Of course foreign bodies, especially sharp or irreg- ular ones, may become arrested elsewhere than at the narrowest points. The (lorta winds spirally around the oesophagus, being in front above, then to the left, then behind and finally behind and to the right. lUion: the aortic arch the oesophagus is just behind the bronchial glands and the pericardium and corresponds to the left auricle, so that in enlarge- ment of the heart or distension of the pericardium with fluid the patient may be unable to swallow with comfort in the supine position. The oesophagus lies between the two pleural sacs but in more direct contact with the left above and the right below. Hence carcinoma of the oesophagus is said to extend to the right lung and pleura more often than to the left, though I have observed it on the left side. The fhomcic duct is to the right below, to the left above and crosses behind it about the fourth or fifth thoracic vertebra. Loose cellular tissue, continuous with that behind the pharynx, connects the oesophagus with the vertebrae and along this a retropharyngeal abscess or a deep abscess of the neck may descend into the mediastinum and press upon the oesophagus. In the neck its relations are of importance especially on ilic left side, on which external oesophagotomy is performed as the oesophagus inclines to the left. In this operation the left recurrent laryngeal nerve, the inferior thyroid artery and the left lobe of the thyroid gland, which lie in front of the left side of the oesophagus, must be carefully avoided. After incising along the anterior border of the sternomastoid, from the thyroid cartilage downward, this muscle and the carotid sheath are retracted outward, the other structures inward. On the ri(/Jd .side the carotid sheath is further removed from the a\sophagus and the recurrent laryngeal nerve runs more along its lateral border. The modern operation of gastrostomy gives good results and is far preferable to oesophagostomy. In cicatricial strictures there is a pouch- like dilatation of the oesophagus above the stricture, the opening of which is usually excentric so as to prevent the passage of bougies. Hence the retrograde dilatation through an opening in the stomach is the best method.' Foreign bodies impacted at the lower end may be removed by gastrotomy (Richardson). Cone/enitally the oesophagus may be deficient in part and ojien into the trachea below or, more rarely, above. There may also be a tracheo-oesophageal fistula, an annular stricture, a dilatation or a doubling or division of the tube. True dircrficida, both jnilsion and traction diverticula, are acquired, the former due to a hernia of the mucosa through the inferior constrictor of the pharynx at the upper end of the oesophagus or the lower end of the pharynx, the latter due to the contraction of scar tissue connecting the cesophagus with surrounding parts (/. e., bronchial glands, etc.). 'See article by tlie writer in Annals of Surgery, March, 1S95. CHAPTER IV. THE ABDOMEN. Shape. — In general the abdomen is barrel-shaped, flattened from before backwards, and wider below than above. In the adn\t female the larger circnmference below than above is dne to the size of the pelvis and is still more marked when the upper part has been com- pressed by corsets. In childhood, owing to the incomplete develop- ment of the pelvis, the abdomen is larger above than below, especially in its transverse diameter. The height of the abdomen in the female is greater than in the male owing to the greater size of the lumbar ver- tebrae. The long axis of the abdominal cavity is not vertical but ob- lique from above downwards and to the right, owing to the greater height of the diaphragm on the right side. The infraahdovunal pres- sure acting most strongly in this line is said to account for the greater frequency of hernia on the right than on the left side. In fed subjects the abdomen protrudes to a varying degree in front, owing to the deposit of fat among the abdominal viscera and the peri- toneal folds and to the large amount of subcutaneous adipose tissue. In infants the abdomen protrudes in front, owing to the relatively large size of the liver and the small size of the pelvis, which crowds the pelvic viscera (bladder, rectum, etc.), partly up into the abdomen. The latter condition, apart from the amount of fat, accounts for the protrusion of the abdomen in children until the pelvis enlarges at the approach of puberty. Certain physiological and pathological conditions cause a general or local protrusion of the abdomen, such as pregnancy, ascites, and tumors of the abdominal contents or walls. After such long-continued dis- tension, an undue amount of prominence or pendulousness often re- mains. In cases of great emaciation from starvation or wasting disease, the contour of the abdomen is much depressed in front and especially just beneath the costal margin where the slight normal median depression, known as the ^' pit of the stomach^' (or scrobiculus cordis) may become so marked that, in the recumbent position, the wall sinks away almost vertically from the costal margin and the prominence of the vertebrae is noticeable. In tubercular meningitis the abdomen shows a " boat- shaped " depression in front, owing to the contraction of the empty bowels. Boundaries. — The abdomen, including the pelvis, is bounded above by the diaphragm, which separates it from the thorax, belon^ by the pelvic floor. A plane drawn through the base of the ensiform carti- 236 LANDMARKS. 237 lage in front and tlie tenth thoracic spine behind suggests the upper limit of tlie cavity, which, however, ascends even higher than tliis into the vault of the diaphragm. The actual upper limit of the abdomen, extending up as it does under cover of the lower ribs and costal cartilages, is higher than the api)arent limit, /'. r., the costal margin. It is hounded fjrhind by the lumbar vertebrte, sacrum, lower two or three ribs, diaphragm, lumbar muscles and the posterior portions o the ilia ; in front, by the free ends of the false ribs and costal carti- lages, the symphysis, the body and rami of the pubis, and the ventral abdominal muscles ; laterol/ij, by the lower ribs and diaphragm, the ilia and ischia, and the fleshy portions of the flat abdominal muscles. Except for operations on subdiaphragmatic and liver abscesses, after suture of the diaphragm to the opening in the costal pleura, no opera- tions arc done through the upper boundary or diaphragm. Many operations are performed through the perineum and the pelvic floor on the rectum, female pelvic organs, and male genito-urinary organs. Hahn's operation for gastrostomy is done through the eighth intercostal space, and occasionally the iliac fossa has been perforate< may l)e diffirxlf by reason of its long narrow neck. As the natural tendency of a congenital sac is to close during early life, especially as the canal grows longer and more oblicpie, we can often eifect a cure in children by keeping the contents permanentlv reduced. Fig. 68. Diagrammatic representation of the varieties of external inguinal hernia due to congenital defects in the v-acinal i)rocess. 1, the processus vaginalis showing the two points where closure of the upper part commences, atC and C ; 2, congenital hernia ; 3, hernia into the funicular process ; 4, infantile hernia; 5, acquired hernia. E, external abdominal ring; I, internal abdominal ring; P.S., peri- toneal sac'; B, herniated bowel ; F.P., funicular process ; T, testis. 2. The upper end of the vaginal process may close while the rest remains open, a condition which is the rule in early inftuicy. If under such circumstances a hernia with its peritoneal sac is forced down or, according to Lockwood's theory, a peritoneal sac is drawn down by the gubernaculum, such a hernia is called an infantile inguinal hernia, for it was first described in infiints. As the sac lies behind the open vaginal process we must pass through the process to open the sac, and in so doing we would dicide three layers of peritoneum, two of the process and one of the sac. The variety is uncommon and unimportant. The hernial sac may occasion- ally project into or invaginate the vaginal process, giving rise to the term encysted hernia. 3. Again the closure of the vaginal process may occur only below, just above the testis, and a hernia into this preformed sac is known as a hernia into the funicular process. This sac is congenital and it differs from the so-called congenital hernia only in the fact that in the latter the contents are in contact with the testicle, in the former they are separated by the septum which has shut off the testicular pouch. Hernii^ which become fully formed in a short time are of congenital origin. 4. Finally those hernia? whose sac is formed anew from the peri- toneum of the external fossa are known as acquired external inguinal hernise. This variety develops more slowly and does not de.-cend as low 266 THE ABDOMEN. in the scrotum or come in sucli close contact with the testis as the con- genital varieties. Internal or direct inguinal hernia is one which emerges internal to the deep epigastric vessels and, as its name implies, passes directly forward through the abdominal wall where it appears to be weakest. Nevertheless it is far less common than the indirect form, a fact due to congenital conditions, the presence of the cord in the canal and the fun- nel-shaped depression of peritoneum at the internal ring which act as predisposing causes of the indirect variety. Direct hernia occurs most often when the abdominal walls have lost their strength and are lax, as in old age, after any prolonged distension, or after emaciation follow- ing obesity. Its jjolnt of entry is usually in the middle inguinal fossa opposite the external ring, rarely in the internal fossa, in which case it has been called " internal oblique hernia^' as its course is somewhat obliquely outward to emerge at the external ring. The neck of a direct hernia is usually loide, admitting one or two fingers, so that the pulsa- tion of the deep epigastric artery can be readily felt to its outer side and strangulation is not common, occurring most often at the external ring. Its coverings differ only nominally from those of the external variety. TransversaUs fascia takes the place of that local subdivision of it, the infundibuliform fascia. In place of the cremasteric fascia we have the conjoined tendon, except in certain cases where the hernia escapes beneath or breaks through between its fibers without receiving a covering. If it escapes through the inner fossa the triangular liga- ment may form one of its coverings. Other features of this form of hernia may be best brought out by observing the differences between internal and external inguinal hernia. The sJiape of an internal inguinal hernia is globular on account of its short neck, that of an external is pear-shaped. The size of the former is smaller and it has little tendency like the latter to follow the cord or descend low into the scrotum. The position of the former is more internal, and it lies more internal to and in front of the cord instead of in front of and external to it. On reduc- tion the track of the neck of the internal is short and straight, that of the external is oblique and longer. Also if the finger can be intro- duced to their deep openings, the pulsations of the deep epigastric artery may be felt internally in external hernia and externally in internal hernia ; while internally in the latter may be felt the edge of the rectus muscle. The external form is often congenital, the internal never. The external form occurs especially in early life, the internal late in life. From these differences it would seem an easy matter to distinguish between the two forms, and so it is where the relations of the various parts are not much disturbed, as in recent or congenital hernise. But in old external inguinal hernia the traction of an increasing weight on the inner side of the internal ring enlarges it on its internal aspect and so shortens the canal and makes it less obli(jue. Also if the rupture is HERNIA OPERATIONS. 267 irreducible some of the diagnostic points will he wanting. Thus it may be difficult or impossible to distinguish between the two varieties. Hernia Operations. — The incision over the course of the canal, and for a short distance internal to it, is laid out according to the land- marks Ave have given for the canal, and the visible or palj)able position of the hernia. The superficial external pudic artery is usually divided but is of no importance. Several large veins, varying in size and num- ber, may be met with crossing the line of incision. In recent or small external hernise the point of constriction, if strangulation occurs, may be at the internal or external ring, but it is more often in the narrow neck of the sac itself, which must then be opened. In the operation most often practised, that of Bassini, the dilated or enlarged canal is obliterated, so as not to leave an easy passage way for the recurrence of the hernia, and a new track is made for the cord. How are We to Recognize the Different Layers ? — It is neither neces- sary or always possible to distinguish all of them. After division of the skin whatever moves with the cut edges belongs to the superficial fascia, unless inflammation has rendered the latter adherent to the parts beneath. The external oblique aponeurosis can easily be told by its pearly shining oblique fibers. The cremaster or conjoined tendon is the only muscle divided, and hence may be recognized. Some diffi- culty may be found in determining whether the peritoneal sac has been opened or not. In congenital inguinal hernise the sac is closely adherent to the fascial layer outside. This may enable us to know when we meet with such a hernia, but it makes it more difficult to free the sac as well as to know when we have opened it. Iloir are loe to (Ji.-ifinr/uish between the sac and the intestinal vail / 1. The outside of the sac has not a shiny sniootJi surface, like that of the peritoneal surface of the intestine, but often shows attached to it little lumps of fat belonging to the subperitoneal tissue. 2. The vessels on the sac run more vertically, those on the intestine, circularly. 3. If we pinch up a fold between the fingers the sac is veri/ thin, the intestinal wall thicker. The presence o{ fluid within the sac, in large amount in strangulated hernia, is also of great diagnostic im- portance. In what direction should we not incise to relieve a constriction of the neck of an inguinal hernia? In the external form, not backwards on account of the cord, nor inwards on account of the deep epigastric artery. In the internal form, not backwards on account of the vas deferens and blood vessels, nor outwards for fear of the deep epigastric artery. But as it is often impossible to distinguish between the two forms it is advisable in any case to incise as if it might be either variety, and not to cut backward, inward, or outward. Hence we should incise u/iirardor upirard and slii/Jiflif iiurard, i. c, parallel with the deep epigastric artery. An extensive cut is unneces- sary, several small cuts answer equally well. 268 THE ABDOMEN. The Length of the Mesentery in its Relation to the Formation of the Hernia, — Mr. Lockwood has shown : (1) That witii a me.^entei-y of normal length the intestine may be drawn down through the external ring but not into the scrotum. (2) That the mesentery is relatively longer in infancy, decreasing rapidly in the second year, and averaging eight inches in length in the adult. In the congenital herni?e of infancy the mesentery may allow the gut to descend into the scrotum without first becoming lengthened, as is necessary in adults. An interstitial inguinal hernia is one into and not through the hdly tcall. It usually starts as an external hernia but instead of passing out through the external ring it makes its way between some of the layers of the abdominal wall. This form of hernia is most apt to occur when, for some reason, the external ring is narrower than normal or is closed. These conditions are present when the testicle has not completely descended but is lodged just above or within the inguinal canal. The latter position of the testis most favors the production of such a hernia, for the upper end of the canal is enlarged and commonly occupied by a pouch of peritoneum. In such a hernia the tumor is flattened out. According to Tillaux, strangulation may occur by compression of the surrounding muscular layers, and taxis is more harmful than useful. Reduction en Masse. — A hernia may be reduced by taxis together with its sac so that any constriction in the neck of the sac still exists. In such cases the sac may be pushed up between the peritoneum and the abdominal walls or, if the iufundibuliform covering is ruptured, in front of or behind the conjoined tendon which forms the upper boun- dary of the canal. Inguinal Hernia in the Female. — A pouch of peritoneum, the canal of ^11 i:h, corresponding to the vaginal process of the male, de- scends in foetal life for some distance along the round ligament and when, as sometimes happens, it remains open it may/orm the sac of a congenital hernia. Inguinal hernia in the female is most common in infancy, early childhood or after the first pregnancy. In the former case it is con- genital, in the latter acquired, the canal having become distended dur- ing pregnancy by the enlargement of the cord, which shrivels after childbirth but leaves the canal more lax. The round ligament bears the same relation to the hernial sac as does the cord in the male. After emerging at the external ring a hernia may pass down into the labium majus. The coverings are the same as in the male except that the cremasteric layer is wanting. The contents are also the same except that the ovary or even the uterus, in part, may be found in the sac. Internal inguinal hernia is very rare in women. Operations in this region, except for hernia, are chiefly those to shorten the round ligaments, to open abscesses, or to tie the external iliac artery. To shorten the round ligament the incision is made as for hernia or a little more horizontally. The external ring is exposed, the tissue lying just internal to it is hooked up with a blunt hook and INGUINO-FEMORAL REGION AND FEMORAL HERNIA. 209 the round ligament is sought for in this tissue. If the ligament can not be so found, tiie canal should be slit up and its contents caught up on the hook. After pulling it down for a certain distance, the liga- ment becoming more flesiiy and thick, a double sheath of peritoneum is drawn down with it. The latter may predispose to subsequent hernia. Abscesses are principally of hco varieties, to be spoken of in the study of the iliac fossa. One variety is in the snhperitonea/ tiaHiic of the iliac fossa and is limited inferiorly by the line of Poupart's liga- ment. Here it raises up the peritoneum and may be inciHcd, just above Poupart's ligament, without opening the peritoneum. The otlier, psoas abscess, is hencath the iliac fascia and raai/ paint above or lx*lo\v the middle or outer half of Poupart's ligament. When above the liga- ment it may be exposed and opened after incising the transversal is fascia and pushing up the lower limit of the peritoneum, thus bringing to view the iliac fascia. AVe proceed in a similar way to expose the external iliac artery, for which see Iliac Region, p. 270. The Inguino -femoral Region and Femoral Hernia. This region is the passarje tray between the upper part of the thigh and tiie region above. Poupart^'i lifjament bridges across the concave iliopubic margin of the hip bone and thereby forms a space, mainly occupied by the iliopsoas muscle and the external iliac vessels in pass- ing into the thigh. The fascia investing these structures subdivides the space into compartments or lacunae. The largest and most external of these is the muscular compartment occupied by the iliopsoas muscle and the anterior crural and external cutaneous nerves. It is bounded externally and behind by the bony iliac margin between the anterior superior spine and the iliopectineal eminence; in front by Poupart's ligament, and internally by the ih'ac fascia. This fascia is firmly attached to the transversal is fascia and Poupart's ligament along the outer 4 cm. of the latter, but then sep:i- rates from them to pass to the iliopectineal eminence, where it is con- tinuous with the pectineal fascia, /. e., the pubic portion of the fascia lata. It is in this compartment that a psoas abscess passes beneath Poupart's ligament to " point " below it. The pectineus muscle passes up a short distance above Poujiart's ligament and may be said to occupy a pectineal compartment, liinited behind by the horizontal pubic ramus and in front by the pectineal fascia. The upper limit of this fascia, along the iliopectineal line, is thickened by transverse fibers from Gimbernat's ligament to fi^'m what is known as Cooper's lir/ament. The rest of the space is frianc/ular in shape and, save the inner angle occupied by Gimbernat's ligament, constitutes the vascular com- partment. This is boKtidrd \n front by Poupart's ligament (/. r., the superjicial femoral arch) and the transversalis fascia, attached to Poupart's liga- 270 THE ABDOMEN. ment, which is thickened by transverse fibers and known as the deep fem- oral arch. Behind the compartment are the iliac and pectineal fasciae, continuous with one another. The external iliac vessels and the cru- ral branch of the genitocrural nerve occupy this compartment in their passage into the thigh, the vein lying internal to the artery. The vessels do not occupy the entire compartment, but there is an interval of 3/5-1 inch between the vein and the outer margin of Gim- bernat's ligament, which constitutes the femoral ring, through which a femoral hernia forces its way beneath Poupart's ligament. In passing beneath Poupart's ligament into the thigh to become the femoral vessels the e.rternal iliac vessel.^- carry irith them a fascial sheath, the femoral sheath, which bounds the vascular compartment and is continuous with the fascia lining the abdomen, /. e., the trans- versalis fascia in front and the iliac fascia behind. These fasciae are continuous with one another internally and externally so as to form a complete sheath. This sheath is funnel-shaped, wide above but closely embracing the vessels below, where it is continuous with their proper sheath. The width of the sheath beneath Poupart's ligament prevents compression of the vein and pinching or stretching of the vessels in movements at the hip. The vessels occupy the outer side of the funnel and leave a pyramidal space, the femoral canal, on the inner side of the vein and separated from it by connective tissue, belonging to the fibrocellular or proper sheath of the vessels. This canal measures one half to three fourths inch in length, and tapers to its louder closed end which is opposite the upper end of the saphenous opening. It is only 2, potential canal, like the inguinal, not a real one unless made so by a hernia or the knife. It represents a iceak spot which forms the passage way of a femoral hernia. The femoral canal is hounded externally by the femoral vein with a septum of connective tissue between, and on the other sides by the fem- oral sheath. It contains fatty and cellular tissue, lymphatics penetrating its anterior wall and passing from the superficial to the deep inguinal nodes, and one or more lymph nodes. Its upper or abdominal aperture is i\\Qo\di\ femoral riwj, mentioned above. The size of the ring varies, but is usually sufficient to admit the tip of the forefinger. It averages three fifths of an inch in diameter in the male and is half again as large in the female, hence the greater frequency of femoral hernia in iroinen in the ratio of three to one. Its grecder width in tvonien'is not due to any greater width of the space beneath Poupart's ligament, for it is not wider, but to the smaller size of the muscles, occupying the muscular compartment, and of Gimbernat's ligament. When vieu-ed from above the femoral ring is seen to l)e covered by peritoneum, which may present a slight de])ression, the foKsa femorrUis. According to Tillaux, such a depression is not normal but ])athological, the peritoneum being drawn down by an attached fat lobule belonging to the subperitoneal tissue. On removing the peritoneum the ring is seen to be closed by the BELATIOXS OF PARTS ABOUT THE RIXG. 271 septum cnirale (Cloquet), a condensed layer of connective tissue, con- tinuous with the subperitoneal tissue and perforated hy lymphatics passing from the inguinal to the iliac nodes. A small h/mp/i node is sometimes found lying on it. Inflammation of this gland or of one in the canal has been mistaken for strangulated hernia, on account of a similarity of symptoms. Fig. 69. ANT. -SUP. ILIAC SPINC ANT. CRURAL NERVE Section of the crural caoal and of the n)u>cular and vascular com part meDts beneath Poupart's ligameut. (Tillacx.) The boundaries of the ring are of great practical importance from their relation to the neck of a femoral hernia. To the outer side lies the vein in its sheath, elsewhere the boundaries are of firm fibrous structures. //* front lies the sujx^rficial femoral arch (Poupart's liga- ment; and the deep femoral arch (see p. 270). Behind is the thin upper end of the pectineus muscle, resting on the horizontal pubic ramus and covered by the thickened upper end of the pectineal fascia. Interna// 1/ there is a series of firm fibrous structures, attached to the iliopectineal line, as follows from below upward : the iliac jwrtiou of the fascia lata, Gimbernat's ligament, the triangular ligament, the conjoined tendon, and the deep femoral arch. These structures present a sharp free mar- gin towards tlie ring. Relation of Parts About the Ring. — The ftpermatic cord in the male and the round /ir/ament in the female lie in loose tissue one fourth to one fifth of an inch above the anterior mare/in of the ring. The epif/nMrie ve-^selx lie above and to its outer side, distant about half an inch. The small pubic l)ranch of this artery runs across in front 272 THE ABDOMEN. of the ring, to ramify on the upper aspect of Gimbernat's ligament. These structures are in danger of being divided by a free incision up- wards but, according to Tillaux, not by an incision or incisions of one fifth of an inch, which may subsequently be enlarged by the finger. The internal and posterior aspcet of the ring are usually free from important relations. Therefore to relieve the constriction in a strang- ulated hernia we may incise bachcard, but little room is to be gained here as only a thin layer of soft parts covers the bone. Hence we incise inwards, bearing in mind the following variations. Once in every 3| cases the obturator artery is given off as a branch of the epigastric artery. The course of this branch is commonly to the outer side of the ring, where it lies close to the vein, and not exposed to injury by incision, for we never incise outwards on account of the vein. Occasionally (in 1 to 3J psr cent.) the common trunk is longer, crossing in front of the ring, and the obturator branch, with its vein, passes back close to the in)ter border of the ring where artery and vein are exposed to injury by a free incision inwards. Cases are recorded where such an injury has resulted fatally, and the reason why it is not more frequent seems to be that the vessels lie in loose tissue, 1 to 2^ lines from the edge of the ring, and may be readily pushed back before the knife, and also that multiple short incisions are often employed. If the finger can be pushed through the ring the pulsation of such an aberrant artery, lying internally, may he felt. It should be sought for so as to avoid the chance of an accident. The size and the tension of the femoral ring and canal and of the saphenous opening, and hence the constriction of a hernia passing through them, varies with the position of the limb. They are enlarged and relaxed in flexion, adduction, and inward rotation of the thigh and hence taxis should be tried in this position. In the reverse position these parts are rendered tense by the traction of the fascia lata upon Poupart's ligament. Femoral hernia is ahrays acquired, never congenital. It occurs almost exclusively in adult life. Though more common in women than in men in the ratio of 3 to 1 , it is less common in iromen than the inguinal variety, contrary to the general impression. The weakening effect of pregnancy on the abdominal walls increases the liability of women to femoral hernia, so that it is more common after the first pregnancy. Course and Coverings. — A pouch is gradually formed of the peri- toneum covering the weak spot, the femoral ring. This forms the hernial sac and a covering is received from the septum crurale in pass- ing through the ring beneath Poupart's ligament. The hernia descends vertically in the femoral canal to its lower end, opposite the saphenous opening. Here it turns fonrard and then upu-ard and outn-ard toward the anterior superior iliac spine, even as far as Poupart's ligament, receiving a covering from the femoral sheath and the cribriform fascia. It thus comes to lie beneath the skin and subcutaneous tissue. Various recvions have been adduced to explain the curved, course of PLATE XXXI J 1 FIG. 67. SAC OF FEMOaflL HERN I* DEEP EPiGAST. . r S E LS INTERNAL A BOOM. -TU- RING ,:.; ^' SAC OF EXT. , I NGUINAL - : = N I A GIMBEB NAT'S LIG. ABNOR. = ORIGINS OF OB- TURATOR ARTERY OBTURATOR NERVE PQUPART-S LIGAMENT EXT. ILIAC / VESSELS LIOPSOAS VAS DEFERENS VES. SEMINAL Rear view of anterior abdominal ^A^all, showing right inguinal and left femoral hernia. The obturator artery is given off by the epigastric, the dotted line on the left showing another, rarer and more important form of this variety. (Joessel.) HERNIOTOMY. 273 the hernia. (1) The canal curves slightly with the CKncavity forward. (2) The downward course is limited by the lower limit of the canal and the firmness of the lower margin of the saphenous ojxMiing which is closely united with the femoral sheath and the cribriform fascia. (o) The constant flexion of the thigh. (4) The loops formed by the vessels passing down to the saphenous opening loop uj) and jirevent the descent of a hernia, (o) The traction of the mesentery. The cour.se of a hernia should be honw in mind in (ippljinrj ta.ci.H in the reverse direction for its reduction. From the above we may summarize the coverings from without as follows: (1) skin ; (2) subcutaneous tissue ; (3) cribriform fascia ; (4) anterior wall of the femoral canal (femoral sheath) ; (-5) septum crurale ; (G) peritoneal sac. The sac of such a hernia comes to lie very close beneath the skin. One or more of Xos. 3, 4 and 5 may be broken through instead of j)ushed before the hernia so as to be wanting as a covering, and the ,torii opening of such layer or layers may be the seat of con.striction. Nos. 4 and 5 (or 3, 4, and 5) often matted together and combined to form a single covering, were called fa.scia propria by Sir A. Cooper. It is often impossible to distinguish the separate layers as they may be thinned out and adlierent to one another. In case of a hernia con- fined to the upper part of the canal, the iliac portion of the fascia lata forms a covering between the femoral sheath and the superficial fascia in the place of No. 3. A hernia confined to the canal is small, owing to the unvielding character of its fibrous walls, and is generally readily reducible as the neck is as large as the rest of the hernia. After protruding at the saphenous o))ening into the loose subcutaneous tissue of the groin a femoral hernia may attain considerable size. The contents are not ciiaracteristic ; omentum is very often present and apt to be adherent, intestine is less often present than in inguinal hernia but is more likely to be strangulated. In the latter case the .seat of the constriction is often in the neck of the sac, but more often outside of it than with the inguinal variety. It occurs at the curved margin formed by Gimbernat's ligament, etc., or, according to some, at the margin of the saphenous opening. Herniotomy. — The incision may be parallel to Poupart's ligament and over the tumor, or vertical and on its inner side. Poupart's ligament should be exposed as a landmark. In large herniie the overlying layers may be few in number or much thinned out, so the incision should be made with care. The amount of subperitoneal fat is some- times very great so as to simulate omentum MJiile the thinned fascia l)ropria may be mistaken f )r the sac. In such a case, after enlarging the ring, the real sac embedded in fat may be reduced with its con- tents and, if the constriction be in the neck of the sac, the strangula- tion would not i)e relieved. In operating I have not infrequentlv found this fat so abundant that, in a tumor of some size, it was not easy to find the small sac. We incise the constriction inwai-d, inwaril 18 274 THE ABDOMEN. and backward, or inward and forward (Cooper). The small externa] pudic vessels lie behind the hernia and therefore are not cut by the incision. In Bassini's radical operation, after removing the sac high up, the canal is closed by suturing the inner end of Poupart's ligament and the falciform edge of the fascia lata to the pectineal fascia (/. e., the pubic portion of the fascia lata). In the diagnosis between femoral and inguinal hernia, Poupart's lig- ament and the pubic spine are the two important landmarks. The neck of a femoral hernia is below the former and external to the latter ; that of an inguinal hernia has the opposite relations, though it often crosses the spine, lying in front of it. The diagnosis is easy in scrotal hernise, in thin subjects, and when the hernise are reducible so that the relations of the neck of the sac to the landmarks can be examined. It is easier in men than in women because of the greater ease of examining the inguinal canal in the former. In women, owing to its small size, the inguinal canal can only be satisfactorily examined when there is an inguinal hernia. In irreducible herniae we must depend upon the position of the hernia rela- tive to Poupart's ligament and the pubic spine, a femoral hernia being altogether below the former and external to the latter. In fat subjects we may not be able to feel Poupart's ligament even in its inner half, but the furrow of the groin nearly corresponds to it, or we may draw a line between its bony attachments, finding the pubic spine in males by invaginating the scrotum. So-called hernia adiposa is not a real hernia but, from its position and form, it may give difficulty in diagnosis here as with other forms of hernia. It is a lipjoma of the suhperitoneaJ tissue which in its growth takes the same course as a hernia. It is irreducible and tends to draw the peritoneum after it, thus forming a pouch which may be the start- ing point of a true hernia. Irregular and rare forms of femoral hernia may occur : (1) To the outer side of the artery ; (2) hourglass-shaped hernia due to the escape of a part of the hernia through a rent in one of the covering layers, generally the cribriform fascia ; (3) within the proper sheath of the vessels, etc. POSTERIOR ABDOMINAL WALL. Iliac Region. This region, the lowest part of the posterior abdominal wall, corre- sponds to the iliac fossa and is bounded below by Poupart's ligament, internally by the pelvic brim (iliopectineal line), above and externally by the iliac crest. The right and left iliac fossae are separated from each other by the pelvic cavity. It is comparatively small in children and attains its size about the time of puberty. It can be examined only through the abdominal wall which should be relaxed by flexion of the thigh. LAYERS OF THE ILIAC REGION. 276 In studying this region layer Ijy layer from before backwards, we notice : 1. Parietal Peritoneum. — This becomes continuous with that lining the antero-lateral abdominal wall along the iliac crest and Poupart's ligament, where it is loosely attached by means of the next layer so as to be easily rnl.srd up. 2. The subperitoneal tissue is here very abunfJont and loose, and contains more or kss I'at. It is continuous with the like layer in the neighboring regions of the abdominal parietes, the antero-lateral re- gion below and externally, the lumbar above and the pelvis internally (the latter including the tissue between the folds of the broad liga- ments in the female). Its loose aeas favors tlie spread of abscess. Such an abscess may ori- ginate in a viscus which occupies this region, the cfecum or appendix on the right, the sigmoid flexure on the left. The infection may reach this layer by passing along the lymphatics or the tissue lying between the layers of peritoneum which attach the viscus. On the other hand an al)scess in this tissue may perforate and discharge into one of these viscera. Again such an abscess may sink down from the lumbar region or rise up from the pelvis, as in cases of retroperitoneal pelvic abscess or pelvic cellulitis in the female. Abscess in this tissue is more common on the right side owing to the presence of the appendix. As a rule it sinks to the level of Poupart's lifjanwut and here it collects and displaces upward the peritoneum from the iliac fa.scia behind and the transversalis fascia in front and "points " above Poupart's ligament. In this position it may be opened by incising the transversalis fascia and the overlying layers without opening the peritoneum which is displaced upward. This was the course of many abscesses originating in the apendix, the so-called perityphlitic abscesses, before the adoption of the modern operation for appendicitis. Many cases of abscess resulting from pelvic cellulitis open or are opened here. Occasionally pus collecting here escapes into the upper and inner aspect of the thigh through the femoral ring or along the iliac vessels, which lie in this layer, or it may sink into the j)elvis. Structures in the Subperitoneal Layer. — The external iliac artery and vein, speniiatic or ovarian vessels, genitocrural nerves, ureter and vas deferens. External Iliac Vessels. — The course of the artery is represented by a line, curved slightly outward, from a point half an inch to the left and below the umbilicus and directed downward and outward to Poupart's ligament, a little internal to its center, or half way between the anterior superior iliac spine and the symphysis pubis. The upper tiro inches of this line would represent the common iliac artery, the lower two thirds or the part below the level of the lumbosacral junction the external iliac. The vein lies to its inner side, inclining behind it above on the right side so as to reach the outside of the right common iliac artery. 276 THE ABDOMEN. Position. — These vessels lie upon the inner border of the psoas muscle along the brira of the pelvis in the fibrocellular sheath, con- nected with the iliac fascia which separates it from the muscle. Relations. — The external iliac vessels are crossed in front hy the sigmoid flexure on the left and the end of the ileum on the right side. The ureter sometimes crosses over their upper end instead of over the bifurcation of the common iliac vessels. The spermatic vessels and the genital branch of the genitocrural nerve lie upon the lower part of the artery for a short distance, and the deep circumflex iliac vein crosses it just above its lower limit. The vas deferens in the male, and the round ligament and ovarian vessels in the female, cross it to reach the pelvis. The crural branch of the genitocrural nerve descends in front of the artery. These relations should be borne in mind in ligature of the external iliac artery. In this operation, whose principal indication is femoral aneurism, the most important relations are those of the vein, for the ligature is passed from the venous side, and the relations to the loose subperitoneal tissue, for the latter allows the exposure of the vessel by permitting the raising up of the peritoneum from the iliac fossa through an incision along the lower or outer border of the region. The incision may be made : (1) slightly above and parallel with the outer half of Poupart^s ligament ; or (2) parallel with and over the course of the artery, a little external to the course of the deep epigastric so as to avoid the latter, and commencing a little above Poupart's ligament. In (1) we incise through the external oblique aponeurosis and then, retracting upward the outer end of the free edge of the conjoined tendon at the inner angle of the wound, w'e may incise the latter along its attachment to the outer half of Poupart's ligament, to gain room. Then incising in the same line the transversalis fascia, we expose the loose subperitoneal tissue, in which the artery lies in front of the iliac fascia. In this tissue at the inner angle of the incision wc may expose the deep epigastric artery, which should be retracted upward and inward. The peritoneum is then bluntly detached from the iliac fossa, from its reflection behind Poupart's ligament upward and inward to the inner border of the psoas, which forms a convenient landmark for the artery. There is clanr/er of wounding the deep circumflex iliac vessels by incising too close to Poupart's ligament and of wounding the deep epigastric vessels by incising too far internally. Mesially the incision is not commonly carried beyond the level of the internal abdominal ring, as that is slightly internal to the middle of Poupart's ligament, but even if it should be there is half an inch between the ligament and the ring, so that the latter need not be injured unless the incision is too high. After separating the artery from the vein, through the loose tissue which forms a kind of sheath for it, the artery is tied about 1^ inches above Poupart's ligament to avoid the proximity of collateral branches and important relations. The operator should avoid including the crural THE ILIAC FASCIA. 277 branch of the genitocrural nerve hi tlie In/ature which \s pa^fut the deep epi- gastric and circumflex iliac vessels and the internal ring are in no danger. The artery may also be tied higher up and the skin incision is further from the groin in case an aneurism bulges there. At the j)re.sent day the Iniiisprritoiu'dl method is more often employed than formerly, and this allows of ligature high up or of ligature of the common iliac, if necessary. The chief objections are those common to abdominal incisions in the semilunar line (see p. 253), unless the in- termuscular method is used. The common iliac artery may be reached and tied extraperitoneal ly by an extension of the incision (1) for the external iliac upward toward the lower ribs, or upward and inward toward the umbilicus. This opera- tion is very rarely called for. I have found McBurney's suggestion, the compression of the common iliac by the finger of an assistant intro- duced through an oblique intermuscular abdominal incision, most effi- cient and useful in amputation at the hip joint. The collateral circulation after ligation of the external iliac artery is derived from the umistomosiH of the deep epigastric with the internal mammary, obturator, lumbar and lower intercostals ; of the deep cir- cumflex iliac with the iliolumbar ; of the internal circumflex with the obturator ; of the external circumflex with the gluteal ; of the external pudic with the internal pudic, and other minor anastomoses. The external iliac lymphatic nodes extend in a chain of about five along the anterior and inner aspect of the external iliac vessels. As they receive the lymphatics from the inguinal nodes and the vessels accompanying the deep epigastric and deep circumflex iliac arteries they may be enlarged from infection from these sources. We may [xd- pate them, when enlarged, through the abdomen, except in very fat sub- jects, and so determine the extent of the lymphatic infection in septic or cancerous cases. These nodes when enlarged may cause persistent cedcmd of the lower extremity by pressure on the external iliac vein. The iliac fascia covers the iliopsoas muscle and is attached to bone and fascia around the limits of this muscle, thus forming for it a single osseo-fibrous compartment. At the most dependent part the muscle and fascia pass into the thigh. The ujipcr part sheaths the ui)])er part of the psoas and is thin and adherent to it. It ends above at the diaphragm in a thickening, the ligamentum arcuatum internum, and is attached, along the outer border of the psoas, to the anterior layer of the lumbar fascia. Tiie loinr jxirf, cov- ering the iliacus and the lower part of the psoas, is thicker and separated from tiie muscle by a thin lai/cr of fatti/ connn'tivc fi.^sav which favors the formation or spread of pus. In this loose tissue lie the anterior crura! and external cutaneous nerves, and some muscular arterial 278 THE ABDOMEN. branches. The large vessels are therefore separated by the iliac fascia from the principal nerves of this region, save the genitocrnral. The lower part of the fascia is attached to the iliac crest externally and above, to the iliopectineal line internally, while inferiorly it is adherent to the outer 4 cm, of Poupart's ligament and continues under the latter into the thigh as the sheath of the muscle as far as its insertion. Internal to the muscle it passes into the thigh behind the vessels, whose sheath it helps to form, and is conti)tuous icitJi the fascia covering the pectineus, /. e., the pectineal fascia or the pubic portion of the fascia lata. Between the iliopsoas and the pectineus it sends back a fibrous 'partition to the pectineal eminence and the capside of the hip. Although in surgery we find that abscesses do not always respect fibrous fascial planes, but sometimes break through them, this is less true of those beneath the iliac fascia, especially in the case of " cold " or tubercular abscesses. Abscesses beneath the iliac fasciaare often known as "psoas abscesses'' and have a quite definite course. They sink by gravity along the course of the muscle, pass under the outer half of Poupart's ligament and point at the upper and anterior part of the thigh, external to the large vessels, where they may be safely opened. Occasionally they do not take this course, but may point elsewhere after breaking through the fascia. They may extend into the lumbar region, over the iliac crest into the gluteal region, over the pelvic brim into the pelvis, or along the inguinal canal into the scrotum and find an exit in the parts named. They may also open above instead of below the fold of the groin. In other cases I have seen a psoas abscess pass lower into the thigh, probably following branches of the anterior crural nerve where they pierce the sheath of the iliopsoas. We call these abscesses "psoas abscesses'' because most of them are due to spinal caries and make their way first into the sheath of the psoas. If the caries is in the lumbar spine direct extension into the psoas muscle readily occurs. The lumbar curve is likely to be flat- tened out in such cases. Instead of entering the ])soas sheath such abscesses may pass behind it and enter and point in the lumbar region, or they may extend between the muscular and fascial planes of the an- terior belly wall. If the caries is in the thoracic rertebra^ the pus de- scends by gravity in the posterior mediastinum along the front of the spinal column to the upper end of the psoas. This it penetrates, like a wedge, between its upper origins, /. e., from the body and the transverse process of the first lumbar vertebra, at the same time passing under the ligamentum arcuatum internum. The pus more or less entirely destroys the muscle, leaving the lumbar nerves free in a pus sac. In inflammation of the iliopsoas, or in psoas abscess before the pus is evacuated, the thif/h is kept flexed, for in this position the muscle is most relaxed, the abscess is least tense, and the lumbar nerves less compressed and irritated. This relaxation is due to the fact that flexion of the thigh is the principal action of the iliopsoas ; the outward rota- tion, sometimes associated with it, is due to other causes, for the ilio- LUMBAR REGION. 279 psoas is not an outward rotator. According to Hyrtl the iliopsoas can- not alone, or even with the poctineus, flex the thi<;h, so that in high amputation of the thigh the patient cannot flex tlie stump until the other flexors have become adherent to the scar or to the bone. Abscess similar in course to the foregoing may arise in the iliac fossa which might properly be called " iliac abscess,'' but this term is more often applied to those in the iliac subperitoneal tissue. In psoas ai)scesses the fold of the groin is partly effaced in its outer part, fluctuation may be obtained below Poupart's ligament and a full- ness is felt in the iliac fossa or, in thin patients, along the course of the psoas. From the above we see that tNso well-marked forms of abscess occur in the iliac region, (1) in the subperitoneal tissue and (2) beneath the iliac fascia, separated as to their position by the iliac fascia. The ilium, forming the iliac fossa, separates this region from the gluteal region behind, hence pus in this region sometimes gains access to the gluteal region by a perforation of the thin translucent bone. The posterior drainage of some cases of abscess in the iliac fossa, through a trephine opening in the bone, has been advised and prac- tised, according to the principle of drainage at the most dependent point, /. e., in the supine position. Tumors, especially enchondroma and osteo-euchondroma, occasionally take origin from the iliac bone or its periosteum. Fracture from direct violence may involve almost any part of the ilium, the fossa, the superior spine or the crest. The latter may be separated entire as an epiphysis previous to about the twenty-fourth year, when it joins the bone. In fractures through the fossa the fragments are usually held in position by the muscles attached on either side, which act as splints. Owing to the many muscular attachments, absolute rest is required in the treatment of fractures of the ilium. Lumbar Region. The two lumbar regions, right and left, adjoin one another in the median liiie and are bounded above by the twelfth ribs ; below by the posterior half of the iliac crests ; and laterally by the external border of the external abdominal oblique muscles. Superficial View from he/iintured by an injury which does no damage to any of the viscera. JiifhniuiKitioii of the peritoneum and its results interfere vifh its distensibility and r the intra-abdominal pressure, causes a distension of the deep alulominal veins and thereby robs the heart of its wonted supply, faintness is liable to occur, but may be prevented by the pressure of an abdominal binder. The surface (f the perito)\euiii is about e(/ual to that of the skin, hence its enormous absorbing function, taking up in one hour three to eight per 286 , THE ABDOMEN. cent, of the body weight. An equal transudation or exudation may occur from very toxic or irritant substances. Fluids may pass through the endothelial layer in many places ; solids are carried largely by leu- cocytes and are said to pass only through the intercellular spaces of the peritoneum covering the diaphragm and thence into the mediastinal lymph nodes. The presence of stomata is denied by Muscatello. There is normally a force in the peritoneal cavity which carries fluids and foreign particles toward the diaphragm, regardless of the position of the body though either retarded or favored by it. The peritoneum in a healthy state is capable of disposing of a large num- ber of bacteria, even of pyogenic varieties, without ill effects ; but if there is a lesion of the membrane, or anything to arrest the normal absorption, so that the bacteria may stagnate and multiply, peritonitis results. If, about the focus of a commencing peritonitis, the surrounding parts become glued together by a plastic exudate on the peritoneal sur- face, the peritonitis may be limited or localized, as in most cases of appendicitis. If the adhesions are imperfect, or do not develop, or the focus is more diffused, the peritonitis is progressive until it becomes general. The latter is the more acute form and in it the muscular coat of the bowel and its nerve plexuses become involved, causing intes- tinal paralysis. The result of this is constipation or complete obstruc- tion of the bowels, and the gas, formed by the decomposition of the intestinal contents, produces distension of the gut, meteorism or tym- fjanites. Hence the danger of giving opium, which increases these dangers. Ti/mpxinites raises the diaphragm so that the heart and lungs work with difficulty. In peritonitis the least pressure, even of the bed clothes, is painful, hence the patient lies with the shoulders raised and the knees drawn up, to relax the abdomen. The abdominal walls are rigid and board- like and the diaphragm is kept quiet to prevent movement of the viscera, respiration being pectoral. In colic, on the other hand, pres- sure relieves the pain and the lax abdominal walls can be freely moved over the bowels. The visceral peritoneum, besides covering the intraperitoneal vis- cera, forms folds known as the mesenteries and false ligaments to attach these viscera to the parietes. The visceral and parietal layers of the peritoneum are continuous by means of these folds, some of which deserve especial notice. The great omentum is the elongated mesentery of the stomach which is connected with its great curvature, or attached margin, and descends as an apron in front of the bowels, which it separates from the abdominal walls. In well-nourished persons it often contains consid- erable fat, which acts like a cholera band in maintaining an even tem- perature of the bowels. In the embryo the omental fold of the mesogas- triura consists of four peritoneal layers which adhere together in infancy and thereafter appear to consist of two layers containing fat and blood vessels between them. The lesser omental sac extends down between THE GREAT OMENTUM. 287 the two anterior and the two posterior omental layers before they ad- here together. The under layers as they pass uj) in front of the trans- verse colon and then back to the parietes, l)cconic adherent to the colon and to the npj)er layer of its mesocolon. The portion of omentum extending from the great curvature of the stomach to the anterior sur- face of the transverse colon, to which it is attached, forms the gastrocolic ligament or omentum. It and the transverse mesocolon prevent <»ur reaciiing the posterior surface of the stomach witiiout passing through one or the other of them. When we pull down the omentum the transverse colon and stomach are pulled down and the former may be seen through it; and when we turn up the omentum we see the trans- verse colon attached to it. Hence the omentum may be used to find both the stomach and the transverse colon. The omentum extends down a variable distance into the iliac and hypogastric regions, hence it is very apt to he found in hernkc as an epip- locele. This is said to be more common on the left side because the omentum is more developed on this side. It may be the only content of a hernia, especially in cases of femoral hernias and it is almost con- stant in umbilical herniae, except in the congenital variety (see umbil- ical hernia). The omentum generally contracts adJtesions to the sac of a hernia in which it is present, provided the hernia is not kept reduced. Such herniie thus become irreducible, and the omentum may form a kind of second sac about the gut and often grows into a large conglomerate fatty )n((ss, connected with the rest of the omentum by a narrow ped- icle passing through the neck of the sac. When the omentum in a hernia is fit to be returned to the abdomen the intestine, if present, should be reduced first. As a result of inflammation the omentum may contract adhesions to contiguous parts and so form bands beneath which, as well as beneath adhesions to a hernial sac, the bowel may be caught and strangulated. Strangulation may also occur through holes or slits in the omentum. Omental adhesions may, under certain conditions, exert such a traction upon the stomacli and colon as to produce functional disturbance. A benign cifect of omental adhesions is seen where they help to limit inflammatory or hemorrhagic extravasations, or to occlude a perfora- tion of the bowel due to disease. The omentum, or sometimes a separated piece of it {(nncntal (/raff), is occasionally similarly employed by the surgeon to fortify an intes- tinal suture, by being fastened over or around the latter. By means of adhesions with ovarian tumors the latter may be supplied with blood through the omentum, in case its blood supply is cut ofl^ by the twisting of the pedicle. From its exposed position iround.-< of the omentum are common. It may plug a small abdominal wound and prevent the escape of other parts. After laparotou)y it is well to replace the omentum over the bowels, when there is no contrainilieation, so as to obviate intestinal adhesion in the line of the cicatrix. 288 THE ABDOMEN. The small omentum, extending from the transverse fissure of the liver to the small curvature of the stomach, helps to hound the lesser peritoneal sac in front. Its rigid border extends a variable distance on to the first portion of the duodenum, where it is called the hepato-duo- denal ligament. The latter bounds the foramen of Winslow in front and contains between its two thin layers the portal vein, the hepatic artery, and the common bile-duct, the vein lying behind the other two, of Avhich the bile-duct is to the right of the artery. Its left extremity encloses the a?sophagus. The mesentery is attached to the posterior abdominal wall for about six inches. This attachment commences at a point to the left of the second lumbar vertebra, on a level with the attachment of the lower fold of the transverse mesocolon, the end of the duodenum, and the lower border of the pancreas, and extends thence obliquely downward and to the right, with a slight convexity to the left, to the right iliac fossa or to the right sacro-iliac articulation. This attachment is second- ary or acquired, its real attachment is mesial and about the origin of the superior mesenteric artery, as in mammals below man. Occasion- ally too in man we find the embryonic type of the single median mesentery for the entire bowel. At its lower end the right layer is continuous with the peritoneum covering the ascending colon, and its left layer with the mesentery of the appendix. It forms a posterior longitudinal partition in the peri- toneal cavity, and its oblique course directs hemorrhagic or other ex- travasations on the right side of the abdomen first into the right iliac fossa and on the left side into the pelvis. Hence the greater frequency of collection of blood in the right than in the left iliac fossa. Between its two layers are contained blood and chyle vessels, nerves, fat in varying quantity and lymphatic nodes, the latter especially near its attached border. In addition a band of fibrous tissue and plain muscular fibers, descending from the left cms of the diaphragm to the end of the duodenum, passes down between the layers of the mesentery and is of sufficient strength to support the weight of the intestines as well as to resist the pressure of the descent of the diaphragm. The name suspensory muscle of the duodenum and. mesentery is suggested by Lockwood for this muscle. Like the omentum the mesentery may contain tumors of various kinds. The leng'th of the mesentery, from its parietal to its intestinal attach- ment, varies in different parts. It affords great mobility to the small intestine, allowing it to be displaced by tumors, etc. Its average length is eight to nine inches, which it reaches not far below its upper end. That part which is connected Avith the intestine between points six and eleven feet below the duodeno-jejunal junction attains its gradest length, i. e., ten inches (Treves). This part of the intestine, as well as the lower ileum, is thus permitted to lie in the pelvis. According to Treves, Avhen the mesentery is normal in length, no part of the small intestine can be dragged onto the thigh through the femoral canal (artificially enlarged) or into the scrotum through the inguinal THE TRANSVERSE MESOCOLOX. 289 canal, and no coil of intestine can be drawn out of the abdomen below a horizontal plane passing through the pubic spine. But Lockwood states that it is quite common in the adult to find that the small intes- tines will pass H inches beyond the right crm-al arch, up to the left crural arch, and one inch below the pubis. Herniae in which the bowel occupies positions beyond the normal are common and require, there- fore, a /cnf/(h('iii)u/ of the mescufrrj/. Whether this is always acquired, or may sometimes be congenital, has not been definitely determined. According to Lockwood the mesentery is relatively longer in infancy, but rapidly decreases after the second year. The length of the mesen- tery is an important factor to be taken into account in the production of hernia. The position of the mesentery allows intestinal hernia more freely on the right than on the left side. The mesentery may contain sUtn, generally due to injury, or round holes of con(fenital orif/in, through which the intestine may be stran- gulated. The round holes are in an oval area of the mesentery of the lower ileum, included within an anastomotic arch betw^een the ileo-colic and the last intestinal branches of the superior mesenteric artery, which is often devoid of fat, lymph nodes and visible blood vessels, and is so atrophied that a knuckle of gut might easily be forced through it. The mesentery is an excellent r/uide to lead us to either end of the small intestine, as in searching for intestinal lesions. Holding up a loop of the intestine vertically w'e trace its mesentery back to its parietal attachment to make sure that it is not twisted. Assured that the mesentery is not twisted, we follow the intestine upward from the upper end of the loop to find the duodeno-jejunal junction, and vice versa to reach the lower end of the ileum. The transverse mesocolon is three to four inches deep and, with the transverse colon, reaches from the posterior to the anterior abdominal wall except at the sides of the abdomen. It forms an imperfect transverse septum between the lower part of the peritoneal cavity, containing the small intestine, and the upper part containing the liver, stomach, and spleen. To a certain extent and for a time it may limit a peritonitis on one side from extending to the other. This protection is also increased by the omentum which is attached to the colon above and descends over the front of the bowels. The transverse mesocolon bounds the lesser peritoneal sac below, so that in order to reach the pos- terior wall of the stomach, to expose an ulcer on this surface as well as to do a posterior gastroenterostomy, we divide the mesocolon verti- cally or parallel with its blood vessels. The lesser peritoneal sac, betw'een the stomach and small omentum in front and the pancreas, etc., behind, e.vtends on the left to the spleen and the left kidney. It opci).'< info the general peritoneal cavity by the foramen of Winslow. The latter normally admits two fingers and through it an internal hernia may pass and become strangulated (Rokitansky, Blondin). This opening may become narrowed or closed and, in the latter case, a kind of cyst may be formed, according to Malgaigne and Begin. 19 290 THE ABDOMEN. THE ABDOMINAL VISCERA. . The Stomach. (Figs. 71, 72, 74, 75.) The shape of the stomach is like that of a pear, bent near its smaller end. The oesophagus opens into it at the right side of its larger end, 80 that the latter projects, as the fundus, about three inches to the left of and one to two inches above the oesophageal orifice, while the pyloru><, or the opening into the duodenum, is at the smaller end. Therefore the length of the lower or left border is the greater, hence the name greater curvature. The lesser curvature, the upper or right border, meamres from three to five inches and is only one fourth the length of the greater curvature. The great curvature is convex until we approach the pyloric end where there is a slight indentation, between which and the pylorus there is a slight bulging, the antrum pylori (or pyloric por- tion). The lesser curvature is concave except over the antrum, where it is slightly convex. The pylorus can be seenas. a slight constricti<.in ixn(\ felt as a thicken- ing. It is the narrowest part of the alimentary canal, having a diameter of one half inch, hence many objects may be swallowed which cannot pass the pylorus and must be removed from the stomach by gastrotomy. This is especially common among lunatics, and the number and variety of articles swallowed by them is remarkable, embracing forks, spoons, nails, pebbles, buttons, coins, keys, etc. Teeth plates are not uncom- monly swallowed accidentally. It is also remarkable in some instances how large an object can be swallowed and pass the pylorus, i. e., coins, buttons, nails, door keys, metal pencil holders 4| inches long, etc. Needles swallowed find their way through the stomach and bowels and appear at various points in the body. The pylorus is liable to obstruction or stenosis from several causes. The atitrum pylori is elon- gated so that it resembles the intestine, especially in the female. The cardiac {or oesophageal) orifice is so called from its close rela- tion to the heart. The two surfaces lying between the two borders are nearly symmetrical and look ventrally and dorsally. The shape changes with age; thus some say that it is nearly cylindrical at hirth and that the fundus, although it grows rapidly in the first year, does not attain full development until late in childhood. Foetal stomachs, however, may possess a well-developed fundus. In the female the stomach is relatively narrower. No definite senile changes occur. The shape varies with the degree of distension. In full distension the fundus and vertical portion are most affected. In the empty state the surfaces are flattened and in apposition. During digestion a constric- tion occurs near the middle of the stomach, almost completely separat- ing the cardiac and pyloric halves. In some cases the fundus may appear more spindle-like and the pyloric half cylindrical, from the uniformly active contraction of the stomach wall. This is probably the normal shape of the empty stomach during life. We can attach no clinical significance to the general shape of the stomach except to PLATE XXXV FIG. 71. Outline of ihe abdominal viscera, showing iheir position with relation to one anothei-, the ribs and vertebrae. (Merkel.) THE POSITIOX OF THE STOMACH. 291 abnormalities, such as those due to diverticula, bands and scars, and hourgloHs-contraetion. The latter may be either pathological or, rarely, con^onital in origin. Diverticula are very rare. The size of" the stomach varica with the age, sex, and degree of disten- sion as well as in certain pathological conditions. The avtrafjc capacity at birth is l-g ounces; at three months, 4i ounces; at six months, 6 ounces ; at twelve months, 9 ounces ; at eighteen months, 1 2 ounces. In the adult its average capacity is five pints (2} liters), though it may hold perhaps four liters witiiout being pathologically enlarged. But according to Ewald, its normal limit of capacity is only 1,GOO to 1,700 c.c, and it cannot be distended by more than lOO c.c, in addition to this. In gastrectasis, or dilatation of the stomach, the capacity may be much increased. Dilatation of the pyloric portion is very rare. Normally when full its oh/iium treatment of peritonitis by decreasing the ])eristaltic movements of the coils against one another. Abdominal tumors cause a displacement or change of position of the intestines, which varies with the size and position of the tumor and is useful in the diagnosis of the latter. In like manner the small intestine floats on the fluid in cases of ascites so as to be mostly in front or above, according as the ]xitient is reclining or erect. The upper part of the jejunum and the lower part of the ileum are the most fixed portions, as their mesentery is shorter than elsewhere. I5ut the jejunum, two feet or less from its upper end, is freely enough movable to allow it to be drawn up without tension 302 THE ABDOMEN. over the transverse colon and fastened to the stomach in anterior gastro- enterostomy. Though the upper two fifths of the small intestine below the duo- denum is called the jejunum and the lower three fifths the ileum, there is no definite point where one may be said to end and the other to begin. It is often difficult to tell to which part a given coil belongs when it is exposed by operation or accident, especially if the size or appearance is altered by disease. But between the upper end of the jejunum and the lower end of the ileum there is considerable differ- ence. The diameter of the former is 1\ inches, of the latter \\ inches. The walls of the former are more vascular and thicker, owing largely to the valvulse conniventes which are large and numerous, while they are nearly wanting in the lower part of the jejunum and scanty in the upper part of the ileum. If the intestine is opened and presents a large number of well-developed valvulte conniventes we may infer that the opening is in the upper jejunum, and if few or no valvulse conniventes that it is in the lower ileum. If we look through the empty gut toward a light the lines of the valvulae conni- ventes can be well seen. The contents also vary in the two parts of the bowel considered, corresponding to the stage of digestion. In the persistent vomiting of intestinal obstruction or peritonitis, after the stomach is emptied the bowel contents are regurgitated by reverse peristalsis and are vomited. The character of the vomit changes from the sour stomach contents to the bitter bile-laden con- tents of the upper bowel, and finally the matter may become faecal. Faical or stercoraceous vomiting usually means vomiting of intestinal contents, though the latter do not really become faecal in odor or char- acter above the lower ileum. The Layers of the Intestinal Wall. — The peritoneal coat is so nearly complete that a wound from without or a perforation from within can scarcely occur without involving it. Between the two lay- ers of the mesentery where they pass onto the bowel, there is a strip of the latter averaging ^^^ of an inch in width uncovered by peri- toneum. This area is the usual cause of the occasional leakage after enterorrhaphy, for the essential feature of the operation is that the serous coat of both ends of the divided gut should be brought together at all points. In enterorrhaphy or in the use of the Murphy button, or other aids to intestinal anastomosis, the two layers of the mesentery, where they pass onto the bowel, should be carefully brought closely together by suture so as to complete the circle of the serous coat. Loss of substance of a limited area of the peritoneal coat may occur without serious impairment of the strength or function of the part of the bowel involved, though strong adhesions are likely to occur here. The inner or circular muscular coat is three times as thick as the outer layer of longitudinal fibers, hence a longitudinal wound gapes more than a transverse one. Owing to the greater thickness of the longitudinal fibers along the free border of the gut, transverse wounds across this part of the gut gape more than elsewhere. Wounds of the THE JXTESTIXAL WALL. 303 jejunum gape more than those of the ileum, owing to the greater mus- cular development of the former. MinnJc iroiinch of the intestine are closed by the contraction of the muscular coat so as to prevent extrava- sation. The bowels have been punctured without ill effects in many places to allow the escape of gas when excessive tympanites exists and in abdominal operations to facilitate the return of the intestine witiiin the al)domen. At present, however, fewer and larger openings are usually made and afterwards sutured. Wounds somewhat larger than punctures are plugged by the protrusion of the loose mucous mem- brane which mayor may not prevent extravasation. Treves' men- tions a stab wound with a small puncture of the ileum which remained closed by such a protrusion of mucous membrane, aided liy recent lymj)h, for four days when fatal symptoms suddenly occurred, and it was found post mortem that an intestinal worm (Ascaris lumbricoides) had escajx'd through the wound and led the way for extravasation. In larger wounds the size of the opening is much reduced bv mus- cular contraction. Thus Gross found in longitudinal wounds a reduc- tion in length of one half. The mucous membrane is also greatly everted by reason of the muscular contraction, and this is to be remem- bered in intestinal suture, for it must be inverted in order to bring the edges of the serous membrane together and thereby secure firm heal- ing of the wound, for mucous membrane does not unite with mucous membrane on its epithelial surface. In order to secure the healing of intestinal wounds the serous as well as the mucous layers are somewhat inverted 1)V Lemberf sitfiire.'<. The latter suture catches up the serous and muscular layers external to the line of the wound, so that the suture punctures do not reach the latter but leave a narrow free strip on either side of it. Thus when the sutures are tightened the strips of the peritoneal coat l)e- tween the two lines of suture punctures on each side are brought in contact, M'hile the edges are inverted and are also in contact with one another. The worm-like peristaltic movements of the intestine are the result of the consecutive contraction of successive i)ortions of the muscuhir coat. Abnormally this action may be reversed, as in intestinal ob- struction, and force the contents toward the stomach instead of toward the colon and thus produce fjecal vomiting. The caliber of the intestine varies with the contraction of its mus- cular wall. When empty the bowel becomes contracted. It may be distended by accumulated ffecal matter or by gas. In septic peritoni- tis and in some other septic conditions the muscular wall in time be- comes paralyzed by sejitie poisoning. Peristalsis therefore ceases aiul obstruction follows, while the stagnant ftecal matter develops iras which distends the bowel. From the muscularis mucosic of sheep comes the "cafr/uf" of commerce, so much used in surgery. The mucous membrane is /ooseli/ coiinecftd with the layers beneath so as to permit it to move freely over them. This allows it to become 'Surj,Mc;il A|i|iliod Anatoiuv. 304 THE ABDOMEN. everted, so as to plug a small wound, and to become prolapsed in some cases of artificial anus, thus preventing spontaneous closure, Feyei-'s patcliei^, occurring principally in the ileum and especially in its lower two thirds, are placed lengthwise of the intestine on the side opposite the mesenteric attachment, and hence are best exposed by opening the gut along the attachment of the mesentery. They are the seat of typhoid as well as tubercular ulcers, the former of which usually extends longitudinally in the axis of the patch, the latter transverselv in the direction of the encircling blood vessels. In one case of perforating typhoid ulcer, on which the writer operated, the long axis of the ulcer was transverse. The vessels of the small intestines eider or emerge from the bowel along the narrow strip, uncovered by peritoneum, at the mesenteric attachment. The arteries run transversely from either side, thus en- circling the gut. This arrangement of the arteries sometimes enables us to distinguish the intestines from other structures in case of doubt. The large anastomosing branches, which lie between the two layers of the mesentery, are liable to be injured in stab or gunshot wounds and to give rise to serious hemorrhage. The veins accompany the arteries singly, and flow through the superior mesenteric into the portal vein. Hence they are affected by portal congestion in some conditions of the liver, and septic infection may be carried by them to the latter from the intestine, sometimes producing abscess of the liver. The lymphatics form two sets as in the stomach, a deep set in the mucous membrane, and a superficial set in the muscular layer. In the mesentery they are known as chyle vessels on account of the milky fluid they contain. They enter numerous (100-200) lymph nodes between the folds of the mesentery, at and near its parietal attach- ment, which are subject to enlargement in lesions of the intestine like tuberculosis, enteric fever, dysentery, cancer, etc. In case of enlarge- ment of these nodes the lesion should be sought in the intestine. The nerves come from the cceliac and superior mesenteric plexuses of the sympathetic, with some fibers from the right pneumogastric. For the connection between the nerves of the intestine and those of the aixlomiual wall see the latter (p. 251). Meckel's diverticulum, a persistent proximal portion of the vit- elliue duct, is a blind glovefinger-like pouch having the same layers as the ileum and a lumen continuous with it. It arises from the free margin of the ileum from one to three feet from its lower end. It averages two or three inches in length but may be much larger, and ends in a free cylindrical, conical or globular extremity or in a fibrous band which may connect it, as in fatal life, with the umbilicus, or with other parts. It can cause ob.strucfioii, when its end is adherent, by forming a bridge beneath which a loop of bowel may be strangulated or by pulling on the ileum at its attachment so as to kink the latter. It occurs once in about fifty cases, has been found in external heruise and may even giv^e rise to a condition resembling appendicitis. OPERATIONS ON THE SMALL INTESTINE. 305 In operations upon the intestines, or in penetrating abdominal wounds which may involve them, it is to be remembered that they are sepa- rated in great part from the anterior abdominal wall by the great omentum. As the omentum is the only thing that intervenes between the intestines and the abdominal wall the intestinrs are much exposed to eontiiHion>i by blows, the effects of which are intensified if received una- wares, when the belly wall is relaxed, or if the body cannot Ix^nd or yield to the blow. In this way the intestine may Ije torn, severed or so bruised as to slough subsequently and thus lead to a fatal result. This possibility should be borne in mind in cases of severe abdominal contusions and the prognosis be reserved. In bullet or stab wounds, penetrating and traversing the abdomen, the intestines almost always receive multiple injuries, the number of which varies but is generally greater in those wounds whose course is transverse or oblique, because more coils of intestine are thus met with. Occasionally a bullet or knife may pass among the intestines without wounding them. Several such cases are reported where the fact has been demonstrated by operation, but it occurs in less than two or three per cent, of cases. A bullet whose course passes through near the edge of a piece of intestine makes a larger opening than one passing through the center, and the wound of entrance and exit may be continuous if they lie along the edge of the gut. Along the ileum as well as the colon diverticula may occur, nearly as large as the bowel itself. These are due to a hernial protrusion of the mucous membrane through the muscular coat. The end of the ileum may slip through the ileocsecal valve and become prolapsed into the colon, possibly even to the anus. This is one variety of intussusception and occurs mostly among children. It may sometimes be reduced by forced inflation of the bowel soon after it has happened, and before the adjacent serous surfaces have finally adhered together. Operations. — Laparotomy or cceliotomy applies simply to the pro- cedure of opening the abdominal cavity for any purpose and is referred to under the abdominal wall, p. 253. The bowel may be opened [en- terotomy) to remove an impacted foreign body, in which case it is sutured immediately; or to make an artificial anus above an obstruc- tion, after the intestine is sutured into the wound. The permanent opening of the bowel below an obstruction and its suture into the wound for the purpose of feeding the patient {enterostomy), is usually done in the upper jejunum (jejunostomy), so that the food may pass through the greatest possible length of intestine, but the operation is not very popular. In enterectomy a portion of tiie bowel is cut out or resected for gangrene, tumors, stricture, multiple injuries from bullet or stab wounds and many other causes. In a successful case of clos- ure of sixteen bullet wounds of the small intestine, reported by the writer, three or four inches of the gut were resected, as there were four holes within two inches, the closure of which would have caused a stricture or kinking of the bowel. The successful resection of two 20 306 THE ABDOMEN. meters of the intestine has been reported, and many cases where more than one meter has been resected. After resection intestinal suture is performed, preferably by the end to end suture or, if it is not possible to bring the ends together with- out tension, lateral anastomosis may be made after inverting and clos- ing the divided ends. As a palliative operation lateral anastomosis is often made between the coils above and below a lesion Avithout resection of the diseased parts. The end to end suture is preferable if feasible, for peristalsis will follow its natural course and there is little or no danger of stricture from contraction of the opening. Various mechanical aids to facilitate both forms of intestinal union and to save time have been devised, among the most perfect of which is the Murphy button. The importance of securing perfect apposition of the opposing peritoneal surfaces throughout, in intestinal wounds or oper- ations, has been referred to above. The Large Intestine. Ileocaecal Region. The caecum (Fig. 73), or blind head of the colon, is the large cul de sac of the colon that lies below the entrance of the ileum. In man and the carnivora it is rudimentary, while in the herbivora and graminiv- ora it is of great size, so that in man it has been called an anatomical protest against vegetarianism. Its uidth, three inches, is greater than its length, 2| inches, and it is relatively and absolutely larger in the adult. As to shape, four types may be distinguished. (1) The feetcd or infantile type is conical with the root of the appendix at the small end of the cone, where the longitudinal bands are about equidistant. This persists in about two per cent, of cases among adults. In type 2 the appendix still comes off from the lower end at the meeting point of the three bands, but on either side of it the csecum is expanded into two equal sacculi. It occurs in the adult in three per cent, of cases. Type 3 is the common or normal form, occurring in man in ninety per cent, of cases. In it the right sacculus and the anterior wall have out- grown the left side so that they form the lower end of the ciecum while the root of the appendix, to which converge the longitudinal bands, has been displaced upward, inward and backward, to about f of an inch below the entrance of the ileum. The longitudinal hands are thus seen to be a uniform and useful guide to the base of the appendix. The anterior band is our best guide to the root of the appendix, for it is the most accessible. Type 4, comprising four or five per cent, of cases, is an exaggeration of 3, in which the root of the appendix is dis- placed to the inferior ileocaecal angle by the atrophy of the left sacculus. The csecum is the most superficial portion of the large intestine. When full it occupies most of the iliac fossa and is in contact with the anterior abdominal wall, but when empty, as after fasting or when there is obstruction in the small intestine, it is smaller and covered by THE C^CUM. 307 coils of the small intestine. Its normal position is in the right iliac fossa, on the psoas muscle, above the outer half of Poupart's ligament, with its apex projecting over the inner edge of that muscle and lying a little to the inside of the middle of Poupart's ligament. It may sometimes lie further mesially, extending down into the pelvis or toward or even across the median line. In other cases it may lie more to the right, entirely on the iliacus muscle or with only its apex on the psoas. It is not infrequently displaced doicmrard so as to Vje found in a right inc/ninal or femoral Jiernia. Such hernite are provided with a complete peritoneal sac except in rare cases. The fcdal civcuin is situated at first within the umbilical region, thence it ascends into the left hypochondrium from which it passes across into the right hypochondrium and then descends into the right iliac fossa. An interesting and important variation in the position is that in which it remains undescended from its fretal position above and to the left of the umbilicus, the ascending and transverse colon being absent. More often it is partly descended and just below the liver or at any point between the liver and its normal position. Accordingly it may even be found in a congenital umbilical hernia. It is not un- common to find the csecum unusually high on the right side, having been arrested in its descent into the right iliac fossa. The writer has met with such cases in operating for appendicitis where the csecum was above the crest of the ileum. The importance of these irregular positions of the coecum lies in the fact that the appendix is correspond- ingly shifted. The direction of the csecum is not quite vertical but it inclines slightly inward below. If we take as its upper limit the lower edge of the ileocolic junction the cai^cum is completely covered by peritoneum. The latter, therefore, is first reflected onto the iliac fossa from the as- cending colon, so that the subperitoneal areolar tissue of the iliac fossa is never in direct contact with the posterior surface of the csecum, which is free in the peritoneal cavity. The level of this reflection of peritoneum and of the upper end of the caecum varies, but is usually about midway between the level of the anterior superior spine and of the highest point of the iliac crest. Quain, Berry and others state that in five per cent, of cases the peritoneum is reflected just below the upper end, leaving the posterior wall of that part connected with the subperitoneal areolar tissue, but they make the caecum reach a higher level, /. e., that of the ilcoca^cal valve. The mobility of the caecum de])ends largely upon the distance between its tiji ami the reflection of peritoneum posteriorly from the colon, and upon the presence of an ascending mesocolon. A mobile csecum may even find its way into a left inguinal or femoral hernia. In some caecal hernire the yicvi- toneum of the iliac fossa and its reflection onto the lower end of the colon appears to have slid down so as to form part of the posterior wall of the sac. Foreign bodies that have been swallowed and have passed the pylorus are apt to lodge in the cfecura, where they may ulcerate through the 308 THE ABDOMEN. caecal wall and cause perityphlitis. The largest accumulation of faeces in cases of /cecal impaction is often found in the csecum. Hence ster- coral ulcers, due to the pressure irritation of retained or impacted fsecal masses, are more common in the csecura than in any other part of the intestine. The caecum, according to Cobbold, is the seat of the jnn u-orm (oxyuris vermicularis), but others claim that this is lower down in the colon. Intestinal concretions are not uncommonly met with here. In cases of intestinal obstruction the condition of the caecum may assist us in diagnosis. If the obstruction be in the colon the caecum wnll be found greatly distended, while it is normal or collapsed in cases of obstruction of the small intestine. The caecum is capable of enormous distension, if gradually effected, and has been observed larger than the full stomach. Flexing the thigh upon the abdomen will empty a slightly distended caecum, if normal in position. The struc- ture of the caecum is like that of the colon, the peculiarities of which are described later. The ileocaecal or ileocolic valve guards the entrance of the ileum into the large intestine at the junction of the caecum and colon. It is normally found on the internal and posterior aspect of the large intestine, but rarely, by a rotation of the latter, the ileum may pass behind it and open on its outer side, or it may open more in front when, occa- sionally, the posterior part of the caecum is more developed than the anterior. The valve consists of tivo flaps formed by the invagination of the ileum into the colon. It is corajwsed of the mucosa, submucosa and circular fibers, while the peritoneum and longitudinal fibers pass directly over the angle between the ileum and the large intestine and form no part of the valve. Hence, if the two outer layers are divided and traction is made on the ileum, the valve is unfolded and pulled up into the ileum, which then presents a funnel-shaped opening into the large bowel. The two flaps project nearly transversely into the lumen of the large intestine and this projection is continued from either end of the slit-like opening for a short distance around the circumference of the colon as the fraena, or retinacula, of the valve, similar to a plica of the colon, so that the valve may be said to open on the summit of a plica. When the caecum and colon are distended the flaps of the valve are pressed together, preventing regurgitation into the ileum. In an ordinary high enema the valve renders impossible the passage of the fluid into the ileum, but if a high pressure is steadily continued the fluid may pass the valve, though probably not before peritoneal lacera- tions and other damage to the large intestine have occurred. Hence practically, for diagnostic and therapeutic purposes, the valve is not j^ervieable to fluids from below, and the attempt to force fluids past the ileocaecal valve from below is unsafe and unjustifiable. Some say that high enemata may pass the valve in a considerable projxjrtion of cases, but in these cases the valve is regarded as imperfect and incompetent from the first. With air or gases it is otherwise ; thus Senn has shown that hydrogen gas inflated into the colon through the rectum, under a pres- sure varying from one fourth to two pounds, may safely pass the valve, THE APPENDIX. 309 enter the small intestine and disclose a wound of the latter in case of stab or bullet wounds of the abdomen. In such cases the incompetency of the valve depends upon gradual lateral and longitudinal distension of the cfficum whicli mechanically separates the margins of the valve. The same explanation applies to those cases of intestinal obstructiendix, one npinird behind the ctecum, the other (loirmnird away from the caecum. Both of these main positions may be modified by a lateral deviation to the right or left. Thus the appendix may point upwards and to the right, and lie to the outside of the cecum and colon, or it may point upward and to the left, lying below the mesentery and the lower end of the ileum. Again when it points downward it may lie along the pelvic brim or project into the pelvis. The order of frequency is (1) retro- 312 THE ABDOMEN. caecal, (2) pelvic, (3) upward . and inward, (4) variable. The up- turned appendix is probably to be explained by adhesion of its dis- tal end in its descent from its foetal position beneath the liver, the down-turned appendix by the absence of such adhesions. It will be observed from the above that the appendix is mostly in the rigid lumbal', hypogastric or umbilical regions and more rarely in the right iliac region, though it usually lies in part or wholly in the right iliac fossa. Its curved or sjiiral course is due to its short mesentery, or in other words to its growth between points fixed at an early date. The most fixed point is where the postcsecal branch of the ileocolic artery joins it; another fixed point is where the fusion between the non-va«cnlar fold and the posterior vascular fold (mesoappendix) terminates. The relations of the appendix to the anterior abdominal wall are most important for clinical purposes. Both for diagnosis and operation McBumey's point is the one most commonly used. This is where the line between the anterior superior iliac spine and the umbilicus meets the outer border of the rectus, or 2|— 3 inches from the iliac spine. It lies in the right lumbar region and is a guide to the base of the ap- pendix. In the vast majority of cases the latter will lie somewhere beneath a. circle two inches in diameter having this point as its center. Clado locates the guiding point lower down on a line with the anterior superior iliac spine at the outer border of the rectus. The walls of the appendix present the same layers as those of the csecum and colon. We have already studied the peritoneal covering. The muscular fibers are largely replaced by fibrous tissue. The exist- ence of lonf/itudiiial muscle fibers is seen in the rapid shortening of the appendix after removal, sometimes by one third of its length. It is spread out uniformly and not arranged in bands as in the caecum and colon. The circular muscular fibers are demonstrated by the peristaltic movements of the appendix that are sometimes observed, and by their retraction so as to expose the mucosa after lengthwise incisions. This layer may form about one third of the thickness of the appendical wall. The submucosa is a thick layer of dense areolar tissue con- taining many solitary lymph follicles which are more abundant here, and in the csecum, than elsewhere in the large intestine. They are also more numerous in early life up to the twentieth or thirtieth year, after which they normally atrophy more or less. Where the lumen is obliterated the mucous glands of the mucosa are found to have disap- peared, while the other parts remain. The mucosa is also rich in lymphoid tissue. Abundance of lymphoid tissue is a marked feature of the appendix and, like that tissue elsewhere, it is prone to infiam- mation, especially so in early life when it is in greatest abundance. This corresponds with the known (jreater frequency of appendicitis in early life. The distal end of the appendix is thick and very fibrous. The pres- ence of faecal concretions in the lumen of the appendix is quite common. They may lead to inflammation and perforation of the appendix, but by no means necessarily cause appendicitis, for we often find them PLATE XXXV I FIG. 73. ILCO-COLIC A. PLICA CAECAL ' SUP. ILEO-CAEC. FOSSA. COURSE OF APPENDIC.A. BEHIND ILEUM PLIC. ILEO_ . CAEC. ANT. INF. ILEO-CAEC. / FOSSA. MESENTERI3LUM APPENDIC. A. SUOCAECAL FOSSA Caecum, appendix and end of ileum, with the blood supply and the neighboring fossae. Some- what schematic. iMerkel.) FOSS^ ABOUT THE C^CUM. 313 post mortem without sign or history of appendicitis, yet in cases of appendicitis they are present in considerably over fifty per cent, of cases. Although JorcUjn bodies may be found in the appendix they are an infrequent cause of appendicitis, as compared with other causes. The swelling of the mucosa in inflammation tends to narrow or entirely close the lumen at points already narrowed by stenoses, valves or duplicatures of mucous membrane, or by twists or angles in the appendix. As the appendix is contractile but not extensible it is thus put to great strain to expel its contents. The pressure on its wall causes venous congestion and adds to the swelling, and it is a question of overcoming the obstruction or becoming gangrenous. If a concre- tion is present as an additional obstructing or compressing agent, local gangrene is even more likely. Vessels and Nerves. — The appendix is supplied by the postcaecal branch of the ileocolic artery. The main or distal branch rearln'ii the appendix by passing along the free border of the raesoappendix, between its folds. The proximal branch passes to the root of the appendix. Exceptionally the artery passes directly to the tip of the appendix without branching and then runs back toward its base. In such a case the stasis of its blood current, from pressure, etc., before it branches within the submucosa would involve the entire appendix iu gangrene. Local blood stasis due to inflammatory pressure is the cause of local gangrene of the appendix. The lymphatics enter the mesoappendix where a lymph node is sometimes present, which may be enlarged or even broken down in appendicitis. They finally pass into those of the mesentery, though occasionally, in the female, they may empty into those of the ovary through the appendicnlo-ovarian ligament. The nerves supplying the appendix come from the superior mesen- teric plexus which also supplies the small intestine, and the large intestine as far as the splenic flexure. Hence the explanation of the pjain in appendicitis being often referred at first to some part of the intestines, or to the epigastric or umbilical regions. Pericsecal Fossae. (Fig. 73.) — There are a number of peritoneal pouches or fossae in the ileociecal region which deserve notice because into them the bowel, and especially the appendix, may be herniated. The upper, or ileocolic fossa, lies just above the ileocolic junction and is bounded on the sides by the ileum and the colon, and in front bv the fold of peritoneum formed by the passage across the ileocolic angle of a branch of the ileocolic artery. It opom downward but is too high to concern the appendix and is also less important than the following because it is smaller and less constant. The ileocaecal fossa is exposed by turning up the ciecum and draw- ing down the appendix. It is bounded on the right by the ciecum, on the left l)y the small intestine, and lies between the intermediate blood- less ileociecal fold in front and the mesoajipendix behind. It njicns outward and downward, is almost constant, and is large, admitting two fi ngers. It sometimes is very deep, extending up behind the ascend- 314 THE ABDOMEN. ing colon as far as the kidney and duodenum. It is to be remembered that the appendix is often found in this fossa which makes it of practical importance. The appendix so placed may be thought to be extra- peritoneal or even to be absent, hence we should look for this fossa and feel behind the csecum and colon when the appendix is not readily found. The subcaecal (or postcecal) fossa is too high to be of clinical im- portance in appendicitis though the appendix may sometimes be found within it, and be tliought to be absent. Its mouth separates the layers of the mesocolon at its lower end. The Colon. The large intestine (Figs. 71, 72, 75 and 77), from the tip of the caecum to the point where the mesorectum ends* opposite the third sacral vertebra, averages four feet eight inches in length in the male, and two inches less in the female. Its diameter decreases from above downwards, measuring 1| inches in the sigmoid flexure and three inches in the csecum. It varies with the fullness or emptiness of the gut, which is liable to enormous dilatation, if this is gradually produced. The small intestine may sometimes be larger than the large intestine, in obstruction of the bowel. In some cases of intestinal obstruction, situ- ated low down, the faecal accumulation may so distend the colon as to displace the heart and lungs upward and cause shortness of breath and palpitation of the heart, wliich can be relieved by the removal of the collection of faeces. Dilatation of the colon may occur among rachitic infants, temporarily ; or it may be associated with hypertrophy of the bowel wall, constipation and abdominal distension. On the other hand the colon is liable to be the seat of stricture. This tendency increases from above downward, being most common at the narrowest part, i. e., the junction of the sigmoid flexure and the rectum, and least common in the ascending colon. The Jiexures of the colon are also a favorite situa- tion for stricture. The jjereussion note of the colon is of a higher pitch than that of the stomach, owing to the difference in size and shape. The Capacity. — The colon of an infant six months old holds one pint, that of a child two years old two or three pints, and that of an adult nine pints. It is useful to remember these figures in irrigating the colon. No attempt should be made to force fluid above the large intestine. The irrigation of the colon empties the lower ileum by exciting active peristalsis. The colon is so arranged as to surround the small intestine in a circuit from right to left. The colon is characterized by (1) three longitudinal bands or taeniae separating (2) three rows of alternating sacculi (haustra) and con- strictions (plicae), (3) the appendices epiploicai. Of the three longi- tudinal bands or taeniae the one along the anterior surface is tlie longest and most prominent. As they start from the base of the appendix this anterior band is most useful in helping us to find the latter. They measure about half an inch in width and are about half as long as the actual length of the large intestine. Accord- VESSELS AND NERVES OF THE LARGE INTESTINE. 315 ingly they pucker up the intervening intestinal walls into three rows of pouches or sacouli, alternating^ with constrictions, and hence if these bands be dissected otf the gut will be made much longer and of uni- form contour. They disappear in the lower part of the sigmoid flexure. Between the three bands the longitudinal fibers are sparingly present, hence the sacculi and pliccc are made up of all layers. The anterior and inner of these bands are useful in operations in distinguishing the large from the small intestine. As these bands are conspicuous only when covered by peritoneum, the posterior band, being along the attached border, is of little use as a guide in the retroj)eritoneal lum- bar operations (lumbar colotomy, etc.). In cases of very great disten- sion the longitudinal bands, as well as the sacculi, are temporarily less noticeable or even effaced. In such a case we can recognize the large intestine by the presence of the third characteristic, the appendices epi- ploicae. These are small pouches or tassels of peritoneum containing more or less fat and attached to the peritoneal covering of the large bowel, except the lower rectum. They are seen especially along the internal band, and are most numerous in the lower part. They there- fore afford no help in seeking for the colon through the loin, along its attached or non-peritoneal area. Solitary h/mphold follicles are most numerous in the caecum and appendix and occur throughout the large intestine. Hernia-like direr- ticula, usually multiple, may occur throughout the colon and may some- times lodge faecal concretions. The large intestine is palpable throughout except at and near the flexures which are deeply placed. Hence, save at the flexures, tumors of the colon, even when of moderate size, can be well made out, the progress along the colon of an intussusception can often be carefully watched, as well as the effects of injections of fluid or gas for its reduc- tion. The outline of the colon in cases of frecal accumulation can also be distinctly defined. In di.sfcnfro».s tissue, which at the transveree fissure accompanies and loosely invests the vessels and ducts throughout the liver. This fibrous tissue, Glisson\/«';io- pexis has also been advised and performed by stitching the spleen in 332 THE ABD031E^. place and forming a new peritoneal shelf for it. Splenectomy for leukaemic enlargement has been practiced but, owing to its uniform fatality, is not now considered justifiable. In splenectomy a free incision is made along the left costal border, or sometimes in the median line or in the left semilunar line. The most important and difficult feature is the securing and ligation of the pedicle, the gastrosplenic omentum, with the very large vessels contained. If too much traction is made there is danger of tearing these vessels, especially the splenic vein. The Pancreas. The pancreas (Figs. 71, 72, 74 and 75) is a retroperitoneal organ and lies deeply in the epigastric and left hypochondriac regions, behind the stomach and lesser peritoneal sac and between the duodenum on the right and the spleen on the left. Hence it is not easily accessible for surgical or diagnostic purposes. It crosses the median line in front of the first and second lumbar vertebrae, from 2^ to 5 inches above the umbilicus. Although it has been ruptured, wounded or even herniated (in some very rare cases of diaphragmatic hernia), these conditions never affect the pancreas alone, but only in connection with similar injuries of other neighboring viscera. It may sometimes be felt on deep pressure in emaciated subjects when the stomach and colon are empty. It riiai/ be reached by raising the omentum and transverse colon, dividing the lower layer of the transverse mesocolon and elevating the upper layer, which covers the pancreas ; or by dividing the gastro- colic or gastrohepatic ligaments, and then the peritoneum at the back of the lesser peritoneal sac. Although it has relations with many most important structures, many of these relations are of no surgical interest. The lower end of the common bile-duct lies in a groove, often a canal, in the head of the pancreas. Hence carcinoma or chronic inflammatory enlargement of the head of the pancreas may so press upon the duct as to partly or completely occlude it and cause persistent jaundice. This part of the pancreas has the vena cava, vena portae, aorta, and superior mesenteric vessels, etc., behind it, so that removal of tumors here situated, unless encapsulated, is almost impracticable, although it has been done. The pancreas also lies in front of the left renal vein and the right renal vessels, and its tail is in front of the hilum and the middle or upper part of the left kidney. These relations are to be borne in mind in nephrectomy. The pylorus of the full stomach lies in front of the neck of the pan- creas. The splenic vein and artery lie in grooves, respectively behind and above its upper border. The tail of the pancreas touches the spleen at its lower end and at the dorsal and lower part of the gastric surface. In operations on the pylorus or the spleen it is important not to wound the pancreas or to include it in the ligature, for, according to Billroth, the secretion of the pancreas may perhaps interfere with the healing of the wound by dissolving the cicatrix and lead to an obstinate THE KIDNEYS. 333 fistula. Perforating ulcers of the rear wall of the stomach may result in adhesion of the latter to the pancreas or, rarely, in abscess of the pancreas. A biliary calculus lodged just beyond the ampulla of Vater, or in the papilla, obstructs the pancreatic duct, which usually joins tlie common bile-duct in tiie duodenal wall just above the ampulla. An accessory communicating duct, iJw dud of Santorini, in the head of the organ above the pancreatic duct, may open separately into the duodenum an inch or so above the papilla and afford an outlet for the pancreatic secretion in such cases. Ci/.its occasionally occur in the pancreas, the result of ol^struction of the duct or other causes. Such cysts apjiear in the epigastrium above the umbilicus, usually below the stomach, which is pushed up, and above the transverse colon. They require opening and drainage of the fluid, which may be under great pressure. Acute inflammation of tlie pancreas (pancreatitis) may involve hemorrhage, necrosis or abscess of the pancreas, fat necrosis or general peritonitis, and demands opera- tion. Chronic pancreatitis may obstruct the common bile-duct by pressure and also calls for operative treatment. The Kidneys. Position. (Figs. 71, 77 and 78.; — The kidneys lie retroperitoncally and are deeply placed, one on either side of the spine, so that they cannot be palpated when normal in size and position, except the lower end of the right kidney in some cases. They approach the surface most nearly below the twelfth rib and to the outer side of the erector spinas muscle. When palpable they may be best felt from in front just below the costal margin and external to the rectus muscle, while the other hand presses forward from behind below the last rib. The vertical line perpendicular to the middle of Poupart's ligament, which marks off the regions of the abdomen, cuts the kidney longi- tudinally so that one third of it lies to tlie outer side and two thirds to the inner side. The infracostal plane, connecting the lowest points of the tenth costal cartilages, cuts the lower ends of tiie kid- neys, though it is not infrequently above the lower end of the left kidney. Hence the kidneys are found in the following regions, epigas- tric, hypochondriac, umbilical, and lumbar, but mainly in the two former and little or none in the lumbar region, wiiere tiiey are often incorrectly thought of as being. In the female and the child they are, as a rule, slightly loioer, often reaching the level of the iliac crest. In the male also they are not infrequently lower than normal. lu most cases the rigid hidney is about half an inch loirn- than the left, espe- cially at the upper end, but excej)tions are common. With these modifications in mind we may say that the kidneys corre-^poud to the last thoracic and the first two or three lumbar vertebne. The left kidney extends from the level of the lower end of the eleventh thoracic spine to a little below the second lumbar s]>ine. The position of the kidney may be indicated posteriorly by a paral- lelogram whose upper and lower ends are drawn horizontally outwards 334 THE ABDOMEN. from the two latter points, about 4 or 4| iuches apart, while the sides are drawn vertically 1 inch and 3| inches from the spine (Morris). The outer border therefore reaches a point 3| to 4 inches from the lumbar spines. The twelfth rib crosses the position of the kidney in such a way that one third or more of the organ is above it, under cover of the thoracic wall. This rib is sometimes resected in operations upon the kidneys in order to gain more room, and Avith care it may be done without risk to the pleura. But in one case, with rudimentary twelfth rib, the eleventh rib was removed for the twelfth, the pleura opened and death resulted. The eleventh rib overlaps the upper pole of the left kidney and the tips of the transverse processes of the first and second lumbar vertebrae overlap the mesial border of both kidneys. The lotrer end of the right kidney is, on the average, 1-1 1 inches above the iliac crest behind and the level of the umbilicus in front, hence the kidneys lie higher than often supposed. 1)1 front the upper ends of the kidneys about correspond to the inter- chondral articulation of the sixth and seventh costal cartilages, and they extend downward from here 4 or 4| inches, i. e., to an inch or so above the umbilicus. The shortest distance between the two kidneys above is about 2| inches. The hilum is about two inches from the median line and opposite the first lumbar spine. Owing to the oblique position of the kidneys, the axis sloping downwards and outwards, the loioer pole of the organ, or the center of the lower end, is one half or one inch further from the median line than the upper pole, which is two inches from it. The inner border of the right kidney lies very close to the vena cava, that of the left kidney an inch or more from the aorta. The slight downward movement (one half inch, Holden) of the kid- neys in inspiration or their lower position in accumulations in the pleura are accounted for by the relation of the kidneys to the dia- phragm and to the organs like the spleen and liver, which move with it. The kidneys also lie slightly lower (about one half inch) in the standing than in the reclining position. Posterior Relations. (Fig. 78.) — The kidneys lie upon the dia- phragm above and the quadratus lumborum, transversalis and outer border of the psoas below, the muscles being covered by their respec- tive fasciae. Intervening between the quadratus muscle and the kidney are the last thoracic, iliohypogastric and ilioinguinal nerves and the first lumbar vessels, all of which pass obliquely outward and downward and may be met with in exposing the kidneys from behind. The last thoracic nerve indicates the lower end of the diaphragm, above which it is not safe to incise. The area of contact with the diaphragm is larger on the left than on the right side, owing to the higher position of the left kidney. But on both sides it is of great importance, as the kidney is here in close relation to the pleura, whose lower limit extends nearly horizontally from the lower border of the twelfth thoracic vertebra, meeting the twelfth rib about 3| inches from the median line and the eleventh rib about 2 inches further laterally. If a marked hiatus diaphragmaticus exists above the lig. arcuatum ext. PLATE XXX IX FIG. 78. OESOPHAGUS INT. ARCUATE LIGAMENT ^\. ELEVENTH V-v ^\\* RIB / \ / \ * ^ HIATUS, DIAPHRA ' , * MATICUS, SHOV ING PLEURA EXTERNAL ARCU- ATE LIGAMENT TWELFTH THORA- CIC NERVE Vi^ I LIO-HYPOGAS- TRIC NCRVe I LIO-INGUINAL NERVE Position of ihe kidney witin reference to tiie posterior' abdonninai wall. The dotted i-ed line r-epresents the position of the lelt kidney. (Testut.) RELATIONS OF THE KIDNEYS. 335 between the vertebral and costal portions of the diaphragm, the kid- ney may come in coiddd irith the s-iihjjleunil tissue. The re/fifion.shij/ of the kidneij and pleard explains (1) the frequency of perforation of perinephritic abscesses into the pleura, especially on the left side, a serious complication, and (2) the danger of opening the pleura in operating upon the kidney, especially if the last rib should be rudi- mentary and the eleventh rib be mistaken for it, from failure tf» ef)unt the ribs. As a rule the incmon may be safely carried just i)elo\v the lower border of the twelfth rib, but it must be remembered that some- times that part of the pleura which extends below the twelfth rib reaches beyond the lateral margin of the quadratus lumborum, under otherwise normal conditions. A thirteenth rib would contract the space available for the lumbar approach to the kidneys. The anterior relations (Figs. 72, 74 and 75) of the two kidneys are diHercnt. In front of the right kidney is the liver (renal impres- sion) in the upper half, the asceneen used thcrajKnitically in Addison's disease, etc. 342 THE ABDOMEN. Blood Vessels of the Abdomen. The following is in addition to the mention made under the several organs and the parietes. The abdominal aorta varies in its distance from the ventral surface in different individuals, but in general it approaches nearer tJte surface as it nears its bifurcation. Hence the most favorable point for compres- sion of the aorta is just above the umbilicusj for it bifurcates just below and to the left of this point. But even here it cannot be readily felt or satisfactorily compressed unless the bowels are quite empty. Aneurism is most likely to occur at or near the coeliac axis which is a weak spot, often giving way in injections of the cadaver, for here several large branches are given off and cause a sudden deviation in the course of the circulation. Such an aneurism gives rise to a pulsat- ing tumor in the epigastric or umbilical region, but a tumor of the organs in front of the aorta (pylorus, pancreas, colon) may also receive a pulsation (not expansile) from the aorta. Pressure of the aneurism on the diaphragm, oesophagus, and stomach may cause dyspnoea, dys- phagia and vomiting ; on the vena cava oedema of the legs ; on the renal veins, albuminuria ; on the lumbar nerves, pain in the back, but- tocks, or thigh ; on the sympathetic plexuses, indigestion, visceral pains, reflex pains in the lumbar nerves, etc., etc. INIany of the branches of the abdominal aorta are of large size, the coeliac axis and superior mesenteric are of the size of the common caro- tid ; the hepatic, splenic, and renals equal the brachial in size. The number of minute extraperitoneal anastomoses between the branches of the parietal vessels (lower intercostal, phrenic, lumbar, iliolumbar, epigastric, and circumflex iliac) and branches of vessels which supply viscera not entirely covered by peritoneum (liver, kidney, adrenals, duodenum, pancreas, ascending and descending colon) are of great importance in case of obstruction to the arterial supply of the vis- cera. The corresponding venous anastomoses are of equal or greater importance in case of obstruction of either the vena cava or the portal vein. A parumbilical vein may also directly connect the portal vein with the epigastric, and thus with the external iliac veins, and be of much service in relieving obstruction of the portal circulation, as in cirrhosis. The above anastomoses explain the efiect of surface blood- letting and counter-irritation in inflammation or congestion of the partly extraperitoneal viscera. The co?Iiac axis, with a semilunar ganglion on either side, arises opposite the top of the first lumbar vertebra, about four inches above the umbilicus. The renal artery arises opposite the lower end of the same vertebra (that of the right side somewhat lower), the inferior mesenteric about two inches above the aortic bifurcation, or H inches above the umbilicus. The left renal vein, crossing in front of the aorta, to reach the vena cav^a, is an exception to the rule that below the diaphragm the large veins pass behind the large arteries, while above the diaphragm they pass in front. NERVE SUPPLY OF THE ABDOMINAL VISCERA. 343 Lymph Nodes of the Abdomen. Besides the lymphatic nodes already noticed, in connection with the organs, there is a central series of retroperitoneal li/mph nodes arranged in tiro fjroiips. (1) The lumbar nodes, twenty to thirty in number, lie on the sides and in front of, or even between, the aorta and vena cava. Great enldrgeiaent of these nodes may cause (edema from pressure on the vena cava. Tiiey receive the lymphatics from the external iliac nodes, the pelvis, kidneys, adrenals and the sigmoid flexure. (2) The coeliac nodes, sixteen to twenty in number, lie above the pancreas, near the celiac axis, and receive lymphatics from the stomach, spleen, pancreas, part of tlie liver and the mesenteric nodes. Nerve Supply of the Abdominal Viscera. This is derived from a series of plcciDi&i formed by tlie Hyrnpatlietic .si/stem with some branches from the vagus and phrenic nerves. Tiie two f/reat splanchnic nerves, descending from the thorax, end in the two large semilunar ganglia, one on either side of the cceliac axis. These are united together, aud with many small surrounding ganglia, by a network of fibrils to form the solar or coeliac plexus, which also re- ceives twigs from the vagus and phrenic nerves. From this central plexus branch plexuses are derived which accompany the visceral branches of the aorta, except the inferior mesenteric, to the organs which they supply. The renal plexus also receives the lower splanch- nic nerves. Mesial branches of the lateral sympathetic cords form the aortic plexus in front of the aorta below the inferior mesenteric artery, along which a branch, the inferior mesenteric pleonts, passes to the viscera supplied by the artery. These plexuses, and the nerves which go to form them, communi- cate with the thoracic and lumbar spinal nerves and thus account for many reilexes, i. e., the reflex pains and muscular contractions in the course of the spinal nerves in case of peritonitis, etc. (see p. 251). The "sympathetic" or reflex pain between the shoulders, or about the angles of the scapulae, in some diseases of the stomach and liver, are probably due to a reflex in the fourth, fifth and sixth thoracic nerves, which supply these parts and communicate with the great splanchnic nerves which, through the solar plexus, go to supply the liver and stomach. Reflex pain in the tip of the shoulder has already been referred to (see liver, p. 325). From the extent of these abdominal nerve centers, especially the solar plexus, we can understand what profound ejf'ects, collapse, vomit- ing and even death may attend an injxi'i/ to them, or tiie viscera most closely associated with them. Hence the danger of a blow over the pit of the stomach, /. c, over the solar plexus, which may even cause death without marks of external injury, and always causes shock out of all proportion to the extent of the injury. Hence also an injury to those viscera which are more remotely eoinieeted with the nerve centers, such as the descending colon which is supplied by the 344 THE ABDOMEN. inferior mesenteric plexus, only indirectly connected with the solar plexus, or even the ascending colon supplied by a part of the superior mesenteric plexus most remote from the centers, is accompanied by less serious symptoms. It is noteworthy that the nearer the lesion is to the stomach, other things being equal, the more profound are the nervous phenomena produced. Distant pain in disease of the ab- dominal viscera is not necessarily reflex but may be due to pressure. Thus pain in the knee may be due to the pressure of the sigmoid flexure, distended with faeces or affected with cancer, upon the obtu- rator nerve. CHAPTER y. PELVIS AND PERINEUM. THE PELVIS. We have already studied, in a preceding section, the upper part or false pelvis which supports some organs and attaches many muscles of the al)d()men. It remains to study the true pelvis and its viscera. The external or superficial boundaries of this region are not well marked, for it is covered by the parts of other regions, i. e., the buttocks be- hind, tiio hips at the side and the perineum below. Hence there are but few bony or other landmarks. Some of these we have considered under the landmarks of the abdomen (see pp. 237-8). From the pubic spine, mesially, to the symphysis we can make out the front of the pelvic brim, formed by the pubic crests, and below this the bodies of the two pubic bones, separated by the symphysis pubis. This part is covered in the female by a thick pad of subcutaneous fat, the mons veneris, which somewhat obscures the bony outlines. The mons veneris is separated from the abdomen above by a transverse furrow which meets the inguinal furrows about their center. Still further down in the median line we can feel the subpubic angle on deep pressure behind the scrotum in the male, in the vestibule in the female. Leading from this angle to the ischial tuberosities we can trace the combined rami of the pubis and ischium on each side, which bound the perineum laterally and lie nearly in the genito-cmral furrows. The latter are the furrows between the inner aspect of the thighs and the perineum and are continuous behind with the (/lufni/ /oW.s. It is near the inner end of the latter that the ischial tuberosities can be readily felt. In the sitting posture these tul)er()sities are only sepa- rated from the skin by the subcutaneous fat and a bursa. This bursa is liable to ivJJammaiion in those who sit a great deal, like coachmen, weavers, etc. Hence the construction of many so-called anatomical bicycle-saddles, for it is on the tuberosities that we rest in sitting. In the standing posture the tui)erosities are overlaj)|ied by the lower borders of the gluteus maximus muscles. The ischial tuberosities form one end of Nelaion's line (see p. 427), and the line connecting them divides the perineum proper in fn>nt from the ischiorectal fossa i)ehind. In the iiu'didii line heliind we can feel the sjtinons jtrorrxs of the fifth lumbar vertebra, often indicated by a little furrow, and below this those of the sacral vertebne, of which the thiiti is the most prominent. 345 346 PELVIS AND PERINEUM. Following down in the median line, in the deep fold between the but- tocks, we can feel the tip of the coccyx, behind which (especially in women) there is often a more or less marked dimple or depression of the skin {Joveola). Through the vagina or rectum can he felt posteriorly the front of the coccyx and sacrum, laterally the spines, the inner aspect of the tuberosities and the bodies of the ischia and the great sacrosciatic foramina, and anteriorly the back of the pubic bones and symphysis and the obturator foramina. With a long finger or half hand, when the patient is anaesthetized, the sacral promontory can be felt above and behind, but if this can be felt in an ordinary examina- tion by a finger of ordinary length the pelvis is considered abnormal. The promontory can also be felt on deep pressure through a thin lax abdomen, about on a level with the anterior superior iliac spines. The Bony Pelvis. — Although in the bony state the outlet or brim of the pelvis is heart-shaped with the base behind, in the natural state the psoas and other muscles make it triangular with the base in front. The outlet of the pelvis is composed of three bony points separated by three notches. The two symmetrically placed posterior notches (sacro- sciatic) are bridged across by the strong sacrosciatic ligaments which thus bound the pelvic outlet and make it lozenge-shaped. The tuber- osities of the ischium may be quite close together in the male. I have seen this condition so marked as to embarrass one in lateral lith- otomy. In the natural position of the pelvis the tuberosity lies behind and below the acetabulum, and only a trifle further behind it than the anterior superior iliac spine is in front of it. Also the ischial suine lies I of an inch above the upper border of the symphysis. The coccyx may be fractured or dislocated as a result of falls or blows or during parturition, especially in those women in whom the coccyx is much incurved as the result of sedentary habits or horseback riding. The displacement of the fracture or dislocation may be readily made out by rectal examination, or by a finger in the rectum and the thumb on the surface. The joint between the coccyx and the sacrum may also be diseased. All these conditions are very painful, owing to the frequent movement at the seat of injury, due to the muscles attached to the coccyx (gluteus maximus, coccygeus, levator and sphincter ani). The injured bone may project into the rectum and be moved in de- fecation mechanically as well as by the sphincter and levator ani muscles. The sacro-coccygeal joint and the parts about the bone are supplied by the posterior divisions of the coccygeal and the second to the fifth sacral nerves and the anterior divisions of the fifth sacral and the coccygeal nerves, which may be the seat of a painful neuralgia (coc- cydijnia). Removal of the coccyx may be called for on account of injury, joint disease or neuralgia. Sacro-coccygeal Tumors. — These are usually congenital, and I have seen them attain such a size that the possessor, a man, wore skirts to conceal the enormous mass. Some, springing from between the coccyx and the rectum, contain epithelial cysts and even fragments of tissue, i. e., cartilages, bone, muscle, nerve, skin, raucous membrane. They SA CR 0-ILIA C JOINT. 34 7 are supposed to arise from the embryonic neurenieric passage, or post- anal gut, though they were formerly thought to originate from Luschka's gland. These tumors are t/ti/roid-derinoid.i. DennouU also occur over the back of the sacrum and coccyx, where they may be confounded with si)ina bifida. Some take such a shape as to form " human tails." Aftdc/ial hniiian fretuses are often joined together at this j)art of the column, and here too third limbs (tripodesia) and parasitic foetuses are found attached. Sacro-iliac Joint. — Normally there is no movement in this joint except, as Farabeuf has shown, a s/if/Jif rotation on a transverse axis. Thus when the thighs are flexed onto the abdomen the conjugate diameter is shortened by the rotation upward of the innominate bones, the symphysis approaching the ])romontory. The reverse occurs on hyperextension of the thighs, which may therefore be made use of in obstetrics to slightly increase the conjugate diameter of the brim. In general the joint screes merely to break sJiochs, but some movement is said to occur when the ligaments are softened by disease. The joint may become diseased as the result of injury, by an exten- sion from spinal caries, etc., or spontaneously. In the two latter instances it is usually tubercular. In disease of this joint much pnin is felt in standing or sitting, as in these positions the weight of the body is transmitted through it. This pain, besides being local, may also be of a peripheral reflex character over the sacral region (upper sacral nerves), in the buttocks (gluteal nerve), or even at times in the thigh and calf (lumbosacral cord). The above-named nerves supply the joint, which sometimes gets a small twig from the obturator nerve which, with the lumbosacral cord, passes over the front of the joint. The obturator nerve accounts for referred pain in the knee or hip joints. If abscess forms it usually comes foricard into the pelvis, as the anterior ligaments are much the thinner and weaker. Such an abscess may enter the iliopsoas sheath, perforate the rectum, or follow the lumbosacral cord and sciatic nerve to the back of the thigh, or the obturator nerve to the inner aspect of the thigh. More rarely the abscess may pa.ss backward and point behind the joint. In examin- ing the joint from behind, it is useful to know that the po.sterior superior iliac spine corresjxinds to its center. In spite of the comparative weakness of the anterior sacro-iliac liga- ments, above mentioned, dislocation never occurs except in fracture of the pelvis, or the rare luxation of the sacrum anteriorly. This fact is due to the very strong po.sterior sacro-iliac ligaments, which sling the sacrum from the ilium, and not to the wedge shape of the sacrum for. in the natural position of the pelvis, the base of the wedge looks down- ward and forward, /. r., in th(> direction in which the weight of the bodv would naturally tend to disj)lace it. The wedge shape would prevent its l)eing dislocated l)ack\\ard, l)ut there is no tendency to this displacement. At the .sime time, owing to the irregularities of the bony surfaces and the slight projecting lips of the ilia in front and below, the sacrum is more or le.ss wedged in between the ilia like the 348 PELVIS AND PERINEUM. keystone of an arch, to the pillars of which, the ilia, it transmits the weight. The innominate bones can be separated at the symphysis, in sym- physiotomy, but a very little distance without first straining the front of the sacro-iliac joint, then tearing the anterior ligaments and the carti- lages connecting the bony surfaces. In addition to the tearing of the anterior ligaments the periosteum is usually strij)ped up for some dis- tance on the ilium in front of the joint. As the axis of this separation or opening of the joint is at the back of the joint and passes obliquely downward and inward, the strong posterior sacro-iliac ligaments avoid injury and the pubic bones on being separated pass downward as well as outward. The symphysis pubis is nearly 2 inches in height, and its thickness may reach nearly 1 inch. In symphysiotomy, proposed by Sigault in 1708 as a substitute for Csesarean section to enlarge the pelvic di- mensions in labor in cases of contracted pelvis, a separation at the symphysis of 2J inches increases the conjugate diameter by only half an inch. But, as the convexity of the child's head may project into the interval between the separated pubic bones, another half inch or so may be gained for the passage of the head. In addition to the laceration of the sacro-iliac joints resulting from the separation at the symphysis, to which we have just referred, the attachments of the pelvic viscera may be damaged. A slight separation of the pubic bones due to swell- ing of the fibrocartilage has been shown to occur toward the end of gestation, but during parturition the decussating tendinous fibers of the abdominal muscles, which cross in front of the joint, would tend to brace the bones more tightly together. Separation at the si/mphi/sis without fracture of the bones has occurred from severe external violence, and Malgaigne has reported three cases where the violence was muscular merely, due to excessive action of the adductors of both sides. The Mechanism of the Pelvis. — The weight of the body is trans- mitted from the sacrum through the pelvis along tiro arches, one for the standing, the other for the sitting posture. The arch for tJie standing posture consists of the sacrum, the sacro-iliac joints, the acetabula, and the thick ridges of bone along the ilio-pectineal line between the two latter points. For the sitting posture fJie arch is much the same, ex- cept that the ischial tuberosities are substituted for the acetabula. These tino arches have been called the femorosacral and the ischiosucral respectively. The bone in the line of these two arches is much thicker than elsewhere in the pelvis. The sacrum occupies the position of the kf^ystone for both arches (see above, p. 347). To strengthen each arch its ends are joined by a counter arch, which completes a ring and serves as a tie to keep the sides of the arch from separating or colla|)sing. The counter arch or tie of the femorosacral arch is formed by the bodies and horizontal rami of the pubcs, that of the ischiofemoral arch by the combined rami of the pubes and ischia. Thus the ties of both arches meet at the symphysis, to which is conveyed FRACTURES OF THE PELVIS. 349 a portion of the weight or strain. Hence the strain felt at the sym- physis when increased weight is to be home, as in pregnancv, abdomi- nal tumors, etc., and hence the inability to stand or sit when tlie symphysis is diseased or weakened by injury or an unhealed sym- physiotomy. Pelvic deformities are also explained, according to the mechanism of the pelvis, by the weight acting on bones that have not become properly ossitied in parts, owing to rickets, or on bones uniformly softened by the much rarer condition, osteomalacia. When the rickety child walks but little and sits most of the time, as thev fre- quently do, the weight of the body thrusts the sacral promontory for- ward and downward, thus diminishing the conjugate diameter of the brim. The counter pressure comes from the ischial tuberosities and is most felt in the counter arch, which is narrowed and pushed forward at the symphysis, while the tuberosities may approach one another and narrow the transverse diameter of the outlet. If the rickety child is more on its feet, lateral counter pressure is exercised at the acetabula, and is felt mostly at the weakest part of the pelvis, /. e., the counter arch. Thus while the acetabula approach one another more or less, the most marked change is a Ijeak-like projection of the symphvsis, the pubic rami sometimes running parallel with one another and close together, showing a collapse of the counter arch. In the softer condition due to oMeonuilacia, which occurs only in adult life, these changes due to lateral pressure are most marked. Fractures of the Pelvis. — Though the sacro-iliac joints and the sympliysis might be thought to be weak points of the pelvis, their connecting ligaments are so strong that they rarely give way pri- marily; the bones yield first. As has been just said the counter arch is the ivea/ceM point, and it is here that fracture commoufi/ occurs from the most varied forms of violence. Fractures of the pelvic arch usually occur as the result of violent pressure on the surface or of falls from a height. Thus, if the force be applied in the antero-posterior direction, the weak counter arch yields to direct or indirect violence on one or, possibly, both sides of the symphysis through the pubes or the rami. The force continuing tends to sepa- rate the two hip bones and to cause a diastasis and finally a dislo- cation of the sacro-iliac joints, as in symphysiotomy. Again, if the force be applied transversely, the pelvis tends to become flattened lat- erally, but the weaker counter arch is more bent and eventually gives way and is fractured by indirect violence. Should the force continue, the two hip bones are pressed toward one another and the strain on the sacro-iliac joint falls upon its posterior part. Here the ligaments are so strong that, instead of their rupture, portions of bone to which they are attached, especially the sacrum, are usually torn away. In falls on the feet or ischial tuberosities, it is again the weaker or counter arch which is usually fractured. In falls from a height or other severe injuries, the head of the femur may be driven through the aeetai)ulum, but this is rare. 350 PELVIS AND PERINEUM. A separation of the hip bone into its three constitutent parts cannot occur after about the eighteenth year, at which time the three parts are firmly united by the ossification of the Y-shaped cartilage. Before this occurs abscess within the capsule of the hip joint may make its way into the pelvis through the cartilage, but this is not as common an occurrence as one would expect. Localized direct violence of suffi- cient force may fracture any part of the pelvis. Apart from the fact that the violence producing fractures of the pel- vis is usually severe and entails shock and often other remote injuries, such fractures are serious on account of and in proportion to the injury to the pelvic viscera from sharp fragments or loose pieces of bone, or from crushing or tearing. Thus the bladder and urethra, and in the female the vagina, are especially liable to be torn by sharp fragments, and the urethra may be ruptured or compressed, owing to its close relation to the subpubic arch. A vesical calculus has been reported having for its nucleus a piece of bone driven into the bladder in a fracture of the pelvis. It is in the double fractures of the pelvic arch that the viscera are most often wounded. In these double fractures the two lines of fracture are most often on one side of the symphysis, rarely on both ; or in place of the second fracture we may have a diastasis of the symphysis, which usually occurs, if at all, in connection with fractures of the pelvic arch. The rectum too has been torn or compressed in fractures of the sacrum or coccyx. Information may often be gained for the diagnosis of fracture of the pelvis by rectal or vaginal examination, and blood in the urine in such cases indicates an injury to the bladder or urethra. The capsule of the hip joint is almost always external to the line of fracture of the pelvic arch and thus escapes injury. Fig. 80. FIFTH LUMBAR VERTEBRA ANTERIOR SUPERIOR ILIAC SPINE ANTERIOR INFERIOR ILIAC SPI NE POUPART'S. LIGAMENT PUBIC SPINE OBTURATOR MEMBRAN Z POST. -SUP. ILIAC SPINE POST. -INF. ILIAC SPINE GREAT SACRO- SCIATIC FORAMEN GREAT SACRO-SCIATIC LIGAMENT SMALL SACRO-SCIATIC LIGAMENT ^SMALL SACRO-SCIATIC FORAMEN ISCH TUBEROSITY Female pelvis viewed from the left side, showing the position of its parts in the erect posture. (JOES.SEL. ) AXES AND DIAMETERS OF THE PELVIS. 351 In the erect position the phine of the hrim or outlet of a normal pelvis makes an angle of 50° to 00° with the horizon, which is due to the sacrovertebral angle and the obliquity of the articulation of the hip bones with the sacrum. This antero-posterior tilting, which we call the obliquity of tlic jjc/cis, varies in different cases and averages greater in the female than in the male. In hip disease, with anchylosis of the hip joint in the flexed position, the pelvis as a whole moves about the transverse axis passing through the acetabula and its obliquity is increased on standing, in order to bring the anchylosed limb into a vertical position. To allow of this increased obliquitv of the pelvis the forward convexity of the lumbar vertebrte is increased (lordosis) by their extension. Increased obliquity causes a protrusion of the belly, a flattening of the adductor region, from lengthening of its muscles, and a backward position of the external genitals. The normal obliquity of the pelvis may be shown by placing tiie anterior superior iliac spines and the pubic spines in the same vertical plane, as against the wall (H. v. Meyer). The inclination of the pelvic outlet, or the angle between the horizon and the line connecting the tip of the coccyx w'ith the lower border of the symphysis, averages 12° to 15°. The axis of the inlet, or the line at right angles to the center of its plane, passes obliquely forward and upward, so that if prolonged it would meet the umbilicus above and the middle of the coccyx below. The axis of tJie outlet prolonged upward touches the base of the sacrum, and prolonged downward is directed slightly backward, whereas the curved line representing the axis of the entire pelvis, if prolonged downward, would curve forward. This distinction is not always understood. The axis of the caviti/, nearly straight above, more curved below, is parallel to the curve of the sacrum and equidistant from all sides of the pelvis. The descent of the foetal head follows this curved line, turning as it were around the symphysis as an axis. As this curved axis, continued downward, passes near the center of the vulva, those cases where the vulva is un- usually far forward are more exposed to rupture of the perineum in delivery. It is also in this curved direction that instruments (sounds, etc.) are passed to the pelvic viscera. With a normal inclination of the pelvis, the sacral i)romontory lies 3| inches (9.5 cm.) above the upper border of the symphysis and the tip of the coccyx one half to one inch above its lower border. The long axis of the symphysis forms an angle of 100° with the conjugate diameter of the brim, /. e., the line between the promontory or sacro- vertebral angle and the upper end of the symphysis. This fact is of importance in obstetrics, as the fetal head makes one of its principal turns around the symphysis. Obstetricians consider three diameters, ventro-dorsal or conjugate, transverse and oblique, in three planes of the pelvis, that of the brim, the center or largest part of the cavity, and the outh't. The oblitpic diameter at tiie brim is between the sacro-iliac joint and the ilio-pubie eminence, in the cavity from thr middle of the sacro-sciatic notch to 352 PELVIS AND PERINEUM. the obturator foramen, and at the outlet from the sacro-sciatic ligament to the ischial ramus. The transverse diameter at the outlet is the dis- tance between the ischial tuberosities. The measurements of the diam- eters vary according to age, sex and individuality, and especially in the presence of pelvic deformities. In the female the conjugate, transverse and oblique diameters measure in inches as follows : at the brim 4|, 5|, 5 + ; in the cavity, 5 +, 5, 5^; at the outlet, 4|,^ 4|, 4^. If the measurements are materially diminished symmetrically, as in a case of "equally contracted pelvis," in women apparently well formed, or unsymmetrically in rachitic pelvic deformities, normal labor may be rendered difficult or impossible. The apparently greater width of the female pelvis, as shown by the hips, is due to the greater amount of subcutaneous fat and the com- parison with the narrower waist. The distance between the anterior superior spines and the iliac crests of the two sides measures about the same in the two sexes, though many authorities give the latter meas- urement greater in the female, while Quain gives both greater in the male. The true pelvis is shallower, broader and more capacious in the female ; the false pelvis is relatively narrower and less deep in the female (Quain). In the female, too, the symphysis is less deep and both the subpubic arch and the distance between the ischial tuberosities is much wider, all of which are of importance in the mechanism of labor. The pelvis as a whole may move on three axes, a transv-erse (flexion and extension), an antero-posterior (tilting), or a vertical (rotation). These movements take place in the lumbar spine. Flexion and extension are the most important and the most extensive, and decrease or increase the obliquity of the pelvis, respectively. When the hip joint is fixed or anchylosed it is the pelvis that is flexed or extended on the trans- verse axis passing through the acetabula. It is enabled to do this by movements of the lumbar spine in the same direction (see above, p. 351). Normally the pelvis is on the same level on the two sides so that the line joining the two anterior superior iliac spines is horizontal in the erect position. Pathologically this line may be oblique so that there is a lateral obliquity or tilting of the pelvis on an antero-posterior axis. In such a case one side of the pelvis is raised while there is a lateral curve of the lumbar vertebrae toward the opposite side to enable the trunk to be held erect. This is often the result of hip disease, where the thigh on the affected side may be fixed in the ad- or abducted position, and the pelvis is tilted to allow the limbs to hang vertically in standing or walking. Or it may result from a shortened limb, from fracture or any other cause, and the length of the two limbs is made apparently and often, for practical purposes, virtually equal by the tilting of the ])elvis downward on the side of the shortened limb. Before illustrating these facts it is well to notice that the anterior superior iliac spines, from which we take our measurements to determine the length of the lower extremities, lie lateral to the acetabula. Hence ^ With the coccyx pressed backward. MEASUREMENT OF THE LOWER EXTREMITY. 353 we measure the long side of an oblique-angled triangle of which the short side is the line between the iliac spine and the acetabulum, and the third side is the lower limb itself. If the tiro HhxIjh are of equal lengtli and one is fixed at the hip in the abducted position, the otlier limb to be parallel with it must l)e adducted. (Fig. 81, ACM' and A'CM".) J5y a lateral tilting of the pelvis both limbs are made appar- ently straight and in the long axis of the body. (Fig. 82.) The pelvis on the abducted side is lowered by the tilting, hence its aceta- bulum is lower than that of the opposite side. Therefore the limb on the abducted side will appear longer (apparrnf (riir/fhrniiif/) than that on the adducted side, which cannot touch the ground. If, however, we measure the two sides we are surprised to find that the abducted and apparently longer limb measures less (measured shortmhtfj) than the other, while in reality the two are exactly equal in length. Fig. 81. Figs. 81 and 82. Diagrams to show the correct (81) and the incorrect (82) position for nieaaure- ment of the lower extremity and the elfects of aV>- and adduction on the apparent and measured length of the limb.s. The plain lines in Fig. 81 show the correct position for measurement, the crossed lines represent the left hand limb abducted, the right adducted. This same position is slnvwn in Fig. 82 but the pelvis is tilted to bring the limbs in line with the a.\is of tlie body. A, anterior superior iliac spine; (', cotyloid cavity; V, umbilicus, M, malleolus; V, point cjuidistant 'from the two malleoli ; VP, line from this pi'iint to the umbilicus ; AA, line connecting the two iliac spines ; AM, the line of measurement ; CM, the real length of the limb ; AC, the line from the iliac spine to the cotyloid cavity. The exphindtlon is simple. As one limb is gradually abducted the triangle, whose long side we measure, approaches more nearly a right- angled triangle until it becomes one, hence the length of the long side we measure decreases as we abduct for, the two sides remain- iDg the same, the long side decreases in length as the angle decreases 23 354 PELVIS AND PERINEUM. from an oblique angle to a right angle and vice versa. As the other limb is gradually adducted the obtuse angle in the triangle in- creases, so that the long side measures more and more until the side representing the limb is in line with the short side of the triangle, and then the line we measure comprises two sides of the triangle which, according to a rule of geometry, are greater than the third side. (i^ig. 82, A'CM'.) Hence we see that abduction decreases measured lengthening and ad- duction increases it. Therefore in measurements to determine the com- parative length of the limbs it is necessary to see that there is neither abduction nor adduction. This we do by seeing that there is no tilting of the pelvis and that the limbs are in the long axis of the body or, in practice, that the line connecting the anterior superior iliac spines (Fig. 81, AA') is at right angles to the long axis of the body (Fig. 81, VP) and that the latter prolonged is equidistant from the malleoli of the two feet to which we measure (Fig. 81, MP-PM). Or stretch a string or bandage from the umbilicus to the mid point between the two ankles (Fig. 81, VP) and see that this is at right angles to a line connecting the two anterior superior iliac spines (Fig. 81, A A). Another anomaly is that if one side is actually a little shorter (actual shortening) and the pelvis is tilted, the short limb if adducted may appear shorter and measure longer than the longer limb or, if abducted, it may appear longer and measure shorter. When the pelvis is tilted the limb on the lower side is always abducted and vice versa. Actual, measured and apparent shortening do not coincide unless there is no tilting of the pelvis. If one limb is a little shorter as a result of fracture of the femur, old hip trouble with loss of substance of the head, excision of the hip or knee joint, etc., it may be made of equal length with the other, to all appearances and for all practical purposes, by tilting the pelvis down on the short side and up on the long side. The slightly shorter limb would appear equal but measures consider- ably shorter. Thus fracture of the femur with an inch or so shortening may be compensated for by such a slight tilting of the pelvis that it is scarcely noticed and produces no awkwardness of gait. The pelvis may also be rotated on a vertical axis so that one anterior superior iliac spine is in advance of the other. This may also occur in hip disease. The Lining of the Pelvis. Pelvic Floor or Diaphragm. — At the sides of the pelvis the is- chium, the obturator membrane, and the bony margins bounding it are well padded by the thick obturator internus muscle. At the back of the pelvis is the pyriformis on either side, while tlie outlet is occupied by the coccygeus behind and, in front of this, by the levator ani. These latter two muscles, especially the levator ani, form the sagging /foor or diaphragm of the pelvis and separate its cavity from the perineum in front and the ischiorectal fossa behind. The anterior border of the levator ani descends along the side of the prostate and some of its fibers unite beneath it with those of the OBTURATOR HERNIA. 355 opposite side at the central tendinous point of the perineum, where they blend with the external sphincter ani and the transversus peri- nei muscles. The posterior fibers of the levator ani are attaciied to the tip of the coccyx. The rectum in both sexes and the vagina in the female perforate in the median line the pelvic Hoor, formed by the levator ani, and at these points the fibers of the muscle interlace with the longitudinal muscle fibers of the walls of those organs, more intimately with those of the rectum. Elsewhere in the median line the levator ani is attached to the median fibrous yv/y>/u', extending from the coccyx to the rectum and thence to the central tendinous point of the perineum. gp^v . Besides the openings for the rectum and vagina there are several srmaJl ojX')iiiif/.s in the pelvic walls for the pa-snarje of vessels and nerves: (1) through the (jreat sciatic notch, above the pyriformis, for the superior gluteal vessels and nerves; (2) through the great sciatic notch between the pyriformis and the coccygeus for the internal pudic and sciatic vessels and nerves and the inferior gluteal vessels ; (3) through the obturator foramen above the internal obturator muscle for the ob- turator vessels and nerves. The gap in the pelvic floor between the levator ani muscles in front is filled by the triangular ligament, which is pierced by the urethra and, above it, by the dorsal vein of the penis, or the corresponding vein in the female. Pelvic Herniae. — Through the first two foramina above mentioned two of the forms of pelvic hernise occur. Obturator hernia occurs through the obturator canal, which is directed downward, forward and inward beneath the horizontal ramus of the pubis for about 2 cm., with a diameter of 1 to 1^- cm. Such a hernia pushes a sac of pelvic peritoneum before it and sometimes the obturator fascia. It comes to lie deepli/ beneath the pectineus and adductor longus muscles, by separating which it may be exposed through an incision near the inner border of Scarpa's triangle. It is often best to reach it by abdominal incision above the pubes. The obturator vessels and nerves are usually on the outer side or, next most com- monly, the nerve may be in front and the artery behind. The proximity of the nerve renders peripheral pain from pressure a con- spicuous symptom, which lias misled surgeons into treating it for some other condition. As the hernia lies on the mesial side of the hip cap- sule pain on moving the hip is often a marked symptom. Obturator hernise generally occur in advanced age and much more commonly in females, in whom, it is well to note, the inner orifice of the canal can be examined through the vagina. It is too deeply situated to l)e evident in Scarpa's triangle and may best be detected by the finger along the pubic ramus and behind the adductor longus, while the thigh is flexed, adductcd and rotated out, or by vaginal or rectal ex- amination. Strangulation is the rule. Ischiatic hernia, escaping tlu\)ugh the great sciatic foramen, above or below the j)yrilormis, lies beneath the gluteus maximus muscle. It is rare. 356 , PELVIS AXD PERINEUM. Other rare forms of hernise occur through the pelvic floor, whose starting point we know only imperfectly. They occur in adults, usually in women, and on one side of the median line. The sac, covered by the rectovesical fascia, escapes through the fibers of the levator ani muscle to appear in the posterior part of the labium majus (pudendal hernia), in the perineum (perinea/ hernia), in the ischio- rectal fossa (ischiorectal hernia) or in the vagina {vaginal liernia). A rare form of hernia, whose sac is covered on one side by the rectal wall, may appear outside of or just within the sphincter ani muscle (rectal hernia). In perineal hernia the sac escapes in front of the rectum be- tween it and the vagina or prostate, and in pudendal hernia it escapes between the ischial ramus and the vagina. Pelvic Fascia. (Fig. 84.) — The muscles of the walls and floor of the pelvis are lined by a fascia, the pelvic fascia. This helps to form a sheath for the muscles and to separate more effectually the pelvic cavity from the perineum and ischiorectal fossa, and it serves to strengthen and support the pelvic viscera by its reflections onto them. Certain parts of these reflections onto the viscera are called their true ligaments, in the case of the bladder, etc. Two principal portions are distinguished, a parietal and a visceral. The parietal portion, or obturator fascia, lines the obturator internus and is contimious with the iliac and trans versalis fasciae at the pelvic brim, along which it is attached. It is also attached to the free border of the ischium, the falciform process of the great sacrosciatic ligament, and the inner lip of the lower border of the ischiopubic ramus. At the latter attachment it is continuous on either side with the deep layer of the triangular ligament. The obturator fascia forms a fibrous canal for the internal pudic vessels and nerves. Along a line from the back of the pubis to the ischial spine the levator ani is attached to this fascia, which is here thickened and hence appears white (the lohite line). The obturator fascia above this line is sometimes distinguished as the ^' pel ric fascia.^' From this white line is given ofi' the visceral portion, or rectovesical fascia, which lines the upper or pelvic aspect of the levator ani muscle and is reflected onto the pelvic viscera where they penetrate this muscle, i. e., rectum and vagina, and onto those immediately related to the pel- vic floor, bladder, prostate, seminal vesicles and uterus. From the lower end of the bladder it is reflected down to form the fihrous capsule of the prostate, at the apex of which it is continuous with the deep layer of the triangular ligament. It thus encloses the vesicoprostatic plexus of veins. From either side of the symphysis a fold of this fascia, cov- ering a small bundle of muscle tissue prolonged from the bladder (vesicopul)ic muscle), passes back to the prostate and bladder as the anterior true ligaments of the bladder (puboprostatic ligaments). In the depression between the latter the pelvic fascia is thin and through it is seen a plexus of veins, connected with the dorsal vein of the penis, which lies beneath the plexus. The fold from either side of tiie pelvis to the sides of the bladder, the lateral true ligaments of the bladder, are PLATE XLI FIG. 8S. OBTURATOR VESSELS AND N ERVt ^^t-WHITE LINC Pelvic floor in the iTiale. The fascia is in place on left and is renioved on right side. The dotted line outlines the bony outlet of the pelvis. (Testut.) FIG. 84. -.-- ^.''''■'■•.'■^•'<^'','-''^Jf*^i. PELVIC PORTION OF OBTURATOR FASCIA OBTURATOM MEMBRANE ISCHIO-CAVER MUSCL lO-RECTAL FOSSA NTERIOR EXTEN- ON ' TRIANCU MENT DEEP LAYER LAYER SUPERFICIAL PERINEAL FASCIA. DEEP LAYER Frontal section of the pelvis thi-ough the middle of tlie ischiopubic rami; partly diagrammatic, to show the pelvic fasciae. Anterior segment of the section viewed from iDchind. The fasciae are in l^lue. (Testut.) PELVIC FASCIA. 357 scarcely demonstrable. Further back the fascia passes across between the bladder and rectum, uniting yet separating tliem in the trigonal area and investing the seminal vesicles. The lower end of the rectum also receives a thin prolongation of the fascia. Behind the levator ani the rectovesical and obturator fasciie are con- tinuous and cover the pelvic aspect of the coccygeus and pyriformis muscles. At the anterior border of the levator ani the rectovesical fascia above it joins the anal fascia beneath it and is continued forward to the obturator fascia, or its prolongation the deep layer of the tri- angular ligament. The reflections and attachments of the rectovesical fascia exclude cer- tain viscera, or parts of viscera, from tlte pelvic cavibj, i. c, the prostate, seminal vesicles, trigone and outlet of the bladder and the lower 2h to 3 inches of the rectum. These may be wounded without entering the pelvic cavity and, provided their fascial sheath is intact, suppuration in them would tend to spread towards the perineum and not into the pelvis. On the rectum the fascia reaches some little way below the rectovesical pouch of peritoneum in front. The pelvic rcwcAs are on the inside of the fascia, the nerves of the sciatic and lumbar plexuses on the outside. The vessels, excepting the obturator, must pierce the fascia to get out of, the nerves to get into the pelvic cavity and through these small openings inflammation may possibly spread. But as a rule supjpur- ation above the fascia is limited to the pelvic and abdominal cavity, that below to the perineum and ischiorectal fossa. Wounds of the latter two regions that involve this fascia have the added danger of pelvic inflam- mation ; hence is seen the surgical importance of the pelvic fascia. Between the pjeritoneum, which lines part of the pelvic floor and covers most of the pelvic viscera, and the ''pelvic" and rectovesical fasciae is a continuous layer of loose subperitoneal connective tissue in which inflammation may spread readily and widely and lead to suppuration. This tissue is found most aljundantli/ between the ante- rior bladder wall and the pelvis and about the outlet of the bladder and, in the female, about the lower part of the uterus and the upper end of the vagina and between the folds of the broad ligament. In- flammation and sup})uration in this tissue, known as pelvic cellulitis, is prevented from escaping through the pelvic floor by the pelvic fascia. Hence, as this tissue is continuous with the subperitoneal tissue of the iliac fossa, the abscess usually passes up over the pelvic brim to the iliac fossa and j)oint.'< in the inguinal region (q. v.). Barely it may open into one of the pelvic viscera or into the peritoneal cavity. In the male it may follow the vas deferens to the inguinal canal and scrotum. //( tromen the inflammation and abscess are often found Mithiu the broad ligaments or beneath the i)eritoneum lining Douglas' pouch, i)etween the uterus and rectum. Clinically pelvic cellulitis is often accompanied by an inflammation of the jielvic porit(»iU'um, jnlvio peritonitis ; the latter may also occur separately. In pelvic hematocele the blood, if intraperitoneal , may trickle into Douglas' pouch, where it may become enclosed by peritoneal adhe- 358 PELVIS AND PERINEUM. sions ; or, if subperitoneal, it collects most often between the layers of the broad ligament. It often comes from a ruptured varicose ovarian vein. Pressure of the mass on the rectum may cause tenesmus. These collections of blood may of course become infected and sup- purate and in such a case can be opened through the vagina. THE VISCERA OF THE PELVIS. The Rectum. As stated above (see Sigmoid Flexure, p. 317) that part of the rectum, formerly called the first portion, which is provided with a mesentery and extends from the left sacro-iliac joint, at the pelvic brim, to the middle of the third sacral vertebra, is now considered as a por- tion of the sigmoid loop, with which it is continuous. Between the layers of the mesentery of this portion of the sigmoid run the inferior mesenteric vessels which divide, where the mesentery ends, into the two sets of bilateral superior hemorrhoidal vessels. The rectum thus limited is more entitled to its name, rectum (straight), as it is not curved laterally, only antero-posteriorly. Of the two parts into which it is naturally divided the upper or jjelvic portion, 3| inches long, follows the curve of the sacrum and coccyx, upon which it lies ; the lower or anal portion bends backward and downward just below the tip of the coccyx. It is important to bear in mind the direction of the tivo curves in examining or passing instruments into the rectum. The axis of the anal portion if continued meets the prostate near its apex or the rectovaginal septum. Hence, in introducing a bougie, the nozzle of a syringe, a speculum, etc., the instrument should first follow the axis of the anal portion for 1| inches, upward and forward, and then be tilted so that its upper end is directed upward and backward in the curve of the upper part. The dividing line between these two parts corresponds about to the point where the rectum pierces the pelvic floor. The anal portion is therefore entirely extra-pelvic and, by the manner of the reflection of the pelvic fascia (see above, page 357), the lower part of the upper portion is also extra-pelvic. In infants the lower end of the large gut is straighter and more or less vertical, and the upper part of what was formerly called the first portion of the rectum is in the abdominal cavity. On account of its more vertical position in childhood, together with its loose connections, the small size of the prostate and the liability to such exciting causes as worms and rectal polypi, prolapsus ani is espe- cially common at this age. The Pelvic Portion. — Above the anal portion the rectum is dilated into a large ampulla extending forward to the apex of the prostate, and backward to the coccyx. This part is very distensible and, in cases of faecal accumulation, may be enormously distended. Curious foreign bodies of large size have been found in this ampulla such as, for instance, a bottle (Desormeaux), a glass tumbler and an iron match box. When this portion of the rectum is distended, in the male. RELATIONS TO THE PERITONEUM. 359 the bladder is raised and pushed forward and the rectovesical pouch of peritoneum is elevated. Adv;intaf2:e has been taken of this fact in suprapubic cystotomy by distending the rectum by a rubber bag, inflated with air or water, to help raise the bladder above the symphysis. This portion is large enour/li to contain the entire hand which mav be introduced, if not over eight inches in diameter, after a gradual dilata- tion of the sphincters under anjusthesia. By a semi-rotary movement it can be insinuated into the lower end of the sigmoid loop. It is said that a large part of the abdomen may be thus examined, even as far as the kidneys, owing to the movability of the part. Yet the practice is dangerous as the bowel may be torn, especially that |)art covered by peritoneum, and the sphincter may be permanently para- lyzed. Moreover the practical results are unsatisfactory owing to the cramping of the hand. By means of a wooden lever, invented by Mr. Davy, introduced into the rectum, the common iliac vessels have been compressed against the pelvic brim to arrest hemorrhage in amputation at the hip joint. Attachments. — Although the rectum, in passing through the pelvic floor, receives an attachment from the pelvic fascia, this fascia is not so firm but that in rare cases all the walls of the gut are prolapsed at the anus. This mobility of the rectum is of use in excision of its lower part, for it allows the upper part to be drawn down so as to be sutured to the skin or the edges of a healthy anal segment. In order to free it for removal the levator ani mu.sclc, some of whose fibers are prolonged into and sup[)ort the bowel, is divided. To allow the upper part to be pulled down the peritoneal attachment must be loosened. This may be done by carefully stripping up the peritoneum from oflP the front and sides of the rectum and then by dividing the mesentery of the lower sigmoid on either side, taking care to avoid the blood vessels, which run superficial to the muscle layers, for injury to these vessels means gangrene of the upper segment. The rectum is loosely attached by loose connective tissue to the lower half of the sacrum and the coccyx, while in front it is more closely attached to the back of the y>/-o.s^«^e and bladder by firmer connective tissue, the prostato-peritoneal aponeurosis, connected with the rectoves- ical fascia. This aponeurosis however allows the separation of the rectum from the prostate and bladder and, if traced u]iward, is found to be attached to the bottom of the rectovesical ]>ouch of the i)eritoneum. /// the female the rectum is attaciied to the vagina in front by a con- siderable amount of looser connective tissue. The relations of the rectum have a twofold importance, first in diseases of or operations on the rectum, second because rectal exami- nation is of the greatest importance in determining the condition of the organs in relation to it. Relations to the Peritoneum. — Commencing op|x>sito the third sacral vertebra there is no mesorectum but the peritoneum, at first covering the front and sides of the bowel, is reflected from tiie sides along an oblique line descending from behind forwanl. It is finally 360 PELVIS AND PERINEUM. reflected from the front of the rectum onto the bladder in the male and onto the vagina, cervix and uterus in the female, forming the 7'ecto- vesical and rectovaginal pouch (Douglas' pouch) respectively. The. dis- tance of the rectovesical pouch from the anus is of importance in rectal operations and measures 3 inches, or somewhat more, when the bladder is empty, and as much as 4 inches when it is full. The distance of the similar pouch in the female (Douglas' pouch) from the anus is somewhat less. In complete prolapse of the rectum of large size this peritoneal pouch may be protruded and may contain coils of intestine, which oc- cupy it in the normal condition. On the posterior rectal loall the peri- toneum does not come within five inches of the anus. Thus ulcers and carcinomata situated anteriorly are more likely to invade the peritoneal cavity and, in excisions of the rectum, more of the bowel may be readily excised posteriorly than anteriorly. But, as we have seen, in the absence of inflammatory adhesions we may detach from the peri- toneum and draw down the rectum as far as the commencement of the mesentery, where the peritoneum encloses the bowel. Above this point the bowel may be freed by dividing the peritoneum of the mesentery on either side, taking care not to injure the blood vessels. By rectal examination in the female we can feel anything abnormal, like a prolapsed ovary or a retroflexed uterus, occupying Douglas' pouch, or, in the absence of these, we can feel the uterus in front and the ovaries at the sides, if the latter are enlarged or displaced. The retroflexed or retroverted uterus may so press upon the rectum as to favor constipation, cause tenesmus, and set up inflammatory or con- gestive conditions in the rectum and an adhesion of the opposed peri- toneal surfaces of the pouch. The close relation of the vagina and anterior rectal wall accounts for the tears into the rectum at childbirth. The foetal head has occasionally been forced through the thin recto- vaginal wall and delivered per rectum. Below the rectovesical pouch in the male we can feel the bladder, corresponding to the trigone, judge of its distension and occasionally feel a calculus when present in the bladder. Through the triangular area of the bladder in contact with the rectum, and below the peri- toneal pouch, the distended bladder was formerly punctured by a trocar but, owing to the danger of infection, this method has been superseded by the suprapubic puncture. Bounding the two sides of the triangular area are the seminal vesicles and the vas deferens. These can be readily felt when diseased (tubercular) or distended, not readily when normal. In violent attempts at defecation they may be pressed upon by the fecal masses and partly emptied, producing a mechanical form of spermatorrhoea. Massage of the seminal vesicles as a therapeutic measure has been practiced through the rectum. A stone impacted in the lower end of the ureter may possibly be felt through the rectum. Below the palpable area of the bladder and seminal vesicles we readily feel the posterior surface of the prostate whose apex, 1| inches from the anus, is in front of the ampulla at the lower end of the upper PLATE XLI I. FIG. 85. Sagittal section of the lower pai-t of a male trunk, the right segment. (Geri-ish, after Tesiut) STRUCTURE OF THE RECTUM. 361 portion of the rectum. By rectal palpation we can feel the changes of size, shape, consistency and sensitiveness in hypertrophy, inflamma- tion and abscess of the prostate. The enlarged prodate naturally pro- jects into the rectum and, when of very large size, may cause obstruction to the passage of feces. We can thus appreciate why defecation is painful in prostatitis, etc. At this part too a prostdtic almresH ynni/ open into the rectum, and such an opening may result in a urethro- rectal fistula. Below and in front of the apex of tlie prostate can be felt the mem- branous urethra especially when occupied by a sound. The forefinger in the rectum with its tip at the apex of the prostate is used as a guide in Cock's operation (perineal section), and is useful in many perineal operations on the urethra, prostate, etc., and even in passing a urethral instrument in difficult cases. The bo)iy points ])alpablc by rectal examination have been mentioned (p. 346). Their palpation is of use in determining the presence of any fracture, disease or new growth connected with them. It is well to remember, in examining for suspected lesions high up in the rectum, that by having the patient strain as at stool, especially in the standing position, one to two inches more of the rectum can be palpated than otherwise. The rectum is not properly a reservoir for feces, and in the healthy condition the presence of the latter stimulate it to contract. In some cases, especially those subject to habitual constipation, it may contain a large amount of feces, as often made out by digital examination, the nerves and muscles having become degenerate and ceasing to act. The anal or terminal portion 1^ inches long, is the narroivest part of the large intestine though very dilatable. It is quite distinct in its surgical relations from the pelvic portion. The internal sphincter sur- rounds it while the levator ani and its enclosing fasciae are attached to and support its sides, which are in relation to the ischiorectal fossne. In front lies the perineal body in the female, separating it from the lower end of the vagina, and the perineum in the male, sej)arating it from the urethra. In the female the urethra is separated from it i)y the vagina and perineal body. In the male the anal portion forms the posterior wall of a triangle of which the perineum forms the base and the membranous portion of the urethra, where it adjoins the rcctiun, the apex. Through this triangle are made the various perineal incisions by which the bladder or pos- terior urethra, and sometimes the prostate and seminal vesicles, are reached. Structure of the Rectum. — The longitudinal muscle fibers are more uniformly spread out than in the rest of the large intestine though, accord- ing to some, the three bands are continued as two bands, one in front and one behind, which broaden as they descend. Tiie circular fiberx are abruptly thickened (to 3 or 4 mm.) in the upi>er inch of the anal portion to form the internal sphincter. The lower litnif ot the anal por- tion is represented on its interior by a circular " "///Vc ///(r " which 362 PELVIS AND PERINEUM. marks the junction of the skin and raucous membrane. The external sphincter, surrounding the anal orifice, is a striped or voluntary muscle. The looseness of the submucous tissue is such as to allow the raucous membrance to be protruded or prolapsed at the anus on prolonged straining at stool or micturition. The greater looseness of this tissue in infants and children and the frequency of straining attending phi- mosis, constipation or the irritation of worms and polypi, makes this accident especially frequent in early life. It may also be due to the relaxation of the parts attending persistent diarrhoea. When small it involves only the mucous membrane and tends to re-ascend, but may be held down by an irritated sphincter. When large all the coats of the bowel are apt to be involved and the rectovesical peritoneal pouch, and even coils of intestine, may be contained in the prolapse. Certain obliquely transverse folds of mucous membrane, " Houston's folds" or " valves," not effaced by the distension of the rectum, are of importance, for they may impede the passage of a bougie or a rectal tube, especially if the rectum is empty. Hence in giving a high enema first fill the rectum with fluid and then these folds will not impede the passage of the tube. Three such folds are usually pres- ent. One, the largest, on the right and anterior aspect is near the rectovesical pouch of peritoneum, or about 3 inches from the anus, and projects I to f inch into the lumen of the gut, extending around half of its circumference or more. It has been described as the third or upper sphincter. The other two are to the left, above and below the former, and the three are so arranged as to form a kind of spiral valve. In the anal portion, coramencing just above the orifice, are several (3 to 8) longitudinal columns or folds of raucous membrane, |^ to ^ inch long, due probably to bands of the muscularis mucosae. Between the lower ends of these colurans are semilunar folds or valves whose up- turned concavities form little sinuses. These are the columns, valves and sinuses of Morgagni. Upon these columns are to be seen little pro- trusions, due to hemorrhoidal veins. The raucous raerabrane is liable to dysenteric inflammation and ulcer- ation and the cicatrization of the ulcers may produce stricture. The liability to ulceration is greater the nearer the anus. As the epi- thelium of the anus is squamous and that of the rectum columnar an epithelial neoplasm of the former is an epithelioma (squamous celled carcinoma) and of the latter a carcinoma or columnar epithelioma. Vessels. — The arteries of the rectum are from three principal sources, the inferior mesenteric, the internal iliac and the internal pudic. The branches of the two lateral trunks of the superior hemorrhoidal pierce the muscular wall about three inches from the anus to form a longitudinal network in the submucous tissue. Hence incisions here should be lengthwise to avoid profuse bleeding. The arteries com- municate freely in a plexiforra raanner near the anus and more or less above. Although the veins have the same plexiforra arrangeraent in the subraucous tissue of the lower rectura and take the sarae course, 7iiost of the blood is relumed by the superior hemorrhoidcd to the inferior THE NERVE SUPPLY OF THE RECTUM. 363 mesenteric vein. Hence congestion of the so-called hemorrhoidal veins of the rectum is apt to follow portal congestion as well as venous con- gestion due to diseases of the heart, lungs, etc. In addition to these causes the tendency to varicosities of the hemorrhoidal veins, hemorrhoids or piles is in part due to their dependent position, the want of valves, and the pressure of fecal masses, etc. They may also be symptomatic of pregnancy, ovarian or abdominal tumors, stricture of the rectum, prostatic enlargement, etc., as all of these conditions may obstruct the return of venous blood. These veins also communicate with those of the prostate and bladder. Hemorrhoids usually commence close to the point where the superior and inferior sets of veins anastomose, ./im< vithin the anal orifice, where the ano-redal groove is produced by the distension of the internal or superior veins above it and the external or inferior veins below it. Both sets of veins are usually simultaneously involved, but when the internal or external set is exclusively or predominantly involved the varicose enlargement is called an internal or external hemorrhoid re- spectively. A series of such swellings often surrounds the outlet of the bowel. Piles are usually confined to the submucous or subcuta- neous tissues so that they are covered only by the niucoua membrane (internal piles) or skin (external piles). The mucous membrane or the skin on the surface of the swelling, due to the dilated and sometimes thrombosed veins, is chronically inflamed. The mucous meml)rane may be thickened, thinned or ulcerated, in the latter case leading to " blerdinr/ piles'' ; the skin is usually thickened, and develops into a flabby tab when acute inflammation is absent. It should be borne in mind that the lower rectum thus furnishes an important aiiasfomosi.'< between the portal and caval veins. The nerve supply of the rectum is from the inferior mesenteric and hypogastric sym})athetic plexuses and the sacral plexus (fourth sacral nerve). The latter accounts for the paralysis with incontinence of feces that follows spinal injuries or diseases in the lumbar region or above. It is also mainly responsible for the close nervous association between the anus and the outlet of the bladder, which is supplied by the same nerve, so that on the one hand painful affections of the former may cause a frequent desire to urinate and operations on the anus are especially apt to be followed by temporary retention of urine ; and on the other hand lesions of the outlet of the ijladder are often associated with tenesmus. The anus is supplied by the internal pudic nerve, which accounts for the wide distribution of reflex pain in anal fissure. The uppjer jjart of the rectum /.v but little sensitive as illustrated l)y the com- parative painlessness of new growths and the passage of instruments high up in the rectum. On the other hand the last two inches of the bowel are extremely sensitive. The lymphatics of the rectum enter the j>elvic and lumbar nodes, those of tlie anus the inguinal nodes. Thus the anus has a blood, nerve and lymphatic supply independent of that of the rectum. 364 PELVIS AND PERINEUM. The anus is an oval, not a circular, orifice at the lower end of the anal portion of the rectum. Hence specula, etc., should be introduced with the long diameter antero-posteriorly in the long axis of the anus. The anus lies in the median line \\ inches in front of the coccyx, mid- way between the two ischial tuberosities and only slightly further from the lower border of the symphysis than from the tuberosities. In health it is tightly closed and, radiating from its margins, there are numer- ous puckerings or small folds of skin, between which fissures or ulcers of the anus form and are often hidden. The painfulness of this affec- tion is due to the reflex contraction of the sphincter, compressing the exposed nerve fibers at the base of the fissure or ulcer. Hence dilata- tion of the sphincter, thereby temporarily paralyzing it and tearing tiie base of the fissure, gives relief and affords the fissure a chance to heal. Incision of the base of the ulcer, so as to divide part of the sphincter, produces a similar result. The anus may be torn by large hard stools- during defecation and some such tears may result in " painful fissure.'^ Near the anus we see the external opening in cases of fistula in ano. The most common form is the result of marginal abscesses, superficial to the sphincters and lying merely beneath the skin and mucous mem- brane. Their internal orifice is generally found a little above the "white line" (mucocutaneous junction) just within the grasp of the sphincter. The upicard extension of an ischiorectal abscess is resisted by the levator ani, between which and the external sphincter it finds a point of least resistance to extend toward the rectum, into which it opens just above the external or internal sphincter. The abscess be- fore opening may extensively undermine the mucous membrane, so that the resulting fistulous tract may extend upward way above the internal opening. Tillaux describes a form of fistula which may ap- parently heal but again breaks out on the same or the opposite side, and which he attributes to a hard semilunar valve-like fold at the upper end of the rear wall of the anal portion. Division of this stricture- like fold results in a cure of the fistula, whose internal opening is above the level of this fold. Inspection of the anus is of diagnostic importance. Thus in cases of obstruction due to stricture of the rectum, greatly enlarged prostate, etc., the anus is patulous and flabby, while in fissure it is tightly closed. Development and Errors of Development. — The pelvic portion of the rectum h formed by the blind caudal end of the hind gut, the anal portion by an invagination of the surface at the site of the anus. Normally the sejitum between them is absorbed so as to form a continuous canal, but abnormally it may leave an annular constriction an inch or so within the anus or it may persist and form an imperforate anus. In such cases the septum persists (1) as a thin membranous scj)tum which bulges with the retained meconium and may be readily incised, or (2) as a thicker partition after division of which the rectal mucous membrane must be brought down to the surface. Again, there may be no anal pouch whatever, and in such cases the lower end of the rectal portion may or may not be deficient. In infants with obstinate con- SHAPE AND POSITION OF THE BLADDER. 365 stipation digital examination of" tlie rectum must not be neglected. If a careful dissection through a median incision prolonged l)ack to the coccyx and carried up to the front of tlie coccyx and sacrum fails to discover the rectal pouch an inguinal colostomy must be made. Ill rare cases the recfiiin ojjcns cutaneously af sdihc unusual polid (symphysis, prepuce, perineum, sacral, gluteal or lumbar regions) and usually by a long canal with a narrow aperture. More often it opens into the genito-urinary tract, bladder, urethra, or vagina. Primarily the allantoic vesicle, from which tlie bladder and tlie posterior urethra are formed, was derived from and ojiened into the hind gut. The per- sistence of this connection may explain the rare opening between the rectum and the bladder. The rectal pouch in such cases lies so high up that inguinal colostomy must be resorted to. The opening into the bladder or urethra is usually small and requires operative relief if possible. I have seen the opening into the vagina sufficient for the purposes of defecation, and this condition has been often reported. In the latter case operation should be deferred until after puberty, when the increased size of the pelvis and perineum facilitates a plastic oper- ation. Women have even married and borne children with a vaginal outlet to the rectum and without inconvenience from the latter. In operations for the removal of neoplasms or for resection of stric- tures of the rectum room may be gained and the exposure of the parts increased by excising the coccyx, after incising back to the sacrum. Or, following Kraske's method or one of its modifications, the lower end of the left half or both halves of the sacrum may be permanently or temporarily resected (osteoplastic method). In these operations the lower border of the third sacral foramen should be the upper limit of the resection of bone, for if it is carried higher there is a risk of perma- nent paralysis of the bladder from interference with the third sacral nerves. These operations are carried out on the left side, for it is on that side that the lower or pelvic portion of the sigmoid loop lies. By division of the sacro-sciatic ligaments or resection of their sacral attach- ments the entire sacro-iliac notch is opened up. When possil)le it is advisable to save the anal portion, containing the sphincters, and use it by suturing the upper segment to it. The Bladder. The shape, position and relations of the bladder, or urinary reser- voir, depend upon age, sex, and the degree of distension of the organ. The average capacity is about a pint (400 to oCtOc.c.) but may reach 1,000 c.c. under normal conditions, ^^'hen distended, in cases of re- tention, etc., the bladder has held as much as ,S,()00 to 4,000 c.c. of urine, and Tillaux reports a case in which it held 7 liters (7,000 c.c). On the other hand a contracted bladder may contain no more than 10 to 20 c.c. The bladder of the male is somewhat more capacious than that of the frinalc. Shape and position of llu' adult male bladder. The form of the empty bladder is a disputed point. Two forms are described: (1) the »i/stollc 366 PELVIS AND PERINEUM. or contracted form, in which the bladder represents a firm oval whose cavity, on sagittal section, forms with that of the urethra, a continuous curved slit, and (2) the diastolic or relaxed form, in which the upper aspect presents to the intestines a cup-shaped concavity and the cavity, with that of the urethra, presents a Y-shaped fissure on sagittal section. It is probable that the systolic form is the common one during life. When moderately filled it is entirely within the pelvic cavity and has a rounded form, which may be flattened or transversely elongated by the pressure of the adjoining viscera. ^,s it becomes distended it be- comes oval, the convexity of the superior and postero-inferior surfaces is increased, the anterior surface is flattened and its upper part, rising out of the pelvis, is in contact with the back of the anterior belly wall. This fact is taken advantage of in suprapubic cystotomy and tapping. In distension the upper or smaller end comes more and more in contact with the anterior belly wall and may reach the umbilicus and even, it is said (Tillaux), the diaphragm. The distended bladder is not quite symmetrical but deviates slightly to the right, owing partly to the rectum on the left side and partly to the greater size of the right half of the bladder. When distended so that its upper end is at the upper margin of the symphysis, its long axis is directed from the latter point to the end of the coccyx. The vesical outlet (or internal urinary meatus) is on a horizontal line a little below the center of the symphysis, about an inch behind the latter and 2 to 1^ inches above the perineum. In distension the bladder is displaced dotvnward as well as upward, displacing the peri- neum so that its outlet is at a somewhat lower level, while in cases of prostatic enlargement the outlet may be displaced upward, even above the symphysis. The bladder lies behind the anterior pelvic wall, in front of and above the rectum in the male, the cervix uteri and the upper end of the vagina intervening in the female, and in contact with the small intestines and the sigmoid loop above and behind. Relations to the Peritoneum. (Figs. 85 and 87.) — The peritoneum covers the entire superior surface, the lateral surfaces down to the line of the obliterated hypogastric artery, or a line extending from the urachus to a point somewhat below the summit of the seminal vesi- cles, and the upper part of the posterior surface, to the bottom of the rectovesical pouch. This pouch is usually filled with convolutions of the small intestine, separating the bladder and rectum, and it reaches to a point just below the upper ends of the seminal vesicles and about an inch above the ])rostate (three inches from the anus). It forms the upper limit of the triangular area over which the rectum and bladder are closely adherent. Normally the peritoneum lines the anterior abdominal wall down to the symphysis pubis, from which it passes onto the upper end and superior surface of the bladder. As the distended bladder rises above the pelvis it pushes up this parietal peritoneum which thus comes to cover the upper half of that part of the anterior bladder surface which ENTRANCE OF THE URETERS. 367 extends above the symphysis, while the lower half of this surface is in direct contact with the anterior belly wall, just above the symphysis, without the intervention of the peritoneum. It is this arrangement of the peritoneum tiiat renders suprapubic cystotomy or tapping a feasible and safe operation, for we can thus puncture or open a dis- tended bladder above the symphysis without opening the i)eritoneum. Exceptionally the peritoneum is adherent to the pubes so that it can- not be pushed up by the bladder. In operating on suchla case wounding of the peritoneum would be likely, but this wound could be sutured, the ])critoneum carefully detached below and drawn upward, and the bladder then opened. Theoretically the lower half of that part of the anterior bladder sui-- face above the symphysis should be devoid of peritoneum no matter how high the bladder rises, but ])ractically there is seldom more than 2 or 2^ inches between the symphysis and the peritoneum, though the lat- ter can be retracted still further upwards. When the l)ladder reaches half way from the symphysis to the umbilicus there will be this 2 or 2^ inches of the anterior abdominal wall above the symphysis devoid of peritoneum and in direct contact with the anterior bladder Avail. The use of Petersen's rubber bag, inflated in the rectum, prevents the bladder, filled with 8 ounces of fluid, from extending downward and backward toward the perineum, and at the same time directly raises it and thus helps to bring it in contact with the anterior belly wall, but it has no special influence in raising the peritoneal fold above the symphysis. By the use of Trendelenburg's position gravity tends to bring the mod- erately filled bladder above the symphysis pubis and in contact with the anterior abdominal wall, so that I have discarded the rectal bag as unnecessary. In fact I have found little difficulty in opening the empty bladder, supra pubes, by the use of the Trendelenburg position. The anterior surface and that part of the lateral surfacc\s below the limit of the peritoneum is separated from the obturator and levator ani muscles, of the anterior and lateral pelvic walls, by a quantity of loose areolar tissue whose meshes contain much fat. This tissue ensheaths the vesical vessels and occupies an area ( cavum Retzii ) more or less triangular, with its base directed downward, and shut in by the peri- toneum above. The l()ose)icss of t/iis tissue readily allows changes in dimension without disturbing the connections of the bladiler, and it also favors the rapid and wide spread of inflammation following wounds of the bladder with extravasation of urine. This tissue separates the distended bladder from the anterior abdominal wall, below the fold of the peritoneum. Ilence it is opened up in supra- pubic cystotomy and traversed by a trocar in tapping the bladder so that suppuration in this tissue, and iu rare cases death, has followed the latter procedure. This tissue is also r()nti)iuous above and at the sides, vifli the abdominal and pelvic subj)erit())ieal eonnerlire tissue, luMiee an iullaniination in it may become widely diffused. The ureters pierce the bladder (Fig. S7) at the juuetion of the lat- eral and posterior surfaces, about IJ inches from each other and the 368 PELVIS AND PERINEUM. same distance above the prostate ; just above the outer and upper limits of the triangular area of vesicorectal contact ; near to, though not in contact with, the rectum, so that a calculus in the lower end of the ureter may possibly be palpated through the rectum. The vasa deferentia c/'o.s.s the later nl bladder irall from before backward and above downward to reach the inner side of the seminal vesicles and form the sides of the above-mentioned triangular area on the posterior vesical sur- face. They cross the obliterated hi/pogastric arteries, and thence to the above triangular area they lie subperitoneally. They pass between the bladder and the ureters just where the latter pierce the bladder. Rupture of the bladder is more serious when it involves in whole or in part the portion covered by peritoneum. A'^iolence applied to the anterior belly wall may rupture the distended bladder without fracture of the pelvis or any external sign of injury. The bladder may be torn by bony fragments of a fractured pelvis or, rarely, in case of an injury of the rectum or vagina. When the bladder is dis- tended by urine, in neglected cases of stricture, the urethra gives way as a rule before the bladder and the urine is extravasated into the perineum. But rupture of the viscus has resulted in some cases from congenital closure of the urethra in infants and in neglected cases of re- tention of urine, especially in women. When the bladder is artificially over-distended it usually gives way laterally, below the peritoneal reflection (Tillaux), but most ruptures intra vitam involve in part, at least, the surface covered by peritoneum, for it is this part that is most distended when the bladder is filled. In intraperitoneal ruptures urine is extravasated into the peritoneal cavity which it does not irritate if normal and fresh, but when abnormal or after becoming stagnant. Hence a primary condition of treatment is the free drainage of the bladder and hence also the fatality of such ruptures unless the rent is repaired by suture and the extravasated urine is removed from the peritoneal cavity. The injury is indicated by inability to urinate, the urine passing through the rent into the peritoneal cavity, by the catheter removing only a little blood-stained urine, and by only a part of the fluid injected returning by the catheter. If the rupture is extraperitoneal the urine escapes into the loose cellular tissue of the cavum Retzii and cellulitis and abscess results, though recovery often ensues. Stab or bullet wounds take the same course according as they are intra- or extraperitoneal, except that a small bullet wound, like the puncture of a small trocar, may become at once plugged by the mucous membrane and the muscular contraction of the wall, thus pre- venting extravasation. Fixation of the Bladder. — The reflections of peritoneum onto the bladder, known as its false lir/aments, steady it without fixing it, while the bands of thickened rectovesical fascia, reflected onto its base and known as its true ligaments, anchor this part. It is still further fixed in position by its attachment behind to the rectum in the male and the uterus and vagina in the female, and by the connection of the ureters, urethra, prostate and the fibro-muscular cord of the urachus. THE BLADDER WALL. 309 Malposition. — In spite of these various nieans of anchoring the bladder it lias h^t^n found in inj^uinal, femoral, vaginal and other forms of pelvic hernke. In inguinal and femoral hernia,' tiie j)art herniated may be entirely extraperitoneal, or in part intraperitoneal. An al>nor- mally high position of the bladder may be due to prostatic, rectal or pelvic tumors. The bladder wall varies in thick hc.sh from one eightii inch, when moderately distended, to one half inch or more when contracted. The anterior wall and trigone are somewhat thicker than the rest of the bladder. When there is obstruction to the escape of urine the hhidder muscle lu/pertrophics from undue exercise, like other muscles. In such cases the interlacing network of the internal layer of fibers is thickened and appears as distinct intersecting ridges beneath the mucous mem- brane (the fasciculated bladder). The bladder wall in the interspaces of this network is thinner and weaker, and its mucous memi)rane may become protruded or lierniated in the form of sacculi, by the increased intravesical pressure {the sacculated bladder). One or several of these sacculi may become so enlarged as to allow urine to stagnate and decom- pose, phosphatic deposits to form and collect, and calculi to developer become hidden [encysted calculi). "When a calculus, previously con- tained in the bladder, slips into a sacculus the symptoms suddenly subside and the stone can no longer be felt by the searcher. Digital rectal examination may sometimes reveal the presence of such calculi. The ridges of a fasciculated bladder may become encrusted with phos- phatic deposits and give rise to possible errors in diagnosis in the use of the searcher. When only one sacculus is developed it may become enlarged, even to the size of the bladder, and give rise to the erroneous designation " double bladder.''^ Below and in front the longi- tudinal fibers of the external lat/er, known from its action as the defru.'ro- lapse, but if we try to pusli it up, usually an easy matter in prolapse, resistance and jiain are at once met with from the tension of its connec- tions. This elongation may affect either the intra- or supravaginal por- tion of the cervix. In the former case the vaginal fornices are deep- ened, in the latter they are not. Such a cervix may even interfi-re with coitus, and a conical, ]M)inted cervix is unfiivorable to romrjttinn and may be a cause of sferi/iti/. Another cause of sterility as well as of dysmenorrhoca is furnished by an (Ureaia or narrowing of the os ex- ternum, by no means rare. The cervix may be enormously enftnr/cd from chronic disease. During pre(/n(fn('i/ it becomes broad and soft and is drawn up from the cavity of the vagina, the extt'rnal os being occluded by a plug of mucus. The intravaginal portion, relatively large and prominent in female children, may nearly completely disap- pear in o/d women, and sometimes in younger mnltipano. It j^ossesses so /itt/e sensation that we can insert sharp hooks to pull it down and make all manner of applications to it without j)rodueing much if anv pain. 382 PELVIS AND PERINEUM. The zone of vaginal attachment, about one fifth inch deep, is ob- liquely placed, extending higher behind than in front, thus making the posterior lip longer and the posterior vaginal fornix deeper. The supravaginal zone represents about half of the cervix behind and two thirds in front. It is connected, as we have seen above, with the bladder anteriorly, while posteriorly it is covered by peritoneum and enters into the anterior wall of Douglas^ pouch. Perhaps the most important relations of the cervix are found at its sides which are connected with the broad ligaments, in which at this level lie the uterine vessels and the ureter. The uterine artery passes nearly horizontally inward in the base of the broad ligament to the supravaginal portion of the cervix, accompanied by the large uterine veins, arranged in a plexiform manner. One of the most important topographical points in the female pelvis is the crossing of the uterine artery in front of the ureter. This occurs on a level with the intravaginal portion of the cervix and about 2 cm. (four fifths of an inch) from the cervix. The ureter passes through the plexus of the uterine veins. The fact of the crossing is important for it occurs close to where we tie or clamp the uterine vessels in remov- ing the uterus or cervix. Hence there is danger of wounding the ureter, a danger which is real for it has occurred in many reported cases. After crossing behind the uterine arteries the two ureters, con- verging slightly, incline somewhat forward so as to reach the front of the sides and then the anterior wall of the vagina. Displacements. — As we have seen (Fixation, page 380) the cervix is the most fixed part of the uterus, while the ligaments holding the body allow it more freedom of motion. The slightly constricted part {isthmus), where the more fixed cervix joins the heavier and more mov- able body, is an exposed and iceah point where ante- and retroflexions occur, the body of the uterus bending and the cervix retaining its proper position. In anteflexion the body is bent forward onto the bladder and we can palpate it by combined vaginal and abdominal palpation, while in retroflexion the body occupies Douglas' pouch and presses upon the rectum, through which or the vagina it may be readily palpated. A certain degree of anteflexion is not pathological but probably normal. If the uterus is ante- or retroverted it seesaws on the Isthmus as a transverse axis so that if the body moves in one direction the cervix is forced in the opposite direction. Thus in anteversion the body lies upon the bladder while the vaginal portion of the cervix tilts up and back into the posterior vaginal fornix ; in retroversion the cervix, tilted forward, presses against the bladder while the body of the uterus presses against the rectum. In either of these cases it may be difficult to make the external os present at the end of a speculum. Any of these malpositions may tend to prevent conception, by reason of the position of the os or the obstruction due to the sharply bent canal. Anteversion is said to be more common among childless women, retroversion among women who have borne children, especially CAVITY AND WALL OF THE UTERUS. 383 if after labor they have been bandaged too tightly and too long in the supine position. As the round lifjanientH prevent backward displacement of the uterus their relaxation allows of retroversion, and their shortening produced anteversion, which may also be caused by the retraction of the utero-mcrnl ligaments, In' pulling the cervix backward and thus tilting the body forward. In anteversion or anteflexion the body of the uterus may so press upon the hladdcr as to cause much irrildhHity. In retroversion the cervix presses upon the bladder near its outlet so as to cause more irrital)ility of the bladder than the pressure of the anteflexed or ante- verted uterus upon its upper part. In the same manner the body in retroversion or retroflexion and the cervix in anteversion may so press upon the rectum as to cause rectal tenesmus and diflicult and painful defecation and thereby induce constipation. The uterus displaced in any of the above ways may regain its normal position unless adhesions occur and fasten it to the viscus against which it presses, whereby the symptoms due to pressure become chronic. Either form of flexion may cause di/smenorrlura by obstruct- ing the escape of the menstrual flow. When the supj)orting ligaments are relaxed and this condition is combined with a weakening of the support of the perineum, following its rupture, and an abnormally heavy uterus, the latter may sink or become prolapsed so as to present at the vulva or even to lie partly or wholly outside the vulva. A much rarer condition, and one more difficult to treat, is where the uterus is inverted or turned inside out, which may be due to the traction of a polypoid submucous fibroid. The small cavity of the uterus is a mere fissure. The cavity of the body is triangular in shape with an ojiening at each angle, the Fallopian tulies above and the narrow internal os l>elow. The latter oj)c'ning is at the upper end of the fusiform cervical canal which ends below in a trans- verse fissure, the external os. The narrowness of the os internum may be such as to be an obstacle to the menstrual flow and a cause of dys- menorrhcea. In old age it becomes still more contracted and even closed. The cervical canal may be gradually yet fairly quickly dilated so as to allow inspection and digital examination of the uterus and even the enucleation of large tumors. The mucfnis rnnnhranr of the cervical canal secretes a viscid alkaline mucus and path* (logically its mucous glands are liable to become vesicular, when they are sometimes known as ovula Xabothi. The motion of the cilia of the uterine mucosa is downward toward the os externum. The length of the uterine cavity averages about two inches in nulli|)ane and 2| to 2A inches in multipane. We can determine the length by the uterine sound. As there is, strictly speaking, no cavity, the bulk of the uterus is made up of its thick wall. A part from its remarkably thick mucoiiH uum- hrane, which is thickened and then i)artly cast off at the monthly periods and becomes the deeidua during gestation, this thick wall con- sists principally of unstriped niusde Jibers. This tissue, arranged in 384 PELVIS AND PERINEUM. three imperfect layers, is remarkable for its hypertrophy and new growth during pregnancy, and it is largely by its contraction that the foetus is expelled. The muscle tissue of the uterus is continuous with that of the utero-sacral, round, utero-ovarian, and broad ligaments, and that of the Fallopian tubes, vagina and bladder. In this tissue in any part of the uterus, but more often in the body, develop the common fibroids, myomata or fibromyomata, as they are variously called. These may be single or more often multiple and may attain a very large size ; one of one hundred and forty pounds has been recorded, but as a rule they do not attain the size of the largest ovarian tumors. In their evolution they often acquire a partial or a complete capsule and may protrude on the surface (^subperitoneal variety), or into the cavity (submucous variety), or they may remain well en- closed in the walls (interstitial variety). They occur during menstrual activity, they tend to degenerate after the menopause and sometimes become involuted with the rest of the uterus after parturition. They are particularly common among negroes. The submucous variety is apt to cause severe bleeding and hence should be removed early. The subserous variety is liable to adhesions from local peritonitis. They may prevent conception, cause miscarriage or complicate parturition, according to their size and situation. The uterus, enlarged from pregnancy or other cause, may press upon the iliac vein, causing hemorrhoids or varicose veins of the legs ; on the lumbar or sacral nerves, causing neuralgia and cramps ; or on the renal veins or kidneys, causing albuminuria, etc. Owing to its small size, its great motility and the protection afforded by the pelvis the unimpregnated uterus is rarely ivounded. The preg- nant uterus may be ruptured by violence or by its own contraction during labor, especially if the passage of the foetus is obstructed. The rupture is usually near the junction of the cervix with the body. Vessels. — The uterus is supplied by the uterine arteries from the internal iliac and the ovarian from the abdominal aorta. The uterine artery of either side passing horizontally inward in the base of the broad ligament crosses in front of the ureter (see p. 382), and reaches the side of the cervix whence it runs up along the side of the uterus, between the folds of the broad ligament. At the cornu or angle it anastomoses freely with the ovarian artery. In young individuals the artery lies |-1 cm. from the uterus and still further removed from the cervix and the lower part of the body. After repeated pregnancies it comes to lie nearer the uterus and becomes more tortuous so that in operations it is more difficult to separate the artery from the uterus. At the uterine end of the round ligament the small funiculitr artery, accompanying the round ligament, anastomoses with the uterine and ovarian arteries. Numerous transverse branches from the uterine arteries supply the uterus and anastomose across the median line. Ow- ing to this fact and the free anastomosis with the ovarian artery, a liga- ture may be placed around the uterus without affecting the circulation above or below. THE OVARY. 385 By a lateral incimon into the upper end of the vagina, opening into the base of the broad liganunts, the uterine arteries may be pulled down and tiefl, the relation of the artery to the ureter being carefully borne in mind, as it should be also in securing and dividing the artery in hysterectomy. The veins form large jjlexuges and accompany the corresponding arteries. The lymphatics from the cervix accompany the uterine veins and enter the pelvic node.s, beneath the bifurcation of the iliac artery, thone from the hofJi/ accompany the ovarian veins and enter the lunthfir nodea. Development. — The uterus and vagina are formed l)y the fusion of the lower cuds of the two (hict.s of Midler, tiie two unuuited upper end.s of which form the Fallopian tubes. The bicoi'ned and double uteri are due to the failures of this fusion in whole or in ])art, and thev mav be associated with a partial or comj)lete septum dividing the vagina. Pregnancy as well as many of the pathological conditions may be con- fined to one half or one cornu of a malformed uterus. The uterus is reached for operation through a median cceliotomy or through the vagina. In its removal (lii/f^terectomi/) its connections with the broad ligaments, vagina and bladder are the principal things to be divided or separated. Kemember that its two arteries reach it through the broad ligament, the ovarian at its cornu, the uterine opposite the cervix. We repeat again that the relation of the ureters to the cervix and the uterine vessels must be borne in mind. The Ovary. The ovary is a paired organ, sluiped like a broad almond whose length is 1} inches, breadth | inch, thickness h inch. Its ireight is about 100 grains in the adult, the right being usually a little larger. Before puberty it is small, it enlarges at puberty, and after the menopause atrophies very much. Position. — We may describe a typical position of the ovary remem- bering that, being a movable body, it may temporarily occupy other positions without causing any disturbance. The latter positions may more readily change into abnormal positions which do cause functional disturbances. When the other pelvic organs are normal and there have not been repeated pregnancies, the typical position of the ovary in the upright posture is with its long axis vertical, its attarlied border in front and slightly external, its free border behind and slightly internal, toward the rectum, its lateral surface against the lateral pelvic wall in the fossa ovarica, and its nn:^-ifd surface looking into the ]>elvis. The fossa ovarica, or the depression on the inner surface of the in- ternal obturator muscle in which the ovary lies, varies much in deptii and is bounded above and in front by the superior vesical artery, behind by the ureter and uterine artery, below and in front by the lat- eral attachment of the broad ligament. Lodged in this fossa the lat- end surf ice o{^ the ovary is not visible and the attadied border, upper end, and a variable amount of the free border antl mesial surface are 386 PELVIS AND PERINEUM. covered by the Fallopian tube, so that but little of the ovary may be vis- ible on inspecting the pelvis. The two ovaries are seldom entirely symmetrical in position, one being higher or more anterior than the other and, if the uterns is deflected to one side (according to His, to the left side in the proportion of three to two), the ovary on the opposite side is more exposed by the tube being somewhat drawn away from it. In the supine position the ovary lies with its long axis horizontal. The changing relations of the contiguous viscera also probably affect its position. The ovary may be displaced into Douglas' sac or even into the utero- vesical pouch ; it may be found, especially in childhood, in an inguinal or femoral hernia, where it is liable to strangulation, and it may become fixed in its abnormal position by adhesions. In ijregnancy the posi- tion of the ovary is normally altered. When enlarged the ovaries may he felt through the vagina, or even better through the rectum. Their position is indicated on the surface by a point about two inches internal to the anterior superior iliac spine or in a sagittal plane midway between the latter spine and the symphysis. A frontal plane at the promontory of the sacrum touches or lies just behind the ovaries. The position of the ovary corresponds to the middle of the upper margin of the acetabulum. The ovary is held loosely in position by the attachment of the tuboovarian ligament (fimbria ovarica) to its upper end and of the uteroovarian ligament to its lower end, and by being contained within the posterior fold of the broad ligament from which it projects backward so as to be connected with it only along the attached mar- gin. The ligamentum infundibulo-pelvicum, a fold of the broad liga- ment containing the ovarian vessels, passes from the side of the pelvis, above and in front of the ovary, to its attached border where the vessels enter the hilum. This "ligament" helps to support the ovary and forms part of the pedicle in removal of the ovary or ovarian tumors. Of the relations of the ovary we have named the most important, the Fallopian tube and the ureter. The ureter, with the uterine artery in front of it, lies behind the ovary. External to the ovary, in the fossa ovarica, are the obturator vessels and nerve. Internal to the ovary, in addition to the tube, are coils of intestine. Structure. — The ovary receives from the posterior layer of the broad ligament an external covering, which differs from the serous membrane of the latter in being covered by columnar epithelium. Many of the ovarian cysts take origin in this epithelium. The surface is smooth before puberty and more and more scarred during menstrual activity. The scars represent where ovisacs have ruptured and the larger ones in multiparse the position of a true corpus luteum which forms when pregnancy occurs. Slight extravasation of blood follows the rupture of an ovisac (or Graafian follicle) but when a vessel of unusual size is ruptured, or possibly when the ovary is unduly congested, a sudden copious bleeding may occur and the blood collect in Douglas' pouch as PLATE XLV. FIG. 89. TIONS OF \ ROUND LIG*- ** ' WENT Female pelvic viscei-a from above. The ovary and tube of the left side have been lifted out of place. (Gerrish, after Testut. ) DEVELOPMENT OF THE OVARV. 387 a pelvic hcematoccle, which we can then feel as a doughy tumor by vagi- nal or rectal examination. The so-called tunica albuginea is a thin layer and is merely a con- densation of the ovarian stroma. Within it Hes the cortex con- taining numberless Gnuifan foUiclen (ovisacs) in various stages of development and the remains of some that have burst at the men>trual periods. Some ovarian tumors (cystic) are due to a collection of tluid in a dilated Graafian follicle (unilocular) or follicles (multilocular). The ovisacs, as they ripen, enlarge and approach the surface, where they appear as large rounded projections when ready to rupture and set free the ovum. The ovary may also be affected by maJIf/nant nnc r/rairllis and l.v (hr- mold Gijsfs^ the latter due to an island of epiblast abnormallv included in the mesoblastic ovarian tissue. Ovarian tumors, if one side alone is involved, are at first unilateral in position, displacing the body of the uterus to the opposite side, the cervix usually to the same side. Later they ascend into the abdomen, disj)lacing the intestine upward so as to cause dullness on percussion, in distinction to the tympanitic note we obtain in ascites from the bowel floating above or in front of the fluid. The ve.'^sels enter or emerge from the ovary at tlie hilum, near which the ovarian veins form a large plexus in the broad ligament (pam- piniform plexus). Development. — The ovary, developed in the lumbar region like the testis, is pulled down into the pelvis in a similar manner by the inguinal liyrtment of the primitive kidney. This ligament, attached to the uterus and the inguinal region, rcm(iin.'< as the uieroovdrinn ligament between the ovary and the uterus, and the round ligament between the uterus and the inguinal region. In hernia of tiie ovary the fibromuscular utcroovarian ligament draws the uterus for- ward and to the side of the hernia, a fact that may be useful in diagnosis. The upper series of Wolffian tubules may persist as a small pedun- culated cystic sac, the Jii/dafid of Morgagni (appendix vesiculosa), at- tached to the part of the broad ligament forming the free border of the mesosalpinx and adherent to the fimbria ovarica or one of the other fimbrine of the tube. The parovarium (organ of Rosenmiiller) is the atrophied remains of the middle series of the ^^'olfllan tubules, which in the male form the epididymis. This lie.^ above the ovary in the mesosalpinx and consists of several vertical tubes joining at right angles a horizontal tube, a segment of the Woltlian duct, which lies above them. The Wolthan duct disapj)ears elsewhere as a rule, but may occasionally persist as a small canal in tiie broad ligament close to the uterus, the duct of (lartner, which is lost in the vaginal wall or may open near the urinary meatus. In these fietal struitures, esj)e- cially the parovarium, develop the majority of the unilocular cysts of the broad ligament [parovarian ci/sts). These generally c(mtain a clear fluid and may often be cured by simple puncture. 388 PELVIS AND PERINEUM. The Fallopian Tubes (Oviducts). These trumpet-shaped tubes, about 4 J inches long, are structurally con- tinuous with the uterus at its superior angles from which they pass out- ward to the sides of the pelvis, where they are closely related and connected with the ovaries. They lie between the two layers of the broad ligaments, along their upper free margins, so that the serous membrane covers three fourths of their circumference and, being re- flected off inferiorly, forms the mesos(djjin.r. The lower fourth of their circumference is in contact with the subperitoneal tissue between the layers of the broad ligaments. Thus a tuba/ pregnanci/ or a fluid col- lection in the tube (hydro- or pi/osalpinx) when it rupAures may burst into the peritoneal cavity, a dangerous course, or between the layers ol the broad ligament. The tubes lie between and slightly above the round ligament in front and the uteroovarian ligament behind. Course and Size. — At the outset it must be remembered that the tube, lying in the free margin of the broad ligament and connected with two movable viscera, the uterus and ovary, must of itself be freely movable and thus affected in its position by the conditions of the neighboring viscera. The narrow sfraigJd inner portion, or isthmus (3—6 cm. long), passes horizontally outward and slightly backward from each superior angle of the uterus to the uterine or lower end ot the ovary at the side of the pelvis. Thence the curved and dilated portion, or ampulla (7—9 cm. long), bends sharply upward along the mesial aspect of the attached margin of the ovary to its upper or tubal end, over which it bends backward and then downward along the free border and the mesial surface, upon which rests the funnel-shaped fimbri- ated extremity, fringed by a circle or circles of diverging fiinbrice | to -| inch long. Thus the ovary is more or less hidden (see Ovary, page 386). One fimbria longer than the rest (1-1| inches) and attached to the upper end of the ovary (^fimbria ovarica) constitutes the tuboova- rian ligament. The Fallopian tube forms a passage ivay between the uterine cavity (and thus the surface of the body) and the peritoneal cavity, whereby the ovum, when it escapes into the latter by the rupture of the ovisac, may reach the uterus. Hence also through this passage way uterine or vaginal douches and microorganisms may reach the peritoneal cavity and cause pelvic and perhaps general peritonitis. The fiynbrice of the funnel-shaped outer end of the ampulla of the tube normally so embrace the ovary that they conduct the ovum into the abdominal opening of the tube. When from inflammation these fimbriae become adherent together, or to neighboring parts, and close the opening on both sides the ova cannot escape out of the abdominal cavity and sterility results. Again, in rare instances when the adapta- tion of the fimbriae is imperfect, an ovum, fecundated by spermatozoa which have passed through the tube, may drop back and develop in the peritoneal cavity as one form of extra-uterine pregnancy. The mucous membrane which lines the tube is arranged in longi- tudinal folds and lined by a ciliated epithelium whose movement is PLATE XLVI FIG. 90. Sagittal section through the ovary and broad ligament. 1. Broad ligament. 1^. Anterior surface. 1". Posterior sur- face. 2. Mesosalpinx. 5. Fallopian tube. 6. Round ligament. 7. Ovary. 1'. Hilum of ovary with vessels entering the same. 8. Graafian follicle. 9. Uterine artery. lO. Uterine veins. 11. Cellular tissue at the base of the broad ligament. 12. Ureter-. (Testut. 1 FIG. 91. .RECTAL PERITONEUM ECTO-UTERINE POUCH ANTERIOR AND POS- TERIOR LAYERS OF BROAD LIGAMENT VESICAL PERITONEUM VESICO-UTERINE POUCH VAG1N»^ The cervix uteri and upper end of the vagina, showing their relations to the peritoneum. Diagrammatic. (Gerrish, after Testut.) THE BROAD LIGAMEi\TS. 380 toward the uterus, thus favoring the passage of the ovum. When from inflammation extending from the uterus, i)erhaps of gonorrh.i-al origin, the tube has lost its epithelium the descent of the ovum is hindered and the ascent of spermatozoa is not, thus favoring the occur- rence of extra-uterine pregnancy. The lumen of the tube varies, being about 1 mm. at the uterine aperture, | incii in tiie isthmus, ^ inch in the ampulla, and ^^^ to | inch at the abdominal ai)erture. Ciliated epithelium extends along the inner surface of the fimbriie and grad- ually merges into the endothelium of the peritoneum on their outer surface. The fimbriated extremities furnish the only instance where serous and mucous membranes adjoin one another. As the result of injianimdiion the tube may be dosed, especiallv at its narrow points, the two extremities, so that the products of inflam- mation are pent up within the tube, which becomes dixtended to the size of the intestine {hydro- or pyosalpinx, pus tube). In such cases also the peritoneum on its surface is apt to contract adhesions to neigh- boring parts. The closure of the lumen of the tubes also causes Htrrilitii. A tube enhirgcd by tubal pregnancy or from hydro- or pyosalpin- gitis may be felt by vaginal or rectal examination. They may be reached for operation (1) by the vaginal route, («) laterally between the layers of the broad ligament, and therefore extra-peritoneallv, {b) jx)steriorly through Douglas' pouch, as in vaginal hysterectomy; (2) through an abdominal incision. It should be remembered in operations that the fimbriated extremity may be in close relation with the ureter, a matter of importance if adhesions exist. The tubal blood supply is from a branch of the ovarian artery run- ning along its lower border in the broad ligament which forms its mesosalpinx. In their development the Fallopian tubes represent the upper ex- tremities or ununited parts of the ducts of Midler ; hence morpho- logically as well as structurally they are continuous with the cornua of the uterus. The Broad Ligaments. These ligaments, also called lateral ligaments from their position on either side of the uterus, form as it were a common mesentery for the uterus and its adnexa, especially the Fallopian tubes. They con- sist essentially of the tico layers of peritoneum which, after covering the anterior and posterior surfaces of the uterus as described (p. 381 ), are reflected from the sides of the latter to the sides and floor of the jwlvis, where they become continuous with the parietal peritoneum. In addition to the Fallopian tube, ovary, round ligament and fietal relics,the broad ligament of each side contains between its folds, the utero- ovarian ligament, the uterine, ovarian, and funicular vessels, the corre- sponding lymphatics, the uterine plcxusof nerves, unstriped muscle tissue continuous with the uterus mesially, and loose adipose cellular tistfuc con- tinuous with the subperitoneal tissue of the pelvis. In this tissue at the base of the ligament lies the ureter in relation with tiie uterine ves- 390 PELVIS AXD PERINEUM. sels (see p. 382). Inflammation of this tissue [parametritis, if near the sides of the uterus) is the commonest form of pelvic ceHulifis in women, and often results in abscess. It may spread from an inflammation of the small amount of similar tissue separating the muscular and perito- neal coats of the uterus (pjerimetritis) and it may extend to the similar tissue beneath the parietal peritoneum of the pelvis, or pass over the pelvic brim into the iliac fossa where it often points just above Poupart's ligament (see p. 275). The muscular tissue ensheaths the vessels and is of special importance in serving as a ."tupport to the uterus and helping to keep it in place. When the uterus enlarges during pregnancy it fills the space between the folds of the broad ligaments so that the latter nearly disappear, to reappear with the involution of the uterus Hence for a time after parturition they are lax and offer but feeble resistance to uterine dis- placements, a reason for not allowing a woman to get up too soon after confinement. Each broad ligament represents a quadrilateral plate which, with the uterus, divides the pelvis into an anterior (utero vesical) and a posterior (uterorectal) fossa. The inner or mesial border of the broad ligament represents its attachment to the sides of the uterus and the upper end of the vagina. In this border the uterine vessels pass up along the sides of the uterus. As the posterior fold passes onto the posterior surface of the upper end of the vagina we can understand how an incision in the lateral wall of this part of the vagina will open into the space between the two layers of the ligament at its base, and how we can palpate through the vagina any tumor or swelling situated here. The base or lower border of the broad ligaments rests upon the floor of the pelvis, formed by the levator ani and covered by the rectovesical fascia. The abundant areolar tissue here gives passage to the uterine vessels and nerves and the ureter, which pass from behind and externally forward and inward. Here, as well as along its lateral border, its layers become continuous with the parietal peritoneum of the pelvis. Owing to the slant of the pelvic cavity the anterior layer is reflected at a higher level than the posterior, so that the latter is deeper or longer than the former. It is also more important on account of its direct relation with the ovary and the fimbriated extremity of the tube. Its lateral borders transmit the ovarian vessels and the round ligaments and meet the sides of the pelvis, lined by the obturator internus muscle and fascia. The two layers are continuous along the free upper border of the broad ligament which contains the Fallopian tube, so that the upper part of the ligament forms the mesentery of the tube (^^mesosalpin.v). But the tube does not extend to the lateral limits of the broad ligament. The outer part of the free upper margin of the ligament, beyond the fimbriated extremity of the tube, is at a lower level than the mesial portion (mesosalpinx) and contains the ovarian vessels as they pass from the sides of the pelvis to the ovary. It presents a concave rounded margin and is called the infundibulo -pelvic ligament, since it extends THE ROUND LIGAMENTS. 391 between the infundibuliim (fimbriated extremity of the tube) and the side of the pelvis. Together with a portion of the broad liji^anient, the Fallopian tube and the utero-ovarian ligament it constitutes the jjedicle of an ovarian tumor. The upper part of the broad ligament which forms the memsalpinx is thin, translucent, devoid of muscular tissue and rontfiinn the fcjetal relics and the tubo-ovarian vessels. Projecting from and attached to the posterior layer is the ovary. More mesially the recto-uterine or posterior ligaments of the uterus are continuous with this same laver. Betircen the folds of the broad ligament um\ocu\nr ci/stic tumor-s (usually originating from f(etal relics), hematocele, abscess and tumors are found, of which the cystic tumors are perhaps the most common. These may all be palpated through the vagina and reached for operation by means of a vaginal or abdominal incision. Unlike many ovarian tumors they are commonly sessile and rarely, if ever, pedunculated. We are accustomed to think of the broad ligaments as vertical, and as such to describe them, but when we consider the normal anteflexed position of the uterus we find that the greater part, except the base, of the uterine end of the ligament is more horizontal than vertical. The Round Ligaments. These two rounded cords of unstriped muscle, fibrous and elastic tissue, about five inches in length, commence at the upper angles of the uterus just below and in front of the Fallo})ian tubes, where thev are continuous with the superficial uterine fibers. P^ach passe.s at first downward and outward toward the base of the broad ligament; then nearly horizontally outward near the base of the ligament and beneath its anterior layer, in front of the ureter and the uterine vessels; thence upward, outward and forward over the pelvic brim and the lower end of the iliac fossa to the internal abdominal ring. In the latter part of its course xicorrcjiponds to that of the vas deferens and crosses, like the latter, the obturator and external iliac vessels and the unobliteratcd portion of the hypogastric artery (/. e., superior vesical artery), and finally loops around the outer side of the curve of the deep ej)igastric artery to enter the inguinal canal. In this part of its course also it not infrequently projects so far forward as to form a kind of short mesentery. In passing through the inguinal canal it receives a cover- ing from the layers of the abdominal wall like the spermatic con), but the striped fibers derived from the cremaster are mostly attached to the pillars of the ring and the pubic spine. It may be accompanied by a process of peritoneum, the canal of Nuck, which correspontls to the processus vaginalis in the male and oi-curs as a sac-like jxnich above and in front of the mund ligament, not as a hollow tube around it, as is sometimes described. This serous pouch is constant in the fojtus, occurs in children in twenty per cent, of cases (Zucker- kandl), and in isolated cases may persist even to adult life. But usu- ally it is only represented by a funnel-shaped depression at the internal ring. 392 PELVIS AND PERINEUM. When present it predisposes to inguinal hernia, or it may form the sac of a hydrocele. After leaving the external ring, which in the female is smaller than in the male and lies just external to and a little above the pubic spine, the round ligament expands fan-like to be at- tached to the connective tissue of the labium majus and the periosteum over the pubic spine. When the uterus is in its typical position the round ligaments are not taut, but only when there is bachvard displacement or a prolapse, hence they play but a secondary role in supporting the uterus. For the displacements just named Alexander's operation of shorten- ing the ligaments, and thereby pulling the uterus forward and, if pro- lapsed, upward, has been often performed. The incision is like that for inguinal hernia. Sometimes there is difficulty in finding the ligament and for this pur- pose the external ring is exposed and the tissues below and internal to it are hooked up and pulled upon, or the canal is slit up for a distance and the contents of the canal similarly dealt with. We may pull down and shorten the ligament by as much as four inches in some cases. After pulling down the cord for a certain distance a pouch of peritoneum is apt to appear at the external ring. This may represent the canal of Nuck, or more often a new pouch pulled down from the peritoneum at the internal ring. Such a pouch occupying the canal naturally pre- disposes to hernia and the latter has not infrequently followed such operations. The round ligament is stronger than one would suppose and bears a very considerable traction (.5-.6 kgr., according to different observers). In pregnancy it becomes four times as stout as in the non-pregnant state. Contraction or preternatural shortness of the ligaments is said to be a cause of anterior displacement of the uterus. Its artery, the funicular, is derived like that of the vas deferens from the superior vesical (/. e., hypogastric), as the ligament crosses the latter. It anastomoses with the uterine and ovarian at the uterine end and with the external pudic in the labium. The Vagina. This musculo-membranous passage tcay between the vestibule and the uterus is directed upward and backward in the line of the pelvic outlet below and the pelvic axis above. It forms an angle of 25 to 35 degrees with the long axis of the body and of 65 to 75 degrees with the horizon, but these measurements vary with the pelvic inclination of the individual and with the condition of the bladder and rectum. Nearly half of it lies below the plane of the pelvic outlet. Its icalls, ordinarily in cotifacf, present on transverse section an H- shaped fissure. Its anterior wall measures 2^ to 3 inches in length, the posterior nearly 3^ inches. In the lateral dimensions it is extra- ordinarily dilatable, admitting the passage of the foetus at birth. The anterior wall is in close relation with the urethra below and the bladder above. The trigonum vesic(e and the base of the bladder just above it THE VAGI^^A. 393 are connected with the vaginal wall by connective tissue continuous with the subperitoneal tissue between tlie cervix and the bladder. So close is this connection, especially with tiie trigonuni, that when the vagina is everted like a glove-finger in pro/apse of the uterus the bladder wall is drawn down with it as a j)ouch projecting into the vagina {ci/s(ocek'). In complete prolapse the urcthm, the lower two thirds of which are most infiniafc/i/ comiccfcd ivifh the raf/ina/ my///, is also in- verted, so that from the meatus its direction is downward and back- ward. When the support afforded by the perineum is weakened by its rupture acystocele may project into the vagina without uterine pro- lapse, but, according to Sims, a cystocele always precedes complete prolapse of the uterus. Owing to prolonged pressure between the fwtal head and the pubic- bones during a tedious labor, the vesicovaginal septum may slough and give rise to a vesicovaginal jiHhda. Similar fistuhemay also occur from a like cause between the urethra and vagina or between the idadder and cervical canal or these three forms of fistula may be combined in one. The trigonum vesicce \s faintly indicated on the anterior vaginal trail as follows: the base by a transverse fold of mucous membrane, slight Iv convex inferiorly, about 2} to 8 cm. below the external os uteri, and the sides by two folds which diverge from the upper end of the ante- rior columna rugarum. Pawlik used these markings in caiheterizing the ureters, whose openings are at the upper angles of the trigonum, but we have a surer way in Kelly's method through a urethral specu- lum. Above the base of the trigonum the ureters pass upward and outward diverging somewhat so as to reach the upper end of the lateral vaginal walls, where they occupy the triangular space between the levator ani muscle and the vagina. Calculi lodged in the lower inch or two of the ureters may therefore be felt and removed through the upper part of the vagina. The lateral walls of the vagina are in contact above with the base of the broad liganients and their contents, including the uterine vessels. Hence we can here palpate or expose these parts by incision (see Broad Ligaments, p. 390). In its lower two thirds the lateral vaginal wall is in contact with the rectovesical fascia and the antero-internal border of the levator ani muscles as well as with the vaginal vessels. The posterior vaginal wall is in contact with the rectum from which its up])cr fourth ( ',' inch or so) is separated hi/ the peritoneal pouch of Douglas, its middle portion by areolar tissue, continuous with the sub- peritoneal connective tissue, and its lower end by the perineal bodif. Hence we can paljjate through the vagina the contods of the lower end of Douglas' pouc/i, whether this be the coils of intestine, normally present, or a retrouterine hicniatocele, a retroflexed uterus, a uterine fibroid, or a displaced and perhaps cystic ovary or tube. Through the upper end of the posterior vaginal wall we may reach by incision the peritoncid cavity in Douglas' pouch and through this incision break up adhesions l)ehind the uterus or reach its adnexa. The peritoneal cavity may also be opened by traumatism inflicted tliroiigh thc^ vagina, 394 PELVIS AND PERINEUM. and through such an opening intestinal coils may protrude. Rarely the intestinal coils occupying Douglas' pouch may protrude from above and behind into the vagina as an enterocele, or lower down the rectum may form a similar pouch or redocele. Such a pouch does not necessarily accompany a prolapse of the uterus with eversion of the vagina, for the latter is more loosely connected ivith the rectum than with the bladder and may not pull it down. Similarly in prolapse of the rectum the vagina is not necessarily pulled down. Although the rectovaginal septum does not suffer from pressure as does the vesicovaginal, yet it may be torn through even to a high level at childbirth. If such a complete rupture is not healed throughout it may leave a rectovaginal fistuUi . The upper end is the largest part of the vagina. Its angle of reflec- tion onto the cervix is known as the fornix and should be supple when normal. Into this upper end the intravaginal portion of the cervix projects at an angle. (See Uterus, p. 381.) The line of vaginal attachment is oblique from behind forward and downward, making the posterior vaginal fornix much deeper than the anterior and the pos- terior vaginal wall longer than the anterior, so that it may sometimes be difficult to reach the limit of the posterior fornix with an examining finger of moderate length. The lower end is the narrowest part and may be still further nar- rowed by the engorgement of the bulbs of the vestibule, which flank it on either side, and by the contraction of the constrictor or sphincter vagince and perhaps also of the levatores ani. The spasmodic contraction of the constrictor vaginse known as vaginismus may interfere with coitus. It may require surgical treatment, but the surrounding parts should first be carefully inspected to discover if possible some cause of reflex irritation. As the vagina near its lower end pierces the triangular ligament, this part of the canal is also the most resistant to dilatation. The lower end, orijicium or introitus vagina', is partly shut off from the vestibule in the virgin by an imperfect septum, the hymen. This mem- branous fold varies much in shape, but it is usually crescentic and attached behind and laterally, having an opening in front, though it may form a complete septum with one, two or several small openings or, occasionally, with no opening {imperforate hymen). The latter con- dition causes a damming back of the menstrual flow which fails to appear and, unless relieved, distends the vagina, the uterine canal and even the tubes, and hence calls for surgical relief. Although the hymen is usually ruptured by the first coitus it may not be until par- turition, hence it is not a proof of virginity nor is its absence incom- patible with virginity. After parturition remains of the hymen ap- pear as rounded elevations [caruncuke myrtiformes) around the orificium vaginae. As to structure the very elastic vaginal mucosa, lined by stratified epithelium, is destitute of glands, hence vaginal discharge is of the nature of a transudation. Beneath the mucosa is a rich venous plexus which may be regarded as erexitile tissue and may become vaj-lcose and THE FEMALE URETHRA. 395 form a pile-like tumor near the external orifice. In infancy and childhood the vagina is often relatively long, corresponding to the high position of the pelvic viscera ; in old (ujc it undergf>es atrophy and sometimes partial closure. Congmitnlly it may be more or less com- pletely divided by a vertical septum into lateral halves, usually con- nected with the halves of a bifid uterus. It may also i)e verv !-mall and rudimentary or even \vantiug. In the latter conditions other parts of the genital system, uterus and ovaries, are likely t*t be rudi- mentary or wanting. Fig. 92. DORSAL VEIN OF CLITORIS PREPUCE OF, CLITORIS GLANS CLI-' TORIOIS Sagittal section of the vagiDa and neighboring parts. (Gebbisii, after Tksti't. ) The Female Urethra. This reprexenfs the prostatic find membranouji ]>ortiontt of the male urethra and, like the latter portion, passes through the two layers of the rather indistinct triangular ligament and the striped muscular fibers representing the compressor urethrre muscle (deep transversus perinei) and possil)ly the prostatic fibers also. The strijicd Jihci'-'^ surrouud the urethra as a sphincter in its upper 1 cm. only, where it is conuected to the vagina by loose connective tissue ; in the lower part of the urethra, where the urethral and vaginal walls blend to form the urethrovaginal septum (1 cm. thick above), these fibers occur in front only. Circular unstriped fihcr.^ around the vesica/ end form a |)o\verful sj>hincfer. As may be ]>roved by distension of the bladder in the cadaver, no muscu- lar action of the sphincters is necessary to retain urine, provided there is no vis a tergo througli abdominal pressure or the contraction of the bladder. The urefhrn may be felt between the anterior vaginal wall and the pubes like a round cord. The female urethra incasurcfii 1|^ to 1.^ inches 396 PELVIS AND PERINEUM. in length. In the erect position it is directed downward and slightly- forward, nearly parallel with the vagina though inclining slightly more forward below. Hence its lower end is further from the vagina than the upper end. It is slightly convex backward yet not enough to inter- fere in any way with the passage of a straight catheter. Its exit from the bladder is a little below and an inch behind the middle of the sym- physis. It passes f to 1^ of an inch below the subpubic arch and its external meatus, usually a. sagittal fiasure, is found near the base of the vestibule on a papilla one inch behind the clitoris. It is possible after practice to pass a catheter without exposure of the parts by means of the latter measurement, or better by means of a tubercle just behind the meatus at the lower end of the anterior columna rugarum of the vagina. In children and when the parts are swollen, as after a difficult labor, the meatus is relatively far back and difficult to find. The mecdus is the narrowest part of the canal, which averages 7 to- 8 mm. in diameter, but it is extremely dilatable as it is not surrounded by dense resisting structures as in the male. Thus it may be gradu- ally dilated under an ansesthetic so as to allow the removal of small calculi or foreign bodies, and the introduction of the finger for explora- tion or of the cystoscope for examination or ureteral catheterization. The resulting jxiralysis, if it occurs, quickly disappears unless the dilatation has been too great and too abrupt, when it may persist, as reports of cases show. In cases of imperforate hymen and narrow- ness or absence of the vagina the urethra has even become the channel of sexual intercourse. In the submuGosa is a cavernous venous plexus which gives the mucosa a darkish hue during life and may become varicose and form a pile-like tumor near the meatus. Small vascular tumors (papillary angiomata) may spring from the mucous membrane at or near the meatus, espe- cially in its posterior segment. These " urethral caruncles " bleed readily and are highly sensitive and sometimes very painful, so as to give rise to marked local and general symptoms and to demand removal. Since the female urethra is a short wide tube which serves the pur- pose of a urethra only, inflarnmcdion is less common, less severe and easier to treat than in the male, and the resulting stricture is cor- respondingly less common and less complete and often requires no treatment. THE BULBI VESTIBULI AND VULVOVAGINAL GLANDS. 397 EXTERNAL GENITALS. A. FEMALE EXTERNAL GENITALS. The vulva i.s really a deJf-Uhe apace between the rima pudendi (the fissure Ix-twcen the two labia majoraj inferiorly, and the hymen or its remains superiorly. It includes all the other external genitals in the female. The two labia majora repretient the two lateral halves of the scrotum in the male and, like it, are compourd of .v/:/// enclosing an im- j)erfectly developed (hnios, and are subject to the same pfifholof/lral coiifJition.s. They are the usual situation of elephantiasis in the female, are greatly swollen in cases of oedema and may contain large extrav- asations of blood (pudendal htematocele) after injury. They contain a considerable amount of fat, with whose fibrous capsule and partitions the round ligament is connected. Inf/uinal Jicrnun (sometimes contain- ing the ovaryj may descend into them anteriorly, pudciidal lierniir., which escape between the vagina and the pubic ramus more posteriorly. Cystic collections, probably in the unclosed canal of Xuck and known as ^^ hydrocele in the female," may also occur in the labia majora. Their point of meeting posteriorly, the posterior rommi^mire or Jour- the common seat of chancres in the female. The labia minora or nymphae contain much vascular tissue and are not infrequently redundant, projecting below the vulva, es|>ecially in certain races (/. e., Hottentots, etc.). On approaching the median line anteriorly they bifurcate and their branches unite from side to side to form the prcrpnfinin and the frenuluni of the clitoris. Extravagant imj)ortance has been attached by some to the adhesion of this prepuce to the clitoris as a cause of various symptoms. The bulbi vestibuli, two pyriform masses of erectile tissue corres|X)nd- ing to the lateral halves of the bulbs of the male urethra, lie on cither side of the orifice of the vagina and extend thence on either side of the vestibule, beneath its mucous membrane, to a point below the clitoris, where the two connect. Rupture of the bulb may occur from injurj', especially during pregnancy when they are enlarged, and results in the formation of a large hjematoma (pudenda/ hnnudocele). Behind the bulbi vestibuli and on either side of the posterior half of the vaginal orifice lie the two vulvovaginal glands {the (/lundx of Bartholin), which probably represent Cowper's glands in the male. The diuis, three rpiarters of an inch long, opi n just outside of the vaginal orifice and opposite its center, where the opening may often be seen as a small red depression on everting tiie nympha? and pressing the hymen inward. The r/lands are one third to one half inch long, lie beneatii the superficial perineal fascia and, like the bulbi vestibuli, are covered externallv bv the sj)hincter vagimo muscle. The duct and gland are liable to i)iflanimation and suppuration, often of gonorrlneal origin. The resulting vidvovaginal abnceHS is felt in the base of one of the 398 PELVIS AND PERINEUM. labia majora and causes oedema there. Cystic dilatation of the duct is not infrequent. These glands atrophy after the menopause if not be- fore. In general the vessels and nerves of the external genitals corre- pond to those of the homologous parts in the male ; thus the lymphatics enter the inguinal nodes. B. THE MALE URETHRA AND EXTERNAL GENITALS. The Male Urethra. The urethra is to be regarded as a dosed valve whose walls are usu- ally in contact. It is a camtl only when open for the passage of urine, semen or instruments. Divisions. — In its passage from the bladder at the vesical outlet, or internal meatus, to the external mea- tus it is divided in various ways ac- cording to (1) the parts through which it passes (prostatic, membranous, spongy, etc.), (2) its fixity and mo- bility, (3) its direction (curved or straight), (4) its pathological and therapeutic peculiarities (anterior and posterior urethra). The prostatic urethra, 1 to 1^ inches long, is spindle-sAa^jcr/. Its upper narrowed end, the vesical out- let or internal meatus, is formed by the annulus urethralis (see p. 369). The latter is as a rule quite dilatable but may become thickened or more resistant as the result of spasmodic action during micturition in gouty subjects or in those with chronic urethral trouble. In such cases the condition may be relieved by stretch- ing, with or without a slight incision. If in such cases the prostatic sinus is deep the beak of the catheter or sound may impinge on its posterior wall, under the back of the annulus, and thus enter the bladder with diffi- culty if at all. The central dilated part of the pros- tatic urethra presents an inverted U on cross section, owing to the median pro- (upperT:Ifri^r'"(GK^Kr.'^aft«T.sxuT:r^ f^om behind of the verumon- tanum. This contains erectile tissue and may serve to close the upper end of the urethra and prevent the passage THE MEMBRANOUS URETHRA. 399 of semen back into the bladder. On its summit in the median line is the fair sized opening of the sinus pocularis, or u(eruf< ludwidinux, the homologue of the uterus. This blind sinus /j/z/.s upward and backward for one fourth to one half of an inch beneath the '* middle lobe." On either side of it run the rjdcn/dfori/ ducf.s, whose slit-like openings are on either side of (sometimes within) that of the sinus. In the two depres- sions or prostatic sinuses, one on either side of the verumontanum, open the (lucf.s of (lie (/Idiul.s of f/ie prostate, of which two are larger and more noticeable. The tip of a sound may lodge in the prostatic sinuses, especially in cases of ])rostatic enlargement. To avoid this tiic Ix-ak of a "prostatic catheter" is longer and curved further forward and the flexible catheters are made with the tip bent up (Mercier catheter). The tip of a small sound or bougie may also lodge in the sinus pocularis un- less it is made to hug the ni)per wall. On account of the various open- ings into the prostatic urethra we can understand how an inHtuinnd.tiou of this part may extend (1) into the bladder and thence to the ureters and kidneys, (2) into the ejaculatory ducts and thence to the seminal vesicles or along the vas deferens to the epididymis, etc., or (3) into the substance of the prostate. In the erect position the course of the prostatic uretlira is nearly vertical with a slight concavity forward. It runs in front of the mid- dle of the upper two thirds and about the middle of the lower one third of the gland, though cases have been observed when it has merely occupied a groove on its anterior surface. The prostatic por- tion is not only of large caliber but also very dilatable, readily admitting the passage of the finger in operations on the urethra or l)laddcr. Stricture is unknown in this part though congenital folds and pock- ets may occur here and interfere with micturition. The lower half of the prostatic urethra may be incised in the median line without injur- ing other structures. Median incisions in the upper half must be in the exact median line to avoid the ejaculatory ducts. The membranous portion, or that lying between the two layers of the triangular ligament is directed obliquely downwards and forwards and forms the beginning of the subpubic curve. It is, next to the external meatus, the narrowest segment and measures about half an inch in Icnr/t/i, though the floor is said by some to measure less than the roof owing to the projection backwards of the bulb along the floor. It is surrounded by the compressor urethra^, muscle which forms (1) the voluntary sphincter, (2) the dividing line between the anterior and posterior portions of the urethra, and (3) the cause of the so-called spasmodic strictures. Close behind it lies the bend in the anterior wall of the rectum between the anal and pelvic jnirtions. At this point an instrument can be felt within or guided into the membranous urethra, or the false passage of an instrument may be felt by the linger in the rectum. Beneath and on either side lie the btdbourethral glands {('oirper's (/lands) the homologue of the glands ol" Bartholin in the female. Enclosed by the compressor urethra^ muscle and resting on the upper surface of the superficial layer of the triangular ligament, 400 PELVIS A SB PERINEUM. one fifth of an inch apart, these glands thus lie above and behind the bulb. The formation of cyds or «6.spr.s-,s may occur in them, the latter by extension of gonorrhceal inflammation from the bulbous urethra, into the floor of which their ducts (| to 1 inch long) open. They atrophy as age advances. The spongy portion, 5 J inches in lenr/th, includes several subdivi- sions. The bulbous portion, about an inch in length, is the most pos- terior. Immediately in front of the triangular ligament the bulb at first covers only the floor and then gradually the sides, while the front of the urethra is only covered by spongy tissue ^ to -| of an inch lower down, so that some authors call the portion not covered by the bulb the prse- diaphragmatic or pi-idrigonal portion. The front wall of the latter portion is thinner than elsewhere. Along the floor of the bulbous por- tion the urethra is much dilated and this dilatation (fossa bulbi) passes suddenly, not by a gradual narrowing, into the narrow and firmly fixed membranous portion at the point where the latter pierces the firm anterior layer of the triangular ligament. This is the critical point in the passage of instruments, for if the instrument is allowed to follow the floor it sinks into the dilatation of the bulb below the level of the membranous portion and then impinges on the triangular ligament, or if pressed too closely against the thin dilatable anterior wall a like re- sult may happen. To enter the narrow opening of the membranous urethra (*^ neck of the bulb " as the French call it) the sound should be kept along the roof of the urethra and as large an instrument as will pass should be used, for it is less likely to catch. We have seen that hugging the roof is also the rule in passing the prostatic portion to avoid catching in the sinuses and the annulus. The bulbous portion continues the subpubic curve, commenced in the membranous portion, and in the erect position it forms the most dependent part of the fixed portion of the urethra. Hence the products of inflam- mation naturally gravitate here and, as the parts are bathed in pus, chronic inflammation is apt to linger here and its results are seen in the common occurrence of stricture. The chronic inflammation, or gleet, alters the lining mucosa so that plastic material is deposited beneath it to prevent the soaking of urine into the surrounding tissues. The natural contraction of this plastic exudate narrows the lumen and so results in stricture and this keeps up the irritation and the discharge, which is only cured by the cure of the stricture. The bulb is covered externally by the accelerator urinae muscle. In front of the bulb the urethra continues in a fixed position, nearly horizontally, but with a slight upward inclination, to a point beneath the suspensory ligament. In front of this ligament the urethra is movable with the penis. The ctdiber of the spongy urethra is fairly uniform between the bulb and the fossa navicularis, the dilatation in the glans penis, especially along the urethral roof. At its distal end this fossa ends in the external meatus, a vertical slit on the antero-inferior aspect of the glans. The meatus is the narrowest and lead dilatable portion of the urethra so that any instrument which can pass the PLATE XLVI 1 FIG. 94. MUSCULAR WALL OF BLAOOE M ASCULINUS UOINAL MUS- OF URETHRA Proximal portions of urethra, NA'itli surrounding parts. (Gerrish, after Testut. ) FIG. 9S. ST POINT OF URETHRAL CURVE Outline diagram of the curved portion of the uieilira, showing the distances from and the relations of the different pai'ts to ilie symi^hysis. (Testut.l THE CURVES OF THE URETHRA. 401 meatus should pass tlie rest ui' -,1 normal unthra. To allow the use of large sounds or instruments in the trt-atmcnt of pathological conditions of the rest of the urethra or the bladder (/. t., litholapaxy, evstoscopv of the bladder, etc.) the meatus must be enlarf/ed hi/ xlittiinj it inferiorly in the middle of the frteuum. The meatus may be foiKjt nitnlhj >iinnil, even admitting only a tine i)robe. This conditi(»n is often associated with congenital pliimosis, and from it urethral spasm may result, though perhaps less often than formerly supposed by many. Besides the many mucous glands found in all parts of the urethra, es|)e- cially in and near the navicular fossa, the small pits or htr.unff of Morgagni occur in the spongy ]K)rtion in longitudinal rows, a median row of larger lacunae on the anterior or upper wall and a row of smaller lacuuse on either side of it. As the opening!^ of these lacunje are dindrd toward the meatus the larger ones may catch the tip of a small sound or bougie, thereby interfering with treatment or misleading the diag- nosis. Hence instruments should be passed along the lower wall or floor of the spongy portion. An additional reason for this is found in the presence of a lacuna of large size, the lacuna maf/ua, h to 1 inch from the meatus in the roof of the navicular fossa, which may easily arrest the point of an instrument. It is nearly covered below by a semilunar valve-like fold (the valvule of Guerin). According to its fixity the urethra is divided into a fixed and a mov- able part (pars fixa and pars raobilis). These divisions do not corre- spond to the preceding but more to the next following division for the fixed portion includes the prostatic, the membranous and the proximal two inches of the spongy portion, or as far as the anterior border of the suspensory ligament. The membranous portion is the on/if a/jxolutclt/ iurcd part and therefore of the greatest importance in catheterization, for we must direct the catheter to and through it; its position does not change to suit the catheter. The bulbous jjortion is the wjcw/ movable 2)art of the fixed pjortion and this part lies immediately in front of the most fixed portion. This is one reason for the difficulty of directing the point of the catheter or sound into the membranous portion, fL>r the bulb may be easily pushed backward or sideways. The rc.-pubic curve. The latter curve is mo.^t marked in the membrainuis and bulbous portions, though it is continued slightly in the uj>ward 26 402 PELVIS AND PERINEUM. direction in the prostatic urethra, which is nearly vertical, and in the forward direction about to the prepubic curve or the end of the fixed portion, though the anterior portion of this rises but little {^ to \ inch) above the level of the lowest point of the curve. The curve (Fig. 90) is described as being an arc of a circle having a diameter ranging, ac- cording to different authors, from 3| to 4| inches, the chord of the arc measuring about 2^ to 2| inches. The curve is sharper in small, thin men and flatter in large stout men. The subpubic curve belongs to the fixed portion of the urethra and hence metal urethral instruments are made with a definite curve to allow them to take the curve of the urethra without letting the tip impinge or catch on the floor. It is possible to pass a stiff straight, or nearly straight, instrument into the bladder but not without painful tension of the connections of the urethra, especially the suspensory ligament, and hence it is often done under anaesthesia and only for certain objects, as litholapaxy, etc. The dividon into anterior and posterior urethrae occurs between the membranous and the bulbous portions at the level of the superficial layer of the triangular ligament. This division is of practical importance from a pathological, prognostic and therapeutic standpoint. The dis- charge from a urcthritii< of the anterior urethra drips from the meatus and injections into this part escape at the same point. A urethritis also is often limited to this part for the compressor urethras muscle offers an obstacle to its further extension. The complications of such an anterior urethritis are principally chordee, gleet and stricture. When an iii^ammation extends into the posterior urethra or an injecting catheter is introduced beyond the compressor urethrse muscle the dis- charge or injection flows into the bladder and does not appear at the meatus. The inflammation here is also liable to spread to the bladder, vas deferens, epididymis, seminal vesicles, prostate and kidneys by continuous extension or otherwise, hence the prognosis of posterior urethritis is more grave. By using considerable pressure and prevent- ing the escape at the meatus fluid may be injected into the bladder from any jioint in the anterior urethra. Embryologically also the posterior urethra is of a different formation {i. e., from the urogenital sinus) and corresponds to the urethra and vestibule in the female, while the anterior urethra is formed by the genital folds of the external genitals. The length of the urethra from the internal to the external meatus varies, but averages about seven inches. It varies with the length of the penis ; when the latter is contracted to the utmost it may be con- siderably (over an inch) shorter, when the penis is more or less erected or is pulled upon during catheterization the urethra may measure eight inches or more. Hypertrophy of the prostate also lengthens the urethra, a fact which is useful in the diagnosis of this condition. The length of the urethra at birth is 5-6 cm., in children of five years 8-10 cm., at the beginning of puberty 10-12 cm. The normal caliber or diameter of the urethra, being that of a cylin- der which separates the walls without stretching them, can only be RELATIVE POSITION OF TIIK URETHRA. 403 given approximately except for the external meatus. Sappey states that, exclusive of the meatus, the urethral circumference ranges between 15 and 18 mm., so that a No. 15 (French) sound could l>e passed without stretching the canal. Tlio innitns is about ] of an inch in its long diaiiietei'. Of more practical importance is the absolute or rela- tive distensibility, which ((rcr(i(/(:s 10.5 mm. in its diameter (Jocssel, Waldeyer). The distensibility varies in different parts and as we pass from end to end of the urethra we find that a narrow jjorlion alternates with a wider portion. Thus the narrow portions are, in order, the external meatus, spongy portion, mcml)ranous portion and internal meatus; the wider portions are the fossa navicularis, the bulbous por- tion and the prostatic portion. In order of distensibility we find the meatus the least (listcnsil)le, next the membranous portion, the spongy portion, the prostatic portion and lastly the l)ull)()us portion, which is the most distensible. The different parts should distend so as to admit the following sounds of the French scale : the meatus No. 24, the spongy portion Nos. 28-30, the bulbous portion No. 32, the mem- branous portion Nos. 26-27, and the prostatic portion Nos. 30-32. Otis proved that the distensibility of the urethra was greater than formerly supposed, though Guyon showed that by the passage of large sounds, 31-34 (French), on the cadaver lacerations were produced, especially on the floor of the penile portion. According to Otis there exists a constant ratio of nine to four beticeen the circumference of the penis and that of the distended urethra. Apart from the fact that it is improbable that such an exact mathematical ratio is constant, it is difficult in measuring an organ, so variable in size as the penis, to measure the latter in the same condition of relative size in different cases. Still Otis' law is of value as a practical guide to the surgeon. The relative position of some parts of the urethra may be more fully given. The internal meatus is on a level with the middle of the symphysis, or somewhat below or above it. It lies above this ])oint in young subjects, and not infre(|Uently in adults. The prostatic portion, in whole or in great part, lies above the horizontal plane passing through the bottom of the symphysis, so that this portion is often entirely behind the symphysis. The deepest point of the subpubic curve is in the bulb and lies 18 to 20 mm. from the subpubic angle, usually more or less behind the vertical plane of this angle, but some- times beneath or even in front of it. We have already referred to the effect on the frequency of stricture here of its being the most depend- ent point of the curve in the erect posture. The prepubic curve lies below the horizontal plane of the subpubic angle, and usually 1 to ]■ of an inch above the lowest level of the urethra in the bulb, so that from the latter the urethra extends slightly upward as well as forward, though it may be horizontal. Betwee)i the suh}>u/)lc rurrr nf flu unthra and the si/nijihi/sis lie the dorsal vein of the penis, the pudendal jilexus and the continuation t)f the perivesical fat. On cross section the enijity urethra is represented by a fissure which is vertical at the external meatus, tmnsverse in the spongy portion, 404 PELVIS AXD PERINEUM. stellate in the membranous portion and like an inverted U in the prostatic portion. A form of rifling is involved by this progressive change in shape Avhich may account for the spiral form of the normal stream of urine. In addition the mucous membrane of the collapsed urethra is in longitudinal folds. Sphincters of the Urethra. — The fixed portion of the urethra passes through a continuous layer of encircling muscle fibers, both plain and striated. This is formed of several parts, of which the most distal is the bulbocavernosus muscle. The internal sphincter is com- posed of plain muscle fibers, derived from the deep layers of the tri- gonum, which pass downward and forward obliquely encircling the upper part of the prostatic urethra and meeting in front of it. This does not include but is be/oiv the circular fibers of the bladder which are aggregated around the internal meatus and form a ring, the "an- niiht.s )irosely with the fascia penis and renders the ftjrnier so movtibh:. This hjose tissue accounts for the stuldcn roid grcnl .sirdlin(f that may occur in the prepuce or on the penis as the result of inflammation, oedema, or the extravasation of blood, urine, etc. The sujjrrjifln/ wmela and nerveH are contained in this tissue. The skin covering the cervix and the proximal side of the corona is lined by this loose tissue, but there is no subcutaneous tissue over the glans. This accounts for the fact that a chancre on the glans shows but little if any induration (parch- ment induration) while a chancre on the cervix or the proximal side of the corona, a favorite position, has a ty[)ical induration i)^ the base, due to tiie infiltration of tiie suljcutaneous connective tissue. The fascia penis is the highly elastic fibrous sheath investing the three erectile bodies which form the bulk of the penis. It extends as far as the cervix, around which it is firmly attached to the erectile bodies and fuses with the skin. At the base of the pendulous portion of the penis this fascia is continuous with the superficial perineal fascia behind and the suspensory ligament in front. It covers the deep dorsal vessels and the lateral tributaries of the dorsal vein, ijy com- pressing which it contributes to the erection of the penis, after this condition has once become established. In this it is aided by those fibers of the bulbocavernosi and the ischiocavernosi which encircle the dorsum of the corpora cavernosa and thus compress the dorsal vein. The contraction of the compressor urethne muscle and the pressure of the ])enis against the pubic arch by means of the ischiocavernosi muscles also compress this vein and thus assist in erection of the penis. Apart from these causes of erection, which act by hindering the venous return, the vaso-dilator nerves act by increasing the arterial su])plv of the erectile bodies through the dorsal arteries, the arteries of tiu- ijulb and of the corpora cavernosa. The .spinal center of erection is in the lumbar enlargement and may i)e stimulated by any local irritation ; it also receives exciting and inhii)itory stimuli from the brain. When the cerebral inhibitory action is shut off, by an injury or dis- ease of the spinal cord above this center, there is liable to be a condi- tion of chronic partial erection, known as priapi.sm. Besides the active erection, in which arterial supply and venous return are both concerned, there may be a jtassirr erertion, such as that due to the jiressure of a full bladder on the venous plexus (prostatit-o- vesical) through which the dorsal vein of the peuis empties into the branches of the internal iliac vein. The pro])osal to tic the dorsal vein to assist an incomplete erection of the penis has been tried with some success. A constricting band around the penis causes rapid and extensive swelling of the organ, hence in tying in a catheter it is best not to employ tajjcs around the penis and no bandage aroiuid the jx-nis should be tight. The large deep dorsal rein (Fig. 9(5) of the penis is usually single and occupies the groove between the two corpora caver- nosa superiorly. It pierces the triangular ligament one half inch be- low the pubic arch. The thick elastic sheath of tlu' cor|x>ra cavernosa, 408 PELVIS AND PERINEUM. called tunica alhuginea from its whitish appearance, consists of an outer layer of longitudinal fibers covering both corpora and an inner layer of circular fibers forming a separate sheath for each. The latter forms a septum between the two which is incomplete anteriorly so that any inequality in the blood supply of the two corpora may be equalized. The suspensory ligament of the penis connects the corpora cavernosa with the front of the symphysis pubis. In front of this ligament we have the movable portion or " body " of the penis, which serves as the pars copulatrix and corresponds to the pars mobilis of the urethra. The angle of the penis, immediately in front of the suspensory liga- ment, is only present in the flaccid condition of the organ. In erec- tion the " body " of the penis comes into line with the " root,^^ which corresponds to the two crura of the corpora cavernosa which, diverg- ing behind the suspensory ligament, are attached to the ischiopubic rami. Each corpus cavernosum measures about 6 x ^ inch, which increases by a third or more in erection. The corpus spongiosum begins behind in an enlargement, the bulb, surrounding the floor and sides and, further forwards, the entire urethra. It ends in front in a heart-shaped enlargement, the glans penis, which overlaps the rounded anterior extremities of the corpora cavernosa. The bulb, measuring H inches long and | inch broad, abuts against the central point of the perineum, 1| cm. in front of the anus. It presents inferiorly an incomplete median septum, indicated on the surface by a slight furrow, hence if the bulb is incised in the exact median line the bleeding is less than it otherwise would be. The bulb is invested by a fibromuscular sheath, continuous with the superficial layer of the triangular ligament, and by the hn/bocavcrnosus muscle, whose action assists in ejaculation, in expelling the last drops of urine and in the erection of the penis. The glans is twice as long on its upper as on its under surface and its pro- jecting base or corona, which limits the cervix, is interrupted in the median line inferiorly by a small median fold, the frenum prseputii, continuous with the inner layer of the prepuce. The frenum grooves the under surface of the glans as far as the inferior angle of the meatus, and contains vessels of some size which, if ruptured in coitus, in case the frenum is unusually short, or eroded by chancroidal ulcer- ation, may cause considerable loss of blood. In erection both the glans and the rest of the corpus spongiosum are soft as compared with the corpora cavernosa and thus they offer no resistance to the passage of semen or urine. When a urethritis extends beyond the mucosa and causes an indura- tion of the submucous structures the corpus spongiosum loses its elasticity, so that in erection it cannot elongate but acts like the string of a l)o\v and bends down the corpora cavernosa, so that the erected penis is curved backward. This condition, known as chordee, is very painful, owing to the traction on the inflamed urethra and corpus spongiosum. The erected corpora cavernosa may be '\fractured " by forcible flexion in coitus and otherwise. Such an injury is irreparable; THE SCEOTU.V. 409 it causes an extravasation of blootl, interrupts the continuity of the erectile tissue and prevents the .striiight erection of the penis, for the corpus cavernosum so affected can not lengthen as much as the other, or if l)otii are affected a portion of both can not become erected. The lymphatics of the penis, including those of the urethral nni- cosa, enter the inner or middle group of the superficial inguinal lymph nodes. Some of the deeper lymj)hatics of the erectile bodies may perhaps enter the pelvic lymph nodes. Congenital Malformations. — Hypospadias, the commonest form, is due to a partial or complete failure to unite on the |)art of the g'liital folds, on the under aspect of the penis. These folds l)y their union convert the groove between them into the spongy portion of the urethra. This failure to unite may affect the entire length of the spongy urethra, so that the urethral opening is in the perineum ; or it may occur at the end and involve only the glans, so that the opening is just back of the glans; or it may occur at any intermediate point. In comp/efe Jiypospadias the corpus spongiosum is wanting or defective, being replaced largely by fibrous tissue which does not lengthen in erection of the penis, so that in this condition the penis is bent sharply downward and backward. Complete hypospadias is one of the ele- ments which go to make u\) jjseu(l()-h<'rmove than below, vice versa in the adult. The skin is thin and transparent, showing an ecchymosis beneath it quickly and distinctly. It is very e/asfic .so that it allows of great dis- tension, as in large hernia% hydroceles and tiunors. It is al. ^ (/) 3C so -' 'X Z < 0) .J *— ti CD 0/ T <— ^ (0 CQ IT CD ^.... r» ^ X ft) 7) 2 > ■n < o -^ ~ |Z' -n < '< (b mJ r. X — ^ O r*" ^ -1 c r* -H S .^-^ " -' o (D (D a> r_ ~; 2 ^ ]3. ■< — Cfi' 'D — cr: 3 BLOOD SUPPLY OF THE SCBOTUM. 411 by the loose connective tissue layer with the scrotum proper and hence is readily separable from the latter. The cremaster is a voluntary muscle occurring in scattered, arched bundles, bound together by thin connective tissue laminie, which also form the sheaths of the muscular bundles. These bundles lie in front of (not behindj the sac formed by the next layer. It issnjjpHnl hi/ the genital branch of the genitocrural nerve. Its contraction suddenly raises the testis and its inner coverings, within the scrotal j)()Ufh. The cremasteric reflex is the reflex contraction of this muscle following stimulation, as by scratching, of the skin of the uj)])('r and anterior aspect of the thigh, which is supplied by the crural branch of this nerve. The muscle becomes lii/pertrop/iied when the size or weight of the enclosed mass is increased, as in large herniie, etc. According to Toldt its contraction favors the venous circulation within the scrotum and helps to |)ress out the contents of the epididymis. The infundibuliform fascia {iitfcmdl sjjennaiic fa.scia), by its direct connection with the lower part of the posterior border of the testis, anchors the latter in the postero-inferior part of the scrotum, so that it retains this position when the cavity of the tunica vaginalis is filled with the fluid of a hydrocele or a hematocele. Hence we pnndurc n hydrocele in front and ai)ove, to be out of reach of the testis. At the point of attachment of the testis the infundibuliform fascia is also ad- herent to the overlying layers, including the dartos and skin. The adhesion together of all these layers forms the Hgdiin'iduin .srroffdr. Loose areolar tissue, continuous with the suhperitoneal connex'tirc tis- sue, connects the infundibuliform fascia with the tunica vaginalis and binds together the various elements of the spermatic cord. In the latter situation it contains some fat and is the seat of faff jf fninors of fhf cord^ which occasionally simulate an inguinal hernia. This layer, together with the infundibuliform fascia, is known as the fa.^cia propria of Cooper, who described it as very strong in large, old hernia?. The parietal layer of the tunica vaginalis extends for halt" an inch above the level of the testis, forming a cul de sac at the l)eginning of the cord. Besides the (external) cremaster, two collections of unstriped muscle fibers are known as cremaster muscles, one of them in the cord (internal cremaster) the other in the subserous layer (middle cremaster). One muscular band of the latter, stronger than the rest, is said sometimes to groove a hydrocele, so as to partly divide it. The two comjiosite layers of the coverings of the testis have a separate blood supply, with anaj.>ie inner circular fibers surround the membranous urethra and are eontinuous with the voluntary fibers in front of the j)rt)statie uretlini. The greater part of its fibers pass transversely and join an iiulistiuct median raphO, while a few run obliquely and sagittally. They com- press and help to expel the contents of the memi)ranous urethra and of Cowper's glands, as in emission, tliey serve as the external sphincter vesicie and assist in the erection of the penis by compression of the veins from the bulb, the corpora cavernosa and the dorsum of the 422 PELVIS AND PERINEUM. penis, which pass through it. Some of its fibers are cut in lateral lithotomy and, to a less extent, in many median perineal operations. The artery of the bulb runs inward in this interspace about half an inch, sometimes less, in front of the base of the ligament or 1|^ to 1|- inches in front of the anus. Hence the incision in lateral lithotomy, etc., should not be commenced more than 1} inches in front of the anus. The superior or deep layer of the triangular ligament is continuous with the obturator fascia along the upper lip of the inner edge of the ischiopubic rami, where both these fasciae are attached. It joins the superficial layer anteriorly, at the preurethral ligament, and posteriorly along the posterior edge of the perineal ledge. Superiorly it forms the floor of the anterior recess of the ischiorectal fossa, on either side of the prostate. The apex of the prostate rests upon it mesially, and its fibrous capsule, derived from the rectovesical fascia, fuses with it. The dorsal vein passes between it and the subpubic ligament, the pudic vessels and nerves pierce it. Incision through the posterior part of this layer on either side opens the anterior recess of the ischio- rectal fossa, and then, being continued more deeply, cuts the levator ani with the anal fascia below and the rectovesical fascia above it, and thus enters the pelvic cavity. Median incision through this layer involves the prostate above it. In lateral lithotomy the 2 to 3 inch incision, commenced about 1^ inches in front of the anus and a little to the left of the median line (to avoid the bulb and its artery), is carried backward and out- ward to a point somewhat behind and external to the mid-point between the anus and the ischial tuberosity. Through the anterior and deeper part of the incision the knife is carried into the membranous urethra and, along the staff, through this and the prostate into the bladder. The prostate is divided obliquely backwards and outwards. We divide the skin ; the superficial fasciae ; the transversus perinei muscle, vessels and nerve ; the external hemorrhoidal vessels and nerves ; the base of the triangular ligament and compressor urethrse muscle ; the meml)ranous and prostatic urethrre ; the anterior fibers of the levator ani ; and the left lateral lobe of the prostate. Parts to be Avoided. — We avoid wounding the bulb by commencing the incision to one side of the median line and by drawing the staff, and with it the bulb, well forward under the pubes. The artery of the bulb is avoided by commencing the incision not more than 1 \ inches in front of the anus. The rectum is easily avoidable if it is not dis- tended and if the posterior part of the incision is not carried too far back or too near the median line. On the other hand the pudic vessels may possibly, though not probably, be wounded if the incision is car- ried far to the side. If the incision in the prostate passes beyond the prostatic capsule, so as to incise the rectovesical fascia, it lays open the subperitoneal tissue of the pelvic cavity, the ischiorectal fossa and the neck of the bladder into one large space. This is most likely to occur in incising the vesical outlet, for the incision into the lower end of the gland is below the reflection of the rectovesical fascia from the MEDIAN LITHOTOMY. 423 pelvic floor onto the prostate. If the jjro.-itdtic inrl.tion is too vertical tlie left ejaculatory duct is in danger of being incised. Tiic j)rostatic venous plexus cannot escape. When the (irccsHorij piulic arkrt/ is present, it in likely to be injured as it passes forward beneath the sides of the pros- tate. In (7/ /W/v'/i lateral lithotomy or any form of jjcrineal approach to the bladder is more difficult and ol/jcctionablc, because tlic pelvis, pel- vic outlet and perineum are narrow ; the bladder is liiglier up, uumt movable and less strongly attached, and the prostate is rudimentary, so that more of the vesical outlet itself has to be cut, while the perito- neal pouch descends lower and may be wounded. The su|irapubic route, on the other hand, is easier on account of the high |)o>iti(jn of the bladder, so that it is to be j)referred. In median lithotomy or cystotomy, or the similar incision in external urethrotomy, perineal section, etc., the parts divided are (1) the skin in the median ra})he in front of the anus for 1| inches, (2) sujierficial fascia, (3) sphincter ani, (4) the central point of the perineum, (oj the base of the triangular ligament and of ((3) the compressor urethra? muscle, (7) the membranous urethra. One finger in the rectum to guide the upwardly directed knife diminishes the risk of wounding the gut. There is less cutting and more dilating in median cystotomy, for the pro.s- tatic urethra and vesical outlet are only dilated and not cut. The ad- vantages of the median operation consist in (1) little bleeding, owing to the slight vascularity of the raph6 and median line of the perineum, and (2) little danger of wounding the pelvic fascia, for the prostate and vesical outlet are stretched and not cut. It is an excellent opera- tion for the extraction of small stones. On the other hand it pos- sesses disadvantages in (1) the danger of wounding the bulb, which, however, does not bleed much if incised in the exact median line, and (2) the little space obtained for the extraction of a stone. ^loreover in children it is contra in< J icated, for, owing to the small size of the pros- tate and vesical outlet and the slight attachments of these parts, the bladder may be torn from the urethra in reaching it with the finger. When we wish to expose fJie prostate or seminal re.^iclcs other j)erineal incisions are useful, such as the curved transverse incision of Zucker- kandl, and the median incision encircling the anus on one side, as in v. Dittel's lateral prostatectomy. The greater part of these incisions is in the ischiorectal region. They aim to expose the ]>rostate after dividing the anterior fibers of the levator ani muscle. Then the seminal vesi- cles may be exposed by separating the rectum from the prostate and bladder. Zuckerkandl's curved incision is concave toward theix'ctum. In all perineal oj)erations on the male bladder it should be remend>ered that the vesical outlet lies "2} to ''> inches from the surface, in the lith- otomy position. But this distance may be so increased in some cases of prostatic hypertrophy as to make the perineal route to tiie bladder difficult or even contraindicated. The perineum in the female dilTers from that in the mah- in the perforation of all the layers in the median line by the vidvovaginnl passage and the resulting necvssary ad:ii)tatiou of the muscles. It is 424 PELVIS AND PERINEU3L as if the bulbocavernosi and the bulb were cleft in two halves through their median raphe. The median cleft thus formed represents the vulva and the lower end of the vagina, while the two halves of the bulb and of the bulbocavernosi represent the bulbi vestibuli and the attenuated compressor or sphincter vaginte respectively. The corpora cavernosa, the ischiocavernosi and the superficial transverse perinei muscles differ only in their smaller size. The deep transversus perinei muscle, like the two layers of the triangular ligament, is of course partly cleft by the vagina. The "perineal body," triaiu/ular on sagittal section and bounded in front by the vulvovaginal wall, behind by the anterior rectal wall and below by the cutaneous surface between the anus and the posterior vul- var commissure, is peculiar to the female. Besides the central point of the perineum and the muscles that meet here it contains a mesh work of connective, elastic and unstriped muscle tissue. Thus it is fitted to stretch in parturition as it does to a remarkable degree during the passage of the head. It is in this part that ruptures of the perineum occur during labor. Such ruptures may be superficial or they may even extend entirely through into the rectum. It is the ischiorectal regions and the portion of the perineum behind the vulva, not the firmer anterior part, that yield most in parturition so as to allow the passage of the foetal head. The cutaneous base of the perineal body, between the anal and vaginal orifices, is often spoken of as the " per- ineum." It measures 1:^ inches from back to front and extends later- ally between the two ischial tuberosities. The Anal Triangle or Ischiorectal Region. The superficial fascia contains a great abundance of fat which fills the two pyramidal ischiorectal fossae, lying one on either side of the anus. (Fig. 107.) These fossse are hounded above and internally by the obliquely directed levator ani and coccygeus muscles (pelvic floor), lined beneath by the ischiorectal or anal fascia, and externally by the vertical obturator internus, covered by the obturator fascia. In front each fossa ends superficially at the base of the perineal ledge, but more deeply it extends forward, nearly as far as the symphysis, as the ante- rior recess. This lies on top of the perineal ledge, beneath the levator ani, and extends forward on either side of the prostate, between it and the ischiopubic rami laterally. Posteriorly each fossa ends superfici- ally along the great sacrosciatic ligament, but deeply it extends back- ward a variable distance toward the sacrum between the ligament and the pelvic floor, as the posterior recess. The apex of the fossa is along the white line on the obturator fascia, or a little below it, so that its depth is about two inches behind, less in front. The bcise measures an inch in breadth and two inches from before backward. Crossing this space about its center, from the lateral wall to the anus, are the external hemorrhoidal vessels, while the exter- nal angle is crossed by the superficial perineal vessels and nerves and along the posterior border runs the fourth sacral nerve. The presence ".i(in should be practiced to prevent the inflammation from extending throughout the entire fossa. IiiffaiiuiKttion in the ischiorectal fossa is fdcond by the poor bhifxl supply of the contained fat and by the tendency to congestion, due to the dependent position and lack of support of the veins, especially in patients suffering from venous congestion or feeble circulation, such as occurs in diseases of the liver (cirrhosis), heart and lungs (])hthisis). The inflammation is also favored by sitting on a cold, wet seat, by injury and by the passage of infection throngh the rectal wall, preceded per- haps by an nicer of the lower rectum. Isc/iionvfal «66vt.s-.s hulfjr:< ami tend'i to break where resistance is least, /. e., in the rectum or on the skin beside the anus or along the border of the gluteus maximus. If it perforates both on the skin and in the rectum a complete fistula in ano results, whose internal openinf/ is usually within half an inch of the anus. Owing to the constant dragging apart of the walls, toward the anus by the sphincter and from the anus \)y the levator ani, and the reinfection of the tract from the rectum spontaneous cure is rare and operation is required (see also p. 3G4). Tiie pad of fat filling the ischiorectal fossa serves as an elastic cushion to the rectum and allows its descent and expansion during defecation. The anal portion of the rectum occupies the space between these two fossae. The ischiorectal fossa is opened into in lateral lith- otomy and in the lateral and transversely curved incisions to explore the prostate, seminal vesicles, etc. CHAPTER VI. THE LOWER EXTREMITY. The lower extremity is especially adapted to bear the weiglit of the body by its stronger and heavier build and the stronger and less mov- able connection of its first segment, the thigh, as compared with the upper extremity. THE HIP. The upper segment, the region of the hip, will be studied in two sections, (1) a posterior or gluteal region, the buttocks, and (2) an anterior region including the hip joint. The Posterior or Gluteal Region, the Buttocks. This region is bounded, above by the iliac crest, below by the gluteal fold, internally by the sacrum and coccyx and externally by a line from the anterior superior iliac spine to the great trochanter. Surface Markings and Landmarks. — The iliac crest and its an- terior superior spine are readily felt. The posterior superior spine is less distinct, especially in stout subjects, in whom its position is indicated by a small depression. The great trochanter is a prominent landmark, especially when the thigh is adducted or rotated out. In very stout subjects a slight depression marks its position. Its upper border is made less sharply defined by the tendon of the gluteus medius which passes over it. The ischial tuberosities are readily felt on the border- line between the buttocks and the perineum. When the thighs are ex- tended they are covered by the fleshy fibers of the lower borders of the glutei maximi, which rise above them when the thighs are flexed. The sciatic notch can only be felt in those greatly emaciated. The transverse gluteal fold, or "fold of the buttocks," is neither due to nor does it correspond with the lower border of the gluteus maximus, which is lower and more oblique than the fold. The fold is due to a creasing of the skin in extension of the hip. In flexion of the hip joint the but- tocks are flattened and the fold becomes oblique and is finally obliterated. Its disappearance in early hip disease is a useful diagnostic sign and is due to the flexion of the hip joint which is almost constantly present. The change in the fold and the flattening of the buttocks are not due to but precede the wasting of the gluteal muscles, which exaggerates these symptoms. The fjreat sacro-sciatic ligament can be felt on deep pressure beneath the lower edge of the gluteus maximus. The tensor vagince femoris forms a slight prominence extending from a point just outside the anterior superior spine downward and somewhat backward to the outer aspect of the thigh three to four inches below the great trochanter. , 426 POSITION OF THE VESSELS AXIJ NERVES 427 Topography. — The posterior superior iliac spine is on a level with the second sacral spine and the center of the sacro-iliac joint. In this connection it may l)e noted that the loireM liinit of flie spinal membranes and the cerebrospinal fluid corresponds to the third sacral spine and the upper border of the great sacro-sciatic notch. The sjiine of the ischium is on a level with the first piece of the coccyx. The level of the upper border of the greed trochanter is about | of an inch below the top of the femoral head, at or just below the center of the hip joint, and nearly on a level with the pubic sj/me. The atrophy of the gluteus medius and minimus muscles, which till up the hollow l>etween the ilium and the trochanter and render the prominence of the latter comparatively slight, makes the trochanter very conspicuous. Nelaton's line, which is drawn from the anterior suj)erior iliac spine to the most prominent part of the tuber ischii, normally touches the top of the great trochanter and crosses the center of the acetabu- lum. Its relation to the trochanter is used in the diagnosis of frac- tures of the neck of the femur, dislocations of the hip and late stages of hip joint disease, in which the trochanter is displaced uj>ward. A still more convenient line for this ])urpose is Bryant's line, the upper line of Bryant's triangle. This line is drawn vertically backward (in the horizontal posture) from the anterior superior iliac spine, and the distance from this line to the top of the great trochanter, as compared with that on the opposite side, indicates any displacement upward of the trochanter. Position of the Vessels and Nerves. — The gluteal artery and the nerve just below it, as they emerge from the pelvis, correspond about to the middle of the superior border of the sriatlr notch. This point is indicated by the junction of the upper and middle thirds of a line drawn from the posterior superior iliac spine to the top of the great trochanter, when the thigh is slightly flexed and rotated inward. In- cising in this line, and splitting the gluteus maximus muscle, the top of the sciatic notch is felt for and the vessel is there found, if its ligature is required. The scifdic artery, with the great sciatic nerve external to it, emerges from the sciatic notch at a point coiresponding to the junction of the middle and lower thirds of a line drawn from the |X)s- terior superior iliac spine to the outer part of the tul)er ischii. This line crosses the posterior inferior iliac spine two inches below the upper end and the ischial spitie four inches below. The latter spine is crossed by the internal pudic artery as it passes from the great to the small sacro-sciatic foramen. The great sciatic nerve, emerging from the pelvis at the point men- tioned, passes thence down the middle of the back of the thigh in a line to the middle of the popliteal space, and crosseji the line from the tuber ischii to the outer side of the great trochanter at the junction of its middle and inner thirds. .1/ this point the nerve emerges from beneath the lower border of the gluteus maximus and is m(>fing stairs, €tc. In parali/si.s of the f//iif<'ns mtdius there is difficulty in maintain- ing the erect position on the side paralyzed. Of the bursae in this region, three at least are over the r/reater trfj- chnnter, separating the latter from each of the three gluteal muscles. Only that between the trorlumter and the f//iiteus indxiians is of much practical importance for it may be inflamed and render painful the movements of the thigh. Hence in the inflammation of this bursa, the thigh is kept flexed and adducted, to rest the muscle whose action is to extend and abduct it. A bursa over the tuber isrhii separates that proc- ess from the skin and subcutaneous tissues, in the sitting posture. (See pp. 345 and 42(3.) Among those whose occupation requires much sitting this bursa is often inflamed and, when inflamed, it is known, according to circumstances, as "weaver's," "coachman's," "draymen's," or *' lighterman's " bursa. When enlarged it may press upon the inferior pudeudal nerve. Vessels. — The gluteal artery is usually the largest of this region, being of the size of the ulnar, hence its wounds are serious and have been rapidly fatal. Wounds of this artery usually involve only its branches, for the portion of its trunk outside of the pelvis is not longer than 5 mm. (Bouisson). Hence in place of extra-pelvic liejature of the vessel for aneurism, ligation of the internal iliac artery is usually performed. Gluteal aneurism is not very uncommon and comjiression of the internal iliac artery, through the rectum, has been tried l>y Dr. Sands (Am. Jour. Med. Sci., 1881), but not effectively. If the aneurism involves the trunk of the gluteal artery, which runs, near its commencement, between the lumbosacral cord and the first sacral nerve, nerve symptoms from pressure can hardly fail to occur. The (/hdeal and sciatic arteries can be and have been ligated for wounds, through an incision in the buttocks over their course. (See p. 427.) The size of the accompanying veins and their close attachment to the artery increase the difficulty of ligation of the gluteal artery. There are several cases known, of which Henle collected six, where the greatly enlarged seitdie artery, running alongside of the sciatic nerve, took the place of the femoral to the popliteal space, in the absence of the femoral artery. The sciatic artery is most im])ortant in {ho collateral circulation after ligature of the femoral. The superficial lymphatics of the buttocks run to tlie inguinal noth's, the deep lymphatics accompany the blood vessels to the nodes lying near the pvriforinis, and thence to the internal iliac nodes. The great sciatic nerve, after emerging from the ju'lvis at the point indicated above, is covered by the gluteus maxinms and lies upon the obturator internus and the quadratus fenioris. Neuralgia in this nerve is known as sciatica, a condition due to a variety of causes. Within the 430 THE LOWER EXTREMITY. pelvis aneurism of some of the branches of the internal iliac artery^ engorgement of some of the pelvic veins lying in front of it (Erb), fecal accumulation in the rectum, the fcetal head in tedious labors and various forms of pelvic tumor may cause sciatica by pressure. I have lately seen two cases where a tumor of the postero-lateral wall of the pelvis, palpable through the rectum, caused severe sciatica. Outside of the pelvis it is near enough to the surface to be affected by cold. Stretching the nerve has been employed in the treatment of this con- dition. The so-called bloodless or dry stretching consists in forcibly flexing the hip while the knee is kept extended. But this stretches not only the nerve, but also the hamstring muscles, hence wet stretch- ing is usually employed, the nerve being first exposed by an incision (see p. 427-8). Trombetta found that a weight of 183 pounds was re- quired to break the great sciatic nerve, representing a force not likely to be equalled in stretching. But the nerve can be torn away from the soft spinal cord by a force not at all sufficient to rupture the nerve, hence care must be exercised in making traction on its proximal side. The possibility of wounding the pelvic viscera through the sciatic foramina, in wounds of the buttocks, should be remembered. Treves mentions a case of a fiital stab wound of the bladder through the but- tock and the rectum has been injured in like manner. We operate upon the pelvic viscera through the great sacrosciatic foramen after divi- sion of the great sacrosciatic ligament, with or without removal of the coccyx and part of the sacrum. The former is the method of Kraske inresection of the rectum. The Anterior or Subinguinal Region, the Region of Scarpa's Triangle. This is hounded above by Poupart's ligament, below by a line 12 to 15 cm. below it, on a level with the gluteal fold. Surface Markings and Landmarks. — The anterior superior iliac spine, the pubic spine and Poupart's ligament are most important landmarks and readily made out (see p. 237-8). The sartorius viuscle is rendered visible or palpable when the thigh is raised and adducted, the adductor longus when it is adducted in spite of resistance. The former runs obliquely downward and inward from the anterior supe- rior iliac spine, the latter downward and outward from just below tiie pubic spine, hence it may be used as a guide to that spine in stout females. These two muscles-, crossing 12 to 15 cm. below Poupart's ligament (10 cm. in muscular subjects), bound, with the latter, Scarpa's triangle. This triangle may appear as a slight hollow below the fold of the groin. In thin subjects the lower group (saphenous) of super- ficial lymph nodes can be felt near the base of the triangle; if enlarged they are readily felt. In emaciated subjects a prominence sometimes appears below the outer half of Poupart's ligament, corresponding to the head of the femur, which may be indistinctly felt in extension and rotation outward of the thigh. THE SUPERFICIAL FASCIA. 431 Topography, — T\\v jcinontl r'my lies on tlie liorizoiital line connect- ing the pubic spine and the top of the great trochanter, one inch from the former. It is also half an inch internal to the femoral artery just below Poupart's ligament. 'Hw (uteni \ii a little internal to the middle of the ligament, or midway between tlir anterior -npe- rior iliac spine and the symphysis. From thence the line of the artery is drawn to the adductor tubercle, or the back of the inner condyle, the thigh being slightly flexed and abducted. The uj)i)er two thirds of this line corresponds to the position of the femoral artery. Its profituda hrancli is given off about 1 }, inches below Poupart's liga- ment and the artery is covered by the sartorius about three to four inches below the same point. The femoral vein in all parts of its course bears a relation to the artery just the reverse of the sartorius muscle. The iia2*I)cnonf< opening lies with its center 1), inches below and also external to the pubic spine, where its position is sometimes indi- cated by a slight depression. In those without much subcutaneous fat the long saphenous vein can be seen or felt running up to the saphenous opening. This vein penetrates the cribriform fascia to join the femoral vein three to four cm. below Poupart's ligament. Just below its pas- sage through the fascia it sometimes presents a dilatation, which might even be mistaken for a femoral hernia. This vein and its tributaries are often the seat of varices, commonly the result of congenital con- ditions. The skin is thin and, below Poupart's ligament, very inovahlr on account of its loose attachment. Incision^'i parallel with Poupart's ligament do not gape, hence in opening abscesses here a vertical in- cision affords better drainage by allowing separation of the edges. After burns and other loss of substance of the skin of this region the resulting cicatrix may cause flexion of the hip by cicatricial contraction. Supernumerary mammary glands are sometimes found in this region and Treves refers to a case, related by Jessieu, of a woman who nursed her child from a breast so placed. The superficial fascia is usually descrii)ed in tu-o layers, of which the superlicial one contains the subcutaneous fat, which may Ik* so thick as to make operations here more difficult. This tissue is a favorite situation for fatty tuinors which here show a tendency to travel in the direction of gravity, owing to the looseness of the tissue aiul of the capside of the tumor. Between the two layers are the lower or vertical group of superficial inguinal nodes [saphenous nodes) which receive lymphatics from the surface of the lower extremity, the perineum and scrotum and sometimes from the penis, vulva, urethra and the lower part of the vagina. They lie over the saphenous oitening. Wlu-n these glands are enlarged or the seat of abscess, as often occurs, we should look to the parts named for the primary lesion. The cribriform fascia is variously described. F-nglish and Ainerit-an authors, for the most l)art, consider it as belonging to the do j) layer of the superficial fascia and as covering an oval noti-h which is sup- posed to intervene between the anterior or iliac jmrtion and the (leej>er 432 THE LOWER EXTREMITY. or pectineal portion of the fascia lata. German and French authors consider it as o. part of the deep fascia (fascia lata) which divides below Poupart's ligament into two triangular layers, one of which passes in front and the other behind the femoral vessels to unite together exter- nally in front of the iliopsoas, internally in front of the pectineus and be- low around the sheath of the vessels, 3 cm. below Poupart's ligament. In either case the cribriform fascia refers to the fascia covering an oval area, the saphenous opening, measuring one inch in its long or vertical diameter. This fascia is thin and perforated by lymphatic vessels, passing from the superficial to the deep nodes, and, at its lower end, by the long saphenous vein as it passes back to empty into the femoral vein. The perforations give rise to the name cribriform (sieve-like). The femoral canal and the vascular and muscular compartments have been already referred to (see pp. 269-70). The firm deep fascia (fascia lata) affects the extension of underlying growths and abscesses and the opening of the latter. If a psoas abscess breaks through the sheath of the iliopsoas below Poupart's ligament it may travel in the line of gravitv far down the thigh before it opens on the surface. AVithin Scarpa's triangle, and at a deeper level, is a second triangle or a groove between the iliopsoas and the pectineus {fossa iliopectinea), in which lie the femoral vessels. The iliopsoas and a layer of fatty and areolar tissue intervenes between the vessels and the hip joint, so that in amputation or excision at the hip joint the vessels are pro- tected from injury, in freeing the head of the bone. Between the ilio- psoas and the thinnest part of the capsule of the hip is a bursa which may communicate with the joint. This bursa may form a large tumor in this region when chronically inflamed. Inflammation of this bursa may extend to the hip joint or vice versa. Sprain or even par- tial rupture of the adductor group of muscles, especially the adductor longus, often occurs in horseback exercise. The lesion is usually close to their pelvic attachments. It may be accompanied by much effusion of blood, and may be followed by the ossification of the tendon of the adductor longus or magnus, to the extent of J to 3 inches, a condition known as rider's hone. Vessels. — The femoral artery bisects Scarpa's triangle from its base to its apex. The line of its course has already been given. Where it crosses the pelvic margin, just below Poupart's ligament and 3| cm. external to the pubic spine (Richet), it is only separated from the ilio- pectineal eminence by a thin layer of the iliopsoas. Hence compression of the vessel is here most easily made by pressure backward. A little lower it lies in front of the head of the femur, from which it is sep- arated by a thicker layer of the iliopsoas. Still lower it lies in front of and internal to the neck of the femur and the hip capsule. In apply- ing pressure to the artery we should avoid pressure on the vein because of the possible danger of phlebitis. The anterior crural nerve is sep- arated from the artery by the iliac fascia, so that, although it lies only one fourth inch external to it just below Poupart's ligament, it is not in danger of injury by pressure in compression of the artery. PLATE LI. FIG. 103. ILIAC FASCIA ANTERIOR CRURAL NCRVC —FASCIA LATA INTERNAL SAPHENOUS VEIN PROFUNDA FEMORIS ARTERy \^J- Region of Scarpa's triangle, left side. (Joessel.) FEMORAL VESSELS. 433 Tlie length of the common femoral artery^ or tliat part above the j)ro- funda, may practically be taken to be the distance between the origin of the deep epigastric and the profunda femoris. Altliough this is about four cm. in the majority of cases, Viguerie found that in about sixteen per cent, the distance was two cm. or less. Tlie common femoral may therefore be so short as to render ligature difficult. Before the days of antisepsis and asepsis the nearness of a large col- lateral branch was most important in the ligature of large arteries, on account of the danger of secondary hemorrhage, so that it was advised to tie the external iliac instead of the common femoral, where ligature of the latter was indicated. Nowadays a long clot, or indeed any clot, betw^een the point of ligature and the nearest large branch is not con- sidered necessary, so that this objection to tying the common femoral no longer holds good. However the femoral is eommonly lif/afrd at the apex of Scarpa''^ trianf/lc, unless ligature at this point is contraindi- cated. Here the sartorius crossing it serves as a guide, the vein is behind and somewhat adherent, the saphenous vein is internal and the long saphenous nerve is external. The femoral artery, from its suj)er- ficial position in Scarpa's triangle, is liable to he rcounded. Aneurism is common in the common femoral, for the artery is affected by the move- ments of the hip, is exposed to injury from its superficial position and it bifurcates into two large trunks. Arterio-venous aneurisms from wounds may also occur here. As the triljutarie.s of the common femoral vein, or that portion of the femoral vein above the entrance of the long saphenous vein, are pro- vided with valves which should normally prevent the backward flow from the femoral to the tributaries of the pelvic veins anastomosing with them, it would appear as if the femoral vein was the only outlet to the pelvis of the blood of the lower extremity. From this premise it was argued that the ligature of the common femoral vein alone would lead to gangrene, and should not i)e done without simultaneous ligature of the artery, to prevent the inflow of too much blood into the limb. In fact many ligated the artery only in case of a wound of the vein. But many cases of isolated ligature of the common femoral vein are on record without gangrene resulting. In fact Braun found from statistics that the ligature of the common femoral vein alone was less often followed by gangrene of the extremity than either ligtiture of the artery alone or of both artery and vein. Experimentally P)raun found that in 85 per cent, the valves of the anastomosing tributaries gave way before a pressure of 180 mm. of mercury. The greater the pressure the better the chance of venous collateral circulation, hence the artery should not be ligated, unless necessary, in order to increase the pres- sure in the veins. According to Richet and Verneuil the coUatonil circulation occurs especially between the external pudic veins and tlie veins of the pelvis and between the internal circumflex veins and the veins of the buttocks. It is (piito probable that there are more col- lateral anastomoses than are known and that the valves are often wanting or insufficient. 28 434 THE LOWER EXTREMITY. Phlebitis involves the femoral vein not infrequently as a sequela of typhoid and other fevers, as well as of operations like appendectomy, hysterectomy, etc., even when they are apparently aseptic. The cause is probably a slight degree of infection, a sluggish circulation and the dependent position of the part in bed ; and the result is pain, followed by swelling of the leg. The deep lymphatic nodes, three to four in number, lie in front of and internal to the femoral vein, and one of them lies upon the septum crurale (see p. 271). The pathology of elephantiasis, which is more common in the lower extremity than elsewhere, is concerned with the lymphatics of this region which are obstructed by the filaria sanguinis hominis, a small thread worm. This obstruction leads to an enor- mous increase in size of the extremity from distension of the lymph channels and hypertrophy of the connective tissue. The crural branch of the genitocrural nerve gives sensory filaments to the skin over Scarpa's triangle, the irritation of which causes the " cremasteric reflex," which consists of the retraction of the testis and is due to the contraction of the cremaster muscle, which is supplied by the genital branch of this nerve. This reflex is most marked in chil- dren and young adults and indicates the condition of the second lum- bar segment of the cord, which is the spinal center of this nerve. The Hip Joint. Topography. — The center of the acetabulum lies in Nelaton's line, on or just above the level of the top of the great trochanter and, in the upright position, a little below the level of the upper border of the symphysis. The tuber ischii lies below and behind it. The center of the head of the femur lies about two inches directly below the anterior inferior iliac spine, and on a line drawn at right angles to the center of the line connecting the anterior superior iliac spine and the spine of the pubis, about two inches from the latter line. At this point it may sometimes be felt in emaciated subjects. The top of the head of the femur is f inch above the upper border of the great trochanter. The portion of the great trochanter which is most external and subcutaneous is about one inch below its upper margin. According to Hueter the top of the great trochanter is relatively higher in the child owing to the relative shortness of the neck. The cartilage-covered portion of the femoral head is somewhat more than a hemisphere and has a radius of about an inch. The superior and anterior aspects of the head are rather more covered by cartilage than the inferior and posterior. The depression for the ligamentum teres, behind and below the center of the head, is a little below the point reached by the prolongation of the axis of the neck. The articular or cartilage-covered surface of the acetabulum is horseshoe-shaped, 1 to I inch in width, and encloses a thin non-articular area of bone. The latter area is seldom fractured, for, in spite of its thinness, it does not receive the direct impact of the femoral head, on account of THE HIP JOIST. 435 the shape of the cavity. According to Tillaux, one of the rhief functions of the /if/(uneiifiiin teres, as indicated by its oblique direction upward and inu-drd to tiie head of the femur, is to arrest the pres.sure of the head against the bottom of the acetabuhmi. In rare cases suj)- puration in the hip joint may reacli the pelvis, or vice versa, bv per- forating this thin area. Before tiie eighteenth year, when the Y- shaped cartUxujc uniting the three bones whicli meet in the acetabuhira has ossified, perforation may occur through the cartilage and the awtab- ulum may be broken up into its three parts by disease. The bone just above the acetabulum is very thick to transmit the weight of the trunk to the head of the femur (see p. 348). The acetabulum measures 'M)- 35 mm. in depth in the male, less in the female, and it averages 5 cm. in diameter at its rim. Fig. 104. THINAREA OFCAPSULE ON WHICH RESTS THE BURSA BENEATH THE PSOAS PUBO-FEMORAL BAND TENDON OF REC- TUS FEMORIS SUPERFICIAL PART OF ILIO-FEMORAL BAND DISSECTED AWAY ILIO-FEMORAL W BAN Ligaments of the hip joint of the left side. Anicricir view. (.Toessel.) The strenf/th of the hip joint dcijcitds not only upon the shape of the bones but also on the strength of the connecting ligaments and of the surrounding muscles and tendons. The strongest part of the capsule is the iliofemoral band or Y ligament, whit-h is a (piartcr of an iiu-h thick in its thickest part :ind is one of the strongest ligaments of the bodv, being capable of sustaining a strain of from 250 to 750 pounds (Bige- low). This ligament is of the utmost iuiportonce In dlsloratlons of the hip joint in determining both the position of the limb and the metliods of reduction by manipulation and it is almost never torn. The thinnest and irvifkcst parts of the vdpsu/e are on either side of the pubo- femoral band. The thin part in front of it is just below and external 436 THE LOWER EXTREMITY. to the iliopubic eminence, between the pubo- and iliofemoral bauds, and under the bursa between the iliopsoas and the joint capsule. There is often a defect in this thin area, so that the bursa and the joint are only- separated by synovial membrane, and the latter is also sometimes want- ing, making a direct communication between the two. This explains how pus in the joint can readily perforate or extend into the bursa and S(j come to lie beneath the iliopsoas, and also how a psoas abscess may occasionally invade the joint. The tliin area bcliind is internal to the pubofemoral band and at the posterior and lower part of the capsule. The rupture of the capsule in dislocation of the hip occurs most com- monly in this area. When the joint is distended with effusion the swelling naturally first appears at these two thin areas, which are acces- sible to pressure and correspond to the most marked and earliest tenderness. The cotyloid ligament closely embraces the head of the femur ex- ternal to its greatest diameter and, by preventing the entrance of air, holds the head in place by atmospheric pressure, when the capsule and the surrounding muscles are divided. Hence in excision or amputation of the hip joint this ligament is divided to permit the removal of the head from the socket. Opening an abscess connected with the hip joint does not increase the risk of pathological dislocation, unless the abscess also communicates with the space between the head and the socket and has destroyed the continuity of the cotyloid ligament or has eroded the head embraced by it. The cotyloid ligament levels over the slight depressions of the margin of the acetabulum, where the pubis joins the ilium and the latter the ischium. Hence these slight depres- sions can have no influence upon the mechanism of dislocation as supposed by Malgaigne. No definite function is agreed upon for the ligamentum teres. Ac- cording to Hyrtl, the vessels which it was supposed to carry to the head of the femur do not reach the latter, but bend around into the efferent veins. Although put on the stretch by adduction and outward rotation these movements are limited by other and stronger ligaments (see p. 437). Surgically it must first be destroyed or cut before the head can be removed from the socket. Unless abnormally long it is always torn in dislocations, except in the congenital variety in which it is lengthened, even to 6 or 8 cm. Owing to the direction of the neck of the femur the two most impor- tant movements of the hip, flexion and extension, cause a rotation of the head in the socket without its projecting far from the latter and thus pressing unequally upon the capsule. Hence the hip joint is very secure in these two principal movements. In the other movements the head projects from the socket on the side opposite to that toward which the movement takes place. As one of the factors of rujjture of the capsule is pressure of a projecting portion of the head against a weak part of the tense capsule, dislocation is not likely to occur during simple flexion, although the thin posterior part of the capsule is then tense, but in flexion combined with adduction, abduction or rotation. In niP DISEASE OR COXITIS. 437 rotation also the head projectis frum the socket, for the axis of rotation does not coincide with that of the neck. The movements of the hip joint are liinifed «.s foHoirx: extensicjn by the iliofemoral band ; flexion by contact of the soft parts in tiie j^roin, when the knee is bent, and by tl>e hamstring muscles, when the knee is extended ; abduction by the pubofemoral band ; adduction by the outer part of the iliofemoral band and capsule ; rotation outward by the iliofemoral band (its inner part during extension, its outer ])art during flexion); rotation inward by the ischiofemoral l)and, (hiring flexion, by the iliofemoral band, during extension. The hip joint, owing to its deep position and thick covering of soft parts, is not very liable to attacks o^ acute infammafion from injury, ex- posure, etc, to which otlier joints are liable. It seems however par- ticularly su.scepfihfe to chronic iiijinininatioii. Thus it is a favorite site for senile rheumatoid arthritis in which the cartilages and bony surfaces are eroded, the latter eburnated and osteophytic processes developed around the joint surfaces, so as to impede its movements. "Hip Disease" or Coxitis. — Still more common and important is the occurrence of tubercular inflammation of the joint known as hip disease or coxitis. In the great majority of cases it commences in early childhood. In this condition the limh assumes certain character- istic positions at various stages. In the first stage the thigh is jicved, abducted and slightly everted. This is the poxition of greateM ease and is that assumed by the limb when fluid is forcibly injected into the joint as in it the joint holds the most fluid. Hence it depends upon the eifusion and is assumed to diminish the tension and thereby relieve the pain. This is borne out by the fact that, in cases where the primary lesion is within the bone and there is no eifusion at first into the joint, this first position of flexion, abduction and eversion, is not observed, but the limb becomes at once adducted and rotated in. According to some this position, as well as that assumed later on, is due to the reflex contraction of muscles which are supplied by branches of the same nerves that supply the joint, /. e., anterior crural, obturattir and branches of the sacral plexus. The jle.red thigh is made to appear straight by lordosis, or the extension of the thoracicolumbar spine, whicii tilts backward the pelvis and therewith the femur without any movement in the sensitive diseased joint. The patient can thus stand or lie with both limbs apparently straight. The lordosis can be detected by moving the thigh when the ])atient lies on a table. When the thigh is flexed to the angle at which it is fixed (in flexion) the lordosis dis- appears, in other words when the lordosis is made to disajijH'ar the degree of flexion is shown. If we continue to ilex the thigh the spine becomes still more straightened, so as to .squeeze the hand placed between it and the table. When the thigh is again exti'uded the lor- dosis can be felt to return. To overcome the abduction and to restore the parallelism of the limbs, without movement in the diseased and painful joint, the inlvis l,s tilted down on the diseased side and up on the sound side. This would ab- 438 THE LOWER EXTREMITY. duct the sound limb which is corrected by its being adducted. Owing to the tilting of the pelv'is the diseased side is lowered and appears lengthened, the sound side appears shortened (Fig. 77). If the tilting of the pelvis be corrected the limb on the side of the disease is found abducted, the sound limb adducted. Hence on measurement from the anterior superior iliac spine (see page 352) we get measured shortening on the diseased side, though at this stage there is no difference in length. The measured shortening is also increased by the flexion. Thus we get apparent lengthening, measured shortening and real equality of the limb on the affected side as compared with the opposite side. Second Stage. — After a variable time the thigh becomes adducted and rotated inward, still remaining flexed. This is probably due to reflex muscular contraction. The adductor muscles are supplied by one ol the principal nerves (obturator) that supply the hip joint, but the in- version is perhaps less easily accounted for. Again in this position to conceal the adduction and to restore the parallelism of the limbs the pelvis is tilted up on the affected side and the opposite thigh is abducted. Hence there is apparent shortening and measured lengthening (in adduction) on the sound side. The actual length of the limb may or may not be affected, but if the disease progresses the limb is shortened by disintegration of the head of the bone, or by its dislocation onto the dorsum ilii. This dislocation is favored by the disintegration of the upper and posterior margin of the acetabulum, and the softening of the capsule. On account of the deep position of the hip joint pus formed in the course of hip disease does not soon reach the surface, but, remaining pent up, it is apt to burrow in various directions and become very de- structive in its results. The epiphysis that forms the head is wholly v-ithin the joint, and the conjugal cartilage that unites it with the dia- physis, and ossifies about the nineteenth year, is usually involved when the primary lesion is in the bone. This may cause a separation of the epiphysis, or it may arrest the growth of the bone at this end and thus lead to a shortening of the limb, unless compensated by increased growth at the lower end. The well-known fact that patients with hip disease often complain of pain in the knee, in excess of or to the exclusion of pain in the hip, is readily explained as a reflex. Thus both hip and knee joints are supplied by filaments from the obturator, anterior crural and sciatic nerves, and the irritation of the hip joint filaments is referred to those of the knee. Dislocation of the Hip. — The comparative rarity of this injury is due to the great strength of -the joint. In spite of the tremendous leverage of the long femur it forms less than 2 per cent, of all dislocations. A considerable proportion (nearly 50 per cent., Prahl) occur before the age of 20. The traumatic dislocations may be practically divided into I. the backward, including (a) the ischiatic and (b) that onto the dorsum ilii, and II. the forward or inward, including (a) the obturator and ih) the pubic. The backward dislocations are by far the most com- DORSAL on liAead in its new position, the depression and inward displacement of the trochanter, and the flattening of the outer aspect of the hip. In the reduction of dislocations of the hip we may lay down the general ride that the head should be made to take, in the reverse direc- tion, the route it took in becoming dislocated. The chief obstacle to re- duction is the tension of the Y ligament in the partly extended posi- tion, and to overcome this the thigh is first flexed. This flexion also brings the head down to the lower part of the socket, where it escaped. As a general rule we may direct to first (1) increase the deformity and then (2) make the opposite movements. (1) Relaxes the Y ligament, releases the head and brings it below the socket while (2) forces the FRACTURES OF THE NECK OF THE FEMUR. 441 head through the tear in the capsule into the socket. In the dorsal form increasing at first the adduction and inversion lifts the head of the femur away from the pelvis and the projecting rim of the acetabulum. At the same time unless we make forward traction after flexion, and otherwise increasing the deformity, a backward dislocation is likely to be converted into a ibrward one and vice versa. In other words the reduction is to be made f"rposite movements too far. It may be convenient to remember that the internal condyle looks nearly in the same direction as the head of the femur. Congenital Dislocations of the Hip. — The hip may be congenitally dislocated from lack of development of the acetabulum, especially its upper or iliac portion. In congenital dislocations the neck is short and the head is flat and slips onto the dorsum of the ilium when the child walks. If reduced there is nothing to keep it from slipping out again. When long displaced the muscles become shortened so that the head can not be reduced without dividing them. A new socket may form on the ilium from osteophytic outgrowths. The ligament nm teres is usually stretched and not torn. Fractures of the Neck of the Femur. — The long axis of the neck measures 3.1 to 4 cm., its vertical diameter averages 313 mm., its antero- posterior 25 mm. The neck forms an ancfle with the shaft, averaging 125° in the adult. This angle is greater in the infant, but does not decrease after adult life is reached. Hence the theory that the fre- quency of fractures of the neck of the femur in old age depends ujion a decrease of this angle to one nearer a right angle, a position that would favor fracture, is not sustained by facts and has been abandoned. Nor is the angle sufficiently less or the trochanter enough more promi- nent in the female to account for the more frequent occurrence of this injury in that sex. The fact remains, however, that this fracture is essential I ij a hsion nj old age, is more common in women than in men and is often the result of slight causes, a stumble, a misstep, or a slight fall. These facts in- dicate the existence of senile cJuinges as a i)redisj)osi)ig cause, and it is found that all parts of the bone are much rarefied and the corticjii sub- stance is much thinner in the aged. This osteoporosis afects also two plates of compact bone which strengthen the neck, (1) the ealcar femorale, a nearly vertical phite projecting into the sjH)ngy substance, 442 THE LOWER EXTREMITY. toward the great trochanter, from a little in front of the small tro- chanter, and (2) a thin dense ji^ate, continuous with the posterior sur- face of the neck, which extends in the spongy tissue toward the outer surface of the shaft and of the trochanter. As the capsule is attached in front to the base of the neck (the intertrochanteric line) and behind half an inch or more internal to the posterior intertrochanteric line, it follows that there can be no strictly extracapsidar fractures of the neck, for the latter is entirely intracapsular in front. A more scientific classification of these fractures than that into intracapsular and extra- capsular is the division into (a) fractures through the neck and (6) fractures at the base of the neck. (rt) Fractures through the neck may occur at any point be- tween the junction of the head and neck and the base of the latter, though they are said to be more common near the head. It is this variety especially that occurs from slight violence in the aged. As a rule there is angular displacement at the fracture, from the crushing of the bone or the penetration of one fragment into the other pos- teriorly, so that the neck is bent at an angle directed upward and forward. If the fracture is near the head the latter is penetrated by the smaller and more compact neck, but true impaction is rare. Tlie periosteum is usually untorn over a portion of the circumference of the neck. This periosteum is reinforced by fibers reflected from the femoral attachment of the capsule toward the head in three bands or retinacula, one behind and one at either end of the anterior intertro- chanteric line. The untorn portion of the periosteum not only holds the fragments together, hut fur 7iishes a source of blood supply to the smaller fragment, to assist in the process of repair. The only other source of blood supply of the head, after fracture, is the ligamentum teres. (6) Fractures at the base of the neck usually follow the line of junction of the neck and shaft quite closely, but other lines of fracture traverse the great trochanter, as a rule. The neck is as a rule bent backward by the crushing of its posterior and more fragile part, or its penetration into the trochanter posteriorly. In this way the tro- chanter may be split into two or many pieces. According to Stimson true impaction, or fixation with penetration, is the exception. In this form tJie cause is usually a fall on the trochanter, and it includes most of those cases where fracture occurs before old age. According to Whitman it is more common in childhood than was formerly supposed. The axis of the neck and of the great trochanter are not in the same plane, but meet in an angle, open posteriorly, at the anterior tro- chanteric line. In a fall on the trochanter this angle is exaggerated and the bone gives way here at the weakest and most spongy portion of the bone. This mechanism helps to explain the greater penetration behind and the eversion of the limb. The eJisenVud point in the prognosis^ and the reason for attempting to distinguish between these two forms, lies in the vitality and power ■of repair of the upper fragm.ent. This depends not so much upon impac- SYMPTOMS AND SIGXS OF FRACTURE. 443 tion or the situation of the fracture as upon tiie preservation of the blood supply, which runs toward the head in the tliick cervical peri- osteum. These vessels are not much injured in fractures at the base of the neck, and in those throu) pressure on the lower end of the aorta by Lister's tourniquet has been used and also (4) pressure on the common iliac against the pelvic brim by Davy's lever introduced into the rec- tum. Both 3 and 4 have been generally abandoned, (o) Pressure on the common iliac by the fingers of an assistant introduced through an intermuscular incision in the iliac region (McBurneyj, I have found very serviceable. (6) The elastic tourniquet around the upper end ot the limb, with or without the use of long needles, or skewers, thrust through the upper end of the thigh, to prevent the rubber tubing or bandage from slipping down, is the method most generally used. In order to control the gluteal and sciatic vessels the tourniquet must be carried internal to the tuber ischii, so as to compress them as they emerge from the great sacro-sciatic foramen. By passing over the groin it compresses the femoral vessels and by being carried above the iliac crest it is prevented from slipping downward. The varieties of incision are numerous. We may make an " external racket" or oval incision, with the summit two inches above the tro- chanter; an "anterior racket" incision, with the center at the middle ot Poupart's ligament ; or a circular amputation of the thigh combined with an external vertical incision extending up two inches above the trochanter, etc. The various incisions have their own advantages and disadvantages. The vessels divided are the femoral, profunda, gluteal, sciatic and branches of the external and internal circumflex, and the long saphenous vein. Their position at the point of section varies with the form and length of the flaps. In those methods with long flaps the branches of the gluteal and sciatic arteries are small and unimpor- tant. In the " anterior racket " incision no tourniquet or compression is used, the vessels are tied as they are met with, as in removing a tumor, and very little blood need be lost. The mufa.se of the triangle (common femoral) or in Hunter's canal. The latter lies at the lower end of the middle third »jf the thigh, beneath the sar- torius muscle, which is retracted internally to reach it. It nuasarcs five to six cm. in length, and is bounded by the adductor longus be- hind, the vastus internus externally, and in front by a firm mem- branous layer of oblique tendinous fibers passing from the adductor magnus downward and outward to the vastus internus. The vein here lien behind and somewhat external to the artery, quite closely con- nected with it, and an extra vena comes may lie in front of the artery and complicate its ligation. The lo)i(j saphenou.s nerve lies in the canal, in front and slightly external to the sheath of the vessels. Within the canal it crosses in front of the vessels, which it accompanies to the opening in the adductor magnus, where it perforates the canal and passes beneath the sartcrius. The vastus internus separates the artery from the femur on the outer side of the vessel, so that in coinpre.^sion of the artery, which must be made from within outward, there is no firm bed against which to compress it. In rare instances the femoral artery is replaced by two trunks. It is occasionally ligated for popli- teal aneurism or for wounds. The great sciatic nerve usually di rides into the internal and ex- ternal popliteal nerves about the middle of the thigh, not infrequcntlv higher up, even within the pelvis, and occasionally lower down. Below the lower border of the gluteus maximus it is quite superficial and a little lower is crossed by the biceps, ^it the middle of the fhi(/h if lies between the biceps behind and the adductor magnus in front, beneath or anterior to the thin fascial layer separating the hamstring and ad- ductor muscles. Lower down it lies between the hamstring muscles which are internal and external to it. It is mrronnded hii a lavcr of loose connective tissue and fat, continued downward from the pelvis. This tissue affords a favorable pathway for the sinking of abscesses, even from the pelvis to the lower thigh or the popliteal space. The place of election for opening deep abscesses of the thigh or the removal of sequestra from the femur is the external surface, for here the bone is not very deep and there are no important vessels or nerves. Fractures of the Femur. — The shaft of the femur may be frac- tured at any part, but mo^t eoviinonli/ at the midiUe third, which is affected by the leverage of both ends. The fracture is uaually obli(jue, 448 THE LOWER EXTREMITY. but may be transverse, especially in children and in direct fractures, which are most common in the lower half. Fractures in the upper half are almost always oblique. The obliquity usually corresponds to the normal curvature of the bone. Thus it cominonly runs: from behind forward and downward in the middle third, forward and out- ward in the upper third. The displacement is marked and is the re- sult of the fracturing violence, the contraction of the thigh muscles and the swelling beneath the firm fascia lata, by means of which the thigh is necessarily shortened at the same time that it is swollen. In addi- tion there is an angular displacement, usually directed forward, or for- ward and outward, in the direction of the natural curve and attributed to the contraction of the adductor muscles, which form the arc of the curve. The lower fragment may also be rotated out by gravity. In fractures of the upper third the usual forw^ard and outward displacement of the lower end of the upper fragment is largely due to muscular action. (1) The adductors and hamstring muscles draw the lower fragment up and in, behind the upper fragment, and tilt the latter forward and outward. (2) The psoas and gluteal muscles also tilt the upper frag- ment forward and outward. The sharp ends of an oblique fracture may be driven into and caught in the surrounding muscles, which, being interposed between the fragments, prevent reduction of the deformity and lead to delayed union or non-union. The artery or vein are rarely torn or compressed by the fragments, an injury leading to gangrene. I have seen one such case. In fractures in the lower third the lower fragment may be tilted backward, probably by the action of the gastrocnemii. Except in rare cases of transverse or incomplete fractures, the limb is always shortened. This shortening may vary from a fraction of an inch to four or even six inches, and is due to the overriding and the angular displacement of the fragments. A principal object of treatment is the overcoming of this shortening by continued extenmon. Practically union never occurs w'ithout shortening, though the possibility of union without shortening may be admitted. The average amount of shortening after union is f inch, though 1| inches of shortening may occur without a limp in the gait, the shortening being compensated by the tilting of the pelvis. In this connection it may be noted that the lower limbs are usually of unequal length, the inequality averaging \ inch, the left being the longer as a rule (Wight). In only about 10 per cent, of cases are they of equal length, so that using one limb as a standard of length for the other is inaccurate. In the treatment of fractures of the upper third the entire limb should be flexed and abducted to coincide with the forward and outward tilting of the upper frag- ment. In amputation at or below the middle of the thigh the circular method is easy and gives good results. The ease of retraction of the skin flap has l)een referred to, and the thigh is seldom so conical as to require the sjilitting of this flap. The muscles retract unevenly, those attached to the femur retracting but little, those not so attached, the LANDMARKS ABOUT THE KWEE. 449 free muscles (sartorius, rectus, gracilis and hamstriug), retracting con- siderably. Hence the stump is retracted and the muscles are divided a second or even a third time. THE REGION OF THE KNEE. Limits. — This includes the region l)et\veen the k'V<'l oi the upper end of the subcrural bursa, 8-4 fingers' breadth or 5-H cm. above the patella, and the level of the tubercle of the tibia. Landmarks and Surface Markings. — (1) Antero-lateral Region. — The patella is plainly seen and felt in front, its inner l)order being somewhat the more prominent. In the extended position of the limb the patella can be moved to and fro, when the quadriceps is relaxed, but is drawn np and firmly fixed against the femur when the muscle is con- tracted. When the knee is flexed the patella occupies the hollow i)e- tween the two bones, and is not so readily palpated. In this position we can feel, above the patella and through the quadriceps exj)ansion, the trochlear surface of the /ewuo', especially its prominent outer border. A line from the upper angle of this border to the adductor tubercle marks the level of the epiphysial line. The adductor tubercle is felt at the upper end of the internal condyle. It is just above the epiphyseal line and is the favorite situation for exostoses in adolescence. The internal condyle and its tuberosity are more prominent than the outer, but the outer tuberosity of the tibia is more prominent than the inner. The tubercle of the tibia is plainly felt at the upper end of the anterior tibial border, and at the lower end of the ligamentum patellje. About on a level with the tubercle, the head of the fibula is felt on the postero- external aspect, 1 cm. below the joint line. In the semiflexed position of the knee, when the quadriceps muscle is contracted, the ligamentum patellae can be plainly felt, and often seen, as a ridge extending from the apex or lower end of the patella to the tubercle of the tibia. In this position there is a slir/ht groove on either side of the tendon but in the extended position, when the quadriceps is relaxed, the grooves are not marked. In stout subjects the grooves may be obliterated by fat, which is found most abun- dantly behind the upper half of the tendon, separating it from the synovial cavity. The ligamentum patelhie lies in the axis of the leg and hence forms a slight angle with the direction of the quadriceps. On either side of the patella is a slight groove, which is obliterated by effusion into the joint and may be filled with fat in the obese. In stout subjects the patella may appear to lie in the bottom of a groove instead of on a ridge. Above the jndella is a dejiression which is con- verted into a prominence in case of effusion into the joint. On both sides, but particularly on the inner side, the interarticular line between the tibia and femur can be felt as a slight de])ression in normal condi- tions. This is just aliove the level of the apex of tiie patella, which serves as a convenient landmark to it. It is here tliat one feels for a displaced semilunar cartilage. The iliotibial band of the fascia lata, descending between the patella and the back of the external condyle to 29 450 THE LOWER EXTREMITY. the external tuberosity of the tibia, may be felt as a rounded band, most distinctly when the joint is forcibly extended. Posterior or Popliteal Region. — In this region the landmarks are best felt when the knee is slightly flexed. In this position the concavity of the space appears, while in the extended position it is flat or bulging. At the outer side, behind the iliotibial band, the tendon of the biceps is felt descending to the head of the fibula. Directly in front of it the upper part of the external lateral ligament is palpable, and close to its inner border the external popliteal nerve is readily felt as a rounded cord. In its descent the nerve crosses the neck of the fibula, where it may be rolled under the finger before it enters the peroneus longus. The internal popliteal nerve may be felt and, in thin subjects, even seen descending vertically in the middle of the space. On the inner side from without inward we can feel the long and slender tendon of the semitendinosus, the thicker and less prominent tendon of the semimem- branosus, and the gracilis. The last two appear as one tendon but by a little manipulation we can insinuate the finger between them. The popliteal lymph nodes when normal can not be felt. At the lower end of the space we can feel the converging fleshy heads of the gastrocne- mius. In the flexed position a crease in the skin crosses this space some distance above the joint line. It disappears in extension. Topography. — The popliteal artery enters the popliteal space be- neath the semimembranosus, a little to the inner side of the middle line, and thence runs in a line to the interval between the two heads of the gastrocnemius at the center of the lower end of the space. It descends at first obliquely outward, reaches the middle line opposite the joint, and thence runs vertically. It bifurcates on a level with the tubercle of the tibia. It lies against the back of the femur, the pos- terior ligament of the knee and the popliteus muscle and can be com- pressed against the femur in the upper part of the space, where also its pidsations can be felt. The popliteal vein lies behind it, to its outer side above, but it crosses to its inner side below. The internal popli- teal nerve descends in the middle line, continuing the course of the great sciatic, and is superficial to the vein, by which it is separated from the artery. The superior articular arteries run transversely just above the con- dyles of the femur ; the inferior articular arteries are just above the head of the fibula externally, and a little below the internal tuberosity of the tibia internally. The deep branch of the anastomotica magna descends in front of the adductor magnus to the internal condyle, the superficial part runs with the internal saphenous nerve. The sliort saphenous i-cin perforates the deep fascia at the lower part of the popli- teal space in the middle line. It is not visible as a rule unless vari- cose and it has been suggested (Herapat) that varices of this vein may depend upon a narrowness of the opening in the fascia. The long saphenous vein passes along the back of the internal condyle, above which it lies along the posterior border of the sartorius. It is joined by the internal saphenous nerve just below the joint line. THE SOFT PARTS BEHIND THE KNEE. 451 Soft Parts in Front of the Knee. — The skin is thick and very movable, thus permitting incisions into the joint to be very indirect or valvular when desired. The deep fascia, continuous with the fascia lata, is attached to the two tuberosities and the tubercle of the tibia and strengthens the joint on either side of the patella. This part of the joint is also strengthened by the lateral expaihsiou.s of tlir quadriceps tendon, which are connected with the sides of the patella and liganien- tum patellae anteriorly and reach as far as the lateral ligaments pos- teriorly. Hence they are called lateral patellar ligarnentj^. In frac- tures of the patella, where there is any considerable separation of the fragments, there is always more or less of a tear in the lateral ex))an- sion on either side of the line of fracture. There are two bursae in this region that require mention. (1) The prepatellar bursa lies in front of the lower two thirds of the patella and the upper end of the ligamentum patellae. It does not reach the internal border but often projects over the external border of the patella. Although it is often described as separating the patella from the skin, it lies, according to Tillaux, beneath the deep fascia. Others (Gruber, Joessel, etc.) describe bursae in three situations, beneath (1) the skin, (2) the superficial fascia and (3) the deep fascia, of which the last is the most constant. When more than one is enlarged they are separated wholly or partly by septa which easily yield to inflammatory changes, so that in opening a purulent pre- patellar bursitis a single cavity is often found. The bursa is ofteii enlarged and not infrequently inflamed in those who kneel much, such as housemaids, etc., hence prepatellar bursitis is commonly known as " house-maids' hieeJ" Suppurative bursitis may lead to caries of the patella, from which the bursa is separated only by the periosteum. I have also met with tubercular inflammation of this bursa. (2) The small bursa between the patellar ligament and the tubercle of the tibia is separated from the synovial cavity by a pad of fat lying behind the upper end of the ligament. It does not communicate with the joint and is not often enlarged or inflamed. An indistinct feeling of fluc- tuation on either side of the upper end of the patellar ligament is often due to the loose fat beneath it and not to an enlargement of this bursa. This fat often protrudes a little on either side of it, and thus still further simulates an enlarged bursa. The soft parts at the back of the knee either bound or are con- tained in the popliteal space. The skin covering it is not so movable as in front, and the contraction of a cicatrix resulting from burns, ulcerations or injury may result in a bent knee. In straightening a knee, long anehylosed in the flexed position, the skin at the Imrk is liable to be torn. The deep fascia, continuous with the fascia lata above, has no bony attachments here. Its flrmness limits the exten- sion toward the surface of ])opliteal tumors or abscesses. Hence being pent up in the popliteal si)ace they cause severe pain and tend to spread down into the leg on up into the thigh. From the latter region abscess may extend to the popliteal space through the opening in the 452 THE LOWER EXTREMITY. adductor magnus for the femoral vessels, or they may follow the great sciatic nerve from the thigh, the buttocks or the pelvis. The muscles which bound the space, and give it a lozenge shape, are the biceps above and externally, the semitendinosus and semimem- branosus above and internally, and the two heads of the gastrocnemius below and on either side. The upper muscles, known as the hamstring muscles, are the cause of flexion of the knee in knee joint disease, from the irritation of articular filaments of the sciatic nerve, motor branches of which supply these muscles. Continued flexion in this disease leads to a partial backward luxation of the tibia and to the contracture and shortening of these muscles. According to Tillaux, the biceps and semi- tendinosus are frequently shortened in these conditions, the semimem- branosus rarely so. The shortened tendons require tenotomy prior to straightening the knee. In tenotomy of the biceps the relation of the external popliteal nerve just internal to it is to be borne in mind. Contraction or contracture of the muscle renders the tendon more superficial and increases its distance from the nerve. To diminish the risk of cutting the nerve the tendon should be cut from within outward about 3 cm. above the head of the fibula. The hamstring tendons, especially the biceps, may be ruptured by violence in the position of extreme flexion of the hip while the knee remains extended, a position in which they are greatly stretched. The popliteal vessels lie deeply and are well protected, hence they are seldom wounded. The artery however is more often the seat of aneurism than any other, with the exception of the thoracic aorta. Many factors have been adduced to account for this disposition. (1) It divides into two large vessels. (2) It is supported by the lax tissue of the popliteal space, and not by muscles. (3) Its course is curved, in the flexed position, like the thoracic aorta. (4) It is subjected to frequent and extensive movement. In straightening the bent knee in cases of chronic knee joint disease the artery may be ruptured. In this respect cuneiform resection of the knee is a safer operation than forcible straightening. Forced flexion of the knee aflects the lumen of the artery as shown by the diminished pulse at the dorsalis pedis artery. When the artery is the seat of an aneurism, the pressure exerted by forced flexion of the knee stops the circulation, and popliteal aneurisms have been successfully treated in this way. The relations of the artery to the vein and the internal popliteal nerve explain the oedema of the leg and the nerve symptoms due to the pressure of an aneurism on these structures. The close relations of the artery to the posterior ligament, on which it lies, explains the occasional penetration of an aneurism into the joint. The artery is more closely connected with the posterior ligament below than above the joint line, hence Tillaux recommends sawing the tibia from behind forward in resection of the knee to avoid accidental wound of the artery, but this is not necessary with ordinary care. A backward luxation of the tibia has occasionally been compli- cated by rupture of the artery. Anomalies of the artery are rare and consist mainly in a high division. PLATE LI I I FIG. 106. :mimembbanosus \ MUSCLE "^ TIB. COMMUNIC. NERVC EXTERNAL SAPHENOUS VEIN EXTERNAL POPLIT- EAL NERVE NTERNAL POPLIT- EAL NERVE °OPLITEAL ARTERY POPLITEAL VEIN CRON. COMMUNiC NERVE Lperon. LONGUS MUSCLE Popliteal region of the right side. (Joessel.l THE KNEE JOINT. 453 The popliteal vein is so doHcly wllurent to (Iw artery tliat some diffi- culty may be found in separating the two in ligature of the latter. In spite of its more superficial position than the artery, the vein is rup- tured by violence even less often than the artery and, according to Treves, never alone. This may be owing to the circumstance, noted by Tillaux, that it is so thick that it does not collapse on section, and thus resembles an artery so closely that it may readily be mistaken for it in operations on the cadaver. The lymph nodes of the ix)pliteal space consist of only four small nodes, one just beneath the fascia and below the opening for the short saphenous vein, the others along the artery. They are rarely swollen and, when involved, form a median tumor, unlike those derived from the l)ursje. The bursae at the back of the knee are situated on either aide, two on the inner and four on the outer side. Many of these are not con- stant and are unimportant on account of the fact that they never com- municate with the joint and are seldom enlarged. 1. Between the internal condyle and the inner head of the gastroc- nemius and extending between the latter and the semimembranosus is the largest bursa of this region and the one most often inflamed. It communicates with the joint in fully fifty per cent, of cases (Gruber) and more often in adults and in robust subjects. Its slit-like opening into the joint may become closed by the tightening of the posterior ligament in extension, which may explain its firm feeling in extension, in contrast with its more flabby feeling in flexion. In the latter posi- tion it may sometimes entirely disappear on pressure. It may become enlarged in effusions into the joint, or independently. (2) A small inconstant bursa, between the semimembranosus and the tuberosity of the tibia, may communicate with (1) but never directly with the joint. O71 the Older side there is (3) a bursa between the popliteus tendon and the external lateral ligament, without joint connection, and (4) one be- tween the same tendon and the external tibial tuberosity. The latter bursa is strictly a diverticulum from the joint and, by occasionally com- municating/ with the upper tibiofibular joi)d (in about fourteen per cent, of cases, Gruber), connects the latter with the knee joint. (5) A bursa between the outer head of the gastrocnemius and the external condvle is neither constant nor connected with the joint. (6) One between the biceps and the external lateral ligament is more constant but is also not connected with the joint. Tumors due to a bursitis are situated lafrrally and Hsuallij intcrndl/f/, but median cysts may occur in the popliteal space due to the hernial protrusion of the synovial membrane through small openings in the posterior ligament. The knee joint oircs its strmf/fh to that of the ligaments, tendons and fasciie, which join together and surround its component parts. By reason of its strength and the large extent of its opposing surfaces, traumatic dislocation is uncotnmon in spite of its exposure to injury, and only occurs from severe violence. The most common form is dis- location of the tibia forward by direct violence or by hyperextension, 454 THE LOWER EXTREMITY. the next commonest is dislocation of the tibia backward. The lesion is a grave one because of the great violence required and the frequency of compounding and of injury of the popliteal vessels. When the femur is held vertically the plane of the lower surfaces of the two condyles is not horizontal, as is that of the upper surfaces of the tibia, but the inner condyle projects lower than the outer. Hence to make the joint surfaces parallel the femur must be inclined inward, the position it normally occupies in the body. Another result of this inclination is to bring the knees together, although the hips are widely separated, and, as the tibia descends nearly vertically, the ankles are also in contact. In the condition known as knock knee or genu valgum the knee is un- usually prominent internally. This condition is due to an overgrowth of the internal condyle, unevenness of the tibial facets, curvature of the bones, or relaxation of the internal ligaments of the joint, with or without contraction of the tissues on the outer aspect. Overgrovih of the internal condyle is the common cause, and may occur primarily or as the result of relaxation of the ligaments on the inner side. By this relaxation the pressure between the bones on the inner side is diminished, but the actual separation of the bony surfaces, thus rendered possible, is pre- .vented by the downward growth of the inner condyle. The pressure between the bones on the outer side is increased, whereby the latter undergo some atrophy and the deformity is thus increased. Knock knee is commonly due to rickets and occurs most often between the ages of two and four. When it occurs in adolescents it is not commonly due to rickets but to a relaxation of the ligaments and muscles. Ac- cording to Mikulicz, the increased downward growth of the inner condyle is confined to the lower end of the diaphysis. The prominence of the internal condyle is readily recognized when the knee is sharply flexed. It is a curious fact that the deformity, however great, disap- pears completely when the knees are flexed. This is because the de- formity is due to the greater length of the internal condyle so that the axis of the hinge motion is not transverse but inclined outward and upward, bringing the feet away from one another when the knees are extended but together when they are flexed. Knock knee, when well established, is treated by osteotomy of the femur above the condyles, with or without the removal of a wedge of bone (cuneiform osteotomy), and then by straightening the limb. Ligaments. — In the semiflexed position of the joint most of the ligaments are relaxed, a condition that favors the backward displace- ment of the tibia by the contracture of the hamstring muscles, in chronic knee joint disease with flexion. Owing to the relaxation of the ligaments in this position rotary and slight lateral motion of the knee is allowed in semiflexion. Hence if we wish to test the knee for abnormal lateral mobility, such as is due to rupture of the lateral ligaments, etc., the test should be made when the knee is extended. All except the anterior ligaments are taut in extension, only the posterior crucial and the anterior ligaments are taut in extreme flexion. The powerful crucial ligaments are not relaxed in any position of the joint. FRACTURE OF THE PATELLA. 455 The anterior crucial not only resists hyperextension and anterior dis- placement of the tibia, i)ut also rotation of the Ie<^ inward. The pos- terior crucial ligament resists forced Hexion and posterior disi)laceuient of the tibia. The lateral ligaments lie behind the center of the joint, about the junction of its middle and posterior thirds, hence they are taut in extension, relaxed in flexion. In the latter j)osition they resist out- ward rotation of the tibia. They are not very strong. If pus within the joint escapes into the popliteal space it usually does so tiirough the thinnest part of the posterior ligament, the part below the oblique ligament of Winslow. AVhen one is in the act of falling backward, or in any direction with the knees bent, an instinctive effort is made to avoid the fall by violently contracting the quadriceps to straighten the knee. By such a spa^smodlc contraction of the quadriceps o)ic of four Icjfions may be caused: (1) fracture of the patella; (2) rupture of the ligamentum patellffi ; (-'>) rupture of the quadriceps tendon ; (4) dislocation of the patella. Fracture of the patella is the commonest of these. The fall ot the patient is only indirectly the cause of the fracture and it may be the result. In a fall on the bent knee, wdien the hip is also flexed, the tubercle of the tibia and not the patella comes in contact with the ground. In some cases, however, the patella is broken by direct violence as by a blow or fall directly on the bone. In over 80 per cent, of cases the fracture is due to muscidar action. The Vuie of frac- ture is quite uniformly transverse when due to muscular action, and usually at or just below the center of the bone. Fractures due to direct violence may be transverse, oblique, comminuted or even longi- tudinal. Another important difference lies in the fact that in direct fractures there may be little or no separation of the fragments, in indirect fractures there is usually some and often considerable separation. This separation depends upon the amount of effusion into the joint, combined with the transverse laceration of the lateral patellar lif/anients. The influence of the latter is seen in direct fractures, in which, though there may be considerable effusion, there is little or no separation, for the lateral patellar ligaments are practically intact. Again in frac- tures due to muscular action the lateral patellar ligaments are more or less extensively torn, but the scpdration disappears or may be easily overcome if the effusion is gotten rid of. The pull of the quadriceps tendon is not an important factor in the separation until later on, after atrophy of the muscle occurs. The rupture of the lateral patellar ligaments and the failure of bony union are ex})lained by the inechanism of fracture by muscular action. (Fig. 107.) In the semiflexed position, in which the knee is usually placed when the violent contraction of the (piadriceps occure, only the middle of the back of the patella rests on the trochlear surfaw of the femur, the upper and lower ends of the bone being unsupportitl. Its vertical axis is in line with the taut ligamentum patelhe, while the line of action of the violently contracted quadriceps muscle is nearly at 456 THE LOWER EXTREMITY. right angles to this axis. The patella is thus broken as one would break a stick over the knee. The bone gives way first and, the force continuing, the fragments are separated and the tear extends a variable distance into the lateral patellar ligaments, on either side of the line of fracture. The periosteum and tendinous fibers in front of the patella stretch a certain distance but, if the fragments are palled further apart, Fig. 107. they give ivai/ and curl back in front of one or both fractured surfaces. This interpjosition of fibrous tissue between the fragments prevents the bony union of these surfaces and often prevents crepitus when the surfaces are rubbed together. This is the reason why treatment by open opera- tion, in this the commonest variety of fracture of the patella, is in such favor, as it alone assures bony union. In direct fractures I have se- cured bony union without operation and this result is by no means rare. As Morris says, a fracture of the lower and non-articular end of the patella without injury of the synovial membrane is an anatomical possibility, provided the amount of separation is slight. In such a case the fat behind the lower end of the patella saves the synovial mem- brane from injury. The patella, which is a sesamoid bone developed in the quadriceps tendon, does not ossify until the end of the second year and may be congenitally absent. Nearly all the arteries around the joint furnish blood sup})ly to it. Rupture of the ligamentum patellae is rare. Exceptionally the tendon is torn from its insertion into the tubercle of the tibia, and rarely the tubercle is avulsed with the tendon. Rupture of the quadriceps tendon above the patella is more com- mon, but rare in comparison with fractures of the patella. It residts DISLOCATION OF THE SEMILUNAR CARTILAGES. 457 from a violent muscular contraction, sometimes from a slight one when the muscle is diseased. Above the patella a well-marked dcprea^iion appears which is occupied by a blood clot. Rupture of the tendon or ligament is treated by aseptic suti(re. In these three forms of injury the ability to extend the knee is lost or impaired. Dislocation of the patella is rare. The coiniaonenl form is the ont- ward dislocation which may be complete or, more often, incomplete. It may be caused bi/ a blow on the prominent inner border or, more commonly, by a violent contraction of the quadriceps muscles. It occurs most often in the extended position of the limi), when the front of the capsule and the ligaments of the patella are most lax. The line of action of the quadriceps, in the axis of the thigh, is not the same as the axis of the patellar ligament, in the axis of the leg. W/ien there- fore the quadriceps contracis, the patella, which lies at the angle of meet- ing of these two axes, is pulled outu-ard, as the muscle and ligament tend to form a straight line. In knock knee therefore the tendency to outward dislocation is increased by the greater angle between the muscle and the ligament. The outward dislocation of the patella is resisted by the prominent outer margin of the trochlear surface of the femur and by the internal expansion of the quadriceps. The latter may re- main intact in an incomplete dislocation, but must be ruptured to allow a complete outward dislocation. In the latter the patella is displaced to the outer side of the external condyle and usually lies with the inner border directed forward and the posterior surface inward. The next most common form is the so-called edgewise or vertical dislocation of the patella. In the commoner variety of this form the inner border rests in or near the bottom of the trochlear groove with the outer bor- der projecting forward and the anterior surface looking inward. The opposite displacement is nearly as common. Muscular action, not always violent, seems to be the most common cause of this form also, but it may be due to a blow on the inner edge of the bone. Inu-ard dislocations are rare. The semilunar cartilages are attached by their peripheral surfaces to the capsule and lateral ligaments of the knee. In effusions into the Joint one sees a groove in the bulging capsule on either side of the lower end of the patella, due to the lateral patellar ligaments and to this attach- ment of the semilunar Ciirtilages, which incompletely divides the syno- vial cavity into an upper larger and a lower smaller portion. Disloca- tion of one or the other of the semilunar cartilages occurs as a rule iVi)m a twist of the leg in the semiflexed position of the joint. In flexion and extension of the knee the cartilages move with the tibia, but in mta- tion one or the other disc is held firmly between the two bones while the other is liable to slip between them. Thus in rotation outward, performed chiefly by the biceps, the external meniscus is held closely between the outer condyle and the tibia, as these two are pressed together by the biceps. This increases the ga]> between the internal condyle and the tibia into which the internal disc is liable to slip. Similarly in internal rotation the outer disc is the one liable to dis- 458 THE LOWER EXTREMITY. placemeDt. Hence the rule that dislocation of the internal disc occurs from an outward twist of the knee, that of the external disc from an in- loard twist. The internal disc is dislocated more than three times as often as the external and the left knee is affected nearly three times as often as the right. This may be partly accounted for by the fact that the external cartilage is smaller, rounder and more movable than the internal, and is attached partly to the posterior crucial ligament, and thereby to the femur. The popliteus tendon which grooves its outer surface, postero-externally, may also help to hold it. The dislocated cartilage is torn from its attachment to the tibia, usually at one end, and is at times pulled into the joint during flexion and rotation, where it becomes pinched and locked between the two bones, giving rise to a sudden pain and fixation of the knee in the flexed position. On pal- pating the line of the joint we may feel a gap, when the disc is dis- placed into the joint, or a marked ridge when it is displaced laterally. The displacement can usually he reduced, by extension followed by sudden flexion and rotation ; but an operation is often required to effect a cure, by removing the loose portion or suturing it in position. The synovial membrane of the knee is the most extensive and com- plicated in the body. It extends as a, jwuch between the quadricejis and the front of the femur for about an inch above the trochlear surface of the femur and the upper end of the patella. Above the pouch is a bursa (subcrural) between the quadriceps and the front of the femur, over an inch long vertically, which communicates with the pouch in 70 per cent, of cases in children and 80 per cent, in adults. The partition varies from a complete septum to a mere trace. In the ex- tended position therefore, we may find a synovial cavity, continuous with the joint, over two inches (5 to 8 cm.) above the 2Mtella or the trochlear surface of the femur, so that a wound or incision at this level may practically open into the joint in a majority of cases. In exten- sion the pouch is supported by the subcrureus while in flexion it is somewhat drawn down. In case of effusion into the joint the pouch and bursa appear as a median prominence or, if separate and both are filled with effusion, as two prominences above the patella. In this condition of effusion into the joint the patella is raised from the trochlear surface of the femur, on account of its connection with the anterior part of the capsule, and is said to "float.'' By sudden pressure on the patella the latter is made to strike the femur producing a click, which is useful as a diagnostic sign of fluid in the joint. The attachment of the posterior crucial ligament to the posterior ligament divides the synovial cavity, posteriorly, into an inner and an outer condylar recess. The upper third of the ligamentum patellae is separated from the synovial membrane by a pad of fat, the lower two thirds from the tibia by fat and a bursa. The synovial membrane is remarkable for the number of fringes from its inner surface, especially about the patella. Laceration of these fringes, followed by their infiltration with blood and their subsequent exfoliation, gives origin to some of the "loose bodies'' in the knee joint. The organization of an PLATE LI V. POPLITEUS TENDON FAT BENEATH LIG. PATELL>E EXT. LATERAL LIGAMENT BICEPS TEN- DON BURSA BENEATH LIG. PATELL/E FIG. 108. SUBCRUREUS MUSCLE ANT. TIBIAL ARTERY SUBCRURAL BURSA QUADRICEPS T L r-i D O N NT. LATERAL PATELLAR LIGAMENT NT. SEMI- LUNAR C AR- TILAGE INT, HAMSTRING TENDONS, WITH BURSA BEN EATH K nee-joint from in front, sliowing synovial sac, anterior ligaments, superficial anastomosis of articular arteries, etc. (Testut.) SUBCRURAL PREPATELLAR BURSA LIGAMENTUM MUCOSUM LIGAMENTUM PATELL>E BURSA — 1, POPLITEAL ' . ■' // VEIN __ii_-ANT. CRUCIAL T/i LIGAMENT POST. LIGAMENT EXT. SEMILUNAR ^..'l CARTILAGE rj •_ POPLITEAL iF~ 'nj POPLITEUS 7? MUSCLE GASTROCNEMIUS MUSCLE Lateral half of vertical sagittal section oi' right knee after dis- tention of the synovial sac. Probe i^assed through opening between pouch above patella and subcrui-al iDursa. (Joessel.) EXCISION OF THE KXEE. 459 intra-articularcl(jt or of fibrinous deposits in the joint may also produce similar " loose bodies." Synovitis from injury or exposure to cold is more frequent in the knee joint than elsewhere, owing to its suj)erficial and exposed position. The floating of the patella and the bulging of the sac above at the sides of the })atella have already been referred to (see page 4o8). In chronic in-ffdinmaf ion of the knee joint the latter almost always assumes the flexed position which may be partly explained ax fo/loirs. (Ij The capacity of the joint is increased on moderate flexion, being greatest in flexion to 2o° and least in com])lete flexion. The knee therefore assumes the flexed position to diminish the tension, which causes pain from pressure on the nerve endings. (2) The irritation of the sensory nerves of the joint causes a reflex contraction of the muscles, which fix the joint and prevent motion, as the latter is painful. The flexor muscles are more powerful and more favorably placed for acting and hence the joint is flexed. The flexed position, at first maintained by muscular action, is later on fixed by fibrous or bony anchylosis. Excision of the knee is sometimes required in chronic tubercular disease (white swelling), or in case of a knee anchylosed from any cause in a strongly flexed position. Through an incision from the hind part of one condyle to that of the other, curving below the patella the joint is opened and the upper flap turned up. The internal saphenous vein and nerve need not be divided. AYhen there is anchylosis with marked flexion we may remove a wedge-shaped segment of bone with the base anteriorly. In this way no undue traction is made on the popliteal vessels. In sawing the fcninr the section should be parallel with the normal joint surface, not at right angles with the shaft. If not properly sawn knock knee or bow legs may result. Both bones are best sawn from before backward. With reasonable care there is no danger of wounding the popliteal vessels, although there is more danger while sawing the tibia than the femur (see p. 452). The operation should be done in such a way that the limb may be absolufcli/ straight. In subjects who have not attained their growth tJie greatest care must be taken to do no damage to the epiphyseal li)ie, for the greatest amount of growth in length occurs at this end of both bones. The level of the epiphyseal line of the femur has already been given (p. 449). The lower femoral epiphysis unites with the shaft about the twentieth year. The limits of the upper tibial epiphi/si,^ are indicated by a horizontal line just below the tuberosities, behind and laterally, so as to include the attachment of the semimembranosus and the facet for the fibula. In front it slants down on each side to meet just below the tubercle, which is included in the epiphysis. It unites with the shaft in the twenty-first or twenty-second year. Arthrectomy of the knee has replaced excision to a large extent, and is j)r('fcrable in suitable cases. Disarticulation at the knee may be done by (1) lateral flaps (Stephen Smith), (2) an elliptical incision or (3) a long anterior flap. The best method is the first. In the method by a long anterior flap there is danger of sloughing of the flap. All methods have the disadvantage 460 THE LOWER EXTREMITY. of leaving a large surface of cartilage which has little or no reparative action. Hence I prefer Gritti's method, in which the lower surface of the condyles and the articular surface of the patella are sawn off and the sawn surfaces brought together. The patella with the tough skin covering it then forms the lower end of the stump. Fractures of the Lower End of the Femur. — Besides the frac- tures of the shaft above the condyles (see p. 448) we find: (1) inter- condyloid fractures, (2) fractures of either condyle and (3) separation of the epiphysis. In (1) the line of fracture between the condyles follows the intercondyloid notch in a sagittal plane and forms a T with the fracture separating both condyles from the shaft. (2) Fractures of either condyle are not common and may be due to avul- sion through the lateral ligaments, direct violence or the pressure of the head of the tibia. The fracture line runs into the intercondyloid notch. (3) Separation of the lower epiphysis of the femur occurs more often than tJud of any otJter, It is coiainonh/ due to great violence, acting especially in extending or abducting the knee. The separation here, as elsewhere, takes place between the cartilage and the shaft. The periosteum is freely stripped up from the shaft, but remains attached to the epiphysis. The epiphysis is commonly displaced forward and to one side, usually the inner. The injury is frequently compound. Direct reposition has sometimes failed, owing to the presence of prom- inent lips on the epiphysis and to the tension of the periosteum. In such cases operative reposition, through an external incision, has given good results. Fracture of the upper end of the tibia is not common, less so than that of any other part of the bone. It may be due to severe direct or indirect violence, and the line of fracture may or may not involve the articular surface. Owing to the proximity of the knee joint, which is often involved directly or indirectly, an effusion occurs within the joint. Separation of the upper epiphysis of the tibia has been observed in a few cases. The upper end of the tibia and the lower end of the femur are favorite situations for osteosarcoma. THE LEG. As the limits of this region we may take the level of the tubercle of the tibia above and that of the base of the malleoli below. Landmarks and Surface Markings. — The anterior tibial border or "shin" can be felt throughout its entire length. It is sharp and curved outward above ; rounded, less prominent and curved inward in its lower third, where it ends in front of the internal malleolus. The inner border can also be felt from the tuberosity above to the mal- leolus below. The internal surface, between these two borders, is sub- cutaneous except above, where it is covered by the tendinous insertion of the sartorius covering those of the gracilis and semitendinosus. Although the liead of the fibula is easily felt its shaft is buried by the overlying muscles in its upper half. In its lower half it becomes pal- TOPOGRAPHY OF THE LEG. 461 pable, especially in the lower four inches, where the malleolus and the triangular surface above it are subcutaneous. This subcutaneous area lies between the peroneus tertius and brevis. Tlie Hl>ula is well behind the tibia, so as to be posterior to the plane of the posterior border of the latter. Anto-iorli/, between the two bones, we can see the outline of the tibialis anticus internally, and that of the narrower and more external extensor communis digitorum can be made out when in action. The groove separating these muscles is quite distinct in muscular subjects and forms the best guide to the anterior tibial artery. In the lower third of the leg the tendon of the extensor longus pollicis comes to the surface and can be felt between these two muscles. Podcriorly the prominence of the calf is mainly formed by the gastrocnemius, whose two heads are conspicuous when one stands on the toes. In this position it is seen that the inner head is larger and longer. In the same position tlw Achil/c.s tendon stands out in promi- nent relief from about the middle of the leg to the heel. The soleus comes to view on either side of this tendon but more especially ex- ternally where it is less covered by the gastrocnemius. Topography. — The course of the anterior tibial artery is indicated by (I fine from a point midway between the head of the tiljula and the prominence of the outer tuberosity of the tibia to tlie middle of the front of the ankle joint. The posterior tibial artery runs from the bifurcation of the popliteal, at the center of the lower end of the pop- liteal space, opposite the lower end of the tubercle of the tibia and about two inches below the joint, to the mid-point of a line from the tip of the internal malleolus to the lower and inner corner of the prom- inence of the heel. At this point the artery bifurcates into the two plantar arteries. About an inch, sometimes less (lo mm.), below its upper end the posterior tibial gives off the peroneal artery, which runs along the inner border of the fibula to about an inch above the ankle joint, where it gives off the anterior peroneal. The internal saphenous vein, arising from the venous arch on the dorsum of the foot, rutis in front of the internal malleolus and thence just behind the internal border of the tibia to the level of the knee, where it lies just behind the internal condyle. The short saphenous vein passes behind the external condyle and thence up the back of the leg to the lower ])art of the ham where it perforates the deep fascia. Both the internal and external saj)henous veins, but more esj)eoially the former, are visible beneath the skin unless the subcutaneous fat is very abundant. Both of the saphenous veins and of the tibial arteries are accompanied by nerves of the same name. The skin of the leg, especially anteriorly, is n)ore adherent to the deep fascia than that of th(> thigh. Thus in circular amputations it is necessary to dissect up the skin Hap and not merely to retract it. Owing to the conical shape of the leg it may be difficult or impossible to dissect back this skin flap without sj)litting it on one side in the form of a cuff. The sul)cutaneou.M tissue oi' the leg, especially in front, contains comparatively little fat, so that the >^kiu over the inner sur- 462 THE LOWER EXTREMITY. face of the tibia lies nearly directly on the hone. The skin is here ex- posed to blows and kicks, which produce a degree of pain, bruisino^ or cutting far in excess of what a similar violence would produce else- where. Llcers and eczema, as the result of varicose veins, are common in front of the leg and run a very chronic course. Ulcers over the bone may expose the latter, lead to disease of its surface and result in scars that are adherent to the bone. In the subcutaneous tissue lie the superficial veins, nerves and lym- phatics. The loiifj saijheiionx vein is not infrequently double in the leg, the second trunk lying behind the regular course of the first trunk (see p. 461), that is further behind the internal border of the tibia. Most of the superficial lymph vessels accompany the long saphenous vein and the majority of them are in front of it, while the long saph- enous nerve usually lies behind and deeper than the vein. A few superficial lymph vessels accompany the short or external saphenous vein to the small popliteal nodes. The latter lymph vessels and the short saphenous vein and nerve are covered by a duplication of the deep fascia so that they are not strictly in the subcutaneous tissue. The musGulo-cutaneous nerve perforates the deep fascia near the septum be- tween the peroneal and extensor muscles at the upper end of the lower third of the leg. Thence it runs downward and inw^ard in the sub- cutaneous tissue^ so superficially that it is easily palpable, or even visible in thin subjects. The deep fascia closely invests the leg and in its upper third is adherent to the underlying muscles. Although it is attached to the anterior and internal borders of the tibia it is not wanting over its internal surface, as stated by Tillaux, but continues over this surface more or less adherent to its periosteum. It is attached to the head and the malleolus of both tibia and fibula and is continuous with the fascia lata above and the annular ligaments and the fascia of the foot below. Tu:o sejjta passing inw'ard from the deep surface of this fascia, to be attached one to the anterior and one to the external border of the fibula, enclose a compartment which lodges the peroneal muscles and sep- arates an anterior from a posterior compartment, externally. These two main compartments are further separated by the bones and inter- osseous ligament. The pjosterior compartment is subdivided into a super- ficial and a deep portion by a fibrous septum, the deep transverse fascia, which stretches across from the internal border of the tibia to the pos- tero-internal border of the fibula. There is an aponeurotic expansion in the substance of the soleus, also connected with the internal border of the tibia, which may be mistaken for the deep transverse fascia in cutting through the soleus to expose the posterior tibial artery. The muscles lodged in the anterior compartment are so compressed within their osseo-aponeurotic walls that they form a protrusion or hernia when the fascia is torn or cut. The jjlantaris tendon has not infrequently been rupAured, producing a sudden sharp pain in the calf. The tendo Achillis has been ruptured ([\\vmg violent exertion, especially at its narrowest and weakest point, about 1| inches above its inser- PLATE LV INT. SAPHENOUS VEIN TIBIALIS POST. rl'i*^, MUSCLE DEEP TRANS- VERSE FASCIA POST. TIBIAL _ __^ ARTERY ANdQ/7 NERVE ^'Vf PERONEAL — XXIA ARTERY EXTENSOR COM. DIG. MUSCLE .INTEROSSEOUS MEMBRANE jLjn — v.M PERONEUS LON- »^t^^ J'l^^ak'^vr '''"= MUSCLE fe^^SW^P>x^i\ !^ i_iiS V.^\ ! NERVE, ART- i- ^-' y* Ip- , V ^'^'. f^ . ERYANOVEIN CCP TASCIA OF LEG Cross section of the lower end. of the upper third of the right leg. Lower segment of the section. (Tiilaux.) GASTROCNEMIUS MUSCLE DEEP LAYER 3F CRURAL FASCIA INT. SAPHE NOUS VEIN / INT. SAPHE- NOUS NERVE PLANTARIS TEN DON — POST. TIBIAL NERVE POST. TIBIAL ARTERY Internal aspect of the lower half of right leg. Superficial dissection. (Joessel.) VARICOSE VEIXS. 463 tion or opposite the internal malleolus. But more often it ref|iiires tenotomy on account of its contracture. This is he.sf (Jour oj)positc its narrowest point by introducing^ tlu' tenotome in front of the tendon at its inner margin to avoid the posterior tibial vessels, and then cutting toward the surface. The posterior tihial V('Ji,se!t<, however, lie beneath the deep transverse fascia and so far forward that they are in no danger of injury with ordinary care. The xJiort saplicnons rein is near and usually in front of the outer margin of the tendon and may possiblv be wounded. Its accompanying nerve is usually in front of the vein at this point. On section the tendon retracts with its sheath. The Vessels. — The anterior tihial aufJ the peroneal arteries, from their close relations with the tibia and fibula respectively, are lial)leto be injured in fradare of these bones. I have seen gangrene of the foot follow the rupture of the anterior tibial artery, in a bad fracture ot the tibia. The anterior tibial artery lies on the interosseous membrane in the upper two thirds and in front of the tibia in the lower third. It lies /?(, the jird interiimsciilar interval on the outer side of the til)ia, but the whitish line, which is said to indicate this interval on the sur- face, is usually indistinct and often absent. The posterior tibial artery in the upper two thirds of the leg is covered by the inner head of the gastrocnemius and the soleus, the former of which must be retracted inward, the latter divided to reach the artery. T/ie incision is carried three quarters of an inch behind the inner border of the tibia, where the long saphenous vein is to be avoided. The artery is covered by the deep transverse fascia in all parts of the leg, so that this as well as the deep fascia must be divided to expose it. In the lower third of the leg it becomes more superficial, being covered only by skin and fasciae (two layers), and in thin persons it can be felt pulsating in the hollow on the inner side of the tendo Achillis. The peroneal artery in the greater part of its course is covered by the flexor longus hallucis, which must be divided or retracted in order to reach it. This artery also is beneath the deep transverse fjiscia. The peroneal artery, by anastomotic branches at the lower end of the leg, takes the place of the posterior and anterior tibial arteries when the latter are rudimentary or wanting. The hifurcatio)! of the jK)|)li- teal, or sometimes that of the short tibio-peroneal trunk, is where einlxtli are apt to lodge. If (janr/rene results, as not infrequently hapi)ens, the embolus is probably at the bifurcation of the popliteal, for in this case all three trunks are blocked. According to Joessel, not only the two regular venae comites but other veins, anastomosing across the artery, accompany the posterior tibial and increase the difficulty of its ligation. Verneuil thinks that the deep veins of the leg are more often varicosi' than those of the surface, and that this condition is indicated by aching of the legs and swelling of the feet in those who stand a great deal. Varicose veins are more commo)i in the leg than elsewhere, with the possible exception of the spermatic and hemorrhoidal veins. This fact may be partly accounted for In/ ( 1) the length of the veins of the 464 THE LOWER EXTREMITY. lower extremity, (2) the action of gravity in resisting their upward flow and in affecting the weight of the blood column which the valves have to support, (3) the loose support of the superficial veins and the lack of the assistance of muscular contraction, and (4) the liability to com- pression, within the abdomen, of the iliac trunk into which they ulti- mately enter. The saphenous veins are also thin-walled and lie outside of the firm deep fascia, and the long saphenous is liable to be affected by the use of garters. Varicose veins are enlarged not only in diame- ter but in length, hence their tortuous course. The contour is irregular and nodular and the nodules, or enlargements of the vein, are found especially just above the valves and at points where the vein is joined by deep veins. At the latter points pressure is exerted from three directions, (1) the weight of the blood column above, (2) the blood current and the resistance of the valve next below and (3) the inflow from the side, the force of which is increased by muscular contraction. The Bones of the Leg. — The tibia bears the entire superincumbent weight. The fibula, besides affording attachment to muscles, plays an important part in the ankle joint and serves as a brace for the tibia, which increases its resistance to lateral strains. The smallest and weaked jMirt of the tibia is at the junction of the middle and lower thirds, which accordingly is where most indirect fractures occur. Direct fractures of the shaft of the tibia may occur at any point and are often more or less transverse so that there is little if any dis- placement. If the fibula is broken at the same time, as it is likely to be, the fractures of the two bones are about on tlie same level. The long, slender fibula, placed as it is on the more exposed aspect of the leg, would apparently be more often broken from direct violence but for its covering of muscles. When one bone alone is broken the other acts as a splint and limits its displacement. Indirect fractures are due especially (1) to a bending or flexion or (2) to violence combined with torsion of the limb. In (-?) tlie frac- ture may be at any point and is more or less transverse and dentated, hence there is little but angular deformity. In (2) the fracture is mostly in the upper end of the lower third (the weakest part) and is oblique, the line of fracture usually running downward, inward and forward. The fibula, which is almost always broken in indirect fractures, breaks as a rule at a higher level. The sharp lower end of the upper fragment of the tibia is liable to puncture the skin and compound the fracture from within. In one variety of this form of fracture, first described by Gosselin, the sharp ends of both fragments end in a triangular point and from the bottom of the depression in the lower fragment, corresponding to the point of the upper fragment, a fissure runs sj)irally downward and often enters the ankle joint. Owing to the subcutaneous position of the tibia its fractures are frejjuerdly compounded, from within in indirect fractures, from without or within in direct fractures. On the subcutaneous inner surface and anterior border we can detect even very slight displacements as well as other pathological conditions. In oblique fractures the lower frag- LANDMARKS OF THE ANKLE. 465 ment is often drawn upward and outward, behind ilie upper, by the calf muscles and rotated outward hy the weight of the foot, which has lost its continuity witii tiie upper leg The tibia, more tlian any other bone, l;ecomes bent in ciiildren with rickets. The bowing, " bow-legs," is xitnudly oatward, at times asso- ciated with or replaced by a forward one. It is caused by a tonic con- traction of the muscles and is increased by the weight of the child in walking. It is generally mod prominent at the weakest part of the bone, the junction of" the lower and middle thirds. In amputation of the leg in the upper third the "place of election " is a hand's breadth below the knee joint. This point was chosen as giving a convenient length of leg stump for wearing a peg leg; for the knee is then bent and the weight is borne on the tubercle of the til)ia. This line of amputation is at or just above the large nutrient artery of the tibia, which therefore does not cause trouble, as it may below. ^It this level three arterial trunks are met with for the tibio-peroneal trunk bifurcates three inches, or slightly less, below the knee joint. Through- out the leg the two posterior arteries are beneath the deep transvei'se fascia, or in a duplication of it, the peroneal behind the fibula, the posterior tibial behind the tibia and separated from it by the tibialis posticus and the flexor longus digitorum. The anterior tibial is to be sought in front of the interosseous membrane in the upper two thirds and in front of the tibia below this. In the upper third of the leg am- putatlon by long external flap is the best method, provided care is used to preserve the anterior tibial artery to the end of the flap, and not to bare the bone so high as to run the risk of injuring this artery where it comes forward above the interosseous membrane. Circular ampu- tation is also suitable in the upper half, but less so below, on account of the conical shape and, in the lower third, the lack of a muscular covering. //* tlie middle third amputation by a lone/ posterior jlaj>, in- cluding (1) the superficial layer of muscles (Lee) or both superficial and deep muscles (Hey), is a favorite method. Owing to the danger of injury to the covering skin from the pressure of the sharp angle of the shin, after sawing the tibia, this angle should always be bevelled ofl'. THE ANKLE. The limits of this region are artificial and may be placed two fingers' breadth above an?. Opposite the joint line this depression corresponds to the thin anterior part of the capsule and hence it is rejjlaced by a bulging in sprains, effusions into the joint, tubercular disease of the latter, etc. The tendo Achillis forms a marked prominence behind. On either side of it, between it and the malleolus, is a marked furroic. Along the inner furrow, behind the inner margin of the tibia and the back of the malleolus, the tendon of the tibialis posticus can be felt and behind and external to it that of the flexor longus digitorum. Behind the extei^nal mcdleolus the long and short peroneal tendons are palpable, the tendon of the brevis being nearer to the bone. Topography. — The line of the ankle joint is half an inch above the tip of the internal malleolus. Opposite the bend of the ankle the an- terior tibial artery becomes the dorsalis pedis and, with the anterior tibial nerve, lies between the tendons of the extensors longus hallucis and longus digitorum, where its pulsation can be felt. The line of the artery is from the middle of the ankle to the proximal end of the interval between the first and second metatarsal bones. In some cases it describes a curve, concave internally. The posterior tibial artery and nerve lie behind the internal malleolus, external and a little pos- terior to the tendon of the flexor longus digitorum. The tendon of the flexor longus pollicis lies still more externally, at the back of the lower end of the tibia, midway between the two malleoli. The pos- terior tibial artery bifurcates into the two plantar arteries opposite the raid-point of a line between the tip of the internal malleolus and the lower and inner corner of the prominence of the heel. The long saphenous vein ascends iu front of the internal malleolus, the short saphenous behind the external malleolus. The skin covering this part is thin and loosely attached, and rests al- most directly upon the bones, with the interposition of but very little subcutaneous tissue. Hence it is readily contused or excoriated, as for instance by ill-fitting splints ; and gangrene may result from slight pressure. Thus I have seen gangrene of the skin over the malleolus result from pressure against the bed in sleeping, in the case of an old gen- tleman who had previously lost a toe from senile gangrene. The sub- cutaneous connective tissue is abundant only in front and at the sides of the tendo Achillis, and only here is there any considerable amount of fat. The deep transverse fascia of the leg is continued down behind the tendons and vessels at the back of the internal malleolus. This fascia and a considerable amount of loose connective tissue and fat separate these structures from the tendo Achillis, so that in the teno- tomy of the latter there is little or no danger of wounding the pos- terior tibial vessels. PLATE LVI FIG. 112. The anterior annular ligament of the ankle and the synovial membi-anes of the tendons beiaeath it artificially distended. (Gerrish, after Testut. ) SYNOVIAL SHEATHS AT THE ANKLE. 407 The deep fascia, continuous with that of the leg above and the foot below, is reinforced in fnjnt and laterally so as to form Jinn baruh, known as annular ligaments, whicli bind down and keep in plar-e the tendons in these situations. Tiiere are two anterior annular ligaments of which the upper passes transversely between the anterior borders of the tibia and fibula and keeps in place the anterior tendons in the slender lower third of the leg. The lower band begins on the outer side of the calcaneus and splits into two layers, which pass one behind and one in front of the tendons of the peroneus tertius and extensor longus digitorum and then unite at the inner border of the latter. It again divides into two branches, of which the upper goes to the front of the internal malleolus, the lower to the scaphoid and the plantar fascia. This ligament biiKhdovra the tendons at the bend of the ankle and prevents them from projecting forward Avhen in action. The lateral annular ligaments connect the back of the malleoli with the calcan( um on the corresponding side and prevent the dislocation forward of the tendons behind these two malleoli. As the result of violence these lateral bands may be ruptured, allowing one or more tendons to be r//.s-- located foricard onto the front of the corresponding malleolus. This has happened to the tibialis posticus and peroneus longus, and the latter is more often displaced than any tendon in the body. From the deep surface of the internal annular ligament processes pass forward to bony ridges at the back of the malleolus and the lower end of the tibia, thus forming separate compjartiaents for each of the three tendons here. Thus it happens that the tibialis posticus tendon may be displaced without the other two, which are further from the inner surface of the malleolus. In passing beneath the two lateral and the lower anterior annular ligament the tendons are pjrovldcd icith separate sjmovial sheaths, except that there is a common sheath for the two peroneal tendons and for those of the extensor longus digitorum and peroneus tertius. The si/novinl sheath of the tibialis anticus extends from 5-0 cm. above the ankle joint nearly to the first metatarsal bone ; that of the peroneal tendons from 3-4 cm. above the joint to the calcaneo-cuboid joint ; that of the extensor longus digitorum and peroneus tertius from 2 cm. above to 4-5 cm. below the joint ; that of the extensor longus hallucis from 1 cm. above the joint nearly to the metatarsus; that of the tibialis posticus from 5 cm. above the inner malleolus to the scaphoid, and that of the flexor longus digitorum from 3 cm. above the malleolus to the sole of the foot, where it is crossed by the extensor longus hal- lucis and communicates with its sheath. These .synovial .sheathif may become injiamed and filled with fluid and, as at the wrist, this inflam- mation may be tubercular, with or without the formation of "rice bodies." I have removed a large mass the size of an egg, due to tubercular inflammation of the extensor tendons in front of the ankle. The long tumor, due to an eff'usion into one of these synovial sheaths, is often constricted where it passes beneath the annular ligament. In- flammation of the sheath of the tibialis posticus may extend to the ankle joint, with which it is in close relation. ••>/ 468 THE LOWER EXTREMITY. Beneath the extensor tendons one finds a second layer of fascia which separates them from the ankle joint and, further forward, covers the extensor brevis digitorum muscle. The dorsalis pedis artery and the accompanying anterior tibial nerve lie beneath this second layer of fascia, which must be divided to reach them. In sprains, fractures and dislocations of the ankle these synovial sheaths are apt to be torn and filled with eiFused blood, and the long-abiding stiffness after such injuries is in part due to these injuries of the sheaths, and the result- ing adhesions. Of the tendons about the ankle the teiido Achillis and the peroneal tendons are quite subject to contracture, the extensor tendons less so and the tendons behind the internal malleolus still less. These contractures of the tendons lead to various deformities of posi- tion of the foot, known as club-foot, and the affected tendons require division (tenotomy) to correct the deformity. The rupture and tenot- omy of the tendo Achillis has already been described (pp. 462—3). The tibialis posticus tendon may be divided (1) two inches above the internal malleolus, which is above its synovial sheath and where the tendon is further from the artery than below. The knife is entered close to the inner border of the tibia. (2) It may be divided a little below and in front of the inner malleolus, between the internal annular ligament and the scaphoid bone. The tibialis anticus may be divided at the latter point with the posticus, or a little above its insertion into the internal cuneiform. The tendon of a sound muscle may be joined to that of a paralyzed one (tendon grafting) to prevent a deformity and restore certain movements of the foot. The tendons of the ankle are not infrequently ruptured through violence, especially the tendo Achillis. A bursa is situated between the tendo Achillis and the os calcis, rising about half an inch above the latter and bulging on either side of the former, when inflamed. Such inflammation, due to excessive walking, an injury or a badly fitting shoe, may simulate ankle joint disease and, if suppurative, lead to caries of the os calcis. Bursse may develop from pressure over the malleoli, especially the external, as in tailors who sit cross-legged. The dorsalis pedis artery from its superficial position is frequently divided in wounds or ruptured in severe contusions while the posterior tibial is well protected from injury by the prominent malleolus, the neighboring tendons and the annular ligament. The dorsalis pedis artery may be compressed against the underlying bones and its pidsation may be sought for, to determine the condition of the artery and of the pulse, in senile gangrene and in suspected embolism at the bifurcation of the popliteal. The ankle joint owes its strength to the strength of the lateral liga- ments and the many closely applied tendons, as well as to the mortise and tenon shape of the bony surfaces. The anterior and posterior lig- aments are unimportant and so thin that effusion, when it occurs within the joint, is first noticeable in front as a fluctuating bulging, beneath the extensor tendons and especially on either side of them in front of PLATE LVI : FIG. 113. Tiie internal annular ligament of the ankle and the artificially distended synovial membranes of the tendons ^A'hich it confines. (Gerrish, after Testut.) FIG. n4. The extei-nai annular ligament of tlie ankle and the ai'tificially distended synovial membranes of the tendons which it confines. (Gerrish, after Testut.) DISLOCATIOSS OF THE AXKLE. 469 the malleoli. This bulging is the more marked because the synovial membrane forms somewhat of a pouch anteriorly and posteriorly. Tfie bulgiiiy in front of the external maUeolna is the heat point to opin or inject the joint. When the effusion is more marked it may be evi- dent behind, as a bulging of the posterior })art of the capsule, which gives rise to fluctuation on either side of the tcndo Achillis. The ankle joint proper is a true hinge joint and normally allows no lateral motion, except passively in extreme extension (plantar flexion) when the narrower part of the upper surface of the astragalus is in the widest part of the tibiofibular mortice. The ankle should i>e tested for lateral motion irith the foot Jiexed nearly to a right angle, care being taken to grasp the astragalus, and not the calcaneum, by the thumb and fingers directly below and in front of the two malleoli. It the foot is grasped a little lower, over the calcaneum, lateral motion is obtained between the astragalus and calcaneum. Lateral movement at the ankle joint indicates disease or injury of the joint. On account of its superficial and exposed position iniiammaiion of the ankle not uncom- monly results from injury. As the position of the joint does not affect its capacity and the flexor and extensor muscles about balance one another, the foot does not assume any characteristic position when the ankle is inflamed. Although sprains of the ankle are considered common, Landerer has expressed the opinion that 95 per cent, of so-called sprains are frac- tures. This is probably literally true if we count as fractures those cases where, instead of a tear of the ligament, a small portion of bone is avulsed at its attachment. The ankle joint may be dislocated so that the foot is displaced back- ward, forward, inward or outward. Only the antero-posterior forms are pure dislocations, the lateral forms being associated with fracture of one or both bones of the leg at the ankle. Dislocation of the foot backward is usually due to extreme plantar flexion and the establishment of a new center of motion be- tween the hind margin of the tibia and the astragalus, so that con- tinued movement ruptures the lateral and anterior ligaments, and then the foot is pushed backward or the tibia forward. It may also be due to great force applied to either the foot or leg while the other is fixed. The foot appears shortened in front, where the lower end of the tibia projects prominently and rests upon the scaphoid and cuneiform bones, and the extensor tendons may be felt as tense cords. The heel is length- ened. As a result of fracture of the ankle by eversion, partial and even complete backward dislocations are not infrc'f|uent, l)Ut pure dislocations of this kind are rare. Forward dislocation is still more rare. The mode of production and the deformity of the foot are the reverse of the last variety. Two forms of dislocation inward are observed. In one (lie foot is much inverted so that the astragalus can be felt and seen as a promi- nence below the outer malleolus. In the other there is less or no inversion, but the foot is much adducted so that the toes may even point 470 THE LOWER EXTREMITY. directly inward. The latter form may be secondary to a backward dislocation. The so-called outward dislocations represent the deformity in cases of Pott's fracture (fracture by eversion). Fractures of the bones of the leg just above the ankle are pro- duced by eversion or inversion of the foot, aided somewhat by the weight of the body. Both eversion and inversion produce fractures which are very similar. In reference to these fractures it should be remembered that the tibia and fibula are very strongly bound together at their inferior articulation, and that this point serves as the fulcrum of a lever, of which the external malleolus represents the short arm and the fibula above the joint the long arm. Fig. 115. Diagram of fracture by eversion of the ankle, showinglthe fractures of the two bones. In fractures due to forcible eversion (Pott's fracture) (Fig. 1 1 5), the strain first comes on the internal lateral ligament^ivhich may tear but, owing to its strength, usually tears off the internal malleolus at its base. This allows the further eversion of the foot and the astragalus then presses the external naalleolus outward. This is resisted by the strong liga- ments of the inferior tibiofibular joint, which suffer violence in the shape of partial rupture or strain, but usually hold the bones together, so that the strain comes upon the long arm of the lever, the shaft of the fibula, which breaks a little (1-3 inches) above the malleolus. The upper end of the lower fragment of the fibula is displaced toward the FRACTURE BY INVERSION. 471 tibia. The foot is displaced outward and often somewhat backward and everted, the inner malleohis is very prominent and may can-^e the laceration of the taut overlying skin. The characteristic features are (1) lateral mobility, due to some spreading of the tibiofii)ular joint and to the fracture of the internal malleolus and the fil)ula above its malleolus and (2) tlivcc points of fcnderncs.s — (r/) in front of the tibio- fibular joint in the groove between the tibia and the external malleolus, (h) over the base or apex of the internal malleolus and [c) over the fibula just above the malleolus, or 1-2 inches higher. Fig. IIG. Diagram of fracture by inversion of tlie ankle. Fracture of the fibula only is represented and at two levels. The dotted lines show a fracture of the fibula some distance above the malleolus, the con- tinuous lines a fracture at the base of the niallculus. In fractures due to forcible inversion (Fig, 1 1(5) the external lat- eral ligament first feels the strain. If the ligament gives way simply d sprain may result, unless the action of the force continues. If the liga- ment holds, and it commonly does, it pulls the tiji of the external malle- olus inward, which forces the long arm of the fibular lever outward, until it breaks close al)()ve tlie malleolus, or still higher. The force continuing inverts the foot still further and theastragalus presses against the internal malleolus and breaks off the latter or a longer portion of the lower end of the tibia. The lateral mohilitif (ouJ the three p()i)it,'< of tendcrnes.s are present in this form, but perhaps not so markeillv. In this form the injury may stop short with fracture of the fibula, no 472 THE LOWER EXTREMITY. injuiy of the internal malleolus or internal ligament resulting. In fractures by inversion the upper end of the lower fragment of the fibula is displaced outward, unless it is held by the untorn periosteum. To determine the presence and the point of fracture of the fibula an excellent way is to press on the tip of the malleolus, the short arm of the lever, which causes a false point of motion, or at least a point of tenderness, to appear at the upper end of the lower fragment. Owing to the frequency of these two classes of fractures and the dis- ability following improper treatment they should be carefully reduced and treated. It is especially important to correct the lateral displace- ment and the eversion, otherwise the gait is painful and im- perfect. The lower epiphysis of the tibia is more often separated than the upper. The fibula is usually broken at the same time at a higher level though its epiphysis, which reaches to the level of the tibial articular surface, is sometimes separated in place of a fracture of the shaft. The lower epiphysis of the tibia includes the malleolus and the articular surface, and unites in the nineteenth year; the loirer epiphysis of the fibula includes the outer malleolus to the limit of its articular facet and unites about the twenty-first year. Both epiphyseal lines are horizontal and are in contact with the synovial membrane, which extends up between the two bones. Excision of the ankle is rarely done for injury and not often for tubercular disease. Symes' or Pirigoff's amputation often gives a better result. Bilateral incisions are usually made over the malleoli ; curving forward over the foot in such a way as to lie between the ten- dons in front and those behind the malleoli. Konig chisels away the attachments of the lateral ligaments to the malleoli to spare the liga- ments. Lauenstein uses a single long external incision, Kocher a transverse external incision, and both of the latter then retract the peroneal tendons backward, divide the external lateral ligaments and fully supinate (invert) the foot, so as to expose both articular surfaces. THE FOOT. Landmarks and Surface Markings. — Along the outer border of the foot nearly the entire outer surface of the calcaneum is subcuta- neous, and we can feel its peroneal tubercle, less than an inch below the malleolus. The short peroneal tendon is above, the long one below it. The base of the fifth metatarsal bone is the most prominent landmark on this border and can be felt under all conditions of swelling, etc. The cuboid extends for an inch or so behind it, and it is about 2| inches in front of the external malleolus. Along the inner border of the foot we can feel the tuberosity of the calcaneum ; the sustentaculum tali, 1 inch below the internal malleolus ; the tuberosity of the scaphoid, about an inch in front of and a little below the internal malleolus ; the base and head of the first metatarsal bone, and the sesamoid bones on the plantar surface of the latter. The tuberosity of the scaphoid is the THE PLANTAR ARTERIES AND ARCHES. 473 best landmark on the inner border and can be felt even when the foot is much swollen. In such conditions the head of the metatarsal bone is not plainly palpable, hence it is well to know that the jimt tarsomrt- atarsal articulation is 3 cm. in front of the tuberosity of the scaphoid and 2 cm. in front of the inner end of a line drawn transversely across the foot from the base of the fifth metatarsal Ixtne. Topography. — The mediotarsal joint, /. e., the joint between the astragalus and calcaneum posteriorly and the scaphoid and cuboid anteriorly, commences internally just beiiind the scaphoid tuberosity and externally midway between the tip of the external malleolus and the base of the fifth metatarsal bone. The joint line is transverse with a slight sinuosity, convex forward internally and concave forward ex- ternally. The position of the first tarsometatarsal joint has already been indicated, that of the fifth lies just behind the prominent base of the fifth metatarsal bone. The tarsometatarsal Joint line, between these two ends, is interrupted by the mortising of the second metatarsal bone between the internal and external cuneiform. The line of its articu- lation with the middle cuneiform is 1 cm. behind that of the first joint. The metatarsopJialanejeal articulations are about one inch behind the webs between the corresponding toes, the proximal and part of the middle phalanges being buried in the web. The gap between the internal malleolus and the tuberosity of the scaphoid is filled by the inferior calcaneoscaphoid ligament and the tendon of the tibialis posticus beneath it. . On the outer part of the dorsum of the foot the fleshy mass of the extensor brevis digitorum can be felt beneath the tendons of the exten- sor longus digitorum, where it can be seen when in action. It fills the gap between the front of the astragalus and the calcaneum. The course of the dorsalis pedis artery has been given above (see p. 46(5); it is crossed by the inner tendon of the extensor brevis muscle. The plantar arteries start at the bifurcation of the posterior tibial, midway between the inner malleolus and the inner border of the heel. Thence the smaller branch, the internal plantar, follows a line to the middle of the plantar surface of the great toe. The course of the e.rter- nal plantar is obliquely across the sole to a point a little internal to the base of the fifth metatarsal bone, and thence obliquely inward across the bases of the metatarsal bones, covered by the interossci, to the iiack of the first interosseous space, where its arch is completed by anasto- mosing with the communicating branch of the dorsalis pedis. By means of this arch the anterior and posterior tibial arteries anastomose. In /rounds of the plantar arch, which are serious on account of its depth beneath many important structures, the ligature of i)oth tibial vessels, at or just above the ankle, would not arrest the hemorrhage without fail, for the peroneal artery would bring blood to the arch through (1) the anastomosis of the anterior peroneal with the external malleolar branch of the anterior tibial and the tarsal branch of the dorsalis pedis, and (2) the anastomosis of its terminal branch with the internal calcaneal branch of the external plantar artery. In fact. 474 THE LOWER EXTREMITY. however, elevation and pressure will check most hemorrhages of the foot. The skin of the dorsum and inner aspect of the foot is thin and movable, that of the sole is dense and thick where it normally comes in contact with the ground, i. e., under the heel, the outer border, and the distal ends of the metatarsal bones. The skin on the dorsum is readily excoriated. The skin of the foot becomes thick and callous wherever it is exposed to undue pressure. Beneath the abnormal thickenings hursce may develop. The subcutaneous tissue on the dorsum is lax and abundant so that great swelling occurs from inflammation, and oedema and general dropsy are often first evident here. This tissue is very thick and dense on the sole, connecting the skin closely with the fascia and enclosing the fat in little spaces, as in the palm and the scalp. Hence the skin of the sole does not gape on being incised, so that exploratory incisions must be longer than otherwise and strongly retracted, to expose foreign bodies, etc. It is most abundant on the sole, where the pressure is greatest, and in those who walk most, and may even reach 2 cm. in thickness beneath the heel, so that it forms a veritable cushion that must diminish the effect of contusions and falls. Owing to its density inflammation in it extends with difficulty and can produce little swelling but much jmin, especially as the skin of the sole is well supplied with nerves and is very sensitive, much more so than that of the dorsum. In the subcutaneous tissue on the dorsum many superficial veins are visible. They form an arch, concave toward the ankle, from the ends or sides of which the internal and external saphenous veins arise. In varicose veins of the leg these veins of the dorsum are often involved. The internal and external saphenous and the musculocutaneous nerves are in the same subcutaneous layer. " Perforating ulcer," a peculiar affection, occurs generally at the points of pressure, and is often attrib- uted to trophic disturbances in certain nerve lesions, like locomotor ataxia, etc. It appears usually as a sinus leading to bone, into a joint, or through to the dorsum, and often heals with rest. The fascia of the dorsum consists of two layers ; the more super- ficial one is continuous with the annular ligaments and covers the long tendons ; the deeper forms a sheath for the extensor brevis muscle and covers the dorsalis pedis artery. They are thin and of no surgi- cal importance. On the contrary the deep fascia of the sole or plantar fascia is very important and, like the palmar fascia, consists of three parts, a dense strong central portion and two thinner lateral portions. The outer portion is however very strong and forms a firm band be- tween the calcaneum and the fifth metatarsal bone. The central por- tion is stretched like a bow-string between the two ends of the longi- tudinal arch of the foot, the inner tuberosity of the calcaneum and the heads of the metatarsal bones, where it divides into slips for the toes similar to those for the fingers in the hand. Hence the plantar fascia, especially its central portion, is an important factor in maintaining the longitudinal arch of the foot, the sinking of which, in flat foot, necessi- LYMPHATICS OF THE SOLE. 475 tales a marked yielding of this fascia. Tfi/iprs cavn«, in which the arch is much raised, (hpauh largely or entirely upon a contraction of tins fascia. In this condition and in talipes varus, in which this fapcia is often contracted and the arch correspondingly raised, the fascia is divided suhcutancousli/ hi/ a frnotomr to cure the deformity. This divi- sion is best made iihont one inch in front of its posterior attachment, in its narrowest part, where the knife, entered from the inner side, is be- hind the external plantar artery. Tliis fascia bears the same relation to inflammation and abscess as the palmar fascia in the hand. Similarly tii'o inter nmscidar septa pass from its deep surface, where it joins the lateral portions, to the plantar aspect of the bones and the interosseous fascia. TJiree muscular compartments are thus formed, of which the central one is the larger and deeper and contains the majority of the muscles and tendons and the plantar vessels and nerves. These inter- muscular septa are too feeble to affect the course of a deep plantar abscess to any great extent. The posterior tibial nerve bifurcates a little above the artery, and the internal plantar nerve, unlike the corresponding artery, is the larger of the two. //( its didribution the internal plantar nerve cor- responds closely with that of the median in the hand, the external plantar with the ulnar. The bursa in the subcutaneous tissue over the first metatarso-pha- langeal joint, when enlarged, constitutes a bunion. This is usually as- sociated with a deformity of the great toe (hallux valfju^), generally due to improperly shaped or too short shoes, which force the great toe outward and render its metatarso-phalangeal joint very prominent in- ternally. The overlying skin becomes thickened and indurated and the bursa, pressed between this thickening and the projecting bone, becomes injlaiiied. If it suppurates it often opens both superficially and into the joint. The latter then becomes disorganized and requires resec- tion. In this operation it must be remembered that the outwardly displaced extensor tendon of the toe and the inner })art of the fibrous capsule of the joint have probably both become contracted and short- ened. Holden describes the frequent occurrence of a large irregular bursa between the tendons of the extensor longus digitorum and the underlying prominent end of the astragalus, which sometimes com- municates with the mediotarsal joint. Burstr may develoji almost anywhere from prat. In the outward dislocation either the outward displacement may be combined irith marked abduefion of the toes, when the foot turns on the posterior calcaneoscaphoid joint if the bones have not separated there, or the foot may be displaced bodily outward. Hence the dislocation may be incomplete as regards the posterior calcaneoastragaloid joint. AVhen the foot is abducted there is more or less eversion and the head of the astragalus is very prominent on the inner side. In the form with simple outward displacement the inner malleolus is very promi- nent and approaches the level of the sole. The head of tlie astragalus projects below and in front of it, while the outer malleolus is buried in the depression above the prominence of the outer surface of the calcaneum and cuboid. The subastragaloid dislocations are often coinpolliidcd. Dislocation of the astragalus is a combination of the subastraga- loid dislocation and that of the ankle, and is much more frequent than either of them. It is often compound and either or both mal/eod may be fractured. The astragalus may be displaced antero-jx)steriorly or laterally. Dislocation outward and forward is the commonest form, inward and forward the next, simply forward or i)a('kward rare, and inward is almost unknown. In the dislocation outward and forward the head of the astragalus rests on the cuboid and I'xternal cuneiform, and is freelv' movable. TJie foot is adducted, inverted and usually displaced inward so that the internal malleolus is burico)ies, the iiie((d(tr.s(d and the phalange.^ is commonly due to direct violence. Such fractures are often compound, owing to the scanty covering of soft parts on the dorsum of the foot which are usually contused or lacerated. The toes very closely resemble the fingers, exce})t in size, and are liable to similar lesions from injury, inflammation, etc., tiiough not so frequently. Dislocation of the proximal phalanx of the great toe is similar to that of the like joint of the thumb in the character of the lesion, the difficulty of reduction and the reasons for this difli- 31 482 THE LOWER EXTREMITY. culty. A peculiar affection of the toes known as " hammer toe," in which the proximal phalanx is extended while the middle is strongly flexed, is most often found in the second toe, which is normally longer than the others. It is due to a contraction of the extensor tendon and of the glenoid and lateral ligaments of the first phalangeal joint. The cutaneous nerve supply of the lower extremity is shown by Figs. 118 and 119. Paralyses of the lower extremity are common and usually due to a lesion of the cord, hence they involve all or a considerable group of nerves. Occasionally a single nerve trunk is paralyzed by a cord lesion or a lesion of the nerve below its exit from the spinal foramen. This involves a limited area of anaesthesia or motor paralysis. An example of motor paralysis of groups of muscles is seen not infre- quently after infantile paralysis. Paralysis of the anterior crural nerve may be due to fractures and tumors of the pelvis, psoas abscess, dislocations of the hip, stab wounds in the groin, and perhaps a partial lesion of the cauda equina. The patient can not flex the hip, as in rising from the recumbent position, (iliopsoas and pectineus), or extend the knee (quadriceps). The sar- torius is paralyzed, the pectineus partly so, being supplied in part by the obturator. In the parts supplied by the internal and middle cutaneous and long saphenous nerves sensation is impaired. The obturator nerve alone is seldom paralyzed but may be, occa- sionally, from the pressure of the foetal head or an obturator hernia or from lesions similar to those paralyzing the anterior crural. The patient can not adduct the thighs or cross the legs (adductors) and out- ward rotation of the thigh is impaired (obturator externus and adduc- tors). Sensation of the cutaneous area supplied is impaired. Paralyses of the internal or external popliteal alone are not common and are usually due to traumatism below the bifurcation of the great sciatic. In paralysis of the internal popliteal nerve the patient can not extend the ankle, flex or stand upon the toes (muscles of the back of the leg) or move the toes laterally (short muscles of the sole). Ad- duction and supination of the foot is impaired (tibialis posticus). The sensatioyi in the skin of the sole, the under surface and ends of the toes, and the lower part of the back of the leg is impaired. In paralysis of the external popliteal nerve the patient is unable to flex the ankle, abduct or pronate the foot or fully extend the toes (anterior leg muscles and peronei). Hence the toes drag in walking. Adduction and su pina tion are impaired (tibialis anticus). Only the ends of the toes can*be extended by the interossei. Sensation over the front, outer side and part of the back of the leg and the dorsum of the foot is impaired. In paralysis of the great sciatic flexion of the knee is lost (hamstrings), and external rotation of the thigh is impaired (obturator internus and quadratus femoris) in addition to the results of paralysis of both the internal and external popliteal nerves. Paralysis of the great sciatic may be due to pelvic tumors. These more commonly cause a neuralgia of the nerve. Paralysis or neuralgia of the individual nerves of the PLATE LV I 1 1 FIG. 118. FIG. 119. DORSAL DIVI- I SIONS OF I SACRAL f NERVES ) PERFORATING I CUTANEOUS I. OF FOURTH I SACRAL J /i ,' 0) EXTERNAL SAPHENOUS I. II. S. ANTERIOR TIBIAL IV. V. L. I. S EXTERNAL PLANTAR-: INTERNAL PLANTAR IV. V. L. 4? <■• ^^-if^'i INTERNAL I CALCANEAN MUSCULOCUTANEOUS IW. V. L. I. S. Areas of distribution of ciiin- neous nerves of the front of the lower limb. ("W. Keiller, after Testut. ) Areas cif (list ribmion of cutn- neoLis nerves of llie back of the lower limb. (Testut.) NERVE LESIONS OF THE LOWER EXTREMITY. 483 lower extremity may be produced by similar causes. Hence it must be borne in mind that pain in any part of the lower extremity may be due to lesions at a distance, intra-spinal, intra-abdominal, intra- pelvic, etc. In the diagnosis of the situation of lesions of the cord, due to di.-^-ase or fracture, a knowledge of the skin areas and the muscles of the lower extremity supplied by the several segments of the cord is important. For this see chapter on the spine. CHAPTER yil. THE SPINE. Landmarks and Topography. — The first spinous process that is readily palpable is that of the seventh cervical (vertebra prominens) or sometimes that of the sixth cervical. Hence we begin to count the spines from the seventh cervical. The first thoracic spine is still more prominent than the seventh cervical. The third thoracic spine is on a level with the inner end of the spine of the scapula ; the seventh with the lower end of the scapula ; the fourth lumbar spine with the highest part of the iliac crest and the bifurcation of the abdominal aorta ; the second sacral spine with the posterior superior iliac spine and the center of the sacro-iliac joint, the third sacral spine with the upper border of the great sciatic notch, and the first piece of the coccyx with the spine of the ischium. The umbilicus is on a level with the interval between the third and fourth lumbar spines. The thoracic spines are oblique and overlap one another, the lumbar are horizontal and correspond with the vertebral bodies. The trayisverse proce.ss of the atlas is palpable a little below and in front of the tip of the mastoid process, the anterior tubercle of the sixth cervical vertebra (^carotid tubercle) is felt on a level with the cricoid cartilage. The bodies of the upper three cervical vertebral can be felt through the mouth at the back of the pharynx, the anterior arch of the atlas being on a level with the hard palate. The spinal column is required to serve many different functions, (1) to bear the weight of the head and upper extremities, (2) to give attach- ment to the ribs, (3) to serve as the central axis of the body, to con- nect its upper and lower segments, (4) to diminish the effect of shocks and jars, (5) to allow of varied and extensive movements and yet (6) to provide a solid canal which safely contains the spinal cord. Corresponding to the increasing weight to be borne by the vertebral bodies, as we pass from the upper end of the spine to the sacrum, we find that their surface area gradually increases from above downward. To allow the varied and extensive movements without injury to the delicate cord within, the spine is composed of a number of small articulated segments, the movement between any two of which is not great but that of the spine as a whole is very considerable. More free movement between a smaller number of segments would not only weaken the spine and make it more liable to injury but also expose the cord to compression by being sharply bent. Of the four antero-posterior curves only two, the thoracic and sacral, are present at birth. These are primary curves, due to the shape of the bones, and are convex backward to give more room in the thoracic and 484 CURVES AND CURVAl URE OF THE SPINE. Fig. 120. 485 CERVICAL VERTEBR>C THORACIC VERTEBR/E LUMBAR VERTEBRiC '<»' ilt^ The spinal column, right lateral view and dorsal view. (Gkbrish, after Testut.) pelvic cavitie.s, which they help to form. The lumbar and crrrical CHiTCii, convex fnnrard, are principally (htv to the shape of the interver- tebral discs. They appear when tiie erect position is assumed and are compensator y curves to allow the child to sit or stand erect. Otherwise the head would project forward and a marked dor.sil (xmvexity would exist in the thoracic region. This position is seen in the aged, in whom it largely depends upon the shrinkage of the discs, wherel)y the compensatory curves dependent upon them are flattened, and thus the primary permanent thoracic curve is exaggerated. The normal curves of the spine nun/ he e.ra(/(/erated so as to constitute the several forms of ciirvature of the spine. Increase of the posterior co)ivexifi/ in the thoracic region is known as kyphosis. This is almost always due to a tubercular caries of the bodies 486 THE SPINE. Fig. 121. B A of the thoracic vertebrse and is known as " Poffs disease of the spine'' When the aiFected vertebral bodies, being destroyed by the ulceration, yield to the pressure of the superincumbent weight the spine bends for- ward above the seat of the disease thereby tJirowitif/ harkivard the sjiinous processes opposite the diseased area. Tliis gives rise to an angular cur- vature or hump back, which is accompanied by an increase of the cer- vical and lumbar compensatory curves. Hence to avoid deformity in spinal caries the superin- cumbent weight should be relieved by apparatus or posture. When the disease attacks the cervical or lumbar vertebrae there is no angular curvature, but the normal posterior concavity of these regions is flattened out and the affected part of the spine is rendered stiff. The neural arches and the cir- cumference of the vertebral canal almost always escape. The spinal caries is often associated icith abscess which tends to sink in the line of gravity along the spine. Spinal abscesses in the thoracic or lumbar region tend to enter the sheath of the psoas muscle, in the former region after passing beneath the internal arcuate ligament. They are the com- mon cause of psoas abscess. If the curvature is extreme, or comes on rapidly, the front of the cord may be pressed upon by the projection at the back of the vertebral bodies and motor paraly- sis results. More often the cord symptoms are due to the pressure of inflammatory thickenings, de- posits or abscesses which may subside from general treatment ; but if degenerative changes in the cord appear the spinal canal should be opened to remove the cause of pressure. In recent years angular curvatures of the spine have been successfully treated by forcible straightening. In severe cases the chest becomes much distorted and the lower ribs, resting on the ilium or sinking into the pelvis, obliterate the iliocostal space. Lordosis is an increase of the forvard curve, as in the lumbar and cervical regions. It is most marked and most often observed in the lum- bar region. It is almost invariably a compensatory curve instinctively assumed to keep the center of gravity from being advanced too far and to allow the patient to stand erect. Thus in obesity, pregnancy, angular curvature, congenital dislocation of the hips, and in liip disease with flexion of the femur it is present as a compensatory curve. The latter condition is its commonest cause. The hip being held or anchylosed in a flexed position, the patient is only enabled to straighten it by a rota- tion of the entire pelvis by which its upper end is moved forward, which increases the lumbar curve. This is seen in examining such a patient in the supine position. When the affected extremity is extended the lumbar spine is arched forward, when it is flexed to the angle in Diagrams to show lor- dosis as a compensating curve in hip disease. A ; normal spinal curves. The hip is anchylosed in the flexed position ; B ; the anchylosed flexed hip is straightened by a tilting of the pelvis, indicated by the position of the dotted line and the presence of lordosis. LATERAL CURVATURE. 487 Fig. 12-1. which it is anchylosed the lumbar curve is normal, and when it is fur- ther flexed tlie curve is straightened and the himbar spines press tlie hand against the table. Scoliosis or lateral curvature may also be said to be an exagyi ration of a normal curve, for very few are without a slight lateral spinal curve usually to the right in right-handed persons. Scoli- osis also mat/ he a compcn.safori/ curve, compensating the lateral tilting of the pelvis which accompanies an inequality of the length of the legs. It may be due to chronic empyema, or the ex- tensive resection of several ribs to cure it. 3Iore often it is an idiopathic con- dition whose etiology we really do not know in many cases. It occurs in children, most often in girls, in whom the muscular development and general condition are below par. A faulty atti- tude in study, etc., has been thought to favor it. As the principal curve, in the upper thoracic region, is Ufiualli/ con- vex to the right in right-handed persons, unequal muscular action is thought to be a causative factor. There are of course compensatory curves in the op- posite direction in the lumbar and cervi- cal regions to allow the erect attitude. When the lateral curve has reached a certain degree the vertebral column begins to rotate on a vertical axis so that the spines turn toward the concavity of the right' in the thoracic region, the com- f, I rrti • pensatorv curves in the opixisite direo- CUrve, tor some unknown reason. IniS tiou in the cervical and lumbar regions. b.i " _ i.1 „ 1" _ The vertebral spines are shown rotated rmgs the spmes nearer the median toward the concavity of the curve. line so as to diminish the appearance of the curve as indicated by them. It also carries the ribs backward on the right and forward on the left, so that the right chest is full and prominent posteriorly but flattened anteriorly, while the left chest is prominent in front but its ribs are crowded together and its capacity is diminished. In time the vertebrie, muscles and ligaments become atrophied and contracted on the concave side, stretched on the convex side. The spinal canal is completed posteriorly by the fusion of the lamina;, or neural arches, at the root of the spinous processes. Each half of the neural arch is formed from a separate ossitic center. Failure of this fusion causes a posterior median defect of the lamina? and spines which is seen in spina bifida. Phis is most common in the lumbosacral Diagram to show lateral curvature of the spine. The primary curve is to the 488 THE SPIXE. or sacral regions, for here the neural arches are last ossified. Other imperfections of development are often associated with spina bifida. Spina bifida is a congenital defect of the vertebral canal through which some of its contents protrude, /. e., (1) the membranes alone (spinal meningocele)', (2) the membranes with the cord or, generally, the nerve trunks of the cauda equina, which usually adhere to the posterior wall of the sac [ineningomyelocele) ; (3) the latter condition with a sac-like dilatation of the central canal of the spinal cord (syringomyelocele). The second variety is the most common, the first, the next, and the third the rarest. In all forms the sac is filled with cerebrospinal fluid, almost always from the subarachnoid space (i. e., in the first two forms). Hence the sac, which forms a median dorsal tumor, is more tense in the upright position and on crying. Pressure may return some of the fluid and, by increasing the pressure within the spinal canal, may result in causing irregular muscular movements or even convulsions. The twenty-three intervertebral discs make up nearly one fourth of the length of the spine, hence the height of the body is appreciably de- creased from their compression on long standing or sitting, and in old age from the shrinkage of the discs. It is owing to the discs that the movements of the spine are permitted, and these movements are most free where the vertebrse are smallest or the intervening discs thickest, i. e., in the cervical and lumbar regions respectively. Therefore move- ment is most free where the spinal canal and cord are the largest, where the curve is convex forward, and where there are no bony cavities containing viscera. Free movement in the thoracic region would be a distinct disadvantage to the thoracic viscera. Movement is per- haps most free in the lumbar region, but rotation and lateral motion is freest in the cervical region and extension is as free there as any- where. The vertebral bodies with the intervening pulpy portion of the discs really form ball and socket joints, but the free movements thereby allowed are resisted by the connecting ligaments and restricted by the articular processes and in parts by the other processes of tlie vertebrte. Owing to the more or less horizontal surfaces of the articular processes of the cervical region movements in all directions are permitted there. Rotary movements are most free in the atloaxoid joints, flexion and extension in the occipitoatloid joints. In the thoracic region extension is prevented by the overlapping spines and by the shape of the artic- ular processes. The latter limit flexion also, whereas lateral move- ments, otherwise possible, are prevented by contact between the ribs. In the lumbar region lateral movements are limited by the great trans- verse diameter of the bodies, rotation by the relation of the articular processes. The overlapping lamina protect the cord from injury in the thoracic region where, owing to the curve, it lies nearer the surface and is most exposed. Between the upper cervical vertebnc the intervals between the narrow laminae are widest and here the cord can be most easily reached DISLOCATION OF THE SPINE. 489 and toounded by a narrow instrument. Infanticide has been accom- plished by pithing the upper cervical cord Ijy a long narrow pin, thrust between the upper cervical vertebrae or between the atlas and the occiput. Again in the lumbar region it is posaihle to enter tlie Mjiinal canal by an instrument thrust obH(jiiely upward and forward. This is taken advantage of in lumbar puncture and spinal cocainization. The puncture is made between two lumbar spines below the second lumbar vertebra (usually between the third and fourth), to avoid the cord which extends to the lower end of the first lumbar. To avoid the spines the puncture is made a little (\ to 1 cm.) to one side of the median line. In adults the puncture is made opposite the middle of the spine below the interval, to give the needle the desired ui)war(l obliquity. 77// needle is then thrust forward, toward the middle line, and in adn/ln slightly upward, for 2 to 7.5 cm.., until the esca])e of fluid (cerebro- spinal) indicates that its point has entered the subarachnoid space. The canal is entered through the ligamentum sul)rtavum. The j)ossible puncture of one of the nerves of the cauda equina may occur and is shown by the twitching of some of the muscles of the lower extremity. On account of the number of the joints and ligaments of the spine and the variety and extent of its movements it is readily understood why the .^pine is liable to sprains. These naturally occur most often where the movements are most free, in the lumbar and cei'vical regions. The nearness of the head and the transmission of violence, received by it, to the spine may increase the tendency to sprains in tiie cervical region. Considerable pain and stiffness often persist long after the injury, and these may depend upon a synovitis of one or more of the many vertebral joints. Ecchymosis rarely appears in these cases, for the spine is separated from the skin by many layers of muscles and fasciae. When the violence applied is more concentrated or more severe frac- tures or dislocations of the spine are produced. The Habilifi/ of the spine to these accidents is, to be sure, di)nini.'ccipiit and the sixth V. npine. These spines, except the latter, cannut l>e felt. First cervical nerve Interval between atlas and occiput Second and third cervical nerves..opposite the axis Fourth to eighth " "(incl. ) op. third to seventh C. ver- tehne respectively. First thoracic nerve op. disc below seventh C. vertebra Seventh C. spine. Second " " op. disc below first T. ver- tebra. Third " " op. disc below second T. vertebra First T. spine. Fourth " " op. disc below third T. ver- tebra Second T. spine. Fifth and sixth thoracic nerves... op. lower border of fourth and fifth T. vertebra- re- spectively Third and fourth T. spines respectively. Seventh to twelfth " "(incl. ) op. lower border of sixth to eleventh T. vertebne respectively Fifth to tenth T. spines respectively. First to third lumbar nerves op. twelfth thoracic verte- " bra Fourth " nerve op. disc below twelfth T. vertebra Fifth " " op. upper border first L. vertebra First to fifth sacral nerves (incl. )..op. first L. vertebra First L. spine. The areas of ancvdhesia corresponding to tlie several segments of the cord are seen by reference to Fig. 124. It will be seen that only when the first lumbar segment is involved does the anjosthesia extend up to the abdominal wall. Wy the area of auiosthesia alone it is impossible to definitely determine lesions of the eauda equina from tho.se of the seg- ments from which they are derived. In all cases the localization of the injury of the cord must he made from the symptoms observed shortly after the injury for within a few days myelitis is aj)t to oceiir and cause an extension of the area of amesthesia and panily.'^is. For the interpretation of the nmscuhir parahisis three methods of de- termininr/ the localization of the seffinents which correspond to the nerve supply of the muscles hare hem emphi/cd : (1) the ex[)erimental, on monkeys, (2) the clinical from an accurate observation of ca.ses, and Opposite eleventh and twelfth T. spini's. 496 THE SPINE. (3) the anatomical from minute dissections. Although perhaps less accurate than the others the clinical method is still of the mod practical service and hence column D of Fig. 125 gives the results obtained by Thorburn from an analysis of careful clinical observations. Fig. 124. Cutaneous sensory distribution of the spinal segments on the anterior and posterior surfaces, from the third cervical to the fourth sacral, inclusive. (After Kocher.) According to Thorburn no motor supply comes from the first and second lumbar segments but many derive part or the whole of the nerve to the cremaster from them. It will be seen that motor paraly- sis is slight in the lower cord lesions, only the perineal muscles, bladder and rectum being involved in lesion just below the second sacral seg- ment and, with the possible exception of the glutei, only the leg and foot muscles are affected if the lesion involves all the sacral segments. In pressure lesions of the cauda equina the pressure may be sufficient to cause Avidespread paralysis when sensation is but slightly affected. Also Fio. 125. euPIUIPINATU*. lhfRAAPI*«ATUB I TtUti UINON. I I 25_il'l';t>'». Bfl*C>1l»l.l». DCL70ID. UrUCHtO- SUPINATOR 6U"ICAI> PKOHATOW M/IJ, LATIU. PICT TniCCP».«eilll.UAC CXTENtOnS OP WRIIT. PLEXOm Of THE WRIST INTER0S8CIAN0 OTHER INTRINSIC WUSCt.CS OP >IAND, V INTERCOSTAL f MUSCLES. D. E. F. MOTOR SENSORY REFLEXES DISTRIBUTION. AREAS. ^NECK ANO 6CALP NECK AND SHOULDER. SHOULOER.- >AflM. •LADDER AND RtCTUW HAN[>. ] / .FRONT OF 'thorax. EPIGASTRIC. ;ENSIF0RM AREA. ^ABDOMEN. I JMBILICUS (IOTm)J ,'ABDOMISAL. CREMASTERIC. ANTERIOR ASPECT OP TMIOM BELOW SECOND LUHBAR ROOT. BACK or THIGH, exec* OtSTRIBUTION OP 1ST, 2n0 * 3R0 SACRAL I NARROW STRIP ON I SACK or THIGH. LEO >ANO ANHLE, SOLI. I PART OP DORtVH OP I POOT. FOOT CLONUS. PtRIN«u«, E«T. OfN TALS, SADOLC SHAPED ARIA or tACA OP ThiOM. 498 THE SPINE. in such lesions the nerves which pass out lower down are more seri- ously involved though they are situated nearer the center and would appear to be less exposed to pressure, a fact that is not explained. According to Starr the control of the bladder and rectum is always lost tor/ether. It is lost if the lower three sacral segments are involved, and the control centers probably lie in the lower two of these. In a lesion involring these reflex centers absolute incontinence follows tempo- rary retention, the bladder first distends and then dribbles from over- distension. In a lesion above these centers the cerebral inhibitory control is cut off so that, after a temporary retention dne to shock, the bladder and rectum are emptied at frequent intervals unconsciously and involuntarily. The reflex mechanism being intact works like a clock without a pendulum. Similarly in lesions above the r^/?e.r center of erection of the penis, which is in the same part of the lumbar en- largement, the inliibitory fibers are cut off and a chronic erection (priapism) usually occurs. Thorburn has called attention to the jxithognomonic posture assumed in lesions below the fifth cervical sef/menf and the explanation of it. The arms are abducted by the deltoid, and rotated out by the supra- and infra-spinati, the elbows are flexed by the brachialis, brachio-radialis and biceps and the hand is supinated by the latter, all the other muscles of the arm being paralyzed. As the phrenic nerve is derived principally from the f)urth cervical segment, receiving contributions from the third and fifth segments, lesions at or above this level are rapidly fatal from failure of respiration. In lesions between this and the upper thoracic segments the respiration is entirely diaphrag- matic. The integrity of the spinal reflexes depends upon that of the afferent sensory nerve, the efferent motor nerve, their connection in the gray matter of the cord, and the inhibitory fibers, descending in the antero- lateral columns, by which the brain regulates the reflexes. If the latter fibers are destroyed by a lesion all reflexes below this point are exag- gerated from the loss of cerebral control. If the afferent or efferent nerves or their association in the gray matter is destroyed the reflex is lost. The reflexes, with the segments to which they correspond clinic- ally, are given in column F of Fig. 125. Hemorrhage may occur within the cord (hcematomyelia) or within the membrane's (hiematorrhachis). The latter may extend the length of the cord or gravitate largely to the lower end, and ])roduces no very localized symptoms. According to Thorburn, haematomyelia is not at all uncommon and occurs principally between the fourth cervical and the first thoracic segments (inclusive), corresponding to the cervical vertebme from the fourth to the seventh inclusive. This is the summit of the cervical curve, where an acute bend of the neck would make itself mainly felt. In fact the cord has been crushed by such a bend without fracture, and with only temporary diastasis. The symptoms produced by such a hemorrliage depend upon (1) a comj^ressing and (2) a destroying lesion ; the former temporary and causing paralysis, anses- OPERATIONS UPON THE CORD. 499 thesia, loss of control of the reflexes of the bladder, iictum and penis, etc., the latter permanent and causing atrophic paralysis, and perhaps anaesthesia, of the parts supplied by some of the roots of the brachial plexus. These, /lemorr/KU/r.s are mosf ncvcrr in the nndr of the curd so that the more peri[)heral filx-rs, whieh emerge near the lesion, may not be affected by the excentric pressure, while the more central fillers, which emerge lower down, arc more and more afTccted ; hence the area of anaesthesia is ill defined and may be far below the seat of the lesion. Some doubt is thrown on the correctness of this exjilanation Ijy the fact, stated by Horsley, that the same tendency to involve the lowest sensory fibers first is found in the case of tumors, whose pressure is concentric. In tumors flie. invasion of paralyniH is from alx^ve down- ward, or the reverse of that of anesthesia. The /V/z-o/vVc sit nation for tumors is below the middle of the cervical region and at the upper and lower ends of the thoracic region. Operations upon the cord, in addition to those for fracture-disloca- tions, are not infrequently done for tumors, or inflammatory dejxjsits, the operator being guided by the above and other minor point.s of localization. The cord is first exposed by a laminectomy. Such operations have been very successful when the tumor has been removed and the operation was not too long deferred. INDEX. A BDOMEN, 236 A axis of 284 hlooil vessels of, 342 blows on, 240, 252 boumlaries of, 236 cavity of, 284 congenital deforniities of, 245, 252 injuries of, 252 lymphatics of, 249, 343 muscles of, 240 operations on, 253 regions of, 255 shape of, 236 skin of, 239 snrftice markings of, 237 topography of, 256 wounds of, 252 Abdominal aneurism, 342 aorta, 342 ascites, 285 cavity, 284 ring, external, 261 internal, 262 tumors, 301 viscera, 290 nerves of, 343 wall, 239 abscess of, 242 anterior, 239 aponeuroses of, 243 blows on, 246, 252 deformities of, 245, 252 fascia of, 239, 240 incisions in, 250, 253 lymphatics of, 249 muscles of, 240 nerves of, 250 reflexes of, 251 posterior, 274 subperitoneal tissue of, 247 vessels of, 248 woimds of, 252, 284 Abscess, alveolar, 100 axillary, lti8 cervical, 143 gluteal, 428 iliac, 2(19. 275 in abdominal wall, 242 in antrum. 5(1, 81 in mastoid, 5() in slioath of rectus. 213 in tlie scalp, 23 in tiie testis, 413 in temporal fossa, 24 intercostal, 20(> ischio-rectal, 425 lumbar, 281 Abscess, mammary, 210 mediastinal, 204 of liip joint, 438 of liver, 323 orbital, 72 palmar, 190 parotid, 89, 90 pelvic, 275, 357, 390 perincpbritic, 282, 335, 336 perityphlitic, 275 plantar, 475 popliteal, 451 prostat i c, 36 1 -37 5 psoas, 269-278 renal, 335 retrf)pliaryngeal, 114, 143 spinal. 486 Accommodation, 70 Acetabulum, 348, 427, 434, 435 Acromion j)rocess, 147 fractures of, 156 Acromio-clavicular joint, 154 dislocation of, 154 movements of, 154 -thoracic arterv, 149 Adductor longus, 430, 432, 446, 447 magnus, 447 tubercle, 449 Adenoids, 116 Adrenals, 341 relations of, 341 Air in veins, 129, 144 Alderman's nerve, 50 Alveolar abscess, 100 Ampulla of Vater, 328 Amputation (see special part) Anal fascia, 357, 422, 424 triangle, 424 Anastomoses about elbow, 177 of vessels of abdomen, 249, 342 Aneurism (si-e speiial arterj- ) Angular curvature of sj»ine, 486 Ankle, 465 fasciie of, 466—468 joint, 4()8 dislocations of, 4«t9 elVusions into. 468, 400 excision of, 472 fractures about. 470 lateral motion in, 469 sjir.iins of, 469, 471 surface markings of, 465 tendons about, 4(>6 sheaths of, 467 ItoiMigrapbv of, 4t>6 Ankvlosis of hip, 2S0, 486 jaw, 98 501 502 ISBEX. Annular ligaments of ankle, 467 of wrist, 188 Anteflexion of uterus, 382 Anterior crural nerve, 432 paralysis of, 482 tibial artery, 461, 463, 465, 473 Anteversion of uterus, 382 Antrum of Highmore, 81 empyema of, 81 relations of, 82 tumors of, 82 mastoid, 54 (see mastoid antrum) Anus, 364, 425 artificial, 305 development of, 364 epithelioma of, 362 fissure of, 364 imperforate, 364 Aorta, abdominal, 342 arch of, 229 relations of, 229 thoracic, 230 variations of, 230 Aortic aneurism, 228-230, 342 orifice, 226 plexus, 343 Apex beat, 226 Aphasia, 42 Aponeuroses, abdominal, 243 Appendices epiploic*, 315 Appendicitis, 311, 312 Appendiculo-ovarian ligament, 311 Appendix vermiformis, 309 (see vermi- form) Aqueduct of Fallopius, 53 Arachnoid, 38 Arches of foot, 476 Argvll-Robertson pupil, TO Arm, 170 amputation of, 174 fascia of, 171 nerves of, 171, 172 skin of, 171 surface markings of, 170 topography of, 171 Arnold's nerve, 50 Arteries, see special artery Arterio-venous aneurism, 38 Aryteno-epiglottic folds, 132-134 Arvtenoid cartilages, 133, 134 Ascites, 285, 324 Asterion, 26 Asthma, 221 Astragalus, 469, 476-478 dislocations of, 479 fracture of, 481 Atlas, 114, 484 Auditory meatus, external, 47 relations of, 50 Auricle, left, 225, 226 right, 22.5-227 Auricles, supernumerary, 47, 146 Auriculo-temporal nerve, 90 Auriculo-ventricular groove, 226 Axilla, 148, 167 boundaries of, 167 Axilla, contents of, 168 suspensory ligament of, 155 Axillary abscess, 168 aneurism, 169 artery, 148, 155, 164, 167, 168 course of, 149 fascia, 168 line, 203 Ivmph nodes. 149, 169, 170 Vein, 155, 164, 168, 169 Azygos major vein, 222, 231 BASE of skull, fracture of, 31 Basilic vein, 172 Biceps, grooves along, 170 cubiti tendon, 159-161, 174, 175, 178 dislocation of, 161 femoris tendon in ham, 450, 452 tenotomv of, 452 Bichat's lobule, 88 Bicipital fascia, 174-176 Bile-duct, common, course of, 299, 328 i obstruction of, 329 i operations on, 328 ' relations of, 288, 298, 299, 328 Bladder, 365 capacity of, 365 development of, 372 I distension of, 366, 498 ' double, 369 extroversion of, 252 fasciculated, 369 female, 372 fixation of, 368 hernia of, 369 interior of, 371 ligaments of, 356, 368 malformations of, 373 mucous membrane of, 369 nerves of, 370, 498 new growths of, 373 of child, 372 outlet of, 366 position of, 365 puncture of, 360, 367 relations of, 359, 360 relation of to peritoneum, 366 rupture of, 368 sacculated, 369 shape of, 365 sphincter of, 368, 375, 421 structure of, 369 vessels of, 370 wall of, 369 wounds of, 368 Blepharo-spasm, 60 Blood vessels of abdomen, 342 abdominal wall, 248 arm, 172 brain, 40 breast, 211 buttock, 427 elbow, 175-6 face, 83 foot, 473-4 INDEX. 503 Blood vessels of forearm, 184 hand, 197 knee, 450, 452, 453 leg, 4G1-463 neck, 121, 122, 125-129 nose, 79 orbit, 71 palate, 108, 110 pelvis, 357 rectum, 302 scalp, 20, 21 .Scarpa's triangle, 431-433 shoulder, 155-168 spermatic cord, 416, 417 thigh, 447 tympanic membrane, 52 Bow legs, 465 Bi-achial artery, 170, 172, 175 abnormalities of, 172 aneurism of, 176 compression of, 172, 176 in phlebotomy, 176 ligature of, 172 line of, 170 fascia, 171 plexus, 122, 123, 151, 152, 200 Brachialis, 178 Brachio-cephalic artery, 231 vein, 229, 230, 231 radialis, 171, 173, 184, 186 Brain, 39 blood supply of, 40 center of sensations of sound, 42 of taste and smell, 42 compression of, 40 concussion of, 40 contusion of, 40 cortical centers of, 40 fissures of, 44 functions, locjilization of, 40 injuries of, 40 membranes of, 33 motor area of, 40 mental or association centers of, 43 relations of, to skull, 43 sensory cortical area of, 42 speech areas of, 42 visual center of, 40 Branchial arches, 145 clefts, 145 listuhe, 145 Branchiogenic cysts, 146 Brasdor's operation, 127 Breast, 208 abscess of, 210 arteries of, 211 cancer of, lii'.t, 211 capsule of, 208 lymphatics of, 169, 211 nerves of, 21 1 removal of, 211 Bregma, 26 Broad iigimient, 389 borders of, 390 contents of, 390 relations of, 390-393 Bronchi, 221-223, 228, 22t) foreign bodies in, 222, 223 Bronchial lynijih nodes, 223 Bronchiectahis, 221 Bronchocele, 138, 141 Brunner's glands in burns, 299 Brvant's line and triangle, 427 Bubonocele, 263 Buccal nerve, 86 Buccinator. K6, 87, 88 Bulb, artery of, 420, 422 of corpus spongiosum, 408, 420, 422, 423 Bulbi vestibuli, 394, 397 Bulbous portion of urethra, 400 Bunion, 475 Bursic about the ankle, 468 elbow, 177 ham, 453 knee joint, 451 shoulder, 158, 159 over the great trochanter, 429 tuber ischii, 345, 429 prepatellar, 451 subacromial, 158 thyro-hyoid, 131 Bursting fractures of skull, 31, 32 Buttocks, 426 fa-scia of, 428 fold of, 426 nerves of, 427 surface markings of, 426 topfigraphy of, 427 [ vessels of, 427 p J^CUM, 306 \j foreign bodies in, 307 forms of, 306 liernia of, 307 in intestinal obstruction, 308 I position of, 307 Calcaneo-astragaloid joint, 479 -scaphoid ligament, inferior. 476, 477 , Calcanemn, 467, 469, 472, 478, 481 j fracture of, 481 I Canal of Nuck, 391 C'analiculi, 63 Cancrum oris, 84 Capsule of Glisson, 323 of Tenon, 66 Cardiac flatness, area of, 225 incisure, 218, 225 orifice of stomach, 291 Carotid artery, common, 126, 231 aneurism of, 126 ligature of, 127 line of. 126 relations of, 127, 231 wounds of, 132 external, 90, 128 in operations on tonsil, 112 ligature of, 128 internal, 37, 12*.* in operations on tonsil, 112 sheath, 128 triangles, 126 504 INDEX. Carotid tubercle, 127, 484 Caruncle, lachrymal, 62 urethral, 396 Castration, 410, 416, 417 Catheterization of Eustachian tube, 58 of uretei's, 393 of urethra, 400, 405 Cauda equina, 494, 496 Cava, inferior, 322, 328, 332, 334, 340 superior, 222, 228, 229, 231 Cavernous sinus, 37, 62 Cavum Retzii, 248, 367 Cephalluematonia, 30 Cephalic vein, 148, 155, 170 Cephaloceles, 27 Cerebellum, 43 Cerebral localization, 40 Cerebro-spinal fluid, 31, 32, 427, 48 489, 492 Cervical abscess, 143 fascia, deep, 141 lymph nodes, 144 nerves, 119, 120 ribs, 122 sympathetic, 129 triangle, anterior, 123 posterior, 120 vertebne, 484, 488, 489, 490, 498 Cervix uteri, 381 canal of, 383 elongation of, 381 external os of, 381 relation to ureters, 382 zones of, 381, 382 Cheeks, 83 Chest (see Thorax). Cholecystectomy, 326 Cholecystenterostomy, 317, 326 Cholecystotomy, 326 Choledocotomy, 328 Chopart's amputation, 480 Chorda tympani nerve, 52, 53, 84, 106 Chordee, 408 Circle of Willis, 127 Circumflex, arteries, 149 nerve, 149, 158, 164, 166 Circumscision, 406 Cirrhosis of liver, 324 Cirsoid aneurism, 21 Clavicle, 147 dislocations of, 152 excision of, 152 fractures of, 149 periosteum of, 151 relations of, 151 Clavipectoral fascia, 155, 167 Cleft palate, 110 Clitoris, 397 Club-foot, 477 Coccydynia, 346 Coccygeus, 354, 357, 424 Coccyx, 427 excision of, 365 fracture of, 346 tip of, 346 Cocks operation, 361 Cceliac axis, 342 plexus, 231, 343 Colles' fracture, 191 Colon, 314 ascending, 316 capacity of, 314 characterized by, 314 descending, 316 diverticula of, 315 hepatic flexure of, 317 mesentery of, 316 sigmoid, 317 splenic flexure of, 317 mesentery of, 318 stricture of, 314 transverse, 287, 316 tube, 318 Colotomy, inguinal, 318, 319 lumbar, 316, 318 Compression fractures of skull, 31, 32 of brain, 40 of cord, 491-493 Compressor urethra?, 399, 421 Concussion of brain, 40 of cord, 493 Condylar vein, posterior, 37 Condyles of femur, 449, 454, 457 of humerus, 175 fractures of, 181, 182 Congenital club-foot, 478 dislocation of hip, 441 liernia, 264 hydrocele, 414 malformations of anus, 364 of bladder, 252 of penis, 409 torticollis, 119 Conjoined tendon, 241, 262 Conjunctiva, (il Constrictors of pliarynx, 116, 117 Contre-coup, fracture by, 32 contusion due to, 40 Convolutions of brain, centers of, 40 Coraco-acromial arch, 160 ligament, 148, 166 Coraco-bracliialis, 169 Coracoid process, 148 fractures of, 156 Cord, spermatic, 202, 271 hydrocele of, 264, 414 spinal, 491 compression of, 491, 493 concussion of, 493 Cords, vocal, 133 Coronal suture, 26, 47 Coronary arteries, 98 Coronoid ])rocess of jaw, 95, 97, 100 of ulna, 179, 183 Corpus cavernosum, 408 luteum, 386 spongiosum, 408 striatum, function of, 43 Costal cartilages, 204, 237 Costo-coracoid memljrane, 155 -mediastinal sinus, 215 Costophrenic sinus, 213, 216 ISDEX. .505 •Cotyloid ligament, 436, 444 Cowper's glands, 399, 420, 421 Coxa vara, 444 Coxitis, 437 Craniectomy, 18, 26 Cranio-cerebral top()gra[)liy, 43 -tabes, 27 Cranium, bony landmarks of, 25 Creases of palm, 193 of wrist, 187, ISK Cremaster nmscle, 262, 411 Cremasteric arterv, 411 fascia, 262, 410 reflex, 411, 434 Cretinism, 140 Cribriform fascia, 272, 431, 432 l)late, 73, 70, 79 Cricoid cartilage, 118 fracture of, 135 Crico-thyroid membrane, 135 Crura, lesions of, 43 Crural arches, 247, 269, 271 canal, 270 nerve, anterior, 432 ring, 270, 431 sheath, 247, 270 Crutch paralysis, 173 Cubital fossa, 174 Cuboid bone, 472 Cuneiform bones, 479-480 Curvature of spine, 202, 485, 487 Curves of spine, 484 Cut-throat wounds, 131 Cystic duct, 327 Cystotoniy, jjcrineal, 422, 423 suprapubic, 359, 367 Cysts, dermoid, 59, 347, 387 DARTOS, 3il7, 406, 410 I)eg]utition, 109, 117 Deltoid muscle, 157, 158, 162, 166, 170 region, 157 tubercle, 147 nerve, 86 Dentition, 101 Dcscendens noni, 128 Descending palatine artery, 108, 110 Diaphragm, 212 level of, 213 malformation of, 212 openings in, 213 wounds of, 213 Diaphragmatic hernia, 212 Digastric muscle, 12.3 Diploi', veins of, 22 Dipl()i)ia, 68, 70 Direct inguinal hernia, 266 Dislocations, see several bones and ji)int< Dorsal vein of penis, 35(), 403, 407, 422 Dorsalis ja'dis artery, 466, 468, 473 scapular artery, 157 Douglas, curvconc, 34 processes of, 36 sinuses of, 36 mechanism to prevent aspiration of, 38 tj'AR, 47 J bleeding from in fractureofba.se, 33 coughing, 50 dcveloimient of, 17 external, 47 foreign bodies in, 49 frost bite of, 47 haMnatomata of, 47 lymphatics of, 58 middle, 52 nerves of, 50 sneezing, 50 specula, 48 watery discharge from, 33 yawning, 50 Ectroj)ion, 59, 63 Ejaculatorv ducts, .".76, .399 Elbow, 174 bursa behind, 177 dislocations of, 178 excision of, 178 fold of, 174 fractures about, 181 joint, 177 effusions into, 177 region, 174 surf:icc markings of, 174 topograjjhy of. 174 Elephantiasis, 412, 4.34 Emissary veins of skull, 21 Emphysema, 221 subcutaneous, 217, 222 I^nipyema, 206 Encephahjcele. 27 Encysted hydrocele (>f the cord, 264 Ensiforin cartilage, 204, 237 I'nterotomy, ."05 llnirojiioii, 60, 61, 63 lOpididymis, 414 glol>us major of, 414 minor of, 415 Epididymitis, 415 Epigastric region, 25(> vein, superficial, 239, 249 ve.-^sels, deep, 245, 248, 262, 2(53, 266, 271 Epiglottis, lis, l.'.l. 1 :'..!, 135 506 INDEX. Epilepsy, cervical sympathetic in, 130 Epiphysis of acetabulum, 435 of acromion, separation of, 156 of femur, 449 lower, in excision of knee, 459 in knock knee, 454 separation of, 460 upper, separation of, 438, 444 of fibula, 472 of humerus, separation of, 165, 182 of radius, 192 of third phahmx, in whitlow, 199 of tibia, 459, 472 Epipteric bone, 27 Epispadias, 409 Epistaxis, 79 Episternal notch, 118 Epitrochlear node, 177 Epulis, 95, 101 Erector spina", 279, 281 Eruption of teeth, 101 Estlander's operation, 206 Eustachian tube, 56 catheterization of, 58 direction of, 56 in infants, 57 obstruction of, 57 pharyngeal orifice of, 57 Excision (see special parts) Exophthalmic goiter, cervical sympathetic in, 130, 141 External abdominal ring, 261 angular process of frontal bone, 25, 59 auditory meatus, 47 abscess of, 49 cartilaginous portion of, 49 diameters of, 48 direction of, 48 nerve supply of, 50 relations of, 50 skin of, 49 carotid artery, 90 in operations on tonsil, 112 cutaneous nerve, 172, 176 iliac artery, 275-6 lymph nodes, 277 mammary artery, 149, 211 oblique muscle, 239, 241 spermatic fascia, 240, 261 Extravasation of urine, 240, 407, 420 Extroversion of bladder, 252, 373 Ej'eball, enucleation of, 67, 68 Ej-ebrows, 59 Eyelids, 59 arteries of, 62 canthi of, 61, 62 epithelioma of, 59 foreign bodies beneath, 62 free borders of, ()2 layers of, 59 cedema of, 60 skin of, 59 FACE, 59, 82 development of, 99, 110 nerves of, 84 Face, skin of, 83 Facial arterv, 83, 112, 124 nerve, o9, 60, 84, 90, 108 paralvsis, 53, 84, 85 vein, '83, 124 Ffecal concretions, 308, 312 impaction, 308 Fallopian tube, 388 course of, 388 fimbriated extremity of, 388 nuicosa of, 388-9 operation on, 389 Fascia, abdominal, 239-40 axilhiry, 168 bicipital, 174-176 cervical, 141 clavi-pectoral, 155-167 iliac, 269, 270, 277 lata, 271, 446 lumljar, 280 obturator, 356, 422, 424 of ankle, 466-468 of arm, 171 of buttocks, 428 of deltoid region, 157 of foot, 467, 474, 477, 478 of leg, 462 of palm, 195 of penis, 407 of scalp, 20 of thigh, 446 orbital, 66 palmar, 195 parotid, 88 pectoral, 155, 167, 210 pelvic, 356 perineal, 419 plantar, 467, 474, 477, 478 popliteal, 451 prevertebral, 142 recto-vesical, 356, 369, 422 temporal, 24 transversalis, 245, 246, 262 Fasciculated bladder, 369 Fauces, isthmus of, 109 pillars of, 109 Felon, 199 Femoral aneurism, 433 arch, 247, 269, 271 artery, 431, 432, 440, 446, 448 compression of, 432, 447 ligation of, 433, 447 line of, 431 canal, 270 hernia, 272 ring, 270, 431 sheath, 247, 270 veins, 270, 431, 447, 448 ligature, of, 433 wound of, 433 Femur, condyles of, 449, 454, 457 dislocation of, 438 fracture of, 447, 460 epiphyses of, 438, 444, 449, 454, 459 excision of, 444, 459 head of, 427, 430, 434, 439, 440 IXDEX. 507 Femur, neck of, angle of, 441 fracture of, 442 fracture at base of, 442 osteoporosis of, 441 trochlear surface of, 449, 4.>"), 4')7 Fenestra ovalis, o8 rotunda, o-'! Fibula, 4()1 fractures of, 4C)4, 470-472 head of, 44it, 4()0 Fifth nerve, 70, 85 section of (see branches) Fimbria ovarica, 38(5, 888 Finger, cutaneous nerve supply of, 198 dislocation of, 199 Fibrous sheaths of flexor tendons, 190 Fissure of anus, 3(34 Fissure of Rolando, 44 of Sylvius, 4-"> parieto-occipital, 4() Fissures of brain, localization of, 44 of Santorini, 49 Fistula, branchial, 145 in ano, 3()4, 425 lachrymal, G4 salivary, 87 umbilical, 259 vesico-vaginal, 372-393 Flat-foot, 474, 477, 478 Fold of buttock, 426 of elbow, 174 Fontanelles, 2G Foot, 472 abscess of, 475 amputations of, 480, 481 arches of, 474, 476 longitudinal, 476, 477 maintained by, 476 transverse, 476 maintained by, 476 blood vessels of, 473, 474 dislocations of, 469, 479, 480 fasciae of, 474 fractures of, 481 joints of, 479 lymphatics of, 475 nerves of, 475 surface markings of, 472 synovial membranes of, 480 topography of, 473 veins of, 474 Foramen ca'cura (of tongue), 104 of Majendie, 39, 492 of AVinslow, 288, 289, 298, 328,341 Forearm, 183 amputation of, 186 bones of, 185 dislocations of, 179, 180 fractures of, 185 landmarks of, 183 surface markings of, 183 vessels of, 184 Foreign body in air passages, 133, 138 in ear, 49 in a'soj)hagus, 234 Fossa, duodeno-jejunal, 300 Fossa, ileo-cffcal, 313 -colic, 313 infraclavicular, 148 inguinal, 263 intersigmoid, 31 H ischio-rectal, 361, 422, 424 nasal, 75 navicularis, 400 of Kosenmiiller, 5>i, IM subcecal, 314 supraclavicular, 120 Fourchette, 397 Fourth nerve, 70 Fracture (see several Ijones) dislocation of vertebra-, 489, 490, 491, 493 Frenum lingua;, 103 preputii, 408 Frontal artery, 21 sinuses, 80 empyema of, 81 fracture of, 81 operations on, 81 Fundus of stomach, 291 Funicular process, hernia into, 265 GAEKTXER. duct of, 387 Gall-bladder, 32-') empyema of, 326 lymphatics of, 326 operations on, 326 position of, 325 relations of, 326 stones, 326 Gasserian ganglion, 38 removal of, 38 Gastrectasia, 292 Gastric ulcer, 296 Gastrocnemius, 450, 461 Gastro-colic ligament, 287, 298, 317, 332 -enterostoniv, 293 Gastroptosis, 292 Gastro-splenic omentum, 330 Gastrostomy, 293 GiLstrotomy, 293 Genital organs, female, 379, 397 male, 373, 398 Geni to-crural furrows, 345 nerve, 411, 417, 434 Genu valgum, 454 Gimbernat's ligament, 244, 269, 271, 273 Glabella, 25 (ilans penis, 408 Glaucoma, cervical sympathetic in, 130 Glenoid cavity. 14S, 'l(il-163 Glisson's capsule, 323 Glossitis, 1(12 Glosso-pharvngeal nerve, 106 Glottis, 133' tt'dema of the, 134 spasm of the, 133 Gluteal abscess, 428 aneurism, 429 artery, 355, 127. 429 ligat\ire and wounds of, 429 fascia, 428 508 INDEX. Gluteal fold, 426 muscles, 418, 425, 428 nerves, 427 region, 426 Gluteus maximus, 418, 425, 428, 429 medius, 427, 428 429 Goitre, 138, 141 (jreat auricular nerve, 120 Groin, fold of, 238, 239 Gubernaculum testis, 412 Gullet (see oesophagus) Gums, 100 Gustatory nerve, 106 operations on, 106 H HEMATOCELE, 357, 387, 391, 393, 397, 414 Haeraatomata of scalp, 23 of ear, 47 Hffimatomyelia, 493, 498 Hiemorrhage froui frenum lingua>, 104 intercostal vessels, 206 internal mammary, 207 operations on tongue, 104, 105 tonsil, 112, 113 in amputation at hip joint, 445 slioulder joint, 167 in lithotomy, 422, 423 in tracheotomy, 138 meningeal, 34 Ha^morrhoidal artery, external, 424, 425 superior, 358, 362 veins, 362 Haemorrhoids, 363 Hfemothorax, 218 Hallux valgus, 475 Hammer toe, 482 Hamstring muscles, 447, 452 tendons, contracture of, 452 rupture of, 452 Hamular process, 109 Hand, 193 cutaneous nerve supply of, 198 extensor tendons of, 198 fasciae of, 195 landmarks of, 193 motor nerve supply of, 198 surface markings of, 193 synovial sheaths of, 196 vessels of, 197 Hard palate, 107 Harelip, 99 operation on, 100 Head, 17 general considerations, 17 natural position of, 17 asvmmetrv of, 17 Heart," 225 apex of, 226 arteries of, 227 displacements of, 226 orifices of, 226 physical examination of, 225 posit itm of, 225 relation to surface, 226 surfaces of, 225 Heart, topography of, 226 wounds of, 227 Hepatic abscess, 317 arterv, 288, 324 colic" 329 duct, 327 flexure, 317 Hepato-colic ligament, 317 duodenal ligament, 288, 297, 299 Hermapliroditism, 409, 412 Hernia, acquired, external inguinal, 165 congenital inguinal, 264 diaphragmatic, 212 direct inguinal, 266 external inguinal, 263 femoral, 272 indirect inguinal, 263 infantile inguinal, 265 inguinal, 263, 397 in tlie female, 268 internal inguinal, 266 interstitial^ 268 into the funicular process, 265 ischiatic, 355 ischio-rectal, 356 lumbar, 280 mesenteric, 289 oblique inguinal, 263 obturator, 355 omental, 287 perineal, 356 properitoneal, 248 pudendal, 397 sigmoid, 318 umbilical, 257-259 vaginal, 356 Herniotomy, 267, 273 Herpes zoster, 251 Hesselbach's triangle, 263 Heys' amputation, 480 Hiatus diaphragmaticus, 212, 334 Hip, dislocations of, 438 dorsal forms of, 439 forward forms of, 440 reduction of, 440 joint, 434 amputation at, 444, 445 control of hemorrhage in, 445 incisions for, 445 vessels divided in, 445 congenital dislocation of, 441 disease of, 426, 437, 438, 486 cflusion into, 437 excision of, 444 movements of, 436, 437 strongest part of, 435 weakest part of, 435 fractures al)out, 441-443 region of, 426 topography of, 434 Housemaid's knee, 451 Houston's folds of rectum, 362 Human tails, 347 Humerus, 148, 171 condyles of, 175 dislocations of, 160 ISDEX. 509 Humerus, epiphyses, separation of, 105, 182 fractures of, 1(34-106, 173 non union after, 173 head of, 148 great tuberosity of, 148, 101 JIunler's canal, 447 Hydatid of Morgagni, ;)87, 410 Hvdrencephalotcle, 27 Hydrocele in the female, 3!i2, 307, 414 of the tunica vaginalis, 411, 412, 414 of the cord, 204, 414 Hydrocephalus, 20 Hydronephrosis, 340 Hymen, 31i4 Hyoid bone, 117 fractures of, 130 Hypertrophy of the prostate, 373-375 Hypochondriac region, 250 Hypogastric artery (ol)literated), 263, 368 Hypogastric region, 257 Hypoglossal nerve, 106, 125 Hypospadias, 409 Hypothenar eminence, 193 Hysterectomy, 385 ICHTHYOSIS of tongue, 104 1 Ileo-ciecal intussusception, 309 region, 300 valve, 308 competency of, 308, 309 Heo-colic, artery, 313 intussusception, 309 Ileum, 300, 301 limits of, 302 position of, 300, 301 Iliac abscess, 209, 275 artery, common, 275 ligature of, 277 external, 275 ligature of, 27*) line of, 275 relations of, 276 crest, 238 fascia, 247, 277 furrow, 238 regions, 257, 274 spine, anterior superior, 237, 352 inferior. 434 posterior superior, 238, 427 Ilio-femoral band, 435, 439, 440, 444 -hypogastric nerve, 250 -inguinal nerve, 250 -pectineal line, 244, 348 -psoas muscle, 432, 444 bursa, 432, 430 -tibial band, 428, 446, 449 Hium, 279 Imperforate anus, 304 Incontinence of feces, 498 of urine, 370, 49S Indirect inguinal hernia, 203 Inequality of liml's in length, 448 Infantile inguinal hernia, 205 Inferior carotid triangle, 120 dental nerve, 80 excision of, 86 Inferior maxilla (see mandible) thyroid veins, 130, 140 Infraclavicular fossa, 148 Infraorbital foramen, 85 nerve, 00, 85 excision of, 85 Infundibuliform fascia, 247, 410, 411 Infnndibnlo-pelvic ligament, 38 transversa', 392, 242 INDEX. 511 Lingual artery, 125 nerve, lOG tonsil, 104 triangle, 125 Liponiata in deltoid region, 157 in region of Scarpa's triangle, 481 on the buttock, 428 Lips, 98 development of, 99 Lisfranc's amputation, 480 Lithotomy in children, 423 lateral, 422 parts divided in, 422 parts to be avoided in, 422 median, 423 versus lateral, 423 supi'apubic, 359, 3()7 Littre's operation, 319 Liver, 319 abscess of, 323 carcinoma of, 325 enlargements of, 321 fixation of, 322 general considerations of, 320 limits of, 320 malposition of, 322 nerves of, 325 position of, ;)20 relations of, 298, 299, 322 ruptures of, 319, 322 structure of, 323 surfaces of, 322, 333 wounds of, 320, 322 Localization, cerebral, 40 Lockjaw, 98 Longitudinal bands of large intestine, 306, 314 Longitudinal sinus, superior, 36 Lordosis, 351, 437, 480 in hip disease, 280, 486 cutaneous nerve supply of, 482 Lower limb, length of, 448 measurement of, 352 motor nerve supply of, 482 Ludwig's angina, 107 Lumbago, 283 Lumbar, abscess, 281 colotomv, 318 fascia, 280 hernia, 280 incisions, 282 lymph nodes, 343 nerves, 242, 283 puncture, 39, 280, 489, 492 region, 257, 279 wounds of, 283 spine, 488, 489, 490 vertebra', spines of, 237, 279, 2S0, 345, 484 vessels, 282 Lung, 218 apex of, 218, 220 at birth, 220 base of, 219 bordei-sof, 218 capacity of, 220 Lung, cardiac incisure of, 218, 225 elasticity of, 221 fissures of, 219 hernia of, 122, 218 in neck, 21 S lobes of, 219 outline of, 218 jiosition of, 218 puncture of, 220 relations of, 219 root of, 220, 222, 229 vessels of, 221 wounds of, 222 Luschka's tonsil, 58, 116 Lymph nofles (see each region) vessels (see each region) McBURNEY'S point, 238, 312 Macroglossia, 105 Macrostoma, 100 Maicudic, foramen of, 39, 492 Malleoli, 4(15-467, 469, 472, 479 fractures of, 470-472, 479 Malleus, jjrocesses of, seen through ear drum, 52 Mamma (see breast) Mammarv line, 203 Mandible, 94 condyle of, 90 dislocation of, 96 excision of, 95 fracture of, 94 necrosis of 92, 101 tumors of, 95, 102 Margo acutus, 225, 226 Masseter, 86, 87, 95, 97 Mastoid antrum, 54 development of, 56 infiammation of, 56 operation on, 54 passageway into, 54 position of, 54 relations of, 55 to sigmoid sinus, 56 cells, 56 region, 25 vein, .■'>7 Masto-s(|Uamous suture, 54 Maxilla, attaciiments of, 92 cleft of, 110 excision of, 93 fnicture of, 92 necrosis of, 92 tumors of, 92, 94, 102 Maxillary sinus, 81 empyema of, 81 relations of, 81, 82 tiimors of, 82 Meiu^urcnicnt of lower limb, 352 of upper limb, 147, U)2 Meatus, external auditory, 47 internal urinary, 366, 371, 403 Meatuses of nose, 77, 78 Meckel's diverticulum, 257, 304 ganglion, 82, ^i^ excision of, 85 512 ISDEX. Median litliotomv, 423 nerve, 171, 172, 188, 197, 198 paralysis of, 198 vein, 176,' 188 basilic vein, 176 cephalic vein, 176 Media.stinura, abscess of, 204 Medio-carpal joint, 190 -tarsal joint, 473, 480 amputation at, 480 Medulla, 43 Meibomian glands, 63 Membrana tympani, 51 otoscopic image of, 51 rupture of, 32 Membranes of brain, 33 spinal cord, 427, 491, 492 Membranous urethra, 361, 399 Meningeal artery, middle, 34 hemorrhage from, 31, 34 operations on, 35 position and course of, 35 Meninges of brain, 33 spinal cord, 427, 491, 492 Meningitis from otitis media, etc., 53 spinal, from carbuncle, bedsores, etc., 492 Meningocele, 27 spinal, 488 Mental foramen, 86 nerve, 86 Mesenteric arteries, 342, 358 hernia, 289 plexuses, 343 Mesenterv, 288 holes in, 289, 301 length of, 268, 288 suspensory muscle of, 288, 300 Mesenteriolum, 31U Meso-colon, transverse, 289, 298, 299, 317 -gastrium, 286 -salpinx, 388, 390 Metacarpal bones, fracture of, 199 Metacarjio-phalangeal joint of thumb, dis- location at, 199 Metatarsal bone, fifth, 472 fractures of, 481 Metatarso-phalangeal joint, 473 amputation at, 481 dislocation at, 481 Microcephalus, 18, 26 Middle meningeal artery (see meningeal) Miner's elbo\s', 177 Mitral orifice, projection of, on chest wall, 226 Mons veneris, 239, 345 Morgagni, columns, valves and sinuses of, 262 lacunse of, 401 hydatids of, 387, 416 Motor centers of cortex, 40 oculi, 61, 69 paralysis in injuries to cord, 495, 496, 498 diaphragm of, 102 Mouth, floor of, 102 Mucous polvpi of nose, 79 Mumps, 89-91 Muscle of Horner, 63 Muscular compartment, 269 Musculo-cutaneous nerve, 171, 474 Musculo-spiral nerve, 171, 172 paralysis of, 173 Mylohyoid muscle, 102 Myxcedema, 140 XT ARES, anterior, 74 li plugging of, 75 posterior, 75 Nasal bones, fracture of, 73 cartilages, 74 douche, 80 duct, 64, 65, 77 fossae, 75 lymphatics of, 79 mucosa of, 78 nerve supply of, 79 polypi, 79 septum, 76 Nates, fold of, 426 Nasopharyngeal adenoids, 116 polypi, 117 Nasopharynx, 116 Neck, 117 abscess of, 143 deep fascia of, 141 embryology of, 145 tistuliB of, 145 landmarks of, 117 lung and pleura in, 215, 218 lymph nodes of, 144 surface markings of, 117 triangles of, 120 vessels of, 121, 122, 125-129 wounds of, 131 Nelaton's line, 345, 427, 434, 439 Nephrectomy, 338 Nephro-lithotomy, 338 Nephrorrhaphy, 338 Nephrotomy, 338 Nerve supply of lower limb, 482 of upper limb, 200 Nerves (see various regions) division of (see various regions) exit of, from spinal cord, 494^ 495 Neuralgia, trigeminal, 85, 86 Nipple, 210 afiiections of, 210 line, 203 position of, 203, 210 Nipples, supernumerary, 211, 212, 431 Nose bleed, 79 blood supply of, 79 cartilaginous part of, 74 coverings of, 73 external, 72 foreign bodies in, 80 operations on, 74 Notch of Rivini, 51 Nuck, canal of, 391, 397 Nymphfe, 397 C^, INDEX. 513 OBLIQUE inguinal hernia, 26:{ muscles of abdomen, 239, 241 aponeuroses of, 243 of orbit, 08 Obturator artery, 272 canal, 355 fascia, 356, 422, 424 foramen, 355, 440 hernia, 355 nerve, 355 paralysis of, 482 or thyroid dislocation of hip, 440 Occipital'artery, 21, 12(5 lymph nodes, 22 protuberance, external, 25, 118 sinus, 37 trianfile, 120 Occipito-frontalis, 20, 22, 5»t aponeurosis of, 19, 20, 22, 34 CEdema of eyelids, 60 of glottis, 134 of hand, 195 of scrotum, 410 CEsophagotomy, 234 (Esophagus, 233 caliber of, 233 cancer of, 234 constrictions of, 233 direction of, 233 diverticula of, 146, 235 foreign bodies in, 234 length of, 233 operations on, 234 stricture of, 234 relations of, 229, 230, 234 Olecranon, 175, 179 fractures of, 183 Olfactory nerve, 78 Omental grafts, 287 adhesions, 287 sac, lesser, 289, 295, 332 Omentum, great, 286 in hernia, 287 small, 2S8, 332 Orao-hyoid, 120 Ophthalmic vein, 37, 62, 71 Optic nerve, 69 and subanichnoid space, 69 Orbicularis oris, 85 palpebrarum, 59, 84 Orbit, 65 abscess of, 72 aponeurosis of, 66 axis of, 65, 66 dimensions of, 65, Wi foreign Ijodies in. 72 fractures of, 65 muscles of, 67, 68 nerves of, 69 ])aralysis of, 70 pulsating tumors of. 71 relations of, 65, i\i\ region of, 59 vessels of, 71 Orchitis, 413 Os calcis, fractures of. 481 33 Os innominatum, 348 Os magnum, position of, 188 Ossicles of ear, 52, 54 Ovary, 385 development of, 387 fossa of, 385 [)alpation of, 386 pedicle of, 386, 391 position of, 385, 386 relations of, 360, 388 structure of, 386 tumors of, 387 vessels of, 387 Oviduct, 388 PACCHIONIAN bodies, 29, 39 Palate, 107 aponeurosis, 108 blood supplv of, 108, 110 cleft, 110 " operations on, 108, 109, 111 formation of, 110 hard, 107 muscles of, 108 s.-,ft, 108 Palatine arterv, posterior, 108, 110 Palm, 193 abscess of, 196 creases of, 193 cutaneous nerve supply of, 198 motor nerve supplv of, 198 skin of, 194 Palmar arch deep, 197 superficial, 197 fascia, 195 Palmaris longus tendon, 188 Palpebral conjunctiva, 61 ligaments, 61 Pampiniform plexus, 387, 415-417 Pancreas, 332 cysts of, 333 disea.ses of, 333 duct of, 328 operations on, 332 position of, 332 relations of, 332 Pancreatitis, 333 Papilla of duodenum, 299, 328 of eyelid, 62, 63 Paracentesis of the aUlomen, 285 [>ericardiun), 215, 224 thorax, 20t;, 207 tympanum, 52 Paralv.sis in spinal injuries, 494-196 "498 of anterior i-rural nerve, 4S2 cervical symiiathetic, 71 external popliteal nerve, 482 facial nerve. 84 fourth cranial nerve, 70 great sciatic nerve, 482 internal poj)liteal nerve, 482 median nerve, 19S musculo-spiral nerve, 173 obtunitor nerve, 482 sixth cranial nerve, 70 514 INDEX. Paralysis of third cranial nerve, 70 ulnar nerve, 198 Paraphimosis, 406 Parietal eminence, 25 fissure, 27 foramen, 26 and visceral anastomoses of abdomen, 249, 342 Parieto-occipital fissure, 46 Parotid absce.ss, 89, 90 compartment, 88 gland, 89 relations of, 89 structures in, 90 nerve supply of, 90 removal of, 92 lymph nodes, 22, 91 region, 88 sheath, 88 tumors, 91 Parovarium, 387 Parumbilical vein, 249, 342 Patella, 449 _ dislocation of, 457 floating of, 458 fractures of, 451, 455-456 Patellar click, 458 ligament, 449, 455, 457 lateral, 451, 455—457 rupture of, 456 Pectineal compartment, 269 fascia, 269 Pectoralis major, 148, 155, 167, 169, 170, 208 minor, 149, 155, 167 Pedicle, ovarian, 386, 391 Pelvic arches, 348 cellulitis, 275, 357, 390 counter arches, 348 deformities, 349 diaphragm, 354 hematocele, 357, 387, 391, 393 hernia?, 355 peritonitis, 357 symphysis, 345, 348 viscera, 358 Pelvis, axis of, 284, 351 diameters of, 351 floor of, 354 fractures of, 349 in female, 352 landmarks of, 345 mechanism of, 348 movements of, 352 nerves of, 357 obliquitv of, 351 outlet of, 346, 354 planes of, 351 vessels of, 357 Penetrating wounds of abdomen, 252, 284 Penis, 405 angle of, 408 dorsal vein of, 356, 403, 407, 422 Penis, erection of, 407, 421, 498 fascia of, 407 layers of, 405-407 malformations of, 409 suspensory ligament of, 408 Perforating ulcer, 474 Pericardium, 223 effusions in, 224 elasticity of, 224 tapping"of, 215, 224 Pericranium, 20 Perineal body, 361, 424 fascia, 419 hernia, 356 incisions, 418, 420, 422, 423 interspaces, 419, 420, 421 ledge, 419, 420, 424 Perinephritic abscess, 282, 335, 336 Perineum, 361, 417 boundaries of, 418 central point of, 418, 424 depth of, 418 divisions of, 418 fascist of, 419, 420, 422 female, 423 landmarks of, 418 layers of, 419-422 median raphe of, 418 muscles of, 420, 421 "proper," 419 rupture of, 424 Peritoneal absorption, 286 adhesions, 285 cavity, 285 sac, lesser, 289, 295, 332 transudation, 286 Peritoneum, elasticity of, 285 parietal, 284 visceral, 286 Peritonitis, 284, 286 Perityphlitic abscess, 275 Peroneal artery, 461, 463, 473 muscles, 477 tendons, 466, 467, 472 contracture of, 468 displacement of, 467, 478 tubercle, 472 Pes cavus, 474, 477, 478 Petit' s triangle, 241, 280 Petrosal nerve, great superficial, 84, 108 sinuses, 37, 38 Petro-squamous suture, 53 Peyer's patches, 304 Phantom tumor, 243 Pharyngeal artery, ascending, 112 tonsil, 58 Pharyngomaxillary space. 111 Pharvngotomy, subhyoid, 116, 131 PharVnx, 113 divisions of, 116 foreign bodies in, 114 relations of, 114 Phimosis, 406 Phrenic nerve, 121, 157, 213, 229, 232, 325, 343, 498 IXDLX. 515 Phreno-colic ligjunent, ol7, :V29 -splenic ligament, .329 Pia mater, 39 Pigeon breast, 202, 221 Piles, -MVA Pinna, 47 Pirogofl's amputation, 481 Plantar arch, wound of, 473 arteries, 4G(;, 473, 481 fascia, 4(57, 474, 477, 478 tenotomy of, 47.") ligaments, 47<), 477 Plantaris tendon, rupture of, 462 Platvsma mvoides, 123 Pleura, 214' borders of, 21') dome of. 122, 21o in lumbar incisions, 215, 282, 335 limits of, 215 wounds of, 21(5, 217 Pleural adhesions, 217, 220 Pleurisy, 217 Plica semilunaris, 245 Pneumatocele, 56 Pneuinogastric nerve, 222, 229, 231, 343 Pneunumia, 220 Pneumothorax, 217 Pollitzer's method of inflating the middle ear, 57, 116 Polypus of nose, 79 Popliteal abscess, 451 aneurism, 452 artery, 450, 452, 459, 463 bursio, 453 fascia, 451 nerves, external, 450, 452 internal, 450, 452 paralysis of, 482 nodes, 453, 475 region, 450 vein, 450, 452, 453 Portal vein, 2S8, 324 Posterior auricular artery, 21, 47 condylar vein, 37 scapular arterv, 157 tibial arterv,' 4(11, 463, 465, 466, 473 Post-prostatic pouch, 371 Pott's disease, 251, 486 fracture, 470 Processus vaginalis, 261, 264, 412 Poupart's ligament, 243, 261, 269, 274 Prejiatella bui"sii, 451 bursitis, 451 Prejiuliic curve of urethra, lOO. 403 Prepuce, 405, 406 Priapism, 407, 498 Profunda arteries of arm, 171 femoris, 431, 433 Prolapsus ani, 358, .362 uteri, 383, 392-394 Pronation, 185 Pronator radii teres, 184, 185 Pronator (picidratus, 186 Prostate, 373 abscess of, 361, 375 Prostate, capsule of, :}56, 375, 422 enlargement of, 361, 373, 375 lobes of, 374, 399 operations on, 376, 42.3 position of, 374 relations of, :i59, .360, .361, :;74, 422 structure of, 375 Prostatectomy, 374 ProstJitic plexus of veins, 375 sinuses, 399 Prostato-peritoneal aponeurosis, .359 Psoas absces.s, 269, 278, 486 muscle, 432, 444 Pterion, 26 Pterygium, 62 Pterygoid muscles, 95, 96 Pterygo-maxillary ligament, 107 Ptosis, 61 Pubic crest, 238, 345 spine, 238, 274, 427, 4.30 Pubo-femoral band, 435, 436 -prostatic ligaments, 356 Pudendal hernia, .356 Pudic artery, internal. 355 nerve, internal, 355 Pulmonary artery, 221, 222, 228-231 orifice, 226 plexus, 222 veins, 222 Puncta lachrymalia, 62, 63 Puncture of bladder, 360, 367 Pylorus, operations on, 294 position of, 202 relations of, 292 stricture of, 297 tumors of, 297 Pyosalpinx, 388, 389 Pvramidalis muscle, 243 Pyriformis, 354, 357 QUADRATUS femoris, 440 lumborum, 281, 316 Quadriceps, 449, 455, 457, 458 expansion, 451, 457 tendon, 455, 456 rupture of, 456 Quinsy, 112 I^ADIAL arterv. 184, 188, 189 ll nerve, 184-187, 198 l)ulse, 188 Radio-carpal joint, 187 ulnar joint, 190 Radius, 183 dislocation of, 180 fracture of, 183, 185 head of, 175, 179 styloid process of, 187, 191 Ranine arterv, 104 vein, 104 Ranula, 107 Rectal examination, 346, 360 polvpi, 358 tuU-, 318 Rectocele, 394 Recto-uterine i)ouoli, 380 51(5 INDEX. Recto-vaginal fistula, 394 pouch, 360 septum, 394 -vesical fascia, 356, 369, 422 pouch, 359, 360, 366, 372 Rectus abdominis muscle, 242, 254 sheath of, 245, 253 femoris, 444, 44G Rectum, 358 anal portion of, 361 attachments of, 359 development of, 364 divisions of, 358 examination of, 360 excision of, 359 foreign bodies in, 358 introduction of hand into, 359 nerve supply of, 363, 498 operations on, 365 pelvic portion of, 358 prolapse of, 358, 362 relations of, 359, 374, 380, 422 to peritoneum, 359 stricture of, 362 structure of, 361 vessels of, 362 Recurrent laryngeal nerve, 133, 135, 140, 229, 230 Reduction en masse, 268 Reflexes of cord, 491, 494 Reid's base line, 44 Renal abscess, 335, 336 arterv, 337, 342 calculus, 337, 338, 341, 360 colic, 341 plexus, 338 vessels, 337 Resections (see various parts) Respiration in fracture of spine, 498 Respiratory wave in veins, 129 Retention of urine, 370, 498 Retro-flexion of uterus, 382 -pharyngeal abscess, 114, 143 -version, of uterus, 382 Rhinoplasty, 74 Rhinoscopy, 75 Rhomboid ligament, 153 Ribs, 205 cervical, 122 counting of, 203, 282 excision of, 206 fractures of, 205 rudimentary, 12, 282, 334, 335 Right auricle, 226, 227 lymphatic duct, 233 ventricle, 225-227 Rima glottidis, 133 Ring, abdominal, 261, 262 crural, 270, 431 Rolando, fissure of, 44 Root of lung, 220, 222, 229 Rosenmiiller, fossa of, 58, 116 Rouge's operation, 74 Round ligaments, 380, 383, 387, 391 course of, 391 shortening of, 268, 392 C ACRAL dimple, 238 Sacro-coccygeal joint, 346 tumors, 346 -iliac joint, 347-349, 427 abscess of, 347 disease of, 347 ligaments, 347, 348 -sciatic ligaments, 346, 418, 426 -vertebral angle, 25, 26, 346 Sacrum, means of holding it in place, 347 promontory of, 346 wedge-shape of, 347 Sagittal fontanelle, 28 suture, 26 Salivary fistulae, 87 Saphenous nerve, external, 462, 463 internal, 433, 446, 447, 450, 459, 462-464 opening, 272, 431, 432 vein, long, 431, 433, 446, 450, 459, 461, 462, 464, 466, 474 short, 450, 461-4()3, 466, 474 Sartorius, 430, 433, 444, 446, 447 Scalenus, anterior, 120, 122 Scalp, 18 abscess of, 23 aponeurosis of, 20 arteries of, 21 bleeding from, 22 dangerous area of, 20 fatty tissue in, 19 hsematoma of, 23 hair of, 19 incisions in, 21 lymphatics of, 22 mobility of, 20 nerves of, 22 neuralgia of, 22 pericranium of, 20 sebaceous tumors of, 19 skin of, 19 subaponeurotic areolar layer of, 20 subcutaneous tissue of, 19 suppuration in, 20-23 temporal region of, 24 vascularity of, 20 vessels of, 20 wounds of, 20, 22 Scaphoid bone, 188, 467, 472, 477, 480 Scapula, 147, 156, 204, 484 excision of, 157 fractures of, 156 Scapular line, 203 Scarpa's triangle, 430, 446 fascia of, 431, 432 landmarks of, 430 lymph nodes of, 431, 434 region of, 430 topography of, 431 vessels of, 431, 432 Sciatic artery, 355, 427, 429 nerve, great, 355, 427, 429, 446, 447 exj)osure of, 427 paralysis of, 482 stretching of, 430 notch, great, 355, 427, 444 INDEX. 517 Sciatica, 429, 430 Scoliosis, 202, 487 Scrotal iifrariiont, 411, 41 1 Scrotum, -10!) blood supply of, 411 develoi)ment f)f, 412 in elephantiasis, 412 in (I'denia, 410 layers of, 40!l-411 Semilunar cartila<,'es of knee, 457 dislocation of, 457 fold of Dou<,das, 245 f^anglia, 34.") line, 238, 244, 258 Semimembranosus tendon, 450, 452 Seminal vesicles, 'M\0, .'{74, 870, 428 position of, 870, 877 relations of, 877 Semitendinosus tendon, 450, 452 Septum crurale, 248, 271 of nose, 70 Serratus raagnus, 150 Seventh cranial nerve, 59, 60, 84, 90, 108 Sheath of rectus, 248 Shingles, 251 Shoulder, 147 anterior region of, 149 bursie about, 158, 159 deltoid region of, 157 dislocations of, 100 fractures about, 1()4-166 joint, 159 amputation at, 167 disease of, 159 excision of, 106 posterior region of, 1?5 surface landmarks of, 147 topography of, 149 Sigmoid llexure, 317 Sinus cavernous, 87, 62 great, of aorta, 228, 229 lateral, course of, 36 sigmoid, 80 course of, 87 relation to mastoid antrum and cells, 5() superior longitudinal, 30 Sinuses of dura, 8>0 mechanism to prevent aspiration of, 38 Morgagni, 110 Valsalva, 229 Sixth cranial nerve, 70 Skull, 2.5 abnormalities of, 18, 27 blood supply of, 28 buttresses of, 29 construction of, 28 deformities of, 27 development of, 27 elasticity of, 80 emissary veins of, 21 fractures of, 80 bitse of, 81 mechanism of, 82 vault of, 8! Skull, fractures of vault of, symptoms and danger of, 31 growth of, 18 neerDsis of, 28 of female, 17 of idiot, 17 of infant, 17 pericninium of, 20 racial fliiTereiues of, IS soft parts covering, IH surface lanis of, 98 dislocation at, 96 -maxillarv vein, 91 Tendo Achillis, 461, 462, 466 bursa beneatii, 468 contracture of, 4()8 rupture of, 462, 481 tenotomy of, 463 oculi, til, ()4 Tenon's capsule, 66 Tenotomy of iiamstrings, 452 external popliteal nerve in, 452 slernoniastoid, 119 tendo Aciiillis, 463 tibialis anticus, 468 posticus, 46S Tensor palati, 108, 109 Testis, 412 i Testis, attachment of, 411, 412 castration of, 410, 416, 417 consistence of, 413 descent of, 264, 412 development of, 412 hernia of, 413 inversion of, 412, 415 nerve su|)piy of, 415 position of, 412 retained, 413 tunic of, 413 vessels of, 415 Tetanus, 98 Thenar eminence, 193 Thigh, 445 amputation of, 446, 448 fascia' of, 446 fractures of, 447 region of, 445 skin of, 44() surface landmarks of, 446 topography of, 446 vessels of, 447 Third nerve, 61, 69 Thoracic aneurism, 230 aorta, 230 duct, 229, 230, 232 wounds of, 232 nerve, long, 1()8 nerves, 207, 242, 250, 251, 343 spine, 4,S4, 488 walls, landmarks of, 203 layers of, 204 vessels of, 206 Thoracico-epigastric vein, 249, 342 Thorax, 201 boundaries of, 203 deformities of, 202 form of, 201 paracentesis of, 206, 207 viscera of, 214-235 (inch) walls of, 201 Tiuimb, dislocation of, 199 Thvnuis, remains of, 216. 228 TliyrogK)ssal duct, 104, 107 Thyro-hyoid lunsa, 131 membrane, US. 131 Thyroid artery, inferior, 140 superior. 1 |0 body, 138 accessory luutions of, 139 enlargement of, 139, 140 function of, 140 opcnilions on. 141 position of, 138 relations of, 139 cartilage, US isthnnis, 138 in tracheoti>mv, 136 veins, 136, 14(t Tiiyroidea inia artery, llU), 231 Tibia, bonlers of, 460 epij.hvses of, 459, 460, 472 fractures of. 1('.0, 464, 470, 471 in rickets, 465 strength of shaft of, 464 520 INDEX. Tibia, tubercle of, 449, 455, 456 tuberosities of, 449 Tibial artery, anterior, 461, 463, 465, 473 posterior, 461, 463, 465, 466, 473 bifurcation of, 466 nerves, 477 Tibialis anticus, 461, 466, 467, 477 tenotomy of, 468 posticus, 466, 467, 477 tenotomy of, 468 Toe, great, amputation of, 481 dislocation of, 481 Tongue, 102 blood supply of, 104, 105 excision of, 104 held in place by, 102, 103 in ana?stliesia, 102 lymphatics of, 105 mucosa of, 104 nerve supply of, 106 new growths of, 1 04 Tongue-tie, 103 Tonsil, lingual, 104 Luscbka's or pharyngeal, 58, 116 Tonsils, 111 bleeding from, 112 blood supply of, 113 hypertropiiy of, 112 position of, 112 Torticollis, 119 Trachea, 118, 135 diameter of, 137 foreign bodies in, 138, 223 in the thorax, 222 relations of, 136, 229 Tracheotomy, 136 Tracts of spinal cord, 493 Transversalis fascia, 245, 246, 262 muscle, 241 posterior aponeurosis of, 280 Transverse cervical artery, 121 colon, 287, 316 process of the atlas, 118 sixth cervical vertebra, 118 Trapezius, 120 Trapezium, 188 Trapezoid ligament, 154 Treitz' fossa,' 300 Trendelenburg's position, 367 Trephining, 29 Triangle, anterior of neck, 123 at elbow, 174 carotid, 126 occipital, 120 of Petit, 241, 280 posterior of neck, 120 Scarpa's, 430, 446 submaxillary, 124 subclavian, 120 Triangles of neck, 120 Triangular fibro-cartiiage, 190 ligament, 244, 261 of the urethra, 35(), 399, 420-422 Triceps, 178 Tricuspid valve, position of, 226 Trigeminal nerve, 70, 85 Trigone, 360, 392, 393 Trismus, 98 Trochanter, great, 426, 427, 434, 439, 440, 444 bursEc over, 429 Tubal ]iregnancy, 388 Tube, Eustachian, 56 Fallopian, 388 Tuber ischii, 345, 348, 426, 429 Tuberosity of humerus, great, 148, 161 Tubo-ovarian ligament, 386, 388 Tunica albuginea, 387, 413 vaginalis, 411, 414 Tympanic membrane, 51 otoscopic image of, 51 rupture of, 32 Tympanites, 286 Tympanum, 52 TTLCER of duodenum, 299 LI of stomach, 296 Ulna, 183, 185 dislocation of, 178 fracture of, 185 styloid process of, 187, 191 Ulnar artery, 183, 188 nerve, 171, 172, 175, 178, 184, 187, 188, 198 paralysis of, 198 Umbilical cord, 257 fistula, 259 hernia, 257-259 region, 257 Umbilicus, 238, 257 fibrous ring of, 258 position of, 238 vessels of, 258 Umbo of membranum tympani, 51, 52 Upper extremity, 147 Urachus, 259 Ureter, 339 course of, 339 distension of, 339 in female, 339, 393 length of, 339 operations on, 341 relations of, 339, 340, 386, 389 to uterine vessels, 339 varieties of, 340 vesical end of, 367, 371 Urethra, female, 361, 393, 395 course of, 395 direction of, 396 external meatus of, 396 male. 398 anterior, 402 bulbous portion of, 400 caliber of, 402, 403 catheterization of, 400, 405 changes according to age of, 404 curve of, 401, 40;{ distensibilitv of, 403 divisions of," 398 external meatus of, 400 fixed portion of, 400, 401 internal meatus of, 366, 371, 403 INDEX. 521 Uretlini, rasile, length of, 402 raeinljrunous, oGl, .'i'.lO movable [joition of, 401 mucosa of, 401 narrowest parts of, 40.3 posterior, 402 prostatic, 376, 398, 403 relations of, 301, 420 rui)tiire of, 405 sphincters of, 395, 404 spongy portion of, 400 stricture of, 400 Urethral (;aruncle, 390 triangle, 418 Urethritis, 402, 405 Uterine artery, 382 tibroids, 384 Utero-ovarian ligament, 386, 387 -vesical pouch, 372, 380 Uterus, 379 axis of, 379, 380 development of, 384 displacements of, 382 fixation of, 380 ligaments of, 380 lymphatics of, 385 masculinns, 399 position of, 379 prolapse of, 383, 392-394 relations of, 360, 380, 381 vessels of, 384 wall of, 383 Uvula, 109 vesicae, 371 VAGINA 392 relations of, 360, 390, 392-394 structure of, 394 walls of, 392, 393 Vaginal cystocele, 393 examination, 346, 381, 393 fornices, 381, 394 hernia, 356 rectocele, 394 Vaginismus, 394 Vagus nerve, 222, 229, 231, 343 Valsalva's method of inflating miildlc ear, 57 Valve, ileo-ca^cal, 308 Valves of heart, position of, 226 Varicocele, 417 Varicose veins, 463, 464 Vas deferens, 360, 367, 378, 416 artery of, 379 |i()sili()n and relations of, 378 Vascular compartment, 269 Veins (see various parts) air in, 129. 144 emissary of skull, 21 of diploi-, 22 Velum pendulum palati, 109 Vena cava inferior, 322, 328, 332, 334, 340 superior, 222, 228, 231 \'ena porta-, 288, 324 Venesection at liie enjiii' iiiiitlu-iUi'iiis call \)i- imrcliased fnim any l>i)<)k>ellcr in liie I iiile THROAT. 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POCKET TEXT-BOOKS Cover the entire domain of medicine in sixteen volumes of 350 to 525 pages each, written by teachers in leading American medical colleges. Issued under the editorial supervision of Bern B. Gallaudet, M.D. , of the College of Physicians and Surgeons, New York. Thoroughly modern and authoritative, concise and clear, amply illustrated with engravings and plates, handsomely printed and bound. The series is constituted as follows : Anatomy, Physiology, Chemistry and Physics, Histology and Pathology, Materia Medica, Theiapeutics, Medical Pharmacy, Prescription VN'riting and Medical Latin, Practice, Diagnosis, Is^ervous and Mental Dis- eases, Surgery, Venereal Diseases, Skin Diseases, Eye, Ear, Nose and Throat, Obstetrics, Gynecology, Diseases of Children, Bacteriology. For further details see under respective authors in this catalogue. Special circular free on application. POTTS (CHAS. S.). 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