Iwtl /£ ■;/ -M A 
TREATISE 
ON 
SURGICAL ANATOMY; 
OR THE 
ANATOMY OF REGIONS, 
CONSIDERED IN ITS RELATIONS WITH SURGERY. 
ILLUSTRATED BY PLATES, 
REPRESENTING 
THE PRINCIPAL REGIONS OF THE BODY. 
BV 
ALF. A. L. M. VELPEAU, M. D. P. 
Agrege Stagiaire to the Faculty of Medicine of Paris, etc. 
IN TWO VOLUMES. 
TRANSLATED FROM THE FRENCH, WITH ADDITIONAL NOTES, BY 
JOHN W. STERLING, M. D. 
Member of the Royal College of Surgeons in London ; Fellow of the College of 
Physicians and Surgeons of the University of New-York, etc. 
VOL. I. 
NEW-YORK: 
PUBLISHED BY SAMUEL WOOD & SONS, 
No. 261 Pearl-street. 
1830. 
R, & G. S. WOOD, PRINTERS. Southern District of New- York, ss. 
BE IT REMEMBERED, That on the ninth day ot' February, in the lit'ty- 
fourth year of the Independence of the United States of America, John W. Ster- 
ling, of the said District, has deposited in this office the title of a book, the right 
whereof he claims as proprietor, in the words following, to wit : 
“ A Treatise on Surgical Anatomy ; or the Anatomy of Regions, considered in 
its relations with Surgery. Illustrated by Plates, representing the different Re- 
gions of the Body. By Alf. A. L. M. Velpeau, M. D. P. Agrege Stagiaire to the 
Faculty of Medicine of Paris, etc. In two volumes. Translated from the French 
by John W. Sterling, M. D., Member of the Royal College of Surgeons in London; 
Fellow of the College of Physicians and Surgeons of the University of New-York, 
etc.” 
In conformity of the Act of the Congress of the United States, entitled, “An Act 
for the encouragement of learning, by securing the copies of Maps, Charts, and 
Books, to the Authors and Proprietors of such copies, during the time therein men- 
tioned and also to an Act, entitled, “An Act, supplementary to an Act, entitled, 
an Act for the encouragement of learning, by securing the copies of Maps, Charts, 
and Books, to the Authors and Proprietors of such copies, during the times therein 
mentioned, and extending the benefits thereof to the arts of designing, engraving, 
and etching historical and other prints.” 
FRED. J. BETTS, 
Clerk of the Southern District of New-York. TO 
ALEXANDER H. STEVENS, M.D. 
Professor of Surgery in the University of New-York ; Surgeon to the New-York 
Hospital; Consulting Physician of the New-York City Dispensary; 
Member of the New-York Literary and Philosophical 
Society; of the Academy of Natural Sciences 
of Philadelphia; of the Linnean 
Society of New-England, 
&c. &c. &c. 
WHO, to Talents of the highest order, great Scientific At- 
tainments, and Professional Skill, unites an Indefatigable Zeal for 
the promotion of Medical Literature ; and to whose Encouragement 
may be attributed this Humble Attempt to introduce to the general 
notice of our countrymen, the Unrivalled Treatise of M. Velpeau 
on Surgical Anatomy, is this Work inscribed 
By his Greatly Obliged, 
And Obed’t Serv’t, 
JOHN W. STERLING. 
New-York, Feb. 9, 1830. PREFACE. 
If it is true that indolence, a false judgment, ignorance, self-love, or 
any other mistaken notions, have induced certain persons to say that 
one may be a skilful and learned physician without being a good anat- 
omist, we may affirm that this paradox will no longer be revived at the 
present day: now that it is the universal desire to substitute facts for 
chimerical abstractions; now that the remains of the dead constitute 
the principal book in which physicians seek for the cause of diseases, 
it is no longer necessary to insist upon the indispensable necessity of 
anatomical knowledge; but there is one branch of medicine to which 
this knowledge appertains in a still more intimate manner, and with 
this opinion learned men have always coincided,—I mean Surgery. 
Anatomy, which is only a collection of facts, though it had been 
cultivated by some few during a long succession of ages, was re- 
strained within very narrow limits, until the progress of civilization, 
by banishing existing prejudices, shed upon it the light derived from 
other branches of natural philosophy. When dissections were per- 
mitted, discoveries multiplied with rapidity, and its details became 
formed into a system. The more recent labours of anatomists have 
so far enlarged the domain of their science, that subdivisions of it 
have become necesary both for the study and the improvement of it. 
To examine the organic systems and whatever they possess in com- 
mon in every part of the body, is the object of general anatomy; to 
study the apparatuses in succession; to describe the figure, volume, 
position, density and composition of each organ is the province of 
descriptive or special anatomy; to take a certain portion of the econ- 
omy, describe all the elements which are comprised within it, and 
point out the peculiarities which each of them present; the direction 
and exact relations of the most important objects; the varieties of 
thickness and position produced by diseases or aberrations of devel- 
opement; to proceed from the skin towards the bones, or from the 
bones towards the surface, and thus observe successively, and layer by VI 
PREFACE. 
layer, in their relative and natural position, the different parts, without 
entering into minute details; this is what constitutes the anatomy oi 
regions or of relations, or topographical anatomy. 
The first, more particularly concerned with the fibrillary arrange- 
ment, and the analysis of the intimate structure of the tissues, is the 
basis of all sound physiology; without it, medicine would never have 
emerged from that confusion of principles which so long prevailed in 
the schools: it truly deserves the title of medical anatomy. 
The second, displaying the organs in the manner which nature pre- 
sents them, describing their most prominent characters, without in- 
vestigating their molecular disposition, or those unknown vital proper- 
ties from which they derive life and motion, appertains, more directly 
to surgery, which owes to it its rapid progress and the certainty with 
which it is honoured: without it, the surgeon would be but a danger- 
ous man. 
The third is as yet altogether new, and can only be considered as a 
complement of the two others. It differs from common descriptive 
anatomy, both by the end which it proposes and the means it employs. 
This takes up one apparatus of organs and follows it to every part to 
which it is distributed, previous to taking up the consideration of the 
others; that, on the contrary, passes in review all the elements of a cir- 
cumscribed point, without investigating either their origin or termina- 
tion. The one tends to make knowrn the special functions of the econo- 
my ; the other to expose the different characters of this or that part of the 
body; to give the mechanical reason for the diverse phenomena which 
we remark in it; to explain the difference in the dangers and forms of 
diseases, by the difference in the relative and visible disposition of the 
systems which compose this or that region; it dwells upon some or- 
gans, passes lightly over others, always seeks to place itself in relation 
with operations; in a word, it is the anatomy which is most intimately 
connected with external pathology, and which, for this reason, is called 
Surgical. 
Some positive notions upon surgical anatomy and the anatomy of 
regions, were first promulgated by Desault, in his oral lectures; and 
all who enjoyed the benefit of hearing this celebrated surgeon, agree in 
saying that he felt its great importance; but baron Boyer is the first 
author who has written upon this subject, and his immortal work on 
anatomy contains a sketch of an anatomy of regions which must dispose 
us to regret that he did not enter more fully into this matter. I say the 
first, for the Treatise on Surgical Anatomy by Palfin, published in the 
beginning of the last century, is a very indifferent work, decorated with PREFACE. 
VII 
•j. vain title. That of Petit was composed after the same model, and 
deserves, in a great measure, the same censure; neither of these au- 
thors had, in fact, investigated this subject under its proper aspect. 
Professor Roux next attempted to incorporate it with his course of 
lectures, and he undoubtedly deserves the honour of directing the at- 
tention of the students of the school of Paris to this particular branch 
of anatomy. Several theses, written after the 'model of his lectures, 
shew that M. Roux then considered, and, from what I have heard him 
express, still considers surgical anatomy under two different points of 
view. On the one hand, he would that all the organic apparatuses 
were examined in succession, according to their relations with surge- 
ry: thus, the skin, cellular tissue, muscles, etc., should be successive- 
ly studied in this manner, and the theses of M. Baget upon the cellu- 
lar tissue, of Bajeard upon the muscular tissue, were arranged accord- 
ing to this method; this is what M. Roux proposed calling general 
surgical anatomy. On the other hand, he thought that we should in- 
vestigate all the organs in their relative situations, which would consti- 
tute the anatomy of regions, properly so called. But he who under- 
took to continue the descriptive anatomy of the most brilliant genius of 
our age, was shortly after called upon to attend to other duties, and the 
impulse, which had been given with so much advantage to anatomical 
students, sensibly diminished. Its utility, however, was not forgotten. 
Already had it attracted the attention of Beclard, who entered upon its 
investigation with so much assiduity, that he soon transformed the 
projects of M. Roux into reality. To the natural divisions of the body, 
he added secondary divisions; he circumscribed the principal regions, 
and the sketch which he made of topographical anatomy, in his course 
to the Faculty of Paris, presented itself under an aspect so imposing 
to the numerous students who were eager to hear him, that it thence- 
forth became the favourite study of the greater proportion of them. 
Indeed, it is sufficient to turn to the articles Axilla, Arm, Elbow, Fore- 
arm, Ham, etc., which he has contributed to the JYouveau Dictionnaire 
de J\t£dicine, in order to have an idea of the interesting remarks which 
accompanied his descriptions. It is from him, from his instructive 
lessons, as well as those of an equally revered professor, M. Marjolin, 
that young surgeons imbibed a taste for this subject; but students 
wanted a guide, an elementary work to direct them; Beclard had pro- 
mised to furnish it; it was eagerly anticipated, and every thing favour- 
ed the belief that it would soon have been presented to the public, if a 
premature death had not deprived anatomy of one of its brightest orna- 
me.nts and firmest supports. This professor has left, in this respect, VIII 
I’REFACi;. 
as well as in many others, a chasm which it is very difficult to till up, 
and which is so much the more severely felt in the science, as we begin 
generally to admit, at the present day, that the anatomy of the regions 
is less dry, and that it is of still more immediate application in sur- 
gery than descriptive anatomy, such as it is exposed in our best treati- 
ses. It is with the view of closing this hiatus that I have undertaken 
to present to the public an Essay on Surgical Anatomy, and the Anat- 
omy of Regions. I do not presume sufficiently upon my own abilities 
to suppose that I have fully accomplished my object: I merely thought 
that it would be agreeable, to students especially, to possess some book 
upon this subject, whilst waiting for some more capable person to en- 
gage in it, or until I could produce a better myself. However, I have 
neglected nothing that might render this work useful to the greater 
number, and I must say that I did not undertake it until I had long re- 
flected upon it. It is to M. J. Cloquet, one of my first preceptors in 
Paris, that I am indebted for the first idea of it; we began together at 
the Hospital Saint Louis, in 1821; the regions were already traced, 
when the attention of this learned anatomist was called to other la- 
bours. Nevertheless, I did not abandon this project, and in 1822,1 
submitted our plan to some students, to whom I gave a course upon 
this subject in the amphitheatre of the E'cole-Pratique. Since then I 
have not ceased occupying myself with it, and I have closed my ana- 
tomical demonstrations every year with some lectures upon surgical and 
topographical anatomy: thus, by teaching, I have been enabled to make 
trial of several different methods. That which I have at length adopted, 
is not altogether the same with the plan which I pursued at first; nei- 
ther is it analogous to that of Professor Bedard. Having no model to 
copy after, I was obliged to depend upon my own judgment; I sought, 
however, to enlighten myself by every possible means previous to 
deciding. For the divisions I consulted the manual of Rosenthal, pro- 
fessor at Berlin,* but the only one I am acquainted with, in which all 
the regions of the body are described; an essay of Doctor Bock,f 
printed at Leipsic, in 1824, accompanied with three figures, in which 
arbitrary lines, serving to limit a certain number of sections, are trac- 
ed; the thesis of M. Gerdy, my colleague to the Faculty, published in 
1823,+ and in which we find a topographical sketch of the different 
parts of the body of man considered in nearly the same point of view as 
in the work of M. Boyer. It will be easy to see how far I differ in 
this respect, from these authors, and in what degree I approximate to 
*Handbuch der chirurgischen Anatomie. Berlin, 1817. f Der mcnschlische 
Korper, etc. von Dr. August Carl Bock. } No. 143, page 29. PREFACE. 
IX 
them. For several years also, my friends, MM. Bouvier, associate, 
Blandin, Bogros, prosectors, and Amussat, anatomical assistant to 
the faculty, have been engaged in teaching the anatomy of regions 
with much success, but as they have not published the plan which they 
follow, I have not been able to profit by their knowledge, nor ascer- 
tain in what measure their method differs from mine. 
With respect to the fundamental part, I have drawn from all the 
sources which I have been able to discover; and I mention them here, 
in order that I may avoid too frequent citations in the text, and also 
that every person may there resume whatsoever appertains to him. 
I have especially had recourse to such works as treat particularly of a 
given point of the body ; and I will mention, among others, for the 
Eye, the works of Zinn, Soemmering, Demours; some numbers of 
the Bibliotheque Chirurgicale of Langenbeck, the book published at 
Berlin in 1822 by Weller; for the lachrymal passages, a very good 
thesis of M. Vesigne, that of M. Dubois, Jun.; for the anatomy of 
the Neck and Head, the treatise of Allan Burns, one of the best works, 
on this subject, which have appeared in England, although it does not 
merit all the praise which it has received in the country of its author. 
In fact, it is not a treatise on surgical anatomy, nor of the regions of 
the head and neck ; it would be better intituled—Cliirurgical Obser- 
vations, accompanied with anatomical remarks ;—that of Doctor Col- 
ies, published in 1811, and which also treats of the surgical anatomy 
of the thorax, abdomen and pelvis ; it enters less into detail than that 
of Burns, but is more purely anatomical; a very fine engraving of 
the neck by Astley Cooper, in one of the German journals for 1825 ;* 
other plates of M. Langenbeck, representing the parotideal region and 
divers other points of the head and neck ; the fourth table of Santo- 
rini, one of Soemmering upon the nasal fossae, mouth and pharynx; 
the works of J. Fabrice and Duverney upon the Ear; of MM. Des- 
champs and H. Cloquet, upon the nostrils, etc.; for the axilla the 
theses of M. Mey (1817, No. 63); and of M. Beulac (1819, 
No. 220) arranged according to the lectures of M. Roux ; that of M. 
Senelle (1822, No. 143) upon the thoracic extremity; for the shoul- 
der, the fingers, foot thigh, perinseum of the female, the canal of the 
urethra, etc. several memoires of M. Lisfranc ; for the different parts 
of the pelvis, perinaeum, groin, the researches of Camper, and the 
plates executed in part under the inspection of this celebrated author; 
the splendid work of W. Hunter upon the pelvis and gravid uterus ; 
that of Hesselbach, who has so correctly described the disposition of 
* Chirurgische Kupfortafeln. X 
runrACK. 
the aponeuroses of the fold of the groin, and the relations of the epi- 
gastric artery in hernia, in 1806, 1816, and 1819 ; those of M. J. Clo- 
quet, Astley Cooper, Hey, Lawrence, upon the same subject and her- 
nia in general; the thesis of M. Breschet, on crural hernia; the re- 
searches of Langenbeck, in 1802, and of M. Dupuytren, in 1812, 
upon lithotomy and the perinaeum; of MM. Carcassonne and Bou- 
vier, upon the aponeuroses of the pelvis ; Bogros, upon the iliac re- 
gion ; Sanson and Scarpa, upon the recto-vesical lithotomy; several 
memoires of the latter, and his elegant plates upon aneurisms, herniae 
and hydrocele ; the first part of the system of surgical anatomy by Dr. 
W. Anderson, upon the groin, pelvis and perinaeum, published at New- 
York, in 1822 ; the essay whicn Dr. Ashton Rey has just published in 
London, upon the section of the prostate in lithotomy, according to the 
process of Cheselden, and his plates upon the pelvis; finally, the 
thesis of M. Senn, of Geneva, upon the perinaeum and the different 
forms of perinaeal lithotomy. I ought also to note three drawings 
which are found in the memoir of Dr. Liston, published in London, in 
1811, upon the fold of the groin ; the work of Groefe upon amputa- 
tions, printed at Berlin, in 1812; (on this subject, I would remark, 
that I have passed by the name of this celebrated surgeon in silence, 
when speaking of the staphyloraphy, not because I was ignorant of his 
having performed this operation in 1816, and a considerable number 
of times since ; but because the method of M. Roux, which actually 
seems to have originated with him in France, deserves the preference 
in every respect); the system of surgical operations, began by Charles 
Bell in 1821 ; the Manual of Anatomy by Stanley, and which is in 
fact an abridgement of the anatomy of regions ; that of Green ; and 
even that of Shaw ; the Anatomical System of Lizars, just published 
in London; lastly, I would cite a treatise upon the aponeuroses by 
Dr. Godman of Philadelphia, and another meritorious work upon the 
surgical anatomy of the arteries, by Robert Harrison of Dublin, both 
of which appeared in 1824-5. 
With respect to classic treatises, I have principally derived assist- 
ance from those of Bichat, MM. Boyer, Portal, H. Cloquet, and J. 
Cloquet, for the anatomy; the manual of the celebrated F. Meckel, 
has also been of much service to me, especially as it regards the varie- 
ties and anomalies of position. For the surgical part I have made use 
of the excellent book of Sabatier, as yvell as the additions of its neyv 
editors. I might cite at every page the treatise on Surgical Diseases 
by M. Boyer, and the Nosographie of M. Richerand, I have especially 
borrowed from the latter professor a part of the lines whjch he first in* PREFACE, 
XI 
cheated for the purpose of discovering the direction of the principal 
arteries of the extremities. In a word, I have endeavoured to profit 
by the numerous works which have been published, during a century, 
upon anatomy and surgery, in France as well as in England, Ger- 
many, Italy, etc.; and, as regards this, I take this opportunity of pre- 
senting my acknowledgements to Dr. Crawford of London, for the 
zeal and activity which he has manifested in procuring for me the 
works which I had need of, and to M. Wessley, doctor in medicine 
of the University of Gottingen for the assistance he has afforded in 
enabling me to understand the numerous publications in the German 
language. Also to M. Paillard, internal surgeon to the civil hospitals, 
my friend and former condisciple at the Hospital St. Louis, who, hav- 
ing been for a long time prosector to M. Lisfranc, and engaged for 
several years in surgical anatomy, has collected an abundance of ma- 
terials, both on the subject of general surgical anatomy and the anat- 
omy of regions, which cannot fail being useful to the science, if he 
publishes them, as he has promised. By placing his manuscripts at 
my disposal, he has given me a proof of confidence which does honour 
to his character, and which it is my duty thus publicly to acknowledge. 
A combination of circumstances so favourable imposes upon me, 
I am well aware, great obligations. My province has been rather to 
make a selection among a multitude of facts than to search too mi- 
nutely after new ones. Nevertheless as the subject was not before 
surveyed from the same point of view, and as the objects of it were 
appreciable; as the most scrupulous exactness in the relative posi- 
tion of the parts is the chief merit and distinguishing character of a 
Treatise on Surgical Anatomy, I have considered it my duty to de- 
rive this from Nature alone. Therefore, all the regions have been 
circumscribed upon the dead body, and I have not indicated a part, 
described a layer, or given a measurement without having a subject 
before me. It was not until I had repeatedly examined the different 
elements of a region that I had recourse to authors or ventured com- 
mitting them to paper ; then if my descriptions coincided with those of 
the most accurate anatomist, I considered them correct; but if, on the 
contrary, they differed, I again returned to interrogate the dead body 
and forbore to contradict until I had established the certainty that some 
circumstance had deceived them. In this manner, I have only dwelt 
upon the description of parts in proportion to their degree of import- 
ance, and with some I have entered more into detail than is usually 
done in elementary treatises: such, as for example, the cellular tis- 
sue, the different aponeuroses, and the layers which are derived from XII 
PREFACE. 
them. It is, in fact, only in investigating anatomy by regions that we 
can conveniently dwell upon the disposition of these laminse, which 
actually deserve additional investigation; on the other hand, I have 
thought proper to omit many indifferent minutiae which relate to sur- 
gery, although they might afford great interest in a treatise on de- 
scriptive anatomy. 
With respect to the numerous preparations required, and all that por- 
tion of this labour which it was necessary to perform in the dissecting 
room, I have derived assistance from several persons, and I cannot, 
on this occasion, give too much credit to my prosector M. Bintot, for 
the accuracy which he has exhibited. To M. Ch. Delange, an enter- 
prising student of the Faculty of Medicine of Paris, more than any 
other, I owe a testimonial of gratitude for the entire devotion which he 
has shewn me in this respect, and for the active part which he has not 
ceased to take in every thing that concerns this work. 
Detained a long time by the first step, that is to say, by the division 
which it would be most proper to establish, and by the number of re- 
gions which might be usefully admitted, I was apprehensive of falling 
into two opposite extremes : too multiplied, they would fatigue the 
memory and occasion incessant repetitions ; too few, they would not 
enable us to display advantageously every important part contained 
within them. The great natural sections of the body being insufficient, 
I have substituted for them arbitrary lines, which I have connected, as 
much as was possible, with osseous or muscular eminences. These 
lines seem to me to present the inappreciable advantage of embracing 
in a given region, objects which can only afford surgical interest so 
long as we consider them united and in their natural connexions : thus, 
should we'separate the arm from the fore-arm, the elbow would remain 
without importance ; the considerations relative to blood-letting, to the 
formation of aneurism in this region, would no longer be applicable ; 
if the arm ceased to be connected with the shoulder, the axilla would 
no longer exist; finally, it is in the environs of the principal folds of 
the limbs that the most severe and important surgical operations are 
performed. But these lines might have been established in diverse 
manners ; they might have been more or less approximated or differ- 
ent directions given them, etc. Every one doubtless will have his 
particular opinion on this subject. Those which I have traced seem 
to me to fulfil tolerably well the principal indications; however, I 
attach very little importance to them, and if it can be demonstrated to 
me that I might have chosen others of more general utility, I will be 
the first to modify them. PREFACE. 
XIII 
The order of arranging the descriptions caused still greater embar- 
rassment, because it is more connected with the most prominent part 
of the subject. At first, I found it more natural, more physiological 
to begin the examination of a region with its skeleton, and terminate 
it with the cutaneous envelope : but this book being particularly des- 
tined for those who study or operate upon the dead body, I thought 
that it would be more convenient for them if the inverse method was 
adopted. The first is altogether synthetical, and can only be of use 
to those who have already acquired the knowledge, or who labour 
in the silence of the closet. The second, on the contrary, truly ana- 
lytical, seems to me perfectly to fulfil the end of the student and 
operator, displaying the different organs in the order in which they 
present themselves under the knife, it admits of their being studied 
better, and it is more surgical and more anatomical. 
As it regards the fundamental plan and the nature of the work, I 
have selected from several methods which naturally presented them- 
selves to my mind. I might have restricted myself to enumerate in 
each region, and layer by layer, without distinction of tissue or of or- 
gans, the parts which compose it; but then it would have been diffi- 
cult to give a distinct perception of their precise relations. By taking 
successively each system in particular, it has not always been possible 
for me to follow exactly the order of superposition of the organic 
planes ; but I found that it was the easiest method of pointing out the 
principal peculiarities and positive relations of each organ with those 
which surround it. It appeared to me also that, by this method, the 
descriptions would be less burthensome to the memory and better un- 
derstood : however, although the anatomy would have been a little less 
dry and uninteresting, presented under this point of view than under 
the preceding, it would not have attained its principal object of utility; 
it would not have been surgical. Finally, I might, in the first place, 
have described each system, and afterwards the surgical remarks which 
appertain to it, after the manner of several English surgeons, and 
especially MM. Anderson of New-York, and Harrison of Dublin, as 
well as of MM. Lawrence, Scarpa, Boyer, etc., in treating of hemiae ; 
but then this would have been a treatise on descriptive anatomy on the 
one part, and on surgery on the other. As all these modes of investi- 
gation conduct more or less directly towards the end which I proposed 
myself, and in another sense deviate from it, I have attempted to amal- 
gamate them, lopping off whatever was superfluous or foreign to my 
subject, endeavouring to combine surgical anatomy with that of the re- 
gions, and surgical anatomy by system of organs, with topographical XIV 
i'KKl'ACK. 
anatomy and the anatomy of relations, without establishing any 
tinction between them. 
To recapitulate :—I have had no intention of making a treatise on 
anatomy to supply the place of those which we already possess, nor a 
book of surgery nor of operations, but to collect in each point of the 
body of man the knowledge which naturally flows from the parts which 
we there meet with : to propose an anatomy, by the aid of which the 
surgeon may always foresee, previous to practising any operation what- 
soever, all the accidents which may immediately follow it, and all the 
precautions which it requires relatively to the parts which should be pre- 
served or avoided ; by the aid of which, one point of the body being 
given, it will be possible to tell, within a few lines, what are the fibrillae, 
arteries, veins, nerves, muscles, etc., which must lie in the way of the 
instrument; and it was with the view of accomplishing this end still 
more effectually, that I was disposed to describe from the central point 
to the periphery, upon sections made at different heights of the trunk 
and extremities, all the objects which present themselves to the eye. 
I was also inclined to traverse the body in a great number of directions 
and at different points, with metallic rods, in order to indicate, by leav- 
ing them in place, the nature and situation of the organs thus trans- 
fixed ; but I was apprehensive of making the work too voluminous, 
and therefore have reserved this project until a future opportunity. 
It is especially in the anatomy of relations that designs well executed 
would be of great assistance ; for by a simple glance at a region cor- 
rectly represented, the mind seizes, embraces much better what is re- 
quired to be acquainted with than by means of a lengthy description r 
and in default of dead bodies, I know of nothing that can be substi- 
tuted for plates. Those which accompany this treatise have been 
drawrn from nature by M. Chazal, one of our most distinguished artists, 
the person who is employed in executing the elegant designs for M. 
Maygrier’s work upon accouchemens. I was at first disposed to profit 
by his skilful pencil, in order to represent a much greater number of 
regions under different aspects, but I soon perceived that this would 
increase the price of the work far beyond what would be convenient for 
the greater number of the readers to whom I address it. 
Finally, in order that this work might be what it ought to be, still 
more numerous researches, and a greater length of time than I have 
been able to devote to it, are necessary. I am well aware that it has 
many defects, and criticism will unveil others which I am not con- 
scious of. I have hastened to publish it for the winter, in order that 
students might make use of it during the session which is about to PREFACE. 
XV 
open ; with the view also of exciting others to works of this kind, and 
of attracting the attention of surgeons and anatomists to a subject 
which must be productive of great practical benefit. I have done 
every thing in my power to render it useful and to avoid advancing 
what was not correct; if, however, blemishes too numerous should be 
discovered in it, my only apology is a sincere desire to remove them 
hereafter, and my grateful acknowledgements to those who will kindly 
point them out to me. I must also claim some indulgence ; requesting it 
to be kept in remembrance that it became necessary for me to trace the 
way, and that “or ne fait point de I’anatomie par la setde force de fa 
pens£e.” 
Paris, November 1st, 1825. TABLE OF CONTENTS. 
VOL. I. 
Preface 
CHAPTER I. OF THE HEAD, 
Article I. of the Cranium, 
Sect. 1. Frontal Region, 
CONSTITUENT PARTS. 
1. The Skin, 
2. The Cellulo-Adipose Layer, 
3. The Muscles and Aponeurosis, 
4. The Pericranium, 
5. The Arteries, 
6. The Veins, 
7. The Lymphatic Vessels, 
8. The Nerves, 
9. The Skeleton, 
Sect. 2. Temporo-Parietal Region, 
CONSTITUENT PARTS. 
1. The Skin, 
2. The Cellulo-Adipose Layer, 
3. The Epicranial Aponeurosis, 
4. The Temporal Aponeurosis, 
5. The Muscles, 
6. The Arteries, 
6. The Veins, 
7. The Lymphatics, 
8. The Nerves, 
9. The Skeleton, 
Sect. 3. Occipital Region, 
CONSTITUENT PARTS. 
1. The Skin, 
2. The Cellulo-Adipose Layer, 
3. The Aponeurosis and the Muscles, 
4. The Pericranium, 
5. The Arteries, 
6. The Veins, 
7. The Lymphatics, 
8. The Nerves, 
9. The Skeleton, 
Sect. 4. Cranium in general, 2l> 
1 Article II. Of the Face, 22 
1 Sect. 1. Parotideal Region, 22 
1 CONSTITUENT PARTS. 
1. The Skin, 23 
2. The Subcutaneous Layer, 23 
2 3. Of the External Ear, 24 
2 4. The Middle Ear or Tympanum, 26 
3 5. The Parotid Gland, 29 
3 6 The Muscles, 31 
3 7. The Arteries, 32 
4 8. The Veins, 33 
4 9. The Nerves, 34 
5 10. The Lymphatics, 35 
5 11. The Skeleton, 36 
7 Sect. 2. Nasal Region, 37 
CONSTITUENT PARTS. 
8 1. The Skin, 37 
8 2. The Cellular Layer, 38 
9 3. The Muscles, 38 
9 4. The Arteries 38 
10 5. The Veins, 39 
10 6. The Lymphatics, 39 
11 7. The Nerves, 39 
12 8. The Bones and Cartilages, 40 
12 
13 Sect. 3. Orbitary Region, 41 
14 CONSTITUENT PARTS. 
1. The Supra-Orbital or Supercilia 
ry Arcade, 41 
15 2. The Superior Palpebra, 44 
15 3. The Inferior Palpebra, 45 
15 A. The Skin.—B. The Cellular 
16 Tissue.—C. The Muscles.—D. 
16 The Palpebral Ligament.—E. The 
16 Cartilages of the Tarsi.—F. The 
17 Conjunctiva.—G. The Palpebral 
17 Follicles, or Glands of Meibomius. 
18 FI. The Arteries.—J. The Veins. XVIII 
CONTENTS 
K. The Lymphatics L. The 
Nerves.—M. The Cilia.—N. The 
Sub-Orbital Arcade.—O. The Tem- 
poral angle of the Palpebree.—P. 
The Great Angle.—Q. The Lach- 
rymal Puncta and Canals.—R. 
The Lachrymal Sac.—S The Or- 
bitary Portion, properly called. 45-56 
Sect. 4. Zygomato-Maxillary Region, 73 
CONSTITUENT PARTS. 
1. The Skin, 74 
2. The Cellulo-Adipose Tissue, 74 
3. The Muscles, 75 
4. The Arteries, 76 
5. The Veins, 76 
6. The Lymphatics, 77 
7. The Nerves, 77 
8. The Skeleton, 78 
Sect. 5. Masseteric Region, 79 
CONSTITUENT PARTS. 
1. The Skin, 79 
2. The Subcutaneous Layer, 79 
3. The Muscles, 80 
4 The Arteries, 80 
5. The Veins, 81 
6. The Lymphatics, 81 
7. The Nerves, 81 
8. The Canal of Steno, 81 
9. The Skeleton, 82 
Sect. 6. The Genial Region, 85 
CONSTITUENT PARTS. 
1. The Skin, 85 
2. The Adipose Tissue, 85 
3. The Muscles, 86 
4. The Canal of Steno, 86 
5. The Arteries, 87 
6. The Veins, 88 
7. The Lymphatics, 89 
8. The Nerves, 89 
9. The Mucous Membrane, 89 
10. The Skeleton, 89 
Sect. 7. Mental Region, 90 
CONSTITUENT PARTS. 
1. The Skin, 90 
2. The Cellular Tissue, 90 
3. The Muscles, 91 
4. The Arteries, 91 
5. The Veins, 92 
6. The Lymphatics, 92 
7. The Nerves, 92 
8. The Skeleton, 92 
Sect. 8. Labial Region4 93 
Superior Lip, 94 
CONSTITUENT PARTS. 
1. The Skin, 94 
2. The Cellular Tissue, 95 
3. The Muscles, 95 
4. The Arteries, 96 
5. The Veins, 96 
6 The Lymphatics, 97 
7. The Nerves, 97 
8. The Skeleton, 97 
Inferior Lip, 98 
CONSTITUENT PARTS. 
1. The Skin—2. The Adipo- 
Cellular Tissue—3. The Mus- 
cles—4. The Arteries—5. The 
Veins and Lymphatics—6 The 
Nerves—7. The Mucous Mem- 
brane—8. The Skeleton, 99-101 
Sect. 9. Olfactory Region (PL 2.) 101 
1 The Anterior Apertures of the 
Nostrils, 102 
2. The Vault, 102 
3. The Internal Walls, 105 
4. The Inferior Wall or Floor, 105 
5. The External Wall, 106 
6. The Posterior Aperture of the 
Nasal Fossae, 112 
A. The Arteries—B. The Veins— 
C. The Lymphatics—D. The Nerves, 113 
Sect. 10. Buccal Cavity or Region, 
(PI. 3.) 114 
The Palatine Vault, 114 
CONSTITUENT PARTS. 
1. The Mucous Membrane— 
2. The Submucous Tissue— 
3. The Arteries—4 The Veins— 
5. The Lymphatics — 6. The 
Nerves—7. The Skeleton, 114-15 
The Circumference of the Buccal 
Cavity, 116 
The Inferior Wall, 118 
PARTS CONSTITUTING THE TONGUE. 
1. The Membranous Envelope, 118 
2. The Cellular Tissue, 119 
3. The Proper or Fleshy Tissue, 119 
4. The Arteries, 120 
5. The Veins, 120 
6. The Lymphatics, 121 CONTENTS. 
XIX 
7. The Nerves, 121 
8. The Skeleton, 122 
The Isthmus of the Throat, 124 
Sect. 11. Pharyngeal Region or Cav- 
ity, 128 
1. The Anterior part, 129 
2. The Posterior Wall, 131 
3. The Lateral Walls, 131 
4. The Superior Extremity or Vault 
of the Pharynx, 133 
5. The Inferior Extremity, 134 
CHAPTER 11. OF THE NECK, 135 
Article I. Anterior Portion of 
the Neck, 135 
Sect. 1 Supra-Hyoideal Region, 136 
constituent parts. 
1. The Skin, 136 
2. The Sub-cutaneous Layer, 136 
3. The Aponeurosis, 137 
4. The Muscles, 138 
5. The Arteries, 142 
6. The Veins, 144 
7. The Lymphatic Glands, 144 
8. The Submaxillary Gland, 145 
9. The Nerves, 147 
10. The Cellular Tissue, 148 
11. The Skeleton, 148 
Sect. 2. Infra-Hyoideal Region, 
{PI. 4.) 150 
CONSTITUENT PARTS. 
1. The Skin, 151 
2. The Subcutaneous Layer, 151 
3. The Aponeurosis, 151 
4. The Muscles, 152 
5. The arteries, 156 
6. The Veins, 162 
7. The Lymphatics, 165 
8. The Nerves, 166 
9. The Larynx and Trachea-Arte- 
ria, 169 
10. The (Esophagus, 178 
11. The Skeleton, 179 
Sect. 3. Supra-Clavicular Region, 
{PI. 5.) 179 
CONSTITUENT PARTS. 
1. The Skin, 180 
2. The Subcutaneus Layer, 180 
3. The Aponeurosis, 181 
4. The Muscles, 182 
5. The Arteries, 185 
6. The Veins, ‘ 190 
7. The Lymphatics, 194 
8. The Nerves, 194 
9. The Skeleton, 198 
Article II. Posterior Part of 
the Neck. 202 
CONSTITUENT PARTS. 
1. The Skin, 203 
2. The Subcutaneous Cellular Layer, 204 
3. The Aponeurosis, 204 
4. The Muscles, 205 
5. The Arteries, 208 
6. The Veins, 209 
7. The Lymphatics, 210 
8. The Nerves, 210 
9. The Skeleton, 211 
CHAPTER III. OF THE THORA- 
CIC EXTREMITIES, 217 
Article I. Of the Shoulder, 218 
Sect. 1. Thoraco-Humeral, Sub-Clav- 
icular or Axillary Region, 218 
constituent parts. 
1. The Skin, 219 
2. The Subcutaneous Layer, 219 
3. The Aponeurosis, 220 
4. The Muscles, 221 
5. The Arteries, 226 
6. The Veins, 231 
7. The Lymphatics, 233 
8. The Nerves, 235 
9. The Skeleton, 238 
Sect. 2. Posterior Region of the Shoul- 
der or Scapidary properly cal- 
led, 243 
CONSTITUENT PARTS. 
1. The Skin, 244 
2. The Subcutaneous Layer, 244 
3. The Aponeurosis, 245 
4. The Muscles, 246 
5. The Arteries, 249 
6. The Veins, 251 
7. The Lymphatics, 251 
8. The Nerves, 251 
9. The Skeleton, 252 
Article II. Of the Arm, 260 
Sect. 1. Anterior Brachial Region, 260 
CONSTITUENT PARTS. 
1. The Skin, 261 
2. The Subcutaneous Layer, 261 
3. The Aponeurosis, 262 XX 
CONTENTS, 
4. The Muscles, 262 
5. The Arteries, 264 
6; The Veins, 267 
7. The Lymphatics, 268 
8. The Nerves, 269 
9. The Skeleton, 270 
Sect. 2. Posterior Brachial Region, 270 
CONSTITUENT PARTS. 
1. The Skin, 271 
2. The Subcutaneous Layer, 271 
3. The Aponeurosis, 271 
4. The Muscles, 272 
5. The Arteries, 273 
6. The Veins, 273 
7. The Lymphatics, 274 
8. The Nerves, 274 
9. The Skeleton, 274 
Article III. or the elbow, 275 
Sect. 1. Anterior Region of the Elbow, 
or simply the Fold of the Arm, 
(PI. 6) 275 
constituent parts. 
1. The Skin, 276 
2. The Subcutaneous Layer, 276 
3. The Aponeurosis, 276 
4.1 The Muscles, 278 
5. The Arteries, 282 
6. The Veins, 286 
7. The Lymphatics, 294 
8. The Nerves, 294 
9. The Skeleton, 296 
Sect. 2. Posterior Region of the El- 
bow, or Elbow properly called, 298 
constituent parts. 
1. The Skin, 299 
2. ; The Subcutaneous Layer, 299 
3. The Aponeurosis, 300 
4. The Muscles, 301 
5. The Arteries, 302 
6. ! The Veins, 302 
7. The Lymphatics, 303 
8. The Nerves, 303 
9. The Skeleton, 304 
Article IV.—of the fore-arm, 307 
Sect. 1. Anterior or Palmar Region, 307 
constituent parts. 
1. The Skin, 308 
2. ! The Subcutaneous Layer, 308 
3. The Aponeurosis, 308 
4. The Muscles, 309 
5. The Arteries. 310 
G. The Veins, 313 
7. The Lymphatic**, 315 
8. The Nerves, 315 
9. The Skeleton, 316 
Sect. 2. Posterior Anti-Brachial Re- 
gion, 317 
CONSTITUENT PARTS. 
1. The Skin, 317 
2. The Subcutaneous Layer, 317 
3. The Aponeurosis, 318 
4. The Muscles, 318 
5. The Arteries, 321 
6. The Veins, 321 
7. The Lymphatics, 321 
8. The Nerves, 322 
9. The Skeleton, 322 
Sect. 3. Borders of the Fore-Arm, 326 
Article V. of the wrist. 327 
Sect. 1. Anterior Region, 327 
constituent parts. 
1. The Skin, 328 
2. The Subcutaneous Layer, 328 
3. The Aponeurosis, 329 
4. The Muscles, 330 
5. The Arteries, 332 
6 The Veins, 333 
7. The Lymphatics, 333 
8. The Nerves, 334 
9. The Skeleton, 334 
Sect. 2. Dorsal, <»• Posterior Region of 
the Wrist, 336 
constituent parts. 
1. The Skin, 337 
2- The Subcutaneous Layer, 337 
3- The Aponeurosis, 337 
4. The Muscles, 338 
5. The Arteries, 339 
6. The Veins, 340 
7. The Lymphatics, 340 
8. The Nerves, 340 
9. The Skeleton, 341 
Article VI.—of tiie hand, 345 
Sect. 1. Palmar Region, 345 
CONSTITUENT PARTS. 
1. The Skin, 346 
2. The Superficial Layer, 347 
3. The Aponeurosis, 347 
4. The Muscles, 348 
5. The Arteries, 350 
6. The Veins. 352 CONTENTS. 
XXI 
7. The Lymphatics, 352 
8. The Nerves, 352 
9. The Skeleton, 353 
Sect. 2. Dorsal Region, 354 
CONSTITUENT PARTS. 
1. The Skin, 354 
2. The Subcutaneous Layer, 355 
3. The Aponeurosis, 355 
4. The Tendons and Muscles, 355 
5. The Arteries, 357 
6. The Veins, 357 
7. The Lymphatics, 357 
8. The Nerves, 358 
9. The Skeleton, 358 
Article VII.—of the fingers, 362 
Sect. 1. Palmar Region of the Fin- 
gers, 362 
CONSTITUENT PARTS* 
1. The Skin, 363 
2. The Subcutaneous Layer, 363 
3. The Tendinous Sheaths, 365 
4. The Tendons, 366 
5. The Arteries, 367 
6. The Veins, 368 
7. The Lymphatics, 368 
8. The Nerves, 368 
9. The Skeleton, 369 
Sect. 2. Dorsal Aspect of the Fingers, 370 
CONSTITUENT PARTS. 
1. The Skin, 370 
2. The Subcutaneous Layer, 371 
3. The Aponeurosis, 371 
4. The Tendons, 372 
5. The Arteries, 372 
6. The Veins, 372 
7. The Lymphatics, 373 
8. The Nerves, 373 
9. The Skeleton, 373 
CHAPTER. IV. OF THE CHEST, 377 
Article. I. of the thorax. 378 
Sectm 1. Anterior or Sternal Region. 378 
PARTS. 
1. The Skin, 379 
2. The Subcutaneous Layer, 379 
3. The Aponeurosis, 380 
4. The Muscles, 380 
5. The Arteries, 382 
6. The Veins, 383 
7. The Lymphatics 384 
8. The Nerves, 384 
9 The Skeleton, 385 
Sect. 2. Posterior Region, 391 
CONSTITUENT PARTS. 
1. The Skin, 392 
2. The Subcutaneous Layer, 392 
3. The Aponeurosis, 393 
4. The Muscles, 394 
5. The Arteries, 396 
6. The Veins, 397 
7. The Lymphatics, 397 
8. The Nerves 398 
9. The Skeleton, 398 
Sect. 3. Costal Region, 403 
CONSTITUENT PARTS. 
1. The Skin, 403 
2. The Subcutaneous Layer, 404 
3. The Aponeurosis, 404 
4. The Muscles, 404 
5. The Arteries, 406 
6. The Veins, 408 
7. The Lymphatics, 408 
8. The Nerves, 409 
9. The Skeleton, 409 
Sect. 4. Mammary Region, 414 
CONSTITUENT PARTS. 
1. The Skin, 415 
2. The Subcutaneous Layer, 416 
3. The Arteries, 416 
4. The Veins, 417 
5 The Lymphatics, 418 
6. The Nerves, 418 
7. The Mammary Gland, 418 
8. The Lactiferous Vessels, 420 
Article. I. op the interior of 
THE THORAX, 
420 
Sect. 1 Median Septum, or Medi- 
astinal Region, 
421 
Sect. 2. Pectoral Cavities, 434 
Sect. 3. Base of the Thorax, 440 
Sect. 4. Summit of the Thorax, 442 ERRATA. 
Page 3, line S, for “at its central,” read “in its middle.” 
“ 7, “ 24, for “aponeurosis,” read “aponeuroses.” 
“ 29, “ 8, for “membrani,” read “membrana.” 
“ 37, “ 4, for “the slide,” read “slide.” 
“ 45, last line, for “eye-lids,” read eye-lashes.” 
*• 80, line 23, for “a deep branch,” read “and a deep branch.” 
“ 136, “ 4, for “cornea,” read cornua.” 
“ 202, “ 15, for “porrigo,” read “prurigo.” 
“ 225, “ 4, for “The Subscapularis. The anterior,” read “The Subscapu- 
laris, the anterior.” 
“ 277, lines 6 & 7, for “and where it dips, the deep-seated sheet, is also ap- 
plied to it, down into the external furrow,” read “and 
it is also applied to the deep sheet, where it dips 
down into the external furrow.” 
“ 277, line 38, for “fibrous sheet sheath,” read “fibrous sheet (sheath)." SURGICAL ANATOMY. 
CHAPTER I. 
or THE HEAD. 
The head is composed of the cranium and face. 
Art. I. OP THE CRANIUM. 
This part of the head may be divided into three regions on 
each side of the median line. These regions will be circum- 
scribed by arbitrary lines, drawn from natural prominences, and 
designated by the name of the principal bone corresponding to 
them; as, for example, the frontal, temporo-parietal and occipi- 
tal regions. 
Sect. 1. The Frontal Region. 
It is triangular, and bounded, inferiorly, by a curved line ex- 
tending above the eyebrow from one of the orbital processes of 
the os frontis to the other ; internally, by the median line which 
separates it from its fellow on the opposite side ; and externally, 
by a third line which ascends from the external orbital process, 2 
OF THE HEAD. 
in the course of the fronto-parietal suture, to the origin of the 
sagittal suture. 
The surface of this region presents, inferiorly, a transverse 
furrow of greater or less breadth ; in the middle, a more or less 
prominent bump, constituting the frontal groove and protube- 
rance ; internally, the frontal vein and some one of its branch- 
es ; and superiorly, the hair, which descends more or less in dif- 
ferent individuals. 
COMPONENT PARTS. 
i. The Skin. 
This is thin and smooth in children and young persons of both 
sexes ; in adults, and old people especially, we sometimes ob- 
serve numerous transverse wrinkles in the lower half of this re- 
gion. Upwards and outwrards, where it usually serves for the 
implantation of the hairs, it is thicker and destitute of wrinkles. 
In this last direction it contains many sebaceous follicles. The 
hairs generally pierce the skin obliquely forwards or outwards, 
whence their tendency to follow one or the other of these direc- 
tions in descending upon the forehead. 
li. The Cellulo-adipose Layer. 
Situated between the frontal muscle and skin it is generally 
very thin ; the cellular tissue which composes it is dense and 
compact ; the adipose cells are very minute and in close con- 
tact ; externally, near the temple, they are larger, less intimately 
connected, and sometimes form a layer of considerable thick- 
ness. The intimate union of this layer with the two strata be- 
tween which it is interposed, explains the reason why lesions 
of the skin here are more liable to produce inflammations of the 
erysipelatous character ; for we may readily conceive that it 
w ould be difficult for pus to collect in the form of abscess in a 
tissue so compact. For the same reason also, when purulent or 
sanguineous tumours form in this region, they are always cir- 
cumscribed, globular, or more or less flattened ; finally, it is in OF THE HEAD. 
3 
this stratum that encysted tumours (lupia) or tannes,* which are 
merely the follicles enormously diluted and filled with a concrete 
sebaceous matter are developed : the roots of the hairs are 
likewise situated in it. 
hi. The Muscles and Aponeurosis. 
The muscles are, inferiorly, a very small portion of the or- 
bicularis palpebrarum ; above this, the frontalis, which is thickest 
at its central, and especially its inferior part, where it covers the 
whole breadth of the bone; its fibres are parallel, and, on con- 
tracting, wrinkle the forehead. It seems as if these muscles 
were developed upon the external surface of the epicranial 
aponeurosis, which is thin and cellular beneath them ; superiorly 
and posteriorly, this aponeurosis alone exists, and is there much 
stronger and decidedly fibrous. It is difficult to separate these 
parts from the subcutaneous stratum: to the pericranium, on 
the contrary, they are but loosely connected by a lamellated 
tissue, especially at the outer and inferior part of the region. 
This cellular tissue encloses a great number of adipose vesicles, 
in consequence of which disposition it happens that, when pus 
or other fluids are secreted into the space between these two 
layers, they become extensively diffused instead of forming- 
distinct tumours. It is necessary to be aware of this circum- 
stance, in order to determine the nature and danger of diseases 
situated in the frontal region. 
iv. The Pericranium. 
It presents nothing of importance; we have just noticed its 
relations with the musculo-aponeurotic layer; it is connected 
to the bones by a lamellated rather than a filamentous cellular 
tissue, so that it can be easily separated from the cranium, ex- 
cept at the sutures. 
v. The Arteries. 
These are branches of the supra-orbital, the trunk of which 
* Acne. 4 
OF THE HEAD. 
was at first situated between the orbicularis and frontalis 
muscles; they afterwards creep in the subcutaneous layer. The 
anterior branch of the superficial temporal also runs through 
it, and forms numerous anastomoses with the preceding. The 
tissue which envelopes these vessels is so compact, that it is 
difficult to seize them with an instrument in order to tie them, 
therefore compression is generally preferred to the ligature. If, 
however, in consequence of acute pain or inflammation, we can 
only employ the latter, we will succeed better with a tenaculum 
than the forceps. 
In the pericranium we only find capillary twigs of the deep- 
seated temporals. 
vi. The Veins. 
Near the median line we generally find the frontal vein, which 
is sometimes wanting, and, at other times, as we have seen it 
in two subjects, double or triple; it is often very large, espe- 
cially in old people. The ancients frequently drew blood from 
it in affections of the head, and we think that this bleeding is at 
present too much neglected. This vein, in fact, returns the 
blood from the anterior half of the cranium to the root of the 
nose ; therefore, it is evident, that by opening it we would 
immediately disgorge the vessels of the hairy scalp. This vessel 
is situated between the skin and the cellulo-adipose layer, and 
is not accompanied by any artery; consequently we may easily 
open it without danger of wounding any important organ. The 
other veins accompany the arterial branches and present nothing 
remarkable, unless it is that some of them pass through the 
frontal and fronto-parietal sutures to the longitudinal sinus or 
dura mater. These branches are generally small and destitute 
of valves: hence they might serve for abstracting blood from 
the interior of the cranium, if cupping-glasses, or leeches, were 
applied over the points of skin corresponding to them: it is for 
this reason that Santorini calls them emissary veins. 
vii. The Lymphatic Vessels. 
They are few in number, and but imperfectly known. They OP THE HEAD. 
5 
pass into the glands of the parotideal region, and it is for this 
reason that diseases of the frontal region sometimes occasion 
tumefaction of the lymphatic glands in the vicinity of the ear; 
whether arising from the transmission of irritating fluids ab- 
sorbed at the diseased part, or continuous sympathy, 4*^- 
vni. The Nerves. 
They are derived from the fifth pair. As the internal fron- 
tal comes out from the orbit it is at first situated between the 
pericranium and corrugator supercilii muscle; it afterwards 
perforates the epicranial aponeurosis, in order to ramify in the 
fibres of the frontalis, and, more especially, in the internal half 
of this muscle. The filaments of the superciliary or external 
frontal nerve, on the contrary, are distributed to the aponeurosis 
and even to the pericranium, which gives them a flattened form 
and much firmness. 
These nerves are spread out, for the most part, in the external 
part of the region, and anastomose, near the external orbital 
process, with some filaments of the facial; more posteriorly, 
they unite with the superficial temporal given off by the auricu- 
lar branch of the inferior maxillary. 
The nerves of the ganglionic system are blended with the 
arterial tunics, and are of no importance in surgery. 
ix. The Skeleton* 
It comprises only one of the halves of the os frontis. This 
bone presents: externally, the external orbital process, which, 
on account of its prominence, is very much exposed to fracture : 
from it commences the semi-circular line of the temporal fossa. 
At this point we sometimes find a veinous canal: from which 
circumstance, a perforatiop of the cranium here might occasion 
* The term squelette (skeleton) is made use of by Mr. Velpeau to signify the 
frame work of each particular region, and therefore comprises, in several regions, 
not only the bones, but also the periosteum, ligaments, cartilages, &c. As no 
other word equally comprehensive and appropriate could have been substituted 
for it, it has been retained in the translation, notwithstanding English and Ameri- 
can anatomists limit its application to the frame work of the whole system.— 
Transl. 6 
OF THE IIEA1J. 
a considerable discharge of blood without any injury of the 
vessels of the dura mater. Internally, we observe the nasal pro- 
tuberance, which is more prominent in man, and in old age, than 
in women and children; also, in the latter the forehead is al- 
most fiat, and, generally, the root of the nose appears less de- 
pressed. This protuberance corresponds, anteriorly, to the head 
of the eyebrow; posteriorly, it forms the anterior wall of the 
frontal smus, cavities produced by the separation of the tables 
of the bone, and with which it is of importance to be welt 
acquainted; for the outer table alone may be fractured, and be 
mistaken for a depression of the cranial arch. As these sinuses 
are lined by a prolongation of the internal membrane of the 
nostrils, puriform mucus, &c., may be discharged from the 
nasal cavities externally through an accidental perforation of 
these sinuses, and deceive inattentive persons, inducing them to 
believe that this matter comes from within the cranium.* Such 
a mistake may likewise occur without any external opening of 
the sinus, where the liquid flows into the nose with the charac- 
ters of pus from the cerebral substance. In the first case also, 
the air, by penetrating into the sinus, may communicate to the 
mucous membrane movements analogous to those of the brain, 
and thereby encourage the error.f This membrane, also, from 
its communication with the nasal cavities and its secretion, is 
considered as the cause of fistulse which sometimes occur in 
this place in consequence of wounds or other diseases which 
have perforated the anterior wall of this sinus;—fistulse which 
are difficult to cure, but not incurable, since Professsor Dupuy- 
tren says that he has seen many of them cicatrise. From the 
unequal separation of the walls of the frontal sinus, it follows 
that we ought to avoid, if possible, trephining in this situation, 
because the crown of the instrument might lacerate the mem- 
branes of the brain in some points, before the section of the 
bone is completed. In an extreme case, however, it would be 
possible to remove the portion of bone without injuring the 
membranes, provided we use a trephine with a large crown, for 
sawing through the external table, and a smalller one for the 
internal, as has been advised by Professor Boyer and M. Lisfranc. 
* Marechal. 
f M. Boyer. OF T1IE HEAD. 
7 
The frontal sinuses sometimes extend as far as the external 
orbital process, and even as high as the os parietale, as observed 
by Ruysch, and twice by us;—this we should likewise bear in 
mind when called upon to trephine this bone. This latter dis- 
position would prevent us from estimating the volume of the 
anterior parts of the brain from an external examination of the 
cranium. When pus or other fluids accumulate, or tumours 
form in the frontal sinuses, the posterior wall of these cavities 
being thinner than the anterior, it will yield first and thereby 
give rise to cerebral compression, &c. These cavities are 
wanting in certain individuals, as is said to be the case in the 
(camus) flat-nosed. 
Above the preceding prominences, the os froritis presents a 
depression which corresponds to the cutaneous groove of the fore- 
head ; still higher, the frontal protuberance, which is more or less 
prominent in different subjects, which disposition may be owing 
to a greater degree of convexity of the bone at this part or in- 
creased thickness. In the latter case, after having been very 
prominent, it may become depressed in old age from absorption 
of the diploe. 
In consequence of this structure we cannot penetrate the cra- 
nium by the frontal region without traversing the different layers 
which have just been pointed out, and of which the following is 
the order of superposition: 
1st. The skin; 2d, the cellulo-adipose layer, which is dense 
and encloses the principal vessels; 3d, the muscles and aponeu- 
roses, the internal frontal nerve, and some branches of the super- 
ciliary ; 4th, the pericranium and some filaments of the latter 
nerve ; 5th, the os frontis. 
Sect. 2. Tcmporo-Parietal Region. 
It is of a quadrangular form, and bounded, inferiorly, by a line 
drawn from the external orbital process along the superior bor- 
der of the zygomatic arch, and terminating at the fore part of the 
mastoid process; superiorly, by the analogous region of the op- 
posite side; anteriorly, by the external boundary of the frontal 
region; and, posteriorly, by a line extending from the anterior 8 
OF THE HEAD. 
part of the mastoid process to the junction of the sagittal with 
the lambdoidal suture. 
Upon its surface we observe, between the ear and frontal re- 
gion, above the zygoma, sometimes a convexity, at others a con- 
cavity, according to the embonpoint of the individual and the 
volume of the temporal muscle. Above the temporal fossa we 
find a broad and regularly circumscribed prominence : this is the 
parietal protuberance. 
CONSTITUENT PARTS. 
i. The Skin. 
In the inferior part of the region this membrane is very thin, 
extensible, and but slightly adherent to the subjacent tissues. 
Anterior to the auricle, and in approximating the external orbital 
process, it becomes a little thicker, and is more intimately 
connected with the adipose layer; thus far, it is not generally 
covered with hair. As we trace it backwards and upwards, it 
gradually becomes thicker, and assumes the same characters 
with that of the upper part of the frontal region. The hairs 
which cover it are implanted into it obliquely, so that those in 
the centre descend towards the ear, the anterior to the forehead, 
and the posterior towards the neck. There are a great number 
of follicles at the roots of these hairs, which last turn gray sooner 
in this region than in any other: whence the name “ temporal 
ii. The Ccllulo-adipose Layer. 
It is generally thin, but becomes thicker as it descends: it lies 
upon a stronger layer of a fibro-cellular nature. The three small 
auricular muscles are included between the plates of the latter, 
or rest upon its external surface, and it is thicker behind than 
before. We may consider it as the fascia superficialis of the 
temporal region, and the superficial temporal vessels and nerves 
creep through its tissue. As it passes under the hairy scalp, it 
becomes blended with the dense and compact texture which sep- 
arates the integuments from the epicranial aponeurosis. 9 
OF THE HEAD, 
iii. The Epicranial Aponeurosis. 
Above the temporal fossa it is strong, thick, firm and unyield- 
ing ; its relations with the pericranium and skin are the same as 
in the frontal region; and, consequently, the same surgical re- 
marks are applicable to it. Surgeons formerly supposed that 
this fibrous sheet was possessed of exquisite sensibility, and there- 
fore attributed to it much of the severity of the symptoms which 
attend upon wounds of the head. Be this as it may, its dense 
and compact texture prevents morbid fluids from accumulating 
beneath it in the form of abscesses, hence they promptly dif- 
fuse themselves and produce denudation and even necrosis of 
the bone. When the cellular tissue beneath this becomes in- 
flamed, the resistance which this aponeurosis affords to the subja- 
cent phlegmonous tumefaction, accounts for the acute pains which 
then manifest themselves, and calls for the different incisions 
recommended in such cases. 
Over the temporal fossa the aponeurosis is thinner; upon the 
zygomatic arch it is blended with the fascia superficialis, and 
passes into the parotideal region; it supports the branches of the 
superficial temporal and auricular arteries, &c. Downwards 
and forwards, it is perforated by the superficial temporal nerve 
of the fifth pair, and is, in general, somewhat firmly united to the 
temporal aponeurosis, although inferiorly it is separated from it 
by some adipose cells. About an inch behind the orbit and 
above the zygomatic arch, these two laminae are fixed to the tem- 
poral aponeurosis by a kind of pedicle, in which are one or more 
nervous filaments, and some arterial and venous twigs which 
come from the zygomatic fossa. 
iv. The Temporal Aponeurosis. 
This fascia is of an oval form, and is attached to the w hole of 
the semicircular line of the temporal fossa: from the superior and 
posterior five-sixths of its internal surface muscular fibres originate; 
but the anterior and inferior sixth of its extent is separated from 
the muscle by a soft adipose tissue. Here, this membrane is bifo- 
liate, and its two sheets are continuous with the periosteum 
covering the internal and external surfaces of the zygomatic arch. 10 
OF THE HEAD. 
These two laminae are separated by fat, which gives a promin- 
ence to the temporal region proportionate to its abundance ; on 
the contrary, where this fat is absent there is a correspondent de- 
pression. 
Inflammation is frequently excited in this adipo-cellular tissue, 
and when matter forms in consequence, we must give it an early 
exit, otherwise it will perforate the internal sheet of the aponeu- 
rosis, which is thinner than the external, and make its way into 
the zygomatic fossa. Anteriorly, towards the point where these 
two laminae unite, they are perforated by the pedicle just men- 
tioned, when on the epicranial aponeurosis. 
v. The Muscles. 
The frontalis muscle sometimes advances a little into the supe- 
rior part of this region ; the three auriculares have already been 
noticed ; the temporalis remains to be spoken of. As the fibres 
of this muscle converge towards the central tendon which em- 
braces the coronoid process of the inferior maxillary bone, it is 
generally recommended, when about to apply the trephine, to 
make the incision in the form of the letter V, in order that their 
action may be preserved. This advice cannot be attended with 
danger, but the idea upon which it is founded does not seem to be 
correct; for, whether the fibres are cut transversely or parallel to 
their axis, a similar number, as the flap must be raised, will be 
divided ; and, as we know that fleshy fibres, when once incised, 
always reunite by means of a fibrous cicatrix, the direction of the 
incision can then make but little difference. 
vi. The Arteries. 
We must examine especially the superficial temporal and its 
branches. Its trunk is situated between the epicranial aponeuro- 
ris and superficial fascia, and, as these fibro-cellular laminae are not 
very compact, if the artery was divided, and we wished to tie it 
in the temporal portion of this region, we would not experience 
the same difficulties as in the parietal portion. Above the zygo- 
matic arch, the superficial temporal artery is situated about two 
or three lines anterior to the auricle, at which place it wTould be 11 
OF TIIE HEAD. 
very easy to open, or apply a ligature around it, if considered ne- 
cessary. It is also useful to note this situation in order to avoid 
the application of caustic, moxa, cups, or leeches over this part, 
unless particular indications demand them, and to take all proper 
precautions. Perhaps it would be more prudent to perform arte- 
riotomy a little higher up, because, the cellular tissue being more 
abundant here, inflammation would be more liable to ensue ; com- 
pression would also be less immediate and more painful, on ac- 
count of the aponeurosis being more remote from the bone, and 
finally on account of the proximity of the meatus auditorius ex- 
ternus. 
The anterior branch of the superficial temporal passes to anas- 
tomose with the frontal, and the posterior with branches of the 
occipital; they often interosculate, thereby forming a complete 
net work which is always covered by the fascia superficialis and 
skin. These numerous anastomoses oblige us to tie or compress 
both extremities of the divided artery in order to arrest the 
haemorrhage effectually ; for if we obliterate but one of them, the 
blood will continue to flow from the other. 
We likewise find in this region the middle temporal, which 
comes off- from the trunk of the preceding on a level with the 
zygoma; it immediately perforates the external sheet of the tem- 
poral aponeurosis, in order to ramify in the adipo-cellular tissue 
which separates it from the internal, and afterwards, penetrating 
the latter, enters into the substance of the muscle, where it inos- 
culates with the deep-seated temporals. 
These last, arising from the internal maxillary, distribute their 
principal branches to the temporal muscle and the external sur- 
face of its central tendon ; the others are applied upon the bones, 
where they meet with certain fissures, in which they become im- 
bedded. The inosculations of the deep-seated anterior temporal 
with twigs which come from the orbit, may, in some measure, 
account for the pain which is sometimes experienced in the tem- 
poral fossa in consequence of diseases of the eye, and vice versa. 
vir. The Veins. 
There is at least one for each deep-seated artery. The ante- 12 
or THE HEAH. 
rior branch of the temporal artery has none when the frontal vein 
exists. In this region we lind a very large emissary vein which 
comes out of the cranium through the parietal foramen. We will 
recur to this when we come to speak of the bones, 
viii. The Lymphatics. 
We are a little better acquainted with these vessels than with 
those of the frontal region; they generally accompany the arte- 
rial branches. The superficial set passes into the glands which 
surround the ear, the other to the deep-seated glands of the neck ; 
whence certain authors have supposed that an engorgement of 
the subcutaneous lymphatic glands indicated disease of the skin 
or parts external to the temporal aponeurosis, whilst deeper 
seated affections gave rise to tumefaction of the intermuscular 
cervical glands, 
ix. The Nerves. 
These are very numerous, but of little importance as it re- 
gards operations: some of them are superficial, the others deep- 
seated. The former arc derived, 1st, from the cervical plexus, 
which distributes branches to the skin and subjacent cellular tis- 
sue ; 2d, from the facial, numerous filaments of which accom- 
pany the arteries in the fascia superficialis, and anastomose with 
the supra-orbital in the frontal region; 3d, from the auricular of 
the inferior maxillary: this branch, which is the superficial tem- 
poral, is anterior, and follows the same direction with the fila- 
ments of the facial, with which it freely inosculates. 
The second originate, 1st, from the temporals of the inferior 
maxillary, and the temporal filament of the orbital branch of the 
superior maxillary; 2d, in the parietal portion of the region, 
from the anastomotic branches of the frontal, sub-occipital and 
eub-mastoid. From this simple enumeration, we see that a disease 
of the temple may give rise to pain in all parts of the head, and be 
repeated in the orbit, jaws, face, ears, neck, etc., and vice versa. 
As to the nerves from the great sympathetic, they can only be 
traced upon the arteries, and their study is of no surgical im- 
portance. OF THE HEAP. 
13 
x. The Skeleton. 
We find in this region the whole of the squamous portion of 
the temporal bone, the temporal part of the great ala of the 
sphenoid, a very small portion of the os frontis, and almost the 
whole of the parietal. Sometimes the squamous portion of the 
bone is convex instead of being plane or concave; whence a 
greater prominence of the temple. At the junction of the sphe- 
noid with the frontal, parietal, and temporal bones, we find the 
greatest depth of the temporal fossa. It is on account of the 
sutures which result from the junction of these different bones, 
and especially because the Arteria Meningea Media runs through 
a groove in the internal surface of the anterior and inferior parie- 
tal angle, that we are forbidden to apply the trephine at this part. 
It is true that the cases which would require a perforation of the 
cranium here must be very rare, because in this situation the 
meninges are firmly adherent to the bones: it is also true that 
the operation would be rendered difficult by the inequality of 
the surfaces and the thickness of the soft parts; but if the indi- 
cation is positive, the situation of the artery should not deter us; 
for even if the artery should be wounded by the instrument, it 
would be very easy to compress it. The tenuity of the os tem- 
poris in this region, sufficiently explains the frequency of its frac- 
tures. We should bear in mind the situation and appearance of 
the squamous and other sutures, in order that we may avoid mis- 
taking them for fissures, an error committed and pointed out by 
Hippocrates, and not unfrequently since his time. This remark 
is applicable to all points of the cranium. 
The arched form of the parietal bone is the most variable as 
well as most remarkable appearance of the skeleton of the tern- 
poro-parietal region. Sometimes the parietal protuberance 
scarcely exists, whilst at others it is very prominent. In some 
subjects it is larger on one side than the other; hence a want of 
symmetry in the cranium. This irregular conformation is not 
infrequent, and is even present in men of the greatest talent, of 
which the celebrated Bichat and the learned Beclard have afforded 
examples. The bone is sometimes very thick at this point; so that 
the parietal projection docs not always indicate an increased 14 
OF THE HEAO 
capacity of the cranium. Here, senile atrophy most frequently 
manifests itself, and then, instead of a bump, we find an excava- 
tion. The parietal bone has sometimes acquired the hardness of 
ivory.* 
The superficial situation of this bone subjects it to numerous 
diseases; nevertheless, its arched form renders it less liable to 
fractures from a direct cause, than it would otherwise be. In 
relation to the application of the trephine, we must recollect that 
the greatest thickness of the parietal bone corresponds to its 
protuberance ; next, to the posterior and superior angle ; then, to 
the inferior and posterior; after which comes the superior and 
anterior; and finally, the inferior and anterior angle, which is the 
thinnest. Between the parietal bump and sagittal suture, there 
are one or more foramina, situated nearer the posterior than the 
anterior part. These foramina communicate with the venous 
canals of the diploe, or with the sinuses of the dura mater, and 
give passage to emissaiy veins of considerable volume, which we 
have before referred to. It is by these veins that we are recom- 
mended to disgorge directly the sinuses, meninges, and brain, by 
applying leeches, etc., over the points corresponding to these 
vessels.* 
The order of superposition in the temporal portion of this 
region is as follows: 1st, the skin; 2d, the cellulo-adipose layer; 
3d, the fascia-superficialis, beneath which are the superficial ves- 
sels and nerves ; 4th, the epicranial aponeurosis, separated from 
the preceding by nerves and vessels; 5th, the temporal aponeu- 
rosis ; 6th, the temporal muscle; 7th, the pericranium; 8th, the 
bones. 
In the parietal portion we only find, 1st, the skin; 2d, the 
fibro-adipose layer, which encloses the nerves and vessels; 3d, the 
epicranial aponeurosis; 4th, the pericranium ; and 5th, the bones. 
Sect. 3. Occipital Region. 
Its figure resembles that of the frontal region: that is to say, 
supposing it to be flattened out, it is triangular. Its boundaries 
are, anteriorly, the preceding region ; upon the median line, its 
* 3\I. Portal. OF THE HEAD. 
15 
fellow of the opposite side ; inferiorly, a line extending from the 
apex of the mastoid process to the occipital protuberance. 
CONSTITUENT PARTS. 
i. The Skin. 
Upon the mastoid process, this membrane is thin, smooth, 
shining, destitute of hairs, and participates in all the characters 
of that which covers the auricle; as it ascends, it becomes con- 
siderably thicker and very dense. At the summit of the region, 
the hairs pierce it almost perpendicularly; as they descend, more 
and more obliquely, and persist for a greater length of time in 
this than in the other regions. 
ii. The Celhdo-adipose Layer. 
Behind the ear, it is altogether cellular; throughout the rest of 
its extent we meet with minute adipose vesicles, which are enclos- 
ed in very compact fibro-cellular loculi, as in the frontal and pari- 
etal regions. Upon the occipital bone this layer is intimately 
adherent to the skin, for which reason wounds occurring here 
with loss of substance cannot be approximated ; neither by sut- 
ures, which would be dangerous, nor by bandages, which would 
be ineffectual. Upon the os temporis, as the adherence is slight, 
wounds may be immediately united. This layer encloses all the 
principal vessels and nerves; its union with the subjacent layer 
is not less intimate than with the skin ; it is this compact union 
which renders the dissection of the occipito frontalis muscle and 
the epicranial aponeurosis so difficult; and it is also for this rea- 
son that the skin which extends from the forehead to the occiput, 
follows all the movements produced by the contractions of this 
muscle. 
in. The Aponeurosis and Muscles. 
The former is very strong; its fibres are very distinct in this 
region, and in some subjects it puts on a shining and pearly ap- 
pearance. The latter are ;—the posterior auricular, which at- 16 
OF THE HEAD 
taches (he auricle to the mastoid process; then the occipital 
which covers only the two external thirds of the bone, so that 
above the occipital protuberance the aponeurosis alone is situated 
between the pericranium and subcutaneous layer. These parts 
are separated from the pericranium by a dense, but not very com- 
pact, lamellated cellular tissue. The superior extremities of the 
sterno-mastoid and splenius capitis muscles, although not specially 
appertaining to this region, must nevertheless be noticed, because 
their attachments near the mastoid process and insertion into its 
apex, expose them to injury when operations are performed at 
this part; as for example in perforating the cells of the mastoid . 
iv. The Pericranium. 
It presents nothing peculiar here, unless it is that it adheres 
more firmly to the bones, on account of the roughness of their 
surface. 
v. The Arteries. 
The most important are the occipital and posterior auricular, 
The former enters this region as it passes from between the sple- 
nius and trapezius muscles, and then goes to inosculate with the 
posterior branch of the temporal; it is enveloped in the subcuta- 
neous layer, and is very difficult to secure by ligature. The sec- 
ond slides along the mastoido-auricular furrow, enters the posterior 
auricular muscle and the deep fibrous tissue, gets above the mas- 
toid process and anastomoses with the preceding. It follows, 
from this distribution of these arteries, that wounds, or incisions 
made in the internal and superior third of this region, will not be 
attended with hoemorrhage; the same applies to the mastoidien 
eminence, unless the division is made very near to the ear. 
We should likewise notice the small branch of the occipital 
artery, which passes to the dura mater through the foramen inas- 
toideum posterius. 
vl. The Veins. 
There is at least one, and often two, for each artery; they fol- 
low exactly the same course, and empty their blood into the jugu- OF THE IIEA.D 
17 
lars. Besides these, we find numerous emissary veins coming out 
at the lambdoidal, mastoido-parietal and mastoido-occipital su- 
tures, and especially one of very large size, which comes through 
the mastoid foramen. This last frequently communicates with 
the venous canals of the diploe, and always with the lateral si- 
nus : on this account, we are advised to apply leeches, cupping- 
glasses, etc. over it, in order to remove congestion of the meninges 
promptly. 
vn. The Lymphatics. 
The superficial pass to the posterior glands of the ear; the 
deep-seated under the sterno-mastoid muscle. 
viii. The Nerves. 
These are numerous, and originate, 1st, from the posterior 
auricular branch given off by the facial, as it emerges from the 
stylo-mastoid foramen ; this nerve generally divides in like man- 
ner with the artery of the same name; 2d, from the sub-mastoid 
branch of the cervical plexus ; this branch ramifies in the subcu- 
taneous tissue, and is distributed principally to the skin ; it anasto- 
moses with the anterior auricular of the same plexus, with fila- 
ments from the internal frontal and sub-occipital; 3d, we find some 
twigs from the first cervical pair, and the posterior branch of the 
sub-occipital. The latter accompany the vessels, and ramify in 
the occipital muscle, aponeurosis and pericranium, and inosculate 
with the preceding, but especially with the frontal. From this 
abundant supply of nerves, and the density of the cellular tissue 
in which they creep, we may explain the symptoms which ac- 
company inflammations of this part of the head, and those which 
follow operations performed upon it. Their anastomoses will 
also teach us why neuralgia of a certain point of the cranium is 
not always removed by the section of the principal nerve distrib- 
uted to it; and they further account for the rapidity with which 
pain and inflammation spread from the occipital region to all the 
other parts of the head and neck. It may be well to note, how- 
ever, that the return of pain, after a nervous branch has been di- 18 
or THE HEAD. 
vided, may be owing to the possible re-union of its divided ex- 
tremities, as well as to anastainosis. 
The ganglionic system does not furnish any distinct branch 
to this region ; all the filaments which come from it are imbed; 
ded in the arterial tunics. 
ix. The Skeleton. 
It consists of the mastoid portion of the temporal bone, the in- 
ferior angle of the parietal, a portion of the occipital, and the su- 
tures which unite these osseous pieces. 
Each of these portions of bone present certain peculiarities 
worthy of notice. Thus the ossa wormiens, which frequently 
occur in the lambdoidal suture, may be mistaken for fractures; 
as also the anormal suture which separates into two the cpactal 
and proved portions of the os occipitis, upon the median line. The 
existence of this separation in the adult likewise renders the 
longitudinal sinus more liable to rupture. 
The portion of the os occipitis appertaining to this region, 
corresponds to the posterior lobe of the cerebrum. If it is true, 
therefore, as M. Gall supposes, that the organ of maternal love 
resides in this portion of the brain, we will readily conceive whyr 
this part of the cranium is more prominent in the female than the 
male, and why wounds or fractures here have sometimes been fol- 
lowed by a decided change in this faculty. Further, the application 
of the trephine should always be made in preference upon the 
middle of the lateral prominence of the occiput, because there the 
bone is very thin, whereas in the surrounding parts it is much 
thicker. The presence of the occipito-parietal suture externally, 
of the longitudinal sinus internally, and of the lateral sinus infe- 
riorly, opposite to the superior curved line, is an additional reason 
in favour of this precept. Neither should we trephine upon the 
posterior and inferior angle of the parietal bone, because it cor- 
responds to the place where the lateral sinus turns behind the 
petrous portion of the os temporis. It is at the junction of this 
angle with the other bones that we find a fontanelle in the foetus, 
which may remain during childhood. Herniae of the cerebellum 
have protruded at this part, and we can conceive the possibility 
of them : those of the cerebrum may also occur here. 
The mastoidien portion of the temporal bone likewise deserves OF THE HEAD. 
19 
very particular attention. In the first place, we should distinguish 
from the mastoid process, properly so called, the posterior and 
superior part of the bone, which is thin, and corresponds to the 
lateral gutter. This mammoid eminence is subject to numerous 
varieties, with which it is useful to be acquainted. It is much 
less prominent in the infant than the adult, in the female than the 
male, and more so in old men; its developement almost always 
depends upon the cells which it encloses, and through which it 
communicates with the cavity of the tympanum ; for which reason 
the mastoid process has been perforated in order to give exit to 
pus, or other fluids extravasated in this cavity, as well as to admit 
of the entrance of air into it. We must recollect, however, that 
this operation is not admissible in children, in whom the mastoid 
cells are not developed ; that sometimes the paries of the mastoid 
cavity is very thick, and formed of two compact laminae with an 
intermediate diploe, which would prevent our arriving at the celts 
readily; that, in other cases, this wall is as hard as ivory; and 
finally, that instances have occurred in which the cells were small, 
compact and having no communication with the ear. In cases 
where the mastoid cells are very large and their parietes thin, we 
should not forget that they may be fractured independent of the 
cranial table. 
In fine, it is evident that the mastoidien portion of the occipital 
region deserves the greatest attention, on account of the numerous 
diseases to which it is subject. Indeed, nature herself sometimes 
accomplishes the perforation of the bone in order to give issue to 
pus accumulated within the ear, and caries and necrosis of this 
process is no unfrequent occurrence. The structure and arrange- 
ment of the tissues render inflammations in this situation danger- 
ous. This region is sometimes the seat of tumours arising either 
from tumefaction of the lymphatic glands which appertain to it, 
or morbid changes of some other nature ; finally it is at this point 
we apply leeches, cupping glasses, the moxa blisters, etc., for a 
great variety of diseases. 
In proceeding from the surface towards the bones we find the 
parts in the following order of superposition: 1st. the skin; 2d. 
the cellulo-adipose layer, enclosing the nerves and principal ves- 
sels ; 3d. the epicranial aponeurosis and muscles: 4th. the peri- 
cranium ; 5th. the skeleton. 20 
or 'inn iieau 
Sect. 4. The Cranium in General. 
There are some remarks applicable to all the regions before 
treated of, into the detail of which we must now enter. 
1st. The density of the skin, the hairs and the numerous follicles 
which surround their roots, appear to be the principal reasons for 
the peculiar character which the different species of Tinea? as- 
sume. 
2d. It is on account of the slight extensibility of the skin that 
tumours developed between the aponeurosis and integuments are 
always more or less flattened in their commencement. 
3d. From the great thickness of the skin, and its intimate 
adhesion to the subjacent tissues, it follows that, after contusions, 
when the extravasated matters become fluid, wrefeela depression 
in the centre of the swelling. This depression is sometimes so 
striking that it has deceived skilful surgeons, who have mistaken 
it for a disease of the bone, and even for a fracture.* 
4th. The compact texture of all the parts covering the bones 
of the cranium sufficiently explains why its inflammations almost 
always assume the erysipelatous form; why its ulcers are of 
difficult cure; why wounds of the scalp, with the least loss of 
substance, are seldom susceptible of immediate reunion; and final- 
ly, when these wounds suppurate, why the pericranium becomes 
detached, and permits the matter to penetrate between it and the 
bones, thus giving rise to necrosis, etc. 
5th. The tenuity of the bones in a great number of places, and 
the frequent vascular communications between the external and 
internal parts of the cranium, account for the severity of most of 
their external diseases, by the facility with which they are trans- 
mitted to the interior. 
6th. There are a great number of points upon the cranium 
where surgeons are forbidden to apply the trephine, many of 
which have been already noticed ; but it remains to speak of the 
sutures in general. 
We do not trephine over their track; 1st. because it is diffi- 
cult to separate the soft parts from them ; 2d. because they ad- 
here firmly to the dura mater; 3d. because they generally trans- 
* See J. L. Petit. OP THE HEAD, 
21 
mit emissary veins of considerable volume; 4th. because their 
seme are unequal and converted into ossa wormiens; 5th. be- 
cause the most remarkable of them correspond to large sinuses. 
But the experience of Garengeot, Sharp, Marchettis, Warner, 
Pott, &c. shews us that this last motive should not deter us when 
the indications are positive. 
It is evident that the most of these anatomical particulars must 
render this operation very rare, if we expect to derive benefit 
from it by trephining over these points. However, in conse- 
quence of the adhesion of the dura mater to the sutures it is diffi- 
cult for fluids to become extravasated beneath them ; but if this 
extravasation has already taken place, the dura mater is then de- 
tached, and then it occasions no particular impediment. It is only 
in those cases where the extravasation exists between the meninges 
that this separation is not effected, but under such circumstances 
it is never indispensible to trephine over the sutures. 
7th. Although the osseous box of the cranium encloses the most 
delicate organ of the economy, it has been destroyed in a great 
number of points, either by repeated trepanations* or by dis- 
eases,f without death being the necessary consequence. 
8th. The fontanelles must also be noticed. Those which are 
seen at the inferior part of the temporo-parietal regions, generally 
disappear early in the foetus: they afford no assistance during 
parturition ; but, as wre have already stated, hernia cerebri may 
protrude through these membranous spaces. Criminals have 
sometimes introduced needles, and other instruments, through 
these spaces, into the skulls of young children, in order to destroy 
them. 
The anterior is the largest, and most constant; it is rhomboi- 
dal, and the four sutures which run into it cross each other at right 
angles, which distinguishes it from the occipital fontanelle, of 
which we shall speak presently. The frontal fontanelle being 
better known than the others, it has been supposed that pins, and 
other slender foreign bodies, found by some surgeons within the 
cranial cavity, without any trace of external aperture, have been 
introduced into it at this part.J It has been found open in a 
* Quesnoy, Petit, f Lachariere, Prof. Richerand, M. Paillard. 
I Valentin, Voyage en Italie, etc., Manne, Bulletin de la Soc'ield mddicale d'Emula- 
tion. Mai 1810. 22 
OF THE HEAD. 
young man of twenty,* and in another of thirty years of 
age.f The continuance of this deficiency exposes the subject 
of it to encephalocele, and it is for the purpose of preventing such 
an occurrence, as well as injury from external agents, that quilted 
caps of various constructions have been recommended. 
The posterior fontanelle is frequently closed at birth, notwith- 
standing it is of greater importance, as it regards paturition, than 
the preceding, since it is uniformly found in the centre of the part 
which generally presents: we distinguish it by its being of 
smaller size, its triangular form, and especially by the three 
branches of sutures which converge towards it. The direction 
of these lines is, in fact, the sole index upon which we can de- 
pend in order to ascertain when the angle of the occipital bone is 
not ossified, or when the sagittal suture is prolonged towards the 
foramen magnum, dividing this bone into two symmetrical por- 
tions. 
9th. From the manner in which the different bones of the cra- 
nium are arranged, an ovate or spheroidal box is formed, which 
resists external violence after the manner of arches, according to 
Bertin, and of spheres, according to Beclard. 
Art. II.—of tiie face. 
We may divide this part of the head into parotideal, nasal, or- 
bital, zygomato-maxillaty, masseterine, genian, mental, labial, 
olfactive, buccal and pharyngeal regions. 
Sect. 1.—Parotideal Region. 
As this region does not appertain, properly speaking, either to 
the cranium or neck, we have preferred connecting it with the 
face. 
Its form is pyramidal, the base of the pyramid corresponding 
with the skin, its apex to the pharynx. It is bounded, superiorly, 
by the temporal region ; posteriorly, by the anterior margin of the 
sterno-mastoid muscle ; anteriorly, by the posterior border of the 
inferior maxillary bone, and inferiorly by a line drawn from the 
angle of the jaw across the sterno-mastoid muscle. 
* Bauhin. i Bartholinc. OF THE HEAD. 
23 
Its surface presents a gutter which is deeper in the aged, in 
men, adults, and those of a spare habit, than in children, women 
and those who are corpulent. This gutter is continued down- 
wards into the supra-hyoideal region; upwards, to the lobe of 
the ear; afterwards, in passing between the auricle and mastoid 
process, it forms only a simple furrow which was spoken of when 
on the occipital region: this is the mastoido-auricular furrow. 
We feel, in the parotideal region, quite near the anterior aspect 
of the tragus, a small prominence which is carried forwards when 
we depress the jaw ; this is the maxillary condyle. When the 
mouth is shut, there exists between this prominence and the mas- 
seter, in emaciated persons who have not a very large parotid, a 
slight excavation. This depression corresponds to the posterior 
part of the sigmoid notch of the jaw, and at this part we might 
easily introduce a pointed instrument into the zygomatic fossa. 
From this superficial situation of the condyle, its fractures may be 
easily detected, by pressing the finger upon it, and at the same 
time depressing the jaw. 
CONSTITUENT PARTS. 
i. The Skin. 
This membrane is delicate, supple, and destitute of hairs ; it 
contains numerous sebaceous follicles, and may be easily raised by 
tumours forming beneath it, without yielding however to any 
yery considerable distension. 
ii. The Subcutaneous Laijer. 
It is composed of a few fibres of the platysma, and a pretty 
dense cellular layer, the characters of which will be more partic- 
ularly investigated, when we speak of the masseterine region. 
In the superior part of this region we have in the first place the 
ear, which requires a distinct examination. This delicate organ 
is susceptible of surgical considerations in its external and middle 
portions only, we will therefore speak but little of the internal 
ear. 24 
OF THE HEAD. 
hi. The External Ear. 
It is divided into the Auricle and Meatus Auditorius Externus. 
The Auricle commences at the concha, is of an oval form, 
its largest extremity being placed upwards, and so situated that its 
superior half rests upon the temporal region, that its posterior part 
conceals the mastoid process, and that its anterior and inferior 
portion alone is placed in the parotideal region. It is composed, 
1st, of a very delicate and thin skin, which slides easily over the 
subjacent tissues ; this skin is smooth throughout, excepting within 
the tragus and antitragus, where a few hairs are generally observ- 
ed ; it encloses numerous follicles, in which the sebaceous matter 
sometimes accumulates and concretes, forming small encysted 
tumours (loupes) known by the name of tannes (acne punctata). 
Where the auricle attaches itself to the temple by means of the 
helix, and upon the face by means of the lobe, it forms two dis- 
tinct folds. 2d. Of a cellulo-fibrous layer, very dense, but lam- 
ellated, separated from the cutaneous envelope by a more supple 
cellular tissue, in which adipose vesicles are never met with. 
When small purulent abscesses form in this last layer, they excite 
but little pain, but sometimes burrow with great rapidity under 
the skin, giving rise to intractable sinuous ulcers. When, on the 
contrary, these abscesses are developed in the former tissue, they 
occasion very acute pain and sometimes very formidable symp- 
toms : 3d, of the five small muscles of the auricle ; viz.: the he- 
licis major and minor, the tragicus, antitragicus, and transversus 
auriculae : 4th, of arteries, which are, the posterior auricular, de- 
rived from the external carotid, and the anterior auriculares, from 
the superficial temporal: 5th, of veins which accompany the ar- 
teries : 6th, of lymphatic vessels which are rather supposed to 
exist in it; their injection being rendered so difficult by the close- 
ness of the cellular tissue in which they are enveloped, that they 
have not as yet been discovered but by very few anatomists. 
These lymphatics, according to Mascagni and Cruikshank, pass 
to the parotideal absorbent glands, and the tumefaction which 
these glands undergo in consequence of certain diseases of the 
external ear, seems to support this opinion: 7th, of numerous 
nerves, which are, in the first place, anteriorly, the superficial 
temporal, originating from the inferior maxillary; the auricular OF TUB HEAD, 
25 
branch of the cervical plexus ; next, posteriorly, the mastoid 
branch from the facial, which we have already seen in the occi- 
pital region, and lastly, the sub-mastoid branch from the cervical 
plexus. This ample supply of nerves accounts for the acute sen- 
sibility of the external ear, and the symptoms which its inflamma- 
tions usually excite in it: 8th, of a cartilage, which is enveloped 
in a very dense species of perichondrium, so much so that Bichat 
has classed this substance amoncj the fibro-cartilages. It consti- 
tutes the solid parts of the auricle, and determines its form, emi- 
nences, depressions, etc. It is very flexible, which defends it 
from being fractured, unless it has become ossified by age, which 
is a very rare occurrence. 
Although the lobe contains almost all the elements which have 
just been passed in review, yet these diverse tissues present certain 
differences worthy of notice. Thus, the skin is equally delicate, 
but more freely supplied with venous capillaries ; hence the livid 
colour it assumes on exposure to cold, or when respiration and 
circulation are impeded. Its cellular tissue contains very small 
adipose vesicles, and these different parts are so much confounded 
with the vessels, nerves, and skin, that the lobe seems to form a 
homogeneous mass, rather than a complex organ. As this part of 
the auricle possesses but little sensible tissue, its perforation is 
scarcely painful. 
The meatus auditorius externus is about an inch in length, and 
its direction obliquely inwards, downwards and forwards ; when 
cut across, its figure is elliptical, its perpendicular diameter being 
greater than its antero-posterior. It is so situated, that it touches 
the maxillary condyle anteriorly, whereby, when the jaw is de- 
pressed, this canal is dilated. It is for this reason, says M. Riche- 
rand, that we instinctively open the mouth the better to distinguish 
sounds which we are anxious to hear. Posteriorly, it lies upon 
the mastoid process, and superiorly, it is circumscribed by the 
superior branch of the horizontal root of the zygomatic process. 
From what has just been said, it follows that in the two last 
directions, the meatus auditorius externus is securely protected by 
the bones; whilst inferiorly, it is almost uncovered. The dispo- 
sition of this canal is such, that forwards and downwards its par- 
ietes are concave, and two lines longer than upwards and back- 
wards, where they are convex. This difference in length is 26 
OF THE HEAD. 
produced by the membrana tympani, which is inclined obliquely 
inwards and forwards. From these data, the principle of passing 
instruments along the inferior paries of the canal, when wTe wish 
to extract foreign bodies from the ear, is derived. This canal is 
hollowed out in the os temporis, where it receives a prolongation 
of the auricle ; but the elements of this auricle here present some 
peculiarities which should be mentioned. In the first place, the 
skin gradually loses its characters, so that as it approximates the 
membrana tympani, the epidermis alone remains, which termi- 
nates in a cul-de-sac upon this membrane; next the follicles are 
numerous, and secrete the cerumen, which sometimes accumulates 
and hardens, producing deafness, especially in the aged ; and 
finally a considerable number of hairs are implanted into it, which 
seem destined to catch minute particles of dust, etc., propelled by 
the air towards the tympanum. 
The cartilage of the meatus is, as it were, incised from 
space to space by what are called the incisures of Santorini, 
and these fissures permit purulent matter, formed in the vicinity, 
to make its way into the auditory canal. One of these fissures 
is met with in the superior and posterior part, quite near the 
anti-tragus; another, which is more distinct, upwards and for- 
wards, between the helix and tragus. The fibrous tissue, which 
alone fills these fissures, may be destroyed by the pus of su- 
perficial abscesses; and hence be discharged through the meatus. 
We have but recently met with a case of this kind: on the 22d 
of March, 1825, Mr. G who had laboured under a pustular 
inflammation of the intestines during twenty-five days, was 
attacked with parotitis, and six days afterwards, the matter made 
its way into the ear through the last mentioned fissure. Besides 
the arteries already mentioned when on the auricle, the meatus 
auditorius receives branches from the stylo-mastoidea (auricula- 
ris 'posterior) and from the temporalis profunda posterior. The 
veins are of no importance in a surgical point of view. The 
same may be said of the nerves: we sometimes find here, 
however, a filament from the great sympathetic, running to 
anastomose with the facial. 
iv. The Middle Ear or Tympanum 
The cavity of the tympanum may be considered as a dilata- OF THE HEAD, 
27 
lion of the preceding canal, from which it is separated only bv 
a thin and fragile membrane. Below this box we find the 
glenoid cavity: anteriorly and a little more internally it corres- 
ponds to the carotic canal; which may, in some measure, ac- 
count for the buzzing in the ears which patients with aneurism 
of the internal carotid sometimes experience. From its relations 
with the fissure of Glaser, blood, pus, &c., may penetrate from 
the cavity of the tympanum into the temporo-maxillary articu- 
lation. 
The mastoid process and cells are situated posterior and 
external to the tympanum, and as the cells are separated from 
this cavity only by the mucous membrane of the latter, we 
conceive that abscesses of the ear may be evacuated through a 
perforation made in this process. The superior wall of the 
middle ear is thin, and corresponds to the anterior aspect of 
the petrous portion of the os temporis. Vascular porosities are 
observed in it, which form a communication between the dura 
mater and the mucous membrane of the tympanum. We also 
see here, in the child, and sometimes in the adult, a trace of 
suture which transmits cellulous processes and emissary veins: 
this disposition accounts for inflammation of the meninges arising 
from acute otitis, discharges of blood from the ears after blows 
or falls upon the head, and tinnitus aurium in diseases of the 
brain, &c. 
The external paries of the cavity is formed by the membrana 
tympani, a species of horny lamina, covered externally by the 
cuticle of the meatus and, internally, by the mucous lining of the 
tympanum. According to Rivinus, Scarpa, Witteman, Vest, 
&c., it is naturally perforated; but this perforation is probably 
only an anomaly or an accidental occurrence. Be this as it 
may, when this state exists, we can readily comprehend how 
gaseous or other fluids, such as tobacco-smoke, air, blood, &c. 
may be propelled from the mouth through the ear. In general 
this does not impair the hearing, unless accompanied with a disea- 
sed state of this organ. The manubrium of the malleus is fixed 
between the laminae of the membrana tympani, a little below 
and before its centre ; and it is for this reason that the operation 
recently advised by Portal, Cooper, &c., for the cure of certain 
forms of deafness should be performed low down and upon the 28 
Ol THE HEAD. 
anterior half of this membrane. This remark is equally applica- 
ble to any other perforations of the membrana tympani which 
diseases of the ear may require. We should always be careful, 
in performing these operations, not to introduce the instrument 
too far, lest we wound the chorda tympani, which comes from 
the posterior paries of the cavity in order to pass out at the 
glenoid fissure. The opening of the Eustachian tube is at the 
inner and fore part of this cavity. This canal, which is of great 
importance in surgical practice, on account of the frequency of 
its diseases and the operations which they require, runs obliquely 
forwards and inwards, between the petrous and squamous por- 
tions of the temporal bone, towards the top of the pharynx, 
where it terminates behind the opening of the nasal fossae. Its 
dimensions generally increase as it passes from the tympanum 
towards the pharynx, which renders easy the introduction of a 
probe from the nostrils; but we will have occasion to speak of 
this again. 
The internal membrane of the middle ear is a prolongation of 
that of the pharynx; it is thin, but very distinct in some persons, 
especially towards the mastoid cells. It envelopes the whole 
chain of bones, but does not penetrate into the labyrinth, on 
account of the horny plates which close the fenestra: rotunda et 
ovalis ; and its nature renders it susceptible to the same diseases 
with the mucous membrane of the pharynx. The cellular tissue 
which connects it to the bones is very compact; we may con- 
sider it as a species of internal periosteum, and from its density 
we may comprehend why inflammations of the ear arc so pain- 
ful. The membrane which lines the cavity of the tympanum 
receives its arteries from the stylo-mastoidea. The internal car- 
otid gives off some twigs to the soft parts of this cavity which 
pass through a small distinct foramen; finally, it receives some 
from the meningea media, by the canal which lodges the tensor 
tympani, and from the maxillaria interna by the fissure of Glaser. 
The veins follow exactly the course of the arteries, and afford 
no interest here. W e have already mentioned what we had to 
say respecting them when treating of the emissary veins of the 
superior paries ; like all other emissary veins they are destitute 
of valves, and empty their blood into the dura-matral sinuses. 
The lymphatic vessels have never been injected. OF THE HEAD. 
29 
The nerves of the middle ear appertain to the facial, the 
carotic plexus and the spheno-palatine ganglion; from which 
result complicated anastomoses, which may explain why diseases 
of the internal ear excite such a variety of sympathetic affections. 
We have already spoken of the chorda tympani which comes 
from the vidian nerve.* If we consider that this chord, in cros- 
sing the tympanum, passes above the malleus, it will afford us an 
additional reason for perforating the membrani tympani at its 
inferior part. 
The internal ear having no relation with surgery, we do not 
consider it our duty to speak of it. 
V. The Parotid. 
Next to the ear we find the gland from which the parotideal 
region derive its name. This organ covers, anteriorly, the pos- 
terior margin of the jaw, and is prolonged more or less upon its 
external surface. Between this bone and the gland, we find, from 
above downwards, the superficial temporal artery and vein ; then 
the facial nerve, which crosses the vessels opposite the neck of 
the condyle, imbedded in the deep granules of the gland; next 
the facial or transverse facial arteries; several veins of consider- 
able volume, which ramify in the secretory tissue; finally the 
cervico-facial branch of the respiratory nerve of the face, (portio 
dura) the termination of the stylo-maxillary ligament, and the 
masseter. 
Posteriorly, the parotid gland is somewhat firmly fixed, from 
above downwards, and from before backwards,—first, to the 
auditory canal, then to the fore part of the mastoid process and 
the anterior edge of the sterno-mastoid muscle ; between the ear 
and the mammoid process it covers the posterior auricular artery; 
upon the apex of this apophysis, and externally, it lies upon an- 
other artery, which is sometimes larger than the preceding. 
Internally or deeply, it rests upon the trunk of the facial nerve 
and the three filaments which are detached from it at its exit 
from the stylo-mastoid foramen; then upon the styloid process 
and the musculo-fibrous bundle arising from it; upon the digas- 
tric muscle, then, a little farther forwards, upon the styloidien ar- 
* M. H. Cloquet. 30 
OF THE HEAD. 
tery, upon many anonymous twigs which penetrate the glandular 
lo'bules, and are lost in their substance ; upon the trunk even of 
the external carotid, behind which the gland sends a process 
which sometimes dips very deep, and is applied upon the glosso- 
pharyngeal nerve, the internal jugular, and internal carotid. It 
is this last lobule which presented so many difficulties to Prof. 
Beclard when he extirpated the parotid in 1823. In this situa- 
tion, the gland and the arteries are so intimately connected, that 
it is almost impossible to remove the one without wounding the 
others. The occipital and inferior pharyngeal arteries are like- 
wise covered by the parotid, which, on the other hand, is finally 
prolonged between the pterygoid muscles and the styloid process 
as far as the pharynx, passing between the external carotid and 
the stylo-maxillary ligament. In the latter direction, this gland 
is continuous with the submaxillary. 
These are the complicated, numerous, and important relations, 
which render the total extirpation of the parotid so dangerous 
and almost impossible; and hence we are induced to affirm, that 
this gland was never completely extirpated, previous to the ope- 
ration by Beclard.* 
It is evident that this operation cannot be terminated without 
applying a ligature to the external carotid ; the facial nerve would 
necessarily be removed ; in seeking for the deep prolongation of 
the gland, there would be the greatest danger of wounding the 
internal carotid artery ; so with the internal jugular, the occipital, 
superficial temporal, and internal maxillary arteries. It is possi- 
ble, however, that these last organs might be avoided if the parts 
remained in their natural relations. But what disease of the par- 
otid is there, sufficiently severe to demand its extirpation, which 
will not derange the relative position of these organs ? All the 
lobules of the gland are separately enveloped in a small cellular 
sac of considerable density; and are united together by a fila- 
mentous tissue of still greater density. It is in this tissue that 
critical inflammations of the parotid appear to have their seat, 
whilst the mumps affect more particularly the glandular element. 
The entire gland is afterwards enclosed in a species of fibrous 
envelope, the external and firmest lamina of which is derived 
* Archives generates de Mddecine. Janvier, 1324. Observation de M. Beclard, 
par M. Berard. OF THE HEAD. 
31 
from tiie aponeurosis which covers the sterno-mastoid and tem- 
poral muscles, and is continued over the external surface of the 
masseter. The internal or deep lamina also comes from the 
same parts; but is more irregularly distributed ; it furnishes 
sheaths for all the vessels, envelopes all the processes which this 
gland sends between the muscles, and unites, anterior to it, with 
the external aponeurotic lamina. Above and external to the di- 
gastric muscle, these two lamime are continuous with the fascia 
cervicalis and the stylo-maxillary ligament. Finally, behind the 
angle of the jaw, and on the inner side of the pterygoideus inter- 
ims muscle, they pass from the parotid to the submaxillary gland, 
to which they equally furnish a sheath. 
From the compact structure of the elements which unite and 
envelope the parotideal granulations, we may account for the 
severity of their acute inflammations, and the tendency of these 
inflammations to terminate by induration; also, when suppura- 
tion has taken place in them, for the difficulty with which the pus 
accumulates in the form of abscess; for the difficulty of detect- 
ing these abscesses when situated beneath the aponeurosis; and 
for their disposition, in certain cases, to penetrate towards deep- 
seated parts, such as the pharynx, tongue, etc., or towards the 
auditory canal, into which they as frequently open, rather than 
towards the skin. The very wise precept, of making an early 
opening into tumours of the parotideal region, in which we sus- 
pect the presence of pus, is founded upon these considerations.* 
The parotid is separated from the skin by a layer of cellular tis- 
sue, generally of considerable density, including some fibres of 
the platysma, nervous filaments of the facial, an ascending branch 
of the cervical plexus, and sometimes venous branches which 
pass to the external jugular. This layer seldom contains fat; it 
adheres firmly to the gland and integuments, for which reason 
tumours which form in it enlarge with difficulty, and generally 
possess but little mobility. 
vi. The Muscles. 
They are of but little importance here, in relation to practical 
surgery. In addition to those which form the limits of the re- 
* Colies Surgical Anatomy, page 132 32 
OF THE HEAD. 
gion, we find posteriorly, between the sterno-mastoid and the 
origin of the digastric, the coinplexus minor; upon the spine, 
the rectus capitis lateralis, rectus capitis anticus major and minor; 
internally, the stylo-hyoideus, stylo-glossus, and stylo-pharyngeus, 
between which the gland sends, as we have said, prolongations, 
so that they are liable to be divided during the extirpation of this 
organ; a circumstance which would not fail to derange, in a 
serious manner, the functions of the larynx, tongue, and pharynx. 
More deeply, the constrictor pharyngaeus, and anteriorly the 
pterygoid muscles, are the only ones which we here observe. A 
little lower down, inwards and backwards, we see the stylo- 
maxillary ligament, which we should avoid in operations, on 
account of its relations with the stylo-glossus muscle and its 
attachment to the os hyoides. 
vii. The Arteries. 
These are large and numerous. We find here the trunks of 
the two carotids, and the greater part of the branches given off 
by the external; viz. the occipital, pharyngeal, stylo-mastoideal, 
the commencement of the external maxillary and of the super- 
ficial temporal, the transverse facial, etc. 
1st. The External Carotid at first placed very deeply within, 
on a level with, and a little above, the digastric and stylo-hyoid 
muscles, afterwards ascends, in order to arrive behind the con- 
dyle of the jaw, forming an arch which is convex externally. In 
this last direction, as well as posteriorly, it is enveloped by the 
gland, to which it firmly adheres; anteriorly, it is separated from 
the posterior border of the maxillary bone by a vein of consid- 
erable size ; the cervico-facial branch of the seventh pair crosses 
it obliquely outwards, in its course to the face and neck. 
2d. The internal maxillary separates from the carotid on a 
level with the neck of the condyle, about one inch and three 
quarters above the angle of the jaw; posteriorly and internally, 
it is only contiguous to the parotid gland; anteriorly, it makes a 
sudden turn under the neck of the maxillary bone, and plunges 
between the pterygoid muscles ; whence it follows that, in frac- 
tures of this neck, the artery may be ruptured and occasion a 
troublesome haemorrhage. OF TIIE HEAD. 
33 
3d. The superficial temporal, in ascending, inclines more and 
more outwardly, as far as the anterior part of the meatus audito- 
rius. Anteriorly, it is separated from the condyle only by its 
superficial vein and by dense cellular tissue ; posteriorly and ex- 
ternally, it is covered first by the parotid, then by the skin and 
the fore-part of the auditory canal. It lies so near the skin that it 
may be tied, should circumstances require it. 
4th. The occipital lies deep in the lower part of the region : it 
is at first situated behind and internal to the stylo-hyoid muscle; 
then it passes between the internal jugular vein, which it crosses 
nearly at a right angle, and the digastric, in order to arrive at the 
internal surface of the sterno-mastoid muscle. It does not ad- 
here firmly to the gland, so that it would not hinder the removal 
of this organ. 
5th. The stylo-mastoideal ascends almost perpendicularly to- 
wards the foramen of the same name: it is separated from the 
preceding, which is internal to it, by the stylo-hyoid muscle, and 
from the external carotid, which is before it, by a prolongation of 
the parotid gland. The posterior auricular branch, which ori- 
ginates from this artery about an inch below the stylo-mastoid 
foramen, is obliged to pass through the glandular tissue, in order 
to arrive at the mastoido-auricular furrow. It is this which is 
most exposed to the action of the instrument when we endeavor 
to divide the facial nerve at its exit from the cranium. 
6th. The transverse facial arteries adhere so firmly to the 
parotid behind the masseter, that it is scarcely possible to separate 
them upon the living subject, when performing operations at 
this part. 
7th. A considerable number of anonymous arteries, branches of 
the preceding, are also scattered throughout the gland, consti- 
tuting its vasa propria; but none of them are so regular or large 
as to merit particular notice. 
viii. The Veins. 
In general, the veins accompany the arteries and possess the 
same relations; but there is also an additional number of branches 
at the surface and in the substance of the gland, which unite to- 
gether externally, in order to form the external jugular: besides, 34 
OF TIIE HEAD. 
we find, in the inferior part of this region, the anastomotic branch 
of the two large veins in the neck. 
The internal jugular vein lies deep upon the fore part of the 
transverse processes of the first three cervical vertebrae, poste- 
rior and internal to the styloid process and the muscles which 
arise from it, to the parotid gland and all the arteries, with the 
exception of the internal carotid, which is upon its pharyngeal 
side. It is crossed in this place by the ninth (hypoglossal) and 
spinal accessory nerves. Its relations with the anterior cerebral 
artery, the great sympathetic and par vagum, are similar to thos<j 
which we w ill find in the neck. 
ix. The Nerves. 
In the subcutaneous layer, we find the anterior auricular nerve 
of the cervical plexus, which is hard and its branches flattened. 
The principal branch of this nerve runs along the external jugu- 
lar vein. 
The spinal or accessory nerve is deeply situated, and at first 
runs obliquely between the internal jugular vein and the digastric 
muscle ; it then traverses the posterior and inferior lobules of 
the gland, in its way to perforate the sterno-mastoid muscle. 
Still deeper we find the glossol-pharyngeal and hypoglossal 
(9thpair) nerves: one of wrhich is situated wdthin, the other 
without, but both anterior to the internal jugular vein and inter- 
nal carotid. 
The pneumo-gastric (par vagum) nerve descends behind these 
two vessels and gives off its pharyngeal branch in this region. 
Still nearer the bones, is the superior cervical ganglion of the 
great symphatetic, and the filaments which go to form the caro- 
tid plexus. 
Finally, the important nerve of this region is the facial (portio 
dura) After coming through the stylo-mastoid foramen, previ- 
ously having given olf its three twigs, this trunk descends ob- 
liquely outwards and forwards through the deep lobules of the 
parotid, before the mastoid process. It is at this point we must 
divide it, if we wish to suspend its action or remove neuralgic 
symptoms. This may be done without difficulty by making an 
incision from the back of the ear to the lowest part of this pro- OP THE HEAD. 
35 
cess, from which we must separate the gland by drawing the 
anterior lip of the wound forcibly forwards, then dissecting cau- 
tiously, we will find the nerve at the depth of about six lines, in 
the middle of the space which separates the fibrous canal of the 
car from the apex of the mammoid process. As the posterior 
auricular and submastoideal arteries are situated directly upon 
this eminence, we will readily avoid them by inclining the inci- 
sion a little further forwards. 
It is in passing through the parotid in order to arrive at the 
external part of the superficial carotid that the portio-dura di- 
vides into two branches: the temporo-facial then ascends in a 
direction which, if continued, would reach the middle of the 
zygomatic arch, and it is so situated in this track, that it may be 
easily discovered by making an incision three or four lines in 
front of the ear. We would have to divide the skin, aponeu- 
rosis, and the parotid itself, which is thin at this part; the nerve 
will then be found anterior to the union of the lobe of the ear 
with the skin of the face; that is to say, eight lines below the 
horizontal root of the zygomatic process, upon the neck of the 
condyle of the lower jaw. We must be careful to cut obliquely 
from above downwards, and from before backwards, in order 
to avoid the temporal artery; we have also to apprehend, in 
endeavouring to make a section of this nerve, the wounding of 
the transverse facial arteries. It would not be difficult, how- 
ever, to compress them against the masseter. We may remark 
that after the section of this nerve its action is not necessarily 
destroyed, since the cervico-facial branch remains. On this ac- 
count, it is preferable to operate anterior to the mastoid pro- 
cess, if we do not wish to see the pains continue or re-appear, 
as has happened in two patients operated upon by Prof. Roux. 
We will examine the cervico-facial branch in the supra-hyoi- 
dcal region. 
x. The Lymphatics. 
These vessels are numerous in the parotideal region, and their 
glands deserve particular attention, because they receive almost 
all the lymphatics from the exterior of the cranium, and some of 
those of the face, mouth and pharynx. Some of these glands 36 
OF THE HEAD 
are superficially situated upon the external surface of the paro- 
tid ; others more deeply, between it and the different tissues of 
this region; we generally meet with two or three before or be- 
low the mastoid process. The frequent tumefaction of these 
bodies, in consequence of disease of the skin, of the cranium, or 
or of the sides of the face, has often led to the necessity of re- 
moving them, and we are induced to believe that the cases of ex- 
tirpation of the parotid, related by authors, were nothing more. 
Finally, there are some glands situated between the sterno- 
mastoid muscle and the internal jugular vein, which form the 
commencement of the submastoideal cervical chain. These last 
receive their vessels from the deep-seated parts, and may, when 
enlarged, be mistaken for aneurism, compress the vessels, and 
produce serious consequences. 
xi. The Skeleton. 
The bones of this region are only met with superiorly, posteri- 
orly, and anteriorly. 
In the first direction, we observe the inferior surface of the 
petrous portion of the temporal, the glenoid cavity and foramen 
caroticum; then the occipito-petrous suture, in the posterior 
part of which is the foramen lacerum posterius, which gives pas- 
sage to the internal jugular vein, the spinal accessory nerve, and 
par vagum; then the basilary process, into which the anterior 
recti capitis muscles are inserted; posteriorly the anterior con- 
dyloid hole for the transmission of the ninth pair; the stylo- 
mastoid foramen for the facial nerve, &c. 
In the second, we have only the fore part of the transverse 
processes of the three first cervical vertebrae, upon which lie the 
anterior branches of the nerves of the same name. 
In the third direction, we find the posterior border of the 
lower jaw only; but we cannot abandon this part without ma- 
king a few remarks upon the temporo-maxillary articulation. 
The glenoid cavity being bounded posteriorly by the styloid 
and vaginal processes, and the vertebral column, does not admit 
of luxations of the condyle in this direction. Internally the spi- 
nous process of the sphenoid bone prevents its displacement on 
this side, and for the same reason opposes the luxation outwards, OF THE HEAD. 
37 
since one of the condyles cannot be thrown outwards without 
the other being driven inwards; therefore, it is forwards only 
that the maxillary bone can be dislocated, because the condyle, 
when the jaw is depressed, always tends to the slide upon the 
transverse root of the zygomatic process (eminentia articularis). 
Furthermore, it is impossible for this accident to occur during 
infancy, as the acute angle at which the os maxillare inferius and 
os temporis are then articulated presents an insuperable obsta- 
cle to it. 
As this articulation is only separated from the skin, externally, 
by a simple ligament, wounds inflicted upon this side may very 
readily open it. 
The reddish cellular tissue, which fills the glenoid cavity pos- 
teriorly, forms an elastic mass of greater or less thickness, which 
separates the condyle from the auditory canal, but permits them 
to approximate very much when the jaw is greatly depressed. It 
is this tissue which shuts in part the fissure of Glaser, and prevents 
a direct communication between the articulation and the tympa- 
num. It is on the inner side of this chink, and without the cavity 
of the joint that we find the corda tympani; it is also on the inner 
side of the condyle that the auricular nerve is seen coming from 
the inferior maxillary, and passing towards the temple where it 
forms the superficial temporal; whence the possible alteration of 
this large branch in diseases of the articulation. 
Section 2. Nasal Region. 
It is bounded superiorly by the frontal; inferiorly by the labial; 
and on each side by the orbital and zygomato-maxillary regions. 
CONSTITUENT PARTS. 
i. The Skin. 
This membrane is pretty thick between the eye-brows and up- 
on the root of the nose ; in the rest of the region it is thin, and of 
but little extensibility. In the first situation it is sometimes 
covered with hairs ; upon the nose, never. It contains a great 
number of sebaceous follicles; for which reason this part of the 38 
OF THE HEAD. 
face is speedily covered with a greasy exudation. The secretion 
from these follicles is profuse, especially in the skin of the lobule, 
and in the lateral furrow of the nose, and in certain subjects it may 
be squeezed out from the crypt® in the form of small filaments. 
When this animal .oil becomes still more concrete it remains in 
the follicles and frequently forms tarmes (acne punctata) which 
seldom acquire any considerable volume. 
ii. The Cellular Layer. 
Upon the body of the nose it is thin, dense, compact and des- 
titute of adipose vesicles ; but at its root it is thicker, more lax, 
and encloses very minute adipose cells. It is on account of its 
compact texture, in the first instance, that tumours occurring in 
this layer are small, flattened and circumscribed, that abscesses 
rarely form in it, and that its inflammations generally assume the 
erysipelatous character; whilst at its root, the opposite pheno- 
mena may occur. On the other hand, however, we may remark, 
that the increased thickness of all these organs, at this point, is of 
much utility, when we wish to form an artificial nose at the ex- 
pense of the skin of the forehead. 
in. The Muscles. 
These arc, in the middle and superiorly, the pyramidalis nasi; 
transversely and laterally, the compressor narium (transversalis 
vel triangularis nasi), crossed by the levator communis. The de- 
pressor al® nasi also appertains to this region, but it may well be 
classed with those of the labial region. The first three seem to 
be confounded in the nasal aponeurosis, and are of no importance 
in surgery; it is only necessary to recollect the direction of their 
fibres, that we may avoid, in the performance of operations, cut- 
ting across them. 
iv. The Arteries. 
They are large and numerous, in proportion to the size of the 
organ. At the root of the nose we observe the nasal branch of 
the ophthalmic, which anastomoses with the facial: upon the dor- OF THE HEAD. 
39 
.sum, the branches which originate from the latter, which also 
sends some twigs to the septum and aim; some small branches 
from the coronary and infra-orbital; lastly, in the lobule we rind 
the ethmoidal coming from the interior of the nose. 
It is on account of this free supply of blood that, when cerebral 
congestions and other affections of the head exist, the nose is 
habitually red in some individuals. 
This same disposition also accounts for the success attendant 
upon the making of new noses, whether according to the Indian 
method, or that of Tagliacozzi. 
v. The Veins. 
Almost all of them pass into the angularis, which also receives 
the frontal veins; whence we may account for the success which 
the ancients derived from bleeding at this point in certain affec- 
tions of the nose and cranium. Their capillaries are numerous; 
but as they are imbedded in the subcutaneous layer, which is 
dense, the circulation through them is not very free. To this 
cause, perhaps, instead of arterial action, we may attribute the 
red colour of the nose in some persons. 
vi The Lymj)hatics. 
They follow the track of the arteries, and generally enter the 
glands beneath the jaw; whence tumefaction of the latter in some 
affections of the nose. 
vn. The Nerves. 
They come from the ophthalmic of Willis and the superior 
maxillary nerve, and are, superiorly, a filament of termination 
from the internal nasal, and another twig from the external nasal 
branch of the frontal; upon the sides numerous branches from 
the infra-orbitar ; upon the dorsum and in the lobule, the ethmoi- 
dal filament of the nasal branch of the ophthalmic which has tra- 
versed the nostrils. 
These nervous supplies sufficiently account for the acute sensi- 
bility of the nose; the sympathetic affections which its inflamma- 40 
OF THE HEAD. 
tions may produce, and the violent pains which frequently accom- 
pany the latter. These phenomena are also aggravated by the 
compact structure of its tissues. 
viii. The Bones and Cartilages. 
The first are the whole of the nasal bones, and almost the whole 
of the nasal process of the superior maxillary bone. The rela- 
tions of this nasal process with the lachrymal passages, its articu- 
lation with the os frontis and ossa nasi, the disposition of the lat- 
ter in relation to the cranium and nasal fossae, readily account for 
the cerebral disturbances, affections of the orbit, of the lachrymal 
sac, &c., produced by the fractures, exostoses or other diseases 
of the bones appertaining to the nasal eminence. These bones 
being somewhat thick and very short, cannot be fractured but by 
a direct cause, and the force necessary to produce this accident 
renders the wound more severe by the injury done to the soft 
parts than by the fracture itself. As they are not supported in 
the nasal fossa, they are readily displaced; and, if we do not take 
the necessary precautions, a disagreeable deformity, impeded 
respiration, alteration in the voice and in the sense of smell will 
ensue. They also differ in length, thickness and degree of ele- 
vation which renders them more or less liable to fractures, and 
produces the varieties in the form of the nose. 
The second are the triangular cartilages, those of the circum- 
ference of the nostrils, and of the alae; then the anterior margin 
of the septum. The latter is encased between the others in such 
a manner that it would be possible to extract a part of it, if it 
was diseased, without penetrating into the nasal fossae. In order 
to do this it would be sufficient to incise the lobule and septum 
upon the median line, and then detach the internal branch of 
each cartilage of the alae. It is at the place where these last unite 
with the lateral cartilage that we observe the most remarkable 
depression which exists upon the nose. A filament of the nasalis 
internus (naso-lobaire) nerve passes between the inferior border 
of the os nasi and the triangular cartilage. If this nerve was 
the seat of neuralgia, it would not be difficult to discover and 
divide it. All these elastic laminae are covered by a very dense 41 
OP TIIE HEAD. 
fibrous perichondrium, which unites them to the surrounding parts 
and is continued upon the bones forming their periosteum. 
Syphilitic affections, cancerous warts, &c. sometimes render it 
necessary to amputate the free extremity of the nose. The pre- 
ceding anatomical remarks show us that this amputation may be 
performed as far as the place where the bones unite with the 
cartilages. It is on account of this amputation, or the loss of the 
lobule by accident or disease, that the formation of a new nose 
(Rynoplastique) has been recommended, whether for the purpose 
of correcting a hideous deformity, or for restoring the sense of 
smell, which, according the experiments of M. Magendie, is lost 
when the extremity of the nose has been removed. Professor 
Beclard has remarked, that a metallic artificial nose equally re- 
established the olfactive function. 
The nose is one of the parts of the face which has the greatest 
influence over the expression of the physiognomy; it is also a 
powerful index of disease; but as this more properly belongs to 
semiology, we will not deviate from our subject to enter into 
details of these peculiarities. 
The following is the order of super-position in this region: 1st, 
the skin; 2d, the fibro-cellular layer; 3d, the muscles and apo- 
neurosis ; the vessels and nerves are distributed among these 
different tissues; 4th, the periosteum and perichondrium; 5th, 
the bones and cartilages. 
Sect. 3. Orbital Region. 
This region comprehends the whole of the apparatus of vision, 
and the greater part of the lachrymal apparatus. It is bounded 
by the circumference of the orbit, and consequently has the nasal 
region internally, the temporal externally, the frontal superiorly, 
and the zygomato-maxillary inferiorly. It presents for our con- 
sideration the orbital arches, the eyelids, the palpebral angles, the 
eye, and the orbit. 
i. The Supra-orbital, or Superciliary Arcade. 
The skin which enters into the composition of this arcade is 42 
OF TIIE HEAD. 
thicker than that of the eyelids, and thinner than that of the fore- 
head ; it is supple, extensible, and gives insertion to the hairs of 
the eyebrow. These hairs are generally darker than those of the 
scalp; they serve to diminish the intensity of the rays of light 
which pass to the eye, and to direct the course of the sweat to- 
wards the root of the nose. This remark enables us to compre- 
hend why their falling out, or destruction, so frequently induces 
inveterate ophthalmia or other diseases of the eye. 
The volume of the eyebrow depends upon several causes: in 
the first place, upon the size and number of the hairs ; next, upon 
the thickness of the soft parts on which they rest, and especially 
upon the prominence of the osseous arch. We will refer to this 
when we come to treat of each of these parts separately. There 
are a great number of follicles between the roots of the hairs 
especially towards the nose. 
The subcutaneous cellular tissue forms a dense, thick, and fila- 
mentous layer, in which we meet with adipose vesicles. This 
layer presents nearly the same characters as that which lines the 
hairy scalp; the same surgical considerations, therefore, are appli- 
cable to it. 
The muscles are, the superior arches of the orbicularis palpe- 
brarum, which follows the same direction as the arcade ; the 
inferior portion of the frontalis which descends perpendicularlv 
behind the preceding; internally, a part of the pyramidalis, and 
lastly, the corrugator supercilii. This last, the most important 
of all, passes obliquely upwards and outwards from the internal 
orbitary process, between the frontalis and orbicularis palpebra- 
rum, in order to terminate in the skin. 
These muscles are not in relation with any aponeurosis; the 
cellular tissue which separates them is loose and lamellated; 
whence it follows that abscesses may form here, and that in con- 
sequence of wounds, of whatsoever nature they may be, the pus 
burrows between these organs and the bones: therefore, if sup- 
puration is imminent, we should not reunite them immediately, 
and when the matter has formed evacuate it immediately. 
The arteries of the superciliary arcade are not proper to it, 
for the most part, they only traverse it. They are: externally, 
some twigs from the anterior temporal branch; at the inner third* OF THE HEAD. 
43 
some small branches from the supra-orbital, the trunk of which 
ascends between the frontalis and corrugator muscles; internally, 
ramusculi from the nasal. 
Consequently, a wound inflicted about one inch above and 
external to the tendon of the orbicularis, may occasion a trouble- 
some haemorrhage. In such a case, if the artery is divided be- 
tween the muscles, it may be easily tied, because the cellular 
tissue here is lamellated, and of slight density. Above the cor- 
rugator, on the contrary, it would be better to compress it, be- 
cause it would be difficult to pinch up the vessel in the subcuta- 
neous layer. 
The superficial veins require no particular notice here ; the 
others follow the course of the arteries ; the frontal, however, 
should be attended to, which descends along the median line be- 
tween the two orbital arcades. We have already seen this vein 
in the frontal region, and will soon find it again in the great an- 
gle. 
It is proper to note that the lymphatic vessels do not all enter 
the same glands. The most internal, like those of the forehead, 
follow the blood vessels of the face, and run into the submaxillary 
lymphatic glands ; whilst those of the external portion direct 
their course towards the fore part of the ear. This disposition 
leads us to believe that diseases of the head of the eyebrow, will 
affect tiie glands beneath the jaw; and those of its external half, 
the absorbent glands of the parotideal region. 
The nerves are the most important parts which we have to con- 
sider here. Externally, we find one or more filaments of the fa- 
cial, which come to anastomose with the supra-orbital; quite 
internally, some twigs from the nasalis interims, which inosculate 
with the frontalis; but the largest are the two cords of the supra- 
orbital, which sometimes come out of the orbit together through 
the supra-orbital foramen; more frequently, however, the small 
branch passes between the cartilaginous pulley of the trochlearis, 
and the internal orbitary process. These nerves appear to be the 
seat of those acute pains known by the name of frontal neural- 
gia ; and it is for this reason that the superciliary nerve is fre- 
quently divided for the purpose of removing these pains. By 
this means, these pains have been sometimes suspended, but as 
they have occasionally returned, their re-appearance has been 44 
OF THE HEAD. 
attributed to the anastomosis of the divided branch with those ill 
its vicinity. Notwithstanding this explanation may appear satis- 
factory, it is not certain that it is correct, because in these cases, 
the two divided extremities of the nerve may have become re- 
united, and the nervous influence thereby transmitted along the 
same cord. Therefore, if this operation is decided on, we should 
not content ourselves with a simple division of the diseased nerve, 
but likewise remove a portion of it. Furthermore, in order to 
reach it easily, we must seek for it immediately as it comes out 
from the supra-orbital notch, because, in this situation, we would 
have to divide only the skin, the orbicularis muscle, and two thin 
layers of cellular tissue. In order to find tliis notch, we have 
only to carry the finger along the border of the osseous arch from 
its internal towards its external extremity, and the first depression 
we meet with, will be that which includes the nerve. It is gen- 
erally situated about one inch external to and above the direct 
tendon of the orbicularis palpebrarum. During the operation, 
we must keep the eye-brow firmly elevated; for its muscle, in 
contracting, would draw it down, and thereby interfere with the 
free play of the instrument. 
The skeleton of this arcade appertains entirely to the os frontis. 
Its external half generally forms a thin edge: its internal is more 
rounded, and it is upon this that the head of the eye-brow rests : 
it is more or less prominent, on account of the frontal sinus which 
corresponds to it. 
External violence acting upon this arch, is much less liable to 
occasion its fracture than that of the vault of the orbit which is 
much thinner. As the eye-brow is frequently the seat of encyst- 
ed tumours (loupes), in which hairs are sometimes observed, certain 
authors have supposed that the presence of the latter is merely 
owing to a simple deviation from their natural direction (Beclard); 
others, to an unnatural elongation of the small root of those of 
the eye-brow; whereas M. Laennec says that they are accidental 
productions. 
n. The Superior Palpehra. 
This eye-lid is continuous, superiorly, with the eye-brow; is 
longer, broader, and more curved than the inferior, and the skin OP THE HEAD. 
45 
which enters into its composition is very delicate and very exteh- 
sible. The layer of lamellated tissue is very lax, and never con- 
tains fat; it encloses a fibrous plate, the external half of which is 
sometimes very strong : this is the palpebral ligament. This lig- 
ament is attached to the external half of the circumference of 
the orbit, and internally is converted into a cellular structure of 
greater or less density. 
The aponeurotic expansion of the levator palpebr® superioris 
muscle, the tarsal cartilage, the meibomian glands and conjunctiva 
also enter into the composition of the upper eye-lid, upon the free 
border of which we observe, in the four external fifths, anteriorly 
the cilia; posteriorly, the orifice of the palpebral follicles ; at the 
union of this portion with the internal fifth, the punctum lachry- 
male, then its canal; finally, between the conjunctiva and the in- 
ternal surface of the tarsal cartilage, near the convex margin of 
the latter, the opening of the ducts of the lachrymal gland. 
hi. The Inferior Palpebra. 
This is shorter and narrower than the preceding, and is contin- 
uous with the inferior orbital arcade. Its constituent parts, like 
those of the superior, are the skin, which is equally delicate; a 
lamellated layer, in which a few adipose vesicles are sometimes 
developed ; the inferior half of the palpebral ligament; very 
rarely a depressor muscle ; the tarsal cartilage ; some fine cellu- 
lar tissue, and the conjunctiva. The free border, less concave 
than that of the superior, does not otherwise differ from it. 
Each element of these membranous veils possesses some pe- 
culiarity which it is proper to point out. 
A. The Skin. 
It is extremely thin, soft and vascular, which causes it to as- 
sume a bluish or livid appearance in certain indispositions ; it is 
never covered with hairs ; in old people, it is wrinkled in arcs of 
circles, and, in all subjects, it is but loosely united to the subja- 
cent laminated tissue. It is owing to this looseness of texture 
that the cutaneous tissue of the eye-lids sometimes elongates suf- 
ficiently to admit of the inversion of the eye-lids, thereby produc- 46 
OF THE I1EAJL». 
ing ophthalmia, which cannot be cured but by removing a certain 
portion of the skin thus relaxed. 
B. The Laminated Tissue. 
This element never contains fat, from which circumstance the 
eye-lids appear depressed in those who are corpulent. Its la- 
mellae are very loosely arranged, whence serous infiltrations fre- 
quently and speedily form in this tissue. It is also owing to the 
same circumstance that such extensive ecchymoses occur here 
after the application of leeches ; therefore it would be better, 
in many cases, to apply them to the conjunctiva itself, which we 
have frequently done with success.* 
The cellular tissue which unites the orbicularis palpebrarum 
muscle to the ligament of the eye lids, the tarsal cartilage or to 
the conjunctiva, although lamellated, is more dense and does not 
admit of infiltrations. It is between the laminae of this cellular 
tissue that encysted tumours of the eye-lids are developed ; conse- 
quently, as these tumours are nearer to the conjunctiva, than the 
skin, it is better to expose them upon the inner surface of the 
palpebra. 
C. The Muscles. 
We only find in the inferior eye-lid the corresponding arches 
of the orbicularis, whereas the superior has in addition its levator 
muscle ; whence the great mobility of the latter, whilst the former 
is scarcely susceptible of any movement. The fibres of the orbi- 
cularis are paler, thinner and less curved, the nearer we ap- 
proximate the edge of the palpebra. Their insertion will be 
examined when we come to speak of the great angle. 
D. The Palpebral Ligament. 
It is attached to the external half of the two orbital arches, and 
is situated between the orbicularis muscle and conjunctiva; it 
seems to be continuous with the external extremity of the tarsal 
* Nouveau Journal, etc. 1821. OF THE HEAD. 
47 
cartilages. Its existence on the outer side of the orbit renders 
inflammations there more painful, on account of the resistance 
which it opposes to the tumefaction of the parts, and it also repres- 
ses, for a length of time, the external projection of tumours which 
form betweenit and the conjunctiva, or in the cavity of the orbit. 
E. The Tarsal Cartilages. 
The tarsal cartilages are much thinner at their convex border 
than towards the palpebral aperture. In the first direction they 
are connected to the ligament of the eye-lids, and, besides, in the 
superior lid, to the levator muscle ; in the second, they are envel- 
oped only by the skin and the mucous membrane to which they 
are very intimately united: from which circumstance the slight 
inflammations which originate here are very painful and produce 
the stye. 
The tarsal cartilage is covered by the orbicularis muscle, and 
rests upon the conjunctiva, from which it is separated by the 
glands of Meibomius only. That of the upper lid is also in relation 
with the ducts of the lachrymal gland; its breadth from above 
downwards, is five lines; its length, transversely, from five to six 
lines; the inferior is also six lines transversely, but only two 
lines from above downwards. Their posterior surface is concave, 
and moulded upon the convexity of the eye; finally, these plates 
form, properly speaking, the skeleton of the eye-lids. 
F. The Conjunctiva. 
This membrane is dense, very firmly adherent to the free margin, 
and about as much as a line upon the internal surfaces of the pal- 
pebrae ; it then becomes soft and supple, in proportion as it ap- 
proximates its point of reflexion upon the globe ; it is supposed to 
to dip into the orifices of the ducts of the lachrymal gland, which 
form an arch towards the point corresponding to the convex mar- 
gin of the tarsal cartilages. As this membrane becomes much 
less adherent in approximating the eye, than it is near the free 
margin of the palpebral veils, it is much better, when we wish to 
make the excision for the cure of ectropium, to cut at a little 
distance from, rather than too near, this margin. 48 
OF THE HEAD. 
G. The Palpebral Follicles or Glands of Meibomius 
These small granulations are collected in perpendicular lines 
upon the grooves which the ocular surface of the tarsal cartilage 
presents; they all open upon the posterior crest of the free margin 
of the palpebrae. Perhaps the conjunctiva penetrates into their 
orifices. It is in the ophthalmia depending upon the affection of 
these small organs that the dessicative ointments of Desault, 
Regent, etc., seem to have proved beneficial. For this purpose 
the unguent should be applied over the entire border of the palpe- 
bra, and not simply introduced at one of the angles. 
II. The Arteries. 
Internally we find the two internal palpebral arteries, furnished 
by the ophthalmic ; externally, the two external palpebral, derived 
from the lachrymal; superiorly, some twigs from the supra-orbital, 
and inferiorly, some ramusculi from the infra-orbital and facial 
arteries. 
The first four form two arcades which have the same direction 
with the curvature of the eye-lids, and are situated four or five 
lines distant from the free border, behind the orbicularis muscle. 
These arches resemble the coronary arteries of the lips, and we 
should pay attention to their volume and situation in all operations 
in which the eye lids are concerned. They are sufficiently re- 
mote from the margin of these veils to permit us to remove a 
considerable portion of them, in cancerous or other diseases, by 
following the advice given by MM. Dubois, Richerand, and Du- 
puytren, without wounding the vessels. On the contrary, if 
according to the ancient method, we are obliged to include the 
morbid tumour in a triangle of sound tissue, resembling the form 
of a V reversed, these arteries will necessarily be divided. 
J. The Veins. 
Almost all of them pass to the ophthalmic, a few only into the 
angular vein; they are larger than the arteries, and communicate 
directly with those of the brain: from this communication we OP THE HEAD, 
49 
may in part account for the pain, redness, and inflammation of the 
eves which we so frequently observe in diseases of the encephalon. 
K. The Lymphatics. 
Those of the external portion of the superior palpebra pass to 
the parotideal region, all the others cross the face, directing their 
course below the jaw. 
L. The Nerves. 
We find, internally, and parallel to the direction of the arteries, 
the palpebral branches of the nasalis internus; externally, fila- 
ments from the lachrymal and a few from the facial; superiorly 
it is also supplied by the two branches of the frontal, and the 
inferior palpebra receives some from the infra-orbital nerve. 
It is to this free supply of nerves that the eye-lids owe their 
exquisite sensibility; a sensibility which is also increased, to- 
wards the free margin, by the compact texture of the tissues. 
This last peculiarity seems to us to explain the reason why the 
application of leeches to the conjunctiva is very painful, when 
made too near the palpebral border, whilst they are scarcely felt 
when applied at a greater distance from it. 
M. The Cilice. 
These are the hairs implanted into the anterior crest of the 
free margin of the eye-lids ; they are continued only as far as the 
punctum lachrymale, and, when the eyes are open, form a curve, 
the concavity of which looks towards the orbital arches. They 
are arranged in two or three rows, and may deviate, in such a 
manner, as to pass towards the eye instead of taking the opposite 
direction. Their roots are surrounded by follicles, which, when 
diseased frequently cause the eye-lashes to fall out. Their bulbs 
receive numerous filaments from the palpebral nerves, which 
may, in general, be easily traced to the piliferous ampululaR. 50 
OF THE HEAU 
N. The Infra-Orbital Arch. 
It is with this that the inferior eye-lid is continuous ; it presents 
successively from the surface towards the deep-seated parts, 1st. 
the skin already stronger and less extensible ; 2d. a cellulo-adi- 
pose layer of more or less thickness; 3d. a portion of the orbicu- 
laris muscle; 4th. a second cellular layer, containing adipose 
vesicles; 5th. the periosteum; 6th. the bones, upon which we 
observe the zygomato-maxillary suture. These bones being thick 
and compact they are seldom fractured ; but the arch which they 
form is of great assistance, in certain cases, in finding the lach- 
rymal groove. We will resume this subject when we come to 
speak of the great angle. 
O. Of the Temporal Angle of the Palpebrcc. 
Through the skin, in this situation, we feel a pretty deep de- 
pression, which is limited, superiorly, by the external orbitary 
process of the os frontis; inferiorly by the frontal angle of the 
os malse. The palpebral commissure is, in general, two or three 
lines on the inner side of these bones, and the eye appears to be 
larger or smaller in proportion to the distance of this commissure 
from them, which is then owing to the slit in the eye-lids being 
more or less extensive. 
As the margins of the palpebra? touch each other towards their 
external extremities even when half open, if we are not particu- 
lar in separating them frequently, when inflamed or excoriated, 
unnatural adhesions will form between them. 
In this angle, we find, 1st. the skin and the lax cellular tissue 
common to the palpebrae; 2d. the external extremity of the 
fibres of the orbicularis, and the raphe which results from their 
intersection ; 3d. the strongest portion of the palpebral ligament; 
4th. the conjunctiva; 5th. the origin of the two external palpe- 
bral arteries; 6th. the termination of the lachrymal nerve ; 7th. 
some filaments from the facial, and 8th. the zygomato-frontal 
(external transverse) suture. 
In some persons, and especially the aged, the skin of the tem- 
poral angle presents many convergent folds, which should be OF THE HEAD. 
51 
attended to when we make incisions into this part. Exclusive 
of these wrinkles, we may incise in all directions without danger, 
since the muscle has no fixed point on this side and there are no 
important nerves or vessels to be avoided. However, it should 
be remarked that the conjunctiva is somewhat removed from 
the palpebral ligament, for it might happen that wounds, pene- 
trating into this space, may be rendered dangerous from the 
facility with which inflammation and pus penetrate into the cavi- 
ty of the orbit. 
P. The Great Angle. 
This angle is one of the most important parts of the orbital 
region, both on account of the frequency of its diseases and of 
the operations here performed. 
This part, connecting the eye-lids to the nose, is covered by a 
skin which partakes of the characters of both of these regions. 
It is much less extensible than upon the eye-lids, but thinner 
than upon the nose: on account of its tenuity, abscesses which 
form beneath soon perforate it, and tumours which raise it sel- 
dom become of large size without disorganizing it. 
Beneath the skin is the common cellular layer. 
Next comes the orbicularis palpebrarum muscle, which here 
deserves great attention. Inferiorly, its fibres are attached to 
the external surface of the ascending process of the superior 
maxillary bone, where they cover a small portion of the levator 
labii superioris alaequae nasi. Superiorly, some of these fibres are 
fixed to the internal orbital process of the os frontis, and in the 
middle they originate from a tendon which requires particular 
examination. 
This tendon is about one line in breadth and three in length, is 
flattened and attached to the external labium of the lachrymal 
groove ; it bifurcates in terminating in the eye-lids in order to 
become continuous with the tarsal cartilages, and rests upon the 
fibrous portion of the lachrymal sac, in the formation of which it 
seems to concur. We designate the tendinous portion, properly 
so called, the direct tendon, and the fibres which it furnishes to 
the sac, or which it receives from it, the reflected tendon. The 52 
OP TIIE HEAD. 
transverse position of the direct tendon divides the sac, as if 
were, into a superior and an inferior portion. 
The inferior is seen in a triangular space with an external 
base, the superior side of which is straight and formed by the 
tendon. The inferior side of this triangle is concave and formed 
by the external labium of the lachrymal groove, and the anterior 
border of the superior maxillary bone. It is in the summit of 
this space that we must introduce the point of the bistoury in 
order to penetrate easily into the lachrymal sac. 
The direct tendon receives the fleshy fibres of the two palpe- 
bras, and serves as their fixed point upon the nose; consequently, 
if we divided this fibrous bandelet, ectropium would follow, as 
was the case in the operation for fistula lachrymalis, recom- 
mended by Wolhouse. 
We will speak of the superior portion when considering the 
lachrymal passages. 
Q. The Puncta and Lachrymal Canals. 
These organs are situated in the rounded and straight portion 
of the free margin of the palpebrae. The puncta, or external 
orifices of the ducts consist of a small fibro-cartilaginous ring, 
and arc situated at the internal extremity of the posterior crest 
of the concave portion of the free border: they dip perpendicu- 
larly into the eye-lid, to the depth of about a line, and afterwards 
form a rectangular turn and become continuous with the canals. 
When the lids arc open, these orifices look obliquely between 
the globe of the eye and the caruncula lachrymalis ; when closed, 
they look directly backwards. On account of this disposition, 
therefore, when we wish to introduce an instrument into them, 
we must evert the lid, and then it will fall perpendicularly into 
the aperture. The canals then pass towards the commissure, 
following exactly the direction of the straight portion of the pal- 
pebral border. They sometimes unite before they enter the 
lachrymal sac, into which they then terminate by a common 
opening; and again they only approximate each other and open 
separately into it. 
The lachrymal canal is situated in the posterior part of the 
margin of the palpebra; therefore, it is less exposed to the action OF THE HEAD. 
53 
of foreign bodies: it is separated from the eye and the caruncle 
by the tunica conjunctiva only, and appears to be merely a pro- 
longation of the mucous membrane of the nose. From this it 
follows that its ocular paries is very thin and soft, so that it is 
liable to be perforated by the stylet, in the operations proposed 
by Anel, Mejan, etc., if we do not pass it in the proper direction. 
The superior canal being more easily placed in a direction 
parallel to the nasal duct by raising the palpebra towards the 
head of the eye-brow, it should be preferred for the purpose of 
introducing probes, setons, or other foreign bodies into the lach- 
rymal passages. It is by the inferior, on the contrary, that we 
should throw in our injections, on account of its transverse posi- 
tion and greater degree of immobility, on the one hand, and, on 
the other, because we can easily obtain a point of support upon 
the os mate. 
R. The Lachrymal Sac. 
This sac seems to form the superior half or termination of a 
canal which comes-from the nose. It is crossed anteriorly, as 
we have already observed, by the direct tendon of the orbicu- 
laris, above which it terminates in a cul-de-sac, and is formed by a 
cellulo-fibrous canal, four lines in length and from two to three 
lines in breadth. Internally, it lies upon the lachrymal groove, 
where it becomes blended with the periosteum, and to which it 
is firmly adherent; externally, it is separated from the caruncle 
and conjunctiva by a fibrous expansion, which is fixed, on the one 
hand, to the posterior margin of this gutter, and on the other, to 
the posterior surface of the direct tendon of the orbicularis 
muscle, from which it originates, and of which it constitutes the 
reflected tendon. This expansion is only found opposite to and 
above the direct tendon, which explains in part why the lachry- 
mal tumour is more fully developed below this fibrous bandelet, 
in the triangle which we there observe. Anteriorly, the sac is 
covered by the origin of the fibres of the orbicularis, and a few 
fibrous lamelte which are continuous with the periostium of the 
root of the nose. Its internal surface is lined by a mucous mem- 
brane, which is usually a little redder than that of the lachrymal 
canals. 54 
or THE HEAD. 
As this sac is adherent by its external surface to solid and 
immoveable parts, its relations are consequently fixed and un- 
changeable ; that is to say, it is incapable of active alternate 
dilatation and contraction in its natural state. This circumstance 
shows us the futility of the advice given by Monro, to introduce 
a sound into the lachrymal sac through the nasal duct, for the 
purpose of stretching the anterior paries of the former, whilst 
cutting into it in the operation for Fistula by the method of J. L. 
Petit. It is also on account of this intimate adhesion of the sac 
to the osseous groove, that we are induced to give the following 
directions for penetrating its cavity: We should direct the point 
of the bistoury obliquely downwards, inwards, and backwards, 
below the direct tendon, and then in proportion as we plunge it 
deeper, gradually elevate the handle of the instrument towards 
the head of the eye-brow. In this manner we will be sure to 
enter into the sac, and to incise it to a great extent, without 
making but a small opening in the skin. In fact, the point of 
the instrument having entered the sac very high up, it follows 
that, in passing it onwards, we will continue to cut its external 
paries, which is longer than the internal, and that we will run no 
other risks than that of penetrating uselessly to the bone, by tra- 
versing the mucous and fibrous laminae of the internal paries of 
the sac: but, on the one hand, the compact union of these 
parts will prevent their being separated, and, on the other, the 
instrument will soon enter the sac by the swinging motion which 
we make it execute ; so that the worst which can happen will be 
reduced to a simple incision of these membranes in a point which 
we are recommended to avoid; an incision which cannot be 
more serious than the external, since the parts divided are of the 
same nature. 
The Nasal Duct is the continuation of the preceding: lined bv 
the same mucous membrane, it adheres to the osseous canal 
throughout its whole extent, which makes it almost an inert pas- 
sage in relation to the operations which its diseases call for; from 
whence arises the success obtained from the use of the metallic 
canula, so highly recommended by Pellier, Foubert, Wathen, 
B. Bell, Dupuytren, Taddei, etc. 
This duct is from five to seven lines in length: it is a little 
broader than the lachrymal sac, and its antero-posterior diameter OF T1IE HEAD. 
55 
is a little greater than its transverse. United to this sac, and con- 
sidered as extending downwards from the tendon of the orbicu- 
laris, it presents a slight curvature with an external and anterior 
convexity. The lachrymal portion alone, on the contrary, is 
slightly convex inwards and backwards. It is important to be 
well acquainted with this disposition, whenever we wish to pass 
instruments, etc., from the puncta lachrymalia to the nose, or to 
place foreign bodies in it. We will take up the consideration of 
the inferior orifice of the nasal duct, when we come to the 
nasal fossae. 
The bones which inclose the nasal canal also merit some atten- 
tion. Thus the lachrymal gutter is hollowed out, anteriorly, in 
the posterior border of the ascending process of the os maxil- 
lare ; posteriorly, in the external surface of the os unguis: there- 
fore, when we wish to make an artificial course for the tears, 
according to the method of Wolhouse or that of Scarpa, it is 
better to perforate the bones in the latter direction than in the 
former, because the os unguis is much thinner than the nasal pro- 
cess. In this situation these bones correspond to the middle 
meatus {of the nasal fossa). The nasal canal is formed, anteri- 
orly, by the prolongation of the lachrymal gutter of the ascending 
process, and on this side, does not correspond to any important 
organ; posteriorly, by the inferior portion of the os unguis and 
its curved crest, by some lamellm of the superior maxillary and 
a small portion of the inferior turbinated bone. This wall is thin 
and very brittle, so that nothing would be more easy, in opera- 
ting for fistula lachrymalis, etc. than to penetrate into the nasal 
fossa? or maxillary sinus, if the instrument is directed too far 
backwards. The internal wall of this canal is formed by the 
prolongation of the os unguis, and the curved portion of the infe- 
rior turbinated bone. It is not more solid than the preceding, 
and as it corresponds directly to the nostril, it may be depressed 
by polypi or other tumours which are developed in the nose: 
whence epiphora, fistula lachrymalis, etc.; finally, its external 
wall is constituted by the lamina which borders the maxillary 
sinus, and sometimes a small process of the inferior maxillary 
bone which is joined with it. It is as thin as any of the others, 
and very much exposed to fractures, or perforations, in probing 
the canal as recommended by Laforest. We then penetrate the 56 
OF Till! HEAD. 
maxillary sinus. For the same reason, tumours of this last cavity 
seldom acquire a certain volume without impeding and even pre- 
venting the descent of the tears into the inferior meatus (of the 
nasal fossae). 
Between the lachrymal sac and the globe of the eye, on the 
one part, the palpebral commissure and the puncta lachryma- 
lia, on the other, we find the caruncula lachrymalis. This small 
organ is pale when serous effusions exist in the large cavities of 
the body, and of a more or less reddish white in the normal 
state. It is formed by a fold of the conjunctiva, in which a con- 
siderable number of agglomerated follicles, hairs and even a small 
cartilage are found. To these may be added the lachrymal 
muscle, which is situated behind the sac and canals of the same 
name, to which it adheres, and which it may compress and even 
draw towards the os unguis, which is its fixed point. These uses, 
recently attributed to this small muscle by Horner and Gery, 
appear to be real, notwithstanding Trasmondi has affirmed the 
contrary. They enable us to understand how a spasmodic con- 
traction may take place in the lachrymal organs in one point, 
whilst it does not appear possible for this phenomenon to mani- 
fest itself in the nasal canal, properly so called. Furthermore, 
the caruncula lachrymalis actually possesses all the elements of 
a complete eyelid, and thus presents us with the rudiment of the 
membrana nictitans of birds, &c. 
It is by the internal extremity of the groove which separates 
the caruncle from the inferior eyelid, that Pouteau advised pene- 
trating into the lachrymal sac; and more recently it has been 
proposed to penetrate it by commencing the incision in the groove 
which separates this caruncle from the superior palpebra, in order 
to incise it to a much greater extent: in the latter case, however, 
the muscle of Horner would be cut across, and if it is true, that 
its action is useful for the excretion of the tears, we conceive 
that considerable inconvenience would result from it. 
S. The Orbitary Portion properly so called. 
The globe of the eye occupies the centre of it, and is more 
nearly approximated to the anterior than the posterior plane. 
The form of this organ is that of a spheroid slightly flattened OF THE HEAD. 
57 
upon four surfaces. Its antero-posterior diameter is about ten or 
twelve lines; in the other directions it presents a line less. 
It is from these dimensions of the interior of the eye that Hey 
advises a needle of only seven or eight lines long for the depres- 
sion of the crystalline, and for the same reason Groefe has added 
a species of shoulder to the shaft of his, for the operation of 
Keratonyxis. 
The eye is divided into two chambers, the anterior and poste- 
rior. The anterior is bounded by the iris behind and by the cor- 
nea before ; its transverse diameter is from four to five lines, its 
perpendicular diameter a little (quelques millimetres) less. From 
the pupil to the centre of the cornea the distance is about two 
lines. This space then gradually diminishes in proportion as we 
approximate the great circumference of the iris, where this mem- 
brane touches the cornea; from which circumstance, when we 
perform the keratonyxis, the concavity of the needle must look 
forwards, whilst we penetrate into the anterior chamber. In fact, 
if the point of this instrument was directed backwards, or if we 
made use of straight needles, like those of Beers, Schmidt, Him- 
ly, &c., it would be difficult to arrive at the pupil without wound- 
ing the iris. 
The transparent cornea, which entirely belongs to this cham- 
ber, forms nearly the anterior fifth part of the eye; its circum- 
ference is, as it were, cased in the anterior aperture of the scle- 
rotica, and as it is the segment of a smaller circle than the rest 
of the organ, it forms a kind of superficial furrow upon the ex- 
ternal surface of the membranes, near the point where this sur- 
face corresponds to the iris. This groove prevents us from inclin- 
ing the handle of the knife so much forwards, in the extraction of 
the cataract, as the perpendicular of the eye would seem to require. 
This membrane is composed of six slightly extensible and brit- 
tle laminae, separated by an albuminous fluid, which, on concre- 
ting, during inflammations of the eye, produces opacity of the 
cornea. It is between these laminae that the ceratotome slides, 
in traversing the cornea, in order to enter the anterior chamber, 
when the surgeon does not follow exactly the perpendicular of 
the furrow mentioned above. Anteriorly, it is covered by a la- 
mella which seems to appertain to the conjunctiva, but which 
only assumes the characters of mucous membranes in certain 58 
or THE HEAD. 
diseases. This lamella is so intimately adherent to the horny 
tissue, that it is scarcely possible to separate them by dissection : 
which has led several anatomists* to suppose that its nature was 
different from that of the conjunctiva. Be this as it may, it is 
between it and the transparent membrane of the eye that the 
serosity accumulates which constitutes the phlyctenae of the 
cornea. 
Posteriorly, it is lined by the membrane of the aqueous hu- 
mour, a species of lamina which does not appear to cover the fore 
part of the iris, notwithstanding several very correct observers say 
that it does so. The anterior chamber is filled with a liquid 
which is reproduced with great facility, in young subjects espe- 
cially. It is on account of the presence of this fluid that, when 
the cornea is once traversed, the instrument must never be with- 
drawn ; because, no longer filling exactly the opening w hich it 
has made, the water will escape from the cavity which encloses 
it, and the eye becoming flaccid, the section must necessarily be 
completed with the scissars. As the tranverse diameter of the 
cornea is the greatest, we prefer, in the operation for cataract, 
the incision from the temporal angle towards the nose, to the ver- 
tical incision. Wenzel and the greater proportion of French 
surgeons advise us to traverse the anterior chamber, not directly 
across, as recommended by La Faye, but very obliquely from 
above downwards and from without inwards, for fear that the 
flap might be raised by the depression of the eye, or by the move- 
ments of the lower lid. This method of operating does not ap- 
pear to us to be free from censure, or, at least, is not so essential as 
many authors pretend. In fact, in attempting to traverse the eye 
in this direction, the prominence of the external orbitary process 
of the os frontis will sometimes throw the handle of the knife so 
far forwards, that it will be difficult to make its point pass out in 
the great angle, without wounding parts which it is of importance 
to avoid ; besides the anatomical disposition of the parts does noi 
permit the flap of the cornea to be readily raised by the free bor- 
der of the lower lid, and further, after the operation, the patient 
has his eyes closed : it is the superior palpebra which descends, 
and not the inferior that rises. Neither would the eye itself, 
when descending, favour the occurrence of this accident; and if, 
* M. Ribcs. OF THE HEAD. 
59 
moreover, it should happen, it is not the oblique incision which 
would prevent it, for the internal extremity of the flap would be 
equally exposed to the same eversion. In short, we think that this 
question requires further examination. 
The posterior chamber is extremely complicated. Its walls 
are formed by three membranes placed one within the other, 
and are thus arranged: the sclerotic, external; the choroid, cen- 
tral ; and the retina, internal. 
The first is thickest posteriorly, but is strengthened anteriorly 
by the fibrous expansion of the muscles ; it is composed of paral- 
lel fibres, which extend from the optic nerve towards the cornea ; 
some also are circular and transverse, but these last are less 
numerous. 
The second, or choroid is essentially formed by vessels. On 
its external surface, between it and the sclerotic, the ciliary nerves 
are observed. When it reaches the ciliary circle it curves be- 
hind the iris in order to form the uvea, and it is at the place of this 
curvature that it gives rise, in folding upon itself, to the ciliary 
processes, which are separated from the great circumference of 
the iris by the commissure of the choroid, upon the posterior sur- 
face of which they are supported. 
The third, or retina, white, pulpy, in which the nervous matter 
of the optic nerve is met with, appears to be the essential organ of 
vision. It is situated between the choroid and the vitreous body, 
and is prolonged at least to the circumference of the crystalline 
lens. We have several times distinctly observed it, in man, ex- 
tend to the iris; and in the bullock it is much more readily distin- 
guished. Is this a natural state, or is it merely an anomaly ? 
These three membranes are traversed by the needle in the 
operation for cataract. As the fibres of the external are parallel 
to the axis of the eye, and as the central is composed of vessels 
and nerves which follow the same direction, it is necessary to in- 
troduce the needle in such a manner that one of its edges looks 
forwards, the other backwards, its concavity being turned down- 
wards. By acting in this way we only separate, if I may so say, 
the fibres and the vessels. On the contrary, if the needle is so 
held that its concavity is directed backwards and its cutting 
edges perpendicular to the axis of the eye, it will necessarily 
divide the parts through which it passes, and thereby give rise to 60 
OF THE HEAD. 
ecchymoses between the conjunctiva and sclerotica, to extra- 
vasation of blood within the posterior chamber, or to nervous 
symptoms, on account of the lesion of the ciliary arteries or 
nerves. 
The posterior chamber is filled by a globular body composed 
of the vitreous body and crystalline. The latter is a species of 
inert and transparent lens, which is always more solid at the cen- 
tre than at the periphery; whence it follows that its opacity is 
generally eccentric. The crystalline capsule, which envelopes 
it, is separated from it by a space which is usually in a direct ra- 
tio to the age: this space is naturally filled by an albuminous 
liquid, susceptible of losing its transparency by passing into a 
milky or purulent state; which constitutes the cataracts thus 
named. The capsule itself is enveloped in a separation of the 
membrana hyaloidea, so that posteriorly it rests upon the anterior 
part of the vitreous humour, the tunic of which sends a lamina 
upon the fore part of that of the crystalline. This capsule ap- 
pears to be of a horny nature; it is dense, elastic and resists the 
entrance of the instrument: a circumstance not to be forgotten 
when wre attempt the depression of the cataract. Some have 
thought that its internal surface secretes the lens itself, and that 
this body may be regenerated after its depression or extraction, 
provided the capsule is not at the same time destroyed. Doctor 
Cocteau has recently presented to the Royal Academy of Medi- 
cine the result of his experiments upon dogs and rabbits, which 
seem to give support to this opinion. Prof. Beclard was deputed 
to resolve this important question, and had already extracted the 
crystalline from the eye of several dogs, when death snatched him 
away in the midst of his useful labours. If the assertion of M. 
Cocteau is confirmed, it will be necessary, in every operation for 
cataract, to extract even the minutest particles of the crystalline, 
unless we take care to destroy the formative organ, that is to say 
the capsule itself. 
The vitreous body is a species of sponge with very fine and 
transparent meshes; it is formed by a substance similar to the 
aqueous humour and by a membrane, the laminae of which split 
and intersect each other a great many times, forming the cellules 
which enclose the fluid. This membrane, according to Mr. J. Clo- 
quet, is reflected upon itself behind, in order to form the hyaloid OF THE HEAD. 
61 
canal, which passes through the entire thickness of the vitreous 
body, conveying an artery to the crystalline capsule. On the 
other hand, according to Petit, the learned anatomist whom we 
have just cited, when the hyaloid membrane arrives near the cir- 
cumference of the crystalline and its capsule it separates into two 
laminae, between which laminae the visual lens is found; so that, 
if we consider the crystalline as removed, the vitreous humour 
would bear a resemblance to the larger end of an egg, and the 
vacancy which habitually exists between the membrane retracted 
by the albumen and the calcareous shell. 
In couching, the vitreous body is always perforated, use what 
precautions we may ; and we think, that, far from seeking to avoid 
this, we should always endeavour to open it sufficiently for the 
purpose of imbedding the lens within it; and in order to do this, 
the needle having entered the posterior chamber, one of its cut- 
ting edges should be carried backwards and downwards, below 
the visual axis, dividing several of the laminae of the hyaloid in 
this direction, so that we may be enabled to push the opaque body 
into it, after having placed the instrument upon the fore part of its 
capsule. In this way, the elasticity of the vitreous body will not 
oppose the entrance of the crystalline into it, but will rather re- 
tain it in the situation in which we leave it. On the contrary, if 
we depress it between the membrana hyaloidea and retina, we 
will necessarily disorganize the latter, and that elasticity, which, 
in the first case, retained, will constantly tend to press it upward. 
We do not see what danger can follow this method, which is 
moreover frequently adopted without anticipating any. Our for- 
mer preceptor and friend, Dr. Bretonneau, always operates in 
this manner, and his success establishes this precept. The meth- 
od by hyalonixis, recently recommended by M. Bowen, and for- 
merly detailed by Farrein to the Academy of Sciences, clearly 
proves that we have nothing to apprehend from the lesion of the 
vitreous body. 
Considered posteriorly, the posterior chamber of the eye forms 
the bottom of this organ, and upon it the image of objects is 
painted. We there find the posterior opening of the hyaloid ca- 
nal, and the artery or pedicle which attaches the vitreous body to 
the retina ; the retina itself, with its folds and its punctum flavum, 
which are about two lines on the outer side of the optic nerve, 62 
OF THE HEAL/. 
that is to say, nearly in the direction of the axis of the eye ; the 
choroid, which is perforated for the entrance of the optic nerve ; 
finally, the sclerotica, which is likewise pierced by the same nerve, 
which furnishes it with a fibrous expansion coming from the dura 
mater, and which is situated about two lines on the inner side of 
the visual axis in man. 
Anteriorly, the posterior chamber is separated from the anterior 
by the iris, a membrane placed vertically, with a central opening, 
which constitutes the pupil. This organ is of a very complicated 
texture, and seems to contain, according to some anatomists, a 
prolongation of the retina, of the choroid, of the membrane of 
the aqueous humour, and a cellulo-vascular lamina propria. Ac- 
cording to others, it is essentially formed by the long ciliary arte- 
ries, which anastomose four or five times in a circular direction, 
vSome say that it is an erectile (spongy) tissue; others, a double 
muscle. Be this as it may, in certain subjects it bulges forwards a 
little, in children especially, and is thereby exposed to the knife as 
it crosses the anterior chamber. This is most liable to happen 
when the aqueous humour has escaped. 
Its posterior surface, slightly concave, is black ; we call it uvea. 
It is separated from the capsule of the lens by an interval of half 
a line, which is filled by the aqueous humour. The narrowness 
of this space renders it at least very difficult to pass a needle be- 
fore the crystalline without perforating the vitreous body; espe- 
cially, as, if we admit that the posterior chamber is bounded be- 
hind by the anterior surface of the vitreous body, the crystalline 
lens being removed, we would have the same disposition behind 
the iris as before it; that is to say, that the hyaloid membrane, like 
the cornea, is at first from two to three lines distant from the pu- 
pil, but afterwards approximates so close to the great circumfer- 
ence of the iris, that it appears to be in direct contact with the 
ciliary processes. Is it not evident, then, according to this dis- 
position which does not vary, that, in passing the instrument 
from the sclerotica to the pupil, whether by the ordinary method, 
or that of M. Bowren, we will divide the vitreous body more or 
less extensively ? 
The great circumference of the iris being attached to the union 
of the cornea with the sclerotica, before the ciliary circle (liga- 
mentum ciliare), and there receiving the principal vessels which OF THE HEAD. 
63 
enter into its composition, it follows, that, in making an artificial 
pupil, according to the recommendation of Scarpa, we are in dan- 
ger of lacerating the nervous ring, and of producing considerable 
hoemorrhage. It must be admitted, however, that it is possible to 
avoid these accidents. 
By taking the precaution of introducing the needle at a suffi- 
cient distance from the triple union of the iris, ciliary body and 
cornea, there would also be an advantage in it relative to the lat- 
ter membrane, which, being more remote from the retractile veil 
of the eye, would run less risk of being caught by the point of 
the instrument. We have witnessed the occurrence of this acci- 
dent in a patient operated upon by one of the most celebrated 
surgeons in Paris. 
The small circumference of the iris is, as we know, susceptible 
of alternate dilatation and contraction, which every body explains 
according to his own notion, or rather does not explain at all. It 
is in passing before this opening, that is to say, before the pupil, 
that Wenzel dips the point of his knife into the posterior cham- 
ber and divides the capsule of the crystalline, at the same time 
that he crosses the anterior chamber in order to form a flap of the 
cornea. It is also by this opening that the diverse kystitomes fulfil 
the same indication, and that we arrive at the lens in the kerato- 
nyocis, etc.; to facilitate which it is useful to dilate it by means of 
the solution of the extract of Belladonna, or any other substance 
possessing analogous properties. This dilatation is also necessary 
in order to prevent the iris from being pricked by the instrument, 
especially when couching. In fact, Beclard was convinced that 
most of the accidents which sometimes follow the depression, are 
owing to the tractions of the iris, and that, according to his expe- 
rience, if care was taken to avoid touching this membrane, couch- 
ing would, without contradiction, be preferable to extraction. 
Would not this idea be in favour of those who admit of a lamina 
of the retina behind the iris ? 
The vessels of the ocular globe are exceedingly numerous and 
delicate. Anteriorly, this organ receives branches from the pal- 
pebral and anterior ciliary arteries, which are distributed to the 
conjunctiva, and are rendered equally visible upon the cornea by 
inflammation; posteriorly, it receives the arteria centralis retinas, 
which accompanies the optic nerve. After having given off 64 
OF TIIE HEAD. 
many minuscules to the nervous membrane of the eye, this ves- 
sel, according to authors who call it the central artery of the 
crystalline, passes through the canalis hyaloidea to the posterior 
lamina of the membrane of the lens. We have never seen it 
penetrate into the lens itself. This artery should be preserved 
during depression, for it is probable that its laceration would be 
detrimental to vision. The ciliary arteries form in the eye a very 
complicated net-work; all of them perforate the sclerotica ob- 
liquely, principally in its posterior third portion ; their numerous 
filaments afterwards place themselves in the choroid and run in 
parallel lines to the ciliary processes and uvea, with the excep- 
tion, however, of the two long ciliary arteries, which run along 
the internal surface of the sclerotica, and do not divide until they 
reach the great circumference of the iris. It is in consequence 
of the position of these two branches upon the two extremities 
of the transverse diameter of the eye, that we are advised to 
introduce the needle below it, in the operation of couching ; and 
it is also on account of their size and direction, that we consider 
it best to turn the edges of the instrument anteriorly and poste- 
riorly, as we have previously mentioned. 
The greater proportion of the veins, also, are situated in the 
choroid. We find, besides, between this tunic and the vitreous 
body, the vortices of Haller, or the vasa vorticosa. These ves- 
sels pass through the fibrous membrane and empty their blood 
into the lachrymal veins. 
The nerves are derived from the ophthalmic ganglion: they 
are distributed in the same manner and follow the same direction 
as the arteries, and are lost in the ciliary circle. This ring, wrhich 
has all the characters of a circular nervous ganglion, would, in 
this case, appertain to the great sympathetic: its figure is pris- 
matic, and its external side rests upon the most anterior part of 
the internal surface of the sclerotica. Anteriorly, it separates the 
iris from the choroid or ciliary processes, to which it adheres 
posteriorly. This point of the envelope of the eye is worthy of 
attention. It is, in fact, with the view of avoiding the iris, that 
we are advised, in extracting the cataract, to penetrate the ante- 
rior chamber half a line before the sclerotica. In depression, if 
we introduced the needle at less than a line and a half behind it, 
we would inevitably wound either the great arterial circle of the OP THE HEAD, 
65 
iris, the ganglion (ciliary ligament), or the ciliary processes. 
Now, if it was certain that we would not more surely avoid the 
retina or vitreous body by introducing the needle at this point 
than more posteriorly, it seems to us that it would still be pref- 
erable to approximate these parts as little as possible. 
The nerves of the interior of the eye may be distributed in 
three orders. 
The first are destined for the movements of the iris, and are 
derived from the nasal branch of the ophthalmic and the lachry- 
mal only ; whence it follows, that wounds inflicted upon the 
angles of the eye sometimes suspend the contractions of the iris 
without interrupting vision. Baron Larrey, with whom this idea 
appears to have originated, has met with several cases of this 
nature ; and but a short time since, there was a case of the kind 
at the Soeiete Philomatique; so that we have been able to con- 
vince ourselves of the correctness of the fact. The second 
order includes the nerve of special sensation, which does not, 
according to the celebrated Magendie, enjoy general sensibility, 
but is destined solely to receive the impression of images : it is 
the optic nerve. Its anatomical disposition explains to us why 
paralysis of the retina does not alter the state of the other parts 
of the eye, or necessarily induce immobility of the iris. Finally, 
the nerves of the third order appertain to the interior life and 
enter into the ganglionic system: these are the numerous ciliary 
filaments and ciliary circle. 
The order in which the parts of the eye present themselves, in 
proceeding from the anterior to the posterior part of this organ, 
is the following: 1st, the conjunctiva, or the lamina, whatsoever 
it may be, which covers the cornea ; 2d, the transparent cornea; 
3d, the membrane of the aqueous humour; 4th, the anterior 
chamber, which is two lines in diameter in the direction of the 
ocular axis ; 5th, the aqueous humour, which is regenerated with 
great facility; 6th, the iris, the pupil, or membrana pupillaris in 
the foetus under seven months; 7th, the space which separates 
the iris from the crystalline, a space which scarcely exists in chil- 
dren, which does not exceed half a line in the adult, and which 
many consider as the posterior chamber, properly so called: it is 
also filled with the aqueous humour: 8th, the anterior portion of 
the capsule of the lens, covered by a lamina of the hyaloid : 9th. 66 
OF THE HEAD. 
a small space which separates the anterior surface of the crystal- 
line from its capsule, and which is filled by the liquor Morgagni; 
10th, the crystalline lens, softer and more spherical in children 
than in old people, whence it follows that myopia is more fre- 
quent in the former and presbyopia, in the latter ; 11th, between 
the posterior surface of this body and its capsule, another space, 
filled with a liquid similar to that v hich is anterior to it; 12th, 
the posterior lamina of the capsule of the lens, thicker and more 
dense than the anterior, invested posteriorly by the membrana 
hyaloidea; 13th, the vitreous body, the canalis hyaloidea, and 
the central artery of the crystalline lens; 14th, the retina formed 
of three laminae, according to some authors; 15th, the choroid, 
bifoliated according to Ruysch, etc.; 16th, the sclerotic. 
In penetrating transversely into the posterior chamber of the 
eye, we find from without inwards, 1st. the sclerotica; 2d. the 
choroid; 3d. the retina; 4th. the hyaloid membrane; 5th. the 
vitreous body; 6th. the hyaloid canal, the central artery of the 
crystalline, or, more anteriorly, the lens itself and its capsule. 
With respect to the anterior chamber, 1st. the conjunctiva; 2d, 
the cornea; 3d. the membrane of the aqueous humour; 4th. the 
aqueous humour; then the same parts on the other side of the axis. 
The parts which surround the ocular globe within the orbit are, 
1st. The muscles, which are, in the first place, the four recti, 
the fibrous expansion of which terminates upon that portion of 
the sclerotica which is covered by the conjunctiva, constituting 
what is called the white of the eye. Departing from thence, 
these muscles converge so as to form a cone, the apex of wrhich 
surrounds the optic nerve, and is attached to the bottom of the 
orbit. From this disposition, wdien these muscles contract to- 
gether, they tend to flatten the eye in four opposite directions, 
and also to draw it backwards. 
Next the levator palpebrm superioris, which is situated between 
the rectus superior and the periosteum; in thin persons, or those 
who have a prominent eye-brow, it is this muscle which draws 
the eye-lid backwards, and makes it appear depressed. 
The great oblique {trochlearis) is situated between the rectus 
internus, rectus superior, levator and periosteum, as far as its 
reflected pulley, three lines within the supra-orbital notch, and 
then passes behind the conjunctiva, between the levator, rec- OF TIIE HEAD. 
67 
tus superior and rectus externus, to be inserted into the sclero- 
tica, three lines anterior to the optic nerve. It is necessary to 
remark that the superficial situation of this muscle, at its point of 
reflexion, exposes it to wounds of different species: for example, 
it might be divided when attempting to divide the supra-orbital 
nerve, if we endeavoured at the same time to cut the internal 
frontal branch. Such an'accident would be attended with loss 
of rotation inwards. 
The small (external) oblique is attached to the floor of the orbit 
quite near its circumference, two lines on the outer side of the 
superior orifice of the nasal canal. From this point it passes be- 
hind the conjunctiva obliquely upwards, backwards and outwrards> 
between the periosteum, the rectus inferior and rectus externus, 
upon the sclerotica. In consequence of its slender size at its 
origin, and its situation, it is liable to be divided in the operation 
for fistula lachrymalis, especially if the knife should slip outside 
of the sac: such an occurrence would destroy rotation outwards. 
The direction of these last two muscles is such that, when they 
act conjointly, they are antagonists to the recti muscles, drawing the 
eye forwards. 
2nd. The nerves, which are, in the centre, the optic nerve, 
enveloped posteriorly by the origin of the recti muscles, from the 
bellies of which it is separated by a considerable quantity of fat, 
which prevents its compression : around it, the superior and infe- 
rior ciliary nerves coming from the ophthalmic ganglion, resting 
upon the external surface of the optic nerve, a little anterior to the 
attachment of the muscles; the third pair {moteur commuri), which 
enters the orbitt hrough the foramen lacerum (sphenoidal fissure), 
crossing the posterior extremity of the rectus externus muscle : 
the superior branch of this nerve is lost in the rectus superior and 
levator palpebrae ; the inferior gives off a large twig to the rectus 
inferior, another to the obliquus externus, a third which passes 
under the optic nerve to be distributed to the rectus internus, and 
lastly a filament which forms the inferior root of the lenticular 
ganglion. Next we find the abductor oculi (moteur externe), or 
sixth pair, which penetrates the orbit through the same foramen 
as the preceding, and immediately enters the rectus externus 
muscle. All these branches are at first situated on the outer side 
and around the optic nerve, and are afterwards dispersed among 68 
of tiil iilao. 
the five essential motores muscles of the eye. The researches 
of Chas. Bell * induced him to think that these nerves presided 
over the voluntary motions within the orbit. The fourth pair 
(pathetici), according to the same author, preside over the instinc- 
tive movements of the trochlearis muscle, and are therefore con- 
genial with the filaments of the facial, which are motors of the 
orbicularis palpebrarum muscle. Jn fact, at the moment of sleep, 
as well as at the approach of death, at the same time that the 
upper eye-lid falls the eye is raised by the action of the troch- 
learis, because the will no longer has power over the recti 
muscles, etc., which alone obey its orders. On the other hand, 
if we destroy the facial nerve, the eye-lids will remain open and 
immoveable, whereas the eye continues to move under the influ- 
ence of the will. The patient from whom Beclard extirpated 
the parotid gland, presented a striking example of this fact -j- 
It must be remarked, however, that in another patient, who came 
under the notice of M. Billard, J the side of the face was para- 
lysed in consequence of the destruction of the facial nerve, never- 
theless, the palpebrae continued moveable. 
Some nerves of another order are also met with in the orbit: 
these are filaments of the ophthalmic branch of the fifth pair 
(trigeminus), which, according to modern research, seem to ap- 
pertain exclusively to the sensitive function of the parts to which 
they are distributed : from which circumstance, if the trunk of the 
nerve is divided, the subject can no longer feel the contact of 
bodies applied to the eye-lids, eye, etc., as has been observed in a 
woman by Dr. Crampton, and in animals by M. Magendie. 
The lachrymal branch, before it is lost in the gland of the same 
name and the external angle of the eye-lids, gives off two small 
filaments which pass through the os malae in order to be distri- 
buted to the cheek and temporal fossa, and also form with a branch 
of the inferior maxillary the superficial temporal. It is situated 
between the rectus externus and the periosteum. 
The supra-orbital, placed upon the superior surface of the leva- 
tor palpebrae muscle, before passing out of the orbit anastomoses 
by its internal frontal branch with the nasal. As the latter passes 
+ Philosophical Trans, etc., 1823. and an Exposition of the natural system of 
the nerves, etc. London 1824. 
f Archives, Janvier 1824. J Archives November 1824. OF THE HEAD. 
69 
over the optic nerve, it gives off the superior root of the ophthalmic 
ganglion; it then approximates the inner wall of the orbit, running 
between the trochlearis and adductor oculi, where it gives off the 
ethmoidal filament and afterwards comes out at the great angle. 
Finally, the superior maxillary nerve sends into the orbit the 
infra-orbital, which is at first half uncovered in its groove, but 
afterwards completely enclosed in its canal, previous to its en- 
trance into the fossa canina; it also gives off the orbital filament, 
which anastomoses with the lachrymal and deep-seated temporal 
branches, and which follows the direction of the spheno-maxillary 
fissure. 
3d. The arteries of the orbit are derived from the ophthalmic, 
and have nearly the same distribution as the nerves; There are 
none so large as to require important surgical remarks. The 
supra-orbital only may be wounded in fractures of the vault of the 
orbit: and the meningea media sometimes sends a considerable 
branch through the sphenoidal fissure which supplies the place 
of the lachrymal. In the extirpation of the eye it is never neces- 
sary to tie these branches; their position and relations with the 
bones enable us to compress them readily. As they are derived 
from the carotids, it has been recommended to tie the latter in 
cases of aneurism within the orbit, and the operation has been 
performed by Mr. Travers of London. 
4th. The veins are larger than the arteries, which they generally 
accompany. There is usually one of larger size than the others, 
which passes from the face to the Sella Turcica, and forms a direct 
communication between the angularis and ophthalmic veins. By 
this communication we may partially account for the ready trans- 
mission of diseases of the organs contained within the orbital 
cavity to the encephalon, and vice versa. By it, also, we may 
perceive that the opening of the facial vein, in diseases of the eye, 
would produce a very prompt disgorgement, and probably we 
neglect this resource too much. All of these veins enter into the 
cranium through the sphenoidal fissure (foramen lacerum), and 
form, previous to their termination in the coronary sinus (sinus 
circularis of Haller and Soemmering), a more or less complicated 
plexus, which might be called the ophthalmic plexus. 
5th. The Lymphatics. Some of them are continuous with 
those of the face and proceed to the base of the lower jaw ; the 70 
OF T11E IIEAH 
others pass through the spheno-maxillary fissure into the paroti- 
deal region. 
6th. The lachrymal gland is concealed behind the external or- 
bitary process, and is so difficult to remove that, after the extir- 
pation of the eye, we are generally obliged to dissect it out 
separately. 
All the organs which have just been enumerated are separated 
by very large adipose cells, which are never entirely wanting, 
even in the most emaciated subjects. This fat is soft, almost 
semi-fluid, and forms an elastic cushion, which favours the move- 
ments of the eye, and prevents the recti muscles from drawing 
it backwards. Also, in consequence of the laxity of the cellular 
tissue which surrounds this organ, inflammations of the interior 
of the orbit promptly terminate in suppuration, and this suppura- 
tion rapidly detaches and disorganizes a multitude of import- 
ant parts. 
7th. The Periosteum of the orbit is a complex fibrous expan- 
sion, which seems to originate from the dura mater. As it enters 
this cavity it divides into two sheets, one of which embraces the 
optic nerve, and is confounded with the sclerotica; the other 
lines the bones, is reflected upon them at the base of the orbit, 
and seems to produce the palpebral ligament, on the one hand, 
and to blend itself with the periosteum of the forehead, on the 
other. 
8th. Lastly, the hones, which are numerous, and several of 
them present some striking peculiarities. The superior paries, 
or vault, is formed by the orbital portion of the os frontis, except 
in its posterior tenth, where we find the small ala of the sphe- 
noid, which is perforated obliquely forwards and outwards by 
the optic foramen. Through this hole the optic nerve and 
artery pass; above it, between the laminae of the periosteum, 
the superior rectus and levator muscles originate, one above the 
other; and between them, but a little more internally, the trochle- 
aris. That portion of the vault which appertains to the os frontis 
is so thin and brittle that it might be perforated by the point of 
the bistoury in extirpating the eye, if proper precautions were not 
taken. The tenuity of the bone also renders it objectionable, in 
this operation, to apply the actual cautery upon the parts which 
might be attached to it, because the dura mater and the anterior OF THE HEAD. 
71 
lobe of the cerebrum would be acutely irritated by the evolution 
of the igneous particles. It is also in consequence of this ana- 
tomical disposition that instruments penetrating into the upper 
part of the orbit so frequently give rise to serious accidents, even 
death itself. In fact, they traverse the bone with the greatest 
facility, and then lacerate the brain. Finally, it is through this 
part that balls get into the cavity of the cranium, when they have 
entered by the orbit; it is through this that Garengeot, J. L. 
Petit, etc. have seen ram-rods, swords, etc. penetrate into the 
skull and occasion death, and it is but recently we observed a 
case, in a student at law, who died at the hospital of la Faculte, 
where a ball passed into the cranium at this part, crossed the 
whole extent of the lateral ventricle, tearing up the parietes of 
this cavity, and lodged in one of the superior occipital fossae. 
On the outer side of this paries, and near the edge of the orbit, 
is the fossette in which the lachrymal gland is situated. This 
excavation is sometimes pretty deep, and requires attention when 
we extirpate the eye, if we wish to remove the gland at the 
same time. 
The floor of the orbit is triangular, but more plane than the 
latter. It is formed, anteriorly and externally, by the os malse; in 
its most posterior part, by the superior surface of the orbital pro- 
cess of the os palati, and throughout the rest of its extent by the 
superior wall of the maxillary sinus The two sutures which 
unite these three bones, adhere pretty firmly to the periosteum, 
and give passage to some small emissary veins. This paries is 
grooved out in its two posterior third portions by the infra-orbi- 
tal gutter, through which the nerve, artery and vein, of the same 
name, take their course ; these organs, therefore, may be wounded 
by an injury inflicted upon the floor of the orbit. The anterior third 
of this gutter is converted into a canal, which conducts the same 
organs into the fossa canina. As the floor of the orbit is very thin, 
and corresponds to the maxillary sinus, tumours which are deve- 
loped in the latter cavity tend to compress the eye, and, if 
greatly enlarged, to thrust it outwards. Pointed instruments also 
may easily penetrate into this sinus; hence it has happened that 
surgeons, in operating for fistula lachrymalis, by directing the point 
of the bistoury too much outwards or backwards, have thrust it 72 
OF THE HE AH, 
into this cavity, and afterwards have introduced the eanula into 
the same place, considering it to he the nasal canal. 
The internal wall, placed in (he direction of the horizontal axis 
of the head, is formed, anteriorly, by the posterior half of the ex 
ternal face of the os unguis, upon which the muscle of Horner 
is attached, and by the plane surface of the ethmoid; at its 
most posterior part, by a small portion of the sphenoid bone. 
The sutures which connect these bones, and those which unite 
them to the superior and inferior parietes, present nothing re- 
markable, unless it is the fronto-ethmoidal, in the tract of which 
we meet with the internal orbital foramina, through which the 
ophthalmic artery and nerve send branches into the cells of the 
ethmoid, to the dura mater and nose. This wall is also very thin, 
and might easily be fractured during the extirpation of the eye. 
For this reason we consider it best, in performing this operation, 
to introduce the curved scissars flat-wise along the internal side 
of this organ, in order to divide its pedicle, rather than to pass it 
along the externa] paries. 
The external wall is formed by the os malae anteriorly, and by 
the great ala of the sphenoid posteriorly; it is firm and solid, and 
corresponds to the temporal fossa; it is separated from the vault 
by the sphenoidal fissure. This fissure encloses internally, where 
it is broadest, a pedicle, from which arise, in part, the superior, 
external and inferior recti muscles; the third, fourth, ophthalmic 
branch of the fifth, and sixth pair of nerves ; the lachrymal vein. 
A cutting instrument might be easily pushed through it, and wound 
the middle lobe of the cerebrum. 
The spheno-maxillary fissure separates the external and infe- 
rior regions of the orbit. Less complicated than the preceding, 
it is filled with fat and a dense fibro-ccllular tissue ; we also see 
in it the infra-orbital nerve and vessels. Foreign bodies entering 
in at the eye, or orbit, might easily penetrate through it into the 
zygomatic and pterygo-maxillary fossae; therefore, in the extir- 
pation of the eye, we should be careful how we dip the bistoury 
in this direction, for we might wound the internal maxillary ar- 
tery, the supra-maxillary nerve, the ganglion of Meckel, etc. 
This external wall is very oblique outwards, which makes it 
appear shorter than the internal. The conjoined base of these OF THE HEAD. 
73 
four surfaces forms the orbitary circle, which is obtuse and round- 
ed in its internal half, but more or less acute in its external por- 
tion. Therefore, in extirpating the eye, we should introduce the 
bistoury at the great angle, carry it along the internal paries, and 
afterwards follow the inferior semi-circumference of the orbital 
cavity until it reaches the temporal angle, then bring back the 
instrument to the point where first introduced, and complete the 
circle bv following the superior paries. This method is not only 
the most speedy, but it is likewise attended with less risk of in- 
troducing the point of the instrument into the sphenoidal and 
spheno-maxillary fissures than if we should commence at the 
external angle. In the first incision, according to this process, 
we only separate the palpebral from the ocular conjunctiva, the 
external oblique muscle, and the cellular tissue which unites the 
muscles to the orbit; in the second, we cut the double tendon of 
the trochlearis and a layer of cellular tissue, which is a little 
more dense than inferiorly. Then the lachrymal gland is sepa- 
rated from its fossette, if we carry the bistoury sufficiently near 
the bones. The eye is now connected to the apex of this cavity 
merely by a pedicle, which is composed of the four recti, troch- 
learis, and levator palpebroe muscles, of the ophthalmic vessels, 
optic nerve, and all the other nerves of the orbit; which pedicle 
is easily divided with one stroke of the scissars. 
The apex of the orbit being very narrow, the eye is with diffi- 
culty drawn back into it, even if there should be no fat to pre- 
vent it. 
Sect. 4. Zygomoto-Maxillary Region. 
It comprises all the parts which compose the pommette* (ma- 
lar protuberance), on the one hand, on the other the canine fossa, 
and all the organs which cover it. It is bounded, superiorly, by 
the orbitary region ; inferiorly, by the genial region: externally, 
by the temporal and masseteric regions, and internally, by the na- 
sal region. 
This region presents, superiorly and externally the jugal emi- 
nence, which is more or less sharp or rounded, more or less prom- 
* Pommette—the name which French anatomists give to the prominent part 
which the face presents below the external angle of each eye. This part is former! 
by the integuments and os mala;.—Transl. 74 
OP THE 1IEAU. 
inent, according to the nation, age, sex, and individual, and 
which has much influence over the expression of the counte- 
nance. Internally, and below this protuberance, there is, in 
many subjects, a groove, which runs obliquely downwards and 
outwards, extending from the great angle of the eye to the geni- 
al region, and separating the fossa canina from the malar protu- 
berance (pommette) : this is the naso-jugal furrow,* above which 
we find the orbicularis palpebrarum and superior portion of the 
zygomatic muscles, which it crosses; below it are the levators 
of the nose and lip, and the buccinator. Another oblique furrow 
extends, in the same direction, from the ala nasi to the angle of 
the lips; this is the naso-labial furrow, which separates the labial 
region from the one under consideration, and which is more con- 
stant than the preceding.! 
CONSTITUENT PARTS. 
i. The Skin. 
It is generally smooth and delicate, more highly coloured upon 
the jugal prominence: it is upon this point that the febrile blush 
appears in pulmonary inflammations, that the yellow or dirty 
tint is manifest in diseases of the liver and internal suppurations. 
Inferiorly, and externally, but in man only, it is covered with a 
few hairs; a great number of follicles exist in it, in which tannes 
(acne punctata) sometimes form and sometimes undergo chronic 
enlargement forming what are called the gutta rosea. 
ii. The Adipo-Ccllular Tissue. 
It forms a layer which varies in thickness according to the de- 
gree of obesity of the individual, and also according as it corres- 
ponds to the muscles or their interstices. Upon the malar emin- 
ence it is dense, filamentous and contains but few adipose cells ; 
and as it is the only part which exists between the skin and the 
* M. Jadelot calls this furrow the oculo-zygomatic trait, and considers it a diagnos- 
tic sign of diseases of the cerebro-spinal system in children. 
f This M. Jadelot calls the nasal trait, and refers it to affections of the abdomina 
organs. OF THE HEAD 
75 
bones, it is consequently very adherent in this situation; there- 
fore, it is important, when we operate upon the face, to pre- 
serve as much of this adipo-cellular tissue as possible, otherwise, 
from its unyielding nature, the lips of the wound will not come 
into contact so as to unite by the first intention. Internally and 
inferiorly the cellular layer is very thin, and the adipose vesicles 
which it contains are small and few in number : it unites the skin 
intimately to the levatores labii superioris et aim nasi. This com- 
pact union renders its inflammations very painful, and gives them 
an erysipelatous rather than a phlegmonous character. In the 
fossa canina the cellular lamellm are more lax ; the adipose vesi- 
cles very large and numerous. They dip between the muscles, 
fill the osseous excavation, and communicate with those of the 
genial region. They envelope all the vessels and nerves, and as 
they do not adhere firmly to the skin, it follows that we can bring 
its wounds together by means of straps, bandages, or sutures, bet- 
ter than upon the malar eminence, so as to induce them to heal 
by the adhesive union. Finally, as this cellular layer is thicker 
and its meshes farther asunder in the canine fossa than internally 
and externally, it follows that inflammations are more frequent in 
it, and more liable to terminate in suppuration. 
in. The Muscles. 
In this region we find, in proceeding from the nose towards the 
malar eminence the levator labii superioris alasque nasi, the leva- 
tor labii superioris proprius and the zygomatici muscles which 
converge as they descend, and adhere to the skin or are sepa- 
rated from it by the cellular layer only. It is necessary to keep 
in mind their direction when we operate upon the face, because 
their transverse section would derange the motions of the mouth. 
Behind the first, consequently deeper seated, we find the dilatator 
vel compressor naris (transversal du nez), concealed by the leva- 
tor communis, and the levator anguli oris which partly covers the 
levator proprius and sometimes a small portion of the zygomati- 
cus minor. The levator anguli oris is separated from the inter- 
nal membrane of the lips only by a thin but dense laminated 
tissue. Between the inferior loops of the orbicularis palpebrarum, 
the levator proprius and zygomatici, there is generally a consid- 76 
or THE HEAD. 
erable space, which is filled only by the cellulo-adipose layer, 
vessels and nerves, and by which we penetrate into the fossa 
canina. 
iv. The Arteries. 
They either terminate in this region or simply pass through it. 
The infra-orbital artery comes out of the sub-orbital foramen, 
which is opposite to the middle of a line drawn from the inferior 
margin of the os nasi to the lower part of the malar eminence, 
and enters the canine fossa. It is situated behind the levator 
proprius muscle, on a level with its external border, before and 
above the levator anguli oris. It is separated from the os max- 
illare superius by the nerves and cellular tissue, and from the 
orbicularis palpebrarum muscle, by the facial vein and adipose 
vesicles. This artery is distributed to the nasal and labial regions, 
and anastomoses with their proper vessels. The transverse 
facial artery, which terminates in this region below the jugal 
prominence, is sometimes so large as to occasion hemorrhage; 
but, as it creeps through a lax lamellated tissue, it may be readily 
secured, if it should become necessary. The facial artery gene- 
rally runs along the internal and inferior limits of this region, 
traversing the levatores anguli oris et labii proprius, behind the 
naso-labial furrow; it then reaches the great angle of the eye, 
where it anastomoses with the ophthalmic, after having received 
the name angularis. 
v. The Veins. 
The facial vein is the only one which merits some attention. 
It does not follow the direction of the arteries, which, for the 
most part, (the infra-orbital excepted) have no vena3 comites. 
This vessel runs in an almost direct line from the internal angle 
of the eye, and seems to be the continuation of the frontal: near 
its origin it communicates with the veins of the orbit; before 
the masseter, as it passes beneath the naso-jugal furrow, it is sub- 
cutaneous, or covered, superiorly, by the inferior fibres of the 
orbicularis palpebrarum muscle: inferiorly, it is enveloped in the 
cellulo-adipose tissue which separates the zygomatici from the OF THE HEAD. 
77 
levator anguli oris and buccinator muscles, and is crossed ante- 
riorly by the ramifications of the facial nerve ; posteriorly by the 
buccal and infra-orbital nerves. 
vi. The Lymphatics. 
They are few in number and pass to the submaxillary lymph- 
atic glands. No absorbent glands have as yet been discovered in 
this region. 
vii. The Nerves. 
We here find the termination of the superior maxillary or 
infra-orbital nerve, which is at first situated on the outer side of 
the artery; its branches then diverge and are lost in the skin 
of the lips, nose, cheek and that which covers the inferior or- 
bital arch, anastamosing in most of these points with filaments' 
from the fascial. When we are perfectly satisfied that this nerve 
is the cause of the tic douloureux of the face, and desire to divide 
it, we may easily fall upon it, between the orbicularis palpebra- 
rum and the origin of the levator labii proprius, by cutting upon 
the naso-jugal furrow. We would then have to reflect the facial 
vein outwards, and the levator inwards; the skin and cellular 
tissue being thus divided, we will see the nerve very near the 
origin of the levator anguli oris. This method appears to us to 
be more simple than that of Langenbeek.* 
The zygomato-maxillary region also receives numerous fila- 
ments from the temporo-facial branch of the respiratory of the 
face (poriio dura). They generally cross the anterior surface of 
the vessels, and are at first enveloped in the subcutaneous layer; 
afterwards, lost in the muscles. The investigations and experi- 
ments of Shaw, Charles Bell, etc., render it probable, if not cer- 
tain, that the muscular movements of this region are under the 
influence of the portio dura; whilst the infra-orbital nerve pre- 
sides over the sensitive functions. There are also some small 
filaments from the lachrymal which anastomose upon the os ma- 
lae; but they can only serve to explain some sympathetic affec- 
tions. 
'r Bibliotheque Chirurg. No. tic 1821. 78 
OF THE 1IEAV. 
viii. The Skeleton. 
In this region we find the os malae, which, although possessing 
considerable solidity, is nevertheless exposed to fracture, on ac- 
count of its superficial situation, externally especially, where it is 
no longer supported by the superior maxillary bone. From it the 
two zygomatic muscles originate ; but more superiorly, and pos- 
teriorly, it is only separated from the skin by the dense cellular 
tissue before mentioned, by the malar branches of the facial nerve, 
the malar twigs of the lachrymal artery and nerve, as well as the 
transverse facial branch. In consequence of this dense, nervous 
and vascular texture, the inflammations which occur upon the 
malar eminence are very painful, and the skin which covers it is 
more sensible and higher coloured. The os maxillare superius 
presents, in this region, all the anterior wall of the antrum, into 
which it would be much easier to penetrate, by following the 
method recommended for the division of the infra-orbital nerve, 
than by acting upon the obtuse crest which separates the fossa 
canina from the malar tuberosity, as recommended by Lamorier. 
This wall of the sinus is so thin and brittle, that it might be perforat- 
ed without much difficulty, even by an instrument with a rounded 
extremity: but then the anterior dental nerves, derived from the in- 
fra-orbital previous to its entrance into the fossa canina, must be 
torn or stretched out of their place. Howr much more liable then 
is it to be traversed by a pointed instrument: a small sword, for 
instance, if thrust violently upwards and backwards, might even 
penetrate through the floor of the orbit, after having passed through 
this sinus, and thus wound the different parts contained within it; 
and if the force with which it is pushed is not exhausted, it will 
break through the orbitary vault, and entering the cranium, lead to 
mortal consequences. The position of this sinus also permits pol- 
ypi, which are developed within it, to become prominent upon the 
face, after having destroyed its anterior paries. The periosteum 
in this region, is not very compact upon the maxillary bone, and 
it is easily separated from it by inflammation. This, therefore, 
accounts for necrosis and caries being very frequently attendant 
upon diseases of the teeth, etc. OF THE HEAD. 
79 
Sect. 5. The Masseteric Region. 
It is bounded by the margins and attachments of the masseter 
muscle. Consequently, we find anterior to it the zygomato-max- 
illary and genial regions; posteriorly, the parotideal; superiorly, 
the temporal; and interiorly, the supra-hyoideal regions. 
Upon the face of most subjects, it forms a prominence which 
varies in proportion to the size of the parotid and masseter, and 
especially to the inclination of the angle of the jaw. 
CONSTITUENT PARTS. 
i. The Skin. 
This is thicker than the skin of the parotideal and genial re- 
gions, and of a compact, unyielding texture. In man, it is cov- 
ered with a great number of hairs, contains also sebaceous folli- 
cles, but presents nothing remarkable in a surgical point of view. 
ti. The Subcutaneous Layer. 
This layer is seldom very thick, and consists of a lamellated 
cellular tissue, which becomes blended with the fascia of the par- 
otideal and supra-hyoideal regions, is lost anteriorly in the cellular 
tissue of the genial region, gives a sheath to the canal of Steno, 
envelopes the superficial nerves and vessels, and is separated from 
the skin by some fibres of the platysma. This stratum may 
therefore be considered as being formed of two cellular laminae ; 
one of which is immediately beneath the skin, and sometimes en- 
velopes a considerable quantity of adipose vesicles; the other, 
which is more dense, invests the masseter, and forms a complete 
aponeurosis; whence it follows, that, in wounds of this region, 
we may employ uniting means with much more advantage than in 
the other points of the face ; whence, also, tumours and abscess- 
es which form under the second lamina, remain for a long time 
flattened, and become of considerable breadth before they ele- 
vate the skin; whereas the same affections, when developed be- 
neath the first lamina, soon become quite prominent. These 80 
OF T1IE HEAD. 
peculiarities should be attended to, as they will assist us in forming 
our diagnosis or prognosis of certain diseases. 
hi. The Muscles. 
There is only one muscle on the outer side of the jaw, which 
is the masseter. It originates from the inferior border of the 
zygomatic arch to within a few lines before its horizontal ramus. 
The posterior, anterior and middle fibres run forwards, back- 
wards, or directly downwards, but do not constitute three mus- 
cles, as Winslow describes it. The masseter muscle cannot, 
when the jaw is depressed, assist in luxating this bone ; but, at 
the moment the condyle is about to pass into the zygomatic fossa, 
its posterior fibres may draw the maxillary angle upwards, and 
thus concur in the depression of the chin. This muscle is fre- 
quently the seat of rheumatism, which may be accounted for by 
the quantity of fibrous tissue entering into its composition Its 
fibres being parallel to the axis of the body, and no important 
vessel crossing it, the incisions which we make in this region 
should be as near the perpendicular as possible. We must pay 
attention, however, to the parotid duct which crosses the superior 
part of this muscle. 
iv. The Arteries. 
The superficial branches are derived from the external carotid 
and facial, a deep branch from the internal maxillary. The trans- 
verse facial originates from the former; it crosses the muscle, en- 
veloped in the lamina? of the aponeurosis, four or five lines below 
the zygomatic arch, and one or two lines above the parotid duct; 
it then enters the zygomato-maxillary and genial regions, and 
anastomoses, inferiorly and anteriorly, with the twigs which are 
detached from the facial as it passes before the masseter. It is 
sometimes so large as to occasion haemorrhage. There are, in 
certain individuals, one or more transverse facial arteries below 
the canal of Steno, but they are generally so small that they 
scarcely deserve surgical attention. The masseteric artery, in its 
course to this muscle, passes through the sigmoid notch, before the 
maxillary condyle, behind the tendon of the temporalis and above OF THE HEAD. 
81 
the pterygoideus externus, so that it may be compressed or lace- 
rated when the condyle of the lower jaw is luxated or fractured. 
v. The Veins. 
They are of but little importance to the surgeon: some of 
them accompany the arteries, the others take a distinct course. 
They generally form a communication between the facial and 
external jugular veins ; but they empty more especially into the 
latter. 
vi. The Lymphatics. 
These vessels are more numerous in this than in the other 
regions of the face, and pass into the submaxillary and parotideal 
lymphatic glands; whence the rapid engorgement which takes 
place in the latter organs in some diseases of the masseteric 
region. 
vii. The Nerves. 
One of them comes from the inferior maxillary, follows the 
masseteric artery, and is lost in the masseter muscle. The 
others are the temporo-facial and cervico-facial branches of the 
respiratory nerve of the face. The first forms a complete net- 
work in the aponeurosis above and below the duct of Steno and 
the transverse facial artery. The filaments of the second being 
less numerous, it follows that wounds are less dangerous in the 
inferior than the superior part of the region. 
viii. The Canal of Steno. (Parotid Duct.) 
This canal having emerged from the parotid, crosses the mas- 
seter, upon which it is immediately applied. We have previously 
said that it received a sheath from the aponeurosis. It is covered 
by nerves, the largest of which run above it, and upon its supe- 
rior margin also lies the transverse facial artery. It is situated 
eight or nine lines below the zygomatic arch, posteriorly; three 
or four only, anteriorly. Between it and this arch there is some- 82 
OP THE HEAD. 
times a distinct glandular lobule, which is the accessory of the 
parotid. The presence of’ this canal must make us very circum- 
spect in forming our diagnosis or prognosis of wounds or ulcers 
of this region, as well as in the performance of operations upon 
it. In fact, as it is more or less superficial, in proportion to the 
embonpoint of the individual, it might be readily opened and give 
rise to fistulous wounds of very difficult cure; especially, as 
salivary fistulae, in this situation, do not admit of the employment 
of M. Deguise’s method, the only chance of success being af- 
forded by the use of the caustic or setons. 
ix. The Skeleton. 
It comprehends the zygomatic arch and the whole ramus of 
the jaw. The superficial position of the arch, and the slender- 
ness of the bones which compose it, render it very susceptible of 
fracture from a direct cause. These fractures are not dangerous 
from the derangement of function which the displaced fragments 
produce, but in consequence of the inflammation and abscesses 
which may supervene in the temporal or zygomatic fossae. An 
instrument introduced under this arch would easily penetrate 
into the zygomatic fossa, and even enter the cranium, if its 
point was directed slightly upwards; from which might result a 
wound of the middle meningeal artery, etc. 
The ramus of the inferior maxillary bone presents, in this 
region, three points for consideration: 1st. the angle, which is 
curved outwards in some individuals, and upon which the princi- 
pal force is applied in indirect fractures of the body of this bone ; 
2d. the condyle, which may be fractured at its neck, and as the 
pterygoid, in this case, draws its inferior portion forwards, the 
reduction is rendered very difficult; 3d. the coronoid process, 
which prevents the luxation of the condyle, excepting when the 
jaws are extensively separated; for otherwise, it would be 
checked by the posterior face of the os malce. As this process 
is enveloped by the tendon of the temporal muscle, if it was 
detached from the rest of the bone, it would be drawn towards 
the temporal fossa. In the interval of these three parts, the 
ascending portion of the jaw is entirely covered by the attach- 
ments of the masseter; so that a fracture of this part will rarely OF THE HEAD. 
83 
be attended with displacement. Internally, this bone forms a 
part of the zygomatic fossa, which, as it may be considered an 
appendage to the masseteric region, we will now examine. 
This fossa encloses the two pterygoid muscles, which are so 
disposed that the external is rather a depressor of the lower jaw 
than its elevator. Between these two muscles, we find the infe- 
rior dental artery and nerve, the internal ligament of the articu- 
lation, the lingual branch of the fifth (gustatory) etc., descend- 
ing in an oblique direction ; quite internally, the levator and cir- 
cumflexus palati, and the superior constrictor pharyngeus: the 
space which intervenes between the latter and the former is 
filled by a lamellated tissue, and frequently by a process of the 
parotid gland. It is in the upper part of this space that we find 
the different branches of the inferior maxillary nerve enveloped by 
the fibres of the origin of the external pterygoid. Consequently, 
we also find here the auricular nerve, which originates from the 
trunk by two roots, between which the middle meningeal artery 
passes ; the gustatory and dental, which here form a communica- 
tion with each other by means of a cord of greater or less 
volume; the gustatory also receives, in this situation, the corda 
tympani. These three branches are situated behind the external 
pterygoid. We also see, in the fibres of this muscle, above or 
before it, the masseteric, temporal, buccal, and pterygoidean 
twigs ; whence it follows that the former would be easily reached 
by an instrument which would traverse the sigmoid notch* of 
the inferior maxillary bone ; but if we wish to divide them, we 
can only succeed by detaching the parotid and the arteries from 
the posterior margin of the jaw, between the twTo branches of the 
facial; and even then we might only reach the dental and 
gustatory. 
The internal maxillary artery and its thirteen branches are 
also distributed in this fossa; all these branches, except the me- 
ningea media, are accompanied by veins which empty into the 
jugulars, and which establish relations in the circulation between 
the nose, orbit, and parotideal region, which the pathologist 
should not be ignorant of. 
At the anterior part of the bottom of the zygomatic fossa is 
* The sigmoid notch separates the condyle from the coronoid process.— Trans!. 84 
or Tin; HEAD. 
the pterygo-maxillary fissure, in which we find, from above 
downwards, the superior maxillary nerve, which passes from the 
cranium into the orbit, the spheno-palatine ganglion and the 
origin of its vidian, palatine, spheno-palatine, etc. branches; the 
termination of the internal maxillary artery, which there gives 
off the spheno-palatine, ptorvgo-palatine, vidian and superior 
palatine arterial branches. We may easily pass an instrument 
through the spheno-maxillary fissure of the orbit into this fbs- 
sette, and we perceive how dangerous wounds in this point 
would be. The bones which compose the pterygo-maxillary 
fossa are somewhat numerous. Its anterior paries is formed by 
the posterior part of the superior maxillary bone, which is perfo- 
rated by a great number of small holes for the transmission of 
the superior and posterior dental filaments, and which will bulge 
out more or less, according as the last molar tooth is contained 
within it or not. It is in the upper and outer part of this paries 
that we see the commencement of the infra-orbital groove. The 
anterior surface of the pterygoid process, perforated at its base 
by the Vidian foramen, forms the posterior paries; the internal 
is constituted by the external surface of the os palati. It is hol- 
lowed out and converted inferiorly into a canal, in the formation 
of which the anterior paries of the fossa concurs: this is the 
posterior palatine canal, along which the artery and nerve of the 
same name pass to the mouth. In the upper part of this paries, 
we see the pterygo-palatine foramen, through which vessels and 
nerves penetrate into the nasal fossm. Polpyi of the nose might 
also make their way through this foramen, and thus get into the 
zygomatic fossa. We saw a remarkable case of this kind in 
1823. The superior paries of the zygomatic fossa does not exist, 
properly speaking ; it falls into the sphenoidal fissure and enters 
the cranium. 
The bones which enter into the zygomatic fossa, properly so 
called, are, anteriorly, the concave part of the os malae, then the 
external surface of the molar portion of the supra-maxillary bone ; 
superiorly, the zygomatic portion of the great ala of the sphenoid, 
to which the external pterygoid muscle is attached; internally, 
the external surface of the pterygoid process ; and externally the 
ramus of the jaw, in the middle of which we observe the orifice 
of the dental canal: a disposition which explains why fractures 85 
OF THE HEAU 
of the neck of the condyle, &c., less frequently produce serious 
accidents than those which correspond to this foramen. 
Sect. 6. The Genial Region. 
It is wedged as it were between the mental, labial, zygomato 
maxillary, masseteric and sub-maxillary regions. Its limits can- 
not be otherwise than arbitrary, and its surgical importance is 
particularly derived from salivary fistulas and the passage of the 
facial artery It is sometimes prominent, at others excavated, 
and in many individuals it presents one or two fossettes, which 
are owing to the contraction of the muscles. 
CONSTITUENT PARTS. 
i. The Skin. 
The skin is delicate and smooth in women and children, but 
in man it is covered by the hairs of the beard ; and although it is 
not intimately adherent to the subjacent parts, yet it does not 
move so freely over them as in the masseteric region. 
ii. The Cellulo-Adipose Tissue. 
It forms a considerable mass anterior to the masseter, between 
the buccinator and the integuments, and is thereby continuous 
posteriorly with that of the temporal fossa: which explains the 
manner in which abscesses of one of these regions communicate 
with the other. The absence of this fatty mass occasions the 
excavation of the cheeks in thin persons. Inferiorly and ante- 
riorly, the adipose cells become smaller and smaller, and at 
length terminate by uniting intimately with the muscles and the 
skin, so that phlegmonous abscesses are more easily formed pos- 
teriorly. 
The cellular tissue is dense or lax, in proportion to the thickness 
of the adipose layer. Its quantity does not vary; but its lamel- 
lae are more or less separated from each other, according to the 
volume of the adipose vesicles. It is from this that the massete- 
ric aponeurosis seems to originate. 86 
OF THE IIFA1) 
in. The Muscles. 
The facial portion of the platysma frequently forms a triangu- 
lar bundle, the base of which is at the masseter and the apex at 
the angle of the lips. This muscle (risorius Santorini) is some- 
times very strong, and its contractions occasion those dimples 
(fossettes) just spoken of, which add to the beauty of the female 
countenance. It is situated in the lamellae of the subcutaneous 
cellular tissue. In the inferior part of this .region, and separated 
from the skin by the platysma, is the depressor anguli oris, the 
fibres of which converge as they approximate the labial angle. 
The buccinator is the principal muscle in this region. Posterior- 
ly, it is separated from the skin by the adipose mass previously 
spoken of, and by the platysma ; anteriorly, it is almost in direct 
contact with it. Its external surface is covered by a fibrous ex- 
pansion which is given off’ by the parotid duct before it perfo- 
rates it: this expansion, being prolonged backwards, becomes 
blended with the bucco-pharyngeal aponeurosis, which attaches 
itself to the base of the coronoid and to the internal ala of the 
pterygoid process. A foreign body, a sword, for example, thrust 
between this aponeurosis, which is internal, the masseter and 
coronoid process which are external, might penetrate into the 
zygomatic fossa, even to the bottom of the parotideal region, and 
thereby wound the internal maxillary artery, the inferior maxilla- 
ry nerve, the internal carotid and jugular, the parvagum, great 
sympathetic, etc. Internally, the buccinator is separated from 
the buccal membrane by a dense and thin cellular lamina, in 
which is found, posteriorly, the molar glands, which are some- 
times very large, being perfect glands, each possessing their ex- 
cretory duct, and not simple follicles. When we are obliged to 
make incisions on the inner part of the cheek we should recollect 
that the fibres of the buccinator are nearly horizontal. 
iv. The Canal of Steno. 
It is accompnnied by a considerable branch of the facial nerve 
and terminates in this region by curving over the anterior mar- 
gin of the masseter, four or five lines before which it penetrates OF THE HEAD. 
87 
the buccinator: it is then also about four lines distant from the 
malar eminence. From this disposition, then, it follows, that the 
operation of M. Deguise for the cure of salivary fistula? is not so 
simple as might be supposed; for the posterior extremity of the 
canula or tent must traverse a considerable thickness of parts 
before it reaches the mouth; besides, this method can seldom be 
applicable, since it can only be resorted to when the disease ex- 
ists some lines anterior to the masseter. Now, the short tract 
which the canal has to traverse in this place, and its depth in this 
situation, prevents its being frequently wounded at this part. 
We may say the same of the advice which we gave in 1823,4 
i. e. to introduce an instrument into the mouth, and make an 
opening in the canal nearer the gland than the fistulous aperture 
in the skin. So with the methods of Leroy, J. L. Petit, Duphenix, 
etc. in which the rule is to perforate the cheek in any manner 
whatsoever. The walls of the parotid duct are much thicker in 
the genial region, so that its volume is considerably augmented; 
but when it is about to perforate the buccinator, it leaves upon 
the external surface of this muscle the fibrous envelope which 
it had derived from the parotideal aponeurosis; so that it is much 
more slender between the fleshy fibres than before it penetrated 
them. Its internal opening is four or five lines below the point 
where the mucous membrane unites with the gums, and general- 
ly opposite the last molar tooth but one. From the masseter to 
the orifice, the canal of Steno represents an arc of a circle the 
convexity of which looks forwards and outwards. Hence the 
utility of everting the fore part of the cheek with one or two 
fingers introduced into the mouth, whilst we push inwards with 
the thumb the portion in proximity with the muscle, as recom- 
mended by Louis, when we wish to introduce a stylet, probe, 
seton, etc. into it. It is in fact this curvature, and the laxity of 
the organ, which oppose the introduction of instruments into the 
duct by the mouth, and not a pretended valve, which does not 
really exist. 
v. The Arteries. 
The only artery of importance in this region is the facial. It 
* Th&se inaugurate. 88 
OF THE HEA.H. 
enters the region at the lower part of its posterior boundary; that 
is to say, before the masseter. In this situation it lies upon the 
bone, behind the depressor anguli oris, being separated from the 
skin merely by cellular tissue and the platysma; so that we are 
able to make firm compression upon it here, when about to oper- 
ate upon the face. It would also be very easy to apply a ligature 
around it, if any diseases of the organs to which its branches are 
distributed should seem to demand it. If, when we wish to com- 
press it, the edge of the masseter is not sufficiently evident through 
the skin, we should carry the finger forwards from the angle of 
the jaw, when we will soon meet with a superficial notch in 
which the artery is always placed. As the facial artery takes its 
serpentine course from this point towards the zygomato-maxillary 
region, it follows the direction of the posterior fibres of the trian- 
gularis (depressor anguli oris),which it traverses in order to enter 
the zygomato-maxillary region : the inferior coronary is given off 
from it whilst it is still in the genial region. It also gives off a 
great number of small branches, which anastomose posteriorly 
with the transverse facial, anteriorly with the mental, and superi- 
orly with the infra-orbital: all these branches, in fact, terminate 
in part in the region under examinnation. We likewise find here 
the buccal coming from the internal maxillary, upon the external 
surface of the buccinator muscle, and communicating internally 
with the alveolares and inferior dental; these twigs, however, are 
of no importance in surgery. 
vi. The Veins. 
The large facial vein alone merits some attention. In the zygo- 
mato-maxillary region, it was remote from the artery ; as it tra- 
verses the genial region, it approximates it, and at length covers 
it, when about to pass into the supra-hyoideal region. This want 
of parallelism between the two principal vessels of the face, is 
owing to the vein being free from curvatures in its course from 
the great angle of the eye to the fore part of the masseter, whilst 
the artery, in passing through the same tract, is very tortuous. 
Furthermore, notwithstanding the magnitude of the vein at the 
lower part of the face, it would be dangerous to draw blood from 
it., on account of the proximity of the artery. OF THE HEAD. 
89 
vii. The Lymphatics. 
These vessels are as yet not well understood ; they are a con- 
tinuation of those which were observed in the upper part of the 
face ; they run into the submaxillary lymphatic glands. There 
are also some deep-seated vessels which pass to the carotic or sub- 
mastoid cervical glandules. 
vm. The Nerves. 
The nerve which appertains to this region is spread out upon 
the buccinator muscle, and for this reason is called buccal (n: 
buccinatorius). The others are, anteriorly and superiorly, fila- 
ments of termination from the mental and infra-orbital, which 
appear to be the nerves of sensation; posteriorly, some filaments 
from the facial (portio dura), which rather appertain to motion. 
We have already mentioned that a considerable branch accompa- 
nied the superior margin of the parotid duct. 
ix. The Mucous Membrane. 
It is polished, delicate, very adherent to the cheek, and insinu- 
ates itself into the canal of Steno, which it lines as far as its radi- 
cles. It is by means of this mucous prolongation that the paro- 
tids sometimes become sympathetically inflamed in consequence 
of diseases of the mouth. Where this membrane is reflected 
over the dental arches {alveolar processes) it is very hard and 
thick, and forms the external part of the gums. Upon the latter, 
we discover neither follicles nor villosities ; but throughout the 
rest of the genial region, the mucous membrane is covered with 
a very distinct epithelium. 
x. The Skeleton. 
It includes that portion of the os maxillare inferius which is 
between the coronoid process and the mental foramen, as well as 
the external face of the superior and inferior dental arches, as far 
as the dens caninus. It should be noticed, that, when the inferior 90 
OF THE HEAD. 
maxillary bone is fractured in this region, the levator muscles 
being attached to the posterior fragment, keep it applied against 
the upper jaw. The anterior fragment, on the contrary, is liable 
to be drawn downwards by the depressors which originate from 
the os hyoides. 
Sect. 7. The Mental Region. 
This region is bounded on each side by the preceding; superi- 
orly, by the inferior labial grove, and inferiorly, by the supra-hyoi- 
deal region. It forms the inferior part of the face, and makes a 
projection, which varies according to age, sex, embonpoint; age 
especially: in the middle of it, and inferiorly, we sometimes ob- 
serve, during the elevation of the lower lip, a slight depression or 
dimple. 
CONSTITUENT PARTS. 
i. The Skin. 
The skin is much thicker than that of the preceding regions, 
bearing a great resemblance to that of the cranium ; that is to 
say, it is dense, compact, and very adherent to the subjacent tis- 
sues. It contains numerous small sebaceous glands, and is shad- 
ed with an abundance of hairs in man, which perforate it in a 
perpendicular direction, constituting the beard. When the cryp- 
tae inflame they give rise to the herpes pustulosus (<dartre pustu- 
leuse d’Alibert) of the chin ; when the sebaceous matter accumu- 
lates in them, it produces those small, red and painful pimples, 
which are cured by puncturing their apex, and squeezing out a 
white concrete substance. If this accumulation takes place more 
slowly, the crypt® become much larger, forming tannes. 
n. The Cellular Tissue. 
This is small in quantity, and does not form subcutaneous layers 
in this region ; it is blended with the muscles, and is merely con- 
nected to the skin by very short and very close filaments ; poste- 
riorly, between the muscles and bones only, there is a certain OF THE HEAD. 
91 
quantity of lamellated tissue. There arc numerous very minute 
adipose vesicles here, and their size is never decidedly augment- 
ed ; so that the embonpoint of the chin, strictly so called, can 
scarcely ever vary. It is in the cellular tissue nearest to the skin, 
between the fleshy fibres, that the bulbs of the hair are situated. 
The compact texture of the cellular element, its intimate union 
with the skin, and the very great density of the latter membrane, 
prevent the formation of abscesses in this region, and cause its 
inflammations to assume the erysipelatous character. 
hi. The Muscles. 
Upon the sides we meet with a small portion of the depressor 
anguli oris, the fibres of which ascend obliquely backwards ; more 
anteriorly, the quadratus gen®, the internal fibres of which blend 
themselves with those of its fellow on the opposite side ; towards 
the labial region, some fibres of the platysma, which are intermin- 
gled with those of the preceding and cover the external surface 
of the depressor anguli; at the centre, in the triangle which ex- 
ists between the quadrati, the superbus (levator menti). This 
small muscle arises by two fibrous pedicles from the two fossettes 
which are situated on each side of the symphysis: superiorly and 
posteriorly, it is invested by the mucous membrane; anteriorly, 
it is attached to the skin, and slightly covered by the quadratus. 
As its fibres are perpendicular to the axis of the body, it must, 
in contracting, approximate the skin to the jaw, elevate and pro- 
trude the lower lip. 
iv. The Arteries. 
Between the bone, the mucous lining of the lip, and the quad- 
ratus, we find, externally, the termination of the inferior dental 
(inf. maxillary) artery; inferiorly, some twigs of the submental 
which anastamose superiorly with other small branches from the 
inferior coronary; and lastly, some twigs which originate from 
the facial, below the giving off of the principal artery of the 
lower lip. These arteries, however, are too small to occasion 
troublesome haemorrhage when the mental region is wounded. 
In operations, should it become necessary to tie them, we must 92 
OF TIIE HEAD. 
expect some difficulties, for they retract within the muscles, and 
as they are enveloped in a compact cellular tissue, it is not easy 
to seize them with the forceps: therefore in such cases it is bet- 
ter to use the tenaculum or compression. 
v. The Veins. 
They accompany the arteries: some of them are pretty large 
and subcutaneous, and descend into the supra-hyoideal region in 
order to terminate in the lingual vein The superficial veins ram- 
ify principally in the skin ; they may become varicose, giving rise 
to that more or less deep red colour of the chin, which is ob- 
served in many individuals. 
vi. The Lymphatics. 
Almost all of these vessels pass directly to the submaxillary 
lymphatic glands. Hence in most diseases of the chin these 
glandules tumefy with the greatest facility. 
vii. The Nerves 
They come from the neck, from the inferior maxillary bone, 
and from the genial region. The former are some filaments 
from the nervus mylo-hyoideus and from the submental branch 
of the cervical plexus; the latter are twigs derived from the in- 
ferior branch of the facial. All these ramuscules are superficial. 
The inferior dental nerve, which comes out through the mental 
foramen, is deep-seated, and is distributed to the muscles. It is 
so situated that if it should be the seat of neuralgia, it might be 
easily divided and without danger. For this purpose an incision 
should be made within the lip, on a level with the canine or first 
molar tooth, when the nerve will be found some lines lower 
down, in contact with the bone, covered by some lamellated cel- 
lular tissue, and the quadratus muscle. 
vm. The Skeleton. 
This consists of the body of the lower jaw simply, and pre- OP THE IIEAH. 
93 
sents, upon the median line, the symphysis, which possesses so little 
solidity in the child that the two osseous pieces may be separated 
in consequence of external violence,—a blow, for example ; be- 
neath this line, a small triangular surface, which is covered mere- 
ly by the skin; and lastly, the mental foramen, quite near the 
limits of this region, opposite the first molar tooth: hence we may 
amputate a great portion of the chin, without including this fora- 
men in the section; and in this case, the principal branch of the 
dental nerve will not be divided, so that the pain and accidents 
consequent thereto will be avoided. In this amputation, we are 
advised to saw the bone in such a manner that its two surfaces 
may be of the same length, that is to say, perpendicular to its 
direction; but it seems to us, that it would be better to cut them 
sloping, at the expense of the internal surface, because, other- 
wise, the curvature would not permit the two divided ends to 
touch in all their points, if we wished to keep them in contact. 
In the adult, the inferior maxillary bone is so thick in this region, 
that its direct fractures are almost impossible. The prominence 
which it forms is greatest in the child, on account of the absence 
of the teeth, and the obtuseness of the maxillary angle. In old 
age, it again becomes more prominent, which is owing to the 
falling out of the teeth, and to the angle, which was more ap- 
proximated to a right angle in the adult, again becoming round- 
ed off, and more obtuse. With regard to its periosteum, there is 
nothing peculiar. The muscles are separated from it by a cellu- 
lar tissue, which is more distinct than the subcutaneous; hence 
its inflammations more frequently assume the phlegmonous char- 
acter, and as the buccal mucous membrane is all that intervenes 
between it and the mouth, superiorly and posteriorly, these small 
abscesses always open into the latter. Furthermore, as all the 
tissues possess less density in this direction than towards the skin, 
abscesses, of whatsoever nature they may be, have a greater ten- 
dency to direct their course internally than externally. These 
collections should always be evacuted from within, whereby less 
pain will be produced, and unsightly scars prevented. 
Sect. 8. The Labial Region. 
This region comprehends the two lips, and is bounded, supe- 94 
or TIIE HEAD. 
riorly, by the nose and the naso-labial furrow; inferiorly, by the 
mento-labial groove ;* and, laterally, by the fossette at the angle 
of the lips; hence its figure is elliptical. 
Superior Lip. 
In the middle of its external aspect we observe a species of 
groove circumscribed by two crests which descend from the sep- 
tum of the nose upon the free border of the lip. According to 
Blumenbach and some modern anatomists, these two crests would 
be the traces of the cicatrization of the three portions of which 
this lip is said to consist in the early stages of foetal existence. 
According to this idea, also, the hare-lip would be owing to the 
cicatrization not being completed on one side: hence this con- 
genital division would never exist on the median line, and if the 
union of the two lateral portions with the median should fail at 
the same time, there would be a double hare-lip. The free bor- 
der of this lip forms a gentle curvature, which is concave infe- 
riorly, and which is divided into two upon the median line by a 
gradual elevation. This eminence is the termination of that por- 
tion of the lip along which the groove, just pointed out upon its 
anterior surface, runs. Since this disposition enters into the nor- 
mal conformation, we should endeavour to re-establish it when 
we perform the operation for hare-lip. It is on this account that 
we are recommended to make the first needle which passes 
through the lip, describe the arc of a circle, the convexity of 
which looks backwards and upwards. 
CONSTITUENT PARTS. 
i. The Shin. 
It supports the moustachios in the adult male; it is a little 
thinner than that of the chin, and becomes more intimately 
blended w ith the subjacent tissues, in proportion as it approxi- 
mates the free border of the lip. It also becomes thinner as it 
approaches this border, and suddenly changes its character, in 
* According to the physiognomical doctrine of Dr. Jadelot this furrow constitutes 
the mental feature, and is concerned in affections of the chest. OF THE HEAD. 
95 
order to form the delicate rosy pellicle which covers it, and which 
is reflected behind the lip under the name of the labial mucous 
membrane. The hairs which we observe upon it perforate it in 
the same manner as those on the chin. It also contains seba- 
ceous follicles, which are subject to the same alterations as in the 
preceding region, but less frequently. 
ii. The Cellular Tissue. 
Its texture is so delicate, and its quantity so inconsiderable, 
that it can scarcely be distinguished from the other elements, 
which are so blended together in the lips as to form but one 
homogeneous mass. The adipose vesicles are still smaller than 
in the mental region. 
hi. The Muscles. 
We have to consider especially the superior half of the orbicu- 
laris oris. Upon the middle of the anterior surface of this mus- 
cle we frequently see two fasciculi, which ascend perpendicularly 
towards the sides of the nasal septum, and which correspond to 
the crests observed upon the surface. These are the nasales 
labii superioris (incisifs superieurs). Behind the superior half 
of the orbicularis and the mucous membrane, upon the sides of 
the anterior nasal spine, we find the depressor labii superioris 
almque nasi (petit myrtiforme) close to the bone. The convex 
border of the former receives, from the median line towards the 
sides, the terminations of the levator labii superioris alaeque nasi, 
of the levator proprius, of the zygomaticus minor, of the levator 
anguli oris, of the zygomaticus major and of a part of the buccina- 
tor. The union of the orbicularis with the mucous membrane is 
less intimate than with the skin; it is effected by means of a thin 
layer of lamellated cellular tissue, in which we see a great num- 
ber of labial glands. The mucous membrane itself is more easy 
to separate from the muscle in proportion as it approximates its 
point of reflexion upon the os maxillare ; hence abscesses of the 
lip generally give way at this point. 96 
OF THE HEAP 
iv. The Arteries. 
In the first place we find the superior coronary which is given 
off by the facial where it passes through the fibres of the levator 
anguli oris, towards the external extremity of the naso-labial 
furrow. This coronary is placed three lines above the free bor- 
der of the lip, in the posterior plane of the fleshy fibres, the di- 
rection of which it follows. Previous to forming its arched union 
with its similar of the opposite side, it gives off a considerable 
branch which ascends towards the septum. A transverse in- 
cision, upon the median line, would divide these ascending arte- 
ries and occasion hoemorrhage ; whilst a wound in the same di- 
rection, but a little further outwards, would not produce it, unless 
it was prolonged as far as the naso-labial furrow, near which the 
facial artery also runs. The arc of a circle which the two su- 
perior coronaries united form, gives off an immense quantity of 
twigs which descend or ascend parallel to each other, and ter- 
minate for the most part in the labial glands and mucous mem- 
brane. These are the twigs which constitute that beautiful and 
complex net-work observed in the latter when the lip is everted. 
As the trunk of this artery is almost in immediate contact with 
the mucous membrane, we may readily feel its pulsations by ap- 
plying the finger under the lip, and it is more easily wounded in 
this direction than from the surface. The artery of the ala nasi 
also sometimes gives a considerable branch to the upper lip ; and 
not unfrequently the facial artery dips more or less into the or- 
bicularis muscle, before it enters the interval of the nasal and 
zygomato-maxillary regions. 
v. The Veins. 
They are still larger and more numerous than the arteries, and 
ramify in the proper tissue of the lip, where they occasionally 
become varicose. This abundant supply of vessels, in the organ 
under consideration, accounts for the frequency with which erec- 
tile tumours form in it, and for the active species of tumefaction 
which it is susceptible of in the normal state. This remarkable 
vascularity, together with the intimate commixture of the differ- OF TIIE HEAD. 
97 
ent elements which enter into the composition of the lips, also 
explains the rapidity with which they tumefy, and the great 
magnitude which they acquire in acute inflammations. 
vi. The Lymphatics. 
These vessels pass through the genial region in their course to 
the submaxillarv lymphatic glands. 
vii. The Nerves. 
The superior lip is freely supplied with filaments from the 
sub-orbital, the buccinatorius and from the temporo-facial branch 
of the seventh pair. These nerves are sufficient to account for 
the exquisite sensibility of this lip and the severe pains which 
accompany its acute diseases. 
viii. The Skeleton. 
It consists of the anterior surface of the ossa maxillaria supe- 
riora and of the corresponding dental arch as far as the dentes 
canini; consequently we find in it, in the middle, the symphysis, 
surmounted by the anterior nasal spine ; a little more externally 
the myrtiforme fossette {a depression for the depressor alee nasi) ; 
then the undulating line of the alveola? and the external surface 
of the teeth. It is in this region that the superior maxillary bone 
presents the greatest resistance ; hence the infrequency of its 
fractures. It is not unusual to see it split from before backwards, 
a little on the outer side of the median line ; and sometimes there 
is a similar fissure on both sides ; a disposition which is frequently 
attendant upon the simple or double hare-lip. The middle bone 
is then the rudiment of the os incisivum or intermaxillare of mam- 
miferous animals, which, by anomaly of developement, was not 
united to those between which it is locked in the normal state. 
Generally, it supports the first two incisor teeth, and projects 
more or less forwards. In adults, especially in those in whom the 
three portions of the lip have never been united, it passes beyond 
the line of the maxillary bones; and this appears to be owing to 
that want of pressure which would naturally have been produced 98 
OF THE HEAD. 
by the upper lip in being reflected upon the bones. 1 he mu- 
cous membrane forms a duplicature which is called the fraenum 
of the lip, and we should not fail to divide this fold before we 
scarify the edges of the fissure, in the operation for hare-lip. 
Without this precaution, it would interrupt the passage of the 
scissors, so that the posterior blade of them would not extend as 
high as might be necessary. So with respect to the plate which 
is introduced between the lip and the bone, when the bistoury is 
employed. It is at the groove which separates the posterior sur- 
face of the superior border of the lip from the bones, that Desault 
has proposed penetrating into the maxillary antrum. In fact 
nothing is more simple: all that is necessary is to detach the 
mucous membrane between the root of the canine tooth and the 
obtuse crest which descends from the malar eminence, in order 
to arrive at it by penetrating a few lines higher up. In the same 
manner we might reach the infra-orbital nerve, if we wished to 
divide it by the mouth. It should be noticed, however, that it 
would be difficult to avoid dividing the caninus muscle (m. lev. 
cmg. oris); but this inconvenience does not counterbalance the 
advantages obtained by preventing the formation of cicatrices 
on the skin, in women especially. The posterior surface of the 
superior lip being concave, it is necessary, if we wish to avoid a 
groove behind the cicatrix after the operation for the hare-lip, 
that the needles should be introduced in such a manner that they 
will pass through the raw edges of the wound at the point where 
the two anterior thirds of their thickness unite with the posterior 
third. 
Inferior Lip. 
This is generally a little thicker than the preceding, and more 
everted forwards. In the middle of its free border we observe a 
depression, into which the superior labial crest is received, and 
as we proceed from the median line this border is slightly convex, 
its extremities being turned downwards. From this normal dis- 
position then, it follows that cancerous tumours, etc., may be 
removed by a semilunar concave flap; and that even if this flap 
should include all the tissues as far as the mento-labial groove, the 
notch which will remain after cicatrization will not be so great as OF THE HEAD. 
99 
we might have expected. In fact it is not necessary that this free 
border should be convex in order to receive the lip above. Its 
natural eversion is not indispensable to its functions, for which 
reason, the lip, although shorter after the operation, ascends suffi- 
ciently to touch that which is above it; and, furthermore, the 
skin of the neck being very extensible, as the cicatrix forms it 
draws it upwards, and thus succeeds in elongating the lip. A 
great number of operations performed by MM. Dubois, Richerand, 
Dupuytren, etc. confirm these assertions. 
The anterior surface of the lower lip has neither vertical crest 
nor groove, which is owing to its being formed apparently of two 
lateral portions only. Hence if congenital hare-lip should be met 
with in it, it ought to be on the median line. 
The union of its free border with that of the upper lip, consti- 
tutes the labial commissures. These commissures are occasion- 
ally the seat of excoriations, ulcers, wounds, etc., which deserve 
strict attention, an account of the contractions of the mouth which 
they might occasion. With respect to wounds which extend 
from one of these commissures externally, they must necessarily 
be brought together by the twisted suture, if we wish to prevent 
deformity. Otherwise, in fact, the movements of the lips will 
prevent cicatrization. This advice is equally applicable to wounds 
of the eye-lids. 
Constituent Parts. 
They are absolutely the same with those of the upper lip; it is 
only in their arrangement that any difference exists, which we 
will now point out. 
i. The Skin. 
This membrane is not covered by so great a quantity of hairs ; 
it scarcely supports more than a small pencillous cluster, which is 
placed in the sub-labial fossette. 
ii. The Adipo-celliilar Tissue. 
It is arranged as in the other lip, and is probably a little more 
abundant. 100 
op Tins iicad. 
in. The Muscles. 
They are the same as in the upper lip, unless it is that the orbi- 
cularis receives upon its convex border the extremity of the 
superbus, of the quadratus and depressor anguli oris, in the place 
of those which enter into the composition of the superior. 
vi. The Arteries. 
They are a little different. Thus the inferior coronary comes 
off from the facial at g. more considerable distance from the com- 
missure, and the arch which it forms with its fellow does not give 
off an inferior vertical branch; therefore a wound across the 
median line of this region will not be attended with haemorrhage ; 
besides, it does not approximate the free border of the lip so much 
as the superior coronary, unless it is in the middle. From this 
disposition it follows that, in dividing the lip from above down- 
wards, we will reach the artery sooner in proportion to the dis- 
tance of the incision from its origin In order to ascertain the 
exact course of this vessel, it is sufficient to imagine a curve passing 
about three lines from the edge of the lip and terminating at the 
anterior and inferior part of the masseter. The lower lip also 
receives some twigs from the mental: a considerable branch is 
also given to it by the coronary itself, near its origin from the facial. 
v. The Veins and Lymphatics. 
These vessels possess the same characters as those of the chin 
and superior lip. 
vi. The Nerves. 
Filaments from the termination of the inferior dental, and some 
of those of the buccal are distributed to the deep-seated parts. 
The superficial twigs are derived from the cervico-facial branch 
of the respiratory of the face, and also from the ascending branch- 
es of the cervical plexus. In short, the lower lip is less freely 
supplied with nerves than the superior, and its sensibility is less 
acute. OP THE IIEAI). 
101 
vii. The Mucous Membrane. 
It likewise forms a duplicature, which is shorter than that of 
the upper lip, and is attached to the maxillary symphysis. The 
labial glands which separate this membrane from the muscles are 
more numerous, larger, and their excretory duct more distinct 
than in the superior lip. 
vm. The Skeleton. 
It comprises the anterior portion of the inferior alveolar arch, 
and the external surface of the dentes incisivi et canini. 
Sect. 6. The Olfactive Region. (Vide Plate 2.) 
It is composed of the wlole of the interior of the nasal fossae. 
The latter are limited, superiorly, by the anterior third of the 
base of the cranium and the internal surface of the nose properly 
so called ; inferiorly, by the palatine arch ; externally, by the zygo- 
matic fossa, the orbit and the maxillary sinus ; posteriorly, by the 
pharynx, and anteriorly by the opening of the nose. A vertical 
septum separates them from each other throughout their whole ex- 
tent ; but this septum frequently inclines more to one side than the 
other; and when this defect of symmetry is carried very far it 
may have effect over the sound of the voice, respiration, and 
induce the belief that polypi exist. This mistake has several 
times occurred, and surgeons, by their inconsiderate manoeuvres, 
have destroyed the septum itself, instead of tearing out these 
pretended polypi. We have seen two patients consulting Prof. 
Bougon this present year, in whom similar attempts had been 
made. In both, the cartilaginous portion of the septum touched 
the inferior turbinated bone; and in one of them, three separate 
trials had been made to extract the supposed polypus, and so 
incautiously, that the two nasal fossae communicated with each 
other through an opening into which the end of the little finger 
might be easily introduced. 
As the nasal cavities are very complicated, we consider it best 
to examine them in their different parts: thus, we will shew sue- 102 
OF THE HE AH. 
cessively the anterior apertures, the vault, the tioor, the internal 
and external parietes, and the posterior opening. 
i. The anterior openings of the Nostrils. 
They look more or less directly downwards, according to 
the degree of elevation or depression of the lobule of the 
nose. Their form is that of an oval, the anterior extremity 
of which is the smallest. The investing mucous membrane is 
thick, adherent, slightly coloured, and participates, for the most 
part, in the characters of the skin; a few hairs originate from it, 
which serve to catch foreign atoms which might be introduced 
into the nostrils. Their skeleton is formed by the cartilage with 
a double branch, which was pointed out, when speaking of the 
extremity of the nose, in the nasal region. This cartilage is en- 
closed, on all sides, between the skin and the mucous membrane ; 
the posterior extremity of its internal branch does not touch the 
anterior nasal spine; on the contrary, this extremity turns out- 
wards, and tends to complete the circle by approximating that of 
the external branch, which, on its side, is inclined inwards. It 
results from this arrangement that the large extremity of the 
anterior opening of the nose is actually situated in the upper 
lip, lower than the floor of the nasal fossae : whence it follows that, 
in order to introduce a probe, forceps, the finger, or any foreign 
body whatsoever into the nose, we must first pass it obliquely 
upwards, to the extent of several lines, before we give it the 
horizontal direction; whence it follows also, that it is necessary 
to press up the lobule of the nose considerably, when we wish 
to have a view of these cavities. 
ii. The Vault. 
The vault is the longest paries of the nostrils, and may be di- 
vided into three portions: the anterior, which is inclined down- 
wards in the direction of the dorsum nasi, to which it corres- 
ponds. In this portion, which forms, in uniting itself with the 
septum, a groove of considerable depth, the mucous membrane 
is delicate and villous, but does not enclose many follicles: this 
membrane is less adherent here than in the opening which ha? OF THE HEAD. 
103 
just been examined; polypi seldom originate from it; but it is 
frequently the seat of cancerous or sanious ulcers called ozena\ 
The skeleton which enters into the composition of this part of 
the vault of the nasal fossae, is formed, from above downwards, 
by a small portion of the nasal notch of the os frontis; by the 
posterior face of the os nasi which is inclined outwards towards 
the nasal process of the superior maxillary bone, which produces 
the groove pointed out above ; by the internal surface of the tri- 
angular cartilage, and of that of the free extremity of the nose. 
It should be remarked that where the nasal gutter terminates 
under the latter, there is a species of cul-de-sac, which renders 
the lobule much thinner than we would suppose it to be from 
an external examination of it simply : therefore, wiien we extir- 
pate or cauterize its cancerous excrescences, we must avoid pen- 
etrating too deeply, lest we occasion an opening into the cavity 
of the nose, which would remain fistulous. There is at present a 
case of this kind in the Hospital of la Faculte, in a woman 
seventy years of age. A cancerous ulcer was situated on the 
left side of the lobule of the nose. The disorganised structure 
was extirpated and the arsenical paste applied. The woman was 
cured, but an opening remains between the lobule and ala nasi. 
It is between the ala nasi and the mucous membrane that the 
vessels and nerves coming from the orbit are placed. A con 
siderable branch of artery and of vein pass through the bone near 
its middle, in their way to the lobule, or remain upon the dorsum 
of the organ, producing habitual redness of it in some individu- 
als, from the varicose state of the capillaries of the venous 
branch. The active circulation in the arterial branch also ex- 
plains the bright colour which is manifested in the same parts du- 
ring the process of certain diseases; which colour generally 
indicates an epistaxis, and which guided Galen in forming his 
celebrated prognosis. The naso-lobar nerve is imbedded in a 
small furrow which conducts it to the inferior border of the 
bone, where a slight notch permits it to pass upon the external 
surface of the cartilages. 
From what has preceded- we see that this part of the superior 
paries is very solid, and so constructed that it opposes great 
resistance to such foreign agents as would tend to depress, or 
fracture it, etc. 104 
OP TIIE HEAD. 
The second, or middle portion, is horizontal, and correspond!* 
to the ethmoidal fossa of the cranium. It is only two or three 
lines in breadth. The mucous membrane, in this situation, is 
thick, soft and villous : the cribrated lamina of the ethmoid, and. 
posteriorly, a very small portion of the wings of Ingrassias form 
the skeleton of it. As these osseous plates are very thin and 
fragile, foreign bodies driven with a certain force into the nose, 
may penetrate the cavity of the cranium, and cause instant death 
by lacerating the brain. It is at this part that wounds are most 
dangerous; and even when their effects do not extend to the 
cranial box, they will at least pervert the sense of smell, by the 
injury which they inflict upon the expansion of the olfactory 
nerve in the Schneiderian membrane. It is at the place where 
this portion of the vault unites with the preceding that we find, 
by the sides of the crista galli, the small fissure of the cribriform 
plate which gives passage to the ethmoidal twig of the ophthal- 
mic nerve and artery from the cranium into the nose. 
The frequency of disease in this portion of the nostrils, the 
tenuity of the bones, and the caries with which they are some- 
times attacked in inveterate cases of syphilis, as well as its ana- 
tomical relations with the cranium, explain in what manner those 
hernia: of the brain, of which M. Boyer has spoken, may pene- 
trate into the cavity of the nose. 
The third, or most remote portion, corresponds to the Sella 
Turcica: it is inclined downwards and backwards. The mucous 
membrane is a little more dense at this point, is continuous with 
that of the vault of the pharynx, and contains some follicles. 
The skeleton is formed by a prolongation of the obitar process 
of the os palati, the superior portion of the vomer, which, to- 
gether with the body of the sphenoid bone, constitutes a small 
canal, through which the pterygo-palatine artery and nerve run : 
more anteriorly, by the body of the sphenoid still, and the (cor- 
nets) ossa turbinata of Bertin. Here we find an irregular open- 
ing, which varies in its dimensions and leads into the sinuses of 
the sphenoid. If we could readily detect the diseases of these 
sinuses, we might easily penetrate into them, as we shall see, 
when we come to speak of the external paries. We are induced 
to believe, for several reasons, that the disagreeable odour which 
exhales from certain individuals, is owing to ulceration of the OF THE HEAL). 
105 
membrane which lines these cavities, the capacity of which 
varies, and which, all other things being equal, is augmented in 
proportion to the advancement of age. It is generally in this 
part of the vault that the force of blows received upon the ver- 
tex of the head are concentrated ; but as the bone is spongy and 
very thick it is rarely fractured. 
hi. The Internal Parietes. 
They are formed by the faces of the septum. The pituitary 
membrane which covers it is very thick, vascular, and lined by a 
very strong fibrous lamina, which also exists throughout the whole 
extent of the nasal fossm; but is in no part so distinct as it is in 
this. Although this species of periosteum is pretty firmly ad- 
herent to the septum, yet it is less so than to the mucous tunic. 
In addition to the internal nervous branches of the first paries, 
which are distributed between these two laminae, we also find 
the naso-palatine nerve similarly interposed. The septum is 
formed by the whole of the vomer; more anteriorly and supe- 
riorly, by the perpendicular plate of the ethmoid; and quite an- 
teriorly, by the cartilage of the septum. To these we must also 
add superiorly the crest of the sphenoid, which is embraced by 
the separation of the plates of the vomer; the nasal spine of the 
os frontis resting upon the ethmoidal plate, and, inferiorly, the 
species of crest which exists at the junction of the superior max- 
illary and palate bones with each other. The two nasal spines 
form the anterior and posterior extremities of the inferior border 
of the septum. As all these parts are thin and fragile, the intro- 
duction of the finger or instruments into the nose requires great 
caution, in order to avoid making a communication between the 
two nasal cavities, which would occasion more or less derange- 
ment in the sense of smell and the sound of the voice. The 
pressure of polypi upon this septum may also produce a perfora- 
tion of it; and we have seen several examples in which this state 
of parts was congenital. 
iv. The Inferior Panes or Floor. 
This paries is formed by the superior surface of the palatine 106 
OF THE JiEAll. 
arch, and is about two inches in length, or three, if prolonged to 
the apex of the nose. It is regularly concave in its transverse 
direction; plane from before backwards, and gently inclined 
towards the pharynx ; its anterior border is raised a little, which 
should be remembered when we wish to probe the nasal canal. 
Its Schneiderian membrane possesses the same characters as 
upon the septum; but it receives a much smaller quantity of 
nerves, and is rarely the seat of polypi: syphilitic and cancerous 
ulcers, however, are frequently observed in it. 
The palatine process of the superior maxillary bone, and the 
horizontal portion of the os palati, constitute the skeleton of this 
paries; consequently, we see upon it a transverse suture which 
unites these two bones ; and sometimes there is a second, ante- 
riorly, which indicates the persistance of the os intermaxillare. 
The latter has been observed in man by Vesalius,* Columbus,f 
etc, and more recently by M. Lobstein. It is the separation 
of this anormal suture which so frequently co-exists with the 
double or single hare lip ; between it, or the situation which it 
occupies when it does exist, and the septum, close to the anterior 
border, we observe the nasal aperture of the naso-palatine 
canal, through which the naso-palatine nerve passes, in order to 
enter the ganglion of the same name. This aperture is closed 
by the mucous membrane, and can only be seen upon the de- 
nuded bones. 
v. The External Paries. 
This is the most complicated and most important. Inferiorly, 
it is quite as extensive as the preceding, longer in the middle ol 
its height, and shorter at its most superior part. The mucous 
membrane which appertains to it is thicker, redder, and more 
vascular than elsewhere ; only it becomes more delicate and 
attenuated where it penetrates the accessory cavities, or rathei 
its fibrous lining then abandons it. Upon the free border oi 
each turbinated bone, it forms a fold which seems to give to 
these shells greater breadth, and prolongs them further anteriorly 
and posteriorly. It adheres very firmly to the skeleton ; and, as 
it is abundantly supplied with vessels, but a very slight conges- 
* I>e Fabric: corporis humani, etc. tDe rc etc. lib. ler. OF THE HEAD. 
107 
tion is necessary to produce epistaxis: hence the frequency of 
this haemorrhage. The irregularities of the surfaces which it is 
obliged to cover, are probably the principal cause of the en- 
gorgements, tumours, and diseases of different natures which so 
frequently occur in it. We should be upon our guard against 
the bulging out of the folds which it forms upon the borders of 
the ossa turbinata, because they have more than once been mis- 
taken for polypi, and wrenched out as such; more than once, 
also, they have been torn in seeking for these excrescences which 
did not exist, and unreflecting surgeons have mistaken the flaps, 
thus violently formed, for portions of these tumours which they 
have been determined to find. This membrane also diminishes 
the greater proportion of those apertures which we are about to 
examine ; but in no part of it do fleshy fibres exist. 
In the summit of, and little towards the posterior part of this 
paries, we find a short and shallow groove, which is separated 
from the vault by a small crest, into which enters what Gavard 
calls the square plate of the ethmoid. This groove does not lead 
to any important cavity. More inferiorly, we see the superior 
turbinated bone of Morgagni, which terminates, anteriorly, to- 
wards the middle of the length of the paries. The gutter which 
this bone circumscribes is broader and more superficial at its 
posterior than at its anterior part. In the first direction it leads 
to two openings; a superior, which communicates with the pos- 
terior ethmoidal cells and the sphenoidal sinus, into which we 
might easily penetrate by passing a stylet above the middle turbi- 
nated bone, along the external paries of the superior meatus, pro- 
vided that, when the extremity of the instrument gets near the 
termination of this gutter, we elevate it a little as we pass it 
backwards. The other is inferior and situated upon the external 
paries: it leads directly into the pterygo-maxillary and zygomatic 
fossae. Through this opening, the spheno-palatine vessels and 
nerves enter the nose. Polypi may also pass from the nasal fossae 
through this aperture into the zygomatic fossa, and be prolonged 
into the substance of the cheek anterior to the masseter. In 
1824, we saw a remarkable example of this kind in a young 
man aetat. 20, who continued a long time in the hospital of the 
Ecole de Medecine. This opening is situated just belowr the 
posterior extremity of the superior turbinated bone, and a probe, 108 
OF THE HEAD, 
having its extremity slightly curved, might be easily introduced 
into it: anteriorly, the meatus terminates upon a plane surface, 
which presents nothing remarkable. 
Below this, we find the ethmoidal or middle turbinated bone, 
which is prolonged in a pointed form near to the pharyngeal 
opening of the nostrils; the anterior extremity of this bone is 
raised a little, and terminates four or five lines from the os nasi. 
Hence it follows that it is more prominent, and consequently that 
the middle meatus is deeper in the centre than towards its two 
extremities. This meatus is much wider anteriorly than poste- 
riorly. In it we meet with two openings which are worthy of 
attention ; one of which is higher than the other, and is situated 
under the anterior extremity of this turbinated bone ; a small ex- 
cavation leads to it from behind forwards, from below upwards, 
and from within outwards: this is the inferior orifice of the ante- 
rior ethmoidal cells, or of the Infundibulum by which we pene- 
trate into the frontal sinus. It is by this communication that 
worms, etc. have made their way from the nose into the frontal 
sinus, deceiving some persons with respect to their real origin. 
It is the cause why wounds of the frontal sinus with loss of sub- 
stance generally remain fistulous ; it enables morbid fluids secreted 
in the nose to pass between the plates of the os frontis, and, on 
the other hand, polypi, pus, etc., to descend from the sinus into 
the nasal fossae. It would also be possible to throw up injections 
through this opening, if they should be deemed useful. 
The other aperture is situated towards the middle of the length 
of the meatus, a little higher than the inferior border of the tur- 
binated bone, about an inch and a half from the anterior nasal 
opening. In this place the nasal gutter is excavated, on which 
account the aperture in question looks slightly downwards and 
inwards: so that, if we wish to pass an instrument into it, we 
must direct it from below upwards and from within outwards, 
in the dead subject this little operation is, in this way, very 
easy to perform. But, if the instrument is at first carried too 
high or too far back, we will meet with many difficulties, and it is 
doubtless owing to this circumstance that surgeons have aban- 
doned this operation, so highly recommended by Jourdin and 
Alouelle. The mucous membrane which covers the border of 
1 his opening is thick, and forms a circular fold, in which there are OF THE HEAD. 
109 
a great number of large follicles, considered by some anatomists 
as one gland. This fold, like those which envelope the loose mar- 
gins of the turbinated bones, is susceptible of becoming turgid, 
and thereby closing the entrance into the antrum of Hygmore; 
but it does not form either a valve, or sphincter which might ob- 
struct the passage into this cavity. The antrum Highmorianum, 
or maxillary sinus, is a very important part of the face ; its figure 
is pyramidal; its superior paries forms the iloor of the orbit, and it 
is in this wall that we find the infra-orbital vessels and nerve. The 
anterior paries corresponds to the canine fossa, and includes the 
anterior and superior dental nerves of the infra-orbital branch: 
the rupture, laceration or any lesion whatsoever of these nerves 
may, to a certain extent, explain the very serious symptoms which 
sometimes follow the extraction of the dens canina. We have 
noticed that Desault perforated this wall in order to expose the 
sinus. 
The inferior paries rests upon the alveoli of the molar teeth, and 
is sometimes perforated by the root of these organs. The third 
or fourth molar tooth approximates nearest to the maxillary cavity, 
and it is by their alveoli that we prefer perforating this cavity; 
especially, as by this means, the artificial opening will correspond 
to the most dependent point, and will thereby favour the escape 
of pus, or any other foreign body which we may desire to extract. 
It is also in consequence of the relations of the molares with the 
antrum Highmoranium that fistula; semetimes follow the extrac- 
tion of these teeth. The posterior paries is rounded and con- 
cave ; it encloses the nervous filaments which pass to the roots of 
the molar teeth, and corresponds to the zygomatic fossa; the 
summit is prolonged into the malar eminence, and is there so near 
the surface that some surgeons have considered it the best place 
for applying the trephine, and Lamorier, among others, advised 
perforating the maxillary sinus below the os malae. The base is 
the largest paries of this cavity, and corresponds to the whole ex- 
tent of the middle meatus; it is perforated in its centre by the 
aperture just spoken of, a little nearer its superior part, however, 
than its inferior. From this arrangement we may comprehend 
why pus, or other fluids accumulated in the sinus, will escape more 
readily through an artificial opening in the alveoli or lower part of 110 
Ol' Tilt HEAD. 
the canine l’ossa, than by the natural aperture which exists in the 
n ose. 
Besides these, the middle meatus presents nothing remarkable 
except at its posterior part, where it leads to the Eustachian tube. 
Next to this meatus is the inferior, or maxillary turbinated bone, 
which is the largest and longest, terminating in an elongated point 
where it approximates the pharyngeal opening, and in a fold 
slightly inclined downwards towards the facial aperture of the 
nostrils. The free margin of this bone is sometimes three, four, 
and even five lines from the floor and external paries of the nasal 
fossae; at other times, on the contrary, it lies so close to them, 
that the inferior meatus is converted into a complete canal. We 
also find all the intermediate degrees, whence arises the various 
results obtained by different surgeons, in their attempts to pene- 
trate into the nasal duct, as recommended by Bianchi, Laforest, 
etc. Nevertheless, this operation does not seem to deserve that 
oblivion into which it has fallen, and as some surgeons of celeb- 
rity, among whom is M. Gensoul, of Lyons, are again attempting 
to bring it into vogue, by advising us to act upon the nasal duct, 
in cases of tumour or fistula lachrymalis, in the same manner as 
we operate upon the canal of the urethra, in cases of stricture, 
according to the method of Ducamp ; we think that we must 
devote a few moments to the investigation of the anatomical dis- 
position of the inferior meatus. It is a gutter, forming the three 
fourths of a canal, which corresponds externally, and from be- 
hind forwards, to the vertical portion of the os palati, to the inter- 
nal surface of the nasal portion of the superior maxillary bone ; 
that is to say, to the inferior fourth of the base of the maxillary 
sinus ; and lastly to the inferior groove of the ascending process of 
the maxillary bone. Superiorly, it is formed by the concave sur- 
face of the inferior turbinated bone, and inferiorly, by the external 
part of the floor of the nasal fossae. The nasal duct opens into 
this meatus at the junction of its external and internal parietes, 
but in such a manner, that it extends a line and a half further upon 
this latter ; i. e. it is cut obliquely at the expense of the turbinate, 
and looks inwards, and a little backwards; hence it follows, that 
we must also give this direction to the slope of the canula, when 
we operate for fistula lachrymalis according to the method of 
Foubert; and in the same manner, when we introduce the probe, OF THE HEAD. 
111 
we must eievate its extremity from behind forwards, and from 
within outwards. The orifice of this canal is situated about six 
lines from the nasal aperture, and we do not think that this dis- 
tance is so variable as Morgagni, and some others since his time, 
have asserted. In fact, in one hundred heads, M. Vesigne* found 
but very trilling variations ; and from what has come under our 
own observation, these differences are so slight, that they could 
not prevent the easy introduction of an instrument into the nasal 
duct. It is bounded anteriorly by a prominence which is formed 
by the posterior margin of the base of the ascending process; 
superiorly, under the inferior turbinate, this prominence is sepa- 
rated from the orifice of the nasal canal by a species of cul-de- 
sac, into which the probe maybe insinuated, and thereby occasion 
the principal obstacle to its introduction. Another cause of diffi- 
culty arises from the instrument not being sufficiently curved : in 
fact, it is necessary to bend its extremity at more than a right an- 
gle with the handle ; unless this is done, it will strike against the 
posterior paries of the duct, and penetrate the maxillary sinus, 
if much force is exerted. The reason of this peculiarity is found 
in the direction of the duct itself, which runs obliquely upwards, 
forwards, and very slightly outwards, and especially in the mem- 
brane which contracts this aperture. This fold is so disposed, 
that the orifice by which it ascends into the canal, is nearer the 
posterior than the anterior semi-circle of this osseous canal. 
In short, we think that it would generally be easy, by recollect- 
ing the anatomical peculiarities which have just been detailed, 
together with a little habit, to introduce into the nasal canal, by 
the inferior meatus, probes, bougies, stylets, with the view of 
throwing injections into it, removing its obstructions, cauterising 
it, etc. 
It is also by the inferior meatus, that a probe may be passed 
from the nose to the pharynx, in order to introduce it into the 
Eustachian tube ; but we must then be careful not to elevate the 
instrument too much, as it would be liable to fracture the turbi- 
nated bone. It is with the view of avoiding this inconvenience, 
that, in attempting to apply a ligature around polypi, or plugging 
the nasal fossoe, it is much better to pass the instruments upon the 
* Th£se, 1824. 112 
OF THU 1IUAO. 
inferior paries, between the floor and os spongiosum, than to slide 
them along the meatus itself. 
The bones which enter into the composition of the external 
wall of the nasal cavities, are remarkable only for their greater or 
less degree of fragility. Thus, posteriorly, the skeleton is pretty 
solid, because it is formed by the internal surface of the pterygoid 
process and the posterior parts of the superior maxillary bones, 
upon which the vertical portion of the ossa palati rest. In the 
middle part, it is extremely brittle, because it there consists only 
of the thin plates of the ethmoid and the internal paries of the 
nasal sinus, which are very slender and very fragile. Therefore, 
operations performed in this point, almost always occasion the 
destruction of these osseous laminae. Anteriorly, the solidity is 
considerable, as it is there constituted by the nasal process of the 
superior maxillary bone. It is proper to remark, before conclud- 
ing, that if this fragility of the bones has its inconveniences in 
most cases, there are, nevertheless, some in which it may prove 
advantageous. For example, it is on account of the tenuity of 
the os unguis, that we are advised to establish through it an arti- 
ficial course for the tears, either by following the method of Wol- 
liouse, or by adopting that of Hunter, of Scarpa, etc. We know 
that the object of all these operations is to cause the nasal canal 
to communicate with the inferior part of the middle meatus, and 
that Hunter recommended the application of a plate of ebony 
between the superior and middle ossa turbinata, in order to serve 
as a point of support for his perforator. With respect to this 
plate, the disposition of the parts is such that we do not think 
that it would be impossible to make use of it, if we wished to 
resort to the method of the English surgeon. At least, we think 
that this question requires still further examination. 
vi. The posterior opening of the Nasal Fossa. 
This opening is double, and formed by the termination of the 
four parietes. Its figure is that of an oblong square placed verti- 
cally ; it is a little broader below than above ; its perpendicular 
diameter measures about an inch ; its transverse inferior diame- 
ter only six lines. These diameters should be kept in mind when 
we are obliged to introduce the finger, plugs, etc., from the pha- or THE HEAD. 
113 
rynx into the nose, in order that the greatest breadth of the for- 
eign bodies may correspond with the greatest diameters of the 
openings through which they are to be passed. 
A few observations remain to be made upon the vessels ami 
nerves of the nostrils. 
A. The Arteries. 
They come from the internal maxillary, through the pterygo- 
palatine foramen ; from the ethmoidal twigs of the opthalmic; 
from the coronary of the facial, etc. They are quite small, and 
of very little surgical importance ; but where they ramify in the 
mucous membrane, they become very superficial, which disposes 
them to hcemorrhage. 
B. The Veins. 
One collateral vein accompanies each artery, which it surpasses 
in volume ; but there is an additional one which communicates 
with the apex of the longitudinal sinus by the foramen coecum, 
and others which pass into the coronary sinus, through the pores 
of the sphenoid, etc. Vicq. d’Azyr thought that the latter might 
explain the active hoemorrhages which oc 'ur in cerebral diseases. 
These small veins always connect the circulation of the nasal 
fossae with that of the encephalon. 
C. The Lymphatics. 
They have not been satisfactorily traced. 
D. The Nerves. 
These organs proceed from the first pair which is entirely dis- 
tributed to this region ; also from the fifth which gives numerous 
branches to it from the spheno-palatine ganglion, ophthalmic 
branch, etc. According to the recent experiments of Magendie, 
the filaments of the first preside over the sense of smell; those of 
the fifth, on the contrary, over the general sensibility. 114 
OF THE HEAR. 
Sect. 10. Buccal Cavity or Region. (See plate 2.) 
It is circumscribed anteriorly and laterally by the internal sur- 
face of the two alveolar arches ; posteriorly, by the pharynx ; su- 
periorly, by the nasal fossae, and inferiorly by the plane of the 
border of the lower jaw. It forms a cavity which is naturally fil- 
led by the tongue, when the jaws are in contact. If we consider 
the tongue as removed, this cavity is from eighteen to twenty-one 
lines in height in the middle, and a few lines less anteriorly and 
posteriorly. We will now examine it successively superiorly, 
laterally, inferiorly and posteriorly. 
The Palatine Vault. 
This part forms the superior paries, and is inclined upon the 
sides and anteriorly, becoming continuous with the dental arches : 
it is very concave and continuous posteriorly with the velum 
palati. 
CONSTITUENT PARTS. 
i. The Mucous Membrane. 
The mucous tissue is dense, compact, slightly coloured, non- 
viilous and presents many very hard transverse wrinkles, espe- 
cially anteriorly, but becomes softer and of a redder colour poste- 
riorly. It is covered by a very distinct epithelium, which is elevated 
in a considerable number of diseases. In consequence of the 
compact texture of this membrane it is but seldom diseased. 
ii. The Sub-mucous Tissue. 
This is a very strong and almost inextensible fibro-cellular 
lamina, which answers the purpose of a periosteum to the bones, 
and of a lamellated envelope to the mucous membrane ; that is to 
say, that its superficial surface is filamentous and less compact 
than its deep surface. The cryptoe are situated upon the former 
of these surfaces, between it and the mucous membrane. This 
tissue sometimes gives origin to extremely hard fibrous bodies, OF THE HEAD. 
115 
winch seldom acquire, however, a large volume. It adheres 
very firmly to the bones, especially at the sutures. 
hi. The Arteries. 
They enter this region through the posterior palatine foramina ; 
their principal branch follows the contour of the vault, first be- 
tween the fibrous tissue and the bones, then between the fibrous 
and mucous membranes. If one of these branches should be- 
come aneurismatic, an example of which lias been observed by 
M. Delabarre, it would be very difficult to treat the disease 
otherwise than by the actual cautery; for the inequality of the 
bones and the firmness of the parts would oppose the application 
of compression or the ligature. 
iv. The Veins. 
They have the same arrangement as the arteries. 
v. The Lymphatics. 
Our knowledge of them is imperfect, but they present nothing 
remarkable. 
vi. The Nerves. 
They all come from the spheno-palatine ganglion, but by two 
different routes; first, the superior palatine nerve wdiich descends 
along the canal of this name in order to meet with the artery, and 
follows its course into the palatine vault: next, the naso-palatine, 
which goes to form the ganglion of the same name in the anterior 
palatine foramen. This ganglion, discovered by MM. Jacobson 
and H. Cloquet, afterwards gives off a pencil of filaments which 
are distributed to the palatine membrane behind the incisores 
teeth. 
vn. The Skeleton. 
We find in it the palatine process of the superior maxillary 116 
of the head. 
bone and the horizontal portion of the os palati. These four os- 
seous pieces are connected together by a crucial suture, and their 
point of junction, upon the median line, exists at the union of the 
two anterior thirds with the posterior third of the vault. These 
bones are frequently attacked with caries or necrosis in the vene- 
rial disease, which frequently occasions a communication be- 
tween the nose and mouth. These accidental openings may be 
made to disappear by means of (obturators) metallic plates suita- 
bly adapted to the deficiency of the parts, nevertheless, they have 
more or less effect over the tone of the voice. Sometimes the 
median suture of this osseous vault is wanting: then the separa- 
tion is prolonged backwards, without being carried forwards to the 
lips; and in this case there is a division of the velum palati. In 
other cases the separation is continued forwards, without being 
extended backwards to the pharynx, which may be attended with 
one of two different species of malconformation ; either the me- 
dian fissure bifurcates, and includes between the two branches 
of this bifurcation the inter-maxillary bone, which generally coin- 
cides with a double hare-lip; or there is no bifurcation, but the 
fissure does not arrive at the superior lip by following the median 
line; it runs obliquely forwards and outwards and corresponds 
■with the simple hare-lip. Finally, it is possible for the palatine 
fissure to extend from one extremity of the vault to the other. 
But an anomaly still more singular may exist. In a male sub- 
ject, of about forty or fifty years, which was brought into the pa- 
villions of the Ecole-pratique, there was neither horizontal portion 
of the os palati, nor palatine process of the os maxillare; the 
palatine membrane was twice its natural thickness, and as hard 
as fibro-cartilage; that of the floor of the nostrils was in the same 
state; they were separated from each other by a space of a line 
and a half, which was filled with a kind of mucus, forming a 
cavity intermediate to the palatine vault and the floor of the 
nasal fossae. 
The Circumference of the Buccal Cavity. 
It presents for consideration only the internal part of the gums, 
in which we find the same elements as in the vault; except that 
they are thicker, more vascular, and of a much less compact tex- OP THE HEAD. 
117 
lure than the palatine membrane ; which accounts for their being 
more frequently subject to disease. In becoming continuous 
with the mucous membrane of the superior paries of the mouth, 
the gums block up, anteriorly and posteriorly, the inferior aper- 
ture of the palatine canals; so that these foramina only exist, 
properly speaking, in the skeleton. 
The internal surface of the teeth forms, anteriorly, a groove, 
the depth of which is proportionate to the degree in which these 
small bones are inclined towards the lips. Posteriorly, between 
the anterior pillar of the velum palati and the last molares, there 
is a small space which will admit the extremity of the little finger, 
and which generally corresponds to the internal surface of the 
coronoid process, or rather, to its anterior margin : by means of 
this space the buccal cavity communicates with the large grooves 
which separate the lips and cheeks from the external surface of 
the dental arches. When the mucous membrane of the cheeks, 
tongue, etc., is inflamed and swollen, it sometimes insinuates itself 
into this space, and is thereby painfully compressed and even 
wounded during mastication, in consequence of advancing be- 
tween the teeth. A foreign body, or any instrument whatsoever, 
might penetrate through this opening into the cavity of the mouth 
or pharynx, notwithstanding the jaws are firmly closed, and wound 
the organs contained within them. In many persons, we also 
observe other small spaces between the teeth, which produce that 
undulated appearance remarked on the borders of the tongue, 
when it is the seat of inflammation. 
We may also remark, that the internal paries of the alveolae 
becomes almost immediately blended with the palatine process, 
and is shorter and stronger than the external. This peculiarity 
seems to indicate that in applying the fulcrum of Garengeot’s 
key upon the palatine side of the alveolae, we will be less liable 
to fracture the walls of these cavities, in extracting the teeth, 
than if we should apply it upon the outer side: the point of sup- 
port, would, in fact, be more solid; and as the fangs of these teeth 
are naturally a little curved, they would be extracted with less 
effort. 118 
OF THE HEAU. 
The Inferior Paries. 
This paries is continuous with the supra-hyoideal region, and 
has no skeleton. In the middle of it is the tongue, which tills the 
mouth when it is closed. The superior surface of the tongue is 
free throughout its whole extent, and is prolonged by the isthmus 
of the throat, to the epiglottis. This surface is convex, from be- 
fore backwards, and even transversely; however, it presents a 
slight depression upon the median line. Of its inferior surface, 
the two posterior thirds of the distance from the epiglottis to the 
tip is adherent: it is at this part that it receives the muscles, ves- 
sels, nerves, etc. Its anterior third is free, or fixed only by a 
membranous fold behind the symphysis of the chin. It is this 
fold or froenum, which, when too short, prevents infants at the 
breast from protruding the tongue and performing suction prop- 
erly ; whence the indication of dividing it. When, on the con- 
trary, it is too long, J. L. Petit and some others, have supposed 
that it would permit the tongue to slide backwards upon the pala- 
tine vault into the pharynx and occasion suffocation. But if these 
apprehensions are not chimerical, they are at least exaggerated. 
The posterior extremity of the tongue is fixed to the os hyoides 
which participates in most of its movements, and which connects 
the function of speech with those of deglutition and respiration. 
COMPONENT PARTS OF THE TONGUE. 
i. Its Membranous Envelope. 
Upon the dorsal surface it is very thick, and studded with a 
great number of small eminences called papillae. At its posterior 
part, these papillae are broad, flattened, and perforated in their 
centre: they are perfect cryptoe, organs of secretion, and are 
collected around the excavation called “foramen caecum.” In the 
middle, as wrell as at the tip and margins, where the membrane is 
much more delicate, these papillae become conical or fungiform; 
they are then small, erectile, and form the organs of sensation. 
The examination of these corpuscules merits the greatest atten- 
tion in acute diseases, and is not without importance in chronic 119 
or THE HEAD. 
affections. The shades of their colour and their degree of prom- 
inence, afford innumerable varieties in the different derangements 
of health ; but, in general, we may say that if they are pale and 
but slightly developed, if the tongue is smooth and more or less 
loaded, the organs of digestion, and the stomach in particular, 
will bear evacuant remedies without danger, provided they are 
otherwise indicated; whereas, if they are red, and raised upon 
the mucous membrane, if they appear tender, we must use them 
with great caution. In consequence of the compact texture of 
this membrane upon the dorsum of the tongue, and its slight ex- 
tensibility, chaps frequently manifest themselves in it, and the 
tumours which we observe in it are almost always hard and of 
small volume. At its most posterior part, it becomes attenuated, 
and forms three folds, two lateral, which envelope the glossal pil- 
lars of the velum palati; and one central, which unites the tongue 
to the epiglottis. On its inferior surface it is thin, supple, slightly 
adherent, and of a brownish colour, a tint which is owing to 
the transparency of the ranine veins, which it immediately covers. 
In reflecting itself upon the inferior paries of the mouth, the 
mucous membrane forms a species of fringed crest, in which 
there are some adipose vesicles. Where this crest unites with 
that of the opposite side, near the froenum, we find the orifice of 
the duct of Wharton: the small ducts of the sublingual gland 
open a little farther back. 4 ** 
n. The Cellular Tissue. 
It is supple, very delicate, and sends off an infinite number of 
processes between the fleshy fibres. It is to the laxity of the 
cellular element that we must attribute the rapidity with which 
the tongue sometimes tumefies, and the enormous volume which 
it may acquire. 
m. The Muscular or Proper Tissue. 
This tissue is composed of very delicate fibres, which intersect 
each other in various directions, but are principally directed from 
before backwards. From the latter circumstance our incisions 
should be longitudinal, and when cancerous tumours are removed 
from the end of tongue, they should be included in a trian- 120 
OF TIIK HEAD. 
gular flap, having its base situated anteriorly, in order that we 
may afterwards be able to bring the two sides of the division 
parallel to the direction of the muscular fibres. These fibres are 
derived from the lingualis, genio-glossus, hyo-glossus, stylo-glossus, 
and several other muscles, with which MM. Bauer, Blandin, et 
Gerdy, have recently been advantageously occupied. 
iv. The Arteries. 
The tongue is very liberally supplied with arteries by the ex- 
ternal carotid; but there are three only which merit particular 
attention, viz: the dorsalis linguae, palatina inferior, which are 
distributed to the neighbourhood of the tonsils and the tissue of 
these organs, and the ranina artery especially. This last passes 
through the inferior portion of this organ, and is at first situated 
deep between the hyo-glossus, genio-glossus and lingualis mus- 
cles ; but as it approximates the tip it becomes very superficial, 
being almost solely covered by the mucous membrane; on this 
account it is very much exposed to the action of the instrument 
in dividing the freenum linguae in children. It is for the purpose 
of avoiding its division, in these cases, that we should direct the 
point of the scissors downwards instead of upwards. Further- 
more, this branch is so large that it will occasion a troublesome 
hoemorrhage, and on>account of its tortuous course, the softness 
and mobility of the tissues which envelope it, it will retract very 
considerably when divided and thereby become difficult to se- 
cure. And on the other hand, the natural humidity of the parts, 
by opposing the astringent action of the air upon the divided tissues 
will also render the haemorrhage more serious. It follows, then, 
from this combination of circumstances, that the actual cautery, 
or compression with the forceps, un valet patina etc. are the on- 
ly means which art can employ when the ranine arteries are 
wounded. 
v. The Veins. 
These are more numerous and larger than the arteries, and 
*A species of forceps joined in the middle with a screw (volsella palini), 
Tranil. OP THE HEAD. 
121 
communicate directly with those of the amygdalae and pharynx; 
which explains the advantageous results which the ancients de- 
rived from bleeding from the ranine vein in angina and other 
diseases of the throat. They form a net work, which is princi- 
pally observed at the inferior surface of the tongue; and it is in 
the free portion of this surface, immediately below the mucous 
membrane, that these veins collecting form the ranine. This last 
vein lies more superficially and more externally than the artery, 
and as it is of considerable size, it might, if opened, produce a 
rapid and beneficial degorgement in diseases of the mouth in 
general, and of the tongue in particular; but its relations to the 
artery must be attended to. When we divide it, it is better to dip 
the point of the lancet obliquely backwards and upwards, and at 
the same time incline it rather outwards than inwards. This dis- 
position of the venous system also indicates that it is more rational, 
in acute swellings and other diseases of the tongue requiring scari- 
fications, to make them upon the sides of the inferior surface of 
the tongue than upon the dorsal surface. It is well to remark, 
however, that the quantity of blood which follows these incisions 
is not always sufficient to account for the sudden and sometimes 
surprising relief which they produce. In 1818, there was a pa- 
tient in the general hospital of Tours afflicted with an enormous 
swelling of the spleen and daily vomiting. About five or six 
o’clock one evening he felt, without any appreciable cause, his 
tongue begin to swell; at eight o’clock the tumefaction was con- 
siderable, suffocation imminent, and the tongue protruding from 
the mouth. Being on the watch, we were called, and made two 
incisions with the lancet, and although not more than two table- 
spoonsful of blood were evacuated, the tongue, on the day follow- 
ing, reduced to its natural size. 
vr. The Lymphatics. 
They pass to the submaxillary and cervical lymphatic glands, 
vn. The Nerves. 
These are numerous, and are derived from three branches; 
the glosso-pharyngeal appertains principally to the base of the 122 
or THE IIEAH. 
tongue, and its filaments may be traced even to the lenticular 
papillae; the lingual branch of the fifth pair {n gustatorius) ra- 
mifies freely in the muscular fibres, and terminates in the conical 
and fungiforme papillae; the ninth pair (hypo-glossal) is lost in 
the muscles. It is in consequence of these anatomical views that 
the latter nerve has long been considered as appertaining to mo- 
tion, and the two former to the sense of taste and the general 
sensibility. Some experiments had already been tried in order 
to resolve this question, which only gave contradictory results; 
but the recent researches of M. Magendie upon the trifacial 
nerve, have manifestly proved the above to be the fact. From 
this difference in the action of the nerves of the tongue we will 
perceive the reason why the taste sometimes persists in persons 
affected with paralysis of this organ, and why the gustative func- 
tion is at other times destroyed notwithstanding the movements 
of the tongue are free. We also find several branches from the 
great sympathetic, following the principal vessels, and distributed 
to the base of the tongue ; and it is by means of these filaments 
that it participates with the functions of the interior life. 
vni. The Skeleton. 
In man the tongue does not present any skeleton, but we find 
in its centre, upon the median line, a fibro-cartilage, placed ver- 
tically, {place de champ.)* which is prolonged backwards towards 
the epiglottis. This plate, sometimes indistinct, gives attachment 
to some fleshy fibres which enter into the composition of the 
muscles of this organ, and forms the only solid part of it. 
Under the mucous membrane, between the tongue and the 
inferior maxillary bone, we find the sublingual gland anteriorly, 
and a prolongation of the submaxillary gland posteriorly. These 
two organs form in this situation an elongated eminence, which 
is liable to vary considerably; but it should be remarked that the 
lymphatic glands sometimes become prominent here in conse- 
quence of tumefaction, and may be mistaken for a disease of the 
salivary glands. If the former should be affected with cancer 
or any other disease requiring extirpation, we should commence 
by detaching it from the side of the bone, at the same time raising 
* Blandin, Archives, 1823. OF TIIE HEAD. 
123 
it with a hook; it will then be very easily removed without in- 
curring any risk, provided the instrument does not glance to- 
wards the ranine and sublingual arteries. When the duct of the 
submaxillary gland dilates in such a manner as to form ranula, 
this tumour, being supported externally by the jaw, pushes the 
tongue upwards, and may thereby contract the isthmus of the 
throat to such a degree as to endanger suffocation. A remarka- 
ble example of this kind is related by Burns. “A man called to 
consult Mr. Cline on account of a tumour which had existed for 
a long time under the tongue, and, while waiting in an adjoining 
room, Mr. C. heard the noise of a fall and stifled groans. lie 
immediately enters and finds the man lying on the floor and on 
the point of suffocation. Suspecting the cause to be a foreign 
body lodged in the trachea, he is about to perform the operation 
for bronchotomy, when he perceives that the tongue of the pa- 
tient is forced backward by a large ranula, which is also project- 
ing out of the mouth. He introduces the lancet and gives vent 
to a large quantity of pus and lymph.” 
As these tumours, when growing, remove the nerves and ves- 
sels of the tongue to a considerable distance, a very extensive 
part of them may be excised without danger. 
According to Marochetti, the pustules, which the Greek peas- 
ants and even physicians, among others Dr. Xanthos, say arc 
developed under the tongue, from the third to the ninth day after 
the bite of a rabid animal, would be situated in the tubercle 
where the excretory ducts of the sublingual and submaxillary 
glands terminate. These pustules, then, in the opinion of this 
surgeon, must be merely a dilatation of the extremities of these 
canals, in consequence of an accumulation of the rabid virus 
within them. If this opinion should be confirmed, and if we 
could be so fortunate as to prevent the developement of hydro- 
phobia by the extirpation of these pustules, the operation would 
neither be difficult nor dangerous; for the anatomical relations of 
the parts are such that we might penetrate to a sufficient depth 
in this situation, without incurring any risk of wounding the arte- 
ries. Nevertheless, we think it would be better to seize the 
vesicle with a hook or forceps, and remove it with the curved 
scissors, than to make use of the scalpel or bistoury. 124 
OF TIIE HEAD. 
The Isthmus of the Throat. 
This opening is formed, inferiorly, by the dorsal surface of the1 
tongue; superiorly, by the velum and velum pendulum palati; 
and laterally, by the pillars of the velum. 
The velum palati is a prolongation of all the soft tissues of 
the superior paries of the mouth and inferior of the nasal fossae, 
and also includes a certain number of muscles which determine 
its movements. We consequently find in it, in the first place, a 
thick, slightly extensible, and lacerable mucous membrane, which 
is generally of a deeper colour than that of the interior of the 
nose and mouth, and lined by a layer of filamentous and dense 
cellular tissue, in which there are a great number of very large 
follicles; next, another lamellated membrane, which unites the 
latter to the muscles. It is in the first of these tissues that puru- 
lent and oedematous infiltrations, etc., are developed, and these 
are the follicles which appear to be the principal seat of disease 
in the various affections of the velum palati. In these laminae 
the principal nerves and vessels ramify; but they are unimpor- 
tant in a surgical point of view\ It is proper to observe, howr- 
ever, that it is very liberally supplied with venous capillaries; 
which perhaps will enable us to explain the prompt and beneficial 
results W'hich some surgeons derive from touching the mucous 
membrane with the nitrate of silver in certain inflammations. 
A man was suddenly attacked with a very acute pain in the 
upper part of the mouth, and, on inspection, we perceived a 
reddish blue spot, of the size of a franc piece, upon the ante- 
rior surface of the velum palati, the rest of the throat being in its 
natural state. We touched this spot with the nitrate of silver : 
one hour afterwards the pain had ceased, and on the day follow- 
ing the redness had disappeared. 
Next, the muscles: these are, the levatores palati, which draw' 
the velum towards the nasal fossoe; the tensores palati, which 
widen it by drawing it horizontally, in consequence of their being 
reflected over the hook of the pterygoid process, forming a 
pulley; the palato-pharyngseus and constrictor isthmi faucium. 
which depress it towards the base of the tongue; lastly, the 
levator uvulae, which appertains especially to the uvula. As all OF THE HEAD. 
125 
ihese muscles, with the exception of the azygos uvulae, lie upon 
the sides, we may easily explain how the separation which exists 
between the two halves of the velum palati, when this organ is 
divided, is produced ; but it is not so easy to account for their 
spontaneous approximation, in some convulsive actions of the 
pharynx, as is frequently observed, for example, when the staphy- 
loraphy is performed. We had an opportunity of observing this 
phenomenon very distinctly, in a female operated upon in June 
by M. Roux. We in fact saw, and M. Roux directed our atten- 
tion to it several times, the two lips of the division pass towards 
each other and come into contact, whilst this skilful surgeon was 
attempting to lay hold of them with the forceps or tenaculum. 
This fact is not satisfactorily explained to us by the known 
laws of muscular contraction. 
The velum, like the vault of the palate, seems to be formed by 
the approximation of the two lateral parts. Now, if this ap- 
proximation is not effected, a congenital division will be the re- 
sult, which may exist alone, and thus form a species of hare-lip 
in the back part of the mouth ; or it may be accompanied with a 
more or less extensive separation of the palatine suture, which 
being prolonged forwards, may coincide with a single or double 
hare-lip. It is for the purpose of removing this infirmity, here- 
tofore considered as incurable, that M. Roux invented the staphy- 
loraphy. This operation, simple and easy in itself, but delicate 
and tedious on account of the depth of the organs upon which it 
is necessary to act, has already been performed by the celebrated 
surgeon of la Charite about twenty times; and if not always 
with complete success, at least with a sensible amelioration in 
such cases as would not admit of a perfect reunion. At first 
view, we might apprehend that the sutures would cut through 
the soft parts which they must embrace; but observation has 
shown that this does not happen; and this may be accounted for 
by the compact texture of the mucous membrane, and especially 
of its cellular tissue, which is almost fibrous ; by that of the cir- 
cumflexus palati, which becomes aponeurotic in this situation; 
and lastly, by that of the azygos uvulae, the entire body of which 
is comprised within the loop of the ligature. When the attach- 
ment of the velum palati to the posterior margin of the vault 
participates in the malformation, it may hinder the re-union of 126 
OF THE HEAD. 
the soft parts: in such a case, M. Roux makes a transverse in* 
cision, and separates this membrane on each side, by carrying it 
along the posterior border of the floor of the nostrils; after which 
there is no obstacle to the approximation of the scarified edges 
of the \Vound. This operation is, without contradiction, one of 
the most brilliant conquests of the surgery of the nineteenth 
century. 
The free margin of the velum palati is prolonged in its mid- 
dle by a conical eminence, the length of which varies consider- 
ably. This small body which is indirectly attached to the pos- 
terior spine of the nasal fossa?, is called uvula, and does not exist 
in animals, unless it is the ape, in which it is very small. It con- 
tains the same elements as the velum palati, and its figure is 
moulded upon the azygos uvula? muscle, which retracts and 
partly elevates it. The mucous membrane forms the greater 
portion of it; indeed, with the follicles, it constitutes the whole 
of the inferior half of its free portion. These follicles are so 
large and numerous that they form a thick layer which gives to 
the uvula a very distinct glandular appearance. M. Lisfranc. 
says that there are three in particular at the extremity of this 
organ, which are very large. It is to their swelling, to the 
inflammation of the cellular tissue which envelopes them, or to 
serous effusions into the lamina? of the mucous membrane, thtit 
wrhat is vulgarly called the falling down of the palate is to be 
attributed. Of whatsoever nature this elongation may be, it 
occasions much inconvenience, and a troublesome cough, in con- 
sequence of the irritation which it keeps up in the throat by titil- 
lating the tongue. In all these cases, if it is not indurated, or of 
very long standing, cauterizing it with the nitrate of silver will 
seldom fail to cure. Rut should this means prove unsuccessful, 
we must resort to excision as the only resource which holds out 
a chance of success. For this purpose the scissors invented by 
Percy, having one of its blades a little longer than the other, and 
bent towards the end transversely, so as to prevent the organ 
slipping from between the blades, are very serviceable; or we 
may seize the end of the uvula with a hook or forceps, and then 
snip it off with a blunt pair of scissors. When the tumefaction 
of the uvula is very great, the greater part of it may be removed 
without inconvenience. Surgeons have frequently supposed that OF TIIE HEAL). 
127 
they have cut it off at its root, when only that portion of it which 
is below the azygos was actually removed, and the congestion of 
the tissues being relieved by the operation, they resume their 
regular position; and the uvula then appearing almost of its 
natural length, some have supposed that it was regenerated. 
Upon each side of the uvula, the border of the velum palati 
forms an arch which bifurcates in descending, in order to form 
the pillars, and thus constitute the lateral parts of the pharyngeal 
isthmus. The anterior branch or pillar includes the glosso-pha- 
ryngeeus muscle and is lost upon the side of the tongue ; the pos- 
terior descends into the lateral paries of the pharynx, and seems 
to go to attach itself to the body of the os hyoides: this encloses the 
palato-pharyngoeus muscle. These two pillars consequently leave 
between them a triangular space, the base of which is below, 
and in which the tonsils are situated. These last organs are com- 
posed of a great number of mucous follicles, intimately adherent 
to the mucous membrane, which also sends numerous processes 
between them, uniting them to each other. The amygdaloe are 
subject to two species of inflammation ; that is to say, the inflam- 
matory state may be developed in the surface of the mucous 
tissue, which generally produces factitious membranes of differ- 
ent species, which may be mistaken for ulcers and even gan- 
grene ; or the inter-follicular and sub-mucous cellular tissue may 
be the principal seat of the inflammation. In the latter case, phleg- 
monous abscesses are disposed to form, and when they frequently 
recur they may occasion induration. As the use of the knife is 
frequently required in inflammations of the tonsils and their con- 
quences, it is necessary to know the exact relations of this gland, 
especially its external part. It is, in fact, in this situation that it is 
approximated to the internal carotid artery, from which it is sep- 
arated, in the natural state, only by the constrictor of the pha- 
rynx, some cellular tissue, nervous filaments and a complicated 
venous plexus. In general, the artery is eight or ten lines be- 
hind and external to the gland; so that in plunging the bistoury 
between the pillars of the velum palati, it would be easier to 
strike this vessel when the tonsil is in a state of tumefaction, as it 
is then carried near to the artery. In order to avoid this terrible 
accident, which must almost inevitably be mortal, it would be 
better to direct, the point of the instrument more towards the 128 
v OF THE liFAJJ. 
pharynx, than towards the ramus of the jaw. Notwithstanding 
Burns relates one example, M. Portal a second, and Beclard a 
third, this accident must be very rare, and can only happen to 
those who, by distraction or some other cause, have entirely for- 
gotten the anatomy of the posterior fauces. In the extirpation 
of this gland when scirrhous, there is still less risk, because the 
organ being drawn forwards by the forceps, it is scarcely possible, 
in cutting it out with the scissors or bistoury, to dip so deep as 
the artery. But it must not be forgotten that, during this opera- 
tion, the velum palati, the pillars and tongue are alternately ele- 
vated and depressed, so that the gland appears prominent at one 
moment and at the next depressed: hence the advantage of using 
the scissors, for although the probe-pointed bistoury may be con- 
ducted by a dexterous hand, it will be liable to wound other organs 
unnecessarily. The haemorrhage which follows this operation 
is sometimes considerable, and proceeds from the very complex 
net-work which is formed in the tonsil by the superior and infe- 
rior palatine arteries, and to the tonsillary circle which results 
from their anastomoses being of considerable volume. But more 
frequently the blood is discharged from numerous large veins, 
which form a species of plexus externally and against the poste- 
rior wall of the pharynx. 
It is in the same depression in which the tonsils are lodged, and 
upon the tonsils themselves, that syphylitic ulcers of the throat 
are generally developed ; it is also upon these organs that croupal 
concretions begin to form in the greater proportion of such cas- 
es ; therefore these parts should be closely inspected when we 
have the least suspicion of these diseases. 
Sect. 11. Pharyngeal Region or Cavity. 
Broader in the middle than at its extremities, it seems formed of 
two cones joined at their base, the superior of which is curved for- 
wards in order to become continuous with the nasal fossae, whilst 
the inferior descends almost perpendicularly. 
We will consider the pharynx anteriorly, posteriorly, laterally, 
superiorly, and inferiorly. GLP the head. 
129 
i. The Anterior Part. 
This is the most complicated part, and presents, from above 
downwards, first, the posterior opening of the nostrils, the supe- 
rior and inferior parietes of which incline considerably down- 
wards in order to enter the pharynx, forming a curve and not a 
right angle. In consequence of this disposition, matters which 
are rejected from the stomach easily enter the nose, when the 
velum palati is drawn down, and, on the other hand, sounds pr 
other foreign bodies, readily descend into the pharynx, when they 
have passed through the nasal fossae. 
2. The posterior surface of the velum palati and of the uvula. 
It is important to remark that this part prolongs the palatine vault 
an inch and a half backwards : whence it follows that the secre- 
tions which come from the nasal fossae into the posterior fauces 
fall behind the larynx, and are thereby removed from the respira- 
tory passages; and that it is difficult to introduce tubes into the 
larynx through the nose ; whereas, by this route, it is much easier 
to pass them into the stomach, than by introducing them through 
the mouth. 
3. The posterior buccal aperture, which we have examined in 
the preceding region. This opening is so disposed that it leads 
very obliquely downwards into the pharynx, or rather that it 
seems to continue the latter cavity upwards and forwards; for 
which reason, when the aliment is formed into a ball upon the 
base of the tongue, it is carried by its own weight into the pha- 
rynx, as soon as the isthmus faucium no longer opposes it. This 
anatomical disposition also explains why substances ejected from 
the stomach have a greater tendency to pass out by the mouth 
than the nose, and so much the more so, as the velum palati being 
prolonged into the pharynx, these substances as they ascend from 
the stomach, strike against its inferior surface, and thus almost me- 
chanically apply it behind the nasal fossae. 
4. The posterior face of the larynx and its epiglottic aperture. 
In the middle of this portion we observe an eminence which cor? 
responds to the cricoid and arythenoid cartilages, an eminence 
more strongly marked, but also narrower superiorly than inferior- 
ity. Upon the sides of this species of crest, we distinguish two 130 
OF THE HEAD. 
deep gutters, especially in repassing towards the mouth, in which 
they are gradually lost after having passed over the sides of the 
epiglottis. Owing to these gutters and the eminence which sep- 
arates them, liquids, as they descend into the assophagus, are na- 
turally divided into two columns; which would prevent them 
from entering the larynx, even if the epiglottis did not exist.* 
They are circumscribed laterally by the internal surface of the 
thyroid cartilage, lined by its villous membrane. The laryngeal 
opening is a fissure about nine or ten lines in length, and from a 
line and a half to three lines only in breadth ; broader towards 
the arythenoid cartilages than anteriorly, and having its posterior 
extremity a little more depressed than the anterior; so that it 
looks upwards and slightly backwards. It is surmounted by the 
epiglottis, which forms a species of valve connected to the larynx 
by a pedicle in the retiring angle of the thyroid cartilage, and 
upon the sides by the arytheno-epiglottic ligaments. The posi- 
tion of this cartilaginous plate is such that it does not actually 
shut the chink of the air-tube except during deglutition, and when 
it is necessary to retain a great quantity of air in the lungs, as, for 
example, in the act of supporting heavy burdens, etc.f: other- 
wise it is raised almost perpendicularly ; so that its anterior sur- 
face Jooks towards the superior dental arch, whilst its inferior 
face regards the bottom of the posterior paries of the pharvnx. 
From this it follows that, during expiration, the air is propelled 
into the upper and back part of the latter cavity, above the velum 
palati, and that its natural exit is through the nostrils. Hence 
also, in order that the epiglottis should fall during deglutition, the 
base of the tongue must be elevated. Consequently, when we 
wish to introduce a tube into the glottis for the purpose of estab- 
lishing respiration, as in still born children, or to resuscitate per- 
sons in the state of asphyxia, we must commence by depressing 
the posterior extremity of the tongue : without this precaution the 
instrument will generally penetrate into the pharynx. For this 
reason also we are less sure of introducing a eanula into the lar- 
ynx when we pass it along the median line, than when we slide it 
upon the sides of the base of the tongue. Furthermore, it is ea- 
* Magendie. 
f M. Isidore Bourdon, Recherches sur le mecanisme de la respiration, etc. Pari* 
1820. ’ OF THE HEAD. 
131 
sler to perform this operation by the mouth, because when the 
instrument is introduced through the nose it will strike against the 
posterior paries of the pharynx, rendering it difficult to pass it 
into the larynx without hooking the extremity of the instrument 
with the finger carried deep into the throat. 
ii. The Posterior Wall. 
It has no striking peculiarities, excepting that its mucous mem- 
brane is very thick, especially superiorly, and contains numerous 
very large sebaceous follicles, which very frequently become the 
seat of ulceration and inflammation. The fleshy layer of this 
wall comprehends the three constrictor muscles, and presents the 
following relations : superiorly it is separated from the atlas and 
dentatus and their ligaments by the insertions of the rectus capi- 
tis anticus major and minor; in descending, it is only separated 
from the forepart of the other cervical vertebrae, upon the median 
line, by the ligamenlum commune anterius, and laterally or before 
the transverse processes, by the rectus capitis anticus major and the 
Iongus colli. There is not, therefore, any organ behind this wall 
which it would be dangerous to wound ; and for this reason cer- 
tain jugglers introduce bars of iron, etc., of a considerable weight 
into their throats with impunity; the extremity of the metallic 
rod which is in the pharynx, rests upon the anterior part of the 
vertebrae, and the jaws maintain the equilibrium. The posterior 
wall of the pharynx is united to the above-mentioned organs by 
means of a very lax and very extensible lamellated cellular tissue, 
in which one of the branches of the inferior pharyngeal artery 
ramifies ; also veins of a larger size and much more numerous, 
which unite and separate several times in order to form a plexus, 
their trunks finally terminating in the interal jugular vein ; lastly, 
some filaments of the glosso-pharyngeal, par vagurn and great 
sympathetic nerves. 
hi. The Lateral Walls. 
In their upper part we meet with the Eustachian tube, which 
is expanded in the form of a funnel, and consists of a fibro-carti- 
lage which forms two-thirds or three-fourths of a canal completed 132 
OF THE HEAD. 
by the mucous membrane, which envelopes besides the whole of 
the cartilaginous extremity in the pharyngeal cavity, and also 
lines its internal surface, extending to the ear. This canal is situ- 
ated some lines behind the middle meatus of the nasal fossae, and 
the notched portion of the cartilage looks forwards and upwards. 
Between the root of the pterygoid process and the basilary apo- 
physis, there is a cul-de-sac or excavation, into which the ex- 
tremity of the probe might be readily insinuated in attempting to 
introduce it into the tube by the middle meatus. In fact, if, w hen 
the end of the instrument gets into the pharynx, it is raised in the 
least degree above what is necessary, and if it does not fall ex- 
actly into the guttural canal of the tympanum, it will almost 
always enter this excavation : a circumstance w'hich requires some 
notice, because injections are frequently thrown into this place 
instead of the natural canal. In order to avoid this mistake, it is 
preferable to introduce the probe by the inferior meatus, because 
when it has once got behind the extremity of the inferior turbi- 
nated bone, it will only be necessary to raise the end of it a little 
outwards for it to slide almost of its own accord into the place 
required; and this is occasioned by the levator palati muscle, 
which, as it descends in the velum palati, represents a column 
directed obliquely from above downwards, from behind for- 
wards and from without inwards. This muscle, the pterygoid 
process, and the tensor palati circumscribe a triangle with a supe- 
rior base, in which the eustachian tube is enclosed ; so that when 
the instrument gets as far as the posterior part of the meatus or 
of the floor of the nasal fossae, it is precisely in the summit of this 
triangle. Then, by tracing the gutter which it represents, to its 
upper part, it will enter directly into the tube ; we must be care- 
ful, however, not to pass it beyond the fleshy pillar, as it would 
then be difficult to find the opening we are in search of. It is 
also proper to observe that the membranous duplicature which 
envelopes the inferior turbinated bone, is generally lost in the su- 
perior paries of the guttural duct of the ear; which renders the 
operation extremely easy, by attending to the preceding direc- 
tions. Furthermore, we should bear in mind that this duct is 
directed outwards, backwards and slightly upwards, therefore we 
should give to the tubes, with which we penetrate into it to any OF I'TlF. HEATH 
133 
depth, whether for the purpose of breaking down obstructions, or 
conveying injections, but a very gentle curvature. 
The posterior pillar of the velum palati forms a second column 
which descends backwards and outwards into the lateral wall 
of the pharynx. Lower down, this paries gradually becomes 
narrower, and no longer presents any thing of importance. The 
characters of its mucous membrane are the same as in the prece- 
ding wall; its follicles and villosities are abundant, and it is gen- 
of a pretty deep colour. 
Its muscles are the three constrictors and the stylo-pharyngoeus; 
the stylo-hyoidseus, palato-pharyngaeus and the levator palati also 
form a part of it. 
This wall corresponds to the parotideal region, and is conse- 
quently coasted by the primitive carotid inferiorly ; a little higher 
by the two branches into which this trunk divides; still higher by the 
internal carotid, and throughout its whole extent by the jugular 
vein which lies upon the external surface of the arteries, and 
which places itself quite behind, resting a little on the outer side 
of the anterior cerebral artery previous to its entrance into the 
foramen lacerum posterius; by the glosso-pharyngeal nerve 
which is partly lost in it; by the superior cervical ganglion, its nu- 
merous filaments and the par vagum which are behind and 
between the vessels, as well as by the spinal accessory in the 
superior part only; finally, by the ninth pair, and more remotely 
by the styloid process, the muscles which originate from it, the 
parotid gland and the external carotid artery. It is sufficient to 
mention these relations in order to show the danger and severity 
of wounds of this side of the pharynx, especially such as are pro- 
duced by balls, and pointed or cutting instruments ; and they also 
point out the necessity of proceeding with the greatest circum- 
spection when performing operations in this situation. 
iv. The Superior Extremity or Vault of the Pharynx. 
This extremity is merely the continuation of the posterior wall 
which bends considerably forwards in order to become continu- 
ous with the vault of the nostrils. This disposition is at least evi- 
dent with regard to the mucous membrane, which is softer, 
thicker and redder in this place than in the rest of the organ. The 134 
or tiij: u BAD. 
superior constrictor muscle is attached very near the sphenoid, 
upon the basilary process, and is separated more than an inch 
from the foramen magnum occipitale by the anterior recti capitis 
muscles. In consequence of this disposition the velum palati, 
when rising, soon comes in contact with the vault, or superior 
part of the posterior wall of the pharynx which is inclined for- 
wards, whereby it is not necessary for this velum to be applied 
directly against the whole of the pharyngeal opening of the nasal 
fossae during deglutition, vomiting, etc. The skeleton which we 
find above the soft parts appertains to the base of the cranium ; 
it is composed of the basilary process and of a part of the occipito- 
petrous sutures. The principal bone being spongy and very 
thick, the encephalon is found sufficiently protected in this situa- 
tion. But it is at the posterior part of this paries, or, if we prefer 
it, in the commencement of the posterior wall, that we find the 
occipito-atloidien articulation; and as there is a considerable 
space between the os occipitis and anterior arch of the atlas 
which is filled by ligaments only, a small sword, or other instru- 
ment, entering the pharynx and passing in an oblique direction 
upwards and backwards, might, without great difficulty, pene- 
trate the spinal canal, or cranium, and divide the medulla ob- 
longata. 
v. The Inferior Extremity. 
It becomes considerably narrower and terminates, on a level 
with the cricoid cartilage, in becoming continuous with the oeso- 
phagus. It is on account of the narrowness of this opening that 
foreign bodies, of a certain magnitude, are frequently stopped in 
it. It should be observed that the tissues composing the pharynx 
here undergo a change of character: thus the lining membrane 
which, in the cavity just examined, was red and filled with folli- 
cles, has suddenly become pale and almost smooth. We might, 
perhaps, in this difference of structure, find the reason why the 
accidental membrane, which is formed in diphthcrite, or pellicu- 
lar inflammation,* terminates abruptly at the commencement of 
* It is thus that M. Bretonneau designates certain affections hitherto known by 
the name of croup, angina maligna, etc., and upon which he is about to give a very 
important work to the public. OF THE NECK. 
135 
the oesophagus, in most subjects. The muscular fibres, which 
were transverse, suddenly take a perpendicular direction, and 
this canal then separates entirely from the larynx. 
CHAPTER II. 
The neck is that narrow part of the body which is situated 
between the head and thorax, and which varies in length accord- 
ing to the degree of embonpoint and constitution of the individ- 
ual. In some it is very short and thick, in others the reverse. 
In the first case, if not owing entirely to embonpoint, it generally 
indicates an apoplectic disposition; and a long slender neck is 
often observed in those who are predisposed to phthisis. We 
divide it into anterior and posterior portions. 
Art. I. ANTERIOR PORTION OF THE NECK. 
This part comprehends all the organs situated before the cer- 
vical vertebrae. Upon its surface we observe, in the course of 
the median line ; inferiorly, the supra-sternal fossette ; and above 
this the laryngeal eminence; more externally, another oblique 
eminence, which passes from the sternum behind the ear, and 
which is more strongly marked when the head is turned to one 
side and inclined towards the shoulder: this is the sterno-mastoid 
ridge. The supra-sternal fossette is prolonged between this ridge 
and the laryngeal eminence into the parotideal region, and thus 
forms a gutter on each side, which is broad and pretty deep supe- 
riorly, superficial and almost indistinct in the middle, and becom- 
ing united and blended with each other in the supra-sternal fos- 
sette. On the outer side of the sterno-mastoid ridge, we see the 
supra-clavicular fossa, bounded posteriorly by the trapezius. 
This portion of the neck is thus naturally divided into three 
regions: first, a superior which we call submaxillary, supra-hyoi- 
dean or sublingual region ; secondly, an inferior and median, or 
infra-hyoidean ? and lastly, the supra-clavicular, which is inferior 
and lateral. 
or THE NECK. 136 
OP THE NECK 
Sect. J. Supra-Ilyoidean Region. 
It is bounded; superiorly, by the base of the lower jaw and 
the floor of the mouth ; a little more posteriorly, by the paroti- 
deal region ; inferiorly, by the os hyoides and its cornea arbitra- 
rily prolonged to the sterno-mastoid muscle; laterally, by the 
anterior margin of this muscle. Broadest in the middle, it after- 
wards gradually becomes narrower, in order to terminate in a point 
upon the sides. From before backwards and from above down- 
wards it forms an oblique plane, which rises or sinks in accordance 
with the motions of the tongue or larynx. In some individuals it 
forms a very distinct semilunar prominence, which is separated 
from the jaw by a groove of greater or less depth; this is called 
the double chin. Posteriorly, at its entrance into the parotideal 
excavation, it becomes more concave. 
CONSTITUENT PARTS. 
i. The Skin. 
In women and children this is thin, delicate, and very extensi- 
ble, whilst in man it is thicker, on account of giving support to 
the beard; it often contains transverse wrinkles which are not 
effaced by any position of the head, and which are produced by 
the contractions of the platysma muscle. Its follicles are more 
numerous and of larger size than in the other regions of the neck, 
but less so than in the face; and pustular eruptions, etc, are of 
more frequent occurrence here than in the other regions. It is 
very vascular, and is frequently the seat of ncevi materni, and 
erectile tumours. 
u. The Subcutaneous Layer. 
It is composed of three laminse: 
The first is formed by a compact filamentous cellular tissue, 
enclosing adipose cells, which are usually very fine, but may be- 
come quite large, in which case they form the submental promi- 
nence previously spoken of. This cellular lamina unites the OF THE NECK. 
137 
platysma intimately with the skin, so that when this muscle con- 
tracts, it always draws with it the cutaneous envelope, and for this 
reason also, whenever we nip up a portion of the latter, the sub- 
cutaneous muscle is comprised in the gripe. Finally, from this 
arrangement of structure, we readily comprehend why tumours 
developed in this tissue are always spherical, prominent, and 
seldom acquire a large size before they perforate the integu- 
ments. 
The second lamina is constituted by the platysma itself. Its 
fibres, sometimes very thick, at others scarcely distinct, ascend 
obliquely forwards and inwards, in order to enter the regions of 
the face, or to attach themselves to the inferior border of the jaw7; so 
that they leave between them, upon the median line, a small 
triangular space, the apex of which is at the chin: these are the 
fibres which produce the wrinkles above mentioned. 
The third is formed by a lamellated cellular tissue, destitute of 
adipose cells, which unites the platysma to the cervical aponeu- 
rosis. This lamina is but loosely united to the aponeurosis, upon 
w7hich it slides with facility, but adheres more firmly to the pla- 
tysma and follows its movements. Beneath it the anterior jugular 
veins are found, and, posteriorly, a small portion of the external 
jugular. In consequence of its loose and lamellated texture its 
inflammations frequently assume the phlegmonous character, and 
pus readily collects in it in the form of abcess; but for the same 
reason also, this fluid may easily penetrate downwards, and detach 
the parts to a very considerable extent. Therefore, these ab- 
cesses should be opened as soon as fluctuation is evident, and in 
dividing the platysma the incision should pass parallel to its fibres. 
It is well to notice also that these abscesses, as well as all other 
tumours developed in this layer, may become very large without 
disorganising the skin, and yet retain considerable mobility. This 
peculiarity may be very useful in establishing the diagnosis of 
certain diseases of the supra-hyoidean region. 
hi. The Aponeurosis. 
This is a simple cellular layer in some subjects, but in others 
it is of a very distinct fibrous texture. This fascia originates 
posteriorly, from the parotideal and masseteric aponeurosis; an- 138 
OF THE XECK. 
teriorlv, it is attached to the base of the lower jaw ; as it descends 
below the chin it is thin at first, but receives a very strong lamina 
from the anterior belly of the digastricus before it becomes blended 
with the fascia cervicalis upon the os hyoides. Laterally and 
posteriorly, it splits in order to envelope the submaxillary gland ; 
then it is its anterior sheet only which descends into the supra- 
hyoideal region; the posterior forms in the first place a sheath 
for the gland and its duct, to the prolongation which it sends 
between the my-lohyoideus and hyo-glossus muscles, to the sub- 
lingual gland even, and is finally lost in the inferior paries of the 
mouth; this sheet then gives offless compact laminae which arc 
insinuated between the muscles of the tongue. 
The study of this aponeurosis is important, especially on ac- 
count of the differences which it produces in the developement 
of diseases situated between its external surface and the skin, 
anil those which form behind or beneath it. For abscesses, or 
fluids collected in the latter direction, are much disposed to take 
their course towards the mouth or pharynx, on account of the 
resistance which they meet with anteriorly, and are, besides, 
with difficulty detected by the fluctuation, which may be obscure 
for a long time, notwithstanding the accumulation may be consider- 
able. The same may be said of other tumours, as they generally 
acquire a great magnitude towards the deep seated parts before 
they render the surface prominent. The surgeon should therefore 
recollect all these particulars, when he wishes to open the one, 
or extirpate the others. This aponeurosis forms a lamellated 
web in which the direction of the fibres is not very distinct; on 
which account it is easily resolved into cellular tissue, and is sub- 
ject to so much variety in point of thickness. 
iv. The Muscles. 
Some are appropriated to the movements of the larynx and 
lower jaw; the others appertain more exclusively to the tongue. 
The former are:—The anterior belly of the digastric, which 
ascends obliquely from the os hyoides to the submental fossettes. 
In contact internally with its fellow of the opposite side, covered 
anteriorly by the aponeurosis, and concealing behind it a portion of 
the mylo-hyoideus, this muscular bundle forms an inverted arch or THE NECK. 
139 
mul is found separated from the os maxillare inferius by a 
space which is constantly varying during the elevation or de- 
pression of the larynx or jaw. This space is always filled by the 
submaxillary gland. The posterior belly of the digastricus, in 
descending from the parotideal region, is situated between the 
facial artery which is on its outer side, and the ninth pair of nerves, 
the lingual artery and sometimes the facial vein, which are on its 
inner side. 
The stylo-hyoideus as it approximates the great cornu of the 
os hyoides, has the same vascular and nervous relations as the 
digastricus. This small muscle presents nothing very remarkable 
in a surgical point of view; it bifurcates in order to give pas- 
sage to the tendon of the preceding, gives off an expansion to the 
cervical aponeurosis, and is inserted into the bone. 
The mylo-hyoideus is covered by the digastricus, by a portion 
of the submaxillary gland, by some lymphatic glands, by the sub- 
mental artery and some cellular tissue. Superiorly, it is separated 
from the buccal membrane by the sublingual gland, the mylo- 
hyoidean nerve, some laminated tissue and adipose vesicles; in- 
ternally, it is kept from being in direct contact with the genio- 
glossus and hyo-glossus by a prolongation of the submaxillary 
gland, its duct, the ninth pair of nerves, the gustatory, and the lin- 
gual artery; but at its most anterior part it touches the genio- 
hyoideus, a thin layer of lamellated cellular tissue only intervening. 
The genio-hyoideus forms a small column which descends from 
a rough protuberance within the arch of the jaw upon the body 
of the os hyoides, and seems to be merely the most inferior bundle 
of the genio-glossus. 
The latter are :—The hyo-glossus, which is perforated by the 
lingual artery obliquely from without inwards, from below-up- 
wards, and from behind forwards, some lines above its attachment 
to the os hyoides; so that the vessel covers a small portion of the 
external surface of the muscle posteriorly, whilst it is afterwards 
covered by the internal surface of the latter. This muscle is 
separated from the aponeurosis and jaw by the termination of the 
stylo-hyoideus muscle, the tendon of the digastricus, the ninth 
pair of nerves, a great part of the submaxillary gland, the facial 
artery and veins, some lymphatic glands and the gustatory nerve j 
anteriorly and superiorly, by a small portion of the sublingual gland 140 
0F THE AECK. 
and of the mylo-hyoideus. All these parts are lodged in a trian- 
gular space, the internal side of which is formed by the muscle, the 
superior by the jaw, and the inferior by the aponeurosis. This 
space is lost posteriorly in the parotideal region ; anteriorly, it is 
prolonged towards the tongue between the mylo-hyoideus and 
genio-glossus. Its internal surface is separated from the genio- 
glossus only by the lingual and sublingual arteries inferiorly and 
anteriorly, and by the lingualis muscle superiorly. As the hyo- 
glossus muscle is not attached to the maxillary bone, its relations 
are not altered by the amputation of the jaw. 
The stylo-glossus is a small bundle which is expanded behind 
the preceding, and is interposed between the internal jugular vein 
and internal carotid artery, and the nerves which come out at the 
foramen lacerum posterius, situated internally; the external ca- 
rotid, the facial and lingual arteries and veins, the ninth pair of 
nerves and the gustatory, externally. In the latter direction it 
is also covered by the submaxillary gland or a prolongation of 
the parotid. 
The genio-glossus, which is the largest and most important 
muscle, is attached by its extremity to the rough protuberance 
within the arch of the lower jaw. Its fibres diverge in the form 
of a fan, and terminate throughout the whole extent of ihe infe- 
rior surface of the tongue. It is separated from its fellow by a 
thin cellular layer only; anteriorly, it rests upon the genio-hyoi- 
deus, and is covered externally by the sublingual gland, which 
separates it from the mylo-hyoideus, by the lingual artery, the 
ninth pair and gustatory nerves, and the hyo-glossus muscle ; be- 
sides, quite superiorly, by the lingualis muscle which separates 
it posteriorly from the preceding. As the principal action of the 
genio-glossus is to bring the base of the tongue forwards during 
deglutition, whilst at the same time it raises the larynx by drawing 
it in the same direction, it follows that these movements, after 
the amputation of the jaw, may be interrupted ; a circumstance 
which constitutes the chief obstacle to the complete success of 
this operation. In fact, after the removal of the chin, this muscle 
has no longer any fixed point; consequently the pharynx can no 
longer be distended in its antero-posterior direction, because the 
tongue and larynx are then merely elevated and depressed without 
being carried forwards. Deglutition is thereby rendered very OF THE NECK. 
141 
difficult, if not impossible, unless assisted by artificial means; and 
notwithstanding the jaw may have been removed with all neces- 
sary dexterity, and the operation, as such, has perfectly succeeded, 
the patient has only exchanged a dangerous, perhaps mortal dis- 
ease, for an infirmity which is also capable of conducting him to 
the tomb. These remarks, which have also been made by Pro- 
fessor Richerand, are unfortunately too true, for we have seen 
several individuals perish from this cause. One of these was a 
man fifty years of age, who was admitted into the hospital of St. 
Louis with an enormous cancer of the jaw. It was amputated 
by M. Richerand just posterior to the mental foramina; the two 
ends were slightly approximated, and cellular granulations filled 
up their interval which were soon converted into a fibrous sub- 
stance ; at the end of three weeks every thing appeared as fa- 
vourable as possible, and the cicatrix seemed solid ; soups were 
given to the patient, but he could not make them pass towards 
the pharynx, so that it became necessary to inject them into this 
cavity. He became gradually exhausted, and at length died six 
weeks after the operation, as much from inanition as from the 
suffocation produced by the thick saliva and mucus which ac- 
cumulated in the posterior fauces in consequence of the immo- 
bility of the tongue. From this fact we may conclude that the 
amputation of the anterior part of the inferior maxillary bone is 
a very serious operation, and that it should never be performed 
unless its necessity is positive, and even then it should be avoided 
if the disease extends beyond the depressor anguli oris. Never- 
theless, M. Dupuytren appears to have obtained complete suc- 
cess in a considerable number of cases ; which ought to encour- 
age surgeons. This, however, can only be explained by admitting 
that the portion of bone removed was but small, and that during 
cicatrization the divided extremities of the genio-glossi and genio- 
hyoidei muscles became agglutinated to the posterior surface of 
the new chin.* 
The lingualis muscle wras noticed when treating of the tongue.. 
* Since this article was written we have seen M. Dupuytren perform this section 
of the jaw in a very remarkable case. The disease obliged this surgeon to saw ofi 
the bone as far back as its ascending branches. A month has elapsed since this 
operation and the patient is almost cured. In consequence of this fact we must 
modify the opinion which we have just expressed in relation to this operation; but 142 
OF TIIK IS'ECR. 
v. The Arteries. 
Posteriorly, we find a small portion of the tivo carotids. The 
external is the outer side of the internal, and is crossed on this 
side by the digastric and stylo-hyoideus muscles, the ninth pair 
of nerves, and covered by the parotid gland and aponeurosis; be- 
hind this artery we see the internal jugular vein, the anastomotic 
branches of the great symphathetic nerve and of the first cervical 
pair; internally, it is separated from the internal carotid by the 
inferior pharyngeal artery, the stylo-glossus and stylo-pharyngmus 
muscles. 
The relations of the internal carotid artery are the same here 
as were pointed out in the pharyngeal and parotideal regions. 
The facial or external maxillary traverses this region in the 
direction of a line drawn from the posterior extremity of the 
great cornu of the os hyoides to the anterior part of the masseter. 
In this track it is tortuous and is covered by the digastricus and 
stylo-hyoideus muscles, the facial vein and especially the sub-max- 
illary gland, in the posterior and internal part of which it is some- 
times imbedded; more externally, by the aponeurosis, platysma 
and skin; also by several lymphatic glands; internally, it rests 
upon the stylo-pharyngseus, constrictor medius and hyo-glossus 
muscles, previous to its curving over the border of the jaw. Be- 
neath this bone it gives oft' the sub-mental, which runs along the 
attachment of the mylo-hyoideus, and passes between this mus- 
cle and the anterior belly of the digastric, in order to anastomose 
with its fellow of the opposite side. This is the only branch 
which must necessarily be divided in the amputation of the an- 
terior portion of the lower jaw, and it seldom occasions a trou- 
blesome haemorrhage; should it, it may be readily tied. Pre- 
vious to giving oft’ the submental, the facial artery distributes 
several very large branches to the substance of the submaxillary 
gland, which render the extirpation of this organ difficult. Final- 
ly, still nearer its origin, this trunk sends some dorsal branches to 
it requires all the skill and dexterity of M. Dupuytren in order to succeed in similar 
eases. We must remark, however, that M. Graefe of Berlin, one of the most cele- 
brated surgeons in Germany, has gone still farther, and has dared to disarticulate 
the lower jaw, removing it in teto. OF TIIE NECK. 
143 
the tongue, others to the surrounding parts; but the latter do not 
deserve particular attention. 
From this somewhat superficial disposition of the facial artery, 
we see that it may be wounded either accidentally or during 
operations, and especially if we attempted to remove the sub- 
maxillary gland. Consequently, it is proper to remark that it is 
not difficult to place a ligature around it, and we think that this 
should be done previous to attempting to remove tumours situat- 
ed deep under the jaw, in the direction of this artery, even if they 
are not of large size- It may be easily discovered between the 
cornu of the os hyoides and the submaxillary gland, by making 
an incision from the latter organ to the anterior edge of the ster- 
no-mastoid muscle, in the direction of the line indicated above. 
We will have to divide the skin, the platysma enveloped between 
its two cellular laminae; the aponeurosis, from which the artery 
is separated only by some cellular tissue, and sometimes the fa- 
cial vein, between the submaxillary gland and the digastric 
muscle. 
The lingual artery is situated a little lower than the preceding, 
and on its inner side ; before it passes into the hyo-glossus mus- 
cle, it is crossed by the nerve of the ninth pair. Thus far its 
relations with the muscles are the same as those of the facial; 
afterwards, as it passes between the hyo-glossus and genio- 
glossus muscles, it is accompanied by the ninth pair of nerves, 
which runs along its inferior and outer side. After having given 
off the sublingual, it takes the name of ranine artery. In its 
course from the os hyoides to the superior part of the hyo-glossus 
muscle, it sends off some small branches, among which we dis- 
tinguish the inferior palatine artery, which is distributed to the 
tonsil, etc., and sometimes the submental, when it does not ori- 
ginate from the facial. 
It follows from these relations, that, in order to apply a ligature 
upon the lingual artery, as Beclard has advised in different dis- 
eases of the tongue, and fungus hcematocles especially, the incis- 
ion should approximate a little nearer the horizontal line than the 
anterior margin of the masseter, so that if its anterior extremity 
was prolonged it would come out at the chin. The ligature 
must also be placed some lines below the submaxillary gland: 
then we may seize the artery, separating the nerve which crosses 144 
OF THE NECK. 
it, behind the hyo-glossus; or even under this muscle, by dividing 
the fibres which form a very thin layer over the vessel. Finally, 
in order to avoid confounding this trunk with that of the facial 
artery, we must recollect that the latter passes above and within 
the submaxillary, whilst the lingual is situated lower down. 
vi. Tlte Veins. 
These are larger, more numerous, and generally less tortuous 
than the arteries, the direction of which they do not exactly fol- 
low ; the facial vein, especially, should be examined under these 
different relations. At first it is external to, then behind the 
artery of the same name, and afterwards separates from it as it 
descends, passing over the external surface of the digastric and 
stylo-hyoid muscles, in order to terminate in the internal jugular 
vein. In its course from the genial to the submaxillary region, 
the facial vein usually plunges under the aponeurosis; but, some- 
times, on the contrary, it runs between the facia of the neck and 
the platysma; in which case it forms what is called the anterior 
jugular, and then terminates somewhat lower down in the exter- 
nal jugular. Nevertheless, the anterior jugular may exist at the 
same time that the facial follows its habitual track. 
The other veins of the region generally surround the arteries, 
and empty their blood into the internal jugular. 
vii. The Lymphatic Glands. 
They are very numerous : several of them are situated behind, 
external to, and before the carotids; others surround the sub- 
maxillary gland; there are two or three above this gland, lying 
upon the facial vessels; and lastly, we find some between the 
mylo-hyoideus muscle, the jaw, the digastricus, and the aponeu- 
rosis. As these different glands receive the lymphatics of the 
pharynx, of the interior of the mouth and of the face, it follows 
that they soon become enlarged in consequence of inflammatory 
affections of the gums, cheeks, tonsils, &c.; especially from such 
as produce morbid secretions. The examination of these organs 
therefore is of great importance, as it may lead us to detect dis- 
eases in the organs from which their lymphatics originate, the OP THE NECK. 
145 
existence of which we might not otherwise suspect, and may 
prevent us from mistaking them for other diseases which occa- 
sionally occur in their vicinity. Thus the tumefaction of those 
in the neighborhood of the carotids might be mistaken for aneu- 
rism ; of those which surround the submaxillary gland, for an 
enlargement of this gland itself; and of those above it, which 
are bound down to the jaw by the aponeurosis, for adherent can- 
cers, which it would be imprudent to meddle with. On this 
occasion, we will say, with Colles, Burns, etc. that the most part 
of what have been considered as extirpations of the submaxillary 
gland, may be set down as removals of enlarged lymphatic1 
glands. 
In October 1823, a young person, aged 20 years, was admit- 
ted into the hospital of the School of Medicine, with a very hard 
tumour of the size of a hen’s egg under the jaw, in the situation 
of the submaxillary gland. The opinions respecting the seat of 
this tumour differed. Some thought that it was a tumefaction of 
one or more lymphatic glands; others, an enlargement of the 
submaxillary gland itself. Nevertheless, it was recommended to 
remove it, and Prof. Bougon performed the operation. When 
the disease was extirpated, a deep cavity was seen between the 
os maxillare and the hyo-glossus muscle, and at that moment it 
was believed that the salivary gland had been removed; but on 
further examination, it wTas found to be merely pushed inwards, 
and that the extirpated tumour consisted solely of several disor- 
ganised lymphatic glands. 
vm. The Sub-maxillary Gland. 
This gland is enclosed in a sac, which is formed by a 
process of the parotideal sheath and of the posterior sheet of the 
aponeurosis, as heretofore described. Posteriorly, it is fre- 
quently continuous with the parotid gland: anteriorly, it bifur- 
cates in order to embrace the posterior margin of the mylo-hyoi- 
deus muscle, and its fibrous envelope sends off a process to the 
glandular portion within this muscle, which forms a sheath for it 
and its duct, and is afterwards expanded over the sub-lingual 
gland. The sub-maxillary gland fills almost the whole of that 
prismoidal space which was pointed out when speaking of the 146 
or THE NECK. 
hyo-glossus muscle; in fact, externally and inferiorly, it touches 
the aponeurosis and may be felt under the skin ; the facial vein 
also sometimes rests upon it in this direction. Externally and 
superiorly, it rests against the inner surface of the lower jaw; 
and it is by this side that it receives the expansion of the mylo- 
hyoid nerve: internally, it is separated from the mylo-hyoideus 
muscle by a cellular lamina, the gustatory and lingualis nerve ; 
and lastly, at its posterior, internal, and superior part, we find the 
facial artery, which lies so close to it in some subjects, that it is, 
as it were, imbedded in its granulations. The lingual artery is 
never adherent to it, but is always found opposite to the inner 
surface of its inferior border, from which it is soon separated by 
the thickness of the hyo-glossus muscle. Limited interiorly by 
the arch of the digastricus, the gland follows all the movements 
which this muscle communicates to the larynx ; therefore, when 
we wish to render it as prominent as possible, the head should be 
thrown backwards; and this is the best position in which to place 
the patient when we wish to extirpate this organ. From what 
has been said when on the lymphatics, it may be inferred that 
we are doubtful whether this operation has ever been performed; 
besides, the anatomical relations of the parts, as has been de- 
scribed, must render it difficult and very dangerous, unless the 
facial artery is previously secured ; and even then, the gustatory 
and lingualis nerves are very liable to be wounded If, however, 
the gland alone was diseased, being as it were encysted, we think 
that, having tied the artery, it would be possible to extirpate it 
without wounding those organs which it is important should be 
avoided. 
The Canal of Wharton (Submaxillary duct) is always found in 
that process which insinuates itself between the mylo-hyoideus 
and genio-glossus muscles, in order to reach the sublingual gland 
and the sides of the frcenum. The two principal nerves of the 
tongue run above and below it to a certain distance. It consists 
of three tunics, the firmest of which is the sheath it derives from 
the aponeurosis. It is its dilation that constitutes ronula, and its 
relations show that, if it is true that we can remove a large por- 
tion of this tumour by the mouth without danger, it would not be 
the same by the submaxillary region. OF THE XECK. 
147 
ix. The Nerves. 
They are deep-seated and superfieicial. 
Among the former we find the Hypoglossal (Motor Linguae, 
S. Lingualis, S. Ninth pair) which is at first situated on the outer 
side of the external carotid artery, within and above the stylo- 
hyoid and digastric muscles, then passes below the submaxillary 
gland, crosses the lingual artery, and ascends upon the external 
surface of the hyo-glossus, to the anterior part of which it dis- 
tributes numerous filaments, in order to terminate in the tongue. 
This trunk, which establishes a communication between the fifth 
and eighth pairs by means of its supra-hyoideal and glossal fila- 
ments ; which in the second place forms a communication be- 
tween its branches and the cervical plexus by means of the ramus 
descendens noni, might be easily exposed almost throughout its 
whole extent, and especially in the direction of a semi-circular 
line commencing at the anterior margin of the sterno-mastoid 
muscle, on a level with the angle of the jaw, and terminating upon 
the body of the os hyoides: the incision should then follow the 
curve which separates the inferior semi-circumference of the 
submaxillary gland from the digastric muscle. 2d, The Lingual 
branch of the trifacial (Gustatory), which descends below the 
mucous membrane of the mouth, above the submaxillary gland, 
between the superior part of the hyo-glossus muscle, to which it 
is very closely approximated, and the internal surface of the os 
maxillare, from which it is separated by the gland. Having 
reached the anterior portion of the hyo-glossus muscle, this nerve 
then perforates the genio-glossus, in order to be distributed to the 
papillae. Previous to this, however, it anastamoses, on the one 
hand, above the secretory organ, with the mylo-hyoidean fila- 
ments of the inferior dental nerve; on the other, with the hypo- 
glossal, and then dips into the muscular fibres, on the inner side 
of the salivary duct of Wharton. If it should be required to 
divide this nerve, we would be obliged to seek for it behind the 
branch of the jaw, because it would be almost impossible to ex- 
pose it in the region under consideration. 
At the posterior part we also find some filaments of the glosso- 
pharyngeal, and especially the par vagum and great sympathetic 148 
OF T11E AKCK. 
(ganglionnaire) which descend behind the carotids and internal 
jugular. 
The superficial nerves are derived from the cervical plexus and 
the inferior branch of the facial (portio dura). The former run 
upon the external surface of the aponeurosis ; the latter are prin- 
cipally distributed through the cellular tissue which lines the pla- 
tysma. These different filaments interosculate freely with each 
other, and as they are numerous and enclosed in a dense tissue, 
they account for the acute sensibility of the skin in this region, 
and for the violent pains and nervous disorders which sometimes 
accompany its inflammations. 
x. The Cellular Tissue. 
Between the muscles it is very delicate ; under the aponeuro- 
sis, it is lamellated, and encloses adipose vesicles. The submax- 
illary gland also contains a considerable quantity of it, which 
envelopes each of its granulations between which we observe 
filamentous processes from its aponeurosis. 
It is from this cellular tissue that the pus is secreted when in- 
flammation is developed in this salivary organ. And the same 
may be observed with respect to the parotid and all glands of the 
same species; which is owing to the glandular tissue being ap- 
parently insusceptible of inflammation or at least of suppuration.* 
But this suppuration may be consecutive to swellings occurring in 
the submaxillary gland, in consequence of inflammation of the 
mucous membrane extending into the roots of its canal, a circum- 
stance which frequently happens. 
xi. The Skeleton. 
Properly speaking there is no skeleton in the supra-hyoideal 
region; the only solid parts which can be made to enter into its 
composition are the os hyoides and the inferior half of the internal 
surface of the os maxillare inferius. The former, almost rudi- 
mental in man, whilst in other vertehres it forms a very compli- 
cated bone,f is sometimes prolonged to the styloid process by 
* Gariot, maladies de la bouche, etc. 
t M. Gcoffroy Saint Hilaire, by joining to it the styloid processes, divides this or T1IE NECK. 
149 
means of the stvlo-hyoid ligament, which is then ossiiied. It is 
on this account that the small cornu, which gives origin to this 
prolongation, usually contains several osseous granules. Such a 
disposition, if it w as recognised, might be a good guide to the dis- 
covery of the facial and lingual arteries, etc. 
Be this as it may, the os hyoides give attachment to almost all 
the depressors of the tongue and jaw, and levators of the larynx. 
Hence it follows that a wound which would divide transversely 
the parts above this bone, would be extremely dangerous, inde- 
pendent of haemorrhage, by paralysing all the movements con- 
fided to these muscles. It is proper to observe that a wound of 
this nature would pass above the epiglottis, and consequently 
would not interfere much with respiration. 
The second portion of the skeleton of this region presents the 
genian process (the rough protuberance within the mental arch), 
into which the genio-glossus and genio-hyoideus muscles are in- 
serted ; the sub-genian fossette, for the insertion of the digastric- 
us; the sublingual excavation, for the gland of this name; the 
submaxillarv fossa, which is prolonged to the angle; and more 
superiorly, the mylo-hyoid crest. It thus forms a solid paries, 
and as all the organs applied against it are supported, on the 
other side, by the cervical aponeurosis, it follows that, when they 
become tumefied, they project into the mouth rather than beneath 
the chin. 
From what has preceded we may conclude, that wounds oc- 
curring in the sub-maxillary region will in general be more dan- 
gerous, the nearer they approximate its extremities. In fact, a 
pointed or cutting instrument cannot penetrate more than a few 
lines in this direction, without danger of wounding the facial or 
lingual arteries, one of the carotids, or the internal jugular vein, 
the ninth pair of nerves, par vagum or the great sympathetic. If 
carried deeper, the pharynx would be penetrated. Upon the 
median line, the danger is much less, since there are no large ar- 
teries in this direction. 
The order of the superposition of the parts is as follows: 1st, 
the skin; 2d, dense cellular tissue ; 3d, the platysma ; 4th, lamel- 
bone into eleven distinct pieces; which he thus designates: the basi-hyal, uro-hyd, 
ento-hyal for the body: the apo-hyaux and cerato-hyaux for the lesser cornua; and 
lastly the glosso-hyaux and stylhyanx. 150 
OF TIIE NECK. 
lated cellular tissue, in which the superficial nerves creep; 5th, 
the aponeurosis; 6th, the digastricus, the stylo-hyoideus, mylo- 
hyoideus, sub-maxillary gland, the facial artery and vein, lymphatic 
glands, a small portion of the lingual artery, the submental artery 
and the hypoglossal nerve ; 7th, the genio-glossus, the duct of 
Wharton, the hyo-glossus, the lingual artery, gustatory nerve, the 
carotids, internal jugular, and the nerves situated behind the latter 
vessels; 8th, the genio-glossus and tongue; 9th, and lastly, the 
mouth superiorly, the pharynx posteriorly and internally. 
Sect. 2. Infra-Hyoidean Region. (See plate 3.) 
This region is bounded, laterally, by the sterno-mastoid emi- 
nences ; inferiorly, by the supra-sternal notch; and superiorly by 
the preceding region. It represents a pretty regular triangle with 
its base turned upwards. Upon the median line we may dis- 
cover, by the sight or touch, from above downwards, in the first 
place, a horizontal semi-circular depression, which corresponds to 
the thyro-hyoidean membrane ; next the laryngeal eminence (po- 
rn,wn Adanii) formed by the thyroid cartilage, and much more 
prominent in the adult man than in women and children ; lower 
down, an excavation which points out the cryco-thyroid mem- 
brane ; next the prominence occasioned by the cricoid cartilage ; 
below this a lesser eminence which indicates the upper part of 
the trachea, and lastly, the infra-thyroidal depression, which is 
deeply excavated in those who are emaciated, superficial and 
scarcely perceptible in those of a full habit of body. 
In an adult male of middle stature, the head being slightly 
thrown back, the distance from the os hyoides to the sternum is 
six inches; from the os hyoides to the sinus of the thyroid gland, 
two inches and a half; from the inferior margin of this gland to 
the sternum, two inches and a half likewise. At the inferior part 
of this region the two sterno-mastoid muscles are only one inch 
asunder ; at its upper part, three inches. 151 
OF THE NECK 
CONSTITUENT PARTS. 
i. The Skin. 
It presents the same characters as in the supra-hyoidal region; 
only it is still thinner, is destitute of hairs, contains fewer sebace- 
ous follicles, and is more extensible. 
ii. The Subcutaneous Layer. 
This layer is likewise formed of three laminae arranged in the 
same manner as below the jaw; the platysma, however, leaves 
upon the median line a more open space, in which the two cellular 
sheets are so blended together that they give much greater density 
to the fascia, which might be called the superficial fascia of the 
neck; and we may say, by way of anticipation, that the fascia 
superficialis exists upon all the regions of the body; only it as- 
sumes in some parts librous appearances, whilst in others it re- 
mains cellular, according to the nature and functions of tiie organs 
which it covers. In this, for example, it is thick and unyielding 
upon the median line ; but upon the sides it is thin and less dis- 
tinct, because its laminae have separated in order to embrace the 
platysma. Finally, it is in its inner laminae that some nervous fila- 
ments of the cervical plexus and vessels take their course, among 
which we distinguish the anterior jugular vein, when it exists. 
hi. The Aponeurosis. 
Continuous, superiorly, with that of the preceding region, it 
passes externally, into the supra-clavicular region, and is attach- 
ed, inferiorly, to the sternum and clavicle. Its external surface 
is uniform, and in contact with the fascia superficialis ; its internal 
or posterior surface is extremely complicated. In order that its 
description may be rendered more intelligible, we will examine it 
from above downwards in the direction of the median line, and 
afterwards trace it from the median line towards the sides. 
From its attachment to the os hyoides, to the upper part of the 
thyroid gland it is single, but then splits in order to form a sac 152 
OF THE NECK. 
for this organ; its two sheets afterwards approximate, forming 
sheaths for the thyroid veins, when they again separate, and de- 
scend to the upper part of the sternum in order to be attached, 
the one to the anterior, the other to the posterior surface of this 
bone. This latter space is filled only by a laminated tissue and 
some adipose cells, and the depth of the supra-sternal excavation 
is increased or diminished in proportion to the scarcity or abund- 
ance of these elements. Abscesses forming in this interval should 
be opened early, lest they make their way through the posterior 
lamina. This posterior lamina splits in its turn, in order to form 
sheaths for the thyroid vessels, and penetrates into the chest, 
where we will find it becoming continuous with the pericardium. 
If we now trace the cervical aponeurosis from the median line 
to each side, we will perceive that it forms as many sheaths as 
there are muscles, nerves and vessels ; that is to say, when it ar- 
rives near each of these organs, its laminae separate in order to 
envelope them. Thus, for example, we find a very distinct sheath 
for the sterno-hyoideus muscle ; another for the sterno-thyroid ; a 
third for the omo-hyoideus ; a fourth, stronger than all the others, 
for the sterno-mastoid ; a fifth for the carotid artery; a sixth for 
the internal jugular vein; in short, the great sympathetic nerve, 
the par vagum, thyroid arteries and external jugular receive from 
it their several fibrous canals. It also envelopes the trachea, pass- 
es behind the pharynx, then spreads over the anterior part of the 
rectus anticus capitis and longus colli muscles; over the trans- 
verse processes, to which it is attached ; embraces the scalenus 
anticus, and becomes continuous, on the one part, with the exter- 
nal sheet, which joins it behind the sterno-mastoid muscle, and, 
on the other, with the lamellae of the aponeurosis of the supra- 
clavicular region. It is doubtless owing to this lamellated dispo- 
sition of the fascia cervicalis, that it has seldom been described as 
an aponeurosis; nevertheless, it evidently possesses a fibrous tex- 
ture in a great many individuals, especially in old and thin sub- 
jects. Besides, all anatomists, as well as surgeons, have said that 
all the vessels, nerves and other organs which enter into the com- 
position of the cervical region are united by a dense, extensible 
cellular tissue, formed of lamellae more or less intimately adher- 
ent to each other. It is worthy of notice that fat is never deposit- 
ed between the numerous laminae of this fascia, and that it is OF TIIE NECK 
153 
always external to it that it accumulates in persons of a gross 
habit. 
It is important to be acquainted with this anatomical arrange- 
ment, as it accounts for the rapidity with which abscesses form 
in deep-seated inflammations of the neck, and, as these inflam- 
mations almost always pervade a great extent of surface, it also 
explains why the pus burrows in various directions, without 
rendering the integuments prominent. It also teaches us that 
purulent or other collections should be opened as soon as their 
existence is positively ascertained, otherwise they will be very 
liable to penetrate into the thorax. As the external lamina is 
more unyielding than any of the deeper seated, tumours which 
form beneath it are disposed to take an internal rather than an 
external direction, and consequently may compress the trachea, 
oesophagus, vessels, etc., in such a manner as to produce alarm- 
ing symptoms before they present any considerable volume ex- 
ternally. Finally, when we wish to expose any organ in this 
region, it is absolutely necessary to recollect the arrangement of 
the cervical aponeurosis. 
iv. The Muscles. 
The first which present themselves are the sterno-cleido-mas- 
toid muscles. These muscles, the internal margin of which 
forms the limits of this region, require particular attention when 
we perform the operation for tying the carotid. It is their ante- 
rior border which serves as a guide to our incisions ; and as this 
border is thin and flattened out in some subjects, we should keep 
in mind the direction of its fibres, and also recollect that it is 
separated from the other muscles by an aponeurotic layer of 
considerable thickness; for if we do not, we might fumble a long 
time, and divide the sterno-hyoideus and sterno-thyroideus mus- 
cles, instead of simply drawing back the sterno-mastoideus. We 
have frequently seen students thus perplexed, in performing ope- 
rations upon the dead body. 
Next come the sterno-hyoid muscles, which circumscribe an 
elongated triangle, the base of which is inferior. In this space 
we observe, under the aponeurosis, and from above downwards; 
—the middle of the thyro-hyoid membrane, the angle of the thy- 154 
OP THE NECK. 
roid cartilage, the crico-thyroid membrane and artery, the cricoid 
cartilage, the union of the two lobes of the thyroid gland, the 
thyroid veins and the trachea. It is consequently in this triangle 
that laryngotomy, bronchotomy, etc., are performed. Enveloped 
in its sheath, the sterno-mastoid covers the inferior part of the 
sterno-hyoid muscle, from which it is separated by the interven- 
tion of the sterno-clavicular articulation. The rest of the external 
surface of the latter muscle is removed from the skin merely by 
the inferior thyroid veins, the aponeurosis and the subcutaneous 
tissue. Its use being to fix the os hyoides during the depression 
of the jaw and tongue, or to approximate it towards the thyroid 
cartilage, it should not be cut across in operations. Its inferior 
half only rests upon the sterno-thvroideus ; it next passes beyond 
it towards the median line, and then immediately covers the 
thyroid gland, the cartilages of the larynx and the thyro-hyoid 
excavation. 
The next muscle is the sterno-thvroideus, which is a little 
broader than the preceding, behind which it is placed, and, with 
its fellow, circumscribes another elongated triangle, with its base 
directed upwards. In this triangle we observe the same parts 
as pointed out in the former, with the addition of a portion of 
the sterno-hyoid muscle superiorly. The external surface of the 
sterno-thyroideus muscle is crossed, superiorly, by the horizontal 
branch of the superior thyroid artery; the anastomosis of the 
ramus descendens noni, and the small plexus which it gives off, 
pass over it inferiorly, and glide between it and the preceding 
muscle. This muscle rests from below upwards upon the thy- 
roidal venous plexus and the carotid, upon the thyroid gland, 
its arteries, and the thyroid cartilage into which it is inserted. 
It also corresponds more or less remotely to the trachea, oesoph- 
agus, recurrent nerves, etc. The two sterno-thyroid muscles 
are about one inch asunder in the middle of the region, and this 
distance diminishes or increases in proportion as they approxi- 
mate to the apex or the base of the triangle. 
In the fourth place, we find the anterior portion of the omo- 
hyoideus, covered, at the moment it emerges from beneath the 
sterno-mastoid, by the anterior jugular vein and a branch of the 
superior thyroid artery. It is enveloped by the fascia cervica- 
!is and is separated fromt he skin by some filaments of the cervical OF TIIE NECK. 
155 
plexus and the subcutaneous tissue ; being readily felt through the 
integuments in some individuals. As it ascends towards the os 
hyoides it crosses the internal jugular vein, the carotid, the great 
sympathetic, par vagum, and descendens noni, the superior thy- 
roid artery, the thyro-hyoideus muscle, the membrane of this 
name, and, lastly, the muscles which have just been examined. 
The omo-hyoideus assists in forming two triangles with which 
the surgeon should be well acquainted. 
The first is superior, and is bounded superiorly by the supra- 
hyoidean region; externally, by the sterno-mastoideus muscle ; 
inferiorly and internally, by the omo-hyoideus. In this triangle, 
which we call omo-hyoidien, we find the following organs: the in- 
ternal jugular and the trunks of the lingual and facial veins, the 
ramus descendens noni, par vagum, superior laryngeal nerve, the 
great sympathetic, and about one inch of the primitive carotid ; 
then the origin of the external and internal carotids, that of the 
facial, lingua], occipital and sometimes inferior pharyngeal arte- 
ries ; the superior thyroid artery is always found in it, and may 
here be readily exposed and tied, as we will mention directly: 
finally, the hyo-thyroideus muscle, a small portion of the inferior 
and middle constrictors, the thyroid cartilage, its superior cornu, 
and the side of the hyo-thyroid membrane. 
The second, we call the omo-tracheal triangle, which is much 
more extensive than the former, and bounded superiorly and ex- 
ternally, by the omo-hyoideus muscle, externally and inferiorly 
by the sterno-mastoideus, and internally by the trachea. In it we 
observe, the whole of the sterno-hyoid and thyroid muscles, a 
small portion of the thyro-hyoideus, one lobe of the thyroid gland, 
the arteries which are distributed to it, the sub-hyoidean veins, 
the plexus of the ninth pair of nerves, the side of the cricoid car- 
tilage, of the trachea and oesophagus, the recurrent nerve, primi- 
tive carotid, inferior thyroid artery, the great sympathetic and par 
vagum, the internal and anterior jugulars, lastly the vertebral 
artery. 
The hyo-thyroidei (thyro-hyoidiens) are the last superficial mus- 
cles which we find in this region; they are covered by all the 
others, resting directly upon the thyroid cartilage, but separated 
considerably from the thyro-hyoid membrane. It is behind their 
posterior margin that the superior laryngeal nerve insinuates itself 156 
or TIIE MXK. 
between the os hyoides and thyroid cartilage before it penetrate* 
into the larynx. 
The longus colli and a portion of the rectus anticus capitis ma- 
jor, deeply situated upon the transverse processes and bodies of 
the cervical vertebrae, also appertain to the infra-hyoidean region. 
Between the former and the scaleni there is a triangle through 
which the vertebral artery runs in its course to the foramina of 
the transverse processes. 
v. The Arteries. 
They are numerous and very important, the carotid arteries 
especially. 
The right carotid is shorter, nearer the median line, more an- 
terior and thicker than the left; which is owing to its being given 
off by the brachio-cephalic trunk. This disposition affords an 
additional reason for not performing msophogatomy on this side, 
for not applying a ligature upon the artery too near the inferior 
part of the neck, and for taking suitable precautions in the opera- 
tion of tracheotomy. Anteriorly, the left carotid is in the first 
place separated from the sternal portion of the sterno-mastoid 
muscle by a space of about an inch in extent, which is filled with 
cellular tissue, fat, veins of considerable size, some descending 
branches of the cervical plexus, etc. On the right, this interval is 
less extensive, and the artery runs nearer the anterior margin of 
the muscle. Both of the vessels are next covered by the internal 
surface of this same muscle, by the posterior margin of the sterno 
thyroideus,and the omo-hyoideus, which crosses them; by the ramus 
descendens noni, which sometimes rests upon the arterial sheath, 
by the thyroid gland itself, whenever it is a little developed, and 
indirectly by the cervical aponeurosis, the subcutaneous layer and 
skin. But as the sterno-mastoid muscle directs its course ob- 
liquely upwards and backwards, it consequently follows that the 
carotid becomes more superficial the higher it ascends and there- 
fore more easy of access. Posteriorly, it rests upon the great 
sympathetic, upon the cardiac filaments of this nerve and the par 
vagum, which are, as it were, glued to its sheath ; upon the infe- 
rior thyroid artery, opposite the omo-hyoideus muscle or a little 
lower down; upon the ascending cervical and vertebral arteries. OP THE KECK. 
157 
and the accompanying vein of the latter; and lastly, immediately 
upon the anterior part of the base of the cervical transverse pro- 
cesses and of the triangle limited by the anterior scalenus and 
longus colli muscles. 
From these relations of the carotid posteriorly it follows that it 
might be compressed efficaciously on the left side, whilst waiting 
for the application of a ligature, in case it should be opened some 
distance above the sternum. It should always be remembered, 
however, that the nerves cannot long sustain this pressure. 
Externally it is coasted by the par vagum, then by the jugular 
vein and phrenic nerve; inferiorly by the trunk of the ascend- 
ing cervical artery, by that of the inferior thyroid, the cervical 
plexus and the parts which constitute the supra-clavicular region. 
Internally, it touches, in several points, the inferior and middle 
constrictors of the pharynx, the trachea on the right, and the 
oesophagus on the left; from which parts it is separated only by 
some dense and lamellated cellular tissue, the recurrent nerve, 
diverse filaments of the sympathetic and by the inferior thyroid 
artery ; so that near the sternum the two carotids are removed 
from each other only by the trachea, that is to say, by an interval 
of about an inch or eighteen lines. Superiorly, on the contrary, 
they are separated by the entire thickness of the larynx. 
From these anatomical dispositions it follows that if we wish 
to cut down to the external side of the carotid artery, we can 
only do it in its inferior third, behind the sterno-mastoid muscle; 
its anterior side, however, may be exposed throughout its whole 
extent. In the first direction, an instrument could not reach it 
without having previously divided the internal jugular vein; in 
the second, on the contrary, there are no important vessels be- 
fore it. Therefore, whenever we wish to apply a ligature on this 
artery, we should endeavor to fall upon its anterior part, and the 
following are the organs which the instrument must then tra- 
verse : 1st. the skin, parallel to the sterno-mastoid, but in such a 
manner that, at the upper part, the incision should pass on the 
inner side of the muscular margin, whilst at the lower part, it is 
better to make it a little more externally, on account of the di- 
rection of the artery: this remark, however, is strictly applicable 
to the left side only; 2d. the aponeurosis, forming a double lamina 
before and behind this muscle, which must be drawn outwards 158 
OF THE NECK. 
after the division of this fascia ; 3d. a thinner but very extensible 
fibrous lamina, which passes from the sterno-hyoid and thyroid 
muscles, as well as from the trachea, anterior to the vessels, in 
order to blend itself externally with the deep lamina of the 
sterno-mastoid muscle. In this lamina we usually find some fila- 
ments of the cervical plexus and the descendens noni: it is this 
which gives a sheath to the omo-hyoideus, a muscle which we are 
sometimes obliged to divide, and which always crosses the caro- 
tid in such a manner, that when we tie this artery in the omo- 
hyoidean triangle, we should depress it inwards, and when in the 
omo-traeheal triangle, we must draw it upwards and outwards; 
in this manner we may generally dispense with cutting this small 
muscle across; 4th. the sheath which the aponeurosis gives to the 
artery, the opening of which is one of the most delicate steps of 
the operation ; for if we cut too much outwards, the internal 
jugular vein may be wounded ; if we incise directly upon the 
artery, we might open this vessel itself. Nevertheless, if this 
sheath is not divided, we will almost inevitably include in the 
ligature, together with the carotid, both the descendens noni and 
the cardiac nerves, which are more or less adherent to its outer 
surface. For this reason, after having separated the artery from 
the vein, we should seize this fibrous canal upon the former with 
the forceps, and then make a small horizontal incision into it, in 
the same way as we would open a hernial sac. Afterwards it 
will be easy to dilate this opening as much as is necessary, by 
means of a director introduced between the aponeurosis and the 
vessel. In this manner the artery alone will be isolated, all the 
nerves avoided, and the consequences of the operation rendered 
less formidable. 
Whenever we wish to secure the primitive carotid, whether for 
an aneurism, a wound, or any disease of its branches whatsoever, 
the omo-hyoidean triangle is to be preferred, because it affords us 
the most room, and the vessels are more superficial. But when 
the aneurism occupies the trunk, we are obliged to place the lig- 
ature nearer the sternum; in which case the operation is more 
easily performed on the right, but it is likewise more dangerous, 
because the proximity of the subclavian will hinder the formation 
of the clot in the origin of the carotid. 
The common carotid divides opposite to the superior margin OF THE NECK. 
159 
of the thyroid cartilage, on a level with the inferior part of the 
third cervical vertebra; so that the infra-hyoidean region includes 
about an inch of the internal and external carotids. These two 
branches present the same general relations as the trunk from 
which they originate. The external, which might here be better 
called the superficial, is placed before and even a little within the 
internal, which is the largest and is situated upon the anterior 
part of the spine. A ligature ought not to be applied on these 
two branches so near their origin. In cases which might seem 
to demand it, the ligature of the common trunk should always 
be preferred. 
Before the external carotid enters the supra-hyoidean region 
it generally gives off' the superior thyroid, the external maxillary, 
the lingual and the pharyngeal arteries. 
The superior thyroid is the most important in a surgical point 
of view. The peculiarities relative to the other branches were 
pointed out in the submaxillary region. This branch separates 
from the trunk on a level with or a little below the cornu of the 
os hyoides, and takes a tortuous, but generally oblique direction 
downwards and forwards, in order to arrive at the superior and 
external part of the thyroid gland. Enveloped in the deep 
lamince of the fascia cervicalis, it is covered a little by the sterno- 
mastoid muscle, by some cellular tissue, the aponeurosis of the 
neck, the subcutaneous layer, and the skin ; it is crossed by the 
descendens noni: posterior to it we find the superior laryngeal 
nerve and numerous filaments of the great sympathetic. In this 
tract the superior thyroid artery gives off’ a branch which runs 
along the inferior border of the os hyoides, and is distributed to 
the thyro-hyoid membrane : this may be wounded from attempts 
at suicide. It also sends oft' a second branch which descends 
behind the gland, upon the inner and anterior part of the caro- 
tideal sheath. This branch must be pressed towards the trachea, 
if the principal artery of the neck should be tied at this point. A 
third branch is the laryngeal, which runs between the constric- 
tors and the posterior margin of the thyro-hyoideus muscle, upon 
the membrane of this last name, perforates it, and is lost in the 
larynx. Here, the thyroid artery next distributes numerous large 
branches to the gland, which in their turn give oft’ a certain 
number of twigs, among which the crico-thyroideal in particular 160 
OF TUB NECK. 
deserves notice, and will be examined when we come to treat of 
the larynx and trachea. All these arteries ramify in the glandular 
tissue, inosculate with their fellows of the opposite side, with 
branches of the inferior thyroid, and thereby form in this organ 
an exuberant plexus, which may occasion profuse haemorrhage, 
notwithstanding the carotids have not been wounded. Indeed, 
we are of opinion, without doubting the sincerity of authors who 
have mentioned that haemorrhages proceeding from wounds of 
the internal, external, or common carotids, have been arrested 
without the application of ligatures, that such cases should be 
considered as divisions of the thyroid artery or its branches, or 
of the facial, lingual arteries, etc. 
According to the disposition of the trunk of the superior thy- 
roid artery, it might be readily exposed and tied, either in the 
direction of a line drawn from the cornu of the os hyoides to 
the anterior and inferior part of the thyroid cartilage, or by 
making an incision obliquely downwards and outwards, from the 
os hyoides to the sterno-mastoid muscle; or, lastly, by dividing 
the parts in the omo-hyoid triangle parallel to the sterno-mastoid 
muscle. In this space, in fact, the artery, before it reaches the 
gland, is covered only by the ramus descendens noni, some 
veins, the aponeurosis, and the common integuments. 
We likewise find in this region two other considerable arte- 
ries ; the inferior thyroid and the vertebral. The inferior thyroid 
is at first situated behind the common carotid and internal jugular, 
the par vagum and great sympathetic nerves, and before the sca- 
lenus anticus and longus colli muscles; it then ascends in a ser- 
pentine manner, behind the inferior part of each of the lobes of 
the thyroid gland, where it terminates in a great number of 
branches which anastomose with those of the opposite side, and 
the superior thyroid. When the left thyroid artery insinuates 
itself behind the carotid very low down, it may be posterior to the 
thoracic duct; at the same time it is nearer the oesophagus than 
the right. Anteriorly and externally it is crossed by the cervical 
branch of the lingual nerve (<descendens noni) ; the inferior la- 
ryngeal nerve {recurrent), on the contrary, is situated internally 
and posteriorly. The inferior thyroid artery is almost always met 
with in the summit of the omo-tracheal triangle, in the direction 
of the omo-hvoideus muscle, behind which it is also sometimes OF THE NECK 
161 
directly situated; a circumstance important to recollect when we 
wish to tie this vessel. This operation might be performed with- 
out difficulty by following the method recommended for the caro- 
tid ; only, instead of opening the sheath of the latter, we should 
push it outwards, whilst we detach inwards the thyroid gland and 
trachea, and draw the omo-hyoideus muscle upwards. The ar- 
tery will always be found a few lines higher or lower in this 
space, quite near the fleshy bundle. In applying the ligature, we 
must exclude the two principal nerves which pass before and be- 
hind the vessel; consequently, we must vary the method accord- 
ing to the position of the parts; if the nervous trunks are very 
close to the trachea, the needle must be passed from below up- 
wards and from within outwards ; if these nerves are nearer the 
carotid, we should pass it in the opposite direction. 
The ligature of the inferior and superior thyroid arteries is an 
operation which might be frequently performed, either on ac- 
count of a wound of these vessels, or with the view of causing 
atrophy of the thyroid gland in bronchocele ; or finally, for the 
purpose of enabling us to extirpate the thyroid body itself; which 
has already been done by several skilful surgeons, and especially 
by the celebrated Walther of Bonn. But it is necessary to re- 
collect that a fifth thyroid artery sometimes exists in the direction 
of the median line. 
We have occasionally met with this branch, which was first 
described by Neubauer in 1772, and since by almost all correct 
anatomists. It sometimes arises from the arteria innominata, but 
more frequently from the arch of the aorta ; it then ascends in a 
more or less tortuous manner towards the inferior part of the 
thyroid gland, anterior to the trachea, covered by the thyroid 
veins, the aponeurosis and the skin. The existence of this artery 
would render tracheotomy very dangerous, and it would be diffi- 
cult to apply a ligature around it on account of the very large 
veins which commonly run before it. It is also well to know 
that the thyroid arteries vary much in volume, position and even 
in number ; and we should especially recollect that variety, des- 
cribed by F. Meckel, in which the thyroid of Neubauer originated 
from the brachio-cephalic trunk, and passed to the left lobe of the 
gland, crossing the anterior surface of the trachea; so that it 
would have been impossible to avoid wounding this vessel, if an 162 
OF THE NECK. 
opening had been made into the air tube. According to M, 
Meckel, Burns has met with the same anomaly; but we have not 
been able to discover this fact in the work of the latter author. 
The second or vertebral artery also originates from the subcla- 
vian : it is situated behind the internal jugular and carotid artery, 
and crosses them very obliquely from without inwards and from 
below upwards, in its course to the infra-hyoidean region; 
so that in some subjects it inclines a little within the common 
carotid. The great sympathetic and eighth pair cross it in the 
same direction, so that inferiorly these nerves are on the inner 
side, whilst superiorly they are on the outer side of the artery. 
On its inner side, it is in relation with the longus colli muscle, 
then with the inferior laryngeal nerve, the oesophagus and 
trachea; on its outer side, with the middle cervical ganglion and 
the filaments detached from it, with the phrenic nerve and scalenus 
anticus muscle ; finally, it enters the canal in the transverse cervi- 
cal processes, and passes on to the cranium. 
vi. The Veins. 
They are numerous and important in the infra-hyoidean re- 
gion ; the most conspicuous are, 
(a) The Internal Jugular. This vein is situated on the outer 
side of the carotid artery, and accompanies it. They are both en- 
veloped by a common fibro-cellular sheath, but have nevertheless 
each a distinct envelope. We distinguish the vein from the artery 
by the tenuity of its coats, which collapse, and are almost transpa- 
rent ; by its external position, and by the colour of its blood. 
Upon the dead body, the internal jugular vein is generally flat- 
tened in such a manner as to form a semi-canal applied upon the 
external half of the carotid artery. Upon the living, its relative 
volume is much greater, so that it covers a considerable portion 
of the anterior surface of the artery, and its dimensions increase 
on expiration and diminish on inspiration. Hence it follows that 
the size of the internal jugular vein will be augmented, during the 
performance of certain operations, in proportion to the degree in 
which respiration is impeded : therefore at such times we should 
endeavour to calm the agitation of the patient, and induce him to 
make full inspirations. It is especially during the application OF THE NECK 
163 
of the ligature of the carotid that this alternate dilatation and col- 
lapse greatly embarrass the operator. It is true that we might 
possibly prevent this, by compressing the vein above the place 
where we wish to lay bare the artery. The internal jugular vein 
is covered anteriorly by the parts which conceal the primitive 
carotid; only, as it is more external, the sterno-mastoid muscle 
covers it to a much greater extent; on the outer side of the vein 
are situated the phrenic nerve and the cervical plexus in general; 
internally, it touches the carotid artery, and is sometimes, as it 
were, even adherent to it; posteriorly, it crosses the inferior 
thyroid artery below, and the nervous filaments of the cervical 
plexus, which anastomose with the great sympathetic, above. In 
the latter direction it usually covers the ascending cervical arte- 
ry, and rests upon the internal side of the scalenus anticus. It is 
between its internal posterior part and the carotid that the par 
vagum and great sympathetic are situated; so that in order to 
avoid wounding these nerves when we are trying to isolate the 
vein, the needle should be introduced on the outer side of the 
artery. Where the jugular empties into the subclavian vein, it 
generally conceals the vertebral artery. Its anterior part receives 
a great number of veins, which cross the common carotid, and 
may thereby cause considerable perplexity when we attempt to 
apply a ligature around this artery; and these veins are the more 
annoying on account of their irregularity, in relation to num- 
ber, magnitude and position. Be this as it may, all these venous 
branches appertain to the organs which constitute the supra and 
sub-hyoidean regions, and are particularly congregated below the 
cornu of the os hyoides, on the one part, and at the inferior part 
of the region, above the sterno-clavicular articulation, on the 
other. We may also state that some venous ramusculi, of a cer- 
tain calibre, from the supra-cavicular region and anterior part of 
the chest, often pass through the latter point, especially on the 
left side, in their course to the subclavian or internal jugular. 
When this disposition exists, a more or less complicated plexus 
is the result, which might increase the difficulties of tying the 
subclavian artery within the sterno-mastoid muscle.* It also 
follows from this arrangement that, in order to avoid these veins. 
'* Langenbeck, loco citat. 164 
OF THE NECK 
when we seek for the carotid, it is much better to lay it bare either 
immediately above or below the omo-hyoideus muscle. 
( b ) The external Jugular Vein usually appertains to the supra- 
clavicular region, where we will examine it; sometimes, however, 
we find it in the sub-hyoidean region, or it may exist there at the 
same time that another is situated in the usual position. In this 
case, it is generally smaller, and the other bears the name of ante- 
rior jugular. We have sometimes found the anterior jugular with 
the external, and we have met with it single, upon the dead body, 
three different times. The anterior jugular vein sometimes re- 
ceives the greater portion of the branches of the face and sub- 
maxillary region; at other times it appears to be formed solely 
of some thyroid branches which have deviated from their natural 
direction. Its trunk sometimes opens near the larynx, in the in- 
ternal jugular; more frequently it descends singly to the inferior 
part of the neck, and then empties into the same vessel; and 
again it proceeds directly to the subclavian, especially on the left 
side. In some subjects this vein is very large, and might be 
opened with equal facility and in the same manner as the external, 
if thought necessary. 
In general, when it supplies the place of the external jugular, 
it lies superficially upon the aponeurosis ; at other times, it runs 
between the muscles and the fascia cervicalis which it traverses, 
especially when it comes from the thyroid gland. It is on this 
account, that, when we operate upon the deep-seated organs, we 
should divide the tissues cautiously, in order that we may tie or 
push it aside, if wre are unwilling to divide it. 
( c ) The Thyroid Veins. They are proportionately larger in 
children than adults, in the female than the male; and their 
volume is generally in a direct ratio to that of the gland. They 
may be arranged under two orders: those which follow the di- 
rection of their collateral arteries, are a little more superficial, 
and cross the carotids anteriorly, in order to terminate in the in- 
ternal jugular vein: the others collect below the gland, forming 
three, four, or five principal branches, which descend before the 
trachea, where they constitute a species of plexus between the 
sterno-thyroid and sterno-hyoid muscles. It is this sub-thyroidean 
plexus which renders dangerous, because it is difficult 
to avoid all these veins, and consequently haemorrhage. It is OF THE AECK. 
165 
enveloped in a lamellatcd cellular tissue, and its branches empty 
into the subclavians as they approximate the trachea. It is proper 
to observe that it would be more easy to reach the trachea, with- 
out wounding these veins, in the vicinity of the sternum, than 
immediately below the thyroid gland, because in the former situa- 
tion these vessels run in a parallel direction, whilst, in the latter, 
they intersect one another in divers manners. 
they lie beneath the aponeurosis; so that they cannot be distin- 
guished through the skin, even when they are in a varicose state. 
( cl) The other veins of the infra-hyoidean region empty into 
one of the preceding branches, and do not require further consid- 
eration. The facial and lingual veins also descend into this 
region, and are found below the great cornu of the os hyoides; 
but they form a part of those which cross the carotid artery 
superiorly, and which were pointed out in the commencement of 
this paragraph. 
vii. The Lymphatics. 
These vessels are numerous and pretty well understood ; some 
of them descend into the glands of the mediastinum ; others into 
those of the axilla ; but the greater number terminate under the 
sterno-mastoid muscle. 
It is very necessary to have a correct knowledge of the glands 
of this region, on account of the variety of diseases to which they 
are subject. In the first place, they form a very remarkable chain 
around the internal carotid and internal jugular; there are also 
some others of smaller size behind the sub-thyroidean plexus, 
upon the anterior part of the trachea, and lastly we sometimes 
find one of them upon the fore part of the larynx.* 
When these glands become tumefied, they may be mistaken for 
other affections. Thus, the slow and gradual developement of one 
of those in the carotideal groove, may lead to the supposition that 
an aneurism of the carotid, of one of its branches, or of the inferior 
thyroid exists. This mistake may easily be made in consequence 
of the enlarged gland being firmly compressed, by the lamina) of 
the cervical aponeurosis and the sterno-mastoideus muscle, against 
the artery situated behind it, whereby a pulsatory motion is trans- 
mitted to the tumour. 
* Burns. 166 
OF THE NECK 
Those situated before the trachea may be mistaken for an 
enlargement of the thyroid gland, and we are of opinion that this 
organ is said to have been removed more than once, when one of 
the surrounding lymphatic glands merely was extirpated. Be this 
as it may, as they correspond to the aponeurosis in those places 
where it is thickest, they will, as they enlarge, compress the 
trachea and oesophagus, and by suspending respiration and degluti- 
tion produce alarming consequences. 
The gland described by Burns may also become greatly en- 
larged ; as has occurred to this author's notice ; and may thereby 
lead to numerous errors, and occasion unpleasant results. 
Lastly, we find some very small absorbent glands, between the 
oesophagus and trachea, around the recurrent nerves. Should 
these become diseased, it would be much more difficult, on account 
of their depth, to form our diagnosis, than in the preceding cases. 
vm. The Nerves. 
The nerves of this region are very numerous, and merit much 
attention. 
(a) From the cervical plexus, it derives both superficial and 
deep-seated nerves. 
The former appertain to the filaments which ascend before 
the larynx and under the chin, between the aponeurosis and the 
platysma. They are flattened, hard, and appear to preside over 
sensation. These branches would necessarily be divided when 
a ligature is applied around the carotid in the omo-hyoidean trian- 
gle. Their inosculations with the facial account for the pain, 
sometimes very acute, which subcutaneous tumours of the neck 
give rise to in the face. 
The latter are filaments of communication with the great sym- 
pathetic, etc., and especially the branch which anastomoses in the 
form of a loop with the descendens noni. As this branch comes 
out from beneath the sterno-mastoid, it crosses the anterior part 
of the jugular vein very obliquely, before it unites with the filament 
of the ninth pair. The other branches of the cervical plexus pass 
behind the deep vessels of the neck. 
( b ) We next find the ramus descendens noni. It separates 
from the trunk or hypo-glossal nerve as high up as the os hyoides, 
and runs first on the outer side of the internal carotid, afterwards OF THE NECK. 
167 
upon the anterior part of the common carotid. Sometimes it 
abandons this vessel, approximating nearer the larynx or trachea, 
but more frequently passes outwards upon the jugular vein. In 
either case we should bear it well in mind when we wish to tie 
the common carotid ; for it is much better to make a complete 
section of this nerve than to comprise it in the ligature. It is in 
the vicinity of the omo-hyoideus muscle that it unites with the 
internal descending branch of the cervical plexus. The filaments 
originating from this union form, in certain subjects, behind or 
beneath this muscle, a sort of plexus, called by some the super- 
ficial cervical plexus. 
Previous to these filaments being distributed to the muscles, 
they cover the primitive carotid artery, and cause more or less 
perplexity when we apply a ligature around this vessel in the 
omo-tracheal triangle. 
( c) In the third place we find the par vagum (pueumo-gastrique), 
the largest and most remarkable of all the nerves of the neck. 
This nerve is situated before the base of the cervical transverse 
processes and the soft parts which immediately cover them, and 
is itself covered by the carotid and the internal jugular vein: it 
is then between and behind these two vessels that we constantly 
find the par vagum ; before, on the outer, and sometimes on the 
inner side of the great sympathetic nerve, to which it is always 
closely approximated. In this place, the pneumo-gastric nerve 
cannot be confounded with any other organ. The lamellated 
cellular tissue which envelopes it is very dense and very com- 
pact ; and as it is this same cellular tissue which forms a sheath 
for the artery, it follows that we should be particular, when tying 
the latter, to exclude the nerve from the ligature. In order that 
we may accomplish this end more surely, and at the same time 
disturb the parts as little as possible, we should introduce the 
needle close along the outer side of the artery, leaving the par 
vagum external to it. 
This step is also rendered much more easy by making a cau- 
tious incision through the arterial sheath, previously pinching up 
this sheath, and making a small horizontal cut, sufficiently large 
to admit the introduction of a director, upon which the opening 
may be dilated. In this manner the artery is completely isolated, 
all the nerves remain untouched; no tissue is lacerated, in short all 168 
OF THE NECK. 
the parts are left in the state best adapted for their prompt reunion. 
The par vagum gives off two principal branches in the sub- 
liyoidean region, which are the two laryngeal nerves. 
(d) The superior laryngeal nerve separates from (lie trunk 
opposite the os hyoides, and is at first situated behind the carotid, 
near its bifurcation ; it then glides along its inner side, in order to 
arrive, on the one hand, at the posterior part of the thyroid gland, 
and on the other, upon the thyro-hvoid membrane ; sometimes it 
is situated higher up than the superior thyroid artery, at others, 
lower down, but always deeper. Nevertheless, it follows nearly 
the same direction as this artery; a circumstance which must be 
recollected when we wish to tie this vessel; for the section of this 
nerve would almost certainly be attended with dumbness. 
(e ) The inferior branch, or recurrent nerve, is longer on the 
left side than on the right, because, in the first direction, it passes 
under the arch of the aorta, whilst, in the second, it turns round 
the subclavian and ascends to the larynx along the cesophago-tra- 
cheal gutter, or, in other words, between the carotid artery which 
is external, the oesophagus and trachea, which are internal. This 
nerve is at first nearest the artery, but afterwards approximates 
the respiratory and alimentary tubes, to which it distributes a 
great number of filaments. Hence it follows that the inferior 
laryngeal nerve may be wounded in cesophagotomy; in extirpa- 
ting the thyroid gland; in tying the inferior thyroid arteries, or 
the common carotid when performed in the omo-tracheal trian- 
gle, or the subclavian on the inner side of the sterno-mastoideus 
muscle. 
(/) We must also notice the cardiac filaments given off by the 
eighth pair. They are more numerous on the left side than on the 
right, and remain a long time behind the trunk of the carotid. Of 
themselves they posses but little consistency, but their tenacity is 
very much augmented by the cellular tissue which envelopes them. 
They are particularly adherent to the arterial sheath, especially 
in the upper half of the region, which affords an additional mo- 
tive for opening this sheath when we wish to tie the carotid ; in- 
deed, without this precaution, it might frequently happen that one 
of the cardiac nerves of the par-vagum would be included in the 
ligature, which would not fail to occasion more or less disturb- 
ance in the action of the heart. OF THE NECK. 
169 
(g) Tlie great sympathetic nerve (le nerf de la vie interleave) is 
also concealed by the carotid, lying deeper than, and on the inner 
side of, the par-vagum. A part of its superior ganglion, the whole 
of its middle ganglion, when it exists, the two cardiac nerves, 
and numerous accessory filaments are found in this region. En- 
veloped in the lamellated tissue of the deep parts of the neck, 
having nearly the same relations with the important vessels of 
this part, the great sympathetic nerve is susceptible of the same 
surgical applications as the nervus vagus, when we perform ope- 
rations upon this region. 
ix. The Larynx and Trachea-Arteria. 
Situated upon the median line, the laryngo-tracheal canal pre- 
sents relations which are common to all the parts entering into 
its composition, and others which are peculiar to each of these 
parts. It is covered throughout its whole extent; anteriorly, by 
the double sheet of the cervical aponeurosis, the subcutaneous lay- 
er and skin; more externally, by the sterno-hyoidei muscles, the 
aponeurosis, the platysma and the two laminae which envelope it, 
lastly by the skin. The carotid arteries, pneumo-gastric nerves, 
great sympathetic, and the jugular vein, run deep along its sides 
throughout its whole extent. 
The different portions of this canal also have special relations, 
which must be examined separately. 
( a ) In the first place we find the thyro-liyoid membrane, of 
the nature of the ligamenta flava (ligamens jaunes), the posterior 
surface of which, separated from the epiglottis by a triangular 
space which is filled with adipose cells and which lodges the epi- 
glottic gland (periglottis), is only removed from the pharynx by 
the mucous membrane. 
Anteriorly, this membrane is covered by an arterial branch 
and some small twigs of the superior thyroid; by the superior 
laryngeal nerve, which penetrates through it into the larynx, into 
which some filaments from the ninth pair also pass; by a cellu- 
lar layer in which the vessels and nerves just mentioned are im- 
bedded ; by the omo-hyoideus, sterno-hyoideus, and thyro-hyoi- 
deus muscles; finally by the aponeurosis, platysma and the skin. 
The length of the thyro-liyoid membrane is about sixteen lines, 170 
OF THU SECR. 
and it is thicker in the middle than upon the sides. From its 
disposition, instruments or weapons which divide it transversely, 
or in any other direction, naturally tend to pass into the pharynx, 
and, consequently, may not strike the glottis: for which reason 
these wounds do not ordinarily produce mutismus, since the voice 
is incontestibly formed in the larynx. Nevertheless, these wounds 
may occasion unpleasant consequences, from their frequently 
dividing the laryngeal nerve and the thyro-hyoid artery. As this 
membrane is more depressed than the os hyoides and thyroid 
cartilage, there is consequently a species of groove formed be- 
tween these two organs, and it is in this groove that instruments 
are most commonly placed in attempts at suicide; and it is for 
this reason that individuals desirous of committing this act, do not 
always succeed in accomplishing it. It is likewise in this place 
that the knot of the hangman’s cord generally stops. 
( b) The Larynx, properly so called, presents for our conside- 
ration, in the first place, the thyroid cartilage ; next the cricoid, 
and lastly the crico-thyroid membrane. 
The first is harder and more disposed to ossify than the second ; 
its superior margin is notched out and forms a very considerable 
prominence, especially in man ; indeed the difference in the de- 
gree of this prominence is so great in the two sexes, that it would 
merely be necessary to feel this part in the adult in order to dis- 
tinguish them. This cartilage is about an inch in length ; its ex- 
ternal surface forms two planes which are inclined backwards, 
upon which the thyro-hyoid and sterno-thyroid muscles rest; its 
internal surface presents two other planes which include the es- 
sential parts of the larynx, that is to say, the parts which consti- 
tute the glottis ; and it is in the retiring angle formed by their con- 
junction, two lines below the superior median notch, that we find 
the anterior extremity of the cordce vocales, then a little lower, the 
thyro-arytenoidei muscles ; so that in performing laryngotomy, ac- 
cording to Desault’s method, the cartilage should be divided ex- 
actly upon the median line, otherwise we will be liable to wound 
the ligaments of the glottis. 
The second, or cricoid cartilage, increases in width as it pro- 
ceeds backwards, and is surmounted posteriorly by the arytenoid 
cartilages, which are articulated with it in such a manner that the\ 
may be flexed anteriorly and laterally, according to our opinion 171 
and that of most physiologists ; or laterally only, as M. Magendie 
supposes. Posteriorly, this cartilage is covered by the crico-ary- 
tenoidei postici and laterales muscles ; afterwards it corresponds 
to the origin of the oesophagus, or to the termination of the pha- 
rynx ; laterally, we find the crico-thyroidei muscles; anteriorly, 
there are no particular organs, excepting occasionally some vascu- 
lar ramuscuh; it is seldom that the thyroid gland reaches so high 
up. It is on a level with it that the trunk of the recurrent nerve 
is lost among the tissues, after the same manner that the superior 
laryngeal nerve is expanded above the thyroid cartilage ; and the 
last twigs of these nerves are distributed to the proper muscles of 
the larynx. But authors are not agreed respecting the precise 
spot where they terminate. M. Magendie thinks that the superior 
laryngeal is distributed merely to the arytenoid and crico-thyroid 
muscles, whilst the inferior distributes its filaments to the crico- 
arythenoid and thyro-arytenoid muscles; so that there would be 
a distinct nerve for the dilator muscles, and another for the con- 
strictor muscles of the .glottis ; but notwithstanding the authority 
of this savant, we cannot subscribe to his opinion, because we 
have frequently traced a filament of the recurrent nerve even 
into the arythenoid muscle, etc. 
The transverse diameter of the membrana crico-tlnjroidea is four 
or five lines, its perpendicular height from three to four; it is of 
the same nature as, but much stronger than the thyro-hyoid mem- 
brane. Its use appears to be merely to fill up the space which 
separates the cricoid and thyroid cartilages: it becomes folded 
when these cartilages approximate or overlap each other, and for 
this reason the chin should be elevated when we puncture this 
membrane. No organ of importance covers it anteriorly, except- 
ing the crico-thyroid artery ; and in order to lay bare this mem- 
brane, we will have to divide the skin, fascia superficialis, platys- 
ma and the layer which supports it, the aponeurosis and the sev- 
eral cellular sheets which are collected upon the median line after 
having enveloped the muscles, which are also easily separated. 
The artery, however, deserves the greatest attention, as it almost 
always forms a complete loop which crosses this membrane trans- 
versely. If this loop was of considerable volume, which is fre- 
quently the case, its division might occasion a troublesome hoe- 
inorrhage : on the one hand, because it would be difficult to stop 
OF THE NECK. 172 
OP T1IE XECK. 
the blood by compression; and on the other, because this fluid 
might make its way into the larynx, through the opening which 
has been made, and produce suffocation: therefore the two ex- 
tremities of the arterial arch should be tied as soon as divided. 
In order, however, that we may avoid a similar accident, in per- 
forming the operation recommended by Vicq. d’Azyr, we may 
proceed in different ways. For example, do we wish to open 
the crico-thyroid membrane simply for the purpose of giving ad- 
mission to air, we should incise the tissues parallel to the direc- 
tion of the artefy, which we push up or draw down with the nail ; 
do we, on the contrary, operate in order to extract a foreign body, 
one of two cases will be present; either this body will be above 
the cricoid cartilage, or it will be below it. In the first case we 
would be obliged to follow the advice of Desault, which is to di- 
vide the thyroid cartilage from below upwards; then before we 
perforate the membrane, we should ascertain the size and exact 
situation of the artery. If the finger does not discover it, or its 
pulsations are not felt, it is certain that this vessel is small, and 
that its section will not be attended with danger. If, on the other 
hand, its pulsations are very perceptible, we may be sure that its 
volume is considerable, and we should then draw it down as much 
as possible, in order to commence the incision above it, or if we 
cannot dispense with cutting it, it would be better to tie it before- 
hand. 
In the second case, it will be necessary to divide the cricoid car- 
tilage from above downwards, as recommended by Boyer, and 
then the artery will require the same precautions as in the pre- 
ceding, except, however, that it should be drawn upwards. We 
must also recollect that the air-tube is only seven or eight lines in 
diameter opposite to the part under consideration, so that we 
should hold the bistoury in such a manner that it will not penetrate 
its posterior wall. For the same reason also we should, when 
we divide either of the cartilages, use a probe-pointed bistoury, 
and the canula which we introduce should be so short that its ex- 
tremity will remain free in the laryngo-tracheal canal. 
( c) The Trachea. Its two superior third portions exist in the 
sub-hyoidean region; its membranous, or posterior fourth por- 
tion, lies upon the oesophagus, to which it is united by means of a 
lax cellular tissue, and from this disposition we may account for OP THE NECK 
1 i~o 
l it> 
the passage of foreign bodies, which have lodged in the oesopha- 
gus, into the trachea, and vice versa; anteriorly and laterally it is 
immediately enveloped by the thyroid gland. 
Although the functions of the thyroid gland have not been 
correctly ascertained by physiologists, it nevertheless performs an 
important part in surgery ; either on account of the diseases to 
which it is exposed, or its complicated relations. 
This gland is enveloped in a species of fibro-cellular sac, which 
is sometimes so dense that it is very difficult to distinguish the fluc- 
tuation of pus or any other fluids which may be collected within 
it, and it is this envelope also which permits the thyroid to become 
considerably enlarged without contracting intimate adhesions with 
the surrounding organs. 
The two lobes which constitute it are sometimes almost com- 
pletely separated, or at least united by a single band, which is 
sometimes placed at its inferior part, leaving the larynx and three 
or four rings of the trachea completely free in the sinus which 
results from it; a disposition which admits of the performance of 
laryngo-tracheotomy without danger ; at other times, on the con- 
trary, the vinculum is much higher up, sometimes even on a level 
with the cricoid cartilage, when the preceding operation will be 
attended with some hazard. There are also other cases in which 
these two lobes are blended together along almost the whole of 
their internal border; whereby the air-tube is entirely concealed 
by the gland, from the larynx to the fifth, sixth, and sometimes 
even the seventh cartilaginous ring. 
Anteriorly, this gland is convex and covered by the anterior 
sheet of its capsule, by the sterno-thyroid and sterno-hyoid mus- 
cles and the common integuments; the omo-hyoideus passes 
more externally and superiorly. Posteriorly it is excavated in 
the form of a gutter, in order to receive the commencement 
of the trachea, from which it is separated only by a dense 
cellular layer and its tunica propria. Laterally it rests upon 
the inferior laryngeal nerves, slightly upon the oesophagus on 
the left, upon the primitive carotid artery and upon the origin 
of the principal divisions of the arteries which bear its name. 
From these relations it follows that tumours of the thyroid 
gland, bound down by the cervical aponeurosis and the muscles, 
may enlarge most posteriorly, and by compressing the trachea 174 
01' THE NECK. 
and other organs lying in this direction, give rise to serious con- 
sequences. It is with the view of preventing these consequences 
as well as removing a disease in itself fatal, that surgeons have 
so frequently manifested a desire to extirpate the thyroid body. 
We may now readily appreciate the difficulties of such an opera- 
tion; in fact the division of the muscles, almost always indispen- 
sable, must, even admitting its complete success, in a great mea- 
sure prevent the depression of the os hyoides, after the cure. 
The inevitable division of four or five thyroid arteries demands 
a multiplicity of ligatures, and may give rise to an exhausting 
haemorrhage. The innumerable veins which are contained in this 
organ, must likewise pour fourth an abundance of blood, because, 
in these agonizing moments, inspiration is but indifferently per- 
formed. We have also to apprehend the admission of air into 
the open mouths of these veins, which, in the opinion of M. Lar- 
rey, from Magendie’s experiments, and some cases derived from 
man, among others those which have come under the observation 
of Dupuytren, etc., may cause the instantaneous death of the 
patient. Neither must we forget that, in the pathological state of 
the thyroid requiring its extirpation, all these vessels have under- 
gone considerable dilatation. Finally, the thyroid gland is some- 
times so greatly enlarged externally, and so intimately united to 
the parts situated behind it, that it is sometimes diffcult to avoid 
the trachea, the carotid and even the internal jugular vein. 
Notwithstanding all these unfavourable circumstances, the ope- 
ration under consideration has already been performed a great 
number of times, and M. Hedenus relates six cases of goitre in 
which it has been attended with complete success.* 
The means by which most of these dangers and difficulties may 
be avoided is by previously tying the four thyroid arteries. This 
preliminary step of the operat ion is generally of easy perform- 
ance upon the dead subject. Walther de Bonn has successfully 
performed it upon the living for an aneurismatic goitre. Perhaps 
it would be well also to tie the large sub-thyroid venous trunks, 
in order to prevent the admission of air into them ; and, finally, 
we might preserve in part the action of the muscles upon the 
* Commentarius tie glandulce thyroideaz extirpatione. Hedenus filius. Leipsick. 
1828,4to. 175 
OF TIIE NECK. 
larynx, by previously cutting them across, and reflecting them 
towards their points of attachment, in order that their extremities 
may be approximated after the operation. 
Below the thyroid gland, the traehea-arteria corresponds to the 
supra-sternal fosseite of the sub-hyoidean region. Its immediate 
covering is a lamellated and filamentous cellular tissue, in which 
there are a great quantity of adipose vesicles, and sometimes one 
or more lymphatic glands, the tumefaction of whith might occa- 
sion great disturbance in the exercise of the respiratory and di- 
gestive functions. These diseased glands may be mistaken for 
aneurism of the commencement of the carotids or subclavians, or 
for a pathological developement of the thymus, which, in children, 
naturally ascends a little into the supra-sternal space.* On the 
other hand, this cellular tissue is sometimes the seat of acute or 
chronic inflammations which terminate by suppuration, the ab- 
scesses resulting from which are generally detected with difficul- 
ty, on account of the aponeurosis behind which they are situated. 
It is very essential, however, to open them early; for the fluid 
will penetrate into the chest with the greatest facility. 
In the next place we find, in proceeding from the deep-seated 
parts towards the skin, the inferior thyroid veins; the artery of 
the same name, when it exists; the aponeurosis, which is here 
very thick, and lastly the subcutaneous cellulo-adipose layer. 
The latter lamina is usually very thin, and the purulent, or other 
fluids, which collect in it, soon render the skin prominent. The 
aponeurosis here consists of two very distinct sheets, one of 
which is fixed to the anterior, the other to the posterior part of 
the sternum ; so that abscesses or tumours which are developed 
between them, do not communicate so directly with the cavity 
of the thorax as they do when they form in the cellular tissue 
which immediately covers the trachea. The veins are naturally 
very large; but they are considerably larger in goitre and other 
affections of the thyroid gland: these are the veins which render 
hronchotomy, or rather tracheotomy so dangerous that several in- 
telligent persons have thought proper to proscribe this operation. 
The principal cause of apprehension is that the blood, which ob- 
scures the view of the operator, will make its way ipto the air 
* Bums, 176 
OF THE NECK, 
tube and produce suffocation. A case related by Virgili strength* 
ens this opinion. Besides, we find it more convenient and less 
dangerous to divide the crico-thyroid membrane only, when our 
object is to re-establish respiration, and at the same time to di- 
vide one or the other of the cartilages wdien it is required to ex- 
tract a foreign body; nevertheless the trachea has been opened a 
great number of times between the thyroid gland and sternum, in 
the last stage of croup, without any serious consequences apparent- 
ly resulting from it. The greater part of the subjects died, it is 
true; but it is too evident that the fatal termination was to be at- 
tributed to the disease, not to the operation. Indeed, it w7ould 
seem that this therapeutic resource has been too frequently re- 
jected in this dreadful angina. It is at least a fact that, by this 
means, M. Bretonneau succeeded in saving the life of the daugh- 
ter of Count Puysegur. Three of the children of this learned 
philanthropist had been cut off by croup; the fourth appeared 
without resource, and upon the point of undergoing the fate of 
her brothers. M. Bretonneau, encouraged by the unhappy father 
of the little patient, decided upon dividing the trachea; portions 
of the accidental membrane in the form of shreds, and sometimes 
resembling cylinders moulded upon the bronchi, were expelled 
or extracted during several days, and on the fifteenth day after 
the operation the patient was completely cured. 
In order to avoid the accident which caused the death of Vi- 
gili’s patient, we should cut three rings of the trachea at least; by 
this means the blood which flow s into the trachea during inspira- 
tion is expelled by expiration; and there is no danger from a 
large opening made into this canal. 
When the thyroid artery of Neubauer exists, it is situated be- 
hind the veins, and usually a little to the right. It may likewise 
be distinguished by its pulsations, the thickness of its coats and 
the distribution of its branches. 
More externally, the relations of the trachea are not exaclly 
the same on the left side as on the right; that is to say, the apon- 
eurotic sheets and sterno-hyoid and sterno-thyroid muscles, etc. 
cover it equally on both sides ; but the primitive carotid is closer 
to it, more anterior and more superficial on the right than on the 
left; a disposition which it is important to note, especially on ac- 
count of the mobility of the air-tube ; for if the latter should glide OF THE NECK. 
177 
only a few lines to the right, when we are performing tracheotomy 
in the inferior part of the neck, the instrument is in danger of 
falling upon the carotid artery; a circumstance which actually 
happened to a student of medicine, who was desirous of resusci- 
tating one of his friends, whilst in a state of asphyxia. 
The great mobility of the laryngo-tracheal canal is a circum- 
stance against which we cannot be too much upon our guard, 
and it is for the purpose of restraining this that the instrument of 
Bauchot was invented. It is this mobility which principally pre- 
vents our penetrating this tube by a simple puncture, whether 
we make use of the trois-quarts recommended by Junkers, Deck- 
ers, etc., or the sharp-pointed bistoury as advised by Dionis. The 
trachea will always tend to slide under these instruments; and, 
on the other hand, if their point should succeed in perforating it, 
the force made use of to overcome the resistance which its elas- 
ticity occasions, will frequently carry the instrument so far as to 
wound other organs. 
In addition to the mobility and elasticity of this canal, there is 
still another reason why we should not employ puncturing instru- 
ments in tracheotomy. In fact, a single puncture being only 
serviceable in admitting air into the lungs, it will always be more 
easy and safe to make an opening between the two cartilages of 
the larynx than through the trachea. But in croup, as well as 
for the extraction of foreign bodies, it is necessary to incise sev- 
eral fibro-cartilaginous rings vertically; for punctures, in such 
cases, would always be insufficient; and we may remark finally, 
that by dividing the tissues parallel to the trachea, it is much more 
easy to separate the vessels which cover it. 
It remains for us to mention, before concluding our observa- 
tions on this important canal, that the escape of the air through 
an aperture below the thyroid cartilage invariably destroys the 
voice ; therefore surgeons should always make it a rule to bring 
the divided edges of the wounds of these parts in as exact coap- 
tation as possible. Sounds being formed in the glottis, it is evi- 
dent that, if the air, which is the sonorous body, escapes below it, 
the voice will not be formed. Numerous experiments made 
upon dogs by Bichat, and others, as well as observations derived 
from man by MM. J. Cloquet and Magendie, have demonstrated 
this point of physiology to a mathematical certainty. 178 
OF T1IE NECK- 
x. The (Esophagus. 
The oesophagus commences opposite to the fourth cervical 
vertebra, and appears to be only the continuation of the pharynx: 
the inferior part, is consequently, comprised in the sub-hyoideai; 
region. 
The oesophagus is at first situated upon the median line behind 
the cricoid cartilage, and afterwards inclines slightly to the left, 
so as to pass a few lines beyond the trachea in this direction. 
It rests upon the bodies of the vertebrae, and is connected to the 
fibrous tissues which unites these bones only by very extensible 
cellular laminae. We have already stated that its anterior por- 
tion was pretty intimately attached to the posterior gutter of the 
trachea. On the right, it is in part concealed by the latter organ, 
and close along this side runs the recurrent nerve, then the car- 
rotid artery, etc. On the left, it is more immediately covered 
by the thyroid gland; it is crossed by the inferior thyroid artery, 
and the recurrent nerve is more upon its anterior part than on 
the right side ; which renders the section of this cord more easv : 
finally, the carotid is a little nearer to it, because on the right the 
oesophagus is entirely covered by the trachea. 
It is owing to these anatomical relations that it is laid down 
as a rule always to perform cesophagotomy on the left side, and as 
much as possible between the thyroid gland and sternum. In 
order to reach the oesophagus at this point, we cut down as if we 
were about to tie the carotid; we then push this artery out- 
wards, the sterno-thyroideus muscle forwards and towards the 
median line; a thick fibro-cellular lamina presents itself, which 
is next to be divided, when the canal of deglutition is exposed to 
view. All that is then necessary to avoid is the recurrent nerve 
and trachea. 
However, notwithstanding surgeons have kept silence in this 
respect, foreign bodies can seldom descend so low and then stop, 
if it is their magnitude alone which opposes their passage to the 
stomach. In fact, when they have succeeded in passing the ori- 
gin of the oesophagus, and have got beyond the cricoid cartilage 
we do not see what can impede their further progress. There- 
fore, it is on a level with the inferior part of the larynx that we OF THE NECK 
179 
will be most frequently obliged to perform cesopliagotomy. The 
operation will then be much more difficult and dangerous, since 
we will have to avoid the thyroid gland and its arteries, and will 
also have to cut deeper for the organ, which has not as yet devi- 
ated to one side or the other. In all these cases the instrument 
of M. Vacca Berlinghieri, or that of Prof. Dupuytren will over- 
come many difficulties. 
xi. The Skeleton. 
There is no skeleton properly appertaining to the sub-hyoidean 
region: it rests upon the bodies of the last four cervical verte- 
bra?. These bones form a convexity at this part, which seems to 
serve as a point of support to certain very heavy metallic rods, 
introduced by jugglers into the oesophagus and balanced in the 
air. We wall have occasion, however, to speak of the spinal 
column in another place. 
Sect. 3. The Supra-Clavicular Region. {See plate 4.) 
The supra-clavicular region is bounded, anteriorly, by the sub- 
hyoidean, submaxillary, and parotideal regions; that is to say, by 
a line drawn from the sterno-clavicular articulation, along the 
anterior margin of the sterno-mastoid muscle to the anterior part 
of the mastoid process; posteriorly, by another line extended 
from the acromio-clavicular articulation, along the anterior bor- 
der of the trapezius, to the posterior part of the mastoid process; 
and inferiorly, by the clavicle and first rib. Consequently, it 
forms a regular triangle writh its base below. 
Upon its anterior limit we observe an elongated eminence, 
which is very evident when the head is inclined towards the 
shoulder, and the face to one side, and which is formed by the 
sterno-mastoid muscle. The trapezius forms another relief pos- 
teriorly, which is blended at the summit with the preceding emi- 
nence. In the interval of these twro species of columns there is 
an excavation, which is deeper in the adult than the child, in man 
than in woman, in thin than in fat subjects, and which is increased 
or diminished according to the elevation or depression of the 
shoulder. This is the supra-clavicular excavation, and is the most 180 
OP TI1E NECK. 
important part of the region, whether we consider it in relation 
to the numerous organs it includes, the diseases which are de- 
veloped in it, or the operations which may be performed upon it. 
CONSTITUENT PARTS. 
i. The Skin. 
This membrane is very strong, very thick, and but slightly 
extensible superiorly, where it is firmly adherent to the subjacent 
tissues; but as it descends it gradually becomes thinner and 
more moveable upon the muscles ; so that in the supra-clavicular 
fossette, it assumes all the characters which distinguish the skin of 
the sub-hyoidean region. In some persons it is dark coloured 
and covered with hairs, in the superior fourth part of the region; 
throughout the rest of its extent it is smooth, and contains a few 
small sebaceous follicles. 
ii. The Subcutaneous Layer. 
This layer, like that of the preceding region, is composed of a 
cellulo-adipose lamina, immediately attached to the skin; of the 
platysma, which does not extend quite to the margin of the tra- 
pezius, and of another supra-aponeurotic cellular lamina, which 
resembles the fascia superficialis. 
These two sheets are blended together wherever the platysma 
does not extend, and form a dense and very strong layer in the 
superior half of the external surface of the sterno-mastoideus. 
There they are very closely united to the aponeurosis on the one 
hand, and to the skin on the other; which explains the slight 
extensibility of the latter. Adipose vesicles are seldom developed 
in it, and when abscesses or tumours form in it, although their 
nature may be acute, they are generally slow in manifesting 
themselves externally: a circumstance which is explained by the 
tenacity of the tissues. Inferiorly, these two laminae are trans- 
formed into a simple lamellated and filamentous cellular tissue, in 
which nervous filaments ramify and adipose vesicles are some- 
times abundantly deposited. It is in the lamellae of the sheet 
under the platysma, that the external jugular vein and several 181 
OF THE NECK 
branches of the cervical plexus are situated. It is necessary to 
observe that the fibres of the platysma itself are more scattered 
and paler in its inferior portion ; so that in a great many subjects 
they are scarcely distinct behind the clavicle. The direction of the 
fibres of this muscle is upwards and inwards, crossing the external 
surface of the sterno-mastoideus very obliquely. This last pecu- 
liarity relates especially to the jugular vein, as we shall see directly. 
hi. The Aponeurosis. 
The fascia cervicalis is much more irregular here than in the 
sub-hyoidean region. Nevertheless, in emaciated subjects and 
those advanced in life, it is generally very distinct and sometimes 
even very strong: it is composed of several sheets, which it is 
possible to separate in some places. Thus, two fibrous laminae, 
which constitute the aponeurosis, properly so called, envelope 
the sterno-mastoideus muscle ; at its posterior border they reunite, 
and again separate when they arrive at the margin of the trape- 
zius. Those laminae which have formed sheaths for the deep- 
seated parts of the sub-hyoidean region, for the omo-hyoideus 
muscle, the nerves of the brachial and cervical plexus, and which 
Vave covered the scaleni muscles, etc., afterwards become 
blended with the internal surface of the deep sheet of this apon- 
eurosis. All these lamellae are very dense and difficult to lace- 
rate, and oppose the easy insulation of the vessels and nerves, 
which they seem destined to protect. In the inferior part of the 
supra-clavicular fossa, there is a considerable quantity of filamen- 
tous cellular tissue and adipose vesicles intermingled with these 
lamellae. As this species of cellular filter is continuous with 
similar structures in the hollow of the axilla, it naturally follows 
that pus, etc., accumulated beneath the aponeurosis, will readily 
infiltrate into the latter region, by following the sheaths of the 
nerves and vessels, or the interstices which separate them. The 
abundance of this cellular tissue and its diffusion with the aponeu- 
rosis between the principal muscles, explains the tendency which 
superficial tumours and abscesses have to become deep-seated; 
and in consequence of this arrangement, we should always give an 
early exit to purulent collections which may be developed be- 
neath the skin of this region. 182 
OF THE NECK. 
iv. The Muscles. 
This region contains a considerable number of important 
muscles. 
( a ) The Sterno-Cleido-Mastoideus is enveloped in a fibrous 
sheath, and the superior part of its posterior margin is blended 
with the splenius capitis; inferiorly, it is attached to the sternum, 
and its internal tendon sometimes gives considerable strength to 
the sterno-clavicular articulation, to the anterior part of which it 
is applied. The external surface of this muscle is covered by 
the external jugular vein, the mastoidean, auricular, and submax - 
illary branches of the cervical plexus, and the layers which we 
have just passed in review ; and it is frequently crossed near its 
origin by the acromio-clavicular vein. Its deep surface rests, 
from above downwards, upon the trachelo-mastoideus (petit 
complexus) and the digastricus, upon the occipital artery and 
cervical plexus, upon the omo-hyoideus and scaleni muscles, upon 
the carotid artery and internal jugular vein, which last is seen a 
little external to its posterior border, and finally upon the subcla- 
vian vein. We have already mentioned that the anterior margin 
of this muscle serves as a guide to the carotid artery. It is tra- 
versed in its superior third by the spinal accessory nerve. 
( b ) The Trapezius. The clavicular portion only of this 
muscle is situated in this region; its fibres ascend obliquely up- 
wards and backwards. Included between the two laminae of 
the aponeurosis, it is separated from the skin merely by the cel- 
lular layer; but its anterior surface is separated from the omo- 
hyoideus and scalenus posticus muscles, from the nerves and 
vessels, by an excavation of considerable depth, which is filled 
by a simple cellular or adipose tissue, in which several nervous 
and arterial branches ramify. Its anterior margin is curved, its 
concavity looking forwards; inferiorly, it serves to limit the 
incisions which are made for the purpose of discovering the sub- 
clavian artery. 
( c) The Levator Anguli Scapulce. It follows the posterior 
line of the region, and lies exposed between the two preceding 
muscles, where it is about to attach itself to the transverse pro- 
cesses of the vertebrae. An adipose and cellular layer, of great- OF THE iVECK, 
183 
er or less thickness, separates it from the trapezius. Its anterior 
surface is removed from the superior part of the chest and the 
splenii by some very lax and very extensible cellular tissue, 
which establishes a communication between the supra-clavicular 
region and the space comprised between the serratus magnus, 
the intercostales and rhomboideus muscles; a communication 
which enables pus, or other fluids, to penetrate from one of these 
regions to the other. 
( d ) The Omo-liyaideus. This muscle frequently possesses a 
middle tendon, where it passes under the sterno-mastoid mus- 
cle. It crosses the subclavian vein and artery, the three or four 
last nerves which go to form the brachial plexus, the two scaleni 
muscles, the phrenic nerve and ascending cervical artery, oblique- 
ly from below upwards. Sometimes, but not most frequently, 
as Langenbeck asserts,* it is united to the posterior convexity 
of the clavicle. In this case, a fibrous process is usually detached 
from it, which fills the sinus resulting from the union of the clav- 
icle, acromion and coracoid process ; which sinus, or space, is 
transformed into a triangle by the muscle in question. 
The omo-hyoideus, in ascending before the scaleni, circum- 
scribes another very important triangle, which might be called 
the omo-clavicular space: this space is divided into two by the 
scalenus anticus. 
In the internal portion, we meet with the termination of the 
two jugular veins, and the subclavian into which they discharge 
their blood ; the vertebral and inferior thyroid vessels; the acro- 
mial vein, and phrenic nerve ; the supra-scapular, posterior and 
ascending cervical, internal mammary and subclavian arteries, 
and the origin of the last cervical nerves. 
In the external, we also find the subclavian vessels, the supra- 
scapulary and transverse cervical veins, the posterior scapular 
artery, the last three cervical and first dorsal nerves, finally a part 
of the scalenus posticus muscle and of the first rib. 
With the trapezius and sterno-mastoideus, the muscle under 
consideration limits a third triangle, which might be denomina- 
ted omo-trapezian. In this space we find the cervical plexus and 
the origin of the branches given off' by it; the fourth and fifth 
pairs which go to the brachial plexus; divers branches of the 
* Biiliotheque, etc., vol. iii. Cahier 2, 1821. 184 
OF THE NECK. 
transverse cervical vessels, and, from above downwards, the ter- 
minating extremity of the splenitis capitis and splenius colli, the 
angularis scapulae and scalenus posticus muscles ; lastly, but 
deeper-seated, the trachelo-mastoideus, and one of the arches of 
the vertebral artery. 
( e ) The Scaleni. Inferiorly, they sometimes form three or 
four distinct bundles, but generally there are only two, which are 
so arranged that the posterior* passes outwards and backwards, 
in order to attach itself to the first rib, being also prolonged upon 
the second: the anterior is shorter and more rounded, and de- 
scends more internally and anteriorly, in order to become insert- 
ed into the tubercle of the same rib by a species of tendon. The 
former is related in a remote manner to the levator scapulae and 
trapezius, and is covered anteriorly by the five nervous branches 
which run to form the brachial plexus; by the trunk of the sub- 
clavian artery and the first twigs which depart from it, in order to 
pass externally. The latter is separated from the scalenus pos- 
ticus by a triangle the base of which is upon the first rib, and 
in which we find, at its most inferior part and a little anteriorly, 
the subclavian artery; more superiorly and posteriorly, the first 
intercostal nerve united to the last cervical, then the sixth cervi- 
cal : still higher, a fleshy fasciculus which sometimes descends 
from the posterior surface of the scalenus anticus upon the cos- 
tal extremity of the posticus; finally, above this fasciculus, in the 
apex of the triangle, the first two branches of the nerves which 
go to the brachial plexus. Anteriorly, the scalenus anticus is 
covered, from below upwards, by the subclavian vein, by those 
which come from the shoulder, by the external jugular, some 
nervous filaments from the cervical plexus, the sterno-mastoideus 
and the common integuments. It is along the external margin 
of the scalenus anticus that we carry the finger when we w ish 
to find the subclavian artery, and upon its internal border that the 
phrenic nerve descends. It is this last border which transforms 
into a triangle the space which separates it from the longus colli 
muscle, and in which the vertebral vessels are situated. 
We shall omit speaking of the other small muscles of the supra- 
* The Scalenus Posticus embraces the Mtdius and Posticus of English anatomists. 
"Transl. OF THE NECK, 
185 
clavicular region, such as the inter-transversales, etc., as they do 
not admit of any surgical application. 
v. The Arteries. 
(a ) The Subclavians. They form two arches, the convexity 
of which looks upwards, and in order that their relations may be 
well understood, we will divide them into three portions; the 
the first, within the scalenus anticus; the second between the 
two scaleni, and the third between these muscles and the clavicle. 
In the first portion the two subclavian arteries must be exam- 
ined separately. 
The right subclavian is the thickest, shortest, and most super- 
ficial ; it arises from the arteria innominata, opposite to the pos- 
terior and external part of the sterno-clavicular articulation, and 
afterwards passes almost transversely upon the first rib. 
Its anterior surface is covered by the phrenic nerve, by pretty 
numerous filaments of the great sympathetic, and by the par va- 
gum. All these nerves touch the artery, and cross it nearly at 
right angles. It is next covered by the subclavian vein which 
passes a little beyond it, during inspiration, in the omo-clavicular 
triangle ; then by the internal jugular, which, as it is about to ter- 
minate in the preceding, is separated from the carotid by a small 
triangular space, in which we observe the artery under consider- 
ation, the par vagum and some filaments from the inferior cervical 
ganglion. The sterno-thyroid, sterno-hyoid, and the sternal por- 
tion of the sterno-mastoid muscles remove all these parts from 
the superficial sheet of the aponeurosis, and are themselves sepa- 
rated from the veins and artery by a very strong fibro-cellular 
lamina which is prolonged into the thorax upon the brachio- 
cephalic trunk. 
Posteriorly, it is crossed by the recurrent nerve and some fila- 
ments of the great sympathetic. It rests upon the inferior cervi- 
cal ganglion, and more deeply upon the longus colli muscle and 
the transverse process of the first dorsal vertebra, from which 
parts it is separated by adipose cellular tissue and some lymphatic 
glands. 
Inferiorly, this artery is supported by the pleura and corres- 
ponds to the summit of the lung. 186 
OF THE NECK 
Superiorly, it is observed in the triangle formed by the scaleni 
and longus colli, and is there found in relation with the vertebral 
and inferior thyroid arteries, the first dorsal nerve, and several 
filaments of the great sympathetic. 
The mere enumeration of the anatomical relations of the right 
subclavian artery on the inner side of the scaleni, is sufficient to 
show the danger and difficulty of applying a ligature around this 
portion of it. In fact, it would be necessary, in order to perform 
this operation, to cut the internal portion of the sterno-mastoideus, 
and frequently the sterno-hyoid and—thyroid muscles; then we 
would have to avoid, anterior to the artery, the vertebral, inferior 
thyroid and internal mammary vessels, the par vagum, phrenic 
nerve, etc. ; posteriorly, the recurrent and great sympathetic 
nerves, and the superior intercostal artery. 
The only means by which we can avoid all these parts, w ith 
the exception of the muscles, consists in dexterously dividing the 
fibrous sheath which envelopes the artery we are about to tie: 
for by this method all the nerves will be isolated, since they run 
in the lamellae of this sheath. Still there would be an obstacle 
to the success of this ligature, in the origin of the inferior thyroid, 
vertebra] and internal mammary arteries, which wrould interfere 
with the formation of the clot, if the thread was placed between 
these arteries and the scalenus muscle. The danger would not 
be less, if the ligature was applied so as to leave these branches on 
the acromial side; for then it wrould be too near the innominata 
and primitive carotid for the origin of the subclavian to be oblit- 
erated without exposing the subject to death from haemorrhage. 
On the left side this primary portion of the subclavian is 
longer, deeper and of smaller calibre; it descends almost per- 
pendicularly upon the arch of the aorta; the subclavian vein 
crosses it as it passes towards the right; the par vagum and 
phrenic nerves are rather internal than anterior to it; the thor- 
acic duct also crosses it, sometimes posteriorly and superiorly, 
at other times anteriorly and inferiorly, in its course to the vein 
into which it discharges itself. The carotid and left cardiac 
nerves run along its inner side ; and, externally, it remains longer 
in relation with the pleura and lungs than the right subclavian. 
It is important to note all these differences, as they shew us that 
it wrould be much less dangerous to apply a ligature here than OF TI1E NECK. 
187 
on the right side, because, being placed at a greater distance from 
the origin of the vessel, the adhesive clot would form without 
difficulty. It would likewise be easier in its execution, for the 
nerves do not cross it as on the right, but descend parallel to its 
direction into the chest, and might be readily separated. Never- 
theless, it must be admitted, that almost all these advantages are 
counterbalanced by the greater depth and almost vertical direc- 
tion of the artery. 
The two other portions of the subclavian artery being perfectly 
similar on both sides, what we shall say of the one will neces- 
sarily apply to the other. 
The subclavian artery, between the scaleni, is immediately ap- 
plied, inferiorly, upon the depression in the first rib ; posteriorly, 
upon the termination of the scalenus posticus; anteriorly, it is a 
little less approximated to the scalenus anticus, which is more 
internal than the posticus: which is owing to the curvature of 
the rib: superiorly and slightly posteriorly, we see the union of 
the first dorsal with the seventh cervical nerve; it is also cov- 
ered or enveloped by fibro-cellular lamellae of considerable thick- 
ness and density. It is in this point that we may compress it in 
two different ways, when we wish to suspend the course of the 
blood in the thoracic member; viz. either by pressing it from 
above downwards upon the first rib, which may be done with 
the thumb better than with any species of mechanical instru- 
ment ; or from before backwards against the anterior part of the 
scalenus posticus and the transverse process of the first dorsal 
vertebra. In both cases the compression is rendered more easy 
and certain by depressing the shoulder; and, notwithstanding 
John Bell is of a contrary opinion, it is possible by this method 
to obliterate the calibre of the artery.* We cannot deny, how- 
ever, that it will be difficult to accomplish this object when the 
clavicle and shoulder are very much elevated, and incapable of 
being depressed. Be this as it may, the disposition of the muscles 
is such that it is necessary to press the thumb from without in- 
wards, from above downwards, and from before backwards, on 
account of the rib being inclined downwards and a little out- 
wards. 
v Anatomy, Sic. vol. 55. 188 
OF THE NECK. 
It is also in this point that the subclavian artery may be seized 
with the greatest ease and certainty; and in order to accom- 
plish it, we must, after having lacerated or divided the different 
cellular laminae, carry the extremity of the index finger along the 
external margin of the scalenus anticus as far as its insertion into 
the first rib. Here, we must seek for the tubercle of this bone, 
which may always be felt; then by sliding the finger from this 
tubercle backwards upon the anterior part of the scalenus pos- 
ticus, it will necessarily pass upon the artery. Nothing then is 
more simple than to raise this vessel, by passing under it an 
aneurisrnal needle, either from behind forwards, or from before 
backwards, alw ays observing to apply the finger upon the point 
of the artery opposite to that under which the needle is intro- 
duced. This process is so sure that it would be possible to ex- 
ecute it without the aid of vision. But we should not forget that 
the artery is invariably the first cord which is met wfith behind 
the tubercle of insertion of the scalenus anticus muscle. 
Between the clavicle and this last muscle, the subclavian artery 
is inclined considerably downwards, so that the nearer we ap- 
proach the axilla the more difficult it is to reach it. In the first 
place it glides upon the first rib, then a little upon the second and 
the external surface of the scalenus posticus, and at length reach- 
es the superior portion of the serratus magnus muscle. The infe- 
rior cord of the brachial plexus runs along its superior or external 
part, and usually passes before the artery as it enters the axilla. 
Anteriorly, this portion of the artery is covered by the subclavian 
vein, which sometimes ascends a little higher than the artery in 
the supra-clavicular hollow, near the scalenus, but inclines more 
and more dowmwards in proportion as it approximates the axilla, 
so that when it passes under the clavicle, the vein is internal, the 
nerve external, and the artery in the middle and posteriorly. In 
the next place it is covered anteriorly and superiorly by cellular 
tissue, some lymphatic glands, a venous plexus, the cervical apon- 
eurosis, the platysma and the integuments. 
This portion of the subclavian artery being included in the 
base of the omo-clavicular triangle, it is necessary, when we wish 
to apply a ligature around it, to draw outwards the omo-hyoideus 
muscle, after having divided its sheath; sometimes, indeed, we 
are obliged to cut across this small muscle. Finally, the opera- OF THE NECK. 
189 
tion should be performed as near to the scalenus anticus as possi- 
ble, because in this point the artery is more superficial, more easily 
distinguished from the nerves, and less embarrassed by the other 
organs. 
( b ) All the other arteries of the supra-clavicular region are 
derived from the preceding; the vertebral, internal mammary 
and superior intercostal originate within the scalenus. The first 
was examined in the infra-hyoidean region ; the other two apper- 
tain to the thorax. All that remain then to be shewn are the 
origin of the inferior thyroid, the ascending, transverse and deep 
cervicals, the supra-scapularv and sometimes the acromial arte- 
ries. 
( c ) The thyroidea inferior is a little more external than the 
vertebral, and is situated behind the sterno-mastoid muscle on the 
inner side of the scalenus anticus. It at first ascends parallel to 
the latter muscle, and after running about an inch, passes behind 
the carotid. It gives off, 
(d) The cervicalis ascendens, which continues the primitive 
direction of the trunk, and soon applies itself upon the anterior 
part of the scalenus anticus, on the inner side of which it was 
inferiorly. It presents nothing interesting in a surgical point of 
view. 
( e ) The Arteria Supra-Scapularis is also occasionally given 
off from the trunk of the thyroid: it passes between the scalenus 
and sterno-mastoid muscles, then generally approximates the clav- 
icle, the direction of which it follows ; so that it might easily be 
wounded in seeking for the subclavian, if we did not proceed with 
the greatest caution. In its course to the coracoid notch of the 
scapula it crosses obliquely the nerves of the brachial plexus, and 
is crossed in its turn by the external jugular vein and the supra 
and sub-clavicular branches of the cervical plexus. When it 
originates from the subclavian external to the scalenus muscle, it 
usually gives off the acromial artery, which, in this case, immedi- 
ately ascends upon the top of the shoulder. 
(/) The Arteria Transversalis Colli likewise arises very fre- 
quently from the trunk of the thyroid ; it curves outwards imme- 
diately after its origin, and passes in the supra-clavicular depress- 
ion, making its way between the same muscles as the supra-scap- 
»dary, which it surmounts more or less. Passing transversely over 190 
OF THE NECK. 
the phrenic nerve and the superior branches of the brachial plex- 
us, it is crossed in its turn by the external jugular and several fila- 
ments of the cervical plexus, and runs sometimes below, at other 
times before the omo-hyoideus; it is covered by the fascia cervi- 
calis, platysma and the skin ; its course is tortuous, and of the 
two branches which terminate it in the posterior region of the 
neck, one passes before the levator scapulae, the other between this 
muscle and the trapezius. It is seldom that this artery is situat- 
ed so low down as to be in danger from the knife when laying 
bare the subclavian. 
Finally, these secondary branches are of considerable impor- 
tance in surgery in relation to the communications which they 
establish with the arteries of the shoulder, thereby supporting the 
circulation in the superior extremity after the principal trunk has 
been obliterated in the omo-clavicular triangle. If however the 
ligature is applied too near their origins, they may tend to turn off 
the column of blood and thereby prevent the formation of the 
adhesive coagulum. 
vi. The Veins. 
(a) The Subclavian. The disposition of this vein is not the 
same on both sides. On the left, it does not terminate on the 
inner side of the corresponding scalenus, but continues its course 
towards the posterior part of the opposite sterno-mastoid muscle, 
crossing before the left carotid, the trachea, the thymus, when it 
exists, and even the right carotid. It is this portion of the left sub- 
clavian vein which English anatomists call “ innominata it re- 
ceives the thymic, inferior thyroid, vertebral and internal mammary 
veins, etc., and is found situated immediately behind the supra- 
sternal notch, and the muscles which cover the posterior parts of 
the sterno-clavicular articulation. 
In the next place, the subclavian vein of each side is at first 
separated from the fore part of the artery by the scalenus anti- 
cus; afterwards it approximates it, then becomes immediately ap- 
plied upon this vessel, and at length, as it passes under the clavi- 
cle, it becomes quite internal or inferior to the artery. Anterior- 
ly, it is covered by the origin of the sterno-thyroideus, the clavi- 
cle, and then by the subclavius muscle ; its inferior side rests upon OF THE NECK. 
191 
the first rib, the costo-clavicular ligament and the superior sur- 
face of the subclavius muscle: superiorly, the subclavian vein is 
covered only by some cellular tissue ; by different veins terminat- 
ing in it, which we shall soon examine ; by the aponeurosis and 
the fibres of the platysma; lastly by the skin. 
This vein then might be easily wounded when we are about to 
expose its accompanying artery, especially as all the large veins 
swell out considerably, upon the living subject, whilst we are per- 
forming an operation of so great importance. It is true that some 
persons, Mr. Lizars* among others, have proposed applying a 
tourniquet upon the arm with the view of preventing this dila- 
tation, by stopping the venous circulation in the limb ; but, in 
addition to the inconvenience which such compression would pro- 
duce in case of aneurism, we imagine that it would not accomplish 
the effect proposed, for the blood would still continue to flow into 
the subclavian through the jugulars and other veins of the neck 
and shoulder. Consequently, it is much better to content our- 
selves with favouring the inspirations, and pass the aneurismal 
needle from before backwards, and from below upwards, in order 
to be more sure of avoiding the laceration of the veins. 
We should not forget that the thoracic duct empties into the 
left subclavian vein opposite to the point where the artery of the 
same name makes a curve in order to pass between the scaleni. 
This circumstance, in fact, renders the ligature of the artery, on 
this side, internal to the scaleni, much more dangerous than on the 
right. This circumstance was not overlooked by Dr. Colies when 
he applied a ligature on the right carotid in 1813 ;f but did not 
this surgeon exaggerate in saying that this operation was imprac- 
ticable on the left ? On the other hand, can we admit with Mr. 
Shaw,J that it would be preferable, incases of aneurism, to am- 
putate at the shoulder joint, than to tie the artery within the sca- 
leni muscles ? Reasoning from the anatomical disposition of the 
parts, we think that the extirpation of the arm would have no 
advantage over the ligature of the artery: besides, from the ope- 
ration of Colles, that of Dr. Mott of which we will speak in 
another place, and analogy, induce us to believe, that, if the situ- 
* System of Anatomical Plates, part 2d, page 70, 
t Edinburgh Medical & Surgical Journal, No. 41, Vol. 2. 
t Manual of Anatomy, page 337. 192 
OP THE NECK. 
ation of the disease should require it, it would be much better to 
attempt this ligature than abandon the patient to inevitable de- 
struction. 
(b). The External Jugular. This vein passes obliquely, from 
above downwards and from before backwards, in the direction of 
the trapezius, and more or less anterior to this muscle. It origin- 
ates by several branches in the parotideal region, and falls into 
the subclavian towards the middle of the supra-clavicular excava- 
tion, occasionally after having received the veins of the shoulder. 
As it descends it rests upon the sterno-mastoid muscle, which it 
crosses very obliquely; its course, on the contrary, is parallel to 
the direction of the fibres of the platysma, which covers it. From 
this relation it follows that, when we open this vessel, we should 
divide the platysma transversely to the direction of its fibres, as 
their retraction will enlarge the aperture and thereby admit of 
the free escape of the blood ; whereas if the incision is made par- 
allel to the course of these fibres, when they contract they will 
tend to close the opening. 
This vein, towards the middle of its tract, generally passes near 
to the different branches of the cervical plexus, especially the 
ascending branches, which cover it or are covered by it upon the 
sterno-mastoid muscle ; for which reason we should always en- 
deavour to open this vein in its inferior half. In the supra-clavi- 
cular excavation it is separated from the deep-seated parts by the 
cervical aponeurosis, so that it is at some distance from the de- 
scending cervical nerves. It is not unusual, however, to see it 
approximate near to the omo-hyoideus muscle, which it crosses at 
an acute angle. As it opens into the subclavian at a greater or 
less distance from the clavicular portion of the sterno-mastoid 
muscle, we are obliged, in order to discover the subclavian artery, 
after having cut through the integuments and platysma, to drawr 
the external jugular vein either forwards or backw ards, with a 
hook, and sometimes even to tie it in two places in order to di- 
vide it afterwards between the ligatures. 
It is in this space that we compress it, when we wish to draw- 
blood from it. 
As it receives the most part of the external veins of the crani- 
um, we conceive that it might almost directly unload the sinuses, 
through the medium of several emissary veins. From its com- OF THE NECK. 
193 
munication with the deep seated jugular we may account for the 
flow of blood being accelerated by the movements of the lower 
jaw ; and the reason why practitioners advise the retention of the 
breath while bleeding from this vein, is, that the blood may be 
forced to remain longer in the veins of the head and neck. Fi- 
nally, during this operation, M. Larrey advises that the pressure 
below the orilice should not be removed until a compress has 
been applied upon the latter, otherwise, says he, the air might 
penetrate into the open mouth of the vein, and thus transform a 
slight operation into a wound suddenly fatal. 
The external jugular vein is generally single in its inferior third 
portion ; sometimes, however, it is double or triple, in which cases 
its branches cannot be readily distinguished through the skin; 
thereby rendering bleeding from the neck somewhat difficult. 
(c) The Collateral Veins. In this region we find the ascend- 
ing and transverse cervical, supra-scapulary, acromial, and, in 
some subjects, the termination of the cephalic. These veins 
almost always follow the direction of the arterial branches of the 
same name ; but they are larger and constantly more superficial. 
Generally, the two former open into the internal jugular, and the 
latter into the subclavian vein. Previous to terminating, or when 
they are about to terminate, they occasionally form a species of 
plexus external to the sterno-mastoid muscle and above the clavi- 
cle ; which plexus may, as Langenbeck has very judiciously ob- 
served, occasion great perplexity in the operation for securing the 
subclavian artery. To these we may also add some small veins 
which come from the thorax. 
(d) The Internal Jugular. Its termination alone appertains 
to the supra-clavicular region. It is situated posterior to the 
sterno-mastoid muscle, external and anterior to the scalenus anti- 
cus, and at a little distance from the carotid. Between it and 
this artery there is a small elongated triangle, in which we usually 
observe the par vagum, phrenic and great sympathetic nerves; 
externally, we perceived it in the hollow of the region ; on the 
left, it falls into the subclavian vein, a little internal to the point 
where the thoracic canal terminates, and is almost directly con- 
tinuous on the right with the superior vena cava. 194 
OF THE NECK. 
vii. The Lymphatics. 
The absorbent vessels of the neck and shoulder, and a part of 
those of the exterior of the chest enter this region. We also 
find in it a very great number of lymphatic glands, which may 
be divided into those situated under the sterno-mastoid, behind 
the clavicle, and those which fill the supra-clavicular cavity. 
When the former become tumefied, they may be mistaken for an 
aneurism of the arteries in their immediate neighbourhood ; the 
latter can seldom occasion mistakes of the like nature. The for- 
mer will frequently compress the carotid, internal jugular and 
subclavian vessels; the latter will produce compression of the 
nerves. 
viii. The Nerves. 
( a ) The Cervical Plexus is almost entirely covered by the 
sterno-mastoid muscle, and lies upon the anterior and external 
portion of the scaleni. In the first place, we observe the as- 
cending branches, one of which, the submaxillary, makes a turn 
from under the sterno-mastoid upon the external surface of this 
muscle, and soon enters the sub-hyoidean region : it is crossed by 
the external jugular. Another makes a similar curve, but ascends 
into the parotideal region: this is the anterior auricular. A third, 
which is the mastoid branch, runs perpendicularly behind this 
muscle, which at first conceals it, and thus rises to the summit of 
this region. The first anastomoses particularly with the portio 
dura (facial); the second with the facial, superficial temporal, 
and filaments from the frontal, and the third unites principally 
with the occipital. 
The spinal (accessory) nerve is the most remarkable among 
the descending branches. It almost always perforates the sterno- 
mastoid from above downwards, descends between the levator 
scapulae and trapezius muscles and ramifies in the latter. It con- 
stitutes the principal external respiratory nerve of Chas. Bell. 
We must avoid wounding it when we bleed from the jugular 
vein, or remove tumours from this region. It is always some- OF THE NECK. 
195 
what deeply situated behind the aponeurosis when it enters the 
trapezius muscle. 
The supra and sub-clavicular, supra-acromial, descending and 
deep cervical filaments, diverge under the aponeurosis, between 
the trapezius and sterno-mastoid muscles, and are situated, for the 
most part, before the omo-hyoideus, but further back than the 
external jugular. We are obliged to divide several of them, in 
operating upon the subclavian artery, because it is difficult to iso- 
late them, on account of the filamentous and dense cellular tis- 
sue which envelopes them. 
( b ) The Phrenic. This nerve requires particular attention 
in the performance of operations, in order that it may escape 
injury. It arises from the third and fourth cervical nerves, and 
seems occasionally to arise from the cervical plexus. It crosses 
the branches which go to the brachial plexus, and descends upon 
the anterior part of the scalenus anticus, buried under the sterno- 
mastoid muscle, on the outer side of the internal jugular vein. 
As it enters the chest, it passes between the subclavian artery and 
vein, opposite to the point of union of the first two portions of 
the latter vessel; so that this is one of the branches which would 
be most exposed in the ligature attempted by Colies. This nerve 
being the chief source of motion to the diaphragm, we conceive 
that its division, by suspending the contractions of this muscle, 
would greatly derange the respiratory function. It is the inter- 
nal respiratory nerve of Chas Bell. 
( c ) The External or Posterior Thoracic. This cord arises 
from the posterior part of the fourth and fifth cervical branches 
anterior to the scalenus posticus, and terminates in the serratus 
magnus. It also enters into the system of the respiratory nerves 
of Chas. Bell. 
( d ) The Nerves of the Brachial Plexus. Included between 
the two scaleni, they are so arranged that the sixth cervical pair, 
as well as the cord resulting from the junction of the seventh 
with the first dorsal nerve, are separated from the others by the 
fleshy fasciculus (Scalenus minimus of Soemmering) which passes 
from the posterior surface of the scalenus anticus to the an- 
terior part of the costal extremity of the scalenus posticus. 
Hence it follows that the subclavian artery and the two first 196 
OF T11E NECK. 
cords are in u distinct space, in a complete triangle, the base of 
which is represented by the first rib; and that the other cords 
are not so much isolated, notwithstanding they are also included 
in a triangular space, the base of which is elongated and rests 
upon the anterior surface of the scalenus posticus. It has oc- 
curred more than once, that even skilful surgeons have applied 
a ligature upon one of the two first cords instead of the artery. 
This mistake may be avoided by recollecting that we always 
meet with the artery first in departing from the tubercle of the 
rib ; that the first nerve is both more elevated and more posterior: 
that it rests upon the muscle, whilst the artery is actually in con- 
tact with the bone; that the artery is of a reddish pale colour 
and flattened upon the body w hich supports it; whilst the nerve 
is of a reddish white, harder, more cylindrical, etc. All these 
nerves approximate each other as they descend; so that at the 
moment they are about passing under the clavicle, they form a 
sort of bundle, the arrangement of which is not always the same. 
In this tract they are only separated from the summit of the 
thorax and the inferior part of the neck, by cellular tissue and 
some lymphatic glands. The levator scapute and omo-hyoideus 
run along their superior and external portion, the latter muscle 
being the most superficial. They are crossed by the supra- 
scapulary and transverse cervical arteries and veins, and the 
external jugular ; finally, they are covered by lymphatic glands 
and the descending nerves of the cervical plexus, by much cellu- 
lar tissue, the aponeurosis, the platysma and integuments. On 
approaching the axilla, the most inferior cord, which was at first 
situated above and behind the artery, upon the first rib, at length 
places itself before this vessel, always remaining a little to its 
outer side. The sixth cervical pair also approximates close to 
this artery, and even touches it as it passes under the clavicle, 
when it is sometimes situated behind it. 
The nervous cords which we have just examined, before they 
enter the cavity of the axilla, give off, besides the posterior 
thoracic, some other branches (the anterior thoracic nerves) 
which are generally distributed to the anterior part of the thorax. 
One of these branches, more constant than the others, should be 
particularly noticed: it is that which generally arises bv two OF THE NECK. 
197 
roots, one of which passes behind, the other before the subcla- 
vian artery and unite, forming a species of loop, which we should 
be careful to exclude from the ligature applied upon this vessel. 
( e ) The Par Vagum. (Pneumo-Gastric.) Properly speak- 
ing, this nerve does not appertain to the supra-clavicular region 
until it is on the point of entering the cavity of the thorax. On 
the right side, previous to passing before the subclavian artery, it 
is situated opposite the vertebral vessels, which separate it from 
the anterior part of the transverse processes and the external 
portion ot the longus colli, muscle. It is separated from the tra- 
chea by the carotid, from the scalenus anticus by the jugular, is 
covered by the subclavian vein, by the root of the sterno-thyroid, 
sterno-hyoid, and sterno-mastoid muscles, then by the sterno- 
clavicular articulation. It is here that the inferior laryngeal 
(recurrent) nerve is detached from it, anterior to the artery, 
around which it makes a turn, so that it ascends from behind this 
vessel towards the oesophagus and trachea: this species of ner- 
vous circle would require the strictest attention, if we should 
attempt to tie the subclavian artery on the inner side of the 
scalenus. 
On the left, the relations of the par vagum differ somewhat 
from those which have just been described. It is much more 
deeply seated ; it crosses the vertebral artery very obliquely, and 
places itself at its internal part; it runs between the carotid and 
subclavian arteries without passing before the latter; and lastly, 
it does not give off the recurrent until it reaches the arch of the 
aorta. 
(/) The Great Sympathetic. Strictly speaking, the middle 
and inferior ganglia appertain to this region ; but it appears more 
proper to defer treating of the latter until we come to describe 
the cavity of the thorax; and, as the former does not always 
exist, it is useless to take up our time in relation to it. We have 
then to speak only of the filaments which originate from these 
ganglia in order to form a species of plexus around the sub- 
clavian vessels. The most of these filaments proceed from the 
middle ganglion; two or three ascend from the inferior, and all 
of them intermingle with the cardiac twigs of the superior gang- 
lion, and with other filaments derived from the recurrent, etc. 
In this manner a complicated net-work is formed before and be- 198 
OF THE NECK. 
hind the arterial trunk ; but the branches which collect to form 
this nervous interlacement are so small and numerous, that it is 
almost impossible to avoid wounding some of them in the 
attempt to lay bare the first portion of the subclavian artery. 
This laesion seems to be the principal cause of the accidents 
which follow the operation, on account of the disturbance which 
it must occasion in the functions of the heart. 
lx. The Skeleton. 
The skeleton of the supra-clavicular region is composed of the 
clavicle and first rib. These two bones leave between them a 
double triangular space with which it is of importance to be well 
acquainted. Thus, let us suppose the shoulder drawn very much 
backwards and elevated as much as possible, the plane of the 
triangle will be perpendicular; that is to say, the clavicle w ill be 
superior and the rib inferior. But if the clavicle is very much 
depressed and at the same time brought forward as much as 
possible, the plane of this triangle will be horizontal. The apex 
of this triangular space is always at the sterno-clavicular articula- 
tion, and its base is represented by an arbitrary line drawm from 
the transverse process of the first dorsal vertebra to the posterior 
part of the clavicle, opposite to the coracoid process, and is 
naturally filled from within outw ards, and from before backwards ; 
(a) By the costo-clavicular ligament, which is so disposed 
that it promptly restrains the movements of the clavicle up- 
wards and forwards, and which is separated from the subcla- 
vian artery only by a cellulo-adipose layer, generally of slight 
thickness; 
(h) By the subclavius muscle, which is prolonged upon the 
inferior surface of the clavicle almost to the point where this 
bone receives the insertion of the coraco-clavicular ligaments. 
Its superior surface is covered by a fibro-cellular expansion, which 
is afterwards spread over the vein, artery and nerves, and is 
finally lost in the cellular tissue of the supra-clavicular excava- 
tion. This lamina, which is attached to the w hole extent of the 
posterior margin of the clavicle, is continuous on the other part 
with the costo-clavicular ligament; 
(c) By the subclavian vessels and nerves arranged in the OP THE NECK. 
199 
following manner: first the vein, next the artery which is more 
posteriorly; then the most inferior cord of the brachial plexus, 
slightly covering the anterior part of the artery; lastly the 
other branches of this plexus situated more externally and 
posteriorly. From this disposition it follows that the subclavian 
artery is covered almost entirely by the vein which is internal, 
and by a nerve which is external. Langenbeck, therefore, is in 
error, when he affirms that the artery is more superficial than 
the nerve; at least we have generally found its relations as just 
stated. 
( d ) More externally, this space is filled only by cellular 
tissue, fat, lymphatic glands, nervous filaments and vascular 
ramifications. It is through this part that morbid fluids, formed 
in the supra-clavicular region, beneath the aponeurosis, pene- 
trate with the greatest facility into the axilla and behind the 
thorax. 
As the artery and vein are fixed in the place which they 
occupy by the fibrous lamina indicated above, it follows that, in 
certain positions of the shoulder, these vessels may be so com- 
pletely compressed as to obliterate their calibre. Thus, by push- 
ing the shoulder downwards and forcibly backwards, the com- 
pression may be so firm as to suspend the circulation in the arm 
entirely, and every body knows that in this way we can imme- 
diately stop the pulsation at the wrist. There are some persons 
in whom this remark my be usefully applied in order to explain 
certain apparent anomalies of the circulation. For example, an 
individual may lie in such a manner that the wreight of the body 
bears principally upon the anterior part of the shoulder; in which 
case the pulse might not be perceptible at the wrist. This cir- 
cumstance would greatly embarrass the physician, if he did not 
reflect on this state of mechanical obliteration of the subclavian 
occasioned by the pressure of the clavicle and its muscle upon it. 
Such an occurrence has presented itself twice to our notice. 
As the nerves pass through a wider part of the triangle, their 
compression must necessarily be less prompt and less complete. 
Nevertheless, when the bones are very much approximated, and 
continue so for some moments, a greater or less degree of numb- 
ness soon indicates that the nerves are compressed. 
From what has just been observed, we find that these organs 200 
OF THE NECK. 
will be the more freeand will fulfil their functions better, in propor- 
tion as the shoulder is carried upwards and forwards; but we 
also see that, in this position, the artery will be at a greater depth, 
and consequently exposed with greater difficulty. Unfortunate- 
ly it is most frequently in such cases that it becomes necessary 
to tie the subclavian. 
In fact, aneurysmal tumours of the axilla, which do not admit 
of the application of a ligature anterior to the clavicle, never be- 
come much enlarged without pushing the shoulder in the direc- 
tion just indicated. Otherwise, whenever the disease does not 
prevent it, we should always depress the shoulder, drawing it 
forwards. It is this position also w hich enables us to compress 
the artery against the first rib, if it could be adopted during the 
performance of the greater proportion of the operations w hich 
such compression requires, in amputations, for example. 
It is proper to remark, that when this double triangle is forci- 
bly contracted, (that is to say, when the clavicle is carried very 
much downwards and backwards,) the clavicle acts upon the first 
rib as a lever of the first order, and is only restrained from luxa- 
tion forwards by the sterno-clavicular ligament. When, howe- 
ver, it is expanded {the shoulder brought very much forwards and 
upwards) the clavicle forms a lever of the second order, and then 
the costo-clavicular ligament as strongly opposes its luxation 
backwards as the ligaments which appertain to the articulation. 
We will resume the consideration of this subject when we come 
to treat of the sternal region, and will speak of fractures of this 
bone when describing the axillary region. 
The first rib is important, as regards its anatomical dispositions, 
in several points of view. Its cartilage is broad, thick and very 
strong; it is also very short, and, if I may so say, incorporates 
the rib with the sternum. These are, here, so many elements of 
strength and resistance. Its vertebral extremity presents a 
rounded head, and not two plane articulating surfaces ; its tuber- 
cle is not applied to the transverse process; the ligaments which 
connect this extremity to the spine are weaker, and less fibrous 
than those of the following ribs: here, these are so many elements 
of mobility, and it is this contrary arrangement of the twro ex- 
tremities of the first rib which has given rise to the opposite 
opinions of Haller and M. Magendie. The first of these physi- OF THE NECK. 
201 
ologists maintains that the first rib is almost immoveable, or at 
least that its mobility is comparatively much less than that of the 
other ribs, and thence concludes that it serves as a fixed point to 
the intercostal muscles during inspiration. M. Magendie, on the 
contrary, thinks that it is more moveable than all the others, and 
that it is elevated, during inspiration, like all those which are below 
it. It is not for us to decide this question; but we are of opinion 
that, whilst the strength of the cartilage and the shortness of the 
bone give weight to the idea of Haller, they do not prevent the 
mobility of this rib upon the spine, nor the elevation of the tho- 
rax en masse; so that if the first rib is actually the fixed point 
for the muscular actions, it must be so only through the medium 
of the scaleni muscles, the anterior especially. 
In tracing this rib from the sternum tow ards the vertebra to 
which it is attached, its superior surface is at first broad, horizon- 
tal and very slightly elevated; the costo-elavicular ligament is 
attached to it obliquely from within outwards, and from the pos- 
terior towards the anterior margin: whence results a gutter 
circumscribed by the clavicle and rib, and excavated upon the 
posterior surface of the ligament, w hich then supports the sub- 
clavian vein and artery. Afterwards, this surface inclines slight- 
ly outwards and backwards, and presents, in this direction, a 
superficial depression, in wrhich the vein lies. Behind this slight 
depression we observe the tubercle to which the scalenus anti- 
cus is attached, then the groove in which the artery is lodged. 
This tubercle is a little broader internally than externally, which 
is owing to this arterial groove being almost transversal, whilst 
the venous depression is oblique posteriorly. Here, the rib is 
a little narrower. Finally, the rest of this surface again becomes 
broader, rises, and resumes the horizontal position; it receives 
the attachment of a part of the scalenus posticus. 
In the supra-clavicular region we penetrate through the fol- 
lowing parts previous to reaching the first rib: 1st. The skin; 
2d. a cellular layer of moderate thickness ; 3d. the platysma, but 
in the anterior half of the region only; 4th. a thin lamellated 
cellular tissue, which supports the platysma, through which the 
external jugular vein and some nervous filaments take their 
course; 5th. the aponeurosis, which splits anteriorly and poste- 
riorly in order to envelope the sterno-mastoid and trapezius mus- 202 
OF THE XECK. 
cles; 6th. much cellular tissue, fat, lymphatic glands, the nerves 
of the cervical plexus, secondary veins and arteries; quite infe- 
riorly, the subclavian vein, the omo-hyoideus muscle; 7th. the 
phrenic nerve, the scalenus anticus muscle ; 8th. the nerves of the 
brachial plexus, the subclavian artery; 9th. the scalenus posti- 
cus and the bone. 
Art. II. posterior part op the neck. 
The posterior region, or nape, of the neck, is bounded ; supe- 
riorly, by the occipital protuberance, transverse ridge and mas- 
toid process; inferiorly, by a transverse line drawn from the 
superior angle of one scapula to that of the other along the cervi- 
cal margin of these bones, and laterally by the supra-clavicular 
region, or a line dropped from the mastoid process upon the 
acromio-clavicular articulation. 
This region is rounded and narrow in the middle ; broader and 
projecting backwards, superiorly; plane and still broader inferi- 
orly, and of various lengths and thicknesses in different subjects. 
These peculiarities generally depend upon its degree of promi- 
nence, the elevation or depression of the shoulders, and the 
developement of the muscles and other soft parts. 
Upon its surface we observe, from above downwards, the ex- 
ternal occipital protuberance, which is more prominent in some 
individuals than in others, and corresponds with the Torcular 
Ilierophili within the cranium; below this, a triangular excava- 
tion, bounded laterally by an eminence occasioned by the com- 
plexi muscles. This hollow is called the pit of the neck, and is 
the place where issues are usually made: it is bounded inferior- 
ly by the spinous process of the axis (dentatus). It corresponds 
to the space which separates the os occipitis from the atlas, and 
an instrument introduced through it might easily wound the me- 
dulla oblongata. More inferiorly we observe merely a simple 
furrow, and that only when the head is in extension ; this furrow 
is the continuation of the preceding triangular excavation. The 
muscles likewise form an eminence on each side, but this is only 
seen when the furrow exists, and during their contraction. In 
the bottom of this furrow we with difficulty feel the spinous pro- 
cesses of the cervical vertebrae. At the most inferior part of the OF THE NECK. 
203 
region we see the spine of the seventh vertebra, which generally 
makes a very distinct prominence. 
CONSTITUENT PARTS. 
i. The Skin. 
Its thickness is considerable, more so upon the median line and 
muscular eminences; a little less anteriorly or laterally; and its 
resistance is very great; which accounts for the agonizing pains 
attendant upon furunculous tumours developed in it. It is very 
elastic, almost inextensible, possesses but little vascularity, and is 
almost entirely composed of the fibrous element. It is to this 
predominance of the solids over the fluids, in the skin of the neck, 
that many attribute the infrequency of acute or chronic pustu- 
lar affections, dartres, in short of cutaneous exanthemata in 
this region. This, however, is not the fact, for we observe her- 
pes furfuraceus (dartres furfuracees), porrigo (prurigo), etc., 
as frequently in this situation as elsewhere. It is sometimes 
wrinkled transversely, especially in old people, and those who 
have lost much of their embonpoint. We do not observe papil- 
lary wrinkles upon it; but we frequently perceive in it points of 
a determinate figure, which correspond to the areolae of its inter- 
nal surtace. The hairs which cover the skin above, seldom de- 
scend lower than the dentatus; the rest of its surface is destitute 
of them. It does not contain many sebaceous follicules, at 
least they are distinguished with difficulty upon the median line. 
This skin generally becomes more adherent the lower it descends ; 
nevertheless, it is commonly sufficiently moveable to allow us to 
pinch up folds of it of considerable thickness, when we wish to 
introduce a seton through it, and for this purpose the middle of 
the region is to be preferred, as well as on account of the dress- 
ings. When we wish to form an issue, however, we give the 
preference to the pit of the neck, because there is in this fossette 
a great quantity of cellular tissue; the form of it is very well 
adapted for the establishment of a drain ; the cellular tissue passes 
directly upon the membranes of the encephalon; indeed, every 
circumstance seems to indicate that an issue, applied in this situa- 
tion, will act much more efficaciously upon the brain and its me- 
ninges, than if established elsewhere. 204 
OF THE NECK. 
ii. The Subcutaneous Cellular Layer. 
This layer is generally thin, formed of lamellae and filaments, 
dense and firmly adherent to the skin, so that when we nip up a 
portion of the latter, in order to pass a seton needle through it, 
the cellular tissue is always included within the gripe. Those of 
its lamella? which are nearest to the dermis contain numerous 
adipose cells, which sometimes form a cushion of considerable 
thickness. The other surface of this species of membrane is 
more uniform, and but loosely united to the aponeurosis; but it 
adheres pretty firmly to the ligamentum nucha? (cerrical liga- 
ment), with which it seems to be blended. It is in this layer that 
pus forms, in the erysipelatous inflammations of the posterior 
part of the neck. In these cases, the great thickness of the skin 
and its slight degree of extensibility afford much resistance to the 
fluid which tends to accumulate beneath it; hence it is that these 
abscesses are seldom circumscribed in a well defined manner, 
and that they promptly extend in different directions. It is with 
the view of avoiding the accidents which might result from the 
diffusion of these collections, that we are recommended to let 
out the morbid fluids so soon as they have formed. Unfortunate- 
ly it is not always easy to seize upon the opportune moment; for 
generally, it is very difficult to detect the fluctuation. This cel- 
lular layer is usually dry, and encloses but a small number of 
vessels and nervous filaments. 
hi. The Aponeurosis. 
In the supra-clavicular region we mentioned that the cervical 
aponeurosis separated into two sheets when it reached the mar- 
gin of the trapezius. These two sheets again become blended 
upon the median line, after having enveloped this muscle. In 
thus terminating, they concur in the formation of the cervical lig- 
ament (Ligamentum Nucha), which, on the other side, is the 
common rendezvous of all the intermuscular cellular lamina?. 
In man, this ligament is reduced to a simple fibro-cellular band, 
which extends from the os occipitis to the last cervical vertebra, 
and unites the spinous processes of the neck to the skin. It 
consequently separates all the muscles of the right side from those OF THE NECK 
205 
of the left. In quadrupeds, especially graminiverous animals, the 
cervical ligament is very strong and elastic: whence it follows 
that the head of these animals is naturally elevated, whenever 
the flexor muscles are in a state of relaxation. Upon the super- 
ficial lamina of this aponeurosis some nervous filaments from the 
posterior cervical branches ramify. This lamina is thin and firm- 
ly adherent to the trapezius muscle ; but its external surface ad- 
heres but slightly to the subcutaneous layer: therefore nothing is 
more easy than to fold the skin of the posterior part of the neck, 
and comprise in the duplicature the cellular tissue which lines it, 
without running the risk of wounding the aponeurosis. 
iv. The Muscles. 
They are very numerous and arranged in strata. Some of 
them extend throughout the wThole length of the region; others, 
on the contrary, only traverse it in part. Among the former, 
are, 
( a) The Trapezii. These muscles are united at the median 
line by means of their aponeurosis, which grows broader as it 
descends, in order to form the fibrous rhombus (losange jibreux), 
the centre of which is at the spine of the seventh cervical verte- 
bra. They form the first stratum, which is separated from the 
skin by the aponeurosis and subcutaneous layer only. 
( h ) The Splenius cervicis et capitis, w hich form a second 
layer, separated from the preceding by an aponeurotic lamina of 
considerable strength, and by a portion of the rhomboideus infe- 
riorly. In passing towards the head, these muscles leave be- 
twen them a triangular space, the apex of which corresponds to 
the middle of the neck, and in which the trapezius rests imme- 
diately upon the complexi. It is in the upper part of this space 
that the occipital artery disengages itself from beneath the splenii, 
in order to ramify under the skin of the cranium. 
(c) The Complexi* which form a third stratum, lying ob- 
liquely upon the subjacent layer. The minor complexus is ex- 
ternal, and both are covered from below upwards by the rhom- 
* The French anatomists describe two complexi muscles, the major and minor; 
the former M. Chaussier denominates trachdlo-occipital; the latter, 
dein.—Transl. 206 
OI TJ1U NECK. 
boideus, the serratus posticus superior, the splenii and trapezius. 
It is between them that the cervical ligament is situated. They 
are, moreover, composed of a great number of bundles, which 
are imbricated as they ascend from the transverse processes to- 
wards the median line; they cross the root of the splenii veiy 
obliquely, then pass over the transversalis colli, the terminations 
of the sacro-lumbalis and longissimus dorsi, over the semi-spi- 
nalis colli, and above the dentatus, over the obliqui et recti cap- 
itis postici. 
Between these different muscular strata, we find nerves, ves- 
sels and cellular lamellae. Between the trapezius and the second 
layer, the cellular tissue is dense, filamentous and very com- 
pact, superiorly; in the middle of the region it is lamellated, but 
still possesses considerable compactness; at its most inferior 
portion, it is much looser, and contains numerous adipose cells 
externally. Between the splenii and complexi the cellular tissue 
is sparing in quantity, except at the superior part, where it forms 
a layer of considerable thickness. Between the complexi and the 
muscles beneath them, it forms thin lamellae in the two inferior 
thirds of the region; but in the superior third this element exists 
in great abundance, in the first place upon the median line be- 
tween the complexi, then laterally, between the latter muscles 
and those which we are now about to examine. 
The muscles which do not extend throughout the whole 
breadth of the posterior cervical region may be divided into two 
sets: those which lie above the axis, and those which are situ- 
ated belowr it. The latter form a mass of greater or less bulk in 
different subjects, which completely fills the cervical gutters, and 
which is composed, in proceeding from the sides towards the me- 
dian line, of the sacro-lumbalis, transversalis colli, longissimus 
dorsi and semi-spinalis colli; in a word, we find the prolonga- 
tions of the different bundles which enter into the composition of 
the sacro-spinalis. They present nothing very remarkable in a 
surgical point of view. 
The others are, 
(«) The rectus capitis posticus major. This extends from the 
spinous process of the second vertebra to the inferior curved line 
of the os occipitis, external to the crest of this bone, and is sepa- 
rated from its fellow by a very narrow triangular space, filled OF THE NECK 
207 
with a yellowish and dense cellular tissue: it is also separated 
from the great coniplexus by a very thick layer of similar tex- 
ture, in which some nerves and vessels ramify. Externally, it is 
free and forms the internal side of a triangle which we will ex- 
amine directly. 
( b) The rectus capitis posticus minor passes from the tubercle 
of the atlas only towards the lossette which exists behind the 
foramen magnum, by the side of the median crest of the os occi- 
pitis. It is covered by the preceding, merely a thin lamina of 
cellular tissue being placed between them. It lies directly upon 
the occipito-atloidal ligament. 
(c) The obliqui are so arranged that the inferior passes from 
the spine of the axis to the transverse process of the atlas, and 
the superior, from the latter tubercle to the os occipitis, between 
the two curved lines, near the termination of the rectus major: 
so that they form a very regular triangle, in which we observe 
several important organs, such as the vertebral artery, the sub- 
occipital nerve, and a portion of the ligaments which unite the 
first two vertebrae to each other, as wrell as to the occipital bone. 
This space is covered by the great complexus, and filled with a 
fibro-cellular tissue, which adheres very firmly to the muscles, 
vessels, and nervous branches, and is united particularly to the 
periosteum and ligaments. The obliquus superior is concealed 
by the complexi, and rests upon the posterior inferior part of the 
os occipitis, between the splenius capitis, the great complexus, 
which are above, and the rectus capitis posticus major, which is 
below; finally, it lies upon the thinnest part of the inferior occi- 
pital protuberance; so that, if we should apply the trepan below 
the superior curved line, this small muscle would necessarily be 
divided. The inferior oblique is also covered by the complexi, 
and rests upon the two vertebrae to which it is attached, upon 
the posterior branch of the second cervical nerves, partially upon 
the vertebral artery, and upon some cellular tissue. 
This region also contains two orders of small muscles: these 
are the inter-spinales and inter-transversales. The former are 
situated between the spinous processes, from the second vertebra 
to the seventh; between the atlas and dentatus (axis), between 
the os occipitis and atlas, the posterior recti appear to be substi- 
tuted for them, They are double and symmetrical, and seem to 208 
Or THE XELK. 
us to give support to an opinion which we might defend here, if 
the nature of this work permitted it; viz. that the yellow elastic 
fibrous tissue is susceptible of being converted into muscular 
tissue, according to the necessities of the organs between which 
it is situated. 
The latter (inter-iransversales) are arranged nearly in the same 
manner between the transverse processes, from the first cervical 
vertebra to the last. Between the first and the head, the ret;us 
capitis literalis supplies the place of the inter-transversalis. They 
are double likewise, and each circumscribe a small triangle 
through which the cervical nerves pass, but in such a manner, 
however, that these nerves cannot be compressed by the mus- 
cular contractions. Finally, they are there confounded with the in- 
sertion of a great number of other muscles ; which are, posteriorly, 
the sacro-lumbalis, splenii, complexi, transversalis colli, longissi- 
mus dorsi, sjemi-spinalis colli, and more superiorly the obliqui; 
anteriorly, the scaleni, angularis scapulae, longus colli, and the 
rectus capitis anticus major. 
v. The Arteries. 
All the arteries of this region come from the anterior part of 
the neck, and are, 1st. the horizontal branch of the transverse 
cervical, which ramifies principally between the first two muscular 
strata; 2d. the cervicalis profunda, which, in coming out from 
the space which exists between the two last cervical vertebrae, 
distributes twigs to the fasciculi of the vertebral gutters, then 
passes between this mass and the complexi, and terminates in 
the latter; 3d. The ascending cervical, which also gives off 
branches to the same parts, but exists in the superior half of the 
region only; 4th. the occipital, which is the most important, and 
requires attention. It originates from the external carotid, 
passes deep under the insertion of the sterno-mastoid muscle, 
between the axis and atlas, then under the splenius capitis, and 
enters the region under consideration ; it next ascends in a tor- 
tuous manner upon the external surface of the great complexus, 
covered by the splenius, then by the trapezius, which it soon 
perforates in order to ramify in the subcutaneous layer. Some- 
times it divides into two branches while it is yet under the mas- OF THE NECK. 
209 
toid process, in which case it would be almost impossible to apply a 
ligature around it; in other cases, however, this division takes 
place under the trapezius: then, if disease or accident renders 
the application of a ligature necessary, it might be discovered by 
dividing the skin, subcutaneous cellular tissue, aponeurosis ,and by 
separating the trapezius from the splenius, from the transverse 
ridge of the os occipitis to the extent of two inches downwards. 
From this disposition, we perceive that a wound in the upper 
part of the neck might be followed by considerable haemorrhage, 
whilst inferiorly there is no artery of sufficient volume to ex- 
cite any apprehensions of this nature; 5th. the vertebral artery 
is sheltered from external violence, as far as the second vertebra, 
by its passing through the canal in the transverse processes; but 
in coming out from the third, it forms an arch with a posterior 
and external convexity, which is liable to be wounded by instru- 
ments penetrating to the spinal column. In the transverse process 
of the atlas, the vertebral artery curves forwards and outwards, 
and is again protected from external violence : as it issues from 
this vertebra in order to enter the cranium through the foramen 
magnum occipitale, it turns behind the condyle of this bone, upon 
the posterior surface of the posterior occipito-atloidal ligament, 
which it perforates, or rather derives from it a fibrous process, 
which is converted into a ring by the basilary process of the os 
occipitis. It is here especially that the vertebral artery forms a 
very distinct curve, which is convex posteriorly, and that it is 
exposed for some time in the triangle heretofore noticed, when 
speaking of the oblique muscle. It is in this situation that it is 
most liable to be wounded. Previous to its entrance into the 
cranium, it gives off some small unimportant branches. 
vi. The Veins. 
They for the most part accompany the arteries, and empty into 
the internal jugular. There are some which are situated in the 
cellular layer beneath the skin, and terminate in the external 
jugular. The former also receive some emissary veins of Santo- 
rini, but they are so irregular and deep-seated, that they afford no 
special indication in relation to venesection. 210 
OF THE NECK. 
vii. The Lymphatics. 
Those of the superficial layer pass to the superficial cervical 
glands; the greater portion of the deep-seated, to the deep-seated 
glands of the neck; the remainder to those of the axilla. From 
these terminations of the lymphatics we may account for the 
tumefaction of the axillary glands and those of the infra-hyoidean 
region, in consequence of diseased affections of the posterior 
part of the head and neck. 
We have occasionally met with two or three lymphatic glands 
upon the splenius, between the trapezius and sterno-mastoid, 
covered by the skin and cellular tissue, about one inch below the 
transverse ridge of the os occipitis. These glands sometimes 
become enlarged, and we should therefore recollect their seat in 
order that we may avoid mistaking such enlargements for tumour's 
of a different nature. 
vni. The Nerves. 
These are principally derived from the posterior branches of 
the cervical nerves; some from the cervical plexus, and the sub- 
occipital is chiefly distributed to this region. The former are 
situated, in the first place, between the splenius and complexus 
muscles ; afterwards their branches separate, some of which pass 
between the complexi and the deep-seated mass, the others pene- 
trate the fleshy strata which cover them, and all send filaments to 
the subcutaneous cellular tissue. 
The second are the spinal (accessory), which ramifies in the tra- 
pezius ; some filaments from the deep descending cervical 
branches, which pass into the same muscle, into the levator sca- 
pulae and the fibro cellular laminae which separate these two 
muscles from those which are beneath them. These are dis- 
tributed to the inferior part of the neck only, and seem to apper- 
tain chiefly to respiration and sensibility. The preceding occupy 
the middle region, and are principally lost in the locomotive or- 
gans. There are also some other filaments from the auricular 
and mastoid branches of the cervical plexus, which are enclosed OP TltE NECK. 
211 
within the laminae of the aponeurosis, and terminate in the cellu- 
lar tissue which separates them from the integuments. 
The sub-occipital, which may be considered as the first cervical 
pair, is the most important nerve in this region. Having passed 
between the cranium and altas, it enters immediately into the 
triangle circumscribed by the obliqui and the rectus capitis posticus 
major, enveloped in the cellular tissue which fills this space, and 
to which it is firmly adherent: here it divides into three principal 
branches, one of which, like the deep seated branches of the 
other cervical nerves, descends under the complexus and finally 
traverses it. The two ascending branches run towards the os 
occipitis, pierce the muscles or their interstices, anastomose with 
the superior twigs of the cervical plexus, between the aponeurosis 
and the skin, and with other filaments appertaining to the facial 
(portio dura). 
From this disposition it follows that the nerves are most numer- 
ous in the supra-axoidal portion of the region; and this is doubt- 
less the reason why inflammations of this part are attended with 
such acute pain. If to this we add the compact texture of the 
different tissues contained in it, we will understand why its inflam- 
mations are so liable to assume the erysipelatous character ; why 
this species of inflammation is so readily developed in wounds of 
this part; why certain inflammatory tumours sometimes occasion 
such excruciating pain, and why pus, when secreted, is with so 
much difficulty collected in the form of abscess in this portion of 
the region. 
ix. The Skeleton. 
It comprises a great part of the os occipitis and the cervical 
portion of the spine. 
That portion of the os occipitis which corresponds to the lateral 
sinuses and comprises the superior curved line, as well as the 
external protuberance, was noticed when treating of the occipital 
region, properly so called. 
Upon the median line, we observe the occipital crest, which 
corresponds to a similar crest within the cranium, consequently 
to the falx cerebelli, and to the sinuses which this duplicature en- 
closes. Into this crest the ligamentum nuchee is inserted, and it 212 
OF THE NECK 
generally forms an eminence which is in a direct ratio to the 
muscular power of the individual. Laterally, we see the occipital 
bumps, which correspond to the inferior occipital fossae and to the 
posterior part of the cerebellum. In this situation the bone is 
extremely thin, but it is covered by a thick cushion of the soft 
parts: nevertheless, fractures are not infrequent here, and are 
the more formidable on account of the difficulty of detecting 
them. These fossae may be perforated by tumours of the dura- 
mater, by the pressure of the cerebellum, thus forming hernia 
cerebelli, two examples of which have been recorded by M. 
Prof. Lallemant and M. Baffos.* It is generally laid down as a 
rule that we should not trephine below the superior curved line 
of the os occipitis: however, if the indication was positive, we 
do not think that the operation would be very difficult or more 
dangerous than in other points of the cranium ; only it would be 
necessary to apply the trephine upon the occipital bump, and not 
upon the median line, nor too near the superior curved line. It 
has also been said that fungous, or rather cancerous, tumours of 
the dura mater should not be removed, notwithstanding they may 
have perforated the cranium, and reasoning, as well as facts, seem 
to give support to this advice ; but we think that it should not be 
too much generalized. It is indeed possible that a tumour of this 
nature may have made its way through the bone, without having 
extensively disorganized the dura-mater or encephalon. In such 
a case, we do not see why its extirpation should not be under- 
taken, especially if the progress of the disease will necessarily 
occasion the death of the patient. 
This observation is strengthened by a fact which was recently 
presented to our notice; the pathological specimen has been 
deposited in the Museum de lafaculte. 
A woman died in Jany. 1825, at the hospital of perfection- 
nement, with a hard and immoveable tumour situated at the inferior 
and internal portion of one of the lateral occipital protuberances : 
this tumour, which was a scirrhus of the dura-mater, had per- 
forated the bone. It was as large as a common nut, and the 
fibrous membrane was perfectly sound at half a line external to 
this morbid production. Now, it is evident that the extirpation 
* Boyer, 'Trait£ des maladies chirurgicalcs, etc., tome V. page 201. OF THE NECK. 
213 
of this cancer was possible, and that the operation would have 
afforded the same chances of success as would have attended a 
similar removal upon other parts of the body. 
If it is true, as M. Gall affirms, that the organ of physical love 
resides in the cerebellum, wounds of the osseous portion, at 
present under consideration, would frequently be followed by 
changes in this propensity. It is from this idea that the celebrated 
author of the Cranioscopie says that we may be able to ascertain, 
from the distance of the mastoid processes from each other, and 
the separation of the lateral eminences of the os occipitis the 
strength or weakness of the instinct of reproduction in different 
individuals. 
The vertebral column presents several remarkable peculiarities 
in this region: 
( a ) It is concave, and this concavity is in a direct ratio to 
the age. 
( b ) The spinous processes are of unequal lengths: thus the 
first vertebra has none, for which reason the head may be thrown 
backwards with greater facility; the spinous process of the se- 
cond is thick and very long; that of the third very short, and 
the following gradually increase to the seventh ; so that, from the 
dentatus (axis) to the last cervical vertebra, there is a notch which 
is mostly filled with soft parts; which notch should induce us to 
select the middle of the neck for the introduction of a seton. 
These processes are almost horizontal, and consequently quite 
remote from each other, a disposition which admits of much 
latitude of motion. 
( c ) The transverse processes are also very short; their length 
gradually decreases from the seventh and from the first towards 
the third: the extent of motion which the neck enjoys is a na- 
tural consequence of the shortness of these processes. Through 
their base passes the canal for the transmission of the vertebral 
artery, wrhich is thus protected against the action of foreign 
bodies. Nevertheless, we are of opinion that a sabre, or other 
cutting instrument, struck against the side of the neck with a 
certain force, might reach these vessels and occasion a wound 
which would be dangerous, both on account of the difficulty of 
securing the vertebral artery, as wras shewn in the infra-hyoidean 
region, and of distinguishing whether the carotid or vertebral has 214 
OP THE NECK 
been divided. The nerves pass out behind the artery, and divide 
on the external side of it. 
( d ) The facets of the oblique articulating processes approxi- 
mate more to the horizontal direction than in the other regions ; 
nevertheless they incline more and more in descending from the 
inferior facets of the second to the seventh; so that their dis- 
placement is more difficult to accomplish in proportion as they 
remove from the axis. This displacement, or luxation of the 
cervical vertebrae below the dentatus, admitted by some, but 
denied by others, is certainly possible: we now possess incon- 
testible examples of it. If only one facet passes before the other, 
without lacerating the intervertebral cartilage, the luxation is 
incomplete, and may exist without paralysis; but if the four sur- 
faces have abandoned each other and the fibro-cartilage is torn, 
the spinal marrow is compressed, paralysis immediately occurs, 
and even death. It is especially between the atlas and second 
vertebra that the arrangement of these surfaces is worthy of at- 
tention Here they are plane, horizontal, or slightly inclined 
outwards. On the other hand, the atlas has no plates, properly 
so called, no spinous process, no body; consequently, no ligamen- 
tum flavum nor fibro-cartilage. Hence it follows that the move- 
ments naturally exist in all directions, that rotation may be car- 
ried very far without danger; but, should it pass beyond the 
quarter of the circle, luxation will inevitably ensue, because then 
one of the facets of the atlas passes before, and the other behind 
those of the axis. We should particularly recollect the possi- 
bility of this accident during the tractions which we exercise 
upon the body of the infant in parturition, when we operate by 
turning. In fact, if, for example, the face is placed anteriorly 
and the accoucheur endeavours to turn it towards the sacrum; 
for this purpose he gives the trunk a slight turn at each traction 
which he executes ; and, if he only considers the form, it would 
not be very difficult to place the back of the foetus towards the 
pubes. But if the head has not followed the movements com- 
municated to the trunk, if it has remained in the position which it 
occupied at the commencement of the manoeuvre, a luxation of 
the first two vertebrae will be produced, and the death of the 
infant will precede its extraction. 
( e ) The union of the head with the atlas, and also with the OF THE NECK. 
215 
axis, deserves particular attention. The condyles of the os 
occipitis being convex, elongated and directed obliquely out- 
wards and backwards, the superior facets of the vertebra upon 
which they rest being adapted to this disposition, an articulation 
is the result which admits only of flexion and extension; but as 
the occipito-atloidal ligaments are supple and broad, as the pos- 
terior arc of the vertebra is thin and destitute of a spinous pro- 
cess, this double movement may be carried pretty far, less so, 
however, than we would be induced to believe at the first glance, 
because the odontoid process and its ligaments prevent the atlas 
from being carried forwards. The rotary motion is principally 
executed upon the odontoid process and the articulatory surfaces 
of the (axis) dentatus. As we examine these parts from before 
backwards they thus present themselves: 1st. the anterior arc 
of the atlas and the ligament which unites it to the os occipitis; 
2d. the odontoid process and ligaments; 3d. the transverse and 
occipito-axoidien ligaments; 4th. the dura mater; 5th. the spinal 
canal filled with the medulla. 
The odontoid process forms a species of pivot around which 
the atlas turns: attached to the inner side of the condyles of the. 
os occipitis by two short fibrous bundles, it cannot press upon 
the marrow without previously rupturing the transverse ligament 
of the first vertebra, unless it should slip from under it, in which 
case the odontoidal ligaments must necessarily be previously 
lacerated. We are of opinion that, in order to produce this 
effect, in either of these ways, considerable force is required. 
It nevertheless appears that those who have been hung frequently 
died in this manner; but more frequently the ligaments of the o- 
dontoid (ligamenta moderatoria) were first broken and this process 
had afterwards escaped from its ring below the transverse liga- 
ment of the atlas, and entered the spinal canal, so as to lacerate 
the medulla, causing instantaneous death: sometimes also the 
transverse ligament was broken and death had taken place in 
the same manner. 
In children, slighter efforts will produce the same effect. In 
them, the vertical process of the second vertebra is but slightly 
developed; its ligaments are much less unyielding; the ring 
which encloses it is less close ; the transverse ligament also pos- 
sesses a certain degree of elasticity ; so that this process might 216 
OF THE NECK. 
r 
escape from beneath the latter band, without lacerating its pro- 
per ligaments. These are the different peculiarities of these 
parts in youth, which enable us to comprehend how, by raising a 
child from the ground by means of the hands placed on each 
side of the head, we might cause his immediate death, if he should 
make any struggles to disengage himself from our grasp. A case 
of this kind is related by J. L. Petit. 
We may also remark that the first two cervical vertebrae are so 
articulated, so connected with each other and with the head, that 
an instrument or weapon might easily be thrust into the spinal 
canal, without dividing any but soft parts, and occasion instant 
death by the injury inflicted upon the superior part of the spinal 
marrow. Thus if a small sword is thrust into the fosselte of the 
neck, it would possibly penetrate the occipilo-atloidal (infundi- 
buliforme) or atloido-axoidien ligament, and cut through the com- 
mencement of the medulla spinalis. It was in this manner that 
the man who destroyed the child spoken of by J. L. Petit, was 
himself killed by the father of this child, if we can give implicit 
credence to the statement of these two cases. 
This disposition seems to be well known to butchers, since 
they frequently strike down animals by plunging a knife behind 
the os occipitis; also by common people, who know that if a 
needle is thrust into this region, death will be the consequence; 
and malefactors have more than once profited by this knowledge, 
in order to perpetrate the worst of crimes, upon j’oung children 
especially. If the instrument was introduced at the anterior 
part it would not be attended with the like danger, because the 
odontoid process of the axis would prevent its reaching the me- 
dulla. 
Below the second vertebra, wounds of this kind can no longer 
take place. All these bones, in fact, so overlap each other as to 
form a complete canal, the parietes of which present no open 
space for the transmission of foreign bodies. 
Be this as it may, it is proper to recollect that a wound of the 
medulla betw een the first vertebra and the os occipitis, woi Id 
leave untouched the roots of the par vagum, glosso-pharyngeal, 
and ninth pair; but that all the other nerves, the sub-occipital 
excepted, would be thus separated from the encephalon between OP THE THORACIC EXTREMITIES. 
217 
the first two vertebrae. Between the second and third, a portion 
of the cervical plexus would remain; between the third and 
fourth the whole of this plexus would escape, as well as the spinal 
accessory, one or two roots of which only would be destroyed. 
Between the fourth and fifth, the phrenic nerve would be saved, 
and the brachial plexus in part respected; lastly, more inferiorly, 
paralysis of the superior extremities will not necessarily ensue. 
The head is so balanced upon the summit of the spine that it 
represents a lever of the first order, the anterior arm of which 
would be longer than the posterior. Hence it follows that the 
head is disposed to preponderate anteriorly, and that the chin na- 
turally approximates the sternum during rest or sleep. 
During parturition, it is this unequal length of the moveable 
lever which the head of the child forms, that disposes this part 
always to advance first, when there are no particular obstacles to 
prevent it. In fact, in this case, the vertebral column, which 
represents the power, bears more towards the occiput than the 
chin ; consequently, when the lever is brought into play, this is the 
first part that must descend. During life, the anterior arm of the 
lever sometimes constitutes the power ; at other times, it is the 
posterior arm which represents it. In both cases, there are mus- 
cles applied upon the whole length of these arms, so that they may 
be lengthened or shortened, according to the demands of nature. 
Considered transversely, the head again represents a lever of 
the first order; but then the point of support is exactly in the mid- 
dle of its length. On the other hand, the lateral movements not 
existing in one articulation solely, but being executed at the 
expense of the whole at the same time, it becomes, in this res- 
pect, much less interesting than the former. 
CHAPTER III. 
OF THE THORACIC EXTREMITIES. 
In the thoracic extremities we will examine successively, 1st, 
the shoulder; 2d. the arm ; 3d. the elbow: 4th. the forearm ; 
5th. the wrist; 6th. the hand. 218 
OF THE THORACIC EXTREMITIES. 
AllT. I. OF THE SHOULDER. 
We divide the shoulder into an anterior, or thoraco-humeral 
region ; and a posterior, or scapulo-humeral region. 
Sect. 1. The Thoraco-humeral, Subclavian, or Axillary Region. 
The axillary, or anterior region of the shoulder, is the most im- 
portant of the superior extremity. It is bounded, superiorly, by 
the supra-clavicular region; interiorly, by the free margin of the 
pectoralis major; externally, by a line which would fall perpendi- 
cularly from the apex of the acromion upon the free extremity of 
the thumb, in the direction of the external border of the limb, 
which line we will call acromio-digital; and internally, by an- 
other line, drawn from the clavicle, one inch external to the sterno- 
clavicular articulation, in order to terminate upon the anterior and 
superior spinous process of the os coxal (ilium), and which we 
will call cl avi-coxal. 
The surface of this region presents, superiorly and externally, 
a spherical prominence which corresponds to the anterior part of 
the head of the humerus; on the inner side of this convexity, a 
broad and superficial groove which corresponds to the hollow of 
the axilla. This groove, more strongly marked in emaciated indi- 
viduals, increases in depth when the arm is approximated to the 
trunk, and presents several points worthy of consideration. 
Superiorly, we observe a triangular depression, by which we may 
easily penetrate into the articulation. If we apply the thumb 
upon this space, we will feel that it is limited, externally, by the 
head of the humerus; internally, by the coracoid process, and. 
superiorly, by the clavicle and acromion. It is at this point that 
MM. de Champesmes and Lisfranc have proposed introducing 
the knife for the purpose of amputating the arm at the joint. 
Below this groove we meet with the anterior margin of the 
axilla, a species of rounded arch, with its concavity directed 
downwards, when the arm is pendent; but straight and tense, 
when elevated; it is of considerable thickness in corpulent sub- 
jects ; very thin, and sometimes almost cutting, in those who are 
emaciated. 219 
OF THE THORACIC EXTREMITIES. 
Behind this border, we find an excavation, which is increased in 
depth as the arm is lowered, and becomes more superficial in pro- 
portion as it is raised. This excavation is triangular, with its 
base resting upon the thorax ; it is bounded posteriorly by another 
border similar to the preceding, which is formed by the anterior 
portions of the teres major and latissimus dorsi muscles: this is 
the posterior margin of the axilla. If we pass the fingers into the 
axilla, we may feel through the skin, when the subject is not very 
fat, the lymphatic glands, the head of the humerus, the nerves of 
the brachial plexus, and sometimes even the pulsations of the hu- 
meral artery. 
CONSTITUENT PARTS. 
i. The Skin. 
It does not possess the same characters throughout the whole 
extent of the region. At the anterior part of the shoulder it is 
thick and less extensible than befoi’e the axilla, where it is gener- 
ally deiicate and very supple. The fibrous tissue which en- 
ters into its composition is more compact in the first direction than 
in the second, and there also the sebaceous follicles are larger 
and more numerous. Inferiorly, in the cavity of the axilla, it is 
much more delicate still, very extensible, of a browner colour 
than elsewhere, covered with hhirs which never acquire a great 
length, which are more abundant in the male than in the female, 
and are not developed until after puberty. The skin in this situa- 
tion contains a great number of large follicles, which secrete the 
unctuous matter usually found in the axilla. This matter is more 
or less abundant in different subjects; sometimes it gives out a 
very strong odour, especially in persons of a fair and ruddy com- 
plexion. At other times, it is so corrosive that it injures the 
linen, and produces excoriation of the skin which it is intended to 
lubricate. 
ii. The Subcutaneous Layer. 
Fat, cellular tissue, vessels and nerves enter into the composi- 
tion of this layer. 220 
OF THE THORACIC EXTREMITIES. 
The adipose vesicles are very large, and may acquire a consid- 
erable developement; they are more abundant in the anterior 
than the inferior part of the region, and may form an extremely 
thick cushion. In proportion as they become filled, they separate 
the lamellae of the cellular tissue, which approximate, on the con- 
trary, when the cells become empty: whence it follows that in 
fat individuals the cellular tissue appears scattered, whilst in those 
who are thin it forms a distinct lamina of considerable strength. 
The cutaneous surface of this lamina is uneven and filamentous: 
it is this which supports the adipose vesicles; the other surface 
is lamellated, smooth, and does not adhere very firmly to the 
aponeurosis ; the vessels, especially the veins, ramify in the sheets 
of this deep surface; whence they are scarcely perceptible in 
fat individuals. In some persons, the subcutaneous veins occa- 
sion vergetures (stains), quite strongly marked upon the skin. It 
is also in this layer that the cephalic vein takes its course. In the 
cavity of the axilla, the cellular tissue is blended with the aponeu- 
rosis, and encloses several lymphatic glands in its areolae. 
iii. The Aponeurosis. 
We may consider it as originating from the arm. In fact, the 
fascia hrachialis, below the pectoralis major and latissimus dorsi, 
is distributed in the following manner: with regard to the pecto- 
ralis major, one layer passes before it, and thus ascends, under 
the form of a simple cellular sheet, upon its anterior surface, and 
over that of the deltoid muscle, in order to attach itself to the 
clavicle. This lamina also penetrates into the coiaco-clavicular 
triangle, and thereby reaches the fibrous capsule of the articula- 
tion ; it adheres firmly to the muscular fibres, and, as it is thin, it 
is not always easy to separate it from them. Externally, it may 
be readily distinguished from the subcutaneous layer. It is im- 
portant to make a distinction between those abscesses which form 
without this lamina and those which are situated beneath it: the for- 
mer have a constant tendency to point at the surface, and are not 
more dangerous than in the extremities ; the latter, on the contrary, 
are very liable to penetrate into the cavity of the axilla, if they are 
not there already, and in this case we know what a variety of 
accidents they may occasion. Another aponeurotic lamina glides OF THE THORACIC EXTREMITIES. 
221 
behind the pectoralis major muscle, lines its posterior surface, is 
thicker and stronger externally than internally, but soon becomes 
converted into cellular tissue. 
The same disposition exists in relation to the latissimus dorsi; 
except that the posterior sheet is the strongest, as we will find in 
the posterior region of the shoulder. The layer which passes 
before this muscle is also at first of considerable strength, but 
becomes thinner as it ascends, so that soon a simple lamella only 
remains which goes to the posterior surface of the pectorales, 
after having covered the free surfaces of the subscapularis and 
serratus magnus; which is at length interposed between all the 
muscles, its different laminae afterwards uniting together at the 
upper part of the cavity of the axilla, so as to form a more com- 
pact aponeurosis before the vessels, the brachial plexus, and the 
subclavius muscle. The cellular tissue, properly so called, seems 
to result from the unfolding of the aponeurosis, as it passes from 
one margin of the axilla to the other. It consists of an assem- 
blage of plates and filaments which are continued without inter- 
ruption as far as the scapulo-humeral articulation, with which it 
contracts the most intimate union. This cellular tissue is also 
prolonged behind the clavicle, into the supra-clavicular region, 
and likewise forms a communication between the axilla and the 
posterior region of the neck, by means of the space which exists 
between the trapezius, angularis and the second muscular stra- 
tum of this region. By this train we may explain the reason 
why the axillary region is, as it were, the common rendezvous of 
all the suppurations which take place in the spaces just indi- 
cated. 
iv. The Muscles. 
(a) The Pectoralis Major. This muscle is separated from 
the skin by the aponeurosis, superficial layer, some vessels and 
nerves: it lies successively, from above downwards, upon the 
subclavius muscle, from which it is removed by a fibrous lamina 
indicated above, and by a ccllulo-adipose cushion of greater or 
less thickness; upon the subclavian vein and artery, and upon 
the nerves of the brachial plexus, from which it is separated by 
venous, arterial and nervous branches of considerable magnitude, 222 
OF TIIE THORACIC EXTREMITIES. 
and especially by a very thick layer of cellular tissue ; upon the 
pectoralis minor, below which it again rests, but in a less direct 
manner, upon the axillary vessels and nerves. Its fibres con- 
verge from the clavicle and ribs upon the humerus ; so that it is 
possible to reach the vessels by simply separating the fleshy fas- 
ciculi without dividing them. This advice, which was first rec- 
ommended by Prof. Marjolin,* and in a vague manner by 
several surgeons, is nowr generally adopted when it becomes ne- 
cessary to tie the axillary artery. In order to follow it, it is suf- 
ficient to make an oblique division of the skin, superficial layer, 
and aponeurosis of the internal boundary of the region, begin- 
ning the incision at the clavicle and extending it to just below the 
coracoid process, that is to say, parallel to the direction of the 
fleshy fibres. This process is undoubtedly preferable to that 
which consists in making a semilunar flap of the integuments 
upon the fore part of the clavicle,f and still more so than that of 
cutting across the tendon of the pectoralis major. J In the latter 
case, in fact, even admitting its success, we see that the drawing 
down of the arm and full inspirations wTould be liable to be great- 
ly impeded. By its insertion into the anterior lip of the bicipital 
sheath, the pectoralis major muscle there constitutes a solid bar- 
rier which prevents the long head of the biceps from escaping 
before the gutter in which it is lodged. There is a groove of 
greater or less depth, commencing from this insertion, w hich sep- 
arates it from the deltoid ; this groove, which we might call cora- 
co-deltoidal, is broader above than belowT; it is filled by adipose 
cellular tissue, the cephalic vein, and the descending branch of 
the acromial artery ; it is also traversed, quite near the clavicle, 
by the transverse branch of this artery; finally, the coracoid pro- 
cess is usually found deeply seated in its superior portion. 
(b ) The Pectoralis Minor. Extended from the coracoid 
process upon the external surface of the second, third, fourth, 
and sometimes fifth ribs, it crosses almost at a right angle 
the posterior face of the pectoralis major, being separated from 
it by a cellular-adipose layer of considerable thickness, in which 
some vessels of a certain magnitude are imbedded. Its poste 
* Dictionnaire de Medicine, article Anevrisme, etc 
f Hodgson, Diseases of the Arteries, etc. 
| M. Roux, Medicine Opcratoire, &c. OF THE THORACIC EXTREMITIES. 
223 
l ior surface crosses the axillary vessels and nerves in such a man- 
ner, that we may reach these vessels, both above and below this 
muscle without dividing it. Its superior margin forms the base of 
a very important triangle, which we call clavi-pectoral. The other 
sides of this space are represented by the anterior part of the clavi- 
cle, on the one hand, and by the upper part of the clavi-coxal Yme, 
on the other. The first of these margins measures, in a subject of 
the middle stature, the arm being slightly extended, five inches; 
the length of the second, beginning at the internal border of the 
coracoid process, three inches and a half; and the last, which ex- 
tends upon the third rib, three inches only. In this space we 
observe, from the chest towards the arm, some lax cellular tissue, 
the axillary anterior thoracics and cephalic veins, the axillary 
and acromial arteries, the nerves of the brachial plexus and the 
anterior thoracic nerves; superiorly, the subclavius muscle. It 
is in this triangle that the artery may be most readily tied, and we 
may reach it by tracing the superior border of the pectoralis mi* 
nor. We will recur to this again. 
Below this muscle, the pectoralis major conceals another trian- 
gle, which is larger than the preceding, but its inferior side does 
not, strictly speaking, exist, since it would be formed by the ante- 
rior margin of the axilla. It would consequently extend from the 
humerus to the sixth rib, and its length would be about five inch- 
es. Its external border is formed by the humerus, and is three 
inches and a half long; its superior side is three inches, and is 
represented by the pectoralis minor. We will call it sub pec- 
toral. 
In this triangle we observe a great abundance of cellular tissue, 
and from within outwards, lymphatic glands, the basilic and axil- 
lary veins, the axillary artery enveloped by the nerves, a portion 
of the coraco-brachialis muscle, the tendons of the latissimus 
dorsi and teres major, finally, a portion of the biceps. In this 
situation the vessels and nerves run nearer the arm, whereas in 
the clavi-pectoral triangle they lie nearer the thorax. 
(c) The Deltoid. A little less than the anterior third of this 
muscle appertains to this region. It forms the fore part of the 
shoulder and the prominence noticed when speaking of the sur- 
face : it there forms a species of concavity in which the anterior 
part of the articulation is encased. It is separated from the pec- 224 
OF THE THORACIC EXTREMITIES. 
toralis major by the coraco-delioidal groove. Its fibres descend 
almost perpendicularly; which should be recollected when we 
wish to make deep incisions in this part of the region. This por- 
tion of the deltoid forms a triangle, which, when removed, expos- 
es a similar space, in which we see the tendon of the pecioraiis 
major, surmounted by a fibrous prolongation which is continuous 
with the scapulo-humeral capsule, and receives below the brach- 
ial aponeurosis; under this tendon, the bicipital sheath, and the 
tendon which it encloses; anteriorly, the anterior part of the hu- 
merus, the two branches of the anterior circumflex artery ; more 
superiorly, the two tubercles of the os humeri, and the tendons 
which are inserted into them; still higher, another small triangle* 
formed anteriorly by the coraco-acromial ligament; posteriorly 
by the external fourth of the clavicle and the apex of the acromi- 
on ; internally, by the coraco-deltoidal line or by the coracoid pro- 
cess. It is at this last space that MM. Champesmes and Lisfranc 
recommend the knife to be introduced in order to amputate the 
arm at the articulation. 
(d) The Subclavius. The superior face of this muscle was 
treated of in the supra-clavicular region; at present we have to 
examine its anterior portion only. It advances more or less into 
the axilla, according to the degree of depression or elevation of 
the shoulder, and is covered by a fibrous lamina, to which it gives 
origin, or is united. This lamina, which was noticed when speak- 
ing of the aponeurosis and cellular tissue, is attached to the ante- 
rior part of the clavicle, to the coracoid process, is continuous with 
the coraco-humeral ligament, and through it to the brachial apon- 
eurosis. It descends upon the fore part of the axillary vein, 
upon which it seems to be counfounded, and is continuous with 
the cellular sheath of the vessel. It is also prolonged upon the 
artery and the nervous bundle of the brachial plexus, but is soon 
lost in the cellular tissue of the axilla. This aponeurosis is of 
considerable strength in some individuals, especially before the 
vein, and is one of the laminae which perplex us most when we 
wish to isolate the axillary artery in order to apply a ligature 
around it. 
(e ) The Coraco-Brachialis and the short portion of the biceps 
originate in common from the coracoid process but soon sepa- 
* Coraco-acromien. OF THE THORACIC EXTREMITIES. 
225 
rate, so that the biceps passes before the tendon of the latissimus 
dorsi, whilst the coraco-brachialis descends obliquely backwards 
and outwards. 
(f) The Subscapular is. The anterior surface of the teres 
major and of the anterior border of the latissimus dorsi, here form 
the posterior paries of the arm-pit. Between the teres major and 
subscapularis there is a space, which enlarges as it approximates 
the humerus. This space is converted into an aperture almost 
qua trilateral, which is circumscribed above by the anterior border 
of the scapula and the subscapularis, by the teres major below, 
posteriorly by the long head of the triceps, and anteriorly by the 
neck of the humerus. This opening is filled by cellular tissue, 
and through it the axillary artery and nerves pass. 
(g) Lastly, the serratus major anticus, which attaches the 
shoulder to the chest, and seems to unite the spinal border of the 
scapula to the posterior surface of the pectoralis major. It con- 
ceals the intercostals, and forms the internal paries of the axillary 
cavity. 
It may now be readily perceived that all these muscles sur- 
round a triangular pyramidal cavity, the base of which is inferior 
and formed solely by the aponeurosis and skin, and its apex, fill- 
ed with cellular tissue merely, situated in the posterior part of 
the supra-clavicular region. Its anterior paries comprises the pec- 
toralis minor, the clavi pectoral and sub-pectoral triangles, and is 
formed principally by the pectoralis major. Besides the subscap- 
ularis, teres major and latissimus dorsi, the posterior paries also 
includes, in part, the anterior surface of the coraco-brachialis. 
The serratus major anticus constitutes almost the whole of the 
internal wall, which is completed by the intercostal muscles and 
ribs. 
The internal and posterior parietes unite, forming an angle 
somewhat acute, upon the posterior margin of the scapula. As 
this angle is completely closed, pus cannot infiltrate from the ax- 
illa into the dorsal region without perforating the serratus major. 
The angle which results from the union of the internal and ante- 
rior parietes is still more acute ; it is prolonged upon the anterior 
part of the thorax, and affords but a feeble opposition to the infil- 
tration of pus or other morbid fluids in this direction. The ex- 
ternal angle is truncated superiorly; it includes a portion of the 226 
OF THE THORACIC EXTREMITIES. 
coraco-brachialis, the humerus and the internal part of the sca- 
pulo-humeral articulation. It is the anatomical disposition of 
this side which permits us to compress the axillary artery in this 
angle. 
v. The Arteries. 
(a) The Axillary is the principal trunk of this region, and 
gives origin to all the branches contained in it This artery is 
the continuation of the subclavian ; it obtains the name of axillary 
from the clavicle as far as the posterior margin of the axilla, that 
is to say, of the latissimus dorsi. Its direction is oblique from 
above downwards, and from within outwards. It becomes small- 
er and smaller as it descends, which is owing to the branches 
given off by it. Superiorly, it is situated nearer to the thorax ; 
inferiorly, on the contrary, nearer to the arm ; whence it follows 
that wounds penetrating the cavity of the axilla will be less lia- 
ble to injure the artery if they approximate the chest; whereas 
if an instrument should penetrate the upper part of this region, 
from before backwards, the nearer it approximates the arm the 
less would be the risk of wounding this vessel. 
The general relations of the axillary artery are the following : 
internally and anteriorly, are found the vein and its principal 
branches, some lymphatic glands, and cellular tissue, the serratus 
magnus, aponeurosis and the skin ; externally and anteriorlv, the 
nerves, subscapularis muscle, tendon of the latissimus dorsi, the 
articulation and the humerus; anteriorly, the artery is covered 
by the nerves, veins, lymphatic glands, fibro-cellular layers, the 
subclavius, pectorales and coraco-brachialis muscles, and the in- 
teguments ; posteriorly, we see some nervous branches, much 
cellular tissue, the subscapularis, teres major and latissimus dorsi 
muscles. But, in order that we may render these relations sus- 
ceptible of practical applications, we will adopt Dr. Harrison’s 
plan of dividing the axillary artery into three portions.* 
(b) In the first portion, which extends to the superior margin 
of the pectoralis minor, the great axillary vein is on the inner 
side of the artery, and upon a plane which is anterior to it: so 
* Surgical Anatomy of the arteries, Vol. I, page 157. OP THE THORACIC EXTREMITIES. 
227 
that it usually covers it so much, upon the living subject, that it is 
indispensable to draw it still more internally when we wish to tie 
this artery. Behind the vein, the axillary artery rests in the first 
place upon the first intercostal muscle, the second rib, and after- 
wards upon the cellular tissue which covers the first portion of 
the serratus major anticus. 
On its acromial side runs the inferior branch of the brachial 
plexus, which inclines more and more before it. All the other 
nerves remain more posteriorly and external to it. Still more 
externally we observe the cellular tissue of the summit of the 
axilla, then the coracoid vault. 
Posteriorly, it rests, as it comes out from the supra-clavicular 
region, upon the first rib, a little upon the second, after which its 
its posterior surface is free in the cellular tissue and is situated 
before the nerves. 
Finally, considered anteriorly, this portion of the axillary is 
included between the vein of this name and the nervous cord 
resulting from the union of the first dorsal with the seventh cer- 
vical, so that at its most inferior part it is concealed by these two 
organs, whereas we sometimes see it pretty distinctly, in its 
superior portion, without separating them. The subclavius mus- 
cle, in crossing it, descends upon it for about the space of half an 
inch below the clavicle. A little lower, it is usually surmounted 
very obliquely by an anterior thoracic nerve which passes between 
the two pectorales, and which might easily be wounded or com- 
prised in the thread which we place upon the artery. Anterior 
to these parts there are some dense cellular laminae, and especial- 
ly the fibrous sheet which passes from the coracoid process to 
the clavicle and upon the cartilage of the first rib, a sheet which 
we will call the coraco-clavicular aponeurosis. This lamina, 
which, as we have already noticed, is continuous with the apo- 
neurosis of the arm by means of the cellular tissue of the axillary 
cavity, sometimes presents upon the fore part of the vessels a 
kind of semilunar border, the concavity of which looks down- 
wards and inwards. Next to this fibrous sheet, the axillary artery 
is separated from the skin by an adipo-cellular layer of more or 
less thickness, by the pectoralis major, the aponeurosis which 
covers it, and the subcutaneous texture. It here divides the 
clavi-pectoral triangle into two nearly equal parts, and its direction 228 
OF Tim TTlOltACIC EXTKEMITIKS. 
follows tliut of the coraco-delloidal groove, so that by cutting upon 
this groove we fall upon the artery, or on the outer side of it. 
In order to tie this vessel in the space just mentioned, the inci- 
sion, which was directed when speaking of the pectoralis major 
muscle, being made, and the limb being approximated to the trunk, 
in order to relax the fleshy fibres, we should separate the lips of the 
wound. Then the cellulo-adipose layer, enclosing several arterial, 
venous and nervous branches, presents itself; which should be 
divided with the greatest caution. This layer being iaid open, 
we see the superior margin of the pectoralis minor, which may 
easily be drawn down ; afterwards the prolongation of the coraco- 
clavicular aponeurosis is met with, which, if cellular merely, may 
be torn with the grooved director, but, if stronger, we should first 
pierce it with the bistoury and afterwards enlarge it upon the 
director. This being done, all that is required is to isolate the 
artery and pass the thread around it. In order to accomplish 
this, we must tear the species of sheath which envelopes the 
bundle of axillary vessels and nerves. As the artery is situated 
between and behind the vein and the first nerve which we see in 
this space in proceeding from the thorax towards the shoulder, 
we will always seize it without great difficulty, if we take the 
precaution to enter the aneurismal needle upon the external side 
of the vein, and push this vessel towards the internal side of the 
region. 
The ligature should not be placed too near the subclavius 
muscle, on account of the thoracic nerve and cephalic vein which 
cross the artery at this point; neither should it be applied too near 
the pectoralis minor, because there we generally find the origin 
of the acromial and anterior thoracic arteries, etc. 
( c) The second portion of the axillary artery is concealed 
by the pectoralis minor; the nerves, all of which were situated 
at its external, anterior and posterior sides, send before and behind 
two cords which cross it very obliquely, in order to reunite upon 
its internal part, where they form the median. In this manner 
the axillary plexus constitutes a kind of sheath for the artery, and 
the vein is no longer in immediate contact with it; and it is 
besides more approximated to the arm than the chest. Anteriorly 
and externally it corresponds to the biceps and pectorales ; poste- 
teriorly, to the subscapularis. and internally, but remotely, to the OF THE THORACIC EXTREMITIES. 
229 
serratus major. We should never attempt to apply a ligature 
upon this portion of the vessel; the relations which have just 
been pointed out are sufficient to shew us the dangers which 
would result from such an operation. If we wished to compress 
it here, the pressure should be directed against the head of the 
humerus; but this will scarcely be possible except in thin sub- 
jects ; and if it was absolutely necessary to suspend the circulation 
in the limb, it would be better to establish the compression behind 
the clavicle; we might also apply the compressive means ante- 
rior to this bone, through the pectoralis major muscle, upon the 
second rib. The latter method, however, is difficult and uncer- 
tain. 
( d ) Lastly, the third portion is seen in the subpectoral trian- 
gle. In passing through this space, the artery has, upon its radial 
side, one root of the median, and the musculo-cutaneus {perforans 
Casserii); upon its cubital side, are seen the posterior root of the 
median, the internal cutaneus and the ulnar; externally and 
posteriorly the radial and the axillary or circumflex. The axillary 
vein bears the same relations to the artery here as it does to its 
middle portion, which is covered by the pectoralis major. This 
vessel rests, posteriorly, upon the tendon of the subscapularis and 
and latissimus dorsi; externally, it is applied against the humerus, 
where we may compress it pretty readily. The aponeurosis, 
ellujar tissue and integuments ascend so as to cover this artery, 
internally, in emaciated persons. In this third of its length, the 
axillary artery may be tied in two different manners; in the first 
place, by making an incision parallel to its direction, between the 
two borders of the arm-pit; and in the second, by cutting upon 
the fore part of the pectoralis major, perpendicular to the direction 
of this muscle, which should be cut across in order to expose this 
artery. In either case, we must expect to find a sheath of con- 
siderable strength, which envelopes, at the same time, the artery, 
vein and nerves. This sheath being laid open, it is very easy to 
separate these different organs from one another, and pass a 
thread around the vessel. 
The branches given off from the axillary artery are: the acro- 
mial, anterior thoracics, external mammary (thoracica longior), 
the subscapularis and circumflex-!. 230 
OF TIIE THORACIC EXTREMITIES. 
( a ) The acromial. This branch, in some subjects, separates 
from the trunk pretty near the subclavius muscle, but more fre- 
quently immediately above the pectoralis minor; for which rea- 
son it is generally preferable to apply the ligature nearer the 
clavicle. Sometimes this branch gives off the anterior thoracics ; 
in which case it is much larger at its origin. The acromial 
portion then passes directly before the pectoralis minor, in order 
to bifurcate behind the cephalic vein, under the apex of the cora- 
coid process: one of the branches of this bifurcation passes upon 
the dorsal surface of the osseous eminence, and goes to lose it- 
self in the deltoid. This branch, which is sometimes as large as 
a crow quill, is necessarily divided in the amputation of the arm 
at the joint, according to the method of MM. Champesmes and 
Lisfranc. 
The other branch runs in the coraco-deltoid groove, is at first 
on the inner side of the cephalic vein, afterwards passes under 
it, then on its external side, and finally anterior to it: which must 
be borne in mind, if we should fix upon this place for vene- 
section. 
(b) The anterior thoracics originate, the superior, in the clavi- 
pectoral triangle, and sometimes even from the acromial; the 
inferior, from the middle portion of the axillary, under the pec- 
toralis minor muscle; their branches are chiefly distributed to 
the pectorales muscles, and intersect each other, in divers man- 
ners, in the cellular layers which separate them ; so that they are 
frequently much in the way in the ligature of the axillary artery. 
(c) The Mammaria externa originates opposite to the infe- 
rior margin of the pectoralis minor and descends upon the side 
of the thorax, between the serratus anticus and pectoralis major, 
to lose itself in the integuments. It is this which we open most 
frequently when we are seeking for some tumour in the axillary 
cavity, as scirrhous glands, for example, which are generally situ- 
ted more anteriorly than posteriorly. It also gives off some other 
branches externally, which ramify in the latissimus dorsi and 
teres major. 
( d ) The Scapularis Communis, or Subscapularis, is found on a 
level with the anterior margin of the subscapularis muscle: it 
descends behind the nerves before the costa of the scapula, and OF THE THORACIC EXTREMITIES, 
231 
soon bifurcates. It is the largest branch given oft' by the axillary, 
and for this reason, we should tie the latter artery above or con- 
siderably below it. 
The anterior branch of the sub scapular is, smaller than the 
posterior, continues the primitive direction of the trunk, and rami- 
fies in the muscles of the posterior border of the region; the 
posterior, or dorsalis scapulae, curves over the anterior margin 
of this bone, in order to pass into the posterior region of the 
shoulder, where we will see it again, as well as the preceding. 
( e ) The Arteries Circumflexes frequently arise by a single trunk, 
very near the subscapularis, from which they are sometimes 
derived. In either case, the posterior circumflex artery passes 
immediately behind the shoulder, through the quadrangular open- 
ing which the posterior paries of the axilla presents, under the 
head of the humerus. 
The anterior, smaller than the other, is situated behind the 
musculo-cutaneus nerve, the coraco-brachialis, biceps and deltoid 
muscles. It is applied upon the bone, and divides at the bicipital 
groove. With the posterior, it forms an arterial circle around 
the neck of the humerus, a circle which may be lacerated in 
fractures of this neck; whence result those extensive ecchymoses 
which occasionally manifest themselves in consequence of these 
wounds. 
The origin, volume, number, and distribution of all these branch- 
es, are susceptible of infinite varieties. The trunk of the axillary 
also presents many anomalies. We have sometimes seen it 
divided into two branches, and, in this case, one of the branches 
is posterior, larger, and gives oft’ the brachial, properly so called ; 
the other is anterior, smaller, and seems to be formed by the radial 
prolonged as far as the axilla. W"e have seen this division con- 
tinued even under the subclavius muscle. 
vi. The Veins. 
The Axillaxy Vein, may be divided like the artery, into three 
portions: its superior portion is very large and is situated, inter- 
nally, upon the border of the first rib, the first intercostal muscle, 
the second rib, and the superior point of the serratus major anti- 
cus; externally and posteriorly, upon the axillary artery, to which 232 
OF THE THORACIC EXTREMITIES. 
it adheres by pretty compact cellular lamelae; anteriorly, it re- 
ceives a process from the coraco-clavicular aponeurosis which 
strengthens its external tunic; it is afterwards crossed by the an- 
terior thoracic nerve and arteries, then it is covered by the cel- 
lulo-adipose sub-muscular layer, etc. The dilatation of the veins, 
which takes place during expiration, causes this portion of the 
axillary vein to conceal the artery entirely. As this dilatation is 
one of the principal obstacles to placing a ligature around the ar- 
tery, it would perhaps be advantageous, in performing this opera- 
tion, to adopt the plan proposed by Mr. Lizars, that is to say, to 
suspend the venous circulation below the axilla by the compres- 
sion of the extremity. 
Behind the pectoralis minor, the axillary vein is crossed by the 
branches of the inferior thoracic artery, and it is separated from 
the internal surface of the artery by the two roots of the median 
nerve. 
In its inferior portion, it is still on the inner side of the artery, 
but it is situated more anteriorly, and the median, internal cuta- 
neus, and ulnar nerves separate these two vessels. Anteriorly it 
is crossed by the external mammary artery, the two nervous 
branches which pass from the second and third intercostals to the 
hollow of the axilla, and some other filaments ; consequently, the 
whole of the brachial plexus is situated behind and external to it. 
It is generally in the sub-pectoral triangle that it receives the 
basilic vein, which sometimes equals it in size, and the collateral 
veins of the subscapulary, circumflex, and, sometimes, external 
mammary arteries. The latter and the basilic into it upon 
its internal and anterior part; the others, on the contrary, into its 
external and posterior portion, and their trunks are seen in the 
interval of the nerves of the brachial plexus. 
Hence it follows that the veins form in this situation a very 
complicated plexus, which produces much embarrassment when 
we attempt to isolate the artery. 
In some subjects, these different venous branches remain dis- 
tinct even under the pectoralis minor ; but this is rare, for gener- 
ally the external mammary and inferior thoracic veins open into 
each other under this muscle. In the superior third the axillary 
vein receives an uncertain number of small venous twigs ; but OF TIIE THORACIC EXTREMITIES. 
233 
uniformly the superior thoracic and the acromial are there emptied 
into it. 
The cephalic vein also enters the subclavian, and from its sur- 
gical importance it requires minute investigation : it is moreover 
the only superficial branch which deserves our attention here- 
It is lodged in the groove which separates the deltoid and pecto- 
ralis major, and is more or less deeply situated in proportion to 
the degree of separation of these two muscles. When the groove 
is but slight, the vein is very superficial; but when it extends to 
the bone, the vein is deeply seated. In the middle of this groove 
the cephalic vein is enveloped by cellular lamellae and adipose vesi- 
cles. In making its way under the clavicle, it passes along the inner 
side of the coracoid process, before the origin of the biceps and 
coraco-brachialis muscles and the insertion of the pectoralis minor ; 
it crosses the nerves of the brachial plexus and axillary artery ob- 
liquely, and falls into the vein upon its external and anterior side, 
quite near to the subclavius muscle. In this track, this vessel 
crosses the acromial artery in such a manner that the latter 
forms a semi-spiral turn upon the vein, as it is passing behind it. 
From what has preceded, it follows that the cephalic vein is, 
all other things being equal, more superficial the nearer it approx- 
imates to the deltoidal groove; that it is always separated from 
the skin by an adipose layer which varies much in thickness, and 
that an artery of considerable volume runs by the side of it. Con- 
sequently, if we wished to open it in venesection, it would be 
preferable to do it rather below than high up. We cannot say 
that a similar operation would be dangerous ; but it appears to us 
so serious, that it is doubtful whether it should be frequently per- 
formed when bleeding presents difficulties at the bend of the 
elbow. 
vn. The Lymphatics. 
They are veiy numerous in this region: all the lymphatics of 
the superior extremity, those of the exterior of the thorax, and a 
part also of those of the posterior portion of the neck enter into 
it. We find in it a considerable number of lymphatic glands, 
some of which form a species of chain around the vessels, whilst 
the others are distributed into two series. The one constitutes 234 
or THIS THORACIC EXTREMITIES. 
an anterior plane situated between the anterior paries of the 
axilla and the vascular and nervous plexus. The other, or pos- 
terior plane is placed between the same plexus and the posterior 
paries of the axilla. These glands occupy, still more especially, 
the space which separates the vessels and nerves from the serra- 
tus magnus, and this circumstance is very advantageous to the 
surgeon ; for, when the extirpation of these organs becomes ne- 
cessary, by recollecting this anatomical disposition, we would not 
be so readily stopped by the depth of their situation. There is 
also a very simple method of ascertaining whether it is prudent to 
attempt their removal; it consists in raising the arm from the 
trunk: if, in this position, the tumours remain applied upon the 
thorax, or, simply, if they do not follow the limb in its movements, 
it is certain that they have no intimate relation with the vessels 
and nerves. 
We know with what facility these glands become engorged and 
swollen in diseases of the breast in females, of the whole chest in 
both sexes, and especially in those of the superior extremity. 
This sympathetic enlargement frequently leads us to detect an 
affection in parts where we would scarcely suspect it. It is in 
virulent inflammations and suppurations particularly that the 
axillary glands tumefy with great rapidity; it is on such occa- 
sions also that the suppuration sometimes invades, with an alarm- 
ing celerity, the lax and abundant cellular tissue which surrounds 
them : hence those enormous abscesses which are propagated so 
speedily into the circumjacent regions, through the medium of the 
cellular prolongations. When swollen, these glands very fre- 
quently produce infiltration of the limb : is this merely owing to 
the obstruction which the lymph meets with in its course to the 
organs destined to receive it ? Is it an effect of the compression 
of the bloodvessels, the veins, for example ? The first cause ap- 
pears to us to be the most frequent; the second, however, is not 
very rare. 
It is necessary to remark, that in the cavity of the axilla there 
is every condition reunited that can favour the production of 
inflammation within it, and the rapid termination of this inflam- 
mation in an abundant purulent secretion: thus, the vascular 
and thin skin, constantly sliding over the tissues which it covers; 
a very abundant, supple, and extensible cellular texture, filled OF THE THORACIC EXTREMITIES. 
235 
with vessels; nervous filaments in great numbers ; an almost 
constant stretching of these parts, from the natural motions of 
the limb, &c. 
It is also in consequence of these conditions that leeches ap- 
plied to the arm-pit usually produce in it extensive ecchymoses. 
viii. The Nerves. 
Almost all of them are derived from the brachial plexus. The 
greater part of this plexus is found in this region: in the clavi- 
pectoral triangle its cords are collected in a bundle behind and on 
the outer side of the artery; free under the clavicle and towards 
the summit of the axilla, where it lies upon the cellular tissue, it 
corresponds, anteriorly, to the coraco-deltoidal groove, and is con- 
sequently only separated from the skin by fat, cellular texture, 
and the transverse branch of the acromial artery, the cephalic 
vein lying more internally. It does not follow from these rela- 
tions that this plexus is not very deeply seated; but they admit 
of its being reached without dividing the muscles. For ex- 
ample : a pointed instrument, thrust perpendicularly to the axis 
of the trunk, upon the internal border of the coracoid process, in 
the retiring angle (angle rentrant) which exists between the 
clavicle and this eminence, will fall directly upon the nerves, and 
will scarcely expose the artery. 
It is in passing under the pectoralis minor that this plexus un- 
ravels itself: it is then that it detaches two branches which pass 
below and before the axillary artery and place themselves be- 
tween this vessel and the vein of the same name, in order to 
form the median nerve. Below this muscle, that is to say, in the 
sub-pectorcd space, all the nerves of the arm are usually isolated. 
(a) The Median Nerve remains on the inner side of the 
artery, and sometimes is found before it when it enters into the 
brachial region ; so that if we attempted to tie the arterial trunk 
in this part of the axilla, it would be more easy to draw this nerve 
backwards, near the pectoralis minor muscle; and, on the con- 
trary, to pull it forwards, if we operated near, the anterior border 
of the region. The vein or veins lie upon its inner side. 
( b ) The Musculo- Cutaneus, which is continuous with the 
anterior root of the median, removes from the vessels and gains 236 
OF THE THORACIC EXTREMITIES. 
the posterior surface of the coraco-brachialis muscle, which it 
traverses. Its relations with the artery, therefore, are very 
remote. 
( c ) The Circumflex separates from the posterior part of the 
plexus, a little higher than the inferior border of the subscapu- 
laris muscle, over which it turns in order to pass under the cervix 
humeri through the sub-scapulo-humeral aperture. The relations 
of this nerve with the bone are such, that, in fractures of its neck, 
it may be lacerated and occasion severe symptoms. In luxa- 
tions downwards, also, it is almost necessarily compressed by the 
head of the humerus. 
( d ) The radial or musculo-spiral is detached on a level with 
the circumflex, and frequently these two cords lorm at first only 
a single trunk. Situated completely behind the plexus, it turns, 
as it descends, upon the inner surface of the humerus, and enters 
between the internal and posterior portions of the triceps. It 
may likewise be stretched, or lacerated, in fractures, and com- 
pressed in luxations inwards. It has no immediate relations 
with the artery. 
( e ) Internally and anteriorly, we see the Internal Cutancus, 
which is placed between the vein and artery, and is sometimes 
so large that some persons have mistaken it for the median, when 
seeking for the axillary artery. 
(f ) The Cubital (Ulnar) is more internal and posterior: it is 
also covered by the veins. Its volume is equal to that of the 
median, from which wTe distinguish it by its position, and because 
in removing from its origin it also removes from the artery, in- 
clining backwards. 
Such is the arrangement of the six brachial branches of the 
axillary plexus ; but this plexus gives oft' in the axilla some other 
nerves, which we are now going to point out: these are the ante- 
rior thoracic and subscapulary branches. 
( g ) The Thoracic Nerves vary in number, but there are two 
m particular which we shall mention. 
The first originates from the fore-part of the plexus, in the 
summit of the clavi-pectoral space, and runs obliquely forwards, 
dowmwards, and inwards: it gives several filaments to the cellulo- 
adipose layer, and terminates by a small number of ramuscules 
in the pectoralis major muscle. Near its root, it passes over the OF THE THORACIC EXTREMITIES. 
237 
axillary vessels; so that it may interfere with the ligature of the 
artery, and, in order to avoid it, it should be pushed upwards and 
towards the sternum. It is, moreover, between this nerve and 
the acromial artery that the thread should be applied around the 
axillary artery. Near its origin it is also crossed, in its turn, by 
the termination of the cephalic vein. 
The second branch arises a little lower down and runs behind 
the artery, then between it and the vein, in order to pass under 
the inferior margin of the pectoralis minor, and is lost in the 
posterior surface of the pectoralis major. As it passes round the 
arterial trunk, this nerve is sometimes so adherent to it that it is 
pretty difficult to separate them. It is of importance to recollect 
this circumstance when about to tie this vessel. 
( h ) The Subscapulary nerves vary still more in number than 
the thoracics. They all pass backwards in the cellular tissue, 
and terminate in the muscle which bears their name. They may 
be compressed, like all the others, in luxations inwards, or by 
tumours which form in the cavity of the axilla. 
( i ) Posteriorly and internally, we observe the posterior tho- 
racic nerve, which comes from the supra-clavicular region. This 
cord rests upon the axillary aspect of the serratus major anticus, 
to which it is distributed. It is important to recollect its rela- 
tions, in order that we may avoid it in operating in the hollow of 
the axilla ; for, if the function of this nerve should be 
it might very seriously disturb the mechanical phenomena of 
respiration, since it is the only one which is distributed to the 
serratus magnus. It is for this reason that Mr. C. Bell has called 
it the inferior external respiratory nerve. Reasoning would lead 
us to infer that the posterior border of the shoulder would then 
be more prominent backwards and upwards, and that the scapula 
would no longer be immediately applied upon the side of the 
thorax. We have seen a man of twenty-six years of age, strong 
and of a good constitution, who was in this state for six months. 
He had fallen and struck the cavity of the axilla against the 
angle of a bureau. The phenomena which have just been men- 
tioned appeared to us to depend upon a paralysis of the serratus 
magnus. This young gentleman recovered under the repeated 
application of blisters around the shoulder and thorax. 
(j) The Intercostal Twigs of the axilla, coming out from the 238 
OF THE THORACIC EXTREMITIES. 
thorax, are placed upon the second and third ribs, before the 
corresponding digitations of the serratus magnus, and ramify in 
the cellular tissue, in the lymphatic glands, around the vena 
basilica and in the skin. These are the filaments most frequent- 
ly wounded in extirpating glands which have become scirrhous 
in consequence of cancer in the breast: it is perhaps these nerves 
also which occasion the sensation of anguish, constriction, and the 
distressing suspirations with which patients are afflicted in these 
affections. 
ix. The Skeleton. 
The Skeleton of the Sub-Clavicular Region is composed of the 
anterior and internal half of the bead of the humerus, and of the cor- 
responding surfaces of this bone ; of a part of the clavicle, and of 
the four ribs which follow the first; of the coracoid process and of 
a part of the acromion, and of the scapulo-humeral articulation. 
( a ) The Humerus here presents the bicipital groove which 
receives upon its anterior labium the tendon of the pectoralis 
major, and upon the posterior, those of the latissimus dorsi and 
teres major. It is important to mark these insertions, both on 
account of fractures and luxations. For, if the fracture exists 
lower down, yet above the insertion of the deltoid, the superior 
fragment will necessarily be drawn near the trunk by the action 
of these muscles : if, on the contrary, it takes place above them, 
the superior fragment will be free on this side, whilst the inferior, 
in its turn, will be drawn towards the chest. In luxations, if the 
displacement occurs whilst the inferior extremity of the humerus 
is fixed upon the ground, during a fall, or upon any solid body 
whatsoever, let the cause be direct or indirect, it is evident that 
the muscles just mentioned will act upon the os brachii as on a 
lever of the third order. Hence, as the power in this case is 
very near the moveable point, we conceive that the head of the 
humerus will be drawn forcibly inwards. 
The bicipital groove becomes deeper and deeper as it ascends, 
and when it passes between the two tubercles of the head of the 
humerus, it is converted into a complete canal by the articular 
capsule ; this disposition is perfectly in relation with the usages 
of the biceps muscle: by this mechanism, it is impossible for the OF THE THOUA.CIC EXTREMITIES, 
239 
tendon of this muscle to escape from the sinus in which it is 
lodged, during the rotatory movements of the arm, and its con- 
tractions are in no measure impeded, let the position of the limb 
be what it may. 
Anterior to this groove, the aspect of the humerus is rounded ; 
the deltoid muscle covers, but does not adhere to it; it is sepa- 
rated from it by a lamellated cellular tissue; two thirds of the 
greater tuberosity (trochiter) are placed under it, into which the 
tendons of the supra and infra-spinati muscles are inserted. 
Posteriorly, we observe the insertion of the coraco-brachialis 
muscle, which, in fractures of the neck of the bone, will act 
upon the lower fragment in the same direction as the pectoralis 
major muscle, etc., likewise tending to draw it forwards and 
upwards: the lesser tuberosity of the os brachii (trockin), upon 
which the tendon of the sub-scapularis muscle is fixed, represents 
tolerably well the powerful extremity of a lever of the first order. 
Below these tuberosities, between them and the body of the 
bone, is the surgical neck. This neck is smooth and round, and 
does not present any muscular impression; which renders it 
more susceptible of fractures. These fractures are accompanied 
with peculiar dangers, and present special indications : 1st. dan- 
gers,—because the circle which is here formed by the circumflex 
vessels may be lacerated, and it is doubtless to the laceration of 
the vein in particular, that we must attribute those extensive 
ecchymoses which sometimes follow fractures of this nature ;— 
because the nerve of the same name may also be stretched, or 
lacerated ; which might paralyze the deltoid, in the first place, and 
afterwards give rise to very severe nervous symptoms; and 
finally, because the inferior fragment, almost always drawn in- 
wards and upwards, may compress, stretch or tear the nerves 
and vessels of the axilla. 2d.—The indications which present 
themselves arise, first, in consequence of these accidents, after- 
wards because the apparatus can scarcely act but on the inferior 
fragment of the bone; for which reason the ordinary bandages 
for fractures of the humerus, in general, those of Ledran and 
Desault for its neck, and many others, are almost useless, whilst 
it is sufficient, in order to accomplish the proposed object, to 
place a pad of moderate thickness between the arm and chest, 
and keep the limb approximated to the trunk in any manner what- 240 
or THE THORACIC EXTREMITIES. 
soever; indeed, we might do without the pad. We have seen 
this very simple means uniformly successfully employed by M. 
Richerand at the Hospital Saint-Louis; and it may be readily 
explained: in fact, all the muscles which produce the displace- 
ment of the inferior fragment are relaxed by this position of the 
arm ; this same fragment is then pretty forcibly drawn outwards 
by the tense fibres of the deltoid, which, on the other hand, pre- 
vent the superior fragment from being carried outwards or for- 
wards. Thus, the muscular action which had di.splaced the parts 
is the means which we employ to retain them in coaptation, and 
immobility alone is the necessary requisite for the cure. 
We will resume the consideration of the articulation in the 
region which follows. 
( b ) The coracoid process is separated from the acromion by a 
triangular space (coraco-acromial), which the point of the knife tra- 
verses in the extirpation of the arm by the process of MM. Cham- 
pesmes and Lisfranc, and at which it comes out when we follow 
the method peculiar to M. Lisfranc. We will recur to this again. 
Being crossed by the clavicle, it opposes acromio-clavicular 
luxations. It is on the inner side of this process that the clavicle 
appears to be deepest. The beak of the coracoid process affords 
attachment to the pectoralis minor, biceps and coraco-brachialis ; 
whence it follows that its fracture must interfere with the inspira- 
torv movements of the thorax, those of elevation and adduction 
of the arm, and the depression of the shoulder. 
The coracoid process is one of the parts which most directly 
oppose the luxation of the arm upwards. It is separated from the 
head of the humerus by a space of about an inch; which space is 
filled by the coraco-immeral ligament and the tendon of the supra- 
spinatus muscle. 
We will examine the acromion and the corresponding extremi- 
ty of the clavicle more particularly in the posterior region of the 
shoulder. 
(c) The Clavicle, the horizontal branch of the angular lever 
which forms the skeleton of the shoulder, enters almost entirely 
into the region of the axilla. 
As this bone is one of those which first make their appearance 
in the foetus, and as its developement is generally very rapid, some 
persons have thence concluded that it enjoyed a much greater de- OP THE THORACIC EXTREMITIES. 
241 
gree of vitality, and have therefore attributed to this cause its 
more frequent liability to exostosis and other tumours. To this 
opinion we might make a great many objections. 
Its superior aspect is covered only by the skin, the superficial 
cellular layer and some fibres of the platysma; so that it may be 
distinctly felt by passing the finger over the surface, and it is for 
this reason that we should choose this part of the bone when we 
wish to discover its fractures. 
Anteriorly, the clavicle gives attachment to the pectoralis ma- 
jor at its internal half, and to the deltoid in its external third. In 
thin individuals the anterior part of this bone may be easily per- 
ceived through the skin, because the muscles are inserted nearer 
to its inferior than its superior aspect; but in fat persons, the cel- 
lular tissue raises the integuments so much, that we cannot 
always distinguish the displaced fragments by means of the touch, 
unless the fracture exists in that portion which is convex for- 
wards. 
Posteriorly, the attachment of the trapezius corresponds to that 
of the deltoid : opposite to the pectoralis major muscle, the bone is 
free, and its diseases, in this direction, may be easily appreciated. 
In general, the clavicle may be fractured in any part of its length; 
but it is more frequently broken at the place where the attach- 
ments of the deltoid and trapezius terminate, than elsewhere ; and 
for these reasons, because, on the one hand, the bone there affords 
less resistance, and, on the other, because it is at this point that 
the two curvatures meet; whence it follows that, in a fall upon 
the shoulder, for example, the weight of the body and the resist- 
ance of the ground, tend to cross one another at this point of con- 
junction of these two osseous portions. This last reason also ex- 
plains why these fractures are almost always oblique, and whv 
the slope of the internal fragment most frequently takes place at 
the expense of the posterior aspect. 
When the clavicle is fractured by a direct cause, the solution 
of continuity generally exists at the union of its two internal 
thirds, on account of the greater convexity of the bone at this 
point, which renders it more exposed to the action of external 
violence. 
In this last case the displacement must take place in the follow- 
ing manner: the internal fragment is drawn upwards by the 242 
or THE THORACIC EXTREMITIES. 
sterno-inastoid muscle, to which the pectoralis major opposes bur 
a very feeble resistance; the external, on the contrary, being 
supported by the trapezius only, is drawn downwards and for- 
wards, by the subclavius, the deltoid and the great pectoral. 
If the fracture is situated in the point first indicated, or more 
externally, it is possible that there will be only a slight degree of 
displacement transversely, because the trapezius and deltoid ex- 
ternally, the pectoralis major, subclavius and sterno-mastoid inter- 
nally, mutually counterbalance the action of one another. As to 
the displacement longitudinally, it manifests itself whatever may 
be the point of fracture. The muscular portion, which brings the 
arm in adduction, at the same time that it raises it, having no lon- 
ger a fixed point, and the prop which is placed between the 
shoulder and sternum, no longer existing, it follows that these pa- 
tients will be unable to carry the hand to the face without de- 
pressing the head. This phenomenon, although pretty constant, 
is not universally so, and we have seen, this year, in the hospital 
of the Ecolede Medecine, a man of forty, who had been affected 
with a very oblique fracture of the clavicle, with considerable 
overlapping, for three days, move and make use of his arm, which 
he raised to the vertex with the greatest freedom. M. Breschet, 
surgeon of Hotel Dieu, has recently met with a similar example. 
Do not these cases give support to the opinion of those w ho ad- 
mit that fractures of the clavicle do not actually require any other 
apparatus than the simple supporting bandage (bandage con- 
tentif) ? It is necessary to observe, however, that by acting thus 
we do not prevent the overlapping of the bones, and the contrac- 
tion wrhich may thereby take place in the axillary space may, per- 
haps, be carried so far as to permit the compression of the vessels 
and nerves. 
(d ) The Ribs do not present any thing very remarkable in the 
sub-clavicular region; the second only, on account of the slight, 
inclination of its external surface, and its more superficial position, 
deserves some attention. It is upon this rib that John Bell ad- 
vises compressing the axillary artery, rather than behind the cla- 
vicle. We have already said that this precept ought not to be 
followed. The other ribs, in this region, can but rarely be frac- 
tured, on account of the thickness and solidity of the parts which 
cover them. This must be understood, however, to refer to direct OF THE TIIORA.CIC EXTREMITIES, 
243 
fractures only; for those which originate from pressure on the 
sternum, etc., may take place in these ribs as well as in the others. 
These accidents will even be more dangerous here than else- 
where, on account of the organs contained in the axilla. 
The following is the order of super-position of the parts in the 
region which we have just examined: In the first place we meet 
with, from before backwards, 1st. the skin ; 2d. the superficial 
layer, including some fibres of the platysma, small veins and fat; 
3d. the thin prolongation of the aponeurosis, or the cellular la- 
mina which covers the muscles; 4th. the pectoralis major and 
minor, the deltoid, an inter-muscular cellulo-adipose layer; 5th. 
the biceps, coraco-brachialis and subclavius; the coraco-clavicu- 
lar aponeurosis, much cellular tissue and lymphatic glands ; 6th. 
the nerves and vessels; 7th. cellular texture also, then the sub- 
scapularis muscle externally, and the serratus magnus internally. 
Next, from the base to the apex [of the region] we find, 
1st. the skin, covered with hairs ; 2d. the subcutaneous layer; 
3d. the aponeurosis; 4th cellular tissue in great abundance, lym- 
phatic glands, venous and arterial ramuscules; 5th. the axillary 
artery and vein, then the brachial plexus; 6th. cellular lamellae 
filling the sub-clavicular aperture. 
Sect. 2. Posterior Region of the Shoulder, or Scapular Region, 
properly so called. 
This region is naturally bounded, posteriorly, by the spinal 
border of the scapula; anteriorly, by the acromio-digital line; 
superiorly, by the supra-clavicular region ; and inferiorly, by the 
posterior margin of the axilla. 
It represents a triangle with its truncated summit directed for- 
wards. 
Its surface presents several prominences and depressions, which 
may easily be distinguished through the skin: thus, posteriorly, 
we may distinctly feel, through the trapezius muscle, the posterior 
margin of the scapula, likewise the superior and inferior angles of 
this bone ; inferiorly, the thick and rounded border of the latissi- 
mus dorsi; from above downwards and from before backwards, 
the coracoid process, and a ridge running from the posterior bor- 
der of the middle region of th' shoulder, which corresponds to the 244 
OF TIIE THORACIC EXTREMITIES. 
spine of the scapula, to the acromion or clavicle : still lower, we 
discover another eminence produced by the infra-spinatus muscle. 
The deltoid and the head of the os humeri generally form a very 
distinct prominence likewise. Between the two latter eminences, 
we observe a kind of groove which runs from the acromion into 
the cavity of the axilla and which we will call the jmsterior deltox- 
dal groove; finally, there is still another species of hollow be- 
tween the acromion and the clavicle. 
CONSTITUENT PARTS. 
i. The Skin. 
The skin is thick in the superior, but still more so in the poste- 
rior part of the region ; less so anteriorly and especially inferior - 
ly: it is never covered with hairs, and we see no wrinkles in it, 
except those which result from the arrangement of the papillae. 
Its sebaceous follicles are not very numerous, but are very large ; 
its vessels form a complicated plexus, and its sensibility is suffi- 
ciently acute. It is on account of these characters, as well as 
the compact texture and slight extensibility of the skin, that the 
boils which are so frequently developed within it generally pro- 
duce a great deal of pain, and appear to differ but little from sim- 
ple anthrax. 
it. The Subcutaneous Layer. 
This layer contains a considerable quantity of arterial and ve- 
nous ramuscules, but few nerves; its adipose cells are few in 
number, at least opposite to the osseous eminences: its cellular 
tissue is both lamellated and filamentous ; it is supple and so dis- 
posed as to admit of a pretty extensive mobility of the skin over 
the supra and infra-spinal fossa?; over the deltoid, in certain 
subjects, it contains considerable fat; is dense and apparently 
fibrous over the spine of the scapula, the acromion and clavicle, 
where it sometimes forms a complete mucous or synovial bursa, 
wdiich facilitates the movements of the shoulder: in fine, it is 
pretty intimately united to the skin, but is very readily separable 
from the aponeurosis. In consequence of this disposition, w ounds OF THE THORACIC EXTREMITIES. 
245 
in the posterior region of the shoulder, which do not extend to 
the muscles, should and may be united by the first intention by 
means of plaisters, bandages or sutures; but we must take care 
that pus or other fluids do not accumulate between the aponeuro- 
sis and the wound. 
hi. The Aponeurosis. 
It is formed by a considerable number of sheets, which are at 
first distinct by their position and usages, but afterwards become 
blended with those of the surrounding regions. Thus, one sheet, 
the two laminae of which are continuous, before and behind the 
trapezius, with those of the back and neck, descends from this 
muscle towards the superior margin of the latissimus dorsi, where 
it splits in order to envelope the latter muscle, and afterwards 
becomes continuous with the brachial aponeurosis. This sheet is 
generally thin upon the muscles, where it merely represents, if I 
may so say, a simple cellular layer. In the interval which sepa- 
rates them, below the spine, it is thicker and evidently fibrous. 
Although dense, it nevertheless always preserves a certain degree 
of extensibility, which prevents its being confounded with the 
other laminm of this region. 
Of these laminae, there is one which originates from the inferior 
margin of the spine and the posterior border of the scapula, and 
passes towards the side of this bone, dividing in such a manner as 
to form two intersections between the teres major, teres minor and 
infra-spinatus muscles; after which it becomes continuous with 
the preceding sheet under the axilla. On the other side, it also 
splits on a level with the posterior deltoidal border, so that one of 
its lamellae, which is the thinnest, applies itself upon the deltoid 
muscle, becomes blended with the superficial sheet which has just 
been examined, and is lost in the aponeurosis of the superior ex- 
tremity ; the other remains under the deltoid, forms a pretty com- 
pact sheath for the infra-spinatus muscle, which it follows to the 
head of the humerus, where it is confounded with the articular 
capsule. We might call this the infra-spinal aponeurosis. 
Finally, we find a third lamina above the spine of the scapula: 
this binds down the supra-spinatus muscle, and is confounded, 
anteriorly, with the coraco-clavicular and acromio-clavicular liga- 246 
OF TIIE THORACIC EXTREMITIES, 
ments, behind the clavicle and the capsule of the joint. We can 
conceive how important it is to be well acquainted with the ar- 
rangement of these aponeuroses, when we wish to ascertain the 
seat and danger of abscesses or other affections at the posterior 
part of the shoulder. 
iv. The Muscles. 
In order to have an exact idea of these organs in the scapulary 
region, it is necessary to divide it into four portions; which are: 
1st, the Supra-Spinal; 2d, the Infra-Spinal ; 3d, the Axillary; 
4th, the Humeral. 
(a ) In the first (supra-spinal), we find the trapezius, which is 
inserted into the superior border of the spine of the scapula, from 
its tubercle as far as the clavicle. The fibres of this muscle, in 
this point, being oblique upwards and backwards, it follows that 
when they contract they must raise the shoulder. It is separated 
from the supra-spinal aponeurosis by a cellular layer, sometimes 
of moderate thickness, which establishes a communication with 
the supra-clavicular and axillary regions. 
Next the Angularis, which is in fact only a digitation of the 
serratus major anticus*, and which appertains to the regions of 
the neck. With respect to the shoulder, we see that it tends to 
draw up the posterior angle of the scapula, and that if this bone 
was fractured transversely, it would separate the fragments con- 
siderably. 
After the angularis, is the omo-hyoideus, another muscle of the 
supra-clavicular region. As this fasciculus is attached to the su- 
perior costa of the bone, behind the coracoid notch, its action 
upon the shoulder must be very slight; on the contrary, it derives 
from this bone its fixed point, in order to depress the larynx. As 
it ascends, it leaves between it and the coracoid process a small 
triangular space, through which the supra-scapulary nerve and 
vessels occasionally pass, previous to their entrance into the supra- 
spinal fossa. 
Finally, the Supra-spinal us Muscle, which fills, and is firmly 
fixed in the fossa of the same name, by the aponeurosis. Ii 
* M. Dumeril. OF THE THORACIC EXTREMITIES 
247 
should be observed that in passing under the acromio-clavicular 
arch, it is applied directly upon the articulation, as well as upon 
the head of the humerus, previous to its insertion into the trochi- 
ter, and that it there slides in a supple fibro-cellular tissue, which 
communicates with the axilla by the posterior surface of the 
deltoid. 
( b ) In the Infra-spinal portion we find, posteriorly, near the 
spine, a small portion of the trapezius. Here, this muscle is con- 
verted into a strong aponeurosis, which fixes it to the tubercle of 
the osseous crista. There is generally a bursa mucosa under this 
aponeurotic triangle. 
Posteriorly also, but still more inferiorly, we find a small por- 
tion of the latissimus dorsi. Sometimes this muscular bundle is 
attached to the angle of the scapula, at other times it only slides 
over this bone as it is passing into the axillary portion of the 
region. In either case this muscle, as well as the trapezius, 
principally acts here by pressing the scapula against the thorax. 
Anteriorly, we observe the scapular portion of the deltoid, the 
border of which becomes more and more isolated in proportion 
as it approximates the humerus. Between this border, the tra- 
pezius and latissimus dorsi, there is a triangular space, of a cer- 
tain extent, in which the skin is only separated from the infra- 
spinatus muscle by the aponeuroses. Under this space and the 
preceding muscles, we meet with the infraspinatus. 
This muscle originates from and fills the fossa infra-spinata, but 
is less and less adherent to it in proportion as it proceeds for- 
wards ; covered by the deltoid, it passes under the acromion; 
its tendon approximates the supra-spinatus, crosses the articula- 
tion in the same manner, and gliding under the acromial arch is 
inserted into the trochiter. It is equally enveloped by the cellu- 
lar tissue which forms a communication between its fossa and 
the cavity of the axilla. It is important to notice that as the 
supra and infra-spinata muscles are enclosed in a species of sac, 
which is fibrous behind and osseous before, abscesses which form 
in their substance, or in their sheath, cannot, without difficulty, 
make their way out in any other direction than by that which 
leads to the axilla. 
(c) The Axillary portion includes the latissimus dorsi, the teres 
major, and teres minor; but only the fleshy portion of these mus- 248 
OF THE THORACIC EXTREMITIES. 
cles. The two former are separated by a sheet of the super- 
ficial aponeurosis, but soon become confounded witli each other: 
as they remove from the third, they slide upon the humerus 
anterior to the triceps, which separates their tendon from the 
deltoid. As the teres major acts upon the inferior angle of 
the scapula, when the arm is fixed, as upon a lever of the first 
order, it thence follows that, in order to consolidate fractures of 
the os humeri, the arm must be retained close to the trunk. The 
teres minor, wrhich appears to be only a fascis detached from 
the infra-spinatus, ascends parallel to the latter under the deltoid, 
in order to fix itself to the great tubercle (trochiter) of the os 
brachii; so that, when it acts upon this bone, it may be consid- 
ered as the antagonist of the sub-scapularis. The space which 
separates it from the teres major is filled with cellular tissue, and 
encloses the posterior branches of the sub-scapulary vessels. As 
it is on the outer side of the joint, its anterior surface rests upon 
the long portion of the triceps. 
(cl) In the humeral portion we observe the middle bundle of 
the deltoid, the curved fibres of which, in raising the arm when 
it is free, act upon the os humeri as upon a lever of the third 
order. But, when the moveable extremity of the limb is retained 
by some power, this muscle might depress the head of this bone, 
and thus favour the luxation downwards. This fascis is, as it 
were, moulded upon the articulation, from which, however, when 
the arm is pendent by the side of the thorax, it is separated by a 
space of almost an inch. A broad kind of bursa mucosa exists 
in this space, which in general contains but a small quantity of 
fluid. 
( e ) Upon the humerus, properly so called, we find the extrem- 
ity of the three portions of the triceps, of which the external 
(great head) is nearest to the deltoid, and is occasionally contin- 
ued by its extremity as far as the tendon of the teres minor. 
The middle portion (long head) gradually detaches itself from 
the humerus, and passes upon the inferior costa of the scapula, 
to which it is attached about half an inch below the glenoid cav- 
ity. It then becomes flattened, and its posterior surface is con- 
cealed by the teres minor, and low'er down by the brachial apo- 
neurosis. Anteriorly, this muscle rests upon the broad tendons 
of the latissimus dorsi and teres major, beyond which it is free in OF THE THORACIC EXTREMITIES. 
249 
tiie hollow of the axilla; and, close to its attachment, it rests 
partially upon the subscapularis muscle. When the arm is fixed, 
this muscular bundle acts upon the scapula in the same manner 
as the teres major; with this difference, however, that here this 
action inclines, in great part, to the profit of the solidity, because 
the branch of the lever is considerably shortened. Relative to 
the articulation, when the arm is raised, the triceps represents a 
tense cord, which opposes luxation downwards by supporting the 
head of the humerus; but in fractures of the neck of this bone, 
it tends to displace the fragments in a longitudinal direction. 
As the tendons of the latissimus dorsi and teres major are in- 
serted into the posterior labium of the bicipital groove, they must 
turn the arm outwards ; and, as their inferior margin is continu- 
ous with the brachial aponeurosis, this fibrous sheet is very appa- 
rent when these muscles contract. We will soon re-examine 
the supra and infra-spinatus muscles and teres minor. 
v. The Arteries. 
(a) They are derived from the supra-scapulary, the transverse 
cervical, the subscapulary and circumflex arteries. 
The first (Supra-scapulary) plunges into the fossa supra-spinata, 
often above and sometimes below the ligament which converts 
the coracoid notch into a foramen. The branches which it here 
gives off, and which are here distributed to the trapezius, supra- 
spinatus, angularis, etc., muscles, are generally so small that they 
do not require a ligature when we perform operations upon these 
parts. One of its branches remains in the fossa supra-spinata; 
the other goes under the spine of the scapula, passing under the 
acromion, behind the glenoid cavity, and is lost in the infra-spina- 
tus, teres minor and major muscles. This artery is important 
in surgery only in relation to its numerous anastamoses. 
( b ) The Transverse Cervical arises from the same trunk with 
the supra-scapulary, and gives to the region of the shoulder its 
descending branch only; it sends off twigs which pass between 
the rhomboideus and trapezius, or which perforate the first of 
these muscles and anastamose with the ramuscules of the prece- 
ding in the fossa infra-spinata. 250 
OF THE TilOItACIC EXTREMITIES. 
( c ) The third (subscupularis) comes from the axilla, and pas- 
ses through the opening which is circumscribed by the teres 
major and subscapularis muscles on the one part, and the long 
portion of the triceps on the other; it ascends between the teres 
minor and the anterior costa of the scapula, an inch and a half 
below the glenoid cavity; the largest of its branches dips imme- 
diately into the subscapulary fossa ; the others pass into the del- 
toid towards the acromion : finally, a considerable number enter 
the latissimus dorsi, the teres major, etc. As it comes out of the ax- 
illa, this artery is sometimes of considerable size ; so that a wound 
penetrating into the scapulo-humeral or posterior-deltoid groove, 
might give rise to a troublesome hemorrhage. In such a case, or 
for any other reason, it might be exposed, by making an incision 
parallel to the anterior costa of the scapula, but upon the exter- 
nal face of the deltoid. Then, by dividing the posterior border 
of this muscle, opposite to the point of intersection of the teres 
minor and the long portion of the triceps, we will easily find 
this vessel by holding the arm very much upwards and back- 
wards: so that, in order to reach it, we will have to cut, 1st. the 
skin ; 2d. the adipose layer ; 3d. the aponeurosis; 4th. the fibres 
of the deltoid; 5th. the cellular tissue. The teres minor must 
be pushed backwards. 
( d ) The Posterior Circumflex, as we have already stated, 
turns round the bone, and is only separated from that which we 
have just considered by the scapulary portion of the triceps 
muscle. It is distributed almost entirely to the deltoid, and 
anastamoses very freely with the anterior circumflex, the acromi- 
al, the supra-scapulary and the preceding branch. 
These are the arterial communications by which the circulation 
in the arm is supported, when we tie the sub-clavian or axillary 
arteries. Thus, the acromial with the subscapulary and circum- 
flex, on the one hand, and, on the other, with the supra-scapula- 
ry ; the subscapulary with the transverse cervical and the exter- 
nal mammary; the latter with the internal mammary and the 
anterior thoracics, etc., are quite sufficient to carry the blood 
from the point above the ligature of the principal artery to the 
parts below, without taking into consideration other branches 
which it is needless to mention. OF THE THORACIC EXTREMITIES. 
251 
vi. The Veins. 
All the veins of this region follow the direction of the arteries, 
to which, in general, they are somewhat intimately adherent: but 
they are much larger; their capillary system in particular is 
very abundant; hence the frequency of naevi materni, spongy 
{erectile) tumours, and fungus haematodes in the region of the 
shoulder. 
vii. The Lymphatics. 
These organs present nothing peculiar in this region. Like 
those of other parts, they consist of two series; one of which is 
superficial, passing almost entirely to the axillary glands; the 
other, deep seated, accompanying the veins, and entering into the 
supra-clavicular and axillary regions. 
vm. The Nerves. 
They are very numerous, but of moderate size, and consist of 
the terminations of the spinal accessory, supra-scapulary, and the 
circumflex which is the principal nerve of this region. 
(a) The Spinal ramifies in the trapezius, and does not appear 
to send filaments to the skin; so that it is probably destined only 
for the contractions of this muscle. Consequently, if it was divi- 
ded, such division would produce paralysis of the movements of 
elevation and abduction of the stump of the shoulder. 
( b ) The Supra-Scapulary comes from the supra-clavicular 
region: it passes into the coracoid notch, gives filaments to the 
supra-spinatus muscle, then descends into the fossa infra-spinata, 
where it divides like the artery of the same. It anastomoses with 
the scapulary and supra-acromial filaments. As it is situated be- 
hind the glenoid cavity, it runs no risk of being injured from am- 
putations, or luxations; but if the neck of the scapula was frac- 
tured, it might give rise to unpleasant symptoms. 
( c ) The Supra-Acromial Nerves are derived from the cervi- 
cal plexus, and appear to be distributed to the skin. The bra- 
chial plexus gives off the sub-scapularies, which pass into the ax- 252 
OF THE THORACIC EXTREMITIES. 
illary muscles of the posterior region of the shoulder. They are 
scarcely susceptible of surgical applications. 
( d ) The Circumflex is much more important; its volume is 
sometimes equal to that of the radial. As it comes out of the 
axilla it passes under the neck of the humerus by the sub-scapulo- 
humeral aperture; it is included in the same cellular sheath with 
the artery and veins, remains in contact with the bone for a long 
time, and is lost in the deltoid, of which it is the nervus proprius, 
and in the circumference of the articulation. From this disposi- 
tion, we may easily comprehend how it is that pressure of this 
nerve suspends almost all the motions of the arm, and that the 
head of the humerus, when luxated, may produce this phcenome- 
non. We also conceive that in fractures of the neck very high 
up, the circumflex nerve is still more exposed to laceration, 
stretching and even compression, than in the articulatory displace- 
ments. 
ix. The Skeleton. 
It is composed of the whole of the scapula, of the acromio- 
clavicular and scapulo-humeral articulations. 
In the scapula and the other osseous parts we should note, 
1st. The Fossa Supra-Sjnnata, the inner wall of which is so 
thin that a pointed instrument may perforate it without difficulty, 
and thereby wound important organs in the axilla. 
2d. The Fossa Infra-Spinata, which is not much thicker; but 
here the same wound would produce accidents of a different na- 
ture. For, as the brachial plexus is more anterior, it would proba- 
bly not be touched, and the vulnerant body would be more liable 
to penetrate into the cavity of the thorax. This portion of bone 
may be fractured; but as the aponeurosis adheres to its whole 
circumference and the infra-spinatus muscle is attached to its 
surface, they must prevent all manner of displacement, and reduce 
the method of treatment to retentive bandages simply; 
3d Its Spine. The triangular surface which forms the root of 
the posterior border of this process permits the trapezius to slide 
upon it, when its inferior fibres contract, as over a pulley. It is 
so disposed that the deltoid, which elevates the arm, and the tra- 
pezius, which draws up the shoulder, derive from it at the same OF TUE THORACIC EXTREMITIES. 
253 
time their fixed or moveable point; from which circumstance 
these two muscles are almost always obliged to combine their 
actions. As this osseous crest can always be felt through the 
skin, it follows that when the shoulder of the foetus presents 
during labour it may be mistaken for the clavicle, and thereby 
lead to an incorrect manoeuvre in the attempt to turn the child. 
4th. The Acromion, which is only the continuation of the pre- 
ceding spine, is inclined slightly outwards and projects at least 
eight lines before the glenoid cavity; so that a luxation of the 
humerus cannot take place in this direction without a fracture of 
this process. In powerful muscular subjects, especially those who 
exercise their arms very much, the acromion is thicker, stronger, 
and curved more downwards; so that its beak is sometimes 
closely approximated to the head of the humerus: such a dispo- 
sition might increase the difficulty of amputating the arm at the 
shoulder joint, according to Lisfranc’s method. The apex of the 
acromion, as well as the external extremity of the clavicle, re- 
main cartilaginous until about the age of fifteen years in which 
case, if the acromio-clavicular vault was diseased in such a man- 
ner as to require its removal, the cutting instrument would easily 
divide these parts and render the saw unnecessary. The same 
would apply to the extirpation of the arm. But we do not see 
that it would be necessary to remove these parts in the latter 
operation; on the contrary, they should be left unmolested, on 
account of the muscles which are attached to them, and which 
are subservient to the formation of the flap. We have several 
times observed the acromion process united to the spine of the 
scapula, in subjects of thirty years, merely by a thin vinculum of 
cartilage. In a like case we consider that a fracture, or rather a 
disjunction of the epiphysis, might easily take place. The ana- 
tomical disposition of this process is such that, when fractured, 
the anterior fragment may be forcibly drawn downwards by the 
action of the deltoid muscle and the weight of the limb: hence 
the rule for keeping the arm firmly elevated in fractures of the 
acromion. 
5th. The Coracoid process, which completes internally the canal 
through which the tendon of the supra-spinatus muscle passes: 
; M. Tiisfranc. Archives, Mai 1821. 254 
OF THE THORACIC EXTREMITIES. 
it is its dorsal aspect which serves as the point of support to the 
clavicle when its sternal extremity is depressed. The conoid 
and trapezoid ligaments, which limit the elevation of the latter 
bone, here deserve some attention. In fact, they are very short, 
very thick, and consequently very strong: their arrangement* 
also, is such that the clavicle cannot be carried more than a few 
lines, either forwards or backwards, without putting them very 
much on the stretch, and thereby opposing these motions. 
6th. The Clavicle. This bone is flat and spongy between the 
two preceding processes, and is about an inch and a half, or at 
most, two inches in length. Fractures occurring in this portion 
of the bone cannot be attended with displacement in a longitu- 
dinal direction, because the acromion on the one hand, and the 
coracoid process on the other, invincibly restrain the fragments 
from crossing each other. Between the spine of the scapula, 
the base of the coracoid process and the clavicle, we observe a 
retiring angle (angle rentrant) which is filled by the trapezius 
muscle. Before the clavicle, we observe the small coraco-acro- 
mial triangle, closed by the ligament of the same name, at which 
we introduce the point of the knife into the articulation. Finally, 
notwithstanding this articulation of the clavicle consists in the 
mere application of simple surfaces, yet the superior and inferior 
ligaments, and all the parts which unite the clavicle to the acro- 
mion, are so compact that its dislocations are difficult and unfre- 
quent. It must be admitted, however, that the infrequency of 
these displacements are also to be attributed to other anatomical 
peculiarities: thus, for example, in consequence of the great 
mobility of the scapula, the two bones of the shoulder always 
move together; the sternal extremity of the clavicle being fixed, 
the powers act but with difficulty upon it, after the manner of a 
lever of the first species, in order to produce this luxation up- 
wards ; and the coracoid process opposes the dislocation of the 
bone, which surmounts it, downwards. We must not, however, 
with some moderns, deny the possibility of the latter accident, 
admitted perhaps too lightly by J. L. Petit. 
7th. The Scapulo-humeral articulation, which comprises the 
head of the humerus, the glenoid cavity, and the fibrous parts. 
The head of the os brachii represents a half sphere, which is 
proportionately larger in children than in adults; its axis is di- OF THE THORACIC EXTREMITIES. 
255 
rected obliquely forwards, outwards, and downwards, so that at 
its junction with the humerus it forms an elbow which makes it 
appear longer interiorly, internally, and posteriorly. At the 
point of this union there is a groove which increases in depth in 
proportion as it advances in the direction last indicated. This 
circular groove, which is the true anatomical neck of the bone, 
deserves the greatest attention whenever we wish to disarticulate 
the arm, and more especially when we follow the process of 
Beclard. It is upon this groove, in fact, that the knife must be 
perpendicularly carried, if we wish to divide the capsule and the 
tendons effectually; otherwise these parts will become folded, or 
roll under the instrument, and the section be executed with diffi- 
culty. It is necessary then to recollect the axis of this groove 
exactly, and the plane of the circle which it forms. There are 
some individuals in whom the head of the humerus continues for 
a long time in the state of epiphysis ; it may then be detached, and 
this, without doubt, is what has usually been denominated a frac- 
ture of this part. We conceive that the consolidation of such 
fractures is scarcely possible, except in young subjects, and when 
it advances a little upon the body of the bone; for as the frag- 
ment included within the capsule has no ligamentum proprium, 
and is not covered by the periosteum, it will be completely sepa- 
rated from the living organs. The dimensions of the head of 
the os humeri are much greater than those of the glenoid cavity; 
so that, were it not for the muscles which surround the joint, the 
weight of the limb alone would be sufficient to produce its luxa- 
tion. This is not founded upon reasoning alone, for it has actually 
been ascertained that these dislocations sometimes take place 
spontaneously in paralytic individuals. In these cases, the mus- 
cles of the shoulder having lost their tonic power, as well as their 
voluntary contractility, cease to support the humerus, which is 
then supported merely by its capsule. Therefore, as the latter 
permits the surfaces to be separated as much as an inch asunder, 
it follows that the least effort may draw the head of the bone in 
this or that direction. 
With respect to luxations of the shoulder generally, we will 
now readily comprehend the manner and direction in which they 
may take place. 
Taking the axis of the head of the humerus for the point of 256 
or THE THORACIC EXTREMITIES. 
departure, we see that, in carrying the arm inwards, the thorax 
will check its adduction before this axis has escaped from the 
glenoid cavity; besides, the capsule, strengthened externally by 
the tendons of the infra-spinatus and teres minor muscles, will 
oppose a resistance in this direction almost insurmountable. 
If we carry the arm backwards, the movement of this axis will 
soon be stopt by insuperable powers; thus, the supra-spinatus 
and deltoid will hinder it from rolling too far forwards; and if it 
tends to slip directly upwards, the capsule, strengthened by the 
coraco-humeral ligament and the arch which is formed above by 
the coracoid process, acromion and clavicle, will not permit it to 
pass beyond the glenoid cavity. 
If, on the contrary, it is inwards that the head of the humerus ro- 
tates, several circumstances will favour its escape in this direction. 
First, nothing bounds the movement of abduction outwards and 
backwards ; next, if the arm is elevated, the deltoid may favour 
this movement in a very evident manner, and lastly the fibrous 
membrane of the joint is much thinner at its internal part, than 
outwards and upwards; sometimes, it is even found reduced to 
a synovial lamina and supported merely by the tendon of the 
subscapularis; This tendon, it is true, is very strong, and, as the 
head of the bone tends to remove from it by curving it, it repels 
or depresses it towards the cavity from which it is disposed to 
escape, with so much the greater force in proportion as its draws 
near the moment of abandoning the glenoid cavity. But it is 
below in particular that luxations take place with most facility. 
Let us suppose, for instance, that the arm is elevated to a right 
angle with the trunk, the elbow being fixed: in this position, 
the axis of the head of the humerus is very near the inferior 
margin of the glenoid cavity. Then the deltoid, pectoralis major, 
latissimus dorsi and teres major will become auxiliaries to the 
displacing powers, and the only resistance which the latter w ill 
meet wit h will be in the portion of the capsule. Now this 
capsule is also very thin here, and is besides but feebly supported 
by the tendinous portion of the long head of the triceps. The 
dislocation directly dowmvards then, is very easily produced ; but 
as, in this case, the head of the humerus rests only upon the side 
of the scapula, and as the limb is elongated, the triceps and sub- 
scapularis muscles being put. upon the stretch will almost alw ays OF THE THORACIC EXTREMITIES. 
257 
draw it inwards, and place it between the latter muscle and the 
scapula. It is possible, however, for it to slip outwards likewise 
into the fossa infra-spinata; but the capsular ligament is stronger 
in this direction ; the muscles oppose it more directly; the costa 
of the scapula is inclined outwards, and besides it is rare that the 
free extremity of the limb is placed in a suitable direction for 
favouring this displacement. 
We may further remark, with respect to the head of the hume- 
rus, that the tendons which are inserted into its tuberosities, are 
so disposed, that, in fractures of its neck, they mutually neutralize 
each other’s action, so that they displace the superior fragment but 
slightly. Thus, the sub-scapulans, teres minor, and infra-spinatus 
counteract one another, and together annul what might be effected 
by the supra-spinatus. 
The glenoid cavity is very superficial in comparison with the 
volume of the semi-sphere which rotates upon it; which disposition 
is necessary, however, for the extensive and varied movements 
of the superior extremity. The perpendicular diameter of this 
cavity is much greater than its horizontal, a circumstance to be 
kept in mind when we disarticulate the arm. It must also be 
remembered, on this occasion, that the coraco-acromial arch is 
nearly an inch above it; whence it follows that between the 
summit of the acromion and the lower part of the glenoid cavity 
there exists a space of about two inches and a half, whilst, trans- 
versely, this space is scarcely an inch. 
Therefore, in order to amputate the arm at the joint, two 
genera] methods have been recommended. In the one, the flaps 
are always parallel to the small diameter of the space indicated 
above ; in the other, on the contrary, they are perpendicular to it. 
Should we perform the first, in making an inferior flap only, as 
practised by Ledran, or a superior, according to La Faye; or 
should we form two, in imitation of Garengeot or M. Dupuvtren, 
we see that the enormous distance which separates the base of 
these two flaps will always render it very difficult to produce an 
immediate re-union, and will very frequently dispose to the forma- 
of abscesses. 
The conjoined method of MM. de Champesmes and Lisfranc, 
may secure the patient from some one of these inconveniences ? 
for, if the knife is introduced at the coraco-acromial triangle, in 258 
OF THE THORACIC EXTREMITIES. 
order to traverse the articulation, it is possible to make its point 
come out sufficiently low, under the external margin of the aero* 
mian, to produce a flap more lateral than superior; but then this 
process will enter into the second method. 
It is to the latter that the methods of Sharpe and Bromfield 
appertain, and especially that of Desault. Whether we make an 
internal flap, by carrying the knife on the inner side of the hume- 
rus, from the apex of the acromion behind the anterior border of 
the axilla, as directed by Desault, in order to pass afterwards 
through the articulation and form, in finishing the incision, an ex- 
ternal flap ; or, on the contrary, we commence, according to MM. 
Larrey, Roux, etc., with the external flap and terminate with the 
internal; or, as recommended by M. Dupuytren, instead of form- 
ing this first flap by cutting from within outwards, we make a 
semilunar incision from the integuments towards the posterior 
part of the capsule ; or, finally, whether we cut the flap by car- 
rying the point of the knife before the posterior margin of the 
axilla, in order to make it traverse the articulation by pushing it 
upwards and forwards, so that it may come out at the coraco- 
aeromial triangle, as is now performed by M. Lisfranc, it is evi- 
dent that we will always have two flaps of equal or unequal 
lengths, which might be approximated, and thus almost entirely 
obliterate the acromio-glenoidal space. The same would occur 
from the circular amputation, which is preferred by many Eng- 
lish surgeons ; as well as by the process of Beclard, which con- 
sists of two incisions, one anterior, the other posterior, which 
commence at the summit of the acromion, are prolonged oblique- 
ly downwards and forwards, and terminate without meeting, in 
order to avoid the nerves and especially the artery, upon the two 
axillary borders. With respect to the execution of these differ- 
ent methods, the anatomical arrangement of the parts exacts for 
each of them particular precautions. 
In that of Desault, for instance, the artery should be previously 
compressed, since it is comprised in the first flap. For the pur- 
pose of forming this first flap, it is necessary that the knife should 
slide beneath the humeral head, for this eminence would otherwise 
throw it too much inwards; afterwards the arm must be drawn 
in abduction, in order to penetrate easily into the articulation. 
In the two methods adopted by M. Larrey. and in. one of those or TIIE THORACIC EXTREMITIES. 
259 
recommended by M. Dupuytren, as we commence with the ex- 
ternal Hap, the artery will only be divided in finishing the opera- 
tion. 
In Bedard’s method, the muscles being divided down to the 
bone, it is necessary to draw upon the humerus so as to render its 
head prominent, and to turn it in extreme pronation or supination, 
according to the side. This rotation is, indeed, indispensable, for 
without it we cannot divide the capsule to a sufficient extent upon 
the groove of the anatomical neck of the os brachii. This sec- 
tion being made, we can readily dislocate the humerus forwards; 
then the knife may be easily insinuated behind the bone without 
touching the artery, which is contained in the pedicle which sepa- 
rates the two flaps ; which pedicle is divided, after its base has 
been seized by an assistant, who compresses the artery. 
In almost all the methods connected with that of Ledran, this 
last step of the operation, relative to the artery, should and may 
be retained, since we finish with the inferior flap. 
That of MM. Champesmes and Lisfranc requires a narrow 
knife, and that the arm should be kept elevated, in order to sepa- 
rate the articular surfaces, and enlarge the space which the instru- 
ment must traverse. The edge of this knife must be directed 
upwards and forwards towards the summit of the acromion, in 
order that it may glide more easily between the glenoid cavity 
and the head of the humerus. When its point comes out behind 
the shoulder, we draw it forwards, first in the direction in which 
it is, in order that it may pass out from the joint; after which we 
decline the edge, so as to lengthen the external flap by grazing 
the external aspect of the os humeri. 
That of M. Lisfranc demands the same precaution relative to 
the articulation ; but it is also necessary to watch attentively the 
place at which the instrument is to make its escape, in order to 
avoid striking its point against the inferior aspect of the clavicle, 
or even propelling it behind this bone into the fossa supra-spinata. 
It is also important that it should not be depressed more than is 
necessary, for it would pass under the coracoid process into the 
coraco-clavicular triangle and divide the pectoralis minor. 
Finally, the scapula forms a kind of shield behind and upon the 
side of the thorax. It covers the first six ribs and their inter-spa- 
ces, and corresponds to the thickest and most spongy part of the 260 
01 THE THORACIC EXTREMITIES. 
lungs: but, although it is enveloped by numerous and thick muscles, 
the stethoscope applied, among other points, over its supra-spinal 
portion, will enable us to distinguish tolerably well the state of 
the respiration. 
Art. II. Of the Arm. 
We will divide the arm into anterior and posterior regions; 
but will examine its general surface, previous to entering into 
those details which concern each of these regions. 
Strictly speaking, the arm comprises all that part of the supe- 
rior extremity which is occupied by the humerus ; but, as it re- 
gards topographical anatomy, the arm extends from the shoulder 
or axillary region to two inches above the elbow only ; in fat per- 
sons, and especially in females, the arm is conoidal. In general, 
it is cylindrical, and more or less flattened on its outer and inner 
surfaces. At its external and superior part it presents a triangu- 
lar eminence, which is formed by the deltoid, and which is bound- 
ed, anteriorly and posteriorly, by two furrows which unite at its 
apex, in order to form the deltoidal depression : it is at this point 
that issues are usually inserted. From this depression another 
broad, but superficial, groove originates, which descends to the 
fold of the arm ; it represents the external aspect of the limb, 
and is the place upon which blisters are applied. A third furrow 
runs along the internal aspect, and extends from the hollow of 
the axilla to the elbow, where it joins the preceding. Between 
these two furrows, anteriorly, we observe an eminence, which is 
sometimes very prominent, bulging in the middle, disappearing in 
the axilla and fold of the elbow : this is the bicipital eminence. 
Posteriorly, the triceps also elevates the integuments in a greater 
or less degree, but does not form any important reliefs. We 
suppose the limb to be in the state of supination. 
Sect. 1. Anterior Brachial Region. 
It is bounded, externally, by the acromio-digital line ; internal- 
ly, by the sub-scapulo-digital line ; superiorly, by the hollow of 
the axilla, and inferiorly, by a transverse line which would unite OF TIIE THORACIC EXTREMITIES. 
261 
the two preceding two inches above the condyles of the hume- 
rus. 
This region comprises the external and internal bicipital fur- 
rows, the eminence which separates them, the deltoidal depress- 
ion, and a portion of the muscular relief which surmounts it. 
CONSTITUENT PARTS. 
i. The Skin. 
It is delicate, white and very extensible, especially internally, 
supplied with but few sebaceous follicles and hairs, and entirely 
devoid of them upon the bicipital eminence. In the internal fur- 
row we sometimes distinguish through it the basilic vein, and in 
ihe external, the cephalic. It moves easily over the organs be- 
neath it; therefore, simple wounds which have their seat in this 
region, unless attended with considerable loss of substance, 
readily unite by the adhesive inflammation. 
ii. The Sub-cutaneous Layer. 
This layer may acquire a very great thickness, and is generally 
thicker in women and children than in men; much thicker, also, 
in the depressions than upon the eminences. It is chiefly formed 
of cellular tissue, in the laminae of which adipose vesicles are in- 
terposed, which agglomerate in small lobules in the furrows, and 
especially below the deltoid; it also envelopes a few nervous fila- 
ments externally, where they are derived from the musculo- 
cutaneous : more numerous internally, where we find the inter- 
nal cutaneous and the filaments from the dorsal nerves. We also 
observe in it the trunks of the basilic and cephalic veins. All 
these parts are so disposed that the veins are more particularly 
enclosed in the deep-seated cellular laminae, whilst the adipose 
cells are developed in the external lamellae. The nerves gener- 
ally lie upon the same plane with the veins; whence it follows 
that the distance of the latter from the skin is in proportion to 
the thickness of the adipose layer. 262 
OF T1IE THORACIC EXTREMITIES. 
hi. The Aponeurosis. 
It is thin and almost cellular upon the median line, but this is 
owing to the splitting of the aponeurosis upon the external limits 
of this region ; then, one of its sheets only passes before the bi- 
ceps muscle, whilst the other passes behind it over the anterior 
face of the brachialis interims. At the internal margin of the 
first of these muscles the deep sheet splits in its turn, and its two 
laminae, in passing to unite with the internal surface of the super- 
ficial sheet, furnish a complete sheath for the humeral artery, its 
collateral veins and the median nerve. This sheath is generally 
continued as far as the axilla. 
On the inner side of the arterial sheath there is another fibrous 
canal, which includes the internal cutaneous nerve and the basilic 
vein ; finally, as the aponeurosis enters the posterior region it re- 
ceives, upon its internal surface, a fibrous intersection, which is 
very strong inferiorly, is attached to the internal ridge of the hu- 
merus, and may be called the epitrochlo-humeral intersection. 
The brachial aponeurosis then is more complicated in this re- 
gion than is usually admitted. Thus, it is thick externally, be- 
cause its sheets are blended; in the internal bicipital groove, it is 
still thicker, because there all its laminae are conjoined ; it forms 
a sheath for the biceps the sheets of which are thin, because they 
seem to have been distended by this muscle, which is of greater 
or less volume ; a second sheath for the artery, the vein and nerve 
which accompany it; and, in this sheath, lamellae are detached 
forming secondary envelopes for each organ ; finally, a third for 
the internal cutaneous nerve and basilic vein, which, however, is 
not always present, neither is it prolonged so far upwards as the 
others. It is important to keep this arrangement in mind when 
about to tie the brachial artery. 
iv. The Muscles. 
We find in this region a small portion of the deltoid and 
coraco-brachialis, the greater part of the biceps and brachialis in- 
terims, the origin of the supinator radii longus and of the extensor 
carpi radialis longior muscles. OP TIIE THORACIC EXTREMITIES. 
263 
(a) The Deltoid here adheres very firmly to the bone, so that 
no fluid can collect beneath it; its anterior border is enveloped 
by the aponeurosis, which is also very strong where it abandons 
it in order to enter into the axilla. 
(b) The termination of the coraco-brachialis is much more 
posterior; it is between it and the preceding muscle that the two 
portions of the biceps ascend to the shoulder. 
( c) The whole of the fleshy belly of the biceps is observed at the 
anterior part of the arm ; its internal margin serves to guide us to 
the vessels; superiorly and externally, it is covered by the del- 
toid ; it lies at first upon the humerus and the tendons of the 
coraco-brachialis, teres major and latissimus dorsi, afterwards 
upon the brachialis mternus. Further, it is free under the skin in 
its aponeurotic sheath ; so that, in amputations, we must expect it 
to retract very much, especially as we generally divide it very far 
from its points of attachment. In order to render it most promi- 
nent it is necessary to extend the fore-arm: in this position, if the 
limb is fixed, and the muscle contracts, it tends to flex the hu- 
merus forwards. Consequently, in fractures of the arm, it may 
displace the fragments, in the first place according to their direc- 
tion, and afterwards according to their length. It is for this rea- 
son that the fore-arm should be retained in a flexed position during 
the cure of these diseases. 
(d) The Brachialis Interims is in a great measure concealed 
by the biceps, which it passes a little beyond, however, on each 
side; so that the artery rests upon its inner portion, etc. It 
originates from the whole of the anterior surface of the os brachii, 
and also from the fore-part of the fibrous intersections attached to 
the borders of this bone; superiorly, it is thinner and bifurcates 
so as to resemble the letter Y, in order to embrace the apex of 
the deltoid. It is between the insertion of these two muscles, the 
biceps which is internal, and the triceps which is external, that we 
find the delioidal fossette, which is also filled by cellular tissue and 
fat. This fossette then is so disposed, that the muscles which 
circumscribe it are not susceptible of moving or sliding over one 
another at this point; and it is for this reason, as well as on ac- 
count of the cellular tissue here met with, that we apply caustics 
upon this excavation. 
As this muscle adheres to all the points of the bone which it 264 
OF THE THORACIC EXTREMITIES. 
covers, and as its moveable point is situated upon the ulna, it fol- 
lows that, in fractures of the inferior half of the humerus, it oppo- 
ses rather than favours the displacement. From this disposition 
also, the brachialis interims cannot retract in amputations; there- 
fore the biceps should be divided first, in these operations, in order 
that the knife may afterwards be carried as high as this muscle 
has retracted. 
( e ) There is only a small portion of the supinator radii longus 
in the anterior brachial region: it appertains to the elbow and 
fore-arm; it was necessary to note here, however, that it origin- 
ates from the fibrous intersection on the inner side of the pre- 
ceding. 
v. The Arteries. 
( a ) The Brachial Artery. The relations of this vessel, from 
the tendon of the latissimus dorsi to its entrance into the region 
of the elbow, are the following: Enveloped in its aponeurotic 
sheath, it is always accompanied by the median nerve and the 
humeral vein or veins, so that we cannot attack one of these or- 
gans without running some risk of injuring the others; superiorly, 
the nerve is on the outer side of, or anterior to, the artery; lower 
down, the former crosses the latter very obliquely, passing almost 
always over its anterior surface, and sometimes only behind it; 
so that, inferiorly, it is almost uniformly upon its inner side. The 
cellular process which unites them in the interior of their com- 
mon canal, is sometimes so dense that it affords a certain resist- 
ance to the needle with which we attempt to separate them. 
This nerve can scarcely be confounded with the arterial trunk; 
its volume, form, colour, consistency, and superficial position, do 
not permit us to commit this error: the vein, or rather the veins, 
for there are almost always two, are still more immediately 
applied upon this vessel; so that in the order of super-position it 
is only upon the third plane. When there is only one vein, it is 
on the inner side; if two, they are situated on each side, and 
sometimes they send, reciprocally, branches of communication 
which pass over the anterior face of the artery: it is then diffi- 
cult to separate and exclude them, in the ligature of this artery. 
If we consider it as divested of its sheath, of the median nerve OF THE THORACIC EXTREMITIES. 
265 
and collateral veins, the brachial artery rests posteriorly, from 
above downwards, upon the humerus, the tendon of the coraco- 
brachialis muscle, the fore-part of the internal portion of the 
triceps, and the brachialis internus ; consequently, we may easily 
compress it against the bone in its superior third. Externally, it 
is still coasted by the coraco-brachialis, then by the biceps ; inter- 
nally, it is separated from the triceps and the (intermuscular) lig- 
aments, iirst by the radial nerve and internal collateral artery, 
afterwards by the ulnar nerve, which diverges from it more and 
more in proportion to its descent; and lastly, by the internal 
cutaneous nerve and basilic vein, enclosed in their sheath. The 
latter are more approximated to the artery above than below, 
and, in many subjects, the septum which separates the two 
fibrous canals disappears in the former direction. In its inferior 
fourth, it no longer has any relation with the triceps; it is the 
brachialis internus which then conceals its internal portion. An- 
teriorly, and more or less internally, it is covered by the aponeu- 
rosis, the superficial layer and the skin, throughout its whole ex- 
tent ; sometimes also the belly of the biceps inclines more or less 
in this direction ; but, generally, in subjects of moderate embon- 
point, whose muscles are not very large, the pulsations of the 
artery may be easily felt by applying the fingers along the internal 
bicipital furrow. Hence it follows that this artery may be surely 
discovered by making an incision upon the furrow just men- 
tioned, in the direction of a line drawn from the hollow of the 
axilla, one inch before its posterior margin, along the inner side 
of the biceps, to the bend of the elbow. The skin being cau- 
tiously divided, on account of its tenuity, we perceive the cellular 
or superficial layer; this being incised, the edge of the knife 
sometimes comes in contact with some small veins, which it is 
convenient to avoid, and even the basilic vein, if it has not yet 
passed through the aponeurosis, which next comes in view: this 
last layer will present only one thick sheet, which will be easily 
traversed, if we have fallen directly upon the arterial sheath; but 
if, on the contrary, we have kept too close to the biceps, we will 
have to divide, first, the delicate expansion which covers this 
muscle, and afterwards the external part of the envelope of the 
artery. 
Then will be exposed the median nerve and the vessels; per- 266 
OF TI1E THORACIC EXTREMITIES. 
haps also the internal superficial vein and nerve ; but, in order to 
avoid mistaking the precise seat of the arterial trunk, it is suffi- 
cient to recollect that the median nerve is the first cord which we 
meet with in departing from the biceps muscle. 
The Arteria humeralis profunda superior, or the great col- 
lateral, generally arises from the brachial a little below the teres 
major; sometimes, also, it is derived from the subscapulary, cir- 
cumflexi, etc., arteries. In either case, it immediately directs its 
course towards the interstice of the internal and middle heads of 
the triceps muscle, in order to enter the posterior region. Its 
volume is sometimes very considerable, and it is the principal 
branch for re-establishing the circulation after the ligature of the 
humeral. The application of this ligature should not, if possible, 
be made too near the arteria anastomotica profunda superior; 
for then the blood cannot readily stagnate above the obliterated 
point, which will render the formation of the coagulum difficult. 
(c ) The middle anastomotic {anastomotica magna) is seen 
about the middle of the arm, and passes for some distance upon 
the brachialis internus previous to perforating the intermuscular 
ligament, in order to get to the posterior part of the arm. It 
follows the ulnar nerve in the same manner that the preceding 
accompanies the radial. Generally of small volume, it is some- 
times very large, and may equal the size of the brachial. We 
must not forget the possibility of such a disposition when we 
perform any operation upon the internal part of the arm, in gen- 
eral, and upon the humeral artery in particular. It is also an 
additional reason for inducing surgeons to place the ligature 
rather near the aneurismal tumour than at a distance from it, 
when wre operate upon this portion of the limb; and it should 
likewise be recollected in amputation, in order that it may be 
secured. 
{d) The Nutrient Artery of the bone {Nutritia magna hu- 
meri) is found towards the termination of the coraco-brachialis; 
it generally traverses the tendon of this muscle, slides obliquely 
upon the humerus, and penetrates its osseous canal. It should be 
noticed, because when its volume is increased, as it is in most 
cases requiring amputation, if the section of the bone is made 
near the deltoidal impression, a considerable flow of blood may 
be the consequence. In fractures of this part of the bone it OF THE THORACIC EXTREMITIES. 
267 
may be lacerated, and give rise to extensive ecchymoses which it 
would be difficult to attribute to a wound of the veins. 
It is not uncommon to see the origin of the inferior or internal 
collateral at the lower fourth of the anterior brachial region ; but 
as it is still more frequently found in the region of the elbow, we 
will there examine it. As to the other branches given off by the 
humeral, they are too small and irregular to arrest the surgeon’s 
attention. 
The Brachial artery is sometimes double from its origin ; at 
other times, from a more or less elevated point of the extremity 
only; then the two trunks may be of equal volume: more fre- 
quently one is smaller than the other; in which case the external 
is the largest: sometimes, but less frequently, it is the internal. 
Be it as it may, this anomaly might give rise to serious errors, if 
we were obliged to tie the humeral artery where it existed. 
vi. The Veins. 
They are superficial and deep-seated. The former are the 
Cephalic and Basilic. 
(a ) The Cephalic ascends parallel to the biceps on the fore 
part of the external furrow of the arm; it gradually inclines in- 
wards, so as to enter the interstice which separates the deltoid 
from the pectoralis major {coraco-deltoidal groove); then it con- 
tinues in the anterior region of the shoulder throughout the whole 
extent of this groove. The cephalic vein is situated external to 
the aponeurosis, enveloped in the deep laminae of the subcutane- 
ous layer; in the coraco-deltoidal groove, on the contrary, it is 
interposed in the laminae of the fascia brachialis, which, in this 
place, is nothing more than cellular tissue more or less condensed. 
However, it follows from this difference in the relations of this 
vein with the aponeurosis, that it is always somewhat deeply 
seated superiorly; whilst, below the deltoid, it is so superficial 
that we see it through the skin, even in persons who are not 
emaciated. It seldom becomes varicose; nevertheless, some 
cases of this nature are recorded.* Strictly speaking, it is pos- 
sible to open it with a lancet, throughout its whole course, with- 
* Briquet, these 1824, Archives, 1S25. 268 
OF TIIE THORACIC EXTREMITIES. 
out danger. Inferiorly, it is only accompanied by some filaments 
of the external cutaneous nerve. 
(b) The Basilic is situated in the middle of the internal bicip- 
ital gutter. It is at first enveloped in the laminae of the fascia 
superficialis, but, like the cephalic, afterwards abandons this 
layer, sometimes immediately above the elbow, at other times 
only when it is about entering the axilla in order to traverse 
the brachial aponeurosis, and empty into the deep-seated veins. 
Whilst it is cutaneous, it is surrounded by numerous filaments of 
the interna] superficial nerve, and in the aponeurosis, we have 
already stated that it runs by the side of the trunk of this nerve, 
in the same manner that the humeral artery does by the median, 
and that it is included in a distinct sheath, separated by a par- 
tition from that of the artery: it is then, so to say, both super- 
ficial and deep-seated. Hence, when it inflames, it may give rise 
to a simple erysipelas in the lower part of the arm, whilst in its 
superior portion, it may occasion a general tumefaction. For 
the same reason it may determine the formation of abscesses 
between the aponeurosis and the integuments, and also give rise 
to them between the muscles; whilst the inflamed cephalic vein 
can only produce similar consequences in the subcutaneous 
layer. 
The deep-seated veins were pointed out when speaking of the 
artery; we will only add here that, when we wish to obliterate the 
latter, we should carefully avoid comprising them in the noose, 
because their ligature is generally dangerous, from the phlebitis 
which it produces. 
vii. The Lymphatics. 
The superficial lymphatics abound in the bicipital furrows, 
where they are clustered around the cephalic and basilic veins. 
The latter in particular is accompanied by a very complicated 
lymphatic plexus, which remains in the superficial cellular layer 
until it reaches the cavity of the axilla. It is on account of the 
great abundance of absorbent vessels and cellular tissue which 
we find in the internal bicipital gutter, and even throughout the 
whole internal surface of the arm ; it is because the skin is more 
delicate and sensible here than elsewhere, that we are advised to 269 
OF THE THORACIC EXTREMITIES. 
apply medicinal substances upon this surface, with the view of 
introducing them into the general circulation. 
The deep-seated lymphatic vessels form two or three bundles 
around the artery and veins: they are interrupted from the elbow 
to the axilla by glands, which seldom exceed four or five in num- 
ber ; very frequently there are none, and when they do exist, 
they are naturally very small. However this may be, it is neces- 
sary to recollect their exact position ; for, if they enlarge gradu- 
ally, they may contract adhesions with the artery, and impose 
upon us for aneurisms. We have twice met with a single lym- 
phatic gland in the upper part of the deltoidal fossette. In both 
cases it was of the size of a large lentil, and the vessels passed 
towards it in a convergent direction: it was external to the apo- 
neurosis. 
viii. The Nerves. 
( a ) The relations of the median were pointed out above, 
when speaking of the artery. 
(h) The musculo cutaneus, or external cutaneous, instead of 
perforating the coraco-brachialis muscle, sometimes remains for 
a considerable time upon the external side of the artery; and in 
this case, if we were not attentive, it might be mistaken for the 
median nerve. Be this as it may, in enters into the sheath of 
the biceps, and is soon found on the outer side of this muscle 
opposite to the cephalic vein, from which, however, it is separa- 
ted by the aponeurosis as far as the inferior part of the region. 
( c ) The Internal Cutaneous. Next to the median, this lies 
nearest to the artery. Situated upon a plane a little more ante- 
rior, it follows the external border of the basilic vein, runs with 
it into its canal, and escapes, at the same time with it, from the 
aponeurosis. In its course it gives off numerous filaments to the 
superficial layer. It is sometimes of considerable volume, so 
that at the first glance it might be mistaken for the median ; but 
this error would soon be corrected by referring to the biceps 
muscle. 
( d) The Ulnar Nerve is placed upon the internal side of the 
brachial artery before the triceps muscle, by which it is enveloped 
almost from its commencement, and which it traverses about the 270 
OF THE TIIOKACIC EXTREMITIES. 
middle of the arm, in order to get into the posterior region, bo 
behind the epicondylo-humeral intersection (intermuscular liga- 
ment). 
( e) The Radial is still more posterior and more external. It 
follows the direction of the great collateral artery of the arm, 
that is to say, it turns round the humerus between the heads of 
the triceps, abandoning almost immediately the region in which 
it originates. It is most frequently the largest of all. The vol- 
ume of the nerves of the arm would be pretty accurately gradu- 
ated in the following order: 1st, The Radial; 2d, the Median ; 
3d, the Ulnar; 4th, the Musculo Cutaneus; 5th, the Internal 
Cutaneous. 
We also have here the nervous filaments which come from the 
intercostal nerves, and which are entirely lost in the superficial 
layer, upon the internal surface of the arm. These twigs estab- 
lish a certain sympathetic relation between the arm and the or- 
gans contained in the thorax; a relation to which many physi- 
cians have ascribed considerable importance, when they have 
endeavoured to explain the revulsive action of blisters applied 
upon the superior extremity in diseases of the thorax. 
ix. The Skeleton. 
It is formed by the anterior part of the humerus, which is 
slightly curved in this direction, rounded and prominent above, 
and which gradually grows broader as it descends. It is between 
the point of insertion of the latissimus dorsi, coraco-brachialis and 
pectoralis major, that this bone may serve for the compression 
of the artery, as it is there prevented from rolling under the fin- 
gers by these muscles. To its anterior surface the coraco-bra- 
chialis, deltoid and brachialis interims are attached. But we will 
examine the different peculiarities which concern this bone with 
more advantage, when we come to speak of the posterior bra- 
chial region. 
Sect. 2. Posterior Brachial Region. 
This region is much less complicated than the preceding, and 
of minor importance in surgery. In its superior portion it pro- OF TIIE THORACIC EXTREMITIES. 
271 
sents a part of the deltoidal eminence and of the posterior groove 
of the same name : as for the rest, it is rounded and convex. 
CONSTITUENT PARTS. 
i. The Skin. 
This layer is compact, thick, rugous, and much less extensible 
than on the fore part of the arm; it is also darker, and contains 
many piliferous bulbs and a great quantity of sebaceous follicles. 
It is these bulbs and follicles which sometimes give to the skin 
that irregular and rough appearance, vulgarly called “ goose-flesh,” 
which manifests itself in consequence of some violent mental 
impression or sudden exposure to cold. Boils frequently occur 
in it. 
n. The Subcutaneous Layer. 
It is less complicated and always much thinner than anteriorly; 
includes only a small number of vascular and nervous twigs, 
and but few adipose vesicles. Consequently, the cellular is al- 
most the only tissue which exists in it; it is lamellated, and its 
lamellae, more or less compact, sometimes form a complete fas- 
cia superficialis. From the compact texture of the skin, and the 
slight adhesion of the cellular layer, pus burrows under these parts 
with the greatest facility and with difficulty makes its escape 
externally; hence we should open abscesses, occurring in this 
region, at an early period. 
in. The Aponeurosis. 
This is generally thicker than upon the fore part of the biceps, 
but thinner than in the brachial gutters. Its fibres are principally 
transversal. It is continuous, superiorly, with the tendon of the 
latissimus dorsi, which may be considered as its tensor; inferior- 
ly, where it passes upon the anterior region, it receives the fibrous 
intersection which originates from each side of the humerus, and 
it is then that these intersections form two species of ligament. 
Elsewhere, it consists of one sheet only, except as it approaches 272 
OF THE THORACIC EXTREMITIES. 
the internal intersection, where its laminae split in order to en- 
velope the ulnar nerve. 
iv. The Muscles. 
Properly speaking, this region includes the Triceps only. That 
portion of the deltoid which is observed in the upper part, can 
give rise to no further remarks than have been made in the pre- 
ceding regions. It is necessary to note that, superiorly, the fibres 
of the triceps are nearly parallel to the direction of the bone; 
whilst inferiorly they run obliquely from the median line towards 
the sides: they are connected to the aponeurosis by means of 
a very supple lamellated cellular tissue, which easily inflames 
and sometimes gives rise to severe symptoms, owing to the 
resistance which the aponeurosis opposes to the accumulation of 
the fluid. Its anterior surface is attached to almost the whole 
length of the bone, and this is a very important circumstance to 
note, both in relation to amputations and fractures. When we 
amputate the arm, for instance, if we wish to make two flaps, 
after the manner of Vermale or Ravaton, the triceps will accom- 
modate itself to this method; but as the biceps is entirely free 
on the fore part of the arm, it will retract too far, and will form 
too round a mass for the flap to be sufficiently regular on this 
side. 
If we operate by the circular method, as the biceps alone is 
capable of retraction, it is useless, with the view of preventing 
the projection of the bone, to dissect up the skin, as was done by 
Petit and Cheselden. It is sufficient for the assistant to draw up 
the skin firmly, whilst we cut it and divide the cellular bridles 
which retain it upon the triceps, in order that this muscle may be 
incised sufficiently high up. 
In fractures which occur lower down than the insertion of the 
deltoid, as the triceps is attached to the two fragments, which are 
enveloped by it, it is incapable of producing displacement; on 
the contrary, like the brachialis interims, it always tends to 
maintain them in contact; therefore these kinds of fractures are 
rarely followed by much over-lapping, unless they are very 
oblique, or the fracturing cause has continued to act after the 
fracture of the bone. OF THE THORACIC EXTREMITIES. 
273 
v. The Arteries. 
These vascular branches are few in number, and are all de- 
rived from the humeral artery; they only merit our attention on 
account of the anastomoses which establish a communication 
between them and the collateral arteries of the fore-arm, and 
which re-establish the circulation after the obliteration of the 
brachial artery. We find in this region the great collateral (pro- 
funda) which turns round the humerus, first between the internal 
and scapulary bundles (short and long portions) of the triceps, 
then before the latter, afterwards upon the external (longer) por- 
tion, in order to terminate in the vicinity of the epitrochlea {inter- 
nal condyle). All the ramuscules which it gives off in this track 
are lost in the triceps. It is seldom that any of them are so 
large as to require a ligature after amputation: but the collateral 
must be carefully tied. In this case we should not forget that 
it is accompanied by the radial nerve, in order to exclude this 
cord from the ligature. 
The other branches are derived from the arteria profunda me- 
dia and the internal collateral (anastomotica magna); they inos- 
culate a great number of times with those just mentioned, and are 
too small to require any particular precautions in operations; so 
that if w'e amputate the arm some inches above the elbow, it will 
scarcely ever be necessary to tie more than the brachial artery 
and the great anastomotic; if, on the contrary, the operation was 
performed in the middle of the limb, haemorrhage might take 
place from the brachial, profunda superior {external collateral) 
and media, and even from the arteria nutritia of the bone; and 
from this circumstance it is necessary to recollect the exact posi- 
tion of these arteries. 
vi. The Veins. 
They have the same disposition with the arteries, are not su- 
perficial, nor susceptible of any particular surgical applications. 274 
OF THE THORACIC EXTREMITIES. 
vii. The Lymphatics. 
Almost all of them pass into the internal bicipital furrow, are 
few in number, and, so far as is known, destitute of glands in this 
region. 
viii. The Nerves. 
(a) The superficial filaments are small and few in number; 
they appertain almost entirely to the internal cutaneous and dor- 
sal branches: externally, in fact, scarcely any of them are fur- 
nished by the external cutaneous nerve. 
(b ) The Ulnar (Cubital) is the most remarkable ; it only en- 
ters into this region towards the inferior third of the arm. It then 
runs between the brachialis internus and triceps, and the aponeu- 
rosis furnishes it with a process which is converted into a canal by 
the internal fibrous intersection ; after which it takes its course, 
surrounded by this sheath, along the inner border of the arm, and 
in so superficial a situation that it is very much exposed to in- 
jury. 
(c ) The Radial, which is likewise very large, gives several 
branches to the different portions of the triceps, and exactly fol- 
lows the course and distribution of the deep humeral artery until 
it arrives opposite to the origin of the supinator longus, where it 
traverses the external fibrous intersection, in order to penetrate 
into the anterior region between this muscle and the brachialis 
internus. This nerve, resting immediately upon the humerus, is 
more exposed than all the others to be stretched or torn in frac- 
tures which take place below the neck of the bone. 
ix. The Skeleton. 
This is formed by the body of the os brachii, which is the nar- 
rowest part of the bone, and consequently is more disposed to 
yield to the action of indirect causes of fractures ; and as blows, 
falls, etc., have a greater hold on it than upon the extremities of 
the bone, it follows that its fractures must be very frequent. 
In consequence of the muscular insertions, these solutions of OF THE THORACIC EXTREMITIES. 
275 
continuity may be arranged in three orders:—1st, In those which 
take place between the deltoid and teres major, the parts are so 
disposed that the inferior fragment is drawn forwards and out- 
wards by the biceps and deltoid, and downwards by the long por- 
tion of the triceps; whilst the coraco-brachialis, latissimus dorsi, 
teres major and pectoralis major, tend to draw the superior frag- 
ment inwards. It is in this species of fracture that the displace- 
ment may be carried to the greatest extent, and it seldom fails to 
take place. 
When the fracture occurs towards the deltoidal depression, 
the superior fragment is abandoned to the deltoid and to the mus- 
cle of the shoulder, which draw it outwards and forwards. The 
inferior end remains under the control of the brachialis internus, 
which then takes its fixed point from the ulna. The biceps and 
the long portion of the triceps, in this case, counteract each other. 
Finally, in the third case, that is where the fracture takes place 
near the inferior third of the region, the two fragments are found 
simultaneously enveloped by the brachialis internus and the tri- 
ceps : so that it is very rare to see the muscles alone produce the 
displacement. 
Art. III. OF THE ELBOW. 
Under this title we comprehend that portion of the superior ex- 
tremity which is circumscribed, superiorly, by the circular line 
w hich forms the inferior boundary of the arm, and inferiorly by 
another circular line drawn three inches below the humeral con- 
dyles. This part, like the arm, will be divided into anterior and 
posterior regions. 
Sect. 1. Anterior Region of the Elbow; or Fold of the Arm, 
(Vide Plate 6.) 
This region is very important with respect to venesection, and 
aneurisms which frequently have their seat in it. Its surface pre- 
sents, superiorly, the termination of the bicipital prominence; ex- 
ternally and internally, two other muscular eminences, which con- 
verge towards one another and at length become conjoined at 
their entrance into the anti-brachial region. These last are sepa- 276 
OF THE THORACIC EXTREMITIES. 
rated, superiorly, by the first prominence, and inferiorly by a tn- 
angular depression of greater or less depth. This excavation, 
which is prolonged upon the fore-arm, forming a simple groove, 
results from the reunion of the two bicipital gutters, which are 
blended between the three eminences just mentioned. 
CONSTITUENT TARTS. 
i. The Skin. 
It is delicate and white, especially in the gutters and the medi- 
an excavation, as well as upon the bicipital prominence ; it is also 
covered with some hairs upon the lateral eminences, where it con- 
tains more sebaceous follicles than in the other points of the re- 
gion. As it receives a great number of nervous filaments and 
blood vessels, it readily inflames, and frequently becomes the seat 
of small phlegmons, or of erysipelas. 
ii. The Subcutaneous Layer. 
This layer is, if I may so say, composed of two sheets: one, 
deep-seated, a species of aponeurosis, in the lamina? of which are 
the subcutaneous nerves and vessels; the other, superficial, con- 
stituted principally of adipose ceils, and variable in thickness. In 
emaciated individuals, the latter sheet scarcely exists, whilst the 
other is then thicker and more firmly adherent to the skin. This 
deep-seated sheet, thicker in the gutters than upon the eminences, 
penetrates, in accompanying the deep median vein, between the 
pronator radii teres and the supinator longus, in order to become 
continuous with the intermuscular cellular plates and the cellular 
tissue surrounding the articulation. 
It is in the subcutaneous layer that phlegmonous erysipelas has 
its seat; and hence we may conceive with what facility the in- 
flammation and pus may traverse into the neighbouring regions. 
m. The Aponeurosis. 
In thin adults, whose aponeuroses are strong and well delineat- 
ed, the following is the natural disposition which that of the fold OF TIIE THORACIC EXTREMITIES. 
277 
of the elbow presents : it is merely a continuation of that of the 
arm ; but as it is excessively complicated, it requires to be exam- 
ined in its several points separately. On the outer side of the 
biceps, the superficial sheet, which covered the inferior portion of 
this muscle, passes upon the anterior face of the external muscu- 
lar eminence ; and where it dips, the deep-seated sheet is also ap- 
plied to it, down into the external furrow. There the aponeurosis is 
thicker, and its laminae soon separate in order to envelope the su- 
pinator longus muscle; lower down, the deep-seated sheet only 
persists in the median excavation, where it is found strengthened 
by a lamina of greater or less thickness, which is detached from 
the tendon of the brachialis internus. As it descends, this deep- 
seated sheet rises again, so that it passes between the radiales and 
supinator longus, on the one part, and, on the other, expands upon 
the anterior face of the latter muscle, becoming blended with the 
superficial sheet; finally, at the inferior part of the region, these 
sheets again approximate, and it is between them that we meet 
with the radial artery, vein and nerve. 
On the inner side of the biceps, the superficial sheet, stronger 
than on the outer side, spreads obliquely over the internal mus- 
cular eminence. The deep-seated sheet, which is still thicker, 
is also derived from the internal and inferior part of the brachialis 
internus : as it ascends, its fibres are directed obliquely inwards 
and upwards; it splits occasionally in order to envelope the basilic 
vein, which also sometimes passes between this and the super- 
ficial sheet. As it descends, it likewise unfolds, and one of its 
laminae rises over the fore part of the pronator radii teres, where 
it blends itself with the superficial sheet, whilst the other dips 
down between the muscles. The bandelet which is detached 
from the external margin of the tendon of the biceps, passes be- 
tween these laminae, in the first place, without adhering to them,, 
but afterwards becomes confounded with them upon the internal 
muscular eminence. 
From what has preceded, it follows that the diverse lami- 
nae of the anti-brachial aponeurosis are principally attached to 
the tendons of the biceps and brachialis internus, and conse- 
quently that, when these muscles contract, they must stretch the 
fibrous sheet sheath now under consideration. It also follows 
that an aponeurotic aperture seems to exist in the middle of the fold OF THE THORACIC EXTREMITIES. 
278 
of the arm. This opening bears a very great resemblance to that in 
the fascia lata femoris; it resembles it in its dimensions, in its oval 
form, by its largest extremity being downwards, by its internal 
semi-circumference which is better defined than the external, by 
the vessels and nerves observed in it, and lastly, by the cellular 
lamellae which close it, and sometimes prevent its being clearly 
distinguished. It commences, in general, some lines above that 
portion of the biceps which sends oil the fibrous bandelet to the 
aponeurosis, and terminates about an inch below this expansion. 
We observe in it, superiorly, the tendon of the biceps, and on 
the inner side of it, when the aperture is considerable, the bra- 
chial artery and median nerve, the origin of the fibrous bandelet, 
the external border of which sometimes forms the internal semi- 
circumference of this circle. Lower down than the biceps we 
•still observe the brachial artery, the origin of the radial and ulnar, 
their venae comites, the communication of the median veins with 
the brachial vein, the median nerve, the tendon of the brachialis 
interims, and lastly the median basilic and median cephalic veins, 
which pass before this aperture. 
It is important to note here that the bandelet given off from the 
inner margin of the bicipital tendon merits, in relation to the 
artery, the greatest attention. In fact, it uniformly crosses the 
anterior aspect of this vessel, as it is passing upon the muscles of 
the fore-arm; so that the humeral artery may be secured below 
this bandelet, before it divides into the radial and ulnar, and we 
may also tie it above it, without being obliged to separate any 
thing but cellular tissue. 
Upon the external muscular prominence the aponeurosis of the 
fold of the arm is very simple and does not adhere to the mus- 
cles ; internally, on the contrary, it is firmly connected to the 
muscular bundles, sends intersections between them and is blend- 
ed with their tendinous origin upon the fore part of the epitrochlea 
(internal condyle). In the bottom of the bicipital aperture, it 
passes back to the articulation of the elbow, and is there continu- 
ous with the ligaments. 
iv. The Muscles. 
They may be arranged according to the three principal emi 
nences of the region. 4>F the thoracic extremities. 
279 
( a ) In the median muscular eminence, we find the termination 
af the biceps; the tendon of this muscle, applied upon the bra- 
chialis interims, makes a turn as it dips into the hollow of the 
elbow, in such a manner as to form an arc of a circle the convexity 
of which looks forwards, inwards and downwards. Between this 
tendon, the fibrous bandelet which it gives to the aponeurosis, 
and the pronator teres muscle, exists a small triangle, in which 
we see the brachial vessels and the median nerve ; and it is upon 
the fore part of this triangle that the basilic vein corresponds to 
the brachial artery. Lower down, and always on the inner side, the 
internal muscular eminence partly conceals the tendinous extre- 
mity of the biceps, at the moment of its insertion into the tubercle 
of the radius: when this tendon abandons the brachialis interims 
it is reflected back, so that one of its surfaces looks inwards whilst 
the other is inclined outwards, and twists upon itself in the latter 
direction, in order to pass upon the radius. 
From this disposition it follows that, in the physiological state, 
the biceps tends, in the first place, to roll the radius outwards 
and consequently to produce supination; afterwards to flex the 
fore-arm, if its action continues after the rotation has been effect- 
ed. It must be observed, in relation to the movement of flexion, 
that this muscle acts upon a lever of the third order, and that it is 
inserted in a manner very unfavourable to this motion, since the 
insertion is very near the fulcrum; but that on the other hand, 
the species of pulley which the brachialis interims muscle forms 
for it behind, by enlarging the angle under which it is fixed to the 
radius, partially compensates for the unfavourable disposition just 
indicated. 
In the pathological state, in luxations of the fore-arm back- 
wards, for example, this muscle counteracts the action of the 
triceps and tends to produce flexion. In fractures of the upper 
third of the radius, the biceps also draws the superior fragment for- 
wards and towards the median line of the limb: whence the 
necessity of keeping the fore-arm flexed, in order to maintain the 
surfaces in contact. 
Next the Brachialis internus (brachial anterieur), which forms 
the bottom of the two lateral furrows. It is covered in the mid- 
dle by the biceps and its tendon, by the radial and musculo- 
cutaneus nerves; by the median cephalic vein, in the external 280 
OF THE THORACIC EXTREMITIES. 
gutter, and, on the outer side, by the external muscular eminence. 
Internally, the brachial artery and median nerve rest upon its 
anterior surface, which dips a little under the pronator radii teres; 
its posterior surface covers the whole of the fore part of the arti- 
culation, without adhering to it. This muscle is separated from 
the anterior face of the humerus by a considerable quantity ol 
very lax lamellated cellular tissue. When this cellular tissue 
becomes inflamed, it frequently gives rise to deep seated abscesses, 
which promptly occasion disorganization of the bone. The very 
strong and very thick tendon of the brachialis interims, in descend- 
ing upon the coronoid process, does not attach itself to it, as is too 
generally repeated, but simply covers this eminence, and is 
evidently inserted into that crest which connects its anterior 
border with the internal border of the ulna. In this manner the 
insertion of the brachialis interims descends to a level with the 
tubercle of the radius. Hence it follows that this muscle really 
acts upon the body of the bone, and that the apophysis answers for it 
the purpose of a pulley; which is much more favourable for its 
action. 
( b ) The external muscular eminence includes the supinator 
longus, the extensor carpi radialis longior and brevior, and the 
supinator radii brevis. The first of these muscles is the most im- 
portant in a surgical point of view; in fact, it is under its inner 
margin that we find the radial artery; it is between it and the 
brachialis interims that the radial nerve descends in the median 
excavation of this region; and it is beneath it that this nerve 
divides into anterior and posterior branches. From its originating 
pretty high upon the humerus, even in the brachial region, and 
from its direction, it seems that this muscle is better adapted to 
act the part of a flexor than a supinator of the fore-arm, which 
appears more properly to belong to the biceps. When the 
humerus is fractured below the deltoid impression, the supinator 
longus acts like the brachialis internus upon the lower fragment. 
The same may be said of the extensor radialis longus: the latter 
and the brevis, being more particularly applied upon the epicondylc 
(external condyle), to which they are attached, and upon the 
small head (cminentia capitata) of the humerus, become the prin- 
cipal causes of displacement in fractures of this part of the os 
brachii. As for the rest, they present nothing very remarkable OF THE THORACIC EXTREMITIES. 
281 
in this region; they are separated, below especially, from the 
supinator longus and radial artery, by a fibrous, or simply cellular 
process, according to the subject. 
As the supinator brevis adheres to the epicondyle and ulna, 
envelopes the humero-cubital articulation and almost all the supe- 
rior fourth of the radius, it constitutes a power which, on the one 
hand, opposes luxations, and, on the other, displacement of the 
fragments when the upper part of this bone is fractured: in this 
respect, it is the antagonist of the biceps, for the tendon of which 
there is a notch in its internal margin. The posterior branch 
of the radial nerve passes through its fibres into the posterior 
region of the fore-arm. 
( c ) The Internal Muscular Eminence contains the greatest pro- 
portion of muscles; but as all these muscles are blended upon 
the epitrochlea, it is not necessary to examine each of them 
separately. This mass then is composed of the pronator teres, 
flexor carpi radialis, palmaris longus, flexor sublimis, flexor carpi 
ulnaris and flexor profundus. All these muscles are united by 
fibrous intersections, among which there is one which will be 
of great assistance to us in finding the ulnar artery in the fore 
arm: it is that which is situated between the flexor ulnaris and flexor 
sublimis. The pronator teres is the only one which deserves 
particular attention; it is below it that the ulnar artery and 
median nerve insinuate themselves, in order to escape from the 
fold of the arm through one or more apertures which result from 
the separation of its fibres; it is before its tendon that the radial 
vessels and nerves are placed as they descend upon the fore- 
arm. As this muscle derives its fixed point from the humerus, 
and as it passes obliquely upon the radius, it follows that its action 
appertains entirely to the latter bone; which in the natural state 
produces pronation ; but in fractures this disposition is very dis- 
advantageous ; for, whether the fracture of the radius is above or 
below the insertion of the pronator teres, whether the bone is 
broken obliquely or transversely, it will always tend to obliterate 
the interosseous space, by drawing one of the fragments towards 
ulna. 282 
OF THE THORACIC EXTREMITIES. 
V. The Arteries. 
(a ) In the fold of the arm we find ; liist the humeral, which 
descends to it obliquely outwards and backwards, in the bottom 
of the internal bicipital furrow. It does not generally divide 
until it arrives at the tubercle of the radius. Enveloped in the 
laminae of the deep-seated sheet of the aponeurosis, the humeral 
artery is covered, from above downwards, by the superficial 
sheet, by the fibrous slip of the biceps, and more inferiorly by 
some cellular tissue only. Anterior to these sheets, it corres- 
ponds to the median basilic vein and internal cutaneous nerve; 
it rests upon the brachialis internus, then upon the tendon of the 
biceps, to which it sometimes adheres: whence it follows that in 
carrying the arm in forcible pronation, the artery, being drawn 
by the tendon, is thus separated, by a greater space, from the 
median vein. Along the inner side of the humeral artery the 
median nerve always runs, which may also be placed behind it; 
more internally and inferiorly, it is in relation with the pronator 
teres muscle ; externally, it runs by the side of the biceps, crosses 
the inner margin of its tendon, and terminates by being free in 
the median excavation. 
In consequence of these relations it is necessary, when about to 
tie the brachial artery at the fold of the arm, to proceed different- 
ly, according to the point at which we wish to expose it. If the 
operation is performed above the articulation, it would be neces- 
sary to divide, in the internal bicipital groove, the integuments 
and the fascia superficialis, to separate the basilic vein and the 
cutaneous nerve, and to cut through the aponeurosis, which is 
frequently double at this point, when the artery will be met with 
between the median nerve, the accompanying vein and the bi- 
ceps muscle. 
If, on the contrary, we seek for it in the bend of the arm, the 
incision should be made parallel to the external border of the in- 
ternal muscular eminence; the instrument will then divide the 
skin and the subcutaneous layer, when the only covering of the 
artery will be the cellular tissue. If we wish to expose it below 
the fibrous bandelet of the biceps, that is to say in the small 
triangle indicated when on the aponeurosis, we should recollect OF THE THORACIC EXTREMITIES. 
283 
that, at this point, the artery, nerve and tendon are very closely 
approximated, although always in the same relations, and that 
the aponeurosis, strictly speaking, no longer exists before them. 
If, finally, we wish to sieze it a little higher, it will be necessary to 
cut through the superficial sheet of the aponeurosis and the ban- 
delet of the biceps. 
It is necessary to note that aneurismal tumours at the fold of 
the elbow are developed differently, according to the point which 
they occupy. If they exist beneath the bicipital fibrous bandelet, 
the aponeurosis will not oppose any resistance to them inferiorly, 
anteriorly and externally, but it will afford much, inwards and 
upwards; the muscles and the fibrous sheets will always hinder 
them from increasing in this direction. Consequently, if we 
operate upon an aneurism at the elbow and the tumour is seated 
below the biceps, we would expect to find the opening of the 
vessel upwards and inwards. If the disease is situated immedi- 
ately above this bandelet, and the aperture which was mentioned 
when speaking of the aponeurosis is prolonged in this direction, 
the tumour will become engaged in it, and will remain globular 
and perhaps appear pediculated ; if the artery had been wound- 
ed or diseased under the fibrous bandelet, it is presumable that 
the sanguineous tumor would still pass through this aperture 
and project beneath the skin. 
Finally, if the aneurism forms in the superior part of the re- 
gion, it will remain flattened for a longer period; it will project 
less readily, externally; the tumour will be less moveable, be- 
cause the aponeurosis, equally applied over the whole anterior 
surface of the sac, will more firmly resist the distending effort of 
the blood, and, from this circumstance, it will be less easy to mistake 
the nature of the disease at this point than in the two preceding. 
It is not uncommon for the brachial artery to bifurcate higher 
up than has been stated; which is the reason why it is preferable 
to apply the ligature above the elbow than at the fold of the arm, 
even when the seat of disease will admit of a choice. This bifur- 
cation may take place upon the tendon, below its bandelet, which 
disposition enters into the normal state ; but if higher than this 
bandelet, in any point whatsoever of the rest of the region, it is 
then a decided anomaly. In the latter case, the two branches 
may remain by the side of one another, between the biceps and 284 
OF TIIE THORACIC EXTREMITIES. 
the median nerve, and enter together into the fold of the arm; 
or the median nerve may be situated between the two branches, 
the external passing before the tendon of the biceps, in order to 
get under the supinator muscle and form the radial, without de- 
scending to the bottom of the middle excavation of the elbow, 
whilst the internal glides, as usual, under the pronator teres to 
constitute the ulnar. This is a circumstance which might be 
attended with danger in phlebotomy, if we did not pay attention 
to it. It may also happen that the internal branch remains at 
some distance from that which is on the outer side of the median 
nerve, and, instead of plunging under the internal muscular emi- 
nence, passes before it in order to form the ulnar, which is then 
subcutaneous; in this case, this internal branch is generally only 
the inferior collateral (anastomotic) greatly developed. Finally, 
we have seen the brachial artery divide very high up, and in such 
a manner that one of its branches descended upon the external 
side of the biceps, in order to constitute the radial, sometimes 
running under the supinator longus, as in the normal state, and at 
others, external to the aponeurosis, immediately beneath the 
skin. 
The simultaneous existence of two humeral arteries beinjj a 
very common anomaly, the ancients had observed it, and, by this 
knowledge, endeavoured to account for the cure of aneurisms at 
the fold of the arm by the obliteration of the artery. They in fact 
preferred supposing that two arterial trunks existed in the limb, to 
admitting the possibility of the circulation of the limb being sup- 
ported after the ligature of the brachial artery. But the research- 
es of the celebrated Scarpa have corrected this error. 
( b ) The ulnar (cubitale) seems to be the continuation of the 
preceding. Immediately after it separates from the radial it dips 
under the internal muscular eminence, traverses the pronator 
teres, runs obliquely downwards and a little inwards, and places 
itself between the flexor sublimis and profundus. We see that 
it would be very difficult to discover it at the fold of the arm, in 
the usual state of conformation: therefore, when it is necessary 
to obliterate it, it is more prudent and certain to take up the 
brachial. 
( c ) The Radial is generally smaller than the ulnar, and lies 
pretty deep at first, but rises a little as it passes outwards and OF THE THORACIC EXTREMITIES. 
285 
forwards, under the supinator Jongus, in order to follow the mid- 
dle furrow of the fore-arm. This artery consequently becomes 
more and more superficial as it descends ; so that immediately 
below its origin it corresponds to the aponeurotic aperture, and 
is pnly separated from the radius by the supinator brevis, the 
tendon of the biceps and some cellular tissue. Anteriorly, it is 
separated from the integuments by several fibro-cellular lamina) 
and the superficial layer. From these circumstances, we might 
discover it by making an incision upon the external margin of 
the pronator teres; but the operation would not fail to be ren- 
dered difficult by the elevation of the muscular eminences, by 
the presence of the median cephalic vein and that of the exter- 
nal cutaneous nerve, which we would frequently be obliged to 
divide. As for the rest, the radial nerve is then several lines 
external to it. Below the aponeurotic aperture, the radial artery 
is placed upon the pronator teres, between two thin fibrous la- 
minae, having on its inner side the flexor carpi radialis, on its 
outer, the supinator longus, the internal margin of which usually 
advances some lines before it. Then the nerve approaches so 
close to it that we might strike it previous to its entrance into 
the anterior anti-brachial region: we would therefore have to 
divide the skin, the subcutaneous layer and the aponeurosis, 
which will present two sheets before the artery, if the instrument 
is directed upon the supinator, and only one, but thicker, if it is 
inclined more towards the median line. Besides, the middle me- 
dian vein and the principal branches of the musculo-cutaneous 
nerve should be drawn outwards, as well as the border of the 
supinator longus muscle. Then the radial artery will be easily 
distinguished between its nerve, which is external, and its col- 
lateral veins. 
( d ) The Interossea arising from the ulnar at the moment that 
it enters between the two muscular layers of the fore-arm, it 
would scarcely be possible to apply a ligature around it. It is 
seated too deep to be frequently wounded. 
( e ) The recurrens radialis anterior most frequently arises 
from the trunk of the humeral on the inner side of the tendon 
of the biceps, upon which it turns in order to pass into the ex- 
ternal furrow of the region. As this branch ascends, it runs 
between the two portions of the radial nerve, between the bra- 286 
OF TI112 THORACIC EXTREMITIES. 
chialis internus and the extensor radialis longus, places itselt be- 
fore the condyle, and goes to inosculate with the external col- 
lateral. It is sometimes so large that we should be apprehensive of 
placing a ligature immediately below it upon the humeral artery. 
(f) The Internal Rccurrents (Recurrentes Ulnaris) originate 
from the ulnar; the anterior glides along the bottom of the inter- 
nal bicipital furrow, between the brachialis internus and the inner 
muscular mass; it ascends before the epitrochlea, above which 
it anastomoses with the inferior collateral of the arm. The pos- 
terior recurrent passes between the flexor sublirnis, flexor pro- 
fundus, and flexor carpi ulnaris, in order to pass behind the epi- 
trochlea, etc. 
(g ) Finally, the internal or inferior Collateral of the arm 
(ramus anastomoticus magnus inferior) is also given off' by the 
brachial in the region under consideration; it is generally de- 
tached from the trunk an inch or two above the internal condyle 
of the humerus, and as its calibre is very considerable in certain 
subjects, it is necessary to pay attention to it in operations. It is 
by means of its anastomoses with the recurrent arteries that the 
circulation in the fore-arm is re-established when the humeral 
artery is obliterated at the fold of the elbow. We have previ- 
ously stated that it sometimes supplies the place of the ulnar, in 
which case it is generally very superficial. We know a physician 
in whom this disposition is so evident, that the pulsations of this 
artery are very perceptible through the skin, from the inferior 
third of the arm to the middle of the fore-arm. 
vi. The Veins. 
The superficial veins are the most important of the region; 
their volume is considerable, and by their communications with 
one another they form a species of plexus; they are : 
( a ) The Cephalic, which is situated upon the radial side of 
the region, in the laminae of the subcutaneous layer, upon the 
external muscular eminence. As this vein is passing from the 
anterior face of the supinator longus upon the side of the biceps, 
it receives the median cephalic and the anterior radial. The 
external cutaneous nerve runs by the side of it, but in such a 
manner that the former is separated from it, in the arm, by the OF THE THORACIC EXTREMITIES. 
287 
aponeurosis, as far as almost an inch above the epicondyle ; and 
upon the external muscular mass there are only some small ner- 
vous branches around the vein : therefore, in relation to nervous 
accidents, bleeding from the cephalic vein is less dangerous than 
that from the others, and the higher we open the vein the less 
cause will we have to apprehend such accidents after this 
operation. 
( b ) The Basilic is situated upon the ulnar side of the bend of 
the arm ; it passes before the epitrochlea in order to arrive at the 
internal bicipital furrow, from whence it proceeds into the bra- 
chial region. At first it is superficial, like the preceding ; that is 
to say, that upon the fore-part of the internal muscular eminence, 
it is included in the laminae of the subcutaneous layer; but as it 
ascends it gradually becomes deeper. When opposite to, or a 
little above the epitrochlea, as it is entering the internal bicipital 
groove, it tends to insinuate itself between the laminae of the 
brachial aponeurosis, which soon furnish for it a complete sheath, 
It is accompanied by the internal cutaneous nerve, included in 
the same aponeurotic sheath, and, above the muscular eminence, 
almost always situated upon its inner side : lower down, the prin- 
cipal branches of this nerve continue to follow" the vessel, but 
sometimes internal to, at other times crossing before it; and again 
they are behind, or upon its outer side. Occasionally they form 
around it a species of plexus: in short, these nervous filaments 
are so disposed relatively to the basilic, that it is scarcely possible 
to open this vein without running the risk of wounding them. In 
this respect, anatomical knowledge and the precautions which we 
might take will be but of slight assistance, on account of the 
numerous varieties in the relative position of these organs. On 
the one hand, if the operation is performed upon the side of the 
biceps, we will perhaps avoid the principal nerve by puncturing 
the vein from the external towards the internal side ; but if w7e 
should strike it, its volume in this place is so considerable, that 
pretty serious symptoms might be the consequence ; besides, the 
vein being deeply situated, it would not always be easy to reach 
it. On the other hand, if we bleed upon the eminence of the 
anti-brachial muscles, the nerves are indeed smaller, but if they 
escape the instrument it will be by chance alone. Venesection, 288 
OF T1IE THORACIC EXTREMITIES. 
therefore, from the trunk of the basilic should not be performed 
when we can do otherwise. 
( c ) The Median is actually the most important, in a surgical 
point of view, of the three veins at the fold of the elbow'. We 
generally meet with it in the lower part of the region, in the me- 
dian groove, occasionally inclined upon the external eminence, 
sometimes also more internally; it is almost always single, and 
thus ascends as far as the aperture of the aponeurosis. There it 
divides into three branches ; one, very short, which almost imme- 
diately empties itself into the deep-seated veins, in the same 
manner that the saphena major does into the femoral. The other 
two remain superficial, follow the two grooves of the fold of the 
elbow, passing upon the sides of the biceps in order to enter, the 
one into the basilic, and the other into the cephalic; so that, in 
the regular conformation, these twro branches, w ith the two trunks 
into which they open, represent somewhat the letter M. The 
median basilic vein consequently runs along the outer side of 
the internal muscular eminence, becoming deeper and deeper in 
proportion to its ascent: it is surrounded by some twhgs of the 
internal cutaneous nerve, and these sensitive filaments, in gene- 
ral of small size, are pretty uniformly situated before the vein. 
Its direction is such that it crosses the artery, which is behind 
it, very obliquely; but this direction is susceptible of numerous 
varieties; so that in some subjects the vein is almost parallel to 
the artery, whilst in others it crosses it at a considerable angle. 
In the the latter case, which is fortunately the most frequent, we 
run less risk of wounding the arterial trunk by making the punc- 
ture near the extremities of this vein. In the other, the dangers 
are almost always the same, at whatever point we may choose ; 
however, as the artery lies deeper superiorly and inferiorly than in 
the middle, we should prefer one of the tw'o former points, the 
second especially. The median basilic is nevertheless always 
separated from the humeral artery by fibrous or cellular lamina, 
according to the place at which we examine it. Thus, anterior 
to the tendon of the biceps, and below the bandelet which it fur- 
nishes to the aponeurosis, these vessels are separated by a lamel- 
lated cellular tissue only, which there forms a layer the thickness 
of which varies in proportion to the embonpoint of the individ- 
ual; w hence it follows, that, in fat persons, we may introduce the ©F THE THORACIC EXTREMITIES. 
289 
iancet very deeply without striking the artery ; whilst in thin sub- 
jects it will often be difficult to avoid it. Hence it is in the latter 
case that we most frequently see aneurism consequent upon bleed- 
ing. One of three things may then happen: 1st, either the in- 
strument will traverse the vein from one side to the other and 
penetrate the anterior paries of the artery, making a large open- 
ing in it: in this case the blood will be immediately thrown out in 
jets, and will only be stopped by the suspension of the circula- 
tion in the limb; a suspension which may be produced by syn- 
cope, but for a few moments only, by the ligature of the artery 
above the elbow, or by pressure above the puncture or upon the 
wound itself. It is, in general, when we have attempted the lat- 
ter method that the blood extravasates into the cellular tissue, and 
produces the false, primitive, or diffused aneurism :—2d, or the 
point of the lancet will have wounded the artery very slightly, 
and the accident will not be detected at the time of the opera- 
tion ; the wound of the vein and of the cellular covering of the 
artery will cicatrize: but the internal and middle arterial tunics 
being insusceptible of agglutination when they have been divided, 
the impulse of the blood will not delay to give rise to a tumour 
at this part, constituted by the fluid which will be extravasated 
in a cyst furnished by the cellular tunic: it is in this manner that 
the false consecutive, or circumscribed aneurism is formed, on the 
fore-part of which the veins usually remain applied. This form 
of aneurismal tumour is developed as frequently when, after the 
artery has been pricked in bleeding, compression has been made 
upon the wound ; then, in fact, the haemorrhage may be suspend- 
ed, and the patient apparently cured; but after a certain period, 
in consequence of some exertion, some sudden movement, or 
even without any appreciable cause, the lips of the arterial 
wound separate and the aneurism forms:—3d, or lastly, the cor- 
responding parietes of both vessels are so exactly applied against 
each other that, after the cicatrization of the subcutaneous wall 
of the vein, the red blood passes into the latter by the opening 
which is common to it and the artery, and thus forms the disease 
so well described by Hunter, Cleghorn, and Guattani under the 
name of Aneuresmal Varix. This pathological state may also 
be complicated with a circumscribed aneurism; that is to say. 290 
OF TUB THORACIC EXTREMITIES. 
after the aneurismal varix has existed for a greater or less length 
of time, it may happen that the two vascular parietes separate 
by the relaxation of the cellular tissue which unites them, and a 
sanguineous tumor forms between them, without interrupting the 
course of the fluid from one vessel into the other. This disposi- 
tion which has been noticed by Messrs. Parck, Physic, etc., con- 
stitutes what English pathologists call Varicose Aneurism. 
In the last two species of Aneurism, anatomy demonstrates, 
and observation has proved, that a cure cannot be accomplished 
with certainty unless a ligature is placed above and below the dis- 
ease. In fact, on the one hand, the collateral arteries are, gen- 
erally, in such cases, greatly enlarged ; the functions of the vein 
being changed, its parietes have assumed the most of the char- 
acters peculiar to the arteries; the latter, on the contrary, per- 
forming in part the functions of the venous system, have become 
weaker. It also follows that after the application of a simple 
ligature above the lesion, neither the vein nor the artery are oblit- 
erated below it, and the disease persists. On the other hand, 
MM. Richerand, Dupuytren, J. Cloquet, &c. have seen subjects 
affected wTith these aneurisms, in whom the operation had been 
performed according to Anel’s method without any advantage ; 
on the contrary, the life of some of them has been seriously 
compromised, and in others it became necessary to resort to am- 
putation of the limb ; finally, in the most fortunate circumstances, 
a second operation has produced a complete cure. These cases, 
therefore, demand the old operation. 
Above the point which has just been examined, the median 
basilic vein is separated from the artery, in the first place, by the 
fibrous bandelet of the biceps, afterwards by the aponeurosis, 
upon which the vein is applied. Here, embonpoint or emaciation 
produce but little difference in the relations of the vessels, be- 
cause the fat always accumulates between the vein and the skin, 
and not between the vein and the aponeurosis, nor between the 
latter and the artery. It must nevertheless be admitted, that, in 
individuals very much emaciated, the cellular laminae united to 
the fibrous layer are firmly applied to one another; so that the 
aponeurotic envelope of the arm is actually agglutinated with the 
corresponding parietes of the two vessels. In this case we con- OF THE THORACIC EXTREMITIES. 
291 
ceive that the only rational method of avoiding the artery con- 
sists in introducing the lancet very obliquely, in order to puncture 
the vein in its anterior half only. 
Whenever we draw blood from the median basilic vein, as the 
humeral artery is bound down upon the tendon of the biceps by 
the aponeurosis, or by the fibro-cellular tissue which fills the aper- 
ture of the latter, we will considerably increase the depth of this 
vessel by turning the fore-arm in forced pronation. Then, in 
fact, in proportion as the tendon is drawn downwards, the three 
muscular eminences become more prominent, and consequently 
render the veins more superficial. The ancient surgeons also 
recommended this plan when about to open the vein under con- 
sideration, with a view of preventing a puncture of the aponeu- 
rosis and tendon ; but, as it relates to this, it is now proved that 
the severe symptoms which sometimes follow venesection, must be 
referred to other causes than the -wounding of the fibrous elements 
of the region. All that we can concede to this idea of the an- 
cients is, that by puncturing the aponeurosis under the vein, we 
may, in certain cases, determine inflammation of the deep cellu- 
lar tissue; and as the tumefaction consequent upon it will be 
repressed by the fibrous expansion, a species of strangulation 
and more or less formidable phenomena would result from it. 
Those symptoms which are referred to pricking the aponeu- 
rosis, tendon or nerves, almost universally arise from phlebitis, or 
from the formation of vast phlegmonous abscesses under the skin. 
Phlebitis was unknown to the ancients; but it seems to us that 
many modems have caused it to perform too extensive a part in 
the inflammations which follow bleeding from the arm, and we 
think that they have too frequently attributed to it the simple or 
phlegmonous erysipelas produced by this operation. During the 
present year, we have seen at the Hospital of the Faculte, six 
patients in wThom, after a puncture with the lancet, pain, redness, 
and tumefaction at the fold of the arm took place: these symp- 
toms extended rapidly throughout the entire limb, and fever was 
excited; four of these patients recovered, after the formation of 
more or less extensive abscesses ; the other two died, and in these 
the skin was detached, by the disorganization of the subcutaneous 
adipo-cellular layer, from the hand to the shoulder. In the 292 
OF THE THORACIC EXTREMITIES. 
midst of this disorganization the veins were healthy, and their 
calibre had undergone no alteration. 
A fact of this kind was recently observed by M. Ch. Delange, 
in a soldier who died at the Hospital Val-de-grace. The pus 
had spread throughout the whole length of the limb, even into the 
thorax; yet, notwithstanding, the internal coat of the vessel pre- 
sented no decided inflammatory character. M. Broussais him- 
self, who assisted at the autopsic examination, could not de- 
tect any. 
The Median Cephalic is generally a little larger than that 
which has just been examined. As it ascends outwards, included 
in the radio-bicipital-furrow, it is accompanied by the internal 
branch of the musculo-cutaneus nerve. This nerve, which is 
always of a certain volume, sometimes passes before, much more 
frequently behind the vein, which on its part crosses the radial 
artery near its origin. Its distance from the humeral artery is 
greater in proportion as it approximates the trunk of the cephalic, 
and it is never so near this artery, unless by anomaly, as to en- 
danger a wound of the latter in drawing blood from the external 
median; but it should be observed, that in cases wherein the 
radial artery comes from the brachial region, this vein is generally 
contiguous to it. The median cephalic is usually less directly 
applied upon the aponeurosis than the basilic; the groove in 
which it is imbedded being broader, and the cellular tissue more 
abundant, it follows that it generally appears deeper, and rolls 
less under the finger; the tissues upon which it rests being less 
solid, less resistant, it sometimes happens that after having opened 
it, the flow of blood is with some difficulty restrained, because 
the pressure is not made so exactly upon it as upon the internal 
median. Every one knows also that occasionally, when we wish 
to stop the bleeding from one of these veins, the blood continues 
to flow, notwithstanding we apply the thumb below the puncture. 
This peculiarity, with regard to both, arises from our pressing 
upon the middle median vein below its division, and from the 
blood returning by the deep median ; or, with respect to the me- 
dian cephalic in particular, from the aponeurosis behind it not af- 
fording sufficient resistance to admit of the obliteration of this 
canal by the pressure of the finger. OF THE THORACIC EXTREMITIES. 
293 
The Trunk of the Median runs parallel to the internal margin 
of the supinator longus; so that it is only separated from the 
radial artery by the aponeurosis, and, more frequently, by the 
border of this muscle. Therefore, when we wish to lay bare 
the artery, we are obliged to push the vein towards the ulnar 
side of the region. The latter is often surrounded by several 
nervous filaments from the musculo-cutaneus, and the internal 
branch of this nerve almost always runs along its outer side ; for 
which reason, phlebotomy, although easy here, might give rise to 
serious symptoms. 
From all these considerations we draw the following conclu- 
sions: 1st. That venesection is more easy from the internal me- 
dian, but also more hazardous than from the external; 2d. that 
this operation may be performed upon all the veins of the fold of 
the arm; 3d. that, if in thin persons these vessels are large and 
distinct, they also roll more easily under the skin, on account of 
the mobility of the cellular titsue ; 4th. that if, in very fat sub- 
jects, it is sometimes very difficult to see and feel them, they are, 
by way of compensation, fixed, scarcely moveable, and more 
remote from the organs which should be avoided: hence, in 
eastern nations, Turkey for example, those empirics who make 
bleeding their trade, plunge their enormous lancets without 
hesitation, an inch deep into the plump arms of these indolent 
people, especially of the females, almost all of whom possess 
considerable embonpoint; 5th. that the flammette, used by Ger- 
man surgeons, applied upon the median basilic would be dan 
gerous, on account of the vicinity of the artery; and, upon the 
median cephalic, would often fail to open the vein, on account of 
the suppleness of the tissues in which it is imbedded ; 6th. that 
the thrombus must supervene more frequently in thin individuals 
than in those of an opposite condition, in consequence of the 
facility with which the parts slide over one another, thereby 
destroying the parallelism of the opening. This accident is most 
liable to occur when, for the purpose of removing the artery, the 
fore-arm is placed in a state of forced pronation during the punc- 
ture, because then, if we do not afterwards retain the arm in the 
same position whilst the blood is flowing, the aperture in the skin 
wrill no longer correspond with that of the vein, and the blood 
will become extravasated into the cellular tissue. 294 
OF THU THORACIC UXTRliMlTf US. 
We find as many deep-seated veins as arterial branches ; some- 
times more. The radial is frequently double; the ulnar some- 
times presents the same disposition, as well as the humeral. At 
the place where the two former unite in order to form the latter, 
they receive the communicating branch of the median, so that in 
this situation there is a species of confluence. When there is 
only one vein for each artery the radial is placed on the inner, 
the ulnar on the outer side ; the humeral also is most frequently 
external, sometimes anterior and even internal. As to the small- 
er branches, their course is similar to that of the arteries. 
vii. The Lymphatics. 
These vessels consist of two sets, a superficial and deep-seated ; 
the former is most abundant, and both accompany the blood-ves- 
sels, the veins in particular. They are so large, especially in the 
internal furrow, that if divided in venesection they will give forth 
considerable lymph. When pus, or other pathological products, 
exist in the tissues through which they pass, they readily become 
engorged and inflamed. Also, after bleeding, they often seem to 
us to be the point at which erysipelatous inflammations, so fre- 
quently consequent upon this operation, originate. We even 
think that what is sometimes referred to inflammation of the 
veins not unfrequently appertains to the lymphatics alone. 
The Lymphatic Glands are situated in the internal bicipital 
groove, before and above the trochlea, and are generally three, 
four, and even five in number. These bodies are situated be- 
tween the deep-seated cellular and aponeurotic layers. They 
sometimes become engorged and considerably enlarged from sup- 
purations of the hand and fore arm, in consequence of inflamma- 
lions, blisters, or any morbid affection whatsoever. 
vm. The Na'ves. 
These are also superficial and deep seated. 
Among the former, we find, first, the musculo-cutaneus: this 
cord is the largest; it comes from under the aponeurosis upon 
the external side of the biceps, about one inch above the articu- 
lation. A little lower down it divides, and its branches generally OF TIIE THORACIC EXTREMITIES. 
295 
toilovv the veins which unite to form the cephalic trunk. We 
have already said that the largest of these branches is situated 
upon the radial side of the common median. 
Next, the Internal Cutaneous, which is situated in the ulnar 
furrow. Its twigs are smaller than those of the preceding, and 
are distributed around the branches which go to empty into the 
basilic and median veins. The filaments of the latter nerve are 
almost always before the veins, whilst those of the musculo-cuta- 
neus are generally situated behind it. 
The second set also comprises two nerves. In the first place 
we meet with the radial; this nerve coming from the posterior 
part of the arm, places itself between the brachialis internus and 
supinator longus, then between the biceps and extensor radialis 
longior, and at length divides opposite to the articulation. Thus 
far it has continued in the bottom of the radial furrow, separated 
from the humeral artery by the entire thickness of the brachialis 
interims and biceps muscles, and sufficiently distant from any vein 
to be out of danger in bleeding. Its posterior branch turns out- 
wards, passes between the extensor radialis brevior and supinator 
brevis, traverses the fibres of the latter and penetrates into the 
posterior region of the elbow. As this branch lies very near the 
head of the radius, and turns over it, it may be stretched, com- 
pressed, etc. in luxations of the humeral extremity of this bone 
forwards. The radial nerve, properly so called, is constituted by 
the anterior branch. Its direction seems to be a continuation of 
that of the trunk ; it rises a little, in order to descend parallel to 
the length of the limb behind the great supinator, and is soon 
found by the side of the radial artery. Hence it follows that the 
anterior branch of the radial nerve is the more remote from the 
artery the nearer it approximates its origin, and that these organs 
are separated by a triangular space with superior base, in which 
we see the tendon of the biceps and a part of that of the brach- 
ialis internus muscle. 
Next the Median Nerve. It enters this region without any 
diminution of its volume. It is almost constantly situated upon 
the ulnar side of the artery, and rests upon the fore part of the 
brachialis internus muscle ; it descends into the hollow of the 
elbow along the inner portion of the bicipital tendon and cover- 
ed by the radial side of the internal muscular mass, always pre- 296 
OF THE THORACIC EXTREMITIES. 
serving its relations with the artery, to which it is then very closely 
approximated. In passing through the pronator teres muscle in 
order to place itself before the flexor profundus, this nerve is found 
behind the radial artery, or rather between it and the ulnar ; so 
that the latter removes from it considerably in passing towards 
the flexor carpi ulnaris muscle. It is when running under the 
muscular eminence that the median gives off many filaments, and 
it is previous to its exit from the region that it furnishes the inter- 
osseous, and the various twigs which sometimes follow the ulnar 
artery. According to this disposition it would be difficult for this 
large nervous cord to be injured in luxations of the elbow, but it 
may be struck with the point of the lancet when we open the ba- 
silic vein. In the operation for aneurism, it may embarrass the 
surgeon, and be taken for the artery, when the pathological state 
oft he tissues no longer permits us to distinguish its characters rea- 
dily. It should not, however, be comprised in the ligature, for 
paralysis of the first four fingers would necessarily follow, if the 
limb does not fall into gangrene. 
ix. The Skeleton. 
It comprises the anterior portion of the articulation, of the in- 
ferior fifth of the humerus, and of the superior fourth of the ulna 
and radius. 
The joint here presents three grooves and four eminences, cov- 
ered by a fibrous lamina of greater or less thickness. In order 
to distinguish these objects, the limb must be extended. The 
median groove is that in which the coronoid process of the ulna 
rolls; it is covered by the brachialis internus, corresponds to the 
humeral artery and median nerve, and it is in this point that the 
ligament of the articulation is the strongest. The second groove 
exists between the condyle and the internal tuberosity; it is not 
articular, and is covered by the origin of the ulnar muscular mass 
The third, or external, rolls upon the superior extremity of the 
radius; it is particularly concealed by an almost isolated bundle 
of the brachialis internus muscle. 
Of the four eminences, the external, formed by the condyle 
or small head of the humerus, surmounted by the epicondyle, is 
the most developed: it is concealed by the external muscular OF THE THORACIC EXTREMITIES. 
297 
mass. That which conics next represents a species of crest, which 
rolls upon the ulna, and even upon the radius also. The third, 
very large, is the trochlea, and the fourth, which is inclined con- 
siderably backwards, is the epitrocldea. Above these different 
points, the humerus presents a species of transverse furrow, 
which is produced by the anterior surface of the articular pulley 
being raised forwards. It is upon this furrow that the knife fre- 
quently strikes, when carried too high in disarticulating the fore- 
arm according to the method of M. Dupuytren ; but this mistake 
will always be avoided, if we take the precaution to draw the 
instrument from one humeral tuberosity to the other, keeping it 
upon a line a little distance below them. In this furrow, two 
fossettes are observed : one, small and of slight depth, above the 
external humeral groove, receives the fore-part of the head of the 
radius in the forced flexion of the fore-arm; the other, very deep 
and broad, receives the coronoid process of the ulna, in the same 
movement, above the median articular groove. Still higher, the 
anterior aspect of the humerus is flattened, and entirely covered 
by the brachialis interims muscle. 
Below the articulation, the ulna presents in the first place, the 
coronoid process which may be more or less curved upon the os 
brachii, and thereby powerfully oppose its luxation. In all cases 
in which amputation of the fore-arm at the joint is required, this 
curvature should be recollected; for it would be in vain to at- 
tempt introducing the knife between the osseous surfaces until 
this process is depressed. Its anterior surface inclines down- 
wards and forms another curve with an inferior concavity, below 
which the brachialis interims is inserted, and where the trochlea 
of the humerus lodges when luxated forwards. It is at this point, 
and especially in the radial and olecranoid excavations of the 
humerus, that those small clusters of synovial tissue exist, which, 
when attacked with chronic or acute inflammation, frequently 
form a focus whence white swellings and other serious diseases 
of the joint radiate. 
The Radius presents, in this region, its head, enveloped by the 
annular ligament, the supinator brevis, and all the muscles of the 
epicondyle ;—its neck, the bicipital tubercle, and the commence- 
ment of the body of the bone: it is upon the neck that the hu- 
meral condvle rest* when displaced forwards. .Above the bicipj- 298 
oi The thoracic extremities. 
tal tubercle, between the radius and ulna, there is a space, through 
which an instrument may be passed, from before backwards, 
without fracturing the bones. From what has just been said we 
perceive that, if the humerus can easily slip upon the anterior 
surface of the fore-arm, it would be very difficult for it to pass 
outwards or inwards, unless the ligaments, muscles, and even 
the vessels are at the same time lacerated. On the other hand, 
the inequality of all these surfaces, and their extensive transverse 
dimensions, render the articulation very solid, and only admit of 
the motions of flexion and extension, always joining to them the 
rotatory movement of the radius. 
Recapitulation. In the anterior region of the elbow we ob- 
serve the following order of super-position ;—1st, the skin; 2d, 
the fascia superficialis, or the subcutaneous layer, varying consid- 
erably in thickness, and including the superficial veins, nerves, 
and lymphatic vessels; 3d, the aponeurosis, thicker upon the 
external and internal eminences and furrows, thinner, and actu- 
ally perforated by a large aperture in the median excavation: 
4th, the arteries, muscles, deep-seated nerves, veins, and lymph- 
atics : 5th, and lastly, the articulation and the bones. But we 
have observed that these different layers are very variable in 
thickness in the different points at which they may be examined. 
Sect. 2. Posterior Region of the Elbow, or the Elbow, properly 
so called. 
The surface of the elbow presents three very distinct osseous 
projections which are;—externally, the epicondyle ; internally, 
the epitrochlea, and in the middle the olecranon, which is, how- 
ever, a little nearer to the internal than the external tuberosity. 
When the limb is extended these eminences are situated nearly 
upon the same line, but then the olecranon is scarcely prominent: 
when flexed, they represent a triangle, the apex of which is in- 
ferior ; and the olecranon, which then seems to be very much 
elongated, is below the articulation. The middle prominence is 
prolonged upwards, under the form of a flattened cord, which 
is produced by the tendon of the triceps; and downwards by 
means of the ulna. In whatsoever position the limb is placed, 
the internal eminence is equally prolonged superiorly by the OF THE THORACIC EXTREMITIES. 
299 
cpitrochlo-humeral (inner intermuscular) ligament, and inferiorly, 
by the extensor carpi ulnaris muscle. As the external ascends 
it becomes less distinctly marked by the outer border of the hu- 
merus ; immediately below it we may distinguish a transverse 
groove, which corresponds to the humero-radial articulation, then 
the head of the radius, which may easily be felt rotating in its 
annular ligament. 
These three projections are separated by two grooves, of 
which the internal, which is deepest, passes between the olecra- 
non and epitrochlea. This species of gutter insensibly contracts 
above the joint, by the gradual approximation of the internal por- 
tion of the triceps and of the epitrochlo-kumeral intersection. It 
is in this groove that we find the ulnar nerve. The external sep- 
arates the epicondyle from the olecranon; it is more superficial 
and irregular than the preceding; in ascending, it is almost im- 
mediately lost behind the tendon of the triceps. A knowledge 
of these features is of importance, especially when we wish to 
establish the diagnosis of fractures and luxations of this region. 
CONSTITUENT PARTS. 
i. The Skin. 
It is thicker and much less extensible than at the fold of the 
arm; its surface is uneven, rugous, even plicated in arcs of cir- 
cles in some subjects, above the olecranon ; it includes numerous 
sebaceous follicles and an abundance of hairs, in some male 
adults. To the latter, the median line must at all times form an 
exception, as it is always bare. 
ii. The Subcutaneous Layer. 
This layer is composed of a lamellated cellular tissue, which is 
very lax behind the triceps, but much more compact upon the 
osseous eminences. Below the articulation this layer generally 
incloses the terminations of the posterior radial and posterior 
ulnar veins; some branches of the musculo-cutaneus, of the in- 
ternal cutaneous and even of the radial nerves, also ramify in it. 
Adipose vesicles are more numerous in it the further we remove 300 
OF THE THORACIC EXTREMITIES. 
from the articular eminences; so that the fatty tissue may form 
a layer of a certain thickness in the lower part of the region, and 
another still thicker in the superior part, whilst behind the elbow 
properly so called, fat very seldom accumulates. Upon the 
olecranon, the lamcllm of the cellular tissue are so much con- 
densed that they frequently produce a complete bursa mucosa, 
which is susceptible of different degrees of capacity, but in the 
normal state never contains more than a small quantity of fluid. 
In certain diseases, on the contrary, it sometimes becomes dis- 
tended with liquid, producing a tumour of greater or less volume 
under the skin. It is equally subject to a form of disease which 
is more frequently observed in the synovial membranes of the 
wrist; we mean the production of cartilaginous granules, which 
may accumulate in this sac to the number of several hundreds. 
It may be remarked that although these tumours are very dan- 
gerous at the wrist, they may be easily cured at the elbow ; at 
least we saw, in 1824, at the Hospital of la Faculte, a patient 
who had one on each olecranon process, and was promptly re- 
lieved of them. M. Bougon opened them extensively; all the 
small productions were removed, the cyst inflamed, suppuration 
followed, and the cicatrization was completed at the end of a 
month without any accident. As this tissue is very moveable, 
the divisions of the skin may be easily united by the first intention. 
Even in wounds with loss of substance, the lips of the solution 
are easily approximated, and the cicatrix is seldom very extensive. 
In consequence of this laxity also, when phlegmonous erysipelas 
or other inflammations supervene, the sub-cutaneous layer is dis- 
organized with a great promptitude and the skin rapidly and 
extensively detached. 
iii. The Aponeurosis. 
Behind the tendon of the triceps, the aponeurosis, as it ap- 
proximates the olecranon, becomes considerably attenuated ; it is 
transformed, as it were, into cellular tissue, so that upon the 
median eminence it is no longer met with. On the inner side 
it passes to the epitrocklo-humeral intersection, but, previous to 
reaching it, splits in order to ensheath the ulnar nerve. In this 
direction, it also becomes thinner as it descends and again grows OP THE THORACIC EXTREMITIES. 
301 
thicker opposite to the olecranon, from whence it detaches a 
species of cord which goes upon the epitrochlea; still lower, this 
fibrous lamina arises from the posterior ridge of the ulna, in order 
to pass internally upon the extensor carpi ulnaris muscle. On 
the outer side, it also arises from the triceps tendon at the epicon- 
dylo-humeral intersection, unfolding in such a manner that one of 
its laminae passes to the border of the bone, and that between the 
two there is a considerable branch derived from the radial nerve. 
Between the olecranon and the epicondyle, the fibres which 
come from the triceps intersect those which proceed from the 
ulna, in order to pass on the outer side of the fore-arm. Finally 
the aponeurosis is of much less importance, in surgical practice, 
in this region, than in the preceding. 
iv. The Muscles. 
i 
Above the prominences the triceps exists alone; its fibres 
cease in the internal groove ; its external bundle, on the contrary, 
is prolonged to the posterior part of the humero-radial articu- 
lation, where it is continuous with the anconeus; its tendon is 
inserted upon the olecranon in such a manner that, in the flexion 
of the fore-arm, it draws this process at a right angle, whilst, in 
extension, it tends to draw it parallel to its length: whence it follows 
that flexion of the limb backwards would not be possible, even 
if the olecranon should not strike against the humerus. It should 
be observed, however, that the tendon is not inserted into the 
superior surface of this process, but into its posterior part. The 
kind of cord which seems to attach the olecranon to the humerus 
during flexion of the fore-arm, is produced by the tension of this 
tendon. A few fibres are occasionally detached from the triceps 
to be inserted into the fibrous layer which covers the olecranoid 
cavity. 
Inferiorly, we find, internally, the flexor ulnaris, the two origins 
of which, from the olecranon and epitrochlea, are united by a 
fibrous arch, before which the ulnar nerve passes; externally, 
the supinator brevis, the origins of the extensor communis, ex- 
tensor minimi digiti, extensor ulnaris, and the anconoeus. These 
muscles are so disposed that the head of the radius is almost 
naked under the skin, between them and the external muscu- 302 
OF THE TH0I4ACIC EXTREMITIES. 
lar mass of the fold of the arm ; so that it would seem much more 
easy for luxation of this bone to take place backwards than 
forwards. They are, moreover, very adherent to the osseous 
surfaces, a circumstance which renders their action of little effect 
in fractures (as it regards displacement). 
v. The Arteries. 
These vessels form two arches, situated in the two principal 
grooves : the external is produced by the anastomoses of the 
posterior radial recurrent, coming from the interosseal, with the 
termination of the external collateral of the arm. It lies deep 
between the muscles, behind the epicondyle and the supinator 
brevis; it is occasionally of large size, so that a wound in its track 
might be attended with a profuse hamorrhage, and render its 
ligature necessary in the disarticulation of the fore-arm. In frac- 
tures of the epicondyle, and in luxations, it might be lacerated 
and produce extensive ecchymoses. 
The internal results from the inosculations of the internal col- 
lateral with the posterior ulnar recurrent; its branches ramify in 
the inner groove, behind the epitrochlea, and anastomose in their 
turn with those of the preceding, as well as with the anterior 
epitrochleal arch. In aneurisms, or when the brachial artery is 
obliterated in any manner whatsoever, these anastomosing arches 
sometimes become very large. It is in such cases that a division 
of the soft parts in the region of the elbow might be accompanied 
with a troublesome haemorrhage, and that, if we were obliged to 
amputate the limb very near the joint, a great number of ligatures 
would become necessary. 
vi. The Veins. 
The deep veins accompany the arteries and have the same 
distribution. The superficial vary considerably in number, and 
still more in disposition. Two of them are usually met with: 
the posterior radial, which ascends and inclines slightly outwards, 
in order to pass before the epicondyle and unite with the ante- 
rior radial, forming the cephalic trunk, of which these two veins 
are only branches of origin : the posterior ulnar, which which is OF THE THORACIC EXTREMITIES. 
303 
generally larger and more constant, ascends upon the flexor ulnaris 
muscle as far as the epitrochlea; then it passes sometimes behind, 
more frequently before this process, in order to unite with the 
basilic, which it concurs in forming. As these two veins are 
surrounded by but few nervous filaments, they might serve for 
the abstraction of blood; but we rarely have recourse to them, 
because the anterior veins are always more distinct and more 
easily opened. 
vii. The Lymphatics. 
We find no glands here. The vessels are few in number; the 
superficial turn over the external and internal borders in their 
course to the fold of the arm; the deep-seated lymphatics ac- 
company the arterial arches, or pass through the interosseal space, 
and enter the glands of the anterior region. 
viii. The Nerves. 
Some filaments, and the posterior branches of the internal cu.- 
taneous and musculo-cutaneus nerves, pass or ramify in the 
superficial layers ; one branch of the radial descends behind the 
epicondylo-humeral intersection (external intermuscular ligament), 
and follows the course of the arteria profunda; this branch is 
frequently larger than the internal cutaneous, and should be 
avoided in cases wherein it is required to tie the artery. The 
posterior branch of the radial also gives off’ several ascending 
ramuscules below the articulation, and ramifies principally in the 
superficial muscles; but the ulnar is the principal nerve here. 
It lies upon the epitrochlo-humeral intersection (internal intermus- 
cular ligament) between the aponeurotic laminae, it descends in 
the internal groove, and, behind the epitrochlea, is covered only 
by the skin and the aponeurosis, so that it may be felt through 
the integuments and may be easily compressed at this point by 
the action of external agents, as, for example, when we strike 
the elbow against the angle of a table, etc. It is this compression 
which gives rise to the sudden numbness, or species of formica- 
tion, which we then feel in the last two fingers. As it passes 
before the flexor ulnaris muscle it gives off some unimportant 304 
OF THE THORACIC EXTREMITIES. 
filaments and soon places itself between the two common flexor 
muscles of the fingers. In the resection of the inferior humeral 
extremity, the ulnar nerve requires some precautions: in fact it 
would be very easy to divide it entirely or incompletely, by mak- 
ing the flap required for exposing the bone at the expense of the 
triceps. It is important, hower, to preserve it, if we do not wish 
to paralyze the last two fingers. It will therefore be necessary to 
separate this nerve from the groove in which it is imbedded, and 
draw it before the epitrochlea previous to making use of the 
saw. 
ix. The Skeleton. 
The humerus presents in this region the posterior part of the os- 
seous grooves and projections mentioned in the preceding region 
Above the articular pulley we observe a deep cavity, into which 
the synovial membrane is prolonged, and which receives the 
olecranon when the fore-arm is extended. It appears to be 
owing to the greater or less depth of this cavity that some per- 
sons possess the power of carrying the fore-arm backwards be- 
yond the axis of the limb. Its bottom is occasionally very thin ; 
it corresponds to the coronoidal depression, and is sometimes 
completely perforated. Be this as it may, it is necessarv to re- 
mark that, when the arm is flexed, this hollow is covered only by 
the soft parts, the triceps and the fibrous membrane, which na- 
turally conceal it: whence it follows, that, in this position, a 
pointed instrument might pass through it from behind forwards 
and wound important organs, the brachial artery, the median 
nerve, for example. The rest of the humerus is smooth and 
slightly convex; it is separated from the triceps by a very sup- 
ple cellular tissue, which readily inflames when acute diseases 
attack the articulation. If the bone was transversely fractured 
here, the inferior fragment would be thrown backwards, in con- 
sequence of the brachialis interims muscle drawing the superior 
end forwards. Oblique fractures easily extend into the joint, 
and may be of two species: either the solution of continuity will 
be made from without inwards, and then the external condyle 
and the tuberosity which surmounts it will constitute the inferior 
or external fragment; or it may take place from within outwards OF THE THORACIC EXTREMITIES. 
305 
so as to comprise the trochlea and epitrochlea in the internal 
fragment. In the first case, the posterior muscles of the fore-arm 
will tend to draw the condyle downwards and backwards; in 
the second, the trochlea will be drawn downwards and forwards 
by those of the anterior part. 
The ulna (oubitus) is covered internally by the flexor carpi 
ulnaris muscle, and by the anconceus, externally; its posterior 
border is covered merely by the skin, and is connected to the 
humerus by the internal lateral ligament, which bifurcates as it 
proceeds from the epitrochlea, in order to attach itself to the 
olecranon and the coronoid process. The olecranon process is 
one of the most essential parts of the elbow; as it is carried back- 
wards in the flexion of the limb, which then becomes a lever of 
the first order, it elongates the arm of power, by separating the 
triceps from the fulcrum; but in this position, an instrument 
thrust behind the elbow might be attended with great danger, 
because it would readily penetrate into the joint. In extension, 
this eminence will not permit a wound of this nature, but will 
prevent any species of weapon from traversing the humerus by 
the olecranoid cavity; besides, it will also oppose an insurmount- 
able obstacle to the luxation of the fore-arm forwards, whilst, in 
the first case, it does not appear impossible for an external cause 
to produce this displacement; finally, it is the olecranon which 
constitutes the greatest impediment to the disarticulation of the 
fore-arm. Indeed, in this operation, a large flap being made at 
the expense of the anterior soft parts, the fore-part of the joint 
being opened by the division of the internal, external and ante- 
rior ligaments, the olecranon remains, and forms an obstacle to 
the separation of the limb. Hence, we are obliged to saw 
through this process, which the triceps will not fail to draw 
considerably upwards; or it may be removed by sliding the knife 
between it and the os brachii, in order to detach it from the 
extensor muscle; but as the muscle, in this case, retracts great- 
ly, the skin alone will remain to form the posterior flap. We 
would therefore prefer the first method, if ever this operation 
should be absolutely necessary, which, however, is very question- 
able. 
The Radius affords nothing very remarkable in this region: 
externally, it is so superficial that it is easy to recognize its frac- 306 
OF THE THORACIC EXTREMITIES. 
tures, and the supinator brevis envelopes it almost entirely. It is 
more easily luxated backwards than in any other direction: on 
the one hand, because the articulation is less firmly supported at 
its posterior part; on the other, because the movement of prona- 
tion is more natural than that of supination, and because, when 
this motion is forced, the radius tends to tilt upon the ulna and 
pass behind the humerus. It is for this reason that this displace- 
ment is not rare among washer-women and those who are much 
occupied in wringing linen. 
The order of superposition in the posterior region of the elbow 
seems to us too simple to require pointing out. 
We may now easily comprehend the obstacles which oppose 
the resection of the bones of the elbow ; as this operation has 
been performed, however, first by Mr. Park of Liverpool, after- 
wards by the two Moreaus of Bar-sur-Ornain, and Prof. Roux, 
and several times with success; as, by this operation, the fore* 
arm and the functions of the hand are preserved, the difficulty of 
executing it should not prevent its being had recourse to. Ac- 
cording to the method of the MM. Moreau, the inferior extrem- 
ity of the humerus may be removed without difficulty. It con- 
sists in making two incisions, one on each side of the bone, and 
uniting them by a third drawn transversely above the olecranon ; 
it will then be necessary to preserve the ulnar nerve, by dissect- 
ing it from its sheath and carrying it before the epitrochlea, as 
advised by M. Dupuytren, previous to separating, by means of a 
suitable instrument, the flesh from the anterior part of the articu- 
lation and sawing through the osseous extremity. It is evident 
that, in this way, the artery and nerves remaining untouched, the 
accidents which must follow will be analogous to those which 
usually accompany extensive wounds ; but if the disease requir- 
ed, at the same time, the resection of the ulna and radius, the an- 
atomical disposition of the organs induces us to believe, that, by 
removing these bones below the insertion of the brachialis inter- 
ims and biceps muscles, the chances of success from the opera- 
tion would be greatly lessened, and the flexion of the fore-arm 
would be rendered impracticable. OF THE THORACIC EXTREMITIES. 
307 
Art. IV. op the fore-arm. 
The fore-arm, properly so called, is comprised between the 
regions of the elbow and a circular line drawn half an inch 
above the radio-carpal articulation. Its form is that of an invert- 
ed cone, truncated and flattened upon two faces, especially infe- 
riorly. This form varies according to age, embonpoint and the 
position of the limb ; in children and fat persons the cone is more 
regular; in emaciated persons, on the contrary, the fore-arm is 
very much flattened, and nearly as broad inferiorly as at its supe- 
rior part; in flexion and pronation, its anterior surface is more 
convex than in extension and supination. 
In the latter position, the fore-arm presents for our considera- 
tion a palmar and a dorsal aspect, a radial and an ulnar margin. 
Sect. 1. Anterior, or Palmar Region. 
When the limb is in the state of pronation, the inferior part of 
this region is directed backwards, its superior portion inwards : 
on its surface we observe, superiorly, the continuation of the two 
muscular eminences of the fold of the arm, and the median 
groove which separates them ; in the middle, these two eminen- 
ces are almost confounded, and the groove is scarcely percepti- 
ble ; in approximating the wrist, we see, or may feel, from within 
outwards, the prominence formed by the flexor carpi ulnaris, a 
groove in which the ulnar artery may be felt, another prominence 
formed by the flexor muscles of the fingers, a third by the tendons 
of the palmaris longus and flexor carpi radialis, and which is 
much increased by the flexion of the wrist upon the fore-arm, 
the fingers being extended; a groove broader and more distinct 
than the first, which groove may be considered as the termination 
of that of the superior part, and in which we distinguish the radial 
artery through the integuments; finally, a fourth prominence, 
which is observed on the outer part and is constituted by the 
radius. A considerable number of veins also raise the skin, and 
form a more or less complicated plexus throughout the whole 
extent of this region. 308 
OF THE THORACIC EXTREMITIES. 
CONSTITUENT PARTS. 
i. The Skin. 
It participates in all the characters of that of the fold of the 
arm : thus, it is soft, white, extensible, sometimes covered with 
hairs, but on the outer and inner borders only, and contains a small 
number of sebaceous follicles upon the median line. 
ii. The Subcutaneous Layer. 
The same observations may be applied to it as to the skin; in 
man it includes but a small number of adipose cells, and the lam- 
ellated tissue which composes it forms a layer of greater or less 
thickness, and always very moveable, which admits of the skin 
being readily drawn up without dissection, when we amputate in 
this part of the fore-arm, etc. In childhood and in the female, an 
abundance of adipose vesicles is sometimes developed in it; it is 
then of greater thickness, and it is this adipo-cellular layer which 
gives to the fore-arm that cylindrical form which is peculiar to 
the female sex. As this tissue incloses the veins, these vessels 
are always more distinct in man than in woman. It is this layer 
also which is the seat of the principal disorders in phlegmonous 
erysipelas ; and as it is nottfirmly adherent either to the aponeuro- 
sis or skin, it is necessary to evacute promptly the diseased fluids 
which may have accumulated in its lamella?, if we wish to avoid 
the detachment of the cutaneous envelope. 
in. The Aponeurosis. 
If we commence with this membrane at the posterior border 
of the ulna and trace it to the anterior margin of the radius, we 
will find that it has not exactly the same arrangement throughout 
the whole extent of the region. In departing from the bone, 
superiorly, it passes over the anterior face of the flexor carpi 
ulnaris muscle ; between this bundle and the flexor sublimis, the 
aponeurosis sends off a sheet which passes inwards before the 
flexor profundus and from thence to the ulna, completing the -OF TIIE THORACIC EXTREMITIES. 
309 
sheath of the flexor ulnaris muscle : the place at which this sheet 
is detached is always marked by a distinct line, which directs us 
in finding the ulnar artery. The aponeurosis is afterwards con- 
tinued over the anterior surface of the muscles; when it gets 
near the supinator longus it splits, and its superficial lamina passes 
before this muscle, whilst the deep-seated passes behind it and 
forms, on its part, a small sheath for the radial artery: beyond 
the supinator, these two laminae approximate and become 
blended with the aponeurosis of the posterior region. Inferiorly, 
the two sheets which envelope the flexor ulnaris, become con- 
joined before they attach themselves to the ulna; and the same 
takes place with respect to those of the supinator longus previous 
to their insertion into the radius; so that between these two 
muscles, the aponeurosis binds down all the other tendinous and 
muscular organs, and no longer forms but a single lamina. It 
must be observed also that a third very thin sheet passes from 
the anterior margin of the ulna before the flexor profundus, and 
that it is upon this that the ulnar artery lies; so that, in order to 
expose this vessel, two fibrous laminae must be divided ; whereas, 
but one only is met with before the radial. 
The most of the fibres of the anti-brachial aponeurosis are 
transversal; superiorly, they give attachment to the fleshy fibres; 
inferiorly, the expansion which they form has no adhesion with 
the muscles. 
iv. The Muscles. 
They are numerous and form twTo strata: the first, taken in 
the direction from within outwards, comprises the flexor carpi 
ulnaris, flexor minimi digiti, flexor sublimis, palmaris longus, 
flexor carpi radialis, and pronator teres; the second, the flexor 
profundus, flexor longus pollicis, and pronator quadratus ; finally, 
upon the fore part of the radius we observe, superiorly, the ter- 
mination of the pronator teres and of the supinator brevis, the 
extensor radialis longior and brevior, and the supinator longus. 
It is between these two layers that the principal nerves and ves- 
sels are situated. The flexor carpi ulnaris and sublimis separate 
as they descend, and give rise to the internal gutter: the ulnar 
artery corresponds to this interval; the supinator longus and the 
flexor carpi radialis also separate, in order to form the externa! 310 
OF T11E THORACIC EXTREMITIES. 
gutter which includes the radial artery. The extensores radiahs 
longior et brevior turn outwards and pass into the posterior re- 
gion. The origin of the flexor profundus is prolonged as far as 
just below the coronoid process, and is also attached to the radius 
below the bicipital tubercle: it is above the species of arch 
which it forms superiorly, that the interosseous artery insinuates 
itself before the interosseous ligament; the flexor longus pollicis 
rests upon the fore part of the radius, and receives a small 
rounded bundle from the coronoid process; the anterior interos- 
seous artery and nerve lie in the bottom of the interstice which 
separates these two muscles. The pronator quadratus, from its 
transverse direction, constantly tends to approximate the two 
inferior fragments of the bones when fractured. 
The superior portion of all these organs is entirely fleshy, 
whilst inferiorly the fibrous element predominates. The tendons 
of these muscles, at first more or less blended with one another, 
afterwards separate ; but, nevertheless, they are always con- 
nected by a species of fibro-cellular or synovial membrane, the 
arrangement of which is very complicated, and its inflammations 
extremely dangerous; whence it follows that wounds of the 
superior part of the fore-arm must be attended with less for- 
midable symptoms than those of its inferior portion. 
v. The Arteries. 
All the arteries of this region are derived from the brachial. 
The first is the radial, which descends parallel to the direction of 
the radius, covered anteriorly and in its superior half by the 
internal border of the supinator longus and the two laminm of 
the aponeurosis; in the other half the aponeurosis alone is before 
the artery, and its two laminae are usually reunited. The radial 
rests, from above downwards, upon the tendons of the supinator 
brevis, pronator teres, then upon the radius: a cellular lamina 
separates it from these parts and from the pronator quadratus, 
which is more inferiorly. On its outer side we see, first, the ex- 
tensores radialis longior et brevior and the supinator longus 
muscles, afterwards the tendon of the latter only. The radial 
nerve lies upon this side also, but it is always a line at least dis- 
tant from this vessel; so that it may be easily avoided when 
applying a ligature upon the artery. The flexor longus pollici« OF THE THORACIC EXTREMITIES. 
311 
and llexor carpi radialis run along its internal surface; more im- 
mediately, this artery is enveloped by a cellular sheath, which 
also contains its two venae comites. From these anatomical 
relations, it follows that the radial artery becomes more super- 
ficial in proportion as it approximates the carpus, and that, in 
order to find it, we may have recourse to three different me- 
thods almost equally certain. Thus, by making an incision in the 
direction of a line drawn from the middle of the space which 
separates the condyles of the humerus and terminating on the 
inner side of the styloid process, we are certain of falling upon 
the artery ; when the radial gutter is distinct, we might make use 
of it in the same manner: lastly, after the integuments have 
been divided, we will always find it between the flexor carpi 
radialis and supinator longus. By attempting to discover it 
according to these methods, the skin being divided, the median 
vein will frequently present itself in the direction of the wound; 
it should be pushed inwards, and we will always avoid mistaking 
it for the artery, if we recollect that the aponeurosis separates 
these two vessels; a grooved director is then to be insinuated 
under this fascia, upon which the bistoury is to be introduced for 
the purpose of incising it, when, if we operate inferiorly, the 
artery will be exposed ; if higher up, the margin of the supi- 
nator must be pressed outwards, when we will see the artery, 
surrounded by its venae comites, through a second fibrous lamina 
which should be divided also, in order that the aneurismal needle 
may be passed behind it, which, as there is no essential organ in 
its immediate vicinity, may be introduced on either side. The 
nerve is sufficiently remote on its outer side to be always avoided. 
The radial artery is sometimes subcutaneous, and this anomaly 
might render very superficial wounds dangerous. In such a case,, 
its pulsations are usually perceived through the skin; but if the 
limb is engorged or tumefied, in any manner whatsoever, and an 
incision is required to be made upon it in the course which this 
artery then takes, we can conceive the accidents which might 
result from it. At other times it changes its direction, and about 
the middle of the fore-arm turns over the outer side of the radius. 
This anatomical variety is one of the most frequent, and requires 
special notice, for it might lead to a deception with respect to 
the nature of the pulse in diseases, if, as frequently happens, 
a branch of a certain calibre supplied the place of the trunk: it 312 
OP THE THORACIC EXTREMITIES. 
might also cause a profuse haemorrhage in a simple wound of the 
external part of the fore-arm. The first disposition generally 
depends upon the high division of the brachial artery ; and the 
second, upon the small dorsal branch of the radial having acquired 
a greater volume than usual. 
The Ulnar comes next, forming as it descends a gentle but 
very long curvature, with external convexity. It is at first si- 
tuated between the superficial muscular stratum and the flexor 
profundus, and in the anti-brachial region is found in relation 
with the following organs;—anteriorly and externally, the flexor 
sublimis; posteriorly, the profundus; internally, the flexor carpi 
ulnaris, the tendon of which lies more or less over it; inferiorly, 
more immediately, we see upon its external side its collateral 
vein or veins : the ulnar nerve touches it upon the internal side. 
It is, consequently, very deep superiorly, and very’ difficult of 
access. If, however, we wish to expose it, we must divide the 
integuments in the direction of a line which would commence at 
the inner part of the trochlea in order to descend perpendicularly 
upon the external side of the os pisiforme: next we would seek 
for the fibrous line which separates the flexor carpi ulnaris from 
the flexor sublimis, and which is always the first which is met 
with in proceeding from the posterior border of the ulna. The 
aponeurosis being cut through upon this line, the muscles will be 
easily separated ; the nerve will soon be discovered at the bottom 
of the wound, upon the flexor profundus, and then, by placing the 
extremity of the needle upon the external side of this nerve, it 
will be sufficient to dip this instrument a little and afterwards 
raise it outwards, in order to seize the artery, which is, in fact, 
almost always placed in the latter direction, and a little forwards ; 
but it is necessary to observe that these relations exist only in the 
four inferior fifths of the fore-arm ; for in the superior fifth, as the 
artery runs obliquely outwards and upwards, it becomes more 
and more remote from the ulnar nerve. Inferiorly, after having 
divided the skin and cellular layer, we must cut the first lamina 
of the aponeurosis upon the internal margin of the tendon of the 
flexor carpi ulnaris muscle; then by pushing this tendon inwards 
we will see the artery through a second fibrous lamina, in general 
of considerable strength, which binds it down upon the inner part 
of the flexor profundus; its relations are, otherwise, the same as 
in the rest of its extent. OF THE THORACIC EXTREMITIES. 
313 
This artery is sometimes superficial, so that its pulsations are 
visible through the skin. In other cases, it does not approximate 
the nerve until very near its inferior part; it would then be 
difficult to apply a ligature around it. 
Finally, the Interosseal divides at the point of union of the flexor 
profundus and flexor longus pollicis, and the interosseal branch, 
properly so called, rests upon the anterior surface of the interos- 
seous ligament, which it passes through at the upper part of the 
pronator quadratus. It is for the purpose of seizing this branch 
the more readily that, in amputating the fore-arm, we are advised 
to cut through the ligament which supports it. 
From what has preceded, we see that the ulnar artery is not 
susceptible of being firmly compressed, whilst the radial, on 
the contrary, may be obliterated by pressing it against the radius, 
in its inferior half. All the other branches are too small to de- 
serve any attention in operations. 
vi. The Veins. 
The superficial veins form a very complicated net-work under 
the skin; they communicate with each other a great number of 
times, and vary greatly both in number and disposition The 
most constant and largest are the vena ulnaris anterior, the me- 
diana, and radialis cutanea anterior. The first receives the most 
of the veins of the hypothenar eminence,* and ascends along 
the ulnar side of the region in order to constitute, upon the inter- 
nal muscular mass of the fold of the arm, one of the roots of 
the basilic. It is sometimes so large that blood may be drawn 
from it, when this operation cannot be performed elsewhere. It 
is accompanied by the anterior twigs of the internal cutaneous 
nerve. 
The second arises principally in the palm of the hand; in as- 
cending it follows the radial groove, and in this manner gradu- 
ally inclines towards the median line of the limb, until it reaches 
* The os metacarpi pollicis is surrounded by a considerable muscular.mass con- 
sisting of four muscles, the abductor brevis pollicis, opponens pollicis, flexor brevis 
pollicis, and abductor pollicis, these constitute the thenar eminence : the hypothenar 
eminence is formed by the muscles surrounding the os metacarpi minimi digiti,- 
Transl. 314 
OF T11E THORACIC EXTREMITIES. 
the anterior region of the elbow, where we have already exam 
ined it: this is usually the most voluminous of the three, and 
therefore that which may be opened most readily, if we cannot 
perform venesection in the ordinary situation. It must then be 
kept in mind, that this vein is accompanied by a considerable 
branch of the musculo-cutaneus nerve, which generally lies 
upon the external side of the vessel. 
The third is one of the principal roots of the cephalic ; it comes 
from the thenar eminence* and thumb, and does not usually enter 
the anterior anti-brachial until it arrives near its middle ; it places 
itself externally and upon the anterior face of the external mus- 
cular eminence, and afterwards inclines more or less backwards 
in order to unite with the posterior radial and form the cephalic. 
This is the most variable, and that which is most frequently want- 
ing ; it is only surrounded by some very delicate filaments of the 
musculo-cutaneus nerve. 
All these veins, like those of the fold of the arm, are here en- 
veloped in the deep plates of the superficial layer, and, in this 
respect, we may apply to them the same surgical considerations. 
The median generally follows the track of the radial artery ; where- 
by, when we attempt to tie the latter, we are frequently embar- 
rassed by the vein, which must be pushed outwards or inwards, 
as may be most convenient. The ulnar does not follow the ar- 
tery of the same name so exactly; so that, when wTe wish to ex- 
pose the latter vessel, vve are seldom obliged to separate the vein. 
They are scarcely distinct in women and children, on account 
of the thickness of the adipose layer ; but in the adult male, old 
people, and especially those who exercise the hands and thoracic 
limbs vigorously, their calibre is generally much greater; which 
is undoubtedly owing to the profuse supply of blood attracted to 
these extremities by the muscular action, wrhich not being able 
to ascend in the same quantity by the deep-seated veins is obliged 
to pass into the superficial. 
The deep-seated veins are disposed like the arteries, and are 
occasionally double. The two radials are situated on each side 
of the artery and communicate writh each other before it, at cer- 
tain intervals. We less frequently meet with a duplicate of the 
ulnar and interosseal veins. All these veins should be cautiously 
* See Note, page 313. OF THE THORACIC EXTREMITIES. 
315 
avoided when we tie one of the accompanying arteries; not 
from fear ot impeding the circulation, but because experience has 
proved that they readily inflame when comprised in a ligature, 
and every body knows that inflammation of the veins is dan- 
gerous. 
vii. The Lymphatics. 
The superficial are very large and numerous; they wind around 
the principal veins, and throughout the whole extent of the cel- 
lulo-adipose layer. The deep-seated form two remarkable clusters 
around the radial and ulnar vessels, and a third, less constant, or 
less distinct, which accompanies the interosseous artery. 
Generally there are no glands in the anterior region of the 
fore arm ; however, we have met with one, two, and even three 
in the track of the radial artery, but they were always very small, 
lenticular, or hordiforme. We may admit that these organs, in 
consequence of some morbid virus, are susceptible of acquiring 
a certain volume, and of producing tumours the nature of which 
might easily be misunderstood. Finally, the abundance of the 
lymphatics upon the palmar aspect of the fore-arm, added to the 
delicate structure of the integuments, is the principal anatomical 
reason for preferring the application of medicaments upon if 
which we intend to administer by absorption. 
vin. The Nerves. 
In speaking of the veins we pointed out the superficial nerves: 
they appertain to the internal cutaneous and musculo-cutaneus, 
the anterior branches of which are almost entirely lost in this 
region, after having ramified a great many times in the cellular 
layer. Their filaments ultimately terminate in the skin. 
The deep-seated nerves appertain to the radial, ulnar and 
median. 
The first (radial) follows the external side of the artery, but 
leaves it inferiorly, turning outwards in order to pass between 
the radius and the tendon of the supinator longus ; so that this 
nerve runs no risk of being included in the ligature of the radial 
artery at the inferior fourth of the fore-arm; whilst above this, 316 
OF THE THORACIC EXTREMITIES. 
these two organs lie so close to each other that it is better, if not, 
indispensable, to introduce the grooved director under the artery 
from the radial towards the cubital side: a wound of it would 
impair more or less the action of the first three fingers. 
The second (iulnar) follows the direction of the line indicated 
when speaking of the ulnar artery, and runs along its internal 
side; it is only about three inches below the epitrochlea that it 
touches, as it were, this vessel; above this, it is separated from 
it by a triangle with its base uppermost, the external side of which 
is represented by an oblique line drawn from the tendon of the 
biceps to four fingers’ breadth below the articulation, and in which 
wre find the internal muscular eminence, a portion of the ulna, 
etc. Near the wrist, the ulnar nerve sends its posterior branch 
behind the carpus, and the anterior retains the same relations 
with the artery as the trunk. From its position, this nerve could 
not be divided by a cutting instrument drawn across the fore- 
arm without the artery being equally wounded; so that in a 
wound of this nature, the paralysis of the last two fingers would 
be sufficient to induce us to infer that the ulnar artery is divided. 
The third, or median nerve, descends perpendicularly between 
the two flexor muscles of the fingers, and like them is found en- 
veloped, near the carpus, in a very dense and very extensible 
fibro-cellular membrane ; it is situated nearly upon the median 
line : the only branch which it gives off, inferiorly, is the palma- 
ris cutaneus ; this, however, is not constant. The interosseous 
is also derived from the median: it follows the artery of the 
same name, is always situated on the outer side of it, and is some- 
limes so adherent to it that it is difficult to separate them : a cir- 
cumstance which should not be forgotten in amputations, when 
we are securing the arteries. 
The other nervous filaments of this region are distributed to 
the muscles, and are of no importance in surgery. 
ix. The Skeleton. 
It is represented by the anterior faces of the ulna, radius and 
interosseous ligament. This surface forms a concavity, the deep- 
est part of which corresponds to the middle of the fore-arm: the 
muscles cover it entirely, with the exception of the anterior and OF TIIE THORACIC EXTREMITIES. 
317 
inferior third of the radius, which is subcutaneous. These bones, 
however, will be described more particularly in the following re- 
gion. 
Sect. 2. Posterior Anti-Brachial Region. 
This region is more regularly convex than the preceding; it is 
more unequal, and its muscles are more distinctly delineated. 
The principal features which we observe upon its surface are, 
from within outwards ; 1st, an elongated prominence which cor- 
responds to the ulna and the extensor carpi ulnaris muscle; 2d, 
a groove, scarcely distinct superiorly, much broader and more 
apparent inferiorly ; 3d, another prominence, formed by the fleshy 
portion of the extensor digitorum communis ; 4th, a second groove 
which separates, superiorly, the latter eminence from that which 
is formed by the extensor radial muscles, and which turns before 
and above the extensor muscles and abductor pollicis longus; 5th 
and lastly, a third relief which corresponds to the latter muscles. 
CONSTITUENT TARTS. 
i. The Skin. 
It is of considerable thickness, is shaded by numerous hairs, 
and contains many sebaceous follicles. Its surface is irregular, 
rough in thin subjects, in certain diseases, and upon a sudden im- 
pression of cold ; it is less vascular than upon the palmar surface, 
though pretty extensible. Solar spots or freckles are as fre- 
quently observed here as upon the rest of the limb, especially in 
those of a fair complexion. 
n. The Subcutaneous Layer. 
This layer is generally thinner than in the anterior region, and 
contains a smaller number of adipose vesicles; on the other hand, 
it has greater suppleness and extensibility, but is less adherent to 
the strata between which it is placed. 318 
OF THE THORACIC EXTREMITIES. 
iii. The Aponeurosis. 
It is blended with the anterior portion of the anti-brachial 
aponeurosis upon the posterior margin of the ulna: opposite to 
the external border of the extensor carpi ulnaris a process, or 
species of intersection, is reflected from it to the bone, forming a 
sheath for this muscle ; then it furnishes, in the same manner, 
another sheath for the tendon of the extensor minimi digiti, after- 
wards a third to the extensor digitorum communis. Finally, the 
abductor pollicis longus (<extensor primi intcrnodii pollicis), and 
the extensores longus et brevis pollicis (extensores tertii et secundi 
inlernodii pollicis), are equally enveloped by it, when they turn 
upon the radius. Above and below these last, the aponeurosis 
attaches itself to the posterior border of this bone; it receives a 
lamina which separates the two muscular layers, and is continu- 
ous with the sheets which enclose the supinator longus, the radi- 
ales (extensores), etc. From this arrangement it follows, tiiat each 
of the dorsal muscles of the fore-arm is enclosed in a species of 
fibrous canal inferiorly, and that superiorly, they are only sepa- 
rated by intersections which are in general very solid: this per- 
fectly coincides with their functions, since their fixed point is the 
same, or nearly so, for all, whilst the moveable extremity of each 
must act independently under a multiplicity of circumstances. 
It should also be observed that these septa of the aponeurosis, by 
being fixed from space to space upon the bones, must give to it 
greater strength and resistance, and that the muscles, more firmly 
supported, .acquire, in contracting, an energy which they would 
not have possessed if they had been loosely applied upon the skel- 
eton. 
iv. The Muscles. 
They form two very distinct strata: the superficial comprises, 
in examining them from the radius towards the ulna, the extensor 
communis, extensor minimi digiti, extensor carpi ulnaris and the 
anconaeus (epicondylo-cubital). 
The first (<extensor communis) lies, superiorly, immediately upon 
the bones and the interosseous ligament: then upon the deep OF TIIE THORACIC EXTREMITIES. 
319 
muscular layer ; externally and internally, it is confounded with 
the radial extensors and extensor carpi ulnaris ; directly behind, it 
is covered by the aponeurosis: as it descends, it divides into two 
bundles, in one of which we distinguish the origin of the tendons 
which pass to the indicator and little fingers ; in the other, those 
which go to the middle and ring fingers; whence it follows, that, 
the hand being shut, it is not possible to extend the annular finger 
completely without the medius, whilst we may very readily extend 
the indicator or little finger separately. The whole of its tendi- 
nous portion is enveloped in a species of fibre-cellular membrane, 
or synovial bursa, which favours its movements, and in which we 
sometimes meet with very soft and very large fatty vesicles, simi- 
lar to those situated within the orbit. 
The second (extensor minimi cligiti) is in fact only a fascis giv- 
en otf from the former at a greater or less elevation, and only 
merits particular mention because it is enveloped in a distinct 
sheath, which permits it to act independently of the tendons of 
the extensor communis ; therefore we may easily extend the little 
finger whilst the others are in a state of flexion. 
The third {extensor carpi ulnaris) is disposed, inferiorly, in such 
a manner that its tendon lies very superficial; whence it is very 
much exposed to the action of foreign bodies, and is frequently di- 
vided by transverse wounds inflicted upon the inner border of the 
fore-arm. 
The fourth (unconcern) seems to be only a prolongation of the 
triceps extensor; its uses are of but slight importance, and, in a 
surgical point of view, it presents nothing worthy of much 
attention. 
The deep-seated layer contains, from within outwards, the 
extensor indicis, the short and long extensors of the thumb, and 
its long abductor; the tendons of the radials (extensors) are also 
partly found in it. All these muscles, imbricated upon one an- 
other, pass obliquely outwards and downwards, so that the tendon 
of the indicator does not actually separate from those of the ex- 
tensor communis until it reaches the wrist. It is the same with 
the extensor longus pollicis {extensor tertii intemodii), which is 
situated a little more externally; but the extensor brevis {extensor 
secundi intemodii) and abductor longus pollicis {extensor primi 
intemodii) make a partial spiral turn, extending from the poste- 320 
or THE THORACIC EXTREMITIES. 
rior aspect of the interosseus ligament and radius to the root of 
the thenar eminence ; from which circumstance these muscles 
are supinators of the thumb and hand, at the same time that they 
are extensors and abductors. The aponeurosis furnishes for them 
a fibrous case, which is stronger and more compact the nearer it 
approaches the wrist. In this canal, the tendons are applied 
upon one another, and that of the short extensor is behind. 
Their surface is smooth and covered with a synovial membrane, 
which also lines the interior of their sheath, and sometimes they 
are separated by a thin septum, which divides this sheath into 
twTo. This theca, or the organs it encloses, is occasionally the 
seat of a very singular disease, which we have met with in ten or 
twelve persons, although it is not generally mentioned in works 
on surgery. We see occurring, without any known cause, or in 
consequence of some effort, a swelling, which never becomes 
very considerable, throughout the whole track of the muscles 
just mentioned : this swelling is accompanied with heat and pain, 
which are not usually very great, unless the patient endeavours to 
move the thumb; but what is most singular, is that, if we grasp 
the tumid part with one hand and move the thumb with the other, 
we feel and hear a very distinct crepitus, so much so that we 
have known a surgeon, in a similar case, pronounce it to be a 
fracture and apply a bandage. This affection, in those in whom 
we have observed it, always disappeared at the end of fifteen 
days or a month, without any one particular method of treating 
it seeming to be attended with more benefit than another. Al- 
though leeches, cataplasms, spirits of camphor, ammoniated lini- 
ments, or other discutients were applied, and compressive ban- 
dages or rest had recourse to, it could not be ascertained which 
of these means actually deserved the preference, and we think 
that its appropriate remedy is yet to be discovered. 
The tendons of the external (extensor) radials slide between 
the preceding muscles and the posterior surface of the radius; 
they soon enter, in their turn, into a fibrous canal not so strong 
as the preceding, and in which they are separated by a septum 
which is sometimes wanting: the radial nerve turns over the 
bone between these latter tendons, the supinator and the abductor 
longus and extensor brevis pollicis muscles. OF THE THORACIC EXTREMITIES. 
321 
v. The Arteries. 
The Interosseous arteries are the only ones observed in this 
region. The posterior, after having given off the recurrens 
ulnaris, ramifies in the superficial muscular stratum, and descends 
almost to the wrist. It is so large as to require a ligature after 
amputations. The anterior interosseal does not enter the dorsal 
portion of the fore-arm until near its inferior fourth part; it 
remajns applied upon the bones, and is so small that it seldom 
presents any particular indications. The posterior branch of the 
artery also enters this region about an inch or two above the infe- 
rior extremity of the ulna, and it is not uncommon to see it of 
the size of a crow-quill. In the preceding region, we stated that 
the radial and ulnar arteries might likewise pass behind the fore- 
arm by anomaly, etc. As, in these cases, they are always very 
superficial, they will then render the solutions of continuity more 
dangerous. 
vi. The Veins. 
The posterior radial and ulnar veins, which are only the con- 
tinuation of the cephalic of the thumb and of the salvatella, are 
the two principal. The first is sometimes the largest, at other 
times the second ; frequently one or the other of them are want- 
ing, from their roots soon passing upon the palmar surface. They 
are more distinct in proportion as they are more inferior, and we 
see them communicating with each other by transverse branches. 
We seldom draw blood from them; not because the operation 
would be dangerous, for they are surrounded by a small number 
of nervous filaments only, but because there are others much 
more easy to open and of a larger calibre. 
The deep-seated veins follow exactly the course of the arteries. 
vn. The Lymphatics. 
They are not very numerous. Those of the superficial layer 
gradually turn over the sides of the ulna and radius, but especially 322 
OF THE THORACIC EXTREMITIES. 
the latter, in order to enter the anterior region; those of the 
deep-seated parts ascend with the bloodvessels, and follow the 
same coarse. This scarcity in the lymphatic system, the hairs 
which cover the skin, and the other characters peculiar to this 
membrane in the region under consideration, are the principal 
reasons why we do not apply to it medicaments, which we wish 
to have absorbed, in the form of frictions; on the other hand, 
dry frictions, or simply revulsives, will produce more effect upon 
it than upon the anterior part of the limb. 
vin. The Nerves. 
The posterior branch of the radial nerve is found externally 
and superiorly. Its twigs, like those of the posterior interosseous 
artery, which they accompany almost every where, are dispersed 
among the fibres of the superficial muscles; a few filaments, 
however, are lost in the deep muscular stratum. The median 
and ulnar send off some delicate but numerous filaments near the 
elbow, which are distributed to the internal and superior part of 
the region. Inferiorly, we see, internally and externally, the 
posterior branches of the radial and ulnar nerves immediately 
applied against the bones; and in the middle, in the bottom of 
the space, the posterior interosseous filament derived from the 
median. According to the disposition of these last branches, we 
conceive that, in fractures near the wrist, they may be painfully 
stretched, contused, or even divided ; and, from their volume, we 
may expect severe symptoms to follow such accidents. We 
ought likewise to note the posterior branches of the internal 
cutaneous and musculo-cutaneus nerves, which ramify in the 
superficial cellular layer around the veins, but which afford no 
interest in relation to operations. 
ix. The Skeleton. 
The two bones of the fore-arm, which compose it, are so dis- 
posed that the radius is largest inferiorly and the ulna superiorly; 
whence it follows that, united, they give to the skeleton of the 
fore-arm nearly equal transverse dimensions throughout its whole 
extent. It also results from this arrangement, that the former is OF THE THORACIC EXTREMITIES. 
323 
more frequently broken superiorly than inferiorly, whereas the 
reverse takes place with respect to the ulna; and that, when both 
bones are broken simultaneously, the solution of continuity sel- 
dom occurs in the same line. They are convex, and slightly curv- 
ed upon the faces which are directed towards the circumference 
of the limb, and are separated, on the side of the median line, by 
the interosseal space; a space an inch in breadth in some persons, 
four or five lines in others, and which gradually diminishes in 
proportion as it approximates the extremities of the region. As 
this space is closed only by a fibrous membrane, and as the bones 
become so much attenuated when they reach it that they present 
a cutting margin, it thence follows that the anterior surfaces of 
the ulna, radius and interosseous ligament represent a species of 
fossa, which is deeper and broader in proportion to the degree of 
separation between these bones: it is in this fossa that the mus- 
cles are lodged. The same is observed at the the posterior part; 
hence the antero-posterior diameter of the fore-arm is naturally 
shorter than the transverse. Therefore, when these bones are 
fractured, we place graduated compresses and splints upon the 
extremities of the first diameter in order to elongate it, and pre- 
vent them from approximating. Besides, it may be observed 
that the displacement of the bones is not difficult to overcome in 
fractures of the fore-arm. Indeed, in order that the fragments 
should be displaced longitudinally, it is necessary that both the 
radius and ulna should be broken together; and even in this case 
the thing would be difficult, unless the fracture existed quite low 
down; for the attachments of the muscles being continued upon 
both divided extremities, they would not tend to make them ride 
past each other.- If the radius only is broken, the two fragments 
will, it is true, be drawn towards the ulna, superiorly, by the 
pronator teres, inferiorly, by the pronator quadratus, and the 
interosseous space will disappear; the osseous portion into which 
the pronator teres is inserted will also pass before the other; but 
it is sufficient to relax the muscles, and apply graduated compres- 
ses, in order to restore the parts to their natural situation. If the 
ulna alone is fractured, the displacement can only take place 
transversely, and that in the inferior fragment; for the articula- 
tion of the superior fragment does not admit of its moving later- 
ally. As, in this case, if the fracture exists very low down, the 324 
OF THE THORACIC EXTREMITIES. 
antero-posterior compression is not sufficiently efficacious, M. 
Dupuytren has recommended, in order to carry the inferior por- 
tion of the fractured bone inwards, to maintain the hand forcibly 
inclined upon its radial border. 
All these fractures may be produced by indirect causes; but 
they are likewise very frequent from the action of direct causes, 
especially upon the radius, which is very superficial, and the ex- 
tremities of which are so placed upon the ulna, that, the latter 
being supported upon a solid body, an external pressure act- 
ing upon the convexity of the other, will not fail, if the force is 
sufficient, to break it by the effort which would tend to straight- 
en its curvature. 
As the radius cannot rotate upon the ulna but at the expense 
of the interosseal space, it is easy to comprehend why fractures, 
which are consolidated in a wrong position, will impede, or pre- 
vent the pronation of the hand. On the other hand, it is neces- 
sary to note that in forced pronation, this space entirely disap- 
pears, the radius then swings upon the ulna, and represents a 
Jever of the first order, the power of which is at its inferior por- 
tion : whence luxation of its superior extremity backwards. Su- 
pination, on the contrary, by separating the bones, tends to luxate 
the head of the radius forw ards: hence this accident is very com- 
mon in young children whose nurses are in the habit of lifting 
them by the hand, in order to assist them in making a long step. 
In amputations, these bones must be held in a state of forced 
pronation, in order to avoid jarring the articulations of the radius 
during the action of the saw. It is for the same reason, and in 
order that the section may terminate by the least moveable bone, 
that we recommend the surgeon to hold it inwards. 
These operations here present different peculiarities, according 
to the part of the limb upon which they are performed. The skin, 
as we have seen, is every W'here very moveable ; it will alwTays 
be easy to draw it up as far as is required without dissecting it, 
as wras the practice of J. L. Petit; but as the volume of the parts 
to be covered is less inferiorly than superiorly, it will be necessa- 
ry to preserve more of it in the latter direction. 
If the operation is performed near the wrist, wre will only have 
the radial and ulnar arteries to tie; it will not be necessary to 
pass the knife into the interosseal space ; but, on the other hand OF THE THORACIC EXTREMITIES. 
325 
we will scarcely meet with any thing more than the tendinous 
portion of the muscles, the synovial tissue and the species of web 
which constitutes it; the soft parts will have but a slight degree 
of thickness, and the skin alone will remain applied upon the ex- 
tremity of the bones. 
In the middle portion, on the contrary, the radial, ulnar, anteri- 
or and posterior interosseous arteries will each require a ligature ; 
it will be necessary to cut the muscles between the bones; but here 
the muscular mass is considerable ; there are no longer tendons 
nor synovial membrane in this situation, and it will always be pos- 
sible to preserve as much of the soft parts as will favour the im- 
mediate union of the wound. Therefore, notwithstanding the ad- 
vantage of preserving a greater length of limb, M. Larrey and 
other surgeons always advise amputating in the muscular portion 
of the fore-arm. Nevertheless, with due deference to the opinion 
of M. Larry, whose authority is doubtless imposing on this sub- 
ject, we think, with many others, that the amputation should be 
made as low down as the disease will permit, and observation 
has sufficiently proved that such cases succeed full as well, and 
that the cicatrix is quite as firm as when the operation is per- 
formed higher up; only it seems to us that, instead of keeping 
the extremity of the stump more elevated than the elbow, dur- 
ing the subsequent treatment, with the view of preventing a de- 
termination of blood towards the part, it would be much better to 
keep it in a dependent position ; for, in the first case, it is evident 
that the pus, if it forms, and the inflammation will be almost 
necessarily propagated towards the fold of the arm, through the 
medium of the retracted tendons and their envelopes, by the 
cellular tissue, the veins and the lymphatics; whilst, in the latter, 
all the inflammatory phoenomena will be confined to the wound. 
Again, the fore-arm is that portion of the limbs which is best 
adapted for the flap amputation, according to the method of Yer- 
male, if it is true that it presents greater advantages than the 
circular operation. It is invariably the case, in operating upon 
the inferior portion of the fore-arm by the latter method, that the 
tedons and other soft parts will roll under the instrument, will be 
pressed by it between the bones, and consequently be divided 
with difficulty; and in amputating higher up, by the same pro- 
cess, that the muscles will also be divided in an unequal manner, 326 
Ob’ THE THORACIC EXTREMITIES. 
especially externally, and that their section upon the anterior and 
posterior surfaces of the bones will not always be less difficult. 
Consequently, it appears to us that the two methods might be 
combined with advantage, as M. J. Cloquet has proposed; or 
rather that the operation would be more expeditious and safe by 
commencing with a circular incision through the skin, which is 
to be sufficiently raised, and afterwards dividing the muscles by 
passing cautiously from one side to the other, between them and 
the bones, a narrow knife, the edge of which would finally be 
directed to their fibres. 
Sect. 3. Borders of the Fore-Arm. 
1. The External, or radial border, is formed superiorly by the 
external muscular eminence of the fold of the arm, and is conse- 
quently found almost entirely in the anterior region. Below this 
prominence, the radius is subcutaneous; more inferiorly, we ob- 
serve the eminence produced by the muscles which pass to the 
thumb. In order, therefore, to distinguish fractures of the radius 
by following the external surface of this bone, we must feel along 
the external groove of the dorsal aspect of the fore-arm. The 
parts composing this border have already been described. 
2. The Internal, or Ulnar Border, presents superiorly the side 
of the internal muscular eminence, which descends lower than the 
external; inferiorly, the ulna is covered by the skin only; so that 
the superior half of this bone is actually in the posterior region, 
and that, in order to ascertain its fracture, it is necessary to trace 
it behind, in the direction of a line which would pass from the 
internal part of the olecranon to its styloid process: in the same 
manner that, with respect to the radius, we would follow another, 
proceeding from the posterior part of the condyle of the humerus 
to the styliforme apophysis of the radius. 
From what has just been said, we see that, properly speaking, 
these borders do not exist as distinct regions; that their superior 
half enters into the palmar aspect, and that their inferior half 
appertains to the dorsal region: therefore we will not dwell any 
longer upon them. OF THE THORACIC EXTREMITIES. 
327 
Art. V. of the wrist. 
This part consists of that assemblage of organs which is com- 
prised between the two regions of the fore-arm and a circular 
line which would pass below the os pisiforme and upon the root 
of the thumb; it consequently includes all the articulations of the 
bones of the carpus with each other, with the bones of the fore- 
arm and with the hand. Its length is about two inches. It will 
be divided into two regions, by the two lines which continue the 
anterior border of the radius and the head of the ulna, towards 
the carpo-metacarpal articulation of the thumb and the posterior 
extremity of the fifth metacarpal bone. 
Sect. 1. Anterior Region. 
Its transverse extent is from two to two and a half inches. In 
examining its surface, through the skin, we feel, from without in- 
wards ;—1st. a prominence formed by the conjoined tendons of the 
abductor longus and extensor brevis pollicis, a prominence which 
seems to be continuous above with the anterior crista and styloid 
process of the radius ;—2nd, a fossette which terminates the radial 
groove of the fore-arm, and by which we may penetrate into the 
joint—3rd, below and within this fossette, a second eminence 
which corresponds to the crests of the scaphoides and trapezium, 
and which may be readily distinguished when the hand is thrown 
back. If the thumb and little finger are in contact, and the other 
fingers extended whilst the wrist is flexed upon the fore-arm, an 
extremely prominent cord will be seen passing upon the preced- 
ing relief: this cord is formed by the tendon of the palmaris 
longus. In the state of rest, this tendon and the bones just 
mentioned gradually subside into the middle prominence of the 
wrist, which is itself formed by the tendons of all the flexors and 
of the anterior radial;—4th, a second fossette, which terminates 
the ulnar groove of the fore-arm, and which corresponds to the 
artery of the same name ;—5th, the eminence represented by the 
os pisiforme and the tendon of the flexor carpi ulnaris, and behind 
which we meet with another fossette surmounted bv the head 328 
OP THE THORACIC EXTREMITIES. 
of the ulna;—finally, in the middle and most inferior part, a super 
ficial excavation which leads into the palm of the hand. 
CONSTITUENT PARTS. 
i. The Shin. 
The skin docs not present exactly the same characters upon 
the fore part of the wrist that it does on the palmar aspect of the 
fore-arm ; it is destitute of hairs, but wrinkles are observed in it 
in greater or less numbers, according to the age, sex, and embon- 
point. Among these wrinkles, three especially are conspicuous, 
which may serve as guides in operations. The first is found 
upon the superior limits of the region, half an inch above the 
styloid process of the radius: it is occasionally wanting. The 
two extremities of the second terminate at the apex of the styloid 
process of the radius and of the ulna ; it corresponds to the radio- 
carpal articulation. Finally, the third, still more distinct than 
the preceding, is slightly convex downwards; it separates the 
thenar and hypothenar eminences, as well as the palm of the 
hand from the wrist properly so called. By cutting upon it, we 
would fall directly upon the articulation of the two carpal rows. 
Below this last the skin is smooth, although thick and more com- 
pact : it then makes a part of the palmar integuments of the 
hand. 
lr. The Subcutaneous Layer. 
This layer is formed of very dense and slightly extensible cel- 
lular lamella) and filaments, and never acquires great thickness, 
although it contains a considerable quantity of adipose vesicles, 
which are met with in the upper, seldom in the lower, and still 
more rarely in the middle portion. As this layer is rather fibrous 
than cellular, and unites the aponeurosis and annular ligament 
intimately to the skin, serous, sanguineous or purulent secre- 
tions can never separate these two membranes; so that in drop- 
sical persons, as well as in those w ho are loaded with fat, we 
observe a kind of strangulation at the wrist. The same thing is 
pretty generally noticed in women and children. In this layer OF THE THORACIC EXTREMITIES. 
329 
the superficial veins and nerves take their course. It is import- 
ant to distinguish diseases developed in this tissue, from those 
which are more deeply seated. 
in. The Aponeurosis. 
Above the radio-carpal articulation, it has the same arrange- 
ment as was detailed in the anterior anti-brachial region; but 
below this it is complicated in a very remarkable manner. If 
we commence with it at the head of the ulna and the os pisi- 
forme, we will perceive that it splits in order to envelope the 
tendon of the flexor carpi ulnaris, and that it afterwards gives a 
sheath to the ulnar artery; its laminae are then re-applied upon the 
fore part of the flexor tendons, in order to separate anew, envel- 
oping the tendon of the palmaris longus in the first place, then 
that of the flexor carpi radialis, and afterwards forming a sheath 
for the radial artery; it then passes to fix itself to the anterior 
border of the styloid process of the radius and becomes blended 
with the fibrous canal in which the tendon of the abductor longus 
pollicis runs. Inferiorly, its fibres are approximated, condensed, 
and thus seem to give origin to the anterior annular ligament of 
the carpus, before which the tendon of the palmaris longus ex- 
pands, and is transformed, as it were, into an aponeurosis ; which 
makes the ligament appear as if formed of two layers: one with 
diverging fibres, appertaining to the tendon; the other, with 
transverse fibres, the continuation of the aponeurosis. This lig- 
ament is attached, on the one hand, to the os pisiforme and the 
process of the os unciforme; on the other, to the crest of the 
scaphoides and trapezium. In terminating, this last extremity 
splits in order to form a sheath for the tendon of the flexor carpi 
radialis. Its inferior border is continuous with the palmar apo- 
neurosis ; in the middle and upon the sides, the fleshy fibres of the 
thenar and hypothenar eminences derive their attachments from 
it. We have already said that, superiorly, it was continuous 
with the aponeurosis. According to this arrangement, the ante- 
rior carpal ligament forms the anterior half of a complete ellip- 
tical ring, the transverse diameter of which is twenty one lines, 
and its antero-posterior, one inch only. This ring, or canal, 
encloses all the tendons of the two common flexors and that of 330 
OP THE THORACIC EXTREMITIES. 
the thumb; those of the palmaris longus and of the flexores carpi 
radialis et ulnaris are without it; the median nerve passes through 
it; but the radial and ulnar arteries, as well as their concomi - 
tant nerves, are external to it. As it is very strong and unyield- 
ing, it invincibly resists the protrusion of tumours which are 
deeply situated and forces them towards the hand or fore-arm 
We will again recur to this subject. 
iv. The Muscles. 
Strictly speaking, this region does not contain any; we only 
lind in it a very small portion of the superior extremity of the 
muscles forming the ball of the thumb and little finger, and the 
most inferior fibres of the pronator quadratus; but if there are 
no fleshy bundles, we find in it a great number of tendons. 
Quite externally, we see the termination of the supinator longus 
upon the base of the styloid process, and the tendons which go 
to the thumb. These last are included in a very strong fibrous 
theca, which is lined by a synovial membrane, and they are those 
tendons which, as we have stated, produce the first prominence 
observed externally. They are so distant from the articulation 
that the point of an instrument, entered at the fossette which 
separates them from the second eminence, might pass between 
them, from before backwards, without opening the joint. The 
tendon of the palmaris longus is at first upon the median line; 
then it descends obliquely outwards and expands upon the annu- 
lar ligament, with which it is blended. As it is only enveloped 
by the superficial lamina? of the aponeurosis, it is strongly delin- 
eated through the skin when its muscle is brought into action, the 
thumb being at the same time thrown into forced opposition. 
External to it and a little deeper, wre distinguish the tendon of 
the flexor carpi radialis, the fibrous sheath of which is stronger 
and more complete than that of the preceding. As it passes to 
the second metacarpal bone, this tendon dips into a very strong 
canal which is formed for it by the os scaphoides and trapezium, 
on the one hand, and the external extremity of the annular liga- 
ment on the other. The flexor carpi ulnaris, having likewise a 
distinct fibrous canal, also raises the skin in the flexion and ad- 
duction of the wrist.. During the forced adduction of the little or THE THORACIC EXTREMITIES. 
331 
ringer, it is sufficiently separated from the bones of the carpus to 
admit of the passage of a pointed instrument between it and the 
articulation, without penetrating into the latter. If the instru- 
ment was directed obliquely from before backwards, and from 
without inwards, or even in the opposite direction, it is probable 
that a similar wound would rarely fail to comprise the artery, 
and even the anterior branch of the nerve. These different ten- 
dons, having each a distinct sheath, are by this means completely 
isolated from the surrounding parts, so that they may easily act 
independently of one another. 
It is not so with those included by the carpal ring; the flexor 
of the thumb alone seems separated from the others, and draws 
with it a portion of the fibro-cellular bursa which envelopes them 
all. They there form a sort of bundle, in which the median 
nerve is also found. The membrane which first connects them 
in a mass, then each in particular, lines the whole interior of the 
canal which contains them. Although this membrane is thin and 
translucent, it nevertheless possesses much firmness; its texture 
is evidently fibrous, and it possesses the greater part of the char- 
acters which appertain to synovial membranes. In the natural 
state, however, we seldom find in it much fluid; it is only lubri- 
cated, very slippery, and polished. Below the annular ligament 
it seems to terminate in a cul-de-sac; so that it will oppose the 
infiltration of pus, serum, etc., in deep-seated affections of the 
wrist. This membrane is of considerable extent, and like all 
others of the same nature, it readily inflames when divided by an 
instrument, or even from simple contact with the external air. 
This inflammation, which in itself is of a very dangerous nature, 
becomes still more so from the which the aponeurosis 
opposes to the inflammatory swelling of the parts, and especially 
from the species of strangulation which the anterior ligament of 
the carpus exercises upon it. It is this inflammation which ren- 
ders wounds, contusions, and all deep-seated diseases of the 
wrist so dangerous, and which we must apprehend when we per- 
form any important operation upon this part. It is in this bursa 
that we have most frequently seen those cartilaginous granulations 
developed of which we treated when on the elbow; granulations 
which do not appear to differ much, except in volume, from those 
accidental cartilages which are sometimes met with in the large 332 
OF THE THORACIC EXTREMITIES. 
articulations; granulations, finally, which have been regarded as 
hydatids, but the nature of which we are as yet almost ignorant 
of. Be this as it may, the tumour which contains them here al- 
most uniformly has the peculiar character of being double, or of 
the form of a wallet; that is to say, it projects both in the palm 
of the hand and fore part of the wrist at the same time, which is 
undoubtedly owing to the disposition of the anterior fibrous arch 
of the carpus. This tumour, which does not seem to be suscep- 
tible of resolution, produces but little inconvenience, unless it 
acquires a large volume; but if the patient wishes to get rid of 
it, and if the surgeon decides on simply opening it, or passing a 
seton through it, the operation may be followed by the most 
serious consequences, even death; which has occurred several 
times at Hotel Dieu. In 1822, we saw Prof. Richerand, at the 
Hospital St. Louis, open a similar tumour in a girl nineteen years 
of age, of a strong and good constitution. The operation was 
performed with every necessary precaution ; notwithstanding, 
intolerable pains ensued, and violent reaction manifested itself; 
it was necessary to make numerous incisions, which did not pre- 
vent abscesses from forming, and this girl was not out of danger 
until after six weeks of suffering, combatted by the most ener- 
getic measures. 
v. The Arteries. 
In the first place we find the Radial, lying upon the fore part of 
the radius and pronator quadratus ; when it reaches the fore part 
of the styloid process, it turns backwards and passes through the 
space which separates the tendons of the short and long abduc- 
tors of the thumb from the bones, in order to enter the posterior 
region ; so that it would be possible to discover it in the radial 
fossette of the wrist, and that, if the wound, indicated w hen speak- 
ing of this tendinous prominence, occurred, it would almost neces- 
sarily involve this vessel. Previous to changing its direction, the 
radial artery sends off a small branch to the thenar eminence ; 
then a second, which runs towards the palmar gutter by passing 
between the tendon of the flexor carpi radialis and the anterior 
annular ligament. This vessel is sometimes so large that its di- 
vision might be dangerous ; and, in such a case, it is so superficial OF TIIE THORACIC EXTREMITIES. 
333 
that it may be exposed and secured. In terminating, it assists in 
the formation of the superficial palmar arch. 
Next the Ulnar, which is still covered by the tendon of the 
flexor carpi ulnaris muscle, and by two aponeurotic laminae, as in 
the palmar aspect of the fore-arm ; therefore, we may also expose 
and apply a ligature around it by following the directions then 
given. In some persons it is so superficial that its pulsations 
may be easily felt in the ulnar groove of this region. In de- 
scending, this artery inclines slightly outwards, in order to pass 
over the fore part of the annular ligament and the radial side of 
the os pisiforme. In the upper part of the region, that is to say, 
about an inch above the head of the ulna, the ulnar artery sends 
off a branch which varies in its dimensions, and which passes 
directly upon the dorsum of the wrist, crossing the nerve, which 
is always situated behind and upon the inner side of the arterial 
trunk. When the volume of this branch is very considerable, it 
may be readily felt upon the internal border of the ulna-; in 
which case also a cutting instrument, carried upon this side, 
would promptly reach it, and if we did not reflect upon it, we 
might be persuaded that the ulnar itself was wounded. 
There are no other remarkable branches in this region. 
vi. The Veins. 
The superficial veins form a more or less complicated net- 
work. They usually represent an arch, the convexity of which, 
turned towards the hand, receives many branches from this por- 
tion of the limb, and the extremities of which constitute the roots 
of the median and ulnar veins. In general, the external branches 
are larger than the internal, and they might possibly serve for 
venesection ; but we seldom open them, because there are always 
others more voluminous. The deep-seated are applied upon the 
anterior aspect, or upon that side of the arteries which is towards 
the central line of the limb. They are of small size and merit 
but little attention. 
vir. The Lymphatics. 
Disposed as in the fore-arm, they present nothing particular. 334 
Ol' THE THORACIC EXTREMITIES. 
viii. The Nerves. 
On the inner side, we see the continuation of the anterior 
branch of the ulnar nerve, which runs directly along the external 
side of the artery and a little posterior to it; externally, some 
twigs of the radial; in the middle, the median, the volume of 
which usually equals that of the tendons with which it is min- 
gled. Before the median enters the ring of the carpus it gene- 
rally gives off its cutaneous palmar branch, which soon becomes 
superficial and ramifies in the subcutaneous layer, becoming 
blended with some of the extreme filaments of the internal cu- 
taneous and musculo-cutaneus, which extend thus far. From 
the small number of sensible cords which are met with in this 
region, we may be permitted to advance the opinion, that, if dis- 
eases are more dangerous here than in many other parts of 
the body, we must not seek for the cause of it in the nervous 
system. 
ix. The Skeleton. 
The skeleton comprehends the anterior faces of the bones of 
the carpus, of the head of the metacarpal bones, and of the ex- 
tremity of those of the fore-arm. At first sight, the metacarpal 
bones of the thumb and little finger only would seem suscepti- 
ble of being luxated forwards; but, on the one hand, if they 
possess more extensive mobility than the others, and if their lig- 
aments are weaker; on the other, the root of the muscles which 
are applied upon their anterior surfaces, maintains them and op- 
poses their displacement. The bones of the carpus are covered 
by a fibrous membrane so strong and compact, that we have no 
example of their luxation upon the palmar aspect. In fact, in 
this region there is only the first row of the carpus which can be 
luxated upon the radius, and the ulna which is susceptible of be- 
ing displaced forwards. The first of these luxations, without 
being very rare, is, however, difficult to accomplish ; because, on 
the one hand, the radio-carpal ligament is very strong, and, on the 
other, because the powers which lend to produce it press the 
hand firmly backwards: whereby all the flexor tendons arc ap- OP THE THORACIC EXTREMITIES. 
335 
plied very firmly against the bones, and thus repel them with 
energy. The ulna is maintained in a less solid manner upon the 
carpus; but its relations with the radius are so fixed that its lux- 
ation forwards must be rare and difficult; we have, nevertheless, 
met with it several times, and we conceive that it may take place 
in a movement of forced supination, when the radius, in rotating 
backwards, tends to tilt in a direction opposite to that which was 
mentioned when considering its superior luxations. In the move- 
ment of forced supination, in fact, if the humeral extremity of 
the radius cannot slip forwards, and if the force is pretty consid- 
erable, the head of the ulna will escape from the cavity which 
contains it below, and the hand will remain in supination. 
In examining all these bones covered by their ligaments, wc 
see superiorly, and from within outwards; 1st, the groove, in 
which is the tendon of the flexor carpi ulnaris, and which sepa- 
rates the styloid process from the head of the ulna; 2d, an emi- 
nence formed by this head itself, and which is more or less prom- 
inent according to the position of the hand; 3d, another small 
groove which corresponds to the radio-cubital articulation; 4th, 
a second prominence represented by the inferior extremity of the 
radius, and which terminates externally by a species of crest 
forming the anterior border of the styloid process; 5th, below 
this, we find a large transverse semi-circular groove, the convex- 
ity of which is directed upwards ; this groove leads directly into 
the articulation of the fore-arm with the carpus ; its two extrem- 
ities separate the apex of the radial and ulnar apophyses from 
the os pisiforme and from the crest of the os scaphoides; 6th, 
still lower and upon the radial side, the eminence formed by the 
trapezium and os naviculare, with the dispositions of which we 
should be well acquainted in amputating at the wrist, in order to 
avoid striking against it and making the knife glide upon the fore 
part of it; 7th, internally, and upon the same line, the promi- 
nence of the os pisiforme and unciforme; this deserves still 
more attention than the preceding, when we perform the flap ope- 
ration at the wrist; on the one hand, because it is more evident, 
and on the other, because it would be more easy to disarticulate 
the os pisiforme, and leave it in the flap; 8th, in the middle, a 
very deep transverse concavity, which forms the posterior half 336 
OF THE THORACIC EXTREMITIES. 
of the carpal ring, and which has for its base a portion of the 
anterior surface of the trapezium, scaphoides, cuneiforme, and 
unciforme, the whole of the trapezoides, lunare, and magnum. 
From what has preceded we find that the order of superposi- 
tion of the parts here is the following: 1st, the skin; 2d, the 
cellular layer, dense and compact, enclosing the superfi- 'al 
veins and nerves; 3d, the aponeurosis, which contains in its lem- 
ma? the tendons of the flexor carpi ulnaris, palrnaris longus, and 
flexor carpi radialis; and still deeper, the radial and ulnar arte- 
ries and nerves; 4th, the anterior annular ligament, uniting the 
aponeuroses of the hand and fore-arm ; 5th, the flexor tendons of 
the fingers and the median nerve enveloped by their synovial 
bursa ; 6th, and lastly, the ligaments and bones. 
Sect. 2. The Dorsal or Posterior Region of the Wrist. 
Upon its surface we observe, from without inwards: 1st. a 
fossette, about an inch in breadth, limited above and below by the 
extremity of the radius and the root of the thumb ; anteriorly, by 
the first eminence of the anterior region, and, externally, by the 
species of cord which is represented by the extensor longus pol- 
iicis; the radial artery crosses the bottom of this fossette, the 
depth of which is much more apparent v, hen the thumb is in abduc- 
tion and extension'; 2d. the thumb being in the same position, and 
the indicator extended whilst the other fingers are flexed, another 
excavation of less depth, but broader, limited externally by the 
tendon of the extensor longus pollicis, and internally by that of 
the extensor indicis, wfliich excavation is divided by the tendon 
of the extensor radialis brevior into two triangular portions; one, 
external, containing the head of the second metacarpal bone and 
the termination of the radial artery, a little more externally; the 
other, on the contrary, internal, having its base towards the 
radius, and which will guide us directly into the joint; 3d. another 
fossette, which corresponds to the interval of the extensor ten- 
dons of the ring and little fingers; 4th. more internally, a small 
excavation, which is also found between this last tendon and 
that of the extensor carpi ulnaris; in this is situated the head of 
the ulna, which sometimes projects considerably; 5th. the depres- OF THE THORACIC EXTREMITIES. 
337 
sion which separates the tendons of the flexor and extensor carpi 
ulnaris, as well as the two regions of the wrist internally. These 
different excavations, circumscribed by as many eminences, per- 
mit, on the one hand, pointed instruments to enter into the ar- 
ticulations, without dividing the tendons; and on the other, to 
synovial tumours, and nodi, to project under the skin. 
CONSTITUENT PARTS. 
i. The Skin. 
This is supple, extensible and covered with numerous hairs in 
man ; it is less delicate than upon the palmar surface, and contains 
some indistinct sebaceous follicles. Although uneven and rough, 
it does not present any complete wrinkles; it only seems as if 
the epidermis was too large for this region, and therefore thrown 
into folds in all directions. The skin upon the dorsal surface of 
the wrist is always of a darker hue than that of the anterior region. 
ii. The Subcutaneous Layer. 
It preserves all the characters which it possessed in the fore- 
arm, and therefore differs much from the subcutaneous layer of 
the anterior region: hence tumours may be developed under it 
as in the rest of the limb, and increase to pretty large dimensions. 
This layer equally contains the superficial veins and some nerves; 
but is destitute of, or contains but very few fatty cells, at least in 
the vicinity of the posterior annular ligament, to which its adhesion 
is stronger than elsewhere ; from which circumstance this portion, 
in children, females and fat subjects, or where the arm is cedema- 
tous, appears as if strangulated. 
hi. The Aponeurosis. 
From the styloid process of the radius to that of the ulna, the 
aponeurosis forms a very strong broad arcade, destined to bind 
down the tendons, to which it furnishes separate sheaths: this is 
the ligamentum carpi annulare posterius. The different canals 338 
OF THE THORACIC EXTREMITIES. 
to which this ligament gives rise from without inwards are: 1st. 
behind and external to the styloid process of the radius, a very 
strong theca directed obliquely forwards and downwards, for the 
tendons of the extensor brevis {extensor secundi internodii) and 
abductor longus pollicis {extensor primi internodii): this sheath 
constitutes a complete canal, and when it is divided into two by a 
septum, the extensor {secundi) tendon lies posteriorly. 2d, 
another theca, which descends perpendicularly, and encloses the 
tendons of the extensores radialis longior et brevior; 3d, the 
fibrous canal which envelopes the tendon of the extensor longus 
pollicis {extensor tertii internodii): this canal is oblique in the same 
direction, as the first, and is only complete below7 the radius ; more 
superiorly it is separated from the sheath common to the entensors 
of the fingers only by a slightly extensible fibro-cellular lamina ; 
4lh, the canal, or rather the proper posterior carpal ring, through 
which the tendons of the extensor communis and indicator pass; 
5th, a separate sheath for the extensor minimi digiti ; 6th, be- 
tween the styloid process and the head of the ulna, another tlieca 
for the tendon of the extensor carpi ulnaris. On the side of the 
anti-brachial region, this ligament gradually becomes thinner, its 
fibres separate, and are finally blended with those of the aponeu- 
rosis. Its inferior margin is converted into a fibro-cellular lamina, 
which is at first very thin, but afterwards becomes thicker as it 
passes to the hand. 
iv. The Muscles, or rather Tendons. 
The tendons of all the extensor muscles of the fingers and hand 
traverse the posterior region of the wrist. They are twelve in 
number, and were made known when describing the sheaths 
which they derive from the aponeurosis. Those which form the 
external limit of the fossette of the first metacarpal bone, were 
seen w hen on the palmar surface. The extensores radialis lon- 
gior et brevior diverge as they descend ; they are usually sepa- 
rated in their sheath by a fibrous septum, and crossed by the ex- 
tensor pollicis longus, which is itself interposed between the fos- 
sette of the first metacarpal bone and that of the second. The 
four tendons of the extensor communis, and that of the indicator OP THE THORACIC EXTREMITIES. 
339 
are disposed in their ring, like those of the flexors anferiorly ; that 
is to say, that a sort of very strong, fibrous, synovial membrane 
envelopes them, and permits them to slide easily, either separately 
or conjointly. This membrane does not, however, form a com- 
plete bursa, and seems less complicated than that of the anterior 
region. It lines all the thecce, and covers all the tendons which 
run through them. The same surgical remarks will apply to it 
as to all other organs of the same nature : nevertheless, as the 
circumjacent tissues are less dense than in the anterior region, its 
inflammations generally produce less acute pain and less formi- 
dable symptoms. We have not met within it those cartilaginous 
corpuscules which were mentioned as sometimes existing in the 
palmar portion ; but those synovial tumours called nodi, or gan- 
glions, are frequently developed in it. It is true that these tu- 
mours may also depend upon a species of hernia of the articular 
synovial capsule ; but most frequently it is the membrane under 
consideration in which they are situated. In this case, as in the 
other, it is always dangerous to open these species of cysts, in 
consequence of the inflammation which frequently ensues, and 
which rapidly extends from the incised sac into all the tendinous 
sheaths, to the fore-arm, hand, etc. There is at present in the 
hospital of la F /culte, an adult female, who has had one of these 
tumours over the track of the extensor longus pollieis for six 
years, and which she was desirous of getting rid of. A young 
surgeon wished to try the radical cure for hydrocele ; he punc- 
tured it, injected a small quantity of cold water into it, and re- 
commended rest; an intense fever supervened, abscesses formed 
in the thecae, fore-arm, and upon the back of the hand, etc.; it 
became necessary to make several incisions, and this woman is 
not yet out of danger, although more than a month has elapsed 
since the operation. 
v. The Arteries. 
The Radial is the largest, and is the only one which deserves 
some attention. As it is passing behind the root of the thumb, 
in the fossette of this finger, in order to reach the first inter- 
osseal space of the metacarpus, it is deeply seated and is crossed 
by the tendons of the extensor pollieis brevis and abductor Ion- 340 
OF THE THORACIC EXTREMITIES. 
gus pollicis, on the one part, and the extensor pollicis longus, oi> 
the other. In order to discover it in the excavation which sepa- 
rates these tendons, we would have to divide only the skin and a 
pretty thick layer of cellular tissue. 
The dorsal artery of the carpus and the posterior branch de- 
rived from the ulnar, are generally too small to require any par- 
ticular attention in operations. The first is crossed by all the 
extensor tendons, and traverses the region below the posterior 
annular ligament; the second, already pointed out in the pre- 
ceding region, crosses the posterior surface of the ulna obliquely, 
from within outwards and from before backwards, so that it 
is crossed in its turn by the tendons of the extensor carpi ulnaris 
and extensor minimi digiti. 
vi. The Veins. 
Those which appear through the skin are generally very large ; 
their number varies greatly, but they are usually collected inter- 
nally and externally in order to form two principal trunks; the 
internal, most constant and voluminous, was called Salvatclla, 
by the ancients ; the external is chiefly made up of the veins of 
the first two fingers, and constitutes the Cephalic of the thumb. 
The first ascends, under the name of ulnar, and the second, 
under that of radial, behind the fore-arm. Formerly, venesec- 
tion was often performed in these veins; but at present we sel- 
dom have recourse to it, unless those of the fold of the arm can- 
not answer the purpose. 
The deep-seated veins present nothing particular. 
vii. The Lymphatics. 
These vessels pass from the hand and fore-arm, and are ar- 
ranged in the same manner as in these regions: they do not pre- 
sent any thing requiring particular notice. 
vin. The Nerves. 
Some filaments of the cutaneous nerves of the brachial plexus 
ramify around the veins and terminate in the superficial layer of OF THE THORACIC EXTREMITIES. 
341 
the dorsum of the wrist. We also observe in this region the 
posterior branch of the radial nerve, which here divides into an in- 
ternal and external cord. On the inner side, the posterior branch 
of the ulnar nerve bifurcates in like manner: their different 
branches creep in the aponeurotic layer, and cross the most of 
the tendons, so that a cutting instrument might possibly divide 
them, without involving the latter ; and as it would then be im- 
possible to extend the fingers, we might easily be mistaken as to 
the nature of such wounds. 
ix. The Skeleton. 
It is remarkable for the number of bones and articulations 
which enter into its composition. 
Superiorly and transversely, from its outer to its inner border, 
we observe, 1st. upon the radius, different crests which separate 
the tendinous sheaths: these crests should be noticed, as they are 
sometimes so prominent that they might posssibly be mistaken 
for exostes; 2d. the gutter which the tendons of the extensor 
communis traverse, and which corresponds internally to the 
radio-cubital articulation ; 3d. the head of the ulna, which natur- 
ally makes a prominence under the skin, between the tendon of 
the extensor minimi digiti and that of the extensor carpi ulnaris. 
Below the bones of the fore-arm there is a narrow, convex 
part, representing the posterior surface of the bones of the car- 
pus, and which unites the hand to the fore-arm. Superiorly, this 
species of neck presents a transverse semi-circular groove, with 
superior convexity, which corresponds to the radio-carpal articu- 
lation. This groove deserves the greatest attention when we am- 
putate the wrist, because, if the knife should fall below it, it 
would enter between the two rows of the bones of the carpus; 
if above it, we would be liable to denude the radius and ulna. In 
order to find it and penetrate directly into the joint, or rather to 
perform the operation in question, divers methods have been re- 
commended. In one, the surgeon makes a circular incision 
through the skin below the inferior transverse line which it pre- 
sents in the anterior region, dissects and raises it, divides the 
tendons, and then removes the hand by traversing the articulation 
from the apex of the external styloid process to the internal, in 342 
OF TIIE THORACIC EXTREMITIES. 
the direction of the groove just indicated. In the other, having 
marked the anti-brachial styloid processes, a semi-lunar incision 
with inferior convexity is made through the integuments; the 
cellular bridles are divided, and the skin drawn up by an assist- 
ant ; the posterior tendons arc then cut across, and, in order to 
disarticulate, the point of the knife is passed into the articulation, 
under the apex of the styloid process of the radius, and makes a 
semi-circular incision, in an inverse direction to that which was 
made through the skin ; all that is then to be done is to form the 
anterior flap, which is the principal, taking care to avoid the pisi- 
forme and the crest of the scaphoides. If, in either of these two 
methods, we carried the instrument directly across from one sty- 
loid process to the other, we would separate the two rows of the 
carpal bones; by following the curved line just mentioned, this 
error will always be avoided, whether the incision commences at 
the radial or cubital border; it is more sure, however, to begin 
upon the outer side, because the scaphoides is more inclined 
under the styloid process of the radius, whilst the apex of that 
of the ulna falls exactly on a level with the articulation of the 
cuneiform with the unciforme bone. 
By a third method, the instrument is carried transversely flat- 
wise, between the bones and the soft parts, to the fore part of 
the radio-carpal articulation. In this way we commence by 
forming the anterior flap, which we raise; then we make an in- 
cision upon the dorsal surface of the wrist, as in the preceding 
case, and the disarticulation is effected in the same manner as by 
the first process. 
The anatomical disposition of Ihe parts permits the belief 
that we may succeed by either of these methods of operating. 
The first, adopted by Sabatier and followed by most English 
surgeons, is certainly as easy and certain as any other: it even 
has the advantage of forming a more regular wound, and of ren- 
dering the apophyses less liable to remain uncovered; but it is 
not always possible to cut the skin so low as to admit of the union 
of the soft parts by the first intention. 
The second is more expeditious, and as we may give much 
length to the flaps, especially to the anterior, an immediate re- 
union will readily take place. We must mention, however, that 
as the skin is not of so great a length at the angles of the wound. OF TIIE THORACIC EXTREMITIES. 
343 
it is more difficult to cover the bones exactly, which are larger 
and more prominent in this situation than in the middle. Lastly, 
the third, which appertains to M. Lisfranc,* presents nearly the 
same advantages, and may also be followed by the same in- 
conveniences. 
It should also be observed, that in the first method, the dissec- 
tion of the skin, which is easy upon the dorsal surface, requires 
caution upon the palmar surface, on account of the compact tex- 
ture of the cellular tissue, and that this reason alone should pre- 
vent us from commencing the operation at the anterior part, by 
the flap method, even when there are sufficient soft parts behind 
to cover the osseous extremities. 
As the articulatory surfaces of the bones of the fore-arm are 
so disposed that they form a very deep transverse concavity, and 
as their apophyses are about two inches and a half asunder, 
whilst the antero-posterior diameter of the radius is not more 
than an inch ; the radio and cubito-carpal ligaments being also very 
strong, it follows that internal or external luxations of the wrist 
must be very rare, and that they cannot be complete without the 
previous laceration of numerous parts. On the other hand, as 
the corresponding articular surface of the bones of the carpus is 
pretty regularly convex, we cannot easily comprehend how in- 
complete carpal luxations can occur in either of these direc- 
tions ; behind and before, on the contrary, the osseous margin 
is scarcely prominent, and the ligaments only can oppose some 
resistance to the displacements, which are likewise favoured by 
the natural movements of the hand. We have already men- 
tioned in what manner the luxation forwards is effected: the 
opposite displacement is produced by the same mechanism ; but 
it is more rare, because the osseous extremities are less disposed 
to slip in the latter direction, and because the hand turns less 
easily forwards than backwards. 
The same cause which occasions the luxation of the head of 
the ulna forwards, in forced supination, will also produce its 
luxation backwards, in pronation, when the head of the radius is 
solidly maintained upon the humerus. 
We would observe, finally, that the two bones of the fore-arm 
* Coster’s Manual of Surgical Operations, &c., Godman’s translation, p. 48. 344 
OF THE THORACIC EXTREMITIES. 
may be separated by those causes which would tend to produce 
lateral luxations, and that this species of diastasis is pretty frequent, 
even in fractures of the inferior extremity of the ulna and radius. 
With respect to the bones of the carpus, they afford too slight 
a hold for the action of external powers, their ligaments are too 
numerous and firm, to permit their luxation upon each other. 
There is one, however, which is less solidly encased, the rounded 
head of which is susceptible of being driven from the cavity 
which encloses it; this is the os magnum: as it is thicker poste- 
riorly than anteriorly, the displacement always occurs in the 
former direction; at least this is the observation of Chopart and 
Boyer. Among the carpo-metacarpal articulations, the first only 
admits of luxation. In fact, it is isolated from the others, and its 
surfaces are enveloped by a species of capsule, which is suffi- 
ciently loose to accommodate them to the movements of the 
thumb; but it is almost impossible for this accident to take place 
forwards, on account of the muscles of the thenar eminence ; or 
inwards, on account of the facet of the os trapezium which lpoks 
outwards and forwards, and which permits the abduction to be 
carried very far without the surfaces abandoning each other; 
finally, or directly outwards, because in adduction the thumb is 
soon stopped by the metacarpal bone of the indicator. Poste- 
riorly and externally, however, the first metacarpal bone is cov- 
ered only by the skin, an aponeurotic expansion of but slight 
strength, and the fibrous capsule, which is also weaker in this 
direction; besides, the articular facets are less extensive from 
before backwards than transversely, and the movement of oppo- 
sition is that which the thumb most frequently executes. The 
only resistance then to the cause of displacement is afforded by 
the extensor tendons of the thumb. As for the rest, this articu- 
lation is easily felt through the integuments, in the summit of the 
fossette situated behind it. We will have occasion to revert to 
this, however, when speaking of the hand, in relation to the am- 
putation of the thumb. 
Although the articulation of the fifth metacarpal bone with the 
os unciformer is so disposed as to admit of some motion, yet it is 
not so moveable as to permit its luxation ; but it deserves notice, 
on account of the operations which are performed upon it. Its 
surfaces are plane and slightly oblique inwards; its dorsal and OF THE THORACIC EXTREMITIES. 
345 
palmar transverse ligaments are strong, and must be divided 
when we adopt the method of M. Lisfranc, before we attempt to 
depress the bone and introduce the point of the instrument into 
the joint. 
With respect to the three other articulations, they are almost 
entirely immoveable. We should observe, however, that the 
posterior extremity of the second metacarpal bone is surmounted 
by two processes which are prolonged upwards for the inser- 
tions of the flexor carpi radialis and extensor carpi radialis 
longior, and that the third presents a similar prolongation for the 
extensor carpi radialis brevoir, which would render their disar- 
ticulation more difficult. 
In the dorsal region of the wrist the different organic strata 
are arranged in the following order: 1st. The skin; 2d. the 
cellular layer; containing the superficial veins and nerves; 3d the 
aponeurosis and annular ligament; 4th branches of the radial and 
ulnar nerves ; 5th the tendons and their synovial envelopes ; 6th 
the deep seated arteries and veins; 7th the bones and their liga- 
ments. 
Art. VI. of the hand. 
The hand is comprised between the inferior limits of the wrist 
and the roots of the fingers; it forms an irregular square, and is 
divided by the acromio-digital and sub-scapulo-digital lines, into 
the anterior or palmar region, and the posterior or dorsal region. 
Sect. 1. The Palmar Region. 
It is more extensive than the dorsal region, and is prolonged 
some lines backwards upon the wrist, and forwards upon the artic- 
ulation of the fingers. Upon its surface we observe, 1st. ex- 
ternally, a muscular prominence, the apex of which terminates at 
the thumb; this is the thenar eminence; 2d. internally, another 
eminence longer, but narrower, extending posteriorly as far as 
the os pisiforme : this is the kypothenar eminence ; 3d. anteriorly, 
when the four fingers are approximated, three risings formed by 
the skin, which correspond to the intervals of the digital roots; 
4th. in the same position, three grooves which separate these last 346 
OF THE THORACIC EXTREMITIES. 
prominences; 5th. in the middle, an excavation terminating ex- 
ternally and posteriorly in the indicator on the one part, and 
which is continuous with the median groove of the wrist, on the 
other; this is the hollow, or palm of the hand ; Oth in this hollow* 
several lines are observed which are pretty constant; one takes 
its origin from the anterior and external extremity of the palmar 
gutter, and almost immediately bifurcates in such a manner that 
the first of its branches makes a semi-circular turn in order to 
circumscribe the thenar eminence, whilst the second passes at first 
transversely and afterwards forms a semi-lunar curve in order to 
terminate upon the posterior part of the hypothenar eminence ; 
another line seems to originate from the place where the first 
terminated, that is to say from the wrist, and descends vertical- 
ly upon the middle of the preceding; finally a third extends from 
the interval which separates the indicator from the medius, to the 
base of the little finger, cutting the hypothenar eminence into two 
unequal portions. Its convexity looks backwards and outwards, 
so that, united with the line of the indicator, it somewhat resem- 
bles an X with lengthened branches. Each of these three fur- 
rows appear to be produced by particular movements; thus the 
first is owing to the movement of opposition of the thumb and 
may be called the thumb line; the second, to the flexion of the 
other fingers, in conjunction with that of the thumb when we wish 
to grasp a cylindrical body, for example, and we may name it the 
indicator line: the third seems to depend upon the momentary 
extension of the index finger whilst the others are flexed upon 
any body whatsoever; this is the line of the little finger. By 
uniting the transverse portion of the last two, wre have a furrow 
crossing the fore part of the hand about three lines behind the 
metacarpo-phalangeal articulation, which might be called the 
metacarpal f arrow. These different creases require attention w hen 
it becomes necessary to make incisions into the hand. 
CONSTITUENT PARTS. 
i. The Skin. 
It is generally very thick throughout the whole extent of this 
region, but preserves a certain degree of suppleness upon the OF THE THORACIC EXTREMITIES. 
347 
thenar eminence; elsewhere it is dense, compact, and almost 
inextensible; it is destitute of hairs and sebaceous follicles. In 
labouring people, the natural polish of its surface is changed into 
rough callosities, which increase its thickness, and render inflam- 
mations of this part among them more severe and dangerous. 
In addition to the lines indicated above we find a great many 
others which are owing tqjhe arrangement of the papillm of the 
corpus mucosum. ThesiPpapillary lines are so disposed that, 
upon the thenar eminence they form curves, the concavity of 
which is towards the thumb, whilst, upon the hypothenar, they 
are circular in its posterior half, and almost transverse anteriorly. 
Those of the hollow of the hand diverge as they approach the 
intervals of the fingers, in such a manner as to receive in their 
span the convexity of the small groupe of curved lines in the 
vicinity of the roots of the digital appendices. The skin of 
cicatrices presents nothing analogous to this arrangement. 
n. The Superficial Layer. 
Before the head of the metacarpal bones, and upon the hy- 
pothenar eminence, this layer consists of a very dense filament- 
ous cellular tissue, which unites the deep-seated textures solidly 
to the skin, and contains a great number of small adipose vesicles. 
This structure constitutes a species of elastic cushion, which varies 
but little in thickness, and is prolonged upon the fingers. Upon 
the thenar eminence, the cellular tissue is rather lamellated than 
filamentous, and consequently unites the aponeurosis less firmly 
to the skin; whence also it follows that the phenomena of its 
inflammations, abscesses, and Rumours differ but little from those 
in other parts of the body, whilst, in the rest of the region, the 
compact texture of the parts gives rise to very severe symptoms. 
In the hollow of the hand this layer is much thinner; the fila- 
ments and lamellae are more approximated and blended, as it 
were, with the aponeurosis and the skin: it no longer contains 
adipose vesicles, and consequently no elastic cushion. 
iii. The Aponeurosis. 
In the palmar excavation this fascia is at first very strong, after- 348 
OF TIIE THORACIC EXTREMITIES. 
wards it becomes gradually thinner externally, forming only a 
simple cellular lamina upon the thenar eminence, where it is lost 
in the preceding layer. As it passes towards the inner border of 
the hand, it also becomes more attenuated, and gives origin to 
the palmaris brevis muscle. If we trace it towards the wrist, 
we will find that it is only a continuation of the tendon of the 
palmaris longus and ligamentum carpi annulare anterius; the 
diverging fibres of the former and tfib transverse of the latter, 
although pretty intimately intermingled, are nevertheless distinct 
where the aponeurosis is strongest. As it approximates the an- 
terior part of the hand, those of the palmaris longus are collected 
into four diverging bandalels which bifurcate in order to embrace 
the root of each finger, applying themselves upon the flexor ten- 
dons, or rather becoming blended with the thecae of these tendons. 
Those of the annular ligament or the transverse fibres, become 
less and less distinct in proportion as they advance, and soon form 
only small arcs of circles, which also apply themselves upon the 
tendons, before they reach the first phalanx, and in this manner 
seem insensibly to give origin to the thecae of the tendons. 
In the palmar aponeurosis there are various apertures formed 
by the separation of its fibres at the place of their intersection. 
Some of these openings are very small, others of considerable 
size ; becoming larger and more numerous towards the fingers: 
they are filled with cellular tissue or fatty processes, by means 
of which a communication is formed between the superficial and 
deep-seated parts. These foramina seem to concur in producing 
those acute pains consequent upon inflammations in the hollow 
of the hand, by the strangulation of the tumefied parts which 
their margins must produce; and hence the necessity of enlar- 
ging them early in these diseases. 
iv. The Muscles. 
Some appertain to the thenar eminence, others to the hypothe- 
nar eminence; the palm of the hand also has its distinct mus- 
cles. 
The first constitute the external muscular mass, and are:—1st, 
the abductor brevis, which especially covers the carpo-metacarpal 
articulation of the thumb, and which is there strengthened by OF THE THORACIC EXTREMITIES. 
349 
the tendon of the abductor longus; this is one of those which 
most strongly oppose the luxation of the first metacarpal bone 
forwards ; 2d, the flexor brevis and opponens pollicis, which also 
prevent the displacement in the same direction and inwards, not 
by applying themselves upon the joint, but by acting upon the 
bone as upon a lever of the third order; as they are fixed very 
far from the point of support, they must act with much force; 
3d, the adductor pollicis, a fan-like muscle, placed transversely, 
which acts in the same direction as the last two in opposing lux- 
ations, especially inwards; indeed it resists still more powerfully, 
because it is inserted at a right angle into the bone which the 
force tends to throw backwards. 
The second form the internal muscular prominence. In it 
we find, first, in the cellular layer, the palmaris brevis, stretched 
over the superior fourth of the aponeurosis, which it fixes to the 
internal surface of the skin, towards the ulnar margin of the 
hand: it is this which produces that small depression observed 
within and below the os pisiforme when the thumb and little fin- 
ger are brought into forcible adduction; next the adductor (aft* 
ductor minimi digiti) attached to the os pisiforme, and apparently 
continuous with the tendon of the flexor carpi ulnaris: therefore, 
when the little finger is thrown into adduction, the latter tendon 
is rendered very tense; finally, the flexor parvus, vel proprius 
minimi digiti, which is frequently confounded with the preceding; 
and deeper still the abductor (opponens minimi digiti), which is 
one of the palmar interossei. 
Those of the palm are the lumbricales, which can only be 
considered as appendages to the tendons of the flexor profundus, 
favouring their action upon the fingers by their insertion into the 
dorsal surface of the first phalanges; and the first two palmar 
interossei which present nothing peculiar. 
Besides these different muscular bundles, all the flexor tendons 
of the fingers pass through this region; we consequently find in 
it the four tendons of the flexor sublimis, as well as those of the 
profundus, all of which diverge towards the metacarpo-phalangeal 
articulations, where they enter into their sheaths. That of the 
thumb slides between the two portions of the flexor brevis mus- 
cle, and also passes on to its theca. Under the aponeurosis, all 
these tendons are enveloped collectively and separately by a 350 
OF THE THORACIC EXTREMITIES. 
synovial membrane, entirely similar to that of the wrist, of which 
it is only the continuation. This membrane is liable to the same 
diseases, which are attended with equal and even greater danger, 
on account of the resistance made by the fascia to the inflam- 
matory tumefaction of the parts. 
v. The Arteries. 
The ulnar and radial arteries terminate here, forming two 
arcades called “ palmar arches.” One of these arcades is super- 
ficial, and is situated between the aponeurosis and the skin; its 
convexity looks downwards, and it is found about sixteen lines 
below the annular ligament; its external extremity is continu- 
ous with the radial artery, through the root of the thenar emi- 
nence. On this side the superficial palmar arch is small, unless 
the artery gives oft’ a larger anterior branch than usual. Inter- 
nally, it passes towards the ulnar artery, of which it is the con- 
tinuation, and consequently its volume is greater than externally ; 
we find it directly upon the radial side of the os pisiforme, and 
in order to follow its direction it is easy to imagine a semicircle 
sixteen lines in depth, the extremities of which would rest upon 
the pisiforme and the crest of the scaphoides. According to 
this disposition, we perceive that this arch is very liable to be 
wounded, in which case it would be very difficult to secure it in 
the situation of the wound, on account of the compact texture 
of the tissues. If we wished to operate immediately, it would 
be necessary to tie both the radial and ulnar arteries; but this is 
not always necessary, for the aponeurosis affords so much re- 
sistance, that compression will, generally, succeed in arresting 
the haemorrhage. Four principal digital arteries originate from 
the convexity of this arch, which pass onwards to bifurcate at the 
base of the fingers, in the interval of the fibrous bandelets of the 
aponeurosis ; it also gives off several considerable branches which 
ramify in the thenar and hypothenar eminences; so that through- 
out the whole palmar surface of the hand, the skin and superficial 
layer receive large and numerous arteries, or give passage to 
these vessels. 
The deep palmar arch is less curved than the superficial; its 
convexity is directed a little inwards and backwards; it lies be- OP THE THORACIC EXTREMITIES, 
351 
tween the flexor tendons and the interossei muscles; its internal 
extremity originates from the ulnar artery, of which it forms the 
deep branch. As this branch separates from the trunk it passes 
through the posterior extremity of the flexor parvus minimi dig- 
iti, in order to get behind the tendons. The other extremity 
passes betwreen the adductor and flexor brevis pollicis muscles, 
into the posterior part of the first interosseous space, where it 
communicates with the radial artery, to which it actually belongs, 
and which also furnishes two very large deep branches to the 
muscles of the thenar eminence, along the ulnar side of the first 
metacarpal bone, and the radial border of the second. The 
convexity of the deep palmar arch gives off four or five small 
branches which follow the direction of the interosseal spaces, and 
which communicate, near the head of the metacarpal bones, with 
twigs from the dorsal artery of the metacarpus; this arch also 
distributes forwards, backwards, and from its concavity, several 
other ramuscules which anastamose with the superficial, dorsal, 
etc., arteries. 
From the arrangement of these two arches it follows, that all 
the arteries of the hand communicate extensively with each other, 
and that the ulnar and radial form a very long loop, which is 
double inferiorly, where its base is, single in the fore-arm, where it 
is prolonged to the brachial trunk. Therefore, when one of the 
branches of this loop is wounded, we cannot effectually arrest 
the haemorrhage without applying a thread upon each divided 
extremity of the artery; and when they are the seat of a spon- 
taneous aneurism, it is prudent to put a ligature above and below 
the vessel. 
We have seen a specimen in the possession of Prof. Beclard 
in which all the arteries of the fore-arm and hand were exces- 
sively dilated, and their tunics at the same time very much thick- 
ened. The palmar arches formed a very complicated plexus, 
since all the branches were of the size of a goose-quill; they 
were tortuous, undulated ; finally, their disposition was precisely 
similar to that of those large varicose knobs frequently observed 
upon the vena saphena: indeed, we might say, that these arte- 
ries were in a state of hypertrophy. It is unnecessary to observe 
that in the subject to whom this specimen orginallv belonged, the 352 
OF TIIE THORACIC EXTREMITIES'. 
slightest wound in the palm of the hand would have occasioned 
a dangerous haemorrhage. 
vi. The Veins. 
Upon the thenar eminence the superficial veins still preserve 
a certain volume; they are smaller upon the hypothenar emi- 
nence and still smaller in the palmar hollow; they follow the 
distribution of the superficial arch, and enter the anterior veins 
of the wrist. 
The deep-seated accompany all the branches of the corres- 
ponding arterial arch, and pass into the deep radial and ulnar 
veins. These vessels have no relation with operations. 
vn. The Lymphatics. 
The superficial form three or four trunks, which are generally 
met with upon the fore part of the muscles of the thumb and 
which pass to the anterior aspect of the wrist. The deep lym- 
phatics are in contact with the arteries, communicate with the 
superficial set, and equally pass to the fore-arm. 
vm. The Nerves. 
We meet with, upon the thenar eminence, some superficial 
twigs from the radial, and filaments from the small cutaneous 
palmar branch of the median are distributed in the cellular layer 
of the palm of the hand; the hypothenar receives the two ter- 
minating branches of the ulnar. These last two cords separate 
on a level with the pisiforme, on the outer side of which their 
common branch is situated like the artery which it accompanies. 
The first passes to the last two fingers, applied upon the muscles 
of the internal eminence, and covered by the fatty cushion and 
palmaris brevis muscle. In its course it leaves one or more 
branches upon the internal part of the hypothenar. The second 
passes through the posterior extremity of the opponens and flexor 
parvus minimi digiti muscles, on the inner side of the hook of 
the os unciforme, and forms an arch upon the fore part of the OP THE THORACIC EXTREMITIES. 
353 
mterossei muscles, like the deep arterial arch. It would seem 
that this branch appertains to the muscles, whilst the preceding 
is chiefly distributed to the skin. Be this as it may, it is easy to 
perceive that the ulnar eminence of the hand is much more abun- 
dantly supplied with nerves than the radial, and consequently 
that its diseases must be attended with much more acute pain. 
Finally, the median terminates in this region in giving origin to 
four or five large branches, which diverge as they pass onwards, 
and bifurcate at the roots of the first four fingers. All these 
branches lie under the fascia, running between it and the ten- 
dons of the sublimis; previous to reaching the fingers they only 
give a small filament to each lumbricalis muscle. 
ix. The Skeleton. 
It represents a species of grate {grillage), concave transverse- 
ly and from before backwards, formed by the anterior face of the 
five bones of the metacarpus, the intervals between which are 
broader than upon the posterior aspect. The transverse concav- 
ity of the metacarpus is occasioned by the posterior extremities 
of the bones being eut in the form of as many small wedges, the 
edges of which are turned forwards, and also to the carpal row 
which corresponds to them being likewise concave. Its antero- 
posterior curvature depends upon its proper bones, and proceeds 
from the expansion of their phalangeal extremity anteriorly and 
laterally, and it is also in consequence of this disposition that the 
interosseous spaces are broader in the middle than before and es- 
pecially than behind. In the latter direction, the bones of the 
metacarpus are, as has been already mentioned, very solidly fix- 
ed ; but their head, or their anterior extremity, is only maintained 
by means of the transverse metacarpal ligament, before which 
the tendons, nerves, and arteries of the superficial arch run, 
whilst the interossei muscles pass behind them. We will recur to 
the peculiarities which relate to these bones, in the dorsal region, 
when we come to speak of the amputations of some of them. 
The following is the order of superposition of the different or- 
gans examined in the palmar region: 1st, the skin; 2d, the super- 
ficial layer, including the ulnar palmar arch, a part of the ulnar 
nerve, und the palmaris brevis muscle ; 3d. the aponeurosis : 4th, 354 
OF THE THORACIC EXTREMITIES. 
the branches of the median nerve ; 5th, the muscles of the in- 
ternal and external eminences; the tendons of the flexors, the 
lumbricales ; 6th, the radial palmar arch; the deep branch of the 
ulnar nerve, the interossei interni muscles ; 7th, the bones. 
Sect. 2. The Dorsal Region. 
It is less complicated than the preceding, and its surface pre- 
sents, when the lingers are extended and separated, 1st, five 
cords, which converge towards the wrist, produced by the tension 
of the extensor tendons; 2d, three grooves between these ten- 
dons, which increase in breadth as they pass to their termination 
at the origin of the fingers; 3d, externally, when the thumb is in 
adduction, a prominence which depends upon the first dorsal in- 
terosseous muscle, and behind which is observed the excavation of 
the indicator, which was mentioned when on the dorsal surface of 
the wrist; 4th in the anterior part of this fossette, behind the mus- 
cular eminence, when the thumb is in abduction and opposition, 
we readily feel the posterior extremity of the first two metacar- 
pal bones, separated by a notch several lines in breadth, in the 
bottom of which we find the radial artery at the instant it is about 
to penetrate into the palmar region in order to form the deep 
palmar arch; 5th, anteriorly, when the hand is shut, the eminen- 
ces produced by the metacarpal heads, the most prominent of 
which supports the middle finger. 
CONSTITUENT PARTS. 
i. The Skin. 
It differs but little from that of the corresponding regions of 
the wrist and fore-arm ; its thickness is greater towards the sides 
than upon the middle of the back of the hand ; near the ulnar 
border, it is covered with hairs, and contains numerous sebaceous 
follicles ; it becomes polished as it approximates the fingers, and 
presents numerous superficial wrinkles which intersect one anoth- 
er in various directions. OF THE THORACIC EXTREMITIES. 
355 
ii. The Subcutaneous Layer. 
This lamina is very thin and very supple, and contains but few 
or no adipose cells ; its characters are the same as in the wrist; 
it encloses the superficial veins, nerves, etc. 
m. The Aponeurosis. 
The fibrous sheet of the back of the hand is thin, and rather 
cellular than truly aponeurotic; its fibres are transverse and 
seem to originate from the annular ligament; in passing towards 
the fingers, it frequently contracts adhesions with the tendons, be- 
comes thicker, stronger, more distinct, and is lost anteriorly in 
the cellular tissue. A second lamina of a similar nature covers 
the posterior surface of the bones and interossei muscles. This 
deep lamina is blended with the superficial near the metacarpo- 
phalangeal articulations ; posteriorly, with the ligaments of the 
carpus, and laterally again with the superficial aponeurosis : so 
that between these two sheets the tendons and principal nerves 
are found, and that, in inflammations and suppurations, the deep 
lamina opposes the passage of the disease or its products into the 
palm of the hand, whilst the superficial hinders them, for some 
time, from making a visible and circumscribed prominence under 
the skin. 
iv. The Tendons and Muscles. 
The tendons are seven in number: one for the thumb, two for 
the index, two for the little, and two others for the ring and middle 
fingers. These different tendons have not the same form ; that 
of the thumb is narrow and cylindrical; those of the indicator, 
that of the extensor proprius minimi digiti, frequently consist of 
two bandelets, which expand over the metacarpo-phalangeal ar- 
ticulation, and are blended with the tendon which each receives 
from the extensor communis : those of the indicator, placed one 
behind the other, are usually spread out in the form of a ribbon. 
All these tendons send off processes from their borders, which, 
with the tendons of the little finger, form a membrane on the 356 
OF THE THORACIC EXTREMITIES. 
back of the hand, resembling a duck’s foot. This disposition sat- 
isfactorily accounts for the greater or less facility with which we 
can move this or that linger. Thus, the indicator, the thumb, the 
little finger, extend and move very well, though the others remain 
in a state of inaction, because each receives several tendons, one 
of which at least does not depend upon the common extensor; 
the movements of the middle and ring finger, on the contrary, 
are, if I may so say, tied to those of the little finger and indi- 
cator ; and the extension of the fourth finger is impossible dur- 
ing the flexion of the third, because there exists between their 
tendons too intimate a connexion. 
The synovial membrane which lines their anterior surface, does 
not form for them a particular bursa. Thinner and less distinct 
than that of the flexor tendons, it is nevertheless more frequently 
the seat of synovial ganglions, which we have frequently seen 
very large, becoming inflamed, bursting, and giving rise to fistu- 
lous ulcers. These tumours may be limited to a single finger, or 
extend to all, to the wrist, and thus cover the entire dorsum of 
the hand ; and, w hen increased to this degree, if they inflame, 
they will seldom be cured without serious symptoms; indeed, 
we are frequently obliged to amputate the member. We are, 
however, acquainted with a medical student who has long had a 
similar disease ; the greater part of the knobs which it formed 
suppurated; several have been opened, with the bistoury, upon 
the wrist, the root of the thumb, metacarpus, etc. Numerous 
leeches have been applied, at different intervals; the whole of 
the affected part no longer formed but a spongy mass, from the 
inferior fourth of the fore-arm to the middle of the fingers. 
Several celebrated surgeons had already thought of amputation, 
and the young man had almost consented to it, when we recom- 
mended to him resolvents and the application of a compressive 
bandage ; an amelioration was soon apparent, and now the cure 
is almost complete; a small fistulous point upon the posterior 
surface of the wrist is all that remains, through which a small 
drop of synovial fluid issues daily. 
The muscles are the four dorsal interossei, among which we 
distinguish the first particularly, both on account of its volume 
and because the radial artery traverses it posteriorly. The 
others fill more or less completely the interosseal spaces, and OF THE THORACIC EXTREMITIES. 
357 
their posterior extremity also gives passage to an artery: it is 
the posterior perforans, which goes to communicate with the deep 
palmar arch. 
v. The Arteries. 
The radial artery merely enters this region in order to pene- 
trate into the palmar through the most remote part of the first 
interosseal space. Its relations to the articulation of the trape- 
zium with the first metacarpal bone are such, that it is almost al- 
ways divided in the extirpation of the latter; but it would be 
possible to avoid it by carrying the edge of the bistoury close 
upon the bone which we wish to remove. The other arteries of 
the back of the hand originate from the transverse metacarpal, 
which also gives off the dorsal interossei and the anterior and 
posterior perforating branches. The posterior branch of the 
ulnar also anastomoses with the metacarpal artery, and both are 
applied directly upon the deep sheet of the aponeurosis. It is 
seldom that any of these branches are so large as to exact any 
precaution during surgical operations. 
vi. The Veins. 
The deep-seated accompany the arterial twigs just mentioned; 
the others, or the subcutaneous veins, vary in number and are very- 
large. Those of the first two fingers unite in order to form the 
cephalic of the thumb; those of the last three are generally col- 
lected on the inner side, and give rise to the s&lvatella. These 
veins run in the superficial cellular layer, and, as this layer sel- 
dom acquires much thickness upon the back of the hand, we 
sometimes perform venesection upon the metacarpus, when we 
experience too much difficulty at the fold of the arm; in which 
case there are no important arteries or nerves to avoid, and the 
tendons only require some attention. 
vii. The Lymphatics. 
They are few in number, and soon turn over the borders of 
the hand, in order to become continuous with those of the palmar 358 
OF TIIE THORACIC EXTREMITIES. 
aspect. Jn this region, as well as in the preceding and the wrist, 
lymphatic glands have never been discovered. 
vm. The Nerves. 
Externally, we find the radial, one of the branches of which 
ramifies upon the thumb and the metacarpal bone which sup- 
ports it, whilst the other subdivides into two branches, which are 
distributed to the index and middle fingers. Internally, we see 
the posterior branch of the ulnar, which is disposed in the same 
manner as that of the radial, and which passes to the last two 
fingers. These nerves penetrate between the tendons and the 
two aponeurotic laminae : they seem to appertain to the sensitive 
system. 
ix. The Skeleton. 
The skeleton of this region comprises all the bones of the 
metacarpus, which are less distant from each other than in the 
palmar aspect, on account of their being broader behind than 
before, and they also present a convexity instead of a concavity. 
The first metacarpal bone being shorter, thicker, more moveable, 
and more thickly covered by the muscles than all the others, it 
follows that it cannot be easily fractured ; but it is occasionally 
affected with caries, necrosis, or other diseases which render its 
extirpation necessary. 
A great many methods of performing this operation have been 
advised; but there are three which are generally adopted. In 
the first, two incisions are made, commencing from the point 
where the abductor longus pollieis muscle is inserted, and carried 
one behind and the other before, uniting them on the inner side 
of the root of the thumb; after which the bone may be easily 
dislocated. 
In the second, the bistoury is at first thrust from without in- 
wards, and from the dorsal towards the palmar aspect, across 
the root of the thenar eminence, in order to form a flap which is 
prolonged to just beyond the metacarpo-phalangeal articulation, 
and which we raise in order to penetrate into the joint by its ex- 
ternal part, and remove the bone by shaving its ulnar surface. OP THE THORACIC EXTREMITIES. 
359 
In the third, we carry the bistoury, its cutting edge being turned 
backwards, from the middle of the commissure of the thumb and 
index finger down to the os trapezium, by gliding it along the first 
metacarpal bone ; we then disarticulate, and finish the operation 
by forming the external flap. 
In certain cases, the pathological state of the parts will doubt- 
less oblige us to adopt one of these processes in preference to 
the others; but where the surgeon can make a selection, the fol- 
lowing is what the anatomical arrangement teaches concerning 
the respective advantages and disadvantages of these operatory 
methods: In the first, the incisions are more regular; it is easy to 
avoid the radial artery, and the flaps can be more exactly adapted 
to each other, because they are only divided upon one of their 
borders; but the disarticulation is difficult and sometimes very 
tedious, because we cannot sufficiently incline the bone in adduc- 
tion in order to luxate it. The wound is necessarily prolonged 
behind the joint, the flaps are quite thin in this direction, and the 
osseous surfaces cannot always be properly covered. 
In the second, the flap is more speedily formed; we enter 
more easily into the joint; the arteries may be as readily avoided, 
and the articular surfaces will be better covered; but the flap is 
frequently unequal, and it is not always possible to give it suffi- 
cient thickness. 
In the third, we obtain almost all the advantages of the two 
others, without incurring their inconveniences. In fact, this 
method is easy, certain, and expeditious. It must only be recol- 
lected, that by pushing the instrument too far backwards we 
would cut the radial artery, and by its penetrating between the 
os trapezium and trapezoides might remove the former with the 
metacarpal bone: but this mistake, which, however, would be 
attended with only slight inconvenience, will not be committed, 
if we take care to direct the edge of the bistoury obliquely out- 
wards, in order to cut the capsular ligament, when it arrives 
opposite to the termination of the abductor longus pollicis, at the 
same time that we endeavour to luxate the bone inwards. This 
process, advised by M. Lisfranc, seems to us to merit the 
preference. 
The last four metacarpal bones being longer and more im- 
moveable than the first, it follows that they may be occasionally 360 
OF TIIE THORACIC EXTREMITIES. 
fractured, especially by direct violence. For example, when the 
palmar surface is laid flat upon a solid plane, if a foreign body 
produces forcible compression upon it, it will tend to efface their 
natural curvature, and may break them in their middle portion. 
Fractures from an indirect cause, although rare, are not impos- 
sible. We have seen a water-carrier, in whom the third meta- 
carpal bone was broken from being draw n forcibly by the index 
and middle fingers by a cart-man. 
All of these bones may be amputated in their continuity, 
when their head is disorganized, or even for a simple disease of 
the finger, when we wish to remove the annoying thickness of 
this head. 
When we perform this operation we should always penetrate 
through the hand from the dorsal tow ards the palmar surface: 
in the first place, because on the dorsum the bones are easily 
felt through the skin; and, in the next place, because, as they 
are broader in this direction than anteriorly, wre are more certain 
of making the two incisions depart from the same point, and of 
uniting them upon the anterior surface, so as to have only a sin- 
gle division, susceptible of cicatrizing by the first intention. 
Although it might be possible to remove the last four bones of 
the metacarpus at their posterior articulation, it would never- 
theless be difficult, especially with regard to the two in the mid- 
dle, which are more compactly wedged between the two others. 
If we washed to amputate that which supports the index finger 
in this manner, we should recollect that its posterior extremity 
receives two tendons, and that its articulatory surface is slightly 
oblique outwrards; which wrould oblige us to carry the knife be- 
tween the indicator and middle finger. 
With respect to the fifth, the operation is not much more diffi- 
cult than for the first, and the same methods have been applied 
to it; as the fourth also rests upon the anterior face of the os 
unciforme, by adopting the third process recommended for 
the thumb, we need not fear making the same mistake relatively 
to the bones of the carpus. This method also appears to us to 
be preferable, unless under some peculiar circumstances. By 
following it, it will always be easy to have a flap of suitable 
thickness, provided wTe take care, the point of the bistoury being 
held upwards and its cutting edge backwards, to incline the han- OF TIIE THORACIC EXTREMITIES. 
361 
die of this instrument towards the thumb, in order that the an- 
terior incision may go to terminate upon the origin of the median 
line of the palm of the hand, whilst the dorsal incision tends to 
prolong itself towards the head of the ulna. In this manner, the 
whole of the hypothenar eminence will be preserved, and the 
point of the bistoury will easily penetrate between the articular 
surfaces, which are slightly inclined inwards and backwards. 
M. Lisfranc here recommends a process which is the same, in 
the main, with that which we pointed out in the second place 
for the disarticulation of the metacarpal bone of the thumb, but 
which, upon the dead body, has always appeared to us more 
difficult and more complicated than the preceding. We think 
that it should only be resorted to in those cases in which we have 
decided upon removing the metacarpal bone without taking 
away the finger which it supports, as has once been successfully 
done by M. Roux. Finally, whatsoever method the surgeon 
may adopt, the articulation will always be easily recognised 
from the surface, by carrying the extremity of the finger along 
the internal posterior border of the bone which we wish to ex- 
tirpate, when the first prominence which he meets with behind 
will be that which results from the union of its posterior head with 
the os unciforme. It may be observed, before abandoning this 
point, that, by following the advice given by M. Lisfranc for the 
amputation of the fifth metacarpal bone at the joint, the two 
arterial palmar arches might be avoided, whilst, by the other 
methods, they would almost to a certainty be divided; but as 
the application of the ligatures will not present any peculiar diffi- 
culties, we think that it will have little or no effect over the con- 
sequences of the operation, and therefore ought not to be brought 
into comparison with the inconveniences which would result 
from the multiplicity of incisions required by the former. 
The arrangement of the different layers of the back of the 
hand is so simple, that it is almost useless to describe it anew". 
However, we find, 1st, the skin; 2d, ths cellular layers and 
veins; 3d, an aponeurotic lamina and some nervous filaments: 
4th, the extensor tendons, the nervous branches of the radial 
and ulnar, the synovial envelope; 5th, a second fibrous sheet 
and the arteries: 6th. and lastly, the bones and interossei muscles. 362 
OF THE THORACIC EXTREMITIES. 
Art. VII. or the fingers. 
Placed parallel to one another, conical and more slender in 
children and females, cylindrical in most men, all the fingers are 
far from having the same length. The medius is the longest of 
all; the index and ring fingers usually terminate upon the same 
line, although in reality the indicator is the shortest, because its 
metacarpal bone is the longest; the little finger terminates on a 
level with the last articulation of the ring finger, and the thumb at 
some lines behind the first phalangeal articulation of the indica- 
tor. The phalangeal articulation of the thumb is exactly upon 
the same line as the metacarpo-phalangeal articulation of the in- 
dicator, which is one of the most important circumstances to be 
noticed, as it may assist us in our endeavours to penetrate into 
these articulations. 
Sect. 1. Palmar Region of the Fingers. 
Upon this surface the fingers present a considerable number 
of furrows, with which it is useful to be well acquainted: there 
is one only before each of the last phalangeal articulations, and. 
by incising perpendicularly upon it, we fall about a line behind 
the joint. There are several, but two in particular, before the 
middle articulations. Of these, the posterior is the most con- 
stant ; it is this which corresponds to the joint and which would, 
if incised upon, lead not more than half a line behind it. A sim- 
ilar furrow is observed at the union of the palmar portion of the 
hand with the fingers; but this furrow does not bear the same 
relations to the articulations as the preceding. It is nearly an 
inch in the anterior region of the hand that the metacarpo-pha- 
langeal union of the fingers is met with; to this, however, the 
thumb forms an exception, for, before its corresponding articula- 
tion, we may observe a furrow, which is disposed as in the mid- 
dle joints. We would, moreover, be sure to fall upon the meta- 
carpo-phalangeal articulation of the thumb, by prolonging upon 
its base, when it is in forced abduction, a line parallel to the di- 
rection of the index finger. 
Between these different furrows, we also observe some wrin- OF TIIE THORACIC EXTREMITIES. 
363 
kies, which are occasioned Ijy the plication of the skin, and 
which are parallel to the direction of the fingers. 
CONSTITUENT PARTS. 
i. The Skin. 
This membrane is of a dingy colour; it is polished, firm, very 
thick, smooth, dense and compact. It has not yet been ascer- 
tained whether it possesses sebaceous follicles: but as we have 
acquired the conviction that, upon the other parts of the body, 
variolous pustules generally have their seat in these organs,* and 
as small-pox pustules are developed upon the fore part of the 
fingers, we are induced to believe that these follicles really ex- 
ist in it. This membrane is covered with an innumerable quan- 
tity of papillary lines, arranged in various directions, but which, 
upon the pulp, generally take the form of as many small ellipses. 
n. The Subcutaneous Layer. 
Upon the anterior part of the body of each phalanx, this lay- 
er forms a very remarkable elastic cushion, the thickness of 
which varies in different subjects, but never exceeds certain and 
even somewhat restricted limits. This cushion is always 
thickest upon the last phalanx and passes a few lines beyond it, 
forming the pulp of the fingers; it consists of fibro-cellular fila- 
ments which seem to be detached from the skin in order to inter- 
sect each other a great number of times, and thus form an in- 
finite number of small compartments, in which adipose vesicles 
are imprisoned: these vesicles are small, never entirely disap- 
pear, nor become so large as to deform the fingers. When they 
partially collapse in thin persons, the fingers are flattened and 
their articulations appear more prominent; if, on the contrary, 
they are distended, the fingers become rounded, and the articu- 
lar furrows deeper. It is to the mixture of the adipo-cellular 
vesicles with the fibrous filaments, that this layer owes its elasti- 
city, and its slight extensibility. It is intimately united with the 
'■ Voyez Archives generates de Mddecxne. Cahier de Juillet, 1825, 364 
OF THE THORACIC EXTREMITIES. 
skin and fibrous sheaths of the tendons; all the nerves and ves- 
sels pass through and are even distributed to it. Before the ar- 
ticulations, the fibrous tissue exists alone, and connects the skin 
very firmly to the tendinous sheaths; at the free extremity of 
the fingers, the pulpy substance is attached directly to the bone ; 
behind the last transverse grooves, it forms the anterior elastic 
part of the hollow of the hand. 
It follows from this anatomical disposition, that acute inflam- 
mations must be easily developed in this layer, since it contains 
some cellular tissue and numerous vessels; that these inflamma- 
tions must be productive of very acute pain, on account of the 
density of the tissue, the nerves which ramify in it, and the resist- 
ance which the cutaneous layer must oppose to the tumefaction. 
Let us suppose, for instance, that a needle had penetrated 
through the skin, if the cellulo-adipose tissue inflames, the ele- 
ments, which then have a tendency to swell, will be squeezed be- 
tween the two articulations, on the one part, and between the 
fibrous sheath and the skin, on the other; they will thus be, as it 
were, strangulated, and will be more firmly compressed in pro- 
portion to the violence of the inflammation ; therefore, it is well 
known that, in order to remove the very severe pain arising from 
whitlow, the best plan is to make deep incisions upon the palmar 
aspect of the inflamed finger. When the inflammation is fur- 
ther advanced, and pus is secreted, the species of sac into 
which the fluid will be forced to collect, meeting with extreme 
resistance on all sides, on account of the thickness of the skin, 
we conceive that the inflammation will extend back into the rest 
of the finger, into the hand and even the fore-arm, and hence all 
the dangers of not making free incisions into the part in the com- 
mencement of the disease. If it is too true that the whitlow 
which has its seat in this layer is a serious disease, we must take 
care and not mistake it for that form of onychia which is called 
whitlow of the first species, and which is only a simple inflamma- 
tion of the corpus mucosum of the skin. In fact, the latter is 
never very painful, and only deserves attention on account of the 
constant tendency which the pus has to detach the epidermis ex- 
tensively, and especially around the nail; a circumstance which 
is owing to the great thickness of the cuticle upon the fingers, 
and which exacts, if we wish to stop the disease, an early remo* OF THE THORACIC EXTREMITIES. 
365 
val of the epidermis thus detached, in order to expose the whole 
of the diseased surface. 
hi. The Tendinous Sheaths. 
These sheaths here supply the place of the palmar aponeu- 
rosis, and are, if I may so say, only a modification of it. The 
terminating bandelets of the latter, are, in fact, evidently contin- 
uous with their longitudinal fibres, and the small arcs of a circle 
which form the greater part of the sheath, and seem to be merely 
the continuation of the transverse fibres of the aponeurosis. 
These canals are completed, posteriorly, by the anterior surface of 
the phalanges; their transverse section has the form of an ellipse, 
the small diameter of which is shorter upon the articulations 
than before the bodies of the phalanges; their anterior or fi- 
brous half is principally formed of transverse curves; of' 
very strong and very close fibres forming a very thick layer, the 
borders of which are inserted into the sides of the osseous part. 
This lamina is thinner before the articulations, especially the 
middle one, than in their intervals: wre not unfrequently see 
small spaces between their fibres, which make a communication 
between the interior of the sheath and the preceding layer, and 
through which small fatty bodies, or processes of the synovial 
membrane of the tendons, penetrate from one to the other; it is 
also through these apertures that the inflammations mentioned 
above, are transmitted to the serous tunic of the sheath, and that 
the latter may escape when it is inflamed, so as to become stran- 
gulated, and thereby occasion extremely acute pains. At least, 
it is in this manner that some persons account for those violent 
sufferings which certain patients experience who are afflicted 
with whitlow of the third species, and wrhich is supposed to have 
its seat even in the tendinous theca. When these thecae have 
passed beyond the third articulation, their tissue becomes rare- 
fied, and they are blended with the pulp and periosteum: their 
interior is lined by a perfect synovial membrane, which does not 
communicate with that of the articulations. When it arrives at 
the palm of the hand, this membrane gradually disappears in the 
fibro-cellular tissue which envelopes the flexor tendons, or rathei 
it forms a species of cul-de-sac upon the fore-part of the trans- 366 
OF THE THORACIC EXTREMITIES. 
verse metacarpal ligament, and thus constitutes a small elongated 
pouch which has no opening, the functions as well as the diseases 
of which, are, to a certain degree, independent of those of the 
other organs of the same nature. It is proper to remark that, 
upon the fore part of all the articulations, and especially of those 
of the metacarpus with the phalanges, these sheaths are altogeth- 
er fibrous; which is owing to the transverse ligament here form- 
ing their posterior part, covering entirely the articular surface. 
iv. The Tendons. 
Each theca includes two tendons, except that of the thumb, 
which contains only one. These cords are so disposed that the 
tendon of the sublimis muscle, which is at first applied upon the 
other, gradually splits into two bandelets, which diverge in order 
to give passage to that of the profundus: whence it follows that 
previous to this division, the first is concave upon its deep sur- 
face, whilst afterwards, it is its superficial surface which presents 
a gutter. The two bandelets then turn and approach each other 
below, and are inserted into the anterior and lateral parts of 
the second phalanx, blending themselves with the periosteum 
and the fibrous sheath. The tendon of the profundus muscle, 
on the contrary, terminates upon the anterior surface of the last 
phalanx, previous to which, however, it detaches a flat fibrous 
plate of greater or less strength, which is inserted into the first 
phalanx, but which does not interfere with its free motion. This 
process, called fulciforme by some anatomists, may explain how 
it is that some persons are able to flex the first phalanx with facil- 
ity, after the last two have been amputated, even when the ends 
of the tendons have not been blended by the effect of inflamma- 
tion, with the flap which covers the extremity of the stump. Sur- 
geons who have advised amputation at the metacarpo-phalan- 
geal joint, when the disease would have permitted the opera- 
tion in the middle articulation of the finger, were, without doubt, 
ignorant of this anatomical peculiarity, when they advanced that 
by allowing the first phalanx to remain it would only be in the 
way, since it must necessarily remain immoveable. And it is 
probably for the same reason that others have advised making 
several deep incisions upon the palmar surface of this phalanx. OP THE THORACIC EXTREMITIES. 
367 
with the view of producing adhesion of the tendon to the 
surrounding parts, previous to amputating either of the other 
phalanges. 
The thumb has no flexor sublimis tendon, whence it follows 
that the movements of its first phalanx are more limited than those 
of the other fingers. Finally, all these tendons are of a very 
dense texture; their fibres, which are mostly parallel, are very 
firmly compacted together; they are covered by the synovial 
membrane which lines their sheath: they are white, smooth, and 
almost inert: therefore, when they remain for some time in 
contact with the air, they slough and become foreign bodies. It 
is the same when the interior of their sheath suppurates, or at 
least they then become agglutinated to the other tissues, and the 
fingers remain immoveable. 
v. The Arteries. 
Each finger has two principal arteries, which are called col- 
lateral, and are distributed in the following manner: When the 
most considerable trunks of the superficial palmar arch arrive 
opposite to the interval which separates the heads of the meta- 
carpal bones, each of them bifurcates, and the two branches of 
this bifurcation immediately pass upon the sides of the two corres- 
ponding fingers; they then apply themselves upon the sides of 
the tendinous sheaths, which they are almost in immediate contact 
with, although enveloped in the superficial layer; near the free 
extremity of the finger, they turn towards each other and anasto- 
mose, forming a loop or an arch in the digital pulp. In their 
course, these branches give off several twigs to the cellulo- 
adipose layer, which are entirely distributed to this membrane; 
they are very large in proportion to the organs which receive 
them, and it is well known that the arterial system abounds in 
the fingers. It is not necessary, however, to secure them in 
amputations, for compression is generally sufficient to stop their 
bleeding. They are always situated behind the collateral nerves, 
and in such a manner that a transverse incision may be made 
upon the palmar aspect of the finger down to the theca, without 
wounding them: it also follows that these vessels will not be 
divided except from incisions made upon the sides of the fin 368 
OF THE THORACIC EXTREMITIES. 
gers: finally, when we amputate at the metacarpophalangeal 
joint, two ligatures only will be necessary, whether the division 
of the tissues has comprised the arterial trunk itself previous to 
its bifurcation, or only one of the arteries on each side. 
Some small arteries, the terminating twigs from the branches 
furnished by the deep palmar arch, are also distributed to the 
palmar face of the fingers; but they are only important as they 
concern the nutrition of the organs. 
vi. The Veins. 
They are as numerous as the arteries; the superficial run in 
the subcutaneous layer, are of considerable size, and accompany 
the collateral arteries; the others are smaller, scarcely distinct, 
they follow the arterial ramuscules of the deep palmar arch, and 
form the roots of the radial vein, collateral to the artery of 
this name. 
vii. The Lymphatics. 
One or two of these vessels are situated upon each side of the 
fingers; they accompany the arteries or blood vessels in general, 
and are of no great importance in surgery. 
vm. The Nerves. 
They are distributed exactly in the same manner as the collat- 
eral arteries, before which they are situated; the palmar nerves 
of the fingers are all derived from the median and ulnar. The 
former supplies the thumb, index, and middle fingers, and one of 
its branches also follows the radial border of the ring finger, at 
the extremity of which it anastomoses, in the form of an inverted 
arch, with the ulnar, which besides supplies the little finger. As 
these extremely large branches are placed before the vessels, 
they may be wounded without the arteries being touched ; they 
ramify and are entirely lost in the subcutaneous elastic layer and 
skin; which leads to the belief that all these nerves appertain to 
the sensitive system: therefore the fingers are endowed with a 
remarkable sensibility, which constitutes the most wonderful OF THE THORACIC EXTREMITIES. 
369 
of their functions. From the great quantity of nervous filaments, 
distributed throughout the first two layers of the palmar aspect 
of the fingers, we may also account for the agonizing pains before 
spoken of. 
ix. The Skeleton. 
We have only to consider here the anterior surface of the pha- 
langes and of their articulations. All these small bones are 
slightly concave transversely and longitudinally, which enables us, 
in amputations, to cut a flap of sufficient breadth and thickness 
upon the palmar aspect of the fingers. All of these articula- 
tions bulge out a little; the last two transversely, the first in a 
spherical manner: whence it follows, that, if we amputate the 
first or second phalanx, in commencing by cutting a flap from 
within outwards upon the palmar surface, as recommended by 
M. Lisfranc, the surgeon should be careful to stop the base of 
this flap on a level with the furrow which wre have noticed upon 
the surface, and not carry the bistoury backwards farther than 
the middle of the first eminence which he will meet with in as- 
cending from the free extremity towards the root of the organ ; 
that, in another process, advised by the same author, and which 
consists in falling directly upon the joint, we should also take 
great care how we carry the instrument behind this eminence, 
because the species of neck upon which it wrould then strike, will 
deceive the surgeon, and he may be embarrassed for a long time 
before he discovers his error. The fold of the skin is also a sure 
guide to prevent making this mistake ; but it must not be for- 
gotten, that the only furrow which we see behind the digital pulp, 
will conduct directly upon the neck in question, if we do not cut 
about a line before it, since the articulation is actually a little 
anterior to it; that, as it regards the union of the first two pha- 
langes, it is always the most remote of those grooves which are 
found before the joint, which must be recollected, and that this 
groove is seldom more than half a line posterior or anterior to 
the articulation. 
With respect to the posterior articulation, we would find it by 
following a slightly curved line with an anterior convexity, the 
extremities of which would fall behind the index and little fin- 370 
OF THE THORACIC EXTREMITIES. 
gers, about three lines before the transverse groove of the hand, 
But, as we do not penetrate into this joint by the palmar surface, 
we will defer the further consideration of it until we come to 
treat of the dorsal portion. 
Sect. 2. Dorsal Region of the Fingers. 
This aspect is longer than the anterior, because in the latter 
the palm of the hand is prolonged, as we have seen, upon the 
posterior third of the first phalanges. Its surface presents, when 
the fingers are extended, the termination of the three grooves 
mentioned when describing the back of the hand; grooves 
which, by uniting the dorsal and palmar faces, form a thin and 
concave border, which we may call the commissure of the fingers. 
Between these grooves, we observe the reliefs produced by the 
continuation of the extensor tendons. During flexion there exist 
three strongly marked angular eminences for each finger, which 
correspond to the articulations, but in such a manner that it is 
always the anterior phalanx which has glided over the posterior, 
and the head of the latter alone projects under the skin; a cir- 
cumstance to be recollected when we amputate. In all posi- 
tions, but more especially in semi-flexion, there are many trans- 
verse wrinkles observed upon the posterior digital surface, 
scarcely perceptible upon the bodies of the phalanges, but al- 
ways very distinct in the immediate neighbourhood of the joints. 
There are generally three of these furrows upon each articula- 
tion : one before, another behind, and the third in the middle. 
The last is generally the deepest, and it is about two lines before 
it that the incision must be made, if we cannot discover the ante- 
rior, in order to penetrate into the joint. It is necessary to note, 
however, that this disposition does not exist with respect to the 
metacarpo-phalangeal articulations. 
CONSTITUENT PARTS. 
i. The Skin. 
The skm is uneven, plicated, and supports a group of hairs, in 
the adult man, upon the bodies of the first two phalanges; it is OTP TIIE THORACIC EXTREMITIES. 
371 
more coloured, supple, and extensible than that of the palmar 
surface, but it is also much thinner, less dense and compact; ex- 
cept by its folds, it scarcely differs from that of the back of the 
hand ; it also contains some distinct sebaceous follicles. When 
it comes near to the nail, it is, in the first place, reflected back 
upon its root, to the extent of about a line and a half or two 
lines, and in this manner forms for it a species of matrix, which 
we should not fail to cut perpendicularly and in the direction of 
the contour of this horny production, when we wish to extirpate 
the latter ; indeed, by taking this precaution, we wrould diminish 
the excruciating pains which this little operation usually produces. 
Next, the integuments slide under the borders of this inert plate, 
and become continuous, under its free edge, with the skin of the 
pulp of the fingers; its texture is then much more compact; the 
dermis adheres almost directly to the bone, and it is the epidermis 
more particularly which envelopes the root of the horny plate; 
now, as it is between these two laminae that the pus or morbid 
fluids, consequent upon onychia, accumulate, we need not be 
surprised that the nail afterwards drops off. 
ii. The Subcutaneous Layer. 
This layer is merely the continuation of that of the back of 
the hand, and is also entirely different from that of the palmar 
aspect. In the point under consideration, it sometimes contains 
fatty cells of a certain volume ; upon the articulations, its laminee 
are united, condensed, and frequently transformed into a sort of 
saccus mucosus; as they approach the nail, they become more 
dense, and are blended with the periosteum and skin. The 
veins and nervous filaments run between them, and the diseases 
which are developed in this layer are attended with the same 
phenomena as in the corresponding aspect of the hand, of the 
fore-arm, etc. 
hi. The Aponeurosis. 
There is none, properly speaking: this layer is confounded 
with the tendons. 372 
OF TIIE THORACIC EXTREMITIES. 
iv. The Tendons. 
These cords are somewhat complicated: when they have 
passed beyond the metacarpo-phalaugeal articulation, they re- 
ceive upon their borders the tendons of the lumbricales and 
interossei muscles, which may thereby become flexors of the firs! 
phalanx. Behind the first phalangeal articulation, the extensor 
tendon expands and even separates into two bands, united by a 
thinner membrane, and thus passes upon the second phalanx 
The two bands then approximate and afterwards separate anew', 
in order to cover the last joint, and finally terminate near the 
nail. These tendons have no sheaths; but the membrane which 
continues their margins fixes them in a pretty solid manner upon 
the back of the fingers, so that they cannot, under any circum- 
stance, slip to one side or the other. They are not enveloped 
by a synovial membrane, but they rest immediately upon those 
of the articulations and upon the body of the bones; a very 
supple and extensible lamellated cellular tissue enables them to 
slide with facility. 
v. The Arteries. 
These arteries are very delicate and almost capillary; they are 
derived from the transverse metacarpal, the interosseus branches 
of the deep palmar arch, and the collaterals. Wounds, there- 
fore, upon the back of the fingers do not occasion troublesome 
heemorrhage. 
vi. The Veins. 
They are of considerable size; upon the dorsum of the first 
phalanx they sometimes form a species of plexus, and may gen- 
erally be perceived through the skin. In short, the' veins are 
much larger here than those upon the anterior aspect, and pass 
to the salvatella or the cephalic of the thumb. IJF THE THORACIC EXTREMITIES. 
373 
vii. The Lymphatics. 
They form the root of the lymphatics of the back of the hand, 
communicate with those of the palmar surface of the fingers, 
and are not more important, as relates to surgery, than the 
latter. 
viii. The Nerves. 
The posterior branch of the ulnar supplies the little and ring 
fingers, and also the ulnar side of the middle finger; the radial 
nerve supplies the thumb and indicator, and generally sends a 
small branch to the middle finger also. According to this ar- 
rangement, we perceive that a wound inflicted upon the ulnar 
side of the wrist would partially paralyze the last three fingers, 
whilst a similar injury upon the radial side would act upon the 
first three only. However, as these nerves, as well as the 
branches of the median upon the palmar surface, apparently be- 
long to sensation alone, it would be interesting, and not unimpor- 
tant, to ascertain if it would be possible to paralyze the fingers 
completely, by dividing the nerves at the lower part of the fore- 
arm, without touching the tendons. 
ix. The Skeleton. 
We will here examine the phalanges and the head of the met- 
acarpal bones, or rather these different bones and their articula- 
tions. The shortness of the former and their great mobility, 
render their fractures very rare, and almost prevent the occur- 
rence of these accidents unless by direct causes. With respect 
to luxations, they are more readily produced in some articulations 
than in others. In the metacarpo-phalangeal articulations, for 
example, they are less frequent in the three middle fingers than 
in the first and last. In this respect, see what anatomy teaches 
us: anteriorly, the joint is firmly secured by the anterior liga- 
ment, the flexor tendons and their thecae; the flattened bands of 
the extensors are found alone behind ; the lateral parts are main- 
tained by two strong ligaments, and strengthened by the tendons 374 
OF THE THORACIC EXTREMITIES. 
of the interossei and lumbricales. On the other hand, the head 
of the metacarpal bones is so much inclined forwards, that the 
phalanx may turn upon it so as to form a right angle, w ithout the 
articular surfaces thereby losing their natural relations: the luxa- 
tion, therefore, will be so much the more difficult in this direc- 
tion, as the fibrous parts oppose an extreme resistance to the dis- 
placing powers; and also, as the articular surfaces admit of very 
extensive motion, which is, besides, checked by the palm of the 
hand itself, before the osseous surfaces can abandon each other. 
On the dorsal side, on the contrary, no ligaments, no fibrous 
sheaths; a single tendon, thin and affording but little resistance, 
because its adhesion to the joint is very slight; articular surfaces, 
which tend to be displaced whenever the movement of exten- 
sion passes a little beyond its natural limits, and nothing upon the 
back of the fingers to check this movement; these are so many 
circumstances favorable to dislocations backwards. Although 
this is an arthrodial articulation, its lateral displacements are, 
nevertheless, very rare ; in the first place, on account of the 
strength of the lateral ligaments; and in the second, because the 
movements of abduction and adduction are naturally very lim- 
ited. With respect to the little finger, the luxation must be more 
common forwards, on account of the adductor and flexor brevis 
muscles, which are inserted into the first phalanx. It wrould 
also seem, that in the thumb it wTould be still more readily pro- 
duced, on account of the muscles of this finger, which are 
stronger and more numerous; but this advantageous disposition 
is counterbalanced by the presence of the ossa sesamoidea, 
which sometimes very considerably augment the extent of the 
articular surface of the first metacarpal bone; it should also be 
noted, that these supernumerary bones partially convert the ar- 
ticulation under consideration into a ginglymus. Moreover, 
when this displacement has once occurred, the muscles must 
afford great opposition to the reduction. Prof. Boyer, w ho does 
not appear to have met with this species of luxation, thinks, how- 
ever, that if it existed it might be easily reduced ; w'hilst he says, 
that he himself, as well as Chopart and Desault, had failed in re- 
ducing certain dorsal luxations some days after the accident. We 
have only once seen the first phalanx of the thumb pass before 
the first metacarpal bone ; but this case is in direct opposition to OF THE THORACIC EXTREMITIES. 
375 
the opinion of the celebrated surgeon just cited. The subject 
was a female, aged 45 years; the luxation had existed three 
days; there was no inflammation. We endeavoured to reduce 
it, but all our efforts were unavailing. M. Prof. Bougon also 
made vain attempts on the day following; and four days after- 
wards, Prof. Roux, notwithstanding his w'ell-known skill and dex- 
terity, was equally unsuccessful. 
The fibrous elements which surround the phalangeal articula- 
tions, are absolutely similar to those which we have seen in the 
preceding; but the articular surfaces differ from them, inasmuch 
as they form a complete ginglymus; lateral luxations of them, 
therefore, must be still more difficult. In order that these dis- 
placements may take place forwards, they must overcome the 
same difficulties; the condyles of the first phalanx are as much 
rounded anteriorly as the head of the metacarpal bones, and the 
flexion of the fingers may be carried still farther: it is posteri- 
orly, then, that the luxation is most likely to occur. It is proper 
to observe, however, that the condyles of the second phalanx are 
not so much inclined upon the dorsal surface as those of the first; 
whence it follows that the last phalanx would be luxated for- 
wards more easily than the bone with which it is articulated; 
this luxation, on the contrary, is more common in the thumb, 
and there are persons who can produce and reduce it at pleasure ; 
which can only depend upon the laxity of the ligaments and the 
particular disposition of the articular facets in such persons. 
In relation to amputations, the skeleton of the fingers also pre- 
sents some remarkable peculiarities: thus the convex form of the 
back of the phalanges wall, in most cases, prevent the formation 
of a dorsal flap of sufficient breath or thickness, even if the 
thickness of the soft parts would permit it; it is for this reason 
that the English recommend making a circular incision through 
the skin three or four lines before the joint, in order to form 
afterwards two flaps, by making twro other incisions upon the 
borders of the phalanx ; but for this method, as well as the cir- 
cular method in general and many other modifications, those 
which were pointed out when on the palmar surface are advan- 
tageously substituted, and especially that which consists in 
making a semi-lunar incision through the skin and flexor tendon 
upon the anterior cutaneous furrow of the articulation, or two 376 
OF THE THORACIC EXTREMITIES. 
lines before the middle fold : we then fall exactly into the joint; 
only, in order to traverse it, we must take care to cut the two 
lateral ligaments, and to recollect that the condyles of the posterior 
phalanx look directly forwards, in order that we may incline the 
handle of the instrument less backwards. Besides, as the articula- 
tion is very close, and as the extremity of the phalanx which we 
wish to remove makes a considerable bulge, it will be necessary 
to use an instrument with a narrow blade, and to carry the edge of 
it sufficiently forwards in order to be able to place it horizontally 
and form the flap, by shaving the palmar aspect of this bone. 
The metacarpo-phalangeal articulation being of a different 
kind, the steps of the operation are no longer the same when we 
amputate the first phalanx. After having made a flap by means 
of a semi lunar incision, the convexity of which corresponds to 
the middle of the commissure of the fingers, and the extremities 
of which fall before and behind the articulation, in order to disco- 
ver the latter, it is sufficient, as M. Lisfranc has very correctly 
stated, to draw the edge of the bistoury backwards along the 
phalanx, its point being at the same time directed upwards. The 
first prominence which we then meet with is the head of the pha- 
lanx ; the articulation will always be found some lines farther, and 
in order to traverse it, all that is necessary is to divide the liga- 
ments and tendons with the extremity of the instrument held 
transversely, whilst we endeavour to luxate the bone with the 
other hand. Moreover, it is always easy to discover this articu- 
lation ; the prominence which the metacarpal heads form exter- 
nally, sufficiently shews the place which it occupies; and if the 
morbid swelling prevented us from seeing this prominence, we 
should recollect that the joint is always eight or ten lines behind 
the digital commissure. Finally, as all the metacarpal joints are 
upon a slightly curved line, almost regular, at least with respect to 
the last four, and as the palm of the hand is prolonged upon the 
palmar surface of the first phalanges, it follows that, if the occa- 
sion should require, we might amputate the four fingers simulta- 
neously ; that is to say, that we might make a curved incision, 
convex anteriorly, upon the fore-part of all the articulations, 
afterwards penetrate into each of them separately, and finish 
the operation with a knife, forming only a single flap for all the 
fingers, at the expense of the palmar part of the hand. This pro- OF THE CHEST. 
377 
cess, advised by M. Lisfranc, has always appeared to us simple 
and very easy upon the dead body. 
After the amputation of a single finger in its articulation with 
the hand, the head of the metacarpal bone forms a projection 
which, alter the cure, keeps the two collateral fingers very much 
separated for a considerable time. Some surgeons have supposed 
that this inconvenience might be avoided by amputating in the con- 
tinuity of the metacarpal bone, and that in this case the deformity 
would be less. It is true that the operation is easy; but it is undoub- 
tedly much more painful than the other; in fact, we are obliged to 
divide a much greater thickness of the tissues, and the cicatrization 
will not always be so prompt; besides, the volume of the head 
gradually diminishes, by the gentle pressure which the surround- 
ing parts constantly exercise upon it, and the roots of the two 
fingers become at length much more approximated than we would 
at first have imagined. 
CHAPTER IV. 
or THE CHEST. 
The Chest forms the middle cavity of the body, and is contin- 
uous, superiorly, with the neck, inferiorly with the abdomen, and 
serves as a point of attachment to the superior extremities. The 
figure of its skeleton is that of a truncated cone with an inferior 
base. When it is surrounded by its soft parts, on the contrary, 
its superior part is broadest; in this direction it appears as if flat- 
tened : and its transverse diameter, from shoulder to shoulder, is 
greater than its antero-posterior. This form presents gradations 
infinitely varied, according to age, sex, and individuals. Anato- 
mists having for a long time, divided the skeleton of this cavity 
into four regions, and as this division can be pretty exactly traced 
upon the surface, we are induced to follow it, with the exception, 
however, of pointing out slight modifications which appear to us 
indispensable, in speaking of the principal sections. 
In the first place we will examine the thorax properly so call- 
called, or the containing parts; in the second, the cavity of the 
thorax and the contained parts. 378 
OF THE CHEST/ 
ART. I. OF THE THORAX. 
Sect. 1. Anterior or Sternal Region. 
it is bounded, superiorly, by the infra-hyoideal and supra-clavi - 
eular regions ; inferiorly, by a curved line which unites the epi- 
gastrium to the chest, and laterally, by the two clavi-coxal lines 
which separate it from the axillary region above, and from the 
costal region, properly so called, below. The surface of this 
region presents, in the middle and from above downwards, the 
supra-sternal notch, much deeper in emaciated than fat persons ; 
a depression which corresponds to the os primi-sternal (Beclard); 
an eminence, which does not always exist, and which depends 
upon the more or less angular junction of the primi et duo-ster- 
nales; a second depression, more constant than the first, of which 
it is sometimes the continuation, and which generally increases in 
depth in proportion as it approximates the fore part of the xiphoid 
appendix, upon which we almost always observe an excavation, 
and the point of which occasionally forms a relief under the skin ; 
upon the sides, the prominences produced by the heads of the 
clavicles ; below', in thin individuals, a series of hollows and ris- 
ings which are in relation with the intercostal spaces and the car- 
tilages which circumscribe them ; in fat persons, on the contrary, 
we remark a prominence, elongated parallel to the axis of the 
body, and which is owing to the muscles and the cellulo-adipose 
tissue. Childhood, sex, embonpoint and constitution occasion 
numerous modifications in these different features. Thus, in the 
first age, this region is generally very protuberant, and forms a 
considerable arch; there is no relief upon the sides. In women 
it is flatter and shorter; but the breasts cause the median groove 
to appear deeper, and the clavicular extremity is more prominent; 
in some adults, the sternal region projects as in childhood, and 
this disposition, which frequently coincides with rachitism, induces 
us to apprehend phthisis pulmonalis. In others, on the contrary, 
it is more depressed than in the well-formed state, as is observed 
especially in mechanics who labour with the trunk habitually 
curved forwards, and which they make use of as a point of sup- 
port, shoe-makers, for example; finally, it is not very uncommon OF THE CHEST. 
379 
to meet with a certain degree of mobility upon the median line, 
and some inequalities which depend upon the imperfect or irreg- 
ular union ot the different pieces of the sternum. It is especially 
necessary to recollect these varieties, when it is required to deter- 
mine the existence of fractures or tumours which frequently man- 
ifest themselves in this region. 
CONSTITUENT PARTS. 
i. The Skin. 
In both sexes, it is much thicker in the middle than laterally ; 
in the adult man it is shaded, throughout the whole extent of the 
median excavation, with hairs, the roots of which are surrounded 
with numerous large follicles ; therefore the lupia, the acne punc- 
tata, and pustules similar to those which we so frequently observe 
upon the face, often have their seat before the sternum, whilst 
they are very rare upon the sides, where the skin does not pre- 
sent the same characters. In women, all things else being equal, 
the skin is more delicate, smooth and polished and especially much 
whiter as it extends towards the breasts. As its extensibility is 
much greater externally than upon the median line, tumours 
which form beneath it more readily acquire a considerable mag- 
nitude in the first direction than in the second. 
ii. The Subcutaneous Layer. 
In emaciated subjects it consists of a lamellated and filament- 
ous cellular tissue, and then forms a membrane of considerable 
thickness and very extensible upon the muscles, where it supplies 
the place of the aponeurosis; as it passes upon the middle por- 
tion it becomes more dense, as it were fibrous, and is blended 
with the sterno costal ligaments. We may separate from it a 
lamina which adheres more particularly to the skin, and in which 
the adipose vesicles are deposited. This latter sheet is only a 
continuation of the superficial layer of the neck, thoracic extrem- 
ities, etc.; in short, it is only a portion of the general fascia su- 
perficialis. The disposition of these sheets is such, that exter- 
nally they split into three layers : the first appertains to the integ- 380 
or THE CHEST. 
uments; the second is applied directly upon the muscles, and the 
third is intermediate; but upon the median line they become 
blended together, and never, or at least but very seldom, contain 
fat; and as they also unite the bones very intimately to the skin, it 
follows that wounds in this situation are very difficult to unite by 
the first intention, and that, in the operations which we perform 
upon it, it is necessary to preserve as much of the integuments 
as possible, if we do not wish to lay the foundation for almost in- 
terminable ulcers. It also follows that in infiltrations and obe- 
sity, the sternum appears to be much depressed. Further, this 
cellulo-adipose tissue, in curving under the inferior margin of the 
pectoralis major muscle, becomes directly continuous with that 
of the axilla, and thereby favours the passage of morbid fluids 
from one of these regions to the other. 
in. The Aponeurosis. 
Laterally, from the clavicle to just below the pectoralis major, 
it consists only of the simple cellular lamina already mentioned, 
and which is blended before the sternum with the periosteum and 
the preceding layer. More inferiorly we observe a completely 
fibrous sheet, which becomes thicker the nearer it approximates 
the epigastrium. It is arranged in the form of bands, and its 
fibres run obliquely downwards and inwards, in order to become 
continuous with the aponeuroses of the belly. It covers the recti 
muscles in particular, and binds them down upon the ribs. 
iv. The Muscles. 
(a) The pectoralis major is the thickest and most powerful of 
the muscles of this region ; as its attachment forms a curved line, 
the convexity of which looks towards that of the opposite side, 
the free space which the two pectoral muscles leave between 
them upon the sternum, is broader superiorly, and especially infe- 
riorly, than in the middle; this disposition is very distinctly de- 
lineated through the skin in strong muscular individuals. This 
muscle is separated from the skin by the thickest part of the sub- 
cutaneous layer, and generally admits of a communication be- 
tween the superficial cellular tissue and the deep adipo-cellular OF THE CHEST. 
381 
layer, through the groove which separates its clavicular and ster- 
nal portions. This communication accounts for the transporta- 
tion of inflammation, pus, etc., although primitively developed 
or formed under the skin of the sternal region, into the hollow of 
the axilla. 
( b) The rectus abdominis comes next. This muscle is gener- 
ally very thin here, and is commonly intersected externally by 
the last digitation of the preceding; it is sometimes inserted into 
the side of the base of the xiphoid cartilage, and always upon the 
seventh and eighth ribs, so that it might more properly be called 
costo-pubic than sterno-pubic. Its fibres are parallel and descend 
perpendicularly; and where they abandon the ribs in order to 
enter the epigastrium, they are usually crossed transversely by a 
fibrous intersection, which adheres firmly to the aponeurosis, and 
is much more complete before than behind, where it even does 
not exist at all. 
It is not uncommon to see the superior extremity of this mus- 
cle, either in whole or in part, pass much higher, ascending some- 
times even to the origin of the sterno-mastoid, and thereby bear- 
ing a resemblance to the natural disposition of several mammi- 
ferae. At other times, the anomaly is independent of this muscle, 
and some supernumerary bundles have been seen upon different 
parts of this region. Thus, there is sometimes a small distinct 
muscle which descends from the superior extremity of the stei- 
num, where it is simply inserted into the bone, or is continued 
with the sterno-mastoideus towards one of the sterno-costal car- 
tilages, binding down the pectoralis major muscle ; at other times, 
it is merely a fascis detached from the ster no-1 turner al (pectoralis 
major), sterno-mastoid or sterno-pubic (rectus) muscles, etc. In 
all which cases, these anormal muscles may elevate the skin so as 
form reliefs, which we should guard against mistaking for patho- 
logical swellings. 
(c) A small portion of the obliquus externus abdominis {costo- 
abdominaT), is found in the inferior part and upon the external 
limits of this region, between the rectus, pectoralis major, and ser- 
ratus magnus muscles, with it digitates. 
(d) All these muscles are applied directly upon the bones or 
cartilages; but the spaces between the latter are also filled by 
the anterior third of the intercostales interni, the fibres of which, 382 
OP THE CIIEST 
directed downwards and inwards, are a mixture of fleshy bun- 
dles and aponeurotic bands; they are separated from the prece- 
ding by a cellular layer, which becomes more distinct as it re- 
moves from the median line. 
(e) Deeply seated, behind the skeleton, between the carti- 
lages and pleura, we find the triangularis sterni muscle, which 
seems to be continuous externally with the internal intercostals, 
and which performs an important part in the fractures of the 
bones to which it is attached. Finally, quite inferiorly, the anterior 
portion of the obliquus internus, (ilio-abdominal) muscle, and of the 
diaphragm, also attach themselves to the inferior border of the 
solid portion of this region. 
v. The Arteries. 
These vessels appertain to three orders : they originate from 
the axillary and subclavian arteries, and from the thoracic aorta. 
The first are generally small ramuscules, which are derived 
irom the branches of the anterior thoracic, acromial and external 
mammary arteries. They are lost in the skin, superficial cellular 
layer, pectoralis major, and the deep lamellated layer, anastomo- 
sing with the external branches of the internal mammary (sub- 
sternal) artery. 
The internal mammary appertains to the second order, and is 
the most important artery of this region. It originates from the 
subclavian opposite to the vertebral artery, descends, directing 
itself forwards, behind the cartilage of the first rib, or some lines 
external to the sterno-clavicular articulation, and thus continues 
its course, gradually diminishing in volume, as far as the sixth in- 
tercostal space. It is only separated from the cavity of the tho- 
rax by the pleura covered by a cellular layer, and by the triangu- 
laris sterni muscle ; its anterior surface is in close contact with 
the cartilages which it crosses, and is only removed from the in- 
ternal intercostal muscles by a cellulo-adipose layer, which is 
usually very thin. It lies about three lines from the outer edge of 
the sternum ; so that, superiorly, its ligature, which has been pro- 
posed by some surgeons, would in fact be possible, provided cir- 
cumstances presented themselves actually requiring the perfor- 
mance of this operation. In order to discover it, it would be suf- OF THE CHEST. 
383 
ficient to make an incision two or three inches long through the 
skin, parallel to the margin of the sternum, and by preference 
upon the third intercostal space, because it is the widest; then, 
we would have to divide the superficial cellular layer, the fibres 
of the pectoralis major muscle, a thin lamellated tissue which se- 
parates it from the intercostal, the most internal fibres of the latter, 
finally a cellular layer of slight thickness, when the artery will be 
exposed. From the position and calibre of this vessel, we see 
that the thrust of a sword, or of any pointed instrument whatso- 
ever, would produce a haemorrhage in the sternal region, espe- 
cially if it passed near the sides of the sternum, and that the 
higher the wound, the greater would be the danger from the 
haemorrhage. 
The principal branches given off from the internal mammary 
are the anterior and the external; the former traverse the inter- 
costal muscles near their internal extremity, in order to reach the 
subcutaneous layer, where they inosculate with twigs from the 
axillary artery. In females, one of these branches is sometimes of 
considerable size : it is that which ramifies in the mammary 
gland. The external branches pass outwards and complete the 
intercostal arches. These arteries increase in volume the lower 
they are given oft'. Finally, the trunk itself, which bifurcates 
near the cartilage ensiformis, and one of its divisions immediately 
gives oft' a large twig which passes before this appendix, in order 
to form an arch with a similar twig from the opposite side. This 
arch is sometimes so large that its pulsations may be distinguished 
through the skin, and may occasion haemorrhage in consequence 
of wounds received in the lower part of the sternal region. 
vi. The Veins. 
We frequently find two for each internal mammary artery, and 
always one for each of the other arterial canals. These vessels 
are not very important in a surgical point of view; except it is 
that the superficial ones sometimes dilate in such a manner as to 
form varicose cords under the skin, as we observe, for example, 
in females affected with scirrhus or cancer of the breast; in 
those also who have nursed several children, or who from a state 
of obesity, have fallen into marasmus : finally, in persons whose 384 
OF THE CHEST. 
venous circulation of the superior systems has for a long time 
been impeded by an organic lesion of the thoracic viscera. To 
the subcutaneous veins are also to be attributed those peculiar 
streaks (vergetures) which the skin upon the anterior part of the 
chest presents in certain individuals. 
vii. The Lymphatics. 
They are pretty numerous towards the axillary and costal re- 
gions, and much more so in women than in men. Those wiiich 
are situated upon the fore part of the pectoralis major muscle 
ascend to the glands of the neck ; hence diseased enlargements 
of the latter organs, when the breasts are affected with cancer. 
Those of the deep series pass directly to the axilla, and also com- 
municate with the lymphatics of the the thoracic cavity. Some- 
times there is a gland in the furrow which separates the inferior 
border of the pectoralis major from the other parts, in which case 
this body is situated upon the largest bundle of vessels which go 
from the sternal region into the axillary cavity. 
The lymphatic system is here disposed in such a manner, that 
blisters, issues, as well as all chronic diseases with alteration of 
tissue, rarely persist beyond many months upon the anterior part 
of the thorax, without re-acting sympathetically upon the glands 
in the sub-clavicular hollow. 
vhi. The Nerves. 
The extreme branches of the intercostal nerves are the onI) 
ones which we observe in the inferior fourth of this region ; supe- 
riorly, it derives numerous filaments from the axillary plexus, 
and from the supra-clavicular branches of the cervical plexus. 
All these nerves are of small volume, and cannot be of moment 
in operations. But it is proper to observe that all those which 
come from the brachial plexus and intercostal branches appear to 
be more particularly distributed to the muscles, whilst the cervical 
twigs seem rather to appertain to the skin. Prof. Laennec thinks 
that angina pectoris is frequently nothing more than a neuralgia 
of the latter. We do not know upon what data this celebrated 
physician founds his opinion ; but we believe that what has been 
described by Rougnon, Heberden, and many English and French OP THE CIIEST. 
385 
physicians, under the name of Angor or Angina Pectoris, is a 
disease which affects organs of higher importance than those un- 
der consideration. 
ix. The Skeleton. 
It is formed by the whole of the sternum, the sterno costal car- 
tilages, and the sternal extremity of the clavicle. We will con- 
sider each of these parts separately. 
It is here especially that we must examine the sterno-clavicu- 
lar articulation. The osseous surfaces are so arranged in this 
joint that the clavicular extremity is, as it were, merely applied 
upon the sternal facet; but to make amends for this, these two 
bones are fixed by means of strong and very short ligaments, 
and the nature of the movements which the clavicle must exe- 
cute, prevent it from being so often luxated as might at first sight 
be imagined. Thus, the clavicle being fixed to the sternum by a 
species of capsule which is very strong superiorly, and, on the 
other hand, attached to the supra-sternal notch, and to its similar 
bone of the opposite side, it will oppose very great resistance be- 
fore it escapes from the cavity which contains it in this direction. 
It is true, that when it is descending, it acts upon the first rib as a 
lever of the first order; but the disposition of the shoulder in 
general, and of the scapula in particular, will almost constantly 
prevent this movement from being carried so far as to effect the 
rupture of the ligaments. The luxation of the clavicle directly 
upwards, therefore, is very difficult, if not quite impossible. 
Posteriorly, this bone makes a prominence in the summit of the 
thorax, and, on the right side, corresponds to the termination of 
the left subclavian vein, and to the arteria innominata, from which 
it is separated by the origins of the sterno-thyroideus and sterno- 
hyoideus muscles; on the left side to the same vein, and to the 
interval which separates the left subclavian and carotid ar- 
teries. This prominence is owing, on the one part, to the 
head of the bone representing a species of triangle, the apex 
of which is inclined backwards and downwards ; on the other, to 
the great convexity which the clavicle presents anteriorly, where- 
by it is naturally thrown back a little in the opposite direction, 
when it arrives at the sternum. Notwithstanding these unfavour- 386 
OF THE CIIEST. 
able dispositions', posterior luxations of this bone are extremely 
rare ; and the reason of it is found in the strength of the fibrous 
capsule, of the costo-clavicular ligament, and the position of the 
scapula, which does not permit the transverse lever of the shoul- 
der to advance sufficiently forwards to produce the luxation. In- 
feriorly, the two bones being in contact, every species of displace- 
ment is impossible ; but it is not so anteriorly. In fact, on this 
side, the articulation is only supported by the sternal tendon of 
the sterno-mastoideus muscle, which is also, most frequently, too 
much approximated to the median line ; and by the anterior lig- 
ament, or capsule, which is weaker than in the other directions. 
Besides, nothing limits the movements of the clavicle backwards, 
and the anterior surface of the shoulder presents itself much 
more advantageously to external powers than the posterior, in or- 
der to produce this movement: there is nothing surprising then 
in the luxation forwards being the most frequent, and almost only 
possible one. 
The sternum is about eight lines in thickness, which thickness 
is mere considerable opposite to the cartilages than to their inter- 
vals, and still greater in the clavicular portion of the bone (manu- 
brium). In childhood it consists of different pieces, which some- 
times preserve their mobility in the adult age, especially the first 
two. It is proper to recollect these peculiarities, as they might 
sometimes be mistaken for fractures. Occasionally also the pri- 
mi-stcrnal and the duo-sternal, in uniting, leave a hole which is 
only filled by a fibrous or fibro-cellular tissue, and which might in- 
duce the belief that the operation of trephining had been perfor- 
med ; this foramen might also permit instruments to penetrate 
more easily into the chest, and thus render wounds in this situa- 
tion more serious : at other times the lateral points of ossification 
do not coalesce upon the median line ; the sternum then remains 
bifid in its inferior fourth, third, and even half, and nothing would 
then be more easy than to wound the central organs of the tho- 
rax, through a similar division. The xiphoid appendix sometimes 
projects outwards, and stretches the skin so much, in thin sub- 
jects, as to occasion its ulceration ; neither is it more uncommon 
to see it curved backwards ; and as it corresponds to the stom- 
ach, it might impair the digestive functions, and occasion symp- 
toms similar to those which characterise gastralgia. It is also OF THE CHEST. 
387 
well to know that this cartilage may incline to the right, to the left, 
and in all possible directions ; that sometimes it is blunt, at others 
acute, and again bifid, even when the sternum is well formed. 
In general, the form of the region under examination is deter- 
mined bv that of the sternum, and it is of importance to note 
this form, on account of the influence which it exercises upon the 
functions of the heart and lungs. Thus, when this bone is very 
protuberant, as is the case in the natural state in children, the 
movements of the heart are very free ; but the lungs are pressed 
against the sides of the pericardium; when on the contrary it is 
convex backwards, the circulatory organs are compressed, as it 
were, upon the spine, whilst those of respiration distend freely on 
each side. 
As the upper and right portion of the sternum is very near to 
the arteria innominata, (brachio-cephalic trunk,) some have sup- 
posed that, by trepanning this bone immediately below and with- 
in the clavicle, we would easily reach the artery; but this ope- 
ration, though not very difficult upon the dead body, must, in our 
opinion, be of very difficult performance upon the living subject. 
M. Laennec has also advised the application of the crown of 
the trephine upon the left inferior third of the sternum, with the 
intention of opening the fibrous envelope of the heart in cases of 
hydrops pericardii: then, it would be necessary to recollect that 
this bone is thinner inferiorly than in its superior portion. Al- 
though the sternum is destined to protect organs of the first im- 
portance, it may be diseased, in great part disorganised, and even 
destroyed, without the life of the individual being thereby truly 
endangered. The case related by Galen, and since so frequently 
repeated ; that mentioned by Harvey, in which the bone wTas 
perforated in such a manner that the heart was, as it were uncov- 
ered, are incontestable proofs of it; so that if blood, pus, or any 
other fluid was accumulated in the anterior mediastinal space, 
and the evacuation of the morbid product might save the pa- 
tient, we should without apprehension apply the trephine here. 
Besides, the bone is so soft and spongy, in the greater proportion 
of adults, that it would be easy to perforate it, even with the 
knife. This softness, which is owing to its great vascularity, also 
accounts for the frequency of its diseases, and for its being less 
subject to necrosis than caries. As the sternum is susceptible of 388 
OF TtfK CIIEST. 
elevation and depression during respiration, and is suspended, a» 
it were, by the extremity of flexible cartilages; as it is likewise 
flexible itself to a certain extent, its fractures must be very diffi- 
cult to produce, and even seem impossible unless by a direct 
cause ; in fact, we can scarcely conceive it possible for it to be 
acted upon by two different powers which would tend to approx- 
imate its extremities towards each other. There is, however, an 
example of fracture by counter stroke, related by David, and 
registered in the. Mem. de Vacademie royale de chirurgie, in 
which we see that a man fell from a great height upon the ensi- 
fonne cartilage and fractured the sternum through its middle. 
In these fractures, by whatever cause they may have been pro- 
duced, the internal derangements, consequent upon them, must 
occupy more of the surgeon’s attention than the lesion of the 
bone: it. is possible, however, that one of the fragments may be 
displaced backwards; in which case it would not fail to occa- 
sion serious disturbance of the heart or principal vascular trunks. 
Finally, on account of its spongy nature, its great vitality, and its 
being interposed between two fibrous layers of a certain thick- 
ness, the sternum is very promptly consolidated; but, in order 
that this consolidation may take place, it is necessary that the 
fragments should be retained immoveable, which is easily done, 
by obliging the respiration to be performed solely by the dia- 
phragm. 
The sterno-costal cartilages, elastic and flexible, uniting the 
first seven ribs to the sternum, and applying the last five to each 
other by the anterior extremities of their inferior border, are so 
disposed that the first is the shortest, broadest, strongest and the 
most firmly united to the two bones which it connects ; and it is 
this last circumstance especially which prevents the first rib from 
being more moveable than the following ones, and which supports 
the clavicle. In examining the others in succession, we find 
that their length and mobility increase as far as the seventh 
inclusively; although the last five gradually diminish in length, 
they are still more moveable, because their union only takes place 
by means of facets which admit of a more or less extensive sli- 
ding motion (glissement), and because they are also much thin- 
ner: whence it follows that they are very seldom fractured, 
whilst the former are pretty frequently broken. But whether OF THE CHEST. 
389 
these fractures are produced by direct or indirect causes, if the 
fragments are susceptible of crossing each other, the displace- 
ment will almost always take place in such a manner that the 
sternal will pass before the costal portion; and for this reason, 
because the pectoralis major muscle acts with more or less force 
upon the former, whilst the triangularis sterni tends to draw back 
the latter. The fracture is always transversal, and the nature of 
the cartilage singularly modifies here the disposition of the callus. 
In fact, although Autenrieth has stated that the costal cartilages 
reunite after their fracture, MM. Magendie, Lobstein, Beclard, 
etc., have observed that the two fragments do not become ag- 
glutinated, and that their perichondrium alone experiences a 
transformation, or such changes, thatjjit at length forms an osseous 
hollow cylinder, in the centre of which the two cartilaginous ex- 
tremities are encased; in short, that the restorative efforts of na- 
ture are limited to what Duhamel, Fougeroux, M. Pelletan Senr. 
etc. have described as the principal phenomenon of reunion, in 
fractures in general, or rather to what M. Dupuytren calls the pro- 
visory callus in the long bones; that is to say, that this union is 
effected entirely at the expense of the fibrous envelope. It is 
necessary to note, however, that these cartilages frequently be- 
come ossified as age progresses, and that the same sometimes 
occurs in certain diseases of the chest, in phthisis, for example ; 
then their fractures must take place more readily and the callus 
form as in the long bones. On the other hand, their cartilagin- 
ous state has been found to persist in persons who have prolonged 
their existence to a very advanced period ; to one hundred and 
thirty years, (Kiel,) and even to one hundred and fifty, (Harvey). 
The first three inter-cartilaginous spaces are broader than those 
which follow them; the sixth is already very much contracted, 
and this is one reason why we should choose the fifth, if we wish- 
ed to open the pericardium, according to the method undertaken 
by Desault. In this point, we would not be obliged to divide the 
pectoralis major; the rectus muscle is here very thin, and fre- 
quently does not ascend so high; the pericardium also is nearer 
to this space than any other, and the internal mammary artery 
bifurcates lower down. Consequently, we would have to divide 
the skin, the superficial layer in some subjects, some fibres of the 
pectoralis major muscle, or the aponeurosis, a second cellular 390 
or THE CHEST. 
layer thinner than the first, the internal intercostal muscle, addi- 
tional cellular laminae, the pleura, finally the pericardium, taking 
care to leave the internal mammary artery on the inner side, and 
to avoid the anterior margin of the lung, which must be pushed 
outwards. It is needless to say that we are speaking of the left 
side. 
From what has preceded, we see that wounds upon the median 
line, in the sternal region, would fall directly upon the heart or 
large vessels, whilst upon the sides they would also encounter the 
lungs. We will see, when examining the internal organs, the 
dangers of their lesions, according to the points upon which they 
are inflicted. We will only observe, by anticipation, that pene- 
trating wounds made by pointed or cutting instruments, will be 
more dangerous when they simply pass through the thoracic par- 
ietes in the inferior intercostal spaces and near the sternum, than 
at the superior part, on account of the internal mammary and its 
branches. 
We will further remark that a transverse wound, before and 
upon the sides of the supra-sternal notch, might produce two 
kinds of accidents: one, relative to the sterno-clavicular articula- 
tion, which would then be easily opened, and the other to the di- 
vision of the sterno-mastoid muscle. The sternal portion of this 
muscle, in fact, descends so low in some persons, that it might 
possibly be divided upon the fore part of the sternum, and as it 
is this muscular portion which supports the upper part of the 
chest in full inspirations, great exertions, etc., serious changes in 
the exercise of these phenomena would result from it. 
All these parts are, besides, arranged in the following order ; 
1st, the skin, thick and compact in the sternal gutter, supple and 
extensible upon the lateral parts; 2d, the subcutaneous layer, 
divisible into three laminae before the pectoralis major muscle, 
where it is sometimes very thick, fibrous upon the median line, 
and in which arterial twigs, nervous filaments and veins more or 
less voluminous, ramify; 3d, the aponeurosis, distinct in the infe- 
rior fourth of the region only ; 4th, the pectoralis major muscle, 
a small portion of the rectus abdominis, a very small part of the 
tendons of the sterno mastoideus ; it is in this stratum that we 
find the principal arteries and the deep nerves ; 5th, the sternum, 
cartilages, intercostal muscles; 6th, a lamellated layer, the inter- OF THE CHEST. 
391 
nal mammary artery ; 7th, the triangularis sterni muscle and the 
pleura. 
Sect. 2. Posterior Region. 
This portion of the thorax is bounded superiorly by the poste- 
rior region of the neck; interiorly, by a curved line similar to 
that which limits the sternal region below, that is to say by a 
line which runs along the inferior margin of the twelfth ribs, in 
order to pass upon the spinous process of the twelfth dorsal ver- 
tebra ; laterally, by a line which arbitrarily prolongs the vertebral 
border of the scapula upon the union of the posterior third of the 
crista of the ilium with its two anterior thirds, and which would 
consequently follow the prominence formed by the angles of the 
ribs : we will call this the scapulo-coxal line. 
Upon the surface of this region, in the inter-scapular portion 
and upon the median line, we observe a ridge, in general not very 
prominent, and which is produced by the vertebral spinous pro- 
cesses ; upon the sides of this ridge, two grooves or gutters, vary- 
ing in depth in different subjects; more externally, two eminen- 
ces which correspond to the muscular masses, and which become 
more prominent in proportion as the shoulder is carried forwards ; 
finally, the posterior margin of the scapula, which changes its po- 
sition during each movement of the superior extremity, and 
which is also more or less prominent according to the conforma- 
tion of the thorax. 
In the inferior part of the region, the median ridge is pretty 
frequently very prominent, the lateral grooves are also much 
deeper and the muscular eminences larger than in the superior 
portion. This difference arises from the spine being very convex 
above, whilst below it is inclined in the opposite direction ; from 
the spinous processes being very oblique superiorly, and horizon- 
tal inferiorly. As the lateral convexities depend as much upon 
the curvature of the ribs as upon the prominence formed by the 
muscles, we will always increase them by carrying the arms for- 
wards, so as to cross them upon the fore part of the chest, or 
over the head, for example ; which it is necessary to do, when 
we endeavor to ascertain the state of the lungs, or of the other 
thoracic, viscera, by percussion or auscultation. 392 
OF THE CHEST. 
CONSTITUENT PARTS. 
i. The Skin. 
It is thicker than that of the posterior part of the neck, but 
does not otherwise differ from it, except in its slighter adhesion 
to the muscles and its firmer union to the spinous processes of 
the vertebra. It contains a great number of sebaceous follicles, 
but is destitute of hairs and wrinkles; it is very dense and its 
sensibility very great, although it does not receive many nerves ; 
the acute pains which are manifest in it, when it becomes the seat 
of boils, carbuncles, erysipelatous or other inflammations, evi- 
dently depend upon these two circumstances, and by the latter 
we can account for the numerous and extensive sympathies 
which its artificial or natural irritations bring into action. Thus, 
every body knows, that an epistaxis is frequently and immedi- 
ately arrested by applying a key, or any cold metallic body, as 
well as linen steeped in refrigerant liquids, etc., between the 
shoulders. It is also founded upon these results that we have 
applied upon this part, and with immediate success, cataplasms of 
mustard, in cases of uterine hemorrhages occurring immediately 
after parturition, or at the expiration of a few days, w hich had 
resisted other rational means, and threatened to become speedily 
mortal. 
ir. The Subcutaneous Layer. 
Divisible into several laminae by maceration, it is compact, 
dense, and forms a complete fascia superficialis. This layer is 
composed of a lamellated and filamentous cellular tissue, in w hich 
are soft, reddish and elongated adipose cells, capable of consider- 
able enlargement, and of forming a fatty stratum of a certain 
thickness in persons who have much embonpoint. It is not unu- 
sual to see some of them agglomerate, and thus enlarge together 
so as to produce lipomatous tumours, which sometimes become of 
a considerable volume. But this pathological developement of 
the fatty vesicles can only take place upon the sides, because, 
upon the median line, the cellular layer, under consideration, OF TIIE CHEST. 
393 
unites the vertebrae intimately to the skin ; and it is also for this 
reason, that infiltrations, abscesses, collections, and tumours of 
eveiy kind, with the exception of those which depend upon dis- 
eases of the bones, never manifest themselves in the nfiddle of 
the dorsal region. 
This layer may inflame and suppurate ; but, as it is interposed 
between two planes which offer much resistance, purulent ab- 
scesses form in it very slowly, extend in breadth, and sometimes 
persist a long time before they project externally ; the skin wThich 
covers them may preserve its thickness and the greater part of 
its other characters during several months. If the inflammatory 
phenomena are not very acute, the collection will be called a 
a chronic abscess, or be mistaken for a purulent deposition {depot 
par congestion), and finally produce the death of the patient. 
As these abscesses are limited anteriorly by the thickened aponeu- 
rosis, they may burrow extensively, even from the posterior part 
of the neck into the lumbar region. It seems evident to us, that, in 
cases of this nature, the danger proceeds from the resistance of 
the tissues, which oppose the evacuation of the diseased secre- 
tions, and that the best means of saving the patients, would be to 
open early and freely the cavities in wdiich they are contained. 
3. The Aponeurosis. 
In some places it is composed of thin cellular laminae of but 
slight strength; in others, it is thick and strong. Thus, the an- 
terior and posterior surfaces of the trapezius and latissimus dorsi 
are covered by a thin and extensible sheet, which adheres to 
them firmly, the layers of which are applied together and blend- 
ed near the inferior angle of the scapula, in the small triangu- 
lar space which separates these twro muscles, so as to form a 
more distinct lamina. Another aponeurotic sheet binds down 
the muscles of the vertebral gutters, and is prolonged upon the 
splenius to the neck, splitting in order to envelope the serratus 
posticus superior, confounded below, upon the serratus posticus 
inferior, with the aponeurosis of the lumbar region, and inserted 
into the spinous processes of the dorsal vertebra? on the one hand, 
and upon the angles of the ribs on the other. In other words, 
the very strong aponeurosis of the latissimus dorsi may be con- 394 
OF THE CIIEST. 
sidered as furnishing envelopes to all the muscles of the back, 
and especially a very regular sheet, which serves to separate the 
muscles which form the superficial stratum from those of the 
deep stratum. These different sheets are too thin, and do not. 
sufficiently assume the aponeurotic characters to become the 
causes of serious accidents in deep-seated inflammations of the 
back ; but, in becoming blended, as it were, with the superficial 
muscles, they form a strong layer, which prevents the abscesses, 
indicated in the preceding paragraph, from penetrating under the 
shoulder, etc. 
iv. The Muscles. 
Those which form the superficial stratum are flat and of 
greater or less breadth ; the deeper seated are long and collected 
into a mass. 
The former comprise, 
(a) The inferior half of the trapezii, which here represents 
a triangle, the apex of which is situated upon the last dorsal ver- 
tebra, whilst the two angles of its base terminate upon the spine 
of the scapula ; so that, in order to render these muscles tense, it 
is necessary to carry the arms more or less forwards; and the 
principal effect of their contractions must be to raise the shoul- 
ders, at the same time that they approximate the two scapulae to 
the chest and spine. The trapezius is covered by a fibro-cellu- 
lar lamina which appertains to the aponeurosis, by the subcuta- 
neous layer and by the skin ; it is separated from the deep stra- 
tum by the rhomboidei, latissimus dorsi, and some lamellae of 
cellular tissue. 
( h ) A considerable portion of the latissimus dorsi, and es- 
pecially of its aponeurotic origin, since it ascends to the fifth 
vertebra of this region ; its fibres are transverse or slightly ob- 
lique, and derive their fixed point from this region. This mus- 
cle is covered by the trapezius, the superficial layer and the skin, 
and is pretty firmly united to the serratus posticus inferior; but it 
adheres to the deep aponeurosis only by means of some soft, and 
extensible cellular lamellae. When it emerges from under the 
trapezius, near the angle of the scapula, it forms the inferior 
border of the small triangular space mentioned when on the OF THE CIIEST. 
395 
posterior region of the shoulder, and through which an instru- 
ment might penetrate into the cavity of the axilla, without divi- 
ding anv other muscles than the serratus magnus. It is also 
through this kind of aperture, that pus or other fluids might pass 
from the dorsal region into the summit of the lateral region, be- 
tween the side of the thorax and the serratus magnus muscle, 
ascend into the supra-clavicular region, or descend into the cos- 
tal region,- finally pass from all these regions into that w hich we 
are nowr considering. Since the use of the latissimus dorsi mus- 
cle is to draw down the arm and carry the inferior angle of the 
scapula backwrarks, it is necessary, in order to make it tense, and 
render the portion of the back w7hich it covers more prominent, 
when wre wish to exercise percussion or apply the stethoscope 
to this part of the chest, to cross the superior extremities over 
the crown of the head. 
( c ) The whole of the rhomboideus major, (rhombo'ide dor- 
sal.) as well as a small part of the rhomboideus minor (rhombo'ide 
cervical) mucles. They are separated from the trapezius by a 
thin layer of cellular tissue, and conceal the serratus posticus 
superior; their distance from the angle of the ribs varies accor- 
ding to the position of the shoulder, and the intervening space 
is filled writh supple and very lax cellular lamellae, in which adi- 
pose vesicles are seldom met with. This space is prolonged be- 
tween the costal portion of the axilla and the serratus magnus 
muscle, which separates it from the cavity of the axilla; it com- 
municates directly with the supra-clavicular region ; and, as the 
cellular tissue which fills it is very extensible and very soft, it fol- 
lows that fluids, accumulated in the lateral part of the neck, soon 
descend between the ribs, the rhomboidei and the serratus an- 
ticus. As the rhomboideus major muscle originates from the 
spinous processes of the back, and is inserted into the vertebral 
border of the scapula by means of an arched aponeurotic cord, 
it can only act upon the shoulder, which it draws backwards 
towards the median line and upwards, if it contracts alone, or 
directly backwards when it acts in concert with the trapezius. 
(d) The serrati postici. The superior passes obliquely dowm- 
wards from the first dorsal spines to the external part of the an- 
gle of the three ribs which follow the first; the inferior, from the 
spinous processes of the first three lumbar and last two dorsal 396 
OF THE CHEST. 
vertebrae to the posterior part of the twelfth, eleventh, tenth, 
and ninth ribs ; so that their common action is to pull the osseous 
arches of the thorax backwards and outwards, and that the first 
raises these bones, whilst the second draws them down. Con- 
sequently, when the ribs are fractured through their middle, they 
must tend to displace the posterior fragment outwards and down- 
wards, or outwards and upwards, according to the situation in 
which the solution of continuity exists. 
The latter, or the deep-seated muscles, are less important in a 
surgical point of view than the preceding; they fill the vertebral 
gutters, and comprise the dorsal portion of the interspinales dorsi 
et lumborum, of the sacro-lumbalis, of the longissimus dorsi, of the 
semi-spinalis dorsi and multifidus spin®, and besides the origins 
of the complexus, splenius and transversalis colli. All these mus- 
cles are separated from the superficial layer by the aponeurosis 
of the serrati postici; they can only act upon the spine and the 
posterior extremity of the ribs. The external tendons of the 
longissimus dorsi are inserted near the angle of these bones, and 
the chest is dilated during their contraction, which also favours 
expiration. The levatores-costarum muscles are partly covered 
by the latter, and descend obliquely outwards from the external 
part of one costo-transverse articulation to the rib which is below 
it, being prolonged upon the second also. They are entirely in- 
cluded in the dorsal region, and are continuous below with the 
external intercostal muscles. Their use is to elevate the ribs, as 
was well observed by Verheyen and Steno. In fractures, they 
act in the same manner as the serratus posticus superior, and 
counterbalance the action of the inferior, and of the external 
bundles of the longissimus dorsi. With respect to the intercos- 
tals, they present nothing particular in this region, and we only 
find in it the origins of the external. 
v. The Ai'teries. 
There are none so large, w ith the exception of the intercos- 
tals, as to occasion a profuse haemorrhage in wounds of this 
region. One of the branches of the descending cervical, origi- 
nating from the subclavian, ramifies before the rhomboideus 
muscle, and is generally distributed to the superficial muscular OF THE CHEST. 
397 
layer, previous to anastamosing, in the latissimus dorsi muscle, 
with the subscapulary artery, and in this manner forming an ar- 
terial arch which unites the subclavian to the brachial. Each 
intercostal artery here gives oft' its posterior branch, which passes 
between the bodies of tne vertebra?, the inferior costo-transversal 
bgameni, and two transverse processes, in order to enter between 
the sacro-lumbalis and inter-spinales dorsi muscles, w here it after- 
wards divides. Then one of the branches approximates the 
median line, as it passes towards the skin ; the other, on the con- 
trary, removes from it, and penetrates between the sacro-lumbalis 
and longissimus dorsi muscles, in its course towards the super- 
ficial layer and skin, where it terminates: finally, the intercostal 
artery itself, included in the space of the same name, passes 
through this region, and in such a manner that it does not actually 
enter its protecting groove in the rib, until it has arrived near the 
ang;e of this bone: it is yet so remote from it, opposite to the 
apex of the transverse process, that an instrument penetrating 
through the intercostal space might easily strike it. But, let us 
admire here, as in a multitude of other points, the disposition of 
parts ; in fact, the thick muscular mass w7hich protects this vessel 
posteriorly against the action of foreign bodies, becomes thinner 
and thinner in proportion as it passes outwards ; but then the ar- 
tery, which was at first free below the rib, afterwards approximates 
so close to it, that it is almost entirely situated under its internal 
surface. In general, the nerve which accompanies it runs along 
its inferior border, and frequently it gives off its descending 
branch before it enters into the costal region. 
vi. The Veins. 
These vessels have the same distribution as the arteries: they 
all pass to the azygos veins through the medium of the intercos- 
tals, and into those of the arm and neck by the cervical and sub- 
"capulary veins. 
vii. The Lymphatics. 
They are very few in number, and merit still less attention 398 
OF THE CHEST. 
than the veins. Those of the deep stratum, for the most part, 
enter into the axillary glands; almost all of the superficial, into 
the supra-clavicular region : htince, from this disposition, diseases 
of the skin and of the cellulo-adipose layer must re-act more 
particularly upon the lymphatic glands of the neck, whilst affec- 
tions of the deep-seated parts will produce tumefaction of those 
in the cavity of the axilla. 
vni. The Nerves. 
Besides the spinal accessory, which is lost in the trapezius 
muscle, some filaments of the deep branches of the cervical 
plexus, which extend as far as the rhomboideus major and ser- 
ratus posticus inferior, and some others derived from the brachial 
plexus, the dorsal region also receives the posterior branches of 
the spinal nerves. These last follow the arteries, divide in the 
same manner, and ramify in the superficial layer and the skin. 
The intercostal nerve, inferior to the artery, equally places itself 
under the margin of the rib, and sometimes divides before it 
abandons the dorsal portion of the thorax. 
ix. The Skeleton. 
It is composed of the twelve dorsal vertebrae and of the ribs, 
as far as the angle or posterior curvature of the latter. The 
former are so arranged that their body, which is more extensive 
in the antero-posterior direction than transversely, forms a spe- 
cies of column which is concave anteriorly, and which advances 
in the thorax. This anterior concavity, which is owing to the 
vertebra) and the intervertebral fibro-cartilages possessing a great- 
er degree of thickness behind than before, presents almost infinite 
gradations. In new -born children, it scarcely exists; in old peo- 
ple, it is generally very much developed ; much slighter in woman 
than in man, in persons who habitually keep themselves erect 
than in those who bend over their w ork, it may increase consid- 
erably, or totally disappear in consequence of rachitis. In the 
first case, a gibbosity is produced, and the sternal region is then 
more or less depressed; in the second, the dorsal region appears 
very much excavated, and the sternum projects more or less OF THE CHEST. 
399 
forwards. Another curvature is observed upon the left side and 
in the superior third of the column, at the place upon which the 
aorta rests in the chest. This last concavity varies less than the 
preceding in a well-formed subject; but in rachitis it perhaps 
more frequently passes beyond its natural limits, and concurs 
very much in the production of gibbosity. The formation of these 
curvatures, moreover, is very easily accounted for, and upon me- 
chanical principles; it is owing to the weight of the body and 
the action of the muscles. Thus, as the head preponderates for- 
wards instead of backwards, the posterior muscles, in order to 
maintain the equilibrium, are kept in a state of almost permanent 
contraction, and cannot fail to make the cervical portion of the 
vertebral column project forwards. The weight of the viscera 
of the thorax, on the one part; that of the head and neck on the 
other, tend to pull the upper part of the chest forwards ; but as 
the line of gravity would not fail to pass beyond the base of sup- 
port, in order to prevent the fall and counter-balance the anterior 
effort, the sacro-lumbalis and longissimus dorsi muscles pull for- 
cibly upon the two inferior thirds of the dorsal portion of the 
spine, and thus produce the convexity which is observed in the 
upper part of this region. In the most common actions of life, 
most people use the right arm much more frequently than they 
do the left; as in raising burdens, etc. Then, at the same time 
that several muscles of the right shoulder draw the correspond- 
ing portion of the vertebral column to this side, those of the op- 
posite side, which fill the spinal gutters, tend to approximate the 
cervical to the last dorsal vertebrae, in order to keep the central 
line of the body in a proper position ; and hence that lateral cur- 
vature which, previous to Bichat and Beclard, was attributed to 
the position of the arch of the aorta. Let us now apply this 
mecanism to rachitic curvatures, and we will readily comprehend 
in what directions they must most frequently be inclined, and we 
will better understand the utility and importance of orthopedic 
means in deformities, when there is no disorganization 
present. 
In these deviations, the spinal canal becomes flattened, but not 
actually diminished; hence they may be carried to an extreme 
degree without compressing the medulla spinalis ; whilst in Pott's 
disease, or the gibbosity which depends upon caries of one or 400 
OF THE CIIESf. 
more vertebrae, paralysis generally soon manifests itself. In the 
latter case, in fact, the caries seldom advances so far as to admit 
of the sinking in of those which are above and below, without 
equally affecting the nervous cord, which is also occasionally 
compressed in the deformed canal in which it is lodged. We 
should remark that, in Pott’s disease, the curvature is more acute 
and almost always posterior, whilst that which arises from softness 
of the bones is more elongated, and frequently lateral. 
The spinous process of the dorsal vertebrae, almost horizontal at 
first, are inclined and very much imbricated in the middle, and again 
become horizontal in the lower part of the back; so that superi- 
orly and inferiorly, the movements of extension may be carried 
pretty far; whilst in the middle portion, they must be extremely 
limited. The plates (lamina;) are short, very thick and overlap 
each other, so as to render it almost impossible for instruments 
to penetrate into the vertebral canal. The articular facets, 
which are very oblique and almost perpendicular, even below, 
are so disposed that the inferior, placed behind the superior, look 
forwards and outwards, and very powerfully resist luxations 
without fracture, but nevertheless admit of distinct flexion, whilst 
they oppose the movement of extension. The transverse pro- 
cesses are remarkable for their thickness, their length, and espe- 
cially for their inclination backwards; which disposition in- 
creases the depth of the vertebral gutters externally, and of the 
thoracic excavations within the chest. The spinal canal is nar- 
row", almost cylindrical. The medulla spinalis here sends off 
nerves to the thoracic and abdominal parietes, to the inferior 
extremities, and one branch only of the brachial plexus; so that 
a wound of this cord, between the second and third dorsal ver- 
tebrae, would not paralyze the superior extremities, and that, in 
order to suspend the nervous action in the inferior, it would be 
necessary for the lesion to take place towards the seventh or 
eighth, because the roots of the nerves pass tow ards the holes of 
conjunction (trous dc conjugaison) by follow ing a line w hich is 
more oblique in proportion as they are more inferior. The re- 
searches of modern physiologists have demonstrated, that, by 
destroying the spinal marrow in the dorsal region, the move- 
ments of the heart w ould be supended, on account of the roots 
of the great sympathetic, at the same time that it wrould pro- 401 
OF THE CHEST. 
duce paralysis; but we have related facts* which tend to prove 
that these laws are liable to some exceptions. Some appropri- 
ate experiments performed by Shaw, Ch. Bell, M. Magendie, 
Beclard, M Descot; certain observations on pathological anat- 
omy related by several authors, and those which we have re- 
corded in the Archives generales de Medecine, tend to prove that 
the posterior columns of the spinal marrow preside over sensi- 
bility, whilst the anterior appertain to motion: it is evident then, 
that one or the other of these two faculties of relation will be 
impaired the first, according as the wound or disease shall have 
primitively existed either anteriorly or posteriorly, in the dorsal 
and cervical portions of the spinal column. 
From the strength of the super-spinal, interspinal, yellow, pre- 
vertebral and posterior vertebral ligaments, and especially that 
of the intervertebral fibro-cartilage, together with the disposition 
of the osseous surfaces, luxations of the dorsal vertebrae must 
be almost impossible; for the same reason, their fractures are 
both very difficult and very unfrequent, and also because the soft 
parts and ribs deaden the force of external powers which might 
act directly upon the vertebrae. 
The curvature of the ribs is also very great here, but it varies 
according to age and in different individuals. In children it is 
proportionately much less than in adults: therefore in the first 
years of life the chest appears compressed laterally, whilst it is 
more prominent anteriorly and posteriorly. When this disposi- 
tion persists in the adult, the scapulae usually project more behind, 
constituting what is called the “ chicken breast”: in this case the 
ribs appear to be less curved under the shoulders, whereby the 
lungs must be pushed forwards, so that it has been supposed that 
this conformation predisposed to tubercular phthisis : a circum- 
stance which would favour the idea that this disease is in a mea- 
sure caused by irritation and inflammation. 
As the ribs are applied upon the whole extent of the anterior 
surface of the transverse processes, we do not conceive that 
their posterior extremity can be luxated, notwithstanding the as- 
sertion of Buttet in the Memoires de Vacademie royale de chi- 
rurgk. If they were driven with sufficient force from before 
'* Archives generales de Medccine Janvier et Fevrier 182a. 402 
OF THE CHEST. 
backwards, they would be fractured towards their angle before 
the costo-vertebral and inter-transverse ligaments could be bro- 
ken. If the force acted behind, the strength of the costo-trans- 
verse ligament and the manner in which the head of the rib is 
supported upon the bodies of the vertebrae, would also render 
its fracture more easy than its luxation. Finally, we do not 
know of an authentic example of this form of displacement, 
and that related by Buttet is not of such a nature to produce 
conviction. 
The intercostal spaces are narrow in the dorsal region, and the 
more so as we approximate the vertebrae. Even if there was 
no other reason to prevent it, we should never perform the opera- 
tion for empyema in the dorsal region. But there are other 
motives which should deter the surgeon from it: first, because 
Ihe operation would be rendered difficult by the thickness of the 
soft parts which it would be necessary to traverse ; and, in the 
second place, because the intercostal artery and nerves there 
present their greatest volume, and, not being sheltered by the 
rib, would render it very dangerous. As all the ribs are not 
supported by the sternum ; as the last five are but loosely united 
to each other anteriorly, it follows that the superior are more 
easily fractured than the inferior. But fractures from a direct 
cause arc uncommon in this region, on account of the thick mus- 
cular layer which covers the bones behind; neither are those by 
contre-coup very common, because, notwithstanding the great 
curvature of the angle, the rib more frequently breaks anteriorly, 
as it is much thinner in this situation and less firmly supported 
than posteriorly. 
Before concluding, we must note that there is sometimes an 
additional rib on each side ; in which case there are thirteen ver- 
tebrae. This anomaly is sometimes observed at the superior, at 
others, in the inferior part. In the first case, the cervical region 
loses its last vertebra, the costiforme prolongation of which con- 
stitutes the supernumerary rib ; in the latter, it is the first lumbar 
vertebra which undergoes a similar deviation. 
If we take up the parts which have just been examined, from 
the surface towards the interior of the thorax, we will find them 
arranged in the following order: 1st. the skin ; 2d. the subcuta- 
neous layer; 3d. the fibro-cellular sheets, which reunite below, OF THE CHEST. 
403 
to form the aponeurosis, and which include the trapezius, latissi- 
rnus dorsi, rhomboidei, and serrati postici muscles ; 4th. the 
deep-seated muscles; 5th. the vertebrae, ribs, the intercostal 
muscles, and the arteries and nerves of the same name. 
Sect. 3. Costal Region. 
The lateral region of the thorax is double, and may be divided 
into two portions on each side: one superior, which enters into 
the axillary region, and which has already been examined; the 
other, inferior, or sub-axillary, which forms the costal region, 
properly so called. Of the first, which was described in its 
place, we will only speak in an accessory manner in this section. 
The costal region is bounded, superiorly, by a line drawn from 
the inferior angle of the scapula, along the hollow of the axilla, 
below the nipples; inferiorly, by another line, carried along the 
margin of the costal cartilages, and thus uniting the two scapulo- 
coxal and clam-coxal lines ; anteriorly by the sternal region, and 
posteriorly by the dorsal. Upon its surface we observe, above, the 
prolongation of the two borders of the axilla, and, in their interval, 
the great excavat ion which forms the commencement of the cav- 
ity of this region. The first prominence supports, anteriorly, a por- 
tion ol the mammary gland, below which we see a depression, 
which we would call, with M. Gerdy, the sub-mammary depression; 
the other descends obliquely backwards, and may be distinguished 
even as far as the last ribs. In strong muscular subjects, we no- 
tice, between the two preceding prominences, some digital impres- 
sions, which indicate the origins of the serratus anticus. Finally, 
we perceive by the touch, unless the subjects are very fat, the 
ribs, intercostal spaces, and the summits of the twelfth and 
eleventh ribs, when they are free in the muscular parietes. 
CONSTITUENT PARTS. 
i. The Skin. 
It is destitute of hairs and wrinkles, but contains a great num- 
ber of sebaceous follicles, which give it a rugous and uneven as- 
pect. Posteriorly, it is of considerable thickness : anteriorly, if 404 
OF THE CHEST. 
is more attenuated, and its characters are a mixture of those of 
the skin of the dorsal, abdominal, and sternal regions. It is less 
adherent to the subjacent tissues than in the dorsal region, moves 
readily over them, and is very extensible ; therefore, its wounds, 
with loss of substance, are easily and promptly united. This 
species of mobility is very serviceable in the operation for em- 
pyema or paracentesis thoracis, as we are thereby enabled to 
prevent the admission of air into this cavity. 
ii. The Subcutaneous Layer. 
In emaciated individuals it is thin, yet very distinct and lamel- 
lated : sometimes, on the contrary, its thickness is so considerable 
as to prevent us distinguishing the intercostal spaces through the 
skin. This layer is prolonged, on the one hand, between the 
pectoralis major muscle and the ribs ; and, on the other, before 
the latissimus dorsi, in order to penetrate the hollow of the axilla. 
It encloses arterial and venous twigs, and nervous ramifications. 
The adipose vesicles which are situated in its external laminae, 
are generally elongated, reddish, and flattened, in persons who 
have lost their embonpoint. 
hi. The Aponeurosis. 
This fascia is also very thin, and rather cellular than fibrous; 
at first, it is pretty strongly marked upon the external surface oi 
the obliquus externus muscle, where it is continuous with the 
aponeuroses of the belly ; it ascends, single and attenuated, upon 
the serratus magnus, as far as the axillary excavation ; after- 
wards, it applies itself, anteriorly and posteriorly, upon the deep 
surface of the great pectoral and dorsal muscles, in order to en- 
velope their margin and thus pass upon the arm. 
iv. The Muscles. 
There are some which are only applied upon the ribs, and 
which we must first examine. Anteriorly, we find a small por- 
tion of the pectoralis major, when it descends upon the sixth and 
seventh ribs ; posteriorly, the most important part of the latissi- OF TIIE CHEST. 
405 
mus dorsi; tiiis last is disposed in such a manner, that its costal 
digitations pass almost directly to the inferior angle of the scapula, 
and that inserted into the humerus, it may depress the arm or 
elevate the last four ribs; for the same reason, when the latter 
bones are fractured, it tends to draw the fragment to which it is 
attached, upwards and outwards; consequently, it is an inspi- 
rator, since it may dilate the thorax: therefore, during exertions 
and in deep inspirations, the arms are raised almost instinctively, 
seeking to fix themselves in a more or less solid manner upon 
surrounding bodies. Inferiorly and anteriorly, we meet with the 
digitations of the external oblique, which originate from the 
last seven ribs, where they intersect those of the preceding, and 
especially the digitations of the serratus magnus; all these fleshy 
tongues cover about an inch and a half of the osseous portion of 
the ribs; they are oblique forwards, downwards, and inwards. 
According to their arrangement, the obliquus descendens is one 
of the most powerful depressors of the ribs, and it cannot draw 
upwards the pelvis, or stretch the aponeurosis of the abdomen, 
until the other muscles have previously fixed the thorax. In the 
space circumscribed by the three preceding muscles, we observe 
the inferior digitations of the serratus anticus, the direction of 
which is nearly parallel to that of the ribs. The last of these 
digitations, in abandoning the scapular angle, leaves between it 
and the rhomboideus and latissimus dorsi muscles, a space, a 
kind of opening, mentioned already when on the dorsal region, 
which leads between the shoulder and the thorax, and which 
forms a communication between the subcutaneous cellular tissue 
of the costal region and the deep layers of the supra-clavicular 
and dorsal regions; a space, finally, through which the pus, 
which may have formed upon the lateral parts of the neck, might 
gravitate, and form an abscess in the lower part of the costal 
region, after having passed under the shoulder. In the last place, 
we see the trapezius and serratus posticus inferior, the latter 
placed under the latissimus dorsi, and which cover only a very 
small portion of the costal region. 
The other muscles of the side of the chest are enclosed in the 
intercostal spaces, and form two planes which intersect each oth- 
er at almost right angles : the external is oblique downwards and 
forwards; the internal, on the contrary, descends backwards, and 406 
OF THE CHEST. 
it is upon this disposition that Hamberger founded his opinion 
that the former was an expirator and the latter an inspirator ; a 
cellular layer, in which we sometimes observe adipose vesicles, 
separates the two, and it is between this layer and the internal in- 
tercostal muscle that the artery, veins and nerves of the same 
name are found; internally, their fibres may be distinguished 
through the transparent pleura, which is separated from them by 
some rare and lamellated cellular tissue, in which adipose clus- 
ters are sometimes developed in such a manner as to repel this 
membrane inwards, and thereby produce those free and floating 
appendices which are observed in certain old men, upon its inner 
surface ; externally a thin fibrous web, which passes from the 
external surface of one rib to the other, separates them from the 
superficial muscles, and seems to be blended with the fibrous 
bundles which are naturally mingled with the lleshy fibres. These 
two muscular planes exist throughout the whole extent of the cos- 
tal region, whilst the external alone is found in the dorsal, and the 
internal in the sternal region. 
v. The Arteries. 
The Intercostal is the only one which deserves much attention 
on account of its size and position, relatively to the operation of 
empyema, on the one part, and to penetrating wounds of the 
chest, on the other. This artery is situated between the internal 
intercostal muscle and the cellular layer which separates it from 
the external, and runs to place itself in the groove of the inferior 
border of the rib, just where that curvature commences which 
forms the angle of this bone ; it passes to the extent of some in- 
ches thus enclosed in a canal, which is muscular internally, and 
osseous posteriorly or externally : so that we might, if I mav 
so say, shave the rib, as far as the middle of the side of the chest, 
without wounding the artery : but then this vessel becomes more 
and more isolated, and finally places itself completely under the 
margin of this bone ; as it advances farther towards the sternal 
region, it loses much of its volume, and inosculates with the ex- 
ternal branches of the internal mammary artery. The intercos- 
tal artery, in its course, gives off a great many branches, which 
meet upon the external surface of the corresponding rib, and OF THE CHEST. 
407 
which traverse the deep muscles in order to ramify in the su- 
perficial : but there is only one among these branches worthy of 
notice; it is that which separates from the trunk towards the mid- 
dle of the space, and which runs obliquely forwards to the superior 
border of the rib below, in order to reach the external muscles. 
Its point of origin is so variable that we are not always sure of 
avoiding it in paracentesis thoracis; but fortunately it is seldom so 
large as to give rise to a dangerous hoemorrhage. In general, the 
trunk of the intercostal artery lies much nearer the pleura than 
to the superficial muscles of the thorax, and is more easily wound- 
ed the nearer we approach the anterior region ; therefore, in or- 
der to avoid this accident, it is customary to penetrate the thorax, 
in operations, by cutting before the angle of the ribs. We should 
also, in these operations, be careful to divide the tissues nearer the 
inferior than the superior rib, and remember that, in certain dis- 
eases, the secondary branches acquire double and even triple their 
ordinary dimensions. 
It follows then from the position of these arteries that they 
may be divided in the operation for empyema, by simple punc- 
ture, penetrating wounds, and in the evacuation of an internal col- 
lection, an abscess of the liver, for example ; finally by fragments 
or spiculm of fractured ribs. In all these cases, let there be a 
wound or not, it would be almost impossible to seize the vessel 
with the forceps and tie it; from without, we cannot compress it, 
and therefore the blood which is almost constantly extravasated 
into the chest, instead of escaping externally, soon gives rise to 
alarming symptoms. Now it is evident that the thread passed by 
Gerard around the rib, by means of a curved needle, in order to 
embrace the artery, or by Goulard with his needle having a long 
handle and perforated near its point, should be rejected ; on the 
one hand, because it exacts a double wound, on the other, because 
the artery would not be completely flattened by it in the groove 
of the rib ; finally, because acting upon one extremity only of the 
divided vessel, the hoemorrhage might continue from the other. 
The jeton of Quaisnay, the plaque of Lottery, the complicated 
machine of Bellocq, would be still less certain ; and all these 
means would be advantageously replaced by those which have 
been recommended by Desault and Sabatier. After having in- 
ireduced through the wound, into the thorax, a small empty sac, 408 
OF THE CHEST. 
made of linen, oiled silk, or a portion of bladder, which should be 
retained externally by threads, it would be easy to fill it with lint 
or any other substance, and thereby give it such a size as will pre- 
vent its escape through the intercostal space. By this means the 
compression will act upon the two divided extremities of the ar- 
tery at the same time, in a certain and exact manner, without 
much inconvenience to the patient. 
The other arteries of the costal region, are, for the most part, 
twigs of the preceding, which anastomose, superiorly and anteri- 
orly, with the sub-scapularis or external mammary; superiorly 
and posteriorly, with the scapular branch of the cervicalis de- 
scendens. All these branches ramify in the superficial muscles, 
the cellular layers and the skin ; they are but small, however, in 
the healthy state, and are not of actual importance in surgery, 
except by forming chains of communication between different 
remote parts of the body. 
vi. The Veins. 
These vessels are disposed exactly in the same manner as the 
arteries. 
vii. The Lymphatics. 
They form two series, which follow two different directions. 
The superficial set ascends to the glands of the axilla, whilst the 
deep seated, following the course of the bloodvessels, run from 
the intercostal spaces upon the sides of the vertebrae, or into the 
glands situated in the anterior and posterior mediastinal spaces: 
whence it follows that diseases of the skin or of the superficial 
layer frequently produce affections of the axillary lymphatic 
glands, without acting upon those in the cavity of the thorax; 
whilst the latter frequently participate in deep seated maladies. 
A blister, for example, applied upon the costal region, will occa- 
sion pain and tumefaction in the axilla; a sarcoma, or caries of 
the ribs, on the contrary, will re-act behind the sternum or before 
the spine. OF TIIE CHEST. 
409 
viii. The Nerves. 
The serratus magnus anticus muscle derives its nerve from the 
fourth and fifth cervical pairs, and might, consequently, preserve 
its action although the spinal marrow had been divided in the 
upper part of the dorsal region. Some filaments are also sent 
otf from the brachial plexus to the latissimus dorsi and pectoralis 
major ; but the nerves proper to this region are the intercostals, 
each of which is nearly of equal volume with the artery of the 
same name, follows the same direction, is situated below and in 
contact with it, and divides in the same manner; so that the 
opening of the vessel alone, almost certainly indicates the divis- 
ion of the nerve. However, these nerves descend farther than 
the artery into the space filled by the muscles, and soon cross the 
internal surface of the inferior rib. The last especially, which 
some persons have considered as the first lumbar branch, soon 
deviates from the osseous arch, in order to pass into the interval 
of the muscular layers of the abdominal parietes. 
ix. The Skeleton. 
It is formed by the bodies of the last seven ribs, and is remark- 
able for the disposition of these bones and their relations with the 
circumjacent organs. We have just seen that the ribs were cov- 
ered externally by large muscles ; that their margins were fixed 
by others, and lodged the principal vessels and nerves, and that 
internally they were lined by the pleura only. It must therefore 
follow from this arrangement that their fractures, whether pro- 
duced by a force which tends to increase the curvature of these 
bones, or to diminish it, will be attended with displacements and 
symptoms more or less serious, according to the situation of the 
solution of their continuity. Thus, does the fracture exist in the 
course of the curved line from which the serratus magnus origin- 
ates? this muscle will draw the posterior fragment outwards, up- 
wards and backwards, whilst the obliquus descendens will carry 
the anterior fragment of the bone in the opposite direction. Is 
the fracture situated further backwards and upwards ? then the 
latissimus dorsi and serratus anticus will act upon the anterior 410 
OP THE CHEST. 
fragment, will tend to make it ride over the posterior, and the dis- 
placement, in relation to length, will be considerable. If the ribs 
are broken nearer their anterior extremity, the over-lapping will 
be more difficult, because at the same time that the serratus mag- 
nus tends to draw one of the portions outwards, and that the 
other is drawn by the pectoralis major in the same direction, the 
obliqui, transversalis and diaphragm act upon the latter, in order 
to draw it downwards and inwards. However, as most of these 
muscles are at the same time attached over a pretty great extent 
of the external surface of the ribs, it is seldom that the displace- 
ment can be carried very far; more especially as the sternum, on 
the one hand, and the spine on the other, equally oppose it, in 
maintaining, by means of the sound ribs, the fragments in a posi- 
tion which can scarcely deviate from the natural state. It is not 
in this way then that fractures of the ribs become dangerous, 
but from the nature of the organs which have been wounded at 
the same time, and the derangement of function consequent 
thereto. In fact, if this fracture is direct, the pleura, lungs, as well 
as the intercostal vessels and nerves, will generally be stretched, 
even torn, and hence extravasations, inflammations of the chest, 
etc. If, on the contrary, it is produced by a counter-stroke, the 
fragments will have lacerated more or less the external soft parts, 
likewise the vessels, nerves and pleura; then we may expect in- 
flammations, abscesses, and pains increased especially by the res- 
piratory movements. Finally, if the fracture is comminuted, if 
spiculae are detached, as frequently happens, these osseous points 
will wound the lungs the intercostal artery, or the external 
organs, or all these parts simultaneously, and will in all cases act 
as foreign bodies. 
As the true ribs become much shorter and less flexible as they 
ascend, it is evident that those which are most superior would be 
most readily fractured, if, on the other hand, the shoulder, the 
arm, and the muscles, did not protect them very efficaciously 
above, in the whole axillary portion, whilst inferiorly, or in the 
costal regions, properly so called, they are almost uncovered, and 
much more exposed to external violence. When one rib only is 
broken, which is unusual, as the displacement can only be pro- 
duced by the same impulse which fractured the bone, it always 
takes place inwards; these isolated fractures are most frequently OP TIIE CHEST. 
411 
produced by balls or other projectiles propelled by gunpowder; 
their frequency, however, is not proportionate to that of wounds 
of this species, and for these reasons;—if the vulnerant body 
strikes near one of the borders of a rib, it will glance and tra- 
verse the intercostal space and chest; if, on the contrary, it is 
driven against the middle of the external surface of the bone, as 
the latter may yield and spring back, the foreign body will still 
be turned aside, and in this case it will plough through the tho- 
racic parietes from before backwards, or from behind forwards, 
without producing fracture or penetrating into the pectoral 
cavity. In the lateral region of the thorax, the ribs are more flat- 
tened, and those which are most superior are so solidly fixed, that 
a knife, sword, etc., might pass along one of these bones, in the 
direction of its length, without fracturing it, or, at least, merely 
detaching some scales, and, again, in such a manner that the point 
of the instrument may be broken off and left in the body of 
the rib, projecting into the chest. Such a case, an instance of 
which came under the care of Gerard, would be somewhat em- 
barrassing, especially if the weapon was broken off so near the 
osseous surface that it could not be taken hold of externally; 
then the means employed by this surgeon, that is to say, a steel 
thimble placed upon the finger and introduced through the inter- 
costal space into the chest, in order to press the point of the 
weapon outwards, is the only one which would afford any chance 
of success. 
The intercostal spaces must now be examined. They gen- 
erally differ in breadth: the third is the broadest of all; the 
first and second follow next; the fourth, fifth, sixth, and seventh, 
differ but little from each other; the last two are broader, but of 
less importance. It should be noted, that this difference in the 
breadth of the spaces which separate the ribs, is most evident in 
the anterior half of the chest, and that this gradual enlargement, 
which we observe from behind forwards, arises from the descent 
which the bones make at first, in order to ascend afterwards. 
This peculiarity merits some attention in surgery, because it ren- 
ders the operation of empyema more easy before the angle of 
the ribs, than at the posterior part of this curvature. However, 
it is at the union of the two anterior thirds with the posterior 
third of a line drawn from the sternum to the spine, that we am 412 
OF T1IJJ CliKST. 
recommended to penetrate into the chest for the purpose oi 
evacuating fluids. In giving this advice, surgeons supposed that 
the artery, which is there concealed by the rib, was less in dan- 
ger, and that the fluid would flow out easier; but we will per- 
ceive directly, that these data deserve further investigation. 
There enters into each intercostal space, 1st, the two intercos- 
tal muscles ; 2d, two cellular layers; 3d, the intercostal artery 
and vein ; 4th, the nerve of the same name. The inferior mar- 
gin of the superior rib limits it above. Thin and excavated inter- 
nally, forming a groove, which disappears anteriorly, where this 
part of the rib is rounded, this margin, considered in its ensemble, 
is convex outwards and downwards. The superior border of 
the inferior rib is thick, obtuse, concave throughout its whole ex- 
tent, and its direction is that which we ought to follow, when we 
traverse one of the intercostal spaces. 
Now the operation of empyema may be the object of several 
anatomical remarks. Thus, although we might perform it indis- 
criminately upon all of the intercostal spaces, and in every point 
of their extent, yet, unless from absolute necessity, we only do it 
upon some one of them, and upon one part in preference to anoth - 
er. We do not operate, for example, upon the five or six supe- 
rior, because they are covered by the shoulder and the pectoralis 
major muscle ; besides, extravasated fluids do not accumulate in 
the upper part of the thorax; we do not operate upon the last 
two, because, the diaphragm which naturally rises up against their 
internal surface, might be divided and thereby allow the instru- 
ment to penetrate into the cavity of the peritoneum ; neither do 
we select the anterior third of these spaces, notwithstanding they 
are broader in this portion ; in the first place, because it is diffi- 
cult to avoid the arteries, next because the matters are usually 
collected more and especially because we cannot ren- 
der this part the most dependent. Finally, we should not per- 
form the operation for empyema at the posterior part, as it would 
then be necessary to cut transversely, sometimes the trapezius or 
serratus posticus inferior, and always the latissimus dorsi; because 
also the space is narrower, and the vessels and nerves are not so 
well protected byr the rib, from what has preceded we con- 
ceive, that, in order to give issue to liquids collected in the tho- 
rax, it will be necessary to penetrate into this cavity, anterior to OF THE CHEST. 
413 
the latissimus dorsi, and, for this purpose, we can only select a point 
between the hollow of the axilla and the last intercostal space but 
one. It is between the second and third ribs, counting from be- 
low upwards, that Verduc and some other surgeons have advised 
makingthe opening, on either side, because this space corresponds 
to the point wiiich is best adapted for the discharge of the pus ; 
but as the diaphragm is pushed up by the spleen on the left, and 
by the liver on the right, we prefer operating upon the third space, 
as recommended by Dionis, Garengeot, Le Dran, Bertrandi; or 
upon the fourth, according to the advice of Sabatier, MM. Boyer, 
Richerand, etc. If we select the right side, it will be imprudent to 
operate lower down, not only because the diaphragm rises dur- 
ing expiration, but also because this organ may contract adhesions 
with the thoracic parietes, in which case it might be readily trans- 
fixed and the instrument enter the belly. M. Laennec was witness 
to an accident of this kind. On the other hand, this professor has 
remarked that the diaphragm sometimes ascends to a level with 
the sixth and even the fifth true rib ; wherefore, he thinks that it 
would generally be more proper to perform the operation for em- 
pyema in the middle of the chest; especially as in females, and 
even in many males, this point is actually the most dependent 
when the patient lies horizontally and a little upon the side. It is 
for the same reason that Samuel Cooper* recommends the incis- 
ion to be made between the sixth and seventh true ribs. Be this 
as it may, it follows from these different opinions, that the place 
of election for paracentesis thoracis is not yet well determined, 
and that we may perform it, with nearly equal advantages, upon 
the third, fourth, fifth and sixth intercostal spaces in the lateral 
region, (counting from below). In either of these places, it would 
only be necessary to divide the skin, the adipose layer, the mem- 
brane of greater or less thickness which covers the muscles, the 
external and internal intercostal muscles, and the pleura. By fol- 
lowing the direction of the rib, the digitations of the serratus 
magnus and obliquus externus will only require to be separated ; 
and if the opening is made immediately before the latissimus dor- 
si, it will always be easy to avoid the artery, since it is then en- 
tirely concealed by the rib. Surgeons have particularly advised 
Dictionary. 414 
OP THE CHEST. 
proceeding with great caution when dividing the pleura, for tear 
of wounding the lung ; but it seems to us that there is very little 
foundation for such fears. In fact, if the respiratory organ is free 
from adhesions, the external air will promptly repel it, and drive 
it beyond the reach of the instrument; if, on the contrary, it ad- 
heres more or less intimately, we will wound it in spite of all our 
precautions; and, moreover, what dangers can result from wounds 
of such a nature ? Finally, if we operate upon the abscess itself, 
we run no risk at all. We think then that empyema, instead of 
being a delicate operation, might, when we have properly ascer- 
tained the intercostal space, be reduced to a simple incision, simi- 
lar to that of opening any deep-seated abscess whatsoever. 
After this operation, as well as after penetrating wounds of 
whatsoever nature they may be, as the intercostal muscles are 
divided transversely to the direction of their fibres, w hen they 
retract, they leave an opening into which the lung may insinuate 
itself and form a tumour of greater or less volume externally. 
The observations of Schenkius, Tulpius, Fabricius de Hilden, 
and Ruysch, support this assertion. It may also happen that the 
external parts will cicatrize, whilst the intercostal aperture re- 
mains : the lung would then form a complete hernia under the 
skin, especially during inspiration; a remarkable example of 
which is related by Sabatier. On this occasion, we may also 
notice another still more singular, w-hich was pointed out to us by 
M. J. Cloquet, whilst dissecting for his anatomical lectures in 
1821. This case occurred in a man of about fifty years, who 
had several of his ribs broken, by the wheel of a carriage, nine 
years previously; the middle portion of the fifth, sixth, and 
seventh ribs had disappeared, and left a space large enough to 
admit the fist; a space through which the lung protruded and 
projected under the skin, whenever this man, w ho otherw ise en- 
joyed perfect health, inspired or made any exertion. 
Sect. 4. Mammary Region. 
It is formed by the mammae, and cannot have any exact limits: 
in man, it scarcely exists, and does not merit any special consid- 
eration ; in the female, on the contrary, it is an important region, 
but after puberty only: previous to this epoch, the breast is only or THE CHEST. 
415 
rudimental, as it always is in the opposite sex. The volume, 
form and density of this organ vary accprding to the age of the 
mature female, her state, constitution, etc. Thus the mammae 
represent two half spheres, regularly rounded and firm upon the 
fore part of the chest of young virgins ; soft, pendent, and more or 
less flattened, in women who have had children. Sometimes they 
form a considerable relief; at others, we scarcely distinguish them, 
and this may depend upon their intrinsic volume or the abun- 
dance of the cellular tissue which surrounds them. If, on the 
one hand, the well-formed breasts concur in setting off the 
graces and elegance of the sex, if their functions render their 
preservation of the highest importance, on the other hand, they 
sometimes embarrass the surgeon considerably, when it becomes 
necessary to apply an apparatus upon the thorax. For example, 
the bandage of Desault, in fractures of the clavicle ; those which 
are used for fractures of the ribs; in short, all compressive ban- 
dages which we are obliged to apply around the thorax of fe- 
males, require considerable precaution, on account of the mam- 
mae. These organs also prevent our deriving such satisfactory 
results in this point from percussion and auscultation, whether 
mediate or immediate, as in man. 
CONSTITUENT PARTS. 
i. The Skin. 
The skin of the breast is delicate, smooth, soft to the touch, 
white or slightly bluish in the pubescent virgin; uneven, wrinkled, 
thicker, and less white, in those who have borne several children, 
or who have arrived at a certain age. In the centre of the re- 
gion, it is surmounted by the nipple, a sort of homogeneous, 
spongy, erectile, extremely sensible, rugous, reddish, or yellowish 
body, perforated by a great many foramina, which lead to the 
lactiferous ducts, surrounded by an areola of greater or less 
breadth, which is generally of a rosy or livid colour, analagous to 
that of the nipple itself. Here, this membrane possesses but a 
very limited extensibility, and encloses a great number of seba- 
ceous follicles; therefore, it cracks very easily during lactation, 
when it is irritable. The proper tissue of the nipple resembles 416 
OF THE CHEST. 
bacon: all the elements composing it are so blended together that 
it is difficult to distinguish them, and hence, although Ruysch 
affirms that he has traced the nervous filaments as far as the cu- 
taneous papilla), it is doubtful that he has done so. 
ii. The Subcutaneous Layer. 
This layer differs from that of the preceding regions by its 
thickness, which is much greater; by its more numerous and 
larger adipose cells, and by including the mammary gland. The 
cellular tissue is rather filamentous than lamellated, and sends off 
many septa, which are intimately attached to the internal surface 
of the skin, and are prolonged across the secretory organ. 
iii. The Arteries. 
They appertain to the internal mammary, intercostals, to the 
anterior thoracic, and especially to the external mammary or in- 
ferior thoracic artery. The latter is the largest; its principal 
branches are found on the outer side of the region, under the 
margin of the pectoralis major; these are the vesssls divided by 
the instrument in terminating the amputation of the breast, and 
which most frequently give rise to hoemorrhage in this operation. 
The branches of the first ramify upon the sternal side, and be- 
come more superficial; the second supplies the superior part, and 
they all anastomose with one another, forming a plexus, which is 
so disposed that the extirpation of the mammary gland would 
rarely be followed by a dangerous bleeding, if the disease had 
not caused an augmentation in the volume of the arteries. We 
must expect, therefore, during the operation, to meet with arte- 
rial branches, which will be more numerous and large in propor- 
tion to the duration and size of the tumour. In all cases, it must 
be recollected that these vessels should be sought for in the supe- 
rior part, at the inner or outer side of the wound, because in its 
inferior half they are generally very small; we should likewise 
keep in mind, that, as these arteries run in the cellulo-adipose 
layer, they will retract as soon as divided, and that their mouths 
will also contract so much as to render their ligature difficult 
after the removal of the tumour. It is with the view of avoiding OF THE CHEST. 
417 
the inconveniences attached to this disposition of the arteries, 
that surgeons recommend us to tie them as soon as they are di- 
vided by the instrument. This advice, dictated by prudence, 
ought always to be followed, especially when we wish to effect 
an union by the first intention; then, in fact, it is necessary to 
prevent the blood from becoming extravasated behind the ap- 
proximated lips of the wound, if we wish them to agglutinate: 
but if the loss of the substance is so great that we are obliged to 
dress it as an open sore, or if the surgeon, from any other reason, 
does not think proper to dress it otherwise, we think that it would 
always be possible, under ordinary circumstances, to secure the 
arteries, after the excision of the diseased parts, so that there 
would be no apprehension of severe hoemorrhage. The other 
method, however, has no other defect than that of uselessly pro- 
longing the operation. 
iv. The Veins. 
Some of them are disposed as the arteries, which they accom- 
pany and exceed in volume, and to which they generally adhere 
so intimately that it is often very difficult to separate them : the 
others are situated under the skin and even in the gland. The 
arrangement of the latter is very different from that of the arte- 
ries ; they intersect each other a great number of times in the 
compact tissue which unites the mammary gland to the skin of 
the areola; and, in women who have nursed many children, they 
form a species of plexus, more or less evident and complicated 
around this coloured part. As we remove from this point, the 
subcutaneous veins of the breast are so large that they are delin- 
eated through the skin ; indeed it is not uncommon to see them 
become varicose* in females, of a certain age, who have fulfilled 
the duties of maternity, in those who have been affected with 
chronic enlargement of the breasts, etc. It is these enlarged 
vessels which give to the cancerous breast that disagreeable ap- 
pearance which induced the ancients to compare this disease to 
a species of lobster, or crab, sticking to the organ in order to de- 
vour it. The veins of the glandular texture have very thin 
*M. Briquet, th&se, etc. 1824. 418 
OF THE CHEST. 
tunics, and are always larger than the arteries; almost all ot' 
them pass into the veins of the axilla, some empty into the inter- 
nal jugular or subclavian, on the inner or outer side of the sterno- 
mastoid muscles, and may be lacerated by the osseous fragments, 
in fractures of the clavicle, so as to give rise to extensive ecchy- 
moses. In short, all these vessels soon enter into the surrounding 
regions, where we have already examined them. 
v. The Lymphatics. 
We do not find any lymphatic glands in the mammary region. 
The vessels are a continuation of those which were pointed out 
in the costal, axillary and sternal regions, and which pass to the 
glands in the anterior mediastinal space and to those in the cavity 
of the axilla, on the one part; and to the glands of the infra-hyoi- 
deal and supra-clavicular regions, on the other. 
vi. The Nerves. 
These are also the same branches as those which we have al- 
ready seen in the other regions of the thorax. 
Thus, the supra-clavicular filaments of the cervical plexus en- 
ter this region in order to ramify in the skin and the superficial 
iaminm of the cellular layer ; the thoracic branches of the brach- 
ial plexus are distributed to the gland and the adipo-cellular tis- 
sue ; the twigs of the corresponding intercostal nerves, and those 
of the posterior thoracic are also lost in it, after having passed 
through the muscles. These different filaments are so small that 
their diseases cannot be correctly appreciated: from analogy, 
however, and certain facts, we are induced to believe that they 
sometimes undergo changes which produce in the breast of 
females exquisite pain, and which continues during a long time 
without any organic lesions being observed in it. 
vii. The Mammary Gland. 
Its circumference is irregular; so that, in extirpating it, some 
lobules might be left behind, although the intention was to remove 
the whole of it. Its anterior or superficial surface is uneven. OP THE CHEST. 
419 
titberculated, convex, and separated from the skin by a layer of 
cellular and adipose tissue, which increases in thickness in pro- 
portion as it recedes from the nipple. Its deep surface is plane 
and smooth, being covered by a very distinct aponeurotic fibrous 
sheet; it is separated from the pectoralis major only by a small 
number of cellular lamellae ; and the relations of the gland with 
this muscle vary but little, whatsoever may be the embonpoint of 
the female. The divers lobules are separated by processes of 
fibro-cellular tissue, which become hard, completely fibrous, and 
sometimes cartilaginous or osseous, in scirrhous enlargements 
{cancers lardaces). These plates, which are also attached to the 
skin, divide the organ into several compartments, and permit pus 
to form in a great number of distinct loculi: therefore, when 
abscesses are developed in the breast, it is not unusual to see 
several of them open successively, or require to be punctured 
separately. In colloid or gelatiniforme cancers, the hydatiforme 
of English authors, these intersections also perform an important 
office. They give to these tumours that lobulated disposition, 
which constitutes one of their principal characters ; but they 
never extend so far as the muscles: they generally terminate in 
the lamellated layer which covers the gland posteriorly. In the 
adipose tissue, on the contrary, we observe these intersections 
prolonged in all directions, which prolongations become harden- 
ed, and are transformed into the fibrous or scirrhous texture in 
cancers of this nature, of which they then seem to form the roots, 
and which we should carefully remove, if we wish to obtain some 
chance of success from the operation. As in the natural state, 
and especially in the pathological, the gland or the disorganizing 
tumour descends more or less below the pectoralis major and into 
the grooves which separate the inferior margin of this muscle 
from the ribs, it is necessary, in order to avoid dividing this fleshy 
border, to dissect the part which we wish to remove, from above 
downwards. It is also necessary, in order to prevent constant 
tractions upon the cicatrix, that the incisions should be made ob- 
liquely to the fibres of this muscle, that is to say from above 
downwards and from without inwards ; finally, in order that the 
pains which its contractions occasion during the treatment of the 
wound, consequent to the removal of the breast, may be mode- 
rated, it is necessary that the arm should be kept immoveable. 420 
OF T1IE CHEST. 
We must also recollect, in relation to this operation, that the dis 
ease frequently obliges us to remove a portion of the muscle in 
question and sometimes even of the ribs, as well as a part of the 
pleura itself, as is proved by the bold operation of this nature per- 
formed by M. Richerand. In all these cases, as several bundles 
of the pectoralis major remain unmolested above the cicatrix, it 
follows that, after the cure, the arm recovers the freedom of its 
movements in a much more perfect manner than would at first 
have been supposed. 
viii. The Lactiferous Ducts. 
The lactiferous ducts arise, like all excretory tubes, by a great 
number of radicles, in the lobules of the gland, and some of them, 
according to Haller, from the adipose layer, all of which run 
towards the nipple and open separately upon its surface. Some 
of these lie so near the skin, and are sometimes so large in cer- 
tain women during lactation, that a very slight incision in the 
neighborhood of the areola, may open them; in which case, a 
listula may be the consequence, which will not exist however 
except during lactation. These canals appear to be the special 
seat of the disease known by the vulgar name of “ ague in the 
breastor engorgement of the breast of lying-in women. In 
these cases it really seems that the milk coagulates within them, 
and thereby becomes a foreign body, irritating, by its presence, 
and producing inflammation of the surrounding cellular tissue. 
It is from this opinion that ammoniated liniments are recommend- 
ed, for the purpose of restoring to the milk its natural fluidity, 
and which actually produces astonishing effects, when employed 
bv a skilful and prudent physician. 
Art. II. OF THE INTERIOR OF THE THORAX. 
We have now to examine successively: the partition which 
separates the chest into two cavities, and the organs included in 
this partition ; the two pectoral cavities themselves, in their rela- 
1 ions with the viscera which they contain; finally, the base and 
the summit of the thorax. OF THE CHEST. 
421 
i. The Median Septum or Mediastinal Region. 
liy making an abstraction of the column formed by the bodies 
of the vertebra?, which prolong this septum backwards, we ob- 
serve that it is constituted by the approximation and junction 
(iadossement) of the two pleurae. It has the figure of a triangle 
rounded off' towards the summit of the cavity which it divides; 
its posterior border rests upon the fore part of the spine, and fol- 
lows the direction of this column, upon the sides of which, the 
two pleura] laminae are applied. 
This separation of the two pleurae upon the anterior part of the 
bodies of the vertebrae, constitutes what certain anatomists call the 
posterior mediastinum. It contains the aorta, on the left; the 
vena azygos, on the right; the oesophagus, before, in the middle, 
and upon a more anterior plane ; the thoracic duct, behind; 
lastly, some cellular tissue, lymphatic glands, etc. 
(a) The Aorta does not penetrate into the posterior medias- 
tinal space, until after it has curved around the left bronchus; 
then it places itself deeply upon the corresponding side of the ver- 
tebrae, and, as it descends lower, it approximates the median line 
and becomes more anterior. It is then found in relation :—an- 
teriorly and on the left, with the pleura, and mediately with the 
root of the left lung, the pericardium and the left side of the 
heart ; internally and anteriorly, with the oesophagus and the par 
vagum of the left side, which from being a half inch and even an 
inch distant from it above, promptly approximate it as they de- 
scend, and are united to it below by a pretty dense cellular tissue. 
Its posterior and internal portion rests upon the vertebrae, between 
the thoracic duct which runs along its inner side, and the great 
sympathetic which is situated on its outer side; so that it crosses 
all the costo-vertebral articulations. From this disposition of the 
great artery of the body, we may perceive that its aneurismal 
tumours will compress different organs, according to the point 
which they may occupy below the transverse portion of its arch. 
Thus, if the aneurism is situated above, and it projects forward, it 
will compress and flatten the left bronchus and pulmonary ves- 
sels ; whence will result the difficulty of breathing and the dis- 
turbance in the circulation, which we so often observe in this dis- 422 
Of THE CHEST. 
ease. If this tumour is situated lower down, it will either com* 
press the cesphagus, the nervi vagi and the thoracic duct, if it is 
developed on the right side : or it will push the heart forwards, if 
it is situated upon the anterior and left portion of the artery; 
finally, it will act more particularly upon the vertebral column 
and the great splanchnic or ganglionic nerves. It is on account 
of this disposition, that aneurisms may open into the bronchi or 
oesophagus ; that they may burst still more frequently into the 
thorax ; that they may occasion disturbance in the digestion and 
circulation of the chyle, nervous symptoms, and sometimes pro- 
duce absorption of the bodies of the vertebrae ; the fibro-cartila- 
ges, etc., remaining for a longer time unmolested. 
The aorta gives oft’, in the space which we are examining, the 
intercostales, mediastinales posteriores, bronchiales, and oesopha- 
geae. None of these branches are so large as to merit of them- 
selves much attention; we should note, however, that the first 
anastomose with the internal mammary, and superior intercostal, 
which are derived from the subclavian, and with several branches 
from the axillary, so as to furnish a connected chain between it 
and the lumbar, epigastric, etc. arteries; a chain which seems to 
be capable of continuing the circulation in case the aorta should, 
be obliterated, as has been observed by Dr. Graham.* 
(b) The vena azyos, which receives directly almost all the in- 
tercostal veins of the right side, where it is disposed as the aorta 
is on the left, is also the rendezvous of the most of those of this last 
side, by means of the demi-azrjgos, which has crossed the spine 
transversely under the aorta and oesophagus. But at the mo- 
ment this vein turns over the right bronchus, it ceases to apper- 
tain to the posterior mediastinal space. The azygos is only of 
importance in surgery, inasmuch as it forms an union between the 
two venae cavae, and might thereby re-establish the venous circu- 
lation, if the calibre of one of these large vessels should be oblit- 
erated between their termination in the auricle and the points 
where they receive the extremities of the azygos. 
(c) The asophagus is covered by the trachea, in the same 
manner as in the neck, as far as the origin of the bronchi ; its 
posterior relations are similar also on the left; it is coasted by the 
* Med. Chir. Transactions, vol. 5. OF TH13 CHEST. 
423 
common carotid and sub-clavian arteries on the right; it is not 
very remote from the arteria innominata and superior cava; con- 
sequently this tube might be compressed by an aneurism of the 
arteries which originate from the arch of the aorta. As it con- 
tinues to descend it inclines slightly to the right, passes behind 
the trunk of the pulmonary artery, the origin of the aorta, the 
heart and the inclined portion of the diaphragm, having behind 
it and upon its sides the right intercostal arteries and the aorta, 
the left intercostal veins and the vena azygos, the thoracic duct, 
some lymphatic glands, and, in a more or less remote manner, 
the dorsal vertebrae. Beginning from the bronchi, it is also sur- 
rounded by the two nerves of the eight pair, which forms a spe- 
cies of plexus around it. Before it passes into the abdomen, it 
again inclines towards the left, and thus forms in the chest an 
elongated curvature, the convexity of which looks towards the 
right, whilst in the infra-hyoideal region, we observe an opposite 
disposition. This direction should be kept in mind, when we at- 
tempt to pass instruments from the mouth into the stomach. It is 
unnecessary to state that, if the oesophagus was the seat of tu- 
mours, it might compress the aorta and all the other canals 
which surround it, and that the nervous plexus, which covers it, 
sufficiently accounts for those dull and sometimes acute pains, 
which are experienced when aliments or any other substances 
are arrested in their progress through it. 
(d) The Thoracic duct, placed between the organs which we 
have just examined, behind the oesophagus, is at first on the right 
of the median line, which it approximates more and more in pro- 
portion as it ascends, and finally passes to the left towards the up- 
per part of the fourth dorsal vertebra. It is enveloped in an ex- 
tensible cellular tissue, adheres but slightly to the other organs, 
which may nevertheless compress it against the vertebral column 
when their dimensions are augmented in consequence of morbid 
alterations. Its diseases are as yet but little known ; M. Andral 
Jun., however, has met with it degenerated into a tuberculous 
matter, which also filled its cavity. In a subject dissected by Dr. 
Riley,in March 1825, at the ecole-pratique, we found it in a vari- 
ricose state, dilated in different places to the size of the little finger. 
(e) Th Glands are numerous here, and form a 
kind of chain; they are traversed by almost all the lymphatics 
of the abdomen, and receive those of the thoracic parietes, which 424 
OF THE CIIEST 
accompany the intercostal vessels; hence, they frequently be 
come swollen from scrofulous, and cancerous diseases, etc., 
which have their seat in the sides of the chest, or in the belly. 
From the anatomical relations we perceive, that, if they should 
become greatly enlarged, they will displace the heart, aorta, 
oesophagus, etc. or compress and flatten these organs; and 
thereby occasion serous infiltrations, indigestion, marasmus and 
difficult respiration. 
(f) The Cellular tissue is always abundant in this space; 
superiorly, it communicates with the deep cellular tissue of the 
neck; so that the pus which forms in the infra-hyoideal region 
may readily descend in the chest along the spine, without being 
extravasated into the pleurae. Inferiorly, this tissue forms a com- 
munication between the posterior mediastinal space and the ab- 
dominal cavity, by means of the apertures through which the 
oesophagus and aorta pass, and may thus conduct into the belly, 
behind the peritoneum, fluids which have been secreted into the 
posterior interval of the thoracic septum. It is in this manner 
that a great many abscesses by congestion* are formed. 
Anterior to these different parts the pleura are arranged in 
the following manner: they are completely joined at the fore 
part of the oesophagus, from the diaphragm to the base of the 
heart, below which they are equally in contact, but much nearer 
the vertebra; in fact they touch each other even behind the 
oesophagus, because the aorta and vena azygos do not exist be- 
tween them until they get on a level with the third dorsal ver- 
teba, opposite to the heart. These laminae separate much more, 
on the contrary, in order to envelope this organ, so that the spe- 
cies of triangular canal formed by the mediastinum posteriorly, 
is at first very narrow, but afterwards very broad, and contains 
a great abundance of cellular tissue behind the heart; that at 
length it includes entirely the aorta, oesophagus, etc. below the 
central organ of the circulation. After these two membranes have 
become more or less intimately joined anteriorly, they again 
diverge from each other and produce another space behind the 
sternum, which appertains to the anterior border of the medi- 
astinum, and which we find described by several authors under 
the name of anterior mediastinum. This space, the existence of 
* Jlbces par congestion, purulent collections which derive their origin from a 
remote point.—Transl. OF THE CHEST. 
425 
which has been denied by Bartholin, Ruysch, Winslow, and 
which Gavard says he never met with, was admitted by Hunter, 
Sense, Sabatier; and all anatomists of the present day are of 
the latter opinion. We must not, however, judge of its dimen- 
sions during life, from what we observe upon the dead body, 
after the sternum is removed. In fact, if for the purpose of ex- 
amining it, we remove all the ribs except the lirst and last, in 
order to maintain the sternum in place, we distinctly perceive 
that the right pleura is adherent very near the median line of 
the posterior face of the breast bone, and that the left, although 
much nearer the border of this bone below, does not, however, 
entirely abandon it. Be this as it may, the anterior splitting of 
the mediastinal septum, and the space thereby produced pass 
obliquely from right to left and from above downwards ; so that 
in order to penetrate into the thorax without perforating the 
pleurae, we should choose the median line above, and the left 
side of the sternum below; in cases, for example, in which the 
supple and abundant cellular tissue which fills this space is in- 
flamed to such a degree as to occasion an abscess, as Avenzoar 
states occurred in himself, we might, by recollecting this dispo- 
sition, perforate the sternum and give exit to the fluid, as advised 
by Columbus, and practised by Purmann and La Martiniere. 
The case related by Salius-Diversus proves that the inflamma- 
tion of the cellular tissue contained in this space, may occasion 
the death of the patient, notwithstanding it may have remained 
circumscribed in it; those by Carpi, Marchetti, Spigel, demon- 
strate that penetrating wounds in this situation, do not necessa- 
rily open the serous cavities; and, from what Freind says, we 
perceive that syphilitic affections may sometimes occasion pur- 
ulent collections here, which might be discharged by means of 
the trepan. 
Furthermore, this space represents pretty correctly two trian- 
gles joined by their apex before the anterior ventricle of the 
heart. In the first triangle, the base of which ascends almost to 
the supra-sternal notch, we find some lymphatic glands, much 
cellular tissue, the thymus in the infant, and the mammary ar- 
tery. When these parts are unusually developed, or when they 
become the seat of tumours of moderate volume, as they cannot 426 
OF THE CHEST. 
protrude externally through the sternum, they ascend in the 
neck, pass upon the trachea, and are sometimes mistaken for 
diseases of the thyroid gland; or they may project backwards 
and compress the arch of the aorta and the large branches which 
arise from it, the superior cava and subclavian veins. The sec- 
ond triangle is of greater length; its left side descends as low as 
the posterior surface of the eighth cartilage; it is filled with cel- 
lular tissue, lymphatic glands, and discovers the anterior surface 
of the pericardium. It is in consequence of this disposition that 
M. I advises opening this bag, by trepanning the left side 
and lower part of the sternum. By this operation, which was 
first proposed by Senac, we would avoid opening the pleurae; 
whereas Desault, Skeildrup and Romero, in their essays, could 
not reach the pericardium without transfixing the left thoracic se- 
rous membrane. 
Superiorly, the cellular tissue which fills the anterior medias- 
tinal space is continuous with that upon the fore part of the tra- 
chea, and with the sub-aponeurotic lamellae of the neck; inferi- 
orly, this tissue is prolonged between the peritoneum and abdom- 
inal muscles, in passing behind the cartilago ensiformis, through 
an aperture, of greater or less breadth, which separates the ante- 
rior digitations of the diaphragm. Hence it follows that tumours 
formed behind the sternal appendix may be prolonged almost to 
the neck by following this space ; that abscesses especially will 
easily descend from the infra-hyoideal region and make their ap- 
pearance in the epigastric region, etc., and that, on the other 
hand, the same diseases, primitively developed in the inferior 
triangle of this space, might be prolonged into the epigastric 
region. 
We must also recollect that the internal mammary artery 
runs along the borders of the sub-sternal mediastinal space 
throughout its whole extent, and that the lymphatic glands are 
principally met with in the track of this vessel. All the other 
organs which we perceive in the bottom of this separation, ap- 
pertain more especially to the septum itself. 
The inferior border of the mediastinum, resting upon the dia- 
phragm, presents, anteriorly, the broadest part of the sub-ster- 
nal space; in the middle, a separation, which is still more exten- OF THE CIIEST. 
427 
sive, for the lodgement of the pericardium; posteriorly, the 
pleurae are in contact upon the fore part of the oesophagus, and 
again separate to form the spinal space. 
At the summit, all the parts are confounded in the superior 
opening of the thorax; but the pleurae are very much separated. 
In the inferior half of the mediastinal septum we find the 
heart, pericardium, and inferior and superior venae cavae. The 
position of the heart is such that its apex strikes the fifth inter- 
costal space and the sixth rib on the left side, whilst on the right, 
it does not pass beyond the sternum: therefore penetrating 
wounds are much more dangerous in the first direction than in 
the second: hence, also, it is its right ventricle which is most 
exposed to the action of vulnerant bodies, unless they have been 
directed transversely; and it is the importance of the functions of 
this organ especially which renders its wounds so serious. Some 
facts, however, would lead us to believe that wounds which 
even penetrate into its cavities are not constantly fatal. The 
case related by Latour of Orleans, in which it is stated that a 
man lived six years after having been wounded in the chest by 
a ball, although on autopsic examination the foreign body was 
found in the cardiac septum, is one of the most inexplicable. In 
1818 we, in conjunction with M. Bretonneau, transfixed the 
heart of several dogs, with thick needles, and in several of these 
animals no disturbance followed. In 1822, we repeated this 
experiment in public, in the amphitheatre of the Ecole-pratique, 
upon a dog of middle size; we passed a needle six inches long 
through the heart, four different times, no inconvenience resulted, 
and the animal enjoyed good health six months after. 
A collier, fifty years of age, of intemperate habits, died at the 
hospital of la Faculte, in the beginning of the present year. In a 
quarrel nine years previous, a common table knife was thrust into 
the thorax of this man, through the left side. For several months 
it was expected that the wound would prove mortal; but the 
patient at length recovered, remaining subject to palpitations. 
On examining the body we found the pericardium opened oppo- 
site to the cicatrix in the thoracic parietes, and the heart itself 
presented a fibrous line which extended throughout the entire 
thickness of the right ventricle, in the place corresponding to 
the loss of substance in the pericardium. Professor Bougon, 428 
OP THE CHEST. 
shewed this specimen to the Royal Academy of Surgery, and 
Baron Larrey has obtained a drawing of it. 
The pericardium, divested of the serous laminae which cover it 
internally and externally, seems actually to be a continuation of 
the eordiform tendon of the diaphragm ; its tissue becomes less 
dense, less compact, where it approaches the principal arteries, 
upon which it is confounded with their external tunic; that is to 
say, that around the aorta and the trunks which originate from 
its arch, the superior cava and the bronchi, the pericardium is 
transformed into lamellae analogous to those which envelope the 
trachea, oesophagus and the large vessels of the neck ; or rather 
that the diverse deep sheaths of the infra-hyoideal region ap- 
proximate each other inferiorly, and unite upon the origin and 
termination of the large vessels which proceed from or enter the 
heart, in order to form the fibrous sheet of the pericardium, and 
in this manner become blended with the diaphragm, and even 
traverse it by being prolonged upon the vena cava, oesophagus 
and aorta. Hence it follows, as Dr. Godman has very satisfacto- 
rily demonstrated, that the pericardium is continuous, without in- 
terruption, with the aponeuroses of the neck, on the one hand, 
and on the other, with the fibrous layers of the abdomen, by 
means of the sheaths w hich cover the aorta, oesophagus, etc., and 
that pus, or inflammations may easily extend from one of these 
regions into the other. 
The inferior vena cava is here seen even in the cavity of the 
•pericardium, which it does not abandon until it traverses the dia- 
phragm. Free between the oesophagus, the heart and lungs, it is 
by this means protected, as it against every compression 
capable of completely obliterating its calibre ; but it may be dis- 
placed by the dilatation of the heart, in aneurisms, by the right 
lung when swollen and hepatized in pneumonia, and thereby 
curved in such a manner as to impede the venous circulation: 
whence doubtless arises the engorgement of the liver, so common 
in these diseases and in phthisis, etc. 
Above the heart, in the mediastinal septum, we find the sub- 
sternal curvature of the aorta, the convexity of which, turned 
forwards and to the left, is only separated from the first portion 
of the sternum by some cellular laminae; from which circum- 
stance, the aneurysmatic dilatation of this trunk often determines OF TIIE CHEST. 
429 
absorption or caries of the bone which covers it. On the left, 
the aorta is crossed by the phrenic nerve, par vagum and the re- 
current, which embraces its concavity in order to pass back into 
the infra-hyoideal region. As it occasionally happens that per- 
sons afflicted with aneurism of the arch of the aorta lose their 
voice, the old surgeons attributed this phenomenon to pressure 
on the inferior laryngeal nerves. It is true that this cause may 
sometimes contribute towards it; but it is also probable that this 
accident most frequently depends upon the compression of the 
bronchi or trachea, which are surrounded by the artery or placed 
behind it. Furthermore, when the aortic arch, while yet within 
the pericardium, is morbidly dilated, it will compress, anteriorly, 
the anterior portion of this membrane, the cellular tissue, lymph- 
atic glands, internal mammary vessels, and sternum ; exterior to 
the pericardium, the thymus in the infant, a greater abundance of 
cellular tissue, and the same parts as lower down ; posteriorly, 
the pulmonary artery, the termination of the trachea; more deep- 
ly, the oesophagus, thoracic duct, cellular tissue, lymphatic glands 
and the spine ; on the left, the bronchus, the pulmonary artery 
and the two pulmonary veins of this side, the par vagum and 
phrenic nerves, and the top of the lung; on the right, the pul- 
monary artery, superior vena cava, the same nerves as on the left, 
but in a less direct manner : consequently, these tumours would 
disturb respiration and suspend the voice ; would impair diges- 
tion by the compression of the nerves, and prevent deglutition by 
obliterating the oesophagus ; would obstruct the passage of the 
arterial blood into the lungs, and oppose the return of the venous 
blood from these organs into the left auricle ; would impede the 
venous circulation of the superior parts, by pressing upon the ve- 
na cava; derange the course of the chyle and lymph ; and lastly, 
occasion absorption or caries of the vertebrae and sternum. 
From these relations we may also explain, how it happens that 
the rupture of these aneurisms sometimes takes place into the left 
bronchus or trachea, and into the oesophagus. 
The pulmonary artery comes next to the aorta, which it turns 
upon from below upwards, from right to left, and from before 
backwards; it is still in the pericardium when it divides, and its 
two branches, in their course to the root of the lungs, circum- 
scribe an irregular rhomboid with the bronchi, the anterior sm> 430 
OF TIIE CHEST. 
face of which they cross, in order to place themselves between 
them and the pulmonary veins. That of the right side is the 
longest and largest; it is covered by the aorta, superior vena 
cava and the vena azygos. Poteriorly, it rests upon the right 
pulmonary veins ; a little higher, upon the oesophagus, then upon 
the corresponding bronchus; its anterior part is also crossed by 
the phrenic nerve, between the vena cava and the aorta ; by the 
cardiac ganglion and plexus, which separate it from the latter. 
The left pulmonary artery is shorter and smaller than the other; 
it rests, at first, upon the left auricle, and, in a remote manner, 
upon the thoracic aorta; it is next situated upon the fore part of 
the bronchus ; the lung conceals it before, and the aortic curva- 
ture turns over it, embracing the pulmonary root; on this side, 
the diaphragmatic nerve is more immediately applied to it than 
upon that of the right. From these relations it is evident, that, 
if the pulmonary arteries became aneurysmatic, they would 
react in a serious manner upon the aorta, vena cava and pulmo- 
nary veins, the bronchi, phrenic nerves, etc. 
The Pulmonary Veins are not of equal lengths: those of the 
left side, which are scarcely an inch in length, place themselves 
immediately before the primary divisions of the bronchi, run at 
first below7 the artery, but afterwards are situated upon its ante- 
rior surface, previous to penetrating into the lung; those of the 
right side are covered by the trunk of the pulmonary artery, the 
aorta, superior cava, and terminate in the same manner as on the 
left. 
The superior vena cava is, consequently, anterior to all these 
parts, and lies very near the sternum; the phrenic nerve is be- 
fore it, superiorly; but, in descending, passes to its outer side. 
The par vagum runs along its internal side, and remains more 
superficial than the trachea, as far as its bifurcation ; but then it 
dips deeper, and directs its course behind the pulmonary root. 
On the left, these two nerves pass upon the corresponding face 
of the aorta, and are thus situated upon a posterior plane; the 
phrenic nerve continues its route before the pulmonary vessels, 
and penetrates, as on the right, between the laminae of the peri- 
cardium ; so that, when the heart is greatly dilated, these cords 
may be put on the stretch, and occasion pains in the neck as well 
as other nervous phenomena. In addition to the pulmonary ves- OF THE CHEST. 
431 
sels and bronchi, which unite and intermingle in order to form the 
root of the respiratory organs, we also observe here a great num- 
ber of lymphatic glands, which, from their situation, are called 
bronchial. These glands receive all the lymphatics of the lung, 
and frequently become swollen and disorganized in phthisis, in 
scrofulous persons, during the measles, hooping cough, and seve- 
ral chronic inflammations of the middle membrane of the respi- 
ratory passages. In such cases, they may compress the pulmo- 
nary veins or arteries, the bronchial vessels, and greatly derange 
the process of sanguification; they will also frequently press 
upon the brom hi, and contract adhesions with them ; they will 
even perforate them, and if they suppurate, the fluid will be 
evacuated by these canals, as has been observed by M. Guersent. 
In a word, these organs are susceptible, in these cases, of giving 
rise to all the phenomena of compression which the dilatation of 
one of the principal arterial trunks ordinarily determines. 
As we advance near the summit of the chest, the mediastinum 
encloses, from right to left, and from before backwards, the su- 
perior vena cava, which has received the subclavian, the right 
internal mammary, etc.; the arteria innominata, before and on 
the outer side of which are seen the nerves of the lung and of 
the diaphragm ; lastly, the carotid and subclavian arteries of the 
left side. 
The arteria innominata or brachio-cephalic trunk, is here the 
most important organ ; it is about an inch and a half in length; 
it ascends, inclining slightly to the right, to a level with the 
sterno-clavicular articulation, wdiere it divides, opposite to the 
point which separates the two portions of the sterno-mastoid 
muscle. It is covered, from the deep parts towards the skin, by 
the par vagum and right cardiac nerves; by the termination of 
the internal jugular, subclavian and thyroid veins, and the supe- 
rior cava; by the origins of the sterno-thyroid and sterno-hyoid 
muscles; by the sternum, the head of the clavicle and the in- 
ternal tendon of the sterno-mastoid muscle ; besides, the dif- 
ferent veins and the artery are enveloped in this place by a very 
strong fibro-cellular lamina; posteriorly it is removed from the 
trachea by some lymphatics and cellular tissue; on the right, it 
is very close to the pleura; finally, this trunk is so disposed, in 
the healthy state, that in order to discover it, it would be neces- 432 
OF THE CI1EST. 
sary to depress the right shoulder firmly, at the same time tiiai 
the head is thrown backwards and to the left, as much as the 
position of the disease will permit; to divide the sternal tendon 
of the sterno-mastoid muscle; to separate some veins which 
descend behind this muscle; to cut across the sterno-hyoid and 
■sterno-thyroid muscles; to tear through a thick and strong 
fibrous plate; to depress the left subclavian vein, pushing back 
the jugular, par vagum and phrenic nerves toward the summit 
of the right lung, and lastly to pass a thread around the artery, 
by introducing the aneurismal needle from before backwards 
and from right to left, taking great care to avoid the right pleura 
and trachea. If we wished to discover the brachio-cephalic 
trunk by trepanning the sternum, as was mentioned in the an- 
terior region of the chest, we should seize the artery below the 
left subclavian vein; but it is important to remark that it is ne- 
cessary here to apply the ligature as high as possible, on account 
of the proximity of the aorta, which must render the formation of 
the clot in the root of the vessel which we wish to obliterate, 
less sure, if the thread is carried low down upon the artery. In 
whatever manner this operation may be performed, it is one of 
the most difficult and dangerous in surgery; upon the living sub- 
ject, there must be something dreadful in it, and it requires all 
the knowledge and all the bold dexterity of modern surgeons, in 
order to dare to undertake it; indeed, it would seem, a priori, 
almost rashness to think of it, especially because it would appear 
as if the circulation must immediately cease in the right superior 
extremity, which does not receive any other arteries than those 
which it derives from the innominata. But reasoning must be 
silent, since observation has spoken. Twice, in fact, has this 
operation been performed: once in New-York by Dr. Mott, and 
once in Germany, by Graefe.* Notwithstanding they were not 
attended with complete success, these essays at least prove that 
life will be preserved in the limb and the other parts to which 
the arteria innominata sends its branches, since, in the first case, 
the patient lived until the sixteenth day, and in the second, about 
* Wc have just been informed that the patient of M. Graefe survived four 
weeks, and that the operation would perhaps have been attended with complete 
success, if this dexterous surgeon had not removed too soon the snre-nceud which 
he is in the habit of employing and which he had applied upon the artery. OF THE CHEST. 
433 
thirty days: then the circulation must have been maintained by 
the inosculations of the arteries of one side with those of the 
other. 
As the brachio-cephalic trunk is supported by the sternum, it 
must, when diseased, readily compress the trachea and even the 
oesophagus, behind ; the cava and subclavian veins before; the 
par vagum on the right, and the carotid on the left. Aneurismal 
tumours may be prolonged into the infra-hyoideal region, and be 
mistaken for aneurisms of the common carotid artery. Burns 
has delineated in his work on the surgical anatomy of the necka 
remarkable example of this kind, and we can conceive how dan- 
gerous it would be to mistake such a case, if we determined to 
seek for the artery below the tumour. Anomalies of the arteria 
innominata are very rare; nevertheless, we possess some pretty 
remarkable specimens of them, and during the preceding winter, 
we met with, in the dissecting rooms of the Ecole-pratique, a va- 
riety in the position of this vessel, which would have rendered its 
ligature impossible: after its origin, the arteria innominata 
passed to the left, in order to turn over the trachea, then pene- 
trated between this organ and the oesophagus, and replaced itself 
on the right side at the moment of its bifurcation, but much more 
deeply than in the natural state. 
The relations of the left carotid, in the upper part of the me- 
diastinum, are the same as in the lower part of the neck; ante- 
riorly, it is covered by the thymus gland in the child, some lax 
cellular tissue and lymphatic glands in the adult, by the subclavian 
vein, the left sterno-thyroid and sterno-hyoid muscles ; lastty, by 
the sternum and sterno-clavicular articulation : posteriorly, it is 
removed from the vertebrae by the longus colli muscle, the pleura, 
and some cellular tissue; finally, on the left, the par vagum runs 
by the side of it, and the serous membrane separates it from the 
lung until near the first rib: it is, therefore, much deeper seated 
than the arteria innominata. 
The left subclavian artery ascends parallel to the preceding, 
from which it is separated by some cellular layers only; this 
branch lies so deep that it is almost in contact with the pleura in 
the summit of the thoracic cavity; so that its ligature, previous 
to its passage over the first rib, requires the greatest precautions 
relatively to the pleura. 434 
OF TI1E CHEST. 
Sect. 2. Of the Pectoral Cavities. 
The left cavity is narrower than the right, on account of the 
inclination of the mediastinum and the position of the heart; but 
it is more elongated, because the diaphragm does not ascend so 
high on the left as on the right. Each of these cavities possesses 
three parietes, one mediastinal, one diaphragmatic, and one 
costal; they are filled by the lungs, but in such a manner that 
these organs descend more or less, according to the side which 
we examine, and several other circumstances. Thus, on the 
right side, the liver, in the natural state, keeps the diaphragmatic 
and costal parietes applied to each other to a level with the tenth 
rib In forcible expirations, M. J. Cloquet has demonstrated that 
these two parietes might touch each other even as high as the 
sixth true rib; so that the lung would not then be wounded by a 
weapon which would penetrate through one of the first five in- 
tercostal spaces (counting from below upwards); whilst, during 
inspiration, as the respiratory organ introduces itself between 
the ribs and diaphragm as far as the attachments of this muscle, 
it would always be injured in penetrating wounds of the chest. 
In the first case, the instrument would traverse the pleura twice, 
then the diaphragm and peritoneum, before it would reach the 
spleen or stomach in the left side of the belly, and the liver in 
the right; in the second, the lung would be transfixed before the 
diaphragm is injured. Superiorly, in the summit of the thorax, 
the lung is separated from the supra-clavicular region merely bv 
some cellular tissue and the pleura; from the axilla, by the first 
riband the internal surface of the four following ones: there, the 
space is narrower and rounded, in a well-formed subject; it may 
be much more so, if the ribs are but little curved ; the respiratory 
organ then is, as it were, compressed between the upper part 
of the mediastinum, the vertebral column, and the costal paries. 
The pleura which lines this paries sometimes presents, in fat 
persons, a kind of adipose appendages, which we should be care- 
ful not to confound with the sequelae of previous inflammations. 
It is destined to favour the sliding of the lung, but sometimes be- 
comes more or less adherent to this organ; and in this case, the 
observations which we have just made, relative to the ascending OF THE CHEST. 
435 
and descending movements of the lungs, are no longer appli- 
cable. The mechanism of the formation of these adhesions, 
which is at present better understood than formerly, deserves 
much attention, especially in relation to effusions. In fact, the 
costal and visceral sheets of the serous membrane of the tho- 
rax {pleurcB pulmonalis et costalis) may, in consequence of pleu- 
ritis, unite throughout their whole extent, and thus obliterate the 
cavity which separates them ; but they may also be separated, to 
a certain extent, by the pus which has been secreted, whilst they 
are completely agglutinated throughout the remaining portions, 
and then the abscess will occupy either the inferior, superior, or 
posterior regions, or any other portion: wherefore, if we consid- 
ered the operation for empyema necessary, we must not refer to 
the gravitation of the liquid and the dependent position of the 
thorax, in order to make an opening into this cavity. 
The same thing may also happen, in consequence of pene- 
trating wounds; but if the extravasation takes place before in- 
flammation is developed and adhesions are formed, the fluid will 
generally collect in the sinuous cavities which separate the dia- 
phragm from the ribs, or in the deep gutter which exists by the 
side of the spine, if the patient is recumbent on the back; that 
is to say, that the matters will then yield to the laws of gravity. 
Therefore, when the extravasation is sanguineous, we frequently 
observe a kind of stain, or ecchymosis, at the lower part of the 
dorsal and costal regions ; a stain which Valentine considers as a 
diagnostic, but which is not always to be depended on. 
If, on the contrary, the collection does not form until several 
days after the wound has been inflicted, the latter will still con- 
tinue to correspond to the centre of the effusion; and, in this 
case, whenever pus fills the cavity, if the collection is small in 
quantity, or even when it is considerable, if it be sanguineous, we 
should take care how we make a counter-opening. Some mod- 
ern surgeons, at the head of whom we must place Baron Larrey, 
consider these adhesions of great importance. They think that 
they convert these depositions into simple abscesses, and that the 
surgeon should reduce his therapeutics to the use of those means 
which will be most likely to favor the absorption of the effused 
liquids, by opposing, as much as possible, the admission of the 436 
OF THE CHEST. 
external air into these cavities, because this gas would confer 
upon the extravasated fluids irritating qualities, whi; h would hin- 
der them from passing into the general circulation. 
When a wound penetrates into the pectoral cavity, and the 
lung is lacerated, if the division of the external parts is exactly 
parallel to that of the intercostal muscles, the air will escape out- 
wards, and it is this phenomenon which gave rise to the precept 
of placing a lighted candle before a wound of the chest, in order 
to ascertain if it is penetrating. If, on the contrary, the openings 
of the different wounded organs do not correspond, the gas will 
pass into the cellular tissue and emphysema will follow. This 
emphysema is itself a disease which may become very serious, 
as is proved by the observations of Mery, Cleghorn, Hunter, etc. 
It sometimes extends throughout the whole body, and may swell 
the subject to an enormous size ; which is owing to the commu- 
nication w hich exists between all the cellular layers. Littre and 
M. Larrey have each related a very extraordinary example of 
this kind. We also conceive that if the pleura and lung are lace- 
rated without the skin being divided, the emphysema will take 
place still more easily: hence, nothing is more common than this 
accident in fractures of the ribs, of which it constitutes one of the 
most certain signs ; finally, if the lung is lacerated, notwithstand- 
ing the thoracic parietes have not been wounded, there will be in 
it an aeriferous fistula and pneumo-thorax. 
The pleura costalis, when diseased, sometimes acquires a con- 
siderable thickness, and that, in two different ways: in one, a 
greater or less number of albuminous layers are deposited and 
organized upon its internal surface ; and this case appertains to 
pleurisies, properly so called, or depends upon a pulmonary affec- 
tion. It would be useful to recollect the possibility of such a 
disposition, if we perform the operation of paracentesis for a col- 
lection of pus, in order that we may penetrate more deeply so as 
to reach the cavity; in the other, which generally coincides w ith 
an external disease of the thorax, it is the sub-pleural cellular tis- 
sue which becomes thickened, and produces in certain patients a 
layer resembling bacon (une couche lardacee), of a line or more 
in thickness. Here, it is a species of barrier which nature op- 
poses to the progress of the disease, and upon which we should OF THE CHEST. 
437 
calculate when we are obliged to operate upon the exterior of the 
chest; a barrier which also repels the pus of deep seated abscess- 
es towards the skin, and prevents them from opening internally. 
There are numerous facts in support of these assertions. We 
will mention but one, however, which we witnessed at the hospi- 
tal of St. Louis in 1821. A man about thirty years of age had a 
large fistulous ulcer covered with vegetations, in the middle of 
the costal region, which had existed two years : one rib was ca- 
rious, and M. Richerand was obliged to remove two inches of its 
length. This celebrated surgeon was apprehensive of penetrating 
into the serous cavity; but the pleura formed a thick, hard and 
opaque wall, which permitted him to remove entirely the diseas- 
ed portion of bone, and this laborious operation was attended 
with complete success. It is well known that a similar disposi- 
tion existed in the subject from whom M. Richerand extirpated, 
by a bold operation, in 1818, several portions of the ribs together 
with a cancer. 
By way of recapitulation: vulnerant bodies can only reach the 
heart, by traversing the chest perpendicularly to its axis, above 
the sixth rib. If they pass through the fourth intercostal space, 
a little to the left, they will fall upon the base of the right ventri- 
cle, or upon the left auricle ; on the right, they would wound the 
ventricle or auricle of this side ; by the third space, they would 
reach the trunk of the aorta or of the pulmonary artery, and the 
superior vena cava on the right; by the second, they would di- 
vide the transverse portion of the arch of the aorta, or the prin- 
cipal branches which originate from it. If they should penetrate 
an inch and a half into the fifth space, at the union of the sternal 
and costal regions, they would strike the apex of the heart. If 
the instrument or weapon is directed from the costal region to- 
wards the median region posteriorly, it will hit against the bodies 
of the vertebra, and wound the great sympathetic nerve or tho- 
racic aorta. But it is proper to observe that these wounds are 
susceptible of pretty numerous variations, relatively to the sepa- 
ration of the ribs, which change the absolute length of the costal 
paries and of the pectoral cavity itself: thus, during a violent 
effort, all the intercostal spaces are enlarged ; it is the same in 
hydro-thorax. In pregnant women, dropsical individuals, new- 
born children, etc., we observe a contrary disposition, and the 438 
OF THE CHEST. 
internal organs must be affected in different points, notwithstand- 
ing those of the exterior are divided in the same manner. Dis- 
eases also occasion changes in the relative position of the organs, 
changes which affect the locality of the injured parts ; so also do 
they occasion variations in the form of the chest and in the move- 
ments of the ribs; in hydro-thorax, for example, or any other 
effusion into one side only, if it is carried to a great extent, this 
side appears longer, more prominent and bulging than the other: 
when this effusion disappears, if the patient recovers, as the lung 
has been for a long time compressed by the fluid, it w ill not re- 
sume its natural volume, whence it follows that the thoracic paries 
goes, if I may so express myself, before it, and the chest thereby 
becomes contracted on the diseased side. M. Laennec has very 
satisfactorily explained the mechanism of this phenomenon, which 
then persists during life. 
When acute pleurisy exists, whether there is effusion or not, 
as the pain prevents the contraction of the muscles, it follows 
that the ribs remain immoveable in the direction corresponding to 
the diseased pleura, and that the movements of expiration and 
inspiration are increased on the opposite side. If the lung be- 
comes hepatized, if there is peripneumonia with or without costal 
pleurisy, the same thing may equally happen ; and besides, the 
respiratory organ actually increases in volume and density, in con- 
sequence of the accumulation of fluids within it. In this case, 
the cavity which encloses it is, if 1 may so say, too small to con- 
tain it; and, as the ribs resist more than the soft parts which sep- 
arate them, they apply themselves upon the external surface of 
the inflamed lung, producing as many grooves, more or less dis- 
tinct, upon this organ. This last peculiarity, which was first 
pointed out by M. Broussais, and which is regarded by M. Laen- 
nec as a very difficult, if not impossible occurrence,* has pre- 
sented itself twice to our observation. 
The walls of the thorax are far from having the same thickness 
m all their points, in all ages or in all individuals: in children 
they are comparatively thin, on account of the absence of fat 
and the small size of the muscles; hence it follows that in early 
life they are much more sonorous than after puberty, and that if 
* Auscultation mediate, etc., tome ler, page 163. OF TIIE CHEST. 
439 
we resorted to the method of Avenbrugger for exploring the 
chest, that is to say to percussion alone in order to establish the 
diagnosis of its diseases, we will often believe that the lungs are 
still permeable to the air, though their hepatization be complete; 
but it is easy to rectify this error by means of the stethoscope. 
In the sternal region, the walls are thin upon the median line, 
where the sternum is only covered by the skin; they are also 
thin upon the sides, in its inferior half, where the cartilages are 
only separated from the integuments by the rectus abdominis 
muscles; but, in general, very thick laterally in the superior half, 
on account of the mamma and pectoralis major muscle. 
In the posterior region, they are extremely thick upon the 
median line, and even as far as the angle of the ribs, on account 
of the spinal column and the muscular masses which fill the ver- 
tebral gutters. Externally and superiorly, the shoulder renders 
them still thicker than elsewhere; but below the axilla, and 
throughout the costal region, they are as thin as in the inferior 
part of the sternal region. 
These data, important relatively to wounds of the thorax, are so 
likewise when we wish to employ percussion or apply the steth- 
oscope to this cavity; then we should also recollect the exact 
relations which the contained viscera bear to the different re- 
gions of the surface. Thus, notwithstanding the spongy texture 
of the sternum, and the slight thickness of the soft parts, below the 
breast, in the sternal region, the chest is not very sonorous in 
these places, at least on the left, because these points correspond 
to the heart and principal vascular trunks. Auscultation there- 
fore must here supercede percussion, in the examination of the 
affections of the central organs of the circulation. The clavicle, 
being never covered by very thick soft parts, and correspond- 
ing to the summit of the lungs, is one of the points which pre- 
sent the greatest advantages for percussion, which we apply 
in a much less certain manner to the anterior thoracic portion of 
the axillary region, especially in women and fat persons, on ac- 
count of the mammae. But this last situation may be perfectly 
explored by means of the cylinder, which equally gives more 
certain results, when placed upon the fossa supra-spinata, than the 
method of the celebrated German physician. In the posterior 
region, upon the lateral convexities, as the angles of the ribs are 440 
OF THE CHEST. 
only covered by thin muscles, and as these prominences corres- 
pond internally to the most spongy portion of the respiratory 
organs, we derive nearly the same advantages from percussion 
and auscultation: the same might be said in relation to the sides, 
if, on the right, the liver did not considerably diminish the sono- 
rousness of the thorax, in the inferior part of the costal region ; 
whilst on the left, the stomach, pushing up the diaphragm more 
or less, enables us generally to derive from percussion a very 
clear sound: which circumstances might induce 11s to believe, 
in the first direction, that the lung is impermeable, although it 
may be sound, and in the second, that this organ is in the natu- 
ral state, when, on the contrary, it is more or less disorganized. 
In such cases we must also have recourse to the stethoscope, in 
order to avoid error, and this instrument may be easily applied 
to all the points of the costal region, even as high as the third 
intercostal space, if we take the precaution to elevate the arm. 
Sect. 3. Base of the Thorax. 
This part, which we might call the diaphragmatic region or 
wall of the chest, is the most moveable and most variable in the 
normal state. Formed entirely by the superior surface of the 
diaphragm, it is greatly elevated during expiration, and more or 
less depressed when the lungs are distended with air. In the 
first case, the muscle represents two rounded eminences, which 
ascend in the thoracic cavities, a little higher on the right side 
than on the left, and sometimes to the seventh or sixth rib. In 
this state, those physiologists who think that the lungs dilate and 
contract in a passive manner, suppose that the diaphragm is in 
contraction, and that it is this muscle w hich expels the air. But it 
is evident that the effect is here taken for the cause, and that this 
fleshy membrane merely follows the lungs, in proportion as the 
gazeous fluid escapes from them by their proper action. 
In the second, it actually contracts, although it may also sink 
mechanically; its fibres straighten themselves; it pushes the 
abdominal viscera downwards, forwards, and slightly towards the 
right, because it is inclined in such manner as to look a little in 
this direction: it is even to this slight inclination of the dia- 
phragm that we may attribute the greater frequency of hernia1 OP TIIE CHEST. 
441 
on the right side. It is especially when we make any great ex- 
ertion that it contracts in a decided manner; then it draws upon 
the ribs to which it is attached, tends to diminish the circle 
which they form, and maintains them more or less solidly fixed; 
so that all the other muscles of the body may here find a solid 
point, either by their direct attachments, or by their actions be- 
ing conveyed to it through the medium of some other muscles. 
On the other hand, the epiglottis hermetically seals the larynx, 
in order that the lungs, distended with air, may exactly fill the 
cavity of the chest, and keep its walls suitably separated.* 
This region presents three portions, which should be distinguished 
in relation to their functions: we find in the first place, the two 
lateral portions, completely lined by the pleura,naturally more con- 
vex on the right than on the left, inclined backwards and upon the 
sides, and which correspond to the muscular portion properly so 
called: it is to these two portions that we must refer what has 
just been said respecting the actions of the diaphragm ; they con- 
stitute the internal wall of the sinuous prolongation of each cav- 
ity of the thorax, the vertical diameter of which they alternately 
elongate and diminish. Their disposition, moreover, is such, that 
this axis or diameter is shorter anteriorly than posteriorly and 
laterally. 
The middle portion corresponds to the central aponeurosis, and 
supports the heart; it is enclosed in the mediastinum, and pre- 
sents anteriorly, behind the xiphoid cartilage, the cellular com- 
munication which exists between the abdomen and thorax; 
more posteriorly, the two pleurae, which are very close, but not 
completely applied to each other. Next comes the great cir- 
cular portion, entirely fibrous, from the circumference of which 
the pericardium seems to originate, and which is perforated on 
the right by an irregularly square foramen, through which the 
inferior vena cava passes ; so that this vessel cannot be compres- 
sed in any manner by the contractions of the diaphragm; more 
posteriorly still, the pleurae again approximate, and are even in 
contact upon the fore part of the oesophagus, which is consid- 
erably inclined to the left; finally, we find in the diaphragmatic 
* M. Isidore Bourdon. Memoire cite. 442 
OP THE CHEST. 
extremity of the posterior separation of the mediastinal septum, 
a hiatus for the transmission of the aorta, through which the 
thoracic duct also passes, in the same way that the nervi vagi 
penetrate into the belly by the oesophageal aperture; the great 
and lesser splanchnic nerves, which result from the union of six 
or seven filaments derived from the last corresponding ganglions 
of the great sympathetic. This portion of the diaphragmatic 
wall is almost immoveable when the lateral parts are elevated 
or depressed ; and we conceive that, if it had been otherwise, the 
action of the heart would have been disturbed at every instant. 
It is almost plane, being but slightly inclined from before back- 
wards and from above downwrards: whence it follows that the 
posterior mediastinal space is longer than the anterior. 
Sect. 4. Summit of the Thorax. 
It comprises the superior opening of the chest and the numer- 
ous organs which traverse it. The osseous circle has the form 
of an ellipse, the posterior part of which seems as if it had been 
forcibly pushed towards the anterior. It is constituted, ante- 
riorly, by the supra sternal notch, which is rendered much deeper 
by the prominence which the clavicles form upon the sides; 
posteriorly, by the body of the first dorsal and of the seventh 
cervical vertebrae; externally, by the concave margin of the 
first rib We may observe that this opening is neither upon an 
even nor horizontal plane. Its anterior notch makes it appear 
more or less elevated posteriorly ; so that several organs deeply 
situated in this direction are already in the thorax, whilst, more 
superficially, they would still be in the infra-hyoideal region. 
On the outer side of the median line, the sterno-clavicular ar- 
ticulation gives to it a greater elevation, and thus affords greater 
protection to the important organs which are situated behind it. 
Upon the sides, it is again depressed, on account of the inclina- 
tion outwards of the superior aspect of the ribs. 
Let us nowr examine the order of superposition of the organs, 
and their relative dispositions in the summit of the chest: by 
comprising in it the constituent parts, we find;—1st the skin; 
2d, the sub-cutaneous cellular and fibrous layer; 3d, the top of OP THE CHEST. 
443 
the sternum, the origin of the sterno-mastoid muscle, the inter- 
clavicular ligament, the sterno-clavicular articulation, the costo- 
clavicular ligament, the cartilage of the first rib, and the termin- 
ation of the two laminae of the fascia cervicalis: this plane is 
completed posteriorly by the origin of the sterno-hyoid and ster- 
no-thyroid muscles, which descend as far as on a level with the 
first intercostal space, behind the sternal notch and the articula- 
tion ; 4th, a thin, but pretty dense cellular layer; upon the same 
plane, on the left, the subclavian vien and the terminations of 
the internal and external jugulars ; in the middle, the subclavian 
vein still, the termination of the thyroideal veins, the thymus ; on 
the right, the junction of the left and right subclavian veins, and of 
the internal and external jugulars, in order to form the superior 
vena cava; 5th, a very compact fibro-cellular layer, which sepa- 
rates the veins from the arteries; behind this layer, and from right 
to left, the termination of the arteria innominata, the origin of the 
common carotid and subclavian arteries, very close to the bones; 
the internal mammary, which runs towards the posterior surface 
of the sternum, accompanied by its two veins ; the thyroid ar- 
tery of Neubauer, when it exists; the vertebral, when it ori- 
ginates from the aorta; the left carotid; more deeply, the sub - 
clavian, giving off the internal mammary of this side ; the par- 
vagum and phrenic nerves placed, on the right, before and a lit- 
tle to the outer side of the arteria innominata; on the left, be- 
fore, and somewhat remote from the subclavian artery ; 6th, the 
body of the trachea, enveloped in a dense and compact fibro- 
cellular tissue ; externally, some lymphatic glands, the recurrent 
nerves ; 7th, the oesophagus, in the middle, and slightly passing 
beyond the trachea on the left; externally, numerous filaments 
of the great sympathetic nerve; the origins of the vertebral, 
superior intercostal and transverse cervical arteries; their col- 
lateral veins ; 8th, the longus colli and scalenus anticus muscles, 
which leave between them a triangular space with its base 
downwards, in which we see the vertebral artery and vein, a 
nervous plexus derived from the great sympathetic, and this 
nerve itself; under the head of the rib, the inferior cervical gan- 
glion ; 9th, lastly, the bodies of the vertebrae, less prominent, 
but of rather greater transverse extent than in the chest prop- 444 
OF THE CHEST. 
erly speaking; the first costovertebral articulation; sometimes 
a costiforme prolongation, which surmounts the transverse pro- 
cess of the seventh vertebra of the neck; the first rib and the 
anterior branch of the first dorsal nerve, which goes to unite 
with the last of the cervical region. 
From this simple enumeration, it is easy to foresee the danger 
arising from wounds penetrating into the summit of the chest, 
and how it is that fluids extravasated or accumulated in the mid- 
dle and lateral regions of the neck, may extend behind the ster- 
num, before the spine, or follow the vessels, and diffuse them- 
selves in the anterior and posterior mediastinal spaces without 
penetrating into the cavities of the pleurae. We can also con- 
ceive the symptoms which may arise from the exostoses occa- 
sionally produced by syphilis upon the fore part of the vertebrae, 
and which still more frequently grow from the clavicle and even 
the sternum; from luxations of the clavicle backwards, when 
they exist; in short, from tumours of any kind, by the prssurc 
which they would exercise upon the trachea, oesophagus, veins, 
arteries or nerves. 
If we now take up the consideration of the order of superposi- 
tion of the parts in another point, we will find some differences, 
with which the surgeon should be well acquainted. Immedi- 
ately above the heart, for example, which corresponds to the first 
two intercostal spaces and the upper piece of the sternum, we 
find, 1st, the skin; k2d, the cellulo-adipose layer, a fibro-cellulous 
lamina, the pectoralis major muscle ; ,3d, the sternum, the car- 
tilages, the intercostal muscles, including the external branches 
of the internal mammary artery; the trunk of this artery 
coasted by two veins, and enveloped by a cellular layer which 
separates it from the pleura; 4th, in the middle, the superior 
triangle of the anterior separation of the mediastinum, filled by 
cellular tissue, lymphatic glands and fat; the pleura upon the 
sides; 5th, a prolongation of the pericardium, and of the thy- 
mus in children; 6th the superior vena cava and the azygos, 
which turn over the right bronchus ; the trunk of the aorta and 
its transverse arch; the origins of the arteria innominata, left 
carotid and left subclavian arteries; the pulmonary artery, at 
first before the aorta, afterwards behind it and to the right; its OF THE CIIEST. 
445 
two branches and the remains of the ductus arteriosus, which 
unites the left pulmonary artery to the aorta, below the curva- 
ture of the latter; the phrenic nerve, upon the aorta on the left, 
the vena cava on the right, and upon the fore part of the root of 
the lungs, on both sides; the nerves of the eighth pair, disposed 
like the phrenic, except that they pass behind the pulmonary 
roots ; the cardiac ganglion, placed between the transverse arch 
of the aorta and the pulmonary arteries; the nerves which this 
ganglion receives and the plexus which depart from it; some 
fibro-cellular tissue, continuous with the pericardium and the 
vascular sheaths of the neck; 7th, the auricles and pulmonary- 
veins ; the termination of the trachea and the commencement of 
the bronchi; next, the root of the respiratory organs, which is 
composed from before backwards and from below upwards, of the 
phrenic nerve, the veins, the arteries, the first division of the bron- 
chi, the plexus of the par vagum ; 8th, the bronchial vessels, the 
cesophagus, thoracic duct, the vena azygos before it rises upon 
the right bronchus; the commencement of the thoracic aorta, 
after it has turned over the left bronchus; 9th, the intercostal 
arteries and veins, the venae azygos and demi-azygos; the great 
sympathetic nerve ; 10th, and lastly, the vertebral column, cov- 
ered by the origin of the longus colli muscle, and the ligamen- 
tous parts. 
Still lower these relations are less complex. Behind the ster- 
num, we see : 1st, the inferior triangle of the sub-sternal separa- 
tion of the mediastinum, an abundance of cellular tissue ; 2d, the 
pericardium, formed of two laminae in the middle, and of three 
at the sides, on account of the pleura which is applied to it; 3d, 
a space which separates the heart from its envelope; 4th, the 
apex of the heart, its right ventricle, the auricles: the right more 
anteriorly, the left more posteriorly; 5th, the left ventricle, the 
posterior part of the auricles, the termination of the pulmonary 
veins and inferior cava; 6th, another space, which separates the 
heart from the pericardium behind ; 7th, the pericardium, dispo- 
sed as anteriorly; 8th, the approximated pleurae; 9th, the oeso- 
phagus and nervi vagi; 10th, the aorta, &c. 
When the viscera of the thorax are removed, its cavity presents 
four portions or regions. The anterior is inclined forwards, or ra- 446 
OF THE CHEST. 
ther it forms a curve, the concavity of which looks backwards and 
downwards: at puberty it elongates more than either of the others; 
which is owing to the rapid developement of the sternum at this 
epoch. The posterior wall is much longer, and proportionally still 
more so in infancy than in the adult, because the vertebral column 
which forms it is already very long at birth, whilst the sternum, 
on the contrary, is very short: whence it follows that the abdo- 
men then seems to have considerable dimensions anteriorly, 
whilst posteriorly the relations of this cavity with the chest are 
nearly the same that they always are. This wall is concave be- 
fore, and not simply inclined backwards. As it is formed, 1st, 
by the bodies of the dorsal vertebrae upon the median line, it 
there represents a sort of rounded crista, which actually consti- 
tutes the posterior part of the mediastinal septum ; 2d, by the 
angular portion of the ribs upon the sides, where there are two 
deep gutters in which the lungs principally are lodged : But these 
peculiarities are more striking towards the adult period, and in 
well-formed subjects. In very young children, in fact, the bod- 
ies of the vertebrae seem to be thrown backwards, because the 
angle of the ribs is not yet developed. Sometimes this disposi- 
tion persists after puberty, in which case the lungs, less free, are 
impeded in their motions, and more disposed to chronic diseases. 
The chest appears narrow in these persons; the shoulders pro- 
ject backwards and the sternum forwards; so that the central 
organs of the circulation move more freely, on account of the 
enlargement of the antero-posterior diameters of the thoracic 
cavity. 
The lateral wall is the longest; posteriorly, it is concave trans- 
versely, and in a regular manner also, from above downwards, in 
many subjects, among others in those females who are in a habit 
of wearing tight corsets. 
In consequence of the difference in the curvature and length 
of the thoracic parietes, the base and summit of this cavity are 
inclined in opposite directions, that is to say, that the superior 
aperture is depressed, whereas the inferior is raised, in the same 
manner as the two straits of the pelvis ; so that a line, dropped 
perpendicularly in the centre of the former, would fall upon the 
base of the dorsal column, and that, if this line was let fall from OF THE CHEST. 
447 
the centre of the second, it would strike upon the body of the 
first vertebrae of the back. It also follows that the vertical axis 
of the chest is oblique from above downwards, from behind for- 
wards, and even from left to right, on account of the lateral cur- 
vature in the middle of the dorsal column. With respect to the 
transverse dimensions, they increase in a prompt and gradual 
manner as far as the seventh rib ; in descending afterwards, they 
also enlarge, but slightly; in some persons they remain the same 
as they were higher up ; and in others, they are diminished in a 
very striking manner. 
END OF THE FIRST VOLUME. 449 
EXPLANATION OF THE PLATES. 
VOL. I. 
PLATE I. 
Figure 1, Representing the Anterior Regions. 
1 1 Frontal Regions, viewed in front, separated from each other 
by the median line. 
2 2 Parietal, 
5 5 5 Orbitary, 
4 4 4 4 4 Parotideal, 
6 6 6 Masseteric, 
7 7 Nasal, 
8 8 8 Zygomato-Maxillary, 
9 9 9 Genial, 
37 37 Labial, 
38 38 Mental, 
10 10 10 Supra-Hyoidal, 
11 11 Infra-Hyoidal, 
12 12 Supra-Clavicular, 
40 40 Sub-Clavicular, 
41 41 Anterior Brachial, 
42 42 Regions of the Fold of the Arm. 
43 43 Anterior Anti-Brachial Regions. 
44 44 Anterior Regions of the Wrist. 
45 Palmar Region of the Hand. 
2121 Sternal Region. 
23 23 Epigastric. 
24 24 Umbilical. 
25 25 Hypogastric, 
39 39 Pubic, 
46 46 Inguinal Regions, 
28 28 Anterior Crural, 
29 29 29 Regions of the Knee. 
47 47 Anterior Regions of the Legs. 
31 31 31 External Tibial Regions. 
48 48 Internal Malleolar. 450 
EXPLANATION OF T11E PLATES. 
Fig. 3, Representing the Posterior Regions. 
3 3 Occipital Regions. 
13 13 13 Posterior Region of the Neck. In order to study this region, 
the reader should make an abstraction of the perpendicular 
line which divides this region into two. 
14 14 14 Posterior Region of the Shoulder. 
15 15 15 15 Posterior Brachial Regions. 
16 16 16 16 Region of the Elbow. 
17 17 17 17 Posterior Anti-Brachial Regions. 
18 18 18 18 Po terior Regions of the Wrist. 
19 19 19 19 Dorsal Regions of the Hand. 
35 Dorsal Region of the Thorax. 
36 Lumbar Region. 
20 20 20 20 20 Costal Regions and Hypochondria^ 
22 22 22 22 22 Regions of the Flanks. 
26 26 26 26 Gluteal Regions. 
27 27 27 Posterior Crural Regions. 
30 30 30 Popliteal Regions. 
32 32 32 Posterior Regions of the Leg. 
33 33 33 33 33 External Malleolar Regions.t 
34 34 34 34 34 Dorsal Regions of the Foot. 
Fig. 2. The same numbers indicate the same regions viewed laterally 
PLATE II. 
This Figure represents a vertical section of the head and of the anterior wall of the 
larynx, but in such a manner that the latter is reflected upon the right side, so as to 
present itself in front. 
1 Portion of the Cranial Cavity. 
2 Fossa Cerebelli of the Cranium, lined by the dura mater. 
3 Portion of the Tentorium Cerebelli, raised by a hook. 
4 Prolongation of the medulla in the spinal canal. 
5 Sphenoidal Sinus, in which we see the extremity of a stylet, 
and which communicates in the superior meatus of the 
nasal fossae. 
6 Frontal Sinus, equally containing a stylet, and opening inte 
the middle meatus. 
7 Superior Cornet, x 
8 Middle or Ethmoidal do. s (Turbinated bones) 
9 Maxillary or inferior do. 5 
10 Superior meatus, leading into the sphenoidal sinus 
11 Middle meatus, broader anteriorly, narrower posteriorly, 
where it no longer forms but a gutter, which conducts into 
the upper part of the pharynx, above the Eustachian 
trumpet. It is in this meatus that the orifices of the frontal 
and maxillary sinuses are observed, each traversed by a 
stylet. EXPLANATION OF THE PLATES. 
451 
12 Inferior meatus. 
13 Stylet introduced into the sinus of the sphenoid. 
14 Another stylet which has passed through the entire length of 
the external wall of the inferior meatus, in order to place 
itself in the guttural canal of the ear. 
15 Third stylet, engaged in the antrum of Hygmore: we 
may perceive that the opening of this sinus seems to be 
situated in a species of excavation, and more approximated 
to the middle than to the inferior cornet. 
16 Fourth stylet which ascends into the frontal sinus by the 
middle meatus. 
17 The fifth, engaged in the nasal canal, under the anterior 
part of the maxillary cornet, where is observed a kind of 
infundibuliform depression. 
These last four stylets are enclosed in the left aperture of 
the nose, the lobule of which is preserved, as well as the 
pedicle which fixes it to the nasal spine. 
18 Stylet introduced into the Parotid duct by its buccal orifice, 
opposite to the interval which separates the third from the 
fourth molar tooth. 
19 Interior of the pharynx, which curves upwards and forwards, 
in order to continue itself with the nasal fossae: its right 
half is reflected backwards and downwards, in order to 
show the posterior wall. 
20 Pharyngeal orifice of the Eustachian trumpet. 
21 Left half of the uvula, drawn downwards and forwards by 
a hook, in order to render the pillars of the velum palati 
tense. 
22 The Tonsil. 
23 Posterior or pharyngeal pillar of the velum palati. 
24 Lingual or anterior pillar. 
25 Vertical section of the palatine vault. 
26 Left portion of the palatine cavity. 
27 Internal wall of the left cheek, presenting, posteriorly, the 
anterior border and a portion of the internal face of the 
eoronoid apophysis of the lower jaw, enveloped by the 
mucous membrane. 
28 Left half of the dorsum of the tongue, slightly drawn for- 
wards and inclined to the right. 
29 Perpendicular section of the inferior maxillary bone and of 
the parts which compose the supra-hyoidal region upon 
the median line: this section prolongs itself upwards with 
that of the tongue, and downwards with that of the an- 
terior part of the larynx, the right half of which is drawn 
backwards. 
30 Inferior part of the pharyngeal cavity, at the moment when 
it passes behind the arythenoid cartilages, in order to 
continue itself with the oesophagus. 
3131 Great Cornua of the thyroid cartilage. 452 
EXPLANATION OF THE PLATES. 
32 32 Ventricles of the larynx, circumscribed by the inferior and 
superior cordae vocales. 
33 Interior of the Laryngeal cavity. 
34 34 Hooks which keep separate the two halves of the larynx, in 
order to show the internal surface. 
35 Inferior portion of the neck. 
PLATE III. 
This figure represents the fore part of the neck, separated from the head and the tho- 
rax : it is relative to the details of the infrarhyoidal region. 
1 l Reflected flap of the subcutaneous layer, continuous by its 
base with the similar layer of the supra-hyoidal region. 
2 2 Another portion of the teguments, likewise reflected. 
3 3 3 3 Superior and lateral parts of the neck, and the commence- 
ment of the head, in the natural state. 
4 Left Sterno-mastoid Muscle, reflected outwards by (5) a hook, 
in order to expose the organs which it covers. 
6 Right Sterno-mastoid Muscle, in its natural position, or 
slightly drawn outwards. 
7 Sterno-hyoid Muscle. 
8 Sterno-thyroid Muscle. 
9 Omo-hyoid Muscle. 
10 Internal Jugular Vein. 
11 Common Carotid Artery. 
12 External Carotid Artery. 
13 Internal Carotid Artery. 
14 External Jugular Vein, or rather, anterior jugular vein in- 
osculating with the internal jugular vein towards the mid- 
dle of its length, and following the internal margin of the 
sterno-mastoid muscle. 
15 Descending branch of the hypoglossal nerve (descender 
noni), a little nearer the median line than usual, in this 
subject. 
16 Pneumo-gastric nerve (par vagum), which communicated 
here with the ramus descendens noni, and of which one 
branch passed transversely between the primitive carotid 
artery and the omo-hyoideus muscle. 
17 Inferior Thyroid Veins. 
18 Superior Thyroid Arteries. 
19 Crico-thyroid branch, furnished by the preceding artery. 
20 Another branch of the superior thyroid, and which pene- 
trates into the thyroid gland, by passing upon the ante- 
rior face of the cricoid cartilage. 
21 Thyroid Cartilage. 
22 Crico-thyroid membrane. 
23 Cricoid Cartilage, covered by its two small muscles. 
24 Thyroid Gland slightly developed. EXPLANATION OF TIIE PLATES 
453 
25 Trachea-Arteria. 
26 Anterior Jugular Vein, enclosed by the laminae of the deep 
sheet of the cervical aponeurosis, which conceals on this 
side the sterno-hyoid and sterno-thyroid muscles, and 
which passes behind the sterno-mastoid. 
7 9 4 14 Omo-tracheal triangle, limited above by the scapulo-hyoid 
muscle; below by the sterno-mastoid; internally, by the 
sterno-hyoid and the trachea-arteria, and in which we 
may tie the primitive carotid artery. 
4 9 18 Omo-hyoid triangle, circumscribed by the sterno-mastoid 
externally; by the omo-hyoideus internally; by the os 
hyoides superiorly, and in which we may easily apply a 
ligature upon the common, internal, and external carotid 
arteries, and the superior thyroid. 
PLATE IV. 
In order that the objects represented in this figure may be fully comprehended, it is neces- 
sary to remark, that the shoulder is firmly depressed, in order to place in view the sub- 
clavian vessels, and that all the parts are in the position which is given them, when 
about to practise the ligature of the subclavian artery. 
1 1 Occiput thrown a little backwards. 
2 2 2 2 Flaps of skin lined by its subcutaneous layer, raised behind 
the ear, and turned down upon the lore part of the chest. 
3 Lobule and part of the pavilion of the ear. 
4 4 4 Perpendicular section of the skin upon the posterior limits 
of the region. 
5 5 Section of the clavicular portion of the trapezius muscle. 
6 Commencement of the shoulder. 
7 7 7 7 Sterno-Mastoid Muscle, showing between its two roots a 
small excavation which corresponds to the brachio-cepha- 
lic trunk. 
8 Flap of adipo-eellular tissue, preserved upon the external 
face of the preceding muscle, and traversed by the two 
nervous branches of the cervical plexus, which go to the 
fore part of the neck. 
9 10 Splenius Cervicis and Lev. Ang. Scapulas muscles. 
11 11 Scalenus posticus muscle, formed of two bundles. 
12 Scalenus anticus muscle. 
13 13 Omo-hyoideus muscle. 
14 Subclavian Artery on the outer side of the scalenus anticus. 
15 Termination of the internal jugular vein. 
16 Termination of the subclavian vein. 
17 External jugular vein, reflected and drawn down with the 
integuments. 
18 18 Acromio-clavicular, or principal vein of the shoulder. 
19 Small anormal muscle, forming an arch, fixed by its two ex- 
tremities to the clavicle. 454 
EXPLANATION OF THE PLATES. 
20 Ascending cervical artery. 
21 Internal mammary artery. 
22 22 Posterior scapulary artery. 
23 23 23 Nerves of the Brachial Plexus. 
24 Supra-clavicular branch of the cervical plexus. 
25 Phrenic Nerve. 
26 Spinal Nerve, confounded with a branch of the cervical 
plexus. 
27 27 27 Sub-mental branches of the cervical plexus. 
28 Sub-mastoid Nerve, or posterior auncular of the cervical 
plexus. 
29 Spinal Nerve, which passes behind the sterno-mastoid, in- 
stead of traversing it. 
30 Portion of the grooved director (sonde cannelSe), which raises 
the subclavian artery, 14, on the outer side of the scalenus 
anticus, upon the first rib, depressing the supra-clavicular 
nerves. 
31 Sonde Cannelte, introduced under the same artery, between 
the origin of the internal mammary, vertebral and ascend- 
ing cervical branches, on the one part, and the internal bor- 
der of the scalenus anticus, on the other. 
32 The same instrument, passed under the common trunk of 
the thyroid and ascending cervical arteries, and also rais- 
ing the phrenic nerve. 
2 13 13 19 7 Omo-clavicidar Triangle, limited by the omo-hyoideus and 
sterno-mastoid muscles, and the clavicle. 
4 4 4 7 7 27 27 13 13 Omo-trapezien Triangle, circumscribed by the sterno-mastoid, 
trapezius, and omo-hyoideus muscles. 
22 Omo-davicxdar Triangle, divided into two portions by the 
scalenus anticus muscle. 
PLATE V. 
In this figure the arm is slightly removed from the trunk; the skin, the subcutaneous lay- 
er, the celhdar tissue and the lymphatic glands are removed. 
1 Portion of the internal face of the arm. 
2 Hairs of the axillary excavation. 
3 3 3 3 3 3 Limits of the region. 
4 4 Flaps of the pectoralis major muscle, one externally upon the 
fore part of the deltoid, the other internally and inferiorly 
upon the chest. 
5 Pectoralis minor muscle. 
6 Anterior portion of the deltoid muscle. 
7 Subclavius muscle. 
8 Coraco-brachialis muscle. 
9 Lateral portion of the thorax. 
10 Anterior part of the clavicle. EXPLANATION OF TIIE PLATES. 
455 
11 Coraco-clavicular aponeurosis, covering the subclavius mus- 
cle : we only see here the internal and superior portion of 
this aponeurosis, the rest having been removed in order to 
expose the vessels and nerves to view. 
12 Sonde Cannelde raising the axillary artery at the place where 
we should apply the ligature upon the vessel in the clavi- 
pectoral triangle. 
13 13 Axillary Vein. 
14 14 Cephalic. 
15 15 Axillary Artery. 
16 16 16 16 Median Nerve and its two roots which embrace the artery. 
17 17 Musculo-cutaneous nerve, running along the internal border 
of the coraco-brachialis muscle, from which a slice has 
been removed parallel to the fleshy fibres in order to give 
, a better view of the nervous cord. 
18 18 Ulnar Nerve, still very close to the artery. 
19 19 Internal cutancus, separated from the preceding by the 
axillary vein. 
20 Posterior Thoracic Nerve, concealed in great part by the 
shadow, in the bottom of the cavity, and applied upon 
the serratus magnus anticus muscle. 
21 21 Brachial branches of the intercostal nerves. 
22 22 22 Acromial artery, originating from the axillary behind the 
pectoralis minor, and being discovered only upon the fore- 
part of the vein. 
24 Croraco-acromion Ligament, sliding under the deltoid muscle. 
25 25 Coraco-acromion triangle. 
26 Small arterial and venous branches of the hollow of the 
axilla. 
27 Head of the Humerus. 
5 3 25 Clavi-pectoral triangle, limited by the pectoral muscle be- 
low and by the clavicle above. 
24 25 25 Coraco-acromion triangle, limited by the coraco-clavicular 
and coraco-acromion ligaments. 
24 14 3 3 5 Sub-pectoral triangle, circumscribed by the humerus exter- 
nally, the pectoralis minor muscle superiorly, and the an- 
terior margin of the axilla inferiorly. 
PLATE VI. 
This figure represents the fold of the arm in such a manner as to show the disposition of 
the organs which may be concerned in the operatim of Venesection, etc. 
1 Trunk of the Basilic vein in the internal bicipital-gutter or 
groove 
2 Cephalic vein on the external side of the biceps, and sepa- 
rated from the musculo-cutaneus nerve by the aponeurosis. 
3 3 Basilic and cephalic veins of the fore arm, or anterior radial 
and ulnar branches. 
4 Sonde Caneid: placed under the humeral artery, above the 
fibrous bandelet of the biceps. 456 
EXPLANATION OF THE PLATES. 
5 Common median vein, which communicates with the deep 
veins, in passing before the aponeurotic aperture, and 
which afterwards divides in order to form the median ba- 
silic and median cephalic. 
6 Posterior ulnar vein. 
7 Posterior radial. 
8 Trunk of the internal cutaneous nerve, placed on the inner 
side of the basilic vein. 
9 Musculo-cutaneus nerve, distributing itself especially 
around the common median vein. 
10 Aponeurotic bandelet which is detached from the bicipital 
tendon in order to pass upon the fore part of the internal 
muscular mass. 
11 Tendon of the biceps muscle. 
12 12 12 12 12 Circumferences of the aponeurotic aperture of the elbow, 
strong and distinct internally, thin and blending itself ex- 
ternally with the cellular tissue which covers the external 
muscular mass. 
13 13 Brachial Artery. 
14 Radial Artery. 
15 Cubital artery, or ulnar. 
16 Median nerve. 
17 17 Brachial vein ; these last two organs, here separated from 
the artery by the sonde, rest upon the brachalis internus 
muscle before insinuating themselves between the fibrous 
bandelet of the biceps and the tendon of this muscle. 
18 20 20 External muscular mass. 
19 19 19 Internal muscular mass, covered in great part by the apon- 
eurosis. 
21 Internal eminence of the elbow or cpitrochlea. 
22 Hook which draws inwards the aponeurotic aperture, in or- 
der to expose to view, above the bandelet of the biceps, the 
brachial artery and vein, the median nerve, the brachialis 
internus and pronator teres muscles. 
23 23 Subcutaneous layer and portion of the reflected skin. 
24 Fore arm covered by its integuments. 
25 Inferior part of the arm likewise covered by the skin. I>L.I. 
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