Book - An Atlas of Topographical Anatomy 11

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Braune W. An atlas of topographical anatomy after plane sections of frozen bodies. (1877) Trans. by Edward Bellamy. Philadelphia: Lindsay and Blakiston.

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Braune W. An atlas of topographical anatomy after plane sections of frozen bodies. (1877) Trans. by Edward Bellamy. Philadelphia: Lindsay and Blakiston.

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PLATE XI

THIS plate represents the upper surface of a lamina about an inch and a half thick, which was cut by a section passing through the trunk immediately beneath the sternal end of the second rib and the upper border of the sixth dorsal vertebra ; the saw passed out through the fat of the axilla, dividing the humerus at the insertion of the teres major.

Attached to the bone are the tendinous insertions of the great pectoral muscles, and on account of the position of the arms as regards the trunk they are so disposed as to exhibit a flat upward curve, and have been twice cut. Under the tendon of the pectoralis major lie the biceps and coraco-brachialis, and close under the last-named muscle are the vessels and nerves. The axillary artery is surrounded by the plexus, and is found next the muscle. The fascia of the coraco-brachialis must be divided to ligature this artery (after the arm has been raised), and the vessel should be reached from the sheath of the muscle, which can be easily drawn outwards; thus there will be little risk of pinching up and wounding the nerves and veins. Those portions of the trunk which are divided in the second intercostal space are of very great importance. The section of the great vessels passes immediately over their valves, and the left auricle with the upper wall of the auricular appendix are shown. The left auricular appendix lies more deeply, and is seen in front of the .ascending aorta.

Immediately behind the sternum the lungs and pleura3 approximate each other so closely, that only a very small interspace remains. This narrow space leads from the anterior mediastinum to the region of the thymus gland; a sagittal section in the mesial plane in this body must have opened the right pleural cavity.

The contour of the pericardium is clearly shown; it extends at this level considerably further back on the left side than on the right, corresponding with the higher position of the left auricular appendix. On the right side it has been opened in front of the superior vena cava, and extends between it and the aorta posteriorly to the right branch of the pulmonary artery, playing the part of a bursa by permitting the necessary movement of these vessels upon each other. As the trunks of the vessels which pass from the lung into the left auricle, and from the right ventricle to the lung, run horizontally, a section which passes through the roots of the lungs exposes much more of their length, whilst the vessels of the greater circulation, which pass more vertically to and from the heart, appear divided more transversely. The pulmonary artery is the most important to examine of the vessels of the lesser circulation, as it is exposed for a large portion of its course. It is met with close to its origin, and its right branch is divided throughout its course. The left branch does not lie in the same plane, but it is also divided. It rises up somewhat in its course to the left lung, arching over the left bronchus and left auricle. The trunk of the pulmonary artery runs somewhat to the left, backwards and upwards, and can be seen in the upper surface of the section.

It is evident that the aorta and pulmonary artery are fixed together, whilst the former is capable of movement upon the vena cava. The relation of the aorta to the right pulmonary artery is important, as in aneurismal dilatations of the first part of the aorta compression of the right pulmonary artery may be expected. The position of the valves of the pulmonary artery and aorta with regard to the chest wall were accurately defined in the preparation, and can be deduced approximately from the plate. The pulmonary orifice lay behind the left border of the sternum under the upper margin of the third costal cartilage. The aortic orifice lay behind the left half of the sternum on a level with the third costal cartilage, behind and to the right of the pulmonary opening. The curvature of the aorta behind the first part of the pulmonary artery, with the position of its valves, is rendered as accurately as possible. It must however be expressly understood that such definitions cannot represent with absolute accuracy the relations on the living body. Apart from the influence which maintains the filling of the vessels, the position of the heart and its great branches is determined chiefly by the lungs and diaphragm, and it varies with each change of position of these important connexions. (This will be referred to again in the text accompanying the next plate.) Both bronchi are clearly seen ; the left is divided more obliquely, in consequence of its being less vertical than the right, and as its ramifications lie in the plane of section, more of its branches are seen; whilst as the right has been divided more transversely, most of its branches have been separated. Between them, at the root of the lung, are a number of the characteristic pigmented bronchial glands.

Nearly in the centre, in front of the sixth dorsal vertebra, is the oesophagus, and behind it, to the left side, is the descending aorta, which already begins to take a direction towards the middle line. Between the oesophagus and the aorta is the thoracic duct, which in this instance is double. The vagus lies on the right side near the oesophagus and the vena azygos major; on the left side it lies between the bronchus and descending aorta.

The practical physician will notice with interest the changes which pathological conditions have given rise to in these sections. I have, therefore, introduced two plates from Pirogoff, which have been taken from the bodies of patients. Fig. 1, taken at the same level as my plate, shows extensive pericardial exudation.

The immense expansion which the pericardium has attained at the roots of the great blood-vessels is remarkable ; both pleural sacs are widely drawn asunder, and the right especially has acquired a considerable inflexion. The pulmonary artery with its right branch has slightly changed its position with regard to the middle line ; the aorta lies considerably further towards the right side than is normal, and is pushed far away from the vena cava. On account of the exudation all the vessels seem to be pushed towards the vertebral column.

The section corresponds with that given by Pirogoff (fasc. ii, p. 22), and passes through the second intercostal space, dividing the third, fourth, and fifth ribs of both sides and the fourth costal cartilage at the level of its upper margin. The age of the man, who had lain in hospital a long time, is not clearly denned, and is as of middle life. In any case the age was greater than that of my subject. It is remarkable that, although in the region of the sternum both sections began almost exactly at the same level, they struck different vertebrae; in PirogofTs case the fourth, in mine the sixth. As the definition of the position of the heart with regard to the bones of the anterior wall of the chest is of clinical importance, I have, in spite of the difference of the vertebrae of Pirogoff's plate, chosen it for the sake of the comparison, as the section happens to pass through the same intercostal space as mine.

FIG. 1. Adult male thorax. Hydro-pericarditis. Insufficiency of aortic valves. Pleurisy.

Pirogoff, ii, p. 1, .

1. Bronchi. 2. (Esophagus. 3. Pulmonary artery. 4. Ascending aorta. 5. Superior vena cava. 6. Descending aorta.

It must be borne in mind that owing to the exudation into the pericardial and pleural cavities in Pirogoff 's subject, the ribs are raised and their anterior extremities lie two vertebras higher than in my case.

The following woodcut, Fig. 2, shows the variation in the position of the parts of a similar section in pleuritic effusion of the left side with pneumo-thorax. The subject is the same as in Fig. 2 of the text of Plate X. The expansion of the left side of the thorax, and the lateral displacement of the great vessels, can be clearly made out.

The commencement of the pulmonary artery lies behind the right border of the sternum, and that of the aorta behind the third costal cartilage.

FIG. 2. Subject C. Adult male thorax. Left lateral pneumo- thorax. Pirogoff, ii, 7, 3, 5.

1. Bronchi. 2. (Esophagus. 3. Pulmonary artery. 4. Ascending aorta. 5. Superior vena cava. 6. Descending aorta.

Pirogoff 's section (cf . text to plate, ' Atlas,' fasc. ii, p. 28) runs horizontally through the upper border of the third- costal cartilage, dividing the third, fourth, and fifth ribs of both sides ; it passes also through the upper border of the fifth dorsal vertebra. Here the section passes a vertebra higher than in my case; this resulted from the expansion of the thorax, and the position of the ribs consequent on inspiration. It is remarkable that both right and left sides of the thorax are equally raised, so that they show a closely symmetrical division of the ribs. Besides the local pleuritic adhesion, which stretches like a cord from the inner surface of the ribs to the lung, there are other and wider bands which divide the pleural cavity into three portions. The left lung is, moreover, very much compressed and adherent to the costal pleura, so that its section appears polygonal.

As the normal relations of the thoracic organs have been exhaustively treated of by Luschka, Henle, Meyer, and others, I must refer the reader to their works, and proceed with a description of certain results of observations on dislocation of the heart from collections of fluid in the pleural cavities.

Fig. 3 shows the normal relations of the heart to the anterior wall of the chest, as determined from numerous examinations which I have made on young male subjects. After injecting the heart, and using only moderate pressure, the left auricular appendix became more visible than is usually the case when it is empty.

FIG. 3. Normal position of the heart.

FIG. 4. Dislocation of the heart. Pleuritic exudation on the left side, .

Fig. 4 represents a very considerable dislocation of the heart to the right side, produced by pleuritic effusion. The body lying on the back, the heart was fixed to the anterior and posterior walls of the thorax by six long needles, and the position of each portion accurately defined with regard to the anterior wall of the chest. It will be observed that the dislocation of the heart is considerably greater as regards its apex than its base, and that at the same time a rotation towards the right side on the long axis has taken place, so that a greater projection of the left ventricle has resulted. The vertical position of the heart's axis in this instance was determined by exact measurement.

The following woodcuts (5 and 6) also show dislocation of the heart from effusion into the pleural cavities. They are, however, the results of experiments which were made by myself on fresh normal bodies.

FIG. 5. Left lateral hydrothorax, artificial, ^th.

FIG. 6. Right lateral hydrothorax, artificial, ^th.

The bodies were placed in the upright position and care was taken that the tracheae remained open, and that the other parts were in their normal positions, and disregarding any experiment which did not seem to be complete, the conditions shown in the accompanying woodcuts were obtained.

After finishing the experiments by injecting a weak solution of common salt, the trachea was closed, so that on opening the thorax any farther falling together of the lungs should be impossible. The heart was fixed to the anterior and posterior walls of the thorax, with long needles, and the intercostal spaces subsequently opened, in order to determine the position of the heart with regard to the framework of the chest. It was found that the apex of the heart was pushed considerably backwards ; and so also was the base, although strengthened by the great vessels forming the root of the lung. There was lateral rotation of the heart on its long axis. The quantity of fluid injected in fig. 5 was five, and in fig. 6 six pounds. It was observed that after the introduction of a pound and a half of fluid, there was an evident increase of dulness on percussion in the region of the liver (corresponding with the observations of Seitz and Zamminer).

As bearing on these experiments, I examined Pirogoff's plates relating to the sections of a subject with empyema of the right side and dislocation of the heart. (The section had been made after freezing.) I also collected material from the same author, of a body with pneumo-thorax of the left side.

After careful measurements on the different plates, the contours of the dislocated heart were constructed and shown in figs. 5 and 6 by the dotted lines, so that a comparison with the results of my own researches might be instituted.

In PirogofFs definitions of the heart's position, exact as they are, the quantity of the morbid fluid could not have been measured, and one cannot expect that a dislocation of the heart could be expressed by a surface of the contours. Moreover, an artificial effusion into the pleural cavity could never produce the same relations as a gradually increasing exudation. But it follows certainly from these instances, and it is even proved by the difference of methods, that in dislocations such as these, the base of the heart does not remain fixed, but that it is considerably moved from its place (and the apex likewise), and that there is a rotation of the heart on its long axis.

PLATE XII

THIS section, like the one just described, is viewed from above downwards, the thickness of the lamina being about one inch and a half. The section passed through both nipples and the third intercostal spaces, dividing the auricles of the heart and their valves. It passes backwards to the upper border of the eighth dorsal vertebra, and shows the eighth ribs of both sides; it cuts also the inferior angle of the shoulder-blade.

The great value of the plate consists in the fortunate section through the heart, both auricle and ventricle being opened. The left auriculoventricular opening is divided nearly in half, and the right is so cut at its upper border that a view is obtained of the ventricle. At first sight the cut surface of the heart and the space which this organ occupies seem immensely large, and yet a subsequent examination shows their relations to be normal. From the oblique position of the heart in the thorax a transverse section of the body would not divide it transversely but obliquely; therefore its walls appear much thicker than they really are.

The left auricle is divided not far from its base. The portion of it here represented shows a cavity about '3 of an inch in its deepest part, while towards the right side the section rises to the level of the pulmonary veins. A small portion of the aortic segment of the mitral valve has been taken away ; it will be found on the right side of the mitral opening.

Behind the left auricle the great cardiac vein is seen passing to the right auricle to open by the coronary sinus below the remains of the Eustachian valve. The point of opening lies too deeply to be clearly shown in the plate.

As the left ventricle lies more posteriorly and the right extends more anteriorly, the auricular septum is drawn out backwards and to the right side ; the left auricle lies considerably higher than the right.

The inferior vena cava projects upwards into the posterior half of the right auricle, and in front of it are the remains of the Eustachian valve. Still more anteriorly the auricle bulges outwards and downwards to a depth of about an inch and a quarter, rising again to open into the right ventricle and by means of the auriculo -ventricular opening, which is guarded by the tricuspid valve. In front of the tricuspid valve is the right ventricle, which is opened by the section, and from which the section has carried away the root of the pulmonary artery. From the anterior wall of the ventricle (the section of which is seen in front) one of the musculi papillares passes backwards to the anterior flap of the valve, and behind this, deeper in the cavity of the ventricle, are the columns carnese of the hinder wall. By comparison with the under surface of the next section the position of both auricles can be accurately determined. It appears that the cavity of the right auricle attains the level of the lower border of the fourth, to the middle of the third, costal cartilage, and that its corresponding auricular appendix reaches to the upper border of the third costal cartilage. Its greatest breadth extends from the middle of the left half of the sternum to about an inch external to the right border of that bone. The left auricle extends from the upper border of the fourth costal cartilage to the middle of the second intercostal space, and in breadth it corresponds to the eighth dorsal vertebra and its articulations with the heads of its ribs ; its auricular appendix rises to the lower border of the second costal cartilage.

The right auriculo-ventricular opening is at the level of the eighth dorsal vertebra and to the right of the middle line of the sternum ; it also extends across slightly to the left half of the body, nearly in the centre between the vertebra and sternum. Anteriorly its position is marked by the level of the nipple and the fourth costal cartilage.

The left auriculo-ventricular opening commences somewhat to the left of the sternum and reaches nearly to the middle line, lying 2'8 inches behind it at the level of the fourth intercostal space.

A needle pushed into the middle of the third intercostal space, at the distance of rather less than half an inch from the left sternal border, would strike the central point of the mitral opening. In order to pierce the tricuspid opening, it must be thrust into the right half of the sternum at the level of its articulation with the fourth costal cartilage.

The pulmonary orifice would be reached at the upper border of the third costal cartilage, about one fifth of an inch external to the left edge of the sternum, and the aortic orifice at the level of the third costal cartilage.

I have frequently performed such experiments on young male subjects, and I am convinced of the accuracy of these statements. But I am far from insisting on their being absolute for all bodies, still less would I maintain that the positions are exactly the same for the living without further observation, entirely waving the question of pathological changes. According to the position of the body whether it lies on the back, side, or abdomen, so the position of the heart is affected, and further it is considerably influenced by the condition of the diaphragm. The heart is placed between the lungs and the diaphragm, so as to be surrounded by structures which can be displaced from it as soon as something else has taken their place. And owing to this arrangement the position of the heart is somewhat variable. The tender organ is not only perfectly protected from shocks which affect the anterior wall of the thorax, but has, moreover, free room for its own movements.

In the body of a young and powerful individual, such as the one here represented, the lungs gradually contract to an extent which is never the case during life. Consequently the external air presses equally on the surface of the abdomen and upon the diaphragm.

When the lungs contract, the heart, which lies between them, naturally moves upwards with the diaphragm, and so attains after death a higher level than is possible during life.

If the elasticity of the lungs be lost, as is the case in old people and in those affected with disease of the lung-tissue, we must expect a deeper position of the heart.

By sections in the bodies of young powerful men I found the pulmonary orifice at the upper border of the third left costal cartilage, and at the level of the sixth dorsal vertebra ; in persons of from fifty to sixty years it lay below the fourth costal cartilage at the level of the eighth dorsal vertebra.

In the event of tympanites the inflated intestines push up the diaphragm and the heart until the latter lies between the yielding and more contracting lungs, so that the pulmonary orifice corresponds to the level of the second costal cartilage.

FIG. 7. Adult male thorax. Hydro-pericarditis. Pirogoff, ii, 14, 4,

1. (Esophagus. 2. Descending aorta. 3. Right auricle. 4. Left ventricle. 5. Left auricle. 6. Left ventricle.

The diameters of the chest have been discussed -with Plates IX to XII, and the relation 1 : 3 has been tolerably well established. It will be seen that these relations are subject to essential changes in disease. For the purpose of comparison I reproduce two of Pirogoff's plates in woodcut.

The section, Fig. 1, is taken a vertebra higher than mine, consequently a small portion of the bulbus aorta3 remains in front of the left auricle, of which a considerable amount is left. The aortic portion of the mitral valve is clearly seen lying stretched flat over the apex of the hinder flap. The right auricle exhibits in its posterior half the point of entrance of the superior vena cava, which has been somewhat compressed by the pericardial exudation, and in its anterior part is seen the entrance to the right ventricle.

If these relations be compared with the normal condition one is struck with the altered form of the thoracic cavity. The antero-posterior diameter is considerably enlarged ; it amounts to the half of the transverse diameter, whereas it should be only one third.

Owing to the great distance of the sternum from the spinal column, space is permitted for the extensive exudation. The heart appears driven backwards, but this is not really the case, as the parts between the heart and vertebra, the ossophagus and descending aorta, have clearly ample room. But it is rolled over entirely to the left side.

The axis of the left side of the heart passes in a direction transverse to the section of the fifth rib, whereas normally it points obliquely forwards towards the left nipple. The axis of the right side of the heart shows a similar change in direction. The lungs are considerably compressed, to give more room for the pericardial exudation. Whilst in my plate they enclose the entire heart and closely approximate its anterior boundaries, they are here widely separated from each other and sunk back, notwithstanding that pleuritic effusion exists on the right side. The pleural cavities should be especially studied with reference to paracentesis pericardii, in opnsequence of their attachment to the chest- wall. In this section they are but slightly dislocated, only a small space near the sternum being left free, so that a trocar would have to be introduced very close to the border of the sternum in order to avoid wounding the pleura.

The section in *Fig. 2 is taken almost exactly at the same level as mine, and the relations of the heart are similar, this organ being slightly pushed over, and at the same time rotated on its axis toward the left side. The left lung is considerably diminished, so that it is not applied to the anterior surface of the heart. The pleurae, however, reach as far as the sternum, a very small space existing between them ; they exhibit so many adhesions (according to Pirogoff's description) that the cavity of the pleura was considerably interfered with. In addition to the disloca-

Fig. 2. Adult male thorax. Partial cystic empyema of the right side. Pirogoff, ii, 11, 2, .

1. (Esophagus. 2. Descending aorta. 3. Bight auricle. 4. Left ventricle. 5. Left auricle. 6. Left ventricle.

tion of the heart, the remarkable pushing over of the oesophagus to the left side is of interest ; but unfortunately Pirogoff gives no further account of this matter.

PLATE XIII

THE section of which the upper surface is here shown was taken two inches below the preceding ; and passed through the lower portion of the sternum and the fifth costal cartilage ; divided the apex of the heart, the diaphragm, and the liver ; and came out posteriorly through the lower portion of the ninth dorsal vertebra, and the corresponding rib.

This plate terminates the series of sections of the thorax ; and the abdominal cavity is already open, showing at a glance how wounds of the liver may involve the lung. Although the left lobe of the liver lies in the section, a very small portion only of the left half of the cupola of the diaphragm has been removed. It rises as high as the lower border of the fourth rib, seen from the front ; whilst the right half, of which considerably more has been removed than of the left, rises as high as its upper border nearly a rib's breadth higher, and almost on a level with the plane of the nipples.

It has been already stated in the last chapter that this position of the diaphragm does not correspond with its relations during life, but that it was so found in the body of a young powerful man, and that it would be pushed higher up in tympanitis.

The position of the heart is in immediate relation with the diaphragm and liver ; and the lowest part of the heart is shown divided behind the fifth costal cartilage of the left side. The absolute apex of the heart is about four fifths of an inch from the plane of section. On the right side, in the apex of the right portion of the heart, is seen the lowest part of the cavity of the ventricle, filled with its columnse carnese. At the apex of the left side the section exhibits the arrangement of the muscular structure.

The heart does not extend downwards beyond the fifth rib, reaching only to its lower border ; the cavity of the pericardium, however, extends about half an inch lower, and contains about a tablespoonful of frozen fluid. In a male fifty years of age I found at the level of the eleventh costal cartilage a portion of the heart corresponding with that here represented, but considerably deeper.

The relations of the pleurae to the front of the heart are of practical importance. The pleuraB appear as folded sacs, which extend from the anterior border of the lungs towards the middle line, leaving in the present instance merely a small interspace between the left edge of the sternum and the fifth costal cartilage, through which the pericardium could be reached by the trocar without wounding the pleurae. Bodies vary considerably in this particular, so that it is readily conceivable why so many different descriptions are given for the position of the point in the introduction of the trocar.

Luschka, however, is right when he maintains that the pericardium presents at the left border of the sternum a narrow strip quite free of pleura, so that it may be safely avoided in paracentesis of the pericardium. The safest method of operating, as I have satisfied myself, is to pass a fine trocar in the upper angle between the left edge of the sternum and the fifth costal cartilage. It does not appear justifiable to depend upon an adhesion of the pleura. Even large collections of fluid in the pericardium may exist for a considerable time without it.

The amount of extension of the liver towards the left appears surprising ; hence the heart seems to be entirely supported by its left lobe, and from its abnormal size one is inclined to assume that some pathological condition was present. Such, however, was not the case, and the viscus was normal both in weight and structure.

It must be borne in mind that the left lobe of the liver shows great varieties of form even under normal relations ; that it reaches down to the spleen ; but that it lies always under the heart, a portion of which projects anteriorly and to the left side over the margin of the liver. Again, it is to be remembered that, in consequence, false notions are formed of the shape and position of the liver ; one having been accustomed to observe it in front as projected on a plane, in which case its entire extent cannot be shown. A good view of the extent and position of the liver is obtained from the diaphragm above ; and this is the easiest method that can be adopted of studying the important relations of the liver to the spleen, stomach, and heart. I have frequently, after the removal of the chest- wall, shown the diaphragm intact, with a portion of the pericardium attached to it, and subsequently removed the diaphragm and introduced the liver into the drawing ; and I always found a similar relation of the heart and liver to that seen in this plate, notwithstanding the variable extent of the left lobe. If the diaphragm be very carefully removed, the peritoneum may be preserved and the individual organs seen through it in their respective relations to each other. If the body be placed in the upright position, the pressure on the surface of the diaphragm is lessened and rupture of the peritoneal sac avoided. I give three plates which were made from the bodies of young powerful men (suicides) which were brought to the anatomical school with the rigor mortis on them.

There is no question that in such operations the position of the diaphragm frequently alters ; and that with the removal of the upper half of the thorax especially the anterior and posterior walls of the lower half somewhat approach each other, and the cupola of the diaphragm rises correspondingly higher in consequence : this alteration of position having, however, but a very slight influence on the subjacent organs. A preparation of this kind may be made on a subject lying on the belly or on the back without any perceptible displacement of the enclosed viscera. Frequent observations show that by means of this method many useful results are obtained in explanation of the topography of this region. I have, then, rested satisfied with the representations obtained, and have refrained from attempting an improvement upon the plates by a previous moulding in plaster of Paris, and from using the drawing apparatus of Lucee. Considering the sources of error which result from the relations in the dead body, an exact definition of the position of the parts must be given up.

Fig. 1 represents the relations of the parts, the stomach being tolerably full. This viscus when full pushes the left lobe of the liver outwards, and lies for the most part covered by it. The portion of the diaphragm that supports the pericardium indicates the position of the heart. If the left ventricle, when full, exceeds the margin on the left side, it is clear that the heart lies, not on the stomach, but on the liver, and only its apex reaches the region of the stomach, and a transverse section would be similar to that represented on Plate XIII. The left cupola of the diaphragm is distended, therefore, by the left lobe of the liver, stomach, and spleen.

Fig. 1. Normal position of the viscera below the diaphragm, viewed from above. J.

1. (Esophagus. 2. Aorta. 3. Inferior vena cava. 4. Liver. 5. Pericardial portion of diaphragm. 6. Stomach. 7. Lobulus Spigelii. 8. Spleen.

Fig. 2 represents the position of the viscera below the diaphragm in still greater distension of the stomach. By simple inspection of the form of the circumference of the liver, it is evident that the figure was taken from another body, and that a body was used in which there was considerable distension of the stomach. This distension was not obtained by mere experiment, which very easily disturbs the relations of the parts : the subject was perfectly fresh, and the examination was made before it was touched in any way. The stomach, which was distended with food, did not extend as far as the left side, but still had against it the fatty portion of the peritoneum, which drags on the left end of the transverse colon, and which is continuous with the greater sac.

The left lobe has a different form from that in Fig. 1, notwithstanding that its relation to the heart is the same, or, at most, so slightly altered that the apex of the heart, in consequence of the greater breadth of the left lobe, has liver substance on the abdominal surface of the diaphragm under it. From observations that I instituted on different subjects, after filling the colon from the anus, or the stomach from the oesophagus, in order to demonstrate the variation in position of the organs in one and the same individual, I was convinced that even by carefully lifting the peritoneum, I obtained no condition of things from which a plate of any value could be made. The stomach was much displaced from its natural position, and was emptied with as much difficulty as the colon ; so that I was forced either to use different subjects for the plate, or to select from them those which showed the organs in the state of distension desired. It appeared in the highest degree remarkable that in a portion of the trunk, to which merely the under half of the thorax was attached, one could inject a large quantity of water through the oesophagus, and leave it any length of time without its escaping. On introducing the finger through the oesophagus into the stomach one could feel its wall between the cardiac extremity and the fundus jutting out so sharply as to form a distinct valve. It must remain for further investigations how far these relations on the subject can be applied to the living body.

IX Normal position of the viscera below the diaphragm, viewed from above, f .

1. (Esophagus. 2. Aorta. 3. Inferior vena cava. 4. Liver. 5. Pericardial portion of diaphragm. 6. Stomach. 7. Great oinentum. 8. Spleen. 9. Lobulus Spigelii.

Fig. 3 shows the stomach empty, and the resulting space filled up on the left side by the colic flexure. The other relations are similar to the preceding. It appears in these plates that the heart always has the left lobe of the liver between it and the stomach, and lies on the stomach by only a portion of its apex, which may vary greatly in size.

Normal position of the viscera below the diaphragm, viewed from above. .

1. (Esophagus. 2. Aorta. 3. Vena cava interior. 4. Liver. 5. Pericardial portion of diaphragm. 6. Stomach. 7. Left flexure of colon. 8. Spleen.

frontal section shows the same condition, and the order of these structures as arranged one above the other can be well studied (compare Henke, ' Atlas der Top. Anat.,' tab. xxxv, xxxvii, and Pirogoff, I A, ii A, ii B).

It will also be seen that, according to the condition of the stomach, the position of the viscera in the left cupola of the diaphragm will be altered. The left flexure of the colon is pushed up if filled with gas and the stomach empty ; and will, as it more often contains air than the stomach, afford especially a full tympanitic percussion note in the lower half of the left side of the thorax ; it may also, by the strong pressure exerted upwards, disturb the functions of the organs within the chest.

The following woodcuts are taken from Pirogoff's atlas to demonstrate the change in the position of the apex of the heart as occasioned by pleuritic or pericardial exudation.

Fig. 4 illustrates the relations of the parts, at the same level, when the pericardium is very much distended with fluid. The section is taken at the same level as mine, and the apex of the heart is pushed strongly backwards and somewhat to the left side.

Male thorax. Hydro-pericarditis. Lungs healthy. Pirogoff, ii, 15, 2. J. 1. (Esophagus. 2. Aorta. 3. Vena cava inferior. 4. Liver. 5. Heart.

The pleurse approach each other in front, leaving only a narrow space at the left edge of the sternum. One would expect a greater separation of the pleurae from each other as the quantity of fluid in the pericardium took up greater space. It is therefore the place to choose for puncture of the pericardium, as has been stated before, so as not to open the pleural cavity. Pirogoff does not mention the age of the individual ; it is merely noticed that the lungs (and very likely the pleurae) exhibited no abnormality.

Fig. 5 is a section showing the relations of the organs in pleurisy and hydropericarditis. It was made on the body of a man of middle age, who died in hospital, and passes deeper than my section by a vertebra. Notwithstanding the mass of exudation, very little of the liver is divided. As regards the position of the apex of the heart, it is dislocated backwards and to the right. The distension of the left pleura is so considerable that it extends forwards to the middle line and posteriorly beyond it.

FIG. 5. Male thorax. Left pleurisy. Hydro-pei'icarditis. Pirogoff, ii, 22, 2. 1. (Esophagus. 2. Aorta. 3. Yena cava inferior. 4. Liver. 5. Heart.

Of the ribs of the left side almost the same are divided as in my case, from which it is evident that the effusion was more considerable, causing a tilting up of their anterior extremities. On the right side, on the other hand, which, according to PirogofTs account, contained very little fluid, the ribs lie wider apart, so that the fourth rib is sawn through.

Fig. 6 shows the relations of the parts in double pleurisy and hydropericarditis. The description is to be found in Pirogoff's atlas, ii, p. 54.

The section, which has passed a vertebra deeper, divided the fifth, sixth, seventh, eighth, and ninth ribs of both sides, and shows almost the same relations of the skeleton as Plate XIII, both halves of the thorax being symmetrical. The man had an encysted empyema of the right side. The right lung was strongly compressed, and appeared polygonal in section

FIG. 6. Male thorax. Partial cystic empyema of right side. Hydro-pericarditis. Pirogoff, ii, 15, 4. 1. (Esophagus. 2. Aorta. 3. Yena cava inferior. 4. Liver. 5. Heart.

in consequence. The left pleura was thickened and very adherent. The heart, it will be observed, is dislocated and drawn to the left. The left lung lies far back, and its pleural sac is firmly adherent for its whole length in front of the heart, so that puncture of the pericardium could be performed without danger of the pleura at the sides. With regard to dislocation and hypertrophy of the heart, some authors have frequently observed a bending in of the inferior vena cava. (Compare Luschka, ' Anat.,' i, 2, p. 445 ; Bartels, * Deutsches Archiv,' iv, p. 269.)

In my opinion the question is not yet decided, and can only be definitely settled by allowing a body to be frozen, and to expose the right auricle with the venae cavaa from behind with hammer and chisel. Transverse sections, like the one under observation, where the vena cava and the entrance of the hepatic vein are cut through immediately below the foramen quadratum, throw little light on the question ; nor can much be expected from experiment or clinical observation. Researches on animals, which I have instituted in Ludwig's laboratory, and published in the reports of the Academy, show that ligature of the inferior vena cava does not set up any considerable disturbance of the circulation, as the blood finds a ready path collaterally by means of the azygos veins and spinal plexus, thus getting into the superior vena cava.

PLATE XIV

THIS plate represents a section through the epigastrium, exposing the liver, stomach, and spleen. No more is to be seen of the lungs ; the black line immediately internal to the ribs represents the pleural cavity, whilst close to it is the diaphragm, appearing as a muscular ring. The structures lying external to it belong to the thorax, and internal to the diaphragm is the abdominal cavity.

The plate is taken from the upper surface of a section two inches thick from the same body as the preceding and the following.

The body of the eleventh dorsal vertebra is seen divided near its under surface, so that a small piece of the interarticular fibro-cartilage is shown. The arch lying behind it also belongs to the eleventh dorsal vertebra : the joint spaces in front belong to the articular processes of the twelfth : and on either side are the sections of the eleventh, tenth, ninth, eighth, seventh, and sixth ribs ; the seventh and sixth ribs being divided twice, but not the xiphoid cartilage, since the section passes below it. It appears strange, at first sight, that the section of the right half of the body should have a larger area than the left, the transverse diameters differing by about half an inch; the cause of this is, however, in some measure, owing to a want of symmetry, and also to the fact that the sawblade diverged somewhat from the horizontal plane.

The liver occupies the greatest amount of space, and is perfectly normal in structure and weight. The left lobe of the liver is prolonged into a thin lamina, which is stretched over the stomach almost as far as the spleen. This explains the great extent of the liver in the left cupola of the diaphragm, in the preceding plate. At the point of junction of the right and left lobes, in the left longitudinal fossa, is the ligamentum teres in a fold of peritoneum ; and posteriorly, lying on the diaphragm, the lobulus Spigelii with the omentum. Close to it on the right is the inferior vena cava ;. and in front of this are the transverse fissure, the portal vein, and the hepatic duct.

The stomach contained some frozen food, which was removed so as to show its walls. It was ascertained subsequently that the fundus of the stomach had attained its highest position, and that beyond the distended portion in the commencement of the stomach, there was contraction where the folds of the mucous membrane were most marked, and that subsequently the cavity became again distended further to the right side and below. It appears, therefore, that Luschka is quite correct in disputing the entire approximation of the anterior and posterior walls of the organ in its empty condition. Here also, where completely normal conditions existed, the stomach was contracted like intestine in its empty portions, and was not flat, as represented in some plates.

The cut edges of peritoneum behind the stomach belong to its lesser sac. Further back is the spleen, normal, with its blood-vessels ; it corresponds with the course of the ninth, tenth, and eleventh ribs, and in its greatest diameter follows their direction. The left supra-renal capsule is not seen, whereas the right is evident between the liver and diaphragm.

Concerning the relations of the peritoneum, it must be remarked that transverse sections are not adapted for displaying it. The cavities can only be represented by black, and the cut edges by fine white lines, which easily mislead the eye.

In order to render any representation advantageous, views of surfaces must be given, or longitudinal or oblique sections taken as the bases of the drawings, by which, semi-diagramatically, the cavities of the peritoneum appear enlarged. Luschka and Henle have excellent plates of this kind.

On the other hand, representations of such transverse sections, here shown true to nature, are of great value surgically. They show what localities are free of peritoneum, and what not, and the surgeon consequently can plan an operation. It is of the first importance to avoid this membrane, and in this, as in the following plates, the boundaries of the cavities and points of investment of the peritoneum have been represented with the greatest fidelity ; and hence the cavity of the omentum between the lobulus Spigelii, and the posterior wall of the stomach, was not drawn as contracted, although both cavities are connected immediately below the surface of the section. The portion of the stomach which lies close to the diaphragm shows the end of the posterior cardiac region free, and uncovered by peritoneum.

An examination of the peritoneum shows that it has two functions to perform, especially mechanical, which are (1) that it fixes the several organs in the abdominal cavity in definite places; and (2), like a colossal, sinuous, mucous membrane, allows of their movements upon one another in their various conditions of distension. These changes of position can occur, where the black lines in the plate, like joint spaces, represent the cavities of the peritoneum ; at points, on the other hand, where the peritoneum is reflected, and leaves a free space for the entrance of blood-vessels, the viscera are fixed to their surroundings.

In order to show the relations as they exist in the extremes of age, I have here introduced two woodcuts. Fig. 1 is taken from a man, get, 50, who had enlargement of the liver and spleen. Fig. 2 from a recent body of a female infant, at full period, born dead.

The body of the old man is the same which furnished Plate IX in the large coloured atlas. Death resulted from hanging, and the stomach and intestines were empty.

The section passed through the tenth dorsal vertebra, and anteriorly through the xiphoid cartilage. The stomach was empty, with the exception of a little frozen mucus. The lung structure was normal and absolutely empty of air. The liver large and fatty. Supra-renal capsules and spleen large.

The well-developed body of the child showed no irregularities.

The great resemblance between Figs. 1 and 2 is singularly remarkable, also the fatty livers of the old and young subjects ; moreover, the relations correspond wonderfully accurately.

In both cases the liver fills up almost the whole interspace internal to the diaphragm, and spreads over a large portion of the spleen, which lies in relation to the spinal column, as in Plate XIV. The stomach alone shows any important change of position. In both cases it is empty; has the same position between the left lobe, of the liver and the spleen ; has a portion of the diaphragm for a covering ; and is not overlaid by peritoneum. On the other hand the shape is different in the two subjects.

FIG. 1. Male, set. 50. . 1. Liver. 2. Stomach. 3. Spleen. 4. Left lung.

Whilst in the former case the stomach is contracted like intestine, in the latter it is an oblique chink ; so that the anterior wall lies relaxed on the posterior a condition I have never observed in the adult.

In front of the right supra-renal capsule is, in the child, the inferior cava, lodged somewhat deeper under the lobulus Spigelii than in the other instance, where the capsules are not seen, notwithstanding that the section lies passed three vertebrae lower, On the other hand, corresponding with the slight power of contraction of the lungs in the old man, they are still visible at the level of the first lumbar vertebra ; whilst in the youth of twenty-two years in Plate XIV the pleural cavities are empty at the eleventh dorsal, and in the new-born child, Fig. 2, at the tenth.

In the new-born child the thorax is fixed at extreme expiration, to which it can never return after the first inspiration. The entire contents of the upper portion of the abdomen must therefore be depressed as soon as the diaphragm, during the first inspiration, leaves its high position ; and the figure, which here lies three vertebrae higher than in the old man, would then take a considerably deeper level.

FIG. 2. Child, at full period. Born dead, Natural size. 1. Liver. 2. Stomach. 3. Spleen. 4. Supra-renal capsule.

As in Plate XIV the space between the liver and the spleen appears to be completely filled up by the stomach, which, however, presents only a slight degree of distension, the question arises, what would be the condition of things if this viscus were more distended ? It is easily seen that, apart from a considerable protrusion of the anterior wall of the abdomen, which is observable after each full meal, the lower ribs also must give way a circumstance which, under a continued swelling of the abdomen, leads even to permanent prominence of the thoracic segment, as may be proved in many ways, and is especially seen in children. The left lobe of the liver must follow more or less the movements of the stomach, since it forms a species of covering to that organ ; it is lifted up by the distended stomach, pushing the pericardium up with it, and sinks down with the contracting stomach, the place of which is taken partially by the left flexure of the colon. The mesentery -like left coronary ligament of the liver renders possible such movements of its left lobe, which are associated either with a turning of the entire liver (the axis of which is to be sought in the right lobe, corresponding with the strong, firm attachments to the right half of the diaphragm), or arise from the yielding or distension of the soft tissues.

Fig. 3 reduced from Pirogoff will make this relation clear, even if one does not obtain an entirely correct idea of the form and position of the left lobe of the liver.

From this cut it is clear that the spleen lies so far back that any determination of its posterior limits by percussion is impossible. It is true that by percussing in a horizontal direction around the thorax towards the spine, at the level of the spleen, we obtain a different sound as we approach the spine ; but from the present plates one would not be warranted in assuming the existence of an air-containing organ between the spleen and the spine. We must look for the cause in the alteration of the elasticity of the ribs at this point. Further, we always find, if we percuss in a vertical direction on the back and in the axilla from above downwards, that the commencement of the dulness is in a horizontal line, corresponding with the limit of the base of the lung, and covering the superior portion of the spleen, which is directed obliquely downwards and forwards. One can easily convince oneself of the firm position of the spleen, which is especially owing to the reflexion of the peritoneum, under the name of phenico-splenic ligament, if the upper portion of the thorax be removed on the dead body, and the sac of peritoneum preserved, so that the liver, stomach, left flexure of the colon and upper wall of the spleen are seen through it. The stomach can be inflated and again allowed to collapse, and the descending colon filled and again emptied, when it will be always found that the upper border of the spleen is unchanged in position.

Fig. 3. Youth, set. 15. Stomach distended with air. Pirogoff, iii, 3, l-$. 1. Liver. 2. Stomach. 3. Spleen. 4. Abdominal aorta. 5. Vena cava inferior.

On laying the subject on the abdomen the spleen does not sink forwards, but remains in its original position. The relations are, however, different when the attachments of the spleen to the diaphragm are sparse or easily lacerable, or drawn out into long bands. This might account for the so-called movable spleen.

PLATE XV

IN this plate the 1st lumbar vertebra is divided in the middle; on the right side are the sections of the twelfth, eleventh, tenth, ninth, eighth, seventh, seventh and eighth ribs, the seventh and eighth being twice cut ; and anteriorly the arches of the cartilages appear. On the left side the twelfth rib is absent, as from being so short it is not met with in the section, but lies entirely in the preceding lamina. This section, like the preceding, exposes the upper portion of the abdomen, with a part of the spleen, stomach, and a large part of the liver. The diaphragm is divided anteriorly through its attachment opposite the seventh rib, near the transversalis muscle ; afterwards in its free portion, so that a portion of the pleural cavity is seen ; and posteriorly through its arch and crura. The pleural cavity, which is clearly evident at the posterior wall .of the trunk, reaches further downwards there than it does in front; and extends on the left side to the section of the ninth, and on the right side to the seventh rib. It appears as a fine chink, which in pleurisy widens out into a considerable cavity, and may hold a large quantity of fluid (about one pound) before its presence can be demonstrated. A normal lung, however, may fill up this space in deep inspiration.

Besides the rest of the liver, stomach and spleen, in the space included by the diaphragm and the transversalis muscle, are seen the kidneys, pancreas and intestines. The section, of which the upper surface is here represented, is three and a half inches below the preceding, its inferior surface reaching to the navel.

In order to make the cavities of the intestines clear, their frozen contents were with great care broken loose before their walls were thawed by means of warm pincers ; and then the cavities accurately drawn with their folds in the hardened condition. Thus the regular sharply projecting folds of Kerkring, of the small intestine, and the irregular flat processes of the mucous membrane of the large intestine, are easily recognisable. On the liver, on the left side, anteriorly and internally, is the kidney, and the descending colon immediately below its left colic flexure, which is divided transversely. The contents were some green coloured faecal matter and a little gas. Between the ascending colon and the right kidney, is the vertical portion of the duodenum, divided transversely just as it winds round the head of the pancreas. The liver fills up the remaining space externally as far as the diaphragm. Its surface has the impression of the neighbouring structures. Its convex upper surface attaches itself intimately to the line of the diaphragm ; internally, on the other hand, the outline of the liver becomes irregular, owing to certain prominences in front from the impression of the colon, and behind from that of the kidney forms still recognisable after these organs have been removed, but which, however, may disappear from the equalisation of pressure within the peritoneal investment. It is open to proof that the form of the liver is not an independent one, but varies with the pressure and volume of neighbouring organs ; so that in a normal condition it must possess a softness of structure which can be compared with fat and connective tissue, and which yields to the movements and change of position of the organs in contact with it. A series of sections of frozen bodies in the region of the liver should be made, or the plates of Pirogoff (fasc. iii, 1, 2, 3, 5, 7) compared, to show that everywhere it is defined by the neighbouring organs, and entirely fills up all remaining spaces.

Only a small portion of the spleen is seen, entirely covered by peritoneum, and at this point nowhere attached thereto. Its posterior extremity reaches to the section of the eleventh rib, and corresponds also, if the preceding plate be examined, to the course and curves of the ninth, tenth, and eleventh ribs. Hence it agrees with what Luschka has recently published (' Prager Yierteljahrschrift,' Bd. 101, 1869, p. 122).

In the text to Plate XIII I have introduced three woodcuts, figs. 1, 2, 3, which explain the position of the spleen, although not originally with this view. They place its position in the upper compartment of the abdominal cavity in the cupola of the diaphragm in the different states of distension of the stomach, and were made from preparations, of which a view was obtained from above after raising the peritoneum by taking away the upper half of the thorax and part of the diaphragm ; and, although the perspective view of the position of the spleen is not quite correct, it gives the same results. PirogofFs plates (fasc. iii, B.), which represent plastic preparations made by chipping the organs out of frozen bodies must be compared with them. It is shown in all these figures, as Luschka states, that the spleen does not occupy the highest point of the cupola of the diaphragm, and moreover does not lie with its hilus on the fundus of the stomach ; but that the fundus of the stomach, covered by the left lobe of the liver, lies in the highest part of the cupola of the diaphragm, and the spleen takes up its position laterally with it. Correspondingly with the greatest amount of play of the diaphragm, the position of the spleen will not be affected ; and in breathing will be less displaced than if it lay high up in its cupola : at the same time, the influence of respiration is considerable enough to be of practical importance. The size of the normal spleen cannot always be felt with certainty in deep inspiration; if, however, it be enlarged, it can be reached with the finger, on causing the individual to take a deep breath. The determination of the size of the spleen, by percussion, always presents certain difficulties which must not be under-rated. Whilst on this subject I may mention that the kidney, and left colic flexure when distended with faeces, have more than once been mistaken for tumour of the spleen.

A small strip only of the stomach is seen in front of the seventh costal cartilage. The connection between the duodenum lying between the liver, pancreas and right kidney no longer exists. It can be seen, however, from the position of the duodenum that the pylorus must have lain near the middle line of the body, and so also that the pyloric portion of the stomach took an oblique direction from below backwards, hence the pyloric valve could not have lain in an antero-posterior direction directly, but more obliquely forwards (Luschka). In Pirogoff's Atlas (iii, 2, fig. l),is a section which passes exactly through the pylorus and shows this relation clearly. According to this plate the pylorus lies in the anterior half of the abdominal cavity near the eleventh costal cartilage, immediately to the right of the middle line of the body. It agrees, however, exactly with Luschka's statement that the pylorus is not to be sought in the right hypochondrium, as it never reaches the right arch of the ribs ; and from the present plate one can see that it must have had the same position. Hence, it follows that the horizontal portion of the duodenum does not run from left to right in a transverse direction, but more in an antero-posterior one between the ductus choledochus and the gall-bladder, close to the transverse fissure of the liver.

The duodenum is divided in its vertical descending portion at the point of flexure of the upper horizontal part. Between the vena cava and the pancreas is the ductus communis choledochus, which has passed directly over to the left side of the duodenum, in order to open into the vertical portion of the duodenum at the head of the pancreas. If we look into the duodenum we see how it curves round the head of the pancreas, becoming continuous on the left side with the inferior horizontal portion. Owing to the mobility of the stomach, without which the different stages of distension would cause great disturbance, we may expect that the pylorus and the upper portion of the duodenum would change with its condition of distension. I have proved that, whilst in the empty stomach the pylorus lies near the middle line of the body, in greater distension it is pushed half an inch further back. The upper portion of the duodenum possesses a mesentery in the hepatico- duodenal ligament, which permits and follows its changes in position. The middle or vertical portion of the duodenum is not absolutely fixed, but follows the movements of the ascending colon ; and in distension is pushed to the left of the middle line, assuming its original position when the colon is emptied.

The pancreas is divided obliquely, so that a small portion of the head remains on the left side and a considerably larger portion on the right. These relations correspond with the position of the pancreas, as it does not lie exactly horizontally, but passes obliquely downwards from left to right ; consequently the splenic vein, which lies below it, has had its upper surface removed in the section, and the mouths of the veins opening into it are seen.

The vein entering it directly in the middle line of the body is the superior mesenteric ; and at their junction the portal vein commences. This position is so constant that vertical sections in the middle line would expose a large portion of it (Plate I and II). The portion of the pancreas lying behind the vein is the so-called lesser pancreas.

The position of the pancreas at the level of the first lumbar vertebra, corresponds with that in Plate I and II ; it is, however, so increased in breadth that it extends downwards to the next vertebra.

Behind the pancreas on the right side is the vena cava, with the left renal vein opening into it, and near it on the left side the abdominal aorta. In front of the latter passes the superior mesenteric artery, in order to gain the root of the mesentery beneath the gland.

The aorta has nearly reached the middle line, where it divides below the third lumbar vertebra into the common iliac arteries. Its distance from the anterior wall of the abdomen is nearly four and a half inches ; whilst the distance in the preceding Plate at the level of the eleventh dorsal vertebra, in the same body, is nearly five inches.

In plate, No. XYI, corresponding with the cartilage between the third and fourth lumbar vertebra, this distance is only three and a half inches ; so that it is clearly evident that the anterior curvature of the lumbar spine brings the vessel nearer the abdominal wall, rendering its compression from the front possible.

The section of the kidneys is such that it cuts the right above its hilus, whilst on the left side it has passed through it. The left kidney lies a little higher than the right a relation which exists in the generality of cases. The length of the kidneys corresponds with the bodies of three and a half vertebras, they extend from the upper border of the twelfth dorsal vertebra to the middle of the third lumbar. As they are in relation with the spleen and liver superiorly, and are bounded posteriorly by the diaphragm and pleural cavity, one would expect that they would be displaced in great pleuritic effusion by the descent of the diaphragm as are the liver and spleen. Enlargements of the liver exert a dislocating effect upon the kidney, as will be shown more exactly in the next plate.

The position of tne kidneys is rather antero-posterior than transverse, the hilus being turned more forwards than inwards. According to Luschka, lines which pass through the hilus corresponding with the greatest breadth of these organs intersect if produced forwards, at an angle of 60 in front of the middle of the first lumbar vertebra a statement which corresponds tolerably with the relations seen of the present plate.

PLATE XVI

THE section in this case passes through the navel dividing the soft parts just above the iliac crest, and the inter- vertebral space between the third and fourth lumbar vertebras. The ribs are no longer seen, and the section is now below the thorax and through the middle of the abdomen. The walls of the abdominal cavity are formed, anteriorly and laterally entirely by the three oblique muscles, behind by the quadratus lumborum and the strong ligaments together with the psoas magnus of both sides. The posterior wall, where no spinous processes are visible, is very thick and strong, and formed by the mass of the dorsal muscles. The contents of the abdominal cavity are the great vessels and ureters, the ascending transverse and descending colon, and the small intestines. The contents of the intestines were carefully removed in order to allow of these viscera being accurately represented in situ. The section is from the same body as the preceding, and is taken about two inches lower down.

Before explaining the details here represented, I have to make some few remarks on the kidneys. They lie entirely above this section and within the region of the ribs, higher than is frequently supposed, and as many are accustomed to seek them. Hence their position may be considered as an independent one as regards the movements of the diaphragm or enlargements of the liver and spleen. I think I can prove that in both respects the relations are otherwise, and that the position of the kidneys is unchangeable.

Both kidneys extend over the bodies of three and a half vertebras, and reach from the upper border of the twelfth dorsal downwards to the middle of the third lumbar ; and it is to be remarked that they do not lie exactly on the same level, but that the left rises somewhat higher than the right.

According to Luschka (Anat., ii, 1, p. 289), they usually lie higher, viz. from the middle of the eleventh dorsal to the lower border of the second lumbar vertebra. I do not lay any stress on this, and I think that these statements may be regarded as coinciding with mine, since half a vertebra makes but little difference. The hilus lies at the level of the first lumbar vertebra, and corresponding with it is the position of the renal vessels in Plates I and II. Pirogoff gives the same (fasc. iv, tab. 4 9) ; but through the hilus in front of the first lumbar vertebra. The upper margin within which the kidneys are divided is determined by the eleventh dorsal vertebra ; the lower by the cessation of the section of the ribs, and corresponds nearly with the third lumbar vertebra.

But the relations are different if there be depression of the diaphragm, or enlargement of the liver and spleen. The kidneys are then pushed out of their position, and undergo a dislocation, which may amount to the extent of several vertebras. In a pleuritic exudation of the right side no kidney is to be seen at the middle of the twelfth dorsal vertebra, Pirogoff (iii, 6, 3) : and in the man of fifty years, with enlargement of the liver and spleen as I have before mentioned, the hilus, as in the woodcut, fig. 1, is met with at the level of the fourth lumbar vertebra. The kidneys were also here directly pushed downwards on to the soft parts.

As regards the intestines, in Plate XYI, the inferior portion of the colon is in front ; behind and on the left side the contracted descending colon ; posteriorly and on the right the ascending colon more distended.

Both the ascending and descending colon lie in the angle formed by the psoas magnus and quadratus lumborum. More in the middle of the cavity of the abdomen are coils of small intestine, though not so many as one might expect. From the descending colon to the anterior border of the transverse colon is seen the cut surface of the great bag of the peritoneum passing across to the ascending colon.

It is remarkable that the intestines should show such extreme differences in calibre. According as they are empty, full, or distended with gas, they exhibit a larger or smaller cut surface. The ascending and transverse colons are large, and so also is a coil of small intestine, which has considerably compressed the end of the latter.

The other portions of the small intestine are only slightly distended ; and the descending colon is nearly empty.

FIG. 1. Male, set. 50. Dislocation of the kidneys. .

1. Kidney. 2. Vena cava inferior. 4. Abdominal aorta.

The vertebra shown is the fourth lumbar.

The following woodcut from Pirogoff (iii, 10, 1), which represents all the intestines fully distended, does not correspond with the natural state of things, but is the result of excessive and equally distributed artificial distension.

Pirogoff states that by inflating the intestines of a subject in all respects normal, before freezing it, he has completely distended the abdomen.

The external contour of the abdominal walls corresponded with this artificial distension of the intestines. This contour is almost in the form of a circle, whereas mine corresponds with the normal relations, and presents a flat oval. It will be observed from the condition of the oblique muscles how considerably the distension of the abdominal walls has compressed them ; and we can estimate from their stretching and thinning the form they must assume in pregnancy, ovarian tumours and ascites, and regulate the depth of an incision when required.

FIG. 2. Male adult. The intestine inflated with air and greatly distended. Pirogoff, iii, 10, 1. 5.

1, 1. Inferior margins of the kidneys. 2. Abdominal aorta. 3. Inferior vena cava. 4. Ascending colon. 5. Descending colon.

We must notice the position of the spinal column. As in Plate XYI the intervertebral substance lies nearly in the middle of the circle, while in PirogofFs plate the position of the vertebra is far behind it.

The distance of the anterior wall of the abdomen from the spine in Plate XVI is nearly 3 inches ; in fig. 1, 2*5 inches ; and in Pirogoff s nearly 6 inches, the section passing immediately below the navel.

A less distance between the spine and the abdominal walls than that shown in Plate XVI is not uncommon. This depends on the position of the diaphragm and the contraction of the lung on the one hand, and on the distension of the intestines on the other : and it is easily understood how, with normal lungs and empty intestines, the abdomen in the dead body can be pressed in so much, and the lumbar vertebra present such a marked prominence through the abdominal walls, the distance being thus reduced to a minimum.

Therefore, in compressing the abdominal aorta, care must be taken to obtain a high position of the diaphragm, and that the intestines be as empty as possible. This compression is indispensable, for example, in disarticulation of the head of the thigh-bone. Pressure must be brought to bear immediately in the region of the navel, as the aorta divides just below the umbilicus, and still further downwards the finger would fall into the pelvis.

Lying near is the aorta in the middle line, and the cava, which is more to the side, also the ureters, and close to them and more externally the spermatic vessels. Behind and partly internal to the psoas are the sections of the lumbar nerves.

The oblique muscles are divided immediately above the crest of the ilium. The relations of their tendons to the sheaths of the rectus abdominis and quadratus lumborum are so clearly shown in the plate that we need not refer to them again. The anterior iliac spines spring forward as projections in the external contour.

It remains now to describe the position of the descending colon, and the operation for opening it, which is practicable in this region without wounding the peritoneum. This proceeding was described by Callisen, but was first performed by Amussat in 1839, and it afterwards obtained the name of Callisen- Amussat 's operation for artificial anus.

This operation is preferred by most surgeons to that of opening the iliac flexure in the left inguinal region (Littre), as the descending colon has a fixed position, and, being incompletely invested by peritoneum, an incision can be made into it without wounding this membrane. It is usually stated that the descending colon lies along the outer border of the quadratus lumborum ; and, in conformity with this, an incision is to be made vertically along the outer border of this muscle. This is not always correct. At the lower border of the kidney the colon lies further outwards than it does in the neighbourhood of the ilium ; and, the quadratus lumborum being narrower above than below, the rule is true as far as regards the level of the third lumbar vertebra, but not so for the deeper regions. At the level of the symphysis between the third and fourth vertebra, and at the fourth below the kidney and therefore exactly in the field of operation the quadratus lumborum covers in the colon posteriorly,- and must be cut in order to reach it. It is only when much distended, a condition which is not so constant as one would expect in operations, that the intestine increases in breadth forwards and inwards, or overlaps the outer border of this muscle (PirogofF, iii, B., tab. 14). Consequently the incision, which is to be directed along the border of the great extensors of the trunk from the ilium to the twelfth rib, would divide the strong tendons of the transversalis until the quadratus is exposed, and subsequently the fibres of this muscle, when the extra-peritoneal fat and cellular tissue would be met with.

When the surgeon has carefully arrived at the cellulo-fatty tissue through the fascia beneath the quadratus lumborum, making the incision of an equal length with the primary one, so as to avoid a funnel-shaped wound, the main point is to fix the colon at its free surface and to open it. In doing so he must avoid the kidney, which from its deep position (cf., fig. 1) can easily obstruct the field of operation, and which must therefore be carefully pushed on one side. From the impossibility of recognising the peritoneum from its posterior aspect, success can only be safely calculated on by measuring the distance of the point of reflection of the peritoneum, and how far from the colon this position is constant.

In the first place, as regards the descending colon, which I here particularly refer to, after measurements on frozen bodies of full grown men, I find that this distance, in a straight line (therefore not corresponding with the curvature of the wall of the intestine), is from four fifths of an inch to one inch, supposing the intestine empty and contracted (at a level between the third and fourth lumbar vertebraa) ; further, that the free side of the intestine, as in Plate XVI, does not look posteriorly but somewhat inwards, exactly towards the angle which the psoas and quadratus lumborum make with each other. If, on the otheiv hand, the small intestines are much distended, the peritoneum between the psoas and colon would be pushed further downwards ; and the colon, by means of the traction of the parietal portion of the peritoneum, would be rotated on its axis, so that its free surface would be directed more outwards.

Should the colon itself be distended, its surface free of peritoneum becomes considerably larger, and may assume a breadth of from 2 to 2' 5 inches. Tympanitis of the small intestine appears to have a rotatory influence on the distended colon ; and on comparing Pirogoff's plates it is shown with its free surface turned somewhat outwards (cf. Pirogoff, iii, B, tab. xiv).

In the performance of the operation of colotomy a distended abdomen will probably often be met with. I therefore do not consider these remarks superfluous, and I hope that they may contribute to make the avoidance of the peritoneum more certain than heretofore where it was so much left to chance ; and, as a third part of the cases show wound of this membrane, the value of Amussat's method appears problematical.

PLATE XVII

IN order to bring the pelvic organs into view, a section was made of the trunk just over the symphysis pubis, and through the lower portion of the sacrum. The section passed through the inguinal region, the outer mass of the muscles of the thigh, the head of the thigh bone near its middle, the pelvis, bladder, rectum, and some coils of intestine lying in Douglas's pouch. The ischia were divided in the tuberosity, so that the section nearly followed the sacro-spinous ligament.

The plate moreover shows, enclosed in the bony pelvis, the obturator internus and levator ani muscles, and laterally the ilio-femoral articulation with its muscles and vessels.

We notice at first that the central portion is bounded by the pubis, ischium, levator ani, sacro-spinous ligament, and the last portion of the sacrum.

The bladder, which contained about four ounces of frozen urine, appeared so contracted on its contents that its form was not affected by the pressure of the neighbouring organs, as is so frequently observed in Pirogoff's plates, whence the upper wall appears considerably fallen in. The body was perfectly fresh when brought in for preparation, and as no decomposition had set in gas had not formed, so that the forms of the cavities were not changed. The contents of the bladder were removed before the drawing was made. The internal orifice of the urethra is clearly seen in the middle of a fringe formed by folds of mucous membrane. More in front is the anterior wall of the bladder, flattened by the pressure of the symphysis. The thickness of the wall of the bladder, considering the amount of distension, is considerable. The thickness of the posterior wall, however, is due to its having been cut obliquely. In order to compare the position and form of the bladder with the section given in Plate I, the mass of ice was carefully removed and represented in profile. This could readily be accomplished, as only a small part of the upper wall of the bladder and its contents was removed with the upper portion of the section. By comparing this with the sagittal section of Plate I a close agreement in form was observed ; though they differed in the fact of the internal orifice of the urethra in Plate I being somewhat higher than in this. In both cases, however, the form and position of the bladder of a young powerful man is defined, as can be verified by injecting tallow either by the urethra or the ureters. It is, at least, certain that the spherical form represented by Kohlrausch is not a natural condition, as he omits to notice a neck to the bladder, which is a funnel-shaped contraction of this viscus towards the urethra. For a wider distension of the bladder there is, as the plate shows, ample room. The cellulo-fatty tissue on both sides of it gives way readily, and the coils of small intestine are easily lifted up and pushed on one side by the swelling bladder. The rectum will be more flattened, and room is afforded by the emptying of great venous plexuses, until at last the bladder alone almost fills the pelvic cavity. With these changes in volume of the bladder, the relations of its peritoneal coat alter. Even in the slight degree of distension shown in the present instance, only the upper wall and a small portion of the posterior were covered by peritoneum, so that there was a passage above the symphysis although but a slight one ; and it is evident that this sub-peritoneal passage must acquire breadth with the increased distension and elevation of the bladder. Behind the bladder is a flat section of the peritoneal sac containing a portion of small intestine divided behind the fold of Douglas, and behind this again is a cul-de-sac of peritoneum, the so-called pouch of Douglas. This is directed in an oblique direction forwards and downwards, and is about three fourths of an inch deep. It held about three fifths of an ounce of frozen water.

The vesiculae seminales, which lie immediately below the section, were exposed by taking away some cellular tissue ; towards the middle line the vasa deferentia take a sharp curve forwards and upwards, and are divided in the section ; their small calibre and thick walls are well seen. Anteriorly and somewhat externally, are the ureters in section. The rectum, which contained a little faeces, was divided shortly before its final curve. The anal extremity was fully 3-8 inches distant from it. If the peritoneum leaves the anterior surface of the rectum entirely free, and, under the form of Douglas's pouch, descends here externally and internally rather more than half an inch ; this pouch is about three inches from the anal aperture, and it follows that at this level an operation on the rectum might be undertaken, without fear of wounding the peritoneum. These relations correspond with those of Plate I.

The question arises with regard to the rectum, as in the case of the bladder, what changes of form it assumes with its varying degrees of distension ; that it is capable of very great changes in volume, both experience and experiments by means of injection show us. The requisite space is provided for in the same way as for the bladder ; the cellular tissue and fat are pushed aside, Douglas's pouch and the intestines are lifted up, and in fuller distension of the rectum the bladder is raised somewhat upwards and forwards. The following woodcut from Pirogoff's atlas is instructive on this point.

There is little here that needs explanation ; the great similarity in form with my plates will facilitate the description. More than half the cavity of the pelvis is occupied by the distended rectum, which is cut through about two inches above the anus, and is considerably distended with air. The semi-lunar fold has not been obliterated by this distension, but springs up sickle-shaped into the cavity. The contour of the pelvic cavity is worthy of notice. The section passes as above mentioned through the spines of the ischia, and partially through the sacro-spinous ligaments, and between the ischiatic notches. Corresponding with it, a process of bone springs from the body of the ischium on both sides, tolerably far backwards, and terminates in the whole length of the sacro-spinous ligament as far as the sacrum. On the right side this band is only to be followed for a certain distance from the sacrum, and does not reach to the apex of the ischium as on the left ; while the sacro-spinous ligament has a horizontal direction, the tuberoso-sacral ligament has a more vertical one, and a small portion only of the latter is seen. It is shown near the sacrum at the edge of the gluteus, where it deviates from the other ligamentous band and lies deep.

Between these fasciculi, on the left side, lie the internal pudic vessels and nerves ; on the right they are further off, and are to be looked for near the spine of the ischium. Internally on either side from the sacro-spinous ligament is a dark band, partly prolonged to the spine of the ischium and partly associated with the fascia of the obturator internus; this is the superior portion of the levator ani. This muscle closes-in the cavity of the pelvis like a muscular funnel, and consequently may not be inaptly compared to the diaphragm. All sections which divide the bladder further downwards must therefore fall within the region of this muscle, and expose it as a muscular ring limiting the pelvic organs. Such a section is shown in the following figure.

Fig. 1. Transverse section of the pelvis of a boy, set. 15. Pirogoff, fasc. iii, tab. xvi, fig. 1. 1,1. Head of femur. 2,2. Great trochanter. 3. Tip of coccyx. 4. Rectum distended with. air. 5. Bladder. 6. Upper border of symphysis pubis. 7, 7. Spermatic cord. 8, 8. Femoral vessels. 9, 9. Obturator internus. 10, 10. Gluteus maximus.

Fig. 2 represents a section that I made on the pelvis of an old man. It passes through the symphysis; on the left side through the lesser sacrosciatic foramen ; on the right somewhat lower, through the tuberosity of the ischium ; and posteriorly through the tip of the coccyx. The levator ani is seen bounding the pelvic cavity, which contains behind the rectum a coil of small intestine, the vesiculse seminales, and the neck of the bladder and urethra.

Since this section is taken considerably deeper, the left gemellus inferior is seen running in direct relationship with the obturator internus muscle ; notwithstanding this, Douglas's pouch with its peritoneum is present. It thus appears that the position of the peritoneal sac is deeper in the present one than on the young subject shown in fig. 1.

If we consider, moreover, that in new-born children the position of the peritoneum relatively within the pelvis is particularly high this relation must be described as natural and corresponding with advanced age ; and hence one must be particularly careful, in operations on the rectum in old people, not to wound the peritoneum, which extends lower down than in younger individuals.

FIG. 2. Transverse section of the pelvic cavity. 1,1. Head of femur. 2. Rectum. 3. Bladder. 4,4. Femoral vessels. 5. Apex of coccyx. 6. Gluteus maximus.

Fig. 3 is reduced from Pirogoff's atlas. It is stated in the text (fasc. iii, p. 59) that it was from the body of a full-grown man, whose bladder and rectum were full. The section passed through the lowest portion of the symphysis, about seven lines below its upper border, through the foramen ovale, the tuber ischii, near the lesser sciatic notch and the insertion of the sacro-sciatic ligament, and included the coccyx posteriorly. The lower half of the section is represented, so that it is viewed from above downwards.

In such a section, a clear view of the levator ani cannot be given, at least not with respect to its physiology, as only a small portion of its fibres would be divided. It will be clearly seen at the same time that when the rectum is full Douglas's pouch and the lower coils of the smaller intestine are lifted up. Between the bladder and rectum lie the sections of the vesiculse seminales. Outside the pelvic cavity, are the thigh bones divided through the neck, with the ligaments and their corresponding vessels and muscles. As the head of the thigh bone presents a spherical form only internally and above, so each transverse section which passes through it near its middle includes a portion of its neck, and therefore produces externally a cut surface very far removed from a circle. The inner contour only would present a portion of a circle, namely at the point of insertion of the ligamentum teres. The component portion of the joint is better seen higher up.

FIG. 3. Section of the lower portion of the pelvis of a full-grown man, with distended rectum. Pirogoff, iii, 16, 3. 1,1. Head of femur. 2. Rectum. 3. Bladder. 4. Femoral vessels. 5. Tip of coccyx. 6, 6. Gluteus maximus.

Fig. 4 is taken from a series of sections on the body of an old man, Section of the pelvis of an old man at the level of the great sacro- sciatic ligament.

1,1. Head of thigh bone. 2. Rectum. 3. Apex of bladder. 4,4. Femoral vessels. 5. Lower end of sacrum. 6, 6. Gluteus maximus.

somewhat higher than Plate XVII, and is therefore useful in comparison with it, since it traverses the entire length of the sacro-sciatic ligament.

The acetabula are divided nearly through their centre. Nothing more of the symphysis pubis is to be seen, as in consequence of the greater inclination of the pelvis it lies considerably deeper. The relation of the vasa deferentia to the femoral vessels is well shown. Corresponding with the deeper position of the viscera in old persons already mentioned, a quantity of coils of small intestine are here shown, whereas on Plate XVII there is merely a small flat section of the ileum.

PLATE XVIII

IT appears to me desirable to introduce here a frontal section of the pelvis, and one that will show the relations of the hip-joint to the best possible advantage. After many investigations, I became convinced that for this purpose a definite position of the bones is necessary, as when the subject lies on the back they are rolled outwards, and the head, neck, and shaft do not lie in the same plane. It is only when the thigh is rolled considerably inwards, so that the inner borders of both feet touch throughout their entire length, that they do so ; I made the section, therefore, with the feet tied together.

The section passed through the pelvis and hip-joint in such a manner as to render the two sides as symmetrical as possible. The upper portion of the shaft of the right femur is not divided quite in its axis, and only a portion of the great trochanter is clear, while the lesser trochanter is covered with muscles. The head and neck are fairly divided. The section passed through the middle of the acetabulum ; through the whole length of the ligamentum teres of both sides, the obturator foramen and the ilium. The promontory of the sacrum and the tuberosities of the ischium lie in the posterior half of the body.

The preparation is viewed from the front, and thus the right side of the body is to the left of the picture and the converse. It represents the lower portion of the abdominal cavity, bounded above by the three flat abdominal muscles, and more externally by the iliaco-psoae, in which are the anterior crural nerves. Within these muscular walls are the intestines, extending as far down as the bladder, the anterior portion of the cavity of which is opened. The sections of the small intestine, which above is jejunum and below ileum, as can be readily recognised from the nature of their mucous coats, indicate that in many instances they have been met with in their long axis. There are singularly few instances in which this has happened in the preceding sections, and it therefore follows that the coils of intestine have a parallel direction with the long axis of the body.

Of the individual portions of the intestine, the section of the vermiform process is seen at the upper border of the right psoas ; and on the left of the iliac vein the transverse section of the rectum. The latter was especially studied in relation to its course. It ascended behind Douglas's pouch, in the left half of the body near the middle line ; curved sharply forwards over the left psoas muscle, so that it fell in the plane of the section ; and then passed somewhat forwards towards the right half of the body as an arc of a large curve, ultimately becoming continuous with the descending colon. It shows, moreover, a deviation from the usual course, at the lower portion, as figured by Pirogoff (fasc. iii B, tab. xv, fig. 1), but does not completely correspond with the relations shown in Plates I and II; and one can easily convince oneself by injecting with tallow that, in individual cases, and those not very rare, the S-curve of the rectum is not sharply marked in a frontal direction with regard to the sacrum, variations which are owing to the inconstant length of the meso-rectum. Should this be strong and reach far back, the position of the rectum is freer, and more dependent on the condition of the neighbouring organs. Shortness and tenseness of this meso-rectum, on the other hand, contribute to a firm and constant position of the intestine.

The effect produced by the distension and by the firmness of the walls of the rectum must be taken into consideration. Great distension from faeces, and flaccidity of its walls especially, permit of considerable stretching of the original curves. It can be proved by investigation and clinical observations, that the surgeon can straighten the curved rectum by means of instruments, and introduce them as far as the iliac flexure. Foreign bodies introduced from the anus, and firmly impacted, can be seized with forceps and withdrawn.

The bladder contained a little urine, and was firmly contracted : it is separated from the section of the levator ani by a little fat ; on both sides of the levator ani lie the sections of the obturator internus, bounded below by the obturator membrane, and laterally by the pelvic bones. If the space between the intestines and the pelvis be followed upwards on both sides from the bladder, beneath the peritoneum, we meet with two whitish oval sections, which represent the lateral ligaments of the bladder. They lie thus far removed from the bladder, because it was small and contracted ; a distended bladder would carry them upon its upper surface, and at the same time occupy the entire space of the inferior aperture of the pelvis, as several of Pirogoff's plates show. Farther outwards, and in the same space, between the peritoneum and the pelvis, is the vas deferens, and above it the obturator vein and nerve and a small artery. The main trunk of the artery passes through the obturator foramen.

Finally, we arrive at the external iliac artery and vein ; both vessels lie on the inner wall of the psoas, as the preceding sections show, not side by side, but behind each other ; hence the artery lies over the vein, and not to its inner side as appears by this frontal section.

The relations of the hip-joint, which have been already briefly alluded to, afford many points for examination. It has been already mentioned that the section has traversed the entire length of the ligamentum teres of both sides. It is evident that this ligament limits extreme adduction, and by simultaneous stretching, assists in maintaining the firm position of the pelvis and trunk. As the section passed through the acetabular notch the course of the articular artery is exposed.

The articular cartilage, ligamentous apparatus, and the extent of the cavity of the joint are well seen in the plate.

The architecture of the upper portion of the thigh bone is well worthy of study, as much so for its general disposition as for its structure. Meyer has the merit of having first called attention to the arrangement of the cancellous tissue, especially in the neck of the bone, which essentially increases its weight-bearing power. The individual laminae and interlacements of bone arrange themselves in rows, which are detached from the borders of the compact tissue, and cross each other in the middle line. In the section of the left thigh bone especially these indications of its structure are shown.

The articular cavities themselves appear merely as chinks. Their extent downwards explains to what limit intracapsular fracture of the neck of the thigh bone may reach, and where the region of extra-capsular fracture commences. Since intra-capsular fractures isolate the upper fragment, and leave it connected by the ligamentum teres and the acetabular vessels, it is evident that, apart from the difficulty of accurate adaptation and retention of the parts, union is of very rare occurrence, on account of conditions unfavourable for its nutrition.

An increase of effusion into the joint, as may happen in inflammation, will not separate the surfaces of the acetabulum and head of the thigh bone. The powerful ilio-femoral ligament, in consequence of its torsion in complete extension, presses the joint-surfaces firmly against each other. On the other hand, in flexing the joint, a corresponding separation of the two surfaces will occur from increased effusion within it ; and, as investigations show, this may be somewhat considerable. If fluid be injected through the acetabulum into the joint-cavity, after the example of Bonnet, the articulation takes successively the positions which afford the greatest amount of space ; but which ultimately place the ilio-femoral ligament in the condition of greatest relaxation. The femur is raised and somewhat rolled outwards. If the joint be frozen, sections can be made of it, and the relations of the articular surfaces to each other rendered clear. The accompanying woodcut represents such a preparation, made from the body of a normal young female.

In order to render the femur more easily movable, the upper layer of muscles was removed and the bone itself sawn through the middle.

On injecting the joint with tallow, and applying as great a pressure as possible, the femur was raised and rolled outwards. In this position it was frozen and sawn as shown in the woodcut ; the section passing not quite through the middle of the head, but slightly in "front, and including the trochanter minor in its course. The mass of tallow, which is here represented by the dark shading, was about one fifth of an inch thick, and a little farther down in the articulation somewhat thicker ; and surrounded the head of the bone like a cap, extending outwards to the attachment of the synovial membrane, which was driven forwards in the form of a bladder

FIG. 1. on its posterior wall. We should expect to find, in diseases of the hip -joint which exhibit similar positions of the articulation, an actual lengthening of the thigh, supposing that a like quantity of fluid exists in the joint cavity. To prove this by measurement is impracticable. Were it possible to measure it accurately to a quarter of an inch, which from the simultaneous displacement of the pelvis can hardly be expected, the flexion of the thigh, associated with this condition, renders such measurement impracticable.

The relations of the corpora cavernosa and urethra next demand attention. It will be seen that the section passes in front of the prostate, dividing the corpora cavernosa penis near their origins, and the urethra at the bulb. The corpus cavernosum, arteries, and muscles of the corpus cavernosum are well shown. Upon it is expanded a portion of the deep perineal muscle with a number of large veins.

Frontal section of the hip-joint injected with tallow and frozen. J.

1. Head of femur. 2. Tendon of rectus. 3. Obturator externus. 4. Pectineus. 5. Tendon of ilio-psoas. 6. Glutens minimus.

FIG. 2. Frontal section of the male pelvis through the membranous portion of the urethra. 4-

1. Prostate. 2. Wall of bladder. 3. Caput gallinaginis. 4. Deep transversus perinei muscle. 5. Bulb. 6. Ascending ramus of the ischium. 7. Obturator membrane. 8. Obturator externus. 9. Obturator internus. 10. Adductor magnus.

As it appeared to me desirable to have a section showing these structures rather farther back, I made one on the body of a normal well-built man, at such a depth as to pass through the prostatic portion of the urethra. The preceding woodcut represents the plate on a smaller scale. The head of the left femur is seen only as a small segment, and not in connection with the rest of the bone.

The body of the ischium shows a large surface in section, corresponding with its more extensive development behind the acetabulum. The obturator membrane, ascending ramus of ischium, and the obturator externus and internus, still show some resemblance to the corresponding portions on Plate XVIII, and so also do the corpora cavernosa. We have, moreover, in the section, in place of the apex of the bladder, its posterior wall, and the posterior half of the prostate, with the caput gallinaginis.

The membranous portion of the urethra and the prostate are opened. On both sides of it are the deep transverse perineal muscles, the fibres of which are expanded towards the middle line. Above is seen the anterior mass of the levator ani. Around it is a layer of fascia, the upper portion of which is continuous with the pelvic and the lower with the perineal fasciae. Both fasciae meet at the inner border of the levator ani muscle, and help to support the prostate. The upper lamina of the perineal fascia and the lower surface of the transversus perinei pass forwards.

The plate, which must not be regarded as diagrammatic, agrees in all its essential particulars tolerably accurately with Henle (* Eingeweidelehre,' p. 504, fig. 392), which should be compared with it.

PLATE XIX

IN order to demonstrate the shape of the cavity of the knee-joint and the extent of its capsule correctly, I injected water into the articulation with a Pravaz's needle under great pressure, and, having slightly flexed the joint, froze it. The limb was taken from a normal body (young female). The section passed tolerably nearly through the middle, and divided the extremity into two nearly equal halves, of which the right one was used for the plate, after the removal of the frozen water.

All the joints, not the hip and shoulder only, are subject to atmospheric pressure ; and, on account of the small quantity of synovia which they contain, can retain their normal position and not show free cavities, as one finds on opening a joint in a soft preparation. Accordingly the synovial cavity appears in the section of a normal joint as a narrow crevice:, which in the following section of a normal uninjected knee-joint is represented by a single black line.

If this joint be compared with the injected specimen, as represented in Plate XIX, one can understand the meaning of the black line which indicates the joint cavity. Further, the position of the patella is seen in normal and abnormal joints. Whilst in the normal condition of the joint the patella touches the femur with a small portion of its cartilaginous surface like a tangent, in the case of the distended synovial membrane it is completely lifted off it. The patella floats, supported by the fluid as a board on water, and must therefore yield under pressure of the finger until it reaches the femur, which lies behind it.

The capacity of the joint-cavity is well shown, whilst in the woodcut the synovial membrane of the extensor muscles appears as separated from it, since the wide aperture of communication which unites it with the bulging out of the capsule is not opened by the section ; and on the injected joint represented in Plate XIX no such separation is to be seen. The fluid injected has penetrated into all the portions and hollows of the joint, and has raised up the posterior wall of the capsule, so that the posterior portion of the condyle of the femur is brought into view.

Fig. 1. The ligamentum mucosum of the patella and the anterior crucial ligament lie in the plane of section.

It is well known that Bonnet was the first to apply the method of injection to the investigation of joints, and to prove thereby what position of the joint corresponded with the greatest distension of the synovial cavity. It appeared in all joints that it was the position of flexion that allowed of the greatest amount of fluid entering the articular cavity; and that, with strong pressure of injection, all joints, no matter what position they may have

had beforehand, acquire the position of flexion and maintain it so long as the pressure is continued. It is natural to suppose also that in diseases of the joint, associated with effusion into the synovial cavity, the position of flexion which the patients involuntarily affect is brought about by the direct pressure of the fluid.

But against such a supposition the following points may be adduced, as can be well explained after consideration of this plate.

Longitudinal section of the frozen knee-joint of a full-grown man. . 4

1. Femur. 2. Tibia. 3. Patella. 4. Posterior crucial ligament divided. 5. Bursa mucosa. 6. Quadriceps extensor. 7. Ligamentum patellae. 8. Semi-membranosus. 9. Gastrocnemius.

The capacity of the joint-cavity also depends on the possibility of the separation of the patella which is developed in the extensor tendon from the surfaces of the condyles. This is, however, the case when the extensor tendon is relaxed, as in extension, or in only slight flexion of the joint ; in greater flexion the patella must be pressed against the condyles, by the tension of the quadriceps, thus causing a diminution of the capsular cavity. It will therefore be expected that in consequence of the extension of the synovial space upwards beneath the extensor tendon, a considerable quantity of fluid may be injected, and that a greater degree of flexion must directly diminish the amount. I therefore considered it necessary to undertake a repetition of Bonnet's researches with the greatest possible care, and that on entire bodies. The method I used was the following :

The subject was fresh and normal, and, after violently breaking down the rigor mortis of the lower extremities, was laid on its back on a horizontal table. The thigh hung down over the free edge, and during the investigation was fixed by means of a support under the heel by an assistant in the necessary position. A screw was driven into the upper third of the tibia, to the free extremity of which a flat piece of wood was fastened ; which served to fix a dial plate, provided with a graduated semicircle ; and it was so arranged that a plumbline fastened to the centre of the circle stood at zero in complete extension of the bone, and the amount of flexion could be immediately read off. No regard was taken of the rotation of the thigh during flexion. In order to prevent diffusion through the capsule, the fluid used for injection was a solution of common salt, contained in a graduated tube about sixty inches in length, to the inferior end of which was fastened a short piece of tubing of india rubber, carrying a strong Pravaz's needle. The tube was fixed in an oblique position by means of a movable support, so that the vertical line, indicating the difference in height of the point of introduction of the needle and of the level of the fluid, always remained the same ; by which means the pressure indicated by the constant height of the support was maintained. The apparatus thus formed a right-angled triangle whose hypothenuse was represented by the obliquely directed tube, the perpendicular by a portion of the support, and the base by a horizontal line running parallel to the table and extending from the point of introduction of the needle to the support. The point of introduction of the needle being as near as possible in the axis of rotation, it remained almost unaltered in flexion of the knee-joint ; consequently it was possible from the changing level of the water in the tube, to read off the diminution or the increase of the fluid in cubic centimetres. Of course, the support had to be constantly placed under the meniscus of the fluid, whilst the zero point of the tube was kept in an unaltered position relatively with the point of introduction of the needle. Thus, whilst the side of the triangle indicating the pressure was constant, the length of the hypothenuse and that of the other side varied, becoming larger on diminution of the volume of the synovial space, and smaller in the contrary condition.

By means of this method of investigation it was possible to determine the following points which Bonnet's proceeding could not afford. We could immediately ascertain the dependence of the capacity of the synovial cavity on the angle at which the bone was placed, since the pressure of the fluid in the walls of the capsule always remained one and the same, and these in the intact condition of the body and extremity presented their original relations to skin, fat, muscle, &c. Thus the grade of flexion, in which the synovial cavity reached the maximum of its capacity (described by Bonnet as the mid-position between flexion and extension), could be accurately recorded. Finally, the volume of the synovial space during the different positions of the bone could be measured by cubic centimetres. The following figures, which indicate each angle of flexion, will be easily understood after the preceding description. corresponds with complete extension, 10 would indicate that the thigh made an angle of 170 with the leg, &c.

The figures referring to the volume give the quantity of fluid in the capsule in each case, in cubic centimetres ; those referring to pressure, in centimetres.

Experiment 1. Body of a man, aet. 50; tolerably recent. Muscular development and nourishment good. The rigor mortis of the limb forcibly broken down. Pressure 19 centimetres.

Angle . 10 20 30 40 50 60 70 80 90 100

Volume . 312 328 332 331 330 326 316 303 283 265 255 c.c.

Experiment 2. Body quite recent. No rigor mortis. Pressure 23 centimetres.

Angle . 10 20 30 40 50 60 70 80 90 100 110

Volume . 114 128 137 141 141 140 135 125 112 99 76 75 c.c.

Experiment 3. The opposite knee of the same body. Pressure 34 centimetres.

Angle . 10 20 30 40 50 60 70 80 90 100 110

Volume . 83 95 104 111 110 109 107 93 91 83 66 54 c.c.

Experiment 4. Body of a man, set. 50; eight days dead, poorly nourished. Rigor mortis forcibly broken down. Pressure 14 centimetres.

Angle . 10 20 30 40 50 60 70 80 90

Volume . 143J 149J 154J 146i 139 136 118 102 88 78 c.c.

Experiment 5. Body of a muscular man, set. 36 ; rigor mortis broken down.

Angle . 10 20 30 40 50 60 70 80 90 100

Volume . 79 90 98 104 101 98 82 91 67 50 32 c.c.

Experiment 6. Well-nourished male, set. 30. Knee very rigid. Pressure 52 centimetres.

Angle ' . 10 20 30 40 50 60 70 80

Volume . 108J H2 125 125J 124 115 105 101 95 c.c.

The results which follow from these researches I may sum up in the following propositions :

1. That the knee-joint, in equal stages of flexion in different individuals, shows a very great difference in the capacity of its synovial membrane.

The difference of the pressure need not be taken into account, as, indeed, at the lowest pressure the volume of fluid in the joint was a maximum. It is the connection of the joint cavity with neighbouring synovial sacs which causes this phenomenon.

I have left the figures referring to the volumes in cubic centimetres and the pressures in centimetres, since, for any practical purpose for which this table may be available, the following equations will facilitate their reduction to English measure :

1 centimetre = -3937 inch = -4 inch nearly.

1 cubic centimetre = "061 cubic inch = '0352 fl. oz. nearly TR.

2. That the capacity of the sync-vial cavity reaches its maximum in a definite degree of flexion, and that the angle at which this happens is 25.

We learn from this that the statement of Bonnet, that the maximum capacity happens in the position of semi-flexion is incorrect, as we see that the position in which this condition exists is rather at the commencement of flexion .

But a second and not less interesting relation is evident from the preceding experiments. It is that the increase of capacity is the greatest from extreme extension to 10 of flexion, less from 10 20, and still less from 20 30. An important practical fact follows from this, that a slight degree of flexion, such as 10, determines the relatively greatest increase of capacity of the capsule.

If the joint be in the position attained, when filled with fluid to its greatest extent, it may be forcibly extended without fear of rupture of the capsule ; and here, again, my results differ from those of Bonnet.

3. The minimum of the capacity of the synovial cavity coincides with the maximum of flexion. Hence, the idea expressed by Bonnet on the method of treating penetrating wounds of joints is disproved that the extension is the position in which the capacity of the capsule diminishes. Although in extension, as sections of frozen tnee-joints show, the joint surfaces are closely approximated by means of the tensely stretched lateral ligaments, the spaciousness of the capsule in this position is, nevertheless, very considerable ; and it is larger in seraiflexion than in complete. If the knee be forcibly flexed, and if the joint be now entirely filled with fluid, there ensues a degree of flexion by which the wall of the capsule is ruptured and the fluid escapes into the cellular tissue.

Moreover the clinical relations throw considerable doubt upon the correctness of Bonnet's theory of the mechanism of the knee-joint. In such cases as acute arthro-synovitis, the ligamentous structures specially suffer, and disease is distinguished by copious effusion into the articulation. We frequently find complete extension of the knee-joint throughout the course of the disease an observation which I have repeatedly made, and which is corroborated by Volkmann (' Krankheiten der Bewegungsorgane,' 1865, p. 195). Again, effusion of blood into the joint in an extended position of the extremity exhibits symptoms compatible with this.

Figure 2. This section of a normal right foot is from the same body. The section runs near the inner border of the foot, and divides in succession the tibia, astragalus, scaphoid, internal cuneiform and first metatarsal bones, and the first phalanx of the great toe. The saw has missed the second phalanx, as the toe was somewhat bent outwards.

The section passes nearer the inner border of the foot than that represented by Weber (' Gehwerkzeuge,' tab. xi), Volz ('Beitrag zur Chirurg Anat.,' tab. x), Henle (* Gelenke,' figs. 136, 137). It was only just possible to avoid the cuboid and third cuneiform bones which project inwards so much that they would have been divided by any section passing further outwards, and made the relations of the plate more complicated. The bones of the foot are not placed so that they simply form an arch from before backwards, but there is also one in a transverse direction.

It can be easily proved by measurement, that from the pressure exerted by the weight of the body, in the upright position, the curves of the skeleton of the foot are flattened in both directions, and that the foot is not only lengthened but broadened.

It is clearly seen from the plate, that the astragalus which has been divided exactly at the attachment of the interosseous ligament, is set as the keystone of the arch. It is wedged in between the scaphoid and os calcis, is pressed against them both, and thus prevents their approach.

The ligaments correspond with the structure of the arch, which the several bones of the foot form. They are proportionally weaker on the convex dorsum, where they hold the separate bones in position during pressure on the arch; and extraordinarily strong on the plantar aspect, where their function is to act as a tie beam, and prevent separation of the bones : and it is not the form of the bones alone that renders the arch secure, since they would fall apart were it not for the immensely strong ligamentous arrangement of the sole of the foot, strengthened by the plantar fascia.

There is no necessity for mentioning the individual parts. The accurate drawing itself sufficiently explains the soft parts. Some notice must be taken of the pad of fat which is so largely developed at the point of greatest pressure on the sole, and which diminishes and distributes as much as possible this pressure over different points. Over the heel and in the region of the ball of the great toe it is half an inch thick ; thus affording a soft support, which partially equalises the irregularities of the ground.

Fig.I.

PLATE XX

THESE two sections of the thigh were taken from the same individual as Plates I A and I B. The sections were so directed that the first (tab. xx, fig. 1) passed immediately below Poupart's ligament and parallel with it, but obliquely with the direction of the thigh itself; it is consequently a section of Scarpa's triangle, and should be compared with that given by Legendre (' Anat. Homolograph,' PL XXIII), and by Voltz (' Chirurg. Anat. der Extrem.,' Tafl. vi, fig. 3). The second section (tab. xx, fig. 2) was not parallel with the first, but at right angles to the axis of the thigh near the perineum, so that the two sections would include a wedge taken out of the thigh, with the base external and the apex internal.

The following sections ran parallel to each other, and they form a segment of about 1'6 inches thick. They are from a very muscular thigh, and form a series. The other sections, from below the knee to the foot, are taken from another, though equally normal, male subject, and show the same relations.

The upper surfaces furnish the plates ; and these, from the symmetrical structure of the extremities, will serve equally well for either limb, although they happen to be taken from the left ; by being reversed they will correspond with the right, so that the under surface may be regarded as the stump of an amputation.

With regard to the bones, we first notice, in tab.xx, fig. 1, the absolutely circular section of the head of the femur completely surrounded by a thin layer of cartilage, behind which is seen the cavity of the joint as a dark circle. It is enclosed by a portion of the acetabulum, which is joined by the divided part of the ischium, or rather by its upper ramus. The section has then passed through the obturator foramen, obliquely outwards through the ascending ramus of the pubis and corpus cavernosum penis, the obturator membrane, and the sacro-sciatic ligament.

Above the capsule of the hip-joint through the divided synovia] membrane is observed the psoas muscle and the portion of the iliacus associated with it. Below the outer extremity of this muscle is the section of the tendon of the rectus femoris. The second head of this muscle is incorporated with the ligamentous structures at the brim of the acetabulum, and could not be shown separately in the plate.

Above the ilio-psoas, is seen the fascia over the last dorsal nerve running down over the vessels to unite with the fascia of the pectineus, and attaching itself to the capsule of the hip -joint. We have here already the commencement of the sheath of the femoral vessels, and observe how it forms a prismatic space, the outer wall of which bears towards the sartorius. The superior boundary of this space would be indicated by a single lamina, as is shown in the preparation. External to the sartorius is the origin of the tensor vaginae femoris attached to its tendinous sheath, and between them the external cutaneous nerve. Next, we observe the gluteus medius muscle with its strong tendinous fascia from which a portion of its fibres arise. The oblique section of its muscular bundles is not quite clearly rendered in the plate a remark which also applies to the gluteus minimus, which is more internal. To the latter is attached the tendon of the pyriformis, and of the gemellus superior and obturator internus, which is seen in its angular course with its large subjacent bursa.

The above-mentioned series of muscles forms the superior limit of the space occupied by the vessels and nerves, as the gluteus maximus does the inferior. The great sciatic nerve is here seen. The fascia which comes from the gluteus medius, to cover the gluteus maximus, is considerably thinner on the latter muscle, passes over this median ridge to be partly inserted into the great sacro-sciatic ligament, and partly into the fascia of the obturator internus.

Of the adductor group are seen the sections of the pectineus, the adductor longus, and the adductor brevis. The adductor magnus is not seen ; and the gracilis is divided in its tendinous origin. The acetabular artery, which in this case comes from the internal circumflex, lies close on the hip-joint. Care has been taken to represent the direction of the fibres of the muscles, and also the masses of the several bundles of fibres as accurately as possible, the coarse fibres of the gluteus maximus being particularly noticeable. It is true that from this plate hardly sufficient can be gathered to form a correct idea of the formation of the crural ring, and the anatomical relations of crural hernia ; but we shall have to rest contented with having obtained the idea of the size of the individual portions and the position of their layers with regard to each other in their natural relations, and I do not think that we should have gained more if the section had been taken farther up. Linhart has already correctly remarked, that for the representation of the relations of crural hernia single sections are not sufficient.

Plate XX, fig. 2, is a section of the thigh at right angles to its axis immediately below the trochanter minor. The lower portion of the iliacus muscle is still seen on the inner surface of the thigh ; close to it and internally the pectineus ; and externally the crureus. The femoral artery has already given off the profunda, which is separated from the main trunk by a lamina of fascia.

The three adductors lie over one another on the inner side ; and above and beneath the adductor brevis are the two branches of the obturator nerve, with it the branches of the internal circumflex artery. More internally is the gracilis, which is now fleshy.

The sartorius is drawn more over to the middle, and is on the point of overlapping, like a muscular roof, the femoral artery, which vessel has acquired a more superficial position with respect to its accompanying vein.

The rectus femoris with its internal tendinous raphe, lies on the crureus and vastus externus, and near it the tensor vaginaa femoris, which is enclosed by the fascia common to it and to the tendon of the gluteus maximus.

The strong lamina of fascia which passes beneath from the gluteus maximus, and turns inwards between the vastus externus and rectus femoris, is worthy of notice. The tendon of attachment of the gluteus maximus to the bone is not yet seen, but its insertion into the fascia lata only, which is especially developed at the external surface of the thigh. Covered over, but separated from it by a thin lamina of fascia, is the common head of the biceps and semi-tendinosus, and above that the strong tendon of the semi-membranosus. Between it and the adductor magnus is the great sciatic nerve, and a large inosculating branch of the ischiatic artery, with the first perforating and the profunda.

The segment, the upper surface of which is here represented, was about two inches thick. If the sections of the arteries in both plates be compared, it will be seen that the femoral artery changes its position with regard to the bone, and to its accompanying vein, in its course downwards. At the level of the horizontal ramus of the pubes it lies so near the bone, that the possibility of its compression against it was obvious ; in fig. 1 the distance of the artery from the head of the bone is so inconsiderable that pressure could be readily exerted on the vessel ; whilst in fig. 2 greater pressure would appear to be necessary.

Besides this distance of the vessel from the bone there is also an alteration in its direction. In figure 1 the artery lies above the bone, so that a force acting vertically from the front might smash both bone and vessel ; in fig. 2 it lies farther down, already so far to the side of the femur, taking its course outwards, that a force acting in the same direction might wound the artery without injuring the bone, or the contrary.

Moreover the position of the artery to the vein changes during its course. Commencing at the abdominal cavity, the main trunks lie alternately in the sagittal and frontal planes. The abdominal aorta lies on the lumbar vertebra close to the vena cava. In the abdominal cavity the iliac artery lies in front of its vein, at the inner border of the psoas ; and then, after passing below the crural arch, lies to the side of the vein. The vessels, however, soon again change their relation, for below the fossa ovalis, as is seen in fig. 2, the vein lies below the artery and accompanies it to the knee ; so that, in attempting to reach the popliteal artery from behind, the vein would be in danger of being wounded, and must be pushed aside in order to render the artery accessible.

PLATE XXI

FIG. 1 of this plate is a section of the thigh taken somewhat below the upper third, about 2'5 inches below the section shown in the preceding plate, and three inches below the trochanter minor.

The individual portions of the quadriceps extensor are clearly seen separated from each other by fascia. At the posterior border of the vastus externus, which is covered by the strong dense fascial tendon of the tensor vaginas femoris, is the termination of the gluteus maximus. This muscle is attached by means of a strong tendinous mass to the thigh bone, and here separates the flexor muscles from the extensors.

Of the flexors which accompany the ischiatic nerve the biceps and semitendinosus are now completely separate.

The semimembranosus has already become muscular. Over it lie the three adductors first, the adductor magnus ; upon it the adductor brevis ; and between this and the adductor longus the profunda artery and obturator nerve.

On the other side of the adductor longus, between it and the vastus internus, is the space for the femoral artery and vein. The sheath of the vessel is clearly seen ; its formation by fascial laminae ; and its closing-in by the sartorius, which continually approaches the inner side of the thigh. This muscle reaches the gracilis, to which it is very similar in form, getting closer and closer to it until at last the two muscles accompany each other.

Fig. 2 represents a section through the middle of the thigh, where the sartorius and gracilis meet, and the short head of the biceps begins to take the place of the gluteus in the external intermuscular ligament, between the vastus externus and the flexors. External to the rectus femoris the individual portions of the quadriceps are not seen any more, the rectus with its central tendon being completely isolated by fascia.

The femoral artery, Avhich begins to lie considerably more laterally with regard to the bone, is still in the same fascial sheath, between the adductor longus and vastus internus, and covered by the sartorius. The adductor longus has already lost its bulk ; and the adductor brevis has disappeared at this level entirely.

The profunda artery is divided at the point where it perforates the adductor magnus close to the bone.

The three flexor muscles are completely isolated from each other, and lie so close together posteriorly that the great sciatic nerve takes a position in a furrow between the long head of the biceps and the semi-tendinosus.

With reference to this plate, it may be added that the thigh was rotated somewhat outwards before the section was made.

PLATE XXII

THIS and the following plates are taken from sections from another body, but can be used equally well in the series. The arteries were injected, the body frozen lying on the back, and the lower extremities left in their normal position, i. e. somewhat rotated outwards.

' Fig. 1. The section here passed through the lower third of the thigh nearly a hand's breadth above the upper border of the knee, at the position of the passage of the artery through the adductor opening. The plate represents the left thigh, and the upper surface of the lower portion ; the external aspect of the extremity being to the left, and the internal to the right.

The adductor longus is not seen, as it terminated just above the line of section. Of the adductors the magnus only is present ; its section is associated with the great vessels. It is no longer attached to the linea aspera, but all the muscular tissue to be seen here passes directly into its tendon, which terminates at the internal condyle of the femur.

This is exactly the spot where the artery passes through the adductor opening, in order to reach the back of the bone. The artery itself lies surrounded by a system of veins, which render ligature a matter of difficulty, on account of their free anastomosis. Between the artery and the bone lies the vein, with two small ones opening into it; on the opposite side are two venae comites, which are lodged between the artery and the long saphena nerve. If the artery be tied at this level, the incision must be made between the sartorius and the internal vastus, but upon the outer side of the former; the strong dense fascia under the sartorius must be divided; and the saphena nerve and vense comites pulled on one side ; there is thus more difficulty in reaching and isolating the artery in this place than higher up (vide Plates XX and XXI).

It is not correct to describe the course of the artery as spiral with regard to the bone. It lies certainly in front of the bone above, in the middle of it farther down, and at the knee-joint completely behind it. One can convince oneself on any preparation, whether the artery be injected or not, that the artery passes downwards in a tolerably straight direction ; it is the bone on the contrary that describes a twist round the artery. The relation of the artery to the sartorius is constant throughout the entire length of the thigh.

The great sciatic nerve, like the artery, has changed its position from the upper section. As higher up it lay behind the adductor magnus, so here it will be seen behind the short head of the biceps. There is nothing further to say about the muscles. The prominence of the central tendinous intersections indicates the termination of the muscles, as well as forming the separation between the individual portions of the quadriceps, which higher up were separated by fascia.

Fig. 2 is a section of the left knee-joint through the centre of the patella. The man, whose lower extremity afforded the preparation, had been a mason, and had probably knelt a great deal. At all events the large development and width of the prsepatellar bursa would suggest it. The patella lies with the external portion of its posterior articular surface so close to the external condyle of the femur, that only a narrow chink separates them ; while on the other hand it is raised from off the external condyle. The synovial cavity is divided by means of the ligamentum mucosum into two portions ; of these, one follows the patellar surface and passes upwards and inwards, whilst the other is applied over the inner condyle. This position of the patella upon the condyles renders it clear why in dislocation it glides by preference over the external condyle. The position itself is conditional on the curving inwards of the femur, so that the action of the powerful extensor muscles alone would cause the patella to glide outwards from off the flat hollow between the condyles, if these lateral tendinous masses did not securely hold it in position. These structures are interwoven as fibrous bundles with the lateral flat tendinous expansions which pass from the great extensor downwards to the leg, and assist in transmitting the power of extension beyond the patella and ligamentum patellae. In fracture of the patella they keep the fragments in position ; and, if the fracture of the bone be transverse, they are torn simultaneously with it. If the patella be sawn through, on the body, maintaining, however, these lateral ligamentous structures, and the leg be flexed, the halves of the patella separate slightly from each other ; if, however, they be divided in addition, there immediately ensues a very wide separation of the fragments. "We can thus understand why stellate fractures of the patella unite by bone, as in this instance the patella alone is involved ; whereas in transverse fracture the ligaments are also torn, the extensor muscles dislocating the upper fragment.

The plate shows broad ligamentous bands passing from the patella to both sides of the femur, and surrounding the entire knee-joint anteriorly and laterally.

Behind the articular surfaces of the condyles is the expansion of the synovial cavity between the crucial ligaments. The nerve, artery, and vein, lie close behind each other, the former being more external ; the sciatic nerve dividing into the external popliteal inside and below the biceps, and the internal popliteal more towards the middle.

The muscles, which in fig. 1 showed such fleshy masses, are here confined and diminished in bulk. They are for the most part completely reduced to tendon ; and the defined form of contour, which is characteristic of the region of the knee-joint, is dependent on that of the bones.

In synovitis, the patella would be lifted off the articular surface of the thigh bone, the distension of the capsule being especially evident in front. The posterior parts are but slightly yielding, and are consequently only slightly separated from the posterior surfaces of the condyles.

PLATE XXIII

FIG. 1 is a section through the upper third of the leg taken from the same subject as the last.

Similar plates will be found in Volz (a a 0, taf. ix, fig. 1) and in Pirogoff (fasc. 4, tab. viii, fig. 8),

The strong framework from which the muscles spring is formed by the tibia and fibula, the inter-osseous membrane, the strong fibular intermuscular aponeurosis, which passes obliquely outwards and forwards from the fibula between the peroneal and extensor muscles, and the dense fascia, from which the fibres of the tibialis anticus in particular arise.

The strongly developed muscles divide themselves into three groups. Anteriorly are the extensors, tibialis anticus, and extensor communis digitorum bounded behind by the interosseous membrane, the extensor longus pollicis is not yet seen, as it arises lower down. Externally and lying on the fibula is the peroneus longus, which belongs to the second group separated from the extensor communis by the intermuscular ligament. Posteriorly to both bones is the third group, in which the flexors preponderate, and their deep layer is analogous to that of the extensor side in having only two muscles.

The tibialis posticus lies on the interosseous ligament between the tibia and fibula, and the flexor longus digitorum, of which only a small portion is seen, on the tibia. Behind them are the large expanded surfaces of the soleus and gastrocnemius, and on the posterior aspect of the tibia is a strip of the popliteus. This muscle lies almost entirely between this and the last section (Plate XXII).

The nerves belonging to the three groups are marked white. The superficial peroneal nerve lies between the peroneus longus and the fibula; and the deep peroneal nerve, which is separated from it by the fibular inter-muscular septum lies on the interosseous ligament and fibula. The posterior tibial nerve is seen between the flexor longus pollicis and the soleus.

The three arteries, the anterior tibial, posterior tibial and peroneal, are seen together with their veins. The two latter arteries lie close to each other, as the section passed immediately below their origins, separated from the interosseous ligament by the tibialis posticus, and they divide the deep layer of the flexor group from the muscles of the calf which form the superior layer. The anterior tibial artery lies on the interosseous membrane. The furrow running between the tibialis anticus and extensor digitorum longus indicates the position of this vessel, hence it may be readily found, its depth being the only difficulty.

Fig. 2. This section through the middle of the left leg may be compared with the plates of Henle (' Muskellehre,' fig. 142), and Voltz (a a 0, tab. ix, fig. 2).

The relations of the muscles, vessels and nerves can be so readily made out that it does not seem worth while explaining the plate.

Beneath the muscles of the calf, in this section, all the flexors are seen together. The flexor longus digitorum has now considerable bulk, and so also has the flexor longus pollicis, which has already the peroneal artery between it and the fibula ; and the anterior tibial artery lies between the extensor communis and the tibialis anticus. The artery is still so deep that its ligature at this place, though practicable, is not to be recommended. Farther down, and nearer the ankle, the muscular tissue ceases somewhat, and the vessel is more easily reached.

The peronei muscles are completely developed, and the superficial peroneal nerve is already approaching so near the surface that it seems about to perforate the fascia.

If the two sections be compared which represent the position of the individual structures in the upper half of the leg, the superficial position of the tibia is evident and can be readily felt, hence affections of this bone from disease and accident are easy of diagnosis. The fibula, on the other hand, is unfortunately situated in this respect. The thick masses of the surrounding muscles do not favour its examination, and we must in its instance use some other diagnostic means, such as fixed, deep-seated pain.

The course the knife must take in order to expose the fibula is indicated by the fibular intermuscular septum. The muscles which bound this septum, the peroneus brevis and extensor proprius pollicis, are easily made out at the outer surface of the bone, and the plate assists the surgeon in judging of the depth the wound should be in muscular individuals. In this proceeding no vessels of large size will be met with, but the peroneal nerve must be carefully avoided, as it would fall in the line of incision.

The superficial position of the tibia also demands attention with regard to the treatment of ulcers, as the periosteum is all the more likely to be involved the fat being so sparingly developed, whilst in almost all other points of the section it is more abundant and consequently the skin is further from the subjacent fasciae.

The main arteries, with their accompanying veins, at this level are still tolerably near their origins, and not very far separated from each other. In the inner portion of the section they lie so near the interosseous ligament, and are so protected from external pressure by the bones of the leg, that they are not so liable to be wounded as elsewhere. At the same time from their position they are not readily compressible against the skeleton, so that in amputation or any operation where much bleeding is expected a toiirniquet must be applied above the knee.

PLATE XXIV

FIG. 1 represents a section through the lower third of the left leg near the joint. From the decrease in the masses of the muscles and the increase of the tendinous structures the section of the limb has become considerably smaller. Although individual muscles, such as the extensor and flexor longus pollicis with the peroneus brevis, have become stronger than in the preceding plate, they do not make up for the want of those of the calf which determine the size and shape of the leg. The soleus and gastrocnemius are no longer separate, a longitudinally directed tendinous mass spreads over the posterior surface of the soleus ; this is the termination of the gastrocnemius, which becoming blended with the fibres of the soleus, forms the tendo Achillis.

The largest surface shown is that of the flexor longus pollicis, which is here divided at its greatest bulk. In flexing the great toe in walking this muscle contracts so forcibly that its power exceeds that of the other flexors of the toes. Its position has altered from the last plate, being further back and more beneath the tibialis posticus, so that after completely crossing it in the malleolar region it lies at last most internally.

The position of the deep flexors is essentially distinct from that of the extensors. The tibialis anticus lies close on the tibia, and gains the inner border of the foot without crossing its neighbours, the extensor longus pollicis and extensor communis digitorum ; whilst the tibialis posticus lies in the middle on the interosseous ligament, the flexor longus pollicis on the fibula, and the flexor longus digitorum on the tibia, and these muscles cross each other before their ultimate insertion. This position is connected with their passage at the inner malleolus. As they are pushed aside by the sustentaculum -tali, they would obtain a very insufficient hold beneath the short internal malleolus if the flexor longus pollicis and tibialis posticus lay on the inner border of the leg, and if the flexor longus digitorum arose from the fibula it would act at a great disadvantage. This defect is remedied in a simple manner by the crossing of the tendons.

The arteries have the same muscular separations as before, notwithstanding that they have materially altered their position with regard to the tibia ; and, in consequence of the diminution of the bulk of the overlying muscles they are considerably nearer the surface, so that their ligature is easier than above. The anterior tibial artery can be reached between the tibialis anticus and extensor longus pollicis, and the posterior tibial can be readily found if the border of the soleus be detached and pulled back from the flexor longus digitorum. The position of the peroneal artery is the most unfavorable for ligature, as it must be searched for behind the peronei, after separating the flexor longus pollicis from the fibula, when it can be drawn out from behind the bone.

Fig. 2. This section of the leg in the region of the malleolus terminates this series. It divides the tibia and fibula immediately above the astragalus, hence the comparatively large size of the tibia. Both are strongly bound together by ligaments, and in front is an opening into the cavity of the ankle-joint.

The muscles now almost entirely present their tendons, only the outer portion of the extensor of the toes, the peroneus tertius, and the extensor flexor longus pollicis, still show muscular tissue. With the tendons are associated their bursse which are shown as dark chinks, and the ligamentous apparatus which renders secure the position of these tendons at the ankle. The upper portion of the annular ligament is met with, the point of origin of which from the os calcis lies deeper and is consequently not seen, and under the middle fasciculus which encloses the extensor longus pollicis, lies the anterior tibial artery which may be here readily reached from the surface. To expose the posterior tibial artery for ligature, the division of one fasciculus only of the internal annular ligament is necessary. It lies between the flexor longus digitorum and flexor longus pollicis, and the bursal sheaths of both muscles can be completely avoided in looking for the artery. The tendo Achillis lies some way further back, so that its division is easily accomplished without wounding the vessel.

The two plates here given are sufficient to show the most important points in the lower half of 'the leg. On the other hand, the relations given of the foot are insufficient, and perhaps a further series of sections might have been shown. From numbers of sections which I have made and had drawn, and have before me, as well also from the examination of Pirogoff's plates, I have come to the conclusion, that sections of the foot are not of very much use for the comprehension of its structure, although a clear idea of the arrangement and form of its bony arches may be obtained ; but for the relations of the soft parts they are only of subordinate importance. Flat preparations are in this respect of more value and are indispensable. The numerous small muscular masses of the sole are divided from each other merely by fasciae and cellular tissue, and the number of tendons on the dorsum which can be but inadequately separated from the ligaments by transverse section, would give unreliable plates. Again, the arrangement of the annular ligament would be absolutely unintelligible if studied on sections only. The arteries, as has already been mentioned in fig. 1, lie much nearer the surface than in the preceding plate, and therefore have far simpler landmarks for their ligature than in the upper half of the leg. They form a triangle with two nearly equal sides. The base of this triangle is formed by a line passing from the anterior tibial artery to the peroneal, directed outwards, as seen in fig. 1. This arterial triangle, in consequence of the termination of the peroneal artery, ceases in fig. 2, and is not seen in Plate XXIII, fig. 1. On the other hand, it is very clear from Plate XXIII, fig. 2, that if this triangle be compared in this and the preceding plate, the direction of its base and the length of its sides remain exactly the same. It so happens that these arteries in their course in the lower half of the leg remain in the same position with regard to each other ; and that they run as parallel vascular tubes, and do not from their own change of position get nearer the surface, but from the continually decreasing masses of the muscles as they proceed downwards.

THE accompanying frontal section of the thorax and shoulder- joints was made from the body of a very powerful man. Beyond the enlarged thyroid body there was nothing abnormal. From the recumbent position of the body, particular regard was taken of the upper extremity, and it appeared desirable to divide the humeri in their long axes, and the arms being placed in the position they would have held in the upright position were rolled outwards so that the bicipital groove was directed forwards. After being frozen in this position, tne head was removed from the neck just below the larynx, and the rest of the body separated by a section through the nipples. The frontal section was so directed that it passed through the middle of the heads of the humeri and their shafts.

Before freezing, the arteries were injected from the femoral.

The cupolas of the lungs are divided thro ugh their highest points. Both subclavian arteries pass over the cupolae of the lungs, and consequently cause an impression on the pleura, which on examining the cavity of the chest can be readily recognised.

The arteries, however, do not cross the cupolae of the lungs at their highest points. They lie considerably behind them and below the brachial plexus in the neighbourhood of the head of the first rib. The section has passed through the arch of the right subclavian artery, but not disturbed the left, running in front of it as is clearly seen in the plate. The preparation showed on further examination that the lungs and pleural cavities extended considerably further up. The first ribs were divided at their anterior extremities, the right behind the origin of the scalenus anticus, the left immediately through its origin.

The roots of the lungs lie behind the section, the left further from its plane than the right.

PLATE XXV 173

Corresponding with this, on the left side of the plate, there is no interruption of the pleura, whilst on the right side (to the left of the spectator), the points of reflexion of this membrane have fallen in the section. The relations are complicated by the pericardium. Between the lungs and heart there are seen two spaces, which are the cavities of the pericardium and pleurse.

The left ventricle is opened, and a portion of the right auricle is shown. In connection with them are seen the aorta and superior vena cava in section. The former is exposed for its whole extent, so that the entrance from behind of the azygos major vein appears. In continuation of the superior cava is the right innominate vein, which as it passes more vertically, is divided throughout, and the two delicate valves are seen. The left innominate vein, which passes more obliquely, was removed with the other half of the body. Its end only is shown, at the point of entrance of the left subclavian vein as a large venous lumen immediately above the first rib.

The aorta is exposed in the horizontal portion of its arch. At its origin it shows a considerable swelling of the bulbus aortsB, produced by the pressure of the injection on the semilunar valves, of which two, one nearly bisected, are seen. Below them, in the left ventricle, is the aortic segment of the mitral valve. The liquor pericardii had collected in the upper portion of the pericardium.

It will be observed from the free surface afforded by the divided left auricular appendix above the left ventricle, that the two laminae of the pericardium are considerably separated from each other in this situation, whilst in all other places they are directly in apposition, so that its cavity is shown only as a crevice. Between the left ventricle and the ascending aorta is the section of the pulmonary artery, which being nearly horizontal, is divided transversely. The vessel is seen from before backwards, and the lumen of the right branch is exposed, curving sharply behind the aorta, to reach the root of the right lung ; whilst the left branch passes obliquely upwards and outwards, to course over the left bronchus and root of the left lung.

The position of the great vessels given off from the aorta is considerably altered by the hypertrophied thyroid gland. This, as the plate shows, has compressed the trachea on both sides ; and very probably interfered wit! deglutition from pressure on the oesophagus. It involved the interspace that the two carotids form with the aorta, and pushed them asunder. I] the left carotid, which is freely divided, this is clearly seen ; whilst in th right a small portion only of its origin from the innominate is involved, a it lay almost entirely in the anterior half of the preparation.

The subclavian artery of the left side is not seen, as it takes its origii from the arch of the aorta behind the carotid ; it lay in this preparatioi behind the section, covered by the pectoralis minor. Its continuation, tb brachial artery, came into the line of section, and is to be seen between it accompanying nerves.

On the right side is seen, on the other hand, the continuation of th innominate artery into subclavian and axillary. The arch of the right sub clavian passes under the right innominate vein, over the cupola of th right lung ; and gives off anteriorly the internal mammary artery, which i here transversely divided, and the inferior thyroid which is slit up am covered at its extremity by the thyroid body ; passes over the first rib fron within outwards ; and finally disappears behind the cut surface of th coraco-brachialis.

The subclavian veins correspond on both sides. The right subclaviai vein is cut short off above the second rib, and the left is widely opene< between the scalenus anticus and pectoralis minor. The latter, whicl receives many small veins, is of large calibre, and passes with its inne wall rather more upwards, towards the internal jugular vein which lie on the outer side of the carotid artery. Of the internal jugular vein o the right side nothing is to be seen, the parts being entirely removed wit] the anterior half of the body. The left subclavian vein consequently lie farther forward than the right.

The right brachial plexus is exposed throughout its length, whilst th left is covered and only its commencement is seen under the anterio scalene muscle.

The several structures of the neck group themselves about the fifth sixth, and seventh cervical vertebrae. At the lower border of the seventl cervical are the cut surfaces of the longi colli muscles, which lie between the spine and the thyroid gland. Above both muscles, on either side of the bodies of the vertebrae, are the vertebral arteries slit open ; of these the left shows a far larger calibre than the right. From behind these vessels proceed the roots of the brachial plexus, which is entirely covered on the left side, and partly on the right, by the cut surfaces of the scaleni. Still more externally and upwards are the sections of the sterno-cleido-mastoids, with a strip of the platysma, immediately beneath which on both sides is the external jugular vein.

The right phrenic nerve is completely removed ; the left is seen between the carotid artery and the lung. The artery accompanying it is the internal mammary.

The vagus is only partially cut on the left side, where it lies in front of the arch of the aorta, and from whence its recurrent branch passes upwards behind that vessel. On the right side, on the contrary, it is divided transversely at the point where it is applied to the root of the lung.

The shoulder- joints have so fallen into the section that the saw has passed on both sides in front of the glenoid cavities ; and nothing is seen of the scapular element of these articulations. The bony elements of this portion of the joint He behind the plane which passes through the middle point of the head of the humerus. On the left side the glenoid cavity was only a quarter of an inch behind the plane of section ; on the right it was so much closer that the limbus cartilagineus fell into it. As the head of the humerus is directed inwards and backwards towards the glenoid cavity and as the section passes deeper on the right than on the left, the greater tuberosity of the right side has been entirely removed. The round section of the head is all that is seen, whereas on the left the greater tuberosity projects in a triangular form.

On the right side a portion of the acromion appears ; and on the left the section has passed more anteriorly, and has nearly divided the coracoacromial ligament. Normally the acromion rises but very little above the head of the humerus, so that anteriorly a tolerably large portion of the latter remains unprotected by bony covering. The coracoid process is divided transversely on either side, and is readily seen between the head of the humerus and the clavicle. It is cut through behind the attachments of the muscles.

The pectoralis minor on both sides of the chest is divided, and shows a large surface of section, on the left side particularly. This is explained by the forward position of the shoulder, and by the muscle becoming relaxed and folded so that its posterior border was bent backwards.

The strongly curved clavicle has a different appearance on the two sides. The right, which projects further forwards, shows beyond the section its entire acromial end, whereas on the left side this is not seen. The section of the clavicular portion of the deltoid of this side is shown. On the right side the anterior attachment of this muscle is completely removed. Its attachment to the humerus is equally divided on both sides ; and the bursa between it and the capsular ligament appears as a black line.

With regard to the relations of this capsule, the following points are to be noticed. Since the shoulder-joint is under the influence of atmospheric pressure, the bone is pressed against the glenoid cavity; and therefore the cavity of the joint notwithstanding its extent and the laxity of its capsule can be shown merely as a crevice in the representation of its section. The ligamentous tissue which terminates at the neck of the humerus is the capsule : this, on the left side, encircles the bone like a ring from the greater tuberosity, and encloses the obliquely divided tendon of the biceps superiorly; these relations on the right side are shown rather differently. In the first place, a portion of the limbus cartilagineus is seen, terminating above in a sharp angle, and externally the supra-spinatus presents itself in section strengthening the capsule by its tendon, and which more externally is so closely united with the tendons of the infra- spinatus and the teres minor that no line of separation can be represented.

On the inner side of the neck the capsule is more loosely attached, so that by raising the humerus its folds are obliterated.

The limit of the capsule towards the middle line is formed by the subscapularis, which is seen divided on both sides. Beneath it lies its bursa, which must be looked for between it and the capsule. It normally forms a communication with the cavity of the joint, but which was not seen in this section. Nevertheless the outer side of the subscapularis is to be seen on the left shoulder-joint limited by a dark line, indicating the synovial membrane in section. This line runs in a curved direction with its concavity outwards, corresponding with the head of the humerus.

In order to demonstrate the extent of the cavity of the capsular ligament and to show the amount of separation of the humerus from the scapula when the joint is distended by effusion, I injected some fresh joints with tallow, froze them, and then made sections. One of these preparations is shown in the following woodcut.

Frontal section of the right shoulder-joint, injected with tallow. Anterior half. 5.

1. Head of humerus. 2. Neck of scapula. 3. Anterior margin of scapula. 4. Clavicle.

5. Deltoid. 6. Triceps. 7. Teres major. 8. Teres minor. 9. Infra- spinatus.

10. Supra- spinatus. 11. Trapezius.

The humerus is seen from behind half extended and somewhat rolled inwards, a position it acquired from the great pressure of the injection, and corresponding with the greatest amount of distension of the capsule. This injection was made from the supra-spinous fossa through the glenoid cavity, and the upper arm amputated at its lower end, so as not to hamper the movements of the joint by its weight. It appeared that the greatest distance of the head of the humerus from the glenoid cavity was somewhat over half an inch ; hence it would appear likely that in inflammation with effusion into the cavity of the joint, there would be some considerable lengthening of the limb.

In order to bring the relations of the heart more completely into notice, it became necessary to extend the section farther downwards than was possible in this preparation. Consequently I made a series of sections to supply this deficiency, but unfortunately none of these specimens could be used to supplement this plate.

PLATE XXVI

THE longitudinal section shown in this plate is taken through the elbow-joint and hand of a young normal female subject, with no previous injection of the vessels.

There was neither artificial injection of the articulation nor any predetermined position thereof. It was frozen and sawn through in its normal condition.

Figure 1. In this plate is shown the sagittal section of the right elbow-joint, taken somewhat obliquely, and seen from the radial aspect. The saw has passed nearly through its centre, and removed a small portion of the radial surface of the ulna. As the forearm is slightly bent, and in semipronation, the radius is met with in its long axis, a small portion of the ulnar aspect of its head only remaining. Farther down its shaft is divided obliquely, and the medullary cavity partially opened. In consequence of pronation the radius does not lie parallel with the ulna but crosses it, and is directed with its inferior extremity forwards.

The expansion of the cavity of the elbow-joint is worthy of notice in flexion and extension of the humerus. The folding-in of the capsular ligament in the posterior supra- trochlear fossa corresponds with the slight degree of flexion, and if this flexion be further increased, this folding-in would become eradicated and take place on the anterior aspect. The cavities above the trochlea are alternately filled at the end of flexion and extension, the capsule, however, being drawn away beforehand by certain muscles, viz. the brachialis anticus and biceps, so that it may not be included between the bones.

It can be seen from the plate that the bones do not lie completely in apposition. Injections of the elbow-joint with strong pressure show that it acquires the position of semiflexion, and that the fluid injected partially separates the joint-surfaces.

The terminations of the flexor muscles of the arm are not seen. The brachialis anticus, which lies close upon the capsule, is divided longitudinally, as is seen from the direction of its fibres ; and the same remark applies to the biceps, its tendon is deeper down behind the radius, and can be exposed only by dissection. The tendinous mass shown in the plate, between the upper end of the radius and the ulna, is a portion of the tendon of the biceps ; another portion of it belongs to the circular ligament of the ulna, which forms the means of checking excessive separation, and becomes broader in pronation. The triceps at the back of the humerus shows its complete connection with the olecranon. On the anterior surface of the biceps is the supinator brevis, and farther in front are portions of the supinator longus and the extensor carpi radialis longior the heads of which are removed with the external condyle. No vessels or nerves are seen in the plate, excepting an obliquely divided vein, a portion of the median-cephalic, and the radial nerve beneath the supinator longus. The main artery, with its accompanying veins and the median nerve, which pass down on the inner side of the arm and afterwards turn forwards on the bend of the elbow, lie concealed in the soft parts below the surface of the section.

Sections made as shown in this plate are rarely successful, and not easy to understand at first sight, since in complete supination and parallelism of the bones of the forearm the usual position from which descriptions are made the radius and ulna lie in a frontal plane.

I have, however, specially chosen the present position of the arm for the section as being the more normal one in which the radius lies in front of the ulna for almost its entire length. A very similar representation is to be found in Pirogoff's Atlas (Fasc. iv B, Taf. iv, fig. 7).

Frontal sections of the elbow-joint agree with the preceding if the forearm is completely extended and supinated, and if, moreover, it be forcibly retained in this position before freezing.

The radius and ulna are divided in their longitudinal axes and in continuation with the humerus. As Pirogoff's and Voltz's Atlases contain an excellent and complete series of such sections, it seems hardly worth while to multiply them in this work.

Fig. 2 is a longitudinal section of the right forearm, hand, and third finger, from the same arm as fig. 1, and is viewed from the ulnar aspect. The radius is divided in its entire length ; on its articular surface is the semilunar bone, and in front of it the os magnum and third metacarpal bone, the first phalanx, and a portion of the second, the third was not included in the section. The joints were not particularly prepared for the section. In the hand they are in the condition of partial extension, whilst the fingers are flexed from the effects of freezing. The skin is smooth on the dorsal aspect, whilst on the volar, which is rich in fat, it forms thick pads, giving rise to deep furrows. During extension these furrows appear as transverse lines, and do not correspond with the opposed articular surfaces of the joints. Those on the volar aspect of the root of the finger lie considerably further forwards than the corresponding metacarpophalangeal joints, and the subsequent furrow exceeds, though not to so great an extent, the joints between the first and second and third phalanges, consequently in disarticulation of a finger from the volar aspect the joint will not be opened if the knife be applied directly upon this furrow. The articulation will be far more certainly reached if the incision be made from the extensor aspect, after slightly flexing the finger, a little in front of the projection which the head of the bone makes with its distal phalanx. Corresponding with the more extensive expansion of the cartilage on the volar aspect, the cavity of the synovial membrane extends further upwards than on the extensor. The capsular ligament is moreover considerably strengthened by the tendinous expansions formed by the lateral ligaments, and which prevent too g^eat an amount of extension of the finger. Immediately beneath the skin, and separated from it merely by bursal tissue, are the flexor tendons of the finger, of which the more superficial disappears at the first phalanx, and the tendon of the deep is shown passing on to its insertion into the ungual. These tendons are easily followed upwards, beneath the annular ligament to their muscles which form the chief bulk of the forearm.

The number of sections which could be made with advantage of the hand is unlimited, as in every change of position new and interesting forms arise. This is more particularly the case with regard to the region of the thumb, where section is especially suitable for the purpose of demonstrating the peculiar relations of the joint in dislocation. It is a pity that no more space can be afforded, and I must therefore refer the reader to PirogofFs Atlas, fasc. iv B, tab. v and vi, where frontal sections of the hand are shown, and to fasc. iv A, tab. iv and v, which represents longitudinal sections of the thumb both in its normal and dislocated conditions.

PLATE XXVII

THE series of transverse sections from which the present and following plates were taken was made from the left arm of a man set. 40. The arteries were injected. The forearm was slightly flexed and pronated. In order to obtain bearing points for the individual laminae, a line was previously drawn passing through the middle of the biceps over the surface of the supinator longus to the thumb, and the uppermost points of each subsequent lamina lie in this line.

Fig. 1. In this instance the line of section passes through the middle of the arm, and its surface is seen from above downwards, hence we may imagine that we have the stump of an amputation of the right arm for examination, as has been before suggested in speaking of the lower extremity. The section is taken below the insertion of the deltoid, the biceps and triceps occupying the greater space. On the anterior aspect of the bone are portions of the brachialis anticus and coraco-brachialis ; in the middle, to the right of the observer, and between the flexor and extensor muscles, are the great vessels and nerves, and the musculo-spiral nerve has already commenced its tortuous course accompanied by the superior profunda artery. This position of the nerve accounts for the fact that blows or injuries from behind are capable of compressing it so directly upon the humerus that paralysis may be the result. The separation of the muscular masses of the flexors and extensors is already at this level so decided, that the intermuscular aponeurosis appears in the frontal plane. The relation of the individual muscles is so clear as hardly to demand any particular explanation.

Fig. 2 is a section of the left arm in the middle of its lower third. The flexor and extensor muscles lie on both sides of the humerus, and the intermuscular aponeuroses are here still more clearly seen than in the preceding section. In the external intermuscular septum is the musculo-spiral nerve, which has nearly terminated its half turn round the humerus, and behind it is the origin of the supinator longus. On the inner side the ulnar nerve has already become distinct from the great vessels and mass of nerves. The brachial artery is on the inner border of the biceps, accompanied by its venae comites, with the median nerve above it. Although its position is here very easily made out and its compression readily performed, there is great difficulty in isolating it and tying it unless the steps of the operation be carried out very correctly. The vessel, as the plate shows, cannot be directly cut down upon, as on account of nerves and veins which here often very freely anastomose, the operator may be much embarrassed ; and experience has shown that the vessel may be easily missed ; the surgeon must therefore make for the edge of the biceps, which is slightly in front of it, and open its sheath from the inner side, when he will come directly upon it.

The distance of the artery from the bone depends on the development of the brachialis anticus. In this instance, on account of the muscles in relation with it having become more developed, the vessel lies further from the bone than in the preceding section. Compare fig. 1 of this Plate, and also Plates X and XI, fig. 3.

Pig. 3. In this instance the plane of section passes through the lower end of the humerus and the olecranon. On the left side is the commencement of the capitellum with the end of the lateral epicondyle, on the left the trochlea with the middle epicondyle. The olecranon lies behind in the posterior supra-trochlear fossa. The extent of the cavity of the synovial membrane and capsule is indicated by a dark line.

Behind the olecranon is a large bursa between the skin and the tendon of the triceps. On the right, in the furrow between the olecranon and medial epicondyle is the ulnar nerve. To the left of the olecranon is the anconeus. The muscles of the arm are much reduced in bulk at their point of attachment. The origins, however, of the flexors and extensors of the hand and fingers, the pronator teres, and the supinator longus, the latter, on account of its high origin from the humerus, are more powerfully developed in the section. On the anterior aspect of the bones are masses of muscle, on the posterior merely ligaments and tendons, which allow of the bony prominences being clearly distinguished. This relation of the muscular masses, and the position of the vessel on the belly of the brachialis anticus, demonstrates the fact that all incisions which are intended to penetrate the joint should be arranged on its exterior aspect, as it can be here entered without fear of any considerable haemorrhage, and the ulnar nerve alone requires care in looking after.

Fig. 4 is a section of the forearm through the head of the radius, which is clearly shown with the annular ligament, and the upper extremity of the ulna the lesser sigmoid notch of which lies in articulation with the radius. The brachialis anticus is now for the most part tendinous, and attached to the ulna on the other side of its tuberosity. The tendon of the biceps is behind the tuberosity, which lies below the surface of the section, and the bursa, between it and the upper part of this tuberosity, is indicated by a black line. The brachial artery lies in the middle in front of the joint, enclosed by the origin of the flexors and extensors. Its division into radial and ulnar is evident. In front of it is the communication between the superficial and deep veins, and shows why bleeding in this region is so copious, if contraction of the muscles around the deep vein be induced ; it is, however, not possible to expose the intimate relations clearly by section. It may, however, be here explained that the "system" of the median vein does not only associate the trunks of the cephalic and basilic with each other, but also keeps up a communication with the deep veins accompanying the radial and ulnar arteries. The irregularly formed and generally small vein which lies in the bend of the elbow requires no particular note, as it possesses no further importance than the trunks which frequently approach close to the basilic and cephalic in the bend of the forearm. It is, however, worth while to designate this communication, which passes deep down, as median (it is named by Arnold, the deep median vein), and to denominate the oblique branches of communication between the basilic and cephalic as median basilic and median cephalic.

The mass of the flexor muscles is already at this level more strongly developed than in the preceding section. They predominate over the extensors, as will be still more clearly seen in the deeper section of the forearm.

FIG. 1. The section here passes through the upper third of the left forearm, and the ulna and radius exhibit surfaces of almost equal size, only the ulna with its sharp edge lies closer to the surface than the radius, which is embedded in muscle. The ulna can be readily felt throughout the entire length of the forearm, but the head and inferior extremity only of the radius. The edge of the ulna affords an easily distinguishable limit between the flexor and extensor muscles. The flexor carpi radialis forms the muscular limit on the flexor surface. It is placed with its tendinous border on the ulna, and covers over the deep flexor lying beneath it. On the opposite side of the ulna is the origin of the interosseous ligament, and in connection therewith fasciae, which pass directly upwards, and consequently separate both groups of muscles. To the left lie the supinators and extensors, and to the right the pronator teres and flexors. Between both groups of muscles are seen the vessels, the ulnar artery deep down, with the interosseous springing from it, and above it the radial. One needs merely to divide the enveloping fasciae, and to pull the muscle to one side to expose the , radial artery. The deep position of the ulnar at this spot renders its ligature difficult. Of nerves the superficial branch of the radial is found below the supinator longus, the deep branch lying in the supinator brevis. The median is between the pronator teres and flexor sublimis digitorum, the ulnar between the latter and flexor carpi ulnaris.

Peculiar interest is attached to the supinator brevis, the function of which can be readily understood by reference to this section. Passing outwards from the ulna (its upper set of fibres from the epicondyle are not seen), it wraps round the radius so that it must by its contraction roll it outwards. The space between it and the radius is taken up by the tendon of the biceps, which from the nature of its attachment assists in supination.

Fig. 2. In this plate, which, shows a section through the middle of the left forearm, there is considerably greater difficulty in recognising the relations of the individual structures than in the preceding, and this difficulty is not so much from the number of muscles, but from the absence of the fascial septa which limit the individual groups. The interosseous ligament alone forms with the skeleton an absolute limit, and this does not extend throughout the entire breadth of the section. The ulna and radius present their sharp edges to each other, and are bound together by the interosseous ligament ; on the right is the mass of the flexors, and on the left that of the extensors. Both groups of muscles are separated from the radius by a very thin fascial covering, which is attached to the radius and it encloses the radial artery and veins. This vessel is at this level easily found beneath the inner border of the supinator longus. The ulnar artery and nerves are here nearer the surface than in the preceding section, and the surgeon has only to make an incision between the flexor carpi ulnaris and the flexor sublimis digitorum to reach it. The fascial lamina passing from it to the median nerve, and which is prolonged beneath the origin of the pronator teres to the radius, divides the deep layer consisting of the flexor profundus digitorum and flexor longus pollicis from the superficial flexors, in which the flexor sublimis digitorum has penetrated beneath the palmaris longus which has already become tendinous. In like manner, on the opposite side of the interosseous ligament the extensors are divided into a superficial and deep layer ; and the extensor ossis metacarpi pollicis and the extensor secundi internodii are already shown.

If the flexor surface be compared with the extensor with reference to the mass of its muscles, it is seen at once that the flexor considerably predominates over the extensor, and farther that the main trunks of the vessels lie on the flexor surface. If the surgeon has a choice of flap in amputation of the forearm in this region, provided there is nothing to the contrary, he should form his flap chiefly from the flexor surface, as much on account of the quantity of soft parts as for the nourishment afforded the stump by the vessels. The formation of flaps from the extensor aspect is much more difficult of performance on account of the closeness of the bones to the surface.

Fig. 3 is a section of the left forearm in its lower third. The radius has become considerably thicker in section. Its surface is covered by the broad pronator quadratus, which from its attachment to the ulna, rolls the radius over to the position of pronation. Beneath it is the interosseous ligament, and on both sides of it the interosseous vessels. The proximity of the radio-carpal joint is evident from the presence of the tendons of the muscles. The flexors and extensors even to the flexor carpi ulnaris have become tendinous, consequently the radial artery lies free, covered only by skin and fascia, hence affording the readiest means of feeling the pulse, and is here very easily ligatured. The ulnar artery, on the contrary, is still covered over by the tendinous border of the flexor carpi ulnaris, which must be drawn aside in order to reach it. On the extensor aspect are the long muscles of the thumb, and passing upwards from below the radial extensors of the carpus. At their points of crossing, bursae are developed to prevent their rubbing against one another. Over-use of these muscles, such as with mowers, may cause inflammation of these bursae and form a tumour over this locality (tenosynovitis). The number of muscles again on the flexor surface exceeds that of the extensor surface in this section. The mass of the muscles has, however, so much diminished that in amputation of the forearm in this region the flap a la manchette is preferable, as the plate sufficiently explains.

Fig. 4. In this plate the section passes through the carpus. The tendons only of the muscles are now shown with their bursal tissue, the presence of which is indicated by the numerous black lines around the divided tendons, the only muscular tissue cut being that of the ball of the little finger. Only a small portion of the radius, the root of its styloid process, is shown.

The bones of the carpus seen, are the semilunar, scaphoid, and cuneiform, and the articulation between it and the pisiform, the surface of which is seen anteriorly, has been opened.

The three bones of the first row represent a surface, the individual portions of which are moveable, and which articulates with the radius, and with the ulna by means of the inter-articular fibro-cartilage. The section of these three bones, as here represented, has not the form of an ellipse, but resembles a parallelogram, with its angles rounded off. The articular surfaces of these bones approximate to the spherical form, being received into an oval hollow, somewhat in the same manner as the head of the humerus into the glenoid cavity of the scapula.

PLATES XXIX (A, B) AND XXX

THE body from which this preparation was made was quite recent, twenty-five years of age, in the last month of pregnancy, and received in the condition of rigor mortis. Beyond the constriction of the neck produced by the means of death (hanging) no abnormality existed. The condition of the genitals corresponded with an advanced stage of pregnancy, and were injected and succulent. The method of preparation was carried out in the usual manner. The foetus, which was divided in the section of the body, was subsequently restored to its original condition, so as to afford a representation of its former position in the uterus. I chiselled out the foetus and the liquor amnii from the left side of the body, and moistened the surface of the section of the uterus, and then froze it on the right side. The portion now lying in the right half of the uterus remained then for the purposes of representation as an untouched foetus. The left half of the uterus and its appendages, after the removal of the rest of the liquor amnii, was represented as empty. The foetus, which was in the second position of the head, was a well-formed female. The vulva were closed and the nails well developed. Its entire length was about twenty-three inches, its weight without the cord about six pounds. The cord was divided, and passed to the placenta between the head and right arm, the placenta being placed downwards and on the right side of the uterus. The child, as the plate shows, lay mostly in the right half of the uterus. In the section more than the right half of the head which was sawn obliquely, was removed. Moreover, the left arm and a portion of the right shoulder were divided longitudinally, and the forearm being placed at right angles with it, transversely, as well as a portion of the right leg, which extended towards the left side. The left knee was moreover grazed by the saw. The back and belly lay in the right half of the uterus, and the greater portion of the liquor amnii remained in the left. As the relations of this oblique section of the foetus offer points of no peculiar interest, I have refrained from reproducing the corresponding plate of the large atlas in this small edition.

The uterus is so folded over the symphysis that its anterior wall forms a kind of sac, indicating a condition of relaxation. The numerous large veins in its tissue are shown in the plate in the wall as simple strokes, their lumina becoming recognisable only when their walls were separated from each other; they appear patent, however, in the vaginal portion of the uterus and in the vagina itself. The vaginal portion of the uterus is proportionately deep, and for the most part lies in the left half of the body, the section having passed through its right half and opened merely the first portion of the cervix, as shown in Plate XXIX u. It was filled with viscid mucus and opened into the cavity of the uterus, about one fifth of an inch below the plane of section, so that its upper half could not be seen. The length of the vagina at this period of pregnancy makes it probable that the woman was not a primipara, notwithstanding that there were no cicatrices on the abdominal parietes, and the os internum was so narrow that only a very small sound could pass it. The number of veins met with in the right half of the vagina and their swollen condition is remarkable, and their lumina are peculiarly well seen in the left half of the preparation, Plate XXIX B. The falling in of the vaginal portion of the uterus is remarkable, considering the empty contracted condition of the bladder. The latter has slipped down bodily from the inner surface of the symphysis, and is so completely displaced that the course of the urethra has become bent at an angle. The external os lies in the hollow of the under border of the symphysis, although, according to Moreau, it corresponds at the end of pregnancy with the level of the upper border of the symphysis, and is still higher according to Schultze.

The level of the fundus corresponds nearly with the under border of the first lumbar vertebra; a more accurate definition cannot be given, as the highest point of the uterus was not included in the section, as it inclined more to the right side. This is almost the level given by Moreau, and according to the measurements of Schultze (' Wandtafeln,' taf. vi), it would appear to be the second lumbar vertebra. As the parts in the meanwhile began to thaw, a more accurate measurement in this particular could not be made.

The depth of the cavity of the uterus and its connections, and of the entire cavity of the abdomen, is less than is usually admitted. Notwithstanding the size of the foetus it is not improbable that the attitude of the body had some influence in this respect, and that lying horizontally on the back the uterus obtained a kind of fulcrum on the vertebral column, whilst in the upright position the yielding walls of the abdomen are pushed forwards. It is farther to be remembered that in dead bodies generally in consequence of the high position of the diaphragm, the depth of the cavity of the abdomen is less than during life.

In the present instance the distance of the lumbar vertebrae from the anterior wall of the abdomen was almost one third of the entire sagittal diameter of the body at its point of greatest distension ; whilst in the body which in Plate II is represented in the second month of pregnancy, the lumbar spine projects slightly beyond the middle of this diameter.

Finally, the vessels were in this case uninjected a circumstance which is to be taken into consideration in estimating the thickness of the walls of the uterus.

The cavity of the abdomen extended tolerably far up in comparison with its slight depth. The highest point of the diaphragm reached the level of the seventh dorsal vertebra, whilst in males, and unimpregnated females of middle age it would extend only as far as the ninth or tenth.

The mass of the intestines was pushed downwards, and chiefly lodged in the left upper half of the abdominal cavity. The pyloric extremity of the stomach was bent at an acute angle backwards and to the left side, so that it was twice cut through. The upper horizontal portion of the duodenum was directed backwards. On the left half of the body the duodenum is contracted against the pylorus, and moreover shows the opening of the pancreatic and choledic ducts. Below the duodenum is the pancreas. The liver and spleen are not enlarged. The latter measured 5'5 inches long, 3'8 inches broad, and 2 inches thick.

The duodenum and pyloric portion of the stomach had pushed the fundus uteri, which lay more to the right, together with the rest of the intestines over to the left side.

The rectum, which was tolerably distended, bent round to its iliac flexure, towards the right side whilst yet in the pelvic cavity, so that this flexure is met with in the course of the section. Between the rectum the folds of which on the right side are so disposed that they might be taken for the valves of Kerkring in the plate and the uterus, is a coil of small intestine, the lowest portion of the ileum passing to the ascending colon, a disposition which does not usually happen with the impregnated uterus, but only in anteversion.

In examining the limit of the peritoneum in the pelvis, it must not be confounded with the fascia, represented rather too thick, which passes down between the uterus, bladder, and rectum. The peritoneum is applied for only a short extent to the posterior wall of the vagina, and envelopes nearly half of the posterior wall of the contracted bladder, whilst the fascias, which enclose a loose, lax cellular tissue, pass forwards nearly to the internal orifice of the urethra, and posteriorly close to the end of the rectum.

The thoracic cavity appears shallow, in consequence of the high position of the diaphragm, but, on the other hand, very wide in the antero-posterior diameter, as may be seen by comparing this preparation with the section of the female subject in Plate II. But on the strength of this, an enlargement of the base of the thorax during pregnancy is not necessarily to be inferred, as measurements for comparison are wanting before and after it. Although it may appear plausible to explain the unvarying size of the spirometer during pregnancy, by the fact that the diminution of the thoracic space dependent on the rising of the diaphragm is compensated for by the traction of the abdominal muscles acting over the uterus like a pulley, the anatomical relations in this respect are not yet determined. Gerhard found, by measurements on living bodies, that in forty-two females in advanced pregnancy the diaphragm was in thirty-six cases in a normal position, in five it was deeper, and only in one higher. Dorn in his measurements by means of the cyrtometer on living females in advanced pregnancy and in lying-in women, found that in most cases the bases of the thorax had a greater breadth during pregnancy than after delivery, but, on the other hand, its depth was less from before backwards. When the uterus was empty this relation was reversed, the thorax collapsed on both sides, the transverse diameter decreased, and the vertical diameter increased (' Bericht iiber die Naturforchenversammlung zu Griessen,' 1865, p. 225).

In the cavity of the -thorax, in consequence of the scoliosis of the spine, the section deviated to the right of the middle line, so that traversing the lumina of the superior and inferior venae cavae, the right auricle and root of lung are met with, consequently the relation of the openings of both veins into the heart are clearly seen. The inferior vena cava, which receives the hepatic vein just before its entrance into the heart, comes from behind into the right auricle, whilst the superior vena cava opens considerably further forwards. The axes, therefore, of the cavaa form an angle, which, owing to the convexity of the septum auriculorum, is rounded off. The eminence, behind which lies the left auricle, is the tuberculum Loweri. On the right half of the body is noticed the external wall of the right auricle, whilst on the left a view is obtained of the left ventricle, in front of the entrance to which is still a small portion of the rudimentary Eustachian valve. This valve limits the posterior portion of the right auricle, in which is still to be seen the original position of the foramen ovale. In the anterior portion of the auricle, to which the superior cava tends, the bulbus aortaa forms a flattish protuberance. The aorta itself is not seen entirely, a portion of it only being exposed. It rises in front of the superior vena cava, and then disappears below the left innominate vein.

The section of the lung seen in Plate XXIX is that of the right.

The soft parts of the neck are considerably dislocated towards the left side, owing to the hypertrophied thyroid body. The trachea lies so far over to the left side that only a small portion of the thyroid cartilage is met with.

The brain was divided through its right half, the radiation of the fibres of the right corpus callosum being thus shown. Beneath it is the descending cornu of the right lateral ventricle with the pes hippocampi. Beneath the dura mater, in the right half of the preparation, a portion of the Gasserian ganglion and some fibres of the fifth nerve are seen.

The relations of the skeleton, however, are of the greatest importance. I had therefore, after all. the plates were drawn, the halves of the skeleton macerated, and the parts as accurately as possible adjusted with regard to each other, as represented in the adjoining woodcut. It presents a slightly scoliosed pelvis, with a like condition of the spine. It shows moreover that the deviation of the line of section from the middle line was not so considerable as the plate might suggest. The section passed through the pelvis, as near as possible in the middle line, externally and to the right of the lumbar vertebrge, meeting the dorsal at their articulation with the* ribs, and passing again in the cervical region to the middle of the spinal column, and subsequently again to the right in the skull.

Beyond the scoliosed condition of the spine there was nothing worthy of remark, except that there were two cervical ribs, one complete on the right side, and a rudimentary one on the left side of the seventh cervical vertebra. There were seven cervical vertebrse, but only eleven dorsal and five lumbar. There was a rudimentary process from the fifth lumbar which was attached to the upper portion of the sacrum. The measurements of the pelvis in inches were as follows : The conjugata vera 3*8 in. (the conjugata at the narrowest points being 3*7) ; the right sacro-cotyloid 2*8 in. ; the left sacro-cotyloid 3'2 in. ; the transverse diameter 5*8 in. ; the left oblique diameter, 5'08 in., and the right oblique diameter 5'6 inches. The sacrum was 4*5 in. deep and 4'8 in. broad.

The question arises whether, in a weak obliquely contracted pelvis, showing such a variation, child-birth be possible without surgical aid.

PLATE XXXI*

THE body from which this plate was made, was that of a person thirtyfive years of age, who died from drink at the commencement of labour. An examination of the genitals showed that the liquor amnii had not escaped. After having been prepared in the usual way, a section was made in the mesial plane from below upwards. The symphysis was not however exactly divided at its centre, but the deviation was so slight that it need not be regarded.

After the drawings were made of the right half of the body, and completely finished, the maternal structures were removed, in order to obtain the other half of the child uninjured and in its original position.

The child was a well-formed male of about six pounds weight including the cord which passed downwards under the left leg, whence it was bent upwards and lay over the left ankle joint, being reflected sharply on to the placenta which was attached to the upper portion of the uterus. The cord must have been cut through on removing the left half of the child, as I afterwards found its placental insertion in the left half of the body. I had divided it close to its placental extremity, and it was so firmly pressed against the child, that it could be with difficulty removed without inducing a change in the position of the left lower extremity.

The child's head as is seen in the plate is apparently in the second position, and was on the point of being born at the death of the mother. The natural rotation of the head in the pelvis has commenced, being turned more to its right side than its trunk. The shoulders are entirely in the false, whilst the head has already entered the true pelvis. The propulsive force must have been considerable, as the fcetal head is large and the pelvis not particularly wide, and the evidences of this force are shown from the form of the head. Its posterior portion is pointed or pearshaped, and an examination showed there was considerable effusion of blood on the skull.

As this chapter refers almost entirely to the section of the child, and the corresponding plates are not reproduced in this small edition, I have thought it advisable to omit such portions of it as are not illustrated directly to the accompanying plate, and to advise the reader interested in the matter to consult Prof. Braune's ' Die Lage des Uterus und Fretus am Ende der Schwangerschaft,' which has been already translated into English. TE.

Further it appears that owing to the strong contractions of the uterus upon the child the joints nowhere exhibit their rounded form with the freely flexed position of the extremities, as it is packed in the smallest space possible.

The skin was thrown into sharp ridges. The nape of the neck appeared as a narrow chink between the deeply folded skin of the back and occiput. The bulging out of the head in the region of the left ear is remarkable, being produced by the pressure exerted by the narrow pelvis. Just below it is the section of the symphysis. A deep notch is produced in the left arm by the internal os, which has also left traces behind on the right forearm which passed down longitudinally over it.

The uterus itself is of especial interest, the relations of which are well seen after the removal of the entire child, and a particular plate of its empty cavity seemed necessary. The uterus held the child firmly, and had no folds in it, from which a lax condition of its walls might be inferred. It was placed with its long axis directed nearly vertically towards the plane of the inlet of the pelvis, so that it had the appearance of having remained in a state of contraction after death. The internal os lay somewhat over the inlet, and is noticeable from the lumen of a large vein with a smaller one beside it, the only veins which were found patent in the walls of the uterus, in consequence of the blood remaining in them.

In the empty cavity of the uterus, the internal os appeared as a freely projecting semicircle, an inch and a half above the symphysis, and four fifths of an inch above the premontory of the sacrum. The external os, which was completely dilated, appeared as a small projection. It was drawn out obliquely, from the region of the lower border of the symphysis towards the articulation between the sacrum and coccyx, and surrounded the protruding occiput of the foetus. The opening of the right Fallopian tube was well seen in the upper third of the uterus.

The depth of the uterine cavity from the horizontal plane of the surface of the section to its lowest point was 2' 6 inches, and the distance of the internal os to the fundus 6*6 inches. The distance of the external os from the inner in the axis of the pelvis was 4' 5 inches. The thickness of the walls of the uterus varied considerably in different places.

The placenta lay in the floor of the uterus, and chiefly in its left half, therefore the origin of the cord must have been divided in the section. Although the patency of the rectum was here and there retained, the bladder was empty and contracted. Behind the symphysis its walls had become so thin as to be hardly recognisable. Above and below the symphysis, where the pressure had not been so great, it was thicker, and consequently better seen. On filling the bladder it became distended upwards, so that the anterior walls of the abdomen must have been lifted up slightly from the uterus.

The protrusion of the abdominal parietes by the uterus is here more considerable than in the preceding case, in which that organ occupies a different position, although not so marked as would appear at first sight. In both the spine projects beyond a third of the entire depth of the trunk.

Unfortunately, during the removal of the left half of the mother in order to obtain the necessary view of the child, the skeleton was destroyed, so that it was impossible to restore it as was done in the previous case.

As the vertebras had no lateral deviations so the section passed exactly in the mesial line. The kyphotic curvature of the thoracic and cervical portions, though marked, is of no particular interest as regards the relations here shown.

The relations of the intestines and stomach, the former being, as in the other body, pushed upwards, afford nothing worthy of remark. The liver and spleen were normal. The former weighed about three pounds, and displayed a protuberance of its anterior wall, as in the first instance, the latter weighed about seven ounces, and measured 5.6 inches long, 2.8 inches broad, and 1/2 inches deep, was therefore rather less than generally met with in advanced pregnancy.

The depth of the cavity of the abdomen, measured from the symphysis to the cupola of the diaphragm, is pretty much the same as in the former case, whilst there is considerable difference in that of the thorax. I need call no particular attention in this case to the diameter of the base of the thorax, which naturally exceeds that of the female at the second month represented at Plate II. Any decided measurement as to the depth of the thorax during pregnancy can only be made on the living body, when the relations of the chest cavity before and after delivery must be determined.

The relations of the heart, trachea, larynx, mouth, and brain were entirely normal.