Surgical Anatomy Part 18

12. Cricoid cartilage.

13. Crico-thyroid interval where laryngotomy is performed.

14. Genio-hyoid muscle.

15. Section of lower maxilla.

16. Parotid duct.

17. Lingual attachment of styloglossus muscle, with part of the gustatory nerve seen above it.

[Ill.u.s.tration: Head and neck, showing blood vessels, muscles and other internal organs.]

Plate 21

COMMENTARY ON PLATE 22.

THE RELATIVE POSITION OF THE SUPERFICIAL ORGANS OF THE THORAX AND ABDOMEN.

In the osseous skeleton, the thorax and abdomen const.i.tute a common compartment. We cannot, while we contemplate this skeleton, isolate the one region from the other by fact or fancy. The only difference which I can discover between the regions called thorax and abdomen, in the osseous skeleton, (considering this body morphologically,) results, simply, from the circ.u.mstance that the ribs, which enclose thoracic s.p.a.ce, have no osseous counterparts in the abdomen enclosing abdominal s.p.a.ce, and this difference is merely histological. In man and the mammalia the costal arches hold relation with the pulmonary organs, and these costae fail at that region where the ventral organs are located.

In birds, and many reptiles, the costal arches enclose the common thoracico-abdominal region, as if it were a common pulmonary region. In fishes the costal arches enclose the thoracico-abdominal region, just as if it were a common abdominal region. I merely mention these general facts to show that costal enclosure does not actually serve to isolate the thorax from the abdomen in the lower cla.s.ses of animals; and on turning to the human form, I find that this line of separation between the two compartments is so very indefinite, that, as pathologists, we are very liable to err in our diagnosis between the diseased and the healthy organs of either region, as they lie in relation with the moveable diaphragm or septum in the living body. The contents of the whole trunk of the body from the top of the sternum to the perineum are influenced by the respiratory motions; and it is most true that the diaphragmatic line, H F H*, is alternately occupied by those organs situated immediately above and below it during the performance of these motions, even in health.

The organs of the thoracic region hold a certain relation to each other and to the thoracic walls. The organs of the abdomen hold likewise a certain relation to each other and to the abdominal parietes. The organs of both the thorax and the abdomen have a certain relation to each other, as they lie above and below the diaphragm. In dead nature these relations are fixed and readily ascertainable, but in living, moving nature, the organs influence this relative position, not only of each other, but also of that which they bear to the cavities in which they are contained. This change of place among the organs occurs in the normal or healthy state of the living body, and, doubtless, raises some difficulty in the way of our ascertaining, with mathematical precision, the actual state of the parts which we question, by the physical signs of percussion and auscultation. In disease this change of place among these organs is increased, and the difficulty of making a correct diagnosis is increased also in the same ratio. For when an emphysematous lung shall fully occupy the right thoracic side from B to L, then G, the liver, will protrude considerably into the abdomen beneath the right asternal ribs, and yet will not be therefore proof positive that the liver is diseased and abnormally enlarged. Whereas, on the other hand, when G, the liver, is actually diseased, it may occupy a situation in the right side as high as the fifth or sixth ribs, pushing the right lung upwards as high as that level; and, therefore, while percussion elicits a dull sound over this place thus occupied, such sound will not be owing to a hepatized lung, but to the absence of the lung caused by the presence of the liver.

In the healthy adult male body, Plate 22, the two lungs, D D*, whilst in their ordinary expanded state, may be said to range over all that region of the trunk of the body which is marked by the sternal and asternal ribs. The heart, E, occupies the thoracic centre, and part of the left thoracic side. The heart is almost completely enveloped in the two lungs. The only portion of the heart and pericardium, which appears uncovered by the lung on opening the thorax, is the base of the right ventricle, E, situated immediately behind the lower end of the sternum, where this bone is joined by the cartilages of the sixth and seventh ribs. The lungs range perpendicularly from points an inch above B, the first rib, downwards to L, the tenth rib, and obliquely downwards and backwards to the vertebral ends of the last ribs. This s.p.a.ce varies in capacity, according to the degree in which the lungs are expanded within it. The increase in thoracic s.p.a.ce is attained, laterally, by the expansion of the ribs, C I; and vertically, by the descent of the diaphragm, H, which forces downwards the ma.s.s of abdominal viscera. The contraction of thoracic s.p.a.ce is caused by the approximation of all the ribs on each side to each other; and by the ascent of the diaphragm. The expansion of the lungs around the heart would compress this organ, were it not that the costal sides yield laterally while the diaphragm itself descends. The heart follows the ascent and descent of the diaphragm, both in ordinary and forced respiration.

But however much the lungs vary in capacity, or the heart as to position in the respiratory motions, still the lungs are always closely applied to the thoracic walls. Between the pleura costalis and pulmonalis there occurs no interval in health. The thoracic parietes expand and contract to a certain degree; and to that same degree, and no further, do the lungs within the thorax expand and contract. By no effort of expiration can the animal expel all the air completely from its lungs, since by no effort of its own, can it contract thoracic s.p.a.ce beyond the natural limit. On the other hand, the utmost degree of expansion of which the lungs are capable, exactly equals that degree in which the thoracic walls are dilatable by the muscular effort; and, therefore, between the extremes of inspiration and expiration, the lungs still hold closely applied to the costal parietes. The air within the lungs is separated from the air external to the thorax, by the thoracic parietes. The air within and external to the lungs communicate at the open glottis. When the glottis closes and cuts off the communication, the respiratory act ceases--the lungs become immovable, and the thoracic walls are (so far as the motions of respiration are concerned) rendered immovable also.

The muscles of respiration cannot, therefore, produce a vacuum between the pulmonic and costal pleura, either while the external air has or has not access to the lungs. Upon this fact the mechanism of respiration mainly depends; and we may see a still further proof of this in the circ.u.mstance that, when the thoracic parietes are pierced, so as to let the external air into the cavity of the pleura, the lung collapses and the thoracic side ceases to exert an expansile influence over the lung.

When in cases of fracture of the rib the lung is wounded, and the air of the lung enters the pleura, the same effect is produced as when the external air was admitted through an opening in the side.

When serous or purulent effusion takes place within the cavity of the pleura, the capacity of the lung becomes lessened according to the quant.i.ty of the effusion. It is more reasonable to expect that the soft tissue of the lung should yield to the quant.i.ty of fluid within the pleural cavity, than that the rigid costal walls should give way outwardly; and, therefore, it seldom happens that the pract.i.tioner can discover by the eye any strongly-marked difference between the thoracic walls externally, even when a considerable quant.i.ty of either serum, pus, or air, occupies the pleural sacs.

In the healthy state of the thoracic organs, a sound characteristic of the presence of the lung adjacent to the walls of the thorax may be elicited by percussion, or heard during the respiratory act through the stethoscope, over all that costal s.p.a.ce ranging anteriorly between B, the first rib, and I K, the eight and ninth ribs. The respiratory murmur can be heard below the level of these ribs posteriorly, for the lung descends behind the arching diaphragm as far as the eleventh rib.

When fluid is effused into the pleural cavity, the ribs are not moved by the intercostal muscles opposite the place occupied by the fluid, for this has separated the lung from the ribs. The fluid has compressed the lung; and in the same ratio as the lung is prevented from expanding, the ribs become less moveable. The presence of fluid in the pleural sac is discoverable by dulness on percussion, and, as might be expected, by the absence of the respiratory murmur at that locality which the fluid occupies. Fluid, when effused into the pleural sac, will of course gravitate; and its position will vary according to the position of the patient. The sitting or standing posture will therefore suit best for the examination of the thorax in reference to the presence of fluid.

Though the lungs are closely applied to the costal sides at all times in the healthy state of these organs, still they slide freely within the thorax during the respiratory motions--forwards and backwards--over the serous pericardium, E, and upwards and downwards along the pleura costalis. The length of the adhesions which supervene upon pleuritis gives evidence of the extent of these motions. When the lung becomes in part solidified and impervious to the inspired air, the motions of the thoracic parietes opposite to the part are impeded. Between a solidified lung and one which happens to be compressed by effused fluid it requires no small experience to distinguish a difference, either by percussion or the use of the stethoscope. It is great experience alone that can diagnose hydro-pericardium from hypertrophy of the substance of the heart by either of these means.

The thoracic viscera gravitate according to the position of the body.

The heart in its pericardial envelope sways to either side of the sternal median line according as the body lies on this or that side. The two lungs must, therefore, be alternately affected as to their capacity according as the heart occupies s.p.a.ce on either side of the thorax. In expiration, the heart, E, is more uncovered by the shelving edges of the lungs than in inspiration. In pneumothorax of either of the pleural sacs the air compresses the lung, pushes the heart from its normal position, and the s.p.a.ce which the air occupies in the pleura yields a clear hollow sound on percussion, whilst, by the ear or stethoscope applied to a corresponding part of the thoracic walls, we discover the absence of the respiratory murmur.

The transverse diameter of the thoracic cavity varies at different levels from above downwards. The diameter which the two first ribs, B B*, measure, is the least. That which is measured by the two eighth ribs, I I*, is the greatest. The perpendicular depth of the thorax, measured anteriorly, ranges from A, the top of the sternum, to F, the xyphoid cartilage. Posteriorly, the perpendicular range of the thoracic cavity measures from the spinous process of the seventh cervical vertebra above, to the last dorsal spinous process below. In full, deep-drawn inspiration in the healthy adult, the ear applied to the thoracic walls discovers the respiratory murmur over all the s.p.a.ce included within the above mentioned bounds. After extreme expiration, if the thoracic walls be percussed, this capacity will be found much diminished; and the extreme limits of the thoracic s.p.a.ce, which during full inspiration yielded a clear sound, indicative of the presence of the lung, will now, on percussion, manifest a dull sound, in consequence of the absence of the lung, which has receded from the place previously occupied.

Owing to the conical form of the thoracic s.p.a.ce, the apex of which is measured by the first ribs, B B*, and the basis by I I*, it will be seen that if percussion be made directly from before, backwards, over the pectoral ma.s.ses, R R*, the pulmonic resonance will not be elicited. When we raise the arms from the side and percuss the thorax between the folds of the axillae, where the serratus magnus muscle alone intervenes between the ribs and the skin, the pulmonic sound will answer clearly.

At the hypochondriac angles formed between the points F, L, N, on either side the lungs are absent both in inspiration and expiration.

Percussion, when made over the surface of the angle of the right side, discovers the presence of the liver, G G*. When made over the median line, and on either side of it above the umbilicus, N, we ascertain the presence of the stomach, M M*. In the left hypochondriac angle, the stomach may also be found to occupy this place wholly.

Beneath the umbilicus, N, and on either side of it as far outwards as the lower asternal ribs, K L, thus ranging the abdominal parietes transversely, percussion discovers the transverse colon, O, P, O*. The small intestines, S S*, covered by the omentum, P*, occupy the hypogastric and iliac regions.

The organs situated within the thorax give evidence that they are developed in accordance to the law of symmetry. The lungs form a pair, one placed on either side of the median line. The heart is a double organ, formed of the right and left heart. The right lung differs from the left, inasmuch as we find the former divided into three lobes, while the latter has only two. That place which the heart now occupies in the left thoracic side is the place where the third or middle lobe of the left lung is wanting. In the abdomen we find that most of its organs are single. The liver, stomach, spleen, colon, and small intestine form a series of single organs: each of these may be cleft symmetrically. The kidneys are a pair.

The extent to which the ribs are bared in the figure Plate 22, marks exactly the form and transverse capacity of the thoracic walls. The diaphragm, H H*, has had a portion of its forepart cut off, to show how it separates the thin edges of both lungs above from the liver, G, and the stomach, M, below. These latter organs, although occupying abdominal s.p.a.ce, rise to a considerable height behind K L, the asternal ribs, a fact which should be borne in mind when percussing the walls of the thorax and abdomen at this region.

DESCRIPTION OF PLATE 22.

A. Upper bone of the sternum.

B B*. Two first ribs.

C C*. Second pair of ribs.

D D*. Right and left lungs.

E. Pericardium, enveloping the heart--the right ventricle.

F. Lower end of the sternum.

G G*. Lobes of the liver.

H H*. Right and left halves of the diaphragm in section. The right half separating the right lung from the liver; the left half separating the left lung from the broad cardiac end of the stomach.

I I*. Eighth pair of ribs.

K K*. Ninth pair of ribs.

L L*. Tenth pair of ribs.

M M*. The stomach; M, its cardiac bulge; M*, its pyloric extremity.

N. The umbilicus.

OO*. The transverse colon.

P P*. The omentum, covering the transverse colon and small intestines.

Q. The gall bladder.

R R*. The right and left pectoral prominences.

S S*. Small intestines.

[Ill.u.s.tration: Chest and abdomen, showing bones, blood vessels, muscles and other internal organs.]