Practical medical anatomy; a guide to the physician in the study of the relations of the viscera to each other in health and disease and in the diagnosis of the medical and surgical conditions of the anatomical structures of the head and trunk

Front matter

IGi U U ta«

Cornell University Library

The original of this book is in the Cornell University Library.

Introduction

T>R. Daewest, wlien lie wrote the preface to Ms " Zoonomia," stated his proposed object in the following sentences : " A theory founded on Nature, that should bind together the scattered facts of medical knowledge, and converge into one point of view the laws of organic life, would thus on many accounts contribute to the interests of society. It would capacitate men of moderate abilities to practise the art of healiag mth real advantage to the public ; it would enable every man of literary attainments to distinguish the genuine disciples of medicine from those of boastful effrontery or of wUy address ; and would teach mankind in some important situations the knowledge of themselves."

To achieve pre-eminence in the discovery of a general law, or to attain renown in science by the value of original investigation is an enviable as well as an uncommon privilege ; but in the voluminous literature of medical science, many a fact still remains which will bear constant repetition, which is pregnant with practical value, and which might otherwise be either forgotten by, or unknown to, the general reader. Compilation is therefore not without some decided value, if discreetly performed.

The anatomy of man must always be the groundwork of aU medical knowledge, since by it alone are we able to understand the various functions of the human frame, the symptoms of disease, and the rationale of treatment. In our present enlightenment, physiology, histology, and pathology are becoming so inseparable from the dry detail of mere anatomical description, and the surgical bearings of the various structures are so intimately connected with general diagnosis, that it is no longer possible, within the limited scope of a single volume, to present to the general practitioner all the valuable points which can be daily applied in the various departments of medicine.

To any one, f amihar with the earlier writers, the fact must, however, be apparent, that, in spite of the rapid strides which are constantly being made (through the aid of greater facilities for research, improved apparatus, and new discoveries as to the application of general laws in physics as a means of diagnosis), most of the fundamental facts, upon whicli great stress is still laid, were known and skilfully used centuries

VI INTRODUCTION.

ago. One, wlio attempts to establish priority to-day in almost any braneli, is more than likely to find, in these earlier works, evidences of previous thought in the same direction ; derived often from investigation pursued with a diligence that deserves more than simple praise, when the difiiculties which then existed are considered. The use of the special senses of the physician were then educated to a degree of acuteness which few of our modem savants can justly claim for themselves. The expressions of the sick were once made a special study ; the attitudes assumed in certain types of disease were carefully noted and impressed upon the student ; the sense of touch was educated until the most trifling variation in the pulse, or the contour of the various anatomical regions seldom escaped detection ; the anatomy of the living subject was taught in those days in all its practical bearings in connection with dissection ; and the student, by a constant repetition of the more important anatomical guides, became familiarized with the contents of surgical regions, the relations of the viscera to each other, the value of the bony prominences, and the general plan of construction which characterizes the biped from the quadruped, man from the lower animals. Taste and smell were, to the physician of that time, faculties which afforded practical points in diagnosis; and the secretions and excretions of the body had not alone a physiological importance, but were often used by the skilful physician as valuable aids to diagnosis.

It is, to my mind, a question if our present methods of medical instruction, as evidenced in our literature, do not tend to make the medical reader attach but a trivial importance to some of those aids which made these men great and which cause their writings to be still respected. Does it not tend to make us rely solely upon the later science of auscultation and percussion in our examinations for obscure diseases of the viscera, to the partial or utter disregard of many of the outward symptoms which were then so carefully studied ; and to bring into prominence chemical and microscopical analyses to the exclusion of the special senses, when positive information upon subjects, to which they are all equally applicable, is demanded ?

This volume is an indirect outgrowth of two courses of lectures delivered by me before the students of the Medical Department of the University of the City of New York, during the winters of 1879 and 1880, upon the anatomy of the circulatory and nervous systems, and one in the spring of 1878, upon the anatomy of the viscera. Then more than ever before, I realized that all practical points were received with greed by the student ; in contrast to the apathy with which long descriptive detail must necessarily be accompanied, unless, by illustration it can be made clear that dry facts are not deficient in interest^ and that nrTBODUCTION. VU.

anatomy is not alone a mere preparatory drill to the practical branches, hut a source of ever varying utihty in all the walks of professional life. It struck me then that if anatomy could be so presented in all its departments as to convince the medical reader that it could be made a source, not only of pleasure at the time, but of unceasing benefit in whatever direction his professional taste might call him, its study would cease to be wearisome and its details no longer a task of memory.

The following pages, ' such as they are, have cost me many hours of research to write ; and it is to be hoped they will afford some useful hints to those who read them. As a prominent author puts it : " That writer accomplishes the most, who gives his reader the inost knowledge, and takes from him the least time ; " and I have not forgotten, in my effort to make the work useful to all, the wise observation of him who says " in the same meadow the ox seeks the herbage ; the dog the hare ; and the stork, the lizard."

In deliberating upon the plan of arrangement of this work, the question naturally arose how the subject could be best treated to systematize its study and at the same time to facilitate reference. It has long been a custom with authors of works upon descriptive anatomy, to exhaust each of the separate divisions of this subject before proceeding to the consideration of the next, thus treating in successive chapters of osteology, arthrology, myology, etc.; while, in works designed for use at the disseeting table, custom has modified the plan so that we find all of the structures contained in special anatomical regions so grouped as to furnish the student with a detailed description of the vessels, muscles, nerves, etc., as they are met with in practical anatomy.

The object of this latter plan is obvious ; it furnishes the reader the information for which he seeks, without the necessity of constant reference to different portions of the volume, which would not be afforded by a general treatise. On the other hand, such a plan in a descriptive treatise would tend to confuse the beginner, who is supposed to be ignorant of anatomy, and even of the terms used in it, and who, very properly, can best acquire a mastery of the general subject by a thorough comprehension of each of the separate departments of anatomy in their proper order ; and thus its utihty as a text-book would be impaired. Furthermore, a different plan in a general treatise greatly f acihtates reference, and thus adds to its popularity with the general medical pubhc.

I have concluded, after much dehberation, to combine these two methods, in the presentation of this work ; since, although, I can see some defects in the arrangement which may cause others to disagree

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with me in my decision, I believe that the aims of this volume wiU be best promoted thereby.

As this work is not intended to be a treatise upon descriptive anatomy, but rather a collection of hints which shall serve as a guide to the study of the practioal hearings of the different portions of the head and trunk upon the field of general medicine, only such points win be touched upon as seem to the author worthy of incorporation from a physiological, surgical, or medical point of view, or bearing, in such a way, upon the boundless field of comparative anatomy as to add to the interest of the reader in showing the object of the Creator in causing man to so deviate from the type of the lower animals.

I have separated the description of the head and the neck, because, anatomically, the latter region is only a portion of the trunk, although, by so doing, the branches of some of the large arteries of the neck wOl be described before the main trunks have been considered, which to the beginner might possibly create confusion. But the same objection appHes with equal force to all dissecting manuals ; and, as the present volume presupposes some education on the part of its readers, it seems to the author that the benefits which this arrangement afEords far outweigh its disadvantages. I have, however, followed the plan of general text-books upon anatomy, as regards the grouping of such points as pertain to the bones, muscles, vessels, and nerves, since, by so doing, reference is greatly facilitated, and the danger of any important omissions on the part of the author decreased.

In regard to the vessels, it is impossible to avoid reference to the surgical anatomy of the more important trunks, in attempting to teach the practical points pertaining to them ; while, as to the nerves of the body, some hints that properly pertain to physiology and surgery cannot be omitted, if the aim of this work is to be fully attained, although the limited size of this volume will preclude the insertion of but scattered hints in this direction. It is not to be inferred, however, that this work pretends to cover the ground, either of physiology or of operative surgery, since but a small portion of the former science treats of the vessels and nerves, while the latter department embraces remedial measures for every existing condition demanding surgical interference.

Again, when special bones are under discussion, and the attachments of the muscles of each seem to indicate that memory will be assisted by a reference to the action of some of these muscles which assist in producing special types of deformity, in case of fracture of the bone, it must not be forgotten that the bearing of anatomy upon the subject ceases with the enumeration of those facts, and cannot possibly suggest

INTEOD0CTION. IX

a discussion either of its symptoms or of the surgical appliances used for its relief.

The points of practical utility which pertain to the integument are •chiefly confined to the region of the head. Many of them are unquestionably due to the insertion of small sKps from the facial muscles into the skin and subcutaneous tissues, but they are, nevertheless, constant, and may often prove of great value. It is common with many authors of the present day to either totally disregard the valuable points of diagnosis afforded by the face, or to stamp as visionary all points of diagnostic value which have been attributed by authors, in the past, to special lines and wrinkles. While, perhaps, there may lae, in many instances, sufficient ground for such scepticism, still the entire subject of medical physiognomy should not, in my opinion, be totally disregarded or pronounced absolutely worthless. If all our examinations of those afBicted with diseases of the thoracic and abdominal viscera were confined alone to a physical examination through the aids of percussion and auscultation, without the opportunity of studying the physiognomy of the patient, an iinf avorable prognosis as to the duration of Hf e would frequently be pronounced ; when, could the brilhancy of the eye, the expressions of the mouth, and the general facial characteristics of the individual bespeak the vitality of temperament and the reactive power which no physical examination could possibly determine, the prognosis might appear less grave. I do not offer this as an apology for the few scattered hints given as to the value of facial lines as a means of diagnosis, or for the illustration of special types of countenance afforded by disease. Each reader must for himself determine to what extent the guides thus afforded by the earher investigators are of value, and, by practical investigation, confirm some which have been mentioned in this volume, and discard those which seem visionary or hypothetical.

If tlie term "medical anatomy" be taken in its most restricted sense, the title of this work is a misnomer. It has been written for the use of the general practitioner, in his daily practice, with the hope that it might present to him the study of anatomy from the stand-point of its general interest and practical utihty, and afford him a means of refreshing certain points which can be constantly applied, without entailing upon him much descriptive detail. It is properly called "medical," since it deals only with the head and the trunk, and the organs contained within the cavities of the thorax and abdomen ; but it would be insufficient for the wants of the general practitioner if it contained only such points as could be applied to the diseases of the viscera alone. I have, therefore, seen fit to incorporate many anatomical guides to the

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superficial, as well as the deeper structures, and to leave no region as complete, until the various parts contained in it have been considered in many of their practical relations, whether they be of a surgical or purely medical character. I have furthermore incorporated such suggestions as would tend to show a definite object in the construction of the human frame, and, in many instances, have called attention to the variations of the human body from that of the lower animals, when such deviations could be explained as a wise provision on the part of Nature.

Some portions of this work have already appeared in print in various medical journals both in this country and in Europe, but they have been altered and enlarged to meet the demands of this work ; while the abundance of illustration will still further assist in making the points more forcible and easy of comprehension to the reader. It is not to be expected, nor is intended, that this work can serve all the purposes of an extended anatomical treatise, since, of necessity, much that pertains to the blood-vessels, nerves, and viscera has been omitted ; but this objection applies with equal force to such valuable works as those of Sibson and Hilton, each of which tills the place for which it was designed.

I have used italics more frequently than would be deemed necessary, or, perhaps, in good taste, if the book were simply intended to be read from a stand-point of its general interest, and I have, in many instances, divided the text into shorter paragraphs than is conducive to the best appearance of the page, but this volume must, of necessity, consist of fragmentary jottings, each of which brings out some individual point of value, and the italics will greatly assist reference to different portions of the text, when much time might be otherwise lost in seeking for some special suggestion.

I have purposely omitted the illustration of anatomical statement or of theory, by the details of cases, even where these rules may have been applied by myself and others with benefit, and I have refrained from dwelling, at any length, upon the methods of treatment employed in the various diseases which have been discussed ; since I consider that the anatomical character of the work should ever be kept uppermost in the mind both of the author and the reader, and that any deviation from the strict line of the task is to be deprecated rather than encouraged. It has been my earnest endeavor, as far as the limited size of the volume would allow, to incorporate all that can be commended in the works of authors in tlie same field, and to omit all that seemed visionary or hypothetical.

If the work, as it stands, will help to verify that hackneyed phrase,.

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with which most courses of anatomical lectures are prefaced, but which few of the listeners are ever able to appreciate, in ah of its bearings and truthfulness of statement — "that anatomy is the foundation of all medical knowledge " — ^the author will feel that his labor has not been done in vain.

156 Madison Ave., New York City.

TABLE OF OONTEE"TS.

Chapter I. The Bones of the Head— Their Points of Special Interest 1-31

Abnormalities of the skull; General construction of the skull; Thickness of the skull and its variations; Tablets of the skull and their points of cHnioal interest; — Bony guides to intra-cerebral points of interest; General rules for trephining; — Sutures of the skull, and their clinical relations; — Occipital bone, its clinical relations; Sphenoid bone, its clinical relations; Frontal bone, its clinical relations; Parietal bone, its clinical relations; Temporal bone, its clinical relations; The bones of the nasal fossa; — The base of the skull, and its chnical relations; — Bones of the face and the clinical relations of special parts; The orbit, its general construction and chnical relations; The nostril, its clinical relations; The upper jaw, its clinical relations; The nasal bone, and the nasal arch; — the inferior maxillary bone, and the teeth; — The cranium as a whole: Its buttresses and their relation to fracture of the skull; — Variations in the form of the skull: Skull of infancy; Skull of childhood; Skull of the two sexes; Skulls of races and their variations: Mechanical deformities of skulls; — Poise of the head, and the diagnostic value of deviations from the normal attitude.

Chapter II. The Human Face in Health and Disease, and its Value AS A Guide in Diagnosis 31-71

Medical physiognomy, its clinical importance; — Facial lines, and the clinical significance of each: The transverse rugae; The oculo-frontal rugse; The linea oculo-zygomatica; The linea nasalis; The linea labialis; The linea coUateralis nasi; — Color of the face, and its changes in disease: Flushing of face, its causes; Red patches on cheek; Pallor (waxy, dusky, and leaden); Green discoloration; Light straw color of face; Yellow discoloration of the face; Blue discoloration of the face; Brown discoloration of the face. — Table of the forms of countenance met with in the more prominent diseases. —Special regions of the face, and their modifications: The forehead, its clinical aspects; The nose, its physiological interest and clinical aspects; The eye, as an indicator of character and disease: The cornea, its clinical aspects; The pupil, its clinical aspects; The eyeUd, its clinical aspects; Squint of eye, its clinical aspects; Special types of the eye in disease; The ear, its clinical suggestions: Ear of gout; Ear of visceral

XIV TABLE OF CONTENTS.

PAGE

cirrhosis; Ear of insane subjects; The cheek, its physiological and clinical points of interest: Modifications with age; Physiological functions; Variations in its color, and its significance; Surgical aspectsofthecheek;The lips, their physiological and medical aspects : Congenital deformities of the lips; Lips of the infant; Lips of the aged; Lips, as indicators of pain; Pallor of lips, its significance; Lividity of lips, its significance, — Deformities of the face — Congenital defects: In region of the orbit; Absence of eyes; Union of orbits; Defects in eyelids; Defects in pupil, andotherstructuresof theeye; Total absence of the face ; Median fissures of the face ; Absence ofnostrils; Absence of mouth; Double nose; Acquired defects — Herniaof the Brain; Tumors in the region of the face; Ulceration (lupus, carcinoma, etc.); Special types of face, and the clinical significance of each: ' ' Facies scrofulosa;" Face of idiots and imbeciles; " Facies Hippocratica;" "Facies stupida;" "Pinched countenance;" Face of apnoea; Face of ansemia; Eye of strumous ophthalmia; Eye, in iritis; Eye, in amaurosis; Eye, in cataract; Abnormal attitudes of face and head from ocular paresis; Eye, in chronic trachoma; Eye, in ptosis; Eye, in epicanthus; Eye, in glaucoma; Eye, in anterior dislocation of the lens; Eye, in locomotor ataxia; Eye, in motor oculi paralysis; Head and face, in hydrocephalus; Face, in thoracic affections; Face, in pneumonia; Face, in emphysema; Face, in extreme dyspnoea, and the diseases which tend to produce it; Face, in renal dropsy; Face, in chronic abdominal diseases; Face, in valvular heart disease; Face, in Graves' or Basedow's disease; Face, in cholera; Face, in chronic atrophy; Face, in epilepsy; Face, in glosso-labial paralysis; Face, in general paralysis of the insane; Face, in tetanus; Face, in chorea; Face, in catalepsy; Face, in cretinism; Face, in crossed paralysis; Face, in Bell's paralysis; Face, in trigeminal paralysis.

Chaptek III. The Blood- Vessels op the Head 71-110

Their clinical importance, in general — The lingual artery: its origin and course; its ranine branch; the operation for ligation; its clinical importance — The facial artery: its origin and course; its surgical relations; its peculiarities and those of its branches; its siu'gical anatomy; the operation for its ligation; its various anastomoses; — The occipital artery: its origin and course; its peculiarities; its surgical anatomy; — The posterior auricular artery: its origin and course; its main branches; its peculiarities; — The ascending phaiyngeal artery: its origin and course; its branches; its peculiarities; its surgical anatomy; — The temporal artery: its origin and course; its peculiarities: its surgical anatomy; — The internal maxUlary artery: its origin and course; its various branches; its peculiarities; its surgical anatomy; — The internal cai'otid artery: its origin and course; its anatomical divisions; its peculiarities; its surgical anatomy; its ophthalmic branch and its points of interest; the cerebral branches and the areas of brain supplied by each; surgical anatomy of the middle cerebral branch; aphasia, and its relation to embolism of the middle cerebral branch; — The vertebral artery: its origin and course; its various branches; its anastomoses; — The basilar artery: its course and branches; its posterior cerebral branch;— The circle of Willis: The vessels which help to form it; its nutrient branches given off to

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FAQE

tue bram;— The arterial supply of special regions of the head: Arterial supply of the meninges; arterial supply of the tympanum; — Hemorrhage, in general: Its varieties; Causes which modify it; Causes which tend to prolong it; Symptoms due to hemorrhage; Guides and suggestions as to the relief of hemorrhage.

The veins of the head — The cerebral sinuses: their formation and the relative situation of each to the skull;— The veins of the exterior of the skull: The facial vein; The temporal vein; The internal maxillary vein; The temporo-maxillary vein; The posterior auricular vein; The occipital vein;— Surgical aspects of the veins of the head.

Chapter rv. Special Regions of the Head, and the Points op General Interest Pertaining to Each 111-135

The temporal region — The Kar; its deformities; its follicles and their clinical importance; the auditory canal; its curve; its relation to foreign bodies; clinical significance of pus in the auditory canal; — The membranatympani; rupture of; perforation of; — The mastoid process, its construction and functions; trephining of ; — Middle ear; functions of; cleansing of; — The wounds of the temporal rrgion; — Trephining over the temporal region ;— Hernial protrusions in the temporal region, through the lateral fontanelle; — Caries and necrosis of the temporal region; escape of blood and cerebro-spinal iluid from the ear: their clinical significance.

The region of the nose — Alterations in its cavities with age; — Probing of the nasal duct from below; — The cavities which communicate with the nasal fossae;— Plugging of the posterior nares for epistaxis; — Catheterism of the Eustachian tube;^Foreign bodies in the nose, the symptoms produced, and the steps necessary for their extraction. — Abnormal growths within the nose, their varieties and clinical points of intei-est.

The region of the orbit — Results of injuries received in the region of the eyebrow; — Opening of the frontal sinus; — Injuries to the nerves of the orbit ; — Penetrating wounds of the orbit, and their possible complications; — Extirpation of the eye, and its possible complications; — Amputation of the globe of the eye; — Tumors of the antrum and their effects upon the orbit; — Clinical relations of the pulley for the superior oblique muscle of the eye; — Probing of the lachrymal canals and nasal duct; — The clinical relations between diseases of the eye and nose; — Paralyses of the nerves of the orbit.

The region of the mouth — Surgical conditions of the cheek; Salivary fistula; — The diseased conditions of the tongue; Furring of the lateral half of the tongue from irritation of the trigeminus or glosso-pharyngeal nerves; Operations for removal of the tongue; — Occlusion of the salivary ducts; — Physiological functions and diseased conditions of the soft palate; — Diseased states of the tonsil; Excision of thetonsil; — Modifications of the teeth in congenital syphilis; — Diseased conditions of the lower jaw; — Resection of the lower jaw; Fissures of the hard palate; — False anchylosis of the lower jaw.

XVI TABLE OP CONTENTS.

PART n. THE TRUNK.

PAGE

Chapter I. The Vertebral Column, its Physiological and Clinical

Points of Interest 136-165

The vertebrsB in general; Curves of the verfebral column and their functions; The intervertebral disks; The movements permitted by the spinal column; Changes in the length and shape of the spinal column; The spinous processes, their varying lengths and their functions; — The vertebrae as surgical guides; The third cervical, fifth cervical, seventh cervical, third dorsal, eighth dorsal, ninth dorsal, tenth dorsal, eleventh dorsal, twelfth dorsal, first lumbar, second lumbar, third lumbar, fourth lumbar; — The relative points of origin of the various spinal nerves; — The spinal canal, its variations in size, its contents, and its surgical aspects; Dislocation of the cervical vertebrae; The atlas and axis; The cervical rib; Peculiarities of the sacral region; — Clinical points suggested by the vertebral column; Variations in length of the neck; Variations in the mobility of the spme with age; Caries of the vertebrae; Congenital and acquired malformations; Spina bifida; Fractui-es of the vertebrae; Pain in spinal lesions, and its clinical significance; Lesions of the spinal nerves following disease or injury of the vertebrae; Abnormal curvatures of the spine; Pott's disease; Dislocation of the last lumbar vertebra upon the sacrum ; Rosenthal's test for existing caries; Displacement of the occipital bone from the atlas, and of the atlas from the axis; Displacement of the transverse processes of the vertebrae.

Chapter II. The Neck and its Structures— their Clinical Aspects 155-185

Alterations in the curve of the neck with age; — Variations in its length, and its medical aspects; The short neck, in disease; The long neck, in disease; — The "Veins of the neck: Causes which tend to make them prominent; Pulsation of the jugulars, its cause; Relation of the veins of the neck to cyanosis; The vems of the neck in surgical operations; Air in the veins, its causes, mechanism of death, symptoms, and treatment; — The muscles of the neck: The platysma; The omo-hyoid; The scaleni; The levator anguli scapulae; The muscles of deglutition; The mechanism of deglutition in its three stages;— Clinical points pertaining to the muscles of the neck; Paralysis of the sterno-mastoid, and its symptoms; Paralysis of the trapezius, unilateral and bilateral, and the symptoms of each; — Regions of special interest in the neck: (1) The supra-clavicular region, its contents, effects of wounds of, its relations to the lung, its nerves and vessels, its surgical guides; (2) The stemo-mastoid region, its boundaries, its contents, effects of wounds of, its glands, and their enlargement; (8) Supra-hyoid region, its contents, its relation to diseases of the pai-otid and submaxillary glands; (4) Anterior cervical region, its boundaries, contents, fasciae, surgical guides, its relation to the operations of laryngotomy and tracheotomy, and diseases of the respiratory organs, pharynx, and larynx; (5) The posterior cei-vical region, its contents, effects of wounds of, its surgical and medical aspects; — Points in the diagnosis of abnormal swellings in the neck: Glandular tumors; Cystic Tumors; Fatty tumors; Suppuration; Malignant and syphilitic gi-owths; Tumors of vessels; — The arteries of the neck:

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The subclavian artery, essentially a vessel of respiration, as shown by its distribution; The internal maxillary artery, essentially a vessel of mastication, as shown by its branches.

Chaptee III. The Bones of the Thoeax and theib Relations to the

Adjacent Structures 186-208

The dorsal curve of the spine and the anatomical peculiarities of that region;— The ribs, a series of arches; The superior and inferior thoracic apertures, and the structures which pass through them; The movements of the ribs and their effect upon the capacity of the thorax; The customary subdivisions of the ribs; The costal cartilages, and their functions; The attachment of the ribs and their obliquity; The effects of direct and indirect violence to the ribs; The first rib, and its surgical and medical aspects; The intercostal muscles, and their functions; — The sternum: Its situation and functions; Its subdivisions; Its surgical guides; Its attachment to the clavicles; Its modifications from mechanical causes; Congenital defects of; Medical aspects of the sternal region; Fracture of the sternum; Displacement of the sternum;— The walls of the thorax, considered as a whole: Congenital malformations; Acquired deformities; The modifications dependent upon the sex; Rules for counting the ribs during life; Relation of the nipple in health; Guide to the second rib; The serratus magnus, as a medical guide; The scapula, as a medical guide; The pectoralis major muscle, as a medical guide; Guide to the sixth rib; Guides to the eleventh and twelfth ribs; The xyphoid cartilage, as a medical guide; — External guides to the thoracic viscera, in health and disease: (1) The heart:— Rules to outline it upon the chest; The areas of cardiac dulness; The apex-beat, and the diseases which tend to modify its position; Means of examining for the apex-beat; Tlie abnormalities of the apex-beat; The relation of the valves of the heart to the chest-wall; Means of examining a patient for valvular defects; The precordial region, and its changes in the course of certain diseases; Pericarditis, its effects on pulmonary displacement; Cardiac hypertrophy, its effects on the lung; The heart-impulse, its relation to pulmonary displacement; General diagnostic points respecting cardiac disease; (3) The limgs — Their position after death; Their position during life; Their changes during respiration; The apices of the lungs, and their surgical aspects; The anterior borders of the lungs; The shape of the thorax as a guide to the amount of lung-tissue; The chest of phthisis; The effects of pleuritic effusions upon the lung and chest; The causes which tend to create variations in the outline of the lung in reference to the chest-wall; Effects of emphysema, all wasting diseases, pneumonic consolidation, pleurisy, pericardial effusion, mediastinal tumors, and diaphragmatic displacement, upon the normal pulmonary limits.