Surgical diseases of the chest

Front matter

Copyright N°^

COPYRIGHT DEPOSIT:

SURGICAL DISEASES OF THE CHEST

Preface

The wonderful progress of modern surgery has given an impetus to a production of special literature unheard of in the history of surgery, every organ of the abdominal cavity being the subject of at least one large and excellent treatise. It seems that the especially technical achievements of American surgeons, whose brilliancy has become most striking in abdominal surgery, absorbed all interest and concentrated it upon the abdominal cavity. This may account for the fact that other cavities of the human body, especially the thoracic, are in spite of their immense importance treated as a quantite negligeable.

Nothing illustrates this state better than the fact that up to the present there is only one special work on the surgery of the chest. It is from the illustrious pen of Stephen Paget, who must properly be considered one of the pioneers in this great field of practice. But since the publication of his book, which bears the date of June, 1896, three great factors have arisen which transformed the character of surgical work to such an extent that many traditions and theories had to be discarded. These three revolutionists, which led to surgical possibilities hitherto not dreamed of, were: Bacteriology, Asepsis, and the Rontgen Method.

I have endeavored to emphasize the great importance of these new branches of science without ignoring the notable researches and the valuable experiences of our ancestors. At the same time I have taken pains to make the book especially useful for the general practitioner by accentuating the border-line character of the work. Consequently more stress is laid upon diagnostic points than is generally expected from a book of a distinctly surgical character.

vi Preface.

I am greatly indebted to Messrs. Wood & Co. for the blocks of some of my illustrations printed in the "Medical Record." My thanks are also due to Professors Waldeyer, Testut, Jacob, Garre, Lejars and von Winckel for their courtesy in allowing me to copy some of their excellent illustrations. The other illustrations are originals depicted from cases treated by myself in the Postgraduate and the St. Mark's Hospitals.

Most of the Rontgen illustrations were taken by my son, Dr. Eric Carl Beck. I am furthermore under special obligations to my wife for preparing bibliography and index and for other valuable assistance.

Carl Beck.

New York, 37 East 31ST Street, March 27, 1907.

Chapter I. Page

The Anatomy of the Thoracic Wall and the Diaphragm i

General Outlines i

Sternum 6

Ribs 10

Thoracic Vertebrae 16

Ligamentous Connections of the Thoracic Bones 24

Interchondral Articulations 28

Muscles, Vessels, and Nerves of the Thoracic Wall 29

CHAPTER II. Malformations of the Thorax 43

Injuries of the Thoracic Wall (Non-penetrating) 61

Asepsis 61

Fracture of Sternum, Rib, and Costal Cartilage 68

Burns of Chest 73

Contusion of the Thorax Associated with Injuries of the Intrathoracic Organs 82

Penetrating Injuries of the Thorax 83

Inflammatory Processes of the Chest-wall 86

Phlegmon of the Thoracic Wall, Genuine and Tuberculous Abscesses ; Necrosis 90

Injection of Iodoform-glycerin 99

Tumors of the Chest-wall 101

(1) Benign Growths 101

(2) Malignant Growths 105

(3) Hodgkin's Disease 108

(4) Echinococcus of the Chest- wall 112

CHAPTER III. Anatomy of the Pericardium 114

Injuries of the Pericardium no

Aspiration of the Pericardium 116

Pericardiotomy 1 iS viii Contents.

PAGE

Anatomy of the Heart 120

Injuries of the Heart 122

Anatomy of the Pleura t 125

Diseases of the Pleura 128

Serothorax (Serous Exudative Pleuritis) 129

Aspiratory Puncture of Thorax 132

Exploratory Pleurotomy 133

Pyothorax (Empyema Pleurae) 137

Hydrothorax 201

Hemothorax 201

Chylothorax 202

Anatomy of the Lungs 203

Abscess of the Lungs 206

Gangrene of the Lungs 211

Bronchiectasis 213

Echinococcus of the Lungs 2 14

Actinomycosis of the Lungs 217

Tuberculosis of the Lungs ". 219

Intrathoracic Tumors 222

Aneurysm of the Thoracic Aorta 226

Anatomy of the Trachea and Bronchi 236

Foreign Bodies in the Respiratory Passages 239

CHAPTER IV. The Value of the Rontgen Method in Thoracic Surgery 246

General Rules 246

Localization of Abscess, Bronchiectatic Cavity, Echinococcus, and

Gangrene of the Lungs 249

The Rontgen Method in Pleuritis 256

The Rontgen Method in Pyothorax 257

The Rontgen Method in Hydropneumothorax 258

The Rontgen Method in Diseases of the Heart 258

The Rontgen Method in Diseases of the Pericardium 259

CHAPTER V. Topography 262

Pathological Anatomy 267

Diagnosis 268

Prognosis 273

Varieties 276

Course 284

Therapy 285

Contents. ix

CHAPTER VI. Anatomy of the Breast 290

Diseases of the Nipple 292

Inflammatory Processes in the Breast (Mastitis) 294

Mammary Cysts 304

Special Inflammatory Processes in the Mammary Gland 305

Echinococcus of the Mammary Gland 306

Mastodynia 307

Hypertrophy of the Breast 307

Tumors of the Mammary Gland 308

Adenofibroma of Breast 310

Adenoma of Breast 311

Lipoma, Atheroma, Myxoma, Angioma, Chondroma, and Osteoma Mammae 311

Sarcoma Mammae 312

Carcinoma Mammae 314

Operative Treatment of Carcinoma Mammae 321

Rontgen Treatment of Carcinoma Mammae 335

Rontgen Treatment of Benign Diseases of Chest 348

Index 369

SURGICAL DISEASES OF THE CHEST.

Chapter I. The Anatomy Of The Thoracic Wall And The Diaphragm

The thorax has a conical shape, its convex walls representing a barrel-shaped osseous structure which is formed by the ribs, the dorsal vertebrae, and the sternum. The axis of this osseo-cartilaginous cage shows an oblique downward and forward direction. It contains and protects the principal organs of circulation and respiration, viz., the heart and its membranous bag, the pericardium, the large blood-vessels, the lungs invested by the pleurae, and the major part of the oesophagus.

The boundary-lines of the cavity are, roughly speaking, the ribs, which surround the thoracic barrel like the hoops of a cask, the dorsal vertebrae, the sternum, and the costal cartilages (Fig. i).

In giving these general outlines, however, it must be considered that its upper as well as lower boundary-lines are not in exact proportion with the osseous thorax, since the upper overlap the sternal end of the first rib and clavicle and also extend beyond the first dorsal vertebra.

Similar conditions exist at the lower boundary-lines, where the diaphragm represents the line of division between the thoracic and the abdominal cavity. A portion of this organ extends high up into the osseous thorax, so that a considerable part of the thoracic wall also covers abdominal organs.

The transverse diameter of the thoracic cavity is widest along the attachment of the diaphragm. The boundary-lines are the ensiform process in front, the lower two ribs, the anterior parts of the false ribs, and the common costal cartilage, which

Floating ribs Fig. i. — The Thorax, Front View. — (Morris' "Anatomy.")

connects these ribs with the sternum, on the side, and the twelfth dorsal vertebra behind.

The exterior aspect of the chest measures, according to the perimetric observations of Wintrich, 89.52 centimetres at

Perimetric Figures. 3

the highest point in the axilla, 86.64 on a level with the mammilla, and' '81.88 at the junction of the ensiform process with the sternal body. These figures comprise the average condition

Fig.

-Six-months-old Embryo Skiagraphed through Amnion, Showing Thoracic Relations.

found in men of twenty-five years. Perimetric figures, gained from the thorax of women of twenty-five years, show Si. 90 centimetres at the highest point of the axilla, 81.00 in the middle, and 78.00 below.

The embryonic thorax and that of new-born children (Fig. 2) show a marked difference, the lungs especially being but little distended at the early period of life while the liver is extumely large (Fig. 3). This explains the projection of the

Fig. 3. — Thorax of New-born Child, Skiagraphed.

lower thoracic sphere at that age (Fig. 4). The average transverse diameter of the thorax in men amounts to 28 centimetres on a level with the eighth rib, the sagittal on a level with the base of the ensiform process 20, and the vertical 35.5 at the posterior and 15.5 at the anterior wall. In women the posterior vertical diameter is, on the average, about 2 centimetres less. The normal female chest is more round-shaped

Thoracic Landmarks. 5

than the male, but has a smaller general capacity. Its sternum is somewhat shorter, the proportion of its superior opening being larger. It may also be said that the upper ribs are more movable in the female, an important circumstance which permits of easier respiration during pregnancy.

For proper localization the following landmarks should be borne in mind:

The median line, alongside the middle of the sternum.

The sternal lines, alongside the lateral margins of the sternum.

M

Fig. 4. — The Thorax at the Eighth Month. — (Morris' "Anatomy.") (On the left side eight cartilages reach the sternum.)

The mammillary or papillary lines, through the nipples.

The parasternal lines, in the middle between the sternal and mammillary lines.

The axillary lines, dropped from the middle of the axilla. Clinically an anterior and a posterior axillary line is distinguished, the anterior extending from the lower margin of the pectoralis major muscle, the posterior beginning at the lower margin of the latissimus dorsi.

The scapular lines, which begin at the lower angles of the scapulae.

The sterno-costal lines, which follow an oblique direction and extend from the sterno-clavicular junction to the tip of the eleventh rib.

The exterior aspect of the thorax is best divided into an anterior region (sternal), two lateral (costal) regions, and a posterior (spinal) region.

STERNAL REGION.

The sternal region is bounded by the jugular fossa above and the ensiform process below, in the parasternal lines, two inches from the sternal margin, laterally. The tissues underneath the integument are represented by their connective tissue, which connects the skin with the sternal periosteum in front and the sterno-costal ligament at the sides.

The Sternum.

The sternum (os or scutum pectoris, os xiphoides, ari t 0o<;, by Hippokrates — hence the term " stethoscope"), a flat and narrow bone, is situated in the median line of the anterior portion of the thorax, directly opposite the spinal column. Its peculiar shape recalls the short ancient sword of the Romans, which justifies its division into handle, blade, and point (Figs. 5 and 6).

The handle (manubrium), which has a triangular shape, represents the upper and broadest portion. It is somewhat nearer the spinal column than the lower, sternal end. Its anterior surface is slightly convex, while the posterior is concave. The superior margin of the manubrium, which is the thickest, shows the pre-sternal notch at its centre and an oval articular surface on each side. The inferior margin is straight, the thin layer of cartilage covering its rough surface articulating with the upper portion of the blade. On each side of the pre-sternal notch a saddle-shaped articular surface

Clavicular notch

For first costal cartilage

Xiphoid foramen

The Sternum.

Interclavicular notch

Sterno-mastoid

Pectoralis major

Rectus abdominis

Xiphoid or metasternum

Fig. 5. — The Sternum, Anterior View. — (Morris' "Anatomy.")

Clavicular notch Sternohyoid

Sterno-thyroid

Triangularis sterni

For first costal cartilage

Fig. 6. — The Sternum, Posterior View. — {Morris' "Anatomy.")

Sternal Blade. g

serves for purposes of articulation with the sternal end of the clavicle.

The lateral margins slightly converge toward the blade and continue in it.

The blade (syn., meso-sternum, body, gladiolus) is three times as long as the manubrium, but much thinner and nar-

Single centre for manubrium ~^r~ sterni ^ifc

Single centre for i each of the four ' pieces of the gladiolus

Single centre for /

ensiform process \y

_ Centre for manubrium sterni

Accessory centre

Single centre for first piece of gladiolus

Bilateral centres for second, third, and fourth pieces of gladiolus

Single centre for ensiform process

Fig. 7. — Ossification of the Sternum. — {Morris' "Anatomy")

A, Common arrangement of the ossific centers. B, Showing accessory centre in the manubrium sterni, and bilateral centres in the second, third, and fourth pieces of the body.

rower. Its anterior surface shows three transverse lines which cross it opposite the third, fourth, and fifth articulationsurfaces. They are the indications of the union of the four separate osseous nuclei during the era of development (Fig. 7). The slightly concave posterior surface also presents these three lines, but less distinctlv.

io Anatomy of Thoracic Wall and Diaphragm.

The superior margin has an oval surface with which the manubrium articulates. The narrow inferior surface articulates with the xiphoid process.

The point (syn., meta-sternum, processus xiphoideus or ensiformis or mucronatus) is much smaller and thinner than the other pieces of the sternum. During the stage of development it remains cartilaginous throughout and only becomes ossified in adults. Its upper margin articulates with the lower end of the sternal body, while its lower end furnishes the attachment for the linea alba. The end is generally sharply pointed, but sometimes it is also found broad or bifurcated, and in rare cases perforated.

The lateral borders of the sternum articulate with the inner ends of seven costal cartilages.

The synchondrosis between manubrium and gladiolus does not ossify before early manhood, while in infants, especially if there be disturbances of respiration, as in pertussis or in narrow-chested children, it may be extremely movable. The connection of the sternum with the elastic cartilages of the true ribs permits so large a degree of flexibility that even a great amount of violence exerted upon it from before is not apt to fracture it. If the sternum is insufficiently developed a hiatus forms, through which the heart may protrude from the thoracic cavity (ectopia cordis).

THE RIBS.

The ribs (costae), which are twelve in number on either side, represent elastic osseous arches which extend from the spinal column to the sternum.

Each rib consists of an osseous portion and its cartilaginous continuation, which is termed the costal end. If a cartilaginous portion of a rib reaches the lateral border of the sternum, we speak of it as a true rib (costa vera or genuina), the upper seven being true ribs. If the costal cartilage does not

The Ribs. n

reach the sternum, as is the case with the live lower ribs, then we term them false ribs (costa spuria or mendosa). The cartilages of the first three false ribs are attached to the cartilage of the rib above, while the two lower have a loose, free end in front, wherefore they are called floating ribs (costae fluctuantes) (Fig. i).

Each rib, the first excepted, shows an external surface which is convex and an internal which is concave. There is also an upper border which is slightly round-shaped and a lower one. The interior surface of the inferior border contains a deep groove (sulcus costalis) which runs parallel to the border, and lodges the intercostal nerve and vessels (Fig. 8).

There are two extremities, viz., a sternal and a vertebral. The intervening part is called the shaft (body).

At the vertebral extremity head, neck, and tuberosity must be distinguished, the head showing an articular surface of renal shape, which is divided into two articular facets by a horizontal projection (Fig. 8). The neck represents the flattened part, which forms the direct continuation of the head and is one inch in length in the adult. Its situation is right in front of the transverse process of the inferior of those two vertebras which serve as the articulation with the head. Near the lower margin and on its posterior surface a slight prominence, called the tubercle or the tuberosity, presents itself. The inferior half of the tuberosity is provided with a small articular surface for the extremity of the transverse process of the inferior of the two vertebrae which articulate with the head. The other half presents a rough eminence to which the posterior costo-transverse ligament attaches itself.

The body is flat and thin. Its smooth and convex external surface is characterized by an oblique eminence, termed the angle, to which a tendon of the ilio-costal muscle attaches itself. Here the rib is slightly bent in two different directions. The distance between the tuberosity of the neck and this ans^le

Subcostal groove

Sternal end for costal cartilage

Fig. 8. — The Seventh Rib of the Left Side, Seen from Below. — (Morris' "Anatomy.")

Costal Body.

gradually becomes longer from the second rib on to the tenth. The rib-portion intervening between the tuberosity and the sternal extremity is twisted on its own axis. Near the sternal portion it is also marked by an oblique line, termed the anterior costal angle. As to the sulcus costalis, see above.

The flattened sternal end of the shaft shows an oval-shaped, concave articular surface for the reception of the costal carti-

Single facet (sometimes two facets are present)

Single facet (this rib has an angle, but no tuberosity and no neck)

Single facet (this rib has neither tuberosity, angle, nor neck)

Fig. 9. — The Vertebral Ends of Tenth, Eleventh, and Twelfth Ribs. — (Morris' "Anatomy.")

lage. All ribs are similar to each other, but they vary in their length, in the degree of their curvature, the direction, the relations of the body to the neck (see above) and the relation of the costal cartilages to each other.

The length of the ribs gradually increases from the first to the eighth and decreases in the same way from there to the twelfth, the latter being shorter than the first. As far as the direction is concerned, it is observed that the superior ribs i 4 Anatomy of Thoracic Wall and Diaphragm.

are less oblique than those further down, the highest degree of obliquity being attained at the ninth. The length of the costal cartilages corresponds with that of the various ribs. Their shape appears more flattened at the upper ten, while the eleventh and twelfth are round-shaped (Fig. 9). The direction of the three upper cartilages is nearly horizontal,

Levator costae

Accessorius (insertion)

Cervicalis ascendens (origin)

Serratus posticus superior (insertion) Scalenus posticus

Third digitation of serratus magnus

Fig. 10. — First and Second Ribs. — {Morris'' "Anatomy")

while those below, in contrast to the ribs, ascend obliquely toward the sternum.

The relations of the ribs among themselves are such that they leave a space between each other. This is termed the intercostal space (spatium interosseum) .

As to the peculiarities of some ribs, it may be said that the

Tuberculum Lisfranci.

first rib, which is the shortest and most curved of all, is flat and very broad and shows a most important tuberosity at its superior surface near its inner margin, which separates two shallow grooves (Fig. 10). The anterior groove is for transmitting the subclavian vein, while the posterior is for the cor-

Epiphysis for the head. Appears at fifteen; fuses at twenty-three

Epiphysis for tubercle. Appears at fifteen; fuses at twenty- three

The cartilaginous shaft commences to ossify at the eighth week of intrauterine life

Fig. 11. — Rib at Puberty. — {Morris' "Anatomy.")

responding artery. The tuberosity, called the scalene tubercle or tuberculum Lisfranci, serves as a valuable landmark in the surgery of the region.

As to the stage of ossification, it may be said that the first ten ribs show three nuclei at the early period of life, one representing the head, another the shaft, and the third the tubercle.

The eleventh and twelfth show no tubercle-centre. Ossification of the shaft begins at the eighth week of intrauterine life, while that of head and tubercle appears between the sixteenth and twentieth years (Fig. 1 1).

The number of ribs may be increased by the presence of a supernumerary one, either at the lumbar or at the cervical ends of the series. While the lumbar variety, which seldom reaches considerable size, is of little surgical importance, the cervical type demands the most thorough consideration. (See Figs. 39, 40, and 41).

The movements of the ribs are different in proportion to

(M/ c

Fig. 12. — Diagram of Axis of Rib-mo vemext, which is Likened to the Movement of a Pump Handle (a, b). — (Morris, after Kirkes.)

their different shapes. The extremities of the first few ribs move up and down, the costal heads and tubercles acting like hinges. The bodies and angles of the ribs below rise as high as the extremities, the tubercles moving up and back during the act of inspiration (Fig. 12).

THE THORACIC OR DORSAL VERTEBRA.

The fundament of the trunk is formed by the spinal column

(rhachis), which is composed of a series of thirty-five bones

termed spondyli or vertebrae. Seven belong to the cervical,

twelve to the dorsal, five to the lumbar, five to the sacral, and

Vertebral Processes.

Cervical vertebra

Costal process

Transverse process

Neuro-central suture Cervical rib

Transverse process Costo-transverse foramen

Neuro-central suture Rib

Transverse process Lumbar rib

Neuro-central suture Costal process

Fig. 13. — Morphology of the Transverse and Articular Processes. — (Morris* 3 " Anatomy.")

four to the coccygeal region, the latter simply figuring as an appendage.

All vertebrae consist of two characteristic portions, a body in front and an arch behind. Two pedicles and two laminae form the latter and support seven processes altogether, namely, a spinous, two transverse, and four articular.

While the vertebrae of the various series differ more or less, the most essential parts are constructed on a common plan. As to their previous mode of development see Figs, n and 13. The dorsal vertebra, in which we are especially interested, being the paradigm for the others, we will confine ourselves to the description of this special type of bone (Figs. 14 and 15).

The dorsal vertebrae, larger than the cervical and smaller than the lumbar, are the carriers of the ribs and therefore provided with small cartilaginous surfaces for articulation with the costal heads at the side of their bodies. The heart-shaped bodies are like those of the cervical and lumbar series, in general, but differ inasmuch as they are much thicker anteriorly than posteriorly, where they are concave, while their front shows a convexity. At each side two cartilaginous demi-facets, an upper and a lower one, present themselves near the pedicles. As mentioned above, they serve the purpose of receiving the heads of the ribs.

The pedicles consist of two short and constricted osseous columns, the concavities of which are termed vertebral notches. They are four in number. By the contact of two vertebrae their notches form the intervertebral foramina, which permit of communication with the spinal canal and transmit the spinal nerves as well as the blood-vessels.

The laminae consist of two broad osseous plates which enclose the small circular spinal foramen. By overlapping each other they appear like assorted tiles on a roof. Their connection with the body is effected by the pedicles.

The long and triangular spinous process projects back-

Transverse Processes.

ward and downward from the point of union of the laminae and ends in a slight tubercle. One process overlaps the other.

Demi-facet for head of rib

Superior articular process Pedicle

Facet for tubercle of rib Transverse process

■ Spinous process

Fig. 14. — A Thoracic Vertebra, Side View. — {Morris' "Anatomy.")

■ Spinous process

Pedicle Demi-facet for head of rib

Transverse process

Fig. 15. — A Thoracic Vertebra. — (Morris' "Anatomy.")

The two transverse processes are long, thick, and massive, and extend obliquely backward and outward from the arch at the point of union between the pedicles and the laminae. They end in a clubbed extremity which contains an oval facet for the corresponding articulation-surface of a rib-tubercle.

The flat articular processes are four in number. They spring from the superior and the inferior part of the pedicles. The direction of the two superior processes is posterior and slightly exterior, while that of the inferior is anterior and slightly interior.

The first dorsal vertebra resembles the seventh cervical very closely, its greatest diameter being transverse and its lateral margins showing two prominent lips. At each side of its body it presents an articular facet for the reception of the head of the first rib and a half facet for the superior half of the second. The ninth dorsal vertebra is characterized by the absence of the demi-facet below, while above it shows well-developed semi-facets. The tenth dorsal vertebra has an entire facet at each side of its upper border and lacks the demi-facets below.

Both the eleventh and twelfth dorsal vertebrae resemble the lumbar, the articular facets for the costal heads being of very large size. The pedicles on which the facets are chiefly placed are so much stronger and thicker in accordance. The twelfth dorsal vertebra distinguishes itself by its very short transverse processes and the presence of three elevations, viz., the external, superior, and inferior tubercles, corresponding to the transverse, mammillary, and accessory processes of the lumbar vertebrae (Fig. 16). The vertebral bodies consist largely of cancellous tissue. If a section is made through the centrum, this tissue appears to be horizontally and vertically arranged (Fig. 17).

Among all the bones of the body the spinal column shows the first signs of ossification in embryonic life.

There are three primary and five secondary ossification centres at the early period of development, the primary ones

Peculiarities of Dorsal Vertebrae.

An entire facet above; a demi-facet below. In shape the body resembles that of a cervical vertebra

Usually a demi-facet above (sometimes it has a demi-facet below)

Usually an entire facet above. Occasionally this facet has been incomplete. The facet on the transverse process is usually small

An entire facet above.

None on transverse process, which is small .

This is the anti-clinal vertebra

An entire facet above; no facet on transverse process, which is tripartite; centrum |large.

Inferior articular processes turn outwards as in a lumbar vertebra

Fig. 16. — Peculiar Thoracic Vertebra. — {Morris' "Anatomy")

Fig. 17. — A Vertebral Centrum in Section to Show the Pressure Curves. — (Morris' "Anatomy.")

forming as early as the seventh week of embryonic life. The nuclei of the bodies divide early and may remain bilobed during lifetime (Fig. 18).

Fig. 18. — A Divided Thoracic Vertebra. — (Morris, after Turner.)

At the time of birth there are three bone-pieces, viz., a body and two side pieces, which are connected by hyaline cartilage (Fig. 19).

Lateral mass

Neuro-central suture Centrum or body

Fig. 19. — A Vertebra at Birth. — (Morris' "Anatomy.")

Relations of Sternum.

2 3

Anterior chondro-sternal ligament

An interarticular ligament

The plate of fibro-cartilage between manubrium and meso-sternum

Fourth rib ^^

Fifth rib "?££

Interchondral capsular ligament

Fig. 20. — The Sternum. — (Morris' "Anatomy")

(Left side, showing ligaments; right side, the synovial cavities.)

LIGAMENTOUS CONNECTIONS OF THE THORACIC BONES.

The connections of the ribs are to be divided into those which are formed by the true ribs and into those of the false. The true ribs connect with the spinal column at their posterior extremities, while at their anterior ends they attach themselves to the lateral margins of the sternum by their cartilages. Both connections form the articulations which are known as costo-sternal and costo-spinal articulations.

Fig. 21. — Anterior View of Sterno-costo-clavicular Joint. — (Morris 7

"Anatomy.")

(The capsule is cut into on the left to show the interarticular fibro-cartilage dividing the

joint into two cavities.)

The costo-sternal articulations (Fig. 20) are of the arthrodial type and include the ribs from the second to the seventh. The first costal cartilage attaches itself to the sternum without forming a joint, the union therefore being of the synarthrodial character. In rare cases, however, a true articulation between the first costal cartilage and the manubrium sterni is observed (Figs. 21 and 22). With the growing popularity of the Rontgen rays, it may be found that this condition is a frequent one.

Joints of Costal Cartilages. 25

The joint of each costal cartilage consists of a synovial

Sternohyoid Sternothyroid

Fig. 22. — Posterior Surface of the Manubrium (Pre-sternum), with Sternal Ends of Clavicles and the First Costal Cartilages. — {Morris' "Anatomy")

capsule, which is strengthened by ligamentous fibres called interchondral ligaments, internally as well as externally.

The interarticular fibro-cartilage

The joint between the sternum and second costal cartilage

Fig. 23. — Section through Sternoclavicular Joint. — {Morris' "Anatomy")

The joint formed by the second costal cartilage and the sternum frequently contains a fibrous cartilage, which must be regarded as a continuation of the cartilage situated between the gladiolus and the manubrium of the sternum. This cartilage, by traversing the joint horizontally, divides the joint-cavity into two separate spaces (Fig. 23). Of the other ligaments, the ligamentum costo-xiphoideum, which springs

The interarticular ligament

The superior or anterior costo-transverse ligaments

The stellate ligament

Fig. 24. — Showing the Anterior Common Ligament of the Spine, and the Connection of the Ribs with the Vertebrae. — (Morris' "Anatomy.")

from the sixth and seventh costal cartilages and attaches itself to the xiphoid process, is notable.

As evident from the description of the vertebrae, the costo-spinal articulations, that is, the joints between them and the posterior extremities of the ribs, are double for the first ten ribs, wherefore they are properly divided into costo-central (costo-vertebrales), that is, those which are formed

Costo-central Articulations.

between the costal heads and the vertebral bodies, and into costo -transverse (costo-transversales), that is, those which are between the neck and tubercles of the ribs and the transverse processes (Fig. 24).

The costo-central articulations are arthrodial in type and consist of a capsule, which contains bundles of ligamentous fibres (anterior costo-vertebral, or stellate ligament, or ligamentum capituli costae anterius or radiatum) (Fig. 25).

Anterior costo-central or stellate ligament

Costo-central synovial sac

Costo-transverse synovial sac

Posterior costo-transverse ligament

Fig. 25. — Horizontal Section through the Intervertebral Disc and Ribs-

(Morris' "Anatomy")

These fibres radiate from the anterior portion of the costal head. The interiors of the first ten joints contain the ligamentum trans versum capituli costse, which springs from the crests of their heads, to be attached to the corresponding intervertebral discs. This ligament is absent at the last two ribs and also at the head of the first whenever the groove for the head is formed by the first dorsal vertebra alone, the seventh cervical vertebra not participating. The structure of this ligament is fibro-cartilaginous.

The costo-transverse ligaments (Fig. 26) consist of a thin capsule which is supported by a strong fibrous band, called the ligamentum costo-transversale posterius, which covers the posterior region of the joint. The costo-transverse articulations permit of slight physiological displacement of the ribs, as necessitated by their excursions during respiration. The transverse processes of the vertebrae prevent any backward deviation of the ribs during that process. It is evident that the eleventh and twelfth ribs, on account of their small size