MEDICAL ANATOMY 
OR, 
ILLUSTRATIONS 
OF THE 
RELATIVE POSITION AND MOVEMENTS 
OF THE 
INTERNAL ORGANS. 
ten l 
BY 
FRANCIS SIBSON, M.D. London and Dublin, F.R.S.; 
Fellow of the Royal College of Physicians; Senior Physician to, and Lecturer on Clinical Medicine at, St. Mary's Hospital; Member of the Senate, and late Examiner 
in Medicine, of the University of London. 
LONDON 
JOHN CHUECHILL & SONS, NEW BUELINGTON STEEET. 
MDCCCLXIX. TO 
WILLIAM STOKES, M.D., D.O.L, LED., Mill.A., 
PHYSICIAN-IN-ORDINARY TO THE QUEEN IN IRELAND ; REGIUS PROFESSOR OF PHYSIC IN THE UNIVERSITY OF DUBLIN; 
THIS WORK IS 
DEDICATED BY 
THE AUTHOR. PREFACE 
Descriptive and surgical anatomy are well taught in our medical schools, but the practical teaching of medical anatomy, or the know- 
ledge of the relative position of the internal organs, is neglected. Indeed, on the present plan and with the existing means, it is impossible 
to teach that subject, which is as important for the physician as surgical anatomy is for the surgeon. 
When a body is prepared for the dissecting-room, the arteries are injected from the arch of the aorta, to the injury of the great vessels. 
The superficial dissection of the body precedes that of the internal organs; and by the time those parts are reached, they have lost that 
freshness which is so necessary for their successful study. Generally, indeed, they are then in a state of decay, and their relative position 
has been altered. 
It is impossible, therefore, that the relative anatomy of the internal organs can be taught in the dissecting-room; but the dead 
house affords all the materials for their study. 
It falls to the teacher of pathology to make the post-mortem examinations; and it would be easy for him to give practical demon- 
strations of the contents of the chest and abdomen in health as well as in disease. It ought, therefore, to be one important duty of that officer 
to teach the topographical anatomy of the healthy viscera on the dead body. Afterwards he might take the pupils into the wards or the 
out-patient room, and indicate to them, on the living body, the varying position of the organs during the healthy exercise of their functions. 
He would at the same time train them to a knowledge of the physical signs furnished by the healthy viscera. Under his tuition, the student 
ought to be as familiar with the position and movements of the organs as if he saw them stripped of their parietes and exposed to view. 
Until this be done, it is self-evident that the teaching of clinical medicine must be imperfect. 
The student naturally rivets his attention upon the subjects of his coming examination to the exclusion of everything else. He knows 
that his acquaintance with the anatomy of the limbs and the head and neck will he carefully tested, and that anatomy he studies. He also 
knows that he will not, as a rule, be examined on the bearings of, say, the great vessels, the heart or lungs in relation to the walls of the chest, 
or on the movements of those parts during life, or on the signs of their healthy functions. The result is, that the student does not seek to 
acquire, and has not the opportunity of acquiring, that kind of knowledge of which I have just spoken. 
If the examiner were to require the candidate to point out accurately, on the exterior of the living body, the corresponding 
position and the movements of the internal organs, and the signs by which they are distinguished in health, the teacher would speedily 
discover the method whereby he could convey the desired information, and the pupil would eagerly avail himself of it. 
This work, which consists of a series of illustrations of medical anatomy, is founded upon the Author’s paper in the ’Provincial Medical 
Transactions for 1841 on the situation of the internal organs. That paper, in the preparation of which he received important aid from 
his friend, the late Dr. Hodgkin, was the result of numerous observations made by himself in the wards, and, more especially, on the dead body. 
In 1848, Conradi published a valuable memoir on the position and size of the thoracic and abdominal organs. In that work, which 
has been translated into English by Dr. Cockle, with a view to publication, Conradi gives the topography of the internal organs as laid down 
by the Author in the paper just referred to. He then describes his own numerous researches by means of percussion on the living body, 
and compares them seriatim with the Author’s observations on the dead. 
Those researches substantiate in the main the anatomical conditions defined by the Author. 
The illustrations in the earlier and larger portion of this work represent the parts exactly as they were found after death. The front, 
the sides, and the hack of the frame, from the surface to the deepest parts, are depicted in succession. 
In making these drawings, the Author employed mechanical aids, described in columns 1 and 85, by means of which he has been able 
to represent with precision every organ, with its external and internal relations, at each stage of the dissection. 
This volume thus presents the exact topography of the parts contained in the body, from its circumference to its centre. 
Accurate representations of the exterior and interior of the dead body give, however, no adequate idea of the movements and varying 
position of those parts during life. At the time of, and after death, indeed, the heart and great vessels and the lungs shrink upwards, the 
diaphragm ascends, and the stomach and liver and the subjacent organs are partially raised. 
In looking, therefore, at all drawings that are literal transcripts from the parts contained in the body after death, due allowance must be 
made for those changes that take place during and after the departure of life. 
To supply, as far as possible, this deficiency, and to represent and describe the organs in motion as they are during life, the later 
portion of the work is devoted to the movements of respiration, and to the movements, structure, and sounds of the heart. 
The part relating to the movements of respiration developes and illustrates the papers by the Author on the “Mechanism of 
Respiration” in the Philosophical Transactions for 1846, and on the “Movements of Respiration in Health and Disease” in the Medico- 
Chirurgical Transactions for 1848. 
The description of the movements, structure, and sounds of the heart is derived from numerous original experiments, observations, 
and dissections made by the Author during the last seven or eight years. The peculiar methods employed by him in pursuing those inquiries 
are described in columns 73-77, 88, 84, and 88. 
These researches have been a work of great labour and deep interest to the Author. He believes that they represent important physio- 
logical truths, and he trusts that they may be useful to those who are engaged in the study of the vital phenomena of respiration and circulation. 
59, BROOK STREET, 
January, 1869. TABLE OF CONTENTS. 
Commentary on Plates L, II., III. (Front views) 1,2 
Explanation of Plate I. . . . . . . . . . . . 1, 2 
Explanation of Plate II. ........... 5, 6 
Explanation of Plate III. ........... 9, 10 
The Sternum, Eihs, and Cartilages 1 
The Anterior Surface of the Lungs 3 
Abnormal causes which affect the position of the anterior surface of the lungs 5 
Examination of the anterior surface of the lungs during life .... 5 
The Superficial Cardiac Eegion 10 
The Superficial Yiew of the Neck 11 
The Anterior Portion of the Diaphragm 12 
Commentary on Plates TV., V., YI. (Front views) 13, 14 
Explanation of Plate IV. . . . . . . . . • •. • 13, 14 
Explanation of Plate V. . . . . . . . . . • . 17, 18 
Explanation of Plate VI. . . . . . . . . ■ . 21, 22 
The Pericardium ............. 13 
The Heart and Great Vessels ........... 15 
Movements and normal displacements of the heart . . . . . 16 
Active or automatic movements of the heart ...... 16 
Movements of the heart and great vessels, caused by respiration . . 17 
Displacement of the heart from changes in the abdominal viscera . . 18 
Changes in situation of the heart from changes in position of the body . 18 
Effect of diseases of the heart and great vessels on the size and position of 
the organ ............ 19 
Effect of diseases of the lungs and pleura on the size and position of the heart . 20 
Effect of diseases of the abdomen on the position of the heart ... 20 
Examination of the heart during life ........ 20 
The Abdominal Organs ............ 23 
The stomach ............. 23 
The liver 24 
Commentary on Plate YII. (Front view) 25, 26 
Explanation of Plate VII. . . . . . . . . . . . 25, 26 
The Larynx, Trachea, Bronchi, and Lungs . . . . , . . . 25, 26 
Commentary on Plates YIII. and IX. (Views of the left side) 29, 30 
Explanation of Plate VIII. ........... 29, 30 
Explanation of Plate IX. ........... 33, 34 
The Eihs 29 
The Diaphragm 29 
The Left Lung 29 
The Heart and Great Vessels 33 
Commentary on Plates X. and XI. (Viewsoftherightsi.de) 37, 38 
Explanation of Plate X. 37, 38 
Explanation of Plate XI. . . . . . . . . . . . 41, 42 
The Eibs and Internal Organs viewed from the side . . . . . . 37, 38 
The ribs and sternum in relation to the immediately subjacent organs . . 37 
Commentary on Plates XII., XIII., XIY., and XY. {Back views) . . . 45, 46 
Explanation of Plate XII. 45, 46 
Explanation of Plate XIII. 49, 50 
Explanation of Plate XIV. 53, 54 
Explanation of Plate XV. 57, 58 
The Spinal Column, the Eihs, and the Internal Organs viewed from behind . . 45, 46 
The scapulae ............. 45 
The spinal column and ribs 47 
Tabular view . 51 
The larynx, trachea, and lungs ......... 51 
COLUMN 
The Aorta and the Aneurisms of the Aorta 53 
The sinuses of Valsalva ........... 53 
The ascending aorta above the sinuses of Valsalva 54 
The transverse aorta , 54 
The ascending and transverse aorta conjointly 55 
The descending portion of the arch ........ 56 
The descending thoracic aorta below the arch 56 
The abdominal aorta at the coeliac axis 56 
Table I.—Showing certain anatomical conditions, signs, and symptoms of each 
group of aortic aneurisms • . . . . . . . . 57, 58 
Table ll.—Cases of aneurism of the sinuses of Valsalva . . . . 59, 60 
Table lll.—Cases of aneurism of the ascending aorta above the sinuses of 
Valsalva ............ 59, 60 
Commentary on Plates XVI., XVII., and XVIII. {Showing the effects of respiration) 61, 62 
Explanation of Plate XVI. (Front views) . . . . . . . . 61, 62 
Explanation of Plate XVII. (Side views) ........ 65, 66 
Explanation of Plate XVIII. (Back views) 69, 70 
On the Effects of Natural and Artificial Eespiration on the external form and the 
internal organs ........... 61, 62 
The ribs and diaphragm . . . . . . . . . . . 61 
The lungs and heart ........... 66 
The abdominal organs ........... 67 
Application to physical diagnosis ......... 69 
The Signs present in Health over the Upper Lobes ...... 72 
Signs over the first and second ribs below the clavicle 72 
Signs over the hack—supra spinous fossa ....... 72 
Commentary on Plates XIX., XX., and XXI 73, 74 
Explanation of Plates XIX. (from a robust man, heart large and full), XX. (from 
a youth, heart small and empty), and XXL (showing the systole and 
diastole of the heart) . . . . . . . . . . 73, 74 
On the Movements, Structure, and Sounds of the Heart . . . . . 73, 74 
The Movements of the Heart (Figs. 1, 2) 73 
The systole of the heart .......... 73 
The lever movement of the ventricles during the systole . . . . 74 
The effects of the pressure of the blood upon the walls of the ventricles 
in producing the impulse ......... 75 
The causes of the impulse 75 
The movements of the papillary muscles ....... 76 
The action of the mitral and tricuspid valves ...... 76 
The Structure and Movements of the Ventricles and their Valves . . . 76 
The left ventricle (Figs. 3 to 17) 77 
The central fibro-cartilage or tendinous septum . . . . 78 
The intervalvular space ......... 79 
The mitral valve 79 
The papillary muscles 80 
The influence of the papillary muscles in opening the valve 
during the diastole ......... 81 
The right ventricle (Figs. 18 to 22) ........ 81 
Comparison between the right ventricle and the left . . . . 81 
The tricuspid valve 82 
The movements of the right ventricle ...... 83 
The Muscular and Tendinous Structures of the Heart of the Cow (Figs.23 to 28) 84 
The tendinous structures of the heart ....... 84 
The muscular structure of the left ventricle, examined from within . 85 
The muscular structure of the right ventricle, examined from within . 86 
Examination of the muscular structure of the ventricles from without . 87 
The Sounds of the Heart ........... 88 
COLUMN JPILo 1L 
Lra-vm from tke Subject & on Stone loj¥illia,m Fairlsuncl 
Printed Py-HuUmsmdel & "Wal1^ COMMENTARY ON PLATES L, 11., & 111. 
THE STERNUM, RIBS, AND CARTILAGES.—THE ANTERIOR SHREAGE OE THE LUNGS.—THE SUPERFICIAL CARDIAC 
REGION.—THE SUPERFICIAL STRUCTURES OE THE NECK AND THE DIAPHRAGM, IN HEALTH AND DISEASE. 
In Plate I. the lungs are unusually large; in Plate 11. they are 
rather smaller than usual. This difference observed in two bodies, 
the internal organs in both of which were healthy, is owing to more 
air having been expelled during the last expiration in the one than 
in the other. It must always be borne in mind, that these drawings 
show the exact position of the organs as they were found in the bodies 
represented. Now, the organs do not occupy precisely the same 
position in the living body as in the dead. Expiration is the last act 
of life, and this last expiration is usually more extensive and forced 
than the expiration of tranquil life. In the dead body, therefore, 
the lungs shrink up within the position that they usually occupy 
during life; at the same time the heart and its vessels retract, and the 
abdominal organs follow the diaphragm somewhat upwards. Dnring 
life the whole of the internal organs are perpetually in motion. 
With each inspiration the lungs and heart are lengthened downwards 
by the descent of the diaphragm, which, at the same time, pushes 
downwards the abdominal and the pelvic organs. The lungs and 
heart of a strong man, working vigorously, are larger than those of a 
weak, bed-ridden man. When a coal-heaver, by an accident, is confined 
to bed for weeks, his lungs shrink up to a marked extent, and his 
chest is narrowed and flattened. The internal organs vary, then, 
in position and size, within certain limits, in different individuals, in 
the same individual at different times, and in the same body during 
life and after death. 
the whole chest, to lengthen the neck, and apparently to shorten the 
abdomen. It is to he observed, that during inspiration, while the 
ribs and sternum are moving upwards, the lungs and heart and 
the abdominal organs are moving downwards, and that, consequently, 
viewed in relation to the ribs, the descent of the internal organs 
appears to be greater than it really is. 
In the robust (Plate I.) the medium expansion of the chest is greater 
than in the slender (Plate II.); therefore, in the former the upper ribs 
are nearer each other, and the lower are further apart, than in the 
latter. In persons affected with emphysema or bronchitis, the whole 
chest has the fulness and form assumed by it during a deep inspiration; 
consequently the neck is short, the clavicles and sternum are unusu- 
ally high, the upper intercostal spaces are narrow, while the lower are 
singularly wide and hollow, and the lower cartilages of opposite sides 
are far apart, so as to widen the abdominal space between them just 
below the xiphoid. In phthisis, on the other hand, the whole 
chest is narrowed and flattened as in expiration, the neck is long, 
the clavicles and sternum are low, the upper ribs are far asunder, while 
the lower ribs are crowded together, and the cartilages of opposite 
sides below the xiphoid approximate. That side on which the 
tuberculous disease is most advanced, partakes most of the expiratory 
character, as regards the form of the chest and the position of the 
ribs; the region below the clavicle being narrower and flatter, and the 
upper intercostal spaces wider on the diseased than on the healthy or 
less affected side. If one side of the chest be distended with pleuritic 
effusion, the whole of that side is full, rounded, and prominent, 
especially over the lower part ; the ribs diverge so as to widen 
the intercostal spaces, which, instead of forming a hollow between 
the ribs, are level with their surface; and the edge of the seventh 
and eighth costal cartilages, below the xiphoid, are raised outwards, 
so as to leave an unusually large space between them and the linea 
alba. If, after the disappearance of the effusion, the lung contract, 
and form strong adhesions with the ribs, the whole of the affected 
side, assuming the expiratory form, shrinks inwards; the lower ribs 
are crowded together, and the space below the xiphoid, between the 
cartilages and the linea alba, is narrowed: while the whole of the 
sound side, in order to compensate for the deficiency, is unusually 
developed, so as to present the type of inspiration; the upper ribs 
converge, the lower diverge, the space below the xiphoid, between 
the cartilages and the linea alba, is widened, and the lower end of 
the sternum is drawn over towards that side. 
THE STERNUM, RIBS, AND CARTILAGES. 
The sternum, ribs, and cartilages, with their relation to the parts 
immediately subjacent, are shown in Plates I. and 11. In both 
views, the lungs are seen through the intercostal spaces, and in 
Plate 1., owing to the removal of the diaphragm as well as the 
intercostal muscles, the upper part of the liver and stomach are also 
seen through the interspaces. These Plates show that the ribs and 
cartilages differ considerably in different individuals, and that they 
vary also in the same person on opposite sides. In Plate I. the upper 
ribs are near each other, while the lower are far apart; whereas, in 
Plate 11., the upper ribs are far apart, while the lower are crowded 
together. In Plate 1., the right upper ribs are considerably nearer 
to each other than the left; so much so, that the lower border of 
the right sixth rib is on a level with the upper border of the left 
sixth. The difference in the position of the ribs in these two bodies, 
is mainly owing to the lungs being more expanded, and the whole 
frame more robust and set in Plate I. than Plate 11. Taken togethei, 
they illustrate the different position taken up by the ribs dming 
inspiration and expiration. During inspiration, the clavicles, first 
ribs, and through them the sternum, and all the annexed ribs, are 
raised; the upper ribs converge, the lower diverge; the upper 
cartilages form a right angle with the sternum, and the lower 
cartilages of opposite sides, from the seventh downwards, move 
further asunder, so as to widen the abdominal space between them, 
just below the xiphoid cartilage: the effect being to raise, widen, and 
deepen the whole chest, to shorten the neck, and apparently to 
lengthen the abdomen. During expiration, the position of the libs 
and cartilages is reversed; the sternum and ribs descend; the upper 
ribs diverge, the lower converge; the upper cartilages form a more 
obtuse angle with the sternum, and the lower cartilages of opposite 
sides approximate, so as to narrow the abdominal space between them, 
just below the xiphoid : the effect being to lower, narrow, and flatten 
Extensive pericardial effusion causes increased fulness over the whole 
pericardial region, the two lower thirds of the sternum being promi- 
nent, as well as the left costal cartilages from the second to the 
seventh, the whole of which are pushed farther apart from each other. 
If the heart be greatly enlarged, the cardiac region is unusually pro- 
minent from the fourth left cartilage and rib down to the seventh, 
the interspaces being generally somewhat widened. If the heart be 
adherent, as well as greatly enlarged, the prominence over the cardiac 
region is usually greater and more extensive than when the heart is 
enlarged without adhesions, the prominence often extending upwards 
to the third or second left cartilage, and sideways to the right of the 
sternum as well as to the left of the nipple; the intercostal spaces 
are widened over the region indicated, and the lower cartilages below 
the xiphoid are pushed outwards, so as to increase the space between 
them and the linea alba. The effect of heart disease on the position 
of the ribs and cartilages, differs mainly from that of the various lung 
EXPLANATION OE PLATE I. 
This and all the following Plates were taken from dissections made by myself. I took 
the outlines of the organs by the aid of a transparent tracing frame, suggested to me 5 
Dr. Hodgkin, on the plan described in my paper on the Situation of the Internal rgans 
in the Prov. Med. Trans, for 1844. Those outlines formed the groundwork for the 
coloured drawings from the body, which, as well as the lithographs, were executed wit 
untiring care by Mr. Pairland, under my close supervision. The lithographs have been 
carefully coloured, from the original drawings, by Mr. Sherwin. 
Plate I. was taken from a robust, well-built man, aged 37, and upwards of six feet lug 1, 
who died of cholera. I am indebted to the kindness of Mr. Pilliter, Surgeon to the 
Marylebone Infirmary, for the opportunity of making the dissection and drawing. 
In Plate I. the ribs are represented in relation to the lungs, heart, and other internal 
organs, to expose which, the intercostal muscles, and the diaphragm, below the edges of 
the lungs, have been removed, after tying the trachea. In this plate the flaps are 
not shown as they were in the dissection, but conventional incisions have been repre- 
sented, in order to exhibit the outlines of the body. 
The Numbers 1 to 7 refer exclusively to a series of dotted lines which indicate the 
outlines of the deeper organs. The outlines of the lungs are indicated on the sternum 
and ribs. 
1. Conjunction of the aorta, vena cava descendens and right auricle.—2. Commencement 
of the arteria innominata and left carotid.—3, Pulmonary artery.—4. 4, Diaphragm. 
5. Stomach and duodenum. —6. Spleen. —7. 7. Kidneys. —B. Umbilicus and 
linea alba. (Reduced from 33 inches to 19| inches.) COMMENTARY ON PLATES 1., 11., & 111. 
diseases in this, that whereas the latter so modify the form of the 
chest in whole or in part, as to produce an effect similar to that caused 
by inspiration, if one or both lungs be enlarged, or by expiration, if 
one or both be lessened; the former diseases cause direct protrusion of 
the sternum, cartilages, ribs, and interspaces immediately superficial 
to the enlarged organ, that protrusion varying in extent and degree 
with the extent and degree of its enlargement. The diseases of the 
heart produce a much more marked effect on the parietes of the chest 
in youth, when the cartilages are. yielding, and the sternum is still 
composed of several bones united by cartilage, than in adult life, when 
the whole frame-work of the chest is firm and unyielding. 
When the whole abdomen is very much distended, whether by 
excessive flatus, by effusion of fluid into the peritoneum, by ovarian 
dropsy, or by large tumours, the diaphragm is pushed upwards, and 
the lower ribs and cartilages are pushed outwards, so as to cause on 
each side a sudden, sometimes almost angular, prominence of all the 
lower ribs subjected to the pressure, those ribs being crowded together 
in an unusual manner; and to induce extensive separation of the lower 
cartilages of opposite sides below the xiphoid, so as greatly to increase 
the abdominal space between them. If the liver be much enlarged 
from hepatic congestion, fatty degeneration, or any cause acting equally 
throughout its tissue, the organ usually finds increased space, not by 
pushing the diaphragm upwards, but by displacing the other abdominal 
organs downwards and to the left, it at the same time pushes the 
ribs and cartilages below the sixth outwards to an unusual extent, 
so as somewhat to enlarge the prominence usually present over the 
liver: but if a large hydatid cyst, or abscess, or malignant tumour be 
imbedded in the mass of the right lobe, the liver then finds its way 
upwards, so as to push up the diaphragm sometimes as high as the 
second rib; under these circumstances, the ribs and cartilages super- 
ficial to the liver are unusually and irregularly prominent, both in 
front and to the side; and the measurement of that side is much 
greater than that of the opposite side. When the stomach is exces- 
sively distended, it pushes the diaphragm upwards, the liver upwards 
and to the right, and all the other abdominal organs downwards; and, 
varying with the extent of the distension, it at the same time causes 
unusual protrusion of the lower left ribs and cartilages. 
The nipple forms one of the superficial landmarks in relation both 
to the ribs, and the lungs, and heart. Usually the nipple is situated 
just over the fourth intercostal space, but it may be seated over the 
fourth rib as it is in Plate 1., on the left side, or over the fifth rib, as it 
is on the right side. During inspiration, the ribs ascend much more 
than the nipple, hence if it be over the fifth rib during inspiration it 
will be over the fourth rib during expiration. On the same grounds, 
the ribs are higher in relation to the nipple in robust and full-chested 
persons, than in feeble, flat-chested persons. In emphysema, the position 
of the nipple is usually the same that it is during inspiration, being 
over the fifth rib, whereas in phthisis it is generally over the 
fourth rib, as in expiration. In emphysema, the sixth rib is so much 
raised as to be sometimes only about one inch below the nipple, while 
in phthisis the sixth rib may be as much as four inches below the 
nipple, especially on the affected side. I observed this difference re- 
cently in two patients in St. Mary’s Hospital. 
costal cartilage; it is then seen through the fifth intercostal space, 
where it makes a curve to the right, disappears again behind the 
sixth cartilage, and soon terminates in the lower edge of the lung, 
which takes a sloping direction to the left, immediately behind the 
sixth cartilage. The inner edge of the right lung continues its course 
behind the sternum, straight downwards, from the point of divergence, 
and ends in the lower edge behind the upper extremity of the xiphoid 
cartilage. The lower edge of the right lung takes a direction to the 
right and slightly downwards, from the centre of the xiphoid, crosses, 
behind the seventh costal cartilage, and reappears through the sixth 
intercostal space just below the edge of the sixth cartilage; it then 
crosses that interspace, keeping a line directly to the right, and passes 
successively behind the seventh rib, the seventh interspace, and the 
eighth rib. The lower edge of the left lung takes a similar course to 
the left, beginning from behind the sixth costal cartilage in front of 
the apex of the heart; it then appears through the sixth intercostal 
space, and crosses in succession that space, the seventh rib, the seventh 
interspace, and the eighth rib. A line drawn directly downwards 
from the nipple would cut the lower edge of the right lung, where 
it appears through the sixth interspace, and a similar line from 
the left nipple would cut the lower edge of the left lung, where it lies 
behind the sixth rib. A line drawn downwards on either side from the 
centre of the axilla would cross the lower edge of the lung where it lies 
behind the eighth rib. In Plates 11. and 111., which are both taken 
from the same subject, the inner edges of both lungs meet behind 
the sternum, between the second intercostal space, pass downwards 
side by side for a short distance, and diverge opposite the head of the 
fourth cartilage. The edge of the left lung rests upon the heart, 
immediately behind the fourth costal cartilage, so as to form the 
upper boundary of the superficial cardiac region, turns downwards 
at the extremity of that cartilage, and crosses the fourth intercostal 
space, the fifth rib, and the fifth intercostal space; as it does so, it 
again curves inwards towards its lower edge, which is seated behind 
the upper edge of the sixth cartilage, just in front of the apex of the 
heart. The inner edge of the right lung descends from the point of 
divergence, behind the middle of the sternum, a little nearer to its left 
margin, and ends in the lower edge of the lung just above the lower ex- 
tremity of the sternum. The lower edge of the right lung crosses succes- 
sively behind the sixth and fifth cartilages, the fifth intercostal space, 
and the sixth, seventh, and eighth ribs. The lower edge of the left lung 
is nearly a rib’s breadth lower than that of the right lung; it at first 
lies behind the sixth cartilage and rib, and crosses successively behind 
the sixth intercostal space and the seventh and eighth ribs. I may be 
excused for giving, in the subjoined note, a quotation from Conradi’s 
valuable paper on the position of the internal organs during life, as as- 
certained by means of percussion, seeing that they directly confirm my 
own previous observations, recorded in a paper on the situation of the 
internal organs, in the Prov. Med. Trans, for 1841.* Conradi’s observ- 
ations were made under the eye of Professor Vogel, who has, since the 
publication of the paper in question, devoted much attention to the 
subject in immediate connexion with clinical medicine. I hope to be 
enabled, through his kindness, to enrich the future parts of this work 
with some of Professor Vogel’s valuable observations. 
The septum between the upper and middle lobes of the right lung, 
is seen through the third intercostal space in Plate 1., and lies behind 
the third ribs in Plates 11. and 111. The division between the middle 
and lower lobes is seen through the sixth intercostal space in Plate 1., 
through the fifth intercostal space in Plate 11. Thence it rises 
upwards and backwards. The septum between the upper and lower 
lobes of the left lung, commences behind the sixth cartilage in Plate 
I.; rising, it thence crosses successively the fifth intercostal space 
and the fourth rib. In Plates 11. and 111. the position of this septum 
is very similar. It may be noticed that, in these two subjects, the 
opposite lungs are not equally large : in Plate I. the left lung is 
altogether smaller than the right, while in Plate 11. the left is the 
largest of the two. The result is that the left lung approximates in 
size and position in the two subjects, while the right lung is much 
larger in Plate I. than in Plate 11. 
The lower edge of the left upper lobe, just where it is in front of the 
heart near the apex, usually projects inwards, so as to form a peculiar 
THE ANTERIOR SUREACE OE THE LUNGS. 
In Plates I. and 11. the front of the lungs is seen through 
the intercostal spaces. In Plate 111., the whole of the anterior 
surface of the lungs is exposed by the removal of the sternum, ribs, 
and cartilages; their relation to the lungs being still shown by a 
series of dotted lines traced along their outline. As I have already 
remarked, the lungs in Plate I. are unusually large, whereas in Plate 
11. they are rather smaller than usual. Plate I. is taken from a 
remarkably fine robust man, in the prime of life; Plate 11. from a 
somewhat slender youth. The medium amount of air in the lungs 
during life has evidently been less in the latter, and he has, during the 
last expiration, expelled a much larger quantity of air from his lungs 
than the former. Plate 1., therefore, more nearly represents inspira- 
tion ; Plate 11., expiration. 
In Plate 1., the inner edges of the lungs meet behind the sternum, 
between the first intercostal spaces, and pass down together behind that 
bone, a little nearer the left than the right edge, until they are opposite 
the head of the fifth costal cartilages : there the left lung diverges; 
its edge, which is immediately superficial to, and just above the heart, 
passes behind the fifth costal cartilage, and the fourth intercostal 
space, and turns directly downwards, so as to cross behind the fifth 
The point of dhergence of the inner margin of both lungs, (behind the sternum,) 
lies, for the most part, at the level of the fourth or fifth left cartilage, quite in accordance 
with the indications of Sibson. In the mammary line, the sixth rib ; in the axillary line, 
the eighth rib, forms the landmark for the lower margin, as well of the right as of the 
left lung; which also coincides with the indications of Sibson, founded on anatomical 
researches. Conradi: “ Ueber die Lage und Grosse der Brustorgane,” &c. 1848. IFLo I. COMMENTARY ON PLATES 1., 11., & 111. 
tongue, or almost pointed wedge of lung. This projecting tongue is 
indicated in Plate 1., but is present in a very marked and peculiar 
manner in Plate 111., where it forms a return lower boundary to the 
superficial cardiac region. 
Thus, in the case just supposed, of permanent contraction of the right 
lung, the impulse may be felt, not to the left but to the right of the 
sternum. The parallel history and state of things was present in a 
case of effusion into the left pleura published in my paper “ On the 
Movements of Respiration in Disease,” in the Med. Chir. Trans., 1848. 
In pericarditis, the effused fluid, which gravitates backwards, is 
at first insufficient to displace the lungs from before the pericardium. 
As the effusion increases, however, it pushes the lungs more and more 
aside, so that the exposed pericardium, when distended, lies immediately 
behind and to each side of the sternum, as high up as the second costal 
cartilages. The pericardium then assumes a conical form, the cone 
pointing upwards. If the fluid increase slowly to a very large extent, 
the pericardium becomes excessively widened, especially to the left, so 
that it pushes the whole of the front of the left lung so far backwards 
as to be out of sight when the chest is opened. The left lung may be 
thus displaced upwards as high, even, as the clavicle. When the heart 
is enlarged, it does not encroach upwards on the lungs, which are 
generally amplified, but makes way for itself downwards and sideways; 
the impulse being low and far to the left, if the left ventricle be 
enlarged; and behind the lower sternum and xiphoid, if the right ven- 
tricle be enlarged. When the heart is adherent, as well as enlarged, it 
not only makes its way downwards, but it also encroaches on the lungs 
upwards, as high as the third or even second left rib, and sideways, to 
the right of the sternum as well as to the left of the nipple. 
ABNORMAL CAUSES WHICH AEEECT THE POSITION OE THE ANTERIOR 
SUREACE OE THE LUNGS. 
The position of the lungs in front of the chest may be changed by 
affections of the lungs themselves, the pleura, and the bronchial 
glands; of the heart and pericardium, and the great vessels; and of the 
abdominal organs. 
In emphysema, the lungs, being unusually expanded, take up the 
same position that they do during the deepest possible inspiration. 
The lower boundary of the lungs descends everywhere from an inch 
to an inch and a half, so that, instead of being behind the lower end 
of the sternum, and a line running thence across the sixth rib, it is 
as low as the lower end of the xiphoid cartilage and the seventh rib. 
At the same time the enlarged lung interposes itself between the ribs 
and sternum and the heart, which is drawn downwards; so that the 
heart is just behind, below, and to the left of the xiphoid cartilage, over 
which part its impulse may be felt and its sounds best heard, instead of 
over the fourth and fifth left intercostal spaces. In phthisis, and in 
lowering diseases, especially when the patient is confined to bed, the 
lungs gradually contract upwards, so that their lower margin may rise 
from the sixth rib to the fifth intercostal space; and they shrink away 
from before the heart and great vessels, so that the region of cardiac 
dulness on percussion, and the seat of impulse, are extended upwards. 
In pneumonia, affecting the middle and lower lobes of the right 
lung, the affected lung is enlarged by the exudation which universally 
distends the air-cells of the affected parts, and the base of the affected 
lung is, therefore, unusually low. The opposite lung is, however, 
called into excessive play, to compensate for the deficient action of the 
diseased one, as well as to supply the increased demand for respiration; 
both lungs are, therefore, unusually large, and the bases of both are 
universally low. In pleuritis with effusion, the lung, as I have 
already said, floats forwards on the affected side, and the heart and the 
edge of the opposite lung are pushed over to the unaffected side. If 
the effusion be in the left pleural sac, the heart is pushed to the 
right, so that its impulse is felt in the epigastrium, or even in the right 
fourth and fifth intercartilaginous spaces ; and the inner margin of the 
right lung is displaced to the right of the sternum. If the right side 
be the seat of the effusion, the heart is pushed unusually to the left, 
its apex being felt quite to the left of the line of the nipple, and the 
inner edge of the left lung is displaced to the left of the sternum. 
During the earliest stage of pleuritis, when the quantity of fluid effused 
is as yet inconsiderable, the friction-sound, if present, is usually heard 
over the sixth and seventh cartilages, just below the margin of the 
lungs; in fact, not over the lung itself, but over the diaphragm, which is 
likewise affected with pleuritis immediately below the lung. With the 
increase of effusion the friction-sound becomes totally lost, but as the 
effusion again disappears, the friction-sounds reappear, exactly over the 
same spot, being of a more harsh, grating, or even creaking character 
than they were at the onset,—the friction between diaphragmatic 
pleura and costal pleura being stronger than that between pulmonic 
pleura and costal pleura. As the fluid disappears, the friction-sounds 
become more extensive, and more harsh and grating, or creaking. 
They gradually extend upwards, sometimes reaching to the fourth, 
third, or even second ribs. As the fluid still lessens, harsh tactile 
vibrations are often present as well as the friction-sounds. 
In aneurism of the arch of the aorta, the lungs are displaced from 
behind the upper part of the sternum, the displacement sometimes ex- 
tending to the right, sometimes to the left, according to the extent and 
direction of the aneurism. 
When the abdomen is unusually distended, from whatever cause, 
whether from flatulent distension, ascites, ovarian dropsy, or large 
abdominal tumours, the diaphragm, as I have said before, is raised, 
and the lungs and heart are crowded upwards into the chest to an 
extent proportioned to the distension. Sometimes the lower margins 
of the lungs are raised as high as the fourth ribs. When the flatus 
is expelled, or the dropsical effusion is removed, the diaphragm and 
lungs descend to their usual place, with immediate relief to the 
shortness of breath, the palpitation, the congestion of the head and 
face, and the sense of suffocation caused by the distension. If the 
stomach and intestines be unusually empty, owing to starvation, 
whether from want of food, or inability to swallow, owing to disease of 
the oesophagus, or to retain food, owing to scirrhous pylorus, the dia- 
phragm, and with it the lower boundaries of the lungs and heart, 
descend to a marked extent. 
If, as I have already said, the liver be simply enlarged, it usually 
pushes the intestines downwards, instead of displacing the diaphragm, 
and the lower margin of the right lung upwards. Should, however, 
a large abscess, hydatid cyst, or tumour occupy the upper part of the 
liver, the diaphragm and the lower boundary of the right lung are 
raised, sometimes as high as the second or third rib, whilst the heart is 
also raised and pushed over to the left, so as to encroach on the cardiac 
margin of the left lung. 
EXAMINATION OE THE ANTERIOR SUREACE OE THE LUNGS 
DURING LIEE. 
The extent, volume, and condition of the anterior surface of the 
lungs, may generally he ascertained with precision during life, by 
observing the form of the chest, and the movements of breathing, 
by percussion, by ascertaining the seat of the heart’s impulse, by aus- 
cultation, by noticing the extent of the vocal vibrations, and by 
measuring the chest. This is the order in which I think it best to 
make those observations. 
The broad outlines and mass of the lungs may be appreciated with 
an approach to accuracy, by carefully observing the form of the chest. 
The examination of the chest ought, indeed, to commence with this 
inquiry. If, as I have already indicated, the whole chest be broad, 
deep, and full; if it be raised towards the neck, and shortened towards 
or raised from the abdomen, we may safely infer that the lungs are 
capacious. If, on the other hand, the whole chest be narrow and flat; 
if it be lowered from the neck, and lowered and lengthened towards the 
If, when the pleuritic effusion totally disappears, the lung remains 
permanently condensed, and is universally and strongly adherent to the 
libs, the opposite lung becomes permanently enlarged, to compensate 
for the deficiency; and its inner margin finds its way over into the 
opposite side of the chest; so that, if the right lung be contracted, the 
inner margin of the left lung may encroach an inch or even more to 
the right of the sternum. At the same time, the heart, which, when 
the effusion was at its height, was pushed entirely over to the un- 
affected side, is now sometimes displaced almost entirely into the 
affected side, so as to make way for the sound, amplified lung. 
EXPLANATION OE PLATE 11. 
This Plate and Plates 111,, IY., Y., YL, and YIL, were taken from a youth, aged 18, 
'ft ho died suddenly in a fit. The dissections and drawings were made at St. Bartholomew s 
Hospital School, through the kindness of Mr. Paget and of Mr. Holden, who, with Mr. 
Holmes Coote, gave me valuable assistance during the progress of the drawings. 
Plate 11. represents the same view as Plate 1., except that the diaphragm is not 
removed, and the flaps are represented as they were in nature. 
1. Umbilicus and linea alba. (Eeduced from 32 inches to 19 inches.) COMMENTARY ON PLATES 1., 11., & 111. 
abdomen, we may infer that the lungs are contracted. The size of the 
upper lobes may he accurately inferred by the fulness, flatness, or 
hollowness of the chest below the clavicles, within the head of the 
humerus, and in the axillae. Any difference in the degree of fulness 
on the two sides over the upper lobes, is readily appreciated by the 
eye just below the clavicles, and by the hand just to the inside of 
the head of the humerus, and in the axilla. If the upper lobe be full, 
a single finger can scarcely be interposed between the head of the 
humerus and the second rib, or be inserted into the axilla when the 
arm is at the side; but if the lobe be contracted as well as flattened, 
two fingers can be readily pressed inwards, by the side of the humerus, 
or be inserted into the axilla. 
sufferings of the patient merely to gratify a scientific curiosity, or to 
make an over-refined diagnosis. 
The exact boundary of the lungs may be very quickly ascertained by 
making a few light taps over the lower boundary of the right and left 
lungs, and over the border of the left lung, just above the superficial 
cardiac region. The percussion must, at those places, be made with a 
very light stroke, else the resonance excited by the superficial and thin 
film of lung will be immediately deadened by the subjacent mass of 
solid liver or heart; or be rendered unduly resonant and amphoric 
by the distended stomach. The same remark applies also to percus- 
sion over the sternum, since the whole bone forms a sounding-board, 
which, when struck forcibly at any part, imparts its vibrations to 
the whole of the lung tissue behind it, whether at the part imme- 
diately subjacent to the point percussed, or at a greater distance. 
In fact, if percussion be made forcibly over the lung, just superficial 
to the liver or heart, the sound excited is dull, when it ought to be 
resonant; and if percussion be made forcibly over the sternum, 
immediately over the heart, the sound excited is resonant, when it 
ought to be dull. 
The normal lower boundary of the middle lobe of the right lung 
is indicated by a depression commencing at the lower end of the 
sternum, and thence crossing in succession the seventh and sixth costal 
cartilages. The sixth, seventh, and eighth intercostal spaces are convex 
where they are over the lung, but plane where they are over the liver; 
since the latter organ, being solid, supports them, while they are forced 
inwards over the lung by atmospheric pressure. The margin of the 
lung may be inferred by noticing the lower limit of the depression in 
each interspace. During inspiration, owing to the descent of the 
lung and the downward displacement of the liver, as well as the 
increased atmospheric pressure, the depression in each interspace 
is deepened, and its limit descends, pari passu, with the descent of 
the margin of the lung, so that the exact inspiratory descent of the 
lung may be thus recognized. The same remark applies to the lower 
boundary of the left lung, but with much less precision, since the 
heart supports the intercostal spaces superficial to it, while the 
stomach does not support the interspaces so well as the liver. 
If a person in health be desired to take a deep breath, and to hold 
it, after the exact lower boundary of the lung above the liver, the 
stomach, and the heart is ascertained, it will be found that the lower 
margin of the lung will descend everywhere from an inch to an inch 
and a half, and that the upper region of liver and heart dulness and of 
stomach resonance will be replaced by lung resonance. In fact, the 
diaphragm draws the lower boundary of the lungs, and of the heart 
also, downwards, to the extent indicated, during a deep inspiration; and 
therefore, in the nature of things, percussion is no longer made over 
the liver, stomach, or heart, but over the lungs, which encroach upon 
the solid organs, and are, at the same time, increased in circum- 
ference, owing to the augmented area of the chest. The extent, 
therefore, to which lung resonance is excited by percussion is not 
only greatly increased, but, if the percussion stroke be made with 
force, the lung resonance is everywhere much louder than before. 
During a deep inspiration, as I have just said, the heart is drawn 
downwards by the diaphragm to the extent of an inch, and at the 
same time the sternum and cartilages in front of the heart advance an 
inch forward, so as to deepen the area of the chest to that extent. 
The lung, therefore, not only occupies the place occupied by the heart 
previously to its descent, but it also encroaches forwards over the 
heart itself, so as to interpose a thicker layer of lung between 
that organ and the ribs. The effect is, that the region of cardiac 
dulness on percussion entirely disappears from over the sternum, ribs, 
and cartilages, and is only present over, below, and to the left of the 
xiphoid cartilage, and over a small portion of the seventh cartilage. 
The superficial cardiac region is, in fact, lowered and narrowed, so 
that, instead of its diameter being two inches from above downwards, 
and three inches from the centre of the sternum to the apex, it is 
now but one inch from above downwards, and an inch and a half 
from side to side. 
In Emphysema, the depression of the lower intercostal spaces is not 
only deepened in degree, owing to the increased atmospheric pressure, 
but in extent also, owing to the great expansion of the lung down- 
wards. In cases of enlarged liver, or of great abdominal distension, 
the lower intercostal spaces are no longer depressed, owing to the extent 
to which the lower boundary of the lung is pushed upwards. The 
ribs, from the seventh downwards, usually form a prominence on each 
side over the liver and stomach. These prominences, which indicate 
the lower boundary of the lungs, and the upper boundary of the liver 
and stomach, and which are more marked in Plate 11. than in 
Plate 1., may be readily felt by pressing the hands firmly on each 
side, and bringing them from the axillae downwards, when they 
will feel the prominences in question, and be stopped by them, 
especially by that over the liver, which is usually fuller than that 
over the stomach, unless that organ be distended. The abdominal 
organs, just below the lungs, have a larger circumference than the 
lungs themselves; hence the fulness in question over the liver and 
stomach, which was first pointed out by the late Dr. Edwin Harrison. 
When a deep inspiration is taken, the circumference of the lungs 
increases from two and a half to five inches; hence the promi- 
nences over the liver and stomach are obliterated by a deep inspira- 
tion, and hence they are less marked in the robust, as in Plate 1., 
than in the weak, as in Plate 11., owing to the medium size of the 
lungs being larger. Eor the same reason, the prominences over the 
liver and stomach are almost or altogether obliterated in emphysema, 
while they are unusually full, especially that over the liver, in phthisis, 
owing to the enlargement of that organ, as well as the contraction of 
the lungs. 
The lungs, as I have already said, are more capacious, and con- 
tain, therefore, a larger medium amount of air in the robust, as in 
Plate 1., than in the feeble, as in Plate 11. It will be at once com- 
prehended, that in the robust the heart is more shielded by lung 
from the sternum and cartilages than in the weak, although in the 
strong the heart is decidedly larger than in the weak. This is actually 
the case in Plate 1., from a robust man, in which the superficial cardiac 
region is both decidedly lower in position and smaller in extent than 
in Plate 11., from a slender youth. When a person is long confined to 
bed, the lung contains a smaller medium amount of air, and the super- 
ficial cardiac region ascends and increases in extent, owing to the 
shrinking away of the lungs from before the heart; the extent of 
cardiac dulness on percussion will, therefore, increase upwards in 
such persons, although the heart itself be smaller in size. 
The movements of breathing are present wherever the lung can 
expand. The extent of the respiratory movement indicates with 
precision the amount to which the lungs, or any part of them, is 
capable of expansion. In a future commentary I will return to 
this subject. 
By percussion we ascertain the extent and volume of the lung 
with greater precision than by any other means. Those other means 
are not, however, to be neglected for this reason, since, as we shall 
see presently, on some occasions, percussion totally fails us in our 
endeavour to ascertain the limits of the lung. In some persons, also, 
the surface is so morbidly sensitive, especially over the seat of disease, 
that percussion is rendered impossible or inefficient. Besides this, 
the nature of many cases is involved in doubt, in spite of the 
combination of all the possible aids towards diagnosis. We cannot, 
therefore, afford to part with or neglect any of those means that 
may enable us more thoroughly to comprehend the case. At the 
same time, I may remark, that the examination of the patient ought 
always to be made with an exclusive regard to the welfare of the 
patient. It ought not to be carried to the extent of increasing the 
The extent and force of the heart's impulse varies with the extent of 
the superficial cardiac region. In the strong, owing to the great ex- 
pansion of the lungs, as we have just seen, the superficial cardiac region 
is small and low, and, although the heart itself is large and powerful, 
the heart’s impulse is either feeble or imperceptible. In the feeble, on 
the other hand, as I have just said, owing to the contraction of the lungs 
from before the heart, the superficial cardiac region is raised and ex- 
tended ; and, although the heart be comparatively small and feeble, the 
heart’s impulse is strong and sharp, and it is felt in the third and fourth, 
and sometimes also the fifth interspace. If the lungs shrink away 
from before the heart as high as the second intercostal space, so as 
to expose the pulmonary artery, a peculiar, short, sharp, diastolic im- 3PM Mo COMMENTARY ON PLATES 1., 11., & 111. 
pulse is felt in the second intercostal space, exactly synchronous with 
the second sound. This diastolic impulse is often felt in phthisis, when 
the lungs shrink away from before the roots of the great vessels. 
The increased extent of the heart’s impulse is not of itself then 
a sign of enlarged heart, but often, on the contrary, of a lessened 
and enfeebled heart, as well as of a contracted lung. The chief 
exception to this rule is in adherent pericardium with enlarged heart, 
when the extent and force of the impulse is unusually great, both 
upwards, downwards, and sideways. When the increased impulse is 
from the mere exposure of the heart, the impulse, while it is increased 
upwards, is lessened downwards; and it is never felt so far outwards 
as the left nipple; but when the impulse is increased from enlargement 
of the heart, though it is increased downwards, it is often lessened 
upwards, owing to the encroachment of the lung on the upper part of 
the heart. 
in tissue, conduct the sounds to the surface better than in the 
robust, with capacious lungs; besides this, the sternum and cartilages 
over the heart themselves consonate with the heart-sounds, and the 
continuous sternum, cartilages and ribs convey the sounds over a con- 
siderable portion of the chest. 
Vocal vibrations are perceptible over the whole surface of the lungs, 
but not over the adjoining organs—the heart, liver, and stomach. The 
boundaries of those organs, where they adjoin the lower margins of the 
lungs, as well as those margins themselves, may, therefore, be defined 
by observing the extent of the vocal vibrations. Vocal vibrations are 
more extensive over the lower part of the chest, at the beginning 
than at the end of a vocal expiration, owing to the shrinking up- 
wards of the lower edge of the lungs. If the middle or lower lobe 
of the right lung be hepatized, we cannot distinguish liver from lung 
by percussion ; but we can do so by observing the vocal fremitus which 
is present with unusual intensity over the lung, but not at all over the 
liver. Under the like circumstances, bronchial breathing will be heard 
over the lung, but not over the liver. By these tests we can readily 
distinguish whether the dulness on percussion over the usual region 
of the lung, be owing to condensation of the lung itself, or to the 
encroachment of the liver upon the lung. If dulness at the 
base be due to pleuritic effusion, the vocal vibration will be intense 
over the mammary region, and absent over the scapula, when the 
patient lies upon the back; but if he be gently turned over on his 
face, the hands retaining their place, the seat of the vocal vibration 
will change places, and instead of being felt over the front of the chest, 
it will be perceived over the dorsum—the lung, in fact, being floated 
towards the back, owing to the fluid occupying the depending part, 
which is now the face. This test of the presence of pleuritic effusion 
is much more easy of application than the equally certain test of the 
change in position, under the like circumstances, of the seat of reso- 
nance or dulness on percussion. 
% auscultation we can ascertain the extent of the surface of the 
lungs, since the breath-sound is heard over the whole of both lungs, 
quite down to, but not below, their lower margins. But by auscult- 
ation we can neither define the boundaries of the lungs, nor ascer- 
tain their volume, so well as by percussion. The breath-sound is 
louder at the top of the sternum, and above and below the clavicles, 
especially the right clavicle, than it is over the sides of the chest 
below the scapulae ; yet the volume of the lung is much larger 
and its expansion greater in the latter regions than the former. 
Indeed, the loudness of the breath-sound is in the inverse ratio of the 
volume of the lung. Thus, it is universally loud and sharp, both 
during inspiration and expiration, over the lungs of a child, while it is 
remarkably soft and feeble over the lungs of the large-chested, robust 
man; especially, as I have just said, over the sides and back, where the 
volume and expansion of the lung are greatest; and where, indeed, 
though the soft inspiration sound can be readily heard, the expiration 
sound is so faint as to be heard with difficulty, even with the closest 
attention. As a rule, the breath-sound is louder the nearer it is to the 
larynx, trachea, or larger bronchim. Eor this reason, both the inspiration 
and expiration breath-sounds are louder below the right than the left 
clavicle; the breathing is, there, in fact, more bronchial in character. 
If we desire the patient to pant, the short, quick breathing then exerted 
is much more audible than tranquil breathing over the whole chest, but 
especially over those parts which are remote from the larynx, or large 
bronchise. It is quite evident to me that the tranquil breath-sound 
originates in the larynx, whence it is conveyed to the air-cells by the 
walls of the tubes and by the current of inspired air, being at the 
same time reinforced by consonating vibrations in the current of air 
itself, and in the walls of the tubes which convey it; but the panting 
breath-sound is actually excited in the air-cells and capillary bronchial 
tubes immediately underneath the ear. If we listen over the liver, 
heart, or stomach, within an inch of the lower margin of the lungs, 
and desire the person to take a deep breath, though the breath-sound is 
absent at first, it becomes distinctly audible towards the end of inspira- 
tion, when the lower margin of the expanding lung descends below 
the point of observation. The presence of healthy breath-sound is 
the most convincing proof of tfie healthy and permeable condition of 
the portion of lung examined; while the absence of healthy breath- 
sound, whether it be, or be not, replaced by bronchial breathing, 
rhonchi or frottement, is one of the most conclusive proofs of its 
unhealthy or impermeable condition. 
The vocal vibrations are stronger or weaker, in proportion to the 
mass of the lung, and to its proximity to, or distance from, large 
bronchial tubes. They are markedly stronger over the right than the 
left infra-clavicular space; hence, if the vocal vibration be more 
marked below the right clavicle, it is no sign whatever of tubercular 
or pneumonic consolidation of the right upper lobe; but should the 
vibration be stronger below the left clavicle, it is quite otherwise, and 
there is reason to suspect consolidation of the left upper lobe. The 
vocal vibrations are stronger over the right than the left mammary 
region; and they are also stronger over both nipples than they are 
over the layer of lung superficial to the liver, heart, and stomach. 
THE SUPEREICIAL CARDIAC REGION. 
The superficial portion of the pericardium which, being uncovered of 
lung, is in contact with the walls of the chest, is seen through the 
intercostal spaces, in Plates I. and 11., and is exposed fully to view in 
Plate 111. The superficial cardiac region is not, as these Plates show, 
triangular, but is irregularly quadrangular. On three sides, it is 
framed by lung, and on the lower side by diaphragm and liver and 
stomach. The inner or right side, behind the centre of the sternum, is 
straight, being bounded by the inner margin of the right lung. The 
outer or left side is curved, a concave edge of the left lung being, as 
it were, carved out so as to adapt itself to the play of the convex 
surface of the heart near the apex. The remarkable tongue or 
horn-like wedge of lung, previously described, which completes this 
concave border below, is well seen in Plate 111., and is evidently so 
arranged, that it can be pushed aside during each systole, while it will 
return again of itself to fill up the space vacated by the heart during 
each diastole. The upper side, bounded by the margin of the left 
lung, and the lower side, by the diaphragm, are slightly oblique in 
direction, and are about one half longer than the inner and outer or 
right and left sides. The superficial cardiac region is usually about 
three inches in diameter from right to left, and about two inches 
from above downwards. As I have already said, more than once, this 
region varies considerably in different persons, being smaller and lower 
in the robust, as in Plate 1., than in the slender, as in Plate 11. In 
emphysema it is very small and low, being quite behind and below the 
If the lungs be large and full, as in the robust (Plate I.), so as to 
cover the greater part of the heart and to form a thick layer over the 
great vessels, the heart-sounds are feeble, although the heart itself be 
large and powerful; for the same reason that, under like circum- 
stances, the region of superficial cardiac dulness, on percussion, is 
small, and that the impulse is rather feeble, or altogether absent, 
between the intercostal spaces. If, however, as in the feeble, the 
lungs be small and contracted, so as to expose the greater part of the 
heart, and to form but a thin layer over the great vessels, then the heart- 
sounds are loud, and are transmitted to a great extent over the front 
of the chest; for the same reason that, under the like circumstances, 
the superficial cardiac region and the impulse are increased upwards. 
The heart-sounds are heard thus extensively over the front of the chest, 
because the lungs are thinner, and being somewhat more condensed 
EXPLANATION OE PLATE 111. 
From the same body as Plate 11. The sternum, and the ribs, and cartilages, in front, are removed, so as to show the anterior surface of the lungs and the superficial portion of the 
pericardium. Plate 111. represents the superficial organs, (Reduced from 32 inches to 19 inches.) COMMENTARY ON PLATES L, 11., & 111. 
xiphoid. In phthisis it is usually extended and raised. Its size, in 
fact, is in the inverse ratio of the size of the lung. Plates IY., Y., 
and YI. will represent the exterior of the heart, and the interior of its 
right and left cavities; I shall, therefore, return to the superficial cardiac 
region when I describe the heart in connexion with those Plates. 
double ridge and deep hollow which they form just above the sternum, 
during each inspiration. 
The omo-hyoid muscles form the two outer borders of a broad, tri- 
angular fascia, which stretches across the front of the neck; the 
base of which is attached to the clavicles and sternum, the apex to the 
hyoid bone; and which comprises within it the sterno-hyoid and 
thyroid muscles. This fascia is stretched on each side, and rendered 
tense by the action of the omo-hyoid muscles, aided by that of the 
sterno-hyoid and thyroid, whenever we speak, cough, or make any 
expulsive or other violent effort. This fascia, and that connected with 
the sterno-cleido-mastoid muscles, evidently form a wall of support for 
the deeper veins of the neck, when those veins are in a state of un- 
usual tension during any violent effort. 
I shall consider the deeper parts of the neck in the Commentary on 
Plates IV., Y., and VI., which will present deepening views of the 
neck. 
SUPEREICIAL YIEW OE THE NECK. 
The neck is shorter during inspiration than expiration, owing to the 
raising of the sternum and the lowering of the head. It is short in 
the robust, Plate I.; long in the slender, Plate 11. It is short in 
those affected with emphysema; long in those affected with phthisis. 
Many of the structures of the neck are of practical interest in a 
medical point of view. The larynx and trachea, the pharynx and 
oesophagus, and the thyroid body, are the seat of medical, in contra- 
distinction to surgical, diseases. The veins, arteries, glands, fasciae, 
muscles, and nerves of the neck, afford important signs and symptoms 
in various diseases of the internal organs. 
The superficial jugular vein is usually but just perceptible in perfect 
health, when we are in a state of repose. During each expiration, 
however, it partially fills, and becomes distinctly visible, just above 
the clavicle. There is more blood in the vein during expiration, owing 
to the increased resistance to the return of the blood into the auricle, 
and the increased force with which the blood is propelled. When 
we lie down, owing to the influence of gravitation, the vein contains 
more blood than when we sit or stand. The vein always fills from 
below upwards, but in health it is never seen to mount over the lower 
edge of the sterno-cleido in a person at rest. 
During the acts of speaking, singing, and coughing, the superficial 
jugular swells up, so that it is usually distinctly seen above, as well as 
below the edge of the sterno-cleido. This is particularly well seen in 
singers on the stage. The force with which they utter each note can 
be measured by the amount of fulness of the veins of the neck. When 
we hold our breath, and strain, or lift a weight, the veins of the 
neck and head, quite up to those of the forehead, become swollen. 
During each systole, the blood meets with increased resistance when 
it flows from the veins into the auricle, while it is propelled along the 
arteries and capillaries with greater force and volume. There is, 
therefore, more blood in the veins during systole than diastole, and 
a slight systolic pulsation is visible, below the sterno-cleido, in the super- 
ficial jugular, in thirty-nine persons out of forty, when they lie down. 
This venous pulsation is more evident during expiration than in- 
spiration, because the veins are then fuller. 
ANTERIOR PORTION OE THE DIAPHRAGM. 
The diaphragm plays the most important part in modifying the 
position of the internal organs, whether in the chest or abdomen. 
I shall not now consider that important muscle as a whole, seeing that 
in later Plates it will be more completely exposed, and its functions 
more directly illustrated. I may here remark, however, that in re- 
lation both to health and disease, the diaphragm must be regarded in 
a double point of view. It is active during inspiration, when it de- 
scends, lengthening and expanding the lungs and heart, and pushing 
downwards all the abdominal and pelvic viscera. It is passive during 
expiration, when it is pushed upwards by the action of the muscles 
of the abdomen, with the effect of compressing upwards the lungs 
and heart. The diaphragm is also passive when it is raised or low- 
ered by the abdominal organs, in proportion as they are large or 
small, full or empty; every meal, every evacuation, produces some 
such effect; hence the oppression in the chest, caused by a full meal 
or by flatulent distension, and hence the great relief afforded by a free 
evacuation. 
In Plate I. the lungs are large, and the extent of the diaphragm 
below their lower edge is therefore small, while in Plate 11. the lungs 
are rather small, so that the extent of diaphragm below their margin 
is comparatively large. In pleuritis, as I have already observed, the 
friction-sounds are often audible over the diaphragm, just below the 
lung, when they are not audible over the lung itself. This is owing 
to the superior pressure exerted by the diaphragm, and to the breath- 
sounds or rhonchi heard over the lung, which tend to mask the 
friction-sounds. 
The superficial jugular contains more blood when we are warm than 
cold. When persons are excited, and when the brain is very active, 
the blood is sent along the carotids with increased force and volume, 
the face flushes, and the veins of the forehead and neck swell. When 
violent efforts are made by a person in anger, the face is red and 
swollen, and all the veins are immoderately distended. 
Whenever there is obstruction to the flow of blood through the 
heart or lungs, owing to disease in either of those organs, the super- 
ficial jugular is unusually full of blood, especially during expiration. 
If the obstacle to the flow of blood be excessive, as in extreme bron- 
chitis, the veins are immoderately and equally distended, during both 
inspiration and expiration. 
I am particularly desirous that the muscular fibres of the diaphragm 
should be noticed, which, in Plates I. and 11., pass obliquely upwards 
from the seventh cartilage, cross the abdominal space below the dia- 
phragm, and disappear behind the xiphoid. The pleura is reflected at 
the lower edge of those fibres of the diaphragm, and the cavity of 
the chest descends, therefore, thus far. During a deep inspiration 
these lower fibres of the diaphragm shorten and descend, and they 
draw down with them the lung on the right side, and the heart and 
lung on the left side. The ascending anterior left fibres, and, to a less 
extent, the corresponding right fibres of the diaphragm, are, as is 
shown in Plate 111., inserted into the lower edge of the pericardium, 
the base of which is, in fact, formed of the central tendon of the 
diaphragm. During a deep inspiration, the fibres in question draw 
down the central tendon of the diaphragm and, with it, the heart, 
so that their lower boundary, as well as that of the right lung, are 
brought down as far as the lower end of the xiphoid cartilage. In 
fact, during inspiration, the chest, owing to the descent of the dia- 
phragm, encroaches upon the abdomen, which, in turn, encroaches 
upon the chest during expiration. I would here remark upon the great 
extent to which, in Plates 11. and 111., the abdomen encroaches upon 
the chest. The ribs, in addition to forming the framework of the 
chest, overlap a great portion of the abdomen. The extent to which 
they do so is less during inspiration than expiration; less in the 
robust than in the slender; less in the patient affected with emphy- 
sema than with phthisis. During inspiration the lower ribs rise up- 
wards, so as apparently to lengthen the abdomen and to shorten the 
chest: in fact, however, it is quite otherwise, since the invisible dia- 
phragm, while it descends, really lengthens the chest and shortens the 
abdomen, both chest and abdomen becoming at the same time more 
voluminous. 
When the veins are abnormally swollen, but not distended, they are 
more full during systole and still more so during expiration, and the 
venous pulsation, which is present in the healthy, becomes unusually 
marked. If, however, the obstacle to circulation through the chest be 
so excessive, that the veins are equally distended during both inspira- 
tion and expiration, venous pulsation is no longer visible. 
If disease be seated in one side only of the chest, the jugular is fuller 
on that side than the other. The reason of this is evident when the 
veins of one side are compressed by enlarged glands, by pleuritic 
effusion, or by a tumour, but not when there is disease of one lung. 
When the brain is diseased, or unduly excited, the veins of the fore- 
head and neck are often unusually full. 
Whenever the jugular is visible above the lower edge of the sterno- 
cleido in a person at rest, it is either a sign that there is some ob- 
struction to the flow of blood into the auricle, or that an undue quan- 
tity of blood is sent to the head. 
When the platysma myoides is in action, it draws down the lower 
lip, and so widens the mouth. This action is sometimes put in force 
when persons gasp for breath, owing to extreme obstruction to respira- 
tion, and it presents a most formidable and threatening symptom. 
The sterno-cleido-mastoid muscles are usually at rest, but they act 
whenever respiration is difficult. Their action is indicated by the 
I shall consider the abdominal organs in the Commentary on Plates 
IY., Y., and YI. JPJL. IT, COMMENTARY ON PLATES IV., V., & VI. 
THE PERICARDIUM.—THE HEART AND GREAT VESSELS. MOVEMENTS AND DISPLACEMENTS OP THE HEART IN 
HEALTH AND DISEASE. EXAMINATION OE THE HEART DURING LIRE.—THE ABDOMINAL ORGANS. 
The effect of increased effusion on the form of the pericardium, is 
shown by comparing Pigs. 1 and 2. In Pig. 1 the pericardium is 
flaccid, in Pig. 2 it is artificially distended with water. The swollen 
pericardium is pyriform. It is composed, as it were, of two spheres, 
the smaller, which surrounds the great vessels, resting as an apex upon 
the larger. The upper part of the sac displaces the lungs to each side 
and comes into immediate contact with the sternum, as high as the 
first intercostal space. 
The increased effusion pushes downwards the central tendon of the 
diaphragm, which forms a globular protrusion into the abdomen and 
displaces the liver and stomach. 
In a case of pericarditis with extensive effusion, the region of in- 
creased dulness on percussion over the pericardium presents the pyri- 
form outline just described, and extends upwards in a characteristic 
peaked form to within an inch of the top of the sternum, sideways to 
THE PERICARDIUM. 
The Pericardium besides being a reflected serous membrane is a 
strong fascia or fibrous aponeurosis. This aponeurosis, as may be 
seen in Plates 111. and IV. and in Pigures 1 and 2, originates in 
the central tendon of the diaphragm, which forms indeed the floor 
of the pericardium, passes upwards enveloping the heart, and is 
inserted into and strengthens the great vessels. The pericardium is 
in fact one of the aponeurotic insertions of the diaphragm. When 
the diaphragm descends it stretches, lengthens, and widens the peri- 
cardium, lowers the heart, and through the medium of the pericardium 
exerts a direct strain upon the great vessels. 
the right of the sternum and left of 
the nipple, and downwards to below 
the xiphoid cartilage. 
Prom twelve to eighteen ounces of 
fluid can be injected into the healthy 
pericardium. In acute pericarditis the 
amount of effusion cannot much exceed 
that quantity. In chronic pericarditis 
more than three pints of fluid have been 
found in the sac. The pyramidal or 
peaked form of the region of pericardial 
dulness, so characteristic of acute peri- 
carditis, is absent when, as in Pig. 3, 
the disease is chronic. The pericardium 
in fact yields, sideways, under the in- 
creasing pressure of the fluid, and en- 
croaches so far on the left lung as to 
push it backwards, almost out of sight. 
The liver and stomach are at the same 
time displaced downwards, to a great 
extent, by the descent of the central 
tendon of the diaphragm. Hence the 
epigastric prominence and the pain on 
Fig.l. 
Pericardial sac distended. 
Fig. 3. 
Chronic Pericarditis with extensive 
effusion. 
Fig. 3. 
Pericardial sac flaccid. 
The extent to which the pericardium is superficial, is seen in Plates 1., 
11., and 111. This superficial pericardial region varies much in different 
individuals. In general it extends from the fourth left cartilage to 
the sixth, and from the centre of the sternum to within an inch of the 
nipple. In the robust, Plate 1., the lungs cover the pericardium to a 
greater extent than in the slender, Plates 11. and 111. 
pressure in the epigastrium, sometimes observed in cases of pericar- 
ditis. While the increasing effusion into the pericardium displaces 
the lungs, liver, and stomach, it also causes, especially in the young, 
prominence of the lower sternum and adjoining left costal cartilages, 
and widening of the left intercostal spaces. 
When the effusion is very extensive it presses backwards and up- 
wards on the bifurcation of the trachea, causing extreme dyspnoea. 
In such cases, relief is experienced by sitting up and leaning forward 
in bed, when the pressure on the trachea is removed by the gravitation 
of the fluid downwards and forwards. Difficulty in swallowing has 
been observed in some cases. This has no doubt been caused by the 
pressure, backwards, of the fluid on the oesophagus where it lies 
between the pericardium and the dorsal vertebrae. 
In pericarditis the friction sounds are first heard over the superficial 
pericardial region. In the robust, therefore, and still more in those 
affected with emphysema, the region offrottement in the early stage of 
pericarditis, is lower and more limited than in the slender, the bed- 
ridden, or the phthisical. If, in such cases, the heart be displaced to 
either side by pleuritic effusion, or pushed upwards by abdominal dis- 
tention, the seat of the friction sound corresponds to the changed 
position of the heart. 
The effusion, while it presses outwards on the surrounding parts, 
reacts within the sac on the heart itself and the great vessels. The 
heart is attached, above and behind, by means of the great vessels. 
The fluid, therefore, interposes itself between the lower surface of the 
heart and the central tendon of the diaphragm. While the central tendon 
is pushed downwards, the heart is pushed upwards. The impulse, the 
In every case of pericarditis, the amount of serum in the peri- 
cardium is increased. At first this does not show itself, since the 
fluid gravitates backwards. As the effusion increases it distends the 
pericardium, which displaces the lungs and surrounding organs, and 
comes more extensively into contact with the parietes. 
EXPLANATION OP PLATE IY. 
From the same subject as Plates 11., 111., Y., YL, YII. 
In the neck, the sterno-cleido and the sterno and omo-hyoid have been removed, 
exposing—the thyroid bodies and the jugular veins. 
In the thorax, the lungs have been reflected back, exposing—the heart and pericar- 
dium, and the diaphragm. 
In the abdomen, the anterior portion of the liver has been removed, and the small 
intestines have been reflected to one side; the arch of the colon to another, exposing— 
the stomach, the pyloric extremity of which is contracted, the duodenum, the gall- 
bladder, and ducts, the vena porta, the head of the pancreas, and the termination of 
the ilium in the caput coecum. 
The outlines of the ribs and sternum are indicated by dotted lines. (Reduced from 32 
inches to 19 -A inches.) COMMENTARY ON PLATES IY., V., & VI. 
friction sounds, and the tactile vibrations, are sometimes present as 
high as the first, second, and third left intercostal spaces. 
The effusion scarcely affects the action of the ventricles, hut it 
doubtless compresses the right auricle, and impedes the flow of blood 
into it from the cavse, thereby causing fulness of the veins of 
the neck. 
the sternum. The right auriculo-ventricular junction crosses obliquely 
from the left of the sternum above, to the right of it below. This junction 
is much more to the left when the auricle is full, as in Plate IY., than 
when it is empty. The tricuspid valve which is shown in Plate Y. is 
immediately to the left of the lower half of the sternum. The valves 
of the pulmonary artery are usually behind the second intercostal space. 
The left auricle, as may be seen in Plate YI., occupies the middle of 
the chest, just between the lungs, to each of which it is attached by 
the pulmonary veins, just below the division of the trachea. Through 
this attachment the heart enjoys definite relations with the lungs and 
shares their movements. The left ventricle lies to the left of the left 
auricle, extending downwards and forwards to the apex. The mitral 
valve (Plate YI.) is just behind and to the left of the tricuspid, while 
the aortic valves are behind and to the right of the valves of the 
pulmonary artery. 
HEART AND GREAT VESSELS. 
In the dead body, the heart and great vessels shrink upwards more 
than half an inch, as may be seen by comparing the lower edge of the 
heart with the lower surface of the pericardium in Plates 111. and IY. 
The auricles form the right side of the heart, the ventricles the left. 
Every portion of the left cavities is behind and a little to the right 
of the corresponding portion of the right cavities. The right auricle 
is in front of the right half of the left auricle. The right ventricle is 
in front of the left half of the left auricle, and the right two-thirds of 
the left ventricle. The tricuspid valve is in front and a little to the 
right of the mitral valve. This arrangement is reversed in regard to 
the great arteries and their valves. Thus the pulmonary artery and 
the pulmonic valves, are in front and to the left of the aorta and the 
aortic valves. 
The great vessels lie side by side in the centre of the chest. The 
aorta is in the middle behind the upper portion of the sternum, the 
pulmonary artery lying to the left, the vena cava to the right. The 
pulmonary artery, being short, encroaches less on the left lung than the 
vena cava does on the right lung. 
In the dead body, the aorta is flaccid, as in Plates IY. and Y., and 
does not present the appearance of an arch. But when it is injected, 
or stuffed with wool as in Plate YL, the arch is more manifest. 
The innominata is exposed, crossing the trachea above the sternum 
in Plates IY., Y., and YI.; while it is concealed by the sternum in 
Plate I. In Pigures I and 5 the innominata is partly above, partly 
behind the top of the sternum. 
The left ventricle has to perform the principal work of the heart. 
Its axis forms the true pivot of the heart, and its walls are much 
stronger than those of the right ventricle, which accommodates itself 
in every way to the left. The left ventricle is cone shaped. The 
right ventricle wraps round the anterior two-thirds of the left, so that 
the ventricular septum, which forms the concave anterior wall of the 
left ventricle, forms the convex posterior wall of the right ventricle. 
The axis of the right ventricle in relation to the pulmonary artery 
is almost vertical, the ventricle being broadest at the part most 
distant from the artery. The axis of the left ventricle is almost 
horizontal, the ventricle being narrowest where it is most distant from 
the aorta. 
The heart and great vessels, viewed as a whole, occupy the centre of 
the chest, and fill up in great part the space between the sternum and 
the vertebrae. The ventricles encroach more on the left lung, the 
auricles and great vessels more on the right lung. 
The superficial cardiac region has been already described in relation 
both to the lungs and the pericardium. The heart is usually in im- 
mediate contact with the walls of the chest, from the fourth to the sixth 
left cartilages, and from the centre of the lower half of the sternum to 
within an inch of the nipple. This space is usually three inches from 
side to side, and two inches from above downwards. The right or anterior 
ventricle lies immediately underneath the hand when it is applied over 
the superficial cardiac region. When this region is small, low, and 
narrow, as in the robust, and in those affected with emphysema, the 
left ventricle is wholly covered by lung even during systole; and the 
diffused impulse sometimes felt over and to the left of the lower 
sternum, or of the xiphoid cartilage, is entirely due to the systole of 
the right ventricle. 
The apex of the heart, which is always also the apex of the left 
ventricle, usually points behind the fifth, sometimes the fourth inter- 
costal space, somewhat within the line of the nipple. In health the 
apex and the outer wall of the left ventricle project to the left of the 
right ventricle. But when, as in emphysema and in mitral regurgita- 
tion, the right cavities are greatly enlarged, the right ventricle some- 
times completely covers the left, even over the apex. On the other 
hand, when, as in aortic narrowing or regurgitation, and in many 
cases of Bright’s disease, the left ventricle is greatly enlarged, its apex 
and adjoining walls protrude to a very large extent beyond the right 
ventricle. 
In Plate IY., the heart and great vessels are rather higher than usual, 
and the origin of the great vessels corresponds with a line running 
across the sternum and along the lower edge of the second cartilages. 
In Plate 1., the heart is rather lower than usual, and the origin of the 
great vessels corresponds with the line of the third cartilages. In the 
accompanying Pigures I and 5, this line runs along the top of the third 
cartilages. 
When the superficial cardiac region is of moderate extent, the left 
ventricle is superficial during systole; and the strong beat felt near the 
nipple, is due to the impulse of the apex of the left ventricle, which 
thrusts aside the small tongue of lung, already described, and comes 
into immediate and forcible contact with the fifth or fourth inter- 
costal space. 
When the superficial cardiac region is extensive and high, as in the 
slender, the bed-ridden, and the phthisical, the exposed portion of the 
left ventricle, the appendix of the right auricle, and the origins of the 
aorta and pulmonary artery, are all superficial. During systole, the 
strong impulse of the apex and the diffused impulse of the right 
ventricle are usually felt. The systolic impulse is often followed by a 
peculiar sharp diastolic impulse, or fillip, which is synchronous with the 
second sound, and is felt in the second left intercostal space, just over 
the pulmonary artery. 
MOVEMENTS AND NORMAL DISPLACEMENTS OE THE HEART. 
The comparison of Plates I. and IY. and of Pigs. I and 5, with each 
other, shows that in health the position of the heart is not always 
the same. 
The heart is indeed itself in perpetual motion, it partakes of the 
constant rhythmical movements of respiration, and it is subject to 
displacement by the normal alterations in the size and situation of the 
abdominal organs, and by changes in the position of the body. There 
is, therefore, a constant but orderly change in the position of the 
various parts of the heart in relation to each other, and of the whole 
heart in relation to the surrounding organs and the parietes. 
Active or automatic movements of the heart. 
I observed these movements, during four hours, on an ass subjected 
to the Wourali poison, the circulation being maintained by artificial 
respiration. (Prov. Med. Trans, vol. xii.) 
During systole, while the ventricles empty themselves, the auricles 
become filled. The auricles therefore displace the ventricles to some 
extent. The right auricle, while being filled, moves an inch from right 
Fig. 4. Superficial view. 
Fig. 5. Deep view. 
Position of the Internal Organs in a healthy adult male. 
The right auricle lies to the right, the right ventricle to the left of Fh* Y. COMMENTARY ON PLATES IY., V., & YI. 
to left at its ventricular edge, while the right ventricle, during its 
contraction, necessarily moves to the same extent from right to left, 
at its auricular edge. The left auricle, being filled from behind 
forward, lifts up and tilts forward the left ventricle at its auricular 
attachment. 
ascent and descent as the heart. Thus the innominata, which may he 
entirely above the sternum during expiration, sinks entirely behind that 
hone during inspiration, when the sternum is itself raised while the 
arteries are lowered and stretched. This is well seen and felt in a 
patient now in St. Mary’s Hospital. The innominata thrills with a 
visible heat above the sternum during each expiration, but during 
inspiration the artery sinks while the sternum rises, and its beat is no 
longer perceived. 
The right ventricle, while it moves from right to left, becomes 
narrowed and flattened. The left ventricle, while it advances, becomes 
firm and pointed; the base gradually approximates to the apex; and 
the posterior wall contracts and advances, while the anterior wall, or 
ventricular septum, bulges forwards. The left ventricle contracts with 
a twisting motion. The axis of each ventricle, which during diastole 
is in the direction of the corresponding auricle, is totally changed 
during systole, being then directed towards the aorta and the pul- 
monary artery respectively. 
The aorta and the pulmonary artery move downwards during 
systole along with the adjoining walls of the respective ventricles. 
The impulse of the apex of the left ventricle, as I have already said, 
is felt in the fifth or fourth intercostal space, about an inch within the 
line of the nipple. That of the right ventricle, when present, is per- 
ceived over and to the left of the lower end of the sternum. 
The impulse of the apex is caused by a combination of forces. These 
forces are—the lifting up and tilting forward of the left ventricle by the 
distention of the left auricle behind it—the recoil of the left ventricle, 
when the blood is propelled into the aorta, as Dr. Alderson first 
demonstrated—the straightening and lengthening of the filled arch 
of the aorta—and the tension of the ventricular walls. So beautifully 
is the heart adjusted that these various forces, as well as those con- 
cerned in the impulse of the right ventricle, instead of conflicting with 
each other, all aid in producing the common result. 
When we listen over the heart to the friction sounds of pericarditis, 
it is important to bear in mind the part of the heart examined, and the 
nature and extent of its movements. 
In some anaemic persons, especially when the upper chest is promi- 
nent, a loud whirring bruit is heard towards the close of each inspiration 
over the scapular end of the clavicle. In one case the noise was 
obliterated and the pulsation at the wrist arrested when the patient 
drew a deep inspiration. This remarkable phenomenon, which may 
lead to the mistaken diagnosis of subclavian aneurism, is evidently due 
to the tightening and compression of the artery where it bends over the 
first rib, seeing that during inspiration the artery is stretched down- 
wards while the rib is raised. 
During expiration, the lung shrinks away from before the heart, 
which is itself raised; consequently the superficial cardiac region is 
raised and extended, the seat of the impulse is correspondingly in- 
creased, and the heart’s sounds are heard over a great part of the chest. 
During inspiration the superficial cardiac region is lowered and 
narrowed so as to be quite below the sternum, being seated to the left 
of the xiphoid cartilage; the impulse is felt only in the epigastrium, 
and owing to the thickened layer of lung above and in front of the 
heart, its sounds are no longer audible over the whole front of the 
chest. 
In thin persons, and in those affected with phthisis, the lungs col- 
lapse, the heart is raised and extensively exposed, the superficial cardiac 
region and the seat of impulse are correspondingly raised and extended, 
the innominata rises above the sternum, and the heart-sounds are 
heard over the whole chest. In the robust, on the other hand, and 
still more in those affected with emphysema, the heart is lowered, a 
thick layer of lung covers the heart and shields it everywhere from the 
ribs, the cardiac region and the seat of impulse are lowered and nar- 
rowed, the innominata completely sinks within the chest, and the heart 
sounds are only heard to a slight extent over the front of the chest. 
Over and to the left of the lower portion of the sternum, we hear 
the friction sounds of the left ventricle, the systolic sound being the 
most harsh. To the right of the lower part of the sternum and over 
the middle of the sternum we hear the to and fro sounds of the right 
auricle, which are equally smooth during both systole and diastole. 
Over the upper portion of the sternum we hear the frottement of the 
aorta and pulmonary artery, which is louder during systole. Over, and 
above the region of the apex beat, the friction sound, caused by 
the left ventricle, is alone heard during systole, that ventricle being 
then only brought into contact with the parietes. 
Displacement of the heart from changes in the abdominal viscera. 
When the stomach is much distended, it raises the diaphragm and 
pushes upwards the heart and lungs. The same effect is induced by 
distention of the colon or small intestines. The cardiac region and the 
seat of impulse are raised and extended upwards, and the heart-sounds 
are heard extensively over the chest. If, on the other hand, the 
intestines be empty, as in Plate 1., the diaphragm is lowered, the 
heart and lungs descend, the superficial cardiac region and the seat 
of impulse are lowered and narrowed in extent, and the heart-sounds 
are feeble or inaudible over a great part of the chest. 
In many dyspeptic persons, palpitation and dyspnoea, and in some 
angina or even syncope, are occasioned by a flatulent meal, owing to 
the pressure exerted on the heart by the distended stomach. 
All these sounds are developed with increased intensity if we 
make pressure, over the heart, with the stethoscope; when, indeed, 
friction sounds are often excited that were previously absent, owing 
to the roughened surfaces being then pressed together, which were 
previously separated by the effusion. 
Movements of the heart and great vessels caused by respiration. 
During a deep inspiration the central tendon of the diaphragm de- 
scends about an inch, and draws downwards the heart and great vessels 
to the same extent. The sternum and ribs are at the same time raised. 
The apparent descent of the heart and great vessels viewed in relation to 
the ribs is therefore greater than the actual descent. Every part of the 
heart ascends thus during inspiration, and descends during expiration. 
During a deep inspiration the lower boundary of the right ventricle 
may be below the lower end of the xiphoid cartilage, and the opening of 
the pulmonary artery may be as low as the fourth left cartilage. During 
a forcible expiration, on the other hand, the lower edge of the right 
ventricle may be above the lower end of the sternum, and the origin of 
the pulmonary artery may be as high as the lower edge of the first rib. 
It is indeed necessary that the whole heart should thus travel up and 
down in the chest with the respiratory descent and ascent of the lungs, 
seeing that the heart is fixedly attached to the lungs by means of the 
pulmonary veins. 
Change in situation of the heart from changes in position of the body. 
The heart changes in position with every movement of the body; 
it falls over to the left when we lie on the right side, to the right 
when we lie on the left side; it ascends when we lie down, and it is 
lowered when we sit up. The position of the superficial cardiac 
region, the impulse and the heart-sounds, changes with the change 
in position of the body. 
It is evident, from what I have just said, that there is no absolutely 
fixed position, in relation either to the parietes or the surrounding 
organs, for any part of the heart. Thus it is the narrow expression of a 
mere dead anatomy to say, that the pulmonic valves are situated either 
behind the second or the third left costal cartilage. In the broader view 
of a truly vital anatomy it may be said, that during the varied actions 
of healthy life the pulmonic valves may be present either behind the 
The great vessels in the neck are subject to the same respiratory 
EXPLANATION OE PLATE Y. 
In the abdomen, the intestines have been removed, and the left lobe of the liver has 
been cut away, exposing—the cardiac orifice of the stomach—the solid organs, the liver, 
pancreas, spleen, and kidneys, in relation to each other, and the eaval, portal, and 
hepatic veins. 
The outlines of the ribs and sternum are not traced, but they can easily be replaced by 
the mind’s eye, by comparing this Plate with Plate IV. (Reduced from 32 inches to 18g- 
inches.) 
From the same subject as Plates IT., 111., IV., VI., and VII. 
In the neck, the veins have been removed, exposing—the arteries, and the summits 
of the lungs. 
In the thorax, the anterior walls of the right auricle and ventricle have been removed, 
exposing—the interior of the right auricle and ventricle, and the tricuspid and 
pulmonic valves. COMMENTARY ON PLATES IV, Y., & VI. 
second or fourth left cartilage—may be in immediate contact with 
the sternum, or may have interposed between it and that bone a thick 
layer of lung—may lie behind the sternum, or to the left of the second 
or third left cartilage. The same in fact may, in principle, be said 
of every part of the heart, which presents an extensive, but orderly, 
variety of position in different persons, and in the same person at 
different times. The same, also, may be said of the great vessels, both 
at their immediate origin from the heart, and at their distribution 
in the upper part of the chest, and lower part of the neck. 
In a practical point of view anatomy is of no use unless it can be 
realized on the living body. 
the bifurcation of the trachea and the oesophagus are sometimes com- 
pressed backwards between the tumour and the dorsal vertebrae. 
When the aorta and great vessels are atheromatous, the affected 
vessels are both dilated and elongated. Consequently, while the arch 
of the aorta is long and bulging, the subclavians, carotids, and all the 
affected vessels, are tortuous and visible. The innominata rises above 
the sternum. The subclavian is sometimes so tortuous as to cause a 
pulsating tumour over the first rib, which may readily be mistaken for 
subclavian aneurism, especially if there be a systolic bruit there during 
inspiration. The left ventricle is enlarged, and the heart is usually 
lowered in position. 
EEEECT OE DISEASES OE THE HEART AND GREAT VESSELS ON THE SIZE 
AND POSITION OE THE ORGAN. 
EEEECT OE DISEASES OE THE LUNGS AND PLEURA ON THE SIZE 
AND POSITION OE THE HEART. 
Dilatation and hypertrophy of the left ventricle may be caused by the 
narrowing of the aortic aperture or insufficiency of its valves, or by any 
cause, such as Bright’s disease, producing general obstruction to the 
systemic circulation. 
Dilatation and hypertrophy of the right cavities may be induced by 
disease of the valves of the pulmonary artery; by any cause, such as 
emphysema, producing general obstruction in the pulmonary circula- 
tion ; or by mitral regurgitation, which operates by inducing dilatation 
of the left auricle and resistance to the circulation through the lungs. 
Active dilatation of any cavity of the heart may in fact be caused 
by permanent resistance to the action of that cavity, from whatever 
cause. 
Active dilatation of all the cavities of the heart may be induced by 
combined mitral and aortic valve-disease. This general enlargement 
of the heart may also be caused by mitral regurgitation, which induces, 
in succession, enlargement of the left auricle, the right ventricle, the 
right auricle, and the left ventricle. 
When the left ventricle is largely dilated and hypertrophied, the 
impulse at the apex is felt with unusual force in the sixth instead of 
the fifth intercostal space, and to the left instead of the right of the 
line of the nipple. 
In phthisis, the lungs shrink upwards and backwards, so as to leave 
the heart exposed ; the heart is itself raised, and, as I have already said, 
the superficial cardiac region and the seat of the impulse are raised and 
extended upwards. The exposure of the heart is greatest on the 
affected side. 
In emphysema, the right side of the heart is enlarged, but owing to 
the great expansion of the lungs, the superficial cardiac region and the 
seat of impulse are below the lower end of the sternum. 
In cases of extensive pleuritic effusion, the heart is thrown over to 
the opposite side. If the effusion be into the left pleura, the heart, as it 
travels over, presents a different front, the left ventricle being the most 
anterior. At first the apex points behind the xiphoid cartilage, but as 
the fluid increases it moves over into the opposite side. If the effusion 
be into the right pleura, the heart moves over more and more to the left. 
As it does so the apex falls backwards, and the right auricle becomes 
the anterior portion of the heart, the left ventricle being quite out 
of sight. 
When contraction of one side of the chest takes place in case of 
pleuro-pneumonia, after the absorption or removal of the fluid, the 
heart formerly pushed over to the sound side, is gradually drawn into 
the affected side, so that if the right side be contracted, the heart may 
beat to the right of the sternum, or if the left side be contracted it may 
beat to the left of the nipple. If the heart moves over into the right 
side of the chest the left ventricle is in front, if into the left side, the 
right auricle is in front. In these cases the right side of the heart is 
usually enlarged. 
When the right cavities only are enlarged, the right ventricle 
encroaches on and covers the whole left ventricle so as to prevent the 
impulse of the apex from being felt. When the right ventricle is 
actively dilated by mitral disease, a strong and diffused impulse is felt 
over the lower end of the sternum and the xiphoid cartilage, and the 
adjoining left cartilages. When the right cavities are dilated, owing to 
emphysema, the heart is lowered, the enlarged lungs cover the heart 
and shield it from observation down to the lower end of the sternum, 
and the impulse of the right ventricle is felt over, below, and to the 
left of the xiphoid cartilage. The epigastric impulse of the right ven- 
tricle is stronger and lower during inspiration than during expiration. 
EEEECT OE DISEASES OE THE ABDOMEN ON THE POSITION OE 
THE HEART. 
When the abdomen is excessively distended by intestinal distention, 
ascites or ovarian dropsy, the diaphragm is pushed upwards, and at the 
same time the heart and lungs are raised and compressed upwards. 
When the stomach is excessively distended it more immediately 
elevates the heart, which is indeed situated just above the stomach. 
Hence one cause of the palpitation felt by dyspeptics after a flatulent 
meal. 
When the liver is enlarged from fatty degeneration or congestion, it 
tends rather to make its way downwards into the abdomen, than up- 
wards into the chest. But if the right lobe of the liver be affected with 
malignant disease, an abscess, or a hydatid cyst, the diaphragm is 
raised, the right lung is encroached upon, and the heart is pushed 
upwards and to the left. 
When the whole heart is greatly enlarged, adhesions not being 
present, it does not encroach on the lungs upwards, but it makes its 
way downwards and sideways; the impulse of the left ventricle is felt 
to the left of the nipple, and in the fifth and sixth intercostal spaces, 
and that of the right ventricle, over and to the left of the lower end of 
the sternum and the xiphoid cartilage. 
When the heart is adherent as well as greatly enlarged, it not only 
encroaches on the surrounding organs downwards and sideways, but 
upwards also, as high perhaps as the second cartilages ; and the super- 
ficial cardiac region, the seat of impulse, and the prominence in the 
heart, are proportionately increased. 
When the heart is simply enlarged, the superficial cardiac region 
and the seat of impulse are extensively lowered and narrowed during 
a deep inspiration, but this is not the case when the heart, besides being 
enlarged, is extensively adherent. The lungs cannot then interpose 
themselves during inspiration between the heart and the parietes, and 
the impulse is but slightly lessened in extent and force. This non- 
diminution of the seat of impulse during inspiration is the chief 
characteristic of enlargement of the heart with adhesions. The 
intercostal spaces over the right ventricle are drawn inwards during 
systole in such cases, but they are equally so when the right ventricle 
is simply enlarged. When the ventricle is adherent as well as enlarged, 
this systolic retraction of the intercostal spaces is maintained during 
inspiration, but it is not so if there be no adhesions. 
When the arch of the aorta is affected with aneurism, the artery is 
lengthened as well as widened; the heart is lowered in position, the 
left ventricle being enlarged ; the lungs are displaced to each side to 
an extent proportioned to the size and situation of the aneurism ; and 
EXAMINATION OE THE HEART DURING LIEE. 
The size, power, and condition of the heart in health and disease 
may he ascertained with more or less precision by observing the seat 
and force of the impulse, the extent of cardiac dnlness on percussion, 
the amount of prominence over the region of the heart, the extent and 
character of the heart-sounds, the influence of respiration on the pheno- 
mena of the heart, the character of the pulse, and the condition of the 
veins in the neck. 
The impulse gives the readiest and most certain sign of the presence 
of the heart. In health, the impulse of the apex may he felt in the 
fifth or fourth intercostal space, about an inch within the line of the 
nipple. In the robust, the impulse is often imperceptible, owing to 
the great extent to which the heart is covered by lung. When the 
impulse is present in the third and fourth intercostal spaces, and is 
followed by a sharp flapping diastolic impulse, felt over the second 
intercostal space, the heart is high and superficial, owing to the retrac- 
tion of the lung, and the flattening of the sternum and cartilages. ffIL.TI. 
Vrktorh Jrcyri ifa Svdj&cft and land* 
fa ¥/?<* £ lladfatty COMMENTARY ON PLATES IV., V., & VI. 
When the impulse is felt in the sixth intercostal space to the left of 
the nipple line, the left ventricle is enlarged and thickened. When it 
is diffused over and to the left of the lower end of the sternum and 
xiphoid cartilage, the right ventricle is enlarged, probably from mitral 
regurgitation. When it is absent from the intercostal spaces, and 
is felt over, below, and to the left of the xiphoid cartilage, and with 
greater force during inspiration than expiration, there is probably 
emphysema with enlargement of the right ventricle. When the 
impulse of the apex is as low as the sixth intercostal space to the left of 
the line of the nipple, and that of the right ventricle is strong and 
heaving over the lower end of the sternum and the xiphoid cartilage, 
there is universal enlargement of the heart, probably from disease both 
of the aortic and mitral valves. When the impulse is strong and 
extensive, and is felt high up in the second interspace, as well as low 
down, and is but little lowered and lessened in extent by a deep 
inspiration, there is probably enlargement of the whole heart with 
universal adhesions. 
neck, from which, instead of to which, it is conveyed by the current of 
blood. It is audible to the left of the apex, that being the direction of 
the reversed stream of blood ; but it is usually loudest over the fourth, 
fifth, and sixth left costal cartilages. This can scarcely be explained 
on anatomical grounds, seeing that the right ventricle is interposed 
between the left ventricle and the aortic valves. 
When the aortic diastolic murmur only lasts through the first half 
of the diastole, and the pulse expands and collapses visibly and rapidly, 
we may infer that the valves are altogether inadequate, and that the 
consequent regurgitation is great and rapid. If, however, that bruit 
be soft but loud, and prolonged through the whole diastole, the 
collapsing pulse being only slightly marked, we may infer that the 
aperture of regurgitation is but slight, and that the valves almost come 
together. When, under these circumstances, there is no systolic bruit, 
and the pulse is full and strong, we may infer that while the regurgita- 
tion is only slight, there is no narrowing of the aortic aperture. If, 
however, the pulse be small and feeble, while the systolic bruit is 
musical and prolonged, especially if a thrilling tremor be felt over the 
great arteries, we may infer that there is contraction of the aortic 
aperture as well as regurgitation. 
When the impulse is absent, or very feeble, although the superficial 
cardiac region be extensive, the walls of the heart are weak or probably 
fatty: in this respect contrasting with those cases in which the impulse 
is absent because the lungs are large and are interposed between the 
heart and the walls of the chest, and in which the heart instead of 
being weaker is probably stronger than usual. 
When the impulse is seated to the right of the sternum, there is 
probably either effusion into the left pleura, or contraction of the right 
side of the chest; and when it is felt unusually far to the left, the heart 
itself not being enlarged, there is, probably, either effusion into the 
right pleura, or contraction of the left side of the chest. 
By percussion we can ascertain the boundaries of the superficial 
cardiac region with great precision. This does not hold good, how- 
ever, with respect to the lower boundary, when the liver extends far to 
the left. A line drawn from below the seat of the apex beat, to the 
lower margin of the right lung, will then indicate the lower boundary 
of the heart. 
When the heart is healthy the second sound of the pulmonary artery, 
which is inaudible over the neck, is merged in that of the aorta over 
the chest. When the aortic valves are insufficient the, second sound of 
the pulmonary artery is still heard over the chest, though that of the 
aorta is absent, and the second sound is consequently inaudible over 
the neck. 
The aortic second sound is sometimes very loud and ringing. This 
may be due to the aorta being atheromatous and dilated, or to hy- 
pertrophy of the left ventricle. If the second sound of the pulmonary 
artery be loud and ringing, it is usually a sign of active dilatation 
of the right ventricle, as in cases of mitral regurgitation or of emphy- 
sema. 
Mitral regurgitation causes a systolic bruit that is loudest over, 
above, and to the left of the apex. It is also heard over the body of 
the heart, and it lessens in intensity as we approach its base. This 
murmur is often audible just below the angle of the left scapula, and 
behind the seventh and eighth dorsal vertebrae, whence it becomes more 
feeble as we ascend, thus differing from the aortic systolic murmur, 
which becomes feebler from above downwards. 
Prominence over the region of the heart. In health the cartilages 
to the left of the lower end of the sternum are somewhat fuller than 
those to its right. When the heart is increased in size, especially in 
the young, the cartilages and ribs superficial to the heart are rendered 
unusually prominent. 
The extent and character of the heart-sounds, when taken in con- 
nexion with the other signs and the symptoms, will generally enable 
us to detect whether the valves of the heart be healthy or diseased. 
When there are no valve murmurs, we may generally infer that there 
is no valve disease. In some rare cases, however, the valve-murmurs 
cease as the valve disease advances, and sometimes also as the powers 
of the heart flag. 
The aortic murmurs are louder in the direction of the current of 
blood, than they are directly over the aortic aperture itself, which 
is usually behind the centre of the sternum. 
In many cases of valve disease, the ringing noise made by the 
impulse of the heart upon the walls of the chest, tends to mask the 
valve murmur. This impulse noise is only heard over the superficial 
cardiac region. It is obliterated by the thinnest layer of lung. Eor 
this reason a mitral bellows murmur can be distinctly heard to the left 
of the nipple, when it is obscured by the impulse noise over the body 
of the heart. Singularly enough, the interposition of a slip of paper, 
or even the shirt of the patient, between the stethoscope and the skin, 
over the superficial cardiac region, obliterates the impulse noise. 
Should a mitral murmur be present, it is thus usually rendered much 
clearer, owing to the obscuring impulse noise being, so to speak, dis- 
sected away. 
The aortic systolic murmur is usually the loudest in the neck, 
just over the innominata, above or to the right of the top of the 
sternum. Thence the morbid sound travels, with diminishing intensity, 
along the carotid and subclavian arteries. This murmur is feeble over 
the upper half of the sternum, if a thick layer of lung separates the 
aorta from that bone; but it is loud if that layer be thin, and louder still 
if the lung retract so completely that the sternum falls back upon the 
aorta. Under all circumstances the bruit is louder at the top than the 
middle of the sternum. The aortic systolic murmur is absent over the 
lower end of the sternum, unless it be musical and penetrating, so as to 
be heard over the whole body. This murmur is often audible over the 
upper dorsal vertebrae, whence it is gradually lost as we approach the 
seventh or eighth dorsal vertebrae. It may, however, when musical in 
character, be heard as low as the sacrum. 
The diastolic aortic murmur being caused by regurgitation through 
the patent aortic aperture, is seldom heard over the great vessels in the 
A mitral murmur is a proof of mitral regurgitation, but not of disease 
of tlie mitral valve; it having been noticed in cases in which post 
mortem examination revealed a healthy mitral valve. 
The movements of respiration, as I have before stated, materially 
influence the size of the superficial cardiac region, the seat of the 
impulse, and the extent to which the heart’s sounds are audible, since 
they are lowered and lessened in extent during inspiration, raised and 
enlarged in extent during expiration. 
The character of the pulse, as I have just described, is an important 
sign in disease of the aortic valves. Aortic regurgitation is not the 
only cause of the visible pulse, since the opposite conditions of anaemia, 
and of active congestion of the brain, may equally give rise to visible 
pulsation of the carotid arteries. In the latter case, the character of 
the pulse is more bounding, in the former it is less collapsing, than in 
EXPLANATION OE PLATE VI. 
In the neck the anterior scalenus is removed. 
In the chest, the right auricle and ventricle have been removed, exposing—the left 
auricle and ventricle, which are laid open, so as to show the mitral and aortic valves. 
The bronchial tubes, and the pulmonary arteries and veins, are shown in the right and 
partly in the left lung. 
In the abdomen, the liver, stomach, and pancreas are removed, exposing—the 
diaphragm, the spleen, and the kidneys. 
The solar plexus has been dissected upon another subject, and so to speak laid on 
upon this. The body, at this stage of the dissection, was not in a fit state for displaying 
the solar plexus. 
In this and the following Plates the reduction has been effected by means of a penta- 
graph; in the previous Plate by the use of reduced squares. (Reduced from 32 inches to 
inches.) COMMENTARY ON PLATES IV., Y., &. VI. 
cases of aortic regurgitation. When the arteries are atheromatous, 
they are both dilated and lengthened, and are therefore tortuous. 
These tortuous and prominent vessels do not pulsate visibly, but, 
having lost their elasticity, appear to be equally full during diastole 
and systole, unless there be also aortic regurgitation, when the pulse 
is remarkably visible, being alternately straight and tortuous. 
The veins of the neck are not swollen in aortic disease, but they are so 
in many cases of enlargement of the right cavities, whether from mitral 
regurgitation, bronchitis, or any other cause inducing resistance to the 
pulmonary circulation. This is not so, however, in emphysema or 
phthisis, since in both those diseases the mass of blood is gradually 
lessened, so as to accommodate itself to the obstruction in the pulmonary 
circulation. 
We ought not to decide rashly on the presence or absence of heart 
disease from the presence or absence of any single morbid phenomenon, 
however characteristic. By observing and combining all the signs 
and symptoms we can generally characterize, with an approach to 
precision, the nature of the disease. In some cases, however, even 
then, our diagnosis will be at fault. An accurate physical diagnosis 
is, however, in such instances practically of less importance than a just 
estimate of the vital phenomena, which will in fact always prove a 
better guide to treatment and prognosis than the mere observation 
of the signs, whether physical, chemical, or microscopical. These im- 
portant signs indeed ought to direct our attention to the vital symp- 
toms, and not to distract it from them. 
by the distended stomach, that sopor, coma, or an epileptic fit may be 
occasioned. A medical friend who died lately of disease in the brain, 
used to have an epileptiform fit whenever he ate pork. The heart and 
lungs are additionally and secondarily affected by the influence of the 
swollen stomach upon the liver. That organ being compressed upwards 
and to the right by the stomach, in turn compresses upwards the heart 
and the right lung. Under the same influence a considerable portion 
of blood is pressed out of the liver through the hepatic vena cava, into 
the right auricle, which is thereby distended with blood. In addition 
to all these serious effects of extreme distention of the stomach, the 
whole diaphragm is raised and its inspiratory descent is impeded. The 
lungs are consequently compressed upwards into the chest, diaphragm- 
ated respiration is difficult, thoracic respiration is laborious, the veins 
of the neck and forehead become swollen, the face is flushed, and the 
brain is congested. 
In gastralgia the pain is generally referred, not to the stomach but 
to the heart, and it is often attended by palpitation and intermission of 
pulse. The patient indeed, in dyspepsia, is often convinced that he 
labours under affection of the heart. 
If we percuss over the stomach when the patient lies on the back, 
the sound elicited is resonant, but when he stands, it is usually dull. 
This is owing to the gravitation of the food. 
THE LIYEH. 
The variation in size and position of the liver is very great. In 
Plate 1., the lower edge of the liver is only two or three inches above the 
umbilicus, while in Plate 11., a small portion only of the organ is seen 
below the xiphoid cartilage. In Plate 1., from a robust man, the lungs 
are large, and the diaphragm and liver are unusually low, their summit 
being behind the fifth right rib; while in Plate 11. from a slender 
youth, the lungs are contracted, and the diaphragm and liver are rather 
higher, their summit being behind the fourth right rib. (Plate IV.) 
Again, in Plate 1., the intestines are not nearly so much distended 
with flatus as in Plate 11. Consequently, in the latter, the liver is dis- 
placed upwards by intestinal distention more than in the former. 
These two causes, the greater or less descent of the diaphragm, and 
the greater or less distention of the stomach and intestines, give rise to 
all the remarkable varieties in position and size of the liver. 
During inspiration the whole liver is lowered, and its convexity is 
flattened by the descent of the diaphragm. An additional quantity of 
blood is thereby pressed into the right auricle, at the very time that the 
lungs as well as the heart, owing to the expansion of the chest, are 
capable of holding more blood. During expiration, on the other hand, 
the chest is contracted, and the right cavities being compressed, the 
blood accumulates in the liver and the veins of the neck. 
THE ABDOMINAL ORGANS. 
The abdominal organs vary greatly in position; they are all 
alternately displaced downwards by the inspiratory descent of the 
diaphragm, and replaced upwards by the expiratory action of the 
abdominal muscles. The stomach and intestines being sometimes 
empty, sometimes enormously distended, present in themselves the 
most extreme variety in size, form, and position; and they react upon 
the surrounding solid organs, which are pressed aside, and replaced, 
when the hollow viscera are distended, and emptied. The distention 
of the abdominal organs forces the diaphragm upwards, so as to con- 
tract the space occupied by the chest organs. 
THE STOMACH. 
The Stomach presents greater variety in size than any other organ in 
the body. In Elate I. it appears below the edge of the left lobe of the liver, 
while in Plate 11. it is completely out of sight. Sometimes the stomach 
is so empty that it is like a mere piece of curved intestine, when the 
middle curve takes a vertical direction; while in the other extreme it is 
enormously distended, when the stomach takes more nearly a horizontal 
direction. Sometimes there is a distinct hour-glass contraction. Some- 
times the pyloric half of the stomach is so contracted as to resemble a 
piece of intestine, as in Plates IV. and V. 
The play of respiration, whereby the liver and spleen, and to a less 
degree the kidneys, are subjected to alternate compression and expan- 
sion, and the stomach and intestines to a perpetual churning motion, 
has an important physiological action on the functions of those organs. 
Hence no doubt one of the reasons for the important influence of exer- 
cise on digestion and the action of the liver and kidneys. 
It is usually the liver and not the stomach that occupies the so-called 
epigastric region or pit of the stomach just below the lower end of the 
sternum, as may be seen in Plates I. and 11. : the cardiac orifice of the 
stomach is situated at the upper part of that region, immediately be- 
hind the liver and upon the diaphragm, Plate Y, Thence the cardiac 
portion of the stomach turns off to the left at a right angle, so as to 
occupy and support the left hollow of the diaphragm, as may be seen in 
Plate I. and in the deeper view given in Plate Y. If the stomach be 
empty or small, as in Plates 11. and 111., it only occupies apart, some- 
times only a small part, of the left hollow of the diaphragm, which is 
then usually filled up and supported by the convolutions of the trans- 
verse arch of the colon, and of the small intestines, as in Plates 11. and 
111. In this situation, the spleen is immediately behind the stomach ; 
the shelving margin of the left lobe of the liver is immediately in front 
of it; and the lower sloping surface of the heart is just above it, resting 
upon the stomach as upon a floor. In fact, as may be seen in Plate Y., 
the apex of the heart and the lower boundary of the right ventricle is 
above and just in front of the stomach, the convex upper portion of 
which is concealed by the shelving lower surface of the heart. This 
truly is the “ cardiac ” portion of the stomach. If pain be situated here 
in the stomach, it is generally referred to the heart. If the stomach be 
distended by a flatulent meal, palpitation and oppression in the region 
of the heart, often attended by dyspnoea, are the distressing sensations 
most complained of. In some persons, the resistance is so great to the 
return of blood from the head when the heart is compressed upwards 
The variety in position of the liver is still greater than that exhibited 
in Plates I. and 11. I examined recently the body of a patient who died 
of a fever, in which the liver was so far displaced upwards by the swollen 
intestines, that its lower margin was hidden by the lower edge of the 
right lung; and I figured in the Prov. Med. Trans, vol. xii., the body 
of a female who died of inanition owing to malignant disease of the 
oesophagus, in which the stomach and intestines were empty, and the 
liver covered the greater part of the abdomen, its lower margin resting 
on the crests of the ilium. 
When the stomach is empty, the left edge of the liyer tends oyer to 
the left side of the abdomen; when the stomach is distended, it pushes 
the liyer unusually to the left and somewhat upwards. When the 
great and small intestines are empty, the liver falls downwards into 
the abdomen; and when they are distended, it is pushed directly 
upwards. 
In emphysema, owing to the low position of the diaphragm, the 
liver is unusually low, and in phthisis and the bed-ridden, in con- 
sequence of the high position of the diaphragm, the liver is un- 
usually high. Hence the position of the lower edge of the liver in 
the abdomen is not, in itself, a guide to the size of the liver. 
I shall return to the consideration of the subject of the abdominal 
organs in a future commentary. To) TT ' WY If 
k Jjjo v JULo COMMENTARY ON PLATE VII. 
THE LARYNX, TRACHEA, BRONCHI, AND LUNGS. 
In Plate YII. a section is made through the centre of the jaw, the 
tongue, the epiglottis and the front of the larynx, so as to expose the 
fauces, pharynx, and interior of the larynx. 
The epiglottis stands erect upon the thyroid cartilage behind the 
base of the tongue, so as to form in part the permanently open 
channel through which the respired air passes from the nostrils 
into the larynx; and to aid, by its elasticity, in keeping that channel 
open. 
During the act of swallowing, the larynx is drawn forcibly forwards 
and upwards, so as to be covered by the back of the tongue, the 
pharynx being at the same time distended, so as to occupy the space 
previously taken up by the larynx. 
noisy, hissing, or stridulous respiration, audible at a distance from the 
patient, and louder during expiration; the same noise over the larynx 
and trachea, with absence of the respiratory murmur over the lungs; 
alteration or loss of voice; imperfect husky character of cough, which 
is never clear and ringing; frequent hut vain efforts to clear the 
larynx ; diminished movement or retraction of the walls of the chest 
during inspiration ; and as the disease advances, especially in the adult, 
pain, and sense of suffocation when swallowing. The pain is caused 
by the pressure of the food against the arytenoid cartilages; the sense 
of suffocation, by the suspension of breathing, induced by the act of 
swallowing, and the impossibility of increasing the supply of air, 
already too scanty, so as to make up for the suspended breathing. 
Indeed the act of drinking, owing to this suspension of respiration, 
excites in all persons deep and hurried, often sobbing inspiration. 
It has been the fashion of late, with some, to sponge the larynx with 
a strong caustic solution in cases of laryngitis, croup, hooping cough, 
and other chest affections. This procedure is of use in some cases 
of croup and of chronic laryngitis, but in acute laryngitis it is some- 
times mischievous, and in phthisis and bronchitis it is irrational. 
I have now under my care, in St. Mary’s Hospital, a man suffering 
from laryngitis. His larynx had been mopped out thrice in the course 
of ten days, with the effect, on each occasion, of aggravating the 
disease; nothing else was done until he declined a fourth application. 
Dr. Green has wisely advised that the fauces should be washed over 
with a solution of nitrate of silver, two or three times before it is 
applied to the larynx. 
When there is oedema of the glottis, the edge of the epiglottis, 
instead of being thin and flexible, is round and tense, as may be 
ascertained by passing the finger over the back of the tongue. Under 
such circumstances the free scarification of the epiglottis sometimes 
gives relief. 
Croup is distinguished from laryngitis by the ringing cough, the 
more stridulous breathing, the presence of the voice, and the power 
to cry. 
Pharyngitis is distinguished by the predominance of dysphagia over 
dyspnoea, and by the pain excited by pressure of the larynx back- 
wards. 
Abscess between the larynx and pharynx may be detected by the 
absence of the usual crepitation when the larynx is moved from side 
to side, as well as by the local swelling and fluctuation. 
Affection of the recurrents, caused by the pressure of aneurismal or 
other tumours, is to be distinguished from laryngeal disease by the ex- 
istence of the tumour causing the affection; and by the absent or altered 
voice, and the imperfect hoarse cough, being more marked than the 
difficulty of breathing, and the hissing or stridulous character of the 
breath sound. 
When the solution is applied to the larynx, the bent probang, armed 
with a sponge saturated with the solution, ought to be passed behind 
the epiglottis, and then pressed steadily forwards and downwards, 
gliding it along the posterior surface of the epiglottis. 
It is perfectly easy to pass a male catheter into the larynx in this 
way, when, owing to laryngitis or other such cause, laryngotomy is 
demanded. The insertion of the catheter, by admitting air, gives 
time for the performance of the more important operation, and it 
may sometimes enable it to be dispensed with. 
In performing laryngotomy, I advise that the tissues between the 
thyroid and cricoid cartilages be divided quite down to, but not 
through the mucous membrane; which ought to he transfixed care- 
fully by the bent trochar and canula, the point of the trochar bearing 
not backwards but downwards. This plan obviates the danger of 
transfixing the hack of the larynx, which is liable to occur in the 
child, when the trochar is thrust through the thick membrane; as 
well as the danger of haemorrhage into the larynx, since the canula 
fills up the aperture. 
In cases of aneurism of the arch of the aorta, dyspnoea is induced, 
and blowing respiration is heard between the scapulae, owing to the 
pressure of the aneurism on the trachea at its bifurcation, the left 
bronchus being more involved than the right. This elfect is often 
lessened when the patient bends forward, so as to relieve the trachea 
and bronchi from the pressure of the tumour. 
The same effect is induced by excessive distension of the pericardium 
with fluid; the dyspnoea excited by the pressure of the fluid backwards 
upon the trachea being greatly relieved when the patient leans for- 
ward. 
The voice originates in the vocal chords. The vocal vibrations, thus 
originating in the larynx, would be feeble, and only audible at a short 
distance, were it not that they are reinforced by the consonating vibra- 
tions which are excited in the cartilages of the larynx, trachea, and 
bronchi, the walls of the chest, the nasal cartilages, and the cranium. 
In the same way, the tuning fork, when struck and held in the air, 
excites a feeble, scarcely audible, sound, but when it touches a table, 
the sound is heard over the whole room, owing to the note being 
propagated from the fork to the entire table, the vibration of which 
When artificial respiration has to be sustained for a long period, 
I advise that the apparatus be adjusted to the canula, inserted, by 
the operation just described, into the larynx. Dr. Marcet’s apparatus 
for artificial respiration, which alternately exhausts and expands the 
lungs, appears to me to be well adapted for its purpose. It certainly 
obviates the danger of rupturing the air-cells, which is apt to occur 
when the bellows are employed, and I think it better than the 
graduated syringe with Mr. Jackson’s double action tap, which I 
recommended some years since as being more accurate than, and there- 
fore preferable to, the bellows. 
The signs of laryngitis, derived from anatomical considerations, are 
EXPLANATION OP PLATE YII. 
the ramifications of the bronchi; and the lungs, aorta, and esophagus in relation to the 
vertebrse and ribs. 
In the abdomen, the spleen, the kidneys, and the diaphragm, have been removed, 
exposing—the aorta in relation to the vertebras. (Eeduced from 32 inches to 21 inches.) 
From the same subject as Plates 11., 111., IY., Y. and YI. 
In the head and neck, a section has been made through the jaw, the tongue, and the 
front of the larynx, exposing the fauces, pharynx and interior of the larynx. 
In the thorax, the heart, the arch of the aorta, the anterior portion of both lungs, and 
the pulmonary vessels have been removed, exposing—the bifurcation of the trachea, and COMMENTARY ON PLATE VII. 
may be felt by the hand. In like manner, when a person speaks, the 
vocal vibrations excited in the chest may be felt by the hand, and the 
vocal resonance may be heard by applying the ear to the chest. 
The vocal vibrations and resonance are present wherever there is 
lung, but they are absent over the ribs superficial to the heart, the 
liver, and the stomach. The distribution, therefore, of the vocal 
vibrations is purely anatomical, and their presence or absence indi- 
cates to us the presence or absence of lung at any particular part of 
the costal walls. When we take a deep breath, the lungs expand 
downwards a full inch, and the vocal vibrations expand downwards 
to the same extent. The vocal vibrations are strong where the volume 
of the lung is large, feeble where it is small. Thus the vibrations are 
strong over the right mammary region, feeble when the lung overlaps 
either the heart or the liver. 
sound does not present the tubular character of pneumonia, hut it is 
much louder and more audible than in health. 
In many cases of tuberculous disease, and of pleuritis with effusion, 
bronchial expiration is absent during tranquil breathing; hut it be- 
comes quite palpable and characteristic when the patient whispers, 
and so increases the energy of the expiration. In all cases of real or 
suspected chest affection, I am in the habit of desiring the patient to 
whisper, while I listen, first oyer the suspected, and then over the 
corresponding healthy region. 
I am convinced that Skoda is right in attributing this altered and 
augmented expiratory breath-sound to consonance in the walls of those 
open tubes, surrounded by solid lung tissue. 
The phenomena of Bronchophony, Pertoriloquy, and iEgophony, are 
not due to the vocal resonance alone, but to the combination of the 
tubular breathing with the vocal resonance. Whenever either of these 
phenomena is present, if we desire the patient to whisper, we hear the 
tubular expiration penetrating the ear with each whisper. If we now 
desire him to speak, we may notice that the vocal resonance is accom- 
panied and modified in character by the whisper. We may notice also 
that, towards the end of each word, a short jet of whispering follows 
after the cessation of the vocal resonance. 
I thus explain the difference between Broncophony and iEgophony. 
In broncophony from pneumonia, the vocal vibrations are unusually 
strong; in segophony from pleuritic effusion, the vocal vibrations are 
unusually weak. Hence, the bleating character in segophony—the 
whisper, as it were, almost drowning the voice, and hence, the 
bronchophonic character in pneumonia, the voice almost drowning the 
whisper. In each, however, the whisper and the voice combine to 
produce the characteristic effect, the one accompanying the other, like 
the drone and the tone of the bagpipe. 
When from pneumonia, tubercular infiltration, or pulmonary apo- 
plexy, the tissue of the lung becomes solid, while the bronchi are 
themselves free, the vocal vibrations are rendered stronger. If, how- 
ever, under these circumstances the tubes are themselves blocked up, 
the vocal vibrations become feeble or disappear. As Skoda has 
advanced, the smaller bronchi, being devoid of cartilage, scarcely con- 
sonate in health; though they consonate freely when their walls are 
rendered solid, and therefore capable of vibrating, by the presence of 
the surrounding exudation in the air cells. The vibrations then excited 
are stronger or weaker in proportion as the exudation, surrounding the 
tubes, is more or less dense and universal. Thus the vibrations are 
stronger in pneumonia than in phthisis. 
When the lungs are separated by pleuritic effusion from the walls 
of the chest, the vocal vibrations are no longer perceptible. In such 
cases the lung floats forward, the fluid gravitates backward. When 
the patient lies on the back, the vibrations are present in front while 
they are absent behind; whereas, when he lies on the face, owing to 
the interchange of position of the effused fluid and the lung, the 
vibrations are present over the dorsum, absent over the front of 
the chest. 
The trachea, in its descent, bears to the right, being, at its bifurca- 
tion, in front of the right half of the bodies of the fifth and sixth dor- 
sal vertebrae, while the aorta, alongside of it, is in front of their left 
half. (See Plates V. YI. YII.) The breath-sounds are consequently 
louder over the right than the left edge of the sternum, from its summit 
to the third costal cartilages. 
A loud smooth breath-sound is heard over the larynx and trachea, 
during respiration. This is equally loud during expiration and in- 
spiration. This sound is caused by the play of the current of respired 
air over the glottis. 
The right bronchus plunges at once into the right lung, the bronchi 
curving upwards to the upper, outwards to the middle, and downwards 
to the lower lobe. The left bronchus takes a long course downwards 
and outwards in front of the oesophagus and through the arch of the 
aorta. The left bronchus consequently enters the left lung, and breaks 
up into its divisions, much lower down than the right bronchus. The 
bronchus leading to the summit of the left upper lobe turns directly 
upwards, being much longer than that to the right upper lobe. The 
bronchus to the lower portion of the left upper lobe passes directly 
outwards, corresponding thus to the right middle bronchus. 
Contrary to Laennec and Skoda, I hold that the respiratory murmur, 
like the vocal resonance, originates in the larynx, and is conveyed 
thence during inspiration by the current of air, the sound being 
somewhat reinforced by consonance in the tubes themselves. If the 
respiratory murmur originated in the air cells and smaller bronchi, 
it would necessarily be loudest, where the respiratory expansion of the 
lungs is most abundant and most active. Now this is quite contrary 
to the fact. In the adult male, the inspiratory murmur is very feeble, 
and the expiratory murmur is scarcely audible over the lower part 
of the dorsum, although at that part the mass of the lung is greater, 
and its expansion more active than elsewhere. On the other hand, 
over the upper part of the chest the inspiratory sound is loud and 
the expiratory sound is quite audible, and yet the volume of the lung 
is there comparatively small and the costal expansion slight. Indeed 
at that very part, the expansion of the lung, in tranquil breathing, is 
mainly due to the descent of the diaphragm, which, in fact, expands 
the whole lung, from base to apex. 
The result of this anatomical arrangement is, that the healthy breath- 
sounds are louder, and the vocal vibrations are stronger, over the right 
than the left upper lobe, both above and below the clavicle and above 
the scapula. When, therefore, the breath-sounds, expiratory as well 
as inspiratory, are louder, and the vocal vibrations are stronger over the 
right than the left upper lobe, there is no ground, from these signs, to 
infer disease of either lobe. If, however, the inspiratory sound is 
more feeble, and the expiratory sound stronger on the right than the 
left upper lobe, while the heart’s sounds are louder, the chest flatter, 
and the stroke on percussion somewhat less resonant on that side, we 
have grounds for suspecting condensation of the right upper lobe. If 
we find that the vocal vibrations are stronger and the breath-sounds 
are louder, especially during expiration, over the left than the right 
upper lobe, our suspicions must then be turned to the left side. 
The fact is, that the inspiratory murmur is louder, and the expiratory 
murmur is more audible, the nearer the portion of lung examined is to 
the larynx. The smaller the lung the louder the murmur; thus it 
is louder in the female than the male, louder in the child than either. 
I regret that I have not space to argue out the whole question. 
When the lung is consolidated by exudation, or condensed by the 
pressure of fluid, or any other cause, the expiratory breath-sound, in 
health so faint, or even imperceptible, becomes developed in a very 
remarkable manner, provided the bronchi are pervious. In pneumonia 
the expiratory sound is blowing, tubular, and metallic. In pleuritis, 
with slight effusion, the same sound is often heard over that part of 
the condensed lung which, being just above the fluid, is in contact 
with the walls of the chest. The region over which tubular breathing 
is heard in pleuritis, shifts with the change of position, and the con- 
sequent gravitation of the fluid. When there is complete tubercular 
infiltration, the tubular breathing is nearly as blowing and metallic as 
in pneumonia, provided the tubes are not occupied by mucus, as they 
often are, owing to the softening of some part of the affected tissue. 
When tubercles are scattered, with, perhaps, here and there small 
interspersed patches of tubercular pneumonia, the expiratory breath- 
The descending vena cava occupies a much larger space to the right 
of the aorta than the pulmonary artery does to its left; since, while 
the pulmonary artery disappears behind the arch, the vena cava ex- 
tends from the top of the sternum downwards. The right lung is 
consequently more encroached upon by the vena cava than the left 
lung by the pulmonary artery. The result is, that the percussion 
stroke is more resonant to the left than the right of the upper portion 
of the sternum. This is more appreciable when the chest is flat and 
the lungs are small, as in the bed-ridden and the feeble, than when the 
chest is full and the lungs are large, as in the robust, and in those 
affected with emphysema. We must, therefore, be careful not to 
condemn the right upper lobe, merely because the percussion stroke 
is more dull to the right than to the left of the upper portion of the 
sternum. Timtei loy Hull miuiiel 8< "Walton 
JPL. TIM. 
Dr*,irn ■from tke Sixbiec-t ati<L on Stone by Tilliaan Hadrian5. COMMENTARY ON PLATES VIII. & IX. 
THE HIES, DIAPHRAGM, LEPT LUNG, HEART AND GREAT VESSELS. 
THE RIBS. 
lower lobe, can only be appreciated by tbe examination of the side 
view. The left upper lobe is really the anterior lobe. When the 
chest is looked at in front, the upper conceals nearly the whole of the 
lower lobe from view, a small portion only of that lobe coming into 
sight at the outer and lower part of the chest. (See Plates 1., 11., 
III.) In like manner the lower is really the posterior lobe, since if 
we examine the chest from behind, the lower lobe appears to occupy 
nearly the whole chest, only a small cap of the upper lobe appearing 
above the lower, the septum being generally in front of the third rib. 
See Columns 1, 2, 3. 
It may be observed in Plate YIIL, which represents a side view, 
that the sixth and seventh ribs present themselves to each other, like 
two bent bows set back to back. The sixth rib has along the upper 
margin a concave edge looking upwards, while the seventh rib has 
along its lower margin a concave edge looking downwards. Every 
rib above the sixth presents, like it, a concave edge looking upwards. 
The eighth and ninth ribs, like the seventh, are bent downwards. 
Owing to this arrangement the ribs from the sixth to the ninth are 
crowded together, the intercostal spaces being very narrow. 
During a deep inspiration, the upper ribs converge, while the lower 
ribs diverge, and all the ribs become parallel to each other. 
When we look at the side view, we at once see how the upper lobe 
laps over and lies obliquely in front of the lower. The upper lobe 
occupies the upper and anterior, the lower lobe the lower and 
posterior part of the chest, the septum between them running 
obliquely from behind forwards and downwards. In Plate YIII. the 
septum begins behind and above, at the third intercostal space or 
fourth rib, crosses, as it works towards the front, the fourth and fifth 
intercostal spaces, and appears finally in the sixth interspace, along 
which it passes forward, parallel to the lower edge of the sixth rib, 
behind which rib it disappears, to end in the base of the lung, near the 
apex of the heart. Usually the septum is a rib’s breadth higher in 
situation, beginning above and behind at the third, instead of the 
fourth rib, passing along the fifth, instead of the sixth intercostal 
space, and disappearing behind the sixth rib, as in Plates I. and 11. 
THE DIAPHRAGM. 
See Column 12. 
In Plate YIII., as in Plate 1., I have cut away the diaphragm, all 
but a thin strip which is seen through the intercostal spaces, just 
below the margin of the lung. By this plan the stomach, spleen, 
kidney, and intestines, can be seen in their relative position through 
the intercostal spaces. The diaphragm, which can be readily replaced 
by the mind’s eye in these views, is left entire in Plate 11. Its left 
arch and central tendon are shown in a side view in Plate IX., and the* 
upper and under surfaces of both arches are exhibited in front views in 
Plates IY., Y., and YI. 
The septum moves downwards during inspiration, upwards during 
expiration; the upper lobe as well as the lower, being expanded 
downwards by the descent of the diaphragm, the movements of which 
act upon the whole lung from base to apex. 
The mind naturally associates the chest with the ribs, the abdomen 
with the whole space below the ribs. In reality, however, the more 
important of the abdominal organs, as can be seen in the plates re- 
ferred to, are shielded by the ribs from pressure and external violence. 
The diaphragm in its descent during a deep inspiration, while it 
expands the lungs downwards, pushes before it the whole of the 
abdominal organs, so that the liver, stomach, spleen, and kidneys are 
no longer protected by the lower ribs. Indeed, during a deep in- 
spiration, the lower portion of the right lung and heart are drawn 
downwards so far in front, by the diaphragm, as to be seated below 
the xiphoid cartilage. During inspiration, therefore, the cavity of the 
chest encroaches downwards upon the abdomen; while during expira- 
tion the cavity of the abdomen encroaches upwards on the chest. 
In the robust, as in Plate 1., especially when they are in constant 
exercise, the diaphragm is habitually low; while in the feeble, and still 
more in the bed-ridden, it is unusually high, so that the heart and 
lungs are crowded upwards into the chest—being encroached upon by 
the abdominal organs. 
"When the whole of the lower lobe is affected with pneumonia, 
the line of the septum forms the exact boundary of the disease. 
Behind that line we find dulness on percussion, blowing respiration, 
and increased vocal vibrations; in front of it, resonance on percussion, 
the respiratory murmur, and normal vocal vibrations. Whether the 
patient lie on his back, his face, or his side, or sit up, the seat of the 
affected lobe is the same, and the anterior boundary line of the 
region of dulness on percussion and of exaggerated vocal vibration is 
unchanged. When the whole lower lobe is the seat of pneumonia, the 
exudation distends the air-cells, and the entire lobe is enlarged to the 
same extent as during a deep inspiration, the base of the lung being 
lower than usual by one inch. While the lower lobe is distended by 
the exudation of pneumonia, the upper lobe is expanded almost to its 
full extent by inspired air, to compensate for its deficiency in the 
lower lobe, and the position of the septum is lowered. 
When the whole of the upper lobe is the seat of pneumonia, or 
of tubercular infiltration, we find the region of dulness on percussion, 
increased vocal vibration, and bronchial breathing, limited behind by 
the line of the septum. In front of, and above that line, we discover 
the abnormal signs; below and behind it, the normal signs. In this 
case, as well as in pneumonia of the lower lobe, the septum is 
lowered. But in this case, while the upper lobe is enlarged, Giving 
to the distension of its air-cells with exudation, the lower lobe is 
expanded to its full extent by inspired air, so as to compensate for 
the deficient breathing above, and the base of the lung is lowered. 
After a full meal, the distended stomach makes way for itself in 
every direction, so that, while it displaces the other abdominal organs 
downwards, it raises the diaphragm and thus encroaches upon the 
heart and the left lung. (See above, at column 23.) 
THE LEET LUNG. 
See Columns 3—lo, 26—28. 
The complete bearing of the upper lobe of the left lung to the 
EXPLANATION OE PLATE YIII 
This Plate and Plate IX. represent views of tlie left side, the body lying upon the 
back. They were taken from a tall, robust man, aged thirty-eight. 
When the outlines of the intestines were taken, those in front of the lumbar region 
were retained in situ by the lumbar fascia; but when the fascia was cut away, the 
intestines gravitated backwards, and were no longer in situ. An imaginary repre- 
sentation has consequently been given of those intestines seated behind a horizontal 
line running from tbe tenth costal cartilage to the ilium. 
In this view the ribs are left, the intercostal muscles and the diaphragm being 
removed. Thus tbe lungs and heart, and the stomach, colon, and spleen, and the upper 
end of the kidney, are seen in their relative position, through the intercostal spaces. 
In this Plate the inferior margin of the lower lobe is represented as coming down too 
far posteriorly. The lower lobe was affected with pleuropneumonia in this body, and 
was thus rendered very distinct from the upper lobe. 
(liedueed from 36 inches to 21.) COMMENTARY ON PLATES VIII. & IX. 
I have observed in several cases of pneumonia of the upper lobe, a 
marked limitation of the disease to that portion of the lobe which is 
above the third rib. The line of demarcation was abrupt. All above 
that line, I found absolute dulness on percussion, intense tubular 
breathing and exaggerated vocal vibration; or at an earlier stage 
coarse crepitation: all below that line, the resonance; the breath- 
sounds, and the vocal vibrations were normal. This tendency to 
limitation is manifestly due to the mode of the distribution of the 
bronchi, arteries and veins to the region indicated. In phthisis, the 
disease tends to limit itself in a like manner, but, owing to the exuda- 
tion being scattered, and being interspersed with sound lung, it is not 
so marked as in pneumonia. In two cases of pneumonia of the upper 
left lobe, this limitation was not present, the whole of that lobe being 
affected. 
is, above the clavicle, somewhat less resonant over the left than the 
right npper lobe. The breath-sounds and the vocal vibrations are also 
more feeble over the left summit, on account both of this anatomical 
arrangement, and of the much greater length of the left than the 
right upper bronchus. (See Plates VII. and IX.) 
In Plates IX. and VII. the head of the third rib is just above 
the level of the top of the sternum. The third rib is in front of 
the spine of the scapula; and as that rib corresponds to the septum 
between the upper and lower lobe at the back, the spine of the 
scapula forms the recognizable boundary behind, between the upper 
and lower lobes. 'When the summit of the upper lobe is affected 
with pneumonia, the morbid signs over the upper lobe are exactly 
divided from the normal signs over the lower lobe by the spine of 
the scapula. It is just the reverse when the upper part of the 
lower lobe is affected with pneumonia. In that case, below the 
spine of the scapula we have the morbid signs, above it the nor- 
mal signs; whereas, in the former case, above the spine we find the 
morbid, below it the normal signs. 
Pneumonia of the upper lobe may usually be readily distinguished 
from phthisis by signs based upon anatomical grounds. In pneumonia 
the upper part of the chest is rather fuller than usual, the nipple 
being generally superficial to the fifth rib; in the early stage, the 
crepitating rhonchus is heard over the whole of the affected region, 
being limited thereto; in the more advanced stage, the dulness on per- 
cussion, tubular breathing and increased vocal vibration, are all of a 
decided character, and the contrast between the healthy and the dis- 
eased portion of lung is complete. In phthisis the chest is flattened 
below the clavicle, the nipple being superficial to the fourth rib; 
the crackling rhonchus, if present, is neither equally diffused nor 
precisely limited; the dulness on percussion, the bronchial breathing 
and the increased vocal vibration, though present, are not of so decided 
a character as in pneumonia; and the morbid signs, instead of giving 
place abruptly to the normal signs, below the limits of the disease, pass 
off by imperceptible shades from the one into the other. The abrupt 
limitation of pneumonia behind, both as regards the exudation and 
the signs, is seated along the line of the spine of the scapula, which 
corresponds to the septum between the upper and lower lobe. 
In phthisis the disease is usually seated above the spine of the 
scapula, but, as I have already remarked, the line of demarcation 
between diseased and healthy lung is by no means so abrupt as in 
pneumonia. 
In pleuritis, the inflamed surfaces are, just at the onset, in contact 
with each other, and frottement is then sometimes audible. The in- 
creasing pleuritic effusion, however, speedily separates those surfaces 
from each other, and to a gradually increasing extent. In most cases, 
therefore, frottement is absent during the early and advancing steps of 
the disease. Luring this period, the effusion when the patient lies on 
his back gravitates to the posterior portion of the chest, forming a 
horizontal line of fluid, which becomes gradually thinner towards its 
anterior edge. Behind this line, we find dulness on percussion, and 
absence of the respiratory murmur and of vocal vibrations; in front of 
this line, we have resonance on percussion, loud respiratory murmur, 
and strong vocal vibrations. The abnormal and the normal signs 
shade gradually off into each other. Just over and adjoining the 
•anterior margin of the fluid we have, generally, bronchial breathing, 
and with it oegophony. If the patient turns over on the face, the 
fluid, yielding to the force of gravity, sinks towards the facial 
aspect of the chest, the lung floating to its dorsal aspect. The 
abnormal signs are now heard over the front, the normal signs over 
the back of the chest. 
That portion of the left upper lobe, which forms the upper and 
left margins of the frame of lung in which the heart is set, and which 
presents, just over the apex, the peculiar tongue of lung, seen in 
Plates 111. and VIII., is not usually affected with phthisis until the later 
stages, when it usually presents itself, not in the form of scattered 
tubercle, but of tuberculous hepatization. If coarse crepitation, or 
tubular breathing, is heard just to the left of the apex-beat, and if the 
region in front of the fifth rib, corresponding to the upper lobe, is 
dull on percussion, while that behind and below the fifth rib corre- 
sponding to the lower lobe is resonant, the disease is probably advanced 
phthisis. The history of the case, as well as the physical signs, will 
readily enable us to decide whether the disease be phthisis or pneumonia 
of the whole upper lobe. 
If the patient sits up, the horizontal line of the gravitating fluid 
completely changes its direction, and traverses the chest horizontally 
instead of vertically. The abnormal signs now occupy the lower, the 
normal signs the upper part of the chest, and the bronchial breathing 
and oegophony, if present, encircle the affected side, over the edge of 
the fluid. 
If the fluid becomes excessive, it compresses the lung more and 
more, and pushes aside the neighbouring organs. The heart is dis- 
placed to the right of the sternum, and the diaphragm, and with it 
the stomach, the adjoining intestine and the spleen are pushed down- 
wards and to the right, so as to be entirely below the lower edge of 
the ribs. 
As the effusion disappears, all these organs gradually regain their 
normal position, and the lung and the diaphragm come again to a 
greater and greater extent in contact with the ribs. 
That part of the upper lobe which is situated above the clavicle, 
and which, when looked at from the front, seems to occupy a part 
of the neck, is represented in front in Plates I. and Y., and at the 
side in Plates YIII. and IX. By examining the side views, it will be 
at once seen that owing to the sternum being raised during inspiration, 
a smaller portion of the lung then appears above the clavicle than in 
expiration. 
In the robust, as in Plate 1., and still more in those affected with 
bronchitis, the extent to which the lung appears above the clavicle 
is much less than in flat-chested persons, and in those affected with 
phthisis. In the robust, the lungs are more as they are during 
inspiration; in the slender, they are more as they are during expira- 
tion. In general, the summit of the upper lobe is about one inch 
higher than the clavicle. The subclavian artery, on either side passes 
over the front of the lung, from half an inch to one-third of an inch 
below the apex. (Compare Plates 1., Y., and IX. with each other.) 
At this stage, the friction-sounds, so long absent, come into play, 
being generally first audible over a space two or three inches square, 
just below the heart, oyer the sixth and seventh costal cartilages. As 
the fluid diminishes, the extent to which the friction-sounds are audible 
increases gradually towards the left side. The anatomical position of 
the frottement at this stage is in fact, not oyer the lung but oyer the 
diaphragm, the movements of which hear with greater rubbing force 
on the ribs than the movement of the lungs. At length, however, 
the friction-sound extends upwards over the lung itself, the area of 
frottement corresponding to the area over which the costal and pul- 
monic pleurae are roughened by the new membrane. 
With the increase in the area of the friction-sound there is generally 
an increase in its loudness and harshness. The extent and harshness 
of the frottement thus increasing as the disease itself diminishes. 
The friction-sound ceases to be audible when and where adhesions 
take place. 
I have now under my care in St. Mary’s Hospital, a young woman 
who was admitted seven weeks since, with extensive pleuritic effusion. 
The right subclavian arises from the arteria innominata, just in front 
of the right edge of the trachea (see Plates Y. and IX.), while the 
left subclavian originates from the aorta itself deep down in the chest, 
just in front of the head of the fourth rib. (See Plates IX. and V.) 
At its origin, and in its course (see Plate IX.), the left subclavian 
is on a level with the posterior edge of the trachea, and is therefore 
much deeper than the right subclavian, which, as we have just seen, 
crosses the front of the trachea. As the left subclavian ascends, it 
is half embedded in the lung, and, owing to its long course and its 
deep position compared with the right subclavian, the left upper 
lobe, above the sternum, is both narrower and shallower than the 
right upper lobe. The result is, that in health the percussion-stroke 'JPJL. IX, 
ted by JtuUmsmiel kWaltov 
l)r*yrn from the Sxtbjcct, saii on iStcme hj WjJljsim Tsdrlsiiii COMMENTARY ON PLATES VIII. & IX. 
The heart was beating to the right of the sternum; the whole of the 
left side was dull on percussion; the face was dusky, the respiration 
excessively hurried. The veins of the neck, especially the left jugular, 
were swollen, even during inspiration. The obstruction to respiration 
and to the circulation through the lungs was so great, and the danger 
so imminent, that I directed the removal of a portion of the fluid, 
sufficient to relieve the lungs and heart from immediate pressure. 
This was done to the extent of 28 ounces, with marked relief. Next 
day she was worse. About 28 ounces of the fluid were again drawn 
off. As on the former occasion, a fine trochar and canula was in- 
serted between the sixth and seventh ribs, rather behind the axillary 
line. During the operation I pushed the left crus of the diaphragm 
upwards by compressing the abdomen on that side, with the effect of 
increasing the stream during inspiration. In spite of this, however, 
a small amount of air was drawn into the cavity of the pleura during 
inspiration. This might have been easily obviated by wrapping a 
small piece of gold-beater’s skin round the shoulder of the canula. 
of the sternum. In the full-chested the sternum is separated from the 
great vessels by a considerable mass of lung; but sometimes, in the 
flat-chested, the lungs collapse to such an extent that the great vessels 
lie immediately behind the sternum. 
While the dorsal vertebrae form a curve looking forwards, the 
sternum forms an arch looking backwards. At the top, the sternum 
is comparatively near to the vertebrae, the space between being only 
filled up by the great vessels and the trachea. At the bottom, the 
sternum is distant from the bodies of the dorsal vertebrae, the space 
between being occupied by the heart, the aorta, and oesophagus. 
The bodies of the vertebrae project forwards into the chest more and 
more from above downwards, and in proportion as they project for- 
wards, do the ribs curve increasingly backwards. Owing to this 
arrangement, the mass of lung occupying the dorsum increases from 
above downwards. We thus see, that, not only is the space for the 
heart largest in front of the bodies of the lower dorsal vertebrae, but 
that the space for the mass of lung behind the heart and occupying 
the dorsum is there largest also. If a horizontal section be made of 
this portion of the chest, it will be found that the space behind a line 
drawn across the front of the bodies of the vertebrae, is equalled by 
the space in front of that line. 
The relief afforded was complete and immediate. Drowsy before, she 
now looked bright and cheerful, and spoke with pleasure of her relief. 
The respirations became slower and more full, the pulse stronger and 
less quick; the face became less dusky, the hands less livid, and the 
white patch made by pressure on the livid hand, which formerly took 
nearly five seconds before it was obliterated, now disappeared in about 
a second. The veins of the neck, previously swollen, even during 
inspiration, now quite flaccid. 
The result of the above arrangement of the vertebrae and ribs is, 
that the lungs chiefly occupy the anterior portion of the chest above, 
and the posterior portion of the chest below. (See Plate VIII.) In 
harmony with this arrangement, the upper is the anterior lobe, the 
lower the posterior lobe; and during inspiration the upper portion of 
the chest moves forwards to expand the upper lobe, while the lower 
portion of the chest moves backwards to expand the lower lobe, the 
diaphragm descending at the same time to complete the expansion. 
Erom that day to this my patient has been gradually improving. 
The fluid lessened from day to day; the heart returned to the left 
side. The friction-sound became audible, first below the heart and then 
behind it. After a time it was heard only during a deep inspiration. 
At length it disappeared. The lung has gradually resumed its func- 
tion. She is now quite convalescent. 
By the examination of the side view (Plate IX.), we at once recog- 
nize that the right ventricle is really the anterior, while the left is 
really the posterior ventricle. I have removed the fat and cellular 
tissue from between the pulmonary artery and the left ventricle, so 
as to expose the origin of the aorta. It may be observed, that the 
pulmonary artery, at its origin, lies immediately in front of the aorta; 
thence it passes almost directly backwards, while the aorta ascends 
almost directly upwards. The two vessels, therefore, cross each other, 
the pulmonary artery at its bifurcation being immediately behind the 
ascending and in front of the descending aorta. 
The presence of permanent distension of the jugular vein in cases 
of effusion into the pleura is a certain sign of extreme obstruction to 
the pulmonary circulation, the relief of which, by paracentesis, is 
immediately demanded. The removal of the venous distension by 
means of the operation is the immediate indication of the relief of the 
obstruction to the circulation. If there be no such tension of the 
jugular veins, even when the accumulation of fluid is very large, the 
effusion usually disappears with wonderful rapidity. There can, there- 
fore, in a case such as that which I have just described, be no necessity 
for removing the whole of the fluid, since the effusion will, if left to 
itself, gradually disappear. Indeed, such a procedure is full of danger. 
A large additional amount of blood suddenly gorges the pulmonary 
capillaries. This blood cannot advance, and bronchitis, with copious 
exudation, is the result. In several cases of paracentesis that have 
come under my notice, death has been caused, not by pleuritis, but by 
bronchitis, induced by the operation. 
Dr. Bowditch has published many cases in which he successfully 
performed paracentesis thoracis on Dr. Wyman’s plan, by drawing off 
about thirty ounces of fluid, by means of a syringe attached to an 
exploring canula, inserted by aid of the trochar. 
If we look at the arch of the aorta in front, as in Plate IY., it 
has little or no resemblance to an arch, since the ascending is almost 
in front of the descending aorta. But when we look at it in the side 
view (Plate IX.), we at once see how truly the aorta forms an arch 
during the first part of its course. 
By comparing Plate IX. with Plates Y. and YI. we recognize 
that the aortic valves lie behind and a little to the left of the pul- 
monic valves, while the mitral lies behind and a little to the left of 
the tricuspid valve. 
In keeping with this anatomical arrangement, the murmur of 
mitral regurgitation is louder to the left of the nipple than to the 
left of the sternum. Inasmuch, also, as the left auricle lies in front 
of the sixth, seventh, and eighth dorsal vertebrae, the mitral murmur, 
if heard along the spine, is louder over those vertebrae than it is 
higher up. 
The aortic murmur during systole is conveyed along the great 
vessels by the current of blood. At first sight we should expect the 
aortic systolic murmur to be most distinct over the upper bone of the 
sternum just in front of the aorta. But usually this is not so; that 
bruit being loudest just above and to the right of the top of the 
sternum, immediately over the arteria innominata. This is particularly 
marked in the full-chested, since in them the thick layer of lung 
between the sternum and the aorta, cuts off or muffles the aortic 
THE HEART AND GREAT VESSELS. 
See Columns 10 and 13 to 23. 
Erom the inspection of Plate IX., we see that the heart occupies 
the whole centre of the chest from the sternum to the spine, and that 
between the sternum and the great vessels a layer of lung is interposed. 
The descending aorta is fixed in its position to the spine by the inter- 
costal arteries. As, therefore, the sternum advances during inspira- 
tion, the layer of lung between it and the great vessels expands, 
the increased thickness of the lung being proportioned to the advance 
EXPLANATION OE PLATE IX. 
Prom the same subject as Plate YIII. The left half of the sternum and the greater 
part of the left ribs have been sawn off, and the left lung, all but the summit of the upper 
lobe, has been removed, exposing—the heart in situ, the pericardium, the pulmonary 
artery, the left pulmonary veins, the arch of the aorta and its branches, the thoracic 
aorta, the trachea and left bronchus, the bronchus and the pulmonary artery and vein of 
the summit of the left lung, and the oesophagus. The inner margin of the right lung, 
and the descending cava, are seen immediately behind the sternum. 
I injected the cavities of the heart and the great vessels with tallow, so that they are 
larger than they were when first exposed, and when they had collapsed, owing to the 
escape of blood. The heart, which would otherwise have fallen backwards, was kept in its 
place by hooks. 
The diaphragm and the adjoining ribs and vertebrae were sketched from another 
subject, since the diaphragm had fallen out of its place in the body from which 
Plates YIII. and IX. were taken, owing to its partial removal, in order to show the 
stomach and spleen through the intercostal spaces. 
In the abdomen, the intestines, all but the lower colon, have been exposing— 
the oesophagus and the cardiac extremity of the stomach, the spleen, pancreas, and liver, 
the left kidney and ureter, and the abdominal aorta and ascending cava. 
Prom manifest causes, it is difficult to represent the organs exactly in situ in a side 
view, but I am justified in saying that their position is accurately given in this plate. 
(Reduced from 36 inches to 21.) COMMENTARY ON PLATE IX. 
systolic murmur. In the flat-chested, however, or when the aorta is 
atheromatous, and consequently dilated and lengthened, so as to 
advance towards the sternum, the aortic systolic murmur is often 
louder over the upper bone of the sternum than it is over the inno- 
minata. 
The automatic and respiratory movements of the heart and great 
vessels are illustrated to a certain extent by the remarkable case of 
M. Groux, an intelligent German, who is the subject of congenital 
fissure of the sternum. When he sits still, the fissure is f-0 of 
an inch wide above the middle of the sternum. Below, the opposite 
sides approximate, and are held together by the articulations of the 
sixth and seventh costal cartilages. The fissure is rather more to 
the right than the left side of the sternum. 
Usually, the second sound of the aorta is simultaneous with that of 
the pulmonary artery. When we listen over the sternum, therefore, 
we cannot tell whether we hear the second sound of one artery or 
of both. It is otherwise over the neck, since, if the second sound be 
audible over the carotids, we know that the valves of the aorta are 
efficient, for the second sound of the pulmonary artery never extends 
above the sternum. 
In the hollow of the fissure appears a pulsating tumour, which 
varies greatly in size. During a deep inspiration, when the sternum 
rises and advances, the hollow is deep, and the tumour is small or 
absent. It then appears and disappears alternately, just at the lower 
part of the fissure, with the alternate systole and diastole of the 
heart. During a forced expiration, when the sternum is lowered and 
falls backwards, the hollow is obliterated by the advance of the 
tumour, which swells forwards and upwards, so as to rise above the 
level of the sternum. The same effects are induced when he exerts 
himself, speaks much, or holds his breath, or presses the sternum 
backwards with his hands. This pulsating tumour is the aorta. 
If we fail to hear the second sound over the arteries in the neck, we 
may suspect aortic regurgitation. The aortic diastolic murmur, indi- 
cating aortic regurgitation, is scarcely ever audible over the arteries in 
the neck, since the regurgitating current of blood conveys the murmur, 
not along the vessels, but back into the heart. Practically, we hear 
the aortic diastolic murmur loudest just to the left of the sternum, 
over the fifth and sixth cartilages. This murmur is also generally 
audible, though with less intensity, over the middle and upper half of 
the sternum, and to the left of the nipple. I see no reason, upon ana- 
tomical grounds, why the aortic diastolic bruit should be louder over 
the fifth left cartilage than elsewhere, since, at that place, the right 
ventricle and its contents are interposed between the aortic valves and 
the cartilages. One would rather have anticipated that the murmur 
in question would be loudest to the left of the nipple, since the blood 
regurgitates directly into the left ventricle, the walls of which usually 
adjoin the nipple. 
During tranquil breathing, the aorta, at the beginning of the systole, 
starts suddenly upwards and forwards, advancing from ylffi to 
of an inch; during the progress of the systole, it gradually descends 
and recedes ; and at the beginning of the diastole, synchronously with 
the second sound, it again starts suddenly forwards and upwards. 
During diastole, when the aorta is at rest, its highest visible part is on 
a level with the second costal cartilage, being two inches below the 
upper edge of the clavicle. At the beginning of the systole, the summit 
of the aorta ascends fof an inch; during the progress of the systole, 
it descends from ftofof an inch; and at the beginning of the diastole, 
it suddenly resumes its original position. 
I have a patient now in St. Mary’s Hospital, a boy, in whom we can 
always hear a mitral murmur to the left of the nipple, and an aortic 
systolic murmur above the sternum, the second sound being there 
absent. The impulse of the apex protrudes with remarkable force to 
the left of the nipple line, so as to widen the space between the fifth 
and sixth ribs. Convinced that the aortic valves were inadequate, I 
listened several times for a diastolic aortic murmur, but unsuccessfully. 
After a ten minutes’ examination, however, I one day heard, over the 
left fifth and sixth cartilages, a fine musical bruit which was audible to 
every one. He then walked quickly to the end of the room and 
back again, with the effect of silencing the sound. In this patient 
the murmur is evidently only audible when the heart’s action is some- 
what quieted. The case proves that we cannot always pronounce on 
the presence or absence of a murmur from a cursory examination ; and 
that the observation of the increased size and force of the left ventricle 
aids us in detecting disease of the aortic valve, in the same way that 
the increased force and size of the right ventricle aids us in detecting 
disease of the mitral valve. 
The finger, when placed over the aorta, is pushed steadily forwards 
at the beginning of the systole. At the beginning of the diastole, syn- 
chronously with the second sound, the aorta recoils upon the finger 
with a peculiar sharp fillip or impulse. The aortic beat can be felt 
to the extent of one inch. 
The beat of the arteria innominata is felt between the clavicles. 
The ordinary beat is felt during systole, and a second beat, or fillip, 
which is sharper and stronger than the systolic beat, is felt at the 
beginning of the diastole. 
During a deep inspiration, the summit of the aorta is two inches 
and a half below the upper edge of the clavicle. At the beginning 
of the systole it ascends J of an inch; during the systole, it 
descends f; and at the beginning of the diastole it again springs 
upwards fof an inch. At the end of the systole the aorta almost 
disappears. 
At the end of a forced expiration, the top of the aorta, at the 
beginning of the systole, is within an inch of the upper edge of the 
clavicle; during the systole it descends one inch; and at the be- 
ginning of the diastole it springs upwards about half-an-inch. 
Owing to the anatomical position of the thoracic aorta in relation to 
the vertebrse, the aortic systolic bruit, when audible over the back, is 
loudest over the third dorsal vertebra; in this respect contrasting with 
the mitral murmur, which is loudest over the eighth vertebra. 
I have given the anatomical position of the various heart-sounds, in 
some points with greater detail, in columns 21 and 22 ; but I think it 
well to bring them again into view, in immediate connection with the 
anatomical relations of the heart and great vessels. 
The origin of the pericardium from the central tendon of the 
diaphragm is shown in Plate IX. The descent of the diaphragm 
necessarily involves that of its central tendon, upon which, as upon a 
floor, the heart rests. The heart, therefore, follows the movements of 
the diaphragm, being lowered in position by its descent, raised by its 
ascent. 
During tranquil breathing, and during a deep inspiration, the aorta 
alone is apparent, occupying the lower third or half of the fissure. 
During forced expiration, however, while the aorta rises, the sternum 
descends, and the top of the aorta is an inch and a half higher in 
relation to the sternum than it is during a deep inspiration. The result 
is, that at the end of a forced expiration, the right auricle occupies the 
fissure to the extent of an inch in addition to and just below the aorta. 
The auricle bulges forward beyond the aorta towards the end of the 
systole, and it evidently moves, during the systole, across the fissure 
from right to left. The movements of the auricle are almost as apparent 
to the eye as those of the aorta; but when the finger is applied over 
the former its movements can scarcely be felt, although the move- 
ments of the latter can be felt with considerable force. In fact, the 
movements of the auricle are seen rather than felt. Considering that 
the right auricle moves to the extent of about an inch from right to 
left during the ventricular systole, and then back again from left 
to right during the diastole, the right ventricle must, during the 
latter period, in part replace the auricle just below the aorta. Con- 
sequently, during a forced expiration, the right ventricle must in part 
occupy the fissure alternately with the right auricle. 
It is clear that the pulsating tumour is the aorta, and that the 
strong double pulsation felt between the clavicles is caused by the 
arteria innominata, for those vessels occupy the same position in the 
dead body that the pulsating tumour and the double pulsation occupy 
in this case. 
But the diaphragm exerts in addition an indirect action on the 
movements of the heart, through the medium of the lungs. When the 
base of the lung is lowered by the diaphragm, the whole lung is 
lengthened, and every part of it, in a diminishing ratio from base to 
apex, is lowered. The inspiratory descent and expiratory ascent of 
the bronchi, where they enter the lungs, are considerable, and are 
indicated by the corresponding respiratory movements of the larynx. 
The heart is intimately attached to the lungs posteriorly by the 
pulmonary veins and arteries, the former of which leave the lung 
just below the bronchus, while the latter penetrate the lung just 
above the bronchus. The heart, therefore, necessarily moves with the 
movements of the lungs, and it is drawn downwards during inspira- 
tion by the diaphragm, indirectly through the medium of the lungs, as 
well as directly by means of the central tendon. rawn from fch.6 Subject & on Stone loy'Williacm ,¥aarlana. 
Printed. or Hxrlbnaxuiel Wa 1 
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Ja Jjj o Zck o COMMENTARY ON PLATES X. & XI. and on PLATES VIII. & IX. (resumed.) 
TFIE RIBS AND INTERNAL ORGANS VIEWED EROM THE SIDE. 
THE RIBS AND STERNUM IN RELATION TO THE 
IMMEDIATELY SUBJACENT ORGANS. 
tenth rib, it will be found to divide the lateral cone of the chest equally. 
This line is called by Conradi the “ axillary line.” It is an interesting 
physiological fact in the mechanism of respiration, that all those parts 
of the costal walls that are in front of this line move forwards, while 
almost all those parts behind that line move backwards during a 
deep inspiration, as I have described in a paper on the Mechanism of 
Respiration, in the Philosophical Transactions for 1846. 
The description at column 29 of the direction of the various ribs on 
the left side (Plate YIIL), applies also to their direction on the right 
side (Plate X.). 
Plates VIII. and X, show that the cage of the chest, composed of 
the ribs and sternum, and containing the lungs immediately within it 
at its two upper thirds, the diaphragm at its lower third, presents 
itself on each side in the form of a cone. The apex of this cone is at 
the articulation of the first rib: its base extends like a girdle across 
the lower ribs, from the end of the eighth rib in front to that of the 
twelfth rib behind. By the base of the thoracic cone, I mean the 
circuit at which the pleura is reflected from the diaphragm upon the 
ribs and intercostal muscles, and down to which the lungs can descend 
during the deepest possible inspiration in the living, and when 
distended to the full in the dead. This base, or line of the dia- 
phragmatic reflection of the pleura, crosses within the ninth, tenth, 
and eleventh ribs, a little above the junction of each rib, to its 
cartilage. During ordinary, and still more during forced expiration, 
the downward obliquity of these ribs increases, and their ends are 
lowered, that of the tenth being the lowest. They consequently 
present a convex edge looking downwards into the flanks, towards 
the crest of the ilium. The result is, that the base of the thoracic 
cone describes, in the tranquil state, a convex curve, looking down- 
wards, which at its lowest part crosses within the lower end of the 
tenth rib. In Plates YIIL and X., as well as in Plate I. (front 
view), the diaphragm is cut away to show the abdominal organs 
through the lower intercostal spaces; but in Plate 11. the diaphragm is 
retained, and in that Plate the line at which the pleura is reflected 
from the diaphragm to the costal walls, is indicated in the seventh 
right intercostal space at its lower end. 
At the same time that the costal walls advance in front of the 
axillary line, and recede behind it, during a deep inspiration, the 
sternum and the whole of the ribs, from the fifth to the eleventh, are 
raised to an extent corresponding rib for rib to the degree to which the 
chest is deepened. The twelfth rib is stationary. The effect on the 
contour of each rib, as well as that of the whole chest, is remarkable. 
The curves of the ribs, and the width of the intercostal spaces, described 
above in column 29, are universally modified. Instead of the six superior 
ribs presenting a convexity looking downwards, and the seventh, eighth 
and ninth ribs a convexity looking upwards, with the necessary result 
that the upper intercostal spaces are wide, while the lower and especially 
the intermediate spaces are narrow, the ribs being there crowded 
together,—the whole of the ribs become, during a deep inspiration, more 
nearly parallel, the four upper ribs and cartilages converge, so as to 
narrow their intercostal spaces, while all the lower ribs diverge, so as 
to widen their intercostal spaces to a marked extent. The depending 
position of the extremities of the tenth and eleventh ribs is completely 
altered by the elevation and unfurling of those and the adjoining ribs, 
and instead of projecting downwards with a convex curve towards the 
ilium, they are nearly on the same level, so that a girdle tied round the 
body would cross in succession the extremities of the three lower ribs. 
The base of the thoracic cavity, formed by the reflection of the pleura 
from the diaphragm to the ribs, is at the same time raised, and presents, 
instead of a convexity looking downwards, an almost straight line, 
crossing the extremities of the four lower ribs in an oblique direction 
from before backwards and downwards. The result is, that the whole 
costal walls are raised above, shortened below, and deepened throughout. 
The cone of the chest increases rapidly from its summit down to the 
fourth cartilage in front, and the eighth rib behind, in Plate X.; and to 
the sixth cartilage in front, and the eleventh rib behind, in Plate VIII.; 
those being the cartilages and ribs which respectively correspond with 
each other, if a tape be tied round the chest. The antero-posterior 
diameter of the chest scarcely increases, from the points indicated, 
down to the base of the thoracic cone. The sternum partakes of the 
advance of the cartilages forwards; but while it advances more rapidly 
than they do, down to the articulation with it of the second costal 
cartilages, they advance more rapidly than it below that point, since the 
cartilages, from the third to the sixth, project more and more beyond 
the level of the sternum. 
In emphysema, the cone of the chest presents, on a side view, the 
form of deep inspiration, exaggerated and modified. Owing to the 
great expansion of the lungs, the chest is abnormally deep; the ribs 
are raised above so as to shorten the neck, and below so as to shorten 
the costal walls and lengthen the abdomen. Behind the axillary line 
the ribs, especially the lower ribs, protrude backwards, and the spinal 
column presents a backward curvature amounting to a deformity. In 
front of the axillary line, the upper ribs and the sternum are unusually 
high and prominent, but the lower end of the sternum and the sixth 
and seventh costal cartilages are markedly depressed, being forced back- 
wards by the atmospheric pressure from without, induced by the 
imperfect entrance of air through the bronchial tubes. The upper 
intercostal spaces are narrowed, and the lower are widened to an 
abnormal extent. 
In phthisis, the cone of the chest presents, on a side view, the form 
of deep expiration, owing to the collapse of the lungs. The chest is 
flat; the ribs are lowered above so as to lengthen the neck, and 
below so as to lengthen the costal walls and shorten the abdomen. 
During a deep inspiration, the thoracic cone, viewed from either 
side, increases markedly in diameter as low as the sixth or seventh 
cartilages, in front, and the tenth or eleventh rib, behind. In the 
robust, the chest has more or less the set of inspiration, so that the 
diameter of the chest widens downwards to a greater extent in them 
than in the slender and flat-chested, as is well illustrated by comparing 
Plate VIII. with Plate X. If a line be dropped downwards, from the 
origin of the outer scalenus to the base of the chest, at the top of the 
EXPLANATION 
OE PLATE X 
This Plate and Plate XI. represent views of the right side of the body. Taken from a 
well-formed man, aged 20, who died of fever. 
In this Plate the ribs are left, the intercostal muscles being removed. The diaphragm, 
where it is immediately subjacent to the lower ribs, has been cut away, all but a thin edge 
immediately below the base of the lung, and a slip of the muscle extending upwards and 
backwards from the tip of the eighth rib and costal cartilage. 
The right lung, the liver, and gall-bladder, and a portion of the colon, are seen through 
the intercostal spaces. 
In the abdomen, the caput coecum coli, the ascending and transverse arches of the 
colon, and a portion of the small intestines are exposed. The lower two-thirds of the 
right kidney are seen behind and below the liver and the eleventh rib, and in front of the 
quadratus lumborum. 
(Reduced from 32| inches to 18f). COMMENTARY ON PLATE X. 
Behind the axillary line, owing to the collapse of the lungs, the ribs 
are contracted, and the spine is usually straight. In front of the 
axillary line, the upper ribs and the sternum are unusually flat; but, 
owing to the liver remaining of the normal size, or becoming enlarged 
hy fatty degeneration, the seventh or even the sixth and the lower 
ribs are often unusually prominent. The upper intercostal spaces are 
widened and the lower are narrowed to an unusual extent. 
extreme gastro-intestinal distension (see Medical Gazette, New Series, 
Yol. YIL, p. 107), the base of the right lung was behind the fourth 
intercostal space in front, and the sixth rib at the side, the left base 
being proportionately high. When the stomach is excessively dis- 
tended, the left base is raised to a greater extent than the right. 
When the liver is simply enlarged, it does not necessarily elevate the 
base of the right lung, since, owing to its weight, it makes its way 
downwards into the abdomen, unless the stomach and intestines are 
distended. When the upper part of the liver is occupied by a large 
abscess, an hydatid cyst, or a malignant tumour, the base of the right 
lung is raised to a remarkable extent. Thus, in a case of extensive 
abscess in the liver (see Medical Gazette, New Series, Yol. YIL, 
p. 107), the base of the right lung is displaced upwards, in front, to 
the third costal cartilage, and at the side, to the fourth rib. 
The lower edge of the right lung,—whichin Platel.,from a robust man, 
is behind the lower edge of the sixth cartilage, and in Plate 11., from 
a slender youth, is behind the fifth intercostal space—is, in Plate X., 
as high as the upper edge of the fifth cartilage, owing to the collapse 
of the lung. Thence the base of the right lung, in Plate X., passes 
backwards with a slight downward obliquity, crossing in succession the 
sixth, seventh, eighth, ninth, and tenth ribs, and their intercostal spaces. 
In Plate YIIL, which presents a view of the left side, the base of the 
lung is anteriorly behind the sixth rib and cartilage. Thence it passes 
backwards, with a downward obliquity, crossingin succession the seventh, 
eighth, ninth, tenth, and eleventh ribs, and their intercostal spaces. 
The position of the base in Plate 11. corresponds with that in Plate 
VIII., but it is a rib’s breadth lower in Plate 1., taken from a robust 
man. In comparing the left side with the right in Plates I. and 11. 
(front views), VIII. and X. (side views), and XII. (back view), it will 
be seen that the base of the left lung is, throughout, lower than that 
of the right lung, to the extent, in front, of about a rib’s breadth, 
behind, of about half a rib’s breadth. During a deep inspiration, and 
when the lungs are distended after death to the full, the right base 
approximates nearly to the level of the left base. The difference 
between the right and left base is consequently but slight in those 
affected with emphysema, while it is often very marked in those 
affected with phthisis, in whom, indeed, the increased size of the liver 
presents an additional hindrance to the descent of the base of the right 
lung. 
The size of the middle lobe of the right lung, and, as a necessary 
consequence, that of the lower and anterior part of its upper lobe also, 
and the position of the septum between the middle and the upper and 
lower lobes, vary much in different persons. Thus in Eig. 4, column 
29, the inner end of the septum between the upper and middle lobes is 
just above the lower edge of the right lung, and the lower end of the 
sternum; in Plate X. it is at the top of the lower fourth of the lung; 
in Plates I. and 11. it divides the anterior portion of the lung into two 
equal parts, being situated in the third intercostal space ; and in tne 
Pigure at p. 591, Medical Gazette, New Series, Yol. YL, it is as high 
as the top of the third costal cartilage. There is less variation in the 
position of the septum between the middle and lower lobes, which is 
truly a continuation of that between the upper and lower lobes. 
Usually the lower end of that septum is seated in the fifth or sixth 
intercostal space, occupying a position corresponding to that of the 
lower end of the septum, between the upper and lower lobes of the 
left lung. With the inspiratory descent of the diaphragm, the middle 
lobe and its septa occupy a lowered and extended position ; the septum 
between it and the upper lobe moving downwards, while that between 
it and the lower lobe moves both backwards and downwards. The 
middle lobe of the right lung is indeed an appendix of the upper lobe, 
it being the exact analogue of the lower half of the left upper lobe. 
During a deep inspiration, the base of each lung is lowered about one 
inch. While the base of the lung moves downwards, the base of the 
thoracic cavity along the line of the reflection of the pleura, moves 
upwards, and to about the same extent. The lungs are, indeed, arrested 
in their downward expansion by the line of the reflection of the pleura 
at the base, especially in cases of emphysema. The base of the expanded 
lung is still somewhat lower behind than before, but, instead of 
presenting a concavity, it presents a convexity, looking downwards. The 
lower edge of the right lung, which was previously behind the lower 
end of the sternum, descends during a deep inspiration to the tip of the 
xiphoid cartilage. The base of the expanded lung anteriorly is, in 
consequence, no longer comprised within the costal walls, but it lies 
behind the abdominal muscles, above a line passing from the tip of the 
xiphoid to the free edge of the eighth cartilage. 
The whole lower edge of each lung can be accurately ascertained by 
the resonance on percussion, the vocal vibrations, and the breath- 
sounds which are present down to the base line, and absent below it. 
Usually the lower intercostal spaces are hollowed out, owing to 
atmospheric pressure, down to the lower margin of the lung, while 
they are tilled up below that margin, especially on the right side, owing 
to the support afforded by the solid liver to the intercostal spaces. 
This depression of the intercostal spaces, where they are superficial to 
the lungs, is scarcely apparent in the flat-chested and during 
expiration, owing to the approximation of the ribs; but during 
inspiration the lower intercostal spaces are widened, while the base of 
the lung is lowered; and the increased furrowing of the intercostal 
spaces exactly indicates the extent of the inspiratory descent of the 
base of the lung. In the robust and, to a remarkable extent, in those 
affected with emphysema, the falling inwards of the intercostal spaces 
over the lung is marked, the lower boundary of the depression indi- 
cating to the eye the exact position of the base of the lung. 
Daring a deep expiration all these processes are reversed : the chest 
is flattened; the ribs being lowered, crowd together below, and are 
lengthened downwards towards the ilium ; the base of the lung 
rises; while the line of the reflection of the pleura, forming the base of 
the thoracic cavity, descends, and becomes more convex downwards. 
In the robust and full-chested, the base of each lung is habitually 
low, approaching to the fulness and position of inspiration. In the 
slender and narrow-chested, on the contrary, the base of each lung is 
habitually high, approaching to the collapse and position of expiration. 
Hence the position of the base of the lung varies so much in different 
bodies, when examined after death. Thus, in Plate 1., from a robust 
man, the base of the right lung extends from below the sternum and 
the sixth intercostal space in front, to below the eleventh rib behind, 
crossing the ninth rib at the axillary line; while in Plate X. it extends 
from above the lower end of the sternum, and the upper edge of the 
fifth cartilage in front, to the tenth rib behind, crossing the seventh 
intercostal space at the axillary line. 
The extent to which the diaphragm is immediately subjacent to the 
ribs is, in the nature of things, exactly limited by the base of the lung. 
Above the base, and as high as the articulation of the first rib, there 
is nothing but lung; below the base, and as low as the cartilages of 
the lowest ribs, there is nothing but diaphragm. The height to which 
the diaphragm rises into the chest corresponds, likewise, with the 
extent to which the lung is expanded. 
The right convexity of the diaphragm is globular or oval, and being 
wider from behind forwards than from side to side, its summit is, in 
Plate X., on a level in front with the fourth cartilage at the side with 
the sixth rib, and behind, with the eighth rib. In Plate IY., from a 
slender youth, the right summit is as high as in Plate X.; but in Pig. 
4s, column 15, it is on a level with the fourth intercostal space in front 
and the sixth at the side; while in Pig. 1, column 13, and in Plate L, 
from a robust man, it is as low as the fifth cartilage in front and the 
sixth intercostal space at the side. In the side view given at page 358 
of the Medical Gazette, New Series, Yol. YL, the right summit is on a 
level in front with the fifth cartilage, at the side with the sixth inter- 
costal space, and behind with the tenth rib. The base of the right 
lung sits like a cap upon the right convexity of the diaphragm. The 
wedge of lung thus interposed between the diaphragm and the ribs is 
In emphysema, the base of the lung is lowered throughout, to an 
extent, in extreme cases, beyond that to which it descends in health 
during the deepest possible inspiration, so that it extends from below 
the tip of the xiphoid cartilage in front, to below the spring of the 
twelfth rib behind. In phthisis, on the other hand, the base of each 
lung is often unusually high, because of the shrinking of the lungs 
themselves, and often, also, on the right side, from enlargement of the 
liver. 
The bases of the lungs are abnormally high when the abdomen is 
distended from any cause, whether from gastro-intestinal distension, 
ascites, abdominal tumours, or ovarian dropsy. Thus, in a case of Prawn from the Subject & on Stone lojWjHia.rnlFajrland 
Printed lay Hu liman del & IValtor 
2P3L- Mo COMMENTARY ON PLATES VIII. & IX. 
larger posteriorly than anteriorly, owing to the base of the lung being 
lower behind than in front. 
The left convexity of the diaphragm is usually from one to two 
ribs’ breadth below the level of the right. Instead of the left being 
oval, like the right, it is more of a half-moon shape, the greater 
portion of it being behind, owing to the position of the ventricles 
and apex of the heart in front of the left side of the chest. In 
Plate IX., which presents a view of the left side, the left summit of 
the diaphragm is on a level with the lower edge of the fifth costal 
cartilage in front, and with the tenth rib behind. It is only by viewing 
the body from before, as in Plates I. and IY., and Pigs. 1 and 4, and 
from behind, as in Plates XII. to XY., that we can compare the relative 
height of the right and left convexities of the diaphragm. In Plate IY., 
the left summit is much lower than theright, since, while the former 
is on a level with the top of the right fourth costal cartilage, the latter 
is on a level with that of the left fifth. 
but slightly protected by the lower edges of the costal walls, those 
organs being mainly situated behind the abdominal walls. 
In Plate X., the liver, although abnormally large, is so completely 
screened by the costal walls, that its lower margin is an inch above the 
lower edge of the eighth, ninth, and tenth cartilages, the transverse 
arch of the colon occupying the intra-costal space immediately below 
the lower margin of the liver. In Plate 11., from a slender youth, the 
stomach being empty, the colon full, the liver juts a little beyond the 
lower margin of the costal cartilages, from the seventh downwards. 
In Plate 1., from a robust man, the intestines being rather empty, the 
liver presents itself to a great extent, both downwards and to the left, 
behind the abdominal parietes, its lower margin being 2£ inches 
below the lower edge of the ninth costal cartilage, and 6 inches below 
the lower end of the sternum. In a drawing from a case of emphy- 
sema now before me, the lower margin of the liver is 2 inches below 
the lower edge of the tenth costal cartilage, and 6i inches below the 
lower end of the sternum. 
In Plate 1., the convexities of the diaphragm are more nearly on a 
level, since their summits are respectively behind the fifth costal 
cartilage, and that of the left crus is scarcely a rib’s breadth lower 
than that of the right. This difference in height of the two sides 
may depend on the right lung being somewhat more expanded than 
the left at the time of death, on the stomach and intestines being 
more or less distended, and on the liver being of greater or less size. 
During a deep inspiration, the diaphragm not only descends so as to 
expand the lungs downwards, and to push before it all the abdominal 
viscera, but each convexity, and particularly the right, becomes 
considerably flattened, so that the concavity formed by the upward 
protrusion of the diaphragm, at the base of each lung, is materially 
lessened, while the summit of the liver is flattened and compressed 
downwards. In cases of emphysema, the flattening as well as the low- 
ering of the diaphragm, is permanent. 
I have already spoken of the influence of abdominal distension in 
pushing up the diaphragm, and of that of an abscess or tumour in the 
upper part of the liver in elevating its right convexity. 
The extent to which the lower and left portion of the liver is 
screened by the right ribs and cartilages, or exposed behind the ab- 
dominal muscles, is affected to a remarkable extent by the distension 
or collapse of the stomach and intestines. Thus in Plate X., the lower 
margin of the liver is raised above the lower edge of the costal carti- 
lages by distension of the colon : in Eig. 1, in the 12th vol. of the 
Prov. Med. Trans., the same effect is induced by distension of the 
stomach, although the summit of the liver is not abnormally high. In 
the figure at p. 107 of the 7th vol. of the Med. Gaz., the same effect is 
caused by excessive gastro-intestinal distension, the summit of the 
liver being also excessively high; and in a case of fever that I ex- 
amined at St. Bartholomew’s Hospital, the gastro-intestinal distension 
was so great, as to push the lower edge of the liver upwards and 
backwards, so that it was above the lower margin of the right lung. 
When the stomach is empty, the liver is lowered, and its edge moves 
so far over to the left as to occupy a large portion of the space within 
the left lower ribs, below the heart and the base of the left lung, as in 
Eig. 2, in the 12th vol. of the Prov. Med. Trans. When the intestines 
as well as the stomach are completely empty, the whole liver drops 
downwards with a bearing to the left, so that its lower margin may 
rest on the crus of the right ilium, as in Eig. 8 in the same volume. 
So far as physical examination is concerned, those important abdo- 
minal organs that are situated in whole or in part immediately within 
the diaphragm, below the base of the lungs, may be regarded as being 
immediately subjacent to the lower ribs. The extent to which those 
infra-diaphragmatic organs are immediately subjacent to the costal 
walls is ruled by the position of the base of either lung. During 
expiration, when the diaphragm and the base of the lungs are high, 
the abdominal organs are shielded by the lower costal walls to a great 
extent. So much indeed are the higher abdominal organs pushed 
upwards during a forced expiration, that they lie, especially on the right 
side, immediately within the costal walls, to a greater extent than the 
lungs themselves. But while the abdominal, intrude thus on the 
thoracic organs during expiration, the thoracic, through the agency of 
the diaphragm, expel the abdominal organs to a great extent from 
within the costal walls during a deep inspiration. 
The size of the liver itself has a marked influence on the extent to 
which it is covered by the ribs, or exposed behind the abdominal 
muscles. If the liver be simply enlarged, as from fatty degeneration 
or congestion, it does not encroach upwards on the lungs, but down- 
wards on the stomach and intestines, unless, as in Plate X., they are 
excessively distended. If, however, the liver be occupied in its mass 
by an abscess, a hydatid cyst, or malignant disease, then the liver 
enlarges in every direction, and while it pushes the other abdominal 
organs downwards, it elevates the diaphragm to a remarkable extent 
as I have already illustrated, and causes general and marked enlarge- 
ment of the lower costal parietes over the region of the enlarged organ. 
When there is effusion of fluid into the cavity of the right pleura, 
the liver is displaced downwards in proportion to the extent of the 
effusion. When the amount of fluid is very great, it causes eversion of 
the diaphragm downwards into the abdomen, and dislocation of the 
liver, so that it lies completely behind the abdominal walls. 
If the lung is condensed after the disappearance of the effusion, 
the liver not only regains its normal situation, but rises above it so as 
to occupy a part of the space previously occupied by lung. 
When there is extensive effusion into the pericardium, especially in 
cases of chronic pericarditis of a low type, the liver, as in Pig. 3, 
column 14, is displaced downwards by the fluid, so as to lie in great 
part behind the abdominal parietes. The same effect is induced, 
In the slender (see Plates 11. and X.), and particularly in those 
affected with phthisis, the base of either lung being habitually high, 
the costal walls flat, low, and long, and the abdominal walls short, the 
liver and stomach are almost entirely shielded by the costal walls, a small 
portion only of either organ being seated behind the abdominal walls, 
just below the xiphoid cartilage. In the robust (see Plate I.), the base 
of either lung being habitually low, the costal walls full, high, and short, 
the abdominal walls long, the liver and stomach are only partially 
shielded by the costal walls, a considerable portion of each organ being 
seated behind the abdominal muscles. In those affected with emphy- 
sema, the base of each lung is so low that the liver and stomach are 
EXPLANATION 
OE PLATE XI, 
Prom the same subject as Plate X. 
In the Head and Neck.—The right half of the nostrils, palate, fauces, tongue, pharynx, 
and larynx, have been removed, by a section through their centre, so as to expose the 
interior of the mouth, fauces, larynx, and pharynx. 
In the Thorax.—The right half of the sternum, and the greater part of the left ribs, 
have been sawn off. The right pulmonary artery and pulmonary veins have been cut 
across, and the anterior portion of the right lung has been removed, exposing—the peri- 
cardium, the right auricle and ventricle, the pulmonary artery, the arch of the aorta, 
and the descending cava; the trachea and the right bronchus and its ramifications, 
separately traced, to the upper, middle, and lower lobes ; the inner and anterior edge of 
the upper lobe of the left lung; and the convex upper surface of the right side of the 
diaphragm. The front of the diaphragm is depressed so as to show the right edge of 
its central tendon, upon the sloping floor of which rest the right auricle and ventricle. 
I injected the right cavities of the heart with water, so that they occupy considerably 
more space forwards than they did when first exposed, and when those cavities had 
collapsed, owing to the draining away of blood. 
In the abdomen, the greater part of the liver and the whole of the intestines have been 
removed, exposing—the cardiac orifice of the stomach, the pancreas, the right kidney and 
ureter, the ascending vena cava and the aorta, which bulges forward too much above its 
bifurcation. 
(Eeduced from 33 inches to 19.) COMMENTARY ON PLATES X. & XI. 
though to a less marked extent, wrhen there is great enlargement of the 
heart with pericardial adhesions, as in Pigs. 28 and 24 in the 12th vol. 
of the Prov. Med. Trans.; and, though to a still less extent, in cases 
of enlargement of the heart without adhesions, as in Pigs. 20 and 21 
in the same volume. 
We thus see that the extent to which the liver is immediately 
subjacent to the costal parietes, the diaphragm being interposed, varies 
with the position of the base of the right lung, the degree of distension 
or collapse of the stomach and intestines, the size of the liver itself, 
and the presence in it of abscesses or tumours, the presence of effusion 
into the right pleura or of condensation of the right lung, and the 
existence of pericardial effusion, or of enlargement of the heart with or 
without adhesion. 
it may be felt protruding, as a solid tumour, below the lower ends of 
the costal cartilages. The enlargement of the spleen, when its boun- 
daries do not transcend the edges of the lower costal cartilages, can 
only be detected by percussion. If, when the patient lies slightly or 
altogether on the left side, the anterior boundary of the dulness on 
percussion, elicited over the spleen, is in front of the axillary line, 
near the edge of the seventh and eighth cartilages, while its lower 
boundary is just above the lower ends of the tenth and eleventh 
cartilages, and if the lower and anterior edge of the organ can be felt, 
like a solid mass, during a deep inspiration, below the ends of these 
cartilages, then the diagnosis of a moderately enlarged spleen can be 
made with precision. In percussing over the spleen, under these 
circumstances, it must not be lost sight of that when the patient lies 
on the back, the solid and fluid contents of the stomach gravitate 
backwards, while its gaseous contents come forwards ; consequently, if 
the stomach be full, the line of dulness on percussion, caused by its 
contents, may be anterior to the axillary line. If, however, the patient 
lies on the left side, the solid contents fall inwards, the gaseous 
contents rise to the side, and the contrast between the gastric resonance 
and the splenic dulness is marked. 
In Plate YIIL, the stomach, which is moderately distended, is seen 
through the sixth, seventh, and eighth intercostal spaces, (the dia- 
phragm being cut away,) below the lower margin of the lung. The 
spleen is seen in a similar position immediately behind the stomach, 
through the eighth, ninth, and tenth intercostal spaces. The stomach 
is seated in front of the axillary line, the spleen behind it. The axillary 
line is indeed the usual and normal boundary of the anterior edge of 
the spleen. A considerable volume of the convolutions of the colon, 
and even some of those of the small intestines, are seen through the 
intercostal spaces below the stomach and spleen. 
When the spleen is considerably enlarged, its anterior margin 
advances beyond the edge of the costal cartilages, and can be readily 
felt through the abdominal parietes as a solid tumour, above which 
there is pulmonic resonance, but behind which there is neither gastric 
nor intestinal resonance; this tumour can be displaced somewhat 
backwards in the direction of the normal position of the spleen, and it 
is lowered to the extent of an inch during a deep inspiration. 
When the spleen is excessively enlarged, it makes way for itself 
extensively downwards as well as forwards, so as to lie behind the 
abdominal muscles as low as the crus of the left ilium, and to the right 
of and below the umbilicus. Under such circumstances, the tumour, 
if it be spleen, is usually very moveable, being easily pushed upwards 
and to the left, towards the norma] position of the spleen. Its upper 
margin is bounded by a line of pulmonary resonance on percussion, 
between which and the tumour there is no gastric or intestinal reso- 
nance whatever. In a case of this class under my care in St. Mary’s 
Hospital, the tumour simulated ovarian dropsy; but the existence of 
intestinal resonance below the lower edge of the tumour, which tended 
towards the pelvis, corrected the first impression, and the presence of 
the signs just described led to the conclusion, verified long after by 
post mortem examination, that the spleen was enlarged. 
The extent to which the stomach, spleen, and intestines, viewed as a 
whole, are comprised within the left lower costal walls, is governed by 
many of the same causes that affect the like position of the liver within 
the right lower costal walls. Since the base of the left lung is usually 
lower than that of the right, the position of the upper surface of the 
stomach and the upper edge of the spleen, are usually much lower than 
the upper surface of the liver. 
The varying position of the base of the left lung during expiration 
and inspiration, in the slender and the phthisical, in the robust and 
those affected with emphysema; the presence of effusion in the left 
pleura or of condensation of the left lung; the existence of pericardial 
effusion and of enlargement of the heart, with or without adhesion; 
exercise precisely the same influence in relation to the extent to which 
the stomach, spleen, and intestines are situated within the left lower 
costal walls, that the like agencies do in relation to the extent to 
which the liver is situated within the right lower costal walls. 
What I have already said with regard to the influence of the disten- 
sion or collapse of the stomach and intestines on the position of the 
liver within the right lower costal parietes, applies, but with more 
immediate reference, to the position of the stomach and intestines 
within the left lower costal parietes. When the stomach is excessively 
distended, it elevates the base of the left lung, and the lower surface of 
the heart, pushes the spleen backwards and upwards, and expels the 
large intestines downwards from behind the left lower costal walls, 
these walls being themselves rendered more prominent. On the other 
hand, when the stomach is quite empty, the base of the left lung and 
the lower surface of the heart are lowered, the left lobe of the liver 
moves over to within the left lower costal cartilages, the spleen is lowered 
and moves forwards, and the convolutions of the large, and to a less 
extent those of the small intestines, ascend within the left lower costal 
walls, which walls at the same time shrink inwards. When the trans- 
verse and descending arch of the colon are much distended, their left 
and upper portions make way for themselves upwards, displacing the 
stomach forwards and inwards, even if distended. The spleen makes 
its way upwards and backwards ; and the base of the left lung, and 
to a less degree, the heart, upwards. 
Erom the examination of the ribs in relation to the subjacent organs, 
we derive these important practical lessons.—-That besides the thoracic 
organs, the more important of the abdominal organs (the diaphragm 
intervening) are comprised within the costal walls to a large but 
varying extent. That when the costal walls are flattened and elon- 
gated below, so as to shorten the abdominal walls, the abdomen in 
reality encroaches upwards on the chest. That when the costal walls 
are rounded and raised, being shortened below so as to lengthen the 
abdominal walls, the chest in reality encroaches downwards on the 
abdomen.—That the liver, even when enlarged, may be completely 
screened behind the right lower costal walls. That the presence 
of the liver to a great extent behind the abdominal walls is no sign of 
its enlargement. That when the substance of the liver itself is 
enlarged, it tends to encroach downwards into the abdomen, but when 
its mass is occupied by large abscesses or tumours, it tends to encroach 
upwards on the chest. That when the liver is disordered pain and 
oppression may be felt over the right costal walls. That when the 
liver is affected with peritonitis, friction sounds may be audible over 
the right costal walls, so as to stimulate pleuritis. That when the liver 
is tender to the touch we ascertain it by pressing upwards below the 
edge of the right costal cartilages; when it is firm from congestion, 
by its offering there a resisting instead of a yielding surface; and 
when it is indurated by disease, by its presenting a hard solid edge 
and surface.—That the stomach is in great part seated within the 
left lower costal walls, just below the heart and the base of the left 
lung; that therefore the stomach sound on percussion is there elicited ; 
and that gastric pain is felt there as well as at the xiphoid cartilage 
and between the scapulae. That gastric distension causes prominence 
of the left lower costal walls, and compresses the heart and left lung 
upwards so as to excite palpitation, pain in the cardiac region, and 
dyspnoea; and that in gastritis, pain is excited by exerting pressure, 
not directly over the costal or abdominal walls, but upwards under 
the edges of the left costal cartilages. 
The spleen, when healthy, is subjected to all the influences of dis- 
placement of which I have just spoken. But although it is extensively 
displaced downwards and slightly forwards during a deep inspiration, 
yet it rarely, even then, protrudes below the lower extremities of the 
costal cartilages. The spleen, therefore, when healthy, cannot he felt 
by the hand, undei; any of the varying circumstances of health. In 
extreme cases of emphysema, and, still more, when the left pleura is 
excessively distended with fluid, the spleen may be displaced downwards, 
so as to be felt below the ends of the costal cartilages. 
When the spleen is enlarged, its anterior margin advances, according 
to the degree of enlargement, more and more in front of the axillary 
line; and while its upper edge extends somewhat upwards, encroaching 
to a slight degree on the base of the left lung, its lower edge extends 
downwards towards the ends of the lower costal cartilages. The spleen 
is still compressed within the left lower costal walls, even when its 
enlargement is considerable, excepting during a deep inspiration, when Mu- xn. COMMENTARY ON PLATES XII., XIII., XIV. & XV. 
THE SPINAL COLUMN, THE MBS, AND THE INTERNAL ORGANS VIEWED PROM BEHIND. 
Although in the living the physical examination of the lungs is 
equally practised over the hack and the front of the chest, yet the 
internal organs are seldom or never examined in the dead from the 
region of the dorsum. Teacher and pupil alike disregard the relation 
of the scapulae, ribs, and vertebrae to each other, and to the trachea 
and lungs, the heart and great vessels, the diaphragm and the 
abdominal organs. The physical examination of the dorsum, although 
constantly practised, is consequently vague and unsatisfactory. 
This ignorance of the position of the internal organs behind is due 
to the fact that the teaching of anatomy is almost entirely conducted 
by minute anatomists and surgeons. I trust that the physician will 
soon share with them that important duty; and that, while they teach 
minute and surgical anatomy, he will teach medical anatomy. We 
shall auscultate, percuss, and observe the outer forms of the body in 
vain, unless we know the proper position of those internal organs 
whose condition we would discover. 
to the narrowing of the ribs, and the lowering of the sternum, can be 
drawn downwards to a greater extent than in the robust, and especially 
in those affected with emphysema. In examining the upper part of 
the dorsum, it is well to direct the patient to rest his arms on his 
thighs, with his hands overlapping each other and hanging between 
them, so as to lower the shoulders and scapulae as far as possible. On 
this plan, which is practised by Hr. Williams, and which obviates the 
tension of the muscles, the scapulae and the trapezii grasp the ribs, 
especially the upper ribs, as closely as possible, thus affording an equal 
tense surface for percussion. When the young man, the movements of 
whose scapulae have been just described, stretched his arms downwards 
in the method indicated, the spines of the scapulae, which were on a 
level with the fourth dorsal spine, were 81 inches apart, the lower 
angles being 10 inches apart. 
When the scapula is in this position in a healthy person, its spine is 
usually just over the septum, between the upper and lower lobes; 
consequently, the space above the spine is occupied by the summit of 
the upper lobe; that below it, by the upper part of the lower lobe. 
Below the spine, the scapula is superficial to the upper and, from its 
overlapping the upper lobe, the less bulky half of the lower lobe, the 
lower and more bulky half of that lobe being below the lower angle of 
the scapula. 
THE SCAPULA] 
The play of the scapula is greater than that of any other bone, so 
as to allow of the free and varied movements of the arms, and the 
extensive ascent of the scapulae during a deep inspiration. 
The following observations as to the exact extent of the mobility of 
the scapulae were made on the person of a well-formed young man, 
now in St. Mary’s Hospital, who had recently recovered from inter- 
mittent fever. When he stands erect, the arms pendant, the dorsum 
of the scapula is nearly but not quite flat, its spine inclining slightly 
forward towards its acromial end. The spine is nearly horizontal, being 
almost on a level with the clavicle. The apex of the chest, composed 
of as much of the first four ribs as appears above the scapula, is 
interposed in the form of a cone between that bone and the clavicle. 
The opposite scapulae are 51 inches apart at the spines, and 6 inches at 
the lower angles. The spine of the scapula at the base is on a level 
with the third dorsal spine, and the lower angle of the scapula is on 
a level with the eighth dorsal spine; the lower angle is above the 
ninth rib. When he throws his arms backwards, so as to approximate 
the scapulae as much as possible, the spines are about inch asunder, 
the lower angles about 3 inches. When he stretches the arms upwards 
and forwards, so as to separate the scapulae as far as possible, the 
spines are 9 inches asunder, the lower angles 13 inches. When he 
crosses his arms over his head, the lower angles, which project at 
each side, are 16£ inches apart. When he shrugs his shoulders as 
high as possible, the spines are on a level, at the base of the scapula, 
with the first dorsal spine; while each acromion is on a level with 
the third cervical vertebra. The spines of the scapulae, instead of being 
horizontal, are inclined obliquely upwards at an angle of about 65°. 
During inspiration, the scapulae seem to ride on the thoracic walls, 
being apparently elevated and displaced forwards and to each side by 
the thrust of the expanding ribs. In reality, however, the scapulae, 
instead of being lifted up by the ribs, are withdrawn from them during 
their inspiratory movements, by a combination of independent forces 
operating immediately upon the scapulae. I will consider what those 
forces are, after describing the inspiratory movements of the scapulae 
in the young man convalescent from ague. 
When he takes a deep breath, the upper end of the sternum, the 
clavicles from end to end, and both shoulders, move forwards one inch, 
and upwards one inch; the acromial end of the spine of the scapula, 
necessarily put in motion by the sternum and clavicles, advances and 
ascends to the same extent, while the end of the spine at the base of 
the scapula only moves forwards three-quarters of an inch. The space 
between the bases of the scapulae is widened, so that at their spines it 
is increased from 4-| inches to inches, and at the lower angles from 
inches to 7; while the spines at the base ascend from the level of 
the third to that of the second dorsal spine, and the lower angles 
ascend from the level of the eighth to that of the sixth dorsal spine. 
It results from these movements that, during a deep inspiration, the 
clavicles, shoulders, and scapulae are raised and drawn forward by the 
forward ascent of the sternum. The scapulae are directly elevated by 
the combined action of the levatores anguli scapulae, the trapezii, and 
perhaps the rhomboidei. Owing to their common elevation to the 
extent of an inch, the clavicle and scapula form a screen, which 
conceals the third, the second, and the greater part of the first ribs. 
The cone formed by those ribs in the neck therefore disappears, being 
replaced behind by the massive rigid fibres of the trapezius, and in 
front by a deep hollow behind the forward sternum and clavicles. The 
neck is shortened, and the shoulders become square. The spine of 
The play of the scapulae is so great, that, at first sight, one naturally 
infers that they are of no value as landmarks for ascertaining the 
position of the ribs, and the internal organs. This is not so, however, 
for the extent to which they can be drawn downwards is very definitely 
limited, owing to their attachment to the body, and the pivot of their 
movement being fixed at the sternal end of the clavicle. In slender 
persons, however, and especially in the phthisical, the scapulae, owing 
EXPLANATION OE PLATE XII. 
The Plate represents a superficial view of the internal organs as seen from behind; the 
ribs and vertebrae, and the diaphragm, being left in situ. 
Previously to making the dissection, the trachea was tied. The vertebrae and ribs were 
then completely denuded, and the intercostal muscles were removed so as to expose the 
lungs and diaphragm through the intercostal spaces. 
The septum between the upper and lower lobes of the lung is shown on each side, 
between the third and fourth ribs. The diaphragm comes into view below the base of each 
lung, a larger portion of it being exposed on the right than the left side. In this Plate, 
otherwise correct, the lower ribs are thicker than they ought to be, where they approach 
the sides of the body. 
Below the diaphragm, and to each side of the upper lumbar vertebrae, the kidneys are 
exposed, the upper portion of them being concealed by the lower portion of the diaphragm. 
The ascending arch of the colon is seen to the right of and below the right kidney, 
outside the fourth and fifth lumbar vertebrae, and above the crest of the ilium. The 
descending arch of the colon is, in like manner, exposed on the left side. 
(Reduced from 34f inches to 18f.) COMMENTARY ON PLATES XII., XIII., XIY., & XV. 
the scapula, instead of being parallel with the clavicle and flat over 
the hack, inclines obliquely forwards and upwards, so as to render the 
back round and stooping. The interscapular space is widened, and 
raised to a greater extent below than above. The scapulae are thus 
lifted outwards from behind the ribs; so that the lower angle, which 
at the beginning of inspiration rests on the ninth rib, at the end of it 
rests on the seventh. 
of the ninth rib. Just below this, the broadest part of the cage of the 
chest, the outline of the lower ribs, the tenth and eleventh, narrows 
inwards on each side for the extent of about an inch and a-half. 
The cone of the chest, just described, does not widen with an equal 
and gradual increase from above downwards. It may be observed, that 
the cone progressively increases in width from the first rib to the fourth; 
that it retains nearly the same diameter over the fourth, fifth, and 
sixth ribs, its sides being there almost perpendicular; and that it 
becomes suddenly wider at the seventh rib, whence it increases in size 
down to the lower edge of the ninth rib. The seventh, eighth, and 
ninth ribs thus present a bulge on each side. This bulge corresponds 
on the right side with the liver; on the left side, with the stomach and 
spleen, in addition to the base of either lung. 
The ribs, from the first to the eighth or ninth, cannot be distin- 
guished by touch over the dorsum, even of thin persons, owing to the 
muscles by which they are covered, and to the position of the scapulae. 
The attachments of the ribs to the transverse processes of the vertebrae, 
cannot be felt at all. The dorsal spines can, however, always be 
discovered by pressure, and they form a series of landmarks, whereby 
we may accurately infer the position of each rib, at its spring from the 
spinal column. 
I have long endeavoured to ascertain the effect induced by the 
contraction of the subclavius muscle, and the cause of the eversion of 
the scapula, especially at the lower angle. I observed in a patient, a 
very lean man, suffering from emphysema, that the subclavius acts 
during each inspiration. I think it probable that this muscle causes 
eversion of the scapula by acting upon it through the clavicle. This 
eversion permits the seventh and eighth ribs, no longer restrained by the 
superposition of the scapula, to move more freely backwards during 
inspiration, so as to aid the lower ribs in the dorsal expansion of the 
lower lobes. 
The above observations show that all the movements of the scapula, 
brachial as well as respiratory, are more restrained at the upper than 
the lower angle. The comparative restraint on the upward, outward, 
and downward movements of the upper angles is caused by the 
shortness of the fibres of the trapezius inserted into the inner 
end of the spine of the scapula; while their forward movement is 
almost prevented by the ribs just in front of them. 
Each dorsal spine, owing to its low position and downward direction, 
is on a level, not with the rib corresponding to its own vertebra, but 
with a lower rib. The last cervical vertebra, which may usually be 
known by its marked prominence, is on a line with the articulations of 
the first ribs. The first, second, and third dorsal spines, which have, 
like the lowest cervical spine, a direction as much backwards as 
downwards, correspond respectively with the articulations of the 
second, third, and fourth ribs. 
In those affected with emphysema, the scapulae and the walls of the 
chest assume, to an exaggerated degree and in a modified manner, 
the position of deep inspiration. The sternum is high and prominent, 
the neck is short, and the shoulders are high and forward. The 
clavicles and scapulae are raised, so as to conceal the cone formed 
by the upper ribs, and to present instead, in some cases, a deep hollow 
between the clavicle and the trapezius. Owing to the increased support 
afforded to it by the fulness of the chest, the scapula is moved upwards 
and outwards, and sits closely upon the ribs. The result is that the 
base is withdrawn from the spinal column, especially at the lower 
angle; the interscapular space is widened and raised ; the spine of the 
scapula, which is unusually high, inclines obliquely forwards and 
upwards from the base to the acromion ; the lower angle is just above 
the seventh rib ; and the whole scapula, instead of being flat, inclines 
obliquely upwards and forwards, from the base to the acromion. 
The first three dorsal spines, like the lowest cervical spine, project 
backwards as much as downwards, at an angle of about 45°, are not 
attached closely to each other, and enjoy some play of movement 
during the varying flexure of the neck. The dorsal spines, from the 
fourth to the ninth, differ materially in direction from the first three, 
since they are lengthened almost directly downwards, at an angle of 
about 85°, overlap closely one upon the other, being attached by 
firm ligaments, and enjoy only a slight play of movement during 
the bendings of the body and the movements of respiration. The 
result is, that the tips of most of these spines indicate the second rib 
below them ; so that the fifth spine is intermediate to the spring of the 
seventh ribs. 
In the very slender, and still more in those affected with phthisis, 
the scapulae, as well as the walls of the chest, take up the position of 
deep expiration. The sternum is low and flat, the neck is long, and 
the shoulders are sloping. The clavicles and scapulae are lowered, so 
as to expose above them, to an unusual extent, the upper portion of the 
cone of the chest, which is narrow, owing to the contraction* of the 
upper lobe. Owing to the collapse of the ribs, the scapula, especially on 
the affected side, loses its support, and drops downwards, falls inwards, 
and projects backwards, particularly at the lower angle. The result is, 
that the base protrudes and approximates to the spinal column, espe- 
cially at the lower angle; the interscapular space is narrowed and 
lowered; the spine of the scapula, which is unusually low, is either 
horizontal, or inclines downwards from the base to the acromion; the 
lower angle is just above the tenth or eleventh rib ; and the whole 
scapula, instead of being flat, protrudes obliquely backwards from the 
acromion. 
The three lower dorsal spines assimilate gradually to the lumbar 
spines, their direction being less and less downwards, more and more 
backwards; so that the twelfth dorsal spine projects, like the first 
lumbar, almost directly backwards. The tenth spine corresponds with 
the spring of the eleventh rib, while that of the twelfth rib is inter- 
mediate to the spines of the eleventh and twelfth dorsal vertebrae. 
The spines of the vertebrae form a series of important landmarks, 
for ascertaining during life the normal position of the subjacent 
organs. 
The apex of each lung is on a level with the lower edge of the first 
cervical spine. The space between the second and third dorsal spines 
is Intermediate to the upper edge of each lower lobe; while the base 
of the lower lobe, in the dead body, is on a line with the tip of the 
tenth dorsal spine, the left base being just below, the right just above, 
the tip. In the living body, however, the base of each lung is about a 
rib’s breadth lower than in the dead. 
The lower edge of the diaphragm is seated to each side of the 
twelfth dorsal spine, and the base of each lung descends, during a deep 
inspiration, to the level of that spine. 
The glottis is in front of the third cervical spine. Thence the 
trachea passes downwards in front of the bodies of the vertebrae, 
inclining somewhat to the right, the bifurcation of the trachea being 
in front, and a little to the right of the tip of the fifth dorsal spine. 
The interscapular space includes those important organs, the trachea 
and its bifurcation, and the roots of both lungs, the oesophagus and 
aorta, and the heart and great vessels. The dorsal spines form a series of 
landmarks, which accurately indicate the normal position of those 
organs. I will, therefore, defer the consideration of their relative 
bearings, until I describe the spinal column. 
THE SPINAL COLUMN AND THE RIBS. 
The pharynx and oesophagus intervene between the bodies of the 
vertebrae and the larynx and trachea; consequently, when the spinal 
column is removed, the oesophagus conceals the trachea from view. 
The oesophagus, like the trachea, bears somewhat to the right during 
its descent. The aorta and the oesophagus lie side by side in front of 
the bodies of the vertebrae, the latter lying upon their right half, the 
former upon their left half. The oesophagus crosses in front of the 
aorta, anterior to the eighth dorsal spine, and it penetrates the 
diaphragm, and enters the cardiac orifice of the stomach to the left of 
the ninth and tenth dorsal spine. 
The cage of the chest, composed of the ribs and dorsal vertebrae, 
viewed from behind, presents itself as a cone, widening at each side 
from above downwards, and attaining its maximum width just 
where the ninth rib disappears from view, as it turns from behind 
downwards and forwards. This broadest part of the cone of the 
chest is in a line with the spine of the twelfth dorsal vertebra, so that 
a girdle tied round the body at the point in question would, at the 
centre, cross the twelfth dorsal spine, and at each side, the lower edge FI. 111. COMMENTARY ON PLATES XII., XIII., XIY., & XV. 
The heart and great vessels, from the top of the arch of the aorta to 
the lower edge of the left ventricle, usually occupy the space extending 
downwards from the third to the ninth dorsal spine. The third 
dorsal spine indicates the top of the arch of the aorta; the fourth, the 
top of the pulmonary artery. The mitral valve is situated in front 
of the space between the sixth and eighth spines, with a bearing to 
the left. The apex of the left ventricle is on a level with, but con- 
siderably to the left of, the eighth dorsal spine. 
The descending aorta lies in front of the left half of the bodies of 
the vertebrae. The spring of the coeliac axis is indicated by the twelfth 
dorsal spine, the origin of each renal artery by the first lumbar spine, 
and the bifurcation of the aorta by the fourth lumbar spine. 
The ascending vena cava, at its commencement in the confluence of 
the iliac veins, is on a line with the fourth lumbar spine. The vein 
pierces the diaphragm in front of the ninth, and empties itself into 
the right auricle on a level with the seventh dorsal spine. 
intercostal spaces and abdominal parietes, all the branches of the 
abdominal aorta have a fixed position at their origin, being uninflu- 
enced either by the movements of respiration, or by the changes in 
position and size of the abdominal organs. 
The solar plexus and the origin of the thoracic duct, which also 
occupy the space indicated by the last dorsal and first lumbar spines, 
are fixed in position, like the arteries to which they are contiguous. 
The pancreas, where it passes from the spleen to the front of the 
aorta, is on a level with the space between the eleventh dorsal and first 
lumbar spines. Where it crosses in front of the aorta and vena cava, 
occupying the inner circuit of the duodenum, it is indicated by the 
space between the twelfth dorsal and second lumbar spines. The 
pancreatic duct enters the duodenum with the biliary duct on a level 
with the lower edge of the first lumbar spine. 
The duodenum, viewed posteriorly, as it takes its circuit round the 
head of the pancreas, comes into view in Plate XIY., on a line with 
the space between the last dorsal and first lumbar spines, being there 
contiguous to the point at which the vena porta enters and the hepatic 
duct emerges from the liver. The duodenum from thence descends 
along the side of the ascending vena cava, curves to the left, and crosses 
before the great vessels in front of the second and third lumbar spines. 
Thence it ascends to the left of the aorta, and disappears among the 
mass of intestines. The portion of pancreas contiguous to the spleen 
is much more subject to the movements of respiration, and to the 
constantly varying size and position of the stomach and intestines, 
than the portion of pancreas surrounded by the duodenum. The 
duodenum and adjoining pancreas, being loosely adherent, ascend 
slightly during expiration and descend during inspiration, and are 
lowered and spread out more widely when the duodenum is itself 
distended. 
The lower boundary of the diaphragm, where the pleura is reflected 
upon it from the ribs, is situated to each side of the twelfth dorsal 
spine. This is the limit to which the lower boundary of the lungs can 
descend during the deepest possible inspiration. 
The right summit of the diaphragm, which corresponds with the 
convex upper surface of the liver, is usually above the eighth dorsal 
spine; while the left summit, which invests the upper convexity of 
the stomach, is below that spine. 
When the liver is large and the stomach empty, the level of the left 
summit of the diaphragm is much lower in relation to that of the 
right, than when the stomach is much distended, in which case the 
diaphragm sometimes encroaches upwards on the chest as much on 
the left side as the right. 
The convex upper surface of the liver corresponds, as I have just 
said, with the right summit of the diaphragm, being on a level with the 
space above the eighth dorsal spine. The liver comes in contact with 
the surface posteriorly just below the base of the right lung, on a 
level usually with the tenth dorsal spine. The vena porta enters and 
the hepatic duct emerges from the liver in Plate XIY., on a level with 
the space between the last dorsal and first lumbar vertebrae. Below 
this point the kidneys and the intestines are interposed between the 
liver and the parietes. 
The upper edge of the right kidney is usually on a line with the 
space between the eleventh and twelfth dorsal spines, its lower edge 
being to the right of the third lumbar spine. The left kidney is usually 
lower than the right. This was the case in eight of the thirteen 
bodies included in the subjoined table, while the right kidney was 
lower than the left in three, and the kidneys were on the same level in 
one of these bodies. The pelvis of each kidney is usually on a level 
with the first lumbar spine. 
Each suprarenal capsule is a degree higher than the upper edge 
of the kidney to which it is attached. 
The cardiac orifice of the stomach is situated to the left of the ninth 
and tenth dorsal spines. A small portion of the stomach is usually, as 
in Plate XIII. S, immediately subjacent to the surface, between the 
base of the left lung and the suprarenal capsule. This exposed portion 
of the stomach (S) is, however, covered by lung, when the left base 
descends, so as to he interposed between the surface and the suprarenal 
capsule. The pylorus (see Plate IV.) crosses from left to right, in front 
of the portal vein, on a level with, or below, the twelfth dorsal spine; 
and, in Plate XIY., is hidden, just before it empties itself into the duo- 
denum (D), by the vena porta, and vena cava. 
The upper edge of the spleen is usually on a level with the ninth, 
its lower edge, with the twelfth dorsal spine. 
The twelfth dorsal and first lumbar spines indicate the position 
of various parts and organs of importance. I advise the careful 
study of the relative position of these parts in Plates XIY., XII. 
and XIII., and, by way of comparison, in Plates IY. to YII. 
(front views), and IX., XI. (side views). The coeliac axis and the 
upper mesenteric artery arise in front of the body of the first 
lumbar vertebra, and are on a level with the last dorsal spine. The 
renal arteries arise in front of the body of the second and the spine of 
the first lumbar vertebra. Owing to the attachment of the aorta to the 
spinal column by means of its branches successively distributed to the 
The liver, the spleen and adjoining portion of the pancreas, the 
kidneys and suprarenal capsules, and the great and small intestines, 
are all pushed downwards, by the descent of the diaphragm, during 
inspiration, and are raised, pushing before them the diaphragm, by the 
contraction of the abdominal muscles, during each expiration; and all 
these organs, whether solid or hollow, vary in size, as they contain 
more or less blood, or more or less liquid and gaseous contents, with 
the constant effect of being displaced by, and displacing each other. 
The origin of the vessels supplying each of these organs forms 
a point of attachment in connection with which their movements 
are modified. Thus the coeliac axis serves as a fixed point of attach- 
ment for the pancreas, spleen, liver, and stomach. The mesenteric 
arteries are points of attachment for the intestines, and the renal 
arteries, for the kidneys. 
The following Table presents at one view the position of various 
parts and organs in relation to the spines of the vertebra, in thirteen 
bodies dissected by myself from the dorsum. In the first five subjects, 
the face and body were embedded in Plaster-of-Paris on the plan 
described in the explanation of Plate XIII, 
EXPLANATION OE PLATE XIII. 
In the bodies from which this Plate and Plates XIY. and XY. were taken, I first 
exposed the ribs, vertebrae, and superficial internal organs, as in Plate XII. After 
taking a tracing of the parts so exposed, I embedded the face, neck, chest, and pelvis, 
and the ribs and abdominal parietes, in Plaster-of-Paris. The ribs were then sawn across, 
and the spinal column was carefully removed. By adopting this plan, the internal organs 
kept their original position, and a solid prop was afforded to the ribs and abdominal 
parietes, which otherwise would have yielded outwards when deprived of their natural 
support. I advise the adoption of this plan to any one who may be induced to make for 
himself the very instructive series of dissections figured in these four plates representing 
the back view of the internal organs. 
The subject from which Plate XIII. was taken was a man said to be seventy-six years 
of age, but muscular, and of broad, square set proportions. He died of suffocative 
catarrh. His internal organs were apparently healthy, the lungs being free from adhesions. 
The arteria innominata, the trachea and right bronchus, and the right pulmonary artery, 
which have been brought into view by drawing aside the inner edge of the right lung, 
were figured, not from this, but from another healthy body. 
The whole spinal column, with the adjoining portion of the ribs, have been removed, 
and the organs immediately subjacent brought into view. 
In the neck—The posterior wall of the pharynx, the extremities of the os hyoides, the 
thyroid bodies, the great vessels and the sternocleido mastoid, the omo-hyoid, and the 
levatores scapulae, are exposed. 
In the chest—The oesophagus, the thoracic aorta, and the lungs in situ, are seen. The 
pericardium, and the entrance into it of the inferior vena cava, and the organs spoken of 
above, have been brought partially into view by the withdrawal of the inner edge of the 
right lung. 
In the abdomen The great vessels, the suprarenal capsules, kidneys and ureters, 
the ascending colon, and the sigmoid flexures are displayed; and above the other organs, 
just beneath the diaphragm, a portion of the liver, spleen (Sp.), and stomach (S) are 
revealed. 
(Reduced from to 18f inches.) COMMENTARY ON PLATES XIL, XIII., XIV., & XV. 
TABULAR VIEW. 
The following Parts and Organs were respectively on a level with the spine of the vertebra initialized in the annexed columns. Thus, in Xo. 1, see 
Plate XIY., the base of the right lung is on a level with the lower edge of the spine of the eleventh dorsal vertebra,—the summit of the 
upper lobe is as high as the space between the last cervical and first dorsal spines. 
1. 
Plate 
XIY. 
2. 
Plate 
XY. 
3. 
Plate 
XIII. 
4. 
Plate 
XII. 
5. 
Adult 
Male. 
6. 
Adult 
Male. 
7. 
Adult Male 
Right Pneu- 
monia. 
8, 
Adult 
Male. 
9. 
Adult 
Male. 
10. 
Adult 
Male. 
Lungs 
adherent. 
n. 
Adult 
Male. 
12. 1 
Adult 
Male. 
13. j 
Adult 
Male. 
Summit of upper lobe 
bel. 7 C 
bel. 7 C 
bel. 7 C 
bel. 7 C 
bel. 7 C 
bel. 7 C 
bel. 7 C 
bel. 7 C 
bei. 7 C 
bel. 7 C 
bel. 7 C 
7 C 
Summit of lower lobe ;— 
right 
4 D 
3 D 
bel. 2 D 
bel. 2 D 
bel. 4 D 
ab. 4 D 
bel. 4 D 
3 D 
i left 
3 D 
bel. 2 D 
2 D 
ab. 3 D 
2 D 
bel, 2 D 
ab. 4 D 
bel. 3 D 
Base of lower lobe ;— 
right 
11 D 
bel.10 D 
bel. 10 D 
10 D 
11 D 
ab 10 D 
bet. 11&12D 
bel. 9 D 
10 D 
ab.12 D 
ab. 10 D 
11 D 
9 D 
left 
11 D 
bel.10 D 
ab. 11 D 
10 D 
ab. 11 D 
bel. 10 D 
ab.10 D 
10 D 
bel. 11 D 
10 D 
bel. 10 D 
ab. 10 D 
Larynx (vocal chords) 
bel. 4 C 
bel. 4 C 
bel. 4 C 
4 C 
ab. 5 D 
5 C 
Bifurcation of trachea, lower edge .. 
ab. 5 D 
5 D 
ab. 5 D 
ab. 4 D 
4 D 
bel. 4 D 
ab. 5 D 
ab. 5 D 
bei. 5 D 
bel. 4 D 
ab. 5 D 
ab. 5 D 
Top of arch of aorta 
bel. 3 D 
bel. 3 D 
bel. 2 D 
ab. 3 D 
ab. 3 D 
bel. 3 D 
ab. 3 D 
ab. 3 D 
ab. 3 D 
ab. 3 D 
bel. 3 D 
Top of right pulmonary artery 
4 D 
4 D 
bel. 3 D 
ab. 4D 
ab. 4 D 
ab. 4 D 
Left auricle:— 
upper boundary 
bel. 5 D 
ab. 5 D 
bel. 5 D 
5 D 
bel. 5 D 
lower boundary 
bel. 7 D 
ab. 7 D 
bel. 7 D 
7 D 
bel. 7 D 
1 Ascending vena cava :— 
entrance into right auricle .... 
7 D 
ab. 7 D 
7 D 
bel. 6 D 
7 D 
ab, 7 D. 
passage through diaphragm .... 
9 D 
bel. 8 D 
9 D 
8 D 
bel. 7 D 
bel. 8 D 
Lower boundary of left ventricle.. .. 
ab. 9 D 
bel. 8 D. 
9 D 
ab. 9 D 
ab. 9 D 
bel. 7 D 
bel. 8 D 
bel. 8 D 
bel. 8 D 
8 D 
bel. 8 D 
Aortic valve 
bel. 5 D 
Mitral valve :— 
upper edge 
ab. 6 D 
1 
lower edge 
.... 
ab. 8 D 
Summit of right convexity of dia- 
phragm (liver) 
ab, 8 D 
ab. 7 D 
8 D 
ab. 8 D 
ab. 8 D 
ab. 7 D 
bel. 7 D 
ab. 8 D 
bel. 9 D 
ab. 8 D 
ab. 8 D 
ab. 8 D 
Summit of left convexity of diaphragm 
(stomach) 
ab. 9 D 
bel. 7 D 
ab. 9 D 
8 D 
bel. 8 D 
7 D 
8 D 
ab. 8 D 
ab.10 D 
8 D 
ab. 8 D 
8 D 
Spleen :— 
npper edge 
9 D 
8 D 
9 D 
ab. 10 D 
9 D 
7 D 
9 D 
ab. 10 D 
lower edge 
bel. 12 D 
12 D 
11 D 
12 D 
12 D 
10 D 
ab.12 D 
ab. 2 L 
Pancreas, duodenal head :— 
upper edge 
12 D 
12 D 
ab. 12 D 
ab. 11 D 
lower edge 
2 L 
2 L 
ab. 2 L 
Entrance of portal vein into, and exit 
of duct from liver 
ab. L 
bel. 11 D 
10 D 
11 D 
Duodenum: — 
entrance of biliary duct into . 
bel. 1 L 
ab. 1 L 
bel. 12 D 
bel. 1 L 
lower edge of 
bel. 3 L 
3 L 
ab, 3 L 
bel. 3 L 
Eight kidney:— 
npper edge 
12 D 
ab. 11 D 
12 D 
11 D 
ab. 12 D 
bel. 11 D 
lower edge 
3 L 
bel. 3 L 
3 L 
3 L 
ab. 3 L 
3 L 
3 L 
ab. 3 L 
bei. 3 L 
2 L 
2 L 
8 L 
Left kidney:—• 
npper edge 
12 D 
11 D 
ab.11 D 
bel. 24 D 
ab. 12 D 
# , 
ab.12 D 
11 D 
11 D 
lower edge 
3 L 
ab. 3 L 
bel. 8 L 
2 L 
ab. 3 L 
ab. 3 L 
3 L 
3 L 
ab. 3 L 
ab. 2 L 
ab. 3 L 
(Esophagus enters stomach at cardiac 
orifice 
bet.9&10D 
9 D 
bet.9&10D 
bet. 9&10D 
9 D 
bet. 9&10 D 
C—signifies The spine of a cervical vertebra. 
D— ~ The spine of a dorsal vertebra. 
L— ~ The spine of a lumbar vertebra. 
When the letter C, D, or L appears alone, the part in question is situated on a level with the lower 
end of the spine initialized. 
When “ bel.” precedes the letter C, D, or L, the part is just below, and when “ ab.” precedes the 
letter C, D, or L, the part is just above the lower end of the spine indicated. Where “bet. 9 & 10, 
EXPLANATION OE THE ABOVE TABLE. 
D” is inserted, the object named is on a level with the space between the spines of the ninth 
and tenth dorsal vertebrae. 
Nos. 1, 2, 3, & 4, correspond with the Plates now under review. 
No. 8 was figured in the Medical Gazette for 1848. 
Nos. 9 & 10 were figured in the Prov. Med. Trans. Vol. 12. The remainder have not been 
published. 
posterior surface of the larynx, and the trachea with its bifurcation are 
exposed. In Plate XY., the interior of the larynx is brought into 
view by cutting away a portion of the cricoid, and by separating the 
arytenoid cartilages. 
The larynx, extending from the top of the epiglottis to the lower 
end of the cricoid cartilage, is situated (the posterior wall of the 
pharynx being interposed) in front of the bodies of the cervical 
vertebrae, from the third to the sixth, in Plates XIY., YIL, and IX. 
In Plates X. and XI., the larynx is higher by the breadth of the body 
of a vertebra, since it extends in them from the second down to the 
fifth dorsal vertebra. The larynx, in fact, has no fixed position, but 
moves downwards with each inspiration, upwards with each expiration. 
In the robust, (as in Plates XIY. and IX.), and still more in those 
affected with emphysema, it is lower than in the flat-chested (as in 
Plates X. and XI.) and the phthisical. The trachea, down to its 
bifurcation, presents the same respiratory movements, and the same 
varieties in position as the larynx. 
THE LARYNX, TRACHEA, AND LUNGS. 
(See columns 3—lo, 25—33.) 
By comparing Plates XIY. and XY. with Plates YIL and XI. the 
position of the larynx and trachea, and their relation to the nostrils 
and fauces, may be studied. As may be seen in Plate XL, the posterior 
fauces form an open channel for the passage of respired air between 
the nostrils and the larynx. This channel is formed in front by the 
soft palate, the tongue, and the epiglottis, at the sides by the tonsils, 
and behind by the bones of the first four vertebrae, the posterior wall of 
the fauces and pharynx being interposed. This channel is only closed 
during the act of deglutition, and when the tongue is voluntarily 
pressed backwards against the soft palate and posterior wall of the fauces. 
The tongue is evidently prevented from falling back upon the posterior 
wall of the fauces, so as to close the respiratory channel, by means of 
the arched os-hyoides, the pillars of which rest on the vertebrae, and to a 
less extent by the forward support given to the tongue by its muscles 
arising from the lower jaw. This respiratory channel, conveying air 
from the nostrils to the larynx, extends downwards from the base of 
the cranium in front of the bodies of the first four vertebrae. 
The top of the cricoid, and the arytenoid cartilages occupy the two 
anterior thirds of the hollow of the thyroid cartilage: they are 
consequently sustained forwards, so as to be free from contact with 
the posterior wall of the pharynx. The thyroid cartilage, in fact, acts 
as a bridge to protect the other cartilages from pressure, its posterior 
edges and cornua resting, with a long, firm support, upon the bodies of 
the third, fourth, and fifth cervical vertebrae, the posterior wall of the 
pharynx being interposed: the result is, that the arytenoid cartilages 
move in a free space, so as to widen the glottis during inspiration, and 
to stretch and approximate the vocal chords during the acts of speaking, 
coughing, and laughing. These sounds would, indeed, be stifled in 
their production, if the vocal chords were damped during their action 
by the contact of the arytenoid cartilages with the posterior wall of 
the pharynx. 
The arch formed by the os-hyoides, acts in like manner as a bridge, 
to prevent the epiglottis from being forced backwards. 
When this respiratory channel is much narrowed by enlargement of 
the tonsils, the patient breathes through the open mouth, especially 
during sleep. 
When the tonsils are enlarged so as materially to narrow the respi- 
ratory channel, loud hissing breath sounds are excited, audible in the 
open air, and oyer the front and back of the neck. 
During the act of deglutition, the morsel of food, and the back of 
the tongue press the soft palate backwards against the posterior fauces, 
so as to close the posterior nares. At the same time the larynx is 
drawn forwards and upwards, and what was formerly a part of the 
channel for breathing becomes now the channel for food. 
In Plate XIII. the larynx, and the trachea, all but its right edge, 
are hidden by the pharynx and oesophagus. In Plate XIY., the ML 2IT. COMMENTARY ON PLATES XII., XIII., XIV., & XV. 
THE AORTA AND ITS ANEURISMS. 
The aneurisms of the sinuses ruptured in 80 per cent, of the cases; 
in 45 per cent, into the pericardium, 13-5 per cent, into the pulmonary 
artery, 8-5 per cent, into the right auricle, 5 per cent, into the right 
ventricle, and 5 per cent, into the left ventricle. 
The heart was stated to be enlarged in 29 per cent, of the cases, 
and the pericardium was adherent in 7 per cent. 
Murmur was observed in 34*5 per cent, of the cases; hut as in more 
than half the signs were not observed, the actual proportion in which 
murmur was present was undoubtedly much greater. The great 
frequency of murmur in aneurisms of the sinuses is due to the regurgi- 
tation which so often takes place through the pulmonic valves, as well 
as through the aortic valves themselves. Pulsating tumour was 
present in 7 per cent, of the cases, one-half being to the right, one-half 
to the left of the sternum. 
The aorta, from its origin to its bifurcation, is surrounded by im- 
portant organs, and protected in front by the walls of the chest and 
abdomen, and behind by the spinal column. Its anatomical relations 
change at each successive part of its course. When the aorta is affected 
with aneurism, there is no symptom of the disease, and rarely any sign, 
unless the pulsating tumour presents at the surface, or presses on the 
surrounding organs so as to interfere with their function. The close 
study of the relative anatomy of the aorta is consequently the true, and, 
indeed, only clue to the diagnosis of aneurisms of the aorta. I shall 
here, therefore, give an analysis of the anatomical relations, signs, and 
symptoms of each aortic aneurism, after describing the relative anatomy 
of the corresponding portion of the aorta. This analysis, as I have 
further detailed in the appendix of tables, is derived from the examina- 
tion of the histories of 584 cases of aortic aneurism, obtained from 
various sources, and of 296 specimens examined in Museums, and to 
which no history was attached. The Museum specimens are never 
referred to unless they are specially mentioned. 
Plates XIII. and XIY. exhibit the aorta in its course from the source 
of the left subclavian to its bifurcation. The arch of the aorta is exposed 
in Plate XY. In studying the aorta in these plates, I advise that 
Plate XII. be kept in view, so that the aorta may be figured on it 
as it were by the mind’s eye, in its relation to the spinal column. The 
aorta may, at the same time, be observed with advantage in Plates 
IY. toYII. (front views), and Plates IX. and XL (side views). 
The ascending aorta, the arch, and the upper portion of the descend- 
ing aorta, vary in position in accordance with the movements of 
respiration. The position of the descending aorta from the point at 
which it comes in contact with the spinal column, down to its bifur- 
cation, is fixed, owing to its attachment to the spine by the intercostal 
and other parietal branches. 
The ascending aorta and arch, the heart itself, the trachea and 
bronchi, and the pulmonary vessels, are all lowered during each inspi- 
ration by the descent of the diaphragm, and they are all elevated by 
the ascent of the diaphragm. 
The descent during inspiration of the ascending aorta is much 
greater than that of the upper portion of the descending aorta, which 
is restrained by its attachment to the spinal column. The play of 
the transverse is less than that of the ascending, and greater than that 
of the descending aorta. During inspiration, the ascending aorta is 
somewhat straightened as well as lowered, and the curve of the arch 
is rendered more acute. 
Dyspnoea was observed in 38 per cent, of the cases, cough in 24 per 
cent., pain in 21 per cent. 38 per cent, appeared to be in perfect 
health up to the time of the fatal attack. The small proportion of 
cases with symptoms of disease, and the large proportion apparently 
healthy, are due to the non-existence in many cases of pressure on 
important organs, and to the early period at which rupture takes place 
into the adjoining pericardium. It will be observed throughout, that 
the greater the proportion of ruptures in any group of aneurisms of 
the aorta, the smaller is the proportion of instances in which the 
disease is indicated by symptoms during life, and vice versd. 
THE AS GENDIN H AOETA ABOVE THE SINUSES OE VALSALVA. 
The ascending aorta, after it clears the heart, rests upon the right 
pulmonary artery and the left side of the trachea. The superior vena 
cava is on its right side, the pulmonary artery and a portion of the 
left lung are on its left. It is separated from the lower half of the 
upper third of the sternum by the approximated edges of both lungs ; 
but when those edges have shrunk to either side, it is immediately 
behind the sternum, the pericardium being interposed. 
Aneurisms of the ascending aorta above the sinuses are sacculated 
in about 51 per cent., and present simple dilatation of the artery in 
about 37 per cent. They originated in the anterior aspect of the aorta 
in 15, in the right in 46, and in the left in only 8 instances, including 
the Museum specimens. This great predominance to the right is 
evidently due to the direction of the current of blood, which being 
propelled forwards and from left to right by the left ventricle, impinges 
on the right anterior wall of the ascending aorta, so as to dilate the 
vessel at that part. In unison with the direction of the aneurism 
anteriorly and to the right, we find that the sac compressed the right 
lung in 34 instances, the left lung in 10 ; the right bronchus in 6 
instances, the left in 1; that the ribs, cartilages, and sternum were 
eroded to a greater or less degree—to the right in 26 cases, to the left 
in 6; and that a pulsating tumour presented externally to the right 
in 20 cases, to the left in 8. The aneurism made pressure on the 
pulmonary artery in 7 instances, on the descending vena cava in 16, 
on the trachea in 9, and on the oesophagus in 9. 
The aneurisms ruptured in 57 per cent, of the cases; externally 
in 8, into the pericardium in 22, the pulmonary artery in 4, the right 
auricle in 1, the descending vena cava in 5, the trachea in 1, the right 
bronchus in 3, the right lung in 5, the left lung in 2, the right pleura 
in 2, and the left pleura in 4. The frequency of adhesions of the right 
pleura, owing to the pressure of the tumour on the right side, appears 
to account for the small number of ruptures into the right pleura, and 
the comparatively large number into the left. 
Murmur was observed in 23 per cent, of the cases. Deficient breathing 
over the right side of the chest, though it must have existed in many 
of the cases, was noticed in but 7. A sharp diastolic shock or second 
impulse was felt over the tumour in several cases. Eourteen per cent, 
died suddenly, and 11 per cent, were apparently in health up to the 
time of the fatal attack. Dyspnoea was noticed in 51 per cent., 
orthopnoea in 18, cough in 36, raucous voice or stridor in 4, and 
dysphagia in 2 per cent. Pain was felt in 40 per cent.; in the 
chest 29, in the neck and shoulders in 10, and in the right arm in 2. 
The first portion of the ascending aorta, including the sigmoid 
valves and sinuses, is imbedded in the body of the heart, being sur- 
rounded by its various walls, cavities, and vessels. The right ventricle 
and the auricular portion of the right auricle are in front of the 'aorta, 
the pulmonary artery is on its right side, the right auricle and the 
vena cava are on its left, and the left auricle and the right pulmonary 
artery are behind it. 
The aortic valves are usually on a level with the top of the body of 
the eighth and the spine of the sixth dorsal vertebrae behind, and with 
the middle of the sternum on a line with its junction to the third 
costal cartilages in front; so that if a rifle bullet went in at one of 
those points, straight through the body, and out at the other, it would 
tear its way through the aortic valves, 
Mr. Thurnam, in his important paper on aneurisms, following the 
descriptions of Yalsalva Senac and Portal, erroneously designates the 
sinuses within which the coronary arteries arise, the “ right and left 
anterior sinuses,” while the intermediate sinus he terms “ posterior.” 
The fact is, as may be readily ascertained when the heart is in situ, 
the sinus that gives origin to the left coronary artery is situated not 
anteriorly, but posteriorly. That valve and the intercoronary valve, 
indeed, meet at the centre of the posterior wall of the aorta. I shall 
here, therefore, to avoid ambiguity, return to Bizot’s term of “ inter- 
coronary,” rejected by Mr. Thurnam, and shall name the two other 
valves and sinuses respectively, the right and left coronary. 
The aneurisms of the sinuses of Yalsalva, and of the ascending aorta 
immediately above and between the valves, are in their very nature 
sacculated. The right coronary sinus is the most, the left coronary the 
least, frequently affected. I conceive that one reason for this is the 
fact, that at the beginning of the diastole the recoil of the current of 
blood from the trunk of the aorta back upon the sinuses takes place 
chiefly on the right anterior aspect of the vessel. The aneurisms of 
the sinuses in about a moiety of the cases compress the pulmonary 
artery, and the adjoining part of the right ventricle, so as to impede 
the exit of blood from the ventricle, and in many instances to cause 
regurgitation through the pulmonic valves. They cause pressure of 
the auricular portion of the right auricle in nearly one-half of the 
cases, and in a small proportion of the cases they compress the right 
and left auricles conjointly, the left ventricle, the descending vena cava, 
the right lung, and the left lung. 
THE SINUSES OE VALSALVA. 
THE TRANSVERSE AORTA. 
The transverse aorta, as it arches over the left bronchus, passes 
backwards with only a slight obliquity to the left. In the dead body 
just opened, when the vessels are flaccid, as in Plate Y., the transverse 
aorta does not look like an arch ; but when it is injected, as in Plate 
YL, it assumes somewhat of an arched form. If however we look at 
the side, view, Plate IX., we at once see how completely the ascending 
transverse and descending aorta form an arch, stretching over the left 
bronchus and the right pulmonary artery. The left recurrent nerve, 
curving backwards and upwards around the arch, close to the sub- 
clavian artery, is figured in Plate XY. The transverse aorta almost 
touches the oesophagus after giving off the left subclavian. 
Aneurisms of the transverse aorta are sacculated in the proportion 
of 61 per cent., and present simple dilatation of the artery in 20 per 
cent. The sac communicated with the aorta by an aperture in its 
EXPLANATION OE PLATE XIY. 
This drawing was obtained from the body of an adult who died of delirium tremens. 
In the neck, the pharynx has been removed, exposing—the posterior nares, the soft 
palate and uvula, the tongue, the epiglottis, and the arytenoid and cricoid cartilages. 
In the thorax, the oesophagus has been removed, and the lungs have, been dissected, 
exposing—the trachea, the bronchi, and the pulmonary arteries and veins; the thoracic 
aorta ; the right and left auricles ; and the left ventricle. 
In the abdomen, the kidneys have been removed, while the posterior part of the pelvis 
has been sawn away, exposing—the liver, spleen, and pancreas (P) ; the stomach (S); 
the duodenum (D) ; the biliary and pancreatic ducts, and the portal vein, which were 
figured from another body; the sigmoid flexure and head of the colon, and the end of 
the ileum (I) ; the small intestines ; the rectum, and bladder; and the great vessels. 
The thoracic duct, which is too large, was drawn from a preparation presented by Mr. 
Lane to the Museum of St. Mary’s Hospital, from Cruikshank’s work on the Absorbents 
and Bourgery’s plates. (Reduced from 36 inches to 19). COMMENTARY ON PLATES XII., XIII, XIV, & XV. 
upper aspect in 19, in its posterior or more properly right aspect in 11, 
and in its anterior or more properly left aspect in 19 instances, 
including Museum specimens. 
Pulsating tumour or fulness was present in 11 per cent, of the cases. 
In 19 per cent, the tumour was central, in 12-5 it appeared to the right 
of the sternum, and in 12-5 to the left. The tumour in these cases 
appeared either at or above the manubrium, while it usually presented 
just below the manubrium in cases of aneurism of the ascending aorta. 
Murmur was detected in 15 per cent. Breathing was deficient over 
the right side of the chest in 6 per cent, over the left in 1. 
Dyspnma was present in 71 per cent, orthopnoea in 20, cough in 57*5, 
haemoptysis in 19 per cent. The voice or cough was raucous or 
whispering, or inspiration was stridulous in 17*5 per cent. This large 
proportion of cases with laryngeal symptoms is due to the frequency 
of pressure on the trachea and on the recurrent nerve. Dysphagia 
existed in 31 per cent. The pulse was weaker at one wrist than the 
other in 26 per cent, the left pulse being the most frequently affected. 
Pain was complained of in 86 per cent, in the chest in 21, the left 
upper extremity in 8, the right in 1 per cent. 
arteries arising from it. When the sac expands, it erodes the vertebras 
and compresses the intercostal nerves backwards against the hone, so as 
to excite fixed and radiating pain. Out of 21 cases in which the 
vertebrae were eroded, fixed pain in the back and radiating pain in the 
side were both present in 10 ; in 1 other there was pain of the back, and 
in 5 others of the side or chest chiefly radiating; in 3 only was there 
no pain. On the other hand, out of 27 cases, in which the vertebrae 
were not eroded, in 12 only was pain noticed, and in but 2 of them 
was there both fixed and radiating pain. 
THE DESCENDING THOEACIC AOETA BELOW THE AECH. 
The descending thoracic aorta, from the sixth dorsal vertebra to the 
twelfth, is situated in front of the left half of the bodies of the 
vertebrae. The left lung down to its base is seated on the left side 
of the aorta, and the oesophagus descends along its right side 
down to the body of the tenth dorsal vertebra, where the oesophagus 
crosses in front of the artery to escape through the diaphragm. The 
ascending vena cava lies more or less near to the right side of the 
aorta, from the tenth dorsal vertebra down to the bifurcation. Ante- 
riorly to the descending aorta are situated, first the left bronchus, 
and then in succession the right pulmonary artery, the posterior 
surface of the pericardium, the oesophagus, and, until it enters the 
abdomen, the crura of the diaphragm. The aorta emerges into the 
abdomen between the crura of the diaphragm, in front of the body of 
the first lumbar vertebra. 
ASCENDING AND TEANSVEESE AOETA CONJOINTLY. 
To avoid confusion I have separated aneurisms of the ascending and 
transverse portions of the arch of the aorta conjointly from those 
affecting either of those portions singly. Although, as might have 
been foreseen, these aneurisms are allied partly to those of the 
ascending, partly to those of the transverse aorta, yet they form a 
natural group, differing in some essential points from either of them. 
While aneurisms of the ascending aorta and of the transverse aorta 
singly are usually sacculated, those of the ascending and transverse 
aorta conjointly are sacculated in only 31 per cent., the artery being 
dilated in as many as 85 per cent. The bearing of the conjoint 
aneurism is usually to the right—in this respect resembling aneurism 
of the ascending aorta singly. Thus the sternum and ribs were eroded 
to the right in 13 per cent., to the left in 4, at the centre in 7. Pulsating 
tumour appeared externally to the right of the sternum in 17 per cent., 
to the left in 4, and in the centre of the chest in 10. The right 
lung was compressed in 17 per cent., the left lung in 6. The 
descending vena cava was compressed in 10 out of 44 specimens observed 
in the various Museums. A smaller proportion of the cases resemble 
aneurism of the transverse aorta, the trachea being compressed in 33 
per cent., the oesophagus in 9. Of the specimens observed in Museums 
there was obstruction of the arteria innominata by clot in 2, the left 
carotid in 1, the innominata and left carotid in 1. The conjoint 
aneurisms ruptured in 37 per cent, of the cases; into the pericardium 
in 10, the pulmonary artery in I*s, the vena cava in 4, the trachea in 
4, the right pleura in 3, and the left pleura in I*s per cent. 
While of the conjoint aneurisms a smaller number rupture than of 
those of the ascending aorta alone, a larger number present formidable 
symptoms during life. There was pulsating tumour in 30 per cent., 
murmur was noticed in 22 per cent. Dyspnoea was present in 74 per 
cent., orthopnoea in 21 •5, cough in 47, haemoptysis in 10, stridulous 
breathing or affection of voice in 17, dysphagia in 21'5. Pain was present 
in 46 per cent.; in the chest in 30 per cent., the right side of it in 
11, the left in 7; in the back in 10 ; the upper extremities (one or both) 
in 18, the right in 6, the left in 3; in the neck in 4 per cent. The 
head and neck were swollen in 14 per cent.; the right pulse was weak 
or imperceptible in 6 per cent., the left pulse in 3. 
Aneurisms of the descending thoracic aorta, below the arch, are 
sacculated in 35 per cent, of the cases; present general dilatation in 
28, and are undescribed in 37. The proportion were respectively 58, 
50, and 4 per cent, in the specimens observed in Museums. The 
aneurism usually lay along the left side of the spinal column, and 
caused erosion of the vertebrae in 74 per cent. The sac displaced the 
oesophagus in Bof the 24 specimens observed in Museums. The left, 
and, though much less frequently, the right lung, were compressed by 
the aneurism in a large proportion of the cases. The sac burst, in 65 
per cent, of the cases; into the trachea in 2, the left lung in 13, the left 
pleura in 26, the right lung in 6*5, and the right pleura in 13 per cent. 
Pulsating tumour presented externally in 26 per cent.; murmur was 
detected in only 4 per cent; dyspnoea existed in 26 per cent.; orthopnoea 
in 4; cough in 24; dysphagia in 9. Pain was complained of in 67 
per cent. The pain was felt in the back in 43-5, in the chest in 29, in 
the abdomen in 13, and the left lumbar region in 19*5 per cent. Of the 
34 cases in which the vertebrae were eroded, pain was present in 26, not 
noticed in 8. Of the 12 cases in which the vertebrae were not eroded, 
pain was present in only 4, not noticed in 8. In 31 of the cases the 
upper portion of the artery was affected; of these 11 complained of 
pain in the chest, sin the loins, and 2in the abdomen. In 15 of the 
cases, the lower portion of the artery was affected; of these, 3 com- 
plained of pain in the chest, 4 in the loins, and 4 in the abdomen. 
In several of the cases, owing to the displacement forwards of the heart 
by the tumour, violent palpitation was complained of, leading to the 
erroneous diagnosis of hypertrophy of the heart. 
THE ABDOMINAL AOETA AT THE CCELIAC AXIS. 
The abdominal aorta, from where it appears between the crura of 
the diaphragm, and gives origin to the coeliac axis, to its bifurcation, 
is attached to the left half of the bodies of the first four lumbar ver- 
tebrae. The solar plexus and the pancreas, the duodenum, and the 
mesentery, successively cover the aorta in front from above downwards. 
The vessel lies between the ascending vena cava on its right side, and 
the cardiac portion of the stomach, the left suprarenal capsule, and the 
fat and cellular tissue within the left kidney, on its left side. 
Aneurisms of the abdominal aorta in the neighbourhood of the 
coeliac axis are sacculated in 60 per cent., present general dilatation in 
10, and are undescribed in 31 per cent. The proportions were respectively 
81, 13, and 6 per cent, in the specimens observed in Museums. Of 46 
cases of sacculated aneurism, 22 communicated with the aorta bv an 
aperture on its anterior aspect, and 19 on its posterior aspect. The 
numbers were respectively 20 and 22 in the specimens observed 
in Museums. In 15 of those specimens the vertebrae were eroded 
by the tumour; and in the whole of these 15 instances the sac 
sprung from the back of the aorta. The vertebrae were eroded in 55 per 
cent, of the cases observed during life. In one only of those cases did 
the aneurism spring from the front of the aorta. It is a fair inference, 
though it is not actually stated of quite one-half, that in nearly the 
whole of those cases (55 per cent.) in which the vertebrae were eroded, 
the sac communicated with the aorta posteriorly. The aneurism rup- 
tured in 77 per cent, of the cases; into the peritoneal cavity in 28*5, into 
the mesentery in 8, into the left pleura in 9, the right pleura in 6*5; 
behind the peritoneum, into the left hypochondriac region in 22 per cent., 
into the right hypochondriac region in 4. I exclude from those rup- 
turing behind the peritoneum 4 cases that presented enormous diffused 
aneurismal sacs extending down to Poupart’s ligament, and lasting for 
months. Hemorrhage behind the peritoneum is slow and very exten- 
sive, and is never rapidly fatal. The aneurism ruptured into the 
duodenum in 7*5 per cent, of those specimens, observed in Museums. 
Of the 21 cases that either ruptured behind the peritoneum into the left 
hypochondrium, or presented diffused false aneurism in that region, the 
sac communicated with the aorta posteriorly in 17, anteriorly in only 3. 
Pulsating tumour was observed in 55 per cent, of the cases, present- 
ing in the scrobiculus cordis in 20*5 per cent., in the left hypochondrium 
in 22, intermediately in 4, and in the right hypochondrium in 4 per 
cent. A tumour not pulsating was observed in the scrobiculus cordis 
THE DESCENDING POETION OE THE AECH. 
The descending portion of the arch lies at first upon the left lung 
and the oesophagus. It gradually separates these from each other, and at 
last rests fixedly on the left half of the body of the fifth or sixth dorsal 
vertebra, where the oesophagus is situated to the right of the aorta, 
the left lung to its left. The left bronchus and the right pulmonary 
artery lie in front of the descending aorta, as they pass between it 
and the ascending aorta. The thoracic duct is immediately behind 
the meeting point of the descending aorta and the oesophagus. 
The aneurisms of the descending portion of the arch are sacculated 
in 81 per cent., and present general dilatation of vessel in only 8 per 
cent. The proportions were 62*5 per cent, and 21 per cent, in the speci- 
mens observed in Museums. The direction of the aneurism is usually 
backwards and to the left. The vertebrae were eroded in 42 per cent., the 
left ribs anteriorly in 4. The tumour made pressure upon the trachea 
in 12*5 per cent., the left bronchus in 37*5, the oesophagus in 31, the 
left lung in 48, the right lung in 6 per cent. The sac ruptured in 75 
per cent, of the cases; into the trachea in 4 percent., the left bronchus 
in 16*5, the left lung in 4, the left pleura in 23, the right lung in 6, 
and the right pleura in 12-5 per cent. Pulsating tumour appeared ex- 
ternally in 6 per cent.; murmur was heard in 23 per cent. Breathing 
was deficient over the left side of the chest in 19 per cent. Dyspnoea 
was noticed in 50 per cent., cough in 46; the respiration was stridulous, 
or the voice was affected in 25 per cent.. Dysphagia existed in 33 per cent. 
Pain was present in 62• 5 per cent. The pain was seated in the back in 27, 
in the chest in 52 per cent.; of these it radiated around the left side from 
the spine in 21 per cent. The pain in about 25 per cent, was of two 
kinds, constant in the back, and radiating in the left intercostal spaces. 
Pain is a more frequent and characteristic symptom in aneurisms of the 
descending portion of the arch, than in those of the ascending and 
transverse portions. The anatomical reason of this is obvious. The 
anterior portion of the arch moves freely, and its aneurism pushes aside 
the par vagum and sympathetic, which yield before the sac. The 
descending part of the arch is comparatively fixed by the intercostal  
Printed by Hullinarid6 
Drscwn fr.om'tfie Subject d on Stone!vfWJliam Faarlajia COMMENTARY ON PLATES XII., XIII., XIV., & XV. 
in 5 per cent. Murmur was observed in 25 per cent. ; dyspnoea was 
noticed in 8 per cent.; cough in 2'5 ; dysphagia in 6’5 ; sickness in 8 ; 
dyspeptic symptoms in 15; constipation in 19 per cent. 
Pain is one of the most important symptoms in cases of aneurism of 
the abdominal aorta. The pain, as I)rs. Beattie and Law have shown, 
is of two kinds,—a fixed pain at or near the tumour, present in most 
cases, and a paroxysmal, often lancinating pain, radiating along the 
course or distribution of those nerves pressed on by the tumour. 
I divide the 77 reported cases of aneurism of the abdominal aorta at 
or near the coeliac axis into two groups, in considering their relation 
to pain as cause and effect. The first group, which I term the posterior 
eroding aneurisms, embraces 15 cases, and includes those, amounting to 
18, in which the sac springs from the back of the aorta, and those, 
amounting to 13, including 16 of the 18 posterior aneurisms, in which 
the vertebrae are eroded; in one only of the 13 does the sac arise from 
the front of the aorta. The second group, which I designate the anterior 
non-eroding aneurisms, embraces 32 cases, and includes those, amounting 
to 22, in which the sac springs from the front of the aorta, the vertebrae 
not being eroded, and those, amounting to 10, in which the vertebrae 
were not eroded, the direction of the sac not being stated. This second 
group does not include either the 2 posterior non-eroding aneurisms, or 
the 1 anterior eroding aneurism. 
Of the 15 posterior eroding aneurisms, in 1 pain is not mentioned, 
in 28 there was fixed pain of the back or loins ; in 20 of the 28, and 
in 1 others, there was paroxysmal often lancinating pain in the course 
of the nerves in the loins, testes, or lower limb, usually the left ; in 
5 there was pain in the epigastrium, in 6 others in the abdomen, and in 
5 others in the hypogastrium. 
Of the 32 anterior non-eroding aneurisms, in 9 pain is not men- 
tioned, in 15 there was fixed pain of the back, or loins, in only lof the 
15 was there paroxysmal pain of the loins or lower limb ; in 11 there 
was pain in the epigastrium, in 8 others in the abdomen, and in 3 
others in the hypogastrium. 
We thus see that while the posterior eroding aneurisms excite 
paroxysmal radiating pains in the loin or limb, as well as fixed pain in 
the back, in a large proportion of the cases, and pain in the epigastrium 
in but a small proportion; the anterior non-eroding aneurisms excite 
paroxysmal lancinating pain in the limb in but a small proportion of 
the cases, and pain in the epigastrium and abdomen in a large propor- 
tion. The pathological reason is obvious. The latter aneurisms usually 
compress and displace only the solar plexus and other splanchnic 
nerves, exciting pain therein; hut the former, while they compress the 
solar plexus to a less degree, press frequently with force on the lumbar 
plexus of nerves, thereby causing in many instances not only fixed pain 
in the back, but excruciating paroxysmal agony in the loins, the ilium, 
the testes, and the lower limb. In many of these cases the course of 
the nerves may be traced with anatomical precision by tracking the 
pain from its fixed origin to its final radiating distribution. 
The aneurisms of the splenic, superior mesenteric, and hepatic 
arteries, afford a beautiful illustration of this truth in medical anatomy. 
I have collected 11 such cases; in 1 of them there was pain in the 
epigastrium, in 3 more in the abdomen, in 1 pain was not noticed. 
In only 1 case was there pain of the limb; when the tumour, which 
was as large as a child’s head, caused erosion of the vertebrae. 
The whole chain of aortic aneurisms illustrates the effect of the pres- 
sure of the tumour on the nerves in exciting pain. Those of the de- 
scending aorta, from the arch downwards, when they cause erosion 
of the vertebrae, press directly backwards on the left spinal nerves 
as they issue from between the vertebrae. The eroding aneurisms 
of the descending portion of the arch excite fixed pain in the back, 
and radiating pain in the upper left intercostal spaces; those of the 
upper part of the descending thoracic aorta induce fixed pain of the 
back, and radiating pain in the lower intercostal spaces ; and those of 
the lower part of the descending thoracic aorta cause fixed pain in the 
back, and radiating pain in the abdominal walls and in the loins. 
I have already noticed that pain is less frequent and less regular in 
aneurisms of the ascending and transverse portions of the arch, those 
portions being comparatively moveable in relation both to the sur- 
rounding parts, and to the adjoining nerves which yield before the 
advancing tumour, and which are rather nerves of function than of 
sensation. Pain is indeed excited in the par vagum and its branches, 
the sympathetic plexuses, and sometimes in the phrenic nerves; but 
the dyspnoea, the croupy voice and cough, and the frothy sputa, are 
the more formidable effects of the pressure on those nerves, and are more 
frequently caused by it than even by the direct compression of the 
trachea and lungs. When in these cases the tumour presses on either 
brachial plexus, radiating pain is felt in the corresponding arm. 
Table 1.-SHOIVING CERTAIN ANATOMICAL CONDITIONS, SIGNS, AND SYMPTOMS, OF EACH GROUP OF AORTIC ANEURISMS. 
Actual number of Museum Specimens and Cases.. 
Sinuses of 
Valsalva. 
Ascending 
Aorta. 
Ascending 
Aorta, 
Dissecting 
Aneurism. 
Transverse 
Aorta. 
Ascending 
and trans- 
verse Aorta 
conjointly. 
Descending 
part of Arch. 
and Descend- 
ing part of 
Arch con- 
jointly. 
AVholo Arch. 
Descending 
thoracic 
Aorta below 
Arch. 
Abdominal 
Aorta, at 
Coeliao Axis. 
Abdominal 
Aorta below 
Mesenteric 
Artery. 
Branches of 
Abdominal 
Aorta. 
Mus. 
Spec. 
29 
Cases. 
58 
Mus. 
Spec. 
41 
Cases. 
100 
Mus. 
Spec. 
3 
Cases. 
49 
Mus. 
Spec. 
40 
Cases 
80 
Mus. 
8pec. 
42 
Cases, 
70 
Mus. 
Spec. 
24 
Cases 
48 
Mus. 
Spec. 
5 
Cases. 
15 
Mus. 
Spec. 
18 
Cases. 
10 
Mus. 
Spec. 
25 
Cases 
46 
Mus. 
Spec. 
54 
Cases. 
77 
Mus. 
Spec. 
8 
Cases. 
18 
Mus. 
Spec. 
7 
Cases. 
13 
Proportion per cent, of Cases of— 
Per 
cent. 
Per 
cent. 
Per 
cent. 
Per 
cent. 
Per 
cent. 
Per 
cent. 
Per 
cent. 
Per 
cent. 
Per 
cent. 
Per 
cent. 
Per 
cent. 
Per 
cent. 
Rupture of aneurism 
48 
80 
27 
57 
100 
79-5 
55 
43 
17 
37 
415 
75 
60 
53 
5 
50 
23 
65 
33 
77 
37 
56 
14 
54 
Ditto externally 
1 
8 
2 5 
62 
25 
7 
10 
Ditto into pericardium 
345 
45 
15 
22 
100 
795 
2-5 
10 
&5 
2-2 
Ditto pulmonary artery 
10-5 
13-5 
5 
4 
13 
2-5 
1-5 
Ditto right auricle 
8-5 
1 
Ditto right ventricle 
5 
Ditto left ventricle 
5 
Ditto vena cava desceudens 
5 
5 
1-3 
43 
Ditto trachea 
1 
27-3 
10 
5 
4 3 
4 
2 2 
Ditto right bronchus 
3 
Ditto right lung 
3-5 
1-5 
5 
2-5 
4 
6 
65 
Ditto right pleura 
2 
25 
2-5 
3 
12*5 
10 
13 
6-5 
Ditto left bronchus 
2-6 
4 
5 
16 5 
165 
6-5 
10 
2 
Ditto left lung 
2 
25 
4 
2-5 
4 
4 
5 5 
10 
13 
1-3 
Ditto left pleura 
4 
25 
5 
2-5 
1-5 
4 
23 
265 
7'5 
26 
5-5 
9 
12-5 
Ditto oesophagus 
10 
6-2 
1-5 
20 
13 3 
10 
115 
2 
Ditto behind peritoneum—left hypochondrium.. 
7-5 
22 
Ditto into peritoneal sac 
35 
11 
28-5 
12-5 
16 
14 
31 
Ditto mesentery, or mesocolon 
8 
Ditto duodenum 
7-5 
10-5 
Ditto ascending vena cava 
16 
(Sacculated aneurism 
935 
98-4 
58-5 
51 
27-5 
61 
50 
31-4 
62-5 
81-3 
50' 
34-8 
81 
59 7 
< Aneurismal dilatation of vessel 
6-5 
1-7 
39 
37 
20 
20 
85-7 
857 
20'8 
8 3 
577 
28-3 
13.3 
104 
(Character of aneurism not defined 
25 
12 
2-5 
22-5 
25 
104 
3-8 
37 
5-6 
31-2 
jErosion of sternum, or ribs (anteriorly) 
27 
27 
16 
21 
21 
4-2 
1 Erosion of vertebrae 
1 
5 
1-5 
25 
417 
74 
28-3 
55 
f Pulsating tumour 
7-4 
34 
44 
30 
6-3 
26 
55 
1 Murmur 
34-5 
23 
2 
15 
22 
23 
43 
25 
f Dyspnoea 
38- 
51 
12 
71 
74-3 
50 
26 
8 
Ortbopnoea 
10-3 
18 
6 
20 
21-5 
19 
43 
Cough 
24 
36 
575 
47 
46 
24 
25 
Haemoptysis 
8-5 
4 
19 
10 
27 
, , 
19-5 
Stridor, or affection of voice 
3 
475 
17 
25 
Dysphagia 
1-5 
2 
31- 
5>l-5 
333 
8 7 
65 
Pain 
207 
40 
8 
36- 
46 
62-5 
67-3 
73 
1 
An abstract of the above, relating to the aorta and its aneurisms, was in print a year ago, when, 
at the suggestion of a friend, I resolved to extend my inquiry as to those aneurisms, and to give the 
results here. With this view I have examined the preparations of aneurism of the aorta contained 
in the museums of Port Pitt and the College of Surgeons, and of Guy’s, King’s College, The London, 
The Middlesex, St. Bartholomew’s, St. George’s, St. Mary’s, St. Thomas’s, and University College 
Plospitals ; and I have analysed all such cases as I could find in The Transactions, the Journals, and 
published works. I have been mainly indebted to the important memoirs of the Dublin physicians, 
Dr. Corrigan, Dr. Beattie, Dr. Stokes, Dr. Porter, Dr. Smith, Dr. Law, Dr. Bellingham, Dr. Lyons, 
Dr. Mayne, Dr. Greene, and Dr. Lees, and to those of Scarpa, Mr. Hodgson, Mr. Thurnam, Dr, Hope, 
Dr. Watson, M. Rokitansky, Dr. Crisp, Dr. Peacock, Dr. Blakiston, Dr. Gairdner, Dr. Todd, and 
M. Porget. I have rejected those cases that did not give a distinct account of the exact position of the 
aneurism. The numbers given in the analysis of the anatomical conditions, signs, and symptoms, are 
necessarily below the actual number, since several of the signs and symptoms were in many cases 
omitted. As a rule, the signs are more frequently omitted than the symptoms. This applies to 
all the cases reported before the days of Laennec. On the other hand, some later observers have 
dwelt on the signs at the expense of the symptoms. 
EXPLANATION OE PLATE XV 
This Plate was taken, in St, Luke’s Workhouse, through the kindness of Mr. Harris, 
from the body of a man, aged thirty-eight, of large stature and robust proportions. 
In the neck, the soft palate, and a portion of the cricoid cartilage have been removed, 
exposing—the tonsils, tlxe top of the tongue, and the interior of the larynx. 
In the chest—The trachea and lungs, and the thoracic aorta have been removed 
exposing—the heart and great vessels, and the recurrent nerves. 
In the abdomen—most of the viscera have been removed, exposing—the liver, its 
vessels and ducts, the gall-bladder and the pelvic organs. Explanation of the Tables.—ln tlie following analysis, the total number of cases of each class —that the heart was large, the right and left ventricles being dilated, their walls being thin—that 
appears in the vertical columns of figures. The horizontal figures following each subdivision refer to during life a systolic murmur was audible, and that the patient had symptoms of heart disease, 
the cases in my own note book. By means of these figures, the various particulars given as to each dyspnoea, cough, haemoptysis, and pain in the region of the heart. In the same way the various 
case may be tracked. Thus if we take Case 8, Table 11., we find—that the aneurismal sac was seated relations of each group can be separately examined. 
above the junction of the right and left coronary valves—that it was of the size of a hen’s egg—that I can only give here the two following Tables, but intend to add the remaining Tables in a 
it rfiptured into the pulmonary artery, and compressed that artery and the right ventricle and auricle contemplated work on the Aneurisms of the Aorta. 
Table lI.—CASES OP ANEUEISM OF THE SINUSES OF YALSALYA. 
SITUATION OE ANEURISM. 
Museum c 
Specimens. 
8 Eight and left auricle, 2. 16. 30. 39. 53 (5) ; Left auricle, 13. 45 (2). 
4 Left ventricle, 5. 36. 37. 47. 
1 Descending vena cava, 34. 
1 2 Eight lung, 21 +3; Left lung, 14. 
Museum Cases (In this and the following Table the Museum specimens, without history, are 
Specimens. ‘ in ordinary figures ; the cases, with history, in long figures.) 
6 io Aneurismal sac above right coronary valve, 5.12. 141.17. 271. 283+ 5. 
6, 16. 20. 29. 34. 37. 38. 42. 58. 
6 3 Ditto above junction ofrt. and It. cor. v., 6.10.16.11. 22. 24 + 8.17. 54. 
4 4 Ditto above left coronary valve, 91. 143. 18 .20 + 21. 431, 47. 52. 
1 2 Ditto above junction of left cor. and intercoronary valves, 131,3 +45, 53. 
4 9 Ditto above intercor. v., 1. 7. 93. 273,3+ 15. 18.23. 33. 35. 36.41.43s. 46. 
2 7 Ditto above junct. of intercor. and rt. cor. v., 2.21+ 7.12.39.44.5 5.56.57 
2 3 Ditto at anterior aspect of aorta, 25. 29+40. 49. 50. 
6 20 Ditto above one valve, w+ich, not stated, 3. 4. 83. 11. 28. 28' +l. 2 3. 
4. 9. io. 11. 14. 19. 22. 24. 25. 26. 27. 28. 30. 31. 32. 48. 51. 
2 1 Aneurismal dilatation of aorta above the three valves, 15. 26+13. 
33 4=29 + 59 1 —5B 
CONDITION OE HEART. 
3 17 Heart large,s. 6.15+1. 5.6. 7.8. 12. 13.15.16. 31. 33. 37.39.43. 53-57-58- 
3 10 Left ventricle hypertrophied, 37. 43 ; dilated (walls thin), 8. 15.; hyp. and dil. 
6. 15+12. 13. 15. 33. 53. 57; large, S. + 39. 
8 Eight ventr. hyp. 13 ; dil. 1. 8. (walls thin) 33. 43. 58 ; hyp. and dil. 7. 15. 
4 Eight ventricle unusually small, 5. 19. 29. 39. 
3 Aortic valves diseased, 52. 55. 57. 
1 4 Pericardium adherent, 15+ 3. 13. 20. 57. 
size oe aneurism (Mere Ulceration, —10). 
2 Pulsating tumour to left of sternum, 14. 20. 
2 Puls. turn, to right of sternum, 3 (bet. 5 and 6 ribs) ; pulsation to rt. of stm. 12. 
1 Diastolic impulse noticed, 5. 
{2O Murmur noticed, 4. 12. 15. 19. 24. 47. 55; systolic, 8. 30; diastolic, 14. 53; 
double, 5. 7. 13. 16. 18. 33.46. 52. 57. 
2 Murmur stated to be absent, 35. 48. 
6 Murmur not noticed, the patient might have been examined, 3.12. 20, 29 36. 39. 
30 Physical signs were not observed. 
{2O Died suddenly, in general unexpectedly, 2. 4. 6. 9. 10. 11. 22. 23. 25. 28, 34. 
35. 40 (epigastric pain same morning) 42. 43. 44. 45. 47. 49. 56. 
4 Died within half an hour of fatal attack, 32. 38. 58(3); Pound dead, 41. 
11 Died within 48 hours after fatal attack, 13. 17. 18. 26. 27. 31. 37. 40. 43. 48. 50. 
22 Apparently healthy up to fatal attack, 2. 9. 10. 11. 22. 25. 27. 28. 31. 32. 34? 
37, 38. 40. 43 (had amaurosis) 44. 45. (ill 7 days) 48 49. 54. 56. 58. 
6 Had symptoms of heart disease, 8. 15. 16. 19. 39. (angina) 47. 
3 Had phthisis, 46 ; pneumonia, 30; apoplexy, 19. 
Cases. 
PHYSICAL SIGNS DURING LIEE. 
Pea, 273’3; Nut, 73. 93. 133.143. 20. 223. 23 . 24. 271. 28. 29 +2.5.6. 9. 25. 30. 48. 55 ; 
Small, 41,3 + 433; Walnut, 6. 7. 8. 9. 10. 12. 13. 16.18. 22 +4. 23. 26. 32. 35. 36. 
42. 54. 58 ; Plum, 2. 3. 5.19+ 19. 37. 38. 46 ; Apple, 25 +39 ; Pigeon’s Egg, I+ 7. 
4+ 50. 52. 57; Hen’s Egg, 11 +7. 8. 12. 15. 33. 40. 43. 49.55. 56; Orange, 17. 
26. 28+17. 18. 20. 21. 27. 31. 47. 53; Cricket-ball, 15+1. 13. 29. 34; Large 
Melon, 21; Cont. Quart, 14; Large, 3. 
THERE WAS RUPTURE OE ANEURISM INTO THE 
10 26 Pericardium, 1. 2. 5. 7. 8. 10. 16. 18. 27. 29 +2.4.6. 9. 10. 11. 22. 23. 25. 
26. 27. 28. 31. 32. 35. 38. 39. 40. 41. 42. 43. 44. 45, 48. 49. 58. 
3 8 Pulmonary artery, 6. 11. 12 +B. 17 18. 24. 30. 50. 51. 54. 
5 Eight auricle, 12. 13. 33. 34. 56. 
6 Eight ventricle, 5. 16. 47 (3); Left ventricle, 36. 37. 52 (3). 
1 1 Eight lung, 21+ 3. ? 
14 46 
1 Perforated by needle shortly before death, 14. 
15 11 Ho rupture. 
29 58 
SYMPTOMS. 
22 Dyspnoea, 1.3. 5. 7. 8.12. 13.14. 16.18. 20. 21.24. 29. 33. 36. 38. 42.47. 50. 52.57. 
5 Orthopnoea, 1. 3. 5. 12. 13, 
14 Cough, 1. 3. 5. 7. 8. 12. 13. 17. 18. 29. 33. 35.47. 50. 
5 Haemoptysis, 3. 8. 17. 29. 33. 
1 Dysphagia, 13. 
9 Face livid, 1. 12. 13.36.47; Great pallor, 4. 17. 18. 24. 
g General anasarca, 3. 7. 12.13. 16. 47. 51. 52. 53. 
12 Pain in region of heart, 3.5.8.20.24.26.31; of chest, 4; 34 in epigastrium, 35. 40.48. 
9 18 Pulmonary artery, 5. 6, 11. 12. 15. 22. 23. 26. 29+1. 4. 8. 17. 18. 20. z\. 
30. 34. 40. 47. 49. 50. 51. 52. 54. 55. 56. 
5 11 Eight ventricle near the pulmonary valves, 22. 23. 24. 25. 29 +l. 5. 7. 8. 
16. 20. 29. 41. 47. 52, 55. 
4 16 Auricular portion of the right auricle, 5. 18. 15. 25+ 1 7. 8. 12. 13. 20. 
29- 3i- 33- 3+ 38. 41 47- 52- 55- S6- 
THE ANEURISMAL SAC MADE PRESSURE UPON THE 
Table lII.—CASES OP ANEUEISM OP THE ASCENDING! AOETA (ABOYE THE SINUSES OP YALSALYA). 
Museum Cases- 
Specimens. ... 
16 37 I- Aneurismal dilatation of the Ascending Aorta to a greater or less extent, 
6. 8. 10. 11. 14. 15. 18. 19. 21. 28. 32. 33. 34. 37. 38. 39+1. 2. 3. 6. 7. 
8. 9. 12. 16. 18. 19. 25. 28. 30. 35. 37. 43. 44. 47. 51. 52. 55. 58. 61. 63. 
71. 74. 75. 82. 84. 85. 86. 87. 89. 90. 91. 95. 
6 8 Of these, the dilatation was chiefly in the right wall in 18. 21. 28. 32. 33. 39 + 1. 
2. iz. 47. 58. 63. 82. 86. 
1 o Of these, the dilatation was chiefly in the left wall in 19. 
18 3S II a. Aneurismal sac, communicating by an aperture with the Asc. Aorta. 
the aorta being of normal size, 2. 3. 4. 7. 12. 13. 17. 201’2. 23. 24. 26, 
27, 31.+ 4. 5. 10. 11. 231. 232. 24. 29. 31. 32. 33. 34. 38 ? 40. 41.42. 45. 
46. 48. 49. 50. 59. 62. 66. 69. 73. 77. 78. 79. 80. 81, 83. 92. 93. 96. 98. 
11 16 11b. An. sac, comm, with Asc. Aorta, the Asc. Aorta being itself affected 
with aneurismal dilatation, 1. 5. 16.22. 25. 29 30. 35. 36. 40. 41+15. 
21. 26. 53. 54. 57. 64. 67. 68. 72. 76. 88 .94. 971'2. 991'2. 100. 
In 11. a. & b. the position of the aperture of communication in the wall of the 
Aorta was just above the sigmoid valves in 15. 34. 45. 79. 92. = (5) just above 
the right auricle in 27 ; about midway between valves and arteria innominata, 
2. 4. 5. 7. 12. 13. 20. 22. 23. 25. 28. 35. 36. 41. = (14)+ 11. 40. 54. 57. 59. 66. 
80. 81. 93. 94. 97. 992 = (12), just below the art. inn. in 17. 24. 30. 31. 40 = 
(5) + 2i. 23s. 31. 32. 48. 593. 62. 76 = (8). 
Aspect of aperture of communication, right, 13. 20. 22. 23. 24. 26, 29. 36 = (8). 
10. 32. 41. 42. 69. 73. 76. 79. 94. 100 = (10); right anterior, 1. 7. 30. 35 = (4) 4. 
48. 49. 50. 53. 57. 78, 97 = (8); right posterior, 31+ 96; anterior, 5. 12, 17. 
27.40. 41 = (6). 15. 31. 32. 34. 38. 46. 72. 80. 92 = (9); left, 25 +26. 64. 
68. 77. 88. 991 = (6); posterior, 59. 66. 98 = (3). 
Diameter of aperture of communication, very small (probe) 16 + 81; small, 41, 
42. 88 ; about i inch, 4. 26 + 46, 59. 93, 1 inch; 17. 25. 27. 35. 36 + 64. 66. 73- 
74. 96; inch, 12. 22. 24. £O, 31. 40. 41 + 10. 29. 32. 33. 69. 83. 94. 100; 2to 
in. 7. 23. 29 + 24. 46. 49. 76. 97 ; wide, 16. 20 + 34. 38. 48. 57. 80, 
i 12 111. Aneurism of Ascending Aorta, precise character not specified, 9+13, 
14. 17. 20. 22. 27. 36. 39. 56. 60. 65. 70. 
Museum Casea THE ANEURISM MADE PRESSURE UPON THE 
Specimens. 
1 2 Heart, 38 ; right auricle, 19 ; right auricle and ventricle, 95. 
3+ 1 3 Pulmonary artery, 12. 16. 25 +6. 40. 87 = Eight pulm. art. 19. 
9 7 Vena cava descendens, 13.18. 19.28. 30.31.32. 36. 38+1.2.44.70. 78. 80. 87. 
3 6 Trachea, 18. 19. 88 +3. 4. 21. 38. 43 57. 
1 6 Eight bronchus, 7 + 24. 25. 76. 87. 100. (5 ); Left bronchus, 5. 
7 Both lungs, 5. 27, 37. 38. 62. 70. 95. 
12 22 Eight lung, 5. 7. 21. 22. 23. 28. 29. 30. 33. 35.36. 41+10. 17. 18. 30. 31. 
33. 38. 48. 49. 50. 53. 56. 65. 69. 73. 76. 78. 79. 86. 94. 97. 100. 
10 Left lung, 14. 26. 34. 52. 60. 62. 64. 66. 77. 87. 100. 
1 2 GEsophagus, I 8 + 55. 87. 
7 33 Heart large, 5. 10. 13. 15. 25. 37. 38+1. 4, 7. 8, 15. 16. 18. 24. 28. 31. 32. 
4°. 43. 49, 53. 58. 63. 64. 65. 67. 72, 73. 76. 80. 90. 91.92. 95. 96. 98. 99. 
6 14 Left ventricle hypertrophied, or dilated, or both, 5.10.13, 25. 37. 88 +4. 25. 
32. 40. 49. 64. 72. 73. 80. 91. 92. 95. 96, 98. 
1 3 Eight ventricle, ditto ditto, 13 +24. 31. 98. 
5 Pericardium adherent, 1. 10. 95. (3.) Pericarditis present, 30. 33. (2.) 
2 22 Heart stated to be healthy, 9. 11 +6. 11. ? 12. 15. 22. 23. 26. 45. 47. 51. 
52. 55. 59. 66. 68. 69. 70. 77. 79. 86. 87. 94. 
32 44 Cases in which the condition of the heart is not specified. 
CONDITION OE HEART. 
EROSION OE 
4 4 Centre of sternum (usually just below manubrium), 17.18.30.414-6.27.62.70. 
8 12 Eight edge of sternum ditto 7. 22 23.28. 29. 30. 
35. 36.+ 17. 30. 31. 32. 38. 49. 53. 73 .78. 79. 86. 97. 
4 Left edge of sternum ditto 14. 52. 77. 87. 
1 Eight and left costal cartilages or ribs, 62. 
9 14 Eight cost. cart, or ribs, 7. 22. 23. 28. 29. 30. 35. 36. 41 +1 o. 17. 31. 38. 48. 
49. 50. 53. 65. 69. 78. 79. 86. 97. 
6 Left cost. cart, or ribs, 52. 60, 64. 77. 87. (5.) Left clavicle, 14. 
1 Dorsal vertebrae and adjoining left ribs, 66, 
41 100 
SIZE OE ANEURISM. 
Nut, 13.I3. 2. 27. + 41. 93; Small, 46; Walnut, 11.I1. 9. 253+23; Of moderate 
size, 11 ; Pigeon’s Egg, 3 + 42. 81 ; Hen’s Egg, 164-213. 22. 24. 36. 57.; Diara. 
about 2 inches, 201. 251. 291. SOhlO1. 4U + i 6. 28. 35. 37. 51. 67. 89. 90.961; Diam. 
2-g-to Scinches, 351. 361+ 65. 73. 85. 881. 9b2; Orange, 4. 11. 12.24.31+1. 15. 30. 
31. 32. 47. 54 56. 59. 76. 80. 83 ; Fist, 2. 5. 6. 19. 29. 62. 63 ; Cricket-ball, 13, 
21. 22. 28. 32. 33. 403. 413.+ 91. 971-2; Small Melon, 23. 293. 303; or 4to 6 in. 15. 
173. 88+14. 26. 66, 69. 79. 883. 92.94. 95; Large, 5. 6. 7. 18.19. 203. 34. 352. 362. 
37 +7. 9. 211. 33. 34. 38.43. 44. 48. 55. 58. 68. 71. 72. 74. 86; Very large, 
]o+io. 17. 18 27. 49. 52, 53. 60. 61. 87. 
Cases. PHYSICAL SIGNS DURING LIEE. 
5 Pulsating tumour at centre of sternum, 5. 27. 37. 62. 95, 
20 Ditto to right of sternum, 10. 17. 18. 30. 31. 32. 33. 38. 48.49. 50. 53. 65. 69. 
73. 76.; (pulsating fulness,) 78. 79. 86. 94 
8 Ditto to left of sternum, 14. 26. 34. 52. 60, 64. 77. 87. 
1 Ditto, side not stated, 72. 
(23 Murmur noticed, 2. 3. 7. 15. 16. 24. 26. 27. 29. 30. 34. 47.49. 54. 57. 61. 63.67. 
\ 76. 77. 78. 79. 98. 
100 <l4 Murmur stated to be absent, 1.5. 25. 31. 32. 33. 35. 36. 37. 38. 48, 52. 68. 97. 
>25 Murmur not noticed, though the patient was, or might have been examined. 
I 38 Murmur was not listened for, of these 26 were before the days of Laennec. 
15 Died suddenly, 12. 19. 20. 23. 39. 41. 42. 43. 43, 36, 38. 74. 92. 93. 99. 
11 Apparently healthy up to fatal attack, 23. 39. 41. 42. 45 46. 56. 58.74. 92. 93. 
THERE WAS RUPTURE OE ANEURISM INTO THE 
6 22 Pericardium, 1. 3. 9. 16. 26. 27+n.i2. 20. 22. 23. 39. 40. 45. 46. 50. 51. 
54. 56. 67. 74. 75. 81. 823. 83. 91. 93. 973. 
2 5 Pulmonary artery, 12. 16 (2)+ 6. 7. 6i. 992. (4) Eight auricle, 58. 
2 5 Yena cava descendens, 13. 31 +l. 2. 57. 63. 70. 
1 2 Trachea, 4. (1.) ; mediastinum 89. (1.); pleura, side not stated, 24. (1.). 
9 Eightbronchus,29.47.9o.(3.);E.lung, 38.48.55 69.79.(5.);E.p1eurai 3.69.(2.) 
5 Left lung, 36. 37. (2.) ; Left pleura, 34. 36. 77. 95. (4.) 
1? 8 Externally, 17. ?+l4. 31. 32. 33. 49. 60. 64. 83. 
1 The sac ruptured, where into, not stated, 34. 
12 57 
29 ? 43 no rupture. 
41 100 
51 Dyspnoea, 1. 2. 4. 5. 7. 8. 9. 10. 13. 13. 16. 21. 24. 25. 27. 28. 30. 31. 34. 33. 37. 
38- 43- 44- 45- 47’ 48- 49- 52- S3- 59- 6°. 61, 62. 63. 68. 69. 72. 76. 77. 78. 
79. 80. 81. 87. 90. 94. 95. 96. 98. 100. 
18 Ortliopnoea, 7. 10. 15, 16. 21. 24. 25. 34. 48. 61. 68, 69. 77. 78. 79. 90. 95.98. 
36 Cough, 1. 2. 4. 5. 8.9. i i 19. 2i. 24. 25. 27. 28. 29. 30. 31. 33.34. 35. 47. 49. 52. 
55. 62. 63. 64. 66. 67. 68. 76. 78. 79. 80. 81. 94, 98. 
3 Yoice raucous, 3 ; Stridor, 3, 4. 25. 
2 Dysphagia, 11. 33. (when recumbent). 
29 Pain in chest, 15. 18. 21. 25. 26. 27. 29. 30. 31, 34. 36. 38. 44. 49. 51. 53. 54. 
55. 59. 62. 67. 69. 71. 76. 77. 79. 95. 96. 97. 
10 Pain in neck and shoulders, 2. 5. 32. 49. 62. 63. 66. 76. 78. 79. 
6 Pain in right arm, 33. 48; hypochondrium, 11 : back and loins, 6. 61. 66. 
SYMPTOMS. ML. XVI. 
Fig. 2 
Eg.l. COMMENTARY ON PLATES XVI., XVII., & XVIII.* 
ON THE EEEECTS OE NATURAL AND ARTIEICIAL RESPIRATION ON THE EXTERNAL EORM AND THE 
INTERNAL ORGANS. 
These three plates, which present front, side, and hack views, are in 
pairs. In each, one figure is taken from the body just as it was 
when laid open, the trachea having been secured to prevent the 
farther collapse of the lungs; the other figure is from the same body 
after the complete inflation of the lungs, when they, the other organs, 
and the ribs have nearly the same position as at the end of a forced 
inspiration. 
When viewed sideways, the fourth, fifth, and sixth ribs curve 
upwards, the seventh rib is straight, while the eighth and ninth ribs 
curve downwards. During inspiration, these ribs, while they diverge 
from each other, become more nearly parallel. 
While there is this conformity between the middle series of ribs, 
from the fourth to the eighth, there is a complete contrast between 
the three upper and the three lower ribs. 
The first ribs form a pair of short strong girders, which only move at 
their articulation with the vertebrae. The three upper ribs increase 
rapidly in size, the second being twice as long as the first. The 
summit of the chest is closed in and vaulted over by this series of 
enlarging ribs. There is, on the other hand, a wide open space, 
occupied by the abdominal viscera, between the free anterior 
extremities of the three lower ribs of opposite sides. 
The ribs offer greater resistance than the diaphragm to the artificial 
inflation of the lungs; consequently, while the expansion of the ribs is 
less, the descent of the diaphragm and abdominal organs and the 
expansion of the abdomen are greater than at the end of a forced 
inspiration. The difference in these respects, however, in the effects of 
artificial and natural respiration, is not great. This is rendered evident 
by the series of photographs now before me, from an Academy model, 
taken during forced expiration and inspiration. 
Allowance being made for those deviations, these views represent 
the influence of forced expiration and inspiration on the size and shape 
of the chest and abdomen, the volume of the lungs, and the raising 
and lowering of the heart, the diaphragm, and the abdominal organs. 
They put the machinery of the body in motion, and furnish us with 
a knowledge of the living movements which take place in the interior 
as well as on the exterior of the body during the act of breathing. 
During inspiration, the three upper ribs converge, the movable 
second rib being drawn much nearer to the immovable first rib by the 
combined action of both intercostal muscles : those ribs also move 
entirely forwards, so as to expand the upper lobe. The three lower 
ribs, on the other hand, diverge like a fan; and they move entirely 
backwards, so as to expand the lower lobe. During expiration, they 
are approximated by the combined action of both intercostals. 
The four lower ribs give origin to the diaphragm. They enlarge both 
its circumference and that of the lower lobe during inspiration, when 
the diaphragm lengthens those lobes downwards, and displaces the liver, 
stomach, and spleen from within the shelter of the lower ribs. Since 
these ribs participate thus in action with the diaphragm, I have named 
them the diaphragmatic ribs; discarding the incorrect term “false” 
because they work as truly as the so-called true ribs; as well as the 
term “floating,” since, though they appear to float in the dead body, 
they are steadied in the living body by powerful respiratory muscles. 
THE EIBS AND DIAPHRAGM. 
Snakes, lizards, and birds breathe by means of ribs alone, the 
diaphragm being either absent or subsidiary. In man, as in the other 
mammalia, the ribs share the act of breathing with the diaphragm, the 
ribs being so moulded as to adjust themselves to the diaphragm. The 
cage of the chest is cone-shaped, and vaulted towards the apex. During 
inspiration, when the floor of the chest, formed by the diaphragm, is 
lowered, the costal walls enlarge, and the vaulted roof expands and 
rises so as to cause general expansion of the lungs. 
The middle series of ribs, from the fourth to the eighth, present a 
general conformity. They are joined to the sternum by cartilages, 
and bend backwards from the vertebrae so as to form a hollow for the 
lungs posteriorly. During inspiration, the ribs bearing on the vertebrae, 
and the cartilages bearing on the sternum, are raised sideways, so as 
to widen the chest; while the anterior extremities of the ribs, carrying 
the cartilages, are raised, and move forwards, and the posterior 
portions move backwards, so as to deepen the chest. 
The seventh cartilages of opposite sides, from their articulation with 
the end of the sternum, form the limbs of a pair of compasses, which 
diverge, and widen the epigastrium! during inspiration, and which con- 
verge, and narrow the epigastrium during expiration. 
The five upper ribs act exclusively on the upper lobe, and have no 
bearing on the lower lobe, or the diaphragm. Their relations are 
entirely thoracic, and I have therefore named them the thoracic ribs. 
The sixth, seventh, and eighth ribs move in common, because their 
cartilages are conjoint, and form an intermediate set, which are mainly 
thoracic during inspiration, but which, during expiration, like the 
diaphragmatic ribs, co-operate with the diaphragm. 
The ribs increase in length from the first to the seventh and eighth; 
consequently, during inspiration, when the chest is deepened by the 
elevation of the ribs, the lower portion of the sternum is pushed 
forwards more than the upper, and the dorsal vertebrae are pushed 
backwards to an increasing extent from the fourth to the eighth or 
ninth rib, so as to increase the curve of the dorsal spine. Since the arc 
of the spine is deepened, the chord of the arc is shortened, and, 
therefore, during inspiration, the length of the dorsal and cervical 
portions of the spinal column is shortened. If the inspiration is volun- 
* For extended details of the subject of this Commentary, I refer to my papers “ On 
the Mechanism of Respiration,” in the Philosophical Transactions for 1846 ; “On the 
Movements of Respiration in Health and Disease,” in the Med. Chir. Trans, for 1848 ; 
“On the Situation of the Internal Organs,” in the Prov. Med. Trans, for 1844; and 
“ On the Causes which Excite Respiration,” in the Prov. Med. Trans, for 1850. 
f By epigastrium is meant the triangular space below tbe lower end of the sternum, 
and between the right and left seventh and eighth cartilages. 
EXPLANATION OE PLATE XYI.—ERONT VIEWS. 
lisr this and the two following Plates, the body is exhibited under two aspects. In 
Pig. 1, the lungs are collapsed as in expiration ; in Pig. 2, they are inflated to the full, 
as in forced inspiration. In order that the lungs in Pig. 1 might retain the exact quan- 
tity of air that they held after the last expiration, I inserted into the trachea a tube, the 
stop-tap of which was turned before opening the chest. 
The intercostal muscles are removed, and the bony cage of the chest is left so as to 
expose the organs within it through the intercostal spaces. 
It was difficult, and took a great deal of time to make the drawings in these plates. 
The difficulty lay not in the figures of the collapsed lung representing expiration, but in 
those of the inflated lung representing inspiration. In the former, the lungs, the other 
organs and the ribs were permanently at rest; in the latter the air escaped very gradually 
from the lungs, thus necessitating a renewal of the inflation from time to time. Owing 
to the length of time occupied in making the dissections and drawings, this could 
not be avoided. To lessen this source of error as much as possible, I took sepa- 
rate outlines of the body, both when the lungs were distended and collapsed, in 
addition to those made for the actual drawings. When making the reduced drawings, 
constant reference was made, rib by rib, to those outlines, and to the costal walls, 
which were preserved, of each of the three bodies figured in these Plates. Every effort 
was made to attain accuracy, and I believe that these drawings are substantially correct. 
In Plate XVI., fig. 1, representing expiration, the collapsed lungs and pericardium 
(P), the diaphragm, in part cut away, and the liver, stomach (St), and spleen (Sp), where 
exposed by the removal of the diaphragm, are seen through the intercostal spaces. In 
Fig. 2, representing inspiration, the distended lungs almost exclusively occupy the inter- 
costal spaces, the right lung (L) appearing below to the right of the xiphoid cartilage. 
The heart (H) is covered by lung within the ribs and intercostal spaces, and is lowered 
and exposed to the left of the xiphoid cartilage, resting, like the tip of the left lung, there 
seen also, and the right lung, on the diaphragm (D). 
(The figures in Plates XYL, XVII., XYIII. are reduced from 82 inches to 12T inches.) COMMENTARY ON PLATES XYL, XYIL, & XYIII. 
tary, the shortening of the cervico-dorsal spine is often more than 
counterpoised by the backward movement of the lumbar spine. 
The chest, when looked at with a sole regard to its bony framework, 
and not to its internal organs, appears much shorter, and the abdomen 
much longer in front than at the side or back. 
In front, the sternum forms the centre-piece and apparent limit of 
the chest, the neck being bounded by its upper end, the abdomen by 
its lower end. In appearance the chest, therefore, is short, while the 
neck and abdomen are long. During a forced inspiration the sternum 
is much raised, so that the neck is shortened, while the abdomen is 
apparently lengthened at the expense of the chest. 
ments has its special advantages. I still prefer my own. It is light, 
simple, and accurate. It shows, to the hundredth of an inch, the 
exact movement of the part examined. Its employment, like that 
of the stethoscope, and every other aid to diagnosis, requires practice. 
I have not seen the callipers invented many years ago by Dr. Stokes. 
At the side, the long single range of ribs, and behind, the long 
double range of ribs and the dorsal vertebrae, convey the impression of 
a lengthy chest and a very short abdomen. 
It is true that the chest is longer behind than in front; but the main 
difference lies in the deceptive appearance presented by the long array of 
ribs and vertebrae behind, compared with the short breastbone in front. 
Behind and within the ribs are seated not only the lungs, but also 
those important abdominal organs, the liver, the spleen, the stomach, 
and a portion of the intestines. 
The diaphragm forms the true limit between the chest and abdomen. 
It is the movable floor of the chest, the movable roof of the abdomen. 
Its descent lengthens the chest and shortens the abdomen; its ascent 
lengthens the abdomen and shortens the chest. The diaphragm forms, 
therefore, the regulator of the size and position of the organs within the 
chest, and of the position of the organs within the abdomen. 
In the majority of males, the thoracic movement during tranquil 
inspiration is about one-twentieth, the abdominal movement one-third, 
of an inch. This indicates that the diaphragm descends about half an 
inch. In the robust, the thoracic movement is even less. In two 
remarkably well built men, Sewell, the American runner, and the third 
best English runner, it was only the thirtieth of an inch. In many weak 
persons, on the other hand, it is as much as the tenth of an inch. 
In females, thoracic breathing is greater than in males, dia- 
phragmatic breathing less. While all physiologists are agreed as to 
the fact, they differ as to its cause. Some consider it to be due to the 
natural difference in the character of breathing in the two sexes; others, 
to the habit of wearing stays. The latter opinion is supported by the 
fact, that when the stays are on the thoracic and diaphragmatic 
movements are nearly equal, while, when they are off, the thoracic 
fall from the tenth to the fifteenth or twentieth of an inch, whilst the 
abdominal rise from the tenth to the fifth of an inch. The respiratory 
movements of male and female children are alike up to the age of 14. 
During a forced inspiration, when the combined powers that expand 
the lungs are all brought into play, thoracic and diaphragmatic 
respiration are nearly balanced; the walls of the chest and the walls of 
the abdomen advance almost equally, and from one to two inches; 
the circumference of the chest and the circumference of the abdomen 
are nearly alike increased, from two to three, or even four inches. We 
must bear in mind, however, that a forced inspiration is very different 
from an ordinary inspiration. The latter is physiological and uncon- 
scious, and the proportional movements of the chest and diaphragm are 
not modified by the emotion or the will; the former is voluntary and 
conscious : and as the attention is directed to the apparatus of breathing, 
in some the chest movements are in excess, in others the abdominal; 
many persons, indeed, breathe entirely by the diaphragm when the 
abdomen is being examined, entirely by the ribs when the chest is 
being examined. Usually, however, the abdominal and thoracic move- 
ments are about equal, but the epigastrium generally advances much 
more than the lower end of the sternum. 
Dr. Hutchinson has shown that when a man six feet high takes a 
deep breath, he inhales nearly a gallon of air. During an ordinary 
inspiration, he inhales only from half to three-quarters of a pint. 
Hence, in tranquil breathing, the size of the chest is but little increased; 
while, in forced breathing, both the chest and the abdomen undergo a 
marked and unusual expansion. 
When we run, we inhale sixteen times as much as when we are 
tranquil. Tranquil breathing is, therefore, made without effort or 
display. The descent of the diaphragm, for half an inch, is performed 
unconsciously. The very slight expansion of the thoracic ribs is 
made less with the object of directly expanding the lungs than of 
sustaining the weight of the atmosphere, which would otherwise 
compress the lungs when they are being lengthened downwards by the 
diaphragm. If from any cause—such as submersion, suffocation, 
laryngismus, hiccup, croup, or a foreign body in the larynx—the 
entrance of air into the lungs is prevented or impeded, the diaphragm 
continues to act rhythmically, so as to lengthen the yielding lungs 
downwards. As the atmospheric pressure can no longer act to force 
the air through the air-tubes into the air-cells, it forces backwards the 
front of the chest. In one man, suffering from chronic laryngitis, the 
obstacle was so great that scarcely any air entered the lungs. His face 
was anxious, ghastly, and covered with sweat. He gasped at each 
effort at inspiration, when the abdomen protruded, but the chest 
collapsed half an inch. Tracheotomy was performed. Instantly the 
chest expanded, breathing was freely re-established, the face became 
ruddy, the eyes beamed with pleasure, and relief was complete. It 
was interesting to notice that the nostrils continued to expand, although 
the air entered the trachea through a tube. The man recovered. 
Since this was written I admitted a man, affected with contraction 
of the glottis, into St. Mary’s Hospital, who inspired with extreme 
effort and difficulty. His respiration was hissing, and heard at a 
In order to measure the movements of breathing with accuracy, 
I contrived a Chest-Measurer. It is figured in the adjoining wood-cuts, 
and described in the Medico-Chirurgical Transactions for 1848. As a 
rule, it is better to dispense with apparatus, and to apply the hands 
immediately over the chest when observing its movements : but in 
many cases they can only be accurately ascertained by mechanical aid. 
Since my Chest-Measurer* was described, Dr. Quain and Professor 
Wintrich have invented ingenious instruments for the same purpose. 
Also Dr. Edwards has recently contrived a pair of callipers for 
measuring the varying diameter of the chest, to which Mr. Becker has 
adapted the dial-portion of my Chest-Measurer. Each of these instru- 
thread movement 
# When using the Chest-Measurer, press upon the skin or clothes over the part to he 
examined with the left fore-finger. Hold the instrument between the thumb and fore- 
finger of the right hand. Do not rest that hand on the chest itself or the part examined, 
hut steady it on some adjoining fixed object, as the patient’s arm. Eest the top of the 
moving rod on the nail of the left fore-finger, and observe the movements on the dial. Be 
careful not to humour the movements so as to make them answer to what you expect, by 
varying the pressure with the left fore-finger, or moving the right hand. FJL. W1 
liui\lxn.3cn-dBL &, alVtcm- 
Fig- !■ 
Tig, 2. 
Txcrnx "SaAixte axui oti Stone "by ~W. Y airland. COMMENTARY ON PLATES XVI., XVII., & XYIII. 
distance. Yesicular breathing was barely audible over the chest; he 
spoke in a whisper. The lower end of the sternum and the epigas- 
trium retracted during each inspiratory struggle, while the upper chest 
and lower abdomen expanded. The thyroid body was hard and large— 
it pressed on the trachea; but it evidently to me compressed the left 
recurrent nerve, whence the narrowing of the glottis. He took six 
grains of iodide of potassium every three hours for four weeks, when 
the thyroid body was greatly lessened, breathing was free, the voice had 
returned, the symmetry of the breathing movements was restored, 
the breath sounds became natural, and he left the Hospital feeling 
well. 
the diaphragm lengthens downwards and expands the right and left 
lungs, so the descent of its central portion lowers and lengthens the 
heart. 
At the end of the sternum, and at the bodies of the lower dorsal 
vertebrae, the central portion of the diaphragm is higher than the 
lateral portions. But deeper, this is reversed, since the central tendon 
is much higher on the right side, and somewhat higher on the left 
side, than at the centre, as is shown in Plates IY., XY., IX., XI. 
The same Plates show, also, that while each lateral portion of the 
diaphragm forms a complete arch from the front to the back of the 
chest, lower behind than in front, the central portion forms a slightly 
inclined plane from the body of the ninth or tenth vertebrae to the 
lower end of the sternum, higher behind than in front. 
The fibres of the central portion of the diaphragm are inserted into 
the central tendon, along the base of the pericardium, by one converging 
muscular web, which stretches from the seventh cartilage on one side 
to the seventh cartilage on the other side, and arises from each of those 
cartilages, from the tip of the xiphoid cartilage, and by a distinct slip 
on each side of that cartilage, from the aponeurosis between the trans- 
versals muscle and the peritoneum. 
The diaphragm has an extensive action on many other organs besides 
the lungs. At each inspiration it draws downwards and lengthens the 
heart, increasing the size of its cavities, and the blood contained in its 
right side; it compresses downwards the bulk of the liver, so as gently 
but firmly to press the blood onwards from the hepatic vena cava into 
the right auricle—the spleen, with an analogous effect—the pancreas 
and the kidneys, so as to help onwards their secretions—the stomach 
and intestines, great and small, so as to churn their contents, and on 
a deep inspiration the uterus even, the rectum and the bladder. 
The expiratory ascent of the diaphragm from the contraction of the 
abdominal muscles causes the reversal of all these actions, so that 
every organ is brought alternately under the downward and upward 
sway of the diaphragm and the abdominal muscles. 
In some bodies, the muscular slips from the xiphoid cartilage are 
replaced by a thick triangular aponeurosis. In one such instance, both 
slips from the abdominal aponeurosis were present; and in two 
others, one slip was present, the other absent. In these instances, 
the inner fibres, from each seventh cartilage, instead of passing 
obliquely backwards to the base of the pericardium, took a course 
directly inwards to the aponeurosis passing from the xiphoid cartilage 
to the lower edge of the pericardium. 
It is to be remarked that a deep breath is habitually drawn imme- 
diately before every act of expulsion; before the acts of sneezing, 
speaking, coughing, and natural or hysterical laughing and crying, 
which are acts of expulsion from the lungs themselves; before those 
of eructation and vomiting when the stomach is compressed downwards 
by the diaphragm; before the expulsion of the urine and the faeces; 
and, finally, before each labour pain. All these expulsive acts are 
truly efforts of expiration, but in all of them the previous deep inspira- 
tion gives additional purchase to the expulsive effort. 
The diaphragm must be regarded as a muscle having three distinct 
portions, the right, the left, and the central, each portion having a 
different anatomical relation, each its own tendon, each operating on 
a distinct set of organs, and, although they act combinedly as one 
muscle, each able to act alone under certain contingencies. 
The right portion expands the right lung and lowers the liver and 
right kidney; the left portion expands the left lung and lowers the 
stomach, spleen, and left kidney; and the central portion lowers and 
expands the heart and depresses the left lobe of the liver, the cardiac 
and pyloric extremities of the stomach, the pancreas, and intestines. 
The right portion, wdiich fits like a cap over the upper convexity of 
the liver, and which in turn is capped by the concave base of the right 
lung, usually in the dead body rises upwards into the chest as high as 
the level of the lower edge of the fourth rib in front, the fifth, sixth, 
and seventh ribs at the side, and the eighth rib behind. This repre- 
sents its position at the end of an expiration. The concave base of the 
right lung laps over the right dome of the diaphragm all round, so as 
to present everywhere a wedge of lung that thins off to a sharp edge 
between the diaphragm and the ribs, immediately below which, the 
right diaphragm in its whole circuit presses against the costal pleura. 
The right portion of the diaphragm, from its origin at the lower ribs 
and cartilages, ascends within the ribs, until it is separated from them 
by the interposed margin of right lung. The costal and diaphragmatic 
pleurae glide upon each other from the reflection of the pleurae to the 
lower margin of the lungs. 
The left portion of the diaphragm is narrower anteriorly than the 
right, owing to the encroachment of the pericardium. To make up for 
this, the whole left portion takes a lower pitch than the right. It is lower 
at the central tendon or summit by about three-quarters of an inch, at its 
origin from the lower cartilages and ribs by about a quarter of an inch, 
and intermediately, where the lower edge of the left lung separates it 
from the costal pleura, by about half an inch. During a deep inspira- 
tion the difference between the two sides is maintained. 
The diaphragm arises, not from the whole length of the seventh 
cartilage, but from its lower half only, by fibres which stop short three 
inches from the articulation of the cartilage with the sternum, so as to 
leave a triangular gap between it and the xiphoid cartilage, which is 
filled up during a deep inspiration by the lower edge of the right 
lung on the right, the heart and the tip of the left lung on the left side. 
When we stretch the two inner thirds of the fibres from each 
seventh cartilage, which ascend inwards to the lower edge of the 
pericardium, we pull down the pericardium, but produce no effect on 
either lateral portion of the diaphragm. When we stretch the outer 
third of the fibres from each seventh cartilage, we lower the lateral 
convexity of the diaphragm, into the central tendon of which they are 
inserted, but produce no effect on the pericardium. 
When the central fibres of the diaphragm, described above, contract, 
they draw downwards the cardiac portion of the central tendon, and 
they lower, lengthen, and stretch the pericardial sac and its aponeurosis, 
the heart, and the great vessels quite up into the neck. 
In estimating the effect of inspiration on the relation of the internal 
organs to each other, and to the walls of the chest, two elements must 
be considered: the descent, namely, of the diaphragm, and the ascent 
of the sternum ribs and cartilages. 
During a forced thoracic inspiration, the walls of the chest ascend 
one inch. If at the same time the diaphragm is stationary, the lower 
boundaries of the lungs and heart, and the upper boundaries of the 
liver and stomach, must be stationary also. The cage of the chest must 
then glide upwards over those organs for the space of an inch, and their 
boundaries, though really stationary, will be nearly an inch lower in 
relation to the costal walls. 
If while the ribs ascend one inch, the diaphragm, as is usual, descends 
from one to two inches, then the actual descent caused by the 
diaphragm must be added to the relative descent caused by the uplifting 
of the cage of the chest. The lowering of the lungs in relation to the 
ribs will then be about two inches; that of the heart, an inch and 
a half; and that of the liver, two and a half or three inches. 
LUNGS AND HEART. 
The descent of the diaphragm, acting as a piston, lowers and 
lengthens, by a common operation, both the lungs and heart, which 
rest on it as on a floor. Huring a deep inspiration, the inferior margins 
of the lungs are lowered from the sixth cartilage in front, from the 
seventh, eighth, and ninth ribs at the side, and from the tenth rib 
While the right dome of the diaphragm supports the right lung, 
and the left dome the left lung, the central portion supports the heart. 
As during inspiration the descent of the right and left portions of 
EXPLANATION OE PLATE XYIL—SIDE YIEWS. 
Ik Fig. 1., representing expiration, the collapsed left lung, the heart, and pericardium 
occupy the upper portion of the space within the ribs; its lower portion being occupied 
by the whole of the stomach (S) and spleen, which is large, a part of the kidney and a 
part of the colon, which are seen through the intercostal spaces. The intestines lie 
below the ribs. 
In Fig. 11., representing forced inspiration, the distended lung covers the heart, and 
occupies the whole space within the ribs down to their cartilages, almost to the exclusion 
of the stomach. The spleen, though much lowered, is still seated within the base of the 
left lung and the lower ribs: in this subject it projects just below their tips. The 
kidney (K) is also lowered, and the intestines are compressed downwards. COMMENTARY ON PLATES XVI., XVII., & XVIII. 
behind, to the seventh cartilage in front, to the eighth, ninth, and 
tenth ribs at the side, and to the twelfth rib behind. The base of the 
left lung is about half an inch lower than that of the right in its 
whole circumference at the beginning as at the end of inspiration. 
The breath-sounds, vocal vibration, and pulmonic resonance on per- 
cussion, descend with the descent of the base of each lung. 
lages must be taken into account. While the latter ascend and advance 
about one inch, the former descend and advance nearly two inches. 
But in relation to the ribs and cartilages, the liver moves downwards 
about three inches, forwards scarcely one inch, since their elevation 
adds to its depression, and their expansion lessens its protrusion. 
The inspiratory lowering of the liver is notably greater than that 
of the stomach and spleen, owing to the great height to which it 
occupies the right dome of the diaphragm. In accounting for the 
relative inspiratory depression of the liver, we must, therefore, keep in 
view three causes: the general descent of the diaphragm, the special 
descent of the right dome of the diaphragm, and the ascent of the right 
cartilages and ribs. 
Under this triple agency, the lowering of the liver would be still 
greater, but that it is compressible, and that the blood is forced freely 
out of the hepatic vena cava into the right auricle, which is happily 
enlarged during inspiration. 
The thin edge of the liver usually appears during expiration, just 
below the xiphoid cartilage, and above the stomach and colon, which 
combine to form a yielding hollow in the epigastrium, resonant on 
percussion. This hollow is replaced during a deep inspiration by the 
liver, which descends towards the umbilicus, stretches across the epigas- 
trium, between the left and right seventh and eighth costal cartilages, 
and forms an elastic rounded prominence, dull on percussion. 
As a general result, the liver during a deep inspiration is compressed 
and shortened from above downwards, widened from side to side, 
lowered so that fully one-half of the organ is exposed below the ribs 
and cartilages, instead of being sheltered almost entirely within them, 
and thrown forwards so as to be more prominent by from half an inch 
to an inch than the seventh and eighth cartilages and the xiphoid 
cartilage, instead of lying quite behind them. 
The left lobe of the liver, the stomach, and the spleen, form, in com- 
bination, a counterpoise to the right lobe of the liver. While it, during 
expiration, is protected within the six right lower cartilages and ribs, 
they lie within the left lower ribs and cartilages. They, like it, also 
are displaced downwards and forwards during a forced inspiration by 
the descent of the diaphragm and the base of the corresponding lung, 
so as to appear to a great extent below the ribs and cartilages. 
Since during inspiration the whole of each lung is elongated, the 
upper lobe as well as the lower, the septum between those lobes is also 
lengthened and lowered. The septum, above and behind, where it is as 
high as the spine of the scapula, is only slightly lowered; but below 
and towards the front, where it bisects the base, severing the upper or 
middle lobe from the lower, the descent of the septum is as great as 
that of the base itself. Luring expiration, the septum usually crosses 
obliquely the line of the fifth rib, its upper portion being above and 
before that rib ; its lower, below and behind it. Luring inspiration, it 
follows the same line of direction in relation to the sixth rib. 
The lower boundary of the heart, which rests upon the central 
portion of the diaphragm, is drawn downwards during forced inspira- 
tion by the descent of the central tendon, from the extremity of the 
sternum almost to the tip of the xiphoid cartilage. While the heart 
thus descends, the lungs expand downwards and forwards so as to 
cover a large portion of the heart that was uncovered during expira- 
tion. The region of cardiac dulness on percussion, therefore, descends 
to the epigastrium from the costal cartilages to the left of the lower 
sternum, where it is replaced by lung resonance. The impulse is also 
lowered and narrowred. The apex-beat is lost, being masked by lung; 
and the beat of the right ventricle descends to the left of the xiphoid 
cartilage. In fact, at the end of a deep inspiration, the lungs absorb 
the costal walls to the exclusion of every other organ. 
During inspiration, owing to the general elongation of the lungs, 
the great bronchi are drawn downwards. This descent of the bronchi 
involves that of the trachea and larynx, which is visible in the neck. 
The descent of the heart during inspiration causes the like descent 
of the great pulmonary vessels behind, and the great systemic vessels 
above the heart. 
The pulmonary vessels have the same respiratory play as the bronchi, 
with which they intertwine as they enter and leave the lungs at their 
roots. The inspiratory descent of the great vessels at the base of the 
heart draws down and stretches the great vessels in the neck, which 
have the same respiratory play as the larynx and trachea. 
Thus, during respiration, the alternate action of the diaphragm and 
the abdominal muscles produces a common downward and upward 
movement of the heart and lungs, a common lowering and raising of 
the pulmonary vessels and bronchi, and a common descent and ascent 
of the vessels of the neck and the trachea and larynx. 
The shelving edge of the left lobe of the liver overlaps, and, there- 
fore, hides the lesser curvature of the stomach and its pyloric and 
cardiac orifices, and it does so during both inspiration and expiration, 
whether the stomach be full or empty. The pyloric extremity of the 
stomach lies, therefore, below the left edge of the liver, and usually 
appears during expiration just beneath the xiphoid cartilage, whence it 
is lowered by a forced inspiration to the level of the umbilicus. The 
cardiac orifice is drawn downwards by the crura of the diaphragm for 
about an inch, while the pyloric orifice is pushed downwards and 
forwards about two inches. 
The inspiratory deepening of the great vessels and trachea at the 
root of the neck is greatly increased by the simultaneous rise of the 
upper edge of the sternum and the clavicles. Thus it is, therefore, in 
the neck, the chest, and the abdomen, that while the parts and organs 
situated therein are lowered during inspiration, the whole bony cage 
of the chest is raised, so that the relative descent of those parts and 
organs, in their association with the ribs and sternum, is everywhere 
considerably greater than their actual descent. 
The greater curvature and cardiac extremity of the stomach, unless 
it is much distended, and the spleen, lie during expiration completely 
within the lower cartilages and ribs. Luring inspiration the stomach 
and the spleen descend together; but while the former is forced for- 
wards to as great an extent as it is downwards, the downward movement 
of the spleen is much greater than its forward movement. 
The spleen, during expiration, lies upon the three or four lower 
ribs, and the posterior part of the convex base of the left lung. 
During forced inspiration, the upper part of the spleen is pressed 
forwards as well as downwards; the lower part, more directly down- 
wards. The inferior edge of the spleen usually descends to the tip of 
the last rib, or even lower when the organ is large, as in Plate XYII. 
During a forced inspiration, while in front the lung makes its way 
downwards below the lower edge of the sternum; behind, it does not 
reach by a couple of inches so low as the tip of the last rib. Hence, 
the lower edge of the spleen on the left side, of the liver on the right 
side, do not usually descend so low as the extremity of the twelfth rib. 
The kidneys are lowered during a forced inspiration from half an 
inch to an inch, or thereabouts. 
The intestines, great and small, are pressed during a forced inspira- 
tion downwards, forwards, and sideways; their displacement being 
effected not by the immediate pressure of the diaphragm, but by 
the intermediate pressure of the liver, stomach, and spleen. The 
ascending portion of the colon, just below the liver, and its descending 
portion just below the stomach and spleen, are the exceptions to this rule, 
they being immediately acted on by the diaphragm. When the stomach 
is full, as in Plate XYII., it fills up the space within the ribs below the 
left portion of the diaphragm. When, however, the stomach is empty, 
the space previously occupied by it is filled up, as in Plate XYIIL, 
by the descending portion of the colon. 
The pelvic organs are subjected, during a forced inspiration, to the 
downward pressure communicated to them from the diaphragm by the 
ABDOMINAL OEGANS. 
When the abdominal organs are pressed upon during a deep inspi- 
ration by the descending diaphragm, they are displaced in three 
directions: downwards, forwards, and sideways. This displacement is 
not limited to the liver, stomach, and spleen, and the other organs 
immediately acted upon by the diaphragm, but through their inter- 
medium it spreads downwards also to the lower abdomen, the pelvic 
viscera, and the perinseum. 
During expiration the six lower ribs and cartilages protect the liver 
on the right side, the stomach and spleen on the left, which organs 
rest solidly on the posterior muscular sheet of the diaphragm in front 
of the lower ribs and the wedge of lung at the base. Those viscera, 
therefore, there occupy the hindermost part of the body. During 
inspiration, the wedge of lung at the base steadily descends, and 
is interposed between the lower ribs and the posterior part of the 
diaphragm, which advances as it descends, and lifts forwards the bulk 
of the liver, stomach, and spleen. The most striking effect of the 
inflation of the lungs in situ is not so much the descent of those 
organs, great as that descent is, as the advance of those organs. They 
appear to be, and they are propelled forwards by an irresistible force, 
acting a tergo, a force allied to that of the Bramah press, pneumatic 
being substituted for hydraulic pressure. 
In estimating the descent and advance of the liver, spleen, and 
pancreas, the ascent and advance of the lower sternum ribs and carti-  
Fig., 2. 
Fig. 1 COMMENTARY ON PLATES XVI., XVII., & XVIII. 
intermediate viscera. This pressure causes the descent not only of the 
intestines freely occupying the cavity of the pelvis, but of the more 
attached organs also, the uterus and vagina, the rectum, bladder and 
prostate. The perinseum itself is subjected to the same influence. 
When we sit we can feel it pressing downwards on the chair if we take a 
deep hreath. It descends, also, with considerable force during the deep 
inspiration which precedes and gives increased purchase to the expulsive 
actions from the rectum, the bladder, and the uterus and vagina. 
symmetry of breathing rapidly returns with the speedy escape of the 
exudation. 
When the entrance of air through the larynx is seriously obstructed, 
the walls of the thorax, especially at the lower sternum, and the 
epigastrium, are forced backwards by atmospheric pressure during 
each inspiration, while the abdomen protrudes. 
In emphysema and bronchitis, the movements of the lower sternum 
and the epigastrium are reversed, as in laryngeal obstruction, but there 
is exaggerated breathing over the upper chest as well as the lower 
abdomen. The respiratory disturbance augments with the increase of 
obstruction to breathing ; lessens with its diminution. 
In severe pericarditis, the movements over and to the left of the 
lower sternum and those of the central abdomen are restrained ; those 
of the upper ribs, exaggerated. If extensive pericardial adhesions follow, 
those respiratory movements are still disturbed; if not, healthy 
breathing is restored. 
In peritonitis, abdominal respiration is at a standstill, the breathing 
being high and laborious at the upper part of the chest. 
In some pulmonary diseases, as in phthisis, and in the emaciated and 
bedridden, the lungs shrink, and the body within and without presents 
the type of expiration. Other diseases, as emphysema, present the 
type of inspiration, the lungs being permanently enlarged. 
When we view the twofold action of breathing—the inspiration by the 
ribs, and the inspiration by the diaphragm—we must study those two 
agencies separately, while we regard them as operating with combined 
force and mutual adjustment. 
Thoracic respiration only slightly expands the lungs during tranquil 
breathing, but it sustains the vast atmospheric pressure that would 
otherwise cause their collapse when those organs are elongated by the 
descent of the diaphragm. It is during forced breathing that thoracic 
inspiration tells. Then the lungs are expanded upwards, and in their 
entire circumference. This inspiratory effect is expended exclusively 
on the lungs and, to a minor extent, on the heart. It produces no effect 
in altering the position of the internal organs. 
Diaphragmatic inspiration is always efficient. During tranquil 
breathing it lengthens the lungs and heart, sustained in their 
circumference by thoracic expansion, and lowers the abdominal organs 
to the extent of about half an inch. During a forced inspiration the 
abdominal viscera are displaced extensively downwards by the 
lengthened lungs and heart, and the circumference of the abdomen is 
greatly enlarged. The expanding lungs completely cover the heart 
within the costal walls. The lungs, in fact, have the ribs and sternum 
entirely to themselves, the exposed portion of the heart being seated 
in the epigastrium. 
In phthisis the chest is flat and narrow, the diaphragm high, the 
liver and stomach encroach upon the heart and lungs. The neck is 
long, the shoulders slope, the shoulder-blades fall and come close 
together. The ribs below the clavicles flatten and diverge. The 
nipple in relation to the ribs is high. The lower ribs sink and lengthen, 
and cover the raised liver and stomach. The opposite seventh 
cartilages converge so as to narrow the epigastrium. The lungs 
shrink and uncover the heart, which is raised and heats from the 
second or third cartilage to the fifth. 
While, then, the ribs sustain the dimensions of the lungs during 
tranquil, and increase them during forced inspiration, they effect no 
change on the position of the internal organs. The diaphragm, on the 
other hand, elongates the lungs and heart, and displaces the whole of 
the abdominal viscera downwards, during both tranquil and forced 
inspiration. 
In emphysema and bronchitis, the chest protrudes, the diaphragm is 
low, the heart and lungs lengthen and encroach on the liver and 
stomach. The neck is short, the head sinks upon the chest, the 
shoulders are high and forward, the shoulder-blades rise, move asunder, 
flatten on the top, and are winged. The ribs below the clavicles 
protrude and converge. The nipple in relation to the ribs is low. 
The lower ribs rise and shorten so as to uncover the lowered liver 
and stomach. The opposite seventh cartilages diverge so as to widen 
the epigastrium. The lungs absorb the intercostal spaces and cover 
the heart, which is lowered, and beats only in the epigastrium. In 
emphysema the lower sternum and epigastrium, instead of advancing, 
recede during inspiration. 
APPLICATION TO PHYSICAL DIAGNOSIS. 
The knowledge of the effects of the respiratory movements on the 
external form and the position of the internal organs is the basis of 
physical diagnosis. I shall occupy the short remaining space with 
illustrations of this truth. 
The movements of breathing in health are symmetrical, those of 
the right and left sides being equal. 
In pleurisy of one entire side, the inspiratory movements of that 
side—the abdominal as well as the thoracic—are lessened, arrested, or 
reversed, those of the healthy side being exaggerated. Usually, respira- 
tion is less restrained over the upper than the lower lobe. If the disease 
yields, the expansion of the affected side increases—of the healthy side 
lessens from day to day, until the equilibrium of health is restored. 
If, however, empyema, or constricting adhesions follow, respiration is 
permanently lessened over the crippled—developed over the sound lung. 
If one upper lobe is affected with phthisis or pneumonia, it expands 
much less than the opposite lobe. In phthisis, the movements in tran- 
quil breathing, even over the diseased lung, are usually greater than in 
health, the contrast over the two sides being maintained. This contrast 
is especially marked during a forced inspiration, when the expansion is 
much less than in health. In pneumonia the movements over the 
affected upper lobe are almost arrested during the stage of hepatization; 
but they increase rapidly when the exudation softens and is expelled, 
the balance of health being speedily re-established. 
When one whole lung is crippled, as from constricting adhesions, the 
opposite lung being developed, the contracted side presents the type of 
expiration, the expanded side that of inspiration. On the affected side 
the shoulder slopes ; the shoulder-blade drops close to the spine. The 
ribs are hollow and diverge below the clavicle, and crowd together 
and lengthen at the side so as to cover the stomach or liver which 
encroaches on the lung. The seventh cartilage comes close to the linea 
alba. The nipple in relation to the ribs is high. The lung shrinks, 
so as to uncover and draw towards it the heart, which beats more 
to the left or on the right side, accordingly as the left or right lung 
is affected. The diaphragm is high. Percussion is dull, respiration 
bronchial, vocal vibration feeble. The heart’s sounds are loud and 
diffused ; the respiratory movements are restrained. On the developed 
side the shoulder is high; the scapula is raised away from the spine. 
The spine is curved towards this side. The ribs converge and are full 
below the clavicle; diverge, rise, and shorten at the side so as to 
uncover the liver or stomach, which is encroached upon by the lung. 
The seventh cartilage diverges from the linea alba. The nipple in 
relation, to the ribs is low. The lung expands so as to cover and 
displace the heart. The diaphragm is low. Percussion is resonant, 
respiration exaggerated, vocal vibration strong. The heart’s sounds 
are feeble or inaudible ; the respiratory movements are increased. 
During expiration, the heart is exposed and raised, while the walls 
When one lower lobe is hepatized, that lobe cannot expand, and the 
breathing of the healthy lung increases. The affected diaphragm is 
motionless, owing to its inflammation and the bedding of the solid lung 
into the intercostal spaces, and the corresponding abdominal move- 
ments are almost abolished; the costal, only slightly lessened. The 
EXPLANATION OE 
PLATE 
XVIII.—BACK VIEW. 
FEOM THE BODY 
OE A FEMALE. 
In Fig. 1., representing expiration, the collapsed lungs come down to the heads of the 
eleventh ribs. Below the lungs, on the right side, the liver rests on the eighth, ninth, 
tenth, and eleventh ribs; on the left side the spleen rests on the four lower ribs. Those 
organs, the upper half of the right kidney, its supra-renal capsule, and portions of the 
colon, are seen through the intercostal spaces. The left kidney, in this instance, is much 
lower than the right; the lower half of the right kidney and a portion of the colon lie 
below the ribs. 
In Fig. 11., representing forced inspiration, the margins of the distended lungs descend 
below the heads of the twelfth ribs. All the abdominal organs are pressed downwards, 
but the liver, resting on the tenth and eleventh right ribs, the spleen, on the twelfth left 
rib, and a portion of the colon, are still seen through the intercostal spaces. The 
colon below the ribs is compressed downwards. The difference in the position of the 
brachial plexus caused by inspiration, as represented in this Plate, is not from actual 
observation. COMMENTARY ON PLATES XVI., XVII., & XVIII. 
of the chest are depressed. The impulse therefore is strengthened and 
raised, and the heart’s sounds are intensified. In the emaciated, seden- 
tary, and bedridden, expiration is feeble, and the average size of the 
lungs is lessened. The heart is therefore permanently exposed and 
raised as in expiration, the impulse being strong and diffused upwards; 
the heart’s sounds, loud and extended. The action of the heart, though 
really weak, appears to be strong, owing to its whole force being 
brought to bear on the surface of the chest. 
During inspiration and in the robust, those effects are reversed. 
The lungs cover the heart within the ribs. The exposed part of it is 
lowered into the epigastrium.. The impulse migrates from the costal 
walls to the xiphoid cartilage. The heart’s sounds are feeble over the 
front of the chest, loud below the sternum. The heart, though really 
strong, appears to be weak, owing to its force being masked by the 
interposition of the lung. 
THE SIGNS PEESENT IN HEALTH OYEE THE UPPEE LOBES. 
The following observations were made by a Committee consisting 
of Dr. Baly, Dr. George Johnson, Dr. Quain, and Dr. Sibson, and 
named by a private Society for the study of Diseases of the Chest. 
The observations were made on fifty healthy men, their ages 
ranging from eighteen to thirty, selected by Dr. Baly from among the 
inmates of Millbank Prison. 
(Published with the sanction of the Society.) 
SIGNS OYEE THE EIEST AND SECOND EIBS BELOW THE CLAYICLES. 
Eespiratory Movements :—Number of Observations.... 47 
Equal 45 
Greater on the Eight .... 1 
Greater on the Left 1 
When the aortic aperture is obstructed, and its valves are patent, 
systolic and diastolic murmurs are both audible over the middle sternum 
during expiration, and if the lungs are permanently contracted; but 
during inspiration, and in the robust, those sounds scarcely penetrate 
through the thick couch of lung interposed between the aorta and the 
sternum. The diastolic murmur is then audible only over and to the 
left of the lower sternum; the systolic murmur, over the upper sternum 
and the great vessels in the neck. Generally in such cases, owing to 
hypertrophy of the left ventricle, the apex-beat is strong and low, and 
far to the left—sometimes in the sixth space ; but during inspiration, 
and in the robust, the expanded lung masks the apex-beat, which 
ceases to be the index of the enlargement of the left ventricle. 
Sound on Percussion:— 
A. Over Ist and 2nd Eibs ;—Number of Observations .... 50 
Equal . 39 Including 1 doubtful. 
More resonant on the Eight 4 All slightly. 
/ 1 decidedly. 
More resonant on the Left 7 \ 4 slightly. 
\ 2 very doubtful. 
B. Over Ist and 2nd Cartilages :—Number of Observations 20 
(Others probably not re- 
Muai 1 \ corded. 
More resonant on the Eight 3 
More resonant on the Left 16 | g softly!7' 
Breath: Sound during Inspiration, ordinary :—Number of Observations 50 
i! 3 Sound distinct. 
7 Sound feeble. 
3 Sound scarely audible. 
1 Sound inaudible. 
2 undecided as to equality. 
I' 1 decidedly. 
5 predominance somewhat 
doubtful. 
/ 2 much. 
Louder on tbe Left 17 < g 
( 1 slightly, but very faint. 
"When the mitral valves are imperfect, the systolic murmur, 
centreing in the apex, is higher or lower, extended or narrowed, 
accordingly as the lung is expanded or contracted. 
In severe pericarditis with effusion, the expansion of the lung is 
prevented by the distension of the pericardium, the descent of the heart 
by the inflammation of the centre of the diaphragm. Inspiration, there- 
fore, scarcely lessens the friction-sound, or extent of cardiac dulness on 
percussion, and the respiratory movement at the epigastrium is arrested. 
As the pain disappears, and the effusion lessens, breathing is re-esta- 
blished, and the friction-sound is increased and raised during expiration 
—lessened and lowered during inspiration. 
Breath Sound during Inspiration, forced -.—Number of Observations. . 50 
(17 decidedly. 
2 equality doubtful, 
1 scarcely audible. 
i 6 decidedly. 
Louder on the Eight .... 10 <3 slightly. 
( 1 predominance doubtful. 
!14 decidedly, 
5 slightly. 
1 doubtful. 
When pericarditis attacks a person affected with emphysema, the 
friction-sounds are audible, not over the front of the chest, but over the 
xiphoid cartilage. 
Breath Sound during Expiration, ordinary :—Number of Observations.. 50 
(3 distinctly. 
6 scarcely audible. 
19 inaudible. 
S2 much. 
7 decidedly. 
10 slightly. 
1 slightly, but very faint. 
1 predominance doubtful. 
n°} Louder on the Left 1 Decidedly. 
When pericardial adhesions are extensive, and the heart is large, the 
lungs are displaced, and they scarcely penetrate between the heart and 
the ribs during inspiration. The impulse is therefore strong, extensive, 
and high; it retracts between the cartilages, and is scarcely lowered 
or lessened in extent during inspiration. The respiratory movements 
at the centre of the abdomen are much lessened, owing to the adhesion 
of the centre of the diaphragm to the heart. These signs, the non- 
diminution and non-descent of the cardiac impulse, and the non-move- 
ment of the centre of the abdomen during inspiration, are the two 
important signs of extensive pericardial adhesions. 
Breath Sounds on Expiration, forced :—Number of Observations. ... 49 
/ 4 more or less loud. 
Equal 6 I 1 feeble. 
( 1 scarcely audible. 
!6 much. 
23 decidedly. 
12 slightly. 
Louder on the Left 2 Decidedly. 
In Fasciculus 11., column 18, I described certain cases in which a 
systolic murmur was heard during health over the clavicle, towards 
the end of a deep inspiration. This sign has been noticed since then 
by Dr. Kirkes in cases of phthisis. The other day, when examining a 
man with Mr. Part and Mr. Gowland, we heard a systolic murmur 
below the left clavicle during inspiration. At the end of a deep breath 
the murmur ceased, and the pulse at the wrist stopped. This murmur 
is caused by the stretching of the subclavian artery over the first rib 
at the insertion of the scalenus during inspiration, when the rib rises 
and the artery descends, as in Plate XVII. When we raised this man’s 
arm over his bead, and so took the pressure off the artery, the murmur 
ceased, and the pulse returned. This sign, which led in one case to the 
erroneous diagnosis of subclavian aneurism, is no indication of disease. 
Since the liver and other abdominal organs descend and advance 
freely during inspiration, any tumour attached to those organs also 
descends and advances freely at the same time. In thin persons such a 
tumour when in front of the aorta pulsates during expiration, but ceases 
to pulsate during inspiration, when it falls forwards away from the aorta. 
The abdominal aorta, on the other hand, is fixed to the bodies of the 
vertebrae, and the pulsation which is present in thin persons above the 
umbilicus disappears when the abdominal walls advance during the 
act of breathing. For the same reason, aneurismal tumours of the 
abdominal aorta which pulsate strongly during expiration, often cease 
to pulsate and become imperceptible during a forced inspiration. 
These instances, which might have been extended, show that a sound 
physical diagnosis is to be made, not from the observation of any single 
siern, however characteristic, but from the rational study of the various 
o y # 
signs which in their ensemble constitute the phenomena of respiration. 
Sound or Whisper :—Number of Observations 42 
Equal 0 
(5 much. 
29 decidedly. 
8 slightly. 
Louder on the Left 0 
Sound oe Voice Number of Observations 50 
Equal 3 
14 much. 
37 decidedly. 
6 slightly. 
Louder on the Left 0 
Vocal Vibration :—Number of Observations 50 
3 {fggf 
(5 much. 
37 decidedly. 
5 slightly. 
Stronger on the Left .... 0 
Heart’s Sounds, especially Second Sound :—Number of Observations.. 50 
Equal 14 
1' 1 much. 
26 slightly!7' 
1 predominance doubtful. 
Louder on the Left 7 | 
( 4 slightly. 
BEEATH SOUNDS OVEE THE BACK.—SUPEA-SPINOUS EOSSA. 
Breath Sounds during Inspiration, forced :—Number of Observations. . 16 
Equal. 7 
Louder on the Eight .... 4 Decidedly. 
Louder on the Left 5 [ \ decidedly. 
(, 3 slightly. 
Breath Sounds during Expiration, eorced Number of Observations.. 16 
Equal 0 
Louder on the Eight .... 16 { sdighdy7'  
J. B.LEVBILLE LITH 
JMP LEMERCIETHB.de SEME 57..PARIS  
JB.LEVEILLE 11TH. 
IMF IJEMERCIEF JtDE SEJM 57 FAB IS Ip IP 'Jj I? 1 
FIG.2 
FIG.I COMMENTARY ON PLATES XIX., XX., & XXI. 
ON THE MOVEMENTS, STRUCTURE, 
AND SOUNDS OE THE HEART. 
The observation of the heart in the dead body gives a very inade- 
quate idea of its intrinsic movements and varying position during life. 
The organ after death almost always shrinks upwards, and as the 
last effort is one of expiration, the diaphragm and the heart and great 
vessels are unduly raised. 
My last commentary contained a description of the movements of 
respiration, and included an account of the effect of inspiration in 
lowering the heart and great vessels, and of expiration in raising them. 
In this concluding part, I shall endeavour to describe and illustrate 
the heart in motion, and give an account of the structure of the organ, 
especially as regards the muscular and valvular apparatus by which 
its movements are accomplished. 
(Kg- 1). at the junction of the ventricle to the auricle, moves exten- 
sively from right to left; while its left margin, at the septum, moves to 
a comparatively slight degree from left to right. At the same time, 
the top of the ventricle, at the origin of the pulmonary artery, 
descends, while its whole lower border, wrhere it rests on the diaphragm, 
ascends. These various movements converge upon a space or point 
of rest, situated about the middle of the ventricle, but comparatively 
near the septum. This point of rest corresponds with the attachment 
of the anterior papillary muscle. 
The right auricle and vena cava are distended, and the pulmonary 
artery is enlarged and lengthened simultaneously with the con- 
traction of the ventricle. The auricle, which just before was pale and 
wrinkled, becomes plump, glistening and purple; and its auricular 
portion and left edge move rapidly inwards, and to the left, so as to 
replace the ventricle. The movement of the auricular portion is 
remarkable. It suddenly enlarges and becomes purple, its tip moving 
from the right to the left edge of the sternum, at the level of the third 
costal cartilages. 
The contraction of the left ventricle is only visible along its left 
border, including the apex, where it moves forwards and to the right, 
the apex having, in addition, a revolving movement upwards. The 
appendix of the left auricle, which is scarcely visible during the 
diastole, distends during the systole, and moves rapidly forwards and 
downwards, so as to replace the retreating ventricles, and fill up the 
angle between them and the pulmonary artery. 
When we remove the left ribs, and look at the heart from the left, 
so as to obtain a view of it in profile (Eig. 2), the animal lying upon 
its back, we see that the whole ventricle moves forwards during the 
systole, the posterior wail advancing much more than the anterior; and 
that the base of the ventricle descends while the apex ascends, so that 
apex and base approximate. It is difficult to fix upon the precise point 
or zone of rest of the ventricular walls towards which the apex, on the 
one hand, ascends, and the base, on the other, descends; but it is 
somewhere about the middle of the ventricle—nearer, perhaps, to 
the apex than the base. This region of stable equilibrium corresponds 
to a similar point of rest in the papillary muscles. Owing to this 
arrangement, the ventricles and the valves adjust themselves to each 
other throughout the whole period of the ventricular contraction. 
The left auricle, like the right, becomes swollen during the systole; 
when it descends and advances, so as apparently to displace the base 
of the left ventricle. That I might discover whether the displacement 
of the base of the ventricle was really caused by the distension of the 
auricle, I cut off the supply of blood to the auricles by tying the 
vense cavse. Both auricles soon became empty, their walls shrinkiug 
inwards. Both ventricles became smaller; but they still contracted 
forcibly during the systole, the base approximating to the apex, though 
to a less extent than when the blood circulated freely through the heart. 
It is, therefore, evident that the descent of the base of the ventricle 
during the systole is intrinsic, and not due to the displacing effect of the 
distending auricle, though it may be influenced by that agency. 
When the left ventricle propels its contents into the aorta, its arch 
is distended and lengthened, and its origin, like that of the pulmonary 
artery, descends. The arch of the aorta enlarges both in length and 
breadth, and becomes tense and rigid. Its lateral enlargement is small, 
but its elongation is considerable, as Skoda remarks in his work “On 
Auscultation and Percussion,” translated by Dr. Markham, page 159. 
There are two agencies at work in common, each of which -would 
necessarily cause the descent of the origin of the aorta. The ventricle, 
by its contraction towrds its own centre, pulls down the artery at 
its point of attachment; and the blood acting from within, distends 
and lengthens the vessel, and pushes downwards the origin of the 
artery. 
Since the auricles and great vessels enlarge in all directions during 
the systole, they not only descend into the place just left by the 
retreating ventricles, but they also enlarge outwards. The result is, 
that there is a greater amount of blood at the base of the heart, 
including the great vessels, at the end of the systole than at the end 
of the diastole. Since, however, during the systole, the ventricles 
empty themselves, the increase of the blood at the base is probably 
balanced by its diminution towards the apex. During the period of 
rest which follows the dilatation of the ventricles, the blood flows from 
the veins into the auricles. At its conclusion, therefore, when the 
auricle contracts, just before the ventricular systole, the amount of 
blood in the heart and great vessels is greater than at any other time. 
The Lever Movement of the Ventricles during the Systole.—ln all 
our early experiments, which were performed when the animal lay 
upon its back, the apex and the anterior walls of both ventricles 
invariably advanced during the systole. On one occasion the creature 
was turned upon its side, when I noticed that the anterior walls of 
the ventricles, instead of advancing, actually receded during the systole. 
I subsequently repeated this experiment again and again, in the same 
and in different animals, and invariably with the same result. When 
the dog lay upon its back, the anterior walls of the ventricles 
always moved forwards; when it was turned on the side, they either 
fell backwards or were stationary. It occurred to me, that if this 
THE MOVEMENTS OE THE HEART. 
My first experiments on the movements of the heart were made 
upon the ass, in the year 1843, in Nottingham, when I was assisted 
by Mr. Shepperley. The animal was rendered apparently lifeless by 
means of the Wourali poison, with which I was kindly supplied by 
my friend, the late Mr. Waterton; and the beating of the heart, and 
the circulation of the blood were maintained in full force, by the aid 
of artificial respiration, for a period of four hours. 
My recent experiments, in which I was assisted by that excellent 
observer, Dr, Broadbent, were performed on the dog and the ass, when 
rendered unconscious by chloroform, which was given by Mr. Edwards. 
Eollowing the plan of Dr. Halford, we watched the movements of the 
heart through the pericardium, which was rendered almost transparent 
by stripping off its fatty covering. 
In order that the successive movements of the heart might be 
observed with accuracy, a millimetre measure was stretched across the 
organ, as in Eig. 1, and its precise position in relation to the measure 
was noticed, first at the end of the diastole, and then of the systole.* 
The heart, when in full action, presents to the eye the most remark- 
able contrasts in the size, position, colour, and form of its various 
cavities and great vessels. When the ventricles contract, they do so 
with a twisting movement, their walls become rigid and corrugated, 
their apex and base approximate, the descent of the base being greater 
than the ascent of the apex, and the arteries and veins on their surface 
become prominent and tortuous. The auricles become swollen with 
blood, and seem to push before them the retreating ventricles at the 
base. The great arteries are distended and lengthened, being appa- 
rently drawn downwards at their origin, by the contracting ventricles. 
When, however, the ventricles expand, the aspect of all the parts is 
reversed. The ventricles enlarge in every direction, but especially 
towards the base. Their walls are flaccid, swollen, and smooth; and 
the arteries and veins on their surface become straight and small. 
The auricles shrink, becoming pale and wrinkled, and are in great part 
replaced by the ventricles, into which they empty their blood. The 
great arteries lessen in size and shorten, and ascend at their origin, 
being apparently raised by the upward enlargement of the ventricles. 
Owing to the reciprocal contraction and distention of the ventricles 
on the one hand, and the auricles and great vessels on the other, the 
whole fluid contents of the heart and great vessels are obviously nearly 
the same in amount during the systole as during the diastole. The 
distribution of the blood, however, is different, its quantity being 
greater in the ventricles at the end of the systole, in the auricles and 
great vessels, at the end of the diastole. 
The Systole of the Heart.—The contraction of the right ventricle, 
owing to its position at the front of the heart, and its consequent 
complete exposure, is marked and vigorous. Its whole right margin 
* The systole and the diastole of the heart are represented in Plate XXI., and in 
Tigs. 1 and 2. In those figures the outlines of the cavities of the heart and the great 
vessels are indicated at the end of the systole of the heart, by continuous lines, at 
the end ot the diastole, by interrupted or dotted lines. The dotted are less accurate 
than the interrupted lines. The systolic movements are everywhere shown by 
arrows, the extent of the movements being marked by the length of the arrows. It is 
more difficult to watch and measure the movements of the heart at the side than at the 
front, ihe side view, Eig. 2, is therefore not so accurate as the front view, Eig. 1. 
1 believe, however, that both figures very fairly represent the movements of the heart. 
EXPLANATION OP PLATES XIX., XX., AND XXI. 
Plate XIX. is taken from a robust man, who died in the prime of life, his internal 
organs being healthy. The heart is large and filled with blood. The lungs are well 
developed, the chest is ample, and the diaphragm is rather low. The heart and great 
vessels are very nearly in the position that they occupy during life at the middle of an 
ordinary inspiration. 
Plate XX. represents a youth who at his death lost much blood. His heart is small 
and empty. His lungs have collapsed, and his diaphragm is high. The heart has shrunk 
upwards after death, and its position and that of the great vessels are unusually high. 
Plate XXI. aims at presenting the heart in motion during life, in the opposite conditions 
of systole and diastole. COMMENTARY ON PLATES XIX., XX., & XXI. 
advance of the apex and front of the ventricles, when the animal was 
lying upon the back, were due to the fulcrum afforded to the base of the 
left ventricle, the walls advancing, as it were, by a lever movement, that 
the same effect would be produced if it were lying upon its side, by 
inserting a fixed prop or fulcrum behind the base of the left ventricle. 
And it was so. When I introduced a flat ruler, or my finger, behind 
the ventricle, so as to give it a fixed support, when the dog lay on 
its side, the anterior walls, which just before were stationary or 
receded during the systole, now advanced, just as when it lay upon 
its back, though scarcely to the same extent. On the frequent 
repetition of this experiment, which always excited my admiration, the 
same result followed. In order to ascertain how far this effect was 
due to the fluid contents of the ventricles, and how far to the rigidity 
of their muscular walls, I cut off the supply of blood by tying 
the venae cavse. The effect not only remained hut was intensified. 
When, in this state, the animal lay on the back, or the prop was 
inserted when it lay on the side, the anterior walls advanced more than 
when the blood circulated freely. It was evident, therefore, that this 
lever movement forwards was due to the intrinsic muscular contraction 
and rigidity of the walls themselves, and in no respect to the blood 
contained in the cavities. That I might discover, if possible, the 
precise part of the muscular structure on which this lever movement 
forwards depended, I removed in succession the anterior wall of the 
right ventricle, the septum, and the papillary muscles of the left 
ventricle; and I found, contrary to my anticipation, that after each 
successive removal, the ventricles continued to advance when the dog 
lay upon its back, or when a fulcrum was introduced behind the heart, 
when it lay upon its side. 
Before leaving this subject we must ask, upon what fulcrum does 
the base of the left ventricle rest when the animal lies upon the back, 
and the apex and anterior walls of the ventricles advance during the 
systole by a lever movement ? That this fulcrum cannot be the spinal 
column is evident, for the aorta and oesophagus are interposed 
between the heart and the bodies of the vertebrae. Neither can it be 
those vitally important tubes, for they could not with impunity be 
subjected to forcible and ever-recurring pressure. We must look for 
this fulcrum to the fibrous structure of the pericardium, which is of 
great strength. In my paper “On the Mechanism of Respiration,” in 
thq Philosophical Transactions for 1816, p. 538,1 stated that, “Erom the 
floor of the pericardial sac” (the central tendon of the diaphragm) “is 
given off a strong tendinous web that sheathes the whole pericardium, 
and is inserted into the investments of the great vessels at the upper 
part of the chest.” The base of the left ventricle rests securely upon 
the strong fibrous pericardium, upon which it is slung as it were upon 
a hammock, and which is attached to the central tendon of the 
diaphragm below, and to the great vessels above. 
whatever may be the position of the body, which, as we have already 
seen, is not the case with the lever movement. 
According to Gutbrod and Skoda, “ the pressure which the blood 
exerts,” owing to the contraction of the ventricles, “ upon the walls of 
the heart opposite to the opening whence the stream escapes, causes a 
movement of the heart in a direction contrary to that of the stream of 
blood; and by this movement the impulse of the heart against the walls 
of the thorax is produced. The heart is driven in a direction contrary 
to that of the arteries, with a force proportioned to the quantity and 
velocity of the current of the blood.” A precisely similar explanation 
of the impulse was given by Dr. Alderson, in the Quarterly Journal of 
Science, Literature, and Arts for 1825. 
Skoda gives also the following additional cause of the heart’s impulse : 
—“The aorta and pulmonary artery, being free and unattached to some 
distance from their origin in the heart, allow of a lengthening of the 
blood column downwards; and the heart will consequently be forced in 
that direction.” 
The two causes thus advanced by Skoda produce the impulse by 
the common effect of forcing the heart in a direction downwards; and 
they are grounded upon his view that the heart descends, “in some 
cases as much as one or two inches lower during the systole than 
during the diastole” ! Now, these two>gencies exist, and they tend to 
produce the effect described, of forcing the heart downwards. They are, 
however, overbalanced by the more powerful agency of the muscular 
contraction upwards of the lower half of the ventricle. The result is, 
that while the upper portion of the ventricles is lowered, their lower 
portion, including the apex, is raised during the systole, when the ven- 
tricles contract from all sides towards their own centres; and that prac- 
tically the heart’s impulse is not influenced by either of those causes. 
It is to be noticed before leaving this important question, that the 
impulse is not a downward movement of the heart, but a propulsive 
movement forwards and outwards. The ventricles, in short, over their 
whole surface, make a direct thrust against any object upon which they 
impinge, and wherever, therefore, they come in contact with the walls 
of the chest. The impulse is concentrated at the apex, in the fourth 
or fifth intercostal space, or diffused over the whole front of the 
ventricles, in the spaces between the costal cartilages, according to the 
extent to which the heart is covered by the lung. When the heart is 
lowered by the descent of the diaphragm, and the lung interposes 
everywhere between that organ and the walls of the chest, the impulse 
is no longer perceptible over those walls, but may be felt in the 
epigastric space close to the xiphoid cartilage. The muscular rigidity 
and the lever movement of the ventricles, and above all the pressure 
of the blood in those cavities during the systole produce the impulse 
wherever the heart is in immediate contact with the parietes. When 
the heart is displaced to the right side of the chest, the same causes 
produce the same effect, and the impulse is then felt, with a propulsion 
not downwards, but forwards, over the right intercostal spaces. 
The Movements of the Papillary Muscles.—That I might observe the 
action of the papillary muscles, I removed the anterior wall of the 
right ventricle when the heart was beating in situ ; and I found that 
the tip of the anterior papillary muscle of the right ventricle contracted 
towards the septum during the systole. 
I then removed the septum, so as to expose the two papillary 
muscles of the left ventricle, and I noticed that the muscles, which 
during the diastole were wide asunder, approached and came close 
together during the systole. At the same time, the tips or free 
ends of the muscles, with their tendinous cords, descended; while their 
attached ends ascended. The fixed point towards which the two ends 
approximated corresponded apparently to the zone of rest, or stable 
equilibrium, in the walls of the ventricle towards which the base and 
the apex of the ventricle approximate during the systole. 
The Effects of the Pressure of the Blood upon the Walls of the Ven- 
tricles in producing the Impulse.—l observed, in repeated experiments, 
that when the finger was pressed upon the front of the ventricles, it 
was lifted forwards with force, during the systole, to the extent of nearly 
half an inch This propulsion forwards of the finger was much 
greater than the forward movement of the walls when not pressed 
upon, as indicated to the eye, or by means of a delicate lever. When 
the finger was applied to the apex, and pressed gently upwards, it was 
pushed forcibly downwards during the systole to the extent of a 
quarter of an inch. This downward propulsion of the finger was the 
reverse of the ordinary movement of the apex during the systole, when 
it ascended towards the base if not thus subjected to pressure. Again, 
when the heart was grasped by the hand, the fingers and thumb sank 
into the flaccid walls of the ventricles during their dilatation, but were 
driven asunder with great power when the walls contracted. 
What is the cause of this protrusion of the finger when pressed on 
the walls of the ventricle during the systole? Is it muscular rigidity? 
That this cause may operate is probable; but when we find that a finger 
pressed upon the muscles of the thigh is propelled forwards only to a 
slight extent when those muscles contract, we must answer, that there 
is some other agent at work besides muscular rigidity. 
A little consideration will show that this additional agent is the 
counter pressure exerted by the blood on the walls of the ventricles, 
when the contraction of those walls drives it into the great arteries. 
The pressure exerted by the blood, when propelled outwards, is equal in 
every direction; it therefore evidently presses not only on the outlets 
through which it escapes, but also on the walls by which it is expelled. 
To use the words of Skoda, as rendered by Dr. Markham, “ During 
the ventricular systole, the blood presses upon every part of the heart’s 
surface with a force equal to that by which it is itself compressed.” 
The pressure of the blood thus reacts on those walls that by 
their contraction propel the blood outwards. In order to test this 
explanation, the blood was shut off from the heart, when it wTas found 
that the finger applied to its front walls or apex was forced forwards or 
downwards during the systole to a much less extent than when the 
blood circulated freely through the heart. 
The Causes of the Impulse.—It is evident, from what has just been 
said, that the impulse of the heart is due to more causes than one. 
The rigidity of the muscular walls is one of those causes. 
The lever movement, described above, and illustrated elsewhere 
by Ludwig, which is itself due to muscular rigidity, is another. 
An additional, and probably the most important, cause of the 
impulse is the outward pressure of the blood in the ventricles on 
the walls by which it is expelled, and through those walls, on the ribs 
and intercostal spaces; just as the pressure of the blood produces the 
pulse at the wrist and the pulsation of an aneurismal tumour. The 
pressure of the blood is a cause of the imnulse which tells invariahlv. 
The Action of the Mitral and Tricuspid Valves.—ln order that I 
might see the movements of the mitral and tricuspid valves, I cut out 
the heart when beating vigorously, and immersed it in water. The 
ventricles contracted with force, and expelled the water from the great 
vessels during each systole. The jet from the aorta was six inches in 
length. The segments of the mitral and tricuspid valves came together 
at their beaded margins, so as to close the valves, and prevent the 
efflux of any liquid. It was difficult to observe whether the valves at 
their outer rim, where they are attached to the muscular walls, altered 
in shape or size towards the end of the systole ; but it appeared to me 
that they retained their form and dimensions, and they were certainly 
completely closed, throughout the contraction of the ventricles. 
At the beginning of each diastole, the margins of the valves 
separated quickly from each other, so as to admit the flow of water 
into the cavities. It was evident that the valves were thus opened by 
the intrinsic action of the heart, and not by the pressure of the fluid 
from behind, since in this experiment no such pressure was exerted. 
THE STEUCTTJEB AND MOVEMENTS OE THE VENTEICLES AND 
THEIE VALVES. 
After death, the left ventricle is generally empty, and firmly 
contracted, so that it represents the completion of the systole. Some- 
times, however, it is distended with blood, and in a, state therefore 
of complete diastole. Different hearts present every stage between the 
complete contraction and complete dilatation of the left ventricle. 
The right ventricle, on the other hand, frequently represents after 
death the state of diastole, rarely that of complete systole. 
That I might fix the heart in the exact form that it presented in 
the dead body, I hardened it by immersion in spirit, the vessels 
having been tied so as to retain the blood. I then exposed the 
interior of the cavities by removing the walls or making sections. In 
this way I obtained a series of hearts for examination, in some COMMENTARY ON PLATES XIX., XX., & XXI. 
of which the ventricles were in a state of complete systole (Pigs. 
7, 8, 22); in others, in that of complete diastole (Pigs. 4, 5, 20); 
while in others they were in an intermediate state (Pigs. 9, 10, 21). 
These figures were accurately drawn by Mr. Harvey Smith, from the 
preparations and photographs. I intend to offer the preparations from 
which the figures were taken that illustrate this part to the Royal 
College of Physicians, iu the hope that they may be placed in the 
Museum of the College, and so be open to inspection. 
the ventricle, with the exception of a small triangular spiral channel 
(Pigs. 7, 8), just behind the septum, and in the direction of the 
aortic opening. The spiral fibres, of which the muscular walls of 
the ventricle are formed, grasp, like the coils of a serpent, the vertical 
papillary muscles and fleshy columns during their contraction. Those 
muscles, consequently, fill up the cavity, and in conjunction with the 
contraction of the outer walls which forces them together, expel 
the blood in the manner described by Borelli. In consequence of this 
packing together and thickening of the papillary muscles and fleshy 
columns during the systole, the extent of the contraction of the mus- 
cular walls required to empty the cavity is materially lessened, and 
their expulsive force is thereby economised. 
The interior of the ventricle, when seen in a vertical section (Plate 
VI., Pigs. 9,10) is like a hollow cone with concave sides. At the end of 
the diastole, when the ventricle is of full size, it is somewhat egg-shaped. 
Its walls are hollow, its apex is blunt, and its cavity widens from apex 
to base; the widest part corresponding with the tips of the papillary 
muscles (Pig. 4). Just above this point, at the base, close to the 
mitral orifice, it again contracts, leaving, however, an ample space 
between the posterior segment of the valve and the posterior muscular 
walls. The cavity contracts rapidly, and curves forward as it approaches 
the aortic valves, where it forms the remarkable intervalvular space 
When we make a cross section through the middle of the ventricles, 
whether they are in the state of dilatation (Pigs. 4, 5) or contraction 
(Pigs. 6, 7), we see that the left ventricle is cylindrical, while the right 
is crescentic in form. The septum forms the anterior concave wall of 
the left ventricle, and the posterior convex wall of the right. 
The base of the left ventricle (Pigs. 3, 4, 6) is occupied, behind, by 
the mitral orifice, and in front, by the aortic orifice. 
THE LEET VENTRICLE. 
Fig. 3. 
Fig. 6. 
(Pigs. 4, 9), which I shall hereafter describe. The two papillary 
muscles are as wide apart as possible. Towards the apex they join 
and intercommunicate with each other and the fleshy columns, so as to 
form the remarkable spiral network of cells just described (Pig. 5). 
The two papillary muscles separate from each other during the diastole 
in the form of a horse-shoe, the space between them being greater low 
down, where in one heart it was -85 in. than higher up between the 
tips, where in the same heart it was *65 in. 
During the progress of the systole (Pigs. 9, 10), the circumference of 
the whole cavity, from base to apex, gradually narrows; the walls 
become less concave; and a remarkable change takes place in the 
relations of the walls to the mitral valve at the base. While the cir- 
cumference of the valve at the tendinous ring undergoes little or no 
diminution, the muscular walls at the base, just below the valve, 
contract steadily inwards, so as to present a shoulder projecting 
into the cavity immediately below the mitral valve (Pig. 10, b, a). 
This shoulder never touches the under surface of the valve, but 
leaves a small space in which the pressure of the blood closes the 
valve up to the end of the systole. The result is, that the contracted 
cavity of the ventricle widens outwards at the base, which is the reverse 
of what takes place in that region at the end of the diastole. 
The cavity of the ventricle, which at the end of the diastole is 
somewhat egg-shaped, is totally changed in form at the end of the 
systole. It is then narrow and triangular, except towards the apex, 
where it is obliterated; and it presents a spiral twist in a direction 
from the aortic orifice to the apex. This spiral curve commences at 
the aortic valves, where it bears backwards and from right to left, is 
just appreciable in the body of the cavity, and becomes again marked 
towards the apex, where it bears forwards and from left to right * 
(Pig. 22). Ido not, however, find that the papillary muscles assume 
a spiral curve during the systole; on the contrary, they lose the bend 
looking inwards, which they presented during the diastole, and they 
become perfectly straight, being parallel to, and all but in contact 
with each other (Pigs. 7, 12, 22.) Towards the apex, however, the 
papillary muscles and fleshy columns curve forwards and to the right 
(Pig. 8, 22). The spiral curve of the left ventricle during the systole 
corresponds with the spiral direction of the aorta. 
The Central Fibre- Cartilage or Tendinous Septum.—The fleshy septum 
of the ventricles terminates at the base in a strong tendinous aponeu- 
rosis, or fibro-cartilage, which performs a part of great importance 
in the structure and mechanism of the heart. This tendinous termina- 
tion of the septum is beautifully seen in the preparation from which 
Pigs. 9 and 10, representing a vertical section of the heart, have been 
taken. The muscular septum (d) is, in fact, converted at this region into 
Fig. 9. 
Fig. 10. 
Fig. 7. 
Fig. 4. 
Fig. 5. 
Fig. 8. 
The muscular circuit of the aortic and mitral openings is in each 
case incomplete, those apertures being completed by a common ten- 
dinous septum (Pigs. 3, 6). In consequence of this, if the heart 
he boiled for many hours, so as to soften out the tendinous structures, 
the two openings are thrown into one (Pig. 23). This tendinous 
septum is formed by the anterior flap of the mitral valve and by its 
continuation, which forms a partition between the left auricle and 
ventricle, on the front of which rests the two posterior aortic valves. 
(Pigs. 3,4, 6.) This septum, likewise, divides the cavity of the ventricle 
near its base, into two portions—a mitral portion behind receiving 
blood from the auricle, and an aortic portion in front sending blood 
into the aorta. (Pigs. 3, 4, 6.) 
The anterior or aortic portion of the left ventricle forms, when the 
cavity is expanded (Pigs. 4, 5), an arched space, the anterior walls of 
which are almost smooth, and are formed by the septum and the left 
anterior free wall of the ventricle. The posterior or mitral portion of 
the ventricle is irregular in shape, being occupied by the two papillary 
muscles which project into the cavity, one on either side, and by the 
fleshy columns which interlace, so as to form a loose network of cells. 
This network, as it approaches the apex, surrounds the whole interior 
of the cavity, and assumes a spiral direction (Pig. 5.) 
During the diastole, the mitral or posterior portion of the ventricle 
is enlarged backwards, its long axis lying in the direction of the mitral 
orifice (Pig. 4). During the systole, the mitral portion is gradually 
narrowed by the advance of its posterior walls, and the approxima- 
tion of the papillary muscles and fleshy columns, the long axis of the 
ventricle taking the direction of the aortic orifice. (Pigs. 7, 8, 12). 
At the end of the systole, the cavity of the ventricle is almost 
obliterated by the packing together of the thickened papillary muscles, 
as is well seen in the cross section of the heart, represented in Figs. 7 
and 8, which looks like the section of a solid muscle. (Pig. 22.) The 
papillary muscles and fleshy columns thus fill up the whole interior of 
* In my paper on the Situation of the Internal Organ (“Prov. Med. Trans.,” 1841, p. 
518), I thus describe the systolic movements of the left ventricle. During the systole, 
“ the cavity changes its place, being more to the right, and with its axis, which was formerly 
in the direction of the auricle, now pointing to the aorta. The contraction proceeds in a 
twisting manner ; the blood is, as it were, wrung out of the cavity, and with a current 
that takes naturallv the twisted direction of the sorirur and arch of the aorta.” COMMENTARY ON PLATES XIX., XX., & XXI. 
a tendinous septum; but while the muscular septum separates the two 
ventricles, the tendinous septum separates the left ventricle from the 
right auricle, and finally the two auricles from each other. This 
fihro-cartilaginous septum corresponds with the central fibro- 
cartilage and hone of the heart of the ox, and I possess one 
human heart in which it is converted into hone. It may he 
seen in Pig. 6, that this fibro-cartilage is intimately attached 
to the right posterior sinus of the aorta, to the tendinous ring 
of the mitral orifice, to the tendinous ring of the tricuspid orifice, 
to the central angle of the mitral valve, especially its anterior segment, 
and to the central angle of the tricuspid valve. It also gives insertion 
to numerous muscular fibres from the right ventricle, the left ventricle 
and the septum, and origin to muscular fibres which go to the right and 
left auricles, and the inter-auricular septum. The connections, in fact, 
of this great central tendon are universal. It binds all these important 
parts together, and gives to them unity, mutual inter-dependence, and 
correlation of action. 
the outside of the valve (Tigs. 13, 16, 17). Just above this range 
of arches the posterior segment of the valve turns over at its rim, 
to be attached to the tendinous ring; and it thus forms a vaulted 
space between the base of the valve and the muscular walls (Tigs. 
16, 17). 
The distribution of the tendinous cords to the angles is different 
from that to the flaps of the valve. The anterior segment, and the 
central portion of the posterior segment of the valve, receive at their 
margins and on their under surfaces two converging sets of cords, one 
set from the right, the other from the left papillary muscle (Tigs. 
3, 4, Plate yi). The cords, on the other hand, that are attached to 
the inner or right, and the outer or left angles of the valve, spring, from 
the longest and outermost tip of the corresponding papillary muscle 
(Figs. 12,13, 16, 17); and are inserted by a divergence or radiation of 
cords into the angle formed by the meeting of the anterior and 
posterior segments (Tigs. 3, 4, Plate yi). Each of the angles formed 
between the central and two lateral subdivisions of the posterior 
segment receives also a set of diverging cords, that radiate from 
one papillary tip. (Tig. 17). This arrangement of the convergence 
of the cords towards the centre of each cusp, and their divergence 
towards the angles where the segments meet, is needful for the perfect 
adjustment of the lips and angles of the valve. 
Ail round the base of the valve, between it and the muscular walls, 
there is, as I have just described, a vaulted space, which becomes 
gradually narrower during the progress of the systole; but which is 
never, even at its very end, obliterated. Turing the contraction of the 
ventricle, as I have already stated, a shoulder of the muscular 
walls projects inwards all round the base. Between this shoulder and 
the under surface of the valve, a distinct space exists, so that the 
shoulder never touches the under surface of the valve itself (Tigs. 10, 
11 A, b). A thin layer of blood intervenes to the very last between 
these opposing surfaces, so as to secure the pressure of blood upon the 
whole under surface of the valve, and its consequent closure throughout. 
This distribution of the cords to the flaps of the valve holds them 
down, when, like sails bellied by the wind, they are pressed upon by 
the blood during the contraction of the ventricle, in the manner first 
pointed out by Lower. 
If the cords were distributed to the margins only of the valve, 
as in Tig. 14, the bellying of the under surface of the flaps, caused 
The Intervalvular Space.—The left ventricle, as I have already 
said, curves forwards and to the right, as it approaches the aortic 
aperture. There it forms a chamber or space of remarkable interest 
which I have called the intervalvular space, situated between the 
aortic valves in front, and the anterior cusp of the mitral valve behind. 
This space is beautifully shown in the preparation from which Eig. 9 
is taken, and in which the aortic valves are seen through an opening, 
cut in the anterior flap of the mitral valve, and the continuous 
wall of the left auricle. Its immediate walls are everywhere rigid 
and aponeurotic, and it cannot therefore be compressed by the con- 
traction of the muscular walls during the systole. The aortic valves, 
during the diastole, play directly into this space, and owing to its 
existence the mitral valve is closed up to the end of the systole by 
the pressure of the blood on its anterior flap. The inner or right 
boundary of this space is formed by the central fibro-cartilage, or 
tendinous septum, just described; the anterior and left, or external 
boundary, by the muscular walls of the ventricle, which are there 
lined by a rigid aponeurosis; and the posterior boundary, by the 
anterior flap of the mitral valve and the continuous wall of the left 
auricle, upon which the two posterior sinuses of the aorta are implanted. 
The Mitral Valve.—When the closed mitral valve is looked at 
from the auricle (Eigs. 6,11), its outline resembles that of a horse- 
shoe or Saracenic arch. The valve is set in the muscular structure of 
the left ventricle, and its base, which is tendinous, is situated imme- 
diately behind the two posterior aortic sinuses, and stretches from 
the left or external to the right or central fibro-cartilage (Pig. 6). 
This tendinous base, which is continuous with the mitral valve, 
forms a portion of the walls of the left auricle. 
by the pressure of the blood, 
would lead to the separation 
of their edges, and the regur- 
gitation of the blood. 
Owing, however, to the dis- 
tribution of the cords to the 
under surface, as well as the 
margins of the valve, so as to 
The mitral valve presents two segments or flaps, 
an anterior and a posterior. The posterior seg- ,t 
ment, which is crescentic in form, is set in the r 
muscular walls, and fills up the two posterior j 
thirds of the mitral orifice. To enable it to do ; 
so with perfect adaptation, it is divided into ( 
three sub-segments. The anterior segment, ) 
which is shaped like a half-moon, is attached to r' 
the membranous structure at the base of the 
valve, and it fits like a lid into the posterior 
or crescentic segment, which forms a frame for 
Fig. 14. 
Fig. is. 
hold them equally downwards, and the formation thereon of many 
small pouches or sacculi, as in Pig. 15, the blood, during the con- 
traction of the ventricle, is forced into these pouches, so that they are 
each filled to distention. The adjoining pouches being all of them 
distended, and held down by the cords, necessarily displace each other 
outwards, so as to widen the whole area, and enlarge the circumference 
of the valve, in the manner represented in Pig. 15. The lips of the two 
segments of the closed valve are sacculated on their inner surface, and 
present, therefore, beaded margins, when looked at from the auricle 
(Pigs. 6,15 a a). When the bead-like sacculi of the lips are distended 
during systole, they dovetail into each other, so that the opposite 
margins fit together with the greatest accuracy. The sides of the lips 
are pressed together by the distention of their sacculi during the systole, 
the firmness with which the valve is closed being proportioned to the force 
with which the ventricle contracts so as to distend the sacculi. At the 
same time the whole surface of the valve is held down and flattened 
by the tightening of the cords {b). These beaded margins are thus 
pressed against each other, so as to shut the valve by the contact, not 
of their mere edges, but of their vertical sides, in the same way that 
the semilunar valves are closed, or that the mouth is shut by the 
contact of the lips (Pigs. 6, 11, 15a). 
When I observed the heart acting vigorously under water, after 
being cut out, it seemed to me that the circumference of the shut valve 
did not lessen with the diminution of the ventricle towards the end of 
Fig. 11. 
its reception, so as to close the valve. When the valve is shut, the 
central, the left, and the right sub-segments of the posterior or 
concave flap are opposed, respectively, to the middle, the left, and 
the right portions of the anterior flap (Tig. 6). The three sub- 
segments, where they meet, form two angles, which are filled up by 
the corresponding angles of the anterior flap. 
The lips of the closed valve at the meeting 
of the two segments are beaded (Tig. 6, 11), 
and its upper surface presents small rounded 
prominences. These prominences, as Skoda 
pointed out, are caused by small pouches, 
or sacculi, on the under surface of the valve. 
These sacculi are formed by the meeting 
together of the fan-shaped expansions by 
means of which the tendinous cords are in- 
serted into the margins and under surface of the 
valve. This structure is beautifully seen on the 
anterior segment. The tendinous cords are dis- 
tributed to that segment in four rows (Tig. 12), 
the two outer rows being attached to its mar- 
the systole. It would appear, in fact, that the pressure of the blood 
by filling the sacculi on its under surface unfurls, flattens out, and 
enlarges the valve so as to maintain it almost of the full size up to the 
end of the systole. Indeed, any material diminution of the valve would 
necessarily cause it to fly open, and so lead to the regurgitation of the 
blood from the auricle into the ventricle, through the mitral orifice. 
The Papillary Muscles. Sometimes the papillary muscles are 
concentrated into two single muscles, an external or left, and an 
internal or right (Tig. 16), each of which presents a row of papillm. 
More often they are distributed into two great groups of papillary 
muscles, a left and a right group, which are distributed to the corre- 
sponding portions of the valve (Tig. 1). In many hearts the two groups 
are united posteriorly, by a series of intermediate muscles; the 
posterior ones being comparatively short (Tigs. 12, 13,17). In such 
instances they are placed round the two posterior thirds of the 
ventricle, just within the muscular walls. The muscles, and the 
tendinous cords which connect them to the valve, are arranged within 
the muscular walls of the ventricle in crescentic rows, which correspond 
with the crescentic form of the posterior segment of the valve (Tigs. 
6,11,12,13,17). 
Whatever be the distribution of the papillary muscles, whether there 
be two single muscles (Tig. 16), two groups of muscles (Tig. 4), or a 
Fig. 12. 
gins, the two inner ones to its under surface. These rows are arranged 
so as to form three arched spaces, the central space being the widest. 
This arrangement is well seen in the prepara- 
tion from which Tig. 12 is taken, in which it 
presents the appearance, as it were, of the nave 
and aisles of a Gothic cathedral. 
The tendinons cords are distributed to the 
crescentic or posterior segment of the mitral 
valve in two rows, an outer and an inner (Tigs. 
18, 16, 17). These rows are inserted by fan- 
like expansions; the inner row into the mar- 
gin of the segment, the outer into its under 
surface, about mid-way between its margin 
and the muscular walls, to which the pos- 
terior segment is attacked. Where the cords 
of the outer row meet each other at the top, 
they form a range of pointed arches, around 
Fig. 13. COMMENTARY ON PLATES XIX, XX, & XXI 
crescentic row of muscles (Eigs. 12, 13, 17), it is convenient to speak 
of them as two, the left or external, and the right or internal. 
distance from the aperture of exit at the pulmonary artery, the 
two orifices being separated by the muscular channel of the conus 
arteriosus. In the left ventricle, the current of blood inwards, 
which descends during diastole behind the anterior segment of the 
mitral valve, is parallel in direction to the current of blood outwards, 
which ascends during the systole in front of that segment (Eig. 18). 
In the right ventricle, the current of blood inwards is at right angles 
to the current of blood outwards, since the blood enters the cavity 
Fig. 16. 
Fig. 17. 
Whether the muscles are simple or compound, the principle of their 
arrangement and distribution is alike in different hearts. Each muscle 
presents, at its extreme point, a lengthened peak or papilla, with 
radiating cords to the corresponding angle of the valve, which are 
short, so as to restrain its movement. The intermediate papillary 
muscles, or papillae, become gradually shorter, and towards the centre 
of the valve, where its segments enjoy the greatest play, the shortness 
of the muscles is compensated for by the greater length of the cords; 
while at each angle, where the movements of the valve are restrained, 
the length of the muscle makes up for the shortness of the cords 
l7). As a rule, the external or left papillary muscle is more 
massive than the right or internal. 
I have already- described the mode in which the two papillary 
muscles communicate with each other, and become subdivided into and 
intermingle with the fleshy columns as they approach the apex (Eig. 5), 
where they combine to form a beautiful spiral network of cells. 
During the systole, when, as we have seen, the papillary muscles and 
fleshy columns are packed together so as to fill the cavity of the 
ventricle, the right and left papillary muscles double upon each other, 
so as to present in a cross section, not a crescent, as during the diastole 
(Eigs. 4, 17), but two oblique parallel rows, which fit into each other 
(Figs. 7,8), as maybe readily seen by making a section of the calf’s heart. 
The Influence of the Papillary Muscles in Opening the Valve during 
the Diastole. As soon as the muscular walls relax after the end of the 
systole, the two papillary muscles move as far from each other as possible. 
In doing so they open the valve, by stretching and so drawing forward 
its anterior flap. When the diastole is complete, the anterior flap is 
held taut between the two papillary muscles (Eigs. 3, I); so that at 
this period the mitral orifice is fully open. I watched the opening of 
the valve, when the heart was beating with full force under water, and 
observed that the flaps separated at the beginning of the diastole, not 
by the pressure of the water, for no such pressure was exerted, but by 
the intrinsic movement of the valve itself. I believe that the stretch- 
ing forwards of the anterior segment of the valve, by means of the 
moving asunder of the relaxed papillary muscles in the manner that I 
have just described, is an adequate explanation of the automatic 
opening of the valve. 
from right to left, and leaves it from below upwards (Eig. 19). 
During the systole, the stream of blood in the left ventricle takes a 
spiral direction towards the aortic orifice, in accordance with the 
spiral direction of the aorta itself (Eig. 18). The stream of blood 
in the right ventricle, as it ascends, mounts over the bulging septum, 
being restrained by the concave free walls. This upward stream, 
which narrows as it proceeds, thus takes the curved direction 
upwards, backwards, and inwards of the conus arteriosus and the 
pulmonary artery. In the left ventricle, the anterior segment of the 
mitral vaHe, and the right and left papillary muscles, form a hollow 
channel for the stream of blood, which, as it ascends to the aorta, 
presses upon the under surface of the valve. In the right ventricle, 
the stream of blood, as it ascends, sweeps onwards at right angles to 
the under surface of the tricuspid valve, and rushes between and across 
the papillary muscles, and through the tendinous cordage that connects 
those muscles to the valve (Eigs. 19, 21). 
The Tricuspid Valve.—The structure and action of the tricuspid 
valve and its papillary muscles are, in principle, the same as those of the 
mitral valve and its papillary muscles. Owing, however, to the differ- 
ence in the form of the two cavities, in the relative position of their 
two orifices, and in the direction, inwards and outwards, of the stream of 
blood in the two ventricles, many important differences are implanted 
upon the tricuspid valve, when compared with the mitral. 
The closed tricuspid, valve, looked at from the auricle (Eig. 6), is 
irregularly oval; being large and rounded in front and below, slightly 
concave towards the septum, and angular behind and above, where it 
is attached to the central fibro-cartilage, close to the right posterior 
aortic sinus. The valve itself is subdivided into three great cusps : the 
anterior, the posterior, and the inferior. The inferior cusp, which is 
the largest, is deeply subdivided into several segments. Two of these 
sub-segments are very long and narrow; their length being twice 
their width. Each of them has a series of tendinous cords, which are 
inserted into the centre of the sub-segment from the tip to the base, 
in addition to a series of cords to each edge (Eig. 20, d). The length 
of these sub-segments, which meet with each other, and with the 
anterior and posterior cusps at a common point, about the centre of 
the valve (Fig. 6), is due to the great breadth of the tricuspid orifice at 
that region, which corresponds with the angle formed by the meeting 
of the anterior and inferior aspects of the free wall. For the same 
reason, the tips of the middle or anterior papillary muscle (Eigs. 20, 21, 
22, f), project into the centre of the cavity; and those of the lower 
papillary muscle do the same, though not to the same extent. To 
afford an advanced basis of support for these papillary muscles, as 
well as to thicken the walls, without materially diminishing the 
cavity and solidifying the walls themselves, a remarkable many-celled 
structure, made up of the net-formed meeting of numerous fleshy 
columns, fills up the angle between the anterior and inferior surfaces 
of the free wall of the ventricle (Eigs. 4, 5, 20). This many-celled 
structure completely occupies the cavity of the ventricle in the neigh- 
bourhood of the apex. Thence the structure extends in two direc- 
tions ; towards and up to the tricuspid orifice on the one hand, and 
on the other, towards the pulmonary artery, so as to occupy the angle 
formed between the septum and the anterior walls. 
The series of central cords which are attached to the tips of the 
prolonged sub-segments of the lower cusp (Eig. 20, d), as well as to 
the middle of the posterior cusp (b), while they permit those tips to 
meet at the centre of the valve, retain them there in exact adaptation, 
when the valve is closed during the systole (Eigs. 6, 21). 
The superior deep angle of the valve, which is implanted, so to speak, 
upon the aponeurotic structure of the septum, close to the right poste- 
rior aortic sinus, is guarded by two small sub-segments (Eigs. 3, 6, 20 n), 
which are situated between the anterior and posterior cusps, and 
which present a complete contrast to the elongated sub-segments of 
the lower cusp. These sub-segments are short, and have very little play, 
being tied closely down by short tendinous cords, which spring imme- 
diately from the adjoining wall, or from very short papillae. They are 
thus fitted to the very restricted angle between the anterior and posterior 
cusps, which they fill up and close during the systole (Eig. 6). 
Fig. 18. 
Fig. 19. 
THE EIGHT VENTRICLE. 
Comparison between the Right Ventricle and the Left.—The right 
ventricle differs in many important features from the left. The 
septum, which is the party wall of the two ventricles, properly 
belongs to the left. How completely the septum is appropriated by 
the left ventricle at the base is well seen in the preparations from 
which Eigs. 6, 9, and 10 are taken. The right ventricle is shorter from 
base to apex than the left, the shortening being chiefly at the base. 
The tricuspid valve and the base of the right ventricle are about half 
an inch lower, or nearer to the apex, than the mitral valve and 
the base of the left ventricle. The base of the left ventricle, there- 
fore, appropriates to itself exclusively the upper or aponeurotic portion 
of the septum, which completes the circuit of the mitral orifice on its 
inner or right side. The result is, that the septum at the base is not 
interventricular, but is situated between the left ventricle and the right 
auricle (Figs. 6, 9, 10 d). 
The right ventricle is then, so to speak, an abutment of the left 
ventricle. It is built upon the septum, which forms its borrowed 
posterior wall, and projects forwards into its cavity. The antero- 
inferior free wall is the only proper wall of the right ventricle. The 
anterior portion of this proper or free wall is situated immediately 
behind the lower costal cartilages and sternum, while its inferior 
portion rests upon the diaphragm. While this proper wall is convex 
without, concave within, the borrowed or party wall is convex within. 
The right ventricle is compelled to adapt itself to the form and 
movements of the left, and it is therefore more complicated than the 
left. Various peculiarities in structure are implanted, therefore, on the 
right ventricle, when compared with the left, which all turn upon this, 
that the left is the principal, the right, the supplementary cavity. 
The left ventricle, in a state of expansion, is cylindrical in form, in 
a cross section, while the right is crescentic. The left ventricle is egg- 
shaped, while the right is pyramidal, the top of the pyramid being 
formed by the pulmonary artery, while its base, prolonged to the left 
(Eigs. 19, 20, 21, 22), rests upon the central tendon of the diaphragm. 
In the left ventricle, the aperture of entrance through the mitral 
orifice is contiguous to the aperture of exit at the aorta, the two 
orifices being separated by a membranous septum. In the right ven- 
tricle the aperture of entrance, through the tricuspid orifice, is at a COMMENTARY ON PLATES XIX., XX., & XXI 
The upper border of each of the two superior cusps, the anterior and 
the posterior (a, b), which taken together are about equal in size to 
the base of attachment of each papillary muscle approximate. The 
tricuspid valve and the tips of the papillary muscles move with equal 
steps towards the apex and the septum, at the same time that the 
apex, the septum, and the attachments of the papillary muscles move 
towards the base. All the parts of the cavity and the tricuspid valve 
are thus maintained in a state of perfect adjustment through the 
whole period of the systole, the closure of the valve corresponding 
with the contraction of the cavity. 
the inferior cusp (Pig. 6), are 
supplied with a series of cords, 
which spring directly from the 
posterior wall of the ven- 
tricle, or from short papillae. 
These papillae and cords com- 
bine to form the superior pa- 
pillary muscle (g) which is in 
great part latent, being in- 
corporated with the muscular 
structure of the septum. 
The three papillary muscles, 
of which I have just spoken, 
the superior (g), the middle or 
anterior (s'), and the inferior 
(h), are so arranged as to be 
placed each of them between 
two adjoining cusps. The 
superior muscle is distributed, 
as I have just said, to the 
upper edges of the anterior 
and posterior segments ; the 
middle muscle, to the lower 
edge of the anterior cusp, 
and the upper edge of the in- 
Fig. 20. 
Fig. 21. 
Fig. 22. 
ferior or compound cusp; 
and the inferior papillary muscle, to the lower edge of the posterior 
cusp, and to the upper edge, and various sub-segments of the inferior 
cusp (See also Eigs. 3, 4). 
In the tricuspid valve, the distribution of the cords to the 
segments, though so different in detail, is the same in principle as in 
the mitral valve. The angles between the segments _ are supplied 
by the diverging cords radiating from one elongated papilla (m), while 
the flap of each segment is supplied by cords which converge from 
two distinct papillary muscles or papillse, upon its upper and lower, or 
its anterior and posterior edges respectively (Eig. 20, f, a, g). 
The Movements of the Tight Ventricle.—The difference between the 
cavity of the right ventricle in a state of complete dilatation (Eig. 20), 
and in that of complete contraction (Eig. 22), is striking. It is 
difficult to recognise that it is the same cavity in the two opposite 
states of dilatation and contraction. The cavity during the middle of 
the systole (Eig. 21),# presents an intermediate approximation to the 
two opposite states of expansion and contraction (Eigs- 20, 22). 
I have already described the external movements of the right 
ventricle. I may, however, repeat them here in a few words. The 
ventricle contracts during the systole from side to side, to the extent 
of three-eighths of its diameter, towards a common point of rest, 
which is near the septum. The movement of the auricular border to 
the left, is six times as great as that of the septum to the right. The 
upper and lower boundaries of the ventricle approximate, the descent 
of the upper boundary and the pulmonary [artery being greater and 
more constant than the ascent of the lower boundary, which rests on 
the central tendon of the diaphragm (Eig. 1). In short, the ventricle 
contracts from all sides towards a common centre, which is situated at 
the attachment of the anterior papillary muscle (f). 
THE MUSCULAR AND TENDINOUS STRUCTURES OE THE HEART 
OE THE COW. 
Erom the days of Lower, Senac, and Wollff, to the present time, the 
muscular structure of the heart has been examined in successive layers, 
from without inwards, each layer being stripped from the subjacent 
one. These observers all agree that the outer layers of fibres take an 
oblique direction from right to left, that the inner layers take a cross 
direction from left to right, and that the intermediate fibres run trans- 
versely. The varying direction of the fibres is admirably described by 
Weber, in his classical edition of Hildebrandt’s “ Anatomic;” and is 
beautifully shown in the valuable paper of Hr. Pettigrew. 
This cross direction of the inner, in relation to the outer fibres, 
which exists throughout the whole heart, is found also in each portion 
of the heart’s walls. Thus Ludwig has shown, in his important memoir 
on the ventricles of the heart (Henle’s “ Zeitschrift,” vii, 193), that in 
every piece of the walls of either chamber, the fibres on the inner sur- 
face take a cross direction to those on the outer surface, the intermediate 
fibres taking, in regular order, a corresponding change of direction. 
While inquiring into the muscular and tendinous structures of the 
heart, I employed three methods, in addition to that just alluded to. 
By the first of these plans, either ventricle was laid directly open 
by a section through its anterior wall, and its papillary muscles and 
walls were examined from within outwards. (Eigs. 24, 25, 26.) 
In the second method, the fibres were unravelled in successive layers 
from without inwards, the layers overlapping each other in the manner 
shown in Eigs. 27, 28. Each layer was traced from its right to its left 
extremity, and from the outer towards the inner surface of the heart. 
The third plan was that followed by Mr. Savory, of making a series 
of sections through the walls and tendinous structures of the heart. 
The Tendinous Structures of the Heart.—The tendinous structures at 
the base of the heart, as Lower, John Reid, and Ludwig have shown, 
give attachment or insertion to the numerous muscular fibres of the 
walls of the ventricles. These tendinous structures, which I shall 
briefly describe in successive order, are all firmly connected together, 
and they rest upon, surround, and support the various great orifices of 
the ventricles. 
Huring the systole, the fleshy columns which form so extensive and 
remarkable a network at the end of the diastole (Eig. 20) shorten, 
approximate, and at length come into close contact. The many-celled 
structure (Eig. 20) contracts, driving the blood out of its meshes, 
and finally disappears, being replaced by solidified and thickened walls 
(Eig. 22). The septum or posterior wall bulges forwards into the 
cavity, while the antero-inferior free wall contracts in every direction. 
The arterial cone is greatly narrowed, flattened, and shortened. The 
walls close in from all sides upon the tricuspid valve. As they do so, 
a shoulder projects into the cavity at the base which never touches the 
valve, but leaves a space in which the blood continues to press upon its 
under surface, so as to close the valve up to the end of the systole 
(Eig. 10, c). It may be seen,by studying Eig. 22, that the right ventricle 
makes a twisting movement in the neighbourhood of the apex, owing to 
the great extent to which the papillary muscles and the network of the 
fleshy columns close in upon each other at that portion of the ventricle. 
During the diastole, the papillary muscles are wide apart, and their 
tips diverge from each other, and look towards the base of the ventricle 
(Figs. 3, 20 f, G, h). The result is, that the flaps of the valve are 
drawn outwards and downwards towards the walls of the cavity, so that 
the tricuspid orifice is thrown wide open, its valve being incapable of 
closure. During the systole, the papillary muscles approximate, and 
their tips converge towards the middle of the valve, so as to permit of 
the approximation and contact of its flaps, and its consequent closure 
(Eig 21). At the end of the systole, the middle and the inferior 
muscles shorten and group into a mass (Eig. 22, f, h), the superior 
muscle (g) being still somewhat apart. 
The papillary muscles contract throughout the systole, so that at the 
end of it they are materially shortened (Eig. 22, f). The tip and 
1. The great central fibro-cartilage (Eig. 22, a a) is situated upon 
the septum, with which it is incorporated, between the mitral and 
tricuspid orifices, and behind the right posterior sinus of the aorta. It 
gives insertion to very numerous muscular fibres from both ventricles, 
and origin to many fibres to both auricles. 
2. The left fibro-cartilage (b), which is much smaller than the central 
fibro-cartilage, is seated to the left of the mitral orifice, and behind the 
left posterior sinus, with which it is closely attached. It gives insertion 
to numerous fibres from the left ventricle. 
3. A strong fibrous half-ring or loop (c c) is situated in front, and 
to the left of the root of the aorta, and stretches from the left to the 
central fibro-cartilage, with both of 
which it is intimately incorporated. 
This tendinous half-ring is divided 
into two layers. The posterior or 
inner layer is united to the anterior 
and left posterior sinuses of the aorta, 
and gives insertion to muscular fibres 
from the left ventricle. The anterior 
and outer layer gives attachment to 
numerous fibres from the conus arte- 
riosus, and from the left ventricle. 
The left and central fibro-cartilages 
(a b), and this connecting fibrous 
loop, form an united and powerful 
fibrous structure. 
4. The tendinous ring of the mitral 
orifice (n) is united at one extremity to 
the left, and at the other to the cen- 
* The preparation from which Eig. 21 was taken represents the mitral and tricuspid 
valves in a state of perfect closure; in this preparation, the cavities were injected with 
size, so as to close the valves. The heart was then hardened by being steeped in methy- 
lated spirit, and the cavities were cut open in the manner represented in the figure. Dr. 
Pettigrew injected plaster of Paris, so as to close the valves, into the hearts from which 
the drawings were made that illustrate his paper on the valves of the heart. By substi- 
tuting size, the cavities can be cut open after their walls are hardened, so as to display 
the internal mechanism of the valves. 
tral fibro-cartilage. It gives insertion to fibres from the left ventricle. 
Fig. 23. COMMENTARY ON PLATES XVI., XVII., & XVIII. 
5. The tendinous ring of the tricuspid orifice (e) is attached at both 
ends to the central fibro-cartilage. It gives insertion to numerous 
fibres from the right ventricle 
6. A fibrous ring surrounds the origin of the pulmonary artery (e), 
which is slightly connected to the fibrous half-ring of the aorta. 
Eibrous pads rest upon the muscular floor of each of the sinuses of 
the pulmonary artery, and upon the muscular structure which gives 
support to the anterior and left posterior sinuses of the aorta. Nume- 
rous muscular fibres are inserted into these tendinous pads, which form 
the floors of their respective sinuses. 
These various fibrous structures of the base are all associated 
together. They form, in fact, if we keep out of view the fibrous ring of 
the pulmonary artery, one common fibrous structure, which surrounds 
the aortic, the mitral, and the tricuspid orifices, which rests upon the 
bases of the left and right ventricles and their septum, and which gives 
a general insertion to the muscular fibres of both of those cavities, and 
a general origin to the muscular fibres of both auricles. 
The Muscular Structure of the Left Ventricle, examined from within 
(Fig. 24).—When a section is made anteriorly through the right ven- 
immediately behind the posterior emerging cord (p) just described. 
Like that cord, these successive layers are composed of converging 
fibres from the left and right papillary muscles. The whole of these 
converging layers of fibres wind round the heart, each in front of the 
other, and as they do so, they diverge (n), ascending towards the 
base, and disappear in the body of the ventricle. 
Fig. 25. 
The Muscular Structure of the Right Ventricle, examined from within 
(Fig. 26).—In order to examine this structure, the ventricle was laid 
open by dividing, first the free wall, close to the septum, from base to 
apex (a a), and then 
the conus arteriosus 
(bb), and pulmonary 
artery (c), close to 
the base of the left 
ventricle. 
The muscular struc- 
ture of the right ven- 
tricle does not present 
the remarkable sym- 
metry of that of the 
left ventricle, which 
is adapted to the 
cylindrical cone-like 
form of the cavity. 
The papillary muscles, 
the intricate fleshy 
columns which inter- 
Fig. 24. 
tricle (a) and the septum (b) into the left ventricle, the posterior aspect 
of that cavity is fully exposed, and the two papillary muscles are 
brought into view, resting upon and incorporated with its walls.* 
The two papillary muscles lie side by side on the posterior wall of 
the ventricle, the whole of which they occupy (Fig. 24, 25, c d). The 
left muscle (d) is solid, massive, and perpendicular. Its truncated 
extremity and body are connected with the whole base of the ventricle, 
including the origin of the aorta (e), by strong diverging fibres (f), 
which are inserted into the tendinous ring and the two fibro-cartilages 
(e i). It interchanges fibres freely along its whole left border with the 
fleshy columns of the septum (g), and along its whole right border (h h,) 
with the right papillary muscle, the two muscles being thus incorporated 
where they adjoin. 
The right papillary musple (c) is straggling, oblique from right to 
left, and pointed. It is reinforced by bands of fibres along its whole 
right margin from the right portion of the tendinous ring, the right 
fibro-cartilage, and (l l) the right portion of the septum, and it gives 
off many fibres (m m) which pass into the septum, intermingling with 
those that go from the septum to the muscle (l). 
Thus both papillary muscles blend with each other where they 
adjoin; send diverging fibres to the tendinous ring and two fibro- 
cartilages ; and interchange fibres with the septum and body of the 
ventricles. It will be seen, therefore, that a complete unity is estab- 
lished between the two papillary muscles, and the base, walls, and apex 
of the ventricle. The papillary muscles are therefore truly a portion 
of the walls of the ventricles, and their contraction and that of the 
walls are not so much simultaneous as one common contraction. 
Fig. 26. 
lace so as to form numerous cells, and the muscular fibres of the right 
ventricle, are adapted to the remarkable muscular cone leading to the 
pulmonary artery and to the form of the cavity, the posterior wall of 
which is convex, being formed of the septum, while its anterior or free 
wall is concave. The anterior papillary muscle is attached to the 
anterior wall, while the superior and inferior papillary muscles are 
incorporated with the posterior wall of the ventricle. 
The anterior papillary muscle (d) projects into the cavity from the 
middle of the anterior wall. During the systole, as I have already 
stated, the anterior wall of the right ventricle contracts from all sides 
towards the anterior papillary muscle, which is itself in a state of rest. 
The base, therefore, of the ventricle, the apex, the pulmonary artery, and 
the septum all move towards that muscle, when the cavity contracts. 
A large and remarkable fleshy column (e) extends from the base of 
the anterior papillary muscle across the cavity of the ventricle to the 
septum, where it forms a portion of the superior papillary muscle. The 
fibres that are connected with the base of the anterior papillary muscle 
are connected also with the root of this column, which forms a bridge 
of connection between the anterior and the superior papillary muscles, 
and between the anterior wall of the ventricle and the septum. 
The fibres (e), from the anterior papillary muscle to the pulmonary 
artery, ascend in a direction almost perpendicular; while those (g) to 
the apex descend in a direction from right to left. These ascending and 
descending fibres form, therefore, with each other a rather obtuse 
angle; and as the papilla (n) projects inwards, the papillary muscle, 
taken in conjunction with those fibres, assumes a pyramidal form.* 
The fibres (ee) from the anterior papillary muscle to the conus 
arteriosus and pulmonary artery are very numerous, and are attached 
to the muscle from its base to its papilla. At first those fibres run 
parallel to each other; but as they ascend they diverge, so as to 
surround the whole cone as it approaches the pulmonary artery. 
Finally they are inserted into the tendinous ring of the pulmonary 
artery, and, chiefly, into the tendinous pads upon which the three 
sinuses (ccc) of the artery rest. The fibres to the left anterior sinus 
go directly upwards (e). Those to the right anterior sinus diverge 
in an angular manner forwards and to the right, and those to the pos- 
terior sinus diverge backwards and to the right, some of them passing 
as they ascend into the septum. These fibres are in several layers, one 
outside the other, and as they approach the pulmonary artery, each of 
the longitudinal layers (e) is associated with a transverse layer of 
fibres (he) which runs in the direction of the circuit of the conus 
arteriosus. These transverse fibres extend some way into the cone, 
from its mouth at the pulmonary artery. The arterial cone, or 
infundibulum, is consequently there composed of circular and longi- 
tudinal bands of fibres, which are woven in and in with each other, like 
a circular piece of basket or wicker-work. 
Numerous fibres (g) descend from the anterior papillary muscle to 
The superficial fibres of the left papillary muscle, the adjoining 
fibres of the right papillary muscle, and the fibres of the left side of 
the septum, converge to form a twisted band or cord of fibres (o), which 
passes out of the ventricle at the apex, where it becomes superficial, 
which takes a direction from left to right, and winds round as it dis- 
appears with a bearing upwards and backwards. This superficial 
band of fibres takes a course over the back of the heart from apex to 
base, in a fan-shaped manner, diverging so as to cover the posterior 
longitudinal furrow, and the adjoining fibres right and left. 
This cord of fibres (o) as it leaves the ventricle to the right, crosses 
in front of another cord or band of fibres (pp), which passes from the 
interior to the exterior of the ventricle, in a direction to the left, in the 
manner pointed out by Dr. Pettigrew. 
The fibres which form this posterior cord (p) come from the right 
portion of the right papillary muscle (c), and (l) the adjoining part of 
the septum. In addition, however, to these fibres, the posterior cord is 
supplied by a fan-shaped layer of fibres from both papillary muscles 
and the left part of the septum, which bear to the left as they pass out 
of the cavity (p). They then become superficial, and wind round the 
front of the left ventricle, being distributed partly to the exterior, partly 
to the body of both ventricles. 
A remarkable series of five or six fan-shaped layers (q) may be seen in 
Fig. 24, which lie one behind the other, the foremost of them being 
* I made the drawings of the muscular structure of the ventricles by tracing the 
outlines of the intimate structure on a piece of glass placed over the preparation. 
method, which has recently been employed in Germany, is the same, substituting glass 
tor lace or muslin, as that by which I made the drawings for this work, and for my 
paper on Position of the Internal Organs, and the figures, many of which are 
minute, that illustrate my paper on the Mechanism of Respiration, in the “ Philosophical 
Transactions ” for 1846. Dr. Hodgkin, who advised me to adopt this plan, saw 
Benjamin West make use of it in his studio, and to him it had come down, according 
to tradition, from its inventor, Leonardo da Vinci. I cannot, however,’ find any 
account of it in that great master’s work on painting. 
* When looking at Fig. 26, it must be borne in mind that the whole anterior or free 
wall of the right ventricle is reflected backwards or to the left, in the form of a large 
square flap (cbla). Consequently all those parts that look outwards or to the left, in 
the reflected flap in the drawing, look inwards or to the right, when the anterior wall of 
the ventricle is in situ. COMMENTARY ON PLATES XIX., XX., & XXI. 
the apex and the septum at the posterior longitudinal furrow. These 
fibres, when unravelled from within outwards, present themselves in 
radiating layers (gi). The inner or deep fibres (go) descend towards 
the apex, while the outer or superficial fibres ascend towards the 
base, the intermediate fibres taking an intermediate direction. 
Towards the base of the ventricle, at the tricuspid aperture (l), the 
inner fibres of the anterior wall are arranged like a net, with large 
irregular meshes (kk). These net-formed fibres descend obliquely, 
and are merged in a group of transverse spiralising fibres, situated 
just above the anterior papillary muscle, with which it is connected. 
By the combined action of these various fibres, during the systole of 
the heart, the anterior or free wall of the right ventricle contracts from 
all directions upon the anterior papillary muscle as a centre, in the 
manner already described. 
The posterior wall of the right ventricle is formed by the convex 
anterior surface of the septum. This surface is comparatively smooth. 
The superior papillary muscle (pe) is, so to speak, latent, being mainly 
embedded in the posterior wall of the ventricle. The only prominent 
portion of that muscle is the strong column (e), which stretches across 
the ventricle from the anterior to the superior papillary muscle. The 
inferior papillary muscle (oo) is comparatively prominent, and although 
it is seated upon the posterior wall, close to the longitudinal furrow, it 
has also connections with the free wall of the ventricle. A considerable 
portion of this muscle is, however, embedded in the posterior wall (oq). 
Ascending fibres from the superior and inferior papillary muscles, 
are inserted into the great central fibro-cartilage. The descending 
fibres from the same structures, and from the intervening portion of 
the posterior wall of the ventricle (qq), when they reach the anterior 
longitudinal furrow, double upon themselves, and so pass from the 
posterior wall or septum to the anterior wall. These fibres from 
the posterior wall, as they pass to the anterior wall, and those from the 
anterior papillary muscle cross each other where they meet, and are 
interwoven so as to form an imperfect wicker-work structure (qg). 
By far the greater number of the fibres of the free wall of the 
ventricle, when they reach the posterior furrow, pass directly over the 
septum, and are incorporated with the fibres of the left ventricle. The 
majority of these fibres are shallow (b) ; but some of them are deep (s), 
so that they may be traced into one of the papillary muscles and the 
inner walls of the left ventricle. 
A certain number, however, of the fibres of the free wall, when they 
reach the longitudinal furrow, bend upon themselves (tt), and pass 
behind or into the inferior papillary muscles, and that portion of the 
septum which forms the posterior wall of the right ventricle. 
Examination of the Muscular Structure of the Ventricles from with- 
out.—After the thin superficial layer of the muscular fibres of the heart 
is stripped off, it is easy to separate the subjacent fibres from each other 
in a succession of layers, which imbricate one over the other. If we 
examine these fibres on the posterior aspect of the heart (Fig. 27), be- 
ginning at the base, and unravelling them from right to left, we find that 
over the right ventricle and the longitudinal furrow (ab), they overlap 
each other in a succession of layers, somewhat like the capes of a coach- 
man’s great coat. The right portion of each of these layers is superficial 
to the one below it. As, however, the layer proceeds from right to left, 
it twists upon itself, and at length dips underneath that layer, to 
which it was superficial at the beginning of its course. Each band of 
fibres, where it turns upon itself, is riband-like in form, and it 
expands towards either extremity, right and left, owing to the radiating 
divergence of the fibres, so as to present a fan-like structure. 
bution of the fibres of the posterior walls. The anterior fibres, traced 
from left to right, present themselves in layers or bands, which turn 
upon themselves at the anterior longitudinal furrow A. These bhnds of 
fibres, like those of the posterior walls, where they turn upon them- 
selves are riband-like in form, and they expand towards either 
extremity, by the divergence of their fibres, in a radiating direction. 
Over the left ventricle, the higher layers of fibres, or those nearer 
to the base, are superficial to the lower layers, or those nearer to the 
apex. These fibres converge upon the longitudinal furrow, where they 
become band-shaped and horizontal. Thence the layers again diverge, 
and, twisting upon themselves, the higher fibres, or those nearer to the 
base, dip under the lower fibres, or those nearer to the apex. 
THE SOUNDS OF THE HEAET. 
I made many observations, with the valuable assistance of Dr. 
Broadbent, on the sounds of the heart in the dog and in the donkey, 
that organ being exposed when the animal was under chloroform. 
We found that the second sound was most loud and sharp over the 
arch of the aorta, where the first sound was also heard, the second 
being three times as intense as the first. The second sound was only 
half as loud over the pulmonary artery as the aorta, the first sound 
being equal over the two vessels. 
Over the whole right ventricle the first sound was louder than the 
second. The first sound was, at the beginning and during its course, 
rather rumbling in character; but it ended in an accent or sharp 
sound. It was of uniform character, and equally loud, over the 
conus arteriosus close to the pulmonary artery, over the base near 
the tricuspid orifice, and over the lower border of the ventricle, 
where it was occasionally of a ringing character. This equal diffusion 
of the sound over every part of the ventricle demonstrates that the 
cause of the sound is not concentrated upon any one valve or outlet, 
but is spread over the whole cavity. The second sound was generally 
audible, though feeble, over the right ventricle. 
Over the left ventricle, also, from base to apex, the first sound began 
and continued with a rumble, and ended with an accent or sharp sound. 
It was carefully noticed that this accent corresponded with the precise 
end or stop of the contraction of the ventricles, when a marked, but not 
strong shock of reaction was felt over their walls. 
The second sound was always coincident with a second impulse or 
sharp shock felt over the arch of the aorta and pulmonary artery, and 
not over either ventricle. The loudness of the second sound corre- 
sponded with and varied exactly in the ratio of the strength of the second 
impulse, the sound being loud where the impulse was strong, faint 
where it was feeble, and almost or quite inaudible where it was 
imperceptible. The second impulse could be felt strongly at the 
top of the arch, feebly along its descending portion, not at all over the 
lower thoracic aorta, and scarcely or feebly over the innominate artery. 
The blow made by the return flow of blood from the arteries back 
upon the arch and valves of the aorta was the common cause of the 
second shock and second sound. The cause of the second sound is not 
therefore limited to the semilunar valves, but is common to them 
and the walls of the arch of the aorta. 
Again, the second sound is not due to the closure of the semilunar 
valves, but to the shock of the return flow of blood upon those valves 
when already closed. A little consideration will make it evident 
that the sigmoid valves must come together at the very end of 
the systole, otherwise blood would at once flow back into the 
ventricle, during a period that, as M. Marey has shown in his im- 
portant work on the Circulation of the Blood, precedes the second 
sound by one-tenth of a second, and coincides with the short pause. 
During this short pause between the first and second sounds, the walls 
of the arteries, just charged to the full by the systole, return upon 
themselves and drive the blood forwards into the smaller vessels, and 
backwards upon the arch and aortic valves; those valves being already 
approximated by the elasticity of their under surface, in the manner 
demonstrated by Dr. Markham, and by the pressure of the blood upon 
their upper surfaces. 
In estimating the cause of the first sound, we must bear in mind 
that it is equally loud over the whole of the ventricle, that it begins 
and continues with a rumble, and that it ends with an accent or sharp 
sound, which is coincident with the extreme contraction of the cavity 
and with a faint shock felt just then over the ventricle. If the blood 
be shut off from the heart by tying the venae cavae, the second sound 
is generally extinguished, and the first sound is rendered so feeble as for 
a time apparently to disappear. There are, however, distinct remains of 
the first sound. The accent appears to be quite lost, and the rumble 
is materially weakened, but a feeble rumble is still distinctly heard 
during each contraction of the ventricle. 
It is clear, therefore, that the systolic accent and the louder share 
of the rumble are due to the action of the blood on the walls as well 
as the valves of the ventricle. The accent, which any one may hear 
by listening over the healthy heart, is undoubtedly synchronous with 
the end of the systole. At that time the semilunar valves necessarily 
come together and are pressed against each other by the blood con- 
tained in the arch. As the expulsion of the blood must then stop, 
the fluid remaining in the ventricle probably causes a faint shock or 
accent at the end of the systole, which shock would not be concen- 
trated upon the valves, but, like the accent, be diffused over the 
whole cavity, the pressure of the blood being equal in every direction. 
The part of the rumble that is still audible when the blood is shut 
off, is doubtless due to the muscular rumble of the contracting walls of 
the ventricle. 
These layers of fibres are easily separated from each other at the 
base, along the posterior longitudinal furrow where they are inserted, 
one below another, into the central fibro-cartilage (a). Some of the 
layers end in the fibro-cartilage; but others, that pass over the furrow 
close to the base, send an off-shoot of fibres to the cartilage, so that 
those layers present the shape of the letter T or Y (a). When this 
angular off-shoot is traced, it is found to be formed by fibres which 
come both from the right and the left. 
The fibres along the furrow (b), at about an inch from the base, are 
no longer readily split into layers; for there the fibres of one layer 
communicate with those of another layer, both upwards and down- 
wards (Fig. 27). This intercommunication is particularly marked 
where the branches of the artery dip into the walls, and is probably 
connected with an arrangement to guard the vessels from the pressure 
of the contracting fibres during the systole. 
The distribution of the muscular fibres of the anterior walls of 
the heart, and of the anterior longitudinal furrow (Fig. 28), when un- 
ravelled from without inwards, is, in principle, the same as the distri- 
Fig. 27. 
Fig. 28. 
LONDON : B. PARDON AND SON, PRINTERS, PATERNOSTER ROW.