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Those too large to be entirely included in one expoaura are filmed beginning in the upper left hand comer, left to right and top to bottom, aa many framea aa required. The following diagrama illustrate the method: Ljw cartea, planches, tableaux, etc., peuvent fttre fllmte A dea taux de rMuction diff Arents. Lorsque ie document est trop grand pour itre reproduit en un seul clichA, 11 est film* A partir da Tangle supArieur gauche, de gauche A droite, et de haut en baa, an prenant le nombre d'imagas n^cessaira. Las diagrammes suivants illustrant la mithoda. 1 2 3 % 2 3 4 '- » ■■ 6 "^^■H^^™*li» ^ 1 'J Ce ^ ^^^^ T."S ^// ■p CERVICAL RIBS. BY FRANCIS J. SHEPHERD, M. D., M. R. C. S., Eng., DEMONSTRATOR OF ANATOMY IN M'OILL UNIVKKSITY, MONTREAL; SURGEON TO THE OUT-PATIENT DEPARTMENT OF THE MONTREAL GENERAL HOSPITAL, ETC. , EXTRACTED FRO>I The American Journal of the MKnrcAi- Sciencks, January, ISSJ. >j [ Extracted from tlio Anuiricaii Journal of the Mwlieal ScicticHS for Jan. 1883.1 CERVICAL 11 IBS.' Br FRANCIS J. SHEPIIEKD, M.D., M.R.C.S. Eso., BEMONSTEATOB OF ANATOMY IN M'OII.L UNIVER3ITr, MONTaEAL ; 8UR0B0N TO THE OUT-PATIBNf DEPARTMENT OF THE MONTRRAI, UENEKAL HOSPITAI,, ETC. From the circumstance that supernumerary cervical ribs are rarely met with in man, I luve thought that a short accou i*^ of some examples which have recently come under my observation mig , rove of interest. Gasp: I This occurred in the dissecting room of McGill University during last winter's session, and was fortunately noticed before the soft parts were destroyed and the dissection carefully recorded by myself at Fig. 1. C, Cervical rib articulating with process, P, ou tlio uppor surface of flrat thoracic rib. the time. The subject was a female between fifty and sixty years of age. Vertebral formula, C 7, D 12, L T), S i), C 4. The supernumerary cer- vical rib occurred on one side only, the left, and had a distinct head, • Read before the Canada Medieal Association, Sept. 1882. net'k, tubprcle, and body. Anteriorly it ended by ai-tic. dating with n bony elevation 1 centimetre lii^li, and 2 centinietre.s broad, on tlio upper suH'aee of the tir«t thoraeic rib U) centimetre in front of its tubercle. Both the extremity of this process and the anterior end of tlie cervical rib were encrusted with cartilage, and the two were united by a capsular ligament which formed a freely movaole joint. The head of the cervical rib ar- ticulated witii what Mr. Turner describes as a " tidiercle like elevation" on the side of the body of the seventh cervical vertebra, and was lield in position by a strong ligament. Its tubercle had a broad movable articu- lation with the transverse process of the same vertebra. On the upper surface of the neck of the rib were two distinct grooves separated by a prominent ridge ; the innermost groov(! was small and lodged the verte- bral artery, which passed up and entered tlie transverse process of the sixth cervical ; the outer groove was of large size and had placed in it the seventh cervical nerve, the eighth nerve passed out between the supernu- merary rib and the first thoracic and united with the seventh at the ante- rior border of the cervical rib. The united nerve was joined by the first dorsal to form tlie lower cord of the brachial plexus, which when formed passed down grooving the under surface of tlie bony prominence on the upper surface of the lirst tlioracic rib. Immediately anterior to this cord was the subclavian artery. A few muscular fibres were seen passing between the anterior transverse process of the sixth cervical and the ridge on the upper surface of the neck of tlie su[)ernun)erary rib. This probably was an intertransverse mi scle. The scalenus anticus muscle was normal; the scalenus medius was inserted into the cervical rib, the process on the upper surface of the first thoracic rib, and also into the whole of its bor- der between the process and the tubercle, thus filling up the interspace between the supernumerary and first rib. The head of the first lib ar- ticulated as is usual in these cases, not only with the first dorsal bu' also with the seventh cervical. The seventh cervical vertebra preseniea the appearance of a dorsal, the transverse process on both sides being quite like. The anterior transverse process on the right side was rudimentary, presenting the appearance of a short spine J centimetre long and not arching over to meet the posterior transverse process. The sixth cervical was the same on the left side, the anterior transverse process standing out as a spine 1 centimetre long and not reaching outwards and backwards far enough to unite with the posterior process. The first rib on the right side was distinctly longer and narrower than that on the left side.^ The anterior and middle scalene muscles had a continuous insertion along the upper border of the Krst rib from the scalene tubercle to the tubercle of the rib, and in front of the conjoined muscle was the subclavian vein ; the subclavian artery with the brachial plexus passed through a slit in the fused muscle one inch above its attachment to the rib. In the same subject there was anchylosis of the spines, transverse pro- cesses, and bodies of the fifth, sixth, and seventh dorsal vertebraj. The intervertebral substance had disappeared from between the bodies of the vertebra). The left transverse processes of the third, fourth, and fifth lumbar vertebne were also united together by bone. Case II. — This is a beautiful example of cervical ribs occurring in a skeleton which Dr. T. Roddick of this city purchased in Paris some years ' T)ic! rig-lit rib measured 15 centirnctirs lonj; by 3 oontimetres broad, measured \'i centimetres long by 3 centimetres broad. The left rib 8 ngo for nnatomicnl piirposes, nnd which lie afterwards kindly placed in the Museum of {\\v Mcdicul Facidty of IMcGIll University. The skeleton is tlial of a well-developed adult nude, and has on each side a supcrnumc- Flg. 2. C C. Corvical rilis. T. Transverse process of seventh cervical vertebra. rary cervical rib. lioth ribs are provided with a head, neck, tubercle, and body. The left measures seven cent, in length, and ends anteriorly ill ii blunt point, which is grooved as if for tlie subclavian artery; on the upper surface of the neck are two grooves, as in the case above described, though not so well marked, which probably lodged the vertebral artery and seventh cervical nerve. The right cervical rib measures only five cent, in length, and is much slighter than the left, gradually tapering down to a fine point. It also presents two grooves on the upper surface of its neck, similar to those on the right, but not to strongly marked. Both ribs in the fresh state probably fioated free anteriorly, the ends show no sign of being tipped with cartilage, nor is there any trace of a bony process on the upper surface of eitiier of the first thoracic ribs. The left cervical rib articulates by its head with a prominent tubercle on the side of the body of the seventh cervical, on the right side this tubercle is hardly to be seen. Both first thoracic ribs articulate with the sides of the bodies of the seventh cervical and first dorsal. In this skeleton the twelfth dorsal vertebra resembles not an ordinary twelfth dorsal, but jiossesses a trans- verse process like the tenth and eleventh dorsals, and on the anterior surface of etich transverse process, near where it joins the body of the vertebra, is a raised tubercle, which has articulating with it a rudimentary twelfth rib. The twelfth ribs are merely fitit pieces of bone, with a head which articulates only with the base of the transverse process. The right measures L') cent, in length, and the left 4 cent. The lirst lumbur vertebra is like mi onliimry Iwelflli dorsiil ; iiiis no tninsver.se proiiess proper, but in its pliUH' on each side is a tubercle-like process tipped witii an articular facet, which (jvideutly carried a, short lumbar rii). Vertebral torinula, (' 7, I) \'2, L .'», S .">, C 4. Cask III. — This was seen in the right sid(^ of a male patient who died in the Montreal CJeneral Hospital transverse processes in birds and tiie ei-rvieal ribs in erocodiU's ; in the hitter with the riuhmentarv ribs conneeted with the eiffjith and ninth cervical vertebriu of the nradi/piiii Iriilacti/lits" (three-tocd sloth). If the cervical rib rciichcs anteriorly past the tiibcrclo for tlio scalcnu.s anticiis, then this nuiHcle is attached to it, and the subclavian artery pll^'scs over if. This abnormal position of the subclavian artery has been ntistakcn for aneurism. The existence of the cervical ribs has often been discovennl dining life, and lias sometimes, as in my third case, been taken lor an exostosis. Prof. \V. Gruber has published, in the Memoirs of the Jmpc.n'dl Academy of St. Petersbiirfffi,^ a valuable pajier on cervical ribs, in which be reviews the whole of the literatufe of the subject. He describes five cases which '.e has biniself seen, and mentions seventy-six other cases in man, which have been recorded, occurring in forty-live individuals. Prof. Turner" gives a description of seven cases, many of them museum specimens. In only one was he fortunate enougb to obtain a knowledge of the arrangem(!nt of tbe soft jtarts, and in one they were recof^nized in a living person. Prof. Struthers^ describes ten cases, many of them very rudimentary. Two much resemble my Hrst case. lie also relates two cases occurring in living individuals, in one of wbicb the subclavian artery passed over the cervical rib, and was raised quite two inches above tbe clavicle. Sir .ianies Paget has diagnosed several cases in the livitig subject, and says:* " In each case the imitation of aneurism was close enough to deceive an un- wary surgeon ; but to one who examines closely, and has in bis mind what tbe case may be, the mistake seems scarcely possible so long as the artery is healthy. I can well believe, however, that great difficulty of diagnosis would exist in any case in which the unusual arrangement of the parts is combined with a morbid state of the artery, especially with that state in which tbe arteries, not evidently diseased in texture, have more than natural pulsation. This state is common in the abdominal aorta, and I bave seen it in the subclavian and carotid arteries." Prof. Strutbers mentions a case which was brought to him for operation as a case of malig- nant growth, but which be easily recognized as a case of cervical rib. In this, as in my third case, the artery did not go over the supernume- rary rib. ' Vol.xiii.No. 2, 180'.). ' Jour. Anat. and Pliys., vol. i.v. 187.5. ' Jour. Anat. and Phys., vol. iv. p. 13G. ' Loc. cit. VI m > "jV, .. THE MEDKJAL NEWS. 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