Henry Gray (18211865). Anatomy of the Human Body. 1918.
4c. The Costal Cartilages
The costal cartilages(Fig. 115) are bars of hyaline cartilage which serve to prolong the ribs forward and contribute very materially to the elasticity of the walls of the thorax. The first seven pairs are connected with the sternum; the next three are each articulated with the lower border of the cartilage of the preceding rib; the last two have pointed extremities, which end in the wall of the abdomen. Like the ribs, the costal cartilages vary in their length, breadth, and direction. They increase in length from the first to the seventh, then gradually decrease to the twelfth. Their breadth, as well as that of the intervals between them, diminishes from the first to the last. They are broad at their attachments to the ribs, and taper toward their sternal extremities, excepting the first two, which are of the same breadth throughout, and the sixth, seventh, and eighth, which are enlarged where their margins are in contact. They also vary in direction: the first descends a little, the second is horizontal, the third ascends slightly, while the others are angular, following the course of the ribs for a short distance, and then ascending to the sternum or preceding cartilage. Each costal cartilage presents two surfaces, two borders, and two extremities.
Surfaces.The anterior surface is convex, and looks forward and upward: that of the first gives attachment to the costoclavicular ligament and the Subclavius muscle; those of the first six or seven at their sternal ends, to the Pectoralis major. The others are covered by, and give partial attachment to, some of the flat muscles of the abdomen. The posterior surface is concave, and directed backward and downward; that of the first gives attachment to the Sternothyroideus, those of the third to the sixth inclusive to the Transversus thoracis, and the six or seven inferior ones to the Transversus abdominis and the diaphragm.
Borders.Of the two borders the superior is concave, the inferior convex; they afford attachment to the Intercostales interni: the upper border of the sixth gives attachment also to the Pectoralis major. The inferior borders of the sixth, seventh, eighth, and ninth cartilages present heel-like projections at the points of greatest convexity. These projections carry smooth oblong facets which articulate respectively with facets on slight projections from the upper borders of the seventh, eighth, ninth, and tenth cartilages.
Extremities.The lateral end of each cartilage is continuous with the osseous tissue of the rib to which it belongs. The medial end of the first is continuous with the sternum; the medial ends of the six succeeding ones are rounded and are received into shallow concavities on the lateral margins of the sternum. The medial ends of the eighth, ninth, and tenth costal cartilages are pointed, and are connected each with the cartilage immediately above. Those of the eleventh and twelfth are pointed and free. In old age the costal cartilages are prone to undergo superficial ossification.
Cervical ribs derived from the seventh cervical vertebra (page 83) are of not infrequent occurrence, and are important clinically because they may give rise to obscure nervous or vascular symptoms. The cervical rib may be a mere epiphysis articulating only with the transverse process of the vertebra, but more commonly it consists of a defined head, neck, and tubercle, with or without a body. It extends lateralward, or forward and lateralward, into the posterior triangle of the neck, where it may terminate in a free end or may join the first thoracic rib, the first costal cartilage, or the sternum.24 It varies much in shape, size, direction, and mobility. If it reach far enough forward, part of the brachial plexus and the subclavian artery and vein cross over it, and are apt to suffer compression in so doing. Pressure on the artery may obstruct the circulation so much that arterial thrombosis results, causing gangrene of the finger tips. Pressure on the nerves is commoner, and affects the eighth cervical and first thoracic nerves, causing paralysis of the muscles they supply, and neuralgic pains and paresthesia in the area of skin to which they are distributed: no oculopupillary changes are to be found.
In rickets, the ends of the ribs, where they join the costal cartilages, become enlarged, giving rise to the so-called rickety rosary, which in mild cases is only found on the internal surface of the thorax. Lateral to these enlargements the softened ribs sink in, so as to present a groove passing downward and lateralward on either side of the sternum. This bone is forced forward by the bending of the ribs, and the antero-posterior diameter of the chest is increased. The ribs affected are the second to the eighth, the lower ones being prevented from falling in by the presence of the liver, stomach, and spleen; and when the abdomen is distended, as it often is in rickets, the lower ribs may be pushed outward, causing a transverse groove (Harrisons sulcus) just above the costal arch. This deformity or forward projection of the sternum, often asymmetrical, is known as pigeon breast, and may be taken as evidence of active or old rickets except in cases of primary spinal curvature. In many instances it is associated in children with obstruction in the upper air passages, due to enlarged tonsils or adenoid growths. In some rickety children or adults, and also in others who give no history or further evidence of having had rickets, an opposite condition obtains. The lower part of the sternum and often the xiphoid process as well are deeply depressed backward, producing an oval hollow in the lower sternal and upper epigastric regions. This is known as funnel breast (German, Trichterbrust); it never appears to produce the least disturbance of any of the vital functions. The phthisical chest is often long and narrow, and with great obliquity of the ribs and projection of the scapulæ. In pulmonary emphysema the chest is enlarged in all its diameters, and presents on section an almost circular outline. It has received the name of the barrel-shaped chest. In severe cases of lateral curvature of the vertebral column the thorax becomes much distorted. In consequence of the rotation of the bodies of the vertebræ which takes place in this disease, the ribs opposite the convexity of the dorsal curve become extremely convex behind, being thrown out and bulging, and at the same time flattened in front, so that the two ends of the same rib are almost parallel. Coincidently with this the ribs on the opposite side, on the concavity of the curve, are sunk and depressed behind, and bulging and convex in front.