« iiilili Ix ATLAS OF APPLIED (TOPOGRAPHICAL) HUMAN ANATOMY FOR STUDENTS AND PRACTITIONERS BY Dr. KARL von BARDELEBEN and PROF. Dr. HEINR. HAECKEL IN COLLABORATION WITH DR. FRITZ FROHSE AND PROFESSOR DR. THEODORE ZIEHEN Only Butborise^ Cnglisb flbaptation from the Zh'irb German Cbition CONTAINING 204 WOODCUTS IN SEVERAL COLOURS AND DESCRIPTIVE TEXT BY J. HOWELL EVANS M.A.,M.B. M. CH., OXON., F. R.C.S., ENGLAND LATE SENIOR DEMONSTRATOR OF HUMAN ANATOMY AT ST. GEORGES HOSPITAL LONDON DEMONSTRATOR OF OPERATIVE SURGERY ST. GEORGES HOSPITAL. LONDON ASSISTANT SURGEON TO THE CANCER HOSPITAL, LONDON LONDON NEW YORK REBMAN LIMITED REBMAN COMPANY 129 SHAFTESBURY AVENUE^ 11 23 BROADWAY 1906 ALL RIGHTS RESERVED Entered at Stationer's Hall 1906. Biomedical n Preface. Nearly every Student of Anatomy and every Practitioner feels the need of some book which shall, for the former, serve as a supplement to dissection and assist in the stud}' of prepared anatomical specimens and which , for the latter who cannot spare the time for the study of specimens or whose work will not countenance any contact with the cadaver, shall present the regional im- portant structures. Such a book must present Anatomical data by numerous and good illustrations, the important details depicted must be presented in a S3'stematic, clear, and practical manner. For such merits and to meet these requirements this English Version has been prepared; it is hoped, therefore, that this book will serve as a means of revision among Students, as a valuable reference both of applied Anatomy to the Practitioner, and as a means of quickening the weakening memories of the Surgeon. The selection of the Plates and their extent has been determined by their relative clinical importance; special attention has been directed to those regions which have, of recent years, become of increased interest to the Physician and Surgeon ; so that those portions of Anatom}' which are likely to be of actual service to the Student in his subsequent study, and to the Practitioner in his clinical work, form the basis of each plate. Lithographic Plates for the finer and Wood-cuts for the coarser detail, when coloured, are imdoubtedly the best means of illustrating Anatomy and Histology; because by these methods the exact relations and distinctness of different structures in the various planes are most admirably shewn. This book cannot replace, and is not intended to replace, the Textbook of Anatomy, but is of great use with the more comprehensive Anatomical Works and Atlases. There C21061 — IV — There is as yet, no Universal Anatomical Nomenclature — in the original German work the B. N. A. nomenclature is employed, but among English Ana- tomists the nomenclature is very variable, at one time purely classical at an- other purely English, frequently a mixture. I have endeavoured to give the terms most frequently employed in England, with a further inclination whenever possible, to an English rather than a Classical term. In connection with the question of nomenclature, the reader is advised to peruse Toldt's Atlas, wherein all synonyms are well explained. London, W. J. Howell Evans. Contents. 0 4 5 6, 7 8 9 lO. 1 1 12 13 14 15 16 17 18, 19 20 21 22 23 24 25 2b 27 29 30 31 32 39 40. 41 42 43 44 45 46 47 48 I. Head. Median Section through the Head. Frontal Section through the Head passing through the Orbits. Outer Surface of the Cerebrum — Centres of Localization. Outer Surface of the Cerebrum — Convolutions and Sulci. Inner Surface of the Cerebrum. Dorsal Aspect of the 4th Ventricle. Course of Fibres in the Internal Capsule. Course of Fibres from Cortex to Spinal Cord. Course of Fibres in the Crura Cerebri — Frontal Section. Convolutions and Bonv Sutures (in the newborn). Convolutions and Bony Sutures (in the child). Convolutions and Bony Sutures (in the adult). Base of Brain with Arteries and Cranial Nerves. Base of Skull ; from above. Base of Skull, with Arteries, Nerves and Venous Sinuses. Base of Skull, with the soft parts, after partial removal of the bones. Projection of the Lateral Ventricle, Middle Ear and Lateral Sinus on to the outer surface of the Skull. Projection of the Middle Meningeal Artery on to the outer surface of the Skull. Cranio-Cerebral Topography. Exposure of the Cerebellum. From a horizontal section — Auditory Apparatus and its relations. Part of Fig. 2 1 — Tympanic Cavity and its relations. Vertical section through the Left Temporal Bone, passing through the Axis of the Petrous portion. Horizontal Section through the Left Temporal Bone. Mastoid Process of child, opened. Mastoid Process of adult, opened, and 28. Tympanic Cavity and its relations; opened from behind. Superficial Vessels and Nerves of the Head. Side View of the Face — Superficial layer. Side View of the Face — Deep layer. Exposure of the Gasserian Ganglion, to 38. Areae of Distribution of the Sensory Cranial Nerves. Nasal Cavity with openings of Accessory Cavities. Antrum of Highmore and Roots of Teeth. Frontal Sinus, Nasal Duct. Orbit and its relations — Horizontal Section. Orbit and Nasal Cavities in a child — Frontal Section. Orbit and its relations in a child — Vertical Section through the Axis of the Optic Nerves. Frontal Section through the posterior part of the Nasal Cavity. Frontal Section through the Sphenoidal Sinus and Nasal Cavity. Frontal Section through the Anterior part of the Cavernous Sinus. Frontal Section through the Posterior part of the Cavernous Sinus. — VI Xig. 11 50. „ 51- >t 52- It 53- Fig. 54- >1 77 55- 56. Fig. 57- 58. 1) 59- i) 60. 61. it ft JI It tt 62. 63- 64. 65- 66. 67. 68. 77 69. 17 70. " 71- Fig 72- )t 73- )» 74- )> 75- 76. 77- 78. 79- 80. J) 81. >> 82. 83. 84. 85- 86. 87. 88. }] 89. » 90. >» 91. >) 92. „ 93- )) 94. }> 95- 96. it 97 98 Inner region of the Eye — Lachrymal Apparatus — .Superficial layer. Lachrymal Passages — Deep layer. Floor of the Mouth. Occipital Region. Horizontal Section through the Head at the level of the A.xis. II. Spinal Cord. Position of the Cord in the Vertebral Canal. Lower End of the Spinal Canal in the Adult. Diagrammatic Cross-Section through the Spinal Cord. III. Neck. Regions of the Neck — from in front. Regions of the Neck — from the side. Transverse section through the Neck passing through the Upjier part of the 5th Cervical Vertebra. Neck, from in front, Superficial la)er, in the adult. Neck, from in front, Deep layer, in the adult. Neck, from in front, Deep layer, in the child. Superior Triangle of the Neck, with Lymphatics. Ligature of the Lingual Artery. Larynx — opened from in front. Side View of the Anterior Region of the Neck. Oesophagus. Side of the Neck, lower triangle. Side of the Neck — Superior Cervical Ganglion of the Sympathetic. Larynx, seen from behind. Apex of the Pleura. Course of the Large Vessels and Nerves to the Upper Limbs. IV. Arm. Axilla. Frontal Section through the Right Shoulder of a Boy. Horizontal Section through the Left Shoulder of a Boy. Anterior Region of the Shoulder-Joint. MoHRENHEiii's Fossa — (Infra-Clavicular Fossa). Posterior Region of the Shoulder-Joint. Right Arm — seen from the inner side. Left Arm — seen from the outer side and behind. Transverse Section through the middle of the right arm. Transverse Section through the lower third of the right arm. Left Antecubital Space, superficial layer. Right Antecubital Space, deep layer. Region of Right Elbow. Transverse Section through the right Elbow-Joint. Longitudinal Section through the left Elbow-Joint. Frontal Section through the right Elbow-Joint (aet. 19 yrs.). Sagittal Section through the left Elbow-Joint (aet. 8 yrs.). Right Forearm, deep layer, from in front. Transverse Section through upper third of right forearm. Transverse Section through lower third of right forearm. Region of Right Wrist, outer side. (Snuff-Box.) Nerves and Veins of the Dorsum of the Right Hand. Tendon-Sheaths of the Dorsum of the Right Hand. Palm of Left Hand; Superficial layer. Palm of Left Hand ; Deep layer. Tendon-Sheaths, and Large Arteries of the Palm of the Right hand, to loi. Tendon-Sheaths of Palm of Hand. Left side. VII 'g- 1 1 1. I 12. 113- 114. 115- 116. 117. 118. 119. 120. 121. 122. 123. ig- 124. 125- 126. 127. 128. 129. 130. 131- 132. 133- 134- 135- 136. 137- 138. 139- 140. 141. 142. 143- 144. 145- ig- 146. 147. 148. 149. 150. 151- 152. 153- 02. Horizontal Section through Dorsum of Hand. 03. Transverse Section through Carpus. 04. Transverse Section through Palm of Hand. 05 and to6. Cutaneous Areae of the Nerves of the Upper limb. 07 and 108. Cutaneous Areae of the Nerves of the Upper limb according to their spinal segmental origin. 09 and 1 1 o. Segmental Innervation of the Muscles of the upper limb. V. Thorax. Regions of the Thorax and Abdomen. Frontal Section through the Trunk. Superior Aperture of the Thorax. Lymphatic Glands of the Breast in the Adult. Lymphatic Glands and Vessels of the Head, Neck, Thorax and Arm in a child one year old. Boundaries nf the Lung and Pleura, from in front — Area of Absolute Cardiac Dulness. Boundaries of the Lung and Pleiu-a from behind. Anterior Wall of the Thorax and Heart in the New-born. Anterior Wall of the Thorax and Heart in the Adult. Heart of Adult — Ventricle opened. Transverse section through the Trunk; at level of ist and 2nd Dorsal Vertebra. Transverse section through the Thorax; at level of 9th Dorsal Vertebra. Transverse section through the Thorax ; at level of 5th Dorsal Vertebra. VI. Abdomen. Position of Viscera, from in front. Position of Viscera, from behind. Left Lung and Spleen, side \'iew. Position of Viscera — Peritoneal Cavity in the Child. Liver, Stomach, Pancreas, Omental Sac. Liver, Spleen, Pancreas, Duodenum, after removal of Stomach. Position of Viscera (Extraperitoneal), Female. Gall-Bladder, Bile-ducts, relations. Female. Gall-Bladder, Bile-ducts, relations, Male. Subphrenic Space, Pelvis of Kidney, Hilum i)f Liver, Bile-ducts. Right Kidney, exposed from behind. Portal Vein, Umbilical and Renal Vessels. Position of Abdominal Viscera, seen from behind, lines of the Peritoneum. Vermiform Appendix and Caecum. Sigmoid Flexure and Inguinal Canal. Transverse Section through the Trunk at level of nth Dorsal Vertebra. Transverse Section through the Trunk at level of ist Lumbar Vertebra. Retroperitoneal Lymphatics. Anterior Abdominal Wall, seen from behind. Anterior Abdominal Wall, Region of Appendix with Nerves. Bladder moder- ately distended. Anterior Abdominal Wall, Hypogastric Region with Nerves. Bladder much distended. Back, with Nerves, Arteries and Lymphatic Glands. VII. Pelvis. Median Section through Female Pelvis — Bladder and Rectum empty. Female pehic organs, seen from above and behind. Vuh-a, Vestibule. Female pelvic organs, seen from in front and above ; Ureter. Male pehic organs exposed from behind. Median Section through Male Pelvis. Median Section through Male PeKnis ; Urethra, Pelvic Fasciae. Frontal Section through Male Pelvis ; Levator Ani. — VIII Fig. 154 „ 155 „ 156 » 157 158 „ 159 160 if 161 J» 162 jf 163 164 165 166 » 167 168 169 170. yj 171 172 Fig. 173 174 175 176 177 178 179 180, 181 182 184 185 186 187 188 189 190, 191 192 193 194 195 196 197 198 199 200, 201 202 204 205 Male Perinaeum; I. Superficial layer. Male Perinaeum; II. Recto- Urethral Muscle; Prostate. Male Perinaeum ; III. Cowper's Glands with their Ducts. Male Perinaeum ; IV. Urogenital Triangle, Ampulla of Rectum. Male Perinaeum; V. Prostate, Seminal Vesicles, Course of Urethra through the triangular ligament. Male Perinaeum ; VI. Pubic Region — Levator Ani. Female Perinaeum. Male Pelvic Organs, from behind. Arteries to Seminal Vesicles. Male Pehic Organs, from left side. Ner\es to Seminal Vesicles. Gluteal Region. Lymphatic Glands and Vessels of Female Pelvis, child. Frontal Section through the Right Hip. Inguinal Region, ist layer, Superficial Lymphatic Vessels and Veins. Inguinal Region, 2nd layer, Fossa Ovalis. Inguinal Region, 3rd layer, Spermatic Cord, Scarpa's Triangle. Inguinal Region, 4th layer, Hernial Orifices, Iliac Bursa. Inguinal Region, 5th layer, Subperitoneal Hernial Orifices. Hip-joint. Ob- turator Region. Frontal Section througli Left Hip-joint of boy aged 8 years. Nelaton's Line. VIII. Leg. Hunter's Canal and Popliteal Space, seen from the inner side (Jobert's Fossa). Transverse Section through the right thigh at junction of middle and upper thirds. Transverse Section through the right thigh at junctfon of middle and lower thirds. Left Knee-joint. Sagittal Section through the left knee-joint (extended). Sagittal Section through the left knee-joint (flexed). Sagittal Section through the right knee-joint, boy aged 16 years. Frontal Section through the right knee-joint, boy aged 8 years. Transverse Section thrcjugh the right knee-joint. and 183. Lymphatics of the Popliteal Space. Right Popliteal Space. Transverse Section through the right leg, junction of upper and middle thirds. Transverse Section through the right leg, near the ankle. Right Leg, from the outer side. External Popliteal Nerve. Right Leg, from behind. Internal Popliteal Nerve. Tendon-Sheaths behind Internal Malleolus. Region behind Internal Malleolus. Sole of Right Foot, superficial layer. Sole of Right Foot, deep layer. Ankle and Dorsum of Foot, left side. Outer side of Left Foot. Dorsum of left foot with Muscles and Tendon-Sheaths. Dorsum of left foot with Tendon-sheaths, Arteries and Bones projected on to surface. Frontal Section through the right AnkJe-joint. Frontal Section through the Anterior part of Tarsus. Sagittal Section through the right foot. Horizontal Section through the right foot (near the sole). Tarsal Joints, exposed from above, Right side, and 203. Areae of the Cutaneous Nerves of the Lower Limb, Right side. Nerve supply of Skin and Muscles of the Lower Limb according to their Segmental Origin — Anterior Surface. Nerve supply of Skin and Muscles of the Lower Limb according to theii Segmental Origin — Posterior Surface. ATLAS OF TOPOGRAPHICAL ANATOMY. Fig. I. Median Section through the Head. Right half of a frozen-section through the Head and Neck of a girl aged 15. In front the plane of section is carried accurately through the middle line, but posteriorly it deviates about ^/sths inch to the left. The bones are left intact, as is shewn by the bisected Odontoid Process ; the soft parts (particularly brain-substance) have been carefully cleared away as far as the middle line. A median section gives the best general idea of the relations and positions of the structures of the head, and in particular of the topographical relations of the brain to the face ; it clearly shows how the brain extends further down posteriorly than in front. That portion of the skull cap under which the Cerebrum lies is only covered by a thin la}er of soft parts — skin and epicranial aponeurosis (the latter is blue in the figure). The Hemispheres, therefore, are easily injured in fracture of the vault of the skull. The Cerebellum is better protected. The thickness of the skull cap varies con- siderably at different points, and in different people — it is normally at the vertex Vio^^ inch. On either side of the middle line the bone may be very thin, because for a distance of ^^ths inch from the middle line Pacchionian bodies may be present, and only covered by a very thin lamina of bone. The Superior Longitudinal Sinus is exhibited throughout its whole length (the oYlier Venous Sinuses are shewn in Figs. 15 and 16), beginning at the Foramen Caecum and increasing in width as it extends backwards and receives more blood it finally forms by junction with the Straight Sinus the Torcular Herophyli at the level of the External Occipital Protuberance (or somewhat higher up) and unites with each lateral Sinus, especially with the right. Its position is very exposed ; as it can be easily injured it demands consideration during trephining. The Nasal Septum is usually asymmetrical, being bent to one side (left in this case). Dense connective-tissue is found at the anterior surface of the base of the skull and is continued downwards as the Anterior Common Spinous Ligament which covers the anterior surfaces of the bodies of the vertebrae. A thick mass of lymphoid tissue lies under the mucous membrane of the posterior wall of the pharynx (i. e. the Pharyngeal Tonsil) ; lower down between the Oesophagus and the Vertebral Column there is only a thin layer of connective tissue in which pus may easily spread downwards (Retropharyn- geal Abscess). When the mouth is closed, the Tongue lies against the Palate (in this figure, depending upon the form of death, suicide by drowning, the tongue is seen pushed be- tween the Canine teeth). On the posterior surface of the Hyoid Bone the Hyoid Bursa is seen lying be- tween the Hyoid Bone and the Thyreohyoid Membrane which is attached to the upper border of the bone. The Larynx is here seen at a higher level than usual; the Glottis, as a rule, is situated at the level of the 5th Cervical Vertebra or of the disc between the 5 th and 6th Cervical Vertebrae. The Pyramidal Process of the Thyreoid Gland (Pyramid of Lalouette), in this figure extends almost up to the Hyoid Bone whereas the usual height to which the Isthmus of the Gland reaches is the ist Tracheal ring. Aponeurosis of Occipito Superior Lonfjitudinal Sinus Frontalis Middle Comtnissure Falx Cerebri 3rd Ventricle Inferior Longitudin. Ventricle of Septum Pcllucidum Genu of Corpus Callosum Anterior Commissure . / / i?t' Anterior Cerebral / •■/ - Artery Free edge of Falx Cerebri (Lamina Tcr- minalis) Crista Galli Frontal Sinus Optic Chiasraa Pituitary (Hj-popt Sphenoidal Sinus Septal Cartilage Vein of Galen Splenium of Corpus Callosum ineal Gland (Epiphysis) Genioglossus - " . Muscle ;■ .■■(', .■'. | i:; ^ ^ ^ ' \ -?. ' Geniohyoid — ■, Muscle Mylohyoid Muscle Semispinalis Muscle Splcnius Capitis Muscle Muscle Fig. 1. Mesial (Sagittal) Section through the Head. Vj Nat. Size. Rebman Limited, London. Rcbman Company, New York. Supt-Ttnr Aponeurosis of Occipito- Longitudinal Frontalis Muscle Sinus Falx Cerebri Anterior Cerebral Artery Olfactory Plate of Ethmoia if»r Obliiiue Muscle Frontalis Muscle (Epicranius) Dura Mater Frontal Sinus Ciliarv Nerves Tcmporo-Malar Nerve Lacrymal Nerve Kxternal Rectus Muscle Zygoma Inferior Oblique Muscle Middle Temporal Bone Uncinate, Process Malar Branch of Temporomalar. Nerve Inferior Tur binated Bone Maxillary Sinus (HlGHMOItK) Canine Muscle Facial Vein Buccinator Muscle- Facial Artery Ducts of Sublingual Gland Duct of Submaxillary Gland Branch of Facial Nerve Genioglossus Muscle Sublingual GUi J Mylohyoid Muscle ingual Nerve Buccal Gland Triangular Muscle of Lower Lip Mandible Quadrate Muscle of Lower Lip Digastric Muscle Inferior Dental Nerve Geniohyoid Muscle Platysma Mylohyoid Muscle Fig. 2. Frontal Section of Head through the Orbits. View from in front. — Nat. Size. Rebman Limited, London. Bcbman Company, New York. Fig. 2. Frontal Section of the Head through the Orbits. Frozen section through the middle of the eye-halls. The slender nerves and vessels as well as the articulations of the bones have been determined by careful dissection. The frontal bones are very thick owing to the obliquit}' of the section. The Superior Longitudinal Sinus bulges to the right, owing to one of the "Lacunae Lateral es" — accessory dilatations of the Sinus which are of frequent occurrence at the Vertex, and may extend Vs^hs inch from the middle line. The Temporal Muscle is observed to be covered by the Temporal Fascia, which extends from the Superior Temporal Ridge to the Zygoma. At the upper border of the Zygoma it splits into 2 laminae (which may reunite), between which some fatty tissue becomes collected. The Cavit}' of the Orbit (into the inner and upper portion of its roof the posterior extremit}" of the Frontal Sinus protrudes) is only partialh' filled b}' the eye-ball; the greater space is taken up bj- fat in which the eye muscles rim. Closely applied to the outer wall of the orbit is the Lacrimal Gland. The point at which the Optic Nerve enters the e}'e-ball is marked in y e 1 1 o w. The figure shews the very large space occupied by the Nasal Cavity and its Accessory Cavities. The Nasal Cavity which is only separated from the Cranial Cavity by the thin cribriform plate of the Ethmoid Bone, presents 3 turbinated bones. On the left side the Sphenoidal Turbinated Bone was so short as to nearly escape the section. Between the Middle and Inferior Turbinated Bones, the communication between the Nasal Cavity and the Frontal Sinus — the Infundibulum — is visible. Directly below this orifice lies the aperture of the Antrum of HiGHMORE. This aperture situated almost at the top of the Antrum, is necessarily most un- favourable to drainage. The Nasal Septum is deviated from the middle Une (cf. Fig. i). The Antrum is separated from the Orbit by the thin floor of the Orbit in which along the Infra-Orbital Canal the nerve and vessels of the same name pass. For the relations of the Alveoli of the Teeth to the Antrum vide Fig. 40. The wall between the Antrum and the Nasal Cavity is thin so that perforation can be easily carried out from the nasal cavity (if better drainage be sought by this route). The Buccal Cavity is closed below by the Mylohyoid Muscle, which ex- tends from the inner surface of the lower jaw downwards and inwards to meet its fellow in the middle line (Diaphragma Oris). 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Medullary Velum Descending Root. of 5th S'erve nXudei of 3rd Nerve N'ucleus of 4th Nerve 5th Nerve (Trigeminus) Motor Nucleus of 5th Nerve Facial Eminence 7th Nerve (Facia Modian Geniculate Body Peduncle of Brain Anterior Medullary Velum Superior Cerebellar Peduncle Locus Caeruleus Nucleus of 6th Nerve (Abducens) Middle Cerebellar. Peduncle Inferior Cerebellar- Peduncle 9th Nerve (Glosso pharyngeal) loth Nerve (Vagus)' Nucleus of Spinal Tract of 5th Nerve Marginal Band of. 4th Ventricle 11th Nerve (Accessory) Hypoglossal Triangle^ Nucleus Ambiguus Auditory Striae Nucleus of 8th Nerve (Driters) Median (Triangular) Nucleus of 8th Nerve Lateral (accessory) Nucleus of 8th Nerve 12th Nerve (Hypoglossal) Nucleus of Spinal Tract of 8th Nerve Nucleus of Ala Cinerea Nucleus of Spinal Accessory Nerve Posterior Median Groove ^>f— Ci«*5^ -^ Trohre fe<,. Clava (Posterior Pyramid) Nucleus of i2th Nerve Funiculus Gracilis ^■Funiculus Cuneatus -Funiculus Lateralis Fig. 6. Dorsal Aspect of Fourth Ventricle. Twice Nat. Size. — By Prof. Ziehen. Rebman Limited, Loudou. Rebman Company, New York. Pig. 6. Dorsal Aspect of Fourth Ventricle. The Cerebellum has been removed by a section parallel with the floor of the 4th Ventricle, so that the 3 Cerebellar Peduncles, strands which connect the Cerebellum with the rest of the Central Nervous System, are seen on both sides in transverse section. 1) Superior Peduncle conducting fibres chiefly to the Dentate Nucleus of the Cerebellum. 2) Middle Cerebellar Peduncle, connecting the Nuclei of the Pons with the Cerebellar Hemispheres. 3) Inferior Cerebellar Peduncle (Restiform Body) chiefly conducts to the Columns of the Spinal Cord those fibres which passed to the Dentate Nucleus through the Superior Peduncle. The Valve of Vieussens which lies across, between the Superior Cerebellar Peduncles, has been cut and thrown to the left. The Facial Eminence (Colliculus Facialis) is produced b}' fibres of the Facial Nerve which, after emerging from their cells, pass towards the floor of the 4th Ventricle and bend at a right angle again, after a course of Vioth inch, to run backwards towards their nucleus of origin. As the Nucleus of the Facial Nerve lies deep in the substance of the Pons and Bulb, with many groups of cells extending upwards and downwards, it must be remembered that this Nucleus is not at the floor of the 4th Ventricle and is accordingly represented diagrammaticallv. The Nuclei of the other Cranial Nerves lie near the surface. The anterior part of the Oculomotor Nucleus contains the fibres for the Sphincter of the Iris and the Ciliary Muscles ; the posterior part contains the Fibres for the Extrinsic Muscles of the Eye. Immedi- ately behind is the Nucleus of the IVth Nerve (Pathetic), the fibres from this pass to the Valve of Vieussens where they decussate and on emerging ^wind round the Crura to reach the base of the brain. The Nuclei of the \'th Nerve (blue) are partly sensory and partly motor; the chief sensory Nucleus (pale blue) extends as far caudally as the 2nd Cervical Segment (De- scending root of the Fifth Nerve), it is club-shaped with its broader end above. The chief Motor Nucleus (dark blue) which is generally connected with the minor Motor Nucleus extends upward into the region of the Anterior Corpora Quadrigemina. Although the shape of the cells of this Nucleus are peculiar, it is probably motor. The function of the Locus Coeruleus is doubtful, its cells previously considered to be sensory are now viewed as motor. The Nucleus of the Vlth Nerve lies directly under the floor of the 4th Ventricle in the bend of the Facial Fibres described above. In the posterior part of the 4th Ventricle, which is separated from the anterior part by the Striae Acusticae, a median grey and two lateral white triangular areae can be delineated on either side. The grey area (Ala Cinerea) contains the Sensory Nucleus of IXth, Xth and Xlth Nerves. The Motor Nucleus of these nerves (Nucleus Ambiguus) is marked yellow; the Nucleus of their ascending root (Solitary Bundle of Meynert) which is not indicated occupies a ventrolateral situation in relation to the Sensory Nucleus. The Sensory Nucleus is situated internal and at a deeper plane than the descending root of the Vth Nerve The inner white triangle corresponds to the Hypoglossal Nucleus and the outer to the Dorsal Nucleus of the Vlllth Nerve (Cochlear Portion). This Cochlear Portion has another Nucleus (the Ventral Nucleus) situated along the outer border of the Inferior Cere- bellar Peduncle. For the Vestibular Portion of the Vlllth Nerve there are two Nuclei shewn in the figure (Deiteks' Nucleus and the Nucleus of the Descending Root of the Vlllth Nerve) [Nucleus Tractus Spiralis Nervi Acustici]. Ziehen. Fig. 7. Arrangement of Fibres in the Internal Capsule. All the fibres from one hemisphere pass together through the Cms at the Base of the Brain. In their course from the Cortex to the Crus these fibres pass between the large Basal Ganglia (Thalamic, Caudate and Lenticular Nuclei), as shewn in the figure. Leaving the outermost and external capsules out of con- sideration these fibres have but one course open to them, viz : between the Caudate and Lenticular Nuclei and between the Thalamic and Lenticular Nuclei. This is the Internal Capsule with its Anterior and Posterior limbs and an intervening bend (genu). The arrangement of the fibres in the Internal Capsule is as follows: — The pyramidal tract, the path of voluntary movements, occupies the anterior Vards of the posterior limb in such a manner that the Facial and Hypoglossal Fibres lie in the genu, next in order come the fibres to the upper Limb and lastly those to the lower limb. In the posterior Vs^d of the posterior limb of the internal capsule lies the great sensory path for "Common sensibility" and the occipito-temporal cortico-pontic tract which passes from the occipital and temporal lobes to the Pons. Furtliermore, fibres pass to and from the Cortex and Thalamus. Close behind the posterior limb is the so-called "Carrefour sensitif" (Charcot's Sensory Tract), through which the paths of the higher senses (Olfactory excepted) pass. In the figure, only the fibres connected with the Optic Nerve are depicted in their passage from this point to the Occipital Lobe. Disease of this "Carrefour" produces mixed Hemianaesthesia i. e. patients feel, taste and hear less definitely or not at all on the opposite side, and do not see with the Xasal half of the Eye on the same side and Temporal half of the opposite eye, whereas disease of the posterior part of the posterior limb of the Internal Capsule produces motor paralysis of the opposite side. The Anterior Limb contains chiefly fibres derived from the Frontal Lobe and Caudate Nucleus; their course and function is unknown. The Caudate Nucleus and its tail curl over the Internal Capsule to terminate by blending with the Hippocampal Convolution and the Amygdaloid Nucleus; so that in this section the Caudate Nucleus has twice been cut — at its body internal to the anterior horn of the lateral Ventricle and at its tail near the descending horn. The lateral and 3rd ventricles communicate through the Foramina of Monro. The pillars of the fornix are cut near their point of junction. The posterior horn of the lateral ventricle is cut at the point where the inferior horn begins. The white fibres of the Corona Radiata between the Cortex and the Corpus Striatum is called the Centrum Semi-Ovale of ViCQ dAzyr. Ziehen. Occipital 1 Interparietal I'issure Parietooccipital Fissure Fissure of Corpus Callosum Posterior Horn Splenium of Corpus Callosum Tail of Caudate Nucleus Optic Thiilainu: Posterior Limb of Internal Capsule Middle Commissure Genu of Internal Capsule Pillar of Fornix Cavit\- of Septum Pellucidum (5th Ventricle) Anterior Limb of Internal Capsule Head of Caudate Nucleus Anterior Horn — Genu of Corpus Callosum Fissure of Corpus Callosum Callosomarginal Fissure Anterior Occipital Fissure Superior Temporal Fissure Optic Radiation (Gratiolet) Charcot's Sensory Tract ("Carrefour sensitif") Posterior Limb of Fissure of Sylvius Island uf Kkil External Capsule Outermost Capsule 0/JPP- ^^'^^^ Fissure of Rolando (Central Fissure) cutuTn Claustrum Globus Pallidus Anterior Ascendinj? Branch of the Fissure of Sylvius Inferior Frontal Fissure jNIiddle l-Vuntal Fissure Frontal Pole Thalamo-Frontal Bundle. Motor Bundle: Facial and Hj-poglossal. Motor Bundle : Leg. Common Sensibility and Motor-Sense Bundle. Fig. 7. Direction of Fibres in the Internal Capsule. Seen from above. — Nat. Size. — Bv Prof. Ziehen. Rebman Limited, London. Rebman Company, New York. SupTif^tr I*"rcii!omotor Nerve Miducens Nerve Sphcno- parietal Sinus External Pterygoid Muscle Temporal Muscle Internal Carotid Artery __ Posterior Com- municating Artery Middle Cerebral Vein Smaller Part of 5th Nerve Middle ^Icningeal Arter\ Articular Fibro-Cartiiage ^Am-iculo-temporal Nerve Chorda Tympani Nerve Tympanic Cavity Superior Petr(»sai Sinus Eustachian Tube Vertebral Artcr>' Rectus Capitis Posticus ilajor Muscle Rectus Capitis Posticus Minor Muscle \ Saccus Endolymphaticus Occipital Artery Superior Oblique Muscle of Head Suboccipital Nerve Straight Sinus Superior Longitudinal Sinus Fig. 16. Base of Skull with the soft parts after partial removal of the Bones. ■>/;, Nat. Size. Rebman Limited, London. Kebman Company, New York. Fig. i6. Base of the Skull and Soft Parts after partial removal of the Bones. This complete fissure is constructed from eight dissections made after hardening in formol and removing various parts of the Brain in successive layers. After decalcifying the bones considerable portions were easily removed by tlie knife. On the left side the part of tlie Occiput forming the Posterior Fossa ivas removed, the Cavernous Sinus opened and the Gasserian Ganglion with its three divisions dissected out. Tlie roof of tlie Orbit was removed and the structures occupying the upper part of this cavity exposed to view. By cutting away the Cribriform Plate of the Ethmoid, the Accessory Sinuses of the Nasal Cavity were opened up — Mucous Membrane is coloured pink. On the right side a more extensive area of the base of the Skull has been removed, only a few thin bars beeing left [Tympanic Cavity pink, Membranous part of Meatus brown). In the lower part of the Orbital Cavity, — the eye-ball having been cut across horizontally and supposed to be transparent, — all the structures including the nerves and muscles are shew}i. The Nerves of the Special Senses are green (Optic Nerve light green ; Auditory Nerx'e and apparatus, dark green). Sensory Nerves, yellow. Motor, dark blue (Veins being light blue), so that the Motor Root of the Vth Nerve is definitely shewn. The Vagus Group IX, X, XI, being mixed nerves, are yellow, like the sensory. Gassertan, Ciliary and Geniculate Ganglia are orange; on tlie left, the air-cells of the Auditory apparatus, the Eustachtax Tube and the unusually large Lateral Recess of the Sphenoidal Sinuses extending into the greater wings of the Bone are projected upwards (pink). This figure — probably the first of this kind — gives, by shewing the vessels and muscles under the base of the Skull in their natural position, an idea of the Topography of this region unattainable from below because in this manner their relations remain undisturbed b}' dissection. The figure shews the topographical relations of the 3 great organs of special sense: e. g. E3'e, Ear and Nose, moreover, it gives a good view of the course of the Nerves which have a primary intra- , and a subsequent extra- cranial course. Lastly connections are exhibited which could scarcely be appreciated by other methods. Fig. 17. Projection of Lateral Ventricle, Middle Ear and Lateral Sinus on the outer surface of the Skull. To SpitzKj^s figure which shews the projection of the Lateral Ventricle on to the outer region of the SkxiU, we have added the projection of the Lateral Sinus (violet) and of the Middle Ear with its Accessory Cavities (red) while retaining our own Specimens and the indications by Frjedrich Muller. Puncture of the Lateral Ventricle is performed (a) to emptj' it of accumu- lated fluid (Hydrocephalus, Serous Meningitis etc.), or (b) to inject drugs into the Ventricle when not dilated (e. g. Tetanus). vox Bergmann trephines the Skull in front, directlj' above and mesial to the Frontal Eminence and pushes a long hollow needle in a slightly downward and inward direction. Keen finds a point on the outer surface of the Skull 3 1 mm. above a line connecting the lower border of the Orbit with the External Occipital Protuberance and 32 mm. behind the External Auditory Meatus. The shape of the Lateral Ventricle does not vary much except in the Posterior Horn. The "Trigone" i. e. where the Body, the Posterior and Descending Horns meet, is the largest part and consequent!}' the most suitable for the operation. Fig. 18. Projection of the Middle Meningeal Artery on the outer surface of the Skull. After Kronlein. The Middle Meningeal Artery is red. To determine certain important Cerebral points and lines, as well as the Middle Meningeal Arterj', Kroklein's landmarks are the most convenient. i) The "German Horizontal Line" runs through the Infra-Orbital margin, and the upper border of the External Auditory Meatus. 2) The "Upper Horizontal Line" runs through the Supra-Orbital margin, parallel with the former. 3) The "Anterior Vertical Line" passes upward from the middle of the Zygoma at right angles to i). 4) The "Middle Vertical Line" passes from the Condyle of the Lower Jaw at right angles to i). 5) The "Posterior Vertical Line" from the posterior margin of the Base of the Mastoid Process at right angles to i). A line connecting (a) the point where the "Anterior Vertical Line" and the upper Horizontal Line cross each other with (b) the point where the "Posterior Vertical Line" cuts the ^^ertex, represents the Central Fissure (ROLANDO). When the angle formed by this line and the upper Horizontal line is bisected by a line drawn to meet the posterior vertical line, the oblique line represents the Fissure of Sylvius. A and B are the points for trephining to evacuate the blood extravasated from a ruptured Middle Meningeal Arter}'. The square marked in thick Unes is the region in which VOX Bergjl\X'X resects the SkuU cap for drainage of Otitic Abscess and Abscess of the Tem- poral Lobe. The Black Circles indicate the following points which are often made use of (cf. Text Figs. 1 1 and 1 2) : Nasion at root of Nose. Bregma at Vertex; further back, Obelion, Lambda; and Inion at the External Occipital Protuberance. Fig. 17. Projection of Lateral Ventricle, Middle Ear and Lateral Sinus on to the Outer Surface of the Skull. 7j Nat. Size. Fig. 18. Projection of Middle Meningeal Ai'tery on to the Outer Surface of the Skull. '^1^ Nat. yize. Rebmun Limited, London. Kebman Coni|i:my, Ni'W York. Fig. 19. Cranio-Cerebral Topography. Vs Nat. Size. Rebman Limited, London. Rcbman Company, New York. Fig. 19. Cranio-Cerebral Topography. Tlie bars of A. Koehler's "Craniencephalometer" are dark red; Brain pink, diagrammatic. For practical purposes it is very important to know the surface markings for the different parts of the hemisphere. By such knowledge a diagnosis can be made of: "Which cortical region is affected in any particular injury of the Skull?" On the other hand, functional disturbances may indicate disease of a certain part of the Corte.N. which may require operation ; by this knowledge of surface markings the surgeon is enabled to find the seat of the lesion. Generally speaking it is sufficient to determine the position of the Fissures of Rolando and Sylvius because the most important centres are situated in the neighbourhood of these fissures (cf. Fig. 3, 5) further with these landmarks other sulci and fissures can be easily marked out. Many methods have been devised, some requiring special instruments. Koehler's method is simple and reliable. Cf. Fig. Three lines are necessary. 1. A Sagittal line extending from the root of the nose to the External Occipital Protuberance. 2. A Vertical line through the Anterior Border of the External Auditory Meatus. 3. A second Vertical line parallel to the former through the Posterior Border of the Mastoid Process. P>om the point where the last mentioned line meets the Sagittal line another line is drawn downwards and forwards to a point situated midway between the junction of the middle with the lower thirds and the mid-point of the first Vertical Line. This point corresponds to the lower end of the ROLANDIC Fissure, the upper end of which lies at the junction of the line drawn from the Sagittal Line. The Fissure of SYLVIUS lies Vs ii^ch below the inferior end of the Fissure of Rolando. About 2 V-, inches above the Zygoma the Short Anterior and Long Posterior Limbs of this fissure begin. Another excellent method of marking out the Fissures of Rolando and Sylvius, devised by Kroenlein, is described in Pis'. 1 8. Fig. 20. Exposure of the Cerebellum. On the left side an incision has been made from the External Occipital Protuberance horizontally outwards as far as the Ear. From either extremity vertical incisions have been made downwards and the muscle-skin flap thrown downwards. The muscles were subsequently dissected out. A large window was chiselled out of the Bone. The Lateral Sinus has been slit open, the Cerebellum is kept inwards by a broad spatula. The Cerebellum is much more protected than the Cerebrum. Only a ver}' small surface area comes in contact with the Bone in a region well protected by thick muscles. Injury to the Cerebellum is accordingly very rare, but operations in this part are far more difficult owing to its position. A glance at the figure shews that suppuration of middle-ear origin may extend from the Lateral Sinus, Posterior Semicircular Canal or Saccus Endolymphaticus and so give rise to an abscess between the posterior surface of the Petrous portion of the Temporal Bone and the Cerebellum or to a Cerebellar Abscess. These purulent collections may be evacuated by an enlargement of the opening made for the exposure of the Lateral Sinus, backwards. If a Temporal abscess has been looked for by opening the skull in VON Bergmann's Rectangular Area (cf. Fig. 18) then further procedure entails enlargement of the osseous opening and incision of the Tentorium CerebeUi in order to compare the superior aspect of the Cerebellum. A large opening is necessary for Cerebellar Tumours. When the Lateral Sinus gets in the operator's way, he should push the Dura Mater away from the Bone ligature the Sinus with a double ligature and divide it. Upon the further removal of bone the Cerebellum can be well exposed. We desire to draw particular attention to a \'ein which runs from the lowest part of the Lateral Sinus or from the Jugular Bulb to the Vertebral Vein through the Posterior Condylar Foramen. Its further course is horizontal be- tween the Occipital Bone and the Atlas. The vein is of great importance in Ligature of the Internal Jugular in cases of Thrombophlebitis of the Lateral Sinus. Cf. Figs. 27 and 28. Cerebellum Superior Cerebellar Vein Superior Petrosal Sinus Emissary Mastoid Vein Mastoid Process Digastric Muscle Occipital Arteries Stemo-mastoid Muscle Splenius Capitis Muscle Spatula Rectus Capitis Posticus Slinor Muscle Rectus Capitis Posticus Major Muscle Occipital Arterj- 1 Semispinalis Capitis Muscle Vertebral Artery Superior Oblique of Head Longissimus Capitis Muscle Fig. 20. Exposiu-e of the Cerebellum. */s Nat. Size. Rebman Limited, London. Eebman Company, New York. Middle 'I'tirbinate Hone Antrum of HioiiMoiti-: Coronoid Process I Nasal Septum Pterygoid Process 3rd Division of 5th Nerve EUSTACHIAN Tube Occipital lione Internal Carotid Artery Tympanic Cavitj* 'r^'Tf Jf^Aw j Temporal Muscle massetcr Muscle External Pterygoid Muscle Par<.tid Gland M Articular Cartilage Temporal Artery Ili-ad of Mandible F.xlcrnal Auditory Meatus ^^ Facial KcTvc :\rastoid Cells Lateral Sii Cerebellum Fig. 21. Horizontal Section of the Head. Organ of Healing and suiTounding Parts. Left side, viewed frcuii below. — i\at. Size. ^^fMM Internal Carotid Artery Tympanic Cavity Superior Petrosal Sinus Facial Nerve Auditory Nerve Tympanic Nerve^ Promontory Umbo. Malleus Fenestra Ovalis Stapes Pyramid Chorda Tjinpani Head of Lower Jaw Tympanic ^Icnibrane Long Process of Incus External Auditory Canal Mastoid Cells Lateral Sinus Facial Nerve Fig. 22. Part of Fig. 21 : Tympanic Cavity and surrounding Parts. X ^y.. Rebmau Limited, London. Rebman Company, New York. Fig. 21. Horizontal Section of the Head: Organ of Hearing and Surrounding Parts. Pig. 22. Tympanic Cavity and Surrounding Parts. X 2V2. Part of a frozen section from a series of Horizontal sections through the Head. The two curves described by the External Auditory Canal in the Horizontal plane are well shewn : a 3rd curve is recognisable in the Vertical plane, so that it is not possible to distinctly see the Tympanic Membrane without traction upon the Cartilaginous portion of the Ear. From the practical point of view the relations which the Auditor}' Appa- ratus bears to neighbouring structures and especially to the Lateral Sinus and Dura Mater are most important. The Dura Mater which covers the posterior aspect of the Petrous Bone is only separated from the numerous air-cells by a thin lamina of bone, so that pus within these cells may easily give rise to a subdural abscess. The Lateral Sinus bears a similar relation to the Mastoid Process so that injury to it may result during operations upon the Mastoid; pus within the Mastoid Cells may extend to the Lateral Sinus and produce Thrombophlebitis. Around the Internal Carotid Artery which incompleteh' fills the Carotid Canal, are \^enous Spaces, continuations of the Cavernous Sinus. The Facial Nerve is seen cut across in its vertical course to the Stylomastoid Foramen. Tn the Facial Canal accompan3'ing the Facial Nerve (Fig. 22) are shewn the Stylomastoid Artery with its 2 Venae Comites. In Fig. 22 are further shewn the structures in the Tympanic Cavit}* : Ear-ossicles, Chorda T3'mpani and Tympanic Nerve. The Eustachian Tube, extending obliquely forwards, inwards and downwards from the Tympanic Cavity to open into the Pharynx has been divided obliquely so that it appears larger than if it had been cut transversely to its axis. Between the Condyle of the Lower Jaw and the External Auditory Meatus there is only a very thin la)'er of bone. The Articular Fibrocartilage is seen almost completely surrounding the Condyle. Internal to the External Pterygoid Muscle is seen the 3rd Division of the Vth Nerve directly after its emergence through the Foramen Ovale; behind and to its outer side is the Middle Meningeal Artery. The Lymphoid Tissue beneath the Pharyngeal ]\Iucous Membrane — the Pharyngeal Tonsil — which appears very large in a horizontal section deserves notice. This has been cut obliquely because the upper wall of the Pharynx is not horizontal but directed obliquely backwards and downwards. Fig. 23. Vertical Section through the Left Temporal Bone in the plane of the Axis of the Petrous Portion. Frozen Section. Mucous Membrane of Tympanic Cavity, Antrum and Mastoid Cells in red. The lower part of tlie Tympanic Cavity has l)een carried aivay in the section so f/iat the External Auditory Canal is exposed. Fig. 24. Horizontal Section through the Left Temporal Bone. Section through a macerated bone. Tlie axis of the Mucous Membrane lining the Eustachian Tube and the Mastoid Antrum is indicated b\ a red line. The axis througli the External and Internal Axiditory Meatus, "Sensory Axis", is indicated by a yellow line. Tlie Cartilage of the Temporo-Mandibular Articu- lation is coloured blue. The middle ear is surrounded by numerous air-cells which aire lined by a continuation of the same mucous membrane and communicate directh' or indi- rectly with the Tympanic Cavity. Pus spreads readily from the Tympanic Cavit}^ to these Accessory Cells. Fig. 23 shews how the cells lie below the plane of the opening into the r3'mpanic Cavity and consequentl}' drainage is very efficient. The size of these air-cells varies not only on the same side but on either side in the same individual. These cells maj- extend far into the Petrous Bone, even into the Occipital Condyle and the root of the Zygoma. The chief Accessory Cavity is the Mastoid Antrum (as large as a French Bean) with its long axis (^/5th inch) corresponding to the axis of the EUSTACHIAN Tube and opens into the Tympanic Cavity on the posterior wall, directly below the Tegmen Tympani which forms the roof of the Antrum. The Mastoid Cells, which vary considerably in number, either few or large, numerous or small open into the Antrum. The cells extending into the Squamous Portion are known as Squamosal Cells, but these never extend higher than the temporal ridge. The lamina of bone covering the Mastoid Process is so variable in thickness that, like the Tegmen it is deficient at some points on its outer wall as well as on its inner wall, which is in relation to the Lateral Sinus. These points of deficiency are merely covered by connec- tive tissue. Pus can spread easily through the thin Tegmen Tympani and cause Meningitis or a Temporal Abscess. Fig. 23 shews the Vth Cranial Nerve in Meckel's Cavity, i. e. the depression on the superior surface of the Petrous Bone covered in by Dura Mater. In Fig. 24 the red line indicates the "mucous membrane axis", i. e. Eustachian Tube, Tympanic Cavity, Antrum and Mastoid Cells on a line which runs backwards and outwards. The yellow line is the "sensory axis" which passes tlirough the External Auditory Meatus, Tympanic Membrane and Cavity, Vestibule and Internal Auditory Meatus. These axes cross in the Tympanic Cavity ; the first passes through all organs of accessory importance for hearing; the second passes through the organs of hearing proper. Superior Ligament of the Malleus Chorda Tynipani Tensor Tynipani Muscle Internal Carotid Artery Cartilage of Edstacuian Tube Levator Palati iluscle I'haryngeal Opening of Eustachian Tube Superior Constrictor of the Pharynx Mastoid Cells Stylo-mastoid Artery Splenius Capitis JIuscle Sterno-cleido-mastoid Muscle Facial Dig^astric Styloid Process Stylo-hyoid Muscle Norve Muscle Fig. 23. Vertical Section thi'ough left Temporal Bone in the plane of the axis of the Peti'ous Portion. Seen from behind. — Nat. Size. Mastoid Cells Lateral Sinus Antnjm / Canal for Facial Nerv-e (Fallopian) Pyramid Posterior Semi-circular Canal Aqueductus VestibuH Vestibule _ Internal Auditory Meatus Cochlea Bony Lamina (Processus Cochlear if orm is) EL'STAClirAN Tube Notch of RiviNi Petrosquamosal Suture External Auditory Meatus Mandibular Fossa Z3'goma Fig. 24. Horizontal Section thi-ough the Left Temporal Bone. Seen from below. — Nat. Size. Kebnian Limited, London. Rebman Company, New Yoi-k. "xJ^^FMiDi Temporal Fascia Squamous Plate'of Temporal Bone Suprameatal Spine External Auditory Meatus (Cutaneous) Auricular Branch of Vagus "^^' Ner\'e (Arnold) External Auditory Meatus (Cartilaginous) Posterior Auricular Ner\-c Posterior Auricular Artery Parotid Gland / Facial Nerve Digastric Muscle Antrum Prominence of External Semi-circular Canal ^ Diploe Lateral Sinus -^ Facial Nerve Sterno-cleidu-mastnid Muscle Splenius Capitis Muscle Longissimus Capitis Muscle Mastoid Process Styloid Process Fig. 25. Mastoid Process of Child opened. Nat. Size. Suprameatal Spine Antrum Temporal Fascia Posterior Auricular Nerve Occipitalis Muscle \ Cartilage of Pinna . -^^ External Auditory Canal Posterior Auricular Muscles Auricular Branch of Vagus Nerve Cartilaginous Portion of the External Auditory Canal Facial Nerve Posterior Auricular Artery Great Auricular Nerve Parotid Gland Great Occipital Nei-ve Small Occipital Nerve Lateral Sinus Facial Ner\*e Splenius Capitis Muscle Sterno-cleido-mastoid Muscle Posterior Auricular Lymphatic Gland Nerve to Digastric Muscle Nerve to Stylo-hyoid Mr F-rokss Fig. 26. Mastoid Process of Adult opened. Kat. Size. Bebman Limited, Londoc. Rebman Company, New York. Fig. 25. Mastoid Process of Child, opened. Fig. 26. Mastoid Process in Adult, opened. Fig. 25. Tlie various layers of the Mastoid region in a child, aged two vears, liave been exposed, and the Mastoid Process cliiselled open. Air-cells, red. — In Fig. 26 the Mastoid region of an adult has been more extensively dissected but only that portion of the Mastoid Process containing air-cells has been opened by chisel. The periphery of the Mastoid Process is indicated by a dotted line. By removal of a portion of the Parotid Gland the Facial Nerve has been exhibited as it emerges from the Stylomastoid Foramen. The Antrum is well marked in the New-Born though the Mastoid Process is scarcely discernible; its posterior and external portion becoming formed during the first years of life; it grows downwards as the formation of air-cells slowly progresses. Even in the adult there are not necessarily any air-cells at the tip of the Mastoid Process. The Facial Nerve after emerging from the Stylomastoid Foramen runs forward at a right angle in the infant, at an obtuse angle in the adult. The groove of the Lateral Sinus is shallow in the child, deep in the adult. The iVntrum and Mastoid Cells are easily accessible for operative purposes from the outer surface of the Mastoid Process. Subcutaneously in the angle between the Pinna and the Skull the Posterior Auricular Artery takes its course. The Periosteum is intimately connected with the tendinous fibres of origin of the Sternocleidomastoid Muscle which gradually become lost in the Temporal Fascia. About 'Vath inch behind the Suprameatal Spine is situated the Antrum at a depth of V.r,th of an inch from the surface. Below this are the Mastoid Cells. The structures in relation with the Antrum are of great importance. The thin Tegmen Tympani alone separates the Antrum from the Cranial Cavity, so that search for an Epidural or Temporal Abscess is easy after perfor- ation of the Tegmen Tympani. If projected on to the surface the floor of the middle Fossa of the Skull lies in the region of the attachment of the pinna either above or on the level of the Temporal line. Posteriorly and internally is the Lateral Sinus which should be avoided when the air-cells are opened. The position of the Lateral Sinus varies, it may lie in a shallow groove on the Mastoid Process, or in a deep furrow in both Mastoid and Petrous portions. According to Bezold the most marked outward curve of the Sinus is V5 inch behind the Suprameatal Spine. At this point the bone is usually 0.3 inch thick (o.i to 0.7). The Facial Nerve may be injured as it lies below the External Semicircular Canal on the inner wall of the Tympanic Cavity close to the opening itito the Antrum (Aditus ad Antrum). The wall of the Facial Canal is ver}' thin so that by a careless use of the chisel this nerve may be divided. Lower down the Mastoid Cells are in relation with the Facial Canal ; this portion has been laid free in both figures. Fig. 27 and 28. Tympanic Cavity and Surrounding Parts opened from behind. In Fig. 27, the outer wall 0/ the Mastoid Process, Antrum and Attic have been removed, the Mastoid Cells gouged out so that only t/ie inner wall of the Mastoid Process remains; Facial Nerve, Posterior and External Semi- circular Canals and Lateral Sinus are still covered by bone. Facial Nerve and Semicircular Canals (yellow) are represented as shewing through the bone. In Fig. 28, the skin incision has been extended downwards, the tip of the Mastoid Process removed, the Digastric Muscle divided and the Attic more freely exposed, the Facial Canal opened, the bony ivall of the Sinus removed and the Sacciis Endolymphaticus exposed. The Posterior portion of the Tympanic Membrane, the Posterior and Superior wall of the Bony External Auditory Canal luive been removed and the skin which lines this portion slit open. The bar of bone behind the Stylo- mastoid Foramen has been sawn through in order to expose the fugidar Bulb. These figures give the relations which are of importance in radical operations. In cases of chronic suppuration and Cholesteomata of the Middle Ear, it is important to expose all the cavities b\' removing their outer wall and bony septa so that the inner wall of the Tympanic Cavit}-, Antrum and Mastoid becomes continuous with the Inferior and Anterior Wall of the External Auditory Canal. The bony canal for the Facial Nerve, the External Semicircular Canal and the Stapes must be carefully avoided. The black area below the Incus represents the Fenestra Rotunda. Fig. 28 shews the whole of the oblique part of the Lateral Sinus to its termination in the Jugular Bulb. After reaching the Temporal Bone its direction changes verticalh' downwards, embedded to varying depths in the inner wall of the Mastoid Process, thence its course is at first horizontalh* inwards (occasionally with a sharp upward curve), then directly downwards to pass through the Jugular Foramen and form the Jugular Bulb. Suppurative Thrombo - phlebitis usually affects this last vertical portion, in many such cases the Sinus must be opened throughout its whole length. Many ways may be employed to expose the Jugular Bulb: Gruxert removes the tip of the Mastoid Process and proceeds towards the Jugular Foramen at the base of the skull where he divides the bone encircling" it. As shewn in the figure the Facial Nerve is in the way. Panse therefore recommends that the nerve be freed and drawn forward. If the Transverse Process of the Atlas is in th3 way it should be carefuUv removed, avoiding any injury to the Vertebral Arter)^ Owing to anatomical variations, this may be impossible so that CtRUNERT's method (as practiced by PiFFL), of removing the floor of the Auditory Meatus and T\'mpanic Ring, under which the Jugular Bulb lies, may be necessary. (Cf. Fig. 17.) By this method the Facial Nerve lies behind the field of operation; the structure to be avoided in front is the Internal Carotid Arter)'. Will ligature of the Internal Jugular Vein in Septic Thrombophlebitis prevent the spread of infection ? This question demands a consideration of the many Venous Channels which open into the Lateral Sinus (Superior Petrosal Sinus, Figs. 15, 16, 20), Mastoid Emissary' Vein (Figs. 20 and 28), Posterior Condylar Emissary Vein (Fig. 20), ilarginal Sinus (Fig. 15), Inferior Petrosal Sinus (Fig. 15), Anterior Condylar Vein which accompanies the Hypoglossal Nerve and passes to the Jugular Bulb from the Vertebral Plexus. The figure shews the close proximit}' of Facial and Spinal Accessory Nerves so that in cases of Facial Parah'sis the Surgeon may be tempted to suture the central portion of the Spinal Accessor}- to the Peripheral portion of the Facial Nerve. Suprameatal Spine Tympanic Cavity Posterior Semicircular Canal Saccus Emlolymphaticus Facial Nerve Lateral Sinus Mastoid Emissary Vein Occipital Vein Spinal Accessory Nerve -Tympanic Cavity Short Process r»t Incus External (Horizontal) Semicircular Canal Posterior Semicircular Canal Facial Nerve Lateral Sinus Digastric Muscle Fig. 27. Superficial Layer. Malleus ■^'i^vij'v-.v.r.v^-^. a rig. 28, Deep Layer. Figs. 27 and 28. Tympanic Cavity and surrounding Parts opened from behind. Nal. Size. Kebman Limited, Loiulon. Rebman Company, New York. Fig. 29. Superficial Vessels and Nerves of the Head. -v., Nat. Size. Rebman Limited, London. Rebrntin Company. New York. Fig. 29. Superficial Vessels and Nerves of the Head. Skin, Parotid Gland, portion of the Orbicularis Palpebrarum and Square Muscle of the Upper Lip (Quadratus Labii Superioris), have been removed. The Superficial Arteries, Veins, Nerves and Muscles have been exposed by dissection. Light red, Arteries. Passing upward over the lower jaw is the Facial Artery which shews through the Muscles as it is covered b}' them : in front of the Ear the Temporal Arter}' gives off the Transverse Facial Artery. At the upper border of the Orbit the Frontal Artery (a branch of the Ophthalmic Arter\- which comes off the Internal Carotid) is seen and at the back is the Occipital Arter\-. Violet, Veins. The Facial Vein (anastomosing, at the Naso-frontal Angle, with the Frontal Vein and indirectly with the Intracranial Venous System) is seen communicating with the Temporal Vein which lies in front of the Pinna. Posteriorly the Occipital Vein is seen. The Facial Nerve and its branches are white. (Cf. Figs. 33 — 38.) The other nerves are coloured in accordance with their area of distribution. (Cf. Figs. 33-38.) Dark red — Ophthalmic Division of Vth Nerve. (F, i). Yellow — Superior Maxillary Division of Vth Nerve (F, 2). [z—t indicates Zygomatico-Temporal, and z—f Temporal-Facial Branches). Blue — Inferior Maxillary Division of Vth Nerve (F, 3). This gives off the Auriculo-Temporal Nerve (a — t) before the Inferior Dental enters its Foramen. Orange — Auricular Branches of Vagus {X) to the Pinna (ARNOLD). Black — Cervical Nerves : Great Auricular, Great and Small Occipital and Superficial Cervical Nerves. The Duct of the Parotid Gland (Stenson's Duct) and its small tributaries are coloured light brown. Fig. 30. Side View of Face. Superficial Layer. The Parotid Region lias been dissected on the Left Side and a windoiv made in the Parotid Gland to shew tlie formation of SrENSOiv's Duct, Branches of the Facial Nerve and the main vessels (all very carefully dissected). Broadh' speaking the Vessels and Nerves of the Face are subcutaneous with the exception of the area covered by the Parotid Gland. The Parotid Gland is co\ered b}' a thick fascia; its outer surface is tri- angular in shape with the base directed upwards and the Apex at the angle of the Lower Jaw. The base extends from the posterior extremity of the Zygoma to the Cartilaginous portion of the External Auditory Canal and to the Anterior border of the Sternomastoid Muscle. The posterior border runs parallel to the Sternomastoid Muscle; at the angle of the Jaw, this is met by the Anterior border which crosses the Masseter Muscle. The greater part of the Gland lies behind the Ramus of the Jaw and extends inwards to the Digastric (i. e. close to tlie Carotid and Jugular Vessels Fig. 53). Stenson's Duct runs almost horizontally forwards ^/^th inch below the Zygoma and turns inwards at the Anterior border of the Masseter to perforate the Buccinator obliquely and terminate within the Buccal Cavity opposite the 2nd upper molar tooth (cf. Fig. 57). There is often present an Accessory Parotid (Socia Parotidis) attached to the Duct (cf. Fig. 30). The Facial Ner\'e bears a close relation to the Gland. After emerging out of the Stxiomastoid Foramen this nerve enters the substance of the Gland at the level of the lobule of the Ear. Here it divides, and its branches run in the substance of the gland, to emerge at the Anterior border and be distributed to all the muscles of Facial Expression. Consequently it is impossible to remove the whole of the Parotid Gland without injury to the Facial Nerve, but removal of the lower part in no way leads to interference with the Nerve: in this case the Mandibular Branch, which supplies the muscles of the angle of the mouth, is chiefly damaged. The branches of the Facial Nerve form an anastomosis with each other (Pes Anserina) and with the Fifth. The Auriculo-Temporal Nerve (from V, 3) runs through the Parotid Gland £is well as the Superficial Temporal Artery (continuation of External Carotid Arter}') ; this vessel in its course through the gland gives off the Tran,sverse Facial Artery which takes a horizontal course. The Superficial Temporal Artery then passes upwards in front of the ear dividing into an Anterior (Frontal) and a Posterior (Parietal) branch to supply the Frontal and Parietal Regions of the Scalp as far as the Vertex. The Temporal Vein, accompanying the Artery-, receives blood from the Temporal Region and the Ear. In the substance of the Parotid Gland are embedded a few h-mphatic glands which are of practical importance; rarely, a cutaneous 13'mphatic gland, superficial to the Parotid, is found. Temporo-Facial Branches ait i of Facial Nerve Auriculo -Temporal ,- . , ^ , , , Nerve Superficial lemporal Artery Tcinpnral Vein ' Zygdiiia — Facial Nerve (iieat Auricular Nerve External Jugular Vein I Facial Artery Long Buccal Nerve Masseter Parotid Gland Muscle Facial Veir Fig. 30. Side View of Face. Superficial Layer. Nat. yize. Rebman Limited, London. Rebman Company, New York. Branches of Deep Posterior Superficial Temporo- Facial Temporal Artery Temporal Masseteric Temporal Internal Maxillary Artery Nerve Temporal Muscle and Nerve Fasciae Nerve Artery Articular Eminence Branches of Teniporo-Facial Nerve ^ Infra-orbital Xrrve Posterior Superior Alveolar Nerves Deep Anterior , . Temporal Artery Parotid Duct Buccal (Sucking) Pad Buccinator iluscle Long Buccal Nerve Auriculo-Temporal Nerve Midille Temporal Artery External Pteryg^'a*''S^ Rebmau Limited, London. Rebmau Company, New York. \ \ Fig. 35. Fig. 33. Fig. 36. Li^ m jz= 5 == r 2 ']] r\ ;VA ir-f"'" Fig. 37. Fig. 34. Fig. 33—38. Area of Distribution of the Sensory Cranial Nerves: Fig. 33 Front View, Fig. 34 Side View, '/, ^'at- Size. Fig. 35 38. Variations, Side View. '/, Nat. Size. Fig. 38. Rebman Limited, London. Rebman Company, New Yorls. Pig- 33 38. Area of Distribution of the Sensory Nerves of the Head. These diagrams have been made in accordance with Frohse's investigations and ZANDElis data. In fig. // the foramina of exit of the chief branches of the Vth Nerve have been indicated by black Dots. A characteristic feature of the Cranial Nerves is that they are either pure Motor or pure Sensory nerves ; when they contain fibres of the other variety they do not represent true mixed nerves lilf( ^-•. V - Middle Cerebr;il Vein --phcnoidal Sinus W^^f, Vidian Canal and Ner\'e * / / Fig. 47, Frontal Section through Anterior Portion of Cavernous Sinus. Nat. Size. Stalk of Pituitar>' Body Pharyngeal Tonsil Cartilage of Eustachian yy'C/^ Tube "^ '^' ilesial Cartilaginous Swelling (Oculomotor) (Trochlear) erve (Abducens) Ophthalmic Nerve 2) Superior Maxillarj' Nerve Fig. 48. Frontal Section5through the Posterior Part of the Cavernous Sinus. N'at. Size. Rebmaii Limited, London. Rebman Company, New York. Pig. 47. Frontal Section through Anterior Portion of Cavernous Sinus. Fig. 48. Frontal Section through Posterior Part of Cavernous Sinus. Sections of the same series as those shewn in Fig. 4^ and 46. Section 4y pas- sed o.j' incli beliind section 46, and 48 passed o.} inch behind 47. On either side of the Sella Turcica is the Cavernous Sinus the most complicated of all the sinuses formed by the Dura Mater. It contains the Inter- nal Carotid Artery, the 3rd, 4th and 6th Cranial Nerves, and is in close relation with the I St division of the 5th Nerve. The Dura Mater is at some distance from the bone, and thus forms with it a space which contains the structures mentioned amid numerous veins. These veins are partly plexiform in character. This sinus is, therefore, unlike the others, not a large venous channel, but a mass of freely anostomosing veins. Both cavernous sinuses are joined to one another by two transx'erse veins which pass respectivel}' in front of and behind the Pituitary Bod}'. Thus a venous ring", the Circular Sinus (or Sinus of Ridley) is formed. Primary thrombosis of the Cavernous Sinus is rare; thrombosis usually occurs secondar\- to the Lateral Sinus with which it communicates through the Superior Petrosal Sinus, or by the spreading of a thrombus along the Ophthalmic Vein. Empyaema of the Sphenoidal Sinus may also give rise to this thrombosis, as the intervening bone is very thin; this process is absolutely analagous with the thrombosis of the Lateral Sinus due to pus in the Mastoid Process. The anatomical relations explain why thrombosis of the Cavernous Sinus ma}' produce Neuralgia of the first division of 5th C. N., Paralysis of 3rd, 4th and 6th Nerves, and wh}' congestion or thrombosis of the Ophthalmic Vein can be followed by Oedema of the Eyelids, Retro-bulbar Oedema and Ex- ophthalmos. Surgical treatment for thrombosis of the Cavernous Sinus has hitherto only once been attempted with success. The diseased sinus was reached by removing the petrous portion of the temporal bone, attacking it from the ear. It can also be got at by the channel made for the removal of the Gasserian Ganghon. Should the Internal Carotid Arter}' be injured where it lies in the Caver- nous Sinus, with a sharp instrument entering the Orbit, or by a piece of bone (fracture), or through a shot, or should the vessel burst .spontaneously (calcified arteries in old people), an abnormal communication may be formed between the artery and the sinus (Aneurysm by Anastomosis), the consequence is a pulsating Exophthalmos which is a rather curious condition. A glance at the figures shews that dangerous haemorrhage may follow the tearing of the ist division of the 5th C. N. in the removal of the Gasserian Ganglion. Externall}' to this nerve lies a venous space, which was unequally developed on the two sides in our specimen. 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"--• re B B re re o B ^-^ 3- O c !:r. ai 0 3 3- re re re H Pi 0 ^ 0 re -t re" B 0 3 C B 3' a. 3- re o" 0' B re_ 0 0 3 B -a 0 a. o re TO o c 2. re re 3 * -o 3 _ o re cr U-. -^ c re w _ a^ S" o' re re ^ S 2 3 5-re 2 re = B 3 o" a- re , 31 a- " TO B 12. C 3 re S — 3- 3 re re ci ^ id re < .C- ■o re - 5333: re r' i!L K JP'ig' 57' Region of the Neck, from in front. Fig. 58. Region of the Neck, from the Side. The Neck, which extends from the lower border of the lower jaw to the clavicle, and from the external occipital protuberance to the 7 th Cervical Vertebra, may be divided into 3 regions, i paired and 2 unpaired: Anterior, Posterior and 2 Lateral regions. The anterior region of the Neck lies between the 2 Sterno-Cleido- Mastoid Muscles; the lateral regions, between these muscles and the Trapezius; the posterior corresponds to the area covered by the Trapezius, as far down as the spinous process of the 7 th Cervical Vertebra (Vertebra Prominens). The anterior cervical region extends from the lower jaw to the upper border of the Sternum. This region may be subdivided into Submaxillary, Hyoid, Sub-hyoid (between the hyoid bone and the upper border of the thyreoid carti- lage), Laryngeal, Tracheal (which the B. N. A. subdivided into Thyreoid and Suprasternal) regions and Suprasternal notch. The area between the lower jaw. Omohyoid and Sterno-mastoid Muscles forms a A which may be subdivided into a Digastric A and a Carotid A- (The small space between the ramus of the lower jaw and the origin of Sterno-Mastoid Muscle belongs to the head.) Anatomists' opinions differ as to whether the broad Sterno-Mastoid should be regarded as a boundary line or as a special (Sterno-Cleido-Mastoid) region. In any case the parts described in the regions bounded by this muscle lie deep to it (vide infra). Between the Sternal and Clavicular heads of this muscle there may be a little fossa (Fossa supraclavicularis minor). From the lateral cervical region a A is cut off b}' the inferior belly of the Omohyoid (Inferior A of the neck). The boundaries of this A are formed by the Clavicle, Sterno-Mastoid and Omohyoid Muscles. When the Sterno-Mastoid is very broad, or present as Sterno-Cleido-Mastoid, if the Trapezius extends far forwards (in some cases touching the Sterno-Cleido-Mastoid), then this A will be very small or even absent. This A is made larger — e. g. for ligaturing the Subclavian Artery — , by pressing the Clavicle (arm) downward and (if necessary), cutting the Omohyoid. A portion of the posterior Cervical Region may be termed, Regio-Nuchae. , Hijoid \ "^ubmaxiUant/Ji egion \ Superior Jrianplej^ "1 „ " , :\ Irxangle \ i ; \\pfNeck Carotid i ¥ Triangle fMryngeat\ / / ^ j Reffion \ vt ' ::?^ Tj'npc'iu.s r ;' .' ' " \ .^ 1- " '' c ■ \ «" # ;V ' > Tracheal Region ^'- Lateral Region •• ^' i of til e Neck ,'- 'o'^^ s qjii- Infrrior ^ Triangle ^ of Neck Supra Sternal Notch Fig. 57. Region of the Neck, from in front. '/,. Nat. Size. /^Lateral Region ''<^j-~.._ of Neck Inferior - :^ Triangle .^^'^-^^ ufNeck Fig. 58. Region of the Neck, jfrom the Side. '/., Nat. Size. Rebman LimiteJ, London. Rebman Company, New York. Ligamentiim Nuchac Spinous Proct-ss of 4th \'ertebra sith Vertebra Middle and Posterior Scalene Muscles Spinal Accessory Xerve Anterior Scalene Muscle Symp.'ithetic ("hain Sterno-Cleido-Mastoid Aluscle Inferior Constrictor of Pharvnx ^ Trapezius Muscle L\nipliatic Node 5tli Cervical Neire .^- (Vertebral Artery* ^[JL_ Internal Jugular Vein External Jugular Vein ^ Vagus Xerve oinnion Carotid Artery Thyreoid Gland Pharynx / ^^. Omohyoid Muscle Stcrnothyreoid Muscle Sternohyoid Muscle Sinus Pvriforniis Arytenoid Cartilage Anterior Jugular Vrin Platysma Vocal Thyreoid Cartilage Cord Fig. 59. Transverse Section thi-ough the Neck at the level of the Fifth Cervical Vertebra. Seen from below. — ^4 Nat. Size. Rebman Limited, Loudon. Rebmau Company, New York. Pig. 59. Transverse Section through the Neck at the level of the Fifth Cervical Vertebra. Frozen Section. This figure shews that all the important structures, Large Vessels, Nerves, Thyreoid Gland, Food and Respiratory passages are in close apposition in the anterior part of the neck whereas the largest spaces, external and posterior to the vertebral column, are almost completely occupied by powerful muscles. In front lies the Larynx with the Subcutaneous Pomum Adami. Its position can, therefore, easily be made out. This section passes exactly through the Vocal Cords; between these the Glottis is continued backwards to a certain extent between the vocal processes of the Arytenoid Cartilages. These cartilages are joined b\' the Aryteno-Arytenoideus Muscle; immediately behind and below this muscle lies the lowest portion of the Pharynx which presents here the Recessus Pyriformis on either side. These recesses extend forward for some distance under cover of the thyreoid cartilage. In a cross-section, the Pharjmx, and its continuation, the Oesophagus, which is usually taken as commencing at the 5th Cervical Vertebra, appear as a transverse slit, when empty. In front of the Vertebral Column and the Longus Colli Muscle which lies upon it, is the strong" Prevertebral Fascia. This fascia is separated from the muscles of the Pharynx and Oesophagus by loose connective tissue in the meshes of which Retropharyngeal Abscesses readily spread downwards. External to the lar\'nx is shewn the apex of the lateral lobe of the Thyreoid Gland with the large Superior Thyreoid Artery which has just entered the substance of the gland. The Thyreoid Gland lies on the Common Carotid Artery, which at the point of section is covered completely b}' the Sterno-Cleido- Mastoid Muscle (cf. Fig. 60, text). External to the Carotid Artery, and some- what posterior lies the Internal Jugular Vein (the right vein is usually larger than the left, cf. Fig. 15, text. Explanation of Lateral Sinus). Between the Artery and Vein and somewhat posterior runs the Vagus Nerve. The Cervical Sym- pathetic Trunk is in apposition with the posterior part of the inner wall of the Common Carotid Artery. The foramen in the transverse process has been cut in such a way that it does not appear as a closed ring. In it run the Vertebral Artery and its Venae Comites. The 3rd Cervical Nerve which has just left its intervertebral Foramen appears very thick, owing to the obliquity of its section. Between the posterior border of the Sterno-Cleido-Mastoid and the Anterior border of the Trapezius, lie the superficial cervical lymphatic glands. Fig. 60. Anterior Aspect of the Neck, Superficial Layer. Adult. The Head is strongly inclined backwards. Plaiysma and part of the super- ficial cervical fascia covering the right Sterno- Mastoid Muscle have been removed. The right Sterno- Mastoid Muscle has therefore dropped backwards. Under the skin lies the Platysma, which, converging from both sides, only reaches the middle line at the chin; it therefore does not cover the anterior cervical region. Deep to it is the superficial layer of the cervical fascia which is important because it pulls the Sterno-Mastoid Muscles towards the Middle line, When the fascia is divided, — as necessar}' for dissecting purposes — these muscles drop backwards and outwards. They cover, as is well seen, in Fig. 59. when in their natural position, the large vessels of the neck at a much higher level, than after division of the fascia. The Anterior Jugular Veins, anastomosing above with the Facial Vein, end below in the jugular venous arch which connects the 2 External Jugular Veins. This communication usually passes behind the Sterno-Cleido-Mastoid Muscles. In some cases, the Anterior Jugular Veins terminate by joining one of the Jugular Veins. The next layer comprises the Infrahyoid Muscles; the Sterno- Hyoid converging above, the Sterno-Thyreoid, converging below. Thus, in the middle line a space is formed which is broadest ('Yo inch) at the mid-point between the Hyoid Bone and Sternum. The deep cervical fascia envelopes these muscles and covers in this space. When this fascia is divided, the muscles mentioned sink downwards and outwards, thus exposing Larynx, Isthmus of Thyreoid Gland and Trachea. In the Submaxillary Region the anterior bellies of the Digastric Muscles converge towards the chin ; between these the ^tylo-H^oid Muscles and their median raphe are visible; our figure shews a lymphatic gland in this region, which is not uncommon. The attachment of the intermediate Tendon of the Digastric to the Hyoid Bone varies; it is either bound down b\- an aponeurotic continuation of the Fascia of the muscle which is fixed to the hyoid bone, or the anterior beUy arises partly from the hyoid bone, either in a tendinous or in a muscular origin. The distance between the intermediate tendon and the hyoid bone also varies; thus the distance is much greater in this figure than in Fig. 63. Bursae are met with occasionally over the Pomum Adami and the space between the Th3'reoid Cartilage and the Hyoid Bone. Digastric Muscle Iv.iplie (tf Mvlohyoid Farial Vein Subinaxill.try (Hand Styloliyoid ^[iiscle Hypoglossal Nerve Spinal Accessory Nerve External Carotid Artery Thyreohyoid iluscle Thyreoid Gland Omohyoid Muscle Sternohyoid ^Muscle Sternothyreoid Muse Stcrno-Clcido-Mastoid Muscle -^^^•3-,X Fig. 60. Anterior Aspect of the Neck, Superficial Layer. Adult. 7,, Nat. Size. Heliman Limiteil, Lnmlnii. Rchman Cnnii>.'iny, Now York. Digastric Muscle stylohyoid Muscle Ncr\e to Mylohyoid Muscle Subment.-il Arterv Geniohyoid Muscle / Genioglossus Muscle Submaxillary Duct / Sublingual Artery Sublingual Gland Facial Vein Submaxillar)' Ganglion Lingual Nerve- Styloglossus Muscle Hyoglossus Muscle Hypogloss;il Xcrve Lingit.'il Artery filosso- Pharyngeal Xeric Ascending Palatine Artery Tlivreohvoirt Muscle Internal Jugular Vein Spinal Ac- cessory Xerve Superior La- ryngeal Nerve Stemo-Ma- stoid Artery Common Facial Vein Omohyoid Muscle ExtJug.Veia Ster no -Thy- reoid Muscle Ansa Hypo- glossi Spinal Ac- cessory N. ^tipraclavicular Nerve ' Suprascapular Artery Superficial Cervical Artery ' Anterior Scalene Muscle Right Lymphatic Duct Thyreoid Cartilage Stcr no -Thyreoid Muscle Thyreoid Gland Cricoid Cartilage Inferior Tliyreoid Artery ScaleniisMe- dius Muscle Common Ca- rotid Artery Vagus Nerve Levator Sca- pulae Muscle ft- \ Trapezius Pectoral is Major Muscle Phrenic Xerve Thoracic Duet Oesophagus Recurrent X^er%*e Sternohyoid Muscle Recurrent Nerve Inferior Thyreoid Vein ^ Trachea Sterno -Mastoid Muscle Connecting Jugular Vein Fig. 61. Anterior Aspect of the Neck, Deep Layer. Adult. 7i Nat. Size. Rebmaii Limited, London. Rebman Comp.any, New York. Fig. 6i. Anterior Aspect of the Neck, Deep Layer. Adult. Position of the head as in last figure. T/ie Superficial Veins are left as stumps., both Sterno-Cleido- Mastoid Muscles are cut off near their attachments ; on the left side, Stemo-Hyoid, Sterno-Thyreoid and tipper belly of Omo-Hyoid Muscles have been removed. Both Submaxillaj-y Glands have been taken aivay : removal of the right Digastric Stylo-Hyoid and Mylo-Hyoid Muscles has given a good exposure of the fioor of the month from below. The Common Carotid Artery enters the neck behind the Sterno-clavicular articulation, externally to Trachea and Oesophagus. Slightl}' inclined outwards at first, it soon runs vertically upwards, without giving off an}' branches. At the level of the upper border of the Thyreoid Cartilage, it divides into External and Internal Carotid (just below the bifurcation, is the most suitable spot for liga- turing the Common Carotid, because it lies superficially here being covered onty by skin, Plat3'sma and Superficial Cervical Fascia). When the fascia is incised, the Sterno-Cleido-Mastoid Muscle drops backwards. External to the Artery lies the Internal Jugular Vein, which, when filled, covers the outer aspect of the Artery. It receives the Superior Thyreoid Vein and, above the bifurcation of the Carotid, the Facial Vein ; the Carotid Artery and Jugular Vein are enclosed in a common fascial sheath (Carotid sheath); they are crossed by the Omo-Hj'oid which runs downwards and outwards. In front of them lies the Descendens Hypoglossi. Between the Artery and ^^ein, somewhat posteriorly above, but more anteriorly below runs the Vagus Nerve. External to the Jugular Vein, the Phrenic Nerve descends on the Scalenus Anticus Muscle. The size of the Thyreoid Gland varies considerabl}' according to the frequency of Goitre in certain districts. The isthmus connecting the 2 lobes lies on the trachea, covering the 2ncl, 3rd and 4th rings. It may, however, extend higher up or lower down (cf. Fig. 62). It often gives off a process upwards, the Pyramidal Lobe (Pyramid of Lalouette) ; this lobe, as shewn in our figure, may also arise from one of the lateral lobes ; it often runs to the Hj'oid bone. The isthmus, being fixed to the trachea by connective tissue, follows the movements of that organ. This is of importance in the diagnosis of tumours of the Neck. The lateral lobes are covered by the Sterno-Hyoid, Sterno-Th3'^reoid and Omo- Hyoid Muscles. Their size varies markedly. They receive blood from the Superior Thyreoid Artery a branch of the External Carotid and from the Inferior Thyreoid Artery, which arises from the Subclavian and runs upwards behind the Common Carotid. The Larynx is subcutaneous, the Trachea lies under the skin at its com- mencement but runs to a deeper level the nearer it approaches the Thorax. In front of its upper portion is the Thyreoid Gland; lower down, fatty tissue; at this point the Thymus is just visible above the sternum in children. Fig. 62. Front View of the Neck, Deep Layer. Child. Child a few months old; head inclined backwards. On the left side, the super- ficial structures are displayed after removal of the Platysma; on the right side, the Sterno-Cleido-Mastoid has been cut off near its attachment. The Sternum has been removed between the middle of the Manubrium and the base of the Xiphoid, and with it the 2nd, p'd, 4th, ^th, 6th Costal Cartilages. The chief difference in this part between the adult and the child, is the Thymus which is large in the latter. This gland continues its development till the 2nd year, then degenerates or remains stationary till puberty. After puberty, it disappears rapidly; its lobes undergo fatty degeneration; there are, however, alwaj's masses of fat containing a few . remains of this glandular tissue present even in the adult. The shape of the gland varies much. There are usually 2 longitudinally placed lobes which are pointed above. The limits of the gland are: the level of the 3rd rib, and the lower border of the Thyreoid Gland. Below the Thymus is in relation with the Pericardium, its middle portion is covered by the Sternum ; between its outer portion and the thoracic wall, the pleural cavity and the lungs find their way. Above the pericardium, this gland is an anterior relation of the Arch of the Aorta, Superior Vena Cava and Innominate Veins. At a still higher level, it lies on the Trachea, being separated from the skin by Sterno-Hyoid and Sterno-Thyreoid Muscles; at this point it becomes an internal relation to the Innominate Artery, Carotid Artery and Internal Jugular Vein. This figure also shews some of the Lymphatic glands of the Neck and Thorax. The chief lymphatic channel, the Thoracic Duct, commences in the ab- domen, usually opposite the ist Lumbar Vertebra (Receptaculum Chyli, cf. Fig. 141). It runs vertically upwards on the right of the Aorta, passing through the Dia- phragm, and lying in the Thorax between the Aorta and Great Azygos Vein. Opposite the body of the 7th Cervical Vertebra it arches over the left Subclavian Artery and opens into the left Subclavian Vein (cf. Fig. 67). The corresponding structure on the right is the short right Lymphatic Duct which opens into the right Subclavian Vein. The great lymphatic channel on the right side is formed by the junction of the Bronchial, Mediastinal, Jugular and Subclavian Lymphatics; on the left, the Thoracic Duct receives the left Jugular and Subclavian Lymphatics which carry the lymph from the head and upper extremity. These last mentioned channels may open separately into the veins. Between the 2 bellies of the Digastric the Submental Glands are shewn ; on the Submaxillary Gland, the Submaxillary Lymphatic Glands are visible; at a lower level on the Internal Jugular Vein the Superficial Cervical Glands are seen (more about this group in Fig. 63, text). On the left side, some of the Inferior Deep Cervical Glands (cf. Fig. 115, text), and finally the Sternal Glands are shewn. These lie near the Internal Mammary Artery and its Venae Comites but are not found in all the interspaces. Their efferent vessels go to the mediastinal glands, to the great lymphatic ducts and to the lymphatics of the neck (cf. Fig. 115). 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CL ;:l^ <■•< a. ft Cfq 3- 3 " >3 TO < I rt 0 -^ — 3 — o_ '"0 ^ - S| ►fl o - re 3 o n ^ -I o re 03 o re -i c« y} re re a. p 3- re 3 CL CO 3 cr p" a- p o 3- re 3- re yj g. re 5-300 gS <3. « 3 - 3- S. p p 3 — cr CL 3' 3 «■ 3 3" re re PL > &' iii- S X re OJ 3" 3 f D ° re yj ?r p °-§ S o a 3 re I w -fl I G _. o 3- > re '^ 3' re o =; p 5. re 3 o 3 o o i e folio wi Axillary Axillary 1 ^ >3% 5 n) ■< 3 •13 Figgs. 73 and 74. Relation of the Capsule of the Shoulder-Joint to the Upper Epiphyseal Line. After von Brunn. Fig. 73. Frontal Section through the right Shoulder-Joint of a boy aged 8 years. Arm abducted to a right angle. Ai'm placed horizontally. Seen from in front. Above, on tlie outer side, tiie Capsule of tiie Shoulder-Joint does not extend as far as the Epiphyseal Line, but on the lower aspect the Capsule passes beyond the Epiphyseal Line on to the inner side of the neck of the Humerus. At the point marked *, the thin dark line shews how the Capsule is reflected .so that Separation of the Epiphysis does not necessarily open the Joint-Cavity. Fig. 74. Horizontal Section through the left Shoulder'- Joint of a boy aged 8 years. Arm abducted to a right angle. Arm placed horizontally. Seen from above. The section passed directly below the Spine of the Scapula and touched the lower border of the Acromion Process. The relation of the Capsule to the Epiphyseal Line is the same on the anterior and posterior aspects, as it is below (cf. Fig. 13). It is true that the Joint-Cavity extends beyond this boundary (only because the Capsule, arising from the Articular Cartilage, is attached for some distance to the Cartilage or to the Bone). The Epiphyseal Lines, Epiphyseal Boundaries or Epiphyseal Cartilaginous Discs are of great importance for many reasons. The longitudinal growth of the long bones takes place chiefly, if not exclusively, at these lines, i. e. at the Residual Cartilage between the Diaphysis (shaft) and the Epiphysis. This growing process is especially marked at puberty, but on the other hand, it is especially liable to be interfered with during the same period, by inflammation, which may result in the Separation of Diaphysis and Epiphysis. Traumatic Separation of the Epiphysis is not so frequent as Inflammatory Separation. Fractures usually occur near, but not (in) along the Epiphj'seal Lines. Excision of joints in children should only be performed with due consideration of the Epiphyseal Lines. Deltoid iluscle Epiphyseal Cartilage Clavicle Humerus Scapula Subscapular Muscle Fig. 73. Frontal Section through the right Shoulder-Joint of a boy aged 8 years. Arm abducted to a right angle. Nat. Size. — After von Brdnn. Acromion Humerus ' Scapula Fig. 74. Horizontal Section through the left Shoulder-Joint of a boy aged 8 years. Arm abducted to a right angle. Nat. Size. — After von Brunn. UclmiMn I^iniitoi], London. Rebnian Comp.my, New York. Subdeltoid Deltoid Muscle Bursa Humerus Coraco-Acromial Ligament Long Head of Bic Coracoid '. Muscle Coracoid Membrane CIa\icle Small Pectoral Muscle Bursa under Coraco- Bracbialis Muscle Humeral Branch of Acromio- Thoracic Arterj* Coraco- Brachiaiis Muscle Anterior f-ircuniflex -\rtery f-oraco- Brachialis ^luscle Great Pectoral Muscle ( epli;ilic Vein Deltoid Muscle Short Head of IJiceps Muscle Long Head of Biceps Muscle Vv Tro'hse Fig. 75. Anterior Relations of the Shoulder-Joint. Nat, Size. Rebnian Limited, London. Rebnian Company, Now Yoi'k. Fig- 75- Anterior Relations of the Right Shoulder-Joint. Skin and Superficial Fascia over the anterior portion of the Deltoid and the outer portion of the Pectoralis Major have been removed; the Deltoid has been cut below the Shoulder- Joint and thrown upwards and outwards. The Sub- deltoid Bursa (pink), the Joint, and the Sheath of the Biceps (light blue) have been opened. The middle third of the Clavicle and Subclavius Muscle, the Coracoid Process with the insertion of Pectoralis Minor Muscle and the common origin of the Coraco-Brachialis and Short Head of the Biceps are shewn. The Long Head runs through the Shoulder-Joint over the Head of the Humerus into the Bicipital Groove. Its synovial sheath always communicates with the Joint. Effusion and Pus in the Joint often extend into this sheath. Between the Capsule of the Shoulder-Joint and the Deltoid Muscle lies the Subdeltoid Bursa, which, as a rule , does not communicate with the Joint. Distension of this Bursa may easily stimulate fluid in the Shoulder-Joint. The fibrous strands running from the Coracoid Process to the Capsule and the wall of the Subdeltoid Bursa are called the Coraco- Humeral Ligament. They are covered in the figure by the much-distended Bursa. Between the Capsule and the Coraco- Acromial Ligament which forms a kind of protective roof for the Joint an important bursa, the Subacromial Bursa, is found. jV third large bursa lies between the Scapula and the Subscapularis Muscle : the Bursa Subscapularis usually communicates with the Joint (cf. Fig. 121). The Capsule of the Shoulder-Joint is wide and loose; it allows the Head of the Humerus to leave the Glenoid Cavity of the Scapula for a distance of as much as one inch. Above, this Capsule is attached to the neck of the Scapula; for the greater part, it is attached to tlie fibrcius ring which deepens tlie Glenoid Cavity (Glenoid Ligament). The Long Head of the Biceps arises from the upper part of the Glenoid Ligament. The Glenoid Cavitj' is not directed exactly outward, but somewhat upwards and forwards. When the arm hangs vertically downwards, only the lower portion of the Head of the Humerus touches the Glenoid Cavity articular surface of the Scapula, at least in dead bodies. The highest point of the Head of the Humerus lies at a distance of 0.15 — 0.25 inch from the highest point of the Joint Cavity. «> N IS •a CO o K O CO o u u > "3 SO o o 5 J S^ S o «fe § g § Is CO c3 y "5: ^ "« 15 <3 O ft. =3 ■» S 55 ^ o a o o T3 C a u o t: < a o o o OS ■a c Cl< .13 ft 3 in « CD > 0 'i^ 0 U3 CD > ■a s < I« s o o o c 2 '> ^ u o > D > o ai" (1/ (/I CS be c c > 0) in C ■ 4) C c en 0) ^ o ;z; S 3 JS C IS c a. H O 2 ^ ^ — ~ c c > 6 I- c -g E S) I — > '^ Co cS C ^ •- O, S E >< CU ^ u JS ^ "■ 73 ,D cS 0) 4) CS & CD P > g C & .i2 cu c fe E t: "I' <^ cS o ■> y 73 o Xt o c^ 2 en (D O O r^ 4,^ X tc ii ~ > s CJ X 4) 5 cj "* >\ 4-> J3 C I— I 41 II ^^ u I b .2 > OJ c c 01 ^> o o u 4> C O 41 .y o 5pp:^^ 4> IT-I 4) > o O O E o 5 S 'C ■S 'Q.Xi'< en en I « ;^ o cts c« ti >- »- ^ cot" -4-1 -^ LL, O U V 4) CU O 4) nj v^ 0) ■a "^ 5 • ^ u cS 00c cS (n in O 4> 41 4) 4) " 41 "5 I 4. - 4) O ""^ ft IIT c^ ^ X bo^ S 4) en <;-5 c cS C 4) > 4> cS 5 ^1 3 "^ C/2 4J O ^ ft — 03 "U 4) 1^ cS u O C "O n3 'o i: 4) I— I fi CS en 4) en •^ ,<^ 4) " S= ^ 4J 4J "be 4) ^ ■s 0 c cS 0 4) ■a en ft 41 (1) 3 t-H ^ ■n .a F c OJ ll n 3 ^ 4; > ii en i==H 41 s "^ CS u 'C o H o 4) 5J 0, t, 4> en i: -■ - •- o D d, c -3 ^6^ ii >, e5 41 10 i " bb ,S3 E 41 j§:^ c 4) •Sb 3 fe fe E o c . (U 4> en >-i 4) O U •—! ft S en .a ?^ ;s ^ IS S ^ E o 4) c O o . ■> en (S 3 O r- I* 4) ^ >^ O O cj 2 o O 4) 4> -B Ah p. ^+-« ft 4) 3 O CS « ft ^ en ^^ I-. . 4) en iS en :3 o C ^ CS ■5 CT' 41 > o E 4J 1 •" O -G ft.y P ^ .3 > -a Ph a> o 4) c o o P4 en (jj .2 is II 4i en 4) n in •3 2 cS a; 13 Ph •3 C cS , u 4J S cs -a "O o cS o 3 2 d 0 26 o -a 3 4) 4> en O 4) cS en CJ 3 0^ o ft 3 3 4) O in feg 41 i< .fl in C <^ OQ o a » o CO Ji O W2 '3, ^ eg O a CO 1^ I'osli-Tiur Circumflex Circumflex Teres I)flt«.i(l Mu-Jcle liunuTus Arterv Nrn-e ^rinor Muscle Ucltoid Muscle PosU-rior Axilliiiy Lymphatic Glands Icrcs Minor Muscle Latissimus Dorsi Muscle Posterior Cutaneous Branch of Circumflex Nerve Outer Head of Triceps Jjr'FrOhSe. Fig. 77. Posterior Relations of the Shoulder-Joint. Nat. 8ize. U(.'bin;iii LimitLMl, L(-'inlttji. Ucltmitii (■oinpniiy, Xrw York. Fig" 11' Posterior Relations of the Shoulder-Joint. Skin and Fascia have been removed over the posterior lialf of the Deltoid, of which a large portion has also been cut away. The Anterior and the Posterior Circumflex Arteries arise, opposite each other, from the last part of the Axillary Artery and wind round the Surgical Neck of the Humerus, the former from in front, the latter from behind. The Posterior Circumflex Artery passes through the Quadrilateral Space formed by the Teres Minor (above), the Teres Major (below), the Humerus (anteriorly) and the Long Head of the Triceps (posteriorly). It supplies the Teres Minor, Deltoid etc., and ends by anastomosing with the Anterior Circumflex. With it run its 2 Venae Comites of which onh^ the larger is shewn in the figure. Taking a similar course, but somewhat posterior, the Circumflex Nerve passes to innervate the Deltoid and Teres Minor Muscles and the skin over this region. Its large cutaneous branch emerges at the posterior border of the Deltoid Muscle and divides into an as- cending and a descending branch. On the Teres Major, below the Deltoid is a lymphatic gland which is prob- ably constant, — the Posterior Axillar}- Gland (FroHSE) — , it is usually subcutaneous ; in pathological cases, we have also found deep glands which lie on the blood vessels. Their efferent vessels pass through the triangular space, between the Teres Major, Minor, and Long Head of the Triceps, forwards to the Axilla. On the dorsal aspect of the trunk there are other subcutaneous lymphatic glands which are neither constant in position nor in number (cf. Fig. 145 and text). The Superficial Glands of the Thorax and Abdomen may be divided into Anterior, Posterior and External, according to their position. Anterior Glands: Clavicular Glands lying on the Clavicle, above the Deltoideo-Pectoral Fossa, sometimes also on the origin of the Sterno-Cleido-Mastoid Muscle. (Cf. Fig. 115.) Internal Pectoral Glands, usually at the level of the 2nd rib, along the inner border of the Breast (the blue gland in Fig. 114). The Xiphoid Gland, at the base of the Xiphoid Process (cf . Fig. 1 1 4). External Glands (i. e. external to the nipple line): External Pectoral or Paramammary Glands, outside the Nipple, and along the outer border of the Breast. The}- are intermediate glands for the lymphatics of the nipple (cf . Figs. 1 1 4 and 1 1 5). Thoraco-epigastric Glands (i — 4) along the External Mammary Vessels. One of these glands is nearly always palpable and sometimes visible through the skin. The most important of these glands are the Thoraco-epigastric. Para- mammar}' and Posterior Axillar}'. The subcutaneous position of the first mentioned is especially well noticeable when Langer's Muscle (i. e. a muscular connection between Latissimus Dorsi and Pectoralis Major) is present. Their efferent vessels run in this case along the free border of the AxiUary Fascia, where it is bounded by that muscle, before they open into the AxiOary Glands. The Shoulder-Joint is accessible for (operations) surgical measures from in front, and from behind. The Circumflex Nerve has, however, to be avoided on the posterior aspect, because injury would produce paralysis and atrophy of the Deltoid Muscle. 0) N CO =0 50 CO ■«sk 'O Co =0 <4i o o Co o x: +-» c , >—< 2 . fe -3 O OJ in fe ^ Xi (1) 4-> 5„ <. S 0. tn rO u, v., C C .£ .S ■3 -c Cti, c IS o o ni C • M TO 5 u u dJ •s s ■-1-. bo be _c '> J) -M in 0) in o -a 0) ■^ '-' in m s > lU c a ^« — Xi bi) ° X T3 H fc ^ ' 5 "a > O (V ;^ c ^ C a! « u -5 O K 11 ^^ in <; 3: ni O I—" D = 2 0) u oi c ■a ■> 4) c •a g -S ^ ■^ t5 fe-S "S x) o '■^ u ^- in X bo 15 C (U 2 -^ in ^"^ "^ 3 •— ■'-' in 3 C 300 in <« oi g, c O !> CJ 43 r- 0) •= ^ 4-> -t-» ni a> 43 43 " .9 oi +-» '<-' ri 43 C ■" 3 ?^£ 0) > bo 0) 43 > u 4) :?; c •5 c 3 &^^ -tJ 4J fe bo o; o >- u £ & fe ^^ „ 4" P3 ^ O £ 4J 4) <^ ID P 43 a> X c in ^ — o. 3 - aj o c a 3 2 S ■ S .■s 43 8 S ni b ^ £ ^ ^ -£ ^ o OJ 4) 1. "a o '*^ iH 15 4) [_| C " in > ^ £ o c o -(-J 4-J u < ni -a <1 m S 13 c ^ c ^ en -S " > a^ I- bo-S "^ c c o 43 § ^ £ o-^ rt 3 .0 4J 4) 43 Cu 43 ^ 13 15 •" ^ 3 n . ni « -S A « . 2 ^ iJ -S ^ -o ^ £ £ ^ in 4) •b: 43 >., a> -tJ u 43 13 £ 1- in CS 4) %.> a, 0) ni 43 ■*-» •a . c 'a ni 1- £^ 2 ^ lU tn >, 3 fj O 16 l-c 4) E u o M-* 4) 43 £ o S ;§ to" be c .2 '53 43 X B 4J c/) o 0) 4) -S bo ni 3 m "3 -r; iS •- ^ £ -22 53 43 o 4) 43 H 4; X ■B ^ 4) t-. in H-, o •-^ f^ o tJ 4) C 43 ni "t: ni" (3" r3 ^ < < 4) 4) ^5 41 4) cq o 42 ni ^ 0) 43 > ni ^ ni •^'t!^ P Ph ■o u c a ni c/) 4) 'in 0 > 4i" S 0 4) ■s 43 -M 4) in i^ 43 Q-X! in 4> c . .9 .3 -£ H ° 4. 4, -a HH 43 Oj *^ S X ni ^ nS 43 '5 2 -^^ E '-' ^ CO 43 ti £ 4) S 43 '-' ■^ 4J •; -^ in -M I-. oj -a >-, c ^ ni ni 4> c o 3 a) ■a o ^ o <« o I- W gj bo Q. 4) in 4) be ^ u u ni ni O I" „, 4) > -S ni D^ 4) in 1-" 41 O- 4) 41 Q 4> 43 0 0 ni ^ nae tery 1 0 4> 0 41 >3 > <1 d PQ 0 4) in m ( ) 43 .ti c ^ ^ ^ •|§ be in ni u O, >i 0 u 4) Jr; ■■!= n! i! 0 .51 -t-T CQ 4) ti! M-l 43 4) 41 ti > O S ni ^^ C ~^ ^ ^ " ;3 o b E" .ti boS <^ .£ ^ 2 "O 4J 43 b 43 MH g -^ o o in -w "i £ ^ 3 •- 5 ^^ 4) _ C ni <2 ° ^ T3 bo C "s ;^ ^ " 'in c » C ni in 8 ^ t4^ en 4) o .ni 43 ni W-, - O in £ "o 3 rt »- 4) <^ 43 ^ C/) ■ 4) 43 in •§ aj 15 ^-5 r % = •a I2; ij 4-) C • 1—* CO a c. G CC ^ ;_ <«l ^ C i- -^' S l 1 '^ ho — ._ Ph a 13 C5 Deltoid Muscle — Teres Elinor Miisrle Posterior Circumflex Artery Humerus Teres Major ^tiiscle I.ong Head of Triceps Superior Protunda .\rlery Coraco-Bracbialis Muscle Brachial Artery Musculo-Spiral Xerve — Ulna)' Nerve Tuuer Head of I'licep; Outer Head of Triceps Musculo-Spiral Groove Brachialis Anticus Muscle Cutaneous Branch of Musculo-Spiral Nerve Musculo-Spiral Nerve Brachio-Radialis {Supinator Longus) Muscle Posterior Branch of Radial Nerve Pig. 79. Outer and Posterior Aspect of Left Arm. — Nat. Size. Fig. 79. Left Arm, Outer and Posterior Aspect. Skin and Fascia have been completely removed ; a large piece of the Ottter Head of the Triceps, and the posterior portion of the Deltoid Muscle beloiv its origin have been cut away. The Long Head of the Triceps has been drawn down- wards and backwards. The Venae Comites have been removed. Below the Shoulder-Joint, from the anterior aspect backwards, amund the Surgical Neck of the Humerus, between the Teres Minor and Teres Major, the Posterior Circumflex Vessels pass (the Artery being a branch of the Axillary and having 2 Venae Comites). The Circumflex Nerve accompanies them ; it supplies the Deltoid and Teres Minor Muscles (cf. Fig. 77). Behind the outer border of the Humerus emerge tlie Musculo-Spiral Nerve and the Superior Profunda Artery, as they wind around the bone in the Musculo- Spiral Groove (cf. Fig. 80). The Nerve pierces the External Intermuscular Septum and runs downwards to the forearm, between the Brachialis Anticus and the Brachio-Radialis Muscles (cf. Fig. 81). This spiral course of the nerve is a serious obstacle in extensive operations on the arm (e. g. extensive scraping of the Humerus for Osteomyelitis). The Anterior and Internal surfaces are not favourable for operations, owing to the large vessels; on the Posterior surface the Musculo-Spiral Nerve is in the way, because its course is not a straight one, like that of the nerves in the thigh. Its close proximity to the bone explains why it is so often injured in fractures, and why it may be pressed upon by or be embedded in Callus-formation. The Ulnar Nerve runs for a short distance parallel to the Long Head of the Triceps. The Superior Profunda Artery anastomosing, by means of a Recurrent Branch, with the Posterior Circumflex Artery, supplies the Triceps and the Humerus (nutrient artery) and divides into an Anterior and a Posterior Division. The former accompanies the Musculo-Spiral Nerve and ends by anastomosing with the Radial Recurrent Artery. The latter runs in the substance of the Inner Head of the Triceps downwards to the Olecranon where it anastomoses with the Interosseous Recurrent Artery. Fig. 80. Transverse Section through the Middle of the Right Arm. A specimen from a series of sections taken from a frozen body. This section sliews the under surface of a right upper stump, or the upper surface of a left arm. For practical purposes, the former interpretation is to be preferred. Note : The relation of the Median Nerve to the Brachial Artery ; the Ulnar Nerve and the Musculo-Spiral Nerve winding round the bone. The External Intermuscular Septum is well displayed; the Internal is not distinctl}' visible in this section. The Flexors (Brachialis Anticus, Biceps and Coraco-Brachialis), are separated from the Extensors (Triceps) by the Intermuscular Septa. The Internal Septum runs along the inner border of the Humerus to the Internal Condyle. The External Septum extends from the insertion of the Deltoid Muscle downwards along the outer border of the shaft of the Humerus to the External Cond3'le. The Internal Septum is really the fibrous continuation of the Coraco-Brachialis (which passes in some animals to the Internal Condyle). The enormous Triceps presses these Septa forwards; in this section they are shewn to describe a curve with its con- vexity directed forwards. Both groups of Muscles thus lie in fibrous sheaths, formed by the Fascia of the arm, the Intermuscular Septa and the Periostium. Fig. 81. Transverse Section through the Lower Third of the Right Arm. Section through a right arm hardened in formalin. Interpretation similar to that of the section above (Fig. 80). Note the differences in shape, size, and position of the various structures, as compared with Fig. 80. Shape of the Humerus, of the Biceps, of the Brachialis Anticus, of the Triceps. — Change in the position of the Musculo-Spiral Nerve which has left the bone, of the Ulnar Nerve which has reached the Internal Inter- muscular Septum etc. In this figure, all the Fasciae are coloured blue. Thus the continuity of the Intermuscular Septa with the Periosteum, at the outer and at the inner border of the Humerus, and with the Deep Fascia is shewn. The latter binds down the muscles and forms thin fascial septa between them; i. e. between Biceps, Brachialis Anticus, Coraco-brachialis, and between the 3 heads of the Triceps. The whole arm is enclosed in the Superficial Fascia which is especially strong on the extensor aspect. On the Deep Fascia run, covered by the super- ficial fascia, the Superficial Veins and Nerves. Biceps Muscle l_ir;it"hialis Anticiis Muscle Musculu-Spiral Nerve- Superior Profunda Arterv jNIedian Norvc Outer Head of Triceps Internal C"utaTic«»us Nerve Hiailiial Artery Coraco-Bradiialis Muscle l7*3xCJP-r^^ Inner Head ni j ^,^r__^ I-T."^ — '^■C^^-^"'^'^ Triceps Muscle Inferior Profunda Artery Fig. 80. Transverse Section tlu'ough the Middle of the (right) Arm. View from li^low. Nat. Siz Biceps Brachialis Anticus Muscle Cephalic Vei Musculo -Cutaneous Nerve Brachial Artcr Median Nerve Musculo-Spiral Ncr\c Brachio-Radialis (Supinator Longus) Muscle Posterior Branch of Radial Nerve External Intermuscular Septum Inner Head of Triceps Internal Cutaneous Ner\e Bfisilic Vein Great Anastomotic ,\rtery Internal Intermuscular Septum Inferior Profunda Artery Ulnar Nerve Inner Head of Triceps Long Head of Triceps Outer Head of Triceps Tendon of Triceps Fig. 81. Transverse Section through the Lower Third of the Right Arm. Nat. Size. KebiiKin Limiteil, Louilon. Rebmau Company, New York. Lesser IiiltTiial Cutaneous 1^ ^ Nerve Ulnar Nerve IJasilic Vein Median Nerve Interniil Cutaneous Nc Median Basilic Ve: Bicipital Fascia Pronator Ratli Teres Muscle Flexor Carpi Radialis Muscle Internal Cutancttus I'.ianch nf the Musculo- Spiral Nerve Cephalic Vein Brachial Ailery Bracbio-Kadialis Muscle (Supinator Longusl Cutaneous liianch — of Musculo- cutaneous Nerve - Kadial Artery Se.fethti Fig. 82. Left Antecubital Space ~ Superficial Layer. Nat. Size. Kebman Limited, Loudon. Rebman Company, New York. Fig. 82. Left Antecubital Space. Superficial Layer. Tlie Skin over the knver part of the arm, and over the upper part of the forearm has been removed. The Superficial Fascia covering the Biceps and tlie Superficial Veins and Nerves have also been taken away, but the Bicipital Fascia and its expansions in the forearm are left intact. The superficial and broad Bicipital Fascia ends by an expansion into the Deep Fascia of the forearm and by blending with the Periosteum of the Ulna. The true Tendon of the Biceps is inserted into the Radius. The Superficial Muscles which arise from the Internal Condyle are intimately connected with the Deep Fascia and the Bicipital Fascia in the upper part of the forearm. Superficial Veins. At the upper end of the forearm 2 constant and one not-constant Veins are found: the Ulnar and Radial Veins, and the Median Vein. The latter vein divides into the Median Basilic, and the Median Cephalic Veins, the former joining the Ulnar forms the Basilic Vein, the latter joining the Radial forms the Cephalic Vein. These veins vary. As a rule, the Median Basilic Vein is the largest vein in the Antecubital Space, and the most suitable for Phlebotomy. The Cephalic Vein runs upwards in the arm and disappears between the Pectoralis Major and Deltoid Muscles, to join the Axillary Vein (cf. Fig. 75 and 76). It thus forms a collateral venous channel. The Basilic Vein joins the Venae Comites of the Brachial Artery and then forms the Axillar}' Vein, which, higher up, becomes the Subclavian (cf. AxiUa). The Median Basilic Vein is separated from the Brachial Artery b}' the Bicipital Fascia. The Arter}^ can therefore be injured in Phlebotomy, and this injury may be followed by an Arterio-venous Aneurysm. The 2 chief Cutaneous Nerves of the forearm, the Cutaneous Branch of the Musculo-Cutaneous Nerve and the Internal Cutaneous Nerve become super- ficial at the Antecubital Space. The latter nerve runs with the Basilic and Ulnar Veins. Its trunk and its branches lie in '/sth of all cases at a slightly deeper level than the veins. The nerve may have divided into 2 large branches, where it pierces the fascia of the arm. Fig. 83. Right Antecubital Space. Deep Layer. Skin, Superficial, and Deep Fasciae have been reinoi'ed. The following muscles are exposed: Biceps with Bicipital Fascia, Brachialis Anticus , as far as it is iiot-covered by Vessels and Nerves, the upper portion of the Superficial Flexors which arise from the Internal Condyle, especially the Pronator Radii Teres. The Brachio-Radialis ichicli has at its upper portion been drawn out- wards, is also displayed. (As to the superficial nerves and veins which have been left in this spe- cimen, see Fig. 82 text.) The Brachial Artery runs, accompanied by its Venae Comites, along the inner border of the Biceps, towards the acute angle formed by the Pronator Radii Teres and the Brachio-Radialis Muscles. In its course, — in front of the line of the joint — it divides into the more superficial and smaller Radial, and the more deeply placed and larger Ulnar Artery. Internal to the Brachial Artery (or rather to its Internal ^'ena Comes) runs the Median Nerve which may, however, lie more than 2/j,th inch internal to the vessel. This nerve pierces the Pronator Radii Teres and supplies the Superficial and the Deep Flexors of the forearm, except the Flexor Carpi Ulnaris and the inner portion of the Flexor Profundus Digitorum (cf. Fig. 89). Along the outer border of the Biceps runs, at a deeper level, the Musculo- Spiral Nerve; this Nerve lies between the Brachio-Radialis and Brachialis Anticus Muscles (cf. Fig. 89). The mass of muscles arising from the Internal Condyle of the Humerus and the portion of bone above it, and from the deep fascia of the forearm, sepa- rates lower down into the Pronator Radii Teres which is inserted at the middle of the outer border of the Radius, into the Flexor Carpi Radialis going to the base of the 2nd Metacarpal Bone, into the Palmaris Longus, which is not always present, and into the Flexor Carpi Ulnaris, which arises also from the Ulna. The lymphatic glands are described in Figs. 89 and 1 1 5 text. Ccphalit Win Biceps Muscle liiiichialis Anticus iluscle Cutaneous Branch of Musculo -Cutaneous Nerve Musculo-Spiral Nerve Deep Portion of Brachialis Anticus Muscle Recurrent Tibial Artery Tendon of Biceps Posterior Interosseous Nerve Supinator Brevis Muscle Radial Nervt Kiidial -Vrtery Deep Cubital Lymphatic Gland Internal Cutaneous Nerve Basilic Vein Superficial Cubital Lymphatic Gland Median Nerve Median Basilic Vein Companion Veins of Brachial Artery Internal Condyle of Humerus Brachial Artery Brachialis Anticus Muscle Bicipital Fascia Ulnar Artery Pronator Radii Teres Muscle Flexor Carpi RadiaUs Muscle — Palmaris Longus Muscle Flexor Sublimis Digitorum Muscle Dr.Frohse Fig. 83. Right Antecubital Space: Deep Layer. Nat. Size. Rebman Limited, London. Rebman Company, New York. Intcriiiil Cutinmus Xcrvc fireat Anastomotic Artcrv Inner Head nf Triceps Ulnar Nerve IJasilic Vein Brachial Artery ^ledian Basilic Vein Cntaneous Branch of Musculo -Cutaneous Nerve Cephalic Vcin- liicipital rasi'i.i. Ulnar Origin of Pronator^ Radii Teres Muscle Humeral Origin of Pronator^ Radii Teres ^luscle Biachialis Anticus Muscle ^ledian Xcrvc - Brachio-Radialis Musclc_ (Supinator Longus) Radial Artery Inferior Profunda Art;rti I It -Cutaneous Xervr Hicops Muscle Brachialis -Vuticus Muscle llicipital I'"ascia Tendon c»f Bircps Posterior Interosseous Ner\' Nerve to Extensor Car] Radialis Brevior Miisr' Ra' Supinator Brevis MuscI Ulnar Head of Pronat. . Radii Teres Muscle Humeral Head of Pronatn Radii Teres Muscle Rndial Nerve Brachio-Radialis (Supinator Longus) Muscle Radial Tymphatic Gland Radial Head (to 3rd Finger] of Superficial Flexor Muscle of the Fingers Anterior Interosseous Nerve. and Artery V^j^ Radial Artery Tong Flexor Muscle of Thumb. Pronator Quadratus ^fuscle Palmar Branch of ifedian Nerve Tendon of Flexor Carpi Radialis Muscle Tendon of Palmaris Longus Muscle Basilic Vein Suiierficial Cubital Lgl. Deep Cubital I,gl. Brachial Artery Posterior Culiitiil C;ianil Flrxoi Muscles Anterior Branch of Ulnar Recurrent Artery Anastomosis between Ulnar ;iik1 "Median Ner\'es < oninion Ulnar Recurrent Artery I'ppcr Belly of Superficial I-'Irxor of Index Finger Anterior Interosseous Arteiy Ulnar Lymphatic Gland Intermediate Tendon of Superficial Flexor of Index Finger Median Nerve Dee]j Flexor of Fingers Lower Belly of Superficial Flexor of Index Finger Ulnar Artery Ulnar Nerve Flexor Carpi Ulnaris Muscle Palmar Cutaneous Branch of —Ulnar Nerve Superficial Flexor Muscle of Fingers Dorsal Branch of Ulnar Nerve '^'Ci'--^^^***^^'*'^" Dr.Froh se Fig. 89. Right Forearm: Deep Layer. Anterior Aspect. — Nat. Size. Mcduin Xcrvc r;ilmaris Lon^ws Miis< Ir l'"l(^xor Carpi Radialis Muscle Radial Artery Pronator Radii Teres Muscle Brachio-Radialis (Supinator Longus) Muscle Superficial Flexor of tlio Finpcrs Ulnar Artery TTlnar Nerve Fli-xor C:irpi Ulnaris Mnsilc Deep Flexor of Fingers ('ommon Extensor of Fingers ^Xj^s^S^^.?- Posterior Interosseous Nerve Extensor of 5th Finger Extensor Ossis Extensor Carpi Uliiari^ Metacarpi Pollicis Fig. 90. Transverse Section at the Junction of the Upper and Middle Thirds of the (right) Forearm. Nat. Size. Superficial Flexors of Fingers 3rd, 2nd, (th, 5th Deep Flexor of Fingers (3rd, 4tli ami s^h) Palniaris Lougus Muscle , 1 i / Elexor Carpi Ulnaris Muscle Median Nerve j Flexor Carpi Radialis MuscU ^.„^ ___ , . ■. . Long Flexor of Thumb ^^'^'^^'^ r^ \ /^ V /''}} 4^ x"N/ Dors;.! Branch r,f Ulnar Nerve Radial Artery ^ / ^^ Q^ Cephalic Vein ^ X ^ ^^~^ _-^^^£:^^^ "! ^^ ,. Q5M Ulnar Artery lljndi Xervc Posterior L'inar Vein Brachio-Radialis (Supinator Longus) Muscle Extensor Ossis Metacarpi Pollicis Muscle Extensor Primi ^y^ /C^!!^^-~^ ^ Internodii PoIHcis Muscle / ^S2Llp* -^^^ Extensor Carpi Radialis Longior Muscle Extensor Carpi Radialis Brevior Muscle P4 o CO 0) u CO « •4-) O u bD o O bio fa ^ s S .8 .SJ ^ry as a. f-i ^ o <5 <0 fc E « o, O > 3 " g ^, 3 O XI -s ~ ■M .22 c ■« nj O >~. P m >^ O h B -i < ^ c ■a ni •? P^ p ^ 0) 0) • ^ J3 -g o c < r. O I- il2 3 ■" CO - ft o a! h o •o <1> c o (0 0) 6 1-4 •a c as m C 'S s^.b " .S O 3 •a c X! +-> bo c 1) c o o ni >\ IP 4) a *^ *-< (11 T^ J '*' el §" •-I 0) r/^ o a> ^> ^ TO +-> 'o ^ S B i3 o ■ <; A ■- E b (D -^ s • 5 be P 3 • E nj O C 3 o ■a 3 o H XI *-> 3 3 4-» 3 03 4) ni •5 O !5 Ci. (D ^■5 j;. XI E P -a 3 O Q in •S P be a; x; _ .2 '5 •a T3 >> O) t-* XT 2 ^ .2 > o ^H Oh' ■a : X2 3 C 4) ID T3 in "* .2 ? '^ in ^^ ' •!-' -^ ^ If) C Cl< Tl "^H S t^ 3 nJ U t; ^ '•B 'a 3 ■a rt 3 ai in 3 - in in I- =* 3 - OJ =* C -S .- 3 ■" 01 03 in u XI 0) ID ^"^ 8 in ^ 2 ID 73 O 0) 1- 3 OJ o 3 •" "^ ID in 1- 3 o ^ O- o Cl^ ID 3 ^ in •a "^ ^■% o y ID 0) •5 I in in ^ 4) 3 3 4) O > XI 41 4) >-. XI t. 2 1 4) T3 i. 4J -^ O ■y 4J n3 v^ n3 03 3 XJ in ^ E -^ box; " ID !-, ^ •~3 j_l to 3 «-! XI 3 0"^ <.S 3 IS .2 H w ■:;: . « in O o3 o3 ^ .y 4^ E 2 4J J^ P a; ^ fin -a bo 73 3 X! 4) O '3 3 4) .3 -n 4) « 03 3 iG 3 3 E S OS 3 h-1 ID " o J5 J= 3 ■" 3 in B<-g Lh . — 4) ■t! ■5 ^ /: OJ W x: .2" 3 o o •a C 3 4J 41 > C 0) XI be o' •S E 4) fe 41 O X3 D in O 1- &. -o ._ in 5^ a. a.i .i 3 N O 4) v^ :2 o XI ro nS ^ a. So Z o •< 3 ^ P 3 3 in O O 3 E in i! O _aj in 42 4) -n 3 XI o ■^ o "= in 03 •a 4) •a _« 03 « 'in "bio .^ .£ 3 ;3 c C « 4J .5 4J ^ ^ o «4H >> in 5 .•a o 3 in -M O 73 in c 2 o 41 •< •a 03 (^ 4) X! H o x: „ y in C/) 03 — !X in =! .-S & CJ aJ 4) "I a; ID o ^ XI ^ u 03 -^ & 4) Vj 4) ni t3 oj OS ^ 8 X! 4> t^ S O 4; XI H o 0^ - .Q E S ~ Tl f-rl ^' y w E o 1-1 tin O n in c 3 , 3 4> H W a) "O 4) ■a 0! 41 ■-5 H> o3 rd -3 03 aj XI H C t3 4> 4:3 3 3 O 4) CIh « § E S S 3 4> t4-l f-l -H .5 ,> C X! ^ -" T3 J 15 4J -a T! o oi t: 1-. '^ 41 " 4) &. >. a; W i^ x: oj t: 4) 3 X 4) ni 4) XI 4) XI xT S -a " 41 X! aj >, •5 '3 x; [^ a> -^ in ^ E I C != 2 -0 i ^ m >, 3 41 O X 4> ' 3 ni < 41 XI 1- w 4) > 4> 12; ■G X! X! —, --: -" ^ 13 03 rO 3 bi)i in XT^ 4) 4) XI in -w ^ -*- o o 10 XI in 71 S. 3 . ni ■a 3 ni ^ 4) 4) ■4-) y, 43 4J be •0 3 4-* 3 ft 3 0 o ^ Id .2 O pQ -a ni 2 5 -5 o > CJ in -Q 03 iS 5 " Fig. 93. Nerves and Veins on the Dorsum of the Right Hand. A fresh specimen, hi which only the skin has been removed. (The Veins and Nerves on the jrd finger have been drawn after RtrD/NGERs Atlas of the Ner- vous System.) Nerves: The Dorsum of the hand is supplied by Sensory Branches of the Radial and of the Ulnar Nerve. Their areae of distribution are not constant; moreover, there is, nearl}' always, at least one anastomosis, and thus an exchange of fibres occurs between these 2 nerves: this explains wh}- in injury, paralysis etc., the loss of sensation ma}' be very slight. In most cases they divide the Dorsum of the hand equally between them; the axis of the middle finger being the boun- dary between the 2 areae. The dorsal surfaces of the distal phalanges (2nd and 3rd) of the 4 inner fingers (2 — 5), and of the terminal phalanx of the thumb are innervated by nerves running on the palmar surface, thus the Median supplies the 2nd and 3rd phalanges of 3rd fingers completely, and the outer half of those of the 4th finger. The dorsal surface of the terminal phalanx of the thumb may, however, be innervated only by the Radial Nerve; there may also be Paccinian Corpuscles here, although these bodies 'are usually found on the palmar surface along the branches of Median and Ulnar Nerve (cf. Fig. 95 middle finger). There are no Motor Nerves on the Dorsum of the hand, because the Dorsal Interossei are supplied, like the Palmar Interossei, b)- the Deep Ulnar Nerve. Veins: The blood flows from the fingers on the dorsum through several (as many as to 4) Superficial Veins which begin at the first phalanges into larger venous channels, the Radial and Posterior Ulnar Veins. The former crosses the Tendons of the Extensor Primi Internodii, Extensor Secundi Internodii, and Extensor Ossis Metacarpi Pollicis (cf. Fig. 92) and then runs upwards on the anterior surface of the limb. The Veins and Nerves are quite superficial, i. e. they lie between the skin and the Tendons of the Extensors. The Posterior Annular Ligament (cf. figure) is formed by transverse and oblique fibres which strengthen the fascia of the forearm. This fascia becomes very thin in the dorsum of the hand (cf. Fig. 92, text). Fig. 94. Tendon Sheaths on the Dorsal Aspect of the Right Hand. Skin, Superficial Fascia, Vessels, except the Radial Artery, and Nerves have been removed. The Posterior Annular Ligament is intact, but supposed to be transparent. The tendon or synovial sheaths of the Extensor Tendons lie in special compartments between the Periostium of the bones of the forearm and the wrists on one hand, and the Posterior Annular Ligament on the other hand; they extend upwards as far as this ligament, i. e. as far as transverse fibres are present ; below, they extend 1^1^/4 inch beyond the ligament. The synovial sheaths may, however, extend higher (^/r.ths inch or more above the highest transverse fibres, vide infra). Starting at the outer (radial) side, and going inwards, we find 6 Com- partments and Sheaths for the Tendons of the following muscles: 1. Extensor Ossis Metacarpi Pollicis, and Extensor Primi Internodii; the sheath for the latter muscle is about y.^ inch longer than the sheath for the former. 2. Extensor Carpi Radialis Longior, and Extensor Carpi Radialis Brevior. 3. Extensor Secundi Internodii. The latter crosses the Radial E.x. tensors at an acute angle, lying on them, i. e. posterior to them. These three sheaths usually communicate, and are to be considered as forming practicall)' one sheath. 4. Extensor Communis Digitorum and Extensor Indicis. The two tendons for the index finger lie in one sheath which communicates with the common sheath for the 3rd, 4th and 5th fingers. The index sheath is, however, shorter. 5. Extensor Minimi Digiti. The sheath of this muscle, which sometimes has two tendons (cf. figure) is usually longer than the others mentioned above. 6. Extensor Carpi Ulnaris, this sheath is quite short, because the muscle ends at the base of the 5th Metacarpal Bone. The broad tendinous slips which connect the tendons to the 2nd, 3rd and 4th fingers are remarkable. Morphologically, they probably represent the form- ation of one broad aponeurosis, analogous to the one on the palmar aspect which is fully developed. Subcutaneous Bursae are shewn (cf. figure) on the 2nd and 3rd fingers. They are due to continuous pressure (professional bursae). The Tendon Sheaths accompany the movements of their tendons. The distal ends of those sheaths which belong to tendons inserted into the metacarpal bones, are easily determined. In order to find the distal ends of the others, the fingers should be completely flexed and hardened with injections of Eormalin. The proximal ends were determined, from another specimen, in the dorsi- flexed position with extended fingers (cf. the black and red lines above the posterior annular ligament). The length of the Tendon Sheaths varies according to the size of the hand. Those of the Extensors of the Carpus are the shortest and of about equal length (Vi5~Vi5 inch). The sheath of the Extensor Communis Digitorum which often contains several compartments, varies most (3^5 — 3-/5 inches). It is some- times longer in small hands than in large ones. The weakest tendons have the largest sheaths. Extensor Secundi Internodii, Extensor Primi Internodii, and Extensor Minimi Digiti; their respective lengths are: 2Y5 — 2%; 2^5 — 2V5; 2^1^ — 3Vf, inches. iLxtcnsor liidicis Muscl Ulna Extensor C;upi Ulnari: Muscle Extensor Minimi Digiti Muscle Extensor Communis Dif^torum Muscle -Vbductor Minimi Dij^iti ^luscle Subcutaneous Dorsal ^letacarpo-Phalangcal Bursa Extensor Carpi Katlialis Longior Muscle Extensor Carpi Radialis Brevior Muscle I Extensor Ossis Metacarpi PoUicis Muscle and Extensor Primi Internodii Pollicis Muscle Radial Artery Extensor Secundi Internodii Pollicis Muscle 1st Dorsal Interosseous Muscle Subcutaneous Dorsal Bursa on Index Finger Fig. 94. Tendon-Sheaths on Dorsal Aspect of Right Hand. Nat. Size. Kebman Limited, Londou. Rebmau Company, New York. Flexor Sublimis Digitorum Muscle fM\ W " l<'"li''l ^^tTVf Jhisrulo-Cut.iiKdUS XiTVi- Flexor Carpi Ulnaris JIuscU^ — |— r, Palraaris Longus Muscli- Dorsal Branch of Ulii;ir Krrve Ulnar Artery Ulnar Nerve Annular Ligament Deep Branch of Ulnar Nerve Transverse Carpal Ligament Palmaris Brcvis Muscl Superficial Palmar Arch Abductor Minimi Digiti Mnscle Kadial Artt-ry Pronator Quatlr.itii^ Miisclf Flexor Longus PolUcis Muscle Median Nerve Flexor Carpi Kadi.ilis Muscle Extensor Ossis Metacarpi PoHicis Muscle — Sftperficialis V'olac Artery Abduct'.r PoUicis TVriisch- \ Muscubir Branch of Mrdian Nerve l'"lexf>r Brevis PolUcis Muscle 4th Lumbricalis Muscle -Vbductor I'ollicls Muscle 1st Dorsal Interosseous Muscic Pig. 95. Palm of Hand (left) : Superficial Layer. Nat. Size. Rebman Limited, Luiidon. Rebman Coin))aiiy, New York. Fig. 95. Palm of Hand (Left); Superficial Layer. The Palmar Fascia has been removed almost completely, the Annular Ligament partly, and all the veins have been cut away. Arteries. At the wrist the Ulnar Arter}' lies between the Annular Ligament and the Transverse Carpal Ligament ; it may, at this point — in contiguity with the Pisiform Bone — give off the branch which joins the deep palmar arch, passing to the deeper layers in association with the deep branch of the Ulnar Nerve (Fig. 96). In the palm of the hand, covered onty by the palmar fascia, lies the Superficial Palmar Arch. This arch is formed by the continuation of the trunk of the Ulnar Artery, and is often completed by an anastomosing branch from the Radial Artery. (Cf. text, Fig. 92.) Nerves. In the lower part of the forearm the Median Nerve lies on the outer aspect of the Palmaris Longus Muscle, or in the case of absence of this muscle on the outer side of the Flexor Sublimis Digitorum Muscle. In the palm of the hand the nerve is more superficial than the tendons. (Cf. Figs. 103, 104.) The Median Nerve supplies the palmar (flexor) aspect of the three outer fingers and the outer border of the fourth finger whereas the Ulnar Nerve supplies the palmar aspect of the fifth finger and the inner border of the fourth finger. The Median Nerve supplies a) all the short muscles of the thumb except the Adductor Transversus Muscle and the Adductor Obliquus Muscle; b) the two Outer Lumbricalis Muscles, and a part of the third (which also derives a supply from the Ulnar Nerve — Bardeleben and Frohse). The Ulnar Nerve supplies a) a part of the third Lumbricalis Muscle as well as the fourth; b) all the muscles of the little finger; c) all the interosseous muscles; d) the Adductor Transversus Muscle and the x\dductor Obliquus Muscle of the Thumb. When the hand is slightly dorsiflexed (cf. text, Fig. 89) the Ulnar Artery and a part of the Ulnar Nerve are shewn above the Annular Ligament. The Tendons of the Flexor Sublimis Digitorum Muscle are arranged in two layers — those to the 3rd and 4th fingers are situated more superficial (cf. Fig. 91), those to the 2nd and 5th fingers at a deeper plane. The Median Nerve is contiguous to the tendon of the 3rd finger. The sheath of the Flexor Carpi Radialis Tendon is laid open at its proximal end ; the Extensor Ossis Metacarpi Pollicis sends a slip to the Abductor Pollicis Muscle. The Thenar Eminence is chiefly composed of muscles whereas upon the Hypothenar Eminence is a thick layer of fat containing a cutaneous muscle — the Palmaris Brevis Muscle. The Palmar Fascia is of great practical importance, — it is very tense and strong, bridging over the space between the Thenar and Hypothenar Eminences ; its intimate connection with the skin explains why the latter cannot be picked up and why celluhtis of the hand is dangerous. This dense fascia prevents the infective process from spreading towards the surface while the delicate tendon- sheaths and the loose tissue which surrounds them affords a favourable means of extension. Injury is well known to produce very free haemorrhage due to the abundant anastomosis in this region. The nerve supply is most complete, numerous Pacinian Corpuscles are observed (cf. Fig. 93). Fig. 96. Palm of Hand (Left); Deep Layer. In addition to those structures removed in Fig. pj, the distal portions of the Flexor Sublimis Digitorum and flie Flexor Profundus Digitorum (except in connection ivith the little finger) muscles, the Palmaris Longns Muscle, the Superficial Palmar Arch and the deep fascia of the hand have been cut away. A piece of the Abductor Pollicis Muscle has been excised, and the Pronator Quadratus Muscle exposed. The Deep Palmar Arch formed by the junction of the deep branch of the Ulnar Artery with the deep division of the Radial Artery lies at a deeper plane than the flexor tendons and the deep fascia, practicalh', in the middle between the superficial arch and the distal border of the carpal bones, on the bases of the metacarpal bones nearer the dorsal than "the palmar aspect of the hand (cf. Figs. 97 — 104). The deep division of the Ulnar Nerve accompanies the deep arch as far as the Adductor Transversus Pollicis Muscle and the ist Dorsal Inter-osseous Muscle, passing on to suppl}^ all the Interosseous muscles, having given off, in its course, the fibres to the Hypothenar Group of Muscles and the two inner Lumbricalis muscles. The tendons and their sheaths run in an Osseo - Aponeurotic Canal (cf. Figs. g8 — loi). Most important is the relation which the flexor tendons bear to the phalanges. When these tendons are divided near the base of the terminal phalanx no suture is required, as it is quite sufficient to fix the finger in the position of flexion; but if the division should occur at the intermediate phalanx, suture of the cut ends of the tendon is necessary. The Flexor Profundus perforates the Flexor Subhmis tendon at the first interphalangeal articulation ; accordingly at this point there are three tendinous strands. At the base of the first Phalanx (proximal phalanx) there are only two tendons to be sewn together. The flexor tendons are enclosed within a fascial canal and often retract considerablj' towards the muscular portion when divided. The distal end retracts to a marked extent when the injury occurs in extreme flexion (e. g. when a bottle breaks in the hand). Under such conditions it ma\' be necessary to open up the tendon-sheath which is relatively thin at the joints (where it is reinforced by a few delicate transverse and oblique fibres) but dense opposite the shaft of the first and second phalanges. In addition to the sensory communication shown in Fig. 95 as a loop around the Ulnar Artery and the motor communication in the 3rd Lumbrical Muscle, others occur. One inconstant communication occurs between the dorsal branch of the Ulnar Nerve and the branch to the inner aspect of the little finger. Another of greater constancy passes through the Adductor Transversus Pollicis Muscle where becoming more superficial it winds round the Flexor Longus Pollicis Muscle and joins the Muscular branch of the Median Nerve. Flexor Subliniis Digitonim Muscle y Flexor Sublimis Slip to Index Finger* ^ Flexor Sublimis Slip to Little Finger Flexor Profundus Digitoruin Muscle Pronator Quadratus iluscle Dorsal Branch of Ulnar Ner\-e^ Flexor Carpi TJlnaris Muscle Pisiform Bone Deep Branch of Ulnar Artery Deep Branch of Ulnar Nerve Deep Palmar Arch ^ 4th Lumbricalis ifuscle Palmaris Longus Muscle Supinator Longus Muscle Radial Artery -— Flexor Carpi Radialis Muscle Median Nerv; Flexor Longus Pollicis Muscle Extensor Ossis Metacarpi Pollicis Muscle uper Flexor Sublimis _ Digitorum Muscle Flexor Profundus Digitorum iluscle Abductor Pollicis Muscle Opponens Pollicis Muscle Muscular Branch of Median Nerve "'^''^P Ulead of Flexor ' Brevis Pollicis L-rficial) ^^"^'-"l*^ Palmar and Dorsal Inter- ^ osseous Muscle Adductor Pollicis Muscle 4th Dorsal Inter- osseous Muscle Flexor Longus Pollicis Muscle 1st Lumbricalis Muscle Transverse Metacarpal Ligament 1st Dorsal Inter-osseous iluscle Division of Flexor Sublimis Digitorum Tendon Chiasma Tendinum 2nd Phalanx of Index Finger Vincula Tendinum Flexor Profundus Digitorum Muscle Fig. 96. Palm of Hand (Left): Deep Layer. Nat. f^ize. Rebmaii Limited, Loudou. Rebmau C'oniiiaiiy, New Ymk. Fig. 97. Palm of Hand (Right) : Tendon-Sheaths and Large Arteries. '/j Nat. Size. Robiuan Limited, Londou. Rebman Company, New York. Fig. 97. Palm of Hand (Right); Tendon-sheaths and large Arteries. This diagram illustrates the Flexor Tendon-sheaths, the large Palmar arteries, the more definite furrows of the skin of the palm, in addition to the outlines of the bones of the hand, as shewn in a skiagram. The more definite furrows of the Palm of the hand present the appearance of M or W according to whether they are viewed from the inner or outer aspect of the limb. The initial upstroke of the M curves around the balls of the 3rd, 4th and 5tli fingers; the second upstroke (or third line) runs almost transversely across from the ulnar to the radial side of the hand. The second line, or initial downstroke joins the two upstrokes (ist and 3rd lines) of the M, and is variable in its continuit}'. The last stroke of the M skirts the Thenar Eminence. The third line is the most important guide for the superficial Palmar arch, whereas the first and third lines combined approximately mark the proximal limitation of tlie tendon-sheaths of the 2nd, 3rd and 4tla fingers. A further description of these tendon-sheaths is found in the text (Figs. g8— loi). The Tendon-sheaths become of great importance in inflammatory conditions. A whitlow originating at the proximal phalanx may invade the tendon-sheath at the base of this phalanx and extend to the palm, thus endangering the whole hand. At the Osseo-aponeurotic canal completed by the anterior Annular Ligament there is formed a constriction of the tendon-sheaths so that in such pathological conditions as Tuberculosis of the Tendon-sheath and Tenosynovitis the swelling presents a constriction at the Annular Ligament with an enlargement both above and below this structure. The fold between the hand and the forearm corresponds roughly to the wrist-joint which extends higher into the forearm with its convexity upwards. The groove between the first (proximal) and second (intermediate) phalanges corresponds to the joint, but the joint between second and third (distal) phalanges is situated Vio to V^ inch distal to the groove. Figs. 98 loi. Palm of Hand (Left); Tendon-sheaths. After JoESSKi. and von Rustih )|\ Flexor Carpi Radialis Muscle Extensor Sccundi Internodii Pol I ids Muscle Flexor Longus Pollicis ilusclc.^ Trapezium Extensor Primi Tntcrnodii I'ollicis Muscle Superficial Branch ot Radial Nerve Extensor Ossis Metacarpi Pollici: Muscle Tuberosity of Trapcziuni-- Opponcns Pollicis Muscl Abductor Pollicis Muscl Anterior Annular Ligament Extensor Indicis INIuscIe / Os Magnum / / Extensor Communis Digitorum Muscle Dorsal Branch of Ulnar Nerve Unciform Bon Extensor ]\Iiniini Digiti Muscle ^ Flexor Profundus Uigitorum ^luscle Extensor Carpi Ulnaris Muscle Abductor Minimi Digiti Muscle Opponens Minimi Digitt iluscle -—Ulnar Nerve — Deep Division ^ Opponens Minimi Digiti Muscle ""Hook of Unciform Bone Ulnar Nerve — Superficial Division I'almaris Brcvis Muscle Palmar Fasci. Ulnar Artery Fig. 103. Transverse Section through Carpus (Left): Distal Aspect. Nat. 8ize. Extensor Indicis ^lusclcajiEj Deep Palmar Arch Extensor Tendon to jrd Finger Deep Division Flexor Longus 1st Dorsal Intcr-osscons Muse Adductor Tiansversus Pollicis Muscle I'^xtonsor Secundi Internodi Pollicis Muscle Extensor Primi Internodi Pollicis Muscle 1st Metacarpal Bone Superficial Branch of Radial Nerve Princeps Pollicis Artery Opponens Pollicis Muscle Flexor Brcvis Pollicis Muscle Abductor Pollicis Muscle 1st Lumbrical Muscle Median Nerve — Digital Branches osseous Muscle Inter-osseous Muscle 4th Lumbrical ilusclcs Dorsal Branch of Ulnar Nerve Deep Palmar Fascia Deep Dorsal Fascia Extensor Minimi Digiti Jluscle Ulnar Artery Flexor Profundus Tendon to Little Finger Opponens Minimi Digiti // y Abductor ^Minimi Digiti •^ J J Flexor Minimi Digiti Digital Branches of Ulnar Nerve Palmaris Brevis Muscle Palmar Fascia Fig. 104. Transverse Section through Palm of Hand (Left) : Distal Aspect. Nat. Size. Rebmau Limited, LouiJou. Rebman Company, New York. Supra-clavicular Branches Lateral Cutaneous Bran< hes of Intercostal Nerves (Intercosto- Humeral Nerve) Cutaneous Branch of Circumflex Nerve Anterior Cutaneous Branches of Intercostal Nerves Internal Cutaneous Nerve and Lesser Internal Cutaneous Nerve (Nerve of WrisukiiO) Upper External Cutaneous Branch of the Musculo-Spiral Nerve ^ledian Nerve Lower External Cutaneous Branch of the Musculo- Spiral Nerve Cutaneous Portion of Musculo-Cutaneous Nerve Anterior Division of the Internal Cutaneous Nerve Palmar Cutaneous Branch of Median Nerve Radial Nerve Palmar Cutaneous Branch of Ulnar Nerve Ulnar Nerve Supra-clavicular Branches Posterior Cutaneous Branches of Inter- costal Nerves Lateral Cutaneous Branches of Inter- costal Nerves Cutaneous Branch »f Circumflex Nerve Internal Cutaneous Nerve and Lesser Internal Cutaneous Nerve (Nerve of Wrisbf.rg) Upper External Cutaneous Branch of the Musculo-Spiral Nerve Posterior Division of the Internal Cutaneous Nerve Lower Externa! Cutaneous Branch of the Musculo-Spiral Nerve Cutaneous Portion of Musculo-Cutaneous Nerve Fig. 105 and 106. Areae of Distribution of Cutaneous Nerves of the "Upper Extremity (Right). Rpbman Limited, London. Rebman Company, New York. Fig. 105 and io6. Areae of distribution of Cutaneous Nerves of Upper Extremity, (right). Outlines of Figs, after Fau's Atlas. Colours correspond to those employed for the spinal segineiiis in the subsequent figures. Unfortunately the areae of distribution of the nerves of the hmb and their variations have not been completely worked out, as in the case of the Head and the Trunk by Frohse and Zander. For practical purposes the diagrams will probabl}' suffice. The upper part of the shoulder (green) is supplied from the Cervical Nerves. The front of the chest is supplied by the Anterior Branches of the Intercostal Nerves (yellow) , the back by the Posterior Branches. The Lateral Branches suppl\^ the Axilla and even the upper part of the inner aspect of the arm. When the arm is supinated the anterior boundary between adjacent areae of distribution extends down the middle of the anterior aspect of the arm to the tip of the 4th finger. But the posterior boundar}' line runs down the middle of the arm to the 3rd finger. The following points should be observed : — The upper part of the shoulder is supplied b}- the Supra -Clavicular and Supra-Acromial Branches of the Cervical Plexus. The lower part of the shoulder by the Circumflex. Below this level the Musculo-Spiral supplies the skin on the outer aspect of the arm corresponding to the area supplied b\- the Internal Cutaneous (red) and Lesser Internal Cutaneous Nerves on the inner aspect. (A further internal branch from the Musculo-Spiral Nerve — Gegenbaur — may assist in com- pleting tlie supply of this region.) On the inner part of the anterior (flexor) surface of the forearm is to be found the Internal Cutaneous Nerve, the dorsal branch of which supplies the inner aspect of the posterior (extensor) surface; on the outer aspect of the back of the forearm the chief nerve is the Radial, only a very small area being supplied by the Musculo-cutaneous Nerve. In the palm of the hand the cutaneous distribution of the Median (violet) and Ulnar (brown) is divided by a line which runs along the axis of the 4th finger. Special branches from the Median and Ulnar Nerves supply smaU areae in the upper part of the Palm. On the outer side a small area of the Thenar eminence is supplied by the Radial Nerve. The Dorsum of the hand is supplied equally by Radial and Ulnar Nerves, but where these become wanting in the case of the 2nd, 3rd and 4th fingers, their deficiency is made up by the Median Nerve. (Cf. Fig. 106.) Figs. 107 and 108. Cutaneous Nerves, according to their Segmental (Spinal) Origin. The nerves distributed to the upper extremit}' are derived from the segments -- 4th Cervical and 2nd Dorsal inclusive. The distribution is such that the upper segments pass to the outer side and the lower the origin of the nerves, the more internal is their distribution. The thick black lines situated on the Anterior and Posterior aspects of the arm indicate the boundary between the rostral and caudal parts of the limb, the correct continuation of this line on to the forearm and hand is not yet defined. WiCHMANN is of opinion that it should continue between the dark-blue and violet areae to the distal end of the ist Metacarpal bone on both the anterior and posterior aspects. The segmentary distribution over the attachment of the limb to the trunk differs in front and behind. The posterior divisions of the Cervical Nerves ramify over the posterior aspect: VIII. C and i. D have, as a rule, no posterior division, so that 2. D follows VII. C; again, i. D has not usually even an anterior division, so that the 2nd intercostal nerve foUows directly upon the Supraclavicular branches distributed to the chest. The boundaries between the intercostal nerves are diagrammatic in the figure inasmuch as only the middle V.f of ^ colour accurately represents the nerve indicated, the upper and lower thirds being the upper and lower association areae of the nerves. In the limb the limitations are much less definite than indicated; moreover there are many variations particularly on the inner side where the red area may be far more extensive and with the brown may pass even as far as the 4th finger. The following segments correspond to the different nerves. IV. C: — the supra-clavicular nerves. V. C (VI. C): — the cutaneous branches of the circumflex. (V. C) VI. C, VII. C (VIII. C) : - the cutaneous branches of the Musculo-Spiral. VI. C : — the cutaneous branches of the Musculo-Cutaneous. On the inner aspect of the limb the Dorsal Nerves enter at the upper part, the Cervical Nerves at the lower. The Intercosto-humeral belongs to the Cervical Plexus if one takes the 2nd Dorsal segment as belonging to this Plexus. The Interna] cutaneous is chiefly derived from i. D and VIII. C. The violet band (VII. C) gives the boundary between VI. C and VIII. C as these nerves ramif}' over this area. The area of the Median and Ulnar Nerves in the hand are not accurately' defined. The dorsal branch of the Ulnar Nerve chiefly contains VII. C , the palmar branch VII. C (only represented in the figure) and i. D. The Palmar branches of the Median Nerve correspond to VI. C and VII. C, the digital branches to VI. C, VII. C, VIIL C (the nearer to the inner side, the lower is the origm of the fibres in the cord). The outer side of the 4th finger ma}- even be partially supplied b)' i. D. Pigs. 109 and no. Nerve-Supply of the Muscles of the Upper Extre- mity, according to their Segmental (Spinal) Origin. The segments are given partly according to WICHMANN and BOLK, partly after ZIEHEN. In the text, Arabic figures represent the Cen'ical Segments, the first Dorsal is indicated by n Roman I. Coloiin as in Figs. loy and 108. The ventral muscles of the superficial layer of the shoulder-girdle are the Sterno- Mastoid and Pectoralis Major; those of the deep layer the Subclavius and Pectoralis Minor. That portion of the Spinal Accessory Nerve which supplies the Stemo-Mastoid Muscle contains 2. C. and 3. C. The Anterior Thoracic Nerves divide into several branches; the upper segments are for the Pectoralis Major 5. C, 6. C, 7. C. (Clavicular portion 5. C), the lower segments are for the Pectoralis Minor 7. C, 8. C. ; 8. C. in some cases also supplies the lowest fibres of the Pectoralis Major. The Nerve to the Subclavius Muscle is composed uf fibres derived from 5. C. and 6. C. The superficial layer of the Extensor Muscles of the Shoulder-Girdle is composed of the Trapezius and Latissimus Dorsi ; in the majorit\- of cases the Spinal Accessor)' Nerve to the Trapezius Muscle contains 2., 3. and 4. C, the long Subscapular Nerve to the Latissimus Dorsi Muscle 6., 7. and 8. C. The other Subscapular Nerves to the Teres Major Muscle 5., 6. (and 7.) C. ; to the Subscapularis Muscle 5. and 6. C, the Supra- scapular Nerve to the Supraspinatus Muscle 5. C, to the Infraspinatus Muscle 5. and 6. C. The deep layer is composed of the Serratus Magnus with Bell's Nerve 5., 6. and 7. C. ; Levator Scapulae (3.) 4. and 5. C. and the Rhomboid Muscles 5. C, possibly further fibres from 4. C. to the Rhomboideus Minor Muscle. Of the mixed nerves, the Median contains fibres derived from each segment, 5., 6., 7., 8. C. and I. D. — (though 5. C. probably contains Sensory fibres only). — The motor part of the Musculo-Cutaneous Nerve contains fibres from 5., 6. and 7. C. ; the Ulnar Nerve usually 7. and 8. C. and I. D. or 8. C. and L D. only. The motor part of the Circumflex 5. and 6. C. The motor part of the Musculo-Spiral (5. C.) 6., 7. and 8. C. Musculo-Cutaneous Nerve: Coraco-Brachialis Muscle 6. and 7. C; Biceps Muscle 5. and 6. C. ; Brachialis Anticus Muscle 5. and 0. C. This last named muscle has a double Nerve-supply as it also recei\'es fibres from the Musculo-Spiral Nerve (derived from the same segments). Median Nerve: Pronator Radii Teres Muscle 6. and 7. C. ; Flexor Carpi Radialis 6. and 7. (and 8.) C. ; Palmaris Longus 7. and 8. C. and L D. ; Flexor Sublimis Digitorum 7. and 8. C. and I. D. ; Flexor Longus Pollicis 6., 7. (and 8.) C. ; Pronator Quadratus (6.) 7. and 8. C. and L D. ; Muscles of the Thenar Eminence 6. and 7. C. The two outer Lumbrical Muscles are usually considered to be supplied from 8. C. and L D. segments. Ulnar Nerve: Flexor Carpi Ulnaris Muscle (7.) 8. C. and I. D. ; the outer (radial) portion may also be supplied b\' the Median Nerve (Frohse) thus having a double Nerve-supply, like the following muscle; Flexor Profundus Digitorum (Ulnar and Median) 7., 8. C. and I. D. The deep portion of the Ulnar contains 8. C. and I. D., but chiefly 8. C. ; at the Hypothenar Eminence even the 7. C. may take part (Bolk). For the Motor Anastomosis between the Ulnar and Median Nerves cf. Figs. 84 and 96. The Circumflex Nerve contains fibres from the 5th and 6th Cervical Segments. The small area of Deltoid Muscle coloured green denotes the probabilit}', as evidenced by clinical observations, that fibres from 4. C. supply this portion (Ziehen). The Anterior part of the Deltoid mav be supplied by the Anterior Thoracic Nerves (Anastomosis with the Circumflex, Frohse). The nerve to the Teres Minor Muscle usually only contains 5. C. I for Long Head of Triceps 6., 7. and 8. C. for Outer Head of Triceps 6., 7. (and 8.) C. for Inner Head of Triceps (6.), 7. and 8. C. for Anconeus 7. and 8. C. Brachio- Radialis (Supinator Longus) 5. and 6. C. Extensor Carpi Radialis Longior and Brevior (5.) 6. and 7. C. Supinator Brevis 5., 6. (and 7.) C. Extensor Communis Digitorum and Extensor Minimi Digiti 6., and 7. and 8. C. Extensor Primi Intemodii Pollicis 6., 7. (and 8.) C. Extensor Indicis 6., 7. and 8. C. Extensor Secundi Internodii Pollicis 6., 7. (and 8.) C. (in Bolk's case 7. C. only) Fig. III. Thorax and Abdomen. The Trunk is divided into two chief divisions; the upper is the Thorax (Chest) and the lower is the Abdomen (Belly). The superficial line of separation between these two regions follows the lower margin of the bones and cartilages which comprise the thoracic cage, but this surface marking by no means indicates the relative size of these cavities. This curved line only shews the attachment of the base of the diaphragm which is in constant movement so that the capacity of these cavities is ever varying and the position of the more movable viscera alter accordingly. Certain points and connecting lines are employed in order to subdivide these regions and thereby endeavours are made to traverse or map out certain important viscera or visceral domains. The most important lines and regions are marked in the figure: to the black lines have been added red lines in order that the most important Con- tinental and English guides may be pictured. The reader is however strongly recommended to appreciate the multi- plicity of visceral surface markings b}' reference to the following authorities: Atlas of Human Anatomy, TOLDT. Textbook of Anatomy, Cunningham. QuAlN's Anatomy. Surgical Anatomy, Deaver. Fig. 112. Frontal Section through the Trunk. Frozen Section. The anterior surface of the second section of a series of Ver- tical Frontal Sections seen from in front. The Thoracic and Abdotninal Viscera are in their position at extreme expiration which is never reached during life. Atmospheric pressure has driven the intercostal spaces inwards so that the outlines of Pleura and Lung are undulating. A frontal section shews much better than a transverse section the different cavities derived from the general (Coelomic) Cavity of the Embryo. The formation of the Diaphragm results in a division into Thoracic and Abdominal Cavities. There is really no Thoracic Cavity but a Thoracic Bony Cage. As the pericardium is pushed downwards from the neck into the Coelom, 3 completely independent cavities are estabhshed: i) Pericardial Cavity, containing the Heart and a part of the large vessels. 2) Left Pleural Cavity with the Lung. 3) Right Pleural Cavity with the Lung. It is the practice of many anatomists to call the space between the Left and Right Pleural Cavities the Mediastinum, — according to this the Heart would be in the Mediastinum (Middle). But if three independent cavities are recognized there remain two spaces communicating above, one in front of and one behind the heart — the Anterior Mediastinum and the Posterior Mediastinum — . The Anterior Mediastinum is further divided by the overlapping right and left pleurae (cf. Fig. 116) between the 2nd and 4th ribs into an upper and lower compartment with free communication. Above the Mediastina communicate freely with the spaces between the structures of the neck. The complementary spaces shewn in the figure between the Thoracic Wall and the Diaphragm are only occupied by the Lung during inspiration. The Pericardium is a closed sac consisting of a visceral layer closely enveloping the heart and the roots of the large vessels and a parietal layer directly continuous with the former but blending with the Mediastinal Pleura, the Diaphragm and the Anterior Thoracic Wall. The Pleural Sacs are two closed cavities, consisting of a visceral layer which at the root of the lung blends with the parietal layer. This parietal layer lines the thoracic wall — (Costal pleura) — the pericardium — (Pericardial pleura) — the diaphragm — (Diaphragmatic pleura) — and the mediastinum — (Media- stinal pleura) — . The uppermost part of the pleura which reaches from V2 to 4/5ths inch above the first rib is the Apical Pleura (this is not shewn in the figure because it lies behind the plane of section). (Vide Figs. 70, 121, 126.) Fig. 113. Upper Aperture of Thorax. The upper part of the Sternum, the ist and 2nd Costal Cartilages and the -muscles attached to these have been removed. The Clavicles and Ribs have been pushed down to their full extent. The Pericardium is exposed. The Thymus and Thyreoid Glands have been cut away, together with tlie Bronchial Lymphatic Glands. The Inferior Thyreoid Vessels are divided and the cervical fascia dissected away. The following structures pass upwards or downwards through the superior aperture of the Thorax. Vessels. The right Common Carotid Arterj' rising from the Innominate Artery. The Left Common Carotid a direct branch of the Arch of the Aorta. The Subclavian Arteries at first pass upwards into the neck and then to the Axilla. To the right of the Arch of the Aorta lies the Superior Vena Cava formed by the junction of the Right and Left Innominate Veins, which pass behind the Sterno-Clavicular Articulation and the Manubrium Sterni. The Innominate Veins are formed by the junction of the Internal Jugular and Subclavian Veins. The large veins are situated to the outer side and in front of the main arteries. The Lymphatic Duct (the chief lymphatic channel) after passing upwards in the posterior mediastinum where it is situated between the Aorta, Large Azygos Vein and Oesophagus directs its course away from the Vertebral Column obliquely upwards and to the left side of the neck; here, under cover of the deep cervical fascia it forms an arch and finally opens into the Left Subclavian Vein (cf. Fig. 67). Nerves. The Phrenic Nerve derived from the 3rd, 4th and 5th Cervical Nerves (chiefly the 4th) runs obliquely across the Scalenus Anticus Muscle to the outer side of the Internal Jugular Vein, then behind this vessel between the Sub- clavian Vein and Artery (Figs. 67 and 70). The Right Phrenic Nerve runs to the outer and anterior aspect of the Vena Cava Superior, between the Pericardium and Mediastinal Pleura, along the right border of the Pericardium to the Diaphragm. (Coronary Ligament of I.iver. Liver and Abdominal Wall.) The Left Phrenic Nerve takes a greater cun'e in its passage from the Neck into the Thorax owing to the asymmetry of the large vessels and is situated on a deeper plane than the right, owing to the rotation of the heart to the left, in its course between the Pericardium and Pleura to the Diaphragm (cf. course of Phrenics in Fig. 122). The Vagus or Tenth Cranial Nerve 'running between the Carotid Artery and Internal Jugular Vein at first passes downwards and slightly backwards but soon inclines forwards to the right and in front of the Right Subclavian Artery, on the left side in front of the Subclavian Artery and Aortic Arch. Both Vagi accompany the Oesophagus in its lower part and through the Oesophageal Opening into the Abdomen on to the walls of the Stomach. The left Vagus merges gradually to the Anterior Aspect whereas the right Vagus becomes directed to the Posterior Aspect of the Stomach; this results from the developmental rotation of the Viscus to the right. From each Vagus is given off a Recurrent Lar}'ngeal Nerve (Motor Nerve to Muscles of the Larynx); the right recurrent nerve looping around the Sub- clavian Artery whereas the left recurrent ner\'e winds round the Ductus Arteriosus at its connection with the Arch of thePAorta; each nerve ascends upwards by the side of the Trachea (cf. Fig. 6q). Viscera: The Trachea bifurcates opposite the 4th or 5th Dorsal Vertebra into Right and Left Bronchus under cover of the large vessels. The Oesophagus is shewn in the figure to the left of the Trachea. Cricothyreoid Vessels ("ricothyreoid Muscle^ Superior Thyreoid Vessels Sternohyoid Muscle Thyreohyoid Cricoid Muscle Curtilagf Thyreoid Cartilage Mertian Vein of Neck Omohyoid Muscle Cricothyreoid Ligament (Ligamentum Conicum) ,Thyreohyoid Muscle Inferior Thyreoid Vessels Recurrent Laryngeal ^^- Ncrve ^- Middle ThjTeoid Vein Antnirir jvi^jular Vein I Thyreoid Ciland Sterno- cleido- mastoid Muscle Rt-current L;iryngcal j N erve i rtirenic Nerve Pectoral is ^lajor Muscle Internal Mammary' Vessels Body of Sternum Pericardium -2nd Rib Internal Intercostal Muscle Fig. 113. Upper Aperture of Thorax. Nat. Size. Bebmau I^imited, Loudou. Rebman Company, New York. / Kxternal Jijg^ilar Vein Thoracic Duct Subclavius ^luscle Deltoid Musrie Pectoralis Minor Musrie Cepbalit: Vein Pectoralis Major Muscle T.atissimusDorsi Muscle ] Teres Major Muscle Intercosto-Humeral Ner\e Subscapularis Muscle i Subscapular Vessels j I Long Thoracic Nerve Scrratus Magnus Muscle (4th Rib) Breast External ^lainmary Vessels External (Jblique Muscle uf Abdomen toralis Major Muscle Sheath of Rectus Abdominis Muscle "3"i'^'*'^-j-' "^'^ Fig. 114. Lymphatic Glands connected with the Mamma in an Adult. Vo Nat. Size. Rebman Limited, London. ReljLuan Company, New York. Fig. 114. Lymphatic Glands connected with the Mamma in an Adult. This figure is not drawn from a dissection but is a diagram constructed from viany sources. (Essay by Frohse on the Axillary Lymphatic Glands.) — On the right side the superficial layer, on the lefit side the deeper layer and the breast with its bloodvessels and lymphatics are shewn. A large part of the Pectoralis Major Muscle and the Clavicle have been removed. — The internal set of glands are coloured blue, the external not coloured, the intermediate green and the deep red. It is absolutely necessary to adopt a definite and universally applicable classification ot the Axillary Lymphatics in order to readily comprehend their distribution. The number of Glands varies enormously (8 to 43) and into these enter the afferent Lymphatic Vessels from the Thorax and Arm. Of the afferent lymphatics which come from the Thorax, those from the Mammary Gland have the greater practical importance. A superficial and a deep set, separated by the Intercosto-Humeral Nerve and the External Mammary Vessels can be made out. The first regional gland for the lymphatics of the Breast lies, when the arm is ab- ducted to a right angle, just below the free border of the Pectoralis Major Muscle at the level of the 3rd rib. An inconstant deep gland is sometimes present; this Paramammary Gland is depicted in the figure at the outer border of the beast. By Lesser enlargement of this gland is considered characteristic of Syphilis. Usually from the Breast the Lymph passes through i to 4 glands which lie under cover of the Pectoralis Minor Muscle, parallel to the inner side of the Axillary Vein. Thus it passes through several smaller glands — Subpectoral and Subclavian Glands. In rare cases, which one should always bear in mind, lymphatic vessels pass between the two pectoral muscles and are associated with an Interpectoral Gland. But the more usual connection lies with the neighbouring External Gland called the Intermediate. Fortunately there seldom exists a direct communication with the deep glands, the Subscapular Glands and thence along the nerve to the Latissimus Dorsi Muscle. When this group becomes affected, the Neuro-Vascular bundle cannot well be left untouched in the course of a operation inasmuch as it is very frequently surrounded by the lymphatics (v. Origin of Subscapular Artery). The lymph from the arm passes usually with the superficial vessels to a gland which lies (cf. Fig.) on the Axillary Vein; thence under cover of the Pectotalis Minor Muscle along the outer side of the vein. A lymphatic channel may accompany the Cephalic Vein and disappear in the Infra- clavicular Fossa, between the Deltoid and Pectoralis Major Muscles, to enter a Deltoideo- Pectoral (Infraclavicular) Gland. The Deep Lymphatics lie partly on the Subscapularis Muscle, partly along the outer Thoracic Wall — the Subscapular and Thoracic Glands. Accordingly it becomes advisable to classify the glands of the Axilla in the follow- ing way : A. Superficial Glands. Pectoral, Intermediate, Brachial, Infraclavicular (Deltoideo-Pectoral). B. Deep Glands. Subscapular. To these regional sets of glands the following intermediate glands have to be added: Subpectoral, Subclavian and Thoracic. An important variation in the Pectoral Glands is the presence of an Interpectoral Gland. Apart from the usual lymphatic channels leading to the Axilla there are two (blue) other important 13'mphatic vessels which in obstruction or removal of the former carry lymph from the lower border of the breast to the Umbilicus, or to the Internal Mammary Artery. From the supero-internal part of the Breast, lymphatics run into the Superficial Internal Pectoral Gland whence the lymph may travel into deeper regions. On the other hand, lymphatics may emerge towards the surface and connect the Internal Mammary Lym- phatic Glands with the Superficial Glands of the Axilla. 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The Parietal Pleura consists of the Costal Pleura, the Diaphragmatic Pleura, the Mediastinal (including the Pericardial) Pleura and the Apical Pleura. The knowledge of the reflections of the Pleura, i. e. the lines upon the Anterior Thoracic WaU at which the Costal Pleura becomes the Diaphragmatic and the Mediastinal Pleura — cf. dotted lines in the figure — is important. The Anterior (Median) Boundary of the right costal pleura extends from the upper margin of the ist costal cartilage at an angle of 45" downwards and inwards to a point Vio^h to i inch to the left of the middle line at the angle of the Sternum (Junction of Manubrium and Body of Sternum). From this point it continues downwards in a vertical direction, gradually approaching the middle line at the level of the 5th Costo-Sternal Articulation ; from this point its course is slightly downwards along the lower border of the 6th costal cartilage in the 6th intercostal space or along the upper border of the 7th costal cartilage, the lower border of which it reaches about -ys^J^ "f an inch mesial to its costo- chondral junction. The costal cartilage of the 7 th rib, like the lower costal cartilages, is almost entirely devoid of Pleura. This also applies to an increasing surface of the ribs themselves as we get lower in the series (27,1 inches). The limit of the Pleura crosses the right nipple line (cf. Fig. iii) at the lower margin of the 6th costal cartilage or slightly lower down, and the axillary line at the lower border of the 9th Costal Cartilage. In tlie upper part, the left costal pleura takes a similar course; it crosses the Sternal Angle (LUDWiGs Angle) a little further to tlie left; from this point it passes so as to often reach the middle line, becoming, to some degree, adherent to tlie pleura of the opposite side; for the distance of 2 inches it extends ver- tically downwards until it reaches the level of the 4th costal cartilage; at this level the margin of the pleura extends obliquely downwards and outwards to the upper border of the 5th Costochondral Articulation whence it curves with its concavity inwards to the upper border of the 7th Costal Cartilage ; from this point it again follows a similar course to the Right Pleura downwards and outwards; though mesially it does not reach the 7th Costal Cartilage it may extend lower down externally. The left pleura crosses tlie axiUary Une at the loth rib or in the gtli interspace (cf. Fig. 126). The pink area indicates Absolute Cardiac Dulness wliich under normal conditions is not encroached upon by lung tissue and which area serves for the exposure of the Pericardium in Pericardiotomy. Cf. Figs. 70 and 121 for a description of the Apical Pleurae. The boundaries between tlie different lobes are shewn in the figure. The Right Lung has three lobes — the superior and middle lobes are separated anteriorly by a fissure which extends to the level of the 4th rib or 1/2 inch lower. The boundary between the middle and inferior lobes lies opposite the 6th intercostal space and extends behind tlie anterior extremity of the 7 th rib obUquely downwards to the lower border of the lung. The Left Lung consists of 2 lobes and the fissure which separates them extends from the posterior end of the 4th interspace to the region behind the 7 th costal cartilage. Fig. 117. Boundaries of Lungs and Pleurae from behind. The Median Boundaries of the Pleurae posteriorly, i. e. the lines at which the Costal Pleurae become continuous with the Mediastinal Pleurae, run along the bodies of the Vertebrae. The lower limit, i. e. where the Costal Pleura becomes continuous with the Diaphragmatic Pleura, is very important. From the lower border of the 12th Dorsal Vertebra this line runs horizontally outwards so that not only the lower rib cartilages but also the bony ribs are free. The 12th rib, which varies much in length and may even be absent, is usually bisected b}- this line. The difference on the two sides in the Axillary Line has been mentioned in Fig. 1 1 6. The Apices of the Pleurae are not visible from behind, because they never pass up as high as the upper surface of the ist Dorsal Vertebra. The fissures between the Upper and Lower Lobes are indicated by black lines, beginning behind in the 3rd intercostal space they run obliquely outwards and downwards. But on the right side a small fissure arises from the main fissure and divides the upper lobe into two — (the Superior and Middle I^obes). Superior Lobe —7- - — Fissure of Lunj; Inferior Lobe Lcjwer Border of Lung Lower Border of Pleura Fig. 117. Boundaries of Lungs and Pleurae, from behind. Vs Nat. Size. — Modified after Joessel. Rebman Limited, London. Rcbm.Ti! Company, New York. Left Innominate Vein Voiia Cava Superior Internal M.mimary V- . Right Pleura Arch of Aorta ■ Pulmonary Artery 1^ I-oft Auricle Atrium of Right Auricle . ;: ;;^ Right Ventricle rcricardium Thymus Pericardium Left Pleura Ventricle Riyht Ventricle Fig. 118. Anterior Thoracic Wall and Heai-t in the New-Born. Nat. Size. Kebman Limited, London. Bebinan Company, New York. Pig. Ii8. Anterior Thoracic Wall and Heart in the New-Born. From the fresh corpse of a iionnal Foetus tlie soft parts, of the Anterior Thoracic Wall over the Sternum unci Costal Cartilages have been removed. The position of the heart and its important parts has been determined by Luscmka's method, (by the introduction of 6 needles). The heart and the great vessels are fully shewn in the figure, the bones and muscles being imagined as transparent. The outline of the Pericardium and the area of Absolute Cardiac Dtdness are yellow. The six points — indicated b}' Arabic figures — employed to determine the position of the heart are : 1. Internal angle of the first intercostal space on the right side close to the Sternum : Right Pleura, Right Phrenic Nerve, Reflection of Pericardium, Superior Vena Cava close to the right margin of the Arch of Aorta (this last- named structure may be pierced by inserting the needle obliquely): in the adult the Internal Mammary vessels would be injured, but not so in the child. Cf. Fig. 1 19. 2. Internal angle of the 2nd intercostal space on the right side close to the Sternum ; Right Pleura, Superior Vena Cava, upper border of Right Auricle. Aperture of Pericardium. 3. Internal angle of 2nd intercostal .space on the left side close to the Sternum ; Region of Pulmonar\- and Aortic Valves (the pulmonar\- valves being anterior, above and to the left ; ■ the Aortic posterior, below and to the right) Cf. Fig. 1 20. The left pleura is opened by the needle. 4. Middle line of Sternum at the level of the 4th Chondro-sternal articu- lations or at a slightly higher level in the new-born: Border of Right Pleura, Boundary between right auricle and right ventricle; Tricuspid Valve. 5. Middle line of Sternum at the junction of the Manubrium with the Xiphisternum : Lower border of right ventricle or of pericardium, and of the area of Absolute Cardiac Dulness. 6. Lower border of 5th rib on the left side at its costo-chondral junction about ' -.th inch internal to the mammary hne: Apex of Heart, or more accurately the limit between the left (red) and the right (blue) Ventricle. This needle passed exactly through the Interventricular Septum without entering either chamber of the Heart. ilie upper and lower parts of tlie Anterior Mediastinum are continuous in the child; the Thymus which lies in front of the Pericardium reaches down- wards between the Parietal pleurae as far as the area of Absolute Cardiac Dulness. The Anterior Mediastinum is filled up by Thymus, loose connective tissue, fat, lymphatics and small vessels. Fig. 119. Anterior Thoracic Wall and Heart in the Adult. hi addition to the soft parts covering the Thorax, the jrd, 4th, ^th Costal Cartilages and the junction of the last named ivith the 6th Costal Cartilage together with the Intercostal muscles lun'e been removed. Between the slips of the Triangularis Sterni Muscle the parietal pleura (blue) is visible ; its lines of reflection behind the Sternum are also delineated in blue. Between the 3rd and 4th Costal Cartilages (cf. Pig. 116) the right and left pleurae are in contact with each other, as in the adult the Th3'mus has con- tracted upwards. The right pleura ma}' extend considerably beyond the middle line, often as far as the left border of the Sternum. Parallel with the borders of the Sternum, at a distance which varies with the width of the bone, the Internal Mammary Artery, a branch of the Subclavian, takes its course accompanied b)' 2 Venae Comites except in the two upper inter- costal spaces where there is only one vein. Around the artery lie lymphatic glands, (Sternal and Anterior Mediastinal Glands) more numerous above than below. The Heart in the Adult is more deepl}' situated than in the Newborn and its apex is further to the left. The distance from the Apex (Left \'^cntricle) to the nipple is 2'^l^ths to iVsthsinch in the vertical line, and Vjths to if/jth inch in the horizontal direction. (As the Figure is ''/jths nat. size, actual measurements according to the Figure will require multiplication by five thirds.) ^\n irregularity in the Costal Cartilage which may even in\olve the rib is shewn in the 4th Costal Cartilage on the right side. The following data connected with the bony Thorax and in particular the costal cartilages have been made out by Bardelebex. In about 10 "/o the Sth Costal Cartilage, on both sides, articulates with the Sternum. The 6th and 7th Costal Cartilages usually articulate with each other ; in 60 % on the left side and in 40 "/o on the right side, articulations exist between the 5th and 6th Costal Cartilages. The arrangement, together with the close apposition of the cartilages, convert the intercostal spaces in front of the pericardium into narrow slits. The position of the Apex of the Heart, the Pulmonar}' and Aortic Valves is not absolutely constant — quite apart from physiological \ariations in form and position of the Heart. The Pulmonary Valves usually lie opposite the 2nd left interspace or behind the 3rd left costal cartilage, rarely in the 3rd interspace. For operations upon the Pericardium the most suitable site is a small area where the pericardium is uncovered by pleura. The entrance may be made through the 4th or 5th intercostal space, close to the Sternum, without wounding the pleura; the Internal Mammar}' Artery must always be borne in mind. Removal of a part of the 4th and 5th Costal Cartilages with a small portion of the left Sternum, allows a fair extent of the pericardium to be exposed. Stcrno-Mastoid Muscle ^laniibrium Steriii External Intercostal Muscle Poctoralis !^^ajor Muscle Internal Mamniary \'essels Pectoralis Minor Muscle -r-^;- Triangularis Stern! ^ Muscle Xiplmid Process Diaphragm External Oblique Muscle of the Ab.lonu-n Superior Epigastric Artery ^^*^'^'«^'< ^\- jfr. Frahse, Rectus Abdominis Muscle Transversalis Abdominis ^[uscle Fig. 119. Anterior Wall of Thorax and Heai-t in the Adult. 7^ Nat. Size. Rebman Limited, Lonilon. Kebuian Conipauy, New York. I,p(t C'arotid Artery Innominate Artery T.eft Subclavian Artery / Ductus Arteriosus (BoTAi.Li) Pulmonary Artery Superior Vena C.i Aortic Semilunar Valves: Left Valv. RJKht Viilve.^ I'o^terior Valve Right Coronary ml Artery Atrium lA Riglil AurirU- Cusps of Tri»:us)jiJ Valve: Septal (-usp Anterior Cusp - Pulmonary Semilunar Valves: Anterior Valve Posterior Cusp Ri^ht Ventriclc-^^ Anterior Papillary Muscl Anterior Cusp (Aortic) of Mitral Valve Posterior Cusp — (Parietal) of Mitral Valve ' Posterior Papillary Muscle --Inter Ventricular Septum Left Ventricle Descending Branch of Left Curonar)' Artery (,ardiac Notch Fig. 120. Heart of Adult. — Ventricles opened. Nat. Size. Reliman Limited, Lfiudou. Reljnian Company, New York. Fig. I20. Heart of Adult, Ventricles Opened. Normal adult heart liardened in for mot ; the ventricle is opened so as to shew the Aortic and Pulmonary serni/iinar valves, the heart is rotated so that tlie Left Ventricle is more to tlie front. TIte figure is senti-diagrai>unatic in order to demonstrate more clearly all th valves of the heart and their relative positions. The figure shews the outer and anterior aspects of the Right Auricle, the Right Auricular appendage and the opening of the Superior Vena Cava. Right Ventricle : Papillary Muscles, Anterior, Posterior and Septal. Chordae Tendineae, 3 Cusps of the Tricuspid valve, one large Anterior, a large Posterior and a small Septal Cu.sp; between the two Ventricles the Inter-Ventricular Septum; on the Anterior aspect of the Heart the inter-ventricular groove, terminating in the Cardiac Notch, and the Descending Branch of the Left Coronary Artery. As the continuation of the Right Ventricle upwards (the Conus Arteriosus) has been widely opened and its left wall removed, the pulmonary semilunar valves appear to be completely disconnected from the Right Ventricle, but their relative positions are well shewn, one anterior, one right and one left. Left Ventricle: Papillary Muscles, anterior or left and posterior or right with chordae tendineae attached to the two cusps of the mitral valve (right or aortic cusp and posterior or left cusp), the right one extending up into the Aorta and almost in continuity with the semilunar valve. The Aortic Valves are three in number, like the pulmonary, one is posterior, two are anterior or right and left, this is due to the common developmental origin of the Aorta and Pulmonary Artery. The Aortic Valves lie (cf. Fig. 119) more to the right, at a lower level and posterior to the Pulmonar}' Valves. Because the Aortic Valves are situated deepl}' and at a considerable distance from the Anterior Thoracic Wall, to obviate the obliterating effect of the Pulmonar}' Valves the Stethoscope is applied over the 2nd right Intercostal space close to the Sternum, i. e. the point where the Aorta lies close to the Anterior Thoracic Wall. The Mitral Valvular sound is listened for at the apex of the Heart. Fig. 121. Transverse Section through the Trunk, at the level of the 1st and 2nd Dorsal Vertebra. Frozen Section. The section passes through the 2nd Dorsal Vertebra anil the Disc between the 1st and 2nd Dorsal Vertebrae, also through the ist and 2nd Ribs, through the lower part of the Trachea, Thyreoid Gland and Clavicle ; the shoulder-joint on either side and Scapula with their muscles have been cut through. The shoulders ii*erc rather elevated. The important details are: — 1 ) Apices of Pleurae as seen from below are unequal because the section is not absolutely horizontal (Difference ' /,„th inch). The Apices of the Lungs separated by the section have been removed. The Subclavian Artery on the left side arching over the Apex of the Lung, and its intimate relation to the 1st rib and the Scalene Muscles is noticed. 2) Course of the Trachea and Oesophagus; the former deviates a little to the right probably' owing to the asymmetry of the Thj'reoid Gland whereas the Oesophagus normallj' deviates to the left. 3) When the Thyreoid Gland is much enlarged (as in the inhabitants of the Saxony Mountain Districts) it not only surrounds the Trachea, but also touches the Oeso- phagus and exerts pressure on the Carotid Artery and thin-walled Jugular Vein — both vessels being pushed backwards and outwards. 4) The Brachial Plexus, on either side, has been cut through. 51 The Vagus Nerve is situated between the Carotid and Jugular Vessels (cf. Figs. 59, 61, and 113). Recurrent Laryngeal Nerve between the Trachea and Oesophagus (cf. Figs. 69 and 113). The space between the Vertebral Column and the front of the neck is remarkably small for the passage of the important Cervical Structures. Finally, the Tendon of the Long Head of the Biceps is seen in its groove and the subscapular bursa between the Subscapularis Muscle and the scapular or shoulder-joint is shewn. Fig. 122. Transverse Section through the Thorax, at the level of gth Dorsal Vertebra. Frozen Section. The sectio7i is made through the gth Dorsal Vertebra, the 4th to f}th ribs ; in front the Stermtin is divided jitst below the articitlation of the 5th rib. As the man had died from Pneitmonia the lungs are fully expanded and not in the cadaveric expiratory position. This figure shews clearly how the Thorax is occupied b\' the 3 cavities (Pericardium con- taining the Heart, Pleurae containing the Lungs) and the spaces or Mediastina (cf. Fig. 112, Text). The Anterior Mediastinum presents a verj* small space occupied by loose connective- tissue, fat and lymphatic glands, and shews that the pericardium is not completely covered by Pleura. In the Posterior Mediastinum at some distance to the left of the Vertebral Column the descending Aorta is seen, on the right side the Oesophagus with both Vagus Nerves, whereas between the Great and Small Azygos Veins the Thoracic Duct is cut across, posteri- orly is the sympathetic cord, and behind the right Vagus nerve is a small lymphatic gland. This figure instinctively shews the position of the Phrenic Nerves between the Peri- cardium and Parietal Pleurae which is a point of considerable practical importance in Pleurisy. On either side at the 7th rib in the Axillar\- line the Interlobar Pulmonary fissure is seen. Oesophagus [ Recurrent Laryngeal Internal Jugular Vein Pectoralis Major Muscle Brachial Plexus Pectoralis Minor Muscle Coraco-brachialis and Short Head of Biceps Muscle Long Head of Biceps Muscle Carotid Artery Vagus Nerve Phrenic Nerve I 1st Rib Trachea ^^^^'^ ' 1st Dorsal Vertebra Thy- reoid Gland Scalenus Anticus Muscle Subclavian Vein Subclavian Artery Subclavius Muscle I Clavicle 1 Cephalic Vein Deltoid Muscle Hull Infraspinatus Musi.li Serratus ^lagnus ^tuscle Apex of Pic-u Sea] Apex of Pleura 2nd Rib Rhoniboideus Major Muscle 2nd Dorsal Trapezius 3rd Dorsal ' jrd Rib A''ertebra Muscle Vertebra Fig. 121. Ti-ansverse Section through the Trunk at the level of the 1st and 2nd Dorsal Vertebra. Scon from below. — -;- N,it. Size. Anterior llediastinum Atrium of. Pericardial I Internal Maui- Right Pectoralis Major iluscle Right Auricle Cavity Sternum j mary Artery Ventricle Left Ventricle 4th Rib Atrium of Left Auricle Left Phrenic Ner\'e Serratus Magnus Muscle Latissimus Dorsi Alusde' ^^ Oesophagu; Descending Aorta Thoracic Duct Right Vagus Nerve oth Rib Intercostal Azj'gosVein oth Dorsal ■"'■^i> , „ ,, , ... Vein Vertebra Sympathetic Splanchnic Nerve and Small Azygos Vein Fig. 122. Transverse Section tlu'ough the Thorax at the level of the 9tii Dorsal Vertebra. Seeu from below. — 7a N^at- Size. Rebmau Limited, London. Rebman Company, New Yor r "■ o f o "^ §i hi c i" o s p 1 5 > S O Q as- « o 2. •< !3- , (I) — 1 O ui C CO r-T- O 0. ;:; I— ( f* eg 3 ft) 3 t« _ w ^ '^ E C 3 fD I " ^ ? f^ ? a> o • 3 tt) c p o 3 3 3 £^ Crq >1 <1 ^ &< 3 r+ 3* fiJ &; n ,^ tr & 1^ -1 fu 3 •-t fu [;i a •-t u tt> f^ 2. «, o o ■-I C3 ' o 3- 3 ^ ft) & ft) S?" o ^ t/t a. 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C) s g X o «. a ^ 5: ^ op H CO < 01 (P n a o n cr ■n o CfQ cr rh o n < 3* o C/i a o •-« (0 p < o H rh n a* n P CO n o » n o 5 p o < Fig. 124. Position of Abdominal Viscera, from in front. Cf. Fi^. Ill for Topography. In the right h3-pochondrium lies the Liver wliich even extends further (however, the 12th rib, costal cartilages of gth, loth, 1 1 th ribs should be excepted). The liver lies in contact with the diaphragm, and indirectly with the Thoracic wall, the lower border of the viscus varies with its size and .shape — this depends upon the shape of the Thorax — and with respiration. In the nipple line it may correspond to the costal arch or extend below it Vr.t^s to r'-,ths inch). In the Axillary line it reaches to the loth intercostal space or extends ''/jths to rV.-.ths inch lower down. The lower concave surface of the Viscus is in relation with the right kidney, right supra-renal body (cf. Renal Impression Fig. 136) ai.d hepatic flexure of Colon. In the left Hypochondrium lie the Kidney, Suprarenal bod\-. Stomach, Spleen, Splenic Flexure of Colon, Tail of the Pancreas and usually a part of the left lobe of the Liver. This region is occupied bv about -/^rds of the Stomach i. e. Cardia and Fundus. The Cardia lies behind the outer end of the 7th Costal Cartilage, the inner concave surface of the Spleen is in relation with the upper part of the left kidne\', its outer convex surface with the Diaphragm (Phrenico- Splenic ligament), cf. Figs. 125, 126, 136. As a rule the liver does not extend further to the left than the inner half of the 7th Costal Cartilage. The Splenic flexure is anchored bv the Phrenico-colic fold to the loth and iith ribs. This fold also forms a platform upon which the spleen reposes, but this fold becomes stretched when the spleen is enlarged and any alteration occurs in the position of the Colon. The form and size of the Epigastric regions varj' with the individual and the sex ; the subcostal angle varies widel}' between 30 " and 70 ". The shape of the Xiphoid Process offers many variations, it may be directed forwards, backwards or laterally, presenting an opening, or be bifurcated, curved or crooked. In the Epigastric region are found a part of the Liver. Gall-Bladder, Stomach, Duodenum and Transverse Colon. The lower border of the Liver extends at the 8th costal cartilage bevond the right costal arch and often reaches to a point midway between the Umbilicus and the top of the Xiphoid Process. At the lower border of the Liver near the gth and loth costal cartilages is situated the gall-bladder (cf. Figs. 131 and 132). Behind the Liver are situated: Lesser Curvature of Stomach, Small Omentum. Omental Sac, Aorta, Coeliac Plexus of Sympathetic; a part of the Stomach, (Antrum Pylori) touches the Abdominal Wall. To the right of the Middle line, normally, Transverse Colon as well as Duodenum lie in this region. The former is often curved and extends downwards into the Umbilical region. In some cases it lies wholly outside the Epigastriuin. The Umbilical Region contains a great portion of small intestine (mostly Ileum) which is usually covered by the Great Omentum. The Iliac Region contains the ascending (right) and descending (left) Colon with Small Intestine. The Hypogastric region lodges in its middle, small intestine, bladder (when distended) and uterus (when pregnant) — on the right the Appendix and on the left the Sigmoid Flexure. The greater part of the anterior wall of the Bladder is imcovered by Peritoneum (cf. Fig. B): when the bladder is much distended this region corresponds to a A Vs^hs to 2 ins. high with a base corresponding to the interval between the 2 pubic spines (about i^l^th inch). Cf. Figs. 143, 144. Gall Bhddei Ascending Colon Descending Colon / Fig. 124. Position of Abdominal Viscera, from in front. Va Nat. Size. — After Luschka. Ilolnuan Limited, London. Rebman Company, New York. / Common Bile Duct Pancreas Descending Colon Ascending Colon Fig. 125. Position of Abdominal Viscera, from behind. /. Nat. Size. — After Luschka. /3 Rebman Limited, London. Kebman Company, New York. Fig. 125. Position of Abdominal Viscera from behind. Between the level of the 9th and nth ribs on the left side is situated the Spleen which lies in relation wath the Diaphragm above, and the left kidney below (cf. Figs. 126 and 136). The Kidneys lie opposite the 12th Dorsal and the 1st and 2nd Lumbar Vertebrae and in front of the 12th rib, on the left side also in front of the nth rib. The right kidney, due to the size of the I^iver, is mostly found at a lower level. Sometimes both kidneys are at the same level, but rarely is the right higher. P)Oth kidneys are occasionally .situated at a considerablv lower level without any evidence of undue mobility. A horseshoe-shaped kidne}-, i. e. when the lower ends of the two \-iscera are joined in front of the Vertebral Column, is no great rarity. (Cf. Fig. 127.) The descending colon lies to the outer side of the left Kidney whereas the ascending colon with its Mesocolon lies in front of the right kidney with the duodenum above (for further details, cf. Fig. 135). The Pancreas — in front of the 1st Lumbar Vertebra — extends to the left as far as the Kidney and Spleen ; its upper part may touch the Suprarenal Gland. In the figure it is visible on either side of the Vertebral Column (yellow^ the intermediate part beiiig indicated by dotted lines. Its head is almost completely encircled by the Duodenum; into the Vertical portion of the Duodenum which is closely applied to the posterior abdominal wall, the Duct of the Pancreas (Duct of WlRSUNG) which is usuall}- joined by an accessory Du't (Duct of Santorini) (cf. I""ig. 130, text), and the Common Bile Duct open. These relations are shewn in the figure, which also depicts the left ureter coming from the left kidney (cf. Figs. 120, 129 and 133). The ascending Colon is seen on the right, the descending on the left (next in continuity the Sigmoid Flexure) between the Costal Arch and the Crest of the Ilium. The relations of the Peritoneum to the Viscera are described in Fig. 136. The last portion of the gut shews the Ampulla of the Rectum against which the Coccyx lies. Below the tip of that bone, the Rectum passes backward (Perineal Curve) and opens in the slit-like laterally compressed Anus. Fig. 126. Left Lung and Spleen. — Side View. The figure shews the diaphragm during extreme expiration (cadaveric expiration); the vault extends as high as the 4th left intercostal space and the left lung to the same degree. The fissure of the Lung — the left boundar\- of the pleura, cf. Figs. 116 and 117 — and especially the normal position of a normal spleen are shewn. The inner concave surface of the spleen lies against the Fundus of the Stomach and the upper part of the left kidney (cf. Fig. 135), the convexity is in relation with the Diaphragm connected with it by the Phrenico-.Splenic Ligament. The spleen e.xtends from (cf. Fig. 125) the 9th to the iith rib with its long axis corresponding to the long axis of the loth rib. in a downward and forward direction, so that the inferior pole points towards the Umbilicus. A normal spleen does not extend beyond the costo-chondral line — i. e. a line drawn from the left Sterno-clavicular articulation to the top of the 1 ith rib. Through the Sacro-Sciatic Foramen the lower part of the*Sigmoid Flexure and the Rectum are visible. The convex diaphragmatic surface of the spleen is shewn; as the spleen is a viscus subject to man}' forms of enlargement, it is desirable to learn the direction in which its increase in size must extend. The upper concave surface is in relation with the fundus of the Stomach; this frequently pre\'ents a permanent enlargement upwards. The lower surface rests upon solid viscera — left kidneA', Pancreas and left Supra-renal glands — which under normal conditions caimot ea.sily be pushed aside. The Phrenico-Splenic Ligament prevents expansion vertically downwards, but it affords a gliding surface along which the spleen may when enlarged slide forwards and downwards. It is thus that the anterior jjole of an enlarged spleen is mo.st readily felt at the anterior border of the loth iMb. Lower Border of Lung, during Inspiration Line of Reflection of Pleura Vault of Diaphragm /-?l — I Lower Border of Lung in Expiration Spleen Trausversalis Abditiniuis lluscle Fig. 126. Left Lung and Spleen, lateral view. '/a iS'at. Size. — After Luschka. Rebmau Limited, Loudo UebuKiu Conijiauv, New Yoi'k. Rectus Abdominis Muscle Gastro- Falciform Transversalis: Right Left duodenal Ligament Hepatic Abdominis' Caudate Gastric Gastric Oesophagus Parietal Layer Hepatic Duct Artery of Liver Artery Muscle ] Lobe Artery Artery (Cardiac End) of Peritoneum Round Ligament of Liver (Obliterated Umbilical Vein) l*orlal Vein Common Bile Duct Cystic Duct Outer Layer of| Peritoneum i Transverse Colon Inferior Recess of Omental Sac Root of Mesentery llco-Colic Artc-ry Ileum Vermiform Appendix ■superior Haemor- rhoidal Artery Ureter Ovarian Ligament Lxtcrnal Iliac Artery Gastrosplenic Ligament Peritoneum of Omental Sac 7lh Rib Jnfciifjr Mesenteric Vein Round Ligament of Uterus Deep Epigastric Vessels Round Rectus Bladder Umbili- Ligament Abdominis cal . ^ . ,^ of Uterus Muscle Artery Uterus "^-O^^ Fig. 127. Position of Viscera covered by Peritoneum - Child. V4 Nat. 8ize. Enbman Limited, London. Ilcbman Company, New York. Fig. 127. Position of Viscera covered by Peritoneum — Child. Child under one year of age. Anterior abdominal iva/l, Stomach, Jejunum, Ileiiiii, Left portion of Transverse Colon, Sigmoid Flexure, Mesenteries and ivall of Omental Sac, Transverse Mesocolon have been removed. Peritoneum, blue. Inner layer of Omental Sac, yellow. This figure shews the Abdominal and part of the Pelvic Viscera in situ after removal of those mentioned above. The Liver is large, its anterior surface passing beyond the right costal arch throughout its whole extent (reminding one of the arrangement in the Foetus). Of the Viscera the following parts are shewn. Cardiac end of Stomach cut across transversely. Pylorus joining the Duodenum, of which, by removal of the Anterior layer (if the lesser Omentum, the hori- zontal and commencement of the descending portion with the opening of the Common Bile Duct are shewn. The remaining part is covered by the Transverse Colon. The lumen of the intestine is visible at the Duodeno-jejunal Flexure, below and posterior to which is found the Duodeno-jejunal Fossa. The Ileo-'caecal junction and the Vermiform Appendix are seen in their usual position at a higher level in the child than in the adult. The Ascending Colon which appears rather short in the figure, the right half of the Transverse Colon (lumen owing to line of section), on the left the Splenic Flexure, Descending Colon, and two openings through which the upper and lower extremities of the Sigmoid P'lexure are also visible. On the lower surface of the Liver we find the Gall Bladder and vessels entering the Hilum of the Liver, the Bile Ducts and further to the left the Spleen. Forming the left inferior boundar}' of the Fossa Duodeno-jejunalis is the Left Colic Artery. In this instance the Kidney is horseshoe-shaped, but the Ureters are normal and occup3' normal positions, crossing the External Iliac vessels (cf. Figs. 131, 134, ij^. 137. 14Q. 150) and disappearing behind the much distended Rectum. By the side of the left Ureter runs the Sujaerior Haemorrhoidal Artery (a branch of the Inferior Mesenteric) to the Rectum. In front of the Rectum is the Uterus, of which the fundus is visible; from either side the round ligament passes to the Inguinal Canal crossing in their course the Deep Epigastric Vessels. The Fallopian Tubes and Ovaries lie on the right side in the true pelvis, on the left side in the false pelvis, either because they have not completely descended, or, more probably, because the much distended Rectum had pushed them upwards. This latter view is supported by the fact that the Fundus Uteri is squeezed in between the Bladder and the left wall of the pelvis. In front of the Uterus lies tlie Bladder, bounded anteriorly by the slightly opened Cave of RetziU-S; in this region the Bladder is uncovered by Peritoneum. 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The median incision extends from the Xiphoid to the left side of the Umbilicus below which part the incisions diverge towards the right and left Anterior Superior Iliac Spines. The two large upper flaps are further divided into two smaller ones by incisions running towards the loth ribs. The two Kidneys (practically at the same level, though the left is usually ihe higher, cf. Fig. 125) together with their large arteries from the Aorta are shewn with their veins which enter into the Inferior Vena Cava. At the hilum the Vein is situated in front of the Artery, which has divided into many branches, whereas the Ureter is situated behind. The left Renal Vein passes in front of the Aorta to join the Inferior Vena ("ava; the termination of this left renal vein and the right vessels are covered by the head of the Pancreas. The Pancreas extends across at the level of the ist Lumbar \'ertebra from the Right Kidney to the Left, terminating in relation with the Spleen and lying in front of the Aorta and Inferior Vena Cava. Above the Pancreas the Coeliac Axis with its three diverging branches is shewn ; below the Superior Mesenteric Artery, (the origin of which lies under cover of the gland), at a lower level and to the right is the Middle Colic Artery. To the right of this Artery is the Superior Mesenteric \"ein whereas further to the left is the Inferior Mesenteric Vein. Above the Pancreas the Portal Vein can be seen, cut off at the hilum of the Liver. This vein is fonned by the union of the Splenic and the Superior Mesenteric Veins. The Ureters passing downwards on the Psoas Muscles cross the Iliac Vessels — on the left ^/j inch above, on the right Vi inch below the origin of the Internal Iliac Arterj^ — and course along the outer wall of the true pelvis to the Trigone of the Bladder. 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C Crq 3 3: r« 3-0(5 Co a.0^ 55 til 2 O ~ . S ^ Si a a ^ o a ?? g ■51 S s ^ f* a ^ Orci" StJo' a, o 03 ;: a. o o a s s' a .0 7i .s. C. a-^ TO g a ■^ TO a S TO ^ '~- ~ TO £ ^ •*l' Oro <-i S S - "^ 03 i I" o Co TO S 5 TO Q TO a " 03 s ■^ s TO ,>^ Co TO TO TO ^- § 8 a =^ »- ?5' C5 <^' s c Cl TO ^ s- "Vi- TO 0 >* ^ ?-v r^ 0 ^a- J^ Cr- a Co TO 1? Op* > a o I-t > p- o 3 s o CTQ PJ tn <-\ M« O a Cfc? ►*• o 3 < a in tit W p. p. tp B o tr Fig. 145. Back shewing Nerves, Arteries and Lymphatic Glands. The Skin and Superficial Fascia have been removed from the whole dorsal aspect, extending from Occiput to Sacrum. On the right side the Trapezius, Latissimus Dorsi, Superficial Layer of Lumbar Aponeurosis, Supra- and Infra-Spinatus Fascia wit/i the attachment of the Splenius Capitis Muscle have been cleared aivay. This figure is purposed to shew those lymphatic glands of the back which are little known and which receive but scant attention. 1. Muscles and Nerves. Trapezius Muscle with Spinal Accessory (Xlth Cranial) Nerve running almost vertically downwards, Latissimus Dorsi Muscle with its nerve running obliquely downwards and inwards, Levator Anguli Scapulae and Rhomboid Muscles with branches from the Posterior Thoracic Nerve, Supra- and Infra-spinatus Muscles with the Supra-scapular Nerve, Teres Minor and Deltoid Muscles with the Circumflex Nerve, Teres Major Muscle, Subscapular Nerve, Serratus A'lagnus Muscle, Long Thoracic Nerve (of Bell) (v. Figs. 109 and iioj. 2. Arteries. The Occipital Arter}' (a branch of the External Carotid) be- comes visible, at the attachment of the Sterno-Mastoid and Trapezius, and ramifies over the Occiput. The Posterior Auricular Artery (External Carotid) passes behind the pinna to anastomose with the former. The Transversalis Colli Artery from the Subclavian Arterj' appears in the space between the Levator Anguli Scapulae and Rhomboid Muscles. The Supra-scapular Artery either a direct branch of the Subclavian or a radicle of the Thyreoid Axis or Inferior Thyreoid Artery, accompanies the Supra-scapular Nerve to the Supra- and Infra-spinous Fossae where it anastomoses with the Subscapular Artery from the Axillary. More externally the Posterior Circumflex Artery accompanies the Circum- flex Nerve as it winds around the Surgical Neck of the Humerus. In close contiguity to Bell's Nerve is found the Long Thoracic Artery (inconstant). LTpon the Dorsum of the Trunk proper only small arteries are found because the Dorsum of the Trunk like the extensor aspects of the limbs receives its blood from the ventral or flexor aspect. 3. Lymphatic Glands. At the point of emergence of the Occipital Arterj' a few Occipital Glands are found. Behind the Pinna accompanying the Posterior Auricular Artery and 13'ing over the tendinous attachment of the Sterno- Cleido-Mastoid is a posterior Auricular Gland which should be called the Superior Posterior Auricular Gland so as to distinguish it from a deeper gland which lies in contact with the Muscle itself. Deeply situated behind the Mastoid Process, and under cover of the Splenius and close to the Occipital Artery Ues a deep Mastoid Gland (cf. Fig.). The subcutaneous glands along the upper border of the Trapezius and near the Vertebral Column are not particularly marked in the figure. They may be called the Superior and Inferior Subcutaneous Nuchal Glands. At the level of the 7th Cervical Vertebra lies the Superior Superficial Dorsal Gland; the Inferior Super- ficial Dorsal Gland lies along the outer border of the Latissimus Dorsi at the level of the ist or 2nd Lumbar Vertebra. At the Clavicular Origin of the Deltoid is the Superficial Clavicular Gland, whereas more deeply situated near the Supra- scapular Artery and at the upper border of the Scapula is the Supra-scapular Gland. Deep Dorsal Glands are situated at the upper border of the Rhomboid Muscles; on the Teres Major Muscle is seen the posterior superficial Axillary Gland; a deep gland is situated between the Teres Major, Teres Minor and Tri- ceps Muscles. These glands are not all constant; they may only be found in pathological conditions; such occurrence does not exclude their normal presence as merely elementary. Occipital Gland Posterior Auricular Artery Siipt-ro-posterior Auricular Gland Sterno-Cleido-Mastoid Muscle (Infero -posterior Auricular Gland) Trapezius Muscle nth Xerve. Spinal Accessory Superficial Superior Dorsal Gland Superficial Clavicular Gland Occipital Artery Splenius Capitis et Cervicis Muscle Deep Mastoid Gland Longissiinus Capitis Muscle Rhomboid (Major) Muscle Levator Angtili Scapulae Muscle Deep Dorsal Gland / ^/OvrSS^ / ^ I-""g Head o / //ni }W '/ Triceps Muscl. / Circumflex / Ner\*e Deep Posterior Axillary Gland Superficial Inferior Dorsal Gland External IVbdominal Oblique Muscle fnternal Abdominal L)blique Muscle iPkti r's Trianglei Postero -superior Iliac Spine Gluteus Medius Muscle / / I Gluteus Maxinius Muscle Teres Minor Muscle Infra-spinatus Muscle Teres Major Muscle Long Thoracic Nerve (Bell) Serratus Magnus Muscle Longissimus Dorsi Muscle Serratus Posticus (Inferior) Muscle 2th Rib Internal Abdominal Oblique Muscle 'S^^-" I'r.i'rohsc . Fig. 145. Back, shewing Nerves, Arteries and Lymphatics. -/, Nat. Size. Promontory Douglas' Pouch Posterior Fornix of Vagina Fundus of Uterus Symphysis Pubis Labium Minus Labium Majus i^^^-i-'^V Fig. 146. Median Section through a Female Pelvis (Bladder and Rectum empty). v., Nat. Size. Rebman Liiititcd, Loudon. Rcbman t'ompany, New York. Fig. 146. Median Section through Female Pelvis ; Bladder and Rectum being empty. Median section through the body of a woman aged ^o. In this instance, owing either to pathological adhesions or post-mortem changes, the Uterus did not lie directly on the Bladder, it has, therefore, been drawn forward into the position of anteversion and anteflexion in accordance with the general investigations upon living subjects. When the bladder is empty the normal position of the uterus during life is anteverted (virgins) and anteflexed (women) i. e. the Uterus lies on the postero- superior aspect of the bladder (B. Schultze). Whether coils of small intestine lie between the Uterus and Bladder or whether other varieties normally exist we have not definitely decided. As the bladder becomes distended the Uterus is pushed upwards and backwards. The course of the Vagina is S-shaped, like the Rectum and Urethra. Into its upper cul-de-sac the Cervix Uteri protrudes, thus forming an Anterior and Posterior Fornix of which the latter is separated from the Pouch of DOUGLAS by V25th inch. (Operation route.) The empty bladder evidences a slight impression due to the body of the Uterus. An "uterine impression" can also be recognized on the distended bladder. The S-shaped Urethra (iVsth inch long) enters the bladder at an acute angle. The Peritoneum does not extend so far down on the posterior aspect of the Rectum (3rd Sacral Segment) as upon its Anterior Aspect (ist Segment of Coccyx). Levator Ani, External and Internal Anal Sphincter Muscles are shewn in the figure. Lastly the extremity of the Dural Sac of the Spinal Cord is seen termin- ating at the level of the 2nd Segment of the Sacrum. a (S 0) > o a o a « CO bo O u > i) Oh "3 a fa tN ■* bo fa o '-I ^ ^ -3 ■^ Co CO ^ . to ^o o (U 'C ■l-J o o 5f § 43 bo o bo — > o a .-J > O o 5 n 2 ^ c fc -a O tn ni rt O ID O t; nJ > o 3 >^ be S "2 1^<^ .s P 'in (U o 3 o nS t3 o o i! O n! ^ C ■ O <0 tS CL, a) 4) ^ 4) ^5 c E 5 "i " - - IP T3 ni 0) J3 H in 3 0) ^ o o ." 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'C C ni C in ni O in (1( 41 43 4J 73 4) i»J 4J 43 3 43 ~ 43 •M 3 +j ^ -t-* « -P 4) C ^ -S &• ■^ P S 4) 43 E 4) E " 4) P 43 43 tu 4-- be 4; in 73 •- >. O o 4) -P P O "o o be c U r- O 5 4j in C -K "! be o >, >Jh -P > & i3 41 P in ni o 4) 43 in P >-, O 73 -Xl 3 ni to 13 in O 4J 43 . ^ 43 p — ^ in O „ t-i bo a; >-^ 4) 73 4J P ^ -i; ^ o — £ in 4> be 4) .5 4J in L- 4) > in P ni u nS 42 4) 43 4) 43 1;^ E75 ^■ E 2 3 -u 4> O u 4) O ni O 4; ni "13 ■C .2 . ft) t- -M 3 c bo Fig. 148. External Female Genital Organs. (Vulva.) Vestibule. The Labia have been drawn apart in order to shew the Vestibule and, in par- ticular, the openings of the ducts of Bartholini's Glands. The Labia Majora corresponding to the Scrotum of the male limit the Rima Pudendi which is closed in Virgins when the thighs are adducted; in front these Labia meet, but behind they are lost near the Anus. They are folds of skin usually well-covered with hair and large sebaceous glands, and contain large Veins. The Labia Minora are separated by a sulcus from the Labia Majora ; their outer surfaces are covered with skin, their inner surfaces with mucous membrane continuous with that of the Vestibule. In front the Labia Minora bifurcate, the outer portions of either side unite to form the Prepuce of the Clitoris, the inner join below the Clitoris and form the Frenum. The Clitoris which corresponds to the Penis of the Male is usually rudimentary, its extremity (Glans Clitoridis) alone being visible. The posterior ends of the Labia Minora vary much, they may merge into the Labia Majora, or may unite together and form an arch which limits the Vestibule posteriorly. At the posterior junction of the Labia Minora is situated the Fossa Navicularis. In the angle between the Labium Minus and the Hymen is situated the opening of the duct of Bartholini's or Duverney's Gland. In front of the Hymen and about midway between the posterior limit of the Vaginal Orifice and the Clitoris is situated the Urethral Orifice which may be of different shapes: — a vertical slit, semilunar or /\ -shaped. The projection of mucous membrane behind this — Lingula Urethrae VON Bardeleben — is correspondingly pointed or rounded off. The Hymen a reduplication of the mucous membrane at the entrance of the Vagina varies much in shape though generally crescentic from side to side with the broad part of the crescent posterior in situation (prior to Defloration); it may be annular, or fimbriated, even double or fenestrated. During "Defloration" the hymen is usually torn and heals with cicatrices. Fresh lacerations occur during the first labour, these lead to the formation of Carunculae Myrtiformes. Fig. 149. Pelvic Organs of Female seen from above and in front. Ureter. Woman aged 50. Intestines removed as far as the Rectum, Uterus retroverted ; Left Appendages of Uterus removed. The Right Fallopian Tube is drawn upwards and its fimbriated extremity thrown upwards oi'er the brim of the true pelvis. The Abdominal Opening of the Fallopian Tube and the Ovarian Fossa are thus exposed; the ovary is somewhat drawn upwards by the tube. On the left side the peritoneum covering tlie important vessels and nerves has been removed, but the portion forming the posterior layer of the Broad Liga- ment has been preserved intact and the round ligament retained in situ. On the left side the Lymphatic Glands are exposed and their corresponding imaginary situations on the right side are depicted through the transparent peritoneum. By Waldeyer the lateral wall of the true pelvis has been divided into the following fossae: Paravesical, Obturator, Hypogastric (Para-Iliac) bounded by the Round Ligament (in the Male — Vas Deferens) and the Ureter. When the Bladder is empty the Paravesical Fossa is divided into an anterior and posterior part by the Transverse Vesical Fold; the anterior part belongs more to the Anterior Abdominal Wall, the posterior part can be fully seen when the Uterus is retroverted. The Obturator Fossa in the depth of which the Obturator Vessels and Nerve run over the surface of the Obturator Internus Muscle contains the Ovarian Fossa which may be a simple groove or a deep alcove against which the lateral half of the Ovary lies while its posterior border remains free and rounded. The Ovary lies on the Uterine Artery touching the Ureter: according to the size of this organ and the position of the Internal Iliac Vessels it reaches or extends beyond the Internal Iliac Vessels, as far as the lower border of the External Iliac Vein. The most posterior fossa is the H3'pogastric (Para-Iliac) Fossa in which the Pyriformis Muscle and on this muscle the Sacral Plexus are found. The Ureter generally enters the True Pelvis at the bifurcation of the Common Iliac Artery passing over the External Iliac Vessels and the Umbilico- Vesical Trunk to lie between the Internal Iliac Vessels and the Uterine Artery and covered for some distance by the broad ligament and the Vessels to the Append- ages. In this part of its course the Ureter lies directly under the Peritoneum. Further forwards, in front of the Broad Ligament, the Uterine Artery crosses over and in front of the Ureter as it leaves the pelvic wall and approaches the Vaginal Portion of the Uterus. It is at the level of the Internal Os (where the Uterine Artery bifurcates — Waldeyer) that the Uterine Artery crosses the Ureter. The Ureter comes very near the Vaginal Portion of the Uterus (cf. dotted line) as it curves round it laterally to open into the bladder. The Ureter is only separated from the Vaginal Portion of the Uterus by the vessels in the cellular tissue of the Parametrium (Branches of the Uterine Artery and Utero- Vaginal Venous Plexus). On its outer side lies the Vesico- vaginal Venous Plexus. These Plexuses communicate freely so that the Ureter is embedded in a venous plexus. Inferior Vena Cava Ovarian Vessels ^ Ureter Bifurcation t»f Aorta Superior IIaeui(»rrlioidal Arterv / Syiiip;ilhetic Chain f Ovarium Artery Fossa Hypojfastrica iWaldevek) (Para-iliac Fossii) ' >bliir;itor F<.)ssa (Waloryki; Uterine Arterv -- Ovary -Viiipiilta uf Falloi'Ian Tube Round Ligament of Uterus Posterior Fossa Para- Vesicalis (WALDElTEtt) Superior Vesical Artery * '< minion Trunk of Deep Epigastric and Obturator Arteries Transverse Vesical Fold (Walueyeu) Anterior Fossa Para- Vesicalis (Waldeyer) Common Iliac Vessels Genito-Crural Nerve Middle Sacral Vessels Promontory iDisc between — 5th Lumbar and 7th Sacral Vertebra) Internal Iliac Vessels Ureter External Iliac Vessels — Obtmatur Artery — Uterine Artery Linea Alba Posterior Layer of the Broad Ligament Obturator Nerve Superior Vesical Arterv Middle Vesical Artery (Vesico -Vaginal) L'^tero -Vagina I Venous Plexus Vesico- Vaginal Venous Plexus Obliterated Hjijogastric Artery Symphysis Pubis Fig. 149. Pelvic Organs of Female, seen from above and in front Ureter. 7,, Nat. Size. Rcbman Limited, London. Rt'Ijuiiin Ciiiiipiuiy. New York. Pustcni- Superior I line Spine 2nd Posterior S.uTiil Koraineii Lateral S.icr.'il Art (TV .interior lirancli of 3r(l SatTiil Nerve Anterior Brani:h of .)tli Sacral Nerve eritoneum I Pouch of Doroi.AS) il adder Keclo* Vesica I Fascia Great) Sciatic Nerve Small Sacro- Sciatic Ligament Perinaeal Raph^ Posterior Scrotal Branch of the Perinaeai Nerve (of Internal Pudic) ^^^'^•^■* .*!). .-^ - Fig. 150. Pelvic Organs of Male, exposed from behind, V, Nat. Size. Rebman Limited, London. RebmjiQ Company, New York. Fig. 150. Male Pelvic Organs, exposed from behind. Male aged }^. The Ghiteus Maximus is detached from the Posterior Inferior Iliac Spine downwards and the Erector Spinae divided transversely at thin level. The Sacrum has been sawn through between the 2nd and p-d Sacral Foramina, the Coccyx between the Jst and srid Segments ; the different layers liave then been successively exposed: Rectum, Bladder, Peritoneum, Vas Deferens, Seminal Vesicle and Ureter. On the right side the Great Sacro-Sciatic Liga- ment has been cut short and the Ischiorectal Fossae cleared out on both sides. The figure particularly shews the different layers through which the Surgeon cuts in order to reach the Rectum or deeper parts. Removal of the lower part of the Sacrum can be carried out, as shewn in the figure, without any great damage. The nerve supply of the Rectum and Bladder is chiefly derived from tlae 3rd Sacral Nerve. There is no risk of opening the Dural Sac which usually terminates at the lower part of the 2nd segment of the Sacrum. Deep to the Sacrum lie the middle and lateral Sacral Vessels; next the Rectal Fascia (yellow) and before reaching the longitudinal muscles of the Rectum a thick layer of fat, in which lie the Superior Haemorrhoidal Vessels and the Lymphatic Glands of the Meso-Rectum, has to be divided. According to the degree of distension the Rectum may occupy the whole of the Recto- Vesical Pouch or leave on either side a peritoneal space (light -blue). The lower boundarj' at which the peritoneum is reflected on the Rectum is about 3 inches above the Anus. Below this level operations on the Rectum can be performed without opening the Peritoneum. In front of the Rectum merely separated by Recto-Vesical Fascia is the Bladder, the base of which is laterally and inferiorly covered by the Ampulla of the Vas Deferens and the Seminal Vesicles. In the angle between these struc- tures lies the Ureter (green), this can be exposed by removing a layer of fatty tissue rich in the vascular anastomoses of the numerous branches of the Inferior Vesical Vessels (cf. Fig. 161). The arrangement of the muscles bounding the Ischio-Rectal Fossa is to be seen as well as their relation to the lesser Sacro-Sciatic Ligament and the Coccygeus Muscle; a small gap engages one's attention (through which a Hernia of the Floor of the Pelvis may occur), next the Levator Ani Muscle and finall}- the External Anal Sphincter (cf. Fig. 153). The Internal Pudic Vessels and Nerve wind round the Spine of the Ischium and run under cover of the Obturator Fascia forwards and downwards. These structures therefore do not re-enter the pelvis through the Sciatic Foramen as usually stated but remain separated by the muscular floor of the pelvis. Neither do these structures pass into the Ischio-Rectal Fossa but remain in Alcock's Canal which is a re-duplication of the Fascia covering the Obturator Internus Muscle on the outer wall of this fossa. Fig. 151. Median Section through Male Pelvis. Frozen section through the body of a robust elderly man. The Rectum was much distended by faeces which were removed after the section had been har- dened; the Bladder contained frozen urine which melted as the section thaived. The parietal layer of Peritoneum lining the Anterior Abdominal Wall can be traced over the summit and posterior aspect of the Bladder to be reflected on to the anterior surface of the Rectum at the level of the lower border of the 4th segment of the Sacrum. This point, of great surgical importance (for the removal of Tumours) is situated 3 inches above the Anus (length of Index Finger). The Peritoneum now continues upwards as far as the 2nd or ist segment of the Sacrum. Between the Anterior Abdominal Wall and the Peritoneum a space is formed when the Bladder is distended (Space of Retzius) because the peritoneum being adherent to the Bladder is pushed upwards as this organ rises out of the Pelvis (Fig. 144). Between the Rectum and the Bladder, close to the middle line is situated the Ampulla of the Vas Deferens — this is partly shewn in the section. The Rectum when filled with faeces is chiefly distended above the 3rd or Anal portion (Ampulla Recti) so that the organs which lie in front of this part are pushed upwards. Below the Ampulla of the Vas Deferens lies the posterior portion of the Prostate; the remainder of this gland lies in front of the Urethra, and is sur- rr>unded by the Prostatic Venous Plexus. In this specimen the Bladder Wall is thickened and presents marked rugae on its inner surface. The Urethra on emerging from -the Bladder passes through the Prostatic portion — Prostatic Sinus or Verumontanum — this portion is usually one inch or a little more in length, though in cases of Hypertroph}' of the Prostate or a greatly distended Rectum this ma}- be exceeded. The next segment of the Urethra is known as the Membranous portion — according to Waldeyer the upper and larger part of this should be called the Muscular portion because it is surrounded by muscles from which it derives both circular and longitudinal fibres. The length of this segment is almost one inch. The Urethra at this situation forms a curve at an angle of 90 degrees which often obstructs the passage of the point of a catheter. The distal segment is 6 to 8 inches long and extends from the Anterior layer of the triangular ligament to the end of the Penis, lying between the Corpora Cavernosa it is surrounded by a delicate erectile tissue (the Corpus Spongiosum) which is enlarged posteriorly to form the Bulb and anteriorl)' to form the Glans Penis. The Corpora Cavernosa arise on either side of the ascending Ramus of the Pubis and tenninate as cones at the level of the Coronar}' Sulcus of the Glans Penis by which they are covered. Slight!}- posterior to the slit-like external urinar}^ orifice the Urethra widens into the Fossa Xavicularis. The Glans may or may not be covered by a Prepuce according to size, age, habits, etc. (Phimosis, Paraphimosis, Circumcision — cf. Fig. 1 5 2 and Text). As the position of the testicles is not quite symmetrical, the Septum of the Scrotum has not been divided but the left testicle within its Tunica Vaginalis has been cut obhquely. IVfillK t .umi.y „f Dun S /■ ^^f ,,-\ ,•? ■ Vns Deferens = (Ampulla Aiiiimlla of Roctum — i ^C. Levator .Vni Muscle Deep Transverse Pcri- iiacal Muscle (Transversus Perlnaei) ^ Bulb uf Urottr.i Fig. 151. Median Section through Male Pelvis. V, Nat. Size. Rebman Limited, Loncion. Rebman Company, New York. n " f to p B CO CD O o o !=! Oq i? » CD ►«1 CD H ST ^.H£; ? 3 3 ft ^ S-ET » Cli (« fu O ^ (/I p rt Si f^' 5 = fu 1/1 3 3 3 ■ 3 3 3- 3-5L o ( 5, •-t CD f" '■< O rt- a> c 3-0 "I c 3 !" !2. O o r: „ o ; crq r-zi '"of o 3-3 3 r-^ 3" :i o '^^ * 3 !^ n a> a- ^ O cr. 3" ' O (T> CD C ^J^ ►J. h^ 3 o -i 3 3 ^ O ^ w T •Td O n B- 3 3' ^ o fu 2- 2". CT S! i-r| tr: >> 3 a> i-h SL 5 w 3 T o o < O 3 r-^ S. 3 fu t£. f" 3'?' 5 <'o 2 3 01 >> !u p- :i O 3" rt m 3t S-' 01 fu S X 3 :n o o r ^ M M £L S CD 04 ^l-" 3;-w~2E== 3' S"^" ^ 2 ^ O 3.>^ ta g's. cr tn 3 3^ CD rt- o 3 Wk. 3'>»'i^"3_ ,C/5 1 (D 3 ii:?u i-* ■-( r-t fD 3 3 c : o (D I CL -1 O 3 3 §>^ 3 3' orq CD 5 2.'' 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Through the body of a Male of middle age a section lias been made almost parallel with the pelvic axis, so that the plane of section is not accurately frontal. This figure is intended to complete the series Figs. 151 and 152; only a short description is necessary. The Bladder B with its overlying peritoneum is, in front of the plane of section, visible above the black hnes which dehneate the peritoneum. All other structures except the Rectum and the folds of the buttocks and parts of the thigh lie in a frontal plane, i. e. lower part of the Bladder, Ampullae of Vasa Deferentia, external to these (cf. Fig. 151) the Seminal Vesicles and directly below the last mentioned the Rectal Wall. Very instructive is the divided Obturator Internus Muscle, which can be felt bulging on examination of the Female Pelvis, and especially the direction of the Levator Ani which arises at the upper border of the Obturator Internus from the White line and approaches the Rectum in a funnel-shaped manner to sur- round it and terminate in the External Anal Sphincter. This muscle may be con- sidered to consist of many parts. At the commencement of the funnel it is markedly thickened (Constrictor of the Vagina). Near the Obturator Internus Muscle are situated the Internal Pudic Vessels and Nerve (cf. Fig. 154) covered by Fascia (not seen in the figure). On either side of the Rectum are seen the Ischio-Rectal Fossae filled with fat. The last part of the Rectum onl}' as it runs obliquely downwards and backwards has been cut through; the upper part lies in front of the plane of section as viewed from behind. Hip-Joint — * \ Vesica! Plexus of Veins — ^^ ^/~*:-fWt t Ampulla of Vas Deferens — y^~rpW3|S Obturator Internus _ "ff^KV . g Extern;!! Iliac \'eiii Obturator Artery — Obturator Nerve Deferens Ureter Seinina! ^'esI(■lt■ Ampulla of Rectum Ischio-Roctal Fossa Tuber Isch Gluteus Afaximu^ ilusc!! Levator Ani ^Muscle Fig. 153. Frontal Section through Male Pelvis — Levator Ani Muscle. Seen from behind. — -/s Nat. Size. Rinjman Limileil, Loiulon. Rcbmaii Company, New York. 0>rpu.'i Sponjjii'Siim Perinaeal Ner\'e (Posterior ^ Scrotal Branches) ^\ Posterior Scrotal Vessels Long Pudendal Xerve Raphe between Biillx Cavernosus Muscles Left Ischio -Cavernosus irusctc Deep Transverse I'ennaeal Miiscic Minpressor Urethrae (.oininunication with Obturator Vein Vessels to the Eulb Central Point of Perinaeiini Superficial 'Iransverstt J'crinae-'tl Muscle Recurrent Gluteal Branches of Small Sciatic Xen*e f 'rvu-i'EK's Gland Perinaeal Vessel: I and Xer\'e Inferior Haemorrhoidal Vessels and Nerve Levator Ani Muscle Obturator Fascia ^(Alcock's Canal) Superficial Perinaeal ^ Brcinch of Internal Piidic \riidi ... - Dorsal Ner\'e of Penis ■Parietal Layer of Pelvic Fascia Externa! Anal Sphincter Internal Anal Sphincter Coccj'geus Muscle Gluteus Maximus Muscle Tip of Coccj-x Ano-Coccygeal Ligament Fig. 154. Male Pei-inaeum, Superficial Layer. Nat. Size. Bebmau Limited, London. Eebman Conij>any, New York. Fig. 154. Male Perineum. I. Superficial Layer. The Superficial Fascia and Vessels of the Perineum with the Ischio-Rectal fat have been removed. The Superficial Fibres of the External Sphincter Ani have been cut away in order to shew more distinctly the Levator Ani Muscle. On the right side the nerves and vessels have been dissected out; on the left side a deeper dissection, with exposure of Cowper's Gland, has been carried out after partial removal of Vessels and Nerves. The connection of the Sphincter Ani and Bulbo-Cavernosus Muscles shews the crossing over of the anterior fibres in the middle line. At the central point of the Perineum, where these muscles join, the Transverse Perineal Muscle is attached. The connection between the Sphincter and Levator Ani Muscles is merely indicated in this figure (cf. Fig. 153). The Ischio-Cavernosus Muscles arising from the descending rami of the Pubis envelop the Corpora Cavernosa; the Bulbo-Cavernosus Muscles, united by a median raphe, lie in contact with the Corpus Spongiosum. The Superficial Fascia of the Perineum (as far as it exists) and the Fascia covering the Levator Ani Muscles (Anal Fascia) have been removed. The Fascia covering the Obturator Internus Muscle is shewn in Sagittal Section (cf. Fig. 153). The Superficial Arteries of the Perineum arise from the Internal Pudic (the terminal Branch of the Internal Iliac Artery): 1. Inferior Haemorrhoidal i — 3 small branches to Anus. 2. Superficial Perineal, runs transversely across either superficial or deep to the Transversus Perinaei. Both these arteries are direct branches of the Internal Pudic Artery. 3. Terminal Branches of the Internal Pudic Artery: a) Artery to Bulb, giving off the Transverse Perineal Artery and the Artery to Cowper's Gland. b) Dorsal Artery of the Penis (or Clitoris). The Nerves of the Perineum are branches of the Internal Pudic Nerve (Ilth, Illth, IVth Sacral) which divide into 2 main branches, the Superficial Perineal and a Deep Branch. Both nerves are mixed, the Deep Branch is continued as the Dorsal Nerve of the Penis. Fig- 155' Male Perineum. II. Recto-Urethral Muscle. Prostate. Tlie Perineum is exposed by a U'ianguUw iviiidoiv section. The Vessels and Nerves have been completely removed. By dividing and throwing back the Anal Sphincter tlie Recto-Urethral Muscle lias been exposed to view and the Prostate exhibited by separation of some of the thin fibres of the Levator Ani. In front of the Anus the divided Superficial Anal Sphincter fibres are shewn , anteriorly in the narrow space between them deeper fibres which pass trans- versely, further forward the retracted fibres of the l.evator Ani Muscle; and between these fibres and the Central point stretches the Recto-Urethral Muscle which blends, posteriorly, with the Levator Ani Muscle and the Rectal Wall, anteriorly, witli the Transverse Perineal Muscle, the Raphe and the fibres of the Bulbo-Cavernosus Muscles as well as the Membranous Portion (Waldeyer) of the Urethra. On either side of the Recto-Urethral Muscle the Prostate is exposed to view. (This dissection can be carried out in the course of operations.) In the triangle between the Superficial Transverse Perineal Muscle and the Pubic Angle, the superficial fascia of the Perineum which covers the Ischio- and Bulbo-Cavernosus Muscles is seen on the right side. On the left side the fascia has been removed so that the muscles mentioned and the superficial layer of the triangular ligament are exposed. The Superficial Fascia is a true superficial fascia, but the triangular liga- ment is an Aponeurosis (v. Bardeleben). Raphe between Bulbo-(.'a\er- nosiis Muscles Central Point of Periniieiim Prostate IUilb()-{_avernnsiis Muscle Tscli io-Cavernosus Muscle Superficial Layer of Triangular Ligament Superficial Trans- verse Perina,eal Muscle Guthrie's Muscle (Recto-Uretliial Muscled Levator Ani Muscle Deep part of Externa! Anal Sphincter Fig. 155. Male Perinaeuin. II. Recto-TJrethral Muscle. Prostate. Nat. Size. Reliinnn I/iinitcil LuikIi.ii. Rcl)iii:in ('iiiiipany, New Yurk. Artcrv to the Bulb Siihiirethral filanfl )(!o\vi'KK*s Gland) Fig. 156. Male Perinaeum. III. Cowper's Glands with their Ducts. Nat. Size. Relmian Limiteil, Lniicioii. Rebm.iii Comiiaiiy, Ntw Yoik. Fig. 156. Male Perineum. III. Prostate. COWPER's Gland with Ducts. Terminal Branches of Internal Pudic Artery. The Vessels and Nerves liave been cut away in the posterior part of the Peri- neum. The Corpus Spongiosum has been denuded of its muscles and laid open so as to exhibit the course of the Artery to the Bulb and the Ducts of Cowpbrs Glands. The Prostate has been exposed by removal of the fibres of the Levator Ani and Sphincter Ani Muscles which center it. This figure is given f(ir the demonstration of the position of CowPER's Glands and their ducts which vary from 1 '/jth to 3V5ths inches in length; whereas their diameter is 0.02 inch and their hmien 0.0 1 inch. The Glands themselves, not always symmetrical, are situated about V5 inch from the middle line on either side of the membranous portion of the Urethra between the z layers of the triangular ligament, near is posterior border and between the fibres of the Compressor Urethrae. These glands are lobulated or mulberry- shaped, hard, almost white in colour, about Yi; to -/d inch long. The}' belong to the racemose type of glands and vary according to the individual and age but are frequentty unobserved owing to incomplete dissection. The Artery to the Bulb (a branch of the Internal Pudic) consisting of two vessels (cf. Fig. 154), supplies the Bulb, Prostate and the structures which lie between the 2 layers of the triangular ligament, e. g. Compressor Urethrae Muscle, Membranous Portion of Urethra, CowPER's Gland and Corpus Spongiosum as far as the Glans Penis. At this point it anastomoses with the Dorsal Artery of the Penis and through this with the Arteries of the Corpora Cavernosa. Fig- 157' Male Perineum. IV. Urogenital Triangle. Ampulla of Rectum. The deep layer of the triangular ligament is exposed on the left side by remov- ing the superficial layer of the triangular ligament and the Corpus Spongiosum as far as the middle line; the Urethra, Cowper's Gland, the left Corpus Caver- nosum and the Dorsal Artery of the Penis have, however, been preserved. In front of the Transverse Perineal Muscle, the Compressor Urethrae Muscle (the Muscle of the Urogenital Triangle of Waldeyer) is shewn. This muscle arising from the bony margin of the Pelvis (Ischium and Pubis) and the fibrous portion of the Ischio-Cavernosus Muscle, passes to join its fellow of the opposite side in the middle line. The outlines of the Bulb are delineated in blue; Cowper's Glands and Duct which are not exposed by the dissection (cf. Fig. 156) are also indicated. Anteriorly the Compressor Urethrae Muscle is connected with the Trans- verse Pelvic Ligament which may be looked upon as an aponeurotic covering of the muscle or as a blending together of the superficial and deep layers of the triangular ligament. Waldeyer has named this the Preurethral Ligament; ■emerging through the fibres near the anterior border of the Compressor Urethrae Muscle, the Dorsal Artery of the Penis is seen ; this vessel a branch of the Internal Pudic soon gives off the artery to the Corpus Cavernosum. The chief object of this figure is to give an idea of the position and size of the Ampulla of the Rectum when distended (red). In this part of the Rectum which lies above the Anus and which is capable of considerable distension faeces may, and frequently do, accumulate if the bowel is not emptied. On the right side an abnormal Muscle the Ischio-Bulbosus is shewn between the Ischio- and Bulbo-Cavernosus Muscles. IrreguNir Muscle frnin Ischium tu Bulb I)(irs;il Artery of Penis and ^Vrtery to (_'<.)rpus Cavornosum .Superficial Layer of Trian- fjuiar Ligament Deep Transverse Perinacal Muscle it'onipressnr I'rethrac Musclel ( owi'Ek's (ilaud Levator Ani Muscle / External Anal Sphincter '•J'rt h^e Perinaeal Artery Anus Superficial Transverse Perinaeal Muscle Central Point of Perinaeum Fig, 157. Male Perinaeum. IV. Tiro-Genital Triangle. Ampulla of Rectum. Nat. Size. Rebman Limited, London. Rebman Company, New York. Dfirsal Artery - - «>f Penis i 'idiiprfs-sor L'rcHir.'ic Musi'It; Duct of Cowi'Bk's Gland Superficial Transverse Pcrinacal Muscles I'K. state \'.is Di-fcrens i.Vmpulla) Seminal i Vesicle Inter-ampullary Muscle Recto- Vesica I Pouch Inter-anipullary Triangle (Base of Bladder Rectum (cut across) Fig. 158. Male Perinaeum. V. Prostate, Seminal Vesicles, TJrethra in its course through the TJro-Genital Triangle. Nat. Size. Rebman Limited, London. Rebmim Company, New York. Fig. 158. Male Perineum. V. Prostate, Seminal Vesicles, COWPER's Glands, Urethra passing through the Urogenital Triangle. Anus and surrounding parts — the Sphincter Ani completely and the Levator Ani Muscle partially (window- section) — have been removed; Prostate, Seminal Vesicles, Bladder and Douglas' Pouch are partly exposed from below and in front, also tlie central point of the Perineum in front of the Prostate Gland. Passing from the Tip of the Coccyx forwards to the anterior margin of the cut Levator Ani Muscle the following parts are seen in order: — Transverse Section through the Rectum, Peritoneum of Douglas' Pouch, Waldeyer's Interampullary Triangle with the base of the Bladder; on either side lie the Ampullae of the Vasa Deferentia with the Seminal Vesicles anteriorly. Between the last named and the Prostate the Interampullary Muscle runs transversely. Next in order is the Prostate Gland with the central point of the Peri- neum directly in front, whereas further forward are exhibited to view the Urethra and the accessory glands entering the Ducts of Cowper's Glands. Special attention is called to Kalischer's Urogenital Sphincter Muscle which is very variable, yet possesses many anatomical and physiological relations. At various times this has been described by Johannes Muller as the Con- strictor of the Membranous portion of the Urethra, by Fr. Arnold as the Ure- thral Muscle ; as GUTHRiE's muscle ; by Cruveilhler as the Transverse Urethral and Ischio-Urethral Muscle; by Krause and Kohlrausch as the Transverse Urethral Muscle ; J. Henle associates it with the Deep Transverse Perineal Muscle (Compressor Urethrae). Cf. the next figure. Fig- J^SQ- Male Perineum. VI. Pubic Region. Levator Ani Muscle. The Levator Ani Muscle has been exposed, a part of the Urethra below the point at which it traverses the Triangular Ligament has been removed. The vessels are preserved but tJie nerves, except the Dorsal Nerve of the Penis, Jiave been cut away. This figure shews ahnost the complete surface of the Levator Ani Muscle with its different parts and the incomplete gap anteriorly. Some of the veins which traverse it have been preserved on the left side. Posteriorly the close relation which the Coccygeus bears to this muscle (of which it really should be regarded as a part) is seen. Furthermore through the gap in the anterior part of the Levator Ani, the Recto-Urethral Muscle (cf. Fig. 155), the Compressor Urethrae Muscle encircling the Urethra by some of its fibres whereas others pass transversely across in front of it can be seen. The Transverse Pelvic Ligament (or the Pre-urethrae Liga- ment of Waldeyer) runs across in front of a gap (for the transmission of veins). Between this ligament and the Suspensory Ligament of the Penis which is attached to the lower border of the Symphysis, is situated the gap for the passage of the superficial vessels of the Penis. The Dorsal Arteries of the Penis are seen anastomosing in this figure, and the Dorsal Vein is seen to have bifurcated into Left and Right branches. The lumen of the Urethra, where it passes through the triangular ligament is almost circular if the mucous folds, which become obliterated during the passage of urine or of an instrument, be neglected. In this Distal portion of the Urethra as it is embedded in the Corpus Spongiosum the Lumen is more oval. Here the separ- ation between the Corpus Spongiosum and Corpora Cavernosa is most distinct. Urethra lAnteiior Segment') Fampinifortii Plcsiis Corpus Cavernosum \ Dorsal Nerve of Penis Dorsal Artery of Penis (Anastomosis) Posterior Scrotal Arterv Art^iy to Corpus Cavernosum Fascia of Penis Dorsal Vein of Penis jUpper portion of Superficial Layer of Triangular Ligament Transverse Fibres of (Compressor Urethrac iluscle Perinaeal Artery Internal Pudic Vein Inferior Haemorrhoidal Artery Coccygeus Muscle Fig. 159. Male Perinaeum. VI. Pubic Region. Levator Ani Muscle. Nat. Size. Rebmau Limited, Londou. Kebiuau Company, New York. Dorsal Upp^r portion of Super- Vein hcial Layer of Trian- Bulbo-Civcrnosus ^lii*iclc of Clitoris giilar Ligament Uulhits Vcstibuli Long Pudendal Nerve PoufAitr's Ligament Xervc \ Kxti-rnal Tudic Vein Obturator Xerv (-(MiiiiuiiULatidn with tjbtui.ititr Vein I >eep Transverse rerinaeal ^luscle (Compressor Urethrae) Posterior Labial Arterv Sciatic Artery I'yriforinis Muscle Nerve to Obturator Internus Gluteal Arterv Great Sacro-Sciatic Ligament Sciata Artery Internal Pudir Arterv CoCLygeus Muscle Superficial Transverse Perinaeal '\Um\e I'turyy Barth'olini's Levator Ani Muscle Gland Fig. 160. Female Perinaeum. Nat. Size. Eebmau Limited, LoiiUuu. Rebmau Company, New York. Fig. i6o. Female Perineum. Body of a Young Female. The skin and Superficial Fascia, except of the Mons Veneris, have been removed On the right side the superficial, on the left side the deep layer of the Perinetim is shewn: on both sides the Os Innominatum is exposed: on the right the Great Sacra-Sciatic Ligament is preserved. Vessels and Nerves are entirely preserved on the right side, but only partly on the left. The chief difference between the Male and Female Perineum consists in the following : — Instead of the small urethral aperture in the triangular ligament of the Male, there exists in the Female, a inuch wider opening for the Vestible. Whereas the Corpora Spongiosa are joined in the Male to form the Corpus Spongiosum, the corresponding parts in the Female remain distinct, as the Bulb of the Vesti- bule. So that the Bulbo-cavernosus Muscles in the Female remain distinct on either side: whereas in the Male, they come together in a median raphe. A connection of the superficial fibres of the Bulbo-Cavernosus, with the Sphincter Ani (like a figure 8), is likewise present in the Female. The Bulbs lie on either side of the Vestibule at the base of the Labia Minora. These Bulbs of the A'esti- bule contain large quantities of Blood, so that injury to them (e. g. during labour), may produce serious haemorrhage. From these there extends forwards a Venous Plexus which, near the Frenum of the Clitoris, passes into the deeper tissues at the side of the Clitoris communicating at its mesial aspect with the Veins of the Clitoris (particularly those of the Glans of the Clitoris). The Corpora Caver- nosa of the Clitoris are much smaller than the Bulbs of the Vestibule or of the corresponding parts in the Male. The}' arise from the descending Ramus of tlie Pubis on either side, and unite under the Suspensory Ligament to form one shaft (divided by an imperfect septum); the Clitoris is curved with its concavity downwards and backwards, so that its extremit}', the Glans, points towards the Vestibule. Many minute veins of the Glans unite to form the Dorsal Vein of the Clitoris, which opens under the Suspensory Ligament into the Pubic Plexus. (Cf. Male.) The Bulb of the Vestibule having a position different from the corre- sponding parts in the male, the glands, corresponding to CowPER's Glands, i. e. Bartholixi's Glands lie internally and behind the Bulbus Vestibuli. The Pubic Arch being much wider, and the Ischio-Cavernosus Muscle less developed in the Female, the Urogenital Triangle is larger than in the Male. In Virgins, the muscles in the subpubic region are well developed. During labour. the Vestible and surrounding parts are stretched to a maximum and even fre- quently torn, so that a perfect restitution to the normal state never occurs. The ^'^estibule and neighbouring parts remain stretched after labour, so that the muscles become .smaller and degenerated, or replaced by connective tissue and fat. The "True Perineum" which lies between the Vestibule and Vagina in front, the Anus and Rectum behind, is neither broad nor strong. "Rupture of the Perineum" is therefore a frequent occurrence during labour. It falls to the duty of the Obstetrician and Gynaecologist, to prevent this rupture by appropriate mechanical intervention, to detect injuries and to suture them, and to cure Recto- ^'aginal Fistulae. a> > a CO «i 4) Vl 4> •u U ^_^ < -o o ,, IC^ •o ^ ti o •»< £^ ^ 4) ^ ,£> fcj •^ a o DS Vc ^-- <4-l d < g (0 u O 09 • ■H < > ^N 0) PU ^ a bo O bo I i ^ s ^1 ^ I - « -1 ,3 -^ > ^ s 5 :^ .^ .§ -g >^ ■S: J' ^ 5; -S § "S s -c^ ■I I: S « ^1 ■^ 5S •5; s a ^ t ^ g "^ -a cp ^s; -5 V r u T3 ™ - c 'ell = £ S -r, cn lu - ^ ^ "3 i' < -5 o a, (U > V > CO c ■5 _o = .= o '•J (D C s S u > CA -1 __ 0 c m ■0 ^ qj B C > <\> v: m cS o > iS -c o -■ o - c .2 -a nJ > TO _^ 6 ii p t; >-• ^ o - •c u -a c c ni -qr- > -2 "U ■S o H 0) T3 C/3 c C/5 a. a. S = So o — g-g 0) --• c a, D o S -13 - u P^ c« tn ^ "^ 0) 'O i > S o g w 0) •S S o g rt ^ o o £ O rt to o .S -fi (U — 1) -^ ^ — s > 1 s PQ ^ C is S SS X .5 3 M > > S t^ (1) > a 03 O ^ >; E o =3 <3 "S S M o OSS u u o a. 'in -i! 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C ^ ^Vbilouiinal A<»rta 4tli laiiiibiii Vertebra Irunk ol Syiiipi'tlietic I'soas ^lusclo Inferior ^rtsenteric Plexii: I >i-cp I-ayer of J.iiinbar Fascia Aortic Plexus Sijjmtiid Flexure- Anterior (iiir.il Xrr\c- 1st SiUTiil Gangli'in Frankel's Recto-Vesical Ganglion FHAKKEL'sGreat Vesico-Semioal Ganglion Frankrl's Small Vesico-Seminal Ganglitm Fkankri/s Semi- nal Ganglion Vas Deferens Adductor Muscles Obturator Externus Muscle Great Sacro- Sciatic Ligament Internal Pudlc Vessels and Nerves Obturator Membrane Tuberosity of Ischium Hamstring Muscles Spine (if Isrliiiim (Obturator Internus Muscle Fig. 162. Organs of the Male Pelvis, seen from the left side. Nerves to the Seminal Vesicles. iModified after Max Frajstkel. — Va N^'- Size. Rebman Limited, Loudou. Rt'linian ('omiiriny, Nuw Yoik. Fig. 162. Organs of Male Pelvis, seen from the left side. Nerves to the Seminal Vesicles. Modified after Max Frankel. A sagittal section has been made through the left half of a male pelvis. The section passes through Sacro-Iliac Articulation, Tuberosity of the Ischium and Horizontal Ramus of the Pubis; this gives a view from the left side of the Pelvis, — its Viscera and Nerves —. Most of the Blood Vessels have been removed. The Inferior Mesenteric Sympathetic Plexus runs from the Artery of this name to the Aorta around which it forms the Abdominal Aortic Plexus, this is continued into the Hypogastric Plexus lying in front of the upper part of the Rectum. A little lower down lies the large RectoA''esical Ganglion of Frankel which is connected with the ist Sacral Ganglion by a large nerve. From this 2 or 3 branches pass to a yet larger Ganglion (Great Vesico-Seminal Ganglion). Some of the branches of the Recto-Vesical Ganglion go to the Plexus surrounding the Rectum. Several small branches pass from the Pudic Plexus to the Great Vesico-Seminal Ganglion and a delicate twig to the Seminal Vesicle directly. Several large and small branches pass from the Great Vesico Seminal Ganglion, one group runs in front of the Ureter, supplying it and terminating in the Posterior Wall of the Bladder, where they either run superficially for some distance, or penetrate at once into the Muscular Coats; another group runs directly downwards; it contains filaments to the Bladder and the Upper Border of the Seminal Vesicle, amongst these is a thicker branch which ramifies around the Vesical Orifice of the Ureter. The bulk of the fibres which leave the Gan- glion pass to the Upper pole of the Seminal Vesicle and form a large plexus around it. Below the Great Vesico-Seminal Ganglion lies the Small Vesico-Seminal Ganglion, directly behind and internal to the Vesical Orifice of the Ureter. The roots of this Ganglion are derived directly from the Recto-Vesical Ganglion but there also exists a connection with the Great Vesico-Seminal (janglion. Fibres are distributed directly to the Ureter and Vas Deferens, a few run behind the Ureter to the Fundus of the Bladder, while 2 or 3 larger branches go to the upper pole of the Seminal Vesicle, here they anastomose with the fibres from the Great Vesico-Seminal Ganglion. A very careful dissection exposes two strata of nerves (not seen in the figure), an upper going directly to the Prostate, and a lower lying on the Seminal X'esicle. Both layers anastomose with each other. In this lower stratum, Frankel found 2 other small ganglia which he calls Seminal Ganglia. From the lower part of the Hypogastric Plexus fibres also run directl\' to the Seminal Vesicles. Johannes MCller called (in 1835) this part of the Plexus "the Inferior Hypogastric Plexus"'. Max Frankel proposes to divide this into a Superior, a Middle and an Inferior Haemorrhoidal Plexus. The latter would be applied to the Plexus on the Rectum below the Levator Ani. Fig. 163. Gluteal Region. A large ivindoiv lias been cut out of tlie Gluteus Maxhntis Muscle; from the Gluteus Medius and the Pyriformis Muscles, smaller pieces have been removed. Under an extremely thick layer of superficial fascia, lies the Gluteus Maximus Muscle, which covers nearly the whole of the Gluteal Region. The following bony prominences can be felt: the Crest of the Ilium, the Great Tro- chanter and with less ease, because covered by the Gluteus Maximus, the Tubero- sity of the Ischium. The upper and outer part of this muscle passes over the posterior and outer aspect of the Great Trochanter and is inserted into the Fascia Lata. A Superficial Trochanteric Bursa placed within the superficial fascia is rare. The Gluteus Maximus covers important vessels and nerves; at the upper border of the Pyriformis Muscle, emerging with it through the Great Sacro- Sciatic Foramen, is the Gluteal Artery, a branch of the Internal Iliac. Outside the Pelvis, the trunk of this vessel is short, and soon divides into 5 — 7 branches to the Glutei Muscles. A large branch (Superficial Branch) becomes more super- ficial by emerging between the Gluteus Medius and Pyriformis Muscle, to run under cover of the Gluteus Maximus. Another large branch (Deep Branch), runs between the Gluteus Medius and the Gluteus Minimus, this divides into a Superior and an Inferior Branch, the former of which follows the middle curved line. Deep to these vessels lies the Superior Gluteal Nerve. At this point a variety of Sciatic Hernia may occur. At the lower border of the Pyriformis Muscle, the Great Sciatic Nerve emerges at a point corresponding to the junction of the inner and middle thirds of a line drawn from the Great Trochanter of the Femur to the Tuberosity of the Ischium. At the lower border of the Gluteus Maximus Muscle, the Great Sciatic Nerve is easily exposed, because at this point, it is only covered by skin and superficial fascia; at a lower level it is covered by the long head of the Biceps Muscle. Internal to the Great Sciatic Nerve, lies the Sciatic Artery, a slightly smaller vessel than the Gluteal Artery. This vessel gives off the Companion Arterj' to the Sciatic Nerve. Between the Sciatic Artery and the Great Sciatic Nerve lies the Nerve to the Gluteus Maximus Muscle, — the Inferior Gluteal Nerve — . Most internally, the Internal Pubic Artery emerges at the lower border of the Pyriformis Muscle, and after crossing the Spine of the Ischium or the smaller Sacro-Sciatic Ligament re-enters the Pelvis through the Sacro-Sciatic Foramen, but does not enter the Pelvic Cavity (cf. Fig. 150). A second variety of Sciatic Hernia may protrude below the Pyriformis Muscle, where the structures mentioned leave the Pelvis; a third variety may occur at the Lesser Sacro-Sciatic Foramen. The Hip-Joint lies under cover of the Pyriformis Muscle in front of the Obturator Internus and Externus Muscles, and in consequence is scarcely acces- sible from behind. An important Bursa lies between the Tuberosity of the Ischium and the soft parts over it, e. g. the Sciatic Bursa. Latissimus Dorsi Muscle External Oblique Muscle of Abdomen Internal Oblique ^Muscle of Abdomen (Pktit's Triangle) Superficial Layer of Lumbar Aponeurosis Gluteus Medius Muscle Posterior Superior Iliac Spine Gluteus Maximus Muscle — ^:- Gluteus Medius Muscle Gluteal Artery with its Deep Division dividing into Superior and Inferior Branches Pyriformis Muscle Gluteus ifinimus Muscli- Great Sciatic Nerve Sciatic Arterv luternal Pudic Ner\'e Small Sacro-Sciatic Ligament Branch of Sciatic Artery perforating Ligament Internal Pudic Artery Nerve to Obturator Intemus Muscle Small Sciatic Nerve Inferior Gluteal Nerve Bursa between Trochanter __ _. and Gluteus Maximus Gemellus Inferior Great Sacro-Sciatic Ligament Tuberosity of Ischium Companion Artery of Sciatic Nerve Quadratus Femoris - — Muscle Recurrent Gluteal Branches of Small -^ Sciatic Nerve Iliotibial Band Semitendinosus Muscle Long Head of Biceps Muscle ■■-^iS" Fig. 163. Gluteal Region. 74 Nat. Size. Rebmau Limited, Lontlou. 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M M c ' T3 ft o ■3 ^ 3 B ;i: O , ^ 3 „ 3 2. ft 3t 3 ft ■ ft — ^ B ^ ^ „ g a. 3- 3- 3- — O ft ft ft B S3 ^ o "^ M- B O ~ ft -T' O B re. S,'^ H " -5 M sT c S. ■a a. 9' O c> 5: !i S "S- 5- ■■ ^ £ ^- ?. ■^ S" ■ s- " to ^ » - ^ ^ ^ ^ ^ ^ "• ss fe it fV .~ ^ a P a a 01 p* n B p to o cr Fig. 165. Frontal Section through the (Right) Hip-joint. This secfioti is not quite vertical, but is directed obliquely from above and in front, downwards and backwards. The Hip-joint is the most deeply situated of all the large joints in the body, and is covered on all sides by thick muscles. Access is obtained more easily from the outer side over the Great Tro- chanter, because in this situation there are fewer Vessels and Nerves. The Socket of the joint is incompletely covered by cartilage at the Fossa Acetabuli which is filled with fat. At this point, the bony wall is very thin, and easily allows of perforation by disease, which may subsequent!}' extend in the Pelvis. The Socket is deepened by a dense fibrous ring, the Glenoid Ligament. The Capsule of the joint extends on to the Femur, — to a varying extent at different parts — . In front it reaches the Intertrochanteric Line, behind it is inserted on to the Neck of the Femur, about Va^h inch below the middle of the neck, so that a considerable part of the Neck lies within the Capsule and fractures of the Femur may consequently^ be completely Intra-Capsular. The Capsule is .strongest in front, owing to the IHo-Femoral Ligament (Bertini, Bigelow) which passes, from the Antero-Inferior Iliac Spine and the bone internal to this, over the Capsule with which it blends, to the Intertrochanteric Line. Superficial to BiGELOW's Ligament, lie the 2 Tendons of origin of the Rectus Femoris Muscle which arise from the Antero-inferior Spine and the brim of the Acetabulum. The angle between the axis of the shaft and the axis of the neck (Angle of inclination of the Neck) of the Femur varies from 116'-' to 138° (MIKULICZ) but is usually about 120" to 133", the average being 125". As a rule the longer the neck, the greater the angle. The architecture of the cancellous tissue is briefly as follows: A pressure system of Cancelli converges from the surface, commencing at right angles to the surface on the inner side; a traction system crosses the former at right angles, forming arches, which run from the outer compact tissue with their convexity directed upwards to the middle and lower parts of the head, and the adjacent portions of the neck. The third (muscular traction) system begins at the Great Trochanter at right angles with the insertion of muscles into it, and passes inwards forming arches with their convexity' directed upwards: this system crosses the former at an angle of 45", together with the first set, this forms the strong vertical plane of compact bone which Merkei. calls the Femoral Spur (Calcar Femoral el Gluteus Minimus Muscle 'iliileiis Meilius Muscl Gluteus ilaxinius Muscle Bursa over the Trochanter Iliacus Muscle Anterior Crural Nerve Psojis Muscle External Iliac Artery External Iliac Vein Femur Ligamentum Teres Obturator Tnternus Muscle Tuberosity of Ischium Fig. 165. Frontal Section through the Hip-Joint; Right side. Seen from in front. — 7:i Nat. Size. Kebman Limited, London. Rebman Company, New York. ►^ K— q<3 M OS p ►H E3 org 0 ^* C3 P H- * &cJ CD OCT? p; 5' Z p 1 I-' 1 CO SI e+ » f g3 C/3 "-s? 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ial Abdominal Oblique Muscle (and the External Abdominal Ring) has been slit np and the chief constituents of the Spermatic Cord dissected out. When the Fascia Lata which stretches across the Inguinal Region has been removed, a triangular space with its base directed upwards, and its apex downwards — Scarpa's Triangle — is exposed. The upper boundary of this area is PouPART's Ligament; the internal, Adductor Longus Muscle, which arising from the bone below the Pubic Spine, runs outwards and downwards, to be inserted into the middle third of the middle lip of the Linea Aspera ; the external, Sartorius Muscle, which arising below the Antero-Superior Spine of the Ilium descends obliquely inwards and downwards, over the Internal Condyle of the Femur, to be inserted on the inner surface of the Tibia as far down as the Crest of the Tibia. In this Triangle, the Anterior Crural Nerve and the main vessels are exposed. The Femoral Artery lies directly under Poupart's Ligament, at the mid-point between the Anterior Superior Iliac Spine, and the Symphysis Pubis, and passes almost vertically downwards. At the ligament, the Femoral Artery can be readily compressed by digital pressure against the horizontal ramus of the Pubis. In Scarpa's Triangle, the Femoral Artery gives off posteriorly, the Deep Femoral Artery, apart from the smaller branches, Fig. 167 — Superficial Epigastric, Superficial External Pudic and Superficial Circumflex Iliac Arteries — . As the Deep Femoral Artery is a branch of large size, tliere occurs at its origin, i V2 inch below Poupart's Ligament, a sudden diminution in the calibre of the Superficial Femoral Artery. The Femoral Vein lies to the inner side of the Artery and is enclosed in its sheath, but soon passes behind the Artery. This Vein receives the Long Saphenous Vein, which passes over the margin of the Fascia (see Fig. 167). Internal to the Vein, is situated the Crural Ring (see Fig. 170). The space below the ring. — between the Adductor Longus, P'emoral Vein, and Pectineus Muscle — is filled up with fat and deep lymphatic glands. The Anterior Crural Nerve appears in the Muscular Compartment under Poupart's Ligament, and lies about -/f,ths inch external to the Artery in Scarpa's Triangle. This nerve disappears under cover of the Sartorius Muscle and divides into branches which supply the skin on the Anterior Aspect of the thigh, the Sartorius and the Quadriceps Extensor. Deep to the Vessels and the Nerve lie the Ilio-Psoas and Pectineus Muscles. At the Apex of Scarpa's Triangle, the Sartorius passes obliquely over the vessels. This muscle has, therefore, to be drawn aside in order to expose the further course of both Artery and Vein. The figure also shews the constituents of the Spermatic Cord : Vas Deferens with the Vessels to the ^"as, Spermatic Artery and the Pampiniform Plexus of Veins, Cremasteric Vessels to the coverings of the Cords. The Cremasteric Vein is of importance because it alwa3's communicates with the Pampiniform Plexus, though it opens into the Deep Epigastric \^ein (Collateral Venous Channel). Fig. 169. Inguinal Region, 4th Layer. Hernial Orifices, Iliac Bursa. Male aged 60. The Spermatic Cord has been drawn out of the Inguinal Canal and cut off. Vas Deferens (blue). Fascia of Penis is opened up and the Dorsal Vessels and Nerves are exposed. External part of Fascia Lata has been removed. Anterior Crural and External Cutaneous Nerves have been lopped off short. A piece has been cut out of the Ilio-Psoas to expose the Iliac Bursa (pink). The Pelvis and Head of the Femur are indicated in dotted lines. The dotted ellipse over the Head of the Femur indicates the position and size of the com- munication between the Iliac Bursa and the Hip-faint (in this case). Immediatelv external to the Common Femoral Artery, but on a slightly deeper plane, are the Ilio-Psoas Muscle and the Anterior Crural Xerve. A very large bursa (Iliac Bursa) separates the Ilio-Psoas Muscle from the Horizontal Ramus of the Pubis and the Capsule of the Hip-Joint whereby the Muscle pla}'s over the edge of the bone without friction. The Capsule of the Hip-Joint is weak at its point of contact with the Iliac Bursa, and in some cases (I in 10) there exists a communication between these 2 cavities. This Bursa may extend some distance into the Pelvis which occurrence is of practical importance in connection with primary disease of this Bursa. When swollen the difficulty of diagnosis arises between enlarged l\-mphatic glands, aneurysm of the Femoral Artery, or disease of the Hip. An accurate anatomical knowledge of this bursa is the only clue to a correct diagnosis. Again inflam- mation ma\' spread from the Hip-Joint into the Bursa, via a direct communication, b}' piercing the thin septum, and further extend into the Pelvis. The figure also shews the important relations of the Hernial Orifices. The fibres of the External Abdominal Oblique Muscle diverge at an acute angle, and form the 2 pillars of the External Abdominal Ring. The Internal Pillar ends in the middle line (or reaches to the opposite side) at the Symphj'sis Pubis by sending fibres into the Suspensory Ligament of the Penis. The Outer Pillar is chiefly inserted into the Pubic Spine. The angle between the diverging fibres and the anterior aspect of the cord are covered by intercolumnar fibres which hold the two pillars together. Poupart's Ligament is a thickened fibrous cord or rather a tendon or tendinous cord (the lower border of the External Abdominal Oblique Muscle). From the External PiUar and PoUTART's Ligament which are blended together, many fibres spread in various directions, and to some of these names have been applied. The fibrous mass which stretches across to the Fascia covering the Pectineus Muscle, near the Spine of the Pubis, and forming a triangular ligament with the base pointing outwards has been called GiMBERNAT's Ligament (Fig. 170). The fibres directed upwards and backwards to reach the bone, have been called the Ilio-Pubic band. Both ligaments are usuallj- blended together. These structures are not constant, and their descriptions are most variable. Externiil Abflmnin.il Obiiiiiic Mus(_le Tensor Muscle of Fascia L;ita Anterior Superior Iliac'Spine External Cutaneous Nerve Iliacus Muscle Rectus Pernor is Muscle Ilio-Femoral Band (Bkrtini) Anterior Crural Nerve Ilio-Pectineal Fascia Bursa Iliaca Femoral Vessel Internal Abdominal Oblique Muscle Femoral Rin; Ilio-Pubic Band — Fascia covering Pectineus Muscle Deep Femoral Artery , Spermatic Cord. (Vas Deferens; Inferior Horn of Fossa Ovalis (Saphenous Opening} External Circumflex. Artery Dorsal Vein of Penis Superficial Femoral Artery Long Saphenous Vein Superficial Dorsal Vein of Penis Fascia Lata Sartorius Muscle Fig. 169. Inguinal Region, left side, 4th Layer. Hernial Oriiices. Bursa Iliaca. V^ Nat. Size. Rebmau Limited Londou. Rebman Company, New Yoik. Rectus Kfmi>ris Muscle (llutrus Mctlius ;ind Minimus Muscles Kxteriiiil Abdominal Oblique Muscle Anterior Inferior Iliac Spine Internal Abdominal Oblique Muscle Transversalis Abdominis Muscle Ilio-Psoas Muscle Anterior Crural Nerve Head of Femur liio-Pectineal Bursa Fascia Transversalis Extcrnil Inguin il Fossa Deep Epiga'^tric Vrtcrj Internal Inguinal Fossa Cremaster Muscle Obturator Artery, Femoral Ring Gimbgrhat's Ligament ^~„:^^^ .-x Pectineus Muscle Ilio-Pectlneal Eminence — -^ Edge of Glenoid Fossa Obturator Canal Posterior Division of Obturator Nerve Obturator Extemus Muscle Anterior Division of Obtiu-ator Nerve Adtluctor Brevis Muscle Internal Circumflex Vessels Ilio-Psoas Muscle Pectineus Muscle Adductor Longus Muscle Deep Femoral Vessels Superficial Femoral Vessels Long Saphenous Nerve Sartorius Muscle Long Saphenous Vein Rectus Femoris Muscle Dr. Ir^si. Great Trochanter External Vastus Muscle Fig. 170. Inguinal Region, left side, Sth Layer. Subperitoneal Hernial Orifices. Hip-joint. Obturator Region. 7, Nat. Size. Rebraan Limited, Loudon. Rebman Company, New York. Fig. 170. Inguinal Region, left side, 5th layer. Subperitoneal Hernial Orifices. Hip-Joint. Obturator Region. The Inguinal Region and neighbouring parte have been exposed layer by layer in an adult male; above Poupart's Ligament the Subperitoneal Hernial Ori- fices are exposed. At the level of Poupart's Ligament Muscles and Vessels are cut across so that the Muscular Compartment and the Vascular Compartment (opening for Femoral Hernia) are seen. Below the Ligament on the inner side a piece of the Pectineus has been cut out so that the opening of the Obturator Canal (external opening of Obturator Hernia) is shewn; on the outer side the Hip-foint has been exposed and the joint cavity widely opened. The Hip-Joint lies immediately external to the Artery but on a much deeper plane. The Anterior Crural Xerve lies almost o\er the middle of the Head of the Femur. The Head of the Femur can onl}' be felt from in-front, in ver}' thin people. So that owing to its deep situation and its proximity to the large vessels, the Hip-Joint is not \ery easih' accessible from in front. The Internal and External Circumflex Arteries, of considerable size, are given off from the Deep F'emoral Artery, but one of them, occasionally both, may come off from the Common or Superficial Femoral Artery. Internal to the vessels is a landmark of some importance. If the Pectineus Muscle be removed the External Obturator Muscle is exposed as it arises from the outer surface of the Obturator Foramen and the Obturator Membrane, and runs outwards to the Digital Fossa. The Membrane closes the Obturator Foramen except at its anterior and external angle; here a small gap hardly Vo^h inch in diameter allows the Obturator Vessels and Nerve to pass. A hernia may protrude through the orifice — Obturator Hernia — its position proves the difficulty of diagnosis, and its close proximity to the Obturator Nerve sometimes causes pain in the area of distribution of the nerve owing to pressure by the Hernia. The figure also shews structures passing under PouPART's Ligament which together with the upper border of the Pelvis forms a large slit-like space divided into two compartments by the Iho-Pectineal F"ascia. This fascia, which is derived from the Fascia covering the Iliacus Muscle and accompanied the Ilio-Psoas down to the Lesser Trochanter of the Femur, is firmly attached to the Ilio-Pectineal Eminence. In the outer compartment is the Ilio-Psoas Muscle with the Anterior Crural Nerve embedded in its anterior surface. In the inner compartment are the Large Vessels and the Pectineus Muscle. Between the Femoral Vein and the outer margin of Gimbernat's Ligament there remains a small space filled by loose connective-tissue; this is the Femoral Ring, the most important spot at which the Peritoneum can readily be pushed forward and give rise to a Femoral Hernia. Here we find situated the Deep Inguinal Lymphatic Glands, one of which goes by the name of Cloquet's Gland. A Femoral Canal does not exist (as a preformed Canal) in normal sub- jects. It is the result of the descent of a Femoral Hernia. c ■> '•5 3 •3 .S *-> ■& bo C c _o 3 0 D >. c c -J-> X oT aj C . 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Sartorius \fust:l loner Head of Gastrocnemius Muscl I^'ppcr pnrt of Sartorius Muscle Vein accompanyintr the Superficial Femoral Vein Fascia Lata IIl'xter*s (Adductor) Canal Tendon of Adductor Magnus Saphenous Xervc Anastomotica ^fagna Arter>' Vein accompanying the Popliteal Vein Intfrnal Vastus Muscle Adductor Tubercle on Inner Condyle of Femur Long Saphenous Vein Saphenous Nerve Fig. 173. Hunter's Canal and Popliteal Space, left side, seen from the inner side. (Jobeet's Fossa.) 7, Nat. Size. Rebmau Limiteil, I^udon. Eebman C'omp.iny, New York. Fig. 173. Hunter's Canal and Popliteal Space seen from the inner side. (JOBERT's Fossa.) Left Leg of a girl aged 75 years. A piece has been citt out of the Sartorius Muscle. In the upper part of the thigh the Femoral Artery hes on the anterior aspect of the limb, lower down it is on the inner side and finally on its posterior aspect. In its course the Artery crosses the Femur at an acute angle. Above the Artery lies internal and superficial to the head of the bone but subsequently it approaches the inner side of the shaft, and gets on to its posterior surface. The course of the Artery is almost in a line drawn vertically downwards whereas the axis of the Femur is oblique, thus the crossing is brought about. Above the Artery is in front of the Adductors but as these muscles, e. g. Pectineus, Adductor Longus and Adductor Magnus, are inserted by a broad membranous tendon along the entire length of the Linea Aspera from the Lesser Trochanter as far down as the Inner Condj'le, the Artery mu.st pierce this tendon in order to reach the posterior surface. This occurs in the Adductor or HuNTER's Canal. Below the apex of Scarpa's Triangle the Artery is covered by the Sar- torius Muscle and rests upon the Adductor Longus Muscle. About the middle of the thigh it reaches Hunter's Canal which is formed by a strong Aponeurosis spreading from the Adductor Longus and Magnus Muscles over the Vastus Internus Muscle. At the end of this canal the artery pierces the Adductor Tendon. This canal bounded in front by the Aponeurosis mentioned, behind by the Adductor Longus and Magnus is about 2 inches long and terminates at the junction of the middle and lower thirds of the thigh. The Long Saphenous Nerve enters the canal with the Artery but perforates, in conjunction with the Great Anastomotic Artery, the Anterior wall of this Canal about its middle. Two accompanA'ing Veins pass through the Canal with the Arter}': of these veins, one is usually very diminutive. The 3 Perforating Branches of the Deep Femoral Artery perforate the insertion of the Adductors in a similar way, to gain the posterior aspect of the Thigh. For operations — e. g. in cases of Acute Osteomyelitis — which require exposure of the Femur throughout its extent, the outer side is chosen because internall}' and anteriorly the large vessels are in the way; on the anterior aspect the upper cul-de-sac of the Knee-joint may be injured, posteriorly the Sciatic Nerve and lower down the vessels. On the outer side there are no important Vessels or Nerves. Figs. 174 and 175. Transverse Sections through the Thigh at the end of the upper and middle thirds. Frozen Section. Three powerful groups of muscles surround the thigh and enclose it so completely that the Great Trochanter and the Condyles alone remain subcutaneous. In front, the Quadriceps Extensor (Rectus arising from the Anterior Inferior Spine and brim of the Acetabulum, Vastus Internus, Vastus Externus and between these the Crureus arising from the Femur); internally, the Adductors (Adductor Brevis, Adductor Longus, Adductor Magnus, Pectineus and Gracilis) arising from the Pelvis; behind, the Flexors (Biceps, Semimembranosus, Semitendinosus) arising from the Tuberosity of the Ischium with the exception of the Short Head of the Biceps. The Extensors increase in mass as far as the lower third because they receive fibres from the Femur. The Adductors diminish regularly until they merely form a tendon at the Knee-joint. The Flexors are reinforced by the Short Head of the Biceps and diverge at the Popliteal Space to the outer and inner sides respectively. A very strong fascia surrounds the muscles of the thigh enclosing them so tightly that after division of the fascia the muscles protrude through the slit, like a hernia. The fascia is strongest on the outer side because it receives the tendinous expansion of the Tensor of the Fascia of the Thigh, and of the Gluteus Maximus. From the Fascia two membranous Septa stretch to the bone, thus dividing the muscles into z groups: the External Septum extending from the great Trochanter along the outer Hp of the Linea A.spera down to the External Condyle; the Internal Septum from the Lesser Trochanter along the inner lip to the Tendon of the Adductor Magnus. The figures shew the different positions of the Femoral Artery. In V\g. 174 it Hes just above the slit in the Adductor on the inner side, and slightly anterior to the Bone. In Fig. 175 it has already reached the posterior aspect of the Bone. The Deep Femoral Artery is still visible as a large vessel in Fig. 174 between the Adductor Longus and Adductor Magnus. It diminishes rapidly in size by giving off the Perforating Arteries. While the Anterior Crural Nerve divides rapidly into its branches so much so that the main trunk is no longer evident in our figures, the Sciatic Nerve remains distinct on the back of the thigh, being well surrounded by fat and lying in the triangular space between the Adductors and the already diverging Flexors. In Fig. 175 the nerve has already divided into External and Internal Popliteal Nerves, which, however, lie in close apposition. The Adductors and Flexors are less distinctly separated from each other than they are from the Extensors. The Sartorius has throughout its course a special canal, formed by the .splitting of the Superficial layer of the Fascia. This statement holds good also for the Gracilis and Rectus in the upper part of the thigh. The thin special fasciae of the F"lexors and Adductors are easily perforated b}- pus. They are practically lymph spaces between the muscle.s and their neigh- bouring parts. RiTtiis Kcnioris Muscle Internal Vastus Muscle External Vastus Muscle fa 1 f 1 ] .ml Artery All t r Long-US Muscle L ^ Saphenous Vein Gr cilis Muscle A.Miirlni- Ma^jnus Muscle Luny Ile.i.l nl" Hic.ps Sciatic N'erve ', Semimembranosus Muscle Semitendinosus IVIuscle Fig. 174. Transverse Section through the Junction of Upper and Middle thirds of the (right) Thigh. Seen from lielow. — -/a i^'At. Size. Rcttiis Fcmoris MiiscK- Periusteimi uf Femur ExtcriKil Vastus Mus( Fascia L; tl _^ /o ^ ^/^ // ^ / External Inter- / il r, ^ muscular Septum Short Head nf Biceps Muscle Extern;il Popliteal _ \\j' (Peroneal) Nerve uTTi^ Internal Popliteal (Tibial) Nerve Long Head of Biceps Muscle Semitendinosus Muscle Intern il \' istus Muscle Vdductur ^lagiius Muscle Int rnal Intermuscular / ^ \ \^ Septum Femoral Artery Saphenous Xeive -^ Hunter's Canal Sartnrius Muscle L ng Saphenous Vein Cr icilis Muscle Semimembranosus Muscle Femoro- Popliteal Vessels (cf. Toldt, Note 313) Small Sciatic Nerve Fig. 175. Transverse Section through the Junction of Lower and Middle thirds of the (right) Thigh. Vb Nat. Size. Kebniau Llinitod, Loiidtm. Rebmun (.'oiiipaiiy, New York. ExtiTiial liitermusciil. Septum Superior Pmirh of Joint Fasciii Liitii Internal Vastus Muscle^ Superior lixtern;il Articular Artery Subcutaneous Prepatellar Bursa Subfascial Prepatellar Bursa External Condyle Alar Linanient External Semilunar^ Cartilage Inferior External Articular Artery Ilio-Tibial Band Biceps Muscle Deep Infrapatellar Bursa Patellar Ligament' Anterior Tibial Muscle Common Extensor of Toes Tendon of Poplitcus Muscle Tibiu-Eilnilar Articulation Peroneal Nerve tExt. Popliteal) Outer Head of Gastrocnemius Muscle Soleus Muscle Peroneus Longus Muscle :.^s^,^.viv,^^ Fig. 176. Left Knee-Joint aiid Surrounding Structures. Seeu from the outer (leftj side. — ^4 ^^^' S^^^- Kebman Limited, Londou. Robman Couipauy, New York. Fig. 176. Left Knee-joint and Surrounding Parts. Seen from the outer side. Preparation made from a female aged 75 years. Plaster of Paris had been injected into tlie Knee-Johit. Boundaries of the Joint-Cavity (pink) ; the Tibia- Fibular Articulation which does not communicate with the knee-joint, dark red. The independent biirsae around the knee-joint (blue). The lower parts of the Vastus Externus and Biceps Muscles have been removed; the attachment of the Ilio-Tibial Band and the insertion of the Biceps into the Head of the Fibula and into the Tibia are preserved. The Fascia Lata of the thigh is continuous with the Fascia enclosing the leg, and is reinforced by a broad strand of fibres the Ilio-Tibial Band of Maissiat, which is derived from the Tensor of the Fascia of the Thigh and some fibres of the Gluteus Maximus Muscle; this Band runs down to the Tibia, and blends with the Capsule of the Knee-joint. It checks Adduction of the Thigh. The figure shews the extent of the Knee-joint Cavit}' and of the upper cul-de-sac, which practically always communicates with it, distended as is the case in serous, purulent or haemorrhagic exudations. One observes that the greatest extension of the joint is possible in the forward direction. A tense effusion pushes the Patella and the Common Extensor Tendon away from the bones, so that, under these conditions, the Patella is not in contact with the underlying bones but rides or dances on the fluid. Laterally no great degree of bulging is possible, firstly, because the Synovial Cavity does not reach far eitlier upwards or downwards over the joint- slit ; secondly, because the extremely strong lateral ligaments are tightly stretched. Posteriorly around the Condyles of the Femur, the capsule is more extensible. In addition to the Prepatellar Bursa (cf. explanation to Fig. 181), and the deep Infrapatellar Bursa, which lies between the Tibia and the Ligament of the Patella, the almost constant External Inferior Bicipital Bursa is shewn lying be- tween the Biceps Tendon and the External Lateral Ligament. Like the bursa above mentioned, this never communicates with the Knee-joint. Further, the vessels which take part in the anastomosis on the outer side of the knee-joint are visible. The blood-supply of the Anterior Aspect of the Joint which has to bear much pressure (e. g. in kneeling) is abundant. On the inner side, the Superior and Inferior Internal Articular Arteries, on the outer side, the Superior and Inferior External Articular Arteries, form the Anastomosis which is reinforced by the Great Anastomotic Artery, and the Recurrent Tibial Artery. The Anastomosis is partly superficial between the Patella and the Skin, partly deep between the Tendons and the Ligaments. Fig. 177. Sagittal Section through the Knee-joint during Extension. Frozen Section ilirough the External Condyle of the Femur and the Tibia; the Patella is not cut along its greatest longitudinal axis. The Knee-joint is easily accessible from in front or either side, onl)' on its posterior surface, do we find large muscles and between them important Nerves and Vessels. This Synovial Cavity is the largest in the body; moreover, it is the most complex joint on account of its various Intrinsic Ligaments. The insertion of the Capsule is different on all sides. The joint-cavity extends highest in front, as far as 1^/4 to 2V4 inch, above the margin of the Patella, if we take into account the Subcrureal Bursa, which nearly always com- municates with the Joint. On both sides (cf . Fig. 1 80), the insertion of the Capsule reaches close to the line of the joint, posteriorly, it extends upwards as far as the upper limit of the Condyles of the Femur, below it follows the Tibia to a lesser extent. Thus the anterior and posterior surfaces of the Femoral Condyles are within the Synovial Sac, but not so their lateral surfaces. The anterior wall of the Capsule is formed above by the Tendon of the Quadriceps; between this tendon and the anterior surface of the Femur there is always a Bursa which is of importance because it communicates, occasionally in children, but invariably in adults (98 %)' by a more or less wide opening (cf. course of a director in the figure), with the Joint-Cavity. This Bursa may, therefore, be regarded as a part of the Joint-Cavity, and be called tlie upper cul-de-sac of the Knee-joint. Accumulations of fluid within the Knee-joint cause bulging at this spot. Below the point of insertion of the Quadriceps Extensor to the upper border of the Patella, the wall of the joint is formed by the cartilaginous covering of the posterior surface of this bone. The Ligamentum Patellae attaches the lower border of this bone to the Tubercle of the Tibia. Between it and the Tibia lies the deep Infra-patellar Bursa which does not communicate with the Joint on account of its being separated by a large Synovial-fold — Plica Synovialis Patellaris. This is attached to the Intercondylar Fossa (Crucial Ligaments) by sagittal fibres. Between the Tibia and the Femur, the External Semilunar Cartilage is seen in the figure, its inner concave margin is sharp, its external convex margin is firmly connected with the capsule of the joint. Popliteal .Vitciy Internal I'opliteal Xer External Seniilunaa- Cartilage Giistrocnemius ituscle Fibul, Anterior Tibial Artery Quadriceps Extensor Subcrureus iluscle . Bursa under Quadriceps - ^-' ' ii Extensor Prepatellar Bursafc - Patellar Ligament Ligamcntuin Mucusum utellar Bursa Fig. 177. Sagittal Section through the (left) Knee-Joint during extension. Seen from the inner (right) side. — % N^at. Size. Rebman Limited, Loiidou. Kebmau Comjiany, New York. Superior Puuth of Jnml TcnJun of Quadrict'ps Extt-nsor Patelli Subfascial Prcp.itolliir Bursa SubfuUneous Pr4i>atellar Bursa Anterior Crucial Ligament External Semilunar Cartilage Liga men turn Mucosum Popliicus Muscle Ligamcntum Patellae Deep Bursa under Patella Subcutiint-ous Bursa o^ tr. Tubercle of Tibia fctus Fcnioris Muscle Subcriireus Muscli- Jntcrnal Vastus Muscle Short Head of Biceps Musdc Kxtrrn.il I'opliU-al (Peroneal) Nerve Popliteal Vessels Internal Popliteal (Tibial) Nei-vc Short Saphenous Vein ~ Intfrnal Sural Cutaneous Nerve Gaslrocni- Soleus Muscle Peroneal .\rtery Posterior Tibial Muscle Interosseous Membrane Anterior Tibial Muscle Pig. 178. Sagittal Section through the^deft) Knee-Joint during flexion. Seen from the outer (left) side. — Vi Nat. Size. Kcbiiuin LiniUcd, Ixiudon. Rebnian Company, Nch York. Fig. 178. Sagittal Section through the Left Knee-joint during Flexion. This preparation was made from a man aged 82 years. Formal was injected into t/ie limb, and the knee, forthwith, flexed to its utmost limit, was kept in that position. On the following day the section was made without freezing. In spite of advanced age and a high amputation through the right leg this joint ivds quite normal. In contrast with the extended position (Fig. 177) this figure indicates the relations during extreme flexion. As the section has been carried almost through the middle of the joint, a larger part of the Intrinsic Ligaments is shewn than in Fig. 177. As the Patella is fixed by the Ligament of the Patella to the Tibia, the Patella leaves the Anterior Surface of the Femur during flexion, and comes to lie in front of the Joint-slit, which it does not cover during extension. The Capsule is folded backwards, and the Vessels and Nerves are extremely bent. To such frequent bandings of an imperfect elastic arterial tube, is attributed the main cause of the not-uncommon aneurysm of the Popliteal Artery. Of the 2 Crucial Ligaments, the figure exhibits the Anterior : this extends from the depression in front of the Spine of the Tibia (Anterior Intercondylar Fossa) upwards, outwards and back- wards to the inner side of the External Condyle; its function, like the Posterior Crucial Ligament, is to check excessive rotatory movements. The Plica Synovialis Patellaris fills up the space between the Patella, Articular Surface of the Tibia, and the Crucial Ligaments. One of the most striking changes which occurs in this joint during flexion, is relaxation of the External Lateral Ligament — this is not seen in the figure — . Attached to the Femur eccentric to the axis of flexion, this ligament becomes tense during extension and prevents rotation, but during flexion it is relaxed and allows inward rotation of the leg. These movements, however, are limited by the Crucial Ligaments. A glance at the figure shews its complexity. Contrary to the other large joints, which either have a free joint cavity or are at the outset traversed by one tendon (e. g. Shoulder, by tendon of biceps. Hip-joint by Ligamentum Teres), the interior of this joint contains a complicated arrangement of ligaments which lead to the formation of numerous pouches. In cases of suppuration in the Knee-joint, the purulent products, therefore, tend to remain in these recesses and clefts, and are only removed with difficulty. o .4 m Ok o 0) a > ja +j z 4J z CO p ci CO 4) cq a z 3 o > ,_) OS OJ ^-tj CO < ;d cu •iH cu » 4) Jd o H o 00 H •« bo 1^ ■5, CO 1 ^ V ^ SO , « w ^ t4-H ^ o (U =■ s§ 'a W •s ° 1/5 o "a ■w I-. ni M > c o (J n U b ■S •a o xi If) M-< i-T 4-* +J rG > :-. & o 0) ^ (T) c ■c c != CD 4-» •V O C '— +-' 5 "i c o •a c O) 4-' D o o be m OJ •- 3 o .ti 3 O ft ni t~- ^ OJ .ii O •a c 0) > O o ni ^ I ^ 8 £ o o -i-t o I s % C c o o c be (D c .2 o 0) ■a C H be 0) be c 0) a; 4) XI ^ ^' -a ■a ^ .-s c bo o W 0) 3 O 'ft OS tn ft ■ft M 0) •a 3 O >^ =. -3 '^3 ti .5 ^ I O 13 H •5 3 0) ft O CT 4-> O 3 •- < (U -O b ft o 3 O o ni H (U o a; en ft ni U 4) 43 43 1) 43 en 3 43 o 4) ft eu ^ be "O r- 0) 3 ^ 4-. 4) 43 ^-i en eS be 3 O 3 '- O o o ft 4) -" en 43 ft 4J O •=• -w ft 4J 43 be _3 "E 4) O O) ■J-" O u ft 3 O en !-, 0 ft be 3 E •= >> 0) y en 3 u 4J O 4J 3 ni 43 O o ° en 3 4) 5 S (U e»j 4) 41 43 4) 3 „ ;^ .3~ --^ X ft 4) >^ ni 4) 43 ft ft £ M £ 43 4J rW 3 ni o 43 *'— 1 3 ^ TJ 42 O > - nS o -^ d i; & C ni 5 -a 43 O) 4-1 -4-4 X 1/ -a 3 nj ni O .S 43 en ' &^ .22 1-4 "" ft 3 ft o 5 '-3 be 4) ^ 4J 3 3 4) /I 42 rt 4) .3 4-» b 4J en 3 43 ft 4) .22 4J 43 O .t^ en _ci " ft -^ -^ eu M 43 7; H 4) ft .-tl o XI W c - •-» r 1 ^ t3 ^ O &(1 rt i 1 ^ o rt m -r o rt 3 t; C|-l 0) O) o ' " ai 5 rt ^*- -fj S3 a; o 0) u '7) Ph d 00 tH bin J^ a = '^,- Xrr so o •7 a> O) fi w ^ z += r> ^ rd &c 03 u ?; <> a> > •S «D w -^^ 5h o rfl rjS -T] OO (U ^ &0 1 P 03 ^^ PI « o ^ 3 S «t-i - S o CQ ^ -4-J -^ g -♦J -(J l c D9 ;i under Tendi' ^^ A(hilli^ Internal Annular Ligament Fig. 190. Region of (right) Internal Malleolus from behind. Nat. Size. Kebman Limited, London. Rebman Company, New York. Fig. 190. Region behind the Internal Malleolus. Right Leg of a girl aged 75 years. The region around the Internal Malleolus is exposed in layers. ^ windows have been made in the Deep Fascia and Internal Annular Ligament. The Long Saphenous Vein runs in the Superficial Fascia as far as the Internal Malleolus accompanied by the Long Saphenous Nerve. The Fascia of the Leg is strengthened behind the Internal Malleolus by thick bands of fibres which radiate from the Malleolus towards the inner surface of the Os Calcis and Plantar Fascia — the Internal Annular Ligament. This Ligament forms a bridge under which tlie Flexor Tendons, Nerves and Vessels pass to the sole of the foot. Nearest to the Internal Malleolus under this fascia and in a strong Apo- neurotic Canal the Tendon of the Posterior Tibial Muscle passes, next to this the Tendon of the Long Flexor of the Toes. The Tendon of this muscle crosses the Posterior Tibial Muscle in the Leg from within outwards. Nextly, the Posterior Tibial Vessels lie between the Long Flexor of the Toes and the Long Flexor of the Big Toe so that, for ligature of this vessel, the mid-point between Internal Malleolus and Tendo Achillis serves as the landmark. Directly posterior to the Artery is the Posterior Tibial Nerve or its ter- minal branches. — Internal and External Plantar Nerves. — The space posterior to this and extending as far back as the Tendo Achillis is occupied by fat; in this is found the Tendon of the Plantaris which is inserted into the posterior part of the Os Calcis, along side of the Tendo Achillis. By pushing the Vessels and Nerves forwards, the posterior segment of the Ankle-joint can be reached. The Long Flexor of the Big Toe passes over the middle of the joint. Between this and the other tendons, posterior to the Inner Malleolus on the one side and the Peroneal Tendons behind the outer Malleolus on the other side, the Capsule of the Joint may bulge in cases of effusion into the joint, because it is not strengthened at these points. For operations, such as Ex- tirpation of the Capsule in Tuberculosis, the joint is accessible from behind. The arrangement is analogous with that on the Anterior Aspect of the joint near the Extensor Tendons (cf. Fiy. 193), there is, however, the difference that, owing to its deeper position, the swelling of the joint is only noticed posteriorly when extensive. It becomes visible when the hollow next to the Tendo Achillis is filled out. u V s 4) Q o o fa •a, o V o to Ok bo fa 4) 4) 09 o o fa bo o o CO H bis fa S'-^ ^ Ql E^ "S ^ — 1 (/I I- a. -a X) « o 4> ;/! 4) 2 — 2 p 1) 3 Ki -^ s ■•-* U3 — nj . ^ E .a £ Q p 60 T3 9 S - .2 5 :S g ^ 5. S? § 2 ^ Q .^ ^ >- ^■. ^ "3 a, rt 2p o o o f^ "T "S ¥ -^ c ■4-* }-4 o r •= •= £3 -C s ^ ^ -s a. a. 3 H o < &■ ■- ^ 3 3c <" oi ra 3 ~ a, E o u _ ^ -^ H .12 O "< ~- o .SP 3 pq o ■^ r^ ^I^ _c ^^ 4) rt J3 ^ ^ X '^ 5; -s ■" 3 O S. o - H « o 2 bo nl .2 S ^ (D td 4J '^ -O 4> O ^ . u o C -:; 3 2 ^ s u rt 2 - " G n! oJ =« e °^ .2 >? 4) " W -S J3 4) <* -? O !* -o H .d ^ bo ^ 4) J2 t« ^ O c 4J _« ^ " - ra "^ 4J ^ . ., "iS 4J 3 X H K S ^ H c 4) O 3 ^ O "^ ■a 3 3 (U u XJ o 4J 3 3 __ 3 ? .12 ca Ph 2 S ^ o -^ O I ^ ^ 41 o Ri S 3 o -a ■^ (1, < "S <=! a; 4) n 3 ^ B 3 S o O .t: - H CM 4> O X. J^ £5 O I- ^ a u O =5 4J -^ -3 4> O, ^ i - S .> 9r o a, < 3 • SI 4J ^ 3 Oh 4) "o I I' ^ OJ f T3 O -S lU 4) *-" .^ FT* 41 4} c20 60 . s § 60 22 3 3 cs 4) 4) 5 O X ^ TJ 2 -S .s -5 .- ^ 5 ^ U i5 S Ph O O n! 4) 4) "^ 4) r; to 3 .3 3 -2 "-3 4; .3 !/i 4) rt -^ 4> ■" a m a 3 rt 3 tOu_ 3 O 4) .»^ •;: O I S A H .. X IB ^ -"^ '^ -^ i; 3 ^ o « 4) D Tj -3 4) — CO ^ 4; 3 1-1 nJ a. 5 -3 3 3 flj •-. M j> 3 4) a-^S W 3 41 3 -O o 4J o 0) G X, P •" ^- a 5 .5.-1 - Cm ;g - X. 4) tfl X 4) S £ _• nl cfl '^ I, E^ .3 3 a, O 4J ■ o ^ 3 .2 g o > l-l s a o J? bo' 3 O X X ^ "OS O 4> ■a == _ o > X o <; a,^ CO '-' fi 4> >-• CJ O <; 4) 4) O bo S 4; .3 .i:i 4i 4> C H ' ^ ^« -3 ^ cd ^ *^ -3 -^ "^ ""■ 3 rt tri x; bo 3 o 1-1 -1^ 60 O ■^ 3 — ^ S 41 ^ "^ > "i^ -• ^ 3 60 41 ^ 2;f^ tfl 4) J: S o nJ 3 O 4) li:: CO (U u c^ ^ O « .-- S 4) ' — 4J .3 4) O X "O ^ 3 o H o -5 "5 3 3 „ ni C -^ ^^ -^ a c- ■<; - S w fe .5 ^H £ 2 ■- 2 5 .2 3 1-. t-H 4) 3 _ rt ■- O 3-"h 3 cS 1) ■" 60 J2 o b c« bo 3 iJ 5 ^x <; 4) "i; <; o t« 4) ca 5 ?, ■=: Ph s 3 13 3 o n! CI) rri 1 41 X 1 O H M 1) 4) 41 »i 3 3 3 O [=4 O _ o 3 -3 Ph ■- 4> X 4! „ o c6 lU OJ .3 .y >*- j: j3 r/1 -P 2'C 3 Rl fi c O O ■a 3 2 £ "5 ■V m -x 3 3 41 4) -3 -3 CO — O ■*-» — ;s 41 3 E-1 a'^ — *S a;, .3 3 X ■'3 _rt -^ .-2 Ph '- "^ — "a, S ca £ M O "^ C ! 3 o a -- s o 3 ca X ^ o u Ph CO ca 3 t« 4) bo O .3 3 -^ O T3 ^3 4J "O -3 SS 4) ■£ -3 _ca •a 3 JJ ca .3 O c a, X a -8 a. -3 a 2 „ 2 « c; OJ i:: _c 4) Ti ca boPn 3 S5 « .a .3 & CO -M ca R a, S ■*H '^ a J- 4) O 4) §« m ^ ca 3 CJ RJ '"V i> 4J O '^ X rS .a W ca -^ Fig. 197. Frontal Section through the (Right) Ankle-joint. Frozen Section. As the section did not pass directly t/irotigh the tip of the External Malleolus some tissue was removed in order to expose this prominence. The Tibia and Fibula by means of their Malleoli form a socket which grips the Astragalus. The External Malleolus extends to a lower level than the Internal ; the joint cavity extends upwards between the lower ends of these bones forming a recess caUed the Inferior Tibio-Fibular Articulation. To the Tibia and Astragalus the Capsule is attached along the border of the articular cartilages (on the anterior surface only does the Capsule extend to the neck of the Astragalus). By this arrangement a considerable portion of the Neck of the Astragalus may enter the joint cavity in extreme dorsi-flexion of the foot. Cor- responding to the free movements in Dorsal and Plantar Flexion, the capsule is loose in front and behind, so as to form folds (vide Fig. 199) but on either side strong tense ligaments attach the Malleoli to the Astragalus and Os Calcis: the Deltoid Ligament extending from the Internal Malleolus to the Astragalus and Sustentaculum Tali, the Anterior and Posterior Astragalo-Fibular Ligaments and the Calcaneo-Fibular Ligaments extending from the External Malleolus to the Astragalus and Os Calcis respectively. The ankle-joint is therefore not easily accessible from the side; behind, it lies at a considerable depth under the Tendo Achillis, but can be reached (cf. Fig. 190). Its anterior aspect, on either side of the Extensor Tendons, is the i^ost accessible (cf. Fig. 193). This figure also shews the position of the Peroneal Muscles enveloped in their sheaths below the Outer Malleolus and the position of the Flexors on the inner side. The Posterior Tibial Artery and Nerve have already divided into Internal and External Plantar Branches which are now lying in a well-protected position between muscles. Between the Astragalus and the Os Calcis, the Posterior Calcaneo-Astragaloid Articulation can be seen ; this lies at a slightly higher level than the tip of the External Malleolus. The Anterior Calcaneo-Astragaloid Joint which is separated from the Posterior by the Interosseus Ligament (v. Fig. 199) is not an independent joint but is a part of the Astragalo-Scaphoid Articulation, whereas the Posterior Calcaneo- Astragaloid Articulation is quite independent and liable to independent affections. If swollen it bulges forwards and outwards to point anteriorly at the Tip of the External Malleolus. The movements of Abduction and Adduction are limited at this joint. The inner border of the foot is arched and does not touch the ground. Fig. 198. Transverse (Frontal) Section through the Anterior Part of the Tarsus. Frozen Section. The Foot is arched both Antero-posteriorly and Transversely. The Trans- verse Arch, shewn in the figure, begins posteriorly where the Os Calcis with its Sustentaculum Tali forms a semicircle (v. Fig. 197). A little further forward the Scaphoid and Cuboid Bones form an arch, whereas in front of these the arch becomes more definite as the Cuneiform Bones with their broad Dorsal and narrow Plantar Surfaces closely resemble the stones of an arch. The Longitudinal Arch is still more pronounced in the Metacarpal Bones. The Plantar Vessels and Nerves run forward under cover of this arch which serves to protect them from pressure (due to the weight of the body). Fig. 199. Longitudinal (Sagittal) Section through the Foot. Frozen Section carried through the middle of the Tibia and the oitter part of the 2nd Toe. This figure shows the Longitudinal Arch w^hich is most marked on the inner side. The inner tubercle of the Os Calcis and the head of the ist Metatarsal Bone form the PiUars of this Arch. On the outer side of the Foot the arch is less curved; here its Anterior Pillar is formed by the base of the 5th Metatarsal Bone. The Astragalus forms the Keystone of this Arch. Strong ligaments bind together the bones on their Plantar Aspect and firmly brace up the arch; the Plantar Fascia stretched across from the Inner Tubercle of the Os Calcis to the Heads of the Metatarsal Bones acts Uke a bowstring. Mention must also be made of the assistance rendered by the Tendon of the Posterior Tibial and other Muscles in keeping up the Arch. This figure further shews: a Bursa (alwa3's present) between the Os Calcis and Tendo AchiUis. (A Bursa between the Tendo AchiUis and the Superficial Fascia is rarely met with.) The cavity of the ankle-joint extends backwards nearlj' as far as the Posterior Calcaneo-Astragaloid Articulation. In front it is Vsths inch distant from the Astragalo-Scaphoid Joint. This explains why inexperienced persons, when per- forming Chopart's disarticulation, easily open the ankle-joint instead of the Astragalo-Scaphoid Articulation. The figure shews also that the Posterior Calcaneo-Astragaloid Articulation is a complete joint, whereas the anterior is merely a part of the Astragalo-Scaphoid Articulation. >^ a> a> P o o . O 02 04 a> bo ^^ ^H ._ M SCO gm ^£ t^i o"= o Si o o bo 00 3 a> Anterior Tibial ^^us«■lc T-ong Saphenous Vein. Saphenous X Annnlar Ligament Anterior Tibial Xerve- Dorsal Arterv nf Foot Plantar Arch 1st Dorsal (Metatarsal) Artery Mnsnilo-Cutanrous; Nerve Superior (Vertical) Annular Ligament — Short Saphenous Vein Limp Extensor Muscle of the Tots Short Saphenous Xervc Short Extensor Muscle of the Toes Peroncus Tcrtius Muscle Dorsal Venous Arch of Foot Fig. 193. Region of AnMe and Dorsum of Foot. Nat. Size. Reliman Limited, Ix)ikIoii. Rebman Comp.^iny, New Yuik. ^ig- 193' Region of the Ankle and Dorsum of Foot. Left. Preparation from a girl aged 75 years. The Fascia of the Leg and Dorsum of the Foot has been removed, but the Superficial Veins and the Anterior An- milar Ligament have been preserved. The open network of superficial fascia which occurs in this situation, con- tains little fat, but is rich in a Venous Plexus which terminates on the inner side in the Long Saphenous Vein, and on the outer side in the Short Saphenous Vein. The Fascia extending from the leg to the foot is considerably strengthened above and over the ankle by the Superior and Anterior Annular Ligaments. The latter is formed by a series of fibres which run from the Internal Malleolus outwards and downwards to the outer border of the foot, these fibres are crossed by another series of fibres which run frorn the inner border of the External Malleolus. These fibres are no independent structures but thickenings of the Fascia; they can only be displayed artificially (cf. Fig. 193). The Extensor Muscles present the same relations as in the Leg. On the inner side, the Anterior Tibial Muscle is inserted into the Scaphoid and base of the first Metatarsal Bone, externally to this the Long Extensor of the Big Toe runs to the terminal phalanx of the Big Toe, next the Long Extensor of the Toes to the 4 outer Toes, and lastly the Peroneus Tertius (Third Peroneal) Muscle to the Tubercle of the 5th Metatarsal Bone. Arising from the first part of the upper and outer surface of the Os Calcis, deep to the Tendon of the Long Extensor of the Toes, lies the Short Extensor of the Toes, with its obliquely directed tendons which blend with the Long Extensor Tendons to form the dorsal aponeurosis of the toes. Between the Metatarsal Bones appear the Dorsal Interosseous Muscles. At the mid-point between the 2 Malleoli and between the tendons of the Long Extensors of the Toes and Big Toe is situated the Anterior Tibial Artery ; in its continuation below the Anterior Annular Ligament it is called the Dorsal Artery of the Foot which runs over the middle Cuneiform Bone onwards into the 1st interosseous space, where it anastomoses with the External Plantar Artery. The Anterior Tibial Artery gives off to each Malleolus — a Malleolar Branch — , the Dorsal Artery of the Foot, to both inner and outer sides of the Foot a Tarsal Artery. The Anterior Tibial Nerve generally on the inner side of the Dorsal Artery of the Foot, supplies tlie Short Extensor Muscle of the Toes and gives a Cutaneous Nerve to the contiguous sides of the Big Toe and the 2nd Toe. On either side of the Extensor Tendons and between the tendinous bundle and each Malleolus is a space of considerable importance, because at these points the Capsule of the Joint is only covered by Skin and Superficial Fascia without any accessory strengthening fibres. At no other place is the joint so exposed or so readily accessible. Moreover by a bulging of these spaces an effusion into the joint will be first observed. Fig. 194. Outer Side of (Left) Foot. Preparation from a girl aged /j years. The Fascia over the Dorsum of the Foot has been removed with preservation of the Annular Ligament, Superficial Veins and Nerves. Fascial Bands which bind down the Peroneal Muscles are slieivn (Retinacnla Peroneorum). Synovial Sheaths of Peroneal Muscles pin k. The Superficial Fascia behind the External Malleolus contains the Short Saphenous Vein and Nerve. Over the External Malleolus, (in V2 to Yj cases), there is a small Subcutaneous Bursa. The Peroneal Tendons are held within their grooves behind the External Malleolus b}' strong bands similar to those on the inner side which are derived from the Anterior Annular Ligament. Without these ligaments a displacement of these tendons over the Malleoli would be of frequent occurrence. These bands, the Superior and Inferior Peroneal Bands are thickenings of the fascia. The Superior Band runs from the outer side of the Malleolus to the lower part of the outer surface of the Os Calcis and has under it the tendon of the Long Peroneal and deep to this the tendon of the Short Peroneal Muscle. The Inferior Peroneal Band, more distally situated, runs from the Tip of the Malleolus to the outer surface of the Os Calcis : a Septum separates these two muscles, of which the Short Peroneal lies anteriorly. Both the Peroneal Tendons are enclosed in a common sheath while in the groove directly behind the External Malleolus, but above and below this point, the sheath is bifurcated: the upper bifurcation lies under cover of the Superior Peroneal Band and the lower bifurcation comes into relation with the posterior border of the Inferior Peroneal Band. The upper end of the sheath enclosing the Long Peroneal Muscle, extends 1^/4 inches above the tip of the Malleolus; the sheath for the Short Peroneal to a less height. The lower end of the sheath of the Short Peroneal Muscle extends to Chopart's Joint but the sheath of the Long Peroneal passes beyond as far as the groove on the Cuboid Bone, here it receives a new sheath which comes almost into contact with the first sheath; a communi- cation between them never occurs. Nevertheless, the intervening septum is so thin that it is easil}' perforated by pus. By this route an Abscess of the sole of the foot may easily spread up into the leg. Again; the relation of the Peroneal Sheaths to Chopart's Joint allows, for example, tuberculosis of this joint to extend up the leg after perforating the tendon sheaths. At the Ankle such easy means for extension are not found, although the Tendons are closely applied to the joint behind the External Malleolus. The reason of this is explained by the definite separation which the strong Calcaneo- Scaphoid Ligament secures. Miisciilo-Ciitancous Xcrve Anterior Tibial Muse I.on{? Extensor Muscle of the Big- Toe Annular lAntcriorl Ligament Dorsal Arterv of Foot Short Extensor Muscie of the Big-Toe Anterior Tibial Nerve Dorsal Venous Arch of Foot 1st Dorsal (Metatarsal) Arterv Short Saphenous Ner\ t- Short Saphenous Vein Peroncus Longus Muscle Peroneus Brevis Muscle External Malleolus Upper part of External Annular Ligament (covering the Peroneal Muscles) 1 Lower part of External 1 Annular Ligament (covering the Peroneal Muscles) Tendon Sheath of Pero- neus Longus Muscle Abductor Muscle of the Little-Toe Slidft Extensor Muscle of the Toes : Tertius Muscle Fig. 194. Outer side of the (left) Foot. ■/.J Nat. Size. Robinaii Limited, Lnndnii. K('l)iii:in ror Muscle uf the Big-Tu Internal Cuneiform Bone Peroneus Longus Muscle 1st Metataisal Bone Short Extensor Muscle uf the Big-Toe Interosseous Muscle Lumbrical Muscles Transverse Adductor of the Big-Toe 2nd Metatarsal Bone Fig. 199. Sagittal Section through the (right) Foot. Seen from the outer side. — 7., Nat. Size. Rebmaii Limited, London. Ilebmau Comijany, New York. Interosseous Muscles Abductor Muscle of the Big-Toe Long Flexor Muscle of the Big- Toe Long Flexor Muscie of the Toes Internal Plantar Ner\e Internal Plantar Artery External Plantar Ner\'e External Plantar .Vrlcry Accessory Muscle Flexor Muscles of }rt\ Ti'e I Subiut.incous Met;it;irso. Phiilangeal Bursa uf the Little- Toe Pl.iiit.ir Arch Tenth 'H of Pcroneus Lungus Muscle I'eroncus Brevis Muscle Cuboid Pcroneus Longus Muscle Os Calcis Tcndo Achillis Fig. 200. Horizontal Section through the (right) Foot, near the sole. 7:, Nat. Size. Rebmau Limited. London. Rebnuin Company, N'e« York. Fig. 200. Horizontal Section through the (Right) Foot near the Sole. Frozen Section. The distal lutlf of tlie ^th Metdtarsal Bone has been freed by dissection. The result of the arching of the foot is that the body-weight is received only by a few points of the skeleton of the foot, namely; — behind; the Inner Tubercle of the Os Calais ; in front on the outer side : the Head, also the base of the 5tli Metatarsal Bone; <:in the inner side: the Head of the ist Metatarsal Bone though many consider that owing to the mobilit\- of this bone the head of the 2nd Metatarsal Bone should be looked upon as the supporting point. According to H. VON Meyer the 3rd Metatarsal Bone should be viewed as the point of support as the other bones only serve for the purpose of preventing the foot from capsizing to either side. However this ma\' be, foot-prints teach us that onl)' the heel, outer margin of foot, balls of toes and toes themselves, touch the ground normally; when the inner margin meets the ground we have to deal with Fiat-Foot. The section shews definitely the share taken by the different bones in this arrangement. The Metatarsal Bones lie at different levels; the heads of the inner three have been divided by the section which passes throughout the length of the 4th and only through the base of the 5th Metatarsal (of which its distal half has been freed by dissection). In the figure is seen the Bursa on the outer aspect of the Little Toe opposite the Metatarso-phalangeal Articulation ; this the most prominent point on the outer margin of the foot is frequently the seat of a corn produced by pressure from the boot. Inflammation readily reaches this Bursa whence it spreads to the joint which is often in communication with the Bursa. Fig. 201. Tarsal and Metatarsal Articulations. Right Side. The preparation is of a frozen foot in extreme plantar flexion; the minimmn of tissue necessary to thoroughly expose the joints has been removed witli a chisel. The Tarsal Bones articulate with each other, with the Bones of the Leg and with the Metatarsal Bones, forming as a rule 8 separate joint-cavities of which some are verj' simple (where onl)- two articular surfaces take part in the joint), others are very complicated (where several joint-spaces combine to form one joint- cavit}' by communication). In the latter case, disease spreads rapidly from one articulation into the communicating joints whereas disease of a simple cavit}' mav remain localized. The separate joint-cavities are: 1. Ankle-joint, between the Astragalus, Tibia and Fibula with an upward recess between the Tibia and Fibula. 2. Posterior Calcaneo-Astragaloid Joint (Fig. 199). 3. Articulation between the A.stragalus on the one hand with the Scaphoid and Os Calcis on the other hand (Fig. 199). The Head of the Astragalus lies in a socket formed by the Scaphoid, Calcaneo-Scaphoid Ligament and the Anterior Part of the Os Calcis. 4. Joint between Os Calcis and Cuboid; the inner extremitj^ of this joint lies exactly opposite the outer end of the former (3) separated only by the Calcaneo- cuboid Ligament. The foot can be easily disarticulated at this S-shaped articulation the Astragalus and Os Calcis being left behind. (Disarticulation after Chopart.) It is to be noticed that this joint consists of 2 separate joint-cavities so that, in disease, one may be affected without the other. 5. Small Articulation between the Cuboid and External Cuneiform. 6. Verj' complex Joint-cavit}' between Scaphoid and the 3 Cuneiforms, between the contiguous Cuneiforms, between the Middle and External Cuneiforms and the bases of the 2nd and 3rd Metatarsals and between the bases of these Metatarsals. 7. Joint between ist Metatarsal and the Internal Cuneiform. 8. Joint between the Cuboid and the 4th and 5th Metatarsals. The joints between the 5 Metatarsals on the one hand and the 3 Cuneiforms and the Cuboid on the other form a curved line which is only interrupted by the proximal projection of the 2nd Metatarsal to the extent of ^/jths inch. Disarticulation of the Metatarsals after LiSFRANC can be performed at this line. 1st Dorsal Interosseous Muscle 1st Metatarsal Bone Line of LisffailC'^ Articulation Internal Cuneiform Bone Middle Cuneiform Bone Tuberosity of Scaphoid Line of Chopart's Articulation Astragalus Tibia Cuneiform Bone ty of 5th Metatarsal Bone LisfranC's Articulation Chopart's Articulation Fig. 201. Tarsal and Metatarsal Joints exposed from above on the right side. 7, Nat. Size. Rebman Limited, Loudon. Rebnian Company, New York. posterior Branches of Lumbar Nerves Anterior Branches of Lumbar Nf*rvf^ Hio-Hj-piiffastric Xcrve Genital Branch of Gcnito- Cniral Ncr\'e Crural Branch of Genito- Crural Nen*c External Cutiineous Ner\'. Middle and Internal Cutaneous Nerves ( *btnrator Nerve I-onn Saphenous Ncrvr . Lateral Branches of Lumbar Nerves Posterior Branches of Lumbar Nerves and first 3 Sacral Ner\-es Remrrent Branches of Small Sciatic Nerve External Cutaneous Nerve Small Sciatic Ncr\-c Obturator Nerve - Long Saphenous Nerve - External Popliteal Nerve External Popliteal Nerve Musculo -Cutaneous Nerve Short Saphenous Nen^e External Calcanean Nerve Internal Calcanean Nerve Anterior Tibial Ner\'e — Internal Plantar Nerve Short Saphenous Nerve External Plantar Nerve ^r- r fee. Fig. 202 and Fig. 203. Ai'eae of Distiibution of the Cutaneous Nerves of the lower Exti'emity. Right side. Vs Nat. Size. Rebman Limited London. Rebman Company, Neu York. Figs. 202 and 203. Areae of distribution of the Cutaneous Nerves of the Lower Extremity. Right Side. Outlines partly after Fau's Atlas. Areae of Nerves are partly diagrauuitatic. Colours are chosen in the order of segmentation : those for the Lumbar Plexus are ill accord with the colours tised, in the two following figures, for the segments of the cord. The Cutaneous Nerves of the Lower Extremity require thorough re-investi- gation, far more than those of the Upper Limb. The upper quarter of the thigh is supplied by the following Cutaneo-sensory Nerves:— Outer third, Ilio-hypogastric (red); Middle, Crural Branch of Genito-Crural; Inner third. Genital Branch of Genito-Crural. These 2 areae, supplied by the same nerve, are yellow; only a small area near the Scrotum (visible on separation of the thighs) is supplied b)^ the Perineal Branch of the Small Sciatic. The remainder of the Anterior Surface is supplied in its outer third, by the External Cutaneous, internal to this, by the Middle and Internal Cutaneous; at its innermost part, by the Obturator Nerve. The two l^ateral Nerves extend on to the posterior aspect which is chiefly supplied by the Small Sciatic Nerve. The Gracilis is not often perforated b}' the Cutaneous Branch of the Obturator; this Nerve usualh' winds round the border of the Adductor Longus Muscle and thus comes to the surface at the Anterior Border of the Gracilis. It nearly alwaj's anastomoses with the Internal Cutaneous Nerve and comes to lie near the Long Saphenous Nerve after piercing the fascia, so that this Nerve is composed of fibres from the Internal Cutaneous as well as from the Obturator Nerve. The inner surface of the Leg is entirely supplied by the Terminal Sensor}' Brjmches of the Anterior Crural Nerve, namel}', the Long Saphenous Nerve which reaches down as far as the inner border of the foot, and so becomes the longest nerve in the bod}'. All other parts of the Foot and Leg are supplied by the Great Sciatic Nerve and its branches. In the Leg, the Internal and External Popliteal Nerves apportion the skin between each other, the former taking the middle of the calf, the latter the outer side. In the Foot, the Dorsum belongs to the External Popliteal, the Sole to the Internal Popliteal. At the Heel, the Internal and External Calcanean Branches should be mentioned. The area of the Internal Plantar corresponds to the distribution of the Median, that of the External Plantar to the Ulnar in the hand. The supply of the Dorsum of the Foot exhibits no similarity to that of the Hand. Besides the Superficial Nerves a Deep Branch from the Anterior Tibial Nerve has to be considered in its supply to the contiguous margins of the Big and 2nd Toes. Fig. 204. Innervation of the Skin and Muscles of the Lower Limb according to their Segmental Origin from the Cord : Anterior Aspect. Outlines modified after FAV's Atlas; Nen>e-siipplv after WiCIIMAMJV ivitji modifications stiggestea bv Ziehen. In the text Arabic figures indicate the Lumbar, Roman the Sacral Segments. As each plexus has only 5 segtnents the fundamental colours of the Spectrum Red, Orange, Yellow, Blue and Green are employed. Black lines represent the boundary betiveen trunk and limb and the so-called A.xial Line luhich, iiivisible in the thigh, appears at the outer side of the leg ru7!7iing obliijuelv doivnwajds to the Internal Malleolus and encircling the latter. The Segmental Distribution of the Nerves in the Lower Extremity is more com- plicated than in the Upper Limb. Li man the distribtition of both Motor and Sensory Nerves has not been properly determined. This figure is intended to contrast the Cutaneous Suj^ply with the Muscular. Naturally the Nerves are to be divided intu Dorsal or Extensor Nerves, and Ventral or Flexor Nerv^es, the former being the Anterior Crural and External Popliteal, the latter the Obturator and Internal Popliteal. Apart from these, special branches for the Muscles of the Pelvic Girdle will (as well as the Flexor Nerves) be considered in tlie next figure. In this figure onlv the Extensor Nerves will be described. The Anterior Crural Nerve corresponds more to the Musculo-Cutaneous than to the Radial; this divides into a branch to the Iliacus (cf. Fig. 105), the Anterior Di\'ision (mixed) which supplies the Sartorius and Pectineus, and the Posterior Division (also mixed) which supplies the Quadriceps Extensor Group of Muscles. These muscles correspond to the following spinal segments, Pectineus 2 and 3 ; Sartorius 2 and 3 : Rectus Femoris 2, 3 and 4 ; Vastus Internus 2 and 3 (and 4), Crureiis (2) 3 and 4; Subcrureus 3 and 4; Vastus Externus 3 and 4. The Sensory Portion of the Nerve is formed by the Middle and Internal Cutaneous (Anterior Divisions) and its communication to the Obturator Nerve, by the Long Saphenous Nerve (Posterior Division). Of these, the former supply the thigh chiefly from 2 and 3, the latter supplies the Leg and is formed from 3 and particularly 4. The External Cutaneous Nerve (a modified lateral branch of the Lumbar Nerves) contains i, 2 and 3; its Posterior Branch may be a trochanteric branch; occasionally its Anterior Branch contains the Crural Branch of the Genito-Crural (the internal twigs of which also contain ventral elements). This nerve is not constant, neither is there any constant relation between the fibres which it receives from 2, 3 and 4. The following remarks are made m connection with the incompletely studied External Popliteal Nerve : — Motor part : Short Head of Biceps 5. I. (II). Long Peroneal Muscle (4) 5. I. Short Peroneal Muscle 5. I. Long Extensor of the Toes 4. 5. I. Long Extensor of the Big Toe (4) 5. I. Anterior Tibial 4. 5. (I). Short Extensor of the Toes 4. 5. I; The slip from the muscle to the Big Toe 4. 5. I. Sensorv part : On the outer side of the leg from above and in front, downwards and backward, 5. I and II. At the foot (iNIusculo-Cutaneous and Anterior Tibial Nerve) 5. I and II. The whole of the Dorsum of the Foot contains: on the inner side, according to Paterson, 3 and 4 ; on the Dorsum proper 4. 5. I ; on the outer .side, I and II. Lumbar i Lumbar Luinbiir < External Oblique Miisclo of Abdomen Rectus Abdominis Tensor of Fascia of Thifjh ^TT lensor of F ;^4 Pyraniidalis Antcriiir Tibial ^Tustlr Long Pcrnnciis Iiitoinal Head of Gastrocnemius Long Extensor of the Toes Soleus Long Flexor ^Vfuscle of the Toes \'ertical Portion of Anterior Annular Ligament Anterior Annular Ligament r.v-v-*v. »v-\ ■Dr. IrjJiSv. ftc. Fig. 204. Nerve-Supply of the Skin and Muscles of the Lower Limb according to theii- Segmental (Spinal) Origin. Anterior Aspect. Vs Nat. Size. Rebmaii T.iinited, Londou. Rebm.in Company, New Ynik. L;iti>siiiius Dorsi External Oblique - Muscle of Abdomen (Uuteus Medius (iluteiis Maxinuis External Vastus Adductor M;i{rnu Gr;i fills Scniitendinnsus IIe;id cif Rirops Seminicnibr;in' Kxteriiiii Ile.id of Gastrocnemius Internal Head of Gastrocnemius Lumbar I Sacral TTI, Ventral Branch Sacral III, Dorsal Branch Lumbar IT S;ural lA' Sacral \' -|- Coccj'geus Nerve Soleus Lumbar I Sacral III Lumbar III Lumbar IV launbar \' Sacral IT ^^- — JJr. Trohsc.f"'^- Pig. 205. Nerve-Supply of the Skin and Muscles of the Lower Limb according to theii' Segmental (Spinal) Origin. Posterior Aspect. Vs Nat. Size. Rebman Limited, Londou. Rebman Company, New York. Fig. 205. Innervation of the Skin and Muscles of the Lower Limb according to their Segmental Origin from the Cord: Posterior Aspect. TJie preliniinarY remarks made in connection will) J^io. 204 a[>plv to tin's fiiriire. Tlie boundary line (difficult to define} between the Trunk and the Limb lias not been especially indicated but the continuation of the A.xial Line is shewn in this figure. This line runs uptvards on the back of the thigh to the Crest of the Ilium and heloiv, after encircling the Inner Malleolus, it runs on the posterior aspect of the leg to reach the inner side of the thigh. On the back of the limb the distribution is still more romplicatcd than on the anterior asfn-ct, because the dorsal neroes of the Plexus enter in, and the neii'es of the muscles of the Gluteal Region haiie to be divided into a Dorsal and a Ventral Group. Obturator Intermis Muscle, Gemelli and Quadratus Femoris Muscles belong to the Flexor Group : to the Extensor Group belong, in front the Psoas Group, behind the Gluteal Muscles, Tensor of the Fascia of the Thigh and the P3Tiformis. The following is the segmental relation ; Obturator Intemus 5. I. 11. (Ill), Gemellus Superior 5. I. II. (Ill), Quadratus 4. 5. I. Gemellus Inferior .4. 5. I. (so that the first two and the last two go together). Psoas and Psoas Minor i. 2. 3. (4), Iliacus 2. 3. 4. belong to the Extensor Group. Gluteus Maximus is supplied by 4. 5. I. II. Medius and Minimus b}- 4. 5. I. Tensor of the Fascia of the Thigh 4. 5. I. Iliac Portion of the Quadratus Lumborum I. 2. 3. (4). The Motor part of the Internal Popliteal supplies the Muscles of the Thigh, Leg and Foot: Long Head of Biceps 4. 5. I (or according to Boi.k I and II); Semitendinosus and Semimembranosus 4. 5. I; Adductor Magnus (hamstring portion) (3) 4. (and 5). To the Superficial Muscles of the Calf and the Popliteus 4. 5. I (II) are generally accepted: for the deep Flexors 5. I. (II). The terminal branches contain 5. I. II, the Internal Plantar chiefl}' 5. I, the External mostly I and II. The motor fibres of the Obturator Nerve (2. 3. 4.) are divided as follows: — Obturator Externus 3 and 4. Adductor Magnus (2) 3 and 4. Adductor Brevis 2. 3. 4. Adductor Longus 2 and 3. Pectineus (exceptionally) 2. 3. Gracilis 2. 3. (and 4). Sensory part : — the Small Sciatic Nerve is composed of I. II and III ; Internal Popliteal Nerve I and II and its continuation also I and II, on the sole of the foot the Internal Plantar 5 and I, the External I and II. The Cutaneous Fibres of the Obturator Nerve are like the motor fibres derived from 2. 3 and 4. Over the Sacrum the Dorsal Branches of the Sacral Nerves and the Coccygeal Nerve must be mentioned. They are chiefly derived from II and III (yellow). As other nerves take part in the supply of this area, the other colours Green, Blue and Red for the Coccygeal Nerve should have been put in. The red colour (indicative of the ist segment of a new plexus) has been omitted to avoid complexity in the figure. On the outer side of the Hip it is necessary to remember the Ilio-hypogastric superficial to the Fascia covering the Gluteus Medius Muscle (Schwalbe). Printed by Hermann Pohle, Jena. Germany. — 2932. ^ UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles --■--c=:r-' '83