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Full text of "Quain's Elements of anatomy"

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QUAIN'S 

ELEMENTS OF ANATOMY 



EDITED BY 



EDWARD ALBERT SCHAFER, F.R.S. 

PROFESSOR OF PHYSIOLOGY AND HISTOLOGY IN UNIVERSITY COLLEGE, LONDON, 



GEORGE DANCER THANE, 

PROFESSOR OF AXATOMY IN I'NIVERSITY COLLEGE, LONDON. 



IX THREE VOLUMES. 

APPENDIX. 

SUPERFICIAL AND SURGICAL ANATOMY. 
By professor G. D. THANE, 

AND 

PROFESSOR H. J. GODLEE, M.S. 
ILLUSTRATED BY 29 ENGRAVINGS. 

Ctnti) euttton. 



LONGMANS, (;REEN, AND CO. 

LONDON, NKW YORK, AND I'.OMIiAY. 
1890. 

[All ri'jh/s reserved.] 






i.ONDON : 
BRADBURY, AONEW, & CO. LD., PPaNTERS, WHITEFR] ARS. 



CONTENTS OF APPENDIX. 



Superficial Anatomy of the Head and 

Neck i 

The Head and Face . . . . i 

The Xeck i6 

Sui'EKFiriAi, Anatomy of the Trunk . 19 

The Chest 19 

The AVidoiiien ..... 22 

The Back 27 

Table of Levels of Structure.s in 

THE TiiiNK 32 

Sri'ERFICIAL An.\TO.MY OF THE IJpI'ER 

Limb 35 

The Shoulder 35 

The Arm -35 

Tlie Elbo\v 37 

The Foreariii 38 



.Superficial Anahjmv of tiik Uitkr 
L I M B — contin uecl. 

The Wrist and Hand .... 

SUPERFICI.A.L Anatomy of the Lower 

LlMIl . ... 

Tlie Hip 

The Thigh 

The Knee .... 

The Leg ..... 

Tlie Ankle and Foot . 
Anatomy of the Gkoin : Heknia 

Inguinal Hernia 

Femoral Hernia .... 
The Perineum of the Malk . 
Examination of the Pelvic Viscera 

INDEX 



39 

42 
42 
43 
45 
47 
4S 

50 
51 
57 
62 

65 
67 



SUPEKFICIAL AND TOPOGEAPHICAL 
ANATOMY. 

By G. D. thane and R. J. GODLEE. 



Ix this section will be comprised, 1, a brief account of the external conforma- 
tion of the body, including the relation of its anatomical constituents to its surface 
forms, and the mode of determining the position of deep-seated organs, such as the 
viscera, large vessels, and other important parts ; and 2, the topographical and 
surgical anatomy of the inguinal and perineal regions. 

SUPERFICIAL ANATOMY OF THE HEAD AND NECK. 

THE HEAD AND FACE. 

The upper part of the cranium is but thinly covered by the scalp, and the 
form of the head is almost exactly that of the skull. The bones can be readily 
examined by passing the hand over the head, and the following parts are thus to be 
distinguished : — In the middle line behind is the external occipital protuberance, 
from which the superior curved line proceeds outwards on each side towards the 
mastoid process ; below this line the bone is obscured by the overlying muscles, 
except in the middle line, where the external occipital crest may sometimes be felt 
at the bottom of the nuchal furroiv between the posterior muscles of the neck. 
Above the occipital protuberance, the lambdoid suture is often to be followed as a 
slight depression on the surface, owing to the projection of the occipital bone 
beyond the hinder part of the parietals. The lambda, corresponding to the central 
and highest point of this depression, is about two and a half inches (6 — 7 cm.) 
above the external occipital protul^erance. Above the lambda there is usually a 
well-marked flattened surface at the region of the obelion (see Osteology, p. 8o) ; 
and in front of this again the parietal bones often form in the neighbourhood of 
their junction a broad longitudinal ridge, in which the position of the sagittal 
suture is indicated by a slight median depression. 

At the fore part of the lateral region of the head the tem.poral crest of the 
frontal bone becomes prominent, and leads down to the external angular process, 
the junction of which with the malar bone is marked by a distinct depression. 
Below this tlie outline of the malar bone can be followed, and from the hinder part 
of the latter the finger passes along the zygoma to its base in front of the ear. 
Higher up on the side of the head the lower temponil line on the parietal bone is 
frequently to be recognised, indicating the extent U])\vards of the temporal muscle. 
The margin of the orbit can be felt in its whole extent, and is Ibund to be 
interrupted above, somewhat internal to the centre, by the supraorbital notch, 
unless this be converted into a foramen, when it is scarcely perceptible. Above the 
orbit is the variable su[)orciliary ridge, small in the female and al)sent in the child ; 
and above this on the forehead is the frontal eminence, which, like the jjarietal 
eminence, is most marked during childhood. In the infant, the anterior Ibntiinelle 
is felt as a lozenge-shaped depression, leading forwards to the interval between the 

APP. * 



2 



SUPERFICIAL ANATOMY OF THE HEAD AND NECK. 



two frontal, and backwards to that between the two parietal bones ; the latter 
interval conducts to the triradiate posterior fontanelle, the lateral limbs of which 
are continued downwards along the upper margins of the occipital bone. 








/ 



■r 



Fig- 1. — Front view of skull, showikg extent of cerebrum, air-spaces, exit of nerves, &c. .|- 

(G. D. T.) 

The outline of the cerebniin is shown in red, and the position of the superior longitudinal sinus in 
blue. The frontal sinus with the infundibulum and the maxillary antrum are indicated by patches of 
shading, and the nasal duct with the lachrymal sac by a dotted line. The following letters refer to the 
nerves : — s o, supraorbital ; s T, supratrochlear ; i t, infratrochlear ; l, lachrymal ; n, nasal ; i o, infra- 
orbital ; M a, malar : b, buccal ; m e, mental. 

The frontal sinuses are contained in the lower part of the frontal bone, above 
the root of the nose and the inner ends of the eyebrows. In extent and capacity 
they vary greatly in different individuals ; as a rule they are larger in the male 
than in the female, and are absent before the seventh year of life. In the adulfc 



FKONTAL SINUSES. 3 

they may extend upwards as far as the frontal eminence, or fully two inches 
above the naso-frontal suture, and outwards over the orbit into the base of 
the external angular process ; or they may exist only as slight recesses in the 
nasal portion of the bone. The dimensions of the sinuses are not necessarily 
related to the degree of prominence of the glabella and superciliary ridges, 
which are sometimes strongly marked without being excavated by the air- 
spaces ; while on the other hand large sinuses not unfrequently co-exist with a 
comparatively flat lower frontal region, having apparently been formed by the 
recession of the inner table of the bone. The right and left sinuses are separated 
by a thin osseous partition, which is seldom defective ; but they are often unequally 
developed, so that the septum deviates strongly from the median plane. In extreme 
cases one sinus may extend equally, or nearly so, in both halves of the frontal bone, 
the cavity of the opposite side being either rudimentary or wanting. The low^er 
part of the sinus tapers into the infiouh'/ndt/m, a narrow passage which leads down- 
wards and backwards through the fore part of the lateral mass of the ethmoid into 
the middle meatus of the nose. The infundibulum is deeply placed behind the 

riijlit frontal sinus 




passage into 7-ir/ht left froittal sinus 

nasal cavity. 

Fig. 2. —Lower portion of a frontal bonf, showing unsymmktrical i«kvei,oi'mknt of thk 
FRONTAL SINUSES. (From a pliotogiapli by G. W. B. Waters.) (G. D. T.) 

nasal process of the superior maxillary bone, and near the inner wall of the orbit 
(rf. Osteology, tig. Od) ; its termination in the middle meatus is about on a level 
with the j)alpebral fissure. 

Vessels and nerves of the scalp. — The supraorbital nerve and artery pass 
almost vertically upwards from the sujjraorbital notch, and more internally the 
frontal artery and supratrochlear nerve ascend over the margin of the orbit, while 
the large frontal vein descends in a similar ])osition to the root of the nose. 
Posteriorly, the occipital vessels and great occipital nerve run upwards to the vertex, 
entering the scalp somewhat internal to a point midAvay between the external 
occipital protuberance and the mastoid jn-ocess. The superficial temporal artery 
crosses the base of the zygoma immediately in front of the ear, and its anterior 
branch can frequently be seen, especially in old i)ersons, running uj)wards and 
foi wards with a tortuous course over the fore part of the temporal muscle towards 
the forehead. 

Endocranial blood-vessels. — In contact with the inner surface of the cranial 
wall the HU|,eri(ii- longitiulinal sinus is directed backwards along the middle line, 
extending from the lower ]>ait of tiie forehead to the external occipital protuberance. 

u 2 



4 SUPERFICIAL ANATOMY OF THE HEAD AND NECK. 

It commonly deviates a little to one side, more frequently the right, especially in 
its hindmost part, as it descends over the upper portion of the occipital bone to its 
termination. From the latter spot the lateral sinus runs outwards and forwards, 
describing a slight curve with its convexity upwards, to the back of the ear on a 
level with the upper margin of the external auditory meatus, and then turns down- 




Fig. 3. — Side view of skull, showing the course of the middle meningeal artery, lateral 
SINUS, &c. (From a photograph by G. W. B. Waters.) f. (G. D. T.) 

The meningeal artery is represented in red and the lateral sinus in blue : the position of these was 
ascertained by drilling holes from the interior of the skull. The shaded area above and behind the 
external auditory meatus indicates the position of the epitympanic recess and mastoid antrum. The 
broken line represents the inferior limit of the cerebral hemisphere as traced on the surface of the 
skull. + "t + indicate the points of intersection of vertical and horizontal lines resj)ectively one inch, 
one inch and a half, and two inches behind the external angular process of the frontal bone, and above 
the upper border of the zygoma. 



wards, following a course directed to the tip of the mastoid j)rocess as far as a point 
about 5 mm. beyond the level of the lower border of external auditory meatus. In 
the first part of its course the sinus usually lies altogether above a hue drawn 
transversely from the external occipital protuberance to the centre of the opening of 
the ear, and the highest part of its arch, where the sinus crosses the postero-inferior 



CRANIO-CEREBRAL TOPOGRAPHY. 5 

angle of the parietal bone, is from 15 to 20 mm. (in extreme cases even 2r» mm.) 
above, and somewhat external to the mid-point of, this line. The distance of the 
descending part of the sinus from the posterior wall of the auditory canal is usually 
from 10 to 12 mm., but may be as little as 2 mm. The course of this part of the 
sinus corresponds roughly to the line of reflection of the skin from the pinna to the 
head posteriorly (Birmingham). The depth of the sinus from the surface of the 
mastoid varies from 1 to 15 mm., with an average of 7 mm. ; and its breadth 
ranges from 5 to 15 mm. The sinus is often much wider in its mastoid than in its 
occipital segment. The right sinus is generally larger, projects more forwards, and 
approaches nearer to the surface than the left. The lateral sinus may be exposed 
by an opening in the bone immediately below the anterior part of the parieto 
mastoid suture, or having its centre 25 mm. (1 inch) behind the highest point of 
the orifice of the osseous external auditory meatus. 

The anterior and larger division of the middle meningeal artery runs upwards 
and backwards within the skull in the fore part of the temporal region, and would 
be reached at points equal distances, one inch, one inch and a half, and in most 
cases two inches, above the zygoma and behind the external angular process of the 
frontal bone. It will be remembered that the vessel in this part of its course is 
lodged in a deep groove, sometimes a canal, on the autero-inferior angle of the 
parietal bone. The ramifications of the posterior division of the artery are variable 
in number and position. 

Cranio-cerebral topography. — Extent of the cerebral hemispltere. — The upper 
margin of the cerebral hemisphere extends from the lower part of the glabella nearly 
to the external occipital protuberance. It does not quite reach the middle line, 
being separated from its fellow by an interval which corresponds to the superior 
longitudinal sinus, and like that increases in breadth posteriorly, where it measures 
fully 1 cm. Owing to the lateral deviation of the sinus, the margin of the hemi- 
sphere commonly approaches nearer to the middle line on the left side than on the 
right. Beiow the sinus the mesial surfaces of the two hemispheres are nearly in 
contact, being separated only by the thickness of the falx cerebri. Inferiorly, the 
cerebral hemisphere reaches in front nearly to the eyebrow, at the side to the upper 
margin of the zygoma, and behind to the superior curved line of the occipital bone. 
The lower limit of the hemisphere is more precisely indicated by marking out its 
lateral margin, which consists of two parts — frontal and occipito-temporal. The 
frontal part begins internally close above the naso-frontal suture (which is felt at 
the bottom of the depression below the glabella), rises in an arch as it passes out- 
wards, being about 8 mm. above the centre of the supraorbital border of the frontal 
bone, and crosses the temporal crest just below the deepest point of the hollow 
formed by the frontal bone immediately above the external angular process. From 
the temporal crest the frontal margin descends slightly in the fore part of the 
temporal fossa to a spot about 25 mm. behind the external angular process, where 
it meets the foremost part of the temporal margin in a receding angle, which 
corresponds to the stem of the fissure of Sylvius. The occipito-temporal division of 
the lateral margin begins posteriorly at the occii)ital pole of the hemisphere, which 
is placed a little (5 to 15 mm.) above and outside the external oc(;ipital protulior- 
ance, and then follows the arch of the lateral sinus, as described alxtve, to the t)ack 
of the ear. Crossing here the snpramastoid crest, the margin is continued 
forwards about G mm. (varying from 3 to 9 mm.) above the roof of the external 
auditory meatus, and then on a level with the uj)per border of the zygomatic arch 
for about the posterior half of its length. Then curving gradually upwards, the 
border reaches its foremost point, corresponding to the temporal jjole of the hemi- 
sphere, about 20 mm. above the zygoma and 15 mm. behind the external angular 



b SUPEKFICIAL ANATOxMY OF THE HEAD AND NECK. 

process, and finally recedes slightly to meet the end of the frontal margin at the 
Sylvian notch. 

Relations of the cerebral fissures and convolutions to the cranial wall. — The point 
of division of the Sylvian fissure is situated in the pterion, beneath or very near the 
spheno-parietal suture towards its posterior end. From this spot the posterior limb 
of the fissure runs backwards and somewhat upwards, at first following the line of 
the squamous suture, and then crossing the temporal area of the parietal bone as far 



nl^ 



cuf. precenifiU 




Fig. 4. — Side view op the skull, showing the relations of the brain to the cranial 

WALL. f. (G. D. T.) 

as the inferior temporal line, beyond which its superior terminal branch ascends for 
a short distance beneath the parietal eminence. In the child the posterior limb of 
the fissure is distinctly above the line of the squamous suture. The anterior 
ascending branch of the Sylvian fissure runs from the hinder part of the spheno- 
parietal suture upwards and somewhat forwards, crossing obliquely the lower end of 
the coronal suture ; and the horizontal branch is directed forwards in the line of 
the spheno-parietal suture. The parieto-occipital fissure is placed opposite the 
lambda, or often rather above that point, especially in young subjects. The fissure 
of Eolando is wholly beneath the parietal bone, its upper end being from 4 to 5 cm., 



ORANIO-CRREBRAL TOPOGRAPHY. ' 

and its lowei' end about :) em., behind the coronal suture. The superior preeentral 
sulcus is from 2 to o cm. behind the upper part of the coronal suture ; and the 
inferior preeentral sulcus is a short distance (1 to 2 cm.) behind the lower part of 
the same suture. The inferior frontal sulcus about corresponds to the stephanion 
and the temporal crest of the frontal bone. The intraparietal fissure is very variable 
in position : its ascending or postcentral portions are approximately parallel to and 
about 1.") mm. behind the fissure of Rolando ; while its lonuitiulinal portion runs 
backwards, with a slight inclination inwards, just above the parietal eminence, and 
at an average distance of 45 mm. from the median line anteriorly, 35 mm. 
posteriorly opposite the lambda. The parallel fissure lies mainly beneath the upper 
part of the squamous and the hinder part of the temporal area of the parietal bone, 
bat its posterior end crosses the temporal lines and runs upw^ardsfor a short distance 
in the parietal lobe of the hemisphere under the superior division of the parietal 
bone : its position in the temporal part of its extent is indicated approximately by a 
line drawn from the marginal tubercle of the malar bone to the lambda. In the 
child, owing in great measure to the relatively small size of the squamous part of the 
temporal bone, the parallel fissure appears to be placed much higher, often reaching 
the level of the squamous suture. 

From the foregoing determination of the situation of the fissure of Rolando and 
preeentral sulci, it follows that the ascending frontal and the bases of the upper, 
middle, and lower frontal convolutions are placed beneath the anterior third of the 
parietal bone. The main parts of the superior and middle frontal convolutions 
correspond to the frontal region of the frontal bone, and of this area the superior 
frontal convolution may be said to occupy rather less than the inner half, and the 
middle frontal convolution rather more than the outer half. The centre of the 
frontal eminence is commonly over the middle convolution. The apex of the pars 
triangularis of the inferior frontal convolution corresponds to the antero-inferior 
angle of the parietal bone ; and the pars orbitalis is covered by the temporal division 
of the frontal bone and the upper end of the great wing of the sphenoid. The 
whole of the parietal lobe is under cover of the parietal bone, the parietal eminence 
corresponding to some part of the supramarginal convolution ; while the occipital 
lobe occupies the cerebral division of the occipital bone, and sometimes extends slightly 
beneath the adjacent part of the parietal bone. The temporal lobe lies for the most 
part beneath the S(piamous division of the temporal bone and the postero-inferior fourth 
of the parietal l)one, its superior convolution being marked otf from the rest l)y tlie line 
given above for the pai-allel fissure ; but the anterior extremity of this lobe projects 
under the great wing of the sphenoid, while ])osteriorly the inferior temporal convolu- 
tion is prolonged beneath the occipital bone to the occipital pole of the hemisphere. 

iJeicrmination of the principal fissures on the surface of the head. — If a median 
line be drawn over tlie head from the nasion (centre of the naso-frontal suture) to 
the inion (external occipital protuberance), a point 1 cm. (or half an inch) behind 
the centre of this line will indicate with sufficient accuracy the spot where the 
fissure of Rolando meets the upper border of the hemisphere, and may be termed 
the superior Rolandic point. From 8 to 10 cm. farther back the lambda may be 
felt, or if that is not possible, a point should be taken on the nasio-inial line O'o cm. 
(or 2\ inches) above the inion, and a line carried transvensely outwards for a 
distance of 2 cm. from this spot will mark the parieto-occipital fissure. 

On the side of the head, a line from the lowest point of the infraorbital margin 
to the centre of the aperture of the ear ( lleid's hase-tine) is taken as the horizontal. 
This line is about parallel with the upper border of the zygomatic arch ; and 
vertical lines are perpendicular to it. A spot on the base-line in the hollow between 
the tragus of the ear and the condyle of the lower jaw is known as tin; preaurirular 
point. From the fronto-malar junction (p. I j let a line Ix; carried iK.rizontally 



8 



SUPERFICIAL ANATOMY OF THE HEAD AND NECK. 



backwards for 35 mm., and from the end of this a vertical line for 12 mm. upwards ; 
the upper end of the latter line marks the spot where the anterior branches are 
given off from the Sylvian fissure, and may be termed the Sijlvmi point. A line 
drawn from the fronto-malar junction through the Sylvian point to the lower part 
of the parietal eminence will about lie over the posterior limb of the Sylvian fissure, 
and may be called the Sylvian Ime. The anterior ascending and horizontal branches 
of the fissure may be marked by lines 2 cm. long starting from the Sylvian point, 



SUR ROLANDIC POINT 



BREGMPi 



LAMBDA 




Fig. 5. — Side view of skull on -which the chief points and lines used in okanio-cerebkal 
TOPOGRAPHY HAVE BEEN MARKED, f. (From a photograph by G. W. B. Waters.) (Gr. D. T. ) 

The contour of the cerebral hemisphere, with the Rolandic and Sylvian fissures, are marked by 
continuous red lines, and the outline of the insula and of the lateral ventricle by broken red lines. 

the one directed upwards and forwards at right angles with the Sylvian line, and the 
other horizontally forwards. 

On the Sylvian line, 25 mm. behind the Sylvian point, is the loiver Rolandic 
point, the spot where the fissure of Eolando, if prolonged, would meet the Sylvian 
line. The lower Rolandic point is about 5*5 cm. (varying from 4 to 7) above the 
upper border of the zygomatic arch, on or slightly in front of a vertical line passing 
through the preauricular point. The Mokmdic line may now be drawn between the 



CRANIO-CEREBRAL TOPOGRAPHY. 9 

upper aud lower Rolandic points, and gives the general direction of the fissure of 
Rolando. The line forms an angle (the Rolandic angle) anteriorly with the median 
line of about 70° (varying in individual cases from 64° to 75°) ; and if prolonged 
downwards it crosses the zygomatic arch about the middle (Le Fort). The fissure of 
Rolando is not quite so long as the Rolandic line, since the margin of the hemi- 
sphere does not quite reach the median line above, while below, the fissure of Rolando 
usually ends about 1 cm. above the Sylvian fissure or lower Rolandic point. The 
Rolandic line coincides most nearly with the upper part of the fissure, the inferior 
genu of which projects somewhat in front of the line a little below its centre, 
a spot which is placed from 5 to 15 mm. above the lower temporal line on the 
parietal bone. 

The precentral sulci are situated about 15 mm. in front of the fissure of Rolando, 
with which they are nearly parallel ; from the lower of these the inferior fi-ontal 
sulcus arches forwards and downwards beneath the temporal crest of the frontal 
bone, which can be felt through the skin ; and the position of the superior frontal 
sulcus may be indicated approximately by a line running forwards from the superior 
precentral sulcus slightly internal to the centre of the interval between the temporal 
crest and the median line of the forehead. 

The postcentral sulci being also nearly parallel to, and about 15 mm. distant 
from, the fissure of Rolando, the average position of the longitudinal portion of the 
intraparietal sulcus may be marked by a line drawn from the centre of the Rolandic 
line to a spot 35 mm. external to the lambda, or 15 mm. from the end of the imrieto- 
occipital line. 

Lastly, the seat of the parallel fissure may be determined by the above- 
mentioned line from the marginal tubercle of the malar bone to the lambda. 

Island of Reil, basal ganglia, and lateral vejitrides. — The Sylvian point marks 
the position of the pole of the insula, and a spot on the Sylvian line 35 mm. behind 
this point will correspond to its posterior angle. The upper limit of the insula may 
then be indicated by a line, slightly convex upwards, drawn from its posterior angle 
to the upper end of the anterior ascending branch of the Sylvian fissure, and 
continued forwards for a distance of 15 mm. beyond the vertical passing through 
the Sylvian point ; the lower limit by a line directed from the posterior angle down- 
wards and forwards to a spot on the parallel line immediately below the Sylvian 
point ; and the anterior limit by a line joining the anterior extremities of the two 
foregoing lines. The area of the insula thus marked out will serve as a guide to 
the position of the basal ganglia, which extend slightly beyond the limits of the 
island, and arc circumscribed by a strongly-curved line corresponding to the outer 
border of the main part of the lateral ventricle. This line may be traced, beginning 
at the anterior extremity of the ventricle 1 era. in front of the foremost point of the 
insula, and passing backwards in an arch, which follows the margin of the anterior 
horn and body of the cavity, an equal distance above the upper limit of the island 
to a spot 2 cm. behind its posterior extremity. Thence, the inferior horn runs 
forwards and downwards, to end about 1 cm. below the level of the parallel fissure 
and somewhat in advance of the coronal plane passing thiough the lower Rolandic 
and preauricular points. From the back of tlie loop thus indicated the posterior 
horn extends a variable distance towards the hindmost ])oint of the hemisphere, 
which is placed a little higher than the occipital pole, beneath the occipital point of 
the skull.' 

' For more detailcl information as to cranio-cerebral topograpliy, reference may lie niaile to the 
memoir by D. J. Cunningham, (Jotitrlhution to the Surface Analoiuf/ of t/ie Ccri'/jral Jlemhplu rex, with 
a (Jhiptiv on Crdnio-Ccrelyral Toiioijraithij, by Victor IIorHley. The subject is also fully illustrated by 
the series of mo<lels prepared under the direction of the former anatomist, showinj; the relations of the 
wrebnii hemispheres i>t »'du, in a nuniber of iiidiviilualsof both sexes and at various perioils of life, from 
infancy it> old age. 



10 



SUPERFICIAL ANATOMY OF THE HEAD AND NECK. 



The cerelellum, occupyiag the inferior occipital fossse, is in contact with the 
cranial wall up to the lower margin of the transverse part of the lateral sinus. This 
vessel may occasionally have a lower position than that given on p. 4, and it is 
advisable, therefore, in operations upon the cerebellum, that the opening in the bone 
should be kept at least 1 cm. (half an inch) below the level of a line drawn from the 
external occipital protuberance to the centre of the external auditory meatus, while 
at the same time it should not extend farther forwards than a vertical line 35 mm. 
(one inch and a half) behind the latter spot. In this way both the lateral sinus and 
the occipital artery will be avoided (fig. 9). 

Mastoid antrum. — The air-cells, which in the adult usually occupy the interior 
of the mastoid portion of the temporal bone, open into a small chamber termed the 
mastoid cmtrum. This is continuous anteriorly with the highest part of the 



cccncU offaclai nertis 
canaL of tefi^or tunpan. 



tpUumpank, recess „ ... 

' •! ' j em. ssmld/vuZar canaZ 

I ! 







tij/Ttp an- Lcm. 

A 



. aiMcL . meatus 



pnhe- ut stytc-maJBtoUL 
forounjsfir 



'rrMsCoCd. cells 



Fig. 6. — Left temporal bone, divided by a vertical section passing through the tympanum 
AND MASTOID ANTRUM : A, INNER PORTION ; B, OUTER PORTION. Natural size. (From a photo- 
graph by ft. W. B. Waters.) (G. D. T.) 

The section is directed somewhat obliquely from before, backwards and outwards. The tympanic 
cavity and the antrum are coloured blue, and the division between the epitympanic recess and the 
antrum is indicated by a dotted line ; c. c. carotid canal. 

tympanic cavity or epitympanic t^ecess (attic of the tympanum), and thus, through 
the Eustachian tube, the mastoid cells are put into communication with the external 
air. In form the mastoid antrum may be compared to the bulb of a retort, 
which is somewhat compressed in the transverse direction, and the truncated neck 
of which corresponds to the opening into the epitympanic recess {aditus ad 
antrum). 

The dimensions of the antrum are subject to considerable variation, but in most 
cases it measures between 10 and 15 mm. longitudinally, about 10 mm. vertically, 
and from 4 to 6 mm. transversely. Its depth from the surface, i.e., the thickness 
of its outer wall, varies from 7 to 14 mm. The bone here is commonly very hard 
and dense, but in the deeper part it is often more spongy, being excavated by cells 
in communication with the cavity. The entrance to the antrum from the epi- 
tympanic recess is rather triangular in form, with the base upwards and the lower 
angle broadly rounded oif : its longest diameter is about 4 mm. both vertically and 
transversely. The lower margin of the opening is on a level with the upper wall of 



THE MASTOID ANTRUM. 



11 



the external auditory meatus : aud the coronal plaue iu which the opening is 
contained, in consequence of the forward inclination of the bony meatus, is placed a 
little (about one-fourth of the horizontal diameter of the meatal opening) in front 
of the posterior margin of the external orifice of that canal. The epitympanic 
recess is situated above the anterior three-fourths of the orifice. Behind the 
entrance the floor of the antrum sinks, forming a hollow which does not usually 
extend below the level of the centre of the auditory meatus. The cavity is, however, 
continued into the mastoid cells, which are often of large size, aud then as a rule 
reach to tlie tip of the mastoid process. 

Superiorly, the antrum is separated from the middle fossa of the base of the skull 
by a thin plate of bone which continues backwards and upwards the tegmen 



■'- ■^'N-v.- 




Fig. 7. — Right temporal bonk, fkom which the supkrficial portion op thk mastoid division 
HAS BKEN REMuvKD, EXPOSING THE MASTOID ANTRUM. Natural size. (From a photograph by 
a. W. B. Waters.) (G. D. T.) 

The broken line iinlicates the position of the lateral sinus. 

tympani. This sometimes presents small deficiencies, in which there is only a 
slender fibrous layer between the mucous lining of the cavity and the dura mater ; 
and these two membranes are always united by connective tissue and vessels passing 
through the petro-squamosal fissure, as well as through minute apertures in the 
tegmen. In position, the roof of the antrum corresponds as a rule to the supra- 
mastoid crest externally, but not unfrequently it rises somewhat above that level, 
and in that case the upper part of the antrum may be overla])ped by the lateral 
margin of the cerebral hemisphere, the inferior temporal convuliition of wliich is 
rew;ived at this spot into a slight groove between the prominent tegmen internally 
and the lower border of the squamous temporal externally. 

From the communication with the epitympanic recess the antrum extends back- 
wards and outwards, so that it comes nearer to the surface Ix^hind than in front. 
Anteriorly, there is only a thin bony wall betwcjen the cavity and the deep part of 



13 



SUPERFICIAL ANATOMY OF THE HEAD AND NECK. 



the auditory meatus. Posteriorly, it approaches the descending part of the lateral 
sinus, in some cases reaching close to the osseous lamina which forms the floor of 
the groove, but more commonly the two are separated by an interval of from 5 to 
10 mm. occupied by mastoid cells. The sinus is usually nearer to the surface than 
the air-space. It will be remembered that the outer wall of the antrum is developed 
from the postauditory process of the squamo-zygomatic division of the temporal 
bone (see Osteology, p. 74) ; and there are generally in the adult some vestiges of 
the infantile masto-squamosal suture in the form of small clefts and canals which 
lead from the cavity to the exterior of the bone, and are occupied by connective 
tissue and veins. 



pi anx-astoid, eicst 

hLuprcc-mca/:cd. fosaa- 







facicuL Tiarue 



Pig. 8. — Lower and posterior portion of right temporal bone, showing the suprameatal 
TRIANGLE, COURSE OP THE FACIAL NERVE, &c. Natural size. (G. D. T.) 

The mastoid antrum may be reached from the exterior by perforating the bone 
close to the upper and posterior part of the external auditory meatus. In this 
region Macewen describes a suprameatal triangle,^ which is bounded above by the 
supramastoid crest, below and in front by the postero-superior quadrant of the outer 
margin of the osseous meatus, and behind by a vertical liue tangential to the hind- 
most point of that opening. The surface of bone included in the triangle is usually 
marked by a small depression — the suprameatal fossa, which is separated from the 
aperture of the meatus by a sharp prominent edge — the siqn'ameatal spine. The 
perforation should be made within this area, at the site of, or close behind, the 
suprameatal fossa, and be directed inwards and slightly fowards, following the 
inclination of the external auditory meatus. The antrum will then be opened at its 
fore part, at a depth from the surface varying generally from 7 to 14 mm. ; in 
extreme cases, and especially as the result of disease, this distance may be reduced 
to 3 mm., or increased to 18 mm., or even more. At the lower part of the entrance 
into the antrum the inner wall of the cavity presents a slight bulging over the 
external semicircular canal (fig. 6), which may be injured if the instrument is not 
checked as soon as the cavity is reached : the distance of the wall of the canal from 
the surface is mostly between 17 and 20 mm. (about three-quarters of an inch). 
Just below and in front of this, on the inner side of the epitympanic recess, is the 
arch of the facial nerve contained in its canal, the osseous wall of which is thin 



W. Macewen, Pyogenic Infective Diseases of the Brain and Spinal Cord, 1893, p. 



THE FACE. 



13 



towards the cavity, and often defective in part. The nerve will best be avoided by 
not directing the perforation too much forwards. Between the semicircular canal 
in front and the lateral sinus behind, the air-spaces are in relation internally with the 
posterior fossa of the base of the skull, the thickness of the intervening bone ranging 
from 1 to 9 mm. The original perforation must be kept below the supramastoid crest 
in order to avoid opening the middle fossa of the skull ; and it should not extend 




mastoid foramen. 



aperture into 
mastoid antrum. 



Fig. 9. — Lower and hinder part of skull, in which an opening has been made into the 

MASTOID Aix'TRUM, AND ON WHICH THE COURSE OF THE OCCIl'ITAL ARTERY AND LATERAL SINUS 

ARE INDICATED. ( Kroru a photograph hy G. W. B. Waters.) ;j' (G. D. T.) 

backwards more than 2 mm. beyond the posterior boundary of the suprameatal 
triangle, or the lateral sinus may be endangered. 

In the infant and child the mastoid antrum has nearly its full size, but its outer 
wall is relatively thin. The mastoid cells are, however, not usually developed before 
twelve years of age. 

The face. — In the face proper, the nasal bones and the margin of the anterior 
nasal aperture are readily traced, and at the lower part of the latter, in the root of 
the septum narium, the anterior nasal spine is felt. In fi'ont of this oj)eiiing the form 
of the upper and lower lateral cartilages can be distinguished, and the inner poi'tion 
of the latter is more clearly made out by passing the finger into the nostril, by which 
means part of the cartilage of the septum, the lower margin of the upper lateral 
cartilage, and sometimes the tip of the inferior turbinate bone, can also be felt. 

With the nasal speculum, if the parts be normal, the dull red mucous mcmlji'ane 
of the floor of the nose and of the lower part of the sej)tum may be seen, the brighter 
red inferior turbinate body for the greater part of or all its extent, and the inferior 
meatus for a variable distance. The anterior border and a small part of the inferior 
border, i.e., the ojmrulum, of the middle turbinate body may also be seen, and a 
very small part of the middle meatus. ^J'he fore ])art of the roof is visible, but the 
superior turbinate Ijoily rarely, and the superior meatus never. Tiie back (jf the 
pharynx can be seen in a nose of moderate dimensions. 

Uelow the base of the zygoma, tlie temporo-ma.xiliary articulation is ([uite super- 



]4 SUPERFICIAL ANATOMY OF THE HEAD AND NECK. 

ficial behind the upper part of the masseter, and from the condyle the posterior 
margin of the ramus of the lower jaw can be followed to the angle. The lower 
margin of the jaw can also be felt throughout, and ascending from its central point 
the anterior edge of the masseter. Immediately in front of the latter, the facial 
artery crosses the base of the jaw, and is readily found by its pulsation ; the course 
of the vessel is roughly marked by a line passing upwards a little outside the corner 
of the mouth and continued by the side of the nose to the inner can thus of the eye. 
The coronary branch of the artery may be felt pulsating beneath the mucous 
membrane in each lip very near its free border. Stensen's duct runs generally in 
the direction of a line drawn from the lower margin of the concha of the ear to a 
point midway between the ala of the nose and the free margin of the lip, but it 
varies somewhat in position in different subjects ; accompanying the duct are the 
transverse facial vessels (usually above) and the infraorbital branches of the facial 
nerve (below). The interval between the ramus of the jaw and the mastoid process 
is occupied by the parotid gland, a part of which extends forwards over the masseter 
muscle, and the trunk of the facial nerve is deeply placed beneath the gland ; the 
position of the nerve may be indicated by a line running downwards and forwards 
Irom the anterior border of the mastoid process at the point where it meets the ear. 
A line carried downwards over the face, crossing the supraorbital notch and the 
interval between the two bicuspid teeth of the lower jaw, will be found to be nearly 
vertical and to pass over the infraorbital and mental foramina, thus forming a guide 
to the spots at which the largest cutaneous branches of the three trunks of the fifth 
nerve come to the surface. The infraorbital foramen is about 1 cm. below the 
margin of the orbit ; and the mental foramen is midway between the upper and lower 
margins of the jaw. 

About the anterior half of the eyeball can be felt in the aperture of the orbit : it 
gives a tense elastic sensation to the fingers. At the upper and inner angle of the 
orbital opening the pulley of the superior oblique muscle may also be felt. 

When the eye is open the skin is drawn into the deep superior palpebral sulcus 
immediately above the upper lid, and forms a loose projecting fold between this 
furrow and the eyebrow. The corresponding inferior palpebral sulcus of the lower 
lid is much slighter, and often broken up : it is most distinct when the eye is 
directed downwards. Below this, another shallow groove, the palpebro-malar sulcus, 
runs round from near the inner canthus of the eye, following fairly closely the lower 
margin of the orbit. A small external palpebral sulcus is continued outwards from 
the outer canthus for about 3 mm., and forms a prolongation of the palpebral cleft 
when the eye is closed. Contraction of the outer part of the orbicularis palpebrarum 
gives rise to radiating furrows outside and below the eye, markings which are 
generally permanent in old persons. 

The skin of the eyelid is very soft and thin ; at the free margin of each lid it 
passes into the conjunctiva along the line of the eyelashes, and within this a sharp 
edge is formed, especially in the case of the lower lid, which is closely applied to the 
surface of the eyeball. The palpebral fissure is somewhat oval, or widely fusiform, 
in shape, but the margin of the upper lid is more arched than that of the lower. 
The fissure is also generally a little inclined from without inwards and downwards. 

The whole length of the palpebral fissure is about 30 mm. (an inch and a 
quarter) ; its breadth is scarcely sufficient, unless when the eyes are unusually widely 
opened, to expose the whole of the cornea ; but these dimensions, especially the 
latter, vary considerably in different persons, thus causing the eye to appear larger 
or smaller, although the size of the globe itself is relatively very constant. At the 
outer canthus, the lids meet in an acute angle ; at the inner, the fissure is prolonged 
downwards and inwards for about 5 mm. between portions of the lid-margins, which 
are straight and rounded. The junction of the curved and straight portions of the 



THE FACE. 15 

margin is marked by a slight elevation, the 2K(piUa lacrimalis, which is much better 
developed in the lower lid than the upper, and on drawing the lid forwards a minute 
opening, the punctiim lacrimaJe, is seen on the summit of the papilla, leading into 
the canaliculus by which the tears are conveyed into the lachrymal sac. In the 
neighbourhood of the inner canthus the lids are separated from the eyeball by the 
caruncula lacrimalis, a red fleshy-looking portion of skin, which supports a few fine 
hairs, and by the fold of mucous membrane known as the plica semilunaris. 

The lids can be readily everted, the lower one by simply pulling it downwards, 
the upper one by turning it over a probe, and the ocular and palpebral conjunctiva 
can thus be completely examined ; the former is transparent and smooth, presenting 
only a few minute vessels in the healthy state ; the latter is more or less red and 
velvety in appearance. The Meibomian glands are seen at the same time, appearing 
through the conjunctiva as lines of yellowish granules arranged perpendicularly to 
the edges of the lids ; and along the latter the openings of their ducts arc visible in 
the form of minute spots within the line of the eyelashes. 

If the eyelids are drawn forcibly outwards, the internal tarsal ligament, or tendo 
palpebrarum, is made to project between the inner canthus and the margin of the 
orbit ; and this band can also be felt as it is tightened during the act of winking. 
Behind the tarsal ligament, and reaching to a somewhat higher level, is the lachrymal 
sac ; into the latter the canaliculi open, taking a course from the puncta lacrimalia, 
at first vertically, and then nearly horizontally, the one above and the other below 
the ligament. A knife entered immediately below the internal tarsal ligament will 
open the lower part of the lachrymal sac, and a probe may then be passed through 
the incision, in a direction downwards and slightly backwards and outwards, along 
the nasal duct into the nose. 

Mouth and fauces.— On looking into the month, the teeth arc seen, and by 
everting the lips, the outer surface of the gums may be inspected, and the alveolar 
processes can be examined with the finger. The smooth mucous membrane lining 
the lips is thus exposed, and in the middle line, passing from each lip to the jaw, is 
a thin fold termed the fraanum ; of these the upper one is the larger. On pulling 
the angle of the mouth outwards, the lining membrane of the inside of the cheek 
can be examined, and the papilla on which the duct of Stensen opens may be seen 
and felt opposite the second molar tooth of the upper jaw ; with some difficulty a 
fine probe may be made to enter the aperture. A little farther back, if the mouth 
be alternately opened and shut, it is easy to distinguish the anterior borders of the 
masseter and temporal muscles, as well as the edge and inner surface of the ramus of 
the jaw. 

By raising the tongue, the inner aspect of the gums and the floor of the mouth 
arc brought into view. The under surface of the tongue is smooth, and is connected 
in the middle line with the floor of the mouth by the fnmum lintjuce, a fold of 
mucous membrane similar to, but much larger than, the frsena of the lips ; from 
this a fine line is continued fcrwai-ds to the tip of the tongue. Somewhat less than 
half an inch external to the fra-num, on each side, the raiiine vein is clearly seen 
through the delicate mucous membrane ; the corresponding artery is more dee^jly 
placed and does not come into view ; an elevated and fringed line of the mucous 
memljrane, plica fimhriata, lies superficially to these vessels, and may be followed, 
converging towarrls its fellow, almost as far as the tip of the tongue. Jietween the 
alveolar border and the tongue, on each side, is the alrcolo-li/uji/a/ sulcus, at the 
bottom of which the mucous membrane is raised into a well-marked ridge, directed 
obliquely forwards and inwards, over the sublingual salivary gland. Each ridge 
ends close to the middle line in a small papilla, and on this is seen, in the form of a 
minute spot, the opening of Wharton's duct, into which u fine probe may be easily 
passed. 



16 SUPEEFICIAL ANATOMY OF THE HEAD AND NECK. 

On putting back the head, the mucous membrane covering the hard palate, and 
the soft palate come into view, as well as the uvula, the anterior and posterior pillars 
of the fauces, and the tonsils. The hamular process is plainly felt a little behind 
and internal to the last molar tooth ; and just in front of this is situated the opening 
of the posterior palatine canal, through which the largest vessels and nerves of the 
palate issue. The pterygo- maxillary ligament is to be felt descending from the 
hamular process to the inferior maxilla, being contained in a more or less prominent 
fold of the mucous membrane, which passes between the jaws behind the extremities 
of the dental arches. Just in front of this, and immediately internal to the last 
molar tooth, the lingual branch of the fifth nerve runs inwards beneath the mucous 
membrane to the side of the tongue. 

Between the posterior pillars of the fauces, a portion of the mucous lining of the 
hinder wall of the pharynx is seen ; and if the finger be passed behind the tongue, 
there is no difficulty in feeling the greater part of the back of the pharynx and the 
epiglottis. By hooking the finger up behind the soft palate, the basilar process of 
the occipital bone is reached, and the posterior nares and adjacent parts may be 
explored. It is easy thus to distinguish the vault of the pharynx, the septum nasi, 
the posterior extremities of the middle and inferior turbinate bones, and the openings 
of the Eustachian tubes ; and the finger may be made to pass some distance into 
the nasal fossse. In this way also the upper four or five (in children six) cervical 
vertebrae may be examined, the anterior arch of the atlas being opposite the lower 
margin of the posterior nares, and the body of the axis corresponding to the soft 
palate. The part of the column which is accessible to a straight instrument 
introduced through the mouth is very limited, extending in the adult from the 
lower border of the axis to the middle or lower part of the fourth cervical vertebra ; 
in the child, owing to the small depth of the face, it comprises the body of the axis 
and of the third cervical vertebra (Chipault). 

By posterior rhinoscopy the upper parts of the posterior nares are seen, separated 
by the septum. They are in great part occupied by the posterior ends of the 
turbinate bodies, of which the most conspicuous is the middle; the superior is 
usually seen, but only the upper part of the inferior, the lower part of the latter, as 
well as the lower part of the septum, being concealed by the soft palate. On each 
side of the posterior nares are seen the Eustachian tube, the salpingo- pharyngeal 
and salpingo-palatine folds, and the lateral recess of the pharynx (fossa of Eosen- 
mliller). By turning the mirror upwards, the vault of the pharynx, the pharyngeal 
tonsil and the median pharyngeal recess (bursa pharyngea) may also be examined. 
The septum appears whitish, the turbinate bodies are of an ash-grey colour, and the 
rest of the mucous membrane is of various shades of red. 

THE NECK. 

The front of the neck is divided into an upper, suprahyoid, submaxillary, or hyo- 
mental region, and a lower, infrahyoid or hyo-sternal region. The hyoid. bone, which 
forms the boundary line between the two divisions, can be felt in the receding angle 
below the chin, and it may be examined by fixing the two great cornua between the 
fingers. The anterior bellies of the digastric muscles form the convex surface in 
the middle of the suprahyoid region, and outside this on each side the submaxillary 
gland is both to be felt and seen. The median prominence (pomum Adami) in the 
upper part of the infrahyoid region is due to the thyroid cartilage, and is strongly 
marked in men, especially those with deep voices, small or indistinct in women and 
children. Above the thyroid cartilage the finger sinks into the depression {thyro- 
hyoid space) between that and the hyoid bone ; below the thyroid, the crico-thyroid 
space and the cricoid cartilage are recognised ; and from the latter the finger passes 
on to the trachea. The rings of the trachea are, however, scarcely to be distinguished, 



THE NECK. 17 

being obscured above by the isthmus of the thyroid body, and below by the muscles 
and the increasing quantity of fat as the air-tube recedes from the surface, the depth 
of the front of the trachea at the upper border of the sternum amounting to nearly 
an inch and a half (o'T) cm.). 

The lower part of the epiglottis is placed behind the thyro-hyoid space, and 
still farther back is the upper aperture of the larynx. The rima glottidis is at a 
lower level, being opposite the middle of the short anterior margin of the thyroid 
cartilage. The lower border of the cricoid cartilage indicates also the termination 
of the pharynx and the commencement of the oesophagus. 

Along the side of the neck, the sterno-mastoid muscle runs obliquely from the 
mastoid part of the temporal bone to the sternum and clavicle ; its anterior border, 
forming the hinder boundary of the anterior triangle of the neck, is thick and 
prominent, and leads down to the strongly marked sternal head, which passes to the 
front of the manubrium and gives rise, with its fellow of the opposite side, to the 
deep suprastei-ncd notch {fossa juyularis). The posterior border of the muscle is 
thin, and in its upper part does not show on the surface ; inferiorly it becomes 
evident and is continued into the clavicular head, which is, however, broader and 
less salient than the sternal origin. A slight depression usually corresponds to an 
interval between the two heads, and the lower boundary of the depression is formed 
by the somewhat prominent inner extremity of the clavicle. A needle thrust back- 
wards in this depression, and in contact with the end of the clavicle, would reach, on 
the right side, the bifurcation of the innominate artery, on the left, the common 
carotid artery as it passes into the neck. 

The carotid arteries are situated just beneath the anterior bordei* of the 
sterno-mastoid muscle, their position being indicated more exactly by a line drawn 
from the sterno-clavicular articulation to a point midway between the angle of the 
jaw and the tip of the mastoid process. The common carotid artery reaches upwards 
as far as, or slightly beyond, the upper border of the thyroid cartilage ; above this 
level, the external and internal carotids are placed side by side, the external being 
the more anterior, until they pass beneath the posterior belly of the digastric 
muscle, the position of which may be indicated by a line drawn from the mastoid 
process to the fore part of the hyoid bone. If deep pressure be made in the situa- 
tion of the great vessels opposite the cricoid cartilage, the prominent anterior 
tubercle of the transverse process of the sixth cervical vertebra {carotid tubercle) can 
be felt, and the common carotid artery may be compressed against it. This is a 
little below the spot at which the omo-hyoid muscle crosses the carotid artery, and 
indicates also the place where the inferior thyroid artery turns inwards, and the 
vertebral artery usually enters upon its course through the foramina in the transverse 
processes. 

The lingual artery arises from the external carotid opposite the hyoid bone ; it 
first forms a small loop with the convexity upwards, then passes forwards along the 
upper margin of the great cornu of the hyoid just below the level of the hypo- 
glossal nerve and ranine vein, which are separated from it by the hyo-glossus 
muscle. At a slightly higher level, the occipital and facial arteries leave the 
external carotid, the former passing up to the transverse process of the atlas, which 
may be felt just below and a little in front of the tip of the mastoid process, the 
latter taking a winding course at first beneath and then above the submaxillary 
gland to the anterior border of the masseter muscle. The superior thyroid artery, 
arising below the lingual, runs downwards and inwards near the back of the thyroid 
cartilage, and sends its crico-thyroid branch across the crico-thyroid space. 

The line of the internal jugular vein is just external to that of the carotid 
arteries ; the facial vein, more superficial than the artery, courses from the anterior 
border of the masseter downwards and backwards, to j<jiii the main trunk about 



18 SUPEEFICIAL ANATOMY OF THE HEAD AND NECK. 

opposite the thyro-hyoid space ; the middle thyroid vein crosses the common 
carotid artery near the level of the cricoid cartilage, and the large inferior thyroid 
veins pass downwards deeply on the front of the trachea. More superficially placed, 
and often showing through the skin, are the anterior jugular vein near the middle 
line, and a communicating branch, frequently of large size, between the facial and 
anterior jugular veins, lying along the anterior border of the sterno-mastoid muscle. 
The right and left anterior jugular veins are generally connected by a cross branch 
of considerable size at the bottom of the suprasternal notch, close to the upper 
border of the manubrium, and the lower part of each vein is then directed outwards 
behind the origin of the sterno-mastoid, so that great care must be exercised, in 
order not to wound the vessel, in dividing this muscle for the cure of wry-neck. 

The position of the tonsil corresponds externally to a spot slightly above the 
angle of the jaw. 

Behind the sterno-mastoid muscle, between it and the trapezius, is the inter- 
muscular space known as the posterior triangle of the neck ; inferiorly, this gives 
rise to a broad depression, the supraclavicular fossa, in which the omo-hyoid muscle 
and the brachial plexus may be felt, and in thin persons seen. In the angle between 
the sterno-mastoid and the clavicle, the third part of the subclavian artery can be 
felt pulsating, and the circulation in the vessel may be arrested here by pressure 
directed downwards and backwards against the first rib. The subclavian artery, as 
it crosses the root of the neck, describes a curve with the convexity upwards, having 
its inner end behind the sterno-clavicular articulation, its outer end beneath the 
centre of the clavicle, and its mid-point from half an inch to an inch (1 — 2'5 cm.) 
above that bone. The left artery is more deeply placed at first than the right, and 
does not usually rise so high in the neck. The subclavian vein is placed at a lower 
level, and is, as a rule, entirely under cover of the clavicle. The pleura and lung 
ascend above the clavicle into the arch formed by the subclavian artery. The pulsa- 
tion of the transverse cervical artery may frequently be distinguished a short distance 
above the clavicle. 

The external jugular vein runs over the surface of the sterno-mastoid muscle in 
the direction of a line drawn from the angle of the jaw to the centre of the clavicle, 
and is covered only by the integument and the platysma, the fibres of the latter 
being nearly parallel to the course of the vein. The distance to which it reaches 
beyond the posterior edge of the sterno-mastoid below varies considerably. Near 
the clavicle the vein becomes considerably enlarged, being joined by some branches 
from the shoulder (transverse cervical and suprascapular), which, with the lower 
part of the trunk, generally form a more or less dense plexus over the third part of 
the subclavian artery. 

About an inch (2-5 cm.) below the tip of the mastoid process, the spinal accessory 
nerve passes beneath the anterior border of the sterno-mastoid ; emerging at, 
or slightly above, the middle of the posterior border of this muscle, it then 
continues its oblique course across the posterior triangular space, and sinks beneath 
the upper border of the trapezius on a level with the sixth or seventh cervical spine ; 
under the latter muscle, the nerve runs downwards immediately internal to the 
vertebral border of the scapula. The great auricular and superficial cervical nerves 
also come out at the posterior border of the sterno-mastoid about the middle of its 
length, and are thence directed, the great auricular upwards to the ear, and the 
superficial cervical forwards to the front of the neck. 

For the back of the neck, see p. 27. 



THE CHEST. 19 

SUPERFICIAL ANATOMY OF THE TRUNK. 

THE CHEST. 

On the front of the chest, the greater part of the thoracic wall is concealed on 
each side by the pectoralis major, the uppermost portion of the muscle extending 
over the inner half of the clavicle from which it arises, while inferiorly, it forms a 
prominent curved margin, which follows the direction of the fifth costal cartilage. 
The interval between the clavicular and sterno-costal portions can often be seen 
when the muscle is at rest, and always when it is put into action Externally, the 
upper and lower borders of the muscle converge as it narrows to its insertion ; the 
former is at first separated from the adjacent anterior margin of the deltoid by the 
infraclavicular fossa, but lower down the two muscles become closely united ; the 
lower margin of the pectoralis major leaves the chest opposite the fifth rib (at which 
spot the lowest slip of the pectoralis minor often appears on the surface) and forms, 
as it passes upwards and outwards to the arm, the rounded anterior axillary fold, 
ending in the sharp tendon, which becomes apparent when the muscle is in action. 
The nipple is placed over the outer and lower part of the pectoral muscle, generally 
between the fourth and fifth ribs, about three-quarters of an inch (2 cm.) external 
to the junction of the bone and cartilage, and rather more than four inches (10 cm.) 
from the middle line ; but its'positiou varies considerably in diflTerent individuals, and 
it is not unfrequently, especially in fat persons and in females, at a much lower level. 

Along the middle line, the sternum is subcutaneous at the bottom of the sierrwX 
groove or furrow between the great pectoral muscles. The furrow is interrupted 
towards the upper part by a slight, but distinct, transverse ridge, which marks the 
sternal amjle formed by the union of the manubrium and the body of the sternum, 
and on each side of this the second costal cartilage, which projects forwards more 
than the others, continues the prominence outwards. Inferiorly, the sternal furrow 
opens out, as the pectoral muscles diverge from one another, exposing the lower end 
of the body of the sternum, a spot which marks the articulation of the seventh 
costal cartilage, and which is always to be readily felt, and usually distinctly seen, 
owing to the formation of the infrasternal depression immediately below it. The 
infrasternal depi-ession (epigastric fossa, scrobiculus cordis) is a generally well- 
marked, although variable, hollow between the seventh costal cartilages and the 
upper ends of the recti muscles, and is placed over the ensiform process, which is 
itself seldom visible on the surface. It will be remembered that the upper margin 
of the sternum is on a level (during expiration) with the disc between the second 
and third dorsal vertebra? ; the junction of the manubrium and body is opposite the 
fifth dorsal vertebra ; and the xiphi-sternal articulation generally corresponds to the 
lower part of the ninth dorsal vertebra. 

To the outer side of the pectoralis major, the ribs are covered by the serratus 
magnus. Of the digitations of this muscle, the first to appear, at the lower margin 
of the pectoralis major, is the one attached to the fifth rib ; the following one, the 
sixth, is the largest and most prominent, and they become less marked below this. 
Below the pectoral muscle, the wall of the thorax is covered by the rectus abdominis 
internally, and the external oblique laterally, the pointed slips of the latter muscle 
being received between the digitations of the serratus magnus. More posteriorly, 
the lati.ssimus dorsi ascends over the hinder part of the serratus, and, winding round 
the teres major muscle, forms the thick posterior fold of the axilla. 

The ribs may generally be followed without difficulty over the front and sides 
of the cliest ; but only a very small portion of the first can be distinguished, as it is 
almost completely covered by the clavicle and scapula. The width of the inter- 
costal spaces, and the form of the subcostal angle vary greatly in accordance with 



20 SUPERFICIAL ANATOMY OF THE TRUNK. 

the shape of the chest. Thus, in a long narrow chest the lower ribs slope very much 
downwards and are near to one another, the subcostal angle is narrow, and the 
lateral margin of the thorax reaches nearly, or in some persons quite, as far as the 
iliac crest. When the chest is broad the opposite conditions are found. The sub- 
costal angle is on the average about 70° in the male and 75° in the female, but it 
may vary from 60° to 80° (Charpy). 

The lungs. — The apex of the lung rises above the anterior end of the first rib 
and the clavicle into the neck, where it is placed behind the interval between the 
two heads of the sterno-mastoid, being covered immediately by the subclavian artery 
and scalenus anticus muscle. Its highest point is on a level with the neck of the 
first rib ; and it projects very slightly, if at all, beyond the plane of that rib. The 
height to which it extends above the clavicle ranges in ordinary circumstances from 
half an inch to an inch (1 — 2'5 cm.), but sometimes it is as much as an inch and three- 
quarters (4 cm.), while in other cases the lung does not project at all above the bone. 
A resonant percussion-note may, however, always be obtained in the living subject 
for some distance above the clavicle, owing to the obliquity of 'the surface of the neck. 
The distance of the apex from the clavicle is actually diminished during inspiration, 
since that bone is then moved upwards with the anterior end of the first rib. There 
does not appear to be any constant difference in the extent upwards of the lung on 
the two sides, but it is not uncommon for the right lung to be somewhat higher 
than the left. From the apex, the anterior border of each lung inclines inwards 
behind the sterno-clavicular articulation and the manubriam, to the junction of the 
latter with the body of the sternum, where the two almost meet in the middle line ; 
they then descend together, the right sometimes projecting a little to the left of the 
mid-line, as far as the fourth costal cartilage ; from this point the margin of the 
right lung continues a nearly straight course to the level of the sixth chondro-sternal 
articulation (sometimes even to the lower end of the body of the sternum), while 
that of the left slopes outwards behind the fifth costal cartilage, in a direction which 
may be indicated with sufficient accuracy by a line drawn from the fourth chondro- 
sternal articulation of the left side to the spot on the chest- wall corresponding to the 
apex of the heart (see below). 

The lower limit of the lung may be marked by a line, slightly convex downwards, 
carried round the side of the chest from the sixth chondro-sternal articulation to 
the tenth dorsal spine. In the mamillary line, the lung extends downwards to the 
sixth rib ; opposite the posterior fold of the axilla, to the eighth rib ; and in the 
scapular line (carried vertically downwards from the lower angle of the scapula, 
while the arms are against the sides), to the tenth rib. At the side of the chest the 
left lung often descends somewhat beyond these limits. This margin of the lung 
descends considerably in inspiration, and rises in expiration. The position of the 
great fissure in each lung may be ascertained approximately by drawing a line fi'om 
the second dorsal spine to the sixth rib in the nipple-line ; and the smaller fissure 
of the right lung extends from the middle of the foregoing to the junction of the 
fourth costal cartilage with the sternum. 

The pleura reaches considerably farther downwards than the lung. Posteriorly, 
its lower margin corresponds most frequently to the head of the twelfth rib, or the 
eleventh dorsal spine ; it is seldom higher than this, but often lower, in many cases 
extending as much as an inch (2*5 cm.) beyond the spot mentioned. Being directed 
at first horizontally outwards, its line then ascends gradually over the side of the chest, 
and passes behind the seventh costal cartilage to the sternum, from which point it 
slopes gradually inwards to reach the middle line at the level of the fifth cartilages. 
As the pleuree of the two sides are almost symmetrical in front, the left extends 
considerably farther over the pericardium than the corresponding lung. At the 
side of the chest, the line of reflection of the pleura is generally from two to three 



THE CHEST. 



9] 

<v i. 



towards the front, it is 



inches (o— 7 cm.) above the lower margin of the thorax 
nsnally a Httle lower on the left side than the right. 

The heart and great vessels.— The upper limit of the heart is represented by 
a line passmg from the lower border of the second costal cartilage of the left side to 
the upper border of the third cartilage of the right side ; the lower limit by a line 




Fig. 10. — Frost view of tiir tkunk, showing thk relative positions op the principal thoracic 

AND AIJDOMINAL VISCERA, &0. ^. (R. J. (i. ainl (i. D. T.) 

The outlincH of the lungs and their large fissures are indicated by thin lines; the poHition of the 
heart and great vessels (superior vena cava, arch of aorta and iinliiionary artery), as well as below the 
abdominal aorta and the common and external iliac arteries, by thick linos ; the. liver is rciirescnted by 
a broken line ; the stomach and transverse colon by thick dotted lines ; and tiio kidneys by thin 
dotted lineH. 

drawn somewhat obliVjiicly, and with a slight downward convexity, from the seventh 
chondro-sternal articulation of the right side to the apex, the latter point being in the 
fifth intercostal space, about three and a half inches (9 cm.) to the left of the middle 



2.3 SUPERFICIAL ANATOMY OF THE TRUNK. 

line, and generally about an inch and a half (4 cm.) below, and three-quarters of an 
inch (2 cm.) to the sternal side of the nipple. The right border of the heart is indicated 
by a line carried from the third to the seventh chondro-sternal articulation, and 
arching outwards to a distance of one inch and a half (4 cm.) from the middle line ; 
the left border, by an oblique line, convex upwards, extending from the second left 
costal cartilage to the apex. The area thus marked out corresponds to what is known 
as the deep cardiac dulness, although the latter can hardly be traced above the third 
costal cartilage of the left side ; the superficial cardiac dulness corresponds to that 
part of the heart which is uncovered by lung, and thus begins at the inner end of the 
fourth left cartilage, extends to the left almost to the apex, to the right as far as the 
middle line, and below merges into the dulness which answers to the liver. 

The pulmonary orifice is placed opposite the upper margin of the third left costal 
cartilage, close to the sternum, whence the artery proceeds upwards to its bifurcation 
behind the second costal cartilage of the same side, which is therefore termed the 
pul7)ionary cartilage. The orifice of the aorta is below and a little internal to the 
pulmonary orifice, being behind the sternum, close to the lower border of the third 
left cartilage ; from this spot the ascending aorta passes across to the right edge of 
the sternum opposite the second (ao7iic) cartilage, and the arch then returns to the 
left side, crossing the middle line about an inch (2'5 cm.) from the suprasternal 
depression. Opposite the middle point of the manubrium, the innominate and left 
common carotid arteries are arising close together from the upper border of the arch 
of the aorta, and they pass symmetrically upwards, the innominate to the back of the 
right, and the carotid to the back of the left sterno-clavicular articulation. The left 
subclavian artery is almost directly behind the left carotid in the thorax. The superior 
vena cava lies to the right of the arch, behind the inner ends of the first and second 
intercostal spaces ; and the left innominate vein, resting on the upper border of the 
arch, is just below the upper margin of the sternum. It sometimes happens, how- 
ever, especially in children, that the arch of the aorta is placed at a higher level 
than usual, and then the left innominate vein projects upwards into the neck. In 
other cases the innominate artery is longer than usual, and may be felt pulsating in 
the suprasternal fossa. 

The auriculo- ventricular openings of the heart are lower down than the arterial 
orifices, the left being behind the inner end of the fourth left costal cartilage and 
the adjoining part of the sternum, while the right lies behind the sternum on a 
level with the fourth interspace and fifth cartilage. 

Arteries of the thoracic wall. — The internal mammary artery descends behind 
the costal cartilages, and across the inner ends of the upper six intercostal spaces, 
about half an inch (1 cm.) from the margin of the sternum ; and it occasionally gives 
off a considerable lateral costal branch which runs downwards on the inner surface of 
the ribs along the side of the thorax (Vol. II, p. 429). The intercostal vessels are 
lodged for the greater part of their extent in the grooves beneath the lower edges of 
the ribs, by which they are thus protected. 

THE ABDOMEN. 

The superficial limits of the abdomen are formed above by the lower margin or 
the thorax, and below by Poupart's ligament and the iliac crest on each side, the 
former corresponding, except in fat persons, to the curved inguinal furrow. The 
abdominal cavity, however, extends considerably beyond these limits, both upwards 
into the vault of the diaphragm, under cover of the lower ribs and their cartilages, 
and downwards into the hollow of the pelvis. The abdomen is arbitrarily divided 
into nine regions by two horizontal and as many vertical lines. Of the horizontal 
lines, one, called infracostal, is drawn across at the level of the lowest point of the 
tenth costal arch on each side, and the other, which may be termed hi-iliac, between 



THE ABDOMEN. 



23 



the most prominent points (laterally) of the two iliac crests. A horizontal plane 
containing the infracostal line usually cuts some part of the third lumbar vertebra, 
while the bi-iliac line lies in a plane passing through the body of the fifth lumbar 
vertebra about the middle of its anterior surface, and about an inch and a quarter 
below the highest point of the iliac crest. The umbilicus is generally from an inch 
and a quarter to an inch and a half (3 — 4 cm.) above the bi-iliac line. The vertical 



Fig. 



11. — Outline of the front of the abdojien, 

THE DIVISION into REGIONS. 



1, epigastric region ; 2, umbilical ; 8, hj-pogastric ; 4, 4, right 
and left hypochondriac ; 5, 5, right and left lumbar ; 6, t), right 
and left iliac. 

distance between the infracostal and bi-iliac planes 
ranges from one and a half to four inches (4 — 10 cm.), 
with an average of two inches and three-quarters 
(7 cm.)i. The vertical lines {mid-Poupart lines) are 
drawn upwards from the centre of Poupart's ligament 
on each side : above the bi-iliac line they nearly 
coincide with the line^e semilunares, and are usually 
a little external to the outer borders of the recti. 

Of the spaces bounded by these lines, the three 
central are called respectively, from above down- 
wards, epigastric, umbilical, and hypogastric, and the 
lateral ones, right and left hypochondriac, lumbar or lateral abdominal, and iliac. 
The lowest portion of the hypogastric region, being covered with hair, is also referred 
to as the^;w&<?s or pubic region ; and the adjacent parts of the iliac and hypogastric 
regions together constitute what is known as the inguinal region or the groin. 




The viscera which 
following table : — 

Epigastric region 
HyiKKjhondriac, right . . ) 



Hyjwchondriac, left . . .' 



Umbilical . 



Lumbar, right ] 

Lumbar, left | 

Hypogastric | 

Iliac, right \ 



Iliac, left. 



are contained in the several regions are shown in the 

The greater part or the whole of the left lobe, and part of the 
right lobe of the liver, with the gall-bladder, part of the stomach, 
including both orifices, the first and second parts of the duodenum, 
the duodeno-jejunal flexure, the pancreas, upper or inner end of the 
spleen, parts of the kidneys, and the suprarenal bodies. 

The greater part of the right lobe of the liver, the hepatic flexure 
of the colon, and part of the right kidney. 

Part of the stomach, with the greater portion of the spleen and 
the tail of the pancreas, the splenic flexure of the colon, part of the 
left kidney, and sometimes a part of the left lobe of the liver. 

The greater part of the transverse colon, the third part of the 
duodenum, some convolutions of the jejunum and ileum, with 
portions of the mesentery and great omentum, and \}&vt of the 
right, or sometimes of both kidneys. 

The ascending colon, part of the right kidney, and sometimes 
part of the ileum. 

The descending colon, part of the jejunum, and sometimes a small 
part of the left kidney. 

The convolutions of the ileum, the bladder in children, and when 
distended in adults also, the uterus when in the gravid state, and 
behind, the sigmoid loop and upper part of the rectum. 

The ca3cum with the vermiform appendix, and the termination of 
the ileum. 

The sigmoid colon, convolutions of the jejunum and ileum. 



Abdominal wall. — 'I'he wall of the abdomen is formed at the front and sides 
mainly by mu.scles, and the forms to be recognized on the surface arc for the mofct 



• Sec D. J. Cunningham, Delimitation of the Jlegiona of the AbiUmen, Journal of Anatomy, xxviii, 
1893, 



24 SUPERFICIAL ANATOMY OF THE TRUNK. 

part to be referred to these. Anteriorly, the rectus muscle extends on each side of 
the middle line from the pelvis to the thorax, its tendinous inscriptions producing 
transverse furrows, of which two are commonly to be recognized, one opposite, or 
just below, the tip of the eusiform process, and the other about midway between 
this and the umbilicus. In some cases the third may be distinguished about the 
level of the umbilicus. Between the two recti is a median groove {ahdomwal 
furroiv) continued dowuAvards from the infrasternal fossa, along the surface of the 
linea alba, as far as, or a little beyond, the umbilicus, where it gradually disappears 
owing to the approximation and eventual union of the muscles of the two sides. 
The lower ends of the recti are concealed by a small accumulation of fat. 

The position of the umbilicus is subject to considerable variation, but it is 
always below the centre of the distance between the xiphi-sternal articulation and 
the pubic symphysis. It is generally on a level with, or slightly above, the highest 
point of the iliac crest, and opposite the upper part of the fourth, or the dis 
between the third and fourth lumbar vertebrae. 

A line joining the two anterior superior iliac spines usually passes just above the 
promontory of the sacrum. 

The convex surface of the side of the abdomen is formed by the fleshy part of 
the external oblique muscle, the outline of which can often be seen in front and 
below. Between this and the outer edge of the rectus there is a shallow depression 
over the upper portion of the linea semilunaris : this depression terminates above 
at the margin of the thorax, in the somewhat triangular infracostal fossa, the upper 
boundary of which is formed by the rounded ninth costal cartilage. 

In the inguinal region, the superior set of glands may usually be felt lying along 
Poupart's ligament. The external abdominal ring is placed immediately above 
and external to the pubic spine, which can always be readily felt, as well as the 
common attachment of the outer pillar of the ring and Poupart's ligament. By 
invaginating the scrotum at some distance from the aperture, the finger may be 
passed through the ring into the lower part of the inguinal canal. The internal or 
deep abdominal ring is situated about half an inch (1 cm.) above Poupart's ligament, 
opposite a spot midway between the anterior superior iliac spine and the pubic 
symphysis ; and the deep epigastric artery runs upwards close to the inner side of 
this opening, in the direction of a line inclining inwards towards the umbilicus. If 
the inguinal canal has been enlarged by the presence of an old hernia, the rings 
are almost opposite co one another, and the finger may be passed through them and 
can explore the surrounding parts in the interior of the abdomen. 

The superficial epigastric vein is often seen through the skin, and it may 
frequently be observed to communicate with another vein {v. tkoraco-epigastrica) 
that passes up into the armpit to join the axillary vein, especially if there be any 
obstruction to the return of the blood through the inferior vena cava. 

Abdominal viscera. — The liver, which occupies the whole of the arch of 
the diaphragm on the right, as well as a part on the left side, is placed for the 
most part under cover of the ribs. In the right hypochondriac region, its lower 
margin just corresponds to the lower border of the thorax, but in the epigastric 
region, a part of both right and left lobes comes into contact with the abdominal 
wall ; the margin of this part runs obliquely across the subcostal angle from the 
ninth right to the eighth left costal cartilage, and crosses the middle line about a 
hand's breadth below the xiphi-sternal articulation. The gall-bladder projects 
beyond this margin immediately internal to the ninth costal cartilage, and close to 
the outer edge of the rectus muscle, i.e., opposite the infracostal fossa. The extent of 
the liver upwards, if traced on the surface of the body, is marked by a line crossing 
the body of the sternum close to its lower end, and rising on the right side to the 
level of the fifth chondro-sternal articulation, on the left to that of the sixth. A 



THE ABDOMEN. 25 

little internal to tlie right mamillary line, it generally reaches as high as the fourth 
intercostal space, or nearly to the level of the nipple. On the left side it does not 
usually extend more than an inch and a half or two inches (4 — 5 cm.) beyond the 
margin of the sternum (see fig. 10). It must be borne in mind, however, that the liver 
is subject to great variations, not only in size, but also in position, both temporarily 
and permanently. Thus, it sinks with inspiration, and rises in expiration ; it 
descends slightly on assuming the upright position ; and it is frequently moved 
downwards by alterations' in the shape of the chest. It is relatively very large in 
the infant and child, and extends across far into the left hypochondriac region. 
In adults, the margin of the liver is seldom to be felt below the ribs on the right 
side during health, unless the abdominal wall be unusually thin. 

The stoiuacli lies in the left hypochondriac and the epigastric regions, in the 
latter being partly covered by the liver and partly in contact with the abdominal 
wall. Its cardiac orifice is situated behind the seventh costal cartilage of the left 
side about an inch (2-b cm.) from the sternum, and at a depth of about four inches 
(10 cm.) from the surface. The pyloric orifice is from three to four inches (8 — 
10 cm.) below the xiphi-sternal articulation, and, when the stomach is contracted, 
in or immediately to the right of the median plane ; but when the stomach is 
distended, the pyloric end moves considerably to the right. The pyloric orifice is 
much nearer to the surface than the cardiac. The fundus of the stomach is directed 
upwards into the left portion of the vault of the diaphragm, and reaches, under 
ordinary circumstances, to the level of, or somewhat higher than, the sixth chondro- 
sternal articulation, or in the mamillary line to the fifth rib, being a little above 
(and behind) the apex of the heart. The great curvature of the stomach is directed 
at first to the left, and afterwards downwards, the latter part reaching, with a 
moderate degree of distension of the organ, about as far as the infracostal line. 

Large intestine. — The transverse colon passes across in the upper part of the 
umbilical region, following closely the great curvature of the stomach. The ctecum 
is comparatively superficial in the right iliac region ; the ascending colon and the 
hepatic flexure are deeply placed in the right lumbar and hypochondriac regions. 
The splenic flexure reaches a higher level than the hepatic, and is situated 
behind the stomach in the left hypochondriac region, while the descending colon 
occupies the hinder part of the left hypochondriac and lumbar regions. Deep 
pressure on the left side detects the sigmoid colon as it passes over the brim of the 
pelvis, in thin persons even when comparatively empty ; if distended with ffeces, it 
forms a distinct tumour in this situation. 

Small intestine. — The intestines below the stomach are all covered moi'e or 
less completely by the great omentum. The coils of the small intestine occupy the 
anterior part of the belly below the transverse colon, those of the jejunum being 
principally found above, those of the ileum below. The upper limit of the attach- 
ment of the mesentery, corresponding to the duodeno-jejunal flexure, is commonly 
between three and four inches (H — 10 cm.) above the umbilicus and slightly to 
the left of the median line, while the lower end is, on an average, four inches 
(10 cm.) from the centre of Poupart's ligament of the right side, along a line 
directed upwards and somewhat inwards, following the course of the psoas muscle 
(Lockwood). The tennination of the ileum in the large intestine corresponds 
generally to a spot on the anterior abdominal wall from one to two inches (y — 5 cm.) 
internal to, and slightly aVjove, the anterior superioi" iliac 8])ine. 

Jn children under ordinary circnmstances, an<l in adults when it is distended, 
the bladder rises out of the pelvis into the hypogastric region, being closely applied 
to the anterior abdominal wall without the intervention of peritoneum for some 
distance ah>ove the pubic bones ; if the distension be excessive, the bladder may 
reach nearly as far as the mnbilicns. 



26 



SUPERFICIAL ANATOMY OF THE TRUNK. 



The kidneys, being situated at the back of the abdominal cavity, are not to be 
felt under normal conditions, or at most the right is at times to be detected. They 
are lodged on each side mainly in the epigastric and hypochondriac regions. That 
of the right side usually extends slightly into the umbilical and lumbar regions ; 
but on the left side the organ is frequently altogether above the infracostal plane. 




Fig. 12. — Determination of the position of the kidneys on the front of the body : scheme. 

(R. J. G. and G. D. T.) 



The inferior pole of the kidney is about two and a half to three inches (6 — 7 cm.) 
from the median plane, and on the right side is about an inch (2 — 3 cm.) above the 
level of the umbilicus, while on the left side it is in the majority of cases about half 
an inch (1 — 2 cm.) higher. The length of the kidney being generally from four to 
four and a half inches (10 — 12 cm.), the position of the superior pole is indicated 
by a spot a corresponding distance above the level of the inferior pole, and about 
two inches (5 cm.) from the middle line. This spot is above the margin of the 
thorax, and is generally over the sixth or seventh costal cartilage, about the place 
where the interchondral articulation is formed between these cartilages. The 
shortest distance between the two kidneys, at the upper part of their mesial borders, 



THE BACK. 27 

measures about two and a half inches ((» cm.): the hikim, which looks mainly 
forwards, is about two inches (5 cm.) from the median plane. 

Like other abdominal organs, the kidneys ai'e subject to considerable variations 
in size and position ; and they are frequently found at a lower level than that just 
given. In the female they are situated as a rule slightly lower than in the male ; 
and during childhood, when the kidneys are relatively of large size, they are at the 
same time lower and more symmetrically placed than in the adult, ^ 

The pancreas lies over the first and second lumbar vertebrae, from two and a 
half to five inches (6 to 12 cm.) above the umbilicus ; and the third part of 
the duodenum crosses the spine at a lower level, often reaching nearly to the 
umbilicus. 

Abdominal vessels. — The abdominal aorta commences rather above the mid- 
point between the infrasternal depression and the umbilicus, and passes downwards 
usually a little to the left of the middle line of the body, although its lower end 
often occupies a median position, or may even extend over slightly to the right. 
The bifurcation occurs on the average about three-quarters of an inch (2 cm.) below 
the umbilicus, and the direction of the common and external iliac arteries is indicated 
by drawing a line from this point to another midway between the pubic symphysis 
and the anterior superior spine of the ilium. The inferior vena cava lies just to the 
right of the aorta. 

The cneliac axis arises opposite the lower part of the last dorsal vertebra, i.e., 
between four and five inches (10 — 12 cm.) above the umbilicus ; the superior 
mesenteric artery a very little lower ; the two renal arteries from three and a 
half to four inches (9 — 10 cm.), and the inferior mesenteric about one inch 
(2*5 cm.) above the umbilicus. 

THE BACK. 

At the back of the neck, a slight median depression — the nuchal furroiv, com- 
mencing immediately below the external occipital protuberance — descends over the 
ligamentum nucha, between the prominences formed by the complcxus and trapezius 
muscles of the two sides. By pressing deeply in this furrow, the spine of the axis is 
readily felt, and generally also the spines of the third, fourth, fifth, and sixth cervical 
vertebrae less distinctly. The furrow disappears gradually towards the root of the 
neck, where the spines of the seventh cervical and upper one or two dorsal vertebrje 
become visibla The first spine to appear is usually that of the seventh cervical 
vertebra, but sometimes the sixth is long and comes to the suiface : the most 
prominent is the first dorsal. They necessarily project more plainly when the neck 
is inclined forwards. Below these, the long spmal or dai'so-lumbar furroiv descends 
in the middle line between the elevations formed by the erector spinte muscles 
covered on each side above by the trapezius and below by the latissimus dorsi. The 
furrow is deepest in the lower dorsal and upper lumbar regions, where the muscles 
are thickest and most fleshy ; in the lower lumbar region and over the upper part of 
the sacrum, the erector muscles are tendinous, and give rise to a somewhat lozenge- 
shaped flattened area through which tlie groove is continued, becoming gradually 
shallower, to terminate at the spine of the third piece of the sacrum (last sacral 
spine) in the angle formed by the meeting of the right and left ghiteus maximus 
muscles. A h'ttle above and external to this point, a sh'ght depression indicates the 
position of the jKjsterior superior iliac spine. At the bottom of the spinal furrow, 
the spines may be felt and counted, the middle dorsal ones generally with consider 
able difficulty in the erect position, but most of them are rendered veiy evident by 

' See Secrmd Annual Report of Committee of Collective Investif/ation of Anat. Soc, 1890-91, by 
ArtliiirThomBon, .Jouni. Anat., xxvi, 83; also K. Helm, Jkitru'jc ziir Knintniss dcr Nic-CM-Topo- 
ijra.jihi'', DinH., JiorJiii, 1S9.'>. 



28 SUPERFICIAL ANATOMY OF THE TEUNK. 

bending the column forwards. The fourth lumbar spine is on a level with the 
highest part of the crest of the ilium : the third lumbar spine is generally somewhat 
higher than the umbilicus. 

The spine of the scapula is easily felt beneath the skin, and may be traced out- 
wards (very little upwards when the arm is hanging) to the acromion, which is 
represented on the surface by a depression in a muscular subject, or when the arm 
is raised. The lower border of the spine and the outer border of the acromion meet 
in the prominent acromial angle, w'hich is always to be distinctly recognized on the 
surface ; from this point measurements of the length of the arm are most 
conveniently taken. The vertebral border and the inferior angle of the scapula are 
seen, although covered for the most part by muscles, the former by the trapezius, 
the latter by the latissimus dorsi. The superior border cannot nsually be 
distinguished, but the axillary border can be felt more or less distinctly through its 
thick muscular covering. With the arms hanging by the side, the upper angle of 
the scapula corresponds to the upper border of the second rib, or the interval 
between the first and second dorsal spines ; the lower angle to the seventh inter- 
costal space (sometimes the eighth rib) or the interval between the seventh and 
eighth dorsal spines ; and the root of the spine of the scapula to the interval 
between the third and fourth dorsal spines. The vertebral border of the bone is at 
the same time nearly perpendicular. 

At the inner end of the spine of the scapula, a distinct depression indicates the 
triangular tendon in which the lower fibres of the trapezius end ; and a shght groove, 
which is seen at times passing upwards and outwards over the surface of the 
eminence formed by the erector spinge, in the direction of a line from one of the 
lowest dorsal spines to the triangular tendon, marks the lower edge of the muscle. 
Immediately above the spine of the scapula is a convex surface formed by the 
thickest part of the trapezius covering the supraspinatus muscle ; and above this, the 
sloping surface leading down from the neck to the shoulder is formed by the upper 
part of the trapezius, supported by the levator anguli scapulee and by fat. 

The lower ribs are to be felt through the latissimus dorsi, outside the edge of the 
erector spin^ ; but it must be borne in mind that the twelfth rib is often very short 
and does not project beyond the margin of the erector muscle, so that the lowest rib 
that can then be felt is the eleventh. The ribs should, therefore, always be counted 
from above downwards, and not from below upwards. 

The lower end of the larynx and pharynx, and the commencement of the 
trachea and oesophagus are about on a level with the interval between the sixth and 
seventh cervical spines. From this spot the trachea descends, at first in the middle 
line, and then inclining slightly to the right divides opposite the fourth dorsal spine 
into the two hronchi. The latter are thence directed outwards and downwards, the 
right usually more nearly in the line of the trachea, and the left becoming more 
transverse in direction, to the hilum of the lung, which they enter about the level 
of the fifth dorsal spine. In the lung the main prolongation of the bronchus 
descends, accompanied by corresponding pulmonary vessels, which are placed 
clorsally to the air-tube, about one and a half or two inches (4 — 5 cm.) from the 
median plane, towards the hinder part of the base of the lung. 

Lungs and pleurae. — The apex of the lung, corresponding to the neck of the 
first rib, extends up to the level of the seventh cervical spine, Mesially, the lungs 
touch the sides of the bodies of the vertebra ; and inferiorly, they reach down to 
the tenth dorsal spine, the pleura to the eleventh or even lower, as has already been 
described (p. 20). 

The oesophagus, from its commencement, inclines at first somewhat to the left, 
but regains the middle line about the fifth dorsal vertebra ; in its lower part it is 
deflected more considerably to the left, and it terminates at the cardiac orifice of the 



THE BACK. 



29 



stomach about on a level with the ninth dorsal spine. The pyloric orifice of the 
stomacli is to the right of the twelfth dorsal spine. 

Aorta. — The arch of the aorta reaches the left side of the vertebral column just 
above the fourth dorsal spine, and the descending aorta passes downwards, gradually 




Fig. 13. — Posterior view op the trunk, showing the relative positions op the principal 

THORACIO AND ABDOMINAL VISCERA, &C. (R, J. G. and G. D. T.) i. 

The several objects are indicated in the same manner as in fig. 10, the trachea and kings by thin 
lines, the aorta by thick lines, the liver, pancreas and spleen by broken lines, the oesophagus, stomach, 
ascending and descending colon by thick dotted lines, and the kidneys by thin dotted lines; x, x, 
seventh cervical and first lumbar spines. 

inclining to the front of the column, to bifurcate at a spot in, or close to, the median 
plane, on a level with tlie fourth lumbar spine. The coeliac axis arises opposite the 
twelfth dorsal, the renal arteries opj)08ite the first lumbar spine. 

The convex surface of the spleen looks backwards and somewhat outwards. It 



30 SUPERFICIAL ANATOMY OF THE TRUNK. 

is placed beneath the ninth, tenth and eleventh ribs of the left side, being separated 
from them by the diaphragm, and at its upper part also by the lung. It lies very 
obliquely, its long axis coinciding almost exactly with the line of the tenth rib. Its 
highest and lowest points are on a level respectively with the ninth dorsal and hrst 



Fig. 14. — Outline view op the kidneys from behind, constructed prom a series op horizontal 

SECTIONS through THE TRUNK OF AN ADULT MALE. (J. Symington.) 

R.K., L.K., right and left kidneys ; e.s., outer border of erector spinse muscle ; q.l., outer border 
of quadratus lumborum muscle ; i.e., iliac crest ; p.p., dotted line to show lower limit of costal pleura. 
In this case the two kidneys were nearly symmetrical in position. 

lumbar spines ; its inner end is distant about an inch and a half (4 cm.) from the 
median plane of the body, and its outer end about reaches the mid-axillary line. 

Kidneys. — The upper end of the right kidney reaches to the level of the 
eleventh dorsal spine ; the lower end is on an average one inch (2*5 cm.) above 
the iliac crest, and a little below the level of the second lumbar spine ; the hilum 
is opposite the first lumbar spine. The last rib, when well developed, is sloped 
downwards and outwards at an angle of about 45° with the vertical, and crosses the 
posterior surface of the kidney in such a way that about one-third of the organ is 
under cover of the thoracic wall. The left kidney is, as a rule, about half an inch 
(1 — 2 cm.) higher than the right. In the female and child the kidneys are some- 
what lower than in the adult male, and not unfrequently reach down as far as the 
iliac crest {cf. p. 26). 



THE BACK. 



31 



G^" CERVICAL" 



e'H CERviCAt* 



A^H DORSAL-< 



VS'" DORSAL 



Colon. — The ascending and descending portions of the colon pass vertically 
along the outermost part of the right and left kidneys respectively ; the part of the 

Fig. 15. — Diagram showing the varying relations op the root- *~'"=:erv,cal.(^& 

ORIGINS of the spinal NERVES TO THE SPINES OP THE VERTEBRAE. rClj ^°° '^^''"'^*'" 

(After R. W. Reid.) 4^.cerv,ca.|^ 

intestine which is in contact with the abdominal wall is 
placed immediately internal to a line carried vertically up- 
wards from the central point of the iliac crest. 

The pancreas crosses the spinal column opposite the 
twelfth dorsal and first lumbar spines, and the third part 
of the duodenum from the second to the third lumbar 
spine. 

Spinal cord and origins of spinal nerves. — The 
lower end of the spinal cord in the adult corresponds 
generally to the interspace between the first and second 
lumbar spines, and is not subject to much variation in 
level ; but in the infant it reaches to the third lumbar 
spine. The cervical enlargement extends downwards to 
about the seventh cervical spine, and the lumbar enlarge- 
ment corresponds mainly to the last three dorsal spines. 

The relations of the origins of the spinal nerve-roots to 
the spinous processes of the vertebrge vary to some extent 
in different individuals, especially in the thoracic region, 
the range of any given dorsal nerve-root being about equal 
to the distance between three adjoining spines, or two 
interspinous intervals, as is shown in the accompanying 
diagram (fig. 15) constructed from the observations of 
R. ^Y. Ptcid upon six subjects. The following rules will, 
however, serve to indicate with sufficient accuracy the 
average position of the several nerve-roots : — The second 
cervical nerve arises opposite the neural arch of the atlas, 
the third opposite the spine of the axis, and the fourth 
opposite the interval between the second and third cervical 
spines. The lower four cervical nerves arise each opposite 
the spine of the second vertebra above the place of exit of 
the nerve from the spinal canal. The origins of the upper 
six dorsal nerves are about on a level with the spines of 
the third, and of the lower six with the sjjines of the 
fourth vertebra above their respective places of exit. The 
lumbar nerves arise in the neighbourhood of the tenth 
and eleventh dorsal spines, and the sacral nerves between 
the eleventh dorsal and first lumbar spines. 



lOTH DORSAL < 



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SUPERFICIAL ANATOMY OF THE UPPER LIMB. -35 

SUPERFICIAL ANATOMY OF THE UPPER LIMB. 
THE SHOULDER. 

In the region of the shoulder, the outer part of the clavicle and the acromion 
process of the scapula can be distinctly felt beneath the skin, and the extremity of 
the former bone usually gives rise to a marked elevation at its junction with the 
acromion. The rounded prominence of the shoulder is formed immediately by the 
thick deltoid muscle, but it is also due in great measure to the large upper extremity 
of the humerus, which can be felt moving under the muscle as the arm is rotated. 
Close to the inner side of the shoulder-joint, and just below the clavicle, the coracoid 
process is to be recognized in the infraclavicular fossa (see below) ; and by pressing 
deeply in the axilla, when the arm is abducted, the lower margin of the glenoid 
cavity and the head of the humerus are also to be felt. 

The adjacent margins of the deltoid and pectoralis major are closely united 
together at their lower parts, so that the division between the two muscles is not 
indicated on the surface ; Ijut superiorly, they are separated by a triangular interval 
of variable ])readth, which gives rise to the well-marked iiifradancular fossa. By 
pressing deeply in this fossa, the axillary artery may be compressed against the 
second rib. The back of the shoulder is flattened, and sloped from within outwards 
and a little forwards, owing to the oblique position of the scapula ; and the hinder 
portion of the deltoid, which is thinner than the anterior, is tendinous at its origin, 
and adheres closely to the subjacent infraspinatus muscle, so that the upper part of 
its margin is not indicated upon the surface. The infraspinatus is continued into 
the teres minor, and below the latter muscle is the thick teres major, with the 
latissimus dorsi winding round it, forming the posterior fold of the axilla. When 
the arm is abducted, the middle portion of the deltoid, being brought into action, is 
seen to present an irregular surface, the prominences corresponding to the separate 
fleshy portions of the muscle, and the depressions to the tendinous septa extending 
downwards from the acromion. 

The course of the axillary artery is marked upon the surface by a line drawn 
from the mid-point of the clavicle to the inner border of the elevation formed by 
the coraco-brachialis muscle (see below). If the limb be raised from the side, the 
third part of the artery may be felt pulsating beneath the integument and fascia 
(the vein intervening) 'as it passes into the arm, being placed at the junction of the 
anterior and middle thirds of the space between the axillary folds. The artery may 
be readily compressed here against the humerus. The posterior circumflex vessels 
and the circumflex nerve are winding round the back of the humerus under cover of 
the deltoid, at the junction of the upper and the middle thirds of the muscle. 

THE ARM. 

The shaft of the humerus is for the most part thickly covered by the muscles of 
the arm, and can only be felt with ditticulty ; but just below the insertion of the 
deltoid the bone comes nearer to the surface, and from this spot the outer border, or 
the external supracondylar ridge, can be followed down to the outer condyle, along 
the bottom of a furrow over the external intermuscular septum, between the 
supinator longus and triceps muscles. The internal supracondylar ridge is less 
prominent, and not so readily felt. 

Along the fore and inner part of the arm (when hanging naturally by the side) 
is the eminence formed by the biceps nuiscle, extending, with a slight inclination 
outwards below, from the anterior margin of the axilla to the elbow. Sui)eriorly, 
this is continued into a narrow elevation produced by the coraco-brachialis muscle, 
which issues from between the anterior and posterior axillary folds. Two 
depressions, the inner and outer bicipital furrows, are found on the inner and outer 



36 



SUPERFICIAL ANATOMY OF THE UPPER LIMB. 



side respectively of the promiaence of the biceps ; along the outer of these the 
cephalic vein may generally be seen ascending beneath the skin ; in the inner, 
which is better marked, are placed the basilic vein (in its lower half or less super- 
ficial to the fascia), the brachial vessels and the median nerve. The brachial artery 



fossa. pectoroyC 



ext. nul. bi-ev. 




flem-uln.. 






FiH 



16. — Superficial anatomy of the uppek limb : antekior vieav. (From a photograph by 
G. W. B. Waters.) (R. J. G. & G. D. T.) 



is usually overlapped to some extent by the margin of the biceps, but it can be felt 
pulsating throughout. Pressure should be applied to the vessel from within 
outwards in the upper half of the arm, from before backwards in the lower. 

On the outer side of the biceps, a portion of the brachialis anticus comes to the 
surface, and beyond that the supinator longus and extensor carpi radialis longior 
form a prominence which descends to the forearm in front of the external condyle ; 



inserUoK oFde/^Lct 



ctrcanffleK 




exi. din-, 



Fig. 17.~ Superficial anatomy of the upper limb : posterior a'ibw. (From a photograph by 
G. W. B. Waters.) (R. J. G. & G. D. T.) 

the supinator muscle shows very plainly if the elbow be forcibly flexed with the 
hand in a state of semipronation. On the inner side of the biceps, in the lower 
part of the arm, a smaller portion of the brachialis anticus is superficial, and between 
this and the triceps, the internal intermuscular septum can be felt, with the ulnar 
nerve close behind it, descending to the internal condyle. 



THE ARM AND ELBOW. 37 

The form of the back of the arm is determined by the triceps muscle, the three 
heads of which, together wich the large teudou of insertion, are to be recognized 
when the muscle is called into play. The inner head is the least distinct ; the 
outer head forms a large prominence immediately below the hinder border of the 
deltoid ; the long head can be seen issuing from between the teres major and minor 
muscles, and descending along the middle of the back of the arm ; while the tendon 
is represented by a depressed area, leading down to the olecranon process of the 
ulna. The musculo-spiral nerve begins to incline backwards immediately below the 
posterior fold of the axilla, and crosses the back of the humerus obliquely from 
within outwards in its middle third, being covered by the long and outer heads of 
the triceps muscle, and accompanied by the superior profunda vessels. At, or a 
little above, the junction of the middle and lower thirds of the arm, the nerve 
perforates the external intermuscular septum, and it then descends in front of the 
outer supracondylar ridge, and under cover of the supinator longus muscle, to the 
level of the external condyle, where it divides into the radial and posterior interos- 
seous nerves. The former takes a straight course downwards to join the artery of 
the same name below the elbow ; but the posterior interosseous is directed back- 
wards across the outer side of the radius in its upper fourth, to gain the back of 
the forearm. 

THE ELBOW. 

At the elbow, the internal and external condyles come to the surface, and also 
the olecranon process of the ulna. The internal condyle, which, it will be 
remembered, is directed more backwards than inwards, is very prominent, and forms 
one of the most important bony landmarks of the limb. The external condyle, 
together with the common tendon of the extensor muscles of tlie forearm, gives rise, 
when the joint is extended, to a well-marked depression at the outer and back part 
of the elbow, between the supinator longus and extensor carpi radialis longior 
muscles externally, and the anconeus internally. In this hollow, when the muscles 
are relaxed, the head of the radius may be felt below the external condyle and the 
capitellum. If the elbow be semi-flexed, the condyle is slightly prominent ; and in 
extreme flexion, the outer part of the triceps muscle is stretched over the capitellum 
of the humerus, which forms a rounded eminence to the outer side of the point of 
the elbow (olecranon), while the condyle itself is no longer visible. The olecranon 
is subcutaneous at its posterior surface, its upper end being entirely covered by the 
insertion of the triceps ; its appearance necessarily vai'ies with the position of the 
joint, as does also the distance between the pi'ocess and the shoulder. A bursa is 
intf^rposed between the bone and the skin. 

At the bend of the elbow, the subcutaneous veins are more or less distinctly 
visible, according to the quantity of subcutaneons fat : — the median vein bifurcat- 
ing into the median-basilic and median-cephalic, which join respectively the 
ulnar and radial veins to form the basilic and cephalic. The median-basilic and 
median-cefihalic veins, diverging from each other, pass upwards on either side of 
the biceps tendon, which is seen, when the elbow is bent, descending from the lower 
end of the muscular belly' into the interval between the two masses of forearm 
muscles. TIk^ sharp upjter edge of the bicipital fascia may also be felt, and, when 
the muscle is fr^rcil^ly contracted, seen, as it passes downwards and inwards between 
the median-basih'c vein and the lower part of the brachial artery. IMie ])u]sation of 
the latter vessel may be felt, and often seen, as it passes obhqucly downwards and 
outwards to a point a little below the middle of the bend of the elbow. 



38 SUPERFICIAL ANATOMY OF THE UPPER LIMB. 



THE FOEEARM. 

From the olecranon, the sinuous jDOsterior border of the ulna is to be followed 
down the forearm, corresponding to a superficial furrow between the ulnar flexor 
and extensor muscles of the wrist ; the border becomes rounded off in the lower 
third, but a narrow strip of the bone is still subcutaneous, leading down to the 
styloid process. When the hand is supinated, the styloid process of the ulna is 
exposed at the inner and posterior part of the wrist ; but if the hand be pronated, 
then the skin is stretched over the opposite (outer) part of the head of the ulna, 
which projects between the extensor carpi ulnaris and extensor minimi digiti 
muscles. Close below the outer condyle of the humerus the head of the radius may 
be felt moving beneath the muscles, more distinctly when the elbow is bent, as the 
forearm is alternately pronated and supinated. The upper half of the shaft of the 
radius is too thickly covered by muscles to be distinctly made out ; the lower half 
is nearer to the surface, and can be readily examined between and through the 
surrounding muscles and tendons ; at the lower end, the styloid process, which 
descends rather lower than the styloid process of the ulna, is superficial in front and 
behind, being covered externally by the tendons of the extensor ossis metacarpi and 
extensor brevis (ext. primi internodii) pollicis muscles ; and the prominent tubercle 
on the outer side of the groove for the extensor longus pollicis (ext. secundi inter- 
nodii) is also to be distinguished. 

Along the inner and fore part of the forearm is the prominence formed by the 
pronato-flexor muscles, the great mass covering the ulna internally being formed by 
the flexor profundus digitorum beneath the flexor carpi ulnaris. A short distance 
below the internal condyle, a slight groove runs obliquely downwards and inwards 
across the muscles, caused by the prolongation of the fibres of the bicipital fascia. 
Near the wrist, the tendon of the flexor carpi ulnaris can be felt, passing down to 
the pisiform bone, and immediately external to the tendon the beating of the ulnar 
artery is perceptible : when the wrist is extended a groove marks the position of 
the tendon. About the centre of the front of the wrist the tendon of the palmaris 
longus descends, being the moct prominent of all the tendons here, and a little 
external to this, the tendon of the flexor carpi radialis is also visible. It will 
however be remembered that the palmaris longus is often wanting. Outside the 
tendon of the flexor carpi radialis is a hollow in which the radial vessels are placed, 
and where the pulse is commonly felt : immediately internal to the tendon lies the 
median nerve. 

Along the outer border of the forearm, the long supinator and radial extensor 
muscles of the wrist descend, becoming tendinous and smaller below the middle ; 
and in the lower third of the forearm a smaller prominence, directed obliquely 
downwards, outwards and forwards, results from the presence of the extensor 
muscles of the thumb crossing over the long tendons. On the back of the forearm 
are the extensors of the fingers, the extensor carpi ulnaris, and the anconeus, all of 
which may be individually distinguished in thin persons. 

Numerous cutaneous veins are seen on the forearm, arising principally from the 
network on the dorsum of the hand, and forming two main trunks, the posterior 
ulnar and the radial, which ascend respectively along the inner and outer borders 
of the limb, and incline forwards to their terminations in front of the elbow ; in 
many cases another large vein is present (assisting or even replacing the radial 
vein), which turns round the outer border of the forearm below the middle to join 
the median vein. The subcutaneous veins of the lower part of the front of the 
forearm (also those of the palm) are small, and terminate in the median and anterior 
ulnar veins. It occasionally happens that the ulnar artery, having been derived 
from the brachial at a higher level than usual, descends over the pronato-flexor 



THE FOREARM AND HAND. 39 

muscles to the wrist, and in that case it would be felt pulsating beneath the skin in 
the neighbourhood of the anterior ulnar vein (Vol. II, p. 445). 

The bifurcation of the brachial artery takes place opposite a spot a finger's 
breadth below the centre of the bend of the elbow. From this point, the radial 
artery runs downwards with a nearly straight course to the fore part of the styloid 
process of the radius, being covered by the supinator longus as far as the centre of 
the forearm, and superficial beyond this spot. The ulnar artery inclines, with a 
slightly curved course, inwards to the middle of a line drawn from the back of the 
internal condyle of the humerus to the outer side of the pisiform bone : this line 
indicates in its whole extent the direction of the ulnar nerve in the forearm, in its 
lower half that of the ulnar artery also. The latter is deeply placed beneath the 
muscles arising from the internal condyle till within an inch of the wrist. 

THE WRIST AND HAND. 

At the front of the wrist, on the inner side, the pisiform bone can be grasped 
between the fingers, and moved slightly from side to side ; below this, and a little 
more externally, the hook of the unciform bone can be felt with difficulty. On the 
outer side, a projection is felt just below and internal to the styloid process of the 
radius, formed by the tuberosity of the scaphoid bone, and close below this, the ridge 
of the trapezium is also to be distinguished. At the back of the wrist, on the inner 
side, the pyramidal bone can be felt, and slightly external to the middle line of the 
hand is a prominence, sometimes indistinct, but often very well marked, formed by 
the styloid process on the base of the third metacarpal bone at its articulation with 
the OS magnum. 

At the metacarpo-phalangeal articulation of the thumb the sesamoid bones can 
be felt ; and on the dorsal aspect of the hand the metacarpal bones and the 
phalanges can be distinctly followed. 

At the outer side of the wrist, when the thumb is extended, there is a deep 
hollow bounded by the prominent teudons of the extensor ossis metacarpi and 
extensor brevis pollicis anteriorly and the extensor longus pollicis posteriorly ; the 
latter tendon may be followed down over the metacarpal bone and first phalanx of 
the thumb almost to its insertion. Beneath those tendons, and across the inter- 
vening hollow, the radial artery runs in its course from the front to the back of the 
wrist ; its direction may be marked by a line drawn from the fore part of the 
styloid process of the radius to the upper end of the first interosseous space ; and 
a considerable vein, ascending from the outer part of the hand, is usually to be seen 
through the skin over the position of the artery. 

On the back of the hand, the tendons of the extensor communis digitorum and 
extensor minimi digiti may all be recognized, together with the connecting band 
between the innermost slip of the common extensor and the outer portion of the 
little finger tendon. In some cases the tendon of the extensor indicis may also be 
perceived on the inner side of the first slip of the extensor communis. Between the 
first and second metacarpal bones is the abductor indicis muscle, which forms a 
well-marked prominence when the thumb is brought to the side of the index finger, 
and below this is the adductor transversus pollicis muscle contained in the fold of 
skin pas-sing across between the thumb and the outer margin of the palm. 

The palm of the hand is concave in the centre, where the skin is tightly adherent 
to the palmar fascia, and i-aiscd on each side. The outer elevation (thenar) is 
formed by the outer group of the short muscles of the thumb ; tli(! inner {lii/polliPiiar) 
by the short muscles of the little finger. From the central IkiHow of the palm a 
slight groove is continued downwards to each of the fingers, corresponding to the 
prolongations of the palmar fa.scia. The palm is traversed generally by four more or 



40 



SUPERFICIAL ANATOMY OF THE UPPER LIMB. 



less regular lines, representing the folds or "flexures" produced in the skin by the 
morements of the principal joints of the hand. Two of these lines are directed 
nearly transversely, the others longitudinally. Of the transverse lines, one 
commences about the junction of the upper three-fourths with the lower fourth of 
the inner border of the palm, and runs outwards and then downwards to the cleft 
between the index and middle fingers ; this is caused by bending the metacarpo- 
phalangeal articulations of the inner three fingers ; the second starts nearly opposite 
the foregoing, at the outer border of the hand, and is directed inwards and some- 



RADIAL 
ARTERY 



SUPtRFICIAL 
ARCH 




Fig. 18. — Palmar surfaok of the hani>, showing the cutaneous lines and the sittjation of 

THE chief arteries IN RELATION TO THE SKELETON. ((x. D. T. ) 



what upwards across the middle of the palm ; this results mainly from the flexion of 
the first joint of the index finger. The metacarpo-phalaugeal articulations are 
placed about midway between these lines and the web of the fingers. Of the 
longitudinal lines, one, beginning near the centre of the wrist, curves outwards to 
join the upper transverse line, and is produced by the opposition of the thumb ; the 
other runs downwards from the wrist through the centre of the palm to meet the 
lower transverse line opposite the middle finger, and is caused by the opposition of 
the fifth metacarpal bone. The four lines give rise to a figure resembling the 
letter M. At the wrist, two or three lines, directed rather obliquely, outwards and 
a little downwards, indicate the position of the principal folds formed during flexion 



THE HAND, 41 

of the joint ; the radio-carpal articulation is placed about three-quarters of an inch 
above the lowest of these lines. There are three well-marked transverse grooves on 
each finger ; the lower and middle ones are nearly opposite the two interphalangeal 
joints ; the upper one, which is produced, as well as the transverse lines of the palm, 
by bending the metacarpo-phalangeal articulations, is placed nearly three-quarters of 
an inch (15 mm.) below the joint, and on a level with the web of the fingers. On the 
thumb, there are only two grooves, and the proximal, which is less distinct than the 
other, continues upwards the line of the radial border of the index finger, thus 
crossing obliquely the corresponding articulation. 

The web of the fingers, containing the superficial transverse ligament, limits the 
interdigital clefts on the palmar side ; on the dorsum of the hand the clefts are 
continued upwards almost to the metacarpo-phalangeal joints. 

The superficial palmar arch is placed beneath the palmar fascia about the centre 
of the palm ; its position may be indicated by a line carried from the outer 
side of the pisiform bone downwards, and then curving outwards across the 
middle third of the palm on a level with the upper end of the cleft between the 
thumb and index finger. From the convex side of the arch digital branches 
proceed, one to the ulnar margin of the little finger, and three which descend 
opposite the intervals between the fingers and bifurcate about half an inch above 
the clefts. The deep palmar arch rests against the metacarpal bones about a quarter 
of an inch nearer the wrist than the superficial arch, and the digital branches given 
off by the radial artery to the thumb and index finger are deeply placed in the 
palm, the collateral arteries of the thumb becoming superficial at the base of the 
first phalanx, that of the index finger issuing from behind the adductor transversus 
pollicis. The latter branch is not unfrequently derived from the radial artery at 
the back of the wrist, and may then be felt pulsating as it descends on the posterior 
surface of the abductor indicis muscle to its destination. The superficial volar 
artery is occasionally visible as it descends over the upper part of the thenar to 
the palm. 



43 



SUPERFICIAL ANATOMY OF THE LOWER LIMB. 



SUPEBnCIAL ANATOMY OF THE LOWER LIMB. 

THE HIP. 

The region of the hip, gluteal region or buttock, extends from the subcutaneous 
iliac crest and the origin of the gluteus maximus muscle above to the fold of the 
nates below. The surface is formed posteriorly by the gluteus maximus, which is 
generally covered by a considerable quantity of fat, and laterally by the gluteus 
medius, together with, at the foremost part, the tensor vaginae femoris. The latter 
muscle may be recognized forming a distinct prominence below the anterior part of 
the iliac crest (fig. 20), especially if the thigh be abducted or rotated inwards. 
The fold of the nates is formed during extension of the hip by the drawing in of the 
skin below the level of the ischial tuberosity, and is directed horizontally outwards, 
crossing the oblique lower border of the gluteus maximus about its middle. 

The iliac crest is represented on the surface, in muscular subjects, by a groove 
{iliac furroiv), in consequence of the projection of the external oblique muscle 




'^ idle <Xrut 



Fig. 19. 



-Posterior view op the hip, showing the situation of the bones and chief arteries, &c. 
(R. J. G. &G. D. T.) 



above, and, to a less extent, of the gluteus medius below. Traced forwards, this 
furrow terminates at the anterior superior iliac spine, which is always easily 
recognized ; posteriorly, the furrow becomes less marked as the crest passes below 
the tendinous portion of the erector spinffi, but a slight depression always indicates 
the position of the posterior superior spine. The latter point is on a level with the 
spinous process of the second sacral vertebra, and immediately behind the centre of 
the sacro-iliac articulation. From three to four inches (8 — 10 cm.) below the iliac 
crest, and somewhat in front of its central point, the great trochanter is to be felt, 
and in thin persons seen. The trochanter projects outwards farther than the iUac 
crest, but it does not usually appear as a prominence on the surface owing to the 
great thickness of the gluteus medius and minimus muscles, which occupy the hollow 
between it and the ilium. It is entirely covered by the aponeurotic insertion of the 



THE HIP AND THIGH. 43 

upper part of the glutens raaximus, and its upper border, which is generally on a 
level with the centre of the hip-joint, is obscured by the tendon of the glutens 
medius descending to its insertion on the outer side of the process. Immediately 
behind the great trochanter is a well-marked depression, where the lower portion of 
the gluteus maximus, after passing over the ischial tuberosity, becomes tendinous 
and sinks in to be inserted into the shaft of the femur. 

Beneath the lower border of the gluteus maximus, the tuberosity of the ischium 
is to be felt, and when the hip is flexed this process is to a great extent uncovered 
by the muscle. A line drawn over the outer surface of the hip from the anterior 
superior iliac spine to the most prominent part of the ischial tuberosity is known as 
Nekilon's line (fig. 20), and will be found to pass over the top of the great trochanter 
and cross the centre of the acetabulum. It thus forms a guide to the natural 
position of the upper end of the femur, and is consequently of service in detecting 
dislocations of the hip and fracture of the neck of the bone. 

If a line be drawn from the posterior superior iliac spine to the outer part of the 
ischial tuberosity, it will cross the posterior inferior spine and the ischial spine : the 
posterior inferior spine is nearly two inches (4 cm.), and the ischial spine about four 
inches (10 cm.), below the posterior superior spine: the sciatic artery appears in the 
buttock at the junction of the middle and lower thirds of this line. The gluteal 
artery leaves the great sacro-sciatic foramen beneath a spot corresponding to the 
junction of the inner and middle thirds of a line drawn from the posterior superior 
iliac spine to the great trochanter, when the thigh is rotated inwards. Between 
the gluteal and sciatic arteries, the great sciatic nerve leaves the pelvis, and it 
thence pursues a slightly curved course to a point midway between the great 
trochanter and the ischial tuberosity. 

THE THIGH. 

The thigh is separated from the abdomen in front by the curved inguinal furroif, 
at the bottom of which Poupart's ligament may be felt (except in fat people), more 
plamly in its inner than in its outer half, as it passes from the anterior superior 
spine of the ilium to the pubic spine : the band is relaxed, and becomes less distinct, 
on flexing and adducting, or rotating inwards, the thigh. From the pubic spine, 
the finger may be carried inwards along the pubic crest to the top of the symphysis, 
in tlie male passing over the spermatic cord, or downwards and backwards along the 
inner margin of the united pubic and ischial rami to the tuberosity of the ischium, 
thus tracing the boundary line Ijetwcen the thigh and the perineum. Externally, 
the thigh is not definitely marked off' from the region of the hip. 

Immediately below Poupart's ligament, a slight hollow is generally seen, 
corresponding to Scarpa's triangular space (Vol. II, pp. 252 and 487), in which, 
just internal to the centre, the femoral artery may be felt pulsating. Close below 
the iimermost part of Poupart's ligament is situated the saphenous opening in the 
fascia lata, the upper end of which is about one inch outside the pubic spine. 
Through the lower part of this aperture, and about one inch and a half below 
Poupart's ligament, the internal saphenous vein passes back to join the femoral 
trunk, and above the vein is the spot where a femoral hernia first makes its 
appearance on the surface of the thigh. Over the opening, and for a short distance 
below it, the femoral or ktwer inguinal iyiii]thatic glands may usually be felt through 
the skin, surrounding the; ujtper end of the internal sajjhciions vein. 

From the apex of Scarpa's triangle a depression is continued downwards along 
the inner part of the thigh, between the masses formed by the quadriceps extensor 
muscle in front, and the adductor muscles on the inner side. The sartorius muscle 
lies along this dejiression, and may be distinctly seen when it is brought into action 
by raising the leg acroas the opposite knee. 'I'lio form of the rectus muscle may be 



44 



SUPERFICIAL ANATOMY OF THE LOWER LIMB. 



distinguished along the front of the anterior mass, and to its inner side, in about 
the lower half of the thigh, the vastus internus gives rise to a large prominence. 



l-'iOA fiwrsi^- 



gluteus 




hlcejos — 




fac paA. .V>-, 

of h.eeL" ^ 



'i- — uasbvus 



tendott' of ijuM/iylceps 

iitfrapa-te-Uaf fai 

cuT't.bU'be-rcLe. 
"" of ti-dCo. 



^■■■tubicdiB Of-vUciiz 



■ ■•:'■— ext. Lotto, diq. 



mt brev. oLitj. 




perorvs-u-i btauib 



iMnal furrow 



pcotellc^- 




■post ttilcd ctfl: 



aJioL h-<Mu^c-s 



Fig. 20. — Superficial anatomy op the lower limb : external view. (From a photograph by 
G. W. B. Waters.) (R. J. G. & G. D. T.) 

Fig. 21. — Superficial anatomy op the lower limb : antero-internal view. (From a photograph by 
G. W. B. Waters.) (R. J. G. & G. D. T.) 

increasing in size towards the knee, while on the outer side of the rectus, the vastus 
externus forms a broad convex surface, extending from the great trochanter above 
almost to the knee-joint below, and being continued backwards to the posterior 



THE THIGH. 45 

aspect of the limb. The surface formed by the vastus extemus is often seen to be 
traversed by a longitudinal groove, due to the pressure exerted by the strong ilio- 
tibial band of the fascia lata as it descends from the insertions of the gluteus 
maximus and tensor vaginas femoris muscles to the outer tuberosity of the tibia. 
Of the adductor muscles, the only parts that are to be separately recognized are the 
strong tendon of origin of the adductor longus below the pubic crest, and the lower 
tendon of the adductor magnus which is felt distinctly, when the knee is bent, in 
the interval between the sartorius and vastus internus muscles, extending down to 
the adductor tubercle on the internal condyle of the femur. The adductors are not 
marked off on the surface from the hamstring group on the back of the thigh, nor 
are the latter muscles to be individually distinguished from one another until they 
become tendinous near the knee. Along the outer and posterior part of the thigh, 
however, the hamstring muscles are separated from the vastus externus by a well 
marked groove, corresponding to the position of the external intermuscular 
septum. 

The whole of the shaft of the femui- is deeply placed, and in fairly muscular 
subjects is not to be detected through its fleshy covering. It approaches the surface 
most nearly in the lower third of the thigh on the outer side, where it may be 
readily exposed in the interval between the vastus externus and biceps muscles. 
The head of the bone is situated close below Poupart's ligament, immediately 
external to its mid-point, and is occasionally, in thin subjects, to be felt in this 
jiosition through the overlying muscles. 

The subcutaneous veins of the thigh all join one trunk, the internal saphenous, 
which ascends from the hinder part of the inner side of the knee, with a gradual 
inclination forwards, to the saphenous opening. The extent to wiiich this vein and 
its branches are to be perceived varies greatly with the amount of subcutaneous 
fat. 

The position of the femoral artery is indicated by a line drawn from a point 
midway between the anterior superior iliac spine and the pubic symphysis to the 
prominent tuberosity on the inner condyle of the femur, the hip having been 
first slightly flexed and the thigh everted. At the junction of the upper three- 
fourths with the lower fourth of this line, the artery passes backwards through the 
opening in the adductor magnus muscle. Pressure is most conveniently applied to 
the vessel as it enters the thigh below Poupart's ligament, and it should be directed 
backwards so as to compress the artery against the pubis and the adjacent part of 
the hip-joint. Lower down, the pressui'c must be made in a direction backwards 
and outwards, as the artery lies considerably to the inner side of the shaft of the 
femur. At Poupart's ligament, the femoral vein is close to the inner side of the 
artery, and the anterior crural nerve is a little distance (a quarter to half an inch) 
from its outer side. The profunda, arising from the main trunk usually between 
one and two inches (3 — ."> cm.j below Poupart's ligament, follows a line almost 
identical with that of the femoral artery. 

The small sciatic (posterior cutaneous) nerve lies immediately beneath the fascia 
along the middle line of the back of the thigh ; and in the same line, but under 
cover of the hamstring muscles, is the great sciatic nerve. 

THE KNEE. 

On the inner side of the knee, the internal condyle of the (emur and the 
corresponding tuberosity of the tibia produce a rounded surface, the most 
prominent point of which is formed by the tuberosity on the internal condyle. The 
interval between the two bones opposite the knee-joint is seldom to be seen, but is 
alwa)'H easily felt. It can usually, however, be readily dem(;nstnit(d by resting the 



46 SUPERFICIAL ANATOMY OF THE LOWER LIMB. 

lower part of the leg on the opposite knee, when the inner tuberosity of the tibia 
projects beyond the inner condyle of the femur. On the upper part of the inner 
condyle, the sharp adductor tubercle and the insertion of the adductor magnus 
tendon are also to be recognized. The external condyle, although not generally 
prominent, is subcutaneous and readily felt ; its tuberosity is comparatively little 
developed. The outer tuberosity of the tibia, on the other hand, forms a marked 
prominence at the outer and fore part of the knee, about an inch below the joint ; 
and behind this, at a slightly lower level, viz., that of the tubercle of the tibia, 
the head of the fibula is distinctly felt at the outer and back part of the limb, where 
it generally corresponds to a depression, when the joint is extended, between the 
tendon of the biceps above and the peroneus longus muscle below : it often forms 
a prominence, however, when the knee is flexed. Anteriorly, the patella is sub- 
cutaneous, and its lateral margins are distinctly seen. When the extensor muscles 
are relaxed, the patella can be easily moved from side to side ; but if these muscles 
are contracted, the patella is drawn upwards and pressed firmly against the end of 
the femur, and the ligamentum patellte can then be followed down to the tubercle of 
the tibia : on each side of the ligament is a soft eminence produced by the infra- 
patellar mass of fat. When the knee is bent, the patella sinks into the hollow 
between the tibia and the femur, and the articular surface of the latter bone is in 
great part exposed ; the trochlear surface can then be distinctly traced, although 
covered by the tendon of the extensor muscle. The upper and outer angle of 
this surface forms a useful landmark ; and a line drawn from it to the adductor 
tubercle on the internal condyle marks the upper limit of the epiphysis of the lower 
end of the femur. There are generally two bursEe, a superficial one and a deep 
one, over the patella, and there is frequently another over the tubercle of the tibia 
(Vol. II, p. 242). 

At the back of the knee is the ham, which is marked by a deep hollow when the 
joint is flexed, but by a slight elevation when it is extended. On each side are the 
tendinous hamstrings ; internally the slender semitendinosus and the stronger semi- 
membranosus are to be recognized, as well as the gracilis a little farther forwards ; 
externally is the thick tendon of the biceps leading down to the head of the fibula. 
Immediately in front of the biceps tendon, when the joint is a little bent, the upper 
part of the external lateral ligament is to be detected ; and between this and the 
outer margin of the patella, the lower end of the ilio-tibial band appears as a strong 
cord beneath the skin, running down on the outer side of the knee to the prominent 
external tuberosity of the tibia ; while on the inner side, the sartorius tendon, with 
the subjacent tendons of the gracilis and semitendinosus, forms a slight elevation as 
it curves forwards below the inner tuberosity, to be inserted close to the tubercle of 
the tibia. 

The external saphenous vein enters the lower part of the ham in the middle 
line of the limb, and perforates the fascia to join the popliteal vein ; but it is not 
usually visible on the surface. The internal saphenous vein is generally seen on the 
inner side of the knee, and the nerve of the same name meets it behind the internal 
tuberosity. 

The popliteal vessels enter the ham somewhat internal to the middle line above, 
and are then continued downwards over the centre of the back of the knee ; the 
vein is more superficial than the artery, but both are very deeply placed. The 
upper articular vessels run transversely inwards and outwards immediately above the 
condyles of the femur ; and the lower articular vessels are respectively just below 
the inner tuberosity of the tibia, and above the head of the fibula. The deep part 
of the anastomotic artery descends to the knee along the front of the adductor 
magnus tendon. 



THE LEG. 47 

The internal popliteal nerve, continuing- the direction of the great sciatic, and 
descending in the median line of the limb, is superficial to the vessels. The external 
popliteal nerve is at first under cover of the fleshy belly of the biceps, and then lies 
on the outer side of the ham, close behind the tendon of that muscle ; it may be felt 
rolling beneath the finger as it crosses the outer side of the neck of the fibula, 
before entering the peroneus longus muscle ; and it is sometimes to be seen giving 
rise to a slight elevation in this position. 

The glands in the popliteal space are not to be felt unless they are enlarged. 

THE LEG 

Along the fore part of the leg, the anterior border of the tibia is to be followed 
downwards from the tubercle, constituting what is known as the shin. This 
border is sharp in the upper two-thirds of the leg, and describes a slight curve with 
the concavity outwards ; in the lower third the border disappears, and the bone is 
concealed by the tendons of the anterior muscles. On the inner side of the shin, 
the broad internal surface of the tibia is subcutaneous below the sartorius, and leads 
downwards to the prominent internal malleolus. At the back of the latter process 
a sharp edge is felt, which is formed by the inner margin of the groove for the 
tendon of the tibialis posticus ; the tendon itself covers the posterior surface of the 
malleolus, and is rendered prominent by inverting the foot. The head of the fibula 
is subcutaneous, as has been before mentioned ; the shaft is surrounded by muscles, 
bat it can be felt through them in the lower half at least of the leg, and it will be 
remembered that it is placed considerably farther back in the leg than the shaft of 
the tibia ; near the ankle, a triangular portion of the bone comes to the surface, and 
is continued down to the external malleolus. 

Along the concavity of the anterior edge of the tibia, the prominence formed by 
the fleshy belly of the tibialis anticus is seen, and external to this is the much less 
distinct and narroAver extensor longus digitorum. The tendons of the muscles 
appear in the lower third of the leg, and between them also that of the extensor 
proprius hallucis ; they are brought into view most distinctly by flexing the ankle 
and extending the toes. From the head of the fibula downwards, the peroneus 
longus and brevis muscles form an elongated swelling, from which the tendons can 
be traced descending behind the external malleolus. Posteriorly the elevation of 
the calf is formed by the gastrocnemius muscle, which terminates about the middle 
of the leg in the tendo Achillis ; the inner head of the gastrocnemius is the larger, 
and descends lower than the outer. On each side of the gastrocnemius and tendo 
Achillis, a portion of the soleus comes to the surface ; and the characteristic form 
of the gastrocnemius, depending upon the peculiar structure of the muscle (Vol. II, 
p. 262), as well as the extent and siiape of the projecting portions of the soleus, are 
brought into view by raising the body on the toes. The tendo Achillis gradually 
becomes narrower as it approaches the heel, but it widens again a little as it passes 
ovfer the tuberosity of the os calcis to its insertion. Between it and the malleolus, 
on each side, is a well-marked hollow, that on the outer side being the deeper ; in 
the inner of these, the tendons of the tibialis posticus and flexor longus digitorum, 
and the posterior tibial vessels and nerve are superficial. 

Both the external and internal saphenous veins are visible beneath the skin of 
the leg, together with numerous tributaries and commuuicating branches. The 
internal is the larger, and, after crossing in front of the internal malleolus, runs 
upwards just behind the inner border of the tibia ; tiie externul passes behind the 
outer malleolus and then ascends over the middle o! the calf to the ham. Each 
vein is accompanied by the nerve of the same name. 

The bifurcation of the popliteal artery takes place about two inches (5 cm.) l)elow 



48 SUPERFICIAL ANATOMY OF THE LOWER LIMB. 

the knee-joint, and on a level with the lower part of the tubercle of the tibia. The 
course of the anterior tibial artery is marked on the front of the leg by a line drawn 
from a point midway between the head of the fibula and the prominence of the outer 
tuberosity of the tibia to the centre of the ankle-joint. The intermuscular space in 
which the artery lies is also indicated by a depression which is seen at the outer 
border of the tibialis anticus when the muscle is called into action. The posterior 
tibial artery runs from the centre of the ham to the mid-point of a line drawn from 
the tip of the internal malleolus to the lower end of the inner border of the calcanean 
tuberosity ; beneath this spot, the vessel divides into the internal and external 
plantar arteries. The posterior tibial artery is covered by the gastrocnemius and 
soleus for about two-thirds of its length, but in the lower third it is superficial, and 
may be felt pulsating in the interval between the tendo Achillis and the tibia. 
x\bout three inches (7'5 cm.) below the knee, it gives off the large peroneal branch, 
which follows the direction of the fibula, and terminates behind the external 
malleolus. 

THE ANKLE AND FOOT. 

Of the two malleoli, the internal is usually the more prominent, but the external 
descends lower and also projects farther back, having its point, as a rule, about 
three-quarters of an inch (2 cm.) nearer to the heel than that of the internal malleolus. 
On the dorsum of the foot, the tarsal bones are not usually to be distinguished individu- 
ally, but the head of the astragalus not unfrequently forms a considerable projection 
when the ankle-joint is extended ; and if the arch of the foot is flattened, it often 
protrudes markedly on the inner side. Along the inner side of the foot, the tube- 
rosity of the OS calcis is first felt, and then, about an inch (2*5 cm.) below the internal 
malleolus, the sustentaculum tali of the same bone ; in front of the latter, and 
about an inch and a half (4 cm.) from the malleolus, the tuberosity of the navicular 
bone is prominent, and to it the tendon of the tibialis posticus may be followed from 
the back of the internal malleolus ; the finger next passes over the internal cuneiform 
bone, and recognizes the base of the first metatarsal bone as a shghtly prominent 
ridge ; from this, the shaft of the bone may be traced forwards beneath the skin to 
its expanded, and often unduly prominent, head, below which the sesamoid bones 
may be felt on the plantar aspect of the metatarso-phalangeal articulation. On the 
outer side of the foot, nearly the whole of the external surface of the os calcis is sub- 
cutaneous, and the peroneal spine of the bone may often be felt a little below and in 
front of the external malleolus. The anterior extremity of the os calcis may be 
distinguished when the foot is inverted, forming a marked prominence above the 
level of the cuboid bone, and in front of this, distant about two and a half inches 
(6 cm.) from the external malleolus, the projecting tuberosity at the base of the fifth 
metatarsal bone is easily felt. 

The interarticular cleft of the ankle-joint is placed about half an inch (1 cm.) 
above the tip of the internal malleolus. The transverse tarsal articulation, at which 
Chopart's amputation is practised, runs from immediately behind the tuberosity of 
the navicular bone, outwards in front of the head of the astragalus and the anterior 
extremity of the os calcis, to end a little in front of the mid-point between the tip of 
the external malleolus and the tuberosity of the fifth metatarsal bone. The line of 
the tarso-metatarsal articulations is very irregular : commencing immediately 
behind the base of the first metatarsal bone, it passes at first transversely between 
that bone and the internal cuneiform, then turns sharply backwards for a full half- 
inch (15 mm.) to reach the cleft between the middle cuneiform and second 
metatarsal bones, next advances for about a quarter of an inch (5 mm.), and then is 
continued outwards, with a slight inclination backwards, between the outer three 



THE ANKLE AND FOOT. 49 

metatarsal bones in front and the external cuneiform and cuboid bones behind, to its 
termination behind the tuberosity of the fifth metatarsal bone. 

Over the front of the ankle, the tendons of the anterior muscles of the leg are 
bound down by the anterior annular ligament ; they can be readily distinguished 
when the joint is flexed, spreading over the dorsum of the foot, and disposed in the 
following order : — the most internal and the largest is the tibialis anticus ; next 
comes the extensor proprius hallucis, and then the extensor longus digitorum, 
dividing into its four slips for the smaller toes ; lastly, proceeding from the outer 
side of the long extensor to the base of the fifth metatarsal bone is the peroneus 
tertius ; the last named is, however, not unfrequently wanting. The anterior tibial 
vessels and nerve are placed, opposite the ankle-joint, between the tendons of the 
extensor proprius hallucis and extensor longus digitorum. Beneath the tendons of 
the extensor longus digitorum, on the dorsum of the foot, is placed the extensor 
brevis digitorum, the fleshy belly of which produces a distinct swelling over the 
tarsal region. The fleshy mass on the inner margin of the foot is formed by the 
abductor and flexor brevis hallucis muscles ; and that on the outer border by the 
abductor and flexor brevis minimi digiti. 

In the sole, the tuberosity of the os calcis and the heads of the metatarsal 
bones are easily felt, but in the intervening region the bones are not to be 
distinguished. The individual muscles are also obscured by the thickness of 
the integument and the manner in which the parts are bound together by the 
strong plantar fascia. When the arch of the foot is well developed the parts 
of the sole that rest on the ground in standing are the heel, a strip near the outer 
border of the foot, the heads of the metatarsal bones, and the ends of the toes. 
The skin over these parts is thick, hard, and smooth, but in the hollow of the foot 
it is soft and wrinkled. The sole of the infant is flatter than that of the adult, 
and is marked by lines similar to those seen in the palm of the hand, but 
these disappear more or less completely as age advances. 

On the back of the foot, the arch or plexus of veins shows plainly through 
the skin, and its extremities may be followed into the internal and external 
saphenous veins respectively. The musculo-cutaneous and external saphenous 
nerves are not uncommonly visible through the skin. 

The dorsal artery of the foot extends from the centre of the ankle-joint to the 
back of the first intermetatarsal space, and it may be felt pulsating midway between 
the tendons of the extensor proprius hallucis and extensor longus digitorum. Just 
before its ending it is crossed by the innermost slip of the extensor brevis 
digitorum. The external plantar artery runs from the bifurcation of the posterior 
tibial (p. 48) obliquely across the sole to within an inch (2*5 cm.) of the tuberosity of 
the fifth metatarsal bone, and then is directed more transversely inwards to the 
back of the first interosseous space, where it meets the termination of the dorsal 
artery. The internal plantar artery is much smaller than the external ; its position 
may be indicated by a line drawn from the place of bifurcation of the posterior 
tibial to the under part of the metatarso-phalangeal articulation of the great toe. 

The metatarsophalangeal articulations are situated about an inch (2-5 cm.) 
behind the web of the toes. 



50 



ANATOMY OF HERNIA. 










INGUINAL HERNIA. 51 



ANATOMY OF THE GROIN : HERNIA. 
Two kinds of abdominal hernife have such definite and important relations that 
the regions concerned require special notice in a work on anatomy. These are 
inguinal herniic, which are associated with the spermatic cord in their passage 
through the abdominal wall, and femoral hernice, which descend through the 
femoral canal on the inner side of the femoral vessels. 

INGUINAL HERNIA. 

The inguinal canal, through which the spermatic cord passes from the cavity 
of the abdomen to the scrotum, begins at the internal abdominal ring, and ends 
at the external ring. It is oblique in its direction, being nearly parallel with and 
immediately above the inner half of Poupart's ligament, and it measures about an 
inch and a half {?yb cm.) in length. The external ring (Vol. II, p. 329) is imme- 
diately above and external to the pubic spine ; the internal {ib., p. 336) is midway 
between the anterior superior iliac spine and the pubic symphysis, and half an inch 
(1 cm.) above Poupart's ligament. In front, the canal is bounded by the aponeurosis 
of the external oblique muscle in its whole length, and at the outer end also by the 
fleshy part of the internal oblique ; behind it is the transversalis fascia, together with, 
towards the inner end, the conjoined tendon of the two deeper abdominal muscles 
and the triangular fascia. Above the canal are the arched lower borders of the 
internal oblique and transversalis muscles ; and below, it is bounded by Poupart's 
and Gimbernat's ligaments, which separate it from the sheath of the large blood- 
vessels descending to the thigh, and from the femoral canal at the inner side of 
those vessels. Below the internal ring, and separated therefrom by Poupart's 
ligament, is the external ihac artery, giving off its epigastric branch, which at first 
runs inwards, aud then ascends close to the inner border of the opening (fig. 28). 

The spermatic cord, which occupies the inguinal canal, is composed of 
the arteiy, veins, lymphatics, nerves, and excretory duct of the testis (vas deferens), 
together with a quantity of loose areolar tissue. 

Coverings of the cord. — The coverings given fi'om the constituent parts of 
the abdominal wall to the spermatic cord, besides the integuments, are, from the 
external ring the intercolumnar or spermatic fascia, the cremasteric muscle 
and fascia from the lower border of the internal oblique muscle, and a thin, funnel- 
shaped prolongation of the transversalis fascia from the edge of the inner ring 
(infundibuliform fascia). Beneath the last, the areolar tissue uniting together the 
constituents of the cord is continuous with the subperitoneal areolar layer. 

Peritoneal fossae. — When the lower part of the anterior abdominal wall 
is viewed from within, the peritoneum is seen to form a series of depressions, 
which are separated by more or less prominent folds. Thus, along the middle line 
is the ])lica urachi {plica wnhilicalis media), which extends from the apex of the 
bladder upwards along the urachus to the umbilicus; a little outside this is the 
well-marked 'plica hyjmgastrica {plica umhilicalis lateralis), containing the obliterated 
hypogastric artery, and also extending from the bladder to the umbilicus ; and still 

Fig. 22. — Anatojiy of ukknia : MurKRKiciAL view. ((x. D. T.) 

On the left hide, only the skin and suijerficial fa.sciie have been removed, expOHing aliovc Poiiiiart's 
ligament the aponeuroHi.s of the external oblifjue, with the sjiermatii: cord emerging through the external 
ulxlominal ring, and below Poupart's ligament the fiuscia lata with the intein.il saphenouH vein pa.s.sing 
through the lower jiart of the sa]>henou« ojiening and piereing the femoral nheath. 

On the right side, the inguinal portion of the external cl)li(|ue has been removed, bringing into view 
l»art of the internal obliijue muHcle and the eremaKter ; and below I'oupart'H ligament the iliae part of 
faxeia lata haH been detached from I'oupart'a ligament and reflected, bo a» to expose the front of tho 
femoral Hbeatb. 

B 2 



53 



ANATOMY OF THE GROIN : HEENIA. 



-2 S: s 










INGUINAL HERNIA. 



53 



Fig. 23. — .\N.i.TOMV OF HERNI.V : DEEP VIEW. (G. D. T.) 

On the right side parts of the external and internal oblique muscles together with the cremaster 
have been taken away, so as to show the spermatic cord invested by the infundilmliforni fascia lying 
in the inguinal canal. By the removal of a part of the front of the femoral sheath the femoral vessels 
have been expo.^ed and the femoral canal opened. Gl., gland occupying the femoral ring. 

On the left side parts of the two oblique muscles have been removed, and also a portion of the 
spermatic cor<l. Poupart's ligament has been divided, and the cut portions turned aside, tlius exposing 
the deep femoral arch. Tr. F., triangular fascia ; G. L. , Girabernat's ligament. The conjoined tendon 
on this side is very wide, and is prolonged outwar.ls along the deep femoral arch as far as the internal 
abdominal ring. 

more externally is a slight elevation, the plica epvjastrica, over the epigastric vessels. 
The depressions are accordingly three in number on each side, viz., from without 
inwards, 1, the fovea ingiiinaUs lateraUs, on the outer side of the plica epigastrica, 




Poupart's Itga 

ment . 
anterior crural [., ' 

nerve 

exterrud 



_/.,,..< Ji miiiulis 



Fig. 24.— The lower i'art of the anterior abdominal wall in the male viewed krom behind,, 

SHOWINC THE PERITONEAL FOLDS AND B'OS.S^K, (After JoCSSel. ) 

the deepest part of which is oi)posite the internal ahdcnninal ring ; 2, the fovea 
iwiuimlu meaiallH between the plica epigastrica and the plica hypogastrica ; and 
:; ' the fovea mpmve.siralis, between the plica hypogastrica and plica urachi, 
immediately above and external to the apex of the bladder. Of these, the fovea 
inguinalis mesialis is the most strongly marked, and often extends inwnrdH for some 



54 ANATOMY OF THE GROIN : HERNIA. 

distance beneath the plica hypogastrica over the back of the rectus muscle. Below 
the last fossa, and separated therefrom by the inner end of Poupart's ligament, 
there is often to be recognised another slight depression, the fovea femoralis, over 
the position of the femoral ring, to the inner side of the external iliac vein and the 
vas deferens, or the round ligament of the uterus, according to the sex. 

Forms of inguinal hernia. — Two principal forms of inguinal hernia are 
described, which are distinguished according to the part of the canal which they 
first enter, as well as by the position which they bear with respect to the epigastric 
artery. Thus, when the hernia takes the course of the inguinal canal from its 
commencement, it is named oblique, because of the direction of the canal, or 
external, from the position of its neck with respect to the epigastric artery. On the 
other hand, when the protruded part, without following the length of the canal, 
passes at once through its posterior wall at a point opposite the external abdominal 
ring, the hernia is named, from its course, direct, or, from its relation to the 
epigastric artery, internal. 

Oblique or external inguinal hernia. — In the common form of this hernia 
the protruded viscus carries before it a covering of serous membrane (the sac 
of the hernia), derived from the outer fossa of the peritoneum (p. 53) ; and, in 
passing along the inguinal canal to the scrotum, it is successively invested by the 
coverings given to the spermatic cord from the abdominal parietes. The hernia 
and its sac lie directly in front of the vessels of the spermatic cord, and do not 
extend below the testis, even when the tumour is of large size. 

There are two other varieties of oblique inguinal hernia, in which the peculiarity depends 
on the condition of the process of peritoneum (^;?'o^e«.??/.s vaginalis) that receives the testis 
when this organ descends from the abdomen. In ordinary circumstances the part of the 
peritoneal process connected immediately with the testis becomes separated after birth from 
the general cavity of that serous membrane by the obliteration of the intervening canal ; and 
the hernial protrusion occurring after such obliteration has been completed, carries with it a 
distinct serous investment — the sac. But if this process of obliteration should not take place, 
and if a hernia should be formed, the protruded part is then received into the cavity of the 
processus vaginalis, which serves in the place of its sac. In this case the hernia is named 
O07igenital. It is thus designated, because the condition necessary for its formation only 
exists normally about the time of birth ; but the same kind of hernia is occasionally found to 
be first formed in the adult, obviously in consequence of the processus vaginalis remaining 
unclosed, and still continuous with the peritoneum. The congenital hernia, should it reach 
the scrotum, passes below the testis ; and, this organ being embedded in the protruded viscus, 
a careful examination is necessary in order to detect its position. This peculiarity serves to 
distinguish the congenital from the ordinary form of the disease. 

To the second variety of inguinal hernia, in which the distinguishing character depends 
on the state of the tunica vaginalis testis, the name infantile has been applied (Hey). The 
hernia in this case is covered with a distinct sac, which is again invested by the upper end of 
the tunica vaginalis. The relative position of the two serous membranes (the hernial sac 
and the tunica vaginalis) may be accounted for by supposing the hernia to descend when the 
process of the peritoneum, which accompanies the testis from the abdomen, has been merely 
closed at the upper end, but not obliterated along the front of the cord. Hence during an 
operation in such a case, the hernial sac is met with only after another serous bag (the 
abnormal prolongation upwards of the tunica vaginalis testis) has been divided. The 
peculiarity here described has been repeatedly found present in the recently-formed hernia of 
grown persons. The term infantile, therefore, like congenital, has reference to the condition 
of certain parts, rather than to the period of life at which the disease is first formed. 

In the female, oblique inguinal hernia follows the course of the round ligament 
of the uterus along the inguinal canal, in the same manner as in the male it follows 
the spermatic cord. After escaping from the external abdominal ring, the hernia 
lodges in the labium pudendi. The coverings are the same as those in the male 
body, with the exception of the cremaster, which does not exist in the female ; but 
it occasionally happens that some fibres of the internal oblique muscle are drawn 



IXGUIXAL HERNIA. 



55 



down over this hernia in loops, so as to have the appearance of a cremaster 
(Cloquet). 



peritoneum 



iilxhimlnal ring 



spe mw ( jc fascia 



process 



tnnicn vagiiwMs 




spermatic cord 



Fig. 25. — Persistent vaginal process of tue rERiTij.NEUii. (After Joessel.) 

The preparation is from a man 20 years of age. The tunica vaginalis is cut ort" from the vagina 
process, tlie tubular portion of which ends Vjlindly a little above the testicle. In the inguinal canal the 
proces.s becomes gradually narrower up to the internal abdominal ring, through which a probe is 
introduced into the cavity. 

A strictly congenital infruinal hernia may occur in the female, the protruded parts bein;? 
received into the little diverticulum of the peritoneum (canal of Xuck). which sometimes 
extends into the infjuinal canal with the round lig-ament. But as this proce.'^s of the 
peritoneum, in such circumstances, would probably not diflfer in any respect from the 
ordinary sac, there are no means of distingui.shing' a congenital hernia in the female body. 

Direct or internal inguinal hernia. — Instead of following the whole course 
of the intriiinal canal, in the manner of the hernia above described, the viscus in 
this case is protruded from the abdomen to the groin directly through the lower end 
of tiie canal, at the e.xternal abdominal ring. At the part of the abdominal wall 
through which the direct inguinal hernia finds its way, there is recognised on its 
jKjsterior aspect a triangular interval, the sides of which are formed by the epigastric 
artery, and the margin of the rectus muscle, and the base by Poupart's ligament 
(fig. 2H). It is commonly named the triangle of Hesselbach. The triangle 
mea-sures about two inches (") cm.j fi<jni above down, and an inch and a half 



56 ANATOMY OF THE GROIN : HERNIA. 

(3*5 cm.) transversely at its base. In this area the abdominal wall consists of, 
besides the integuments, 1, the aponeurosis of the external oblique muscle, which 
is perforated towards the lov\'er and inner corner of the space by the external 
abdominal ring ; 2, the inner portion of the cremaster muscle covering the sper- 
matic cord at the lower and outer part of the space, and above this the lower 
fibres of the internal oblique and transversalis muscles passing to their insertion by 
the conjoined tendon, which, as a rule, extends over the inner two-thirds of the 
lower part of the triangle ; 3, transversalis fascia ; 4, subperitoneal tissue ; and 5, 
peritoneum. 

The conjoined tendon varies greatly in its development. In many cases it is very slight, 
and scarcely to be distinguished, while in others its deeper portion, derived from the trans- 
versalis muscle, covers the whole breadth of the triangle, reaching outwards along the deep 
femoral arch as far as the internal abdominal ring (fig. 23, left side). Sometimes the outer 
part is detached from the rest, and forms a band which has been designated ligamentum 
interfoveolare or ligament of Hesselhach, while to the remaining inner portion the name olfalx 
inguinalis or ligament of Henle has been given. (See W. His, in die anatomische JVumenclatur , 
1895, p. 121 ; and K. M. Douglas, The Anatomy of the Transversalis Muscle and its Relation 
to Inguinal Hernia, Joum. Anat., xxiv, 1890.) 

The distance of the obliterated hypogastric artery from the middle line, and with it the 
breadth of the fovea supravesicalis, is also subject to variation. In most cases, however, the 
hypogastric cord ascends altogether behind the rectus muscle, and therefore an internal hernia 
will project in the mesial inguinal fossa. Only in rare cases does a hernia protrude in the 
supravesical hoUow, between the obliterated hypogastric artery and the edge of the rectus. 

A hernia emerging to the inner side of the epigastric vessels in the majority of 
cases protrudes in the inner part of the triangle of Hesselbach, and is forced onwards 
directly into the external abdominal ring. The coverings of such a hernia, taking 
them in the order in which they are successively applied to the protruded viscus, are 
the following : — The peritoneal sac and the subperitoneal tissue which adheres to it, 
the transversalis fascia, the conjoined tendon of the internal oblique and transversalis 
muscles, and the spermatic fascia derived from the margin of the external abdominal 
ring, together with the superficial fascia and skin. With regard to the conjoined 
tendon, this hernia may be covered by it, or may pass through an opening in its 

fibres. 

The spermatic cord is commonly placed behind the outer part of the hernia. The 
hernial sac is not, however, in contact with the vessels of the cord, the investments 
given from the transversalis fascia to those vessels and to the hernia respectively, as 
well as the cremasteric fascia, being interposed. 

But the spot at which an internal inguinal hernia passes through the triangle of 
Hesselbach is subject to some variation, and there is a second form of internal 
hernia which differs somewhat in its course and relations from the foregoing. In 
this variety the hernia protrudes to the outer side of the conjoined tendon, between 
that and the epigastric vessels. Such a protrusion passes through a considerable 
portion of the inguinal canal to reach the external ring, and has therefore a certain 
degree of obliquity, whence this variety is frequently termed Mernal oUique. inguinal 
hernia. It is also known as superior internal hernia, the direct form being called 
inferior internal. As an internal oblique hernia passes outside the conjoined tendon, 
it has no covering derived from that structure, but it receives one from the cremaster 
in the same way as an external hernia. 

Direct inguinal hernia is very rarely met with in the female. In the single case 
observed by Richard Quain, as well as in the few cases found recorded in books, the 
hernia though not inconsiderable in size was still covered by the tendon of the 
external oblique muscle. 



FEMOEAL HERNIA. 



57 



FEMOEAL HERNIA. 

A femoral hernia leaves the abdomen at the groin, passing beneath Poupart's 
ligament, and over the anterior border of the hip-bone immediately at the inner side 
of the femoral vessels. It takes a downward course through the innermost com- 
partment of the femoral sheath till it reaches the saphenous opening, when it turns 
forwards through the opening towards the front of the thigh, and is then bent upwards 
in the groin. 






•fe" 



Povjxiit s Iiqcment 



/ 

/ Gimhe) ufit s hqmnnit 

nvUr inlhn 




Fig. 26. — Poupart's ligament and the neioiibooking fasci.*; in relation to the uu'-isone. 

(ii. D. T.) 

The space between Poupart's ligament and tlie hip-bone is seen to be sul)(liviile(l into tliroe com- 
partments by the fiiKciic. Anteriorly is the vascular compartment, and posteriorly are the two 
muscular compartments— the larger one externally occupied by the ilio-psoas, and the smaller one 
internally occupied by the upper end of the pectinens : the two are separated by * the ilio-pectineai 
intermuscular septum attached to the ilio-pectineal eminence. 

The concave ilio-pubic margin of the hip-bone is bridged across in the recent 
state by Poupart's ligament or the (Hiipcrficial) femoral arch {ligammtum hujuinale), 
extending from the anterior superior ihac spine to tlie pubic spine. The intervening 
space, which is somewhat diminished at the internal angle by OimberiiaL's ligament 
{lujamentum lacunare), is mainly occupied by the ilio-psoas muscle and the external 
iliac vessels on their way into the thigh, and the uj)j)'jr end of the pectineus muscle. 



58 



ANATOMY OF THE GROIN : HERNIA. 



These structures are invested by special fascite, which by their connection together 
subdivide the space into three chief compartments. 

The vascular compartment {lacuna vasorum), situated in front of the others, is 
bounded anteriorly by Poupart's ligament and the continuation of the transversahs 
fascia into the front of the femoral sheath, with its thickening termed the deep femoral 



Exx, cuTAr rouS nerve 



ANt, CRURAL NER9E 
/ ILWC IWSCIA 

' CRURAL BBANCH OF GENlTO-CRURAL MERVB 

PEMORAt ABTERY 

FEMO'EAL VErN 

GLAND in FEHORAU RIN'S 



CIMBCrrJAT'S LIG*MEST 
'-PERWATIC CORO 




'■*-*->*0STURJ\TOR 
tsSERVE 

Fig. 27. — Dissection of the parts beneath poupart's ligament, s. (G. D. T.) 
The femoral vessels, which are seen enclosed in the femoral sheath, have been divided close below 
Poupart's ligament. The fasciaj forming the back of the sheath, and the subjacent muscles have been 
divided at successively lower levels. * indicates the ilio-pectineal intermuscular septum attached to 
the capsule of the hip-joint along the inner part of its anterior surface. 

arch (fig. 23) ; posteriorly by the continuous iliac and pectineal fasciee. It allows of 
the passage into the thigh of the external ihac vessels and the crural branch of the 
genito-crural nerve, the vein being to the inner side, and the nerve to the outer side 
of the artery, while between the vein and Grimbernat's ligament is the interval known 
as the femoral ring. The iliac compartment {lacuna musculorum), the largest of 



FEMORAL HERNIA. 



59 



the three, is situated outside and behind the foregoing : it is bounded posteriorly 
by the ilium, anteriorly by Poupart's ligament and the iliac fascia, and internally is 
separated from the pectineal compartment by the ilio-pectineal intermuscular septum: 
it transmits the ilio-psoas muscle with the anterior crural and external cutaneous 
nerves. The pectineal compartment, lodging the upper end of the pectineus 
muscle, is between the pectineal fascia (or pubic portion of the fascia lata) in front 
and the superior ramus of the pubis behind. It extends only a short distance 
upwards beyond Poupart's ligament, being closed above by the attachment of the 
fascia to the superior border of the pubic ramus. 

At the upper part of the pectineal fascia, immediately in front of its bony attachment, 
is a thickening- formed mainly by bundles of transverse fibres, which are closely connected 
internally with, and in part derived from, Gimbernat's ligament. This is the j)^'^i<^ Ugami'tit 
of Astley Cooper, and is frequently spoken of as C/kij)/-/-'^ li/jnmcnf. 



EPrCASTRiC VESSELS 




OBT VESSELS 



^■■v 



^VAS DEFERENS 



Pi„ 28 — IN5KH VIEW OK TIIK OnOIN, SHOWING TIIR INTERNAL AULOMINAL AND KKMOKAI. KINaS. (Modilicd 

"■ ■ from Kllis.) (G. D. T.) 

The T,erit..ne..in ur.d Huh,.e,iionoal ti.sue l.ave been removed ; and tl.e rectus and tran.sver.salis 
muHcleH are Hccn covered by the transversal Ik fancla. Tl.e ilio-pHous muHcle and external cutaneous 
nerve are covered by the iliac fascia. _ ii r .,:,.. ^.„/, i.nl.i,. 

y K, femoral ring ; o, (Jimbernat's ligament ; I'KCT., pectineus n.uscle eovercl b.v fa.se>!. , p»h., pui,,.. 
branch of epiga-stric artery anastomosing with pubic of oi*turat<jr. 



60 AX ATOMY OF THE GROIN : HERNIA. 

The femoral or crural sheath (figs. 22 and 23), is a somewhat funnel-shaped 
structure surrounding the upper parts of the femoral artery and vein. It is wide 
.above, but embraces the vessels closely below. It is continuous superiorly with 
the lining fascise of the abdomen, namely, with the transversalis fascia in front, 
and the iliac fascia behind. On removing its anterior wall, the sheath is found 
to be divided into three compartments by fibrous septa ; the outer compartment 
containing the femoral artery, the middle, the femoral vein, and the inner being 
occupied merely by lymphatic vessels, a gland, and some fat. The inner compart- 
ment is about half an inch long, and from its being the passage through which 
the hernia descends, has been called the femoral or crural canal. The upper 
extremity of the canal presents an oval aperture towards the cavity of the abdomen, 
usually of sufficient size to admit the point of the forefinger : its size, however, 
varies in different persons, and it is larger in the female than in the male, its 
transverse diameter, which is the longest, being on an average 25mm. in the 
former, and 15mm. in the latter. This aperture is called the femoral or crural 
ring {annulus femoralis), and is covered when viewed from the inside by perito- 
neum, which at this spot frequently shows a slight depression — fovea femoralis 
(p. 54), and beneath that by the subperitoneal connective tissue, which here forms 
the femoral septum (Cloquet). On the outer side lies the external iliac vein covered 
by its sheath, but on the other three sides the ring is bounded by very unyielding 
structures. In front are the femoral arches, the superficial being formed by Poupart's 
ligament, and the deejj by a variably developed bundle of fibres, which, springing 
from the under surface of Poupart's ligament outside the femoral vessels, extends 
across the fore part of the femoral sheath and, widening at its inner end, is fixed to 
the ilio-pectineal line behind Grimbernat's ligament. Behind the ring is the hip- 
bone covered by the pecfcineus muscle and the thickened upper part of the pectineal 
fascia ; and on the inner side are several layers of fibrous structure connected with 
the ilio-pectineal line — namely, Gimbernat's ligament, the conjoined tendon of the 
two deeper abdominal muscles, and the transversalis fascia, with the deep femoral 
arch. The last-mentioned structures — those bounding the ring at the inner side — 
present more or less sharp margins towards the opening. 

Relations to blood-vessels. — Besides the external iliac vein, the position of 
which has been already stated, the epigastric vessels are closely related to the ring, 
lying above its outer side. It not infrequently happens that an aberrant obturator 
artery descends into the pelvis at the outer side of the ring, or immediately across it ; 
and in rarer cases this vessel passes in front of the ring to its inner side (Vol. II, 
p. 477). A pubic vein, also, has occasionally the same course ; and the 'small pubic 
branch of the epigastric artery will be generally found ramifying on the superior 
aspect of Gimbernat's ligament. In the male, the spermatic vessels are separated 
from the canal only by the femoral arches. 

The saphenous opening (fossa ovalis) of the fascia lata is placed at the upper 
and inner part of the thigh, immediately below Poupart's ligament. Its upper 
extremity is about one inch (2"5 cm.) external to the pubic spine, and its vertical 
extent measures from one and a half to two inches (4^ — 5 cm.). On the inner side the 
opening is not sharply defined, the pectineal fascia being here prolonged over its 
muscle, and passing behind the femoral vessels. On the outer side of the opening, 
when the loose tissue in its area constituting the cribriform fascia [fascia cribrosa) has 
been removed, the iliac portion of the fascia lata forms a distinct crescentio edge 
known as the falciform harder, which ends above and below in curved portions termed 
the superior and inferior cornua. Through the lower part of the opening the 
internal saphenous vein passes backwards to enter the femoral vein, and the inferior 
cornu curves sharply round in the angle between the two vessels to join the pectineal 
fascia iubernally The superior cornu is thicker and less curved thaa the inferior : 



FEMORAL HERNIA. 61 

it crosses over the upper and inner part of the femoral sheath to join Poupart's 
and Gimbernat's h'gaments, its terminal portion beini,^ often distinguished as the 
femoral ligament or Heijs ligament. The femoral ligament crosses the antero-internal 
aspect of the femoral canal, and the closed extremity of that passage lies immediately 
behind the upper part of the saphenous opening. 

Descent of the hernia. — When a femoral hernials being formed, the protruded 
part is at first vertical in its course ; but at the lower end of the canal it bends 
forwards through the saphenous opening, and, as it increases in size, ascends over the 
iliac part of the fascia lata and the femoral arch. Within the canal the hernia is very 
small, being constricted by the unyielding structures which form that passage ; but 
when it has passed beyond the saphenous opening, it enlarges in the loose fatty layers 
of the groin : and, as the tumour increases, it extends outwards in the groin towards 
the anterior superior iliac spine. 

Coverings of the hernia. — The coverings of a femoral hernia in order from 
within outwards are, the peritoneum (which forms the sac), the septum femorale 
and the sheath of the femoral vessels. These two structures combined constitute a 
single covering, known as the fascia propria of the hernia (Cooper). It sometimes 
happens that the hernia is protruded through an opening in the sheath, which there- 
fore in that event does not contribute to form the fascia propria. Lastly, the hernia 
is covered by the cribriform fascia stretching across the saphenous opening, the 
superficial fascia, and the skin. 



63 THE PEllINEUM OF THE MALE. 



THE PERINEUM OF THE MALE. 

The perineum is the region which is included within the outlet of the pelvis, and 
which is traversed by the lower end of the rectum and by the urethra. It extends, 
therefore, from the apex of the subpubic arch in front to the tip of the coccyx 
behind, and from the ischial tuberosity of one side to that of the other. It is 
bounded on each side, at the fore part, by the conjoined rami of the pubis 
and ischium, and at the back part by the great sacro-sciatic ligament, together 
with a portion of the lower border of the gluteus maximus muscle. Its form is 
rather heart-shaped in consequence of the projection of the coccyx posteriorly ; it 
measures about three and a half inches (9 cm.) from side to side, and about four 
inches (10 cm.) over the curved surface (three and a quarter inches in a straight 
line) from before back in the middle line. The perineal space is separated from 
the pelvic cavity above by the recto-vesical fascia and the levatores ani muscles ; 
its depth is considerable (from two to three inches) at the posterior and outer 
part, much less (not exceeding an inch) at the fore part. 

The perineal space is conveniently divided into two parts by a line drawn across 
from one ischial tuberosity to the other, and passing immediately in front of 
the anus. The anterior division is termed the urethral part, and is ofteu referred 
to as the true perineum ; the posterior division is called the anal part, or the false 
perineum. 

The several muscles and fasciae, vessels and nerves, which enter into the 
formation of the perineum have been fully described in the second and third volumes 
of this work, and it now only remains to give a short sketch of its superficial 
and topographical anatomy, with which may be included also the relations of 
the adjoining parts of the pelvic viscera. 

Superficial anatomy. — The osseous portions of the boundaries of the 
perineum can be felt more or less distinctly through the skin, but the anterior 
portion of the subpubic arch is obscured by the presence of the penis, and the ischial 
tuberosities are at some distance from the surface, being covered by a thick layer of 
fat and, in the erect position, also by the great gluteal muscles. The sacro-sciatic 
ligament is scarcely to be distinguished beneath the gluteus maximus, except in 
very thin subjects. The lower part of the coccyx is very plainly felt. The anus is 
placed directly between the ischial tuberosities, its centre being about one inch and 
a half from the extremity of the coccyx. 

^ The skin of the perineum is thin and provided with more or less abundant 
hairs ; it is gathered into puckered folds round the anus, to which a farther 
irregularity is often given by swollen heemorrhoidal veins. In front of the anus is a 
median ridge, the raphe, which runs forwards and is continued on to the scrotum 
and penis. Beneath this, the bulb of the urethra forms a slight median elevation, 
more perceptible in emaciated subjects. In such subjects, again, the fat in the 
ischio-rectal fossa does not reach the level of the ischial tuberosities so as to form a 
rounded surface sinking in towards the anus, as is the case in those who are well 
nourished. A fine white line round the anus indicates the point of junction of the 
skin and mucous membrane, and corresponds precisely to the division between the 
external and internal sphincters (Hilton). 

One inch (2-5 cm.) in front of the anus is situated the central point of the 
perineum, which corresponds to the centre of the free border of the triangular 
ligament. Immediately in front of this, the bulb of the urethra commences, but 
the membranous part perforates the triangular ligament about half an inch farther 
forwards, and therefore one inch and a half (4 cm.) in front of the anus. 

Topographical anatomy. — The superficial fascia of the perineum consists of 



THE ISCHIO- RECTAL FOSSA. 



63 



two layers, the more superficial ofArhich is the ordinary subcutaneous fascia, and 
contains fat, especially in the posterior portion of the space, where it is very 
abundant and tills the ischio-rectal fossa. The deep layer or fascia of CoUes is 
membranous, and is confined to the anterior part of the space ; it is attached on 
each side to the rami of the ischium and pubis, and posteriorly to the base of the 
triangular ligament ; it thus forms a somewhat triangular pouch in the fore part of 
the perineum, which may modify the course of an extravasation of urine or a 
collection of pus in this situation. The pouch is, moreover, subdivided posteriorly 
by a median septum, which extends from the back of the perineum to the scrotum. 
The hinder part of the perineum is occupied in the centre by the lower end of 
the rectum, and between this and 
the ischial tuberosity on each ^ 

side is a considerable hollow \ ^^^'=-=''^'^ ^^^ 

known as the ischio-rectal fossa. 

Fig. 29. — Dissection of the perineum 
IN THE MALE. (Allen Tliomson. ) \ 

The right side shows a superficial, the 
left a deeper view. 

o, anus, with a part of the integu- 
ment surrounding it : h, left half of the 
bulb of the corpus spongiosum, exposed 
by the removal of the bulbo-cavernosus 
muscle ; c, coccj'x ; cZ, right ischial tube- 
rosity ; e, e, superficial iierineal fascia ; 
/, fat occupying the right ischio-rectal 
fossa ; fj, gluteus maximus muscle ; 1, 
on the right transversus perinei muscle, 
points to the superficial perineal artery 
as it emerges in front (in this casej of 
the muscle : 1', on the left side, on the 
surface of the triangular ligament, points 
to the superficial perineal artery cut 
short ; 2, on the right iscliio-cavernosus 
muscle, points to the superficial j)erineal 
artery and nerves passing forwards ; 2', 
on the left side, the same vessel and 
nerves divided ; -3, on the right half of 
the triangular ligament, points to the 
transverse perineal artery ; 4, on the left 
ischial tuberosity, points to the pudic 
artery deep in the ischio-rectal fossa ; 
5, 5', inferior hiemorrhoidal branches of 
the pudic arteries and nerves ; 6, on the 
left side, placed in a recess from which 
the inferior layer of the triangular liga- 
ment has been removed, in order to show 
the continuation of the pudic artery, its 
branch to the bulb, and Oowjicrs gland. 

The ischio-rectalTfossa is a hollow of an irregularly pyramidal shape. Its 
base is turned downwards, and mt^asurcs about two inches {J^ cm.) from before 
back, and one inch (2-5 cm.) from side to side. Its outer wall is nearly perpen- 
dicular, and is formed by the obturator internus muscle covered by its fascia below 
the level at which the rectovesical fascia is attached to it. The inner wall is 
oblique in direction and convex towards the fossa ; it is formed by the levator ani 
muscle, covered by the thin anal fascia, and at the lower part by the external 
sphincter. Anteriorly, the fossa is limited by the base of the triangular ligament, 
and posteriorly by the gluteus maximus muscle and the great sacro-sciatic ligament. 
Its depth is about two inches (&cm.) from the margin of the tuberosity at the hinder 
part, where it extends upwards to the ischial spine, the small sacro-sciatic ligament 
and the coccygeus mu.scle. 





64 THE PERINEUM OP THE MALE. 

The pudic vessels and the dorsal and perineal divisions of the pudic nerve run 
forwards along the outer wall of the fossa, being embedded in the obturator fascia 
about an inch and a half (3*5 cm.) above the lower margin of the ischial tuberosity ; the 
inferior hgemorrhoidal branches of these trunks run obliquely inwards and forwards 
from the hinder part of the fossa towards the anus ; and anteriorly the superficial 
perineal vessels and the perineal nerve leave the shelter of the hip-bone and also 
enter the fat of the fossa. 

The ischio-rectal fossa is often the seat of abscesses which burrow freely in the 
loose fat of the part, and frequently result in the formation of a fistula in ano, 
involving a communication with the bowel, sometimes above, but more frequently 
below, the external sphincter. 

The lower dilated part of the rectum, which occupies the space between the two 
ischio-rectal fossag, is supported by the levatores ani and the external sphincter 
muscles, as well as by the recto-vesical fascia. Its lateral wall is exposed for 
a distance of about three inches (7*5 cm.), its posterior wall for little more than an 
inch (3 cm.). 

On removing the fasciee of the fore part of the perineum the bulbo-cavernosus 
muscle is exposed covering the corpus spongiosum, the ischio-cavernosus covering the 
crus penis on each side, and the transversus perinei directed inwards over the base 
of the triangular ligament to meet the first-named muscle, as well as the external 
sphincter and its fellow of the opposite side, in the central point of the perineum. 
Between the bulbo-cavernosus, ischio-cavernosus, and transversus muscles is a small 
triangular space, in which a portion of the triangular ligament is exposed, and over 
the surface of the muscles (sometimes in part beneath or through the transversus) 
the superficial perineal vessels and nerves run forwards to the scrotum, while the 
small transverse perineal artery is directed inwards close to the transverse muscle 
towards the central point of the perineum. 

The triangular ligament or deep perineal fascia, which occupies the subpubic 
arch, has a depth of an inch and a half in the middle line, but extends somewhat 
farther backwards on each side, at its attachment to the ischial ramus. It consists 
of two layers, the upper of which is continuous with the recto-vesical fascia. The 
membranous part of the urethra descends, first through the superior, and then 
through the inferior layer, about an inch from the pubic symphysis, and it is 
surrounded by the fibres of the constrictor urethrse muscle, which occupies the 
greater part of the space between the two layers. Near the urethra, also embedded 
in the muscular fibres, is Cowper's gland. The pudic vessels and the dorsal nerve 
of the penis enter the base of the triangular ligament and run forwards close to the 
bone, in small canals formed in the origin of the constrictor muscle, and the artery 
gives off here its considerable branch to the bulb, which is directed inwards about 
half an inch (1 cm.) from the base of the triangular hgament, and an inch and a 
half (3*5 cm.) in front of the anus. 

Resting on the upper surface of the triangular ligament is the apex of the 
prostate, and this body is surrounded by its sheath, which is continuous on each 
side with the upper layer of the ligament ; beneath the sheath is the large prostatic 
plexus of veins, derived mainly from the breaking up of the dorsal vein of the penis, 
which passes into the pelvis between the pubic symphysis and the triangular liga- 
ment. In the recess between the lateral part of the upper surface of the triangular 
ligament and the sheath of the prostate, the anterior part of the levator ani muscle 
is lodged. 

Above the prostate, and at a depth generally of from two and a half to three 
inches (6 — 7 cm.) from the surface, is the bladder, the base of which projects back- 
wards into the concavity formed by the rectum and overlaps the second part of 



RECTAL EXAMINATION. 65 

the bowel to a variable extent, accordiuoj to the degree of distension of the l:)ladder. 
Between the bladder and rectum are the vesiculffi seminales and the terminal por- 
tions of the vasa deferentia. AVhen the bladder is full, the recto-vesical pouch of 
the peritoneum does not usually reach below a line an inch and a half from the base 
of the prostate. 

In contact with the upper surface of the levator ani is the recto-vesical fascia, 
forming the deep boundary of the perineal space. It extends from the side wall of 
the pelvis downwards and inwards to the side of the rectum, to the bladder and 
prostate. Its line of attachment to the bladder on each side runs upwards and 
backwards immediately above the prostate, and external to the position of the 
vesiculfe seminales ; and it is essential, in the operation of lateral lithotomy, that 
the bladder be opened entirely below this level. If the incision be carried through 
the fascia beyond this line, then the pelvic cavity will be opened, and extravasation 
of urine into the loose areolar tissue will probably follow. 

EXAMINATION OF THE PELVIC VISCERA. 

Rectal examination in the male. — On passing the finger into the rectum 
in the adult male, the constriction {anal canal) caused by the internal and external 
sphincters is first encountered, the internal sphincter extending one inch above the 
anal orifice. The soft mucous membrane of the bowel is then felt more or less 
doubled into transverse folds (folds of Houston, ;;/myc transversales recti) : these 
are usually three in number, the largest? being found on the front and right side of 
the bowel about three inches from the anus, and on a level with the extremity of the 
recto-vesical pouch of peritoneum, while another is placed on the left side about one 
inch higher ; and the third, which is less constant, is on the left side, posteriorly, 
below the first. These folds are visible when the rectum is examined wnth the aid 
of a speculum, the body being placed in the genu-pectoral position. They some- 
times render the introduction of the finger or an instrument beyond a certain point 
difficult or impossible. The columns of Morgagni (columnce. rectaJcs) and the small 
folds of mucous membrane (valves of Morgagni) directed upwards which join them, 
with the enclosed recesses (sinus recfaks), are not to be felt, but are easily seen with 
a speculum. The mucous membrane of the anal canal is thicker and drier than the 
velvety lining membrane of the bowel higher up. It often presents small polypoid 
projections from its surface. 

Through the wall of the bowel numerous objects may be felt : — In front is the 
base of the triangular ligament, a little distance above which is the apex of the 
prostate. The outline of the prostate is readily made out, and above it the bladder 
may be felt if distended. The vesiculae seminales are not to be recognized unless 
enlarged, and even then only their lower parts by a finger of average length. 

Behind, after passing over the soft posterior part of the perineum (ano-coccygeal 
body), the tip of the coccyx is reached and the finger explores the hollow of the 
sacrum, IVora this there passes out on each side a resistent band consisting of the 
small sacro-sciatic ligament and the coccygeus muscle, which lead to the ischial 
spine. 

On each side, the ischial tuberosity and the wall of the true pelvis arc felt, and 
in this way the condition of the structures at the back of the acetabulum, in the 
neighbourhood of the caecum, or of the large vessels may be determined. 

This examination of the pelvis is easier in the infant, and is aided by bimanual 
examination, one hand being placed on the lower part of the abdomen. In the 
infant the jjarts felt are the same, except that the prostate is scarcely 
perceptible. 

Rectal examination in the female.--In the female the anus is placed 



QQ EXAMINATION OF THE PELVIC VISCERA. 

slightly farther forAvards than in the male, and is not so deeply sunk between the 
nates ; the surrounding skin is usually destitute of hairs. Behind the rectum the 
parts to be felt are the same as in the other sex. In front, above the perineal body, 
the first part met with is the soft recto-vaginal septum ; then the cervix and os 
uteri, and higher up the lower part of the body of the uterus. Any abnormality in 
the position of the organ or in the state of the pouch of Douglas can also be 
determined. At each side, besides the structures met with in the male, the 
resistance caused by the base of the broad ligament may be detected, the ovaries 
may be felt on bimanual examination, and the outline of the uterus more accurately 
determined. 

Vaginal examination. — In a digital examination of the vagina, the passage 
is found to be small, and more or less obstructed by the hymen in the virgin, and 
the mucous membrane is rugose. In a woman Avho has borne children the parts are 
more capacious, there is no hymen, and the rugse are no longer felt. The outline 
of the subpubic arch may be traced in front, and the region of the bladder explored ; 
behind is the soft recto-vaginal septum ; and on each side the pelvic wall may be 
examined, and the ovaries can easily be felt on bimanual examination. At the 
upper end of the vagina, and projecting from the anterior wall, is the cervix uteri, 
in which the os is to be felt as a transverse slit. 



INDEX TO APPENDIX. 



Abdomek, superficial anatomy of, 22 
Abdominal aorta, 27, 34 

cavity, 22 

furrow, 24 

regions, 22 
lateral, 23 
viscera of, 23 

ring, external, 24, 51, 55, 56 
internal, 24, 51, 53 

vessels, 27 

viscera, 23, 24 

wall, 23, 56 
Abductor. See Muscles. 
Acetabulum, 43, 65 
Acromial angle, 28 
Acromio-clavicular articulation, 32 
Acromion, 28, 32, 35 
Adductor. Sen Ml'scles. 

tubercle. 45, 46 
Aditus ad antrum, 10 
Alveolar jirocesscs, 15 
Alveolo-lingual sulcus, 15 
Anal canal, 65 

fascia, 63 

part of perineum, 62 
Anastomotic arterj' of thigh, 46 
Anatomy, superficial. Sec Superfictal Axa- 

TOMV. 

topographical. Sec Topographical Axa- 

TOMY. 

Anconeus muscle, 37, 38 
Angle, acromial, 28 

of jaw, 14, 32 

Rolandic, 9 

of scapula, 28, 32, 33 

sternal, 19 

subcostal, 19 
Angular proi'.ess, external, i 
Ankle, superficial anatomy of, 48 
Ankie-joint, 48 
Annular ligament, anterior, 49 
Annulus femoralis, 60 
Ano-coccygeal body, 65 
Antrum, mastoid, 10, 11, 13 
Anus, 60, 65 
Aorta, abdominal, 27, 34 

arch of, 22, 29, 33 

a.scendiiig, 22, ^^ 

descending, 29, ^^ 
Aortic cartilage, 22 

orifice, 22, 33 
Aperture of larynx, upper, 17, 32 
Ajterture, nasal, anterior, 13 
Apex of bladder, 53 

of lieart, 21 

of lung, 20, 28, 32 

of prostate, 64, 65 
Aponeurosis of external oblique muscle, 51, 56 
Appendix, vermiform, 23 



Arch of aorta, 22, 29, 33 

azygos vein, 33 
femoral, deep, 58, 60 

superficial, 57, 60 
palmar, deep, 41 

superficial, 41 
of subclavian artery, 32 
subpubic, 62, 66 
of thoracic duct, 32 
Arm, .superficial anatomy of, 35 
Artery or Ar>TERiEs, aberrant obturator, 60 
anastomotic of thigh, 46 
articular of knee, 46 
axillary, 35 
brachial, ^6, 37, 39 
of bulb, 64 
carotid, common, 17, 22, 32 

external, 17 

internal, 17 
cervical, transverse, iS 
circumflex, posterior, 35 
crico-thyroid, 17 
coronary, of facial, 14 
digital of hand. 41 
dorsal of foot, 49 
endocranial, 3 

epigastric, 24, 51, 53, 54, 55, 60 
facial, 14, 17 
femoral, 43, 45, 57, 60 
frontal, 3 
gluteal, 43 
hypogastric, 51, 56 
iliac, common, 27, 34 

external, 27, 51, 57, 58 
innominate, 17, 22, 32, 33 
intercostal, 22 
lateral costal, .'?2 
lingual, 17 

miuiimarj-, internal, 22 
meningeal, middle, 5 
mesenteric, superior, 27, 34 

inferior, 27, 34 
occipital, 3, 10, 17 
perineal superficial, 64 

transverse, 64 
plantar, 48, 49 
jpopliteal, 46, 47 
jirofunda of thigh, 45 

superior, 37 
pubic, of epigastric, 60 
]iuilic, 64 
pulmonary, :i;i 
radial, 38, 39 
renal, 27, 29, 34 
of scal[), 3 
sciatic, 43 

8i)ormatic, 54, 56, 60 
subclavian, 18, 22, 32 
superficial volar, 41 



68 



INDEX TO APPENDIX. 



Artery or Arteries — continued. 

supraorbital, 3 

temporal, superficial, 3 

of thoracic wall, 22 

thyroid, inferior, 17 
superior, 17 

tibial, 47, 48, 49 

transverse facial, 14 

ulnar, 38, 39 

vertebral, 17 
Articular arteries of knee, 46 
Articulation or Articulations, acromio- 
clavicular, 32 

of ankle, 48 

chondro-sternal, 20, 21, 22, 24, 25, 33 

of elbow, 37 

of hip, 43 

interphalangeal, 41 

of knee, 45 

metacarpo-phalangeal, 40, 41 

metatarso-phalangeal, 49 

radio-carpal, 41 

sacro- iliac, 42 

of shoulder, 35 

sterno-clavicular, 18, 22 

tarsal, transverse, 48 

tarso-metatarsal, 48 

temporo-maxillary, 13 

xiphisternal, 19, 24, 25, 33 
Astragalus, 48 
Atlas, 16, 31 
Attic of tympanum, 10 
Auditory meatus, external, 11, 12 
Auricles of heart, 33 
Auricular nerve, great, 18 
Auriculo-ventricular openings, 22, 33 
Axilla, folds of, 19, 35 
Axillary artery, 35 
Axis, 16, 27, 31 

coeliac, 27, 29, 34 
Azygos vein, 33 



Back, superficial anatomy of, 27 
Basal ganglia, 9 
Base of bladder, 64 
of jaw, 14 
line of Reid, 7 
Basilar process, 16 
Basilic vein, 36, 37 
Bend of elbow, 37 
Biceps. See Muscles. 
Bicipital fascia, 37, 38 

furrows, 35 
Bifurcation of aorta, 27, 29, 34 
brachial artery, 39 
common carotid artery, 32 
common iliac artery, 34 
innominate artery, 32 
popliteal artery, 47 
posterior tibial artery, 4S 
trachea, 33 
Bi-iliac line, 22 

plane, 23, 34 
Bladder, 23, 25, 53, 64, 65, 66 
Blood-vessels. Sec Arteries, Veins, 
Body, ano-coccygeal, 65 
thyroid, 17 
turbinate, 13, 16 
Brachial artery, 36, 37, 39 
plexus, 18 



Brachialis anticus muscle, 36 
Broad ligament of uterus, 66 
Bronchi, 28, 33 
Bulb, artery of, 64 

of urethra, 62 
Bulbo-cavernosus muscle, 64 
Bursa, over olecranon, 37 
patella, 46 

pjharyngea, 16 

over tubercle of tibia, 46 
Buttock, 42 



C^CUM, 23, 25, 65 

Calf, 47 
Canal, anal, 65 

crural, 60 

of facial nerve, 12 

femoral, 51, 60, 61 

inguinal, 24, 51, 54, 55, 56 

of Nuck, 55 

f)alatine, posterior, 16 

semicircular, external, 12 
Canaliculi, lachrymal, 15 
Can thus, 14 
Capitellum, 37 
Cardiac dulness, deep, 22 
superficial, 22 

orifice of stomach, 23, 25, 28, 33 
Carotid artery. See Arteries. 

tubercle, 17 
Cartilage, aortic, 22 

costal, 19, 20, 21, 22, 24, 25, 26, 33, 34 

cricoid, 16, 17, 32 

of nose, 13 

pulmonary, 22 

of septum nasi, 13 

thyroid, 16, 32 
Caruncula lacrimalis, 15 
Central point of perineum, 62, 64 
Cephalic vein, 36, 37 
Cerebellum, 10 
Cerebral, convolutions, relations of, to cranium, 6 

fissures, relations of, to cranium, 6 
determination of, 7 

hemispheres, 5 
Cervical enlargement of spinal cord, 31 

vertebrae, 16, 27 
Cervix uteri, 66 

Chest, superficial anatomy of, 19 
Chondro-sternal articulations, 20, 21, 22, 24, 25, 

33 
Circumflex artery and nerve, 35 
Clavicle, 17, 18, 32, 35 

Clavicular head of sterno-mastoid muscle, 17 
Coccygeus muscle, 63, 65 
Coccyx, 62, 65 
Coeliac axis, 27, 29, 34 
CoUes, fascia of, 63 
Colon, 23, 25, 31 
Columnse rectales, 65 
Columns of Morgagni, 65 
Compartments, of femoral sheath, 60 

iliac, 58 

pectineal, 59 

vascular, 58 
Condyles of femur, 45, 46 

humerus, 35, 36, 37 
Congenital hernia, 54, 55 
Conjoined tendon, 51, 56, 60 
Conjunctiva, 15 
Constrictor urethrte muscle, 64 



INDEX TO APPENDIX. 



69 



Convolutions, cerebral, relations of, to craninm, 6 
Cooper, ligament of, 59 
Coraco-brachialis muscle, 35 
Coracoid process, 35 
Cord, spermatic, 43, 51, 54, 56 
coverings of, 51, 54 

spinal, 31. 34 
Cornua of falciform border, 60 

of hyoid bone, 1 7 

of lateral ventricle, 9 
Coronary branch of facial artery, 14 
Corpus spongiosum, 64 
Costal artery, lateral, 22 

cartilages, 19, 20, 21, 22, 24, 25, 26, 33, 

34 
Coverings of spermatic cord, 51, 54 
direct inguinal hernia, 56 
femoral hernia, 61 
oblique inguinal hernia, 54 
Cowper's gland, 64 
Cranio-ceiebral topography, 5 
Cranium, i 

relations of cerebrum to, 6 
Cremaster muscle, 51, 55, 56 
Cremasteric fascia, 51 
Crest, external occipital, i 

iliac, 22, 23, 28, 30, 34, 42 

pubic, 43 

temporal, i, 7, 9 

supramastoid, 11, 12, 13 
Cribriform fascia, 60, 61 
Cricoid cartilage, 16, 17, 32 
Crico-thyroid arterj', 17 

space, 16, 17 
Crural branch of genitc-crural nerve, 58 

canal, 60 

nerve, anterior, 45, 59 

ring, 60 

sheath, 60 
Crus penis, 64 
Cuneiform Ijones. 48 
Curved line, superior, i 



Deltoid muscle, 35 
Diaphragm, 33 
Digastric muscle, 16 
Digital arteries of hand, 41 
Direct inguinal hernia, 54, 55 
Dorsal artery of foot, 49 

nerve of penis, 64 

vein of yienis, 64 
Dorso-lumbar furrow, 27 
Douglas, pouch of, 66 
Duct, nasal, 15 

of Stensen, 14, 15 

of Wharton, 15 

thoracic, arch of, 32 
Dulness, cardiac, deep, 22 

superficial, 22 
Duodeno-jejunal fiexure, 23, 25, 34 
Duodenum, 23, 27, 31, 34 



Eli!0\v, superficial anatomy of, ;i,7 
Eminence, frontal, i 

hyj)othenar, 39 

parietal, I, 6, 7 

thenar, 39 
Endocranial blood-vessels, 3 



Ensiform pi'ocess, 19, 33 

Epigastric artery, 24, 51, 53, 54, 55, 60 

fossa, 19 

region, 23 

vein, superficial, 24 
Epiglottis, 16, 17, 32 
Epiphysis, lower, of femur, 46 
Epitympanic recess, 10 
Erector spinse muscles, 27, 28 
External inguinal hernia, 54 
Extensoi". See JIuscles. 
Eustachian tube, 16 
Eyeball, 14 
Eyelid, 14 



Face, superficial anatomy of, i, 13 
Facial artery, 14, 17 

transverse, 14 
nerve, 14 

canal of, 12 
vein, 17 
Falciform border, 60 
False perineum, 62 
Falx inguinalis, 56 
Fascia, anal, 63 

bicipital, 37, 38 
of Colles, 63 
cremasteric, 51 
cribriform, 60, 61 
cribrosa, 60 
iliac, 58, 59, 60 
infuudibuliform, 51 
intercolumnar, 51 
lata, 45, 59 
obturator, 63, 64 
palmar, 39 
pectineal, 58, 59, 60 
of perineum, deep, 63, 64 

superficial, 62 
propria, 61 

recto-vesical, 62, 64, 65 
spermatic, 51, 56 
transversalis, 51, 56, 58, 60 
triangular, 51 
Fauces, 15 

pillars of, 16 
Femoral arch, deep, 58, 60 
superficial, 57, 60 
artery, 43, 45, 57, 60 
canal, 51, 60, 61 
glands, 43 

hernia, 43, 51, 57, 61 
ligament, 61 
ring, 54, 58, 60 
septum, 60 
sheath, 57. 58, 60, 61 
vein, 45, 57, 60 
Femur, 45, 46 
Fibula, 46, 47 
Fingers, ficxures of, 41 
Fissure or Fissures, cerebral, situation of, 6 
intraparietal, 7, 9 
of lung, 20 
])alp<!ljral, 14 
parallel, 7, 9 
parieto-iiccipital, 6 
I)etr(j-s<iuamosal, 1 1 
of Rolando, 6, 7, 8 
of Sylvius, 6, 8 
1 Flexor. See iAIuscles. 



70 



INDEX TO APPENDIX. 



Flexure, duodeno-jejimal, 23, 25, 34 

hepatic, 23, 25, 34 

splenic, 23, 25, 34 
Flexures of palm, 40 

fingers, 41 
Floor of mouth, 15 
Fold or Folds, of axilla, 19, 35 

of Houston, 65 
of nates, 42 

peritoneal, 51 

salpingo-palatine, 16 

salpingo-pharyngeal, 16 
Fontanelles, i, 2 
Foot, superficial anatomy of, 48 
Foramen, infraorbital, 14 

mental, 14 

sacro-sciatic, 43 

supraorbital, i 

of Winslo'w, 34 
Forearm, superficial anatomy of, 38 
Fossa or Fossae, epigastric, 19 

infraclavicular, 19, 35 

infracostal, 24 

ischio-rectal, 62, 63 

jugularis, 17 

middle of skull, 11, 13 

nasal, 13, 16 

ovalis, 60 

peritoneal, 51, 54, 60 

posterior, of skull, 13 

of Rosenmiiller, 16 

supraclavicular, 18 

suprameatal, 12 
Fovea supravesicalis, 53, 56 

femoralis, 54, 60 

inguinalis lateralis, 53 
mesialis, 53, 56 
Frsenura linguae, 15 

of lips, 15 
Frontal artery, 3 

convolutions, 7 

eminence, i, 7 

lobe of cerebrum, 7 

margin of cei'ebrum, 5 

sinuses, 2 

sulci, 7, 9 

vein, 3 
Fronto-malar suture, i, 7 
Fundus of stomach, 25, 33 
Furrow, abdominal, 24 

bicipital, 35 

dorse-lumbar, 27 

iliac, 42 

inguinal, 22, 43 

nuchal, i, 27 

spinal, 27 

sternal, 19 



Gall-bladder, 23, 24 

Ganglia, basal, 9 

Gastrocnemius muscle, 47 

Genito-crural nerve, 58 

Genu, inferior, of Rolandic fissure, 9 

Gimbernat's ligament, 51, 57, 58, 59, 60, 61 

Glabella, 3 

Gland or Glands, of Cowper, 64 

femoral, 43 

inguinal, 24, 43 

Meibomian, 15 

parotid, 14 



Gland or Glands — continued. 

popliteal, 47 

sublingual, 15 

submaxillary, 16 
Glenoid cavity, 33, 35 
Gluteal artery, 43 

region. 42 
Gluteus. See Muscles. 
Gracilis muscle, 46 
Groin, 23, 51, 57 
Groove, sternal, 19 
Gums, 15 

Ham, 46 

Hamstring muscles, 45, 46 

Hamular process, 16 

Hand, superficial anatomy of, 39 

Hard palate, 16 

Head of a.stragalus, 48 

clavicular, of stern o-mastoid, 17 
of femur, 45 

fibula, 46, 47 
gastrocnemius miiscle, 47 
humerus, 35 
metatarsal bones, 48, 49 
pancreas, 34 
radius, 37, 38 
sternal of sterno-mastoid, 17 
superficial anatomy of, i 
of triceps muscle, 37 
of ulna, 38 
Heart, 21, 23, 33 
Hemisphere, cerebral, 5 
Henle, ligament of, 56 
Hepatic flexure, 23, 25, 34 
Hernia, 51 

femoral, 43, 51, 57, 61 
infantile, 54 
inguinal, 51, 54 

congenital, 54, 55 
direct, 54, 55, 56 
external, 54 
internal, 54, 55, 56 
oblique, 54 

internal, 56 
sac of, 54, 61 
Hesselbach, ligament of, 56 

triangle of, 55, 56 
He}''s ligament, 61 
Hip, superficial anatomy of, 42 
Hip-joint, 43 

Hook of unciform bone, 39 
Houston, folds of, 65 
Humerus, 35 
Hymen, 66 
Hyoid bone, 16, 32 
Hyo-mental region, 16 
Hyo-sternal region, 16 
Hypochondriac region, 23 
Hypogastric artery, 51, 56 

region, 23 
Hypoglossal nerve, 17 
Hypothenar eminence, 39 



Ileum, 23, 25 

Iliac artery. Sec Aeteeies. 

compartment, 58 

crest, 22, 23, 28, 30, 34, 42 

fascia, 58, 59, 60 

furrow, 42 

part of fascia lata, 60 



INDEX TO APPENDIX. 



7i 



Iliac region, 23 

spine, anterior superior, 23, 34, 42, 43, 51, 
57, 61 
posterior inferior, 43 
superior, 27, 42, 43 
vein, external, 54, 57, 58, 60 
Ilio-pectineal intermuscular septum, 59 
Ilio-psoas muscle, 57, 59 
Ilio-tibial band, 45, 46 
Ilium, 59 

Infantile hernia, 54 
Infraclavicular fossa, 19, 35 
Infracostal fossa, 24 
line, 22 
plane, 23, 34 
Infrah5-oid region, 16 
Infraorbital foramen, 14 
Infrapatellar fat, 46 
Infraspinatus muscle, 35 
Infrasternal depression, 19 
Infundibuliform fascia, 51 
Infundibulum of frontal sinus, 3 

of heart, 33 
Inguinal canal, 24, 51, 54, 55, 56 
furrow, 22, 43 
glands, 24, 43 
hernia, 51, 54 

congenital, 54, 55 
direct, 54, 55 
external, 54 
internal, 54, 55 
oblique, 54 

internal, 56 
region, 23 
Inion, 7 
Innominate arterj', 17, 22, 32, 33 

vein, 22, 33 
Insula, 9 

Intercolumnar fascia, 51 
Intercostal spaces, 19, 21, 22, 28 

vessels, 22 
Intermetatarsal spaces, 49 
Intermuscular septum of arm, external, 35, 37 
internal, 36 
ilio-pectineal, 59 
of tliigh, external, 45 
Internal inguinal hernia. See Heunfa. 
Interosseous nerve, posterior, 37 
Interphalangeal articulations, 41 
Intestines, 25 
Intraparictal fissure, 7, 9 
Ischial ramus, 43, 62, 63 
spine, 63, 65 
tuberosity, 43, 62, 65 
Ischio-cavernosus muscle, 64 
Ischio-recta! fossa, 62, 63 
Island of Keil, 9 
Isthmus, thyroid, 17 

Jaw, lower, 14, 15, 32 
Jejunum, 23, 25 
Joint. See AuncuLATiONS. 
Jugular veins. Sc; Veins. 

Kidney, 23, 26, 30, 31, 34 

Knee-joint, 45 

Knee, superiicial anatomy of, 45 

Labium pudcndi, 54 
Lachrymal sac, 15 
Lacuna musculorum, 58 
vasorum, 58 



Lambda, i, 6, 7 
Lambdoid suture, i 
Larynx, 17, 28, 32 

aperture of, 17 
Lateral abdominal region, 23 
Lateral sinus, 4, 10, 12 
Latissimus dorsi muscle, 19, 35 
Levator. See Muscles. 
Leg, superficial anatomy of, 47 
Levels of structures of trunk, 32 
Ligiiment, annular, anterior, of ankle, 49 

broad, of uterus, 66 

of Cooper, 59 

femoral, 61 

of Gimbernat, 51, 57, 58, 59, 60, 61 

of Henle, 56 

of Hesselbach, 56 

of Hey, 61 

lateral, external, of knee, 46 

ptery go-maxillary, 16 

of Poupart, 22, 24, 43, 51, 55. 57, 58, 59, 
60, 61 

pubic, 59 

round, of uterus, 54, 55 

sacro-sciatic, 62, 63, 65 

tarsal, internal, 15 

transverse, superficial, of hand, 41 

triangular, 62, 63, 64, 65 
Ligamentum inguinale. 57 

intert'oveolare, 56 

lacunare, 57 

patellfe, 46 
Limb, lower, superficial anatomy of, 42 

upper, sujierficial anatomy of, 35 
Line or lines, base, of Pieid, 7 

bi-iliac, 22 

infracostal, 22 

inid-Poupart, 23 

nasio-inial, 7 

of Nekton, 43 

of palm, 40 

of parallel fissure, 7, 9 

Rolandic, 8 

Sylvian, 8 
Linea semilunaris, 23, 24 
Lingual artery, 17 

nerve, 16 
Lips, 15 

Liver, 23, 24, 33, 34 
Longitudinal sinus, superior, 3, 5 
Lumbar enlargement of spinal cord, 31 

region, 23 
Lung, 18, 20, 28, 32, 34 

root of, 2)Z 

Malleolus, external, 47, 48 

internal, 47, 48 
Mammar}' artery, internal, 22 
Mannlnium, 19, 20, 22, 32, 33 
Marginal tubercle, 7 
Masseter muscle, 14, 15 
Mastoid antrum, 10 

cells, II, 12, 13 

jjrocess, i 
Masto-sijuamosal suture, 12 
Meatus, external auditory, 11, 12 

middle, of nose, 13 
Median nerve, 36, 38 

vein, 37, 38 
Median-basilic vein, 37 
Median-ce])iialic vein, 37 
Meibtnnian glands, 15 



72 



INDEX TO APPENDIX. 



Membranous urethra, 62, 64 

Meningeal artery, middle, 5 

Mental foramen, 14 

Mesenteric artery. See Arteuy. 

Mesentery, 23, 25 

Metacarpal bones, 39 

Metacarpo-phalangeal articulations, 40, 41 

■Metatarsal bones, 48, 49 

Metatarso-phalangeal articulations, 49 

Mid-Poupart line, 23 

Morgagni, columns of, 65 

valves of, 65 
Mouth, 15, 32 

Muscle or Muscles, abductor liallucis, 49 
indicis, 39 
minimi digiti, 49 
adductor longus, 45 
magnus, 45, 46 
of thigh, 43, 45, 46 
transversus pollicis, 39 
anconeus, 37, 38 
biceps brachii, 35, 36, 37 

femoris, 45, 46, 47 
brachialis anticus, 36 
bulbo-cavernosus, 64 
coccygeus, 63, 65 
constrictor urethrte, 64 
coraco-brachialis, 35 
cremaster, 51, 55, 56 
deltoid, 35 
digastric, 16 
erector spinfe, 27, 28 
extensor brevis digitorum, 49 
pollicis, 38, 39 
carpi radialis, 36, 37, 38 

ulnaris, 38 
communis digitorum, 39 
of fingers, 38, 39 
of forearm, 37 
indicis, 39 
longus digitorum, 47, 49 

pollicis, 38, 39 
minimi digiti, 38, 39 
ossis metacarpi pollicis, 38, 39 
proprius hallucis, 47, 49 
of thumb, 38, 39 
flexor brevis hallucis, 49 
minimi digiti, 49 
carpi radialis, 38 

ulnaris, 38 
longus digitorum, 47 
profundus digitorum, 38 
gastrocnemius, 47 
gluterrs maximus, 42, 43, 62, 63 
medius, 42, 43 
minimus, 42 
gracilis, 46 
hamstring, 45, 46 
ilio-psoas, 57, 59 
infraspinatus. 35 
ischio-cavernosus, 64 
latissimus dorsi, 19, 35 
levator anguli scapulie, 28 

ani, 62, 63, 64, 65 
of little finger, short, 39 
masseter, 14, 15 

obliquus abdominis, externus, 19, 24, 51, 
56 
internus, 51, 56 
obturator internus, 63 
omo-hyoid, 17, 18 
palmaris longus, 38 



Muscle or Muscles — continued. 

pectineus, 57, 59, 60 

pectoralis major, 19, 35 
minor, 19 

peronei, 46, 47, 49 

quadriceps extensor, 43 

rectus abdominis, 19, 24, 55 
femoris, 43 

sartorius, 43, 46 

semimembranosus, 46 

semitendinosus, 46 

serratus magnus, 19 

soleus, 47 

sphincter ani, 62, 63, 64, 65 

sterno-masioid, 17 

supinator longus, 35, 36, 37, 38, 39 

supraspinatus, 28 

temporal, i, 15 

tensor vagimE femoris, 42 

teres, 35 

of thumb, short, 39 

tibialis anticus, 47, 48, 49 
posticus, 47, 48 

transversalis abdominis, 51, 56 

transversus perinei, 64 

trapezius, 28 

triceps, 35, 37 

vastus, externus, 44, 45 
internus, 44 
Musculo-cutaneous nerve, 49 
Musculo-spiral nerve, 37 



Naues, posterior, 16 
Nasal aperture, anterior, 13 

cartilages, 13 

duct, 15 

fossa, 13, 16 

spine, anterior, 13 
Nasion, 7 
Nasio-inial line, 7 
Naso-froutal suture, 5 
Nates, fold of, 42 
Navicular bone, 48 
Neck, superficial anatomy of, 1, 16 
Nelaton's line, 43 
Nerve or Nerves, auricular, great, 18 

circumflex, 35 

crural, anterior, 45, 59 

cutaneous, external, 59 

dorsal of penis, 64 

facial, 12, 14 

genito-crural, 58 

hypoglossal, 17 

interosseous, posterior, 37 

lingual, 16 

median, 36, 38 

musculo-cutaneous, 49 

musculo-spiral, 37 

occipital, great, 3 

perineal, 64 

popliteal, 47 

pudic, 64 

radial, 37 

saphenous, external, 47, 49 
internal, 46, 47 

of scalp, 3 

sciatic, great, 43, 45 
small, 45 

spinal, 31, 32, 33, 34 

spinal accessory, 18 

superficial cervical, 18 



INDEX TO APPENDIX. 



73 



Nerve or Nerves — continued. 

supraorbital, 3 

supratrochlear, 3 

tibial, anterior, 49 
posterior, 47 

ulnar, 36, 39 
Nerve-roots, spiual, 31, 32, 33, 34 
Nipple, 19, 22, 33 
Notch, supraorbital, i, 14 

suprastevnal, 17 
Nuchal lurrow, i. 27 
Nuck, caual of, 55 



Obeliox. I 

Oblique inguinal hernia, 54 

internal. 56 
Obliquus abdomiuis. See Muscles. 
Obturator artery, abenaut, 60 

fascia, 63, 64 

internixs muscle, 63 
Occipital artery, 3, 10, 17 

crest, external, i 

nerve, great, 3 

protuberance, external, i 
Occipito-temporal margin of cerebrum. 5 
Oesophagus, 17, 28, 32 
Olecranon, 37 
Omentum, great, 23, 25 
Omo-hyoid muscle, 17, 18 
Operculum of middle turbinate body, 13 
Orifice, aortic, 22, 23 

auriculo-ventricular, 22, 33 

cardiac, 23, 25, 28, 33 

of inferior vena cava, 33 

pulmonan.', 22, 33 

pyloric, 23, 25, 29, 34 
Origin of spinal nerve-roots, 31, 32, 33, 34 
Os calcis, 47, 48, 49 
Os uteri, 66 
Ovary, 66 



Palate, 16, 32 
Palatine canal, posterior, 16 
Palm, 39 

Palmar arch, deep, 41 
suijerficial, 41 

fascia, 39 
Palmaris longus, 38 
Palpebral fissure, 14 

sulcus, external, 14 
inferior, 14 
sui>erior, 14 
Palpebro-malar sulcus, 14 
Pancreas, 23, 27, 31, 34 
Papilla lacrimalis, 15 
Parallel fissure, 7, 9 
Parietal eminence, i, 6, 7 
Parieto-occipital fissure, 6 
Parotid gland, 14 
Patella, 46 

ligament of, 46 
Pectineal coinpartmcnt, 59 

fascia, 58, 59, 60 
Pectineus muscle, 57, 59, 60 
Pectoral muscles, 19, 35 
I*elv:c viscera, examination of, 65 
Penis, crura of, 64 
Perinwil artery. See Aetery. 

fascia, 64 

nerve, 64 



Perineum, central point of, 62, 64 
false, 62 
anatomy of, 62 
true, 62 
Peritoneal folds, 51 

fossffi, 51, 54 
Peritoneum, 54, 56, 60. 61 
Peroneal .spine. 48 
Peronei muscles, 46, 47, 49 
Petro-squamosal fissure, 1 1 
Pharyngeal recess, lateral, 16 
median, 16 
tonsil, 16 
Pharynx, 13, 16, 17, 28, 32 
Pillars of abdominal ring, 24 

of fauces, 16 
Pisiform bone, 38, 39 
Plantar arteries, 48, 49 
Pleura, 18, 20. 28, 34 
Plexus, brachial, 18 

prostatic, 64 
Plica epigastrica, 53 
fimbriata, 15 
hypogastrica, 51 
semilunaris, 15 
umbilicalis lateralis, 51 

media, 51 
urachi, 51 
Plicfe transversales recti, 65 
Point, preauricular, 7 
Rolandic, inferior, 8 

superior, 7 
Sylvian, 8, 9 
Pomum Adanii, 16 
Popliteal artery, 46, 47 
glands, 47 
nerves, 47 
vein, 46 
Postcentral sulci, 9 
Pouch of Douglas, 66 
recto-vesical, 65 
Poupart's ligament, 22, 24, 43, 51, 55, 57, 58, 

59, 60, 61 
-Preauricular ]>oint, 7 
Precentral sulci, 7, 9 
Process, alveolar, 15 
basilar, 16 
coracoiil, 35 
ensiform, 19, ^^ 
external angular, i 
hamular, 16 
mastoid, i 

styloid of third metacarpal, 39 
radius, 38, 39 
ulna, 38 
transverse, of atlas, 17 

of sixth cervical vertebra, 1 7 
Processus vaginalis, 54 
Profunda artery. See Arteuy. 
Promontory of sacrum, 24 
Prostate, 64, 65 

sheath of, 64 
Prostatic plexus, 64 
Pterion, 6 

Pterygo-maxillary ligament, 16 
Pube.s, 23 

Pubic branch of epigastric artery, 60 
crest, 43 
ligament, 59 
portion ot fascia lata, 59 
rami, 43, 59, 63 
legion, 23 



74 



INDEX TO APPENDIX. 



Pubic spine, 24, 43, 51, 57, 60 

symphysis, 43 

vein, 60 
Pudic artery, 64 

nerve, 64 
Pulley of superior oblique muscle, 14 
Pulmonary artery, 33 

cartilage, 22 

orifice, 22, 33 
Pulse, 38 

Punctum lacrimale, 15 
Pyloric orifice, 23, 25, 29, 34 
Pyramidal bone, 39 



Quadriceps extensor muscle, 43 



Radial artery, 38, 39 

nerve, 37 

vein, 38 
Radio-carpal ai'ticulation, 41 
Radius, 37, 38 
Ranine vein, 15, 17 
Rtiphe of perineum, 62 
Receptaculum cliyli, 34 
Rectal examination, 65 
Recto-vaginal septum, 66 
Recto-vesical fascia, 62, 64, 65 

pouch, 65 
Rectum, 23, 64, 65 
Rectus muscle. Sec Muscles. 
Region or Regions, abdominal, 22 
viscera of, 23 

epigastric, 23 

gluteal, 42 

hyo-mental, 16 

hyo-sternal, 16 

hypochondriac, 23 

hypogastric, 23 

iliac, 23 

infrahyoid, 16 

inguinal, 23 

lateral aladominal, 23 

lumbar, 23 

of neck, 16 

pubic. 23 

submaxillary, 16 

suprahyoid, 16 

umbilical, 23 
Reid, base-line of, 7 
Reil, island of, 9 
Renal artery, 27, 29, 34 
Ribs, 19, 20, 25, 28, 30, 32, 33, 34, 35 
Rima glottidis, 17, 32 
Ring, abdominal, external, 51, 55, 56 
internal, 51, 53 

crural, 60 

femoral, 54, 58, 60 
Rolandic angle, 9 

line, 8 

point, inferior, 8 
superior, 7 
Rolando, fissure of, 6, 7, 8 
Root of htng, 33 

Roots of spinal nerves, 31, 32, 33, 34 
Rosenmiiller, fossa of, 16 
Round ligament of uterus, 54, 55 



Sac of hernia, 54, 61 

lachrymal, 15 
Sacro-iliac articulation, 42 
Sacro-sciatic foramen, 43 

ligament, 62, 63, 65 
Sacrum, 65 

pi'omontory of, 24 
Sagittal suture, i 
Salpingo-palatine fold, 16 
Salpiugo-pharyngeal fold, 16 
Saphenous nerves. See Nerves. 

opening, 43, 57, 60, 61 

veins. See Veins. 
Sartorius muscle, 43, 46 
Scalp, vessels and nerves of, 3 
Scaphoid bone, 39 
Scapula, 28, 32, 33 
Scarpa's triangle, 43 
Sciatic, artery, 43- 

nerve, great, 43, 45 
small, 45 
Scrobiculus cordis, 19 
Scrotum, 54 

Semicircular canal, external, 12 
Semimembranosus muscle, 46 
Semitendinosus muscle, 46 
Septum, femoral, 60, 61 

intermuscular of arm, external, 35, 37 
internal, 36 
ilio-pectineal, 59 
of thigh, external, 45 

nasi, 13, 16 

recto-vaginal, 66 
Serratus magnus muscle, 19 
Sesamoid bones of foot, 48 

of thumb, 39 
Sheath, crural or femoral, 57, 58, 60, 61 

of prostate, 64 
Shin, 47 

Shoulder, superficial anatomy of, 35 
Shoulder-joint, 35 
Sigmoid colon, 23, 25 
Sinus, froiital, 2 

lateral, 4, 10, 12 

rectales, 65 

superior longitudinal, 3, 5 
Soft palate, 16, 32 
Sole, 49 

Soleus muscle, 47 
Space, crico-thyroid, 16 

intercostal, 19, 21, 22, 28 

thyro-hyoid, 16 
Spermatic artery, 54, 56, 60 

cord, 43, 51. 54, 56 

fascia, 51, 56, 60 
Sphincter muscles of anus, 62, 63, 64, 65 
Spinal accessory nerve, 18 

cord, 31, 34 

furrow, 27 

nerve-roots, 31, 32, 33 
Spine, iliac, posterior inferior, 43 

superior, 27, 42, 43 
anterior superior, 24, 34, 42, 43, 51, 
57, 61 

of ischium, 63, 65 

nasal, anterior, 13 

peroneal, 48 

pubic, 24, 43, 51, 57, 60 

of scapula, 28, 33 

suprameatal, 12 
Spines, vertebral, 20, 27, 28, 29, 30, 31, 42 
Spleen, 23, 29, 33, 34 



INDEX TO APPENDIX. 



75 



Splenic flexure, 23, 25, 34 
Stenseu's duct, 14, 15 
Stephanion, 7 
Sternal angle, 19 

furrow or groove, 19 
head of sterno-mastoul, 17 
Sterno-clavicular joint, iS, 22 
Sterno-mastoid muscle, 17 
Sternum, 19, 32, 33 
Stomach, 23, 25, 29, 33 
Styloid process of radius, 38, 39 

of third metacarpal bone, 39 
of ulna, 38 
Subclavian artery, 18, 22, 32 

vein, 18 
Subcostal aijgle, 19 
Sublingual gland, 15 
Submaxillary gland, 16 

region, 16 
Subpubic arch, 62, 66 
Sulcus, alveolo-lingual, 15 
palpebral, external, 14 
inferior, 14 
superior, 14 
palpebro-malar, 14 
Superciliary ridge, i, 3 
Superficial anatomy of abdomen, 22 
of ankle, 48 
of arm, 35 
of back, 27 
of chest, 19 
of elbow, 37 
of foot, 48 
of forearm, 38 
of hand, 39 

of head and neck, i, 16 
of hip, 42 
of knee, 45 
of leg, 47 
of limb, lower, 42 

upper, 35 
of perineum, 62 
of shoulder, 35 
of thigh, 43 
of trunk, 19 
of wrist, 39 
Supinator longus muscle, 35, 36, 37, 38, 39 
Supraclavicular fossa, 18 
Supracondylar ridges, 35, 37 
Suprahyoid region, 16 
Supramastoid crest, 11, 12, 13 
Suprameatal fossa, 12 
spine, 12 
triangle, 12, 13 
Supraorbital artery, 3 

foramen or notch, i, 14 
nerve, 3 
Suprarenal bodies, 23, 34 
Suprascapular vein, 18 
Supraspinatus muscle, 28 
Supiasternal notch, 17 
Supratroclilear nerve, 3 
Suture, fronto-malar, i, 7 
lambdoid, i 
masto-sijuamoKal, 12 
naso-froutal. 5 
parieto-mastoid, 5 
sagittal, I 
Sustentaculum tali, 48 
Sylvian line, 8 
point, 8, 9 
Sylvius, fissure of, 6, 8 



Table of levels of structures of trunk, 32 

Tail of pancreas, 23 

Tarsal articulation, transverse, 48 

bones, 48 

ligament, internal, 15 
Tarso-metatarsal articulations, 48 
Teeth, 15 

Tegmen tympani, 1 1 
Temporal artery, superficial, 3 

convolution, inferior, 1 1 

crest, I, 7, 9 

line, lower, i 

lobe of cerebrum, 7, 11 

muscle, I, 15 
Temporo-maxillary joint, 13 
Tendinous inscriptions, 24 
Tendo Achillis, 47 

palpebrarum, 15 
Tendon, conjoined, 51, 56, 60 
Tensor vaginaj femoris, 42 
Teres muscles, 35 
Testis, 54 

Thigh, suiierticnal anatomy of, 43 
Thenar eminence, 39 
Thoracic duct, arch of, 32 
Thyro-hyoid s[)ace, 16 
Thyroid arteries, 17 

body, 17 

cartilage, 16, 32 

veins, 18 
Tibia, 45, 46, 47, 48 
Tibial arteries, 47, 48, 49 

nerves, 47, 49 
Tibiales muscles, 47, 48, 49 
Tongue, 15, 32 
Tonsil, 16, 18 

pharyngeal, 16 
Topographical anaioniy, cranio-cerebral, 5 
of groin, 51 
of mastoid antrum, 10 
of perineum, 62 
Trachea, 16, 28, 32, 33 
Transversalis abdominis muscle, 51, 56 

fascia, 51, 56, 58, 60 
Transverse ligament, superficial, of hand, 41 

process of atlas, 17 

of sixth cervical vertebra, 1 7 

tarsal articulation, 48 
Transversus perinei muscle, 64 
Trapezium, 39 
Trapezius muscle, 28 
Triangle of neck, anterior, 17 
posterior, 18 

of Hesselbach, 55, 56 

of Scarpa, 43 

suprameatal, 12, 13 
Triangular fascia, 5 1 

ligament, 62, 63, 64, 65 

tendon of trapezius, 28 
Triceps muscle, 35, 37 
Trochanter, great, 42, 43 
Trochlear surface of femur, 46 
True perineuui, 62 
Trunk, levels of structures in, 32 

HUjierlicial anatomy of, 19, 
Tubercle, adductor, 45, 46 
carotid, 17 
marginal, 7 
of radius, 38 
of tibia, 46, 48 
Tuberosity of femur, 45, 46 
of fiftli mctataisal, 48, 49 



76 



INDEX TO APPENDIX. 



Tuberosity of ischium, 43, 62, 65 
of navicular bone, 48 
of oa calcis, 47, 48, 49 
of scaplioid, 39 
of tibia, 45, 46 

Tunica vaginalis, 54 

Turbinate bodies, 13, 16 
bone, inferior, 13, 16 

Tj'mpanum, attic of, 10 



Ulna, 38 

Ulnar artery, 38, 39 

nerve, 36, 39 

vein, 37, 38 
Umbilical region, 23 
Umbilicus, 23, 24, 28, 34 
Unciform bone, 39 

Upper limb, superficial anatomy of, 35 
Uraclius, 51 
Urethra, bulb of, 62 

membranous part of, 62, 64 
Urethral part of perineum, 62 
Uterus, 23, 66 

broad ligament of, 66 
U villa, 16 



Vagixal examination, 66 
Valves of Morgagni, 65 
Vas deferens, 51, 54, 65 
Vascular compartment, 58 
Vasti muscles, 44, 45 
Vein or Veins, azygos, 33 

basilic, 36, 37 

at bend of elbow, 37 

cephalic, 36, 37 

cervical, transverse, 18 

dorsal of penis, 64 

endocranial, 3 

epigastric, sirperficial, 24 

facial, 17 

femoral, 45, 57, 60 

frontal, 3 

iliac, external, 54, 57, 58, 60 

innominate, 22, 33 

intercostal, 22 



Vein or Veins — continued. 

jugular, anterior, 18 
external, 18 
internal, 17 

median, 37, 38 

median-basilic, 37 

median-cephalic, 37 

popliteal, 46 

pubic, 60 

radial, 37, 38 

ranine, 15, 17 

saphenous, external, 46, 47, 49 
internal, 43, 45, 46, 47, 49, 60 

of scalp, 3 

subclavian, 18 
. suprascapular, 18 

thyroid, 18 

ulnar, 37, 38 
Vena cava inferior, 27, 33, 34 

cava superior, 22, 33 

thoraco-epigastrica, 24 
Ventricles, lateral, 9 

of heart, 33 
Vermiform appendix, 23 
Vertebrae, cervical, 16, 27 

bodies of, 19, 23, 27, 32, 33, 34 

spines of, 20, 27, 28, 29, 30, 31, 42 
Vertebral artery, 5 
Vesiculffi seminales, 65 
Vessels. Sec Arteries, Veins. 
Viscera abdominal, 23, 24 

pelvic, examination of, 65 
Volar artery, superficial, 41 



Wall of abdomen, 23, 56 
Web of fingers, 40, 41 
Wharton, duct of, 15 
Winslow, foramen of, 34 
Wrist, superficial anatomy of, 39 



Xiphisternal articulation, 19, 24, 25. 33 



Zygoma, i 
Zygomatic arch, 7 



THE END. 



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