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' fW'^'Tj)R^\T'''''''l^W»lP!Wwpp?Pf>W'^^ 
 
 SURFACE ANATOMY AND LANDMARKS 
 
V, 
 
 m '''' 
 
 % 
 
A HANDBOOK 
 
 OF 
 
 SURFACE ANATOMY 
 
 AND 
 
 LANDMARKS 
 
 ♦ ,' 
 
 P^-^ 
 
 BY 
 
 BERTRAM C?^Af'^^INDLE, D.Sc, M.D., 
 
 M.A. (DuBL.). 
 
 PROFESSOR OF ANATOMY IN MASON COLLEQE, BIRMINGHAM ; SOMETIME 
 EXAMINER IN ANATOMY IN THE UNIVERSITIES OF CAMBRIDGE, 
 ABERDEEN AND DURHAM 
 
 SECOND EDITION 
 
 A 
 
 .-0 
 
 REVISED AND ENLARGED IN COLLABORATION WITH 
 
 T: manners-smith, M.A. (Cantab.), m.r.c.s. 
 
 LECTURER ON OSTEOLOGY AND SENIOR DEMONSTRATOR OF ANATOMY, MASON 
 
 COLLEGE, BIRMINGHAM 
 
 LONDON 
 H. K. LEWIS ^nS GOW ER STREET, W.C. 
 
 MEDICAL FACULTY, 
 , McGlLL^ 
 
1 1 
 
 PRINTED BY 
 
 H. K. LEWIS, 130 GOWBR STREET, 
 
 LONDON, W.C. 
 
 // 
 
 I f 
 
 mmmiffmym'msWi 
 
TO 
 
 ALEXANDER MACALISTER, 
 
 M.D„ D.Sc, M.A., F.R.S., F.S.A. 
 
 PROFESSOR OF ANATOMY IN THE UNIVERSITY OF CAMBRIDGE. 
 
//, 
 
 I ': \i 
 
 y/ 
 
 1) 
 
 \ 
 
 'J«s^^T«W«W»««-^'^? « ■"^*-1'#'*!i»i«Biap*^^ 
 
PEEFACE TO SECOND EDITION. 
 
 This second edition has been carefully revised and 
 several new figures have been added. A sense of 
 importance of the relations of the brain to the cranium 
 and scalp has led us to bestow especial attention on 
 this section, which has been largely re-written. 
 
 / 
 
 Mason College, Birmingham. 
 June 30th, 1896. 
 
 B. C. A. W 
 T. M-S. 
 
■.-If: 
 
 M 
 
 V 
 
 
 V ' • 'ii 
 
 ■1 1/ 
 
 wvrwf P'f r gyj ti'g • ^ ^ra ri* 
 
 '^mfm-^io. 
 
 yyHHI 
 
PREFACE TO FIEST EDITION. 
 
 This little book is not a surgical applied anatomy. 
 Had its author ever entertained any idea of writing 
 such a work, he would certainly have abandoned it, as 
 the ground is already occupied by Mr. Treves* excellent 
 manual on that subject, to which he is indebted for 
 various hints. This book is intended for anatomical 
 students in their first and sc .ad years as a guide to 
 that important portion of the knowledge of the human 
 body which can be gained without the use of the scalpel 
 and forceps. Junior students will find it useful after 
 having first dissected a part of the body, to study the 
 relations of the various structures, as given herein, on a 
 fresh part, or still better, on the living subject. It is 
 scarcely possible to impress too strongly upon the 
 student desirous of obtaining a thorough practical 
 knowledge of his profession, the importance of taking 
 advantage of the opportunities afforded to him in the 
 wards of the hospital and elsewhere, of familiarising 
 himself with the surface markings, surgical and medical 
 landmarks, and relations to the exterior of the impor- 
 tant structures, in the living body. 
 
 Whilst not pretending to be a surgical anatomy pro- 
 perly so-called, certain surgical facts have from time to 
 time been mentioned, where the importance of the 
 anatomical point in question might be overlooked, with- 
 out reference to its practical bearing. But the writer 
 has preferred to err on the side of omission in this 
 
12 
 
 PREFACE. 
 
 matter, lest the student should be confused by the ir- 
 troduotion of too many unfamiliar facts. 
 
 Full directions have been given for the examination 
 of certain of the orifices and for the use of some of the 
 commoner surgical instruments, the author believing 
 that it is of great value to the student to acquire a 
 readiness and dexterity in handling them on the dead 
 body, and that such should be learnt concurrently with 
 the anatomical study of the parts in question. 
 
 It is difficult to exhibit anj'^ great originality in a 
 work such as this (indeed much of what might be called 
 original would inevitably be another name for incorrect), 
 since the facts which are contained herein have mostly 
 appeared in different manuals. To these it would be 
 impossible to refer here in detail, but to their authors, 
 whether their names are mentioned in the text or not, 
 the writer desires to express his full acknowledgments. 
 He has to thank his friend Dr. Crooke, Pathologist to 
 the General Hospital in this town, for help in some of 
 the details gained from the bodies in the post-mortem 
 room of that Institution. Several careful dissections 
 have been made in relation especially to the positions 
 of certain of the thoracic and abdominal viscera, in 
 order to ensure accuracy in the facts stated, and for 
 assistance in these he has to thank his former pupil 
 Mr. E. Teichelmann and his present pupils Messrs. 
 A. R. Green and S. W. Warneford. He has also to 
 thank his friend, Dr. Reid, for two blocks. 
 
 ii i\ ■ 
 
 I '^y'- 
 
 i> 
 
 T"!" 
 
 flFW 
 
 . .flUkliw.-vWvi .T.y, 
 
TABLE OF CONTENTS. 
 
 CHAPTER I. 
 
 '■-: - THE FACE. 
 
 .- ■ ♦■ 
 
 Sections : — i. The Fare o tk- u j « . ''"S^" 
 
 ne tace. 2. The Eye and Appendages. 3. The 
 
 Nose. 4. The Ear. 5. The Mouth 
 
 \ 
 
 1-26 
 
 CHAPTER II. 
 
 THE SCALP. 
 
 Sections 
 
 I. The Scalp. 2. Reiation to Bony Vault. 3. Rda- 
 tion to Membranes of Brain and their Vessels. 4. Fon- 
 
 tanelles. 5- Relation of Cranium to Brain. 6. Relation of 
 Scalp to Biain . 
 
 27.41 
 
 ' CHAPTER HI. 
 THE NECK. 
 Sections:-!, The Middle Line of the Neck. 2. Parts near 
 
 Anterior Border of Sterno-Mastoid. 3. Structures Posterior 
 to Sterno-Mastoid . 
 
 43-51 
 
14 
 
 CONTENTS. 
 
 v.. 
 
 CHAPTER IV. 
 
 THE THORAX. 
 
 Pages 
 
 Sections: — i. Bony Points. 2. Soft Parts. 3. Relations of 
 Lungs to Thoracic Wall. 4. Relations of Heart to Thoracic 
 Wall. 5. Relations of Vessels, &c., to Thoracic Wall . 5264 
 
 ■ .y> 
 
 M 
 
 CHAPTER V. 
 
 THE ABDOMEN. 
 
 Sections: — i. Bony Prominences. 2. Skin Markings. 3. Rela- ' 
 tions of Viscera to the Abdominal Wall. 4. Relation of 
 Vessels to the Abdominal Wall ' 65-74 
 
 // 
 
 CHAPTER VI. 
 
 THE PERINEUM AND GENITALIA. 
 
 Sections:— I. The Male. 2. The Female 
 
 75-82 
 
 CHAPTER VII. 
 " THE BACK. 
 
 ''■■■•■ ' ■ ■ '-' • V 
 
 Spinal Cord and Nerves. Kidneys. Colon. Relations of Vis- 
 cera, &c., to Vertebral Column 83-89 
 
 » \ 
 
 ri 
 
 i> 
 
CONTENTS. 
 
 15 
 
 CHAPTER VIII. 
 
 THE UPPER EXTREMITY. 
 
 Sections:— I. Shoulder and Axilla. 2. Arm and Elbow. 3. Fore- 
 arm and Wrist. 4. Hand 
 
 Pages 
 go-ii2 
 
 . CHAPTER IX. 
 
 THE LOWER EXTREMITY. 
 
 Sections :-i. Buttock. 2. Thigh. 3. Knee. 4. Popliteal Spa 
 5. Leg. 6. Ankle. 7. Foot 
 
 • • 
 
 • • 
 
 ce. 
 • "3-137 
 
 Index 
 
 139-143 
 
 l^^i 
 
*\ 
 
 V 
 
 LIST OF FIGURES. 
 
 FIG. 
 I. 
 
 2. 
 
 3- 
 4- 
 5- 
 6. 
 
 7- 
 8. 
 
 9- 
 
 lO. 
 
 II. 
 
 12. 
 
 13- 
 14. 
 
 16. 
 
 17- 
 
 Nervous Supply of Face and Scalp, &c. 
 
 Diagram of Cranium, showing Base Line of Brain, &c. 
 
 Diagram of Cranium, showing Lateral Sinus, &c. . fac\ 
 
 Diagram of Cranium, showing Fissures ' . . . fac 
 
 Relations of Chief Fissures to Scalp .... 
 
 Relations of Fissures and Convolutions to Scalp 
 
 Relations of Lungs to Wall of Thorax 
 
 Relations of Heart and Great Vessels to Wall of Thorax 
 
 Diagram of Anterior Abdominal Wall ... 
 
 Anterior Aspect of Abdomen fac 
 
 Posterior Aspect of Abdomen fac 
 
 Cutaneous Areas — Upper Extremity, Anterior Aspect 
 Cutaneous Areas — Upper Extremity, Posterior Aspect * 
 
 Diagram of Side of Buttock fact 
 
 Bony Prominences of Foot 
 
 Cutaneous Areas — Lower Extremity, Anterior Aspect 
 Cutaneous Areas — Lower Extremity, Posterior Aspect 
 
 PAGE 
 
 8 
 
 28 
 
 ng 32 
 
 >»^32 
 
 35 
 
 39 
 
 57 
 61 
 
 67 
 ng^o 
 ng 86 
 106 
 107 
 \g 114 
 132 
 134 
 135 
 
 'i2^y 
 
 \ 
 
 W 
 
A HANDBOOK 
 
 Of 
 
 SURFACE ANATOMY 
 
 I I 
 
 '. • Chapter I. 
 
 THE FACE. 
 
 I. The Face. 
 
 Bony points. — The forehead presents on either side 
 two elevations, the frontal eminences, varying consider- 
 ably in the amount of their development in different in- 
 dividuals. Below and separated from these by a shal- 
 low groove is a supra-ciliary ridge on each side. These 
 ridges which also vary greatly in size may, but need 
 not necessarily, owe their prominence to large cavities 
 in the substance of the bone — the frontal sinuses. This 
 is a fact of surgical importance, since a fracture of this 
 ridge apparently deep and serious may not open up the 
 cranial cavity, but only that of the sinus. 
 
 Like other air cavities in connection with the cranial 
 and facial bones, these sinuses are small or non-existent 
 in the young child, developing gradually in the course 
 of growth. Between the supra-ciliary ridges is a flat 
 
 r 
 
 B5iir.;;> 
 
^ THE FACE. 
 
 smooth surface named the glabella, from which certain 
 cranial measurements are made. 
 
 Below the supra-ciliary ridges are the margins of the 
 orbit, or supra-orbital ridges as they are sometimes 
 called. 
 
 Each ridge is bounded at either extremity by a 
 strong prominent angle, the outer of which is by far 
 the better marked ; these angles are the external and 
 internal angular processes. The former limits ante- 
 riorly the temporal fossa, the temporal muscle which 
 it contains, and the temporal ridge with its attached 
 fascia. ,, 
 
 By pushing up the skin covering the eyebrows, the 
 supra-orbital notch may generally be felt at about the 
 junction of the middle and internal thirds of the supra- 
 orbital ridge. This notch is sometimes replaced by a 
 foramen, which may be situated somewhat deeply in 
 the cavity of the orbit ; its discovery is then more diffi- 
 cult, but it may be found by deep pressure. Through 
 this notch or foramen pass the supra-orbital nerve and 
 artery. The former, a branch of the ophthalmic division 
 of the fifth nerve, is one of the common seats of facial 
 neuralgia, for which complaint it may be necessary that 
 it should be stretched or divided. Two other spots, at 
 which branches of the fifth nerve emerge from bony 
 canals are of similar importance. The infra-orbital 
 branch of the superior maxillary division emerges from 
 the infra-orbital canal beneath the prominent ridge 
 which forms the lower margin of the orbit. The infra- 
 orbital foramen whose aperture looks inwards, is covered 
 
 / 
 
 ^^ 
 
THE FACE. 
 
 I I 
 
 by muscles and cannot generally be felt from the sur- 
 face. The same remark applies to the mental foramen 
 situated in the inferior maxilla. Through this foramen 
 which also looks inwards the mental branch of the in- 
 ferior maxillary division of the fifth nerve escapes. The 
 position of these two last mentioned foramina may be 
 ascertained by drawing a line from the supra-orbital 
 notch downwards and outwards so as to pass between 
 both pairs of bicuspid teeth {vide fig. i). 
 
 This line will cross the infra-orbital foramen about a 
 quarter of an inch below the margin of the orbit. The 
 position of the mental foramen varies according to the 
 age of the individual examined. In the child at puberty 
 it is placed rather nearer to the lower than to the upper 
 border of the jaw. In the adult it lies nearly midway 
 between the two borders and about a quarter of an inch 
 below the fold of mucous membrane passing from the 
 jaw to the cheek inside the mouth. In old edentulous 
 persons, owing to the disappearance of the alveoli from 
 atrophy, the foramen is placed close to the upper mar- 
 gin of the jaw. 
 
 In the middle line of the face below the glabella the 
 points to be noticed are the nasal bones with the carti- 
 lages attached to them, the nasal spine of the superior 
 maxilla which can be felt between the openings of the 
 nostrils, and the ridge at the centre of the inferior 
 maxilla which marks the symphysis menti. 
 
 Following outwards, on either side, the lower margin 
 of the orbit, the zygoma is reached and may be traced 
 in its entire extent. The space between it and the 
 
 B 9 
 
V 
 
 4 THE FACE. 
 
 cranial bones cannot be estimated in the undissected 
 state, partly on account of the muscles which lie therein, 
 and partly because of the firm and tense attachment of 
 the temporal fascia above and of that of the parotid 
 below. By passing the finger along the lower border 
 of the zygoma, its tubercle may be distinguished im- 
 mediately in front of the outer part of the glenoid fossa 
 and the head of the inferior maxilla, the movements of 
 which latter can be distinctly felt, and, in a moderately 
 thin person, seen. , 
 
 When the lower jaw is protruded its head will of 
 course be brought nearer to the tubercle ; when a dislo- 
 cation occurs it is carried still further forward and 
 passes over the tubercle into the zygomatic fossa. Be- 
 hind the head of the lower jaw the posterior root of the 
 zygoma (supra-mastoid crest) may be felt passing above 
 the external auditory meatus. In the region below the 
 orbit the canine eminence may be distinguished, though 
 not so clearly as from within the mouth. On its inner 
 side is the incisive fossa, on its outer, but at a higher 
 level, the canine. 
 
 The greater portion of the inferior maxilla may be 
 defined by manipulation, the symphysis, body, posterior 
 portion of the ramus, head, and neck being all clearly 
 distinguishable. The coronoid process almost to its 
 apex may be felt by pressing the finger under the 
 zygoma and protruding and depressing the jaw. 
 
 Skin, &c. — The skin over the forehead is fairly 
 smooth and moveable, characteristics which it main- 
 tains as it covers the nose until it reaches the cartila- 
 
 t^ 
 
THE FACE. 
 
 ginous portion of that organ. Here its attachment 
 becomes much firmer, a fact which explains the great 
 pains caused by the small boils which form not unfre- 
 quently in the sebaceous follicles here very abundant. 
 In the remainder of the face the attachments of the 
 skin are loose save over the chin where its connections 
 with the deeper parts are somewhat greater. It is this 
 laxity of attachment which permits of the great mobility 
 of the skin under the influence of the numerous muscles 
 connected with it and engaged in the production of the 
 ' various expressions of the countenance. 
 
 The depth of the hollow under the zygoma varies 
 greatly in different individuals, presenting all varieties 
 from the plump rounded contour of the young girl to 
 the hollow che- k of the emaciated sufferer from some 
 wasting disease. This difference is due to the presence 
 or absence of a pad of fat, the " buccal pellet" which 
 lies beneath the zygoma and in front of the masseter 
 under both of which structures it sends prolongations. 
 In the adult this portion of adipose tissue is one of the 
 first to disappear in wasting diseases. 
 
 In the child the pads of fat in the cheeks are much 
 larger than in the adult, a fact to which is partly owing 
 the comparative squareness of the infantile face. Ac- 
 cording to Symington, besides the subcutaneous fat 
 there exists a mass " in the form of one or more lobules 
 surrounded by a clearly defined capsule, so that it can 
 be very easily shelled out." These masses have been 
 called *' sucking-cushions " from the assistance which 
 they are supposed to lend the infant in performing that 
 function. 
 
V 
 
 6 THE FACE. 
 
 These cushions diminish in the process of develop- 
 ment until they come to be represented by the pellets- 
 first alluded to. According to Ranke they are only 
 slightly decreased in size in emaciated children in 
 whom the subcutaneous fat is almost entirely absent. 
 
 The skin of the face may be furrowed by various- 
 lines, to some of which, when strongly marked, dia- 
 gnostic importance has been attached. These lines- 
 individually and collectively differ greatly in the extent 
 of their development in different persons. The most 
 important of these furrows or wrinkles are: — i. The 
 transverse rugae of the forehead caused by the action of 
 the occipi to-frontal muscle. 2. The oculo-frontal rugae 
 passing vertically between the eyebrows to the root of 
 the nose and due to the corrugator supercillii. 3. The 
 linea oculo-zygomatica or line of Jadelot extending 
 from the internal angle of the eye downwards and 
 outwards to cross the face below the malar bone. This- 
 furrow is sometimes of a noticeably darker colour than' 
 the skin around it. 4. The naso-labial fold which 
 commences between the side of the nose and the cheek, 
 and passing obliquely downwards and outwards ter- 
 minates near the commissure of the lips. It is almost 
 always well-marked in old people. Lastly, so far as 
 skin markings are concerned, the filtrum, a groove 
 leading from the septum of the nose to the most pro- 
 minent point of the upper lip, may be mentioned. 
 
 Blood-vessels. — The facial artery appears upon the 
 face by crossing the inferior maxilla just in front of the 
 masseter, where its pulsations may be felt and its flow; 
 
 . i 
 
 !\ 
 
THE FACE. 
 
 checked by compression against the bone. It may 
 again be felt in its tortuous course near the commissure 
 of the lips, where it gives off the coronary artery of 
 either lip, which can be distinguished running beneath 
 the mucous membrane. Two other branches may also 
 be made out, the lateralis nasi, a short distance above 
 and external to the ala of the nose, and the angular 
 artery, whose pulsations may be felt at the side of the 
 root of the nose. This vessel and the anterior branch 
 of the superficial temporal are of service to the 
 anaesthetist, since they often enable him to feel his 
 patient's pulse without incommoding the operator. 
 
 The supra-orbital artery emerges from the notch or 
 foramen with the nerve of the same name, and r^asses 
 toward the vertex of the head. Nearer to the inner 
 angle of the orbit, the frontal artery escapes; this 
 vessel is included in the root of the flap in the Indian 
 operatic-i for the restoration of a partly destroyed nose^ 
 and affords it nutriment. 
 
 The transverse facial artery, a branch of the super- 
 ficial temporal, cannot be felt save when exceptionally 
 large, but its position may be found by remembering 
 that it crosses the face immediately above Steno's duct,, 
 to which attention will shortly be drawn. 
 
 The pulsations of the trunk of the superficial tem- 
 poral artery may be felt where the vessel crosses the 
 zygoma immediately in front of the external auditory 
 meatus. It divides into its anterior and posterior 
 divisions two inches above the zygoma. Its anterior 
 branch lies rather more than a finger's breadth behind 
 
V 
 
 I 
 
 s 
 
 THE FACE. 
 
 the external angular process, {vide fig. i). This vessel 
 is very liable to degeneration in old persons, in whom 
 its tortuous tnmk may be seen standing prominently 
 out. Its pulsations also are very visible in some in- 
 dividuals, notably in those affected with incompetence 
 
 Fig. I. — Nervous Supply, etc., of Face and Scalp. 
 
 I. II. III. Regions supplied by the ophthalmic, superior and inferior maxillary 
 divisions of the fifth nerve. C. Cervical nerves. 
 
 In this and succeeding similar figures it must, of course, be understood that 
 the regions are not sharply marked off as would appear from the diagrammatic 
 representation. 
 
 I, 2, 3. Points of exit of the supra- and infra-orbital and mental nerves. 4. Line 
 of Steno's duct. 5. Point where facial artery cr sses inferior maxilla. 6. Lateralis 
 nasi. 7. Angu' ir arteries. 8. Superficial temporal, g. Anterior ; and 10, pos- 
 terior branches II. Occipital artery. 
 
 of the aor. ; valves. It is the vessel which was divided 
 in the now eldom performed operation of arteriotomy. 
 The poster or branch lies about two inches behind the 
 anterior, under cover of the hair. 
 
 •IV 
 
THE FACE, 
 
 The veins of the face are not of much importance so 
 far as their surface relations are concerned. The vein 
 which runs with the angular artery, a vessel of great 
 importance from its intra-cranial ccmections, through 
 the ophthalmic vein, is not unfrequently to be seen, 
 and may be very distinct, especially in children. Some 
 individuals possess an exceptionally large frontal vein 
 on one side or the other, which may be seen standing 
 prominently out during laughter, &c. ; this vessel runs 
 vertically down near the centre of the forehead to join 
 the veins alluded to above. The facial vein pursues a 
 straight course external to the artery from the inner 
 angle of the orbit to the antero-inferior corner of the 
 masseter. 
 
 Ner tf^es. — The positions of the three branches of the 
 fifth nerve have already been indicated in the description 
 of their foramina of exit. The areas which they supply 
 will be seen by a reference to the diagram ; in con- 
 nection with which it should be noted that the supply 
 of the upper part of the region belonging to the inferior 
 maxillary division is gained from the auriculo-temporal 
 nerve, which emerges from under cover of the parotid 
 gland and crosses the zygoma near the superficial tem- 
 poral artery. The facial, the motor nerve of the face, 
 passes out of the substance of the parotid below the 
 duct of the latter, some of its branches, notably the 
 infra-oibital, running along the inferior border of that 
 structure. The remainder ramify over the face in lines 
 more or less divergent from that of the duct. The line 
 of the nerve in the parotid may be indicated by drawing 
 
10 
 
 THE FACE. 
 
 ill 
 
 '■ / 
 
 a line forwards and slightly downwards from the an- 
 terior border of the mastoid process, where it meets- 
 the ear. 
 
 Other structures. — The parotid gland occupies a 
 space fairly well defined on each side, save its ante- 
 rior border, which lies for a variable extent upon the 
 masseter, and from which projects its only superficial 
 process, the socia parotidis, a portion which varies con- 
 siderably in size. The body of the gland is limited 
 above by the zygoma. Its inferior border may be 
 marked out by a line drawn from the angle of the jaw 
 to the mastoid process, whilst its posterior touches the 
 external auditory meatus, the mastoid process and the 
 sterno-mastoid muscle. From the anterior border 
 emerges Steno's duct, which lies on the masseter be- 
 low the socia parotidis. The position of the duct may 
 be indicated by drawing a line from, the point where the 
 lobule joins the cartilage of the ear to a point midway 
 between the nostrils and the red margin of the lips. 
 About two inches of this line measured from the an- 
 terior border of the gland will correspond to the duct 
 itself {vide fig. i). 
 
 The student can readily ascertain its position in 
 his own face by firmly clenching the jaws, when the 
 masseter muscle will be tense and firmly contracted. 
 By manipulating the central portion of the muscle with 
 the points of the fingers the duct will easily be dis- 
 tinguished ; it will be recognised by its whip-cord like 
 feel and by the flow of saliva into the mouth which 
 generally follows its stimulation. 
 
 I > 
 
 h 
 
THE EYE AND ITS APPENDAGES. 
 
 II 
 
 Before passing to the cavities associated with the 
 face, it may be well to call the student's attention to 
 the very common asymmetry of the two sides in one 
 or more particulars. Hasse, from a very careful exam- 
 ination of the face of the celebrated Venus of Milo, 
 found that whilst the portion lying below the nose was 
 comparatively symmetrical, the upper part presented 
 various deviations. Thus, the nose deviates to the left, 
 the left ear stands higher than the right, the left half of 
 the skull is broader than the right, and the left eye is 
 higher and nearer the middle line than the right. He 
 was led from this observation to examine carefully vari- 
 ous skulls and heads of living individuals, and, as a 
 result, states that whilst symmetry of the lower half of 
 the face is the rule, deviations such as those occurring 
 in the statue, are commonly to be met with in the upper 
 half. 
 
 !'■ 
 
 i 
 
 Hi 
 
 il 
 
 II. The Eye and its Appendages. 
 
 Orbit. — The bony margin of th? orbit has been 
 already alluded to, and it need therefore only here be 
 mentioned that for protective purposes the outer and 
 upper portions are stronger and more prominent than 
 the inner and lower, and especially the former. By 
 tolerably deep pressure in the internal and superior 
 angle the little projection to which the pulley of the 
 superior oblique muscle is attached, may be distin- 
 guished. The roof of the orbit as well as part of its 
 
 1^ 
 
 ■I 
 
 I'M 
 
 
12 
 
 THE EYE AND ITS APPENDAGES. 
 
 
 floor is excessively thin, the former in old persons being \ 
 sometimes no thicker than writing paper ; it may there- 
 fore be easily fractured by a comparatively insignificant 
 implement. 
 
 Eyelids, 6cc. — The skin covering the upper eyelid 
 is thin and delicate, loosely attached to the subjacent 
 tissues, fringed at its margin with two or more rows of ' 
 hairs, the eye-lashes, and marked with several cres- 
 centic furrows, convex upwards. Incisions in this part 
 should be made parallel to these lines. The lax attach- 
 ment of the skin renders the accumulation of fluid in 
 the subcutaneous areolar tissue an easy matter, the 
 large eff'usion of blood in the common black eye being 
 thus accounted for. This is also a position often 
 selected for the first appearance of puffiness at the com- 
 mencement of renal anasarca or dropsy. 
 
 By pinching up the eyelid in the subject the student 
 will feel the so-called tarsal cartilage, to the inner end 
 of which is attached the palpebral ligament or tendo 
 oculi afiixed at its other end to the margin of the orbit. 
 To find this it is only necessary to close the eyelids 
 and draw them outwards when the ligament will be 
 made tense and appear under the skin as a transverse 
 ridge. This ridge is an important surgical landmark, 
 as it crosses the lachrymal sac at the junction of its 
 upper and middle thirds, and thus serves as a guide to 
 the surgeon in opening the latter for the evacuation of 
 an abscess. The student should place h's finger upon 
 his own tendo, and open and close the eyelids several 
 iimes, in order to note that each time the latter occurs 
 
 t \ 
 
 .'I 
 
THE EYE AND ITS APPENDAGES. 
 
 13- 
 
 the ligament is made tense. A sucking action on the 
 part of the subjacent sac is thus produced, by means of 
 which the tears are drawn into its interior through the 
 canaliculi. , 
 
 Having studied this ligament the student may next 
 practice eversion of the eyelid, one of those very minor 
 operations on the deft performance of which so much of 
 the comfort of a patient depends. Mr. Nettleship 
 thus describes it : — " The patient looks down, a probe 
 is laid along the lid above the upper edge of the 
 " cartilage," the lashes, or edge of the lid, are then 
 seized by a finger and thumb of the other hand, and 
 turned up over the probe which is simultaneously 
 pushed down. After a little practice the probe can be 
 dispensed with, and the lid everted by the forefinger 
 and thumb of one hand alone, one serving to fix and 
 depress the lid, the other to turn it upwards." 
 
 When the lid is everted the roots of the hairs will be 
 seen under the conjunctiva as well as the Meibomian 
 follicles which appear like rows of yellow granules. It 
 is in these or in connection with the hair follicles that 
 the common styes are formed. The transition of epi- 
 dermis into conjunctiva at the margin of the lid should 
 be noticed, as also the fornix or cul-de-sac formed by 
 the passage of the palpebral conjunctiva on to the eye. 
 A similar but shallower depression exists in connection 
 with the lower lid. The lid may now be restored to its 
 normal position. At the inner angle or canthus will 
 be noticed a recess bounded by two prominences, the 
 papillx lachrymales, on each of which opens the minute 
 
 
 i 
 
 ;■* 
 
H 
 
 THE EYE AND ITS APPENDAGES. 
 
 !1 
 
 
 - lit 
 
 aperture of the punctum lachrymale, the loiver being a 
 little larger and more external. Through these the 
 tears pass by the canaliculi into the lachrymal sac, and 
 thus into the inferior meatus of the nose by the nasal 
 duct. The canaliculi may have to be slit open and a 
 probe passed into this duct, which is a little more than 
 half an inch in length, and is directed downwards and 
 slightly backwards and outwards. Two other struc- 
 tures are to be noticed in connection with the above 
 mentioned recess, the plica semilunaris, a fold of con- 
 junctiva representing the membrana nictitans or third 
 eyelid of birds, and the caruncula lachrymalis, a red- 
 dish eminence covered with a few fine hairs and con- 
 taining in its interior specialised sweat glands and 
 sebaceous glands. 
 
 Eyeball. — A description of the eyeball is outside the 
 scope of this book, but the attention of the student may 
 be drawn to the fact that neither the cornea nor the 
 pupil are as a rule mathematically circular, the former 
 having a tendency to be broader transversely. The 
 pupil is situated very slightly to the inner side of the 
 iris. The student should take the opportunity of ex- 
 amining a number of healthy eyes in order to form a 
 standard in his own mind of the normal tension of the 
 globe. With respect to this procedure, Nettleship 
 states: — " The patient looks steadily down and gently 
 closes the eyelids ; the observer then makes light pres- 
 sure on the globe through the upper lid, alternately 
 with a finger of each hand as in trying for fluctuation 
 but much more delicately. The finger-tips are placed 
 
 ;; 
 
 l\ 
 
 r\ 
 
THE NOSE. 
 
 15 
 
 very near together, and as far back over the sclerotic 
 as possible, not over the cornea. The pressure must 
 be gentle, and be directed vertically downwards, not 
 .backwards. It is best for each observer to keep to one 
 pair of fingers, not to use the index at one time and 
 the middle finger at another. Patient and observer 
 should always be in the same relative position, and it 
 is best for both to stand and face one another. Always 
 compare the tension of the two eyes. Be sure that the 
 eye does not roll upwards during examination, for if 
 this occur a wrong estimate of the tension may be 
 formed. Some test both eyes at once with two fingers 
 of each hand." The tension may be increased so that 
 indentation of the globe is difficult or impossible, or on 
 the other hand it may be decreased. For the scale 
 employed in registering these changes, and the condi- 
 tions in which they occur, the student is referred to 
 special text-books on the eye. 
 
 ;:ki I 
 
 III. The Nose. 
 
 There is not very much to be made out from an 
 anterior inspection of this organ unaided by instru- 
 ments, and the investigation of its posterior part may 
 be more conveniently deferred to be considered with 
 the cavity of the mouth. It should first be noticed 
 that the apertures of the nostrils are placed at a lower 
 level than the floor of the inferior meatus ; in order 
 therefore that this may be seen or that a speculum 
 
91 
 ill 
 
 
 .ii;i 
 
 !ii 
 
 V 
 
 i6 
 
 THE NOSE. 
 
 may be introduced, it will be necessary to raise the tip 
 of the nose, the head being thrown back. The mobility 
 due to the cartilaginous basis of the anterior part of the 
 nose, allows of the tip bjing raised and of the dilatation 
 of either nostril. ' ' 
 
 The apertures of the nostrils are generally more or 
 less compressed laterally in the adult, circular in chil- 
 dren, and separated from one another by the thickened 
 lower margin of the septum — the columna nasi. On 
 looking into either, the vestibule or dilated anterior 
 part is seen containing coarse hairs— the vibrissae. 
 The anterior extremity of the inferior turbinated bone 
 can be seen and felt ; in the undissected state only 
 about one-twentieth of this consists of bone, the re- 
 mainder consisting of the erectile tissue of Voltolini 
 and others. The other turbinated bones cannot be 
 seen without the aid of a speculum, which brings into 
 view the middle one ; but it is well to remember that 
 they encroach largely upon the space in the posterior 
 part of the organ. In inserting forceps, therefore, they 
 should be so introduced that the blades may be opened 
 upwards and downwards, not laterally. The septum 
 in a portion of its extent may be seen, the part visible 
 being chiefly cartilaginous ; it is often deflected to one 
 side or the other, or sometimes first to one side and 
 then to the other, the so-called sinous deflection. In 
 76*9 per cent, of a large number of skulls examined 
 by Morell Mackenzie, the bony septum was more or 
 less asymmetrical. It is placed in the median line 
 until the seventh year (Zuckerkandl and Symington),. 
 
 f\ 
 
THE NOSE. 
 
 17 
 
 and the subsequent deflection which is most often to 
 the left is attributed by some writers to the habit of 
 constantly blowing the nose with the same hand. It 
 may be so great as to cause the introduction of instru- 
 ments to be difficult or even impossible. 
 
 In connection with the examination of the nose from 
 the front, the student should practise the operation 
 of introducing the Eustachian catheter. Should the 
 actual instrument not be at hand, one may be im- 
 provised from a probe or even a piece of wire of 
 suitable size with a rounded end, either being bent at 
 an angle of 60° a short distance from its extremity. 
 The operator will be much assisted by practising at 
 hrst upon a head which has been divided by a mesial 
 antero-posterior section, as he will then be able to 
 watch the point of his instrument as he endeavours to 
 introduce it into the opening of the Eustachian tube. 
 Should such a section be unattainable for this purpose, 
 the position of parts should at least be exairiined in 
 a specimen before the operation is attempted. The 
 directions for performing the operation are thus given 
 by Pritchard : — " The curved end is introduced into 
 one nostril, keeping the beak close along the angle 
 formed by the septum and the floor. By this means 
 the surgeon will avoid getting into the middle meatus, 
 and so finding himself in difficulty further on. When 
 the catheter has passed the posterior nares, it will soon 
 encounter the back of the pharynx, and this will be 
 easily recognised by its tension, for it has been very 
 aptly described as feeling like the outstretched palm 
 
 ) i 
 
V. 
 
 )l< 
 
 i8 
 
 THE EAP. 
 
 of the hand. The catheter should then be withdrawn' 
 about half an inch, and the point turned almost directly 
 outwards, after which, on the catheter being again 
 slightly pushed in, the point will enter the Eustachian 
 tube." 
 
 When the catheter is engaged in the Eustachian 
 aperture its beak will be found to point towards the 
 outer angle of the orbit on the same side. 
 
 i'i 
 
 IV. The Ear. ■ 
 
 The external ear or pinna is formed throughout the 
 greater part of its extent of a cartilaginous substratum, 
 to which, as in the case of the cartilaginous part of the 
 nose, the skin is very closely adherent. The dependent 
 portion, the lobule, alone contains no cartilage, and 
 consists mainly of fat, the amount of its connection with 
 the side of the neck being variable. The plate of car- 
 tilage occupying the remainder of the pinna is folded 
 so as to present several elevations and depressions, to 
 which designations have been assigned. Surrounding 
 the entrance to the meatus is the deepest hollow, the 
 concha, which is prolonged downwards and forwards 
 into a notch, bounded on either side by a prominence. 
 The anterior of these, which bears hairs, is called the 
 tragus, the posterior the anti-tragus. Superior and in- 
 ternal to the former the helix commences and passes 
 round the outer border of the ear as a well-marked fold, 
 which terminates at the posterior part of the lobule. 
 
 \v 
 
THE EAR. 
 
 19 
 
 It is sometimes possessed of a pointed process placed on 
 its inner bord t, and at its upper and posterior part, 
 which was first noticed by Woolner, the sculptor, and 
 to which attention was directed by Darwin in his 
 Expression of the Emotions. 
 
 Commencing at the anti-tragus is another elevation, 
 the anti-helix, which passing round the concha, bifur- 
 cates to enclose a triangular depression — the fossa tri- 
 angularis or fossa of the anti-helix. Between the two 
 elevations is a shallow groove — the fossa scaphoidea or 
 fossa of the helix. The outer aperture of the external 
 auditory meatus is largest from above downwards ; it 
 possesses a number of hairs, and under the skin are 
 , placed the ceruminous or wax-producing glands. 
 
 The canal of the meatus passes forwards in its entire 
 course. Its outer portion also passes upwards and its 
 inner downwards. In order to obtain a view of the 
 meatus and membrana tympani, either with or without 
 the aid of a speculum, it is necessary to straighten the 
 canal as far as possible. This is done by taking hold 
 of the pinna above and pulling it upwards and slightly 
 backwards and outwards. 
 
 Bony points in connection with the ear. — Be- 
 hind the ear is the mastoid process, which commences 
 to become prominent about the second year. Its 
 interior is occupied by air spaces, divided into two 
 groups, viz.: — {a). The vertical which commence to 
 develop about the time of puberty, these have a close 
 relationship internally to the sigmoid sinus, and cere- 
 bellum, (ft). The mastoid antrum, which is present at 
 
 t 
 
 1:' 
 
 
 tul 
 
V. 
 
 'i|!s 
 
 <20 
 
 THE MOUTH. 
 
 birth, is horizontal in direction and communicates with 
 the tympanum on the one hand and with some of the 
 mastoid cells on the other. It is immediately subjacent 
 to the temporo-sphenoidal lobe, a thin bony plate, which 
 forms its roof, intervening between the two. The posi- 
 tion of the superior limit of the antrum is indicated on 
 the surface of the skull by the supra-mastoid crest. Its 
 inferior limit is a little below the upper border of the 
 external auditory meatus. The antrum may be reached 
 from the surface by perforating the skull at the base 
 of Macewen's supra-meatal triangle {see fig. 3). This is 
 bounded above by the supra-mastoid crest, below by 
 the posterior superior fourth of the external auditory 
 meatus and behind by a base line joining the two 
 dropped from the supra-mastoid crest on a level with 
 the posterior border of the external auditory meatus. 
 
 ',! I! 
 
 M t 
 
 ' ' V. The Mouth. 
 
 The cavity of the mouth may be divided into two 
 parts. One between the lips and cheeks and the teeth — 
 the vestibulum oris, and a second behind the teeth — the 
 cavum oris. Still further back behind the pillars of 
 the fauces is the upper part of the pharynx. In the / 
 vestibule there may be felt with the tip of the tongue 
 in one's own mouth or with the fingers in another per- 
 son's, a number of small granules under the mucous 
 membrane. These are mucous glands, which may, in 
 certain conditions, become chronically hypertrophied or * 
 
THE MOUTH. 
 
 21 
 
 otherwise diseased. On the inner side of the cheek the 
 aperture of the duct of Steno should be sought. This 
 opening, which is much smaller than the calibre of the 
 canal which it terminates, is placed opposite the second 
 upper molar tooth. 
 
 It may be found in the living subject by everting the 
 cheek and wiping the inner surface dry, when in a short 
 time the appearance of a drop of saliva will indicate the 
 opening. If the upper lip be everted a fold of mucous 
 membrane — the fraenum labii superioris, will be seen 
 passing from it to the gums. A finger should be passed 
 up between the cheek and the teeth and the coronoid 
 process felt from within the mouth. The spot above 
 the second bicuspid tooth, where the antrum is some- 
 times tapped, should also be noticed. Without pausing 
 to describe the teeth, an account of which must be 
 sought in the ordinary textbooks, we may pass to the 
 cavum oris situated behind them. The tongue with its 
 filiform and fungiform papillae is the first object for in- 
 spection ; a good idea of the distribution of the last 
 mentioned papillae will be gained by looking at them in 
 a patient suffering from scarlet fever. At the posterior 
 part will be seen the large circumvallate papillae, seven 
 to twelve in number, arranged in the form of a V, with 
 the apex directed backwards, and the foramen caecum 
 situated just behind. If the tongue be pulled well out 
 and to one side the student will see in front of the 
 anterior pillar of the fauces on the border of the tongue, 
 an area with a few. f "crally five, longitudinal folds — 
 the papilla foliata. 
 
 u 
 
 '1 
 ill 
 
V 
 
 22 
 
 THE MOUTH. 
 
 A finger should now be introduced gradually back- 
 wards in the middle line, and the various structures 
 nr^t with investigated. Immediately behind the centre 
 of the root of the tongue, a ridge of mucous membrane 
 will be felt passing to the epiglottis. This is the glosso- 
 epiglottic fold or fraenum epiglottidis, on each side of 
 which there is a shallow depression in which a foreign 
 body may lodge. Behind this fold is the epiglottis 
 itself, which may be distinctly felt and even seen in 
 some individuals if the tongue is pulled well out in the 
 middle line. Passing over the epiglottis the finger 
 reaches the ary-epiglottic folds of mucous membrane 
 with the entrance to the larynx between. On each side 
 will be felt the hyoid space, another favourite spot for 
 the lodgment of foreign bodies, and the great cornu of 
 the hyoid bone. 
 
 In the middle line the cricoid, as far down as its 
 lower border, can be made out, together with the com- 
 mencement of the oesophagus. As this spot is one of 
 the two narrowest parts of the gullet, insufficiently mas- 
 ticated lumps of meat and other bodies are liable to 
 lodge in it. The posterior wall of the pharynx over- 
 lying the vertebral column may be investigated in its 
 entire extent. In the course of these observations the 
 student should consider their ]>earing upon the passing 
 of an oesophageal tube or borgie, and in either case the 
 end of the instrument should be kept well against the 
 posterior wall in order to avoid any danger of its enter- 
 ing the larynx by mistake. 
 
 The tip of the tongue should now be turned upwards, 
 
 ■VI 
 
i' 
 
 THE MOUTH. 
 
 23 
 
 when the large ranine veins will be distinctly seen on 
 the under surface of the organ. Two fringes of fim- 
 briated mucous membrane which indicate the position 
 nf the more deeply seated ranine arteries, will also be 
 noticed. Passing from the tongue to the floor of the 
 mouth is a fold of mucous membrane, the fraenum 
 linguae, sometimes abnormally short, and tlien causing 
 the condition known as •' tongue-tie." On each side of 
 this a duct of Wharton opens on a papilla in the floor 
 of the mouth. If one forefinger be pres; ed upwards 
 and inwards from without, beneath the angle of the 
 jaw, and the other be placed in a corresponding position 
 under the tongue, the sub-maxillary gland will be felt 
 between the two under the floor of the mouth. A long 
 ridge of mucous membrane on either side of the floor 
 contains the sublingual gland, and indicates to a certain 
 extent the direction of Wharton's duct and the lingual 
 nerve. Upon this ridge open, by a number of aper- 
 tures, such of the ducts of the last mentioned gland 
 as do not join the Whartonian canal. Finally, so far 
 as this part is concerned, the attachment of the genio- 
 hyo-glossi muscles may be felt under the floor of the 
 mouth, immediately behind the symphysis of the lower 
 jaw. 
 
 The tongue being restored to its place, the student 
 should examine the hard palate, the shape of the arch 
 of which varies in different subjects. The mucous 
 membrane is very firmly adherent to the bones which 
 it covers ; under it on either side at the posterior part 
 may be felt the pulsations of the posterior palatine 
 
 nil 
 
 m 
 
 i:' 
 
24 
 
 THE MOUTH. 
 
 artery. The canal through which this vessel passes tO" 
 reach the palate is placed just internal to the last molar 
 tooth, and may be plugged for the arrest of haemor- 
 rhage. Carry the finger a little further back and the 
 point of the hamular process of the pterygoid plate, as 
 well as that structure itself, and the pterygoid fossa 
 may all be felt, together with the back of the antrum 
 and the external pterygoid plate behind the last molar. 
 The pterygo-maxillary ligament may be seen and felt 
 when the mouth is widely opened, extending from the 
 internal pterygoid plate to the lower jaw behind the 
 last molar, and separating the buccinator from the 
 superior constrictor. This ligament helps us to find 
 the position of the gustatory nerve, which lies a little 
 below it, on the bone below the last molar tooth. It 
 is here that the nerve is sometimes divided for the relief 
 of painful cancer of the tongue. The guides for the 
 division of two other nerves in the cavity of the mouth 
 may also here be mentioned. The inferior dental nerve 
 is reached by an incision " from the last upper molar 
 to the last lower molar, just to the inner side of the 
 anterior border of the coronoid process. The cut passes 
 through the mucous membrane down to the tendon of 
 the temporal muscle. The finger is introduced into the 
 incision, and passed between the ramus of the jaw and 
 the internal pterygoid muscle, until the bony point is 
 felt that marks the orifice of the dental canal. The 
 nerve is here picked up with a hook, isolated and 
 divided." (Treves). 
 The buccal nerve >vhich is sometimes divided for 
 
 '\ 
 
THE MOUTH. 
 
 25 
 
 neuralgia is thus reached ; *' the surgeon places the 
 hnger nail upon the outer lip of the anterior border of 
 the ascending ramus of the lower jaw at its centre, and 
 divides in front of this border the mucous membrane 
 and the fibres of the buccinator vertically. He then 
 seeks for the nerve, separating the tissues with a direc- 
 tor, and divides it." (Stimson). 
 
 The student should now examine the structures 
 separating the cavity of the mouth from the pharynx 
 the soft palate with its central dependence, the uvula 
 the folds of mucous membrane covering the palato 
 glossus and palato-pharyngeus, and forming the an 
 terior and posterior pillars of the fauces, and the tonsil 
 lying between them. This latter should not .project 
 under normal circumstances into the isthmus faucium, 
 and a consideration of its inter-muscular position will 
 explain the great pain caused in swallowing when it is 
 enlarged, and especially when ulcerated also, as in 
 *• hospital sore-throat." 
 
 The head being thrown well back the posterior nares 
 should be thoroughly explored. By hooking the finger 
 round the soft palate the posterior part of the septum 
 and of the middle and inferior turbinated bones may 
 be felt, also the vault of the pharynx, the openings of the 
 Eustachian tubes, the basilar process of the occipital, 
 and the upper four cervical vertebrae. Of these the 
 first is opposite the lower margin of the posterior 
 nares, and the second, the soft palate. If the finger be 
 pushed onwards into the inferior meatus, and the little 
 finger of the other hand be introduced from the front 
 
^6 
 
 THE MOUTH. 
 
 into the same, the two may be made to meet without 
 -difficulty unless the passage is abnormally constricted. 
 The apertures of the posterior nares measure a little 
 less than an inch vertically, and half an inch trans- 
 versely. An investigation of this part will be useful 
 m assisting the student to understand the operation of 
 plugging the posterior nares. 
 
 >t 
 
 
 I 
 
 fk 
 
I 
 
 THE SCALP, 
 
 27 
 
 ^l 
 
 Chapter II. 
 
 THE SCALP. ' 
 
 I. The Scalp. 
 
 For purposes of convenience the scalp is here limited 
 to the part of the head normally clad with hair. The 
 skin and subjacent tissues are here closely united to 
 one another so as to form a dense and thick covering 
 to the cranium. Free movement is permitted, how- 
 ever, between the scalp and the bone beneath it, by the 
 layer of loose connective tissue which lies between the 
 aponeurosis of the occipito-frontalis muscle and the 
 pericranium. The supra-orbital, frontal, and two 
 branches of the superficial temporal artery have already 
 been alluded to. Behind the ear and over the mastoid 
 process, the pulsations of the posterior auricular artery 
 may be felt ; the occipital artery will be found slightly 
 internal to the centre of a line drawn from the apex of 
 the mastoid process to the external occipital protuber- 
 ance. A lymphatic gland, the sub-occipital, which 
 receives the lymphatics of the occipital and posterior 
 parietal region, lies a short distance behind the mastoid 
 process, and may be felt when enlarged, a condition 
 which occurs in syphilis and in skin diseases of this 
 region of the scalp. 
 
v.. 
 
 28 
 
 RELATION TO BONY VAULT. 
 
 II. Relation to Bony Vault. 
 
 i 
 
 Comparatively few bony points are to be felt through 
 the scalp, yet by means of a few measurements and 
 rules, the positions of the various sutures may be 
 
 Fig. 2.— Cranium, showing Base-line of Brain (indicated by dotted line), &c. 
 (I. Bregma, b, Pterion, c. Lambda, d. Asterion. c. Nasion. /. Inion. 
 
 mapped out with considerable accuracy. The bony 
 points which may be felt are the external occipital 
 protuberance at the back of the head, with a portion of 
 the superior curved line passing from it ; above the 
 former the apex of the occipital bone may often be 
 distinguished. The mastoid process can be distinctly 
 
RELATION TO BONY VAULT. 
 
 29 
 
 felt behind the ear, and is a valuable landmark ; it is 
 much smaller in the child than in the adult, from the 
 non-development of the air-cells in its interior. 
 
 The following points are valuable in mapping out the 
 sutures : — 
 
 1. The bregma, or junction of the coronal, sagittal, and 
 in the young subject, frontal sutures ; this is placed at 
 the centre of a line drawn across the vertex from one 
 external auditory meatus to the other, the head being 
 in the usual erect position. 
 
 2. The pterion, or junction of the frontal, temporal, 
 parie .^l and sphenoid bones in the anterior part of the 
 temporal fossa. This is generally shaped like an H, of 
 which the anterior limb is formed by the fronto-parietal 
 and sphenoid sutures, the posterior by the temporo- 
 parietal and sphenoid, and the cross-bar by the parieto- 
 sphenoid. The relations of the four bones to one 
 another vary considerably, but we may take the cross- 
 bar as being about half an inch in length in the 
 majority of cases. The pterion is situated a little 
 above a line drawn backwards from the external 
 angular process, and from i J to i^ inches posterior to 
 that point. 
 
 3. The lambda or junction of the sagittal and lamb- 
 doidal sutures is situated about 2f inches above the 
 external occipital prominence, and may often be felt 
 through the scalp. 
 
 4. The astevion is the point of junction of the lambdoid 
 and parieto-mastoid sutures ; it is placed about i of an 
 inch behind and ^ an inch above the superior part of 
 the posterior border of the mastoid process. 
 
V 
 
 30 RELATION TO MEMBRANES OF BRAIN. 
 
 5. The nasion, is the point of junction of the inter- 
 nasal and naso-frontal sutures. - - 
 
 6. The inion is the external occipital protuberance. 
 With the aid of these points we may indicate on 
 
 the scalp the position of the sutures of the vault as 
 follows : — 
 
 Sagittal extends from the bregma to the lambda. 
 
 Coronal extends from the bregma downwards and 
 forwards, to the anterior end of the pterion. 
 
 Lambdoidal extends from the lambda, past the 
 asterion, and forwards internal to the mastoid pro- 
 cess. 
 
 Squamous and pavieto - mastoid may be indicated by 
 drawing a curved line from the posterior part of the 
 pterion to the asterion, the highest part of which is 
 about two inches above the zygoma. The posterior 
 inch is parieto-mastoid. 
 
 III. Relation to Membranes of Brain and their 
 
 Vessels. 
 
 The falx cerebri extends from the root of the nose 
 along the frontal and coronal sutures to the external 
 occipital protuberance, and the falx cerebelli is con- 
 tinued down in the middle line to the posterior margin 
 of the foramen magnum. The tentorium so far as it 
 is related to the cranial wall, will be indicated by a 
 line from the external occipital protuberance to the 
 asterion. 
 
RELATION OF MEMBRANES TO BRAIN. 
 
 31 
 
 The middle meningeal artery reaches the side of the 
 cranium near the lower end of ihe squamo-sphenoid 
 suture, which it follows to the pterion by the posterior 
 end of which it runs. From this point it runs nearly 
 parallel to the coronal suture and about one inch pos- 
 terior to it. A large branch is given off backwards 
 which crosses the squama transversely at about its- 
 centre. This may originate near the foramen spinosum, 
 
 Erichsen gives the following rule for finding this 
 artery ; draw a straight line backwards from the ex- 
 ternal angular process, take a point at any distance 
 between one and two and half inches on this line and 
 draw a vertical line through it to the zygoma, measure 
 a corresponding distance up this line and the point so 
 found will be over the artery. If this distance be under 
 one and a half inches, the artery will be found in a 
 canal in the bone, beyond this it is usually in a 
 groove. 
 
 The torcular Herophili corresponds nearly to the 
 external occipital protuberance being usually slightly to 
 its right ; a line therefore from this point to the root 
 of the nose will indicate the position of the superior 
 longitudinal sinus and one from the former point down- 
 wards, that of the occipital. 
 
 The limit of the upper border of the lateral sinus, as 
 far as the posterior part of the squamous suture is 
 indicated by the base line of the brain in that region 
 (p. 34). From this point it is directed downwards f be- 
 hind the external auditory meatus towards the tip of 
 the mastoid process, as far as a point ^" below the 
 
V 
 
 il 
 
 32 
 
 FONTANELLES. 
 
 lower level of the meatus, where it turns inwards to the 
 base of the skull. As a guide to the position of the sinus 
 in operations, Birmingham suggests the use of the 
 following lines. One drawn convex upwards from a 
 point \" above the occipital protuberance to a point 
 i^" behind and i \" above the centre of the meatus, and 
 the second from ^" below the occipital protuberance to 
 Reid's base-line i^" behind the meatus. Between these 
 two lines the sinus will be found ; above or below the 
 space included between them trephining may be prac- 
 tised with safety. 
 
 IV. FONTANELLES. 
 
 The student should examine the shape and position 
 of the fontanelles in the head of a young infant. These 
 are spots where the bony vault is incomplete, and 
 where membrane alone underlies the scalp. The two 
 most important, from the assistance they lend to the 
 obstetrician, in diagnosing the position of the descend- 
 ing head of the child in parturition, as well as from 
 their diagnostic value during infancy, are the anterior 
 and posterior. The former is diamond-shaped, occupies 
 the position of the bregma, and is included between the 
 two frontal and two parietal bones. The latter is 
 triangular with its apex directed forwards, it occupies 
 the position of the lambda and is included between the 
 parietal and occipital bones. ^ 
 
 .1 ■ \ 
 
I 
 
 Fig. 3.— Diagram of Cranium, showing positions of middle meningeal 
 artery (A), Lateral Sinus (S), and Supra-meatal Triangle (T). (Modified 
 from Birmingham and v. Barduleben.) 
 
 Fig 4,— Diagram of Cranium, showing positions of fissures, i. Sylvius 
 h. horizontal, a. ascending, p. posterior. 2. Rolando. 3. Parieto-occipital, 
 4. Parallel. 5. Intraparietal joining inferior post-central (i). Sup. post-central 
 is above (s). 6. Precentral, (t) inferior and (s) superior segments. ;. Superior 
 Frontal. 8. Inferior Frontal, {Modified from Quain and v. liardelehcn.) 
 
i 
 
 im,t 
 
 
 (: 
 
RELATION OF CRANIUM TO BRAIN. 33; 
 
 1 
 
 V. Relation of Cranium to Brain. 
 
 1 ' ■*! 
 
 '. y 
 
 Although it is much more important for the student 
 to be acquainted with the relations of the different parts 
 of the brain to the scalp, a subject to be dealt with in 
 the next section, their position in connection with cer- 
 tain of the bony points mentioned in Section III. rnajr 
 here be mentioned. 
 
 The level of the base of the brain may be indicated 
 in the following manner with sufficient accuracy : — 
 
 1. Draw a slightly sinuous line upwards and out- 
 wards from just above the nasion to the posterior line 
 of the pterion. This line crosses the temporal ridge 
 about i" above the root of the external angular process, 
 and indicates approximately the lower limit of the 
 frontal lobe. 
 
 2. From the last point draw a line downwards and 
 forwards parallel to the ptero-temporal suture, and at 
 a maximum distance of a quarter of an inch from it, to 
 a point a quarter of an inch above the middle of the 
 pterygoid ridge. This line indicates approximately the 
 anterior limit of the temporo-sphenoidal lobe. 
 
 ' 3. From the last point draw a line backwards, cross- 
 ing the ptero-temporal suture, and followinf^ the level 
 of the upper border of the zygoma. Behind tiie zygoma 
 it curves slightly upwards, so as to lie \" above the ex- 
 ternal auditory meatus. Thence it passes backwards, 
 slightly above the first \" of the parieto-mastoid suture 
 
 I 
 
 V\ 
 
 I'i 
 
 
 > 
 
34 RELATION OF CRANIUM TO BRAIN. 
 
 and terminates i" above the asterion. This Une indi- 
 cates approximately the lower border of the temporo- 
 sphenoidal lobe. 
 
 4. From the last point draw a sinuous line to a point 
 ^" above the superior curved line about its middle. 
 Thence it passes backwards and slightly upwards to 
 i" above the external occipital protuberance. This line 
 approximately indicates the lower border of the oc- 
 <:ipital lobe. 
 
 The fissure of Sylvius divides at the posterior end of the 
 cross-bar of the pterion, its anterior ascending limb runs 
 upwards and forwards to meet the coronal suture, its 
 anterior horizontal corresponds to the cross-bar, and its 
 posterior lies along the anterior part of the squamous 
 suture, and where that turns down to pass to the 
 astPiion, continues backwards and upwards across the 
 parietal bone. The fissure of Rolando commences a little 
 less than two inches posterior to the bregma and a shori 
 distance from the middle line, and passes down towards 
 the squamous suture, gradually approaching the coronal 
 so as to be about f " nearer to it below than above. 
 The external parieto -occipital fissure lies just in front of or 
 frequently coincides with the lambda. It should be 
 mentioned that Symington has shown that in the child 
 the fissure of Sylvius lies ^" or more above the squamous 
 suture, and that the fissure of Rolando lies further for- 
 ward than in the adult. 
 
 i W. 
 
 r\ 
 
1 
 
 RELATION OF SCALP TO BRAIN. 35 
 
 VI. Relation of Scalp to Brain. 
 
 The more important fissures may be marked out on 
 the scalp by the following rules. 
 
 The longitudinal fissure is indicated by a line from the 
 nasion to the inion. 
 
 FiQ. 5.— Showing Relation of Chief Fissures to Scalp. (Reid). 
 
 A, Glabella. B. External occipital protuberance, f. a. p. External angular 
 process of frontal. B. C. Transverse fissure. A. B, Horizontal Assure. Sy, fis. 
 Sylvian fissure. Sy. h. fis. Posterior limb of Sylvian fissure. Sy. a. fis. Anterior 
 limb of Sylvian fissure. DE, FG, Perpendiculars alluded to in text. F. H. Fissure 
 of Rolando. ^. o. ^s. Parietooccipital fissure. + Most prominent part of parietal 
 eminence. , 
 
V 
 
 I 
 
 36 
 
 REL Ana's OF SCALP TO BRAIN. 
 
 The transverse fissure is indicated by a line drawn from 
 J" above the external auditory meatus to \" above the 
 inion (see p. 30). 
 
 The fissure of Sylvius (Reid) is found by taking a point 
 an inch and a quarter posterior to the external nngular 
 process of the frontal, and drawing a line from thence 
 to a point three-quarters of an inch below the most 
 prominent part of the parietal eminence. Measured 
 from before backwards, the first three-quarters of ari 
 inch represent the main fissure, and the remainder the 
 posterior Hmb. The anterior ascending and anterior 
 horizontal limbs start two inches behind the external 
 angular process and run vertically upwards for about 
 an inch. 
 
 Quain's method of finding the fissure of Sylvius is as 
 follows : — " From the fronto-malar junction let a line be 
 carried horizontally backwards for 35 mm. (i:^") and 
 from the end of this a vertical line for 12 mm. (a little 
 less than \") 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 
 Sylvian 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 Hne. The anterior ascending and horizontal 
 branches of the fissure may be marked by lines 2 cm. 
 (ij"), starting from the Sylvian point, the one directed 
 upwards and forwards at right angles with the Sylvian 
 line and the other horizontally forwards." 
 
RELATION OF SCALP TO BRAIN. 
 
 37 
 
 The external parieto-occipital fissure is found by drawing 
 a line outwards for i" from the lambda at right angles 
 to the line indicating the loi ^itudinal fissure. 
 
 To find the. fissure of Rolando by Reid's method, it will 
 be necessary to erect a kind of scaffold formed of three 
 lines. The first or base runs through the lowest part of 
 the infra-orbital margin and the middle of the external 
 auditory meatus. Upon this line are erected two per- 
 pendiculars, one starting from the hollow in front of the 
 external auditory meatus, the other from the posterior 
 border of the mastoid process at its root. 
 
 These two perpendiculars, together with the line for 
 the longitudinal iissure and that for the posterior limb 
 of the fissure of Sylvius, enclose a quadrilateral space, 
 and if a diagonal line be drawn from the posterior 
 superior corner to the anterior inferior it will be over 
 the fissure of Rolando. 
 
 An alternative method is to measure the distance 
 from the nasion to the inion and take the centre of this 
 line. A point ^" behind this will indicate the upper 
 end of the fissure of Rolando. A line draw downwards 
 and forwards for 3f" from this point, making an angle 
 of 70° with the longitudinal fissure, will indicate the 
 remainder of the fissure. 
 
 The student having thus mapped out on the scalp the 
 great fissures of the brain and laving fully mastered the 
 method, he should next prot- td to put in the smaller 
 details as directed l>y Prof. Keid. 
 
 The frontal lobe is bounded above by the line for the 
 longitudinal fissure, below by the line for the trunk 
 
 'IS 
 
 i 
 
v.. 
 
 S: ■ 
 
 ill 
 
 38 
 
 RELATION OF SCALP TO BRAIN. 
 
 and horizontal limb of the Sylvian fissure, behind by 
 the line for the fissure of Rolando, and in front by a line 
 just above and parallel with the supra-orbital margin. 
 The precentral sulci are situated ^" in front of the 
 fissure of Rolando with which they are parallel. A line 
 drawn from the supra-orbital notch backwards to within 
 three-quarters of an inch of the line for the fissure of 
 Rolando, and parallel with the line for the longitudinal 
 fissure, will indicate the first frontal fissure. The 
 frontal part of the temporal ridge will indicate the 
 second frontal fissure. The first, second, and third 
 frontal convolutions, will thus be mapped out. The 
 ascending frontal convolution will occupy a space about 
 three-quarters of an inch broad, parallel with, and in 
 front of, the line for the fissure of Rolando. 
 
 The parietal lobe will be marked out by the line for 
 the longitudinal fissure superiorly, and in front and 
 behind by the lines for the fissure of Rolando and the 
 parieto-occipital fissure respectively. Below, the line 
 for the horizontal limb of the fissure of Sylvius will 
 separate it from the temporo-sphenoidal lobe. The 
 interval between the posterior end of the Sylvian line 
 and the outer end of the parieto-occipital line is 
 occupied by the junction of the postero-parietal lobule 
 {p. p. /., fig. 6) with the first annectant convolution, 
 and the angular gyrus {aiig. g., fig. 6) with the second 
 annectant convolution, the arrangement of these con- 
 volutions with regard to one another being very variable, 
 the angular gyrus usually projecting somewhat more 
 posteriorly than the postero-parietal lobule. We can, 
 
RELATION OF SCALP TO BRAIN 
 
 39 
 
 therefore, only indicate the separation of this part of 
 the parietal lobe from the neighbouring temporo- 
 sphenoidal and occipital lobes by drawing a line 
 (a, fig. 6) slightly convex downwards from the pos- 
 
 
 1 1' 
 
 i 
 
 Fio, C. -Showing Kelation of Fissures and Convolutions of Brain t Scalp. 
 
 (Reid). 
 
 + Most prominent part of parietal eminence, a Convex line b'tunding parietal' 
 lobe below, h. Convex line bounding temporo-sphenoidal lobe behind, ifr.c. 
 First frontal convolution, tfr.f. First frontal fissure. /. A'. Fissure of Kolando, 
 6>./. Sylvian fissure, i'j'. /(,/. Horizontal limb of Sylvian fissure. ii> .(./.As- 
 cending limb of Sylvian fissure. />. o.f. I'arielo-occipital fissure. ; t''-/- Intra- 
 parietal fissure. ii((«'. «•. Angular gyrus, s. in, c. Supra-marginal convolution. 
 1 /. s. f. First temporo-sphenoidal convolution, i ^ s.f. First temporo-sphenoidal 
 fissure. 1 (I. ( . First oceipitd convolution. />. p. I. I'oslero-parietal lobule. 
 
 fm 
 
II *■ 
 
 I 
 
 f< 
 
 IT 
 
 V 
 
 40 
 
 RELATION OF SCALP TO BRAIN. 
 
 terior end of the Sylvian line to the outer end of the 
 parieto-occipital line. An irregularly triangular space 
 will thus be marked out to indicate the parietal lobe. 
 If in this space we draw a line from a point half an 
 inch outside the outer extremity of the parieto-occipital 
 line to a point about an inch above and behind the an- 
 terior and inferior angle of the space, this line will lie 
 ovGX the intva-pavietal fissure [i. par. /., fig. 6). The line 
 must be curved, with its convexity directed forwards 
 and inwards, and parallel in its anterior third or so (post- 
 central sulcus) with the line for the fissure of Rolando, 
 and about three-fourths of an inch behind it. In the 
 space above the intra-parietal sulcus we shall have, in 
 front, parallel with the whole length of the fissure of 
 Rolando, the ascending parietal convolution, and behind, 
 the postero-parietdl lobule. The space below the sulcus 
 will indicate, in its anterior part, the supra-marginal 
 convolution (5. m. c, fig. 6) filling up the most prominent 
 part of the parietal eminence, and in its posterior part, 
 the angular gyrus {ang. g., fig. 6). 
 
 The temporo-sphenoidal lobe is, like the last, somewhat 
 difficult to indicate posteriorly, because it becomes con- 
 tiimous there with the parietal and occipital lobes with- 
 out any distinct line of demarcation. Its outline will 
 lie in the lower part of the temporal region, extending 
 a little beyond the temporal ridge behind. It will be 
 bounded above by the line of the main trunk and hori- 
 zontal limb of the fissure of Sylvius, below by the upper 
 border of the zygoma and a line carried back from the 
 posterior end of that to a point midway between the 
 
RELATION OF SCALP TO BRAIN. 
 
 41 
 
 external occipital protuberance, and the posterior bor- 
 der of the mastoid process at its root. The anterior 
 border or apex of the lobe will extend as far forwards 
 as the posterior superior border of the malar bone. Be- 
 hind, the lobe will be bounded by a slightly convex line 
 •(&., fig. 6) with the convexity directed backwards, ex- 
 tending from the posterior end of the Sylvian line to 
 the posterior end of the line indicating the lower 
 boundary of the lobe. 
 
 A line running about an inch below and parallel with 
 the line for the main trunk and horizontal ramus of 
 the fissure of Sylvius, will indicate the first temporo- 
 sphenoidal fissure {1 t. s. /., fig. 6) and another line 
 about three-quarters of an inch below and parallel with 
 the last, will indicate the second temporo-sphenoidal 
 fissure {2 t. s. f., fig. 6). Thus, the first, second, and 
 third temporo-sphenoidal convolutions will be mapped 
 out (i t. s. c, 2 t. s. c, 3 t. s. c.y fig. 6). 
 
 The occipital lobe will occupy the remaining surface 
 of the scalp. It will be bounded above by the parietal 
 lobe, below by the superior curved line in its inner half, 
 that is, the part of the line unoccupied by the lower 
 limit of the temporo-sphenoidal lobe. Internally, the 
 line of the longitudinal fissure, and externally, the con- 
 vex line for the posterior border of the temporo-sphe- 
 noidal lobe, will bound it. The area of the lobe being 
 marked out, the first, second, and third occipital con- 
 volutions, can be readily filled in (i 0. r., 2 0. c, 3 0. c, 
 fig. 6). 
 
 n 
 
 I 
 
 I 
 
V 
 
 42 
 
 THE NECK, 
 
 Chapter III. 
 
 THE NECK. 
 
 i ■ 
 
 In this section only the anterior and lateral portions of 
 the neck will be dealt with, the posterior being included 
 with the back. r 
 
 The skin of the neck is loose and mobile, and is under- 
 laid by a thin layer of muscle passing from the clavicle 
 to cross the lower jaw. This is the platysma myoides, 
 and its fibres run from above downwards and back- 
 wards. A great number of structures, many of which 
 are of the highest surgical importance, lie in the region 
 now under consideration, they will be dealt with in the 
 following order : — those in the middle line, between that 
 line and the anterior border of the sterno-mastoid, and 
 those behind that muscle. 
 
 I. The Middle Line of the Neck. 
 
 The first structure which can be felt beneath the 
 lower jaw is the hyoid bone, the body and great cornua 
 of which can be distinguished. The student in seeking 
 for this should not stretch the tissues of the nock, but 
 should allow the chin to fall and push his finger and 
 thumb up underneath it, when the object of his search 
 will readily be discovered. In the normal position this 
 
THE MIDDLE LINE OF THE NECK. 43 
 
 bone corresponds to the fourth cervical venebra. Be- 
 neath it is a space which ovedies the anterior thyro- 
 hyoid membrane, behind which lies the apex of the 
 epiglottis. The next structure met with is the thyroid 
 cartilage, or Adam's apple, the largest and most pro- 
 minent hard body in the neck, of greater size and pro- 
 minence proportionally in men than in women. The 
 upper border with its notch and superior cornua, the 
 angle, lower border and inferior cornua by the side of 
 the cricoid, can all be distinguished. The middle of 
 the angle corresponds to the attachment of the vocal 
 cords. Beneath the thyroid cartilage lies the crico- 
 thyroid membrane, which is divided in laryngotomy, 
 and on which lie the crico-thyroid branches of the 
 superior thyroid arteries. The student will note that 
 these are the first vessels met with in the middle line, 
 and they are of small size ; incisions for the relief of 
 cellulitis of the neck may therefore be made in this line 
 without fear of wounding any vessel of importance. 
 
 Below this membrane lies the cricoid cartilage, a 
 surgical landmark of much importance, which corre- 
 sponds with the disc between the fifth and sixth cer- 
 vical vertebrae. At the lower border of this cartilage 
 the pharynx ends, and the oesophagus commences, this 
 point being, as has already been mentioned, one of 
 the narrowest part*? of that canal. Below the cricoid 
 we reach the trachea, about eight of the rings of which 
 lie above the sternum in the ordinary position, none 
 of which can, however, be felt as separate structures. 
 According to Holden only i^ inches of trachea lie abo^e 
 
"s 
 
 HI 
 
 ! 
 
 I 
 
 i 
 
 
 44 THE MIDDLE LINE OF THE NECK. 
 
 the sternum, though an additional | inch may be gained 
 by stretching the neck, but Tillaux gives somewhat 
 different figures. He states that in a child from three 
 to five years there is i^ inches, from six to seven 2, 
 from eight to ten 2^, and in the normal adult 2f , the 
 head being in the ordinary position. In the operation 
 of tracheotomy this tube is opened, in that of laryngo- 
 tracheotomy its upper rings and the cricoid cartilage 
 being divided. On account of these operations, and 
 especially the former, which is by far the commoner, it 
 is very important to know what structures lie in front 
 of the trachea before it enters the thorax. The first in 
 order from above downwards is a transverse communi- 
 cating branch between the two superior thyroid veins, 
 which is generally present, and lies over the first ring 
 of the trachea. Next in order is the isthmus of the 
 thyroid, which varies in size, but usually overlies the 
 second, third, and fourth rings. According to Treves 
 the importance of avoiding the wounding of this struc- 
 ture is overrated, and, as he points out, it has been 
 shown that an injection will not cross the isthmus from 
 one lobe of the thyroid to the other. Over the isthmus 
 is a plexus of veins, and below it they unite into one or 
 generally more inferior thyroid veins. In this position 
 also is the thyroidea ima artery when such a vessel 
 exists. At the root of the neck the trachea recedes con- 
 siderably from the surface, a depth of an inch and a half 
 intervening between it and the skin at the episternal 
 notch. Just above this last is a transverse trunk uniting 
 the two anterior jugular veins, which may themselves 
 
 W 
 
ANTERIOR OF STERNO-MASTOID. 
 
 45 
 
 lie in front of the trachea, though as a general rule they 
 are some little distance from the middle line. In chil- 
 dren, up to the age of two, the thymus gland covers the 
 trachea for a variable distance above the sternum, and 
 the innominate artery may also be in that high position, 
 a position which it may retain, though rarely, in the 
 adult also. Behind the trachea lies the oesophagus, 
 which in this part of the neck lies slightly to the left 
 side. In feeling for a hard foreign body the attempt 
 should be made on the left side by the trachea, and here 
 also the operation of oesophagotomy is performed. 
 
 I II. Parts near Anterior Border of Sterno- 
 
 Mastoid. 
 
 The student should first note the exact line of the 
 anterior border of the sterno-mastoid muscle, ?.s he is 
 apt to obtain an incorrect idea of it, from an examina- 
 tion made in the dissected condition. When in an un- 
 disturbed condition it does not run a straight course 
 from the sternum to the mastoid proc;e«5, as it appears 
 to do when its fascial connections hive been cut. On 
 the contrary its anterior border pa&ses practically to the 
 angle of the jaw, and is held there by its relations 
 with the cervical fascia. It follows from this that the 
 common carotid artery and its divisions, the external 
 and internal carotids are completely covered in by the 
 anterior border of the muscle in the undissected state. 
 The muscle below arises by two heads, sternal and 
 
 \ 
 
 m 
 
 ii 
 
 . 
 
V 
 
 46 
 
 ANTERIOR OF STERNO-MASTOID. 
 
 11 
 
 I 
 i 
 
 
 clavicular, between which a triangular space of variable 
 size is included. At its base lies the line of the sterno- 
 clavicular joint. If a needle be pushed in here on the 
 right side, it will pass immediately above the innominate 
 artery at its bifurcation, and will have below it and to 
 the right the subclavian artery, external to it the inter- 
 nal jugular vein, and internal to it the common carotid 
 artery. Sometimes in children, and even in adults, the 
 innominate artery, as has been already mentioned, rises 
 higher than the sternum, in which case a needle so in- 
 troduced would pierce it. 
 
 A needle thrust through in a similar position on the 
 left side would pierce the common carotid artery, and 
 possibly the internal jugular vein. 
 
 The relations of these vessels to the lower end of the 
 sterno-mastoid should be borne in mind, since it is some- 
 times necessary for the relief of wry-neck to divide some 
 part of the muscle in that position. At the upper part of 
 the anterior border, if a line be drawn from the hyoid to 
 the mastoid process, it will correspond to the posterior 
 belly of the digastric muscle. Above this lies that por- 
 tion of the sub-maxillary gland, which is not deeply 
 placed behind the jaw, and on its surface are some 
 lymphatic glands, which are perceptible when enlarg^^d. 
 Farther down is the lateral lobe of the thyroid body, 
 which cannot be distinctly made out save when en- 
 larged, but which lies beside the inferior part of the 
 thyroid cartilage, the cricoid, and the upper five or six 
 rings of the trachea. 
 
 Two veins are related to the external surface of the 
 
 W 
 
ANTERIOR OF STERNOMASTOID. 
 
 47 
 
 sterno-mastoid, viz., a communicating branch from the 
 facial to the anterior jugular, which runs downwards 
 along its anterior border, and the external jugular, 
 which commencing at a point near the angle of the 
 jaw crosses the muscle and terminates in the posterior 
 angle at the middle of the clavicle. This latter vein 
 can be made prominent by pressure applied at its lower 
 extremity. The anterior jugular runs down slightly 
 external to the middle line of the neck. 
 
 The most important structures in the region now 
 under consideration are the carotid arteries, common, 
 external and internal, with the branches of the second 
 named vessel. A line from the sternal extremity of the 
 clavicle to a point midway between the angle of the jaw 
 and the mastoid process, indicates the position of the 
 common carotid. It bifurcates as a rule on a line with 
 the upper border of the thyroid cartilage. If a line be 
 drawn downwards and outwards from the anterior part 
 of the hyoid bone, so as to cross the line of the carotid 
 at the level of the cricoid cartilage, it will indicate the 
 position of the anterior belly of the omo-hyoid muscle. 
 The cricoid cartilage is the guide for the incisions which 
 are made along the anterior border of the sterno-mastoid 
 muscle in ligature of the common carotid. This opera- 
 tion is performed either above or below the omo-hyoid ; 
 in the former case the centre of the incision is at the 
 level of the cricoid, in the latter its upper extremity. 
 At the level of the cricoid cartilage the carotid can be 
 compressed against the vertebral column, and here also 
 by deep pressure can be felt the anterior tubercle of the 
 
 
 I 
 
 lit- 
 
 11 
 
 ] i 
 
V, 
 
 el . 
 
 48 
 
 POSTERIOR TO STERNQ-MASTOID. 
 
 transverse process of the sixth cervical vertebra, which 
 is called the " carotid tubercle," and used sometimes 
 as a guide in the operations mentioned above. It may 
 also be used as a landmark in tying the vertebral artery. 
 The internal jugular vein lies external to the artery, and 
 the pneumogastric and sympathetic nerves posterior. 
 As regards the branches of the artery, the superior 
 thyroid comes off just below the great cornu of the 
 hyoid, and curves downwards towards the lateral lobe 
 of the thyroid body on the anterior surface of the upper 
 portion of which it may be felt pulsating. 
 
 The lingual lies immediately above the great cornu 
 of the hyoid, having above it the lingual nerve and the 
 tendon of the digastric muscle. The facial arises im- 
 mediately above the lingual, sometimes indeed by a 
 common trunk with the latter, and passes under the 
 jaw in the sub-maxillary gland ; it emerges again and 
 crosses the jaw in front of the masseter muscle. The 
 occipital artery may be represented by a line starting 
 from the carotid line just above the level of the great 
 cornu of the hyoid, and passing backwards and upwards 
 so as to cross the mastoid process, beneath which the 
 vessel lies, about a quarter of an inch above its apex. 
 
 w 
 
 III. Structures Posterior to Sterno-Mastoiu. 
 
 Behind the sterno-mastoid lies the posterior triangle 
 of the neck, bounded behind by the anterior border of 
 the trapezius, passing from the occiput to the point of 
 the shoulder. 
 
 »\ 
 
w 
 
 POSTERIOR TO STERNO-MASTOID. 
 
 49 
 
 The lower portion of this triangle, separated from the 
 remainder by the posterior belly of the omo-hyoid 
 muscle, is surgically the most important part of the 
 region, and is called the sub-clavian or supra-clavicular 
 triangle. The belly of the muscle just alluded to may 
 be seen in a thin neck after swallowing, when its con- 
 traction assists to depress the hyoid ; it may also be 
 seen in a person sobbing. It lies nearly parallel with 
 the clavicle, and so short a distance above it that its 
 inferior border is often beneath the edge of that bone,- 
 especially if the point of the shoulder is raised. It is- 
 only when the shoulder is depressed, and after the skin^ 
 fasciae, and other superficial structures have been re- 
 moved, that any very distinct triangle therefore exists. 
 
 The most important structure in the triangle is the 
 sub-clavian artery, which there rises about half an inch 
 above the clavicle, so that if a segment of a circle be 
 described of that height, v 1th one cornu at the sternal 
 end and the other at the middle of the clavicle, it will 
 correspond fairly to the position of the artery. Its vein 
 lies on a plane anterior, but under cover of the clavicle. 
 If the student stand behind a living subject, and press 
 his finger or thumb behind the posterior border of the 
 sterno-mastoid, downwards and a little inwards, he will 
 feel the pulsations of the vessel, and can compress it 
 against the first rib. The posterior border of the sterno- 
 mastoid corresponds fairly to the outer border of the 
 scalenus anticus lying under it, and is a guide to the 
 surgeon in tying the artery. If pressure be made back- 
 wards and inwards a little above the artery, the trans- 
 
 E 
 
 m 
 
 ,1- 
 
 tj : 
 
 h i 
 
 % 
 
 9f 
 
 \ I 
 
V 
 
 50 
 
 POSTERIOR TO STERNO-MASTOID, 
 
 verse process of the seventh cervical vertebra will be 
 felt. The transverse cervical artery may be felt as a 
 rule running a short distance above the clavicle and 
 parallel to it. The cords of the brachial plexus may be 
 felt and even seen in a suitable subject, especially if the 
 arm be pulled down and the head drawn to the opposite 
 side. The outer edge corresponds to a line drawn from 
 a point a little above the cricoid cartilage to one a little 
 external to the centre of the clavicle. The apex of the 
 lung also reaches up into the neck in this position, a fact 
 which should be borne in mind, since this portion is 
 liable to be first attacked in phthisis. The sub-clavian 
 artery arches over it, being only separated from the lung 
 by the dome of the pleura and the fascia covering it. 
 The lung extends into the neck for a distance varying 
 from f to li inch, being higher according to some ob- 
 servers on the right than on the left side. Eichorst, 
 however, says that the apices are, alr^ost without ex- 
 ception, placed at the same height. It is safe to 
 conclude that if one side is higher than the other, it 
 will almost certainly be the right. 
 
 At the upper part of the posterior triangle, indeed 
 strictly speaking, in front of the triangle and under 
 cover of the sterno-mastoid, the transverse process of 
 the atlas may be felt just below and in front of the apex 
 of the mastoid process. One inch below the tip of the 
 mastoid the spinal accessory nerve passes beneath the 
 anterior border of the sterno-mastoid. It leaves the 
 posterior border of this muscle at a point opposite the 
 third cervical spine. Its position in the posterior tri- 
 
 ■ \ 
 
 
 n 
 

 V i^ 
 
 \ 
 
 i t 
 
 POSTERIOR TO STERNO-MASTOID. 
 
 51 
 
 angle may be indicated by a line drawn from this point 
 ;to the upper border of the trapezius where it again dis- 
 , appears at the level of the seventh cervical spine. 
 
 Three other nerve trunks lying in the upper part of 
 ■the posterior triangle may be indicated by three lines, 
 each drawn from the central point of the posterior border 
 of the sterno-mastoid. The first line passing trans- 
 versely across that muscle from behind forwards, will 
 indicate the superficial cervical nerve ; the second to the 
 back of the cartilage of the ear, the great auricular ; and 
 the third along the posterior border of the muscle to the 
 jscalp, the small occipital. 
 
 K2 
 
 I 
 
 tvSrf 
 
 iBiiilHIHaafi 
 
3.2 
 
 THE THORAX. 
 
 li 
 
 n 
 
 
 
 
 Chapter IV. 
 
 <." . 
 
 THE THORAX. ' ' 
 
 In this chapter only the anterior and lateral aspects of 
 the thorax will be considered, the remainder being in- 
 cluded in that oh the back. It is not necessary here to- 
 describe the general shape and structure of the thorax, 
 but the student should note the great difference pro- 
 duced in the skeleton by the removal of the shoulder 
 girdle, and should study the relations of the clavicle to 
 the upper part of the cavity. The right side of the 
 thorax is, as a rule, larger than the left. According 
 to Holden, '• of ninety-two persons of the male sex and 
 good constitutions, seventy-one had the right side the 
 larger, eleven the left, ten had both sides equal. The 
 maximum of difference in favour of the right was one 
 inch and a quarter. The measurements were made on 
 a plane with the nipple." 
 
 Bony points. — The sternum is of course the first 
 object of study. Its upper border, the episternal notch, 
 in inspiration is on a level with, the disk between the 
 second and third dorsal vertebraj, and about two inches 
 anterior to it. If the finger be carried downwards, a 
 prominent ridge or angle will be encountered at the 
 junction of the manubrium and gladiolus. This is 
 called the angulus Ludovici, it marks the part of the 
 
 i 
 
 l\ 
 
THE THORAX. 
 
 53 
 
 sternum where union takes place latest, and is of 
 especial impoitance as a landmark, since it corresponds 
 ito the junction of the second costal cartilages with the 
 sternum, and thus enables us to find the second pair of 
 ribs in a fat subject. This ridge corresponds with the 
 lower border of the fifth dorsal vertebra. At the lower 
 part of the sternum the junction of the manubrium with 
 the xiphoid cartilage will be found, this point corre- 
 sponding to the interval between the ninth and tenth 
 .dorsal vertebrae. It is placed a little below the junction 
 .of the seventh pair of costal cartilages with the sternum. 
 Though distinct enough in the skeleton it is difficult 
 to make out accurately the edges of the xiphoid carti- 
 lage in the recent condition, on account of the liga- 
 (Hients which p^ss to it from adjacent structures. Some- 
 times its apex is curved very distinctly forwards, in 
 which case there is a cup-like depression between it 
 and the end of the manubrium (infra-sternal depression 
 ,or epigastric fossa). 
 
 On either side of the episternal notch the sterno- 
 clavicular articulation will be seeu, and the changes 
 produced at this joint, as well as in the position of the 
 •clavicle during its movements, should be studied by 
 raismg and lowering the arm of the subject. 
 
 The student should next direct his attention to the 
 ribs, which can easily be counted in a thin person, but 
 are more difficult to identify where there is much sub- 
 cutaneous fat. The first can be felt by pressing the 
 finger backwards and downwards under the clavicle, 
 external to its articulation with the sternum. This rib 
 
 l\ 
 
 Si 
 
 i.i' I 
 
m 
 
 I 
 
 •; 
 
 54 
 
 THE THORAX. 
 
 has much less mobility than the others, and its cartilage 
 is more often ossified, this being not uncommonly the 
 case in tolerably old subjects. The second corresponds 
 to the angulus Ludovici. Rules for finding some of 
 the others- will be found in the next section, in con- 
 nection with the muscular and other markings related 
 to the soft parts. # '•-• 
 
 By commencing above and counting downwards be- 
 hind the posterior axillary line, the student will be able 
 to discover the last two ribs, which from their position 
 are sometimes difficult of detection. The last rib is 
 very variable in length, being in some cases four times 
 longer than in others. It is proportionately smaller in 
 women than in men (MacaHster). The importance of 
 the last rib as a landmark will be dealt with in the 
 chapter on the abdomen. 
 
 The oblique sweep of the ribs causes the anterior 
 extremity of each to lie on a lower plane than its 
 posterior, thus, the first rib in front corresponds to the 
 fourth behind, the second to the sixth, the third to the 
 seventh, the fourth to the eighth, the fifth to the ninth, 
 the sixth to the tenth, and the seventh to the eleventh. 
 By remembering these facts the student will be able to 
 determine what ribs would be divided in a transverse 
 section at any level. The anterior portions of the inter- 
 costal spaces are wider than the posterior, and of the 
 former the third, second, and first are the widest, in the 
 the order mentioned. The operation of paracentesis 
 thoracis, or tapping the pleura, is generally performed 
 in the sixth interspace, at a point midway between the 
 
 
 I 
 
 i\ 
 
i 
 
 SOFT PARTS. S$ 
 
 aQterior and posterior axillary lines. Some surgeons 
 recommend that a space higher should be taken on the 
 right side, on account of the fact that the dome of the 
 diaphragm, rises higher on that side. The trocar 
 should be inserted immediately above the upper border 
 of the lower rib in the space indicated, since there is 
 thus less danger of wounding the intercostal vessels^ 
 which lie under cover of the lower border of each rib, 
 in the position in which the operation is performed. 
 
 II. Soft Parts. 
 
 One of the most important landmarks in the thorax 
 is the nipple. This lies in the majority of cases in the 
 interspace between the fourth and fifth ribs, and about 
 four inches from the middle of the sternum. It may 
 also lie on the fourth rib, more rarely on the fifth, most 
 rarely in the fifth interspace. It is not unfrequently 
 farther from the middle line on the right side, and may 
 be placed at a higher level. 
 
 The female breast covers the thorax from the third 
 to the sixth or seventh rib, and from the edge of the 
 sternum to the anterior border of the axilla, its base 
 being somewhat oval, with its long diameter directed 
 downwards and inwards. The nipple is placed a little 
 below the centre of the gland, and is surrounded by an 
 areola, which is pink in the nullipara, dark brown, and 
 dappled with lighter spots in the pregnant woman, and 
 after pregnancy becomes a dingy brown, never returning 
 
 : ! 
 
 I 
 
 I 
 
 
t ;! 
 
 Ill 
 
 li 
 
 56 
 
 RELATIONS OF LUNGS 
 
 to its first hue. Beneath the clavicle the deltoid muscle 
 and the upper border of the pectoralis major will be 
 seen, with a triangular interval between. If the finger 
 be pressed deeply into this space, the coracoid process 
 will be felt. It is covered by the fibres of the former 
 muscle. 
 
 If the arm be drawn outwards from the chest the 
 great pectoral will be placed on the stretch, and its 
 lower border will indicate the position of the fifth rib 
 with which it corresponds. 
 
 If the arm be drawn up by the side of the head, the 
 digitations of the serratus magnus muscle will be seen 
 in a fairly thin subject. The highest of these which is 
 visible corresponds to the fifth rib, the next, which is 
 the largest and most prominent to the sixth, and the 
 two below to the seventh and eighth. 
 
 i 
 
 III. Relations of Lungs to Thoracic Wall. 
 
 After studying the structures to be seen or felt in the 
 wall of the thorax, the student should turn his attention 
 to the relation of the various important structures which 
 that cavity contains to its exterior. He may first pro- 
 ceed to map out the position of the lungs, which may be 
 done in the following manner. A point should be taken 
 behind the outer border of the sterno-mastoid muscle, 
 and about an inch and a half above the clavicle. From 
 this a line should be drawn, passing on each side through 
 the sterno-clavicular articulation to the centre of the 
 
 , 
 
 m^: 
 
TO THORACIC WALL. 
 
 57 
 
 1 
 
 angulus Ludovici. This line will be slightly indented 
 above the clavicle by the notch for the subclavian ves- 
 sels. From the centre of the angulus Ludovici the 
 borders of the two lungs run downwards, parallel and 
 close to one another, to a point midway between the 
 
 Fio. 7.— Diagram. o( Relation of Lungs to Chest Wall. , 
 
 The portion shaded horizontally marks out the area of the lungs, that shaded 
 vertically the supplementary pleural space, i— 10. Ribs, c, c. Clavicles, a, In- 
 cisura cardiaca. b. Processus lingualis. 
 
 fourth pair of costal cartilages, where they diverge. 
 The left passes outwards along the fourth rib to the apex 
 beat point, turns downwards, crosses the fifth rib, and 
 again turns for a short distance inwards in the fifth 
 interspace, and behind the sixth rib, to form a small 
 
 4 
 
 ! 
 
 I 
 
 : 
 
 iiifii 
 
58 
 
 RELATIONS OF 
 
 tongue-like process, the processus lingualis. The hol- 
 low or bay in the lung thus formed corresponds to the 
 part of the heart uncovered by lung (the area of cardiac 
 dulness, hereafter to be more particularly alluded to) 
 and is called the incisura cardiaca. The right lung on 
 the contrary, passes downwards to meet the sixth costal 
 cartilage at the parasternal line. The level at which 
 the lower border of the lung lies may be indicated in the 
 following manner : — Draw a line slightly convex down- 
 wards, from the sixth chondro-sternal articulation round 
 the chest to the tenth dorsal spine. In the nipple line 
 the lung extends downwards to the sixth rib, in the 
 posterior axillary to the eighth, and in the scapular to 
 the tenth. 
 
 The sac of the pleura extends farther down than the 
 limits mentioned, as of course also does the edge of the 
 lung in a full inspiration. Thus, at the front of the 
 chest the reflection of the pleura corresponds to the 
 seventh rib cartilage, passing from its upper to lie 
 below its lower border at the nipple line. In the 
 axillary line it lies at the level of the ninth rib, and 
 posteriorly at that of the twelfth, or lower if that rib 
 be longer than usual. Thus, it is possible for the pleura 
 and diaphragm to be wounded without the lung being 
 involved, and also for the diaphragm to be pierced 
 without any injury to lung or pleura. 
 
 
 i\ 
 
HEART TO THORACIC WALL. 
 
 IV. Relations of Heart to Thoracic Wall. 
 
 The base of the heart corresponds to a line drawn 
 across the sternum at the level of the upper border of 
 the third costal cartilages, which extends half an inch 
 to the right, and about one inch to the left. The right 
 border may be indicated by a curved line drawn from 
 the right extremity of the base to the junction of the 
 seventh right costal cartilage with the sternum ; this 
 line will be rather more than i^ inches from the centre 
 of the sternum at the level of the fourth costal cartilage. 
 The lower border may be indicated by a line drawn 
 from the termination of the last to a point in the left 
 fifth interspace, two inches below the nipple, and three 
 and a half from the middle line. The line for the left 
 border runs from the apex in a curve to the left limit of 
 the base. This line will be nearly three inches from the 
 middle point of the sternum at the level of the fourth 
 costal cartilage. The general position of the heart 
 having thus been mapped out, it remains to be seen how 
 its various cavities lie. The right auricle forms the 
 major part of the right border, and lies beneath the 
 third, fourth, and fifth costal cartilages, with the intei- 
 vening spaces and a part of the sternum, the tip of its 
 appendix being placed on the base line at the mid- 
 sternum. The groove between right auricle and ven- 
 tricle nearly corresponds to a line drawn from the third 
 left costal cartilage at its junction with the sternum, to 
 the sixth right at a similar point. The left border is 
 
SV 
 
 '60 
 
 RELATIONS OF 
 
 formed by the small portion of the left ventricle, which 
 lies in front, the greater portion of the anterior surface 
 unaccounted for belonging to the right ventricle. 
 
 The tip of the left auricular appendix lies behind the 
 lower part of the second left interspace and the upper 
 part of the third costal cartilage. 
 
 The position of the apex-beat is in the fifth interspace 
 two inches below, and one inch internal to the nipple, 
 that is about 3^ inches to the left of the middle line, but 
 varies slightly according to the position of the body. 
 Symington and others have pointed out that in the 
 infant the heart has a greater breadth in proportion to 
 the size of the chest than in the adult. Consequently 
 in children the apex-beat is often below or even external 
 to the nipple line. Steffen believed that it was patho- 
 logical if it lay more than f inch external to that line. 
 In children the beat may also be in the fourth inter- 
 space, whilst in the aged it may be in the sixth. 
 
 The portion of the heart uncovered by the lungs, or 
 area of precordial dulness, may be indicated by a tri- 
 angle, of which the base is formed by a line drawn from 
 the apex-beat to a little to the right of the middle line 
 of the lower end of the gladiolus, and the left side by a 
 line from the apex to the mid -sternal line at the level of 
 the fourth pair of costal cartilages. The third side is 
 formed by joining the upper and lower sternal points. 
 At the lower angle on the right side the cardiac dulness 
 shades off into that caused by the liver. The precordial 
 area may also be indicated by Latham's method, which 
 consists in describing a circle two inches in diameter, 
 
 \ \ i 
 
 w 
 
 M 
 
HEART TO THORACIC WALL. 
 
 6i 
 
 around a point midway between the left nipple and the 
 end of the gladiolus. This circle is sufficiently accurate 
 for practical purposes. The position of the valves 
 should next be marked out. The pulmonary orifice 
 
 Fig. 8. — Diagram of Relation of Heart and Great Vessels to Chest Wall (m idified 
 
 from Quain). 
 
 i-io. Ribs. c. c. Clavicles. R. V. Right ventricle, L. V. Left ventricle. 
 R. A. Right auricle. L. A. Left auricle. P. Pulmonary, A. Aortic, M. Mitral, 
 T. Tricuspid valves. Ac. Aorta. R. L Innominate artery. R. S. and R. C. 
 Right subclavian and carotid. L. S. and L. C. Left subclavian and carotid. 
 P. A. Pulmonary artery. V. C. S. Superior vena cava. 
 
 lies most superficially, and is placed to the left of the 
 sternum, and behind it and the third costal cartilage. 
 The aortic valves lie posteriorly and slightly inferiorly 
 
63 
 
 RELATION OF VESSELS 
 
 I 
 
 to the last, being placed opposite the lower part of the 
 third left cartilage and the third intercostal space. The 
 tricuspid valves lie behind the sternum at the level of 
 the fourth intercostal space and a part of the fourth 
 costal cartilage. The mitral valves, which are the most 
 deeply situated of all, lie under the left half of the 
 sternum and a small portion of the fourth left costal 
 cartilage. The student should bear in mind that these 
 are the anatomical positions of the valves, but in examin- 
 ing the chest with the stethoscope, they are not the 
 points at which murmurs at the various orifices are best 
 heard. Murmurs at the aortic orifice are most distinct 
 at the second right costal cartilage, sometimes called the 
 " aortic cartilage " from this fact ; those of the pulmon- 
 ary orifice are heard over the second left interspace 
 close 10 the sternum ; of the mitral at the apex-beat ; and 
 of the tricuspid at the ensiform cartilage. 
 
 V. Relations of Vessels, etc., to Thoracic Wall. 
 
 I. Aorta. — The ascending portion of the aortic arch 
 passes from the lower part of the third left costal car- 
 tilage to the upper border of the second right, and passes 
 just so far from under cover of the sternum that a needle 
 driven through the second right interspace, close to the 
 sternum, will penetrate the great sinus. The transverse 
 portion crosses behind the sternum, just below the 
 middle of the manubrium, a needle driven through at 
 that point passing immediately above it. The end of 
 
 n. 
 
TO THORACIC WALL. 
 
 63 
 
 the transverse and the descending portions form such a 
 <:urve that a needle, pushed in through the first left inter- 
 space beside the sternum, passes under the concavity of 
 the arch close to the ductus arteriosus, and enters the 
 right border of the descending portion deeper in the 
 thorax. 
 
 2. Innominate artery. — This vessel arises from the 
 arch at the middle of the manubrium, a needle pushed 
 through at this point passing through the left vena in- 
 nominata, the innominate artery, the trachea and oeso- 
 phagus, and lodging in the third dorsal vertebra. From 
 the point mentioned it passes upwards, and to the right 
 to terminate behind the right sterno- clavicular articula- 
 tion, or sometimes a little higher. 
 
 3. Iieffc common carotid. — This vessel arises from 
 the arch a little to the left of the middle line, and passes 
 to the left sterno-clavicular articulation. To its left 
 again arises the left subclavian artery, which is almost 
 direc<-ly behind the left common carotid whilst in the 
 thorax. 
 
 4. Superior vena cava. — A needle pushed through 
 the first right interspace, half an inch from the sternum, 
 pierces this vessel at the point of its formation by the 
 junction of the right and left innominate veins. A 
 needle pushed in through the third right interspace, half 
 an inch from the edge of the sternum, pierces the vein 
 where it opens into the right auricle. 
 
 5. Left vena innominata. — This lies transversely 
 behind the sternum and just below its upper border. It 
 may project into the neck, when the transverse part of 
 
 ! 
 
Vs. 
 
 fir 
 
 64 
 
 DIAPHRAGM. 
 
 the arch is situated at a higher level than usual as may- 
 be the case especially in children. 
 
 6. Inferior vena cava. — The opening of this vein 
 into the right auricle lies under the mesial portion of the 
 fifth right interspace, and the adjacent part of the 
 sternum. 
 
 7. Internal mammary artery. — This descends be- 
 hind the ck vide, the costal cartilages and the first six 
 intercostal spaces. It is situated about half an inch 
 from the edge of the sternum and parallel to it. 
 
 8. Trachea. — The trachea bifurcates at or just below 
 the angulus Ludovici, and opposite the fourth dorsal 
 vertebra. The right bronchus lies behind the cartilage 
 of the secoi'd right rib at the edge of the vertebral 
 column, and the left behind the second left interspace in 
 a similar position. 
 
 9. Diaphragm. — In the dead subject the dome of the 
 diaphragm is generally said to rise as high as the fifth 
 rib on the right side, and the sixth on the left. This is 
 of course subject to great variations, according to the 
 period of respiration in the living, ano may vary also in 
 the dead. Thus, a needle pushed through at the point 
 oi the apex-beat in the fifth interspace at the left side, 
 may pass twice through the diaphragm, wounding the 
 stomach intermediately. 
 
 I f 
 
THE ABDOMEN. 
 
 65 
 
 Chapter V. 
 
 THE ABDOMEN. 
 
 In this chapter the anterior part of the abdominal wall 
 alone is considered, together with its relation to the 
 viscera and other sti'v;tures. The posterior and 
 postero-lateral portions will be dealt with in the chapter 
 on the back, and the perineum and male and female 
 genitalia form a separate chapter. 
 
 
 1 
 
 tx 
 
 1 
 
 
 ; 1 
 
 
 
 
 R 
 
 
 1 
 
 
 '■■ 1 
 
 1 
 
 '•' i 
 
 1 
 
 ■ 
 
 V 
 
 1- 
 
 
 1 
 
 
 1 
 
 
 1 
 
 I. HoNY Prominencf.s. 
 
 The xiphoid cartilage and the costal arch have 
 already been alluded to. At the lower part of the 
 abdomen the creKt of the ilium and anterior superior 
 spine of th<' ilium are readily to be distmguished. In 
 the evf^ri posture a line drawn so as to connect the latter 
 piori;in>;nces ofi either fti/le, passes a little above the 
 promont//fy of the sacrum. The sympiiysis pubis, and on 
 either side of it the pubic spine, should be idcntifi<;d. 
 The former is covered by a pad of fat of considerable 
 size in females, in whom it is called the mons Ven<*ns, 
 the term mons Jovis being sometimes applied to it in 
 the male. Should any difficulty be found in distinguish- 
 ing the spine it may be discoverer} by inv.iginating the 
 
66 
 
 SKIN MARKINGS. 
 
 scrotum and pushing the finger up along the cord, or by 
 abducting the leg and tracing upwards the border of the 
 adductor longus muscle. The spine of the pubes is an 
 important landmark in connection with inguinal and 
 femoral herniae, as it lies inferior and external to the 
 first, and superior and internal to the last. It is nearly 
 in the same horizontal line as the apex of the great 
 trochanter. 
 
 II. Skin Markings, etc. 
 
 The linea alba forms the middle line of the abdomen, 
 it is the line of junction of the anterior aponeuroses in 
 the interval between the two recti muscles, and though 
 it extends from the xiphoid cartilage to the pubes, is 
 only distinctly marked as a groove above the umbilicus. 
 It is the thinnest and least vascular part of the abdo- 
 minal wall, for which reasons it is selected usually as 
 the site of the incision in abdominal sections. On each 
 side of it lies the prominence of the rectus muscle, 
 bounded externally by a curved line, the linea semi- 
 lunaris, which extends from the tip of the ninth or tenth 
 costal cartilage to the spine of the pubes. The rectus 
 muscle is intersected by certain horizontal lines, the 
 lineae Iransversfe. There are usually three of these, 
 one being placed at the tip of the xiphoid cartilage, a 
 second midway between it and the umbilicus, or on a 
 level with the tenth costal cartilages, and the third at 
 the umbilicus itself. A fourth may be present below 
 
! 
 
 SKIN MARKINGS. 
 
 67 
 
 the umbilicus. The position of the umbilicus is some- 
 what variable, but always below a point midway be- 
 tween the xiphi-sternal articulation and the symphysis 
 pubis. It is generally described as corresponding to the 
 disk between the third and fourth lumbar vertebrae, or 
 
 Fig. 9.— Diagram of Anterior Surface of Abdomen. 
 
 .1. Xiphoid cartilage, b. b. Costal arch. c. c. Linea alba. d. d, Lineo: semi- 
 lunarcs. t.'.i'. Line.L- transversa. /.Umbilicus, g.g. Poupart's ligaments. A. .Ab- 
 dominal .iurta. I Common, k. External iliac arteries. /. Internal, m. E.\ternal 
 abdominal rings. )i, Supra-pubic fold. 
 
 to the tip of the spinous process of the third lumbar 
 yertebra. 
 
 Th« oWer writers i>elieved it to be the central point 
 of th* body, but tfeie; idf a is incorrect. According to 
 }4g, Roberts (AnthvopomJry) "at the time of birth, when 
 mt /fJifA\A IB about the sixth of the height it will ulti- 
 
 V2 
 
 1 
 
 1 1 
 
 1 J 
 
 j i 
 
 i ! 
 
 ■ \ i 
 
 t »«'' ' 
 
 ■ 
 
i;« 
 
 f 
 
 68 
 
 SKIN MARKINGS. 
 
 mately attain to, the point which divides the total height 
 into two equal parts is a little above the navel ; at two 
 years of age it is at the navel ; at three years, when the 
 child has attained half its total height, the central point 
 is on a line with the upper borders of the iliac bones ; 
 at ten years of age, when the child has attained three- 
 fourths of its total height, the central point is on a line 
 with the trochanters ; at thirteen years it is at the 
 pubes, and in the adult man it is nearly half an inch 
 lower. In the adult woman the central point is a little 
 above the pubes." 
 
 In fat subjects two lines cross the abdomen trans- 
 versely, one at the umbilicus and one above the pubes. 
 When the bladder is tapped above the pubes the trochar 
 is passed through the linea alba at the point where it is 
 intersected by the latter. 
 
 Poupart's ligament may be seen and felt extending 
 in a gentle curve convex downwards, from the anterior 
 superior spine of the ilium to the spine of the pubes. 
 The external abdominal ring lies just above the crest of 
 the pubes, having the spine external to it. It may be 
 felt by invaginating the scrotum and pushing the finger 
 up in front of the cord. 
 
 The internal ring is situated half an inch above the 
 middle point of Poupart's ligament. A line drawn from 
 one ring to the other will indicate the position and 
 limits of the inguinal canal. It should be remembered 
 that in the child at birth there is scarcely any true in- 
 guinal canal, as the rings almost overlie one another. 
 
 The position of the nerves of the abdomen is of ini-- 
 
STOMACH. 
 
 69 
 
 portance in connection v/ith certain forms of vertebral 
 disease which cannot here be particularly considered, 
 and the student should, therefore, be familiar with their 
 approximate position. The tenth nerve is nearly in a 
 line with the umbilicus, the eighth with the middle 
 linea transversa, the sixth and seventh supply the area 
 above this and between the two limbs of the costal arch. 
 The ilio-hypogastric and ilio-inguinal lie close above 
 Poupart's ligament. 
 
 III. Relations of Viscera to the Abdominal Wall. 
 
 . In the middle line behind the lint.", alba the dis- 
 position of the viscera from above downwards is briefly 
 as follows. Below the xiphoid cartilage lies a part of 
 the left lobe of the liver, beneath which is the stomach. 
 Next comes the transverse colon, then the small intes- 
 tine, and finally the apex of the bladder, if sufficiently 
 distended. It will now be necessary to consider these 
 and other viscera more particularly. 
 
 I. Stomach. — This organ, whilst comparatively fixed 
 at its cardiac extremity, is moveable to a considerable 
 extent at its pyloric, and consequently alters m its 
 relations according to the amount of its distension. 
 The cardiac orifice lies about one inch from the sternum 
 behind the seventh left costal cartilage, and corresponds 
 to the spine of the ninth dorsal vertebra posteriorly. 
 The fundus lies to the left of this and on a higher level, 
 rising as high as the upper border of the sixth sterno- 
 
 ^m- 
 
70 
 
 LIVER. 
 
 \ ,1 
 
 chondral articulation, or even higher, so as to be placed 
 just behind the apex of the heart. If a line be drawn 
 downwards from the right border of the sternum, and 
 another from the end of the bony portion of the seventh 
 rib, the point at which these intersect will indicate the 
 position of the pylorus in the empty condition of the 
 stomach. But when full the pylorus may move as much 
 as three inches to the right, so as to lie behind the 
 junction of the seventh and eighth right rib cartilages. 
 It is situated more superficially than the cardiac open- 
 ing. A line drawn so as to connect the tips of the tenth 
 costal cartilages will indicate the lower limit of the 
 moderately distended organ ; when further distended it 
 reaches to a point from f to i^ inches above the umbilicus. 
 In the operation of gastrostomy the incision is generally 
 made parallel \o the left side of the costal arch, and 
 about two fingers breadth below it, as the stomach is 
 here uncovered by liver, and in contact with the anterior 
 abdominal wall. This area is bounded on the right by 
 the edge of the liver, on the left by the cartilages of the 
 eighth and ninth ribs and below by a horizontal line 
 passing between the tips of the tenth costal cartilages. 
 
 2. Liver. — In the erect posture the liver descends 
 about half an inch below the costal arch, though it is a 
 matter of some difficulty to feel it in that position. It 
 is much more obvious beneath the xiphoid cartilage, 
 where in the angle of the costal arch the lower border 
 of the organ may be indicated by a line drawn from the 
 ninth right to the eighth left costal cartilage. The size 
 of the left lobe is somewhat variable, and its left 
 
Fio, lo. — DiiiKram of AiUtJiidr aspect of Abdomen and Thorax, showing 
 relalions of Viscera to Hurfncc [l.f .hka sltKhtly modifttct). lii'il, Liver; 
 Yellow, Stomach. ♦ Gail-hladd»i. 
 
 tl)i 
 
 i 
 
 W 
 
SPLEEN. 
 
 71 
 
 i 
 
 extremity may extend from an inch and a half external 
 to the sternum, or to any point between this and the 
 left mammillary line. Its extent is much greater in the 
 infant. The position of the convex upper surface 
 varies according to the posture, and to the period of re- 
 spiration at which it is examined. The convex surface 
 on the right side lies beneath the seventh to the 
 eleventh ribs inclusive, and the cartilages of the sixth 
 to the ninth also inclusive. On the left side it does not 
 reach so high a level. " The extent of the liver up- 
 wards 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 and on the left to that 
 of the sixth " (Quain). Under ordinary circumstances 
 about an inch of the left lobe lies to the right of the 
 middle line, but Symington has shown that the left 
 lobe and the anterior surface of the right have a 
 certain amount of mobility, and are displaced slightly 
 to the right when the stomach is distended. The gall 
 bladder has its fundus placed near the surface, by the 
 outer border of the right rectus muscle, and under the 
 ninth right costal cartilage. 
 
 Posteriorly the liver reaches the surface below the 
 the right lung opposite the tenth and eleventh dorsal 
 vertebrae and for an extent equal to that of their bodies. 
 
 3. Spleen. — This organ cannot be felt under the 
 edge of the ribs save when pathologically enlarged. It 
 lies beneath the ribs from the eighth or ninth to the 
 eleventh inclusive, and nearly in the line of the posterior 
 
 i 
 
72 
 
 PA NCREA S— INTESTINES. 
 
 '\ 
 
 part of the tenth. Its mesial extremity is about i^ 
 inches from the middle line, and its outer about the 
 same distance from the mid-axillary. It should, how- 
 ever, be remembered that it is subject, within physio- j 
 logical limits, to considerable variations in size. 
 
 4. Pancreas. — It is very rarely possible to feel this , 
 organ, but in a very thin subject with flaccid abdominal 
 walls, it may be distinguished. It lies on the vertebral 
 column over the disk between the first and second 
 lumbar vertebrae and the adjacent bodies, and should 
 consequently be sought in the middle line of the ab- 
 domen, nearly midway between the xiphoid cartilage 
 and the umbilicus. 
 
 5. Intestines. — Save where it is hidden by the liver 
 and spleen at the hepatic and splenic flexures, the 
 transverse colon is near to the surface, varying in height 
 from the region 01 the umbiM'. as or below it, to two inches 
 or so above. When dilated by gas its situation may be 
 ascertained by percussion, and masses of hardened 
 faeces, when present, can be felt in its interior. The 
 caecum, which is the most superficial part, lies in the 
 right iliac fossa. The sigmoid flexure, lies in the left 
 iliac fossa. The vermiform appendix lies in a line from 
 the anterior superior spine to the umbilicus and about 
 three inches from the former (McBurney's point). The 
 small intestine occupies the portion of the abdomen 
 below the transverse colon. Mr. Treves concludes from 
 his laborious investigations, that it is impossible to ^ 
 localise the position of any of the coils connected with 
 the mesentery. 
 
 i \ 
 
 r. 
 
VESSELS. ^ 
 
 73 
 
 6. Bladder. — The bladder cannot be distinguished 
 above the pubes save when distended. In this con- 
 dition it may extend up to the umbilicus, or to any 
 point between it and the pubic symphysis. In extreme 
 distension from retention of urine, its outline can easily 
 be distinguished, and the fluctuation of its contents 
 felt. It carries the peritoneum before it as it pushes its 
 way upwards, so that an uncovered space of greater or 
 less extent exists, through which the trocar is passed in 
 the operation of tapping above the pubes. 
 
 Other points in connection with the colon and the 
 kidneys will be dealt with in the chapter on the back. 
 
 IV. Relation of Vessels to the Abdominal Wall, 
 
 The abdominal aorta commences rather above the 
 centre of a line drawn from the supra-sternal depression 
 to the umbilicus ; lies on the left side of the vertebral 
 column, and generally divides into the two common iliac 
 arteries opposite the middle of the body of the fourth 
 lumbar vertebra. Its bifurcation is, however, subject to 
 considerable variations. 
 
 When it divides at the usual situation it will nearly 
 correspond to a point a little to the left side of the centre 
 of a line drawn so as to connect the highest parts of the 
 two iliac crests. This point will be placed about f of 
 an inch below and to the left of the umbilicus. If two 
 lines be drawn from it, curving slightly outwards, 
 to a point a little internal to the middle of either 
 
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 74 
 
 VESSELS. 
 
 m 
 
 Poupart's ligament, they will correspond to the common 
 and external iliac arteries. The former of these vessels 
 is somewhat variable in length, but, speaking generally, 
 about two inches of either line, or rather more on the 
 right, will correspond to its limits. A line drawn from 
 the point where Poupart's ligament crosses the external 
 iliac to the edge of the rectus, about an inch or more 
 below the umbilicus, will indicate -the position of the 
 deep epigastric artery, and the triangle thus included 
 will correspond to Hesselbach's triangle. The coeliac 
 axis corresponds to the twelfth dorsal vertebra behind, 
 and to a point four or five inches above the umbilicus 
 in front. The superior . mesenteric artery arises just 
 below this, and the renal arteries an inch lower down. 
 The inferior mesenteric is given off about an inch above 
 the umbilicus 
 
THE MALE. 
 
 75 
 
 Chapter VI. 
 
 THE PERINEUM AND GENITALIA. 
 
 I. The Male. 
 
 The student should first of all practise the operation of 
 passing the catheter or sound, a procedure more difficult 
 in the dead subject than in the living, when the latter 
 is not affected with a stricture. The sound should be 
 well oiled, and its passage will be facilitated by dilating 
 the mouth of the urethra and pouring a little oil into it. 
 The operator should stand on the left side of the body 
 and hold the penis in the left hand. Stretching the 
 penis he should introduce the instrument, keeping the 
 handle in the line of the left groin at first. As it glides 
 down the urethra it should gradually be carried towards 
 the middle line, until its direction corresponds with the 
 long axis of the body, from which it should not be 
 allowed to swerve. When the instrument has been 
 passed a certain distance a slight obstruction will be 
 met with, which is the base of the triangular ligament. 
 The handle should then be slightly depressed, when a 
 little gentle pressure will carry the point of the instru- 
 ment into the bladder. If the student finds it difficult 
 to accomplish this he may pass his left forefinger into 
 the rectum and guide the point of the instrument, which 
 
76 
 
 PENIS —SCROTUM— FERINE UM. 
 
 will be easily felt with the point of the finger. Having 
 passed the sound into the bladder, it should be with- 
 drawn, and the manoeuvre repeated several times. The 
 instrument may then be left in the bladder. 
 
 1. Penis. — This organ should next be examined. 
 The large dorsal vein will generally be visible on its 
 upper surface, and on either side of it,- in a well injected 
 subject, an artery may be visible. The prepuce should 
 be reflected and its fraenum examined. The glans, with 
 its corona at its base, and the constricted portion or 
 cervix, around which are collected the glands of Tyson, 
 will then be seen. 
 
 2. Scrotum. — The spermatic cord should be felt and 
 the vas deferens distinguished from its other constit- 
 uents, which can easily be done by its whipcord-like 
 feel. The testicle is of course easily to be felt, and the 
 epididymis lying posteriorly and superiorly should be 
 distinguished from the gland itself. The rugae of the 
 scrotum are much less distinct in the dead subject than 
 in a healthy living individual, on account of the relaxa- 
 tion of the muscular fibres of the dartos. 
 
 A median line or raphe, continuous with a similar 
 line in the perineum, indicates the position where the 
 originally separate halves came together and united in 
 the process of development. 
 
 3. Perineum. — The scrotum should now be hooked 
 up on the front of the abdomen, and the body placed in 
 the lithotomy position, so that the perineum may be 
 examined. This position is maintained by different 
 methods in different schools, so that no particular 
 
 V) 
 
V, 
 
 PERINEUM. 
 
 17 
 
 
 description need be given. The boundaries of the 
 perineum should first be ascertained. Commencing 
 in front, the pubic arch, rounded off by the sub-pubic 
 ligament will be felt, and passing round on either side 
 the rami of the pubis and ischium up to the tuberosity 
 of the latter. In the middle line behind is the coccyx, 
 and on either side of it the great sacro-sciatic ligament 
 may be distinguished under cover of the edge of the 
 gluteus maximus muscle. A line from the most pro- 
 minent part of one tuber ischii to the other divides 
 this diamond-shaped space into two triangles, an 
 anterior or urethral, and a posterior or rectal. It is 
 divided also by the mesial ridge or raphe, which has 
 already been alluded to. Like many other middle lines 
 of the body, this last is comparatively non-vascular, 
 and incisions should consequently there be made for the 
 escape of extravasated urine. • 
 
 The central point of the raphe between the scrotum 
 and anus corresponds to the central tendinous point of 
 the perineum, or point of junction of the perineal 
 muscles. This is placed at the centre of the lower 
 border of the triangular ligament, which may be felt on 
 each side of it when the legs are straight and the parts 
 relaxed. The bulb of the urethra and its artery are 
 always placed in front of this point. The urethra 
 pierces the triangular ligament about three quarters of 
 an inch in front of it, and its position can be distinctly 
 felt when the sound is within it. 
 
 Around the anus, in dissecting room subjects, knots 
 of venous enlargement or piles are not uncommonly 
 
 f i 
 
78 
 
 PERINEUM. 
 
 the most prominent structures. Apart from these 
 pathological structures, the student will note the radiat- 
 ing folds into which the mucous membrane is thrown, 
 as also a thin white line surrounding the aperture where 
 the skin and mucous membrane join, which indicates 
 the line of division between the external and internal 
 sphincters. By everting the mucous membrane of the 
 rectum slightly, the small pouches, one to three lines in 
 depth, which lie between the ends of the columnae recti, 
 and are sometimes the seat of ulceration, will be seen. 
 
 The left forefinger should now be introduced into the 
 rectum, while the staff is held in the right hand so that 
 it may be moved about when necessary. In the 
 anterior part of the cavity, the student will feel the sound 
 in the membranous part of the urethra. It is here that 
 strictures most commonly occur, and that the catheter 
 requires at times that careful guidance, which, as will 
 now be perceived, the finger in the rectum can give to 
 it. Passing further upwards, the apex of the prostate 
 gland will be met with at about an inch and a half from 
 the anus, and the shape of the gland can be explored. 
 About an inch and a quarter higher up, the superior 
 border of the prostate will be reached, and the finger 
 having passed beyond it will touch that part of the 
 rectum where the bladder is in contact, without the 
 intervention of peritoneum, and where the operation of 
 tapping per rectum is performed. On each side of this 
 point are placed the common ejaculatory ducts and 
 seminal vesicles. The lowest of the transverse folds, 
 valves of Houston or plicae transversales, may be dis- 
 
 i\ 
 
 At 
 
v. 
 
 PERINEUM, 
 
 79 
 
 tinguished on the left side at about the level of the 
 prostate, the next, about four inches from the anus, is 
 on the right side, and roughly marks the lowest point 
 to which the recto- vesical pouch of peritoneum descends. 
 Otis has shown that by placing the dead body in what 
 is known as the knee- elbow position, the rectum be- 
 comes dilated by atmospheric pressure, and by suitable 
 illumination (electrical) three or four of these plicae can 
 be seen placed alternately on either side of the tube. 
 Contrary to a commonly received view, he denies that 
 they have any action as valves in holding back the 
 faeces. At the sides of the rectum the finger can ex- 
 plore the ischio-rectal fossae, and finally behind, near 
 the orifice, the coccyx will be felt. It is sometimes 
 movable in males, generally freely so in women who 
 have borne many children. 
 
 Before leaving he perineum the student should mark 
 out the lines of tlie incisions made in the operations of 
 lithotomy. In tht lateral operation the incision is com- 
 menced a little to the )«»ft of the middle line, and just 
 below the central tendino s point, and i*- then carried 
 downwards and outwards lor two or three inches to a 
 point just below the anus, but one-third nearer to the 
 tuberosity of the ischium than to the margin of that 
 orifice. 
 
 In the median operation the edge of the knife is 
 turned upwards instead of downwards, and its point is 
 entered in the middle line about half an inch in front of 
 the anus, and carried onwards until it strikes the groove 
 in the staff which is lying in the urethra. 
 
8o 
 
 THE FEMALE. 
 
 II. The Female. 
 
 m 
 
 The labia majora, covered with hair on the outer 
 surface, and on their inner with mucous membrane, are 
 the first objects visible ; they unite below the mons 
 Veneris and in front of the perineum, these junctions 
 being known as the anterior and posterior commissures. 
 When these folds are separated, two smaller folds of 
 mucous membrane, the nymphae or labia minora, will 
 be seen, each being about an inch and a half in length. 
 Traced upwards these will be found to be continuous 
 with the prepuce, covering the glans of the clitoris. 
 Below the nymphae, and uniting the labia majora, there is 
 in the nullipara a transverse fold, the fraenulum pudendi, 
 forming with the posterior commissure a triangular area, 
 the fossa navicularis. The student will generally seek 
 in vain for these in dissecting room subjects, as the 
 first parturition usually destroys them. Between the 
 nymphae is the vestibulum, and in it, about an inch 
 below the clitoris, is the opening of the urethra. A 
 tubercle is often stated in text-books to be placed at 
 this orifice, but as a practical landmark it is almost 
 valueless. Having ascertained the position of the orifico 
 the student should practise passing the catheter. As 
 this operation has to be performed on the living subject 
 without causing exposure, it is well to accustom the 
 fingers to the parts engaged. The subject should be 
 placed on its back, with the knees slightly bent and 
 separated from one another, and the operator should 
 
 h 
 
 
 
PERINEUM. 
 
 8i 
 
 stand on the left side. The forefinger of the left hand 
 should be passed down between the vulvae, over the 
 clitoris, and into the vestibule, where the orifice of the 
 urethra may sometimes be felt. In any case, by pass- 
 ing the point of the catheter along the palmar surface 
 of the finger, it can, with a Httle practice, be made to 
 enter the urethra easily. The ordinary sound found 
 in dissecting rooms is an inconvenient instrument for 
 the purpose, but a probe may be used, or still better, 
 a piece of small sized glass tube about six or eight 
 inches in length, one end of which has been sealed and 
 rounded in a flame, and at the same time slightly bent. 
 When the student has familiarised himself with this 
 operation, he should leave the instrument in situ, and 
 examine the relation of the urethra, which passes just 
 below the sub-pubic ligament and the posterior wall 
 of the bladder to the vagina. The close connection be- 
 tween the walls of these two cavities, and their com- 
 parative thinness, lead to their occasional rupture and 
 the formation of a vesico- vaginal fistula. The same 
 might be said of the posterior wall, where recto-vesical 
 fistula occurs. The proper orifice of the vagina is just 
 below the meatus urinarius, and is generally narrowed 
 in the virgin by the hymen. This is a structure which 
 is seldom seen in the dissecting room, but may be 
 studied in a female foetus at full term or in the post- 
 mortem room, in the bodies of virgins. The examina- 
 tion of a sufficient number will teach the student that 
 it is variable in size and shape. It may even in the 
 virgin be entirely absent, or represented by a fringe^ 
 
 G 
 
82 
 
 PERINEUM, 
 
 i I 
 
 ! h 
 
 On the other hand it may be imperforate, or its opehing 
 may be so small as only to admit the point of a probe. 
 The aperture may be enlarged so that the hymen forms 
 a circular ring, but most commonly it is semilunar, with 
 its concavity directed towards the pubes. From all this, 
 the student will perceive that any diagnosis of virginity, 
 or the reverse founded upon the condition of the hymen 
 alone, must be very guarded in its nature. After its 
 rupture, small w^art-like remains, the carunculae myrti- 
 formes, may persist, but these generally disappear after 
 a few parturitions. 
 
 The forefinger should be passed into the vagina, and 
 the OS uteri with the anterior and posterior cul-de-sac 
 explored. The posterior is the higher, and corresponds 
 to the pouch of Douglas or recto-vaginal pouch in the 
 cavity of the abdomen. This is the lowest point of that 
 cavity, and the position, therefore, where fluid will first 
 collect. One forefinger may be passed into the rectum 
 and the other into the vagina, and the wall between 
 examined. At the highest part the recto-uterine fold of 
 peritoneum will lie between the fingers. The description 
 of the anus, mucous folds of the rectum, ischio-rectal 
 fossa, and coccyx, in the male, need not be repeated 
 for the female. Between the anus and the uro-genital 
 fissure, lies the perineum of the obstetrical text-books, 
 about one inch in breadth. It is easy to see how the 
 head of the child in parturition may tear through this, 
 and even through the rectum and anus. V 
 
 /•> 
 
THE BACK. 
 
 83 
 
 • ■^^ 
 
 Chapter VII. ' 
 
 V- •: ; '■ , , ■ ■ -" . _'-■ ' >'V ■ ■ '■ 
 
 THE BACK. * 
 
 In the middle line of the back there is a furrow, more or 
 less well-marked, according to the muscularity of the 
 subject, and bounded by muscular masses, which are 
 formed chiefly by the complexus muscle of either side 
 in the cervical region, and by the erectores spinae in the 
 remainder of the back. At the bottom of this furrow 
 the spines of the vertebrae may be felt, and, as Holden 
 remarks, made evident in the living subject to the 
 eye by friction in the median line, when red patches 
 will appear and indicate their position. The spine of 
 the axis may easily be felt beneath the occiput, and that 
 of the seventh or vertebra prominens at the root of the 
 neck, with frequently the spine of the sixth above it. 
 The spines of the vertebrae between the second and the 
 sixth cannot be felt as individual structures, but a ridge 
 indicating their position and that of the ligamentum 
 nuchae can distinctly be made out. 
 
 The third dorsal spine corresponds to the inner end 
 of the spine of the scapula, and the seventh to the 
 inferior angle of that bone. The twelfth corresponds to 
 the head of the last rib, and the lowest part of the 
 trapezius muscle, which may be made evident in a thin 
 
 G2 
 
 n 
 
 ! 
 
U' 
 
 " i!ii 
 
 Mi 
 
 84 
 
 THE BACK. 
 
 subject by raising the arm and scapula as high as 
 possible. The highest point of the crest of the ilium 
 corresponds to the fourth lumbar spine. On account of 
 the downward direction of the spines of the dorsal ver- 
 tebrae, these prominences do not all correspond to the 
 rib which belongs to them. The second dorsal spine 
 corresponds to the head of the third rib, and so on, each 
 spine corresponding to the head of the rib of the ver- 
 tebra below it, until the eleventh and twelfth spines, 
 which are on a level with their own ribs. 
 ., The scapula covers the ribs from the second to the 
 seventh inclusive, and its superior and inferior angles 
 and spine can easily be distinguished. - . . . 
 
 The crest of the ilium and its posterior superior spine 
 can be felt ; at the central point of the former there is a 
 triangular space bounded by the latissimus dorsi and 
 external oblique muscles, known as Petit's triangle. 
 The upper limit of the origin of the latissimus dorsi 
 corresponds to a line drawn from the sixth dorsal spine 
 transversely across the scapula. 
 
 The trachea bifurcates at a point midway between 
 the third and fourth dorsal spines, the roots of the lungs 
 thus lying a little below and external to that point, the 
 edge of the lung extending as low as the spinous process 
 of the tenth dorsal vertebra. The apex of the lower 
 lobe is at the level of the third rib behind. The pleura 
 reaches to the tenth dorsal spine or even lower. 
 . The thoracic aorta commences at the left side of the 
 vertebral column opposite the fourth dorsal spine ; 
 thence passes downwards, gradually approaching the 
 
 '•, 
 
 \\ 
 
SPINAL CORD AND NERVES. 
 
 85 
 
 anterior aspect to bifurcate opposite the fourth lumbar 
 spine. ' • . ' , V 
 
 Spinal cord and nerves. — The cord extends in 
 the adult from the under surface of the foramen 
 magnum to the lower edge of the first lumbar vertebra 
 as a rule, or on the other hand, may be as low as the 
 second lumbar. Its position alters slightly in the move- 
 ments of the body, as it rises during flexion of the spine. 
 In the child at birth it extends to the third lumbar 
 vertebra. The cervical nerves are named after the 
 vertebra above which they escape, the first nerve 
 emerging above the first vertebra, and the eiglith below 
 the seventh, and between it and the first dorsal. The 
 remaining nerves are numbered after the vertebra beiow 
 which tiicy escape. In relation to the symptoms follow- 
 ing upon fractures and dislocations of different parts of 
 the spinal column, it is important to know the point at 
 which each nerve arises from the spinal cord, this point 
 by no means corresponding to that at which it emerges. 
 
 The following rule will enable the student to find the 
 relationship of the root origin of the cervical and dorsal 
 spinal nerves to the spines of the vertebrae with suffi- 
 cient accuracy. For the upper four nerves subtract 
 one from the number of the nerve, thus the root origin 
 of the third cervical is opposite the second spine. For 
 the lower four cervical and upper six dorsal, subtract 
 two from the number of each nerve, thus the root origin 
 of the eighth cervical is opposite the sixth cervical spine. 
 For the lower six dorsal nerves subtract three from the 
 pumber of the nerve, thus the root origin of ninth dorsal is 
 
 I 
 
 it 
 
86 
 
 KIDNEYS. 
 
 opposite the sixth dorsal spine. 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. It is right, however, to say 
 that these relations are subject to considerable varia^ 
 tions. 
 
 Kidneyi. — The kidneys lie on a level with the last 
 dorsal and first two or three lumbar vertebrae, the right 
 being about half an inch or more lower than the left, so 
 that about one and a half inches on the left, and one 
 inch on the right, intervene between the lower border 
 of the gland and the iliac crest. The hilus lies from 
 two to two and a half inches from the middle line, and 
 is about opposite the first lumbar spine. The following 
 method of mapping out the kidney on the posterior 
 aspect of the body may be adopted: — i. Draw a line 
 parallel with and one inch from the spine, between the 
 lower edge of the tip of the spinous process of the 
 eleventh dorsal, and the lower edge of the spinous pro- 
 cess of the third lumbar vertebra. 2 and 3. Lines 
 drawn from the top and bottom of this line outwards at 
 right angles to it for 2f inches. 4. A line parallel to the 
 first and connecting 2 and 3. Within this parallelogram 
 the kidney lies (Morris). In the normal condition it is 
 difficult to feel these organs, but in a thin subject with 
 flaccid walls the rounded outer border may be made 
 out. When abnormally enlarged they may be distin- 
 guished, and in searching for them the student should 
 adopt the following method. Stand on the side of the 
 body opposite to the kidney to be examined, pass one 
 
 / 
 
Fio. II.— Diagram of posterior aipect of Abdomen and 'fliorax, KhowinR 
 relatiotiB of Viscera to surface. Heil, Liver; I'urfle, Spleen; Yellow, the 
 Kidneys and Ureters. (Modified from Lusthhd). 
 
. / 
 
 . 
 
 I ' 
 
 
 V 
 
 ■m\ 
 
 w 
 
COLON-^CERVICAL. 
 
 87 
 
 hand under the back until the fingers slip over the edge 
 of the erector spinae muscle of the opposite side, then 
 press backwards with the other hand upon the anterior 
 abdominal parietes, so that the points of the fingers of 
 either hand may be brought as near to one another as 
 possible, when the organ may be felt between them. 
 
 Oolon. — The ascending and descending parts of the 
 colon can be approached through the posterior parietes 
 of the abdomen in the lumbar region between the crest 
 of the ilium and the last rib, but the operation of colo- 
 tomy is, for various reasons, generally performed upon 
 the latter. The incision in this operation is made from 
 the edge of the erector spinae muscle, at a point midway 
 between the crest of the ilium and the last rib, and 
 parallel to the last named structure. 
 
 This seems to be the best place to give a table of the 
 relations of certain of the viscera and other structures 
 to the bodies of the vertebrae, which it is hoped may be 
 useful to the student as a guide to the topography of the 
 parts in and near the middle line. 
 
 Oervical. 
 
 1. Level of hard palate. 
 
 2. Level of free edge of upper teeth. 
 
 3 & 4. Superior cervical ganglion of sympathetic. 
 
 4. Hyoid bone and upper aperture of larynx. 
 
 5. Middle cervical ganglion ; rima glottidis. 
 
 6. Cricoid cartilage, end of pharynx, commencement 
 
 of oesophagus and trachea. 
 
 7. Inferior cervical ganglion. 
 
I 
 
 
 «8 
 
 DORSAL— L UMBAR. 
 
 Dorial. 
 
 I. Apex of lung. 
 ■ 2. Termination of second part of aortic arch (L). 
 Disk. Level of episternal notch. 
 
 3. Termination of arch of aorta (L). Bifurcation of 
 
 trachea (lower border). 
 
 4. Level of angulus Ludovici. 
 5 to 8. Base of heart. 
 
 6. Pulmonary orifice. > 
 
 7. Aortic orifices. .' • 
 
 8. Mitral and tricuspid orifices. 
 
 9. Level of lower end of gladiolus. Opening in dia- 
 
 phragm for vena cava inferior, g to 11. Spleen. 
 
 10. Level of tips of xiphoid cartilage. Opening in 
 
 diaphragm for oesophagus. Lower limit of lung 
 posteriorly (transverse process). 10 and 11. 
 Spigelian lobe of liver. 
 
 11. Supra-renal capsule ; upper end L. kidney. 
 
 12. Disk — upper end of R. kidney. Aortic orifice in 
 
 diaphragm, coeliac axis (lower border). .; 
 
 Iiumbar. ^- 
 
 1. Pancreas. Superior mesenteric artery (lower bor- 
 v der). Hilus of kidney (spine). Receptaculum 
 
 chyli. * • -.v: • ::.; , y • " '••", •' 
 
 :■;•• Lower end of spinal cord. » \ 
 
 2. Upper limit of third stage of duodenum (L). Renal 
 
 arteries. ' . , ■.•• 
 
 \\ 
 
L UMBA R—SA CRA L— COCCYX, 
 
 89 
 
 laumbar. 
 
 3. Lower limit of second stage of duodenum (R). 
 
 Inferior mesenteric artery. 
 Disk. Umbilicus. 
 
 4. Bifurcation of aorta. Level of highest point of 
 
 crest of ilium. 
 Disk. Ilio-caecal valve. 
 
 5. Commencement of inferior vena cava. 
 
 Sacral. ;*;" "'"''•" 
 
 3. End of first stage of rectum. 
 
 -r " ■ • • . 
 
 Cocc3rx, tip. 
 
 End of second stage of rectum. 
 
 - . /; 
 
 •\ • • f ■ , 
 
go 
 
 SHOULDER AND AXILLA, 
 
 ':! 
 
 f 1 H 
 
 Chapter VIII. 
 
 ,/'" '■ ■ ^ \ ^ 
 
 •' UPPER EXTREMITY. '^ 
 
 , ~ I. Shoulder and Axilla. 
 
 I. Bony points. — The clavicle may be seen and felt 
 in its entire extent. In the ordinary position in men 
 it is not horizontal but slopes upwards from the middle 
 line, the amount of this slope being increased when 
 the weight is taken off the arm as in the recumbent pos- 
 ture. But in women commonly, and sometimes in men 
 also, its slope is downwards from the middle line. The 
 outer extremity of the clavicle leads to the acromion 
 process, which, with the spine of the scapula, is quite 
 distinct. The tip of the former is one of the pro- 
 minences from which measurements of the upper limb 
 are made, and it may be remembered that in the hanging 
 position of the arm, the palm being directed forwards, 
 it is in the same line as the external condyle of the 
 humerus and the styloid process of the radius. The 
 student should remember that the end of the acromion 
 process may be unconnected with the spine, by a failure 
 of bony union between the centres from which it and the 
 spine are developed. Under cover of the deltoid muscle 
 the two tuberosities of the humerus will be felt, the 
 greater being external and in the line of the external 
 
 r, 
 
SHOULDER AND AXILLA. 
 
 91 
 
 condyle, the lesser anterior. Between them the bicipital 
 groove and tendon may sometimes be distinctly made 
 out. By placing the hand on the apex of the shoulder 
 and the thumb in the axilla, and pressing deeply with 
 the latter, the arm being in the dependent position, the 
 neck of the scapula and the lower border of the glenoid 
 fossa can be distinguished. If now the arm be abducted 
 and the thumb moved a little outwards the head of the 
 humerus will be felt, and can be easily identified by 
 rotating the arm, when its shape will be distinctly re- 
 cognized. It lies in the same line as the internal 
 condyle. By deep pressure beneath the clavicle, in the 
 interval between the deltoid and pectoralis major mus- 
 cles, the tip of the coracoid process will be felt under 
 the former. This is another point from which measure- 
 ments of the upper extremity are made, and is also 
 valuable as a guide to the axillary artery in its first 
 stage. 
 
 2. Soft parts. — The point of the shoulder is capped 
 over by the deltoid muscle, the limits of which are 
 easily to be defined. Under ordinary circumstances it 
 forms a smooth rounded surface over the subjacent 
 bony prominences ; but in dislocation downwards of the 
 humerus, and to a lesser degree in paralysis of the 
 deltoid following upon injury to the circumflex nerve, a 
 depression will be visible at the outer part of the shoulder 
 corresponding to the interval between the head of the 
 humerus and the acromion process. In the groove 
 between the deltoid and pectoralis major lie the cephalic 
 vein and the humeral thoracic artery. The coraco- 
 
 lll* 
 
 I, 
 
92 
 
 SHOULDER AND AXILLA. 
 
 \- ■ '. 
 
 acromial ligament lies under the anterior fibres of the 
 deltoid, and may there be distinguished, the shoulder 
 joint being immediately underneath it. Under the 
 clavicle is a hollow of variable depth, the sub-clavicular 
 fossa, in which the axillary vessels lie ; it is obliterated 
 or replaced by a prominence in certain dislocations of 
 the humerus. At a lower level the line of division 
 between the clavicular and sternal portions of the pec- 
 toralis major may be distinctly seen in some subjects. 
 The student should next examine the axilla and move 
 the arm in different directions so as to observe the 
 alterations in its shape caused thereby. Its base is 
 somewhat triangular, the apex being at the humerus, 
 and the base at the chest wall. The anterior fold 
 contains the pectoralis major, and the posterior, the 
 latissimus dorsi. The depression between the anterior 
 and posterior folds is deepest when the arm is at an 
 angle of 45° with the chest, and shallowest when the 
 arm is raised above the level of the shoulder. The 
 hollow, however, never quite disappears, a fact which is 
 partly due to the action of the suspensory ligament, a 
 part of the deep fascia connected with the skin below. 
 The skin of the axilla is well supplied with hairs, 
 sebaceous and sweat glands. Three sets of lymphatic 
 glands are contained in the axilla, which, however, can- 
 not be felt unless enlarged. These are placed, (i) along 
 the anterior fold, (2) along the posterior, (3) along the 
 vessels, j . • " 
 
 When the arm is stretched out at a right angle to the 
 body, the prominence of the coraco-brachialis muscle 
 
 I I 
 
 A 
 
 w 
 
SHOULDER AND AXILLA. 
 
 93- 
 
 I 
 
 may , be distinctly seen passing down to the middle of 
 inner border of the humerus. If the arm be maintained 
 in this position, and a line drawn from the centre of the 
 clavicle to the humerus, internal to the lower end of the 
 coraco-brachialis, it will correspond to the axillary 
 artery. This vessel may be compressed in its first stage 
 against the second rib, beneath the clavicle and internal 
 to the coracoid process, pressure being applied down- 
 wards and backwards. In its third stage it may be 
 compressed against the humerus by the side of the 
 coraco-brachialis, pressure here being applied outwards 
 and a little backwards. In its second stage it lies 
 deeply beneath the pectoralis minor muscle. The 
 boundaries of this last may be defined by two lines start- 
 ing from the coracoid process, and running, the upper to 
 the third rib close to the cartilage, and the lower to a 
 similar point on the fifth rib. The point where the 
 upper line crosses the line of the axillary artery indicates 
 the site of the acromial axis. The long thoracic artery 
 runs along the lower border of the pectoralis minor and 
 consequently corresponds to a portion of the second line. 
 The axillary vein is internal to its artery, lying in the 
 angle between the clavicle and the first rib, and the 
 nerve cords of the brachial plexus are, in the first stage, 
 external to it. ' ' - "' • •" 
 
 The circumflex nerve winds round the back of the 
 humerus, a little above the middle point between the 
 apex of the shoulder and the lowest part of the insertion 
 of the deltoid and its cutaneous branches ramify over 
 the lower part of that muscle, the supra-acromial 
 
 i ■! 
 
l! 
 
 94 
 
 ARM AND ELBOW. 
 
 branches of the cervical plexus lying over its upper 
 portion. I 
 
 II. Arm and Elbow. ' \<., 
 
 I. Arm. — On either side of the distinct rhedian pro- 
 minence of the biceps will be seen a depression, that on 
 the inner side being the better marked. These grooves 
 are caused by the two partitions of fascia which cut off 
 the anterior from the posterior muscles of the arm, the 
 intermuscular septa. The external groove passes from 
 the muscles above the outer condyle to the lower end of 
 the insertion of the deltoid and corresponds also to a 
 part of the cephalic vein.. The internal groove extends 
 from near the internal condyle to the insertion of the 
 coraco-brachialis muscle and indicates a portion of the 
 course of the brachial artery which lies on its outer side. 
 The course of this vessel may be marked out by a line 
 drawn from the inner side of the coraco-brachialis at its 
 insertion to the centre of the elbow joint. Throughout 
 it may easily be felt as it lies close beneath the skin, and 
 may also be compressed against the humerus, though 
 the direction in which the pressure is applied differs 
 above where it lies internal to the bone, and below 
 where it lies in front of it. The inner edge of the 
 bicipital prominence is the guide to the surgeon in 
 making his incision for the ligature of this artery in its 
 upper part. Its first branch, the superior profunda, 
 winds round the back of the arm with the musculo-spiral 
 nerve at the level of the lowest point of the insertion of 
 
 iin 
 
 A 
 
 l\ 
 
ARM AND ELBOW. 
 
 95 
 
 the deltoid. It may be remembered that this point 
 which is at the centre of the shaft of the humerus 
 corresponds to the junction of the cylindrical and 
 prismatic portions of that bone, a favourite site for 
 fractures. A short distance below the insertion of the 
 deltoid the cutaneous branch of the musculo-spiral nerve 
 appears close to the external intermuscular septum. 
 The triceps muscle is the only structure to be studied on 
 the back of the arm ; its details can be seen when a 
 living person forcibly extends the forearm on the arm. 
 The flat tendinous surface below with its pointed upper 
 extremity and the two muscular masses, one arising on 
 either side of it, are then brought into view in a well 
 developed subject. 
 
 2. Elbow, a. Bony points. — The two condyles of the 
 humerus should first be studied. The internal is the 
 more prominent, descends lower, and is further from the 
 line of the articulation than the external (more than one 
 inch as compared with three-quarters of an inch). It 
 can easily be grasped by the fingers as it lies under the 
 skin, and the edge of the trochlear portion of the lower 
 end of the humerus will be felt about three-quarters of an 
 inch from its apex. The internal supra-condyloid ridge 
 can only be traced for a short distance above it, but a 
 sharp fibrous band will be felt under the skin, which is 
 the internal intermuscular septum at its lower end. Be- 
 tween the internal condyle and the olecranon is a de- 
 pression in which lies the ulnar nerve (the "funny- 
 bone" as it is commonly called), the posterior ulnar 
 recurrent and the posterior branch of the inferior pro- 
 
 
 ^1 
 
96 
 
 ARM AND ELBOW. 
 
 
 H 
 
 ill 
 
 iii'i 
 
 funda artery. The external condyle is less prominent, 
 more rounded at its extremity, placed higher and nearer 
 to the joint line. It can be distinctly felt, and especially 
 posteriorly, and the external supra -condyloid ridge can 
 be traced upwards from it for about three inches. It 
 may be mentioned here that in about one out of every 
 fifty arms (Struthers) there is a hook-like process of 
 bone, the supra-condyloid process, above the internal 
 condyle, which when present can be distinctly felt. The 
 olecranon process is obvious in all positions of the joint, 
 together with the triangular subcutaneous portion of the 
 ulna which passes down from it and is covered by a 
 bursa. The position of this bony eminence with respect 
 to the condyles should be studied in the various posi- 
 tions of the joint. If the thumb and the next two fingers 
 be placed on the three points respectively and the fore- 
 arm be moved, this can easily be eflfected. It will then 
 be found that in extension the three points lie on the 
 same line, in semi-flexion the olecranon is below the 
 condyles, and in extreme flexion it is in front of them. 
 Thus normally the olecranon is never at a higher level 
 than the condyles. The relation of these points to one 
 another is of importance in the diagnosis of fractures 
 and dislocations at or near the elbow joint. If the 
 point of the thumb be pressed deeply i nder the muscles 
 arising from th( external condyle and forming the outer 
 boundary of th ■■ triangular area in front of the elbow 
 joint the head : the radius will be felt, and if the 
 fingers be place at a corresponding point at the back 
 of the arm it mr / be grasped and felt rotating beneath 
 
 f\ 
 
ARM AND ELBOW. 
 
 97 
 
 them during the movements of pronation and supina- 
 tion. In complete extension a small groove can be dis- 
 tinguished between the head of the radius and the back 
 of the capitellum behind, as the two are not in contact 
 with one another in that position. If the thumb be now 
 shifted a little inwards and deep firm pressure be made, 
 the coronoid process of the ulna will be felt, though not 
 distinctly, especially in a muscular subject. In extreme 
 pronation the tubercle of the radius may be felt behind 
 a short distance below the head of that bone, though 
 again not distinctly in a muscular subject. 
 
 b. Soft parts. — In the semi-flexed condition a curved 
 crease passing from one condyle to the other and con- 
 cave upwards, the "fold of the elbow," will be first seen. 
 This line does not quite correspond to the articulation 
 but is placed a little above it. The student should next 
 carefully study the position and relations of the large 
 superficial veins, and for this purpose should select a 
 muscular living subject. The vessels may be made pro- 
 minent, and thus be investigated with greater ease, if 
 a bandage be tied firmly round the arm a few inches 
 above the elbow. It is impossible to adhere closely to 
 regional limitations in this instance, and the veins should 
 therefore be traced up» from their origin to the elbow, the 
 student remembering that deviations from the arrange- 
 ment regarded as normal are very common. 
 
 The veins having been made prominent in the manner 
 indicated, the commencement of the f^rst trunk should 
 be sought on the dorsum of the thumb. Above the cleft 
 between the thumb and the index finger this vein is 
 
 H 
 
 II 
 
98 
 
 ARM AND ELBOW, 
 
 ill 
 
 joined by another coming from the back of the latter 
 digit. The combined trunk passes to the flexor aspect 
 of the fore-arm above the wrist, and runs along its radial 
 border, receiving tributaries from both anterior and pos- 
 terior surfaces. The veins on the ulnar side commence 
 by tributaries which unite above the cleft between the 
 ring and little fingers to form a trunk, the vena salva- 
 tella. This vessel runs up the back of the fore-arm 
 turning round to its anterior surface below the elbow, 
 where it is joined by the anterior ulnar vein which takes 
 its course along the ulnar border on the anterior aspect. 
 The m«iian vein which runs up the centre of the ante- 
 rior surface of the fore-arm is very variable in size 
 and length. Below the ante-cubital fossa it receives a 
 deep tributary which cannot be seen from the surface, 
 and the combined trunk divides into two, the median 
 basilic which passes inwards to join the common ulnar 
 and form the basilic vein, and the median cephalic 
 which, taking the opposite direction, unites with the 
 radial to constitute the cephalic vein. The median 
 basilic lies in front of the brachial artery, the bicipital 
 fascia intervening between the two vessels, and is 
 crossed uy twigs of the internal cutaneous nerve. The 
 median cephalic overlies branches of the external cuta- 
 neous nerve. The anatomy of these vessels is not sur- 
 gically of such importance as it was in the not very 
 distant days when phlebotomy was the commonest of 
 minor operations. As this has, however, still sometimes 
 to be performed the parts concerned should be con- 
 sidered in this relation. The median basilic is usually 
 
 './ 
 
 / 1 
 
 \'\ 
 
ARM AND ELBOW. 
 
 99 
 
 the larger vessel and affords, therefore, the better supply 
 of blood, but the median cephalic is the safer, because 
 the former, as has been mentioned, is crossed by nervous 
 fibres which being wounded may cause the patient to 
 start, and the operator to plunge his scalpel through the 
 vein into the subjacent artery, the result being the for- 
 mation of an arterio- venous aneurism. 
 
 The muscular masses in front of the elbow enclose a 
 triangular depression, the ante-cubital fossa. On the 
 outer side is the extensor eminence, the inner border of 
 which is formed by the supinator longus. On the inner 
 side is the flexor eminence with the pronator radii teres 
 externally. At the upper part or base the lower end of 
 the bicipital elevation will be seen, and the tendon of 
 that muscle can be seen and felt easily lying near the 
 centre of the fossa. Passing off from the biceps at its 
 upper end ai/d on its inner side is a fibrous expansion 
 the bicipital fascia which crosses and helps to bind 
 down the flexor muscles. When this is fairly well- 
 marked it can be seen in a thin subject during flexion, 
 ac it produces a furrow in the flexor mass about two 
 finger breadths 1 -^low the internal condyle. The student 
 will notice that when the biceps is brought gradually 
 into action, the globular mass which it then forms 
 commences near the elbow, and ascends towards the 
 level of the pectoralis major. If the finger be pressed 
 into the ante-cubital fossa under the inner edge of the 
 tendon of the biceps, the pulsations of the brachial 
 artery will be felt at a point about a finger's breadth 
 below the line of the internal condyle. The student 
 
 ! i 
 
 !i ^1 
 
 \ 4 
 
lOO 
 
 ARM AND ELBOW. 
 
 ,. ;. .. .! 
 
 will feel just below this point, the sharp upper edge of 
 the bicipital fascia preventing him from pushing his 
 finger deeply further down towards the apex of the 
 fossa. He should next place his fingers on his own 
 radial artery, at the point where the " pulse " is felt, and 
 flexing gradually his arm he will feel what an effect is 
 produced upon the blood current by that movement. 
 If he be fairly muscular he will be able to entirely stop 
 the flow of blood in his radial artery, or at least, materi- 
 ally to decrease its volume. This fact is of surgical 
 importance in connection with aneurisms of the brachial 
 artery. The radial recurrent artery passes upwards in 
 the groove between the supinator longus and brachialis 
 anticus to anastomose with the superior profunda. The 
 anterior ulnar recurrent runs on the opposite side be- 
 tween the brachialis anticus and pronator radii teres 
 to anastomose with the inferior profunda and anasto- 
 motica. The posterior ulnar recurrent runs upwards 
 to the depression between the internal condyle, and the 
 edge of the trochlea, and the interosseous recurrent 
 takes the same upward course to the interval between 
 the olecranon and the external condyle. The brachial 
 artery itself bifurcates at a point opposite the neck of 
 the radius as a rule, but the student should be on the 
 look out for a high division either of the axillary or 
 brachial trunks, two arteries which may be distinguish- 
 able thus existing, a condition which obtains in about 
 one in every five and a half cases. (R. Quain). 
 
 In the ante-cubital fossa the median nerve lies first 
 internal to the brachial artery. The musculo-spiral 
 
 V 
 
 I 
 
FOREARM AND WRIST. 
 
 lOI 
 
 nerve, not strictly in the fossa, lies between the supina- 
 tor longus and brachialis anticus and under cover of the 
 foimer muscls. As already mentioned, the ulnar nerve 
 lies in the depression between the internal condyle and 
 the edge of the trochlea. Over the olecranon lies a 
 bursa which is sometimes enlarged, as a result of some 
 special occupation leading to constant pressure upon it, 
 the disease being known as " miner's elbow." 
 
 III. Forearm and Wrist. 
 
 I. Bony points. — The radius can be explored pos- 
 teriorly throughout its entire length, from its head to 
 its lower end, though less distinctly for some inches 
 below the head than in its lowest part, on account of 
 the muscles which cover it. Externally and anteriorly, 
 its styloid process can be distinctly felt a finger's breadth 
 above the upper border of the ball of the thumb. Pass- 
 ing the finger round the back of the lower end, there 
 will be felt, near its centre, a bony prominence, round 
 which turns the tendon of the extensor secundi internodii 
 pollicis, and still further, towards the ulnar side of the 
 forearm, the groove between the radius and the ulna. 
 Anteriorly, only about the lower half of the radius can 
 be made out, and that not very distinctly. The ulna is 
 also very distinct from the olecranon to the lower end, 
 posteriorly. The rounded prominence of the latter is 
 very obvious to sight and touch at some little distance 
 above the wrist joint ; internally and posteriorly, the 
 
 I I 
 
 w .1 
 
 ! 
 
I02 
 
 FOREARM AND WRIST. 
 
 
 styloid process can be felt. The ulna also can only be 
 indistinctly felt on its anterior aspect. The tip of the 
 styloid process of this bone corresponds to the line of 
 the wrist joint, but the styloid process of the radius is 
 placed at a lower level, and corresponds to the scaphoid, 
 
 A line drawn from the tip of one styloid process to 
 that of the other would consequently fall below the line 
 of the joint. In order to indicate this it will be neces- 
 sary to cause the line, joining the two above mentioned 
 points, to form a curve, with its convexity upwards, and 
 half an inch at its farthest point from the straight line 
 alluded to. 
 
 2. Soft parts, (a) Muscles. — A little manipulation 
 along the outer border of the forearm in its lower half 
 will enable the student to feel the tendons of the radial 
 extensors and supinator longus. If the thumb be fully 
 extended, the bellies of the extensores ossis metacarpi 
 and primi internodii poUicis will be seen distinctly as 
 a rounded elevation, crossing the radius in its lower 
 third, downwards, outwards, and forwards ; their ten- 
 dons can be made out close to the lower end of the 
 radius, lying on the bone, and still more distinctly as 
 they pass over the wrist joint. If the fingers of the 
 right hand be laid on the posterior aspect of the left 
 forearm at its lower part, and the left fingers be ex- 
 tended, the tendons of the extensor communis will be 
 felt, and those of the little finger will be distinguished 
 on the ulnar side, if that digit alone be brought into 
 action. Still farther towards the ulnar side, the tendon 
 of the extensor carpi ulnaris may be indistinctly made 
 
 1^ 
 
FOREARM AND WRIST. 
 
 103 
 
 out. Anteriorly, commencing at the ulnar side, the 
 tendon of the flexor carpi ulnaris can be grasped as it 
 lies under the skin, when the wrist is semiflexed and 
 adducted. Extend the hand, and the palrnaris longus 
 tendon in the centre of the forearm becomes visible in 
 a considerable part of its extent. This muscle is 
 absent once in every ten bodies on the average, and is 
 three times oftener symmetrically absent than asymme- 
 trically (Macalister). 
 
 Under this tendon, and on each side of it, the tendons 
 of the flexor sublimis digitorum can be felt by gentle 
 pressure. At their outer border lies the strong, but not 
 very distinctly to be felt, tendon of the flexor carpi 
 radialis, and finally at the radial border, the tendons of 
 the two first extensors of the thumb, as they cross the 
 wrist joint. • , 
 
 {b) Arteries. — Just internal to the two last mentioned 
 extensors, the pulsations of the radial artery can be felt 
 against the subjacent radius, this being the position 
 where the " pulse" is generally observed. A line drawn 
 from this point to the outer border of the biceps tendon 
 just below the head of the radius, will indicate the 
 position of the artery. It is fairly superficial through- 
 out, being overlapped above by the inner border of the 
 supinator longus. It is in the line just mentioned that 
 the incisions to tie the artery are made, the edge of the 
 supinator longus and its tendon being the guide to the 
 vessel. 
 
 If the wrist be semiflexed to relax the skin, &c., and 
 the fingers be thrust under the tendon of the flexor 
 
 ( 
 
 
I04 
 
 FOREARM AND WRIST. 
 
 
 
 M 
 
 carpi ulnaris, the pulsations of the ulnar artery will be 
 felt. A line drawn from this point and curved slightly, 
 so as to be convex inwards, to the same upper point as 
 that given for the radial artery, v, .11 indicate the position 
 of the ulnar, which is, however, quite deeply placed in 
 the upper part of the forearm. When it requires to be 
 tied in the upper third of the arm the incision is made 
 along a line drawn from the front of the internal condyle 
 to the outer border of the pisiform, so that the centre of 
 the incision is three fingers' breadth below the internal 
 condyle. 
 
 (c) Nerves. — The course of the chief nerves of the 
 forearm may be indicated by three lines. That for the 
 median commences just internal to the brachial artery 
 in the antecubital fossa, and is drawn to the centre of 
 the front of the wrist joint, where it lies under, or on the 
 ulnar side of, the tendon of the palmaris longus. The 
 ■ ulnar nerve is indicated by a line drawn from below and 
 in front of the outer part of the internal condyle, to the 
 outer side of the corresponding artery at the wrist. It 
 meets the artery at the apex of its convexity, that is at 
 the junction of the upper and middle thirds of the arm. 
 The radial nerve is indicated by a line drawn from the 
 outer edge of the upper part of the tendon of the biceps, 
 meeting the artery about two inches below the elbow 
 joint. It accompanies the artery to a point three inches 
 above the wrist joint, where it leaves its vessel, passing 
 to the back of the forearm under the tendon of the 
 supinator longus muscle. The cutaneous nerve supply 
 of the forearm, as well as that of the arm and hand. 
 
THE HAND. 
 
 105 
 
 •will be seen from the diagrams (figs. 12 and 13), and the 
 student should accustom himself to map out the parts 
 in correspondence with their nerves. 
 
 IV. The Hand. 
 
 I. Bony points. — On the radial side of the hand at 
 the upper part of the muscles of the thumb a bony 
 ridge can be made out, which is formed by portions of 
 two bones, the tubercle of the scaphoid above, and the 
 ridge on the trapezium below, but any line of division 
 between the two is hard to distinguish. At the upper 
 part of the hand, on the ulnar border, the pisiform is 
 easily identified, and lower down the process of the 
 unciform may be found, but with less readiness. At 
 the lower end of the metacarpal bone of the thumb, and 
 in front of the metacarpo-phalangeal joint, the two 
 sesamoid bones of that digit can be felt. The lower 
 ends of the metacarpals of the remaining digits can be 
 felt in the palm, but not their proximal extremities, o^ 
 account of the muscles and other structures lying upon 
 them. On the back of the hand, since there are less 
 soft structures between the skin and the bones, the 
 outlines of the latter can be more distinctly made out. 
 The upper end of the metacarpal bone of the thumb 
 can be readily felt, especially if that digit be extended. 
 The upper ends of the metacarpal bones of the other 
 fingers are not so easy to distinguish, but the ulnar edge 
 of that of the little finger can be felt at the border of 
 
 I '«i 
 
 ' m 
 
 i (1 
 
 1 ii !■ 
 
io6 
 
 THE HAND. 
 
 
 
 Fio. la.— Cutaneous Areas Upper Extremity. 
 Anterior Aspect. 
 
 a. Supraclavicular (3, 4c). 
 
 b. Circumflex (5, 6c). 
 
 c. Internal cutaneous (8c, id). 
 
 d. Wrisbergand intercosto-humeral (i, id). 
 
 e. Musculo-spiral (up. ext. cut.) (6c). 
 
 f. Musculo- cutaneous (5, 6c). 
 g Ulnar (id). 
 
 h. Median (6, 7, 8c, xd). 
 
 j. Radial (6). • ' 
 
 t\' 
 
THE HAND. 
 
 107 
 
 Fig. 13.— Cutaneous Areas Upper Extremity. 
 Posterior Aspect. 
 
 a. Supraclavicular (3, 4^). ' 
 
 b. Circumflex (5, 6c). 
 
 c. Internal cutaneous (8c, irf). 
 
 d. Wrisberg and intercosto-humeral (i, ai). 
 e'. Musculo-spiral (int. cut.), (8c). 
 
 e". Do. (lower ext. cut.), (6, 7, 8c), (the 
 upper part of this area is supplied by 
 the upper ext. cut. e). 
 
 f. Musculo-cutaneous (5, 6c). 
 
 g. Ulnar (8c). 
 
 h. Median (6, 7, 8c, irf). 
 j. Radial (6, 7c). 
 
 I ■ 
 
 ^i 
 
 :i; . 
 
 f 
 
io8 
 
 THE HAND. 
 
 fr 
 
 If 
 
 ■A. J 
 
 the hand, if that member be adducted and pressure be 
 made upwards along the metacarpal until the point 
 sought for be reached. A line very slightly curved 
 downwards, drawn from this point to the carpo-meta- 
 carpal joint of thumb, will correspond to the line of the 
 carpo-metacarpal articulations. Along this line the 
 articulations in question may be felt for, that of the 
 index being distinguishable without much difficulty. 
 The spur on the upper end of the metacarpal of the 
 middle finger may be indistinctly felt, as well as the 
 base of the corresponding bone of the ring finger. 
 Attention should next be directed to the knuckles, and 
 it will first be noted that in every case the bony promin- 
 ence to which that name is attached, belongs to the 
 proximal bone of the articulation, that is, the first row 
 of knuckles is formed by the heads of metacarpals, the 
 second by those of the first phalanges, and so on. Con- 
 sequently the line of articulation is somewhat lower in 
 each case than the corresponding knuckle. The lines of 
 all the articulations are curved, but the curves are not 
 all in the same direction. Those of the metacarpo- 
 phalangeal joints are concave towards the wrist, and 
 are situated from half to three-quarters of an inch from 
 the free edge of the webs of the fingers. The lines of 
 the remaining articulations are concave in the opposite 
 direction, that is, towards the tips of the fingers, and 
 correspond in their curves fairly accurately to the curve 
 of the skin surrounding the attached upper borders of 
 the nails. 
 
 2. Skin and soft parts. — The hollow of the palm 
 
 ■' i 
 
THE HAND. 
 
 109 
 
 is somewhat triangular, with its apex directed upwards. 
 It is bounded by a muscular elevation on either side, 
 belonging to the thumb and little finger respectively. 
 The former or thenar eminence is circumscribed by a 
 groove due to the movement of the thumb in opposition, 
 which commences on the ulnar side of the fold of skin 
 uniting the thumb and index finger, and runs upwards 
 to be lost in the apex of the triangle of the palm. If 
 the palmaris brevis muscle be made to act, as it can be 
 in many individuals, an irregular longitudinal crease 
 will be found along the ulnar border of the hand at the 
 side of the hypothenar eminence. The apex of the 
 triangle of the palm corresponds to the lower border of 
 the anterior annular ligament, the upper margin of 
 which is indicated fairly accurately by the lower point 
 of the curved skin crease, which crosses the wrist just 
 above the two muscular elevations. Another palmar 
 crease commences close to that of the thumb and passes 
 across the hand, gradually approaching nearer to the 
 wrist until it is lost on the hypothenar eminence. Its 
 radial, most strongly marked portion, is due to the 
 flexion of the index, the remainder being a secondary 
 fold caused by flexion of the three inner digits. In the 
 cleft between the index and middle fingers, another 
 crease commences, which runs at first upwards and 
 inwards, as far as the line of the cleft between the next 
 two digits, and then inwards across the lower part of 
 the hypothenar eminence. It is the primary fold caused 
 by the flexion of the three inner digits. The first of 
 these two last mentioned folds, as it crosses the third 
 
 
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 1 
 
 
 
 
 
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 ! 
 
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Ill 
 
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 F:J^ 
 
 1.^: 
 
 no 
 
 THE HAND, 
 
 metacarpal bone, corresponds to the lowest point of the 
 superficial palmar arch. Its highest point may be indi- 
 cated by a line drawn from the ulnar side of the com- 
 missure of the thumb, when that digit is extended 
 transversely across the palm. The digital branches 
 arise from this arch opposite the clefts of the fingers, 
 bifurcate half an inch below the webs of the fingers, 
 and run along the borders of the digits on their palmar 
 surfaces, where their pulsations may distinctly be felt. 
 The deep palmar arch lies about half an inch nearer 
 the wrist than the superficial. The second crease 
 crosses the necks of the metacarpal bones, and corre- 
 sponds also pretty nearly to the upper limits of the 
 synovial sheaths of the flexor tendons of the three inner 
 digits, and to the point where the palmar fascia divides 
 into its terminal slips. The folds at the joints of the 
 fingers should next be examined. Those over the 
 metacarpo-phalangeal articulations of the index and 
 minimus are single, those of the other two digits double. 
 Each is placed about three-quarters of an inch below 
 the joint to which it corresponds. The creases over the 
 first row of interphalangeal articulations are double in 
 each case, and the line of the joint lies between the two. 
 Those of the second interphal:ii3geal articulations are 
 single, and lie a very little above the corresponding 
 joints. The thumb is crossed above and external to 
 the thenar eminence by two oblique lines ; the lower of 
 these, which commences nearly at the radial side of the 
 commissure, crosses the metacarpo-phalangeal articula- 
 tion. The line of articulation in the case of each of the 
 
 • \ 
 
THE HAND. 
 
 Ill 
 
 joints is more distinct dorsally than on the palmar sur- 
 face, on account of the flexor tendons, and especially of 
 the so-called glenoid ligaments, which lie between these 
 tendons ?nd the articulations. The flexor tendons of 
 the fingers can be indistinctly felt on the anterior sur- 
 faces of the fingers, and the long flexor of the thumb 
 may be distinguished by pressing the finger under the 
 ulnar border of the thenar eminence at its lower eud, 
 and extending the thumb. The superficialis volae 
 artery, when large enough, can be felt pulsating on the 
 thenar eminence. The student will notice that there is 
 no great amount of mobility between the skin in the 
 palm of the hand and the subjacent tissues, a fact which 
 is due to the connection of the former with the palmar 
 fascia. A similar condition obtains at the pulps of the 
 fingers, which is here due to the cutaneo-phalangeal 
 ligaments of Cleland, which pass from the bone to 
 the skin. The result of this immobility of the skin is 
 to give a firmer grasp than would be afforded if the skin 
 glided easily upon the subcutaneous tissues. 
 
 On the dorsum of the hand, at the radial side, will be 
 seen, if the thumb be extended, a triangular hollow, 
 " Cloquet's snuff-box," which is bounded radially by the 
 tendons of the two first extensor muscles of the thumb, 
 and on its ulnar side by that of the second internode. 
 In its roof lies the vein which forms the origin of the 
 radial vein of the arm. The base of the metacarpal 
 bone of the thumb lies at its lower part, and the radial 
 artery can be felt pulsating within it. Deeper still lie 
 the scaphoid and trapezium. The princeps pollicis 
 
 \ '! 
 
 i 
 
 i ( 'i 
 
 i 
 
112 
 
 THE HAND. 
 
 h?.i 
 
 '? I 
 
 
 .hl- 
 
 ims 
 
 artery can be felt pulsating in the thumb just below the 
 radial end of the commissure, and the princeps indicis 
 in its digit below the ulnar end of the same. Numerous 
 veins are visible on the dorsum of the hand, passing 
 upwards to form the radial or the posterior ulnar trunks. 
 On the radial side of the index the prominence of the 
 first dorsal interosseous muscle or abductor indicis is 
 very distinct. The extensor tendons of the fingers can 
 be seen and felt, and if the fingers be fully flexed, the 
 lateral slips, passing from that for the ring finger, to 
 those of the adjacent digits, can also be observed. 
 
 '■' '».■ 
 
 ' ( 
 
U M 
 
 THE BUTTOCK. 
 
 113 
 
 .' » 
 
 Chapter IX. 
 
 , THE LOWER EXTREMITY. ' 
 
 I. The Buttock. 
 
 I. Bony points. — The crest of the ilium, which 
 forms the upper boundary of this region, can be felt 
 easily in its entire extent. At its posterior extremity 
 its posterior superior spine will be encountered, lying at 
 the level of the second sacral spine, and corresponding 
 to the centre of the sacro-iliac synchondrosis. The 
 spines of the sacral vertebrae lie in the middle line, and 
 below them the tubercles of the last two sacral vertebrae. 
 Just below the last of these, and practically undistin- 
 guishable from them, are the cornua of the first bone of 
 the coccyx, the highest point of which process corre- 
 sponds to the spine of the ischium. The upper border 
 of the great sciatic notch is about on a level with the 
 third sacral spiiu:. The tip of the coccyx can be felt 
 just behind the rectum, and can be grasped between the 
 fingers, if one be inserted into that tube and the other 
 placed on the sarlace opposite to it. It will be found 
 to be mobile in many women and some men. The great 
 trochanter is easily distinguished, even in fat persons, 
 in whom its position is indicated by a small pit 'n the 
 soft parts. Its apex corresponds with a point a little 
 
 t 
 
 i ?■■ 
 
114 
 
 THE BUTTOCK. 
 
 .5 
 
 
 above the centre of the hip-joint in old persons ; in 
 younger individuals, since the neck of the femur makes 
 a larger angle with the shaft, it is placed a little lower . 
 down. It is covered by the fascial insertion of the 
 gluteus maximus, between which and the bone lies a 
 large and important bursa. 
 
 The tuberosity of the ischium can also be readily felt, 
 especially in the sitting posture, when it comes from 
 under cover of the gluteus maximus, and forms with its 
 fellow of the opposite side the main support of the body. 
 It is also covered by a bursa, which is one of three in 
 the body especially liable to inflammation and enlarge- 
 ment, as a result of occupation. The disease commonly 
 known as " Drayman's bottom " is due to this enlarge- 
 ment. In connection with certain of the bony points 
 just mentioned, two methods have been adopted of 
 determining the position of the trochanter in relation to 
 injuries at the hips. The first of these is known as 
 ** Nelaton's line." This is a line drawn from the anterior 
 superior spine of the ilium to the most prominent por- 
 tion of the tuber ischii of the same side. It crosses the 
 acetabulum near or above its centre, and just strikes 
 <,he apex of the great trochanter. In dislocations at the 
 hip, the apex of the trochanter will be either above or 
 below this line. The second method of determining 
 the position of the trochanter is known as " Bryant's 
 ilio-femoral triangle." This is constructed by placing 
 the subject in the recumbent position, and drawing a \ 
 vertical line from the anterior superior spine of the 
 ilium. A second is drawn from the same point to the 
 
 (' . ■ 
 
 (' 
 
 ^ 
 
 
 r. 
 
 ! 
 

 Pio. 14. — Diagram of side of Buttock, ti. Post. Sup, Sptne of Ilium; 
 b. Great Trochanter; c, Tuber Iscliii ; tl. Ant. Sup. Spine of Ilium. 
 
 ). Nelat(mV> line. 3. Line to find Gluteal Artery, j. Line to find Sciatic 
 Artery. (The pointer fmm the star in each case indicates the position of tht 
 (irtery). 
 
 I: i 
 
 11 
 
 i 
 
 
\ 
 
 i 
 
 //' 
 
 n 
 
 ■"» 4 
 
THE BUTTOCK. 
 
 "5 
 
 apex of the great trochanter, and the third completes 
 the triangle, and is drawn at right angles to the first 
 line. The measurements must be made on both sides, 
 when any increase or decrease of the third or test line 
 on the affected as compared with the normal side can 
 be ascertained. 
 
 2. Soft parts. — The greater portion of the rounded 
 contour of the buttock is formed by the gluteus maxi- 
 mus muscle. By pushing the fingers upwards beneath 
 the lower border of this, the sharp edge of the great 
 sacro-sciatic i" lament can be felt. The lower boundary 
 of the region under description is formed by a distinct 
 crease, the fold of the nates or buttock. This is com- 
 monly, but erroneously, said to correspond to the lower 
 margin of the gluteus maximus, but this really crosses 
 the fold obliquely, being higher than it mesially, and 
 lower than it externally. It is not caused by the lower 
 border of the gluteus maximus, as is also often stated, 
 but as wa'; pointed out by Symington, it is largely due 
 to the tuberosity of the ischium, being always best 
 marked where it passes outwards beneath that promi- 
 nence. The skin is placed on the stretch in llexion of 
 the thigh, and is relaxed during its extension, a fold 
 thus being formed. The position of the arteries of the 
 buttock can be found by means of lines described by 
 Lizar. The first of these is drawn from the posterior 
 superior spine of the ilium to the apex of the great 
 trochanter, the thigh being rotated inwards. The point 
 of junction of the inner and middle thirds of this line 
 indicates the position at which the gluteal artery emerges 
 
 I a 
 
 i I 
 
ii6 
 
 THE THIGH. 
 
 from the upper part of the great sciatic foramen. The 
 second line is drawn from the posterior superior spine 
 of the ilium to the outer part of the tuber ischii. Two 
 inches below its upper extremity the line crosses the 
 posterior inferior spine of the ilium, and four inches 
 below the sam.e point, the spine of the ischium. The 
 sciatic artery emerges from the great sciatic foramen, 
 at a point corresponding to the junction of the middle 
 and lower thirds of the line. The pudic artery is, of 
 course, external to the pelvis, as it crosses the spine of 
 the ischium on its way from the greater to the lesser 
 sciatic foramen. 
 
 If a line be drawn from the point at which the sciatic 
 artery emerges from the foramen downwards, so as to 
 lie midway between the great trochanter and the tuber 
 ischii, it will correspond to the position of the great 
 sciatic nerve. 
 
 The long or inferior pudendal nerve crosses the bone 
 a short distance in front of the tuber ischii, and then 
 curves round into the perineum, to be distributed to the 
 posterior and under surface of the scrotum. The effects 
 of pressure upon this nerve may often be felt in the 
 sensation of " pins and needles " in this region, after 
 long sitting upon a hard surface. 
 
 
 II. The Thigh. 
 
 The anterior superior spine of the ilium and the spine 
 of the pubes, both of which prominences have been 
 
THE THIGH. 
 
 117 
 
 already alluded to, are the most important ])ony points 
 in this region. The former is taken as the point from 
 which measurements of the lower extremity are made, 
 and the latter, which is at the same level as the apex 
 of the great trochanter, is an important factor in the 
 diagnosis between inguinal and femoral herniae. If 
 the two points just mentioned, and the most prominent 
 part of the tuberosity of the ischium, be marked out, 
 the acetabulum will lie about midway between them. 
 Poupart's ligament, stretching in a line curved down- 
 wards between the anterior superior spine of the ilium 
 and the spine of the pubes, is easily to be distinguis'ied. 
 The inner inch corresponds to the extent of Gimbernat's 
 ligament. , 
 
 Crossing the upper part of the thigh, a second line, 
 described by Holden, and usually named after that 
 surgeon, may in many cases be seen, especially if the 
 limb be slightly flexed. It " begins at the angle be- 
 tween the scrotum and the thigh, passes outwards, and 
 is gradually lost between the top of the trochanter and 
 the anterior superior spine of the ilium." When pre- 
 sent it runs across the front of the capsule of the hip- 
 joint. The sartorius and adductor longus should be 
 made out as they form the boundaries of Scarpa's 
 triangle. The former is brought into action when the 
 thigh is flexed and adducted, and the latter in abduc- 
 tion, its sharp internal edge, leading to the spine of the 
 pubes, being very easily distinguished. 
 
 The femoral artery passes under Poupart's ligament 
 at a point midway between the spine of the pubes and 
 

 i[8 
 
 THE THIGH. 
 
 J' 
 
 :.f. 
 
 rt 
 
 the anterior superior spine of the ilium, where its pul- 
 sations may very distinctly be felt. If a line be drawn 
 from this point to the tubercle for the adductor magnus 
 on the inner condyle of the knee, its upper two-thirds 
 will overlie the artery. The common femoral divides 
 into its superficial and deeper portions about an inch 
 and a half or more below Poupart's ligament. " In the 
 upper third of the thigh the common and superficial 
 femoral arteries lie in Scarpa's triangle, and are super- 
 ficial ; below this point they have a deeper position. 
 Pressure should be applied to the femoral in order to 
 check its current, backwards and slightly upwards, be- 
 low Poupart's ligament, the patient being in the recum- 
 bent position. At the apex of Scarpa's triangle, pressure 
 should be applied outwards, as the artery is here on the 
 inner side of the femur. 
 The femoral vein below Poupart's ligament lies in- 
 ternal to its artery, and has on its other side the femoral 
 ring and crural canal. The former lies an inch out from 
 the pubic spine, on a line drawn from that eminence to 
 the apex of the great trochanter. It may also be found 
 by ascertaining the position of the femoral artery by its 
 pulsations, and allowing half an inch on its inner side 
 for the vein. It is through this aperture that a femoral 
 hernia escapes from the abdomen ; in the crural canal, 
 along the inn.r side of the vein, lie the deep set 
 of femoral glands. The saphenous opening is placed 
 just below Poupart's ligament, and its centre is about 
 an inch and a half below and external to the spine of 
 the pubes. The most important structure, surgically 
 
 w 
 
THE THIGH, 
 
 119 
 
 speaking, which passes through it, is the long saphenous 
 vein, which will be dealt with further on. This vessel 
 may sometimes be seen in thin individuals, the position 
 of the saphenous opening itself being at times indicated 
 by a dimpling of the skin. Two sets of superficial lym- 
 phatic glands lie at the upper part of the thigh, one 
 horizontal and in a line with Poupart's ligament, the 
 other vertical and parallel to the femoral artery. The 
 sources of the various lymph streams which enter these 
 are of some importance, and are thus described in Mr. 
 Treves' Surgical Anatomy. 
 
 Superficial vessels of lower limb = vertical set. 
 
 Superficial vessels of lower half of abdomen = middle 
 glands of horizontal set. 
 
 Superficial vessels of outer surface of buttock = exter- 
 nal glands of horizontal set. 
 
 Vessels of inner surface of buttock = internal glands 
 of horizontal set. (A few of these vessels go to the ver- 
 tical glands). - 
 
 Superficial vessels from external genitals = horizontal 
 glands, and a few to vertical. 
 
 Superficial vessels of perineum = vertical set. 
 
 These glands can sometimes be felt beneath the skin, 
 especially in thin children. 
 
 Externally to the femoral artery lies the anterior 
 crural nerve, and under it and the artery, and also 
 external to both, is the ilio-psoas muscle, forming part 
 of the floor of Scarpa's triangle. This muscle overlies 
 the front of the capsule of the hip-joint, a large bursa 
 intervening. 
 
 HI 
 
 i i 
 
 >1 
 
 ] 
 
 
I20 
 
 THE THIGH. 
 
 :fi. 
 
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 If 1 
 
 w 
 
 . 1 i 
 
 11:1! 
 
 The chief remaining objects worthy of note in the 
 thigh are the muscular markings, of which, besides those 
 which have already been alluded to, the following may 
 be observed. The tensor vaginae femoris forms an ele- 
 vation directed downwards and backwards, and com- 
 mencing at the anterior superior spine of the ilium, 
 immediately behind the sartorius. Below it is inserted 
 into the fascia lata, which in extension of the hip and 
 knee will be noticed to be particularly tense and re- 
 sistant on the outer side of the thigh. A specialised 
 band of this fascia, called the ilio-tibial band, may be 
 looked upon as the tendon of insertion of the muscle in 
 question ; it extends down to the outer part of the head 
 of the tibia, and may be distinctly felt above the knee- 
 joint, when the muscle is placed upon the stretch. The 
 rectus femoris forms the median prominence of the 
 quadriceps and about four inches above the knee-joint 
 it joins a triangular tendon, which passes downwards to 
 be attached to the patella. The outline of this tendon 
 stands out very distinctly in a muscular individual when 
 the knee is fully extended. In the same position the 
 two vasti muscles are brought into prominence. The 
 lower fibres of the inner descend as low as the inner 
 border of the patella, those of the outer not descending 
 so far by an inch or more. A groove between the inner 
 vastus and the adductor muscles marks the position of 
 the lower portion of the sartorius and the subjacent 
 Hunter's canal. A similar groove on the outer side of 
 the thigh marks the position of the external intermus- 
 cular septum, the line of demarcation between the 
 vastus externus and the hamstring muscles. 
 
 |\ 
 
THE KNEE. 
 
 121 
 
 III. The Knee. 
 
 ll! 
 
 The first object which the student should examine is 
 the patella, and he can, with advantage, in this as in 
 other parts of the body, carry out his observations upon 
 himself. In order to examine this bone the leg should 
 be placed in the extended position, the heel resting upon 
 the ground so as to fully relax the muscles and other 
 structures. Its shape can then be fully investigated, 
 and the fingers can even be pushed a little underneath, 
 so as to feel a small part of the posterior surface. It 
 will be noticed that the patella can be moved freely 
 in different directions, gliding easily over the smooth 
 trochlear surface of the femur. 
 
 In the same position of the extremity, the whole of 
 the outer border and a part of the upper limit and ante- 
 rior surface of the articular surface of the external con- 
 dyle can be felt. In semi-flexion the articular surface of 
 the internal condyle becomes more easy of investigation, 
 when its inner border and a part of its anterior surface 
 can be felt. In extreme flexion the greater part of the 
 anterior surface comes under observation, but not very 
 distinctly, on account of the tension of the skin. Below 
 the patella, and stretching between it and the tubercle 
 of the tibia, is the ligamentum patellae, which should be 
 studied in the different positions of the joint. If the 
 forefingers of both hands be pushed under the ligaii.ont 
 on opposite sides, and alternate pressure be made, a 
 feeling like fluctuation is obtained. This is due to the 
 
 i i ^'1 
 
122 
 
 THE KNEE. 
 
 \t^ 
 
 presence, in that position, of a large pad of fat, lying be- 
 tween the ligament and the subjacent bone, and should 
 not be mistaken for the presence of fluid. In front of 
 the patella and a portion of its ligament, is a large 
 bursa, the prepatellar bursa, which like some others is 
 liable to be enlarged in certain occupations In the case 
 of the bursa in question, constant kneeling has this 
 effect, and the condition is known as " Housemaid's 
 knee." It may be noted that the ligamentum patellae, 
 the tubercle of the tibia, and the centre of the ankle 
 joint, are all normally in the same straight line. The 
 student should now carefully follow the movements of 
 the patella, and its position in the varying conditions of 
 the joint. He will observe that in extension this bone 
 lies nearly altogether above the articular surface of the 
 femur, its two inferior facets being then in contact with 
 the upper part of the articular portions of the two con- 
 dyles. In semi-flexion the positions of the bones alter so 
 that the patella, resting on its two central facets, lies in 
 contact with a lower part of the condyles. In greater 
 flexion it rests on its two superior facets. Finally, in 
 extreme flexion, the patella passes almost from off the 
 internal condyle, being turned outwards partly by the 
 increasing prominence of the inner condyle, and partly 
 by the slightly oblique plane, in which the tibia is moved 
 inwards in flexion. It then rests only on its internal 
 narrow facet, which is in contact with the outer border 
 of the inner condyle. Here, as in the other joints of the 
 body, the student should not be content with a dissec- 
 tion of the dead subject, but should take frequent oppor- 
 
 V 
 
 
POPLITEAL SPACE. 
 
 123 
 
 tunity to examine the bony parts and other structures 
 all the various positions of the joints in himself and 
 others. He will find much assistance in this study in 
 the descriptions of the mechanism of the articulations 
 in Mr. Morris' work on the A natomy of the Joints. 
 
 The inner condyle of the femur, on its inner side, pre- 
 sents as its most prominent structure the tubercle for 
 the attachment of the adductor magnus, the tendon of 
 which muscle can be felt above the projection. The 
 inner aspect of this condyle points nearly in the same 
 direction as the head of the femur. At its lower border 
 the interarticular line between the femur and the tibia 
 can be readily felt. The external lateral ligament can 
 be distinguished on the outer side, passing down to the 
 head of the fibula. 
 
 The synovial membrane of the knee jomt is more ex- 
 tensive than that of any articulation in the body, and 
 reaches upwards in the extended condition of the limb 
 for two inches or more above the patella. In flexion it 
 sinks considerably, so that in operations about the lower 
 end of the femur there is less danger of opening up the 
 cavity of the knee joint if this position of the limb be 
 adopted. 
 
 IV. Popliteal Space. 
 
 The student should first note that the shape of the 
 space varies according to the position of the joint, being 
 flattened out in extension, but hollowed in Tiexion. 
 Commencing at the outer side, the tendon of the biceps 
 
124 
 
 POPLITEAL SPACE. 
 
 will be felt behind the external lateral ligament. In 
 extension these two structures lie so close to one 
 another that it is somewhat difficult to identify them 
 separately. But if the knee be semi-flexed, the latter 
 will be felt as a distinct rounded cord, whilst the former 
 can be easily grasped beneath the skin. Anterior to the 
 biceps tendon, between it and the ilio-tibial band of 
 fascia, there is a depression, where, in consequence of 
 the absence of large arteries, incisions can be made for 
 surgical purposes. If the fingers be pushed under the 
 inner border of the biceps tendon, a cord-like structure, 
 which is the external popliteal nerve, will be felt. On 
 the inner side of the knee three tendons are to be made 
 out, and may be most easily studied in semi-flexion, 
 with the foot on the ground so as to relax the tissues. 
 The most external and most prominent of these is the 
 semi-tendinosus. Internal to this is what at first 
 appears to be a single tendon, but by a little manipula- 
 tion the point of the finger can be made to sink into the 
 interval between the semi-membranosus, with its thick 
 rounded border, externally and the gracilis internally. 
 
 At the lower part of the space is the angular interval 
 between the two heads of the gastrocnemius. Between 
 the inner head of this muscle and the tendon of the 
 semi-membranosus is a large bursa, often called the 
 popliteal bursa, though there are several others in that 
 region. In one subject out of every five, according to 
 Holden, this bursa communicates with the cavity of the 
 knee-joint. The popliteal artery in the upper part of 
 the spaces lies to the inner side, under cover of the 
 
 \. 
 
THE LEG. 
 
 125 
 
 I I 
 
 i 
 
 semi-membranosus. Emerging from under this muscle 
 the artery passes downwards in the centre of the space, 
 terminating opposite the lower part c the tubercle of 
 the tibia. The pulsations of the artery can be felt, and 
 its current checked by compression against the femur 
 in the flexed condition. 
 
 The internal popliteal nerve is in the direct continua- 
 tion of the line of the great sciatic, and lies in the centre 
 of the space. 
 
 y The lymphatic glands of the space cannot be felt in 
 the normal condition, but when enlarged they are to be 
 made out, and should be remembered, as they may 
 form important factors in coming to a diagnosis in 
 certain surgical conditions. 
 
 V. The Leg. 
 
 The tubercle and external and internal tuberosities 
 of the tibia are all prominent at its upper extremity, and 
 the large flat anterior subcutaneous surface, which forms 
 the shin, can be traced downwards to the internal 
 malleolus. Its sharp outer border should be felt, and 
 the irregularity of its edge noted. The head of the 
 fibula, with a small part of the shaft below, and the 
 attachments of the external lateral lig;.:nent of the knee 
 and the biceps tendon, will be found at the outer side. 
 In the greater part of the leg this bono is hidden be- 
 neath masses of muscle, but in the lower third it can be 
 felt again, and becomes subcutaneous over a triangular 
 
 I ill 
 
126 
 
 THE LEG. 
 
 II 
 
 area above the external malleolus. This triangular area 
 lies between the peronei behind, and the extensors in 
 front. 
 
 After the bony points have been fixed the muscular 
 prominences should be studied. The prominence of the 
 calf is mainly formed, so far as is visible from the sur- 
 face, by the gastrocnemius, the strong tendon of which 
 can be seen passing down to help to form the tendo 
 Achillis, behind and above the heel. If the muscles of 
 the back be caused to contract, as when the weight of 
 the body rests on the toes and anterior part of the leet, 
 the heels being raised from the ground, the outline of 
 the soleus can be seen on either side of the upper part of 
 the tendon, but more distinctly on the outer side of the 
 leg, where it is less overlapped by the gastrocnemius. 
 Anteriorly, starting from the outer border of the tibia, 
 there can be felt and seen, when in action, tirst the 
 tibialis anticus, next, and separated from the former by 
 a groove, the extensor communis Jigitorum, a much 
 narrower muscular mass, and finally the peronei. In the 
 lower part of the leg the tibialis anticus and extensor 
 communis digitorum separate from one another, and here 
 the extensor proprius hallucis can be felt. 
 
 The popliteal artery, as has already been mentioned, 
 bifurcates at a point opposite to the lower border of the 
 tubercle of the tibia. Its posterior tibial branch is 
 indicated by a line drawn from the point of meeting of 
 the two heads of the gastrocnemius, to a point midway 
 between the posterior part of the os calcis and the inner 
 malleolus. At its lower part the artery is superficial, 
 
 \^ 
 
 \\ 
 
THE LEG. 
 
 127 
 
 and can be felt pulsating by the side of the tendo 
 Achillis, but above it is deeply placed. In the upper 
 part of the leg, it is reached, for purposes of ligation, by 
 two methods. In the first the incision is made along 
 the inner border of the tibia, and half an inch behind it, 
 the vessel being thus reached from the side. In the 
 second, which is called Guthrie's or the military opera- 
 tion, and is comparatively seldom performed, the in- 
 cision is made in the centre of the calf, the two halves 
 of the gastrocnemius being subsequently separated, and 
 the artery approached directly from behind. 
 
 The peroneal branch of the posterior tibial runs along 
 the inner margin of the fibula, on its posterior aspect. 
 The incision to reach it is made along the posterior line 
 of that bone, and rather above its centre. 
 
 The anterior tibial artery may be indicated by a line 
 drawn from a point midway between the heads of the 
 tibia and fibula, to a point over the centre of the front of 
 the ankle. The groove, already alluded to, between the 
 tibialis anticus and extensor comi unis digitorum, is a 
 good guide to this vessel. 
 
 The veins of the leg are of great im])ortance on 
 account of the tendency, which for various reasons they 
 possess, of becoming varicosed. The short or external 
 saphenous vein in normal condition cannot always be 
 seen. It is formed by branches which arise on the 
 outer side of the dorsum of the foot. The trunk when 
 constituted passes behind the external malleolus, runs 
 along the border of the tendo Achillis, lies in the mesial 
 line of the gastrocnemius, and enters the popliteal vein 
 
 
128 
 
 THE ANKLE. 
 
 in the popliteal space. The short saphenous nerve lies 
 close to this vein. The internal or long saphenous vein 
 is commonly visible even in the normal condition. It 
 commences by radicles on the dorsum of the foot, passes 
 upwards in front of the internal malleolus, and runs 
 along the inner border of the tibia to the internal condyle 
 of the knee. Here it lies close to the bone, and its current 
 is liable to be arrested by pressure, such as is applied by 
 tight garters or knickerbocker bands. From this point 
 it ascends along the inner and anterior aspect of the 
 thigh, passing through the saphenous opening into the 
 femoral vein. As far as the knee it is accompanied by 
 the internal saphenous nerve, which above this pcyint 
 lies under cover of the sartorius. 
 
 These veins become very visible after prolonged 
 standing or exercise in the upright posture, and par- 
 ticularly if pressun^ has been applied to the longer of 
 the two at the point mentioned above. 
 
 VI. The Ankle. 
 
 The two malleoli are very important bony landmarks 
 in relation to this joint, and they present several points 
 of contrast. The external in the first place descends half 
 an inch lower than the internal, so that whilst the line 
 of the ankle joint is about half an inch above the latter, 
 it is an inch above the former. Secondly, the external 
 is rather less prominent than the internal. Thirdly, the 
 external is placed half an inch further back than the 
 
 !^ 
 
 . 
 
THE ANKLE. 
 
 129 
 
 internal, and finally the latter is considerably broader 
 than the former, so that whilst its anterior border is so 
 far in front of its fibular companion, the posterior 
 borders of the two projections are on the same line. 
 Owing to the numerous tendons which pass over the 
 front of the ankle joint, it is rather difficult to feel any 
 of the superior articular surface of the astragalus, but in 
 semi-extension a small portion may be distinguished in 
 front of the external malleolus, and outside the tendon 
 of the peroneus tertius. 
 
 The student will notice, in looking at the bones of the 
 foot, that the posterior portion of the superior articular 
 surface of the astragalus is somewhat narrower than the 
 anterior. In the ordinary position of the foot no move- 
 ments are possible but those of flexion and extension. 
 In the position of extreme extension the narrower part 
 of the superiv^r articular surface of the astragalus lies 
 between the malleoli, and it is stated that at this point 
 a very slight amount of lateral movement is possible. 
 Theoretically, this doubtless is true, but the student by 
 grasping the lower end of the leg with one hand, and the 
 astragalus with the other, the foot being in the position 
 indicated, will be able to satisfy himself that such move- 
 ment in a muscular living subject is practically non- 
 existent. 
 
 A large number of tendons which lie around the ankle 
 joint, and materially contribute to its strength, should 
 next be studied. Posteriorly, the tendo Achillis stands 
 out as the most prominent structure in the region under 
 consideration. Anteriorly, commencing at the tibial side 
 
 K 
 
130 
 
 THE ANKLE. 
 
 and passing to the fibular, the tendons of the tibialis 
 anticus, extensor proprius hallucis, extensor longus 
 digitorum and peroneus tertius, will be felt in the order 
 mentioned. The best position in which to examine 
 them is that of flexion. 
 
 The tendons of the peroneus longus and brevis lie 
 immediately behind the external malleolus, but are in- 
 distinguishable as separate structures in this position. 
 Behind the internal malleolus lie, from before backwards 
 the tendons of the tibialis posticus, flexor longus digi- 
 torum, and flexor longus hallucis. The first named can 
 be easily seen and felt, but it is impossible to make the 
 other two out with any distinctness. 
 
 The anterior tibial artery with its nerve lies on the 
 front of the joint, the latter being external, between the 
 tendons of the extensores longus digitorum and proprius 
 hallucis, and its pulsations can here be felt as it lies 
 upon the lower end of the tibia. 
 
 The posterior tibial artery with its nerve, the latter 
 being external, lies behind the internal malleolus, be- 
 tween the tendons of the flexores longus digitorum and 
 longus hallucis, and can here be felt pulsating. The 
 incision to tie the vessel in this position is made in the 
 middle line between the posterior border of the tibia 
 and the tendo Achillis, and parallel to the former. 
 
 As the last point in connection with the study of the 
 ankle and foot, the student should consider the relation 
 of the parts to the various amputations practised in that 
 region. The line of each of these will consequently be V 
 mentioned here, the reader being referred for the details 
 
 . \ 
 
THE FOOT, 
 
 131 
 
 of each operation to any of the text-books on operative 
 surgery. 
 
 Syme's amputation, which is the one generally per- 
 formed in the position under consideration, consists in 
 removing the foot at the ankle joint, and subsequently 
 sawing off the malleoli with the lower articular surface 
 of the tibia. The two malleoli are the bony guides to 
 the line of the joint in this operation, and consequently 
 their relations to it, as given above, should be carefully 
 borne in mind. In Pirogoff 's operation the os calcis is 
 sawn through, the posterior portion being retained in 
 the flap. 
 
 : VII. The Foot. 
 
 I. Bony points. — Along either border of the foot 
 are certain bony prominences, the practical bearing of 
 which will appear when the operations in which they 
 are concerned are described ; these points should first 
 be identified. 
 
 Commencing posteriorly, there will be felt, along the 
 outer border of the foot, first the external tuberosity of 
 the OS calcis, secondly, about an inch below the point 
 of the external malleolus, the peroneal tubercle of the 
 OS calcis, thirdly, the spur on the outer side of the base 
 of the fifth metatarsal bone, and finally the head of the 
 same and the base of the adjacent phalanx. 
 
 Along the inner border from behind forwards are : — 
 first, the internal tuberosity of the os calcis ; secondly, 
 about an inch below the internal malleolus, the edge of 
 
 K 2 
 
13^ 
 
 THE FOOT. 
 
 the sustentaculum tali ; thirdly, the tubercle of the 
 scaphoid ; fourthly, the internal cuneiform bone ; fifthly, 
 the base of the fifth metatarsal, and finally the head of 
 the same bone with its sesamoid bones on its inferior 
 surface. Two amputations only need be mentioned 
 through various parts of the foot to show the practical 
 bearing of these points. 
 
 Lisfranc's operation consists in an amputation through 
 the tarso-metatarsal line of articulations. The line 
 
 Fig. 15.— Diagram of Foot showing Bony Prominences and Lines of Operation 
 
 (after Smith and Walsham). 
 
 T. Tibia. F. Fibula. As. Astragalus. Ca. Os calcis. Cu. Cuboid. S. Sca- 
 phoid. E. C, M. C, I. C. External, midcil? and internal cuneiform bones, a, b. 
 External and internal malleoli, c. Peroneal tubercle, d. Spur of fifth metatarsal, 
 r. Tubercle of scaphoid. /. Base of first metatarsal, 
 
 AA. Line of Syme's amputation. ' ^ 
 
 BE. Line of Chopart's amputation. 
 
 CC. Line of Lisfranc's amputation. ■ 
 
 f \ 
 
r 
 
 THE FOOT, 
 
 133 
 
 of these joints is somewhat irregular, a fact which is 
 chiefly due to the unequal lengths of the three cunei- 
 form bones, but, speaking- generally, extends across the 
 foot in a slight curve, with its convexity directed down- 
 ward, from the base of the fifth metatarsal to that of 
 the first. If, therefore, the student grasps between his 
 fore-finger and thumb the bases of these bones he will 
 have the tarso-metatarsal line immediately behind them. 
 Should he have any difficulty in finding the base of the 
 first metatarsal he may remember that it is placed one 
 and a half inches in front of the scaphoid tubercle, a 
 prominence which is always recognizable. 
 
 Chopart's amputation passes through the mediotarsal 
 joint, between the astragalus and scaphoid, and calcis 
 and cuboid. The guide to the line between the first two 
 bones is the tubercle of the latter. The line of the 
 calcaneo-cuboid articulation lies midway between the 
 external malleolus and the spur on the base of the fifth 
 metatarsal bone. 
 
 2. Soft parts. — On the dorsum of the foot the nu- 
 merous tendons will first claim the attention of the 
 student. Commencing at the inner side, tlie strong 
 tendon of the tibialis anticus will be seen passing down- 
 wards, and next to it that of the extensor proprius 
 hallucis, the most prominent of all. Then, still further 
 out will be seen the four tendons of the extensor longus 
 digitorum passing obliquely across the foot from within 
 outwards, with the tendon of the peroneus tertius ly:.ng 
 to the outer side of the tendon for the fifth toe. Exter- 
 nally to this if the toes be extended, a rounded mus- 
 
 \^\ 
 
134 
 
 THE FOOT. 
 
 U 
 
 h 
 
 e. 
 
 \ I J 
 
 i/V ' 
 
 ..V" 
 
 h. J 
 
 Fio. i6.— Cutaneous Nerve Areas, 
 Lower Extremity. Anterior Aspect. 
 
 a. IHo-hypogastric (L, i). 
 
 b. Genito-crural (L, i, 2). 
 
 c. Ilio-inguinal (L, i). 
 
 d. Small sciatic (S, i, 2, 3). 
 
 e. External cutaneous (L, 2, 3). 
 /. Middle cutaneous (L, 2, 3). 
 g. Internal cutaneous (L, 2, 3). 
 
 h. Peroneal cutaneous (L. 5, S. i, 2). 
 
 j. Internal saphenous (L. 3, 4). 
 
 k. Internal cutaneous and obturator 
 
 (L. 2, 3, 4). 
 I. Musculo-cutaneous (L. 4, 5, S. i). 
 m. External saphenous (S. i. 2). 
 n. Anterior tibial (L. 4, 5, S. i). 
 
 / 
 
 im 
 
 If 
 
 u 
 
 u 
 
Tn 
 
 THE FOOT. 
 
 135 
 
 a 1 i. 
 
 ! 
 V /. y — /'" 
 
 / d / \ C 
 
 V. 
 
 Fig. 17.— Cutaneous Nerve Areas, 
 Lower Extremity. Posterior Aspect. 
 
 a. Posterior sacral. 
 
 b. Posterior lumbar (L. i, 2, 3). 
 
 c. Ilio-hypogastric (L. i). 
 
 d. Perforating cutaneous (S. 3, 3). 
 
 e. Small sciatic (S. i, 2, it- 
 
 /. External cutaneous (L. 2, 3). 
 g. Internal cutaneous (L. 2, 3). 
 h. Do. and obturator (L. 2, 3, 4). 
 j. Peroneal cutaneous (L. 5, S. i, 2). 
 
 k. Internal saphenous (L. 3, 4). 
 
 I, External saphenous (S. x, 3). 
 
 m. Calcaneo-plantar (S. i, 2). 
 
 n. Internal plantar (L. 4, 5, S. i). 
 
 0. External plantar (S. i, 3). 
 
 \ 
 
 \c- 
 
136 
 
 THE FOOT. 
 
 cular elevation the belly of the extensor brevis digitorum 
 can be seen and felt lying on the front and outer side 
 of the foot. Its tendons pass under those of the long 
 extensors in an opposite direction, that is from without 
 inwards, and may be seen sometimes in thin persons. 
 On the outer side of the foot the tendons of the peroneus 
 longus and brevis can be seen and felt. The former 
 lies behind the peroneal tubercle, the latter in front of 
 it. The tendons of the inner side cannot be made out 
 distinctly, though that of the tibialis posticus with the 
 calcaneo- scaphoid ligament lies in the interval between 
 the malleolus and the tubercle of the scaphoid. 
 
 The dorsal ai:tery of the font passes over the ankle 
 joint, and runs to the first metatarsal space along the 
 outer border of the tendon of the extensor proprius 
 hallucis, where its pulsations may be felt throughout its 
 entire course. Under the skin over the dorsum a num- 
 ber of veins will be seen, forming a kind of arch, the 
 extremities of which form the commencement of the two 
 saphenous veins. / . 
 
 The metatarso-phalangeal joints lie an inch behind 
 the skin commissures between the toes. 
 
 The skm on the plantar surface of the foot is firmly 
 adherent to the subjacent structures, so as to permit of 
 very little mobiHty. The remarks made as to the use of 
 this arrangement, and the anatomical explanation of the 
 same in connection with the skin of the palm of the 
 hand, will apply also to that now undor consideration. 
 
 The plantar arteries cannot be seen or felt, but their 
 position may be marked out by the following rules : — A 
 
 n 
 
r 
 
 THE FOOT. 
 
 137 
 
 point should be taken midway between the tip of the 
 internal malleolus and the most prominent point of the 
 plantar surface of the heel. A line drawn from this 
 point to the middle of the plantar surface of the great 
 toe indicates the position of the internal plantar artery. 
 
 A line drawn from the first named point to another 
 one inch internal to the outer border of the base of the 
 fifth metatarsal bone will indicate that portion of the 
 external plantar artery which runs longitudinally. 
 From this point it turns and runs across the bases of the 
 metatarsal bones to the first interspace. 
 
 Before leaving the lower extremity the student should, 
 as in the case of the upper, map out the areas of the 
 subcutaneous nerves as given in the figures. 
 
INDEX. 
 
 ^w^ 
 
 Acromion, go 
 
 Angular gyrus, 38 ^ 
 
 processes, 2 
 Angulus Ludovici, 52 
 Ante-cubital fossa, 99 
 Anus, 77 
 Apex-beat, 60 
 Artery, aorta, t32 
 
 I abdominal and 
 
 branches, 73 
 thoracic, 84 
 axillary and branches, 93 
 brachial and branches, 94, 
 
 99 
 carotid, common, 46, 47, 
 63 
 
 external, 47 
 ' crico-thyroid, 43 
 
 dorsalis pedis, 136 
 epigastric, deep, 74 
 facial, 6, 48 
 
 transverse, 7 
 femoral, 117, 118 
 gluteal, 115 
 iliac, 74 
 , innominate, 46, 63 
 lingual, 48 
 
 mammary internal, 64 
 meningeal, middle, 31 
 occipital, 27, 48 
 of elbow, 99 
 palmar arch, no 
 
 Artery, plantar, 136 
 
 popliteal, 126 
 
 posterior auricular, 27 
 '. , palatine, 23 
 
 princeps pollicis, in 
 
 pudic, 116 
 
 radial, 103 
 
 sciiatic, 116 
 . subclavian, 46, 49 
 
 superBcialis volas in 
 
 superficial temporal, 7 
 
 superior thyroid, 48 
 
 supra-orbital, 7 
 
 thyroidea ima, 44 
 
 tibial anterior, 127, 130 
 posterior, 126, 130 
 
 transverse cervical, 50 
 
 ulnar, 104 
 Ary-epiglottic folds, 22 
 Asterion, 29 
 Asymmetry efface, n 
 Atlas, transverse process of, 150 
 Auricle, left, 60 
 
 "ght, 59 
 Axilla, 92 
 
 Bicipital fascia, 100 
 Bladder, 73 
 
 Bones of hand, 105, 108 
 Brachial plexus, 50 
 Brain, base of, 33 
 
140 
 
 INDEX. 
 
 Breast, 55 
 
 Bregma, 29 
 
 Bryant's ilio-femoral triangle, 114 
 
 Buccal pellet, 5 
 
 Carotid tubercle, 48 
 
 Carpo - metacarpal articulations, 
 
 108 
 Caruncula lachrymalis, 14 
 Catheter, pa^.^age of Eustachian, 
 
 * female, 81 
 
 male, 75 
 Chopart's amputation, 133 
 Clavicle, go 
 Clitoris, 80 
 
 Cloquet's snuff-box, 1 11 
 Coccyx, 113 
 Colon, 87 
 
 Coraco-acromial ligament, 92 
 brachialis muscle, 92 
 Coracoid process, 91 
 Coronal suture, 30 
 Creases on hand, 109, no 
 Cricoid, 22, 43 
 Crico-thyroid membrane, 43 
 Crural canal, 118 
 Cutaneo-phalangeal ligaments, in 
 
 Deltoid muscle, 56, 91 
 Diaphragm, 64 
 Douglas' pouch, 82 
 Drayman's bottom, 114 
 
 Ear, external, 18 
 
 Epiglottis, 22 
 
 Eustachian tube, 17 
 
 External occipital protuberance, 
 
 ^1 
 
 Eyeball, 14 
 
 tension of, 14 
 Eyelids, 12 
 
 eversion of, 13 
 
 Falx cerebelli, 30 
 
 cerebri, 30 
 Femur, condyles of, 123 
 Fibula, 125 
 Filtrum, 6 
 Fissures of brain, 
 
 longitudinal, 35 
 
 parieto-occipital, 34, 37 
 
 Rolando, 34, 37 
 
 Sylvius, 34, 36 
 
 transverse, 36 - ' 
 
 Fontanelles, 32 
 Foot, bony points ot, 131 
 
 tendons, 133 
 Fossa navicularis, 75 
 Fraenum labii, 21 
 
 linguae, 23 
 Frontal eminence, i 
 
 lobes and iissures, 37 
 
 Genio-hyo-glossus muscle, 23 
 Gimbernat's ligament, 117 
 Glabella, 2 
 Glands of Tyson, 76 
 Glenoid fossa (scapular), 91 
 Glosso-epiglottic fold, 22 
 
 Heart, relation to chest wall, 59 
 Hernia, 66 
 
 Hesselbach's triangle, 74 
 Holden's line, 117 
 Housemaid's knee, 12a 
 Houston's valves, 78 
 Humerus, condyles, 93 
 
 h 
 
INDEX. 
 
 141 
 
 Humerus, head, 91 
 
 tuberosities, 90 
 Hunter's canal, 120 
 Hymen, 81 
 Hyoid bone, 22, 42 
 space, 22 
 
 Ilium, anterior superior spine, 65, 
 116 
 
 crest, 65, 113 
 
 posterior superior spine, 113 
 Incisura cardiaca, 58 
 Inferior maxilla, 4 
 Infra-orbital foramen, 2 
 
 sternal depression, 53 
 Inion, 30 
 Intestines, 72 
 Intra-parietal fissure, 40 
 Ischial tuberosity, 117 
 
 Jaw, lower, 4 
 
 Kidney, 86 
 
 Knee joint, synovial membrane, 
 123 
 
 Labia majora, 80 
 
 Lachrymal sac, 14 
 
 Lambda, 29 
 
 Lambdoid suture, 30 
 
 Lateral sinus, 31 
 
 Latham's circle, 60 
 
 Ligamentum patella:, 121 
 
 Linea alba, 66 
 
 oculo-zygomatica, 6 
 semilunaris, 66 
 
 Lineee transversae, 66 
 
 Lisfranc's amputation, 132 
 
 Lithotomy, 79 
 Liver, 70 
 Lizar's lines, 115 
 Lung, in neck, 50 
 
 relation to chest wall, 56, 
 84 
 Lymphatics of groin, 119 
 
 McBurney's point, 72 » 
 
 Macewen's triangle, 20 
 Malleoli, 128 
 Mastoid process, 19, 28 
 Meibomian glands, 13 ' 
 Mental foramen, 3 
 Metacarpo- phalangeal articula- 
 tions, 108 
 Miner's elbow, loi 
 Mons veneris, 65 
 Murmur?, cardiac, 62 
 Muscles of calf, 126 
 
 forearm,- 99, 102 
 
 thigh, 120 
 
 Nasion, 30 
 Naso-labial fold, 6 
 Nates, folds of, 115 
 Nelaton's line, 114 
 Nerves, anterior crural, iig 
 
 buccal, 24 
 
 circumflex, 93 
 
 facial, 9 
 
 great auricular, 51 
 
 gustatory, 24 
 
 inferior dental, 24 
 
 pudendal, 116 
 
 infra-orbital, 2 
 
 lingual, 24 
 
 median, 100, 104 
 
 mental, 2 
 
 musculo-spiral, 94, 100 
 
142 
 
 INDEX. 
 
 Nerves, occipital, small, 51 
 
 of abdominal parietes, 6g 
 pneumogastric, 48 
 popliteal, 124 
 radial, 104 
 sciatic, great, 116 
 spinal accessory, 50 
 superficial cervical, 51 
 supra-orbital, 2 
 tibial, anterior and poste- 
 rior, 130 
 ulnar, 95, loi, 104 
 
 Nipple, 55 
 
 Nostrils, 16 
 
 Occipital lobe and fissures, 41 
 CEsophagus, 22, 43, 45 
 Olecranon, 95, 96 II 
 
 Omo-hyoid muscle, 49 
 Orbit, II 
 
 Palate, 23 
 
 soft, 25 
 Palmaris brevis muscle, 109 
 Pancreas, 72 
 Papillae of tongue, 21 
 Paracentesis thoracis, 53 
 Parietal lobe and fissures, 38 
 Parieto-mastoid suture, 30 
 Parotid gland, 10 
 Patella, 121, 122 
 Pectoralis major, 56, 92 
 
 minor, 93 
 Penis, 76 
 Perineum, female, 82 
 
 male, 76 , , 
 Petit's triangle, 84 
 Pharynx, 43 
 Piles, 77 
 Pillars of fauces, 25 
 
 Pirogoff's operation, 131 
 Platysma myoides, 42 
 Pleura, extent of, 58 
 Plica semilunaris, 14 
 Popliteal space, 123 
 Posterior nares, 25 
 Poupart's ligament, 68, 117 
 Precordial dulness, 60 
 Processus lingualis, 58 
 Prostate gland, 78 
 Pterion, 29 
 Pterygoid process, 24 
 Pterygo-maxillary ligament, 24 
 Pylorus, 70 
 
 Radius, head, 96 
 shaft, loi 
 tubercle, 97 
 Rectal pouches, 73 
 Rectus muscle, 66 
 Ribs, 53 
 
 Rings, abdominal, 6\i 
 Rugae, oculo-frontal, 6 
 transverse, 6 
 
 Sacro-sciatic ligament, great, 115 
 Sagittal suture, 30 
 Saphenous opening, iiS 
 Scalp, 27 
 Scapula, 90 
 Scarpa's triangle, 117 
 Scrotum, 76 
 Seminal vesicles, 78 
 Septum nasi, 16 
 Serratus magnus, 56 
 Sinuses of dura mater, 31 
 Spinal cord and nerves, 85 
 Spine of pubes, 65, 116 
 Spines of vertebrae, S3 
 Spleen, 71 
 
 / \> 
 
 h 
 
INDEX. 
 
 H3 
 
 Squamous suture, 30 
 Steno's duct, 10, 21 
 Sterno-clavicular articulation, 46, 
 
 53 
 mastoid, 45 
 
 Sternum, 52 
 Stomach, 6g 
 Subclavian triangle, 49 
 Sub-clavicular fossa, 92 
 Sub-maxillary gland, 23, 46 
 Sub-occipital lymphatic, 27 
 Sucking cushions, 5 
 Supra-ciliary ridge, i 
 Supra-marginal convolution, 40 
 Supra-mastoid crest, 4 
 Supra-meatal triangle, 20 
 Supra-orbital notch, 2 k>>: 
 
 Syme's amputation, 131 
 Symphysis pubis, 65 
 
 Temporo-sphenoidal lobe and fis- 
 sures, 40 
 Tendons at ankle, 129 
 knee, 124 
 Tendo oculi, 12 
 Tentorium, 30 , 
 
 Testicle, 76 
 Thenar eminence, 109 
 Thorax, size of, 52 
 Thymus gland, 45 
 Thyroid body, 44, 46 
 cartilage, 43 
 Tibia, 125 
 Tongue, 21 
 Tonsil, 25 
 
 Torcular Herophili, 31 
 Trachea, 43, 64, 8 f 
 Triceps, 95 
 
 Trochanter, great, 113 
 Turbinated bones, 16 
 
 Ulna, coronoid process, 97 
 
 olecranon process, 95, 96 
 shaft, loi 
 
 Umbilicus, 66 
 
 Urethra, female, 75 
 male, 78 
 
 Uvula, 25 
 
 Vagina, 81, 82 
 Valves of heart, 60 
 Veins, basilic, 98 
 
 cephalic, 91, 94, 98 
 innominate, 63 
 jugular, anterior, 44, 47 
 ^ external, 47 
 
 internal, 46, 48 
 ranine, 23 
 
 saphenous, 119, 127, 128 
 thyroid, 44 
 
 vena cava, inferior, 64 
 superior, 63 
 salvatella, 98 
 Ventricle, left, 60 
 
 right, 60 
 Vertebral column, relations of 
 viscera to, 87-89 
 
 Wharton's duct, 23 
 
 Xiphoid cartilage, 53 
 
 Zygoma, 3 
 
 I 
 
:IV: 
 
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