z tääq?

'4

sl§|MS|
iiliii
^2Ä«;
!•<..*;
'

‘-in 7
..•*>« •

"#••,'.•/,
•
•
7: v:.,«;f.ii
:
-« j
ii'MUWO
-f
j:;, '.

. ,
~. . iU nam*''.v "Wu

'

-• ’
; / -;
Y.“

•
'
-
'-?/; ' ‘'/. nf- f

.
-,

ImWäMmh
T^WWWj
'
'

-O

tt
* si

M wmm.
?y/j/j /A/////j/fr///A

S '

is;
"'"

bBBBWMI
1 ',;

•
: ;

'
:
VA^-.:/, -;'.ii; :
-. 'U.:!.y^.
|
•:?k ppffi! * I

'. /'' ... •.

it '' '
•

vMwt.
/'
'i'/':. '/'

i: "j'f/WiAilMY.Mtyr'.-t.:. />•-. ./.'.

»ÄÄI
// #,
J
yt^unmwM
WMm
••WUi’jf/jrMnW".

.
'

"
'

'

'
, ;
.;.
: -

y
:
.

mfmm '•»X -'-'•

/,l /,'/. 'n'rY. V

MM; w? Wmm

:..;:::x

'ffit/W'.'
 The Library of the
Wellcome Institute for
the History of Medicine

MEDICAL SOCIETY
OF
LONDON
DEPOSIT

Accession Number

Press Mark
Rfl ft {)£ LB fttjO I verw

H f\ E C l'CL.
(
Kcc^' ci\
 Med
K7368

ATLAS
OF

APPLIED (TOPOGRAPHICAL)
HUMAN ANATOMY FOR

STUDENTS AND PRACTITIONERS

BY

Dr. KARL von BARDELEBEN and PROF. Dr. HEINR. HAECKEL

IN COLLABORATION WITH
DR- FRITZ FROHSE
AND

PROFESSOR DR- THEODORE ZIEHEN

Only Authorised English Adaptation from the Third German Edition

CONTAINING 204 WOODCUTS IN SEVERAL COLOURS AND DESCRIPTIVE TEXT

BY

J. HOWELL EVANS M.A.,M.B.

M. CH., OXON., F.R.C.S., ENGLAND
LATE SENIOR DEMONSTRATOR OF HUMAN ANATOMY AT ST. GEORGE’S HOSPITAL LONDON
DEMONSTRATOR OF OPERATIVE SURGERY ST. GEORGE’S HOSPITAL, LONDON
ASSISTANT SURGEON TO THE CANCER HOSPITAL, LONDON

LONDON NEW YORK

REBMAN LIMITED REBMAN COMPANY
129 SHAFTESBURY AVENUE 1123 BROADWAY
1906
 ALL RIGHTS RESERVED
Entered at Stationer’s Hall

1906.

WELLCOME INSTITUTS
LI6RAPV
1

Coll. WelMOmec
Coll.

No

06
 Preface.

Nearly every Student of Anatomy and every Practitioner feels the need

of some book which shall, for the former, serve as a supplement to dissection
and assist in the study of prepared anatomical specimens and which, for the

latter who cannot spare the time for the study of specimens or whose work will

not countenance any contact with the cadaver, shall present the regional im-

portant structures.

Such a book must present Anatomical data by numerous and good

illustrations, the important details depicted must be presented in a systematic,

clear, and practical manner. For such merits and to meet these requirements
this English Version has been prepared; it is hoped, therefore, that this book

will serve as a means of revision among Students, as a valuable reference both

of applied Anatomy to the Practitioner, and as a means of quickening the

weakening memories of the Surgeon.

The selection of the Plates and their extent has been determined by

their relative clinical importance; special attention has beeil directed to those

regions which have, of recent years, become of increased interest to the Physician

and Surgeon; so that those portions of Anatomy which are likely to be of actual

service to the Student in his subsequent study, and to the Practitioner in his

clinical work, form the basis of each plate.

Lithographic Plates for the finer and Wood-cuts for the coarser detail,

when coloured, are undoubtedly the best means of illustrating Anatomy and
Histology; because by these methods the exact relations and distinctness of

different structures in the various planes are most admirably shewn.

This book cannot replace, and is not intended to replace, the Textbook

of Anatomy, but is of great use with the more comprehensive Anatomical

Works and Atlases.
There
 IV

There is as yet, no Universal Anatomical Nomenclature — in the original

German work the B. N. A. nomenclature is employed, but among English Ana-

tomists the nomenclature is very variable, at one time purely classical at an-

other purely English, frequently a mixture. I have endeavoured to give the

terms most frequently employed in England, with a further inclination whenever

possible, to an English rather than a Classical term.

In connection with the question of nomenclature, the reader is advised

to peruse Toldt’s Atlas, wherein all synonyms are well explained.

London, W.

J. Howell Evans.
 Contents.
I. Head.
Fig. 1. Median Section through the Head.
2. Frontal Section through the Head passing through the Orbits.
3. Outer Surface of the Cerebrum —
Centres of Localization.
4. Outer Surface of the Cerebrum —
Convolutions and Sulci.
5. Inner Surface of the Cerebrum.
6. Dorsal Aspect of the 4th Ventricle.
7. Course of Fibres in the Internal Capsule.
8. Course of Fibres from Cortex to -Spinal Cord.
11 9. Course of Fibres in the Crura Cerebri —
Frontal Section.
10. Convolutions and Bony Sutures (in the newborn).
11. Convolutions and Bony Sutures (in the child).
12. Convolutions and Bony Sutures (in the adult).
13. Base of Brain with Arteries and Cranial Nerves.
14. Base of Skull; from above.
15. Base of Skull, with Arteries, Nerves and Venous Sinuses.
16. Base of Skull, with the soft parts, after partial removal of the bones.
17. Projection of the Lateral Ventricle, Middle Ear and Lateral Sinus on to the
outer surface of the Skull.
18. Projection of the Middle Meningeal Artery on to the outer surface of the Skull.
19. Cranio-Cerebral Topography.
20. Exposure of the Cerebellum.
21. From a horizontal section — Auditory Apparatus and its relations.
22. Part of Fig. 21 — Tympanic Cavity and its relations.
11 23. Vertical section through the Left Temporal Bone, passing through the Axis
of the Petrous portion.
24. Horizontal Section through the Left Temporal Bone.
25. Mastoid Process of child, opened.
26. Mastoid Process of adult, opened.
27 and 28. Tympanic Cavity and its relations; opened from behind.
29. Superficial Vessels and Nerves of the Head.
30. Side View of the Face — Superficial layer.
11 31. Side View of the Face — Deep layer.
11 32. Exposure of the Gasserian Ganglion.
33 to 38. Areae of Distribution of the Sensory Cranial Nerves.
39. Nasal Cavity with openings of Accessory Cavities.
11 40. Antrum of Highmore and Roots of Teeth.
41. Frontal Sinus, Nasal Duct.
42. Orbit and its relations— Horizontal Section.
43. Orbit and Nasal Cavities in a child —Frontal Section.
44. Orbit and its relations in a child —
Vertical Section through the Axis of the
Optic Nerves.
45. Frontal Section through the posterior part of the Nasal Cavity.
46. Frontal Section through the Sphenoidal Sinus and Nasal Cavity.
47. Frontal Section through the Anterior part of the Cavernous Sinus.
48. Frontal Section through the Posterior part of the Cavernous Sinus.
 VI

I- lg. 49- Inner region of the Eye —

Lachrymal Apparatus — Superficial layer
„ 50. Lachry mal Passages —
Deep layer.
„ 51. Floor of the Mouth.
„ 52 . Occipital Region.
»1 53- Horizontal Section through the Head at the level of the Axis.

II. Spinal Cord.

F *g 54- Position of the Cord inthe Vertebral Canal.
„ 55. Lower End of the Spinal Canal in the Adult.
„ 56. Diagrammatic Cross-Section through the Spinal Cord.

III. Neck.
F >g- 57- Regions of the Neck —
from in front.
.. 58. Regions of the Neck —
from the side.
» 59- Transverse section through the Neck passing through the Upiier part of the
5th Cervical Vertebra.
» 60. Neck, from in front. Superficial layer, in the adult.
„ 61. Neck, from in front. Deep layer, in the adult.
„ 62. Neck, from in front. Deep layer, in the child.
„ 63. Superior Triangle of the Neck, with Lymphatics.
» 64. Ligature of the Lingual Artery.
,, 65. Larynx — opened from in front.
„ 66 . Side View of the Anterior Region of the Neck.
Oesophagus.
„ 67. Side of the Neck, lower triangle.
„ 68 . Side ol the Neck —
Superior Cervical Ganglion of the Sympathetic.
„ 69. Larynx, seen from- behind.
„ 7°- Apex of the Pleura.
„ 7i. Course of the Large Vessels and Nerves to the Upper Limbs.

IV. Arm.
Fig. 72. Axilla.
„ 73. Frontal Section through the Right Shoulder of a Boy.
„ 74. Horizontal Section through the Left Shoulder of a Boy.
„ 75. Anterior Region of the Shoulder-Joint.
„ 76. Mohrenheim’s Fossa —
(Infra-Clavicular Fossa).
» 77- Posterior Region of the Shoulder-Joint.
„ 78- Right Arm — seen from the inner side.
„ 79. Left Arm — seen from the outer side and behind.
„ 80. Transverse Section through the middle of the right arm.
„ 81. Transverse Section through the lower third of the right arm.
„ 82. Left Antecubital Space, superficial layer.
„ 83. Right Antecubital Space, deep layer.
„ 84. Region of Right Elbow.
» 85. Transverse Section through the right Elbow-Joint.
„ 86. Longitudinal Section through the left Elbow-Joint,
u 87. Prontal Section through the right Elbow -Joint (aet. yrs.).
19
” 88. Sagittal Section through the Elbow-Joint (aet. 8 yrs.).
left
„ 89. Right Forearm, deep layer, from in front
„ 00. Transverse Section through upper third of right forearm.
„ 91. Transverse Section through lower third of right forearm.
„ 92. Region of Right Wrist, outer side. (Snuff-Box.)
» 93. Nerves and Veins of the Dorsum of the Right Hand.
„ 94. Tendon-Sheaths of the Dorsum of the Right Hand.
» 95- Palm of Left Hand; Superficial layer.
1, 96. Palm of Left Hand; Deep layer.
” 97- 1 endon -Sheaths, and Large Arteries of the Palm of the Right
hand.
„ 98 to 01. Tendon-Sheaths of Palm of Hand. Left side.
1
 VII

Fig. 102. Horizontal Section through Dorsum of Hand.

103. Transverse Section through Carpus.
>> 104. Transverse Section through Palm of Hand.
J? 105 and 106. Cutaneous Areae of the Nerves of the Upper limb.
yy 107 and 108. Cutaneous Areae of the Nerves of the Upper limb according to
their spinal segmental origin.
yy 109 and no. Segmental Innervation of the Muscles of the upper limb.

V. Thorax.
Fig. in. Regions of the Thorax and Abdomen.
1 12. Frontal Section through the Trunk.
1 13. Superior Aperture of the Thorax.
1 1 4. Lymphatic Glands of the Breast in the Adult.
1 15. Lymphatic Glands and Vessels of the Head, Neck, Thorax and Arm in a
child one year old.
1 1 6. Boundaries of the Lung and Pleura, from in front —
Area of Absolute Cardiac Dulness.
1 1 7. Boundaries of the Lung and Pleura from behind.
1 18. Anterior Wall of the Thorax and Heart in the New-born.
1 19. Anterior Wall of the Thorax and Heart in the Adult.
120. -Heart of Adult —Ventricle opened.
1 2 1. Transverse section through the Trunk; at level of ist and 2nd Dorsal Vertebra.
122. Transverse section through the Thorax; at level of 9th Dorsal Vertebra.
123. Transverse section through the Thorax; at level of 5th Dorsal Vertebra.

VI. Abdomen.
Fig. 124. Position of Viscera, from in front.
125. Position of Viscera, from behind.
126. Left Lung and Spleen, side view.
127. Position of Viscera — Peritoneal Cavity in the Child.
128. Liver, Stomach, Pancreas, Omental Sac.
1) 129. Liver, Spleen, Pancreas, Duodenum, after removal of Stomach.
JJ 130. Position of Viscera (Extraperitoneal), Female.
JJ 13 1. Gall-Bladder, Bile-ducts, relations, Female.
yy 132. Gall-Bladder, Bile-ducts, relations, Male.
133. Subphrenic Space, Pelvis of Kidney, Hilum of Liver, Bile-ducts.
134. Right Kidney, exposed from behind.
135. Portal Vein, Umbilical and Renal Vessels.
yy 136. Position ofAbdominal Viscera, seen from behind, lines of the Peritoneum.
JJ 1
37 . Vermiform Appendix and Caecum.
J> 138. Sigmoid Flexure and Inguinal Canal.
J) 139. Transverse Section through the Trunk at level of nth Dorsal Vertebra.
» 140. Transverse Section through the Trunk at level of ist Lumbar Vertebra.
1 4 1 . Retroperitoneal Lymphatics.
142. Anterior Abdominal Wall, seen from behind.
143. Anterior Abdominal Wall, Region of Appendix with Nerves. Bladder moder-
ately distended.
3J 144. Anterior Abdominal Wall, Hypogastric Region with Nerves. Bladder much distended.
>> 145. Back, with Nerves, Arteries and Lymphatic Glands.

VII. Pelvis.
Fig. 146. Median Section through Female Pelvis —
Bladder and Rectum empty.
9J 147. Female pelvic organs, seen from above and behind.
}> 148. Vulva, Vestibule.
yy 149. Female pelvic organs, seen from in front and above; Ureter.
yy 150. Male pelvic organs exposed from behind.
yy 15 1. Median Section through Male Pelvis.
yy 152. Median Section through Male Pelvis; Urethra, Pelvic Fasciae.
yy 153. Frontal Section through Male Pelvis; Levator Ani.
 VIII

Fig. 154. Male Perinaeum; I. Superficial layer.

155. Male Perinaeum; II. Recto-Urethral Muscle; Prostate.
156. Male Perinaeum; III. Cowper's Glands with their Ducts.
tt 157. Male Perinaeum; IV. Urogenital Triangle, Ampulla of Rectum.
158. Male Perinaeum: V. Prostate, Seminal Vesicles, Course of Urethra through the
triangular ligament.
159. Male Perinaeum; VI. Pubic Region — Levator Ani.
160. Female Perinaeum.
16 1. Male Pelvic Organs, from behind. Arteries to Seminal Vesicles.
162. Male Pelvic Organs, from left side. Nerves to Seminal Vesicles.
163. Gluteal Region.
it 164. Lymphatic Glands and Vessels of Female Pelvis, child.
165. Frontal Section through the Right Hip.
ft 166. Inguinal Region, ist layer, Superficial Lymphatic Vessels and Veins.

167. Inguinal Region, 2nd layer, Fossa Ovalis.

ft 168. Inguinal Region, 3rd layer. Spermatic Cord, Scarpa’s Triangle.
169. Inguinal Region, 4th layer, Hernial Orifices, Iliac Bursa.
ft 170. Inguinal Region, 5th layer, Subperitoneal Hernial Orifices. Hip-joint. Ob-
turator Region.
1 7 1. Frontal Section through Left Hip-joint of boy aged 8 years.
172. Nelaton’s Line.

VIII. Leg.
Fig. 173. Hunter’s Canal and Popliteal Space, seen from the inner side (Jobert’s Fossa).
174. Transverse Section through the right thigh at junction of middle and upper thirds.
175. Transverse Section through the right thigh at junction of middle and lower thirds.

1 76. Left Knee-joint.

177. Sagittal Section through the left knee-joint (extended).
1 78. Sagittal Section through the left knee-joint (flexed).
179. Sagittal Sectionthrough the right knee-joint, boy aged 16 years.
180. Frontal Section through the right knee-joint, boy aged 8 years.
1 8 1. Transverse Section through the right knee-joint.
ft
182 and 183. Lymphatics of the Popliteal Space.
ft 184. Right Popliteal Space.
ft 185. Transverse Section through the right leg, junction of upper and middle thirds.
186. Transverse Section through the right leg, near the ankle.
187. Right Leg, from the outer side. External Popliteal Nerve.
188. Right Leg, from behind. Internal Popliteal Nerve.
it 189. Tendon-Sheaths behind Internal Malleolus.
it 190. Region behind Internal Malleolus.
it 1 91. Sole of Right Foot, superficial layer.
it 192. Sole of Right Foot, deep layer.
tt 193. Ankle and Dorsum of Foot, left side.

it 194. Outer side of Left Foot.

it 195. Dorsum of left foot with Muscles and Tendon-Sheaths.
it 196. Dorsum of left foot with Tendon-sheaths, Arteries and Bones projected on to
surface.
it 197. Frontal Section through the right Ankle-joint.
tt 198. Frontal Section through the Anterior part of Tarsus.
tt 199. Sagittal Section through the right foot.

a 200. Horizontal Section through the right foot (near the sole).
it
201. Tarsal Joints, exposed from above, Right side.
202 and 203. Areae of the Cutaneous Nerves of the Lower Limb, Right side.

tt 204. Nerve supply of Skin and Muscles of the Lower Limb according to their
Segmental Origin —
Anterior Surface.
it 205. Nerve supply of Skin and Muscles of the Lower Limb according to theii
Segmental Origin — Posterior Surface.
 ATLAS
OF

TOPOGRAPHICAL ANATOMY.
 Fig. i. Median Section through the Head.

Right half of a frozen-section through the Head and Neck of a girl aged 15.
In front the plane of section is carried accurately through the middle line, but posteriorly
it deviates about */ 5 ths inch to the left. The bones arc left intact, as is shewn by the
bisected Odontoid Process ;
the soft parts (particularly brain-substance) have been carefully
cleared away as far as the middle line.

A median section gives the best general idea of the relations and positions of
the structures of the head, and in particular of the topograplucal relations of the brain
to the face ;
shows how the brain extends further down posteriorly than in front
it clearly
That portion of the skull cap under which the Cerebrum lies is only covered by a thin
layer of soft parts —
skin and epicranial aponeurosis (the latter is blue in the figure).
The Hemispheres, therefore, are easily injured in fracture of the vault of the
skull. The Cerebellum is better protected. The thickness of the skull cap varies con-
siderably at different points, and in different people — it is normally at the vertex */I0 th
inch. On either middle line the bone may be very thin, because for a
side of the
distance of 4/5 ths inch from the middle line Pacchionian bodies may be present, and only
covered bv a very thin lamina of bone.
The Superior longitudinal Sinus is exhibited throughout its whole length (the
other Venous Sinuses are shewn in Figs. 15 and 16), beginning at the Foramen Caecum
and increasing in width as it extends backwards and receives more blood it finally forms
by junction with the Straight Sinus the Torcular Herophyli at the level of the External
Occipital Protuberance (or somewhat higher up) and unites with each lateral Sinus,
especially with the right.
Its position is very exposed; as it can be easily injured it demands consideration
during trephining.
The Nasal Septum is usually asymmetrical, being bent to one side (left in this
case). Dense connective-tissue is found at the anterior surface of the base of die skull
and is continued downwards as the Anterior Common Spinous Ligament which covers
the anterior surfaces of the bodies of the vertebrae. A thick mass of lymphoid tissue
lies under the mucous membrane of the posterior wall of the pharynx (i. e. the Pharyngeal

Tonsil); lower down between the Oesophagus and the Vertebral Column there is only a
thin layer of connective tissue in which pus may easily spread downwards (Retropharyn-
geal Abscess).
When the mouth is closed, the Tongue lies against the Palate (in this figure,
depending upon the form of death, suicide by drowning, the tongue is seen pushed be-
tween the Canine teeth).
On the posterior surface of the Hyoid Bone the Hvoid Bursa is seen lying be-
tween the Hyoid Bone and the Thvreohyoid Membrane which is attached to the upper
border of the bone.
The Larynx is here seen at a higher level than usual: the Glottis, as a rule, is

situated at the level of the 5th Cervical Vertebra or of the disc between the 5th and
6th Cervical Vertebrae.
The Pyramidal Process of the Thyreoid Gland (Pyramid of Lalouctte), in this
figure extends almost up to the Hyoid Bone whereas the usual height to which the
Isthmus <>f the Gland reaches is the ist Tracheal ring.
 Aponeurosis of Occipito
Superior Longitudinal Sinus Frontalis
.
Middle Commissure
Falx Cerebri 3rd Ventricle
Fornix
Inferior Longitudinal Sinus Vein of Galen

Splenium of Corpus Callosum

Ventricle of Septum Pellucidum

Pineal Gland (Epiphysis)

Genu of Corpus Callosum
Corpora
Quadrigemina
Anterior Commissure

Anterior Cerebral
Aqueduct of
Artery
Sylvius
Free edge of Falx
Cerebri (Lamina Ter-
minalis)
Straight
Sinus
Crista Galli

Frontal Sinus
Corpus
Mamillare
Optic Chiasma

Pituitary Body
(Hypophysis)
Basilar
Sphenoidal Sinus Artery

Septal Cartilage
4th Ven-
tricle
Spheno-oc-
cipital syn-
chondrosis
Lateral Sinus
Pharyngeal
Tonsil
Falx Cerebelli
Frenum of
Upper Lip
Odonto- Atlantal
Levator Palati Synovial joint
Muscle
Semispinalis Muscle
Azygos Uvulae
Muscle
Genioglossus Splenius Capitis Muscle
Muscle

Geniohyoid Trapezius Muscle

Muscle
Mylohyoid Muscle

Digastric Muscle
Epiglottis
Hyoid Bone
Thyreoid Cartilage

Ventricle of the Larynx

Cricoid Cartilage

Thyreoid Gland

Fig. 1. Mesial (Sagittal) Section through the Head.

2
/3 Nat. Size.

Rebman Limited, London. Rcbman Company, New York.

 f Occipito- Longitudinal
rrontaU» M Falx Cerebri
Anterior (
Olfactory Bulb
raid
Perpendicular Plate of Ethmoid
Frontal Lob*

Superior Turbinate»!
Bone

Frontalis Muscle
(Epicramus)

1/natnr
Dura Mater . Palprbrac
Mimic

Frontal Sinus ^ Temporal

Muscle

Ciliary Nerves Temporal

Fascia

Temporo- Malar
Nerve >rbiculam
<
#
Oculi Muscle
Lacrymal Nerve

External I~acr\ mal

Rectus Muscle Gland
Zygoma
S* let ot it
Inferior Oblique
Muscle
Middle
Temporal Bone Ih ul< -motor
Uncinate Nrr>» lid
Process

Infra-orbital
Malar Branch Nerve
ofTemporo malar Nasopalatine
Nerve Nerve
Inferior Tur-
binated Bone

Maxillary Sinus Vomer

(Higiixiokk)
Branch of
Facial Nerve
Canine Muscle
Anterior
Palatine Nerve
Facial Vein

Zygomatic Muscle

Buccinator M

Facial Artery Buccinator Nerve

Ducts of Sublingual
Gland Lingual Nerve

Duct of Submaxillar}' Buccal Gland

Gland
Triampilar Muscle of
Branch of Facial Nerve — Lower Lip

Mandible
Genioglossus Muscle

Quadrate Muscle of Lower Lip

Sublingual Gland

Mylohyoid Muscle
Inferior Dental Nerve
Digastric Muscle

Geniohyoid Muscle Platysma Mylohyoid Muscle

Fig. 2. Frontal Section of Head through the Orbits.

View from in front. — Nat. Size.

Rebmnn Limited, London. Rchtnan Company, New York.

 Fig. a. Frontal Section of the Head through the Orbits.

Frozen section through the middle of the eye-balls. The slender nerves and
vessels as well as the articulations of the bones have been determined by carefid
dissection.

The frontal bones are very thick owing to the obliquity of the section.
The Superior Longitudinal Sinus bulges to the right, owing to one of the
“Lacunae Laterales“ — accessory dilatations of the Sinus which are of frequent
occurrence at the Vertex, and may extend 4
/ 5 ths inch from the middle line.
The Temporal Muscleobserved to be covered by the Temporal Fascia,
is

which extends from the Superior Temporal Ridge to the Zygoma. At the upper
border of the Zygoma it splits into 2 laminae (which may reunite), between which
some fatty tissue becomes collected.
The Cavity of the Orbit (into the inner and upper portion of its roof the
posterior extremity of the Frontal Sinus protrudes) is only partially by the
filled
eye-ball; the greater space is taken up by fat in which the eye muscles run.
the Lacrimal Gland. The
Closely applied to the outer wall of the orbit is

point at which the Optic Nerve enters the eye-ball marked in yellow. is

The figure shews the very large space occupied by the Nasal Cavity and
its Accessory Cavities. The Nasal Cavity which is only separated from the Cranial

Cavity by the thin cribriform plate of the Ethmoid Bone, presents 3 turbinated
bones. On the left side the Sphenoidal Turbinated Bone was so short as to nearly
escape the section.
Between the Middle and Inferior Turbinated Bones, the communication
between the Nasal Cavity and the Frontal Sinus the Infundibulum— is visible. —
Directly below this orifice lies the aperture of the Antrum of HIGHMORE.
This aperture situated almost at the top of the Antrum, is necessarily most un- 7

favourable to drainage. The Nasal Septum is deviated from the middle line
(cf. Fig. 1).

The Antrum is separated from the Orbit by the thin floor of the Orbit
in which along the Infra-Orbital Canal the nerve and vessels of the same name
pass. For the relations of the Alveoli of the Teeth to the Antrum vide Fig. 40.
The wall between the Antrum and the Nasal Cavity is thin so that perforation
can be easily carried out from the nasal cavity (if better drainage be sought by
this route).
The Buccal Cavity is closed below by the Mylohyoid Muscle, which ex-
tends from the inner surface of the lower jaw downwards and inwards to meet
its fellow in the middle line (Diaphragma Oris).
At the junction of the mucous membrane of the Cheek and the Gums,
groups of mucous glands are found — buccal glands.
 n T; C — X eg 0
93
*3
*— *-* <_ C
3 3 •—

O 3 53
o
0
— -S
i—
r 0 x
f
-

gS paRc.)

* S3 0 *3 0
0 3
Ü „ £ ^ •5
X 0 be
£ 3 *5
53
O co X
£ 0
x
0 i- b next

53 £ E
0
•—
„
.
u
be
3 ° - § 3 v 3
o n
-.r
O 0
x0—
o j”

o
5 ’S
^ be 0 (Continuation

.2 95
be .£ U 0
^ ~3 jy
.be g c
<<•
0
U. 4-
O 0 x
'53 0 3 0 X 3
o •a H be.
*5 C3
U ~ T3 0 TJ
g .£ 3
•3
0 0 <d x0 V0
•5 0
•a
o
0
Gj
X* *
J
4-i
5
>
u
* 0 Vh c3
o x §
_ a — E • d 4-*

3 0 ’S *35
X •3 be
~ C/5 AS T! 0
"> c; *5 C«
Cerebrum.
CD
X y> u 0 rz: c
0 <13
d 0 3
Sr.

X d3 £ r- Cv3
- S
0 —o
35
.a he
be X -
d c75 53 tf) u
co - £ .ts > rj
0
3 2 o
the 0) o 0 "d £ 0
4-* <u bo C u 0 u.
X
0
X 'O
'55
0 > U*
4—>
of
rC u 0 u 0
0 4-1 0 3 O
o u
X XI u
C/5
0
U
vd
0 Ä 3
O be
M Zj
u d- o J2
r- O
co 4->
r| 4-i c 0 -
Surface
T3 0 c
C/3
0) 0 c/5

0 “ Q 4-i 0 £ 0
4-4
cci
<D
X d Ö 175 d rj
4-»
0
>
0
'd be "o *d
c o JT
<1 o W*-l
p W
be x d & c^ c

X0
Convex •3
C « C
)-.
o 3 £
Gj
4-» Gj O u 0
V»-.
CO o G- Ph £ O 0 be
c 0 3
O 0 <N
0 CD
O 3
o X o X 2 CO
0
>
o 2 c.-
.3 4-1
d C/5 tr\
C/3
I

rateral
_c
Xc a X
1-
£ P X h.

Xc o •3
0)
rQ >.
c3
1h
•4 X Gj u
Gj
•a
CD
-a c/3
*d 0
>
gj
4H
rt
X r — 0
3
x0
c P 14 CO
Gj
4->
0 _3 0 bc
c/3 r* o 3 O 0
CD P c > 3 14
c X
Gj
13 XI > 0 •3
rt CO _o (/)
c/5

d
X 4-1
<

O O 0
co
’So
o s* CD
u X c3
v-
X be s
4-1 0 U-t

c
o < X
nj 3
O 3
o
"co co
0 3 u o 0
X x0
be >> ‘X u
o
H
X0 > 4->
•
X l. 0 3 c
4-»
3 c 3
fc gJ
pH IX :~ c
*r-< O - X o (D
£ CD Ph
4-1 It
G] E £
X 3 0
Xo X2
co ‘be 3
E 0
g!
4-1
£
ü
x0 0 1-4 4—
u
£
3 CO
>
o
&0 £
4—»
cä > £
.5 o ffi
.S2 3
u
4-> W X X "bo .O X
u>

X 0 X>4 3t
'S
pH 4-> 3 :
'S
V- X C
*a
P
15
u.
X £
cd
a rs *d 0
>4
X0 X •3 33
.»-4
0) <D p co
l-l

3
L-
0 u C/5
V-
o3 X 0 15
a o 0 _0 0 >
CJ £ -~
1/3 <D
93
3
n
0
4-*
CJ £ W
X o
<4-1 X0
3
•3 3
5 0 c 0 X O
< a S
Ih
be 'S 3 X
Cfl r-
3 X 3
XO
gS
G
£ o C/5 X £*4X
0 s
be '53
x CD 0 X0 o 1-
CO
O o
0
u
Ph
r O
Gj
x 13
H U X X0 OX
co CO
Sq
CO
be
c
•c 3 0 £ .£
3 0 X o gJ
o
a)
>-
X X
u
c/3 x' CJ 4X u
 York.

New

Company,

(Rolando)
<X> Rebman

S-.

'S
O <X>

Fissure

c3
Ph
«
'S
<X>
Central

cD
CD

£ Oh

<
4 h
O CQ

-C3
*c
23
m -»j
03

eS 52h
5 h
<X>

H?

CO

bi)

£
London.

Limited,

ebman
 Fig.

4.

Lateral

Inferior

Nnt.

Aspect

Size. Temporal

of
—

Sulcus

By

Prof.

Cerebrum-Sulci

Ziehen.

and

Convolutions.

»v
O
<r
a
a

o
vr
 > t

Sä»

71 p o O
bcr 3 cr
CD
CD
brb o
3
i->

0 P
P
CL
passive
unable
CD
i-t
CD B 71
CD
V
CD
o'
3
3
CD
O
V0 .
O
rb^

O* 3
CO r-t-L
CD
3
r-t-
3 aq

I > P .CD
to i-t 3 H
O
CD m CD
i-t
71 O
o & cr 0
Mu
p
!—
crq
CD CD
P p cr 3 crq cr o CD
CD P 4

3 Vi
CD
r-t-
i-t
B
CD
CD o 3
CD
3
rb
cr
rb
I
i-t

O' CD CO 71
CD Cr
movements

CD CO 71 CO
CL O 3 p
CD CD O P 3
appreciate,
cl 3 P 3 b i-t
r-t- CL
>-t CD
<’ CO
o
I-*
CD 3
7) i-t
t-i
CD
i-t

CD
71
a CD
CL
of 51 V! 3 CD cr CL o
CO 3'
(D O 71 CD
0 3
a p
r-t- cr cr O 3 CL
his
with m a*
I-t

CD
P
o
CD
p
<
CD
3 H
cr
B
5’
rb
P" <T
§ 2 - P 3 P* CD r-t-
CD
a> 51
3 o 51
>t crq 3
right
o CD
p.
O'
CD % c*. 3 V 3
cr
o
71
O'
3
— P
i-t
CD

closed
w bp O,
b
O
P
O
CD P. CD
P o
3 o O o' cr
I-t
m
CD 3 O CD
limbs.
<+ m- CD
3 rb
o o
I-t
cr
b
bO
P.
3
CD

co
CD CD cr
I-t

o &
p
CD M-
CD
a 4
3
eyes, 51 CL CD 71 71 cr >-t o
CD in
71 3 r+ CD p
t—
rb
CD
o i-t »
o
any
b3
CD
cr
3
cl CD 3
3 3 $ M
>1

o
p ?r 0 CD CD
2 o 3 cl rb
crq
Cr 3 P
3
o’
c cr CL p CD O rb rb
I-t
CD p 3 *-i K’ t
>-t
CD b i-t
tr
CL O ffi
P 4
CD
73 o
o
altered
CL CD rb CD H+5
3 CD 3
rb cr cr c-t-
o r-t-

5'
cr CD CD i-t
jD •-t
71 71
CD
V!
cr
CD
71 bcr P cn c
B1

bP o
)

-c
b
i-t
o
a P CD
73
CD
CD
-o’
position
rb o o
.
i-t -I
CD O 3
cd’ 3 o'
CD CD
P*
3 < O cr
o' 3 p
or
3"
b'
<
CD
B g cr
re

fails
cr
3 B Ö O0
P
cr
CD
hears rb Sr
g* CO
CD* cr 3
to 3 Ö £ |-t

cr
p
rb GO* p cr
P P b
CD
71
71 or crq'
CL CD i-t
every O <5 o
c-t-
cr
P 71
CD or cr
cr CD P 73
p CD p p
v- CD P 3 CO cr p
73 p. |-t 3
understand.

o CD
CD cr
CD
71 <1
CL
word
cr
3 rf cr
CD
+>
£2
3 cr o’ cr
o O CD CD
P CD O 3 p
I-t

CL
v; P P i-t

CD
71
but
cr B g 3 2.
5‘
o
p a 4
a >
d CD O' CO Crq
op p CD
o H
CD
73
rb
cr 31
71 3
CD
P
CD o' P p p p
does p O 3 o p
cr
0 <
t-h
3
I-t

CD K 71 H
p
rb 73
CD
Vi o
CD P CD I-t
CD
P CD 3 crq i-t
cr
71 P 3 C/3
CD |-t 3 rb
not 71
p O CD O o’
CD
3’ i-t o P 3 — 3 3
cr
P
i-t
crq 'irr p
3
crq
P 3
b
71
o 5‘
a
C/5 b p
CD
CL CL p bo cr
CD
3 CD
3 a i-t
3'
rb
recognise
71
CL
CL
in CD b cr
3 31 orq cr
o K 3
73
rb
1
CD
CL
rt o’ cr CD
I-t

VJ H
p
CD CD
P o B CD
b
O g o p o
71 rb^
3 W CL o
b>
i-t
5 o‘ 3 O I-t
them CL op CD
p P O S’ f-t-

cr
n p rb CL CD
p i-t

H
cr B 3 X
£2.
p’
o CD
p
CD 5’ *-t
CD CD O
o
and
O 71 H crq
O
O
71
71 o
o o
CO
I-t

CD
Cr CD

3
£
5’ crq
- <
B ll
cr p rb
co co 5. o N p.
CD vj 3 o CD o 73*
or 3 CD
ZIEHEN.
3 CL I-t CD 71
£2 o B °s cr
O
i-t

o CO O
B
consequently

CO o'
I-t
in o’
cl
p 3 o
71 3 d
o
p o 3
I-t

o 31
71
cr
rb 3 CD*
O o or CD’
CD
cc cr crq CC
CL CD CD 71 cl 3 VJ
 • I 0 1

0 ” C/3 X c/3 r* r- 0 r l

0 — f/f
3 c c
T
Sio Si
0
•£'5 2 3
2 a
* • •***

•O
S3 5 /
S 8
rt
O C" u
2 o w u _c

G b
3 j; _» a >
- ‘7
0 c
0 /—
X
0 £
~U —
?
15 ^
7) <** w 0 Z ~
:
•3
p /
O
0 mm
•

C O — 5 "3 'U
,2
•G
f-i
C/J

s — f * o C/3
_ A
£ *13
0 s
a- .b 0 CJ 2 *5 <y CJ
C X x ‘b o
«; •
m ?
5 c
—
c-
0 cj ~ 15
bo -a o
— 2u ca. 2
.b
Ct)S *x 0 £ b
— y.
rt
CJ .2 X —0O 02
.
0 0
0 S3
^c .2 r
-

2 C 2 3
Oi

— a> P-J ’S S3
S3 =
ra
0 E ^ <
1 r-
00 *!3 r*
"2
«-*

^ S3 U
.
c >.
.0 0 id 0 *3
X
7)
u ‘u 3 j U
0 o
^
O ? ^ O 0 «/)
C •—
'
S
0 U cj
I |
C/5 CJ
> rp z: > c
0 rt x O b
r-> , 5 'S
t
a>
^ g ^
°
15
2 ro U E 0 2
<u
X Jä S3
0
0
d>
O ^ c5
^ ST S3 0
“ <
c ’S
c
0 £ O
?P
L .

zz;
Ü
. c/3 0
O c
_ ^
J
s
41 41
JO
•— S3 2O 0 g
h-. s
O g
’S bjO a _ •a S: jj c Ü u rt -G
~ ’3
.50
- c c .= *t? *X3 c *r
’C 2 a) b 0 •—
0 >*-
r
'-‘ C cj
rs
2 ^
C 41
C 2 o a; 0 .2
41 S 0 0 p z ^ s >
5 Ö u
3 in +3
rt
u
41
>
j~
ca c _ Pi cn
^
C
_ C
%
•=
S3
0
s! o a a>
« in d) ,i2 o 3 0 > o 0 0 2 a £
_
^ 2 X r. ‘C -G = 0
z: a> .2 x S3 0 ^ 0
— .0
0a
0
^ H 0
13
r->
x
u u b o c
4-i
o •= 0 0
2 u O
4->
X^O 2 ri 0 aJ
E b )
O -3
•3
Pu'“
0a o .s (/} S3g .2 x
X 0 T3 c4
rt
0 Sf u 0
bo 0 K' 3 I S — m 0 0 —
a>
i—
S3
ccS 0 ^b
0 0 2 P
3
s 0
s.‘
O 0 <D *Z-> ci rzC
r-
0 Ü S PC
o
u
S3 2 5
0 0 N
bo ‘S
0 c
0
0
x I
S
^ 5Xo
03 > 2 y 4J Oh S) 0 2 Ü* 5 - ~ 0
2 ,£3 W .0
-4->

J3
ä£ o
S3 <5
>i3
£ iS p4
n ^ O
c !>
o « .T
S3 W CJ S3
ss rt

o
H
•
+> S X «
x A -G S3
v 2 6 0 0 c g
3 '0 I
o Mri
-± > 0 001 0 0 c 0 2 w
<u C »“
*
S3
2
0
2 0
0 0
O
!

,230 o o
S3 CJ 0
03 >
-
J» 4g P3
cn 2 2 M—
b? o 0 0
-«

c
°
1 <2
u S3
CJ
0 •2 o S3
x -3 t-l
> 0 S3
a
c /3

0 -0 O 0i C. S3 0
0 o
C/2
rt 0
.
_C 0 ’rt 0 _ 3 2 -ä S3
•

-d
^4
0
o .2 ^ a g 1.2 03
o
X iP
0 o
^
1G
S3 12
0- >
<*-
C
0 —
0
x
'S! 0 0 A 0 X
00 ^ oi u
»-
0 0 «< 0 aJ
O x 03 i_ 0) 0 0 03 0
30
S3 0 0 0 x 2
b
O 0 d- <2 0 0
Pi
o a 0 0
0
x S “ 03
1

-2 —
c -0 -
> -b E 0 3 S .

C *-> £ 8 2 0 0 ^
£0 %
^ ^CJ -> 0
0
E
o
0
0 *8
0
LO cS 2 0
4->
C £
W « </> CJ 02 a
0
S3
0 £
‘
02 S3 PC O JZ 02 -5 0 03 -01 2.
•5 CJ 05 33 ^0 > ^ X rJ)
0
bo
H
2 *+1
0 o X 0
.2 G
..
S3 O S3
'£ 8 c ^ 0
< 01
X
w
-5
•
H -S 2 2
(D
4J
CJ ^ — 1

'ip b x c 0 0 .2 Xr > 03
? *H
0 2
0
rQo rzz
rj •— - 0 o 0 0 S3 r-
O --
J3
G. S3
u O 'S 0
0 o 2 O ,2 £ b 0 0 01

& o 0 O iS p 0;>1 0 X
3 0 ^ X £
O ’S ’S 00 0-0 3 c/D >
^
r'l
C-> -0
4-J
02 G- 0 - 5r o
01
g .X ^
c o< 0 S3
0>:
03 4-J g r- 0) *+-<
03 X »- .2 CJ x b
0 13
C 0) 0 o 0-0 3:
0 o -S ’5o
0 0 0 1—1
a”
d; r- "? 0
0 cj r* 03
Ü ca 0 03 O <*
CA

J-> t: o *o 2 fe
0 1
X a 0 *2 O
2 a Ph <9
0 § £ « 0 .£ 0
-G ^ 0 S3
r->
^ 0 0 0 .2
03 0 «
bio 0 6 !
’S
C
,G S3
- a t
p 03 0 8.2
iS 1 03 ^ o .2og 0 -C
33 £
S
01

0o X
•-
c/)
£ J
4-J
5 C 14
•
- d» be
0)
® .g x d) u> 0 o X iP
2
gut>0
_

.2 jc £
X 0 4-»
0 Uh 0 G 4->
0 0
03 0 0 01
.2 S3 .G 0 G
0 "So
03 0 d b
S0 0O x S3 0 S3 C g a
•“ 0 0
0 X
0 o3
ec <2 °* 2
d- <2
0 15
0 3 c 15 0 S3 0
- I g o0 0 02 0
0 0 b 0 0 0 0 2
.S3 § 0 O o 0
u 0
01
0 0 'S- CP 0 03 > .
13 o, 0
c 4J — 0 cj
o U
•3 CJ -r
2 6 o .2 .2
^
CP Clj
0 0 0 HI 0 *c 0 ---
0 X •C V-i

2x Su 03 0: 0 — G-
ffi
^ 2 0 •2 0p
30 ^ PP « 2 *n 03 d
H 0 Oh
»-I

a/
•

„
*d
m rt S ’S
^
3 •

C 2 > ‘55
M »—
03
> £ 'o 2
•3 U
0 > 'a & 0 0
'
Z3
O .2 .
O. S3
O 02 i
o o
0 b 2 2 c S3
0 2 0 03 0
c/5 r*
0 2 o •a £ 0 o c *£
O 6 -S cj -2 E, <2 02 si 0 a 2 2 U 0
 '

3rd Ventricle Posterior Commissure

3rd Nerve ^Oculomotor /

Trigonum Habenulae
Peduncle of Pineal Body
oth Nerve 'Abducensi
Superior Corpus (Quadrigeminum Thalamus
4th Nerve (Trochlear)

Inferior Corpus Quadrigeminum

Pulvinar Median Geniculate Body

Hand of Anterior. of Brain

Medullary Velum

lemniscus
Descending Root
of 5th Nerve
Medullary
5th Nerve (Trigeminus) Velum
Superior Cerebellar
Motor Nucleus Peduncle
of 5th Nerve
- - Locus C aerulcus
Facial Eminence

7th Nerve (Facial) Nucleus of Oth

Nerve (Abducensi

Nucleus 8th Nerve

7th Nerve (Auditory)

Middle Ccrebel
Peduncle Auditory Striae
Inferior Cerebellar
Peduncle Nucleus of 8th Nerve
9th Nerve (Glosso (Dritkks)
pharyngeal) Median (Triangular) Nucleus
10th Nerve (Va of 8th Nerve
Nucleus of Spinal Tract Lateral (accessory) Nucleus
of 5th Nerve of 8th Nerve
Marginal Hand of
4th Ventricle 1 2th Nerve (Hypoglossal)

11th Nerve (Accessory)

of Sninal Tract
of 8th Nerve

Hypoglossal Triangle^ Auditory Area

Nucleus Ambiguus Ala Cinerea

Obex Canal
Nucleus of Ala Cinerea
Clava Posterior Pyramid)
Nucleus of 12th Nerve

Nucleus of Spinal Accessory Nerve Funiculus Gracilis

Funiculus Cuncatus
Posterior Median Groove

Funiculus Lateralis

Fig. 6. Dorsal Aspect of Fourth Ventricle.

Twice Nut. Size. — By Prof. Ziehen.

Rcbman Limited, London. Rcbinun Company, New York.

 Pig. 6. Dorsal Aspect of Fourth Ventricle.

The Cerebellum has been removed by a section parallel with the floor of the 4th
Ventricle, so that the 3 Cerebellar Peduncles, strands which connect the Cerebellum with the
rest of the Central Nervous System, are seen on both sides in transverse section.
1) Superior Peduncle conducting fibres chiefly to the Dentate Nucleus of the
Cerebellum.
2) Middle Cerebellar Peduncle, connecting the Nuclei of the Pons with the Cerebellar
Hemispheres.
3) Inferior Cerebellar Peduncle (Restiform Body) chiefly conducts to the Columns of
the Spinal Cord those fibres which passed to the Dentate Nucleus through the Superior
Peduncle.
The Valve of Vieussens which lies across, between the Superior Cerebellar Peduncles,
has been cut and thrown to the left.
The Facial Eminence (Colliculus Facialis) is produced by fibres of the Facial Nerve
which, after emerging from their cells, pass towards the floor of the 4th Ventricle and bend
at a right angle again, after a course of 1 /10 th inch, to run backwards towards their nucleus
of origin.
As the Nucleus of the Facial Nerve lies deep in the substance of the Pons and
Bulb, with many groups of cells extending upwards and downwards, it must be remembered
that this Nucleus is not at the floor of the 4th Ventricle and is accordingly represented
diagrammatically.
The Nuclei of the other Cranial Nerves lie near the surface. The anterior part of
the Oculomotor Nucleus contains the fibres for the Sphincter of the Iris and the Ciliary
Muscles the posterior part contains the Fibres for the Extrinsic Muscles of the Eye. Immedi-
;

ately behind is the Nucleus of the IVth Nerve (Pathetic), the fibres from this pass to the Valve
of Vieussens where they decussate and on emerging wind round the Crura to reach the base
of the brain. The Nuclei of the Vth Nerve (blue) are partly sensory and partly motor; the
chief sensory Nucleus (pale blue) extends as far caudally as the 2nd Cervical Segment (De-
scending root of the Fifth Nerve), it is club-shaped with its broader end above. The chief
Motor Nucleus (dark blue) which is generally connected with the minor Motor Nucleus extends
upward into the region of the Anterior Corpora Quadrigemina. Although the shape of the
cells of this Nucleus are peculiar, it is probably motor.
The function of the Locus Coeruleus is doubtful, its cells previously considered to be
sensory are now viewed as motor.
The Nucleus of the Vlth Nerve lies directly under the floor of the 4th Ventricle in
the bend of the Facial Fibres described above.
In the posterior part of the 4th Ventricle, which is separated from the anterior part
by the Striae Acusticae, a median grey and two lateral white triangular areae can be
delineated on either side. The grey area (Ala Cinerea) contains the Sensory Nucleus of IXth,
Xth and Xlth Nerves. The Motor Nucleus of these nerves (Nucleus Ambiguus) is marked
yellow; the Nucleus of their ascending root (Solitary Bundle of Meynert) which is not
indicated occupies a ventrolateral situation in relation to the Sensory Nucleus.
The Sensory Nucleus is situated internal and at a deeper plane than the descending root
of the Vth Nerve. The inner white triangle corresponds to the Hypoglossal Nucleus and the
outer to the Dorsal Nucleus of the Vlllth Nerve (Cochlear Portion). This Cochlear Portion has
another Nucleus (the Ventral Nucleus) situated along the outer border of the Inferior Cere-
bellar Peduncle. For the Vestibular Portion of the Vlllth Nerve there are two Nuclei shewn
in the figure (Deiters’ Nucleus and the Nucleus of the Descending Root of the Vlllth Nerve)
[Nucleus Tractus Spiralis Nervi Acustici]. Ziehen.
 Fig. 7. Arrangement of Fibres in the Internal Capsule.

All the fibres from one hemisphere pass together through the Crus at the
Base of the Brain. In their course from the Cortex to the Crus these fibres pass
between the large Basal Ganglia (Thalamic, Caudate and Lenticular Nuclei), as
shewn in the figure. Leaving the outermost and external capsules out of con-
sideration these fibres have but one course open to them, viz: between the Caudate
and Lenticular Nuclei and between the Thalamic and Lenticular Nuclei. This is
the Internal Capsule with its Anterior and Posterior limbs and an intervening bend
(genu). The arrangement of the fibres in the Internal Capsule is as follows: -
The pyramidal tract, the path of voluntary movements, occupies the anterior
/ rds of the posterior limb in such a manner that the Facial and Hypoglossal
2
;)

Fibres lie in the genu, next in order come the fibres to the upper Limb and
lastly those to the lower limb. In the posterior ^rd of the posterior limb of the
internal capsule lies the great sensory path for “Common sensibility” and the
occipito-temporal cortico-pontic tract which passes from the occipital and temporal
lobes to the Pons. Furthermore, fibres pass to and from the Cortex and Thalamus.
Close behind the posterior limb is the so-called “Carrefour sensitif” (Charcot’s
Sensory Tract), through which the paths of the higher senses (Olfactory excepted)
pass. In the figure, only the fibres connected with the Optic Nerve are depicted
in their passage from this point to the Occipital Lobe.
Disease of this “Carrefour” produces mixed Hemianaesthesia e. patients i.

feel, taste and hear less definitely or not at all on the opposite side, and do not

see with the Nasal half of the Eye on the same side and Temporal half of the
opposite eye, whereas disease of the posterior part of the posterior limb of the
Internal Capsule produces motor paralysis of the opposite side.
The Anterior Limb contains chiefly fibres derived from the Frontal Lobe
and Caudate Nucleus; their course and function is unknown. The Caudate Nucleus
and its tail curl over the Internal Capsule to terminate by blending with the
Hippocampal Convolution and the Amygdaloid Nucleus; so that in this section
the Caudate Nucleus has twice been cut — at its body internal to the anterior horn
of the lateral Ventricle and at its tail near the descending horn.
The lateral and 3rd ventricles communicate through the Foramina of
MONRO. The pillars of the fornix are cut near their point of junction. The
posterior horn of the lateral ventricle is cut at the point where the inferior
horn begins.
The white Corona Radiata between the Cortex and the Corpus
fibres of the
Striatum is called the Centrum Semi-Ovale of ViCQ d’Azyr. Ziehen.
 Occipital Pole

Interparietal Fissure
Cuneus

Parietooccipital Fissure

Anterior Occipital Fissure

Superior Temporal Fissure

Fissure of Corpus Callosum
Posterior Horn Optic Radiation (Gratiolet)
Splenium of Corpus Callosum
Tail of Caudate Nucleus Charcot’s Sensory Tract
(“Carrefour sensitif”)
Posterior Limb of Fissure of Sylvius

Optic Thalamus
Island of Reil

Posterior Limb of Internal Capsule

External Capsule
Outermost Capsule
Middle Commissure Fissure of Rolando (Central Fissure)

Genu of Internal Capsule Claustrum

Pillar of Fornix Globus Pallidus

Cavity of Septum Pellucidum

(5th Ventricle)
Anterior Limb of Internal Capsule
Putamen

Head of Caudate Nucleus

Anterior Ascending Branch of the
Fissure of Sylvius
Anterior Horn

Genu of Corpus Callosum

Fissure of Corpus Callosum

Inferior Frontal Fissure

Callosomarginal Fissure

Middle Frontal Fissure

Frontal Pole

Thalamo-Frontal Bundle. Motor Bundle : Leg.

Motor Bundle: Facial and Hypoglossal. Common Sensibility and Motor-Sense Bundle.

,, : Arm.

Fig. 7. Direction of Fibres in the Internal Capsule.

Seen from above. — Nat. Size. — By Prof. Ziehen.

Rebman Limited, Loudon. Rebman Company, New York.

 Superior Frontal Sulcus Pracccnlral Sulcus

Central Fissure (Roi,

Cal loco- Marginal Suit us

Caudate Nucleus
_Taenia Scmicircularis
Post-Central Sulcus
Lateral Ventricle

Sulcus of Corpus Callosum

Fibres of Corona Radiata — Corpus Callosum
Parietal Operculum
Optic Thalamus
Island of Rkil
K issure p f Lenticular Nucleus
Fornix
Sylvius Claustrum Optic Thalamus
Internal Capsule
3 rd Ventricle
Temporal Operculum Optic Thalamus
Outermost Capsule I^imina Medullaris
External Capsule
Fibres to Thalamus
Fibres to Lenticular Nucleus
Red Nucleus
Superior Temporal Sulcus Lev’s Nucleus
Anterior Commissure
Z
Substantia Nigra

Fibres to Cerebellum
Nucleus of 7th Nerve
Inferior Temporal Sulcus
(Facial)

Pons
Inferior Horn of Lateral Ventricle

Fibres from Pons to Cerebellum

Fillet

Hippocampus Major (Cornu Ammonis)

Sensory Decussation

1 Motor Decussation

— Posterior Column
_ Posterior Horn
Lateral Column
Anterior Horn

Anterior Column

Fig. 8. Course of Fibres from Cortex to Spinal Cord.

Nat. Size. — By Prof. Ziehen.

Rchtnan Limited, London. Relnnan Company, New York.

 Pig. 8. Course of Fibres from Cortex to Spinal Cord.

This section is not accurately in the Frontal plane but is directed some-
what obliquely so that above it passes through the Praecentral Convolution and
below through the middle of the Pons. At the Point marked Z it passes through
the Posterior Perforated Spot. A transverse section of the cord has been added
in order to shew the topographical relations of the long cerebral tracts to the
columns of the spinal cord. The posterior limb of the internal capsule is divided
and the pyramidal tract is seen running from the motor area, through the posterior
limb, to the middle third of the ventral portion of the Pons; at the Bulb (Decus-
sation of the Pyramids) these fibres cross the middle line and continue their course
in the Lateral Columns of the Cord, whence they pass to arborize around the
Anterior Cornual Cells which give off the fibres of the peripheral nerve.
The fibres of the pyramidal tract which arborise around the Nucleus of
the Facial Nerve of the opposite side cross the middle line in the Pons. The
course of the Facial Fibres and the Facial Nucleus is schematic. (Cf. Fig. 6 Text.)
The Posterior Columns of the Spinal Cord contain the path of the “Muscle-
Sense”. Probably the fibres from the lower extremity lie in the tract of Goll in
the cervical region and those from the upper limb in the tract of Burdach.
These tracts decussate in the Bulb, practically opposite the Decussation of the
Pyramids. The further course of this path is known as the “mesial fillet”; the
fibres end partly in the Corpora Quadrigemina, partly in the Thalamus and partly,
after tracking through the posterior limb of the internal capsule, in the cortex
of the Parietal Lobe.
The Occipito - temporal cortico - pontic tract (previously mentioned in
Fig. 7), appears again in the outer V3 rd of the base of the Pons, arborising around
the Nuclei of the Pons whence new fibres cross the middle line to reach the
Cerebellum through the Middle Cerebellar Peduncles. The Optic Tract is cut
transversely, the anterior commissure obliquely —
its fibres pass to the Olfactory

Area, to the Hippocampal convolution.

The Caudate Nucleus is again cut in 2 places, at the commencement of
its tail near the Thalamus and at its descending horn. The
termination in the
Fimbria represents the termination of the Fornix which in its course along the
lower aspect of the Corpus Callosum has 2 (posterior) columns which, after diverg-
ing, ascend in the form of an arch with its convexity backwards to finally (this
is the part called the Fimbria) join the floor of the ventricle. The gray matter
situated between the Cortex and the Fimbria is the Fascia Dentata; above these
structures (Fimbria and Fascia Dentata) is the Lateral Choroid Plexus. This is not
indicated in the figure. It is probable that the Lateral Choroid Plexus does not
close in the descending horn of the Lateral Ventricle completely but allows the
intra-ventricular cerebro-spinal fluid to communicate with that of the basal sub-
arachnoid spaces. Ziehen.
Fig. 9. Frontal Section through the Crus Cerebri at the level of the
Posterior Corpora Quadrigemina.

The Mesencephalon (Crura) containing all the Projection Fibres from the
Cerebral Hemispheres is divided into 2 layers, an upper the "tegmentum", a lower
the “crusta” these are separated by the "substantia nigra”. The Tegmentum chiefly
—
;

contains:
1. Fibres from Thalamus and Corpora Quadrigemina. To these belongs
the so-called commissure which represents the connection of
posterior
the Tegmen with the Thalamus of the opposite side.
2. Fibres from Lenticular Nucleus. Cf. Explanation to Fig. 8.
3. Fibres from Cortex. To these belongs the path of “Muscle-Sense".
Cf. Text to Fig. 7. It moreover contains 3 Nuclei.

a) Nucleus of Descending Root of Yth Nerve on either side of the

Aqueduct of Sylvius.
b) Nucleus of the Illrd (Oculomotor) Nerve, on either side of the Aque-
duct of Sylvius.
c) Nucleus of the IVth Nerve which lies posterior to the Illrd Nucleus

at the posterior end of the Aqueduct of Sylvius.

The Internal Geniculate Body probably belongs to the auditor} -
path.
The posterior longitudinal bundle is derived partly from the anterior column of
the spinal cord and possibly connects the nuclei of the motor nerves of the eye.
A large number of the fibres in the tegmentum stop in the "Red Nucleus”
where new fibres arise to cross the middle line and leave the tegmentum bv
passing to the Cerebellum through the Superior Cerebellar Peduncle. (Cf. Fig. 6 Text.»
The Crusta chiefly contains: —
1. Cortico-crustal Fibres — Geniculate Bundle (MEYNERT).
2. the Frontal Lobe and
Frontal Cortico-pontic Tract which passes from
Caudate Nucleus to the Pontine Nuclei, whence fibres cross the middle
line and pass to the Cerebellum through the Middle Cerebellar Peduncle.
3. Pyramidal Tracts. Cf. Fig. 7 Text.
4. Occipito-temporal cortico-pontic Tract which passes from the Temporal

and Occipital lobes to the Pontine Nuclei. Course of these fibres as in 2.

The course and function of the fibres in close proximity to die Sub-
stantia Nigra is unknown.

Fig. 10. Convolutions of the Brain and Sutures of the Skull

in the New-Born.

The detailed description of die convolutions is given in die text accom-

panying the following figures. We only desire to lay stress upon, the high position
of the Fissure ofSylvius, and the Fontanelles.
The smaller fontanelles (Sphenoidal and Mastoid) may be very small at
birdi; whereas the largest, die Frontal, remains open till the end of the first
year of life.
 Descending Root of 5th Nerve Aqueduct of Sylvius
Anterior Corpus Quadrigeminum
Bundle from the Posterior Commissure Grey Matter
Oculomotor Nucleus
Red Nucleus of Tegmen
Brach ium of Posterior
Corpus Quadrigeminum

Mesial Fillet

Internal Geniculate Body

Tegmen
Fibres from Temporo-
parietal Lobe to Pons

Superior Limiting
Zone of Crusta Oculomotor Root

Pyramidal Tract
Crusta

Fibres to Interpeduncular Space

Substantia Nigra Fibres from Frontal Lobe to Pons

Fig. 9. Direction of Fibres in the Crus Cerebri — Frontal Section.

Nat. Size X 2. — By Prof. Ziehen.

Central Fissure Posterior Limb of Fissure of Sylvius

Superior Temporal Sulcus Frontal Fontanelle

Frontal Sulcus
Interparietal

Coronal Suture

Occipital
Triangular Portion of the
Inferior Frontal Convolution

Occipital Lobe Sphenoidal Fontanelle

Lateral Sinus (Trans-

verse Portion)

Mastoid Fontanelle

D r.rroh S
’fee.

Fig. 10. Convolutions of the Brain and Sutures of the Skull in the Newborn.

V2 Nat. Size. — After Prof. Cunningham.

Rebman Limited, London. Rebman Company, New York.

 Temporal KiJk« Coronal Suture Superior Frontal Convolution
I\**tefjwr Limb of the Fissure of Svutius
Prarcmtral Sulcus
I nferior Frontal Sulcus

Central Fissure Squamosal Suture

Retro« rnlr.il Sulcus Middle Temporal Convolution

Great Wing of Sphenoid Bone

Termination of Calloao*
marginal Fissure

Zvgoma

Parieto-occipital Fissure

Interparietal Sulcus

Lambdoid Suture

Occipital Pole

Dura Mater of Cerebellum

Lateral Sinus

Child.
Fig. 11. Convolutions of the Brain and Sutures of the Skull in the
Nat. Size.
1 — After Prof. CUNNINGHAM.

Coronal Suture
Superior Frontal Sulcus
Temporal Ridges Frontal Bone
Praeccntral Sulcus
Inferior Frontal Sulcus
Central Fissure Ascending Limb of Fissure
of Sylvius

Rctrocentral Sulcus Superior Temporal Convolution

Interparietal Sulcus
Greater Wing of
Sphenoid Bone

Termination of
*
'a loso- marginal
( I
Zygoma
Fissure

Parietal Bone

Paricto-occipital
Fissure

Posterior Limb
of Fissure
of Sylvius

Squamosal
Suture

Lambdoid Suture

Occipital Lobe

Lateral

ura Mater of

5S*P**F W the Adult.

ü r. Frohia F ee.

Fig. 12. Convolutions of the Brain and Sutures of the Skull in

7 Nat. Size. — After Prof.
Cunningham.

Rebman Company, New York.

Rebuian Limited, Loudon.
 Fig. ii. Convolutions of the Brain and Sutures of the Skull
in the child.

Fig. 12. Convolutions of the Brain and Sutures of the Skull

in the Adult.

Cunningham’s Method of removing the Skull Bones, except narrow bars at the
sutures, affords an excellentmethod of shewing the relations of the Cerebral Convolutions to
the Cranial Sutures. (Skeletotopy of the Brain, Waldeyer.) It is advantageous to consider the
fissures and sulci rather than the convolutions. In the removal of the skull bones in the infant
it should be remembered that they become attenuated at the regions farther away from their
ossific centres; this diminution in the thickness of the Bone is replaced by a corresponding
thickening of the Dura Mater and Pericranium. This close union of the fibrous skull-cap
checks the spreading of subdural and subperiosteal Haematomata within the limiting area of
any one bone. Moreover, it follows, that Bone and Dura Mater are removed in one piece
during this dissection in the new-born. In later childhood and adult life the bones are, as a
rule, easily separated from the dura mater, difficulties only occurring at the following points:
near the Superior Longitudinal Sinus because Pacchionian bodies may be present, and at the
Parietal Foramen (Santorini). The Mastoid Emissary Vein may be a point for dangerous
haemorrhage because of the proximity of the Lateral Sinus. The Emissary Veins favour the
spread of inflammation (cf. Erysipelas complicated by Meningitis).
At the Sphenoparietal Sinus there is danger of Haemorrhage from laceration of the
Anterior Branch of the Middle Meningeal Artery which may be embedded in a partial or
complete canal near to it. (Cf. Fig. 32.)
In connection with the position of the Sulci and Fissures it should be noted that in
the new-born (Fig. 10) the Fissure of Sylvius lies at a higher level than the Squamosal Suture,
and that the Central Fissure (Rolando) is placed more anteriorly than in the adult. In the
child (Fig. 11) the squamous portion of the Temporal Bone grows upwards and the temporal
ridges become more definite (blue in the figure in order to distinguish them from the
sutures [r e d]).
In the adult the Fossa of Sylvius corresponds closely to the Squamosal Suture.
(Cf. Fig. 19.)
Accordingly, with certain individiual variations, the relation of the Fossa of Sylvius
to the skull bones gradually alters with the bony development. The most important central
convolutions, however, lie at all ages in the middle third of the Parietal Bone, being slightly
further forward in the new-born. To the surgeon interest is attached to the sutures, because
certain anthropometric markings are employed (Fig. 18).
Nasion, at base of nose, and Inion, at external occipital protuberance, both points
are employed in connection with the determination of the upper extremity of the Central
Fissure (Rolando).
Lambda, in middle line, where the Sagittal and Lambdoid Sutures meet, is employed
for the determination of the Parieto-occipital Fissure.
Obelion, a point above the former, less irregular in shape, corresponds to the Parietal
Foramen.
Bregma, junction of Sagittal and Coronal Sutures, is at the anterior border of the
Parietal Bones.
On the lateral aspect of the Skull, the Asterion, is the postero-inferior angle of the
Parietal Bone, where the lateral sinus turns downwards.
Stephanion, the crossing of the coronal suture and the temporal ridges (near the
Spheno-parietal Sinus).
Pterion, the point of meeting of the Sphenoid, Parietal and Temporal Bones; this is
the site for ligature of the Anterior Branch of the Middle Meningeal Artery: underneath lies
the Fossa of Sylvius.
 Fig. 13. Base of Brain with Arteries and Superficial Origin of
Cranial Nerves.

The Pin Muter lias been removed. Unimportant branches of the Arteries have

been cut away; the Pituitary Body has been remoi'ed. (Names of Arteries
cf Fig. 23.)

The vertical and lateral surfaces of the Cerebrum are of importance in

connection with Motor and Sensory Centres while the Base of the Cerebrum
demands consideration in connection with the position of the Cranial Nerves and
the Arteries.
Functional disturbance of a single nerve or of a group of nerves will

guide us to the seat of a tumour or any other pathological basal lesion which
brings about the particular disturbances. It is a remarkable fact that, with the
exception of the Olfactory and Optic Tracts which are really outgrowths from
the Brain, all Cranial Nerves emerge from the Brain between the upper border
of the Pons and the lower end of the Bulb.

The Superficial (apparent) Origin of the YIth and XUth nerves are very
close to each other at the posterior border of the Pons and side of the Bulb.

The course of the nerves after leaving the Brain until they reach their
foramina of exit varies in length. The IVth nerve has the longest intra-cranial
course, arising on the dorsum of the Mid-Brain (Mesencephalon), near die valve

of VlEUSSENS (cf. Fig. 6), it winds round the Crus to reach the Ventral aspect
of the Brain. A portion of the roots of the Spinal Accessory also has a long
course arising as it does low in the Cervical portion of the Spinal Cord.
The brain is supplied with blood from its base through the Internal
Carotid and Vertebral Arteries. The two Vertebral Arteries unite to form die
Basilar which gives off the Postero-Inferior Cerebellar (this is more often a branch
from the Vertebral), the Auditory, the Antero-Inferior Cerebellar, and the Superior
Cerebellar Arteries. At the inferior border of the Pons the Basilar Artery divides
into Right and Left Posterior Cerebral Arteries each of which communicates
(posterior communicating) with the Internal Carotid. The Internal Carotid gives
off the large Middle Cerebral (Sylvian) Artery, the smaller Choroidal Branches
and the Anterior Cerebral Artery. As the two Anterior Cerebral Arteries are
connected by the Anterior Communicating in front of the Optic Chiasma a large
circular anastomosis is formed round die Sella Turcica (Circle of Willis).
All the vessels pass to and ramify in the Pia Mater, and give off small

branches, which enter the brain and supply it with blood.

 Fig. 13. Base of Brain with Arteries and Superficial Origin of Cranial Nerves.
Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Fur amen Caecum

Crista Galli

Lamina Cribruva

< >ptic Furamen

Foramen Rotundum

Carotid Groove

Foramen Ovale

Foramen Spi nosun»

Grtxn • f..t

If\»l Lateral Si mi*

Foramen Magnum

Groove for Transverse

Portion of Lateral Sinus

(Torcular HvcropiiiuI
Internal Occipital Protuberance

Fig. 14. Base of Skull — seen from above.

4
/5
Nat. Size.

Robmnn Limited, London. Kebtnan Company, New York.

 :

Fig. 14. Base of Skull seen from above.

Cochlea and Semicircular Canals, on the right side, exposed.

The base of the Skull is more complicated and irregular than the Vertex.

Three Fossae are recognised, the anterior bounded behind by the sharp border
of the lesser wing of the sphenoid, in this lies the Frontal Lobe, in the middle
line are found the Crista Galli and the Cribriform Plate of the Ethmoid through
which the Olfactory Nerves pass.

The Middle Fossa extends from the Sella Turcica on either side being
limited by the upper border of the Petrous portion of the Temporal Bone. This
Fossa contains the Temporal Lobe and many Foramina through which the vessels

and nerves pass.

Optic Foramen for Optic Nerve and Ophthalmic Artery.

Sphenoidal Fissure for Superior Ophthalmic V ein, VIth, IV th and Illrd

and Ophthalmic Division of Vth Nerve.

Foramen Rotundum for 2nd Division of Vth Nerve.
Foramen Ovale for 3rd Division of the Vth Nerve.
Foramen Spinosum for Middle Meningeal Artery.
The Middle Lacerated Foramen is closed by fibro-cartilage ,
a
remnant of the primary cartilaginous skull. The Posterior Fossa contains the
Cerebellum and Bulb ;
its boundaries are the Petrous Bones and the Lateral Sinus.
The Facial and Auditory Nerves leave the skull by passing through the Internal
Auditory Meatus; the Internal Jugular Vein, Glossopharyngeal, Vagus and Spinal
Accessory Nerves by passing through the Jugular Foramen and the Hypoglossal
Nerve through the Anterior Cond)dar Foramen.
When the base of the skull is held up to the light, the bones are seen
to vary much in thickness. The stoutest portions are: great wing of Sphenoid,

Basisphenoid, Basiocciput and Middle V3 rd of Petrous Bone. The thinnest are

Cribriform Plate, Sella Turcica (because the Sphenoidal Sinuses are beneath),
lateral parts of middle fossa, Tegmen Tympani, region over Temporo-maxillary
articulation and floor of the Posterior Fossa. Violence, broadly speaking, can
only affect the base indirectly in as much as it is everywhere protected by the
parts covering it. At a few places only is it exposed to trauma : at the Cribriform

plate if foreign bodies are pushed into the Nasal Cavities, at the roof of the orbit
if foreign bodies are pushed upwards into the orbital cavity.

The excavated right petrous bone shews the Internal Ear, Cochlea, Internal
Auditory Meatus, and 2 Semicircular Canals (the Anterior, Vertical; and the Internal,
Horizontal). The 3rd or Posterior Canal is not shewn.
Fig. 15. Base of skull with Arteries, Emerging Nerves and Sinuses
of Dura Mater.

The lira in has been cut away layer by layer to preserve the Basal Arteries in

position and as much as possible of the Nerves. The Spinal Cord, has not
been cut at the level of the 2nd Cervical Nerve as usual, but the Bulb has l>eett

divided through the Olivary Body. On the left side, the Tentorium has been
removed from the Apex of the Petrous Bone to the Torcular HerophUi, the
Superior Petrosal and Lateral Sinuses being opened (the right middle meningeal
artery has been drawn double by mistake).

The Venous Blood returning from the Brain runs into the Sinuses which

are found in the Dura Mater. The Blood from all the Sinuses eventually passes

into the Lateral Sinus and thence into the Internal Jugular Vein which commences
below the Jugular Foramen.
The most important Sinuses are those which lie against the Skull and are

liable to be affected in injury or disease of the bone, especially the Superior

Longitudinal Sinus and the lateral Sinus. Cf. Fig. 1. As the Superior Longi-

tudinal Sinus usually opens into the right Lateral Sinus, this Sinus and the Internal
Jugular Vein on the right side are usually larger than on the left.

The Lateral Sinus extends from the Torcular Herophili, (or either side)

horizontally outwards (cf. Fig. 17) and then descends behind the Mastoid Process,
forming two curves towards the Jugular Foramen. In this last portion of its

course it gradually leaves the outer surface of the skull and is hardly liable to

injury from without.

The course of the Cranial Nerves from the Brain to their foramina varies;

in the Anterior and Middle Fossa the Nerves pass directly to their foramina;

but in the Middle Fossa the Vth Nerve runs under the Dura Mater for some
distance, when it forms the GASSERIAN Ganglion and divides into its 3 Divisions,

which again run separately under the Dura Mater to leave the Skull by the

Sphenoidal Fissure, Foramen Rotundum and Foramen < )vale respectively. 1 'he

Bird and I Vth Nerves run in the outer wall of the Cavernous Sinus to the

Sphenoidal Fissure; the Internal Carotid Artery and the VI th Nerve run in the

Cavernous Sinus.
 Superior Longitudinal Sinus

Crista Galli

Anterior Meningeal Artery

Inferior Longitudinal Sinus

Anterior Communicating
Artery

Anterior Cerebral
Artery

Middle Cerebral Artery

Infundibulum

Spheno-parietal
Sinus

Posterior Com-
municating
Artery

Anterior Branch
of Middle
Meningeal Artery

Posterior Cerebral
Artery

Anterior
Cerebellar Artery

Basilar Artery

Auditory Artery

Superior Petrosal
Sinus

Posterior Inferior
Marginal Cerebellar Artery
Sinus

Vertebral Artery

Meningeal Branch
Occipital Artery Posterior Branch of the
Middle Meningeal Artery

Posterior Inferior Meningeal

Straight Sinus Artery
Right Lateral Sinus

Superior Longitudinal Sinus

Fig. 15. Base of Skull with Arteries, Emerging Nerves and Sinuses of Dura Mater.
Nat. Size.

Rebman Limited, London, Rebman Company, New York,

 Frontal Vein

Frontal Sinus Crista Galli

Anterior Ethmoidal Nerve Nasal Duct
Trochlea
y \
Tendon of Su|»erior Oblique Mum Inferior Oblique Muscle
Infratrnchlcar Nerve
Inferior Rectus Muscle
Insertion of Superior Oblique \
rrontal Nerve Bony Septum of Nose
La cry mal Gland
Posterior Ethmoidal Cells
Superior Oblique Muscle
External Rectus Muscle
Lacryrnal Nerve s
Superior Obliuue Muscle
Tomporo-Malar Nerve - ^Trochlear Nerve)
Oculomotor Nerve
Pmterior Ethmoidal _
Nerve
Ciliary Ganglion Abduccns Non e

Sphenoidal Sinus Spheno-parietal Sinus

Nasal Nerv* External Pterygoid

Superior
M usclc
Temporal Muscle
Maxillary Division
of 5th Nerve Internal Carotid
Lateral Recess of Arten*
Sphenoidal Sinus Posterior Com-
Sulk of Pituitary municating Artery
Body Middle Cerebral
Inferior Maxillary Vein
Division Smaller Part of
of 5th Nerve 5th None

Incus M iddle
Meningeal Artery
Cochlea A rticular
5th Nerve Fibro-Cartilage
A uriculo-temporal
Basilar Artery Nerve
Chorda Tympani
Lateral Sinus Nerve
Mastoid Emissary Vein Tympanic Cavity

Superior Petrosal Sinus

tytli, loth, nth, Nerves

Facial Nerve

Emissary Vein passing through Eustachian Tube

Posterior Condylar Foramen
\ Saccus Endolymphaticus
Vertebral Artery Occipital Artery

Rectus Capitis Posticus Major Muscle Superior Oblique Muscle of Head

Rectus Capitis Posticus Minor Muscle I
Suboccipital Nerve
Straight Sinus
Superior Longitudinal Sinus

Fig 1

. 16. Base of Skull with the soft parts after partial removal of the Bones.
*/
5 Nat. Size.

Rebmnn Limited, London. Rebman Company, New York.

 —

Fig. 1 6. Base of the Skull and Soft Parts after partial removal
of the Bones.

This complete fissure is constructed from eight dissections made after

hardening in formol and removing various parts of the Brain in successive
layers. After decalcifying the hones considerable portions were easily removed
by the knife.
On the left side the part of the Occiput forming the Posterior Fossa
was removed, the Cavernous Sinus opened and the Gasserian Ganglion with

its three divisions dissected out. The roof of the Orbit was removed and the
structures occupying the upper part of this cavity exposed to view. By cutting
away the Cribriform Plate of the Ethmoid, the Accessory Sinuses of the Nasal
Cavity were opened up —
Mucous Membrane is coloured pink.
On the right side a more extensive area of the base of the Skidl
has been removed, only a few thin bars beeing left Tympanic Cavity pink, (

Membranous part of Meatus brown). In the lower part of the Orbital Cavity,
— the eye-ball having been cut across horizontally and supposed to be transparent ,

all the structures including the nerves and muscles are shewn.

The Nerves of the Special Senses are green (Optic Nerve light green;
Auditory Nerve and apparatus, dark green).
Sensory Nerves, yellow. Motor, dark blue (Veins being light blue), so
that the Motor Root of the Vth Nerve is definitely shewn.
The Vagus Group IX, X, XI, being mixed nerves, are yellow ,
like the

sensory. Gasserian, Ciliary and Geniculate Ganglia are orange; on the left,

the air-cells of the Auditory apparatus, the Eustachian Tube and the unusually
large Lateral Recess of the Sphenoidal Sinuses extending into the greater wings

of the Bone are projected upwards (pink).

This figure — probably the first of this kind — gives, by shewing the vessels

and muscles under the base of the Skull in their natural position, an idea of the

Topography of this region unattainable from below because in this manner their

relations remain undisturbed by dissection.

The figure shews the topographical relations of the 3 great organs of

special sense: e. g. Eye, Ear and Nose, moreover, it gives a good view of the

course of the Nerves which have a primary intra-, and a subsequent extra-
cranial course.

Lastly connections are exhibited which could scarcely be appreciated by

other methods.
Fig. 17. Projection of Lateral Ventricle, Middle Ear and Lateral
Sinus on the outer surface of the Skull.

To figure which shews the projection of the Lateral Ventricle on to

S/'/t/.Ka’s
the outer we have added the projection of the Lateral
region of the Skull,
Sinus (violet ) and of the Middle Ear with its Accessory Cai'ities (red) while
retaining our own Specimens and the indications by FRIEDRICH Miller.

Puncture of the Lateral Ventricle is performed (a) to empty it of accumu-

lated fluid (Hydrocephalus, Serous Meningitis etc.), or *b) to inject drugs into die
Ventricle when not dilated (e. g. Tetanus). #

vox Bergmann trephines the Skull in front, direcdy above and mesial
to the Frontal Eminence and pushes a long hollow needle in a slightly downward
and inward direction.
Keen finds a point on the outer surface of die Skull 31 mm. above a line
connecting die lower border of the Orbit with the External Occipital Protuberance
and 32 mm. behind the External Auditory Meatus.
The shape of the lateral Ventricle does not van much except in the -

Posterior Horn. The “Trigone” e. w here the Body, the Posterior and Descending
i.

Horns meet, is the largest part and consequently the most suitable for die
operation.

Fig. 18. Projection of the Middle Meningeal Artery on the outer

surface of the Skull.

After KRÖNLEIN. The Middle Meningeal Artery is red.

To determine certain important Cerebral points and lines, as well as the

Middle Meningeal Arten', KröNLEIN’s landmarks are the most convenient
1) The "German Horizontal Line” runs through the Infra-Orbital margin,
and the upper border of the External Auditory Meatus. 2 The “Upper Horizontal )

Line” runs through the Supra-Orbital margin, parallel with the former. 3) The
“Anterior Vertical Line” passes upward from the middle of the Zygoma at right
angles to 1). 4) The “Middle Vertical Line" passes from the Condyle of die
Lower Jaw at right angles to 1). 5) The “Posterior Vertical Line" from the
posterior margin of the Base of the Mastoid Process at right angles to 1).

A line connecting where die “Anterior Vertical Line" and

(a) the point
the upper Horizontal Line cross each other with (b) the point where the “Posterior
Vertical Line” cuts the Vertex, represents the Central Fissure (Rolando). When
the angle formed by this line and the upper Horizontal line is bisected by a line
drawn to meet the posterior vertical line, the oblique line represents the Fissure
of Sylvius.
.1 and II are the points for trephining to evacuate the blood extravasated

from a ruptured Middle Meningeal Artery.

The square marked in thick lines is the region in which VON BERGMANN
resects the Skull cap for drainage of Otitic Abscess and Abscess of the Tem-
poral Lobe.
'l he Black Circles indicate the following points which are often made use
of (cf. Text Figs. 11 and 12):
Nasion at root of Xose. Bregma at Vertex; further back, Obelion. Lambda;
and Inion at the External Occipital Protuberance.
 Fig. 17. Projection of Lateral Ventricle, Middle Ear and Lateral Sinus on to the
Outer Surface of the Skull.
s
/4
Nat. Size.

Fig. 18. Projection of Middle Meningeal Artery on to the Outer Surface of the Skull.
s
/4 Nat. Size.
Rebman Limited, London. Rebman Company, New York.
 Fig. 19. Cranio-Cerebral Topography.

The bars of A. Koehler' s “ Craniencephalometer” are dark red ; Brain pink,

diagrammatic.

For practical purposes it is very important to know the surface markings

for the different parts of the hemisphere. By such knowledge a diagnosis can

be made of: “Which cortical region is affected in any particular injury of the Skull?”

On the other hand, functional disturbances may indicate disease of a certain part

of the Cortex which may require operation ;

by this knowledge of surface markings
the surgeon is enabled to find the seat of the lesion.

Generally speaking it is sufficient to determine the position of the Fissures

of Rolando and Sylvius because the most important centres are situated in the

neighbourhood of these fissures (cf. Fig. 3, 5) further with these landmarks other

sulci and fissures can be easity marked out.

Many methods have been devised, some requiring special instruments.

Koehler’s method is simple and reliable.

Cf. Fig. Three lines are necessary.

1. A Sagittal line extending from the root of the nose to the External

Occipital Protuberance.

2. A Vertical line through the Anterior Border of the External Auditory

Meatus.

3. A second Vertical line parallel to the former through the Posterior

Border of the Mastoid Process.

From the point where the last mentioned line meets the Sagittal line another

line is drawn downwards and forwards to a point situated midway between the

junction of the middle with the lower thirds and the mid-point of the first Vertical Line.

This point corresponds to the lower end of the Rolandic Fissure, the

upper end of which lies at the junction of the line drawn from the Sagittal Line.

The Fissure of SYLVIUS lies Y2 inch below the inferior end of the Fissure
of Rolando. About 2Y2 inches above the Zygoma the Short Anterior and Long
Posterior Limbs of this fissure begin. Another excellent method of marking out
the Fissures of Rolando and Sylvius, devised by Kroenlein, is described

in Fig. 18.
 Fig. ao. Exposure of the Cerebellum.

On the left side an incision has been made from the External Occipital
Protuberance horizontally outwards as far as the Ear. From either extremity

vertical incisions have been made downwards and the muscle-skin flap thrown
downwards. The muscles were subsequently dissected out. A large window
was chiselled out of the Bone. The Lateral Sinus has been slit open, the

Cerebellum is kept inwards by a broad spatula.

The Cerebellum is much more protected than the Cerebrum. Only a very

small surface area comes in contact with the Bone in a region well protected by

thick muscles.

Injury to the Cerebellum is accordingly very rare, but operations in this

part are far more difficult owing to its position. A glance at the figure shews

that suppuration of middle-ear origin may extend from the Lateral Sinus, Posterior

Semicircular Canal or Saccus Endolymphaticus and so give rise to an abscess

between the posterior surface of the Petrous portion of the Temporal Bone and
the Cerebellum or to a Cerebellar Abscess.

These purulent collections may be evacuated by an enlargement of the

opening made for the exposure of the Lateral Sinus, backwards. If a Temporal
abscess has been looked for by opening the skull in VON BERGMANN’s Rectangular
Area (cf. Fig. 1
8) then further procedure entails enlargement of the osseous opening

and incision of the Tentorium Cerebelli in order to compare the superior aspect
of the Cerebellum.

A large opening is necessary for Cerebellar Tumours. When the Lateral

Sinus gets in the operator’s way, he should push the Dura Mater away from the

Bone ligature the Sinus with a double ligature and divide it. Upon the further

removal of bone the Cerebellum can be well exposed.

We desire to draw particular attention to a vein which runs from the
lowest part of the Lateral Sinus or from the Jugular Bulb to the Vertebral Vein

through the Posterior Condylar Foramen. Its further course is horizontal be-

tween the Occipital Bone and the Atlas.

The vein is of great importance in Ligature of the Internal Jugular in

cases of Thrombophlebitis of the Lateral Sinus. Cf. Figs. 27 and 28.

 Cerebellum

Lateral Sinus

Tentorium

Superior Cerebellar
Vein

Superior
Sinus

Superior Semi-
circular Canal

Posterior Semi-
circular Canal

7th, 8th Nerves

Saccus Endo-
lymphaticus

9th, 10th, 1
Nerves

Lateral Sinus

Emissary Mastoid
Vein

Mastoid Process

Digastric Muscle Spatula

Rectus Capitis Posticus

Occipital Arteries
Minor Muscle
Sterno-mastoid Muscle Rectus Capitis Posticus
Major Muscle
Occipital Artery
Splenius Capitis Muscle
Semispinalis Capitis Muscle

Vertebral Artery

Superior Oblique of Head

Longissimus Capitis Muscle

Fig. 20. Exposure of the Cerebellum.

4
/5 Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Middle Turbinate Bone Antrum of Highmore Coronoid Process

Temporal Muscle
Nasal Septum

Masseter Muscle
Pterygoid Process
External Pterygoid
Muscle
3rd Division of
5thNerve Parotid Gland
Eustachian Tube Articular Cartilage

Temporal Artery
Occipital Bone
Head of Mandible

Internal Carotid
Artery
External Auditory
Meatus
Tympanic Cavity
Facial Nerve

Mastoid Cells

Lateral Sinus

Cerebellum

Fig. 21. Horizontal Section of the Head. Organ of Healing and surrounding Parts.
Left side, viewed from below. — Nat. Size.

Plead of Lower Jaw

Internal Carotid
Artery

Tympanic Cavity Tympanic Membrane

Superior Petrosal Long Process of Incus

Sinus

External Auditory
Facial Nerve Canal

Auditory Nerve

Tympanic
Mastoid Cells

Promontory

Umbo. Malleus
Fenestra

Lateral Sinus

Chorda

Facial Nerve

Fig. 22. Part of Fig. 21: Tympanic Cavity and surrounding Parts. X 2 1/ 2 .

Rebman Limited, London. Rebman Company, New York.

 Fig. 2 i. Horizontal Section of the Head: Organ of Hearing and
Surrounding Parts.

Fig. 22. Tympanic Cavity and Surrounding Parts.

X X/2 .

Part of a frozen section from a series of Horizontal sections through the Head.

The two curves described by the External Auditory Canal in the Horizontal
plane are well shewn: a 3rd curve is recognisable in the Vertical plane, so that
it is not possible to distinctly see the Tympanic Membrane without traction upon
the Cartilaginous portion of the Ear.
From the practical point of view the relations which the Auditory Appa-
ratus bears to neighbouring structures and especially to the Lateral Sinus and
Dura Mater are most important.
The Dura Mater which covers the posterior aspect of the Petrous Bone
is only separated from the numerous air-cells by a thin lamina of bone, so that
pus within these cells may easily give rise to a subdural abscess. The Tateral
Sinus bears a similar relation to the Mastoid Process so that injury to it may
result during operations upon the Mastoid; pus within the Mastoid Cells may
extend to the Lateral Sinus and produce Thrombophlebitis.
Around the Internal Carotid Artery which incompletely fills the Carotid
Canal, are Venous Spaces, continuations of the Cavernous Sinus. The Facial Nerve
is seen cut across in its vertical course to the Stylomastoid Foramen. In the
Facial Canal accompanying the Facial Nerve (Fig. 22) are shewn the Stylomastoid
Artery with its 2 Venae Comites. In Fig. 22 are further shewn the structures
in the Tympanic Cavity: Ear-ossicles, Chorda Tympani and Tympanic Nerve. The
EUSTACHIAN Tube, extending obliquely forwards, inwards and downwards from
the Tympanic Cavity to open into the Pharynx has been divided obliquely so that
it appears larger than if it had been cut transversely to its axis. Between the
Condyle of the Lower Jaw and the External Auditory Meatus there is only a verv
thin layer of bone. The Articular Fibrocartilage is seen almost completely
surrounding the Condyle. Internal to the External Pterygoid Muscle is seen the
3rd Division of the Vth Nerve directly after its emergence through the Foramen
Ovale; behind and to its outer side is the Middle Meningeal Artery.
The Lymphoid Tissue beneath the Pharyngeal Mucous Membrane — the
Pharyngeal Tonsil — which appears ver}' large in a horizontal section deserves
notice. This has been cut obliquely because the upper wall of the Pharynx is

not horizontal but directed obliquely backwards and downwards.

Fig. 23. Vertical Section through the Left Temporal Bone in the
plane of the Axis of the Petrous Portion.
Frozen Section. Mucous Membrane of Tympanic Cavity Antrum and Mastoid ,

Cells in red. The lower part of the Tympanic Cavity has been carried away
in the section so that the External Auditory Canal is exposed.

Fig. 24. Horizontal Section through the Left Temporal Bone.

Section through a macerated bone. The axis of the Mucous Membrane lining
the Eustachian Tube and Mastoid Antrum is indicated by a red line.
the
The axis through the External and Internal Auditory Meatus, “Sensory Axis”,
is indicated by a yellow line. The Cartilage of the Temporo- Mandibular Articu-
lation is coloured bTie.

The middle is surrounded by numerous air-cells which are lined by

ear
a continuation of the same mucous membrane and communicate directly or indi-
rectly with the Tympanic Cavity. Pus spreads readily from the Tympanic Cavity
to these Accessory shews how the cells lie below the plane of the
Cells. Fig. 23
opening -
Tympanic Cavity and consequently drainage is very efficient.
into the
The size of these air-cells varies not only on the same side but on either side in
the same individual. These cells may extend far into the Petrous Bone, even
into the Occipital Condyle and the root of the Zygoma. The chief Accessory
Cavity is the Mastoid Antrum (as large as a French Bean) with its long axis
(
2
5 th
/
inch) corresponding to the axis of the Eustachian Tube and opens into
the Tympanic Cavity on the posterior wall, directly below the Tegmen Tympani
which forms the roof of the Antrum. The Mastoid Cells, which vary considerably
in number, either few or large, numerous or small open into the Antrum. The
cells extending into the Squamous Portion are known as Squamosal Cells, but
these never extend higher than the temporal ridge. The lamina of bone covering
the Mastoid Process is so variable in thickness that, like the Tegmen it is deficient
at some points on its outer wall as well as on its inner wall, which is in relation
to the Lateral Sinus. These points of deficiency are merely covered by connec-
tive tissue.
Pus can spread easily through the thin Tegmen Tympani and cause
Meningitis or a Temporal Abscess. Fig. 23 shews the Vth Cranial Nerve in

Meckel’s Cavity, i. e. the depression on the superior surface of the Petrous Bone
covered in by Dura Mater.
the red line indicates the ‘'mucous membrane axis”,
In Fig. 24 e. i.

Eustachian Tube, Tympanic Cavity, Antrum and Mastoid Cells on a line which
runs backwards and outwards.
The yellow line is the “sensory axis” which passes through the External
Auditory Meatus, Tympanic Membrane and Cavity, Vestibule and Internal Auditory
Meatus. These axes cross in the Tympanic Cavity the first passes through all
;

organs of accessory importance for hearing; the second passes through the organs
of hearing proper.
 Antrum

Incus

Superior Ligament of the Malleus

Chorda Tympani

Tensor Tympani Muscle

Malleus. Umbo
Eustachian Tube

5th Nerve

Internal Carotid
Artery

Cartilage of
Eustachian Tube

Levator Palati
Muscle

Pharyngeal Opening
Mastoid Cells of Eustachian
Tube
Stylo-mastoid Artery

Splenius Capitis Superior Constrictor

of the Pharynx
r
Sterno-cleido-mastoid Muscle Facial Digastric Styloid Process Stylo-hyoid Muscle
Nerve Muscle

Fig. 23. Vertical Section through left Temporal Bone in the plane of the axis
of the Petrous Portion.
Seen from behind. — Nat. Size.

Mastoid Cells

Lateral Sinus

Antrum
Canal for Facial Nerve (Fallopian)

Pyramid
Posterior Semi-circular Canal

Aqueductus Vestibuli
Vestibule

^ Internal Auditory Meatus

Bony Lamina (Processus

Cochleariformis)

jsustachian Tube

Notch of Rivini

Petrosquamosal Suture

External Auditory Meatus

Mandibular Fossa

Zygoma

Fig. 24. Horizontal Section through the Left Temporal Bone.

Seen from below. — Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Antrum

Prominence of External
Semi-circular Canal

Temporal Fascia

Squamous Plate'of Temporal Diploe

Bone

Suprameatal Spine
Lateral Sinus
External Auditory Meatus
(Cutaneous)

Auricular Branch of Vagus Facial Nerve

Nerve (Arnold)

External Auditory Sterno-cleido-mastoid Muscle

(Cartilaginous)
Posterior Auricular
Posterior Auricular Artery

Parotid Splenius Capitis Muscle

Longissimus Capitis Muscle
Facial Nerve
Digastric Muscle Mastoid Process
Styloid Process

Fig. 25. Mastoid Process of Child opened.

Nat. Size.

Suprameatal Spine Antrum Temporal Fascia Posterior Auricular Nerve Occipitalis Muscle

Great Occipital Nerve

Cartilage of Pinna

Small Occipital Nerve

External Auditory
Canal

Lateral Sinus
Posterior Auricular
Muscles

Facial Nerve
Auricular Branch
of Vagus Nerve

Splenius Capitis
Cartilaginous Portion Muscle
of the External
Auditory Canal
Sterno-cleido-mastoid
Muscle
Facial Nerve

Posterior Auricular
Lymphatic Gland
Posterior Auricular
Artery

Nerve to Digastric
Muscle

Great Auricular Nerve

Nerve to Stylo-hyoid

Parotid Gland

Fig. 26. Mastoid Process of Adult opened.

Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Fig. 25. Mastoid Process of Child, opened.
Fig. 26. Mastoid Process in Adult, opened.

Fig. 25. The various layers of the Mastoid region in a child, aged two years,
have been exposed, and the Mastoid Process chiselled open. Air-cells, red.—
In Fig. 26 the Mastoid region of an adidt has been more extensively dissected
but only that portion of the Mastoid Process containing air-cells has been
opened by chisel. The periphery of the Mastoid Process is indicated by a dotted
line. By removal of a portion of the Parotid Gland the Facial Nerve has been
exhibited as it emerges from the Stylomastoid Foramen.

The Antrum is well marked in the New-Born though the Mastoid Process

is scarcely discernible; its posterior and external portion becoming formed during"
the first years of life; it grows downwards as the formation of air-cells slowly
progresses. Even in the adult there are not necessarily any air-cells at the tip
of the Mastoid Process. The Facial Nerve after emerging from the Stylomastoid
Foramen runs forward at a right angle in the infant, at an obtuse angle in
the adult.
The groove of the Lateral Sinus is shallow in the child, deep in the adult.
The Antrum and Mastoid Cells are easily accessible for operative purposes from
the outer surface of the Mastoid Process. Subcutaneously in the angle between
the Pinna and the Skull the Posterior Auricular Artery takes its course. The
Periosteum is connected with the tendinous fibres of origin of the
intimately
Sternocleidomastoid Muscle which gradually become lost in the Temporal Fascia.
About 2/5 th inch behind the Suprameatal Spine is situated the Antrum at a depth
of 2/ 5 th of an inch from the surface. Below this are the Mastoid Cells.
The structures in relation with the Antrum are of great importance.
The thin Tegmen Tympani alone separates the Antrum from the Cranial
Cavity, so that search for an Epidural or Temporal Abscess is easy after perfor-
ation of the Tegmen Tympani. If projected on to the surface the floor of the
middle Fossa of the Skull lies in the region of the attachment of the pinna either
above or on the level of the Temporal line. Posteriorly and internally is the
Lateral Sinus which should be avoided when the air-cells are opened. The position
of the Lateral Sinus varies, it may lie in a shallow groove on the Mastoid Process,
or in a deep furrow in both Mastoid and Petrous portions.
According to Bezold
most marked outward curve of the Sinus is
the
3
/5 At this point the bone is usually 0.3 inch
inch behind the Suprameatal Spine.
thick (0.1 to 0.7). The Facial Nerve may be injured as it lies below the Extermil
Semicircular Canal on the inner wall of the Tympanic Cavity close to the opening"
into the Antrum (Aditus ad Antrum). The wall of the Facial Canal is very thin
so that by a careless use of the chisel this nerve may be divided.
Lower down the Mastoid Cells are in relation with the Facial Canal: this
portion has been laid free in both figures.
Fig. 27 and 28. Tympanic Cavity and Surrounding Parts opened
from behind.

In Fig. 27, the outer wall of the Mastoid Process, Antrum and Attic
have been removed, the Mastoid Cells gouged out so that only the inner wall
of the Mastoid Process remains; Facial Nerve Posterior and External Semi-
,

circular Canals and Lateral Sinus are still covered by bone. Facial Nerve and
Semicircular Canals (yellow) are represented as shewing through the bone.
In Fig. 28, the skin incision has been extended downwards, the tip of
the Mastoid Process removed, the Digastric Muscle divided and the Attic more
freely exposed, the Facial Canal opened, the bony wall of the Sinus removed
and the Saccus Endolymphaticus exposed.
The Posterior portion of the Tympanic Membrane, the Posterior and
Superior wall of the Bony External Auditory Canal have been removed and
the skin which lines this portion slit open. The bar of bone behind the Stylo-
mastoid Foramen has been sawn through in order to expose the Jugular Bulb.
These figures give the relations which are of importance in radical operations.

In cases of chronic suppuration and Cholesteomata of the Middle Ear, it is

important to expose all the cavities by removing their outer wall and bony septa
so that the inner wall of the Tympanic Cavity, Antrum and Mastoid becomes
continuous with the Inferior and Anterior Wall of the External Auditory Canal.
The bony canal for the Facial Nerve, the External Semicircular Canal and the
Stapes must be carefully avoided. The black area below the Incus represents
the Fenestra Rotunda.
Fig. 28 shews the whole of the oblique part of the Lateral Sinus to its
termination in the Jugular Bulb. After reaching the Temporal Bone its direction
changes vertically downwards, embedded to varying depths in the inner wall of
the Mastoid Process, thence its course is at first horizontally inwards (occasionally
with a sharp upward curve), then directly downwards to pass through the Jugular
Foramen and form the Jugular Bulb. Suppurative Thrombo - phlebitis usually
affects this last vertical portion, in many such cases the Sinus must be opened
throughout its whole length.
Many ways may be employed to expose the Jugular Bulb: GRUNERT
removes the tip of the Mastoid Process and proceeds towards the Jugular Foramen
at the base of the skull where he divides the bone encircling' it. As shewn in
the figure the Facial Nerve is in the way. PANSE therefore recommends that the
nerve be freed and drawn forward. If the Transverse Process of the Atlas is in
the way it should be carefully removed, avoiding any injury to the Vertebral
Artery. Owing to anatomical variations, this may be impossible so that Grunert’s
method (as practiced by PlFFL), of removing the floor of the Auditory Meatus and
Tympanic Ring, under which the Jugular Bulb lies, may be necessary. (Cf. Fig. 17.)
By this method the Facial Nerve lies behind the field of operation; the
structure to be avoided in front is the Internal Carotid Artery. Will ligature of
the Internal Jugular Vein in Septic Thrombophlebitis prevent the spread of infection?
This question demands a consideration of the many Venous Channels
which open into the Lateral Sinus (Superior Petrosal Sinus, Figs. 15, 16, 20), Mastoid
Emissary Vein (Figs. 20 and 28), Posterior Condylar Emissary Vein (Fig. 20),
Marginal Sinus (Fig. 15), Inferior Petrosal Sinus (Fig. 15), Anterior Condylar
Vein which accompanies the Hypoglossal Nerve and passes to the Jugular Bulb
from the Vertebral Plexus. The figure shews the close proximity of Facial and
Spinal Accessory Nerves so that in cases of Facial Paralysis the Surgeon may
be tempted to suture the central portion of the Spinal Accessory to the Peripheral
portion of the Facial Nerve.
 Suprameatal Spine
Tympanic Cavity

Short Process of Incus

External (Horizontal)
Semicircular Canal

Posterior Semicircular Canal

Facial Nerve

Lateral Sinus

Digastric Muscle

Qr. Frohst.

Fig. 27. Superficial Layer.

Malleus

Tympanic Cavity

Posterior Semicircular
Canal

Saccus Endolymphaticus

Facial Nerve

Lateral Sinus

Mastoid Emissary Vein

Occipital Vein

Spinal Accessory
Dr. Trol, St-

Fig. 28. Deep Layer.

Figs. 27 and 28. Tympanic Cavity and surrounding Parts opened from behind.
Nat. Size.

Rebman Limited, London. Rebman Company, New York.

Rebman Limited, London. Rebman Company, New York,
 f ) t

Fig. 29. Superficial Vessels and Nerves of the Head.

Skin, Parotid Gland, portion of the Orbicularis Palpebrarum and Square Muscle
of the Upper Lip (Quadratus Labii Superioris), have been removed. The
Superficial Arteries, Veins, Nerves and Muscles have been exposed by dissection.

Light red, Arteries. Passing upward over the lower jaw is the Facial

Artery which shews through the Muscles as it is covered by them : in front of

the Ear the Temporal Artery gives off the Transverse Facial Artery. At the

upper border of the Orbit the Frontal Artery (a branch of the Ophthalmic Artery
which comes off the Internal Carotid) is seen and at the back is the Occipital Artery.

Violet, Veins. The Facial Vein (anastomosing, at the Naso-frontal Angle,

with the Frontal Vein and indirectly with the Intracranial Venous System) is seen

communicating with the Temporal Vein which lies in front of the Pinna. Posteriorly

the Occipital Vein is seen.

The Facial Nerve and its branches are white. (Cf. Figs. 33 — 38.)

The other nerves are coloured in accordance with their area of distribution.

(Cf. Figs. 33-38.)

Dark red — Ophthalmic Division of Vth Nerve. (F, 1).

Yellow — Superior Maxillary Division of Vth Nerve (F, 2). [z — indicates

Zygomatico-Temporal, and z — Temporal-Facial Branches).

Blue — Inferior Maxillary Division of Vth Nerve (F, 3). This gives off

the Auriculo-Temporal Nerve (a — l) before the Inferior Dental enters its Foramen.
Orange — Auricular Branches of Vagus (
X to the Pinna (Arnold).
Black — Cervical Nerves: Great Auricular, Great and Small Occipital and

Superficial Cervical Nerves.

The Duct of the Parotid Gland (Stenson’s Duct) and its small tributaries

are coloured light brown.

 Fig. 30. Side View of Face. Superficial Layer.

The Parotid Region has been dissected on the Left Side and a window made
in the Parotid Gland to shew the formation of Stenson's Duct, Branches of
the Facial Nerve and the main vessels (all very car efidly dissected).

Broadly speaking the Vessels and Nerves of the Face are subcutaneous
with the exception of the area covered by the Parotid Gland.
The Parotid Gland is covered by a thick fascia; its outer surface is tri-
angular in shape with the base directed upwards and the Apex at the angle of the
Lower Jaw. The base extends fromthe posterior extremity of the Zygoma to
the Cartilaginous portion External Auditory Canal and to the Anterior
of the
border of the Sternomastoid Muscle. The posterior border runs parallel to the
Sternomastoid Muscle; at the angle of the Jaw, this is met by the Anterior
border which crosses the Masseter Muscle. The greater part of the Gland lies
behind the Ramus of the Jaw and extends inwards to the Digastric (i. e. close to
the Carotid and Jugular Vessels Fig. 53). Stenson’s Duct runs almost horizontally
2
forwards tyth inch below the Zygoma and turns inwards at the Anterior border
of the Masseter to perforate the Buccinator obliquely and terminate within the
Buccal Cavity opposite the 2nd upper molar tooth (cf. Fig. 57). There is often
present an Accessory Parotid (Socia Parotidis) attached to the Duct (cf. Fig. 30).
The Facial Nerve bears a close relation to the Gland. After emerging
out of the Stylomastoid Foramen this nerve enters the substance of the Gland at
the level of the lobule of the Ear. Here it divides, and its branches run in the
substance of the gland, to emerge at the Anterior border and be distributed to
all the muscles of Facial Expression. Consequently it is impossible to remove the
whole of the Parotid Gland without injury to the Facial Nerve, but removal of
the lower part in no way leads to interference with the Nerve: in this case the
Mandibular Branch, which supplies the muscles of the angle of the mouth, is
chiefly damaged. The branches of the Facial Nerve form an anastomosis with
each other (Pes Anserina) and with the Fifth.
.
The Auriculo-Temporal Nerve (from V, 3) runs through the Parotid Gland
as well as the Superficial Temporal Artery (continuation of External Carotid
Artery); this vessel in its course through the gland gives off the Transverse Facial
Artery which takes a horizontal course. The Superficial Temporal Artery then
passes upwards in front of the ear dividing into an Anterior (Frontal) and a
Posterior (Parietal) branch to supply the Frontal and Parietal Regions of the Scalp
as far as the Vertex. The Temporal Vein, accompanying the Artery, receives
blood from the Temporal Region and the Ear. In the substance of the Parotid
Gland are embedded a few lymphatic glands which are of practical importance;
rarely, a cutaneous lymphatic gland, superficial to the Parotid, is found.
 Temporo-Facial Branches Auriculo-Temporal
of Facial Nerve Superficial Temporal Artery
Nerve

Temporal Vein

Zygoma

Facial Nerve

Gieat Auricular
Nerve

External
Jugular Vein

Masseter Parotid Gland

Facial Artery Long Buccal Nerve
Muscle

Facial Vein

Fig. 30. Side View of Face. Superficial Layer.

Nat. Size.

Rebman Limited, London Rebman Company, New York

 Branches of Deep Poster ior Superficial
Temporo-Facial Temporal Artery Temporal Masseteric Temporal
Internal Maxillary Artery Nerve Temporal Muscle and Nerve Fasciae Nerve Artery Articular Eminence

Branches of
Temporo-Facial
Nerve
Auriculo-Temporal
Nerve

Infra-orbital Nerve Middle Temporal

Artery

Articular
Posterior Superior
Fibrocartilage
Alveolar Nerves

External Pterygoid
Muscle
Deep Anterior
Temporal Artery Communicating
Branch between Fa-
cial and Auriculo-
Parotid Duct Temporal Nerves

Middle Meningeal
Artery
Buccal (Sucking)
Pad External Carotid
Artery

Buccinator Muscle

Long Buccal Nerve

Facial Nerve

Parotid Gland

Nerve to Mylohyoid Muscle

Masseter Muscle

Internal Maxillary Artery Inferior Dental Nerve

Internal Pterygoid Muscle Lingual Nerve

Fig, 31. Side View of Face. Deep Layer.

Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Fig. 31. Side View of Face, deep layer.

The branches of the Facial Nerve have been exit of but its communications
with the Auriculo-Temporal Nerve have been exposed to view: the Zygoma has
been sawn through and removed together with the upper part of the Masseter
Muscle, (in a similar manner, the Coronoid Process with the attached Temporal
Muscle). All the chief branches of the 2nd and 3rd divisions of the Vth Cranial
Nerve and the branches of the Internal Maxillary Artery are exhibited.

Under cover of the Coronoid Process of the Lower Jaw and the Temporal
Muscle attached to it, the structures of the Zygomatic Fossa are covered with fat.
After the removal of this fat the External Pterygoid Muscle is seen extending
from the Pterygoid Process to the Condyle of the Lower Jaw. The relation of
the Internal Maxillary Artery (terminal branch of External Carotid Artery) to
this muscle varies as it runs, either superficial or deep to the muscle, to gain the
Spheno-Maxillary Fossa. This vessel gives off the Middle Meningeal Artery which
runs upwards to the Foramen Spinosum and the Inferior Dental Artery which
enters the Inferior Dental Foramen. After removal of the External Pterygoid
Muscle the 3rd or Inferior Maxillary-Di vision of the Vth Nerve is visible.
After passing through the Foramen Ovale this breaks up into numerous
diverging branches. The Auriculo-Temporal Nerve passing backwards emerges
behind the Temporo-Maxillary Articulation and supplies the skin of the temporal
region with common sensibility, this nerve generally forms a loop through which
the Middle Meningeal Artery passes. The other branches are partly motor and
supply the Muscles of Mastication (Internal and External Pterygoids, Masseter
and Temporal), and partly sensory, long Buccal to the skin and Mucous Membrane
of the Cheek. The two largest branches, Inferior Dental and Lingual, pass down-
wards on the Internal Pterygoid Muscle; the former, the larger nerve, is the
more posterior.
In the Spheno-Maxillary Fossa but situated anteriorly, is the posterior
surface of the Superior Maxilla. The branch of the Internal
Infra-orbital Artery, a
Maxillary Artery, enters the Infra-orbital Canal, while close above this vessel lies
the 2nd division of the Vth Nerve which in its course from the Foramen Rotundum
to enter the Infra-orbital Canal inclines outward. In its short course it gives
off the Spheno-Palatine Nerves to the Spheno-Palatine Ganglion (Meckel’s,
cf. Fig. 44) and through the Pterygo-Maxillary Fossa the Zygomatic, Superior

Dental and Sphenopalatine Nerves.

Operations in this region — for removal of tumours, resection of the 2nd
or 3rd divisions of the Vth Nerve for Acute Neuralgia —
are rendered difficult
by the diffuse Venous Plexus (Pterygoid Plexus) which replaces the Venae Comites
of the Internal Maxillary Artery. This plexus which has been removed in the
dissection ,
extends from the Infra-orbital Canal and Spheno-Maxillary Fissure
between the Pterygoid Muscles as far as the Temporo-Mandibular Joint.
 Fig. 32. Exposure of the Gasserian Ganglion. Natural Size.

On the right side an incision, curvilinear with its base at the Zygoma, has been
carried through the soft parts. The bone has been chiselled through and the
osteoplastic flap, broken at its base, is turned downwards. The Dura Mater of
the Middle Fossa and the Temporal Lobe are raised so that after division
of the Middle Meningeal Artery, the Gasserian Ganglion and the 3rd division
of the Vth Nerve are exposed outside the Dura Mater. (As the bone was
removed the Anterior Division of the Middle Meningeal Artery was lacerated
in its bony canal.)

Persistent Facial Neuralgia which is unrelieved even by extensive resection

of the peripheral branches of the Vth Nerve as they emerge from the skull and
which is unrelieved by medicaments has recently been dealt with by removal of
the GASSERIAN Ganglion. Two methods may be adopted
either (Rose) the
Zygoma may be temporarily resected, when
exposure of the Foramen Ovale
after
from below the base of the skull is opened up; or the skull may be opened in
the Temporal region (Hartley, Krause) and the Ganglion with its branches
exposed. This latter method is perhaps the better one; moreover, it may be
employed for removing tumours of the Middle Fossa or for ligature of the Middle
Meningeal Artery. After turning down an osteoplastic flap as described above,
the Dura Mater covering the Temporal Lobe is lifted away from the Skull. Con-
siderable haemorrhage follows from the laceration of numerous small veins. At
a depth of one inch from the Squamous portion of the Temporal Bone, just above
the root of the Zygoma lies the Middle Meningeal Artery. This vessel is divided
between two ligatures in order to expose the Foramen Ovale which lies Vioth
inch internal and in front of the Foramen Spinosum; 2 /5 th inch forwards and nearer
to the middle line than the Foramen Ovale is situated the Foramen Rotundum
through which the 2nd division of the Vth Nerve passes; Y5 th inch from the
Foramen Ovale and 2/5 th inch from the Foramen Rotundum is the Convex margin
of the GASSERIAN Ganglion. It lies in an impression on the upper surface of

the petrous bone and covered by Dura Mater in Meckel’s Cave (cf. Fig. 23).
The trunk of the Vth Nerve enters its Dural Sac by passing through a slit
in the Dura Mater at the attachment of the Tentorium Cerebelli to the superior
border of the petrous bone. The Gasserian Ganglion and its three divisions
are outside the Dura Mater and can be operated upon without opening the
meninges or exposing the brain.
Particular attention should be paid to the first division of the Vth Nerve,
as it lies in the outer wall of the Cavernous Sinus; so that in freeing this division
the Sinus is necessarily injured. (Cf. Fig. 17.)

Another method, devised by LEXER, is still less liable to injure the brain
whereas it gives a good exposure of the Ganglion. Lexer makes a smaller
temporal flap but enlarges the area of operation downwards by temporarily resecting
the Zygoma and removing the base of the skull as far as the Foramen Ovale.
 Dura Mater y
of Temporal ,
Trochlear
Middle Meningeal Artery Lobe 3 2 1 Nerve Dura Mater of Frontal Lobe

Superficial Temporal Artery Superficial Posterior Anterior Muscle Fascia

Temporal
Vein Branch of Middle Temporal
Meningeal Artery

Fig. 32. Exposure of the Gasserian Ganglion.

Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Fig. 35.

Fig. 33.

Fig. 37.

Fig. 38.
Fig. 34.

Fig. 33—38. Area of Distribution of the Sensory Cranial Nerves:

Fig. 33 Front View, Fig. 34 Side View, V* Nat Size - -

Fig. 35 — 38. Variations, Side View. V« Nat. Size -

Rebman Limited, London. Rebman Company, New York.

Fig. 33 —38. Area of Distribution of the Sensory Nerves of the Head.

These diagrams have been made in accordance with Frohse’s investigations and
Zander’s data. In fig. 33 the foramina of exit of the chief branches of the
Vth Nerve have been indicated by black Dots.

A characteristic feature of the Cranial Nerves is that they are either pure
Motor or pure Sensory nerves; when they contain fibres of the other variety they
do not represent true mixed nerves like the Spinal Nerves. The anterior half
of the head is supplied by the Vth Cranial Nerve, the posterior half by the Cervical
Nerves, a very small portion only of the Pinna being supplied by the Auricular
—
Branch of the Vagus (cf. the black area in Figs. 35 38, and in Fig. 34 the white
nerve marked A).
The ist division of the Vth Nerve (red) supplies the forehead and vertex
of the skull as far back as a vertical line drawn upwards from the posterior border
of the Pinna, the middle portion of the upper Eyelid and the Lateral aspect of
the Dorsum of the Nose. A
branch of the Nasal Nerve supplies the anterior part
of the nasal mucous membrane whereas its outer branch only becomes superficia
between the Nasal Bone and the Nasal Cartilage (cf. Fig. 50).
The 2nd Division (yellow) covers the smallest cutaneous area supplying
the teeth of the upper jaw (Superior Dental Nerves), the nasal mucous membrane
(Nasopalatine Branches) and through the Infra-orbital Nerve the lower eyelid and
the upper lip.
The 3rd Division (blue) gives off Motor Branches to the muscles of
mastication and to the Mylohyoid Muscle. Its Sensory Branches are the Auriculo-
Temporal, Long Buccal and Mental Nerves.
Cervical Nerves. The Great Auricular plays an important part in the
Nerve supply of the Face by supplying the region over the Parotid and the
Masseter.
One of its branches ascends between the Helix and Antihelix. The outer
side of the Pinna is accordingly supplied by 3 nerves: —
Auriculo - Temporal,
Auricular Branch of Vagus and Great Auricular.
The foramina of the 3 branches of the Vth Nerve viz. the Supra-orbital
Foramen (notch), Infra-orbital and Mental Foramina lie almost in a vertical line
(K. v. Bardeleben). In Neuralgia these points are exceedingly tender. A glance
at Figs. 35 to 38 indicates the enormous variations in the cutaneous supply. Thus
(cf. Fig. 36) the Infra-orbital Nerve may supply the whole of the middle portion
of the Dorsum of the Nose and eliminate the Outer Branch of the Nasal Nerve
from the Tip of the Nose. Fig. 38 shews a very considerable extension of the
Cervical Area. Variations not only occur in different individuals but even in the
same individual, so that ihe cutaneous supply is different in each lateral half of
the face. Frequent anastomoses occur so that one area may be supplied by
several nerves. Stress should be laid on the fact that the nerves cross the middle
line to the opposite side (cf. Fig. 33).
Fig. 39. The Nasal Cavity with the Opening of its Accessory Sinuses.

The Sagittal Section has been made a little to the right of the Nasal Septum,
Sphenoidal and Frontal Septtim. Portions have been removed from the

Turbinated Bones in order to exhibit the orifices of the accessory Cavities.

Into some of these directors have been introduced. The Tongue has been almost
completely removed to shew the Tonsil.

The Accessory Cavities of the Nose may be considered Embryologically

as Ethmoidal Cells which have grown beyond the area of the Labyrinth. They
become formed by the resorption of the bony walls of the Nasal Cavity. The
mucous membrane follows this process and grows into the accessory cavities. The
Nasal Duct opens, covered by the inferior turbinated bone, into the inferior nasal
meatus. This meatus readily allows the introduction of a canula into the opening
of theEUSTACHIAN Tube which lies in the Outer Wall of the Pharynx. At this
opening is the EUSTACHIAN Cushion, behind it the Fossa of ROSENMÜLLER.
Under the Mucous Membrane covering the roof and back of the Pharynx is a
mass of lymphoid tissue (Pharyngeal Tonsil) which in the middle line exhibits a

recess of variable shape, grooved, saccular or double (Pharyngeal Bursa).

Into the middle meatus, at the Anterior part of a ridge, is the opening of
the Frontal Sinus (Infundibulum), at the posterior part the aperture of the Antrum
of Highmore. The communication between the Antrum and the Nose is not always
single, it may be double.

We have already stated (in Fig. 2 Text) that the opening of the Antrum is

in a most unfavourable position for drainage, because it is situated at the top

of the cavity. The Anterior Ethmoidal Cells also open into the Middle Meatus
(cf. Fig. 2) directly above the aperture of the Antrum. The Superior Meatus con-
tains the opening for the Posterior Ethmoidal Cells. Above the Superior Turbinated
Bone is the aperture for the Sphenoidal Sinus into which guided by a mirror one
can introduce a canula through the Anterior nares. The aperture of the Sphenoidal
Sinus is not situated at the lowest part of the cavity and is consequently not
favourable for drainage. All the accessory nasal cavities are lined with mucous
membrane.
The figure shews the Tonsil situated between the two pillars of the Fauces.

About one inch long and composed of Lymphoid Tissue it only becomes distinctly
visible when the tongue is depressed. (Cf. Fig. 53.)
 Posterior Ethmoidal Cells

Sphenoidal Sinus

Frontal Sinus

Anterior Ethmoidal Cells

Infundibulum

Opening of
of Highmore

Opening of -
Nasal Duct

Pharyngeal Recess
(Rosenmüller)
Eustachian Tube
Pharyngeal Tonsil

Uvula

Anterior Pillar
of Fauces

Tonsil

Posterior Pillar
of Fauces

Fig. 39. Nasal Cavity with Openings of Accessory Sinuses.

4
/5 Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Nasal Opening of Antrum

Inferior Wall of Orbit

Tuberosity of Maxilla

Antrum

Lateral Incisor Tooth

Canine Tooth
1st Molar Tooth 1st Bicuspid Tooth

Fig 1

. 40. Antrum of Highmore with Hoots of Teeth.

Nat. Size.

Septum between
F rontal Sinuses

Supra-orbital
Foramen
Supra-orbital
Nerve
Trochlea

Right Frontal Levator Palpebrae

Sinus Muscle

Infundibulum
Frontal Bone

Ethmoidal Bulla

Frontal Process
of Maxilla
Nasal Duct

Antrum
Nasal Bone

Septum of Nose

Inferior
Triangular
Turbinated Bone
Cartilage of Nose

Lateral Cartilage
of Nose

Fig. 41. Frontal Sinus. Nasal Duct.

Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 .

Fig. 40. Antrum of HIGHMORE with Roots of Teeth.

The Alveolar Process and Teeth were ground off until the Antrum of Highmore
was well exposed; its Anterior wall was removed.

The Incisor Teeth are in no relation with the Antrum. The Canine and
first Bicuspid Teeth are closely related to this cavity, but separated from it by a
thick layer of bone. The 2nd Bicuspid and
the 3 Molar Teeth are in closer relation
to it. The roots of the Molars frequently project upwards as conical processes,
separated from it only by a thin layer of bone. Thus disease of the roots of the
last four teeth may lead to suppuration in the Antrum. On the other hand, an
empyaema of the Antrum of Highmore may be drained by extracting one of the
teeth mentioned and perforating the thin layer of bone.

Fig. 41. Frontal Sinuses. Nasal Ducts.

Both Frontal Sinuses are chiselled open from the front. On the right, the
bones and sutures at the root of the nose are laid bare; on the left, the outer
wall of the Nose has been removed, as far as necessary to expose the duct which
leads from the Frontal Sinus to the Nasal Cavity. Mucous membrane is
coloured pink.

The Frontal Sinuses lie directly above the root of the nose, they entend
towards the forehead and over the orbital cavities from which they are separated
by the thin roof of the Orbit. Their greatest depth is above the nose externally ;

they gradually become more flattened. Their size and shape vary enormously in
different Their utmost limits are laterally the fronto-malar suture and
people.
Summit of the vertical portion of the frontal bone. They
superiorly half-way to the
are separated from each other by a thin lamina of bone, which practically always
deviates from the middle line.

They are to be cells which have been pushed

considered as ethmoidal
into the frontal bone, way, the external table and diploe He in front, and
in this
the internal table behind them. This explains the strength of the anterior wall
and its resistance to external violence.
Their inner surface is irregular and may present recesses resembling diverti-
cula. They are, as their origin explains, lined by mucous membrane.
They always communicate with the nasal cavity; the opening of this
communication lies invariably in the middle nasal meatus (infundibulum), into which
the Antrum of Highmore also opens (cf. Fig. 39). The Frontal Sinus may reach
as far as the anterior end of the Ethmoidal turbinated bone and open by means
of a simple sUt, or the anterior ethmoidal cell may be very large and thus cause
constriction of the lower part of the Sinus ;
in this case a Canal is formed :
— the
naso-frontal duct —
These deviations explain why it is very easy in some cases, and difficult
in others — or even impossible —
to introduce a canula into the Frontal Sinus
through the nose.
 Fig. 42. Orbit and surronding Structures — Horizontal Section.

From a frozen section which passes horizontally through the middle of the eye
of a male body, 45 years old, the brain is removed; middle Meningeal Artery
and Gasserian Ganglion Mucous membrane of Nasal and Accessory
dissected.

Cavities, red. Tenon’s Capsule and Periosteum blue. Lachrymal apparatus

orange.

This section shews the conical shape of the orbital cavity which has also
been compared with a pyramid. The inner wall is chiefly formed by the Os
Planum of the Ethmoid ;
it is very thin, and separates the orbit from the accessory
nasal cavities. Pus may thus easily spread from them into the orbit. The centre
of the eyeball does not lie in the axis of the orbit, but slightly external to it.

The orbit is filled with fat through which the muscles, vessels and nerves to the

eyeball run. (The Ciliary Ganglion is shewn in Fig. 16.) The Optic Nerve,
flattened in the skull, leaves its foramen as a round cord, runs forwards and out-
wards — then inwards — and just before reaching the eyeball again slightly out-
wards. It thus describes an S-shaped curve (cf. Fig. 44).
The connective tissue of the orbital fat forms near the eyeball a strong
membrane Tenon’s Capsule — The eyeball moves in this membrane, as if
— .

this were a ball- and socket-joint. There is, however, no free space between the
eyeball and capsule, as the space is filled up by a delicate scaffold-like tissue.

Tenon’s Capsule ends behind at the Optic Nerve, in front at the Fornix of the
conjunctiva: the eye muscles pass through slits in the capsule, which sends at

these points sheaths to surround the muscles; these sheaths blend witlt the

aponeurosis of the muscles. Internal to the Inner Rectus, Tenon’s Capsule forms
a triangular cushion and thus blends with the fascia of Horner’s Muscle, the
lachrymal sac and the puncta lacrimalia
At that point it is only indirectly — through the internal tarsal ligament
— attached to the wall of the orbit. At the outer angle of the eye the Capsule
is in relation with the walls of the recess which lodges the lower portion of the
Lachrymal Gland and with the external tarsal ligament by which means it becomes
attached to the bone.
 Lower Lacrymal Opening Superior Lacrymal Canal

ar Vein (of Facial)

al Palpebral Ligament
Duct
mal Canals
Meibomian Glands
er ’s Muscle

External Palpebral ior Ethmoidal Cells

Ligament
enon’s Capsule
Lacrymal Gland
'iatus Semilunaris
External Rectus Muscle iternal Rectus Muscle
Inferior Oblique Muscle
Branch of Temporo-facial
Nerve
Lacrymal Artery Optic Nerve
Middle Turbinated Bone
3rd Nerve
Periorbita (Periosteum)
Inferior Rectus Muscle
Middle Ethmoidal Cells
Temporal Muscle
Superior Turbinated Bone
Waldryrr’s “Meningo-
orbital Foramen” Posterior Ethmoidal Cells

6th Nerve Uppermost Turbinated Bone

Septum between
3rd Nerve Sphenoidal Sinuses
Superior Ophthalmic Vein
Superior Maxillary Nerve
Vidian Nerve

Middle Meningeal Artery

Sphenoidal Sinus

Gasserian Ganglion Cavernous Sinus

Inferior Maxillary Nerve Internal Carotid Artery

Motor Root of 5th Nerve

Superior Petrosal Artery

Basilar Plexus

Superior Petrosal Sinus Dura Mater

Abducens Nerve

Fig. 42. Orbit and surrounding Structures — Horizontal Section.

% Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Superior Ol- Superior Car- Middle Tur-
trontal Oblique factory Turbinat- tilage of binated
Frontal Bone Nerve Muscle Bulb ed Bone Septum Bone Optic Nerve Ethmoidal Bulla
Lacrymal G’

External Rectus
Muscle Temporal Muscle

Inferior Oblique
Tenon’s Capsule
Muscle

Inferior Rectus
Muscle

Inferior Division
of 3rd Nerve

Zygoma

Infra-orbital Nerve

Masseter Muscle

Antrum
\
\
Buccinator M Vomer Maxilla Inferior Uncinate Process
Molar Tooth Turbinated Bone

Fig. 43. Orbital and Nasal Cavities in a Child. Frontal Section.

Nat. Size.

Superior Rectus Muscle Tenon’s Capsule

Levator Palpebrae Muscle

Frontal Nerve

Periorbita
Nasal Nerve

Inferior Rectus Muscle Orbicularis Oculi

Muscle
Ophthalmic Artery
Internal Carotid Artery
X Orbital Septum
Superior reflec-
tion of Con-
Dorsum Sellae junctiva
Ciliary Body
Cavernous Sinus
Crystalline Lens

Inferior Oph- Upper Eyelid

thalmic Vein (Tarsus)
Eyelashes
Sphenoidal Cells
Lower Eyelid
Internal Maxil-
lary Artery Inferior reflection
of Conjunctiva
Spheno-Palatine
Ganglion Tenon’s Capsule
Spheuo-occipital
Synchondrosis Inferior Oblique
Basal Fibro- Muscle
cartilage
Descending Pa-
Infra-orbital
latine Artery
Nerve
Pharyngeal
Tonsil Facial Vein

2nd Temporary
Molar Tooth

Fig 44. Orbital Cavity and surrounding Structures in the Child. Vertical Section through Axis
of Optic Nerve.
3
/2 Nat. Size.

Rebman Limited, London. Rebman Company, New York.

Fig. 43. Orbital and Nasal Cavities in a Child. Frontal Section.

Portion of a frozen section through the head of a girl, i 1f years old.

A comparison with Fig. 1 shews, how different the accessory cavities of

the Nose and Upper Jaw are in the child when compared with those in the adult.
The Frontal Sinuses are formed at the end by ethmoidal cells
of the first year
growing into the diploe of They attain the size of a pea at
the Frontal Bone.
the 6th or 7th year; they are fully developed when the nose and frontal bone
cease growing — about the 20th year —
The Antrum of FflGHMORE is virtually
.

present before the middle of Intra-uterine life; in the newborn it appears as a

bulging of the middle nasal meatus the upper jaw being almost completely filled
with developing teeth. With the beginning of the 2nd dentition, it increases rapidly
in size. The Infraorbital Nerve is still external to the Antrum in our figure. The
Outer Rectus Muscles of the Eye were so contracted on both sides, in our body,
segment of the eyeball was markedly directed inwards:
that the posterior this ex-

plains why the Optic Nerve has been divided by this section.

Fig. 44. Orbital Cavity and surrounding Structures in the Child.

Vertical Section through Axis of Optic Nerve.

From a frozen section through the head of a child, i 1j2 years old. Tenon’s
Capside, Periosteum, and Orbital Septum, blue.

This figure shews that the upper eyelid covers a greater portion of the
cornea than the lower. The rima palpebrarum therefore lies, when the eyes are
closed, below the middle of the cornea.
The Orbital Septum
(cf. figure) is a plate of connective-tissue which runs

from the margin of the orbit, downwards; behind the Orbicularis Palpebrarum, in
the upper eyelid, it blends with the anterior slip of the Levator Palpebrae Superioris
Muscle and is separated from the tarsal plate by loose connective tissue. In the
lower lid, it enters the subtarsal connective tissue. It is a structure of no parti-
cular value it is merely the Aponeurosis of the Orbicularis palpebrarum Muscle.
;

This figure also shews the termination of Tenon’s Capsule at the Con-
junctiva. It splits into 2 layers, and blends with the Tunica Propria of the Con-
junctiva lining the eyeball and of the palpebral conjunctiva.
Very complicated is the arrangement of Tenon’s Capsule, where it is
crossed by the Inferior Oblique. From the under surface of the capsular portion
of the fascia of the Inferior Rectus a lamina —
“the Accessory Fascia” runs —
forwards under the Inferior Oblique, blends with its sheath, and terminates in the
subtarsal connective tissue of the lower eyelid, where the capsule proper also ends.
Above the Pharyngeal Tonsil lies the basilar fibrocartilage, above this
again lies the Spheno-Occipital Synchondrosis which may be injured in the too-
energetic scraping of adenoids.
Fig. 45. Frontal Section through Posterior Part of Nasal Cavity.

Fig. 46. Frontal Section through Sphenoidal Sinuses and Nasal Cavity.

A section from a skull was hardened, together with its soft parts, in formalin,

and decalcified before further division into frontal sections. The section shewn
3
in Fig. 46 passed about / 10 th inch behind Fig. 45.

In Fig. 45, the posterior part of the Antrum of HIGHMORE has been
cut on both sides; the 3 turbinated bones are well shewn. The great variations
met with in the sinuses accessory to the nasal cavity, are well shewn by the fact,

that, on the left, the most Posterior Ethmoidal Cell has been cut by the section,
whilst, on the right, the Ethmoidal Cells did not extend so far back. The posterior

part of the orbit has also been divided by this section. The numerous Vessels
and Nerves which lie close together in the Cavernous Sinus, diverge and divide
into groups; the origin of the Ocular Muscles near them, are shewn in cross-

section. The Optic Nerve which has left the skull-cavity, in company with the
Ophthalmic Artery through the Optic Foramen, lies, enclosed by Dura Mater, to

the inner side of these structures.

In Fig. 46 the Sphenoidal Sinuses (their openings into the nose are

shewn in Fig. 45) are laid open. They are separated from each other by a
median septum and occupy the body of the Sphenoid Bone. They often extend

as far (cf. Fig. 47) as the Sella in which lies the Pituitary Body; in fact, they may
reach the Spheno-Occipital Synchondrosis. They form the most posterior part of

the inner wall of the Orbit (cf. Fig. 42) and may in some cases extend into the
Greater Wings of the Sphenoid Bone (cf. Fig. 16 Lateral Recess of the Sphenoidal

Sinus). In chronic inflammation of the nose, these may become the seat of
suppuration, and have to be opened, because their natural narrow opening into
the nose affords insufficient drainage.
In most cases, it will be possible to open them from the Nasal Cavity;
they are also accessible from in front, after having well exposed the Ethmoidal
Cells from the Orbit (cf. Fig. 42).

The Optic Nerve is cut as it enters the Optic Foramen. The Nerves from
the Cavernous Sinus lie close to each other in the Sphenoidal Fissure; below
them at some distance, is the 2nd division of the Vth Cranial Nerve.
 Oculomotor
Foramen for 5th Nerve Foramen Optic Nerve Posterior Ethmoidal Cells

Middle Cerebral Vein IV. Nerve (Trochlear)

(V, 1) Lacrymal Nerve

Ophthalmic Artery (V, 1) Frontal Nerve

III. Nerve (Oculomotor)
Superior Division
(V, 1) Nasal Nerve
Sphenoidal Sinus
VI. Nerve (Abducens)
III. Nerve (Oculomotor)
Inferior Division

Inferior Maxillary Nerve

Antrum

Fig. 45. Frontal Section through Posterior Part of Nasal Cavity.

Nat. Size.

Optic Chiasma

IV. Nerve (Trochlear)

(V, 1) Frontal Nerve
Superior Division of 3rd Nerve
III. Nerve (Oculomotor)
’V, 1)Nasal Nerve
VI. Nerve (Abducens)
(V, 2) Superior Maxillary Nerve

Vidian Canal (Vidian Nerve)

Fig. 46. Frontal Section through Sphenoidal Sinus and Nasal Cavity.
Nat. Size.

Rebman Limited, London. Rebmau Company, New York.

 Pituitary Body Anterior Intercavernous Sinus

III. Nerve (Oculomotor)

IV. Nerve (Trochlear) Internal Carotid Artery

Mucous Membrane
Ophthalmic Nerve (V, i) (oblique section of)
VI. Nerve (Abducens) Middle Cerebral Vein
Superior Maxillary
Nerve (V, 2)
Sphenoidal Sinus

Vidian Canal and Nerve

Fig. 47. Frontal Section through Anterior Portion of Cavernous Sinus.

Nat. Size.

Stalk of Pituitary Body

III. Nerve (Oculomotor)

IV. Nerve (Trochlear)
Pharyngeal Tonsil
VI. Nerve (Abducens)

Ophthalmic Nerve
Cartilage of Eustachian
Tube )
Superior Maxillary Nerve

Mesial Cartilaginous
Swelling

Fig. 48. Frontal Section through the Posterior Part of the Cavernous Sinus.

Nat. Size.

Rebman Limited, London. Rebman Company, New York.

Fig. 47. Frontal Section through Anterior Portion of Cavernous Sinus.

Fig. 48. Frontal Section through Posterior Part of Cavernous Sinus.

Sections of the same series as those shewn in Fig. 45 and 46. Section 47 pas-
sed 04 inch behind section 46, and 48 passed 04 inch behind 47.

On either side of the Sella Turcica is the Cavernous Sinus the most
complicated of all the sinuses formed by the Dura Mater. It contains the Inter-
nal Carotid Artery, and 6th Cranial Nerves, and is in close relation
the 3rd, 4th
with the ist division of the 5th Nerve. The Dura Mater is at some distance
from the bone, and thus forms with it a space which contains the structures
mentioned amid numerous veins. These veins are partly plexiform in character.
This sinus is, therefore, unlike the others, not a large venous channel, but a mass
of freely anostomosing veins. Both cavernous sinuses are joined to one another
by two transverse veins which pass respectively in front of and behind the Pituitary
Body. Thus a venous ring*, the Circular Sinus (or Sinus of Ridley) is formed.
Primär}^ thrombosis of the Cavernous Sinus is rare; thrombosis usually
occurs secondary to the Lateral Sinus with which it communicates through the
Superior Petrosal Sinus, or by the spreading of a thrombus along the
Ophthalmic Vein. Empyaema of the Sphenoidal Sinus may also give rise to this
thrombosis, as the intervening bone is very thin; this process is absolutely
analagous with the thrombosis of the Lateral Sinus due to pus in the Mastoid
Process. The anatomical relations explain why thrombosis of the Cavernous
Sinus may produce Neuralgia of the first division of 5th C. N., Paralysis of 3rd,
4th and 6th Nerves, and why congestion or thrombosis of the Ophthalmic Vein
can be followed by Oedema of the Eyelids Retro-bulbar Oedema and Ex-
,

ophthalmos.
Surgical treatment for thrombosis of the Cavernous Sinus has hitherto
only once been attempted with success. The diseased sinus was reached by
removing the petrous portion of the temporal bone, attacking* it from the ear.
It can also be got at by the channel made for the removal of the Gasserian

Ganglion.
Should the Internal Carotid Artery be injured where it lies in the Caver-
nous Sinus, with a sharp instrument entering the Orbit, or by a piece of bone
(fracture), or through a shot, or should the vessel burst spontaneously (calcified

an abnormal communication may be formed between the

arteries in old people),
arteryand the sinus (Aneurysm by Anastomosis), the consequence is a pulsating
Exophthalmos which is a rather curious condition.
A glance at the figures shews that dangerous haemorrhage may follow
the tearing of the ist division of the 5th C. N. in the removal of the GASSERIAN
Ganglion. Externally to this nerve lies a venous space, which was unequally
developed on the two sides in our specimen.
 1 j > j |

ü
G G
73 73 73
43 4 X! be 43 t3 43
J 2
te
s O j)
C G G •'" in'"(d

^a 43 4G
CU
-si
% £ ^
H
,S CU
O cd cd
"t»-. ^ "• "cd C3 G c .2„
o‘ P£ d .2 G 73
^ Co
oä
k o G ® -
c/5
O g
43
Jh
C P 7)'

•2 S Tä
o ö
0) ^ U 4) cö
4-j
~ P 43 2 'd
G
.22 cS 53
>
c c aj
gj

2 ^ U.
H 43 -S
^-i
cd cd
7.
43 4-> 43
O ^ 43 43 <D
4>
G bc d 43 <1 ^
^•S Ö 43
&
!« ,

^ ^ O
% £
B43 £ S £
H § § B o
c ’C ^ 0)
P -2 4—» . |
_r^
<0
£ £ 43 4) <D U 4— 1

£>
•2 js
u
'S
^ ffi
o
O
C/}

4
<4-1

B
M
bß
p
43
ö 43 43
cd

3
•x, <3
CG_o -

^ ^
>
43
lj o C o ^ 44 G G>
« ^ 0 c/) CG
^ CU
-w
_
.

2 2
XS O
co

Si o d3 £
s "
73
43 43
P « P
§ fU rO -Z3 2 G 1 s a E GoO d
U
Co
Ul
ö H c D
a> 43 S 3 3
jo >3 cö
8 8
cd
1/2
^
>> So 42 O § bß « 'G cd 43
cd
g
>
>2 § ü 2 t

cd
P 43 _, "d G 43
^ o br >
~
§ s
t; T3 <U 43 r 3
i
cö
Co
<V
.
>% >-
-t)
Vh
O 73 cd ^ G cd

§ -O G
S co 8 ^2
cu 43 43
43
E 5
cd
c’o
cd
•H o d G cu

G c
2 - 43 43
o tä § (ü "cö .5 g
4_j CJ
cd ’g
cm 2 'cs G rS
13
U CS CG »o ^ O CO C/2 cu

4»
^
aj
H-H
u Co p 1
2 73
4)
u 43
73 d
52 T3
cd
o > c c
% &
* *
4—

Ö o bß 4)
G <4—1
J2J

O
cd

,5 rt •° g .2 O .a 'S _ 73
C cd
cn _1 5 u
•S cs 2 CS .2 g G 03
43 43
42 C Gi u
d Gl
I s
4_j Cvj O cd H 4->
G
43
d O
_ >
tß 0- 43
S<
<3, 8 ?4 bß
3 G 43 43 43
^
g
4 43
43
3d cd d p3
g 0 ) <«
SO
cs
2 3
h-H
c ’S
'O'
ro o ^ 'd
p G 41
"5 4-j
O u o ^
0 aj o
t; t> 4> 43 — G
2 P 43
>
<u in
43
3
G bß
-i

cd bß 73
. i

O cd
E J§
4J
(/)

rt
'aj
Ü -G
0
c/3
p c
03 73
c/5
U 42 d T3 .2 8 .2 ffi
£ o <-M
o «-M ’> "cb

£
öS
2
T3
d
43
G G
d d
4)
k ,
G O Pi
0)
°3 lj cd cd Gl
H—
C/5 fll

« Q 4j <>

g 35
O o
cu C/5 c/5
p
aj
4)
4)
"

'S
G
<S (U C/5 43 G cd g ^
cd
“
2! 43 <U 1-.
.2^ o ’

cu d 43 £3 d ^
-s; o CU
rO >s ei O c CU Cu cd
a cd -G u ^5 C/5
3 pq
4-5
O cd
ffl E G 'V
<
cd cd ei >
^
•vi ü+jjjT
tß c»
cd 1
8 o So
43 18 U O
o S3
« u 0)
c/3
CU B B E p' G «* 8 4)
G ^O
aj
G G G Gf P "cd a
tf)
G 50 43 ~3
4—4 r—
> 5
aj
u
P
cd
<5 X °ß S Sd
<^
E
o ’ä! d I 2 CU d S
:

43 43
O
T, 5
73
tu
03
OS'
co
,
'Hi
CS
S
43
CS d
d 4343
BC — 43 43 43
c gS d
bß d
G
G
^
u
H
> Cd G
'^3 ,
G c/5 <D {§
^O XE G P O 4— > '
i

<U I XS
cs

Qh -2 ^ So G d G ^ Id
cd c
-G>

E d c d bß
43
c/3 aj
C
>1 Ui U S oj
G C/5 U
Ö 43
CJ
42 o Bo ° 73
C O G3 .S •P 0
^
)
43
ü •
2 P ’S S P 4)
o c J3 4->

cd
S ^-h
43
43
% E 43 t> * i!
cd o-c cd
O
C C 43
d H
1
h-H
D
P -2
S>
s*
o»
3
g » % 4)'
P s’
4)
C d -32
^ 43
^ t .2 3 hD
” 43 43
g
t .5 s .

G 43
cd
r^> G
3

G G r G- 43 Ph h o-o
73 cd
^
cd o d % C 43 P S
d) H
G G
2 G u3
cd
X.
o ^
43
Do G
•SS
& LO p»
X > Go •r-l cd 0
ö Do v8 f "0 Ch
„d P
13
43 o-o
"cd

X
g
"CS
2 S •2 £
r* B •

-o
G 43
43
cd 43
G CU
£
<U
bjo <^>
p»
o*
H*
^ 52 Pu
d 3-. 5 bß
:

43 TSi ^ 8
G > §
d Cd So 43
d G G P cu
<4, +- £ B"^3 G
d <d 33
43
cd _o B u h d 43 O
G
-H
cd S 8
p ^ 1 ‘g
43
ä
cu d !_,
13
G
d
_
c~

aj
»-o ^ I K CU Do
'S
cd bß G •G >o (U c/5

O' cs
8 -G
~s PP
PP
’S 8
^
oj ^ P Pi
aj E
c^
.9 £ 1^ ^o ^ ^ Tb
tJ-
2
5 O
^ § 2 d O
T3
PCU
S
°
S 43
43 43
aj
<4-1
o
U 'r
bß
cj
ef) ^
43
.* O
cd
bjo 43 r- 1
Cd H aj
O O 43
D 5
_G

—
u s •g -ö X O 8 s o 0
c^" Tb aj

p ."
cd
Cd
-2 G S3
d
CU c^
4-J
c/5

_ £ Oß 43 73
c/3

•2
d id iS iß u C ^ .9 o 9
B D
CU G ^O
so
bjo
^ P Hg
Ui C cu _ .33 43
Pi
Pi
aj 2 O
P.
»70 < 2 CU cd 43 -G o a.
4->
£
X
<13
— G
de cd
CS
Ä,
'"^O

« ^ O 34 G p C
10
.X
G-
CU 15 <4-1 <u
>
43
^ H
;

-O «+o 73 0
d
43 J2
G
1

Xl
13

p Vf
Oß
Cd
43 43
d
O 3
G | P
| 1 ? G G
s O X! Oß 4Ü
Plj
P E
O
4-0
P d
_.
d 43 d
G3 G
•ro
st. ^ «o Oß
ei;

^ t 43 P
S3" pp* ^ 43
73
B P .£
5 P c .£ G 4)3 G
E So
6 43
43 43
X!
xj
4) 43 S B d O <u
4—
,
o>
43 _73 o-> .
43
X 5 13 d ^ G
1

s o o 43 — 43 -g
"g '>
H Oß 73
73
.2
g
"cß
O ö O >
O 43 'S
3cd o D
bß
43
43
CU p
O HP
bß G
oC
X CU 73
43
E -D
J-3
aj p
O +o C 43 G
Cd ^ -2 G G G 73 X 3
43 73
>
> 'S *C/5
 York.

New

Company,

Rebman

oT
P
cö

c3
Ph
Ph
<1

CÖ

>»
pH
a
hJ 2^
c3

<D
. ^ a3
N
CO
W o3
O c3

's 'S S?
<u London.

'S p

Ph
o> Limited,

p
Ö

Rebman

C5
r±l

Muscle bß
£
Frontalis
 Rebman

Limited,

London.

Rebman

Company,

New

"iork.
 . o 1 . . 1

cr 5“ 3
O % 5
O Oq
o P 5’ SJ o
^ 70 5 H H
f rr
CO CD 3 ^ 2 3
££ >1 3 CD 3 _
33
h3 3 P
a a
H-h 3“ 3
eg. -
3"
O P 3* P K " o CD CD a CD 3
s
CL Co' *“*
H a 3 3 3 to 3i
o o P fu '» & & P 3 3 3- | g; 3 a
Z 3-'
co
CL - 2
CL cr 3 » » ;
° 33 CD O CD
3 3 3
< r-t
o' ^ SL ?L
Co 3 - p p Rc t
*-t

3 o
^ 3- < cr
3“ 3
p O 33 »1
3 V 3 1

CL
o£CD v; 5 S
K' 3*
oq'
3 »
o ^
<3 O °
r p
o _ 33
CD ^ 3 3 l
CD* 3
^
CD

2, CO
O'

jj » O
c/> CD CD ,

CO
O ^ *
in
a q‘ a^
I P °
rt-
3 Cr Co
CD
3 a
§ _ o C/3 O'
3 o i-j
3 P
CD

CD
3“
_ o 5 P
rt- £ CD y rt-

o' *
o
% S i-l § ^ v,
S' °°
X O O CD in
</) cd a to
^ a‘ 3 fT
<Si .
a g 3 - CD cro. CO cci V;
O oq o' o CD
to 7
t/d
J
cr a r*
g n- a P 3 oq cr O 3
i.s-8
tr
a
P PCL fcS
<3
CD
CL
cr
CD
O rt*
4 a
CD Co

§«Ö 2
3
a
Oo

o O
v Co
C/3
p' CD CO p cr
& CD p* CP
.

2 ® O P £ 5- 3 a £
o 3S O CD
EB
w
o
r 2
3 3 ^ CD 3
CD
V rr co
a
r, < oq 4
3
O CL cd O P. 3' <^5
Co Si
cr
C/J
CD CL a o °B. ,0* Co
§*| a cr
p -8 I— p
CO a CD
O ^ a g CD
p* CO 3!
CD O
a
CD
— o sr § Co
co 2 o' 35
<3
CD
3 rt-4 a 3 o Co
C^i
s
P P a
3“
"
3 O P CD
^ o P cr
o a
< CD g
o
3
Co
«2
P 3 a
Ci -

7) a cd S 2, S °
% 5‘
CD 5'
3 ^ cr 3 3- Ä S: a
" CD
oq O >73 CD Q
-

M-J
o S'
3 cr
c/3
c
<3
CD
a-
3* co CIO o 3 rr W
a ro OK) ViOa er 33cd CL cr
cl 3 to
Xfi

3 a O
oq r-s
)
CD
^ 1
3 3 % | Co
•-t -

3^
s\ ^
CD 33 ’
oq a 3
o .S 3
CD
p a cd cr.
ö 3 pj S' CL cr
4
to CO
-

id2 CD
^
h*«
•t 3 OQ 3 5‘ o 5 3 cr 3 eg
S: © ffq
aSLcp CD
P CL
a 3
3
O
fu
3 ^ H CD. 3 .
ri
CD
5 JS
in

3 5T
O
CL O cd cr o
3 g
Si 7q c
H
n
3* o
•
CD
3 ° - p* p
£ g o 3 £ CO
3! 3 3
o
3 cr.
t i_, a 3
a
o V o' Si o' o'
.
Sr-
£ b:
“
§
Cr o
rr cr C3
cr 3 o 3;
«5 aj.
co
a CD
CD CL co a to' S' o
s 2 w s-
a a ^ sa 3 n
T3
P |3 B < Cr
3
G
2 “3
P o
a CL
CL W
cr
“• CD
3
CD
Oq
CD
5' 2
3
.
2 P
<J O
a>
•n
3
3
a h3 -
3»f. §
3“ ° « 2
>
O > H cr.
O p
hr)
3
P
CD P-
S* o CD
m »-s
c% ^
3 §; 3
rr> 3“ CD
g o 3 O O P 3* B
CD a p' 1 O D a a.
s. S' S* c 3- o
O p P* CL
CD
- <§; > . .

CD
S M-»
SL Sc.
S3
3 P "» _
•-S
P
o. 3
3 3t > 2
<*
^
5*
P 2 a
rt
P“
3
co'

o' rr
r*.
to
v
CD O
3 to
CD
CL
w 3
CL
c/)
p CD
C?
CD ^ Co
Co
CD
i-H 3 0 5^
<* o CD .

3 ^ 5 Ä. Si
3 O co p 3
I-+»
o’ CL p Oa
S
S“ s'
p
rr
5'
a-
O
S* 3“ P
rP
3t
O
3
O CÖ
^
CD
^
CD
m
rt-
(D 3 a hh
9 ^
rj^ ^Po 53
^
«>K
S
3
O*
3
m
&.
3 CD 3
L
Boa rr>
CD
2 3
Or 0
CD
rT
O
.
CD
3 c*

>o
Si

1
CD
CD
cr
CD
>— • p 3 O
o
p
a
a Pa B^^P 3
O S:
Co s o
«*.

? >05
cr cl a*
P o o
3“ 3" 3 ff 3 CD
Si
v cd a S
£ cr
W a- 3 3. CflV CD ^5
2 . oq CD
3 o g B“ p 3 O CD
CL a "h a o CD
g cr p
o Si
> a P CD
03 ^ 2
cr
3 CD CD CD
o-
o
CD ra.

CL 2 ä
oq a«s O ^ r-V
3“ ^
3 cr 3 CD

cr
CD " 2 3.
O Ja“ CO

CD O ^ g 3! 3
^
(70
3 a
rr !> o CD* ^ CD °s‘ CD

O cr h r P -f s,
O CD
3
oq
CD
(D >> 3 a v 3 B- o p O
^ ^ 3
3 cr Ca a 3 'a a 3* -a a. „3
CD
CD
o' ^ P “ o 3 CD
O p
g* CD
- ^ o Oq
37 o to a
c
% O CDV.
cr
p
P
P CD
*1 cr
CD
cr 3 w 3
-
5“ ^
'hta

to 3 —
< . CD
a P
h-f (D 3
3 aoq 01
H P ^5 a. 'Sa
CD
X
5'
CD
p
CL C>o_
cr
CD
3
O
W 1/1

o
O
3“
cr 3
- CD
O hi
“O
o
CO > p 22 Q
cr a;
5‘
H
cn‘

3
t

3 0 )
a a
3_ a
a CD «1 o
CD
CL
rt“
CD
“3
P
CD
3 OQ '

p
Ä a
H 2 q 3 P
ff
£
>-t
a o'
in O CD

li
 (

co
Co ^ "d Oj o o
jfi 0) b f)
•rn K. ’o a
d <D
cd aCD
a Ph U Ö Cj <£
O 03

J ^ Pa
v>
<3
O o ft
co
.,
03
> ft
c be
^ 1
<D
Pb
S s
o
03
ft ’> •a rd
CO co 53
53 ^ g
O
ft
a o
a
-d H ft ft 53 „ co a
,

(ft
-ft o O co
(/) d ft ’

•'S» K» Ü rn 3-i

O ft <1
O 53 ft 53 <3 oj
So ft ft &
CO
+-> a CO
5 o
cs
g ;a^>
I— 03 oj
.SP £ fe
I

co 0)
G co
'

O
d CO 'S § a
CO
CO S £ o ft
O
£
ft C/) 53 ? ft ft
a ft
oj
Oh
o 21
ft 2 53
w aj

so ft ft ft 'ft b*^ co

<0 »3
"ft a
> <D
a ^
ft
H a
>, CO co 8
43
O CD
ft VP N ft o <1 ft ft be a
& > CD
^
ft a
'~m -O Ph O >, & ft
a a
a S ., <1 bo a ^
mT ft ft <D
5s ° 2 'S ° “
m G f-P
+->
o
CO
ft
^
° ft be -2 CO ft
a a
•>»
a ft ’ft ft
s <» S co a 2 a ftj— boS^
a <.u

> O O
<a ft; ft a co J-H
ft
K co
a w o) a H <D ^
CO a
o a be
r-»
CJ • a g "o a
co
C o5 ft
"ft be a ft a CD
a a a ft S & a O c/5

^ a
to
ft be a
a ft
ft a
a ‘C a 2
a
S a
<4X
a a
Q <W
~C>
03 a
d5
a ft
O ft
a • a S ft ^
a ^
ft a
ft
ft
a & _o
ft a a 1/2
ft t> .d 3
a CD a ry) o
V °5
W 3a -ö
.2
co
a
ft t/j
a 03
ft a S a o ft
3 «
'

a
ft 03 a 3 a
^ be

53 <0
<3
ft P2
ft
O a a a
ft
'
Ö
oi
1
M-H
*
CO
ft
S a a 'S | a
ft ^ CJ
ft ft ft
^
$
° ft
ft Cm a
bjo
<ü 53 -2 <->
6 o a ft
a
ft
b g be
a £ a
co co CO
U 4-i a a a
t8 '°P
P ft
f-H
a a
ft a
2!
P2 ’ft <n £ d
^ ä y
>
o c
od a
ft a aCO
<1 ft
a
^ a d
o <D ^
CJ co
tß •ft, o *— ! 2 V a SH a a
53 Q Ph O Jr* CJ
a o ft
ft
53 •»
fc. <3 S £ (f) yp £ oS ft CJ
a an o' ft
hH S CO

.53
53 ft.
Ü ft a a a d an
ft
o ~si
So o
ft
c
>-, ft .2 ft ft be
d
c/3 o a a .2 a Jh

O ft «3 0$ a
42
1

a S SP-S g c
03 o ft ^ CD ft
CD

ft ^ ft
a - a ft 1o & ft ft '<_> a
C
^ Fm
6 a G d o
o5
C
N a ft2 > o ^ pH .2
^
ft O '-*—!

o n
ft
<«
a a a ^ Hft
'* H CO 03
a cj a u >
- -ft ^ a c be o
CD
co
Co
0)
ft
bfl co
O a CJ a ft

ft
If
O ft
^ ^a
f i_i b
Vh
a
- 1
03
03
ft
^ ftO
, 03 co Od ft
ft
ft ft
|3 ft >-, be
<» ft a & §
ft ft
ft 'S
$
a ^ ft
CO
^ o
a
V-4
H .ft
M 2 a co
a g ft a ft
^ to a
a
£
ft ^
J-H (1)

ft 'S
<3 a CO >~, aj

a u
"53 o5 * ?-H CD
a 2 co CD0
.

ft fP
s <D
a ft a Vh
a a o O
53 JP co G
a ” a a c , ft
ft
a e ft > a > d +-> ‘53 c
a be a
co 03 CO
CO
CO Co
a a
.rJ
MM G
(— a
^
d
^ 2 G M O
« ft ft >'l
co 53
53 ’-—
to a +j 1 .2 aj
0 £ >3 a ft 2 ft a ft IP co
a a S ft Q,
O c 2ß a a >,
H PT
CO
CD
53
^ a (0 £P § P 0 )
G
CJ CJ
’S be a P > a £ O
a
^.co G^aaGaD-
03 ^
& CO
O
45 ft -a
(1) CD
g ’a _
O u
Ph
U ^
r-< CO 03
^ .-s
-ft
d o s :s
P
P ^
_G
ft a •£ a o ^ft CD
5 s & a <3 ft £
Ph j v.
m ft P ;

co
O
^ (D a ft a a P
>3 ^ H a a
CD
a ft
Cv3 Ph
a
.

ft
a 03
C a
ft a f-H ft
CJ >3 o
o co co P ft mm a be
o a a a '

S
H
d"
<D
aj 4-5

h P-
CO 03 .5 a
a a ft a a g a
ft
ft
^ aj ^
h a a a 03
— a
a
P
b ft
ft H a g g
G 03 a > a ft
< aa T3
ft
g ft a a a
s ft
$ ^ a be .2 ft a a
o o
'6 I
'S
pies g a g
a co ft
ft & £ a ft
 Sterno-Cleido-Mastoid Muscle

Axis Vertebra (II C)

Vertebral Vagus Nerve

Internal Jugular Vein

Parotid Gland
Spinal Accessory Nerve

Temporal Vein Hypoglossal Nerve

Internal Carotid Artery Glossopharyngeal Nerve

External Carotid Artery Digastric Muscle

Pharyngeal Plexus
of Veins Internal Pterygoid
Muscle
Masseter Muscle Styloglossus Muscle

Submaxillary Gland

ylohyoid Muscle
Inferior Dental

Lingual Nerve

Cavity of Mouth

Sublingual Gland

Submaxillary Duct Antrum Oris

Fig. 53. Horizontal Section through the Head at the level of the Axis.
Seen from below. — 2
/s
Nat. Size.

Rebman Limited, London. Rebman Company, New York.

Fig. 53. Horizontal Section through the Head at the level of the Axis.

One of a series of frozen sections through the head.

The Vestibule of the Mouth and the Buccal Cavity have only been cut at their
lowest points, where the tongue is adherent to the floor of the mouth. Of the 3 salivary
glands (Sublingual, Submaxillary and Parotid) the last is of interest because it extends far
inwards, and, on the left side of the figure, even forwards under cover of the lower jaw.

The tip of the Uvula was cut by this section.

The Tonsil is divided below its middle; it lies in a capsule which is closely
connected with the muscles of the Pharynx. Very important are the parts around the
tonsil, in deciding the question of the source of furious haemorrhage in some cases of
tonsillotomy? We mentioned that the Tonsillar Branch of the Ascending Palatine Artery
is far too small to cause serious haemorrhage. Of the large vessels, the Internal Carotid

which is said to have been wounded during the operation, lies 3

/5
inch away from the
tonsil. It could only be injured when a particularly clumsy surgeon cuts very deeply.
This statement also holds good for the External Carotid. It is the Facial Artery which
lies very near the tonsil and may be injured (Merkel). This vessel arises from the Ex-
ternal Carotid at the level of the lower end of the tonsil, passes between the muscles
coming from the Styloid Process, describes an S-shaped curve and runs along the circum-
ference of the tonsil. Serious haemorrhage may also be due to injury of the Pharyngeal

Venous Plexus.
Externally and behind the Tonsil the following structures are in close relation:
Internal Carotid Artery, Internal Jugular Vein, 9th, 10th, nth, Cranial Nerves and Hypo-
glossal Nerve, all lying in one sheath which is attached above to the fibro-cartilage of the
posterior lacerated foramen.
The Vertebral Artery having arisen from theVSubciavian runs upwards, passing
through the foramen in the transverse processes of the upper 6 Cervical Vertebrae. Then
curving horizontally backwards — this part of its course is shewn on the left side of our
figure — it comes to lie under the Dura Mater which it pierces. (Cf. Fig. 15.) It now
lies in the cranial cavity on the side of the bulb, and after running inwards it joins with
its fellow to form the Basilar Artery.

General Remarks on the Jugular Veins.

A large share of the venous blood is carried from the Head and the Neck to

the Heart by Veins which have a separate course and do not correspond exactly to any
artery. These veins are termed Jugular Veins. To the Internal Carotid corresponds
more or less the Internal Jugular; to the External Carotid, the External Jugular, formed
by the union of Temporal and Facial Veins. The Facial Vein may also be continued
downwards as the Anterior Jugular Vein. There may further be a Posterior Jugular Vein
(cf. Fig. 67) at the anterior border of the Trapezius Muscle.
The relation of these veins to the Sterno-Cleido-Mastoid is as follows: the Ex-
ternal Jugular crosses the outer surface of the muscle which, with its inner surface, covers
the Internal. Along the Anterior border runs the Anterior Jugulai'. The Posterior Jugular
is the least constant of these vessels.
All these veins end under cover of the Sternomastoid, where the large Lymphatic
Channels open into the Venous System. The Anterior Jugular Veins communicate just

above the clavicle by a transverse anastomotic branch.

 Fig. 54. Position of Spinal Cord and Spinal Nerves in the Spinal
Canal.

The Skull and the Spinal Canal of a female child, a few months old, have
been opened from behind ; the Dura Mater slit open; and the ribs ivith the

transverse processes of the vertebrae dissected out.

The spinal cord, is, as a whole, very well protected. Anteriorly, it lies

at a great distance from the surface of the body; behind, a very thick mass
of muscles fills the space between the vertebrae and the prominent spinous pro-
cesses (cf. the transverse section through neck, thorax and abdomen). The spinal

canal, in which the cord lies, is closed completely in front by the bodies of the

Vertebrae and the Intervertebral Discs; behind there is a space between the neural
arches through which a knife, dagger or other sharp instrument (e. g. for Lumbar
Puncture) may enter. These interlaminar spaces are widest in the cervical region
where the neural arches are furthest apart ;
this explains why the spinal cord is

more frequently injured by sharp weapons in this region than in any other part.
In the upper dorsal region, the neural arches overlap each other and thus almost
close the spinal canal posteriori}". In the lumbar region the arches are very broad
and thus afford protection to the cord.

The close relation of the cord to the column accounts for the frequent
injury to the Cord in fractures of the Spinal Column. These fractures are usually
indirect, and occur chiefly where a comparatively movable portion joins a more
fixed portion; i. e. at the 5th and 6th Cervical and at the 12th Dorsal and ist

Lumbar Vertebrae.
The Dura Mater does not lie on the wall of the Spinal canal; a cushion,
formed by fat, and a large venous plexus lie between the bone and the meninges.
Between the Dura Mater and the Cord lies the Arachnoid Sac filled with cerebro-
spinal fluid : these arrangements allow the cord to follow the movements of the
Column, without friction against the bone.

As the upper limit of the spinal cord, the upper border of the posterior
arch of the Atlas, is usually taken, i. e. the point where the first Cervical Nerve
emerges. The cord shews two fusiform enlargements in the regions where the
nerves to the extremities leave it. The direction of these enlargements is more
in the transverse than in the antero-posterior diameter. The upper or Cervical

enlargement is most marked between the 5th and 6th Cervical Vertebrae, the lower
or Lumbar is most marked at the 11th Dorsal Vertebra. The cord then becomes
more slender, ending in the Conus Terminalis which lies at the level of the ist

or 2nd Lumbar Vertebra. A filiform continuation of the Conus Terminalis, called

the Filum Terminale, runs vertically downwards to the periosteum of the Coccyx.

The 31 pairs of Spinal Nerves leave the Spinal Canal through the Sub-
vertebral Foramina, ensheathed in processes of Dura Mater. This explains why
 Fig. 54. Position of Spinal Cord in the Vertebral Canal.
Natural Size

Rebinan Limited, Lond( Rebman Company, New York

 (Continuation of the text of Fig. 54.)

in our figure, the nerves appear thicker outside than inside the dorsal sac. As
the spinal cord ends at the ist or 2nd Lumbar Vertebra, the course of the spinal
Nerves inside the canal becomes longer the lower their origin. Thus the first

Cervical Nerve runs horizontally outwards, the course of the next nerve is more
oblique etc; the lowest nerves run almost vertically downwards, parallel to the

Filum Terminale. They form with this last mentioned structure and the Conus
Terminalis, the so-called Cauda Equina. Injury below the second Lumbar Vertebra,
therefore, only involves the Cauda Equina, not the spinal cord.

The spinal nerves arise by 2 roots, anterior and posterior ;

these roots leave
the cord as root-fibres. As a rule, the posterior roots are thicker than the
anterior; an exception is, however, found in the ist Cervical Nerve — as shewn
in our figure — . Its posterior root-fibres are very slender; they may even
be absent.
On every posterior root is a spinal ganglion, which lies in the interverte-
bral foramen; the posterior and anterior roots join outside. Just above the ist
Cervical Nerve our figure shews the Vertebral Artery leaving the foramen in the

transverse process of the Atlas and running horizontally inwards. It then pierces
the Dura Mater and enters the cranial cavity. The Dura Mater does not extend
further down in the Spinal Canal than to the level of the 2nd Sacral Vertebra
in the adult, and to the 3rd Sacral Vertebra in the child (cf. figure). It ends in

a blind sac (cf. Fig. 55). These levels are of great importance, because injury or

operation above will necessarily open the dural sac and may be followed by
purulent Meningitis which in usually fatal. Below there is no danger of Meningitis.
This fact is taken advantage of in operations (Kraske’s) in which portions of
the Sacrum are removed, in order to expose pelvic organs. Of course, when
removing portions of this bone, temporarily or permanently, one has to consider
the important nerves which should not be damaged. The Coccygeal Nerve which
emerges between the ist and 2nd piece of the Coccyx forms with a branch of

the 5th Sacral Nerve the Coccygeal Plexus which innervates the Skin over the

Coccyx. The 4th and 5th Sacral Nerves enter into the formation of the Sacral
Plexus, the former supplying the Levator Ani and Coccygeus Muscles is more
important than the latter. Damage to the Sacral Plexus means damage to the

floor of the Pelvis. Twigs from it also go to the Bladder and Rectum. The
higher up one goes, the more important are the nerves for the innervation of
the pelvic muscles, pelvic organs, and lower limbs (Great Sciatic Nerve).
 Fig. 55. Lower End of Spinal Canal in the Adult.

A Figure combined afler a specimen from a man of 18, and several skeletons.
On the right, bones only, on the left, ligaments and nerves have been drawn
diagrammatically.

The anatomical relations make it possible to introduce a trocar or a hollow

needle from behind, between 2 neural arches, into the dorsal sac, thus enabling
one to increase the pressure of the cerebrospinal fluid in and to draw
the sac,
off some of the fluid for chemical and microscopical examination. This operation
lumbar puncture — has become of vast importance for diagnostic purposes
in recent years.
Not only does it yTeld information as to the condition of the fluid around
the spinal cord, but also as to the intra-ventricular pressure, the pathological
changes and the presence of bacteria in the cerebral fluid, because these fluids
communicate through the Foramen of MAGENDIE at the floor of the 4th Ventricle.
The lowest portion of the dural sac is selected for lumbar puncture,
because the needle cannot, at that point, injure the spinal cord; it meets the
Cauda Equina which gets pushed out of the way. The needle should be intro-
duced below the 3rd or 4th Lumbar Vertebra. The vertebra may be found by
counting the spinous processes downwards from the 7th Cervical Vertebra, or by
counting downwards from the attachment of the 12th rib.
-
far more simple A
method —
(cf. figure) —
consists in drawing a line connecting the highest points
of the Iliac Crests. This line crosses the middle of the 4th Lumbar Vertebra.
Slightly above it, therefore, is the spinous process of the 3rd. In children, the
needle may be introduced exactly in the middle line at the lower border of the
spinous process; in adults, it should be introduced 2/5 ths inch outside the middle
line, because the strong median ligaments offer considerable resistance.
If one follows the usual rule, introducing the needle at the level of the

lower border of the spinous process and then pushing it forwards, upwards, and
inwards, one may come on to bone, especially when the spinous process is short,
(this was the case in our specimen). It is infinitely better to introduce the needle

horizontally inwards.
In the figure, “Point for Lumbar Puncture’’ indicates the spot on the skin,
at which the needle should be introduced and then pushed inwards.
4
In children the needle has to enter about one inch, in adults i
/5 to
i
2 f inches.
This figure also shews the Dural Cul-de-sac at the 2nd Sacral Vertebra.
The importance of this level has been discussed in Fig. 54, Text.
 Thoracic Vertebra

Dural Sac

Puncture Point Mammillary Process of

4th Lumbar Vertebra

Fig. 55. Lower End of Spinal Canal in the Adult.

2
/s
Nat. Size.

Rebman Limited, London Rebman Company. New York,

 Rebman

Limited,

London.

i—< •

crq

Cn
Ci

Ö
So'
crq
H
- p
p
-5 3
aq
-
o
>-+i

co H
-$
P
s s
o
w
Cfl

<
CD
-$
1
1

U CD

<<3
GO
CD
O
o e£
O*
N P
tu O
hh
ft <rt-
3 P"
CD

CO
—< •
p
p*
o
o
HS Funiculus

Rebman p-

Cuneatus

Company,

(Burdach)

New

\ork.
 — , 3

H 3 reo a tr
o o' U 1
3 era
5*
p e o
|
^ ^p s «
ff
o £" « £ § £ 'S. o
i> <-f' 2 cr 3 EE S £ 1.1 I Pa 3eL*ü73
p £ v v; p
73
Eh g n ^ o 'E
2 H
EE cr £• o 8 n> p ET et' Cl p -• *~
a Cl. 3- 3 s o ^d 3’ s;
o d
el
to
< m —
CD p a.
0)
^ o ci
°
P J-*
p w 3
w
si
I S’ SL K
re
S' CD g •t r*
•—
hJ 03 3 O
^"d ~ ^ a
CD

??a
n
C? £2.
cl
- O
3 e
'*o
: o g
73 g
* cr? ^
er
CD
cr
cd
CD P
5-^ ff. o'
ee jr g o 3
o era
^

re S' -. CD 3 ?> ^ a 5 3
2 3 S P Pj a
Sy!» 3. CD Ch PO -o
p £ CD 73

o £
CD
0 3 3 CL
< 2. cr « 5 O
o 3
*

1 Cß Ö)
+> < S'
p o =r
Cl o o « § I
3
P CD
M '>

CD 10 era
£ P ^ rf
P g £. n H
^ I 3
O o d. rt
3- ? 'C c r
p: n>
g
^ CD
72 j. p ^ O
3
-h pa O ^ O 73
o
°
Ch o’
a* ^ 2 re
a
no
cr ro
cd

^s ^ o P rt- CD §f 3 2 O CD
cr - a EE'C
>-!

ö *ZL
P CD
.
CD
a O *

p g
<
,

a °
a
n> ^
p g 3 S' 3
S £ ^ §
P O -O-
P CD
n 2.’^
3
g . O o
o <
cT^ CD 5
P-
CD
P ^
< Er 3 P a 3
<D P PP CD
o o _ 3 n 3 o 3 O 3
0=3.3 o O P- a cr o
crq s ,
ci g o p P P P
.

P * re P p o
§ S §
•

3 a
3.
H .

3 3 p-
CD
"*
p sr Q
>-t
73

~ 3 “ 3- ä P «
3 73
rt- <““h M»
£o a Cf P 1
CT ~ O 3 o w rj o p
ci „ cr
CD
^ era 23 P o
Ofq
3 o' 0 S
0 St
P P
73 orq
.
<r§ a> - 3 3 O
— -
C 3 P
et cl
a>
3 3
— p ,
<i
<-f
re 0-0 3 O
Cf3 o'
§ a
^
CD C
CL
ft* cn

£ o 'o’0
3.^
3
i* 2 .
P a P h l=h
73
73 56.
'
£ 3 ci o 3 S- CD Cl
p-
3 73 3 3 ^
o' £ EE V! a
73
3 5- era S re -P 72 ^ 3
‘*i C.LcJ CD
P C S'
a 2O 3
cr -a 73
3 p_,
a ^ 3 0
o P
CD
o 3 3 — P 3“
72
3 P Pl
a
cr.
p‘ Jz
73 JM

3
cl
g-
cr
» P ^ a? re
LeJ
re
•
g? P
CT a
P 3 3
‘
3 p p
cr Diagram

EE CD 2 ? H P s°
P o
73

a ^
,

g O 1
<1 <T>
£ n>
.
CD
3
C/2
3 - era H era
a- P 72
S — 5
o i
o P
T) O
"< J
I

Qj a cr o p 3 2 3 O-.
C“
CD '-
CD B.I
N
no
o
o p P 0 p> 3 ° *

O
O CD
X3 >
.

3
S’ S
p a
3 73 of
S T3
*3 5 i
cr sr O
C/3
p £
^ 3 J" P
1
*

P P
73 no PD
3 2- P p 73 a
£ °
0 Cn £ o o -t
O
m->
3 §• O*a
P cd er CD
P O O’ P- CD 1 O P
H 3
1
™ 5’ p 3 O CD ^ O ° e- O o
(jq

3 2 3 cn
v> p- ? O o 3
o 3
-
P- 3 P 5* O Transverse

2 o.
q CD
CD 72 P H-h

EE o M Eg P P 3 ^ o oa a CL Ct P
Q
c o ^3
to Ch
3 p o P ro 'Tl
° 3 2 O . tT
^ et o
.

0
CD
5T cd
P cr p
o 2^ o 3 cr g CD
no
pp
W £ g-
? 3 Si3. H ^ p g
2
73
a r p* 3
S 3 ~
! o -S 01 3 3 el
re
3 p 3 cr 73
'*
p 3 o
a,
?> 5 p-
a no OL
H 3 ps o
CD
v; o
*
p E. f Efl
^ Section

re ^ P Q Cr a- S EE p a cr CL er
*-d

^ r-t-
9h| O O
3 S3
1—1 P
S' ».
£. ci
re
cr
>-k
3j CD
rt.
5* "< P
p
^
3 72’ g"
tT p
g*« a3 pa lt 73 CD
q "-O W P o O
cr. no 3
03 CO
o
? *3 o a 3 p
c;-
CL O ^ ^
2" ee
EE
ci
-1 o re m o
g 73 P H ,
p o era
^ of
cr r—
2 .
*3
no cr
p
£ o
-r §^ £ O EfO 3 re

kh -• o 3 BJ
£T
P o S J»
— 03 o o
I 3 O
p
T3 ’S a 73 3 £
C/3 3 re the
a 05
cr H £ 3
cn

rr p P ?£ 3
p
73
rl cr
2.
5' g* 73 3
§ 2 O o I
71
cr EL-d
. p 73
O p, ^ a ^
3 ”
p w
P
Ef>

^ EL
'

2. 3 re

3 p “ S
§
= 30 5
2
0
et
ee 3-
re
C /2
cr O ‘

a c s; Spinal
p 3 o cr «a-

H "o no 3
aq
H
a
P 3 “
<
< ^ 3 p
a £
32 Ha 3 P
a cr
<; a
o 3
-C
3 P
3
P
3 orq 73
CD

p Oä-
CL g]
rt->
£j p ci
3 O P
O 3 5-
P £*
no 3. o.
S' o' 73 3 £ »cl E
3 ti- ~ ^r
J* CL y 1 «a-
cr 3 P p
C-
CD
P-
p p £. no
p
P p P
Cord.

S.
re
g
re
Ö & fa
p er
p 3 P
^ p pCD
a C/3 3- 1/1
O
p p o no
P- p
3 3
P a
P
a
CD
-z
^3
P- 2.
° P
EE
—
r
> Eh vj
3 ^ S' no 70
’
EE £
p 72
3 p O 3’ 3- < g cr P O P a- P
S'
O cr p •S 3.
H S S hI.
•re

a 3
P o' -
K™ ^
EM ^ o
ft
3
p
a a
o
5 ’
9 ^ 2 § o
3
P rt- 3 cr o
rt-
~
03 a
^0
o
w 3 O p ti- no - p cr re" £ § 31
° E
o
v o £
g
52
cr ^
S»
er p O £ 5 r S p p cr
72 CD <
D-
cr. p
o _
rrn
P a O p S o 5 « S? p
3
o EL
a
33 3 p 3 a o -S'22 p no
sa “ S' t3 S-5' H.
r
re

3 2 3 p 175
.
a- o 3
P 72
73
CL
p* pu * ^
rt.

E- Eh
H-*.
73
2-
I

P
o
— M-) * 8-0 3
S' re
»
3 3
P
CO
C 0~
w
^ ^r 33 *
crq
o
2. era
-«
o ir
cr
s ^
g
-
72 72.
3* ^a CL p
Cfq_ O rt-
> 3-
5'
S’
3 3 P - O-*
O
»-K
r r ^ rt- S’
S ^ CD O 3 o' O P
^ P
p.
° 8 3 p p —— re ° L 3 p
3
3 f 3 §
? s o 73 o cr red el O 3
recd
, cr
P 72 ^
P 3 uj 3 3 S a p- rt-
rt-
Et) EL^E
3
O de
3 ^
CD 73
a £ g P cr 72
Ef re td et tf p_ P P a c tr era S' g.
3 Ct3 *L a
3
1/3
CD o o w ^ Vi gt, 2 ^ P
cr
8 H H 2.
*

2 0 P O P 72
o p o _ o o a Cl s' p O *
P <J

S o 73 3- p id 3 5 o :
S' o 3 g 3 l-t
no p
3 3 p W re era. 72 O 8 a ^
re
o o
cr. rt
S 3 P-
1

3 PJ
orq
o’
P rt-
H c S
cr
P 3 P- 73^
o r? p a CD 3^ P o o 3 '
3
e. § p i° P 73 P 1 O- S
 ,

Fig. 57. Region of the Neck, from in front.

Fig. 58. Region of the Neck, from the Side.

The Neck, which extends from the lower border of the lower jaw to the

clavicle, and from the external occipital protuberance to the 7th Cervical Vertebra,

may be divided into 3 regions, 1 paired and 2 unpaired: Anterior, Posterior and

2 Lateral regions. The anterior region of the Neck lies between the 2 Sterno-Cleido-

Mastoid Muscles; the lateral regions, between these muscles and the Trapezius;
the posterior corresponds to the area covered by the Trapezius, as far down as

the spinous process of the 7th Cervical Vertebra (Vertebra Prominens).

The anterior cervical region extends from the lower jaw to the upper

border of the Sternum. This region may be subdivided into Submaxillary, Hyoid,

Sub-hyoid (between the hyoid bone and the upper border of the thyreoid carti-

lage), Laryngeal, Tracheal (which the B. N. A. subdivided into Thyreoid

and Suprasternal) regions and Suprasternal notch. The area between the lower

jaw, Omohyoid and Sterno-mastoid Muscles forms a A which may be subdivided

into a Digastric A and a Carotid A. (The small space between the ramus of
the lower jaw and the origin of Sterno-Mastoid Muscle belongs to the head.)

Anatomists’ opinions differ as to whether the broad Sterno-Mastoid should

be regarded as a boundary line or as a special (Sterno-Cleido-Mastoid) region. In

any case the parts described in the regions bounded by this muscle lie deep to

it (vide infra). Between the Sternal and Clavicular heads of this muscle there
may be a little fossa (Fossa supraclavicularis minor).

From the lateral cervical region a A is cut off by the inferior belly of

the Omohyoid (Inferior A of the neck). The boundaries of this A are formed

by the Clavicle, Sterno-Mastoid and Omohyoid Muscles. When the Sterno-Mastoid

is very broad, or present as Sterno-Cleido-Mastoid, if the Trapezius extends far

forwards (in some cases touching the Sterno-Cleido-Mastoid), then this A will be

very small or even absent.

This A is made larger — e. g. for ligaturing the Subclavian Artery —
by pressing the Clavicle (arm) downward and (if necessary), cutting the Omohyoid.

A portion of the posterior Cervical Region may be termed, Regio-Nuchae.

 \
Submental

'Submaxillary Region Superior

" Tri angle^
;
Triangle
/
i
\of Neck
Carotid,
laryngeal
Region

Tracheal I

Tcapezius Region j
Lateral Region
of the Neck
ftjjl?" Inferior
Triangle
of Neck
Supra
Sternal
mm
Fig. 57. Region of the Neck, from in front.

7, Nat. Size.

Submaxillary
Trianglef^~^^

r \ Carotid
V
\

\ Triangle #

of Neck
Inferior \
Triangle
ofNeck

Fig. 58. Region of the Neck, from the Side.

7, Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Ligamentum Nuchae Spinous Process of 4th Vertebra

Trapezius Muscle

5th Vertebra
Lymphatic Node

Middle and Posterior

Scalene Muscles

5th Cervical Nerve

Spinal Accessory Nerve
(Vertebral Artery)
Internal Jugular Vein
Anterior Scalene Muscle
External Jugular Vein
Sympathetic Chain
Vagus Nerve
Sterno-Cleido-Mastoid Common Carotid Artery
Muscle

Inferior Constrictor of Pharynx Thyreoid Gland

Pharynx Sinus Pyriform is

Omohyoid Muscle
Sternothyreoid Muscle Arytenoid Cartilage

Sternohyoid Muscle Anterior Jugular Vein

Platysma Vocal Thyreoid Cartilage
Cord

Fig. 59. Transverse Section through the Neck at the level of the
Fifth Cervical Vertebra.
Seen from below. — •
3
/4 Nat. Size.

Rebman Limited, London. Rebman Company, New York.

Fig. 59. Transverse Section through the Neck at the level of the
Fifth Cervical Vertebra.

Frozen Section.

This figure shews that all the important structures, Large Vessels, Nerves,
Thyreoid Gland, Food and Respiratory passages are in close apposition in the

anterior part of the neck whereas the largest spaces, external and posterior to the

vertebral column, are almost completely occupied by powerful muscles.

In front lies the Larynx with the Subcutaneous Pomum Adami. Its

position can, therefore, easily be made out. This section passes exactly through
the Vocal Cords; between these the Glottis is continued backwards to a
certain extent between the vocal processes of the Arytenoid Cartilages. These
cartilages are joined by the Aryteno-Arytenoideus Muscle; immediately behind
and below this muscle lies the lowest portion of the Pharynx which presents here
the Recessus Pyriformis on either side. These recesses extend forward for some
distance under cover of the thyreoid cartilage. In a cross-section, the Pharynx,
and its continuation, the Oesophagus, which is usually taken as commencing at
the 5th Cervical Vertebra, appear as a transverse slit, when empty.
In front of the Vertebral Column and the Longus Colli Muscle which
lies upon it, is the strong Prevertebral Fascia. This fascia is separated from the
muscles of the Pharynx and Oesophagus by loose connective tissue in the meshes
of which Retropharyngeal Abscesses readily spread downwards.
External to the larynx is shewn the apex of the lateral lobe of the
Thyreoid Gland with the large Superior Thyreoid Artery which has just entered
the substance of the gland. The Thyreoid Gland lies on the Common Carotid
Artery, which at the point of section is covered completely by the Sterno-Cleido-
Mastoid Muscle (cf. Fig. 60, text). External to the Carotid Artery, and some-
what posterior lies the Internal Jugular Vein (the right vein is usually larger
than the left, cf. Fig. 15, text, Explanation of Lateral Sinus). Between the Artery
and Vein and somewhat posterior runs the Vagus Nerve. The Cervical Sym-
pathetic Trunk is in apposition with the posterior part of the inner wall of the
Common Carotid Artery.
The foramen in the transverse process has been cut in such a way that

it does not appear as a closed ring. In it run the Vertebral Artery and its Venae
Comites. The 3rd Cervical Nerve which has just left its intervertebral Foramen
appears very thick, owing to the obliquity of its section.

Between the posterior border of the Sterno-Cleido-Mastoid and the Anterior

border of the Trapezius, lie the superficial cervical lymphatic glands.
 Fig. 6o. Anterior Aspect of the Neck, Superficial Layer. Adult.

The Head is strongly inclined backwards. Platysma and part of the super-

ficial cervical fascia covering the right Sterno- Mastoid Muscle have been removed.
The right Sterno- Mastoid Muscle has therefore dropped backwards.

Under the skin lies the Platysma, which, converging from both sides, only

reaches the middle line at the chin; it therefore does not cover the anterior
cervical region. Deep to it is the superficial layer of the cervical fascia which
is important because it pulls the Sterno-Mastoid Muscles towards the Middle line,

When the fascia is divided, — as necessary for dissecting purposes — these

muscles drop backwards and outwards. They cover, as is well seen, in Fig. 59.
when in their natural position, the large vessels of the neck at a much higher
level, than after division of the fascia.
The Anterior Jugular Veins, anastomosing above with the Facial Vein,
end below in the jugular venous arch which connects the 2 External Jugular
Veins. This communication usually passes behind the Sterno-Cleido-Mastoid
Muscles. In some cases, the Anterior Jugular Veins terminate by joining one of

the Jugular Veins. ’

The next layer comprises the Infrahyoid Muscles; the Sterno-Hyoid

converging above, the Sterno-Thyreoid, converging below. Thus, in the middle
line a space is formed which is broadest (
3
/5 inch) at the mid-point between the Hyoid
Bone and Sternum. The deep cervical fascia envelopes these muscles and covers
in this space. When this fascia is divided, the muscles mentioned sink downwards
and outwards, thus exposing Larynx, Isthmus of Thyreoid Gland and Trachea.
In the Submaxillary Region the anterior bellies of the Digastric Muscles

converge towards the chin ;

between these the Mylo-Hyoid Muscles and their

median raphe are visible; our figure shews a lymphatic gland in this region,

which is not uncommon. The attachment of the intermediate Tendon of the

Digastric to the Hyoid Bone varies; it is either bound down by an aponeurotic
continuation of the Fascia of the muscle which is fixed to the hyoid bone, or

the anterior belly arises partly from the hyoid bone, either in a tendinous or in

a muscular origin.
The distance between the intermediate tendon and the hyoid bone also
varies; thus the distance is much greater in this figure than in Fig. 63.
Bursae are met with occasionally over the Pomum Adami and the space
between the Thyreoid Cartilage and the Hyoid Bone.
 Digastric Muscle

Raphe of Mylohyoid
Muscle Facial Artery

Facial Vein
Cervical Fascia

Submaxillary Gland
Parotid Gland

Stylohyoid Muscle
Common Facial Vein
Hypoglossal Nerve

Spinal Accessory Nerve

External Jugular Vein

External Carotid Artery

Anterior Jugular Vein
Thyreohyoid Muscle

Median Vein of Neck

Thyreoid Gland

Omohyoid Muscle

Sternohyoid Muscle

Sternothyreoid Muscle

Stcrno-Cleido-Mastoid
Muscle

Fig. 60. Anterior Aspect of the Neck, Superficial Layer. Adult.

3
/4 Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Digastric Muscle Geniohyoid Muscle
Genioglossus Muscle
Mylohyoid Muscle
Nerve to Mylohyoid Muscle Submaxillary Duct
/* Sublingual Artery
Submental Artery

Sublingual Gland

Facial Vein
Lingual Nerve

Submaxillary Styloglossus Muscle

Ganglion

Internal
Pterygoid Hyoglossus Muscle
Muscle
Hypoglossal Nerve

Masseter Lingual Artery

Muscle

Glosso-Pharyngeal Nerve
Facial
Artery

Ascending Palatine
Stylohyoid Artery
Muscle

Thyreohyoid Muscle
Parotid
Gland

Lingual Stylohyoid Muscle

Artery

Internal
Digastric Muscle
Jugular Vein
Spinal Ac-
cessory' Nerve Internal Carotid Artery
Superior La-
Inferior Constrictor of
ryngeal Nerve
Pharynx
Sterno-Ma-
stoid Artery Thyreoid Cartilage
Common
Facial Vein Sterno-Thyreoid Muscle
Omohyoid
Muscle Thyreoid Gland
Ext.Jug. Vein
Sterno-Thy- Cricoid Cartilage
reoid Muscle
Inferior Thyreoid Artery
Ansa Hypo-
glossi Seal on us Me-
Spinal Ac- dius Muscle
cessory N. Common Ca-
rotid Artery

Vagus Nerve
Levator Sca-
pulae Muscle

Trapezius
Muscle
Brachial
Plexus

Subclavian
Artery

Pectoralis
Major
Muscle

Phrenic Nerve

/j
Thoracic Duct
Supraclavicular
Oesophagus
Nerve
Suprascapular Artery

Superficial Cervical Artery Recurrent Nerve

Anterior Scalene Muscle

Right Lymphatic Duct

\ Inferior Thyreoid

Trachea
Vein

Recurrent Nerve Sterno-Mastoid Muscle

Sternohyoid Muscle Connecting Jugular Vein

Fig. 61. Anterior Aspect of the Neck, Deep Layer. Adult.

3
/i Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Fig. 61. Anterior Aspect of the Neck, Deep Layer. Adult.

Position of the head as in last figure. The Superficial Veins are left as stumps ,

both Stern o-Cleid o- Mastoid Muscles are cut off near their attachments ; on the
left side, St er no- Hyoid, Sterno-Thyreoid and tipper belly of Omo-Hyoid Muscles
have been removed. Both Submaxillary Glands have been taken away: removal
of the right Digastric Stylo-Hyoid and Mylo-Hyoid Muscles has given a good
exposure of the floor of the mouth from below.

The Common Carotid Artery enters the neck behind the Sterno-clavicular
articulation, externally to Trachea and Oesophagus. Slightly inclined outwards at
first, it soon runs vertically upwards, without giving off any branches. At the
level of theupper border of the Thyreoid Cartilage, it divides into External and
Internal Carotid (just below the bifurcation, is the most suitable spot for liga-

turing the Common Carotid, because it lies superficially here being covered only
by skin, Platysma and Superficial Cervical Fascia). When the fascia is incised,
the Sterno-Cleido-Mastoid Muscle drops backwards. External to the Artery lies
the Internal Jugular Vein, which, when filled, covers the outer aspect of the Artery.
It receives the Superior Thyreoid Vein and, above the bifurcation of the Carotid,
the Facial Vein ;
the Carotid Artery and Jugular Vein are enclosed in a common
fascial sheath (Carotid sheath); they are crossed by the Omo-Hyoid which runs
downwards and outwards. In front of them lies the Descendens Hypoglossi.
Between the Artery and Vein, somewhat posteriorly above, but more anteriorly
below runs the Vagus Nerve. External to the Jugular Vein, the Phrenic Nerve
descends on the Scalenus Anticus Muscle.
The size of the Thyreoid Gland varies considerably according to the
frequency of Goitre in certain districts. The isthmus connecting the 2 lobes lies

on the trachea, covering the 2nd, 3rd and 4th rings. It may, however, extend
higher up or lower down (cf. Fig. 62). It often gives off a process upwards, the
Pyramidal Lobe (Pyramid of Lalouette) this lobe, as shewn in our figure, ma.y
;

also arise from one of the lateral lobes it often runs to the Hyoid bone.
;
The
isthmus, being fixed to the trachea by connective tissue, follows the movements
of that organ. This is of importance in the diagnosis of tumours of the Neck.
The lateral lobes are covered by the Sterno-Hyoid, Sterno-Thyreoid and Omo-
Hyoid Muscles. Their size varies markedly. They receive blood from the Superior
Thyreoid Artery a branch of the External Carotid and from the Inferior Thyreoid
Artery, which arises from the Subclavian and runs upwards behind the Common
Carotid.
The Larynx is subcutaneous, the Trachea lies under the skin at its com-
mencement but runs to a deeper level the nearer it approaches the Thorax. In
front of its upper portion is the Thyreoid Gland; lower down, fatty tissue; at
this point the Thymus is just visible above the sternum in children.
 ;

Fig. 62. Front View of the Neck, Deep Layer. Child.

Child a few months old; head inclined backwards. On the left side, the super-
structures are displayed after removal of the Platysma ; on the right side,
ficial
the Sterno-Cleido- Mastoid has been cut off near its attachment. The Sternum
has been removed between the middle of the Manubrium and the base of the
Xiphoid, and ivith it the 2nd, 3rd, 4th, yth, 6th Costal Cartilages.

The chief difference in this part between the adult and the child, is the
Thymus which is large in the latter. This gland continues its development till

the 2nd year, then degenerates or remains stationary till puberty. After puberty,
it disappears rapidly; its lobes undergo fatty degeneration; there are, however,
always masses of fat containing a few remains of this glandular tissue present
even in the adult. The shape of the gland varies much. There are usually
2 longitudinally placed lobes which are pointed above. The limits of the gland
are: the level of the 3rd rib, and the lower border of the Thyreoid Gland. Below
the Thymus is in relation with the Pericardium, its middle portion is covered by
the Sternum between its outer portion and the thoracic wall, the pleural cavity
;

and the lungs find their way. Above the pericardium, this gland is an anterior
relation of the Arch of the Aorta, Superior Vena Cava and Innominate Veins.
At a still higher level, it lies on the Trachea, being separated from the skin by
Sterno-Hyoid and Sterno-Thyreoid Muscles; at this point it becomes an internal
relation to the Innominate Artery, Carotid Artery and Internal Jugular Vein.
This figure also shews some of the Lymphatic glands of the Neck
and Thorax.
The chief lymphatic channel, the Thoracic Duct, commences in the ab-
domen, usually opposite the ist Lümbar Vertebra (Receptaculum Chyli, cf. Fig. 141).
It runs vertically upwards on the right of the Aorta, passing through the Dia-

phragm, and lying in the Thorax between the Aorta and Great Azygos Vein.
Opposite the body of the 7th Cervical Vertebra it arches over the left Subclavian
Artery and opens into the left Subclavian Vein (cf. Fig. 67). The corresponding
structure on the right is the short right Lymphatic Duct which opens into the
right Subclavian Vein. The great lymphatic channel on formed
the right side is

by the junction of the Bronchial, Mediastinal, Jugular and Subclavian Lymphatics;

on the left, the Thoracic Duct receives the left Jugular and Subclavian Lymphatics
which carry the lymph from the head and upper extremity. These last mentioned
channels may open separately into the veins.
Between the 2 bellies of the Digastric the Submental Glands are shewn
on the Submaxillary Gland, the Submaxillary Lymphatic Glands are visible; at
a lower level on the Internal Jugular Vein the Superficial Cervical Glands are seen
(more about this group in Fig. 63, text).
On the left side, some of the Inferior Deep Cervical Glands (cf. Fig. 115,
text), and finally the Sternal Glands are shewn. These lie near the Internal
Mammary Artery and its Venae Comites but are not found in all the interspaces.
Their efferent vessels go to the mediastinal glands, to the great lymphatic ducts
and to the lymphatics of the neck (cf. Fig. 115).
 Facial Vein

Temporal Vein
Submaxillary Gland

Hypoglossal Nerve Digastric Muscle

Facial Vein
Hyoid Bone
Spinal Accessory Nerve Thyreoid Cartilage

Ansa (or Loop) Cricoid Cartilage

Hypoglossi
External Jugular Vein
Isthmus of Thyreoid
Gland
Inferior Thyreoid
Omohyoid Muscle
Vein
Internal Jugular Sterno-Cleido-
Vein Mastoid Muscle
Right
Lymphatic Thymus
Duct Gland
imunication Cephalic
)etween Vein
ular Veins
Internal Manu-
Mammary brium
Vessels Sterni

Right Thymus
Pleura Gland

Triangularis Sterni Muscle Pericardi um

Fig. 62 . Front view of Neck, Deep Layer. Child.

Nat. Size.

Rebman Limited, London,

Rebinan Company, New York.
 Submaxillary Salivary
Facial Gland
Hyoglossus Muscle Arterv I
TO rrictri r'
i 1\ T 1 10 . ' 1

Lingual
Supramandibular Nerve Artery

Parotid Gland

Great Auricular Nerve

Digastric
Muscle [Mylohyoid Muscle

Stylohyoid Muscle
External
Jugular Vein
Hypoglossal Nerve

Spinal Accessory Facial Vein

Nerve
Omohyoid Muscle

Internal Jugular Superior Laryngeal

Vein Nerve
Internal Carotid
Thyreohyoid Muscle
Artery

Superior Thyreoid
Facial Vein
Vessels

Descending Branch of — Thyreoid Gland

Hypoglossal Nerve

Sternohyoid Muscle
Superficial Cervical Nerve

Anterior Jugular
Vein
Platysma Muscle*-
Sterno-Thyreoid
Muscle

Sterno-Clcido-Mastoid Muscle

f
I

Fig. 63. Upper Triangle of Neck: Lymphatics.

Nat. Size.

Rebman Limited. London, Rebman Company, New York.

 Fig. 63. Upper Triangle of Neck: Lymphatics.

The Platysma isalmost completely removed. The Cervico- Facial and Cervical
Nerves are cut short. The lymphatic glands have been drawn accurately from
the specimen (an old man), the lymphatic vessels with the aid of Starr’s
investigations.

Recent investigations have shewn that the number and the position of
the lymphatic glands in the submaxillary region do not vary as much as in the
other parts of the body (e. g. There are usually only 3 glands,
Axilla and Groin).
which we call anterior, middle and posterior. They all lie above the submaxillary
gland. The anterior is usually the smallest and lies next to the Submental Vein
on the Mylo-Hyoid Muscle; the middle is nearer the border of the jaw and
usually touches the Facial Artery the posterior lies near the Facial Vein, either
:

immediately behind it, or nearer the angle of the jaw.

A second group of glands lies between the anterior bellies of the Digastric
Muscles. Their number is less constant; but one can make out a superior set
(small glands, the upper submental glands) and an inferior set (the lower sub-
mental glands) often consisting of only one large gland (cf. Fig. 62).
The efferent vessels from the upper submental set go partly to the lower
set, partly to the anterior submaxillary gland. From the lower set the lymph
travels to the Anterior Submaxillary Gland and partly to the deep Cervical Glands.
The typical arrangement for the submaxillar}^ lymphatics is as follows: lymph
goes from the anterior gland to the middle, thence to the posterior. Only in a
few cases, does it go directly to the deep cervical glands. Of the efferent vessels
from the posterior submaxillary gland, our figure shews the superficial channels
running to the cervical glands, but also one vessel going to an Inferior
Parotid Gland.
A
portion of the superior deep cervical glands along the Internal Jugular
Vein and the Carotid Artery is shewn in the figure. They receive lymph from
the Submental, Submaxillary, Lingual and Parotidean Glands, i. e. indirectly from
the whole Face, from the Skull Cavity, Larynx, Pharynx and Thyreoid Gland;
this explains why they become enlarged so very frequently in disease.
The lymphatics of the lips (cf. Fig. 115) are important, in consideration
of the frequent occurrence of epithelioma. We need to distinguish between the
lymphatics of the skin, and the lymphatics of the mucous membrane. The vessels
from the mucous membrane of the lower lip (2 3 inches) usually go to the —
middle submaxillary gland, into which the vessels from the upper lip (1 to
2 inches) frequently open the latter may also pass to the posterior sub-
,

maxillary gland.
The subcutaneous lymphatics vary more widely; these entered beyond the
middle line to a greater extent than the submucous vessels (2 4 subcutaneous —
vessels go from the lower lip to the submental glands). The lymphatics of the upper
lip usually go to the middle submaxillary gland; in a few cases to an inferior

parotid gland or even to a superficial cervical gland on the Sterno-Mastoid. As

epithelioma of the lip usually starts at the junction of the skin and mucous mem-
brane, and as the lymphatic areae meet here, all glands and also those of the
opposite side demand consideration.
 Fig. 64. Situation for Ligature of the Lingual Artery.

The Submaxillary Region and the surrounding parts are exposed by removal of Platysma,
Lymphatic Glands, small Nerves and Fasciae. The Submaxillary Gland has been thrown upwards
and appears to be composed of 2 portions, because the Facial Artery holds the deep portion in
position. A piece has been taken out of the Facial Vein ; this enables one to throw the gland
upwards more easily, and gives a better view of the deep structures. Specimen from a man
aged 40.

The Lingual Artery soon disappears, after its origin from the External Carotid,
under cover of the Hyoglossus Muscle and runs forwards parallel with the hyoid bone
accompanied by two Venae Comites. The course of the Hypoglossal Nerve is similar;
the nerve however, at a higher level and superficial to the Hyoglossus Muscle.
being,
The Sublingual Vein accompanies the nerve. This nerve forms a small A together with
the border of the Mylo-Hyoid Muscle and the posterior belly of the Digastric. In this '

A, the Lingual Artery can be tied, after division or separation of the fibres of the Hyo-
glossus Muscle, as shewn in our figure.
Another point is suitable for ligaturing this artery, which is so frequently tied in
operations for removal of the tongue. The vessel may be ligatured in its course between
the External Carotid Artery and the border of the Hyoglossus Muscle below the posterior
belly of the Digastric. The place first mentioned is more superficial and more accessible,
and would be preferable, if the artery had not given off its main branches as is fre-
quently the case.
The Facial Artery runs —
in a tortuous course —
behind the submaxillary gland,
,

emerging between the gland and the border of the lower jaw (cf. Fig. 63) and extending
on to the face along the anterior border of the Masseter. The artery is frequently
embedded in the gland and ensheathed by the fascia of the gland. This accounts for
the fact, that in removing the submaxillary gland, the Facial Artery is so often damaged.
The Facial Vein passes in front of the gland.
The Common Carotid Artery bifurcates into Internal and External at the level
of the upper border of the Thyreoid Cartilage. On it rests the Descendens Hypoglossi
Nerve. Behind the External Carotid, the Superior Laryngeal Nerve (from the Vagus)
emerges; this nerve divides into an outer and an inner branch, the former to supply
the Cricothvreoid Muscle, the latter sensation inside the larynx.

Fig. 65. Larynx opened from in front.

The Laryngeal Region in a man (aged 38) has been exposed, and the Larynx slit open in
the middle line between the thyreohyoid ligament and the upper borderof the cricoid cartilage,
a wedge placed between the 2 halves of the thyreoid cartilage keeps the larynx open. (This
has not been drawn in the figure.)

This figure shews the aspect seen in Laryngo-fissure or Laryngotomy, an operation

which is performed for the removal of Laryngeal Tumours, when the neoplasm cannot
be extirpated by the transbuccal endolaryngeal method.
The middle of the laryngeal region is not covered by muscles. Under the skin,
is seen the cervical fascia in its intimate connection with the larynx. Immediately, under
the fascia, is the Thyreoid Cartilage. In some cases, there may be a bursa over it. The
Anterior Jugular Vein is sometimes very large. There are no other important structures
within the area of operation.
This figure also shews that High Tracheotomy is only possible, owing to the
position of the thyreoid gland, after the Isthmus of the Thyreoid Gland has been divided
or pushed downwards.
 Facial Artery
Masseter Muscle Submaxillary Salivary Gland
Stylohyoid Muscle Hyoglossus Muscle
Parotid Salivary Gland Mylohyoid Muscle
Digastric Muscle

Lingual Artery

Hyoid Bone

Omohyoid Muscle

Temporal Vein
|
Thyreohyoid Muscle
Hypoglossal- Nerve
_

Superior Thyreohyoid Artery

|External Carotid Artery Superior Laryngeal Nerve

Fig. 64. Situation for Ligature of Lingual Artery. Nat. Size.

Anterior Jugular Vein Epiglottis Hyoid Bone Platysma Muscle Sternohyoid’Muscle

Cavity of
Pharynx

Ventricle of Arytenoid
Larynx Cartilage
[Morgagni)

Vocal Cord

Inferior
Thyreoid
Vein

Fig. 65. Larynx opened from in front. Nat. Size.

Rebman Limited, Loudon,

Rebman Company, New York,
 ,

Internal Carotid
Occipital Artery Artery Vagus Nerve
Posterior Belly of Digastric Muscle
Parotid Gland
Temporal Vein Spinal Accessory Nerve

Glosso-Phäryngeal Nerve Great Auricular Nerve

Sterno-Cleido-
Mastoid Muscle
Facial Artery

Hypoglossal Nerve

Mandibular Brandi of
Facial Nerve

Masseter Muscle

Posterior Branch
of Digastric
Muscle

Facial Vein

Submaxillary
Salivary Gland

Anterior Belly of
Digastric Muscle

Hyoglossus Muscle

Anterior Jugular Vein

Lingual Artery
Superior Laryngeal Nerve
(External Branch)
Carotid Body

Upper Border of Thyreoid Cartilage

Thyreohyoid Muscle

Inferior Constrictor Muscle of Pharynx

Sterno-Thyreoid Muscle

Ansa (or Loop) Hypoglossi

Superior Posterior Parathyreoid Body-

Middle Thyreoid V
Inferior Posterior Parathyreoid

Inferior Thyreoid Artery

Thyreoid G1

Oesophagus-

Inferior Thyreoid

Inferior (Recurrent) Laryngeal N

Transverse Communicating

Interclavicular
DrFron sc

Fig. 66. Lateral Aspect of the Neck. Oesophagus.

4
/k Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Fig. 66. Lateral Aspect of the Neck. Oesophagus.

The outer region of the neck in a man ,

aged jo, was exposed by a large window-
section. Platysma, Superficial Nerves, Facial Vein and lymphatic glands were
removed. The Sterno-Cleido-Mastoid Muscle was drawn backwards, the Thyreoid
Gland and the muscles near it forwards, in order to shew the Oesophagus (red).
The Sympathetic is white; the head is rotated to the right and inclined

backwards.

The Oesophagus lies between the Trachea and the Vertebral Column,
surrounded by loose conective tissue which allows its dilatation and movement
upwards and downwards. It begins at the 6th Cervical Vertebra (cf. Fig. i) and
passes downwards behind the Trachea, deviating somewhat to the left. This is

the reason why the left side is usually chosen for operating. An incision is made
along the Anterior border of the left Sterno-Mastoid Muscle between the level

of the Cricoid Cartilage and the Suprasternal Notch; after division of the Platysma
and Superficial Cervical Fascia, the Sterno-Mastoid is drawn outwards, and the Omo-
Hyoid Fascia divided, — also the Omo-Hyoid Muscle if it cannot be drawn

downwards. One now proceeds between the Carotid Artery, which is pulled out-

wards and the Thyreoid Gland and the Sterno-Hyoid Muscle which cover it. When
the gland is very large, it may be necessary to remove the left lobe, in order to

have sufficient room. Deep in the wound, the Oesophagus can be recognised,
by its longitudinal pale red muscle fibres, in front of the vertebral column and

Longus Colli Muscle. The Oesophagus can be opened between the Superior and

Inferior Thyreoid Arteries; if it is desirable to open the Oesophagus at a lower

point, the Inferior Thyreoid Vessels are divided between a double ligature. In

order to avoid the Recurrent Laryngeal Nerve, the canal is opened along its outer

wall ;
the cervical portion of the Oesophagus can thus be exposed, a stricture or

cancer removed, and an oesophageal fistula made by sewing the edges of the

lumen of the Oesophagus to the skin.

The anatomy for the operation of removal of the Thyreoid Gland is similar

(cf. Fig. 67).

At the bifurcation of the Common Carotid Artery lies the Carotid Body,

composed of a delicate plexus of blood vessels and sympathetic nervous tissue.

Its functions are not known.

 1

Fig. 67. Outer Region of the Neck. Subclavian Triangle.

The head is rotated to the right. Platysma and a portion of the Supraclavi-
cular Nerves have been removed, the lymphatic glands have been removed in order
to simplify the figure; the course of the chief lymphatic tracts has been indicated.

Under the skin we distinguish a Superficial and Deep Cervical Fascia,

separated from each other by loose connective tissue, which stretches across the
space between Sterno-Mastoid and Trapezius Muscles. The Supraclavicular Nerves
become subcutaneous by piercing this fascia.
For the removal of tumours and especially, for the removal of diseased
lymphatic glands, a longitudinal incision is made along the posterior border of
the Sterno-Mastoid Muscle, the External Jugular Vein is divided. This vein runs
downwards from end of the Parotid Gland across the Sterno-Mastoid
the lower
and Omo-hyoid, to pierce the Omo-hyoid Fascia and open into the Subclavian
Vein. Of more importance is the Spinal Accessory Nerve. Emerging at the
posterior border of the Sterno-Mastoid, this nerve runs obliquely downwards to
the Trapezius.
As it crosses the area of operation, it cannot always be avoided injury :

to it may cause paralysis of the Sterno-Mastoid and Trapezius Muscles; but not
in every case as both muscles receive fibres from the 2nd, 3rd, and 4th Cervical
Nerves which may run separately to the muscles and independent of the Spinal
Accessory.
The Brachial Plexus emerges through the slit between the Scalenus
Anticus and Scalenus Medius Muscles. Of particular importance is the position
of the Phrenic Nerve. Deriving its fibres from the 4th Cervical Nerve, as well
as from the 3rd and 5th, it runs obliquely inwards, superficial to the Scalenus
Anticus Muscle. At this point, behind the posterior border of the Sterno-Mastoid
Muscle, it can be best stimulated electrically.
When the clavicular portion of the Sterno-Cleido-Mastoid does not extend
far backwards (as in our figure) the Internal Jugular Vein is visible at its posterior
border. The Suprascapular Artery which either comes from the first, or from
the 3rd part of the Subclavian Artery, takes a rather high course in this
specimen ;
as a rule, it lies behind the clavicle (cf. Fig. 68). On the other
hand, the Transversalis Colli Artery runs usually at a higher level than in

our figure.
The most important point, just above the Clavicle, is where the Subclavian
Artery and Vein leave the Thorax. Ascendin’g out of that cavity, they form an
arch over the first rib on their way to the axilla. The Vein is in front of, the
Artery behind the Scalenus Anticus Muscle. The Vein is fixed to the first rib
and to the clavicle by tense connective tissue; it cannot, therefore, collapse, when
punctured (danger of air embolism). Just above the clavicle, it receives the Supra-
scapular Vein. The Clavicle and first Rib form the gate through which the Neuro-
vascular Bundle passes into the arm, most external and posterior (highest-up) being
the nerves; then comes the artery, and on the inner side and most anterior,
the vein.
The large Lymphatic Tracts are in black; the Thoracic Duct opens at the
junction of the left Subclavian and Internal Jugular Veins. This Duct receives
the Jugular and Subclavian Lymphatic Trunks. When removing the deep cervical
glands, which are so very frequently diseased (cf. Fig. 1 5), there is always a danger
of damage to this most important lymphatic tract of the body.
 Splenius Capitis
Muscle

Small Occipital Nerve

Great Auricular Nerve

Spinal Accessory Nerve

Sterno-Cleido-Mastoid Muscle

Supraclavicular Nerve »'

Descending Branch of
Superficial Cervical Nerve
Levator Anguli Scapulae Muscle

Phrenic Nerve
Trapezius Muscle

Scalenus Anticus Muscle

Posterior Jugular Vein

Brachial Plexus
External Jugular Vein
Internal Jugular Vein
Jugu Scalenus Medius Muscle

Suprascapular
ArtPry

Thoracic Duct Omohyoid Muscle

Transverse
Communicating
Vein

Subclavian Lymphatic Trunk

Pectoralis Major Muscle |
1st Rib Subclavian I Clavicle |
Deltoid Muscle
Subclavian Vein Artery |
Suprascapular Nerve
Transverse Artery of Neck (Transversalis Colli)

Fig. 67. Outer Region of Neck. Subclavian Triangle.

2
/
;}
Nat. Size.

Rebman limited, London. Rebman Company, New York.

 Upper Cervical Ganglion of Sympathetic

Sterno-Cleido-Mastoid Muscle

Vagus Nerve

Splenius Capitis Muscle

Spinal Accessory Nerve

External Jugular Vein

\

Great
Auricular
Nerve
Trapezius Muscle
Superficial
Cervical __ Anterior
Nerve Division of 3rd
t , Cervical Nerve
Levator
Internal Jugular Vein Anguli Scapulae

Small Occipital Nerve

Common Carotid
Artery
Nerve to Levator Anguli Scapulae
Ansa (or Loop)
Hypoglossi Middle Scalene Muscle

Longus Colli Muscle Spinal Accessory Nerve

Middle Cervical Ascending Cervical Artery

Ganglion of
Sympathetic Long Thoracic Nerve
Inferior Thyreoid Artery

Nerve
Thoracic Supra-
scapular
Nerve

Vertebral Vein

Omohyoid M

Anterior Scalene Muscle

Phrenic Nerve
Brachial Plexus
External Jugular Vein
Anterior Thoracic Nerve
Suprascapular Artery
Middle Scalene Muscle
Subclavian Artery

Outer Region of Neck. Upper Cervical Ganglia of Sympathetic.

Fig. 68.
'-/
s
Nat. Size.

Rebman Limited, London.

Rebman Company, New York.
 Fig. 68. Outer Region of the Neck. Upper Cervical Ganglia of
Sympathetic.

The head of a male, aged jo, is turned to the right, and drawn backwards.
A large window has been made in the skin, the Platysma and External Jugular
Vein have been removed, the Sterno-Cleido- Mastoid Muscle and Internal Jugular
Vein drawn forwards, and the Trapezius pulled backwards. 7 he Thoracic
Duct is white, the Sympathetic Chain and, its Ganglia are orange (by mistake,
the Spinal Accessory Nerve has been drawn superficial to the Great Auricular
Nerve: it should be the reverse).

In Fig. 67, the parts are in their natural position in this figure, the deeper
;

structures have been exposed by drawing the superficial muscles apart; the In-
ternal Jugular Vein, which really lies external to the Carotid Artery, has been
pulled inwards, the Sympathetic Chain begins with the Upper Cervical Ganglion
4
which is /5 th inch, long, and upper end lies opposite the trans-
0.3 inch, broad; its

verse process of the 2nd or 3rd Cervical Vertebra; its lower end, opposite the 4th,
5th or 6th Cervical Vertebra. At its lower end is seen the sympathetic chain
which goes to the Inferior Cervical Ganglion (cf. Fig. 70). This Ganglion varies
in size and may form one mass with the ist Dorsal Ganglion, it lies on the head
of the ist rib at its point of articulation with the body of the ist Dorsal Vertebra.
The sympathetic chain Subclavian Artery
frequently forms a loop around the
(Ansa of VlEUSSENS). Between the Upper and Lower Cervical Ganglia lies the
middle Cervical Ganglion in front of the Inferior Thyreoid Artery, which may
also be surrounded by a loop of sympathetic fibres. The Sympathetic Chain lies
behind the Carotid Artery, and is fixed to the Vertebral Column and the Pre-
vertebral Muscles. It therefore does not move with the Carotid Sheath, in the
same way as the Vagus. When ligaturing the Carotid Artery, there is no need
to trouble about the Sympathetic but one has to take care not to include the
Vagus in the ligature with the Artery.
The Sympathetic is, therefore, in a well protected position, and rarely
damaged in accidents, or during operations (removal of tumours). In recent years,
the Sympathetic has been divided and more or less removed (Superior Cervical
Ganglion etc.) for Epilepsy, Glaucoma and Grave’s disease. The Sympathetic
can be exposed by a longitudinal incision along the anterior border of the Sterno-
Mastoid Muscle; the Carotid Artery, Internal Jugular Vein and Vagus are drawn
aside. This proceeding is inconvenient, because the thin-walled much distended
vein is held by the retractor. If one operated along the posterior border of the
Sterno-Mastoid drawing the muscle with the vein inwards, more room is obtained;
if the incision has been continued downwards on to the clavicle, the lower Cervi-

cal Ganglion can also be removed, after having freed the clavicular head of the
Sterno-Mastoid from its attachment. The latter operation, however, is difficult,
because the Vertebral Vessels may lie up against the Ganglion near the Apex
of the Pleura (cf. Fig. 70). This should on no account be injured.
This incision is the best for ligaturing the Vertebral Artery before it

enters the foramen in the transverse processes of the Cervical Vertebrae.

 ,;

Fig. 69. Larynx from behind — Goitre.

From the body of an old woman, the enlarged Thyreoid Gland (Goitre) was
removed with the Larynx and the Trachea, and hardened in Formalin ; only a
small portion of the Oesophagus remains; the posterior wall of the Larynx is

dissected. The Parathyreoids are or an ge, the lymphatic glands, red. The larger
leftlobe of the Thyreoid Gland caused the Trachea to rotate around its axis.

The Recurrent Laryngeal Nerve has been drawn aside, on both sides, in order
to more clearly show its branches.

The topographical position of the Thyreoid Gland is shewn in Fig. 6.

Fig. 60 indicates those structures which must be divided in exposure of the gland.
The topographical relations at the point where the Superior Thyreoid Artery
enters the gland, are most important (cf. Fig. 66). The difficulty in removal of
the Thyreoid Gland is to avoid the Recurrent Laryngeal Nerve, injury to which
causes paralysis of the Vocal Cords. This nerve ascends in the groove between
the Trachea and Oesophagus, supplies these structures and enters into the formation
of the Oesophageal Plexus (Plexus Gulae). It then follows the Inferior Thyreoid
Artery, in some cases running upwards in front of the Artery, or — more often —
it passes between its branches at the point of bifurcation ;
it only lies in a
few cases behind this vessel, always closely applied to the Thyreoid Gland. For
the removal of the gland, the nerve must be freed, and great care taken, to
avoid inclusion with the ligature for the Artery. It then passes under the Inferior
Constrictor Muscle and ends at the Crico-Thyreoid articulation by dividing into

its terminal branches; one of these joins the descending branch of the Superior

Laryngeal Nerve, thus forming the loop of Galen — Ansa Galeni — ,

the other
supplies the muscles of the Larynx, except the Crico-Thyreoid. This muscle is

supplied by the External branch of the Superior Laryngeal Nerve (cf. Fig. 66),

whilst the bulk of that nerve pierces (internal branch) the Thyreo-hyoid Membrane
together with the Superior Thyreoid Artery and supplies the laryngeal mucous
membrane with sensation.
Of great practical importance are the Parathyreoid Glands. When enlarged
or the seat of a tumour, they may cause great diagnostic difficulties.
Usually, their position is as shewn in the figure near the Thyreoid Gland
but there may be Parathyreoids anywhere between the frenum of the tongue and
the hyoid bone, and between the lower border of the Mandible, the Clavicle and
the Trapezius Muscle.
 .

Greater Cornu of Hyoid Bone

Lateral Thyreohyoid Ligament

Internal Branch of Superior

( unoi form ( 'artilage
Laryngeal Nerve

Superior Thyreoid Vessels

External Branch of Superior

Superior Thyreoid Vein
Laryngeal Nerve
Corniculo-Pharyngeal Ligament
Anastomosis between Superior and Nerve to Transverse Arytenoid
Inferior Laryngeal Nerves Muscle
(Ansa Galenj)
Posterior Crico- Arytenoid Muscle
Cricoid Cartilage
Inferior Horn of Thyreoid
Cartilage

Posterior Superior Parathyreoid Anterior Branch of Inferior

Body (Recurrent) Laryngeal Nerve

(Interior) Recurrent Larvngeal

Nerve Inferior Laryngeal Artery

Inferior Thyreoid Artery

Inferior Thyreoid Artery

Deep Cervical
(Thyreoid) Lgl.

Tracheal Nerve
Middle Thyreoid Wins
Anterior Inferior
Parathyreoid Body
Posterior Inferior
Parathyreoid Body

Oesophagus

Oesophageal Nerves

Tracheal Nerve
Inferior Thyreoid Vein

Deep Cervical Lymphatic

Glands Right Inferior (Recurrent)
Laryngeal Nerve
Left Lateral Lobe of
Thyreoid Gland (Goitre)

Inferior Thyreoid Veins

Fig. 69. Larynx from behind — Goitre —

Rebman Limited, London.

Rebman Company, New York.
 5th Longus
Sympathetic Cervical Colli . .

Vagus Nerve Chain Vertebral Artery

‘
Vertebra Muscle Rectus Capitis Anticus Muscle

Phrenic Nerve

Transverse Process of
6th Cervical Vertebra
(Chassaignac’s Tubercle)
Ascending Cervical
Artery
Anterior Scalene Muscle

Inferior Thyreoid Artery

Common Carotid
Artery

Middle Scalene
Muscle

Suprascapular
Artery

Brachial Plexus

Transverse
Artery of Neck
(Transversalis
Colli)

Subclavian
Artery

Scalene Tubercle Thoracic Duct

(Lisfranc)
Internal Mammary Artery
Phrenic Nerve
Apex of Pleura
nternal Mammary Vein
Right Recurrent Laryngeal Nerve
Right Innominate Left Inferior (Recurrent) Laryngeal Nerve
off- Tnnnmintifp Vpill
Innominate Artery

Trachea Oesophagus Inferior Thyreoid Vein

Fig. 70. Apex of the Pleura.

Nat. Size.

Rebman Company, New York

Rebman Limited, London,
 .

Fig. 70. Apex of the Pleura.

From the neck of a man

aged 40, both clavicles have been removed, Trachea
,

and Oesophagus cut off, and

the important vessels and nerves displayed in their
relation to the apex of the pleura (which is coloured light blue). On the left
side, special attention has been paid to the Veins and the Thoracic Duct ; on
the right side to the Arteries and the Nerves, in particular, to the Sympathetic

The apex of the Pleura ends exactly at the level of the ist rib. This
rib which forms with the Sternum and ist Dorsal Vertebra the upper aperture
of the Thorax, ascends behind, in an oblique direction. The slope of the apex
of the pleura, and the lung within it, corresponds to that of the rib mentioned.
An instrument, introduced immediately above the first rib, horizontally backwards,
will therefore open the pleura. By percussion, one can also prove the presence
of resonant lung about one inch above the clavicle. Despite all this, it is wrong
to say that the pleural cavity extends everywhere beyond the upper aperture of
the thorax. Normally, it passes above the level of that inclined plane only at
one spot, at the middle of the ist rib, and only to the extent of V2 inch. Strands
of connective tissue keep the apex of the pleura in position this fascia runs from
;

the Cervical Vertebrae and the neck of the first rib to the apical pleura.
The large vessels and nerves which pass through the upper aperture of
the Thorax to the head and the upper limb, and the Nerves which go from the
neck to the arm are in close relation with the apex of the Pleura. Internal to
the latter, on the right side, the Innominate Artery, on the left, the Subclavian
Artery passes. The Innominate Artery bifurcates into Common Carotid and Sub-
clavian either behind the Sterno-Clavicular articulation or at a higher level. The
Subclavian Artery arches over the apex of the Pleura, leaving it at the Scalene
Tubercle on the first rib. The Internal Mammary Artery which arises from the
Subclavian, before it passes between the Scalenus Anticus and Medius Muscles,
is also in relation to the Apex
of the Pleura; external to it is the Phrenic
Nerve. The Ganglion (cf. right side of the figure) lies on the
Inferior Cervical
apex, between the Longus Colli Muscle and the arch of the Subclavian Artery, in
front of which the Vagus descends (also in relation with the apex of the Pleura).
Both Innominate Veins, formed by the Internal Jugular and Subclavian Veins
are also relations of the apical pleura, on which the Brachial Plexus, —
external to the Subclavian Artery rests. —
Lastly, the Pleura lines the inner
,

border of the Scalenus Anticus Muscle where it is attached to the first rib.
Disease of the Pleura can, especially on the right side, affect the Recurrent
Laryngeal Nerve.
The fact that so many structures of vital importance are in close ap-
position within a small space renders removal of tumours, growing in that region,
and ligature of the vessels very difficult and even dangerous. Apart from the
possibility of injury to the vessels and nerves in the neighbourhood, there is danger
of opening the Pleura.
 Fig. 71. Course of the Main Vessels and Nerves to the Arm.

The head is turned to the left, the arm drawn downwards, slightly abducted

and rotated outwards. The Platysma and the clavicular portion of the Pecto-
ralis Major have been removed. A piece has been excised from its sternal

portion, its origin and insertion being throivn inwards and outwards respectively.

Between the clavicular portion of the Pectoralis Major which usually arises

from the inner half of the Clavicle, and the origin of the Deltoid from the outer
third of that bone, a A space is left in which the Cephalic Vein disappears to

join the Subclavian Vein (for further details cf. Fig. 76, text).

The Subclavian Vein, Artery and Brachial Plexus pass under the

Clavicle (as if it were a bridge!) from the neck into the Axilla. The Vein, sepa-

rated from its Artery on the ist rib by the Scalenus Anticus Muscle, lies on its

inner aspect, lower down. Externally, and partly behind the artery is the Brachial

Plexus which soon surrounds this vessel. The Neuro- Vascular bundle is almost

completely covered by muscles, even when the latter are ill-developed. Proceeding
directly backwards, without interfering with the muscles, separation of the

clavicular portion of the Pectoralis Major from its origin, is necessary.

The following surface marking can be used for ligature of the Subclavian

Artery in this region. Take the midpoint of the Clavicle; the artery lies at a

finger’s breadth interval from this point.

Above the upper border of the Pectoralis Minor, the Subclavian Artery gives

off two branches which are not shewn in our figure: the Acromio-Thoracic and

the minute Alar Thoracic (Thoracica Suprema). The anterior Thoracic Nerves which

supply the 2 Pectoral Muscles run with the former vessel. They perforate the

costo-coracoid membrane.

Lastly, we mention that in our figure — and this is not uncommon —

there is a gap between the sternal and the clavicular portions of the Stern o-Cleido-

Mastoid Muscle in which the Internal Jugular Vein is visible.

 \

Clei dom as!

Anterior Scalene Muscle

Small Pectoral Muscle

Deltoid Muscle

Cora co- Brachial is

Muscle

Great Pectoral
Muscle

Short Head of
Biceps

Fig 1

. 71. Course of Main Vessels and Nerves to the Arm.

2
/3 Nat. Size.

Rebman Limited, London.

Rebman Company, New York.
 C o^O' h4-
^ C/3 O H § Et p 0 q SrS G
id
C * ft 3 o o §*i-h O
T3 X
hC,
^
73
o •a n p ° -
er I
CD p
t -EC. » of
a ü ? s-
3
r 2 a o O
CD p-
n>
cr p CD 3 3^ CD
cd
^ 2 “t P 2 8 S'
-G
2, CD CD
2,
3° p CD Ql
o m CD r
5- 3 r-* ^ p
CD
O C
U PG 2 cr
o 2
CfQ <j CD
p_’ ^ _ o p gf -i ,93 CD N B- P'
c R a
&« Ct- -t O O P
P 2 O 13
CD

p
o «' '-<
co’
C/3 CD
73
CL O'
(A

C 3 ? O » a
J?.
P
M !? O T* CD
CD i_3
^ C-H
CD CD & 3
?> |3 ^
CD
o> cr p o •t
r* a. £ O
o p C_ a, •g g § °
73
_
0)
P Et
cr
n-
5-
CD
P CO 73
a p
3 n w O O g & Ou £ 2
cd
c/T
cr g 3 a
w cd
o P p
P-* p >1 P M
gr
CD
p rt-
O r-h
2 p O
i-

.
3

o p 3 <
(7)

G
£2. 3
-h
^ ^ 3
° G
'o’

h— °5
I §-
cd ^-i cr ? 03 CD

d o
CD* 73
n P- 2
crq H "
2. «/>
ET a o
g p P C (/I
O <; cd
it
g S3 sr p o sr *T3 ^ g"
a- 73

2 -o g CD CD O
- er
S3
rrT
a>
M. ^ CD
< p So a- p
briJ 3
C sa
> G 2 ° P c §
73

° p CTQ cr P G c § p co‘
T)
?.so- £ 03
co
gag 3
«' p* G P O p
*-*
CD 3
D-
H
C/3 o «"t-
X
p 5 0 w “ s
g W o w s >
CD
3
«'
3 S
CD j—
03 73
I &
< 3 — jj
O 3 n co § P ^ "Öo ^ O
•"+>
q_,
W 2 05 .
1 ?a 2 P cr -a
.
p. X
O G
2
CD C 5
£L
CT r-H
CD
£
rt
G ^ 2" ^ as er- o
— *-*
-t
sr
73
O CD 73 w
^ 2 g
CD cr 03 73 - (J
a> .

" p CD CD
^ n i < 3 C O
h k o' O P
*-< 73
I
i_j

n^
0) 03
o,
5* 3
BL P “
3 P
1
s ^ § p 03
S’ p t+3 B
c J CD
CD
s
i
s- B os p. p
O g 2
ft)

° p ere
5- r 03 o
U 2 O 73
^ O
^ 2 p
CD
p »-<
d 2. O 2
cr g p g 3
O s=
£L 5 3 3 -P" J
§ 8
S3

~ H
CD

o' g
CD
3
CL
O 73 O ^ 3
o cr o £ n- a ,
g-
CD
^
p
O 1/3
s-|i? »3 H S
2. CDG p p 3
*-t
cr
a
cr CD
p o £L Ö
g-_
3 O s “ f
P H- «*O CD
O
g
3
sT
73
cr
P ^ s yl ^ET P H °S
" CD 2 cr !?-

sa 3 g S3P
3 p
C/3

JO g2 o O
-T cl 73’ Et H— P o
2 o o n
73

S g g
CD £l 73
2 3 — cr
g.G P
Cl* • CD
S3
Fig.
tA*73
3
“ « p EL
/Ti
C
‘"T
cr ft
S‘
H 1 U
o
0)

g
. H-t-
T3
o G £ "Ö c-H cr 2-
“1
£*>
o 73
“ O S'
P
P-
CD
S o % « > G
G.
«O' 1

£ Herep §
3 HI
w 3
3 3 3
° s » §
g
S» p CD
5
r-t 0 o
o »
rt>
*0 a 3
q •-t S'
2
O i
2 2 »3 72.
O
" G
CD
3
o>
2
G CD
•t
P^
CD
CD
73
J33

^ 73
5
CD
S'
crq
d 73
rr
w
p
.

CD
<
O
i-h a g S ^ 1 cr
CD
3
co S' P& o cd
co
cr
o > "
o a g
5'
73 ^-1 Left

c X
s« ^q §I
CD G'
^ CD *H r-t- C < "d p o O^
3 73 §• -^r
cr < § p, q p CL CD
O
>-t
3
P CD
5
0-
CD — 21 o CD
£ ^ CD
73 £ _
» w » 73
CD
w^ H
to
73 3 O P g-§ O cr
^ §’ O o
CD

w 5' ^ ^s H
cr
H^<
er
Ö-
er
o ^
»
Ee>M X
J> CD
Axilla.

Hi -7d_
CD CD CD
^ 2 o 3:
H+,

*— *1
r-H
p- CD < er cr as

^ P 3 p p O
CD
^ “I
c O r? CD
a CD Ct-

2 ^ < p 2
g q.
2,
r-H
*0
CD
3
o O
3
JO?
m
cr cd
^
cd
73

"0
S j*
< >5'
2: 63 cr -*
3 CD crq g 2
o g a H-.
“ < G
n
s CD ^S.
3 Tl ^ —
-,

. CD E-T ore

0 73 CD G gerq H CD <j
- <
o P
3 r-t
3 & o
o „
2
CD
D CD
Cr
O s i 3
^ M H
1»
CD

o 3 O '•

0 a G
*) VJ CO o
P 73 Hi X CD

p 2 "> CD_ O 3 o p a
p- o G 3 £ EL -t
n
8 si
" CD
o'
2 CD
S p
?
-r

o «
? S3 ?? a 73* r-H
o g
er cd
b. pl P
ft
a

> ro ?l G n p 3
HI
2
r 2.
I—r>
& 3
V v DD g 3 3
^ cr EL
~ P
“
X 73
CD
o o S3 EL
8 9
5" Qcre CD
G G& CD *-H
O
a-.
< 3 CD 2:

G g
^ 3. H-H, H-.
crq
EL P^
cr CD
ft-
•< p- 3 CD n- P C/3 CD
31 tr 3 p ^ CD

>
CD
2 S-
cl
5’
b 73 CD cr
0.
p- 3
£
£ 2 cr ^
d0^3
.

a. 3: « 3G 3 p CD
CD
3
> a
3 CD O 3
cd ere CD
J> p p cr S’ 3
a, CD CD P
i-*

c
cr
cr hi a o •-t “ q
S
£ tr 73
• 03 3 CD
a 3
s 2 £- >TJ O
2^(re'
?^
3 &
rt'
2
<
G
CD

G
s?
s p
^ 3 S
CD f—v
S’
CD r-H
^> ST
M
cr
CD
hm
rq
o
^ >
73
p X
CD

P*
r-t-

o>
.
crq

<
S33
CD CD
as
G
CD
O EJ,
HH
cyi 3
l*x
G M" cd
cr
p F^
#

'o'
S4, C/3
» H G HI £ «? CD
H ,
cr
§ CD
1-4 73
cd
H g § o Q p
!=r
<
-l
<i £ 2. H O g
CD
S!
^ h S3 CD
EL 3“
S'
>
G G
CD CD 3
ere"
*-<
CD
Qrq G H CD CD < OG X
g 3- X5 <
O
Si P
P cc n
(D
^ <5j ere' O
O
P
3
er 0
o ^ CD
CD

W §
Ä H (i

of rd
73 3
CD
EL
CO
o I'S* g 03 G O
3-
5 < '

p •H p p o 3 3P CD cr os' 2.
3 2 3 H-h J4- co
" 3
y W EL CD 0 P -
.
O* 3:
g^ 73
%
r/5
2 ^ 2 0 0-2! cr.
•-t

p o °
a 3 C P _ 3 -
o g
£. a < 03 G
^ r-H
S n- H « " G G <
n
s 3
3 "
O
CD
**
P
cr tr
CD
G p
H-. CD cr ,
2.
3
P EC
CD CD 03 CD CD 1 S'
Figg s 73 and 74. Relation of the Capsule of the Shoulder- Joint
. to the
Upper Epiphyseal Line. After von Brunn.

Fig. 73. Frontal Section through the right Shoulder-Joint of a

boy aged 8 years. Arm abducted to a right angle.
Arm placed horizontally. Seen from in front.

Above, on the outer side, the Capsule of the Shoulder-Joint does not
extend as far as the Epiphyseal Line, but on the lower aspect the Capsule passes
beyond the Epiphyseal Line on to the inner side of the neck of the Humerus.
At the point marked *, the thin dark line shews how the Capsule is reflected
so that Separation of the Epiphysis does not necessarily open the Joint-Cavity.

Fig. 74. Horizontal Section through the left Shoulder-Joint of

a boy aged 8 years. Arm abducted to a right angle.

Arm placed horizontally . Seen from above. The section passed directly below

the Spine of the Scapula and touched the lower border of the Acromion
Process.

The relation of the Capsule to the Epiphyseal Line is the same on the
anterior and posterior aspects, as it is below (cf. Fig. 13). It is true that the
Joint-Cavity extends beyond this boundary (only because the Capsule, arising
from the Articular Cartilage, is attached for some distance to the Cartilage or
to the Bone).

The Epiphyseal Lines, Epiphyseal Boundaries or Epiphyseal Cartilaginous

Discs are of great importance for many reasons. The longitudinal growth of the

long bones takes place chiefly, if not exclusively, at these lines, i. e. at the
Residual Cartilage between the Diaphysis (shaft) and the Epiphysis. This growing
process is especially marked at puberty, but on the other hand, it is especially

liable to be interfered with during the same period, by inflammation, which may
result in the Separation of Diaphysis and Epiphysis.
Traumatic Separation of the Epiphysis is not so frequent as Inflammatory
Separation. Fractures usually occur near, but not (in) along the Epiphyseal Lines.
Excision of joints in children should only be performed with due consideration
of the Epiphyseal Lines.
 Deltoid Muscle Epiphyseal Cartilage Clavicle

Supraspinatus
Muscle

Humerus

Scapula

Subscapular Muscle

Fig-. 73. Frontal Section through the right Shoulder- Joint of a boy aged 8 years.
Arm abducted to a right angle.
Nat. Size. — After von Brunn.

Fig, 74. Horizontal Section through the left Shoulder- Joint of a boy aged 8 years.
Arm abducted to a right angle.
Nat. Size. — After von Brunn.

Rebinun Limited, London. Rebman Company, New York.

 Subdeltoid
Deltoid Muscle Bursa Humerus Coraco- Acromial Ligament
Long Head of Biceps Muscle
j
Coracoid Process Costo-Coracoid Membrane

Clavicle

Small Pectoral
Muscle

Bursa
under Coraco-
Brachialis
Muscle

Humeral Branch
of Acromio-
Thoracic Artery
Coraco-
Brachialis
Muscle
Anterior
Circumflex
Artery
Coraco-
Brachialis
Muscle

Great Pectoral
Muscle

Cephalic Vein

Deltoid Muscle

— Short Head of Biceps Muscle

Long Head of Biceps Muscle

Th JYo7ise
•

Fig. 75. Anterior Relations of the Shoulder-Joint.

Nat. Size.

Rebman Limited, London Rebman Company, New York

 :

Fig* 75* Anterior Relations of the Right Shoulder-Joint.

Skin and Superficial Fascia over the anterior portion of the Deltoid and the
outer portion of the Pectoralis Major have been removed ; the Deltoid has been

cut below the Shoulder- foint and thrown upwards and outwards. The Sub-
deltoid Bursa (pink), the foint ,
and the Sheath of the Biceps (light blue)
have been opened.

The middle third of the Clavicle and Subclavius Muscle, the Coracoid
Process with the insertion of Pectoralis Minor Muscle and the common origin of

the Coraco-Brachialis and Short Head of the Biceps are shewn. The Long Head
runs through the Shoulder-Joint over the Head of the Humerus into the Bicipital

Groove. Its synovial sheath always communicates with the Joint. Effusion and
#

Pus in the Joint often extend into this sheath.

Between the Capsule of the Shoulder-Joint and the Deltoid Muscle lies

the Subdeltoid Bursa, which, as a rule, does not communicate with the Joint.

Distension of this Bursa may easily stimulate fluid in the Shoulder-Joint. The
fibrous strands running from the Coracoid Process to the Capsule and the wall

of the Subdeltoid Bursa are called the Coraco- Humeral Ligament. They are

covered in the figure by the much-distended Bursa.

Between the Capsule and the Coraco-Acromial Ligament which forms a kind
of protective roof for the Joint an important bursa, the Subacromial Bursa, is found.

A third large bursa lies between the Scapula and the Subscapularis Muscle
the Bursa Subscapularis usually communicates with the Joint (cf. Fig. 121).

The Capsule of the Shoulder-Joint is wide and loose; it allows the Head
of the Humerus to leave the Glenoid Cavity of the Scapula for a distance of as
much as one inch. Above, this Capsule is attached to the neck of the Scapula;

for the greater part, it is attached to the fibrous ring which deepens the Glenoid

Cavity (Glenoid Ligament). The Long Head of the Biceps arises from the upper
part of the Glenoid Ligament.

The Glenoid Cavity is not directed exactly outward, but somewhat upwards
and forwards.
When the arm hangs vertically downwards, only the lower portion of the

Head of the Humerus touches the Glenoid Cavity articular surface of the Scapula,

at least in dead bodies. The highest point of the Head of the Humerus lies at a

distance of 0.15 — 0.25 inch from the highest point of the Joint Cavity.
Size.

Natural

Side.

Right

Fossa

MOHRENHEIM’s

Fossa

Infraclavicular

76.

Fig.
 Artery

Acromio-Thoracic

Fossa).

Gland

Lymphatic

(Mohrenheim’s

Interpectoral

Fossa Size.

Nat.

Nerve

Thoracic Infra-Clavicular

Anterior

76.

Muscle

Fig.
al
 Posterior
Circumflex Circumflex Teres
Deltoid Muscle PLumerus Artery Nerve Minor Muscle Deltoid Muscle

Long Plead of
Triceps

Posterior Ax i 1 1 ary
Lymphatic Glands

Teres Major Muscle

Latissimus Dorsi
Muscle

Posterior Cutaneous
Branch of
Circumflex Nerve

Outer Plead of
Triceps

Fig. 77. Posterior Relations of the Shoulder-Joint.

Nat. Size.

Rebrnan Limited, London. Siebman Company, New York.

 Fig 77-
-

. Posterior Relations of the Shoulder-Joint.

Skin and Fascia have been removed over the posterior half of the Deltoid, of
which a large portion has also been cut away.

The Anterior and the Posterior Circumflex Arteries arise, opposite each
other, from the last part of and wind round the Surgical
the Axillary Artery
Neck of the Humerus, the former from in front, the latter from behind. The
Posterior Circumflex Artery passes through the Quadrilateral Space formed by
the Teres Minor (above), the Teres Major (below), the Humerus (anteriorly) and the
Long Head of the Triceps (posteriorly). It supplies the Teres Minor, Deltoid etc.,
and ends by anastomosing with the Anterior Circumflex. With it run its 2 Venae
Comites of which only the larger is shewn in the figure. Taking a similar course,
but somewhat posterior, the Circumflex Nerve passes to innervate the Deltoid
and Teres Minor Muscles and the skin over this region. Its large cutaneous branch
emerges at the posterior border of the Deltoid Muscle and divides into an as-
cending and a descending branch.

On the Teres Major, below the Deltoid is a lymphatic gland which is prob-
ably constant, — the Posterior Axillary Gland (Frohse) — ,
it is usually subcutaneous;
in pathological cases, we have
found deep glands which lie on the blood
also
vessels. Their efferent vessels pass through the triangular space, between the
Teres Major, Minor, and Long Head of the Triceps, forwards to the Axilla.
On the dorsal aspect of the trunk there are other subcutaneous lymphatic
glands which are neither constant in position nor in number (cf. Fig. 145 and text).
The Superficial Glands of the Thorax and Abdomen may be divided into
Anterior, Posterior and External, according to their position.
Anterior Glands: Clavicular Glands lying on the Clavicle, above the
Deltoideo-Pectoral Fossa, sometimes also on the origin of the Sterno-Cleido-Mastoid
Muscle. (Cf. Fig. 115.)
Internal Pectoral Glands, usually at the level of the 2nd rib, along the
inner border of the Breast (the blue gland in Fig. 114).
The Xiphoid Gland, at the base of the Xiphoid Process (cf. Fig. 114).
External Glands (i. e. external to the nipple line):
External Pectoral or Paramammary Glands, outside the Nipple, and along
the outer border of the Breast. They are intermediate glands for the lymphatics
of the nipple (cf. Figs. 114 and 115).

Thoraco-epigastric Glands (1 —
4) along the External Mammary Vessels.
One of these glands is nearly always palpable and sometimes visible through
the skin.
The most important of these glands are the Thoraco-epigastric, Para-
mammary and Posterior Axillary. The subcutaneous position of the first mentioned
is especially well noticeable when Langer’s Muscle e. a muscular connection
(i.

between Latissimus Dorsi and Pectoralis Major) is present. Their efferent vessels
run in this case along the free border of the Axillary Fascia, where it is bounded
by that muscle, before they open into the Axillary Glands.
The Shoulder-Joint is accessible for (operations) surgical measures from in
front, and from behind. The Circumflex Nerve has, however, to be avoided on
the posterior aspect, because injury would produce paralysis and atrophy of the
Deltoid Muscle.
 * 8 l o 1

,
0) 4 4 02 43 b c is
%2
<D

g §? 0
C/3
13
£ >
4
02
3 8 £ 02
P
43
^ c3
° £ §
C/3 u 02 «p
'
S

co
^ a s-
P
ffl arteries

CO
$ 1-1
<D
> 4-»
CD

C
£ H •5
.5
S 3 £3
02
•y
p
02
02
This
division

ffl C — 02 02
^ S 73
02 P u (D
l

02
4 4 02 43 43 "33
& be
.
43 2
h.a ^ <D +->
CD 33 P3 43
02
+J
op
43
o « pq U c-]
2 O 33 r-< TO

0)
K^l
4
'ffl-

O
_

4->
&
H-, -3
H £ 13
s-i

2
43 ^ p
small.
high the

P 43
1) s-i
43 _ s
£ 02
P -t! -g
+J P 3 4 3 'p 7:3
a
02
O
S
02
S

02 a 0 44 ° 02 is
§ 43 <4 43 te oe
4 o O 43 o c 40 73 02
S-.
02 02 43 in
«3 P c/2 3P
43 43
between

<3 4 to 5 ü £
& P3
02 -3 Vessel

pq 02 that

o « S-I 4 73 02
I? O
co 'S 0) 02 p s
rs ° 43 S3
4 02 5
ctf 02 ^
c /2 43 P S 3 .2 ^ > S-i
£
aj fact

4 4 a 0 S'
4-1
0)
02
02
+j
S 3
Sz
5 02
S-I

3 73 k*'»

^ ^ £
02
02
£3
02
P > 43
A->
02
S

O
S-.
43
<D

§
Jh
Superficial
the communication

p 2 02
4 02 02 P 03 s-i CO
02
2 g > rP |S
CJ
CO
4 .2 Ei
'4 " 2 o w £ £3 P by
be bß
£ £ £ & 02 P 43 C pq 4)
_>
3
&
^
-r

0 to pq
4P 1
Size.
- ^ O 8 g !? 02 CO ^2 the
be * 2 W
^ p=& O>
Oh 02
r
a;
•3 c O
~
02 43
4
43
+*
PP
02 >,
’be S 3P important

A>
S3
£ 02 H CO 2 C? 2 p
:&
io
O if large
Space.
O' g
S=
ffl G <D 43 73 • & C 02
43
Natural
t§ ^ 4 «
~ 2 -*- >
S
P
3 •
>!
J-H O 02 ^ 5^ ’ll
>
„
(0 * a
n Ph 0) <D S' ’G C 4
8 w
02
.
c 02
£ 43 ^
02 •-I 02
> ^ -J
S ^ —O
02
> > ^
-
02 5
< pq
02 .p CO
4 ffl JP
especially more

4 > ^ <+h Id 02

A, äo 02 A M 5 02 O u ffl it 02
>
£3 ffl
frequently
Antecubital

^ 1
43 £ g 02
73
. 3
C
4
+-I

4-1
ctf

P
still

Arm. ^ kJ 0 73 43
02
.
CO .§£ aj
CÖ
02
ffl
1 1 p 02
»-I 53 co
ffl
o
o 02
0 ""
S-I u 0 ) Jh
ffl

O qq 43 C /3

p 0$
4
Nerve,
is
73
c
02

£
02
§ « Jffl H ‘u
0) C/3
.p
£ bffl the
aj
02
c 3
"2 <D
<D 0 rendered

Right 02 C/3 02 0) there

o c
O S U
72 5 5 oj the at

.°
2 oi c3 U G /3 l
02 be
—G a be C
"S K*S

H
C/f co"
the
*73 c/f
— g
CC O £ > rO 0 p
Its
P O S
.£ p 4 -»
ffl acute front
- 0 p o £ C/3
0 U *G
Nerve

o 2 O U 02 .£ 'S
€5
C/3
g £ ffl ffl 0 02
G £
02 ffl
of
2 .£ ^
S +-> _ fflg3 Ih
c^ aj

a^
pn
Vh
rb o
P
ffl
in
0°
size.
4; CD <D 4 ffl: an
4
a
C !

s £ p 4—2
p 2 pi, 02 £3
. co the
S' o +j &v-i
4 Pi 02 p 43 aj O 02 ffl
at lies
Side js -s. ~ 0 5 <1 m ® 6 o ^ p its

CO 3
°0
£ p 8 u r? C it
g J7 p pq
ffl to
2 o 02 c <v
4— & Ü £
73
8 I o CJp > 4
O 02 artery
arm,

part
Jh o c o P (J 43
Inner
jfJ
<D 0 4 .y a
C/3
the
tH *g fc <J 4 O 4 ffl Jj ^
ffl
rj u CD
c
02 ffl _ ffl
c /3
aj
02
ffl
£ ^ 2 ^ ffl
Q4 g
^ £ ^
p ffl
4 according
the
of
co a 43
22
r-— I

+->
(/)
co ffl 4
ffl ffl

P O £ £ p
8
<D
</) f 02
O C/3 ^ biO
_ CO part
middle

78.
02 sp - > ^0 02
c

^ /3 p p.
o )
cj
43
02
C 02 g CD - 43 .
ffl
p 57 >> ® ,g
crosses

W) 1 * dll
ffl ffl ffl
<V
-Ü
ffl
•*“>
»H
CD
02
"4
4- pq muscle,
the

• H 2 w •r; <D oj - c t:
co
4 -•5 CO
4
upper

in
fa
02
-5
^7 rO
Cö ^ C/3 co
<1
02 ffl
02ffl
-33 ffl
02
;
co
02
> O
+-»
c/3
a)
K.
P
^
P S

p
3
P P 4P which

4 be 43
o c 02 co
^ 4-1
this the
4J '
43 ffl 73
c c d ffl - O
Ö ^
< 1)
o> c
o d
cvi co
10 02
<»
Hs» S3 jD
C/3 ffl/
0 p P
ffl
02
£
p C ffl In
Artery

ffl
M 4
•'A
<s 73 P ffl 02 <D
H p oj
G
<D
rC
.£ > P 02
pq 4 02 by Nerve

£ £ >
5
aj > ° % aj Jh
o 02
ä 'ö
02
O
ffl 02 02 Jh the
O 43
4 _o4
<D
Co
32 1
4
r~j
41 ni
^
P
P 41
02
4
43 a o p ^ ffl
Vh
i_)

O
—
02 ’4 important.
to
CO P ffl 4 PP r~]
Median

ffl
P
4 ic> o 02
oe
02
^

in
overlapped

<5 1)
(

U 0) <p
c 'ffl 02 4 H 02
4
be
4
<D
bo
4 Ü ^ ^
* - r* 43
4 £
43
02
p ^p 8
the

J-h r- S 02 Ö ffl
^ ffi fflJ
most

*’“'
-3
ß £
3 p
.

C/3 8 «
> 43 1 ^
be
p
less

to
antero-external

’S o ’S £ ß
l^ 44 'S 02 o
c
n f is
<13 CO
^ H
MH § cti Ä 02 p3 'S
or

H c 3 43
0 >
02 pq 4S 44 ^ >
if O
73 ffl ffl .3
02 p relation

02 ffl o .a 02 £ 02 fc § 02 ffl to 02 more angle

hv P 6
s ffl
1 •§ 43 43 43 4 4
ri
pq 6 P ffl
is
 'll

York.

New

Company,

Rebman

London.

Limited,

Rebman

ji|

1J!| j
 Deltoid Muscle

Teres Minor Muscle

Posterior Circumflex
Artery

Humerus

Teres Major Muscle

Long Head of Triceps

Superior Profunda Artery

Coraco-Brachialis Muscle

Brachial Artery

Musculo-Spiral Nerve

Ulnar Nerve

Inner Head of Triceps

Outer Head of Triceps

Musculo-Spiral Groove

Brachialis Anticus Muscle

Cutaneous Branch of
Musculo-Spiral Nerve

Musculo-Spiral Nerve

Brachio- Radialis
(Supinator Longus)
Muscle

Posterior Branch of
Radial Nerve

Fig. 79. Outer and Posterior Aspect of Left Arm. — Nat. Size.

Rebman Limited, Loudon. Rebman Company, New York,

 Fig. 79. Left Arm, Outer and Posterior Aspect.

Skin and Fascia have been completely removed ; a. large piece of the Outer Head
of the Triceps, and the posterior portion of the Deltoid Muscle beloiv its origin

have been cut away. The Long Head of the Triceps has been drawn down-
wards and backwards. The Venae Comites have been removed.

Below the Shoulder-Joint, from the anterior aspect backwards, around the

Surgical Neck of the Humerus, between the Teres Minor and Teres Major, the
Posterior Circumflex Vessels pass (the Artery being a branch of the Axillary and
having 2 Venae Comites). The Circumflex Nerve accompanies them; it supplies

the Deltoid and Teres Minor Muscles (cf. Fig. 77).

Behind the outer border of the Humerus emerge the Musculo-Spiral Nerve
and the Superior Profunda Artery, as they wind around the bone in the Musculo-

Spiral Groove (cf. Fig. 80). The Nerve pierces the External Intermuscular Septum
and runs downwards to the forearm, between the Brachialis Anticus and the
Brachio-Radialis Muscles (cf. Fig. 81). This spiral course of the nerve is a serious

obstacle in extensive operations on the arm (e. g. extensive scraping of the Humerus
for Osteomyelitis). The Anterior and Internal surfaces are not favourable for

operations, owing to the large vessels; on the Posterior surface the Musculo-Spiral
Nerve is in the way, because its course is not a straight one, like that of the

nerves in the thigh. Its close proximity to the bone explains why it is so often

injured in fractures, and why it may be pressed upon by or be embedded in

Callus-formation.

The Ulnar Nerve runs for a short distance parallel to the Long Head of

the Triceps.

The Superior Profunda Artery anastomosing, by means of a Recurrent

Branch, with the Posterior Circumflex Artery, supplies the Triceps and the Humerus
(nutrient artery) and divides into an Anterior and a Posterior Division. The former
accompanies the Musculo-Spiral Nerve and ends by anastomosing with the Radial
Recurrent Artery. The latter runs in the substance of the Inner Head of the

Triceps downwards to the Olecranon where it anastomoses with the Interosseous

Recurrent Artery.
Fig. 80. Transverse Section through the Middle of the Right Arm.

A specimen from a series of sections taken from a frozen body. This section
shews the under surface of a right upper stump or the upper surface of a left
,

arm. For practical purposes, the former interpretation is to be preferred.

Note: The relation of the Median Nerve to the Brachial Artery; the Ulnar
Nerve and the Musculo-Spiral Nerve winding round the bone. The External
Intermuscular Septum is well displayed; the Internal is not distinctly visible in
this section.
The Flexors (Brachialis Anticus, Biceps and Coraco-Brachialis), are separated
from the Extensors (Triceps) by the Intermuscular Septa. The Internal Septum
runs along the inner border of the Humerus to the Internal Condyle. The External
Septum extends from the insertion of the Deltoid Muscle downwards along the
outer border of the shaft of the Humerus to the External Condyle. The Internal
Septum is really the fibrous continuation of the Coraco-Brachialis (which passes
in some animals to the Internal Condyle). The enormous Triceps presses these
Septa forwards; in this section they are shewn to describe a curve with its con-
vexity directed forwards. Both groups
Muscles thus lie in fibrous sheaths,
of
formed by the Fascia of the arm, the Intermuscular Septa and the Periostium.

Fig. 81. Transverse Section through the Lower Third of the

Right Arm.

Section through a right arm hardened in formalin. Interpretation similar to

that of the section above (Fig. 80).

Note the differences in shape, size, and position of the various structures,
as compared with Fig. 80. Shape of the Humerus, of the Biceps, of the Brachialis
Anticus, of the Triceps. — Change in the position of the Musculo-Spiral Nerve
which has left the bone, of the Ulnar Nerve which has reached the Internal Inter-
muscular Septum etc. In this figure, all the Fasciae are coloured b 1 u e. Thus the
continuity of the Intermuscular Septa with the Periosteum, at the outer and at
the inner border of the Humerus, and with the Deep Fascia is shewn. The latter
binds down the muscles and forms thin fascial septa between them e. between
;
i.

Biceps, Brachialis Anticus, Coraco-brachialis, and between the 3 heads of the Triceps.
The whole arm is enclosed in the Superficial Fascia which is especially
strong on the extensor aspect. On the Deep Fascia run, covered by the super-
ficial fascia, the Superficial Veins and Nerves.
 Biceps Muscle

Median Nerve

Internal Cutaneous
Nerve

Brachialis Anticus Brachial Artery

Muscle

Ulnar Nerve

Cor aco - Br ach i a 1 i s

Muscle
Mtisculo-Spiral
Nerve

Inner Head of
Superior Profunda Triceps Muscle
Artery

Outer Head of Triceps

Inferior Profunda Artery

Fig. 80. Transverse Section through the Middle of the (right) Arm.
View from below. — Nat. Size.

Biceps

Brachialis Anticus Muscle

Musculo-Cutaneous Nerve

Brachial Artery

Cephalic Vein
Median Nerve

Internal Cutaneous
Nerve

Basilic Vein

Musculo-Spiral Nerve
Great Anastomotic
Artery

Internal Intermuscular
Septum
Inferior Profunda
Brach io -Rad ialis
Artery
(Supinator Longus)
Muscle
Ulnar Nerve

Posterior Branch of
Radial Nerve

Inner Head of Triceps

External Intermuscular
Septum

Long Head of Triceps

e.

Outer Head of Triceps

Tendon of Triceps

Fig. 81. Transverse Section through the Lower Third of the Right Arm.
Nat. Size.

Rcbman Limited, London. Rebman Company, New York.

 Lesser Internal Cutaneous
Nerve

Internal Cutaneous
Branch of the Musculo-
Spiral Nerve
Ulnar Nerve

Basilic Vein Cephalic Vein

Median Nerve
Biceps

Internal Cutaneous Nerve

Brachial Artery

Median Basilic Vein

Brach io- Radial is

Bicipital Fas< Muscle (Supinator
Longus)

Cutaneous Branch
Pronator Radii of Musculo-
Teres Muscle Cutaneous Nerve

Radial Artery

Flexor Carpi
Radialis Muscle’

Or. Fro b ee

Fig. 82. Left Antecubital Space — Superficial Layer.

Nat. Size.

Rebman Limited, London. Rebmau Company, New York.

 Fig. 82. Left Antecubital Space. Superficial Layer.

The Skin over the lower part of the arm, and over the upper part of the
forearm has been removed. The Superficial Fascia covering the Biceps and
the Superficial Veins and Nerves have also been taken away, but the Bicipital
Fascia and its expansions in the forearm are left intact.

The superficial and broad Bicipital Fascia ends by an expansion into

the Deep Fascia of the forearm and by blending with the Periosteum of the Ulna.
The true Tendon of the Biceps is inserted into the Radius. The Superficial Muscles
which arise from the Internal Condyle are intimately connected with the Deep
Fascia and the Bicipital Fascia in the upper part of the forearm.
Superficial Veins. At the upper end of the forearm 2 constant and one
not-constant Veins are found: the Ulnar and Radial Veins, and the Median Vein.
The latter vein divides into the Median Basilic, and the Median Cephalic Veins, the
former joining the Ulnar forms the Basilic Vein, the latter joining the Radial
forms the Cephalic Vein. These veins vary. As a rule, the Median Basilic Vein
is the largest vein in the Antecubital Space, and the most suitable for Phlebotomy.
The Cephalic Vein runs upwards in the arm and disappears between the
Pectoralis Major and Deltoid Muscles, to join the Axillary Vein (cf. Fig. 75 and 76).

It thus forms a collateral venous channel. The Basilic Vein joins the Venae
Comites of the Brachial Artery and then forms the Axillary Vein, which, higher
up, becomes the Subclavian (cf. Axilla).

The Median Vein

is separated from the
Basilic Brachial Artery by the
Bicipital Fascia. The Artery can therefore be injured in Phlebotomy, and this

injury may be followed by an Arterio-venous Aneurysm.

The 2 chief Cutaneous Nerves of the forearm, the Cutaneous Branch of
the Musculo-Cutaneous Nerve and the Internal Cutaneous Nerve become super-
ficial at the Antecubital Space. The latter nerve runs with the Basilic and Ulnar
'

Veins. Its trunk and its branches lie in

1
l8
th of all cases at a slightly deeper level
than the veins. The nerve may have divided into 2 large branches, where it

pierces the fascia of the arm.

 Fig. 83. Right Antecubital Space. Deep Layer.

Skin, Superficial, and Deep Fasciae have been removed. The following muscles
are exposed: Biceps with Bicipital Fascia, Brachialis Antic us ,
as far as it

is not-covered by Vessels and Nerves, the upper portion of the Superficial

Flexors which arise from the Internal Condyle, especially the Pronator Radii
Teres. The Brachio-Radialis which has at its upper portion been drawn out-

wards, is also displayed.

(As to the superficial nerves and veins which have been left in this spe-

cimen, see Fig. 82 text.)

The Brachial Artery runs, accompanied by its Venae Comites, along the

inner border of the Biceps, towards the acute angle formed by the Pronator Radii
Teres and the Brachio-Radialis Muscles. In its course, - in front of the line of

the joint — it divides into the more superficial and smaller Radial, and the more
deeply placed and larger Ulnar Artery. Internal to the Brachial Artery (or rather

to its Internal Vena Comes) runs the Median Nerve which may, however, He more
2
than / 5 th inch internal to the vessel. This nerve pierces the Pronator Radii

Teres and supplies the Superficial and the Deep Flexors of the forearm, except
the Flexor Carpi Ulnaris and the inner portion of the Flexor Profundus Digitorum

(cf. Fig. 89).

Along the outer border of the Biceps runs, at a deeper level, the Musculo-

Spiral Nerve; this Nerve lies between the Brachio-Radialis and Brachialis Anticus
Muscles (cf. Fig. 89).

The mass of muscles arising from the Internal Condyle of the Humerus
and the portion of bone above it, and from the deep fascia of the forearm, sepa-

rates lower down into the Pronator Radii Teres which is inserted at the middle

of the outer border of the Radius, into the Flexor Carpi Radialis going to the

base of the 2nd Metacarpal Bone, into the Palmaris Longus, which is not always

present, and into the Flexor Carpi Ulnaris, which arises also from the Ulna.

The lymphatic glands are described in Figs. 89 and 115 text.

 Cephalic Vein
Deep Cubital Lymphatic
Gland

Internal Cutaneous Nerve

Biceps Muscle Basilic Vein

Superficial Cubital
Lymphatic Gland
Brachialis Anticus Muscle
Median Nerve

Cutaneous Branch of Median Basilic Vein

Musculo-Cutaneous Nerve
Companion Veins of
Brachial Artery

Musculo-Spiral Nerve j Internal Condyle of

Humerus

Deep Portion of /
Brachialis Anticus
Muscle Brachial Artery

Recurrent Tibial
Brachialis Anticus
Artery
Muscle

Tendon of Biceps
Bicipital Fascia

Posterior
Interosseous Nerve Ulnar Artery

Supinator Brevis Pronator Radii Teres

Muscle Muscle

Flexor Carpi Radialis

Radial Nerve
Muscle

Palmaris Longus Muscle

Radial Artery

Flexor Sublimis
Digitorum Muscle

Br.lrohso

Fig. 83. Right Antecubital Space: Deep Layer.

Nat. Size.

Rebman Limited, London.

Rebman Company, New York.
 Inner Head of Triceps

Internal Cutaneous
Nerve

Ulnar Nerve

Great
Anastomotic
Artery
Brachialis Anticus Muscle

Basilic Vein

Inferior Profunda
Artery
Brachial x^rtery

- Olecranon Bursa
Median Basilic Vein

Cntaneous Branch of
Musculo-Cutaneous Nerve

Flexor Carpi
Cephalic Vein U lnaris Muscle

Bicipital h
Anterior Ulnar
Recurrent Artery

Common Ulnar
Ulnar Origin of Pronator Recurrent Artery
Radii Teres Muscle

Common Interosseous
Median Nerve Artery

Flexor Muscle of
Fingers
Humeral Origin of Pronator
Radii Teres Muscle

Median Artery
Brachio-Radialis Muscle
(Supinator Longus)

Ulnar Vessels

Radial Artery

Superficial Flexor
Muscle of Fingers

Flexor Carpi
Palmaris Longus Muscle

Fig. 84. Region of Elbow — Right Side.

Nat. Size.

Rebman Company,
Rebman Limited, London.
 Fig. 84. Region of Elbow — Right Side.

Skin, Superficial Fascia (except the Bicipital Fascia) and the upper portions of
the Superficial Muscles arising from the Internal Condyle have been removed;
the Pronator Radii Teres, however, is left intact.

This figure shews the region of the Elbow, the deep layer of the Ante-
cubital Space and the upper third of the Forearm, from the inner side.
The course of the Ulnar Nerve behind and below the Internal Condyle
is well displayed. The nerve having pierced the Internal Intermuscular Septum,
comes to lie behind this Septum, often embedded in the Triceps Muscle; then,
passing behind the Internal Condyle, it runs between the Humeral and the Ulnar
Origins of the Flexor Carpi Ulnaris Muscle. The Ulnar Nerve supplies the Inner
Head of the Triceps, and both Heads of the Flexor Carpi Ulnaris, giving off an
anastomotic branch to the Median Nerve. In man, only a portion of the Flexor
Profundus Digitorum, the slips to the 4th and 5th fingers, are supplied by the
Ulnar Nerve.
Behind the Olecranon is the subcutaneous bursa which is the bursa most
frequently diseased, with the exception of the Patellar Bursa (Miner’s Elbow).
Cf. Fig. 86.
There may be a Common Ulnar Recurrent Artery (branch of the Ulnar
Artery) which divides into Anterior and Posterior Ulnar Recurrent Arteries, or
these vesselsmay come off directly from the Ulnar Artery. The Anterior Ulnar
Recurrent Artery anastomoses with the anterior division of the Inferior Profunda
and the Anastomotica Magna, both from the Brachial Artery, and the posterior
branch with the posterior division of the Inferior Profunda.

Remarks on the Mechanics of the Elbow-Joint.

The articular surfaces correspond
to the type of hinge-surfaces, but not
exactly. has been suggested that they are analogous to screw surfaces. As a
It
matter of fact, they correspond to neither type, although the Trochlea of the
Humerus has the shape of a screw surface shewing an inclination of 0.15 inch,
movement of the Ulna does
a lateral not take place during flexion and extension.
Careful shews that the axis of rotation varies constantly during
investigation
movement, and that the change in direction is much greater than a simple screw
movement would account for. —
If the movement were a simple rotation, the

Ulna should move on the Humerus with as equal freedom as the Humerus on the
Ulna; this is not the case according to Otto Fischer.
This joint has, therefore, been described as a loose-joint, but Fischer has
shewn that during life the cartilaginous coverings of the joint continuously change
their position and shape during movement owing to the action of the muscles
which press them firmly together, and that the joint is no “loose-joint”.
 :

Pig. 85. Transverse Section through the Right Elbow-Joint.

The section (through a frozen body) has passed, transversely to the axis of the
Humerus, through the Trochlea and Radial Head of the bone, through the
base of the Olecranon, and the tip of the Coronoid Process of the Ulna.

The reader looks at a right forearm from above. The Head of the Radius
with its elevated border lies free; the deeper middle portion is taken up by the
radial head of the Humerus. The strength of the Internal and External Lateral
Ligaments, the Bursa over the Olecranon, the position of the Ulnar Nerve behind
the Internal Condyle, and the positions of Median Nerve, Brachial Artery and
Musculo-Spiral Nerve on the flexor aspect are all worthy of observation. The
Brachial Artery divides, as a rule, at the level of the line of the joint (i. e. the
level of this figure) into Radial and Ulnar Arteries. Below this level, the lumina
of these 2 arteries, one superficial (Radial Artery), and one deep (Ulnar Artery),
would appear in a transverse section.
When the forearm
is extended, the tip of the Olecranon Process (cf. Lig. 86),

lies immediately below a line connecting the 2 Condyles of the Humerus. In

flexion, it lies at a considerable distance below this line. Dislocation of the Ulna
or fracture of the Olecranon Process is present, if the Olecranon lies above this
line during flexion of the Lorearm.

Fig. 86. Longitudinal Section through the Left Elbow-Joint.

The Forearm is in the position of almost complete extension. The section passed
through the Trochlea of the Humerus, the Greater Sigmoid Cavity of the Ulna
and through a portion of the Radius ; it is, therefore, intermediate between a
frontal and a sagittal section.
Note
1) The Subcutaneous Bursa over the Olecranon Process.
2) The Deep Bursa, above the Olecranon Process, situated in front (under
cover) of the Triceps, or in the muscle substance, just above the upper
recess of the Capsule of the Joint.
3) The Bursa at the Insertion of the Biceps (Bicipital Bursa).
The insertion of the Capsule of the Elbow-Joint on to the Humerus runs
along the upper borders of the 3 fossae which receive the Olecranon (posterior)
Coronoid Process (anterior larger) and Head of Radius (anterior smaller). These
three fossae are therefore intracapsular. — On the Ulna, the Capsule is attached
to the border of the cartilage of the Sigmoid Lossa or very near that border. —
On the Radius, the attachment is in the middle between the lower border of the
Head, and the Bicipital Tuberosity, extending lower down on the outer side than
on the inner.
The Capsule itself is very thin, but it is strengthened by anterior and
posterior longitudinaland oblique fibres, and especially by the Lateral ligaments,
an Internal and an External Ligament (cf. Fig. 85). The External Lateral Ligament
blends with the Orbicular Ligament, of the Radius, which surrounds the Head
of that bone and is attached to the Ulna.
(Continuation next page.)
 Brachial Artery Tendon of Biceps with Bursa
Median Basilic Vein
Musculo-Spiral Nerve
Bicipital Fascia

Brachio-Radialis Muscle
Median Nerve (Supinator Longus)

Brachialis Anticus Muscle

Extensor Carpi Radialis

Coronoid Process of Ulna
Longior Muscle

Pronator Radii Teres

Muscle Extensor Carpi Radialis
Brevior Muscle
Superficial Flexor Muscles

External Lateral
Ligament
Internal Lateral Ligament

Humerus

Humeral Head of Flexor

Carpi Ulnaris

Ulnar

Ulnar Head of Flexor Carpi Ulnaris

Olecranon Bursa Olecranon

Fig. 85. Transverse Section through Right Elbow-Joint.

Seen from above. — Nat. Size.

Humerus

Triceps

Biceps Muscle

i Bursa under Triceps

Brachialis Anticus

Bicipital Fascia

Olecranon Bursa

Internal Cutaneous
Nerve

Tendon of Biceps

Radial Artery

Ulna
Median Basilic Vein

Brachio-Radialis Muscle Deep Radial Radius Bursa under Biceps

(Supinator Longus) Muscle

Fig. 86. Longitudinal Section through (left) Elbow- Joint.

View from outer Side. — Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Humerus

Epiphysis of Internal Condyle

lying in the Olecranon Fossa

Epiphysis of Trochlea Epiphysis of External Condyle

Epiphysis of Capitellum

Epiphysis of Ilead of Radius

Ulna Radius

Fig. 87. Frontal Section through (right) Elbow-Joint of a person aged 19 years.
Nat. Size. — After von Brunn.

Long Head of Triceps

Humerus
Muscle

Brachio-Radialis (Supinator
Longus) Muscle

Epiphysis of Trochlea

Epiphysis of Olecranon

Ulna

Fig. 88. Sagittal Section through (left) Elbow-Joint of a child aged 8 years.
Nat. Size. — After von Brunn.

Rebman Limited, London. Rebman Company, New York.

 (To Fig. 86, former page.)
The lateral ligaments are very important in relation to the movements of
the joint. They become tense in marked flexion and extension.
Synovial continuations corresponding to the 3 fossae (vide supra) are
formed by the wall of the Capsule: a larg'e posterior, and 2 smaller anterior con-
tinuations. The one first mentioned is drawn upwards and backwards, during
extension, thus coming to lie above the Olecranon, between this bone and the
Triceps (cf. figure). During flexion, it fills the Olecranon Fossa; the 2 anterior —
processes present an opposite movement; thus the Anterior Ulnar Synovial Con-
tinuation (cf. figure) lies in the greater anterior fossa in front of the Trochlea of
the Humerus, during extension.
During extension a recess of the Capsule analogous to the one above —
the Patella in the knee-joint —
is formed above and behind the Olecranon.

This cul-de-sac extends higher in the living subject than is shewn in our figure,
which, necessarily, was drawn after death.
The Joint is most readily accessible from behind: in front there are
powerful muscles, and large vessels and nerves to be avoided, behind there is
only the Ulnar Nerve. Effusion into the joint bulges most at either side of the
Olecranon.

Fig. 87 and 88. Relation of the Capsule of the Elbow-Joint to the

Epiphysial Lines. (After von Brunn.)

Fig. 87. Frontal Section through the Right Elbow-Joint of a

person aged 19 years.
View from behind.

The Joint-Cavity extends far beyond the Epiphysial Line of the Head of
the Radius; but even here, the Capsule arises (cf. Shoulder-Joint) from the Arti-
cular Cartilage, and is loosely attached to the Radius as far as the lower end of
the cavity.
Disconnection of the united Epiphyses of the External Condyle and the
Radial Head of the Humerus from the rest of the bone will involve the Joint-
Cavity; the latter would also be affected if the Epiphysis of the Trochlea were
separated at the place where the Trochlea and the Radial Head meet.

Fig. 88. Sagittal Section through the Left Elbow-Joint of a child

aged 8 years.
View from the inner side.

The boundary line between the Diaphysis of the Ulna and the Epiphysis
of the Olecranon passes across the Joint-Cartilage. —
The Capsule also extends
above the line of the Diaphysis of the Humerus: Though fairly strong in front
and readily removed as far as the Joint-Cartilage it is firmly attached to the
Olecranon Fossa, and very thin, thus defying dissection.
Separation of the Epiphyses, — both of Humerus and Ulna — ,
will there-
fore affect the Joint-Cavity.
 Fig. 89. Right Forearm, Deep Layer: Anterior Aspect.

The Fasciae of the Antecubital Space and of the anterior aspect of the forearm
are removed, including the Bicipital Fascia, e. g. of the Superficial Flexors,
only their origin and insertion are left. The Deep Head of the Pronator
Radii Teres is intact, and the Brachio-Radialis is drawn outwards.

The Brachial Artery divides into Radial and Ulnar usually in front of
the line of the Joint. The Ulnar Artery runs downwards and inwards, under
cover of the muscles which arise from the Inner Condyle of the Humerus; below
the middle (or near the middle) of the forearm, it meets the Ulnar Nerve, which
runs along its inner (ulnar) side.
The Median Nerve, as a rule, leaves the vessels in the antecubital space,
pierces the Pronator Radii Teres and runs downwards between the Superficial
and Deep Flexors. Near the wrist, the Nerve emerges at the outer border of
the Flexor Sublimis Digitorum (or Palmaris Longus, if present), and comes to lie
just under the Fascia.
The Musculo-Spiral Nerve lies at the inner border of the Brachio-Radialis,
and divides into (1) the Posterior Interosseous, which supplies the Extensors of the
forearm (cf. Fig. 90) and (2) the Radial Nerve, which accompanies the Radial Artery
in the upper 2/3rds of the forearm, and then passes to the posterior aspect (cf. Fig. 93).
The Ulnar Nerve having pierced the Flexor Carpi Ulnaris, runs, to the
hand, along that muscle. At the junction of the middle and lower i/3rd of the
forearm, it gives off the Dorsal Cutaneous Branch for the hand (cf. Fig. 93). The
Ulnar Artery and Nerve only accompany each other in the lower i/3rd of the forearm.
The Anterior Interosseous Artery, the Radial and Ulnar Recurrent
Arteries are shown in the figure; these latter are important for carrying on the
collateral circulation on the outer and inner sides of the arm respectively.
We make special mention of the Lymphatic Glands in this region about
which so little is known; in the Antecubital Space: Superficial, Deep, Posterior
Cubital Glands; on the forearm: Radial and Ulnar Glands.
When the Palmaris Longus is absent —
and in some cases also where
it is present —
one can make the following observation. When the hand is
flexed upon the forearm, the tendons recede, and thus the Median Nerve comes
to lie directly under the fascia, where it can be seen, felt and rolled about. The
Ulnar Artery becomes at the same time more deeply placed, owing to the relax-
ation of the Flexor Carpi Ulnaris Muscle. When the hand is extended (dorsi-

flexed) the Median Nerve slides back into position and the Flexor Carpi Ulnaris
presses the Ulnar Artery to the surface. The pulse can now be readily felt by
placing the finger on the outer side of the tendon of that muscle.
The hand and the fingers at the moment of injury, trau-
position of the
matism, etc. is therefore most important. In Flexion, there is more danger for
the Median Nerve. In Extension the Ulnar Artery (and even the Ulnar Nerve)
is in greater peril, even when no muscle or tendon is injured.
 Basilic Vein

Cephalic Vein
Superficial Cubital Lgl.
Cutaneous Branch of
Musculo-Cutaneous Nerve

Biceps Muscle Deep Cubital Lgl.

Brachial is Anticus Muscle Brachial Artery

Bicipital Fascia Posterior Cubital Gland

Tendon of Biceps Flexor Muscles

Anterior Branch of Ulnar

Posterior Interosseous Nerve
Recurrent Artery

Nerve to Extensor Carpi Anastomosis between Ulnar

Radialis Brevior Muscle and Median Nerves

Radial Recurrent Artery

Common Ulnar Recurrent

Artery
Supinator Brevis Muscle

Upper Belly of Superficial

Ulnar Head of Pronator Flexor of Index Finger
Radii Teres Muscle

Humeral Head of Pronator Anterior Interosseous Artery

Radii Teres Muscle

Radial Nerve Ulnar Lymphatic Gland

Intermediate Tendon of
Brachio-Radialis (Supinator
Superficial Flexor of
Longus) Muscle
Index Finger

Radial Lymphatic Gland Median Nerve

Radial Head (to 3rd Finger)

of Superficial Flexor Muscle of Deep Flexor of Fingers
the Fingers

Anterior Interosseous Nerve Lower Belly of Superficial

and Artery V;
Flexor of Index Finger

Radial Artery. Ulnar Artery

Long Flexor Muscle of Thumb.

Ulnar Nerve

Pronator Quadratus Muscle

Flexor Carpi Ulnaris Muscle

Palmar Branch of Median Nerve Palmar Cutaneous Branch of

Ulnar Nerve
Tendon of Flexor Carpi
Radialis Muscle Superficial Flexor Muscle of Fingers

Tendon of Palmaris
Longus Muscle Dorsal Branch of Ulnar Nerve

dr.FroJme.

Fig. 89. Right Forearm: Deep Layer. Anterior Aspect. — Nat, Size.

Rcbm an Limited, London. Rebman Company, New York.

 Median Nerve Palmaris Longus Muscle

Flexor Carpi Radialis Muscle Superficial Flexor of the Fingers

Radial Artery
Ulnar Artery

Pronator Radii Teres Muscle

Radial Nerve Ulnar Nerve

Brachio-Radialis (Supinator
Longus) Muscle
Flexor Carpi Ulnaris Muscle

Radial Extensors

Supinator Brevis Muscle )eep Flexor of Fingers

Common Extensor of Fingers

Posterior Interosseous Nerve

Extensor of 5th Finger
Extensor Ossis Extensor Carpi Ulnaris
AT 0+0 r-d rr-ii

Fig. 90. Transverse Section at the Junction of the Upper and

Middle Thirds of the (right) Forearm.
Nat. Size.

Superficial Flexors
of Fingers

3rd, 2nd, 4th, 5th Deep Flexor of Fingers (3rd, 4th and 5th)
Pal mar is Longus Muscle Flexor Carpi Ulnaris Muscle
Median Nerve |
Ulnar Artery
Flexor Carpi Radialis Muscle
Long Flexor of Thumb Ulnar Nerve
Dorsal Branch of Ulnar Nerve
Radial Artery

Cephalic Vein
Posterior Ulnar Vein

Brachio-Radialis (Supinator
Longus) Muscle Ulna

Extensor Ossis Metacarpi

Poilicis Muscle Pronator Quadratus Muscle

Extensor Primi
Internodii Poilicis Muscle Extensor Carpi Ulnaris'
Extensor Carpi Radialis Longior M
Extensor Carpi Radialis Brevior Muscle Interosseous Membrane
• Posterior Branch of Radial Nerve Extensor Indicis Muscle
Extensor of Little Finger
Long Extensor Muscle of Thumb Common Extensor of Fingers
Posterior Interosseous Nerve

Fig. 91. Transverse Section through Lower End of (right) Forearm.

Nat. Size.

Rebman Limited, London. Rebmau Company, New York.

Fig. 90. Transverse Section through the Right Forearm at the
junction of the Upper and Middle Thirds.

Frozen section. View of a Right Arm from below, or a Left Arm from above.

On the Flexor Aspect are to be noted Position of the Palmar Branch of the
:

Radial Nerve (too large in the figure) under cover of the Brachio-Radialis position of ;

the Radial Artery between this muscle and the Pronator Radii Teres, about s/5ths inch
from the fascia. Median nerve in the middle between the Radial and Ulnar Nerves,
both deeply embedded in the muscles. Between the Median and Ulnar Nerves is the
Ulnar Artery the Anterior Interosseous Artery runs very near the Radius. Intermuscular
;

Septa are seen between the superficial and the deep flexors, and between the flexor and
the extensor muscles.
Dorsal aspect: Posterior Interosseous Nerve and Artery between the Supinator
Brevis and the Extensors. Near the condyles of the Humerus the special Fasciae blend
with the Deep Fascia of the forearm at the middle 1 /3 rd they are separate, thus forming
;

the “Lymph spaces” in which inflammation —

simple and suppurative rapidly spreads. —

Fig. 91. Transverse Section through the Right Forearm at the

lower end.

Frozen section. View of a Right Arm from below, or of a Left Arm from above.

Note: Portion of the Radial Artery, where the pulse can be felt and where the
artery generally ligatured, between the skin and the bone, separated from the latter
is

by fibres of the Pronator Quadratus. —

Ulnar Artery usually covered by the Tendon
of the Flexor Carpi Ulnaris; at a deeper level, and more towards the inner (ulnar) side
lies the Ulnar Nerve —
Median Nerve, between the Flexor Carpi Radialis and Flexor
Sublimis Digitorum, usually somewhat covered by the Palmaris Longus (cf. Fig. 95), if
this muscle is present and normally developed.
Fasciae and Septa are coloured blue in the figure which is a supplement to
Figs. 94, 97 and 98 in which the tendon sheaths at the wrist are shown.
The separation of the special fasciae and the fascia of the forearm
(cf. Fig. 90)

is also although there are no synovial sheaths.

well carried out here, The fascia forms
on the flexor aspect special compartments for the Flexor Carpi Radialis, Flexor Carpi
Ulnaris and Palmaris Longus. This explains why there are 2 Fasciae in front of the
Ulnar Artery, whilst the Radial Artery lies immediately under the fascia of the forearm.
An incision for ligaturing the Ulnar Artery, carried along the border of the Flexor Carpi
Ulnaris, divides not only the fascia of the forearm, but a second fascia which becomes
thicker lower down. This fascia forms the posterior wall of the fascial canal, in which
the muscle runs.
The Pronator Quadratus is covered by a fascia of its own. It is true that the
other Flexor Muscles and the Median Nerve also have their own fasciae, but they are
of no practical importance, and one should regard these muscles as lying in a common
“Lymph Space” which ends below at the upper limits of the Tendon Sheaths and is
bounded on either side by the Septa forming the canals for the 3 muscles mentioned
above. Above, this Lymph Space is continued into the arm, along the Vessels and
Nerves. This explains the danger (and also the necessity of making, deep incisions) of
deep suppuration in the forearm.
 1 I I 1 1 I H

b b d
u S
,
S' 8 o o
-
p -
X
d
^ >„
C/3
!

^0
O^PP-W'irfP
S
tfl
+h
co
2
Vh P
p d —p
.
^ Q
” ^ ^
<D 0)

o
0) .JL,

h
^
^
'
1 ’ A3 _,
£ IS O 0 .Sc %-» CL
c/3 co
o o^ u c p - £ CJ
^ m ^
2 p A
P— g, - pH
O
<4-H
0 <4
CJ
^ «3 UJ
J-. CO
-
<!
rG
0) ^ (T*
0 c
+-> "" c § Ö a)
P ?
O - S P 0 "G >
,.
9
73 .“2 in ~
G 91 ® ^ 'uO 73+H
m
£ 2 0)
•

S § a £
£
O •«p gP
P 4-> 73 D
a
^ p
-
.
in
pJ-H
C/)
. .

be a
=
« ^1
b - S 'S
0
kT
c/3

f> 3
S H P
d)
^ p C ]
i_.

S c b p 'u
b 2 Pi°
D
2j -pp 2 s
'TP; Jh C_) D P 5
™ (/) ^
—
JJ
<H
"o Pi § - M
u G J,
0) o
O < <q^ PP be .«. -4—> <v . 'L' g_> r-*—
CO
A be
2 be
So
.

§ 3 6 <u C/3 D
.5 « E p Vh h «2 (D o s S „
O
o _
G
t3 J£
AP ctf CO
E
iw
$ n ._ « .t! 2 ^
g- 2 p p 2 be E 0
H o > >4 o ^ D o c
. j_, a) t/3

X ^
^ ^ -
Pi b c +->
u co
ni 0) CU
O -S CO 4-1
S-.
„J
c
-rH o -y D
D P D 2
co _, aj iS vh
u c •0 S3
p P —P
•2 P A
a> a) :

o t;
H o .s bß
co
rP O E P G Ph O
tf o ~ 2 S < S3 Oh +-J .r-t

0
H G
G 0 f— G Ph D — >>
A
^
i

$ Lh P in
£ < >h .§ "S 3 IT ^
fe .P n $ CD
O
O £
D 4P P
ft-> QJ •*-’ nS
n3 ccS

u c * ed 0)
P P &rP
(“Snuff-Box”)

•S 1 Jd C <D
+J
-
"o u ,cö Gh S

5 S3
D E i
Ki CO
2 E 6 p O Ph
H-H
Vh
’u
CJ
co
D rrH
D
D as P^P S sTD-h'
&
Hj
^
0
4)
hhH
(/}
J_, .s 2 rG
C4-HH -H '

7S >, <D a) u w p > D TS p p E

. .
Ph'
L O ^ be s
.sl^ a3 'ft H-. b So Ph
CJ

P?2 0 E D
H-H

a c > S D o ^ D
eb E S3 £ a 4H
CO
o E
o P o
53
o to ,2 P P h Pi
o a .5 O P3 0
o P CO (n in 3 )H
d b -
<4-1
03
D s
O'
Surface

^ § 0 bjQ ,rH
in
(D
S D ^
V

- _ ’A 73 «- # Ph P CO
i_,
-4

D p *+* A
_ CD pD r CP ^
D PS 0
* CTj

E
G CO

£ g 5P
p ^
v G v-
P
Ph b c/3 S3
G D P g .

-2 ^ 0 C/) O „
S-H

^ ’S b
?
Pp
P C D C bC^ ^ D
*i
>i r< c^ tW G
Ph r2 G P Vh § Qh .5 s <
Outer
>
0 0
rG
4->
O
0 >; d
rf
.2Cp
co 2 4j I ts
g a
J—
I J,

.2 4^
c/3

g
Ä
'T!

.2 -4-P
IS Ph-PD^O-PPD^
D H s tS P
P |
CA)
0 O
G 4-> +J 2 co lL c P1r! rUO-'-H r

0 £ 5 E P XOcS O D P P
CA3

’0 G pH C
7S pG G .2 r—
O oUiPt/SU^.SH p C4 P P p
Wrist, «
a$ D
D P P
S £ b i P o p P
D bc T T3 P
Pb .E
C
pD 4-> p
G MH^ £ o P- c D
.5
EE s-h
P
rO
"d
A 4-* '”1 Vh
P
Dh P
hi
^ E D g Ph
a CO CG P
P
Right
D
Ph ° D p
D A ,/% pb d 73
CO
^ s D
*
*

Si
% O rj +-*
D
Vh
P D 73 A
.bp c
pb & P- P
O
|2
Pb O G
^
4 O 3 fti
P
^5
<»
D J 2 I >>
.
^ U P
rr-j
4->
- p
fti
""p
o ^ D P
the
^ D CO
O
co

©
1-.

EP w E CO
bO 10
D p CO t+H 3
2
4-J
P P
co 73
of g .3 n ° CO be t-h
p
Ph 2 ;
P
C CO P D < g ^
P ’d S *3 'o p
k 'S P Ph o pp .2 c
Ph «-t-H V-i
0
s 1 Hg-§ ire p •g S3 § ^ A A
^ O p J-. G Gd
r~]
2
G
> P CO
p
Vh
H I O CD s O
P O ° >4 H G
<-• 5-i

O 4J y> D
G P
P
tH ~ ' Sr 03 CZ ft:
p
Region
•* .O Ph
iS
Vh
D g
o pp _r ^
U L -a o
&
4-H
to
'
o p C
§C 'g ti "O
hH & A? D p 4-J
P
<»
M 2 2 p
S>
Ö
’S
D
O
5 (V
co
"
pH .P
s-h
P
o
o «J ‘o
j* Pb
P-
O 2
Vh

O G E 1
0
-Ills ^ 2 D co G
P O (J
P P S •* C w Ä
r—H 1
.
P ^ p D
>
^2 be be
O
92 P "s A l CJ) SSpH *2I p p D s s ° o 2 L
o £
t I .5
S s
^ b
5 ^ 0 C/3 o 1/2
Hp
co ^ ^o 2 ^
4->

P D .2
!

pi T3
1
?
Lb in
,TH
v-
be
Fig.
ftp » £B p 0 Oft
"O 2 2 Vh
Hi
H ^ d CQ PW
p P O -
ft
2 p G
o ’S 2
<J II
Ä 2I^ J-H
g
4-H
i
“

p D
CO
<©)

P
+H

o co v- .-
.5 2 O T3
d
D 5 o) v d
“ 2 b d 0
*~t—

X be
2u HH
P CO P w G o
_ ß
Vh
c 2 £ i>"> 0
2 eft P g G H D
bo
O* P
>i.

S 8
? CD
A ^ a P
«o
iM»
D « Vh
O
o5 ^ m
Ph
pDftir CL kT'
5
p
D > ^
G p _
Vh
O
O P A >4
pb ••
g P -d
D p
.
«
g .
bc
o
co

7« *
g
u
1 1 Vh
O
B bei I L g jp
5
73 .E .E p P4 73
7b
2
pr
P
l
_o G .

P
0
b p 2
E D
O
03 * I H W
\A p p 8 13 ^ 8 ^5
D D
x CD Vh
D CO
2
rE IQ u p Ph 73
be
be 2 -2 -B
.£
5 p d 2 a be
p p
p -ü
c 10
-j •53
’Ph
D
Ö 2 s 5 c 10 E P >
hi £ Ü P co PP S c/3 I— lA Vh
York.

New

Company,

Rebman

London.

Limited,

Rebman
 Fig. 93. Nerves and Veins of Dorsum of Right Hand.
2
/3
Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Fig. 93. Nerves and Veins on the Dorsum of the Right Hand.

A fresh specimen, in which only the skin has been removed. (The Veins and
Nerves on the 3rd finger have been drawn after Rüdinger’s Atlas of the Ner-
vous System.)

Nerves: The Dorsum of the hand is supplied by Sensory Branches of

the Radial and of the Ulnar Nerve. Their areae of distribution are not constant;

moreover, there 'is, nearly always, at least one anastomosis, and thus an exchange

of fibres occurs between these 2 nerves: this explains why in injury, paralysis etc.,

the loss of sensation may be very slight. In most cases they divide the Dorsum
of the hand equally between them ;
the axis of the middle finger being the boun-

dary between the 2 areae:

The dorsal surfaces of the distal phalanges (2nd and 3rd) of the 4 inner

fingers (2 — 5), and of the terminal phalanx of the thumb are innervated by nerves
running on the palmar surface, thus the Median supplies the 2nd and 3rd phalanges

of 3rd fingers completely, and the outer half of those of the 4th finger.

The dorsal surface of the terminal phalanx of the thumb may, however,
be innervated only by the Radial Nerve; there may also be PACCINIAN Corpuscles
here, although these bodies (are usually found on the palmar surface along
the branches of Median and Ulnar Nerve (cf. Fig. 95 middle finger).

There are no Motor Nerves on the Dorsum of the hand, because the

Dorsal Interossei are supplied, like the Palmar Interossei, by the Deep Ulnar Nerve.
Veins: The blood flows from the fingers on the dorsum through several

(as many as to 4) Superficial Veins which begin at the first phalanges into larger

venous channels, the Radial and Posterior Ulnar Veins. The former crosses the

Tendons of the Extensor Primi Internodii ,

Extensor Secundi Internodii ,
and
Extensor Ossis Metacarpi Pollicis (cf. Fig. 92) and then runs upwards on the
anterior surface of the limb.

The Veins and Nerves are quite superficial, i. e. they lie between the skin
and the Tendons of the Extensors. The Posterior Annular Ligament (cf. figure)

is formed by transverse and oblique fibres which strengthen the fascia of the

forearm. This fascia becomes very thin in the dorsum of the hand (cf. Fig. 92,

text).
 3 2 ;

Fig. 94. Tendon Sheaths on the Dorsal Aspect of the Right Hand.

Skin, Superficial Fascia, Vessels, except the Radial Artery, and Nerves have
been removed. The Posterior Annular Ligament is intact, but supposed to be
transparent.

The tendon or synovial sheaths of the Extensor Tendons lie in special

compartments between the Periostium of the bones of the forearm and the wrists
on one hand, and the Posterior Annular Ligament on the other hand; they
extend upwards as far as this ligament, e. as far as transverse fibres are present
i.

below, they extend 3

1 —
4 inch beyond the ligament.
j
|

The synovial sheaths may, however, extend higher 2 5 ths inch or more ( /

above the highest transverse fibres, vide infra).

Starting at the outer (radial) side, and going inwards, we find 6 Com-
partments and Sheaths for the Tendons of the following muscles:
1. Extensor Ossis Metacarpi Pollicis, and Extensor Primi Internodii; the
sheath for the latter muscle is about inch longer than the sheath for the former.
2. Extensor Carpi Radialis Longior, and Extensor Carpi Radialis Brevior.

3. Extensor Secundi Internodii. The latter crosses the Radial Extensors

at an acute angle, lying on them, e. posterior to them.
i. These three sheaths
usually communicate, and are to be considered as forming practically one sheath.
4. Extensor Communis Digitorum and Extensor Indicis. The two tendons
for the index finger lie in one sheath which communicates with the common
sheath for the 3rd, 4th and 5th fingers. The index sheath is, however, shorter.
5. Extensor Minimi Digiti. The sheath of this muscle, which sometimes
has two tendons (cf. figure) is usually longer than the others mentioned above.
6. Extensor Carpi Ulnaris, this sheath is quite short, because the muscle

ends at the base of the 5th Metacarpal Bone.

The broad tendinous slips which connect the tendons to the 2nd, 3rd and
4th fingers are remarkable. Morphologically, they probably represent the form-
ation of one broad aponeurosis, analogous to the one on the palmar aspect
which is fully developed.
Subcutaneous Bursae are shewn (cf. figure) on the 2nd and 3rd fingers.
They are due to continuous pressure (professional bursae).
The Tendon Sheaths accompany the movements of their tendons. The
distal ends of those sheaths which belong to tendons inserted into the metacarpal
bones, are easily determined. In order to find the distal ends of the others, the
fingers should be completely flexed and hardened with injections of Formalin.
The proximal ends were determined, from another specimen, in the dorsi-
flexed position with extended fingers (cf. the black and red lines above the
posterior annular ligament).
The length the Tendon Sheaths varies according to the size of the
of
hand. Those Extensors of the Carpus are the shortest and of about equal
of the
length (V 15 V15 inch). The sheath of the Extensor Communis Digitorum which
often contains several compartments, varies most (y 1fi 2
/5 inches). It is some-
)
—
times longer in small hands than in large ones. The weakest tendons have the
largest sheaths, Extensor Secundi Internodii, Extensor Primi Internodii, and
Extensor Minimi Digiti; their respective lengths are: 2%— 2%; 2% — 4
/5 ; 2% —
inches.
 Extensor Indicis Muscle

Ulna Radius

Extensor Carpi Ulnaris

Extensor Carpi Radialis
Muscle
Longior Muscle

Extensor Minimi Digiti

Extensor Carpi Radialis
Muscle
Brevior Muscle

Extensor Ossis Metacarpi Pollicis

Extensor Communis Muscle and Extensor Primi Internodii
Digitorum Muscle Pollicis Muscle

Radial Artery
Abductor Minimi Digiti
. Muscle
Extensor Secundi
Internodii Pollicis
Muscle

1st Dorsal Interosseous

Muscle

Subcutaneous Dorsal
Metacarpo-Phalangeal
Bursa

Subcutaneous Dorsal Bursa on Index Finger

Fig. 94. Tendon-Sheaths on Dorsal Aspect of Right Hand.

Nat. Size.

Rebman Limited, Londou. Rebman Company, New York.

 Flexor Sublimis Digitorum Muscle

y nr u m

Musculo-Cutaneous Nerve

Radial Nerve

Flexor Carpi U In axis Muscle Radial Artery

Pronator Quadratus Muscle

Palmaris Longus Muscle

Flexor Longus Pollicis Muscle

Dorsal Branch of Ulnar Nerve
Median Nerve
Ulnar Artery-
Flexor Carpi Radialis Muscle
Ulnar Nerve
Extensor Ossis Metacarpi
Pollicis Muscle
Annular Ligament
Superficialis Volae Artery
Deep Branch of Ulnar Nerve

Abductor Pollicis Muscle

Transverse Carpal Ligament

Muscular Branch of
— Median Nerve
Palmaris Brevis Muscle

Superficial Palmar Arch Flexor Brevis Pollicis

Muscle

Abductor Minimi
Digiti Muscle
Abductor Pollicis
Muscle
4 th Lumbricalis Muscle

1st Dorsal Interosseous

Muscle

Palm of Hand (left): Superficial Layer.

Fig. 95.
Nat. Size.

Limited, London.
Rebman Company, New York.
Rebman
 ;

Fig. 95. Palm of Hand (Left); Superficial Layer.

The Palmar Fascia has been removed almost completely the Annular Ligament
,

partly, and all the veins have been cut away.

Arteries. At the wrist the Ulnar Artery lies between the Annular
Ligament and the Transverse Carpal Ligament it may, at this point — in contiguity
—
;

with the Pisiform Bone give off the branch which deep palmar arch,
joins the
passing to the deeper layers in association with the deep branch of the Ulnar
Nerve (Fig. 96).
In the palm of the hand, covered only by the palmar fascia, lies the
Superficial Palmar Arch. This arch is formed by the continuation of the trunk
of the Ulnar Artery, and is often completed by an anastomosing branch from
the Radial Artery. (Cf. text, Fig. 92.)
Nerves. In the lower part of the forearm the Median Nerve lies on
the outer aspect of the Palmaris Longus Muscle, or in the case of absence of
this muscle on the. outer side of the Flexor Sublimis Digitorum Muscle. In the
palm of the hand the nerve is more superficial than the tendons. (Cf. Figs. 103, 104.)
The Median Nerve supplies the palmar (flexor) aspect of the three outer fingers
and the outer border of the fourth finger whereas the Ulnar Nerve supplies the
palmar aspect of the fifth finger and the inner border of the fourth finger.
The Median Nerve supplies
a) all the short muscles of the thumb except the Adductor Transversus
Muscle and the Adductor Obliquus Muscle;
b) the two Outer Lumbricalis Muscles, and a part of the third (which also
derives a supply from the Ulnar Nerve — Bardeleben and Frohse).
The Ulnar Nerve supplies
a) a part of the third Lumbricalis Muscle as well as the fourth;
b) all the muscles of the little finger;
c) all the interosseous muscles;
d) the Adductor Transversus Muscle and the Adductor Obliquus Muscle
of the Thumb.
When the hand is slightly dorsiflexed (cf. text, Fig. 89) the Ulnar Artery
and a part of the Ulnar Nerve are shewn above the Annular Ligament. The
Tendons of the Flexor Sublimis Digitorum Muscle are arranged in two layers —
those to the 3rd and 4th fingers are situated more superficial (cf. Fig. 91), those
to the 2nd and 5th fingers at a deeper plane. The Median Nerve is contiguous
to the tendon of the 3rd finger.
The sheath of the Flexor Carpi Radialis Tendon is laid open at its
proximal end; the Extensor Ossis Metacarpi Pollicis sends a slip to the Abductor
Pollicis Muscle. The Thenar Eminence is chiefly composed of muscles whereas
upon the Hypothenar Eminence is a thick layer of fat containing a cutaneous
muscle — the Palmaris Brevis Muscle.
The Palmar Fascia is of great practical importance, — it is very tense

and strong, bridging over the space between the Thenar and Hypothenar Eminences
its intimate connection with the skin explains why the latter cannot be picked
up and why cellulitis of the hand is dangerous. This dense fascia prevents the
infective process from spreading towards the surface while the delicate tendon-
sheaths and the loose tissue which surrounds them affords a favourable means of
extension. Injury is well known to produce very free haemorrhage due to the
abundant anastomosis in this region.
The nerve supply is most complete, numerous Pacinian Corpuscles are
observed (cf. Fig. 93).
 Fig. 96. Palm of Hand (Left); Deep Layer.

In addition to those structures removed in Fig. g$, the distal portions of the
Flexor Sublimis Digitorum and the Flexor Profundus Digitorum (except in
connection with the little finger) muscles, the Palmaris Longus Muscle, the
Superficial Palmar Arch and the deep fascia of the hand have been cut away.
A piece of the Abductor Pollicis Muscle has been excised, and the Pronator
Quadratus Muscle exposed.

The Deep Palmar Arch formed by the junction of the deep branch of
the Ulnar Artery, with the deep division of the Radial Artery lies at a deeper
plane than the flexor tendons and the deep fascia, practically, in the middle
between the superficial arch and the distal border of the carpal bones, on the
bases of the metacarpal bones nearer the dorsal than the palmar aspect of the
hand (cf. Figs. 97 — 104).
The deep division of the Ulnar Nerve accompanies the deep arch as far
as the Adductor Transversus Pollicis Muscle and the ist Dorsal Inter-osseous
Muscle, passing on to supply all the Interosseous muscles, having given off, in
its course, the fibres to the Hypothenar Group of Muscles and the two inner
Lumbricalis muscles.
The tendons and their sheaths run in an Osseo - Aponeurotic Canal
(cf. Figs. 98 — 1 01). Most important is the relation which the flexor tendons bear
to the phalanges. When these tendons are divided near the base of the terminal
phalanx no suture is required, as it is quite sufficient to fix the finger in the
position of flexion; but if the division should occur at the intermediate phalanx,
suture of the cut ends of the tendon is necessary.
The Flexor Profundus perforates the Flexor Sublimis tendon at the first

interphalangeal articulation; accordingly at this point there are three tendinous

strands. At the base of the first Phalanx (proximal phalanx) there are only two
tendons to be sewn together. The flexor tendons are enclosed within a fascial
canal and often retract considerably towards the muscular portion when divided.
The distal end retracts to a marked extent when the injury occurs in extreme
flexion (e. g. when a bottle breaks in the hand).
Under such conditions it may be necessary to open up the tendon-sheath
which is relatively thin at the joints (where it is reinforced by a few delicate
transverse and oblique fibres) but dense opposite the shaft of the first and second
phalanges.
In addition to the sensory communication shown in Fig. 95 as a loop
around the Ulnar Artery and the motor communication in the 3rd Lumbrical
Muscle, others occur. One inconstant communication occurs between the dorsal
branch of the Ulnar Nerve and the branch to the inner aspect of the little finger.
Another of greater constancy passes through the Adductor Transversus Pollicis
Muscle where becoming more superficial it winds round the Flexor Longus
Pollicis Muscle and joins the Muscular branch of the Median Nerve.
 Palmaris Longus Muscle

Flexor Sublimis Digitorum Supinator Longus Muscle

Flexor Sublimis Slip to Index Finger
Radial Artery
Flexor Sublimis Slip to Little Finger

Flexor Profundus Digitorum Muscle Flexor Carpi Radialis Muscle

Pronator Quadratus Muscle Median Nerve

Flexor Longus Pollicis Muscle

Dorsal Branch of Ulnar Nerve

Extensor Ossis Metacarpi Pollicis
Muscle
Flexor Carpi Ulnaris Muscle

Abductor Pollicis Muscle

Pisiform

Opponens Pollicis Muscle

Deep Branch of Ulnar Artery

Muscular Branch of
Median Nerve
Deep Branch of Ulnar Nerve

Deep Hlead of Flexor

Deep Palmar Arch \ Brevis Pollicis
Superficial) Muscle

4th Lumbricalis Muscle Flexor Longus Pollicis

Muscle
Palmar and Dorsal Inter-
osseous Muscle Lumbricalis Muscle
1 st

Adductor Pollicis Muscle

Transverse Metacarpal
Ligament
4th Dorsal Inter- 1 st Dorsal Inter-osseous
osseous Muscle Muscle
Division of Flexor
Sublimis Digitorum
Flexor Sublimis Tendon
Digitorum Muscle

Flexor Profundus
Digitorum Muscle

Chiasma Tendinum

2nd Phalanx of Index Finger

Vincula Tendinum

Flexor Profundus Digitorum Muscle

Fig. 96. Palm of Hand (Left): Deep Layer.

Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Fig1

. 97. Palm of Hand (Right): Tendon-Sheaths and Large Arteries.

4
/5 Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Fig. 97. Palm of Hand (Right); Tendon-sheaths and large
Arteries.

This diagram illustrates the Flexor Tendon-sheaths ,

the large Palmar arteries,

the more definite furrows of the skin of the palm, in addition to the outlines

of the bones of the hand, as shewn in a skiagram.

The more definite furrows of the Palm of the hand present the appearance
of M or W according to whether they are viewed from the inner or outer aspect
of the limb.

The initial upstroke of the M curves around the balls of the 3rd, 4th and
5th fingers; the second upstroke (or third line) runs almost transversely across

from the ulnar to the radial side of the hand.

The second line, or initial downstroke joins the two upstrokes (ist and
3rd lines) of the M, and is variable in its continuity. The last stroke of the M
skirts the Thenar Eminence.
The third line is the most important guide for the superficial Palmar arch,

whereas the first and third lines combined approximately mark the proximal
limitation of the tendon-sheaths of the 2nd, 3rd and 4th fingers.

A further description of these tendon-sheaths is found in the text

(Figs. 98—101).
The Tendon-sheaths become of great importance in inflammatory conditions.

A whitlow originating at the proximal phalanx may invade the tendon-sheath at

the base of this phalanx and extend to the palm, thus endangering the whole hand.

At the Osseo-aponeurotic canal completed by the anterior Annular Ligament

there is formed a constriction of the tendon-sheaths so that in such pathological
conditions as Tuberculosis of the Tendon-sheath and Tenosynovitis the swelling

presents a constriction at the Annular Ligament with an enlargement both above

and below this structure.

The fold between the hand and the forearm corresponds roughly to the

wrist-joint which extends higher into the forearm with its convexity upwards.

The groove between the first (proximal) and second (intermediate) phalanges

corresponds to the joint, but the joint between second and third (distal) phalanges

is situated V10 t° Ve inch distal to the groove.

 Figs. 98 — 101. Palm of Hand (Left); Tendon-sheaths.
After Joessel and yon Rosthorn.
(Cf. Fig. 97.)

The tendon-sheaths of the Flexor Muscles (Flexor Sublim is Digitorum and

Flexor Profundus Digitorum Flexor Longus Pollicis) extend from a distance of
;

a little less than an inch above the Annular ligament far into the palm of the hand.
There are generally two tendon-sheaths —
one for the Flexor Sublimis
and Flexor Profundus Digitorum Muscles, another for the Flexor Longus Pollicis
Muscle — which are frequently in communication.
The sheath of the Flexor Carpi Radialis Muscle extending from the
trapezium to the 2nd Metacarpal bone is of but little practical importance. The
large flexor tendon-sheath shews after inflation a bulging above the constriction
caused by the annular ligament. On the inner side of the hand the sheath extends
lower down, and invariably communicates with the sheath for the tendons of the
little finger.
In a similar manner the Sheath of the Flexor Longus Pollicis extends as
far as the Distal phalanx.
This is a very important point of practical application because suppuration
of the sheath of the thumb or of the little finger always extends into the main
sheaths; this does not occur in the case of the 2nd, 3rd or 4th digits.
Moreover, we have herein an explanation of the extension of Suppuration
from the thumb to the little finger and vice versa — the inflammatory process
passing from the thumb to the main flexor sheath and into the sheath of the
little finger owing to the free communication.

The Median Nerve is situated between the main Sheaths and the Annular
Ligament whereas the Ulnar Nerve lies superficial to the ligament so that it only
comes in close relation with the main sheaths above and below this structure.
The Ulnar Artery, not shewn in the figure, lies nearer the Sheaths than
the Ulnar Nerve.
The Tendons of the Flexor Sublimis and Flexor Profundus muscles lie
in common sheaths as they extend down upon the fingers from the metacarpo-
phalangeal joints as far as the bases of the terminal phalanges, i. e. the insertion
of the Profundus tendons.
Injury, therefore, to the terminal phalanges distal to these points would
not involve the sheaths.
Figs. 99 and 100 depict variations which are described by some authors
as normal —
a third sheath being inserted as a wedge, between the two main
sheaths at their proximal end —
When this third sheath becomes markedly
.

developed (Fig. 100) the tendon of the Flexor Profundus passing to the Index
finger is transmitted through it.

The somewhat complicated arrangement of the tendons of the long flexor

muscles is schematically represented in Fig. 101.
The “Mesotendina” analogous to the Mesenteric folds, are shewn in the
cross-section.
 Flexor Longus Pollicis _ t J
Muscle Flexor Muscles (Sheath)
to Little Finger

Median Nerve
Ulnar Nerve

Flexor Carpi Radialis Muscle

Proximal End of Common
Synovial Sheath

Fig. 98.

Fig. 101.

Fig. 98—101. Palm of Hand (Left); Tendon-Sheaths.

1
Fig. 98 and 101 1
/2
Nat. Size, Fig. 99 and 100 /i Nat. Size.

Rebman Limited, London. Rebman Company, New York

 1st Metacarpal Bone

5 th Metacarpal Bone

Trapezium
Unciform Bone
— Trapezoid Bone

Cuneiform Bone
Os Magnum
Pisiform Bone
Scaphoid Bone
Semilunar Bone

Triangular Fibro-Cartilage —

Ulna Radius

Fig. 102. Horizontal Section through the Dorsum of the Right Hand.
Articulations. — Nat. Size.

Bebman Limited, London. Rebinan Company, New York.

 Fig. 102. Horizontal Section through the Dorsum of the Right
Hand; Articulations.

A horizontal section has exposed to view from the dorsal aspect all the arti-

culations which lie between the forearm above and the Metacarpal bones below,

but those joints which do not lie in the plane of the section have been opened
independently ,
viz: a) Cuneiform — Pisiform, b) Trapezium — ist Metacarpal.

The following Joint Cavities or combination of Joint Cavities are found

in the hand: —

1) Joint between Radius, Scaphoid & Semilunar extending almost to the

Cuneiform but separated from the following joint by the Triangular

Articular Fibro-Cartilage, “the Radio-Carpal Articulation”, the Wrist

Joint Proper.

2) Joint between Head of Ulna, Radius and Inter-articular Fibro-Cartilage,

“the Inferior Radio-Ulnar Articulation”.

3) Joint between the Cuneiform and Pisiform Bones.

4) Joint between the Trapezium and the ist Metacarpal Bone.

5) Joint between the Unciform Bone and the bases of the 4th and 5th
Metacarpal Bones; this may communicate with the following (6).

6) Combination of the joint cavities between the distal surfaces of the

Scaphoid, Semilunar and Cuneiform Bones, the proximal surface of the

Unciform Bone, all the articular surfaces of the Os Magnum and the

Trapezoid, the inner surface of the Trapezium and the bases of the

2nd and 3rd Metacarpal Bones. “Intercarpal and Carpo-Metacarpal

Articulation”.

The wide extension of No. 6 forms an important point in the spreading

of pathological processes.

The Dorsal and Palmar ligaments of the Carpal Joints are very strong

so that extreme Dorsiflexion (e. g. as in a fall on the hand) is more likely to

result in a fracture of the lower end of the radius than in a rupture of these
ligaments. (LECOMTE; cf. the behaviour of the malleoli, in particular the external

or fibular.)
 Fig. 103. Transverse Section through Carpus.

Frozen section viewed from the Fingers. The second row of Carpal Bones and
the Styloid Process of the 3rd Metacarpal Bone have been sawn through.

On the back of the hand the Extensor Tendons, on the outer side the

Extensor Ossis Metacarpi and the Extensor Primi Internodii Pollicis, in the palm

of the hand the Flexor Tendons are shewn in their relations to each other and

to the Bones of the Hand.

The Concavity of the Carpus with the tunnel completed by the Anterior
Annular Ligament are well shewn.
Note: Radial Artery; Ulnar Artery, and Nerve. The Median Nerve
becoming more superficial at the wrist, lies in close approximation to the Flexor

Sheath, and directly under the Palmar Fascia.

(Vide Figs. 98 and 101.)

Fig. 104. Transverse Section through Palm of Hand.

Frozen Section. Left Hand, seen from the fingers.

The P'lexor and Extensor Tendons have diverged towards either the

inner (ulnar) or outer (radial) side. The median nerve has divided into many
branches. The fleshy muscles of the Thenar and Hypothenar Eminences are

evident. The Radial and Ulnar Arteries have divided so that the smaller

branches of the Radial, with the exception of the Princeps Pollicis artery, are
scarcely visible ;
the branches of the Ulnar Artery are readily found accompanying

the nerves on the Palmar aspect near the 4th Metacarpal Bone.

The Palmar Fascia which bridges over the space between the Thenar

and Hypothenar Eminences is of great practical importance, because the skin is

bound firmly to it so that suppuration deep to the fascia, i. e. around the Tendons

or their sheath, becomes pent up, and deep incisions become necessary for the

evacuation of the pus.

The concavity of the hand is well shewn. (Cf. Foot.)

 Styloid Process of 3rd Metacarpal Bone
Extensor Carpi Radialis Brevior Muscle Extensor Indicis Muscle
Os Magnum
Trapezoid Bone
Extensor Communis Digitorum Muscle
Flexor Profundus Digitorum Tendon
to Index Finger
Dorsal Branch of Ulnar Nerve
Median

Extensor Carpi Radialis Longior

Unciform Bone
Muscle

Radial A
Extensor Minimi Digiti Muscle
Flexor Carpi Radialis
Extensor Secundi Internodii
Pollicis Muscle Flexor Profundus Digitorum Muscle
Flexor Longus Pollicis Muscle

Extensor Carpi Ulnaris Muscle

Extensor Primi Internodii Abductor Minimi Digiti Muscle
Muscle
Pollicis
Superficial Branch of Radial Opponens Minimi Digiti Muscle
Nerve
Extensor Ossis Metacarpi Ulnar Nerve — Deep Division
Muscle
Tuberosity of Opponens Minimi Digiti Muscle

Opponens Pollicis of Unciform Bone

Abductor Pollicis Muscle Nerve — Superficial Division

Palmaris Brevis Muscle

Anterior Annular Ligament Palmar Fascia Ulnar Artery

Fig. 103. Transverse Section through Carpus (Left): Distal Aspect.

Nat. Size.

Extensor Indicis Muscle

Deep Palmar Arch Extensor Tendon to 3rd Finger

Deep Division of Ulnar Nerve 3rd Dorsal Inter-osseous Muscle

2nd Palmar Inter-osseous Muscle

Flexor Longus Pollicis Muscle

1 st Dorsal Inter-osseous Muscle 3rd and 4th Luinbrical Muscles

Adductor Tiansversus Pollicis Dorsal Branch of Ulnar Nerve

Muscle
Extensor Secundi Internodii Deep Palmar Fascia
Pollicis Muscle
Extensor Primi Internodii Deep Dorsal Fascia
Pollicis Muscle
Extensor Minimi Digiti Muscle
1 st Metacarpal Bone
Ulnar Artery
Superficial Branch of
Radial Nerve Flexor Profundus Tendon
Princeps Pollicis Artery to Little Finger

Opponens Minimi Digiti

Opponens Pollicis Muscle
Abductor Minimi Digiti
Flexor Brevis Pollicis Muscle
Flexor Minimi Digiti
Abductor Pollicis Muscle
Digital Branches of Ulnar
1 st Lumbrical Muscle Median Nerve — Digital Nerve
Branches Palmaris Brevis Muscle
Palmar Fascia

Fig. 104. Transverse Section through Palm of Hand (Left): Distal Aspect.

Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Supra-clavicular
Branches

Supra-clavicular Branches Posterior Cutaneous

Branches of Inter-
costal Nerves

Lateral Cutaneous
Branches of Inter-
Lateral Cutaneous Branches of
costal Nerves
Nerves (Intercosto-
Intercostal
Humeral Nerve)

Cutaneous Branch
of Circumflex Nerve
Cutaneous Branch of Circumflex
Nerve

Internal Cutaneous
Nerve and Lesser
Anterior Cutaneous Branches of Internal Cutaneous
Intercostal Nerves Nerve (Nerve of
Wrisbbrg)

Internal Cutaneous Nerve and

Lesser Internal Cutaneous Nerve Upper External
(Nerve of Wriskkrgj Cutaneous Branch of
the Musculo-Spiral
Nerve

Upper External Cutaneous Branch Jjr.Frölisc

of the Musculo-Spiral Nerve
Posterior Division of
the Internal
Cutaneous Nerve

Lower External Cutaneous

Branch of the Musculo-
Spiral Nerve
Lower External
Cutaneous Branch of
the Musculo-Spiral
Nerve

Cutaneous Portion of
Musculo-Cutaneous Cutaneous Portion of
Nerve Musculo-Cutaneous
Nerve
Anterior Division
of the Internal
Cutaneous Nerve

Dorsal Branch of
Palmar Cutaneous Branch Ulnar Nerve
of Median Nerve

Palmar Cutaneous Branch Superficial

of Ulnar Nerve Branch of
Radial
Nerve

Ulnar Nerve

Median
Nerve

Fig. 105 and 106. Areae of Distribution of Cutaneous Nerves of the Upper Extremity (Right).

Rebman Limited, London. Rebman Company, New York.

 Fig. 105 and 106. Areae of distribution of Cutaneous Nerves
of Upper Extremity, (right).

Outlines of Figs, after Fau's Atlas. Colours correspond to those employed for
the spinal segments in the subsequent figures.

Unfortunately the areae of distribution of the nerves of the limb and

their variations have not been completely worked out, as in the case of the Head
and the Trunk by Frohse and Zander. For practical purposes the diagrams
will probably suffice.

The upper part of the shoulder (green) is supplied from the Cervical
Nerves. The front of the chest is supplied by the Anterior Branches of the
Intercostal Nerves (yellow) ,
the back by the Posterior Branches. The Lateral
Branches supply the Axilla and even the upper part of the inner aspect of the arm.

When the arm is supinated the anterior boundary between adjacent areae
of distribution extends down the middle of the anterior aspect of the arm to the

tip of the 4th finger. But the posterior boundary line runs down the middle of
the arm to the 3rd finger.

The following points should be observed — :

The upper part of the shoulder is supplied by the Supra - Clavicular

and Supra-Acromial Branches of the Cervical Plexus.

The lower part of the shoulder by the Circumflex.

Below this level the Musculo-Spiral supplies the skin on the outer aspect
of the arm corresponding to the area supplied by the Internal Cutaneous (red)
and Lesser Internal Cutaneous Nerves on the inner aspect. (A further internal
branch from the Musculo-Spiral Nerve — GEGENBAUR — may assist in com-
pleting the supply of this region.)
On the inner part of the anterior (flexor) surface of the forearm is to

be found the Internal Cutaneous Nerve, the dorsal branch of which supplies the
inner aspect of the posterior (extensor) surface; on the outer aspect of the back
of the forearm the chief nerve is the Radial, only a very small area being
supplied by the Musculo-cutaneous Nerve.
In the palm of the hand the cutaneous distribution of the Median (violet)

and Ulnar (brown) is divided by a line which runs along the axis of the 4th

finger. Special branches from the Median and Ulnar Nerves supply small areae
in the upper part of the Palm. On the outer side a small area of the Thenar
eminence is supplied by the Radial Nerve.
The Dorsum of the hand is supplied equally by Radial and LTlnar Nerves,
but where these become wanting in the case of the 2nd, 3rd and 4th fingers,
their deficiency is made up by the Median Nerve. (Cf. Fig. 106.)
Figs. 107 and 108. Cutaneous Nerves, according to their Segmental
(Spinal) Origin.

The nerves distributed to the upper extremity are derived from the
segments — 4th Cervical and 2nd Dorsal inclusive. The distribution is such that
the upper segments pass to the outer side and the lower the origin of the nerves,
the more internal is their distribution. The thick black lines situated on the
Anterior and Posterior aspects of the arm indicate the boundary between the
rostral and caudal parts of the limb, the correct continuation of this line on to
the forearm and hand is not yet defined.
WlCHMANN is of opinion that it should continue between the dark-blue
and violet areae to the distal end of the ist Metacarpal bone on both the anterior
and posterior aspects.
The seg'mentary distribution over the attachment of the limb to the trunk
differs in front and behind. The posterior divisions of the Cervical Nerves ramify
over the posterior aspect: VIII. C and 1. D have, as a rule, no posterior division,
so that 2. D follows VII. C; again, 1. D has not usually even an anterior division,
so that the 2nd intercostal nerve follows directly upon the Supraclavicular branches
distributed to the chest.
The boundaries between the intercostal nerves are diagrammatic in the
l
figure inasmuch as only the middle /3 of a colour accurately represents the
nerve indicated, the upper and lower thirds being the upper and lower association
areae of the nerves.
In the limb the limitations are much less definite than indicated ;
moreover
there are many variations particularly on the inner side where the red area may
be far more extensive and with the brown may pass even as far as the 4th finger.
The following segments correspond to the different nerves.
IV. C: — the supra-clavicular nerves.
V. C (VI. C) :
— - the cutaneous branches of the circumflex.
(V. C) VI. C, VII. C (VIII. C) : the cutaneous branches of the Musculo-Spiral.
VI. C :
— the cutaneous branches of the Musculo-Cutaneous.
On of the limb the Dorsal Nerves enter at the upper
the inner aspect
part, the Cervical Nerves at the lower. The Intercosto-humeral belongs to the
Cervical Plexus if one takes the 2nd Dorsal segment as belonging to this Plexus.
The Interna] cutaneous is chiefly derived from 1. D and VIII. C. The
violet band (VII. C) gives the boundary between VI. C and VIII. C as these
nerves ramify over this area.
The area of the Median and Ulnar Nerves in the hand are not accurately
defined. The dorsal branch of the Ulnar Nerve chiefly contains VII. C the ,

palmar branch VII. C (only represented in the figure) and 1. D.

The Palmar branches of the Median Nerve correspond to VI. C and
VII. C, the digital branches to VI. C, VII. C, VIII. C (the nearer to the inner
side, the lower is the origin of the fibres in the cord). The outer side of the 4th
finger may even be partially supplied by 1. D.
 vm

YU YU

Fig. 107 and 108. Cutaneous Nerve-Supply of the Upper Extremity, according to the
Spinal Segments from which the Nerves are derived.

Rebman Limited, London. Rebman Company, New York.

 Trapezius Trapezius

Deltoid Deltoid

Pectoral is Major

Coraco-Brachialis

Long Head of Triceps Latissimus Dorsi

Long Head of Triceps

Outer Head of Triceps
‘
Outer Head of Triceps

Biceps
-Tendon of Triceps

Inner Head of Triceps - Brachialis Anticus

Brachio-Radialis
Brachialis Anticus (Supinator Longus)
r
Inner Head of Triceps

Brachio-Radialis
. Extensor Carpi Radialis
(Supinator Longus)
Longior
— Anconeus
Pronator Radii Teres

— Flexor Carpi Ulnaris

Extensor Carpi Radialis
Flexor Profundus Digitorum
Flexor Carpi Radialis
Extensor Carpi Ulnaris
Palmaris Longus
-_Extensor Communis
Extensor Carpi Radialis Digitorum
_ Extensor Carpi Radialis
Brevior
Brevior
Flexor Carpi Ulnaris -
Extensor Minimi Digiti

_ Extensor Ossis Metacarpi

Flexor Sublimis Digitorum
Pollicis

Flexor Longus Pollicis

_ Extensor Primi Internodii
Pollicis
Palmaris Brevis

Abductor Minimi Digiti

Flexor Brevis
Pollicis

Adductor 1st Dorsal Interosseous

Transversus
Pollicis /

Adductor Transversus
Pollicis

Lumbrical

Fig. 109 and 110. Nerve Supply of the Muscles of the Upper Extremity,
according to their segmental (spinal) Origin.

Rebman Limited, London. Rebman Company, New York.

Pigs. 109 and no. Nerve-Supply of the Muscles of the Upper Extre-
mity, according to their Segmental (Spinal) Origin.

The segments are given partly according to WlCHMANN and BOLK, partly after ZIEHEN.
In the text, Arabic figures represent the Cemical Segments, the first Dorsal is indicated by a
Roman I. Colours as in Figs. 107 and 108.

The ventral muscles of the superficial layer of the shoulder-girdle are the Sterno-
Mastoid and Pectoralis Major; those of the deep layer the Subclavius and Pectoralis Minor.
That portion of the Spinal Accessory Nerve which supplies the Stemo-Mastoid
Muscle contains 2. C. and 3. C. The Anterior Thoracic Nerves divide into several branches;
the upper segments are for the Pectoralis Major 5. C., 6. C., 7. C. (Clavicular portion 5. C.),
the lower segments are for the Pectoralis Minor 7. C., 8. C. 8. C. in some cases also supplies
;

the lowest fibres of the Pectoralis Major.

The Nerve to the Subclavius Muscle is composed of fibres derived from 5. C. and 6. C.
The superficial layer of the Extensor Muscles of the Shoulder-Girdle is composed
of the Trapezius and Latissimus Dorsi;
in the majority of cases the Spinal Accessory
Nerve Muscle contains 2., 3. and 4. C., the long Subscapular Nerve to
to the Trapezius
the Latissimus Dorsi Muscle 6., 7. and 8. C. The other Subscapular Nerves to the Teres
Major Muscle 5., 6. (and 7.) C. to the Subscapularis Muscle 5. and 6. C, the Supra-
;

scapular Nerve to the Supraspinatus Muscle 5. C, to the Infraspinatus Muscle 5. and 6. C.

The deep Nay er is composed of the Serratus Magnus with Bell’s Nerve 5., 6.
and 7. C. Levator Scapulae (3.) 4. and 5. C. and the Rhomboid Muscles 5. C., possibly
;

further fibres from 4. C. to the Rhomboideus Minor Muscle.

Of the mixed nerves, the Median contains fibres derived from each segment, 5., 6.,
7., 8. C. and I. D. —
(though 5. C. probably contains Sensory fibres only). The motor —
part of the Musculo-Cutaneous Nerve contains fibres from 5., 6. and 7. C. the Ulnar ;

Nerve usually 7. and 8. C. and I. D. or 8. C. and I. D. only. The motor part of the
Circumflex 5. and 6. C. The motor part of the Musculo-Spiral (5. C.) 6., 7. and 8. C.
Musculo-Cutaneous Nerve: Coraco-Brachialis Muscle 6. and 7. C.; Biceps
Muscle 5. and 6. C. Brachialis Anticus Muscle 5. and 6. C.
;
This last named muscle
has a double Nerve-supply as it also receives fibres from the Musculo-Spiral Nerve
(derived from the same segments).
Median Nerve: Pronator Radii Teres Muscle 6. and 7. C. Flexor Carpi ;

Radialis 6. and 7. (and 8.) C. Palmaris Longus 7. and 8. C. and I. D. Flexor Sublimis
; ;

Digitorum 7. and 8. C. and I. D. Flexor Longus Pollicis 6., 7. (and 8.) C.

;
Pronator ;

Quadratus (6.) 7. and 8. C. and I. D. Muscles of the Thenar Eminence 6. and 7. C.

;

The two outer Lumbrical Muscles are usually considered to be supplied from 8. C. and
I. D. segments.

Ulnar Nerve: Flexor Carpi Ulnaris Muscle (7.) 8. C. and I. D. the outer ;

(radial) portion may also be supplied by the Median Nerve (Frohse) thus having a
double Nerve-supply, like the following muscle; Flexor Profundus Digitorum (Ulnar and
Median) 7., 8. C. and I. D. The deep portion of the Ulnar contains 8. C. and I. D.,
but chiefly 8. C. at the Hypothenar Eminence even the 7. C. may take part (Bolk).
;

For the Motor Anastomosis between the Ulnar and Median Nerves cf. Figs. 84 and 96.
The Circumflex Nerve contains fibres from the 5th and 6th Cervical Segments. The
small area of Deltoid Muscle coloured green denotes the probability, as evidenced by
clinical observations, that fibres from 4. C. supply this portion (Ziehen). The Anterior
part of the Deltoid may be supplied by the Anterior Thoracic Nerves (Anastomosis with the
Circumflex, Frohse). The nerve to the Teres Minor Muscle usually only contains 5. C.
for Long Head of Triceps 6., 7. and 8. C.
for Outer Head of Triceps 6., 7. (and 8.) C.
for Inner Head of Triceps (6.), 7. and 8. C.
Anconeus I for 7. and 8. C.

Brachio-Radialis (Supinator Longus) 5. and 6. C. Extensor Carpi Radialis Longior

and Brevior (5.) 6. and 7. C. Supinator Brevis 5., 6. (and 7.) C. Extensor Communis
Digitorum and Extensor Minimi Digiti 6., and 7. and 8. C.
Extensor Primi Internodii Pollicis 6., 7. (and 8.) C. Extensor Indicis 6., 7. and
8. C. Extensor Secundi Internodii Pollicis 6., 7. (and 8.) C. (in Bolk’s case 7. C. only).
 Fig. hi. Thorax and Abdomen.

The Trunk is divided into two chief divisions; the upper is the Thorax
(Chest) and the lower is the Abdomen (Belly).

The superficial line of separation between these two regions follows the

lower margin of the bones and cartilages which comprise the thoracic cage, but

this surface marking by no means indicates the relative size of these cavities.

This curved line only shews the attachment of the base of the diaphragm
which is in constant movement so that the capacity of these cavities is ever

varying and the position of the more movable viscera alter accordingly.

Certain points and connecting lines are employed in order to subdivide

these regions and thereby endeavours are made to traverse or map out certain

important viscera or visceral domains.

The most important lines and regions are marked in the figure: to the

black lines have been added red lines in order that the most important Con-
tinental and English guides may be pictured.
The reader is however strongly recommended to appreciate the multi-

plicity of viscera] surface markings by reference to the following authorities:

Atlas of Human Anatomy, Toldt.

Textbook of Anatomy, Cunningham.
Quain’s Anatomy.
Surgical Anatomy, Deaver.
 Mid Clavicnlar
Line

t Hypodhondr: iLypockomb

l ranspyloric
TtpigastHififi Line

In fracostal
Line

R.umbilicalis

Intcrtubcrcular
Line
Hypogastrm

Poupart
Vertical Line

Fig. 111. Regions of the Breast and Belly.

V5 Nat. Size.

Rebmaa Limited, London. Rebnnm Company, New York.

 Thyreoid
Cricoid Cartilage Oesophagus Cartilage Trachea

Thyreoid Gland
External Jugular Vein
Internal Jugular Vein
Cephalic

Subdeltoid Bursa

Head of Humerus

Subclavian Vein

Left Innominate
Vein
Right Lung

Left Lung

Ascending
Aorta
Pulmonary Artery

Vena Cava Superior

Left Ventricle
Vena Cava Inferior

Coronary Sinus

Liver

Gall Bladder

Pylorus

Duodenum

Hepatic Flexure
of Colon

Duodenum

3*
Root of Mesentery

Fig. 112. Frontal Section through the Trunk.

V3 Nat. Size.

Kebman Company, New York.

Ttebman Limited, London.
 ) .

Fig. ii2. Frontal Section through the Trunk.

Frozen Section. The anterior surface of the second section of a series of Ver-
tical Frontal Sections seen from in front. The Thoracic and Abdominal
Viscera are in their position at extreme expiration which is never reached
during life. Atmospheric pressure has driven the intercostal spaces inwards so
that the outlines of Pleura and Lung are undulating.

A shews much better than a transverse section the different

frontal section
cavities derived from the general (Coelomic) Cavity of the Embryo.
The formation of the Diaphragm results in a division into Thoracic and
Abdominal Cavities. There is really no Thoracic Cavity but a Thoracic Bony
Cage. As the pericardium is pushed downwards from the neck into the Coelom,
3 completely independent cavities are established:
1) Pericardial Cavity, containing the Heart and a part of the large vessels.

2 Left Pleural Cavity with the Lung.

3) Right Pleural Cavity with the Lung.
It is the practice of many anatomists to call the space between the Left

and Right Pleural Cavities the Mediastinum, —

according to this the Heart would
•

be in the Mediastinum (Middle). But if three independent cavities are recognized

there remain two spaces communicating above, one in front of and one behind
the heart —
the Anterior Mediastinum and the Posterior Mediastinum —
The Anterior Mediastinum is further divided by the overlapping right and
left pleurae (cf. Fig. 116) between the 2nd and 4th ribs into an upper and lower

compartment with free communication. Above the Mediastina communicate freely

with the spaces between the structures of the neck.
The complementary spaces shewn in the figure between the Thoracic
Wall and the Diaphragm are only occupied by the Lung during inspiration.
The Pericardium is a closed sac consisting of a visceral layer closely
enveloping the heart and the roots of the large vessels and a parietal layer
directly continuous with the former but blending with the Mediastinal Pleura, the
Diaphragm and the Anterior Thoracic Wall.
The Pleural Sacs are two closed cavities, consisting of a visceral layer
which at the root of the lung blends with the parietal layer. This parietal layer
lines the thoracic wall — (Costal pleura) — the pericardium — (Pericardial pleura)
— the diaphragm — (Diaphragmatic pleura) — and the mediastinum — (Media-
stinal pleura) — . m
The uppermost part of the pleura which reaches from 1
/2 to 4/5 ths inch
above the first rib is the Apical Pleura (this is not shewn in the figure because
it lies behind the plane of section). (Vide Figs. 70, 121, 126.)
 '

Pig. 113. Upper Aperture of Thorax.

The upper part of the Sternum, and 2 nd Costal Cartilages and the muscles
the 1st
attached to these have been removed. The Clavicles and Ribs have been pushed
down to their full extent. The Pericardium is exposed. The Thymus and
Thyreoid Glands have been cut away, together with the Bronchial Lymphatic
Glands. The Inferior Thyreoid Vessels are divided and the cervical fascia
dissected away.

The following structures pass upwards or downwards through the superior

aperture of the Thorax.
Vessels. The right Common Carotid Artery rising from the Innominate
Artery. The Left Common Carotid a direct branch of the Arch of the Aorta.
The Subclavian Arteries at first pass upwards into the neck and then to
the Axilla.
To the right of the Arch of the Aorta lies the Superior Vena Cava formed
by the junction of the Right and Left Innominate Veins, which pass behind the
Stern o-Clavicular Articulation and the Manubrium Sterni. The Innominate Veins
are formed by the junction of the Internal Jugular and Subclavian Veins. The
large veins are situated to the outer side and in front of the mam arteries.
The Lymphatic Duct (the chief lymphatic channel) after passing upwards
in the posterior mediastinum where it is situated between the Aorta, Large Azygos
Vein and Oesophagus directs its course away from the Vertebral Column obliquely
upwards and to the left side of the neck here, under cover of the deep cervical
;

fascia it forms an arch and finally opens into the Left Subclavian Vein (cf. Fig. 67).
Nerves. The Phrenic Nerve derived from the 3rd, 4th and 5th Cervical
Nerves (chiefly the 4th) runs obliquely across the Scalenus Anticus Muscle to the
outer side of the Internal Jugular Vein, then behind this vessel between the Sub-
clavian Vein and Artery (Figs. 67 and 70).
The Right Phrenic Nerve runs to the outer and anterior aspect of the
Vena Cava Superior, between the Pericardium and Mediastinal Pleura, along the
right border of the Pericardium to the Diaphragm. (Coronary Ligament of Liver.
Liver and Abdominal Wall.)
The Left Phrenic Nerve takes a greater curve in its passage from the
Neck into the Thorax owing to the asymmetry of the large vessels and is situated
on a deeper plane than the right, owing to the rotation of the heart to the left,
in its course between the Pericardium and Pleura to the Diaphragm (cf. course
of Phrenics in Fig. 122).
The Vagus or Tenth Cranial Nerve running between the Carotid Artery
and Internal Jugular Vein at first passes downwards and slightly backwards but
soon inclines forwards to the right and in front of the Right Subclavian Artery,
on the left side in front of the Subclavian Artery and Aortic Arch.
Both Vagi accompany the Oesophagus in its lower part and through the
Oesophageal Opening into the Abdomen on to the walls of the Stomach. The
left Vagus merges gradually to the Anterior Aspect whereas the right Vagus
becomes directed to the Posterior Aspect of the Stomach; this results from the
developmental rotation of the Viscus to the right.
From each Vagus is given off a Recurrent Laryngeal Nerve (Motor Nerve
to Muscles of the Larynx); the right recurrent nerve looping around the Sub-
clavian Artery whereas the left recurrent nerve winds round the Ductus Arteriosus
at its connection with the Arch of the Aorta; each nerve ascends upwards by
the side of the Trachea (cf. Fig. 69).
Viscera: The Trachea bifurcates opposite the 4th or 5th Dorsal Vertebra
into Right and Left Bronchus under cover of the large vessels. The Oesophagus
is shewn in the figure to the left of the Trachea.
 Thyreoid Cartilage
Median Vein of Neck
Sternohyoid Muscle Omohyoid Muscle
Thyreohyoid Cricoid
Muscle Cartilage Cricothyreoid Ligament (Ligamentum Conicum)
Cricothyreoid Vessels
Thyreohyoid Muscle
Cricothyreoid Muscle

Anterior Jugular Vein

Superior
V

Inferior Thyreoid Gland

Thyreoid
Vessels
Sterno-
cleido-
mastoid
Recurrent Muscle
Laryngeal
Nerve Internal
Jugular
Vein

Middle
Thyreoid Trachea
Vein
Recurrent
Tendon of Laryngeal
Omohyoid Nerve
Muscle
Oesophagus
External
Jugular Scalenus
Vein Anticus
Muscle
Phrenic n
Nerve Artery
Thoracic
Subclavian Duct
Artery
Subclavian
Vein

Innominate Vagus
Artery Nerve

Inferior
Clavicle
Thyreoid
Vein

Subclavius 1st Rib

Muscle

Left
Phrenic Nerve Innominate
Vein

Superior Costal
Vena Cava Pleura

Vein from
Thymus
Gland Pericardium

Costal Pleura

2 nd Rib
Pectoralis
Major Muscle
Internal
Internal Intercostal
Muscle
Vessels

Body of
Sternum

Fig. 113. Upper Aperture of Thorax.

3
/i Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 External Jugular Vein

Thoracic Duct

Subclavius Muscle

DeltoiJ M uscle
Pectoralis Minor Muscle

Cephalic Vein

PectoralisMajor
Muscle

Basilic Vein

Lntissjmus Dorsi Muscle

Teres Major Muscle
Jntercosto-Humeral Nerve

Subscapularis Muscle

Subscapular Vessels

Long Thoracic Nerve

Serratus Magnus Muscle

(4th Rib)

Breast

External Mammary Vessels

External Oblique Muscle of

Abdomen

Pectoralis Major Muscle

Sheath of Rectus Abdominis Muscle

Fig. 114. Lymphatic Glands connected with the Mamma in an Adult.

Vg Nat. Size.

Rcbman Limited, London Rebman Company, New York.

Fig. 114. Lymphatic Glands connected with the Mamma in an Adult.

This figure is not drawn from a dissection but is a diagram constructed from many sources. (Essay
by Frohse on the Axillary Lymphatic Glands.) — On the right side the superficial layer ,
on the left

side the deeper layer and the breast with and lymphatics are shewn. A large part of
its bloodvessels
the Pectoralis Major Muscle and the Clavicle have been removed. —
The internal set of glands are
coloured blue the external not coloured the intermediate green and the deep red.
, ,

It is absolutely necessary to adopt a definite and universally applicable classification

of the Axillary Lymphatics in order to readily comprehend their distribution. The number
of Glands varies enormously (8 to 43) and into these enter the afferent Lymphatic Vessels from
the Thorax and Arm.
Of the afferent lymphatics which come from the Thorax, those trom the Mammary
Gland have the greater practical importance. A superficial and a deep set, separated by the
Intercosto-Humeral Nerve and the External Mammary Vessels can be made out.
The first regional gland for the lymphatics of the Breast lies, when the arm is ab-
ducted to a right angle, just below the free border of the Pectoralis Major Muscle at the level
of the 3rd rib. An inconstant deep gland is sometimes present; this Paramammary Gland is
depicted in the figure at the outer border of the beast. By Lesser enlargement of this gland
is considered characteristic of Syphilis.
Usually from the Breast the Lymph passes through 1 to 4 glands which lie under cover
of the Pectoralis Minor Muscle, parallel to the inner side of the Axillary Vein.
Thus it passes through several smaller glands —
Subpectoral and Subclavian Glands.
In rare cases, which one should always bear in mind, lymphatic vessels pass between
the two pectoral muscles and are associated with an Interpectoral Gland. But the more usual
connection lies with the neighbouring External Gland called the Intermediate. Fortunately
there seldom exists a direct communication with the deep glands, the Subscapular Glands and
thence along the nerve to the Latissimus Dorsi Muscle. When this group becomes affected,
the Neuro-Vascular bundle cannot well be left untouched in the course of a operation inasmuch
as it is very frequently surrounded by the lymphatics (v. Origin of Subscapular Artery).
The lymph from the arm passes usually with the superficial vessels to a gland which
lies (cf. Fig.) on the Axillary Vein; thence under cover of the Pectoralis Minor Muscle along

the outer side of the vein.

A lymphatic channel may accompany the Cephalic Vein and disappear in the Infra-
clavicular Fossa, between the Deltoid and Pectoralis Major Muscles, to enter a Deltoideo-
Pectoral (Infraclavicular) Gland.
The Deep Lymphatics lie partly on the Subscapularis Muscle, partly along the outer
Thoracic Wall —
the Subscapular and Thoracic Glands.
Accordingly it becomes advisable to classify the glands of the Axilla in the follow-
ing way:
A. Superficial Glands.
Pectoral, Intermediate, Brachial, Infraclavicular (Deltoideo-Pectoral).
B. Deep Glands.
Subscapular.
To these regional sets of glands the following intermediate glands have to be added:
Subpectoral, Subclavian and Thoracic.
An
important variation in the Pectoral Glands is the presence of an Interpectoral Gland.
Apart from the usual lymphatic channels leading to the Axilla there are two (blue)
other important lymphatic vessels which in obstruction or removal of the former carry lymph
from the lower border of the breast to the Umbilicus, or to the Internal Mammary Artery.
From the supero-internal part of the Breast, lymphatics run into the Superficial
Internal PectoralGland whence the lymph may travel into deeper regions. On the other
hand, lymphatics may emerge towards the surface and connect the Internal Mammary Lym-
phatic Glands with the Superficial Glands of the Axilla. (Cf. the transverse black line at the
upper border of the Mamma.)
 : . r

73
• .Q >-»,?> c dd cd «5 >

>n
>-
ft
3 V
5
ft
b
£
t:
P 3-C^ J 03 03 dd
p
T3
p
O
b #g J?
O s
03 O
-c
03
w -a w w ^O p dd p as as
Q O
nd .
ft
d c v£ ^ ft
l£ 03

42 n S£
c t) 42 cd o 4
73
o
o _ dd
CL ^
+J 73
ü£ 2
^h

^
03
-
4 P 73 Cd 4-* 03 1
4>
7)
as d P O P <L>
73 03
43 K r* 42
03
d CT3
dd O > ’si cd O cd ft
nd +J
bC a;
d O £ b«
03
*-
03 42 O bD <D
P p -p 4)
42
O ^.
o -Ö .4)
03 M 2 ^ a o cd

1
2 bC
c
O
03
7)
44
£
^P 5 03 ^
dd
o
“
4
2 ö
>
CQ
u -d M
lh 2 o P ~ ^ 03
p ™
cd

^o
73
c 03 -P cd
P - t/) w p o
-C
^ dd 03

7)-— nd
'/i nd
C
cd
<U bJO — in 03
.2 cc
'cl
Ml
p H
“ o
P
cd
G 0
>
3^ u Ö 03
~ 42
I

T3 .P C as
£o w g g
as S £ > ° dd ^
£ "5) TJ -d p CÜ 'd < O ° | d
u P cd P
O -P P S
cd J2
03
AS
u in
in
3
.2
be
u ^ 03 _
p .5^
a CL 2 z u
cd o 43o O
O
£ -S
o
H £ r
. <D
o o _ 5 0
5
<L>
O O 03 H 03 3 o
•£ >, 73 cd
s
Ti ,G
!>> as

a 73 -a d w a
03
03
42
=P
£ 42 dd £
c ft
Q. .2 .2

> ft > « dd
_ OS 8
4 42 d
« c «5 2 G
D Q .

P >a 3 CL>
<U
>.4 -‘
u nd 5 p *
T3 Oo _ 03
CL
9-
- £ P u
0 )
CL 'S
0) H S 42 ,H 03
b£ 73
P g P .a S o £ .3 <n ^ +5
bo 03 rj-J
dd Oh O 42
03 o is
be
^ ps o -d o
u yd jd \rd J s
a Q p u 03 +_.
P
‘

bC 73
O P Cd 5-1

d H 2
cd •2
cd a,
O
3 Q Cl 03
o P
-
cd 4-» 03 03 r-<

p « 03 c p £ « a ft os p 0l
^ —
>-. 03 ° 4s 3 ft
*P -Ö 03 73 2 4
£^
cd os
X
)

as
O cd cd £?£
b/j 73
a) ft
u 4
o 1)^
O _cd dd cd
8j|
03

o 4) 'S

o °H £ ^§
2 Ö
O X) 7)
CL
3 J - 3 _P
a)
03
03 .P o qd
+J
o o h
a <o ^ OS 73
c
Cd
o
.2
«
>>o ^ ^
cd 0 73
bfl
jL
cd
3
dd
03
P- 03
*.2 3
>,.2.4
u 5 7d >3 ’-P
6 P
<
.

O 'P
03
be Cud
u .o in
cd

«
.

X3 -d 42
P P CL
42 '
'
cd m 3 ^‘O
CL P
£>~j

*13
P 4 J2
73
o O
CL S3 o cd

J « 2 Mä
ctf
03 .S s ^ ft S cd
T3 CL
7)
o Td S
> b£ -G
s ^
,

S P 42 03 <U CL cd S'
^Ö ^S £ 6 H O 03 c > U C r2 P
,

«-* 7)
75 03 '

g 3 o
CL
rt
03
as
J k .2 uL 2 >- §>
03
03 P 03
cd
a
42
.P dd
d
Sd
42 r
O -C o o -P
w d .
"75 £-
in O M 73 JJtH tLl H 'oT O p
03
be bC73 S t
cd

V nd -P CD
c
p 2
*-
X t: ö
aS 03
d
o P
^ s
G
rtt
<»!

H _0 T3 (3
& U TO
4 -S
O bf. cd
as
Oh bC O O 03 73 cd ft 2.75 C

ft!
o T3 O •
03 03 p-T CO ’Z
1

& b °
d dd 2 03
73
nd 03 L
LP .« 'P 4)
^ w c
5
<u
a v Si si cd 'C
03
-c
03 -r: *- o
p +-’
be -G v
P ° E S
in 03 cd G 2 «* os
£ o
•’-> .2 cd N
o S ft B
-e. o P P
03

^ -
° <u o« o •c O O p
S • 0)P 03
42
CL
cd
° s 73
o3
3 1 )

0 73 nd P 4>
T3 03 JC Uj 03 r: 03 •§ «
cd -
, 42
03
O
•
03
P2
_ be
^ w P 03 jg
ci
03
73
aj
o- be
P
.

>
— dd
73 >
% £f'
73

G S
.d2

42
03
4-*

be 03
CL ^ u 5c
03C
u'>>S
•

dd
u p nd _p 'p ^ ^ P
d 2 3 d cn P cd o O s
^3 O £ w 03 P c o - « ji g P
P o s 4) be' 3 4)
O 03
^ 42^
o U h
O O
4
T ° P dd
£
03
ndG ^ ^ be >
s
“ "5i
«
O 3-
2
S
03
C
'S p
’o P
nd
G nd
VH
4) £ r-» S-
4)
03
42 d
<-m d "3 33 03 ^2 O 03 P bC
n
cd g
o 3 G o-
CL —P z
>^5 S p d S £ '§ T3 O 03
p d r—
5 %
s ' « s bß cd x pt2 cd

C G x
.2 bß
bD
rt
cd
0 a ° be m 3 £ 2
w
4>
Jb
4)
as
4)
__
X 7A „
v-
O T3 03
G
os
>, "o ft
_O ^ O O -
a,
v ^ u 0)
-d .2
p 2 dd O 1 03 ^- S "Ö — 5 cd
73 G £ 4)

a cd -P cd P ^ cd
cd

£ « j
« ra - tP <u O p 4) as CL,
JS ai £ ^ 4)

ta
O 03 'S Jd - T3 u 2 as in
a
be ^
as P.
nd c
4 «; cd
o c O •ö o a 2
g T3 £ nd ft o CD S
ns
a cd ^ ^
O
p-
03 g C
03 r* U °
-
'

_ P
P 3 £ So G 3
O'
o O
> 03 >
ö Is 4-;
Q *< p £ 'S O "re
£ £
*j
O cd
Q aU£ —
-
cd
in > c s
B 3 be G
42 03 o <D u X) "a
- u
ft nd < ^ O bl
4)
-G nd jc
-
<J

o »> JC
- o s o T3 C u O G 3
Jai
o
cd 4d
h p ^ -C 73 -e G ^ 03
P c/5
O <€
as
in qd o d & dd JD S nd
O
bfl
03
d p dd
CO a*
—o £S
m
«
g 4
'g -G V £
as
a) )
^O p
p p c5 S >-' 4)
3 JB
o o be S' 3
S? nd
-8 * ~ Q
J 75 73 OP cd
r2 —
o ^ ^P ^^
7)
CL
p 2
03
P
P 42 03
p c - to
M p d) ’-p
O O
Si 2 •

cd nd
p "O „4) C ^ n 5 CU
2 5 03
Ü Oh 03
cd nf .2 p « 4 O
3 o ^ - o* _o Ü G B vOro o d°
ro 03
73
cd 2
u u
O 03 "3 o
O 03 a o 73
o nd P ft 03 42
03
H
cd
o
d o
g a. ro ^
b S ft d - ^
4 4/-,
4)
&u ^ 42
03
' M ai
G
4 p c P ^ 0 ^ be
03
42 03
o P ^ ~ 42 P 73 03
42
CL 42
^ O cd 3 % S
> O dd *n
be 4
4
^ 42
P
5
.03
03
.Si
03 " .2 75
G
<-M
o
O 03

s p p — cd
nd o cd 03
*d
03 C '->

>> p p > 42 U 'S Ö

03
4 P
p s rP5 4 o > 03 P
03
03 . 03 4 03
N Ö 73
5 p CL P
.feo 03
CL
CQ 03 nd ^
4
ft 41
03 73
.w) «
j-j

75
ft h
4) G- «Cl AX .2 -o P
03 r-
c _c Td -G G ft 75 -P
42 O P ^ — — P r=
go £
H >
> dd ft H o £
.

be 73 03 O o 03
H dd 75 o p
O SI >
5 4
03 os

S
** 03
73
03 G ft
4J

'S
ft
<u

(£2 P 3 JH p 03

b p
b C3
a ft o
-2
73
3
*
4»
GB
S 5 O ^ p § 42
 York.

New

Company,

Rebman

a %
u O
<1 o
^ö 'S,
s

hH
S
^
o II

r
>JT 5o
o ^
<U I

-V ^
-Ö .8
c3 CO
<D .

w 3
^
CtH
° 2
on
c

Ph

London.

Limited,

Rebman
 Costal Pleura

Visceral Pleura

Upper Lobe
Upper Lobe

Middle Lobe
Area of Absolute
Cardiac Dulness

Lower Lobe

Lower Lobe

Lower Border
of Lung Lower Border
of Lung

Lower Limit Lower Limit

of Pleura
of Pleura

Fig. 116. Boundaries of the Lungs and Pleurae as seen from in Front.
Area of Absolute Cardiac Dulness.
2
/6 Nat. Size. — After Joessee (modified).

Rebman Limited, London. Rebman Company, New York.

Pig. 116. Boundaries of the Lungs and Pleurae as. seen from in front.
Area of Absolute Cardiac Dulness.

The Parietal Pleura consists of the Costal Pleura, the Diaphragmatic

Pleura, the Mediastinal (including the Pericardial) Pleura and the Apical Pleura.
The knowledge of the reflections of the Pleura, i. e. the lines upon the
Anterior Thoracic Wall at which the Costal Pleura becomes the Diaphragmatic
and the Mediastinal Pleura —
cf. dotted lines in the figure is important. —
The Anterior (Median) Boundary extends from
of the right costal pleura
the upper margin of the ist costal cartilage at an angle of 45 0 downwards and
inwards to a point Vioth to 1 inch to the left of the middle line at the angle
of the Sternum (Junction of Manubrium and Body of Sternum). From this point
it continues downwards in a vertical direction, gradually approaching the middle
line at the level of the 5th Costo-Sternal Articulation; from this point its course
is slightly downwards along the lower border of the 6th costal cartilage in the
6th intercostal space |or along the upper border of the 7 th costal cartilage, the
3
lower border of which it reaches about /5 th of jan inch mesial to its costo-
chondral junction.
The costal cartilage of the 7th rib, like the lower costal cartilages, is

almost entirely devoid of Pleura. This also applies to an increasing surface of the
ribs themselves as we get lower in the series {2 1/i inches). The limit of the Pleura
crosses the right nipple line (cf. Fig'. 1 1 1) at the lower margin of the 6th costal
cartilage or slightly lower down, and the axillary line at the lower border of the
gth Costal Cartilage.
In the upper part, the left costal pleura takes a similar course; it crosses
the Sternal Angle (Ludwig's Angle) a little further to the left; from this point
it passes so as to often reach the middle line, becoming, to some degree, adherent
to the pleura of the opposite side; for the distance of 2 inches it extends ver-

tically downwards until it reaches the level of the 4th costal cartilage '
;
at this
level the margin of the pleura extends obliquely downwards and outwards to the
upper border of the 5th Costochondral Articulation whence it curves with
its

concavity inwards to the upper border of the 7th Costal Cartilage; from this point
it again follows a similar course to the Right Pleura downwards and outwards;
though mesially it does not reach the 7 th Costal Cartilage it may extend lower
down externally. The left pleura crosses the axillary line at the 10th rib or in
the 9th interspace (cf.The pink area indicates Absolute Cardiac Dulness
Fig. 126).
which under normal conditions is not encroached upon by lung tissue and which
area serves for the exposure of the Pericardium in Pericardiotomy. Cf. Figs. 70
and 12 1 for a description of the Apical Pleurae.
The boundaries between the different lobes are shewn in the figure.
The Right Lung has three lobes —
the superior and middle lobes are
separated anteriorly by a fissure which extends to the level of the 4th rib or
V2 inch lower. The boundary between the middle and inferior lobes lies opposite
the 6th intercostal space and extends behind the anterior extremity of the 7 th
rib obliquely downwards to the lower border of the lung.
The Left Lung consists of 2 lobes and the fissure which separates them
extends from the posterior end of the 4th interspace to the region behind the 7th
costal cartilage.
 Fig. 117. Boundaries of Lungs and Pleurae from behind.

The Median Boundaries of the Pleurae posteriorly, i. e. the lines at which

the Costal Pleurae become continuous with the Mediastinal Pleurae, run along the

bodies of the Vertebrae. The lower limit, i. e. where the Costal Pleura becomes
continuous with the Diaphragmatic Pleura, is very important. From the lower

border of the 12th Dorsal Vertebra this line runs horizontally outwards so that

not only the lower rib cartilages but also the bony ribs are free. The 1 2th rib,

which varies much in length and may even be absent, is usually bisected by

this line.

The difference on the two sides in the Axillary Line has been mentioned

in Fig. 1 16.

The Apices of the Pleurae are not visible from behind, because they never
pass up as high as the upper surface of the ist Dorsal Vertebra.

The fissures between the Upper and Lower Lobes are indicated by black
lines, beginning behind in the 3rd intercostal space they run obliquely outwards

and downwards.
But on the right side a small fissure arises from the main fissure and

divides the upper lobe into two — (the Superior and Middle Lobes).
 Fig. 117. Boundaries of Lungs and Pleurae, from behind.
% Nat. Size. — Modified after Joessel.

Rebman Limited, London, Rebman Company, New York.

 Left Innominate
Vein

Right Ventricle Pericardium Thymus Pericardium Left Pleura

Fig. 118. Anterior Thoracic Wall and Heart in the New-Born.

Mat. Size.

Rebman Limited, London. Rebman Company, New York

 Fig. 118. Anterior Thoracic Wall and Heart in the New-Born.

From of a normal Foetus the soft parts, of the Anterior Thoracic

the fresh corpse
Wall over the Sternum and Costal Cartilages have been removed. The position
of the heart and its important parts has been determined by Luschka s method, 1

(by the introduction of 6 needles). The heart and the great vessels are fully
shewn in the figure, the bones and muscles being imagined as transparent. The
outline of the Pericardium and the area of Absolute Cardiac Dulness are yellow.

The six points — indicated by Arabic figures — employed to determine

the position of the heart are :

1. Internal angle of the first intercostal space on the right side close to
the Sternum: Right Pleura, Right Phrenic Nerve, Reflection of Pericardium,
Superior Vena Cava close to the right margin of the Arch of Aorta (this last-

named structure may be pierced by inserting the needle obliquely): in the adult

the Internal Mammary vessels would be injured, but not so in the child. Cf. Fig. 1 19.

2. Internal angle of the 2nd intercostal space on the right side close to
the Sternum; Right Pleura, Superior Vena Cava, upper border of Right Auricle.
Aperture of Pericardium.

3. Internal angle of 2nd intercostal space on the left side close to the

Sternum; Region of Pulmonary and Aortic Valves (the pulmonary valves being
anterior, above and to the left; the Aortic posterior, below and to the right)

Cf. Fig. 120. The left pleura is opened by the needle.

4. Middle line of Sternum at the level of the 4th Chondro-sternal articu-

lations or at a slightly higher level in the new-born: Border of Right Pleura,

Boundar}^ between right auricle and right ventricle; Tricuspid Valve.
5. Middle line of Sternum at the junction of the Manubrium with the
Xiphisternum : Lower border of right ventricle or of pericardium, and of the area

of Absolute Cardiac Dulness.

6. Lower border of 5th rib on the left side at its costo-chondral junction
about inch internal to the mammary line: Apex of Heart, or more accurately
the limit between the left (red) and the right (blue) Ventricle. This needle
passed exactly through the Interventricular Septum without entering either

chamber of the Heart.

The upper and lower parts of the Anterior Mediastinum are continuous
in the child; the Thymus which lies in front of the Pericardium reaches down-
wards between the Parietal pleurae as far as the area of Absolute Cardiac Dulness.
The Anterior Mediastinum is filled up by Thymus, loose connective tissue,

fat, lymphatics and small vessels.

 Fig. 119. Anterior Thoracic Wall and Heart in the Adult.

In addition to the soft parts covering the Thorax, the j rd, 4th, pth Costal
Cartilages and the junction of the last named with the 6th Costal Cartilage
together with the Intercostal muscles have been removed.

Between the slips of the Triangularis Sterni Muscle the parietal pleura
(blue) is visible; its lines of reflection behind the Sternum are also delineated in blue.
Between the 3rd and 4th Costal Cartilages (cf. Fig. 116) the right and
left pleurae are in contact with each other, as in the adult the Thymus has con-
tracted upwards. The right pleura may extend considerably beyond the middle
line, often as far as the left border of the Sternum.
Parallel with the borders of the Sternum, at a distance which varies with
the width of the bone, the Internal Mammary Artery, a branch of the Subclavian,
takes its course accompanied by Venae Comites except in the two upper inter-
2

costal spaces where there vein.

is Around the artery lie lymphatic
only one
glands, (Sternal and Anterior Mediastinal Glands) more numerous above than
below. The Heart in the Adult is more deeply situated than in the Newborn
and its apex is further to the left.

The distance from the Apex (Left Ventricle) to the nipple is

2
2 / 5 ths to
2 4/5 ths inch in the vertical line, and 4
/ 5 ths to 1 V5 th inch in the horizontal direction.
3
(As the Figure is /5 ths nat. size, actual measurements according to the Figure
will require multiplication by five thirds.)
An irregularity in the Costal Cartilage which may even involve the rib
is shewn in the 4th Costal Cartilage on the right side.
The following data connected with the bony Thorax and in particular
the costal cartilages have been made out by Bardeleben.
In about 10 % the 8th Costal Cartilage, on both sides, articulates with
the Sternum. The 6th and 7th Costal Cartilages usual A articulate with each
other ;60 in %
on the left side and in 40 %
on the right side, articulations exist
between the 5th and 6th Costal Cartilages. The arrangement, together with the
close apposition of the cartilages, convert the intercostal spaces in front of the
pericardium into narrow slits.

The position of the Apex of the Heart, the Pulmonary and Aortic Valves
is not absolutely constant — quite apart from physiological variations in form
and position of the Heart.
The Pulmonary Valves usually lie ojoposite the 2nd left interspace or
behind the 3rd left costal cartilage, rarely in the 3rd interspace.
For operations upon the Pericardium the most suitable site is a small
area where the pericardium is uncovered by pleura. The entrance may be made
through the 4th or 5th intercostal space, close to the Sternum, without wounding
the pleura; the Internal Mammary Artery must always be borne in mind.
Removal of a part of the 4th and 5th Costal Cartilages with a small portion of
the left Sternum, allows a fair extent of the pericardium to be exposed.
 Sterno-Mastoid
Muscle

Interclavicular
Ligament

Manubrium Sterni

External Intercostal
Muscle

Left Pleura

Pectoral is Major
Muscle

Costal Pleura

Internal Mammary
Vessels

Pectoralis Minor
Muscle

Triangularis Sterni
Muscle

Pericardium

Xiphoid Process

Diaphragm

External Oblique
Muscle of the
Abdomen

Superior Epigastric
Artery

Rectus Abdominis Muscle Transversalis Abdominis Muscle

\

Fig. 119. Anterior Wall of Thorax and Heart in the Adult.

3
/6 Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 : :

Left Carotid Artery

Innominate Artery Left Subclavian Artery

Ductus Arteriosus (Botalli)

Aorta

Pulmonary Artery

Superior Vena Cava

Aortic Semilunar
Valves
Left Valve Auricle

Pulmonary Semilunar Valves:

Right Valve Anterior Valve

Right Valve
Posterior Valve

Right Coronary
Artery

Anterior Cusp (Aortic)

of Mitral Valve
Atrium of Right
Auricle
Posterior Cusp
(Parietal) of Mitral
Cusps of Tricuspid
Valve Valve
Septal Cusp

Posterior Papillarj
Anterior Cusp Muscle

Posterior Cusp
Inter Ventricular
Septum

Right Ventricle-

Left Ventricle

Anterior Papillary Muscle

Descending Branch of Left Coronary Artery Cardiac Notch

Fig. 120. Heart of Adult. — Ventricles opened.

Nat. Size.

Limited, London
Rebman Company, New York.
Rebman
 Fig. 120. Heart of Adult, Ventricles Opened.

Normal adult heart hardened in formol; the ventricle is opened so as to shew

the Aortic and Pulmonary semilunar valves, the heart is rotated so that the
Left Ventricle is more to the front.

The figure is semi-diagrammatic in order to demonstrate more clearly all th

valves of the heart and their relative positions.

The figure shews the outer and anterior aspects of the Right Auricle, the
Right Auricular appendage and the opening of the Superior Vena Cava.
Right Ventricle: Papillary Muscles, Anterior, Posterior and Septal. Chordae
Tendineae, 3 Cusps of the Tricuspid valve, one large Anterior, a large Posterior
and a small Septal Cusp; between the two Ventricles the Inter- Ventricular Septum;
on the Anterior aspect of the Heart the inter-ventricular groove, terminating in

the Cardiac Notch, and the Descending Branch of the Left Coronary Arter)n
As the continuation of the Right Ventricle upwards (the Conus Arteriosus)
has been widely opened and its left wall removed, the pulmonary semilunar valves
appear to be completely disconnected from the Right Ventricle, but their relative
positions are well shewn, one anterior, one right and one left.

Left Ventricle: Papillary Muscles, anterior or left and posterior or right

with chordae tendineae attached to the two cusps of the mitral valve (right or
aortic cusp and posterior or left cusp), the right one extending up into the Aorta
and almost in continuity with the semilunar valve.
The Aortic Valves are three in number, like the pulmonary, one is posterior,

two are anterior or right and left, this is due to the common developmental
origin of the Aorta and Pulmonary Artery.
The Aortic Valves lie (cf. Fig. 119) more to the right, at a lower level
and posterior to the Pulmonary Valves.
Because the Aortic Valves are situated deeply and at a considerable
distance from the Anterior Thoracic Wall, to obviate the obliterating effect of
the Pulmonary Valves the Stethoscope is applied over the 2nd right Intercostal
space close to the Sternum, i. e. the point where the Aorta lies close to the
Anterior Thoracic Wall.
The Mitral Valvular sound is listened for at the apex of the Heart.
 Fig. 121 . Transverse Section through the Trunk, at the level of
the ist and 2nd Dorsal Vertebra.

Frozen Section. The section passes through the 2nd Dorsal Vertebra and the Disc between the ist and
2nd Dorsal Vertebrae also through the ist and 2nd Ribs through the lower part of the Trachea
, , ,

Thyreoid Gland and Clavicle ; the shoulder-joint on either side and Scapula with their muscles have been
cut through. The shoulders were rather elevated.

The important details are :

—
Apices of Pleurae as seen from below are unequal because the section is not
1)

absolutely horizontal (Difference inch). The Apices of the Lungs separated by

the section have been removed. The Subclavian Artery on the left side arching
over the Apex of the Lung, and its intimate relation to the 1st rib and the Scalene
Muscles is noticed.
2) Course of the Trachea and Oesophagus; the former deviates a little to the right
probably owing to the asymmetry of the Thyreoid Gland whereas the Oesophagus
normally deviates to the left.
3) When the Thyreoid Gland is much enlarged (as in the inhabitants of the Saxony
Mountain Districts) it not only surrounds the Trachea, but also touches the Oeso-
phagus and exerts pressure on the Carotid Artery and thin- walled Jugular Vein —
both vessels being pushed backwards and outwards.
4) The Brachial Plexus, on either side, has been cut through.
5) The Vagus Nerve is situated between the Carotid and Jugular Vessels (cf. Figs. 59,
61, and 1 13). Recurrent Laryngeal Nerve between the Trachea and Oesophagus
(cf. Figs. 69 and 113).

The space between the Vertebral Column and the front of the neck is remarkably
small for the passage of the important Cervical Structures.
Finally, the Tendon of the Long Flead of the Biceps is seen in its groove and the
subscapular bursa between the Subscapularis Muscle and the scapular or shoulder-joint is shewn.

Fig. 122. Transverse Section through the Thorax, at the level of

9th Dorsal Vertebra.

Frozen Section. The section is made through the gth Dorsal Vertebra ,
the 4 th to gth ribs ; in front the
Sternum is divided jtist below the articulation of the gth rib. As the man had died from Pneumonia the
lungs are fully expanded and not in the cadaveric expiratory position.

This figure shews clearly how the Thorax is occupied by the 3 cavities (Pericardium con-
taining the Heart, Pleurae containing the Lungs) and the spaces or Mediastina (cf. Fig. 112, Text).
The Anterior Mediastinum presents a very small space occupied by loose connective-
tissue, fat and lymphatic glands, and shews that the pericardium is not completely covered
by Pleura.
In the Posterior Mediastinum at some distance to the left of the Vertebral Column
the descending Aorta is seen, on the right side the Oesophagus with both Vagus Nerves,
whereas between the Great and Small Azygos Veins the Thoracic Duct is cut across, posteri-
orly is the sympathetic cord, and behind the right Vagus nerve is a small lymphatic gland.
This figure instinctively shews the position of the Phrenic Nerves between the Peri-
cardium and Parietal Pleurae which is a point of considerable practical importance in Pleurisy.
On either side at the 7th rib in the Axillary line the Interlobar Pulmonary tissure
is seen.
 Oesophagus
Recurrent
Laryngeal Internal Jugular Vein
Scalenus Anticus Muscle
Pectoralis Major Muscle Subclavian Vein
Brachial Plexus
Pectoralis Minor Muscle
Coraco-brachialis and Short Head Deltoid Muscle
of Biceps Muscle

Long Head of Biceps Muscle

Humerus

Scapula

Infraspinatus Muscle

Serratus Magnus Muscle

Apex of Pleura Apex of Pleura

2nd Rib
Rhomboideus Major Muscle 2nd Dorsal Trapezius 3rd Dorsal 3rd Rib
Vertebra Muscle Vertebra

Fig. 121. Transverse Section through the Trunk at the level of the 1 st and 2 nd Dorsal Vertebra.
Seen from below. — 2
/s
Nat. Size.

Anterior Mediastinum
Atrium of Pericardial Internal Mam- Right
Pectoralis Major Muscle Right Auricle Cavity Sternum mary Artery Ventricle Left Ventricle

4th Rib Atrium of Left Auricle

Left Phrenic Nerve

Serratus Magnus Muscle

Right Pulmonary
Vein
Left Lung

Left Vagus Nerve

Latissimus Dorsi Muscle

Oesophagus Descending Aorta

Thoracic Duct

Right Vagus Nerve 9th Rib Intercostal Azygos Vein 9th

Vein Vertebra Sympathetic Splanchnic Nerve and Small Azygos Vein

Fig. 122. Transverse Section through the Thorax at the level of the 9 th Dorsal Vertebra.
Seen from below. — '
2
/- Nat. Size.

Rebmun Limited, London. Rebman Company, New York.

 3
a?

to
co

H
-$
P

CO
cd
o
££
o
CO
0 erf
CD £5-
P “*
^ O
1
P-
P
JT H
s*
l

I
x
^
c
p
erf

erf
P S5-
cd

N <jf
o <3
*
CD

erf
>—--«

CD

Or

Ö
o

<J
CD
>-j
<rf
CD
>-*

<r>

K*
O
 P P 3 g Cr
O
rti
Oj Cn
3 rt
3 . P
< « CJ
3
13*
P h a h
£ fT CO
£ p
p co
rt
& cr crq
2 g- Sf O < 5^ ''S
» a
M«
° cf g; a o CD °!9
sf H £ rt
Q o td a £, a 3 d.
a
2 p. CD C/3 H >
3 £ o o 3> CD
m -t
.

P CT cn.
3 &
cn
cn
S- O"
P G rt -
H
W
3 » O 3 CD
g- 3 a a C/3
m in
p P cn S’ 3 - co CD
^
O 0)
cr
O a 33 CD 3a o £
cr 2 P3
3 _.
3 CO
p
p 2 a.
< 3
^ a
CD
3
b a
§ Ck)
^ cn
in hd
ri a 3 a rt P 3
'

Cn CO a 3 2 o cd
§ 3 I P
in
O 4
id O'
a P 3 V) G P
ft

o
2, g a a 5
^
-
fD
3
cr p3 cr
Cr< ^
c-t

o n P Co h
a & § S
G G
3 09 Oj
S*
o .
Q V
P ö
3 P
> 3 ^ 7q so
CO
<8
P
<!
cr 2
P in h o
3 £0
3 a
Cn O
g P
3 g p
°i ^ S 'S».
tt
~
“ o < in
a O cr a 8 0 CO
tr <
bd^ p
g WI
•
CO
p o CD p. o S. m
3 a > 3
H . 0) cn
3 cr cr a %. 3-
3 O crq g Ct"
n
a a p
ft"
0Q
in
3
O
a-
(0
tr a
P
p
3
o 31
CD
^ 3
t

!z|
j
O
ri-

£J a
CO
p CD
in
n
3 v; JS.a o 3 ^ tJ* r+ CT g cr
< 3
3
P co 5 p cr 3
p CD
tr co 5" CO Ui
CD_

3 ’
P "C P 31
"
p
3.
in
co
<c
2.
71
CD
co
01
cro. ° a n
o
o td
tf)
co 2 n cr
p a C3
rt-

1 ^ O
in .
CO
o 3 cr < 2 rt«
>*' i__i

2 p' cr co
a. crq
p cn p O
3 3 < CO
3
r+ a
ri
8 a o4
3 P p
C/3
r-h Ü
cr I’ O
7
a CD CO
C3
CO CD co
p CD a rt-
3 rt p ffi-
P <_
p"
3
3 p C/3
>~i
C/3
o'
3
CO 5. s a
t
o O p
i

_ CD
— a a.
3 a
3 a 3 3 O cr 2 3 a Cn
o 3 3 cr 1
1

3 CS o
' O
Crq
3 dr
.§“g*
hd 3 CD
CO p ° a o
o 55
crq
<3-
^OK r
Co d
> Si a
J5 3)
CL 3 <1 P S- Co crq

a 5' in

§ & CD
W P cr C/3
CO
in
C/3
3
<
CO
C-f
«>
a a
o
1

CO
J
CfQ •— 1

<’ o 3 CD '-C
a r ^ CP
P3
o ^ a
a
3
< crq
C/5

P
3_
n" 2 ? 3
T) p Cn
o ^ a
p- p
4
P* C/5
CD
o P JO
P
CO
cr OK -K
s
CD
3 a a.
3 <* rr CO
p 3 3 P a 2
rt
CD
S. 0)
h O G r"C
cr 3
1
ffQ
CD
*
£ CO
O CD
h
B" i •
cn’
,ct
^ G <5
CD
a 3 - cn
co
0^ a
p a
^ cr ~ P,
a
t-j

3 p 0 ic
0 O
h O o
33 tJ <J 'S
S 0 a t
g ° Cd 12. <5 C » a a0 -P seen 0 0
h
5'
P Cd
C/5 pr 0
N 3
S- *
p
a
m
cK
o 3
3 a
5’p
3 3
rq^4
3 rr rt
a or cn
rt
CD
rt
G cr
G rt a.
to X
p cr < 0 S»
O 2 p 2. ft ts. Co
Cl.
O 0 G a a O rt 0 G Crq a. K.
P n cr p m. 3 p 0 0 h p a 1 0 C/3
Ö
O
a s c> a
O g O^ C3 3 p p p 3 O
ri-
O
O
Ml td P GO* 0 H p" by rt
td g
Srt
^5' CD
5 a
^ G* rt
o 2 in
a. crq
5 .

3-
G
P
*-t
rt
M-i
a ri- o' 1—
50
o a a 3 a <5 a.
o
a>
? S*
a -a td §
-
CO
a cn’
cn
> p o
c/5
G G
(J)
*rt-

S
S, S
<
fe

H o ^ “
hi C3 ^ r co
3
a
3 a o CD
O 0 O - *~0
ri-

p h G O
Co
ca
dr a P CD
3 CO
O rt
fo
in
CD <h
CD CO s § 3
3 3 Q- > 3 a a o' H o* h in
i 0 o*
crq
cn
a "
O O a
CO co 3 p
3 '< p" 0 ft Srti S?
Cb
a.
Co a
3 o CO a 3 oq3 g* o CO
<j 3 c*i
<n
CO
p
3-)

a CD
O ^ “ O
EB p O* G 4 CTO
rt
a O CO o Cn
'

o cc a H. O co crq co
S 'a ~ a
adr p a
i

in
3 P 3 O rt-
CO
Ö 8 Crq 3 CO

a O as
>-(

n ™
(Ji
3- CO m a
n- rtSs a
P T a co 5
3 a 5J
o
° ^ a
a gr p p a^ a,
ä
crq
3
p P
-

CD
S ^3 3
3.
13 S t O
i 3 3 3 p o cd cn
crq
e 3
a 60 o
in
a COp ^in3
fo 3 p 2. r3 a.
a
o CO 0 a
3
in 0q 1 n
in

^
,

3
CO rr
<S
™ p > $ a3 s
So

H ono
Cn >—«
2. CD ^ COr— ri-
* a^a
p p * •
3
3 ='
co
3
O
Co
TO

ra h hH
O P 3 a 3 3 3 p P
4 td L.
0 p
»1
rt CO Cb 'CS b <
O O cn
2
3 a
3 n
P .
'
o> a
tp a
3 cn ri
p P
Ä.
3 O
fD
t
3 —
ft-C-f-
3 g*
ro
a a
‘ r-h
p 3 t+.
1

CD o
c-t- CD
P
3- p b: rt-
HT a 2 3
(D
3 £3
o ^-3
P o 3
> p 2a ^ °b ft)

a
in
2 . ^
a p g*
C/)

o
3 a. P
co’
a co
£L
Grq
n
3
3
. Crq
S
crq
a c-
r3
p ^ P td
3 a aa
—
Dj co a
a cd
3 2
^3 ri-
p rt CD K-.
t-j

P
b
p
r~h
O
(D
P 3 a? a 3 2
> rt Ä n
«•

P 3- a a a a a
3
P a CO
3
CD
co
rtQ
g
_
g; a a o co
(0
3
<d
cn
SC,*g ^ al Cd
ft)

P CO P
a °
rt-
a ft G. a; {d <J $ P (I)

p
°
P
•-t 3 a
3
8 3 c
<
&
o
2
ft
co
0 C/5
«1 to

p 2
3 p> °a p tr
a ^ P‘ < a,
£ b
3 p
DP a
3 a
p 3 P
CD 3T CD
3 v ^p p 3 0
:
CO
n co
O 3* P P 3- G r 1
3 a a a
p
>— ? P
P.Ö 3
;3 P n
as 3 <1 C/3 5U
3 _ CD
3 O CD ft
P 2"
.

a 3' > h CD CO
^3 33 o
'S-
p
a
a O>ag
& 2.3« CD
O 3 h 0) h crq cn <; Qj 0 0
< ft’ s 0
a CL 2 CD 2, crq <1 3
a cop ri. 3 3 0 CD 'S . ö
77 Hy» CD
p “L p Ä
<3
3 CO
0 Sv
^ En‘
CD
in
B*.)<
1
w gr P (0 p p 1 'S.
'S-
£2-1 a>
 Fig. 124. Position of Abdominal Viscera, from in front.

Cf. Fig. hi for Topography.

In the right hypochondrium lies the Liver which even extends further
(however, the 12th rib, costal cartilages of gth, 10th, th ribs should be excepted).
1 1

The liver lies in contact with the diaphragm, and indirectly with the Thoracic
wall, the lower border of the viscus varies with its size and shape —this depends
upon the shape of the Thorax — and with respiration. In the nipple line it may
correspond to the costal arch or extend below it 4/5 ths to i 3/5 ths inch). In the
Axillary line it reaches to the 10th intercostal space or extends 4 /5 ths to 3/5 ths inch
i

lower down. The lower concave surface of the Viscus is in relation with the
right kidney, right supra-renal body (cf. Renal Impression Fig. 136) and hepatic
flexure of Colon.
In the left Hypochondrium lie the Kidney, Suprarenal body, Stomach,
Spleen, Splenic Flexure of Colon, Tail of the Pancreas and usually a part of the
left lobe of the Liver. This region is occupied by about ^rds of the Stomach
i. e. Cardia and Fundus. The Cardia lies behind the outer end of the 7th Costal
Cartilage, the inner concave surface of the Spleen is in relation with the upper
part of the left kidney, its outer convex surface with the Diaphragm (Phrenico-
Splenic ligament), cf. Figs. 125, 126, 136. As a rule the liver does not extend
further to the left than the inner half of the 7th Costal Cartilage. The Splenic
flexure is anchored by the Phrenico-colic fold to the 10th and 1 th ribs. This
1

fold also forms a platform upon which the spleen reposes, but this fold becomes
stretched when the spleen is enlarged and any alteration occurs in the position
of the Colon.
The form and size of the Epigastric regions vary with the individual and
the sex; the subcostal angle varies widely between 30 0 and 70 °. The shape of the
Xiphoid Process offers man}^ variations, it may be directed forwards, backwards
or laterally, presenting an opening, or be bifurcated, curved or crooked.
In the Epigastric region are found a part of the Liver. Gall-Bladder,
Stomach, Duodenum and Transverse Colon.
The lower border of the Liver extends at the 8th costal cartilage beyond
the right costal arch and often reaches to a point midwa}^ between the Umbilicus
and the top of the Xiphoid Process. At the lower border of the Liver near the
9th and 10th costal cartilages is situated the gall-bladder (cf. Figs. 131 and 132).
Behind the Liver are situated: Lesser Curvature of Stomach, Small
Omentum, Omental Sac, Aorta, Coeliac Plexus of Sympathetic; a part of the Stomach,
(Antrum Pylori) touches the Abdominal Wall.
To the right of the Middle line, normally, Transverse Colon as well as
Duodenum lie in this region. The former is often curved and extends downwards
into the Umbilical region. In some cases it lies wholly outside the Epigastrium.
The Umbilical Region contains a great portion of small intestine (mostly
Ileum) which is usually covered by the Great Omentum. The Iliac Region
contains the ascending (right) and descending (left) Colon with Small Intestine.
The Hypogastric region lodges in its middle, small intestine, bladder (when
distended) and uterus (when pregnant) —on the right the Appendix and on the
left the Sigmoid Flexure. The greater part of the anterior wall of the Bladder
is uncovered by Peritoneum (cf. Fig. B ): when the bladder is much distended
this region corresponds to a A Vsths to 2 ins. high with a base corresponding to
the interval between the 2 pubic spines (about i 3/5 th inch). Cf. Figs. 143, 144.
 Fig. 124. Position of Abdominal Viscera, from in front.

7a Nat. Size.
— After Luschka.

Eebman Limited, London, Bcbman Company, New York

 Spleen Liver

Common Bile Duct

Kidney Pancreas

Descending Colon
Ascending Colon

W: il \m
!

Fig. 125. Position of Abdominal Viscera, from behind.

V3 Nat. Size. — After Luschka.

Rebman Limited, London. Rebman Company, New York.

 Fig. 125. Position of Abdominal Viscera from behind.

Between the level of the 9th and nth ribs on the left side is situated the

Spleen which lies in relation with the Diaphragm above, and the left kidney below
(cf. Figs. 126 and 136).

The Kidneys lie opposite the 12th Dorsal and the ist and 2nd Lumbar
Vertebrae and in front of the 12th rib, on the left side also in front of the nth
rib. The right kidney, due to the size of the Liver, is mostly found at a lower

level. Sometimes both kidneys are at the same level, but rarely is the right

higher. Both kidneys are occasionally situated at a considerably lower level

without any evidence of undue mobility. A horseshoe-shaped kidney, i. e. when
the lower ends of the two viscera are joined in front of the Vertebral Column,
is no great rarity. (Cf. Fig. 127.)

The descending colon lies to the outer side of the left Kidney whereas
the ascending colon with its Mesocolon lies in front of the right kidney with the

duodenum above (for further details, cf. Fig. 135).

The Pancreas — in front of the ist Lumbar Vertebra — extends to the left

as far as the Kidney and Spleen ;

its upper part may touch the Suprarenal Gland.

In the figure it is visible on either side of the Vertebral Column (yellow) the

intermediate part being indicated by dotted lines. Its head is almost completely

encircled by the Duodenum; into the Vertical portion of the Duodenum which
is closely applied to the posterior abdominal wall, the Duct of the Pancreas (Duct
of WlRSUNG) which is usually joined by an accessory Duct (Duct of Santorini)
(cf. Fig. 130, -text), and the Common Bile Duct open.
These relations are shewn in the figure, which also depicts the left ureter

coming from the left kidney (cf. Figs. 120, 129 and 133).

The ascending Colon is seen on the right, the descending on the left (next

in continuity the Sigmoid Flexure) between the Costal Arch and the Crest of

the Ilium.

The relations of the Peritoneum to the Viscera are described in Fig. 136.

The last portion of the gut shews the Ampulla of the Rectum against

which the Coccyx lies. Below the tip of that bone, the Rectum passes backward
(Perineal Curve) and opens in the slit-like laterally compressed Anus.
 Fig. 126. Left Lung and Spleen. — Side View.

The figure shews the diaphragm during extreme expiration (cadaveric

expiration); the vault extends as high as the 4th left intercostal space and the
left lung to the same degree. The fissure of the Lung — the left boundary of

the pleura, cf. Figs. 116 and 117 — and especially the normal position of a normal
spleen are shewn.

The inner concave surface of the spleen lies against the Fundus of the

Stomach and the upper part of the left kidney (cf. Fig. 135), the convexity is in

relation with the Diaphragm connected with it by the Phrenico-Splenic Ligament.

The spleen extends from (cf. Fig. 125) the 9th to the nth rib with its long axis
corresponding to the long axis of the 10th rib, in a downward and forward
direction, so that the inferior pole points towards the Umbilicus. A normal spleen
does not extend beyond the costo-chondral line — i. e. a line drawn from the

left Sterno-clavicular articulation to the top of the nth rib.

Through the Sacro-Sciatic Foramen the lower part of the Sigmoid Flexure

and the Rectum are visible.

The convex diaphragmatic surface of the spleen is shewn; as the spleen

is a viscus subject to many forms of enlargement, it is desirable to learn the

direction in which its increase in size must extend.

The upper concave surface is in relation with the fundus of the Stomach;

this frequently prevents a permanent enlargement upwards. The lower surface

rests upon solid viscera -

— left kidney, Pancreas and left Supra-renal glands —
which under normal conditions cannot easily be pushed aside.

The Phrenico-Splenic Ligament prevents expansion vertically downwards,

but it affords a gliding surface along which the spleen may when enlarged slide

forwards and downwards. It is thus that the anterior pole of an enlarged spleen

is most readily felt at the anterior border of the 10th rib.

 Vault of Diaphragm

Lower Border of Lung

in Expiration
Lower Border of Lung-

during Inspiration

Line of Reflection
of Pleura Spleen

Transversalis Abdominis Muscle

Fig. 126. Left Lung and Spleen, lateral view,

l

/3
Nat. Size. — After Luschka.

Rebman Limited, London, Rebman Company, New York,

 Rectus Abdominis Muscle
Gastro- Falciform Transversalis Right Left
duodenal Ligament Hepatic Abdominis Caudate Gastric Gastric Oesophagus Parietal Layer
Hepatic Duct Artery of Liver Artery Muscle |
Lobe Artery Artery (Cardiac End) of Peritoneum

Gastrosplenic
Ligament

Round Ligament of Peritoneum of

Liver (Obliterated Omental Sac
Umbilical Vein)

7th Rib

Portal Vein
Spleen

Common Bile Duct

Pancreas

Cystic Duct
Splenic Artery

Outer Layer of
inferior Mesenteric
Peritoneum
Vein

Duodeno-Jejunal
Transverse Colon Flexure
Inferior Recess of
Omental Sac Left Colic Artery

Root of Mesentery Spermatic Vessels

Ileo-Colic Artery Duodeno-Jejunal
Fossa
Ileum
Vermiform Descending Colon
Appendix
Superior Haemor- U reter
rhoidal Artery
U reter Kidney (Horse-shoe-
shaped)

Ovarian Ligament Fallopian Tube

Ovary
External Iliac
Artery
Rectum

Round Ligament
of Uterus

Deep Epigastric
Vessels

Fig. 127. Position of Viscera covered by Peritoneum — Child.

3
/i Nat. {Size.

Rebman Limited, London. Rebman Company, New York.

 Fig. 127. Position of Viscera covered by Peritoneum — Child.

Child under one year of age. Anterior abdominal wall, Stomach, Jejunum, Ileum,
Left portion of Transverse Colon, Sigmoid Flexure, Mesenteries and wall of
Omental Sac, Transverse Mesocolon have been removed. Peritoneum, blue.
Inner layer of Omental Sac, yellow.

This figure shews the Abdominal and part of the Pelvic Viscera in situ
after removal of those mentioned above. The Liver is large, its anterior surface
passing beyond the right costal arch throughout its whole extent (reminding one
of the arrangement in the Foetus). Of the Viscera the following parts are shewn.
Cardiac end of Stomach cut across transversely. Pylorus joining the Duodenum,
of which, by removal of the Anterior layer of the lesser Omentum, the hori-
zontal and commencement of the descending portion with the opening of the
Common Bile Duct are shewn.
The remaining part is covered by the Transverse Colon. The lumen of
the intestine is visible at the Duodeno-jejunal Flexure, below and posterior to
which is found the Duodeno-jejunal Fossa.
The Ileo-caecal junction and the Vermiform Appendix are seen in their
usual position at a higher level in the child than in the adult.
The Ascending Colon which appears rather short in the figure, the right
half of the Transverse Colon (lumen owing to line of section),
on the left the
Splenic Flexure, Descending Colon, and two opening's through which the upper
and lower extremities of the Sigmoid Flexure are also visible.
On the lower surface of the Liver we find the Gall Bladder and vessels
entering the Hilum of the Liver, the Bile Ducts and further to the left the
Spleen. Forming the left inferior boundary of the Fossa Duodeno-jejunalis is
the Left Colic Artery.
In this instance the Kidney is horseshoe-shaped, but the Ureters are normal
and occupy normal positions, crossing the External Iliac vessels (cf. Figs. 13 1, 134,
136, 137, and disappearing behind the much distended Rectum.
14Q, 150)
By the side of the left Ureter runs the Superior Haemorrhoidal Artery
(a branch of the Inferior Mesenteric) to the Rectum.

In front of the Rectum is the Uterus, of which the fundus is visible;

from either side the round ligament passes to the Inguinal Canal crossing' in
their course the Deep Epigastric Vessels. The Fallopian Tubes and Ovaries lie
on the right side in the true pelvis, on the left side in the false pelvis, either
because the}f have not completely descended, or, more probably, because the much
distended Rectum had pushed them upwards. This latter view is supported by
the fact that the Fundus Uteri is squeezed in between the Bladder and the left
wall of the pelvis.
In front of the Uterus lies the Bladder, bounded anteriorlv by the slightly
opened Cave of RetziuS; in this region the Bladder is uncovered by Peritoneum.
The Peritoneum which lines all these organs, and encloses them to a greater
or lesser degree, has been cut off at the root of the mesentery. (Cf. Fig. 136.)
 i

a)
JS
<u 44 03 0 03 03
rG G 03 "O 43'
OC G 03 Ö p
X o O
§o
V Cds c3
44
(J
G >%
rg
^
Ci
bC
U
03
o "0
S ^ X3
p t
>-i

p 0 be
03
£2
s
03
14 aj "U
%03 O| 03
43
o
42 O
03
>
-H
G
G
p
U c
ffi {3 43 5-
be Ph JL3
S >-, 3r>
Ö
J3 0)
mOh
44 ^
-S s§ 42
G
03 «D
(J rG
OC
03
03 2 ^
h 0
'S,
~ -5
Sä ;
5 «5
o L)
rS 42 43
3J
X3
G 03
o3 3
^
X a X3 q 03 £h rt 'O
"RS
*>
~
,SS
~
*
g u < o O 43
03 G
a3
cS
C O
t « Ö
« t
"G X3 03 00 G b*
-«s
go ; "Rs o 44
riij "0 0)
G be x 03 44 -G
03 03 >-H
IU <-> JQ <5 .
^H
Ps 03 44 p--
'•^

S
«5 Ph 03
5-h

Ph
42
o G 03
03
G 03
33
03
fll

s a>

S>
"^3
C/3 03 2
5 2,
B C J üo I
G
03
03
P4
'
03'

03
o
£sl
03
H TO
Ph O « °
U 5 4v
CN
^ Vj
£ x O
52
05
T3
r-<
Pi
o 2 ö
SS £
rG C/3
3 ^ c/3
43 *5 03 o
<3 T3
n
. bo ? ^G a
o
5
s G g
-R I 03
03 _03 -p
T3 £ X-
^3 W) M G <u
cS Sfi SJ p Ph
G <U 3
o ^ c^ p O £
~

T3 CO p 03
Ö
cd
<3

S .V*
G & «
C/3 ^ -a° 03 r— to .Ü3
2 G
rr-

cd
53
S»
S>
<3
Ö | $ 03
be 0 Ph
Ph
g X3
03 G C/3

I o3 3 G 03 G
H->
G c3 " « g
5-c

43 ^ O s
03
G
03
oe
cd 0
oj
<u « hQ
^ S S £ be G s 03
i-i
> G
.be
B cd o3 •*-* OJ 03 be
bo 4G
O I I be </) 0 J-

^ ^
03 Ph
•(V ^ o
^oT
'-4—

o
(
03
Ph G
oS
^03 o
o
w t > gR ,<3
CTj
<
o 44
03
0 413
^ 0
44
cd § ^ Ph
IS
03
42 "d
a»
w £ O 03
in
o & s Sä <u

G ei G P o 0 J13
0 03
42
^£
5/3

G G "U
cd fep O >
>-«
Qh
03
G
O G o
15 co u
Ph
3 4 ^ O >-H
o3
s : a 4 cO o 03
43 42 42
"g
Xo 5 •&
b/3 £>
§
CD p 44 G X
53
g 'fe.
44 —S rt 03 '8 x
cd '
cn •2 -§
H <
‘

03 c/1
£« is -s? Ö O O o .52 4)
B >-, -
o ,t3
03 Q q CJ
1! X,
G
"™
*<
+j *§ bO e t: cß rt
l

C/3
^ On o rS
03 <i
T3 G < [ ^ ^ ^ x G 203 03
.g O 0 cd
bo
03 O bo
5 2 42 o > 03
G
^W
03
U G
^ g
•s
i O-
C/3

03
03
03 S'
5-h

G
G
44
Ph
4) bo
^
O
P
O
0 ^ 0 O
•
>
H •8
r
ci
U cd o O 44
03
03
c/3

P 44
H
m

« G
4 <5 R
5 i3 42
03
G
5-
G
C/3
03
<U bo ^ 'pf ;q
bo

a | O
| oe o S 03
03 ^ .G
^ s 42 ^ 'S
ö
c/3 r-H
o ce
Ph p
be
£
2
o *G
GO g 8
s
g 03
\G
G
14
cd
P,
03

3
'Tn
O S Oc
03

G
03
42
H
be _
‘P •£ P X o
0
S
s ^ G
G
I ^
CM f. cd Ph Jr;

M C/3 0 03
03
44 ‘

S ^2 Ö0
bio 'S
“S
<U O
4 £ 2 42
ä 5
„ G
| 0/3 03 b p
Ph
<u <>5
<3

^S
03
£ « 03
42
X3 G
03
42
§ S
<3
be G & 4J
X
O 03
C/3
G o 42
03
o3

1R
C/3
m
p .03
X 03
42 ft
Cb
a^ 2 Ol 03
_4 G
O
0
<0>
CD
4h
C/3
"o
Ph
be 03 03
rt
-H &< G J>
>
C/3 T2
G 42 O
E3 g
§,
>v>
05
’ 1-1
O) 3 G P Q "O 03
C/3 >x
5-h

o o
C/3
03
03
O 03
0 U
•§ O H P O 03 .O oj

<3 ^5
'4_>

3G >-H

o G
03
44 0 u •-H
w ’G
V
00
03
C/3 Ph O S 03
Ph C/3
03 44
Ci 44 S G 03
o Ph 03
P "Ö
G C/3
G cd
"SS GO 03
O 03 p
V
H . ^ be
«S 0 rs
Ph
cr
'S
. 03
cd
r<.
rP r2
.ö 0) G 42
** 0 H nD
1 s 03 .2 G
TJ
>-h

G
0 03

'S £ 03
rS G 03
> G £ P3
>H O
§
5ä
.g 0 »
G G G
"Ö 03 be .2 G Ph ^ o.
«v G 43 G c3 O (D

^ •§
03

0)
42
s
0 T2
T3
•«
O
4)
^3
H
u
.S P 0 03
„
§ ^ 2 03 G
pH 'S °
8
O
J3

r^ rs R
Oh
03 42
o ’o*
I-H
0 o3
2 4
n s 0> «S o Ph C/3 44 O O 03 03 Ph (X) 42 8 Ph is
Sac.

Omental Size.

Nat.

L
3
—
Pancreas,

below.

and
Stomach,

front

in
Liver,

from

128. Seen

Fig.
 Rebmau

Limited,

London.

I—i .

oq
I
— 1

to
CO

co XJl
8 'E
=>

CD
3 »
5
•n
p
P
o
h-j
CD

^ Ö
o' P
o
p-
cd
P
p
Ö
P
a?
CD
**
05

O
<
P
o
i-b

02
c-f-
O
P
o
SP

Rebmau

Company,

New

York.
 1-

U a a f 4 ‘
£ Q g
^ g H
33 cr
o co n 3
i-d
ft CD3 £>•§ 33 cr
3' S 3 I <
CD CD
3 O S CD o r CD fe-
3 3rt 3 | S Ö "
i
CD
r+
°* O fL o ft) CD 3 < CD
OQ _ 2 °
»T S, 3L *0
-

3 ü u (D
D 3 a 3 H
4
.
^ StS5-
&
33
3
3 3 i-+>
^ 2
3
CD
3 a tr
^ crq cd
CO^ O
O
CO JB PL ft o 33 3T 2
< f H w.
pj
3
o* ft
CD
g- O' CD

_
S
3D 3 *0 > S si
o4

2 V g
„ CD CD
W 33 to cl ft 3 2L CD 3 ^ S §
O » £ CTQ
ft)
E?
tr*
3
» a <
"-i
3'
3 CO
H I S
CO
» a
CD
CD <
? CD
CJ* 3 3
<3
«1
s-
S 1 «-a.
33 CT ‘IS
5° C/5
3 qI
p
o
fx.
CD

o 2.
CD & >
2 * 3
CD
c^ co
h-i r-r
'C
3
2 a,
s
3
2 CD
P- 3
o
C3
to co
i-l

r
’

%
22 a
-
S3
0>
V)
<—h 2. < 3 3 h 33 Cj 3
-

M*
ns. O P fro P O
*-t o o 33 2 3 33 CD
f * f“ O Q
ffQ
3 P 3 CD
5T o cj i>
o* .
ft % 2 CD Q
— CD
g t+-
co
f
*-t
cl 3' CD CO )-t
'
' CD 3
3
03
E±. i2j co
& 33 g
ft gi OQ 33 )-t CD W O O CD
o c fi CD 3j 3 3 CO
CD 3 CD P 129.
cl "ö * 3 *“t

2
3 n>
& > O g
i-t
W g o
f H 33 w .

3
p 3. ° 2 3‘ P c CO CD 3 ^ ^
nw o
^2S ^f a 3 4 •

o £L CD S CD
•--* <-+
t3 ^ K
i- 33
> > K CD O'
!“ n> ?r £ 33 ^ 3 1
CO CD Liver,

*-t »1
3
I"
^
O P 3 33
& O 4
wOS I-C

3
CO

3*
cd

§
'o’ !3i

> 8 ft CD
S.
^
CD
3 S 4
> 3
S'
2 3 o 3 3
3 f
CD
£ V! bH P 75 cd
D a 3 f PL tr 3 S5 V
> n 3
i-t

CL 75
p 'ö
a P CD >lj 3 S S »0
Ö- SL °°
P £ CD n CD CD 3 £.
Co’
CD
g O ^p O 33 o 33 S* S g ^ <=~
Spleen,

5' 3 r-h
33 P 3 < S3 33 03 S$-

CD 3 & a ^ O' 3
*
>-t

P 3 CO CD q
3
4
cd
Co ^
co 3 ^ <5 2
3 3T j
r-t-
P^U -
O CD
3 <! 3 O £3 s<j S5- to g
CD CD
" o 2
CD vg 3c* 3 3 CD
CD *-+>
S3 f 3 2
a
5a
s
tr
3 fa 3> 3
co

£ O f
3 3 3. c/i 3 CD
2 7) S 3
^-
CD CD 3 s n 33
a 3
I
^
O
§
CTQ tr
3
CO
O 2a
o
3
3
f* 33
CD ft)
CD
3
a
CO o
^3 q £2 Pancreas,

3 I—.. 3 o
f b
3 a
r+ £> 3 <J i-t- 3
3
3 3 to . 33 O a cd
-or*
g
a
co
0 rt
<
.
3“ CD O 3
o g:
CD
h
a 33 r+ CD

S, 3 33 pi < CD CD
% 3
CO
S3
CD
01
rT LL
o 33
CO
to
f>
r Ü « 3 S3 b
3
a 4
£± S3
33 3 < o’
CD O 3 2 tJ4 3 Di 3 3
tt-
o & ^ -

a g s
CD
CD 3 Mr> CD » 3 cd co i-t a ~L C3
g S' 4
^ CD CJ
Duodenum,

S CD CJ
^ o ct-a

a a O 4 S'
CD
3
'S | W % 3 cT
O |3*
<:
CD
crq
p 5 CD
S CJ
3 8
CO CD CD i-t CD 7) a 8
o S3 a SJ
3
to
3 < X t—K
O 3
to fit
CfQ

3 U. 2 ^ S' > CD H-*

3 |_) 3-’ CD
i— * 3 H
a
.

CfQ 3 ° Bt r3 3 3 CD
CD
3
33 s J S O
f ^
ct-
^ 3 3 3 o
3* CD S3- the
£ 33 O ß
CD
B4 *-1 m-j CD CfQ
^ 3 I-* CD g
^ CD
P -
O c-t- c/)
CL » Co
[-H
3
CD
ff r+-
7)
3
3 h+1
a 3
3
1

< « a 33 CL
g*
aa a.
CD

§:§ o aa S'
o O CD
a CD
CL
^o aQ
hj O
f 3 3 "2
CD CfQ
3 i-t-
tr 2 ^ 3
<Si -

£L 2 S O
CD 33 33
3 ^
§:
o 2 CL
CD
t-t
P j, o CJ
3
^ O CD Stomach

o to
ffi.
2. CD CJ* co r-3
p hj 3 ~
CL f~3
co ^ o 3_
P f o O3 TJ 33 (“t-
co H
cSi
Co
.
CD £
33 o 3 33 3 2 »•
O CD ~t Co
CD
3 O 3 CD ^
CD
3 3 3 O 3 CD ^ -a

fa CO W
CD
O 3
3 tg
CL & CL
a^ p CfQ 3 O 3
o
P*
^
CD
P
< 3
i-t
^ CD
CD
<’
ot
r4- p ^ CO aa 2 75
having
(D in
r+
<-+-
r+ Q 2 3
O 3 tr 3 CO O
CD *-t |-t
33 33 si
*-t
f 2 _ o
p CD O 3 CD
^ 3T
3 aa2 tri
O ^ Cfq o
3 3 g f P g. S3 O CL
P ~ o P
CD
CS O
3 ^ 33
CD
3
CfQ
c3 in
in CD
v> 2a CO
O P
CL 33
ct> been
33 CD 3 g 3
<D hrj P a
• o 3 3 ^ o O 3 <
CD CD
X O
f I-t

CD
CD S3
f ao S $ CD o 2 tr co

atf CD 3.
3

u
33 to
CD CO
co
CO C3
3^ ° i-i-
CD g 3
_CO CO
CD 3 3 CD O p
3
H a
CD
cT 3 33 o p
CO
3 < ffl V! removed.

CD g CL 3 CL 3 33 P.
3 3 S P O 4
»-t r-3
CD ft O 4
3 O S’
1-1
£L v; CO hj
CfQ CL CD
<
f-
33
a
co
3 S'
in
<
< i-J. a a na
SJ
3 | 3
2
a c
aa 3 3
s tf>
(g
3 o' 5 2 rt 3
a ^ CL 3 ^ O
13* GfQ
3 3
CD
CD 3. CD

^ r+3
7)
CD
3 p
* O CD CD
3 H C3
3 Vi
fa
O CO ri*
33 3 ft
f. tr
to <4 3 ^ o'
4

CL
^ f f 3
CD

co
33 a
O 3
CD CD
Vi
„ S3 3 Q ^ Cfq
CD C3
3 O rj 3 CO co td f
3 3 3 f
CD CD
S3 2 w 3 CD
i-t

p 3 CD O o
3 sT o
S3
O
CO CD CO
a4 3f 3 ti
a S' 2 3 E
3
f
33
3
a 4
S'
CD CfQ ? $ 3 ? to
P
I I-t CX> P- in CD

I
Fig. 130. Position of the Viscera which lie outside the Peritoneum.

Woman aged The Intestines have been removed from the Cardiac end of
30.
the Stomach down to the Rectum. Pancreas and Spleen in normal position.
Parietal peritoneum has been removed in the Abdominal but left in the Pelvic
Cavity.

The Peritoneal Cavity has been opened in the following way. The median
incision extends from the Xiphoid to the left side of the Umbilicus below which
part the incisions diverge towards the right and left Anterior Superior Iliac
Spines. The two large upper flaps are further divided into two smaller ones by
incisions running towards the 10th ribs.
The two Kidneys (practically at the same level, though the left is usually
the higher, cf. Fig. 125) together with their large arteries from the Aorta are
shewn with their veins which enter into the Inferior Vena Cava. At the hilum
the Vein is situated in front of the Artery, which has divided into many branches,
whereas the Ureter is situated behind.
The left Renal Vein passes in front of the Aorta to join the Inferior Vena
Cava; the termination of this left renal vein and the right vessels are covered by
the head of the Pancreas.
The Pancreas extends across at the level of the ist Lumbar Vertebra
from the Right Kidney to the Left, terminating in relation with the Spleen and
lying in front of the Aorta and Inferior Vena Cava.
Above the Pancreas the Coeliac Axis with its three diverging branches is
shewn; below the Superior Mesenteric Artery, (the origin of which lies under cover
of the gland), at a lower level and to the right is the Middle Colic Artery. To the
right of this Artery is the Superior Mesenteric Vein whereas further to the left
is the Inferior Mesenteric Vein. Above the Pancreas the Portal Vein can be seen,
cut off at the hilum of the Liver. This vein is formed by the union of the
Splenic and the Superior Mesenteric Veins.
The Ureters passing downwards on the Psoas Muscles cross the Iliac
Vessels — on the left /2 inch above, on the right x /2 inch below the origin of the
]

Internal Iliac Artery —and course along the outer wall of the true pelvis to the
Trigone of the Bladder. In the Male the Ureter crosses the Vas Deferens, passing
below this duct; in the Female the Ureter passes below the Uterine Artery.
To the right of the Aorta lies the Inferior Vena Cava, between these
large vessels and to the left of the Aorta are large lymphatic glands.
The Aorta bifurcates into the Common Iliac Arteries at the lower border
of the 4th Lumbar Vertebra.
The inlet of the true pelvis is almost completely filled up by the much
distended Rectum (ligatured) and the Uterus (in this instance enlarged) which
overlies the Bladder. (Cf. Figs. 146 and 147.)
 Hepatic Veins

Left Gastric
Artery
Inferior Phrenic
Inferior Vena Artery
Cava

Portal Vein Oesophagus

Hepatic Artery Spleen

Middle Colic Artery Suprarenal

Gland

Pancreatic Duct
Splenic Vessels

Common Bile Duct

Tail of Pancrea
Sympathetic Chain
Inferior
Mesenteric Vein
Right Ureter
Left Kidney
Transversal is
Abdominis
Muscle Iliohypogastric
Quadratus Nerve
Lumborum
Muscle Ilioinguinal
Nerve
Genito-crural
Nerve
4th Lumbar
Psoas Muscle A rtery
External
Crural Branch Cutaneous
Nerve
Genital Branch Spermatic
Vessels
External Iliac
Artery Anterior Crural
Nerve
Fallopian Tube
Internal Iliac
V essels
Fundus of
U terus
Ovary

Bladder
Deep Epigastric
Artery

Urachus
Obliterated
ypogastric
Artery

Dr. Frohse.

Fig. 130. Position of the Viscera which lie outside the Peritoneum Female.
s
/5
Nat. Size.

Rebman Limited, London Rebman Company, New York.

 Sheath of Rectus
Abdominis Muscle
Superior Epigastric
Artery
Rectus Abdominis
Muscle Left Lobe of Liver

Falciform
Ligament
External
Abdominal Oblique Round Ligament
of Liver (Oblitera-
Muscle
ted Umbilical Vein)
Caudate Lobe

8th Rib
Hepatic Duct

Transversalis Hepatic Artery

Abdominis
Muscle Omental Sac

Cystic Duct
Common Bile Duct
Hepato-Duodenal
Fold (Foramen Portal Vein
of Winslow)

Pylorus
Internal Abdominal
Oblique Muscle
Upper Portion of
Duodenum
Right Epiploic
(Omental) Branch
Hepatic Flexure Middle Colic
of Colon Artery

Deep Epigastric
Artery

Fig. 131. Gall-Bladder, Bile Ducts and Neighbouring Structures Female.

3
/4 Nat. Size.

Rebman Limited, London Rebman Company. New York

 Fig. 131. Gall-Bladder, Bile Ducts, and Surrounding Structures
Female.

On the body of a woman, aged 55, a large window, ff2 inches long by 4 inches
wide was made through the skin of the right hypochondriac region. The window
aperture is diminished through the deeper layers. The Liver and Gall-Bladder
have been drawn upwards and to the right while the Stomach and Duodenum
have been drawn doivnwards. By removal of a part of the Anterior layer of
the Hepato-duodenal fold the structures at the liilum of the Liver have been
exposed.

This figure shews the window with its inner boundary situated Y5 th inch
from the middle line. At the margin of the window, especially at the outer margin,
the various layers of the abdominal wall are to be seen External Oblique Muscle.
:

Internal Oblique Muscle, Transversalis Muscle; at the upper and lower margins
— the Rectus Muscle and its sheath together with the lumina of the severed
vessels which run behind the muscles: Superior Epigastric Branch of the Internal
Mammary Artery (cf. Fig. 1
1 9) and the Deep Epigastric from the External
Iliac Artery.
In this figure the Liver and Gall-bladder have been drawn upwards and
to the right in order to shew the structures in the Hepato-Duodenal Fold, but the
natural position of the Gall-bladder shewn in Fig. 124.
is

The fundusof this organ, which is normal, extends a little way beyond
the lower border of the Liver at the point where this viscus leaves the Costal
Arch (8th or 9th Costal cartilage) and runs obliquely upwards into the epigastric
region. The fundus is
Y5 th to 2 inches from the middle line so that access is
1

gained to by a longitudinal incision from the costal arch through or along the
it

outer border of the Rectus Muscle.

In pathological conditions, the gall-bladder may be so shrunken as to be
hidden under cover of the liver, but when distended or the seat of a neoplasm, it
may be easily palpated and even become of such a size as to be mistaken for an
ovarian cyst.
The size from i 3/5 th inches (as in this
of the Gall-bladder varies greatly
instance) to 5Y2 inches long. It is covered by peritoneum on its free surface

only (cf. Fig. 133). The Gall-bladder is directed backwards and inwards. Its
duct (1 Y5 th to 1 3||ths inches long) has always an acute S curve and it joins
the hepatic duct at an acute angle (the length of the hepatic duct is one inch).
The Hepato-Duodenal Fold forms the Anterior boundary of the Foramen
of Winslow: the arrangement of the structures in this fold are: —
To the Right: Common Bile Duct.
To the Left: Hepatic Artery.
Behind: Portal Vein.
 Fig. 132. Gall-Bladder. Bile Ducts and Surrounding Structures
Male.

As in Fig. 131 a largewindow, 6 inches long and 3 inches wide, was cut out
of the right Hypo-chondr iac region of the corpse of a robust male. (Other
details as in Fig. 131.)

The Fundus of the Gall-Bladder lies more to the side than in Fig. 13 1.

No difference dependent on sex could be made out in the position of the organ.
All the structures are shewn of normal size, more distinctly, and somewhat
differently arranged from Fig. 13 1 e. g. the position of the Gall-Bladder is more
transverse, the Pylorus is at a higher level, the Hepato-duodenal fold extends
further on to the Duodenum (cf. Fig. 13 1 where it does not go beyond the
Cystic Duct), consequently the Foramen of WlNSLOW is in a somewhat different

position.

The two lymphatic glands seen, e. g. a smaller Cystic at the neck of the Gall-
Bladder, and a larger Gland of the Portal Vein on the anterior aspect of the Portal
Vein near the Hepatic Duct, are constant. Another gland may be found lower
down near the Common Bile Duct at the upper border of the Duodenum. It is

right to know of these glands, because they become enlarged in chronic inflam-
mation of the Biliary passages and may become so hard as to be mistaken for

gall-stones.

The Gall-Bladder is supplied by the Cystic Artery (a branch of the Hepatic)

which divides into two branches, one running along the free surface of, the other
running between, the Gall-bladder and the Liver. (Both branches need a ligature
in Cholecystectomy.) Considerable importance is attached to a small but constant
artery (cf. Figs. 13 1 and 132) which, derived from the Hepatic or Gastro-duodenal,
runs across the anterior aspect of the Common Bile-Duct and ramifies on it, on the
Duodenum and on the Pancreas. It sends a branch upwards to the Gall-Bladder
which we call the Accessory Cystic Artery. It reasonably follows that in per-

forming Choledochotomy the operator should look out for this artery.

Both figures shew that, when the Liver is pushed upwards, the Duodenum
and Pylorus drawn downwards, the Bile passages are easily accessible ;
thus removal
of the Gall-Bladder, opening of the Cystic Duct, and other operations are rendered
possible.

The Common Bile-Duct lies for a short part of its course in the Supra-
duodenal portion and favourable for surgical measures. Its further course behind
the Duodenum is covered by the Pancreas. (Cf. Fig. 133.)
 Transversalis Superior
Cystic Duct Cystic Artery Hepatic Duct Portal Vein Abdominis Muscle Epigastric Vessels Left Lobe of Liver

External Round
Abdominal Ligament of
Oblique Liver
Muscle (Obliterated
Umbilical
Vein)

Caudate
Lobe
8th Rib
Hepatic Ar-
tery (Left
Branch)

Quadrate
Lobe Pylorus

Hepatic Ar-
tery (Right
Cystic Branch
Lymphatic Abnormal)
Gland
Stomach

Gastro-Duo-
denal Artery

Gall-
Common
Bladder Bile Duct
Superior Ho-
rizontal por-
tion of the
Duodenum
Foramen of
Winslow
Right
Gastro-Epi-
ploic Artery
Hepatic
Flexure of
Colon
Middle Colic
Vessels

Internal

Oblique
Muscle Rectus
Abdominis
Transversalis Muscle
Abdominis
M uscle

'S

Fig. 132. Gall-Bladder, Bile-Ducts and Surrounding Structures — Male.

Seen from in front. — Nat. Size.

Rebman Limited, London.

Rebman Company, New York.
 Vena Cava Inferior

Central Tendon of Diaphragm

Lung Right Auricle

Lung

Pericardium
Right Ventricle

Costal Pleura

Diaphragm

Parietal Peritoneum

Branch of Portal Vein with

Fibrous Capsule (Glisson)
Latissimus
Dorsi Visceral Peritoneum
Muscle

Branch of Hepatic Vein

Tendinous intersection
in Rectus Muscle
Diaphragm
Hilum of Liver

Hepatic Duct
Pleura
Cystic Duct

Common Bile Duct

Gall-Bladder
Upper pole of
Kidney
Inferior Vena Cava
Foramen of
Winslow
Sacro-Spinalis
Muscle Portal Vein

Pylorus

Renal Vessels Rectus Abdominis

Muscle

Common Bile-Duct

Pancreatic Duct
Psoas Major (Wirsung)
Muscle
Head of Pancreas

Umbilicus

Ampulla of Vater

Transverse Mesocolon

Inferior Horizontal
portion of Duodenum

Peritoneal Cavity

Transverse Colon

Ilium

Sacro-Uiac Omental Sac

Ligament

Sacrum Root of Mesentery

5th Lumbar Nerve \

Lumbar Plexus Spermatic Vessels

\
Internal Iliac Vein Ureter

Common Iliac Artery

Fig. 133. Subphrenic Space; Pelvis of Ureter, Hilum of Liver, Bile-Ducts.

Sagittal Section, seen from the right. — 2
/s
Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Fig. 133. Sub-Phrenic Space: Pelvis of Ureter, Hilum of Liver;
Bile Ducts.

Sagittal Section passing i 3/$th inches to of the middle line of a

the right
frozen female body. The Common Bile Duct was exposed in its course behind
the Duodenum and Pancreas. The Peritoneum is in red.

This figure shews with great accuracy the course of the Common Bile

Duct which is usually 3 to 4 inches long. Its upper portion — Supra-Duodenal

Portion — lies within the Peritoneum of the Hepato-Duodenal fold ,
and is

C/sth inch long.

The Duct next passes behind the upper part of the Duodenum and
crosses it — Retro-Duodenal Portion 1 inch long.
The last portion — Pancreatic Portion — iY5 th inch in length, runs
either through the substance of the Pancreas or in a groove on this gland to
the left side of the descending portion of the Duodenum where it opens into the
Ampulla of Vater close to the Pancreatic Duct, or together with it in some cases.

The Retro-Duodenal and Pancreatic portions are both retro-peritoneal. (Cf. Fig. 136.)

This is of importance in operations on the Bile Duct (gall-stones) ;

the most
easily accessible part is the Supra Duodenal portion. (Cf. Fig. 132, text.)

To expose the Retro-Duodenal portion the Gastro-Hepatic Omentum must

be divided at the upper portion of the Duodenum, and this structure drawn
downwards. When the upper and descending parts of the Duodenum have been
freed and drawn to the left, the Pancreatic portion of the Duct is accessible (Trans-
duodenal Choledochotomy). Cf. Fig. 129. Exposure of the Retro-peritoneal portion

of the Duct from the back, as practised by TuFFIER, is less commendable. Rupture
of this portion of the Duct leads to extensive retro-peritoneal exudation of Bile.

The organs below the Diaphragm, viz. Liver, Spleen, Stomach, are separ-
ated by a narrow space from the Diaphragm, which is lined by Peritoneum, and
communicates with the Abdominal Cavity: this does not apply to those parts of
the Liver (cf. Fig. 131) which are not covered by Peritoneum but connected with
the Diaphragm by loose connective tissue. When pus spreads into this space from
neighbouring organs; Stomach, Gall-Bladder, Appendix, Kidney, or in general
Peritonitis, a Subphrenic abscess is formed.
Accordingly, a Subphrenic abscess may be either Intra- or Extra-peritoneal

the latter variety is very likely to occur if suppuration extends along the perinephric
connective-tissue. (Cf. Figs. 133 and 136.)
 Fig. 134. Right Kidney, exposed from behind.

On the right side of a male corpse a window-section has been made by removing
skin , part of the Latissimus Dorsi, two digitations of the Serratus Posticus
Inferior, the tendinous origin of the Transver salts Muscle and the fatty tissue
behind the Kidney.
The Kidney is tilted forward to exhibit the hilum.

The Left Kidney extends from the upper border of the 12th Dorsal
Vertebra to the lower border of the 2nd or to the middle of the 3rd Lumbar
Vertebra. The Right Kidney is usually about the space of i
/2 a vertebra lower.
The upper half of the Kidneys lie very near the pleural cavities from which they
are only separated by the Diaphragm.
The distance from the lower end of the Kidney to the crest of the Ilium

varies considerably (D/^th inch in the male, 1 inch in the female, on the right
side; L/sths inch in the male and D/sth inch in the female on the left side).
Access to the kidney is obtained by two routes, either from in front (trans-
peritoneall}' — cf. Fig. 135, text) or from behind (from the Lumbar region). By
the latter route the surgeon has the advantage that in operations upon the kidnefl
the peritoneum is not opened. The route followed is at the border of the Sacro-
Spinalis Muscle after division of the lower border of the Latissimus Dorsi, the
deep layer of the lumbar fascia is then divided. After division of the Fascia
Transversalis and the Renal Fat the lower end of the Viscus is exposed. In
extending the incision upwards as far as the 12th rib the Pleura may be slightly

injured, as its line of reflection runs from the lower border of the 1 2th Dorsal
Vertebra in a horizontal direction outwards across the 12th rib if this bone be
of some length; in this case the anterior part of the rib lies below the pleura.

If the bone is very short the nth rib may easily be mistaken and thus an incision
carried forward may open into the pleura.

For operations near the Pelvis of the Kidney the situation of the Artery

and Vein anteriorly affords a great advantage in rendering the Pelvis easily
accessible from behind; the same advantage applies to the upper part of

the Ureter.
The lower part of the Ureter is reached by “an Oblique lateral incision”
as for ligature of the Common Iliac Artery. This incision is carried from the

upper border of the 12th rib obliquely downwards and forwards to the junction
of the outer and middle third of Poupart’s ligament. The peritoneum is pushed
aside without opening. The lowest part of the Ureter below where it crosses

the Common Iliac Artery can also be reached extra-peritoneally by an incision

made parallel with and directly above Poupart’s ligament.
Latissimus Dorsi Muscle

Serratus Posticus
Inferior Muscle

Sacro Spinalis

121h

Right

Inferior Vena Cava

Renal Vessels

Ureter

Ascending Colon

Quadratus Lumborum
Muscle

Iliohypogastric Nerve

Spermatic Vessels

Uio-inguinal Nerve

Superficial Lamella of
Lumbar Fascia

Lateral Cutaneous
Branch

Gluteus Maximus
Muscle

Gluteus Medius Muscle

Origin of Transversalis External Abdominal
Abdominis Muscle Oblique Muscle
Internal Abdominal
Oblique Muscle

Fig. 134. Right Kidney, Exposed from behind.

% Nat. Size.

Rebman Limited, London.

Rebman Company, New York.
 Ductus

Venosus

Fig.

135.
Hepatic

Veins

Portal

Vein,

Seen

from

in Umbilical

Xiphoid

front.

and Process

8
/.
Renal
Nat.
Oesophageal

Size.

Vessels.

Opening

in

Diaphragm
“Renal

Areae”.

Aortic

Opening

in

Diaphragm
 S 3 P3 3
M-
0-
..
- C
o i
in
bj cl 03
colon
cd
3- o d
CD CD
d_ 3 o 3
3
d. #
2 3 r-b (

&
.
portion
“Jejunal uistenaea r"b
o g* F H
r-b
o
<-t
o
0
f?
%
Ihe Li
3
0> 33
'
3* 3
3 3
3
3 & er I 3
75
3 3 3 l
of away 05
'-t
3
jd 3 » ?a ^ S'
3
Area”;
3 3
3 3 cg. *0 3 3
the inner

coion 3 ffq 3 o 3
7) 75 3- fe-
CL qr
^ 3 3 0 3
from 3 » 3. 3
3 S'
w
O m 3- <-b Qa r*b qr qr
3 CD o P qr
S' tr o 0Hi § 1-5
o 3 3
3 M.
border
the
again may cl ^ 3 CD 3 3 _ T3
CTQ
Duodenum.

tr 3 in d. . 3 o
3 3 3 d 3’
in
qr V S
'

„
CD
d 3 3
S“
-

of kidney.
pusn
CD 1

3
3
W qr qr P p 3 3 (= o
the
turn
> hQ 51 51 rt.
3 3
3 do 3
in 3 3 3 s' M- 3 3
0 a
^ 3 qr 3 3 in
The
a CD 3 V 3 3 3
3 75
C

TIH 3,
asiae

D. d 3 •fV
3 2 3 qr 05
O1 3- 3 3
5“
Kidney
Many
Bj < ffq .

o ffq if
2 CD CD
qr j-t
3 51
3 S' p «>
ffq 3 3 Ds-
relations
distended the
* 3 3 3 3 3
S S
is
!>
S,
CD
>-3
o r-b
O rb X
qr r-b
-
v S 3 o
in
CO
M-.
qr
qr
CD 03 p (n o, 3 CD
3 3
2 n O 3
in R-
0 d*
3 o' di
of 3 dl J—
3" 3 os g-
variations

3 3 5 <1 3
jejunum
n 3 in p}
the
covered o 33 03 3 3 d 3 O p
jejunum
o' 3 3
in — r-b
.
r-b
.
P5 3 CD d
P
—
1 CD
P in in P* 0 P3 3 d P. 3 cl
CD 3 CD 3 p p -.

by are
and
CD d 3 d 3 in H X 33
CD
Left P s* qr V
d O
r-t
3 33 3 in3 3
may 3 <;< 3 3 3 O hd w
O 3
the
occupy
^o o 3
3
-. 3-
33
CD
in
in
3
w <
O a
in
o
o o o
< 3 3 q
3" o O
o
< ft 3 gj
Kidney
3 3 3 3 3 2
3 O C-t-

3 3. O 3 C 3
Vo' 3 3 3 3
encountered,

push
3 o m1
CL 3, 3
vertical
‘
m 3
2 ffq < a. ™ & 3. cl
r-b
Ci 3- O
3
are the the
> 3
qr
la 3 vcr 3qr 3-> in3 8CO Vqr O' 3
.V V ao o 3 H o o < LC
Ystihs give 3 3
0 SL d o
<
o
d
o 5. c
joined
Foetus p o CD r+
new-born •t p
O 3 ^ CD O
^
on
an
o' a qr a
o 0) P4

together
the they
and
idea in
P"
3
>rJ
q B-
3
B P I 5 ch dl
2, 3 3
H-b>

s
3
!=l r+ o
o 3 o td 3 3
1 0;

oi cr in in S' CL 3 -

Child.
3 3 3
*0
3 >
left, »-t
in — S' qr 75
are 1 M-
3
o r-b
qr CL
1
» •

3 o r-b
«
3
3 3
/
their

2 qr
the
.

3 3 o H+1
while
5
th
In
ffq
5“ ^ o
3- O
3 3
3 51 M. r+ 3
3 ^
3 3 CO qr
shape
to
the
oq 3 ;> 3 SL ^ in d
position,
; CD $ S' 3
their /
5
4 Jiy CD
<
51
bj
3
5
t3 '
3
o
qr cr
§
3
_j
o
of 3 P 3 o' 3 < 3 3
ths adult

3 I a 3 ^ a o
3 qr jw
a size
a CD
3 CL O
3
P
3
Si /5

O d-
3 n
upper inch they
and
3 o CD
3 d
3 d
CL hC O'
75
n
3
3
3
qr
CL
3
3 5
3 rt
o
3 3
horse-shoe.

long
CD
qr O 3
o r*b
tr
3
P
CD
4
r-b
cr Cl
w g. CL
3
. CD r-b
3 CD ffq o CL 3 5’ 05 75
75

3 a 3
are
shape 3- S' ft ffq
P 4 O
3 3 3 CD >
3 n
0 o o 3
^ Bl O
75
extremities

on
Cl r-b
< _
3 in 3
3
^ d
li -S
h
as d_ 3 P^ in 51
o’ 3 3 CL X
the
rudimentary.

CD
r-b N
cj
'3
3 ^
3 3-.
3
3
are
met a o 3
75 u in HH 3
3^ 21 O'
<3 qr Vi
in 5! tr 1-3
z.
S= o 05 3 3
5^
right,
H 3 3 CL bj
with P fL 3- ffq 3
3 3. CO

oftentimes
Y
5 In in
W
i>
S! <
3
O
75 r-b
o
3
th 3 O 3
d 3 75
3 ft 3
O O d 3' S'
the the CL
to
75 3 3 3
 .

Fig. 136. Position of the Abdominal Viscera seen from behind: lines
of Peritoneal Reflection.

The plaster model by His which has been made from nature (cf. Archiv, f.

Anat. u. Phys., Anat. Abt, 1878) shews when taken to pieces and put together again
the form and position of the Abdominal Org'ans in a beautiful manner; further
this model shews the individual relations of the various organs, the lines of
reflection of the Peritoneum, and the relations of intra- and extra-peritoneal areae.

Our figure varies slightly from the model by His (cf. Fig. 130).

Uncovered by Peritoneum: A considerable area of the posterior surface

of the Liver, posterior surface of the Pancreas, of the Duodenum and of both

kidneys, the anterior surface of the Kidneys in contact with the Pancreas (cf.

Fig. 135 and 139). The large vessels are also extra-peritoneal: — Aorta and
Inferior Vena Cava, the posterior wall of the greater part of the Ascending Colon
and Descending Colon. The posterior aspect of the middle portion and the whole
of the lower portion of the Rectum. The Caecum is also uncovered by the peri-

toneum except where the Ileum opens into its posterior aspect as it becomes
closely applied to the wall of the False Pelvis.

On rare occasions only does the Caecum possess a Mesentery whereas the
Vermiform Appendix is enveloped in Peritoneum and has its own Mesentery —
Mesenteriolum —
The extra-peritoneal position of the Kidneys, Ascending and Descending
Colon afford an important means of operating upon these Viscera without opening

the peritoneal cavity (cf. Fig. 134). Moreover, as the peritoneum is only loosely
attached to the anterior surface of the kidney, it can be easily detached, and thus
the kidney removed without opening the peritoneal cavity.

Formerly, Lumbar Colostomy was frequently performed for disease of the

Sigmoid and Rectum.
The absence of Peritoneum on the posterior surface of the Rectum bears
an important^ relation to the spread of inflammation. This absence of peritoneum
is unfavourable for circular enterorrhaphy after removal of Rectal Carcinoma
because gut surrounded by Peritoneum heals more readily.
 Inferior Vena Cava
Caudate Lobe
(Spigelius) Hepatic Artery
Oesophagus
Left Triangular Ligament of Liver Portal Vein

Coeliac Common Bile Duct

Suprarenal Body

Superior
Artery Foramen of Winslow

Inferior Mesenteric
Vein Supra-Renal Body

Spleen
Fatty Capsule of
Kidney

Pancreas Right Kidney

Pancreatic Duct
Duodeno-Jejunal Flexure

Hepatic Flexure of
Colon
Left Colic
Inferior Horizontal
Portion of Duodenum

Descending
Right Ureter

Abdominal Aorta

Inferior Vena Cava

Inferior Mesenteric
Artery

Left Ureter Ascending Colon

Left Common Iliac

Vessels Ileocolic Artery

Superior
Haemorrhoidal Vessels

Internal Iliac Vessels Artery to Appendix

Caecum

Sigmoid
Vermiform Appendix
Rectum

Fig. 136. Position of Abdominal Viscera, seen from behind; Lines of Peritoneal Reflections.
Model made in Plaster of Paris by Stager, Leipzig. According to W. His. — 2
/5
Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Superior Ueo- Inferior Ileo- Rectus Abdominis
Caecum Transverse Colon Caecal Fossa Caecal Fossa Ileum Ureter Muscle

Anterior Superior
Iliac Spine Deep Epigastric Artery
Superficial Epigastric
Vessels
Vas Deferens
Ilio-hypogastric
External Iliac Vessels
Nerve
Spermatic Vessels Plica Epigastrica

Fig. 137. Vermiform Appendix and Caecum.

Nat. Size.

Rebman Limited, Loudon Rebman Company, New York,

 Fig. 137. Vermiform Appendix and Caecum.

In a robust male a lozenge-shaped window has been made 5 inches

corpse,

by 4 inches through the skin but of a smaller area through the deeper layers

of the right Hypogastric and Iliac Regions; Omentum and Transverse Colon
are thrown upwards.

The Appendix is at a higher level, and more laterally situated than usual

its position varies with the degree of distension of the neighbouring intestines.

As the Appendix is completely enveloped in Peritoneum, its mobility is very

marked in contrast to the commencement of the Ascending Colon which is only
covered anteriorly whereas posteriorly it remains fixed to the posterior abdominal
wall (cf. Fig. 136).
The Caecum, usually 2 4 /sths inch long, is situated in the Right Iliac

Fossa on the Fascia Iliaca above the outer 1

/2 of Poupart’s Ligament; when
moderately distended and the neighbouring coils of intestine empty or onfy
slightly distended it lies against the Anterior Abdominal Wall, but if more
movable it may lie bent upwards upon the Ascending Colon.
Coming off the lower end of the Caecum near the lleo-Caecal Junction and
in possession of its own mesentery the position of the Vermiform Appendix is

very variable; in length it varies from 1 to 10 inches (usual length 3 to 4 inches);

in shape it may be straight, serpiginous, spiral or bent upon itself; in position it

may come in contact with the Bladder or Ovary in the true Pelvis, it may lie

behind the Ileum or extend up behind the Caecum, Kidney or even the Liver,
or Stomach, and extending beyond the middle line.

Its base corresponds to Me Burney’s point — midway between the

right Anterior Superior Iliac Spine and the Umbilicus.
The Arteries to the Ileum, Caecum and Appendix produce folds of Peri-

toneum in relation with which small recesses are formed, e. g. Superior and
Inferior lleo-Caecal Fossae.

As Appendicitis is of frequent occurrence, operations upon the Vermiform

Appendix are often necessary. The usual incision is made directly above and
parallel to the outer V2 °f Poupart’s Ligament; — though the viscus can be
reached by an incision along the outer border of the Rectus Abdominis Muscle
at the level of the Anterior Superior Iliac Spine.
 Fig. 138. Sigmoid Flexure and Inguinal Canal.

The Hypogastric and Iliac Regions are exposed on the left side of a normal
male cadaver —
(aet. 38). The upper portion of the Abdominal Wall in this
region has been removed and the Inguinal Canal dissected out, the Sigmoid
,

thrown upwards and inwards, after accurately determining its position (dotted \

lines).

The Sigmoid Flexure which, variable in length, extends between the

Descending Colon —
attached to the posterior Abdominal Wall —
and the Rectum
— attached to the posterior Pelvic Wall —
is the most movable portion of the

large intestine.
The Sigmoid Flexure usually possesses a lower (left) curve with its con-

vexity downwards, and an upper (right) curve with convexity upwards. Such
its

are indicated by the dotted lines. When the Sigmoid is turned upwards, as in
the figure, a small peritoneal pouch over the left psoas becomes evident — the
Fossa Sigmoidea.
Lying internal to the Psoas Muscle are seen (cf. Fig. 137) the Iliac
Vessels;above the divided Rectus Muscle is seen the Obliterated Flypogastric
Artery passing upwards towards the Umbilicus as the lateral vesico-umbilical
ligament in the Plica Umbilicalis.
The fibres of the External Oblique Muscle of the Abdomen diverge in the
Inguinal Region forming the two pillars of the External Inguinal Ring, so that
the upper or inner pillar ends in the middle line at the Symphysis and the Sus-
pensory Ligament of the Penis or even extends beyond the middle line to the
opposite side, whereas the inferior or outer pillar terminates at the Spine of the
Pubis. The upper sharj;» angle of the External Abdominal Ring, and the anterior
surface of the cord are covered by the Intercolumnar Fibres (removed in the
figure), the function of which is to prevent a wide divergence of the pillars.
These intercolumnar fibres are derived from the External Oblique Muscle
of the opposite side and terminate by blending with PouPART’s Ligament.
Accordingly this ligament is formed by the External Oblique Muscles of
both sides and represents a tendon which most authors view as a band of con-
nection between two bony points or as the lower border of the External Oblique
Muscle. This latter view is probably the more correct but it fails to take into
consideration the connection of this ligament with the Fascia Lata of the Thigh.
Several small ligaments, of which some have been named are connected
with Poupart’s Ligament.
There exists, occupying a horizontal position between the Pubis and Pou-
PART’s Ligament, a triangular-shaped ligament, with its base directed outwards,
which is named GlMBERNAT’s Ligament. When this structure is looked at from
above and behind it receives the name of Colles’ Ligament.
Its sharp outer edge is sometimes called the Falx Inguinalis (Ligament
of Henle).
Internal and external to the Deep Epigastric Vessels lie respectively the
Internal and External Abdominal Rings; between these is HeSSELBACH’s Ligament.
 Obliterated External Fossa
Hypogastric Artery 'IliacVessels Intersigmoidea Left Colic Artery Sigmoid Flexure Ascending Colon

Spermatic Cord
I
Ilio-pubic Band (Colles) Poupart’s Ligament
Ilio-h)^pogastric Nerve
Free Edge of Gimbernat’s Ligament
Spermatic Vessels
External Abdominal Ring
Internal Abdominal Ring
Deep Epigastric Artery
Vas Deferens
Hesselbach’s Ligament

Fig. 138. Sigmoid Flexure and Inguinal Canal.

Nat. Size.
Rebman Limited, London. Rebman Company, New York
 6th Costal 5th Costal
Pericardial Cavity Sternum Cartilage Cartilage Apex of Heart

Pectoralis Major Muscle

5th Rib
Caudate Lobe (Spigelius)

6th Rib
Lower Border
of Lung

7th Rib
Diaphragm

Inferior Vena 8th Rib

Cava

Stomach
Serratus Magnus
Muscle

qth Rib

Liver
Spleen

10th Rib
Latissimus Dorsi
Muscle
Oesophagus

Supra-renal Body Right Vagus Nerve Thoracic Duct nth Dorsal Vertebra Thoracic Aorta

Fig. 139. Transverse Section through the Trunk at the level of the 11th Dorsal Vertebra.
Seen from below. — 2
/s
Nat. Size.

Rectus Abdominis Muscle Xiphoid Process Portal Vein 7th Costal Cartilage

Diaphragm Right Hepatic Duct

Stomach

7th Rib

Transverse Colon

Liver

Greater Omentum

8th Rib
Descending
Colon

Duodeno-
jejunal Flexure
9th Rib

Spleen

10th Rib
Pancreas

Latissimus Dorsi
Muscle
Pleural Cavity

nth Rib
Left Kidney

Supra-renal Body Abdominal 1 st Lumbar Inferior Vena Cava

Aorta V ertebra

Fig. 140. Transverse Section through the Trunk at the level of the 1st Lumbar Vertebra.
Seen from above. — 2
/5 Nat. Size.

Rebman Limited, London. Rebman Company, New York.

Fig. 139. Transverse Section through the Trunk at the level of the
nth Dorsal Vertebra, from below.

Frozen section of the same body as in Figs. 121 and 122. In front the 6 th
Chondro-Sternal Articulation is cut through, also the yth, 6 th, Jth, 8 th, gth,
10th and nth ribs; the vertebral column is slightly deviated to the right.

In this section the lowest portions of the Thoracic Viscera, Heart and
Lungs (in the condition of inspiration as in Fig. 122) and the Abdominal Viscera,
Liver, Stomach and Spleen are shewn in transverse section; between these two
groups of viscera lies the diaphragm. The Liver occupies the greatest space, the
remaining space is chiefly occupied by the Stomach, a small area is left by the
Liver for the Apex of the Heart, and by the Stomach for the Spleen.
The Lungs in their position during inspiration are seen at the periphery.
The entrance of the Oesophagus into the Stomach and the numerous broad
plications of the Gastric Mucous Membrane are well shewn.
Behind the Oesophagus lies the Aorta ;
at a higher level the Oesophagus
occupies the more posterior position while in close relation behind it and in con-

tact with the Vertebral Column are found the large and small Azygos Veins, the
Thoracic Duct and the Sympathetic System.

Fig. 140. Transverse Section through the Trunk at the level of the
ist Lumbar Vertebra. Seen from above.

Frozen section as in Fig. iyg passing through the disc between the 12th Dorsal
and ist Liimbar Vertebra.

The Liver occupies almost as much space as in Fig. 139, now taking up
the space previously occupied by the heart whereas, behind, room ismade for the
right kidney. To the left is Between this Viscus and the Spleen,
the Stomach.
the Splenic Flexure has introduced extending upwards beyond the plane of
itself

the section so that only sections of the Transverse and Descending Colon are seen.
Between the Colon and Stomach a lumen of small intestine is visible and
between the Colon and Abdominal Wall the Great Omentum.
The Pancreas has been cut almost throughout its whole length as it
extends horizontally across from Liver to Spleen. The Oblique position of the
kidneys is also seen; on either side a “Pleural Space” is found between their
upper half and the posterior abdominal wall.
The space between the Pancreas and the posterior abdominal wall is
occupied by the Left Kidney which has been cut through at its greatest diameter
whereas the Right, situated at a lower level, was divided nearer its upper pole.
The peculiar shape of the transverse section of the Aorta is due to
the origin of the Superior Mesenteric Artery.
 Fig. 141. Retroperitoneal Lymphatic Glands and Vessels.

The whole of the Anterior Abdominal Wall and the lower part of the Anterior Thoracic Wall have
been removed in a male infant 4 weeks old. A small area of peritoneum has been left over the right
,

kidney ; the Receptaculum Chyli has been exposed to view by cutting away a short piece of the Aorta.
The renal lymphatics are described after Stahr; the lymphatics of the testicle partly after Most and
partly after Br uhns whose description has been adopted for the deep inguinal glands.

Apart from the glands above the fascia lata of the thigh described in Fig. 166, deep
glands demand consideration both as regional and as intermediate to the deep lymphatic
vessels of the lower limb. As a rule, they are small and only 1—4 in number; their efferent
vessels run, as shewn along the inner border of the Femoral Vein and along the
in the figure,
outer and anterior surfaces of the vessels of the thigh into the Pelvis.
The former path leads
to Cloquet’s Gland, the outer tract to a (usually) very large gland just above Poupart’s
Ligament.
The large lymphatic vessels (4 to 6) of the testicle have a very long course before
they arrive at their regional glands (the lumbar glands); occasionally, there is an intermediate
gland on the course of the Spermatic Vessels (black spot on the right side at the level of the
Rectum). The regional glands on the right side are usually at a lower level than on the left
side; with the Vas Deferens lymphatic vessels run to the base of the bladder. The lym-
phatics of the inferior half of the Ureter pass to a Pelvic Gland, those of the superior half
to a Lumbar Gland.
The Lymphatics of the Kidney form on its surface a network quite distinct from the
Stellate Veins ofVerheyn.
The efferent vessels (2 — 4) pass with the renal blood-vessels either directly or through
an intermediate gland to the group of lymphatic glands situated at the angle formed by the
Renal Veins and the Inferior Vena Cava. When accessory renal vessels are present (cf. Fig. 164)
lymphatic vessels with a special regional gland usually accompany them (Frohse).
As the Peritoneum gives a covering to all the abdominal viscera its lymphatics do
not correspond to the limitations of each viscus (cf. peritoneum over right kidney after Stahr
who has kindly allowed us to make use of his hitherto unpublished figures).
All the lymphatics referred to, as well as those from the Intestine which convey the
Chyle, directly or indirectly pass into the Receptaculum which lies behind the Abdominal
Aorta and from which the Thoracic Duct leads. The Aorta and Inferior Vena Cava are
surrounded by a network of lymphatics and glands.

General Remarks on Lymphatic Glands.

As many regional glands are secondary to other organs it remains that only a few
intermediate glands (a collection of lymphoid tissue on the course of a lymphatic vessel) are
purely regional.
From pathological observations, lymph nodes or small collections of lymphoid tissue
are frequently found on the course of lymphatic vessels; Frohse and Hein have seen in a
case of Arterio-Venous Aneurysm (the injected specimen of an amputated arm) 6 large glands
situated along the radial and ulnar arteries.
Hein has further observed in an apparently healthy arm a small gland near the ulnar
nerve, just below the Elbow-Joint. Frohse found in a case of Carcinoma Mammae with
obstructed axillary lymphatics 4 newly formed glands on the clavicle and in yet another
pathological case 14 axillary glands on the healthy side and 31 on the diseased side; —
to sum up:
pathological conditions favour the new-formation and development of lymphatic glands. In
some cases the lymphatic glands are not visible to the naked eye but when injected with
mercury even a gland of the size of a pin’s head can be recognized because it becomes
distended by preventing the passage of mercury.
 Mam-
Body of Sternum mary Artery

Pericardium

Inferior Lobe
of Right Lung

Diaphragm

Inferior Phrenic
Phrenico-Costal Artery
Space

Inferior Vena Supra-renal

Cava Body

Supra-renal Fatty Capsule

Body of Kidney

Abdominal
Aorta Lymphatic
Plexus
Receptaculum
Stellate Veins
Chyli
(Vkrheyn)
Right Renal
Vessels 1 2th Dorsal
Nerve
Peritoneum Origin of Trans-
versalis Ab-
dominis Muscle
Spermatic
Artery Inferior Mes-
enteric Artery

Ureter lio-inguinal
Nerve

Common Iliac
4th Lumbar
Artery
Artery

Internal Iliac External Cu-

Artery taneous Nerve

External Iliac Vesical

Artery Artery

Vas Deferens Circumflex

Artery

Epigastric and
Obturator Trunk
Iliopsoas Muscle
Inferior Epi-
gastric Glands
Anterior Crural
Nerve
Edge
Pectineus Muscle of Fossa Ovalis

Deep
Sub-inguinal Fascia Lata
Glands

Sartorius Long Saphenous

Muscle Vein

Adductor
Longus Muscle Spermatic Cord

Testicle

Fig. 141. Retroperitoneal Lymphatic Glands and Vessels.

Newborn male Child. — Nat. Size.

-Rebman Limited. London. Re bm an Company, New York.

 •

t—1 •

aq

JO

ts
r-^
CD
>-*

P-
o
&
£
p
h—

CD
CD
£
o

a -1

CD
tf-
»—• •

P
P^

CC
B
p
£3

o
 3 3 H 5' '

<1
the be 0 a 3" P bj
3 3
1

sents 3 3
5. cr 3 o a 4
Ci
produce
3 S3 3 31 H Id.
til *"t
5'
5t
-
P C^>
8
From the Hilum
S3* o'
3-
p ft 3 s 3
3 O
d

o* 2 3 CTQ
33 04 ^
ü O O 0 ft l_ CTQ
a %
obliterated

p
fb 3 3* 3
w N 2 **
o a o 31 -3
5' 3
CD
co
<;
<!
P
£
Co
s 0
three
of CD 3 (3 o O Ä. eD

below
3
Cü
3
ju CD
CD
co
_h
in 8 o S
Q.
CD t^
CD
b o
the
2, o'
cr
in
P ft ,-h 3 bb S
Umbilical
3 CD *0 i-+> cv o
folds.

P
CD
O a 3
-t l
4
3 s ^ tft

^
t3-
13- CD 0 b3 3 I s
3 O CT0 TO
three
Liver
completely. CD

H-b
3 co 3
3.
Co
^ iftj
Vein
o
o
U
1

CO
S &
3. g-
CD cd 33
a a 3 4
co 3 Co 5 §
r-t-

3
(t C ft
O 0 ;

(— 1 3 t3 | O* a a
cords passes co

P
V
3
£3 p
3 ^ 3' 3j
X
to
o' 3. P 51 _ 8 g4 1
in
3
a
CT
3J
CDb 33
w P
L_|

(t
01
d
34 ft3
’

05
the
3* bj 3 tr
H33 S a 3
2. (5 CO
W. o
P P £ tr p
33 3 P
a>
Upwards

< 3 ft'
w a
ft a bb
05
33 § 3 3
their
*5' a Co C2
3 CD 05 p CD
%
Round
3 3* P
3 £2 a & b)
3 S b>
M*
_ 2 Crq 3 ft -
3“ n
o (W
and
3 ^
S co I— p tT dd 34
3 CD
passage
3 CD wo. CD
CD
ft
O d *
P
a cf
CD
>
U -
<fi

34 p 3 ft bä-
3
3
CD 3 a a 3
4
p TO
142.
Ligament
3 - 3 Co
to
towards

P p 1-3 3 33 3 a TO
b
a 3’ *+ s
ft Q
the 3"
3-
Ooq
w o a
0
TO
a
Co

the CD V
<
CD
4 o in
tr P
o SP o
Mo 5" fT
fb 5=
O Co

0 w
Anterior
which

-o p CD
a
1

0
CO a H > fb aC/5 on

3 CD
id b3 a 3 3 Mo 34 0, fb 3 t
p 33
0 . P 3’
o’ Q fb 0
CD
< 3
CD h
right CD bb &
CD •-1 0 p- Mo 0 Mo a CD
Umbilicus

repre-

3
CO
trj
ft 3 ft in O aCO a
^ o
p C
orq
CD
tr p may in c>
to O 3 §
*“t
I
tr 3 r- d 4 um-
0 Er
3 CD bb
in in
P co" s*tJ
r ^
i/) g»

H O 5 ^ Abdominal

3- 3 3
tr
4 34 crq
3 o
co 3 d
co 3
Hernia

Ligament
oi o'
30
to ft
3*
. p CD
ft' V4
Ü 4
bj
-0 r+ O tr 34 0
appearance

S & O P P
^ 30 3
Ü O a ft
O 3
O “
CD

W 2 p ^ & d
- w 3 ft 3 3. X 3 CO
05
0 CD
34
fa
d 3O 3P a^,
a
Wall,
CD 3 ft a^ft 3 4
o
internal

Oblique
U.
*
3
'

3 CD 3i n p co ^ C)s
3 ^
- CO ft 34 o ^
below
extei
3 2
crq
O
O 3 C-H
W q tr
3
co
a
b*+-
CD
crq
3 O 3 3 p
1-1 p CD •“'
o ,CD Co from

to nal
01
eft
CD
eft
<>
tr c co
3 3 P 3"

04
3
o P
t crq a * Orq*
2 p CO
Vd
> 3 3 3
.

3 ft. O a
this
to a4
a ft
34
%
3 04 ft
fb CD
4
0 Cft
M 0 bt
4 34 34
0 0
3 .

o el
'S» .

o tr* ^ o
Poupart

>
Indirect
behind.

34 a 4
3 g d. crq
s fta O
the
CD 'C h-H bd crq l-t p Co

s Artery.
3
ft <-*
03
K 2
r-f CO 04
£ Co
^ CD
fft 34 4 CD
^
Deep
3 3
X 33 C/5
3-
CD
3 0 ft.^
o
CD
H
(O
g
§
Hernia

3 P
P r~b

^ 0 tr >
3
i_i
3
Ligament, OTQ
3
04
o « §
TO
4 ft

a > 4
3 "
m
3< 0 ^ a
Femoral
a p
V! "*
4
TO
04 crq 3T
Epigastric
bj 2 o 3 0 S
p
4 3
C5 d
protrudes

o ^ d 2
a 3 -
n 3 o w 04
04 "C
ft-
«> ^+. CD
3 p 2 a 3 t*!
0 >3
{ ^ 04 CO w
co
orq
su
ft-
CD
tr
fj ft-
34
.CD
°b d.
TO g.
Herniae 5ö
p b P co 3 0 « g.Cr^
Artery H 0 r+
P 3 S' , a
above

c/T 3 3 2
04
-&* fb4
CO
ft-
S ft. 60
'm- Co
crq CD o' o' 0 p
o a ^ tr
3
3
0
04
0 CD 53
a
3
<55

§• -a
*a
make
;a OC/5
3 I
P
O d O
a
TO
'S».
CD
CD
^
CD CD o
d3 33 ^3 23. .

> 3
21 !> 3
Pouparts

P co p r+ O 3
O
co
2 o bi- a,
V
Kj
Sv«
Direct
3- w CD
o' O’ p" S
their

3 W
04 Mi
Uj
ft
04 30 0
CD 3
P
0
»-t
p
0 5 1 a
TO'

to
a
TO
a
TO
 1 c ^

s s s 05 Pa a .4 ^ C i a 05’ 05
Pj ^ a 43 r£ C 05 5P b 05 43 43
S ^ > J3 O ^ 4-<
45
+J
^ §
'a
co !<J 0 'S
•P
U2 Vh 3^1
CÖ
u O O
CO
o 'S
cw a;
^
C 43
i O S«3 S-H 02
43
0»
*0 ^ 'S G C/3
C
C 0 [S > 0 33 r
C5

O 35
^
05
> h- ^ a a;
O
^a £a _05
b<

§ 1 02 G c .S a c/2

4 05 a a
a Vh
05
u 33
4-;
a _,
a a
V a *a ro 43 .2
•5 a be > >
c/2

45 ^0 0 05 ^ g
n c

. o Oh zr *05
'Ö
-ö o ^^ G
43
C ,5
in
a & 05 c
CÖ ^ -
CT)
•r* c/3 2
'55 a
PQ « g a
05
6 s ^ 33
.5 o ^ aj C 33 c/i
hH 33 £
CJ '55
^ 4
.
g 03
U O <a 05
a c3 £ a
pH
a 43 a
.

* co G _0
G 4T-
33 £ o <1 <D
hH 0)
JG
aS
4-> & 0) aS
a Vh
a,
Ph
Ö Q eg 0)
n rG C*4 0) 1/3 0 c/3

43
c

c S S £ hG ^
a
<0
'S
"S
02 O G <-m 05 a;
3 <1 o "G <d
33 > Tl
a
0)

o O 33 M-l ° 55
a f-a
*+o
o 05
CJ
o Cj
in
<+H
• — be £ 33
.

a >^
vi
G 2± a
< ^ -
~G 0)
6
o VH
<V
a 3^
35
05
33
05
.2 -*
43
0) <5, OJ ^ "G^ £
_ 43
05
c/2

" nj '> ,
a
.2^
*S
S
a> aS <D 2
G 4—
43
Co ^ "O
& £ 1

n ^
rO S 5 .£ o
0) c/2
.“2

_ ^ !S
cö

X O
(A 2
a ° £ >
12 ^O * 'S T5
„
05
rt
O'-

£ "
.,

4 M
Q2
cH
a
05
a a
a 05 h
ca o
Ö
-S ts
3 nj £
S> C 3c*^ V- c/)

s
. a
a 43 P
5
a -ö
05 33
on
<3
.'J
05 C o -a S c/2
05 33
O ^ Ti w
05 43 3 Vh 05
jf 4$ .£ 0 G 4-»
• fH
bo -sg 05 33 £
05
a
H ? ^
b/} o
4) co •
<s>
G £
4-4
b V^ rG
^ 44 UZ P
V ,C0 O p a 4J
G
O
•*-*
43 a g>
0
<u bO
02 »s>
G> <5 G C /5 bß C 0
H
0
. G 05 a ^ 0 Ü
“
a —a
.
43 a o ^
+> •G"
^<
!> 0 4-J a eg >v.S a .£ 4-> G
r
O 43 V-
^
1 1
H
~L
-O 7U G ^ a 'G "a £ i5
33 a £ be >v
. r
G G Oh c &
'b
O s bs
C
a o3 £
.4
o
P
P_ £ Hr!
ui_i
05
.05
o
'U
a
l-H
Vh
aS 'w
O
-O c/2 If} t-(-H C/3
tn
<u
a
> a)
i 0 G ^ a0 > a 0 TU
O r-H 4b 4 2
V«
•hi
be s u £ <5 e 05

45 •
G a 05 'öS
c/2 £ G O
£ ^ a I *fc
"*
’
g g:
a 05
C/2 C/2
^ 0 a o
P HH
£ ^
15 O' Vh G Vh C/2 'S
-K» Vh a >
£ C be 2 a
43
+J
<v

O
o
•f*A £ 05 C
a
^
^
a
05
>5 33
a ^
te
•hi
o
o
^
05 43
a 0 a a . 2
'
a <n
G
bjo
-£ -S
-o 43 O o
O £ 2 £ 2 .2 be o O
o <5 -a
c C/2

•
a
H ^ c/T
-h>
a 33 o
£ 05
c/2

Q
-j_>
C/3
a ‘c/2

^ p
05
a be 2 0
& O V^ >>
a 2
a 4-J
a
a
ni
u3 C/3
• T-H

Ma ^ Vh
a 2
o & .£
43
45
v< %1<*
-hi
O ^
TU
G 43 0
G rH xj ^a <n
a C/3
a _
G 0 p .£
M JÖ
*£ ^ & O Vh a G Gh
*>g 2 0 be S 2 a
^ ^
o a
J3 Vh-H)

^ G a
c/2

a a 0 O ^
«4-1
Vh

^43
c/2

2
05
be
a <

be P 2 a cj a ui

a X ^
. Co
^ '+--v
%
£ ^<p>
oh K^J^
<^v h-i
fb
2 «
.
o
a .

h-^ 05
3 I
a'
05 b II Vh
W W G P
.

s!a '"—

"s
« ^S 00a,
C
c
C/2 r-
a-
a C/3

a > Vh
Oh Vh
O
Oh ^ >
-
^ '
c/2

a
rt
•« ? a « a _
b e
P ^
C/2
Gh 0
a Co
0
CD
^ 05 0
O' ^
rV ^
05
Vh
'S
Vh
2
C
'

a bp •

S CJ
G G
4-4 G
0
.CO
0 Gh
>
[l_, Vh
0
fe
Vh 0 <<
Vh
E
0 4_)
'G 4-4
be ~
£ *0 S < £
S
5H
oj
G a
» G
'S -

0 G rG
1/3
45 33 G
a 02
Vh 4-»
,

Vh
05 U
b/)
O
O Vh 2 -a b *C
< <3 § be
0/5

ao 2 a 43 ,
CD
Vh C &
o
G G 3 4-4
C/3

u -a
O PÖ
a o
bC
a
G G G 33 G G

^a
Co Vh be
•
0
H 02 !h
a o
>>g G
Vh
GJ ^
^ 0
C/3
05 H 'a S
Vi c 02 v-2^ »G G .£ 2 W '5
45 -h.
S 4_> Gj
2 £ t>
Vi o a g U ^
HH s g c ^0
0 02 b 2 a a *c 33 P-i

hH
Ö £3 P 2 a .2 >> -a
_.
TU
C/3
c /3
a
a P a 33
a 1 s s g
ao o 2
0)
a o .2 ^ b
P ^
a G 4H 05

s S -hi
a ;£ 2
a c3 - o 33 O E<! & 05
C/2

<J
0 P5
05
-a
a
ro
H -a 33
05
hS o J 1—1
P «H-H
0 a •'-
-4-
£>^ S
^8''* 33
05
43 2D ^ —G o3 0)
a a
^ 2 H 2 2
a a
C/2 05
43 J5 H öS
vh 5
S •& 1
<1
-3 ~3 ’as G in
Q ^ *2
• ?H
b/o
<5 Q fl) ^ C/2
G 1
C*H ^ g o a P
4-4 «4H Gh
CH-H
O
m-h
o
M—
o I %
Iö
o>
Ph

cd

£
g
rO

•
o
pH

a>
5 h
CD QQ

3 CÖ

> .

*H
1
<X>

« «2

+3 P
<»
bp 'S
.3 £
I >>
r^H *<3
CO -f3
_. c3
*

3
£l
c3
?H
CD
.3
3
o
'Ö
c3
tS r-H
^2 pq
<1

O
•a a
<x> o
-H 'd
Ö c
o

•d*
o
co
a
3
bb
• i-H c3

Ph a
<D
Ph
 External

Oblique

Muscle
Abdominal

Internal

Oblique

Muscle Abdominal

Rectus

Abdominis

Muscle

Linea

Alba

Semilunar

Fold

of

DouglAs
 3 cd
S’ &
in
O
71
’
3’ d
in
0
3’ a
55*
o
£ 3^ CD
d
CD a v s 3.
S- 5? Sc
^ a
0 gj (— ftt
O CD Co

0 D o ^ K
LL o a o’ 0 orq o »-?*
tr S.
2 “d O
Mi O GO Hp S'
™ 3 ft pj ft ft
& a> 3 3‘ CD
O* ftt d P
r-J r~t-
CD
71 ^ ft ft° S § S
ftCrq
3 aCD o CD
P r-t
4
w„ 3 CD *
8 ^ a
cd MO P- fth d^ ft d tr
a p d
o' 55*
p o 0
ftt~
o- a
4
P
•°a Fi
o4 0 ‘C 3 3. §
tr aq g;cft 3
t+> Hp *•0 ” q CD CfQ
1
71
o 3 tr g-
< to a
3 O
CD
CD

ftt
ftt 0^ tr cd 3
o »> y
ftt-
3
CD
cd
2. 3 ^
''-a |
ftr ft
CD tr >d O in tr
0 55*
ft CD
Co
o
ft
CD o tr D. g^ 71 a o 4

144*
ftt .
|
ft in j-t ft
tr tr *pö CD
tr ^
.

tr CD
P
-Tr
O O O n CD
* - CD CD
t—r-*
f 1p CD CD CD
g 3 0
D (/>-.*
^ st
^ 7l
ftt ^ 2
-s a 2. “ td I
^ | . ft o .

5 f? g f)
5=
^s§ tr p i ^
g.
Ä ft.

sH: 2 rs>.
f: cd ^ 3
O p S n,
-
CD
sa P E3 CD CD , Ci CJ «1 Anterior

P CL o
,

-* a.
2 cd ^ o t?
3 w cl 2, p
CD
ft ,5 »- » tr O H+ CD l_i_
3
o 5 CD p
(ft ‘a-
ti crq
71 — r in 5
ft ft ft §
r o S
ft h tr
3
cd
a _ 3 3 3 *o
S'
- d ft T3
tT p £ p CD 3
ftt
p 5-,^
^33a
CD 'D C/3
J.
ft §’ «1
.

3 3 Wi
a > pj S' <c CD’
cr ^_ .

^g O 2
..
P
Oft?
w
CTO
d «-+
^
71

n
ju
ft
3
m
C/3
c/l
3
3
P 4
^s.
^ S
.ft» .

o
3 3' >1TJ 2
*0
a o o 3 3
Jr
3
CD
CD
ft
ft
^
tft

CD ts CD
O _
’T
CD
3 2-' ft 3 o'
^ ft _
!-t

3
ct
-38 ^ Co
ftft
ft2
Abdominal

ft c P. o
^ ft
5 3 o o
3 3» m O
tr CD CD C/j
ft ft
CD
^ 3^ a 3 O i-+ ft
3 CD CD 3 ft 2. o £ ^ 3
ft
a g 3 5 s >3 ^
Ob
ft
* 3. S § 4 W T g T)M CD ^ o "<;2. $.
ft** o' % Cb
Lu
s
S4 ^
ft
P . .
c c 3 o* o ft CD ft O
3 ft
Q-> O ftt
n .
2 3 3 d) tr a- 3 ^ o 3 CD §5
Co ftft
C^b
3 3

p
CL
CD CD
S
ft
CD

td
$
o
§
2 P o
a ft a
.

2 CD 71
3
—
3 _ ft 3 H ,*<
3 Qft 71 a ft
3
CMC . CD ft
CD
a
a a
o 2
^
Wall;

3
CL K ”
^ S’ CD ft
CD
QP
a, w
2 o ^
^ 3 •"*» a ^
cr CD § s a
O
3 CL pi « < 3 a wi; t c c CD
ft4 3 S- &3 ft
S
CD
CD
CD
'-1 71
^
tr 3 t- p O o s
.

t ti g 3° °S ft CD- CD r 3 O •61 Cl
S' 2 o
ftt
d _ “d
O Pi P <% ft | ^ r2 ^3
71
2 & CD Crq' ^
P O 3 r
3 3 CD
ft CfQ CD 3
cd ft crq
ft 3 3
'

ft3
O 3 | £ rs
2
s
ft
^ S Hypogastric

o a
cd crq
.

in
w ft P cq
4
P H, 8ft
d s o
R ft 5 < a ft-J rft

ft ft § 3 CD 3 ft CD S’ ft 00 5- % a 5

W.
CD p ft 3 0
o O Ü 3 4
o ftft

3 crq
O 71 3 O Oi aa
_ § 3
P I H 3ft tq (“h ^ ft 0 C/3

3 3 CD r-

3
CD
C/l

ft
71

CD tr
^ 2 r aq
O - • —
cn g ^ 8 O 4
:

0 x
Co
Ob
rft

a ft
Region

3 3pcDft ?? 5
3 on
ft 2. a' p 3 O a.
3 P3 PO a
-ft
3 ft CD Ö1 3 ft g 71
8*1 -
3 ^ CD
^ o
.

3 > - ft
3. 3 S O a 3, < CL
§-^
3 S — » 71 a O ^ ^ CD
ft 2 5i
ft* ~
3 D 2.
ft W ^
2 3 tr S' 2L ^ a 2
ft.
CD
r i

o 3,
ft crq < ft 3
P CD ft
W p
C/3 p
0
o CD
with

ft^c Ul crq 3 ^ p O
3-- 3 3 3 CD 2 2. td
ft p’ I-*.
»-{

0 o
2 O
ft 71
3
CD j— * ft CfQ ^ 3 -
3 Co

s
g ft 2
r+ cd
2
pi
3 CD
3 H
3 3 3
o ft
< P
a 4 «>Co
o 5
p 3 CD
CD ft- ft
P ^ p Pi ft O Co
S ft
.
Vessels,

ft CD
3 3
3 a m '
' 3‘ pi /*!
"d
ft
P 3 ft 71
3 0 3
ft ft cr
s> ft
u
CD *
e/1
o
O
S' o
dp0 ^ ft
as
71 Co

I 3
05
ft ^ 2
CD
CD ft
CD
a
71
CD
CD
2 CD CD
GO
p O
CD
7) a Cr-
v§-

a
3,
? 3 ft O CD 3 ft O
3
•
a ^
o ft 5;
ft
CP
a.
ft ft o rft JL 71 3 CP
pi c
3 O CD
7i
0 " ft ft p a M O s s Bladder

71 C/l
o 3 3 1
O' ft CD
a CD
o. ft 3 US o 2 Crq
p’ CD S' g s 3 ft p g CL CD 3 CD
a ftb
3 O p ft 3 3' 3 P ^
ft
H C/3ft
ft 3 3,
^ C/i CD <-
S'
ft
ft^4? ^ ft 01 ft o'
CD 71 ft 3
..
a CD CD a Ti ft § ^ O ft 3'
5 g
a P? J ft tr
CD 2 ^
7i
rr)
jq '-‘ft
C/3 ft
-

3 ft ft
HT
CD a §
» o much

O P 0 o ft S
o
3> 3 S CD
ftS

^ a a
rt <5
0 3 cn
.

3
ft
r-J
ftCD \ ^
CP
cp
*- ^ 0 p §
CD
ft 2
3 2 O es
o
O
?» 5 cr
* L_j
2,^ G
cyj
2 o 3 CD
a 3 CD O CL CD
3 CD
S'
p P
ft
St
a-
O' o?" Crq
bb
ft
65*
pj
CD ^ ft CD 2 1-3 O
< -
P
CD
3 Cl ft cr
CL o
S ^ 4
ft distended.

o % o 3o 3 pi o CD < i^.

rft
£ w 712 7) ft CD O a 3 a CD
£ g s ^ O 3 | g
o. 71 CD X P Crq 3 a CP
in
ft ° N P rft CD
1
3. "*
0
~ ^a ^ ft 4
C -
55* CD

Ö
O
rft ®
3 -Cf
.

a
co
.

ft
i

3 a
cd
a < CL
tft 8

p 3
a- P ft
a 33 § ft _ CD
]
J
rt
O 3
r 2?
T5 p
t) a-
,Cfl
P CD
a 5 ft 7)
in 7i
O g 3. 3 ft
3. $
ft ft
CD
P
3
•

_ g a- g 2 CD ft. 3 crq 3 p 3 JÄ
C^5o’
ft
ftK ~a
^
3 CD o' 3 3 ft 3 ft Grq
i
tft
O bft
 Fig. 145. Back shewing Nerves, Arteries and Lymphatic Glands.

The Skin and Superficial Fascia have been removed from the whole dorsal aspect,
extending from Occiput to Sacrum. On the right side the Trapezius, Latissimus
Dor si, Superficial Layer of Lumbar Aponeurosis, Supra- and Infira-Spinatus Fascia
with the attachment of the Splenius Capitis Muscle have been cleared away.

This figure is purposed to shew those lymphatic glands of the back which
are little known and which receive but scant attention.
1. Muscles and Nerves. Trapezius Muscle with
Spinal Accessory (Xlth
Cranial) Nerve running almost downwards, Latissimus Dorsi Muscle with
vertically
its nerve running obliquely downwards and inwards, Levator Anguli Scapulae and
Rhomboid Muscles with branches from the Posterior Thoracic Nerve, Supra- and
Infra-spinatus Muscles with the Supra-scapular Nerve, Teres Minor and Deltoid
Muscles with the Circumflex Nerve, Teres Major Muscle, Subscapular Nerve,
Serratus Magnus Muscle, Long Thoracic Nerve (of Bell) (v. Figs. 109 and no).
2. Arteries. The Occipital Artery (a branch of the External Carotid) be-
comes visible, at the attachment of the Sterno-Mastoid and Trapezius, and ramifies
over the Occiput. The Posterior Auricular Artery (External Carotid) passes behind
the pinna to anastomose with the former. The Transversalis Colli Artery from the
Subclavian Artery appears in the space between the Levator Anguli Scapulae
and Rhomboid Muscles. The Supra-scapular Artery either a direct branch of the
Subclavian or a radicle of the Thyreoid Axis or Inferior Thyreoid Artery,
accompanies the Supra-scapular Nerve to the Supra- and Infra-spinous Fossae
where it anastomoses with the Subscapular Artery from the Axillary.
More externally the Posterior Circumflex Artery accompanies the Circum-
flex Nerve as it winds around the Surgical Neck of the Humerus. In close
contiguity to Bell’s Nerve is found the Long Thoracic Artery (inconstant). Upon
the Dorsumof the Trunk proper only small arteries are found because the Dorsum
of the Trunklike the extensor aspects of the limbs receives its blood from the
ventral or flexor aspect.
3. Lymphatic Glands. At the point of emergence of the Occipital
Artery a few Occipital Glands are found. Behind the Pinna accompanying the
Posterior Auricular Artery and lying over the tendinous attachment of the Sterno-
Cleido-Mastoid is a posterior Auricular Gland which should be called the Superior
Posterior Auricular Gland so as to distinguish it from a deeper gland which lies
in contact with the Muscle itself. Deeply situated behind the Mastoid Process,
and under cover of the Splenius and close to the Occipital Artery lies a deep
Mastoid Gland (cf. Fig.).
The subcutaneous glands along the upper border of the Trapezius and near
the Vertebral Column are not particularly marked in the figure. They may be
called the Superior and Inferior Subcutaneous Nuchal Glands. At the level of the
7th Cervical Vertebra lies the Superior Superficial Dorsal Gland; the Inferior Super-
ficial Dorsal Gland lies along the outer border of the Latissimus Dorsi at the
level of the ist or 2nd Lumbar Vertebra. At the Clavicular Origin of the Deltoid
is the Superficial Clavicular Gland, whereas more deeply situated near the Supra-
scapular Artery and at the upper border of the Scapula is the Supra-scapular Gland.
Deep Dorsal Glands are situated at the upper border of the Rhomboid
Muscles; on the Teres Major Muscle is seen the posterior superficial Axillary
Gland; a deep gland is situated between the Teres Major, Teres Minor and Tri-
ceps Muscles.
These glands are not all constant; they may only be found in pathological
conditions; such occurrence does not exclude their normal presence as merely
elementary.
 Occipital Gland Occipital Artery Splenius Capitis et Cervicis Muscle

Posterior Auricular Artery Deep Mastoid Gland

Longissimus Capitis Muscle

Supero-posterior Auricular Gland

Sterno-Cleido-Mastoid Muscle (Major) Muscle

(Infero-posterior Auricular Gland)

Levator Anguli Scapulae Muscle

Trapezius Muscle
Deep Dorsal Gland
nth Nerve. Spinal Accessory
Transversalis Colli Artery

Superficial Superior Dorsal Gland

Supra-scapular Artery
Omo-hyoid Muscle Sub-deltoid Bursa
Superficial Clavicular Gland

Circumflex
Deltoid Nerve
Muscle
Long Head of
Superficial Triceps Muscle
Posterior
Axillary
Gland Deep Posterior
Axillary Gland
Branch of
Subscapular
Artery
3rd or Long Teres Minor Muscle
Subscapular
Nerve
Infra-spinatus Muscle

Rhomboid
(Major) Muscle
Teres Major Muscle

Latissimus Dorsi
Muscle Long Thoracic Nerve
(Bell)
Lumbar
Aponeurosis
Serratus Magnus Muscle
Superficial Inferior
Dorsal Gland

Dorsi Muscle

External
Abdominal Oblique
Muscle Serratus Posticus
(Inferior) Muscle

Internal Abdominal 12th Rib

Oblique Muscle
(Petit’s Triangle)

Internal Abdominal
Postero-superior Oblique Muscle
Iliac Spine

Gluteus Medius
Muscle

Gluteus Maximus
Muscle

Mr. Frohst .

Fig. 145. Back, shewing Nerves, Arteries and Lymphatics.

2
/s Nat. Size.
Rebman Limited, London.
Rebman Company, New York.
 Promontory.

Rectum
Fundus of Uterus

Douglas’ Pouch

Posterior Fornix
of Vagina Bladder

Levator Ani
Muscle
Symphysis Pubis
Internal
Sphincter of
Anus

Labium Minus

Labium Majus

Fig. 146. Median Section through a Female Pelvis (Bladder and Rectum empty).
Nat. Size.

Rebman Limited, London. Rebman Company, New York.

Fig. 146. Median Section through Female Pelvis Bladder and Rectum ;

being empty.

Median section through the body of a woman aged yo. In this instance, owing

either to pathological adhesions or post-mortem changes, the Uterus did not lie

directly on the Bladder, it'has, therefore, been drawn forward into the position

of anteversion and anteflexion in accordance with the general investigations

upon living subjects.

When the bladder is empty the normal position of the uterus during life

is anteverted (virgins) and anteflexed (women) i. e. the Uterus lies on the postero-
superior aspect of the bladder (B. Schultze). Whether coils of small intestine

lie between the Uterus and Bladder or whether other varieties normally exist we
have not definitely decided.

As the bladder becomes distended the Uterus is pushed upwards and

backwards.
The course of the Vagina is S-shaped, like the Rectum and Urethra. Into

its upper cul-de-sac the Cervix Uteri protrudes, thus forming an Anterior and
Posterior Fornix of which the latter is separated from the Pouch of DOUGLAS by
7 2 5t:h inch. (Operation route.)

The empty bladder evidences a slight impression due to the body of the

Uterus. An “uterine impression” can also be recognized on the distended bladder.

The S-shaped Urethra (i

3
/5 th inch long) enters the bladder at an acute angle.

The Peritoneum does not extend so far down on the posterior aspect of

the Rectum (3rd Sacral Segment) as upon its Anterior Aspect (ist Segment of

Coccyx). Levator Ani, External and Internal Anal Sphincter Muscles are shewn

in the figure.

Lastly the extremity of the Dural Sac of the Spinal Cord is seen termin-

ating at the level of the 2nd Segment of the Sacrum.

 > i 1 > >

s r\ c/2
Xbe xd 0) ^ d >•.
X d 2
.2 xd d d
tne 151).
*
o3 £> be .2 03 03 03 2
U C X
<S>

C/*
0 'u
0 § o
'C aj c/2

d
aj
x boun-
almost

Xod
c/3 aj 01
4->
X > T C > 5-<
d
0
o U0> d0 C
3
0
-a <1
*-J 4->

'd
c/3

l-i
xi 03
X
> go 3-4

X side
is
149,

03 p ns lateral

2 .a be
d
S X d 0 +_> Dd
CD te
0
fa cfl 03
X
Xd X X d>
146,
0 +*
4—*
£ +->
O
u % M
4-»
£ X o ^o
figure,

bjO
X C 03 SogX
rignt
upper

03
C/3
X . X o d
142,

•3 t'
X
4->
4— 1
4-1

a
'S
? d 'd a d be tne
this

£
(-»-I

03
"- X>4 03 H 2 Ö « d
Pi
o ^
be
. Ö
°
1

yi
*>
c^
^
rv <D
u d
03
'd
03 on
the
in (Fig.

x be x
03 C/3

d
(D
X X
o
'S
'S .S
IS £ O form

Ex U 'E o d
which,

aj 0 -4 0 0 03 rectum

d Q_| £ 0 u H o d
£ £ C a) especially

^ c ~x 2 X X p d d -d
X Ih £ X
aj <D
i x ^2 d d folds

behind.
"d O 03 X Jh
X O 4—0
03
>4 03 ^ d
^o d b x Ü o
'S
§ B I2
£ aj -i_>

H these
DOUGLAS
distended

o
-§ 2 0)
x
O **
03 03
holds,

and
so ^ ^ § H V4 _,
^4-4
o
X
+-*
f

<1 d 03 'S«3
of
so d ^ C/3
the
J-4 <l d S £ £ O _ o
^ so o <1 d O d d d
Uterine marked;

d .2
CD

— ^ > X
4-
above
CJ
03 'S
^ .S S Pouch
by
5 ^ X E 2 73
aj
c
J-h
03 03

X E dd r—Oh XO—
4-4 _.
•8 1 <1
"d
0
xt ^ g 03
I 4
Ivecto-
well filled

§ t 1

|<S .E>
aj
d ,0 S X x°
03 the

X %da
from
C/3 cj
be 2 4-> *73
(

d ^ 8 A .2 9 03 are

S §
—
e £ X C/3
^ x d x t!0 <u x— Cq
03
4 lhe
of

CS <b O eeo o, X xd H S d > g ^

c^
K*'» i
completely

seen

aj g \2 S S .H •s E
Jo CD Eo O be d X <? figure, daries

o ^ p Q £
•d bo d
X d d s & § 2

Organs, | § vO 03
'

X
03
c^ JL ^ x 2 0 73
x
M
0
ad
'

0 ^ ^cS d
O
03
<—
“ 8 E S
1
the
’
the

X O Ö
hr0
Oj
^
-I
o
V- 5

a (J X
c/3

d * o 2
4 « -<
Appendix

to
-^8 0 0
’
Co #

0 > 0 4-» l£ with

X d C/2
03 d x x d ^
x x ^3O X
__

Pelvic
$•! S C d
c/3 d -S S CJ +->
03 - colon

’d _J M-h
E 2
.2 B 03x 03 -d be x
0 5 ° 0 the
^ 4s o 03 ^03 > d d 0 4X 03 v- Ileum

8 tä O X & _4 i—
"d <>)
c/3
0 Xd n d 0 x > d g -2
_ X rC
. .

03 c

X X .2
2
:*
'

03 03 g 1
O the
E X
Female aj 4_3 ascending
.5 o «4-4 "it O d 'S
o 0 r-
0 O
0
CD
0 d > posteriorly,

d
c/3 c/l
*C o 0 >4 of
-S
•44
0.
03
s
0 dd
C/3

X 03
S d
be X H X 1-1
> .2 d
s 0 rl-
~ be X
03
o Xo ’d X 0 H 2d
147. 0. V-
0 03 -8
.2 0
X g ^ d o lumen divided

be d
“ O 0 o E ocT E
5 ^ X X 03 14 H a u bbO rO P
^ 03
^ o ä
Qh
§ 0 0 X
0 c^ *

C
HH
P4
‘H
situated

"03
d
J—
t3-< # £ .2
the

X
'
.
Fig. Zj 'C 4->
2 « a b aj 0 '-5
0
be 0
d 0
j-i
•" .2
C«
>0 s o
1-.
^ r£ x -S
.2 s x < X
4-J
cS ^ d aj aj
seen
Fossa transversely

4-1
to > X 0 £
OjQ
2 '55
» 0 TS
X c* ° B
cs
co
^ X d 1 C/2

E>
(—(

Xo 0
^
is
-s
^ oj X-l
d S3
be X
03
O 0 o X 0
03 CD
0 x X
JD m X X
right the
^0 C/3
<<
o £ d - Ileo-Caecal

x X X 03 >4
X>.
o
s ^ O ®
d X p
c/3

C/3
and
0 d d 0 hJ id be the

II X «I a;
*
to 0)
Vh P
cb
7) ^ (
d 1/3
c X
X >4' d +j o
d 0 Q .2 8 O 4^
c o X
0 g to
CQ X d d
C/3

d o d ^ 4-4 4—> Superior

anteriorly

o Xd o £ 03
S
0 ^
fl
right.

&
more

Xx
O 2 X 3 o
,

oq d .
•S ft s c
 behind.

and

above

from

seen

Female

of

Organs

Pelvic

147.

Fig-.
 Prepuce ofCfti
Frenwn of Ell ‘or/s

Labium Minus Urethral Orifice

Labium AlaJus •
Opening of Vulvar Gland
( Bar Choi inis Gland)

-Fossa Navicuh

Fig. 148. External Female Genital Organs. (Vulva.) Vestibule.

Nat. Size.

Rebman Limited, London. Rebman Company, New York,

 Fig. 148. External Female Genital Organs. (Vulva.) Vestibule.

The Labia have been drawn apart in order to shew the Vestibule and, in par-

ticular, the openings of the ducts of Bartholin/ s Glands.

The Labia Majora corresponding to the Scrotum of the male limit the
Rima Pudendi which is closed in Virgins when the thighs are adducted; in front
these Labia meet, but behind they are lost near the Anus. They are folds of
skin usually well-covered with hair and large sebaceous glands, and contain
large Veins.
The Labia Minora are separated by a sulcus from the Labia Majora ;
their

outer surfaces are covered with skin, their inner surfaces with mucous membrane
continuous with that of the Vestibule.
. In front the Labia Minora bifurcate, the
outer portions of either side unite to form the Prepuce of the Clitoris, the inner
join below the Clitoris and form the Frenum. The Clitoris which corresponds to

the Penis of the Male is usually rudimentary, its extremity (Gians Clitoridis) alone
being visible. The posterior ends of the Labia Minora vary much, they may
merge into the Labia Majora, or may unite together and form an arch which
limits the Vestibule posteriorly. At the posterior junction of the Labia Minora
is situated the Fossa Navicularis.

In the angle between the Labium Minus and the Hymen is situated the

opening' of the duct of BARTHOLINl’s or Duverney's Gland. In front of the

Hymen and about midway between the posterior limit of the Vaginal Orifice and
the Clitoris is situated the Urethral Orifice which may be of different shapes: —
a vertical slit, semilunar or [\ -shaped.
The projection of mucous membrane behind this — Lingula Urethrae
VON Bardeleben — is correspondingly pointed or rounded off.

The Hymen a reduplication of the mucous membrane at the entrance of

the Vagina varies much in shape though generally crescentic from side to side
with the broad part of the crescent posterior in situation (prior to Defloration); it

may be annular, or fimbriated, even double or fenestrated. During “Defloration”

the hymen is usually torn and heals with cicatrices. Fresh lacerations occur
during the first labour, these lead to the formation of Carunculae Myrtiformes.
 ;

Fig. 149. Pelvic Organs of Female seen from above and in front.
Ureter.

Woman aged 50. Intestinesremoved as far as the Rectum, Uterus retroverted

Left Appendages of Uterus removed. The Right Fallopian Tube is drawn
upwards and its fimbriated extremity thrown upwards over the brim of the
true pelvis. The Abdominal Opening of the Fallopian Tube and the Ovarian
Fossa are thus exposed; the ovary is somewhat drawn upwards by the tube.
On the left side the peritoneum covering the important vessels and nerves has
been removed but the portion forming the posterior layer of the Broad Liga-
,

ment has been preserved intact and the round ligament retained in situ. On the
left side the Lymphatic Glands are exposed and their corresponding imaginary
situations on the right side are depicted through the transparent peritoneum.

By WALDEYER the lateral wall of the true pelvis has been divided into
the following fossae: Paravesical, Obturator, Hypogastric (Para-Iliac) bounded by
the Round Ligament (in the Male — Vas Deferens) and the Ureter.
When the Bladder is empty the Paravesical Fossa is divided into an
anterior and posterior part by the Transverse Vesical Fold; the anterior part
belongs more to the Anterior Abdominal Wall, the posterior part can be fully
seen when the Uterus is retroverted. The Obturator Fbssa in the depth of which
the Obturator Vessels and Nerve run over the surface of the Obturator Internus
Muscle contains the Ovarian Fossa which may be a simple groove or a deep
alcove against which the lateral half of the Ovary lies while its posterior border
remains free and rounded.
The Ovary lies on the Uterine Artery touching the Ureter: according to
the size of this organ and the position of the Internal Iliac Vessels it reaches or
extends beyond the Internal Iliac Vessels, as far as the lower border of the
External Iliac Vein.
The most posterior fossa is the Hypogastric (Para-Iliac) Fossa in which
the Pyriformis Muscle and on this muscle the Sacral Plexus are found.
The Ureter generally enters the True Pelvis at the bifurcation of the
Common Artery passing over the External Iliac Vessels and the Umbilico-
Iliac
Vesical Trunk to lie between the Internal Iliac Vessels and the Uterine Artery and
covered for some distance by the broad ligament and the Vessels to the Append-
ages. In this part of its course the Ureter lies directly under the Peritoneum.
Further forwards, in front of the Broad Ligament, the Uterine Artery crosses
over and in front of the Ureter as it leaves the pelvic wall and approaches the
Vaginal Portion of the Uterus. It is at the level of the Internal Os (where the
Uterine Artery bifurcates —
Waldeyer) that the Uterine Artery crosses the
Ureter. The Ureter comes very near the Vaginal Portion of the Uterus (cf.
dotted line) as it curves round it laterally to open into the bladder.
The Ureter is only separated from the Vaginal Portion of the Uterus by
the vessels in the cellular tissue of the Parametrium (Branches of the Uterine
Artery and Utero-Vaginal Venous Plexus). On its outer side lies the Vesico-
Vaginal Venous Plexus. These Plexuses communicate freely so that the Ureter
is embedded in a venous plexus.
 Bifurcation of Aorta
Superior ITacmorrhoidal Artery
Inferior Vena Cava

Sympathetic Chain
Ovarian Artery

Iliac Vessels

Gcnito-Crural Nerve

Fossa Hypogastrica Middle Sacral Vessels

(W-aldeyer) (Para-iliac Fossa)
Promontory (Disc between
5th. Lumbar and 7th Sacral
Vertebra)
Obturator Fossa (Waldeyer)
Internal Iliac Vessels

Uterine Artery U reter

Ovary External Iliac Vessels

Obturator Artery
Ampulla of
Fallopian Tube
Uterine Artery

Round Ligament Posterior Layer of

of IJterus the Broad Ligament

Posterior Fossa Para- Obturator Nerve

Vesicalis (Waldeyer)
Superior Vesical
Superior Vesical Artery
Artery

Common Trunk of Middle Vesical Artery

Deep Epigastric and (Vesico- Vaginal)
Obturator Arteries

Transverse Vesical Fold Utero- Vaginal Venous

(Waldeyer) Plexus

Vesico-Vaginal Venous
Anterior Fossa Para- Plexus
Vesicalis (Waldeyer)
Obliterated Hypogastric
Artery
Linea Alba

Pubis

Fig. 149. Pelvic Organs of Female, seen from above and in front Ureter.

% Nat. Size.

Rcbmitn Limited, London. Rebman Company, New York.

 Lateral Sacral
Postero- Superior Artery
Iliac Spine

Anterior Branch
of 3rd Sacral
Sacro-Spinalis Nerve
Muscle Anterior Branch
of 4th Sacral
Nerve
2nd Posterior Peritoneum
Sacral Foramen (Pouch of
Douglas)

Sacral Canal Bladder

Recto- Vesical
Middle Sacral
Fascia
Artery
Ureter
Pyriformis
Muscle
(Great) Sciatic
Superior Nerve
Haemorrhoidal
Artery Small Sacro-
Sciatic Ligament
Rectum
Sciatic Vessels
Pelvic Fascia
Internal Pudic
Rectal Fascia Vessels

Gemellus
2nd Segment Superior Muscle
of Coccyx

Coccygeus Vas Deferens

Muscle (Ampulla)
Great Sacro-
Sciatic Ligament Recto-Vesical
Fascia
Levator Ani
Muscle Obturator
Internus Muscle
Ischio-Rectal
Fossa
Gemellus
External Anal Inferior Muscle
Sphincter

Gluteus
Great Sacro-
Maximus Ligament
Sciatic
Muscle

Perinaeal Raphe Inferior

Haemorrhoidal
Nerve

Obturator Fascia

Ischio-
Cavernosus
Muscle

Posterior Scrotal
Branch of the
Perinaeai Nerve
(of Internal
Pudic)

Fig. 150. Pelvic Organs of Male, exposed from behind.

s
/4 Nat. Size.

Rebman Limited, London. Rebman Company, New York

 Fig. 150. Male Pelvic Organs, exposed from behind.

Male aged 33. The Gluteus Maximus is detached from the Posterior Inferior
Iliac Spine downwards and the Erector Spinae divided transversely at this
level. The Sacrum has been sawn through between the 2nd and 3rd Sacral
Foramina, the Coccyx between the ist and 2nd Segments ; the different layers
have then been successively exposed: Rectum, Bladder, Peritoneum, Vas Deferens,
Seminal Vesicle and Ureter. On the right side the Great Sacro-Sciatic Liga-
ment has been cut short and the Ischiorectal Fossae cleared out on both sides.

The figure particularly shews the different layers through which the
Surgeon cuts in order to reach the Rectum or deeper parts.
Removal of the lower part of the Sacrum can be carried out, as shewn
in the figure, without any great damage. The nerve supply of the Rectum and
Bladder is chiefly derived from the 3rd Sacral Nerve. There is no risk of opening
the Dural Sac which usually terminates at the lower part of the 2nd segment of
the Sacrum. Deep to the Sacrum lie the middle and lateral Sacral Vessels; next
the Rectal Fascia (yellow) and before reaching the longitudinal muscles of the
Rectum a thick layer of which lie the Superior Haemorrhoidal Vessels and
fat, in
the Lymphatic Glands of the Meso-Rectum, has to be divided. According to the
degree of distension the Rectum may occupy the whole of the Recto- Vesical Pouch
or leave on either side a peritoneal space (light -blue). The lower boundary at
which the peritoneum is reflected on the Rectum is about 3 inches above the
Anus. Below this level operations on the Rectum can be performed without
opening the Peritoneum.
In front of the Rectum merely separated by Recto- Vesical Fascia is the
Bladder, the base of which is laterally and interiorly covered by the Ampulla of
the Vas Deferens and the Seminal Vesicles. In the angle between these struc-
tures lies the Ureter (green), this can be exposed by removing a layer of fatty
tissue rich in the vascular anastomoses of the numerous branches of the Inferior
Vesical Vessels (cf. Fig. 161).
The arrangement of the muscles bounding the Ischio-Rectal Fossa is to
be seen as well as their relation to the lesser Sacro-Sciatic Ligament and the
Coccygeus Muscle; a small gap engages one’s attention (through which a Hernia
of the Floor of the Pelvis may occur), next the Levator Ani Muscle and finally
the External Anal Sphincter (cf. Fig. 153).
The Pudic Vessels and Nerve wind round the Spine of the
Internal
Ischium and run under cover of the Obturator Fascia forwards and downwards.
These structures therefore do not re-enter the pelvis through the Sciatic Foramen
as usually stated but remain separated by the muscular floor of the pelvis. Neither
do these structures pass into the Ischio-Rectal Fossa but remain in Alcock’s
Canal which is a re-duplication of the Fascia covering the Obturator Internus
Muscle on the outer wall of this fossa.
 Fig. 151. Median Section through Male Pelvis.

Frozen section through the body of a robust elderly man. The Rectum was
much distended by faeces which were removed after the section had been har-
dened ; the Bladder contained frozen urine which melted as the section thawed.

The parietal layer of Peritoneum lining the Anterior Abdominal Wall

can be traced over the summit and posterior aspect of the Bladder to be reflected
on to the anterior surface of the Rectum at the level of the lower border of the
4th segment of the Sacrum. This point, of great surgical importance (for the
removal of Tumours) is situated 3 inches above the Anus (length of Index Finger).
The Peritoneum now continues upwards as far as the 2nd or ist segment of the
Sacrum. Between the Anterior Abdominal Wall and the Peritoneum a space 'is
formed when the Bladder is distended (Space of Retzius) because the peritoneum
being adherent to the Bladder is pushed upwards as this organ rises out of the
Pelvis (Fig. Between the Rectum and the Bladder, close to the middle line
1 44).
is Ampulla of the Vas Deferens
situated the —
this is partly shewn in the section.
The Rectum when filled with faeces is chiefly distended above the 3rd or Anal
portion (Ampulla Recti) so that the organs which lie in front of this part are
pushed upwards.
Below the Ampulla of the Vas Deferens lies the posterior portion of the
Prostate; the remainder of this gland lies in front of the Urethra, and is sur-
rounded by the Prostatic Venous Plexus.
In this specimen the Bladder Wall is thickened and presents marked rugae
on its inner surface. The Urethra on emerging from the Bladder passes through
the Prostatic portion — Prostatic Sinus or Verumontanum — this portion is usually
one inch or a more in length, though in cases of Hypertrophy of the Prostate
little

or a greatly distended Rectum this may be exceeded. The next segment of

the Urethra is known as the Membranous portion —
according to Waldeyer
the upper and larger part of this should be called the Muscular portion because
it is surrounded by muscles from which it derives both circular and longitudinal

fibres. The length of this segment is almost one inch. The Urethra at this
situation forms a curve at an angle of 90 degrees which often obstructs the
passage of the point of a catheter. The distal segment is 6 to 8 inches long and
extends from the Anterior layer of the triangular ligament to the end of the
Penis, lying between the Corpora Cavernosa it is surrounded by a delicate erectile
tissue (the Corpus Spongiosum) which is enlarged posteriorly to form the Bulb and
anteriorly to form the Gians Penis. The Corpora Cavernosa arise on either side
of the ascending Ramus of the Pubis and terminate as cones at the level of the
Coronary Sulcus of the Gians Penis by which they are covered. Slightly
posterior to the slit-like external urinary orifice the Urethra widens into the Fossa
Navicularis. The Gians may or may not be covered by a Prepuce according to
size, age, habits, etc. (Phimosis, Paraphimosis, Circumcision —
cf. Fig. 152 and Text).
-

As the position of the testicles is not quite symmetrical, the Septum of

the Scrotum has not been divided but the left testicle within its Tunica Vaginalis
has been cut obliquely.
 Promontory
Extremity of Dural Sac

Small Intestine

Cavum Retzii

Vas Deferens
(Ampulla) Bladder

Ampulla of Rectum
Symphysis

Prostate
Prostate
Levator Ani Muscle
Deep Transverse Peri-
naeal Muscle (Transversus
Perinaei)
Bulb of Urethra

Fig-. 151. Median Section through Male Pelvis.

Vo Nat. Size.

Rebman Limited, London.

Rebman Company, New York.
 Fig.

152.

Median

Section

through

Nat.

Male
Size.

Pelvis.

Urethra.

Pelvic

Fasciae.
 H
G
3 ggH 3
ä
a p 3 >
3
^
GG
CD CD
a CD
Ö
a 5' H H 3ft HGH3 < 3j - GQ 4
KJ
pli -3G 3^ ÄK p
hd
u < CD
G p O ® 'gg
ft. CD
71 ft
« ^ G
(t> CD
rt
5f G 2 G O
CD
p CD*
c ,2 O
>< 33
td
CM
i-i

t-
(D
t < 3
CD
?? 2 J8 ft
.

CD $u O 3 % 3 H [Jt 3. > •0^ ,

P3
71
CD
P Tj
-t
gd °
G
3 O
O 3 p ^ O C Q)
£
W p
w.

a? 5‘h
3 Ö
?. O ft ^ 3 O 3 1/
O rr _» \t <-r 4
" . „
3 w
i

2 £7 o a S’ p 3 -t
s:^ o
‘
G-j
« P o 3
1/ CD Ü 3
£ rt Kj
3 o
Go
»
p ™
“^rta, G E33
CD CT
o g o
71 3
° /3
G rt 3 33
o
& P
-rt^
° W
3 S B-| ? ^ o _ P’S .. o 3
a “e-s?3g-J S'
a
xe
rt 3 G
o S 3^
p" Is
3
/" td'-' o >— 3
cm
i

—
s c.S ft^
i ^-U
- _r. 3
f-t
" *
*->
,-j
®3 3 3 ^ 3 »3
>-i
3 33 *-t * to {>,

CD
<*t\

2 2 3 °S “t a td 3
S ccrp 3
'g 3
?8 O «I O
|. Q
a S' o' S
U ° 3 ' /—
w 3
33 _ 3 3 Co 2
3 2 P 5 crq
.

!-

r- 3
l

V at«
“ p 3S' S
O ^ K ^
CD
§g H.P a <1 «“
O <,
C/5 i-t 3 3 CD
<~ 3
3 CD- rt}
CC 3 i— P 33 L|J CD
^ / H
7) 3 G$ h- O P cf)
^ O S'
S'
rt S 1
3
O 3 33 S'
3 3 5 t 3 c 0 3 5
3.*
S' MP 3
£“ P cu
'Q M
iD 3
5S 3-^3
w 3 co
2- 2. HH 3
3 Öo
.

w 33
ej,
r\i T r> H7-4 S' r+ O
p
aG O *-t
dg P " CD
OJ r

3‘i C-n 3 CD

3 w £• 3 o’g S 5: ^ o 3
"> 3 S G. *1
p (D
H S On H tT*
CD
5“ O 3 3 ji
71 ni
3/3 33 CD P
Z' 3 a I Cfq
& al S § crq
rt.

& 3 S- •
S' 3 g.-lgiss 3 3 G
O 3 H*o “ Z.
3 ° — l-T co crq 0 ( 2 ^ S' 3 ' ^
s' 3
Hi O 3 ° 3*
1

Cn
w H cf p 3 p CD td
is 3 3
o3
O C/3
p p I»
G ^ 3 o 2.3 s' / o a 71
S' ° <j
3 3 ^ 2 -• 3 P (D s ^
^QJ^^S-OS-Ö"
^ Sf >—. . 3 2. 3 p a g S:
3 3jJ l 3* > w JzT C/) ft CD rt-
3 3 S'
h
O^ >3 33^CDC 3^ S-Oq
3 3! 3.3 W S' p
3 3 o
3 3 3 ?5- S'-
H7-5 L (T>rt w ^ N Sfj— S'
£.TJ
^ o
CD CD Gw n>
rn 0
2 rt X 2
C3 3 M 33 ?! 3 3
3 p 33 .
3 2 3 td
DC
crq
3 3
S' 33
P
G
ö o
3 O 0
O' 3 3 3 M
Kj O
S' 3 -
o
o 33
o <J
7)
Da
c/)
5
H-*
a
3 o-
o S
p o J? 3 CD
O'
3 p CD JÖ
3 3 3 Q
Q* 3
CD 3
3 'C o 3 ^ o
3- 3
Is| 33
o
3
cn .crq
P
O *s»

°o r
U)
3
/ 3
J>"^3 3
3
CD P 3C G. S' 5
p CD 3 5?3 S'
Co fD
O
O S' 3! 3 3 CD
^ 3 3 CD3 33o 2S OpJ rt
rt 3 .
o 3
3
O o
Sj-Ofq

3-f p
< D s 3 hr-*
S'
C S' S' ^
&|
CTi ^ 3 3 2
CfQ o' 3 w
Scrq CD o o -
S' a>
3 3^CD
3 o
Krt

^rt'
CD
^
rtK
CD 3 S'
1

S'-
05
G
n
3 3; 3 fD
P
3 td 3
w O G 5? "33 O opw 3,0^ •33 P o
<to

ra 23
,3
o
»-+^ 3 Oj 3
a>
3 2 7> <z . CD
3cs'a 3 71
3
-t 3 G
3 o
J2
P 3 O 3 3 ,g’ ^ 3 G 3 cq
/ / c3 3 d3 ° H 3 O d 3 ^ n i*j
G
.

cd
3 a. ^ > > 71 Co
3 S' So' 3 £ 3 33 H3o
.

3- 3 ^ 3 3 p 3
.
O
3 >
S' 3 3
CD Oo S' w 3
3 3 rt 5 tL 3 3 td S 3 O K
3 O 3 asG3 t 33 crq G G p Q 3" $rt- 3* 3'a§3 (SI
.

t3
P3
O
3
O'
-
3 Cfl
S'
3 P o JD p £2- C/3 cd’
G 33 3 S G
2! G 3G 3rt3 G
3 3 3 ^ 3 ^
H-*

3 2 G.
2.
O CD 3
cn
G
3 Kmi-l
3
rt.
. (T>

0 2 oG 3 3 2 P 71 3
rt.
3 S s 3 CD
G
-
3 d
s 5TJ“ p t3. G 3 G 3
3 o >-t ’H w C/3 3
^ g^crq s £
3 3 G 3— 3 Qu ft . s, d ^
3) 3 —
(p
3' crq ss 3, 3 p CD
HSto G G S' < <
33
O P
3 rt- 3 3 3
3 i-t
G^ t2 Q
2^ ^
CD
3 3 y’S'S 3 3
703 55’
3.
5"
X
3 Co M*
to
S' G0 CD
^ 3 S' GH 2 3
:
3
*>K

2 3 G ft
. ,

HJ u>
b S' d
3 < § o
tr* CD
3 3 0 03 <t O L* CD p
f-j t- 4 i-J ^
<3 t> p 3 o
G ^,^3 i

3 p
crq
o
c/G
3 3
to
3 3
3 3
CD
3 G.
“5 <3 a
3
g*g p M GCrq o G
O
^ CD
3-
3 3
<J
G
3 a 3 o
CD
hD 0 S' crq
O P o3 n>

G S' G
'

C Gw
<-i sj 71 H G p Sr* d
tr
d %> 3 3 Gk t,
3
G so
P O 3 3-
d 71
3 p' <* 3
O
3
G CD to
S'
3 P crq
H 3 to
CD
JK fa
^ <1 P 71 Ü to
p
^ °t
N.
Gw S*
d"
g 3
a
_2 P-»

p 3 ö 3 3 ^ tr CT
G
rt 3 P
•-« d 3 ^ Q G r+ 2- o {» 0 d
^ U-f
CD
c/i
to
to
to o ^ 3
p
71
I
•

p ° 3 O G _ I3r CD _
3 3 3
G p 75
P
*—
-
C/5

Gw
Gw
'

o rt
P P
I
G 3 a cd 3_ 71 Q-303 *

71 ^ 7) ^ 9 3 t
as o'^
P tdG^S Qrt CD 3 rJg n3 i-l

Crt- % (-3
<
G
3 wrt

S
G d 3 O 3 G \3-
'
p' 3 3
3 o
C/3
1-1
GG 3
3 < <J -‘ 3^
^
|
5 Gft,3 _
Da O^
O-

G K n ® cr
3 ^ S
_ 3 GG^ v-ur
O
G 3 Co

G _ 3
^ Ktü
o - 3 3
«.y

3
.
.
.

03
3d
3
crq C] cd
s 3 ~
>0 P g .3 P P
2 ft
i-t

o’ d 3 G3 3 3 >*
•I
zz
O Gü
rt
3
S >-t
c/>

S'
CD

p
3
rvi GH
tr ^
3 a--
0
O r/) 3 P o o w U) orq
„.
hH£ as au G
I

» s-d CD s 3 G
£3 CT* Hi? 3 s
3^ p G G
slS & o 3 rS t 5 3
3 crq K
*

P /
Sr*
CD
71
P
71
G o «t ° >— " rt rt o
n g^°g J
O
G
rtf.
•
Co
Co
» g-s 3 3
l

3 -rt- G G 3 3
*
rrt

GG 3 3
71 D- G G 3 CD gj GO 3 32 'o
Fig. 153. Frontal Section through Male Pelvis. Levator Ani Muscle.

Frozen section. Through the body of a Male of middle age a section has been

made almost parallel with the pelvic axis, so that the plane of section is not
accurately frontal.

This figure is intended to complete the series Figs. 15 1 and 152; only a
short description is necessary.

The Bladder B with its overlying peritoneum is, in front of the plane of

section, visible above the black lines which delineate the peritoneum.
All other structures except the Rectum and the folds of the buttocks and

parts of the thigh lie in a frontal plane, i. e. lower part of the Bladder, Ampullae

of Vasa Deferentia, external to these (cf. Fig. 15 1) the Seminal Vesicles and

directly below the last mentioned the Rectal Wall.

Very instructive is the divided Obturator Internus Muscle, which can be
felt bulging on examination of the Female Pelvis, and especially the direction of
the Levator Ani which arises at the upper border of the Obturator Internus from
the White line and approaches the Rectum in a funnel-shaped manner to sur-

round it and terminate in the External Anal Sphincter. This muscle may be con-

sidered to consist of many parts. At the commencement of the funnel it is

markedly thickened (Constrictor of the Vagina).

Near the Obturator Internus Muscle are situated the Internal Pudic Vessels

and Nerve (cf. Fig. 154) covered by Fascia (not seen in the figure). On either

side of the Rectum are seen the Ischio-Rectal Fossae filled with fat.

The last part of the Rectum only as it runs obliquely downwards and

backwards has been cut through; the upper part lies in front of the plane of

section as viewed from behind.

 Extern Jil Iiiac Vein

Obturator Artery
Peritoneum
Obturator Nerve

Vas Deferens

Vas Deferens
Hip-Joint
Ureter

Vesical Plexus of Veins

Seminal Vesicle
Ampulla of Vas Deferens

Obturator Internus
Muscle

Internal Pudic
Artery

mn
Ampulla of Rectum Internal Pudic
Nerve

Ischio-Rectal Fossa Levator Ani Muscle

Tuber Ischii
msml Internal
Sphincter
Anal

Gluteus Maximus Muscle External Anal

Sphincter

Fig. 153. Frontal Section through Male Pelvis — Levator Ani Muscle.
Seen from behind. — 2
/9 Nat. Size.

Rob man Limited, London, Rebman Company, New York.

 Corpus Spongiosum -

Perinaeal Nerve (Posterior

Scrotal Branches)

Posterior Scrotal Vessels

Long Pudendal Nerve

Raphe between Bulbo-

Cavernosus Muscles

Left Ischio-Cavernosus
Muscle

Deep Transverse
Perinaeal Muscle
(Compressor Urethrae)

Communication with
Obturator Vein

Obturator
Vessels to the Fascia
Bulb (Alcock’s
Canal)

Central Point
Superficial
of Perinaeum
Perinaeal
Branch of
Internal
Superficial Pudic
Transverse Nerve
Perinaeal
Muscle

Recurrent
Gluteal
Branches of
Small Sciatic
Nerve

Dorsal Nerve
Cowpeii’s Gland of Penis

Perinaeal Vessels
and Nerve

Inferior Haemorrhoidal
Vessels and Nerve Parietal Layer of
Pelvic Fascia

Levator Ani Muscle

External Anal Sphincter

Internal Anal Sphincter

of Coccyx
Coccygeus Muscle

Gluteus Maximus Muscle Ano-Coccygeal Ligament

Eig. 154. Male Perinaeum, Superficial Layer.

Nat. Size.

Eebman Limited, London. Eebman Company, New York.

 Fig. 154. Male Perineum. I. Superficial Layer.

The Superficial Fascia and Vessels of the Perineum with the Ischio- Rectal fat

have been removed. The Superficial Fibres of the External Sphincter Ani have
been cut away in order to shew more distinctly the Levator Ani Muscle. On
the right side the nerves and vessels have been dissected out; on the left side

a deeper dissection, with exposure of Cowper’s Gland, has been carried out

after partial removal of Vessels and Nerves.

The connection of the Sphincter Ani and Bulbo-Cavernosus Muscles shews

the crossing over of the anterior fibres in the middle line. At the central point

of the Perineum, where these muscles join, the Transverse Perineal Muscle is

attached. The connection between the Sphincter and Levator Ani Muscles is

merely indicated in this figure (cf. Fig. 153).

The Ischio-Cavernosus Muscles arising from the descending rami of the

Pubis envelop the Corpora Cavernosa; the Bulbo-Cavernosus Muscles, united by

a median raphe, lie in contact with the Corpus Spongiosum.

The Superficial Fascia of the Perineum (as far as it exists) and the Fascia
covering the Levator Ani Muscles (Anal Fascia) have been removed. The Fascia
covering the Obturator Internus Muscle is shewn in Sagittal Section (cf. Fig. 153).

The Superficial Arteries of the Perineum arise from the Internal Pudic
(the terminal Branch of the Internal Iliac Artery):

1. Inferior Haemorrhoidal 1
— 3 small branches to Anus.

2. Superficial Perineal, runs transversely across either superficial or deep to

the Transversus Perinaei.

Both these arteries are direct branches of the Internal Pudic Artery.

3. Terminal Branches of the Internal Pudic Artery:

a) Artery to Bulb, giving off the Transverse Perineal Artery and the
Artery to Cowper’s Gland.

b) Dorsal Artery of the Penis (or Clitoris).

The Nerves of the Perineum are branches of the Internal Pudic Nerve
(Ilth, Illth, IVth Sacral) which divide into 2 main branches, the Superficial Perineal
and a Deep Branch. Both nerves are mixed, the Deep Branch is continued as

the Dorsal Nerve of the Penis.

 Fig* I SS* Male Perineum. II. Recto-Urethral Muscle. Prostate.

The Perineum is exposed by a triangular window section. The Vessels and

Nerves have been completely removed. By dividing and throwing back the

Anal Sphincter the Recto- Urethral Muscle has been exposed to view and the
Prostate exhibited by separation of some of the thin fibres of the Levator Ani.

In front of the Anus the divided Superficial Anal Sphincter fibres are shewn,
anteriorly in the narrow space between them deeper fibres which pass trans-

versely, further forward the retracted fibres of the Levator Ani Muscle; and
between these fibres and the Central point stretches the Recto-Urethral Muscle
which blends, posteriorly, with the Levator Ani Muscle and the Rectal Wall,

anteriorly, with the Transverse Perineal Muscle, the Raphe and the fibres of the

Bulbo-Cavernosus Muscles as well as the Membranous Portion (Waldeyer) of

the Urethra. On either side of the Recto-Urethral Muscle the Prostate is exposed
to view. (This dissection can be carried out in the course of operations.)

In the triangle between the Superficial Transverse Perineal Muscle and

the Pubic Angle, the superficial fascia of the Perineum which covers the Ischio-

and Bulbo-Cavernosus Muscles is seen on the right side. On the left side the

fascia has been removed so that the muscles mentioned and the superficial layer

of the triangular ligament are exposed.

The Superficial Fascia is a true superficial fascia, but the triangular liga-

ment is an Aponeurosis (v. BARDELEBEN).

Raphe between
Bulbo-Caver- Bulbo-Cavernosus
nosus Muscles Muscle

Fascia of ,

Ischio-Cavernosus
Perinaeum
Muscle

Superficial Layer of
Triangular Ligament
Central Point
of Perinaeum Superficial Trans-
verse Perinaeal
Muscle
Prostate
Guthrie’s Muscle
(Recto-Ureth ral
Muscle)

Levator Ani Muscle

Deep part of
External Anal
Sphincter

Fig. 155. Male Perinaeum.

II. Eecto-Prethral Muscle. Prostate.
Nat. Size.

Rebman Limited, London.

Rebman Company, New York.
 Artery to the Bulb Suburethral Gland (Cowprr’s Gland)

|illiliiuiiiS»i|i

Fig. 156. Male Perinaeum. III. Cowper’s Glands with their Ducts.
Nat. Size.

Rebman Limited, London. Rebman Company, New York.

Fig. 156. Male Perineum. III. Prostate. COWPER’s Gland with
Ducts. Terminal Branches of Internal Pudic Artery.

The Vessels and Nerves have been cut away in the posterior part of the Peri-
neum. The Corpus Spongiosum has been denuded of its muscles and laid open

so as to exhibit the course of the Artery to the Bulb and the Ducts of Cowper s

Glands. The Prostate has been exposed by removal of the fbres of the Levator
Ani and Sphincter Ani Muscles which cover it.

This figure is given for the demonstration of the position of Cowper's

Glands and their ducts which vary from 1

75 th to 3 1 /5 ths inches in length; whereas
their diameter is 0.02 inch and their lumen 0.0 1 inch.

The Glands themselves, not always symmetrical, are situated about V5 inch
from the middle line on either side of the membranous portion of the Urethra between
the 2 layers of the triangular ligament, near is posterior border and between the
fibres of the Compressor Urethrae. These glands are lobulated or mulberry-
shaped, hard, almost white in colour, about l
/6 to 2
/s inch long. They belong to

the racemose type of glands and vary according to the individual and age but

are frequently unobserved owing to incomplete dissection.

The Artery to the Bulb (a branch of the Internal Pudic) consisting of

two vessels (cf. Fig. 154), supplies the Bulb, Prostate and the structures which lie

between the 2 layers of the triangular ligament, e. g. Compressor Urethrae Muscle,

Membranous Portion of Urethra, Cowper’s Gland and Corpus Spongiosum as far

as the Gians Penis. At this point it anastomoses with the Dorsal Artery of the
Penis and through this with the Arteries of the Corpora Cavernosa.
Fig* I 57* Male Perineum. IV. Urogenital Triangle. Ampulla of

Rectum.

The deep layer of the triangular ligament is exposed on the left side by remov-
ing the superficial layer of the triangular ligament and the Corpus Spongiosum

as far as the middle line; the Urethra, Coivper’s Gland, the left Corpus Caver-
nosum and the Dorsal Artery of the Penis have, however, been preserved.

In front of the Transverse Perineal Muscle, the Compressor Urethrae

Muscle (the Muscle of the Urogenital Triangle of Waldeyer) is shewn. This

muscle arising from the bony margin of the Pelvis (Ischium and Pubis) and the
fibrous portion of the Ischio-Cavernosus Muscle, passes to join its fellow of the

opposite side in the middle line. The outlines of the Bulb are delineated in blue;
Cowper’s Glands and Duct which are not exposed by the dissection (cf. Fig. 156)

are also indicated.

Anteriorly the Compressor Urethrae Muscle is connected with the Trans-

verse Pelvic Ligament which may be looked upon as an aponeurotic covering of

the muscle or as a blending together of the superficial and deep layers of the
triangular ligament. Waldeyer has named this the Preurethral Ligament;
emerging through the fibres near the anterior border of the Compressor Urethrae
Muscle, the Dorsal Artery of the Penis is seen ;
this vessel a branch of the Internal
Pudic soon gives off the artery to the Corpus Cavernosum. The chief object of

this figure is to give an idea of the position and size of the Ampulla of the

Rectum when distended (red). In this part of the Rectum which lies above the
Anus and which is capable of considerable distension faeces may, and frequently

do, accumulate if the bowel is not emptied. On the right side an abnormal Muscle

the Ischio-Bulbosus is shewn between the Ischio- and Bulbo-Cavernosus Muscles.

 Dorsal Artery of
Bulbo-Ca- Penis and Artery
vernosus to Corpus
Muscle Cavernosum

Duct of Superficial
Cowper’s Layer of Trian-
Gland gular Ligament

Deep Transverse
Perinaeal Muscle
Urethra (Compressor
Urethrae
Muscle)

Irregular
Muscle from Cowper’s Gland
Ischium to
Bulb

Levator Ani Muscle Perinaeal Artery

External Anal Sphincter Superficial Transverse Perinaeal Muscle

Central Point of Perinaeum

Fig. 157. Male Perinaeum. IV. Uro-Genital Triangle. Ampulla of Rectum.

Nat. Size.

Rebman Limited, London Rebmau Company, New York.

 Dorsal Artery L Duct ofCowukr’s
of Penis Gland

Compressor
Urethrae Muscle Urethra

Superficial
Transverse Central
Perinaeal Point of
Muscles Perinaeum

Levator Ani
Prostate
Muscle

Vas Deferens (Ampulla)

Seminal Vesicle
Recto- Vesical Pouch

Inter-ampullaryMuscle
Inter-ampullary Triangle (Base of Bladder)

Rectum (cut across)

Fig. 158. Male Perinaeum. V. Prostate, Seminal Vesicles, Urethra in its course through
the Uro-Genital Triangle.
Nat. Size.

Rebman Limited, London. Rebman Company, New York.

Fig. 158. Male Perineum. V. Prostate, Seminal Vesicles, COWPER’s
Glands, Urethra passing through the Urogenital Triangle.

Anns and surrounding parts — the Sphincter Ani completely and the Levator

Ani Muscle partially (window- section) — have been removed ; Prostate ,

Seminal
Vesicles, Bladder and Douglas’ Pouch are partly exposed from below and in
front, also the central point of the Perineum in front of the Prostate Gland.

Passing from the Tip of the Coccyx forwards to the anterior margin of

the cut Levator Ani Muscle the following parts are seen in order: — Transverse

Section through the Rectum, Peritoneum of Douglas’ Pouch, Waldeyer’s

In teram pullary Triangle with the base of the Bladder; on either side lie the

Ampullae of the Vasa Deferentia with the Seminal Vesicles anteriorly. Between
the last named and the Prostate the Interampullary Muscle runs transversely.

Next in order is the Prostate Gland with the central point of the Peri-

neum directly in front, whereas further forward are exhibited to view the Urethra
and the accessory glands entering the Ducts of Cowper’s Glands.
Special attention is called to Kalischer’s Urogenital Sphincter Muscle
which is very variable, yet possesses many anatomical and physiological relations.

At various times this has been described by JOHANNES Müller as the Con-

strictor of the Membranous portion of the Urethra, by Fr. Arnold as the Ure-

thral Muscle; as Guthrie’s muscle; by Cruveilhier as the Transverse Urethral

and Ischio-Urethral Muscle; by KRAUSE and KOHLRAUSCH as the Transverse

Urethral Muscle ; J. Henle associates it with the Deep Transverse Perineal Muscle

(Compressor Urethrae). Cf. the next figure.

Fig* I 59* Male Perineum. VI. Pubic Region. Levator Ani Muscle.

The Levator Ani Muscle has been exposed, a part of the Urethra below the point

at which it traverses the Triangular Ligament has been removed. The vessels
are preserved but the nerves, except the Dorsal Nerve of the Penis, have been

cut away.

This figure shews almost the complete surface of the Levator Ani Muscle

with its different parts and the incomplete gap anteriorly. Some of the veins

which traverse it have been preserved on the left side. Posteriorly

1

the close

relation which the Coccygeus bears to this muscle (of which it really should be
regarded as a part) is seen.

Furthermore through the gap in the anterior part of the Levator Ani, the
Recto-Urethral Muscle (cf. Fig. 155), the Compressor Urethrae Muscle encircling

the Urethra by some of its fibres whereas others pass transversely across in front

of it can be seen. The Transverse Pelvic Ligament (or the Pre-urethrae Liga-

ment of WALDEYER) runs across in front of a gap (for the transmission of veins).

Between this ligament and the Suspensory Ligament of the Penis which is attached

to the lower border of the Symphysis, is situated the gap for the passage of the

superficial vessels of the Penis.

The Dorsal Arteries of the Penis are seen anastomosing in this figure, and

the Dorsal Vein is seen to have bifurcated into Left and Right branches. The
lumen of the Urethra, where it passes through the triangular ligament is almost

circular if the mucous folds, which become obliterated during the passage of urine

or of an instrument, be neglected. In this Distal portion of the Urethra as it is

embedded in the Corpus Spongiosum the Lumen is more oval. Flere the separ-

ation between the Corpus Spongiosum and Corpora Cavernosa is most distinct.
 Urethra (Anterior Segment)

Pampiniform Plexus
Corpus Cavernosum

Artery to Corpus Cavernosum

Dorsal Nerve of Penis

Fascia of Penis
Dorsal Artery of Penis
(Anastomosis)

Dorsal Vein of Penis

Posterior Scrotal

of
Layer of
Ligament
Pubic

Urethra (Posterior
Transverse Fibres Segment)
of Compressor
Urethrae Muscle

Circular
Fibres of
Compressor
Levator Ani Urethrae
Muscle Muscle

Triangular
Artery Ligament
Bulb

Perinaeal Artery Internal Pudic Vein

Inferior Haemorrhoidal Artery Coccygeus Muscle

Fig. 159. Male Perinaeum. VI. Pubic Region. Levator Ani Muscle.
Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Dorsal Upper portion of Super-
Vein ficial Layer of Trian-
Buibo-Cavernosus Muscle of Clitoris gular Ligament Bulbus Vestibül i

Long Pudendal Nerve

External Pudic Vein

Poupart’s Ligament

Communication with Obturator Vein

Obturator Nerve

Deep Transverse
Perinaeal Muscle
Femoral Vein
(Compressor Urethrae)

Posterior
Labial Artery

Sciatic
Artery

Pyriformis Muscle
Nerve to Obturator
Internus

Sciatic Artery
Gluteal Artery

Internal Pudic Artery

Great Sacro-Sciatic Ligament
Coccygeus Muscle

Superficial Transverse Perinaeal Muscle Coccyx Bartholini’s Levator Ani Muscle

Gland

Fig. 160. Female Perinaeum.

Nat. Size.

Rebman Limited, London. Robman Company, New York.

 Fig. 160. Female Perineum.

Body of a Young Female. The skin and Superficial Fascia, except of the Mons
Veneris, have been removed. On the right side the superficial, on the left side
the deep layer of the Perineum is shewn: on both sides the Os Innominatum
isexposed : on the right the Great Sacro-Sciatic Ligament is preserved. Vessels
and Nerves are entirely preserved on the right side, but only partly on the left.

The chief difference between the Male and Female Perineum consists in
the following :
—
Instead of the small urethral aperture in the triangular ligament of the Male,
there exists in the Female, a much wider opening' for the Vestible. Whereas
the Corpora Spongiosa are joined in the Male to form the Corpus Spongiosum,
the corresponding parts in the Female remain distinct, as the Bulb of the Vesti-
bule. So that the Bulbo-cavernosus Muscles in the Female remain distinct on
either side: whereas in the Male, they come together in a median raphe. A
connection of the superficial fibres of the Bulbo-Cavernosus, with the Sphincter
Ani (like a figure 8), is likewise present in the Female. The Bulbs lie on either
side of the Vestibule at the base of the Labia Minora. These Bulbs of the Vesti-
bule contain large quantities of Blood, so that injury to them (e. g. during labour),
may produce serious haemorrhage. From these there extends forwards a Venous
Plexus which, near the Frenum of the Clitoris, passes into the deeper tissues
at the side of the Clitoris communicating at its mesial aspect with the Veins of
the Clitoris (particularly those of the Gians of the Clitoris). The Corpora Caver-
nosa of the Clitoris are much smaller than the Bulbs of the Vestibule or of the
corresponding parts in the Male. They arise from the descending Ramus of the
Pubis on either side, and unite under the Suspensory Ligament to form one shaft
(dividedby an imperfect septum) ;
the Clitoris is curved with its concavity
downwards and backwards, so that its extremity, the Gians, points towards the
Vestibule. Many minute veins of the Gians unite to form the Dorsal Vein of the
Clitoris, which opens under the Suspensory Ligament into the Pubic Plexus.
(Cf. Male.)
The Bulb of the Vestibule having a position different from the corre-
sponding parts in the male, the glands, corresponding to Cowper’s Glands, i. e.
Bartholini’s Glands lie internally and behind the Bulbus Vestibuli.
The Pubic Arch being much wider, and the Ischio-Cavernosus Muscle
less developed in the Female, the Urogenital Triangle is larger than in the Male.
In Virgins, the muscles in the subpubic region are well developed. During labour,
the Vestible and surrounding parts are stretched to a maximum and even fre-
quently torn, so that a perfect restitution to the normal state never occurs. The
Vestibule and neighbouring parts remain stretched after labour, so that the
muscles become smaller and degenerated, or replaced by connective tissue and fat.
The “True Perineum” which lies between the Vestibule and Vagina in
front, the Anus and Rectum behind, is neither broad nor strong. “Rupture of the
Perineum“ is therefore a frequent occurrence during labour. It falls to the duty
of the Obstetrician prevent this rupture by appropriate
and Gynaecologist, to '

mechanical intervention, to detect injuries and to suture them, and to cure Recto-
Vaginal Fistulae.
 — I

I
^ <u
X4
) T 5
*>
O 05 1)
X
a
P
'p S oj
}-*

O
the

H •r
ö
ca
« to
Vh
<D
^“s~ CO ^
TP
^ § §
TP ,p
2 a O
8 P — a ^ <!
2
& Xy m g
c3
o3
C/3
0)
<+-. o3 g
Artery

c a
> M
03 p3
£ Ö cS
MU •**
“g
a ^v S T3
the
Vesical,

Si
.o> s k.
4
JD
U
> 4
r~|
>
O
§ §
> n K*S
r
t-H (A
Co
Si 41 O *c
CD
from
Vesicles.

js
.<u>
«52 > 00 > O
i <
CD
G 13 "O
<D
(A
Inferior

CJ
P U > X V derived

oj 03 Oh
S ;o a D T3
'S cd o ^
I ^
^ ’c/3
<d
m p a ‘C o S XO the
<o
s: p* ° § ’C
Seminal
4> c/3 <D -§ -4 -» <D are

<3 <3
«S X X 4>
<u
t

o
a £-,
a
>-H

O • oj
1

and
oj
e CL Oh
5 a U
^

“’s
8 tJ .S o
**
P
* P <D >, <u
c/a
<V
CO
S'
s8 s
03 03
«2 A > Ampulla

the ^ 8 rs
QJ C/3
4 nj
P s
CM Q
" x .2
O
>-t
X a o
X
Haemorrhoidal

to <D
o <V
<D 3
a; a
<J Ml 3
the
W u >
03 <U x M D
JS £
<5 < a
to
<s i <D
03
O
U3
<U pH
oj
..
.52 5c
Arteries

A Pm s?
3 O) <D
1 PM (J
a
> 4)

PM .2
nj

£
Vessels
os g Middle

I, - °3 < Oj P
> ^O Üo
<U CÖ 03
S “S . .

Tt- S S 5 .a CO <M

>
XI
o X
X^ M
(modified).

00 03 t: <U
JS
S>
.-Ö
*4
a m3 03 Xa oj
M2 (h The the
H sH PM H Vas.

behind:
^ s8
J? Cj

J2 cu
T3
ü
fi
CU
T3
Oh Oh
x '-S
<u X
cti
O the
Vas,

cö

Frankel
J3
^3 § s of
-S CJ 03 ° bß
from
g ^ <L) .CJ § P
4 & Oh ‘era
t: f O Spermatic
Ampulla

3
t ^ f? c/a
03
<L)
o «
u
Max
4
X
> T3
C u '
X PM
41 X2 branches

seen S 's § Si “ o O p,
4-*

g
<D
CM - — oj
<u
43
03 CM
- 03
> the
the

After e I P ä I
.to ^3
^
^G X!
G
G
4 4)
X > a
<D
rC
with
to with

Pelvis,
«S fic; o oJ <D "p CD ^
S CJ Xi Arteries.

CM
2 ^
vO O
O
Oh
Ö
o3
Oh
distributed

Male
k ^ s8 s
S 2
t/a
r*

bb <3
cj K*S
Vh 4-»
a
o anastomoses
anastomoses

.8
<3
s
cv
»-H

10
•’“'

cj m
>
<D
<U
<L>

f>
0) 03 CJ
cj
oj
is
of Oh <i 3
Haemorrhoidal

53
2 o o
<L)
^
c

X
CJ
which
and
<D
<3 2o p CD <L> 2 o and
> Oh ^ X ^
Organs bß ^ £ >s
5

in cya
<3. <D .

03
,

'D p -g Vesicle

«o
bß
j-i
CD
Xo bp
Ö
oj Scrotum
branch

<D
Ö 03 Middle

CD <D
. bß >h
bß
•- ^0 bß
161 R PM
)

o C/3
X
(J
>s
c/a
qj
c/a
—
c/3 _ P
"3
the
Seminal

CD Ö
G CD ob <v
and
> cj G
P CJ Oj CD to descending

CD CJ
*8 <J oj
p the
Oj C/3
-S
Fig. <3
H P
CJ
i
f-O rO Pg Canal
Vesical

<u
<D
X <D o
2
pQ
2 ^ a and

CO X' a rO <D
o <D and
-V> s Tb oj Vas

I8 ‘g
CÜ
ob
03
J2
S vS
Inguinal
Inferior

H ö 2 pH
^
k .2
.tb

^ G PQ the
^ v Oh B <D <D Artery,

H X the of the
 Abdominal Aorta 4 th Lumbar Vertebra Trunk of Sympathetic Psoas Muscle

Deep Layer of
Inferior Mesenteric Plexus«
Lumbar Fascia

U reter

Aortic Plexus-

Sigmoid Flexure

Anterior Crural Nerve

1st Sacral Ganglion

Frankel’s
Recto-Vesical
Ganglion
Fkänkel’s Great
Vesico-Seminal
Ganglion
Frankel’s Small
Vesico-Seminal
Ganglion
Frankel’s Semi
nal Ganglion

Internal Pudic
Adductor Vessels and
Muscles Nerves

Obturator
Externus Muscle

Spine of Ischium

Obturator Membrane Tuberosity of Ischium Hamstring Muscles Obturator Internus Muscle

Fig. 162. Organs of the Male Pelvis, seen from the left side. Nerves to the Seminal Vesicles.
Modified after Max Frankel. —% Nat. Size.

Rebman Limited, London. Rebinnn Company, New York.

Fig. 162. Organs of Male Pelvis, seen from the left side. Nerves
to the Seminal Vesicles. Modified after Max Frankel.

A sagittal section has been made through the left half of a male pelvis. The
section passes through Sacro-Iliac Articulation ,
Tuberosity of the Ischium and
Horizontal Ramus of the Pubis ; this gives a view from the left side of the
Pelvis, — its Viscera and Nerves — . Most of the Blood Vessels have been
removed.

The from the Artery of this

Inferior Mesenteric Sympathetic Plexus runs
name to forms the Abdominal Aortic Plexus, this is
the Aorta around which it

continued into the Hypogastric Plexus lying in front of the upper part of the
Rectum. A
little lower down lies the large Recto-Vesical Ganglion of FräNKEL

which is connected with the ist Sacral Ganglion by a large nerve. From this
2 or 3 branches pass to a yet larger Ganglion (Great Vesico-Seminal Ganglion).

Some of the branches of the Recto-Vesical Ganglion go to the Plexus surrounding

the Rectum. Several small branches pass from the Pudic Plexus to the Great
Vesico-Seminal Ganglion and a delicate twig to the Seminal Vesicle directly.
Several large and small branches pass from the Great Vesico Seminal
Ganglion, one group runs in front of the Ureter, supplying it and terminating in

the Posterior Wall where they either run superficially for some
of the Bladder,
distance, or penetrate at once into the Muscular Coats; another group runs
directly downwards; it contains filaments to the Bladder and the Upper Border
of the Seminal Vesicle, amongst these is a thicker branch which ramifies around
the Vesical Orifice of the Ureter. The bulk of the fibres which leave the Gan-
glion pass to the Upper pole of the Seminal Vesicle and form a large plexus
around it.

Below the Great Vesico-Seminal Ganglion lies the Small Vesico-Seminal

Ganglion, directly behind and internal to the Vesical Orifice of the Ureter. The
roots Ganglion are derived directly from the Recto- Vesical Ganglion but
of this
there also exists a connection with the Great Vesico-Seminal Ganglion. Fibres
are distributed directly to the Ureter and Vas Deferens, a few run behind the
Ureter to the Fundus of the Bladder, while 2 or 3 larger branches go to the
upper pole of the Seminal Vesicle, here they anastomose with the fibres from the
Great Vesico-Seminal Ganglion.
A very careful dissection exposes two strata of nerves (not seen in the
figure), an upper going directly to the Prostate, and a lower lying on the Seminal
Vesicle. Both layers anastomose with each other. In this lower stratum, FräNKEL
found 2 other small ganglia which he calls Seminal Ganglia. From the lower
part of the Hypogastric Plexus fibres also run directly to the Seminal Vesicles.
Johannes Müller called (in 1835) this part of the Plexus “the Inferior
Hypogastric Plexus'’. Max FrAnkel proposes to divide this into a Superior, a
Middle and an Inferior Haemorrhoidal Plexus. The latter would be applied to
the Plexus on the Rectum below the Levator Ani.
 Fig. 163. Gluteal Region.

A large window has been cut out of the Gluteus Maximus Muscle; from the
Gluteus Medius and the Pyriformis Muscles, smaller pieces have been removed.

Under an extremely thick layer of superficial fascia, lies the Gluteus

Maximus Muscle, which covers nearly the whole of the Gluteal Region. The
following bony prominences can be felt: the Crest of the Ilium, the Great Tro-
chanter and with less ease, because covered by the Gluteus Maximus, the Tubero-
sity of the Ischium. The upper and
outer part of this muscle passes over the
posterior and outer aspect Great Trochanter and is inserted into the Fascia
of the
Lata. A Superficial Trochanteric Bursa placed within the superficial fascia is
rare. The Gluteus Maximus covers important vessels and nerves; at the upper
border of the Pyriformis Muscle, emerging with it through the Great Sacro-
Sciatic Foramen, is the Gluteal Artery, a branch of the Internal Iliac. Outside
the Pelvis, the trunk of this vessel is short, and soon divides into 5 — 7 branches
to the Glutei Muscles. A large branch (Superficial Branch) becomes more super-
ficial by emerging between the Gluteus Medius and Pyriformis Muscle, to run

under cover of the Gluteus Maximus. Another large branch (Deep Branch), runs
between the Gluteus Medius and the Gluteus Minimus, this divides into a Superior
and an Inferior Branch, the former of which follows the middle curved line. Deep
to these vessels lies the Superior Gluteal Nerve. At this point a variety of Sciatic
Hernia may occur.
At the lower
border of the Pyriformis Muscle, the Great Sciatic Nerve
emerges corresponding to the junction of the inner and middle thirds
at a point
of a line drawn from the Great Trochanter of the Femur to the Tuberosity of
the Ischium. At the lower border of the Gluteus Maximus Muscle, the Great
Sciatic Nerve is easily exposed, because at this point, it is only covered by skin

and superficial fascia; at a lower level it is covered by the long head of the
Biceps Muscle.
Internal toGreat Sciatic Nerve, lies the Sciatic Artery, a slightly
the
smaller vessel Gluteal Artery. This vessel gives off the Companion
than the
Artery to the Sciatic Nerve. Between the Sciatic Artery and the Great Sciatic
Nerve lies the Nerve to the Gluteus Maximus Muscle, the Inferior Gluteal —
Nerve — .

Most internally, the Internal Pubic Artery emerges at the lower border
of the Pyriformis Muscle, and after crossing the Spine of the Ischium or the
smaller Sacro-Sciatic Ligament re-enters the Pelvis through the Sacro-Sciatic
Foramen, but does not enter the Pelvic Cavity (cf. Fig. 150).
A second variety of Sciatic Hernia may protrude below the Pyriformis
Muscle, where the structures mentioned leave the Pelvis; a third variety may
occur at the Lesser Sacro-Sciatic Foramen.
The Hip-Joint lies under cover of the Pyriformis Muscle in front of the
Obturator Internus and Externus Muscles, and in consequence is scarcely acces-
sible from behind. An important Bursa lies between the Tuberosity of the Ischium
and the soft parts over it, e. g. the Sciatic Bursa.
 Latissimus Dorsi Muscle

External Oblique
Muscle of Abdomen
Internal Oblique
Muscle of Abdomen
(Pktit’s Triangle)
Superficial Layer of
Lumbar Aponeurosis

Gluteus Medius Muscle

Posterior Superior
Iliac Spine

Gluteus Maximus Muscle

Gluteus Medius Muscle

Gluteal Artery
with its
Deep Division dividing
into Superior and
Inferior Branches

Pyriformis Muscle

Gluteus Minimus Muscle

Great Sciatic Nerve

Sciatic Artery

Internal Pudic Nerve

Small Sacro-Sciatic
Ligament
Branch of Sciatic
Artery perforating
Ligament
Internal Pudic Artery

Nerve to Obturator
Internus Muscle

Small Sciatic Nerve

Inferior Gluteal Nerve

ursa between Trochanter

and Gluteus Maximus

Gemellus Inferior

Great Sacro-Sciatic
Ligament
Tuberosity of Ischium

Companion Artery of
Sciatic Nerve

Quadratus Femoris
Muscle

Recurrent Gluteal
Branches of Small
Sciatic Nerve

Iliotibial Band

Semitcndinosus Muscle

Long Head of Biceps

Muscle

Fig. 163. Gluteal Region.

74 Nat. Size.

Rebman Limited, London.

Rebman Company, New York.
 o
ffq Si

orq *g m

!>p.

Fig
1
.

164. Clitoris

Modified

after Lymphatic

C.

Bruhns.

Channels

and
Nat.

Size.
Glands

of
(Lgl.

the

Female

Lymphatic

Hymen
Pelvis

Gland.)

Child.
 ( :

ET dd g f°o
03 03
C
xi er
S- w > S. ö
CD 8 3 "d
P er cd »
gf
ä 3t
« w
SS

^ §
CD Er kh &. ß rt 5 »
oV 31 O
de - ft
S' CD CD
5 3 •3 3 ^
c
er
8 g S
£T o 2
ß » a ° W o
.. p* 73 CD
n>
et
o 3 a g.
cH 5' P
3 x
dg
.
3.
03
3 «g
F 3'
03
O
a
a
CD J=j erq
C-t-
cd ^
.

i; d
SO
73
CD
erq

S cr
0)

o 3 i- r-t-
O ft
S CD OÖ 2S

2 D D- r+ O QL er 73 3 3 er 3*
3 QL CD o CD S « o o TJ
erq erq
O g ß
SO
O a ^ a fter 33(ö CD 3 73 3 ^ Ä
fV

*— a pT sb 3' O £
P
•
a ^ ß er -t 2 CL 3 rS*
?sJ
.
CD
5 o 3
ß s' 3 so
^ P-< £)
a
3
Pu CD 3 °
ft a>
n
u> fl p erq^
co
3 I
er O p
Cb T) “ « ft er a er d 3
§
Du
>
• • er Qi 73*
_

o’ o) 2 .

er <, o a 3 O
2 3 3 3 73 Cb £r
73
CD
ft m 73
CD 0> ^ - D. 3 3
(l
^
£3
a
bH er 3 Cb ^ a P et v fl
ft t 3 M*
o .

^ o’
cd er CD er
« 3 St a erq 3 5! S
3 =r P £
CD GTQ^
"d n> er
o
>-t

a o 0 ) ^ ^ erq

5 cd
H g- 373 CD23
P
o o M 05 cd er p. fl
er o .

Cb _
a P CD O 5 s? 3
^ ^ S
er. g-^
§ <T>

^ o d er cd
O
— rr
CD
CD
Q.
2 o
cd
a 3 o »2 ^ §
w-> a
pr*
Er ET CD d3 CD ° -o a> p 3
CD .
1
1
73 164.
O o er ^
QL P 73 v; rt
a3 a s
a P- *2m
CD
tr n> dd 2 3 CD 3 o rt- er ^
a | r w
.

d 3 p- et SB
s
er CD 3 P
? cr ° er °3
§' Cb a 03 -c« 7q' p
c/3
*—< ft 3 « 2 « ^
O 3 o ß CD
q
cd
p 3 ?i a
<3 fi

3. so
£ Cb 3 W
*
3-
O Xi p '

c 3 °
- 5b
er
3 C
cd
O 3 3 per o w
Cb d Pad* cd erq o' o 3 ?r 3 t-H
£)
~73 3. o hh o
3 ^
‘
CD
O 3 Cfe
3
Cb so
er
^ -ö o
< *< ä fl 3* 3 *3-
Lymphatic

a CD 2 w »
~
O a ^ £. o O P 3 ^
L_U
3 3
CD 73 a
52. O 3 t) fl d 2 3 3 P
o ^ p a
t—f.
3 a jo
a 3
so
3
-S-
O ~ 3 h a. s“ a a-
CD
a Qu ^ 3 CO
Pu
fif

F
£?
5’
fl
2. 3 Cb 3
& & ft
o
3 OP
er o'
p
3 a o erq « P 3
03 3"
CD'
Cb

M
73
S'
CD
_

£ >
a
V
H
er
3 3 2-
er o ^ rrl Cb er
CD CD
O
o
oc fl W 05'^ g ^ 3 5“
fl 8
3
_ <J
Cb
3
K-U T) ß>
tq 'S
* ^
^ß3 et er
Cb
x c 2. PL
^
ßl g Channels

Cb m o o- «3 O 73
>— a »JQ 3 3 CD 5)
HU. P
•

w
*

o p s H.
Q_.
BJ. a
•-{
CT a
p p 73 erq ^ B- g M 3 a> o
G3
er 3 or.
55*

CD ^ ß << p p < p s ° *3-

> Er
O “ 3 fi erq
CD
£
erq
33
CE. ß et
_
»—
P
n
73 s ^
CD o
d
s
s -*. o V 3
3 3 P-
73

2 POP
5
3
s < and

8* Ql
w c7T er cd Cb Cb fl
CB
^
K,
.Ca

3 g" CT
> 3
a
et TO
3-^
X5 -d er
p er P p
er or.
de
° a < dg oes a
P g. 5 5
-
^
P
rr rö p p" p CD 73 p ^ d P 03 § Glands

3 er. er o 2 5> P ^ ft
31 a
CP q
an ql w p
erq
f I:
P d O rr
er 3' o
< h 3 oT o 3 3
a dt cr
a S" TO
p
O « p p 2 o 03 a cL f° er S
»
p g rt
73
er
n,
3
3
cr
0 >
rt o a
er o ^ ß c 2
ßg a O oO^ ß
p d 3 O
SS
54.
of
^ rt O o
i-3 a
.

^ 3 73 a 3 O 3 g w
fl
d3 O b>
3 3
c. *31
r „
3 VJ et p
er o
® &
a CD
d d Cb a 3
a "c 5 o 3 ' o the
< p
ß o P ^ p er P 2 p Cb H
p P
P 3 3
er T 3 ^ m
> n3 p eo
o
< o 3 o
B>

a .
a
§ 3 ” p er rt 3 a er S’ ßf' P
O fl ^3 O' a p rt T3 p et 03 d
p erq »L
o
»>
a- a o
O o’ 73 O
d 3
Xi Cb
W o ^ °S-
3 erq S33 “ & ^ ^
^
3
^
% Ä P
a.

^
p 51
^ £ 3_ VJCb
o
° 3
a P-
ä sr fl

l [
ee
B5
^
ft.
0^
Female

ef. cd 3 51 Cb S: ft

p o 3 Cb
w o
CD [— > er 3. erq
p p 3 a
" H H.
er
o =r g ö p P er 73
a
P d °a
El
3 2 o* M o o er
HH P a o
a
p
3
% p O
er "d ^ p
p P 3
kJ
W oT
rr 3
3
TO
3
-T-
(-+•

^
¥ s 2 °
a
or 3 cT
P .
er ft, S Pelvis.

p 3 W p Cb d r Xi ti
O
O o
0
3 P H-] P a ,
a er s ^ 2;
«
P
rcl
p 5' -a
3 er
n p
O a a p o P O
a 3 erq _ 3
p rt £1 ft
ft “ d-' erq ,
ßS ^__ TO5 *
er
c
to

er p er eb o P _ 3^
er 3 es
sb_ tr i<i
o ^ ft“

50 3
^ S o «
tz. Qi
er pa P
P P p a- P ß a P g
3 P QT dj
ßß
P
de
er
£L
ft
Q
" p w
P « O 5* o
ßF p
<J
P 3 c Cb ed
a P
°S. Cb ^ erq g
> ^
Cb 93 rt w P SO
(Child.)

^
,"#n
erq
o’ w o £ 3
o p o' a 3 ^rt 3 a O
3 ft s c P P 3 ^ o g 3
P s>
05 rt &. tü
3- er y^
S' O p ^ er fi a P
p C3
p SL
H-
3
a3a 33ft fi $ 3 Q- Cp
fl
r CP
a p S
p 2
er
d ET! 3
3
3
SB
W erqP oo
P a*- O SB ft O 2
Cd p o
.

P
< ~73 re
p a cd’
^ d 03 a>
ft: ^
_
T3 ^ ?P 23 mQL ft a P 3 TO 3 p t—
i-5
<1
^ H
B
a
4
rt
3 rt. c 3
(I

te 3
O 03
Cb > .
o
add •

5
a TO
’

^ q a O
"d 5 es 3, 3 U ^u
er
F £•

<3
'

O rq S fi o er a d’ Bä p fo ‘d^ O
a a ^ ft- _
q a, 0 3 |- er o
g- 4 «5*
W p _
> 73
73 a » er 33 ^
O
—
05
3 03
B) 73 a O
SB
a er
er qt vi
^ O ^e p O P ft

3 Cb O 3 p S'* rt 3 Bä
a v £L -

§ M "a
3 £L 3
3 a ei 3 a- f“ 03 g
S
a £ ° s-og d
'
05
’f3
P QL, o § ft
73 P
-
-1

er rt 2Ra.-d O
*§ M
-d g-w 33
o'
p S5
3 O 2? 3 «Ö.
ö
w *
E a er er er
o g
fl rt fl 05 ß? f<!
3 g § »
er.
o p p p ß ß o o Ä- •V
 Fig. 165. Frontal Section through the (Right) Hip-joint.

This section is not quite vertical, but is directed obliquely from above and in

front, downwards and backwards. The Hip-joint is the most deeply situated
of all the large joints in the body, and is covered on all sides by thick muscles.

Access is obtained more easily from the outer side over the Great Tro-
chanter, because in this situation there are fewer Vessels and Nerves. The
Socket of the joint is incompletely covered by cartilage at the Fossa Acetabuli
which is filled with fat. At this point, the bony wall is very thin, and easily

allows of perforation by disease, which may subsequently extend in the Pelvis.

The Socket is deepened by a dense fibrous ring, the Glenoid Ligament. The
Capsule of the joint extends on to the Femur, — to a varying extent at different

parts — . In front it reaches the Intertrochanteric Line, behind it is inserted on

to the Neck of the Femur, about 2

/5 th inch below the middle of the neck, so that

a considerable part of the Neck lies within the Capsule and fractures of the
Femur may consequently be completely Intra-Capsular. The Capsule is strongest
in front, owing to the Ilio-Femoral Ligament (BERTINI, BlGELOW) which passes, from
the Antero-Inferior Iliac Spine and the bone internal to this, over the Capsule
with which it blends, to the Intertrochanteric Line. Superficial to Bigelow’s
Ligament, lie the 2 Tendons of origin of the Rectus Femoris Muscle which
arise from the Antero-inferior Spine and the brim of the Acetabulum. The angle
between the axis of the shaft and the axis of the neck (Angle of inclination of
the Neck) of the Femur varies from 1 1 6° to 138° (Mikulicz) but is usually
about 120 0 to 1 33
0
,
the average being 125 0 . As a rule the longer the neck, the
greater the angle.
The architecture of the cancellous tissue is briefly as follows: A pressure
system of Cancelli converges from the surface, commencing at right angles to the
surface on the inner side ;
a traction system crosses the former at right angles,

forming arches, which run from the outer compact tissue with their convexity

directed upwards to the middle and lower parts of the head, and the adjacent
portions of the neck. The third (muscular traction) system begins at the Great

Trochanter at right angles with the insertion of muscles into it, and passes
inwards forming arches with their convexity directed upwards: this system crosses
the former at an angle of 45 0 , together with the first set, this forms the strong
vertical plane of compact bone which Merkel calls the Femoral Spur (Calcar
Fern orale).
 Iliacus Muscle

Ilium

Psoas Muscle

Gluteus Minimus Muscle External Iliac Artery

External Iliac Vein

Gluteus Medius Muscle

Gluteus Maximus Muscle

Ligamentum Teres

Bursa over the

Trochanter Obturator Internus
Muscle

Femur
“ Tuberosity of Ischium

Fig. 165. Frontal Section through the Hip-Joint;

Right side.
Seen from in front. —% Nat. Size.

Rebman Limited, London.

Rebman Company, New York.
 Rebman

Fig.
Limited,

166.

London.

Inguinal

Region,

Child.

—
1st

Nat.

Layer.

Size.

Modified
Superficial

after

Carl

Lymphatic

Bruhns.

Vessels

and

Rebman

Glands;

Company,

Veins.

New

York.
 " r 1 .

( to
£ — ^ cr
-* - "> H CR n cr cr. ft tt> re ^ 3 r+ H p
O
o _ fü O ^ Co
- -
cd S, CL o £L Cr o 5 c Q3
r+ 3
*— 1
33 «—i
cd a» O 3 3 g- ® cn 3 x
Jn o
p 3 B
o
«—
E
CB ^ B C cr
p crq

o
-t &S rr, n>
02 w 2, o:T3 5"
0 3 O 02 “ r-
H
s § <-c

0) a. c o o ®3. -
ffl
o
0/3

e +> a
p CR -a Ö. "2. 3
n nr
o cr T)
3
« O O
L_L ^
P o
_
—
CR P
^
CD
ns
p _
_
’-*>
CD
T-
|-i ’-{

"2 ft

jj) nr to
nr p cd )_h
< ^ CD << 3' C o <5 cd
2
2- 3 o O’ Pc P
nr H CD D
.,

p ^ CB o P orq
CD pr to £3 m X 3 £L 3 (2l E p c ^
»t P _ cr
n <3 o
O _ ££
CD
X GTq CD P. P p 3 3
_l O o a* r>
3- Er 3 CR Be 3 •~h r-t- '-t

2 *< P o ST 7q nr o cr
P CR fq
cn o p cr. ^ P
3 3 CD o Q - to P CD
3 o P r ><1

CD X _ CL o l/l to
*o
2 o cr 5' p p Hf to *<3
1

3- 3
r+
o nr ^ 3 c to CL 2 CD S
S? « 11

CD S 3 x p
p to x to *1 ^
cn o C P
.— 3 3 J3 "O
P p
3 C/3

P O) -t
^. too^onr CD
CD
^ CD o
nr
CD w
^ P-
CD o a p ^ nr
p p
~ *X 2- CD^ _
^ p S3 CD
° 3 H "C M P |
1
^
? 3 O < 2 » H Q a
k.

S "5 £3- 8 Fig.

f Q
x o °> p CL 0 S
to 5
^ 2.
CD
J? CD
po
5‘
to -o
^— nT p to er Q it
o “ si
P p CD
CD O cl nr. or'
T3 CD
1 § V! p
3
s g-

X <B. 3 CD P o s &
S- 3
CB
o o n p 3 3 3 03 cr tv
03 'TD
b 2
•o 2.
CD
2 CD
P
S- ^
3 X p'* O ^ n qs. p ^
p CD
-S B O CDnr
g,
CD
to
, >
nr
» 2 ®
n

c
n
^ SB

§-
§
§
5
S"
166.

o C 5 3 s P s 3- P
S' S r 3 I l
m % O o i-f
g.
**
3 3 C3 P S' §
•

P 3* 0-
— P ol o CDP ^ *— 3
H cl ° cdnr CDnr ^
p S TO H
1

S £- _ cr o 3^ H 2. > CD *-s *"* Inguinal

CD CL O o
o 3h 2 3 03 cr P to *-h p O 3- P 73 2. 03
P- CL 0
nr-o U> O 3 H
•-t CD CC
P CD
2 3 Ct p ^ s
,
2 ^ rT ^ JC a g, _ 2-0 CD rr d> » CR r/T O CD
3- rt-
?
o n> o 3 ^
.

n ^ 5 *§.
<c " % 2 3 3 ?
•"
^°a a 0
Q 3*
op ft 3 3 g CL
p* nr CR O
S' R
m cr n 1 •
s.
o S5’
c cr “ p P ^
3
p cr 3 3 3- np
p- p y ^ g
n>
P f
Lr 03
C/3
js'

x SL or - 3
P -Q "o
n <t ^ to 7) c n. to
^ Oi ^ cr
E CD
g 5- CD r
-

:§ 3 1 Region

o 3 o a> CD p e M 2 P. P CD Cl ^ ^ v
« 3 O o X X3 & S*
3 3 3 ^ rh Ln oq 3 n Si Oo
.

rq
X:
tv
ft
«
cr qs. CD p ••
< ntj cr
p" a 33 *< 3 3 ,rt. s'
3 CR 2 *< o 2 n 3 s: s-°@ a m s> »
CB X) cr' 3 * a
—

S
O 0« > S
Hj CR -3
" rt OR
P to P-< — CD
cn
•
1
* 5 3
r* P r+
3-3 3-
p rt- g ~ 3
p ~ ?
nr
° P 3
2 o ^ 3 ;• 1 O 2. §tj
sl! a?
p
^ -«'to
ist

pr>-? o CD X
(S)
CC o> ^ 2
CD
S p o 3 „« o a >i

S* S Si

»-
% <S
X5
O 3^3- tr°s. p O O
3 3-0
«0
3 J2.o ^ 33^M 33 h ir u *- ft
Layer
"t
i~t

o’
p
o e
< S H
<T> i1 _
2 P M rt-3
a.
^30
p 3-33
O ft1 » 0 n> ~
5 ^p ~
p 2
^ n
|> f T33 O3- ^o
3
3 « 2
3
3'
ft
8
s>
*
^
ns‘

7Q
O
w « I 00 CjrJ P 3
CD
3 m
CD
if o 3 2 S 2j bo ^ a —

P 3 -a «0 3
CD Ct ^pS“CTP-a<3.
"2. i p -o 3 P 3 -
q- m
5 .

3 03
^ ^
'

^ 5* p p sr
s
P-
§ 3 s CD p
ö S 5 p ||f I
-
- XP ^ 5
s ^
or
lr!
r:
p » 0 2 = CD ^ ^ 8
CR
*-o ^ “h O ^ 3 CD
B-
p
a- rT
S- r-r*
cr P
P ^
r’g. o ^ o*
40

p -J o_ O r+ g
^
CL cd
M XP P ,

CL ^
Superficial

P CD
3 ^ p P 3 3 P-
x8 1 1

^
p- H-h
Cl O P — P 2. nr
W r
^
•
r-t- *
to P rr P
*.
? »s 0 S- ~ ?!• o p CD CD . §.
n ^ p a 3- nr 2
3
crq -
£3 ^ L Sp
S' s g
“
p X nn to <
5 3-
X
=f
® Hr .

3
p ^^
nr
3 2
cd p
"<
2
^ 3- 2
P w p c o
2
CD
— o I r"t E 2 ^ CL CD

QTQ
1

hd
i

o ^ P < & o P Ö5
n
5*
E O£ 3 < P p CD
CD CL — ,

3 OJ P
Pa>
P CD
a O
w
2-
’
CD
CL CD
CL O -
o
P er
CD
1/3 cd nr
P JO -?o
n ? o
p
O 2^ 0 O CD
v p- p.. V »
hJ LL. rt ^ w »x Lymphatic

3 ^
nr
O P < ^5- « cr Ss 3
«-t-
<5
3 cn3 ^ m y 3 o
C
O 2 S'
P
ST 2 3
p
cd •“
2- x
•
h-t O P O
S
• •
P to “(in CD
p ^ P G 2- -a 3 a> p c
n>
—x 73 3’^
CL
^
orq
cn p nr 2
^ 3 ^
Q p
2-
nr vg 3 g-“ e 0 X 2-
t] er S CJ—
3- CD S' p P o ,,
p
cr
P 3
2 &“-tüS
_ »— • to
o 3* 3
“ 3 g » ^ o ® 3 L
m CL _
^ X^ PO
'-!
2 ,, » s 2 c 2. p 2 ° O CD
P
o^-
Glands.
O to P
3 S'
3 qs t-K
jij
CDo P
2. § t 3 I
CL
«r
CD
&^
to
•a P
o P^ o 3 0
op
E < 2. P a-
o
IP
nr ^ o
‘
2
0
rf ^ qs.
o
P CD w
CL XJ p ” B-H 3“3 >rt- 1 nr-u
x x
3
3 3-0
n 2
P
orq
to
P
< P „OSO2 XJ 0 '!»« 3 P '
CD
2. -2
fX « 3 g
^
F-.

P S’ cdr to’ cd qq. p S ^ nr jo

CL
2. 3 X CD r-f

?qi
55’
CD
cr
X-
nr to
“ «-a £
_
p
n 3 § ® £ er sö
O 2
O
o’
p
CD
3 W 3 Cl U) M P
P to X7f4CLCL H <; ^ -t _^n 3-| r tocl
n « r-f v<j
2.5 w 3 srU
r P ^ bE CD
O jo" 2
P
P
O
PES
3. 05
3 —
t->2 -NS c& o 3
^ P? 3 3- CB^o ^E
« rl-
'

rt s ^ g-
Y-L .
^(jq 3 o
p X S
»-K
t-*
\
tv
2
2
2" -• a o n 3* * S- >2
3 0 0 E 3 y-v 3
-I
o 2. n ft - n nr
< c
Sr°3. 3
“> go
«-o'-
3 3 -3
-
g S' <
p p
& C
ft <. - CD '

2 3
a 2 o-1
3“ «. O
0 0 3 3
tfl
fT
5 o O
3
° sc 2
3 3! 3 >
cr
^ s
or 3 7
CD
3
Fig. 167. Inguinal Region; 2nd Layer. Fossa Ovalis (Saphenous
Opening).

Specimen from a man aged yy. Skin, Subcutaneous Tissue and Lymphatic
Glands have been removed. The Lymphatic Vessels which perforate the Deep
Fascia in one region — the Cribriform Fascia — have also been removed. The
Fossa ovalis ( Saphenous Opening) and above the Femoral Vein, the“ Infundibuliform
,

Process” ( Waldeyer) derived front the Transv ersalts Fascia are shewn.

Not only the Aponeurosis proper of the External Abdominal Oblique

Muscle but also the Fascia Lata and the Fascia covering the Pectineus Muscle
etc., may be looked upon as tendinous expansions of this Muscle. Not only in

animals, but also in man, this muscle extends directly or indirectly on to the
Thigh. The Fascia Lata can be made tense in all bodies by pulling on the
External Oblique Muscle. Below PouPARTs Ligament, special arrangements occur
which have been produced by the passage of the Vessels through the Fascia.
The usual description given is: The Fascia Lata which envelopes the
thigh, like a tense membrane, divides below the inner part of PouPARTs Liga-
ment into 2 layers. The Deep Layer blends with the Ilio-Pectineal Fascia, and
passes upwards behind the Vessels. The Superficial Layer is attached to Pou-
PART’s Ligament; over the Femoral Vein and internal to it, this fascia is per-

forated at many points, through which Superficial Vessels enter the deep layers
(Cribriform Fascia). When this fascia is removed together with the subjacent fat,

a groove is exposed; Fossa Ovalis or Saphenous Opening. The lower margin

of this opening is always sharp (the Falciform Margin); over this the Long

Saphenous Vein passes to open into the Femoral Vein. The upper and outer
margin which can be dissected out is attached above to Poupart’s Ligament,
and partly to GlMBERNAT’s Ligament. The Saphenous Opening is merely
intended for the transmission of vessels comparable to many other openings in
superficial fasciae, through which veins pass; with this difference that the opening
is too large for the vein.
The Superficial Vessels which pierce this Fascia are: — on the inner side.

External Pudic Vessels; above, Superficial Epigastric Vessels; on the outer side,

the Superficial Circumflex Iliac Vessels. Like all vessels situated close to their

origin from a large artery or near their opening into a large vein, these small

vessels bleed furiously when cut.

 External Pudic Vessels Superficial Epigastric Vessels Superficial Circumflex Iliac Vessels

D* Ire h se

Long Saphenous Vein Middle Cutaneous Nerve

Fig. 167. Inguinal Region, left side, 2nd Layer. Saphenous Opening.
(Fossa Ovalis Femoris.)
*/, Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Ilio-Hypogastric Nerve
Superficial Circumflex Iliac Artery |
Ilio-Psoas Muscle
Pouiari s Ligament
Internal Abdominal Oblique Muscle ^ 1

External Cutaneous Nerve

Genital Branch of Genito-Crural Nerve

Cremaster Muscle
Femoral Vein
Cremasteric Vessels
Pampiniform Plexus of Veins

Ilio-Pubic Band

Vessels of the Vas

Vas Deferens

Pectineus Muscle

Spermatic Artery

Deep External Pudic

Artery

Femoral Artery

Anterior Crural Nerve

Long Saphenous Vein

Adductor Longus Muscle

Middle Cutaneous Nerve

Sartorius Muscle

Fig. 168. Inguinal Region, left side, 3rd Layer. Scarpa’s Triangle.
3
/4
Nat. Size.

Rebman Limited, London Rebman Company, New York,

Fig. 168. Inguinal Region, 3rd Layer. Spermatic Cord. SCARPA’s
Triangle.

Male aged
, 37. The Fascia Lata and the Lymphatics of the Groin have been
removed. The Aponeurosis of the External Abdominal Oblique Muscle (and
the External Abdominal Ring) has been slit up and the chief constituents of
the Spermatic Cord dissected out.

When the Fascia Lata which stretches across the Inguinal Region has
been removed, a triangular space with its base directed upwards, and its apex
downwards —
Scarpa’s Triangle —
is exposed. The upper boundary of this
area is Poupart’s Ligament; the internal, Adductor Longus Muscle, which arising
from bone below the Pubic Spine, runs outwards and downwards, to be
the
Aspera the external,
inserted into the middle third of the middle lip of the Linea ;

Sartorius Muscle, which arising below the Antero-Superior Spine of the Ilium
descends obliquely inwards and downwards, over the Internal Condyle of the
Femur, to be inserted on the inner surface of the Tibia as far down as the Crest
of the Tibia.
In this Nerve and the main vessels are
Triangle, the Anterior Crural
exposed. The Femoral Artery lies under Poupart’s Ligament, at the
directly
mid-point between the Anterior Superior Iliac Spine, and the Symphysis Pubis,
and passes almost vertically downwards. At the ligament, the Femoral Artery
can be readily compressed by digital pressure against the horizontal ramus of the
Pubis. In SCARPA’s Triangle, the Femoral Artery gives off posteriorly, the Deep
Femoral Artery, apart from the smaller branches, Fig. 167 —
Superficial Epigastric,
Superficial External Pudic and Superficial Circumflex Iliac Arteries As the — .

Deep Femoral Artery is a branch of large size, there occurs at its origin, 1V2 inch
below Poupart’s Ligament, a sudden diminution in the calibre of the Superficial
Femoral Artery.
The Femoral Vein lies to the inner side of the Artery and is enclosed in
its sheath, but soon passes behind the Artery. This Vein receives the Long
Saphenous Vein, which passes over the margin of the Fascia (see Fig. 167).
Internal to the Vein, is situated the Crural Ring (see Fig. 170). The space
below the ring, —
between the Adductor Longus, Femoral Vein, and Pectineus
Muscle —
is filled up with fat and deep lymphatic glands. The Anterior Crural
Nerve appears in the Muscular Compartment under Poupart’s Ligament, and
lies about 2/ 5 ths inch external to the Artery in Scarpa’s Triangle. This nerve
disappears under cover of the Sartorius Muscle and divides into branches which
supply the skin on the Anterior Aspect of the thigh, the Sartorius and the
Quadriceps Extensor. Deep to the Vessels and the Nerve lie the Ilio-Psoas and
Pectineus Muscles.
At the Apex of Scarpa’s Triangle, the Sartorius passes obliquely over
the vessels. This muscle has, therefore, to be drawn -aside in order to expose the
further course of both Artery and Vein.
The figure also shews the constituents of the Spermatic Cord: Vas Deferens
with the Vessels to the Vas, Spermatic Artery and the Pampiniform Plexus of
Veins, Cremasteric Vessels to the coverings of the Cords.
The Cremasteric Vein is of importance because it always communicates
with the Pampiniform Plexus, though it opens into the Deep Epigastric Vein
(Collateral Venous Channel).
Fig. 169. Inguinal Region, 4th Layer. Hernial Orifices, Iliac Bursa.

Male aged 60. The Spermatic Cord has been drawn out of the Inguinal Canal
and cut off. Vas Deferens (blue). Fascia of Penis is opened up and the Dorsal
Vessels and Nerves are exposed. External part of Fascia Lata has been removed.
Anterior Crural and External Cutaneous Nerves have been lopped off short.
A piece has been cut out of the I/io-Psoas to expose the Iliac Bursa (pink).
The Pelvis and Head of the Femur are indicated in dotted lines. The dotted
ellipse over the Head of the Femur indicates the position and size of the com-
munication between the Iliac Bursa and the Hip-Joint (in this case).

Immediately external to the Common Femoral Artery, but on a slightly

deeper plane, are the Ilio-Psoas Muscle and the Anterior Crural Nerve.
A
very large bursa (Iliac Bursa) separates the Ilio-Psoas Muscle from the
Horizontal Ramus of the Pubis and the Capsule of the Hip-Joint whereby the
Muscle plays over the edge of the bone without friction. The Capsule of the
Hip-Joint is weak at its point of contact with the Iliac Bursa, and in some cases
(1 in 10) there exists a communication between these 2 cavities.
This Bursa may extend some distance into the Pelvis which occurrence
is of practical importance in connection with primary disease of this Bursa. When
swollen the difficulty of diagnosis arises between enlarged lymphatic glands,
aneurysm of the Femoral Artery, or disease of the Hip. An accurate anatomical
knowledge of this bursa is the only clue to a correct diagnosis. Again inflam-
mation may spread from the Hip-Joint into the Bursa, via a direct communication,
by piercing the and further extend into the Pelvis.
thin septum,
The shews the important relations of the Hernial Orifices.
figure also
The fibres of the External Abdominal Oblique Muscle diverge at an acute angle,
and form the 2 pillars of the External Abdominal Ring. The Internal Pillar ends
in the middle line (or reaches to the opposite side) at the Symphysis Pubis by
sending fibres into the Suspensory Ligament of the Penis. The Outer Pillar is
chiefly inserted into the Pubic Spine. The angle between the diverging fibres
and the anterior aspect of the cord are covered by intercolumnar fibres which
hold the two pillars together. Poupart's ligament is a thickened fibrous cord
or rather a tendon or tendinous cord (the lower border of the External Abdominal
Oblique Muscle).
From the External Pillar and Poupart’s Ligament which are blended
together,many fibres spread in various directions, and to some of these names
have been applied. The fibrous mass which stretches across to the Fascia covering
the Pectineus Muscle, near the Spine of the Pubis, and forming a triangular
ligament with the base pointing outwards has been called GlMBERNAT’s Ligament
(Fig. 170). The fibres directed upwards and backwards to reach the bone, have
been called the Ilio-Pubic band. Both ligaments are usually blended together.
These structures are not constant, and their descriptions are most variable.
 External Abdominal Oblique Muscle

Tensor Muscle of Fascia Lata

Anterior Superior Iliac Spine

External Cutaneous Nerve

Iliacus Muscle
Rectus Femoris Muscle

Ilio-Femoral Band (Bertjni)

Anterior Crural Nerve

Ilio-Pectineal Fascia

Bursa Iliaca

Femoral Vessels

Internal Abdominal
Oblique Muscle

Femoral Ring

Ilio-Pubic Band

Fascia covering
Pectineus Muscle

Deep Femoral Artery

Spermatic
(Vas
Inferior Horn of Fossa
Ovalis (Saphenous Opening)

External Circumflex Artery

Dorsal Vein of Penis

Superficial Femoral

Long Saphenous Vein

Superficial Dorsal
Vein of Penis

Fascia

Sartorius

Fig. 169. Inguinal Region, left side, 4th Layer. Hernial Orifices. Bursa Iliaca.
7* Nat. Size.

Rebman Limited. London.

Rebman Company, New York.
 .

Rectus Femoris Muscle

Gluteus Medius and Minimus Muscles

External Abdominal Oblique Muscle

Anterior Inferior Iliac Spine

Internal Abdominal Oblique Muscle

Transversalis Abdominis Muscle

Ilio-Psoas Muscle

Anterior Crural Nerve

Head of Femur
Ilio-Pectineal Bursa

Fascia Transversalis

External Inguinal Fossa

Deep Epigastric Artery

Internal Inguinal Fossa

Cremaster Muscle
Obturator Artery

Femoral Ring

Gimbernat’s Ligament

Pectineus

Ilio-Pectineal Eminence

Edge of Glenoid Fossa

Obturator Canal
Posterior Division of
Obturator Nerve
Obturator Externus Muscle
Anterior Division of
Obturator Nerve
Adductor Brevis Muscle
Internal Circumflex
Vessels
Ilio-Psoas Muscle

Pectineus Muscle

Adductor Longus Muscle

Deep Femoral Vessels

Superficial Femoral Vessels

Long Saphenous Nerve

Sartorius Muscle

Long Saphenous Vein

Rectus Femoris Muscle Great Trochanter External Vastus Muscle

Fig 170. Inguinal Region, left side, 5th Layer. Subperitoneal Hernial Orifices.

Hip-joint. Obturator Region.

2
/;i
Nat. Size.

Ifcebman Limited, London. Rebman Company, New York.

Fig. 170. Inguinal Region, left side, 5th layer. Subperitoneal Hernial
Orifices. Hip-Joint. Obturator Region.

The Inguinal Region and neighbouring parts have been exposed layer by layer
in an adidt male; above Poupart’s Ligament the Subperitoneal Hernial Ori-
fices are exposed. At the level of Poupart’s Ligament Muscles and Vessels are

cut across so that the Muscular Compartment and the Vascular Compartment
(opening for Femoral Hernia) are seen. Below the Ligament on the inner side
a piece of the Pectineus has been cut out so that the opening of the Obturator
Canal (external opening of Obturator Hernia) is shewn ; on the outer side the
Hip-foint has been exposed and the joint cavity widely opened.

The Hip-Jointlies immediately external to the Artery but on a much

deeper plane. The Anterior Crural Nerve lies almost over the middle of the
Head of the Femur. The Head of the Femur can only be felt from in-front, in
very thin people. So that owing to its deep situation and its proximity to the
large vessels, the Hip-Joint is not very easily accessible from in front.
The Internal and External Circumflex Arteries, of considerable size, are
given off from the Deep Femoral Artery, but one of them, occasionally both,
may come off from the Common or Superficial Femoral Artery.
Internal to the vessels is a landmark of some importance. If the Pectineus
Muscle be removed the External Obturator Muscle is exposed as it arises from
the outer surface of the Obturator Foramen and the Obturator Membrane, and
runs outwards to the Digital Fossa. The Membrane closes the Obturator Foramen
except at its anterior and external angle; here a small gap hardly Y5 th inch in
diameter allows the Obturator Vessels and Nerve to pass. A
hernia may protrude
through the orifice - Obturator Hernia its —
position proves the difficulty of
diagnosis, and its close proximity to the Obturator Nerve sometimes causes pain
in the area of distribution of the nerve owing to pressure by the Hernia. The
figure also shews structures passing under Poupart’s Ligament which together
with the upper border of the Pelvis forms a large slit-like space divided
into two compartments by the Ilio-Pectineal Fascia. This fascia, which is derived
from the Fascia covering the Iliacus Muscle and accompanied the Ilio-Psoas down
to the Lesser Trochanter of the Femur, is firmly attached to the Ilio-Pectineal
Eminence. In the outer compartment is the Ilio-Psoas Muscle with the Anterior
Crural Nerve embedded in its anterior surface. In the inner compartment are
the Large Vessels and the Pectineus Muscle. Between the Femoral Vein and
the outer margin of GlMBERNAT’s Ligament there remains a small space filled
by loose connective-tissue; this is the Femoral Ring, the most important spot at
which the Peritoneum can readily be pushed forward and give rise to a Femoral
Hernia. Here we find situated the Deep Inguinal Lymphatic Glands, one of which
goes by the name of Cloquet’s Gland.
AFemoral Canal does not exist (as a preformed Canal) in normal sub-
jects. It is the result of the descent of a Femoral Hernia.
 ] * j ( (1
i < >(

’"g
O 1C l

g 2 C
d
G3
2 0 0)
dP
4-»
'00 Troch-
'S
G
t— 1
.2
0
O 0
be 2G 2 43
o
<4h
rO 0 0 d — t/3

So be <D
<D
0 0 & I

c 0 Co 0 0 o G 03
the
(D
d> 0 0 4-»
4->
1 —o 1
d
o 0 jp dP
c dP
4-»
X
03
£5 43
d 13
03 dd 0 <u
43
6 CJ r^* CO
X G O
C g O upwards
4->
• 1-1
• rH
dP
'(I)
0
0 £ M—
0
4-»
S
C/3
4-> 0 0 ’53
G C3 dp 0 G o
Uw 0
4-> £ D*". H dP 0 t/3
tu
Sw
03
X
0
0 0
rQ G3 43
o
43
03' 73 •o & G
< 0 73 d 0 G H
Line,

.£ 0 .0 g e X u o dislocated

s PP d 0 0
2d 'W
>
o
CD
73 _
r~]
4
03
«4-1
G 43
03

d 0 o 0
0 0 £ o
o
0 tu "g
rG
d
CO
2
1
0 43 0 0 is
’co
Pi
§
CO
G H CO O 03
Nelaton’s

dP w .2 o G
Vh C
Cu O
0
CG
.2
d
'S
CD 0 H ‘cu
*PU o 0 jd 0
0
X)
G dp
K m Femur

W d O 2CD o dd CU R G
0 o
0 oq 0 0 d 'T 1 u G
O
dP 4-J dP
4h
o above

0 N d tu sJ the

M-H
o
S
H
CD dP 43
4-J
G
P 43
4->
03
03
43
of
£ co
'p 0 be
H—
0 73 CD c Pd o 03

o fe 0 bjo 73 G CU
• H o 0 4-J
*d .0 73 Head

0 0 2 Cu ‘eo
d CU
<
'fl also
d d
d
0 A 0) 0 a
4-*
<4-H £ ffl 0 G o 4-> 03
CO 43
0 O o CD
dD
o 43 43 the must

03
73 CO r-| C o 03
G
0 H d Sw 03
If
-g
4->
0 H £ £ <
o o
0
2d 73
c
tu 0 o b/0
c
anter

dD 43 rd Ug
d be 73 d 4-> CD g

0 .to
dn CO 0 1 CO 4->
O
rt r~ 0 d d be £
4-J
u /— the
4->
d 0
U-l
O
03 CO
2 4-J
£ 2 Ph
2 Ph articular
brings

"d 5 O 4->
4-> CO of
G to 'd 0 0
4-» Ph 0 d Ph be Q
O d
G G
03
2
’> 4->
u o (J
.£ 73
w 0 0 4-J
‘C
o 0 rd G d 4-J surface
the
»7^
03
u ’o 0 dp 4-J 0 o .CO therefore

43 Ph 4-> 0
•
cu
r4 123
co
0 H <4H 0
Ph
fe
M0 £ dP
0 rQ
dP 73
0
‘co
of
ffl L 2
*CO
H-C
O dJ
4-> UP
0
0
o
u "O
d ‘0
bp
2
_
r~|

Ph the
Oh 5-3 4-> <4H *> d
CU CQ G 4-J
d G o
43
4J 2 £ torn
0
H-H
o 0 Gh^
2 0 0
Ph
Q removal

03 r~| ‘co 4-> r~|

from Hip-Joint

43
O G Pu
s
2
CO
rX
0
_

d
0 d
G
4-J
UC
4—
03

i> O 03 pH 0 cj G o 0
bß d CO
’d
G Sw o 43
0 o 0 o
CO Line The

O 03
4-»
*

Ss*
'S*
73
CO 4-J
sis
0 0 H-H
Vh 4-J
d
.£ ,r
p 2
Sh
«4H 0 G M-H
rd J-H Ph d the
<3 0 O r~| dd 4-> "d d .2 be #

&
43 4-J ^ 4->
0 Ph
r~|
+J o
_

X Ph 0 0 .£
43 o IP
d TV—
0 4_) of
•
§ 0 03 ’Ph rrt
44
0
CO G 0 Epiphyseal
short.

G d G
O 0
03
w te;
on
d
Ph .2 G 4->
0>
_
r~]
4H 73
CO

• —H o o 0 *CO d2
X
rD d 03
03
f—
to CO £ 03 0 d
Ü tn 43 Pj g ass
0
^
r~]
0 d
4-J
& very
excision

(U Ui 4— cu U— .to r*
03 rt s G Ph d2 G ‘to O
0 0 0 .£
S h-h £ the is
r-H
0) 4-> *d
0 O s 2 43
0
0
o
4-*
ctf § C
rd
£
d 4->
‘co *>0) CU Ph
73 of of
00 O 0 "d d 0
G 2 0 •s 'Sh d?
O *> 03
7d
0
rO d
0 M-h
G W d? 2 Femur

G 0 .> cases

o
45
o
c d
G
0 0 K d
0 4-J
01 Q3
r\
*C
d 2 distance

Ph 0 0 0 _
co

"g
o 5 dP
4-> 2G d
4-J
dP
4-J
4H 0
0
CO
2 the
in
M
0 03
to
2"* 2
’> CO CO
£
dP
o 0
X
0 of
M 2u 0 0
_

H
r-j
Si
43
4-> >
d 0
£ .£
#

dP
G 73
d
The

CU 0 d .2 4->
0
0 & *d CO
bio
• ^4 U
W
r
S
be
-1
.2
*0
dn
4-> dP
4-J
0
r-
G
0
u o
d
£
G
£
0
Ph
CO
Head
surface,
 London.

Limited,

Rebman
 Long Saphenous
Vein

Femoral Vein
Upper part of Sartorius
Muscle

Vein accompanying the

Femoral Vein
Superficial
Gracilis Muscle

Fascia Lata

Sem membranosus
i
Hunter’s (Adductor)
Muscle Canal

Tendon of Adductor
Magnus
Opening in Adductor
Magnus

Saphenous Nerve

Popliteal Artery

Anastomotica Magna
Artery

Popliteal Vein
Vein accompanying the
Popliteal Vein

Short Saphenous Vein

Internal Vastus Muscle

Adductor Tubercle on
Semitendinosus Muscle. Inner Condyle of Femur

Sartorius Muscle Long Saphenous Vein

Inner Head of
Gastrocnemius Muscle 'Saphenous Nerve

Fig. 173. Hunter’s Canal and Popliteal Space, left side, seen from the inner side. (Jobert’s Fossa.)

% Nat. Size.

Rebman Limited, London. Robman Company, New York.

Fig. 173. HUNTER’s Canal and Popliteal Space seen from the inner
side. (JOBERT’s Fossa.)

Left Leg of a girl aged if years. A piece has been cut out of the Sartorius
Muscle.

In the upper part of the thigh the Femoral Artery lies on the anterior
aspect of the limb, lower down it is on the inner side and finally on its posterior

aspect. In its course the Artery crosses the Femur at an acute angle. Above the
Artery lies internal and superficial to the head of the bone but subsequently it

approaches the inner side of the shaft, and gets on to its posterior surface. The
course of the Artery is almost in a line drawn vertically downwards whereas the
axis of the Femur is oblique, thus the crossing is brought about.

Above the Artery is in front of the Adductors but as these muscles, e. g.

Pectineus, Adductor Longus and Adductor Magnus, are inserted by a broad

membranous tendon along the entire length of the Linea Aspera from the Lesser
Trochanter as far down as the Inner Condyle, the Artery must pierce this tendon
in order to reach the posterior surface. This occurs in the Adductor or Hunter’s
Canal. Below the apex of Scarpa’s Triangle the Artery is covered by the Sar-
torius Muscle and rests upon the Adductor Longus Muscle. About the middle
of the thigh it reaches Hunter’s Canal which is formed by a strong Aponeurosis
spreading from the Adductor Longus and Magnus Muscles over the Vastus Internus
Muscle. At the end of this canal the arter}^ pierces the Adductor Tendon. This
canal bounded in front by the Aponeurosis mentioned, behind by the Adductor
I.ongus and Magnus is about 2 inches long and terminates at the junction of the
middle and lower thirds of the thigh. The Long Saphenous Nerve enters the
canal with the Artery but perforates, in conjunction with the Great Anastomotic
Artery, the Anterior wall of this Canal about its middle. Two accompanying
Veins pass through the Canal with the Artery: of these veins, one is usually very
diminutive. The 3 Perforating Branches of the Deep Femoral Artery perforate
the insertion of the Adductors in a similar way, to gain the posterior aspect of
the Thigh.
For operations — e. g. in cases of Acute Osteomyelitis — which require
exposure of the Femur throughout its extent, the outer side is chosen because
internally and anteriorly the large vessels are in the way; on the anterior aspect
the upper cul-de-sac of the Knee-joint may be injured, posteriorly the Sciatic Nerve
and lower down the vessels. On the outer side there are no important Vessels
or Nerves.
Figs. 174 and 175. Transverse Sections through the Thigh at the end
of the upper and middle thirds.

Frozen Section.

Three powerful groups of muscles surround the thigh and enclose it so

completely that the Great Trochanter and the Condyles alone remain subcutaneous.
In front, the Quadriceps Extensor (Rectus arising from the Anterior Inferior Spine
and brim of the Acetabulum, Vastus Internus, Vastus Externus and between these
the Crureus arising from the Femur); internally, the Adductors (Adductor Brevis,
Adductor Longus, Adductor Magnus, Pectineus and Gracilis) arising from the
Pelvis behind, the Flexors (Biceps, Semimembranosus, Semitendinosus) arising
;

from the Tuberosity of the Ischium with the exception of the Short Head of
the Biceps.
The Extensors
increase in mass as far as the lower third because they
from the Femur. The Adductors diminish regularly until they
receive fibres
merely form a tendon at the Knee-joint. The Flexors are reinforced by the
Short Head of the Biceps and diverge at the Popliteal Space to the outer and
inner sides respectively.
A very strong fascia surrounds the muscles of the thigh enclosing them
so tightly that after division of the fascia the muscles protrude through the slit,

like a hernia. The fascia is strongest on the outer side because it receives the
tendinous expansion of the Tensor of the Fascia of the Thigh, and of the Gluteus
Maximus. From the Fascia two membranous Septa stretch to the bone, thus
dividing the muscles into 2 groups: the External Septum extending from the great
Trochanter along the outer lip of the Linea Aspera down to the External Condyle;

the Internal Septum from the Lesser Trochanter along the inner lip to the Tendon
of the Adductor Magnus. The figures shew the different positions of the Femoral
Artery. In Fig. 174 it lies just above the slit in the Adductor on the inner side,
and slightly anterior to the Bone. In Fig. 175 it has already reached the posterior
aspect of the Bone. The Deep Femoral Artery is still visible as a large vessel
in Fig. 174 between the Adductor Longus and Adductor Magnus. It diminishes

rapidly in size by giving off the Perforating Arteries.

While the Anterior Crural Nerve divides rapidly into its branches so much
so that the main trunk is no longer evident in our figures, the Sciatic Nerve
remains distinct on the back of the thigh, being well surrounded by fat and lying
in the triangular space between the Adductors and the already diverging Flexors.
In Fig. 175 the nerve has already divided into External and Internal Popliteal
Nerves, which, however, lie in close apposition.
The Adductors and Flexors are less distinctly separated from each other
than they are from the Extensors. The .Sartorius has throughout its course a
formed by the splitting of the Superficial layer of the Fascia. This
special canal,
statement holds good also for the Gracilis and Rectus in the upper part of
the thigh.
The thin special fasciae of the Flexors and Adductors are easily perforated
by pus. They are practically lymph spaces between the muscles and their neigh-
bouring parts.
 Rectus Femoris Muscle; Internal Vastus Muscle

Crureus Muscle Long Saphenous Nerve

Sartorius Muscle

Superficial Femoral Artery

Adductor Longus Muscle

Long Saphenous Vein

External Vastus Muscle

Gracilis Muscle

Adductor Magnus Muscle

Long Head of Biceps

Sciatic Nerve
Semimembranosus Muscle
Semitendinosus Muscle

Fig. 174. Transverse Section through the Junction of

Upper and
Middle thirds of the (right) Thigh.
Seen from below. — 2
/3 Nat. Size.

Rectus Femoris Muscle Crureus Muscle

Periosteum of Femur
External Vastus Muscle

Internal Vastus Muscle

Adductor Magnus Muscle

External Inter-
muscular Septum
Internal Intermuscular
Septum

Femoral Artery
Short Head of Biceps
Muscle
Saphenous Nerve

External Popliteal Hunter’s Canal

(Peroneal) Nerve

Sartorius Muscle
Internal Popliteal
(Tibial) Nerve
Long Saphenous Vein

Long Head of Biceps Muscle Gracilis Muscle

emimembranosus Muscle

Semitendinosus Muscle
Femoro-Popliteal Vessels (cf. Toldt, Note 313)
Small Sciatic Nerve

Fig. 175. Transverse Section through the Junction of Lower and

Middle thirds of the (right) Thigh.
4
/6 Nat. Size.

Rebman Limited, Loudon. Rebman Company, New York.

 External Intermuscular
Septum
Superior Pouch of Joint

Fascia Lata

Internal Vastus Muscle

Superior External
Articular Artery
Biceps Muscle
Patella

Subcutaneous Popliteal Vein

Prepatellar Bursa

Popliteal Artery
Subfascial
Prepatellar Bursa

External Condyle Plantaris Muscle

Tendon of Popliteus
Alar Ligament Muscle

Lateral Ligament
External Semilunar (External)
Cartilage
Inferior External Popliteus Muscle
Articular Artery
Bursa
Ilio-Tibial Band
Tibio-Fibular
Biceps Muscle Articulation
Peroneal Nerve
(Ext. Popliteal)
Deep Infrapatellar Outer Head
Bursa Gastrocnemius
Muscle
Patellar Ligament
Soleus Muscle

Anterior Tibial Muscle

Peroneus Longus
Common Extensor of Muscle
Toes

Fig. 176. Left Knee-Joint and Surrounding Structures.

Seen from the outer (left) side. — 3
/i
Nat. Size.

Rebinan Company, New York.

Rebman Limited, London.
Fig. 176. Left Knee-Joint and Surrounding Parts. Seen from the
outer side.

Preparation made from a female aged 15 years. Plaster of Paris had been
injected into the Knee-Joint.Boundaries of the Joint-Cavity (pink) ; the Tibia-
Fibular Articulation which does not communicate with the knee-joint, dark red.
The independent bursae around the knee-joint (blue). The lower parts of the
Vastus Externus and Biceps Muscles have been removed ; the attachment of the
Ilio-Tibial Band and the insertion of the Biceps into the Head of the Fibida
and into the Tibia are preserved.

The Fascia Lata of the thigh is continuous with the Fascia enclosing the
leg, and is reinforced by a broad strand of fibres the Ilio-Tibial Band of Maissiat,
which is derived from the Tensor of the Fascia of the Thigh and some fibres of

the Gluteus Maximus Muscle ;

this Band runs down to the Tibia, and blends with
the Capsule of the Knee-Joint. It checks Adduction of the Thigh. The figure
shews the extent of the Knee-Joint Cavity and of the upper cul-de-sac, which
practically always communicates with it, distended as is the case in serous, purulent
or haemorrhagic exudations. One observes that the greatest extension of the joint
is possible in the forward direction. A tense effusion pushes the Patella and the
Common Extensor Tendon away from the bones, so that, under these conditions,
the Patella is not in contact with the underlying bones but rides or dances on
the fluid. Laterally no great degree of bulging is possible, firstly, because the
Synovial Cavity does not reach far either upwards or downwards over the joint-
slit ;
secondly, because the extremely strong lateral ligaments are tightly stretched.
Posteriorly around the Condyles of the Femur, the capsule is more extensible.

In addition to the Prepatellar Bursa (cf. explanation to Fig. 18 1), and the
deep Infrapatellar Bursa, which lies between the Tibia and the Ligament of the
Patella, the almost constant External Inferior Bicipital Bursa is shewn lying be-
tween the Biceps Tendon and the External Lateral Ligament. Like the bursa
above mentioned, this never communicates with the Knee-Joint.
Further, the vessels which take part in the anastomosis on the outer side
of the knee-joint are visible.

The blood-supply of the Anterior Aspect of the Joint which has to bear
much pressure (e. g. in kneeling) is abundant.
On the inner side, the Superior and Inferior Internal Articular Arteries,
on the outer side, the Superior and Inferior External Articular Arteries, form the
Anastomosis which is reinforced by the Great Anastomotic Artery, and the

Recurrent Tibial Artery.

The Anastomosis is partly superficial between the Patella and the Skin,
partly deep between the Tendons and the Ligaments.
 Fig. 177. Sagittal Section through the Knee-Joint during Extension.

Frozen Section through the External Condyle of the Femur and the Tibia; the
Patella is not cut along its greatest longitudinal axis.

The Knee-Joint is easily accessible from in front or either side, only on

its posterior surface, do we find large muscles and between them important Nerves
, and Vessels. This Synovial Cavity is the largest in the body; moreover, it is the
most complex joint on account of its various Intrinsic Ligaments.
The insertion of the Capsule is different on all sides. The joint-cavity
3
extends highest in front, as far as 1 J to
1
2 /i inch, above the margin of the
Patella, if we take into account the Subcrureal Bursa, which nearly always com-
municates with the Joint. On both sides (cf. Fig. 180), the insertion of the Capsule

reaches close to the line of the joint, posteriorly, it extends upwards as far as the
upper limit of the Condyles of the Femur, below it follows the Tibia to a lesser
extent. Thus the anterior and posterior surfaces of the Femoral Condyles are
within the Synovial Sac, but not so their lateral surfaces.
The anterior wall of the Capsule is formed above by the Tendon of the
Quadriceps; between this tendon and the anterior surface of the Femur there is

always a Bursa which is of importance because it communicates, occasionally in

children, but invariably in adults (98 %), by a more or less wide opening (cf. course
of a director in the figure), with the Joint-Cavity. This Bursa may, therefore, be
regarded as a part of the Joint-Cavity, and be called the upper cul-de-sac of the
Knee-joint. Accumulations of fluid within the Knee-joint cause bulging at this
spot. Below the point of insertion of the Quadriceps Extensor to the upper
border of the Patella, the wall of the joint is formed by the cartilaginous covering
of the posterior surface of this bone. The Ligamentum Patellae attaches the lower
border of this bone to the Tubercle of the Tibia. Between it and the Tibia lies

the deep Infra-patellar Bursa which does not communicate with the Joint on
account of its being separated by a large Synovial-fold — Plica Synovialis Patellaris.

This is attached to the Intercondylar Fossa (Crucial Ligaments) by sagittal fibres.

Between the Tibia and the Femur, the External Semilunar Cartilage is

seen in the figure, its inner concave margin is sharp, its external convex margin
is firmly connected with the capsule of the joint.
 -

Quadriceps Extensor
Tendon

Subcrureus Muscle

Femur

Popliteal Artery

Bursa under Quadriceps

Extensor

Internal Popliteal Nerve

Patella

Prepatellar Bursa

— Patellar Ligament

External Semilunar
Cartilage — Ligamentum Mucosum

Infrapatellar Bursa
Gastrocnemius Muscle.

Fibula-
— Tibia

Anterior Tibial Artery -

5 A- \>

Fig. 177. Sagittal Section through the (left) Knee-Joint during extension.
Seen from the inner (right) side. — 2
/3 Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Rectus Femoris Muscle

Superior Pouch of Joint. — Subcrureus Muscle

Tendon of Q Femur
Extensor

Patella
Internal Vastus
Muscle
Subfascial
Short Head of
Prepatellar Bursa
Biceps Muscle
Subcutaneous
Prepatellar Bursa
Anterior Crucial External Popliteal
Ligament (Peroneal) Nerve
External Semilunar
Cartilage Popliteal Vessels

Ligamentum
Internal Popliteal
Mucosum
(Tibial) Nerve
Popliteus Muscle
Short Saphenous
Vein
Ligamentum Patellae
Internal Sural
Cutaneous Nerve
Deep Bursa under Patella

Gastrocnemius Muscle
Tibia

Subcutaneous Bursa over. Soleus Muscle

Tubercle of Tibia

Peroneal Artery

Posterior Tibial Muscle

Interosseous Membrane

Anterior Tibial Muscle

Fig. 178. Sagittal Section through the (left) Knee-Joint during flexion.
Seen from the outer (left) side. — 3
/i Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 .

Fig. 178. Sagittal Section through the Left Knee-Joint during

Flexion.

This preparation was made from a man aged 82 years. Formol was injected

into the limb, and the knee, forthwith, flexed to its utmost limit, was kept in

that position. On the following day the section was made without freezing.
In spite of advanced age and a high amputation through the right leg this joint
was quite normal.

In contrast with the extended position (Fig. 177) this figure indicates the
relations during' extreme flexion. As the section has been carried almost through
the middle of the joint, a larger part of the Intrinsic Ligaments is shewn than
in Fig. 177.
As the Patella is fixed by the Ligament of the Patella to the Tibia, the
Patella leaves the Anterior Surface of the Femur during flexion, and comes to

lie in front of the Joint-slit, which it does not cover during extension. The Capsule
is folded backwards, and the Vessels and Nerves are extremely bent. To such
frequent bendings of an imperfect elastic arterial tube, is attributed the main cause
of the not-uncommon aneurysm of the Popliteal Artery. Of the 2 Crucial Ligaments,
the figure exhibits the Anterior : this extends from the depression in front of the

Spine of the Tibia (Anterior Intercondylar Fossa) upwards, outwards and back-
wards to the inner side of the External Condyle; its function, like the Posterior

Crucial Ligament, is to check excessive rotatory movements. The Plica Synovialis

Patellaris fills up the space between the Patella, Articular Surface of the Tibia,
and the Crucial Ligaments.
One of the most striking changes which occurs in this joint during flexion,
is relaxation of the External Lateral Ligament — this is not seen in the figure —
Attached to the Femur eccentric to the axis of flexion, this ligament becomes tense
during extension and prevents rotation, but during flexion it is relaxed and allows
inward rotation of the leg. These movements, however, are limited by the Crucial
Ligaments. A glance at the figure shews its complexity. Contrary to the other large
joints, which either have a free joint cavity or are at the outset traversed by one tendon
(e. g. Shoulder, by tendon of biceps, Hip-joint by Ligamentum Teres), the interior

of this joint contains a complicated arrangement of ligaments which lead to the

formation of numerous pouches. In cases of suppuration in the Knee-joint, the
purulent products, therefore, tend to remain in these recesses and clefts, and are
only removed with difficulty.
 H

c/3

0 0 cti « 2
P.
O on 0 (cf.

Co
C/3 p 0
C/3
fp p-h
E Bursa

>1 c/3 o3 c/3

Ph 5h TP p EE
p PP P c/3

Ph P PP
13 )h
<ö
CJ Ph
-J-» 0 aj & T!
Ph
oj c<
0 be 0 cavity

'E
’

TP
1

Joint. 'O W w ^C/3

pp
P
c 4-J
p
the

0 u 0
"P P 0 ’c/3
H 0 )
pp
4-J
of
joint
<0 <3 pp EE p:
O 4-J
0 &
the
PP & 1

C/3
*a
W 0 E =1
<D
0)
of U 0 G
the
-O aj «-M
cS
CD
PP 0 pp
0 El 0 PP s communication

IS pp +->
PP
C /3

d 0 with
S-H
Cl
50
4-
H MH
O
P4
u
pp
4-J
Capsule
*3 0 0 0 TP TP 0
<»
pp p c p
o pp
15 td 0 o & TP
.'u
pp 0 Pp P
^
T3
=o
0
0
Ph
03
EE
C/3

>1
-P
pp
ip
0 the
Muscle

Pi pp C/3

"d o —P 0 £ PP
the
S’
aj
c 0 PP
’IS Ph PP
Cj d u
§P O g W _ C/3
73 0
4-J
Jh
0
to 4->
C/3
0 p oj
shews
Text).

S' PP c 0 u 4-J
d PP G
<5 be 0 0 Cl)

Ph p. 0
int a CO 0
0 <4-1 184,

0 0 Semimembranosus

[PP
PP be
p
£ 0)
E4-»3 _P
figure

C/3 C/3
±i pp
<u 0 0 0 0
<u pp Sh PP JE P joint. Fig.
Ö p O d
0 0 the
a bo > o
u
be
p 0
C/3
P
Jh
c^
d
CD
Jh
pp
4-J

the
and
be CO <D
<D Ph
P
o
C /3 TP 0 2 the
4->
£ ^ E TP
0 u ' - PP
p
0
Ph
P
"0
£
C/3 Lastly, 183

<0 > 0 CO 0 fe d u
p bo +H o pp Pd
C/3
<D opening

Ph E +-> .&> p 0 0 under

p
PQ to
co
0
0 'S e E pp
pp
4-J
i§
CD
Fig.

be
p 5$

o CS o 0 p h-P TP 0 be
> H—
pp Ph Ph
I'- 0 PP for
0
cö 0
w w 1-1

0 Epiphyseal

«
m £
^5
0
PP
PP _be o
connection

TP Ph P E Pi
Ph be
because

m h
1 therefore,

Jp o P SP

A S-i
Ph P o
E 8E < 0
Ph
in
a, CO
this

W P
0 P
<1 be
p of
CO 0 persons,
can,
0 *e» •+<, £ TP
'0 important

.o
^ £
PP
Ph
E p Ph <«
pp

E o a" P P
o Ph c 0 piece

W iS pp u
<1 0 0 is preservation

0
hP
H 0 0 pp
Ph
Ph
f rb>
Jh
G
young

0 pp pp > point
s
"Si
e TP •B
p ^
03
EE in thicker

0> bo E -5 0 CO
g3
p 6 0 Ph 0 03
u CD this

Pi Ph PQ c c/3
EE
El 00 PP
be (D
<v length

A
P •>, CO 0 C/3 E3
hP“ Ph p d 0 EE oj
§ P 03
)

_
Knee-joint

O 0 .’^0 P3 CJ
u
J-H

EE EE Tibia; in
•HH
H P G w b
00
H s<,
0 E 0 0 Vh
O P
.2
CO

T3 bQ pp E^ ^ 2 •E
p d G 3 ^ .S P=l
Ph
the
the
Femur

C/3 indispensable.

EE TP TP
rt
" 'E of
O'
03
0
5 Cj
CD
Eh
P
O
>1
£ O
>
W of the
,hh
H P
H E Ph 0)
.2 d +j E
-c
CL*
of
in
2 E 03
EE .5
CD"
’c/3
.2
c u
5

O
TP
P
Epiphysis

is
bfl E PPh i£
0 d PP <P Excision

•
—
1
c/3
03
0
l-J
0 P growth

P *13 'Ph CJ 1h
3
PP
C/3

"O
pp
o .22
c/3
O 03
c^ W EE
4-J
G w H Cartilage

O is -P 03
£ Upper

1? 0 4-J
X 0 with

I Ph 5 15
4-J
It '1
03
0
M-
the the
 s

.3
O 44
“D i

<x>
<D

«
/—

£
|3
*G 03
CQ
a?

00 O
3 "Ö ^
UD
3
g>
bß
Ä
<£
^ c3 <3

5 >>
3 O I
'

« w ^
i
- I
*8 -

0Q

o
CD

— CJ
&D
,jS

5
bß
—
</) -f:
S
go
 Patella Prepatellar Bursa
Ligamentum Mucosum

«BS?

Joint-Capsule

JmEutommtom
ÄÄt® Ä
//O'lfö/:)/' wffi fc
5 -5f'«SC

Internal Lateral Ligament

External Lateral Ligament

Posterior Crucial Ligament

Sartorius Muscle
»I ^i^vy
f 1

^
Anterior Crucial Ligament

External Popliteal Nerve

Gracilis Muscle External Plead of Gastrocnemius Muscle

Ramus Communicans Tibialis
Semimembranosus Muscle and Bursa Internal Popliteal Nerve
Semitendinosus Muscle Popliteal

Internal Head of Gastrocnemius Muscle

Fig. 181. Transverse Section through the right Knee-Joint.

Seen from above. — 7
/io Nab Size.

Figs. 182 and 183. Lymphatics of the Popliteal Space. v* Nat. Size.

Eebman Limited, London. Rebman Company, New York.

 Fig. 181. Transverse Section through the Knee-Joint.

Frozen Section.

This frozen section shews the Prepatellar Bursa (Subcutaneous and Subfascial Com-
partments), the lateral ligaments and anterior to these, the Retinacula of the Patella, which
strengthen the Capsule. These Retinacula become of importance in Fracture of the Patella.
When the Patella is broken transversely, the functional impairment of the Extensor Apparatus
will depend on the extent of the destruction of these Retinacula.

Figs. 182 and 183. Lymphatics of the Popliteal Space.

Fig. 182. From a ?nan aged 41 years. — Fig. 183. From a wo7nan aged 60 years.

Normally there occur in the Popliteal Space more Lymphatic Glands than are usually
stated (3 — 5);
they are easily overlooked on account of their small size and the difficulty of
their dissection in fat subjects. They may be divided into three groups (of at least one gland
each"): a Superficial group between the External Saphenous Vein and External Popliteal Nerve,
separated from the latter by a thin fascia — the Superficial Popliteal Gland. The greater
number lie close to the Popliteal Vessels under cover of the Internal Popliteal Nerve the —
Deep Popliteal Glands. Variable in position is a gland below the vessels which receives the
bulk of the lymphatics of this space; whereas the Afferent Lymphatic Vessels to the different
groups of glands are fairly constant, there is much variation in the Efferent Vessels. Therefore
different cases are depicted.
In Fig. large Lymphatics, accompanying the Short Saphenous Vein, join the
182,
Superficial Gland; one Efferent Lymphatic extends upwards with the Femoro-popliteal Vein,
another Efferent Lymphatic divides and joins the Articular Gland, which thus becomes a second-
ary gland to the Superficial as well as to the Deep Gland and the Lymphatics of the
Joint. The large Efferent Vessel opened, in this instance, into the Efferent Tract (first mentioned),
of the Superficial Gland and extended upwards as a stray vessel, to 4 inches beyond the figure,
under cover of the fascia. After piercing the fascia it divided into 5 branches, and after a
curved course opened into the Lower Internal Group of the Superficial Inguinal Glands.
The arrangement of the Lymphatics in Fig. 183 is similar. The Afferent Vessels join,
in this case, to form a thick trunk which passes with the Popliteal Vein through the opening
in the Adductor Magnus. Between these two extremes there are endless variations, both paths
being used in equal or unequal proportions at the same time. We are not satisfied of the
presence of a third path; if such were employed it would, theoretically, lead along the Great
Sciatic Nerve to the Pelvic Glands. The Lymphatics of the lower extremity begin at the foot
and follow, in front and on the inner side, the Long Saphenous Vein; on the posterior aspect
they partly pass over the Popliteal Space and go to the inner side; partly, as shewn in the
figure, to the Popliteal Space, under the fascia, accompanying the Short Saphenous Vein.
So that these Lymphatics may reach the Deep Inguinal Gland by following the
Popliteal and Femoral Vessels, or join the Superficial Inguinal Glands after having pierced
the fascia.
In Fig. 183, the Bursa in connection with the Semimembranosus Muscle has been
opened and the Bursa under the Inner Head of the Gastrocnemius is shewn projected through
that Muscle. Both communicate at the red spot which is marked by a f. We were unable
in these cases and in 8 others, to shew any communication between these Bursae and the
Knee-joint.
It, therefore, seems doubtful whether this Bursa communicates (in %rd or 1
/2 of all

cases), with the Joint as is stated in the books.

Weak spots in the Capsule favour the perforation backwards in pathological cases;
in the removal of Hygromata, the joint is frequently opened on account of the tenuity
of its wall.
 Fig. 184. Popliteal Space.

The immediate continuation of the Fascia Lata is known as the Popliteal

Fascia which, after covering the Popliteal Space, becomes directly continuous with
the Fascia of the leg. On this lies the Short Saphenous Vein which sinks into
the Popliteal Space and opens into one of the Popliteal Veins. After removal of
this fascia, the Popliteal Space is exposed. This space is formed by the diverging
Flexors of the leg (Biceps on the outer side inserted into the Head of the Fibula,

Semimembranosus and Semitendinosus on the inner side inserted into the Crest of
the Tibia), while out of the depth of the space, emerge the two converging heads
of the Gastrocnemius. In this way a lozenge-shaped space is formed (void of

muscles), which contains, well surrounded by fat, the Large Vessels and Nerves.
The most superficial structure is the Internal Popliteal Nerve which traverses the
space almost vertically, to disappear, after giving off its Communicating Tibial
Branch, under cover of the Gastrocnemius Muscle. The division of the Great
Sciatic Nerve into Internal and External Popliteal Nerves, has occurred at about
or above the middle of the thigh. While the Internal Popliteal Nerve passes
almost vertically downwards in the middle line, the External runs downwards and
outwards along the inner border of the Biceps Muscle.
Somewhat internal and on a deeper plane is situated the Popliteal Vein,
i. e. the largest of the 2 or 3 Veins which accompany the Artery; this vein is

closely bound down to the Artery by connective-tissue. The Artery lies at a still

deeper plane and more towards the middle of the space, it is here separated by
a layer of fat, '/
2 inch thick, from the Femur; near the articular surfaces of the

Tibia it is closely applied to the capsule of the joint. Now the artery, having left

the middle line, lies somewhat to the outer side (cf. Fig. 181). In cases of Excision
of the Knee-joint, it could only be wounded at this spot. Its branches are the
Superior and Inferior Internal and External Articular Arteries and the Azygos
Articular Artery which pierces the posterior wall of the Capsule.
Close to the Internal Popliteal Nerve, is a small Lymphatic Gland: another
may lie subcutaneously on the fascia, but there are rarely ever more than 4
(cf. Figs. 182, 183).

This figure also shews the Bursa under the Inner Head of the Gastro-

cnemius Muscle, which may communicate with the Knee-joint (Fig. 179). (Cf. Figs. 182

and 183, Text.)

This is of importance, because this Bursa may be the seat of a Hygroma

which needs removal. It is, therefore, possible to infect the Knee-joint during an

operation on this Bursa.

 Cutaneous Branch of
Small Sciatic Nerve
Obturator Nerve

Superficial Popliteal
Sartorius Muscle Lymphatic Gland

Femoro-Popliteal Vein
Gracilis Muscle (Tributary of the Short
Saphenous Vein)

Semitendinosus Muscie
External Popliteal Nerve

Popliteal Vessels Internal Popliteal Nerve

Semimembranosus Plantaris Muscle

Muscle

Bursa between Internal Biceps Muscle

Head of Gastrocnemius
and Semimembranosus

Ramus Communicans
Long Saphenous Nerve Tibialis

Short Saphenous Vein

Long Saphenous Vein

External Head of
Internal Head of Gastrocnemius
Gastrocnemius

Ramus Communicans
Small Sciatic Nerve Fibularis

Dy Frohs”

Fig. 184. Popliteal Space on the right side.

IJ

/ 10 Nat. Size.

Kcbman Limited, London. Rfebman Company. New York.

 Anterior Tibial Muscle Interosseous Membrane

Common Extensor Muscle of Fingers Posterior Tibial Muscle

Anterior Tibial Artery Tibia

Anterior Tibial Nerve Tibial Artery

Musculo-Cutaneous Nerve

Tibial Nerve

Peroneus Brevis Muscle

Peroneus Longus
Muscle
Popliteus Muscle

Fibula

Tendinous Arch of
Soleus Muscle
Long Saphenous Vein

Outer Head of
Gastrocnemius

Long Saphenous Nerve

Ramus Communicans
Fibularis

Muscular Vein (Varicose Vein)

Soleus Muscle

Internal Head of Gastrocnemius Muscle

Ramus Communicans Tibialis
Plantaris Muscle

Short Saphenous Vein Fascia of Leg.

Fig. 185. Transverse Section through the right Leg at the Junction of Upper and Middle thirds
Seen from below. —
-
Nat. Size.

Anterior Tibial Artery

Tibial Muscle
Long Extensor of the Big-

Anterior Tibial Nerve

Long Extensor of the Toes

Long Saphenous Vein

Tibia
Anterior Peroneal Artery

Posterior Tibial Muscle

Fibula

Long Flexor of the Toes

Peroneus Longus Muscle Posterior Tibial Artery

Posterior Tibial Nerve

Peroneus Brevis Muscle

Short Saphenous 'Vein

Long Flexor of the Big-Toe

Tendo’ Achillis

Fig. 186. Transverse Section through the right Leg near the Ankle.
Seen from below. — Nat. Size.
Rebman Limited, London. Rebman Company, New York.
Figs. 185 and 186. Transverse Sections through the Leg at the begin-
ning of the middle third and near the ankle.

Frozen Sections.

The Fasciae (blue) in Fig. 185, shew that on the Anterior aspect of the
limb, the Extensor Group of Muscles arise from fascia; on the Posterior aspect
from the Fascia enveloping the limb, and forming a special canal for the Short
Saphenous Vein; the particular Fasciae of the Muscles are represented.
At a higher level this Fascia is continuous on the flexor aspect with
muscular attachments: on the outer side, with the expansion of the Biceps Tendon
internally with the expansion of the Sartorius, Gracilis and Semitendinosus Tendons.
The circumference of the leg diminishes below the middle as the muscles
become tendinous, thus near the ankle there are practically only tendons and bones.
In the subcutaneous tissue, the Long Saphenous Vein on the inner, and
the Short Saphenous Vein on the posterior surface are observed. The Fascia,
which is a continuation of the Fascia Lata, is only interrupted by the Anterior
Surface of the Tibia as it becomes intimately blended with the Periosteum. On
the An tero- external aspect the Fascia sends a septum to the Fibula, which sepa-
rates the Peroneal Muscles from the Extensors. A deep layer passes transversely
across from the Posterior Surface of the Tibia to the outer surface of the Fascia,
this layer lies deep to the Soleus and Gastrocnemius Muscles, which it separates
from the still more deeply situated Flexors. Above the ankle this layer is very
strong and binds the Flexors down to the Bone; the Tendo A chillis becomes
more prominent near the Os Calcis. The space formed in this way is filled by
large pads of fat. The Internal Surface of the Tibia is palpable throughout its
whole extent being only covered by skin and thin superficial fascia. The other
surfaces of this triangular prism of bone are covered by muscles. The Fibula is
completely surrounded by muscles except the Head and a triangular surface above
the External Malleolus which are subcutaneous.
The bond of union between the Tibia and Fibula is very firm. The upper
Tibio-Fibular Articulation allows of scarcely any movement; this joint may com-
municate with the Bursa under the Popliteus Muscle and indirectly with the Knee-
joint. Lower down these two bones are held together by a very strong Interosseous

Membrane, whereas in the lower third, the union is yet more firm.
Near the ankle, so firmly are these bones held together, that they may
be viewed as one while the Inferior Tibio-Fibular Articulation is rather to be con-
sidered as an excavation of the Ankle-joint, than as an independent joint.
In the upper third of the leg, of the 2 most important vessels w hich require
7

ligation, the Anterior Tibial Artery is easily found on the Posterior Surface of
the Posterior Tibial Muscle in the Neuro- Vascular Bundle; external to this is the
Peroneal Artery.
 Fig. 187. Outer Aspect of Leg. External Popliteal Nerve.

On the outer side a larger window has been cut out of the fascia; portions
have been removed from the following muscles: Anterior Tibial, Long Extensor
of the Toes, Long Extensor of the Big Toe, Long and Short Peroneal Muscles,
so that portions of the Tibia and Fibula have been exposed.

The Anterior Aspect of the Leg is occupied by the Extensor Muscles of

the Foot; the External Surface of the Tibia is covered by the Anterior Tibial
Muscle and the Long Extensor of the Toes. About the middle of the leg, the
Long Extensor of the Big Toe appears between these two muscles and in these

relations the Tendons pass under the Annular Ligament, on to the Dorsum of

the Foot.
On the outer side, the 2 Peroneal Muscles which arise from the Fibula
pass down, as tendons, behind the Outer Malleolus. The large Vessels and Nerves
are on the Flexor Aspect (cf. all large joints). Their branches to supply the
anterior aspect of the leg pass to the front from the Popliteal Space by various
routes. The Anterior Tibial Artery passes directly forwards over the upper margin
of the Interosseous Membrane, and runs downwards upon this Membrane lying at
first between the Anterior Tibial Muscle and Long Extensor Muscle of the Toes,

then between the former and the Long Extensor Muscle of the Big Toe. In the
lower third this tendon crosses the Artery obliquely, so that finally the Artery
reaches the Dorsum of the Foot by passing below the Anterior Annular Ligament
between the Long Extensor Muscles of the Toes and Big Toe.
The External Popliteal Nerve takes quite a different course, coming off

the Great Sciatic Nerve at or above the middle of the thigh this nerve passes
towards the outer boundary of the Popliteal Space and perforating the Long
Peroneal Muscle winds around the head of the Fibula and appears on the anterior
aspect of the Leg. In its course this nerve divides into a Superficial and a Deep
branch; the former — Musculo-Cutaneous Nerve supplies the Peroneal Muscles
and pierces the deep fascia at the junction of the middle and lower thirds of the
Leg, whence it runs down to the Dorsum of the Foot as a Cutaneous Nerve.
The Anterior Tibial Nerve passes obliquely through the Origin of the Long
Extensor Muscle of the Toes, and runs downwards on the outer side of the
Artery; lower down the Nerve crosses in front of the Artery and lies antero-

internal to it at the ankle-joint. In its course it supplies the three Extensors on

the front of the Leg.

The position of the External Popliteal Nerve passing round the head of

the Fibula requires great care in operations on the upper end of the Fibula
because a deep longitudinal incision would divide the nerve.
 Tendon of Quadriceps Muscle

Short Head of
Ilio-Tibial Band
Biceps Muscle

Long Head of Biceps

Patella
Muscle

Outer Head of Gastrocnemius Ligament of Patella

Muscle (Tendon of Origin)

External Popliteal Nerve Insertion of Biceps into Tibia

Head of Fibula Long Extensor Muscle of Toes

Peroneus Longus Muscle Upper portion of Anterior Tibial

Muscle

Outer Head of Gastrocnemius Tendinous Arch for Anterior

Muscle Tibial Nerve

Soleus Muscle -Anterior Tibial Artery

Musculo-Cutaneous Nerve .Superior portion of Long

(Branch to Peroneus Brevis) Extensor of Big-Toe

Tibia
Fibula

Interosseous Membrane
Peroneus Brevis Muscle

Periosteum (Fascia of Leg)

Ramus Communicans Fibularis

Inferior portion of Long

Fascia of Leg Extensor of Big-Toe

.Lower part of Long Extensor

Peroneus Longus Muscle Muscle of Toes

Lower part of Anterior

Anterior Intermuscular Septum - Tibial Muscle

Fig-. 187. Right Leg. Outer Side. External Popliteal Nerve.

73 Nat. Size.
Rebman Limited, London. Rebman Company, New York.
 Outer Head of
Short Saphenous Vein
Gastrocnemius
Branches to Inner Vessels to Outer
Head of Plead of
Gastrocnemius Gastrocnemius

Popliteal Vein Vasomotor Nerve

Oblique Popliteal
Ligament Internal Popliteal
(Semimembranosus) Nerve
Inferior External
Inferior Internal Articular Artery
Articular Artery
Popliteus
Gracilis Muscle
Ramus Communicans
Bursa under Fibularis
Semimembranosus
Nerve to Soleus Muscle
Bursa
Nerve to Posterior Tibial
Internal Lateral Muscle
Ligament
External Popliteal Nerve
Fascia covering
Popliteus

Long Saphenous Nerve Soleus Muscle

Nerve to Posterior Tibial

Ramus Coinmunicans Tibialis Muscle

Fibula
Tibia

Posterior Tibial Artery Peroneal Artery

Upper Nerve to Long Flexor

Superior Branch to Long
of Big-Toe
Flexor of Toes

Flexor Muscle of
Posterior Tibial Muscle
Big-Toe

Long Flexor Muscle of Peroneus Longus Muscle

Toes

Inferior Branch to Long Long

Flexor of Toes and
Lower Nerve to
Flexor of Big-Toe
Vasomotor Branch

Muscular Vein (Varicose

Soleus Muscle Vein)

Tendon of Gastrocnemius' Short Saphenous Vein

Muscle

I/rFrohse.

Fig. 188. Right Leg from behind: Deep Layer. Internal Popliteal Nerve.
4
/5 Nat. yize.

Rebman Limited, Loudon. Rebman Company, New York.

Fig. 188. Posterior Aspect of Leg. Deep Layer, Internal Popliteal
Nerve.

After removal of the Superficial Fascia, a large piece has been cut out of the
Gastrocnemius and Soleus Muscles, the heads of origin of the Gastrocnemius
have been thrown outwards. By further removal of the Deep Fascia, the large
Vessels and Nerves have been exposed. An incision through the fascia covering
the Popliteus Muscle has exposed the Bursa under the Semimembranosus Muscle.

The arrangement of the muscles on the back of the leg is very simple:
a Superficial Layer formed by the Gastrocnemius, Soleus and the slender Plantaris;
a Deep Layer formed by the Posterior Tibial, Long Flexor of Toes and Long
Flexor of Big-Toe. On this latter group lie the important Nerves and Arteries,
which are quite separated from the Superficial Layer of muscles by the Deep
Fascia of the Leg (v. Figs. 185, 186). Between the Deep P'ascia of^the leg and
the Superficial Muscles, loose connective tissue, favourable to the spread of
Cellulitis is found.
In order to allow the vessels and nerves, leaving the Popliteal Space, to
reach the deep aspect of the superficial muscles an aponeurotic opening is formed
by the Soleus i. e. an arch is thrown across from its Tibial to its Fibular Origin
under which the above mentioned structures pass.
At the lower border of the Popliteus Muscle, the Popliteal Artery divides
into Anterior and Posterior Tibial Arteries (occasionally this division takes place
at a higher level). The Anterior Tibial Artery (the smaller branch), passes directly
over the upper border of the Interosseous Membrane to the Anterior Aspect of
the Leg; the Posterior Tibial Artery passes under the arch of the Soleus, approaches
the inner side of the limb and lies in its outer third under the skin between the
Tendons on the Long Flexor of the Big-Toe and the Long Flexor of the Toes;
together with these tendons it passes behind the Internal Malleolus into the sole
of the foot. The chief this vessel is the Peroneal Artery which runs
branch from
outwards through the arch of the Soleus, under cover of the Fibular origin and
the muscular belly of the Long Flexor of the Big Toe, to near the ankle where
it emerges and terminates by giving off a Perforating Branch to the Anterior
Tibial Artery and a large Communicating Branch (sometimes double) to the
Posterior Tibial Artery or the outer side of the heel.
The Posterior Tibial Nerve runs along the outer side of the Artery, and
after giving off numerous branches, passes with it under the Internal Annular
Ligament to the sole of the foot.
Deeply situated on the Interosseus Membrane lies the Posterior Tibial
Muscle. As the Tibia is subcutaneous throughout its whole length, the structure
of the leg is convenient for extensive operations. The Fibula is readily exposed
after removal of the Soleus Muscle, but care must be taken in the neighbourhood
of its head to avoid injury to the External Popliteal Nerve.
 Fig. 189. Synovial Sheaths of the Tendons behind the Internal
Malleolus.

The Tendo Plantar Fascia, a large part of the Abductor Muscle of

Achillis,

the Big Toe, the Short Flexor of the Toes and the Deep Fascia of the Leg have

been removed. The Annular Ligament has been dissected out and the Tendon-
sheaths distended with Gelatin.

.Strong Septa extend from the Internal Annular Ligament to the posterior

surface of the Tibia, so that the Tendons run in Osteo-aponeurotic Canals, enclosed
by synovial sheaths. The Sheath of the Posterior Tibial Tendon commences two
inches above the tip of the Internal Malleolus and reaches as far as the insertion
of this Tendon into the Scaphoid Bone, so as to extend a little further downwards
on the bony aspect of the tendon. Immediately behind this sheath and rarely
communicating with its upper end lies the Sheath of the Long Flexor Muscle of

the Foot. This sheath extends to a higher level up the leg than the former
and is inserted obliquely on the tendon, leaving its posterior border free as long
as muscle fibres are inserted into it.

The sheath ends at the level of the Astragalo-Scaphoid Joint. Still

nearer the Os Calcis is the Sheath of the Long Flexor of the Big-Toe separated
from the Long Flexor of the Toes by a space occupied by the Posterior Tibial
Nerve and Vessels on their way to the sole of the foot. This sheath commences
one inch above the Tip of the Malleolus and may reach as far as the base of the
First Metatarsal Bone. At the point where the Tendon of the Long Flexor of
the Big-Toe crosses the Long Flexor of the Toes and has a band of communication
with the latter, the Tendons still remain within their proper sheaths, but these
sheaths communicate with each other; in many cases the Long Flexor of the Big-

Toe is without synovial covering at the point of crossing.

Like the tendon-sheaths in the hand, these sheaths are of importance in
connection with the spreading of inflammatory processes from the foot to the leg
and vice versa. Moreover, as they pass over the Capsule of the Ankle-joint
disease may perforate these Sheaths and extend to the Ankle-joint or in the
reverse direction.
At the toes the Flexor Tendons, like those of the Hand, have sheaths
with one important difference; at the toes they never communicate with the
Central Synovial Sheaths.
 Gastrocnemius Muscle

Soleus Muscle

Long Flexor Muscle of the Toes

Peroneal Muscles

Posterior Tibial Muscle

Long Flexor of the Big-Toe

Ten do A chillis Internal Malleolus

Internal Lateral Ligament

Abductor Muscle of
the Big-Toe
Short Flexor Muscle
of the Toes

Tubercle of Scaphoid Bone

Accessorius Muscle

Long Flexor Muscle

of the Toes

Abductor and Flexor Muscle

Abductor Muscle of
of the Little Toe the Big-Toe

Fig. 189. Tendon Sheaths behind the Internal Malleolus.

V2 Nat. Size.

Rebman Limited, Loudon. Rebman Company, New York.

 Fascia of Leg

Fascia of Leg (Deep Layer)

Long Saphenous
Nerve
Soleus Muscle

Long Flexor Muscle Long Flexor Muscle of

of the Toes the Big-Toe

Posterior Tibial Artery

Long Saphenous
Vein

Posterior Tibial Nerve

Tibia

Tendo Achillis
Internal Annular
Ligament
Tendon of Plantaris
Muscle

Internal Malleolus

Bursa under Tendo

Achillis

Posterior Tibial
Muscle
Internal Annular
Ligament

Abductor
Muscle
ofBig-Toe

Fig. 190. Region of (right) Internal Malleolus from behind.

Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Fig. 190. Region behind the Internal Malleolus.

Right Leg of a girl aged 15 years. The region around the Internal Malleolus
is exposed in layers. 3 windows have been made in the Deep Fascia and Internal

Annular Ligament.

The Long Saphenous Vein runs in the Superficial Fascia as far as the
Internal Malleolus accompanied by the Long Saphenous Nerve. The Fascia of

the Leg is strengthened behind the Internal Malleolus by thick bands of fibres
which radiate from the Malleolus towards the inner surface of the Os Calcis and
Plantar Fascia — the Internal Annular Ligament. This Ligament forms a bridge
under which the Flexor Tendons, Nerves and Vessels pass to the sole of the foot.

Nearest to the Internal Malleolus under this fascia and in a strong Apo-
neurotic Canal the Tendon of the Posterior Tibial Muscle passes, next to this the

Tendon of the Long Flexor of the Toes. The Tendon of this muscle crosses the
Posterior Tibial Muscle in the Leg from within outwards.
Nextly, the Posterior Tibial Vessels lie between the Long Flexor of the
Toes and the Long Flexor of the Big Toe so that, for ligature of this vessel, the

mid-point between Internal Malleolus and Tendo Achillis serves as the landmark.
Directly posterior to the Artery is the Posterior Tibial Nerve or its ter-

minal branches. — Internal and External Plantar Nerves. — The space posterior

to this and extending as far back as the Tendo Achillis is occupied by fat; in

this is found the Tendon of the Plantaris which is inserted into the posterior part

of the Os Calcis, along side of the Tendo Acjiillis.

By pushing the Vessels and Nerves forwards, the posterior segment of the
Ankle-joint can be reached. The Long Flexor of the Big Toe passes over the
middle of the joint. Between this and the other tendons, posterior to the Inner
Malleolus on the one side and the Peroneal Tendons behind the outer Malleolus
on the other side, the Capsule of the Joint may bulge in cases of effusion into the

joint, because it is not strengthened at these points. For operations, such as Ex-
tirpation of the Capsule in Tuberculosis, the joint is accessible from behind. The
arrangement is analogous with that on the Anterior Aspect of the joint near the
Extensor Tendons (cf. Fiy. 193), there is, however, the difference that, owing' to
its deeper position, the swelling of the joint is only noticed posteriorly when
extensive. It becomes visible when the hollow next to the Tendo Achillis is

filled out.
 h a H >< o 1 ,

c n 4 T3 h 2 02 bO
a
a h—
o O >-4
V ^
_c3 ^ P 2G
DU
“
Lj § O 2
•=t
O 'pU C/3
-— Cij

<1 S 02
a. a
02
DU P c/3
cd n
1

is
~ m 02

a, 73 o -3 h Jh
m
Ph
£
a 73 P _ < CD 0 •
o 3 bp
<U
£ .23
x)
c4 DU
<d
c*
’S
i-G
y E C/3

42 J?
cö !>
.^0 . o 0 2 p
) 73 -a
h4 -s c>
KC)
g Ö .Üf a q EO M « p
Pn
>-( —ao P 'S o
^ 02a
« < §
,

Ph <d a ~ & 0 -a
<D DU
^ bO „ p X'
02 o
E>
<u *D
§ P öß <|
g ^ 2 H j"
«
.2
si
53
-2 H
<D
d wcq
cr
DU (D co £ £
G -3 G co G P P P
.So P 2 Oh P CD
S ^ "O > g
s;
^ §
-4->
a
.23
H CD
O
<D
^
§ ^ o 02 8 X
Foot. •S
^
'«
^
•—
o *o > o w -S
« Ö 02
g P
<D
tU
X
<D
ö CD
Ö
Ph
^ 43
o
H rP
p
.<2*
O DU )_ .P o
G H pq s 5 §
np P
O "d H
p
<D P C Ö D
CD
"
^ P fo W *H-H
p
(Right) P PQ
C/3
p a !p bß
£0) £j
^ P o
c
a pn Ph p^ -5 P ^
QQ
rO 3 *a F
« 13 8
r-P

s; <V
H jD
^ ^ ^ S Q o o
‘o
of
UCD
Ö
^
o <
vh
J-j
^
^
a;
"8 « P
d" ^
CO

0^0 flj

Oh p
•0
P
CO 0) ^ Ph
^p
P
(1)
02
02 "
td -t2
Ph X5
P
n ^p ^
Sole
1 02 *5 CO
t3 02 •-
P P P ip
P 2U
5 E 'S
o> E-h 43
- 3
T5
P w o
02
c/2
r*
p—
"2
£2
"O
- "O X p p p
rt
c

rt
P << P O rp'
- <3'
0i
o ^ •4—> p 'B
>> Ö ^
2 j_r
(U
o
a;
co '1 s «
•
ffi
p Pd <
t-D
co
Q 8 '2 t y « Tj
*9 H a
•S
CD
CD
£
S 4,
Ü
<U
bo
P o a
® 6
C/3

P ^S «
s
2 .2*
0)

Ö
i o3
.

bO
CQ
'
n3
&.
*42

02 O d
o a
a 3
Fig* Sh £ X) Cfi
-5 2 P 8
g O O
to <b>
^ £ <D
^p
C/3

p "d P 02 H p
P
H P M o ^ "C/3

c^ Pn
p 3 a.
« p a ^
R ^ ^ -a ^2
4->
03 o h k a d ^ ^ h-1 p .tS -5 H
co 10 c X) o CO (1) 02 c/3 4 T3 02 02 *H CO p *+H
2d.
+-» *0 P
- c “ .-p
^ Tj '0 i5 02 43 O 0 a -5 °
p -p O P s H
P P
CO
d Ü r8 “>
a P b0
,
02

P U
r \
.P „ 02
0
B'
P-5
CO
<L>
L) d p 0 CP
ps )
c/3

02
Ph e*-- p" OJj P p .S
)

d: p bO > p
r° P
Layer. CO Vh
^h JT a P co Ph
8 d +J H
p *5
8 CO O I
co
*_rt
c
P 02 02 o o 33
8 2 a 73 „
.p
2co DUP
« bO UU .£3
g-'S - DU X5
02
§ a : .
P •5 £ P pH )-H

o i2 -S > &*' S o p ^ P ^
p
Oh
P
C/3
Ph

fH d
«2
c<_
C/3

O
*S « 4

Sfn OTu
"Ö o p ^
X 4-1 cn C/3~
02 02
dT

II
4H
co

.
T3 73
a a
4d
<U
rs
*
8^
H E s _
0 ~ §
02
S u
E?
2+2 ^3
X5

2 0
Superficial
D. "O 44
p >h *r 5E Ä 02
02
U 43 p o a
p bo +-» P r] rd CCS
M a rt O DU
H « o u 02 ^ >%
'

s a w ^
^H »H
<! p E
p
^
1

^ s s P *2^ a
02 73
^ o a
<u
P o 02
a 2
^ Eaa ^
<3.
1
T-i 02

<s
P
o
33 ;?
bo
73
“ ^
33 .2
„ a E
C/8 p -j-H
^ S 0
S3 J-« co .a 03
P O a
hd ^a
*P T3 C2 Ph 43 43 *Q p p 02
x a
: Cti 02
«0 p *2 P P P cj
b i)
k H 2PSE 0 b o a
•
P P p cd
CO > — * *"H
< _02
02
I,
02£ «3ni Ph a
P Ü ,. X
-4

o 02
^
Ph SO ^ §^ CH
Foot.
« s 02 .a ^ 02
02

£
J5 a .

Ö G 1115 e a
d
r P t
23
h-*
so
a
§ Ph
ajj so O p ft 3 20
^
bO-S
2 E «8 ..
a a 0
P nj P 04-H P
< 4 DU M
p ,a O DU
p p P <U
_ rt C p p t? bß
^ 2 a
p 43 o S2
|co
O co bß d 3 s 0 w c
E
< 73 _ o DU OJ 02
A a m
*2 p ^ a a
-ED
- .

Ph
(Right)
g 73 J a
H P
pa >H~
sw
'*‘

"P co co co~ P > J-H

o DhE
55 'S 02
P *P
'« co
a 2 P
^ 02 73 a a x 2 P G
p ~ p£ 2 p 02 02
j# 43 o -< <5 p
^ 3 a
*

p O 02
0 p 73 bß .a w 2
of p: a p 2 u
<1
P O g ^H G rr
. 73 2 O m
>£ P ^ P
I-h
fJ 2 !s
«
-a
p •«
<* o p
, 02
^ X
HE
G
5 ° 2 ,
P .+U >
-*->

§ 43 a 4= 33 0 Oh -h

H «P H
5

h
^ E 2^0 5 I _ ^P E 02a
HH .<U
.g p 1

O 3 »3 rt
Sole
.Q .§0
Oh
DD &M 1

bo
L.
i 4 S X O a
S°
^ a
O 02
-a
I P
op so c. CO "O
o
x
£2 S
*5
ft
r a cp “ g « a
Ph a p ^ m d
P P
a «
w J-
/-<
O '
g-g-Sj —a 73
191. ^o P P
2 £ E Pd bß o
S a soPh
CO CO
a 43 as '0 a
.

.a 3
a o P r—
^
rt
a 73 PQ IS p
EE
- CO -p, t: a
P a
- p* 02

Fig.
<1
CO

co C/3
«2
73
_
(U
co
co
P -
co
P
+
02
43 -a
02 43
w
o 02
a
.E
pH
E-i
a02 02
43
a g ^ E
^Sg
^
1

-
o"

Ph 02
02 o

-a "Ö
g.£ £ ^ CO
G 3
02 02
2 ^ G p a P <+H
o E a .
4-»
-

'd g p p o o 43
o ED O S < rO Xi ^ E 43 M a a-
 the

of

Muscle

Flexor

Short

London.

Limited,

Rebman
 Musculo -Cutaneous
Anterior Tibial Nerve

Long Saphenous Superior (Vertical)

Annular Ligament

Short Saphenous Vein

Long Extensor Muscle

of the Toes

Annular

Short Saphenous Nerve

Anterior Tibial .Short Extensor Muscle

of the Toes

Dorsal Artery of Foot

Peroneus Tertius Muscle

Plantar Arch Dorsal Venous Arch

of Foot

1st Dorsal (Metatarsal)

Artery

Fig. 193. Region of Ankle and Dorsum of Foot.

Nat. Size.

P.ebman Limited, London. Eebman Company, New York.

 Fig. 193. Region of the Ankle and Dorsum of Foot. Deft.

Preparation from a girl aged 15 years. The Fascia of the Leg and Dorsum
of the Foot has been removed, but the Superficial Veins and the Anterior An-
nular Ligament have been preserved.

The open network of superficial fascia which occurs in this situation, con-
tains little fat, but Venous Plexus which terminates on the inner side
is rich in a
in the Long Saphenous Vein, and on the outer side in the Short Saphenous Vein.
The Fascia extending from the leg to the foot is considerably strengthened above
and over the ankle by the Superior and Anterior Annular Ligaments. The latter
is formed by a series of fibres which run from the Internal Malleolus outwards

and downwards to the outer border of the foot, these fibres are crossed by another
series of fibres which run from the inner border of the External Malleolus. These
fibres are no independent structures but thickenings of the Fascia; they can only
be displayed artificially (cf. Fig. 193).
The Extensor Muscles present the same relations as in the Leg. On the
inner side, the Anterior Tibial Muscle is inserted into the Scaphoid and base of
the first Metatarsal Bone, externally to this the Long Extensor of the Big Toe
runs to the terminal phalanx of the Big Toe, next the Long Extensor of the Toes
to the 4 outer Toes, and
Peroneus Tertius (Third Peroneal) Muscle to
lastly the
the Tubercle of the 5th Metatarsal Bone. Arising from the first part of the upper
and outer surface of the Os Calcis, deep to the Tendon of the Long Extensor of
the Toes, lies the Short Extensor of the Toes, with its obliquely directed tendons
which blend with the Long Extensor Tendons to form the dorsal aponeurosis of
the toes. Between the Metatarsal Bones appear the Dorsal Interosseous Muscles.
At the mid-point between the 2 Malleoli and between the tendons of the Long
Extensors of the Toes and Big Toe is situated the Anterior Tibial Artery; in its
continuation below the Anterior Annular Ligament it is called the Dorsal Artery
of the Foot which runs over the middle Cuneiform Bone onwards into the 1 st
interosseous space, where it anastomoses with the External Plantar Artery.
The Anterior Tibial Artery gives off to each Malleolus a Malleolar —
Branch —
the Dorsal Artery of the Foot, to both inner and outer sides of the
,

Foot a Tarsal Artery.

The Anterior Tibial Nerve generally on the inner side of the Dorsal Artery
of the Foot, supplies the Short Extensor Muscle of the Toes and gives a Cutaneous
Nerve to the contiguous sides of the Big Toe and the 2nd Toe.
On Extensor Tendons and between the tendinous bundle
either side of the
and each Malleolus is a space of considerable importance, because at these points
the Capsule of the Joint is only covered by Skin and Superficial Fascia without
any accessory strengthening fibres.
At no other place is the joint so exposed or so readily accessible. Moreover
by a bulging of these spaces an effusion into the joint will be first observed.
 Fig. 194. Outer Side of (Left) Foot.

Preparation from a girl aged 15 years. The Fascia over the Dorsum of the
Foot has been removed with preservation of the Annular Ligament Superficial ,

Veins and Nerves. Fascial Bands which bind down the Peroneal Muscles are
shewn (Retinacula Peroneorum). Synovial Sheaths of Peroneal Muscles pin k.

The Superficial Fascia behind the External Malleolus contains the Short
Saphenous Vein and Nerve. Over the External Malleolus, (in Y2 to V3 cases), there

is a small Subcutaneous Bursa. The Peroneal Tendons are held within their grooves
behind the External Malleolus by strong bands similar to those on the inner
side which are derived from the Anterior Annular Ligament. Without these
ligaments a displacement of these tendons over the Malleoli would be of frequent
occurrence. These bands, the Superior and Inferior Peroneal Bands are thickenings
of the fascia. The Superior Band runs from the outer side of the Malleolus to
the lower part of the outer surface of the Os Calcis and has under it the tendon

of the Long Peroneal and deep to this the tendon of the Short Peroneal Muscle.

The Inferior Peroneal Band, more distally situated, runs from the Tip of
the Malleolus to the outer surface of the Os Calcis : a Septum separates these two
muscles, of which the Short Peroneal lies anteriorly.

Both the Peroneal Tendons are enclosed in a common sheath while in the
groove directly behind the External Malleolus, but above and below this point,

the sheath is bifurcated: the upper bifurcation lies under cover of the Superior
Peroneal Band and the lower bifurcation comes into relation with the posterior
border of the Inferior Peroneal Band. The upper end of the sheath enclosing the

Long Peroneal Muscle, extends i

3
/4 inches above the tip of the Malleolus; the
sheath for the Short Peroneal to a less height. The lower end of the sheath of
the Short Peroneal Muscle extends to Chop art’s Joint but the sheath of the Long
Peroneal passes beyond as far as the groove on the Cuboid Bone, here it receives

a new sheath which comes almost into contact with the first sheath; a communi-
cation between them never occurs. Nevertheless, the intervening septum is so

thin that it is easily perforated by pus.

By this route an Abscess of the sole of the foot may easily spread up
into the leg. Again; the relation of the Peroneal Sheaths to Chopart’s Joint allows,

for example, tuberculosis of this joint to extend up the leg after perforating the
tendon sheaths.
At the Ankle such easy means for extension are not found, although the
Tendons are closely applied to the joint behind the External Malleolus. The
reason of this is explained by the definite separation which the strong Calcaneo-
Scaphoid Ligament secures.
 Short Saphenous Ner\c

Short Saphenous Vein

- Peroneus Longus Muscle

Peroneus Brevis Muscle

Musculo-Cutaneous Nerve

External Malleolus
Upper part of External
Annular Ligament (covering
Anterior Tibial Muscle the Peroneal Muscles)

Long Extensor Muscle of

the Big-Toe

Lower part of External

Annular (Anterior) Ligament Annular Ligament
(covering the Peroneal
Muscles)

Tendon Sheath of Pero-

neus Longus Muscle

Dorsal Artery of Foot

Abductor Muscle of the
Little-Toe

Short Extensor Muscle of

the Big-Toe
Short Extensor Muscle
of the Toes

Peroneus Tcrtius Muscle

Anterior Tibial Nerve

Dorsal Venous Arch of Foot

1st Dorsal (Metatarsal)

Artery

Fig. 194. Outer side of the (left) Foot.

Nat. Size.

Rebm'ain Limited, London. Rebmau Company, New York

 Subcutaneous Bursa Subcutaneous Bursa over
over Internal Malleolus External Malleolus

Tendon-Sheath of Anterior Annular (Anterior) Ligament

Tibial Muscle

Tendon-Sheath of Long Ex- Tendon-Sheath of Peroneus

tensor Muscle- of the Big-Toe Tertius Muscle

Bursa under the Tendon of Tendon-Sheath of the Long

the Anterior Tibial Muscle Extensor Muscle of the Toes

Short Extensor Muscle Peroneus Tertius Muscle

of the Big-Toe

1 st Accessory Tendon-Sheath Tendon-Sheath of the

of Long Extensor Muscle of Short Extensor Muscle
the Big-Toe of the Big-Toe

1 st Dorsal Interosseous Short Extensor Muscle of

Muscle the Toes

2nd Accessory Tendon- Metatarso-Phalangeal Bursa

Sheath of Long Extensor of the 5th Toe
Muscle of the Big-Toe

Metatarso-Phalangeal Bursa Intermetatarso-Phalangeal

of the Big-Toe Bursae

Subcutaneous Bursa over

Subcutaneous Bursa over ~ Dorsum of 3rd Toe
Dorsum of the Big-Toe

Fig. 195. Dorsum of (left) Foot shewing Muscles and Tendon-Sheaths.

4
/5 N.at. Size.

Rebman Limited, London. Rebman Company, New York.

Pig. 195. Dorsum of (Left) Foot with Muscles and Tendon-sheaths.

The Fascia of the Dorsum of the Foot has been removed except the Superior

and Anterior Annular Ligaments. The Tendon-sheaths have been opened except
the cttl-de-sac at their extremities ,
the length of which is indicated by an arrow.

The Superior and Anterior Annular Ligaments keep the Extensor-Tendons

in position during movements at the ankle; this arrangement is perfected by a

separate compartment for each tendon with its own special sheath in order to

avoid any friction.

The Sheath of the Anterior Tibial Muscle commences 2

1
/ 2 inches above

the Intermalleolar-Line (between the tips of the Malleoli) and ends usually at

CHOPART’s Joint. The Sheath of the Long Extensor of the Big Toe begins

% inch above the Intermalleolar-Line and extends down to LlSFRANC’s Joint.

A second and even a third Synovial Sheath may be present (Fig. 195) in connection

with this tendon.

The Long Extensor of the Toes and the Third Peroneal Muscle occupy
a common sheath which commences lower down than the sheath of the Anterior

Tibial and extends to the middle of the External Cuneiform Bone.

A sling-like ligament which arises in the Sinus Tarsi assists in keeping'

these tendons in place under the Annular Ligament. Sometimes an extensive

Bursa is found between this Ligament and the Neck of the Astragalus.

Many other Synovial Sacs may be present: those between the heads of
the Metatarsal Bones (Intermetatarso-phalangeal Bursa) are quite frequent. Whenever
tendons pass over bony prominences, small synovial sacs are placed to act like

cushions; even where the Lumbrical Muscle winds around the shaft of the first

phalanx these are found. Again Subcutaneous Bursae occur whenever there is

pressure of skin against bone especially under “Corns'’. The Bursae over the

Malleoli are fairly constant as well as those on the lateral aspect of the Heads
of the ist and 5th Metatarsal Bones, and those over the Heads of the ist Phalanges.
 ;

Fig. 196. Dorsum of (Left) Foot, with Tendon-sheaths. Arteries and

Bones projected on to the Skin.

This is a reconstructed figure: The outlines are taken from a young individual
the bones are of a corresponding size; moreover in comparison with several

other specimens the position of the Arteries and Tendon-sheaths have been
relatively determined.

This figure (cf. Fig. 97) has been constructed to shew the relation of

Arteries and Tendon-sheaths to Bones and Joints. In the Hand furrows and folds

indicate the position of deeper structures, but in the Foot bony prominences are

to be taken as the reliable points. Along the inner border, the Tubercle of the

Scaphoid, on the outer side the Tuberosity of the 5th Metatarsal Bone are plainly

evident. The Tarso-Metatarsal Articulation (Lisfranc’s Joint) is determined thus:

Immediately proximal to the tuberosity of the 5th Metatarsal Bone is the one point,

the other point lies F/2 inches distal to the tubercle of the Scaphoid. A curved

line joining these 2 points indicates the line of the joint. (Cf. Fig. 20.)

The Mid-Tarsal Joint is determined by connecting on the inner border

2
a point /3 rd inch proximal to the Tubercle of the Scaphoid, on the outer border

Vs inch proximal to the Tuberosity of the 5th Metatarsal. The figure shews the

relations which the extremities of the Tendon -sheaths bear to these lines. The
joint space can be made out directly in most cases by feeling at 2
/3 rds to 3
/ 5 th

jnch above the tip of the Inner Malleolus the Anterior Border of the Articular

Surface of the Tibia where it is only covered by skin and tendons. (For certain

Synovial Bursae see Fig. 197.)

Frequently a Bursa is placed between a tendon and its insertion into the

bone where it acts as a cushion when pressed against the bone by the opposing
muscles. Consider, from this point of view, the bursa over the Internal Cuneiform

Bone, which lies under the Anterior Tibial Muscle close to its point of insertion

into the Internal Cuneiform and the ist Metatarsal Bones.

 Perforating Branch of
Anterior Tibial Artery
Peroneal Artery

Anterior Internal Malleolar External Malleolar Artery

Artery

Tendon -Sheath of Posterior Ten don -Sheath of Long Extensor

Tibial Muscle Muscle of the Toes

Tendon-Sheath of Anterior Tendon-Sheath of Peroneus

Tibial Muscle Brevis Muscle

External Tarsal Artery Tendon-Sheath of Peroneus

Longus Muscle

Internal Tarsal Artery Tendon- Sheath of Long Extensor

Muscle of the Big-Toe

Bursa under Tendon of Anterior Dorsal Artery of Foot

Tibial Muscle

Transverse Metatarsal Artery Metatarsal Artery

Deep Branch passing to the

Plantar Arch Posterior Perforating Branch

Internal Plantar Artery

Anterior Perforating Branch

Dorsal Digital Artery

Dorsal Digital Artery

Fig. 196. Dorsum of Foot with Tendon-Sheaths, Arteries and Bones.

(Projection on to the surface.) Left side.
4
/_ Nat. Size.

Rebman Limited, London, Rebman Company, Now York.

 w v j

Tibia
JlPIlk
mmium I Fibula

6*
MWȣJki sits
«
is* «S'®
fr< »» vf,o-« > U y0^

®w
li-J

Jg'trt
•» 4 , «o 4'^ tt 0 fca I

< " *& in Qfi/9 <* {.«I® • * * « «12

ribwort
1
~ ȣ ^5 -.j

Internal Malleolus
v /?«*£ , i«is B
,
w 7i
‘

Astragalus
Posterior Tibial Muscle

Interosseous Ligament External Malleolus

Long Flexor Muscle

of the Toes

Internal PlantarNerve
Long Flexor Muscle
ÄiSKiÄ
*
r
, ‘Mft (f ff ff #,Ä| f\ * Alv^y^^I’i
Peroneus Brevis Muscle

of the Big-Toe

Accessory Muscle
’iv £*» Ä & mI' Peroneus Longus Muscle

External Plantar Nerve

i&mm Calcaneus
Abductor Muscle
the Big-Toe

Short Flexor Muscle

of

wmmB
of the Toes Abductor Muscle of
the Little-Toe

Fig 197. Frontal Section through the (right) Ankle-Joint.

Seen from behind. — Nat. Size.

Rebman Limited, London. Rebmau Company, New York.

 Fig. 197. Frontal Section through the (Right) Ankle-Joint.

Frozen Section. As the section did not pass directly through the tip of the
External Malleolus some tissue was removed in order to expose this prominence.

The Tibia and Fibula by means of their Malleoli form a socket which
grips the Astragalus. The External Malleolus extends to a lower level than the
Internal; the joint cavity extends upwards between the lower ends of these bones
forming a recess called the Inferior Tibio-Fibular Articulation. To the Tibia and
Astragalus the Capsule is attached along the border of the articular cartilages
(on the anterior surface only does the Capsule extend to the neck of the
Astragalus). By this arrangement a considerable portion of the Neck of the
Astragalus may enter the joint cavity in extreme dorsi-flexion of the foot. Cor-
responding to the free movements in Dorsal and Plantar Flexion, the capsule is

loose in front and behind, so as to form folds (vide Fig. 19g) but on either side
strong tense ligaments attach the Malleoli to the Astragalus and Os Calcis: the
Deltoid Ligament extending from the Internal Malleolus to the Astragalus and
Sustentaculum Tali, the Anterior and Posterior Astragalo-Fibular Ligaments and
the Calcaneo-Fibular Ligaments extending from the External Malleolus to the
Astragalus and Os Calcis respectively.
The ankle-joint is therefore not easily accessible from the side; behind, it

lies at a considerable depth under the Tendo A chillis, but can be reached (cf.

Fig. 190). Its anterior aspect, on either side of the Extensor Tendons, is the most
accessible (cf. Fig. 193).

This figure also shews the position of the Peroneal Muscles enveloped in
their sheaths below the Outer Malleolus and the position of the Flexors on the
inner side. The Posterior Tibial Artery and Nerve have already divided into
Internal and External Plantar Branches which are now lying in a well-protected
position between muscles. Between the Astragalus and the Os Calcis, the Posterior

Calcaneo-Astragaloid Articulation can be seen ;

this lies at a slightly higher level
than the tip of the External Malleolus.
The Anterior Calcaneo-Astragaloid Joint which is separated from the
Posterior by the Interosseus Ligament (v. Fig. 199) is not an independent joint
but is a part of the Astragalo-Scaphoid Articulation, whereas the Posterior Calcaneo-
Astragaloid Articulation is quite independent and liable to independent affections.
If swollen it bulges forwards and outwards to point anteriorly at the Tip of the
External Malleolus.
The movements of Abduction and Adduction are limited at this joint.
The inner border of the foot is arched and does not touch the ground.
Fig. 198. Transverse (Frontal) Section through the Anterior Part
of the Tarsus.

Frozen Section.

The Foot is arched both Antero-posteriorly and Transversely. The Trans-

verse Arch, shewn in the figure, begins posteriorly where the Os Calcis with its

Sustentaculum Tali forms a semicircle (v. Fig. 197).

A little further forward the Scaphoid and Cuboid Bones form an arch,
whereas in front of these the arch becomes more definite as the Cuneiform Bones
with their broad Dorsal and narrow Plantar Surfaces closely resemble the stones
of an arch.
The Longitudinal Arch is still more pronounced in the Metacarpal Bones.
The Plantar Vessels and Nerves run forward under cover of this arch which
serves to protect them from pressure (due to the weight of the body).

Fig. 199. Longitudinal (Sagittal) Section through the Foot.

Frozen Section carried through the middle of the Tibia and the outer part
of the 2nd Toe.

This figure shows the Longitudinal Arch which is most marked on the
inner side. The inner tubercle of the Os Calcis and the head of the ist Metatarsal
Bone form the Pillars of this Arch. On the outer side of the Foot the arch is

less curved; here its Anterior Pillar is formed by the base of the 5th Metatarsal

Bone. The Astragalus forms the Keystone of this Arch. Strong ligaments bind
together the bones on their Plantar Aspect and firmly brace up the arch; the
Plantar Fascia stretched across from the Inner Tubercle of the Os Calcis to the

Heads of the Metatarsal Bones acts like a bowstring.

Mention must also be made of the assistance rendered by the Tendon of

the Posterior Tibial and other Muscles in keeping up the Arch.

This figure further shews : a Bursa (always present) between the Os Calcis

and Tendo Achillis. (A Bursa between the Tendo Achillis and the Superficial
Fascia is rarely met with.)

The cavity of the ankle-joint extends backwards nearly as far as the

3
Posterior Calcaneo-Astragaloid Articulation. In front it is /5 ths inch distant from
the Astragalo-Scaphoid Joint. This explains why inexperienced persons, when per-

forming Chopart’s disarticulation, easily open the ankle-joint instead of the

Astragalo-Scaphoid Articulation.
The figure shews also that the Posterior Calcaneo-Astragaloid Articulation
is a complete joint, whereas the anterior is merely a part of the Astragalo-Scaphoid
Articulation.
 Middle Cuneiform Bone Long Extensor Muscle of the Big-Toe
Short Extensor Muscle of the Toes | j
Dorsal Artery of Foot. Anterior Tibial Nerve

Long Extensor Muscle of the Toes

Internal Cuneiform Bone

External Cuneiform Bone
Accessory Muscle with the Tendon of the
Long Flexor Muscle of the Toes
Anterior Tibial Muscle

/
Oblique portion of Adductor
Muscle of the Big-Toe
Peroneus Longus Muscle

Internal Plantar Artery

Cuboid

Abductor Muscle of
the Big-Toe
Short Flexor Muscle of
the Toes Long and Short Flexors
of the Big-Toe
5th Metatarsal Bone
Internal Plantar Nerve

External Plantar Nerve

and Vessels Plantar Fascia
Opposing Muscle of
Little-Toe

Abductor and .Short

Flexor Muscle of the
Little-Toe

Fig. 198. Frontal Section through the Anterior Part of the Tarsus.
Seen from in front. — Nat. Size.

Tibia Anterior Tibial Muscle

Accessory Muscle
Long Flexor Scaphoid
Muscle of
the Big-Toe Posterior Tibial Muscle

Long Extensor Muscle of the Big-Toe

Tendo Achillis
Internal Cuneiform Bone
Peroneus Longus Muscle
Astragalus 1 st Metatarsal Bone
Short Extensor Muscle of the Big-Toe
Interosseous Muscle

Os Calcis Lumbrical Muscles

Bursa under
Transverse Adductor of the Big-Toe
Tendo
Achillis
2nd Metatarsal Bone
External
Plantar
Artery
and Nerve
Short Flexor
Muscle of
the Toes

Abductor
Muscle of the
Little-Toe

Fig. 199. Sagittal Section through the (right) Foot.

Seen from the outer side. —% Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Fig. 200. Horizontal Section through the (right) Foot, near the sole.

-L* Nat. Size.

Rebman Limited, London. Rebman Company, New York.

Fig. 200. Horizontal Section through the (Right) Foot near the Sole.

Frozen Section. The distal half of the yth Metatarsal Bone has been freed by
dissection.

The result of the arching of the foot is that the body-weight is received

only by a few points of the skeleton of the foot, namely: — behind; the Inner

Tubercle of the OsCalcis; in front on the outer side: the Head, also the base of
the 5th Metatarsal Bone ;
on the inner side: the Head of the ist Metatarsal Bone

though many consider that owing to the mobility of this bone the head of the

2nd Metatarsal Bone should be looked upon as the supporting point. According
to H. VON Meyer the 3rd Metatarsal Bone should be viewed as the point of

support as the other bones only serve for the purpose of preventing the foot from

capsizing to either side. However this may be, foot-prints teach 11s that only the

heel, outer margin of foot, balls of toes and toes themselves, touch the ground

normally; when the inner margin meets the ground we have to deal with Flat-Foot.

The section shews definitely the share taken by the different bones in

this arrangement. The Metatarsal Bones lie at different levels; the heads of the

inner three have been divided by the section which passes throughout the length

of the 4th and only through the base of the 5th Metatarsal (of which its distal

half has been freed by dissection).

In the figure is seen the Bursa on the outer aspect of the Little Toe
opposite the Metatarso-phalangeal Articulation; this the most prominent point on

the outer margin of the foot is frequently the seat of a corn produced by pressure
from the boot.
Inflammation readily reaches this Bursa whence it spreads to the joint which

is often in communication with the Bursa.

 Fig. 20i. Tarsal and Metatarsal Articulations. Right Side.

The preparation is of a frozen foot in extreme plantar flexion; the minimum

of tissue necessary to thoroughly expose the joints has been removed with a chisel.

The Tarsal Bones articulate with each other, with the Bones of the Leg
and with the Metatarsal Bones, forming as a rule 8 separate joint-cavities of which
some are very simple (where only two articular surfaces take part in the joint),

others are very complicated (where several joint-spaces combine to form one joint-

cavity by communication). In the latter case, disease spreads rapidly from one
articulation into the communicating joints whereas disease of a simple cavity may
remain localized.

The separate joint-cavities are:

1. Ankle-joint, between the Astragalus, Tibia and Fibula with an upward

recess between the Tibia and Fibula.
2. Posterior Calcaneo-Astragaloid Joint (Fig. 199).

3. Articulation between the Astragalus on the one hand with the Scaphoid
and Os Calcis on the other hand (Fig. 199). The Head of the Astragalus lies in

a socket formed by the Scaphoid, Calcaneo-Scaphoid Ligament and the Anterior

Part of the Os Calcis.

4. Joint between Os Calcis and Cuboid; the inner extremity of this joint

lies exactly opposite the outer end of the former (3) separated only by the Calcaneo-

Cuboid Ligament. The foot can be easily disarticulated at this S-shaped articulation
the Astragalus and Os Calcis being left behind. (Disarticulation after Chopart.)
It is to be noticed that this joint consists of 2 separate joint-cavities so that, in

disease, one may be affected without the other.

5. Small Articulation between the Cuboid and External Cuneiform.

6. Very complex Joint-cavity between Scaphoid and the 3 Cuneiforms,

between the contiguous Cuneiforms, between the Middle and External Cuneiforms
and the bases of the 2nd and 3rd Metatarsals and between the bases of these
Metatarsals.

7. Joint between ist Metatarsal and the Internal Cuneiform.

8 . Joint between the Cuboid and the 4th and 5th Metatarsals.
The joints between the 5 Metatarsals on the one hand and the 3 Cuneiforms

and the Cuboid on the other form a curved line which is only interrupted by the
2
proximal projection of the 2nd Metatarsal to the extent of /5
ths inch. Disarticulation

of the Metatarsals after LlSFRANC can be performed at this line.

 1st Dorsal Interosseous
Muscle

1st Metatarsal Bone

Line of Lisfranc’s
Articulation

Internal Cuneiform Bone

External Cuneiform Bone

Middle Cuneiform Bone il# Tuberosity of 5 th Metatarsal

Bone

Line of Lisfranc’s Articulation

Tuberosity of Scaphoid Cuboid

Line of CflOpEirt’s Articulation

Line of Chopart’s
Articulation

Astragalus

Tibia mm. Fibula

Fig. 201. Tarsal and Metatarsal Joints exposed from above on the right side.
*/
3
Nat. Size.

Rebman Limited, Loudon. Rebman Company, New York.

 Posterior Branches of
Lumbar Nerves
Anterior Branches of
Lumbar Nerves
Lateral Branches of
Lumbar Nerves

Ilio-Hypogastric Nerve
Posterior Branches of
Lumbar Nerves and
first 3 Sacral Nerves

Genital Branch of Genito-

Crural Nerve

Recurrent Branches of
Small Sciatic Nerve

Crural Branch of Genito-

Crural Nerve
y
External Cutaneous Nerve

External Cutaneous Nerve

Small Sciatic Nerve

Middle and Internal

Cutaneous Nerves Obturator Nerve

Obturator Nerve

Long Saphenous Nerve

External Popliteal Nerve

Long Saphenous Nerve

Short Saphenous Nerve

External Popliteal Nerve

External Calcanean Nerve

Musculo-Cutaneous Nerve

Internal Calcanean Nerve

Anterior Tibial Nerve

Internal Plantar Nerve

External Plantar Nerve

Short Saphenous Nerve

Fig. 202 and Fig. 203. Areae of Distribution of the Cutaneous Nerves of the
lower Extremity. Right side.
7B Nat. Size.

Rebman Limited London. Rebman Company, New York.

 Figs. 202 and 203. Areae of distribution of the Cutaneous Nerves
of the Lower Extremity. Right Side.

Outlines partly after Fau’s Atlas. Areae of Nerves are partly diagrammatic.
Colours are chosen in the order of segmentation : those for the Lumbar Plexus are
in accord with the colours used, in the two following figures, for the segments
of the cord.

The Cutaneous Nerves of the Lower Extremity require thorough re-in vesti-
gation, far more than those of the Upper Limb. The upper quarter of the thigh
is supplied by the following Cutaneo-sensory Nerves: — Outer third, Ilio-hypogastric

(red); Middle, Crural Branch of Genito-Crural ;

Inner third, Genital Branch of
Genito-Crural. These 2 areae, supplied by the same nerve, are yellow; only a
small area near the Scrotum (visible on separation of the thighs) is supplied by
the Perineal Branch of the Small Sciatic. The remainder of the Anterior Surface

is supplied in its outer third, by the External Cutaneous, internal to this, by the
Middle and Internal Cutaneous; at its innermost part, by the Obturator Nerve.
The two Lateral Nerves extend on to the posterior aspect which is chiefly
supplied by the Small Sciatic Nerve.
The Gracilis is not often perforated by the Cutaneous Branch of the
Obturator; this Nerve usually winds round the border of the Adductor Longus
Muscle and thus comes to the surface at the Anterior Border of the Gracilis. It

nearly alwaj^s anastomoses with the Internal Cutaneous Nerve and comes to lie

near the Long Saphenous Nerve after piercing the fascia, so that this Nerve is

composed of fibres from the Internal Cutaneous as well as from the Obturator Nerve.
The inner surface of the Leg" is entirely supplied by the Terminal Sensory
Branches of the Anterior Crural Nerve, namely, the Long Saphenous Nerve which
reaches down as far as the inner border of the foot, and so becomes the longest
nerve in the body. All other parts of the Foot and Leg are supplied by the
Great Sciatic Nerve and its branches.
In the Leg, the Internal and External Popliteal Nerves apportion the skin
between each other, the former taking the middle of the calf, the latter the outer side.
In the Foot, the Dorsum belongs to the External Popliteal, the Sole to the

Internal Popliteal.
At the Heel, the Internal and External Calcanean Branches should be
mentioned. The area of the Internal Plantar corresponds to the distribution of the
Median, that of the External Plantar to the Ulnar in the hand.

The supply of the Dorsum of the Foot exhibits no similarity to that of the

Hand. Besides the Superficial Nerves a Deep Branch from the Anterior Tibial

Nerve has to be considered in its supply to the contiguous margins of the Big
and 2nd Toes.
Fig. 204. Innervation of the Skin and Muscles of the Lower Limb
according to their Segmental Origin from the Cord Anterior Aspect. :

Outlines modified after FAU’s Atlas ; Nerve-supply after WlCHMANN with modifications suggestea
by ZIEHEN. In the text Arabic figures indicate the Lumbar, Roman the Sacral Segments.
As each plexus has only 5 segments the fundamental colours of the Spectrum Red, Orange,
Yellow , Blue and Green are employed. Black lines represent the boundary between trunk
and limb and the so-called Axial Line which, invisible in the thigh, appears at the outer side

of the leg running obliquely downwards to the Internal Malleolus and encircling the latter.

The Segmental Distribution of the Nerves in the Lower Extremity is more com-
plicated than in the Upper Limb. In man the distribution of both Motor and Sensory
Nerves has not been properly determined. This figure is intended to contrast the Cutaneous
Supply with the Muscular.
Naturally the Nerves are to be divided into Dorsal or Extensor Nerves, and
Ventral or Flexor Nerves, the former being the Anterior Crural and External Popliteal,

the latter the Obturator and Internal Popliteal. Apart from these, special branches for

the Muscles of the Pelvic Girdle will (as well as the Flexor Nerves) be considered in the

next figure. In this figure only the Extensor Nerves will be described.
The Anterior Crural Nerve corresponds more to the Musculo-Cutaneous than to
the Radial; this divides into a branch to the Iliacus (cf. Fig. 105), the Anterior Division
(mixed) which supplies the Sartorius and Pectin eus, and the Posterior Division (also mixed)
which supplies the Quadriceps Extensor Group of Muscles.

These muscles correspond to the following spinal segments, Pectineus 2 and 3;

Sartorius 2 and 3; Rectus Femoris 2, 3 and 4; Vastus Internus 2 and 3 (and 4), Crureus
(2) 3 and 4; Subcrureus 3 and 4; Vastus Externus 3 and 4.
The Sensory Portion of the Nerve is formed by the Middle and Internal Cutaneous
(Anterior Divisions) and its communication to the Obturator Nerve, by the Long Saphenous
Nerve (Posterior Division). Of these, the former supply the thigh chiefly from 2 and 3,

the latter supplies the Leg formed from 3 and particularly 4.

and is

The External Cutaneous Nerve (a modified lateral branch of the Lumbar Nerves)
contains 2 and 3; its Posterior Branch may be a trochanteric branch; occasionally its
1,

Anterior Branch contains the Crural Branch of the Genito-Crural (the internal twigs of
which also contain ventral elements). This nerve is not constant, neither is there any
constant relation between the fibres which it receives from 2, 3 and 4.

The following remarks are made in connection with the incompletely studied
External Popliteal Nerve: — Motor part: Short Head of Biceps 5. 1 .
(II). Long Peroneal
Muscle (4) 5. I. Short Peroneal Muscle 5. I. Long Extensor of the Toes 4. 5. I. Long
Extensor of the Big Toe (4) 5. I. Anterior Tibial 4. 5. (I) Short Extensor of the Toes

4. 5. I ;
The slip from the muscle to the Big Toe 4. 5. I.

Sensory part : On the outer side of the leg from above and in front, downwards
and backward, 5. I and II.

At the foot (Musculo-Cutaneous and Anterior Tibial Nerve) 5. I and II. The
whole of the Dorsum of the Foot contains: on the inner side, according to Paterson,

3 and 4 ;
on the Dorsum proper 4. 5. I ;
on the outer side, I and II.
I

External Oblique Muscle of

Abdomen

Rectus Abdominis
Lumbar i

Tensor of Fascia of Thigh

Pyramidalis

Iliopsoas

Cremaster

Pectineus

Long Adductor
Lumbar 2

Gracilis

Sartorius

Rectus of Thigh

External Vastus

Lumbar 3 Internal Vastus

Ilio-Tibial Band

Patella

Ligament of Patella

Anterior Tibial Muscle

Long Peroneus
Lumbar 4

Internal Head of Gastrocnemius

Long Extensor of the Toes

Lumbar 5
Soleus

Long Flexor Muscle of the Toes

Sacral 1
Vertical Portion of Anterior
Annular Ligament

\nterior Annular Ligament

Sacral 2

'S NNV-O-^V t . Dr. Frohst’, fee.

Fig. 204. Nerve-Supply of the Skin and Muscles of the Lower Limb
according to their Segmental (Spinal) Origin. Anterior Aspect.
7b Nat. Size.

Rebman Limited, London. Rebman Company, New York.

 Latissimus Dorsi

External Oblique
Muscle of Abdomen
Lumbar II
Gluteus Modi us

Lumbar I

Sacral III, Ventral

Branch
Gluteus Maximus Sacral III, Dorsal
Branch
Lumbar II

Sacral IV
Sacral V -f- Coccygeus
External Vastus Nerve-

Sacral 1

Adductor Magnus

Sacral II
Gracilis

Lumbar I

Somitendinosus
Sacral III

Long Head of Biceps

Lumbar III

Semimembranosus

Plantaris

Sartorius
1

A\n\
/
mM
A >
\V n
'/

External Head of
( Jastrocnemius
ill Lumbar IV

Internal Head of
Gastrocnemius Lumbar V

Sacral II

Soleus

Sacral I

Fig. 205. Nerve-Supply of the Skin and Muscles of the Lower Limb
according to their Segmental (Spinal) Origin. Posterior Aspect.

Vs Nat. Size.

Rebman Limited, London. Rebman Company, New York.

Fig. 205. Innervation of the Skin and Muscles of the Lower Limb
according to their Segmental Origin from the Cord Posterior Aspect. :

The preliminary remarks made in connection with Fig. 204 apply to this figure. The boundary
line (difficult to define) between the Trunk and the Limb has 7iot bee7i especially indicated b7il

the continuation of the Axial Line is shewn in this figm'e. This line runs upwards 071 the

back of the thigh to the Crest of the Ilium and below, after encircling the Liner Malleolus, it

rims on the posterior aspect of the leg to 7-each the inner side of the thigh. On the back of the

limb the distribution is still moi'e complicated than on the anterior aspect, because the dorsal
nerves of the Plexus enter in, and the nerves of the muscles of the Gluteal Region have to be

divided into a Dorsal and a Ventral Group.

Obturator Internus Muscle, Gemelli and Quadratus Femoris Muscles belong to

the Flexor Group : to the Extensor Group belong, in front the Psoas Group, behind the
Gluteal Muscles, Tensor of the Fascia of the Thigh and the Pyriformis.
The following is the segmental relation :

Obturator Internus 5. I. II. (Ill), Gemellus Superior 5. I. II. (Ill), Quadratus 4.

5. I. Gemellus Inferior 4. 5. I. (so that the first two and the last two go together).
Psoas and Psoas Minor 1. 2. 3. (4), Iliacus 2. 3. 4. belong to the Extensor Group.
Gluteus Maximus is supplied by 4. 5. I. II. Medius and Minimus by 4. 5. I-

Tensor of the Fascia of the Thigh 4. 5. I. Iliac Portion of the Quadratus Lumborum
1. 2. 3. (4).

The Motor part of the Internal Popliteal supplies the Muscles of the Thigh, Leg
and Foot: Long Head of Biceps 4. 5. I (or according to Bölk I and II); Semitendinosus
and Semimembranosus 4. 5. I; Adductor Magnus (hamstring portion) (3) 4. (and 5). To
the Superficial Muscles of the Calf and the Popliteus 4. 5. I (II) are generally accepted:
for the deep Flexors 5. I. (II). The terminal branches contain 5. I. II, the Internal Plantar
chiefly 5. I, the External mostly I and II.

The motor fibres of the Obturator Nerve (2. 3. 4.) are divided as follows: —
Obturator Externus 3 and 4. Adductor Magnus (2) 3 and 4. Adductor Brevis 2. 3. 4.

Adductor Longus 2 and 3. Pectineus (exceptionally) 2. 3. Gracilis 2. 3. (and 4).

Sensory part: — the Small Sciatic Nerve is composed of I. II and III; Internal
Popliteal Nerve I and II and its continuation also I and II, on the sole of the foot the

Internal Plantar 5 and I, the External I and II. The Cutaneous Fibres of the Obturator
Nerve are like the motor fibres derived from 2. 3 and 4.

Over the Sacrum the Dorsal Branches of the Sacral Nerves and the Coccygeal
Nerve must be mentioned. They are chiefly derived from II and III (yellow). As
other nerves take part in the supply of this area, the other colours Green, Blue and
Red for the Coccygeal Nerve should have been put in.

The red colour (indicative of the ist segment of a new plexus) has been omitted
to avoid complexity in the figure.

On the outer side of the Hip it is necessary to remember the Ilio-hypogastric

superficial to the Fascia covering the Gluteus Medius Muscle (Schwalbe).