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NEW YORK SCHOOL OF REGIONAL ANESTHESIA
Hadzic’s Peripheral Nerve

Blocks and Anatomy for
Ultrasound-Guided
Regional Anesthesia
Hadzic_FM_00i-xvi.indd 1 14/06/21 10:35 PM

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NEW YORK SCHOOL OF REGIONAL ANESTHESIA
Hadzic’s Peripheral Nerve

Blocks and Anatomy for
Ultrasound-Guided
Regional Anesthesia
THIRD EDITION
Editors
Ana M. Lopez, MD, PhD, DESA
Consultant Anesthesiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
Angela Lucia Balocco, MD
Research Associate NYSORA, The New York School of Regional Anesthesia
Anesthesia Resident, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
Catherine Vandepitte, MD, PhD
Research Associate NYSORA, The New York School of Regional Anesthesia
Admir Hadzic, MD, PhD
Director NYSORA, The New York School of Regional Anesthesia
Visiting Professor, Department of Anesthesiology, Katholieke Universiteit Leuven (KUL), Belgium
Honorary Professor, University of Ljubljana, Slovenia
Doctor Honoris Causa, Karol Marcinkowski University of Medical Sciences, Poznan, Poland
New York Chicago San Francisco Lisbon London Madrid Mexico City
New Delhi San Juan Seoul Singapore Sydney Toronto

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DEDICATION
We dedicate this book to Jerry Vloka, MD, PhD

in recognition of his pioneering contributions to regional anesthesia
and immense inspiration for generations of students
and scholars of anesthesiology.

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9781260470055_PTCE_PASS3.indb 2
CONTENTS
Contributors ix 15. Infraclavicular Brachial Plexus Block 161

Foreword xiii 16. Costoclavicular Brachial Plexus Block 169
Acknowledgments xv 17. Axillary Brachial Plexus Block 177
18. Blocks for Analgesia of the Shoulder:
Phrenic Nerve Sparing Blocks 185
SECTION 1
19. Blocks About the Elbow 195
FOUNDATIONS 20. Wrist Block 205
1. Functional Regional Anesthesia Anatomy 3
2. Local Anesthetics: Clinical Pharmacology
and Selection 33 SECTION 4
3. Equipment for Peripheral Nerve Blocks 47 LOWER EXTREMITY BLOCKS
4. Electrical Nerve Stimulation 57 21. Lumbar Plexus Block 217
5. Optimizing Ultrasound Image 67 22. Fascia Iliaca Block 229
6. Monitoring and Documentation 23. Blocks for Hip Analgesia 239
in Regional Anesthesia 75
24. Femoral Nerve Block 247
7. Indications for Peripheral Nerve Blocks 89
25. Subsartorial Blocks: Saphenous Nerve,
8. Continuous Peripheral Nerve Blocks 101 Adductor Canal, and Femoral
9. Local Anesthetic Systemic Toxicity and Triangle Blocks 255
Allergy to Local Anesthetics 107 26. Lateral Femoral Cutaneous
10. Neurologic Complications of Nerve Block 265
Peripheral Nerve Blocks 117 27. Obturator Nerve Block 271
11. Preparation for Regional Anesthesia and 28. Proximal Sciatic Nerve Block 281
Perioperative Management 123
29. Popliteal Sciatic Block 291
30. Genicular Nerves Block 299
SECTION 2
31. iPACK Block 305
HEAD AND NECK BLOCKS 32. Ankle Block 313
12. Cervical Plexus Block 131
SECTION 5
SECTION 3
TRUNK AND ABDOMINAL
UPPER EXTREMITY BLOCKS WALL BLOCKS
13. Interscalene Brachial Plexus Block 143 33. Intercostal Nerve Block 325
14. Supraclavicular Brachial Plexus Block 153 34. Pectoral Nerves Block 333

viii Contents
35. Serratus Plane Block 341 39. Rectus Sheath Block 379
36. Paravertebral Block 349 40. Quadratus Lumborum Blocks 385
37. Erector Spinae Plane Block 359
38. Transversus Abdominis Plane Blocks 367 Index 395

CONTRIBUTORS
David Alvarez, MD Javier Domenech de la Lastra, MD, DESA

Department of Anesthesiology Department of Anesthesiology
Hospital Universitari de Bellvitge Hospital Clinic de Barcelona
Barcelona, Spain Barcelona, Spain
(Chapter 20) (Chapter 16)
Angela Lucia Balocco, MD Robin De Meirsman, MD

Ziekenhuis Oost-Limburg UZ Leuven
Genk, Belgium Leuven, Belgium
(Chapters 9, 11, 19, 31, 35, 37, 38, 39, and 40) (Chapter 34)
Jonas Bruggen, MD Dimitri Dylst, MD

UZ Leuven Ziekenhuis Oost-Limburg
Leuven, Belgium Genk, Belgium
Robbert Buck, MD Christopher J. Edwards, MD

UZ Antwerpen Wake Forest Baptist Medical Center
Antwerpen, Belgium Winston Salem, North Carolina
(Chapter 12) United States of America
(Chapter 36)
Eveline Claes, MD
Department of Anesthesiology Gert-Jan Eerdekens, MD
AZ Diest Department of Anesthesiology
Diest, Belgium UZ Leuven
(Chapter 10) Leuven, Belgium
(Chapters 17 and 40)
Tomás Cuñat, MD, DESA
Department of Anesthesiology Victor Frutos, MD
Hospital Clinic de Barcelona Department of Anesthesiology and Pain Clinics
Barcelona, Spain Hospital Universitari Germans Trias i Pujol
(Chapter 30) Badalona, Spain
(Chapter 1)
Lotte Cuyx, MD
Department of Anesthesiology Jeff Gadsden, MD
UZ Leuven Department of Anesthesiology
Leuven, Belgium Duke University Hospital
(Chapter 38) Durham, North Carolina
United States of America
Olivier De Fré, MD (Chapter 10)
Anesthesiology Department
AZ Herentals Levin Garip, MD
Herentals, Belgium Department of Anesthesiology
(Chapter 2) UZ Leuven
Leuven, Belgium
(Chapter 2)

x Contributors
Admir Hadzic, MD, PhD Leen Janssen, MD

Director, The New York School of Regional Anesthesia Department of Anesthesiology
New York, United States of America UZ Antwerpen
Department of Anesthesiology Antwerpen, Belgium
Ziekenhuis Oost-Limburg (Chapter 5)
Genk, Belgium
(Chapters 3, 4, 10, and 11) Manoj K. Karmakar, MD
Director of Pediatric Anesthesia
Rawad Hamzi, MD Chinese University of Hong Kong
Department of Anesthesia and Pain Management Prince of Wales Hospital
Wake Forest Baptist Medical Center Sha Tin, Hong Kong, China
Winston Salem, North Carolina, (Chapter 21)
(Chapter 33) Bram Keunen, MD
Department of Anesthesiology
Tyler Heijnen, MD Ziekenhuis Oost-Limburg
Department of Anesthesiology Genk, Belgium
Ziekenhuis Oost-Limburg (Chapter 15)
Genk, Belgium
(Chapter 18)
Samantha Kransingh, FCA, FANZCA
South Canterbury District Health Board
Jelena Heirbaut, MD
Timaru, New Zealand
(Chapters 5 and 22)
UZ Antwerpen
Antwerpen, Belgium
(Chapter 4) Queenayda A. D. Kroon, MD
Department of Anesthesia and Pain Management
Jore Hendrikx, MD University Medical Centre Maastricht
Department of Anesthesiology Maastricht, The Netherlands
UZ Leuven (Chapter 33)
Leuven, Belgium
(Chapter 31) Annelies Langenaeken, MD
Lotte Hendrix, MD UZ Leuven
Department of Anesthesiology Leuven, Belgium
UZ Leuven (Chapter 29)
Leuven, Belgium
(Chapter 13) Raphaël Lapré, MD
Daryl S. Henshaw, MD
AZ Rivierenland
Department of Anesthesiology and Pain Management
Reet, Belgium
Wake Forest Baptist Medical Center
(Chapter 2)
Winston Salem, North Carolina
(Chapter 36) Ana Lopez, MD, PhD
Peter Hulsbosch, MD Ziekenhuis Oost-Limburg
Department of Anesthesiology Genk, Belgium
Regionaal Ziekenhuis Heilig Hart (Chapters 1, 11, 12, 16, 18, 20, 21, and 32)
Leuven, Belgium
(Chapter 15) Sofie Louage, MD
J. Douglas Jaffe, MD AZ Glorieux
Department of Anesthesiology and Pain Management Ronse, Belgium
Wake Forest Baptist Medical Center (Chapters 27, 28, and 29)
Winston Salem, North Carolina
(Chapter 33)

Contributors xi
Leander Mancel, MD Filiep Soetens, MD

UZ Leuven AZ Turnhout
Leuven, Belgium Turnhout, Belgium
(Chapter 6) (Chapters 2 and 9)
Berend Marcus, MD Sam Van Boxstael, MD

UZ Leuven Ziekenhuis Oost-Limburg
Leuven, Belgium Genk, Belgium
(Chapter 7) (Chapters 24, 25, and 26)
Evi Mellebeek, MD Imré Van Herreweghe, MD

Ziekenhuis Oost-Limburg AZ Turnhout
Genk, Belgium Turnhout, Belgium
(Chapter 24) (Chapters 2 and 7)
Felipe Muñoz-Leyva, MD Astrid Van Lantschoot, MD

Department of Anesthesia and Pain Management Department of Anesthesiology
University Health Network, University of Toronto, Ziekenhuis Oost-Limburg
Toronto Western Hospital Genk, Belgium
Toronto, Ontario, Canada (Chapters 34 and 35)
(Chapters 9 and 37)
Kathleen Van Loon, MD
Gwendolyne Peeters, MD Department of Anesthesiology
Department of Anesthesiology UZ Leuven
UZ Gent Leuven, Belgium
Gent, Belgium (Chapter 9)
(Chapter 9)
Jill Vanhaeren, MSc
Xavier Sala-Blanch, MD Research Associate
Department of Anesthesiology The New York School of Regional Anesthesia
Hospital Clinic de Barcelona New York, United States of America
Barcelona, Spain (Chapter 39)
(Chapters 1 and 23)
Catherine Vandepitte, MD, PhD
Amar Salti, MD, EDRA Department of Anesthesiology
Department of Anesthesia and Pain Medicine Ziekenhuis Oost-Limburg
Sheikh Khalifa Medical City Genk, Belgium
Abu Dhabi, United Arab Emirates (Chapters 6, 8, 11, 15, 17, 19, and 28)
(Chapter 22 and 27)
Stefanie Vanhoenacker, MD
Ruben Schreurs, MD Department of Anesthesiology
Department of Anesthesiology Sint-Jozefskliniek Izegem
Ziekenhuis Oost-Limburg Izegem, Belgium
Genk, Belgium (Chapter 14)
(Chapter 25)
Thibaut Vanneste, MD
Jeroen Smet, MD Department of Anesthesiology
Department of Anesthesiology Ziekenhuis Oost-Limburg
UZ Gent Genk, Belgium
Gent, Belgium (Chapters 13, 14, 23, and 30)
(Chapter 3)

xii Contributors
Rob Vervoort, MD Daquan Xu

Department of Anesthesiology Associate Researcher
UZ Leuven The New York School of Regional Anesthesia
Leuven, Belgium New York, United States of America

FOREWORD
The third edition of this standard textbook on ultrasound NYSORA’s Reverse Ultrasound Anatomy™ (RUA) images
nerve blocks is released during a unique period in human his- feature functional anatomy or block techniques with clear
tory. The COVID-19 pandemic and the threats that the disease instructions on the principles and goals of each given tech-
poses to both patients and healthcare workers have substan- nique. These cognitive aids entailed countless hours of work
tially changed perioperative practice. During the pandemic, and collaboration between NYSORA’s creative and edito-
regional anesthesia was established as the preferred method rial teams to develop highly didactic creatives that facilitate
over general anesthesia whenever possible. Nerve blocks pre- understanding of the anatomy, fascial planes, and principles
serve respiratory function and avoid aerosolization during of nerve blockade. RUA helps students memorize sono-
intubation and extubation and, hence, viral transmission to anatomy patterns, which is essential for ultrasound imaging.
other patients and healthcare workers. As an example, the use The knowledge of the sonoanatomy patterns substantially
of nerve blocks as the preferred surgical anesthesia method increases ultrasound proficiency and skills retention. Wher-
during the pandemic allowed many limb surgeries to be car- ever applicable, clinical images of the patient’s position,
ried out with decreased exposure to healthcare workers and ultrasound transducer placement, and anatomical detail are
less burden on post-anesthesia care units (PACUs) and utili- featured. Recent relevant literature was added to the “Sug-
zation of hospital beds. With regional anesthesia, patients can gested Reading” for readers who like to explore the original
leave acute postoperative care facilities faster and avoid admis- sources of the information presented. We chose this approach
sion to the limited hospitalization beds. In our center, using in an effort to provide the most practical, pragmatic informa-
regional anesthesia and nerve blocks as the main anesthetic tion and relieve the content from massive literature citations.
choice allowed elective orthopedic surgery in many patients. Readers should be advised that this book is not meant to be
The use of ultrasound-guided local regional anesthesia (LRA) an encyclopedic listing of all techniques and their variations.
has increased exponentially in the last few years. The traditional Rather, our textbook should be viewed as a compendium of
techniques have been refined and a number of new approaches well-established knowledge, didactically organized for learn-
have been devised to better suit the evolving clinical practice. ing, and transferring knowledge to students of anesthesiology.
Nerve blocks are an essential component of multimodal analge- With this approach, the textbook aims to help standardize, and
sia in enhanced recovery after surgery (ERAS) protocols. Their implement well-established techniques, indications, pharma-
use enhances analgesia and reduces or eliminates the use of opi- cology, monitoring, and the documentation of nerve blocks.
oids in the postoperative period. Some traditional nerve block Instead of burdening the reader with experimental block tech-
techniques have been substituted by more selective techniques niques with unproven clinical benefit, we aimed to include
to minimize motor block and facilitate early rehabilitation and the most clinically useful nerve block, fascial, and infiltration
recovery. New ultrasound-guided fascial plane techniques, dis- techniques with proven efficacy and clinical applicability.
tal nerve blocks, and selective periarticular injections also are Information about perioperative management and local anes-
increasingly being used to yield a better balance between effi- thetic toxicity treatment was also added, and/or fully revised.
cacy, simplicity, safety, and sensory-motor block ratio. Because patients commonly present with a vague history of
This third edition of NYSORA’s textbook is substantially allergy to local anesthetics, the new edition also features highly
updated and revised to include the many new developments practical algorithms to facilitate decision-making and manage-
in regional anesthesia and trends in clinical practice. The new ment of allergy to local anesthetics.
edition features entirely new artwork, new clinical images, We are confident that this textbook will continue to be one
and new fascial plane and infiltration techniques. All in all, of the primary resources on peripheral nerve blocks in medi-
some 500 new algorithms, illustrations, ultrasound images, cal practices worldwide.
clinical photographs, and cognitive aids were included to
Sincerely,
facilitate learning. In addition to anesthesiologists, the highly
didactic and organized technique descriptions and func- Drs Hadzic, Lopez, Balocco, and Vandepitte
tional anatomy principles will be valuable to all anesthesia
providers, acute and chronic pain specialists, as well as inter- Free access to online videos at www.accessanesthesiology.com.
ventional pain, musculoskeletal medicine, and emergency Search for this title in the library and select “View All Videos”
department physicians. in the Multimedia widget on the landing page of the book.

9781260470055_PTCE_PASS3.indb 2
ACKNOWLEDGMENTS
This book would not be possible without the extraordinary football teams; innovators; and above all incredibly skilled
people who contributed their time and talent and undying and passionate surgeons. It has been an absolute pleasure
commitment to create an educational masterpiece. Many building the orthopedic anesthesia service with you. A short
thanks to Drs Ana Lopez (senior editor), Angela Lucia glimpse at the website of the department of orthopedic
Balocco, and Catherine Vandepitte, the third edition editors. surgery at ZOL is sufficient to get a sense that NYSORA-
Their combination of commitment, knowledge, research, EUROPE at ZOL is flanked by true giants of orthopedic sur-
and clinical expertise is apparent on every page of this book. gery (https://www.zol.be/raadplegingen/orthopedie).
Many thanks to the leadership at Ziekenhuis Oost-Limburg Thank you to the NYSORA International Team: Pat Pokorny
(ZOL; Genk, Belgium) for their support and for facilitating a (UK), Kusum Dubey (New Delhi), Katherine Hughey-Kubena
creative platform in the hospital’s clinical setting. In particu- (USA), Elvira Karovic, Medina Brajkovic, Ismar Ruznjic (B&H),
lar, many thanks to the medical director, Dr. Griet Vander Nenad Markovic (SER), Jill Vanhaeren, and Greet van Meir
Velpen, and the “can-solve-all” manager, Chantal Desticker. (BE). This is an incredible team of NYSORA’s go-getters.
Without your support, this book, and the creation of our cen- Thank you to NYSORA’s illustrator Ismar Ruznjic for
ter of excellence for regional anesthesia at ZOL, would not be the new-style illustrations and artwork he imparted to this
possible. Thank you to the leadership of the department, espe- edition. Ismar has grown with NYSORA to become one of
cially Rene Heylen, Jan Van Zundert, and Pieter De Vooght; the world’s very best anatomy illustrators.
their vision led to the creation of one of the best regional A big thank you to our designer and 3-D maestro, Nenad
anesthesia centers in the heart of Europe. Thank you to our Markovic, an ultimate perfectionist, whose eye has been con-
regional anesthesia team and block nurses Birgit Lohmar, structively critical to many artistic and stylistic aspects of this
Joelle Caretta, Ine Vanweert, Kristell Broux, Ilse Cardinaels, book, and NYSORA’s content at large.
Sydney Herfs, Elke Janssen, Hüda Erdem, Mohamed Rafiq, Finally, a huge thanks to all the contributors to this book,
Danny Baens, and all the operating nurses in the N-Block at as there have been quite a few. Such a volume, packed with so
the orthopedic surgery unit. much anatomical information, can always have hidden errors.
Many thanks to all top fellows in regional anesthesia. We have relied on our stellar contributors to detect and cor-
These young, bright doctors contribute immense value to rect them wherever possible. However, should the readers
our teaching mission, and carry on the mission of national find any that we have missed that require correction, please
ambassadors of regional anesthesia after graduation. Big forward them to info@nysora.com. We vouch to improve
gratitude to our anesthesia residents who rotate through our upon them and thank you immensely in advance for your
service from their mothership Universities: Leuven (KUL), feedback.
Gent, Antwerp, and others.
Many thanks to all,
Our orthopedic surgery department is by all means one
of the best in Europe and beyond. Made up of ultra high- Editors
achievers; physicians of national, Olympic, and professional

9781260470055_PTCE_PASS3.indb 2
1
SECTION
Foundations
Chapter 1 Functional Regional Anesthesia Anatomy 3

Chapter 2 Local Anesthetics: Clinical Pharmacology
and Rational Selection 33
Chapter 3 Equipment for Peripheral Nerve Blocks 47
Chapter 4 Electrical Nerve Stimulation 57
Chapter 5 Optimizing Ultrasound Image 67
Chapter 6 Monitoring and Documentation in Regional Anesthesia 75
Chapter 7 Indications for Peripheral Nerve Blocks 89
Chapter 8 Continuous Peripheral Nerve Blocks 101
Chapter 9 Local Anesthetic Systemic Toxicity
and Allergy to Local Anesthetics 107
Chapter 10 Neurologic Complications of Peripheral Nerve Blocks 117
Chapter 11 P
reparation for Regional Anesthesia
and Perioperative Management 123
Hadzic_Ch01_p001-032.indd 1 10/06/21 3:55 PM

9781260470055_PTCE_PASS3.indb 2
1 Functional Regional
Anesthesia Anatomy
Knowledge of anatomy is essential for the practice of regional biotechnology may eventually result in development of the
anesthesia and ultrasound-guided regional anesthesia proce- strategies to promote axonal growth and reduce neuronal death.
dures. This chapter provides a concise overview of the essential A typical neuron consists of a cell body (soma) with a
functional anatomy necessary for the implementation of tradi- large nucleus. The cell body is attached to several branching
tional and ultrasound-guided regional anesthesia techniques. processes, called dendrites, and a single axon (Figure 1-2).
Figure 1-1 demonstrates the anatomical planes and directions Dendrites receive incoming messages, whereas single axons per
used as a conventional approach throughout the book. neuron conduct outgoing messages. In peripheral nerves, axons
are long and slender; they are often referred to as nerve fibers.
Anatomy of Peripheral Nerves
The neuron is the basic functional unit responsible for nerve
conduction. Neurons are the longest cells in the body, often as
Connective Tissue
long as 1 meter. Most neurons have a limited ability to repair The peripheral nerve is composed of three types of fibers:
after injury. Advances in the understanding of the neurobi- (1) somatosensory or afferent nerves, (2) motor or effer-
ology of nerve regeneration and experimental advances in ent nerves, and (3) autonomic nerves. In a peripheral
FIGURE 1-1. Conventional body planes and directions. Red,

sagittal; orange, sagittal paramedian; green, transverse; and purple,
coronal or axial.

4 SEC TION 1 Foundations
FIGURE 1-2. Composition of the neuron.
nerve (Figure 1-3), individual axons are enveloped in a loose structures filling the space in between them, such as the
and delicate connective tissue, the endoneurium. Groups neurovascular bundles of intermuscular septae. This tissue
of axons are arranged within a bundle (nerve fascicle) sur- contributes to the functional mobility of nerves during joint
rounded by the perineurium. The perineurium imparts and muscular movement.
mechanical strength to the peripheral nerve and functions Of note, the fascicular bundles are not continuous through-
as a diffusion barrier to the fascicle, isolating the endo- out the peripheral nerve but divide and anastomose with one
neurial space and preserving the ionic milieu of the axon. another as frequently as every few millimeters (Figure 1-4).
At each branching point, the perineurium splits with the This arrangement of peripheral nerves helps to explain why
fascicle. The fascicles, in turn, are embedded in loose con- intraneural injections, which disrupt this organization, may
nective tissue called the interfascicular epineurium, which result in disastrous consequences as opposed to clean needle
contains adipose tissue, fibroblasts, mastocytes, blood ves- nerve cuts, which heal more readily. In the vicinity of joints,
sels, and lymphatics. The outer layer surrounding the nerve the fascicles are thinner, more numerous, and are likely sur-
is the epineurium, a denser collagenous tissue that protects rounded by a greater amount of connective tissue, which
the nerve. The paraneurium consists of loose connective reduces the vulnerability of the fascicles to pressure and
tissue that holds a stable relationship between adjacent stretching caused by movement.

Functional Regional Anesthesia Anatomy CHAPTER 1 5
Blood vessels
Axon Perineurium
Schwann cell
Epifascicular epineurium
Endoneurium
Mesoneurium
Spinal nerve
Dorsal root ganglion
Ventral root
FIGURE 1-3. Organization of the peripheral nerve.
Peripheral nerves receive blood supply from the adjacent group of longitudinal capillaries that run within the fascicles
blood vessels running along their course. There are two inde- and endoneurium. Neuronal injury after nerve blockade may
pendent interconnected vascular systems. The extrinsic sys- be due, at least partly, to the pressure or stretch within con-
tem consists of arteries, arterioles, and veins that lie within nective sheaths and the consequent interference with the vas-
the epineurium. The intrinsic vascular system comprises a cular supply to the nerve.

FIGURE 1-4. Diagram of fascicular arrangement in a peripheral nerve.
the dorsal root ganglia and enter the dorsolateral aspect of the
Communication Between the spinal cord to form the dorsal root. The motor fibers arise from
Central Nervous System and neurons in the ventral horn of the spinal cord and pass through
Peripheral Nervous Systems the ventrolateral aspect of the spinal cord to form the ventral
The central nervous system (CNS) communicates with the body root. The dorsal and ventral roots converge in the interverte-
through spinal nerves, which have sensory and motor compo- bral foramen to form the spinal nerves, which then divide into
nents (Figure 1-5). The sensory fibers arise from neurons in dorsal and ventral rami. The dorsal rami innervate muscles,
FIGURE 1-5. Schematic transverse section of thoracic vertebra showing the spine and the origin of
spinal nerves.

FIGURE 1-6. Anatomy of a typical spinal intercostal nerve.
bones, joints, and the skin of the back along the posterior mid- is no C8 vertebra, the C8 nerve passes between the C7 and
line. The ventral rami innervate muscles, bones, joints, and the T1 vertebrae.
skin of the antero-lateral aspect of the neck, thorax, abdomen, In the thoracic region, the T1 nerve passes between the T1
pelvis, and the extremities (Figure 1-6). and T2 vertebrae. This pattern continues down through the
remainder of the spine. The vertebral arch of the fifth sacral
and first coccygeal vertebrae is rudimentary. Because of
this, the vertebral canal opens inferiorly at the sacral hiatus,
Spinal Nerves where the fifth sacral and first coccygeal nerves pass. Roots of
There are 31 pairs of spinal nerves: 8 cervical, 12 thoracic, spinal nerves must descend through the vertebral canal before
5 lumbar, 5 sacral, and 1 coccygeal. Spinal nerves pass exiting the vertebral column through the appropriate inter-
through the vertebral column at the intervertebral foramina vertebral foramen since the inferior end of the spinal cord
(Figure 1-7). The first cervical nerve (C1) passes superior to (conus medullaris) is located at the L1-L2 vertebral level in
the C1 vertebra (atlas). The second cervical nerve (C2) passes adults. Collectively, these roots are called the cauda equina.
between the C1 (atlas) and C2 (axis) vertebrae. This pattern Outside the vertebral column, ventral rami from cervi-
continues down the cervical spine; however, because there cal and lumbosacral spinal levels coalesce to form intricate

Thoracic and Abdominal Wall

1 C1
Thoracic Wall
2 C2
3
C3 The intercostal nerves originate from the ventral rami of
Cervical 4
5
C4
C5
the first 11 thoracic spinal nerves (T1-T11). Each intercostal
6 C6 nerve becomes part of the neurovascular bundle of the rib
7
and provides sensory and motor innervations (Figure 1-9).
C7
8 T1
1
2
T2
T3
Except for the first, each intercostal nerve gives off a lateral
3 T4 cutaneous branch that pierces the overlying muscle near the
T5
4
5 T6 midaxillary line. This cutaneous nerve divides into anterior
Thoracic
6 T7
and posterior branches, which supply the adjacent skin. The
7 T8
8 T9 intercostal nerves from the second to the sixth space reach
9 T10 the anterior thoracic wall and pierce the superficial fascia
10
11
T11
near the lateral border of the sternum and divide into medial
T12
12 and lateral cutaneous branches.
L1
1 Most fibers of the anterior ramus of the first thoracic spinal
L2
2
nerve join the brachial plexus for distribution to the upper
L3
limb. The small first intercostal nerve is the lateral branch
Lumbar 3 L4
and supplies only the muscles of the intercostal space, not the
4 L5 overlying skin. In contrast, the lower five intercostal nerves
5 S1
S2
abandon the intercostal space at the costal margin to supply
1
2
S3
S4 the muscles and skin of the abdominal wall.
Sacral 3 S5
4
5
Coccygeal
Anterior Abdominal Wall
The lower six thoracic nerves and the first lumbar nerve
FIGURE 1-7. Spinal nerves. innervate the skin, muscles, and parietal peritoneum of the
anterior abdominal wall. At the costal margin, the seventh
to eleventh thoracic nerves (T7-T11) leave their intercostal
networks called plexuses from which nerves extend into the
spaces and enter the abdominal wall in a fascial plane between
neck, the arms, and the legs.
the transversus abdominis and internal oblique muscles. The
seventh and eighth intercostal nerves slope upward following
Dermatomes, Myotomes, the contour of the costal margin, ninth runs horizontally, and
the tenth and eleventh have a downward trajectory. Anteri-
and Osteotomes orly, the nerves pierce the rectus abdominis muscle and the
A dermatome is the area of the skin supplied by the dor- anterior layer of the rectus sheath to emerge as anterior cuta-
sal (sensory) root of a specific spinal nerve (Figure 1-8). In neous branches that supply the overlying skin (Figure 1-9).
the trunk, each segment is horizontally disposed, except C1, The subcostal nerve (T12) takes the line of the twelfth rib
which does not have a sensory component. The dermatomes across the posterior abdominal wall. It continues around the
of the limbs from the fifth cervical to the first thoracic nerve flank and terminates similarly to the lower intercostal nerves.
(C5-T1) and from the third lumbar to the second sacral ver- The seventh to twelfth thoracic nerves (T7-T12) give off lat-
tebrae (L3-S2) extend like a series of bands from the midline eral cutaneous nerves, which further divide into anterior and
of the trunk posteriorly into the limbs. Of note, there is con- posterior branches. The anterior branches supply the skin as
siderable overlapping between adjacent dermatomes. far forward as the lateral edge of the rectus abdominis. The
A myotome is the segmental innervation of skeletal mus- posterior branches supply the skin overlying the latissimus
cle by a ventral root of a specific spinal nerve (Figure 1-8). dorsi. The lateral cutaneous branch of the subcostal nerve is
An osteotome is the area of the bone supplied by the sensory distributed to the skin on the side of the buttock.
root of the specific spinal nerve. The iliohypogastric and ilioinguinal nerves, both branches
Distribution of dermatomes, myotomes, and osteotomes of L1, supply the inferior part of the abdominal wall. The ilio-
does not follow the same pattern in some areas, where dif- hypogastric nerve runs above the iliac crest and splits into
ferent nerves supply the innervation of deep and superfi- two terminal branches. The lateral cutaneous branch supplies
cial structures (Figure 1-8). Regardless, the knowledge of the side of the buttock; the anterior cutaneous branch sup-
their distribution is relevant for the application of regional plies the suprapubic region.
anesthesia as a guide to decide which block techniques are The ilioinguinal nerve leaves the intermuscular plane by
appropriate to provide adequate analgesia and anesthesia piercing the internal oblique muscle above the iliac crest.
for specific surgical procedures. It continues between the two oblique muscles to enter the

FIGURE 1-8. Distribution of dermatomes, myotomes, and osteotomes: (A) anterior view and (B) posterior view.

Dorsal root
(sensory root)
Ventral root
(motor root)
Spinal ganglion
Meningeal ramus
Spinal nerve
Dorsal ramus (posterior)

with medial ramus and Sympathetic ganglion
lateral ramus Lateral cutaneous ramus
Ventral cutaneous ramus
Ramus communicans
Ventral ramus
FIGURE 1-9. Course and distribution of an intercostal nerve.
inguinal canal through the spermatic cord. Emerging from periphery of the diaphragm. Inflammation of the peritoneum
the superficial inguinal ring, it gives cutaneous branches to gives rise to pain in the lower thoracic and abdominal wall. In
the skin on the medial side of the root of the thigh, the proxi- contrast, the peritoneum on the central part of the diaphragm
mal part of the penis, and the front of the scrotum in males receives sensory branches from the phrenic nerves (C3, C4,
and the mons pubis and the anterior part of the labium majus and C5), and irritation in this area may produce pain in the
in females. region of the shoulder (the fourth cervical dermatome).
Nerve Supply to the Peritoneum Nerve Plexuses

The lower thoracic and first lumbar nerves innervate the The ventral rami of the cervical, lumbar, and sacral spinal
parietal peritoneum of the abdominal wall. The lower tho- nerves form a neural network known as plexuses. The nerve
racic nerves also innervate the peritoneum that covers the fibers from these spinal segments distribute in different

FIGURE 1-10. Organization of the cervical plexus from roots to terminal nerves.
terminal nerves. The four major nerve plexuses are the cervi- anterior scalene muscle, passes through the superior tho-
cal, brachial, lumbar, and sacral plexus. racic aperture, and descends on the walls of the mediasti-
num to innervate the diaphragm (phrenic nerve). Thus, the
cervical plexus has a relevant role in maintaining the respira-
The Cervical Plexus tory function. Superficial branches from the cervical plexus
The cervical plexus originates from the ventral rami of C1 pass around the posterior margin of the sternocleidomas-
to C5, which form three loops (Figure 1-10). Deep motor toid muscle and provide sensory innervation to the skin of
branches originating from these loops innervate the infra- the lateral scalp, neck, clavicle, shoulder, and upper thorax
hyoid and scalene muscles. Fibers from C3 to C5 form the (Figure 1-11). Table 1-1 describes the origin and innerva-
phrenic nerve, which descends on the anterior surface of the tion of each nerve of the cervical plexus.

FIGURE 1-11. Dissection of the superficial branches of the cervical plexus.
TABLE 1-1 Organization and Distribution of the Cervical Plexus

NERVES SPINAL SEGMENTS DISTRIBUTION
Ansa cervicalis (superior and inferior C1-C3 Five of the extrinsic laryngeal muscles (sternothyroid,
branches) sternohyoid, omohyoid, geniohyoid, and thyrohyoid)
by way of cranial nerve XII
Lesser occipital, transverse cervical, C2-C4 Skin of upper chest, shoulder, neck, and ear
supraclavicular, and greater auricular
nerves
Phrenic nerve C3-C5 Diaphragm
Cervical nerves C1-C5 Levator scapulae, scalene muscles, sternocleidomastoid
muscles, and trapezius muscles (with cranial nerve XI)

FIGURE 1-12. Organization of the brachial plexus from roots to terminal nerves.
The Brachial Plexus (C8-T1) trunks (Figure 1-12). At the level of the clavicle,
every trunk gives off an anterior and a posterior division.
The ventral rami of spinal nerves C5-T1 form the brachial These divisions rearrange their fibers to form the lateral,
plexus, which innervates bones, joints, muscles, and the medial, and posterior cords, which in turn give off the
skin of the upper extremity and shoulder girdle. Between peripheral nerves for the upper extremity (Figure 1-13).
the anterior and middle scalene muscles, the roots converge Table 1-2 describes the origin and innervation of each nerve
to form the superior (C5-C6), middle (C7), and inferior of the brachial plexus.

FIGURE 1-13. Dissection of the brachial plexus from the roots in the neck to the axillary fossa.
TABLE 1-2 Anatomy of the Brachial Plexus C5-T1

MYOTOMES
NERVE
(TERMINAL SPINAL MOTOR
BRANCH) NERVES TRUNK CORD MUSCLES RESPONSE SCLEROTOMES DERMATOMES
Long thoracic C5-C7 Serratus Forward
anterior flexion of
the arm and
contraction of
the serratus
anterior
Dorsal C5 Levator scap- Elevation of
scapular ulae, rhom- the scapula
boid muscles
Nerves to C4-C6 Upper Subclavius Sternoclavicular
subclavius joint

TABLE 1-2 Anatomy of the Brachial Plexus C5-T1 (Continued)

MYOTOMES
NERVE
Suprascapular C5-C6 Upper Supra- Abduction Glenohumeral
spinatus, and lateral and acromiocla-
infraspinatus rotation of vicular joints, sub-
the shoulder acromial bursa
Subscapular C5-C6 Upper Posterior Subscapularis, Adduction Deep surface of
(upper and teres major and medial the scapula
lower) rotation of
the shoulder
Thoracodorsal C6-C8 Upper, Posterior Latissimus Extension,
middle, dorsi adduction,
lower and medial
rotation of
the shoulder
Axillary C5-C6 Upper Posterior Deltoid, teres Abduction Glenohumeral Anterior and
minor and lateral anterior and posterior
rotation of acromioclavicular shoulder
the shoulder joints
Radial C5-T1 Upper, Posterior Triceps, Extension of 1st/3rd superior Posterior arm
middle, anconeus, the elbow, humerus, elbow and forearm,
lower brachioradia- wrist, and joint, radius, ulna, dorsal aspect of
lis, extensor fingers, supi- carpus, 1st-3rd the hand (1st-4th
carpi radialis nation of metacarpus and fingers)
longus and the forearm, phalanges
brevis, supina- abduction of
tor, extensor the wrist and
digitorum thumb
communis,
extensor
digiti minimi,
extensor carpi
ulnaris, exten-
sor indicis,
extensor pol-
licis longus
and brevis,
abductor
pollicis
Lateral C5-C7 Upper, Lateral Pectoralis Glenohumeral
pectoral middle minor, pecto- and acromiocla-
ralis major vicular joints
Musculocuta- C5-C6 Upper Lateral Coracobra- Flexion of the Humerus elbow Lateral forearm
neous chialis, biceps elbow and and proximal rim
brachii, supination of radioulnar joints
brachialis the forearm

TABLE 1-2 Anatomy of the Brachial Plexus C5-T1 (Continued)

MYOTOMES
NERVE
Median C6-T1 Upper, Lateral, Elbow: Pro- Flexion of Elbow joint Palmar aspect of
middle, medial nator teres, the wrist (anterior), radius, the hand (1st-4th
lower flexor carpi and 2nd-3rd ulna, 1st-4th fingers) and dor-
radialis, pal- fingers, pro- metacarpus and sal aspect of the
maris longus nation of the phalanges distal half of the
Forearm: forearm 2nd-4th fingers
Flexor
digitorum
superficialis/
profundus,
flexor pol-
licis longus,
pronator
quadratus
Hand: Thenar
muscles, 1st-
2nd lumbrical
muscles
Medial C8-T1 Lower Medial Pectoralis Clavicle
pectoral minor, pecto-
ralis major
Medial T1 Lower Medial Medial aspect of
brachial the arm
cutaneous
Medial C8-T1 Lower Medial Medial aspect of
antebrachial the forearm
cutaneous
Ulnar C8-T1 Middle Medial Flexor carpi Flexion of the Elbow joint, ulna Medial aspect of
ulnaris, flexor wrist and 4th- and medial aspect the hand, 4th-5th
digitorum 5th fingers, of the wrist, hand finger
profundus adduction of and 4th-5th
and interos- the thumb fingers
seous (4th-
5th fingers),
muscles of
the hypothe-
nar eminence,
adductor
pollicis, flexor
pollicis brevis

FIGURE 1-14. Organization of the lumbar plexus from roots to terminal nerves.
The Lumbar Plexus in the posterior abdominal wall between the psoas major
and quadratus lumborum muscles. The main branches
The ventral rami of spinal nerves L1-L4 form the lumbar of the lumbar plexus are the iliohypogastric, ilioinguinal,
plexus. They divide into anterior and posterior divisions genitofemoral, lateral femoral cutaneous, obturator, and
that coalesce to form the terminal nerves (Figure 1-14). femoral nerves (Figure 1-15 and Figure 1-16). Table 1-3
The lumbar plexus innervates the skin, muscles, peritoneal describes the origin and innervation of each nerve of the
lining of the lower abdominal wall, and the anteromedial lumbar plexus.
aspect of the lower extremities. The plexus runs caudally

FIGURE 1-15. Dissection of the lumbar plexus in the pelvic cavity.
Lateral femoral cutaneous

nerve
Inguinal ligament
Iliopsoas muscle
Femoral nerve
Tensor fasciae latae
Sartorius muscle
Pectineus muscle
Femoral artery
Femoral vein
Adductor longus muscle
Great saphenous vein
Gracilis muscle
FIGURE 1-16. Dissection of the femoral nerve below the inguinal ligament.

TABLE 1-3 Anatomy of the Lumbar Plexus L1-L4

MYOTOMES
NERVE
BRANCH) NERVES MUSCLES RESPONSE SCLEROTOMES DERMATOMES
Iliohypogastric T12-L1 Abdominal muscles Contraction of the Skin over inferior
(external and internal abdominal wall abdomen and
oblique, transverse (inguinal area) buttocks
abdominis)
Ilioinguinal L1 Internal oblique Contraction of the Skin over superior,
abdominal wall medial thigh, and
(inguinal area) portions of external
genitalia
Genitofemoral L1-L2 Cremaster Elevates the scrotum Anteromedial surface
of thigh and portions
over genitalia
Lateral femoral L2-L3 Anterolateral aspect
cutaneous of thigh
Femoral (anterior/ L2-L4 Sartorius, pectineus Flexion, aduction, Anteromedial aspect
superficial branches): and external rotation of thigh
anterolateral cutane- of the hip
ous, anteromedial
cutaneous
Femoral (posterior L2-L4 Quadriceps Extension of the Ilium, anterior and Anterior surface of
branch): saphe- knee, patellar lateral aspect of thigh, medial surface
nous, nerves to the femur, superior artic- of leg, and foot
quadriceps ular aspect of tibia;
hip and knee joints
Obturator L2-L4 Adductors of thigh Adduction of the Ischium, pubis, medial Medial surface of
(adductors magnus, thigh, external rota- aspect of femur; hip thigh
brevis, and longus); tion of the hip and knee joints
gracilis, obturator
externus
The Sacral Plexus between the greater trochanter and ischial tuberosity in the
gluteal area (Figure 1-18). In the proximal thigh, the nerve
The ventral rami of spinal nerves L4-L5 and S1-S4 form lies behind the lesser trochanter of the femur and is covered
the sacral plexus, which innervates the buttocks, perineum, superficially by the long head of the biceps femoris muscle.
posterior aspect of the thigh, and the whole leg below the The two components of the sciatic nerve diverge into two
knee, except the sensory territory of the saphenous nerve recognizable nerves as it approaches the popliteal fossa: the
(Figure 1-17). The main nerve is the sciatic nerve that leaves common peroneal and the tibial nerves. Table 1-4 describes
the pelvis through the greater sciatic foramen and travels the origin and innervation of each nerve of the sacral plexus.

FIGURE 1-17. Organization of the sacral plexus from roots to terminal nerves.
better understanding of the neuronal components that need

Innervation of the Major Joints to be anesthetized to achieve anesthesia for or analgesia after
Much of the practice of peripheral nerve blocks involves joint surgery. Table 1-5 summarizes the innervation and
orthopedic and joint surgery. Consequently, knowledge of kinetic function of the major muscle groups of the upper
the sensory innervation of major joints is important for a and lower extremities.

Gluteus maximus muscle
Superior gluteal
artery and nerve
Tendon of piriform muscle
Sacrotuberous ligament
Pudendal nerve
Sciatic nerve
Inferior gluteal nerve
Posterior femoral
cutaneous nerve
Ischial tuberosity
FIGURE 1-18. Dissection of the sciatic nerve at the pelvic outlet.
TABLE 1-4 Anatomy of the Sacral Plexus L4-S4

NERVE
(TERMINAL SPINAL MOTOR MOTOR RESPONSE TO
BRANCH) NERVES INNERVATION NEUROSTIMULATION DERMATOMES SCLEROTOMES
Gluteal (superior/ L4-S2 Abductors of thigh Contraction of the Medial and supe-
inferior) (gluteus minimus, buttocks and external rior aspect of the
gluteus medius, and rotation of the hip buttocks
tensor fasciae latae) and
extensor of thigh
(gluteus maximus)
Posterior femoral S1-S3 Skin of perineum
cutaneous and posterior
surface of thigh
and leg

TABLE 1-4 Anatomy of the Sacral Plexus L4-S4 (Continued)

NERVE
(TERMINAL SPINAL MOTOR MOTOR RESPONSE TO
BRANCH) NERVES INNERVATION NEUROSTIMULATION DERMATOMES SCLEROTOMES
Sciatic Gluteal Three of the hamstrings Extension of hip, flexion Hip joint; ischium,
level (semitendinosus and of knee posterior aspect
semimembranosus long of the femur
head of biceps femoris);
adductor magnus (with
obturator nerve)
Tibial L4-S3 Flexor of knee and Flexion of the knee, plan- Posterior aspect Knee, ankle, and
plantar flexors of ankle tar flexion of the foot and of leg, plantar all foot joints;
(popliteus, gastrocne- toes, inversion of the foot aspect of foot tibia, fibula, and
mius, soleus plantaris, plantar aspect of
and tibialis posterior the foot
muscles and long head
of biceps femoris mus-
cle); flexors of toes
Common L4-S2 Biceps femoris muscle Flexion of the knee, dorsi Anterior surface Knee, ankle, and
peroneal (short head); fibularis flexion of the foot and aspect of leg and all foot joints;
(brevis and longus) and toes, eversion of the foot dorsal aspect of proximal tibia and
tibialis anterior muscles; foot; skin over fibula and dorsal
extensors of toes lateral portion aspect of the foot
of foot (through
the sural nerve)
Pudendal S2-S4 Muscles of perineum, Motor contraction of the External genitalia,
including urogenital dia- muscles involved lower third of
phragm and external anal the urethra and
and urethral sphincter vagina, skin of the
muscles; skeletal muscles anal circumfer-
(bulbospongiosus, ischio- ence, caudal third
cavernosus muscles) of the rectum
Nerve to the qua- L4-L5 Quadratus femoris, infe- Adduction and external Hip joint
dratus femoris and rior gemellus rotation of the hip
inferior gemellus
Nerve to obtura- L5-S1 Superior gemellus, Abduction of the hip
tori and superior obturator internus
gemellus
Nerve to piriformis S1-S2 Piriformis Abduction and lateral
rotation of the hip
Nerves to coccyg- S3-S4 Coccygeus, levator ani Motor contraction of the
eus and levator ani muscles involved

TABLE 1-5 Summary of Movement by Joint

UPPER EXTREMITY
Shoulder (Glenohumeral) Joint
Flexion Biceps brachii—long head Musculocutaneous nerve
Coracobrachialis
Deltoid Axillary nerve
Pectoralis major Medial and lateral pectoral nerve
Extension Triceps brachii—long head Radial nerve
Latissimus dorsi Thoracodorsal nerve
Adduction Latissimus dorsi Thoracodorsal nerve
Pectoralis major Medial and lateral pectoral nerves
Teres major Lower subscapular nerve
Subscapularis Upper and lower subscapular nerve
Abduction Supraspinatus Suprascapular nerve
Medial rotation Pectoralis major Medial and lateral pectoral nerve
Latissimus dorsi Thoracodorsal nerve
Teres major Lower subscapular nerve
Subscapularis Upper and lower subscapular nerves
Lateral rotation Teres minor Axillary nerve
Infraspinatus Suprascapular nerve
Elbow (Humeroulnar, Humeroradial) Joint
Flexion Brachialis Musculocutaneous
Biceps brachii—long and short heads
Flexor carpi radialis Median nerve
Extension Triceps brachii—long lateral, medial head Radial nerve
Anconeus
Radioulnar Joints
Supination Biceps brachii—long and short head Musculocutaneous
Supinator Radial nerve
Pronation Pronator teres Median nerve
Pronator quadratus
Wrist (Radiocarpal, Ulnocarpal) Joint
Flexion Flexor carpi radialis Median nerve
Palmaris longus
Flexors of fingers listed below
Flexor carpi ulnaris Ulnar nerve
Extension Extensor carpi radialis longus and brevis Radial nerve
Extensors of fingers listed below
Extensor carpi ulnaris
Carpometacarpal Joints
Opposition Opponen pollicis Median nerve
Opponens digiti minimi Ulnar nerve

TABLE 1-5 Summary of Movement by Joint (Continued)

UPPER EXTREMITY
Metacarpophalangeal Joints
Flexion Flexor digitorum superficialis Median nerve
Flexor digitorum profundus Median and ulnar nerves
Flexor pollicis longus and brevis Median nerve
Interosseus Ulnar nerve
Lumbricals Median and ulnar nerves
Extension Extensor digitorum communis Radial nerve
Extensor indicis
Extensor digiti minimi
Adduction Palmar interosseous Ulnar nerve
Abductor pollicis
Abduction Dorsal interosseous Ulnar nerve
Abductor digiti minimi
Abductor pollicis longus Radial nerve
Abductor pollicis brevis Median nerve
Interphalangeal Joints
Flexion Flexor digitorum superficialis Median nerve
Flexor digitorum profundus Median and ulnar nerves
Flexor pollicis longus and brevis Median nerve
Extension Extensor digitorum communis Radial nerve
Extensor indicis
Extensor digiti minimi
Lumbricals (index, middle fingers) Median nerve
Lumbricals (ring, little fingers) Ulnar nerve
Interosseous muscles
LOWER EXTREMITY
Hip (Acetabulofemoral) Joint
Flexion Iliacus/psoas major Femoral nerve
Pectineus
Rectus femoris
Sartorius
Adductor magnus Obturator nerve
Adductor longus and brevis
Tensor fascia lata Superior gluteal nerve
Extension Biceps femoris—long head Sciatic nerve
Semimembranosus
Semitendinosus
Gluteus maximus Inferior gluteal nerve
Adductor magnus Obturator nerve

TABLE 1-5 Summary of Movement by Joint (Continued)

LOWER EXTREMITY
Hip (Acetabulofemoral) Joint
Adduction Adduct magnus, longus, brevis Obturator nerve
Gracilis
Pectineus Femoral nerve
Abduction Gluteus minimus Superior gluteal nerve
Gluteus medius
Tensor fascia lata
Medial rotation Gluteus minimus Superior gluteal nerve
Gluteus medius
Tensor fascia lata
Lateral rotation Piriformis Nerve to piriformis
Obturator internus Nerve to obturator internus
Superior gemilli Nerve to obturator internus
Inferior gemelli Nerve to quadratus femoris
Quadratus femoris Nerve to quadratus femoris
Sartorius Femoral nerve
Knee (Tibiofemoral) Joint
Flexion Bicep femoris—long and short heads Sciatic nerve
Semitendinosus
Semimembranosus
Popliteus Tibial nerve
Gastrocnemius
Sartorius Femoral nerve
Extension Rectus femoris Femoral nerve
Vastus lateralis
Vastus intermedius
Vastus medialis
Medial rotation Popliteus Tibial nerve
Semimembranosus Sciatic nerve
Semitendinosus
Lateral rotation Biceps femoris Sciatic nerve
Ankle (Talocrural) Joint
Plantar flexion Soleus Tibial nerve
Gastrocnemius
Tibialis posterior
Flexor digitorum longus
Flexor hallucis longus
Peroneus longus and brevis Superficial peroneal nerve
Dorsiflexion Tibialis anterior Deep peroneal nerve
Extensor digitorum
Extensor hallucis longus

Shoulder Joint Elbow Joint

Innervation to the shoulder joints originates from the supe- Branches of all major nerves of the brachial plexus
rior and middle trunks of the brachial plexus that can be that cross the joint, including the musculocutaneous,
blocked at the interscalene level. Most of the shoulder capsule radial, median, and ulnar nerves, supply the elbow joint
is supplied by the axillary and suprascapular nerves, which (Figure 1-20).
can be selectively blocked more distally. (Figure 1-19).
FIGURE 1-19. Innervation of the shoulder joint.
FIGURE 1-20. Innervation of the elbow joint.

Hip Joint Wrist and Hand

Branches from the femoral and obturator nerves from the Most of the terminal branches of the brachial plexus, includ-
lumbar plexus and from the sciatic nerve and the nerve to the ing the radial, median, and ulnar nerves, innervate the wrist
quadratus femoris from the sacral plexus innervate the hip and hand joints (Figure 1-23).
joint (Figure 1-21).
Ankle and Foot
Knee Joint The innervation of the ankle and foot joints is complex and
Branches from the femoral nerve innervate the knee joint ante- involves the terminal branches of the common peroneal (deep
riorly. On its medial side, the nerve receives branches from the and superficial peroneal nerves), tibial (tibial nerve), and fem-
posterior division of the obturator nerve, while both divisions oral nerves (saphenous nerve). An easier view is that the entire
of the sciatic nerve supply its posterior side (Figure 1-22). innervation of the ankle joint originates from the sciatic nerve,
FIGURE 1-21. Innervation of the hip joint.

FIGURE 1-22. Innervation of the knee joint. The origin of the superomedial and superolateral genicular
nerves (from the sciatic nerve or femoral nerve) is controversial.
FIGURE 1-23. Innervation of the wrist.

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Ruth was getting herself together during these moments of
realization. She opened the bedroom door and called in Milicent.
Charles Gail had been gassed. Milicent had not seen him, but
Lieutenant Byrne had visited him and repeated to Milicent that he
was not sure whether Charles knew him. Ruth scarcely could bear
thought of visiting Charles Gail and pretending that she was Cynthia;
but it was evident that he was so weak that he would suspect
nothing.
The chance of George Byrne betraying her was greater. He had
been in Paris, Milicent said, upon some special duty of indefinite
duration. Every time he had called he had left messages with
Milicent and had assumed that he might not be able to return to the
Rue des Saints Pères.
“He was here the day we got the news that Mirevaux was taken,”
Milicent said. “We tried in every way to get word of you. He was
almost crazy, dear. He loves you; don’t you ever doubt that!”
Ruth made no reply, though Milicent waited, watching her.
“I didn’t say anything to him about Gerry Hull, dear.”
“I’ve written him about meeting Gerry,” Ruth said, simply. “I’ll start
for the hospital now, Mil.”
“You’ll let me go with you, Cynthia?”
“Thanks; but it’s not—I think I’d rather not.”
Milicent gazed at her, a little surprised and hurt, but she made no
further offer.
Ruth went out on the Rue des Saints Pères alone; a start of panic
seized her as she gazed up and down the little street—panic that
from a neighboring doorway, or about one of the corners, George
Byrne might suddenly appear and speak to her.
The late spring afternoon was clear and warm; and that part of
Paris was quiet, when from Ruth’s right and ahead of her came the
resound and the concussion of a heavy explosion. Ruth gazed up,
instinctively, to find the German airplane from which a torpedo might
have dropped; but she saw only the faint, dragon-fly forms of the
French sentinel machines which constantly stood guard over Paris.
They circled and spun in and out monotonously, as usual, and
undisturbed at their watch; and, with a start, Ruth suddenly
remembered. From beyond the German lines in the forest of Saint
Gobain, Paris was being bombarded by some new monster of
Krupp’s; the explosion where a haze of débris dust was hanging over
the roofs a half mile or more away had been the burst of a shell from
that gun. Since the start of the German assault the Germans had
been sending these random shells to strike and kill at every half hour
for several hours upon almost every day. So Paris had learned to
recognize them; Paris had become accustomed to them; Parisians
shrugged when they struck. But Ruth did not.
The studied brutality of that German gun, more than sixty miles
away, dispatching its unaimed shells to do methodical, indiscriminate
murder in the city, was the sort of thing Ruth needed at that moment
to steady her to what lay before her. She was setting herself to this,
as to the rest, to help stop forever deeds like the firing of that gun.
She hastened on more resolutely; the gun fired again, its monstrous,
random shell falling in quite another quarter. Presenting herself at
the doors of the hospital, she ascertained that Sergeant Charles
Gail, who had originally been enrolled in a Canadian battalion under
another name, was still living. Consultation with a nurse evoked the
further information that he was conscious at the present minute, but
desperately weak; he had been asking many times for his friends or
word of his people; it was therefore permissible—indeed, it was
desirable—that his sister see him.
Ruth followed the nurse between the long rows of beds where
boys and men lay until the nurse halted beside a boy whose wide-
open eyes gazed up, unmoving, at the ceiling; he was very thin and
yellow, but his brows yet held some of the boldness, in the set of his
chin was still some of the high spirit of defiance of the picture in the
portfolio—the boy who had quarreled with his father four years ago
and who had run away to the war.
“Here is your sister,” the nurse told him gently in French.
“My sister?” he repeated the French words while his eyes sought
and found Ruth. A tinge of color came to his cheek; with an effort a
hand lifted from the coverlet.
“Hello, Cynth,” he said. “They said—you were—here.”
Ruth bent and kissed his forehead. “All right, Cynth,” he
murmured when she withdrew a little. “You can do that again.”
Ruth did it again and sat down beside him. His hand was in hers;
and whenever she relaxed her tight grasp of it he stirred impatiently.
He did not know she was not his sister. His eyes rested upon hers,
but vacantly; he was too exhausted to observe critically; his sister
had come, they said; and if she was not exactly as he remembered
her, why he had not seen her for four years; a great deal had
happened to her, and even more had happened to him. Her lips were
soft and warm as his sister’s always had been; her hands were very
gentle, and it was awfully good to have her there.
Ruth was full of joy that she had dared to come; for she was, to
this boy, his sister.
“Tell me—about—home,” he begged her.
“I’ve brought all my letters,” she said; and opening them with one
hand—for he would not have her lose grasp of him—she read the
home news until the nurse returned and, nodding, let Ruth know she
must go.
He could not follow in his mind the simple events related in the
letters; but he liked to hear the sentences about home objects, and
the names of the people he had loved, and who loved him.
“You’ll—come back—tomorrow, Cynth?” he pleaded.
Ruth promised and kissed him again and departed.
It was quite dark now on the streets with only the sound of the
evening bustle. The long-range German gun had ceased firing; but
the dim lights beside doorways proved that on this clear, still night
the people of Paris realized the danger of air raids. Ruth was
hurrying along, thinking of the boy she had left and of his comrades
in the long rows of beds; from them her thoughts flew back to the
battle, to “1583” and his English on the hill, to Grand’mère Bergues’
farm, and to Gerry Hull; she thought of the German soldiers she had
seen with him and of her errand to their land. Almost before she
realized it, she was turning into the little street of the Holy Fathers
when a man, approaching out of the shadows, suddenly halted
before her and cried out:
“Cynthia!”
The glow of light was behind him, so she could not make out his
face; but she knew that only one stranger, recognizing her as
Cynthia, could have cried out to her like that; so she spoke his name
instantly, instinctively, before she thought.
Her voice either was like Cynthia’s or, in his rush of feeling,
George Byrne did not notice a difference. He had come before her
and was seizing her hands; his fingers, after their first grasp, moved
up her arms. “Cynthia; my own Cynthia,” he murmured her name. At
first he had held her in the glow of the light the better to see her; but
now he carried her back with him into the shadow; and his arms
were around her; he was crushing her against him, kissing her lips,
her cheeks, her lips again, her hands from which he stripped the
gloves.
She strained to compress her repulse of him. He was not rough
nor sensuous; he simply was possessing himself of her in full
passion of love. If she were Cynthia, who loved this man, she would
have clung in his embrace in the abandonment of joy. Ruth tried to
think of that and control herself not to repel him; but she could not.
Reflexes, beyond her obedience, opposed him.
Ever since Milicent had informed her that he was in Paris, Ruth
had been forming plans for every contingency of their meeting; but
this encounter had introduced elements different from any
expectations. If this visit to the street of the Holy Fathers was to be
his last one before leaving Paris, then perhaps she had better keep
him out upon the street in the dark and play at being Cynthia until
she could dismiss him. She must feel—or at least she must betray—
no recoil of outrage at his taking her into his arms. He had had that
right with Cynthia Gail. Though he and Cynthia had quarreled—and
Ruth had never mended that quarrel—yet Cynthia and he had loved.
Too much had passed between them to put them finally apart. And
now, as Ruth felt his arms enfolding her, his lips on hers, and his
breath whispering to her his passionate love, she knew that Cynthia
could not have forbidden this.
He took Ruth’s struggle as meant to tempt his strength and he
laughed joyously as, very gently, he overpowered her. She tried to
cease to struggle; she tried to laugh as Cynthia would have laughed;
but she could not. “Don’t!” she found herself resisting. “Don’t!”
“Oh! I hurt you, dearest?”
“Yes,” she said; though he had not. And remorsefully and with
anxious endearments, he let her go.
“You’ve heard about Charles?” he asked.
“I’ve just come from him.”
“He’s—the same?”
“Yes.”
She stood gasping against the wall of a building, entirely in the
shadow herself, with the little light which reached them showing her
his face. Ruth liked that face; and she liked the girl whom she played
at being—that Cynthia whose identity she was carrying on, but about
whom she yet knew so little—for having loved this man. George
Byrne had been clean-living; he was strong and eager, but gentle,
too. He had high thoughts and resolute ideals. These he had told her
in those letters which had come; but Ruth had not embodied them in
him till now. She was recovering from the offense of having anyone’s
arms but Gerry’s about her. She was not conscious of thinking of
Gerry that way; only, his arms had been about her, he had held her;
and, because of that, what she had just undergone had been more
difficult to bear.
“I love you; you love me, Cynthia?” Byrne was begging of her now.
“Of course I do,” she said.
“There’s not someone else, then? Tell me, Cynthia!”
“No—no one else,” she breathed. What could she say? She was
not speaking for herself; but for Cynthia; and now she was absolutely
sure that, for Cynthia, there could have been no one else. But she
could not deceive him.
“My God!” he gasped the realization to himself, drawing back a
little farther from her. “Then that’s—that’s been the matter all the
time.”
“All what time?” she asked.
“Since you met Gerry Hull in Chicago.”
He meant, of course, since the girl who had loved him had died;
but he did not know that. He had felt a change in the letters which
had come to him which he could not explain as merely the result of
their quarrel. Another man seemed to him the only possible
explanation.
Someone opened a door behind them; and Ruth withdrew from
the shaft of light. “We can’t stay here, George,” she said.
She thought that now he was noticing a difference in her voice;
but if he did, evidently he put it down as only part of her alteration
toward him.
“Where can we go?” he asked her.
“Not back to the pension,” Ruth said.
“No; no! Can’t you stay out with me here? We can walk.”
“Yes.”
He faced down the street of the Holy Fathers away from the
pension; she came beside him. He took her hand and for a moment
held it as, undoubtedly, he and Cynthia had done when walking in
darkened streets together; but after a few steps he released her.
“Your hand’s thinner, Cynthia.”
“I suppose so.”
“You’re a little thinner all over. I can’t see you well; but you felt that
way,” he said a little sadly, referring to his embrace which she had
broken. “You’ve been overdoing, of course.”
She made no reply; and for several seconds he offered nothing
more but went on, gazing down at her. “You’ve been fine, Cynthia, in
getting those people out.” He spoke of what he had heard of her
work in the retreat. “I knew ten days ago you were in it; but I couldn’t
go to you! I tried to; I tried to get into the fight. We all tried—our men;
but they didn’t want us. Except Gerry Hull, of course, and a few like
him.”
He said this so completely without bitterness—with envy, only—
that Ruth felt more warmly for him. “It’s Gerry Hull, isn’t it, Cynthia?”
he demanded directly.
“Yes,” she admitted now. Denial had become wholly impossible;
moreover, by telling the truth—or that much of the truth which had to
do with Gerry Hull—she might send George Byrne away. It was a
cruel wrong to him, and to the girl who was dead; but the wrong
already was done. Ruth merely was beginning herself to reap some
of the fruits of her deception.
“You love him?” Byrne inquired of her inevasively.
“Yes.”
“He loves you?”
“I don’t know.”
“What’s he said to you?”
“Nothing—about loving me.”
“But he loves you, all right; he must, if he knows you!” Byrne
returned in pitiful loyalty to his Cynthia. “How much has gone on
between you?” he demanded.
Ruth related to him much about her meetings with Gerry, while
they walked side by side about the Paris streets. A dozen times she
was on the point of breaking down and telling him all the truth; when
his hand reached toward hers, instinctively, and suddenly pulled
away; when they passed a light and, venturing to gaze up, she saw
his face as he looked down at her; when he asked her questions or
offered short, hoarse interjections, she almost cried out to him that
she was a fraud; the girl he had loved, and who she was saying had
turned from him, was dead and had been dead all that time during
which he had felt the difference; she had never met Gerry Hull at all.
“What are you stopping for?” he asked her at one of these times.
“Thinking about the Sangamon River?”
That was the Illinois river which flowed close by Cynthia Gail’s
home. And Ruth knew from his voice that by the river Cynthia and he
first had known love.
“Yes,” Ruth said; but now her courage completely failed her.
“What did you say to me, then; oh, what did we both say,
Cynthia?”
This was no test or challenge of Ruth; it was simply a cry from his
heart.
How do I love thee? Let me count the ways,
I love thee to the depth and height....
He was starting to quote something which they used to repeat
together.
“Go on, Cynthia!” he charged.
“I can’t,” Ruth cried.
“You can’t—after you found it and taught it to me? ‘I love thee with
the breath, smiles, tears, of all my life,’” he quoted bitterly to her. “Let
me look at you better, Cynthia!”
They were passing a light and he drew her closer to it.
“What has happened to you?” he whispered to her aghast when
he had searched her through and through with his eyes. Then, “Who
are you?”
He had made, he realized, some frightful mistake; how he could
have come to make it, he did not know. “You’re not Cynthia Gail!” he
cried. For an instant, that discovery was enough for him. The agony
which he had been suffering this last half hour was not real; the girl
whom he had found on the street never had been his; they had both
been going about only in some grotesque error.
“No; I’m not Cynthia Gail,” Ruth told him.
“Then where is she?” he demanded. “Where is my Cynthia?” His
hands were upon Ruth and he shook her a little in the passion of his
demand. He could not even begin to suspect the truth; but—from
sight of her now—fear flicked him. If this girl was not Cynthia——
“How are you so like her?” he put his challenge aloud. “Why did
you pretend to be her? Why? You tell me why!”
“I’ll tell you,” Ruth said. “But not here.”
“Where?”
“We must find some place where we can talk undisturbed; where
we can have a long talk.”
“Take me to her, first. That’s all I care about. I don’t care about you
—or why you did that. I don’t care, I say. Take me to Cynthia; or I’ll
go there.”
He started away toward the Rue des Saints Pères and the
pension; so Ruth swiftly caught his sleeve.
“You can’t go to her!” Ruth gasped to him. “She’s not there.
Believe me, you can’t find her!”
“Why not?”
“She’s—we must find some place, Mr. Byrne!”
“She’s—what? Killed? Killed, you were going to say?”
“Yes; she’s been killed.”
“In Picardy, you mean? Where? How? Why, she was at her rooms
two hours ago. Miss Wetherell told me; or was she lying to me?”
“I was at the rooms two hours ago,” Ruth said. “Miss Wetherell
knows me as Cynthia Gail. I’ve been Cynthia Gail since January.”
“What do you mean? How?”
“Cynthia Gail died in January, Mr. Byrne.”
“What? How? Where?”
“She was killed—in Chicago.”
“That’s a lie! Why, I’ve been hearing from her myself.”
“You’ve been hearing from me. I’m Cynthia Gail, I tell you. I’ve
been Cynthia Gail since January.”
He caught another glimpse of her face; and his impetuousness to
start to the Rue des Saints Pères collapsed, pitifully. “Where shall we
go?” he asked.
Ruth gazed about, uncertainly; she had not attended to their
direction; and now she found herself in a strange, narrow street of
tiny shops and apartments, interrupted a half square ahead by a
chasm of ruins and strewn débris, where one of those random shells
from the German long-range gun, or a bomb dropped from a night-
raiding Gotha recently had struck. The destruction had been done
sufficiently long ago, however, for the curiosity of the neighborhood
to have been already satisfied and for all treasures to have been
removed. The ruin was fenced off, therefore, and was unguarded.
Ruth gazed into the shell of the building and Byrne, glancing in also,
saw that in the rear were apartments half wrecked and deserted, but
which offered sanctuary from the street.
CHAPTER XIV
FULL CONFESSION
“No one will be likely to come in here,” Ruth said, and stepped into
the house.
Byrne followed her without comment, quite indifferent to their
surroundings. When Ruth spoke to him again about the house, he
replied vacantly; his mind was not here, but with Cynthia Gail, where
he had last seen her in Chicago that Sunday night in January when
they had parted. What had thereafter happened to her was the first
matter to him.
Ruth, exploring the ruin, came upon a room which seemed to
have been put in some sort of order, so far as she could see from the
dim light which came through the doorway.
“Give me a match,” she asked Byrne; he took a matchbox from his
pocket and, striking a light, he held it while they peered about. There
was a fixture protruding from the wall, but no light resulted when
Ruth turned the switch. Byrne’s match went out; he struck several
others before their search discovered a bit of a candle in an old
sconce in a corner. Byrne lit it, and Ruth closed the door which led
into what had been a hallway. She returned to Byrne, who had
remained in the corner where the candle diffused its light. There was
a built-in bench there beside an old fireplace, a couple of old chairs
and a table.
“Let’s sit down,” Ruth said.
“You sit down,” Byrne bid. “I’ll—” he did not finish his sentence; but
he remained standing, hands behind him, staring down at her as she
seated herself upon the bench.
“Now,” he said to her.
His lips pressed tight and Ruth could see that he jerked with short
spasms of emotion which shuddered his shoulders suddenly
together and shook his whole body.
Ruth had desired the light instinctively, with no conscious reason;
the same instinct which made her need to see him before she could
go on, probably affected him; but with him had been the idea that the
light would banish the illusion which overswept him again and again
that this girl still was his Cynthia. But the faint, flickering illumination
from the candle had failed to do that; it seemed, on the contrary, at
times to restore and strengthen the illusion. A better light might have
served him more faithfully; and if he brought her close to the candle
and scrutinized her again as he had under the light of the street, he
would see surely that she was someone else. But here, Ruth
realized, she was falling into the postures of the girl who was dead.
“Cynthia!” Byrne whispered again to her.
“What I know about Cynthia Gail,” Ruth said to him gently then, “is
this.” And she told, almost without interruption from him, how Cynthia
had met her death. Ruth did not explain how she had learned her
facts; for a while the facts themselves were overwhelming enough.
He made sure that he could learn nothing more from her before he
challenged her as to how she knew.
“You read this in a newspaper, you said?”
“Yes; in all the Chicago newspapers,” Ruth replied. “I read the
accounts in all to find out everything which was known about her.”
“Wait now! You said no one knew her; she was not identified.”
“No; she was not.”
“Then you saw her? You identified her?”
“No; I never saw her.”
“Then how do you know it was Cynthia? See here; what are you
holding from me? How do you know she’s dead at all?”
“The Germans told me. The Germans said that she was the girl
who was killed in that wreck.”
“The Germans? What Germans? What do you mean?”
“A German—I don’t know who—but some German identified her
from her passport and took the passport.”
“Why? How do you know that? How did you get into her affairs,
anyway?”
“Because I was like her,” Ruth said. “I happened to be so very like
her that——”
“That what?” He was standing over her now, shaking, controlling
himself by intervals of effort; and Ruth faltered, huddling back a little
farther from him and gazing up at him aghast. She had determined,
a few minutes earlier, that there had become no alternative for her
but to confess to him the entire truth; but the truth which she had to
tell had become an incredible thing, as the truth—the exact truth of
the circumstances which fix fates—has a way of becoming.
Desperately her mind groped for a way to arrange the events of
that truth in a way to make him believe; but each moment of delay
only made her task more impossible. He had roused from the
suspicion, which had begun to inflame him when they were yet on
the street, to a certainty that the girl whom he loved had been foully
dealt by.
“That what?” he demanded again.
So Ruth told him about herself, and the first meeting with Gerry
Hull, and the pencil boxes, and the beggar on State Street. She did
not proceed without interruptions now; he challenged and catechized
her. If he had refused her whole story, it would not have been so
bad; but he was believing part of it—the part which fitted his
passions. He believed that the Germans had found the body of
Cynthia Gail, and he believed more than that. He believed that they
had killed her, and he cried out to Ruth to tell him when, and how. He
believed that the Germans, having killed Cynthia, had tried to make
use of her identity and her passport; and that they had succeeded!
His hands were upon Ruth once more, holding her sternly and firmly.
“I put you under arrest,” he said to her hoarsely, “as accessory in
the murder of Cynthia Gail and as a German spy.”
And yet, as he held her there before him in the dim light of the
tallow wick in the sconce upon the wall, she seemed to him, for
flashes of time, to be the girl he accused her of having killed.
“Cynthia; where are you?” he pleaded with her once as though,
within Ruth, was the soul of his love whom he could call to come out
and take possession of this living form.
Then he had her under arrest again. “Come with me!” he
commanded, and he thrust her toward the door. But now Ruth fought
against him.
“No; we must stay here!”
“Why?”
“Till you will believe in me!”
“Then we’ll never leave here. Will you come, or must I take you?”
“Leave me alone just a minute.”
“So you can get away?”
“No; just you stay here. I’ll go back there,” Ruth tossed toward the
corner where she had sat. “There’s no way out. Only—let go of me!”
He did so, watching her suspiciously. She dropped into her seat in
the corner under the candle. “I’ve told you why I did this,” she said.
“And you didn’t fool me.”
“I’ve no proof of anything I’ve told you,” Ruth went on, “only
because, if you’ll think about it, you’ll see I couldn’t carry proof.”
“I should say not.”
“But I’ve done something since I’ve been here which proves what I
am.”
“What? Helping refugees out of Picardy? What does that prove—
except that you’ve nerve?”
“Nothing,” Ruth admitted. “If I was a German agent, I might have
done that. I wasn’t thinking of that.”
“What of, then?”
She was thinking about her exposure of De Trevenac; but, though
now it was known that Louis de Trevenac had been proved a spy,
had been tried and punished, no explanation had been given as to
how he had been caught. Those who tried him had not known,
perhaps; only Gerry knew.
“Gerry Hull will tell you,” Ruth replied. “I don’t ask you to take my
word about myself anymore; I ask you only, before you accuse me,
to send for him.”
“Gerry Hull!” Byrne iterated, approaching her closely again and
gazing down hostilely. For an instant he had not been able to
disassociate Gerry Hull from himself as a rival for Cynthia Gail. “So
he knows all about you, does he?”
“No; he thinks I am Cynthia Gail; but——”
“What?”
“He knows—he must know that, whoever I am, I’m loyal! So send
for him, or go and speak to him before you do anything more; that’s
all I ask. Oh, I know this has been horrible for you, Mr. Byrne.” For
the first time Ruth was losing control of herself. “But do you suppose
it’s been easy for me? And do you suppose I’ve done it for myself or
for any adventure to see the war or just to come here? I’ve done it to
go into Germany! Oh, you won’t stop me now! For if you leave me
alone—don’t you see—I may get into Germany tomorrow or this
week or anyway before the next big attack can come! What do I
count, what do you count, what can the memory of Cynthia Gail
count in comparison with what I may do if I can go on into Germany?
What——”
“Don’t cry!” Byrne forbade her hoarsely, seizing her shoulder and
shaking her almost roughly. “My God, Cynthia,” he begged, “don’t
cry.”
He had called her by that name again; and Ruth knew that, not
her appeal, but her semblance in her emotion to Cynthia, had
overcome him for the moment.
“I’m not going to cry,” Ruth said. “But——”
He stopped her brusquely. He seemed afraid, indeed, to let her go
on. “Whether I’ve got to bring you to the army authorities and give
you over at once under arrest,” he said coldly, “is up to you. If you
agree to go with me quietly—and keep your agreement—I’ll take you
along myself.”
“Where?” Ruth asked.
“I know some people, whom I can trust and who can take you in
charge till I can talk to Hull. He’s the only reference you care to
give?”
“Yes,” she said.
“If he stands for you, that won’t mean anything to me, I might as
well tell you,” Byrne returned. “You’ve probably got him fooled; you
could do it, all right, I guess.”
“Then what’s the use in your sending for him?”
“Oh; you think now there’s none? It was your idea, not mine.”
“I’ll go with you quietly to your friends,” Ruth decided, ending this
argument. “I’ll understand that you’re going to communicate with
Gerry Hull about me.”
She arose and Byrne seized her arm firmly. He blew out the
candle and, still clasping her, he groped his way to the door. Some
one stepped in the rubbish on the other side. They had been
conscious, during their stay in the room, that many people had
passed outside; once or twice, perhaps, a passer-by might have
paused to gaze at the ruin; but Ruth had heard no one enter the
house. Byrne had heard no one; for his grasp on Ruth’s arm
tightened with a start of surprise as he realized that the someone
who now suddenly moved on the other side of the door must have
come there moments before.
Byrne stepped back, drawing Ruth with him, and thrusting her a
little behind him. The person on the other side of the door was a
watchman, perhaps, or the owner of this house or a neighbor
investigating to what use these ruined rooms were now being put.
Byrne, thinking thus, spoke loudly in labored French, “I am an
American officer, with a companion, who has looked in here.”
“Very well,” came in French and in a man’s voice from the other
side of the door. Byrne advanced to the door and opened it,
therefore, and was going through when a bludgeon beat down upon
him. Byrne reeled back, raising his left arm to shield off another
blow; he tried to strike back with his left arm and grapple his
assailant; but with his right, he still held to Ruth as though she would
seize this chance to escape; and yet, at the same time, Ruth felt that
he was protecting her with his body before hers.
“Let me go!” she jerked to be free. “I’ll—help you!”
He did not mean to let her go when she struggled free; he was still
trying to hold to her and also fight the man who was beating at him.
But her getting free, let him close with his assailant and grapple with
him. They spun about and went down, rolling over and over in the
débris. Ruth grabbed up a bit of iron pipe from among the wreckage
on the floor; and she bent over trying to strike at the man with the
bludgeon.
“Help!” she called out. “Secours!”
She knew now that the man who had waited outside was no mere
defender of the house; the treachery and the violence of his attack
could not be explained by concern for safety of that ruin. Ruth could
not think who the man might be or what was his object except that
he was fighting to kill, as he struck and fought with Byrne on the
floor. And Byrne, knowing it, was fighting to kill him, too.
“Secours!” Ruth screamed for help again and with her bit of iron,
she struck—whom, she did not know. But they rolled away and
pounded each other only a few moments more before one overcame
the other. One leaped up while the other lay on the floor; the one
who had leaped up, crouched down and bludgeoned the other again;
so that Ruth knew that Byrne was the one who lay still. She
screamed out again for help while she flung herself at the man who
was bending over. But he turned about and caught her arms and
held her firmly. He bent his head to hers and whispered to her while
he held her.
“Weg!” The whisper warned her. It was German, “Away!” And the
rest that he said was in German. “I have him for you struck dead!
Careful, now! Away to Switzerland!”
He dropped Ruth and fled; she went after him, breathless, trying
to cry out; but her cries were weak and unheard. He ran through the
rear of the house into a narrow alley down which he disappeared;
she went to the end of the alley, crying out. But the man was gone.
She stopped running at last and ceased to call out. She stood,
swaying so that she caught to a railing before a house to steady
herself. The words of the whisper ran on her lips. “I have him for you
struck dead!”
They gave her explanation of the attack which, like the words of
De Trevenac to her, permitted only one possible meaning. The man
who had waited in the ruined house must have been one of the
German agents in Paris whom Ruth had returned to meet. Evidently,
while Byrne had been inquiring for her, the Germans too had been
vigilant; they had awaited her return either to get her report of what
she had seen in Picardy or to assign her to another task or—she
could not know why they awaited her; but certainly they had. One of
them had learned that afternoon that she had returned; he was
seeking her, perhaps, when Byrne found her. Perhaps he had known
the peril to her from Byrne; perhaps he merely had learned, from
whatever he had overheard of their talk in that ruined room, that
Byrne accused her of being a German spy; and so he had taken his
chance to strike, for her, Byrne dead.
The horror of this realization sickened her; the German murderer
“for her” had made good his escape; and it would be useless to
report him now. She would be able to offer no description of him; and
to report that a large man, who was a German spy, had been about
that part of Paris this evening would be idle. But she must return at
once to Byrne who might not be dead. So she steadied herself and
hastened down the street seeking the ruined house.
It was a part of Paris quite unfamiliar to her; and, as she had not
observed where she and Byrne had wandered, she passed a square
or two without better placing herself; and then, inquiring of a passer-
by, where was a ruined house, she obtained directions which
seemed to be correct; but arriving at the ruin, she found it was not
the one which Byrne and she had entered. Consequently it was
many minutes before she found the ruined house which gave her no
doubt of its identity. For people were gathered about it; and Ruth,
approaching these, learned that a monstrous attack had been made
upon an American infantry officer who, when first found, was
believed to have been killed; but the surgeon who had arrived and
had removed him, said this was not so. Robbery, some said, had
been the motive of the crime; for the officer had much money in his
pocket; but the murderer had not time to remove it. Others, who
claimed to have heard a girl’s voice, believed there might have been
more personal reasons; why had a man and a girl been in those
rooms that night?
Ruth breathed her thankfulness that Byrne was not dead; and she
withdrew. Since Byrne had been taken away, she could do nothing
for him; and she would simply destroy herself by giving herself up to
the authorities. If Byrne lived and regained consciousness,
undoubtedly he would inform against her.
But though she would not give herself up, certainly she would not
try to escape if Byrne accused her; she would return to her room and
go about her work while she awaited consequences.
None followed her that night. She admitted to Milicent, when
questioned, that she had met Lieutenant Byrne upon the street and
they had walked together; Ruth said also that she had seen her
brother. Milicent evidently ascribed her agitation to a quarrel with
Byrne.
Ruth lay awake most of that night. The morning paper which
Milicent and she read contained no mention, amid the tremendous
news from the front, of the attack upon an American officer in a
ruined house; and no consequences threatened Ruth that morning.
She planned for a while to try to trace Byrne and learn whether he
had regained consciousness; then she abandoned that purpose. She
was satisfied, from one of those instincts which baffle question, that
Byrne lived; and it would be only a question of time before he must
accuse her.
Yet she might have time enough to leave Paris and France—to
get away into Switzerland and into Germany. For the fact that a
German had for her attempted to strike her accuser dead was final
proof that the Germans had not connected her with the betrayal of
De Trevenac; they believed that she had been in Picardy all this time
on account of orders given her by De Trevenac.
It was possible, of course, that the German who had struck for her
and whom she had pursued, would now himself suspect her. Yet her
flight after him might have seemed to him only her ruse to escape.
What he had last said to her, she must receive as her orders from
the Germans in Paris. “Away to Switzerland!”
That concurred with the sentence of instruction given upon that
page which she had received with her passport that cold January
morning in Chicago.... “You will report in person, via Switzerland;
apply for passport to Lucerne.”
At this moment when, for the cause of her country and its allies,
she had determined that she must make the attempt to go on to
Germany, the Germans were ready to have her. And that was easy
to understand; she had spent weeks going about freely behind the
newly formed English and French lines which bagged back about the
immense salient which the Germans had thrust toward Amiens; she
was supposed, as a German, to have ready report about the
strength of those lines as seen from the rear, of the strength of the
support, the morale of soldiers and civilians and the thousand other
details which the enemy desired to know.
So Ruth went early that morning to the United States Consul
General with her passport which long ago had been substituted for
that ruined passport of Cynthia Gail’s; and she offered it for visé,
asking permission to leave Paris and France for a visit to the neutral
country of Switzerland, and, more particularly, to Lucerne. She
stated that the object of her journey was rest and recuperation; she
knew that, not infrequently in the recent months, American girls who
had been working near the war zones had been permitted vacations
in Switzerland; but she found that times were different now. She
encountered no expressed suspicion and no discourtesy; she simply
was informed that in the present crisis it was impossible to act
immediately upon such requests. Her application would be filed and
passed upon in due time; and a clerk questioned Ruth concerning
the war service which she had rendered which was supposed to
have so exhausted her that she desired rest in Switzerland.
Ruth, hot with shame, perforce related what she had been through
in the retreat. She was quite aware when she went away and
returned to her work that her application for permission to go to
Switzerland would be the most damning evidence against her, when
Byrne should bring his accusation; and now, having made
application, she could do nothing but wait where she was. However,
she heard nothing from Byrne or from the authorities upon that day
nor upon the succeeding days of the week during which she worked,
as she had when she first came to Paris, in the offices of the relief
society; upon almost every afternoon she visited Charles Gail who
was slowly sinking.
After three days and then after a wait of three more, she revisited
the consulate and inquired about her permission for Switzerland; but
she got no satisfaction either time. But when at last the week wore
out and she met no interference with her ordinary comings and
goings, she was beginning to doubt her beliefs that George Byrne
lived; he must have died, she thought, and without having been able
to communicate his knowledge of her to anyone. Then one night she
was returning to the Rue des Saints Pères a little later than usual;
the mild, April afternoon had dimmed to twilight and, as she passed
the point where George Byrne had encountered her, fears
possessed her again; they lessened only to increase once more, as
they now had formed a habit of doing, when she approached the
pension.
“Letters for me, Fanchette?” she said to the daughter of her
landlady who was at the door when Ruth came in.
“No letters, Mademoiselle; but Monsieur le Lieutenant!”
Ruth stopped stark. Many Messieurs les Lieutenants and men of
other ranks called at the pension for Milicent or for Ruth, just for an
evening’s entertainment; but such did not appear at this hour.
“He is in the salon, Mademoiselle.”
Ruth went in. If it was George Byrne, at least then he was alive
and now strong again. The lamp in the little salon had been lit; and a
tall, uniformed figure arose from beside it.
“Hello, Cynthia,” a familiar voice greeted. Gerry Hull’s voice!
Ruth retreated a little and held to the door to support her in her
relaxation of relief. A hundred times during this terrible week, Ruth
had wanted to send for him.
“I’m so glad to see you, Gerry.”
“That’s good.” His tall, lithe self was beside her; his strong, steady
fingers grasped her arm and gently supported her when she let go
the door. He closed the door and led her to a chair where the light of
the lamp would fall full upon her. “Sit down there,” he commanded
kindly; and, when she obeyed, he seated himself opposite pulling his
chair closer the better to observe her but at the same time bringing
himself under the light.
He had changed a great deal since last she saw him, Ruth
thought. No; she corrected herself, not so much since she had
parted from him after the retreat from Picardy; but he had altered
greatly since last he sat opposite her in this little salon at that time
they talked together about De Trevenac. The boy he had been when
she first saw him on the streets of Chicago; the boy he had been
when he had spoken at Mrs. Corliss’, had been maturing with
marvelous swiftness in these last weeks into a man. His eyes
showed it—his fine, impulsive, determined eyes, no less resolute
and not less impatient, really, but somehow a little more tolerant and
understanding than they had been. His lips showed it—thinner a trifle
and a trifle more drawn and straight though they seemed to smile

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Hadzic's Peripheral Nerve Blocks and

Anatomy for Ultrasound-Guided

Hadzic’s Textbook of Regional Anesthesia and Acute Pain

Hadzic's Textbook of Regional Anesthesia and Acute Pain

Atlas of Ultrasound-Guided Regional Anesthesia 3rd

Pediatric Liver Transplantation: A Clinical Guide 1st

Imaging Anatomy. Ultrasound 2nd Edition Paula J.

Atlas of Interventional Orthopedics Procedures:

Miller's Anesthesia Review 3rd Edition Lorraine M.

Hadzic’s Textbook of Regional Anesthesia and Acute Pain

Hadzic’s Peripheral Nerve

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Hadzic’s Peripheral Nerve

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eBook conversion by codeMantra

We dedicate this book to Jerry Vloka, MD, PhD

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Contributors ix 15. Infraclavicular Brachial Plexus Block 161

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David Alvarez, MD Javier Domenech de la Lastra, MD, DESA

Angela Lucia Balocco, MD Robin De Meirsman, MD

Jonas Bruggen, MD Dimitri Dylst, MD

Robbert Buck, MD Christopher J. Edwards, MD

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Admir Hadzic, MD, PhD Leen Janssen, MD

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Leander Mancel, MD Filiep Soetens, MD

Berend Marcus, MD Sam Van Boxstael, MD

Evi Mellebeek, MD Imré Van Herreweghe, MD

Felipe Muñoz-Leyva, MD Astrid Van Lantschoot, MD

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Rob Vervoort, MD Daquan Xu

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Chapter 1 Functional Regional Anesthesia Anatomy 3

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FIGURE 1-1. Conventional body planes and directions. Red,

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FIGURE 1-2. Composition of the neuron.

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FIGURE 1-3. Organization of the peripheral nerve.

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FIGURE 1-4. Diagram of fascicular arrangement in a peripheral nerve.

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FIGURE 1-6. Anatomy of a typical spinal intercostal nerve.

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Thoracic and Abdominal Wall

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Dorsal ramus (posterior)

FIGURE 1-9. Course and distribution of an intercostal nerve.

Nerve Supply to the Peritoneum Nerve Plexuses

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FIGURE 1-11. Dissection of the superficial branches of the cervical plexus.

TABLE 1-1 Organization and Distribution of the Cervical Plexus

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TABLE 1-2 Anatomy of the Brachial Plexus C5-T1

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