John Marshall Williamson
ELEMENTS OF ANATOMY
EDWARD ALBERT SCHAFER, F.R.S.
PROFESSOR OF PHYSIOLOGY AND HISTOLOGY IN UNIVERSITY COLLEGE, LONDON,
GEORGE DANCER THANE,
PROFESSOR OF ANATOMY IN UNIVERSITY COLLEGE, LONDON.
IN THREE VOLUMES.
SUPERFICIAL AND SURGICAL ANATOMY.
BY PROFESSOR G. D. THANE,
PROFESSOR R. J. GODLEE, M.S.
ILLUSTRATED BY 29 ENGRAVINGS.
LONGMANS, GREEN, AND CO.
LONDON, NEW YORK, AND BOMBAY.
[All rights reserved.]
BRADBURY, AGNEW, & CO. I.D., PRINTERS, WHITEFRI ARS.
CONTENTS OF APPENDIX.
SUPERFICIAL ANATOMY OF THE HEAD AND
NECK . . . ... , . i
The Head and Face . . . . i
The Neck 16
SUPERFICIAL ANATOMY OF THE TRUNK . 19
The Chest . ... . . . 19
The Abdomen . . . .22
The Back . ..... 27
TABLE OF LEVELS OF STRUCTURES IN
- THE TRUNK . . . . .32
SUPERFICIAL ANATOMY OF THE UPPER
LIMB . . . . . . 35
The Shoulder . . .- . .35
The Arm ... 35
The Elbow . . . . .37
The Forearm . . . . . 38
SUPERFICIAL ANATOMY OF THE UPPER
The Wrist and Hand . . . .39
SUPERFICIAL ANATOMY OF THE LOWER
LIMB . 42
The Hip ...... 42
The Thigh 43
The Knee . . . . . . 45
The Leg . .' . . . . 47
The Ankle and Foot .... 48
ANATOMY OF THE GROIN : HERNIA . . 50
Inguinal Hernia . . . . 51
Femoral Hernia . ... ..57
THE PERINEUM OF THE MALE . . .62
EXAMINATION OF THE PELVIC VISCERA . 65
INDEX ." 67
SUPERFICIAL AND TOPOGRAPHICAL
BY G. D. THANE AND R. J. GODLEE.
IN this section will be comprised, 1, a brief account of the external conforma-
tion of the body, including the relation of its anatomical constituents to its surface
forms, and the mode of determining the position of deep-seated organs, such as the
viscera, large vessels, and other important parts ; and 2, the topographical and
surgical anatomy of the inguinal and perineal regions.
SUPERFICIAL ANATOMY OF THE HEAD AND NECK.
THE HEAD AND FACE.
The upper part of the cranium is but thinly covered by the scalp, and the
form of the head is almost exactly that of the skull. The bones can be readily
examined by passing the hand over the head, and the following parts are thus to be
distinguished : In the middle line behind is the external occipital protuberance,
from which the superior curved line proceeds outwards on each side towards the
mastoid process ; below this line the bone is obscured by the overlying muscles,
except in the middle line, where the external occipital crest may sometimes be felt
at the bottom of the nuchal furrow between the posterior muscles of the neck.
Above the occipital protuberance, the lambdoid suture is often to be followed as a
slight depression on the surface, owing to the projection of the occipital bone
beyond the hinder part of the parietals. The lambda, corresponding to the central
and highest point of this depression, is about two and a half inches (6 7 cm.)
above the external occipital protuberance. Above the lambda there is usually a
well-marked flattened surface at the region of the obelion (see Osteology, p. 83) ;
and in front of this again the parietal bones often form in the neighbourhood of
their junction a broad longitudinal ridge, in which the position of the sagittal
suture is indicated by a slight median depression.
At the fore part of the lateral region of the head the temporal crest of the
frontal bone becomes prominent, and leads down to the external angular process,
the junction of which with the malar bone is marked by a distinct depression.
Below this the outline of the malar bone can be followed, and from the hinder part
of the latter the finger passes along the zygoma to its base in front of the ear.
Higher up on the side of the head the lower temporal line on the parietal bone is
frequently to be recognised, indicating the extent upwards of the temporal muscle.
The margin of the orbit can be felt in its whole extent, and is found to be
interrupted above, somewhat internal to the centre, by the supraorbital notch,
unless this be converted into a foramen, when it is scarcely perceptible. Above the
orbit is the variable superciliary ridge, small in the female and absent in the child ;
and above this on the forehead is the frontal eminence, which, like the parietal
eminence, is most marked during childhood. In the infant, the anterior fontanelle
is felt as a lozenge-shaped depression, leading forwards to the interval between the
2 SUPERFICIAL ANATOMY OF THE HEAD AND NECK.
two frontal, and backwards to that between the two parietal bones ; the latter
interval conducts to the triradiate posterior fontanelle, the lateral limbs of which
are continued downwards along the upper margins of the occipital bone.
Fig. 1. FRONT VIEW OF SKULL, SHOWING EXTENT OF CEREBRUM, AIR-SPACES, EXIT OF NERVES, &c. f
(G. D. T.)
The outline of the cerebrum is shown in reel, and the position of the superior longitudinal sinus in
blue. The frontal sinus with the infundibulum and the maxillary antrum are indicated by patches of
shading, and the nasal duct with the lachrymal sac by a dotted line. The following letters refer to the
nerves : s o, supraorbital ; s T, supratrochlear ; i T, infratrochlear ; L, lachrymal ; N, nasal ; i o, infra-
orbital ; M a, malar ; B, buccal ; M e, mental.
The frontal sinuses are contained in the lower part of the frontal bone, above
the root of the nose and the inner ends of the eyebrows. In extent and capacity
they vary greatly in different individuals ; as a rule they are larger in the male
than in the female, and are absent before the seventh year of life. In the adult
FRONTAL SINUSES. 3
they may extend upwards as far as the frontal eminence, or fully two inches
above the naso-frontal suture, and outwards over the orbit into the base of
the external angular process ; or they may exist only as slight recesses in the
nasal portion of the bone. The dimensions of the sinuses are not necessarily
related to the degree of prominence of the glabella and superciliary ridges,
which -are sometimes strongly marked without being excavated by the air-
spaces ; while on the other hand large sinuses not unfrequently co-exist with a
comparatively flat lower frontal region, having apparently been formed by the
recession of the inner table of the bone. The right and left sinuses are separated
by a thin osseous partition, which is seldom defective ; but they are often unequally
developed, so that the septum deviates strongly from the median plane. In extreme
cases one sinus may extend equally, or nearly so, in both halves of the frontal bone,
the cavity of the opposite side being either rudimentary or wanting. The lower
part of the sinus tapers into the infundibulum, a narrow passage which leads down-
wards and backwards through the fore part of the lateral mass of the ethmoid into
the middle meatus of the nose. The infundibulum is deeply placed behind the
right frontal sinus
' \ ..
passage into right left frontal sinus
Fig. 2. LOWEK PORTION OF A FRONTAL BONE, SHOWING UNSYMMETRICAL DEVELOPMENT OF THE
FRONTAL SINUSES. (From a photograph by G. W. B. Waters.) (GK D. T.)
nasal process of the superior maxillary bone, and near the inner wall of the orbit
(</. Osteology, fig. 66) ; its termination in the middle meatus is about on a level
with the palpebral fissure.
Vessels and nerves of the scalp. The supraorbital nerve and artery pass
almost vertically upwards from the supraorbital notch, and more internally the
frontal artery and supratrochlear nerve ascend over the margin of the orbit, while
the large frontal vein descends in a similar position to the root of the nose.
Posteriorly, the occipital vessels and great occipital nerve run upwards to the vertex,
entering the scalp somewhat internal to a point midway between the external
occipital protuberance and the mastoid process. The superficial temporal artery
crosses the base of the zygoma immediately in front of the ear, and its anterior
branch can frequently be seen, especially in old persons, running upwards and
f 01 wards with a tortuous course over the fore part of the temporal muscle towards
Endocranial blood-vessels; In contact with the inner surface of the cranial
wall the superior longitudinal sinus is directed backwards along the middle line,
extending from the lower part of the forehead to the external occipital protuberance.
4 SUPERFICIAL ANATOMY OF THE HEAD AND NECK.
It commonly deviates a little to one side, more frequently the right, especially in
its hindmost part, as it descends over the upper portion of the occipital bone to its
termination. From the latter spot the lateral sinus runs outwards and forwards,
describing a slight curve with its convexity upwards, to the back of the ear on a
level with the upper margin of the external auditory meatus, and then turns down-
Fig. 3. SIDE VIEW OF SKULL, SHOWING THE COURSE OF THE MIDDLE MENINGEAL ARTERY, LATERAL
SINUS, &c. (From a photograph by G. W. U. Waters.) f. (G. D. T.)
The meningeal artery is represented in red and the lateral sinus in blue : the position of these was
ascertained by drilling holes from the interior of the skull. The shaded area above and behind the
external auditory meatus indicates the position of the epitympanic recess and mastoid antrum. The
broken line represents the inferior limit of the cerebral hemisphere as traced on the surface of the
skull, t f t indicate the points of intersection of vertical and horizontal lines respectively one inch,
one inch and a half, and two inches behind the external angular process of the frontal bone, and above
the upper border of the zygoma.
wards, following a course directed to the tip of the mastoid process as far as a point
about 5 mm. beyond the level of the lower border of external auditory meatus. In
the first part of its course the sinus usually lies altogether above a line drawn
transversely from the external occipital protuberance to the centre of the opening of
the ear, and the highest part of its arch, where the sinus crosses the postero-inferior
CRANIO-CEREBRAL TOPOGRAPHY. 5
angle of the parietal bone, is from 15 to 20 mm. (in extreme cases even 25 mm.)
above, and somewhat external to the mid-point of, this line. The distance of the
descending part of the sinus from the posterior wall of the auditory canal is usually
from 10 to 12 mm., but may be as little as 2 mm. The course of this part of the
sinus corresponds roughly to the line of reflection of the skin from the pinna to the
head posteriorly (Birmingham). The depth of the sinus from the surface of the
mastoid varies from 1 to 15 mm., with an average of 7 mm. ; and its breadth
ranges from 5 to 15 mm. The sinus is often much wider in its mastoid than in its
occipital segment. The right sinus is generally larger, projects more forwards, and
approaches nearer to the surface than the left. The lateral sinus may be exposed
by an opening in the bone immediately below the anterior part of the parieto
mastoid suture, or having its centre 25 mm. (1 inch) behind the highest point of
the orifice of the osseous external auditory meatus.
The anterior and larger division of the middle meningeal artery runs upwards
and backwards within the skull in the fore part of the temporal region, and would
be reached at points equal distances, one inch, one inch and a half, and in most
cases two inches, above the zygoma and behind the external angular process of the
frontal bone. It will be remembered that the vessel in this part of its course is
lodged in a deep groove, sometimes a canal, on the antero-inferior angle of the
parietal bone. The ramifications of the posterior division of the artery are variable
in number and position.
Craiiio-cerebral topography. Extent of the cerebral hemisphere. The upper
margin of the cerebral hemisphere extends from the lower part of the glabella nearly
to the external occipital protuberance. It does not quite reach the middle line,
being separated from its fellow by an interval which corresponds to the superior
longitudinal sinus, and like that increases in breadth posteriorly, where it measures
fully 1 cm. Owing to the lateral deviation of the sinus, the margin of the hemi-
sphere commonly approaches nearer to the middle line on the left side than on the
right. Beiow the sinus the mesial surfaces of the two hemispheres are nearly in
contact, being separated only by the thickness of the falx cerebri. Inferiorly, the
cerebral hemisphere reaches in front nearly to the eyebrow, at the side to the upper
margin of the zygoma, and behind to the superior curved line of the occipital bone.
The lower limit of the hemisphere is more precisely indicated by marking out its
lateral margin, which consists of two parts frontal and occipito-temporal. The
frontal part begins internally close above the naso-frontal suture (which is felt at
the bottom of the depression below the glabella), rises in an arch as it passes out-
wards, being about 8 mm. above the centre of the supraorbital border of the frontal
bone, and crosses the temporal crest just below the deepest point of the hollow
formed by the frontal bone immediately above the external angular process. From
the temporal crest the frontal margin descends slightly in the fore part of the
temporal fossa to a spot about 25 mm. behind the external angular process, where
it meets the foremost part of the temporal margin in a receding angle, which
corresponds to the stem of the fissure of Sylvius. The occipito-temporal division of
the lateral margin begins posteriorly at the occipital pole of the hemisphere, which
is placed a little (5 to 15 mm.) above and outside the external occipital protuber-
ance, and then follows the arch of the lateral sinus, as described above, to the back
of the ear. Crossing here the supramastoid crest, the margin is continued
forwards about 6 mm. (varying from 3 to 9 mm.) above the roof of the external
auditory meatus, and then on a level with the upper border of the zygomatic arch
for about the posterior half of its length. Then curving gradually upwards, the
border reaches its foremost point, corresponding to the temporal pole of the hemi-
sphere, about 20 mm. above the zygoma and 15 mm. behind the external angular
STJPEKFICIAL ANATOMY OF THE HEAD AND NECK.
process, and finally recedes slightly to meet the end of the frontal margin at the
Relations of the cerebral fissures and convolutions to the cranial wall. The point
of division of the Sylvian fissure is situated in the pterion, beneath or very near the
spheno-parietal suture towards its posterior end. From this spot the posterior limb
of the fissure runs backwards and somewhat upwards, at first following the line of
the squamous suture, and then crossing the temporal area of the parietal bone as far
Fig. 4. SIDE VIEW OF THE SKULL, SHOWING
THK RELATIONS OP THE BRAIN TO THE CRANIAL
(G. D. T.)
as the inferior temporal line, beyond which its superior terminal branch ascends for
a short distance beneath the parietal eminence. In the child the posterior limb of
the fissure is distinctly above the line of the squamous suture. The anterior
ascending branch of the Sylvian fissure runs from the hinder part of the spheno-
parietal suture upwards and somewhat forwards, crossing obliquely the lower end of
the coronal suture ; and the horizontal branch is directed forwards in the line of
the spheno-parietal suture. The parieto-occipital fissure is placed opposite the
lambda, or often rather above that point, especially in young subjects. The fissure
of Rolando is wholly beneath the parietal bone, its upper end being from 4 to 5 cm.,
CRANIO-CEREBRAL TOPOGRAPHY. 7
and its lower end about 3 cm., behind the coronal suture. The superior precentral
sulcus is from 2 to 3 cm. behind the upper part of the coronal suture ; and the
inferior precentral sulcus is a short distance (1 to 2 cm.) behind the lower part of
the same suture. The inferior frontal sulcus about corresponds to the stephanion
and the temporal crest of the frontal bone. The intraparietal fissure is very variable
in position : its ascending or postcentral portions are approximately parallel to and
about 15 mm. behind the fissure of Kolando ; while its longitudinal portion runs
backwards, with a slight inclination inwards, just above the parietal eminence, and
at an average distance of 45 mm. from the median line anteriorly, 35 mm.
posteriorly opposite the lambda. The parallel fissure lies mainly beneath the upper
part of the squamous and the hinder part of the temporal area of the parietal bone,
but its posterior end crosses the temporal lines and runs upwards for a short distance
in the parietal lobe of the hemisphere under the superior division of the parietal
bone : its position in the temporal part of its extent is indicated approximately by a
line drawn from the marginal tubercle of the malar bone to the lambda. In the
child, owing in great measure to the relatively small size of the squamous part of the
temporal bone, the parallel fissure appears to be placed much higher, often reaching
the level of the squamous suture.
From the foregoing determination of the situation of the fissure of Kolando and
precentral sulci, it follows that the ascending frontal and the bases of the upper,
middle, and lower frontal convolutions are placed beneath the anterior third of the
parietal bone. The main parts of the superior and middle frontal convolutions
correspond to the frontal region of the frontal bone, and of this area the superior
frontal convolution may be said to occupy rather less than the inner half, and the
middle frontal convolution rather more than the outer half. The centre of the
frontal eminence is commonly over the middle convolution. The apex of the pars
triangularis of the inferior frontal convolution corresponds to the antero-inferior
angle of the parietal bone ; and the pars orbitalis is covered by the temporal division
of the frontal bone and the upper end of the great wing of the sphenoid. The
whole of the parietal lobe is under cover of the parietal bone, the parietal eminence
corresponding to some part of the supramarginal convolution ; while the occipital
lobe occupies the cerebral division of the occipital bone, and sometimes extends slightly
beneath the adjacent part of the parietal bone. The temporal lobe lies for the most
part beneath the squamous division of the temporal bone and the postero-inferior fourth
of the parietal bone, its superior convolution being marked off from the rest by the line
given above for the parallel fissure ; but the anterior extremity of this lobe projects
under the great wing of the sphenoid, while posteriorly the inferior temporal convolu-
tion is prolonged beneath the occipital bone to the occipital pole of the hemisphere.
Determination of the principal fissures on the surface of the head. If a median
line be drawn over the head from the nasion (centre of the naso-frontal suture) to
the inion (external occipital protuberance), a point 1 cm. (or half an inch) behind
the centre of this line will indicate with sufficient accuracy the spot where the
fissure of Koiando meets the upper border of the hemisphere, and may be termed
the superior Rolandic point. From 8 to 10 cm. farther back the lambda may be
felt, or if that is not possible, a point should be taken on the nasio-inial line 6'5 cm.
(or 2| inches) above the inion, and a line carried transversely outwards for a
distance of 2 cm. from this spot will mark the parieto-occipital fissure.
On the side of the head, a line from the lowest point of the infraorbital margin
to the centre of the aperture of the ear (Eeid's base-line) is taken as the horizontal.
This line is about parallel with the upper border of the zygomatic arch ; and
vertical lines are perpendicular to it. A spot on the base-line in the hollow between
the tragus of the ear and the condyle of the lower jaw is known as the preauricular
point. From the fronto-malar junction (p. 1) let a line be carried horizontally
SUPERFICIAL ANATOMY OF THE HEAD AND NECK.
backwards for 35 mm., and from the end of this a vertical line for 12 mm. upwards ;
the upper end of the latter line marks the spot where the anterior branches are
given off from the Sylvian fissure, and may be termed the Sylvian point. A line
drawn from the fronto-malar junction through the Sylvian point to the lower part
of the parietal eminence will about lie over the posterior limb of the Sylvian fissure,
and may be called the Sylvian line. The anterior ascending and horizontal branches
of the fissure may be marked by lines 2 cm. long starting from the Sylvian point,
SUP ROLAND.C POWT
Fig. 5. SIDE VIEW OF SKULL ON WHICH THE CHIEF POINTS AND LINES USED IN CKANIO-CEREBRAL
TOPOGRAPHY HAVE BEEN MARKED. 3. (From a photograph by G. W. B. Waters.) (G. D. T. )
The contour of the cerebral hemisphere, with the Rolandic and Sylvian fissures, are marked by
continuous red lines, and the outline of the insula and of the lateral ventricle by broken red lines.
the one directed upwards and forwards at right angles with the Sylvian line, and the
other horizontally forwards.
On the Sylvian line, 25 mm. behind the Sylvian point, is the lower Rolandic
point, the spot where the fissure of Rolando, if prolonged, would meet the Sylvian
line. The lower Rolandic point is about 5'5 cm. (varying from 4 to 7) above the
upper border of the zygomatic arch, on or slightly in front of a vertical line passing
through the preauricular point. The Rolandic line may now be drawn between the
CRANIO-CEREBRAL TOPOGRAPHY. 9
upper and lower Rolandic points, and gives the general direction of the fissure of
Rolando. The line forms an angle (the Rolandic angle) anteriorly with the median
line of about 70 (varying in individual cases from 64 to 75) ; and if prolonged
downwards it crosses the zygomatic arch about the middle (Le Fort). The fissure of
Rolando is not quite so long as the Rolandic line, since the margin of the hemi-
sphere does not quite reach the median line above, while below, the fissure of Rolando
usually ends about 1 cm. above the Sylvian fissure or lower Rolandic point. The
Rolandic line coincides most nearly with the upper part of the fissure, the inferior
genu of which projects somewhat in front of the line a little below its centre,
a spot which is placed from 5 to 15 mm. above the lower temporal line on the
The precentral sulci are situated about 15 mm. in front of the fissure of Rolando,
with which they are nearly parallel ; from the lower of these the inferior frontal
sulcus arches forwards and downwards beneath the temporal crest of the frontal
bone, which can be felt through the skin ; and the position of the superior frontal
sulcus may be indicated approximately by a line running forwards from the superior
precentral sulcus slightly internal to the centre of the interval between the temporal
crest and the median line of the forehead.
The postcentral sulci being also nearly parallel to, and about 15 mm. distant
from, the fissure of Rolando, the average position of the longitudinal portion of the
intraparietal sulcus may be marked by a line drawn from the centre of the Rolandic
line to a spot 35 mm. external to the lambda, or 15 mm. from the end of the parieto-
Lastly, the seat of the parallel fissure may be determined by the above-
mentioned line from the marginal tubercle of the malar bone to the lambda.
Island of Reil, basal ganglia, and lateral ventricles. The Sylvian point marks
the position of the pole of the insula, and a spot on the Sylvian line 35 mm. behind
this point will correspond to its posterior angle. The upper limit of the insula may
then be indicated by a line, slightly convex upwards, drawn from its posterior angle
to the upper end of the anterior ascending branch of the Sylvian fissure, and
continued forwards for a distance of 15 mm. beyond the vertical passing through
the Sylvian point ; the lower limit by a line directed from the posterior angle down-
wards and forwards to a spot on the parallel line immediately below the Sylvian
point ; and the anterior limit by a line joining the anterior extremities of the two
foregoing lines. The area of the insula thus marked out will serve as a guide to
the position of the basal ganglia, which extend slightly beyond the limits of the
island, and are circumscribed by a strongly-curved line corresponding to the outer
border of the main part of the lateral ventricle. This line may be traced, beginning
at the anterior extremity of the ventricle 1 cm. in front of the foremost point of the
insula, and passing backwards in an arch, which follows the margin of the anterior
horn and body of the cavity, an equal distance above the upper limit of the island
to a spot 2 cm. behind its posterior extremity. Thence, the inferior horn runs
forwards and downwards, to end about 1 cm. below the level of the parallel fissure
and somewhat in advance of the coronal plane passing through the lower Rolandic
and preauricular points. From the back of the loop thus indicated the posterior
horn extends a variable distance towards the hindmost point of the hemisphere,
which is placed a little higher than the occipital pole, beneath the occipital point of
the skull. 1
1 For more detailed information as to cranio-cerebral topography, reference may be made to the
memoir by D. J. Cunningham, Contribution to the Surface Anatomy of the Cerebral Hemispheres, with
a Chapter on Cranio-Cerebral Topography, by Victor Horsley. The subject is also fully illustrated by
the series of models prepared under the direction of the former anatomist, showing the relations of the
cerebral hemispheres in situ in a number of individuals of both sexes and at various periods of life, from
infancy to old age.
SUPERFICIAL ANATOMY OF THE HEAD AND NECK.
The cerebellum, occupying the inferior occipital fossa?, is in contact with the
cranial wall up to the lower margin of the transverse part of the lateral sinus. This
vessel may occasionally have a lower position than that given on p. 4, and it is
advisable, therefore, in operations upon the cerebellum, that the opening in the bone
should be kept at least 1 cm. (half an inch) below the level of a line drawn from the
external occipital protuberance to the centre of the external auditory meatus, while
at the same time it should not extend farther forwards than a vertical line 35 mm.
(one inch and a half) behind the latter spot. In this way both the lateral sinus and
the occipital artery will be avoided (fig. 9).
Mastoid antrum. The air-cells, which in the adult usually occupy the interior
of the mastoid portion of the temporal bone, open into a small chamber termed the
mastoid antrum. This is continuous anteriorly with the highest part of the
^g sem&tsEular canal
cctnal offadaL nenie j
canal of ten&or tytnfianL\ j /
tube. : ..
GliuxSiaa, Assure. \VJ&
\ La&raL sulcus
e.xt. uwd,. meatus
Fig. 6. LKET TEMPORAL BONE, DIVIDED BY A VERTICAL SECTION PASSING THROUGH THE TYMPANUM
AND MASTOID ANTRUM : A, INNER PORTION ; B, OUTER PORTION. Natural size. (From a photo-
graph by G. W. B. Waters.) (G. D. T.)
The section is directed somewhat obliquely from before, backwards and outwards. The tympanic
cavity and the antrum are coloured blue, and the division between the epityrapanic recess and the
antrum is indicated by a dotted line ; c. c. carotid canal.
tympanic cavity or epitympanic recess (attic of the tympanum), and thus, through
the Eustachian tube, the mastoid cells are put into communication with the external
air. In form the mastoid antrum may be compared to the bulb of a retort,
which is somewhat compressed in the transverse direction, and the truncated neck
of which corresponds to the opening into the epifcympanic recess (aditus ad
The dimensions of the antrum are subject to considerable variation, but in most
cases it measures between 10 and 15 mm. longitudinally, about 10 mm. vertically,
and from 4 to 6 mm. transversely. Its depth from the surface, i.e., the thickness
of its outer wall, varies from 7 to 14 mm. The bone here is commonly very hard
and dense, but in the deeper part it is often more spongy, being excavated by cells
in communication with the cavity. The entrance to the antrum from the epi-
tympanic recess is rather triangular in form, with the base upwards and the lower
angle broadly rounded off : its longest diameter is about 4 mm. both vertically and
transversely. The lower margin of the opening is on a level with the upper wall of
THE MASTOID ANTRUM.
the external auditory meatus ; and the coronal plane in which the opening is
contained, in consequence of the forward inclination of the bony meatus, is placed a
little (about one-fourth of the horizontal diameter of the meatal opening) in front
of the posterior margin of the external orifice of that canal. The epitympanic
recess is situated above the anterior three-fourths of the orifice. Behind the
entrance the floor of the antrum sinks, forming a hollow which does not usually
extend below the level of the centre of the auditory meatus. The cavity is, however,
continued into the mastoid cells, which are often of large size, and then as a rule
reach to the tip of the mastoid process.
Superiorly, the antrum is separated from the middle fossa of the base of the skull
by a thin plate of bone which continues backwards and upwards the tegmen
Fig. 7. RIGHT TEMPORAL BONK, FROM WHICH THE SUPERFICIAL PORTION OF THF. MASTOID DIVISION
HAS BEEN REMOVED, EXPOSING THE MASTOID ANTRUM. Natural size. (From a photograph by
G. W. B. Waters.) (G. D. T.)
The broken line indicates the position of the lateral sinus.
tympani. This sometimes presents small deficiencies, in which there is only a
slender fibrous layer between the mucous lining of the cavity and the dura mater ;
and these two membranes are always united by connective tissue and vessels passing
through the petro-squamosal fissure, as well as through minute apertures in the
tegmen. In position, the roof of the antrum corresponds as a rule to the supra-
mastoid crest externally, but not unfrequently it rises somewhat above that level,
and in that case the upper part of the antrum may be overlapped by the lateral
margin of the cerebral hemisphere, the inferior temporal convolution of which is
received at this spot into a slight groove between the prominent tegmen internally
and the lower border of the squamous temporal externally.
From the communication with the epitympanic recess the antrum extends back-
wards and outwards, so that it comes nearer to the surface behind than in front.
Anteriorly, there is only a thin bony wall between the cavity and the deep part of
SUPERFICIAL ANATOMY OF THE HEAD AND NECK.
the auditory meatus. Posteriorly, it approaches the descending part of the lateral
sinus, in some cases reaching close to the osseous lamina which forms the floor of
the groove, but more commonly the two are separated by an interval of from 5 to
10 mm. occupied by mastoid cells. The sinus is usually nearer to the surface than
the air-space. It will be remembered that the outer wall of the antrum is developed
from the postauditory process of the squamo-zygomatic division of the temporal
bone (see Osteology, p. 74) ; and there are generally in the adult some vestiges of
the infantile masto-squamosal suture in the form of small clefts and canals which
lead from the cavity to the exterior of the bone, and are occupied by connective
tissue and veins.
remains of y'
masto - scjuamosdl
Fig. 8. LOWKR AND POSTERIOR PORTION OP RIGHT TEMPORAL BONE, SHOWING THE SUPRAMEATAL
TRIANGLE, COURSE OP THE FACIAL NERVE, &C. Natural size. (GJ. D. T.)
The mastoid antrum may be reached from the exterior by perforating the bone
close to the upper and posterior part of the external auditory meatus. In this
region Macewen describes a suprameatal triangle, 1 which is bounded above by the
supramastoid crest, below and in front by the postero-superior quadrant of the outer
margin of the osseous meatus, and behind by a vertical line tangential to the hind-
most point of that opening. The surface of bone included in the triangle is usually
marked by a small depression the suprameatal fossa, which is separated from the
aperture of the meatus by a sharp prominent edge the suprameatal spine. The
perforation should be made within this area, at the site of, or close behind, the
suprameatal fossa, and be directed inwards and slightly fowards, following the
inclination of the external auditory meatus. The antrum will then be opened at its
fore part, at a depth from the surface varying generally from 1 to 14 mm. ; in
extreme cases, and especially as the result of disease, this distance may be reduced
to 3 mm., or increased to 18 mm., or even more. At the lower part of the entrance
into the antrum the inner wall of the cavity presents a slight bulging over the
external semicircular canal (fig. 6), which may be injured if the instrument is not
checked as soon as the cavity is reached : the distance of the wall of the canal from
the surface is mostly between 17 and 20 mm. (about three-quarters of an inch).
Just below and in front of this, on the inner side of the epitympanic recess, is the
arch of the facial nerve contained in its canal, the osseous wall of which is thin
1 W. Macewen, Pyogenic Infective Diseases of the Brain and Spinal Cord, 1893, p. .
towards the cavity, and often defective in part. The nerve will best be avoided by
not directing the perforation too much forwards. Between the semicircular canal
in front and the lateral sinus behind, the air-spaces are in relation internally with the
posterior fossa of the base of the skull, the thickness of the intervening bone ranging
from 1 to 9 mm. The original perforation must be kept below the supramastoid crest
in order to avoid opening the middle fossa of the skull ; and it should not extend
Fig. 9. LOWER AND HINDER PART OF SKULL, IN WHICH AN OPENING HAS BHEN MADE INTO THE
MASTOID ANTRUM, AND ON WHICH THE COURSE OF THE OCCIPITAL ARTERY AND LATERAL SINUS
ARE INDICATED. ( From a photograph by G. W. B. Waters.) f (G. D. T.)
backwards more than 2 mm. beyond the posterior boundary of the suprameatal
triangle, or the lateral sinus may be endangered.
In the infant and child the mastoid antrum has nearly its full size, but its outer
wall is relatively thin. The mastoid cells are, however, not usually developed before
twelve years of age.
The face. In the face proper, the nasal bones and the margin of the anterior
nasal aperture are readily traced, and at the lower part of the latter, in the root of
the septum narium, the anterior nasal spine is felt. In front of this opening the form
of the upper and lower lateral cartilages can be distinguished, and the inner portion
of the latter is more clearly made out by passing the finger into the nostril, by which
means part of the cartilage of the septum, the lower margin of the upper lateral
cartilage, and sometimes the tip of the inferior turbinate bone, can also be felt.
With the nasal speculum, if the parts be normal, the dull red mucous membrane
of the floor of the nose and of the lower part of the septum may be seen, the brighter
red inferior turbinate body for the greater part of or all its extent, and the inferior
meatus for a variable distance. The anterior border and a small part of the inferior
border, i.e., the operculum, of the middle turbinate body may also be seen, and a
very small part of the middle meatus. The fore part of the roof is visible, but the
superior turbinate body rarely, and the superior meatus never. The back of the
pharynx can be seen in a nose of moderate dimensions.
Below the base of the zygoma, the temporo-maxillary articulation is quite super-
J4 SUPERFICIAL ANATOMY OF THE HEAD AND NECK.
ficial behind the upper part of the masseter, and from the condyle the posterior
margin of the raraus of the lower jaw can be followed to the angle. The lower
margin of the jaw can also be felt throughout, and ascending from its central point
the anterior edge of the masseter. Immediately in front of the latter, the facial
artery crosses the base of the jaw, and is readily found by its pulsation ; the course
of the vessel is roughly marked by a line passing upwards a little outside the corner
of the mouth and continued by the side of the nose to the inner canthus of the eye.
The coronary branch of the artery may be felt pulsating beneath the mucous
membrane in each lip very near its free border. Stensen's duct runs generally in
the direction of a line drawn from the lower margin of the concha of the ear to a
point midway between the ala of the nose and the free margin of the lip, but it
varies somewhat in position in different subjects ; accompanying the duct are the
transverse facial vessels (usually above) and the infraorbital branches of the facial
nerve (below). The interval between the ramus of the jaw and the mastoid process
is occupied by the parotid gland, a part of which extends forwards over the masseter
muscle, and the trunk of the facial nerve is deeply placed beneath the gland ; the
position of the nerve may be indicated by a line running downwards and forwards
from the anterior border of the mastoid process at the point where it meets the ear.
A line carried downwards over the face, crossing the supraorbital notch and the
interval between the two bicuspid teeth of the lower jaw, will be found to be nearly
vertical and to pass over the infraorbital and mental foramina, thus forming a guide
to the spots at which the largest cutaneous branches of the three trunks of the fifth
nerve come to the surface. The infraorbital foramen is about 1 cm. below the
margin of the orbit ; and the mental foramen is midway between the upper and lower
margins of the jaw.
About the anterior half of the eyeball can be felt in the aperture of the orbit : it
gives a tense elastic sensation to the fingers. At the upper and inner angle of the
orbital opening the pulley of the superior oblique muscle may also be felt.
When the eye is open the skin is drawn into the deep superior palpebral sulcus
immediately above the upper lid, and forms a loose projecting fold between this
furrow and the eyebrow. The corresponding inferior palpebral sulcus of the lower
lid is much slighter, and often broken up : it is most distinct when the eye is
directed downwards. Below this, another shallow groove, the palpebro-malar sulcus,
runs round from near the inner canthus of the eye, following fairly closely the lower
margin of the orbit. A small external palpebral sulcus is continued outwards from
the outer canthus for about 3 mm., and forms a prolongation of the palpebral cleft
when the eye is closed. Contraction of the outer part of the orbicularis palpebrarum
gives rise to radiating furrows outside and below the eye, markings which are
generally permanent in old persons.
The skin of the eyelid is very soft and thin ; at the free margin of each lid it
passes into the conjunctiva along the line of the eyelashes, and within this a sharp
edge is formed, especially in the case of the lower lid, which is closely applied to the
surface of the eyeball. The palpebral fissure is somewhat oval, or widely fusiform,
in shape, but the margin of the upper lid is more arched than that of the lower.
The fissure is also generally a little inclined from without inwards and downwards.
The whole length of the palpebral fissure is about 30 mm. (an inch and a
quarter) ; its breadth is scarcely sufficient, unless when the eyes are unusually widely
opened, to expose the whole of the cornea ; but these dimensions, especially the
latter, vary considerably in different persons, thus causing the eye to appear larger
or smaller, although the size of the globe itself is relatively very constant. At the
outer canthus, the lids meet in an acute angle ; at the inner, the fissure is prolonged
downwards and inwards for about 5 mm. between portions of the lid-margins, which
are straight and rounded. The junction of the curved and straight portions of the
THE FACE. 15
margin is marked by a slight elevation, the papilla lacrimalis, which is much better
developed in the lower lid than the upper, and on drawing the lid forwards a minute
opening, the punctum lacrimale, is seen on the summit of the papilla, leading into
the canaliculus by which the tears are conveyed into the lachrymal sac. In the
neighbourhood of the inner canthus the lids are separated from the eyeball by the
caruncula lacrimalis, a red fleshy-looking portion of skin, which supports a few fine
hairs, and by the fold of mucous membrane known as the plica semilunaris.
The lids can be readily everted, the lower one by simply pulling it downwards,
the upper one by turning it over a probe, and the ocular and palpebral conjunctiva
can thus be completely examined ; the former is transparent and smooth, presenting
only a few minute vessels in the healthy state ; the latter is more or less red and
velvety in appearance. The Meibomian glands are seen at the same time, appearing
through the conjunctiva as lines of yellowish granules arranged perpendicularly to
the edges of the lids ; and along the latter the openings of their ducts are visible in
the form of minute spots within the line of the eyelashes.
If the eyelids are drawn forcibly outwards, the internal tarsal ligament, or tendo
palpebrarum, is made to project between the inner canthus and the margin of the
orbit ; and this band can also be felt as it is tightened during the act of winking.
Behind the tarsal ligament, and reaching to a somewhat higher level, is the lachrymal
sac ; into the latter the canaliculi open, taking a course from the puncta lacrimalia,
at first vertically, and then nearly horizontally, the one above and the other below
the ligament. A knife entered immediately below the internal tarsal ligament will
open the lower part of the lachrymal sac, and a probe may then be passed through
the incision, in a direction downwards and slightly backwards and outwards, along
the nasal duct into the nose.
Mouth and fauces. On looking into the mouth, the teeth are seen, and by
everting the lips, the outer surface of the gums may be inspected, and the alveolar
processes can be examined with the finger. The smooth mucous membrane lining
the lips is thus exposed, and in the middle line, passing from each lip to the jaw, is
a thin fold termed the fraenum ; of these the upper one is the larger. On pulling
the angle of the mouth outwards, the lining membrane of the inside of the cheek
can be examined, and the papilla on which the duct of Stensen opens may be seen
and felt opposite the second molar tooth of the upper jaw ; with some difficulty a
fine probe may be made to enter the aperture. A little farther back, if the mouth
be alternately opened and shut, it is easy to distinguish the anterior borders of the
masseter and temporal muscles, as well as the edge and inner surface of the ramus of
By raising the tongue, the inner aspect of the gums and the floor of the mouth
are brought into view. The under surface of the tongue is smooth, and is connected
in the middle line with the floor of the mouth by the frcenum linguae,, a fold of
mucous membrane similar to, but much larger than, the frsena of the lips ; from
this a fine line is continued forwards to the tip of the tongue. Somewhat less than
half an inch external to the frsenurn, on each side, the ranine vein is clearly seen
through the delicate mucous membrane ; the corresponding artery is more deeply
placed and does not come into view ; an elevated and fringed line of the mucous
membrane, plica fimbriata, lies superficially to these vessels, and may be followed,
converging towards its fellow, almost as far as the tip of the tongue. Between the
alveolar border and the tongue, on each side, is the alveola-lingual sulcus, at the
bottom of which the mucous membrane is raised into a well-marked ridge, directed
obliquely forwards and inwards, over the sublingual salivary gland. Each ridge
ends close to the middle line in a small papilla, and on this is seen, in the form of a
minute spot, the opening of Wharton's duct, into which a fine probe may be easily
16 SUPERFICIAL ANATOMY OF THE HEAD AND NECK.
On putting back the head, the mucous membrane covering the hard palate, and
the soft palate come into view, as well as the uvula, the anterior and posterior pillars
of the fauces, and the tonsils. The hamular process is plainly felt a little behind
and internal to the last molar tooth ; and just in front of this is situated the opening
of the posterior palatine canal, through which the largest vessels and nerves of the
palate issue. The pterygo- maxillary ligament is to be felt descending from the
hamular process to the inferior maxilla, being contained in a more or less prominent
fold of the mucous membrane, which passes between the jaws behind the extremities
of the dental arches. Just in front of this, and immediately internal to the last
molar tooth, the lingual branch of the fifth nerve runs inwards beneath the mucous
membrane to the side of the tongue.
Between the posterior pillars of the fauces, a portion of the mucous lining of the
hinder wall of the pharynx is seen ; and if the finger be passed behind the tongue,
there is no difficulty in feeling the greater part of the back of the pharynx and the
epiglottis. By hooking the finger up behind the soft palate, the basilar process of
the occipital bone is reached, and the posterior nares and adjacent parts may be
explored. It is easy thus to distinguish the vault of the pharynx, the septum nasi,
the posterior extremities of the middle and inferior turbinate bones, and the openings
of the Eustachian tubes ; and the finger may be made to pass some distance into
the nasal fossae. In this way also the upper four or five (in children six) cervical
vertebrae may be examined, the anterior arch of the atlas being opposite the lower
margin of the posterior nares, and the body of the axis corresponding to the soft
palate. The part of the column which is accessible to a straight instrument
introduced through the mouth is very limited, extending in the adult from the
lower border of the axis to the middle or lower part of the fourth cervical vertebra ;
in the child, owing to the small depth of the face, it comprises the body of the axis
and of the third cervical vertebra (Chipault).
By posterior rhinoscopy the upper parts of the posterior nares are seen, separated
by the septum. They are in great part occupied by the posterior ends of the
turbinate bodies, of which the most conspicuous is the middle ; the superior is
usually seen, but only the upper part of the inferior, the lower part of the latter, as
well as the lower part of the septum, being concealed by the soft palate. On each
side of the posterior nares are seen the Eustachian tube, the salpingo-pharyngeal
and salpingo-palatine folds, and the lateral recess of the pharynx (fossa of Kosen-
muller). By turning the mirror upwards, the vault of the pharynx, the pharyngeal
tonsil and the median pharyngeal recess (bursa pharyngea) may also be examined.
The septum appears whitish, the turbinate bodies are of an ash-grey colour, and the
rest of the mucous membrane is of various shades of red.
The front of the neck is divided into an upper, suprahyoid, submaxillary, or hyo-
mental region, and a lower, infrahyoid or hyo-sternal region. The hyoid bone, which
forms the boundary line between the two divisions, can be felt in the receding angle
below the chin, and it may be examined by fixing the two great cornua between the
fingers. The anterior bellies of the digastric muscles form the convex surface in
the middle of the suprahyoid region, and outside this on each side the submaxillary
gland is both to be felt and seen. The median prominence (pomum Adami} in the
upper part of the infrahyoid region is due to the thyroid cartilage, and is strongly
marked in men, especially those with deep voices, small or indistinct in women and
children. Above the thyroid cartilage the finger sinks into the depression (thyro-
hyoid space) between that and the hyoid bone ; below the thyroid, the crico-thyroid
space and the cricoid cartilage are recognised ; and from the latter the finger passes
on to the trachea. The rings of the trachea are, however, scarcely to be distinguished,
THE NECK. 17
being obscured above by the isthmus of the thyroid body, and below by the muscles
and the increasing quantity of fat as the air-tube recedes from the surface, the depth
of the front of the trachea at the upper border of the sternum amounting to nearly
an inch and a half (3'5 cm.).
The lower part of the epiglottis is placed behind the thyro-hyoid space, and
still farther back is the upper aperture of the larynx. The rima glottidis is at a
. lower level, being opposite the middle of the short anterior margin of the thyroid
cartilage. The lower border of the cricoid cartilage indicates also the termination
of the pharynx and the commencement of the oesophagus.
Along the side of the neck, the sterno-mastoid muscle runs obliquely from the
mastoid part of the temporal bone to the sternum and clavicle ; its anterior border,
forming the hinder boundary of the anterior triangle of the neck, is thick and
prominent, and leads down to the strongly marked sternal head, which passes to the
front of the manubrium and gives rise, with its fellow of the opposite side, to the
deep suprasternal notch (fossa jugularis}. The posterior border of the muscle is
thin, and in its upper part does not show on the surface ; inferiorly it becomes
evident and is continued into the clavicular head, which is, however, broader and
less salient than the sternal origin. A slight depression usually corresponds to an
interval between the two heads, and the lower boundary of the depression is formed
by the somewhat prominent inner extremity of the clavicle. A needle thrust back-
wards in this depression, and in contact with the end of the clavicle, would reach, on
the right side, the bifurcation of the innominate artery, on the left, the common
carotid arteiy as it passes into the neck.
The carotid arteries are situated just beneath the anterior border of the
sterno-mastoid muscle, their position being indicated more exactly by a line drawn
from the sterno-clavicular articulation to a point midway between the angle of the
jaw and the tip of the mastoid process. The common carotid artery reaches upwards
- as far as, or slightly beyond, the upper border of the thyroid cartilage ; above this
level, the external and internal carotids are placed side by side, the external being
the more anterior, until they pass beneath the posterior belly of the digastric
muscle, the position of which may be indicated by a line drawn from the raastoid
process to the fore part of the hyoid bone. If deep pressure be made in the situa-
tion of the great vessels opposite the cricoid cartilage, the prominent anterior
tubercle of the transverse process of the sixth cervical vertebra (carotid tubercle) can
be felt, and the common carotid artery may be compressed against it. This is a
little below the spot at which the omo-hyoid muscle crosses the carotid artery, and
indicates also the place where the inferior thyroid artery turns inwards, and the
vertebral artery usually enters upon its course through the foramina in the transverse
The lingual artery arises from the external carotid opposite the hyoid bone ; it
first forms a small loop with the convexity upwards, then passes forwards along the
upper margin of the great cornu of the hyoid just below the level of the hypo-
glossal nerve and ranine vein, which are separated from it by the hyo-glossus
muscle. At a slightly higher level, the occipital and facial arteries leave the
external carotid, the former passing up to the transverse process of the atlas, which
may be felt just below and a little in front of the tip of the mastoid process, the
latter taking a winding course at first beneath and then above the submaxillary
gland to the anterior border of the masseter muscle. The superior thyroid artery,
arising below the lingual, runs downwards and inwards near the back of the thyroid
cartilage, and sends its crico-thyroid branch across the crico-thyroid space.
The line of the internal jugular vein is just external to that of the carotid
arteries ; the facial vein, more superficial than the artery, courses from the anterior
border of the masseter downwards and backwards, to join the main trunk about
18 SUPERFICIAL ANATOMY OF THE HEAT) AND KECK.
opposite the thyro-hyoid space ; the middle thyroid vein crosses the common
carotid artery near the level of the cricoid cartilage, and the large inferior thyroid
veins pass downwards deeply on the front of the trachea. More superficially placed,
and often showing through the skin, are the anterior jugular vein near the middle
line, and a communicating branch, frequently of large size, between the facial and
anterior jugular veins, lying along the anterior border of the sterno-mastoid muscle.
The right and left anterior jugular veins are generally connected by a cross branch
.of considerable size at the bottom of the suprasternal notch, close to the upper
border of the manubrium, and the lower part of each vein is then directed outwards
behind the origin of the sterno-mastoid, so that great care must be exercised, in
order not to wound the vessel, in dividing this muscle for the cure of wry-neck.
The position of the tonsil corresponds externally to a spot slightly above the
angle of the jaw.
Behind the sterno-mastoid muscle, between it and the trapezius, is the inter-
muscular space known as the posterior triangle of the neck ; inferiorly, this gives
rise to a broad depression, the supraclavicular fossa, in which the omo-hyoid muscle
and the brachial plexus may be felt, and in thin persons seen. In the angle between
the sterno-mastoid and the clavicle, the third part of the subclavian artery can be
felt pulsating, and the circulation in the vessel may be arrested here by pressure
directed downwards and backwards against the first rib. The subclavian artery, as
it crosses the root of the neck, describes a curve with the convexity upwards, having
its inner end behind the sterno-clavicular articulation, its outer end beneath the
centre of the clavicle, and its mid-point from half an inch to an inch (1 2'5 cm.)
above that bone. The left artery is more deeply placed at first than the right, and
does not usually rise so high in the neck. The subclavian vein is placed at a lower
level, and is, as a rule, entirely under cover of the clavicle. The pleura and lung
ascend above the clavicle into the arch formed by the subclavian artery. The pulsa-
tion of the transverse cervical artery may frequently be distinguished a short distance
above the clavicle.
The external jugular vein runs over the surface of the sterno-mastoid muscle in
the direction of a line drawn from the angle of the jaw to the centre of the clavicle,
and is covered only by the integument and the platysma, the fibres of the latter
being nearly parallel to the course of the vein. The distance to which it reaches
beyond the posterior edge of the sterno-mastoid below varies considerably. Near
the clavicle the vein becomes considerably enlarged, being joined by some branches
from the shoulder (transverse cervical and suprascapular), which, with the lower
part of the trunk, generally form a more or less dense plexus over the third part of
the subclavian artery.
About an inch (2-5 cm.) below the tip of the mastoid process, the spinal accessory
nerve passes beneath the anterior border of the sterno-mastoid ; emerging at,
or slightly above, the middle of the posterior border of this muscle, it then
continues its oblique course across the posterior triangular space, and sinks beneath
the upper border of the trapezius on a level with the sixth or seventh cervical spine ;
under the latter muscle, the nerve runs downwards immediately internal to the
vertebral border of the scapula. The great auricular and superficial cervical nerves
also come out at the posterior border of the sterno-mastoid about the middle of its
length, and are thence directed, the great auricular upwards to the ear, and the
superficial cervical forwards to the front of the neck.
For the back of the neck, see p. 27.
THE CHEST. 19
SUPERFICIAL ANATOMY OF THE TRUNK.
On the front of the chest, the greater part of the thoracic wall is concealed on
each side by the pectoralis major, the uppermost portion of the muscle extending
over the inner half of the clavicle from which it arises, while inferiorly, it forms a
prominent curved margin, which follows the direction of the fifth costal cartilage.
The interval between the clavicular and sterno-costal portions can often be seen
when the muscle is at rest, and always when it is put into action Externally, the
upper and lower borders of the muscle converge as it narrows to its insertion ; the
former is at first separated from the adjacent anterior margin of the deltoid by the
wfradavicular fossa, but lower down the two muscles become closely united ; the
lower margin of the pectoralis major leaves the chest opposite the fifth rib (at which
spot the lowest slip of the pectoralis minor often appears on the surface) and forms,
as it passes upwards and outwards to the arm, the rounded anterior axillary fold,
ending in the sharp tendon, which becomes apparent when the muscle is in action.
The nipple is placed over the outer and lower part of the pectoral muscle, generally
between the fourth and fifth ribs, about three-quarters of an inch (2 cm.) external
to the junction of the bone and cartilage, and rather more than four inches (10 cm.)
from the middle line ; but its'position varies considerably in different individuals, and
it is not unfrequently, especially in fat persons and in females, at a much lower level.
Along the middle line, the sternum is subcutaneous at the bottom of the sternal
groove or furrow between the great pectoral muscles. The furrow is interrupted
towards the upper part by a slight, but distinct, transverse ridge, which marks the
sternal angle formed by the union of the manubrium and the body of the sternum,
and on each side of this the second costal cartilage, which projects forwards more
than the others, continues the prominence outwards. Inferiorly, the sternal furrow
opens out, as the pectoral muscles diverge from one another, exposing the lower end
of the body of the sternum, a spot which marks the articulation of the seventh
costal cartilage, and which is always to be readily felt, and usually distinctly seen,
owing to the formation of the infrasternal depression immediately below it. The
infrasternal depression (epigastric fossa, scrobiculus cordis) is a generally well-
marked, although variable, hollow between the seventh costal cartilages and the
upper ends of the recti muscles, and is placed over the ensiform process, which is
itself seldom visible on the surface. It will be remembered that the upper margin
of the sternum is on a level (during expiration) with the disc between the second
and third dorsal vertebrae ; the junction of the manubrium and body is opposite the
fifth dorsal vertebra ; and the xiphi-sternal articulation generally corresponds to the
lower part of the ninth dorsal vertebra.
To the outer side of the pectoralis major, the ribs are covered by the serratus
magnus. Of the digitations of this muscle, the first to appear, at the lower margin
of the pectoralis major, is the one attached to the fifth rib ; the following one, the
sixth, is the largest and most prominent, and they become less marked below this.
Below the pectoral muscle, the wall of the thorax is covered by the rectus abdominis
internally, and the external oblique laterally, the pointed slips of the latter muscle
being received between the digitations of the serratus magnus. More posteriorly,
the latissimus dorsi ascends over the hinder part of the serratus, and, winding round
the teres major muscle, forms the thick posterior fold of the axilla.
The ribs may generally be followed without difficulty over the front and sides
of the chest ; but only a very small portion of the first can be distinguished, as it is
almost completely covered by the clavicle and scapula. The width of the inter-
costal spaces, and the form of the subcostal angle vary greatly in accordance with
20 SUPERFICIAL ANATOMY OF THE TRUNK.
the shape of the chest. Thus, in a long narrow chest the lower ribs slope very much
downwards and are near to one another, the subcostal angle is narrow, and the
lateral margin of the thorax reaches nearly, or in some persons quite, as far as the
iliac crest. "When the chest is broad the opposite conditions are found. The sub-
costal angle is on the average about 70 in the male and 75 in the female, but it
may vary from 60 to 80 (Charpy).
The lungs. The apex of the lung rises above the anterior end of the first rib
and the clavicle into the neck, where it is placed behind the interval between the
two heads of the sterno-mastoid, being covered immediately by the subclavian artery
and scalenus anticus muscle. Its highest point is on a level with the neck of the
first rib ; and it projects very slightly, if at all, beyond the plane of that rib. The
height to which it extends above the clavicle ranges in ordinary circumstances from
half an inch to an inch (1 2*5 cm.), but sometimes it is as much as an inch and three-
quarters (4 cm.), while in other cases the lung does not project at all above the bone.
A resonant percussion-note may, however, always be obtained in the living subject
for some distance above the clavicle, owing to the obliquity of the surface of the neck.
The distance of the apex from the clavicle is actually diminished during inspiration,
since that bone is then moved upwards with the anterior end of the first rib. There
does not appear to be any constant difference in the extent upwards of the lung on
the two sides, but it is not uncommon for the right lung to be somewhat higher
than the left. From the apex, the anterior border of each lung inclines inwards
behind the sterno-clavicular articulation and the manubrium, to the junction of the
latter with the body of the sternum, where the two almost meet in the middle line ;
they then descend together, the right sometimes projecting a little to the left of the
mid-line, as far as the fourth costal cartilage ; from this point the margin of the
right lung continues a nearly straight course to the level of the sixth chondro-sternal
articulation (sometimes even to the lower end of the body of the sternum), while
that of the left slopes outwards behind the fifth costal cartilage, in a direction which
may be indicated with sufficient accuracy by a line drawn from the fourth chondro-
sternal articulation of the left side to the spot on the chest-wall corresponding to the
apex of the heart (see below).
The lower limit of the lung may be marked by a line, slightly convex downwards,
carried round the side of the chest from the sixth chondro-sternal articulation to
the tenth dorsal spine. In the mamillary line, the lung extends downwards to the
sixth rib ; opposite the posterior fold of the axilla, to the eighth rib ; and in the
scapular line (carried vertically downwards from the lower angle of the scapula,
while the arms are against the sides), to the tenth rib. At the side of the chest the
left lung often descends somewhat beyond these limits. This margin of the lung
descends considerably in inspiration, and rises in expiration. The position of the
great fissure in each lung may be ascertained approximately by drawing a line from
the second dorsal spine to the sixth rib in the nipple-line ; and the smaller fissure
of the right lung extends from the middle of the foregoing to the junction of the
fourth costal cartilage with the sternum.
The pleura reaches considerably farther downwards than the lung. Posteriorly,
its lower margin corresponds most frequently to the head of the twelfth rib, or the
eleventh dorsal spine ; it is seldom higher than this, but often lower, in many cases
extending as much as an inch (2*5 cm.) beyond the spot mentioned. Being directed
at first horizontally outwards, its line then ascends gradually over the side of the chest,
and passes behind the seventh costal cartilage to the sternum, from which point it
slopes gradually inwards to reach the middle line at the level of the fifth cartilages.
As the pleurae of the two sides are almost symmetrical in front, the left extends
considerably farther over the pericardium than the corresponding lung. At the
side of the chest, the line of reflection of the pleura is generally from two to three
inches (5 7 cm.) above the lower margin of the thorax : towards the front, it is
usually a little lower on the left side than the right.
The heart and great vessels. The upper limit of the heart is represented by
a line passing from the lower border of the second costal cartilage of the left side to
the upper border of the third cartilage of the right side ; the lower limit by a line
Fig. 10. FRONT VIEW OP THR TRUNK, SHOWING THE RELATIVE POSITIONS OP THE PRINCIPAL THORACIC
AND ABDOMINAL VISCERA, &c. |. (R. J. G. and Gr. D. T.)
The outlines of the lungs and their large fissures are indicated by thin lines ; the position of the
heart and great vessels (superior vena cava, arch of aorta and pulmonary artery), as well as below the
abdominal aorta and the common and external iliac arteries, by thick lines ; the liver is represented by
a broken line ; the stomach and transverse colon by thick dotted lines ; and the kidneys by thin
drawn somewhat obliquely, and with a slight downward convexity, from the seventh
chondro-sternal articulation of the right side to the apex, the latter point being in the
fifth intercostal space, about three and a half inches (9 cm.) to the left of the middle
22 SUPERFICIAL ANATOMY OF THE TRUNK.
line, and generally about an inch and a half (4 cm.) below, and three-quarters of an
inch (2 cm.) to the sternal side of the nipple. The right border of the heart is indicated
by a line carried from the third to the seventh chondro-sternal articulation, and
arching outwards to a distance of one inch and a half (4 cm.) from the middle line ;
the left border, by an oblique line, convex upwards, extending from the second left
costal cartilage to the apex. The area thus marked out corresponds to what is known
as the deep cardiac dulness, although the latter can hardly be traced above the third
costal cartilage of the left side ; the superficial cardiac dulness corresponds to that
part of the heart which is uncovered by lung, and thus begins at the inner end of the
fourth left cartilage, extends to the left almost to the apex, to the right as far as the
middle line, and below merges into the dulness which answers to the liver.
The pulmonary orifice is placed opposite the upper margin of the third left costal
cartilage, close to the sternum, whence the artery proceeds upwards to its bifurcation
behind the second costal cartilage of the same side, which is therefore termed the
pulmonary cartilage. The orifice of the aorta is below and a little internal to the
pulmonary orifice, being behind the sternum, close to the lower border of the third
left cartilage ; from this spot the ascending aorta passes across to the right edge of
the sternum opposite the second (aortic} cartilage, and the arch then returns to the
left side, crossing the middle line about an inch (2'5 cm.) from the suprasternal
depression. Opposite the middle point of the manubrium, the innominate and left
common carotid arteries are arising close together from the upper border of the arch
of the aorta, and they pass symmetrically upwards, the innominate to the back of the
right, and the carotid to the back of the left sterno-clavicular articulation. The left
subclavian artery is almost directly behind the left carotid in the thorax. The superior
vena cava lies to the right of the arch, behind the inner ends of the first and second
intercostal spaces ; and the left innominate vein, resting on the upper border of the
arch, is just below the upper margin of the sternum. It sometimes happens, how-
ever, especially in children, that the arch of the aorta is placed at a higher level
than usual, and then the left innominate vein projects upwards into the neck. In
other cases the innominate artery is longer than usual, and may be felt pulsating in
the suprasternal fossa.
The auriculo-ventricular openings of the heart are lower down than the arterial
orifices, the left being behind the inner end of the fourth left costal cartilage and
the adjoining part of the sternum, while the right lies behind the sternum on a
level with the fourth interspace and fifth cartilage.
Arteries of the thoracic wall. The internal mammary artery descends behind
the costal cartilages, and across the inner ends of the upper six intercostal spaces,
about half an inch (1 cm.) from the margin of the sternum ; and it occasionally gives
off a considerable lateral costal branch which runs downwards on the inner surface of
the ribs along the side of the thorax (Vol. II, p. 429). The intercostal vessels are
lodged for the greater part of their extent in the grooves beneath the lower edges of
the ribs, by which they are thus protected.
The superficial limits of the abdomen are formed above by the lower margin or
the thorax, and below by Poupart's ligament and the iliac crest on each side, the
former corresponding, except in fat persons, to the curved inguinal furrow. The
abdominal cavity, however, extends considerably beyond these limits, both upwards
into the vault of the diaphragm, under cover of the lower ribs and their cartilages,
and downwards into the hollow of the pelvis. The abdomen is arbitrarily divided
into nine regions by two horizontal and as many vertical lines. Of the horizontal
lines, one, called infracostal, is drawn across at the level of the lowest point of the
tenth costal arch on each side, and the other, which may be termed bi-iliac, between
THE ABDOMEN. 23
the most prominent- points (laterally) of the two iliac crests. A horizontal plane
containing the infracostal line usually cuts some part of the third lumbar vertebra,
while the bi-iliac line lies in a plane passing through the body of the fifth lumbar
vertebra about the middle of its anterior surface, and about an inch and a quarter
below the highest point of the iliac crest. The umbilicus is generally from an inch
and a quarter to an inch and a half (3 4 cm.) above the bi-iliac line. The vertical
Fig. 11. OUTLINE OF THE FRONT OF THE ABDOMEN, SHOWING
THE DIVISION INTO REGIONS.
1, epigastric region ; 2, umbilical ; 3, hypogastric ; 4, 4, right
and left hypochondriac ; 5, 5, right and left lumbar ; 6, 6, right
and left iliac.
distance between the infracostal and bi-iliac planes
raugesfrom one and a half to four inches (4 10 cm.),
with an average of two inches and three-quarters
(7 cm.) 1 . The vertical lines (mid-Poupart lines) are
drawn upwards from the centre of Poupart's ligament
on each side : above the bi-iliac line they nearly
coincide with the lineae semilunares, and are usually
a little external to the outer borders of the recti.
Of the spaces bounded by these lines, the three
central are called respectively, from above down-
wards, epigastric, umbilical, and hypogastric, and the
lateral ones, right and left hypochondriac, lumbar or lateral abdominal, and iliac.
The lowest portion of the hypogastric region, being covered with hair, is also referred
to as thepubes or pubic region ; and the adjacent parts of the iliac and hypogastric
regions together constitute what is known as the inguinal region or the groin.
The viscera which
following table :
Epigastric region ....
Hypochondriac, right . .
Hypochondriac, left . .
Lumbar, right ........
Iliac, left. .
are contained in the several regions are shown in the
The greater part or the whole of the left lobe, and part of the
right lobe of the liver, with the gall-bladder, part of the stomach,
including both orifices, the first and second parts of the duodenum,
the duodeno-jejunal flexure, the pancreas, upper or inner end of the
spleen, parts of the kidneys, and the suprarenal bodies.
The greater part of the right lobe of the liver, the hepatic flexure
of the colon, and part of the right kidney.
Part of the stomach, with the greater portion of the spleen and
the tail of the pancreas, the splenic flexure of the colon, part of the
left kidney, and sometimes a part of the left lobe of the liver.
The greater part of the transverse colon, the third part of the
duodenum, some convolutions of the jejunum and ileum, with
portions of the mesentery and great omentum, and part of the
right, or sometimes of both kidneys.
The ascending colon, part of the right kidney, and sometimes
part of the ileum.
The descending colon, part of the jejunum, and sometimes a small
part of the left kidney.
The convolutions of the ileum, the bladder in children, and when
distended in adults also, the uterus when in the gravid state, and
behind, the sigmoid loop and upper part of the rectum.
The cascum with the vermiform appendix, and the termination of
The sigmoid colon, convolutions of the jejunum and ileum.
Abdominal wall. The wall of the abdomen is formed at the front and sides
mainly by muscles, and the forms to be recognized on the surface are for the most
1 See D. J. Cunningham, Delimitation of the Regiom of the Abdomen, Journal of Anatomy, xxviii,
24 SUPERFICIAL ANATOMY OF THE TRUNK.
part to be referred to these. Anteriorly, the rectus muscle extends on each side of
the middle line from the pelvis to the thorax, its tendinous inscriptions producing
transverse furrows, of which two are commonly to be recognized, one opposite, or
just below, the tip of the eusiform process, and the other about midway between
this and the umbilicus. In some cases the third may be distinguished about the
level of the umbilicus. Between the two recti is a median groove (abdominal
furrow} continued downwards from the infrasternal fossa, along the surface of the
linea alba, as far as, or a little beyond, the umbilicus, where it gradually disappears
owing to the approximation and eventual union of the muscles of the two sides.
The lower ends of the recti are concealed by a small accumulation of fat.
The position of the umbilicus is subject to considerable variation, but it is
always below the centre of the distance between the xiphi-sternal articulation and
the pubic symphysis. It is generally on a level with, or slightly above, the highest
point of the iliac crest, and opposite the upper part of the fourth, or the dis
between the third and fourth lumbar vertebras.
A line joining the two anterior superior iliac -spines usually passes just above the
promontory of the sacrum.
The convex surface of the side of the abdomen is formed by the fleshy part of
the external oblique muscle, the outline of which can often be seen in front and
below. Between this and the outer edge of the rectus there is a shallow depression
over the upper portion of the linea semilunaris : this depression terminates above
at the margin of the thorax, in the somewhat triangular infracostal fossa, the upper
boundary of which is formed by the rounded ninth costal cartilage.
In the inguinal region, the superior set of glands may usually be felt lying along
Poupart's ligament. The external abdominal ring is placed immediately above
and external to the pubic spine, which can always be readily felt, as well as the
common attachment of the outer pillar of the ring and Poupart's ligament. By
invaginating the scrotum at some distance from the aperture, the ringer may be
passed through the ring into the lower part of the inguinal canal. The internal or
deep abdominal ring is situated about half an inch (1 cm.) above Poupart's ligament,
opposite a spot midway between the anterior superior iliac spine and the pubic
symphysis ; and the deep epigastric artery runs upwards close to the inner side of
this opening, in the direction of a line inclining inwards towards the umbilicus. If
the inguinal canal has been enlarged by the presence of an old hernia, the rings
are almost opposite to one another, and the finger may be passed through them and
can explore the surrounding parts in the interior of the abdomen.
The superficial epigastric vein is often seen through the skin, and it may
frequently be observed to communicate with another vein (v. thoraco-epigastrica)
that passes up into the armpit to join the axillary vein, especially if there be any
obstruction to the return of the blood through the inferior vena cava.
Abdominal viscera. The liver, which occupies the whole of the arch of
the diaphragm on the right, as well as a part on the left side, is placed for the
most part under cover of the ribs. In the right hypochondriac region, its lower
margin just corresponds to the lower border of the thorax, but in the epigastric
region, a part of both right and left lobes comes into contact with the abdominal
wall ; the margin of this part runs obliquely across the subcostal angle from the
ninth right to the eighth left costal cartilage, and crosses the middle line about a
hand's breadth below the xiphi-sternal articulation. The gall-bladder projects
beyond this margin immediately internal to the ninth costal cartilage, and close to
the outer edge of the rectus muscle, i.e., opposite the infracostal fossa. The extent of
the liver upwards, if traced on the surface of the body, is marked by a line crossing
the body of the sternum close to its lower end, and rising on the right side to the
level of the fifth chondro-sternal articulation, on the left to that of the sixth. A
THE ABDOMEN. 25
little internal to the right mamillary line, it generally reaches as high as the fourth
intercostal space, or nearly to the level of the nipple. On the left side it does not
usually extend more than an inch and a half or two inches (4 5 cm.) beyond the
margin of the sternum (see fig. 10). It must be borne in mind, however, that the liver
is subject to great variations, not only in size, but also in position, both temporarily
and permanently. Thus, it sinks with inspiration, and rises in expiration ; it
descends slightly on assuming the upright position ; and it is frequently moved
downwards by alterations 1 in the shape of the chest. It is relatively very large in
the infant and child, and extends across far into the left hypochondriac region.
In adults, the margin of the liver is seldom to be felt below the ribs on the right
side during health, unless the abdominal wall be unusually thin.
The stomach lies in the left hypochondriac and the epigastric regions, in the
latter being partly covered by the liver and partly in contact with the abdominal
wall. Its cardiac orifice is situated behind the seventh costal cartilage of the left
side about an inch (2'5 cm.) from the sternum, and at a depth of about four inches
(10 cm.) from the surface. The pyloric orifice is from three to four inches (8
10 cm.) below the xiphi-stemal articulation, and, when the stomach is contracted,
in or immediately to the right of the median plane ; but when the stomach is
distended, the pyloric end moves considerably to the right. The pyloric orifice is
much nearer to the surface than the cardiac. The f undus of the stomach is directed
upwards into the left portion of the vault of the diaphragm, and reaches, under
ordinary circumstances, to the level of, or somewhat higher than, the sixth chondro-
sternal articulation, or in the mamillary line to the fifth rib, being a little above
(and behind) the apex of the heart. The great curvature of the stomach is directed
at first to the left, and afterwards downwards, the latter part reaching, with a
moderate degree of distension of the organ, about as far as the infracostal line.
Large intestine. The transverse colon passes across in the upper part of the
umbilical region, following closely the great curvature of the stomach. The csecum
is comparatively superficial in the right iliac region ; the ascending colon and the
hepatic flexure are deeply placed in the right lumbar and hypochondriac regions.
The splenic flexure reaches a higher level than the hepatic, and is situated
behind the stomach in the left hypochondriac region, while the descending colon
occupies the hinder part of the left hypochondriac and lumbar regions. Deep
pressure on the left side detects the sigmoid colon as it passes over the brim of the
pelvis, in thin persons even when comparatively empty ; if distended with faeces, it
forms a distinct tumour in this situation.
Small intestine. The intestines below the stomach are all covered more or
less completely by the great omentum. The coils of the small intestine occupy the
anterior part of the belly below the transverse colon, those of the jejunum being
principally found above, those of the ileum below. The upper limit of the attach-
ment of the mesentery, corresponding to the duodeno-jejunal flexure, is commonly
between three and four inches (8 10 cm.) above the umbilicus and slightly to
the left of the median line, while the lower end is, on an average, four inches
(10 cm.) from the centre of Poupart's ligament of the right side, along a line
directed upwards and somewhat inwards, following the course of the psoas muscle
(Lockwood). The termination of the ileum in the large intestine corresponds
generally to a spot on the anterior abdominal wall from one to two inches (3 5 cm.)
internal to, and slightly above, the anterior superior iliac spine.
In children under ordinary circumstances, and in adults when it is distended,
the bladder rises out of the pelvis into the hypogastric region, being closely applied
to the anterior abdominal wall without the intervention of peritoneum for some
distance above the pubic bones ; if the distension be excessive, the bladder may
reach nearly as far as the umbilicus.
SUPERFICIAL ANATOMY OF THE TRUNK.
The kidneys, being situated at the back of the abdominal cavity, are not to be
felt under normal conditions, or at most the right is at times to be detected. They
are lodged on each side mainly in the epigastric and hypochondriac regions. That
of the right side usually extends slightly into the umbilical and lumbar regions ;
but on the left side the organ is frequently altogether above the infracostal plane.
Fig. 12. DETERMINATION OF THE POSITION OF THE KIDNEYS ON THE FRONT OF THE BODY : SCHEME.
(R. J. G. ar,dG. D. T.)
The inferior pole of the kidney is about two and a half to three inches (6 7 cm.)
from the median plane, and on the right side is about an inch (2 3 cm.) above the
level of the umbilicus, while on the left side it is in the'majority of cases about half
an inch (1 2 cm.) higher. The length of the kidney being generally from four to
four and a half inches (10 12 cm.), the position of the superior pole is indicated
by a spot a corresponding distance above the level of the inferior pole, and about
two inches (5 cm.) from the middle line. This spot is above the margin of the
thorax, and is generally over the sixth or seventh costal cartilage, about the place
where the interchondral articulation is formed between these cartilages. The
shortest distance between the two kidneys, at the upper part of their mesial borders,
THE BACK. 27
measures about two and a half inches (6 cm.): the hilum, which looks mainly
forwards, is about two inches (5 cm.) from the median plane.
Like other abdominal organs, the kidneys are subject to considerable variations
in size and position ; and they are frequently found at a lower level than that just
given. In the female they are situated as a rule slightly lower than in the male ;
and during childhood, when the kidneys are relatively of large size, they are at the
same time lower and more symmetrically placed than in the adult. 1
The pancreas lies over the first and second lumbar vertebrae, from two and a
half to five inches (6 to 12 cm.) above the umbilicus ; and the third part of
the duodenum crosses the spine at a lower level, often reaching nearly to the
Abdominal vessels. The abdominal aorta commences rather above the mid-
point between the infrasternal depression and the umbilicus, and passes downwards
usually a little to the left of the middle line of the body, although its lower end
often occupies a median position, or may even extend over slightly to the right.
The bifurcation occurs on the average about three-quarters of an inch (2 cm.) below
the umbilicus, and the direction of the common and external iliac arteries is indicated
by drawing a line from this point to another midway between the pubic syrnphysis
and the anterior superior spine of the ilium. The inferior vena cava lies just to the
right of the aorta.
The creliac axis arises opposite the lower part of the last dorsal vertebra, i.e.,
between four and five inches (10 12 cm.) above the umbilicus ; the superior
mesenteric artery a very little lower ; the two renal arteries from three and a
half to four inches (9 10 cm.), and the inferior mesenteric about one inch
(2'5 cm.) above the umbilicus.
At the back of the neck, a slight median depression the nuchal furroiv, com-
mencing immediately below the external occipital protuberance descends over the
ligamentum nuchae, between the prominences formed by the complexus and trapezius
muscles of the two sides. By pressing deeply in this furrow, the spine of the axis is
readily felt, and generally also the spines of the third, fourth, fifth, and sixth cervical
vertebras less distinctly. The furrow disappears gradually towards the root of the
neck, where the spines of the seventh cervical and upper one or two dorsal vertebras
become visible. The first spine to appear is usually that of the seventh cervical
vertebra, but sometimes the sixth is long and comes to the surface : the most
prominent is the first dorsal. They necessarily project more plainly when the neck
is inclined forwards. Below these, the long spinal or dorso-lumbar furroiv descends
in the middle line between the elevations formed by the erector spinae muscles
covered on each side above by the trapezius and below by the latissimus dorsi. The
furrow is deepest in the lower dorsal and upper lumbar regions, where the muscles
are thickest and most fleshy ; in the lower lumbar region and over the upper part of
the sacrum, the erector muscles are tendinous, and give rise to a somewhat lozenge-
shaped flattened area through which the groove is continued, becoming gradually
shallower, to terminate at the spine of the third piece of the sacrum (last sacral
spine) in the angle formed by the meeting of the right and left gluteus maximus
muscles. A little above and external to this point, a slight depression indicates the
position of the posterior superior iliac spine. At the bottom of the spinal furrow,
the spines may be felt and counted, the middle dorsal ones generally with consider
able difficulty in the erect position, but most of them are rendered very evident by
1 See Second Annual Report of Committee of Collective Investigation of Anat. Soc., 1890-91, by
Arthur Thomson, Journ. Anat., xxvi, 83; also F. Helm, Beitriiye zur Kenntniss der Niercn-Topo-
graphie, Diss., Berlin, 1895. '
28 SUPERFICIAL ANATOMY OF THE TRUNK.
bending the column forwards. The fourth lumbar spine is on a level with the
highest part of the crest of the ilium : the third lumbar spine is generally somewhat
higher than the umbilicus.
The spine of the scapula is easily felt beneath the skin, and may be traced out-
wards (very little upwards when the arm is hanging) to the acromion, which is
represented on the surface by a depression in a muscular subject, or when the arm
is raised. The lower border of the spine and the outer border of the acromion meet
in the prominent acromial angle, which is always to be distinctly recognized on the
surface ; from this point measurements of the length of the arm are most
conveniently taken. The vertebral border and the inferior angle of the scapula are
seen, although covered for the most part by muscles, the former by the trapezius,
the latter by the latissimus dorsi. The superior border cannot usually be
distinguished, but the axillary border can be felt more or less distinctly through its
thick muscular covering. With the arms hanging by the side, the upper angle of
the scapula corresponds to the upper border of the second rib, or the interval
between the first and second dorsal spines ; the lower angle to the seventh inter-
costal space (sometimes the eighth rib) or the interval between the seventh and
.eighth dorsal spines ; and the root of the spine of the scapula to the interval
between the third and fourth dorsal spines. The vertebral border of the bone is at
the same time nearly perpendicular.
At the inner end of the spine of the scapula, a distinct depression indicates the
triangular tendon in which the lower fibres of the trapezius end ; and a slight groove,
which is seen at times passing upwards and outwards over the surface of the
eminence formed by the erector spinae, in the direction of a line from one of the
lowest dorsal spines to the triangular tendon, marks the lower edge of the muscle.
Immediately above the spine of the scapula is a convex surface formed by the
thickest part of the trapezius covering the supraspinatus muscle ; and above this, the
sloping surface leading down from the neck to the shoulder is formed by the upper
part of the trapezius, supported by the levator anguli scapula and by fat.
The lower ribs are to be felt through the latissimus dorsi, outside the edge of the
erector spinas ; but it must be borne in mind that the twelfth rib is often very short
and does not project beyond the margin of the erector muscle, so that the lowest rib
that can then be felt is the eleventh. The ribs should, therefore, always be counted
from above downwards, and not from below upwards.
The lower end of the larynx and pharynx, and the commencement of the
trachea and oesophagus are about on a level with the interval between the sixth and
seventh cervical spines. From this spot the trachea descends, at first in the middle
line, and then inclining slightly to the right divides opposite the fourth dorsal spine
into the two bronchi. The latter are thence directed outwards and downwards, the
right usually more nearly in the line of the trachea, and the left becoming more
transverse in direction, to the hilum of the lung, which they enter about the level
of the fifth dorsal spine. In the lung the main prolongation of the bronchus
descends, accompanied by corresponding pulmonary vessels, which are placed
dorsally to the air-tube, about one and a half or two inches (4 5 cm.) from the
median plane, towards the hinder part of the base of the lung.
Lungs and pleurae. The apex of the lung, corresponding to the neck of the
first rib, extends up to the level of the seventh cervical spine. Mesially, the lungs
touch the sides of the bodies of the vertebras ; and inferiorly, they reach down to
the tenth dorsal spine, the pleura to the eleventh or even lower, as has already been
described (p. 20).
The oesophagus, from its commencement, inclines at first somewhat to the left,
but regains the middle line about the fifth dorsal vertebra ; in its lower part it is
deflected more considerably to the left, and it terminates at the cardiac orifice of the
stomach about on a level with the ninth dorsal spine. The pyloric orifice of the
stomach, is to the right of the twelfth dorsal spine.
Aorta. The arch of the aorta reaches the left side of the vertebral column just
above the fourth dorsal spine, and the descending aorta passes downwards, gradually
Fig. 13. POSTERIOR VIEW OP THE TRUNK, SHOWING THE RELATIVE POSITIONS OP THE PRINCIPAL
THORACIC AND ABDOMINAL VISCERA, &C. (R. J. Gr. and G. D. T.) i.
The several objects are indicated in the same manner as in fig. 10, the trachea and lungs by thin
lines, the aorta by thick lines, the liver, pancreas and spleen by broken lines, the oesophagus, stomach,
ascending and descending colon by thick dotted lines, and the kidneys by thin dotted lines ; x , x ,
seventh cervical and first lumbar spines.
inclining to the front of the column, to bifurcate at a'spot in, or close to, the median
plane, on a level with the fourth lumbar spine. The cceliac axis arises opposite the
twelfth dorsal, the renal arteries opposite the first lumbar spine.
The convex surface of the spleen looks backwards and somewhat outwards. It
30 SUPERFICIAL ANATOMY OF THE TRUNK.
is placed beneath the ninth, tenth and eleventh ribs of the left side, being separated
from them by the diaphragm, and at its upper part also by the lung. It lies very
obliquely, its long axis coinciding almost exactly with the line of the tenth rib. Its
highest and lowest points are on a level respectively with the ninth dorsal and first
Fig. 14. OUTLINE VIEW OP THE KIDNEYS FROM BEHIND, CONSTRUCTED FROM A SERIES OF HORIZONTAL
SECTIONS THROUGH THE TRUNK OF AN ADULT MALE. (J. Symington.)
R.K., L.K., right and left kidneys ; E.S., outer border of erector spinae muscle ; Q.L.. outer border
of quadratus lumborum muscle ; i.e. , iliac crest ; p. p. , dotted line to show lower limit of costal pleura.
In this case the two kidneys were nearly symmetrical in position.
lumbar spines ; its inner end is distant about an inch and a half (4 cm.) from the
median plane of the body, and its outer end about reaches the mid-axillary line.
Kidneys. The upper end of the right kidney reaches to the level of the
eleventh dorsal spine ; the lower end is on an average one inch (2 - 5 cm.) above
the iliac crest, and a little below the level of the second lumbar spine ; the hilum
is opposite the first lumbar spine. The last rib, when well developed, is sloped
downwards and outwards at an angle of about 45 with the vertical, and crosses the
posterior surface of the kidney in such a way that about one-third of the organ is
under cover of the thoracic wall. The left kidney is, as a rule, about half an inch
(1 2 cm.) higher than the right. In the female and child the kidneys are some-
what lower than in the adult male, and not unfrequently reach down as far as the
iliac crest (cf. p. 26).
Colon. The ascending and descending portions of the colon pass vertically
along the outermost part of the right and left kidneys respectively ; the part of the
Fig. 15. DIAGRAM SHOWING THE VARYING RELATIONS OP THE ROOT- ""--^I"
ORIGINS OF THE SPINAL NERVES TO THE SPINES OF THE VERTEBRA. fRj " CERV ' CAt
(After R. W. Reid.) 4 C E *V,CA J U i
intestine which is in contact with the abdominal wall is
placed immediately internal to a line carried vertically up-
wards from the central point of the iliac crest.
The pancreas crosses the spinal column opposite the
twelfth dorsal and first lumbar spines, and the third part
of the duodenum from the second to the third lumbar
Spinal cord and origins of spinal nerves. The
lower end of the spinal cord in the adult corresponds
generally to the interspace .between the first and second
lumbar spines, and is not subject to much variation in
level ; but in the infant it reaches to the third lumbar
spine. The cervical enlargement extends downwards to
about the seventh cervical spine, and the lumbar enlarge-
ment corresponds mainly to the last three dorsal spines.
The relations of the origins of the spinal nerve-roots to
the spinous processes of the vertebrse vary to some extent
in different individuals, especially in the thoracic region,
the range of any given dorsal nerve-root being about equal
to the distance between three adjoining spines, or two
interspinous intervals, as is shown in the accompanying
diagram (fig. 15) constructed from the observations of
R. W. Reid upon six subjects. The following rules will,
however, serve to indicate with sufficient accuracy the
average position of the several nerve-roots : The second
cervical nerve arises opposite the neural arch of the atlas,
the third opposite the spine of the axis, and the fourth
opposite the interval between the second and third cervical
spines. The lower four cervical nerves arise each opposite
the spine of the second vertebra above the place of exit of
the nerve from the spinal canal. The origins of the upper
six dorsal nerves are about on a level with the spines of
the third, and of the lower six with the spines of the
fourth vertebra above their respective places of exit. The
lumbar nerves arise in the neighbourhood of the tenth
and eleventh dorsal spines, and the sacral nerves between
the eleventh dorsal and first lumbar spines.
I2 T H DORSAL'
Objects, with average p
Soft palate and mouth.
Base of tongue.
Upper end of epiglottis. Angle
Hyoid bone. Superior aperture <
cation of common carotid artei
Lower end of pharynx and lary;
trachea and oesophagus.
Arch of thoracic duct.
Apex of lung. Summit of arch of
Upper angle of scapula.
Bifurcation, of innominate artery,
S3 o *
oo i .y o
"-P vn ~j| '4^
s ^ "T*
o ?^ ^
O i i
S O S
Innominate artery and veins. Spine of scapi
Beginning of superior vena cava.
Bifurcation of trachea. Arch of azygos vein,
of arch of aorta.
Right and left bronchi. Left pulmonary a
Highest part of roots of lungs. Descending
Highest part of heart. Division and right b
of pulmonary artery.
Ascending aorta. Pulmonary artery. Righ
left auricles. Left bronchus.
End of superior cava. Pulmonary orifice.
Aortic orifice. Infundibulum of right ven
Left ventricle. Lowest part of roots of lung:
Lower angle of scapula. Four cavities of ]
Both auriculo-ventricular apertures.
Right vault of diaphragm. Orifice of inferior
Right auriculo-ventricular aperture.
Left vault of diaphragm and fundus of stoma
Lowest part of heart. Central leaflet of
Cardiac orifice of stomach.
Upper limit of spleen.
a a ^
&o s ^
O o 1 -^
S o> 'C
Lower margin of lung posteriorly.
Upper end of left kidney. Suprarenal
. Upper end of right kidney.
Lower boundary of pleura behind.
Pyloric orifice and first part of duodem
flexure of colon.
Beginning of abdominal aorta,and origin
; Pyloric orifice and first part of duoden
of superior mesenteric artery.
Hepatic flexure of colon. Pancreas. E
chyli. Hila of kidneys. Renal arte:
end of spleen.
End of spinal cord.
Lower end of left kidney.
Lowest part of liver. Lower end of r
Third part of duodenum. Origin
mesenteric artery. Infracostal plan
Bifurcation of aorta. Highest part of
Beginning of inferior vena cava. Bi-i]
Bifurcation of common iliac artery.
SUPERFICIAL ANATOMY OP THE UPPER LIMB. 35
SUPERFICIAL ANATOMY OF THE UPPER LIMB.
In the region of the shoulder, the outer part of the clavicle and the acromion
process of the scapula can be distinctly felt beneath the skin, and the extremity of
the former bone usually gives rise to a marked elevation at its junction with the
acromion. The rounded prominence of the shoulder is formed immediately by the
thick deltoid muscle, but it is also due in great measure to the large upper extremity
of the humerus, which can be felt moving under the muscle as the arm is rotated.
Close to the inner side of the shoulder-joint, and just below the clavicle, the coracoid
process is to be recognized in the infraclavicular fossa (see below) ; and by pressing
deeply in the axilla, when the arm is abducted, the lower margin of the glenoid
cavity and the head of the humerus are also to be felt.
The adjacent margins of the deltoid and pectoralis major are closely united
together at their lower parts, so that the division between the two muscles is not
indicated on the surface ; but superiorly, they are separated by a triangular interval
of variable breadth, which gives rise to the well-marked infraclavicular fossa. By
pressing deeply in this fossa, the axillary artery may be compressed against the
second rib. The back of the shoulder is flattened, and sloped from within outwards
and a little forwards, owing to the oblique position of the scapula ; and the hinder-
portion of the deltoid, which is thinner than the anterior, is tendinous at its origin,
and adheres closely to the subjacent infraspinatus muscle, so that the upper part of
its margin is not indicated upon the surface. The infraspinatus is continued into
the teres minor, and below the latter muscle is the thick teres major, with the
latissimus dorsi winding round it, forming the posterior fold of the axilla. When
the arm is abducted, the middle portion of the deltoid, being brought into action, is
seen to present an irregular surface, the prominences corresponding to the separate
fleshy portions of the muscle, and the depressions to the tendinous septa extending
downwards from the acromion.
The course of the axillary artery is marked upon the surface by a line drawn
from the mid-point of the clavicle to the inner border of the elevation formed by
the coraco-brachialis muscle (see below). If the limb be raised from the side, the
third part of the artery may be felt pulsating beneath the integument and fascia
(the vein intervening) as it passes into the arm, being placed at the junction of the
anterior and middle thirds of the space between the axillary folds. The artery may
be readily compressed here against the humerus. The posterior circumflex vessels
and the circumflex nerve are winding round the back of the humerus under cover of
the deltoid, at the junction of the upper and the middle thirds of the muscle.
The shaft of the humerus is for the most part thickly covered by the muscles of
the arm, and can only be felt with difficulty ; but just below the insertion of the
deltoid the bone comes nearer to the surface, and from this spot the outer border, or
the external supracondylar ridge, can be followed down to the outer condyle, along
the bottom of a furrow over the external intermuscular septum, between the
supinator longus and triceps muscles. The internal supracondylar ridge is less
prominent, and not so readily felt.
Along the fore and inner part of the arm (when hanging naturally by the side)
is the eminence formed by the biceps muscle, extending, with a slight inclination
outwards below, from the anterior margin of the axilla to the elbow. Superiorly,
this is continued into a narrow elevation produced by the coraco-brachialis muscle,
which issues from between the anterior and posterior axillary folds. Two
depressions, the inner and outer licipital furrows, are found on the inner and outer
SUPERFICIAL ANATOMY OF THE UPPER LIMB.
side respectively of the prominence of the biceps ; along the outer of these the
cephalic vein may generally be seen ascending beneath the skin ; in the inner,
which is better marked, are placed the basilic vein (in its lower half or less super-
ficial to the fascia), the brachial vessels and the median nerve. The brachial artery
Fig. 16. SUPERFICIAL ANATOMY OF THE UPPER LIMB : ANTERIOR VIEW.
G. W. B. Waters.) (R. J. G. & G. D. T.)
(From a photograph by
is usually overlapped to some extent by the margin of the biceps, but it can be felt
pulsating throughout. Pressure should be applied to the vessel from within
outwards in the upper half of the arm, from before backwards in the lower.
On the outer side of the biceps, a portion of the brachialis anticus conies to the
surface, and beyond that the supinator longus and extensor carpi radialis longior
form a prominence which descends to the forearm in front of the external condyle ;
/ nefue. and vessels
Fig. 17. SUPERFICIAL ANATOMY OF THE UPPER LIMB : POSTERIOR VIEW.
G. W. B. Waters.) (R. J. G. & G. D. T.)
(From a photograph by
the supinator muscle shows very plainly if the elbow be forcibly flexed with the
hand in a state of semipronation. On the inner side of the biceps, in the lower
part of the arm, a smaller portion of the brachialis anticus is superficial, and between
this and the triceps, the internal intermuscular septum can be felt, with the ulnar
nerve close behind it, descending to the internal condyle.
THE ARM AND ELBOW. 37
The form of the back of the arm is determined by the triceps muscle, the three
iieads of which, together with the large tendon of insertion, are to be recognized
when the muscle is called into play. The inner head is the least distinct ; the
outer head forms a large prominence immediately below the hinder border of the
deltoid ; the long head can be seen issuing from between the teres major and minor
muscles, and descending along the middle of the back of the arm ; while the tendon
is represented by a depressed area, leading down to the olecranon process of the
ulna. The musculo-spiral nerve begins to incline backwards immediately below the
posterior fold of the axilla, and crosses the back of the humerus obliquely from
within outwards in its middle third, being covered by the long and outer heads of
the triceps muscle, and accompanied by. the superior profunda vessels. At, or a
little above, the junction of the middle and lower thirds of the arm, the nerve
perforates the external intermuscular septum, and it then descends in front of the
outer supracondylar ridge, and under cover of the supinator longus muscle, to the
level of the external condyle, where it divides into the radial and posterior interos-
seous nerves. The former takes a straight course downwards to join the artery of
the same name below the elbow ; but the posterior interosseous is directed back-
wards across the outer side of the radius in its upper fourth, to gain the back of
At the elbow, the internal and external condyles come to the surface, and also
the olecranon process of the ulna. The internal condyle, which, it will be
remembered, is directed more backwards than inwards, is very prominent, and forms
one of the most important bony landmarks of the limb. The external condyle,
together with the common tendon of the extensor muscles of the forearm, gives rise,
when the joint is extended, to a well-marked depression at the outer and back part
of the elbow, between the supinator longus and extensor carpi radial is longior
muscles externally, and the anconeus internally. In this hollow, when the muscles
are relaxed, the head of the radius may be felt below the external condyle and the
capitellum. If the elbow be semi-flexed, the condyle is slightly prominent ; and in
extreme flexion, the outer part of the triceps muscle is stretched over the capitellum
of the humerus, which forms a rounded eminence to the outer side of the point of
the elbow (olecranon), while the condyle itself is no longer visible. The olecranon
is subcutaneous at its posterior surface, its upper end being entirely covered by the
insertion of the triceps ; its appearance necessarily varies with the position of the
joint, as does also the distance between the process and the shoulder. A bursa is
interposed between the bone and the skin.
At the bend of the elbow, the subcutaneous veins are more or less distinctly
visible, according to the quantity of subcutaneous fat : the median vein bifurcat-
ing into the median-basilic and median-cephalic, which join respectively the
ulnar and radial veins to form the basilic and cephalic. The median-basilic and
median-cephalic veins, diverging from each other, pass upwards on either side of
the biceps tendon, which is seen, when the elbow is bent, descending from the lower
end of the muscular belly into the interval between the two masses of forearm
muscles. The sharp upper edge of the bicipital fascia may also be felt, and, when
the muscle is forcibly contracted, seen, as it passes downwards and inwards between
the median-basilic vein and the lower part of the brachial artery. The pulsation of
the latter vessel may be felt, and often seen, as it passes obliquely downwards and
outwards to a point a little below the middle of the bend of the elbow.
38 SUPERFICIAL ANATOMY OF THE UPPER LIMB.
From the olecranon, the sinuous posterior border of the ulna is to be followed
down the forearm, corresponding to a superficial furrow between the ulnar flexor
and extensor muscles of the wrist ; the border becomes rounded off in the lower
third, but a narrow strip of the bone is still subcutaneous, leading down to the
styloid process. When the hand is supinated, the styloid process of the ulna is
exposed at the inner and posterior pjfrt of the wrist ;, but if the hand be pronated,
then the skin is stretched over the opposite (outer) part of the head of the ulna,
which projects between the extensor carpi ulnaris and extensor minimi digiti
muscles. Close below the outer condyle of the humerus the head of the radius may
be felt moving beneath the muscles, more distinctly when the elbow is bent, as the
forearm is alternately pronated and supinated. The upper half of the shaft of the
radius is too thickly covered by muscles to be distinctly made out ; the lower half
is nearer to the surface, and can be readily examined between and through the
surrounding muscles and tendons ; at the lower end, the styloid process, which
descends rather lower than the styloid process of the ulna, is superficial in front and
behind, being covered externally by the tendons of the extensor ossis metacarpi and
extensor brevis (ext. primi internodii) pollicis muscles ; and the prominent tubercle
on the outer side of the groove for the extensor longus pollicis (ext. secundi inter-
nodii) is also to be distinguished.
Along the inner and fore part of the forearm is the prominence formed by the
pronato-flexor muscles, the great mass covering the ulna internally being formed by
the flexor profundus digitorum beneath the flexor carpi ulnaris. A short distance
below the internal condyle, a slight groove runs obliquely downwards and inwards
across the muscles, caused by the prolongation of the fibres of the bicipital fascia.
Near the wrist, the tendon of the flexor carpi ulnaris can be felt, passing down to
the pisiform bone, and immediately external to the tendon the beating of the ulnar
artery is perceptible : when the wrist is extended a groove marks the position of
the tendon. About the centre of the front of the wrist the tendon of the palmaris
longus descends, being the moet prominent of all the tendons here, and a little
external to this, the tendon of the flexor carpi radialis is also visible. It will
however be remembered that the palmaris longus is often wanting. Outside the
tendon of the flexor carpi radialis is a hollow in which the radial vessels are placed,
and where the pulse is commonly felt : immediately internal to the tendon lies the
Along the outer border of the forearm, the long supinator and radial extensor
muscles of the wrist descend, becoming tendinous and smaller below the middle ;
and in the lower third of the forearm a smaller prominence, directed obliquely
downwards, outwards and forwards, results from the presence of the extensor
muscles of the thumb crossing over the long tendons. On the back of the forearm
are the extensors of the fingers, the extensor carpi ulnaris, and the anconeus, all of
which may be individually distinguished in thin persons.
Numerous cutaneous veins are seen on the forearm, arising principally from the
network on the dorsum of the hand, and forming two main trunks, the posterior
ulnar and the radial, which ascend respectively along the inner and outer borders
of the limb, and incline forwards to their terminations in front of the elbow ; in
many cases another large vein is present (assisting or even replacing the radial
vein), which turns round the outer border of the forearm below the middle to join
the median vein. The subcutaneous veins of the lower part of the front of the
forearm (also those of the palm) are small, and terminate in the median and anterior
ulnar veins. It occasionally happens that the ulnar artery, having been derived
from the brachial at a higher level than usual, descends over the pronato-flexor
THE FOREARM AND HAND. 89
muscles to the wrist, and in that case it would be felt pulsating beneath the skin in
the neighbourhood of the anterior ulnar vein (Vol. II, p. 445).
The bifurcation of the brachial artery takes place opposite a spot a finger's
breadth below the centre of the bend of the elbow. From this point, the radial
artery runs downwards with a nearly straight course to the fore part of the styloid
process of the radius, being covered by the supinator longus as far as the centre of
the forearm, and superficial beyond this spot. The ulnar artery inclines, with a
slightly curved course, inwards to the middle of a line drawn from the back of the
internal condyle of the humerus to the outer side of the pisiform bone : this line
indicates in its whole extent the direction of the ulnar nerve in the forearm, in its
lower half that of the ulnar artery also. The latter is deeply placed beneath the
muscles arising from the internal condyle till within an inch of the wrist.
THE WBIST AND HAND.
At the front of the wrist, on the inner side, the pisiform bone can be grasped
between the fingers, and moved slightly from side to side ; below this, and a little
more externally, the hook of the unciform bone can be felt with difficulty. On the
outer side, a projection is felt just below and internal to the styloid process of the
radius, formed by the tuberosity of the scaphoid bone, and close below this, the ridge
of the trapezium is also to be distinguished. At the back of the wrist, on the inner
side, the pyramidal bone can be felt, and slightly external to the middle line of the
hand is a prominence, sometimes indistinct, but often very well marked, formed by
the styloid process on the base of the third metacarpal bone at its articulation with
the os magnum.
At the metacarpo-phalangeal articulation of the thumb the sesamoid bones can
be felt ; and on the dorsal aspect of the hand the metacarpal bones and the
phalanges can be distinctly followed.
At the outer side of the wrist, when the thumb is extended, there is a deep
hollow bounded by the prominent tendons of the extensor ossis metacarpi and
extensor brevis pollicis anteriorly and the extensor longus pollicis posteriorly ; the
latter tendon may be followed down over the metacarpal bone and first phalanx of
the thumb almost to its insertion. Beneath these tendons, and across the inter-
vening hollow, the radial artery runs in its course from the front to the back of the
wrist ; its direction may be marked by a line drawn from the fore part of the
styloid process of the radius to the upper end of the first interosseous space ; and
a considerable vein, ascending from the outer part of the hand, is usually to be seen
through the skin over the position of the artery.
On the back of the hand, the tendons of the extensor communis digitorum and
extensor minimi digiti may all be recognized, together with the connecting band
between the innermost slip of the common extensor and the outer portion of the
little finger tendon. In some cases the tendon of the extensor indicis may also be
perceived on the inner side of the first slip of the extensor communis. Between the
first and second metacarpal bones is the abductor indicis muscle, which forms a
well-marked prominence when the thumb is brought to the side of the index finger,
and below this is the adductor transversus pollicis muscle contained in the fold of
skin passing across between the thumb and the outer margin of the palm.
The palm of the hand is concave in the centre, where the skin is tightly adherent
to the palmar fascia, and raised on each side. The outer elevation (thenar) is
formed by the outer group of the short muscles of the thumb ; the inner (hypothenar)
by the short muscles of the little finger. From the central hollow of the palm a
slight groove is continued downwards to each of the fingers, corresponding to the
prolongations of the palmar fascia. The palm is traversed generally by four more or
SUPERFICIAL ANATOMY OF THE UPPER LIMB.
less regular lines, representing the folds or " flexures " produced in the skin by the
movements of the principal joints of the hand. Two of these lines are directed
nearly transversely, the others longitudinally. Of the transverse lines, one
commences about the junction of the upper three-fourths with the lower fourth of
the inner border of the palm, and runs outwards and then downwards to the cleft
between the index and middle fingers ; this is caused by bending the metacarpo-
phalangeal articulations of the inner three fingers ; the second starts nearly opposite
the foregoing, at the outer border of the hand, and is directed inwards and sorne-
Fig. 18. PALMAR SURFACE OF THK HAND, SHOWING THE CUTANEOUS LINES AND THE SITUATION OF
THE CHIEF ARTERIES IN RELATION TO THE SKELETON. (G. D. T. )
what upwards across the middle of the palm ; this results mainly from the flexion of
the first joint of the index finger. The metacarpo-phalaugeal articulations are
placed about midway between these lines and the web of the fingers. Of the
longitudinal lines, one, beginning near the centre of the wrist, curves outwards to
join the upper transverse line, and is produced by the opposition of the thumb ; the
other runs downwards from the wrist through the centre of the palm to meet the
lower transverse line opposite the middle finger, and is caused by the opposition of
the fifth metacarpal bone. The four lines give rise to a figure resembling the
letter M. At the wrist, two or three lines, directed rather obliquely, outwards and
a little downwards, indicate the position of the principal folds formed during flexion
THE HAND. 41
of the joint ; the radio-carpal articulation is placed about three-quarters of an inch
above the lowest of these lines. There are three well-marked transverse grooves on
each finger ; the lower and middle ones are nearly opposite the two interphalangeal
joints ; the upper one, which is produced, as well as the transverse lines of the palm,
by bending the metacarpo-phalangeal articulations, is placed nearly three-quarters of
an inch (15 mm.) below the joint, and on a level with the web of the fingers. On the
thumb, there are only two grooves, and the proximal, which is less distinct than the
other, continues upwards the line of the radial border of the index finger, thus
crossing obliquely the corresponding articulation.
The web of the fingers, containing the superficial transverse ligament, limits the
interdigital clefts on the palmar side ; on the dorsum of the hand the clefts are
continued upwards almost to the metacarpo-phalangeal joints.
The superficial palmar arch is placed beneath the palmar fascia about the centre
of the palm ; its position may be indicated by a line carried from the outer
side of the pisiform bone downwards, and then curving outwards across the
middle third of the palm on a level with the upper end of the cleft between the
thumb and index finger. From the convex side of the arch digital branches
proceed, one to the ulnar margin of the little finger, and three which descend
opposite the intervals between the fingers and bifurcate about half an inch above
the clefts. The deep palmar arch rests against the metacarpal bones about a quarter
of an inch nearer the wrist than the superficial arch, and the digital branches given
off by the radial artery to the thumb and index finger are deeply placed in the
palm, the collateral arteries of the thumb becoming superficial at the base of the
first phalanx, that of the index finger issuing from behind the adductor transversus
pollicis. The latter branch is not unfrequently derived from the radial artery at
the back of the wrist, and may then be felt pulsating as it descends on the posterior
surface of the abductor indicis muscle to its destination. The superficial volar
artery is occasionally visible as it descends over the upper part of the thenar to
SUPERFICIAL ANATOMY OF THE LOWER LIMB.
SUPERFICIAL ANATOMY OF THE LOWER LIMB.
The region of the hip, gluteal region or buttock, extends from the subcutaneous
iliac crest and the origin of the glutens maximus muscle above to the fold of the
nates below. The surface is formed posteriorly by the gluteus maximus, which is
generally covered by a considerable quantity of fat, and laterally by the glutens
medius, together with, at the foremost part, the tensor vaginas femoris. The latter
muscle may be recognized forming a distinct prominence below the anterior part of
the iliac crest (fig. 20), especially if the thigh be abducted or rotated inwards.
The fold of the nates is formed during extension of the hip by the drawing in of the
skin below the level of the ischial tuberosity, and is directed horizontally outwards,
crossing the oblique lower border of the gluteus maximus about its middle.
The iliac crest is represented on the surface, in muscular subjects, by a groove
(iliac, furrotv), in consequence of the projection of the external oblique muscle
Fig. 19. POSTERIOR VIEW OF THK HIP, SHOWING THK SITUATION OF THE BONES AND CHIEF ARTERIES, &c.
(B. J. G. &GK D. T.)
above, and, to a less extent, of the gluteus medius below. Traced forwards, this
furrow terminates at the anterior superior iliac spine, which is always easily
recognized ; posteriorly, the furrow becomes less marked as the crest passes below
the tendinous portion of the erector spinte, but a slight depression always indicates
the position of the posterior superior spine. The latter point is on a level with the
spinous process of the second sacral vertebra, and immediately behind the centre of
the sacro-iliac articulation. From three to four inches (8 10 cm.) below the iliac
crest, and somewhat in front of its central point, the great trochanter is to be felt,
and in thin persons seen. The trochanter projects outwards farther than the iliac
crest, but it does not usually appear as a prominence on the surface owing to the
great thickness of the gluteus medius and minimus muscles, which occupy the hollow
between it and the ilium. It is entirely covered by the aponeurotic insertion of the
THE HIP AND THIGH. 43
upper part of the glutens raaximus, and its upper border, which is generally on a
level with the centre of the hip-joint, is obscured by the tendon of the gluteus
medius descending to its insertion on the outer side of the process. Immediately
behind the great trochanter is a well-marked depression, where the lower portion of
the gluteus maximus, after passing over the ischial tuberosity, becomes tendinous
and sinks in to be inserted into the shaft of the femur.
Beneath the lower border of the gluteus maximus, the tuberosity of the ischium
is to be felt, and when the hip is flexed this process is to a great extent uncovered
by the muscle. A line drawn over the outer surface of the hip from the anterior
superior iliac spine to the most prominent part of the ischial tuberosity is known as
Nelatm's line (fig. 20), and will be found to pass over the top of the great trochanter
and cross the centre of the acetabulum. It thus forms a guide to the natural
position of the upper end of the femur, and is consequently of service in detecting-
dislocations of the hip and fracture of the neck of the bone.
If a line be drawn from the posterior superior iliac spine to the outer part of the
ischial tuberosity, it will cross the posterior inferior spine and the ischial spine : the
posterior inferior spine is nearly two inches (4 cm.), and the ischial spine about four
inches (10 cm.), below the posterior superior spine : the sciatic artery appears in the
buttock at the junction of the middle and lower thirds of this line. The gluteal
artery leaves the great sacro-sciatic foramen beneath a spot corresponding to the
junction of the inner and middle thirds of a line drawn from the posterior superior
iliac spine to the great trochanter, when the thigh is rotated inwards. Between
the gluteal and sciatic arteries, the great sciatic nerve leaves the pelvis, and it
thence pursues a slightly curved course to a point midway between the great
trochanter and the ischial tuberosity.
The thigh is separated from the abdomen in front by the curved inguinal furrotv ,
at the bottom of which Poupart's ligament may be felt (except in fat people), more
plainly in its inner than in its outer half, as it passes from the anterior superior
spine of the ilium to the pubic spine : the band is relaxed, and becomes less distinct,
on flexing and adducting, or rotating inwards, the thigh. From the pubic spine,
the finger may be carried inwards along the pubic crest to the top of the symphysis,
in the male passing over the spermatic cord, or downwards and backwards along the
inner margin of the united pubic and ischial rami to the tuberosity of the ischium,
thus tracing the boundary line between the thigh and the perineum. Externally,
the thigh is not definitely marked off from the region of the hip.
Immediately below Poupart's ligament, a slight hollow is generally seen,
corresponding to Scarpa's triangular space (Vol. II, pp. 252 and 487), in which,
just internal to the centre, the femoral artery may be felt pulsating. Close below
the innermost part of Poupart's ligament is situated the saphenous opening in the
fascia lata, the upper end of which is about one inch outside the pubic spine.
Through the lower part of this aperture, and about one inch and a half below
Poupart's ligament, the internal saphenous vein passes back to join the femoral
trunk, and above the vein is the spot where a femoral hernia first makes its
appearance on the surface of the thigh. Over the opening, and for a short distance
below it, the femoral or lower inguinal lymphatic glands may usually be felt through
the skin, surrounding the upper end of the internal saphenous vein.
From the apex of Scarpa's triangle a depression is continued downwards along
the inner part of the thigh, between the masses formed by the quadriceps extensor
muscle in front, and the adductor muscles on the inner side. The sartorius muscle
lies along this depression, and may be distinctly seen when it is brought into action
by raising the leg across the opposite knee. The form of the rectus muscle may be
SUPERFICIAL ANATOMY OF THE LOWER LIMB.
distinguished along the front of the anterior mass, and to its inner side, in about
the lower half of the thigh, the vastus internus gives rise to a large prominence,
foe pod. __..
Fig. 20. SUPERFICIAL ANATOMY OP THE LOWER LIMB : EXTERNAL VIEW. (From a photograph by
G. W. B. Waters.) (R. J. G. & G. D. T.)
Fig. 21. SUPERFICIAL ANATOMY OF THE LOWER LIMB : ANTERO-INTERNAL VIEW. (From a photograph by
G. W. B. Waters.) (R, J. G. & G. D. T.)
increasing in size towards the knee, while on the outer side of the rectus, the vastus
externus forms a broad convex surface, extending from the great trochanter above
almost to the knee-joint below, and being continued backwards to the posterior
THE THIGH. 45
aspect of the limb. The surface formed by the vastus externus is often seen to be
traversed by a longitudinal groove, due to the pressure exerted by the strong ilio-
tibial band of the fascia lata as it descends from the insertions of the gluteus
maximus and tensor vaginas femoris muscles to the outer tuberosity of the tibia.
Of the adductor muscles, the only parts that are to be separately recognized are the
strong tendon of origin of the adductor longus below the pubic crest, and the lower
tendon of the adductor magnus which is felt distinctly, when the knee is bent, in
the interval between the sartorius and vastus internus muscles, extending down to
the adductor tubercle on the internal condyle of the femur. The adductors are not
marked off on the surface from the hamstring group on the back of the thigh, nor
are the latter muscles to be individually distinguished from one another until they
become tendinous near the knee. Along the outer and posterior part of the thigh,
however, the hamstring muscles are separated from the vastus externus by a well
marked groove, corresponding to the position of the external inter muscular
The whole of the shaft of the femur is deeply placed, and in fairly muscular
subjects is not to be detected through its fleshy covering. It approaches the surface
most nearly in the lower third of the thigh on the outer side, where it may be
readily exposed in the interval between the vastus externus and biceps muscles.
The head of the bone is situated close below Poupart's ligament, immediately
external to its mid-point, and is occasionally, in thin subjects, to be felt in this
position through the overlying muscles.
The subcutaneous veins of the thigh all join one trunk, the internal saphenous,
which ascends from the hinder part of the inner side of the knee, with a gradual
inclination forwards, to the saphenous opening. The extent to which this vein and
its branches are to be perceived varies greatly with the amount of subcutaneous
The position of the femoral artery is indicated by a line drawn from a point
midway between the anterior superior iliac spine and the pubic symphysis to the
prominent tuberosity on the inner condyle of the femur, the hip having been
first slightly flexed and the thigh everted. At the junction of the upper three-
fourths with the lower fourth of this line, the artery passes backwards through the
opening in the adductor magnus muscle. Pressure is most conveniently applied to
the vessel as it enters the thigh below Poupart's ligament, and it should be directed
backwards so as to compress the artery against the pubis and the adjacent part of
the hip-joint. Lower down, the pressure must be made in a direction backwards
and outwards, as the artery lies considerably to the inner side of the shaft of the
femur. At Poupart's ligament, the femoral vein is close to the inner side of the
artery, and the anterior crural nerve is a little distance (a quarter to half an inch)
from its outer side. The profnnda, arising from the main trunk usually between
one and two inches (3 5 cm.) below Poupart's ligament, follows a line almost
identical with that of the femoral artery.
The small sciatic (posterior cutaneous) nerve lies immediately beneath the fascia
along the middle line of the back of the thigh ; and in the same line, but under
cover of the hamstring muscles, is the great sciatic nerve.
On the inner side of the knee, the internal condyle of the femur and the
corresponding tuberosity of the tibia produce a rounded surface, the most
prominent point of which is formed by the tuberosity on the internal condyle. The
interval between the two bones opposite the knee-joint is seldom to be seen, but is
always easily felt. It can usually, however, be readily demonstrated by resting the
46 SUPERFICIAL ANATOMY OF THE LOWER LIMB.
lower part of the leg on the opposite knee, when the inner tuberosity of the tibia
projects beyond the inner condyle of the femur. On the upper part of the inner
condyle, the sharp adductor tubercle and the insertion of the adductor magnus
tendon are also to be recognized. The external condyle, although not generally
prominent, is subcutaneous and readily felt ; its tuberosity is comparatively little
developed. The outer tuberosity of the tibia, on the other hand, forms a marked
prominence at the outer and fore part of the knee, about an inch below the joint ;
and behind this, at a slightly lower level, viz., that of the tubercle of the tibia,
the head of the fibula is distinctly felt at the outer and back part of the limb, where
it generally corresponds to a depression, when the joint is extended, between the
tendon of the biceps above and the peroneus longus muscle below : it often forms
a prominence, however, when the knee is flexed. Anteriorly, the patella is sub-
cutaneous, and its lateral margins are distinctly seen. When the extensor muscles
are relaxed, the patella can be easily moved from side to side ; but if these muscles
are contracted, the patella is drawn upwards and pressed firmly against the end of
the femur, and the ligamentum patellae can then be followed down to the tubercle of
the tibia : on each side of the ligament is a soft eminence produced by the infra-
patellar mass of fat. When the knee is bent, the patella sinks into the hollow
between the tibia and the femur, and the articular surface of the latter bone is in
great part exposed ; the trochlear surface can then be distinctly traced, although
covered by the tendon of the extensor muscle. The upper and outer angle of
this surface forms a useful landmark ; and a line drawn from it to the adductor
tubercle on the internal coudyle marks the upper limit of the epiphysis of the lower
end of the femur. There are generally two bursae, a superficial one and a deep
one, over the patella, and there is frequently another over the tubercle of the tibia
(Vol. II, p. 242).
At the back of the knee is the ham, which is marked by a deep hollow when the
joint is flexed, but by a slight elevation when it is extended. On each side are the
tendinous hamstrings ; internally the slender semitendinosus and the stronger semi-
membranosus are to be recognized, as well as the gracilis a little farther forwards ;
externally is the thick tendon of the biceps leading down to the head of the fibula.
Immediately in front of the biceps tendon, when the joint is a little bent, the upper
part of the external lateral ligament is to be detected ; and between this and the
outer margin of the patella, the lower end of the ilio-tibial band appears as a strong
cord beneath the skin, running down on the outer side of the knee to the prominent
external tuberosity of the tibia ; while on the inner side, the sartorius tendon, with
the subjacent tendons of the gracilis and semitendinosus, forms a slight elevation as
it curves forwards below the inner tuberosity, to be inserted close to the tubercle of
The external saphenous vein enters the lower part of the ham in the middle
line of the limb, and perforates the fascia to join the popliteal vein ; but it is not
usually visible on the surface. The internal saphenous vein is generally seen on the
inner side of the knee, and the nerve of the same name meets it behind the internal
The popliteal vessels enter the ham somewhat internal to the middle line above,
and are then continued downwards over the centre of the back of the knee ; the
vein is more superficial than the artery, but both are very deeply placed. The
upper articular vessels run transversely inwards and outwards immediately above the
condyles of the femur ; and the lower articular vessels are respectively just below
the inner tuberosity of the tibia, and above the head of the fibula. The deep part
of the anastomotic artery descends to the knee along the front of the adductor
THE LEG. 47
The internal popliteal nerve, continuing the direction of the great sciatic, and
descending in the median line of the limb, is superficial to the vessels. The external
popliteal nerve is at first under cover of the fleshy belly of the biceps, and then lies
on the outer side of the ham, close behind the tendon of that muscle ; it 'may be felt
rolling beneath the finger as it crosses the outer side of the neck of the fibula,
before entering the peroneus longus muscle ; and it is sometimes to be seen giving
rise to a slight elevation in this position.
The glands in the popliteal space are not to be felt unless they are enlarged.
Along the fore part of the leg, the anterior border of the tibia is to be followed
downwards from the tubercle, constituting what is known as the shin. This
border is sharp in the upper two-thirds of the leg, and describes a slight curve with
the concavity outwards ; in the lower third the border disappears, and the bone is
concealed by the tendons of the anterior muscles. On the inner side of the shin,
the broad internal surface of the tibia is subcutaneous below the sartorius, and leads
downwards to the prominent internal malleolus. At the back of the latter process
a sharp edge is felt, which is formed by the inner margin of the groove for the
tendon of the tibialis posticus ; the tendon itself covers the posterior surface of the
malleolus, and is rendered prominent by inverting the foot. The head of the fibula
is subcutaneous, as has been before mentioned ; the shaft is surrounded by muscles,
bat it can be felt through them in the lower half at least of the leg, and it will be
remembered that it is placed considerably farther back in the leg than the shaft of
the tibia ; near the ankle, a triangular portion of the bone comes to the surface, and
is continued down to the external malleolus.
Along the concavity of the anterior edge of the tibia, the prominence formed by
the fleshy belly of the tibialis anticus is seen, and external to this is the much less
distinct and narrower extensor longus digitorum. The tendons of the muscles
appear in the lower third of the leg, and between them also that of the extensor
proprius hallucis ; they are brought into view most distinctly by flexing the ankle
and extending the toes. From the head of the fibula downwards, the peroneus
longus and brevis muscles form an elongated swelling, from which the tendons can
be traced descending behind the external malleolus. Posteriorly the elevation of
the calf is formed by the gastrocnemius muscle, which terminates about the middle
of the leg in the tendo Achillis ; the inner head of the gastrocnemius is the larger,
and descends lower than the outer. On each side of the gastrocnemius and tendo
Achillis, a portion of the soleus comes to the surface ; and the characteristic form
of the gastrocnemius, depending upon the peculiar structure of the muscle (Vol. II,
p. 262), as well as the extent and shape of the projecting portions of the soleus, are
brought into view by raising the body on the toes. The tendo Achillis gradually
becomes narrower as it approaches the heel, but it widens again a little as it passes
over the tuberosity of the os calcis to its insertion. Between it and the malleolus,
on each side, is a well-marked hollow, that on the outer side being the deeper ; in
the inner of these, the tendons of the tibialis posticus and flexor longus digitorum,
and the posterior tibial vessels and nerve are superficial.
Both the external and internal saphenous veins are visible beneath the skin of
the leg, together with numerous tributaries and communicating branches. The
internal is the larger, and, after crossing in front of the internal malleolus, runs
upwards just behind the inner border of the tibia ; the external passes behind the
outer malleolus and then ascends over the middle of the calf to the ham. Each
vein is accompanied by the nerve of the same name.
The bifurcation of the popliteal artery takes place about two inches (5 cm.) below
48 SUPERFICIAL ANATOMY OF THE LOWER LIMB.
the knee-joint, and on a level with the lower part of the tubercle of the tibia. The
course of the anterior tibial artery is marked on the front of the leg by a line drawn
from a point midway between the head of the fibula and the prominence of the outer
tuberosity of the tibia to the centre of the ankle-joint. The intermuscular space in
which the artery lies is also indicated by a depression which is seen at the outer
border of the tibialis anticus when the muscle is called into action. The posterior
tibial artery runs from the centre of the ham to the mid-point of a line drawn from
the tip of the internal malleolus to the lower end of the inner border of the calcanean
tuberosity ; beneath this spot, the vessel divides into the internal and external
plantar arteries. The posterior tibial artery is covered by the gastrocnemius and
soleus for about two-thirds of its length, but in the lower third it is superficial, and
may be felt pulsating in the interval between the tendo Achillis and the tibia.
About three inches (7'5 cm.) below the knee, it gives off the large peroneal branch,
which follows the direction of the fibula, and terminates behind the external
THE ANKLE AND FOOT.
Of the two malleoli, the internal is usually the more prominent, but the external
descends lower and also projects farther back, having its point, as a rule, about
three-quarters of an inch (2 cm.) nearer to the heel than that of the internal malleolus.
On the dorsum of the foot, the tarsal bones are not usually to be distinguished individu-
ally, but the head of the astragalus not unf requently forms a considerable projection
when the ankle-joint is extended ; and if the arch of the foot is flattened, it often
protrudes markedly on the inner side. Along the inner side of the foot, the tube-
rosity of the os calcis is first felt, and then, about an inch (2*5 cm.) below the internal
malleolus, the sustentaculum tali of the same bone ; in front of the latter, and
about an inch and a half (4 cm.) from the malleolus, the tuberosity of the navicular
bone is prominent, and to it the tendon of the tibialis posticus may be followed from
the back of the internal malleolus ; the finger next passes over the internal cuneiform
bone, and recognizes the base of the first metatarsal bone as a slightly prominent
ridge ; from this, the shaft of the bone may be traced forwards beneath the skin to
its expanded, and often unduly prominent, head, below which the sesamoid bones
may be felt on the plantar aspect of the mctatarso-phalangeal articulation. On the
outer side of the foot, nearly the whole of the external surface of the os calcis is sub-
cutaneous, and the peroneal spine of the bone may often be felt a little below and in
front of the external malleolus. The anterior extremity of the os calcis may be
distinguished when the foot is inverted, forming a marked prominence above the
level of the cuboid bone, and in front of this, distant about two and a half inches
(G cm.) from the external malleolus, the projecting tuberosity at the base of the fifth
metatarsal bone is easily felt.
The interarticular cleft of the ankle-joint is placed about half an inch (1 cm.)
above the tip of the internal malleolus. The transverse tarsal articulation, at which
Chopart's amputation is practised, runs from immediately behind the tuberosity of
the navicular bone, outwards in front of the head of the astragalus and the anterior
extremity of the os calcis, to end a little in front of the mid-point between the tip of
the external malleolus and the tuberosity of the fifth metatarsal bone. The line of
the tarso-metatarsal articulations is very irregular : commencing immediately
behind the base of the first metatarsal bone, it passes at first transversely between
that bone and the internal cuneiform, then turns sharply backwards for a full half-
inch (15 mm.) to reach the cleft between the middle cuneiform and second
metatarsal bones, next advances for about a quarter of an inch (5 mm.), and then is
continued outwards, with a slight inclination backwards, between the outer three
THE ANKLE AND FOOT. 49
metatarsal bones in front and the external cuneiform and cuboid bones behind, to its
termination behind the tuberosity of the fifth metatarsal bone.
Over the front of the ankle, the tendons of the anterior muscles of the leg are
bound down by the anterior annular ligament ; they can be readily distinguished
when the joint is flexed, spreading over the dorsum of the foot, and disposed in the
following order : the most internal and the largest is the tibialis anticus ; next
comes the extensor proprius hallucis, and then the extensor longus digitorum,
dividing into its four slips for the smaller toes ; lastly, proceeding from the outer
side of the long extensor to the base of the fifth metatarsal bone is the peroneus
tertius ; the last named is, however, not unfrequently wanting. The anterior tibial
vessels and nerve are placed, opposite the ankle-joint, between the tendons of the
extensor proprius hallucis and extensor longus digitorum. Beneath the tendons of
the extensor longus digitorum, on the dorsum of the foot, is placed the extensor
brevis digitorum, the fleshy belly of which produces a distinct swelling over the
tarsal region. The fleshy mass on the inner margin of the foot is formed by the
abductor and flexor brevis hallucis muscles ; and that on the outer border by the
abductor and flexor brevis minimi digiti.
In the sole, the tuberosity of the os calcis and the heads of the metatarsal
bones are easily felt, but in the intervening region the bones are not to. be
distinguished. The individual muscles are also obscured by the thickness of
the integument and the manner in which the parts are bound together by the
strong plantar fascia. When the arch of the foot is well developed the parts
of the sole that rest on the ground in standing are the heel, a strip near the outer
border of the foot, the heads of the metatarsal bones, and the ends of the toes.
The skin over these parts is thick, hard, and smooth, but in the hollow of the foot
it is soft and wrinkled. The sole of the infant is flatter than that of the adult,
and is marked by lines similar to those seen in the palm of the hand, but
these disappear more or less completely as age advances.
On the back of the foot, the arch or plexus of veins shows plainly through
the skin, and its extremities may be followed into the internal and external
saphenous veins respectively. The musculo-cutaneous and external saphenous
nerves are not uncommonly visible through the skin.
The dorsal artery of the foot extends from the centre of the ankle-joint to the
back of the first intermetatarsal space, and it may be felt pulsating midway between
the tendons of the extensor proprius hallucis and extensor longus digitorum. Just
before its ending it is crossed by the innermost slip of the extensor brevis
digitorum. The external plantar artery runs from the bifurcation of the posterior
tibial (p. 48) obliquely across the sole to within an inch (2'5 cm.) of the tuberosity of
the fifth metatarsal bone, and then is directed more transversely inwards to the
back of the first interosseous space, where it meets the termination of the dorsal
artery. The internal plantar artery is much smaller than the external ; its position
may be indicated by a line drawn from the place of bifurcation of the posterior
tibial to the under part of the metatarso-phalangeal articulation of the great toe.
The metatarso-phalangeal articulations are situated about an inch (2'5 cm.)
behind the web of the toes.
ANATOMY OF HERNIA.
al branch of qesiUe -cru.rcd.rwoe.
5? .2 S'S s j.
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INGUINAL HERNIA. 51
ANATOMY OP THE GROIN" : HERNIA.
Two kinds of abdominal hernias have such definite and important relations that,
the regions concerned require special notice in a work on anatomy. These are
inguinal hern-tee, which are associated with the spermatic cord in their passage
through the abdominal wall, and femoral hernice, which descend through the
femoral canal on the inner side of the femoral vessels.
The inguinal canal, through which the spermatic cord passes from the cavity
of the abdomen to the scrotum, begins at the internal abdominal ring, and ends
at the external ring. It is oblique in its direction, being nearly parallel with and
immediately above the inner half of Poupart's ligament, and it measures about an
inch and a half (3'5 cm.) in length. The external ring (Vol. II, p. 329) is imme-
diately above and external to the pubic spine ; the internal (ib., p. 336) is midway
between the anterior superior iliac spine and the pubic symphysis, and half an inch
(1 cm.) above Poupart's ligament. In front, the canal is bounded by the aponeurosis
of the external oblique muscle in its whole length, and at the outer end also by the
fleshy part of the internal oblique ; behind it is the transversalis fascia, together with,
towards the inner end, the conjoined tendon of the two deeper abdominal muscles
and the triangular fascia. Above the canal are the arched lower borders of the
internal oblique and transversalis muscles ; and below, it is bounded by Poupart's
and Gimbernat's ligaments, which separate it from the sheath of the large blood-
vessels descending to the thigh, and from the femoral canal at the inner side of
those vessels. Below the internal ring, and separated therefrom by Poupart's
ligament, is the external iliac artery, giving off its epigastric branch, which at first
runs inwards, and then ascends close to the inner border of the opening (fig. 28).
The spermatic cord, which occupies the inguinal canal, is composed of
the arteiy, veins, lymphatics, nerves, and excretory duct of the testis (vas deferens),
together with a quantity of loose areolar tissue.
Coverings of the cord. The coverings given from the constituent parts of
the abdominal wall to the spermatic cord, besides the integuments, are, from the
external ring the intercolumnar or spermatic fascia, the cremasteric muscle
and fascia from the lower border of the internal oblique muscle, and a thin, funnel-
shaped prolongation of the transversalis fascia from the edge of the inner ring
(infundibuliform fascia). Beneath the last, the areolar tissue uniting together the
constituents of the cord is continuous with the subperitoneal areolar layer.
Peritoneal fossae. When the lower part of the anterior abdominal wall
is viewed from within, the peritoneum is seen to form a series of depressions,
which are separated by more or less prominent folds. Thus, along the middle line
is the plica urachi (plica umlilicalis media'), which extends from the apex of the
bladder upwards along the urachus to the umbilicus; a little outside this is the
well-marked plica hypogastrica (plica umlilicalis lateralis), containing the obliterated
hypogastric artery, and also extending from the bladder to the umbilicus ; and still
Fig. 22. ANATOMY OF HERNIA : SUPERFICIAL VIEW. (Gr. D. T.)
On the left side, only the skin and superficial fasciae have been removed, exposing above Poupart's
ligament the aponeurosis of the external oblique, with the spermatic cord emerging through the external
abdominal ring, and below Poupart's ligament the fascia lata with the internal saphenous vein passing
through the lower part of the saphenous opening and piercing the femoral sheath.
On the right side, the inguinal portion of the external cblique has been removed, bringing into view
part of the internal oblique muscle and the cremaster ; and below Poupart's ligament the iliac part of
fascia lata has been detached from Poupart's ligament and reflected, so as to expose the front of the
ANATOMY OF THE GROIN : HERNIA.
s -S x
Fig. 23. ANATOMY OF HERNIA : DEEP VIEW. (G. D. T.)
On the right side parts of the external and internal oblique muscles together with the cremaster
have been taken away, so as to show the spermatic cord invested by the infundibuliform fascia lying
in the inguinal canal. By the removal of a part of the front of the femoral sheath the femoral vessels
have been exposed and the femoral canal opened. Gl., gland occupying the femoral ring.
On the left side parts of the two oblique muscles have been removed, and also a portion of the
spermatic cord. Poupart's ligament has been divided, and the cut portions turned aside, thus exposing
the deep femoral arch. Tr. F., triangular fascia ; G. L. , Gimbernat's ligament. The conjoined tendon
on this side is very wide, and is prolonged outwards along the deep femoral arch as far as the internal
more externally is a slight elevation, the plica epigastrica, over the epigastric vessels.
The depressions are accordingly three in number on each side, viz., from without
inwards, 1, the fovea inguinalis lateralis, on the outer side of the plica epigastrica,
ment . . .
nerve . .
oU. liypogastric ]
pig 24. THE LOWER PART OP THE ANTERIOR ABDOMINAL WALL IN THE MALE VIEWED FROM BEHIND,
SHOWING THE PERITONEAL FOLDS AND FOSS<. (After JoCSSel.)
the deepest part of which is opposite the internal abdominal ring ; 2, the fovea
inguinalis mesialis between the plica epigastrica and the plica hypogastrica ; and
3, the fovea supravesicalis, between the plica hypogastrica and plica urachi,
immediately above and external to the apex of the bladder. Of these, the fovea
inguinalis mesialis is the most strongly marked, and often extends inwards for some
54 ANATOMY OF THE GROIN : HERNIA.
distance beneath the plica hypogastrica over the back of the rectus muscle. Below
the last fossa, and separated therefrom by the inner end of Poupart's ligament,
there is often to be recognised another slight depression, the fovea femoralis, over
the position of the femoral ring, to the inner side of the external iliac vein and the
vas deferens, or the round ligament of the uterus, according to the sex.
FOKMS or INGUINAL HERNIA. Two principal forms of inguinal hernia are
described, which are distinguished according to the part of the canal which they
first enter, as well as by the position which they bear with respect to the epigastric
artery. Thus, when the hernia takes the course of the inguinal canal from its
commencement, it is named oblique, because of the direction of the canal, or
external, from the position of its neck with respect to the epigastric artery. On the
other hand, when the protruded part, without following the length of the canal,
passes at once through its posterior wall at a point opposite the external abdominal
ring, the hernia is named, from its course, direct, or, from its relation to the
epigastric artery, internal.
Oblique or external inguinal hernia. In the common form of this hernia
the protruded viscus carries before it a covering of serous membrane (the sac
of the hernia), derived from the outer fossa of the peritoneum (p. 53) ; and, in
passing along the inguinal canal to the scrotum, it is successively invested by the
coverings given to the spermatic cord from the abdominal parietes. The hernia
and its sac lie directly in front of the vessels of the spermatic cord, and do not
extend below the testis, even when the tumour is of large size.
There are two other varieties of oblique inguinal hernia, in which the peculiarity depends
on the condition of the process of peritoneum (JWOCCSSHS vaginalis) that receives the testis
when this organ descends from the abdomen. In ordinary circumstances the part of the
peritoneal process connected immediately with the testis becomes separated after birth from
the general cavity of that serous membrane by the obliteration of the intervening canal ; and
the hernial protrusion occurring- after such obliteration has been completed, carries with it a
distinct serous investment the sac. But if this process of obliteration should not take place,
and if a hernia should be formed, the protruded part is then received into the cavity of the
processus vaginalis, which serves in the place of its sac. In this case the hernia is named
congenital. It is thus designated, because the condition necessary for its formation only
exists normally about the time of birth ; but the same kind of hernia is occasionally found to
be first formed in the adult, obviously in consequence of the processus vaginalis remaining
unclosed, and still continuous with the peritoneum. The congenital hernia, should it reach
the scrotum, passes below the testis ; and, this organ being embedded in the protruded viscus,
a careful examination is necessary in order to detect its position. This peculiarity serves to
distinguish the congenital from the ordinary form of the disease.
To the second variety of inguinal hernia, in which the distinguishing character depends
on the state of the tunica vaginalis testis, the name infantile has been applied (Hey). The
hernia in this case is covered with a distinct sac, which is again invested by the upper end of
the tunica vaginalis. The relative position of the two serous membranes (the hernial sac
and the tunica vaginalis) may be accounted for by supposing the hernia to descend when the
process of the peritoneum, which accompanies the testis from the abdomen, has been merely
closed at the upper end, but not obliterated along the front of the cord. Hence during an
operation in such a case, the hernial sac is met with only after another serous bag (the
abnormal prolongation upwards of the tunica vaginalis testis) has been divided. The
peculiarity here described has been repeatedly found present in the recently-formed hernias of
grown persons. The term infantile, therefore, like congenital, has reference to the condition
of certain parts, rather than to the period of life at which the disease is first formed.
In the female, oblique inguinal hernia follows the course of the round ligament
of the uterus along the inguinal canal, in the same manner as in the male it follows
the spermatic cord. After escaping from the external abdominal ring, the hernia
lodges in the labium pudendi. The coverings are the same as those in the male
body, with the exception of the cremaster, which does not exist in the female ; but
it occasionally happens that some fibres of the internal oblique muscle are drawn
down over this hernia in loops, so as to have the appearance of a cremaster
internal abdominal ring
. spermatic cord
Fig. 25. PERSISTENT VAGINAL PROCESS OF THE PERITONEUM. (After Joessel.)
The preparation is from a man 20 years of age. The tunica vaginalis is cut off from the vagina
process, the tubular portion of which ends blindly a little above the testicle. In the inguinal canal the
process becomes gradually narrower up to the internal abdominal ring, through which a probe is
introducer! into the cavity.
A strictly congenital inguinal hernia may occur in the female, the protruded parts being
received into the little diverticulum of the peritoneum (canal of Nuck), which sometimes
extends into the inguinal canal with the round ligament. But as this process of the
peritoneum, in such circumstances, would probably not differ in any respect from the
ordinary sac, there are no means of distinguishing a congenital hernia in the female body.
Direct or internal inguinal hernia. Instead of following the whole course
of the inguinal canal, in the manner of the hernia above described, the viscus in
this case is protruded from the abdomen to the groin directly through the lower end
of the canal, at the external abdominal ring. At the part of the abdominal wall
through which the direct inguinal hernia finds its way, there is recognised on its
posterior aspect a triangular interval, the sides of which are formed by the epigastric
artery, and the margin of the rectus muscle, and the base by Poupart's ligament
(fig. 28). It is commonly named the triangle of Hesselbach. The triangle
measures about two inches (5 cm.) from above down, and an inch and a half
56 ANATOMY OF THE GROIN : HERNIA,
(3 - 5 cm.) transversely at its base. In this area the abdominal wall consists of,
besides the integuments, 1, the aponeurosis of the external oblique muscle, which
is perforated towards the lower and inner corner of the space by the external
abdominal ring ; 2, the inner portion of the cremaster muscle covering the sper-
matic cord at the lower and outer part of the space, and above this the lower
fibres of the internal oblique and transversalis muscles passing to their insertion by
the conjoined tendon, which, as a rule, extends over the inner two-thirds of the
lower part of the triangle ; 3, transversalis fascia ; 4, subperitoneal tissue ; and 5,
The conjoined tendon varies greatly in its development. In many cases it is very slight,
and scarcely to be distinguished, while in others its deeper portion, derived from the trans-
versalis muscle, covers the whole breadth of the triangle, reaching outwards along the deep
femoral arch as far as the internal abdominal ring (fig. 23, left side). Sometimes the outer
part is detached from the rest, and forms a band which has been designated lig amentum
interfoveolare or ligament of Hesselbacft, while to the remaining inner portion the name of / fa;
inguinalis or ligament of Henle has been given. (See W. His, in die anatomiselie Nomenclatur,
1895, p. 121 ; and K. M. Douglas, The Anatomy of the Transversalis Muscle 'and its Relation
to Inguinal Hernia, Journ. Anat., xxiv, 1890.)
The distance of the obliterated hypogastric artery from the middle line, and with it the
breadth of the fovea supravesicalis, is also subject to variation. In most cases, however, the
hypogastric cord ascends altogether behind the rectus muscle, and therefore an internal hernia
will project in the mesial inguinal fossa. Only in rare cases does a hernia protrude in the
supravesical hollow, between the obliterated hypogastric artery and the edge of the rectus.
A hernia emerging to the inner side of the epigastric vessels in the majority of
cases protrudes in the inner part of the triangle of Hesselbach, and is forced onwards
directly into the external abdominal ring. The coverings of such a hernia, taking
them in the order in which they are successively applied to the protruded viscus, are
the following : The peritoneal sac and the subperitoneal tissue which adheres to it,
the transversalis fascia, the conjoined tendon of the internal oblique and transversalis
muscles, and the spermatic fascia derived from the margin of the external abdominal
ring, together with the superficial fascia and skin. With regard to the conjoined
tendon, this hernia may be covered by it, or may pass through an opening in its
The spermatic cord is commonly placed behind the outer part of the hernia. The
hernial sac is not, however, in contact with the vessels of the cord, the investments,
given from the transversalis fascia to those vessels and to the hernia respectively, as
well as the cremasteric fascia, being interposed.
But the spot at which an internal inguinal hernia passes through the triangle of
Hesselbach is subject to some variation, and there is a second form of internal
hernia which differs somewhat in its course and relations from the foregoing. In
this variety the hernia protrudes to the outer side of the conjoined tendon, between
that and the epigastric vessels. Such a protrusion passes through a considerable
portion of the inguinal canal to reach the external ring, and has therefore a certain
degree of obliquity, whence this variety is frequently termed internal oblique, inguinal
hernia. It is also known as superior internal hernia, the direct form being called
inferior internal. As an internal oblique hernia passes outside the conjoined tendon,
it has no covering derived from that structure, but it receives one from the cremaster
in the same way as an external hernia.
Direct inguinal hernia is very rarely met with in the female. In the single case
observed by Richard Quain, as well as in the few cases found recorded in books, the
hernia though not inconsiderable in size was still covered by the tendon of the
external oblique muscle.
A femoral hernia leaves the abdomen at the groin, passing beneath Poupart's
ligament, and over the anterior border of the hip-bone immediately at the inner side
of the femoral vessels. It takes a downward course through the innermost com-
partment of the femoral sheath till it reaches the saphenous opening, when it turns
forwards through the opening towards the front of the thigh, and is then bent upwards
in the groin.
! Gimbernat's ligament
- -,,.'' / outer pillar
'; /.'."<':/ inner pillar
Fig. 26. POUPART'S LIGAMENT AND THE NEIGHBOURING FASCIAE IN RELATION TO THE HIP-BONE.
(G. D. T.)
The space between Poupart's ligament and the hip-bone is seen to be subdivided into three com-
partments by the fascise. Anteriorly is the vascular compartment, and posteriorly are the two
muscular compartments the larger one externally occupied by the ilio-psoas, and the smaller one
internally occupied by the upper end of the pectineus : the two are separated by * the ilio-pectineal
intermuscular septum attached to the ilio-pectineal eminence.
The concave ilio-pubic margin of the hip-bone is bridged across in the recent
state by Poupart's ligament or the (superficial) femoral arch (ligamentum mguinale),
extending from the anterior superior iliac spine to the pubic spine. The intervening
space, which is somewhat diminished at the internal angle by Gimbernat's ligament
(ligamentum lacunare), is mainly occupied by the ilio-psoas muscle and the external
iliac vessels on their way into the thigh, and the upper end of the pectineus muscle.
ANATOMY OF THE GROIN : HERNIA,
These structures are invested by special fasciae, which by their connection together
subdivide the space into three chief compartments.
The vascular compartment (lacuna vasorum), situated in front of the others, is
bounded anteriorly by Poupart's ligament and the continuation of the transversalis
fascia into the front of the femoral sheath, with its thickening termed the deep femoral
AKIt. CRURAL NERVE
/ CRURAL BRANCH OF GENlTO-CRURALNERtfH
-,, -,, .^ GLATJO IN FEHORAL RINO
, ^v "'''/---"* *^ /
' , Cll>l SCR WAT'S LIGAMENT
Fig. 27. DISSECTION OP THE PARTS BENEATH POUPART'S LIGAMENT. 2. ((j. D. T.)
The femoral vessels, which are seen enclosed in the femoral sheath, have been divided close below
Poupart's ligament. The fasciae forming the back of the sheath, and the subjacent muscles have been
divided at successively lower levels. * indicates the ilio-pectineal intermuscular septum attached to
the capsule of the hip-joint along the inner part of its anterior surface.
arch (fig. 23) ; posteriorly by the continuous iliac and pectineal fascias. It allows of
the passage into the thigh of the external iliac vessels and the crural branch of the
genito-crural nerve, the vein being to the inner side, and the nerve to the outer side
of the artery, while between the vein and Gimbernat's ligament is the interval known
as the femoral ring. The iliac compartment (lacuna musculorum), the largest of
the three, is situated outside and behind the foregoing : it is bounded posteriorly
by the ilium, anteriorly by Poupart's ligament and the iliac fascia, and internally is
separated from the pectineal compartment by the ilio-pectineal intermuscular septum :
it transmits the ilio-psoas muscle with the anterior crural and external cutaneous
nerves. The pectineal compartment, lodging the upper end of the pectineus
muscle, is between the pectineal fascia (or pubic portion of the fascia lata) in front
and the superior ramus of the pubis behind. It extends only a short distance
upwards beyond Poupart's ligament, being closed above by the attachment of the
fascia to the superior border of the pubic ramus.
At the upper part of the pectineal fascia, immediately in front of its bony attachment,
is a thickening formed mainly by bundles of transverse fibres, which are closely connected
internally with, and in part derived from, Gimbernat's ligament. This is the pubic ligament
of Astley Cooper, and is frequently spoken of as Cooper's ligament.
X VAS DEFEREN3
Fit, 28 INNER VIEW OP THE GROIN, SHOWING THE INTERNAL ABDOMINAL AND FEMORAL RINGS. (Modified
from Ellis.) (G. D. T.)
The peritoneum and subperitoneal tissue have been removed ; and the rectus and tran.sversalis
muscles are seen covered by the trausversalis fascia. The ilio-psoas muscle and external cutaneous
nerve are covered by the iliac fascia.
F R, femoral ring ; G, Gimbernat's ligament ; PECT., pectineus niuscle covereil by fascia ; pub., pubic
branch of epigastric artery anastomosing with pubic of obturator.
60 ANATOMY OF THE GROIN : HERNIA.
The femoral or crural sheath (figs. 22 and 23), is a somewhat funnel-shaped
structure surrounding the upper parts of the femoral artery and vein. It is wide
above, but embraces the vessels closely below. It is continuous superiorly with
the lining fasciae of the abdomen, namely, with the transversalis fascia in front,
and the iliac fascia behind. On removing its anterior wall, the sheath is found
to be divided into three compartments by fibrous septa ; the outer compartment
containing the femoral artery, the middle, the femoral vein, and the inner being
occupied merely by lymphatic vessels, a gland, and some fat. The inner compart-
ment is about half an inch long, and from its being the passage through which
the hernia descends, has been called the femoral or crural canal. The upper
extremity of the canal presents an oval aperture towards the cavity of the abdomen,
usually of sufficient size to admit the point of the forefinger : its size, however,
varies in different persons, and it is larger in the female than in the male, its
transverse diameter, which is the longest, being on an average 25mm. in the
former, and 15mm. in the latter. This aperture is called the femoral or crural
ring (annulus femoralis'), and is covered when viewed from the inside by perito-
neum, which at this spot frequently shows a slight depression -fovea femoralis
(p. 54), and beneath that by the subperitoneal connective tissue, which here forms
the femoral septum (Cloquet). On the outer side lies the external iliac vein covered
by its sheath, but on the other three sides the ring is bounded by very unyielding
structures. In front are the femoral arches, the superficial being formed by Poupart's
ligament, and the deep by a variably developed bundle of fibres, which, springing
from the under surface of Poupart's ligament outside the femoral vessels, extends
across the fore part of the femoral sheath and, widening at its inner end, is fixed to
the ilio-pectineal line behind Gimbernat's ligament. Behind the ring is the hip-
bone covered by the pectineus muscle and the thickened upper part of the pectineal
fascia ; and on the inner side are several layers of fibrous structure connected with
the ilio-pectineal line namely, Gimbernat's ligament, the conjoined tendon of the
two deeper abdominal muscles, and the transversalis fascia, with the deep femoral
arch. The last-mentioned structures those bounding the ring at the inner side-
present more or less sharp margins towards the opening.
Relations to blood-vessels. Besides the external iliac vein, the position of
which has been already stated, the epigastric vessels are closely related to the ring,
lying above its outer side. It not infrequently happens that an aberrant obturator
artery descends into the pelvis at the outer side of the ring, or immediately across it;
and in rarer cases this vessel passes in front of the ring to its inner side (Vol. II,
p. 477). A pubic vein, also, has occasionally the same course ; and the 'small pubic
branch of the epigastric artery will be generally found ramifying on the superior
aspect of Gimbernat's ligament. In the male, the spermatic vessels are separated
from the canal only by the femoral arches.
The saphenous opening (fossa ovalis) of the fascia lata is placed at the upper
and inner part of the thigh, immediately below Poupart's ligament. Its upper
extremity is about one inch (2 - 5 cm.) external to the pubic spine, and its vertical
extent measures from one and a half to two inches (4 5 cm.). On the inner side the
opening is not sharply defined, the pectineal fascia being here prolonged over its
muscle, and passing behind the femoral vessels. On the outer side of the opening,
when the loose tissue in its area constituting the cribriform fascia (fascia cribrosa) has
been removed, the iliac portion of the fascia lata forms a distinct crescentic edge
known as thefakiform border, which ends above and below in curved portions termed
the superior and inferior cornua. Through the lower part of the opening the
internal saphenous vein passes backwards to enter the femoral vein, and the inferior
cornu curves sharply round in the angle between the two vessels to join the pectineal
fascia internally. _The superior cornu is thicker and less curved than the inferior :
FEMORAL HERNIA. 61
it crosses over the upper and inner part of the femoral sheath to join Poupart's
and Gimbernat's ligaments, its terminal portion being often distinguished as the
femoral ligament or Hey's ligament. The femoral ligament crosses the antero-internal
aspect of the femoral canal, and the closed extremity of that passage lies immediately
behind the upper part of the saphenous opening.
Descent of the hernia. When a femoral hernia is being formed, the protruded
part is at first vertical in its course ; but at the lower end of the canal it bends
forwards through the saphenous opening, and, as it increases in size, ascends over the
iliac part of the fascia lata and the femoral arch. Within the canal the hernia is very
small, being constricted by the unyielding structures which form that passage ; but
when it has passed beyond the saphenous opening, it enlarges in the loose fatty layers
of the groin ; and, as the tumour increases, it extends outwards in the groin towards
the anterior superior iliac spine.
Coverings of the hernia. The coverings of a femoral hernia in order from
within outwards are, the peritoneum (which forms the sac), the septum femorale
and the sheath of the femoral vessels. ' These two structures combined constitute a
single covering, known as the fascia propria of the hernia (Cooper). It sometimes
happens that the hernia is protruded through an opening in the sheath, which there-
fore in that event does not contribute to form the fascia propria. Lastly, the hernia
is covered by the cribriform fascia stretching across the saphenous opening, the
superficial fascia, and the skin.
62 THE PERINEUM OF THE MALE.
THE PERINEUM OF THE MALE.
The perineum is the region which is included within the outlet of the pelvis, and
which is traversed by the lower end of the rectum and by the urethra. It extends,
therefore, from the apex of the subpubic arch in front to the tip of the coccyx
behind, and from the ischial tuberosity of one side to that of the other. It is
bounded on each side, at the fore part, by the conjoined rami of the pubis
and ischium, and at the back part by the great sacro-sciatic ligament, together
with a portion of the lower border of the gluteus maximus muscle. Its form is
rather heart-shaped in consequence of the projection of the coccyx posteriorly ; it
measures about three and a half inches (9 cm.) from side to side, and about four
inches (10 cm.) over the curved surface (three and a quarter inches in a straight
line) from before back in the middle line. The perineal space is separated from
the pelvic cavity above by the recto-vesical fascia and the levatores ani muscles ;
its depth is considerable (from two to three inches) at the posterior and outer
part, much less (not exceeding an inch) at the fore part.
The perineal space is conveniently divided into two parts by a line drawn across
from one ischial tuberosity to the other, and passing immediately in front of
the anus. The anterior division is termed the urethral part, and is often referred
to as the true perineum ; the posterior division is called the anal part, or the false
The several muscles and fasciae, vessels and nerves, which enter into the
formation of the perineum have been fully described in the second and third volumes
of this work, and it now only remains to give a short sketch of its superficial
and topographical anatomy, with which may be included also the relations of
the adjoining parts of the pelvic viscera.
Superficial anatomy. The osseous portions of the boundaries of the
perineum can be felt more or less distinctly through the skin, but the anterior
portion of the subpubic arch is obscured by the presence of the penis, and the ischial
tuberosities are at some distance from the surface, being covered by a thick layer of
fat and, in the erect position, also by the great gluteal muscles. The sacro-sciatic
ligament is scarcely to be distinguished beneath the gluteus maximus, except in
very thin subjects. The lower part of the coccyx is very plainly felt. The anus is
placed directly between the ischial tuberosities, its centre being about one inch and
a half from the extremity of the coccyx.
The skin of the perineum is thin and provided with more or less abundant
hairs ; it is gathered into puckered folds round the anus, to which a farther
irregularity is often given by swollen haemorrhoidal veins. In front of the anus is a
median ridge, the raphe, which runs forwards and is continued on to the scrotum
and penis. Beneath this, the bulb of the urethra forms a slight median elevation,
more perceptible in emaciated subjects. In such subjects, again, the fat in the
ischio-rectal fossa does not reach the level of the ischial tuberosities so as to form a
rounded surface sinking in towards the anus, as is the case in those who are well
nourished. A fine white line round the anus indicates the point of junction of the
skin and mucous membrane, and corresponds precisely to the division between the
external and internal sphincters (Hilton).
One inch (2'5 cm.) in front of the anus is situated the central point of the
perineum, which corresponds to the centre of the free border of the triangular
ligament. Immediately in front of this, the bulb of the urethra commences, but
the membranous part perforates the triangular ligament about half an inch farther
forwards, and therefore one inch and a half (4 cm.) in front of the anus.
Topographical anatomy. The superficial fascia of the perineum consists of
THE ISCHIO-KECTAL FOSSA.
two layers, the more superficial of which is the ordinary subcutaneous fascia, and
contains fat, especially in the posterior portion of the space, where it is very
abundant and fills the ischio-rectal fossa. The deep layer or fascia of Colles is
membranous, and is confined to the anterior part of the space ; it is attached on
each side to the rami of the ischium and pubis, and posteriorly to the base of the
triangular ligament ; it thus forms a somewhat triangular pouch in the fore part of
the perineum, which may modify the course of an extravasation of urine or a
collection of pus in this situation. The pouch is, moreover, subdivided posteriorly
by a median septum, which extends from the back of the perineum to the scrotum.
The hinder part of the perineum is occupied in the centre by the lower end of
the rectum, and between this and
the ischial tuberosity on each
side is a considerable hollow
known as the ischio-rectal fossa.
FIG. 29. DISSECTION OF THE PERINEUM
IN THE MALE. (Allen Thomson. ) ^
The right side shows a superficial, the
left a deeper view.
a, anus, with a part of the integu-
ment surrounding it ; b, left half of the
bulb of the corpus spongiosum, exposed
by the removal of the bulbo-cavernosus
muscle ; c, coccyx ; d, right ischial tube-
rosity ; e, e, superficial perineal fascia ;
/, fat occupying the right ischio-recta!
fossa ; g, gluteus maximus muscle ; 1,
on the right transversus perinei muscle,
points to the superficial per ineal' artery
as it emerges in front (in this case) of
the muscle ; 1', on the left side, on the
. surface of the triangular ligament, points
to the superficial perinea] artery cut
short ; 2, on the right ischio-cavernosus
muscle, points to the superficial perineal
artery and nerves passing forwards ; 2',
on the left side, the same vessel and
nerves divided ; 3, on the right half of
the triangular ligament, points to the
transverse perineal artery ; 4, on the left
ischial tuberosity, points to the pudic
artery deep in the iscbio-rectal fossa ;
5. 5', inferior haemorrhoidal branches of
the pudic arteries and nerves ; 6, on the
left side, placed in a recess from which
the inferior layer of the triangular liga-
ment has been removed, in order to show
the continuation of the pudic artery, its
branch to the bulb, and Cowper's gland.
The ischio-rectaltfossa is a hollow of an irregularly pyramidal shape. Its
base is turned downwards, and measures about two inches (5 cm.) from before
back, and one inch (2'5 cm.) from side to side. Its outer wall is nearly perpen-
dicular, and is formed by the obturator internus muscle covered by its fascia below
the level at which the rectovesical fascia is attached to it. The inner wall is
oblique in direction and convex towards the fossa ; it is formed by the levator ani
muscle, covered by the thin anal fascia, and at the lower part by the external
sphincter. Anteriorly, the fossa is limited by the base of the triangular ligament,
and posteriorly by the gluteus maximus muscle and the great sacro-sciatic ligament.
Its depth is about two inches (5 cm.) from the margin of the tuberosity at the hinder
part, where it extends upwards to the ischial spine, the small sacro-sciatic ligament
nnd the coccygeus muscle.
64 THE PERINEUM OF THE MALE.
The pudic vessels and the dorsal and perineal divisions of the pudic nerve run
forwards along the outer wall of the fossa, being embedded in the obturator fascia
about an inch and a half (3'5 cm.) above the lower margin of the ischial tuberosity ; the
inferior hsemorrhoidal branches of these trunks run obliquely inwards and forwards
from the hinder part of the fossa towards the anus ; and anteriorly the superficial
perineal vessels and the perineal nerve leave the shelter of the hip-bone and also
enter the fat of the fossa.
The ischio-rectal fossa is often the seat of abscesses which burrow freely in the
loose fat of the part, and frequently result in the formation of a fistula in ano,
involving a communication with the bowel, sometimes above, but more frequently
below, the external sphincter.
The lower dilated part of the rectum, which occupies the space between the two
ischio-rectal fossae, is supported by the levatores ani and the external sphincter
muscles, as well as by the recto-vesical fascia. Its lateral wall is exposed for
a distance of about three inches (7'5 cm.), its posterior wall for little more than an
inch (3 cm.).
On removing the fasciae of the fore part of the perineum the bulbo-cavernosus
muscle is exposed covering the corpus spongiosum, the ischio-cavernosus covering the
cms penis on each side, and the transversus perinei directed inwards over the base
of the triangular ligament to meet the first-named muscle, as well as the external
sphincter and its fellow of the opposite side, in the central point of the perineum.
Between the bulbo-cavernosus, ischio-cavernosus, and transversus muscles is a small
triangular space, in which a portion of the triangular ligament is exposed, and over
the surface of the muscles (sometimes in part beneath or through the transversus)
the superficial perineal vessels and nerves run forwards to the scrotum, while the
small transverse perineal artery is directed inwards close to the transverse muscle
towards the central point of the perineum.
The triangular ligament or deep perineal fascia, which occupies the subpubic
arch, has a depth of an inch and a half in the middle line, but extends somewhat
farther backwards on each side, at its attachment to the ischial ramus. It consists
of two layers, the upper of which is continuous with the recto-vesical fascia. The
membranous part of the urethra descends, first through the superior, and then
through the inferior layer, about an inch from the pubic symphysis, and it is
surrounded by the fibres of the constrictor urethras muscle, which occupies the
greater part of the space between the two layers. Near the urethra, also embedded
in the muscular fibres, is Cowper's gland. The pudic vessels and the dorsal nerve
of the penis enter the base of the triangular ligament and run forwards close to the
bone, in small canals formed in the origin of the constrictor muscle, and the artery
gives off here its considerable branch to the bulb, which is directed inwards about
half an inch (1 cm.) from the base of the triangular ligament, and an inch and a
half (3'5 cm.) in front of the anus.
Resting on the upper surface of the triangular ligament is the apex of the
prostate, and this body is surrounded by its sheath, which is continuous on each
side with the upper layer of the ligament ; beneath the sheath is the large prostatic
plexus of veins, derived mainly from the breaking up of the dorsal vein of the penis,
which passes into the pelvis between the pubic symphysis and the triangular liga-
ment. In the recess between the lateral part of the upper surface of the triangular
ligament and the sheath of the prostate, the anterior part of the levator ani muscle
Above the prostate, and at a depth generally of from two and a half to three
inches (6 7 cm.) from the surface, is the bladder, the base of which projects back-
wards into the concavity formed by the rectum and overlaps the second part of
RECTAL EXAMINATION. 65
the bowel to a variable extent, according to the degree of distension of the bladder.
Between the bladder and rectum are the vesiculse seminales and the terminal por-
tions of the vasa deferentia. When the bladder is full, the recto- vesical pouch of
the peritoneum does not usually reach below a line an inch and a half from the base
of the prostate.
In contact with the upper surface of the levator ani is the recto-vesical fascia,
forming the deep boundary of the perineal space. It extends from the side wall of
the pelvis downwards and inwards to the side of the rectum, to the bladder and
prostate. Its line of attachment to the bladder on each side runs upwards and
backwards immediately above the prostate, and external to the position of the
vesiculse seminales ; and it is essential, in the operation of lateral lithotomy, that
the bladder be opened entirely below this level. If the incision be carried through
the fascia beyond this line, then the pelvic cavity will be opened, and extravasation
of urine into the loose areolar tissue will probably follow.
EXAMINATION OF THE PELVIC VISCERA.
Rectal examination in the male. On passing the finger into the rectum
in the adult male, the constriction (anal canal) caused by the internal and external
sphincters is first encountered, the internal sphincter extending one inch above the
anal orifice. The soft mucous membrane of the bowel is then felt more or less
doubled into transverse folds (folds of Houston, plicce, transversaks recti) : these
are usually three in number, the largest being found on the front and right side of
the bowel about three inches from the anus, and on a level with the extremity of the
recto-vesical pouch of peritoneum, while another is placed on the left side about one
inch higher ; and the third, which is less constant, is on the left side, posteriorly,
below the first. These folds are visible when the rectum is examined with the aid
of a speculum, the body being placed in the genu-pectoral position. They some-
times render the introduction of the finger or an instrument beyond a certain point
difficult or impossible. The columns of Morgagni (column rectales] and the small
folds of mucous membrane (valves of Morgagni) directed upwards which join them,
with the enclosed recesses (sinus rectales], are not to be felt, but are easily seen with
a speculum. The mucous membrane of the anal canal is thicker and drier than the
velvety lining membrane of the bowel higher up. It often presents small polypoid
projections from its surface.
Through the wall of the bowel numerous objects may be felt : In front is the
base of the triangular ligament, a little distance above which is the apex of the
prostate. The outline of the prostate is readily made out, and above it the bladder
may be felt if distended. The vesiculae seminales are not to be recognized unless
enlarged, and even then only their lower parts by a finger of average length.
Behind, after passing over the soft posterior part of the perineum (ano-coccygeal
body), the tip of the coccyx is reached and the finger explores the hollow of the
sacrum. From this there passes out on each side a resistent band consisting of the
small sacro-sciatic ligament and the coccygeus muscle, which lead to the ischial
On each side, the ischial tuberosity and the wall of the true pelvis are felt, and
in this way the condition of the structures at the back of the acetabulum, in the
neighbourhood of the caecum, or of the large vessels may be determined.
This examination of the pelvis is easier in the infant, and is aided by bimanual
examination, one hand being placed on the lower part of the abdomen. In the
infant the parts felt are the same, except that the prostate is scarcely
Rectal examination in the female. In the female the anus is placed
66 EXAMINATION OF THE PELVIC VISCERA.
slightly farther forwards than in the male, and is not so deeply sunk between the
nates ; the surrounding skin is usually destitute of hairs. Behind the rectum the
parts to be felt are the same as in the other sex. In front, above the perineal body,
the first part met with is the soft recto-vaginal septum ; then the cervix and os
uteri, and higher up the lower part of the body of the uterus. Any abnormality in
the position of the organ or in the state of the pouch of Douglas can also be
determined. At each side, besides the structures met with in the male, the
resistance caused by the base of the broad ligament may be detected, the ovaries
may be felt on bimanual examination, and the outline of the uterus more accurately
Vaginal examination. In a digital examination of the vagina, the passage
is found to be small, and more or less obstructed by the hymen in the virgin, and
the mucous membrane is rugose. In a woman who has borne children the parts are
more capacious, there is no hymen, and the rugae are no longer felt. The outline
of the subpubic arch may be traced in front, and the region of the bladder explored ;
behind is the soft recto-vaginal septum ; and on each side the pelvic wall may be
examined, and the ovaries can easily be felt on bimanual examination. At the
upper end of the vagina, and projecting from the anterior wall, is the cervix uteri,
in which the os is to be felt as a transverse slit.
INDEX TO APPENDIX.
ABDOMEN, superficial anatomy of, 22
Abdominal aorta, 27, 34
viscera of, 23
ring, external, 24, 51, 55, 56
internal, 24, 51, 53
viscera, 23, 24
wall, 23, 56
Abductor. See MUSCLES.
Acetabulum, 43, 65
Acromial angle, 28
Acromio-clavicular articulation, 32
Acromion, 28, 32, 35
Adductor. See MUSCLES.
tubercle, 45, 46
Aditus ad antrurn, 10
Alveolar processes, 15
Alveolo-lingual sulcus, 15
Anal canal, 65
part of perineum, 62
Anastomotic artery of thigh, 46
Anatomy, superficial. See SUPERFICIAL ANA-
topographical. See TOPOGRAPHICAL ANA-
Anconeus muscle, 37, 38
Angle, acromial, 28
of jaw, 14, 32
of scapula, 28, 32, 33
Angular process, external, I
Ankle, superficial anatomy of, 48
Annular ligament, anterior, 49
Annulus femoralis, 60
Ano-coccygeal body, 65
Antrum, mastoid, 10, n, 13
Anus, 60, 65
Aorta, abdominal, 27, 34
arch of, 22, 29, 33
ascending, 22, 33
descending, 29, 33
Aortic cartilage, 22
orifice, 22, 33
Aperture of larynx, upper, 17, 32
Aperture, nasal, anterior, 13
Apex of bladder, 53
of heart, 2 1
of lung, 20, 28, 32
of prostate, 64, 65
Aponeurosis of external oblique muscle, 51, 56
Appendix, vermiform, 23
Arch of aorta, 22, 29, 33
azygos vein, 33
femoral, deep, 58, 60
superficial, 57, 60
palmar, deep, 41
of subclavian artery, 32
subpubic, 62, 66
of thoracic duct, 32
Arm, superficial anatomy of, 35
ARTERY or ARTERIES, aberrant obturator, 60
anastomotic of thigh, 46
articular of knee, 46
brachial, 36, 37, 39
of bulb, 64
carotid, common, 17, 22, 32
cervical, transverse, 18
circumflex, posterior, 35
coronary, of facial, 14
digital of hand. 41
dorsal of foot, 49
epigastric, 24, 51, 53, 54, 55, 60
facial, 14, 17
femoral, 43, 45, 57, 60
hypogastric, 51, 56
iliac, common, 27, 34
external, 27, 51, 57, 58
innominate, 17, 22, 32, 33
lateral costal, 22
mammary, internal, 22
meningeal, middle, 5
mesenteric, superior, 27, 34
inferior, 27, 34
occipital, 3, 10, 17
perineal superficial, 64
plantar, 48, 49
popliteal, 46, 47
prof'unda of thigh, 45
pubic, of epigastric, 60
radial, 38, 39
renal, 27, 29, 34
of scalp, 3
spermatic, 54, 56, 60
subclavian, 18. 22, 32
superficial volar, 41
INDEX TO APPENDIX.
ARTERY or ARTERIES continued.
temporal, superficial, 3
of thoracic wall, 22
thyroid, inferior, 17
tibial, 47, 48, 49
transverse facial, 14
ulnar, 38, 39
Articular arteries of knee, 46
ARTICULATION or ARTICULATIONS, acromio-
of ankle, 48
chondro -sternal, 20, 21, 22, 24, 25, 33
of elbow, 37
of hip, 43
of knee, 45
metacarpo-phalangeal, 40, 41
sacro- iliac, 42
of shoulder, 35
sterno-clavicular, 18, 22
tarsal, transverse, 48
xiphisternal, 19, 24, 25, 33
Atlas, 1 6, 31
Attic of tympanum, 10
Auditory meatus, external, II, 12
Auricles of heart, 33
Auricular nerve, great, 18
Auriculo-ventricular openings, 22, 33
Axilla, folds of, 19, 35
Axillary artery, 35
Axis, 16, 27, 31
cceliac, 27, 29, 34
Azygos vein, 33
BACK, superficial anatomy of, 27
Basal ganglia, 9
Base of bladder, 64
of jaw, 14
line of Reid, 7
Basilar process, 16
Basilic vein, 36, 37
Bend of elbow, 37
Biceps. See MUSCLES.
Bicipital fascia, 37, 38
Bifurcation of aorta, 27, 29, 34
brachial artery, 39
common carotid artery, 32
common iliac artery, 34
innominate artery, 32
popliteal artery, 47
posterior tibial artery, 48
Bi-iliac line, 22
plane, 23, 34
Bladder, 23, 25, 53, 64, 65, 66
Blood-vessels. See ARTERIES, VEINS,
Body, ano-coccygeal, 65
turbinate, 13, 16
Brachial artery, 36, 37, 39
plexus, 1 8
Brachialis anticus muscle, 36
Broad ligament of uterus, 66
Bronchi, 28, 33
Bulb, artery of, 64
of urethra, 62
Bulbo-cavernosus muscle, 64
Bursa, over olecranon, 37
over tubercle of tibia, 46
CAECUM, 23, 25, 65
Canal, anal, 65
of facial nerve, 1 2
femoral, 51, 60, 61
inguinal, 24, 51, 54, 55, 56
of Nuck, 55
palatine, posterior, 16
semicircular, external, 12
Canaliculi, lachrymal, 15
Cardiac dulness, deep, 22
orifice of stomach, 23, 25, 28, 33
Carotid artery. See ARTERIES.
Cartilage, aortic, 22
costal, 19, 20, 21, 22, 24, 25, 26, 33, 34
cricoid, 16, 17, 32
of nose, 13
of septum nasi, 13
thyroid, 16, 32
Caruncula lacrim'alis, 15
Central point of perineum, 62, 64
Cephalic vein, 36, 37
Cerebral, convolutions, relations of, to cranium, 6
fissures, relations of, to cranium, 6
determination of, 7
Cervical enlargement of spinal cord, 31
vertebrae, 16, 27
Cervix uteri, 66
Chest, superficial anatomy of, 19
Chondro-sternal articulations, 20, 21, 22, 24, 25,
Circumflex artery and nerve, 35
Clavicle, 17, 18, 32, 35
Clavicular head of sterno-mastoid muscle, 17
Coccygeus muscle, 63, 65
Coccyx, 62, 65
Coeliac axis, 27, 29, 34
Colles, fascia of, 63
Colon, 23, 25, 31
Columnse rectales, 65
Columns of Morgagni, 65
Compartments, of femoral sheath, 60
Condyles of femur, 45, 46
humerus, 35, 36, 37
Congenital hernia, 54, 55
Conjoined tendon, 51, 56) 60
Constrictor urethra muscle, 64
INDEX TO APPENDIX.
Convolutions, cerebral, relations of, to cranium, 6
Cooper, ligament of, 59
Coraco-brachialis muscle, 35
Coracoid process, 35
Cord, spermatic, 43, 51, 54, 56
coverings of, 51, 54
spinal, 31, 34
Cornua of falciform border, 60
of hyoid bone, 17
of lateral ventricle, 9
Coronary branch of facial artery, 1 4
Corpus spongiosum, 64
Costal artery, lateral, 22
cartilages, 19, 20, 21, 22, 24, 25, 26, 33,
Coverings of spermatic cord, 51, 54
direct inguinal hernia, 56
femoral hernia, 61
oblique inguinal hernia, 54
Cowper's gland, 64
Cranio-cerebral topography, 5
relations of cerebrum to, 6
Cremaster muscle, 51, 55, 56
Cremasteric fascia, 51
Crest, external occipital, i
iliac, 22, 23, 28, 30, 34, 42
temporal, i, 7, 9
supramastoid, n, 12, 13
Cribriform fascia, 60, 61
Cricoid cartilage, 16, 17, 32
Crico-thyroid artery, 1 7
space, 1 6, 17
Crural branch of genito-crural nerve, 58
nerve, anterior, 45, 59
Crus penis, 64
Cuneiform bones. 48
Curved line, superior, i
DELTOID muscle, 35
Digastric muscle, 16
Digital arteries of hand, 41
Direct inguinal hernia, 54, 55
Dorsal artery of foot, 49
nerve of penis, 64
vein of penis, 64
Dorso-lumbar furrow, 27
Douglas, pouch of, 66
Duct, nasal, 15
ofStensen, 14, 15
of Wharton, 15
thoracic, arch of, 32
Dulness, cardiac, deep, 22
Duodeno-jejunal flexure, 23, 25, 34
Duodenum, 23, 27, 31, 34
ELBOW, superficial anatomy of, 37
Eminence, frontal, i
parietal, I, 6, 7
Endocranial blood-vessels, 3
Ensiform process, 19, 33
Epigastric artery, 24, 51, 53, 54, 55, 60
vein, superficial, 24
Epiglottis, 1 6, 17, 32
Epiphysis, lower, of femur, 46
Epitympanic recess, 10
Erector spinse muscles, 27, 28
External inguinal hernia, 54
Extensor. See MUSCLES.
Eustachian tube, 16
FACE, superficial anatomy of, I, 13
Facial arteiy, 14, 17
canal of, 12
Falciform border, 60
False perineum, 62
Falx inguinalis, 56
Fascia, anal, 63
bicipital, 37, 38
of Colles, 63
cribriform, 60, 61
iliac, 58, 59, 60
lata, 45, 59
obturator, 63, 64
pectineal, 58, 59, 60
of perineum, deep, 63, 64
recto-vesical, 62, 64, 65
spermatic, 51, 56
transversalis, 51, 56, 58, 60
pillars of, 16
Femoral arch, deep, 58, 60
superficial, 57, 60
artery, 43, 45. ,57, 60
canal, 5i> 6o> 61
hernia, 43, 51, 57, 61
ring, 54, 58, 60
sheath, 57, 58, 60, 61
vein, 45, 57, 60
Femur, 45, 46
Fibula, 46, 47
Fingers, flexures of, 41
Fissure or Fissures, cerebral, situation of, 6
intraparietal, 7, 9
of lung, 20
parallel, 7, 9
of Rolando, 6, 7, 8
of Sylvius, 6, 8
Flexor. 'See MUSCLES.
INDEX TO APPENDIX.
Flexure, duodeno-jejanal, 23, 25, 34
hepatic, 23, 25, 34
splenic, 23, 25, 34
Flexures of palm, 40
Floor of mouth, 15
Fold or Folds, of axilla, 19, 35
of Houston, 65
of nates, 42
salpingo-palatine, 1 6
Fontanelles, I, 2
Foot, superficial anatomy of, 48
Foramen, infraorbital, 14
of Winslow, 34
Forearm, superficial anatomy of, 38
Fossa or Fossa?, epigastric, 19
infraclavicular, 19, 35
ischio-rectal, 62, 63
middle of skull, n, 13
nasal, 13, 16
peritoneal, 51, 54, 60
posterior, of skull, 13
of Rosenmuller, 16
Fovea supravesicalis, 53, 56
femoralis, 54, 60
inguinalis lateralis, 53
mesialis, 53, 56
Fraiium lingua?, 15
of lips, 15
Frontal artery, 3
eminence, I, 7
lobe of cerebrum, 7
margin of cerebrum, 5
sulci, 7, 9
Fron to-malar suture, I, 7
Fundus of stomach, 25, 33
Furrow, abdominal, 24
inguinal, 22, 43
nuchal, i, 27
GALL-BLADDER, 23, 24
Ganglia, basal, 9
Gastrocnemius muscle, 47
Geuito-crural nerve, 58
Genu, inferior, of Rolandic fissure, 9
Gimbernat's ligament, 51, 57, 58, 59, 60, 61
Gland or Glands, of Cowper, 64
inguinal, 24, 43
Gland or Glands continued.
Glenoid cavity, 33, 35
Gluteal artery, 43
Gluteus. See MUSCLES.
Gracilis muscle, 46
Groin, 23, 51, 57
Groove, sternal, 19
Hamstring muscles, 45, 46
Hamular process, 16
Hand, superficial anatomy of, 39
Hard palate, 16
Head of astragalus, 48
clavicular, of sterno-mastoid, 17
of femur, 45
fibula, 46, 47
gastrocnemius muscle, 47
metatarsal bones, 48, 49
radius, 37, 38
sternal of sterno-mastoid, 17
superficial anatomy of, i
of triceps muscle, 37
of ulna, 38
Heart, 21, 23, 33
Hemisphere, cerebral, 5
Henle, ligament of, 56
Hepatic flexure, 23, 25, 34
femoral, 43, 51, 57, 61
inguinal, 51, 54
congenital, 54, 55
direct, 54, 55, 56
internal, 54, 55, 56
sac of, 54, 6 1
Hesselbach, ligament of, 56
triangle of, 55, 56
Key's ligament, 61
Hip, superficial anatomy of, 42
Hook of unciform bone, 39
Houston, folds of, 65
Hyoid bone, 16, 32
Hyo-mental region, 16
Hyo-sternal region, 16
Hypochondriac region, 23
Hypogastric artery, 51, 56
Hypoglossal nerve, 17
Hypothenar eminence, 39
ILEUM, 23, 25
Iliac artery. Sec ARTERIES.
crest, 22, 23, 28, 30, 34, 42
fascia, 58, 59, 60
part of fascia lata, 60
INDEX TO APPENDIX.
Iliac region, 23
spine, anterior superior, 23, 34, 42, 43, 51,
posterior inferior, 43
superior, 27, 42, 43
vein, external, 54, 57, 58, 60
Ilio-pectineal intermuscular septum, 59
Ilio-psoas muscle, 57, 59
Ilio-tibial band, 45, 46
Infantile hernia, 54
Infraclavicular fossa, 19, 35
Infracostal fossa, 24
plane, 23, 34
Infrahyoid region, 1 6
Infraorbital foramen, 14
Infrapatellar fat, 46
Infraspinatus muscle, 35
Infrasternal depression, 19
Infundibuliform fascia, 51
Infundibulum of frontal sinus, 3
of heart, 33
Inguinal canal, 24, 51, 54, 55, 56
furrow, 22, 43
glands, 24, 43
hernia, 51, 54
congenital, 54, 55
direct, 54, 55
internal, 54, 55
Innominate artery, 17, 22, 32, 33
vein, 22, 33
Intercolumnar fascia, 51
Intercostal spaces, 19, 21, 22, 28
Intermetatarsal spaces, 49
Intermuscular septum of arm, external, 35, 37
of thigh, external, 45
Internal inguinal hernia. See HERNIA.
Interosseous nerve, posterior, 37
Interphalangeal articulations, 41
Intraparietal fissure, 7, 9
Ischial ramus, 43, 62, 63
spine, 63, 65
tuberosity, 43, 62, 65
Ischio-cavernosus muscle, 64
Ischio-rectal fossa, 62, 63
Island of Reil, 9
Isthmus, thyroid, 17
JAW, lower, 14, 15, 32
Jejunum, 23, 25
Joint. See ARTICULATIONS.
Jugular veins. See VEINS.
KIDNEY, 23, 26, 30, 31, 34
Knee, superficial anatomy of, 45
LABIUM pudendi, 54
Lachrymal sac, 1 5
Lacuna musculoruni, 58
Lambda, i, 6, 7
Lambdoid suture, I
Larynx, 17, 28, 32
aperture of, 17
Lateral abdominal region, 23
Lateral sinus, 4, 10, 12
Latissimus dorsi muscle, 19, 35
Levator. See MUSCLES.
Leg, superficial anatomy of, 47
Levels of structures of trunk, 32
Ligament, annular, anterior, of ankle, 49
broad, of uterus, 66
of Cooper, 59
of Gimbernat, 51, 57, 58, 59, 60, 6l
of Henle, 56
of Hesselbach, 56
of Hey, 6 1
lateral, external, of knee, 46
of Poupart, 22, 24, 43, 51, 55, 57, 58, 59,
60, 6 1
round, of uterus, 54, 55
sacro-sciatic, 62, 63, 65
tarsal, internal, 15
transverse, superficial, of hand, 41
triangular, 62, 63, 64, 65
Ligamentum inguinale. 57
Limb, lower, superficial anatomy of, 42
upper, superficial anatomy of, 35
Line or lines, base, of Eeid, 7
of Nelaton, 43
of palm, 40
of parallel fissure, 7, 9
Linea semilunaris, 23, 24
Lingual artery, 17
Liver, 23, 24, 33, 34
Longitudinal sinus, superior, 3, 5
Lumbar enlargement of spinal cord, 31
Lung, 18, 20, 28, 32, 34
root of, 33
MALLEOLUS, external, 47, 48
internal, 47, 48
Mammary artery, internal, 22
Manubrium, 19, 20, 22, 32, 33
Marginal tubercle, 7
Masseter muscle, 14, 15
Mastoid antrum, 10
cells, II, 12, 13
Masto-squamosal suture, 12
Meatus, external auditory, i j , 12
middle, of nose, 13
Median nerve, 36, 38
vein, 37, 38
Median-basilic vein, 37
Median-cephalic vein, 37
Meibomian glands. 15
INDEX TO APPENDIX.
Membranous urethra, 62, 64
Meningeal artery, middle, 5
Mental foramen, 14
Mesenteric artery. Sec ARTERY.
Mesentery, 23, 25
Metacarpal bones, 39
Metacarpo-phalangeal articulations, 40, 41
Metatarsal bones, 48, 49
Metatarso-phalangeal articulations, 49
Mid-Poupart line, 23
Morgagni, columns of, 65
valves of, 65
Mouth, 15, 32
MUSCLE or MUSCLES, abductor hallucis, 49
minimi digiti, 49
adductor longus, 45
magnus, 45, 46
of thigh, 43, 45, 46
transversus pollicis, 39
anconeus, 37, 38
biceps brachii, 35. 36, 37
femoris, 45, 46, 47
brachialis anticus, 36
coccygeus, 63, 65
constrictor urethras, 64
cremaster, 51, 55, 56
erector spinte, 27, 28
extensor brevis digitorum, 49
pollicis, 38, 39
carpi radialis, 36, 37, 38
communis digitorum, 39
of fingers, 38, 39
of forearm, 37
longus digitorum, 47, 49
pollicis, 38, 39
minimi digiti, 38, 39
ossis metacarpi pollicis, 38, 39
proprius hallucis, 47, 49
of thumb. 38, 39
flexor brevis hallucis, 49
minimi digiti, 49
carpi radialis, 38
longus digitorum, 47
profundus digitorum, 38
gluteus maximus, 42, 43, 62, 63
medius, 42, 43
hamstring, 45, 46
ilio-psoas, 57, 59
latissimus dorsi, 19, 35
levator anguli scapulae, 28
ani, 62, 63, 64, 65
of little finger, short, 39
masseter, 14, 15
obliquus abdominis, externus, 19, 24, 51,
internus, 51, 56
obturator internus, 63
omo-hyoid, 17, 1 8
palmaris longus, 38
' MUSCLE or MUSCLES continued.
pectineus, 57, 59, 60
pectoralis major, 19, 35
peronei, 46, 47, 49
quadriceps extensor, 43
rectus abdominis, 19, 24, 55
sartorius, 43, 46
serratus magnus, 19
sphincter ani, 62, 63, 64, 65
supinator longus, 35, 36, 37, 38, 39
temporal, I, 15
tensor vaginae femoris, 42
of thumb, short, 39
tibialis anticus, 47, 48, 49
posticus, 47, 48
transversalis abdominis. 51, 56
transversus perinei, 64
triceps, 35, 37
vastus, exteruus, 44, 45
Musculo-cutaneous nerve, 49
Musculo-spiral nerve, 37
NARES, posterior, 16
Nasal aperture, anterior, 13
fossa, 13, 1 6
spine, anterior, 13
Nasio-inial line, 7
Naso-frontal suture. 5
Nates, fold of, 42
Navicular bone, 48
Neck, superficial anatomy of, I, 1 6
Nelaton's line, 43
NERVE or NERVES, auricular, great, 18
crural, anterior, 45, 59
cutaneous, external, 59
dorsal of penis, 64
facial, 12, 14
interosseous, posterior, 37
lingual, 1 6
median, 36, 38
occipital, great, 3
saphenous, external, 47, 49
internal, 46, 47
of scalp, 3
sciatic, great, 43, 45
spinal, 31, 32, 33, 34
spinal accessory, 18
superficial cervical, 18
INDEX TO APPENDIX.
NERVE or NERVES continued.
tibial, anterior, 49
ulnar, 36, 39
Nerve-roots, spinal, 31, 32, 33, 34
Nipple, 19, 22, 33
Notch, supraorbital, i, 14
Nuchal iurrow, i, 27
Nuck, canal of, 55
Oblique inguinal hernia, 54
Obliquus abdomiuis. See MUSCLES.
Obturator artery, aberrant, 60
fascia, 63, 64
internus muscle, 63
Occipital artery, 3, 10, 17 '
crest, external, i
nerve, great, 3
protuberance, external, I
Occipito-temporal margin of cerebrum, 5
(Esophagus, 17, 28, 32
Omentum, great, 23, 25
Omo-hyoid muscle, 17, 1 8
Operculum of middle turbinate body, 13
Orifice, aortic, 22, 23
auriculo-ventricular, 22, 33
cardiac, 23, 25, 28, 33
of inferior vena cava, 33
pulmonary, 22, 33
pyloric, 23, 25, 29, 34
Origin of spinal nerve-roots, 31, 32, 33, 34
Os calcis, 47, 48, 49
Os uteri, 66
PALATE, 16, 32
Palatine canal, posterior, 16
Palmar arch, deep, 41
Palmaris longus, 38
Palpebral fissure. 14
sulcus, external, 14
Palpebro-malar sulcus, 14
Pancreas, 23, 27, 31, 34
Papilla lacrimalis, 15
Parallel fissure, 7, 9
Parietal eminence, i, 6, 7
Parieto-occipital fissure, 6
Parotid gland, 14
ligament of, 46
Pectineal compartment, 59
fascia, 58, 59, 60
Pectineus muscle, 57, 59, 60
Pectoral muscles, 19, 35
Pelvic viscera, examination of, 65
Penis, crura of, 64
Perineal artery. See ARTERY.
Perineum, central point of, 62, 64
anatomy of, 62
Peritoneal folds, 51
fossae, 51, 54
Peritoneum, 54, 56, 60, 6 1
Peroneal spine, 48
Peronei muscles, 46, 47, 49
Petro-squamosal fissure, 1 1
Pharyngeal recess, lateral, 16
tonsil, 1 6
Pharynx, 13, 16, 17, 28, 32
Pillars of abdominal ring, 24
of fauces, 16
Pisiform bone, 38, 39
Plantar arteries, 48, 49
Pleura, 18, 20, 28, 34
Plexus, brachial, 18
Plica epigastrica, 53
umbilicalis lateralis, 5 1
Plicae transversales recti, 65
Point, preauricular, 7
Rolandic, inferior, 8
Sylvian, 8, 9
Pomum Adami, 16
Popliteal artery, 46, 47
Postcentral sulci, 9
Pouch of Douglas, 66
Poupart's ligament, 22, 24, 43, 51, 55, 57, 58,
59, 60, 6 1
Preauricular point, 7
Precentral sulci, 7, 9
Process, alveolar, 15
ensiform, 19, 33
external angular, I
styloid of third metacarpal, 39
radius, 38, 39
transverse, of atlas, 17
of sixth cervical vertebra, 1 7
Processus vagiualis, 54
Profunda artery. See ARTERY.
Promontory of sacrum, 24
Prostate, 64, 65
sheath of, 64
Prostatic plexus, 64
Pterygo-maxillary ligament, 16
Pubic branch of epigastric artery, 60
portion ot fascia lata, 59
rami, 43, 59, 63
INDEX TO APPENDIX.
Pubic spine, 24, 43, 51, 57, 60
Pudic artery, 64
Pulley of superior oblique muscle, 14
Pulmonary artery, 33
orifice, 22, 33
Punctum lacrimale, 15
Pyloric orifice, 23, 25, 29, 34
Pyramidal bone, 39
QUADRICEPS extensor muscle, 43
RADIAL artery, 38, 39
Radio-carpal articulation, 41
Radius, 37, 38
Ranine vein, 15, 17
Raphe of perineum, 62
Receptaculum chyli, 34
Rectal examination, 65
Recto-vaginal septum, 66
Recto- vesical fascia, 62, 64. 65
Rectum, 23, 64, 65
Rectus muscle. See MUSCLES.
REGION or REGIONS, abdominal, 22
viscera of, 23
lateral abdominal, 23
of neck. 1 6
Reid, base-line of, 7
Reil, island of, 9
Renal artery, 27, 29, 34
Ribs, 19, 20, 25, 28, 30, 32, 33, 34, 35
Rima glottidis, 17, 32
Ring, abdominal, external, 51, 55, 56
internal, 51, 53
femoral, 54, 58, 60
Rolandic angle, 9
point, inferior, 8
Rolando, fissure of, 6, 7, 8
Root of lung, 33
Roots of spinal nerves, 31, 32, 33, 34
Rosenmiiller, fossa of, 16
Round ligament of uterus, 54, 55
SAC of hernia, 54, 61
Sacro-iliac articulation, 42
Sacro-sciatic foramen, 43
ligament, 62, 63, 65
promontory of, 24
Sagittal suture, I
Salpingo-palatine fold, 16
Salpingo-pharyngeal fold, 16
Saphenous nerves. See NERVES.
opening, 43, 57, 60, 6 1
veins. Sec VEINS.
Sartorius muscle, 43, 46
Scalp, vessels and nerves of, 3
Scaphoid bone, 39
| Scapula, 28, 32, 33
Scarpa's triangle, 43
Sciatic, artery, 43.
nerve, great, 43, 45
Scrobiculus cordis, 19
Semicircular canal, external, 12
Semimembranosus muscle, 46
Semitendinosus muscle, 46
Septum, femoral, 60, 61
intermuscular of arm, external, 35, 37
of thigh, external, 45
nasi, 13, 16
recto- vagina], 66
Serratus magnus muscle, 19
Sesamoid bones of foot, 48
of thumb, 39
Sheath, crural or femoral, 57, 58, 60, 61
of prostate, 64
Shoulder, superficial anatomy of, 35
Sigmoid colon, 23, 25
Sinus, frontal, 2
lateral, 4, 10, 12
superior longitudinal, 3, 5
Soft palate, 16, 32
Soleus muscle, 47
Space, crico-thyroid, 1 6
intercostal, 19, 21, 22, 28
Spermatic artery, 54, 56, 60
cord, 43, 51. 54, 56
fascia, 51, 56, 60
Sphincter muscles of anus, 62, 63, 64, 65
Spinal accessory nerve, 18
cord, 31, 34
nerve-roots, 31, 32, 33
Spine, iliac, posterior inferior, 43
superior, 27, 42, 43
anterior superior, 24, 34, 42, 43, 51,
of ischium, 63, 65
nasal, anterior, 13
pubic, 24, 43, 51, 57, 60
of scapula, 28, 33
Spines, vertebral, 20, 27, 28, 29, 30, 31, 42
Spleen, 23, 29, 33, 34
INDEX TO APPENDIX.
Splenic flexure, 23, 25, 34
Stensen's duct, 14, 15
Sternal angle, 19
furrow or groove, 19
head of sterno-ruastoid, 1 7
Sterno-clavicular joint, 18, 22
Sterno-mastoid muscle, 17
Sternum, 19, 32, 33
Stomach, 23/25, 29, 33
Styloid process of radius, 38, 39
of third metacarpal bone, 39
of ulna, 38
Subclavian artery, i8,*22, 32
vein, i 8
Subcostal angle, 19
Sublingual gland, 15
Submaxillary gland, 16
Subpubic arch, 62, 66
Sulcus, alveolo-lingual, 15
palpebral, external, 14
Superciliary ridge, I, 3
Superficial anatomy of abdomen, 22
of ankle, 48
of arm, 35
of back, 27
of chest, 19
of elbow, 37
of foot, 48
of forearm, 38
of hand, 39
of head and. neck, i, 16
of hip, 42
of knee, 45
of leg, 47
of limb, lower, 42
of perineum, 62
of shoulder, 35
of thigh, 43
of trunk, 19
of wrist, 39
Supinator longus muscle, 35, 36, 37, 38, 39
Supraclavicular fossa, 18
Supracondylar ridges, 35, 37
Snprahyoid region, 16
Supramastoid. crest, n, 12, 13
Suprameatal fossa, 12
triangle, 12, 13
Supraorbital artery, 3
foramen or notch, i. 14
Suprarenal bodies, 23, 34
Suprascapular vein, 18
Supraspinatus muscle, 28
Suprasternal notch, 17
Supratrochlear nerve, 3
Suture, fronto-malar, i, 7
Sustentaculum tali, 48
Sylvian line, 8
point, 8, 9
Sylvius, fissure of, 6, 8
TABLE of levels of structures of trunk, 32
Tail of pancreas, 23
Tarsal articulation, transverse, 48
ligament, internal, 15
Tarso-metatarsal articulations, 48
Tegmen tympani, 1 1
Temporal artery, superficial, 3
convolution, interior, 1 1
crest, i, 7, 9
line, lower, I
lobe of cerebrum, 7, 1 1
muscle, i, 15
Temporo-maxillary joint, 13
Tendinous inscriptions, 24
Tendo Achillis, 47
Tendon, conjoined, 51, 56, 60
Tensor vaginae femoris, 42
Teres muscles, 35
Thigh, superficial cinatorny of, 43
Thenar eminence, 39
Thoracic duct, arch of, 32
Thyro-hyoid space, 16
Thyroid arteries, 17
* body, 17
cartilage, 16, 32
Tibia, 45, 46, 47, 48
Tibial arteries, 47, 48, 49
nerves, 47, 49
Tibiales muscles, 47, 48, 49
Tongue, 15, 32
Tonsil, 1 6, 1 8
Topographical anatomy, cranio-cerebral, 5
of groin, 51
of mastoid antrum, 10
of perineum, 62
Trachea, 16, 28, 32, 33
Transversalis abdominis muscle, 51, 56
fascia, 51, 56, 58, 60
Transverse ligament, superficial, of hand, 41
process of atlas, 1 7
of sixth cervical vertebra, 1 7
tarsal articulation, 48
Transversus perinei muscle, 64
Trapezius muscle, 28
Triangle ot neck, anterior, 17
of Hesselbach, 55, 56
of Scarpa, 43
suprameatal, 12, 13
Triangular fascia, 5 1
ligament, 62, 63, 64, 65
tendon of trapezius, 28
Triceps muscle, 35, 37
Trochanter, great, 42, 43
Trochlear surface of femur, 46
True perineum, 62
Trunk, levels of structures in, 32
superficial anatomy of, 19,
Tubercle, adductor, 45, 46
of radius, 38
of tibia, 46, 48
Tuberosity of femur, 45, 46
of fifth metatarsal, 48, 49
INDEX TO APPENDIX.
Tuberosity of ischium, 43, 62, 65
of navicular bone. 48
of os calcis, 47, 48, 49
of scaphoid, 39
of tibia, 45, 46
Tunica vaginalis, 54
Turbinate bodies, 13, 1 6
bone, inferior, 13, 1 6
Tympanum, attic of, 10
Ulnar artery, 38, 39
nerve, 36, 39
vein, 37, 38
Umbilical region, 23
Umbilicus, 23, 24, 28, 34
Unciform bone, 39
Upper limb, superficial anatomy of, 35
Urethra, bulb of, 62
membranous part of, 62. 64
Urethral part of perineum, 62
Uterus, 23, 66
broad ligament of, 66
Uvula, 1 6
VAGINAL examination, 66
Valves of Morgagni, 65
Vas deferens, 51, 54, 65
Vascular compartment, 58
Vasti muscles, 44, 45
VEIN or VEINS, azygos, 33
basilic, 36, 37
at bend of elbow, 37
cephalic, 36, 37
cervical, transverse, 18
dorsal of penis, 64
epigastric, superficial, 24
femoral, 45, 57, 60
iliac, external, 54, 57, 58, 60
innominate, 22, 33
VEIN or VEINS continued.
jugular, anterior, 18
median, 37, 38
radial, 37, 38
ranine, 15, 17
saphenous, external, 46, 47, 49
internal, 43, 45, 46, 47, 49, 60
of scalp, 3
ulnar, 37, 38
Vena cava inferior, 27, 33, 34
cava superior, 22, 33
Ventricles, lateral, 9
of heart, 33
Vermiform appendix, 23
Vertebrae, cervical, 16, 27
bodies of, 19, 23, 27, 32, 33, 34
spines of, 20, 27, 28, 29, 30, 31, 42
Vertebral artery, 5
Vesicula; seminales, 65
Vessels. Sec ARTERIES, VEINS.
Viscera abdominal, 23, 24
pelvic, examination of, 65
Volar artery, superficial, 41
WALL of abdomen, 23, 56
Web of fingers, 40, 41
Wharton, duct of, 15
Winslow, foramen of, 34
Wrist, superficial anatomy of, 39
XIPHISTEHNAL articulation, 19, 24. 25. 33
Zygomatic arch, 7
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