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·LANDMARKS AND SURFACE MARKINGS OF THE HUMAN BODY

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·RAILING'S
LANDMARKS AND
SURFACE MARKINGS OF
THE HUMAN BODY
VINTH CDITION
REVISED BY
JO ROBINSON M D M Chir TRCS
SRGICAL C A STAKT ST B THOLOX & HOSPITAL
TORUR YDX STRATO O AKATO Y ST B THOLOMEW's HOSPITA
WITH THIRTY EIGHT ILLUSTRATIONS
LONDON
HK LEWIS & Co Ltd
1958
(Repeaid)

·ILLUSTRATIONS FIGS 1 and 2 Cranio-cerebral Topography To face 4 3 and 4 The Side of the Meck 14 15 5 The Front of the Neck 19 6 The Iront of the Arm and Torearm 22 7 The Clbow and Back Region 23 8 The Elbow Region 9 The Veins of the Arm and rorearm 24 10 and 11 The Palm of the Iland 26 12 The Back of the Wrist 28 13 The Shoulder and Arm 31 14 The Heart Great Vessels Kidney and Ureter 15 and 16 The Pleural Sacs Lungs etc 17 and 18 The Abdominal and Thoracic Planes 50 52 19 The Alimentary Canal 36 20 The Lurer Anterior Abxlominal Hall etc 64 21 to 24 The Thigh and Leg 70-74 25 to 29 The Region of the Ankle and root 76-80 30 to 38 Ossification and Epiphyses of the Skeleton Bo-go *********** 38 ·LANDMARKS AND SURFACE MARKINGS ON THE HUMAN BODY CHAPTERI THE HEAD AND NECK CRANIO-CEREBRAL TOPOGRAPITY OLY thosc landmarks and surface markings will be given which are of practical value and as far as possible each landmark will be rendered independent of any other as by such means any given structure can be rapidly depicted on the surface the important question of time and of space rendering the more complicated systems in which it is necessary to map out a network of intersecting lines in order to fix the position of any single structure of little Surgical value It is necessary however to recognize first certain important bony points etc The nasion situated at the base of the nose at the Fig 1 1 central point of the naso frontal suture The inion or external occipital protuberance Fig 1 2 -a projection variable in size which can be felt on the occipital bone inmediately above the nuchal furrow A line uniting these two points over the vertex of the skull corresponds in direction to the longitudinal fissure of the brain to the upper attached margin of the falx cerebri and to the superior sagittal venous Sinus This sinus originates in the region of the foramen cæcum just anterior to the crista galli of the frontal bone broadening out as it passes backwards to the internal occipital protuberance which corresponds on the outer aspect of the shull to the inion The sinus then turns sharply to I ·2 THE HEAD AND NECK the right, forming the nght transterse sinus The left sinus denves its blood manly from the straight sinus which receti cs at the anterior margin of the tentorium cerebells the great cerebral vcin (Galen) and the inferior sagittal sinus ishich is contained in the free margin of the falx cerebri The line drawn as aborc from the nasion to the inion also corresponds in direction to the occa sionally persistent metopic suture between the two halses of the frontal bone and to the sagitlal suture between the two parietal bones The frontal bone is separated off from the two parietal boncs by the coronal suture, and the point of junction of thic coronal and sagittal sutures is known as the dregma the site of the fatal anterior fontanelle an opening wuch should be closed bclore the end of the second year Between the pinetal and occipital bones the lambdoid suture lies and at the junction of thc sagittal and lambdard sutures the posterior fontanelle is siturtal closed at or soon after birth The point of Fig 1 13 junction of the last tno sutures is 2n0n77 79 the lambda This point lies about 21 inches 101c thc inion or cxtcrnal occipital protuberncc About I inci from its posterior superior angle and close to the sagittal suture the parietal banc is perforated by a small foramen --thc prrietal foramen-for the trasmission of an cmissary tuin A linc uniting the two fornmini crosses thc sagittal suture at a point nown as the obelion The pinetal bone is outwardly bulged at 3 point mther above its centre forming the parse'al cminence-this is more pronounced in the fu til skull and indicates the point at which the single osific nucleus miles its appearance Tuming nox one s attention to their laterilaspect of this ·TIIC CAD AND NECK 3 shull, the temporal lines should be examined Fig 1,6 They are two in number, superior and infcrior, crossing the parietal bone rather below the junction of the middle and lower thirds cutting off the vault proper above from the temporal fossa below The ridges arc often so feebly developed in this region that it may be necessary to verify their position by tracing them backwards from the zygomatic process of the frontal bonc at which level the upper line is always well marked The temporal muscle arises from the interior temporal linc and from the temporal fossa bulow, wulst the overlying fascia thi tem poral fascia gains attachment to the superior Fig 1 5 temporal lune--a fccbly developed ridge which runs above and parallel to the inferior line The zygomatic process of the frontal bone articulates with the corresponding process of the zygomatic Fig 11, 16 bone and the articulation between the two processes is easily felt at the upper and outer border of the orbital cavity The marginal tubercle a small prominence to be felt along the postenor border of the frontal Fig 1 12 process of the zygomatic bone a short dis tance below the fronto-zygomatic suture The zygomatic process of the temporal bone should be traced backwards towards the ear and an examination of the skull will show that this process divides in front of the ear into three roots the anterior merging into the articular eminence the middle helping in the formation of the post glenoid tubercle whilst the posterior or upper Fig 1 13 root sweeps backwards above the external 14 auditory meatus to become continuous with Fig ! 17 the suprameatal and supramastoid crests and to blend with the posterior curved end of the temporal line ·4 THE SEAD AND NECH The suprament al crest is of special Surgical importance as it forms the upper boundary of Miccicn's supramcatal triangle (aural operations) and also indicates famly accu mately the lower level of the cerebrum in this situation The transverse SiS --Drau band inch in width Fig16 from the inion or external occipital protuber™ FIC 11, 19 ance to a point 7 inch bchind the extemit auditory meatus so cursed that the lughest point of the conexity lies about 2 inch above Reid's base line The lower limit of the cerebrum can be mapped out in FIC I 17 the following manner A point is taken in the 17, 17 median antero-posterior linc about # inch above the nasion and from this point 1 lincus drawn out wards which fics about tinch bove, and follows the curve of the upper border of the orbit This line » carried backwards as far as the level of the zygomatic process of the frontal bond then cursing awards and bac} wards tou ards the plerion (we next page) The temporo splienoidal lobc non sheep, downwards and forwards towards the posterior border of the 71 gomatic bont, and then fics practically on a level with the suppur border of the zygomatic process of the temporrl long It and lyhind the car the cerebrum lies flush with the supramcatal and supramastoid crests and subsequently follows the cunc of the transserse sinus from the base of the mastoid process to theexternal excipital protulrranc Tie transierse sinus is to a large extent, walled in boy thre ter lorium cerebell, a membrane separating the cuttbrum aborc from the cerelyllum below The suptis curto therefore corresponds not only to the partion of the transierse sinus but alo represents the outer attachment of thic tentorium cerclxils and the interval xlucen the anbrum zboic and the cerebellum lxlon Reids kiseline A line is drawn backwards from the

·RIVIO CI RI BRVI TOI OCRATIS
10
MOTOR
SENSOREN
BROCA
10
HEARING
Fic 1
T face P 4

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·CRAVIO CI RI BRAL 101OCRI111Y
tt
14

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·FIG I
1 The nasion
- The inion
3 The mid point between nasion and inton
4 The central sulcus (fissure of Rolando)
5 The superior temporal line
6 The inferior temporal line
7 Thc pterion
8 The anterior horizontal ramus of the lateral cerebral
sulcus (Sylvian fissure)
9 The antcrior ascending ramus of the Interal cerebral
sulcus
TO The posterior ramus of the lateral cerebral sulcus
11 The parictal prominence
12 The marginal tubercle of the zygomatic bone
13 The lambda
14 The superior temporal suicus
15 The parıcto-occipital sulcus
16 The transverse sinus
17 17 17 The level of the base of the cerebrum
19 The extemal auditory meatus
19 19 Reids birse line

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·TIG II
Reids base line
2 2 A line parallel to the above at the level of the
supra-orbital margin
3 The middle meningeal artery
4 Tlie anterior branch
5 5 5 The three sites for trephining
6 The posterior branch
The site for trephining
& The point for trephising to reach the inferior cornu
of the lateral ventrcle
9 The transierse sinus
IO The inion
11 The mastoid process
I 2 Maceuen s suprameatal triangle
120 The ty mpanic antrum
12b The fncial neric
13 The supramental and suprimastoi 1 crests
14 14 The temporrl line
15 The temporal fossa
16 The zigomitic process of the frontal lone
17 The site of attachment of the medial pairert 1187
ment (tendo ocul)
18 The lacrimal groosc

·TIC ITAD AND NECK 5 lower border of the orbit to the middle of the Fig 1 19 19 external auditory mcatus and when further Fig 11,1 1 produced the line will be found to fall just below the level of the inion and to lie almost entirely below the level of the transt crse sinus This line is utilized by some surgeons in trephining the skull distances being measured along this line and points taken above or below 1ccording to the seat of the lesion The Sylvian point represents the site of divergence of the three rami of the lateral cerebral sulcus Fig 1 7 (Sylvius) It corresponds on the surface to a point known as the plerion which is situated it inches behind thc zygomatic process of the frontal bone and It inches above the upper border of the zygomatic process of the temporal bonc The main postenor ramus of thic Fig 1 10 sulcus passes backwards and upwards from the Sylvian point to 2 second point situated #inch below the most prominent part of the parietal bonc (parietal prominence) The anterior ascending ramus is directed upwards for about inch,u hilst thc antenor horizontal rainus Fig 1 8 9 passes forwards for about the same distance The pterion corresponds also to the antenor pole of the insula and to the middle cerebral artery as that vessel lics deeply embedded in the anterior part of the lateral cerebral sulcus To mark out the parelo occipital sulcus and the superior temporal sulcus it is necessary to find two bony points—the Fig 1 12- marginal tubercle of the zygomatic bone and the 15 lambda A line uniting these two points com responds in its posterior part to the parieto-occipitalsulcus and in its middle third to the superior temporal sulcus The central sulcus (fissure of Rolando) -Take a point ·8 THE HEAD AND ECK above and bchind the postenor meningeal point The necdle should be directed toutards the summit FIS 118 of the opposite ear the rentnde being reached sithin 2 inches from the surface (heen) The basic fossa - There is no cternal sign to indicate the situation of the fosse of the skull In general however it may be said that the anterior ſossa extends as far back is the antenor end of the zygoma that the middlc fossa lies between this and the mastoid process ud the posterior includes all the base behind the process (Lisendmth) The ty mpanic antrum may be exposed by trepning in Fig !! 12a Maceuen s suprancalal Inangle a space wluch Fig 11 12 is bounded aborc by the backward continu? tion of the posterior root of the zygoma (the supmmastoid crest) behind by a icrtical linc drawn upwards from the posterior border of the cxtcmil auditory menlus and below and in front by the suprameatal spise ? prominent bony process which assists in the forination of the posterior supxrior quadrunt of the external auditory meatus In this triangle there is usually a well marked depression-the suprameatal fossa The supramastoid crest not only indicates the uppermost possible limit of the tympanic antrum but as has already been stated at correspond also to the level of the base of brain in this situation The crest therefore represents the level of thr tegmen (ympast and in mastoid FIG 11, 13 Explorations the field of operation must be confined to an arta below this crest in the adult the antrum usually lies at a depth of į to } inch from the surface In the child it is much ncarer the surface The trans-erse enous Sinus lies posterior and nearer to the surface whulst the facial ricrre pursues its Fig 11,9 FIC !! 126 course in front and on 7 derper planc ·TIC HEAD AND NECK 9 llic parolid gland occupies the space which is bounded above by the zygomatic arch, bchumd by the Fig ilt 2 nurcle and the mastoid process and below by a line dmwn from the angle of the jaw to the apex of the mastoid process In front the gland extends a variable distance over the anterior surface of the masseler muscle This muscle passcs downwards and backwards from the lower border of the zygomatic arch to be attached to the outer surface of the descending ramus and angle of the lower jas When the teeth are clenched the anterior border of the muscle is casily defined a well marked line of demarcation being so formed between the masseter muscle behind and the buccinator in front Parotid (Stenson s) duct the duct of the parotid gland corresponds to the middle third of a linc drawn Fig ill 3 from the lower border of the tragus of the car to a point situated half way between the ala of the nose and the red line of the upper lip At the anterior border of the masseter muscle the duct dips inwards through the buccinator muscle to open on the buccal mucous mem brand opposite the second molar tooth of the upper jaw The transierse facial artery a branch of the superficial temporal runs forwards parallel to and imme- Fig til 4 diately below the zygoma lying above the level of the parotid duct The facial nerte after emerging from the stylo mastoid foramen curls round the neck of the mandible Fig fit 5 and traverses the substance of the parotid gland in which part of its course it divides into numerous branches The general transparotid course of the nerve and the direction of its buccal branch may be indicated by a line drawn forwards parallel to and below the parotid duct from the lobule of the ear ·12 THE HEAD AND NECK The mouth - In the median line hangs the arena The soft pilate traced in the outward direction is seen to diverge into the tuo pillars of the fauces-anterior pillar (palatoglossus) and posterior pillur (palıtopharyngeus)- enclosing a triangular recess at the base of which the tonsil is situated The dorsum of the tongue is divided into an anterior two-thirds and a posterior third by a V shaped furrow the sulcus terminalis the umbs of which pass obliquely forwards from the foramen cæcum Thic papillt of thic tongue—tallate (8-12 in number immediately antenor to the sulcus terminalis) fungiform filiforn and simplerarc supplied by the lingurl branch of the mandibular nerve (ordinary sensibility) chordz tympani (specrul taste for anterior two thirds) and by branches from the glossom pharyngeal to the villate papillc (taste) When the tip of the tongue is turned up the fronulum is scen pissing in the middle line from tip to brse when it meets tuo lateral irregular folds wuch correspond to the underlying ducts of the submandibular plund (Il'harton s ducts) In close proximity to the junction of these mucous folds two pipilie are seen onc on cither side of the middle line-the openings of the ducts Running Interal to the frenum but duerging out wards the two lingual iesns are seun and still more latcral tuo ſnnged mucous folds thc plıca fumtırıata On cu erting the check thic onfice of the parotid duct sult bc obscrcd opening opposite the second upper molir tooth The lecth (1) Deciduous Teeth Il'ften the child is between 2 and 3 years old all deciduous tarth ten in eich 378 should be present Though subject to considerable dates iration they appear it about the following ·TIIF JIEAD AND NECK 13 gth und) 15th Lowcr Central incisors 6th month Upper incisors Lowcr Intcral incisors and Ist molars Canines 18th and molars 24th (2) Permanent Iceth-When complcte there are sixteen in each jas They appear it or about the following dates Ist molars Central incisors 7th Lateral incisors 8th ist premolars 9th 2nd premolars 10th Canines IIth 2nd molars 12th 3rd molars I rom 17th to 25th year 6th year The Triangles of the Neck The lateral aspect of the neck is divided by the sternomastold muscle into two triangles-anterior and posterior The anterior triangle is bounded in front by the middle line of the neck behind by the antenor border Fig iv of the stcrnomastoid muscle and above by the lower border of the ramus of the mandible The space so marked out is divided into thrce smaller triangles by the digastric muscle and by the anterior belly of the omohyoid (1) The digastric triangle above the digastrıc Fig 1v 5 muscle containing the submandibular gland (2) The muscular triangle anterior to the Fig iy 11 omohyoid muscle bounded by the anterior belly of the omohyoid the anterior border of the sternomastoid and by the median vertical line 2 ·14 THE HEAD AND NECK (3) The carotid triangle bounded aboue by thc postenor belly of the digastric behind by the antenor Fig fv, 10 border of the sternomastoid muscle and in front by the anterior belly of the omohy od In this triangle the common carotid bifurcates, and the external carotid gives off most of its branches The posterior triangle is bounded in front by the posterior border of the stornomastoid behind by thic anterior border of the tmpcrius and below by Fig ly the middle third or fourth of the clavicle Thic triangle is subdivided by the posterior belly of the omohyoid which cuts off the small supraclauscular tringlu below from the more extensive occipital triangle above 8 The Vessels and Neries The carotid arleries correspond in direction to n line from the sternoclaviculır joint to the hollow FIS HI, 6 betucen the angle of the mindible and the mastoid process The common carotid usually bifurcates at the level of the upper border of the thyroid cartilag Fig III %, (fourth cervical u crtebra) the extemal carotid subscquently lying superficul to and slightly to the inner side of the internal carotid The onohyoid muscle (upper belly) crosses the common carotid at the level of the cricoid cartılage and in tius situation the artery may be compressed against the prominent anterior tubercle of the transicrse process of the sixth cervical vertebra (Chiassaignac s tubercle) The superior thyroid artery arises from the cxternal carotid in the carotid triangle immediately aboic the les cl of the upper border of tlic thyroid cırtı lage and turning downwards under cour of the anterior belly of the omoh; oid muscle in directer! Fi, ili 11

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·TIL SIDE OI THI I ICI AD \Ech
15
.
11 111
1 lygomi
) I 1cial arters
1 arotid gland
10 fogul utery
3 Parotid duct (Stenson) 11 Suprir thu starters
Transverse facia) arter
5 Internal jugular rin
5
I acul nene luccal branchi 13 I rral jugulur sein
6 Common carotid triangle 14 5 Luminarters
7 Internal carotid arten
is typer limit of trachu
8 I sternal cartul arten
Terus

·TIIC SIDI 01 10 11( ID) Vch
4
F
TIG IV
I Transverse process of the atlas 77 Anterior and posterior
2 The accessory nerve (spinal bellies of the Omohioid
accessory)
muscle
3 Sternomastoid muscle
8 8 Supraclavicular triangle
4 4 Superficial cervical plexus 9 Posterior trian, le
5 Digastric triangle
Io Carotid triangle
6 6 Anterior and posterior bellies 11 Muscular triangle
of the digastric muscle
Trg III DPS

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·THE HEAD AND NECK 15 10 towards the apcı of the latcral lobe of the thyroid glund The lignal artery arises midway between the level of the upper border of the thyroid cartilage and the great rig 11 comu of thic hyod bone and enters the digastric tningle by passing deep to the digastric muscle The artery so gains the upper border of the hyoid bone and runs inwards for a short distance parallel to that bone under cover of the hyoglossus muscle The facial artery anses opposite thc great cornu of the hyod bone and enters the digastric triangle by passing deep to the tendon of the digas- Fig fli 9 tric In this triangle the artery lies deeply embedded in the substance of the submandibular salivary gland and then cnters on its facial course by curling round the inferior border of the mandible immediately anterior to the masseter muscle about iinches in front of the angle of the mandible The vessel then passes upwards towards the inner canthus of the eye there terminating as the angular artery The occipital artery arises from the posterior part of the external carotid artery in the upper part of the carotid triangle and passes upwards and backwards under cover of the posterior belly of the digastric muscle towards the interval between the mastoid process and the transverse process of the atlas At the apex of the posterior triangle the artery is joined by the greater occipital nerve (posterior primary ramus of the second cervical nerve) the two structures then passing upwards on to the vault of the skull The posterior annicular arlery anses from the external carotid immediately above the posterior belly of the ·18 THE HEAD AND NECh below and in front of the apex of the anastoid process The nerve enters the substance of the sternomastoid at the junction of the upper and second quarters along the anterior border of the muscle emerging from the posterior border of the muscle at the junction of the upper and middlc thirds Thic point of emergence is honever subject to some variation, and the nurse may enter the posterior angle of the nech at a somewhat lower level pursuing subscquently a down ard and backward course towards the interior border of the trpezius muscle beneath wluch muscle it sinhs * The superficial conscal plexus ---Tole a point midway Fig iv, along the posterior border of the stcromastoid muscle, and from this point draws three lines I Upwards towards the lobe of the car = the great auricular nere (2 and 3 C) 2 Upwards along the posterior border of the sternomastoid muscle = lesser occipital nen (C) 3 Torwards towards the middle line of the neck the antenor cutancous neric (2 and 3 C) These three lines produced downuardo represent the direction of the descending branches of the plerus Thus the great auricular produced = the intermediate supra claticular nerie the anterior cutaneous the laten! supraclavicular nene and the lesser occipital medial supraclavicular nere These three descending branches are derived from the 3rd and 4th anical o the ncres • Another surlace marking for the spinal accessory MITTE Draw a line from a point midway between the tip of the masloki process and the angle of the mandible to the middic of the fksterior lorder of the sternomastoid muscle and hence acroti the postenot triangle to the anterior border of trapezius

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·THE FRONT or THE VI Ch
12
17
I Supri riitali mnen
Infrarlitir ramen
3 Ventilf rimen
+ (en hul muxle
55
Intuir ind fxntcsir
bellies of the distri
17 lc
olohud muscle
- Ilvon Inc
8 Thyrohs membrane ind
грн1tv
Thyroid cartilage
Jo Rimini tulis
11 (ric this rollis ment and
CHIC xil ncmbrane
1
(Tic :l cartiin
13 Isrst ring of trichea
# Isthmus of the thiro!
glind
15 Trachel ring
16 Sternal half strino
:I J 14k
I (Lisa Lar hel of strron
mil

·TIC HEAD AND NECK 19 15 The brachnal plerus - The upper limit of the nerve FIG II trunks which form this plexus is represented by a linc down from thic mid point between tlic anterior and posterior borders of the stornomastoid muscle at the level of the cricoid cartilage to 1 second point situated just external to the mid point of the clavicle The lowest cord lies behind the third part of the subclavian artery The rima glottid bounded Interally by the truc vocal cords lies opposite the mid point along FIS v 10 the anterior border of the thyroid cartilage The epiglottis though fixed below to the thyroid angle immediately above the point of attachment of Fig v 8 the true vocal cords extends upwards to above the level of the body of the hyoid bone A suicidal cut throat frequently involves the thyro hyoid membrane and the epiglottis may be scvered from its thyroid attachment The isthmus of the thyroid gland crosses the trachea about to inch below the cricoid cartilage Fig y 14 The lateral lobes extend upwards to the middle of the thyroid cartilage downwards nearly to the clavicle and outwards to be overlapped by the sternomastoid muscle Fig y The structures in the middle line of the neck (1) Passing down from the mandible to the body of the hyoid bone the two geniohyoid muscles lie each side of the middle line (2) The body of the hyoid bone (3) The thyrohyoid membrane (4) The thyroid cartilage (5) The cricothyroid ligament and cricovocal membrane (6) The cricoid cartilage (7) The first ring of the trachea (8) The isthmus of the thyroid gland (9) The trachea (10) The suprasternal notch ·CHAPTER II THÌ UPPER LIB spine of In this chapter and in that on the lower extremity, the reader s attention is directed muniy to those bony pronu nences and muscular or tendinous cicvations wluch lic in the region of the joints since these form thic more. important landmarks which ard in the representation of the arteries nerves, ctc, of the limbs The muscular masses which completc thc symmetry of the arm or leg between the joints are only mentioned where necessary 1 fair general knowledgc of the anatomical structure of the body being assumed The Shoulder region - The acromion the the scapulz and thic clavicle being subcutincous through out their whole length can readily be palpated from end to cnd The chanclc should be clamined first from its blunted stemul extremity to the cromioclauicular joint The inner thurd of the shrit is rounded and presents a mari ed forward conicuity whilst the outer third of the bone is flattened from before backwards and shows concasc anterior border At the outcr end of the bone a slight clevation may be felt on the supx rior surface and immediately crtemal to this is the acromioclavicult joint the long ris of which lies in the intcroposterior direction 20 ·TIIL UPIIR LIVI 21 1 The acromul spine is narrow at about its centre brordening out towards the vertebral border of the scapul and forming there a smooth triangular surface our wluich glides the tendinous part of the trapezius Laterally the spinc terminates in the upuud curicd Fig xl11 acromul process at the anterior border of whuch an oval facet is situated for articulation with the clasicle The supra- and infraspinatus muscles till up the depressions or fossic which lic above and below the spine of the acromion The clavicle is also bounded above and below by depressions little csident in fat subjects but most marked when as the result of pathological or physiological con ditions fat is fecbly represented The supraclavicular or subclavian trangle is dealt with in the first chapter The infraclavicular space is bounded abore by the clavicle below by the clavicular head of the pectoralis major muscle medially by the costal cartılage of the first nb and laterally by the anterior border of the deltoid muscle The floor is formed by the subclavius muscle and the clave pectoral fascia In the outer part of the space the coracoid process may be felt lying under cover of the anterior border of the deltoid muscle I inch below the junction of the outer and middle thirds of Fig xlll the clavicle The bulky deltoid muscle arising from the clavicle and from the acromion and the spine of the scapula is so to speak pushed outwards by the underlying head and greater tuberosity of the humerus so producing the normal rounded appearance of the shoulder This outward displacement of the muscle is tahen advancage of by Hamilton in the diagnosis of a dislocation of the houlder joint as after such an injury the humerus is rawn inwards by the pectoralis major latissimus dorsi ·42 TITE UPPER LIVB and other muscles to such a degree that a ruler placed along the outer side of the arm will be in contact with the acromion and the lateral epicondyle of the bumeris at one and the same time In the normal condition this is not possible To measure the length of the humerus the tape measure Fig xlli should be carried from the lower margin of 1-2 the acromion to the lateral cpicondylc of the humerus Between the greater and lesser tuberosities of the humcrus is the bicipital grooze, in which runs the long tendon of the biceps muscle Thc groove may be represented by a line, about 2 inches long, which runs downwards from the tip of the acromion parallel to the long axis of the humerus The upper epiphysis of the humcrus includes the head and both tuberosities, and the cpiphysıal linc ruins trans versely, at nght angles to the long axis of the humerus at the lower border of the great tuberosity The arilla -To examine this space the elbon should be supported and the patient instructed to relax all muscles The anterior wall is formed by the major and minor pectoral muscles and by the clau pxectoril fascia Tlıc pectoralis major alonc forms the anterior fold of the aulla and does not cxtend 25 for down Fig vi, 3 wards as the posterior fold whilst its rounded apparnce results from the tu isting of the files of the muscle previous to inscrtion into the outer bicipitil ridge The posterior wall is formed by the latissimus dorst tcres major and sulyscapularis muscles The rounding of the postenor fold of the axilla is due to the Irissimus dorsi wluch curls roind thic teres major muscle from be hind for ards in order to reach its insertion into the floor

·THE FRONT OF THL ARM AND TORCARM
4
1
The radial nerve
FIG VI
3 The axilla
5 Radrul artery
4 Brachial artery
6 Ulnar artery
7 7 Vedian nerve
8 8 Ulnar neric
2
To face p 21

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·III II 1011 "\ BIN RLGIOV 5 0 -501 2 11 III ( 3 10 ile 1 Q 5 dk 11 1- IL- RL --7 701 TAN L Telettrit Tio VII TIE 114 Ch. The terminatra {tte ut b The fura totalnale b! Ne at the The trainat a wetto) the Luca Dr by dhati Lot tte tip {tbe a to forte Sheklane 71. 11 The la tutere slane tetest e lixcret 1 10. The ul tx latobe purtw If The list te te ·TIIF UPI CR LIMB 23 of the bicipital groove The narrow outer boundary of the axilla corresponds to thic upper part of the shaft and to the head of the liumcrus and in this situation in a well-developed arm, two prominent longitudinal folds are scen the anterior of which corresponds to the coraco brachialis and biceps (short hicad) muscles wulst the more posterior fold results from the projection of the neuro-vascular bundle The head of the humerus and of the scapula can be felt at the upper and posterior part of the axilla the second rib on the inner side and the cora cord process in front The head of the humerus looks in the same direction as the medial epicondyle of the humerus The inner wall of the axılla is formed by the upper part of the lateral wall of the thorax which is here clothed by the serrations of the serratus anterior muscle The axıllary lymphatic glands are arranged in three main groups all converging towards the apex of the axılla (a) The pectoral set running upwards and outwards under cover of the outer border of the pectoral muscles and draining the anterior and lateral aspects of the chest wall and the abdomen above the level of the umbilicus (6) The subscapular set running upwards along the axıllary border of the subscapularis muscle and draining the lateral and posterior aspect of the chest above the level of the umbilicus (c) The brachial and axıllary set running upwards in the line of the axıllary vessels and draining the whole of the upper limb The Elbow region — When the forearm is extended a line joining the medial and lateral epicondyles of the humerus cuts across the tip of the olecranon process which bony prominence lies well to the medtal side of the mid point of the intercondyloid line 1-3 ·24 THE VI FER LISB When the forearm is flered the olecranon moies down wards and by umiting the three bony points Fig :) ! a triangle is formed Immediately below the lateral cpicondyle the head of the radius is felt lying in the valley behind the brichioradialis (tolden) The humero mdial articulation is transserse but the humero ulnar artıculation slopxs obliquely douzu ards and ins irds and consequently whilst the Inteml cpi condylr is about inch aborc the humcro ridial joint the mudul epicondyle lics rather more than I inch above the line of the humcro-ulnar articulation The junction of the diaphysis and loveer epiphysis of the humerus corresponds to a trinsverse line dmun across the humcrus immediately above the tips of the epicon dyles The bony points on thc outer side of the joint no generilly obscured in those cases where there is considerablc effusion into the elbow joint, thc sy noujal membrane bulgını outsirds below the latcral cpicondyle of the humerus and between that process and the olccrinon process Under sunilar conditions there is also an out ward projection of the synovial membrane between the olccranon and the medial epicondyle of the humerus obscunng the deep depression that normally exists in that situation--a depression at the base of which the ulnır neric can be rolled bencatfi tfic finger In front of the clbox is the cubilal fossa 2 trangular Fig 112 space the base of which corresponds to a Ime drawn across the front of the ellow between thic two humınl cpicondyks wulst the inner and outer boundaries are formed respectacls by the pro- FIESTAS nator tires and brachondinis muscles T1114 Higit a triangulur space is tistically sulxlos de ding list biceps tendon on either side of slucha de presa

·TULI LI POV RICION
2
4
110 VIII
The inter conds loid line
2 Biceps muscle
3 Bicipital aponeurosis
+ Brachoradials.
5 Pronator radu teres
(Trachial artery
Yedian nerve
8 Padial nerve
To fa!

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·TII UUSIX S141 son rusts ---the inner und outer bicipslal sales in the outer culcus the mill nen hies OnLiN to its por Fig 13,6 teror interosseous brunch mdıthen continued 15 ? pure sensors nemic Tic median nesse und tricbrick Cint arters lic in the immer sulcus, tlu uteng atur 67 mediato byctween the tendon mi tie neric nic artery d ncrc in how cser obscured in the louc part of the inner sulcus by the ou crlaying lice F 4583 Dit al aponeurosis which can in mad insards 10 the prostor ref1011 Iulst its upper free margin presents 1 Helli murha crescentic odige wlucht looks upwards and nu ard's This aponeurosis becomics well dcfind on forcible flesson of the elbon The superficial seins in front of the land of the clbos Fig ix are arranged in the form of a letter M the meal median and ulnar group ol icis being recen cd from below 1 Iulst the two main cfferent vessels, thic cephalic and the basilic carry the blood Fig 1x 6 upwards The basılıc rein passes upmards in the superficial fascia along the inner side of the arm and pierces the deep fascia about half way between the mula and thic mcdialepicondyle, and at the foramen so produced in the deep fascia the medial antebrachial cutancous nerse emerges to become superficial The epitrochlear gland lies in close connection with the median basılıc or basılıc veins above and in front of the internal condyle The cephalic tein can be traced upwards along the outer side of the arm as far as the groove between Fig ix the deltoid and pectoralis major muscles In the interval between these two muscles the vein lies embedded and eventually pierces the clavı Fig x,7 pectoral fasuja in the infraclavicular region to open into the axillary vein ·26 THE UPPER LIVB THE REGION OF THE WRIST AND HAND Tuo tendons only are conspicuous at the front of the wrist-the palmınıs longus in the middle line Fig x 2,3 and the flexor carpi radiali, to the outer side of the palmans longus The fletor carpi ulnaris can however, be distinguished by palpation along the ulnar border of the forearm and can be traced down Fig x, 5,6 wards to its insertion into the pisiform bone Between the palmaris longus and the fletor carpi ulnaris the main mass of the flexor digitorum sublinus les no transverse creases arc seun in this situation the Fig x, 7 upper of which corresponds roughly to the level of the radiocarpal joint, while the lower represents almost exactly the upper limit of the flexor setinaculum (transverse carpal ligament) Just literal to where the fic or carpi radialis tendon cuts across the t«o transierse creases there is a depres sion in the floor of which the lower end of the modus and the tubercle of the scaphoid bone may be felt The radial artery crosses this space in a downward and outsard direction The traperium lies at the FC X, 1 lower limit of the depression immeuncly below and external to the scaphoid tulcrosits The prominent pisiform bonc can be distinguished by tracing downwards the tendon of the flexor Fig x, 5, 6 carpi unans muscle and postenor to tlus bonc both triquetral and hamate bones are situated A fingers breadth below and Interal to tlic pisiform bonc dcep pripation will serify the position of the hooh of the hamate lone The prror relınaculum is attached to four bony points tuo on the radil side the sport tubercle and the ndye on the trujx 7l|1m 21:41 Fig x1 5 Fig x 1

·TII Por THE HAND
ho
FIG
Tfal P6

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·THE PUV or TIC HID
FIG VI
I The flexor retinaculum
2 Scaphoid tubercle
3 Ridge of trapezium
4 Pisiform bone
5 Hook of hamate
6 Common flexor synovial sheath
7 Flexor pollicis longus sheath
8 8 Distal flexor sheaths

·IO
1 Radınl uteri
2 Flexor carpi manlı
3 Palmırıs longus
4 Ulnar artery
5 rlexor carpi ulnaris
6 The pisiform bonc
7 The two transverse creases in front of the joint
8 The superficial branch of the ulnar utery forming
with the superficial polmar branch of the radul artery
the superficul pılmır arch
9 9 The digital branches of the superficial primar arch
10 The deep branch of the ulnır forming the deep palmır
arch passing between the two heads of the first
dorsal interosseous muscle to join the mal

·THE UPPER LIVB 27 tuo on the ulnar side thc pisiform and the hook of the liamnte The upper limit of the ligament corresponds to the lower of the two transverse creases in front of the wrist whilst the inferior limit of the ligament lies about inch below The flexor synovial sheaths --The flexor pollicis longus, the flexor digitorum sublimis and profundus Fig x1 all pass beneath the flexor retinaculum In this situation the flexor sublimis consists of four tendons of which the medius and annulans lie superficial to the tendons which pass to the index and little fingers The profundus consists of two parts only the tendon to the index finger being alone differentiated off from the main mass Bencath the ligament these tendons are surrounded by two synovial sheaths one for the flexor pollicis longus and one for the remaining tendons plus the median nerve These sheaths extend upwards about 1 inch above the upper limit of the ligament and therefore the same distance above the lower transverse Fig xi crease in front of the wrist The flexor pollicis longus sheath is continued downwards to the insertion of the tendon into the distal phalanx of the thumb The main sheath broadens out below the ligament and though generally continued onwards to the end of the little finger the major portion terminates at the Fig xi level of the upper transverse crease of the palm The flexor tendons to the index middle and ring fingers also possess more distally distinct synovial sheaths which extend from the terminal phalanges of the fingers upwards to the necks of the metacarpal bones a level corresponding roughly to the lower transverse crease of the palm A distance of } inch separates the main synovial sheath above from the more distal segments below 3 6 6 ·28 THE UPPER LIVB On the lateral side of the wrist the most inarhed feature is the anatomical snuff bou - sprce bounded on the radial side by the tendons of the abductor pollicis longtis and extensor policis brey is muscles and on the ulnar side by the tendon of the extensor pollicis longus In the floor of the space the styloid process of the radius is felt this prominence lying fully } inch below the level of the corresponding process of the ulna and also on 1 slightly more anterior planc Immedintely below the radial stylord process the scaphoid bonc lics most pro minent when the hund is well ndducted Below this agun the trapezium and the bases of the first iridd second metacarpals are to be felt On thc dorsum of the land there is a well marked elevation most noticeably when thic wrist is fully fic al duc to the projection of the buses of the second and third mutacarpal bones thc stylord process of the latter lone being especially prominent Immediately above tlus eles ation there is a depression where the tendons of the extensor cirpu radnulis Jon, us and brevis are felt 75 they pass to their insertion into thc bases of the second and thurd meticarpal bones Maar the middle of the posterior aspect of the lower end of the mdius a tubercle can gunemilly le dis rig xll + tinguished the dorsal fibercie (Lisler)-separ ating the extensor pollicis longus on the medial side from thi tendon of the extensor carpi radnis breuis which Ires more lateral The extensor remnaculum ligament is representer by an obliquc band about 1 inch brord uachi Fig xll 1 cxtends from the lower part of the outer border of the ndius to the stuloid process of the ulni and the carpal bones brlou the ulni Thic ligament ins

·1HC BICh or 111 WRISI
FIG II
To far p 28

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·TIG 211
I The extensor retinaculum
2 Synovial sheath for the abductor and extensor
pollicis brevis tendons
3 Sheath for the extensor carpi radialis langus and
brevis tendons
4 Dorsal tubercle
5 Sheath for extensor pollicis longus tendons
6 Sheath for extensor digitorum and indicis tendon
7 Sheath for extensor digiti minimi
8 Sheath for extensor carpi ulnans
9 Radial artery cutting across the anatomical snuff
box
10 Radial artery dipping down betucen the two herds of
the first dorsal interosscous muscle
11 The method of insertion of an extensor icndon to the
bases of the middle and distal phalanges
12 Tmnsverse lines corresponding to the levels of the
metacarpo-phalangeal and inter phalingeal joints

·TIIE UPPER LINIB 29 therefore a downward and inward direction and beneath it pass the extensor tendons These occupy distinct compartments and possess synovial shcatlıs as under I One compartment and synovial sheath for the Fig xil 2 abductor pollicis and cxtensor pollicis brevis 2 One for the extensor carpi radialus longus Fig xil 3 and brevis Fig xil 5 3 One for the extensor pollicis longus 4 One for the cxtensor (communis) digi Fig xil 6 torum and extensor indicis Fig xli 7 5 Onc for the extensor digiti minimi Fig xil 8 6 One for the extensor carpi ulnans The extent of the synovial sheaths is indicated in the diagram where the radial artery is also depicted as it Fig xll crosses the anatomical snuff box towards 9, 10 the base of the first interosseous space at which level the vessel dips down between the two heads of the first dorsal interosseous muscle to complete the deep palmar arch The bony prominence on the medial aspect of the dorsum of the lower end of the ulna alters with pronation and supination of the forearm In pronation this promi nence is formed by the head of the ulna while in supınation the prominence is formed by the styloid process of the ulna VESSELS ETC OF THE UPPER LIMB The axıllary artery extends from the outer border of the first rıb to the lower margin of the teres major muscle When the arm is held out at right angles to the long axis of the body and the palmar surface of the hand turned ·30 THE UPI ER LIVB upwards the artery corresponds in direction to a lune drawn from the middle of the clavicle to the junction of the anterior and middlc thirds of the outer a Ullary wall at the outlet of that spice At its termination the artery and the accompanying nerves the neuro-Vascular bundle --form a projection which lies behind that due to the coracobrachialis and biceps (short licad) muscles The artery is dis ided into three parts by the pectoralis minor muscle shich muscle can be represented by a trianske the basc corresponding to the intenor extremities of the third, fourth and fifth ribs, whilst the apex is situated at the end of the corncoid process The brachial artery --Tbic am and forearm being field in the position already indicated as necessary Fig vi, 4 in order to map out the villary arten the brachial artery corresponds to a line drawn from thic outer wall of the axillary outlet at the junction of its anterior and middlc thirds to the mid point in front of the bed of the elbow at the level of the head of the mdius At the last point the artery bifurcates into mdul and ulnar arteries Thc radial artery cutends from tlic middle of the Riend of the ciboy at the Icsel of the head of the Fig 5 Tadius to the radial side of the tendon of the flexor carpi radıllıs muscle just above the base of the thumb The artery then crosses the anatomical snuft bor towards the base of the first intcrosscous space The usar artery in the loser tko turds of its counc 7ccompanies and lies to the lateral suite Fig 16 of thc ulnar neric The uppxer turd of its course is represented by a line which pasks obliques upuards and outs ards to tlic middle of the boxni of the elbow at the level of the head of the radius

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·THỊ SIIRUI DLR VD RW
5
IR VIL
1 Tlie ncr min
Thic lateral cpicondile of the humerus (Iktscan thirsti
fxnts the len, th of the humcrus mas lcmeiste!
3 The in crtin 1 the delt muscle
+ The minint of the felt ! coses a little mitti 1
I the circumfles nerse in circumflri urienes
55 The ridul neric

·31 TIIT UPPER LIVB The superficial palmar arch is formed by the anastomosis of the superficial division of the ulnar urtery Fig x, 8 with the superficial palmar branch or some other branch of the radial artery The convexity of the arch looks towards the fingers and lics on a level with the lower border of the outstretched thumb Occasionally the arch extends lower down, reaching as far as the upper of the two transverse creases on the palmar aspect of the hand The deep palmar arch formed by the anastomosis of the radial artery with the deep branch of the ulnar, Fig x 10 lics about one finger s breadth proximal to the level of the superficial palmar arch The digital branches of the superficial palmar arch pass downwards in the intervals between the mcta Fig x 9 carpal bones to within 4 inch of the digital clefts where the vessels bifurcate to run along the adjacent sides of the fingers The digital nerves bifurcate proximally to the deep transverse metacarpal ligament whereas the arteries divide distally The circumflex serve and the posterior circumfler artery pass backwards through the quadrilateral Fig xlll 4 space (teres minor and subscipulus above teres major below long head of triceps medially and humerus laterally) and curl round the surgical neck of the humerus towards the outer and anterior aspect of the shoulder region The artery anastomoses with the anterior circumflex artery and the level of the arterial circle so formed and of the circumfler sierve may be represented by a line drawn at night-angles to the shaft of the humerus from a point just above the centre of the deltoid muscle The inusculo cutaneous nene usually pierces the inner ·32 THE UPPER LIVB aspect of the cor cobrichialis muscle about 1 to 2 inches bclou thc coracoid process it then runs downwards and outwards, decp to the biceps muscle towards the outer bicipital sulcus, at which level it becomes cutaneous The course of the nerve in the arm can therefore be roughly indicated by a line from the concord process above to the outer bicipital sulcus belos The radial nere accompinied by the anterior brunch of the profunda brachu artery pierces the lateral intermuscular scptum of the arm from belund forwards at the junction of the upper and middle thords Fig xlll 5 of a line dra117from the inscrtion of the deltoid muscle to the lateral epicondyl of the humcris Below this point the nerve passes dontiu ards and in wards to the outer bicipital sulcus where it gives origin to its posterior interosscous branch Above the point at which the nerve pierces the lateral intermuscular septum its course may bc represented by a curved line drown ups ards and inwards to the junction of the upper arın with the posterior fold of the nulla From the outer bicipital sulcus the radial none is con tinued down the forearm accompanying und FIS v 2 lying to thic outcr side of the radial artery in its middletlurd At the junction of the muddle and lower thurds of the forcarm the nere turns round the outer border of the radius under cover of the Oracluoradialis tendon to be distributed to the back of the wrist and hund The posterior interosseous nense is given off from the radırl in the outer bicipital sulcus and curls round the nech of the ridius in the substance of the supinator muscle cmerging from the posterior border of that muscle 2 inches below the head of the rulus It then passes down the posterior aspect of the forearm lying ·THE UPPER LIB 33 Fig vl 7 about midway between the inner and outer borders and terminating in 1 gangliform cnlargement at the posterior aspect of the wrist The mediast siene in the aril --This nerve accomprntes tlic brichrzl artery and therefore presents a similar surface marking It is necessary howcver to bear in mind that the nerve crosses the artery superficially from abovc downwards and from without in ards The median nerve in the forearm passes downwards from the inner bicipital sulcus to the front of Fig vi 7 the wrist there lying to the medial side of the flexor carpi radialis and under cover of the pulmans longus tendon The nerve then passes under the flexor retinaculum to the palm The ulnar nere in the upper third of the arm lies along the inner side of the brachial artery It then Fig v! 8 leaves thnt vessel and accompanied by the ulnar collateral artery passes downwards and backwards to reach the hollow between the medial epicondyle and the olecranon process The ulnar nerve in the forear corresponds in direction to a line drawn from the medial epicondyle of Fig vi 8 the humerus to the medial side of the pisiform bone In front of the wrist the nerve lies to the medial side of the tendon of the flexor carpi ulnaris muscle and subsequently passes superficial to the flexor retinaculum protected by the volar carpal ligament to its palmar distnbution The palmar fascia is triangular in shape the apex attached to the flexor retinaculum between the thenar and hypothenar eminences whilst the base corresponds to the proximal ends of the four fingers ·34 THE UPPER LISB THE CREASES OF THE PALY AND FINGERS The proximal transierse crease on the palmar espect of the hand lies just below the normal limit of the superficial palmar arch but at the level of the lower limit of the main flexor synovial sheath The distal crease crosses the nechs of the metacarpal bones and corresponds to the praumal limit of the distal flexor synovial sheaths The metacarpo phalangeal joints lic about half way between the distal crease of the pulm and the proximal crcase of the fingers The middle and distal creases on the palmar aspect of the fingers correspond furk accurntely to the respective interphalangeal joints The hnuckles are formed by the heads of metacarpal bones ·CHAPTER III THE THORA The majority of the thoracic viscera are depicted on the surface in relation to the costal cartilages ribs and inter costal spaces and it is therefore necessary to lay stress on certain importunt points I That the twelve ribs are divided into two groups (a) True ribs seven in number articulating by means of their costal cartilages with the sterno vphoid bone (6) False ribs five in number all falling short of the middle line the upper three attached to the costal cartılage of the rib above the lower two not articulating with the transverse process of the corresponding vertebra and the antenor extremities not attached to the costal cartilage of the rib above These last two nbs are therefore known as floating ribs 2 That the ist nb lies mainly under cover of the clavicle but that its costal cartilage can generally be palpated with ease as it lies below the sternal end of the clavicle 3 That the ist interspace which can be felt to the outer side of the sternum is the ist interspace This axiom may appear at first sight to be quite unnecessary but it is in reality not uncommon for students to regard the first space which can be felt as the second interspace 35 ·34 THE UPPER LIMB THE CREASES OF THE PALS AND TIGERS The proximal transverse crezse on the palmır aspect of the hand lies just belou the normal limit of the superficial palmar arch, but at the level of the lower limit of the mun flexor synovial sheath The distal crease crosses the necks of the metacarpal bones and corresponds to the praumal limit of the distal flexor synovial sheaths The metacarpo phalangeal joints lie about huu between the distal crease of the palm and the proximni crease of the fingers The middle and distal creases on the palmar aspect of the fingers correspond furly accurately to the respectue interphalangcal joints The hnuchles" are formed by the heads of metacarpal bones ·CHAPTFR III THE THORAS The majority of the thoracic viscera are depicted on the surface in relation to the costal cartilages ribs and inter costal spaces and it is therefore necessary to lay stress on certain important points I That the twelve ribs are divided into two groups (a) True nibs seven in number articulating by means of their costal cartilages with the sterno uphold bone (0) False nibs five in number all falling short of the middle line the upper three attached to the costal cartilage of the rib above the lower two not articulating with the transverse process of the corresponding vertebra and the anterior extremities tot attached to the costal cartilage of the rib above These last two ribs are there fore known is floating ribs 2 That the ist nb lies mainly under cover of the clavicle but that its costal cartilage can generally be palpated with ease as it lies below the sternal end of the clavicle 3 That the Ist interspace which can be felt to the outer wide of the sternum is the ist interspace This axiom may appear at first sight to be quite unnecessary but it is in reality not uncommon for students to regard the first space which can be felt as the second interspace 35 ·TUD ISIONAX may the tentricular area belon and to the list This icntncular area is occupied munly by the right ventrick, Fig xls, 6 whilst a partou stnp along the telt border represents that part of thr left sentnct which Fig xlv, 7 comes to the surface The four points 611 en above for marking out the pro jection of the herrt on the anterior thoracic wall be simplified by taking and joining the following four points I The upper border of the 3rd right chondro-stemnil Joint 2 Tize lower border of the end Icit chondro-stemal joint 3 The loner border of the oth right cliondro-st1512? joint Tlic position of the apex bcat By Initing these four points thic licart is mapped out for most pmctscal purposes with sufficient accuracy 1 14: AFs of Thr }{EA!! I The podocnary sale is situnted at the lughest kiel and lics opposite the upper border of the 3rd Fig bly 9 Iuft costal cartilage close to its junction with tie sternum 2 The aortic vale lics just below and medial to the rig XIV, pulmonary talic at the lower Border of the 3rd liſt costal cartılı, c at its junction with the sternum 3 The mitral or left aunculo-scntricular rahe is situ Fig xlv ned Inhuse the left hall of the stemuin at the la ct of the 4th chondro-stemul joint The tricuspid or night juriculo-scntnculır akse lies 11. xlv very obliquely behind the stemum at the end of the 4th Interspace and the anterior extrem 13

·Tir NEART
KIDIY
GREIT ESSLLS
VALTER
19
19
RI
23
32
331
32
30
7 & 1$
LIG VIL

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·TILE TITORAX 39 itics of the 5th costul cartilages extending downwards and to the right almost as far as the 6th chondro-stemal joint THE AORTA AND OTHER VESSELS ETC The ascending aorta 2 to 21 inches long iriscs bclund Fig xiy, the left border of thc sternum at the les cl of the 3rd costul cartilage and passes upwards and to the right towards the right border of the sternum at the level of the 2nd costal cartilage The aortic arch is directed backwards and to the left Fig xly the upper limit lying about 1 inch below the 15 suprastemal notch or half way between that notch and the angle of Louis (unction of manubrium and body of sternum) The arch becomes the descending aorta at the left side of the lower part of the body of the 4th thoracic vertebra The descending thoracic aorla 7 to 8 inches long passes onwards through the posterior mediastinum and pierces the diaphragm at the level of the 12th dorsal vertebra The site of diaphragmatic perforation is represented on the surface by a point situated just to the left of the middle line tuo fingers breadth above the transpyloric plane * The innominate artery it to 2 inches long arises from the aortic arch in the middle line I inch below 16 the suprasternal notch and passes upwards and to the right to the right sternoclavicular joint at which level it bifurcates into its two terminal branches The left common carotid (thoracic course) anses from the aortic arch on a posterior plane to and slyhtly to the Fig xly, left of the trunk of the innominate artery and 17 passes upwards and to the left to the left sternoclavicular joint * Any planes mentioned in this chapter will be explained in the chapter on the abdomen 4 ·THE THORAX 10 The left subclavian artery (thoracic course) arises from flg xiy thc aortic arch on a posterior pinne to and 18 slightly to the left of the thoracic part of the left common carotid artery and passes Umost vertically upwards behind the left border of the sternum to the kft sternoclavicular joint The superior mediastinam is bounded above by the plane of the thomcic iniet and below by ? pline Fig xvll which passes bnchwards from the sternal angle in front to tlir lower border of the ith thoracic vertebru (Louis plane) The pulmonary artery arises opposite thic upper border Fig xlv, of the 3rd felt costal cartilage at its junction with the sternum, and passes Inckwards and slightly upwards to its bifurcation which takes place opposite the 2nd left costal cartilage The internal mammary artery arises from the first part of thc cervical coursc of the subclavi in artery, Fig xx, 8 and passes almost sertically downwards bc lund the corresponding sternoclaucular joint In its further thoracic course, thic artery lics & inch lateril ta the outer border of the sternum, bifurchting opposite thic Fig Xx9 6th costal cartilage or the oth interspace into 10 the musculophrenic and superior epigasine arteries The former vessel cines outis ards, following the line of the costal arch whilst the latter passas on wards to enter the sheath of the rectus abdominis muscle The left innominale icirt 3 inches long is formed opposite the left sternoclavicular joint, and passes to the right slightly overlapping the upper part of the sortic F , urch and occupying the greater part of the 21 spice between the summit of the urci lelou and the suprastcrnul notch aborc ·THE THORAY 41 The right innominale ieint is formed at the night stemo- Fig xly clavicular joint and passes obliquely down 21 wards and inwards to meet the corresponding Tein of the opposite side at the lower border of the ist right costal cartilage close to its junction with the stemum The superior tena cara formed by the junction of the Fig xlv, above tuo seins is directed almost vertically 22 downwards from the lower border of the ist right costal cartilage close to its junction with the sternum to open into the right auricle of the heart at the level of the upper border of the 3rd nght chondro sternal junction The inferior vena cava enters upon its short intra Fig xiv thoracic course by passing through the Venacaval or quadrate tendinous opening of the diaphragm at the level of the 8th thoracic vertebra opening into the right auricle of the heart opposite the 5th right interspace and the adjoining part of the stemum The cena azygos drains the whole thoracic wall except the first space on the right side and the upper three spaces on the left It opens into the superior vena cava at the level of the lower part of the 2nd right interspace curlig round the root of the nght lung in order to reach its destination The main aortic intercostal vessels occupy the costal groove of a rb as they pass round the chest wall lying between the corresponding vein above and the nerve below 23 THE PLEURA AND LUNGS 1 The pleural sacs -- When the shoulders are depressed Fig xv 5 the two clavicles lie practically at night angles Fig xvi 4 to the long axis of the body and in this ·42 THIE THORA -- position the apices of the plearal sacs extend into the supriclavicular segion, lying about it inches above the clavicle under cover of the clavicular head of the sternomastoid muscle The antenor margin of each sac atleeps downwards and inwards behind the corresponding stemnoclasscular joint, the twosacs converging towards the sternal angle (junction of manubrium and body of sternum) nt wuch level they meet one another just to the left of the middle line They then pass tertically downwards parallel to one another as far as the level of the 4th chondro-sternal junction The night sac passes onwards in the same straight linc to the 6th or gth chondrosternal joint, and then succps round the antenor, lateral and posterior aspects of the chest wall cutting across (1) The upper part of the 8th costal cartilage in the lateral scrtical line (2) The roth rib in the mid axillary line (3) The rith nb in the line of the inferior angle of the scapula (4) The 12th rib at the outer border of the sacrospinalis muscle The obliquity of tlic 12th rib causes the picura to fall below the less of the inner hall of the nb), thc picuri in the last part of its course being directed inwards towards the spine of the 12th dorsal vertebra The left pleurs from the level of the 4th Ielt chondro stemal jount, siceps obuquely outwards and downwards behind the costal cartilages of the sth 6th and 7th ribs to the Sth costal cartilage in the lateral vertical plane Beyond this point the left pleura follows the same general dircction as the night sac, descending honoyer to a slightly lower lesel

·TIIL PLLURAL SICS LUIGS I TC
5
5
6
8
7
Fig 11
1 The trachea
7 7 The main oblique fis
2 The left bronchus
sure of the lungs
3 The eparterial bronchus 8 The sinall transierse fis
4 The hyparterial bronchus
sure of the night lyg
5 The pleure
9 The Iner
6 The lungs
10 Area of

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·TIE THORAX 43 The lowest limit reached by the two pleural sacs is situated in the mid axillary line the sacs there cutting across the oth rib about 2 inches above the costal margin which is in this situation usually represented by the tip of the 11th rib Difficulty is sometimes experienced in endeavouring to verify the position of the 12th thoracic spine and in such cases the pleural reflection behind the mid axıllary region may be represented by a line which passes almost transversely backwards towards the middle line of the back from the roth nb in the mid axıllary line The two sacs are for the most part separated from one another by the width of the vertebral bodies- Fig xvl 4 about it inches In the lower part of the posterior mediastinum however the right sac approaches the middle line 2 The lungs may be mapped out in part by lines similar to those given for the pleural sacs The apex of Fig xv 6 the upper lobe of each lung extends into the Fig av 5 supraclavicular region and the antenor margins converge towards the stemal angle cutting obliquely across the corresponding stemoclavicular joint The two antenor borders do not however meet at the sternal angle for the right lung on reaching the middle line passes vertically downwards as far as the level of the 6th or 7th chondro-sternal joint whilst the left lung runs down behind the left border of the sternum to the junction of the 4th costal cartilage with the sternum The night lung from the level of the 6th or 7th chondrosternal joint sweeps outwards cutting across (1) The 6th costal cartilage in the lateral vertical line (2) The 8th nb in the mid axıllary line (3) The roth nb in the line of the inferior angle of the

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·THI PLEURAL SACS IVGS I TC 1 4- 6- B- -5 9 10- 13--- 14 9 The spleen FIG VI II The spinal dural sheath 2 The spinal cord 10 The left kidney in Nor 3 The filum terminale Tis s parallelogram 4 4 The pleuræ II The ureter 5 5 The lungs 12 The liver 6 6 The main oblique fissures 13 The descending colon of the lungs 14 The rectum 7 7 The apex of the lower lobe 15 The posterior superior of the lungs 88 The roots of the lungs The tra erse proc ses ftbe first ad second 1 mbar ertebre hould be drawn in сь om 1 to cont t th the Irder of th kidney Jiac spine manner as f To face 44 ·44 THE THORAS scapula and finally passing inwards towards the oths thoracic spine The left lung, from the outer border of the stemum at the level of the 4th chondro-sternal joint passes outwards for ? short distince along the lower border of the 4th costal cartilage, and then turns downwards and inwards in a cursed direction to the oth costal cartılıgı in the latcral sertical plane Thc lung then sweeps round the chest sall following a course similar to that alreads indicated as pursued by the right lung the left lung lyng honcur at a slightly lower level Stress should perhaps beland on the fact that is thic lower border of cach lung sweeps round the antero-laterial, lateral and posterior aspects of the chest wall, from the 6th costal cartilage in front to the roth thomcic spic behind the course pursued is practicius transterse to the long axis of the body It will be convenient to put here in a tabulated manner the comparalae lower lads of the right pleura and lung Starting in each case at the oth right chondro-sternal fomt the pleum and lung may be represented by lines winch traverse the chest wall cutting across the Pleura Luns (1) Lateral scrtical plane 8th costa) (th costu) cartilige cartilage (2) Mid axillary line roth rib Bth nib (3) Scapular line uth rib 10th ritu (4) and sweeping tanards towaris the 12th spinc 10th spine The numbers to be remembered are therefore, 6.8 20 11 and 12 for the pleura and 6 6 8 10 10 for the luns On the left side the Isels are similar with two main riceptions ofa) thic lung and pleura sweep outsirds so as to lease a part of the herrt uncostred (see 'superficial ·TUL TIJORAY 15 thoracic spine cardiac dullness ) (b) both lung and pleurn descend to ? slightly loner level The Lorcy limit of the I 119g the Plesira and the I ll cr 11 the Right Mid axıllary Line (1) Thc lung corresponds to the 8th rib pleur oth nib (3) liser costal margin or cien lower The fissures of the lungs -The mun fissure of cach lung, Fig XV 7 is indicated by n curicd line which starts FIR 6 behind at the level of the 2nd Thoracic spune the apex of the main lower lobe of cach lung thercforc being situated immediately below and inteml to this When the arms fall naturally to the side of the body the line representing the main fissure cuts across the infraspinous_surface of the scapul and crossing then the 5th rib in the mid axıllary line termin atcs in front at the inferior border of the lung at the level of the 6th coslochondral 201nt When the arms arc extended above the head the inferior angle of the scapula slides up wards and outwards on the chest wall In this position the main fissure is represented by a line from the 2nd thoracic spine which passes downwards and outwards to the inferior angle of the scapula and then forwards to the termina tion of the fissure at the inferior border of the lung The smaller or transverse fissure of the right lung sepa rates off from the main fissure in the mid axıllary line and passes almost transversely forwards along Fig xv 8 the lower border of the 4th rib and costal cartilage to the anterior border of the lung It is thus manifest that the anterior aspect of the chest above the level of the 6th coslal cartilage corresponds to the upper ·46 THE THORLY tuo lobes of the nght lung and to the upper lobe of thic lelt lung whilst the postenor aspect of the chest below the lerel of the end thorac spine corresponds to the ncht and left main lower lobes. The apices of the upper and lorer lobes --It will be here in place to agun lay stress on the fact that the apex of the upper main lobe lies about I inch bosc thc czuicle in the supmclavicular fossa, under cover of the clavicular heart of a well-developed stemnomastoid muscle and that the FIG I apes of the lower lobe lies immediately below Fig XV, 7 and lateral to the spine of the and thioricic crtebra The rools of the lungs lie opposite the spines of the 4th tul, 5th and 6th thomcic vertebre and the bodies of the 5th 6th and 7th They may be so represented lying also midway between the middle linc of the back and the vertebral border of the scapula the urms hanging loosely from the shoulders The arcas of deep and superficial cardiac dullness - I The area of deep cardiac dullness quadrate in form Fig xlr corresponds to the complete are already mapped out as representing the projection of the heart on to the antenor aspect of the chest wall 3 The arca of superficial cardiac dullness, more or less triangular in shape corresponds to that part of the heart which is not covered by the thighmlenor margin of thic Tuna Theater man with suffici be dcfinel- FIFB ·THE THORA 47 and the base by a line which passes laterally from the level of the 7th costal cartilage to the position of the apex bcat A reference to Tigs viv and a will make it evident that paracentesis of the pericardium can be performed without injury to pleura or lung in the 5th left intercostal space The internal mammary artery runs vertically downwards about 1 inch from the outer border of the stemum and the needle should therefore be inserted through the 5th intercostal space about 1 inch from the outer border of the sternum The trachea and bronchi --The trachca 44 inches long commences immediately below the cricoid FIG XY 1 cartilage on a level with the 6th cervical vertebra and passing downwards through the superior mediastinum bifurcales opposite the level of the lower part of the body of the 4th thoracic terlebra (Louis plane) The two bronchi diverge the left being the longer and the narrower The tendency of foreign bodies to pass more frequently into the right bronchus is explained by the fact that the septum between the two bronchi is placed to the left of the middle line of the trachea The right bronchus previous to the givingoff of the eparterial bronchus is less obliquely inclined than the left bronchus though subsequently it follows much the same course The greater obliquity of the left bronchus accounts also for the fact that the left pulmonary artery tends to lie at the higher level whilst the night pulmonary artery lies below the level of the corresponding bronchus The æsophagus 9 inches long also commences at the Fig xix level of the cricoid cartilage and passing downwards through the superior and posterior mediastina pierces the diaphragm at the level of the ·48 THE THORA Ioth thoracic vertebra entering the stomach at the level of the rith thoracic vertebra The entrance of the resophagus into the stomach may be indicated by taking a point on thc 7th Ict costal cartilage 1 inch 25 ay from the left side of the uphistemul joint The thoracic duct 15 to 18 inches long commences at the cisterna chyli, 1 spindle shaped sac which lies opposite the bodies of the Ist and 2nd lumbar Fig xx 5 vertebre and between the thorcic nort1 on the left and the lumbar azygos on the right It may be rep on the surface by an oval enlargement placed just to the right of the middlc line occupying the upper tuo-thurds of the space between the trinspyloric (ist lumbar) and subcostal (3rd lumbar) planes The efferent duct pierces the dnphrigm through the aortic onfic opposite the 12th thoracic verte Fig xx 6 bra and passes almost vertically upwards through the posterior mediastinum just to the right of the middle line is far as thic lower part of the 4th thoracic vertebra (Louis s planc) The duct nou crosses behind the ccsophagus to the left of the middle linc and then again passes i crtically upwards through the superior mechas tinum and into the neck as far is the lcscl of the transverse process of the 7th cervical vertceri linally the duct curls outwards and downwards to open into the ingle between the internal jugular and sul) Fig xx 7 clavan cins of the left side The duct druns the whole of the lymphatic arca of the body crcept the right side of the head and nech the right arm, the nght side of the thorax and the convexity of the Inter the lymphatics from these regions dmining into a smaller duct which opens into the angle between the night internal jugular and subclavian veins } ·CHAPTER IV THL ABDOMEN Evil The anterior aspect of the trunk (a e thorax and abdomen) is divisible into right and left halves by a median verlıcal plane from the middle point at the suprastern al notch above to the pubic symphysis below Lach half is again divided by a lateral vertical Fig XV plane which is drawn parallel to the median plane half way between that plane and the anterior superior iliac spine Prolonged downwards this lateral plane crosses the inguinal (Poupart s) ligament rather nearer to the medial than to the lateral end Prolonged upwards it crosses the clavicle about midway between the median point at the suprastemal notch and the acromioclavicular joint That part of the lateral vertical plane which traverses the mammary region is sometimes called the mammary plane that part which crosses the clavicle the clavicular plane and the downward prolongation which cuts across the inguinal ligament the Poupart plane The clavicular mammary and Poupart planes are however continuous and they together form the lateral vertical plane which is chosen in preference to the mid Poupart plane of many anatomists since it is measured from the median plane to a fixed bony point Two vertical planes only will be consequently retained in the subdivision of the anterior aspect of the trunk--the median and lateral zertical planes ub ·THE ABDOJIEN 50 The median plane can be bisected by a horizontal plane which is on the same level as the body of the first lumbar vertebra This plane so constantly cuts across the pyloric end of the stomach that it is called the transpy loric plane (of Addison) and it will be found that not Fig xvii only does this plane lie half way between the suprasternal notch and the pubic symphyses, but that it also lies midway between the umbilicus and thc xiphisternal joint It is therefore not necessary to expose the whole of the antenor aspect of the trunk in order to verify the position of the transpylonc plane-a planc of the greatest value in defining the position of sci eral abdominal viscera The point at which the median tertical and transpy loric Fig xvil FIS, planes intersect has been suitably called the central point' and the point of intersection of the lateral tertical and transpyloric planes may be Fig wil tentaticly called the lateral central' or paracentral point This latter point usu ully corresponds to the antenor extremity of the net! costal cartilage The distance between the central point and the to, of the pubic symphysis is bisected by a honzontal planc which passes through the tubercles of thic ilac Fig Xu crests the transtubercular plane a planc corrcsponding to the level of the body of the fifth lumbar crtebra It has also been suggested that the distance between the central point and the suprastemal notch should likewise be bisccted by a planche thoracic plane hich crosses the body of the sternum at the level of some part of the anterior crtremities of the fourth costal cartilages This plane is however of little Fig wil salue and is merely mentioned as completing 2 ·THIE BDOUNT AND THORACIC PAVIS Jevel of hard palntc - 1st certical Level of free margin of upper teeth = 2nd cervical Les cl of hyoid bone and to 3rd cervical Level of upper part of this rond cartilage 4th cervical Level of cricoid cartilage = 6th cersical Supra sternal plane Louis plane Disc - between 1 and 3 D Disc → between 4 and 5 P Гhoracic plane Sterno - 7D Disc between 9 and 10 D kiphord plane Trans pyloric - plane Subcostal plane Umbilical plane Transtuber cular plane Spinous - plane 3 and 3L Disc between 4 L SL Below sacral promontory 6 6 Tic IVIL The central point The lateral central or paracentral point 3 1 The median vertical plane 4 4 The lateral vertical plane 55 The mid point of the inguinal ligament (o The pubic spines T fue as

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·THT ANDoNry 51 the symmetrical sululus ssion of the median crtical plane into four cqual parts The following plancs are thereforc, chosen as the most scientific in the suixlivision of the interior assicct of thic trunk Two vertical planes (1) Thic mcdian, (2) the lateral Three transicrse planes—(1) The trinstubercular (2) the transp; loric, (3) the thoracic Two important points are also nimed-(1) Thc central point (2) the lateral central point The abdominal regions mapped out by the intersection of the transpyloric and transtubercular plancs with the lateral vertical plane receive the same nomenclature as in the older methods of regional subxdu ision of the abdomen These regions are nine in number I Right hypochondriac 2 Epigastric 3 Left hypo chondrinc Right lumbar 5 Umbilical Fig xvlil 6 Left lumbar 7 Right iliac 8 Hypogastric 9 Left iliac OTHER TRANSVERSE PLANES WITH THEIR CorrrsroND- ING VERTEBRAL LEVELS (a) The suprasternal plane on a level with the disc between the 2nd and 3rd thoracic vertebræ Fig xvi (b) Louis plane (junction of manubrium and body of the sternum) on a level with the disc between the 4th and 5th thoracic vertebre * (c) The sterno riphoid plane (unction of sternum and xiphoid process) on a level with the disc between the gth and roth thoracic vertebræ • The manubrium and body of the sternum unite at an angle known as the sternal angle (Louis) ·52 THE ABDOVEN 8 (7) The subcostal plane on a level with the loss or part of the 3rd lumbar sertebra (e) The umbilical plane on a level with the disc between the 3rd and 4th lumbar vertebre The spinous plane drawn between the two anterior Superior iliac spines and usually falling below the level of the sacral promontory The liner semilunaICS Corresponds to the latemi border FIB FIG XIII of the rectus abdominis muscle and extends with a slight outward comclity from the pubic tubercle below to the up of the oth costal cirklage above (the lateral central point) The linea transtersa result from the tendinous inter Fig tvill, sections in the rectus abdominis muscle They are three in number and are situated-(1) at the level of the umbilicus (2) midway between the umbilicus and the riphoid cartilage (3) immediately below the xiphoid cartilage Tlic arcuate linc (semilunar fold of Nou, las) represent Fig 11 ing the lower limit of the posterior Inmuella of the rectus slıcath lies about hill was Ulkoch thic umbilicus and the upper border of thc pubic sy mpliyan The timbilicus usually lies I to Xd inches love the Fig x1 lll transtubercular plane and corresponds to the level of the disc between the 3rd and 4th lumbar Vertcbre The umbilicus is foncier so incon stant in position that the umbilical plane is rejected as often as possible in las our of a morç definite and scientific planc The Iliac spines and cresi 11hen the boxly is in the dorsal recumbent position the anterior supx rior 17c pine is usually visible to the cye ind no palpation is needful in order to fix its position In the obere hincter, 11 15

·BDOTIV II PLINS TTC
6
8
6
Tic VIII
I Sterno-viphoid pline
7 I mea semilunaris
Transpıloric plane
8 I inet transverse
3 Subcostal plane
9 Arcuate line (semilunar
4 Umbilical plane
fold of Douglas)
5 Transtubercular plane
10 Anterior renal point
6 Linea alba
15

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·Tiir ANIXONIA 33 sonorilly necessary to incc foru and the elize crmt to its anterior termination By tricing ther gline crests in 7 backward direction the line tubercles will Ixc found, lying about 2 to 2] inches Brelund tlic antrins superior spines and 1 line unting these two (ulxrcles (the trans tubercular plane) corresponds to tiiclouclof the 5th lumlu scrtclon l'osterior to thesc tubercles the line crostsic to n lugher level so tluat a linc passing round the lxxly nt the lughest level of thc crests cuts tlic middlc line of thir bich at the les cl of the interspice lutween the lunint of the 3rd and 4th lumbar vertebrc (sc lumbar pundure p 67) Still further backward tlic posterior superior ilac spines will be found at the posterior termination of thic iliac crest A line wluch joins the posterior Fig xxl 1 superor iliac spines cuts across the spinc of the 2nd sacral vertebra The pubic lubercle lies at the latenl extremity of the FIG Xvl1 pubic crest In the male it is usisable to 66 invaginate the scrotum in order to locate the position of this tubercle whilst in the female, owing to the prominence of the mons pubis it is usually necessary to abduct the thigh to feel for the rounded tendon of the adductor longus muscle and to trce this tendon up to its origin from a depression on the pubic bone which is situated immediately below and internal to the pubic tubercle In the crect position of the body the pubic symphysis is nearly honzontal the inner or pelvic surface looking upwards and only slightly backwards whilst the external surface faces downwards and a little forwards The pubic crest is therefore practically directed forwards and the pubic arch backwards A knife inserted honzontally backwards immediately above the pubic symphysis would pass above the upper limit of the prostate gland and below ·54 TIE ABDOMEN the promontory of the sacrim whilst of directed Jior zontally backwards below the pubic symphysis it would pierce the prostate near its centre and pass below the level of the tip of the coccye The inguinal canal. In the adult this cinal is about Fig xx, 19, Ił inches long and extends from the deep 19 Fig xx 17, to the superficial inguinal rings The deep 17 inguinal ning n funnel shaped prolongrtion of thie trans crsalis fascia 15 stuated & inch above the mid point of the inguinal ligament The superficial ingunal Fie xx. 18, ring, formed by the splitting of the sponcurosis 18 of the external oblique muscle is triangular in shape, the base directed dou7iu ards and inu zrels and opening up immediately above the pubic tubcicle wulst the apey is directed upwards and outwards The lumbar inangle (trangic of Petit) - This triangle is bounded antenorly by the posterior border of the external oblique and posteriorly by the antenor border of tlic latis simus dorsi muscle whilst the base is formed by part of the linc crest The external obliquc is inserted into the antenor half of the ilac crest in the basc of the triangle corresponds to 1 to 2 inches of the bonc br.lind the mid point of the crest Tic triangle is subject to great variation in size the two bounding muscles con verging rapidly abosc to form the apex of the triangle Thic floor is formed by the internal obliquc muscle THE ALIMLYTARY CANAL The stomach --Capacıts about 2 pints "The cardiac. on fice lies opposite tht Iith thoracic i crtebr Fig xix, 2 and is situated about 4 inches au 73 from the surface It corresponds in position to a point on the 7th costal castilage lunch asay from the Intero) bosiler of ·THE ABDOMEN 55 the siphisternal joint The seventh costal cartilage is the lowest of the series of cartilages which articulate in front with the central xiphersternal bar and forms therefore the upper lateral boundary of the epigastric tningle Thic Pj loric orifice lies opposite the ist lumbar vertebra and corresponds in position to a Fig xix, 3 point in the transpyloric plane just to the right of the middle line The lesser curature is represented by a cur cd line convexity to the left uniting the above two points The greater curature in the moderately distended condition of the stomach ascends to the lower border of the left 5th costal cartilage and nb lying immediately above and behind the apex of the heart Sweeping then downwards the greater curvature usually cuts the left costal margin at some part of the 9th costal cartilage and finally curves upwards and inwards to the pylorus The Fig xlx 3 upper limit of the fundus of the stomach corresponds to the level of the left dome of the diaphragm Thus the stomach may be represented diagrammatically but owing to the changes in shape which it undergoes during digestion it is impossible to indicate its appearance and dimensions on the surface with any real accuracy After banum \ray it appears more as a vertical tube the lower border before turning up to the pylorus descending to the level of or below the umbilical plane Perhaps it suffices to indicate the two more or less fixed points cardiac and pyloric orifices and to draw a some what U-shaped organ between the two The duodenum Total length about 10 inches Part 1 Fig xix 4 = 2 inches part 2 = 3 to 4 inches part 3 4 to 5 inches The pylonc orifice of the stomach lies opposite the ist 5 4 4 ·56 TIC ABDOYEV lumbar vertebra and the first part of the duodenum is directed backwards, with a slight inclination upwards to the right side of the body of the ist lumbar Vertebra Part 2 descends, on the right side of the mcdian vertical plane from the level of the ist lumbar vertebra (trans pyloric piane) to the level of the 3rd lumbar ucrtebra (subcostal plane) The third part of the duodenum passes almost transversely across thc middle line at the level of the subcostal planc and having reached the left side of the middle line, ascends sharply to the d110- Fig xlx, 5 denojejunal flexure whuch is placed on a level with the 2nd lumbar vertebra just belou the transpyloric planc and I to it inches to the left of the middle linc The duodenum is subject to great vanation in position and the description 821en merely represents the average situation of this loop of the small gut The pyloric orifice of the stomach and thc duodenojejunal fcrure are both furly constant in position and between these two morc or fcss fixcd points the gut descnbes a loop winch varies both in shape and in extent Thc pancreas -The head of the pancreas occupies the concavity of the duodenal loop tlic body cross- FI! xlx 4 ing the middle line at the level of the ist und 2nd lumbar vertebre and occupying therefore the upper two-thirds of the space between the trnspyloric (1st lum vzr) and subcostal (3rd lumbar) planes The tail of the pin creas extends to the Inft as far as the hulum of the spleen Tjic small intestine is about 23 fcet in length the upper two fiftis being known as the jcjunum tire lower three fifths is the ulcum The mesenteric attachmet of the small gut extends from a point i to aj inches to the left of the muldl Fig de 6 line and just below the transpy loric plane

·THF ALIMLNTARI CANAI
-
u
4611
WALIO
6
6
Z
10
-C
13
14
I IG VI
a a and a a = the lateral sertical planes
The transpıloric plane
1 he subcostal plane
dd The transtubercular plane
To face o 11

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·FIGLIS
II The cesophagus
2 The stomach
3 The pylorus
4 4 4 The three parts of the duodenum 4 The pan
creas
5 The duodenojejunal flexure
6 The attachment of the mesentery of the small intes
tinc
7 The aleocolic valve
8 The cacum
9 The vermiform appendix
10 The ascending colon
11 The right colic flexure
12 The left colic ficture
13 The descending colon
11 Tlie iliac colan
15 The illo-pelvic colon
10 The lesser omentum (gastro-hepatic)
17 The aditus to the lesser sac (foramen of \linslos)
18 The common bile-duct
VB-The transverse colon hay lxeen intentionally omittel

·THE ABDONEY 57 (duodenojejunal Nexure), to the junction of the nght lateral virtical and transtubercular plancs The line draun betucen these two points should pass at first obliquely outwards and downwards to the right slac fossa curving finally outwards to the region of the zleocolic valve The cleocolic talle is placed opposite the junction of the right lateral scrtical and transtubercular Fig xix 7 planes The cEcun is about 24 inches long and the long axis of the sac is directly downis ards forvards, and Fig xlx 8 inwards This blind end of the large gut lies below the level of the transtubercular plane and occupies the right iliac fossa and part of the night half of the hypogastric region The termi form appendit -The opening of the appendix into the cæcum is situated just below and Fig sit 9 medial to the junction of the right lateral vertical and transtubercular planes at the top right hand comer of the hypogastric region The surface marking of the cæcal orifice of the appendix does not coincide with McBurnej s point which is situated at the junction of the outer and middle thirds of a line drawn from the right anterior superior iliac spine to the umbilicus (spino umbilical line) This point represents the usual seat of maximum pain on palpation in an attack of appendicitis The appendıx is usually 3 to 4 inches long and is directed downwards and inwards overhanging the pelvic brum, upwards and inwards towards the spleen or vertically upwards behind the cæcum Stress should be laid on the fact that the ileocoic valve and the cæcal orifice of the appendıx are both situated on the postero medial aspect of the crecum ·58 TNE ABDOMEN The ascending color passes upwards from thic level of rig xix, the transtubercular plane to the upper part of 10 the gth right costal cartilage, the gut there turning on itself to form the right colic flexure In its upward course the uscending colon lies almost entirely to the nght of the night latemi vertical plane The transverse colon extends from the right colic flexure on the right to the lefl colic ſexuse on the left The former flexure corresponds to the gt! costal cartilage, wulst the latter reaches upwards as lugh 75 the 8th In between these two points the gut vines greatly in direction in different subjects Most commonly the gut passes almost transversely from one side to the other crossing the middle line at about the level of the 2nd Jumbar vertebra It also crosses the second part of the Fig xix duodenum, and lies thercíorc, usually above 12 the umbilical plane In the diagram the tuo flexures arc depicted but the inter ching portion of the gut has been omitted intentionally The descending colon passes almost serticilly downwards Fig xix, from the region of the Icft colic ficture to the 13 level of the posterior part of the illac crest below which level it becomes known as the tlac color The descending colon fies wholly to the left of the Icft lateral sertical plane The operation of lumbar colostomy is nou seldom Big XV performed but it is nevertheless necessary to 13 indicate the position of the descending colon on the posterior aspect of the trunk It corresponds in direction to a line drawn vertically upisards to the top of the rzth rib, from 1 point situated inch Lund the mid point along the iliac crest between the interior and pastrrior supenor iliac spines ·TE ABDOVEN 59 The iliac and pelvic colon --Between the termination of the descending colon at the les cl of the iliac crest and the beginning of the rectum proper at the level of the third piece of the sacrum the large gut describes so varied a course that no definite detailed account can be given of its surface marking It may however, be briefly described FIS, *x, as passing downwards and inwards from the level of the uliac crest parallel to the inguinal ligament as far as the left side of the pelvic brım (the iliac colon) The gut then forms a great loop (the pelvic big xlx colon) which sweeps over to the right side of 15 the pelvic brım turning on itself to become the Tectum at the level of the 3rd sacral vertebra The recliiin -A line which unites the two posterior supenor iliac spines crosses the spinous process of the second sacral vertebra The rectum begins at the level of the third sacral vertebra and may be indicated on the surface by drawing in the gut as starting about 1 to 1 inch below the above mentioned line and extending downwards following the curves of the sacrum and coccyx to the anal orifice which is placed about 2 inches below the level of the tip of the coccyx The dura mater enclosing the spinal cord (see spinal cord ) reaches downwards to the level of the Fig xvi 3rd sacral vertebra The spinal dura mater therefore terminates at the same level as the rectum begins--a point to be borne in mind in those operations carried out in the sacral region for the exposure of a growth involving the gut in the neighbourhood of the junction of the pelvic colon and the rectum ·бо THE ABDOMEN TRF KIDNES (Length, 41 inches breadth, 24 inches thick tiess, It inches neight 4t olnces) (a) Anterior surface marking --The two huneys ar Fig xlv, obliquely placed in such 1 manner that the 32 superior poles lie it to inches and the in- Ieror poles 2 to 3 inches distint from the nuddle line The left hidney lies at : slightly higher level than its fellow, and the lulum is placed just below and medial to the junction of the transpyloric and left lateral vertical planes in other words the hulum of the left ficny lies just medial to the anterior extremity of the oth costal cartilage The upper pole lies half szy betsscen the sterno-uploid and transpyloric planes whilst the lower pole corresponds to the subcostal plane The right kidney docs not ascend to quite such a high level, and the interior pole lics opposite the umbilical plane Thic linum of this kidney also lies just below the level of the hilum of the opposite Lidney () Posterior surface marking allorris s parallelogram Fig xvi, -Two vertical lines are drawn at a distancı of 1 inch and 34 inches respectively from the middle line of the back and two Jonzontni lincs arc drawn outwards at the level of the spinous processes of the with thoracic and 3rd lumbar vertebrt In the parallelogram so marked out the hidney's rrc drawn, care being taken to place the long axis of cich hidncy 1.1 the required oblique direction Tur VRFTENS (Length 10 inches) {a) Anterior surface marking ---Thic ureter passes nearly Fig xlt, sertically dostiisards from the hulum of the kidney Gust Irlou and mell to the junction 10 33 ·ΤΙΙΕ ΑΣΒΣΣΟΥΣΣΑ 61 of the transpyloric and lateral scrtical plancs se from the tip of the gth costal cartilage) and dips into tlic truc pelvis in close relation to the vifurcation of the common iliac artery The intrpels sc course of the ureter 15 unsuited to any surface marking-->ł passes downwards and slightly backwards towards the spine of the ischium and tlich forwards to the base of the bladder (h) Posterior surface marking ~The course of the ureter FIS, XVI on the posterior aspect of the trunh can be represented by a line drawn vertically upwards from the posterior superior iliac spinc to the level of the spinous process of thc and lumbar 1 crtebra The ovary lies in the angle between the internal and Fig xiy external iliac artenes immediately below the pelvic brim The urachus is directed upwards from the apex of the bladder at the upper border of the pubic symphysis to the umbilicus Fig xx, 15 ABDOVINAL, VESSELS The abdominal aorta --The thoracic aorta enters the xiv abdominal cavity by passing through the 24 aortic opening of the diaphragm at the level of the 12th thoracic vertebra The vessci then changes its name and the abdominal aorta passes vertically downwards as far as the left side of the body of the 4th lumbar vertebra at which level at bifurcates into the two common iliac artenes The course of the vessel may be mapped out on the surface by taking a point about two fingers breadth above the transps loric plane and slightly to the left of the middle line and by drawing a line vertically downwards to a second point situated 1 inch below and to the leít of the umbilicus ·62 THE ABDOMEN The first lange sessel which arises from the abdominal Fig xlv, aorta is the cæliac artery This trunk is g11cn 25 off at the level of the 12th thoracic vertebra and divides after a course of about #inch into three main trunks--the hepatic splenic and left 52stric arteries The superior mesenteric (level of disc between the 12th Fig xiv, dorsal and the ist lumbar Vertebra) follows 26 next springing from the anterior aspect of the aorta immediately above the transpy lonc plane The (level of the ist lumbar vertebra) pass out Fig xlv, wards from the lateral aspect of the aorta 27 immediately below the love of the transpylonc plane The inferior mesenteric (level of the 3rd lumbar vcrtc- Fig xiv, bra) arises from the left side of the main trunk 28 at about the level of the subcostal plane The common thac artery corresponds to the upper tlurd Fig xlv, of a line drawn from a point inch below and 29 to the left of the umbilicus to a second point situated half way between the antenor superior iliac spine Fig. xlv. and the pubic symphysis The external triac 31 artery corresponds in direction to the lower two-thirds of this line The inferior epigastric artery is gis en off from the extemal alac just as that i iessel passes under 20 the inguinal ligament half way between the anterior superior iliac spine and the pubic symplysis The epigastric artery then passes upwards and inwards along the medial side of the deep inguinal ning towards a point immediately extemal to the umbilicus cntering the rcctus sheath at the level of the arcuito line This vessel forms the literal boundary of ile irruinal ·TIJE ADDOVE 63 friangle (of Hesselbach) the medial boundary being I X formed by the linea semilunans of the same 16 side and the base by the inguinal ligament Lach triangle is subdivided in a vertical direction into two parts by the obliterated umbilical artery on cither side of which hernie may protrude The inferior rena cara is formed by the junction of the two common iliac veins on the right side of the body of the 5th lumbar vertebra about 1 inch below and I inch to the nght of the umbilicus The vein passes upwards Fig xlv. through the venacaval opxning of the diaphragm at the level of the Sth thoracic vertebra entering the nght auncle of the heart opposite the 5th right interspace and the adjoining part of the sternum 23 THE LIVER The anterior border can be mapped out by drawing a cuned line from a point in the 5th left inter Fig xx 2 space 34 inches from the middle line (the position of the apex of the heart) the line cutting the left costal margin at the tip of the 8th costal cartilage and the right costal margin at the top of the oth costal cartilage Between these two latter points the anterior border of the liver crosses the middle line half way between the umbilicus and the xiphisternal joint (=trans pylonc plane) whilst a notch to the nght of the middle line indicates the hepatic attachment of the ligamertum leres which passes from that notch downwards and inwards to the umbilicus Beyond the tip of the oth right costal cartilage the Fig yt anterior border of the liver follows the lower 12 limit of the costal arch descending sometimes } ·TIIE ABDOMES cien below that level, and after cutting across the 21); mb ascends towards the level of the 11th thoracic spine The upper limit of the later as indicated by a line starting 25 before in the 5th left interspice 3) inchny from the middle line and ascending slightly as it passes to the right This line cuts across the oth nyht chondro-sternal articulation, the upper border of thc nght 5th costal cartilage in the night latem) sertical plane the 6th rib in the mid axillary line sweeping thence just below thc angle of the scapulz towards the 8th thoracic spine The gall bladder The fundus projects from under the anterior border of the liver in the angle betacen Fig xx, 3 the tips of the oth and 10th costul cartilages and the outer border of the rectus abdominis muscle The diaphragm - On ordinary inspiration the right dome of thic diaphragm corresponds to love to FIS XX1 the lower part of the 4th right interspace Sulst the kit dome uscends to the lower part of the 5th left rib and cost cartilage THE COMMOY BILE DUCT, ETC The lesser on enlum passing upnards from the lesser Fig is curtatu e of the stomach to the porta hentrs 16 of the laser, presents a free edgr, which looks downwards and to the night and unch for the anterior boundary of the aditus to the lesser sac {forımın of llins sis los--the channel of communication Extween 17 the greater and the lesser genitoneal sacs The free edge of this omentum contains (between 11$ tuo layers of portoneum) threu important structures 1 The common bile duct to the neht + Thic hepatic artery to the list

·THE LIVER
ANTERIOR ABDOMINAL WALL I TC
18
2---
*13
12
-12
P.
14
20
X16A
.-15
19
18
FIG I

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·TIGI
11 The diaphragm
2 The hver
3 The gall bladder
4 The ligamentum tores
5 The cisterna chylı
The thoracic duct
7 The venous termination of the duct
8 The internal mammary artery
The superior epigastric artery
10 The musculo-phrenic artery
11 The rectus abdominis muscle
12 12 The lineæ semilunares
13 13 13 The lineæ transversa
14 The arcuate line (semilunar fold of Douglas)
15 The urachus
16 The inguinal triangle (Hesselbach)
17 17 The decp inguinal ring
18 18 The superficial inguinal ring
19 19 The inguinal canal
20 The inferior epigastric artery

·TUIL ABLONEN 63 3 The portal sein bchind und between the two former structures In mapping out any of these structures it is therefore advisable first to draw in the lesser curvature of the stomach, the pylorus the three parts of the duodenum and the pancreas The pylorus occupies such a definite position in the transpy lonc plane that all these structures are easily and quickly drawn in The free margin of the lesser omentum should be represented as a curved line passing upwards and to the right for it to 2 inches from the duodeno pyloric junction The portal zein is formed behind the head of the pancreas by the union of the superior mesenteric and splenic i eins and passes upwards to the porta hepatis of the liver behind the first part of the Juodenum and in the free edge of the lesser omentum The hepatıc artery a branch of the coeliac artery passes upwards from the upper border of the first part of the duodenum in the free edge of the lesser omentum to the porta hepatis The common bile duct is 3 inches long and is formed Fig xix by the union of the common hepatic and cystic 18 ducts It passes downwards in the free edge of the lesser omentum behind the first part of the duodenum behind the head of the pancreas and opens on the inner and posterior aspect of the second or descending part of the duodenum THE SPLEEN The long axis of the spleen corresponds to the roth nib and the viscus extends upwards to the Fig xv 9 upper border of the oth nb and downwards to the lower border of the IIth nb The upper and inner pole lies i} to 2 inches away from the oth thoracic spine ·66 THE ABDOVEV whilst the louer or interior pole reacties as far forwards as the mid axillary linc THE SPINAL CORD The spinal cord extends from the foramen magnum to Fig 11,5 the lower border of the rst lumbar crtcbra Fig xvl (transpy lonic plane) The cord follows the curves of the vertebral column and presents also tuo enlargements cervical and lumbar The former selling lies between the 3rd cervical and and thorcic vcrtcort the latter between the 9th and 12th thoracic vertebre Neir its termination the cord tapers 2way as the contes medullars The filum terminale the prolongation of the cord ss Fig vil 7 continued onwards from the lower part of the Fig xv1 3 body of the Ist lumbar vertebru to near the tip of the coccyx at which level it blends with the peri osteum lining that bone The spinal dural sheath extends as low is the 3rd FIS ! 6 sacral vertebra at wluch lcucl it is pierced by Fig xyl 11 the filum terminale A line uniting the two posterior superior iliac spines Fig vil 10 cuts across the 2nd sacral spine and the dural FIS ! sac therefore terminates about inch Exclos 15 the lescl of this interspinous line At the third month of intra utenne life the cord extends the whole length of the scrtebral canal khulst at birth it reaches as low down as the 3rd lumbar vertebra A reference to Tig 7 will show that cerebro-spinal fluid might be withdrawn from the dural canal anyu leru betu een the termination of the cord at the lusch of the transpy loric plane and the base of the sacrum A line drawn across the back at right angles to the long exis of ·TIL ABDOVEN the body, at the level of the highest part of the iliac crests, cuts across the middle line of the back at the level of the interspace between the laminæ of the 3rd and 4th vertebræ It is at this point or rather to one side of this point that lumbar puncture is carried out THE PERINEUM A brief account only will be given as though the landmarks are most important the tendency is great to drift into the question of surgical applied anatomy-a pitfall which the water is most anxious to avoid The perineum is in shape roughly quadrilateral the lateral boundaries being formed in front by the diverging rami of the pubis and ischium and behind by the ischial tuberosity and the gluteus maximus muscle The antenor and posterior angles of the space are formed respectively by the pubic symphysis and the tip of the coccyx The pubic arch angle is obtuse in the female and acute in the male In the female also the ischial tuberosities are further apart and slightly everted The perineum 15 divided into two areas by a line drawn between the antenor part of the ischual tuberosities, thus forming- (a) The urogenital area (6) The anal area This transverse line passes about x inch in front of the anus and represents the level of the two transversus perinci superficialis muscles the posterior border of the penneal membrane (triangular ligament) and the line along which the membranous layer of the superficial fascia (Colles fascia) is reflected round the postenor border of the two transverse perinei muscles to become continuous with the posterior border of the perineal membrane The central tendinous point of the perineum 6 ·68 THE ABDOVEN (perincal body), corresponds to the middle of this line and forms the point of attachment of several muscles (a) The urogenital area in the male this arez is divided into two lateral triangles by the median antcroposterior prominence of the bulb of the penis (corpus spongiosum) The two crura of the penis (corpori cavemosa) diverge as they piss backuards towards the tuberosity of the ischium and the main pudendal vessels lie under cover of these erectile organs The thinglc is completed bchind by the transversus perinci muscle All the above mentioned erectile structures and muscles le superficial to the perineal membrane In the female this area is practically cut into two lateral triangles, by the orifice of the vagina each side of which lies the bulb of the estibule an organ of crectile tissuc corresponding developmentally to the male corpus spongi osum More superficially, the two labia major converge towards the mons pubis in front whilst on the inner aspect of the labra majora, the labia minora contcrge towards the clitoris between which body and the vaginal murgın a smooth trangular space exists--the restibule At thic junction of thic vagina and the vestibule the urethra opens Vaginal examination ---Passing along the posterior vaginal all the finger enters the posterior fornix upper part of wluch is in direct relation urth the peritoneal causis (Douglas s pouch) Along the anterior wall the smaller anterior fornix is first encountered, thus cul-de sac not being directly related to the pentoncal cavity, and immediately above this the cervixideri may be examined Bunanually much infornation can usually be guned with regard to the size and position of the uterus, the condition of the uterine appendages the contents of Douglas s pouch cc (6) The anal area --This area is divided into to lateral parts by a line drawn from the contri point ol ·THE ABDOMEN 69 the perineurn to tlic tip of the coccyx and the examining fingers may in thin subjects be made to sink deeply into each lateral recess (the ischiorectal fossæ) being then in relation with the rectum and levator anı muscle on the inner side the ischial tuberosity and the obturator internus muscle on the outer side the transverse perinei muscle in front and the gluteus maximus and sacro tuberous ligament behind Rectal examination - If the forefinger be gently inserted into the rectum definite resistance is offered by the external and internal sphincters the latter aided by contraction of the levator anı muscle further on the finger enters the dilated ampullary portion of the rectum meeting perhaps further obstruction from the transverse rectal folds (valves of Houston) When insinuated as far as possible the palmar aspect of the distal phalanx will in the male be in contact with the vasa deferentia the vesiculæ seminales and the base of the bladder the middle phalanx with the prostate gland and the proximal phalanx with the sphincters which intervene between the finger and the perineal membrane and the spongy and membranous parts of the urethra Posteriorly the hollow of the sacrum and the coccyx can be explored It is most important to bear in mind that the peritoneum is reflected from the rectum on to the upper third of the ragina in the Jemale and on to the vesicula seminales about I inch aboże the upper limit of the prostate gland in the male In children since the true pelvis is but little developed and the later pelvic viscera are practically abdominal a rectal examination enables one to explore all the lower abdominal vi.cera including the bladder In the female the cervix uteri can be felt projecting against the anterior rectal wall ·CHAPTER V THE LOWER LIMB The pubic tubercle the illac crest, the antenor ind sos terior superior illac spines and the ilsac tubercles fasc all been alluded to previously and located It has also been stated that a line uniting the two postenor superior iliac spines cuts across the spine of the 2nd sacsal estebra Beloss this line the semuning sacral spines and the coccy arr casily fult, though the coccy r itself is more riy xx readily verified by inserting the forefinger into the rectum whilst the thumb is placed oicr the bonc externally The region of the hip--{a} Posterior and lateral aspect The greater trochanter of the femur and the iscul tubcrosity must now be examined Tic latter process lies under cover of the lower part of the gluteus maximus muscle, ulust the trochanter is subcutancous in its lower part and cou cred oser in front and abosc by thic insertion of the gluteus medius muscle The trochanter is more or less quadmlateral in shape fig wat 2 fading off into the shaft of the femur belou Fig utly and presenting? well marked posterior border the highest point of the trochanter corresponds to the postenor superior angle of the quadnlateral When the body is in the crect position, there is a well-defined depression situated aboucand behind the great trochanter which becomes less murhed when as the result of disease 70

·THT BACK OF THE THIGH AND LCG
2
W.76
12
13
FIG XXI
T ja 7

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·TIG X41
1 Posterior superior Iliac spine
2 Greater trochanter of femur
3 Nélaton s line from ischial tuberosity to the anterior
superior uliac spine cutting across the summit
of the greater trochanter
4 Puriformis muscle
5 Scratic nerve
6 Medial popliteal nerve
7 Lateral popliteal nerve
8 Posterior tibial nerve
9 Popliteal space
to Biceps tendon
11 Semimembranosus and semitendinosus
12 Mantarıs and lateral head of gastrocnemius
13 Medial head of gastrocnemius
14 The short sphenous vein

·TIIE LOWER LIMB 17 5 or disuse the gluteus maximus undergoes atrophic changes The fold of the nates does not correspond to the lower border of the gluteus muximus Fig xxl muscle as it crosses almost transversely the lower oblique fibres of that muscle This fold also becomes less distinct when the glutei muscles degenerate The head and nech of the femur form with the shaft of that bone an angle of 125 to 130 degrees Nelaton s line — If in the normal state you examine the relation of the greater trochanter to the Fig xxl 3 Fig xxly other bony prominences of the pelvis you will find that the top of the greater trochanter corresponds to a line drawn from the anterior superior iliac spine of the alıum to the most prominent point of the tuberosity of the ischium This line also runs through the centre of the acetabulum The extent of displacement in dislocation or in fracture is marked by the projection of the trochanter behind and above this line (Nélaton) Bryant s triangle-When the patient is in the dorsal recumbent position draw a line round the body at the level of the anterior superior iliac spine and from this line drop a perpendicular to the top of the great trochanter To complete the triangle draw a line from the anterior supenor iliac spine to the top of the trochanter When the trochanter is displaced upwards the perpendicular line is diminished in length as compared with the sound side and when it undergoes a backward displacement the spino trochantenc line is relatively increased in length (6)-Anterior and medial aspect The lower limb is demarcated from the abdomen by a well marked furrow the inguinal groove This corresponds to the situation of the ingunal ligament (Poupari s ligament) the recurved Fig, xxiv ·72 THE LOWER LIMB lower border of the obliquus externus abdominis muscle This ligament as it passes from the antenor superior cuac spune to the pubic tubercle of the same side forms the upper boundary of the femoral triangle (Scarpa s tnangle) a space which is best demonstrated when the thigh us Figs xxx, flexed abducted and everted Thc sartorius muscle is then thrown into action and the outer boundary of the space so shown If the hand be now placed on the upper and inner aspect of the thigh and the limb be sharply adducted a rounded tendon at once becomes noticeable This is the adductor longus which forms the inner boundary of the femori triangle The outwardly directed adductor longus and the iny udly curving sartorius converge to form the apex of the triangle The floor of the space is formed from without inwards by the shacus psoas major, pectincus and adductor longus muscles In the superficial fascia which overlies this region numerous lymphatic glands are situated and it wall here be convenient to discuss briefly their general arrangement "The superficial lymphatic glands are placca in three main groups (1) The oblique or inguinal glands, running parallel to and bclou the inguinal ligament and draining the anterior aspect of the abdomen below the level of the umbilicus the lower falf of the side and back the glutcal region and the upper and outer part of the thigh (2) Therertical or femoral glands running with the long saphenous sein and draining the greater part of the inner aspect of the foot leg and thigh (3) Thc pubic glunds situated below and lateral to the pubic tubercle and drining mainly the exteril genitals perineum and anus

·THE FRONT Or THE THIGH AND LEG
10
12
13+
15
FIG XXII

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·IIG IIII
I The anterior superior iliac spine
2 The pubic tubercle
3 The inguinal ligament (Poupart s ligament)
4 The sartonus muscle
5 The adductor longus muscle
6 The fernoral nerve
7 Temoral arteries
8 rcmonl vein
9 Icmoral ring
10 Saphenous vein and opening
11 Upper limit of hnec joint (sulxrurcus rouch)
12 Level of knce joint
13 The long saphenous sein
14 Anterior tibial artery
15 Anterior tibial neric

·TUI LOWER LIVB 73 9 7 The deep fascia presents an opening the sapl enous Fig wil, opening for the transmission of the long 10 Fig xlll saphenous vein to the femoral vein This fora 13 men is oval in shape being Liach Jong and to 4 inch broad the long axis vertical The central point of the opening is situated it inches below and it anches lateral to the pubic tubercle Bencath the deep fascia overlying the femoral trangle certain important structures are situated, such as the femoral artery superficial branches and profunda femoris arteries, the corresponding veins and the femoral nerve These will all be dealt with later the femoral ring alone needing here further definition The femoral ring through which a femoral hernia commonly escapes from the abdominal cavity les F16 !! below the medial part of the inguinal ligament and lateral to the pubic tubercle A good wav to define the ring with precision is that recommended by Hoiden Teel for the pulsation of the common) fumoral arterv Zallow } inch on the inner side for the femoral vein/ then comes the femoral ring The femoral ring presents the following boundaries To the inner side is Gimbernat s ligament* to the lateral side is the femoral in front is the inguinal ligament behind is the pectineus muscle and the horizontal ramus of the os pubis The subsartorial castal (Hunters canal) a more or less Fig xxili triangular muscular channel for the transmission of the femoral artery occupies the middle third of the antero-medial aspect of the thugh During forcible contraction of the thigh muscles the femoral triangle may be seen to be continued downwards as a shallow depression between the extensor and adductor • This is the lacunar ligament tbe pectineal reflection of the foguinal ligament vein ID ·74 THE LOWER LSNB muscles, this furrow corresponding to the position of the canal in question The anatomical boundaries of the canal are (1) sastus medialis laterally (2) adductor posterior longus and magnus posterior (3) sartorius and a strong fascial bind between the adductors and vastus medialis in front and medially The canal transmits the fcmoral vein and artery the saphenous nerve and the nere to the vastus medialis In order to compare the length of the lower extremities the limbs should bu placed parallel to one another, and the tape measure carried from the anterior superior aliac spink to the top of the medial malleolis of the tibin of Tig xx}} the same side The distance between these 12 tso points may be subdivided if necessary by marking out on the medial aspect of the Ince thic transverse line which indicates the level of the ance joint The lengths of the femur and of the tibia arc thus separately estimated The region of the knet ---The biceps tendon forms the upper and lateral boundary of the popltcal Fig 1,9 space, and under coser of this tendon on its medial or pophtcal aspect a cord bike structure is felt the lateral popliteal nene This intimate relation of tendon and of nerve must be remembered in the operi. tion of tenotomy of the biceps tendon 11 FIA XXI 7 10 the biceps tendon be nok traced douards the head of the fibula is reached this process Fig al lying beloss lateral and on a posterior planc to the lateral tuberosity of the tilt The stylord process of the head of the fibula projects upwards from the posterior part of the head and in front of this the rounded long lateral ligament of the inec joint can be traced upwards to its ft mora] attachment in front of

·THE SIDE OF THC THIGH AND LEG
12V
12
FIG XXIII
7a fac

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·CHIGIL
TII SIDI OF T11!
ILLUS
6
Irc 111
1 Iliac crest
2 Anterior superior iliac spine
3 The inguinal ligament
4 Bryant s triangle
5
Vélaton s line
6 Great trochanter of femur
To follow Fig XXII

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·FIG IIV
Right foot
1 Peroneus longus
2 Peroneus brevis
3 Peroneal tubercle of calcaneum
4 Herd of calcaneum and origin of the extensor digi
torum brevis muscle
5 Peroneus tertius
6 Extensor digitorum longus
7 Innermost tendon of extensor digitorum longus
Left foot
I Tibialis postenor
2 Flexor digitorum longus (passing over sustentaculum
tab)
3 rleror hallucis longus
4 Tendo calcancus (Achilles)
5 Sustentaculum tali (of calcancum)
6 Tuberosity of the navicular
7 Hend of talus
8 Tibialis antenor
9 Extensor hallucis longus

·TUFLOKTR'LIMB 77 under aspect by the peroncus longus tendon The tendon crosses the plantar aspect of the foot in a forward and inward direction, to be inscrted into the lateral aspect of the base of the first metatarsal bone Immediately in front of the lateral malleolus there is a well FIE XIV marked depression which is bounded in front by a prominence due to the fleshy mass of the extensor digitorum brevis and above by the tendon of the peroneus tertius If the floor of this depression be examined, the head of the talus will be felt above and to the medial side and the head of the calcancum below and to the lateral side Between the two malleoli in front of the ankle joint four tendons can be felt The most prominent and the innermost is the tendon of the tibialis anterior Fig XXV muscle Lateral to this follow the extensor hallucis longus the extensor digitorum longus and the peroneus tertius When the foot is well extended the head of the talus can also be identified lying under cover of the extensor tendons Fig xxv, Immediately below the medial malleolus is 5 the sustentaculium fal grooved on its under 3XY 2 aspect by the flexor hallucis longus tendon The tibialis posterior tendon can be traced upwards Fig XXY behind the medial malleolus and downwards to the tuberosity of the navicular bone to which process the tendon gains its main attachment in front of the medial malleolus there is another depression which Ires below the line of the tibialis antenor tendon and here the head of the talus can again be felt especially pro- Fig mv, minent when the foot is well everted About I inch below and in front of the medial mat Fig XY leolus the tuberosity of the navicular Ivone 7 ·78 TIIE LOHIER LIND forms the most prominent bony point on the medırl side of the foot and a line which joins the tip of the medial malleolus the head of the talus, and the Fig XXY navicular tubercle normally presents a slight upward convexity In flat-foot, the head of the talus undergoes a down ward displacement and the line uniting the three bony points becomes straight or cyen downwardly consex A line drawn almost transversely across the foot from a point proximal to tle navicular tuberosity indicates the level of the transverse tarsal Joint In front of the navicular tuberosity, the FIG XXV medial cuneiform and the first metntarsal bones may be located and crified Behind the ankle joint the tendo calcancus (Achilles) is FIG AXY, placed the tendon being at its narrowest at a point about id inches above its inscrtion into the postenot part of the calcancum When distended with fluid the synovial micmbrane of the ankle joint bulles outwards so as to obliterate the depressions that normally lic between the tendo calcancus and the two millcoli The extensor retinacular ligaments of the ankle --Thu Fig xxv, superior portion of this ligament about I inch broad, extends transversely across the ankle from tibia to fibula It presents two compartments only one for the tibialis anterior, and one for the FIS VI remaining extensor tendons The former tendon alone possesses a synovial slicatlı The infenor portion of the ligament is Y-shaped the FIG AV single limb arising from the upper and lateral aspect of the head of the calcaneum in close connection with the ongin of the extensor digitorum brevis muscle The upper limb of the divided portion 4

·THE RI GIO Or Thir ANNICAD TOOT
11
3-
11G II
I The medial malleolus
The lateral malleolus
3 The superior transverse band of the extensor retinaculum
4 The Y shaped inferior portion of the extensor retinaculum
5 The tibialis antenor snoval sheath
6 The extensor hallucis longus synovial sheath
7 The extensor digitorum longus and feroneus tertius
Synovial sheath
I ja 19

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·80 THE LOWER LIVIA The peroneal retinaculum is less definito in shape and can only be descnbed as a broad band passing from the lateral malleolus to the lower margin of the calcucum Beneath it tuo tendons pass the peroncus vig Xxvių, longus and brevis These two tendons possess 1 2, 3, 4 a common synovial sheath, which extends upwards 2 to 3 inches above the tip of the latcrud malleolus and downwards as far as the peroner! tubercle where the sac divides into two one part accompanying the peroncus brevis to near the base of the fifth metatarsal bone the other extending forwards to the outer and under aspect of the cuboid bonc The FIA xxlx. FIA peroneus longus is also usually enclosed in a synovial sheath in the last inch or so of its Course, previous to its insertion into the lateral aspect of the base of the first metatarsal bone 1,4 Tue Vessels AND NERVES OF THE LOWER LIMB The superior gluteal artery emerges from the greater sciatic foramen, abore the pinformuy musclc. at the junction of the inner and middle thurds of a line drawn from the posterior supunor tlac spine to the top of the greater trochanter of the femur of the same side The inferior gluteal artery may be ligatured at a point which lies just lateral to the junction of the Fig at middle and lower thirds of z line drawn from the posterior supenor ilirc spine to the outer part of the ischnal tuberosity of the same side This line also cuts across the posterior inferior tlac spirt and the tip of thic ischial spine hilst the issternal pudendal artery lies imme dritely medial to the seat of clection for ligation of the inferior gluteal astery

·11il REGION OF THE VILT AVD 1oor
FIG SL11)
1 The peroneus longus inu brevis havin) sheath
The peroneus brevis sheath
3. The peroneus longtis sherth
The peroneal tubercle
TIGTI
1 The peroncus longus si noual sheath
The flexor digitorum longus 5
noul sheith
3 The flexor hallucis longus ynoval
shenth
+ The insertion of preroneus longus
into base of ist trictatarsal lone
TRIP

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·TIC LOWER LIVB Ar The femoral arten With the tiugh ficred cvcrted Figs xxil and slightly abducted thus vessel corresponds and txill in direction to a line drawn from a point midway beturen the anterior superior iliac spine and the pubic symphysis to the adductor tubercle of the femur belou Fig xxl The upper it inches of this line = the femori artery before the profunda femons is 5 frien oft FIS, Fig xl The upper third = the femoral artery in the femoral tringle The upper tuo-thirds = tlic complete course of the femoral artery Fig xlll. The middle third the femoral artery in 10 the subsartorial canal The popliteal artery enters the upper ang le of the popliteal space (from the medial side) by passing between the femur and the adductor magnus tendon. The vessel at first passes obliquely outwards and downwards to the mid point of the space and then changes direction by passing vertically downwards as far as the lower border of the popliteus muscle at 3hich level at bifurcates into anterior and posterior tibial arteries The point of bifur cation corresponds to the level of the tubercle of the tibia The anterior tibial artery --The course of thus vessci may be indicated by a line drawn from a point 14 Fle all just below the level of the tibial tubercle and midway between the lateral tuberosity of the tibia and the head of the fibula to a second point in front of the ankle midway between the two malleol at which level the artery lies between the tendons of the extensor hallucis longus and digitorum longus muscles Fig i

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·Titr 10WIR LIST! SI and til The femoral artery -\lith the thigh lerce csested Fifs xxl1 and slightly zlxlucted thi ressel corresponds 11 direction to 1 line dmin from 1 point mudway between the interior suprnor Ilinc spine and the pubic simplıysis to the adductor tuixcrcle of the femur below Fig all The upper il inches of this line the femoral artery Ixefore the profunda femoris is 871 en off The upper third = the femoral artery in the (cmoral triangle The upper two-thirds = the complctc course of the 3 7 femoral artery الله وFI 10 The middle third = tlic fcmonl artery in the subsartonni canal The popliteal artery cnters tlic upper angic of the popliteal space (from the medial side) by passing between the femur and the adductor magnus tendon/The sessel at first passes obliquely outwards and downu ards to the med point of the space and then changes direction by passing vertically downwards as far as the lower border of the popliteus muscle at which les cl at bifurcates into anterior and posterior tibial arteries The point of bifurcation corresponds to the level of the tubercle of the tibia The anterior tibial artery -The course of this vessel may be indicated by a line drawn from a point just below the level of the tibial tubercle and midway between the latcral tuberosity of the tibia and the head of the fibula to a second point in front of the ankle midway between the two malleoli at level the artery lies bet is een the tendons of the ext hallucis longus and digitorum longus muscles Fig Exil Fig xxlll ·82 THE LOWER LIMB The anterior tibial artery is continued onwards as the dorsals pedis as far as the base of the first interosseous space The posterior (bral artery starts at the lower border of the poputeus muscle as one of the terminal branches of the popliteal artery It can be represented by a lie which starts at the inferior angle of the poputeal space, on a level with the tubercle of the tibia, and which passes downwards and inwards to the mid point betucen the posterior border of the medial malleolus and the medial border of the calcaneum At this level it bes under cover of the flexor retinaculum, and bifurcates in this situation into the medial and lateral plantar arteries Behind the medial malleolus the postenor tibial artery lies between the tendons of the flexor hallucis longus and digitorum longus muscles, but on a slightly superficial piane The inedial plantar arlery passes forwards to the cleft between the first and second tocs whist Fig xxix the more important lateral planlar arlery is first directed forwards and outwards towards the base of the fifth metatarsal bone and then changing direction passes forwards and inwards to the bisc of the Fig xxix first intcrosscous spice, forming in this latter part of its course the planlar arch It anastomoses with the dorsalis pedis artery which dips downwards between the two heads of the first dorsal interosscous muscle The short saphenous zein arises from the lateral side of Fig , the enous arch on the dorsum of the foot Fig tal, passing upwards behind the latcral malleolus and along the lateral and posterior part of the leg to the middle of the popliteal space where it pierces the deep fascia to open into the popliteal vein ·TIIT LOI CR LIVD 83 is accompanied in the greater part of its course by the sural nene, which cxtends forwards on the lateral side of the foot as far as the tip of the little toc The long saphenous icin arises from the inner side Fig xxll, of the venous ?rch found on the dorsum of 13 Fig xxll1 the foot It passes upwards in front of the 12 mcdial malleolus along the inner wide of the leg and hnee behind the medial condyle of the femur and its further upward course in the thigh is indicated by a line drawn from the adductor tubercle to the saphenous opening Attention has previously been drawn to the clevation below the medial tuberosity of the tibia winch is formed by the sartorius gracilis and semitendi nosus muscles and below this prominence the saphenous vein is accompanied by the saphenous nerve a branch of the deep division of the femoral nerve The saphenous nerve runs down the leg with the vein in front of the medial malleolus of the tibia and extends as far forwards as the ball of the great toe In the thigh the nerve crosses in front of the femoral artery from without inwards and accompanies that artery throughout the whole length of the subsartorial canal The femoral nene emerges from under cover of the Fig xll inguinal ligament about half way betwcen the Fig anterior superior iliac spine and the pubic tuberclc The nerve lics nearly finch lateral to the femoral artery and the same distance lateral to the fernoral sheath The sciatic nene makes its exit from the pelvis through the greater sciatic foramen below the 5 piriformis inuscle The nerve emerges from under cover of the lower border of the gluteus maximus muscle just to the mediul side of the mid point between 6 ·8.4 TIE I OWER LIVB 6,8 the ischial tuberosity and the greater trochunter of the fcmur The nerve corresponds in direction to the uppur so thirds of ? line drawn downui nrds from the aborc point to the middle of the popliteal space below At the junction of the middle and lower thirds of tic thigh thic sciatic nerve divides into its two terminal branches medial and lateral popliteal The posterior femoral cutaneous (small scintic) serie lies in the same line is the scintic but cutends down ards as far is the inferior angle of the popliteal space The medial popliteal nere crosses the popliteal artery Fig x superficially from thout inwards its on ward continuation the posterior tibial nene and the two terminal branches of the posterior tibial nerve the medial and lateral plantars, all have the same surface marking as the corresponding arteries Tuo points however need to be bome in mind first the posterior tibral nerve crosses tlic corresponding artery superficiilis from within outwards and downsards and, secondly. the medial plantar nerve is relatii cly much more important than the corresponding arter The lateral popliteal nene sas list scen to lie under cover of the biceps femons tendon at the upper and lateral boundary of the popliteal space The nerve follows the tendon downwards to the head of the fibula, and curls round to the antero-lateral aspect of the leg about 1 inch below the head of that bone dividing there into its two terminal branches antcrior tibial and musculocutaneous The anterior tibial nene passes downwards and insids to join the corresponding arterlying Interal to the Tig xxl upper third of the attery, superficul to the middk third and literal 182 10 the lo set 7

·THE LOWER LIMB
85
third The nerve cxtends forvards along the lateral side
of the dorsalis pcdis artery as far as the cleft between the
first and second toes, the contiguous sides of which toes it
supplies
The musculocutaneous ner e running down in the sub
Fig lil stance of the peronei muscles becomes cuta
5
neous below the middle of the leg It then
passes obliquely downwards and inwards across the
extensor retinaculum to be distnbuted to the greater
part of the dorsal surface of the foot

·88
APPENDI
THE WEIGHT OT SOME ORGANS
The brain Male, 50 ounces, female, 45 ounces
The lungs Together, 42 ounces right 22 ounces,
left, 20 ounces
The heart Male 10 to 12 ounces, female, 8 to
10 ounces
The liver 50 to 60 ounces
The kidneys, 45 ounces
The suprarenals, i to 2 drachms
The prostate ounce
The testis I ounce
The ovary, 1 ounce
The spinal cord it ounces
The pancreas 2 to 4 ounces
The spleen 7 ounces
I ounce = 28 grammes

·ATTENDI 89 AN OUTLINE Or THE OSSIFICATION AND EPIPHY SES or TIC SULLETOV I\CLUDING THE CRANIUV Certain cmphyses and epiply seal lines have been alluded to in the text and the following table compiled from Grays Ana tomy trazer s The Anatomy of the Human Shelcton and Cunninghams Text book of Anatomy has consequently been appended (a) Tur UPPER LIBIB The Claticle l'nmary centre ! for the shaft (in membrane) in the fourth or filth weck (ul) Secondan centre I centre for the sternal end in the eighteenth to tu en tieth ycar Union between the two in the twenty fifth year 4-5 WK 18-20 25 Primary catre Secondary centre FIC 30 CLAVICLE The Scaprela Primary centre I for the body in the eighth week (1 ul) Secondary centres I for the coracoid proper in the first year i for the subcoracoid region (lateral part of the root of the corcaoid and upper one thurd of the glepoid cavity) in the tenth year Union occurs at puberty in the fifteenth I for the margins of the glenoid year fusing i for the inferior angle between the I for the vertebral border twentieth and 2 for the acromion twenty fifth years iul intr-uterin life

·90
API ENDI
10
15
15
TIG 31 --SCATLLA
The Itmerias
Primary centre
1 for the shaft in the eighth weh (1u))
Secondary centres
i for the head on the first y car
I for the greater tuberosity in the third year
i for the lesser tuberosity in the fifth y car
- 20
18
11-13
I'c 3? - HERS

·APPENDIX 91 Head and tuberositics unite in the fifth year and with the shalt in the twentieth year 1 for the medial epicondyle in the fifth year 1 for half the trochlea in the twelfth year I for half the trochlea and capitulum in the second Year 1 for the lateral epicondyle in the thirteenth year The last three umute together to form an epiphysis which unites with the shaft in the seventeenth year the medial epicondy le joining separately in the eighteenth year The Radius and Ulna Primary centres 1 for the shaft of the radius in the ci hth week ( 11) 1 for the shaft of the ulna in the eighth week (ul) Secondary centres 1 for the lower end of the radius in the second year I for the lower end of the ulna in the sixth year These unite with the shaft in the twentieth year lo 18 18 DI 20+ 20 FIG 33-RADIUS AND ULNA 1 for the upper end of the radius in the sixth year I for the upper end of the ulna in the tenth year These unite with the shaft in the eighteenth year The carpus All the bones are cartilaginous at buth The first centre of ossification appears in the os capitatum and the last in the pisiform Capitate and hamate first yeat-tnquettum third year--lunate trape 8 ·92 APPENDI zium and scaphoid fifth and sixth years trapezoid eighth year-pisiform tuelfth year The inetacarpus and phalanges Primary centres I for the shaft of each metacarpal in the ninth week i for the shaft of each phalanx between the eighth and the twelfth week Secondary centres I for the head of each metacarpal bone and the 5250 of each phalanx in the third year Union between diaphyses and epiphyses in the twentieth year 8-12 IK 20-1 +3 A-3 2041 9WK FIG 34-ETACARPAL And PIAI ANGES The thumb metacarpal is an exception to the rule a well marked epiphysis always appeanng at the base This bone therefore resembles a phalanx in its mode of ossification though an epiphy 515 is not infrequently seen in the head of the bone itselt (b) THE LOWER LIIB The os cox Three main primary centres for ilum sschium and pubis appeanng respectuely in the second third and fourth months (1 u 1) The three parts of the bonc are separated at first by the Y shaped acetabular cartilage Fue secondary centres appear about puberty for the crest pubic symphysis Interior inlenor Mac Spine ischial tuberosity and the acctabular cartilage These unite at about the twenty fifth year The femur Primary centre 1 for the shift in the sisenth sreek (tu 1.)

·APPENDIX 93 14 14 14- 14 +14 FIG 35 - Os COXAE Secondary centres I for the head in the first year I for the greater trochanter in the fourth year I for the lesser trochanter in the fourteenth year These unite with the shaft in the eighteenth year I for the lower end in the ninth month (i ul) This unites with the shaft in the twentieth year The patella I centre in the third year The tibia and fibula Primary centres I for the shaft of the tibia in the seventh week (ul) I for the shaft of the fibula in the eighth week (ul) Secondary centres 1 for the upper end of the tibia in the first year Union occurs at the twentieth year I for the upper end of the fibula in the fourth year Union occurs at the twenty fourth year I for the lower end of the tibia in the second year Union at the eighteenth year I for the lower end of the fibula in the second year Union at the twenty first year re as

·94
API CNDI
The larsus
There are primary centres for each of the tarsal boncs
I for the Calcaneus in the sixth month
I for the Talus in the eighth month
I for the Cuboid in the ninth month (nt birth)
for the 3rd Cuneiform in the 1st year
I each for the Naticular ist zad and Cuneiforms in thic
third year
The calcancus possesses a secondary centre for its
posterior Surface appeanog about the tenth year
18
20
mth
TIG 36 --TESIUR
The metatarsus and phalanges
The centres appear as in the metacarpus cte
The certebral column
There are three primary centres
i for the body (starts in the lowest dorsal region and
spreads from thence in both directions)
1 for each neural arch (starts at the axis and succes!
one another from above downs 2014)
These appear in thc seventh weck (ul) and by the
third month there are primary centres in all vertebrate

·APPENDIX
95
204
+ 24
18
→ 21
FIG 37 - TIBIA AND FIBULA
There are five secondary centres
for the top of the spine
I for each of the tips of the transverse processes
1 for the upper surface of the body
i for the lower surface of the body
These appear at puberty and unite in the twenty
first year
15
15
15
15
TIG 38—VERTEBRA

·96 APPENDIX } old age The ribs Primary centre I near the angle in the sixth neeh (101) Secondary centres I for the head At puberty and unite in the 1 for the tubercle twenty fifth year The manubritem and sternum Primary centres The manubrun in the fifth month Tusc in The sternum Ist segment in the Sixth month Twenty first 2nd segment in the year seventh month Tifteenth 3rd segment in the y car eighth month Childhood 4th segment in the ninth month Suphord process in Middle the third jear decade The mandible Develops in the first branchial arch from an 0491 fication centre in membrane to the literal site of Meckels cartilage during the sixth week ( 11) The two halves fuse in the first year ·INDEX Abdominal aorta 61 plancs 50 Acromion 20 Adductor tubercle 75 Aditus to lesser sac" (Winslow) occipital 15 plantar medial and lateral 82 pophteal 81 posterior auricular 15 tibial 82 pulmonary 40 radial 26 30 renal 62 subclavian 16 40 superficial femoral 81 palmar arch 31 temporal 16 superior gluteal 80 mesenteric 67 thyroid 14 transverse facial 9 ulnar 30 Aunçular area of heart 37 Axilla 22 64 Anatomical snuff box 28 29 Anterior triangle of nech 13 Aorta 39 Aortic arch 39 intercostals 41 valve 38 Apex beat 37 Apices of lungs 16 Appendix 57 Arcuate lune 52 62 ARTERIES anterior tibial 81 axillary 29 brachial 25 30 carotid 14 39 circumflex posterior 31 celiac 62 common lac 62 deep palmar arch 31 digitals 31 dorsalis pedis 82 facial 15 femoral 81 hepatic 64 iliac 62 inferior epigastric 62 gluteal 8o mesenteric 62 innominate 39 internal mammary 40 pudendal 80 lingual 15 Base of the brain 4 Basic fosse 8 Bicipital aponeurosts 25 groove 22 sulci 25 Bile-duct 64 Brain 4 Bregma 2 Bronchi 47 Bryant s triangle and line Cæcun 57 i Calcaneum 77 Cardiac dullness deep 46 superficial 46 orifice of the stomach 54 97 ·98 INDEX Houston s valies 69 Hypochondrium 57 Hypogastrium 57 Carotid triangle of neck 14 Central point 50 sulcus (Rolando) 5 Chassaignac s tubercle 14 Clavicle 21 Clas: pectoral fascia 21 25 Colon 58 86 Colles s fascia 67 Conus medullarıs 66 Coracoid process 21 Coronal suture Cubital fossa 24 Cvsterna Chyli 48 Ileocolic salse 57 Iliac regions 51 spines 52 56 tubercles 53 Tliotibial tract 75 Infraclavicular space 21 Infraorbitat foramen 10 Ingumal canal 54 87 rings 54 triangle (Hesselbach) 62 Injoni Insula 5 Isthmus of thyroid 19 Diaphragm 64 Digastric triangle of neck 13 15 Dorsal tubercle of radrus 28 Douglas s pouch 68 Duodeno-jejunal flexure 56 Duodenum 55 86 Dura cerebral ? spinal 59 JOINTS acromioclavicular no metacarpo-pralangea) etc 34 transverse tarsal 78 I piglottis 19 piphyses and assification of the si eleton 89-96 hidneys 60 87 68 Talv cerebri 1 remoral ring 73 triangle (Scarpa) 72 Filum terminale 66 Itssures of lung 45 Irontal sinuses II Tronto nasal duct if Lacunar ligament 73 Lambda 2 Lambdoid suturcs 2 Lateral cercbral sulcus (Syl209) 5 ventricles 7 Vertical princ 49 Lesser omentum 64 | Ligimentum patelle 75 Scres 63 Liser 63 88 Longitudinal fissure of the lirain Gall bladder 64 Gimbernat s Irganent (lacunar) 73 Hamilton shine 21 Heart 36 89 Itiatus semilun 119 11 Louis plane 40 47 51 Lumbar puncture 66 region St triangle (Petit SI ·INDEX 99 I ungs 43 88 LYAPI GLANDS asıllar 23 epitrochlear 25 femoral 72 inguinal 72 McBurney s point 57 Mammary glands 36 Varginal tubercle 3 Maxillary sinus (Highmore) 11 Mleati of rose II Median vertical plane 49 Mediastinum 40 Mental foramen to Mesentery small intestine 56 Middle line of the neck 19 meningeal points 7 Mitral valve 38 Morris s parallelogram Co Motor area (Rolandic) 6 speech area (Broca) 6 Mouth 12 Muscular trian le of the neck 13 MUSCLES adductors 53 75 biceps femoris 74 deltord 21 flexor carpi radialis 26 ulnaris 26 palmaris longus 26 peroneus longus 72 80 scalenus anterior 16 semimembranosus 75 temporal 3 tibialis anterior and pos terior 77 NERVES accessory 17 anterior tiba) 8.4 brachial plexus 19 circumflex 31 facial 89 femoral 83 grrater occipital 15 lateral popliteal 74 84 mandibular 10 medial popliteal 84 mednan 25 33 middle meningeal 6 musculocutaneous (arm) 31 (leg) 85 occipitals 15 phrenic 17 plantar medral and lateral 84 postertor femoral cutaneous 84 interosseous 25 32 tibial 84 radial 25 32 saphenous 83 sciatic 83 superficial vertical plexus 18 sural 83 ulnar 33 vagus 17 Nipple 36 -- Obelion 2 (Csophagus 47 | Orbit Io Ossification and epiphyses 89 Ovary 61 87 Nasal sinuses 11 Nasion 1 Nasolacrimal duct so Velaton s line 71 Palmar arches 31 fascia 33 Palpebral ligament to Pancreas 56 88 Paracentesis cardtac 42 ·100 IN DEV 12 Parietal eminence 25 Parieto-occipital sulcus 5 Paroud duct (Stenson) 9 gland 9 12 Patella 75 Perineal membrane 67 Perineum 67 Peroneal tubercle 76 80 Pharynx 86 Pisiform bone 26 Planes of abdomen 50 Pleura 41 Plica fimbriata 12 Porta hepatis 64 65 Posterior triangle of neck 14 Post glenoid tubercle 3 Poupart s plane 49 Prepatellar bursa 76 Pterion 5 Pubic symphysis 53 tubercle 53 Pulmonary valve 38 Pylorus 55 Siauses of the nose 11 Small intestine 56 86 Sphenoidal sinus II Spinal cord 66 86 88 dura 59 66 dural sheath 66 Spinous plane 52 Spleen 65 88 Sternal angle 36 Sterno-xiphoid plane 51 Stomach 54 86 Straight sinus 2 Subcostal plane 52 Submandibular ducts (Wharton) I2 gland 12 13 Subsartorial canal (Ilunter) 73 81 83 Superficial cervical plexus 18 Superior sagittal sinus ? temporal sulcus 5 Supraclavicular triangle 14 25 Supramastoid crest 3 4 8 Suprameatal triangle (facemen) 8 Supraorbital for men 10 Suprusternal plane st 57 Sustentaculum tal 77 Sympathetic trunk 17 Synosial membrane of knee 76 Rectal examination 69 folds (Houston) 69 Rectum 59 Region of abdomen 49 of ankle and foot 76 of elbow 23 of gemtals 67 of h 70 of knee 74 of orbit jo of perineum 67 of shoulder 20 of wrist 26 Reid s basp line 45 Retinaculum of ankle 78 80 of wist 26-29 1 Talus 77 Teeth 12 Tegmen tympani 8 Temporal lines 3 Tendons of ankle 76 of wrist, 26 Tendo calcaneus (Achillest oculi TO Tentorium cerebells 4 Testis 87 Thoracic aorta 39 duct 48 87 plane 50 Thyroid gland 19 Ribs 35 Rima glottidis 19 Roots of lungs 46 Sagittal suture 2 Saphenous opening 73 ·INDEX IOT Tongue 12 Tonsil 12 Trachea 47 86 Transp; loric plane 50 60 Transtubercular plane 50 Transverse process of the atlas 15 17 18 sinus 8 Triangles of neck 13 Tncuspid valve 38 Tympanic antrum 8 Valves of heart 38 Vas deferens 87 VEINS azygos 41 basilic 25 cephalic 25 inferior vena cava 41 63 innominate eid 40 41 jugular external 16 internal 17 of forearm 25 portal 65 saphenous long and short, 73 82 83 supenor vena cava 41 Ventricular area of heart 38 Vermiform appendix 57 Umbilical plane 52 Umbilicus 52 Urachus 61 Ureters 60 87 Urethra 87 Vaginal examination 68 Zygomatic processes 3 4 5

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