SURFACE ANATOMY AND LANDMARKS A HANDBOOK 
OF 
SURFACE ANATOMY 
AND 
LANDMARKS 
BY 
BERTRAM C. A. WINDLE, D.Sc., M.D., 
M.A. (Duel.). 
PROFESSOR OF ANATOMY IN MASON COLLEGE, BIRMINGHAM ; SOMETIME 
EXAMINER IN ANATOMY IN THE UNIVERSITIES OF CAMBRIDGE, 
ABERDEEN AND DURHAM 
SECOND EDITION 
REVISED AND ENLARGED IN COLLABORATION WITH 
T. MANNERS-SMITH, M.A, (Cantab.), M.R.C.S 
LECTURER ON OSTEOLOGY AND SENIOR DEMONSTRATOR OF ANATOMY, MASON 
COLLEGE, BIRMINGHAM 
PHILADELPHIA 
P. BLAKISTON, SON, & Co. 
1012 Walnut Street 
1896 TO 
ALEXANDER MACALISTER, 
M.D., D.Sc., M.A., F.R.S., F.S.A. 
PROFESSOR OF ANATOMY IN THE UNIVERSITY OF CAMBRIDGE. PREFACE TO SECOND EDITION. 
This second edition has been carefully revised and 
several new figures have been added. A sense of 
importance of the relations of the brain to the cranium 
and scalp has led us to bestow especial attention on 
this section, which has been largely re-written. 
B. C. A. W. 
T, M-S. 
Mason College, Birmingham. 
June 30th, 1896. PREFACE TO FIRST EDITION. 
This little book is not a surgical applied anatomy. 
Had its author ever entertained any idea of writing 
such a work, he would certainly have abandoned it, as 
the ground is already occupied by Mr. Treves’ excellent 
manual on that subject, to which he is indebted for 
various hints. This book is intended for anatomical 
students in their first and second years as a guide to 
fhat important portion of the knowledge of the human 
body which can be gained without the use of the scalpel 
and forceps. Junior students will find it useful after 
having first dissected a part of the body, to study the 
relations of the various structures, as given herein, on a 
fresh part, or still better, on the living subject. It is 
scarcely possible to impress too strongly upon the 
student desirous of obtaining a thorough practical 
knowledge of his profession, the importance of taking 
advantage of the opportunities afforded to him in the 
wards of the hospital and elsewhere, of familiarising 
himself with the surface markings, surgical and medical 
landmarks, and relations to the exterior of the impor- 
tant structures, in the living body. 
Whilst not pretending to be a surgical anatomy pro- 
perly so-called, certain surgical facts have from time to 
time been mentioned, where the importance of the 
anatomical point in question might be overlooked, with- 
out reference to its practical bearing. But the writer 
has preferred to err on the side of omission in this PREFA CE. 
12 
matter, lest the student should be confused by the in- 
troduction of too many unfamiliar facts. 
Full directions have been given for the examination 
of certain of the orifices and for the use of some of the 
commoner surgical instruments, the author believing 
that it is of great value to the student to acquire a 
readiness and dexterity in handling them on the dead 
body, and that such should be learnt concurrently with 
the anatomical study of the parts in question. 
It is difficult to exhibit any great originality in a 
work such as this (indeed much of what might be called 
original would inevitably be another name for incorrect), 
since the facts which are contained herein have mostly 
appeared in different manuals. To these it would be 
impossible to refer here in detail, but to their authors, 
whether their names are mentioned in the text or not, 
the writer desires to express his full acknowledgments. 
He has to thank his friend Dr. Crooke, Pathologist to 
the General Hospital in this town, for help in some of 
the details gained from the bodies in the post-mortem 
room of that Institution. Several careful dissections 
have been made in relation especially to the positions 
of certain of the thoracic and abdominal viscera, in 
order to ensure accuracy in the facts stated, and for 
assistance in these he has to thank his former pupil 
Mr. E, Teichelmann and his present pupils Messrs. 
A. R. Green and S. W. Warneford. He has also to 
thank his friend, Dr. Reid, for two blocks. TABLE OF CONTENTS. 
CHAPTER I. 
THE FACE. 
Sections:—i. The Face. 2. The Eye and Appendages. 3. The 
Nose. 4. The Ear. 5. The Mouth .... x-26 
Pages 
chapter.il 
THE SCALP. 
Sections:—1. The Scalp. 2, Relation to Bony Vault. 3. Rela- 
tion to Membranes of Brain and their Vessels. 4. Fon- 
tanelles. 5. Relation of Cranium to Brain. 6. Relation of 
Scalp to Brain . 27-41 
CHAPTER 111. 
THE NECK. 
Sections:—l. The Middle Line of the Neck. 2. Parts near 
Anterior Border of Sterno-Mastoid. 3. Structures Posterior 
to Sterno-Mastoid . . . . . . . 42-51 14 
CONTENTS. 
CHAPTER IV. 
THE THORAX. 
Sections:—1. Bony Points. 2. Soft Parts. 3. Relations of 
Lungs to Thoracic Wall. 4. Relations of Heart to Thoracic 
Wall. 5. Relations of Vessels, &c., to Thoracic Wall . 52 64 
Pages 
CHAPTER V. 
THE ABDOMEN. 
Sections:—l. Bony Prominences. 2, Skin Markings. 3. Rela- 
tions of Viscera to the Abdominal Wall. 4. Relation of 
Vessels to the Abdominal. Wall . . . . 65-74 
CHAPTER VI. 
THE PERINEUM AND GENITALIA. 
Sections:—1. The Male. 2. The Female .... 75-82 
CHAPTER VII. 
THE BACK. 
Spinal Cord and Nerves. Kidneys. Colon. Relations of Vis- 
cera, &c., to Vertebral Column 83-89 CONTENTS. 
15 
CHAPTER VIII. 
THE UPPER EXTREMITY. 
Pages 
Sections:—l. Shoulder and Axilla. 2. Arm and Elbow. 3. Fore- 
arm and Wrist. 4. Hand 90-112 
CHAPTER IX. 
THE LOWER EXTREMITY. 
Sections:—l. Buttock. 2. Thigh. 3. Knee. 4. Popliteal Space. 
5- Leg. 6. Ankle. 7. Foot 113-137 
Index 139-143 LIST OL EIGUEES. 
FIG. 
1. Nervous Supply of Face and Scalp, &c. .... 8 
2. Diagram of Cranium, showing Base Line of Brain, &c. . 28 
3. Diagram of Cranium, showing Lateral Sinus, &c. . facing 32 
4. Diagram of Cranium, showing Fissures . - . facing 32 
5. Relations of Chief Fissures to Scalp ..... 35 
6. Relations of Fissures and Convolutions to Scalp . . 39 
7. Relations of Lungs to Wall of Thorax .... 57 
8. Relations of Heart and Great Vessels to Wall of Thorax . 61 
q. Diagram of Anterior Abdominal Wall .... 67 
10. Anterior Aspect of Abdomen ..... facing 70 
ir. Posterior Aspect of Abdomen ..... facing 86 
12. Cutaneous Areas—Upper Extremity, Anterior Aspect . 106 
13. Cutaneous Areas—Upper Extremity, Posterior Aspect . 107 
14. Diagram of Side of Buttock .... .facing 114 
15. Bony Prominences of Foot 132 
16. Cutaneous Areas—Lower Extremity, Anterior Aspect . 134 
17. Cutaneous Areas—Lower Extremity, Posterior Aspect . 135 
PAGE A HANDBOOK 
OF 
SURFACE ANATOMY. 
Chapter I. 
THE FACE. 
I. The Face. 
Bony points,—The forehead presents on either side 
two elevations, the frontal eminences, varying consider- 
ably in the amount of their development in different in- 
dividuals. Below and separated from these by a shal- 
low groove is a supra-ciliary ridge on each side. These 
ridges which also vary greatly in size may, but need 
not necessarily, owe their prominence to large cavities 
in the substance of the bone—the frontal sinuses. This 
is a fact of surgical importance, since a fracture of this 
ridge apparently deep and serious may not open up the 
cranial cavity, but only that of the sinus. 
Like other air cavities in connection with the cranial 
and facial bones, these sinuses are small or non-existent 
in the young child, developing gradually in the course 
of growth. Between the supra-ciliary ridges is a flat THE FACE. 
smooth surface named the glabella, from which certain 
cranial measurements are made. 
Below the supra-ciliary ridges are the margins of the 
orbit, or supra-orbital ridges as they are sometimes 
called. 
Each ridge is bounded at either extremity by a 
strong prominent angle, the outer of which is by far 
the better marked ; these angles are the external and 
internal angular processes. The former limits ante- 
riorly the temporal fossa, the temporal muscle which 
it contains, and the temporal ridge with its attached 
fascia. 
By pushing up the skin covering the eyebrows, the 
supra-orbital notch may generally be felt at about the 
junction of the middle and internal thirds of the supra- 
orbital ridge. This notch is sometimes replaced by a 
foramen, which may be situated somewhat deeply in 
the cavity of the orbit ; its discovery is then more diffi- 
cult, but it may be found by deep pressure. Through 
this notch or foramen pass the supra-orbital nerve and 
artery. The former, a branch of the ophthalmic division 
of the fifth nerve, is one of the common seats of facial 
neuralgia, for which complaint it may be necessary that 
it should be stretched or divided. Two other spots, at 
which branches of the fifth nerve emerge from bony 
canals are of similar importance. The infra-orbital 
branch of the superior maxillary division emerges from 
the infra-orbital canal beneath the prominent ridge 
which forms the lower margin of the orbit. The infra- 
orbital foramen whose aperture looks inwards, is covered THE FACE. 
3 
by muscles and cannot generally be felt from the sur- 
face. The same remark applies to the mental foramen 
situated in the inferior maxilla. Through this foramen 
which also looks inwards the mental branch of the in- 
ferior maxillary division of the fifth nerve escapes. The 
position of these two last mentioned foramina may be 
ascertained by drawing a line from the supra-orbital 
notch downwards and outwards so as to pass between 
both pairs of bicuspid teeth (vide fig. i). 
This line will cross the infra-orbital foramen about a 
quarter of an inch below the margin of the orbit. The 
position of the mental foramen varies according to the 
age of the individual examined. In the child at puberty 
it is placed rather nearer to the lower than to the upper 
border of the jaw. In the adult it lies nearly midway 
between the two borders and about a quarter of an inch 
below the fold of mucous membrane passing from the 
jaw to the cheek inside the mouth. In old edentulous 
persons, owing to the disappearance of the alveoli from 
atrophy, the foramen is placed close to the upper mar- 
gin of the jaw. 
In the middle line of the face below the glabella the 
points to be noticed are the nasal bones with the carti- 
lages attached to them, the nasal spine of the superior 
maxilla which can be felt between the openings of the 
nostrils, and the ridge at the centre of the inferior 
maxilla which marks the symphysis menti. 
Following outwards, on either side, the lower margin 
of the orbit, the zygoma is reached and may be traced 
in its entire extent. The space between it and the 4 
THE FACE. 
cranial bones cannot be estimated in the undissected 
state, partly on account of the muscles which lie therein, 
and partly because of the firm and tense attachment of 
the temporal fascia above and of that of the parotid 
below. By passing the finger along the lower border 
of the zygoma, its tubercle may be distinguished im- 
mediately in front of the outer part of the glenoid fossa 
and the head of the inferior maxilla, the movements of 
which latter can be distinctly felt, and, in a moderately 
thin person, seen. 
When the lower jaw is protruded its head will of 
course be brought nearer to the tubercle ; when a dislo- 
cation occurs it is carried still further forward and 
passes over the tubercle into the zygomatic fossa. Be- 
hind the head of the lower jaw the posterior root of the 
zygoma (supra-mastoid crest) may be felt passing above 
the external auditory meatus. In the region below the 
orbit the canine eminence may be distinguished, though 
not so clearly as from within the mouth. On its inner 
side is the incisive fossa, on its outer, but at a higher 
level, the canine. 
The greater portion of the inferior maxilla may be 
defined by manipulation, the symphysis, body, posterior 
portion of the ramus, head, and neck being all clearly 
distinguishable. The coronoid process almost to its 
apex may be felt by pressing the finger under the 
zygoma and protruding and depressing the jaw. 
Skin, &c.—The skin over the forehead is fairly 
smooth and moveable, characteristics which it main- 
tains as it covers the nose until it reaches the cartila- THE FACE. 
5 
ginous portion of that organ. Here its attachment 
becomes much firmer, a fact which explains the great 
pains caused by the small boils which form not unfre- 
quently in the sebaceous follicles here very abundant. 
In the remainder of the face the attachments of the 
skin are loose save over the chin where its connections 
with the deeper parts are somewhat greater. It is this 
laxity of attachment which permits of the great mobility 
of the skin under the influence of the numerous muscles 
connected with it and engaged in the production of the 
various expressions of the countenance. 
The depth of the hollow under the zygoma varies 
greatly in different individuals, presenting all varieties 
from the plump rounded contour of the young girl to 
the hollow cheek of the emaciated sufferer from some 
wasting disease. This difference is due to the presence 
or absence of a pad of fat, the “ buccal pellet ” which 
lies beneath the zygoma and in front of the masseter 
under both of which structures it sends prolongations. 
In the adult this portion of adipose tissue is one of the 
first to disappear in wasting diseases. 
In the child the pads of fat in the cheeks are much 
larger than in the adult, a fact to which is partly owing 
the comparative squareness of the infantile face. Ac- 
cording to Symington, besides the subcutaneous fat 
there exists a mass “ in the form of one or more lobules 
surrounded by a clearly defined capsule, so that it can 
be very easily shelled out.” These masses have been 
called “ sucking-cushions ” from the assistance which 
they are supposed to lend the infant in performing that 
function. 6 
THE FACE. 
These cushions diminish in the process of develop- 
ment until they come to be represented by the pellets- 
first alluded to. According to Ranke they are only 
slightly decreased in size in emaciated children m 
whom the subcutaneous fat is almost entirely absent. 
The skin of the face may be furrowed by various- 
lines, to some of which, when strongly marked, dia- 
gnostic importance has been attached. These lines 
individually and collectively differ greatly in the extent 
of their development in different persons. The most 
important of these furrows or wrinkles are :—i. The 
transverse rugae of the forehead caused by the action of 
the occipito-frontal muscle. 2. The oculo-frontal rugae 
passing vertically between the eyebrows to the root of 
the nose and due to the corrugator supercillii. 3. The 
linea oculo-zygomatica or line of Jadelot extending 
from the internal angle of the eye downwards and 
outwards to cross the face below the malar bone. This 
furrow is sometimes of a noticeably darker colour than 
the skin around it. 4. The naso-labial fold which 
commences between the side of the nose and the cheek, 
and passing obliquely downwards and outwards ter- 
minates near the commissure of the lips. It is almost 
always well-marked in old people. Lastly, so far as 
skin markings are concerned, the filtrum, a groove 
leading from the septum of the nose to the most pro- 
minent point of the upper lip, may be mentioned. 
Blood-vessels.—The facial artery appears upon the 
face by crossing the inferior maxilla just in front of the 
masseter, where its pulsations may be felt and its flow THE FACE. 
7 
checked by compression against the bone. It may 
again be felt in its tortuous course near the commissure 
of the lips, where it gives off the coronary artery of 
either lip, which can be distinguished running beneath 
the mucous membrane. Two other branches may also 
be made out, the lateralis nasi, a short distance above 
and external to the ala of the nose, and the angular 
artery, whose pulsations may be felt at the side of the 
root of the nose. This vessel and the anterior branch 
of the superficial temporal are of service to the 
anaesthetist, since they often enable him to feel his 
patient’s pulse without incommoding the operator. 
The supra-orbital artery emerges from the notch or 
foramen with the nerve of the same name, and passes 
toward the vertex of the head. Nearer to the inner 
angle of the orbit, the frontal artery escapes; this 
vessel is included in the root of the flap in the Indian 
operation for the restoration of a partly destroyed nose, 
and affords it nutriment. 
The transverse facial artery, a branch of the super- 
ficial temporal, cannot be felt save when exceptionally 
large, but its position may be found by remembering 
that it crosses the face immediately above Steno’s duct, 
to which attention will shortly be drawn. 
The pulsations of the trunk of the superficial tem- 
poral artery may be felt where the vessel crosses the 
zygoma immediately in front of the external auditory 
meatus. It divides into its anterior and posterior 
divisions two inches above the zygoma. Its anterior 
branch lies rather more than a finger’s breadth behind THE FACE. 
the external angular process, (vide fig. i). This vessel 
is very liable to degeneration in old persons, in whom 
its tortuous trunk may be seen standing prominently 
out. Its pulsations also are very visible in some in- 
dividuals, notably in those affected with incompetence 
Fig. x.—Nervous Supply, etc., of Face and Scalp. 
I. 11. 111. Regions supplied by the ophthalmic, superior and inferior maxillary 
divisions of the fifth nerve. C. Cervical nerves. 
In this and succeeding similar figures it must, of course, be understood that 
the regions are not sharply marked off as would appear from the diagrammatic 
representation. 
i, 2, 3. Points of exit of the supra- and infra-orbital and mental nerves. 4. Line 
of Steno’s duct. 5. Point where facial artery crosses inferior maxilla. 6. Lateralis 
nasi. 7. Angular arteries. 8. Superficial temporal, g. Anterior; and 10, pos- 
terior branches. 11. Occipital artery. 
of the aortic valves. It is the vessel which was divided 
in the now seldom performed operation of arteriotomy. 
The posterior branch lies about two inches behind the 
anterior, under cover of the hair. THE FACE. 
9 
The veins of the face are not of much importance so 
far as their surface relations are concerned. The vein 
which runs with the angular artery, a vessel of great 
importance from its intra-cranial connections, through 
the ophthalmic vein, is not unfrequently to be seen, 
and may be very distinct, especially in children. Some 
individuals possess an exceptionally large frontal vein 
on one side or the other, which may be seen standing 
prominently out during laughter, &c. ; this vessel runs 
vertically down near the centre of the forehead to join 
the veins alluded to above. The facial vein pursues a 
straight course external to the artery from the inner 
angle of the orbit to the antero-inferior corner of the 
masseter. 
Nerves.—The positions of the three branches of the 
fifth nerve have already been indicated in the description 
■of their foramina of exit. The areas which they supply 
will be seen by a reference to the diagram ; in con- 
nection with which it should be noted that the supply 
of the upper part of the region belonging to the inferior 
maxillary division is gained from the auriculo-temporal 
nerve, which emerges from under cover of the parotid 
gland and crosses the zygoma near the superficial tem- 
poral artery. The facial, the motor nerve of the face, 
passes out of the substance of the parotid below the 
duct of the latter, some of its branches, notably the 
infra-orbital, running along the inferior border of that 
structure. The remainder ramify over the face in lines 
more or less divergent from that of the duct. The line 
•of the nerve in the parotid may be indicated by drawing THE FACE. 
a line forwards and slightly downwards from the an- 
terior border of the mastoid process, where it meets 
the ear. 
Other structures.—The parotid gland occupies a 
space fairly well defined on each side, save its ante- 
rior border, which lies for a variable extent upon the 
masseter, and from which projects its only superficial 
process, the socia parotidis, a portion which varies con- 
siderably in size. The body of the gland is limited 
above by the zygoma. Its inferior border may be 
marked out by a line drawn from the angle of the jaw 
to the mastoid process, whilst its posterior touches the 
external auditory meatus, the mastoid process and the 
sterno-mastoid muscle. From the anterior border 
emerges Steno’s duct, which lies on the masseter be- 
low the socia parotidis. The position of the duct may 
be indicated by drawing a line from the point where the 
lobule joins the cartilage of the ear to a point midway 
between the nostrils and the red margin of the lips. 
About two inches of this line measured from the an- 
terior border of the gland will correspond to the duct 
itself (vide fig. i). 
The student can readily ascertain its position in 
his own face by firmly clenching the jaws, when the 
masseter muscle will be tense and firmly contracted. 
By manipulating the central portion of the muscle with 
the points of the fingers the duct will easily be dis- 
tinguished ; it will be recognised by its whip-cord like 
feel and by the flow of saliva into the mouth which 
generally follows its stimulation. THE EYE AND ITS APPENDAGES. 
11 
Before passing to the cavities associated with the 
face, it may be well to call the student’s attention to 
the very common asymmetry of the two sides in one 
or more particulars. Hasse, from a very careful exam- 
ination of the face of the celebrated Venus of Milo, 
found that whilst the portion lying below the nose was 
comparatively symmetrical, the upper part presented 
various deviations. Thus, the nose deviates to the left, 
the left ear stands higher than the right, the left half of 
the skull is broader than the right, and the left eye is 
higher and nearer the middle line than the right. He 
was led from this observation to examine carefully vari- 
ous skulls and heads of living individuals, and, as a 
result, states that whilst symmetry of the lower half of 
the face is the rule, deviations such as those occurring 
in the statue, are commonly to be met with in the upper 
half. 
11. The Eye and its Appendages. 
Orbit.—The bony margin of the orbit has been 
already alluded to, and it need therefore only here be 
mentioned that for protective purposes the outer and 
upper portions are stronger and more prominent than 
the inner and lower, and especially the former. By 
tolerably deep pressure in the internal and superior 
angle the little projection to which the pulley of the 
superior oblique muscle is attached, may be distin- 
guished. The roof of the orbit as well as part of its 12 
THE EYE AND ITS APPENDAGES. 
floor is excessively thin, the former in old persons being 
sometimes no thicker than writing paper ; it may there- 
fore be easily fractured by a comparatively insignificant 
implement. 
Eyelids, &c.—The skin covering the upper eyelid 
is thin and delicate, loosely attached to the subjacent 
tissues, fringed at its margin with two or more rows of 
hairs, the eye-lashes, and marked with several cres- 
centic furrows, convex upwards. Incisions in this part 
should be made parallel to these lines. The lax attach- 
ment of the skin renders the accumulation of fluid in 
the subcutaneous areolar tissue an easy matter, the 
large effusion of blood in the common black eye being 
thus accounted for. This is also a position often 
selected for the first appearance of puffiness at the com- 
mencement of renal anasarca or dropsy. 
By pinching up the eyelid in the subject the student 
will feel the so-called tarsal cartilage, to the inner end 
of which is attached the palpebral ligament or tendo 
oculi affixed at its other end to the margin of the orbit. 
To find this it is only necessary to close the eyelids 
and draw them outwards when the ligament will be 
made tense and appear under the skin as a transverse 
ridge. This ridge is an important surgical landmark, 
as it crosses the lachrymal sac at the junction of its 
upper and middle thirds, and thus serves as a guide to 
the surgeon in opening the latter for the evacuation of 
an abscess. The student should place his finger upon 
his own tendo, and open and close the eyelids several 
times, in order to note that each time the latter occurs THE EYE AND ITS APPENDAGES. 
13 
the ligament is made tense. A sucking action on the 
part of the subjacent sac is thus produced, by means of 
which the tears are drawn into its interior through the 
canaliculi. 
Having studied this ligament the student may next 
practice eversion of the eyelid, one of those very minor 
operations on the deft performance of which so much of 
the comfort of a patient depends. Mr. Nettleship 
thus describes it;—“ The patient looks down, a probe 
is laid along the lid above the upper edge of the 
“ cartilage,” the lashes, or edge of the lid, are then 
seized by a finger and thumb of the other hand, and 
turned up over the probe which is simultaneously 
pushed down. After a little practice the probe can be 
dispensed with, and the lid everted by the forefinger 
and thumb of one hand alone, one serving to fix and 
depress the lid, the other to turn it upwards.” 
When the lid is everted the roots of the hairs will be 
seen under the conjunctiva as well as the Meibomian 
follicles which appear like rows of yellow granules. It 
is in these or in connection with the hair follicles that 
the common styes are formed. The transition of epi- 
dermis into conjunctiva at the margin of the lid should 
be noticed, as also the fornix or cul-de-sac formed by 
the passage of the palpebral conjunctiva on to the eye. 
A similar but shallower depression exists in connection 
with the lower lid. The lid may now be restored to its 
normal position. At the inner angle or canthus will 
be noticed a recess bounded by two prominences, the 
papillae lachrymales, on each of which opens the minute THE EYE AND ITS APPENDAGES. 
aperture of the punctum lachrymale, the lower being a 
little larger and more external. Through these the 
tears pass by the canaliculi into the lachrymal sac, and 
thus into the inferior meatus of the nose by the nasal 
duct. The canaliculi may have to be slit open and a 
probe passed into this duct, which is a little more than 
half an inch in length, and is directed downwards and 
slightly backwards and outwards. Two other struc- 
tures are to be noticed in connection with the above 
mentioned recess, the plica semilunaris, a fold of con- 
junctiva representing the membrana nictitans or third 
eyelid of birds, and the caruncula lachrymalis, a red- 
dish eminence covered with a few fine hairs and con- 
taining in its interior specialised sweat glands and 
sebaceous glands. 
Eyeball.—A description of the eyeball is outside the 
scope of this book, but the attention of the student may 
be drawn to the fact that neither the cornea nor the 
pupil are as a rule mathematically circular, the former 
having a tendency to be broader transversely. The 
pupil is situated very slightly to the inner side of the 
iris. The student should take the opportunity of ex- 
amining a number of healthy eyes in order to form a 
standard in his own mind of the normal tension of the 
globe. With respect to this procedure, Nettleship 
states :—“ The patient looks steadily down and gently 
closes the eyelids; the observer then makes light pres- 
sure on the globe through the upper lid, alternately 
with a finger of each hand as in trying for fluctuation 
but much more delicately. The finger-tips are placed THE NOSE. 
15 
very near together, and as far back over the sclerotic 
as possible, not over the cornea. The pressure must 
be gentle, and be directed vertically downwards, not 
backwards. It is best for each observer to keep to one 
pair of fingers, not to use the index at one time and 
the middle finger at another. Patient and observer 
should always be in the same relative position, and it 
is best for both to stand and face one another. Always 
compare the tension of the two eyes. Be sure that the 
eye does not roll upwards during examination, for if 
this occur a wrong estimate of the tension may be 
formed. Some test both eyes at once with two fingers 
of each hand.” The tension may be increased so that 
indentation of the globe is difficult or impossible, or on 
the other hand it may be decreased. For the scale 
employed in registering these changes, and the condi- 
tions in which they occur, the student is referred to 
special text-books on the eye. 
111. The Nose. 
There is not very much to be made out from an 
anterior inspection of this organ unaided by instru- 
ments, and the investigation of its posterior part may 
be more conveniently deferred to be considered with 
the cavity of the mouth. It should first be noticed 
that the apertures of the nostrils are placed at a lower 
level than the floor of the inferior meatus; in order 
therefore that this may be seen or that a speculum THE NOSE. 
may be introduced, it will be necessary to raise the tip 
of the nose, the head being thrown back. The mobility 
due to the cartilaginous basis of the anterior part of the 
nose, allows of the tip being raised and of the dilatation 
of either nostril. 
The apertures of the nostrils are generally more or 
less compressed laterally in the adult, circular in chil- 
dren, and separated from one another by the thickened 
lower margin of the septum—the columna nasi. On 
looking into either, the vestibule or dilated anterior 
part is seen containing coarse hairs the vibrissae.- 
The anterior extremity of the inferior turbinated bone 
can be seen and felt; in the undissected state only 
about one-twentieth of this consists of bone, the re- 
mainder consisting of the erectile tissue of Voltolini 
and others. The other turbinated bones cannot be- 
seen without the aid of a speculum, which brings into 
view the middle one; but it is well to remember that 
they encroach largely upon the space in the posterior 
part of the organ. In inserting forceps, therefore, they 
should be so introduced that the blades may be opened 
upwards and downwards, not laterally. The septum 
in a portion of its extent may be seen, the part visible 
being chiefly cartilaginous ; it is often deflected to one 
side or the other, or sometimes first to one side and 
then to the other, the so-called sinous deflection. In 
76*9 per cent, of a large number of skulls examined, 
by Morell Mackenzie, the bony septum was more or 
less asymmetrical. It is placed in the median line 
until the seventh year (Zuckerkandl and Symington),, THE NOSE. 
and the subsequent deflection which is most often to 
the left is attributed by some writers to the habit of 
constantly blowing the nose with the same hand. It 
may be so great as to cause the introduction of instru- 
ments to be difficult or even impossible. 
In connection with the examination of the nose from 
the front, the student should practise the operation 
of introducing the Eustachian catheter. Should the 
actual instrument not be at hand, one may be im- 
provised from a probe or even a piece of wire of 
suitable size with a rounded end, either being bent at 
an angle of 6o° a short distance from its extremity. 
The operator will be much assisted by practising at 
first upon a head which has been divided by a mesial 
antero-posterior section, as he will then be able to 
watch the point of his instrument as he endeavours to 
introduce it into the opening of the Eustachian tube. 
Should such a section be unattainable for this purpose, 
the position of parts should at least be examined in 
a specimen before the operation is attempted. The 
directions for performing the operation are thus given 
by Pritchard ;—“ The curved end is introduced into 
one nostril, keeping the beak close along the angle 
formed by the septum and the floor. By this means 
the surgeon will avoid getting into the middle meatus, 
and so finding himself in difficulty further on. When 
the catheter has passed the posterior nares, it will soon 
encounter the back of the pharynx, and this will be 
easily recognised by its tension, for it has been very 
aptly described as feeling like the outstretched palm THE EAR. 
of the hand. The catheter should then be withdrawn 
about half an inch, and the point turned almost directly 
outwards, after which, on the catheter being again 
slightly pushed in, the point will enter the Eustachian 
tube.” 
When the catheter is engaged in the Eustachian 
aperture its beak will be found to point towards the 
outer angle of the orbit on the same side. 
IV. The Ear. 
The external ear or pinna is formed throughout the 
greater part of its extent of a cartilaginous substratum, 
to which, as in the case of the cartilaginous part of the 
nose, the skin is very closely adherent. The dependent 
portion, the lobule, alone contains no cartilage, and 
consists mainly of fat, the amount of its connection with 
the side of the neck being variable. The plate of car- 
tilage occupying the remainder of the pinna is folded 
so as to present several elevations and depressions, to 
which designations have been assigned. Surrounding 
the entrance to the meatus is the deepest hollow, the 
concha, which is prolonged downwards and forwards 
into a notch, bounded on either side by a prominence. 
The anterior of these, which bears hairs, is called the 
tragus, the posterior the anti-tragus. Superior and in- 
ternal to the former the helix commences and passes 
round the outer border of the ear as a well-marked fold, 
which terminates at the posterior part of the lobule. THE EAR. 
It is sometimes possessed of a pointed process placed on 
its inner border, and at its upper and posterior part,, 
which was first noticed by Woolner, the sculptor, and 
to which attention was directed by Darwin in his- 
Expression of the Emotions. 
Commencing at the anti-tragus is another elevation,, 
the anti-helix, which passing round the concha, bifur- 
cates to enclose a triangular depression—the fossa tri- 
angularis or fossa of the anti-helix. Between the two 
elevations is a shallow groove—the fossa scaphoidea or 
fossa of the helix. The outer aperture of the external 
auditory meatus is largest from above downwards ; it 
possesses a number of hairs, and under the skin are 
placed the ceruminous or wax-producing glands. 
The canal of the meatus passes forwards in its entire 
course. Its outer portion also passes upwards and its 
inner downwards. In order to obtain a view of the 
meatus and membrana tympani, either with or without 
the aid of a speculum, it is necessary to straighten the 
canal as far as possible. This is done by taking hold 
of the pinna above and pulling it upwards and slightly 
backwards and outwards. 
Bony points in connection with the ear.—Be- 
hind the ear is the mastoid process, which commences 
to become prominent about the second year. Its 
interior is occupied by air spaces, divided into two 
groups, viz.:—(a). The vertical which commence to 
develop about the time of puberty, these have a close 
relationship internally to the sigmoid sinus, and cere- 
bellum. (6). The mastoid antrum, which is present at 20 
THE MOUTH. 
birth, is horizontal in direction and communicates with 
the tympanum on the one hand and with some of the 
mastoid cells on the other. It is immediately subjacent 
to the temporo-sphenoidal lobe, a thin bony plate, which 
forms its roof, intervening between the two. The posi- 
tion of the superior limit of the antrum is indicated on 
the surface of the skull by the supra-mastoid crest. Its 
inferior limit is a little below the upper border of the 
external auditory meatus. The antrum may be reached 
from the surface by perforating the skull at the base 
of Macewen’s supra-meatal triangle {see fig. 3). This is 
bounded above by the supra-mastoid crest, below by 
the posterior superior fourth of the external auditory 
meatus and behind by a base line joining the two 
dropped from the supra-mastoid crest on a level with 
the posterior border of the external auditory meatus. 
V. The Mouth. 
The cavity of the mouth may be divided into two 
parts. One between the lips and cheeks and the teeth— 
the vestibulum oris, and a second behind the teeth—the 
cavum oris. Still further back behind the pillars of 
the fauces is the upper part of the pharynx. In the 
vestibule there may be felt with the tip of the tongue 
in one’s own mouth or with the fingers in another per- 
son’s, a number of small granules under the mucous 
membrane. These are mucous glands, which may, in 
certain conditions, become chronically hypertrophied or THE MOUTH. 
21 
otherwise diseased. On the inner side of the cheek the 
aperture of the duct of Steno should be sought. This 
opening, which is much smaller than the calibre of the 
canal which it terminates, is placed opposite the second 
upper molar tooth. 
It may be found in the living subject by everting the 
cheek and wiping the inner surface dry, when in a short 
time the appearance of a drop of saliva will indicate the 
opening. If the upper lip be everted a fold of mucous 
membrane—the fraenum labii superioris, will be seen 
passing from it to the gums. A finger should be passed 
up between the cheek and the teeth and the coronoid 
process felt from within the mouth. The spot above 
the second bicuspid tooth, where the antrum is some- 
times tapped, should also be noticed. Without pausing 
to describe the teeth, an account of which must be 
sought in the ordinary textbooks, we may pass to the 
cavum oris situated behind them. The tongue with its 
filiform and fungiform papillae is the first object for in- 
spection ; a good idea of the distribution of the last 
mentioned papillae will be gained by looking at them in 
a patient suffering from scarlet fever. At the posterior 
part will be seen the large circumvallate papillae, seven 
to twelve in number, arranged in the form of a V, with 
the apex directed backwards, and the foramen caecum 
situated just behind. If the tongue be pulled well out 
and to one side the student will see in front of the 
anterior pillar of the fauces on the border of the tongue, 
an area with a few, generally five, longitudinal folds— 
the papilla foliata. THE MOUTH. 
22 
A finger should now be introduced gradually back- 
wards in the middle line, and the various structures 
met with investigated. Immediately behind the centre 
of the root of the tongue, a ridge of mucous membrane 
will be felt passing to the epiglottis. This is the glosso- 
epiglottic fold or fraenum epiglottidis, on each side of 
which there is a shallow depression in which a foreign 
body may lodge. Behind this fold is the epiglottis 
itself, which may be distinctly felt and even seen in 
some individuals if the tongue is pulled well out in the 
middle line. Passing over the epiglottis the finger 
reaches the ary-epiglottic folds of mucous membrane 
with the entrance to the larynx between. On each side 
will be felt the hyoid space, another favourite spot for 
the lodgment of foreign bodies, and the great cornu of 
the hyoid bone. 
In the middle line the cricoid, as far down as its 
lower border, can be made out, together with the com- 
mencement of the oesophagus. As this spot is one of 
the two narrowest parts of the gullet, insufficiently mas- 
ticated lumps of meat and other bodies are liable to 
lodge in it. The posterior wall of the pharynx over- 
lying the vertebral column may be investigated in its 
entire extent. In the course of these observations the 
student should consider their bearing upon the passing 
of an oesophageal tube or bougie, and in either case the 
end of the instrument should be kept well against the 
posterior wall in order to avoid any danger of its enter- 
ing the larynx by mistake. 
The tip of the tongue should now be turned upwards, THE MOUTH. 
23 
when the large ranine veins will be distinctly seen on 
the under surface of the organ. Two fringes of fim- 
briated mucous membrane which indicate the position 
of the more deeply seated ranine arteries, will also be 
noticed. Passing from the tongue to the floor of the 
mouth is a fold of mucous membrane, the frsenum 
linguae, sometimes abnormally short, and then causing 
the condition known as “tongue-tie.” On each side of 
this a duct of Wharton opens on a papilla in the floor 
of the mouth. If one forefinger be pressed upwards 
and inwards from without, beneath the angle of the 
jaw, and the other be placed in a corresponding position 
under the tongue, the sub-maxillary gland will be felt 
between the two under the floor of the mouth. A long 
ridge of mucous membrane on either side of the floor 
contains the sublingual gland, and indicates to a certain 
extent the direction of Wharton’s duct and the lingual 
nerve. Upon this ridge open, by a number of aper- 
tures, such of the ducts of the last mentioned gland 
as do not join the Whartonian canal. Finally, so far 
as this part is concerned, the attachment of the genio- 
hyo-glossi muscles may be felt under the floor of the 
mouth, immediately behind the symphysis of the lower 
jaw. 
The tongue being restored to its place, the student 
should examine the hard palate, the shape of the arch 
of which varies in different subjects. The mucous 
membrane is very firmly adherent to the bones which 
it covers ; under it on either side at the posterior part 
jnay be felt the pulsations of the posterior palatine THE MOUTH. 
24 
artery. The canal through which this vessel passes to 
reach the palate is placed just internal to the last molar 
tooth, and may be plugged for the arrest of haemor- 
rhage. Carry the finger a little further back and the 
point of the hamular process of the pterygoid plate, as 
well as that structure itself, and the pterygoid fossa 
may all be felt, together with the back of the antrum 
and the external pterygoid plate behind the last molar. 
The pterygo-maxillary ligament may be seen and felt 
when the mouth is widely opened, extending from the 
internal pterygoid plate to the lower jaw behind the 
last molar, and separating the buccinator from the 
superior constrictor. This ligament helps us to find 
the position of the gustatory nerve, which lies a little 
below it, on the bone below the last molar tooth. It 
is here that the nerve is sometimes divided for the relief 
of painful cancer of the tongue. The guides for the 
division of two other nerves in the cavity of the mouth 
may also here be mentioned. The inferior dental nerve 
is reached by an incision “from the last upper molar 
to the last lower molar, just to the inner side of the 
anterior border of the coronoid process. The cut passes 
through the mucous membrane down to the tendon of 
the temporal muscle. The finger is introduced into the 
incision, and passed between the ramus of the jaw and 
the internal pterygoid muscle, until the bony point is 
felt that marks the orifice of the dental canal. The 
nerve is here picked up with a hook, isolated and 
divided.” (Treves). 
The buccal nerve which is sometimes divided for THE MOUTH. 
25 
neuralgia is thus reached; “ the surgeon places the 
finger nail upon the outer lip of the anterior border of 
the ascending ramus of the lower jaw at its centre, and 
divides in front of this border the mucous membrane 
and the fibres of the buccinator vertically. He then 
seeks for the nerve, separating the tissues with a direc- 
tor, and divides it.” (Stimson). 
The student should now examine the structures, 
separating the cavity of the mouth from the pharynx, 
the soft palate with its central dependence, the uvula, 
the folds of mucous membrane covering the palato- 
glossus and palato-pharyngeus, and forming the an- 
terior and posterior pillars of the fauces, and the tonsil 
lying between them. This latter should not project 
under normal circumstances into the isthmus faucium, 
and a consideration of its inter-muscular position will 
explain the great pain caused in swallowing when it is 
enlarged, and especially when ulcerated also, as in 
“ hospital sore-throat.” 
The head being thrown well back the posterior nares 
should be thoroughly explored. By hooking the finger 
round the soft palate the posterior part of the septum 
and of the middle and inferior turbinated bones may 
be felt, also the vault of the pharynx, the openings of the 
Eustachian tubes, the basilar process of the occipital, 
and the upper four cervical vertebrae. Of these the 
first is opposite the lower margin of the posterior 
nares, and the second, the soft palate. If the finger be 
pushed onwards into the inferior meatus, and the little 
finger of the other hand be introduced from the front 26 
THE MOUTH. 
into the same, the two may be made to meet without 
difficulty unless the passage is abnormally constricted. 
The apertures of the posterior nares measure a little 
less than an inch vertically, and half an inch trans- 
versely. An investigation of this part will be useful 
in assisting the student to understand the operation of 
plugging the posterior nares. THE SCALP. 
27 
Chapter 11. 
THE SCALP. 
I. The Scalp. 
For purposes of convenience the scalp is here limited 
to the part of the head normally clad with hair. The 
skin and subjacent tissues are here closely united to 
one another so as to form a dense and thick covering 
to the cranium. Free movement is permitted, how- 
ever, between the scalp and the bone beneath it, by the 
layer of loose connective tissue which lies between the 
aponeurosis of the occipito-frontalis muscle and the 
pericranium. The supra-orbital, frontal, and two 
branches of the superficial temporal artery have already 
been alluded to. Behind the ear and over the mastoid 
process, the pulsations of the posterior auricular artery 
may be felt; the occipital artery will be found slightly 
internal to the centre of a line drawn from the apex of 
the mastoid process to the external occipital protuber- 
ance. A lymphatic gland, the sub-occipital, which 
receives the lymphatics of the occipital and posterior 
parietal region, lies a short distance behind the mastoid 
process, and may be felt when enlarged, a condition 
which occurs in syphilis and in skin diseases of this 
region of the scalp. 28 
RELATION TO BONY VAULT. 
11. Relation to Bony Vault. 
Comparatively few bony points are to be felt through 
the scalp, yet by means of a few measurements and 
rules, the positions of the various sutures may be 
Fig. 2.—Cranium, showing Base-line of Brain (indicated by dotted line), &c, 
a. Bregma, b. Pterion, c. Lambda, d. Asterion. e. Nasion. /. Inion. 
mapped out with considerable accuracy. The bony 
points which may be felt are the external occipital 
protuberance at the back of the head, with a portion of 
the superior curved line passing from it; above the 
former the apex of the occipital bone may often be 
distinguished. The mastoid process can be distinctly RELATION TO BONY VAULT. 
29 
felt behind the ear, and is a valuable landmark; it is 
much smaller in the child than in the adult, from the 
non-development of the air-cells in its interior. 
The following points are valuable in mapping out the 
sutures:— 
1. The bregma, or junction of the coronal, sagittal, and 
in the young subject, frontal sutures ; this is placed at 
the centre of a line drawn across the vertex from one 
external auditory meatus to the other, the head being 
in the usual erect position. 
2. The pterion, or junction of the frontal, temporal, 
parietal and sphenoid bones in the anterior part of the 
temporal fossa. This is generally shaped like an H, of 
which the anterior limb is formed by the fronto-parietal 
and sphenoid sutures, the posterior by the temporo- 
parietal and sphenoid, and the cross-bar by the parieto- 
sphenoid. The relations of the four bones to one 
another vary considerably, but we may take the cross- 
bar as being about half an inch in length in the 
majority of cases. The pterion is situated a little 
above a line drawn backwards from the external 
angular process, and from to i-J inches posterior to 
that point. 
3. The lambda or junction of the sagittal and lamb- 
doidal sutures is situated about 2f inches above the 
external occipital prominence, and may often be felt 
through the scalp. 
4. The asterion is the point of junction of the lambdoid 
and parieto-mastoid sutures; it is placed about f of an 
inch behind and \ an inch above the superior part of 
the posterior border of the mastoid process. 30 
RELATION TO MEMBRANES OF BRAIN. 
5. The nasion, is the point of junction of the inter- 
nasal and naso-frontal sutures. 
6. The inion is the external occipital protuberance 
With the aid of these points we may indicate on 
the scalp the position of the sutures of the vault as 
follows: 
Sagittal extends from the bregma to the lambda. 
Coronal extends from the bregma downwards and 
forwards, to the anterior end of the pterion. 
Lambdoidal extends from the lambda, past the 
asterion, and forwards internal to the mastoid pro- 
cess. 
Squamous and parieto -mastoid may be indicated by 
drawing a curved line from the posterior part of the 
pterion to the asterion, the highest part of which is 
about two inches above the zygoma. The posterior 
inch is parieto-mastoid. 
111. Relation to Membranes of Brain and their 
Vessels. 
The falx cerebri extends from the root of the nose 
along the frontal and coronal sutures to the external 
occipital protuberance, and the falx cerebelli is con- 
tinued down in the middle line to the posterior margin 
of the foramen magnum. The tentorium so far as it 
is related to the cranial wall, will be indicated by a 
line from the external occipital protuberance to the 
asterion. RELATION OF MEMBRANES TO BRAIN. 
31 
The middle meningeal artery reaches the side of the 
cranium near the lower end of the squamo-sphenoid 
suture, which it follows to the pterion by the posterior 
end of which it runs. From this point it runs nearly 
parallel to the coronal suture and about one inch pos- 
terior to it. A large branch is given off backwards 
which crosses the squama transversely at about its 
centre. This may originate near the foramen spinosum. 
Erichsen gives the following rule for finding this 
artery; draw a straight line backwards from the ex- 
ternal angular process, take a point at any distance 
between one and two and half inches on this line and 
draw a vertical line through it to the zygoma, measure 
a corresponding distance up this line and the point so 
found will be over the artery. If this distance be under 
one and a half inches, the artery will be found in a 
canal in the bone, beyond this it is usually in a 
groove. 
The torcular Herophili corresponds nearly to the 
external occipital protuberance being usually slightly to 
its right; a line therefore from this point to the root 
of the nose will indicate the position of the superior 
longitudinal sinus and one from the former point down- 
wards, that of the occipital. 
The limit of the upper border of the lateral sinus, as 
far as the posterior part of the squamous suture is 
indicated by the base line of the brain in that region 
(p. 34). From this point it is directed downwards i" be- 
hind the external auditory meatus towards the tip of 
the mastoid process, as far as a point below the 32 
FONTANELLES. 
lower level of the meatus, where it turns inwards to the 
base of the skull. As a guide to the position of the sinus 
in operations, Birmingham suggests the use of the 
following lines. One drawn convex upwards from a 
point above the occipital protuberance to a point 
11" behind and if" above the centre of the meatus, and 
the second from V' below the occipital protuberance to 
Reid’s base-line i£" behind the meatus. Between these 
two lines the sinus will be found; above or below the 
space included between them trephining may be prac- 
tised with safety. 
IV. Fontanelles. 
The student should examine the shape and position 
of the fontanelles in the head of a young infant. These 
are spots where the bony vault is incomplete, and 
where membrane alone underlies the scalp. The two 
most important, from the assistance they lend to the 
obstetrician, in diagnosing the position of the descend- 
ing head of the child in parturition, as well as from 
their diagnostic value during infancy, are the anterior 
and posterior. The former is diamond-shaped, occupies 
the position of the bregma, and is included between the 
two frontal and two parietal bones. The latter is 
triangular with its apex directed forwards, it occupies 
the position of the lambda and is included between the 
parietal and occipital bones. Fig. 3.—Diagram of Cranium, showing positions of middle meningeal 
artery (A), Lateral Sinus (S), and Supra-meatal Triangle (T). (Modified 
from Birmingham and v. Bardeleben.) 
Fig 4.—Diagram of Cranium, showing positions of fissures. 1. Sylvius 
h. horizontal, a. ascending, p. posterior. 2. Rolando. 3. Parieto-occipital, 
4. Parallel. 5. Intraparietal joining inferior post-central (i). Sup. post-central 
is above (s). 6. Precentral, (t) inferior and (s) superior segments. 7. Superior 
Frontal. 8. Inferior Frontal. (Modified from Quain and v. Bardeleben.) RELATION OF CRANIUM TO BRAIN. 
V. Relation of Cranium to Brain. 
Although it is much more important for the student 
to be acquainted with the relations of the different parts 
of the brain to the scalp, a subject to be dealt with in 
the next section, their position in connection with cer- 
tain of the bony points mentioned in Section 111. may 
here be mentioned. 
The level of the base of the brain may be indicated 
in the following manner with sufficient accuracy : 
1. Draw a slightly sinuous line upwards and out- 
wards from just above the nasion to the posterior line 
of the pterion. This line crosses the temporal ridge 
about f" above the root of the external angular process, 
and indicates approximately the lower limit of the 
frontal lobe. 
2. From the last point draw a line downwards and 
forwards parallel to the ptero-temporal suture, and at 
a maximum distance of a quarter of an inch from it, to 
a point a quarter of an inch above the middle of the 
pterygoid ridge. This line indicates approximately the 
anterior limit of the temporo-sphenoidal lobe. 
3. From the last point draw a line backwards, cross- 
ing the ptero-temporal suture, and following the level 
of the upper border of the zygoma. Behind the zygoma 
it curves slightly upwards, so as to lie above the ex- 
ternal auditory meatus. Thence it passes backwards, 
slightly above the first of the parieto-mastoid suture 34 
RELATION OF CRANIUM TO BRAIN. 
and terminates 4" above the asterion. This line indi- 
cates approximately the lower border of the temporo- 
sphenoidal lobe. 
4. From the last point draw a sinuous line to a point 
4” above the superior curved line about its middle. 
Thence it passes backwards and slightly upwards to 
4” above the external occipital protuberance. This line 
approximately indicates the lower border of the oc- 
cipital lobe. 
The fissure of Sylvius divides at the posterior end of the 
cross-bar of the pterion, its anterior ascending limb runs 
upwards and forwards to meet the coronal suture, its 
anterior horizontal corresponds to the cross-bar, and its 
posterior lies along the anterior part of the squamous 
suture, and where that turns down to pass to the 
asterion, continues backwards and upwards across the 
parietal bone. The fissure of Rolando commences a little 
less than two inches posterior to the bregma and a short 
distance from the middle line, and passes down towards 
the squamous suture, gradually approaching the coronal 
so as to be about f" nearer to it below than above. 
The external farieto-occipital fissure lies just in front of or 
frequently coincides with the lambda. It should be 
mentioned that Symington has shown that in the child 
the fissure of Sylvius lies 4'' or more above the squamous 
suture, and that the fissure of Rolando lies further for- 
ward than in the adult. RELATION OF SCALP TO BRAIN. 
35 
VI. Relation of Scalp to Brain. 
The more important fissures may be marked out on 
-the scalp by the following rules. 
The longitudinal fissure is indicated by a line from the 
,nasion to the inion. 
A. Glabella. B. External occipital protuberance, e. a. p. External angular 
process of frontal. B. C. Transverse fissure. A. B. Horizontal fissure. Sy. fis. 
Sylvian fissure. Sy. h. fis. Posterior limb of Sylvian fissure. Sy. a. fis. Anterior 
limb of Sylvian fissure. DE, FG. Perpendiculars alluded to in text. F. H. Fissure 
of Rolando, p. o. fis. Parieto-occipital fissure. + Most prominent part of parietal 
eminence. 
Fig. 5.—Showing Relation of Chief Fissures to Scalp. (Reid). 36 
RELATION OF SCALP TO BRAIN. 
The transverse fissure is indicated by a line drawn from 
above the external auditory meatus to i” above the 
inion (see p. 30). 
The fissure of Sylvius (Reid) is found by taking a point 
an inch and a quarter posterior to the external angular 
process of the frontal, and drawing a line from thence 
to a point three-quarters of an inch below the most 
prominent part of the parietal eminence. Measured, 
from before backwards, the first three-quarters of an 
inch represent the main fissure, and the remainder the 
posterior limb. The anterior ascending and anterior 
horizontal limbs start two inches behind the external 
angular process and run vertically upwards for about 
an inch. 
Quain’s method of finding the fissure of Sylvius is as 
follows :—“ From the fronto-malar junction let a line be 
carried horizontally backwards for 35 mm. (ij") and 
from the end of this a vertical line for 12 mm. (a little 
less than £") upwards. The upper end of the latter line 
marks the spot where the anterior branches are given 
off from the Sylvian fissure, and may be termed the 
Sylvian point. A line drawn from the fronto-malar 
junction through the Sylvian point to the lower part of 
the parietal eminence will about lie over the posterior 
limb of the Sylvian fissure and may be called the 
Sylvian line. The anterior ascending and horizontal 
branches of the fissure may be marked by lines 2 cm. 
(I"), starting from the Sylvian point, the one directed 
upwards and forwards at right angles with the Sylvian 
line and the other horizontally forwards.” RELATION OF SCALP TO BRAIN. 
37 
The external parieto-occipital fissure is found by drawing 
a line outwards for f" from the lambda at right angles 
to the line indicating the longitudinal fissure. 
To find the fissure of Rolando by Reid’s method, it will 
be necessary to erect a kind of scaffold formed of three 
lines. The first or base runs through the lowest part of 
the infra-orbital margin and the middle of the external 
auditory meatus. Upon this line are erected two per- 
pendiculars, one starting from the hollow in front of the 
external auditory meatus, the other from the posterior 
border of the mastoid process at its root. 
These two perpendiculars, together with the line for 
the longitudinal fissure and that for the posterior limb 
of the fissure of Sylvius, enclose a quadrilateral space, 
and if a diagonal line be drawn from the posterior 
superior corner to the anterior inferior it will be over 
the fissure of Rolando. 
An alternative method is to measure the distance 
from the nasion to the inion and take the centre of this 
line. A point behind this will indicate the upper 
end of the fissure of Rolando. A line draw downwards 
and forwards for 3'f" from this point, making an angle 
of yo° with the longitudinal fissure, will indicate the 
remainder of the fissure. 
The student having thus mapped out on the scalp the 
great fissures of the brain and having fully mastered the 
method, he should next proceed to put in the smaller 
details as directed by Prof. Reid. 
The frontal lohe is bounded above by the line for the 
.longitudinal fissure, below by the line for the trunk 38 
RELATION OF SCALP TO BRAIN. 
and horizontal limb of the Sylvian fissure, behind by 
the line for the fissure of Rolando, and in front by a line 
just above and parallel with the supra-orbital margin. 
The precentral sulci are situated f" in front of the 
fissure of Rolando with which they are parallel. A line 
drawn from the supra-orbital notch backwards to within 
three-quarters of an inch of the line for the fissure of 
Rolando, and parallel with the line for the longitudinal 
fissure, will indicate the first frontal fissure. The 
frontal part of the temporal ridge will indicate the 
second frontal fissure. The first, second, and third 
frontal convolutions, will thus be mapped out. The 
ascending frontal convolution will occupy a space about 
three-quarters of an inch broad, parallel with, and in 
front of, the line for the fissure of Rolando. 
The parietal lohe will be marked out by the line for 
the longitudinal fissure superiorly, and in front and 
behind by the lines for the fissure of Rolando and the 
parieto-occipital fissure respectively. Below, the line 
for the horizontal limb of the fissure of Sylvius will 
separate it from the temporo-sphenoidal lobe. The 
interval between the posterior end of the Sylvian line 
and the outer end of the parieto-occipital line is 
occupied by the junction of the postero-parietal lobule 
[p. p. L, fig. 6) with the first annectant convolution, 
and the angular gyrus (ang. g., fig. 6) with the second 
annectant convolution, the arrangement of these con- 
volutions with regard to one another being very variable, 
the angular gyrus usually projecting somewhat more 
posteriorly than the postero-parietal lobule. Weccarnr RELATION OF SCALP TO BRAIN. 
39 
therefore, only indicate the separation of this part of 
the parietal lobe from the neighbouring temporo- 
sphenoidal and occipital lobes by drawing a line 
{a, fig. 6) slightly convex downwards from the pos- 
Fig. 6. —Showing Relation of Fissures and Convolutions of Brain to Scalp 
(Reid). 
+ Most prominent part of parietal eminence, a Convex line bounding parietal 
lobe below, b. Convex line bounding temporo-sphenoidal lobe behind, i fr. c. 
First frontal convolution, i fr. f. First frontal fissure. f.R. Fissure of Rolando. 
sy. /. Sylvian fissure. Sy. h, f. Horizontal limb of Sylvian fissure. Sy.a.f. 
cending limb of Sylvian fissure, p. o.f. Parieto-occipital fissure, i. par. f. Intra- 
parietal fissure, ang. g. Angular gyrus, s. m. c. Supra-marginal convolution, 
it.s. c. First temporo-sphenoidal convolution, it. s.f. First temporo-sphenoidal 
fissure, io. c. First occipital convolution, p. p. I. Postero-parieta! lobule. RELATION OF SCALP TO BRAIN. 
terior end of the Sylvian line to the outer end of the 
parieto-occipital line. An irregularly triangular space 
will thus be marked out to indicate the parietal lobe. 
If in this space we draw a line from a point half an 
inch outside the outer extremity of the parieto-occipital 
line to a point about an inch above and behind the an- 
terior and inferior angle of the space, this line will lie 
over the intm-pavietal fissure (i. par. /., fig. 6). The line 
must be curved, with its convexity directed forwards 
and inwards, and parallel in its anterior third or so (post- 
central sulcus) with the line for the fissure of Rolando, 
and about three-fourths of an inch behind it. In the 
space above the intra-parietal sulcus we shall have, in 
front, parallel with the whole length of the fissure of 
Rolando, the ascending parietal convolution, and behind, 
the postero-parietal lobule. The space below the sulcus 
will indicate, in its anterior part, the supra-marginal 
-convolution (5. m. c., fig. 6) filling up the most prominent 
part of the parietal eminence, and in its posterior part, 
the angular gyrus (ang. g., fig. 6). 
The ternpovo-sphenoidal lobe is, like the last, somewhat 
difficult to indicate posteriorly, because it becomes con- 
tinuous there with the parietal and occipital lobes with- 
out any distinct line of demarcation. Its outline will 
lie in the lower part of the temporal region, extending 
a little beyond the temporal ridge behind. It will be 
bounded above by the line of the main trunk and hori- 
zontal limb of the fissure of Sylvius, below by the upper 
border of the zygoma and a line carried back from the 
posterior end of that to a point midway between the RELATION OF SCALP TO BRAIN. 
41 
external occipital protuberance, and the posterior bor- 
der of the mastoid process at its root. The anterior 
border or apex of the lobe wilt extend as far forwards 
as the posterior superior border of the malar bone. Be- 
hind, the lobe will be bounded by a slightly convex line 
(b., fig. 6) with the convexity directed backwards, ex- 
tending from the posterior end of the Sylvian line to 
the posterior end of the line indicating the lower 
boundary of the lobe. 
A line running about an inch below and parallel with 
the line for the main trunk and horizontal ramus of 
the fissure of Sylvius, will indicate the first temporo- 
sphenoidal fissure (1 t. s. /., fig. 6) and another line 
about three-quarters of an inch below and parallel with 
the last, will indicate the second temporo-sphenoidal 
fissure (2 t. s. /., fig. 6). Thus, the first, second, and 
third temporo-sphenoidal convolutions will be mapped 
out (i t. s. c., 2 t. s. c., 3 t. s. c., fig. 6). 
The occipital lobe will occupy the remaining surface 
of the scalp. It will be bounded above by the parietal 
lobe, below by the superior curved line in its inner half, 
that is, the part of the line unoccupied by the lower 
limit of the temporo-sphenoidal lobe. Internally, the 
line of the longitudinal fissure, and externally, the con- 
vex line for the posterior border of the temporo-sphe- 
noidal lobe, will bound it. The area of the lobe being 
marked out, the first, second, and third occipital con- 
volutions, can be readily filled in {1 o. c., 2 o. c., 3 o. c., 
fig. 6). 42 
THE NECK. 
Chapter 111. 
THE NECK. 
In this section only the anterior and lateral portions of 
the neck will be dealt with, the posterior being included 
with the back. 
The skin of the neck is loose and mobile, and is under- 
laid by a thin layer of muscle passing from the clavicle 
to cross the lower jaw. This is the platysma myoides, 
and its fibres run from above downwards and back- 
wards. A great number of structures, many of which 
are of the highest surgical importance, lie in the region 
now under consideration, they will be dealt with in the 
following order:—those in the middle line, between that 
line and the anterior border of the sterno-mastoid, and 
those behind that muscle. 
I. The Middle Line of the Neck. 
The first structure which can be felt beneath the 
lower jaw is the hyoid bone, the body and great cornua 
of which can be distinguished. The student in seeking 
for this should not stretch the tissues of the neck, but 
should allow the chin to fall and push his finger and 
thumb up underneath it, when the object of his search 
will readily be discovered. In the normal position this THE MIDDLE LINE OF THE NECK. 
bone corresponds to the fourth cervical vertebra. Be- 
neath it is a space which overlies the anterior thyro- 
hyoid membrane, behind which lies the apex of the 
epiglottis. The next structure met with is the thyroid 
cartilage, or Adam’s apple, the largest and most pro- 
minent hard body in the neck, of greater size and pro- 
minence proportionally in men than in women. The 
upper border with its notch and superior cornua, the 
angle, lower border and inferior cornua by the side of 
the cricoid, can all be distinguished. The middle of 
the angle corresponds to the attachment of the vocal 
cords. Beneath the thyroid cartilage lies the crico- 
thyroid membrane, which is divided in laryngotomy, 
and on which lie the crico-thyroid branches of the 
superior thyroid arteries. The student will note that 
these are the first vessels met with in the middle line, 
and they are of small size ; incisions for the relief of 
cellulitis of the neck may therefore be made in this line 
without fear of wounding any vessel of importance. 
Below this membrane lies the cricoid cartilage, a 
surgical landmark of much importance, which corre- 
sponds with the disc between the fifth and sixth cer- 
vical vertebrae. At the lower border of this cartilage 
the pharynx ends, and the oesophagus commences, this 
point being, as has already been mentioned, one of 
the narrowest parts of that canal. Below the cricoid 
we reach the trachea, about eight of the rings of which 
lie above the sternum in the ordinary position, none 
of which can, however, be felt as separate structures. 
According to Holden only i-| inches of trachea lie above 44 
THE MIDDLE LINE OF THE NECK. 
the sternum, though an additional -| inch may be gained 
by stretching the neck, but Tillaux gives somewhat 
different figures. He states that in a child from three 
to five years there is i-| inches, from six to seven 2, 
from eight to ten and in the normal adult 2f, the 
head being in the ordinary position. In the operation 
of tracheotomy this tube is opened, in that of laryngo- 
tracheotomy its upper rings and the cricoid cartilage 
being divided. On account of these operations, and 
■especially the former, which is by far the commoner, it 
is very important to know what structures lie in front 
of the trachea before it enters the thorax. The first in 
order from above downwards is a transverse communi- 
cating branch between the two superior thyroid veins, 
which is generally present, and lies over the first ring 
of the trachea. Next in order is the isthmus of the 
thyroid, which varies in size, but usually overlies the 
■second, third, and fourth rings. According to Treves 
the importance of avoiding the wounding of this struc- 
ture is overrated, and, as he points out, it has been 
shown that an injection will not cross the isthmus from 
one lobe of the thyroid to the other. Over the isthmus 
is a plexus of veins, and below it they unite into one or 
generally more inferior thyroid veins. In this position 
also is the thyroidea ima artery when such a vessel 
exists. At the root of the neck the trachea recedes con- 
siderably from the surface, a depth of an inch and a half 
intervening between it and the skin at the episternal 
notch. Just above this last is a transverse trunk uniting 
the two anterior jugular veins, which may themselves ANTERIOR OF STERNO-MASTOID. 
lie in front of the trachea, though as a general rule they 
are some little distance from the middle line. In chil- 
dren, up to the age of two, the thymus gland covers the 
trachea for a variable distance above the sternum, and 
the innominate artery may also be in that high position, 
a position which it may retain, though rarely, in the 
adult also. Behind the trachea lies the oesophagus, 
which in this part of the neck lies slightly to the left 
side. In feeling for a hard foreign body the attempt 
should be made on the left side by the trachea, and here 
also the operation of oesophagotomy is performed. 
11. Parts near Anterior Border of Sterno- 
Mastoid. 
The student should first note the exact line of the 
anterior border of the sterno-mastoid muscle, as he is 
apt to obtain an incorrect idea of it, from an examina- 
tion made in the dissected condition. When in an un- 
disturbed condition it does not run a straight course 
from the sternum to the mastoid process, as it appears 
to do when its fascial connections have been cut. On 
the contrary its anterior border passes practically to the 
angle of the jaw, and is held there by its relations 
with the cervical fascia. It follows from this that the 
common carotid artery and its divisions, the external 
and internal carotids are completely covered in by the 
anterior border of the muscle in the undissected state. 
The muscle below arises by two heads, sternal and ANTERIOR OF STERNO-MASTOID. 
clavicular, between which a triangular space of variable 
size is included. At its base lies the line of the sterno- 
clavicular joint. If a needle be pushed in here on the 
right side, it will pass immediately above the innominate 
artery at its bifurcation, and will have below it and to 
the right the subclavian artery, external to it the inter- 
nal jugular vein, and internal to it the common carotid 
artery. Sometimes in children, and even in adults, the 
innominate artery, as has been already mentioned, rises 
higher than the sternum, in which case a needle so in- 
troduced would pierce it. 
A needle thrust through in a similar position on the 
left side would pierce the common carotid artery, and 
possibly the internal jugular vein. 
The relations of these vessels to the lower end of the 
sterno-mastoid should be borne in mind, since it is some- 
times necessary for the relief of wry-neck to divide some 
part of the muscle in that position. At the upper part of 
the anterior border, if a line be drawn from the hyoid to 
the mastoid process, it will correspond to the posterior 
belly of the digastric muscle. Above this lies that por- 
tion of the sub-maxillary gland, which is not deeply 
placed behind the jaw, and on its surface are some 
lymphatic glands, which are perceptible when enlarged. 
Farther down is the lateral lobe of the thyroid body, 
which cannot be distinctly made out save when en- 
larged, but which lies beside the inferior part of the 
thyroid cartilage, the cricoid, and the upper five or six 
rings of the trachea. 
Two veins are related to the external surface of the ANTERIOR OF STERNO-MASTOID. 
47 
sterno-mastoid, viz., a communicating branch from the 
facial to the anterior jugular, which runs downwards 
along its anterior border, and the external jugular, 
which commencing at a point near the angle of the 
jaw crosses the muscle and terminates in the posterior 
angle at the middle of the clavicle. This latter vein 
can be made prominent by pressure applied at its lower 
extremity. The anterior jugular runs down slightly 
•external to the middle line of the neck. 
The most important structures in the region now 
under consideration are the carotid arteries, common, 
•external and internal, with the branches of the second 
named vessel. A line from the sternal extremity of the 
clavicle to a point midway between the angle of the jaw 
and the mastoid process, indicates the position of the 
common carotid. It bifurcates as a rule on a line with 
the upper border of the thyroid cartilage. If a line be 
drawn downwards and outwards from the anterior part 
of the hyoid bone, so as to cross the line of the carotid 
at the level of the cricoid cartilage, it will indicate the 
position of the anterior belly of the omo-hyoid muscle. 
The cricoid cartilage is the guide for the incisions which 
are made along the anterior border of the sterno-mastoid 
muscle in ligature of the common carotid. This opera- 
tion is performed either above or below the omo-hyoid ; 
in the former case the centre of the incision is at the 
level of the cricoid, in the latter its upper extremity. 
At the level of the cricoid cartilage the carotid can be 
compressed against the vertebral column, and here also 
by deep pressure can be felt the anterior tubercle of the 48 
POSTERIOR TO STERNQ-MASTOID. 
transverse process of the sixth cervical vertebra, which 
is called the “ carotid tubercle,” and used sometimes 
as a guide in the operations mentioned above. It may 
also be used as a landmark in tying the vertebral artery. 
The internal jugular vein lies external to the artery, and 
the pneumogastric and sympathetic nerves posterior. 
As regards the branches of the artery, the superior 
thyroid comes off just below the great cornu of the 
hyoid, and curves downwards towards the lateral lobe 
of the thyroid body on the anterior surface of the upper 
portion of which it may be felt pulsating. 
The lingual lies immediately above the great cornu 
of the hyoid, having above it the lingual nerve and the 
tendon of the digastric muscle. The facial arises im- 
mediately above the lingual, sometimes indeed by a 
common trunk with the latter, and passes under the 
jaw in the sub-maxillary gland ; it emerges again and 
crosses the jaw in front of the masseter muscle. The 
occipital artery may be represented by a line starting 
from the carotid line just above the level of the great 
cornu of the hyoid, and passing backwards and upwards 
so as to cross the mastoid process, beneath which the 
vessel lies, about a quarter of an inch above its apex. 
111. Structures Posterior to Sterno-Mastoid. 
Behind the sterno-mastoid lies the posterior triangle 
of the neck, bounded behind by the anterior border of 
the trapezius, passing from the occiput to the point of 
the shoulder. POSTERIOR TO STERNO-MASTOID. 
The lower portion of this triangle, separated from the 
remainder by the posterior belly of the omo-hyoid 
muscle, is surgically the most important part of the 
region, and is called the sub-clavian or supra-clavicular 
triangle. The belly of the muscle just alluded to may 
be seen in a thin neck after swallowing, when its con- 
traction assists to depress the hyoid ; it may also be 
seen in a person sobbing. It lies nearly parallel with 
the clavicle, and so short a distance above it that its 
inferior border is often beneath the edge of that bone, 
especially if the point of the shoulder is raised. It is 
only when the shoulder is depressed, and after the skin, 
fasciae, and other superficial structures have been re- 
moved, that any very distinct triangle therefore exists. 
The most important structure in the triangle is the 
sub-clavian artery, which there rises about half an inch 
above the clavicle, so that if a segment of a circle be 
described of that height, with one cornu at the sternal 
end and the other at the middle of the clavicle, it will 
correspond fairly to the position of the artery. Its vein 
lies on a plane anterior, but under cover of the clavicle. 
If the student stand behind a living subject, and press 
his finger or thumb behind the posterior border of the 
sterno-mastoid, downwards and a little inwards, he will 
feel the pulsations of the vessel, and can 'compress it 
against the first rib. The posterior border of the sterno- 
mastoid corresponds fairly to the outer border of the 
scalenus anticus lying under it, and is a guide to the 
surgeon in tying the artery. If pressure be made back- 
wards and inwards a little above the artery, the trans- POSTERIOR TO STERNO-MASTOID. 
verse process of the seventh cervical vertebra will be 
felt. The transverse cervical artery may be felt as a 
rule running a short distance above the clavicle and 
parallel to it. The cords of the brachial plexus may be 
felt and even seen in a suitable subject, especially if the 
arm be pulled down and the head drawn to the opposite 
side. The outer edge corresponds to a line drawn from 
a point a little above the cricoid cartilage to one a little 
external to the centre of the clavicle. The apex of the 
lung also reaches up into the neck in this position, a fact 
which should be borne in mind, since this portion is 
liable to be first attacked in phthisis. The sub-clavian 
artery arches over it, being only separated from the lung 
by the dome of the pleura and the fascia covering it. 
The lung extends into the neck for a distance varying 
from f to if inch, being higher according to some ob- 
servers on the right than on the left side. Eichorst, 
however, says that the apices are, almost without ex- 
ception, placed at the same height. It is safe to 
conclude that if one side is higher than the other, it 
will almost certainly be the right. 
At the upper part of the posterior triangle, indeed 
strictly speaking, in front of the triangle and under 
cover of the sterno-mastoid, the transverse process of 
the atlas may be felt just below and in front of the apex 
of the mastoid process. One inch below the tip of the 
mastoid the spinal accessory nerve passes beneath the 
anterior border of the sterno-mastoid. It leaves the 
posterior border of this muscle at a point opposite the 
third cervical spine. Its position in the posterior tri- POSTERIOR TO STERNO-MASTOID. 
angle may be indicated by a line drawn from this point 
to the upper border of the trapezius where it again dis- 
appears at the level of the seventh cervical spine. 
Three other nerve trunks lying in the upper part of 
the posterior triangle may be indicated by three lines, 
each drawn from the central point of the posterior border 
of the sterno-mastoid. The first line passing trans- 
versely across that muscle from behind forwards, will 
indicate the superficial cervical nerve; the second to the 
back of the cartilage of the ear, the great auricular; and 
the third along the posterior border of the muscle to the 
scalp, the small occipital. THE THORAX. 
52 
Chapter IV. 
THE THORAX. 
In this chapter only the anterior and lateral aspects of 
the thorax will be considered, the remainder being in- 
cluded in that on the back. It is not necessary here to 
describe the general shape and structure of the thorax,- 
but the student should note the great difference pro- 
duced in the skeleton by the removal of the shoulder 
girdle, and should study the relations of the clavicle to 
the upper part of the cavity. The right side of the 
thorax is, as a rule, larger than the left. According 
to Holden, “ of ninety-two persons of the male sex and 
good constitutions, seventy-one had the right side the 
larger, eleven the left, ten had both sides equal. The 
maximum of difference in favour of the right was one 
inch and a quarter. The measurements were made on 
a plane with the nipple.” 
Bony points.—The sternum is of course the first 
object of study. Its upper border, the episternal notch, 
in inspiration is on a level with the disk between the 
second and third dorsal vertebrae, and about two inches 
anterior to if. If the finger be carried downwards, a 
prominent ridge or angle will be encountered at the 
junction of the manubrium and gladiolus. This is 
called the angulus Ludovici, it marks the part of the THE THORAX. 
53 
•sternum where union takes place latest, and is of 
especial importance as a landmark, since it corresponds 
to the junction of the second costal cartilages with the 
sternum, and thus enables us to find the second pair of 
ribs in a fat subject. This ridge corresponds with the 
lower border of the fifth dorsal vertebra. At the lower 
part of the sternum the junction of the manubrium with 
the xiphoid cartilage will be found, this point corre- 
sponding to the interval between the ninth and tenth 
dorsal vertebrae. It is placed a little below the junction 
.of the seventh pair of costal cartilages with the sternum. 
Though distinct enough in the skeleton it is difficult 
to make out accurately the edges of the xiphoid carti- 
lage in the recent condition, on account of the liga- 
ments which pass to it from adjacent structures. Some- 
times its apex is curved very distinctly forwards, in 
which case there is a cup-like depression between it 
.and the end of the manubrium (infra-sternal depression 
or epigastric fossa). 
On either side of the episternal notch the sterno- 
clavicular articulation will be seen, and the changes 
produced at this joint, as well as in the position of the 
clavicle during its movements, should be studied by 
iraising and lowering the arm of the subject. 
The student should next direct his attention to the 
ribs, which can easily be counted in a thin person, but 
are more difficult to identify where there is much sub- 
cutaneous fat. The first can be felt by pressing the 
finger backwards and downwards under the clavicle, 
external to its articulation with the sternum. This rib 54 
THE THORAX. 
has much less mobility than the others, and its cartilage 
is more often ossified, this being not uncommonly the 
case in tolerably old subjects. The second corresponds 
to the angulus Ludovici. Rules for finding some of 
the others will be found in the next section, in con- 
nection with the muscular and other markings related 
to the soft parts. 
By commencing above and counting downwards be- 
hind the posterior axillary line, the student will be able 
to discover the last two ribs, which from their position 
are sometimes difficult of detection. The last rib is 
very variable in length, being in some cases four times 
longer than in others. It is proportionately smaller in 
women than in men (Macalister), The importance of 
the last rib as a landmark will be dealt with in the 
chapter on the abdomen. 
The oblique sweep of the ribs causes the anterior 
extremity of each to lie on a lower plane than its 
posterior, thus, the first rib in front corresponds to the 
fourth behind, the second to the sixth, the third to the 
seventh, the fourth to the eighth, the fifth to the ninth, 
the sixth to the tenth, and the seventh to the eleventh. 
By remembering these facts the student will be able to 
determine what ribs would be divided in a transverse 
section at any level. The anterior portions of the inter- 
costal spaces are wider than the posterior, and of the 
former the third, second, and first are the widest, in the 
the order mentioned. The operation of paracentesis 
thoracis, or tapping the pleura, is generally performed 
in the sixth interspace, at a point midway between the SOFT PARTS. 
55 
anterior and posterior axillary lines. Some surgeons 
recommend that a space higher should be taken on the 
right side, on account of the fact that the dome of the 
diaphragm, rises higher on that side. The trocar 
should be inserted immediately above the upper border 
of the lower rib in the space indicated, since there is 
thus less danger of wounding the intercostal vessels, 
which lie under cover of the lower border of each rib, 
in the position in which the operation is performed. 
11. Soft Parts. 
One of the most important landmarks in the thorax 
is the nipple. This lies in the majority of cases in the 
interspace between the fourth and fifth ribs, and about 
four inches from the middle of the sternum. It may 
also lie on the fourth rib, more rarely on the fifth, most 
rarely in the fifth interspace. It is not unfrequently 
farther from the middle line on the right side, and may 
be placed at a higher level. 
The female breast covers the thorax from the third 
to the sixth or seventh rib, and from the edge of the 
sternum to the anterior border of the axilla, its base 
being somewhat oval, with its long diameter directed 
downwards and inwards. The nipple is placed a little 
below the centre of the gland, and is surrounded by an 
areola, which is pink in the nullipara, dark brown, and 
dappled with lighter spots in the pregnant woman, and 
after pregnancy becomes a dingy brown, never returning 56 
RELATIONS OF LUNGS 
to its first hue. Beneath the clavicle the deltoid muscle 
and the upper border of the pectoralis major will be 
seen, with a triangular interval between. If the finger 
be pressed deeply into this space, the coracoid process 
will be felt. It is covered by the fibres of the former 
muscle. 
If the arm be drawn outwards from the chest the 
great pectoral will be placed on the stretch, and its 
lower border will indicate the position of the fifth rib 
with which it corresponds. 
If the arm be drawn up by the side of the head, the 
digitations of the serratus magnus muscle will be seen 
in a fairly thin subject. The highest of these which is 
visible corresponds to the fifth rib, the next, which is 
the largest and most prominent to the sixth, and the 
two below to the seventh and eighth. 
111. Relations of Lungs to Thoracic Wall. 
After studying the structures to be seen or felt in the 
wall of the thorax, the student should turn his attention 
to the relation of the various important structures which 
that cavity contains to its exterior. He may first pro- 
ceed to map out the position of the lungs, which may be 
.done in the following manner. A point should be taken 
behind the outer border of the sterno-mastoid muscle, 
and about an inch and a half above the clavicle. From 
this a line should be drawn, passing on each side through 
the sterno-clavicular articulation to the centre of the TO THORACIC WALL. 
57 
angulus Ludovici. This line will be slightly indented 
above the clavicle by the notch for the subclavian ves- 
sels. From the centre of the angulus Ludovici the 
borders of the two lungs run downwards, parallel and 
close to one another, to a point midway between the 
The portion shaded horizontally marks out the area of the lungs, that shaded 
vertically the supplementary pleural space. I—lo.1—10. Ribs. c. c. Clavicles, a. In- 
■ cisura cardiaca. b. Processus lingualis. 
Fig. 7.—Diagram o{ Relation of Lungs to Chest Wall. 
fourth pair of costal cartilages, where they diverge. 
The left passes outwards along the fourth rib to the apex 
beat point, turns downwards, crosses the fifth rib, and 
again turns for a short distance inwards in the fifth 
interspace, and behind the sixth rib, to form a small 58 
RELATIONS OF 
tongue-like process, the processus lingualis. The hol- 
low or bay in the lung thus formed corresponds to the 
part of the heart uncovered by lung (the area of cardiac 
dulness, hereafter to be more particularly alluded to) 
and is called the incisura cardiaca. The right lung on 
the contrary, passes downwards to meet the sixth costal 
cartilage at the parasternal line. The level at which 
the lower border of the lung lies may be indicated in the 
following manner ;—Draw a line slightly convex down- 
wards, from the sixth chondro-sternal articulation round 
the chest to the tenth dorsal spine. In the nipple line 
the lung extends downwards to the sixth rib, in the 
posterior axillary to the eighth, and in the scapular to 
the tenth. 
The sac of the pleura extends farther down than the 
limits mentioned, as of course also does the edge of the 
lung in a full inspiration. Thus, at the front of the 
chest the reflection of the pleura corresponds to the 
seventh rib cartilage, passing from its upper to lie 
below its lower border at the nipple line. In the 
axillary line it lies at the level of the ninth rib, and 
posteriorly at that of the twelfth, or lower if that rib 
be longer than usual. Thus, it is possible for the pleura 
and diaphragm to be wounded without the lung being 
involved, and also for the diaphragm to be pierced 
without any injury to lung or pleura. HEART TO THORACIC WALL. 
IV. Relations of Heart to Thoracic Wall. 
The base of the heart corresponds to a line drawn 
across the sternum at the level of the upper border of 
the third costal cartilages, which extends half an inch 
to the right, and about one inch to the left. The right 
border may be indicated by a curved line drawn from 
the right extremity of the base to the junction of the 
seventh right costal cartilage with the sternum ; this 
line will be rather more than inches from the centre 
of the sternum at the level of the fourth costal cartilage. 
The lower border may be indicated by a line drawn 
from the termination of the last to a point in the left 
fifth interspace, two inches below the nipple, and three 
and a half from the middle line. The line for the left 
border runs from the apex in a curve to the left limit of 
the base. This line will be nearly three inches from the 
middle point of the sternum at the level of the fourth 
costal cartilage. The general position of the heart 
having thus been mapped out, it remains to be seen how 
its various cavities lie. The right auricle forms the 
major part of the right border, and lies beneath the 
third, fourth, and fifth costal cartilages, with the inter- 
vening spaces and a part of the sternum, the tip of its 
appendix being placed on the base line at the mid- 
sternum. The groove between right auricle and ven- 
tricle nearly corresponds to a line drawn from the third 
left costal cartilage at its junction with the sternum, to 
the sixth right at a similar point. The left border is^ RELATIONS OF 
formed by the small portion of the left ventricle, which 
lies in front, the greater portion of the anterior surface 
unaccounted for belonging to the right ventricle. 
The tip of the left auricular appendix lies behind the 
lower part of the second left interspace and the upper 
part of the third costal cartilage. 
The position of the apex-beat is in the fifth interspace 
two inches below, and one inch internal to the nipple, 
that is about inches to the left of the middle line, but 
varies slightly according to the position of the body. 
Symington and others have pointed out that in the 
infant the heart has a greater breadth in proportion to 
the size of the chest than in the adult. Consequently 
in children the apex-beat is often below or even external 
to the nipple line. Steffen believed that it was patho- 
logical if it lay more than f inch external to that line. 
In children the beat may also be in the fourth inter- 
space, whilst in the aged it may be in the sixth. 
The portion of the heart uncovered by the lungs, or 
.area of precordial dulness, may be indicated by a tri- 
angle, of which the base is formed by a line drawn from 
the apex-beat to a little to the right of the middle line 
of the lower end of the gladiolus, and the left side by a 
line from the apex to the mid-sternal line at the level of 
the fourth pair of costal cartilages. The third side is 
formed by joining the upper and lower sternal points. 
At the lower angle on the right side the cardiac dulness 
shades off into that caused by the liver. The precordial 
area may also be indicated by Latham’s method, which 
■consists in describing a circle two inches in diameter, HEART TO THORACIC WALL. 
61 
around a point midway between the left nipple and the 
end of the gladiolus. This circle is sufficiently accurate 
for practical purposes. The position of the valves 
should next be marked out. The pulmonary orifice 
Fig. B.—Diagram of Relation of Heart and Great Vessels to Chest Wall (modified 
from Quain). 
i-io. Ribs. c. c. Clavicles. R. V. Right ventricle, L. V. Left ventricle. 
R. A. Right auricle. L. A. Left auricle. P. Pulmonary, A. Aortic, M. Mitral, 
X. Tricuspid valves. Ao. Aorta. R. I. Innominate artery. R. S. and R. C. 
Right subclavian and carotid. L. S. and L. C. Left subclavian and carotid. 
P. A. Pulmonary artery. V. C. S. Superior vena cava. 
lies most superficially, and is placed to the left of the 
sternum, and behind it and the third costal cartilage. 
The aortic valves lie posteriorly and slightly inferiorly 62 
RELATION OF VESSELS 
to the last, being placed opposite the lower part of the 
third left cartilage and the third intercostal space. The 
tricuspid valves lie behind the sternum at the level of 
the fourth intercostal space and a part of the fourth 
costal cartilage. The mitral valves, which are the most 
deeply situated of all, lie under the left half of the 
sternum and a small portion of the fourth left costal 
cartilage. The student should bear in mind that these 
are the anatomical positions of the valves, but in examin- 
ing the chest with the stethoscope, they are not the 
points at which murmurs at the various orifices are best 
heard. Murmurs at the aortic orifice are most distinct 
at the second right costal cartilage, sometimes called the 
“ aortic cartilage ” from this fact; those of the pulmon- 
ary orifice are heard over the second left interspace 
close 10 the sternum; of the mitral at the apex-beat; and 
of the tricuspid at the ensiform cartilage. 
V. Relations of Vessels, etc., to Thoracic Wall. 
i. Aorta.—The ascending portion of the aortic arch 
passes from the lower part of the third left costal car- 
tilage to the upper border of the second right, and passes 
just so far from under cover of the sternum that a needle 
driven through the second right interspace, close to the 
sternum, will penetrate the great sinus. The transverse 
portion crosses behind the sternum, just below the 
middle of the manubrium, a needle driven through at 
that point passing immediately above it. The end of TO THORACIC WALL. 
63 
the transverse and the descending portions form such a 
curve that a needle, pushed in through the first left inter- 
space beside the sternum, passes under the concavity of 
the arch close to the ductus arteriosus, and enters the 
right border of the descending portion deeper in the 
thorax. 
2. Innominate artery.—This vessel arises from the 
arch at the middle of the manubrium, a needle pushed 
through at this point passing through the left vena in- 
nominata, the innominate artery, the trachea and oeso- 
phagus, and lodging in the third dorsal vertebra. From 
the point mentioned it passes upwards, and to the right 
to terminate behind the right sterno-clavicular articula- 
tion, or sometimes a little higher. 
3. Left common carotid.—This vessel arises from 
the arch a little to the left of the middle line, and passes 
to the left sterno-clavicular articulation. To its left 
again arises the left subclavian artery, which is almost 
directly behind the left common carotid whilst in the 
thorax. 
4. Superior vena cava.—A needle pushed through 
the first right interspace, half an inch from the sternum, 
pierces this vessel at the point of its formation by the 
junction of the right and left innominate veins. A 
needle pushed in through the third right interspace, half 
an inch from the edge of the sternum, pierces the vein 
where it opens into the right auricle. 
5. Left vena innominata.—This lies transversely 
behind the sternum and just below its upper border. It 
may project into the neck, when the transverse part of DIAPHRAGM. 
64 
the arch is situated at a higher level than usual as may- 
be the case especially in children. 
6. Inferior vena cava.—The opening of this vein 
into the right auricle lies under the mesial portion of the 
fifth right interspace, and the adjacent part of the 
sternum. 
7. Internal mammary artery.—This descends be- 
hind the clavicle, the costal cartilages and the first six 
intercostal spaces. It is situated about half an inch 
from the edge of the sternum and parallel to it. 
8. Trachea.—The trachea bifurcates at or just below 
the angulus Ludovici, and opposite the fourth dorsal 
vertebra. The right bronchus lies behind the cartilage 
of the second right rib at the edge of the vertebral 
column, and the left behind the second left interspace in 
a similar position. 
g. Diaphragm.—ln the dead subject the dome of the 
diaphragm is generally said to rise as high as the fifth 
rib on the right side, and the sixth on the left. This is- 
of course subject to great variations, according to the 
period of respiration in the living, and may vary also in 
the dead. Thus, a needle pushed through at the point 
of the apex-beat in the fifth interspace at the left side, 
may pass twice through the diaphragm, wounding the 
stomach intermediately. THE ABDOMEN. 
65 
Chapter V. 
THE ABDOMEN. 
In this chapter the anterior part of the abdominal wall 
alone is considered, together with its relation to the 
viscera and other structures. The posterior and 
postero-lateral portions will be dealt with in the chapter 
on the back, and the perineum and male and female 
genitalia form a separate chapter. 
I. Bony Prominences. 
The xiphoid cartilage and the costal arch have 
already been alluded to. At the lower part of the 
abdomen the crest of the ilium and anterior superior 
spine of the ilium are readily to be distinguished. In 
the erect posture a line drawn so as to connect the latter 
prominences on either side, passes a little above the 
promontory of the sacrum. The symphysis pubis, and on 
either side of it the pubic spine, should be identified. 
The former is covered by a pad of fat of considerable- 
size in females, in whom it is called the mons Veneris, 
the term mons Jovis being sometimes applied to it in 
the male. Should any difficulty be found in distinguish- 
ing the spine it may be discovered by invaginating the 66 
SKIN MARKINGS. 
scrotum and pushing the finger up along the cord, or by- 
abducting the leg and tracing upwards the border of the 
adductor longus muscle. The spine of the pubes is an 
important landmark in connection with inguinal and 
femoral hernias, as it lies inferior and external to the 
first, and superior and internal to the last. It is nearly 
in the same horizontal line as the apex of the great 
trochanter. 
11. Skin Markings, etc. 
The linea alba forms the middle line of the abdomen, 
it is the line of junction of the anterior aponeuroses in 
the interval between the two recti muscles, and though 
it extends from the xiphoid cartilage to the pubes, is 
only distinctly marked as a groove above the umbilicus. 
It is the thinnest and least vascular part of the abdo- 
minal wall, for which reasons it is selected usually as 
the site of the incision in abdominal sections. On each 
side of it lies the prominence of the rectus muscle, 
bounded externally by a curved line, the linea semi- 
lunaris, which extends from the tip of the ninth or tenth 
costal cartilage to the spine of the pubes. The rectus 
muscle is intersected by certain horizontal lines, the 
linese transversae. There are usually three of these, 
one being placed at the tip of the xiphoid cartilage, a 
second midway between it and the umbilicus, or on a 
level wfith the tenth costal cartilages, and the third at 
the umbilicus itself. A fourth may be present below SKIN MARKINGS. 
67 
the umbilicus. The position of the umbilicus is some- 
what variable, but giwavs belcw a point midway be- 
tween the xiphi-sternal articulation and the symphysis 
pubis. It is generally described as corresponding to the 
disk between the third and fourth lumbar vertebrae, or 
Fig. g.—Diagram I' Ai-.tsric v Sr.■ ‘V.ce of Abdomen. 
a. Xiphoid cartilage, b. b. Costal arch. <■. c. Linea alba. d.d. Linete serai- 
lunares. e.e. Line® transversal /. Umbilicus. ,g. Poupart’s ligaments, h. Ab- 
dominal aorta, i. Common,,/;. I i'.irc ; t-ries. I. Internal, m. External 
*" 
abdominal rings, n. Supra-pubic : V 
to the tip of the spinous process of the third lumbar 
vertebra. 
The older writers believed it to be the central point 
of the body, but this idea is incorrect. According to 
Mr. Roberts (Anthropomdry > at the time of birth, when 
the child is about the sixth of the height it will ulti- SKIN MARKINGS. 
mately attain to, the point which divides the total height 
into two equal parts is a little above the navel; at two 
years of age it is at the navel ; at three years, when the 
child has attained half its total height, the central point 
is on a line with the upper borders of the iliac bones ; 
at ten years of age, when the child has attained three-- 
fourths of its total height, the central point is on a line 
with the trochanters ; at thirteen years it is at the 
pubes, and in the adult man it is nearly half an inch 
lower. In the adult woman the central point is a little- 
above the pubes.” 
In fat subjects two lines cross the abdomen trans- 
versely, one at the umbilicus and one above the pubes. 
When the bladder is tapped above the pubes the trochar 
is passed through the linea alba at the point where it is 
intersected by the latter. 
Poupart’s ligament may be seen and felt extending 
in a gentle curve convex downwards, from the anterior 
superior spine of the ilium to the spine of the pubes. 
The external abdominal ring lies just above the crest of 
the pubes, having the spine external to it. It may be 
felt by invaginating the scrotum and pushing the finger 
up in front of the cord. 
The internal ring is situated half an inch above the 
middle point of Poupart’s ligament. A line drawn from 
one ring to the other will indicate the position and 
limits of the inguinal canal. It should be remembered 
that in the child at birth there is scarcely any true in- 
guinal canal, as the rings Almost overlie one another. 
The position of the nerves of the abdomen is of im- STOMACH. 
portance in connection with certain forms of vertebral 
disease which cannot here be particularly considered, 
and the student should, therefore, be familiar with their 
approximate position. The tenth nerve is nearly in a 
line with the umbilicus, the eighth with the middle 
linea transversa, the sixth and seventh supply the area 
above this and between the two limbs of the costal arch. 
The ilio-hypogastric and ilio-inguinal lie close above 
Poupart’s ligament. 
111. Relations of Viscera to the Abdominal Wall. 
In the middle line behind the linea alba the dis- 
position of the viscera from above downwards is briefly 
as follows. Below the xiphoid cartilage lies a part of 
.the left lobe of the liver, beneath which is the stomach. 
.Next comes the transverse colon, then the small intes- 
tine, and finally the apex of the bladder, if sufficiently 
.distended. It will now be necessary to consider these 
.and other viscera more particularly. 
1. Stomach.—This organ, whilst comparatively fixed 
at its cardiac extremity, is moveable to a considerable 
.extent at its pyloric, and consequently alters in its 
relations according to the amount of its distension. 
The cardiac orifice lies about one inch from the sternum 
behind the seventh left costal cartilage, and corresponds 
to the spine of the ninth dorsal vertebra posteriorly. 
The fundus lies to the left of this and on a higher level, 
irising as high as the upper border of the sixth sterno- LI VEIL 
chondral articulation, or even higher, so as to be placed 
just behind the apex of the heart. If a line be drawn 
downwards from the 3:ght border of the sternum, and 
another from the end of the bony portion of the seventh 
rib, the point at which these intersect will indicate the 
position of the pylorus in the empty condition of the 
stomach. But when full the pylorus may move as much 
as three inches to the right. so as to lie behind the 
junction of the sever;h and eighth right rib cartilages. 
It is situated more superficially titan the cardiac open- 
ing. A line drawn so as to connect the tips of the tenth 
costal cartilages will indicate the lower limit of the 
moderately distended organ : when further distended it 
reaches to a point from g to ty incites above the umbilicus. 
In the operation of gastrostomy the incision is generally 
made parallel to the left side >f the costal arch, and 
about two fingers brea ;th below it, as the stomach is 
here uncovered by liver, and in c intact with the anterior 
abdominal wall. This area is bounded on the right by 
the edge of the liver, on the left'by the cartilages' of the 
eighth and ninth ribs an 1 below by a horizontal line 
passing between the tips of the tenth costal cartilages. 
2. Liver.—ln the erect posture the liver descends 
about half an inch below the costal arch, though it is a 
matter of some difficulty to fed it in that position. It 
is much more obvious beneath the xiphoid cartilage, 
where in the angle of the costal arch the lower border 
. of the organ may be-indicated by a line drawn from the 
ninth right to the eighth left costal cartilage. The size 
of the left lobe is somewhat variable, and its left Fig. io.—Diagram of Anterior aspect of Abdomen and Thorax, showing 
relations of Viscera to surface (Luschka slightly modified). Red, Liver; 
Yellow, Stomach. * GalLbladder- SPLEEN. 
71 
extremity may extend from an inch and a half external 
to the sternum, or to any point between this and the 
left mammillary line. Its extent is much greater in the 
infant. The position of the convex upper surface 
varies according to the posture, and to the period of re- 
spiration at which it is examined. The. convex surface 
on the right side lies beneath the seventh to the 
eleventh ribs inclusive, and the cartilages of the sixth 
to the ninth also inclusive. On the left side it does not 
reach so high a level. “ The extent of the liver up- 
wards if traced on the surface of the body is marked 
by a line crossing the body of the sternum, close to its 
lower end and rising on the right side to the level of the 
fifth chondro-sternal articulation and on the left to that 
of the sixth” (Quain). Under ordinary circumstances 
about an inch of the left lobe lies to the right of the 
middle line, but Symington has shown that the left 
lobe and the anterior surface of the right have a 
certain amount of mobility, and are displaced slightly 
to the right when the stomach is distended. The gall 
bladder has its fundus placed near the surface, by the 
outer border of the right rectus muscle, and under the 
ninth right costal cartilage. 
Posteriorly the liver reaches the surface below the 
the right lung opposite the tenth and eleventh dorsal 
vertebrae and for an extent equal to that of their bodies. 
3. Spleen.—This organ cannot be felt under the 
edge of the ribs save when pathologically enlarged.. It 
lies beneath the ribs from the eighth or ninth to the 
eleventh inclusive, and nearly in the line of the posterior 72 
PANCREA S—INTESTINES. 
part of the tenth. Its mesial extremity is about 
inches from the middle line, and its outer about the 
same distance from the mid-axillary. It should, how- 
ever, be remembered that it is subject, within physio- 
logical limits, to considerable variations in size. 
4. Pancreas. —lt is very rarely possible to feel this 
■organ, but in a very thin subject with flaccid abdominal 
walls, it may be distinguished. It lies on the vertebral 
column over the disk between the first and second 
lumbar vertebrae and the adjacent bodies, and should 
consequently be sought in the middle line of the ab- 
domen, nearly midway between the xiphoid cartilage 
and the umbilicus. 
5. Intestines.—Save where it is hidden by the liver 
and spleen at the hepatic and splenic flexures, the 
transverse colon is near to the surface, varying in height 
from the region of the umbilicus or below it, to two inches 
or so above. When dilated by gas its situation may be 
ascertained by percussion, and masses of hardened 
faeces, when present, can be felt in its interior. The 
caecum, which is the most superficial part, lies in the 
right iliac fossa. The sigmoid flexure, lies in the left 
iliac fossa. The vermiform appendix lies in a line from 
the anterior superior spine to the umbilicus and about 
three inches from the former (Mcßurney’s point). The 
small intestine occupies the portion of the abdomen 
below the transverse colon. Mr. Treves concludes from 
his laborious investigations, that it is impossible to 
localise the position of any of the coils connected with 
the mesentery. VESSELS. 
73 
6. Bladder.—The bladder cannot be distinguished 
above the pubes save when distended. In this con- 
dition it may extend up to the umbilicus, or to any 
point between it and the pubic symphysis. In extreme 
distension from retention of urine, its outline can easily 
be distinguished, and the fluctuation of its contents 
felt. It carries the peritoneum before it as it pushes its 
way upwards, so that an uncovered space of greater or 
less extent exists, through which the trocar is passed in 
the operation of tapping above the pubes. 
Other points in connection with the colon and the 
kidneys will be dealt with in the chapter on the back. 
IV. Relation of Vessels to the Abdominal Wall. 
The abdominal aorta commences rather above the 
centre of a line drawn from the supra-sternal depression 
to the umbilicus; lies on the left side of the vertebral 
column, and generally divides into the two common iliac 
arteries opposite the middle of the body of the fourth 
lumbar vertebra. Its bifurcation is, however, subject to 
considerable variations. 
When it divides at the usual situation it will nearly 
correspond to a point a little to the left side of the centre 
of a line drawn so as to connect the highest parts of the 
two iliac crests. This point will be placed about f of 
.an inch below and to the left of the umbilicus. If two 
lines be drawn from it, curving slightly outwards, 
.to a point a little internal to the middle of either 74 
VESSELS. 
Poupart’s ligament, they will correspond to the common 
and external iliac arteries. The former of these vessels 
is somewhat variable in length, but, speaking generally, 
about two inches of either line, or rather more on the 
right, will correspond to its limits. A line drawn from 
the point where Poupart’s ligament crosses the external 
iliac to the edge of the rectus, about an inch or more 
below the umbilicus, will indicate the position of the 
deep epigastric artery, and the triangle thus included 
will correspond to Hesselbach’s triangle. The cceliac 
axis corresponds to the twelfth dorsal vertebra behind, 
and to a point four or five inches above the umbilicus 
in front. The superior mesenteric artery arises just 
below this, and the renal arteries an inch lower down. 
The inferior mesenteric is given off about an inch above 
the umbilicus. THE MALE. 
75 
Chapter VI. 
THE PERINEUM AND GENITALIA. 
I. The Male. 
The student should first of all practise the operation of 
passing the catheter or sound, a procedure more difficult 
in the dead subject than in the living, when the latter 
is not affected with a stricture. The sound should be 
well oiled, and its passage will be facilitated by dilating 
the mouth of the urethra and pouring a little oil into it. 
The operator should stand on the left side of the body 
and hold the penis in the left hand. Stretching the 
penis he should introduce the instrument, keeping the 
handle in the line of the left groin at first. As it glides 
down the urethra it should gradually be carried towards 
the middle line, until its direction corresponds with the 
long axis of the body, from which it should not be 
allowed to swerve. When the instrument has been 
passed a certain distance a slight obstruction will be 
met with, which is the base of the triangular ligament.. 
The handle should then be slightly depressed, when a 
little gentle pressure'will carry the point of the instru- 
ment into the bladder. If the student finds it difficult 
to accomplish this he may pass his left forefinger into 
the rectum and guide the point of the instrument, which 76 
PENIS -SCROTUM—FERINE UM. 
will be easily felt with the point of the finger. Having 
passed the sound into the bladder, it should be with- 
drawn, and the manoeuvre repeated several times. The 
instrument may then be left in the bladder. 
1. Penis. This organ should next be examined. 
The large dorsal vein will generally be visible on its 
upper surface, and on either side of it, in a well injected 
subject, an artery may be visible. The prepuce should 
be reflected and its fraenum examined. The glans, with 
its corona at its base, and the constricted portion or 
cervix, around which are collected the glands of Tyson, 
will then be seen. 
2. Scrotum.—The spermatic cord should be felt and 
the vas deferens distinguished from its other constit- 
uents, which can easily be done by its whipcord-like 
feel. The testicle is of course easily to be felt, and the 
•epididymis lying posteriorly and superiorly should be 
distinguished from the gland itself. The rugae of the 
scrotum are much less distinct in the dead subject than 
in a healthy living individual, on account of the relaxa- 
tion of the muscular fibres of the dartos. 
A median line or raphe, continuous with a similar 
line in the perineum, indicates the position where the 
originally separate halves came together and united in 
the process of development. 
3, Perineum.—The scrotum should now be hooked 
up on the front of the abdomen, and the body placed in 
the lithotomy position, so that the perineum may be 
■examined. This position is maintained by different 
methods in different schools, so that no particular PERINEUM. 
description need be given. The boundaries of the 
perineum should first be ascertained. Commencing 
in front, the pubic arch, rounded off by the sub-pubic 
ligament will be felt, and passing round on either side 
the rami of the pubis and ischium up to the tuberosity 
of the latter. In the middle line behind is the coccyx, 
and on either side of it the great sacro-sciatic ligament 
may be distinguished under cover of the edge of the 
gluteus maximus muscle. A line from the most pro- 
minent part of one tuber ischii to the other divides 
this diamond-shaped space into two triangles, an 
anterior or urethral, and a posterior or rectal. It is 
divided also by the mesial ridge or raphe, which has 
already been alluded to. Like many other middle lines 
of the body, this last is comparatively non-vascular, 
and incisions should consequently there be made for the 
escape of extravasated urine. 
The central point of the raphe between the scrotum 
and anus corresponds to the central tendinous point of 
the perineum, or point of junction of the perineal 
muscles. This is placed at the centre of the lower 
border of the triangular ligament, which may be felt on 
each side of it when the legs are straight and the parts 
relaxed. The bulb of the urethra and its artery are 
always placed in front of this point. The urethra 
pierces the triangular ligament about three quarters of 
an inch in front of it, and its position can be distinctly 
felt when the sound is within it. 
Around the anus, in dissecting room subjects, knots 
of venous enlargement or piles are not uncommonly 78 
PERINEUM. 
the most prominent structures. Apart from these 
pathological structures, the student will note the radiat- 
ing folds into which the mucous membrane is thrown, 
as also a thin white line surrounding the aperture where 
the skin and mucous membrane join, which indicates 
the line of division between the external and internal 
sphincters. By everting the mucous membrane of the 
rectum slightly, the small pouches, one to three lines in 
depth, which lie between the ends of the columnae recti, 
and are sometimes the seat of ulceration, will be seen. 
The left forefinger should now be introduced into the 
rectum, while the staff is held in the right hand so that 
it may be moved about when necessary. In the 
anterior part of the cavity, the student will feel the sound 
in the membranous part of the urethra. It is here that 
strictures most commonly occur, and that the catheter 
requires at times that careful guidance, which, as will 
now be perceived, the finger in the rectum can give to 
it. Passing further upwards, the apex of the prostate 
gland will be met with at about an inch and a half from 
the anus, and the shape of the gland can be explored. 
About an inch and a quarter higher up, the superior 
border of the prostate will be reached, and the finger 
having passed beyond it will touch that part of the 
rectum where the bladder is in contact, without the 
intervention of peritoneum, and where the operation of 
tapping per rectum is performed. On each side of this 
point are placed the common ejaculatory ducts and 
seminal vesicles. The lowest of the transverse folds, 
valves of Houston or plicse transversales, may be dis- PERINEUM. 
79 
tinguished on the left side at about the level of the 
prostate, the next, about four inches from the anus, is 
on the right side, and roughly marks the lowest point 
to which the recto-vesical pouch of peritoneum descends. 
Otis has shown that by placing the dead body in what 
is known as the knee-elbow position, the rectum be- 
comes dilated by atmospheric pressure, and by suitable 
illumination (electrical) three or four of these plicae can 
be seen placed alternately on either side of the tube. 
Contrary to a commonly received view, he denies that 
they have any action as valves in holding back the 
faeces. At the sides of the rectum the finger can ex- 
plore the ischio-rectal fossae, and finally behind, near 
the orifice, the coccyx will be felt. It is sometimes 
movable in males, generally freely so in women who 
have borne many children. 
Before leaving the perineum the student should mark 
out the lines of the incisions made in the operations of 
lithotomy. In the lateral operation the incision is com- 
menced a little to the left of the middle line, and just 
below the central tendinous point, and is then carried 
downwards and outwards for two or three inches to a 
point just below the anus, but one-third nearer to the 
tuberosity of the ischium than to the margin of that 
orifice. 
In the median operation the edge of the knife is 
turned upwards instead of downwards, and its point is 
entered in the middle line about half an inch in front of 
the anus, and carried onwards until it strikes the groove 
in the staff which is lying in the urethra. THE FEMALE. 
11. The Female. 
The labia majora, covered with hair on the outer 
surface, and on their inner with mucous membrane, are 
the first objects visible ; they unite below the mons 
Veneris and in front of the perineum, these junctions 
being known as the anterior and posterior commissures. 
When these folds are separated, two smaller folds of 
mucous membrane, the nymphae or labia minora, will 
be seen, each being about an inch and a half in length. 
Traced upwards these will be found to be continuous 
with the prepuce, covering the glans of the clitoris. 
Below the nymphae, and uniting the labia majora, there is 
in the nullipara a transverse fold, the fraenulum pudendi, 
forming with the posterior commissure a triangular area, 
the fossa navicularis. The student will generally seek 
in vain for these in dissecting room subjects, as the 
first parturition usually destroys them. Between the 
nymphae is the vestibulum, and in it, about an inch 
below the clitoris, is the opening of the urethra. A 
tubercle is often stated in text-books to be placed at 
this orifice, but as a practical landmark it is almost 
valueless. Having ascertained the position of the orifice 
the student should practise passing the catheter. As 
this operation has to be performed on the living subject 
without causing exposure, it is well to accustom the 
fingers to the parts engaged. The subject should be 
placed on its back, with the knees slightly bent and 
separated from one another, and the operator should PERINEUM. 
stand on the left side. The forefinger of the left hand 
should be passed down between the vulvse, over the 
clitoris, and into the vestibule, where the orifice of the 
urethra may sometimes be felt. In any case, by pass- 
ing the point of the catheter along the palmar surface 
of the finger, it can, with a little practice, be made to 
enter the urethra easily. The ordinary sound found 
in dissecting rooms is an inconvenient instrument for 
the purpose, but a probe may be used, or still better, 
a piece of small sized glass tube about six or eight 
inches in length, one end of which has been sealed and 
rounded in a flame, and at the same time slightly bent. 
When the student has familiarised himself with this 
operation, he should leave the instrument in situ, and 
examine the relation of the urethra, which passes just 
below the sub-pubic ligament and the posterior wall 
of the bladder to the vagina. The close connection be- 
tween the walls of these two cavities, and their com- 
parative thinness, lead to their occasional rupture and 
the formation of a vesico-vaginal fistula. The same 
might be said of the posterior wall, where recto-vesical 
fistula occurs. The proper orifice of the vagina is just 
below the meatus urinarius, and is generally narrowed 
in the virgin by the hymen. This is a structure which 
is seldom seen in the dissecting room, but may be 
studied in a female foetus at full term or in the post- 
mortem room, in the bodies of virgins. The examina- 
tion of a sufficient number will teach the student that 
it is variable in size and shape. It may even in the 
virgin be entirely absent, or represented by a fringe. 82 
PERINEUM. 
On the other hand it may be imperforate, or its opening 
may be so small as only to admit the point of a probe. 
The aperture may be enlarged so that the hymen forms 
a circular ring, but most commonly it is semilunar, with 
its concavity directed towards the pubes. From all this, 
the student will perceive that any diagnosis of virginity, 
or the reverse founded upon the condition of the hymen 
alone, must be very guarded in its nature. After its 
rupture, small wart-like remains, the carunculae myrti- 
formes, may persist, but these generally disappear after 
a few parturitions. 
The forefinger should be passed into the vagina, and 
the os uteri with the anterior and posterior cul-de-sac 
explored. The posterior is the higher, and corresponds 
to the pouch of Douglas or recto-vaginal pouch in the 
cavity of the abdomen. This is the lowest point of that 
cavity, and the position, therefore, where fluid will first 
collect. One forefinger may be passed into the rectum 
and the other into the vagina, and the wall between 
examined. At the highest part the recto-uterine fold of 
peritoneum will lie between the fingers. The description 
of the anus, mucous folds of the rectum, ischio-rectal 
fossa, and coccyx, in the male, need not be repeated 
for the female. Between the anus and the uro-genital 
fissure, lies the perineum of the obstetrical text-books, 
about one inch in breadth. It is easy to see how the 
head of the child in parturition may tear through this, 
and even through the rectum and anus. THE BACK. 
83 
Chapter VII. 
THE BACK. 
In the middle line of the back there is a furrow, more or 
less well-marked, according to the muscularity of the 
subject, and bounded by muscular masses, which are 
formed chiefly by the complexus muscle of either side 
in the cervical region, and by the erectores spinse in the 
remainder of the back. At the bottom of this furrow 
the spines of the vertebrae may be felt, and, as Holden 
remarks, made evident in the living subject to the 
eye by friction in the median line, when red patches 
will appear and indicate their position. The spine of 
the axis may easily be felt beneath the occiput, and that 
of the seventh or vertebra prorninens at the root of the 
neck, with frequently the spine of the sixth above it. 
The spines of the vertebras between the second and the 
sixth cannot be felt as individual structures, but a ridge 
indicating their position and that of the ligamentum 
nuchse can distinctly be made out. 
The third dorsal spine corresponds to the inner end 
of the spine of the scapula, and the seventh to the 
inferior angle of that bone. The twelfth corresponds to 
the head of the last rib, and the lowest part of the 
trapezius muscle, which may be made evident in a thin THE BACK. 
84 
subject by raising the arm and scapula as high a.S- 
possible. The highest point of the crest of the ilium 
corresponds to the fourth lumbar spine. On account of 
the downward direction of the spines of the dorsal ver- 
tebrae, these prominences do not all correspond to the 
rib which belongs to them. The second dorsal spine 
corresponds to the head of the third rib, and so on, each 
spine corresponding to the head of the rib of the ver- 
tebra below it, until the eleventh and twelfth spines,, 
which are on a level with their own ribs. 
The scapula covers the ribs from the second to the 
seventh inclusive, and its superior and inferior angles 
and spine can easily be distinguished. 
The crest of the ilium and its posterior superior spine 
can be felt ; at the central point of the former there is a 
triangular space bounded by the latissimus dorsi and 
external oblique muscles, known as Petit’s triangle. 
The upper limit of the origin of the latissimus dorsi 
corresponds to a line drawn from the sixth dorsal spine 
transversely across the scapula. 
The trachea bifurcates at a point midway between 
the third and fourth dorsal spines, the roots of the lungs 
thus lying a little below and external to that point, the 
edge of the lung extending as low as the spinous process 
of the tenth dorsal vertebra. The apex of the lower 
lobe is at the level of the third rib behind. The pleura 
reaches to the tenth dorsal spine or even lower. 
The thoracic aorta commences at the left side of the 
vertebral column opposite the fourth dorsal spine ; 
thence passes downwards, gradually approaching the SPINAL CORD AND NERVES. 
85 
.anterior aspect to bifurcate opposite the fourth lumbar 
spine. 
Spinal cord and nerves.—The cord extends in 
the adult from the under surface of the foramen 
magnum to the lower edge of the first lumbar vertebra 
as a rule, or on the other hand, may be as low as the 
.second lumbar. Its position alters slightly in the move- 
ments of the body, as it rises during flexion of the spine. 
In the child at birth it extends to the third lumbar 
vertebra. The cervical nerves are named after the 
vertebra above which they escape, the first nerve 
emerging above the first vertebra, and the eighth below 
the seventh, and between it and the first dorsal. The 
remaining nerves are numbered after the vertebra below 
which they escape. In relation to the symptoms follow- 
ing upon fractures and dislocations of different parts of 
the spinal column, it is important to know the point at 
which each nerve arises from the spinal cord, this point 
by no means corresponding to that at which it emerges. 
The following rule will enable the student to find the 
relationship of the root origin of the cervical and dorsal 
spinal nerves to the spines of the vertebrae with suffi- 
cient accuracy. For the upper four nerves subtract 
one from the number of the nerve, thus the root origin 
of the third cervical is opposite the second spine. For 
the lower four cervical and upper six dorsal, subtract 
two from the number of each nerve, thus the root origin 
of the eighth cervical is opposite the sixth cervical spine. 
For the lower six dorsal nerves subtract three from the 
number of the nerve, thus the root origin of ninth dorsal is 86 
KIDNEYS. 
opposite the sixth dorsal spine. The lumbar nerves arise 
in the neighbourhood of the tenth and eleventh dorsal 
spines and the sacral nerves between the eleventh dorsal 
and first lumbar spines. It is right, however, to say 
that these relations are subject to considerable varia- 
tions. 
Kidneys.—The kidneys lie on a level with the last 
dorsal and first two or three lumbar vertebrae, the right 
being about half an inch or more lower than the left, so 
that about one and a half inches on the left, and one 
inch on the right, intervene between the lower border 
of the gland and the iliac crest. The hilus lies from 
two to two and a half inches from the middle line, and 
is about opposite the first lumbar spine. The following 
method of mapping out the kidney on the posterior 
aspect of the body may be adopted:—i. Draw a line 
parallel with and one inch from the spine, between the 
lower edge of the tip of the spinous process of the 
eleventh dorsal, and the lower edge of the spinous pro- 
cess of the third lumbar vertebra. 2 and 3. Lines 
drawn from the top and bottom of this line outwards at 
right angles to it for 2| inches. 4. A line parallel to the 
first and connecting 2 and 3. Within this parallelogram 
the kidney lies (Morris). In the normal condition it is 
difficult to feel these organs, but in a thin subject with 
flaccid walls the rounded outer border may be made 
out. When abnormally enlarged they may be distin- 
guished, and in searching for them the student should 
adopt the following method. Stand on the side of the 
body opposite to the kidney to be examined, pass one Fig. it.—Diagram of posterior aspect of Abdomen and Thorax, showing 
relations of Viscera to surface. Red, Liver; Purple, Spleen; Yellow, the 
Kidneys and Ureters. (Modified from Luschka), COL ON—CER VIC A L. 
87 
hand under the back until the fingers slip over the edge 
of the erector spinae muscle of the opposite side, then 
press backwards with the other hand upon the anterior 
abdominal parietes, so that the points of the fingers of 
either hand may be brought as near to one another as 
possible, when the organ may be felt between them. 
Colon.—The ascending and descending parts of the 
colon can be approached through the posterior parietes 
of the abdomen in the lumbar region between the crest 
of the ilium and the last rib, but the operation of colo- 
tomy is, for various reasons, generally performed upon 
the latter. The incision in this operation is made from 
the edge of the erector spinae muscle, at a point midway 
between the crest of the ilium and the last rib, and 
parallel to the last named structure. 
This seems to be the best place to give a table of the 
relations of certain of the viscera and other structures 
to the bodies of the vertebrae, which it is hoped may be 
useful to the student as a guide to the topography of the 
parts in and near the middle line. 
Cervical. 
1. Level of hard palate. 
2. Level of free edge of upper teeth. 
3 & 4. Superior cervical ganglion of sympathetic. 
4. Hyoid bone and upper aperture of larynx. 
5. Middle cervical ganglion ; rima glottidis. 
6. Cricoid cartilage, end of pharynx, commencement 
of oesophagus and trachea. 
7. Inferior cervical ganglion. DORSAL—L UMBAR. 
88 
Dorsal. 
1. Apex of lung. 
2. Termination of second part of aortic arch (L). 
Disk. Level of episternal notch. 
3. Termination of arch of aorta (L). Bifurcation of 
trachea (lower border). 
4. Level of angulus Ludovici. 
5 to 8. Base of heart. 
6. Pulmonary orifice. 
7. Aortic orifices. 
8. Mitral and tricuspid orifices. 
g. Level of lower end of gladiolus. Opening in dia- 
phragm for vena cava inferior. 9to 11. Spleen. 
10. Level of tips of xiphoid cartilage. Opening in 
diaphragm for oesophagus. Lower limit of lung 
posteriorly (transverse process). 10 and 11. 
Spigelian lobe of liver. 
11. Supra-renal capsule ; upper end L. kidney. 
12. Disk—upper end of R. kidney. Aortic orifice in 
diaphragm, coeliac axis (lower border). 
Lumbar. 
1. Pancreas. Superior mesenteric artery (lower bor- 
der). Hilus of kidney (spine). Receptaculum 
chyli. 
Lower end of spinal cord. 
2. Upper limit of third stage of duodenum (L). Renal 
arteries. L UMBAR—SACRAL—COCCYX. 
89 
Lumbar. 
3. Lower limit of second stage of duodenum (R). 
Inferior mesenteric artery. 
Disk. Umbilicus. 
4. Bifurcation of aorta. Level of highest point of 
crest of ilium. 
Disk. Ilio-caecal valve. 
5. Commencement of inferior vena cava. 
Sacral. 
3. End of first stage of rectum. 
Coccyx, tip. 
End of second stage of rectum. SHOULDER AND AXILLA. 
Chapter VIII. 
UPPER EXTREMITY. 
I. Shoulder and Axilla. 
i. Bony points.—The clavicle may be seen and felt 
in its entire extent. In the ordinary position in men 
it is not horizontal but slopes upwards from the middle 
line, the amount of this slope being increased when 
the weight is taken off the arm as in the recumbent pos- 
ture. But in women commonly, and sometimes in men 
also, its slope is downwards from the middle line. The 
outer extremity of the clavicle leads to the acromion 
process, which, with the spine of the scapula, is quite 
distinct. The tip of the former is one of the pro- 
minences from which measurements of the upper limb 
are made, and it may be remembered that in the hanging 
position of the arm, the palm being directed forwards, 
it is in the same line as the external condyle of the 
humerus and the styloid process of the radius. The 
student should remember that the end of the acromion 
process may be unconnected with the spine, by a failure 
of bony union between the centres from which it and the 
spine are developed. Under cover of the deltoid muscle 
the two tuberosities of the humerus will be felt, the 
greater being external and in the line of the external SHOULDER AND AXILLA. 
condyle, the lesser anterior. Between them the bicipital 
groove and tendon may sometimes be distinctly made 
out. By placing the hand on the apex of the shoulder 
and the thumb in the axilla, and pressing deeply with 
the latter, the arm being in the dependent position, the 
neck of the scapula and the lower border of the glenoid 
fossa can be distinguished. If now the arm be abducted 
and the thumb moved a little outwards the head of the 
humerus will be felt, and can be easily identified by 
rotating the arm, when its shape will be distinctly re- 
cognized. It lies in the same line as the internal 
condyle. By deep pressure beneath the clavicle, in the 
interval between the deltoid and pectoralis major mus- 
cles, the tip of the coracoid process will be felt under 
the former. This is another point from which measure- 
ments of the upper extremity are made, and is also 
valuable as a guide to the axillary artery in its first 
stage. 
2. Soft parts.—The point of the shoulder is capped 
over by the deltoid muscle, the limits of which are 
easily to be defined. Under ordinary circumstances it 
forms a smooth rounded surface over the subjacent 
bony prominences; but in dislocation downwards of the 
humerus, and to a lesser degree in paralysis of the 
deltoid following upon injury to the circumflex nerve, a 
depression will be visible at the outer part of the shoulder 
corresponding to the interval between the head of the 
humerus and the acromion process. In the groove 
between the deltoid and pectoralis major lie the cephalic 
vein and the humeral thoracic artery. The coraco- SHOULDER AND AXILLA. 
acromial ligament lies under the anterior fibres of the 
deltoid, and‘may there be distinguished, the shoulder 
joint being immediately underneath it. Under the 
clavicle is a hollow of variable depth, the sub-clavicular 
fossa, in which the axillary vessels lie; it is obliterated 
■or replaced by a prominence in certain dislocations of 
the humerus. At a lower level the line of division 
between the clavicular and sternal portions of the pec- 
toralis major may be distinctly seen in some subjects. 
The student should next examine the axilla and move 
the arm in different directions so as to observe the 
alterations in its shape caused thereby. Its base is 
somewhat triangular, the apex being at the humerus, 
and the base at the chest wall. The anterior fold 
■contains the pectoralis major, and the posterior, the 
latissimus dorsi. The depression between the anterior 
and posterior folds is deepest when the arm is at an 
angle of 450 with the chest, and shallowest when the 
arm is raised above the level of the shoulder. The 
hollow, however, never quite disappears, a fact which is 
partly due to the action of the suspensory ligament, a 
part of the deep fascia connected with the skin below. 
The skin of the axilla is well supplied with hairs, 
sebaceous and sweat glands. Three sets of lymphatic 
glands are contained in the axilla, which, however, can- 
not be felt unless enlarged. These are placed, (1) along 
.the anterior fold, (2) along the posterior, (3) along the 
vessels. 
When the arm is stretched out at a right angle to the 
body, the prominence of the coraco-brachialis muscle SHOULDER AND AXILLA. 
may be distinctly seen passing down to the middle of 
inner border of the humerus. If the arm be maintained 
in this position, and a line drawn from the centre of the 
clavicle to the humerus, internal to the lower end of the 
coraco-brachialis, it will correspond to the axillary 
artery. This vessel may be compressed in its first stage 
against the second rib, beneath the clavicle and internal 
to the coracoid process, pressure being applied down- 
wards and backwards. In its third stage it may be 
compressed against the humerus by the side of the 
coraco-brachialis, pressure here being applied outwards 
and a little backwards. In its second stage it lies 
deeply beneath the pectoralis minor muscle. The 
boundaries of this last may be defined by two lines start- 
ing from the coracoid process, and running, the upper to 
the third rib close to the cartilage, and the lower to a 
similar point on the fifth rib. The point where the 
upper line crosses the line of the axillary artery indicates 
the site of the acromial axis. The long thoracic artery 
runs along the lower border of the pectoralis minor and 
consequently corresponds to a portion of the second line. 
The axillary vein is internal to its artery, lying in the 
angle between the clavicle and the first rib, and the 
nerve cords of the brachial plexus are, in the first stage, 
externa] to it. 
The circumflex nerve winds round the back of the 
humerus, a little above the middle point between the 
apex of the shoulder and the lowest part of the insertion 
of the deltoid and its cutaneous branches ramify over 
the lower part of that muscle, the supra-acromial ARM AND ELBOW. 
94 
branches of the cervical plexus lying over its upper 
portion. 
11. Arm and Elbow. 
i. Arm.—On either side of the distinct median pro- 
minence of the biceps will be seen a depression, that on 
the inner side being the better marked. These grooves 
are caused by the two partitions of fascia which cut off 
the anterior from the posterior muscles of the arm, the 
intermuscular septa. The external groove passes from 
the muscles above the outer condyle to the lower end of 
the insertion of the deltoid and corresponds also to a 
part of the cephalic vein. The internal groove extends 
from near the internal condyle to the insertion of the 
coraco-brachialis muscle and indicates a portion of the 
course of the brachial artery which lies on its outer side. 
The course of this vessel may be marked out by a line 
drawn from the inner side of the coraco-brachialis at its 
insertion to the centre of the elbow joint. Throughout 
it may easily be felt as it lies close beneath the skin, and 
may also be compressed against the humerus, though 
the direction in which the pressure is applied differs 
above where it lies internal to the bone, and below 
where it lies in front of it. The inner edge of the 
bicipital prominence is the guide to the surgeon in 
making his incision for the ligature of this artery in its 
upper part. Its first branch, the superior profunda, 
winds round the back of the arm with the musculo-spiral 
nerve at the level of the lowest point of the insertion of ARM AND ELBOW. 
95 
the deltoid. It may be remembered that this point 
which is at the centre of the shaft of the humerus 
corresponds to the junction of the cylindrical and 
prismatic portions of that bone, a favourite site for 
fractures. A short distance below the insertion of the 
deltoid the cutaneous branch of the musculo-spiral nerve 
appears close to the external intermuscular septum. 
The triceps muscle is the only structure to be studied on 
the back of the arm; its details can be seen when a 
living person forcibly extends the forearm on the arm. 
The flat tendinous surface below with its pointed upper 
extremity and the two muscular masses, one arising on 
either side of it, are then brought into view in a well 
developed subject. 
2. Elbow, a. Bony points.—The two condyles of the 
humerus should first be studied. The internal is the 
more prominent, descends lower, and is further from the 
line of the articulation than the external (more than one 
inch as compared with three-quarters of an inch). It 
can easily be grasped by the fingers as it lies under the 
skin, and the edge of the trochlear portion of the lower 
end of the humerus will be felt about three-quarters of an 
inch from its apex. The internal supra-condyloid ridge 
can only be traced for a short distance above it, but a 
sharp fibrous band will be felt under the skin, which is 
the internal intermuscular septum at its lower end. Be- 
tween the internal condyle and the olecranon is a de- 
pression in which lies the ulnar nerve (the “funny- 
bone” as it is commonly called), the posterior ulnar 
recurrent and the posterior branch of the inferior pro- 96 
ARM AND ELBOW. 
funda artery. The external condyle is less prominent,, 
more rounded at its extremity, placed higher and nearer 
to the joint line. It can be distinctly felt, and especially 
posteriorly, and the external supra-condyloid ridge can 
be traced upwards from it for about three inches. It 
may be mentioned here that in about one out of every 
fifty arms (Struthers) there is a hook-like process of 
bone, the supra-condyloid process, above the internal 
condyle, which when present can be distinctly felt. The 
olecranon process is obvious in all positions of the joint, 
together with the triangular subcutaneous portion of the 
ulna which passes down from it and is covered by a 
bursa. The position of this bony eminence with respect 
to the condyles should be studied in the various posi- 
tions of the joint. If the thumb and the next two fingers 
be placed on the three points respectively and the fore- 
arm be moved, this can easily be effected. It will then 
be found that in extension the three points lie on the 
same line, in semi-flexion the olecranon is below the 
condyles, and in extreme flexion it is in front of them. 
Thus normally the olecranon is never at a higher level 
than the condyles. The relation of these points to one 
another is of importance in the diagnosis of fractures- 
and dislocations at or near the elbow joint. If the 
point of the thumb be pressed deeply under the muscles 
arising from the external condyle and forming the outer 
boundary of the triangular area in front of the elbow 
joint the head of the radius will be felt, and if the 
fingers be placed at a corresponding point at the back 
of the arm it may be grasped and felt rotating beneath ARM AND ELBOW. 
97 
them during the movements of pronation and supina- 
tion. In complete extension a small groove can be dis- 
tinguished between the head of the radius and the back 
of the capitellum behind, as the two are not in contact 
with one another in that position. If the thumb be now 
shifted a little inwards and deep firm pressure be made,, 
the coronoid process of the ulna will be felt, though not 
distinctly, especially in a muscular subject. In extreme 
pronation the tubercle of the radius may be felt behind 
a short distance below the head of that bone, though 
again not distinctly in a muscular subject. 
b. Soft parts.—In the semi-flexed condition a curved 
crease passing from one condyle to the other and con- 
cave upwards, the “fold of the elbow,” will be first seen.. 
This line does not quite correspond to the articulation 
but is placed a little above it. The student should next 
carefully study the position and relations of the large 
superficial veins, and for this purpose should select a 
muscular living subject. The vessels may be made pro- 
minent, and thus be investigated with greater ease, if 
a bandage be tied firmly round the arm a few inches 
above the elbow. It is impossible to adhere closely to- 
regional limitations in this instance, and the veins should 
therefore be traced up from their origin to the elbow, the 
student remembering that deviations from the arrange- 
ment regarded as normal are very common. 
The veins having been made prominent in the manner 
indicated, the commencement of the first trunk should 
be sought on the dorsum of the thumb. Above the cleft 
between the thumb and the index finger this vein is ARM AND ELBOW. 
joined by another coming from the back of the latter 
digit. The combined trunk passes to the flexor aspect 
of the fore-arm above the wrist, and runs along its radial 
border, receiving tributaries from both anterior and pos- 
terior surfaces. The veins on the ulnar side commence 
by tributaries which unite above the cleft between the 
ring and little fingers to form a trunk, the vena salva- 
tella. This vessel runs up the back of the fore-arm 
turning round to its anterior surface below the elbow, 
where it is joined by the anterior ulnar vein which takes 
its course along the ulnar border on the anterior aspect. 
The median vein which runs up the centre of the ante- 
rior surface of the fore-arm is very variable in size 
and length. Below the ante-cubital fossa it receives a 
deep tributary which cannot be seen from the surface, 
and the combined trunk divides into two, the median 
basilic which passes inwards to join the common ulnar 
and form the basilic vein, and the median cephalic 
which, taking the opposite direction, unites with the 
radial to constitute the cephalic vein. The median 
basilic lies in front of the brachial artery, the bicipital 
fascia intervening between the two vessels, and is 
crossed by twigs of the internal cutaneous nerve. The 
median cephalic overlies branches of the external cuta- 
neous nerve. The anatomy of these vessels is not sur- 
gically of such importance as it was in the not very 
distant days when phlebotomy was the commonest of 
minor operations. As this has, however, still sometimes 
to be performed the parts concerned should be con- 
sidered in this relation. The median basilic is usually ARM AND ELBOW. 
99 
the larger vessel and affords, therefore, the better supply 
of blood, but the median cephalic is the safer, because 
the former, as has been mentioned, is crossed by nervous 
fibres which being wounded may cause the patient to 
start, and the operator to plunge his scalpel through the 
vein into the subjacent artery, the result being the for- 
mation of an arterio-venous aneurism. 
The muscular masses in front of the elbow enclose a 
triangular depression, the ante-cubital fossa. On the 
outer side is the extensor eminence, the inner border of 
which is formed by the supinator longus. On the inner 
side is the flexor eminence with the pronator radii teres 
externally. At the upper part or base the lower end of 
the bicipital elevation will be seen, and the tendon of 
that muscle can be seen and felt easily lying near the 
•centre of the fossa. Passing off from the biceps at its 
upper end and on its inner side is a fibrous expansion 
the bicipital fascia which crosses and helps to bind 
down the flexor muscles. When this is fairly well- 
marked it can be seen in a thin subject during flexion, 
as it produces a furrow in the flexor mass about two 
finger breadths below the internal condyle. The student 
will notice that when the biceps is brought gradually 
into action, the globular mass which it then forms 
commences near the elbow, and ascends towards the 
level of the pectoralis major. If the finger be pressed 
into the ante-cubital fossa under the inner edge of the 
tendon of the biceps, the pulsations of the brachial 
artery will be felt at a point about a finger’s breadth 
below the line of the internal condyle. The student ARM AND ELBOW. 
will feel just below this point, the sharp upper edge of 
the bicipital fascia preventing him from pushing his 
finger deeply further down towards the apex of the 
fossa. He should next place his fingers on his own 
radial artery, at the point where the “ pulse” is felt, and 
flexing gradually his arm he will feel what an effect is 
produced upon the blood current by that movement. 
If he be fairly muscular he will be able to entirely stop 
the flow of blood in his radial artery, or at least, materi- 
ally to decrease its volume. This fact is of surgical 
importance in connection with aneurisms of the brachial 
artery. The radial recurrent artery passes upwards in 
the groove between the supinator longus and brachialis 
anticus to anastomose with the superior profunda. The 
anterior ulnar recurrent runs on the opposite side be- 
tween the brachialis anticus and pronator radii teres 
to anastomose with the inferior profunda and anasto- 
motica. The posterior ulnar recurrent runs upwards 
to the depression between the internal condyle, and the 
edge of the trochlea, and the interosseous recurrent 
takes the same upward course to the interval between 
the olecranon and the external condyle. The brachial 
artery itself bifurcates at a point opposite the neck of 
the radius as a rule, but the student should be on the 
look out for a high division either of the axillary or 
brachial trunks, two arteries which may be distinguish- 
able thus existing, 'a condition which obtains in about 
one in every five and a half cases. (R. Quain). 
In the ante-cubital fossa the median nerve lies first 
internal to the brachial artery. The musculo-spiral FOREARM AND WRIST. 
nerve, not strictly in the fossa, lies between the supina- 
tor longus and brachialis anticus and under cover of the 
former muscle. As already mentioned, the ulnar nerve 
lies in the depression between the internal condyle and 
the edge of the trochlea. Over the olecranon lies a 
bursa which is sometimes enlarged, as a result of some 
special occupation leading to constant pressure upon it, 
the disease being known as “ miner’s elbow.” 
111. Forearm and Wrist. 
i. Bony points.—The radius can be explored pos- 
teriorly throughout its entire length, from its head to 
its lower end, though less distinctly for some inches 
below the head than in its lowest part, on account of 
the muscles which cover it. Externally and anteriorly, 
its styloid process can be distinctly felt a finger’s breadth 
above the upper border of the ball of the thumb. Pass- 
ing the finger round the back of the lower end, there 
will be felt, near its centre, a bony prominence, round 
which turns the tendon of the extensor secundi internodii 
pollicis, and still further, towards the ulnar side of the 
forearm, the groove between the radius and the ulna. 
Anteriorly, only about the lower half of the radius can 
be made out, and that not very distinctly. The ulna is 
also very distinct from the olecranon to the lower end, 
posteriorly. The rounded prominence of the latter is 
very obvious to sight and touch at some little distance 
above the wrist joint; internally and posteriorly, the 102 
FOREARM AND WRIST. 
styloid process can be felt. The ulna also can only be 
indistinctly felt on its anterior aspect. The tip of the 
styloid process of this bone corresponds to the line of 
the wrist joint, but the styloid process of the radius is- 
placed at a lower level, and corresponds to the scaphoid. 
A line drawn from the tip of one styloid process to 
that of the other would consequently fall below the line 
of the joint. In order to indicate this it will be neces- 
sary to cause the line, joining the two above mentioned 
points, to form a curve, with its convexity upwards, and 
half an inch at its farthest point from the straight line 
alluded to. 
2. Soft parts. (a) Muscles.—A little manipulation 
along the outer border of the forearm in its lower half 
will enable the student to feel the tendons of the radial 
extensors and supinator longus. If the thumb be fully 
extended, the bellies of the extensores ossis metacarpi 
and primi internodii pollicis will be seen distinctly as 
a rounded elevation, crossing the radius in its lower 
third, downwards, outwards, and forwards ; their ten- 
dons can be made out close to the lower end of the 
radius, lying on the bone, and still more distinctly as 
they pass over the wrist joint. If the fingers of the 
right hand be laid on the posterior aspect of the left 
forearm at its lower part, and the left fingers be ex- 
tended, the tendons of the extensor communis will be 
felt, and those of the little finger will be distinguished 
on the ulnar side, if that digit alone be brought into' 
action. Still farther towards the ulnar side, the tendon 
of the extensor carpi ulnaris may be indistinctly made FOREARM AND WRIST. 
103 
out. Anteriorly, commencing at the ulnar side, the 
tendon of the flexor carpi ulnaris can be grasped as it 
lies under the skin, when the wrist is semiflexed and 
adducted. Extend the hand, and the palmaris longus 
tendon in the centre of the forearm becomes visible in 
a considerable part of its extent. This muscle is 
absent once in every ten bodies on the average, and is 
three times oftener symmetrically absent than asymme- 
trically (Macalister). 
Under this tendon, and on each side of it, the tendons 
of the flexor sublimis digitorum can be felt by gentle 
pressure. At their outer border lies the strong, but not 
very distinctly to be felt, tendon of the flexor carpi 
radialis, and finally at the radial border, the tendons of 
the two first extensors of the thumb, as they cross the 
wrist joint. 
(b) Arteries.—Just internal to the two last mentioned 
extensors, the pulsations of the radial artery can be felt 
against the subjacent radius, this being the position 
where the “ pulse” is generally observed. A line drawn 
from this point to the outer border of the biceps tendon 
just below the head of the radius, will indicate the 
position of the artery. It is fairly superficial through- 
out, being overlapped above by the inner border of the 
supinator longus. It is in the line just mentioned that 
the incisions to tie the artery are made, the edge of the 
supinator longus and its tendon being the guide to the 
vessel. 
If the wrist be semiflexed to relax the skin, &c., and 
the fingers be thrust under the tendon of the flexor 104 
FOREARM AND WRIST. 
carpi ulnaris, the pulsations of the ulnar artery will be 
felt. A line drawn from this point and curved slightly, 
so as to be convex inwards, to the same upper point as 
that given for the radial artery, will indicate the position 
of the ulnar, which is, however, quite deeply placed in 
the upper part of the forearm. When it requires to be 
tied in the upper third of the arm the incision is made 
along a line drawn from the front of the internal condyle 
to the outer border of the pisiform, so that the centre of 
the incision is three fingers’ breadth below the internal 
condyle. 
{c) Nerves.—The course of the chief nerves of the 
forearm may be indicated by three lines. That for the 
median commences just internal to the brachial artery 
in the antecubital fossa, and is drawn to the centre of 
the front of the wrist joint, where it lies under, or on the 
ulnar side of, the tendon of the palmaris longus. The 
ulnar nerve is indicated by a line drawn from below and 
in front of the outer part of the internal condyle, to the 
outer side of the corresponding artery at the wrist. It 
meets the artery at the apex of its convexity, that is at 
the junction of the upper and middle thirds of the arm. 
The radial nerve is indicated by a line drawn from the 
outer edge of the upper part of the tendon of the biceps, 
meeting the artery about two inches below the elbow 
joint. It accompanies the artery to a point three inches 
above the wrist joint, where it leaves its vessel, passing 
to the back of the forearm under the tendon of the 
supinator longus muscle. The cutaneous nerve supply 
of the forearm, as well as that of the arm and hand, THE HAND. 
105 
will be seen from the diagrams (figs. 12 and 13), and the 
student should accustom himself to map out the parts 
in correspondence with their nerves. 
IV. The Hand. 
1. Bony points.—On the radial side of the hand at 
the upper part of the muscles of the thumb a bony 
ridge can be made out, which is formed by portions of 
two bones, the tubercle of the scaphoid above, and the 
ridge on the trapezium below, but any line of division 
between the two is hard to distinguish. At the upper 
part of the hand, on the ulnar border, the pisiform is 
easily identified, and lower down the process of the 
unciform may be found, but with less readiness. At 
the lower end of the metacarpal bone of the thumb, and 
in front of the metacarpo-phalangeal joint, the two 
sesamoid bones of that digit can be felt. The lower 
ends of the metacarpals of the remaining digits can be 
felt in the palm, but not their proximal extremities, on 
account of the muscles and other structures lying upon 
them. On the back of the hand, since there are less 
soft structures between the skin and the bones, the 
outlines of the latter can be more distinctly made out. 
The upper end of the metacarpal bone of the thumb 
can be readily felt, especially if that digit be extended. 
The upper ends of the metacarpal bones of the other 
fingers are not so easy to distinguish, but the ulnar edge 
of that of the little finger can be felt at the border of THE HAND. 
Fig. i 2 Areas Upper Extremity. 
Anterior Aspect. 
a. Supraclavicular (3, 4c). 
b. Circumflex (5, 6c). 
c. Internal cutaneous (Bc, id). 
d. Wrisberg and intercosto-humeral (1, 2d). 
e, Musculo-spiral (up. ext. cut.) (6c). 
}. Musculo-cutaneous (5, 6c). 
g Ulnar (id). 
h. Median (6, 7, Bc, id), 
j. Radial (6). THE HAND 
107 
Fig. 13.—Cutaneous Areas Upper Extremity. 
Posterior Aspect. 
а. Supraclavicular (3, 4c). 
б. Circumflex (5, 6c). 
c. Internal cutaneous (Bc, id). 
d. Wrisberg and intercosto-humeral (1, 2.1). 
c\ Musculo-spiral (int. cut.), (8c). 
e”. Do. (lower ext. cut.), (6, 7, 8c), (the 
upper part of this area is supplied by 
the upper ext. cut. e). 
/. Musculo-cutaneous (5, 6c). 
g. Ulnar (8c). 
h. Median (6, 7, Bc, id), 
j. Radial (6, 7c). THE HAND. 
the hand, if that member be adducted and pressure be 
made upwards along the metacarpal until the point 
sought for be reached. A line very slightly curved 
downwards, drawn from this point to the carpo-meta- 
carpal joint of thumb, will correspond to the line of the 
carpo-metacarpal articulations. Along this line the 
articulations in question may be felt for, that of the 
index being distinguishable without much difficulty. 
The spur on the upper end of the metacarpal of the 
middle finger may be indistinctly felt, as well as the 
base of the corresponding bone of the ring finger. 
Attention should next be directed to the knuckles, and 
it will first be noted that in every case the bony promin- 
ence to which that name is attached, belongs to the 
proximal bone of the articulation, that is, the first row 
of knuckles is formed by the heads of metacarpals, the 
second by those of the first phalanges, and so on. Con- 
sequently the line of articulation is somewhat lower in 
each case than the corresponding knuckle. The lines of 
all the articulations are curved, but the curves are not 
all in the same direction. Those of the metacarpo- 
phalangeal joints are concave towards the wrist, and 
are situated from half to three-quarters of an inch from 
the free edge of the webs of the fingers. The lines of 
the remaining articulations are concave in the opposite 
direction, that is, towards the tips of the fingers, and 
correspond in their curves fairly accurately to the curve 
of the skin surrounding the attached upper borders of 
the nails. 
2. Skin and soft parts.—The hollow of the palm THE HAND. 
109 
is somewhat triangular, with its apex directed upwards. 
It is bounded by a muscular elevation on either side, 
belonging to the thumb and little finger respectively. 
The former or thenar eminence is circumscribed by a 
groove due to the movement of the thumb in opposition, 
which commences on the ulnar side of the fold of skin 
uniting the thumb and index finger, and runs upwards 
to be lost in the apex of the triangle of the palm. If 
the palmaris brevis muscle be made to act, as it can be 
in many individuals, an irregular longitudinal crease 
will be found along the ulnar border of the hand at the 
side of the hypothenar eminence. The apex of the 
triangle of the palm corresponds to the lower border of 
the anterior annular ligament, the upper margin of 
which is indicated fairly accurately by the lower point 
of the curved skin crease, which crosses the wrist just 
above the two muscular elevations. Another palmar 
crease commences close to that of the thumb and passes 
across the hand, gradually approaching nearer to the 
wrist until it is lost on the hypothenar eminence. Its 
radial, most strongly marked portion, is due to the 
flexion of the index, the remainder being a secondary 
fold caused by flexion of the three inner digits. In the 
cleft between the index and middle fingers, another 
crease commences, which runs at first upwards and 
inwards, as far as the line of the cleft between the next 
two digits, and then inwards across the lower part of 
the hypothenar eminence. It is the primary fold caused 
by the flexion of the three inner digits. The first of 
these two last mentioned folds, as it crosses the third THE HAND. 
metacarpal bone, corresponds to the lowest point of the 
superficial palmar arch. Its highest point may be indi- 
cated by a line drawn from the ulnar side of the com- 
missure of the thumb, when that digit is extended 
transversely across the palm. The digital branches 
arise from this arch opposite the clefts of the fingers, 
bifurcate half an inch below the webs of the fingers, 
and run along the borders of the digits on their palmar 
surfaces, where their pulsations may distinctly be felt. 
The deep palmar arch lies about half an inch nearer 
the wrist than the superficial. The second crease 
crosses the necks of the metacarpal bones, and corre- 
sponds also pretty nearly to the upper limits of the 
synovial sheaths of the flexor tendons of the three inner 
digits, and to the point where the palmar fascia divides 
into its terminal slips. The folds at the joints of the 
fingers should next be examined. Those over the 
metacarpo-phalangeal articulations of the index and 
minimus are single, those of the other two digits double. 
Each is placed about three-quarters of an inch below 
the joint to which it corresponds. The creases over the 
first row of interphalangeal articulations are double in 
each case, and the line of the joint lies between the two. 
Those of the second interphalangeal articulations are 
single, and lie a very little above the corresponding 
joints. The thumb is crossed above and external to 
the thenar eminence by two oblique lines ; the lower of 
these, which commences nearly at the radial side of the 
commissure, crosses the metacarpo-phalangeal articula- 
tion. The line of articulation in the case of each of the THE HAND. 
joints is more distinct dorsally than on the palmar sur- 
face, on account of the flexor tendons, and especially of 
the so-called glenoid ligaments, which lie between these 
tendons and the articulations. The flexor tendons of 
the fingers can be indistinctly felt on the anterior sur- 
faces of the fingers, and the long flexor of the thumb 
may be distinguished by pressing the finger under the 
ulnar border of the thenar eminence at its lower end, 
and extending the thumb. The superficialis volae 
artery, when large enough, can be felt pulsating on the 
thenar eminence. The student will notice that there is 
no great amount of mobility between the skin in the 
palm of the hand and the subjacent tissues, a fact which 
is due to the connection of the former with the palmar 
fascia. A similar condition obtains at the pulps of the 
fingers, which is here due to the cutaneo-phalangeal 
ligaments of Cleland, which pass from the bone to 
the skin. The result of this immobility of the skin is 
to give a firmer grasp than would be afforded if the skin 
glided easily upon the subcutaneous tissues. 
On the dorsum of the hand, at the radial side, will be 
seen, if the thumb be extended, a triangular hollow, 
“ Cloquet’s snuff-box,” which is bounded radially by the 
tendons of the two first extensor muscles of the thumb, 
and on its ulnar side by that of the second internode. 
In its roof lies the vein which forms the origin of the 
radial vein of the arm. The base of the metacarpal 
bone of the thumb lies at its lower part, and the radial 
artery can be felt pulsating within it. Deeper still lie 
the scaphoid and trapezium. The princeps pollicis THE HAND. 
112 
artery can be felt pulsating in the thumb just below the 
radial end of the commissure, and the princeps indicis 
in its digit below the ulnar end of the same. Numerous 
veins are visible on the dorsum of the hand, passing 
upwards to form the radial or the posterior ulnar trunks. 
On the radial side of the index the prominence of the 
first dorsal interosseous muscle or abductor indicis is 
very distinct. The extensor tendons of the fingers can 
be seen and felt, and if the fingers be fully flexed, the 
lateral slips, passing from that for the ring finger, to 
those of the adjacent digits, can also be observed. THE BUTTOCK. 
113 
Chapter IX. 
THE LOWER EXTREMITY. 
I. The Buttock. 
1. Bony points.—The crest of the ilium, which 
forms the upper boundary of this region, can be felt 
easily in its entire extent. At its posterior extremity 
its posterior superior spine will be encountered, lying at 
the level of the second sacral spine, and corresponding 
to the centre of the sacro-iliac synchondrosis. The 
spines of the sacral vertebrae lie in the middle line, and 
below them the tubercles of the last two sacral vertebrae. 
Just below the last of these, and practically undistin- 
guishable from them, are the cornua of the first bone of 
the coccyx, the highest point of which process corre- 
sponds to the spine of the ischium. The upper border 
of the great sciatic notch is about on a level with the 
third sacral spine. The tip of the coccyx can be felt 
just behind the rectum, and can be grasped between the 
fingers, if one be inserted into that tube and the other 
placed on the surface opposite to it. It will be found 
to be mobile in many women and some men. The great 
trochanter is easily distinguished, even in fat persons, 
in whom its position is indicated by a small pit in the 
soft parts. Its apex corresponds with a point a little 114 
THE BUTTOCK. 
above the centre of the hip-joint in old persons; in 
younger individuals, since the neck of the femur makes 
a larger angle with the shaft, it is placed a little lower 
down. It is covered by the fascial insertion of the 
gluteus maximus, between which and the bone lies a 
large and important bursa. 
The tuberosity of the ischium can also be readily felt, 
especially in the sitting posture, when it comes from 
under cover of the gluteus maximus, and forms with its 
fellow of the opposite side the main support of the body. 
It is also covered by a bursa, which is one of three in 
the body especially liable to inflammation and enlarge- 
ment, as a result of occupation. The disease commonly 
known as “ Drayman’s bottom ” is due to this enlarge- 
ment. In connection with certain of the bony points 
just mentioned, two methods have been adopted of 
determining the position of the trochanter in relation to 
injuries at the hips. The first of these is known as 
“ Nelaton’s line.” This is a line drawn from the anterior 
superior spine of the ilium to the most prominent por- 
tion of the tuber ischii of the same side. It crosses the 
acetabulum near or above its centre, and just strikes 
the apex of the great trochanter. In dislocations at the 
hip, the apex of the trochanter will be either above or 
below this line. The second method of determining 
the position of the trochanter is known as “ Bryant’s 
ilio-femoral triangle.” This is constructed by placing 
the subject in the recumbent position, and drawing a 
vertical line from the anterior superior spine of the 
ilium. A second is drawn from the same point to the Fig. 14.—Diagram of side of Buttock, a. Host. Sup. Spine of Ilium; 
b. Great Trochanter; c. Tuber Ischii ; d. Ant, Sup. Spine of Ilium. 
1. Nelaton’s line. 2. Line to find Gluteal Artery. 3. Line to find Sciatic 
Artery. (The pointer from the star in each case indicates the position of the 
artery). THE BUTTOCK. 
115 
.apex of the great trochanter, and the third completes 
the triangle, and is drawn at right angles to the first 
line. The measurements must be made on both sides, 
when any increase or decrease of the third or test line 
on the affected as compared with the normal side can 
be ascertained. 
2. Soft parts.—The greater portion of the rounded 
contour of the buttock is formed by the gluteus maxi- 
mus muscle. By pushing the fingers upwards beneath 
the lower border of this, the sharp edge of the great 
sacro-sciatic ligament can be felt. The lower boundary 
of the region under description is formed by a distinct 
crease, the fold of the nates or buttock. This is com- 
monly, but erroneously, said to correspond to the lower 
margin of the gluteus maximus, but this really crosses 
the fold obliquely, being higher than it mesially, and 
lower than it externally. It is not caused by the lower 
border of the gluteus maximus, as is also often stated, 
but as was pointed out by Symington, it is largely due 
to the tuberosity of the ischium, being always best 
marked where it passes outwards beneath that promi- 
nence. The skin is placed on the stretch in flexion of 
the thigh, and is relaxed during its extension, a fold 
thus being formed. The position of the arteries of the 
buttock can be found by means of lines described by 
Lizar. The first of these is drawn from the posterior 
superior spine of the ilium to the apex of the great 
trochanter, the thigh being rotated inwards. The point 
of junction of the inner and middle thirds of this line 
indicates the position at which the gluteal artery emerges THE THIGH. 
from the upper part of the great sciatic foramen. The 
second line is drawn from the posterior superior spine 
of the ilium to the outer part of the tuber ischii. Two 
inches below its upper extremity the line crosses the 
posterior inferior spine of the ilium, and four inches 
below the same point, the spine of the ischium. The 
sciatic artery emerges from the great sciatic foramen, 
at a point corresponding to the junction of the middle 
and lower thirds of the line. The pudic artery is, of 
course, external to the pelvis, as it crosses the spine of 
the ischium on its way from the greater to the lesser 
sciatic foramen. 
If a line be drawn from the point at which the sciatic 
artery emerges from the foramen downwards, so as to 
lie midway between the great trochanter and the tuber 
ischii, it will correspond to the position of the great 
sciatic nerve. 
The long or inferior pudendal nerve crosses the bone 
a short distance in front of the tuber ischii, and then 
curves round into the perineum, to be distributed to the 
posterior and under surface of the scrotum. The effects 
of pressure upon this nerve may often be felt in the 
sensation of “ pins and needles ” in this region, after 
long sitting upon a hard surface. 
11. The Thigh. 
The anterior superior spine of the ilium and the spine 
of the pubes, both of which prominences have been THE THIGH. 
117 
already alluded to, are the most important bony points 
in this region. The former is taken as the point from 
which measurements of the lower extremity are made, 
and the latter, which is at the same level as the apex 
of the great trochanter, is an important factor in the 
diagnosis between inguinal and femoral hernise. If 
the two points just mentioned, and the most prominent 
part of the tuberosity of the ischium, be marked out, 
the acetabulum will lie about midway between them. 
Poupart’s ligament, stretching in a line curved down- 
wards between the anterior superior spine of the ilium 
and the spine of the pubes, is easily to be distinguished. 
The inner inch corresponds to the extent of Gimbernat’s 
ligament. 
Crossing the upper part of the thigh, a second line, 
described by Holden, and usually named after that 
surgeon, may in many cases be seen, especially if the 
limb be slightly flexed. It “ begins at the angle be- 
tween the scrotum and the thigh, passes outwards, and 
is gradually lost between the top of the trochanter and 
the anterior superior spine of the ilium,” When pre- 
sent it runs across the front of the capsule of the hip- 
joint. The sartorius and adductor longus should be 
made out as they form the boundaries of Scarpa’s 
triangle. The former is brought into action when the 
thigh is flexed and adducted, and the latter in abduc- 
tion, its sharp internal edge, leading to the spine of the 
pubes, being very easily distinguished. 
The femoral artery passes under Poupart’s ligament 
at a point midway between the spine of the pubes and THE THIGH. 
the anterior superior spine of the ilium, where its pul- 
sations may very distinctly be felt. If a line be drawn 
from this point to the tubercle for the adductor magnus 
on the inner condyle of the knee, its upper two-thirds 
will overlie the artery. The common femoral divides 
into its superficial and deeper portions about an inch 
and a half or more below Poupart’s ligament. In the 
upper third of the thigh the common and superficial 
femoral arteries lie in Scarpa’s triangle, and are super- 
ficial; below this point they have a deeper position. 
Pressure should be applied to the femoral in order to 
check its current, backwards and slightly upwards, be- 
low Poupart’s ligament, the patient being in the recum- 
bent position. At the apex of Scarpa’s triangle, pressure 
should be applied outwards, as the artery is here on the 
inner side of the femur. 
The femoral vein below Poupart’s ligament lies in- 
ternal to its artery, and has on its other side the femoral 
ring and crural canal. The former lies an inch out from 
the pubic spine, on a line drawn from that eminence to 
the apex of the great trochanter. It may also be found 
by ascertaining the position of the femoral artery by its 
pulsations, and allowing half an inch on its inner side 
for the vein. It is through this aperture that a femoral 
hernia escapes from the abdomen ; in the crural canal, 
along the inner side of the vein, lie the deep set 
of femoral glands. The saphenous opening is placed 
just below Poupart’s ligament, and its centre is about 
an inch and a half below and external to the spine of 
the pubes. The most important structure, surgically THE THIGH. 
119 
speaking, which passes through it, is the long saphenous 
vein, which will be dealt with further on. This vessel 
may sometimes be seen in thin individuals, the position 
of the saphenous opening itself being at times indicated 
by a dimpling of the skin. Two sets of superficial lym- 
phatic glands lie at the upper part of the thigh, one 
horizontal and in a line with Poupart’s ligament, the 
other vertical and parallel to the femoral artery. The 
sources of the various lymph streams which enter these 
are of some importance, and are thus described in Mr. 
Treves’ Surgical Anatomy. 
Superficial vessels of lower limb = vertical set. 
Superficial vessels of lower half of abdomen = middle 
glands of horizontal set. 
Superficial vessels of outer surface of buttock = exter- 
nal glands of horizontal set. 
Vessels of inner surface of buttock = internal glands 
of horizontal set. (A few of these vessels go to the ver- 
tical glands). 
Superficial vessels from external genitals = horizontal 
glands, and a few to vertical. 
These glands can sometimes be felt beneath the skin, 
especially in thin children. 
Superficial vessels of perineum = vertical set. 
Externally to the femoral artery lies the anterior 
crural nerve, and under it and the artery, and also 
external to both, is the ilio-psoas muscle, forming part 
of the floor of Scarpa’s triangle. This muscle overlies 
the front of the capsule of the hip-joint, a large bursa 
intervening. THE THIGH. 
120 
The chief remaining objects worthy of note in the 
thigh are the muscular markings, of which, besides those 
which have already been alluded to, the following may 
be observed. The tensor vaginae femoris forms an ele- 
vation directed downwards and backwards, and com- 
mencing at the anterior superior spine of the ilium, 
immediately behind the sartorius. Below it is inserted 
into the fascia lata, which in extension of the hip and 
knee will be noticed to be particularly tense and re- 
sistant on the outer side of the thigh. A specialised 
band of this fascia, called the ilio-tibial band, may be 
looked upon as the tendon of insertion of the muscle in 
question ; it extends down to the outer part of the head 
of the tibia, and may be distinctly felt above, the knee- 
joint, when the muscle is placed upon the stretch. The 
rectus femoris forms the median prominence of the 
quadriceps and about four inches above the knee-joint 
it joins a triangular tendon, which passes downwards to 
be attached to the patella. The outline of this tendon 
stands out very distinctly in a muscular individual when 
the knee is fully extended. In the same position the 
two vasti muscles are brought into prominence. The 
lower fibres of the inner descend as low as the inner 
border of the patella, those of the outer not descending 
so far by an inch or more. A groove between the inner 
vastus and the adductor muscles marks the position of 
the lower portion of the sartorius and the subjacent 
Hunter’s canal. A similar groove on the outer side of 
the thigh marks the position of the external intermus- 
cular septum, the line of demarcation between the 
vastus externus and the hamstring muscles. THE KNEE. 
111. The Knee. 
The first object which the student should examine is 
the patella, and he can, with advantage, in this as in 
other parts of the body, carry out his observations upon 
himself. In order to examine this bone the leg should 
be placed in the extended position, the heel resting upon 
the ground so as to fully relax the muscles and other 
structures. Its shape can then be fully investigated, 
and the fingers can even be pushed a little underneath, 
so as to feel a small part of the posterior surface. It 
will be noticed that the patella can be moved freely 
in different directions, gliding easily over the smooth 
trochlear surface of the femur. 
In the same position of the extremity, the whole of 
the outer border and a part of the upper limit and ante- 
rior surface of the articular surface of the external con- 
dyle can be felt. In semi-flexion the articular surface of 
the internal condyle becomes more easy of investigation, 
when its inner border and a part of its anterior surface 
can be felt. In extreme flexion the greater part of the 
anterior surface comes under observation, but not very 
distinctly, on account of the tension of the skin. Below 
the patella, and stretching between it and the tubercle 
of the tibia, is the ligamentum patellae, which should be 
studied in the different positions of the joint. If the 
forefingers of both hands be pushed under the ligament 
on opposite sides, and alternate pressure be made, a 
feeling like fluctuation is obtained. This is due to the 122 
THE KNEE. 
presence, in that position, of a large pad of fat, lying be- 
tween the ligament and the subjacent bone, and should 
not be mistaken for the presence of fluid. In front of 
the patella and a portion of its ligament, is a large 
bursa, the prepatellar bursa, which like some others is 
liable to be enlarged in certain occupations In the case 
of the bursa in question, constant kneeling has this 
effect, and the condition is known as “ Housemaid’s 
knee.” It may be noted that the ligamentum patellae, 
the tubercle of the tibia, and the centre of the ankle 
joint, are all normally in the same straight line. The 
student should now carefully follow the movements of 
the patella, and its position in the varying conditions of 
the joint. He will observe that in extension this bone 
lies nearly altogether above the articular surface of the 
femur, its two inferior facets being then in contact with 
the upper part of the articular portions of the two con- 
dyles. In semi-flexion the positions of the bones alter so 
that the patella, resting on its two central facets, lies in 
contact with a lower part of the condyles. In greater 
flexion it rests on its two superior facets. Finally, in 
extreme flexion, the patella passes almost from off the 
internal condyle, being turned outwards partly by the 
increasing prominence of the inner condyle, and partly 
by the slightly oblique plane, in which the tibia is moved 
inwards in flexion. It then rests only on its internal 
narrow facet, which is in contact with the outer border 
of the inner condyle. Here, as in the other joints of the 
body, the student should not be content with a dissec- 
tion of the dead subject, but should take frequent oppor- POPLITEAL SPACE. 
123 
tunity to examine the bony parts and other structures 
in all the various positions of the joints in himself and 
others. He will find much assistance in this study in 
the descriptions of the mechanism of the articulations 
in Mr. Morris’ work on the Anatomy of the Joints. 
The inner condyle of the femur, on its inner side, pre- 
sents as its most prominent structure the tubercle for 
the attachment of the adductor magnus, the tendon of 
which muscle can be felt above the projection. The 
inner aspect of this condyle points nearly in the same 
direction as the head of the femur. At its lower border 
the interarticular line between the femur and the tibia 
can be readily felt. The external lateral ligament can 
be distinguished on the outer side, passing down to the 
head of the fibula. 
The synovial membrane of the knee joint is more ex- 
tensive than that of any articulation in the body, and 
reaches upwards in the extended condition of the limb 
for two inches or more above the patella. In flexion it 
sinks considerably, so that in operations about the lower 
end of the femur there is less danger of opening up the 
cavity of the knee joint if this position of the limb be 
adopted. 
IV. Popliteal Space. 
The student should first note that the shape of the 
space varies according to the position of the joint, being 
flattened out in extension, but hollowed in flexion. 
Commencing at the outer side, the tendon of the biceps 124 
POPLITEAL SPACE. 
will be felt behind the external lateral ligament. In 
extension these two structures lie so close to one 
another that it is somewhat difficult to identify them 
separately. But if the knee be semi-flexed, the latter 
will be felt as a distinct rounded cord, whilst the former 
can be easily grasped beneath the skin, interior to the 
biceps tendon, between it and the ilio-tibial band of 
fascia, there is a depression, where, in consequence of 
the absence of large arteries, incisions can be made for 
surgical purposes. If the fingers be pushed under the 
inner border of the biceps tendon, a cord-like structure, 
which is the external popliteal nerve, will be felt. On 
the inner side of the knee three tendons are to be made 
out, and may be most easily studied in semi-flexion, 
with the foot on the ground so as to relax the tissues. 
The most external and most prominent of these is the 
semi-tendinosus. Internal to this is what at first 
appears to be a single tendon, but by a little manipula- 
tion the point of the finger can be made to sink into the 
interval between the semi-membranosus, with its thick 
rounded border, externally and the gracilis internally. 
At the lower part of the space is the angular interval 
between the two heads of the gastrocnemius. Between 
the inner head of this muscle and the tendon of the 
semi-membranosus is a large bursa, often called the 
popliteal bursa, though there are several others in that 
region. In one subject out of every five, according to 
Holden, this bursa communicates with the cavity of the 
knee-joint. The popliteal artery in the upper part of 
the spaces lies to the inner side, under cover of the THE LEG. 
125 
semi-membranosus. Emerging from under this muscle 
the artery passes downwards in the centre of the space, 
terminating opposite the lower part of the tubercle of 
the tibia. The pulsations of the artery can be felt, and 
its current checked by compression against the femur 
in the flexed condition. 
The internal popliteal nerve is in the direct continua- 
tion of the line of the great sciatic, and lies in the centre 
of the space. 
The lymphatic glands of the space cannot be felt in 
the normal condition, but when enlarged they are to be 
made out, and should be remembered, as they may 
form important factors in coming to a diagnosis in 
certain surgical conditions. 
V. The Leg. 
The tubercle and external and internal tuberosities 
of the tibia are all prominent at its upper extremity, and 
the large flat anterior subcutaneous surface, which forms 
the shin, can be traced downwards to the internal 
malleolus. Its sharp outer border should be felt, and 
the irregularity of its edge noted. The head of the 
fibula, with a small part of the shaft below, and the 
attachments of the external lateral ligament of the knee 
and the biceps tendon, will be found at the outer side. 
In the greater part of the leg this bone is hidden be- 
neath masses of muscle, but in the lower third it can be 
felt again, and becomes subcutaneous over a triangular 126 
THE LEG 
area above the external malleolus. This triangular area 
lies between the peronei behind, and the extensors in 
front. 
After the bony points have been fixed the muscular 
prominences should be studied. The prominence of the 
calf is mainly formed, so far as is visible from the sur- 
face, by the gastrocnemius, the strong tendon of which 
can be seen passing down to help to form the tendo 
Achillis, behind and above the heel. If the muscles of 
the back be caused to contract, as when the weight of 
the body rests on the toes and anterior part of the feet, 
the heels being raised from the ground, the outline of 
the soleus can be seen on either side of the upper part of 
the tendon, but more distinctly on the outer side of the 
leg, where it is less overlapped by the gastrocnemius. 
Anteriorly, starting from the outer border of the tibia, 
there can be felt and seen, when in action, first the 
tibialis anticus, next, and separated from the former by 
a groove, the extensor communis digitorum, a much 
narrower muscular mass, and finally the peronei. In the 
lower part of the leg the tibialis anticus and extensor 
communis digitorum separate from one another, and here 
the extensor proprius hallucis can be felt. 
The popliteal artery, as has already been mentioned, 
bifurcates at a point opposite to the lower border of the 
tubercle of the tibia. Its posterior tibial branch is 
indicated by a line drawn from the point of meeting of 
the two heads of the gastrocnemius, to a point midway 
between the posterior part of the os calcis and the inner 
malleolus. At its lower part the artery is superficial, THE LEG. 
127 
and can be felt pulsating by the side of the tendo 
Achillis, but above it is deeply placed. In the upper 
part of the leg, it is reached, for purposes of ligation, by 
two methods. In the first the incision is made along 
the inner border of the tibia, and half an inch behind it, 
the vessel being thus reached from the side. In the 
second, which is called Guthrie’s or the military opera- 
tion, and is comparatively seldom performed, the in- 
cision is made in the centre of the calf, the two halves 
of the gastrocnemius being subsequently separated, and 
the artery approached directly from behind. 
The peroneal branch of the posterior tibial runs along 
the inner margin of the fibula, on its posterior aspect. 
The incision to reach it is made along the posterior line 
of that bone, and rather above its centre. 
The anterior tibial artery may be indicated by a line 
drawn from a point midway between the heads of the 
tibia and fibula, to a point over the centre of the front of 
the ankle. The groove, already alluded to, between the 
tibialis anticus and extensor communis digitorum, is a 
good guide to this vessel. 
The veins of the leg are of great importance on 
account of the tendency, which for various reasons they 
possess, of becoming varicosed. The short or external 
saphenous vein in normal condition cannot always be 
seen. It is formed by branches which arise on the 
outer side of the dorsum of the foot. The trunk when 
constituted passes behind the external malleolus, runs 
along the border of the tendo Achillis, lies in the mesial 
line of the gastrocnemius, and enters the popliteal vein 128 
THE ANKLE. 
in the popliteal space. The short saphenous nerve lies 
close to this vein. The internal or long saphenous vein 
is commonly visible even in the normal condition. It 
commences by radicles on the dorsum of the foot, passes 
upwards in front of the internal malleolus, and runs 
along the inner border of the tibia to the internal condyle 
of the knee. Here it lies close to the bone, and its current 
is liable to be arrested by pressure, such as is applied by 
tight garters or knickerbocker bands. From this point 
it ascends along the inner and anterior aspect of the 
thigh, passing through the saphenous opening into the 
femoral vein. As far as the knee it is accompanied by 
the internal saphenous nerve, which above this point 
lies under cover of the sartorius. 
These veins become very visible after prolonged 
standing or exercise in the upright posture, and par- 
ticularly if pressure has been applied to the longer of 
the two at the point mentioned above. 
VI. The Ankle. 
The two malleoli are very important bony landmarks 
in relation to this joint, and they present several points 
of contrast. The external in the first place descends half 
an inch lower than the internal, so that whilst the line 
of the ankle joint is about half an inch above the latter, 
it is an inch above the former. Secondly, the external 
is rather less prominent than the internal. Thirdly, the 
external is placed half an inch further back than the THE ANKLE. 
129 
internal, and finally the latter is considerably broader 
than the former, so that whilst its anterior border is so 
far in front of its fibular companion, the posterior 
borders of the two projections are on the same line. 
Owing to the numerous tendons which pass over the 
front of the ankle joint, it is rather difficult to feel any 
of the superior articular surface of the astragalus, but in 
semi-extension a small portion may be distinguished in 
front of the external malleolus, and outside the tendon 
of the peroneus tertius. 
The student will notice, in looking at the bones of the 
foot, that the posterior portion of the superior articular 
surface of the astragalus is somewhat narrower than the 
anterior. In the ordinary position of the foot no move- 
ments are possible but those of flexion and extension. 
In the position of extreme extension the narrower part 
of the superior articular surface of the astragalus lies 
between the malleoli, and it is stated that at this point 
a very slight amount of lateral movement is possible. 
Theoretically, this doubtless is true, but the student by 
grasping the lower end of the leg with one hand, and the 
astragalus with the other, the foot being in the position 
indicated, will be able to satisfy himself that such move- 
ment in a muscular living subject is practically non- 
existent. 
A large number of tendons which lie around the ankle 
joint, and materially contribute to its strength, should 
next be studied. Posteriorly, the tendo Achillis stands 
out as the most prominent structure in the region under 
consideration. Anteriorly, commencing at the tibial side THE ANKLE. 
and passing to the fibular, the tendons of the tibialis 
anticus, extensor proprius hallucis, extensor longus 
digitorum and peroneus tertius, will be felt in the order 
mentioned. The best position in which to examine 
them is that of flexion. 
The tendons of the peroneus longus and brevis lie 
immediately behind the external malleolus, but are in- 
distinguishable as separate structures in this position. 
Behind the internal malleolus lie, from before backwards 
the tendons of the tibialis posticus, flexor longus digi- 
torum, and flexor longus hallucis. The first named can 
be easily seen and felt, but it is impossible to make the 
other two out with any distinctness. 
The anterior tibial artery with its nerve lies on the 
front of the joint, the latter being external, between the 
tendons of the extensores longus digitorum and proprius 
hallucis, and its pulsations can here be felt as it lies 
upon the lower end of the tibia. 
The posterior tibial artery with its nerve, the latter 
being external, lies behind the internal malleolus, be- 
tween the tendons of the flexores longus digitorum and 
longus hallucis, and can here be felt pulsating. The 
incision to tie the vessel in this position is made in the 
middle line between the posterior border of the tibia 
and the tendo Achillis, and parallel to the former. 
As the last point in connection with the study of the 
ankle and foot, the student should consider the relation 
of the parts to the various amputations practised in that 
region. The line of each of these will consequently be 
mentioned here, the reader being referred for the details THE FOOT. 
of each operation to any of the text-books on operative 
surgery. 
Syme’s amputation, which is the one generally per- 
formed in the position under consideration, consists in 
removing the foot at the ankle joint, and subsequently 
sawing off the malleoli with the lower articular surface 
of the tibia. The two malleoli are the bony guides to 
the line of the joint in this operation, and consequently 
their relations to it, as given above, should be carefully 
borne in mind. In Pirogoff’s operation the os calcis is 
sawn through, the posterior portion being retained in 
the flap. 
VII. The Foot. 
i. Bony points.—Along either border of the foot 
are certain bony prominences, the practical bearing of 
which will appear when the operations in which they 
are concerned are described ; these points should first 
be identified. 
Commencing posteriorly, there will be felt, along the 
outer border of the foot, first the external tuberosity of 
the os calcis, secondly, about an inch below the point 
of the external malleolus, the peroneal tubercle of the 
os calcis, thirdly, the spur on the outer side of the base 
of the fifth metatarsal bone, and finally the head of the 
same and the base of the adjacent phalanx. 
Along the inner border from behind forwards are;— 
first, the internal tuberosity of the os calcis ; secondly, 
about an inch below the internal malleolus, the edge of THE FOOT. 
132 
the sustentaculum tali; thirdly, the tubercle of the 
scaphoid ; fourthly, the internal cuneiform bone ; fifthly, 
the base of the fifth metatarsal, and finally the head of 
the same bone with its sesamoid bones on its inferior 
surface. Two amputations only need be mentioned 
through various parts of the foot to show the practical 
bearing of these points. 
Lisfranc’s operation consists in an amputation through 
the tarso-metatarsal line of articulations. The line 
Fig. 15.—Diagram of Foot showing Bony Prominences and Lines of Operation 
(after Smith and Walsham). 
T. Tibia. F. Fibula. As. Astragalus. Ca. Os calcis. Cu. Cuboid. S, Sca- 
phoid. E. C., M. C.,T. C. External, middle and internal cuneiform bones, a. b. 
External and internal malleoli, c. Peroneal tubercle, d. Spur of fifth metatarsal. 
e. Tubercle of scaphoid. /. Base of first metatarsal. 
AA. Line of Syme’s amputation. 
88. Line of Chopart’s amputation. 
CC. Line of Lisfranc’s amputation. THE FOOT. 
133 
of these joints is somewhat irregular, a fact which is 
chiefly due to the unequal lengths of the three cunei- 
form bones, but, speaking generally, extends across the 
foot in a slight curve, with its convexity directed down- 
ward, from the base of the fifth metatarsal to that of 
the first. If, therefore, the student grasps between his 
fore-finger and thumb the bases of these bones he will 
have the tarso-metatarsal line immediately behind them. 
Should he have any difficulty in finding the base of the 
first metatarsal he may remember that it is placed one 
and a half inches in front of the scaphoid tubercle, a 
prominence which is always recognizable. 
Chopart’s amputation passes through the mediotarsal 
joint, between the astragalus and scaphoid, and calcis 
and cuboid. The guide to the line between the first two 
bones is the tubercle of the latter. The line of the 
calcaneo-cuboid articulation lies midway between the 
external malleolus and the spur on the base of the fifth 
metatarsal bone. 
2. Soft parts.—On the dorsum of the foot the nu- 
merous tendons will first claim the attention of the 
student. Commencing at the inner side, the strong 
tendon of the tibialis anticus will be seen passing down- 
wards, and next to it that of the extensor proprius 
hallucis, the most prominent of all. Then, still further 
out will be seen the four tendons of the extensor longus 
digitorum passing obliquely across the foot from within 
outwards, with the tendon of the peroneus tertius lying 
to the outer side of the tendon for the fifth toe. Exter- 
nally to this if the toes be extended, a rounded mus- THE FOOT. 
Fig. is.—Cutaneous Nerve Areas, 
Lower Extremity. Anterior Aspect. 
a. Ilio-hypogastric (L, i). 
b. Genito-crural (L, i, 2). 
c. Ilio-inguinal (L, 1). 
d. Small sciatic (S, x, 2, 3). 
e. External cutaneous (L, 2, 3). 
/. Middle cutaneous (L, 2, 3). 
g. Internal cutaneous (L, 2, 3). 
h. Peroneal cutaneous (L. 5, S. i, 2). 
j. Internal saphenous (L. 3, 4). 
k. Internal cutaneous and obturator 
(L. 2, 3, 4). 
l. Musculo-cutaneous (L. 4, 5, S. 1). 
m. External saphenous (S. 1. 2). 
n. Anterior tibial (L. 4, 5, S. 1). THE FOOT. 
Fig. 17.—Cutaneous Nerve Areas, 
Lower Extremity. Posterior Aspect. 
a. Posterior sacral. 
b. Posterior lumbar (L. 1, 2, 3). 
c. Ilio-hypogastric (L. 1). 
d. Perforating cutaneous (S. 2, 3). 
e. Small sciatic (S. 1, 2, 3). 
/. External cutaneous (L. 2, 3). 
g. Internal cutaneous (L. 2, 3). 
h. Do. and obturator (L. 2, 3, 4). 
j. Peroneal cutaneous (L. 5, S. 1, 2). 
k. Internal saphenous (L. 3, 4). 
l. External saphenous (S. 1, 2). 
vi. Calcaneo-plantar (S. 1, 2). 
n. Internal plantar (L. 4, 5, S. 1). 
0. External plantar (S. i, 2). 136 
THE FOOT. 
cular elevation the belly of the extensor brevis digitorum 
can be seen and felt lying on the front and outer side 
of the foot. Its tendons pass under those of the long 
extensors in an opposite direction, that is from without 
inwards, and may be seen sometimes in thin persons. 
On the outer side of the foot the tendons of the peroneus 
longus and brevis can be seen and felt. The former 
lies behind the peroneal tubercle, the latter in front of 
it. The tendons of the inner side cannot be made out 
distinctly, though that of the tibialis posticus with the 
calcaneo-scaphoid ligament lies in the interval between 
the malleolus and the tubercle of the scaphoid. 
The dorsal artery of the foot passes over the ankle 
joint, and runs to the first metatarsal space along the 
outer border of the tendon of the extensor proprius 
hallucis, where its pulsations may be felt throughout its 
entire course. Under the skin over the dorsum a num- 
ber of veins will be seen, forming a kind of arch, the 
extremities of which form the commencement of the two 
saphenous veins. 
The metatarso-phalangeal joints lie an inch behind 
the skin commissures between the toes. 
The skin on the plantar surface of the foot is firmly 
adherent to the subjacent structures, so as to permit of 
very little mobility. The remarks made as to the use of 
this arrangement, and the anatomical explanation of the 
same in connection with the skin of the palm of the 
hand, will apply also to that now under consideration. 
The plantar arteries cannot be seen or felt, but their 
position may be marked out by the following rules:—A THE FOOT. 
point should be taken midway between the tip of the 
internal malleolus and the most prominent point of the 
plantar surface of the heel. A line drawn from this 
point to the middle of the plantar surface of the great 
toe indicates the position of the internal plantar artery. 
A line drawn from the first named point to another 
one inch internal to the outer border of the base of the 
fifth metatarsal bone will indicate that portion of the 
external plantar artery which runs longitudinally. 
From this point it turns and runs across the bases of the 
metatarsal bones to the first interspace. 
Before leaving the lower extremity the student should, 
as in the case of the upper, map out the areas of the 
subcutaneous nerves as given in the figures. INDEX 
Acromion, go 
Angular gyrus, 38 
processes, 2 
Angulus Ludovici, 52 
Ante-cubital fossa, gg 
Anus, 77 
Apex-beat, 60 
Artery, aorta, 62 
abdominal and 
branches, 73 
thoracic, 84 
axillary and branches, 93 
brachial and branches, 94, 
99 
carotid, common, 46, 47, 
63 
external, 47 
crico-thyroid, 43 
dorsalis pedis, 136 
epigastric, deep, 74 
facial, 6, 48 
transverse, 7 
femoral, 117, 118 
gluteal, 115 
iliac, 74 
innominate, 46, 63 
lingual, 48 
mammary internal, 64 
meningeal, middle, 31 
occipital, 27, 48 
of elbow, 99 
palmar arch, no 
Artery, plantar, 136 
popliteal, 126 
posterior auricular, 27 
palatine, 23 
princeps pollicis, in 
pudic, 116 
radial, 103 
sciatic, 116 
subclavian, 46, 49 
superficialis volae, in 
superficial temporal, 7 
superior thyroid, 48 
supra-orbital, 7 
thyroidea ima, 44 
tibial anterior, 127, 130 
posterior, 126, 130 
transverse cervical, 50 
ulnar, 104 
Ary-epiglottic folds, 22 
Asterion, 29 
Asymmetry of face, n 
Atlas, transverse process of, 150 
Auricle, left, 60 
right, 59 
Axilla, 92 
Bicipital fascia, 100 
Bladder, 73 
Bones of hand, 105, 108 
Brachial plexus, 50 
Brain, base of, 33 INDEX 
140 
Breast, 55 
Bregma, 29 
Bryant’s ilio-femoral triangle, 114 
Buccal pellet, 5 
Carotid tubercle, 48 
Carpo - metacarpal articulations, 
108 
Caruncula lachrymalis, 14 
Catheter, passage of Eustachian, 
I 7 
female, 8x 
male, 75 
Chopart’s amputation, 133 
Clavicle, go 
Clitoris, 80 
Cloquet’s snuff-box, in 
Coccyx, 113 
Colon, 87 
Coraco-acromial ligament, 92 
brachialis muscle, 92 
Coracoid process, 91 
Corona! suture, 30 
Creases on hand, 109, no 
Cricoid, 22, 43 
Crico-thyroid membrane, 43 
Crural canal, 118 
Cutaneo-phalangeal ligaments, in 
Deltoid muscle, 56, 91 
Diaphragm, 64 
Douglas’ pouch, 82 
Drayman’s bottom, 114 
Ear, external, 18 
Epiglottis, 22 
Eustachian tube, 17 
External occipital protuberance, 
Eyeball, 14 
tension of, 14 
Eyelids, 12 
eversion of, 13 
Falx cerebelli, 30 
cerebri, 30 
Femur, condyles of, 123 
Fibula, 125 
Filtrum, 6 
Fissures of brain, 
longitudinal, 35 
parieto-occipital, 34, 37 
Rolando, 34, 37 
Sylvius, 34, 36 
transverse, 36 
Fontanelles, 32 
Foot, bony points of, 131 
tendons, 133 
Fossa navicularis, 75 
Frrenum labii, 21 
linguae, 23 
Frontal eminence, 1 
lobes and fissures, 37 
Genio-hyo-glossus muscle, 23 
Gimbernat’s ligament, 117 
Glabella, 2 
Glands of Tyson, 76 
Glenoid fossa (scapular), 91 
Glosso-epiglottic fold, 22 
Heart, relation to chest wall, 59 
Hernia, 66 
Hesselbach’s triangle, 74 
Holden’s line, 117 
Housemaid’s knee, 122 
Houston’s valves, 78 
Humerus, condyles, 95 INDEX 
Humerus, head, gx 
tuberosities, 90 
Hunter’s canal, 120 
Hymen, 81 
Hyoid bone, 22, 42 
space, 22 
Ilium, anterior superior spine, 65, 
116 
crest, 65, 113 
posterior superior spine, 113 
Incisura cardiaca, 58 
Inferior maxilla, 4 
Infra-orbital foramen, 2 
sternal depression, 53 
Inion, 30 
Intestines, 72 
Intra-parietal fissure, 40 
Ischial tuberosity, 117 
Jaw, lower, 4 
Kidney, 85 
Knee joint, synovial membrane, 
123 
Labia majora, 80 
Lachrymal sac, 14 
Lambda, 29 
Lambdoid suture, 30 
Lateral sinus, 31 
Latham’s circle, 60 
Ligamentum patellae, 121 
Linea alba, 65 
oculo-zygomatica, 6 
semilunaris, 65 
Lineae transversae, 65 
Lisfranc's amputation, 132 
Lithotomy, 79 
Liver, 70 
Lizar’s lines, 115 
Lung, in neck, 50 
relation to chest wall, 56, 
84 
Lymphatics of groin, ng 
Mcßurney’s point, 72 
Macewen’s triangle, 20 
Malleoli, 128 
Mastoid process, 19, 28 
Meibomian glands, 13 
Mental foramen, 3 
Metacarpo-phalangeal articula- 
tions, 108 
Miner's elbow, ioi 
Mons veneris, 65 
Murmurs, cardiac, 62 
Muscles of calf, 126 
forearm, 99, 102 
thigh, 120 
Nasion, 30 
Naso-labial fold, 5 
Nates, folds of, 115 
Nelaton’s line, 114 
Nerves, anterior crural, 119 
buccal, 24 
circumflex, 93 
facial, 9 
great auricular, 51 
gustatory, 24 
inferior dental, 24 
pudendal, 116 
infra-orbital, 2 
lingual, 24 
median, 100, 104 
mental, 2 
musculo-spiral, 94, 100 142 
INDEX 
Nerves, occipital, small, 51 
of abdominal parietes, 69 
pneumogastric, 48 
popliteal, 124 
radial, 104 
sciatic, great, 116 
spinal accessory, 50 
superficial cervical, 51 
supra-orbital, 2 
tibial, anterior and poste- 
rior, 130 
ulnar, 95, 101, 104 
Nipple, 55 
Nostrils, 16 
Occipital lobe and fissures, 41 
(Esophagus, 22, 43, 45 
Olecranon, 95, 96 
Omo-hyoid muscle, 49 
Orbit, 11 
Palate, 23 
soft, 25 
Palmaris brevis muscle, 109 
Pancreas, 72 
Papillae of tongue, 21 
Paracentesis thoracis, 53 
Parietal lobe and fissures, 38 
Parieto-mastoid suture, 30 
Parotid gland, 10 
Patella, 121, 122 
Pectoralis major, 56, 92 
minor, 93 
Penis, 76 
Perineum, female, 82 
male, 76 
Petit’s triangle, 84 
Pharynx, 43 
Piles, 77 
Pillars of fauces, 25 
Pirogoff’s operation, 131 
Platysma myoides, 42 
Pleura, extent of, 58 
Plica semilunaris, 14 
Popliteal space, 123 
Posterior nares, 25 
Poupart’s ligament, 68, 117 
Precordial dulness, 60 
Processus lingualis, 58 
Prostate gland, 78 
Pterion, 29 
Pterygoid process, 24 
Pterygo-maxillary ligament, 24 
Pylorus, 70 
Radius, head, 96 
shaft, 101 
tubercle, 97 
Rectal pouches, 73 
Rectus muscle, 66 
Ribs, 53 
Rings, abdominal, 68 
Rugas, oculo-frontal, 6 
transverse, 6 
Sacro-sciatic ligament, great, 115 
Sagittal suture, 30 
Saphenous opening, 118 
Scalp, 27 
Scapula, go 
Scarpa’s triangle, 117 
Scrotum, 76 
Seminal vesicles, 78 
Septum nasi, 16 
Serratus magnus, 56 
Sinuses of dura mater, 31 
Spinal cord and nerves, 85 
Spine of pubes, 65, 116 
Spines of vertebras, 83 
Spleen, 71 INDEX 
Squamous suture, 30 
Steno’s duct, 10, 21 
Sterno-clavicular articulation, 46, 
53 
mastoid, 45 
Sternum, 52 
Stomach, 6g 
Subclavian triangle, 49 
Sub-clavicular fossa, 92 
Sub-maxillary gland, 23, 46 
Sub-occipital lymphatic, 27 
Sucking cushions, 5 
Supra-ciliary ridge, 1 
Supra-marginal convolution, 40 
Supra-mastoid crest, 4 
Supra-meatal triangle, 20 
Supra-orbital notch, 2 
Syme’s amputation, 131 
Symphysis pubis, 65 
Temporo-sphenoidal lobe and fis- 
sures, 40 
Tendons at ankle, 129 
knee, 124 
Tendo oculi, 12 
Tentorium, 30 
Testicle, 76 
Thenar eminence, 109 
Thorax, size of, 52 
Thymus gland, 45 
Thyroid body, 44, 46 
cartilage, 43 
Tibia, 125 
Tongue, 21 
Tonsil, 25 
Torcular Herophili, 31 
Trachea, 43, 64, 84 
Triceps, 95 
Trochanter, great, 113 
Turbinated bones, 16 
Ulna, coronoid process, 97 
olecranon process, 95, 96 
shaft, 101 
Umbilicus, 66 
Urethra, female, 75 
male, 78 
Uvula, 25 
Vagina, 81, 82 
Valves of heart, 60 
Veins, basilic, 98 
cephalic, gi, 94, g8 
innominate, 63 
jugular, anterior, 44, 47 
external, 47 
internal, 46, 48 
ranine, 23 
saphenous, 119, 127, 128 
thyroid, 44 
vena cava, inferior, 64 
superior, 63 
salvatella, 98 
Ventricle, left, 60 
right, 60 
Vertebral column, relations of 
viscera to, 87-89 
Wharton’s duct, 23 
Xiphoid cartilage, 53 
Zygoma, 3 Catalogue No. 8. 
October, 1896. 
CLASSIFIED SUBJECT 
CATALOGUE 
OF 
MEDICAL BOOKS 
AND 
Books on Medicine, Dentistry, Pharmacy, 
Chemistry, Hygiene, Etc., Etc., 
PUBLISHED BY 
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4®“ SEE NEXT PAGE FOR SUBJECT INDEX. 
Gould’s Dictionaries, Page 8. SUBJECT INDEX. 
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SUBJECT. PAGE 
Anatomy 3 
Anesthetics 3 
•Autopsies (see Pathology) 16 
Bandaging (see Surgery) 19 
Biology (see Miscellaneous) ... 14 
Brain 4 
Chemistry 4 
Children, Diseases of 6 
Clinical Charts 6 
Compends 22, 23 
Consumption (see Lungs) 12 
Deformities 7 
Dentistry 7 
Diagnosis 17 
Diagrams (see Anatomy, page 
3, and Obstetrics, page x 6). 
Dictionaries 8 
Diet and Food (see Miscella- 
neous) 14 
Dissectors 3 
Domestic Medicine 10 
Far 8 
Electricity 9 
Emergencies (see Surgery) 19 
Eye 9 
Fevers 9 
Gout 10 
Gynecology 21 
Headaches 10 
Heart 10 
Histology 10 
Hospitals (see Hygiene) 11 
Hygiene 11 
Insanity 4 
Journals 11 
Kidneys 12 
Lungs 12 
Massage 12 
Materia Medica 12 
Medical Jurisprudence 13 
Microscopy 13 
M ilk Analysis (see Chemistry) 4 
Miscellaneous 14 
SUBJECT. PAGE 
Nervous Diseases 14 
Nose 20 
Nursing 15 
Obstetrics.. 16 
Ophthalmology 9 
Osteology (see Anatomy) 3 
Pathology 16 
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Physical Training (see Miscel- 
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able Eye and Ear Infirmary; Chief of Ear Clinic, Chicago Med. 
College. 
No. 16. DISEASES OF NOSE AND EAR. Illustrated. Same 
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A Text-Book of the Practice of Medi- 
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