iiilili
«
Ix
ATLAS OF
APPLIED (TOPOGRAPHICAL)
HUMAN ANATOMY FOR
STUDENTS AND PRACTITIONERS BY
Dr.
KARL von BARDELEBEN and PROF. Dr. HEINR. HAECKEL IN COLLABORATION WITH FROHSE
DR. FRITZ AND
PROFESSOR
DR.
THEODORE ZIEHEN
Only Butborise^ Cnglisb flbaptation from the
Zh'irb
German
Cbition
CONTAINING 204 WOODCUTS IN SEVERAL COLOURS AND DESCRIPTIVE TEXT BY J.
HOWELL EVANS
M.A.,M.B.
ENGLAND LATE SENIOR DEMONSTRATOR OF HUMAN ANATOMY AT ST. GEORGES HOSPITAL LONDON DEMONSTRATOR OF OPERATIVE SURGERY ST. GEORGES HOSPITAL. LONDON ASSISTANT SURGEON TO THE CANCER HOSPITAL, LONDON M. CH.,
OXON.,
F.
R.C.S.,
LONDON
NEW YORK
REBMAN LIMITED
REBMAN COMPANY
129
SHAFTESBURY AVENUE^
11
1906
23
BROADWAY
ALL RIGHTS RESERVED Entered at Stationer's Hall 1906.
Biomedical
n
Preface. Nearly every Student of of
some book which
and
assist
latter
who
shall,
Anatomy and every
Practitioner feels the need
former, serve as a
for the
supplement
to
anatomical specimens and which
the stud}' of prepared
dissection for
the
cannot spare the time for the study of specimens or whose work
will
in
not countenance any contact
with
the cadaver, shall
,
present the regional
im-
portant structures.
Such a book must present Anatomical data
the important details depicted must be presented in
illustrations, clear,
and practical manner.
means
will serve as a
of
For such merits and
English Version has been prepared;
this
applied
Anatomy
weakening memories
The their
by numerous and good
selection
relative
clinical
of revision
the
to
among
it
is
to
meet these requirements
hoped, therefore, that this book
Students,
as a valuable reference both
and as a means
Practitioner,
a S3'stematic,
of
quickening
the
of the Surgeon.
and
the Plates
of
importance;
their
extent has been
attention
special
determined by
has been directed to those
regions which have, of recent years, become of increased interest to the Physician
and Surgeon
;
so that those portions of
service to the Student in clinical
his
Anatom}' which are
likely to
be of actual
subsequent study, and to the Practitioner in his
work, form the basis of each
plate.
Lithographic Plates for the finer and Wood-cuts for the coarser
when
coloured,
Histology;
are imdoubtedly
because by
these
means
the best
methods the exact
different structures in the various planes are
This book cannot replace, and of
Anatomy,
Works and
but
is
of
great
use
is
with
of illustrating relations
detail,
Anatomy and
and distinctness
of
most admirably shewn.
not intended to replace, the Textbook the
more comprehensive Anatomical
Atlases.
There
C21061
— There
German work
is
as yet, no Universal Anatomical Nomenclature
the B. N. A. nomenclature
tomists the nomenclature
other purely
English,
is
employed, but
a mixture.
frequently
in
the original
among English Ana-
in
I
have endeavoured
to
give
the
England, with a further inclination whenever
an English rather than a Classical term.
In connection with to
is
—
very variable, at one time purely classical at an-
terms most frequently employed possible, to
—
IV
the question
peruse Toldt's Atlas, wherein
London,
all
of
nomenclature, the reader
synonyms are
is
advised
well explained.
W. J.
Howell Evans.
1
Contents. I.
Head.
Median Section through the Head.
17
Frontal Section through the Head passing through the Orbits. Outer Surface of the Cerebrum Centres of Localization. Outer Surface of the Cerebrum Convolutions and Sulci. Inner Surface of the Cerebrum. Dorsal Aspect of the 4th Ventricle. Course of Fibres in the Internal Capsule. Course of Fibres from Cortex to Spinal Cord. Course of Fibres in the Crura Cerebri Frontal Section. Convolutions and Bonv Sutures (in the newborn). Convolutions and Bony Sutures (in the child). Convolutions and Bony Sutures (in the adult). Base of Brain with Arteries and Cranial Nerves. Base of Skull from above. Base of Skull, with Arteries, Nerves and Venous Sinuses. Base of Skull, with the soft parts, after partial removal of the bones. Projection of the Lateral Ventricle, Middle Ear and Lateral Sinus on to the
18,
outer surface of the Skull. Projection of the Middle Meningeal Artery on to the outer surface of the Skull.
—
4 5 6,
7
8 9 lO. 1
12 13 14 15 16
—
—
;
20
Cranio-Cerebral Topography. Exposure of the Cerebellum.
21
From
19
22 23
—
a horizontal section Auditory Apparatus and its relations. Part of Fig. 2 1 Tympanic Cavity and its relations. Vertical section through the Left Temporal Bone, passing through
—
the Axis
of the Petrous portion.
24
25
2b 27 29 30 31
32
39 40.
41
42 43 44
45 46 47
48
Horizontal Section through the Left Temporal Bone. Mastoid Process of child, opened. Mastoid Process of adult, opened, and 28. Tympanic Cavity and its relations; opened from behind. Superficial Vessels and Nerves of the Head. Side View of the Face Superficial layer. Side View of the Face Deep layer. Exposure of the Gasserian Ganglion, to 38. Areae of Distribution of the Sensory Cranial Nerves.
— —
Nasal Cavity with openings of Accessory Cavities. of Highmore and Roots of Teeth. Frontal Sinus, Nasal Duct. Orbit and its relations Horizontal Section. Frontal Section. Orbit and Nasal Cavities in a child Vertical Section through the Axis of the Orbit and its relations in a child Optic Nerves. Frontal Section through the posterior part of the Nasal Cavity. Frontal Section through the Sphenoidal Sinus and Nasal Cavity. Frontal Section through the Anterior part of the Cavernous Sinus. Frontal Section through the Posterior part of the Cavernous Sinus.
Antrum
—
—
—
— Xig. 11
VI
VII
'g-
— Fig.
VIII
ATLAS OF
TOPOGRAPHICAL ANATOMY.
Fig.
Median Section through the Head.
I.
Right half of a frozen-section through the Head and Neck of a girl aged 15. In front the plane of section is carried accurately through the middle line, but posteriorly The bones are left intact, as is shewn by the it deviates about ^/sths inch to the left. bisected Odontoid Process
away as far A median
cleared
section
the head,
of
the structures
the soft parts (particularly brain-substance) have been carefully
;
as the middle line.
the
gives
and
best general idea of the relations
in particular of the topographical
and
relations
positions of
of the brain
shows how the brain extends further down posteriorly than in front. under which the Cerebrum lies is only covered by a thin skin and epicranial aponeurosis (the latter is blue in the figure). la}er of soft parts The Hemispheres, therefore, are easily injured in fracture of the vault of the skull. The Cerebellum is better protected. The thickness of the skull cap varies conit is normally at the vertex siderably at different points, and in different people Vio^^ inch. On either side of the middle line the bone may be very thin, because for a distance of ^^ths inch from the middle line Pacchionian bodies may be present, and only to the face
it
;
That portion
clearly
of the skull cap
—
—
covered by a very thin lamina of bone.
The
Sinus
Superior Longitudinal
Venous Sinuses
oYlier
shewn
are
in
is
exhibited
throughout
its
15 and 16), beginning at the
Figs.
whole length (the
Foramen Caecum
and increasing in width as it extends backwards and receives more blood it finally forms by junction with the Straight Sinus the Torcular Herophyli at the level of the External Occipital Protuberance (or somewhat higher up) and unites with each lateral Sinus, especially with the right. Its
position
very exposed
is
;
as
it
can be easily injured
it
demands consideration
during trephining.
The Nasal Septum is usually asymmetrical, being bent to one side (left in this Dense connective-tissue is found at the anterior surface of the base of the skull continued downwards as the Anterior Common Spinous Ligament which covers
case).
and
is
surfaces of the bodies of the vertebrae. A thick mass of lymphoid tissue under the mucous membrane of the posterior wall of the pharynx (i. e. the Pharyngeal Tonsil) lower down between the Oesophagus and the Vertebral Column there is only a thin layer of connective tissue in which pus may easily spread downwards (Retropharyn-
the
anterior
lies
;
geal Abscess).
When
the
mouth
is
closed,
the
Tongue
lies
against the Palate (in this figure,
depending upon the form of death, suicide by drowning, the tongue is seen pushed between the Canine teeth). On the posterior surface of the Hyoid Bone the Hyoid Bursa is seen lying between the Hyoid Bone and the Thyreohyoid Membrane which is attached to the upper border of the bone.
The Larynx situated
at
the
level
is
here seen at a higher level than usual; the 5th Cervical Vertebra
of
or of
the Glottis, as a rule,
is
the disc between the 5 th and
6th Cervical Vertebrae.
The Pyramidal figure
extends
Process
almost up
to
Isthmus of the Gland reaches
of the
the is
Thyreoid Gland (Pyramid
Hyoid Bone whereas the
the
ist
Tracheal
ring.
usual
of Lalouette),
height
to
in this
which the
'
Aponeurosis of Occipito Superior Lonfjitudinal Sinus Middle Comtnissure Frontalis
Falx Cerebri
3rd Ventricle
Vein of Galen
Inferior Longitudin.
Splenium of Corpus Callosum Ventricle of Septum Pcllucidum ineal
Genu
Gland
(Epiphysis)
of Corpus Callosum
Anterior Commissure
/
.
Anterior Cerebral Artery
/
/
•/
i?t'
-
Free edge of Falx Cerebri (Lamina Tcrminalis)
Crista Galli
Frontal Sinus
Optic Chiasraa Pituitary (Hj-popt
Sphenoidal Sinus
Septal Cartilage
Semispinalis Muscle
Genioglossus
-
"
Muscle
Splcnius Capitis Muscle
.
;
.(',
.'.
^
'
|
—
Geniohyoid Muscle
^
^
i:;
-?. \
,
Muscle
Mylohyoid Muscle
Fig.
1.
Mesial (Sagittal) Section through the Head. Vj Nat. Size.
Rebman
Limited, London.
Rcbman Company, New York.
Supt-Ttnr
Aponeurosis of OccipitoFrontalis Muscle Anterior Cerebral Artery
Longitudinal Sinus
Falx Cerebri Olfactory Plate of Ethmoia
if»r
Obliiiue Muscle
Frontalis Muscle (Epicranius)
Dura Mater
Frontal Sinus
Ciliarv Nerves
Tcmporo-Malar Nerve Lacrymal Nerve Kxternal Rectus Muscle
Zygoma Inferior Oblique
Muscle Middle Temporal Bone Uncinate, Process
Malar Branch of
Temporomalar. Nerve Inferior Tur binated
Bone
Maxillary Sinus (HlGHMOItK)
Canine Muscle Facial Vein
Buccinator Muscle-
Facial Artery
Ducts of Sublingual
Gland Duct
ingual Nerve
of Submaxillary
Buccal Gland
Gland
Triangular Muscle of
Branch of Facial Nerve
Lower Lip Mandible
Genioglossus Muscle
Sublingual
GUi
Quadrate Muscle of Lower Lip
J
Mylohyoid Muscle Inferior Dental
Nerve
Digastric Muscle
Geniohyoid Muscle
Fig. 2.
Frontal Section of View from
Rebman
Limited, London.
Platysma
Mylohyoid Muscle
Head through
in front.
—
the Orbits.
Nat. Size.
Bcbman Company, New York.
Fig.
2.
Frontal Section of the Head through the Orbits.
Frozen section through the middle of the eye-halls. The slender nerves and vessels as well as the articulations of the bones have been determined by careful dissection.
The frontal bones are very thick owing The Superior Longitudinal Sinus bulges to "Lacunae Lateral es"
— accessory
occurrence at the Vertex, and
The Temporal Muscle
dilatations
of
to the obliquit}' of the section.
the right, owing to one of the
Sinus which are of frequent
the
may extend Vs^hs
inch from the middle
line.
observed to be covered by the Temporal Fascia, which extends from the Superior Temporal Ridge to the Zygoma. At the upper border of the Zygoma it splits into 2 laminae (which may reunite), between which
some
fatty tissue
The
becomes
is
collected.
Cavit}' of the Orbit (into the inner
and upper portion
posterior extremit}" of the Frontal Sinus protrudes) eye-ball; the greater space
is
taken up
is
of
only partialh'
its
roof the
filled b}'
the
which the eye muscles rim. the orbit is the Lacrimal Gland. The
bj- fat in
Closely applied to the outer wall of
is marked in y e 1 1 o w. shews the very large space occupied by the Nasal Cavity and its Accessory Cavities. The Nasal Cavity which is only separated from the Cranial Cavity by the thin cribriform plate of the Ethmoid Bone, presents 3 turbinated bones. On the left side the Sphenoidal Turbinated Bone was so short as to nearly
point at which the Optic Nerve enters the e}'e-ball
The
figure
escape the section.
Between the Middle and Inferior Turbinated Bones, the communication the Infundibulum — is visible. between the Nasal Cavity and the Frontal Sinus Directly below this orifice lies the aperture of the Antrum of HiGHMORE. This aperture situated almost at the top of the Antrum, is necessarily most unfavourable to drainage. The Nasal Septum is deviated from the middle Une
—
(cf.
Fig.
i).
is separated from the Orbit by the thin floor of the Orbit which along the Infra-Orbital Canal the nerve and vessels of the same name For the relations of the Alveoli of the Teeth to the Antrum vide Fig. 40. pass. The wall between the Antrum and the Nasal Cavity is thin so that perforation can be easily carried out from the nasal cavity (if better drainage be sought by
The Antrum
in
this route).
The Buccal Cavity is closed below by the Mylohyoid Muscle, which extends from the inner surface of the lower jaw downwards and inwards to meet its
fellow in the middle line (Diaphragma Oris).
At
the junction
of the
mucous membrane
groups of mucous glands are found
— buccal
glands.
of the
Cheek and the Gums,
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^rd Ventricle
Posterior Commissure
/ /
Peduncle of Pineal Body
3rd Nerve tOculomotor) ' Trigonum Habenulae 6th
Superior Corpus Quadrigeminum
Nerve (Abducens) Thalamus
Nerve {Trochlear
4th
nXudei
Nerve
of 3rd
N'ucleus of 4th
Inferior
Nerve
Corpus Quadrigcminu
Modian Geniculate Body
Pulvinji
Band
Peduncle of Brain
of Anterior.
Medullary Velum
Descending Root. of 5th S'erve
Anterior Medullary 5th
Velum
Nerve (Trigeminus)
Superior Cerebellar
Motor Nucleus of 5th Nerve
Peduncle
Locus Caeruleus
Facial Eminence 7th
Nucleus of 6th
Nerve (Facia
Nerve (Abducens)
Middle Cerebellar. Peduncle
Auditory Striae
Inferior Cerebellar-
Peduncle 9th
Nucleus of 8th Nerve (Driters)
Nerve (Glosso pharyngeal)
loth
Median
(Triangular) Nucleus of 8th Nerve
Nerve (Vagus)'
Nucleus of Spinal Tract
Nerve Marginal Band
Lateral (accessory) Nucleus of 8th Nerve
of 5th
of.
12th
4th Ventricle
11th
Nerve (Hypoglossal)
Nerve (Accessory) Nucleus of Spinal Tract of 8th
Nerve
Hypoglossal Triangle^
Nucleus Ambiguus
Nucleus of Ala Cinerea
Clava (Posterior Pyramid) Nucleus of i2th Nerve Nucleus of Spinal Accessory Nerve
Funiculus Gracilis
^Funiculus Cuneatus Posterior
Median Groove -^ Trohre
^>f—Ci«*5^
Fig.
6.
Limited, Loudou.
-Funiculus Lateralis
Dorsal Aspect of Fourth Ventricle.
Twice Nat.
Rebman
fe<,.
Size.
—
By
Prof. Ziehen.
Rebman Company, New York.
Pig.
Dorsal Aspect of Fourth Ventricle.
6.
The Cerebellum
been removed by a section parallel with the floor of the 4th
has
Ventricle, so that the 3 Cerebellar Peduncles, strands which connect the Cerebellum with the rest of the Central Nervous System, are seen on both sides in transverse section. 1)
Superior
Peduncle
conducting
fibres
chiefly
to
the
Dentate
Nucleus
of
the
Cerebellum. 2) Middle Cerebellar Peduncle, connecting the Nuclei of the Pons with the Cerebellar Hemispheres. 3) Inferior Cerebellar Peduncle (Restiform Body) chiefly conducts to the Columns of the Spinal Cord those fibres which passed to the Dentate Nucleus through the Superior Peduncle. The Valve of Vieussens which lies across, between the Superior Cerebellar Peduncles, has been cut and thrown to the left. The Facial Eminence (Colliculus Facialis) is produced b}' fibres of the Facial Nerve which, after emerging from their cells, pass towards the floor of the 4th Ventricle and bend at a right angle again, after a course of Vioth inch, to run backwards towards their nucleus
of origin.
As the Nucleus many groups
Bulb, with that
this
Nucleus
is
of the Facial
Nerve lies deep in the substance of the Pons and upwards and downwards, it must be remembered of the 4th Ventricle and is accordingly represented
of cells extending
not
at
the
floor
diagrammaticallv.
The Nuclei
near the surface. The anterior part of of the Iris and the Ciliary Muscles the posterior part contains the Fibres for the Extrinsic Muscles of the Eye. Immediately behind is the Nucleus of the IVth Nerve (Pathetic), the fibres from this pass to the Valve of Vieussens where they decussate and on emerging ^wind round the Crura to reach the base of the brain. The Nuclei of the \'th Nerve (blue) are partly sensory and partly motor; the chief sensory Nucleus (pale blue) extends as far caudally as the 2nd Cervical Segment (Descending root of the Fifth Nerve), it is club-shaped with its broader end above. The chief Motor Nucleus (dark blue) which is generally connected with the minor Motor Nucleus extends upward into the region of the Anterior Corpora Quadrigemina. Although the shape of the of the other Cranial Nerves
the Oculomotor Nucleus
contains the fibres
for
lie
the Sphincter
;
Nucleus are peculiar, it is probably motor. function of the Locus Coeruleus is doubtful, its cells previously considered to be sensory are now viewed as motor. The Nucleus of the Vlth Nerve lies directly under the floor of the 4th Ventricle in cells of this
The
the bend of the Facial Fibres described above.
which is separated from the anterior part median grey and two lateral white triangular areae can be delineated on either side. The grey area (Ala Cinerea) contains the Sensory Nucleus of IXth, Xth and Xlth Nerves. The Motor Nucleus of these nerves (Nucleus Ambiguus) is marked yellow; the Nucleus of their ascending root (Solitary Bundle of Meynert) which is not In the posterior part of the 4th Ventricle,
by the Striae Acusticae,
a
indicated occupies a ventrolateral situation in relation to the Sensory Nucleus. The Sensory Nucleus is situated internal and at a deeper plane than the descending root of the Vth Nerve The inner white triangle corresponds to the Hypoglossal Nucleus and the
outer to the Dorsal Nucleus of the Vlllth Nerve (Cochlear Portion). This Cochlear Portion has another Nucleus (the Ventral Nucleus) situated along the outer border of the Inferior Cerebellar Peduncle. For the Vestibular Portion of the Vlllth Nerve there are two Nuclei shewn in the figure (Deiteks' Nucleus and the Nucleus of the Descending Root of the Vlllth Nerve) [Nucleus Tractus Spiralis Nervi Acustici]. Ziehen.
Fig.
7.
Arrangement
of Fibres in
the Internal Capsule.
All the fibres from one hemisphere pass together through the Cms at the Base of the Brain. In their course from the Cortex to the Crus these fibres pass between the large Basal Ganglia (Thalamic, Caudate and Lenticular Nuclei), as shewn in the figure. Leaving the outermost and external capsules out of con-
have but one course open to them, viz between the Caudate and Lenticular Nuclei and between the Thalamic and Lenticular Nuclei. This is the Internal Capsule with its Anterior and Posterior limbs and an intervening bend sideration these fibres
:
The arrangement
(genu).
The pyramidal
tract,
the
of the fibres in the Internal Capsule
posterior limb in such a
Fibres
the genu,
in
as follows:
—
path of voluntary movements, occupies the anterior manner that the Facial and Hypoglossal
Vards of the lie
is
next in order come
the fibres to the upper
Limb and
In the posterior Vs^d of the posterior limb of the internal capsule lies the great sensory path for "Common sensibility" and the occipito-temporal cortico-pontic tract which passes from the occipital and temporal lobes to the Pons. Furtliermore, fibres pass to and from the Cortex and Thalamus.
lastly those to the
lower limb.
Close behind the posterior limb is the so-called "Carrefour sensitif" (Charcot's Sensory Tract), through which the paths of the higher senses (Olfactory excepted) pass.
In the figure, only the fibres connected with the Optic
Nerve are depicted
passage from this point to the Occipital Lobe. Disease of this "Carrefour" produces mixed Hemianaesthesia i. e. patients taste and hear less definitely or not at all on the opposite side, and do not
in their
feel,
Eye on the same side and Temporal half of the whereas disease of the posterior part of the posterior limb of the Internal Capsule produces motor paralysis of the opposite side. The Anterior Limb contains chiefly fibres derived from the Frontal Lobe and Caudate Nucleus; their course and function is unknown. The Caudate Nucleus and its tail curl over the Internal Capsule to terminate by blending with the
see with the Xasal half of the
opposite
eye,
Hippocampal Convolution and the Amygdaloid Nucleus; so that in this section the Caudate Nucleus has twice been cut — at its body internal to the anterior horn of the lateral Ventricle and at its tail near the descending horn. The lateral and 3rd ventricles communicate through the Foramina of
Monro.
The
pillars of
the
fornix
are
cut
near their point of junction.
The
horn of the lateral ventricle is cut at the point where the horn begins. The white fibres of the Corona Radiata between the Cortex and the Corpus Ziehen. Striatum is called the Centrum Semi-Ovale of ViCQ dAzyr. posterior
inferior
Occipital
1
Interparietal I'issure
Parietooccipital Fissure
Anterior Occipital Fissure
Superior Temporal Fissure Fissure of Corpus Callosum
Posterior
Horn
Optic Radiation (Gratiolet)
Splenium of Corpus Callosum Tail of Caudate Nucleus
Charcot's Sensory Tract ("Carrefour sensitif") Posterior
Limb
Island uf
Kkil
of Fissure of
Sylvius
Optic Thiilainu:
Posterior
Limb
External Capsule Outermost Capsule
of Internal Capsule
Middle Commissure
^^'^^^
0/JPP-
Fissure of
Rolando
(Central Fissure)
cutuTn Genu
Claustrum
of Internal Capsule Pillar of Fornix
Globus Pallidus
Cavit\- of Septum Pellucidum (5th Ventricle)
Anterior
Limb
of Internal Capsule
Head
of Caudate Nucleus
Anterior
Genu
Horn
Anterior Ascendinj? Branch of the
—
Fissure of Sylvius
of Corpus Callosum
Fissure of Corpus Callosum Inferior Frontal Fissure
Callosomarginal Fissure
jNIiddle l-Vuntal Fissure
Frontal Pole
Motor Bundle
Thalamo-Frontal Bundle.
Motor Bundle: Facial and
Fig.
7.
Limited, London.
Leg.
Sensibility
and Motor-Sense Bundle.
Direction of Fibres in the Internal Capsule.
Seen from above.
Rebman
Common
Hj-poglossal.
:
—
Nat. Size.
—
Bv
Prof.
Ziehen.
Rebman Company, New York.
SupTif^tr
I*"r
Sulcus
Praccentral Sulcus
Central Fissure (Rolaxho)
Calldso-Marginal Sulcus
Caudate Nucleus Taenia Scmicircularis Post- Central Sulcus
Lateral Ventricle Sulcus of Corpus Callosum
Fibres of Corona Radiata
Corpus Callosum
Parietal Operculum Island of Reil Fissure of Lenticular Xucleus
SvLVius
Optic Thalamus Fornix
Claustrum
Optic Thalamus
Internal Capsule
3rd Ventricle
Temporal Operculum Outermost Capsule
Optic Thalamus
Lamina Medullaris
External Capsule ''ibrcs
Fibres to Lenticular Kucleus
to
Thalamus
Red Nucleus
Superior Temporal Sulcus Anterior Commissure
Luy's Nucleus
Z Substantia Nigra Fibres to Cerebellum
Inferior
Nucleus of 7th Nerve
Temporal Sulcus
(Facial)
Pons Inferior
Horn
of Lateral Ventricle
Fibres from Pons to Cerebellum
Hippocampus Major (Comu Aramonis) Sensory Decussation
Motor Decussation
Posterior Posterior
Lateral
Column Horn
Column
Anterior
Horn
Anterior Colunm
Fig. 8.
Course of Fibres from Cortex to Spinal Cord. Nat. Size.
RebmaD
Limited, London.
—
By
Prof.
Ziehen.
Rebman Company, New York.
•
Fig.
8.
Course of Fibres from Cortex to Spinal Cord.
This section is not accurately in the Frontal plane but is directed somewhat obliquely so that above it passes through the Praecentral Convolution and below through the middle of the Pons. At the Point marked Z it passes through the Posterior Perforated Spot. A transverse section of the cord has been added in order to shew the topographical relations of the long cerebral tracts to the columns of the spinal cord. The posterior limb of the internal capsule is divided and the pyramidal tract is seen running from the motor area, through the posterior limb, to the middle third of the ventral portion of the Pons; at the Bulb (Decussation of the Pyramids) these fibres cross the middle line and continue their course in the Lateral Columns of the Cord, whence they pass to arborize around the Anterior Cornual Cells which give off the fibres of the peripheral nerve. The fibres of the pyramidal tract which arborise around the Nucleus of the Facial Nerve of the opposite side cross the middle line in the Pons. The course of the Facial Fibres and the Facial Nucleus is schematic. (Cf. Fig. 6 Text.) The Posterior Columns of the Spinal Cord contain the path of the "Muscle-
Probably the fibres from the lower extremity region and those from the upper limb
Sense".
the
cervical
These
tracts
fibres after
end
in
in
GOLL in BuRDACH.
the tract of
the tract of
decussate in the Bulb, practically opposite the Decussation of the
The
Pyramids.
lie
further
parti}' in
course of this path
is
known
as the "mesial
the Corpora Quadrigemina, partly in the
fillet";
Thalamus and
tracking through the posterior limb of the internal capsule,
in the
the
partly,
cortex
of the Parietal I^obe.
The
Occipito
-
temporal
cortico
-
pontic
tract
(previousl)^
mentioned
in
7), appears again in the outer Ygrd of the base of the Pons, arborising around the Nuclei of the Pons whence new fibres cross the middle line to reach the Cerebellum through the Middle Cerebellar Peduncles. The Optic Tract is cut
Fig.
transversely,
the anterior commissure obliquely
—
its
fibres pass to the Olfactory
Area, to the Hippocampal convolution.
The Caudate Nucleus its
tail
is
again cut in
near the Thalamus and at
Fimbria represents the termination lower aspect of the Corpus Callosum ing, ascend in the form of an arch is
the part called the Fimbria) join
situated
2
places,
at the
commencement
of
descending horn. The of the Fornix which in its course along the has 2 (posterior) columns which, after divergwith its convexity backwards to finally (this the floor of the ventricle. The gray matter
its
termination
between the Cortex and the Fimbria
structures (Fimbria and Fascia Dentata)
is
is
in the
the Fascia Dentata; above these
the Lateral Choroid Plexus.
This
is
not
probable that the Lateral Choroid Plexus does not
indicated in the figure.
It is
close in the descending
horn of the Lateral Ventricle completely but allows the fluid to communicate with that of the basal subZiehen.
intra-ventricular
arachnoid spaces.
cerebro-spinal
Fig.
Frontal Section through the Crus Cerebri at the level of the Posterior Corpora Quadrigemina.
9.
The Mesencephalon Cerebral Hemispheres the "crusta"
;
—
contains: 1.
2.
is
(Crura)
these are separated
all the Projection Fibres from the an upper the "tegmentum", a lower
containing
divided into
2 layers,
by the "substantia
nigra".
The Tegmentum
chiefly
To these belongs commissure which represents the connection of
Fibres from Thalamus and Corpora Quadrigemina. the
so-called
the
Tegmen
posterior
with the Thalamus of the opposite
Fibres from Lenticular Nucleus.
Cf.
side.
Explanation to Fig.
8.
from Cortex. To these belongs the path of "Muscle-Sense". It moreover contains 3 Nuclei. Cf. Text to Fig. 7. a) Nucleus of Descending Root of Vth Nerve on either side of the Aqueduct of SYLVIUS. b) Nucleus of the Ilird (Oculomotor) Nerve, on either side of the Aqueduct of Sylvius. c) Nucleus of the IV th Nerve which lies posterior to the Ilird Nucleus at the posterior end of the Aqueduct of SYLVIUS. The Internal Geniculate Body probably belongs to the auditory path. The posterior longitudinal bundle is derived partly from the anterior column of the spinal cord and possibly connects the nuclei of the motor nerves of the eye. A large number of the fibres in the tegmentum stop in the "Red Nucleus" where new fibres arise to cross the middle line and leave the tegmentum by passing to the Cerebellum through the Superior Cerebellar Peduncle. (Cf. Fig. 6 Text.) 3.
Fibres
The Crusta
chiefly contains:
—
— Geniculate
Bundle (Meynert).
1.
Cortico-crustal Fibres
2.
Frontal Cortico-pontic Tract which passes from the Frontal Lobe and
Caudate Nucleus to the Pontine Nuclei, whence fibres cross the middle and pass to the Cerebellum through the Middle Cerebellar Peduncle. Cf. Fig. 7 Text. 3. Pyramidal Tracts. 4. Qccipito-temporal cortico-pontic Tract which passes from the Temporal and Occipital lobes to the Pontine Nuclei. Course of these fibres as in 2. The course and function of the fibres in close proximit}' to the Substantia Nigra is unknown. line
Fig. 10.
Convolutions of the Brain and Sutures of the Skull in the New-Born.
The detailed description of the convolutions is given in the text accompanying the following figures. We only desire to lay stress upon, the high position of the Fissure of SYLVIUS, and the Fontanelles. The smaller fontanelles (Sphenoidal and Mastoid) may be very small at birth; whereas the largest, the Frontal, remains open till the end of the first year of
life.
Descending Root of
5tli
Nerve
Anterior Corpus Quadrigcminum
Bundle from the Posterior Commissure Red Nucleus of Tegmen Brachiuni of Posterior
Aqueduct of Svi.vius
1
/ Grey
'"'
Matter Oculomotor Nucleus
J^ V,-''^
^-
/
Corpus Quadrigcminum
^a
Mesial Fillet
Internal Geniculate I3od\-
Tegmen Fibres from Temporoparietal
Lobe
to
A
Pons
\
Superior Limiting Zone of Crusta
\ \Orulnmotor
Root
Crusta
Pyramidal Tract
I
Fibres to Interpeduncular Space Fibres from Frontal
Substantia Nigra
Fig. 9.
Dii-ection of Fibres in the Nat. Size
X
^-
Central Fissure
Superior Temporal Sulcus
—
Cms By
Cerebri
Prof.
Posterior
Lobe
Pons
to
—
Frontal Section.
Ziehen.
Limb
of Fissure of Stltius
Frontal Fontanelle
\
Superior Frontal Sulcus Interparietal Sulcus.
Coronal Suture
Occipital Fontanelle.
Triangular Portion of the Inferior Frontal Convolution
Occipital Lobi
Sphenoidal Fontanelle
Lateral Sinus (Transverse Portion)
Mastoid Fontanelle
Oi-f^oh^^^^
Fig. 10.
Convolutions of the Brain and Sutures of the Skull in the Newborn. v..
Rebman
Limited,
Loudon.
Nat. Size.
—
After Prof.
Cunningham.
Rebman Compauy, New Vurk.
Temporal Ridfj'^
Coronal Suture
Superior Frontal Convolution Posterior
Pr.iecentral Sulcus
Limb
of the Fissure of SvLVius
Inferior Frontal Sulcus
Ontiiil Fissure
Squamosal Suture
Retroi-entral Sulcus
Middle Temporal Convolution Great
Termination of Calloso marginal Fissure
Wing
of Splu-noid
Bone
Zygoma Parieto-occipital Fissure
Interparietal Sulcus
I^ambdoid
Suti
Occipital
Dura Mater
Fig. 11.
of Cerebellum
Convolutions of the Brain and Sutures of the Skull in the Child. Nat. Size. — After Prof. Cunningham. '
.
Coronal Suture Superior Frontal Sulcus
Temporal Ridges
Frontal
Bone
Praecentral Sulcus
Infenoi Ficnttl Sulcus \scending Limb of Fissure of SiLTlUS
Central Fissure
Retrocentral Sulcus
Super
r
Temporal Convolution
Interparietal Sulcus
Greater
Wing
of
Sphenoid Bone Termination of Calloso -marginal Fissure
Paiietal
Zygoma
Bon
Parieto-occipital Fissure
Posterior Limb of Fissure of SvLVias
Squamosal., Suture
Lambdoid Suture
Occipital Lobe'
Lateral Sinus
Dura Mater
of Cerebellum
^_^ ;2^«^T^\T-A, V,.
Fig. 12.
Rebmau
Limited,
i
" ffohsj
fee.
Convolutions of the Brain and Sutures of the Skull in the Adult. — After Prof. Cunningham. Va Nat. Size. London.
Rebm.Tu Company,
New
York.
II.
Convolutions of the Brain and Sutures of the Skull in the child.
Fig. 12.
Convolutions of the Brain and Sutures of the Skull in the Adult.
Fig.
Cunningham's
Method of removing the Skull Bones, except narrow bars at the method of shewing the relations of the Cerebral Convolutions to the Cranial Sutures. (Skeletotopy of the Brain, Waldeyer.) It is advantageous to consider the fissures and sulci rather than the convolutions. In the removal of the skull bones in the infant it should be remembered-that they become attenuated at the regions farther away from their ossific centres; this diminution in the thickness of the Bone is replaced by a corresponding thickening of the Dura Mater and Pericranium. This close union of the fibrous skull-cap checks the spreading of subdural and subperiosteal Haematomata within the limiting area of any one bone. Moreover, it follows, that Bone and Dura Mater are removed in one piece during this dissection in the new-born. In later childhood and adult life the bones are, as a sutures, affords an excellent
separated from the dura mater, difficulties only occurring at the following points: near the Superior Longitudinal Sinus because Pacchionian bodies may be present, and at the Parietal Foramen (Santorini). The Mastoid Emissary Vein may be a point for dangerous haemorrhage because of the proximity of the Lateral Sinus. The Emissary Veins favour the spread of inflammation (cf. Erysipelas complicated by Meningitis). rule, easily
At the Sphenoparietal Sinus there is danger of Haemorrhage from laceration of the Anterior Branch of the Middle Meningeal Artery which may be embedded in a partial or complete canal near to it. (Cf. Fig. 32.) In connection with the position of the Sulci and Fissures
it
should be noted that in
Sylvius lies at a higher level than the Squamosal Suture, and that the Central Fissure (Rolando) is placed more anteriorly than in the adult. In the child (Fig. II) the squamous portion of the Temporal Bone grows upwards and the temporal ridges become more definite (blue in the figure in order to distinguish them from the the new-born (Fig. lo) the Fissure of
sutures
[r
e d]).
In the
the Fossa of Sylvius
adult
corresponds closely to the Squamosal Suture.
(Cf. Fig. 19.)
Accordingly, with certain individiual variations, the relation of the Fossa of Sylvius bones gradually alters with the bony development. The most important central convolutions, however, lie at all ages in the middle third of the Parietal Bone, being slightly further forward in the new-born. To the surgeon interest is attached to the sutures, because certain anthropometric markings are employed (Fig. 18). Nasion, at base of nose, and Inion, at external occipital protuberance, both points are employed in connection with the determination of the upper extremity of the Central to the skull
Fissure (Rolando).
Lambda,
in
middle
line,
where the
Sagittal
and Lambdoid Sutures meet,
is
employed
for the determination of the Paiieto-occipital Fissure.
Obelion, a point above the former, less irregular in shape, corresponds to the Parietal
Foramen.
Bregma, junction of Sagittal and Coronal Sutures,
is
at
the anterior border of the
Parietal Bones.
On
the lateral aspect of the Skull, the Asterion,
Parietal Bone,
where
Stephanion,
the lateral sinus turns
the
crossing of the
is
the postero-inferior angle of the
downwards. coronal suture and the temporal ridges (near the
Spheno-parietal Sinus). this is Pterion, the point of meeting of the Sphenoid, Parietal and Temporal Bones the site for ligature of the Anterior Branch of the Middle Meningeal Artery: underneath lies ;
the Fossa of Sylvius.
Base
Fig. 13.
with Arteries and Superficial Origin of
of Brain
Cranial Nerves.
The Pia Mater has been removed. Unimportant branches of the Arteries have (Names of Arteries been cut away; the Pituitary Body has been removed. cf Fig.
The
vertical
and
lateral surfaces
connection with Motor and Sensory
demands
25.)
Cerebrum are
of the
of importance in
Centres while the Base of the Cerebrum
consideration in connection with the position of the Cranial Nerves and
the Arteries.
Functional disturbance of a single nerve or of a group of nerves will
guide us to the seat of a tumour or any other pathological basal lesion which brings about the particular disturbances.
exception the Brain,
Cranial Nerves
all
a remarkable fact
It is
that,
with the
and Optic Tracts which are really outgrowths from
of the Olfactory
emerge from the Brain between the upper border
of the Pons and the lower end of the Bulb.
The
Superficial (apparent) Origin of the
VI th and.XIIth
close to each other at the posterior border of the
The course
of the nerves
foramina of exit varies
of VlEtfSSENS of the Brain.
A
course arising as
The
Fig.
(cf.
6),
portion it
brain
it
of
does low is
which gives
of the
the roots in
side of the Bulb.
until they
reach their
the longest intra-cranial
Mid-Brain (Mesencephalon), near the valve
winds round the Crus
reach the Ventral aspect
to
Accessory
of the Spinal
also
has a long
the Cervical portion of the Spinal Cord.
supplied with blood from
Carotid and Vertebral Arteries. Basilar
The IVth nerve has
in length.
course, arising on the dorsum
Pons and
after leaving the Brain
nerves are very
its
The two Vertebral
base through the Internal Arteries unite to form
off the Postero-Inferior Cerebellar (this
is
more
the
often a branch
from the Vertebral), the Auditor}^ the Antero-Inferior Cerebellar, and the Superior Cerebellar Arteries. into
At
the inferior border of the
Pons the Basilar Artery divides
Right and Left Posterior Cerebral Arteries each
(posterior
communicating) with the Internal Carotid.
off the large
of
The
which communicates Internal Carotid
gives
Middle Cerebral (Sylvian) Artery, the smaller Choroidal Branches
and the Anterior Cerebral Artery.
As
the two Anterior Cerebral Arteries are
connected by the Anterior Communicating circular anastomosis
is
in front of
formed round the Sella Turcica
All the vessels pass to and ramify branches, which enter the brain and supply
in it
the Optic Chiasma a large (Circle of
Willis).
the Pia Mater, and give off small
with blood.
Fig. 13.
Base of Brain with Arteries and Superficial Origin of Cranial Nerves. Nat. Size.
Eebman
Limited, London.
Rebman Company, New York.
Lamina Cribrosa
Groove
for
Lateral Sinus
Foramen Magnum
Groove for Transverse Portion of Lateral Sinus
(Torcular Hbhophili) Internal Occipital Protuberance
Pig. 14.
Base of Skull
-
seen from above.
Vs Nat. Size.
Rebraan Limited, Londou.
Kebman Company, New York.
:
Base
Pig. 14.
seen from above.
of Skull
Cochlea and Semicircular Canals, on the right side, exposed.
The base
of the Skull
more complicated and
is
irregular than the Vertex.
Three Fossae are recognised, the anterior bounded behind by the sharp border of
wing
the lesser
line are
of the sphenoid,
in this lies
which the Olfactory Nerves
pass.
The Middle Fossa extends from limited
the Frontal I^obe, in the middle
found the Crista Galli and the Cribriform Plate of the Ethmoid through
by the upper border
of the Petrous portion of the
on either side being
Temporal Bone.
many Foramina through which
Fossa contains the Temporal Lobe and
and nerves
the Sella Turcica
This
the vessels
pass.
Optic Foramen for Optic Nerve and Ophthalmic Artery. Sphenoidal Fissure for Superior Ophthalmic Vein, VI th, I Vth and Ilird and Ophthalmic Division
of
Vth Nerve.
Foramen Rotundum for 2nd Division of Vth Nerve. Foramen Ovale for 3rd Division of the Vth Nerve. Foramen Spinosum for Middle Meningeal Arterj'. The Middle Lacerated Foramen is closed by f ibro-cartilage remnant of the primary cartilaginous Cerebellum and Bulb
The
its
;
The
skull.
;
a
contains the
boundaries are the Petrous Bones and the Lateral Sinus.
Facial and Auditory Nerves leave the skull
Auditory Meatus
Posterior Fossa
,
b}'
passing through the Internal
Vagus and Spinal Foramen and the Hypoglossal
the Internal Jugular Vein, Glossopharyngeal,
Accessor}' Nerves by passing through the Jugular
Nerve through the Anterior Cond3-lar Foramen.
When
the base of the skull
much
The
held up to the
is
light,
the bones are seen
great
wing
Basisphenoid, Basiocciput and Middle ^/^rd of Petrous Bone.
The
to
vary
in
Cribriform Plate, lateral parts
articulation
thickness.
Sella
middle
of
and
floor
Turcica fossa,
of
stoutest portions are:
(because
Tegmen
plate if
if
it.
At
Sphenoidal
Sinuses
thinnest are
are beneath),
T3'mpani, region over Temporo-maxillary
the Posterior Fossa.
only affect the base indirectly in as parts covering
the
of Sphenoid,
much
a few places only
is
as it
Violence, it
is
broadl}- speaking,
can
ever3'Where protected by the
exposed to trauma:
at the Cribriform
foreign bodies are pushed into the Nasal Cavities, at the roof of the orbit
foreign bodies are pushed
The excavated Auditory Meatus, and Horizontal).
The
2
upwards
right petrous
into the orbital cavity.
bone shews the Internal Ear, Cochlea, Internal
Semicircular Canals (the Anterior, Vertical; and the Internal,
3rd or Posterior Canal
is
not shewn.
;
Base
Fig- IS-
of skull
with Arteries, Emerging Nerves and Sinuses
Dura Mater.
of
The Brain has been cut away layer by layer
and as much as
position
removed from
2nd Cervical Nerve as
the Olivary Body.
Apex of
the
The Spinal Cord,
possible of the Nerves.
been cut at the level of the
divided through
preserve the Basal Arteries in
to
On
the
the Petrous
Bone
not
usual, but the Bulb has been side, the
left
lias
Tentorium has been
Torcular Herophili, the
to the
Superior Petrosal and Lateral Sinuses being opened (the right middle meningeal
drawn double
artery has been
The Venous Blood returning from are found in the
into the Lateral Sinus
the Brain runs into the Sinuses which
The Blood from
Dura Mater.
and thence
by mistake).
all
the Sinuses eventually passes
into the Internal Jugular
Vein which commences
below the Jugular Foramen.
The most important Sinuses liable
to
be affected
in
injury
are those which
or disease
Longitudinal Sinus and the Lateral Sinus.
against the Skull and are
lie
of the bone, Cf. Fig.
i.
especially
As
the Superior Longi-
tudinal Sinus usuall}' opens into the right Lateral Sinus, this Sinus
Jugular Vein on the right side are usually larger than on the
The
Lateral Sinus extends
horizontally outwards
(cf.
Fig. 17)
injur)'
it
but
the in
(or either side)
In
this
last
portion
of its
hardly liable to
is
from without. of the Cranial
Nerves from the Brain
to their
foramina varies
Anterior and Middle Fossa the Nerves pass directly to their foramina; the
distance,
Middle Fossa the Vth Nerve runs under the Dura Mater
when
it
forms the Gasserian Ganglion and divides into
which again run separately under the Dura Mater Sphenoidal Fissure, Foramen Ilird
left.
and then descends behind the Mastoid Process,
gradually leaves the outer surface of the skull and
The course in
and the Internal
from the Torcular Herophili,
forming two curves towards the Jugular Foramen. course
the Superior
and IVth Nerves run
to
Rotundum and Foramen Ovale in
the outer
wall
of
the
Sphenoidal Fissure; the Internal Carotid Artery and
Cavernous Sinus.
leave the
its
for
3 Divisions,
SkuU by
Nerve run
the
The
respectively.
Cavernous Sinus
the Vlth
some
to the in
the
Superior Longitudinal Sinus
Anterior Meningeal Artery
i
Inferior Longitudinal Sinus
AnterKir Comniunirating Artery
Anterior Cerebral Artery
iliddie Cerebral Artery
Anterior Branch of iliddle
Meningeal Artery Posterior Cerebral
Artery
Anterior Cerebellar Artery
Basilar Artery
Auditory Artery
^
/
r)
,
ihj
// J^ ^'*
y
•*
/-^ j
j
Superior Petrosal Sinus
/
Posterior Inferior Cerebellar Artery
/
Vertebral Artery
Meningeal Branch Occipital Artery
Ptjsterior Branch of the Middle Meningeal Artery
Posterior Inferior Meningeal
Straight
Artery
Right Lateral Sinus Superior Longitudinal Sinus
Fig. 15.
Base of Skull with Arteries, Emerging Nerves and Sinuses of Dura Mater. Nat. Size.
Rebman
Limited, London.
Kebmau
C'oiui)any,
New
York.
Frontal Vein Crista Galli
Frontal Sinus
Ethmoidal Ne Trochlea Tcntlori
uscle
ertus Muscle
Insertion of
Septum
Nose
rif
Lacrv Posterior Ethmoidal Cells
Superior Oblique External Rectus Muscle
Lacrymal Nerve 'I'cinporo-Malar
Superior Oblique Muscle (Trochlear Nerve)
Ncrv
(
Posterior Ethmoidal
>cii!omotor
Nerve
Nerve Miducens Nerve
Ciliary Ganglion
Sphcno- parietal Sinus
Sphenoidal Sinus
External Pterygoid
Nasal Nerve
Muscle Temporal Muscle
Superior Maxillary Division «if
5th
Internal Carotid
Nerve
Lateral Recess of
Sphenoidal Sinus Stalk of Pituitary
Artery
1m:
777 /
'
Posterior
__
Com-
municating Artery Middle Cerebral
I
Rody InfcTJnr Maxillary
Vein
l)ivi*iion
Smaller Part of 5th
of 5th Ner\'e
Incus
Nerve
Middle ^Icningeal Arter\
Cochlea 5th
Articular Fibro-Cartiiage
Ntr^c
^Am-iculo-temporal
Nerve
Basilar Artery
Chorda Tympani Nerve Tympanic Cavity
Lateral Sinus ilastoid Emissary Vein
Superior Petr(»sai Sinus 9th, loth,
nth. Nerves Eustachian Tube
Emissary Vein passing thrt)UL Posterior Condylar Foramen \
Vertebral Artcr>'
Rectus Capitis Posticus ilajor Muscle
Saccus Endolymphaticus Occipital Artery
Superior Oblique Muscle of Suboccipital Nerve Straight Sinus Superior Longitudinal Sinus
Head
Rectus Capitis Posticus Minor Muscle
Fig. 16.
Base of Skull with the
soft parts after partial >/;,
Rebman
Limited, London.
removal of the Bones.
Nat. Size.
Kebman Company, New York.
;
Base
Fig. i6.
of the Skull
and Soft Parts
removal
after partial
of the Bones.
This complete fissure
is
constructed
from
eight dissections
made
after
hardening in formol and removing various parts of the Brain in successive layers. After decalcifying the bones considerable portions were easily removed by
knife.
tlie
On
the left side the part of tlie Occiput forming the Posterior Fossa ivas removed, the Cavernous Sinus opened and the Gasserian Ganglion with its
three divisions dissected out.
Tlie
roof of
tlie
Orbit was removed and the
By
structures occupying the upper part of this cavity exposed to view.
away
the
cutting
Cribriform Plate of the Ethmoid, the Accessory Sinuses of the Nasal
—
Mucous Membrane is coloured pink. On the right side a more extensive area of the base of the Skull has been removed, only a few thin bars beeing left [Tympanic Cavity pink, Membranous part of Meatus brown). In the lower part of the Orbital Cavity, Cavity were opened up
— the eye-ball having been cut across horizontally and supposed to be transparent, — all the
structures including the nerves
The Nerves of
and muscles are
shew}i.
the Special Senses are green (Optic
Nerve
light
green
Auditory Nerx'e and apparatus, dark green). Sensory Nerves, yellow. that the
Motor, dark blue (Veins being light blue), so
Motor Root of the Vth Nerve is definitely shewn. The Vagus Group IX, X, XI, being mixed nerves, are yellow, Gassertan, Ciliary and Geniculate Ganglia are orange; on
sensory.
the air-cells
like the tlie
left,
of the Auditory apparatus, the Eustachtax Tube and the unusually
large Lateral Recess of the Sphenoidal Sinuses extending into the greater wings
of the Bone are projected upwards This figure
— probably the
and muscles under the base
Topography relations
first of this
figure
special
sense:
course
of
the
e.
b}'
— gives,
by shewing the
below because
vessels
an idea of the
in this
manner
their
dissection.
shews the topographical
g. E3'e,
kind
of the Skull in their natural position,
of this region unattainable from
remain undisturbed
The
(pink).
relations
Ear and Nose, moreover,
Nerves which have a primary
of
3 great
organs of
gives a good view
it
intra-
the
,
of the
and a subsequent extra-
cranial course.
Lastly other methods.
connections are exhibited which could scarcely be appreciated by
:
Fig. 17.
Projection of Lateral Ventricle, Middle Ear and Lateral Sinus on the outer surface of the Skull.
To SpitzKj^s figure which shews the projection of the Lateral Ventricle on to outer region of the SkxiU, we have added the projection of the Lateral Sinus (violet) and of the Middle Ear with its Accessory Cavities (red) while retaining our own Specimens and the indications by Frjedrich Muller.
the
Puncture of the Lateral Ventricle
is
lated fluid (Hydrocephalus, Serous Meningitis
Ventricle
when
not dilated
vox Bergmann
performed etc.),
or
(a)
(b)
to emptj'
to inject
it
of
accumu-
drugs into the
g. Tetanus).
(e.
trephines the Skull in front,
above and mesial
directlj'
to the Frontal Eminence and pushes a long hollow needle in a and inward direction. Keen finds a point on the outer surface of the Skull 3
slightly
downward
mm. above a line connecting the lower border of the Orbit with the External Occipital Protuberance and 32 mm. behind the External Auditory Meatus. The shape of the Lateral Ventricle does not vary much except in the Posterior Horn.
Horns meet,
The "Trigone"
is
the
largest
i.
e.
part
1
where the Body, the Posterior and Descending and consequent!}' the most suitable for the
operation.
Fig. 18.
Projection of the Middle Meningeal Artery on the outer surface of the Skull. After Kronlein.
The Middle Meningeal Artery
is red.
To determine certain important Cerebral points and lines, as well as the Middle Meningeal Arterj', Kroklein's landmarks are the most convenient. i) The "German Horizontal Line" runs through the Infra-Orbital margin, and the upper border of the External Auditory Meatus. 2) The "Upper Horizontal Line" runs through the Supra-Orbital margin, parallel with the former. 3) The "Anterior Vertical Line" passes upward from the middle of the Zygoma at right angles to i). 4) The "Middle Vertical Line" passes from the Condyle of the Lower Jaw at right angles to i). 5) The "Posterior Vertical Line" from the posterior margin of the Base of the Mastoid Process at right angles to i). line connecting (a) the point where the "Anterior Vertical Line" and the upper Horizontal Line cross each other with (b) the point where the "Posterior Vertical Line" cuts the ^^ertex, represents the Central Fissure (ROLANDO). When the angle formed by this line and the upper Horizontal line is bisected by a line drawn to meet the posterior vertical line, the oblique line represents the Fissure of Sylvius. A and B are the points for trephining to evacuate the blood extravasated from a ruptured Middle Meningeal Arter}'. The square marked in thick Unes is the region in which VOX Bergjl\X'X resects the SkuU cap for drainage of Otitic Abscess and Abscess of the Temporal Lobe. The Black Circles indicate the following points which are often made use
A
of
(cf.
Text Figs.
1 1
and
1
2)
Nasion at root of Nose. Bregma at Vertex; further back, Obelion, Lambda; and Inion at the External Occipital Protuberance.
Fig. 17.
Projection of Lateral Ventricle, Middle Ear and Lateral Sinus on to the Outer Surface of the Skull. 7j Nat. Size.
Fig. 18.
Projection of Middle Meningeal Ai'tery on to the Outer Surface of the Skull. '^1^
Rebmun
Limited, London.
Nat. yize.
Kebman
Coni|i:my,
Ni'W York.
Fig. 19.
Cranio-Cerebral Topography. Vs Nat. Size.
Rebman
Limited, London.
Rcbman Company, New York.
Cranio-Cerebral Topography.
Fig. 19.
bars of A. Koehler's "Craniencephalometer" are dark red; Brain pink,
Tlie
diagrammatic.
For
practical purposes
very important to
is
By
the different parts of the hemisphere.
for
be made
On
of:
"Which
cortical region
is
the surgeon
which may require operation
is
may
it
Rolando and Sylvius
neighbourhood of these sulci
and
is
Koehler's method Cf. Fig.
such knowledge a diagnosis can
indicate disease of a certain part
this
knowledge
of surface
markings
lesion.
determine the position of the Fissures
fissures
Fig.
(cf.
3,
5)
in the
further with these landmarks other
out.
some requiring
devised,
special instruments.
simple and reliable.
is
Three
Sagittal
the surface markings
because the most important centres are situated
can be easily marked
fissures
A
by
sufficient to
Many methods have been
1.
;
enabled to find the seat of the
Generally speaking
know
affected in any particular injury of the Skull?"
the other hand, functional disturbances
of the Corte.N.
of
it
lines are necessary.
extending from the root of the nose to the External
line
Occipital Protuberance. 2.
A
Vertical line through the Anterior Border of the External Auditory
Meatus. 3.
A
second Vertical
line
parallel
to
the former through the Posterior
Border of the Mastoid Process.
P>om line
is
the point where the last mentioned line meets the Sagittal line another
drawn downwards and forwards
to a point situated
midway between
junction of the middle with the lower thirds and the mid-point of the
This point corresponds to the lower end of the
upper end of which
The of
Fissure of
Rolando. About
Posterior
the in
lies at
Limbs
Fissures Pis'.
1
8.
of
the junction of the line
SYLVIUS
2 V-,
lies
Rolando
Vertical Line.
ROLANDIC
drawn from the
Fissure,
the
Sagittal Line.
Vs ii^ch below the inferior end of the Fissure
inches above the
of this fissure begin.
first
the
Zygoma
the Short Anterior and
Another excellent method
and Sylvius,
devised by
of
Kroenlein,
Long
marking out is
described
Exposure
Fig. 20.
On
the
an incision has been made from
side
left
of the Cerebellum.
Protuberance horizontally outwards as far as the Ear. vertical incisions have been
downwards.
was
made downwards and
Cerebellum
The Cerebellum
is
is
either extremity
A
out.
The Lateral Sinus has been
of the Bone.
out
From
the muscle-skin flap
The muscles were subsequently dissected
chiselled
External Occipital
the
large
thrown
window
open,
slit
the
kept inwards by a broad spatula.
much more
protected than the Cerebrum. Only a ver}'
small surface area comes in contact with the
Bone
in
a region well protected
by
thick muscles.
Injury part
are far
Cerebellum
to the
more
difficult
owing
is
accordingly very rare, but operations in this
A
to its position.
that suppuration of middle-ear origin
may extend from
glance at the figure shews the Lateral Sinus, Posterior
Semicircular Canal or Saccus Endolymphaticus and so give rise to an abscess
between the posterior surface of the Petrous portion of the Temporal Bone and the Cerebellum or to a Cerebellar Abscess.
These purulent collections may be evacuated by an enlargement of the opening made for the exposure of the Lateral Sinus, backwards. abscess has been looked for by opening the skull in
Area and
(cf.
If a
Temporal
VON Bergmann's Rectangular
Fig. 18) then further procedure entails enlargement of the osseous opening
incision
Tentorium CerebeUi
of the
in
order to compare the superior aspect
of the Cerebellum.
A
large opening
is
When
necessary for Cerebellar Tumours.
the Lateral
Sinus gets in the operator's way, he should push the Dura Mater away from the
Bone
ligature the Sinus with a double
ligature
and divide
Upon
it.
the further
removal of bone the Cerebellum can be well exposed.
We
desire
to
draw
particular attention
to
a
\'ein
which runs from the
lowest part of the Lateral Sinus or from the Jugular Bulb to the Vertebral Vein
through the Posterior Condylar Foramen.
Its
further course
is
horizontal
be-
tween the Occipital Bone and the Atlas.
The
vein
is
of
great importance in Ligature of the Internal Jugular in
cases of Thrombophlebitis of the Lateral Sinus.
Cf. Figs.
27
and
28.
Cerebellum
Superior Cerebellar
Vein
Superior Petrosal Sinus
Emissary Mastoid
Vein Mastoid Process
Digastric Muscle
Spatula
Rectus Capitis Posticus Slinor Muscle
Occipital Arteries
Stemo-mastoid Muscle
Rectus Capitis Posticus
Major Muscle Occipital Arterj-
Splenius Capitis Muscle
1
Semispinalis Capitis Muscle
Vertebral Artery Superior Oblique of
Head
Longissimus Capitis Muscle
Fig. 20.
Exposiu-e of the Cerebellum. */s
Rebman
Limited, London.
Nat. Size.
Eebman Company, New York.
Middle
'I'tirbinate
Hone
Antrum
of HioiiMoiti-:
Coronoid Process I
'r^'Tf
Jf^Aw
j
Temporal Muscle
Nasal Septum
massetcr Muscle Pterygoid Process External Pterygoid
Muscle
3rd Division of
Nerve EUSTACHIAN Tube 5th
Par<.tid
M
Gland
Articular Cartilage
Temporal Artery Occipital lione Ili-ad of
Mandible
F.xlcrnal
Auditory
Internal Carotid
Artery
Tympanic
Meatus
Cavitj*
^^
Facial
KcTvc
:\rastoid Cells
Lateral Sii
Cerebellum
Horizontal Section of the Head.
Fig. 21.
Left side, viewed
frcuii
Organ below.
of
—
Healing and suiTounding Parts. i\at. Size.
^^fMM
Head
of
Lower Jaw
Internal Carotid
Artery
Tympanic Cavity
Tympanic ^Icnibrane
Superior Petrosal Sinus
Long
Process of Incus
External Auditory
Facial Nerve
Canal
Auditory Nerve
Tympanic Nerve^ Mastoid Cells
Promontory
Umbo. Malleus Fenestra Ovalis
Stapes
Pyramid
Lateral Sinus
Chorda Tjinpani Facial
Fig. 22.
Rebmau
Part of Fig. 21
Limited, London.
:
Nerve
Tympanic Cavity and surrounding
Parts.
X
^y..
Rebman Company, New York.
Horizontal Section of the Head: Organ of Hearing and
Fig. 21.
Surrounding Parts. Pig. 22.
Tympanic Cavity and Surrounding
X Part of a frozen section from a
is
of Horizontal sections through the Head.
the External Auditory Canal in the Horizontal is
:
it
2V2.
series
The two curves described by plane are well shewn a 3rd curve
Parts.
recognisable
the Vertical plane, so that
in
Tympanic Membrane without
not possible to distinctly see the
upon
traction
the Cartilaginous portion of the Ear.
From ratus bears
the practical point of view the relations which the Auditor}'
Appa-
neighbouring structures and especially to the Lateral Sinus and
to
Dura Mater are most important.
The Dura Mater which covers is
only separated from
pus within these
numerous
the
may
cells
the
posterior
air-cells
easily give
rise
by
lamina of bone, so that
The
to a subdural abscess.
Lateral
Sinus bears a similar relation to the Mastoid Process so that injury to
during operations upon the Mastoid;
result
Bone
aspect of the Petrous
a thin
it
pus within the Mastoid Cells
may may
extend to the Lateral Sinus and produce Thrombophlebitis.
Around
the Internal Carotid Artery which incompleteh'
Canal, are \^enous Spaces, continuations of the Cavernous Sinus.
seen cut across in
is
vertical
its
the
in
its
Tympanic
2
Venae Comites.
Cavit}*
the it
Tympanic Cavity
appears larger than
Condyle thin
of the
la)'er
of
open
to
it
if
3rd Division of the
shewn the
structures
Chorda T3'mpani and Tympanic Nerve. The
obliquely forwards, inwards and into the
downwards from
Pharynx has been divided obliquely so
had been cut transversely
to
its
axis.
that
Between the
Internal to the External Pterygoid Muscle
Vth Nerve
Ovale; behind and to
its
directly after
outer side
is
The Lymphoid Tissue beneath notice.
Tn the
Lower Jaw and the External Auditory Meatus there is only a very bone. The Articular Fibrocartilage is seen almost completely
surrounding the Condyle.
Pharyngeal
Facial Nerve
shewn the Stylomastoid
In Fig. 22 are further
Ear-ossicles,
:
Eustachian Tube, extending
The
course to the Stylomastoid Foramen.
Facial Canal accompan3'ing the Facial Nerve (Fig. 22) are
Artery with
the Carotid
fills
Tonsil — which
This has been
its
is
seen the
emergence through the Foramen
the Middle Meningeal Artery.
the Pharyngeal
appears very
]\Iucous
Membrane
large in a horizontal section
cut obliquely because the
— the
deserves
upper wall of the Pharynx
not horizontal but directed obliquely backwards and downwards.
is
Vertical Section through the Left Temporal plane of the Axis of the Petrous Portion.
Fig. 23.
Bone
in the
Frozen Section. Mucous Membrane of Tympanic Cavity, Antrum and Mastoid The lower part of tlie Tympanic Cavity has l)een carried aivay Cells in red. in the section so f/iat the External Auditory Canal is exposed.
Fig. 24.
Horizontal Section through the Left Temporal Bone.
Tlie axis of the Mucous Membrane lining Mastoid Antrum is indicated b\ a red line. The axis througli the External and Internal Axiditory Meatus, "Sensory Axis", Tlie Cartilage of the Temporo-Mandibular Articuis indicated by a yellow line. lation is coloured blue.
Section through a macerated bone. the
Eustachian Tube and
The middle
the
is surrounded by numerous air-cells which aire lined by same mucous membrane and communicate directh' or indiwith the Tympanic Cavity. Pus spreads readily from the Tympanic Cavit}^
ear
a continuation of the rectly
shews how the cells lie below the plane of the and consequentl}' drainage is very efficient. The size of these air-cells varies not only on the same side but on either side in the same individual. These cells maj- extend far into the Petrous Bone, even into the Occipital Condyle and the root of the Zygoma. The chief Accessory Cavity is the Mastoid Antrum (as large as a French Bean) with its long axis (^/5th inch) corresponding to the axis of the EUSTACHIAN Tube and opens into the Tympanic Cavity on the posterior wall, directly below the Tegmen Tympani which forms the roof of the Antrum. The Mastoid Cells, which vary considerably in number, either few or large, numerous or small open into the Antrum. The cells extending into the Squamous Portion are known as Squamosal Cells, but these never extend higher than the temporal ridge. The lamina of bone covering the Mastoid Process is so variable in thickness that, like the Tegmen it is deficient at some points on its outer wall as well as on its inner wall, which is in relation to the Lateral Sinus. These points of deficiency are merely covered by connecto these
Accessory
opening
into
Cells.
Fig. 23
the r3'mpanic Cavity
tive tissue.
through the thin Tegmen Tympani and cause Meningitis or a Temporal Abscess. Fig. 23 shews the Vth Cranial Nerve in Meckel's Cavity, i. e. the depression on the superior surface of the Petrous Bone covered in by Dura Mater.
Pus can
spread
easily
e. In Fig. 24 the red line indicates the "mucous membrane axis", Eustachian Tube, Tympanic Cavity, Antrum and Mastoid Cells on a line which i.
runs backwards and outwards.
The yellow line is the "sensory axis" which passes tlirough the External Auditory Meatus, Tympanic Membrane and Cavity, Vestibule and Internal Auditory Meatus. These axes cross in the Tympanic Cavity the first passes through all organs of accessory importance for hearing; the second passes through the organs of hearing proper. ;
Superior Ligament of the Malleus
Chorda Tynipani Tensor Tynipani Muscle
Internal Carotid
Artery Cartilage of
Edstacuian Tube Levator Palati iluscle
I'haryngeal Opening
Mastoid Cells
of
Eustachian Tube
Stylo-mastoid Artery
Superior Constrictor of the Pharynx
Splenius Capitis JIuscle Sterno-cleido-mastoid Muscle
Fig. 23.
Facial
Dig^astric
Norve
Muscle
Stylo-hyoid Muscle
Styloid Process
Vertical Section thi'ough left Temporal Bone in the plane of the axis of the Peti'ous Portion. Seen from behind.
—
Nat. Size.
Mastoid Cells Lateral Sinus
Antnjm /
Canal for Facial Nerv-e (Fallopian)
Pyramid Posterior Semi-circular Canal
Aqueductus VestibuH Vestibule
_
Internal Auditory
Meatus
Cochlea
Bony Lamina
(Processus
Cochlear if orm is) EL'STAClirAN
Notch
Tube
of RiviNi
Petrosquamosal Suture
External Auditory Meatus
Mandibular Fossa Z3'goma
Fig. 24.
Horizontal Section thi-ough the Left Temporal Bone. Seen from below.
Kebnian Limited, London.
—
Nat. Size.
Rebman Company, New
Yoi-k.
Antrum
"xJ^^FMiDi
Prominence of External Semi-circular Canal
Temporal Fascia
Squamous Plate'of Temporal Bone
^
Diploe
Suprameatal Spine Lateral Sinus
External Auditory Meatus (Cutaneous)
Auricular Branch of Vagus Ner\'e (Arnold)
-^
"^^'
Facial Nerve
Sterno-cleidu-mastnid Muscle
External Auditory Meatus (Cartilaginous)
Posterior Auricular Ner\-c
Posterior Auricular Artery
Parotid Gland
Splenius Capitis Muscle
/
Longissimus Capitis Muscle
Facial Nerve Digastric Muscle
Mastoid Process
Styloid Process
Fig. 25.
Mastoid Process of Child opened. Nat. Size.
Suprameatal Spine
Antrum
Temporal Fascia
Posterior Auricular Nerve
Occipitalis Muscle
\ Great Occipital Nei-ve Cartilage of Pinna
.
-^^ Small Occipital Nerve
External Auditory
Canal Lateral Sinus Posterior Auricular
Muscles
Facial Ner\*e
Auricular Branch of
Vagus Nerve Splenius Capitis
Muscle
Cartilaginous Portion of the External
Auditory Canal Sterno-cleido-mastoid
Muscle Facial Nerve
Posterior Auricular
Lymphatic Gland Posterior Auricular
Artery
Nerve to Digastric Muscle Great Auricular Nerve
Nerve
to Stylo-hyoid
Parotid Gland
Mr F-rokss
Fig. 26.
Mastoid Process of Adult opened. Kat. Size.
Bebman
Limited, Londoc.
Rebman Company, New York.
Fig. 25.
Mastoid Process
Fig. 26.
Mastoid Process in Adult, opened.
of Child, opened.
various layers of the Mastoid region in a child, aged two vears, and the Mastoid Process cliiselled open. Air-cells, red. In Fig. 26 the Mastoid region of an adult has been more extensively dissected but only that portion of the Mastoid Process containing air-cells has been Fig. 25.
Tlie
—
liave been exposed,
opened by
The periphery of the Mastoid Process is indicated by a dotted a portion of the Parotid Gland the Facial Nerve has been exhibited as it emerges from the Stylomastoid Foramen.
chisel.
By removal of
line.
The Antrum is
is
scarcely discernible;
well its
marked
posterior
in the New-Born though the Mastoid Process and external portion becoming formed during
grows downwards as the formation of air-cells slowly progresses. Even in the there are not necessarily any air-cells at the tip The Facial Nerve after emerging from the Stylomastoid of the Mastoid Process. the
first
years of
life;
it
adult
Foramen runs forward
at
a right angle in
the infant, at an obtuse angle in
the adult.
The groove of the The iVntrum and Mastoid
Lateral Sinus Cells
is
the outer surface of the Mastoid Process. the Pinna and the Skull
shallow in the child, deep
in
the adult.
are easily accessible for operative purposes from
Subcutaneously
the Posterior Auricular Artery
in the
takes
angle between
its
The
course.
Periosteum is intimately connected with the tendinous fibres of origin of the Sternocleidomastoid Muscle which gradually become lost in the Temporal Fascia. About 'Vath inch behind the Suprameatal Spine is situated the Antrum at a depth of V.r,th of an inch from the surface. Below this are the Mastoid Cells.
The The
structures in relation with the thin
Tegmen Tympani
Cavity, so that search for an Epidural or ation
of
the
Tegmen Tympani.
If
Antrum
are of great importance.
alone separates the
Antrum from
Temporal Abscess
is
the Cranial
easy after perfor-
projected on to the surface the floor of the
middle Fossa of the Skull lies in the region of the attachment of the pinna either above or on the level of the Temporal line. Posteriorly and internally is the Lateral Sinus which should be avoided when the air-cells are opened. The position of the Lateral Sinus varies, it may lie in a shallow groove on the Mastoid Process, or in a deep furrow in both Mastoid and Petrous portions. According to Bezold the most marked outward curve of the Sinus is V5 inch behind the Suprameatal Spine. At this point the bone is usually 0.3 inch thick (o.i to 0.7). The Facial Nerve may be injured as it lies below the External Semicircular Canal on the inner wall of the Tympanic Cavity close to the opening itito the Antrum (Aditus ad Antrum). The wall of the Facial Canal is ver}' thin so that
by a careless use of the Lower down the Mastoid
chisel this nerve
may be
divided.
Cells are in relation with the Facial Canal
portion has been laid free in both figures.
;
this
Fig. 27 and 28.
Tympanic Cavity and Surrounding Parts opened from behind.
In Fig. 27, the outer wall 0/ the Mastoid Process, Antrum and Attic have been removed, the Mastoid Cells gouged out so that only t/ie inner wall of the Mastoid Process remains; Facial Nerve, Posterior and External Semicircular Canals and Lateral Sinus are still covered by bone. Facial Nerve and Semicircular Canals (yellow) are represented as shewing through the bone. In Fig. 28, the skin incision has been extended downwards, the tip of the Mastoid Process removed, the Digastric Muscle divided and the Attic more freely exposed, the Facial Canal opened, the bony ivall of the Sinus removed and the Sacciis Endolymphaticus exposed. The Posterior portion of the Tympanic Membrane, the Posterior and Superior wall of the Bony External Auditory Canal luive been removed and the skin which lines this portion slit open. The bar of bone behind the Stylomastoid Foramen has been sawn through in order to expose the fugidar Bulb. These figures give the relations which are of importance in radical operations. In cases of chronic suppuration and Cholesteomata of the Middle Ear, it is important to expose all the cavities b\' removing their outer wall and bony septa so that the inner wall of the Tympanic Cavit}-, Antrum and Mastoid becomes continuous with the Inferior and Anterior Wall of the External Auditory Canal. The bony canal for the Facial Nerve, the External Semicircular Canal and the Stapes must be carefully avoided. The black area below the Incus represents the Fenestra Rotunda. Fig. 28 shews the whole of the oblique part of the Lateral Sinus to its termination in the Jugular Bulb. After reaching the Temporal Bone its direction changes verticalh' downwards, embedded to varying depths in the inner wall of the Mastoid Process, thence its course is at first horizontalh* inwards (occasionally with a sharp upward curve), then directly downwards to pass through the Jugular Foramen and form the Jugular Bulb. Suppurative Thrombo - phlebitis usually affects this last vertical portion, in many such cases the Sinus must be opened throughout its whole length. Many ways may be employed to expose the Jugular Bulb: Gruxert removes the tip of the Mastoid Process and proceeds towards the Jugular Foramen at the base of the skull where he divides the bone encircling" it. As shewn in the figure the Facial Nerve is in the way. Panse therefore recommends that the nerve be freed and drawn forward. If the Transverse Process of the Atlas is in th3 way it should be carefuUv removed, avoiding any injury to the Vertebral Arter)^ Owing to anatomical variations, this may be impossible so that CtRUNERT's method (as practiced by PiFFL), of removing the floor of the Auditory Meatus and T\'mpanic Ring, under which the Jugular Bulb lies, may be necessary. (Cf. Fig. 17.) By this method the Facial Nerve lies behind the field of operation; the structure to be avoided in front is the Internal Carotid Arter)'. Will ligature of the Internal Jugular Vein in Septic Thrombophlebitis prevent the spread of infection ? This question demands a consideration of the many Venous Channels which open into the Lateral Sinus (Superior Petrosal Sinus, Figs. 15, 16, 20), Mastoid Emissary' Vein (Figs. 20 and 28), Posterior Condylar Emissary Vein (Fig. 20), ilarginal Sinus (Fig. 15), Inferior Petrosal Sinus (Fig. 15), Anterior Condylar Vein which accompanies the Hypoglossal Nerve and passes to the Jugular Bulb from the Vertebral Plexus. The figure shews the close proximit}' of Facial and Spinal Accessory Nerves so that in cases of Facial Parah'sis the Surgeon may be tempted to suture the central portion of the Spinal Accessor}- to the Peripheral portion of the Facial Nerve.
Suprameatal Spine -Tympanic Cavity
Short Process
Incus
r»t
External (Horizontal) Semicircular Canal Posterior Semicircular Canal
Facial Nerve
Lateral Sinus
Digastric Muscle
Fig. 27.
Superficial Layer.
Malleus
Tympanic Cavity
Posterior Semicircular
Canal
Saccus Emlolymphaticus
Facial Nerve
Lateral Sinus
Mastoid Emissary Vein
Occipital Vein
Spinal Accessory Nerve
^'i^vij'v-.v.r.v^-^.
rig. 28,
Figs. 27
and
28.
a
Deep Layer.
Tympanic Cavity and surrounding Parts opened from behind. Nal. Size.
Kebman
Limited, Loiulon.
Rebman Company, New York.
Fig. 29.
Superficial Vessels -v.,
Rebman
Limited, London.
and Nerves of the Head.
Nat. Size.
Rebrntin
Company. New York.
—
Superficial Vessels
Fig. 29.
and Nerves
of the
and Square Muscle
Skin, Parotid Gland, portion of the Orbicularis Palpebrarum
of the
Upper Lip (Quadratus Labii
Superficial Arteries,
Veins,
Light red,
Superioris),
Head.
Nerves and Muscles have been exposed by
dissection.
Passing upward over the lower jaw
the Facial
Arteries.
is
Artery which shews through the Muscles as
it
the Ear the
Transverse Facial Artery.
Temporal Arter}' gives
off
the
upper border of the Orbit the Frontal Artery
which comes
off the Internal Carotid)
Violet, Veins. The
is
(a
is
covered
them
b}'
in front of
:
At
seen and at the back
is
the Occipital Arter\-.
Facial Vein (anastomosing, at the Naso-frontal Angle,
communicating with the Temporal Vein which is
the
branch of the Ophthalmic Arter\-
with the Frontal Vein and indirectly with the Intracranial Venous System)
the Occipital Vein
The
have been removed.
lies in front of
the Pinna.
is
seen
Posteriorly
seen.
—
The
Facial Nerve and
The
other nerves are coloured in accordance with their area of distribution.
(Cf. Figs.
branches are white.
its
(Cf.
Figs. 33
38.)
33-38.)
Dark red
—
Ophthalmic Division of Vth Nerve.
Yellow — Superior Zygomatico-Temporal, and
Blue — Inferior
(F,
i).
Maxillary Division of Vth Nerve (F,
2).
z—f
Temporal-Facial Branches).
Maxillary Division of Vth Nerve (F,
the Auriculo-Temporal Nerve (a
Orange — Auricular Black — Cervical
[z—t indicates
t)
:
This gives off
before the Inferior Dental enters
Branches of Vagus {X)
Nerves
3).
to the
its
Foramen.
Pinna (ARNOLD).
Great Auricular, Great and Small Occipital and
Superficial Cervical Nerves.
The Duct are coloured
of the Parotid
light brown.
Gland (Stenson's Duct) and
its
small tributaries
Side
Fig. 30.
The Parotid Region in the Parotid the Facial
lias
Gland
to
View
of Face.
Superficial Layer.
been dissected on the Left Side and a windoiv made tlie formation of SrENSOiv's Duct, Branches of
shew
Nerve and
the
main
vessels (all very carefully dissected).
Broadh' speaking the Vessels and Nerves of the Face are subcutaneous with the exception of the area covered by the Parotid Gland.
The
Parotid Gland is co\ered b}' a thick fascia; its outer surface is trishape with the base directed upwards and the Apex at the angle of the Lower Jaw. The base extends from the posterior extremity of the Zygoma to the Cartilaginous portion of the External Auditory Canal and to the Anterior border of the Sternomastoid Muscle. The posterior border runs parallel to the Sternomastoid Muscle; at the angle of the Jaw, this is met by the Anterior border which crosses the Masseter Muscle. The greater part of the Gland lies
angular
in
behind the
Ramus
of the
Jaw and extends inwards
to the Digastric
(i.
e.
close to
tlie 53). Stenson's Duct runs almost horizontally below Zygoma and turns inwards at the Anterior border inch the forwards ^/^th Buccinator obliquely and terminate within the of the Masseter to perforate the Buccal Cavity opposite the 2nd upper molar tooth (cf. Fig. 57). There is often present an Accessory Parotid (Socia Parotidis) attached to the Duct (cf. Fig. 30). The Facial Ner\'e bears a close relation to the Gland. After emerging out of the Stxiomastoid Foramen this nerve enters the substance of the Gland at the level of the lobule of the Ear. Here it divides, and its branches run in the substance of the gland, to emerge at the Anterior border and be distributed to Consequently it is impossible to remove the all the muscles of Facial Expression. whole of the Parotid Gland without injury to the Facial Nerve, but removal of the lower part in no way leads to interference with the Nerve: in this case the Mandibular Branch, which supplies the muscles of the angle of the mouth, is The branches of the Facial Nerve form an anastomosis with chiefly damaged. Anserina) and with the Fifth. other (Pes each Auriculo-Temporal The Nerve (from V, 3) runs through the Parotid Gland well as the Superficial Temporal Artery (continuation of External Carotid £is
Carotid and Jugular Vessels Fig.
this vessel in its course through the gland gives off the Tran,sverse Facial Artery which takes a horizontal course. The Superficial Temporal Artery then passes upwards in front of the ear dividing into an Anterior (Frontal) and a Posterior (Parietal) branch to supply the Frontal and Parietal Regions of the Scalp
Arter}')
;
as the Vertex. The Temporal Vein, accompanying the Artery-, receives blood from the Temporal Region and the Ear. In the substance of the Parotid Gland are embedded a few h-mphatic glands which are of practical importance; as far
rarely, a
cutaneous 13'mphatic gland, superficial to the Parotid,
is
found.
Temporo-Facial Branches of Facial
Nerve
ait
Auriculo -Temporal i
Nerve
, , lemporal Artery Superficial ^ ,-
.
,
,
Tcinpnral Vein
'
—
Zygdiiia
Facial
Nerve
(iieat Auricular
Nerve
External Jugular Vein
I
Facial Artery
Masseter
Long Buccal Nerve
Parotid Gland
Muscle
Facial Veir
Fig. 30.
Side
View
of Face.
Superficial Layer.
Nat. yize.
Rebman
Limited, London.
Rebman Company, New York.
Deep
Branches of Internal Maxillary Artery
Posterior
Temporal Artery Temporo- Facial Temporal Muscle and Nerve Nerve
Superficial
Temporal Fasciae
Masseteric
Temporal
Nerve
Articular Eminence
Artery
Branches of Teniporo-Facial
^
Nerve
Auriculo-Temporal
Nerve
Infra-orbital
Midille
Xrrve
Temporal
Artery
Posterior Superior
Alveolar Nerves
External Pteryg
Muscle
Deep Anterior
,
.
Temporal Artery
_ ^g
^^
V J,
Parotid Duct
y
.
^—
Communicating Branch between Facial and AuriculoTemporal Neives :\liddle
Meningeal
Buccal (Sucking) External Carotid Artery
Pad
Buccinator iluscle
Long Buccal Nerve Facial Nerve
Parotid Gland
Nerve
to
Mylohyoid Muscle
Masseter Muscle Inferior Dental
Internal ilaxillary Artery
Lingual Nerve
Internal Pterygoid Muscle
Fig. 31.
Nerve
Side
View
of Face.
Deep Layer.
Nat. Size.
Rebmao
Limited, LouUou.
Rebman Company, New York.
Fig- 3^'
Side
View
of Face,
deep layer.
The brandies of the Facial Nerve have been cut off but its communications with the Auriculo-Temporal Nerve have been exposed to view: the Zygoma has been sawn through and removed together with the upper part of the Masseter Muscle, (in a similar manner, the Coronoid Process with the attached Temporal Muscle). All the chief branches of the 2nd a7id jrd divisions of tJie Vth Cranial
Nerve and
the branches of the Internal Maxillary Artery are exhibited.
Under cover of tlie Coronoid Process of the Lower Jaw and the Temporal Muscle attached to it, the structures of the Zygomatic Fossa are covered with fat. After the removal of this fat the External Pterygoid Muscle is seen extending from the Pterygoid Process to the Condyle of the Lower Jaw. The relation of the Internal Maxillary Arter}' (terminal branch of External Carotid Artery) to this muscle varies as it runs, either superficial or deep to the muscle, to gain the Spheno-Maxillary Fossa. This vessel gives off the Middle Meningeal Arter}^ which runs upwards to the P'oramen Spinosum and the Inferior Dental Artery which enters tlie Inferior Dental Foramen. After removal of the External Pterygoid Muscle the 3rd or Inferior Maxillar3'-Division of the Vth Nerve is visible. After passing through the Foramen Ovale this breaks up into numerous diverging branches. The Auriculo-Temporal Nerve passing backwards emerges behind the Temporo-Maxillary Articulation and supplies the skin of the temporal region witli common sensibilit}', this nerve generally forms a loop through which the Middle Meningeal Artery passes. The other branches are partly motor and supply the Muscles of IMastication (Internal and External Pterygoids, Masseter and Temporal), and partly sensory, long Buccal to the skin and Mucous Membrane of the Cheek. The two largest branches, Inferior Dental and Lingual, pass downwards on the Internal Pterj-goid Muscle; the former, the larger nerve, is the more
posterior.
In the Spheno-Maxillary Fossa but situated anteriorh^,
The
is
the posterior
branch of the Internal MaxiUary Artery, enters the Infra-orbital Canal, while close above this vessel lies the 2nd division of the Vth Nerve which in its course from the Foramen Rotundum to enter the Infra-orbital Canal inclines outward. In its short course it gives off the Spheno-Palatine Nerves to the Spheno-Palatine Ganglion (Meckel's, cf. Fig. 44) and through the Pterygo-Maxillary Fossa the Zygomatic, Superior Dental and Sphenopalatine Nerves. Operations in this region — for removal of tumours, resection of the 2nd or 3rd divisions of the Vth Nerve for Acute Neuralgia are rendered difficult by the diffuse Venous Plexus (Pterygoid Plexus) which replaces the Venae Comites of the Internal MaxiUar)' Artery. This plexus which has been removed in the dissection, extends from the Infra-orbital Canal and Spheno-Maxillary Fissure between the Pterj'goid Muscles as far as the Temporo-Mandibular Joint. surface of the Superior Maxilla.
Infra-orbital Artery, a
—
Fig. 32.
On
Exposure
the right side
of
the Qasserian Ganglion.
an incision, curvilinear with
its
Natural Size.
base at the Zygoma, has been
carried through the soft parts. The bone has been chiselled through and the osteoplastic flap, broken at its base, is turned downwards. The Dura Mater of
Middle Fossa and the Temporal Lobe are raised so that after division of the Middle Meningeal Artery, the Gasserian Ganglion and the ^rd division of the Vth Nerve are exposed outside the Dura Mater. (As the bone was removed the Anterior Division of the Middle Meningeal Artery was lacerated in its bony canal.) the
Persistent Facial Neuralgia
which
is
which
is
unrelieved even by extensive resection
Vth Nerve
of the peripheral branches of the
unrelieved by medicaments has recentl}^
Gasserian Zygoma may be
the
Ganglion.
Two
emerge from the skull and been dealt with by removal of
as they
methods may be adopted
temporarily resected,
when
after
either (Rose) the exposure of the Foramen Ovale
from below the base of the skull is opened up; or the skull may be opened in the Temporal region (Hartley, Krause) and the Ganglion with its branches exposed. This latter method is perhaps the better one; moreover, it may be employed for removing tumours of the Middle Fossa or for ligature of the Middle Meningeal Artery. After turning down an osteoplastic flap as described above, the Dura Mater covering the Temporal Lobe is lifted away from the Skull. Considerable haemorrhage follows from the laceration of numerous small veins. At a depth of one inch from the Squamous portion of the Temporal Bone, just above the root of the Z^^goma lies the Middle Meningeal Arter}'. This vessel is divided between two ligatures in order to expose the Foramen Ovale which lies Vioth inch internal and in front of the Foramen Spinosum ^/sth inch forwards and nearer to the middle line than the Foramen Ovale is situated the Foramen Rotundum through which the 2nd division of the Vth Nerve passes; Ysth inch from the Foramen Ovale and ^gth inch from the Foramen Rotundum is the Convex margin of the Gasserian Ganglion. It lies in an impression on the upper surface of the petrous bone and covered by Dura Mater in Meckel's Cave (cf. Fig. 23). The trunk of the Vth Nerve enters its Dural Sac by passing through a slit in the Dura Mater at the attachment of the Tentorium Cerebelli to the superior border of the petrous bone. The Gasserian Ganglion and its three divisions are outside the Dura Mater and can be operated upon without opening the meninges or exposing the brain. Particular attention should be paid to the first division of the Vth Nerve, as it lies in the outer wall of the Cavernous Sinus; so that in freeing this division ;
the Sinus
is
necessarily injured.
(Cf.
Fig.
17.)
Another method, devised by LEXER, is still less whereas it gives a good exposure of the Ganglion.
liable to injure the brain
LEXER makes
a smaller
temporal flap but enlarges the area of operation downwards by temporarily resecting the
Zygoma and removing
the base of the skull as far as the
Foramen Ovale.
V
Dura Mater Temporal Lobe
of
Middle Meningeal Artery
-\-
Trochlear
.
3
2
1
Nerve
Dura Mater
of Frontal
Lobe
^!'.Sr{:lisQ
'S'>^'a*''S^ Superficial
Temporal
Arterj'
Superficial Ygjjj
Fig. 32.
Posterior
Anterior
Branch of Middle Meningeal Artery
Muscle
Fascia
Temporal
Exposure of the Gasserian Ganglion. Nat. Size.
Rebmau
Limited, London.
Rebmau Company, New York.
Fig. 35.
\ \
Fig. 36.
Fig. 33.
Li^ ']]
m
jz= 5 ==
r
r\ ;VA
2
Fig. 37.
ir-f"'"
Fig. 38.
Fig. 34. Fig.
33—38. Fig.
Area
Fig. 35
Rebman
Limited, London.
of Distribution of the Sensory Cranial
33 Front View, Fig. 34 Side View, 38.
Variations, Side View.
'/,
'/,
Nerves:
^'at- Size.
Nat. Size.
Rebman Company, New
Yorls.
Pig- 33
38.
Area
of Distribution of
the Sensory Nerves of the Head.
These diagrams have been made in accordance with Frohse's investigations and ZANDElis data. In fig. // the foramina of exit of the chief branches of the Vth Nerve have been indicated by black Dots.
A characteristic feature of the Cranial Nerves is that they are either pure Motor or pure Sensory nerves when they contain fibres of the other variety they do not represent true mixed nerves lil
—
the upper
lip.
The 3rd
Division
(blue)
gives
mastication and to the M3'lohyoid Muscle.
off
Motor Branches
Its
to the muscles of Sensory Branches are the Auriculo-
Temporal, Long Buccal and Mental Nerves. Cervical Nerves. The Great Auricular plays an important part in the Nerve supply of the Face by supplying the region over the Parotid and the Masseter.
One
branches ascends between the Helix and Antihelix. The outer is accordingly supplied b}- 3 nerves: Auriculo - Temporal, Auricular Branch of Vagus and Great Auricular. The foramina of the 3 branches of the Vth Nerve viz. the Supra-orbital Foramen (notch). Infra-orbital and Mental Foramina lie almost in a vertical line (K. v. Bardeleben). In Neuralgia these points are exceedingly tender. glance side
of
the
of its
—
Pinna
A
at Figs. 35 to 38 indicates the (cf.
Fig. 36)
enormous variations
in
the cutaneous suppl}\
Thus
the Infra-orbital Nerve ma}' supply the whole of the middle portion
Dorsum of the Nose and eliminate the Outer Branch of the Nasal Nerve from the Tip of the Nose. Fig. 38 shew-s a very considerable extension of the Cervical Area. Variations not only occur in different individuals but even in the same individual, so that the cutaneous supply is different in each lateral half of the face. Frequent anastomoses occur so that one area may be supplied by several nerves. Stress should be laid on the fact that the nerves cross the middle of the
line to the opposite side
(cf.
Fig. 33).
The Nasal Cavity with the Opening
Fig. 39.
The Sagittal Section has been made a
and Frontal Septum.
Sphenoidal
Turbinated Bones in order Into
some of
to the right
little
Portions
Accessory Sinuses.
of its
have
of the Nasal Septum, removed from the
been
exhibit the orifices of the accessory Cavities.
to
these directors have been introduced.
The Tongue has been almost
completely removed to shew the Tonsil.
The Accessory as Ethmoidal Cells
Cavities
Nose may be considered Embryologically
of the
which have grown be3'ond the area
become formed by the
resorption
mucous membrane follows
of the
bony walls
and grows
this process
They
of the Labyrinth.
of the Nasal Cavity.
into the accessory cavities.
The The
Nasal Duct opens, covered by the inferior turbinated bone, into the inferior nasal This meatus readily allows the introduction of a canula into the opening
meatus.
Eustachian Tube which lies in the Outer Wall of the Phar}-nx. At this is the EUSTACHIAN Cushion, behind it the Fossa of RoSENMtJLLER. Under the Mucous Membrane covering the roof and back of the Pharynx is a of the
opening
mass
of
lymphoid
which
tissue (Pharyngeal Tonsil)
in
the middle line exhibits a
recess of variable shape, grooved, saccular or double (Pharyngeal Bursa).
Into the middle meatus, at the Anterior part of a ridge,
is
the opening of
the Frontal Sinus (Infundibulum), at the posterior part the aperture of the iVntrum of
HiGHMORE. The communication between
single,
it
may be
We in
have already stated
Antrum and
(in
Fig.
2
Fig.
tains the
Bone
is
2)
The Anterior Ethmoidal CeUs
directly
opening
is
Nose
is
not always
is
it
Antrum
situated at
the
is
top
open into the Middle Meatus
also
The Superior Meatus conAbove the Superior Turbinated
above the aperture of the Antrum.
for the Posterior
Ethmoidal
Cells.
the aperture for the Sphenoidal Sinus into which guided
The aperture
can introduce a canula through the Anterior nares. Sinus
the
Text) that the opening of the
a most unfavourable position for drainage, because
of the cavit}^ (cf.
the
double.
not situated at the lowest part of the
favourable for drainage.
All
the accessory
cavity
and
is
nasal cavities are
by a mirror one
of the Sphenoidal
consequently not
Uned with mucous
membrane.
The figure shews the Tonsil About one inch long and composed visible
when
the tongue
is
situated of
depressed.
between the two
Lymphoid Tissue (Cf.
Fig. 53.)
it
pillars of the
Fauces.
only becomes distinctly
Posteriur Ethmoidal Cells
Si)hcn(iidal Sinus
Frontal Sinus
-Vnterior Kthuioida! Cells
Infundibuluui
Opening of Antrum of HlOllMORK Opening
of _
Nasal Duct Pharyngeal Recess
(ROSCSMULLEK) Eustachian Tube Pharyngeal Tonsil
I'vula
-Viitcrior Pilhir
of Fauces
Posterior Pillar of Fauces
Fig. 39.
Nasal Cavity with Openings of Accessory Sinuses. *l^
Rebman
Limited, London.
Nat. Size.
Rebman Company, New York.
Nasal Opening of Antrum
Inferior
Wall
of Orbit
^
Tuberosity of Maxilla
Antrum
—
Lateral Incisor Tcioth
Canine Tooth 1st
Fig. 40.
Antrum
of
Molar Tooth
1st
Bicuspid Tooth
Highmore with Roots
of Teeth.
Nat. Size.
Septum between Frontal Sinuses Supra-orbital
Foramen Supra-orbital
_
Nerve
Right Frontal
Levator Palpebrae
Sinus
Muscle Infundibulum
Frontal Bone
Ethmoidal Bulla Frontal Process of Maxilla
Nasal Duct
Antrum Nasal Bone
Septum of Nose
Triangular Cartilage of Nose
Inferior
Turbinated Bone
Lateral Cartilage _ of Nose
Fig. 41.
Frontal Sinus.
Nasal Duct.
Kat. Size.
Rebman
Limited, London.
Rebman Company, New York.
.
Antrum
Fig. 40.
HIGHMORE
of
The Alveolar Process and Teeth were ground
was The
well exposed;
its
with Roots of Teeth.
off until the
Antrum of Highmore
Anterior wall was removed.
Incisor Teeth are in no relation with the
Bicuspid Teeth are closely related to
Antrum.
The Canine and
but separated from
it by a Molar Teeth are in closer relation to it. The roots of the Molars frequently project upwards as conical processes, separated from it only by a thin layer of bone. Thus disease of the roots of the last four teeth may lead to suppuration in the Antrum. On the other hand, an empyaema of the Antrum of HiGHMORE may be drained by extracting one of the teeth mentioned and perforating the thin layer of bone.
first
thick layer of bone.
this cavity,
The 2nd Bicuspid and
tlie 3
Frontal Sinuses.
Fig. 41.
Both Frontal Sinuses are
chiselled open
from
Nasal Ducts. the front.
On
the
right,
the
bones and sutures at the root of the nose are laid bare; on the left, the outer wall of the Nose has been removed, as far as necessary to expose the duct which leads from the Frontal Sinus to the Nasal Cavity. Mucous membrane is coloured pink.
The
above the root of the nose, they entend towards the forehead and over the orbital cavities from which they are separated by the thin roof of the Orbit. Their greatest depth is above the nose; externally they gradually become more flattened. Their size and shape vary enormously in different people. Their utmost limits are laterally the fronto-malar suture and Frontal Sinuses
superiorly half-way to the
lie directly
Summit
of the vertical portion of the frontal bone.
They
are separated from each other by a thin lamina of bone, which practically always
deviates from the middle
They
line.
are to be considered as ethmoidal cells which have been pushed
into the frontal bone,
in this
way, the external table and diploe lie in front, and This explains the strength of the anterior wall
the internal table behind them.
and
its
cula.
resistance to external violence.
Their inner siirface is irregular and may present recesses resembling They are, as their origin explains, lined by mucous membrane. They alwa3's communicate with the nasal cavity; the opening
communication
lies
diverti-
of this
invariably in the middle nasal meatus (infundibulum), into which
Highmore
opens (cf. Fig. 39). The Frontal Sinus may reach Ethmoidal turbinated bone and open by means of a simple slit, or the anterior ethmoidal cell may be very large and thus cause constriction of the lower part of the Sinus; in this case a Canal is formed: the
the
Antrum
of
as far as the anterior
end
also
of the
—
—
naso-frontal duct
These deviations explain why in others
—
or
even impossible
through the nose.
—
it
is
very easy
to introduce
in
some
cases,
and
difficult
a canula into the Frontal Sinus
—
Orbit and surronding Structures
Fig. 42.
Horizontal Section.
Front a frozen section which passes horizontally through the middle of the eye of a male body, 4^ years old, the brain is removed; middle Meningeal Artery and Gasserian Ganglion dissected. Mucous membrane of Nasal and Accessory
Tenon's Capsule and Periostenni blue.
Cavities, red.
Lachrymal apparatus
orange.
This section shews the conical shape of the orbital cavity which has also
been compared with a pyramid.
The
Planum
thin,
of the
of
the eyeball
The
orbit
ej'eball
Ethmoid
does not
is filled
lie
wards.
—
then inwards
It
in
chiefly
and separates the
formed by the Os
orbit
spread from them into the
from the accessory
The
orbit.
centre
the axis of the orbit, but slightly external to
(The Ciliary Ganglion
run.
—
easily
is
it.
with fat through which the muscles, vessels and nerves to the
shewn
is
in
Fig.
16.)
The Optic Nerve,
its
foramen as a round cord, runs forwards and out-
and
just before reaching the eyeball again slightly out-
flattened in the skull, leaves
wards
very
is
it
;
Pus may thus
nasal cavities.
inner wall
thus describes an S-shaped curve
(cf.
Fig. 44).
The connective tissue of the orbital fat forms near the eyeball a strong membrane Tenon's Capsule The eyeball moves in this membrane, as if
—
this
were a
eyeball
—
ball-
and
socket-joint.
and capsule, as the space
Tenon's Capsule ends behind
There
at the
is,
however, no free space between the
filled
is
points
sheaths
to
surround
aponeurosis of the muscles.
up by a
delicate scaffold-like tissue.
Optic Nerve, in front at the Fornix of the
the eye muscles pass through
conjunctiva:
these
.
slits
the muscles;
in the capsule,
these sheaths
Internal to the Inner Rectus,
a triangular cushion and thus blends with the fascia of
which sends blend
with
at
the
Tenon's Capsule forms
HORNER's
Muscle, the
lachrymal sac and the puncta lacrimalia
At
— is
that point
it
is
only indirectly
attached to the wall of the in relation
orbit.
At
—
through the internal
tarsal
ligament
the outer angle of the eye the Capsule
with the walls of the recess which lodges the lower portion of the
Lachrymal Gland and with the external attached to the bone.
tarsal
ligament by which means
it
becomes
Superior Lacrymal Canal
Meibomian Glands External Palpebral
Ligament
-^
Lacrymal Gland External Rectus Muscle Inferior Oblique
Muscle
Branch of Temporo- facial Nerve Lacrymal Artery ^rd Nerve Inferior Rectus
Muscle
Temporal Muscle
Waldf.ter's "Meningoorbital Foramen" 6th Nerve
3rd Nerve
Superior Maxillary Nerve
Middle ^Meningeal Artery
Gasserian Ganglion
Inferior Maxillary
Nerve
Superior Petrosal Artery
Superior Petrosal Sinus
—
Frontal
Car-
Superior
Ol-
Frontal
Oblique
factory
Superior Turbinat-
tilagc of
Nerve
Muscle
Bulb'
ed Bone
Septum
Bone
^Fiddle Turbinatcd
Bone
Optic "Serve
Ethmoidal Bulla
Lacrymal Gland.
—
External Rectus Aluscle
Inferior Oblique
Temporal Muscle
Tenon's Capsule
—
Muscle •
Inferior Rt-ctus
Muscle
Inferior Division of 3rd Nerve
Zygoma
Infra-orbital
Xcrvc Massetfir Muscle
Antrum Buccinator Muscle
Vomer
Tempor;iry
Maxilla
Fig. 43.
Orbital
Uncinate Process
Inferior
Turbinated Bone
Molar Tooth
and Nasal Cavities
in a Child.
Frontal Section,
Nat. Size.
Superior Rectus Muscle
Tf.nok's Capsule
Levator Palpebrae Muscle Frontal Nerve
\
Periorbita
Nasal Nerve Inferior Rectus
Orbicularis Oculi
Muscle
Muscle
Ophthalmic Artery
Orbital Septum Superior reflec-
Internal Carotid Ai
Dorsum
tion of Conjunctiva Ciliary Body
Sellae
Cavernous Sinus
—
Crystalline
Lens
Upper Eyelid Inferior
Oph-
(Tarsus)
thalmic Vein
Eyelashes
Sphenoidal Cells
Lower Eyelid
Internal Maxillary Arterj*
Inferior reflection of Conjunctiva
Spheno-Palatine Ganglion
Tenon's Capsule
Spheuo-occipital Inferior Oblique
Synchondrosis Basal Fibro-
Muscle
cartilage
Descending Pa-
Infra-orbital
latine jVrtery
Ner\*e
Pharj-ngeal Tonsil
Facial Vein
2nd Temporary Molar Tooth
Pig, 44.
Orbital Cavity
and surrounding Structures in the
Child.
Vertical Section through Axis
of Optic Nerve.
%
Rebman
Limited, London.
Nat. Size.
Eebman Company, New York.
Orbital and Nasal Cavities in a Child.
Fig. 43.
Frontal Section.
Portion of a frozen section through the head of a girl,
A
comparison with Fig.
i
how
shews,
1^/2
years
old.
different the accessory cavities of
Nose and Upper Jaw are in the child when compared with those in the adult. The Frontal Sinuses are formed at the end of the first year by ethmoidal cells growing into the diploe of the Frontal Bone. They attain the size of a pea at the 6th or 7th year; they are fully developed when the nose and frontal bone cease growing — about the 20th year The Antrum of Highmore is virtuall)' present before the middle of Intra-uterine life; in the newborn it appears as a bulging of the middle nasal meatus the upper jaw being almost completely filled with developing teeth. With the beginning of the 2nd dentition, it increases rapidl\' in size. The Infraorbital Nerve is still external to the Antrum in our figure. The Outer Rectus Muscles of the Eye were so contracted on both sides, in our body, that the posterior segment of the eyeball was markedly directed inwards: this explains why the Optic Nerve has been divided by this section. the
—
Orbital Cavity and surrounding Structures in the Child. Vertical Section through Axis of Optic Nerve.
Fig. 44.
From
.
a frozen section
through the head of a
Capsule, Periosteum,
child,
i^j,
years
old.
Tenon's
and Orbital Septum, blue.
This figure shews that the upper eyelid covers a greater portion of the The rima palpebrarum therefore lies, when the eyes are closed, below the middle of the cornea.
cornea than the lower.
The Orbital Septum (cf. figure) is a plate of connective-tissue which runs from the margin of the orbit, downwards behind the Orbicularis Palpebrarum, in the upper eyeUd, it blends with the anterior slip of the Levator Palpebrae Superioris Muscle and is separated from the tarsal plate by loose connective tissue. In the lower lid, it enters the subtarsal connective tissue. It is a structure of no particular value it is merely the Aponeurosis of the Orbicularis palpebrarum Muscle. This figure also shews the termination of Tenon's Capsule at the Conjunctiva. It splits into 2 layers, and blends with the Tunica Propria of the Con;
;
junctiva lining the eyeball and of the palpebral conjunctiva.
crossed
Very complicated is the arrangement of Tenon's Capsule, where it is by the Inferior Oblique. From the under surface of the capsular portion
—
—
tlie fascia of the Inferior Rectus a lamina "the Accessory Fascia" runs forwards under the Inferior Oblique, blends with its sheath, and terminates in the subtarsal connective tissue of the lower eyelid, where the capsule proper also ends.
of
Above again
lies
the
Pharyngeal Tonsil
lies
the basilar fibrocartilage, above this
the Spheno-Occipital Synchondrosis which
energetic scraping of adenoids.
may be
injured in the too-
Frontal Section through Posterior Part of Nasal Cavity.
Fig' 45'
Fig. 46. Frontal Section through Sphenoidal Sinuses and Nasal Cavity.
A
from a
section
and
was hardened,
skull
together witli
decalcified before further division into frontal
46 passed about
in Fig.
its soft
Antrum
In Fig. 45, the posterior part of the
HiGHMORE
of
The
left,
on the
whilst,
Ethmoidal Cells did not extend so far back. The posterior
right, the
and Nerves which
by
of
The numerous
this section.
the Ocular Muscles near them,
The Optic Nerve which has
left
Vessels
Cavernous Sinus, diverge and divide
close together in the
lie
groups; the origin
section.
the fact,
bj'
the most Posterior Ethmoidal Cell has, been cut by the section,
part of the orbit has also been divided
into
has been
great variations
shewn
in the sinuses accessory to the nasal cavity, are well
on the
that,
The section shewn
\(,th inch behind Fig. 45.
cut on both sides; the 3 turbinated bones are well shewn.
met with
parts, in formalin,
sections.
the skull-cavity,
Ophthalmic Artery through the Optic Foramen,
lies,
are in
shewn
in cross-
company with
the
enclosed by Dura Mater, to
the inner side of these structures.
In
shewn
Fig. 46 Fig.
in
4,5)
the Sphenoidal Sinuses are laid
They
open.
median septum and occupy the body as far
(cf.
Fig. 47) as the Sella in
which
inner wall of the Orbit
Greater
Wings
Sinus).
In
inflammation
of
suppuration, and have to be opened,
Sphenoid Bone.
(cf.
the Pituitary
lies
They form and may
Fig. 42)
Sphenoid Bone
of the
chronic
(cf.
openings
these
are
each other by a
They
Body;
often extend
in fact,
they ma}'
the most posterior part of
some cases extend
in
Fig. 16 Lateral
the nose,
nose
the
into
are separated from
of the
reach the Spheno-Occipital Synchondrosis. the
(their
Recess of
tlie
may become
into the
Sphenoidal
the seat of
because their natural narrow opening into
the nose affords insufficient drainage.
In most cases,
it
will
they are also accessible from in Cells from the Orbit
(cf.
The Optic Nerve the Cavernous Sinus
them
at
some
lie
distance,
is
to
open them from the Nasal Cavity;
front, after
having weU exposed the Ethmoidal
be possible
Fig. 42). is
cut as
close to
it
enters the Optic
each other
in
the 2nd division of the
Foramen. The Nerves from
the Sphenoidal Fissure;
Vth Cranial Nerve.
below
Oculomotor
Foramen
for 5th
Neire
Foramen
Optic Nerve
Posterior Ethmoidal Cells
Middle Cerebral Vein
IV. Nerve (Trochlear) (V,
i)
Lacrj-raal
Nerve
Frontal Nerve III. Nerve (Oculomotor) Superior Division (V, i) Nasal Nerve
Ophthalmic Artery
(V,
Sphenoidal Sinus
i)_
VI. Nerve (Abducens) III. Nerve (Oculomotor) Inferior Division
Nerve
Inferior Maxillary
Fig. 45.
Frontal Section through Posterior Paii: of Nasal Cavity. Nat. Size.
Optic Chiasma
rV. Nerve (Trochlear)^Superior Division of 3rd Nerve
Frontal Nerve
(V,
i)
III.
Nerve (Oculomotor)
(V, i) Nasal Nerve VI. Nerve (Abducens) (V,
2)
Superior Maxillar)' Nerve
Vidian Canal (Vidian Nerve)
Fig. 46.
Frontal Section through Sphenoidal Sinus and Nasal Cavity. Xat. Size.
Rebtnan Limited, London.
Eebman Company, New York.
Pituitary
III.
Body
Anterior Intercavernous Sinus
Xerve (Oculomotor) Internal Carotid Artery
IV. Nerve (Trochlear)
^lucous ^lerabranc Ophtfaalfnic Ner\'e (V,
blique section
i)
^-•. V
VI. Nerve (Abducens) Superior Maxillary Ner\'e (V, 2)
-
i>f(
Middle Cerebr;il Vein --phcnoidal Sinus
W^^f, Vidian Canal and Ner\'e
Fig. 47,
*
/
/
Frontal Section through Anterior Portion of Cavernous Sinus. Nat. Size.
Stalk of Pituitar>'
Body
(Oculomotor) (Trochlear)
Pharyngeal Tonsil
erve (Abducens)
Ophthalmic Nerve Cartilage of Eustachian
Tube
"^
yy'C/^ '^' 2)
Superior Maxillarj' Nerve
ilesial Cartilaginous
Swelling
Fig. 48. Frontal Section5through the Posterior Part of the Cavernous Sinus. N'at. Size.
Rebmaii Limited, London.
Rebman Company, New York.
Pig. 47. Frontal Section through Anterior Portion of Cavernous Sinus.
Frontal Section through Posterior Part of Cavernous Sinus.
Fig. 48.
Sections of the same series as those shewn in Fig. 4^ and 46. Section 4y passed o.j' incli beliind section 46, and 48 passed o.} inch behind 47.
On
either
complicated of
all
nal Carotid Artery,
with the
I
St
of
side
the
Sella Turcica
the sinuses formed by the
is
the Cavernous Sinus
Dura Mater.
It
the 3rd, 4th and 6th Cranial Nerves, and
division
of the
5th Nerve.
The Dura Mater
is
the most
contains the Interis in
at
close relation
some distance
from the bone, and thus forms with it a space which contains the structures mentioned amid numerous veins. These veins are partly plexiform in character. This sinus is, therefore, unlike the others, not a large venous channel, but a mass of freely anostomosing veins. Both cavernous sinuses are joined to one another by two transx'erse veins which pass respectivel}' in front of and behind the Pituitary Bod}'. Thus a venous ring", the Circular Sinus (or Sinus of Ridley) is formed. Primary thrombosis of the Cavernous Sinus is rare; thrombosis usually occurs secondar\- to the Lateral Sinus with which it communicates through the Superior Petrosal Sinus, or by the spreading of a thrombus along the Ophthalmic Vein. Empyaema of the Sphenoidal Sinus may also give rise to this thrombosis, as the intervening bone is very thin; this process is absolutely analagous with the thrombosis of the Lateral Sinus due to pus in the Mastoid Process. The anatomical relations explain why thrombosis of the Cavernous Sinus ma}' produce Neuralgia of the first division of 5th C. N., Paralysis of 3rd, 4th and 6th Nerves, and wh}' congestion or thrombosis of the Ophthalmic Vein can be followed by Oedema of the Eyelids, Retro-bulbar Oedema and Exophthalmos. Surgical treatment
for
thrombosis of the Cavernous Sinus has hitherto
success. The diseased sinus was reached by removing the petrous portion of the temporal bone, attacking it from the ear. It can also be got at by the channel made for the removal of the Gasserian Ganghon. Should the Internal Carotid Arter}' be injured where it lies in the Cavernous Sinus, with a sharp instrument entering the Orbit, or by a piece of bone
only once been
attempted
with
through a shot, or should the vessel burst .spontaneously (calcified an abnormal communication may be formed between the artery and the sinus (Aneurysm by Anastomosis), the consequence is a pulsating Exophthalmos which is a rather curious condition. A glance at the figures shews that dangerous haemorrhage may follow the tearing of the ist division of the 5th C. N. in the removal of the Gasserian Ganglion. Externall}' to this nerve lies a venous space, which was unequally developed on the two sides in our specimen. (fracture), or
arteries in old people),
<
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ti
E
Sterno-Cleido-Mastoid Muscle
V\is Vertebra (TI C)
Vagus Nerve
Vertebral Artery
Internal Jugular Vein
Parotid GUnil
Spinal Accessory Nerve
Temporal Vein
Hypoglossal Nerve Glossopharyngeal Nerve
Internal Carotid Artery
Digastric Muscle
External Carotid Artery
Pharyngeal Plexus of Veins
Internal Pterygoid
Muscle
Masseter Muscle
Styloglossus Muscle
Tonsil
Submaxillary Gland
M\lohyoid ^^uscle Inferior Dental Nerve'
Lingual Ner\e
Cavity of Mouth Sublingual Gland
Antrum Oris
Submaxillary Duct
Fig. 53.
Horizontal Section through the Seen from belosv.
Rebman
Limited, London.
—
Head
at the level of the Axis.
-L Nat. Size.
Rebman Company, New York.
:
Fig. 53- Horizontal Section through the
One of a
The
series
is
the Buccal Cavity have only been cut at their
adherent to the floor of the mouth.
glands (Sublingual, Submaxillary and Parotid) the
on the
inwards, and,
The
The
Tonsil
connected with the muscles deciding
in
tonsil,
tonsillotonnis
We
?
middle
it lies in a capsule which is closelv Very important are the parts around the
source
of the
when
be injured
may be
\ery near the tonsil and
ternal Carotid
:
haemorrhage
of furious
Of the
some
in
cases of Artery-
large vessels, the Internal Carotid lies ^5 inch away from the clumsy surgeon cuts \ery deeph'.
a particular!}-
the
at
level
of
It
injured (Merkel).
end of the
the lower
the Facial Arter}- which
is
This vessel arises from the Expasses between the muscles
tonsil,
coming from the Styloid Process, describes an S-shaped ference of the tonsil. Serious haemorrhage may also be
Venous
far
under cover of the lower jaw.
This statement also holds good for the External Carotid. lies
3 saiivarv
extends
have been wounded during the operation, only
could
It
the question
it
mentioned that the Tonsillar Branch of the Ascending Palatine
to
said
is
tonsil.
its
the Pharynx.
of
Of the
of interest because
is
section.
to cause serious haemoirhage.
far too small
which
this
below
divided
is
last
side of the figure, even forwards
left
Uvula was cut by
of the
tip
at the level of the Axis.
of frozen sections through the head.
Mouth and
Vestibule of the
lowest points, where the tongue
Head
and runs along the circum-
cur\'e clue
injurv of the Pharyngeal
t'.i
Plexus.
Externally
and behind the Tonsil the following
Internal Carotid Artery, Internal Jugular Vein, 9th, glossal Nerve,
all
lying in
one sheath which
structures are in close relation
nth. Crania! Nerves and Hypo-
loth,
attached above to the fibro-cartilage of the
is
posterior lacerated foramen.
The
Vertebral Artery
through the foramen
curving horizontally backwards figure lies its
—
comes
it
in the cranial
having
from the Subcla\ian runs upwards, passing
arisen
Then
the transverse processes of the upper 6 Cervical Vertebrae.
in
to lie
cavity
—
this
part of
course
its
under the Dura Mater which
on the side
of the bulb,
and
shewn on the
is it
pierces.
(Cf.
Fig.
running inwards
after
side of our
left
Il
15.) it
now
joins with
fellow to form the Basilar Artery.
General Remarks on the jugular
A
large
of the venous
share
blood
is
\'
e
n
i
carried from the
s.
Head and
the
Neck
to
the Heart by Veins which have a separate course and do not correspond exactly to any artery.
more
These veins are termed Jugular Veins. or less the Internal Jugular;
by the union
downwards (cf.
of
Temporal
The
the
Internal
The Facial Vein There may further be
and Facial Veins.
as the Anterior Jugular Vein.
Fig. 6") at the anterior
To
the Internal.
ma}'
also
formed
be continued
a Posterior Jugular Vein
border of the Trapezius Muscle.
relation of these veins to the Sterno-Cleido-Mastoid
ternal Jugular crosses the outer surface of the muscle which, with
is
Carotid corresponds
to the External Carotid, the External Jugular,
is its
Along the Anterior border runs the Anterior Jugular.
as follows:
the Ex-
inner surface, covers
The
Posterior Jugular
the least constant of these vessels. All these veins
end under cover
Channels open into the Venous System.
above the
clavicle
bv
a
of the Sternomastoid,
The
where the large L3'mphatic
Anterior Jugular Veins
transverse anastomotic branch.
comnnmicate
just
Position of Spinal Cord and Spinal Nerves in the Spinal
Fig' 54-
Canal.
The Skull and
Spinal Canal of a female child, a few months
tlie
from behind ;
been opened
Dura Mater
the
slit
and
open;
the
have
old,
ribs
ivith
the
transverse processes of the vertebrae dissected aid.
The at
spinal cord,
of muscles
cesses
Anteriorly,
which the cord
lies,
closed completely in
is
Vertebrae and the Intervertebral Discs; behind there
lies
The
spinal
is
front
by the bodies
of the
a space between the neural
arches through which a knife, dagger or other sharp instrument
Puncture)
it
the space between the vertebrae and the prominent spinous pro-
fills
the transverse section through neck, thorax and abdomen).
(cf.
canal, in
well protected.
from the surface of the body; behind, a very thick mass
distance
a great
whole, very
as a
is,
may
enter.
where the neural arches are
more frequenth'
(e.
g. for
Lumbar
These interlaminar spaces are widest in the cervical region furthest apart;
weapons
injured h\ sharp
why
explains
this in this
the spinal cord
is
region than in any other part_
In the upper dorsal region, the neural arches overlap each other and thus almost In the lumbar region the arches are very broad
close the spinal canal posteriorly.
and thus afford protection
The
close
relation
to the cord.
cord to the column accounts for the frequent
of the
Column.
injury to the C'oril in fractures of the Spinal
and occur
indirect,
fixed ]3ortion;
Lumbar
i.
e.
chiefl}'
at the 5th
and 6th Cervical and
formed by
not
fat,
spinal fluid
and
ist
:
As emerges.
cord to follow the movements of the
friction against the bone.
usually taken,
is
The cord shews two
nerves to the extremities leave transverse than
Lumbar
is
in
slender,
i.
ending
Lumbar
cord,
the upper border of the posterior
the point where the
The
it.
first
Cervical
Nerve
the regions where the
fusiform enlargements in
direction of these enlargements
The upper
the antero-posterior diameter.
in
Vertebra.
at the
nth Dorsal Vertebra.
the Conus Terminalis which
A
is
more
or Cervical
31 pairs of Spinal
vertebral Foramina,
ensheathed
downwards
The cord then becomes
lies
filiform continuation of the
the Filum Terminate, runs vertically
The
e.
most marked between the 5th and 6th Cervical Vertebrae, the lower
most marked
is
between the bone and the meninges.
these arrangements allow the
the upper limit of the spinal
enlargement
lie
the Arachnoid Sac filled with cerebro-
arch of the Atlas,
or 2nd
12th Dorsal
lies
Column, without
more
the
more
on the wall of the Spinal canal; a cushion,
lie
and a large venous plexus
Between the Dura Mater and the Cord
or
at
joins a
\^ertebrae.
The Dura Mater does
in the
These fractures are usually
where a comparatively movable portion
at the level of the
Conus Terminalis,
to the periosteum of the
ist
called
Coccyx.
Nerves leave the Spinal Canal through the Subin
processes of
Dura Mater.
This explains wh}'
ri..^i-J(Hia«m..
Fig. 54-.
Position of Spinal Cord in the Vertebral Canal. Natural
Kriiiodii
I.iiniiril.
I^niliiii
Sizt:
Ilcbmnn
Cninpiinj'.
New
Ytiit
:
..
(Continuation of the text of Fig.
54.)
As
our figure, the nerves appear thicker outside than inside the dorsal sac.
in tlie
2nd Lumbar V^ertebra, the course of the spinal
spinal cord ends at the ist or
Nerves inside the canal becomes longer the lower
Thus
their origin.
the
Cervical Nerve runs horizontally outwards, the course of the next nerve
They form with
Filum Terminale.
Terminalis, the so-called
The
this
mentioned structure and the Conus
last
Cauda Equina. Injury below the second Lumbar Vertebra, by
spinal nerves arise
As
root-fibres.
anterior; an exception
—
our figure
in
more
invohes the Cauda Equina, not the spinal cord.
therefore, onl}'
the cord as
is
run almost vertically downwards, parallel to the
the lowest nerves
oblique etc;
first
roots, anterior
2
the
rule,
in
root-fibres
posterior
and posterior
posterior
however, found
is,
Its
.
a
are
roots
;
these roots leave
—
Cervical Nerve
the
ist
are
\ery
than
thicker
they
slender;
as
the
shewn
may even
be absent.
On
every posterior root
bral foramen;
the
a spinal ganglion,
is
and anterior roots
posterior
which
lies
foramen
tlie
transverse process of the Atlas and running horizontallv inwards. the
Dura Mater and
further in
down
in
than
a blind sac
(cf.
Fig. 55).
These
This fact
is
taken advantage of
Sacrum are removed,
removing portions
in
ist
the 5th Sacral Nerve the
The
Below there
fatal.
in
is
ends
in
injur}-
or
It
be followed by
no danger of Meningitis.
operations (Kraske's) in which portions of
order to expose pelvic organs.
and 2nd piece
of
the
Of
course,
when
The Coccygeal Nerve which
Coccyx forms with a branch
Cocc}-geal Plexus which
of
innervates the Skin over the
4th and 5th Sacral Nerves enter into the formation of the Sacral
the former supplying
important than the floor of
figure).
of this bone, temporarily or permanently, one has to consider
emerges between the
Plexus,
(cf.
dural sac and ma}-
the
the important nerves which should not be damaged.
Coccyx.
2nd Sacral Vertebra
levels are of great importance, because
necessarih' open
purulent Meningitis which in usually
the
to the level of the
the adult, and to the 3rd Sacral Vertebra in the child
operation above will
in the
then pierces
It
The Dura Mater does not extend
enters the cranial cavity.
the Spinal Canal
the interverte-
Just above the ist
join outside.
Nerve our figure shews the Vertebral Artery leaving
Cervical
in
the Pelvis.
latter.
the Levator
Damage
Twigs from
it
to
Ani and Cocc\'geus Muscles
the Sacral Plexus
also
go
to
is
means damage
the Bladder and
Rectum.
more to the
The
higher up one goes, the more important are the nerves for the innervation of the pelvic muscles, pehic organs, and lower limbs (Great Sciatic Nerve).
Lower End
^^g- 55-
of Spinal
Canal in the Adult.
A
Figure combined after a specimen from a man of i8, and several skeletons. On the rigid, bones only, on the left, ligaments and nerves have been drawn diagrammatical ly.
The anatomical one off
—
to increase
some
make
relations
needle from behind, between
2
it
possible to introduce a trocar or a hollow
neural arches,
into the dorsal sac,
thus enabling
and to draw and microscopical examination. This operation has become of vast importance for diagnostic purposes
the pressure
of the cerebrospinal fluid in
the sac,
of the fluid for chemical
lumbar puncture
—
in recent years.
Not the spinal
onl\^
does
cord, .but
it
yield information as to the condition of the fluid around
also
as to
the intra-ventricular pressure, the pathological
changes and the presence of bacteria in the cerebral fluid, because these fluids communicate through the Foramen of Magendie at the floor of the 4th Ventricle. The lowest portion of the dural sac is selected for lumbar puncture, because the needle cannot, at that point, injure the spinal cord; it meets the Cauda Equina which gets pushed out of the way. The needle should be introduced below the 3rd or 4th Lumbar Vertebra. The vertebra may be found by counting the spinous processes downwards from the 7th Cervical Vertebra, or by counting downwards from the attachment of the 12th rib. far more simple method (cf. figure) — consists in drawing a line connecting the highest points of the Iliac Crests. This line crosses the middle of the 4th Lumbar Vertebra. Slightl}' above it, therefore, is the spinous process of the 3rd. In children, the needle may be introduced exactlj' in the middle line at the lower border of the spinous process; in adults, it should be introduced Vs'hs inch outside the middle line, because the strong median ligaments offer considerable resistance. If one follows the usual rule, introducing the needle at the level of the lower border of the spinous process and then pushing it forwards, upwards, and inwards, one may come on to bone, especially when the spinous process is short,
A
—
(this
was
the case in our specimen).
horizontally inwards.
at
It is infinitely
better to introduce the needle
.
In the figure, "Point for Lumbar Puncture"' indicates the spot on the skin, which the needle should be introduced and then pushed inwards. In children the needle has to enter about one inch, in adults 1Y5 to
2^/5 inches.
This figure also shews the Dural Cul-de-sac at the 2nd Sacral Vertebra.
The importance
of this level has been discussed in Fig. 54, Text.
th
Fig. 55.
Lower End
Thoracic Vertebra
of Spinal Canal in the Adult. Nat. 8ize.
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Limited, Londou.
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Region
of
Fig. 58.
Region
of the Neck,
JP'ig'
the Neck, from in front.
The Neck, which extends from clavicle,
and from the external
may be
divided into
2
The
Lateral regions.
the lower border of the lower jaw to the
occipital protuberance to the
regions,
3
i
paired and
The
anterior
Sterno-Cleido-
2
down
as far
region extends from the lower jaw to the upper
may be
This region
subdivided into Submaxillary, Hyoid,
Sub-hyoid (between the hyoid bone and the upper border of the thyreoid Tracheal
Laryngeal,
lage),
(which
the
jaw.
Omohyoid and Sterno-mastoid Muscles forms
into
a Digastric
and a Carotid A-
a
carti-
into
Thyreoid
The area between
the lower
A.
N.
B.
and Suprasternal) regions and Suprasternal notch.
A
as
Cervical Vertebra (Vertebra Prominens).
7 th
cervical
border of the Sternum.
between the
lies
by the Trapezius,
the posterior corresponds to the area covered the spinous process of the
th Cervical Vertebra,
between these muscles and the Trapezius;
regions,
lateral
7
unpaired: Anterior, Posterior and
2
Neck
anterior region of the
Mastoid Muscles; the
from the Side.
subdivided
A
which may be subdivided
(The small space between the ramus of
the lower jaw and the origin of Sterno-Mastoid Muscle belongs to the head.)
Anatomists' opinions differ as to whether the broad Sterno-Mastoid should
be regarded as a boundary
line or as a special (Sterno-Cleido-Mastoid) region.
any case the parts described it
(vide
may be
is
a
fossa (Fossa supraclavicularis minor).
little
the lateral (Inferior
region a
cervical
A
the neck).
of
Clavicle, Sterno-Mastoid
A
is
(in
The boundaries
and Omohyoid Muscles.
some cases touching
of
muscle this
lie
deep
to
muscle there
cut off b}' the inferior belly of
very broad, or present as Sterno-Cleido-Mastoid,
forwards
this
Between the Sternal and Clavicular heads
Omohyoid
by the
bounded by
infra).
From the
in the regions
In
if
of this
When
A
are formed
the Sterno-Mastoid
the Trapezius extends far
the Sterno-Cleido-Mastoid), then this
A
will
be
very small or even absent. This
A
by pressing the
is
made
larger
Clavicle (arm)
A portion
—
e.
g. for ligaturing the
downward and
of the posterior Cervical
(if
Subclavian Artery
necessary), cutting the
—
Omohyoid.
Region may be termed, Regio-Nuchae.
,
Hijoid
"^ubmaxiUant/Ji egion
Jrianplej^
\
"1 Superior „ " \
,
:\
\
i
;
\\pfNeck
Carotid i ¥ Triangle fMryngeat\ Reffion / / ^ j
r
Tj'npc'iu.s
;'
.'
Irxangle
\
vt
::?^
'
Ligamentiim Nuchac
Spinous Proct-ss of 4th \'ertebra
Trapezius Muscle
sith
Vertebra L\nipliatic
Node
Middle and Posterior Scalene Muscles Cervical Neire (Vertebral Artery*
5tli
Spinal Accessory Xerve
.^-
^[JL_ Internal Jugular Vein
Anterior Scalene Muscle External Jugular Vein Symp.'ithetic ("hain ^
Sterno-Cleido-Mastoid
oinnion Carotid Artery
Aluscle Inferior Constrictor of
Vagus Xerve
Pharvnx
^
Thyreoid Gland
Pharynx
/
^^.
Sinus Pvriforniis
Omohyoid Muscle Stcrnothyreoid Muscle
Arytenoid Cartilage
Sternohyoid Muscle
Platysma
Fig. 59.
Vocal Cord
Anterior Jugular Vrin Thyreoid Cartilage
Transverse Section thi-ough the Neck at the level of the Fifth Cervical Vertebra. Seen from below.
Rebman
Limited, Loudon.
—
^4 Nat. Size.
Rebmau Company, New York.
Transverse Section through the Neck at the level of the
Pig. 59.
Fifth Cervical Vertebra.
Frozen Section. This figure shews that
all
the important structures, Large Vessels, Nerves,
Thyreoid Gland, Food and Respiratory passages are
anterior part of the neck whereas the largest spaces, external
front
can,
position
Vocal
the
between
Cords;
extent between
certain
are joined b\'
cartilages
and below
this
muscle
made
Glottis
In
upon
front
it,
is
lies
of the
to
a
These
Pharynx which presents here
the lowest portion of the
These recesses extend forward In
Vertebral
a
Column and
slit,
the
commencing
taken as
at
when empty. Longus Colli Muscle which
This fascia
the strong" Prevertebral Fascia.
some
for
the Pharjmx,
cross-section,
usually
is
the 5th Cervical Vertebra, appear as a transverse
lies
backwards
continued
is
behind
the Oesophagus, which
continuation,
Its
the Aryteno-Arytenoideus Muscle; immediately
distance under cover of the thyreoid cartilage. its
Adami.
the vocal processes of the Arytenoid Cartilages.
the Recessus Pyriformis on either side.
and
to the
This section passes exactly through
out.
the
these
and posterior
Pomum
Larynx with the Subcutaneous
the
lies
therefore, easily be
the
in
by powerful muscles.
vertebral column, are almost completely occupied
In
apposition
close
in
is
separated from the
muscles of the Pharynx and Oesophagus by loose connective tissue
meshes
in the
of which Retropharyngeal Abscesses readily spread downwards.
External to the lar\'nx
is
shewn
the apex of the lateral lobe of the
Thyreoid Gland with the large Superior Thyreoid Artery which has just entered the substance of the gland.
The Thyreoid Gland
Artery, which at the point of section
Mastoid Muscle
what
posterior
than the
left,
Fig. 60, text).
(cf.
lies
cf.
is
15, text.
covered completely
b}'
(the
right
Trunk
Common
is
in
Explanation of Lateral Sinus).
apposition with
in
usually larger
The
Cervical
Sym-
the posterior part of the inner wall of the
the transverse process has been cut in such a
does not appear as a closed ring.
Comites.
is
Between the Artery
Carotid Artery.
The foramen it
Carotid
the Sterno-Cleido-
vein
and Vein and somewhat posterior runs the Vagus Nerve. pathetic
Common
on the
External to the Carotid Artery, and some-
the Internal Jugular Vein
Fig.
lies
The 3rd
In
it
run the Vertebral Artery and
Cervical Nerve which has just
appears very thick, owing to the obliquity of
Between the posterior border border of the Trapezius,
lie
its
left its
intervertebral
way its
that
Venae
Foramen
section.
of the Sterno-Cleido-Mastoid
and the Anterior
the superficial cervical lymphatic glands.
Anterior Aspect of the Neck, Superficial Layer. Adult.
Fig. 60.
The Head
strongly
is
Plaiysma and part of the superright Sterno- Mastoid Muscle have been removed. backwards.
inclined
fascia covering the
ficial cervical
The right Sterno- Mastoid Muscle has therefore dropped backwards.
Under
the skin
the middle line
reaches
Deep
cervical region. is
important because
When
the
fascia
is
it
the Platysma, which, converging from both sides, only
lies
the chin;
at
to
pulls the Sterno-Mastoid
—
divided,
as
necessar}'
They
muscles drop backwards and outwards.
when level,
their
in
therefore does not cover the
natural position,
anterior
the superficial layer of the cervical fascia which
is
it
it
Muscles towards the Middle purposes
dissecting
for
cover, as
is
—
line,
these
well seen, in Fig. 59.
the large vessels of the neck at a
much
higher
than after division of the fascia.
The Anterior Jugular end below
in
communication
This
Veins.
Muscles.
some
In
anastomosing above with the Facial Vein,
Veins,
arch which connects the
the jugular venous
passes
usually
cases, the Anterior
behind
the
2
External Jugular
Sterno-Cleido-Mastoid
Jugular Veins terminate by joining one of
the Jugular Veins.
The next
layer
comprises
the
Muscles;
Infrahyoid
converging above, the Sterno-Thyreoid, converging below. line a
space
is
formed which
broadest
is
Bone and Sternum. The deep in this space.
When
('Yo
Sterno- Hyoid
the
Thus, in the middle
inch) at the mid-point
between the Hyoid
cervical fascia envelopes these muscles
this fascia is divided, the
and covers
muscles mentioned sink downwards
and outwards, thus exposing Larynx, Isthmus of Thyreoid Gland and Trachea. In the Submaxillary
converge towards the chin
median raphe are
which
is
not
visible;
;
anterior bellies of the Digastric Muscles
between these the ^tylo-H^oid Muscles and
Hyoid Bone
varies;
it
is
of
the
beUy
arises partly
intermediate
the
either
bound down
continuation of the Fascia of the muscle which anterior
their
our figure shews a lymphatic gland in this region,
The attachment
uncommon.
Digastric to the
Region the
is
Tendon
b\-
of
fixed to the hyoid bone,
from the hyoid bone, either
in
the
an aponeurotic or
a tendinous or in
a muscular origin.
The
distance between the intermediate tendon and the hyoid bone also
varies; thus the distance
is
much
greater in this figure than in Fig. 63.
Bursae are met with occasionally over the
Pomum Adami
between the Th3'reoid Cartilage and the Hyoid Bone.
and the space
Digastric Muscle
Iv.iplie (tf
Mvlohyoid
Farial Vein
Subinaxill.try
(Hand
Styloliyoid ^[iiscle
Hypoglossal Nerve Spinal Accessory Nerve
External Carotid Artery
Thyreohyoid iluscle
Thyreoid Gland
Omohyoid Muscle Sternohyoid ^Muscle Sternothyreoid
Muse
Stcrno-Clcido-Mastoid Muscle
-^^^•3-,X
Fig. 60.
Anterior Aspect of the Neck, Superficial Layer. 7,,
Heliman
Limiteil,
Lnmlnii.
Adult.
Nat. Size.
Rchman
Cnnii>.'iny,
Now
York.
Digastric Muscle
Geniohyoid Muscle /
Genioglossus Muscle
stylohyoid Muscle
Ncr\e
to
Submaxillary Duct
Mylohyoid Muscle
/
Sublingual Artery
Subment.-il Arterv
Sublingual Gland Facial Vein
Lingual NerveStyloglossus Muscle
Submaxillar)'
Ganglion
Hyoglossus Muscle Hypogloss;il Xcrve Lingit.'il
Artery
filosso- Pharyngeal
Xeric
Ascending Palatine Artery
Tlivreohvoirt
Muscle
Internal
Jugular Vein Spinal Accessory Xerve
Superior Laryngeal Nerve
Stemo-MaThyreoid Cartilage
stoid Artery
Common
Stcr no -Thyreoid Muscle
Facial Vein
Omohyoid Thyreoid Gland
Muscle ExtJug.Veia Ster no -Thyreoid Muscle
Cricoid Cartilage Inferior Tliyreoid Artery
Ansa Hypo-
ScaleniisMe-
glossi
dius Muscle
Spinal Accessory
Common Ca-
N.
rotid
Artery
Vagus Nerve Levator Scapulae Muscle ft-
\
Trapezius
Pectoral is
Major Muscle Phrenic Xerve
Thoracic Duet ^tipraclavicular
Nerve
Oesophagus
'
Suprascapular Artery Superficial Cervical Artery
Recurrent Nerve
'
Inferior Thyreoid Vein
Anterior Scalene Muscle ^
Right Lymphatic Duct Recurrent
Sternohyoid Muscle
Fig. 61.
Trachea
Sterno -Mastoid Muscle
X^er%*e
Connecting Jugular Vein
Anterior Aspect of the Neck, Deep Layer.
Adult.
7i Nat. Size.
Rebmaii Limited, London.
Rebman Comp.any, New York.
Anterior Aspect of the Neck, Deep Layer.
Fig. 6i.
Position of the head as in last figure.
T/ie Superficial
Veins are
Adult.
as stumps.,
left
both Sterno-Cleido- Mastoid Muscles are cut off near their attachments ; on the left side, Stemo-Hyoid, Sterno-Thyreoid and tipper belly of Omo-Hyoid Muscles
Both Submaxillaj-y Glands have been taken aivay : removal and Mylo-Hyoid Muscles has given a good exposure of the fioor of the month from below.
have been removed. of
the
right Digastric Stylo-Hyoid
The Common
Carotid Artery enters the neck behind the Sterno-clavicular
articulation, externally to first,
it
Trachea and Oesophagus.
Slightl}' inclined
outwards
soon runs vertically upwards, without giving off an}' branches.
At
at
the
upper border of the Thyreoid Cartilage, it divides into External and Internal Carotid (just below the bifurcation, is the most suitable spot for ligaturing the Common Carotid, because it lies superficially here being covered onty by skin, Plat3'sma and Superficial Cervical Fascia). When the fascia is incised, the Sterno-Cleido-Mastoid Muscle drops backwards. External to the Artery lies level of the
the Internal Jugular Vein, which, It
when
filled,
covers the outer aspect of the Artery.
receives the Superior Thyreoid Vein and, above the bifurcation of the Carotid,
the Facial Vein fascial
;
the Carotid Artery and Jugular Vein are enclosed in a
sheath (Carotid sheath);
they
common
are crossed by the Omo-Hj'oid which runs
downwards and outwards. In front of them lies the Descendens Hypoglossi. Between the Artery and ^^ein, somewhat posteriorly above, but more anteriorly below runs the Vagus Nerve. External to the Jugular Vein, the Phrenic Nerve descends on the Scalenus Anticus Muscle.
The
size
of the
Thyreoid Gland varies
frequency of Goitre in certain on the trachea, covering the higher up or lower
down
(cf.
districts. 2ncl,
considerabl}'
The isthmus connecting
3rd and 4th rings.
Fig. 62).
according to the
It often
It
the
2
lobes lies
may, however, extend
gives off a process upwards, the
Pyramidal Lobe (Pyramid of Lalouette) this lobe, as shewn in our figure, may The also arise from one of the lateral lobes it often runs to the Hj'oid bone. isthmus, being fixed to the trachea by connective tissue, follows the movements of that organ. This is of importance in the diagnosis of tumours of the Neck. The lateral lobes are covered by the Sterno-Hyoid, Sterno-Th3'^reoid and OmoHyoid Muscles. Their size varies markedly. They receive blood from the Superior Thyreoid Artery a branch of the External Carotid and from the Inferior Thyreoid Artery, which arises from the Subclavian and runs upwards behind the Common ;
;
Carotid.
The Larynx is subcutaneous, the Trachea mencement but runs to a deeper level the nearer
under the skin at its comapproaches the Thorax. In front of its upper portion is the Thyreoid Gland; lower down, fatty tissue; at this point the Thymus is just visible above the sternum in children. lies it
;
Front View
Fig. 62.
of the
Neck, Deep Layer.
Child.
Child a few months old; head inclined backwards. On the left side, the superficial structures are displayed after removal of the Platysma; on the right side, The Sternum the Sterno-Cleido-Mastoid has been cut off near its attachment.
has been removed between the middle of the Manubrium and the base of the Xiphoid, and with it the 2nd, p'd, 4th, ^th, 6th Costal Cartilages.
The
difference in this part between the adult and the child,
chief
Thymus which
large in the
is
latter.
This gland continues
the 2nd year, then degenerates or remains stationary
disappears rapidly;
it
alwaj's masses
even 2
in
the
of
its
Thymus
is ;
in relation
between
and the lungs find relation
At
of
the
its
their
Arch
till
puberty.
After puberty,
.
The shape
of the
gland varies much.
longitudinally placed lobes which are pointed above.
the Sternum
the
lobes undergo fatty degeneration; there are, however,
are: the level of the 3rd rib,
the
is
development
containing a few remains of this glandular tissue present
fat
adult.
till
its
of
The
There are usually limits of the
gland
Below covered by
and the lower border of the Thyreoid Gland.
with the Pericardium,
its
middle portion
is
outer portion and the thoracic wall, the pleural cavity
way.
Above
the pericardium, this gland
the Aorta, Superior
is
an anterior
Vena Cava and Innominate
Veins.
on the Trachea, being separated from the skin by Sterno-Hyoid and Sterno-Thyreoid Muscles; at this point it becomes an internal relation to the Innominate Artery, Carotid Artery and Internal Jugular Vein. This figure also shews some of the Lymphatic glands of the Neck and Thorax. The chief lymphatic channel, the Thoracic Duct, commences in the abdomen, usually opposite the ist Lumbar Vertebra (Receptaculum Chyli, cf. Fig. 141). It runs vertically upwards on the right of the Aorta, passing through the Diaphragm, and lying in the Thorax between the Aorta and Great Azygos Vein. Opposite the body of the 7th Cervical Vertebra it arches over the left Subclavian Artery and opens into the left Subclavian Vein (cf. Fig. 67). The corresponding structure on the right is the short right Lymphatic Duct which opens into the right Subclavian Vein. The great lymphatic channel on the right side is formed by the junction of the Bronchial, Mediastinal, Jugular and Subclavian Lymphatics; on the left, the Thoracic Duct receives the left Jugular and Subclavian Lymphatics which carry the lymph from the head and upper extremity. These last mentioned channels may open separately into the veins. Between the 2 bellies of the Digastric the Submental Glands are shewn on the Submaxillary Gland, the Submaxillary Lymphatic Glands are visible; at a lower level on the Internal Jugular Vein the Superficial Cervical Glands are seen (more about this group in Fig. 63, text). On the left side, some of the Inferior Deep Cervical Glands (cf. Fig. 115, text), and finally the Sternal Glands are shewn. These lie near the Internal Mammary Artery and its Venae Comites but are not found in all the interspaces. Their efferent vessels go to the mediastinal glands, to the great lymphatic ducts and to the lymphatics of the neck (cf. Fig. 115). a
still
higher
level,
it
lies
Facial Vein
iVinporal Vein
Ilypiiglossal
Submaxiliary
Digastric Muscle
Xcrvc
Hyuid Bone
Facial Vein Spin.il
1 liyrcoid Cartilage
Accessorv Nerve
An
(or
fllaiul
Loop)
Hypoglossi External Jugular Vein
Isthmus of Thyreoid
Gland
Sterno-Cleido^lastoid Muscle
Internal Jugular
Vein Ris-ht
Lymphatic Duct Communication between Jugular Veins '
Internal
Mammary. Vessels
Triangularis Sterni Muscle
Fig. 62.
Front view of Neck, Deep Layer. Nat.
Rebmau
Limitod, Lomlo
Child.
iSize.
Rebmaii Company,
New
York.
Subm.ixillary Salivary FiK-ial
Hyoglossus Muscle
Artery
Gland \
Uigastiic MuscKI
T-ingual Sii|)ramaiiilibiil;ir
Xcrvc
Artcrv
Parotid Gland
(in-at Atiricular X^
Npinal Accessory
Nerve
Internal Carotid
Artery
Descending Branch nf H}-pogloss;il Nerve
Superficial Cervical
Xerve
Platysnia Miiscl
Sterno-Clcido-Mastoid Muscle
D
Fig. 63.
Upper Triangle
r.
of
F roh se
^j^^^-^^':^'^-
Neck: Lymphatics.
Nat. Size.
Rebman
Limited, London.
Rebnijin Coni|i;iuy,
New
York.
Upper Triangle
Fig. 63.
of
Neck: Lymphatics.
The Platysma is almost completely removed. The Cervico- Facial and Cervical Nerves are cut short. The lymphatic glands have been drawn accurately from the specimen (an old man), the lymphatic vessels with the aid of Stahr's investiga tions.
Recent investigations have shewn the lymphatic
glands
in
other parts of the body
that the
number and the
the submaxillary region do not vary as
position of
much
as in the
Axilla and Groin).
There are usually only 3 glands, which we call anterior, middle and posterior. They aU lie above the submaxillary gland. The anterior is usually the smallest and lies next to the Submental Vein on the Mylo-Hyoid Muscle; the middle is nearer the border of the jaw and usually touches the Facial Artery the posterior lies near the Facial Vein, either (e.
g.
:
immediately behind
A
it,
or nearer the angle of the jaw.
between the anterior bellies of the Digastric but one can make out a superior set (small glands, the upper submental glands) and an inferior set (the lower submental glands) often consisting of only one large gland (cf. Fig. 62). The efferent vessels from the upper submental set go partly to the lower Muscles.
second group of glands
Their number
partly
set,
to
is
the anterior
less
lies
constant;
submaxillary gland.
travels to the Anterior Submaxillary
F^rom the lower set the lymph
Gland and partly
to the deep Cervical Glands. arrangement for the submaxillary lymphatics is as follows: lymph goes from the anterior gland to the middle, thence to the posterior. Only in a few cases, does it go directlj- to the deep cervical glands. Of the efferent vessels from the posterior submaxillary gland, our figure shews the superficial channels running to the cervical glands, but also one vessel going to an Inferior
The
typical
Parotid Gland.
A
portion of the superior deep cervical glands along the Internal Jugular Vein and the Carotid Artery is shewn in the figure. They receive lymph from the Submental, Submaxillary, Lingual and Parotldean Glands, i. e. indirectly from the whole Face, from the SkuU Cavity, Larynx, Pharynx and Thyreoid Gland; this explains why they become enlarged so very frequently in disease. The lymphatics of the lips (cf. Fig. 115) are important, in consideration of
the frequent occurrence of epithelioma.
We
need
to disting-uish
lymphatics of the skin, and the lymphatics of the mucous membrane.
between the
The
vessels
—
from the mucous membrane of the lower lip (2 3 inches) usually go to the middle submaxillary gland, into which the vessels from the upper lip (i to Inches) frequently open, the latter may also pass to the posterior sub2 maxillary gland.
The subcutaneous lymphatics vary more middle
line
to
a greater extent
widely; these entered beyond the
than the submucous vessels
(2
—4
subcutaneous
go from the lower lip to the submental glands). The lymphatics of the upper usually go to the middle submaxillary gland; in a few cases to an Inferior
vessels lip
parotid gland or even to a superficial cervical gland on the Sterno-Mastoid. As epithelioma of the lip usually starts at the junction of the skin and mucous membrane, and as the
opposite side
lymphatic areae meet here, aU glands and also those of the
demand
consideration.
Fig. 64.
Situation for Ligature of the Lingual Artery.
and
the
Lvmpliatic Glands, small Nen
and
The Subma:\illa>y Region
and
appears
A
position.
to
surrounding parts Fasciae.
are exposed by remo7'al of Platvsina, The Subina.xillarv Gland has been Ihroivn upwards
of 2 portions, because the Facial Arterv holds the deep portion in has been taken out of the Facial Vein : this enables one to throw the gland Specimen from a man easily, and gij'es a belter view 0/ the deep structures. be composed
piece
upwards more
aged
40.
The Lingual Artery soon disappears, after its origin from the External Carotid, under cover of the Hyoglossus Muscle and runs forwards parallel with the hyoid bone accompanied by two Venae Comites. The course of the Hypoglossal Nerve is similar; the nerve being, however, at a higher level and superficial to the Hyoglossus Muscle. The Sublingual Vein accompanies the nerve. This nerve forms a small A together with In this the border of the Mylo-Hyoid Muscle and the posterior belly of the Digastric. A, the Lingual Artery can be tied, after division or separation of the fibres of the Hyoshewn in our figure. Another point is suitable for ligaturing this artery, which is so frequently tied in operations for removal of the tongue. The vessel may be ligatured in its course between the External Carotid Artery and the border of the Hyoglossus Muscle below the posterior belh' of the Digastric. The place first mentioned is more superficial and more accessible, and would be preferable, if the artery had not given off its main liranches as is freglossus Muscle, as
quently the case.
—
—
behind the submaxillary gland, in a tortuous course The Facial Artery runs emerging between the gland and the border of the lower jaw (cf. Fig. 63) and extending on to the face along the anterior border of the Masseter. The artery is frequentl}embedded in the gland and ensheathed by the fascia of the gland. This accounts for the fact, that in removing the subma.xillary gland, the Facial Artery is so often damaged. The Facial Vein passes in front of the gland. The Common Carotid Artery bifurcates into Internal and External at the level On it rests the De.scendens Hypoglossi of the upper border of the Thyreoid Cartilage. 13ehind the External Carotid, the Superior Laryngeal Nerve (from the Vagus) Nerve. emerges this nerve divides into an outer and an inner branch, the former to supply ,
;
the Cricothvreoid Muscle, the latter sensation inside the larvnx.
Fig- ^5-
Tlie
Laryngeal Region
in
the middle line betiveen
a
Larynx opened from
man
a
and the Laryiix slit open in upper border of the cricoid cartilage, (This halves of the thyreoid cartilage keeps the larynx open. (aged jS^
has
the thyreohyoid ligament
wedge placed between
the
2
in front.
been exposed,
and
the
has not been drawn in the figure.)
This figure shews the aspect seen in Laryngo-fissure or Laryngotomy, an operation which is performed for the removal of Laryngeal Tumours, when the neoplasm cannot be extirpated by the transbuccal endolaryngeal method. The middle of the laryngeal region is not covered by muscles. Under the skin, Immediately, under is seen the cervical fascia in its intimate connection with the larynx. the fascia, is the Thyreoid Cartilage. In some cases, there may be a bursa over it. The Anterior Jugular Vein is sometimes very large. There are no other important structures within the area of operation.
This figure also
shews that High Tracheotoni}-
is
only
position of the thyreoid gland, after the Isthmus of the Thyreoid
or pushed downwards.
possible, owing to the Gland has been divided
Facial Artery
Masseter Muscle Stylwbyoid Muscle i'lrnti.l S:ilivarv
|
Submaxillary Salivary Glaiul Hyoglossus Sluscle
Mylohyoid Muscle
Gland
Digastric Muscle
Lingual Artery
Hyuid Bone
Oimdiyoid Muscle
Temporal Vein
j"
I
H\-poglossal Nerve External Carotid Artery
"
l^^^^eohyoid Muscle p Superior Thyreoliyoid Artery Superior Laryngeal Nerve
Situation for Ligature of Lingual Artery.
Fig, 64.
Anterior Jugular Vein
Nat. Size.
Sternohyoid Muscle
Platvsma M^uscle
Thyreoid
Membrane
Ventricle of Laiy-nx
tMoitOAGNl)
Vocal Cord
\
'^(^
% Cricoid Cartilage
'f-
Inferior
Thyreoid Vein
"
Fig. 65.
Rebman
Limited, Loudou.
Larynx opened from
in front.
—
J r*^ Fr'ah
s'c'
Nat. Size.
Eebman Company, New York.
.
Internal Carotid Occipital Artery
Artery
Tiirutid Cilaiid
Va^jiis
Ncnc Posterior Belly of Digastric Musclr
Spinal Accessory Nerve
'[Vmimral Vein
f
Glosso-Pliaryngcal Xitv
m'at Auricular Kt
i
Steroo-Clcidn-
Mastnid Muscle Vacial Artery
Hypoglossal Nerve
Mandibular Branch Facial Ncr\'e
Masseter Muscit
Pcisterior Jiranch
of Digastric
Muscic
Kacial Vein
Submaxillary Salivary Gland
Anterior Belly of Digastric Muscle
Hyoglossus Muscl
Anterior Jugular Vein
Lingual Arte Superior Laryngeal Nerve (External Branch)
Carotid Body of Thyreoid Cartilage
Upper Border
Thyreohyoid Muscle Inferior Constrictor Ifusclc of Ph.trynx
Stcrno-Thyreoid Muscle
Ansa
(or
Loop( Hypoglossi
Superior Posterior Parathyreoid
Body-
Middle Thyreoid VeinInferior Posterior P^irathyreoid
Body
Inferior Thyreoid Artery
Thvreoid Gland' OesophagusInferior Thyreoid Vein-
Inferior (Recurrentj Larj-ngeal
Nerve
TracheaTransverse Communicating Vein.
Interclavicuhir Ligament, Di:/'ro/ts
'i'l^\o.-
Fig. 66.
Lateral Aspect of the Neck. Vfi
Rebman
Limited. Lniulon.
Oesophagus.
Nat. Size.
Rebman ComiKiny, Now
York.
Lateral Aspect of the Neck.
Fig. 66.
The outer region of
the neck in a
man, aged
^o,
Oesophagus.
was exposed
window-
by a large
Platysma, Superficial Nerves, Facial Vein and lymphatic glands were
section.
removed.
The Sterno-Cleido-Mastoid Muscle was drawn backwards,
Gland and
the muscles near
The Sympathetic
is
it
white;
forwards, in order
head
the
to
rotated
is
shew
Oesophagus (red).
the
and inclined
right
the
to
the Thyreoid
backwards.
The Oesophagus
between the Trachea and the Vertebral Column,
lies
surrounded by loose conective tissue which allows
upwards and downwards.
the reason
why
the
the Trachea, deviating
side
left
left
and the Suprasternal Notch;
—
divided,
the
also
(cf.
to the
An
Fig.
have
by
very large,
is
sufficient
room.
longitudinal
its
Longus
it
Deep
is
in
Colli Muscle.
if
necessary to remove the
;
it
is
is
pulled out-
When
it.
left lobe, in
in front of the vertebral
desirable to open the
order to
column and
the Superior and
Oesophagus
at
a lower
the Inferior Thyreoid Vessels are divided between a double ligature. is
opened along
its
In
outer
the cervical portion of the Oesophagus can thus be exposed, a stricture or
cancer removed, and an
oesophageal
lumen
to the skin.
of the
Oesophagus
The anatomy (cf.
Platysma
the wound, the Oesophagus can be recognised,
order to avoid the Recurrent Laryngeal Nerve, the canal wall
made
cannot be drawn
it
The Oesophagus can be opened between if
is
is
drawn outwards, and the Omo-
the Carotid Artery, which
pale red muscle fibres,
Inferior Thyreoid Arteries; point,
may be
and
This
incision
wards and the Thj'reoid Gland and the Sterno-Hyoid Muscle which cover the gland
i)
left.
after division of the
Omo-Hyoid Muscle
One now proceeds between
downwards.
and movement
Sterno-Mastoid Muscle between the level
and Superficial Cervical Fascia, the Sterno-Mastoid
Hyoid Fascia
somewhat
usually chosen for operating.
is
along the Anterior border of the of the Cricoid Cartilage
dilatation
begins at the 6th Cervical Vertebra
It
downwards behind
passes
its
fistula
for the operation of
made by sewing
the edges of the
removal of the Thyreoid Gland
is
similar
Fig. 67).
At composed
the bifurcation of the
Common
Carotid Arter)-
of a delicate plexus of blood vessels
Its functions are
not known.
lies
the Carotid Body,
and sympathetic nervous
tissue.
Outer Region
Pig. 67.
The head
is
of
rotated to the right.
the Neck.
Subclavian Triangle.
Platysma and a portion of the Supraclavi-
cular Nerves have been removed, the lympliatic glands have been removed in order to simplify the figure; the course of the chief lymphatic tracts has been indicated.
Under
we
skin
the
distingxiish
a Superficial
separated from each other by loose connective
tissue,
space between Sterno-Mastoid and Trapezius Muscles. become subcutaneous b}' piercing this fascia.
and Deep Cervical Fascia, which stretches across the The Supraclavicular Nerves
For the removal of tumours and especially, for the removal of diseased lymphatic glands, a longitudinal incision is made along the posterior border of the Sterno-Mastoid Muscle, the External Jugular Vein is divided. This vein runs downwards from the lower end of the Parotid Gland across the Sterno-Mastoid
and Omo-hyoid, to pierce the Omo-hyoid Fascia and open into the Subclavian Vein. Of more importance is the Spinal Accessory Nerve. Emerging at the posterior border of the Sterno-Mastoid, this nerve runs obliquely downwards to the Trapezius.
to in
it
As may
it
crosses
the
area of operation,
cannot always be avoided:
it
injur}'
cause paralysis of the Sterno-Mastoid and Trapezius Muscles; but not
every case as both muscles receive fibres from the 2nd, 3rd, and 4th Cervical to the muscles and independent of the Spinal
Nerves which may run separately Accessory.
The Brachial Plexus emerges through the slit between the Scalenus Anticus and Scalenus Medius Muscles. Of particular importance is the position Deriving its fibres from the 4th Cervical Nerve, as well of the Phrenic Nerve. as from the 3rd and 5th, it runs obliquely inwards, superficial to the Scalenus Anticus Muscle. At this point, behind the posterior border of the Sterno-Mastoid Muscle,
it
can be best stimulated
When far
backwards
electrically.
the clavicular portion of the Sterno-Cleido-Mastoid does not extend in
(eis
our figure) the Internal Jugular Vein
visible at its posterior
is
border. The Suprascapular Artery which either comes from the first, or from the 3rd part of the Subclavian Artery, takes a rather high course in this specimen; as a rule, it lies behind the clavicle (cf. Fig. 68). On the other hand, the Transversalis Colli Artery runs usually at a higher level than in our figure. The most important point, just above the Clavicle, is where the Subclavian Artery and Vein leave the Thorax. Ascending out of that cavity, they form an arch over the first rib on their way to the axilla. The Vein is in front of, the Artery behind the Scalenus Anticus Muscle. The Vein is fixed to the first rib
and
to the clavicle
by tense connective
punctured (danger of scapular Vein.
The
air
embolism).
Clavicle
and
first
tissue;
cannot, therefore, collapse,
it
Just above the clavicle,
Rib form
when
receives the Supra-
it
the gate through which the Neuro-
vascular Bundle passes into the arm, most external and posterior (highest-up) being
the nerves; then
comes the
artery,
and on the inner
and most
side
anterior,
the vein.
The
large Lymphatic Tracts are in
b1ack
;
the Thoracic
Duct opens
at the
This Duct receives
Subclavian and Internal Jugular Veins. and Subclavian Lymphatic Trunks. When removing the deep cervical glands, which are so very frequently diseased (cf. Fig. 115), there is always a danger of damage to this most important lymphatic tract of the body.
junction
of the left
the Jugular
Splenius Capitis
M uscle
SnKill Occipital
Norvo
Great Auricular Kervo
"^terno-Clcido-Mastnid Muscle
Disjcending Branch Superficial Cervical
—
i»f
Xerve
Phrcnir Xerve
ficalcnus Anticus
-
Levator Anguli Scaj)ulac Muscle
Trajjczius
Muscle
Muscif
/-.
Pttsterinr Jiit(ular
Vein
Brachial Plexus
Internal Jugular Vein
Jugular Lymph.itic
Scalenus ^Nfcdius Muscle
Trunk Suprascapular Artery
.
Oniohvoitl Muscle
Thoracic Duct
Transverse (
oMiniunicatiti^ \'ein
Subclavian Lymphatic Trunk Pectoralis
Major Muscle
i
Subclavian Vein
Fig. 67.
1st
Rib
Deltoid Muscle Clavicle Subclavian Suprascapular Kerve Artery Colli iTransversalis of Xeck Transverse Artery |
Outer Region of Neck. 7:1
Uebman
Limited, Lr»ndon.
i
Subclavian Triangle.
Nat. Size.
Krl>nuin Cuiiipjiny,
New
York.
Upper
Cfrvic;il
Ganglion of Sympathetic Stciiuf-Cli'i
Muscle
Vagus Jferve
Spinal Accessory Nerv
I'"xternal lni^ul.ii
Splonius Cajjitis Muscle
\'cin
\
Omohyoid MnscI
Anterior Scalene Miiscl
Phrenic Nerve Brachial Plexus
External Jugular Vein
Anterior Thoracic Nerve Suprascapular Artery
Middle Scalene Muscle Subclavian Aitery
Fig. 68.
Outer Region of Neck. Va
RiOnnau Limited, Lomloii.
Upper Cervical Ganglia JSfat.
of Sympathetic.
Size.
Rebman Compauy, New Ymlc.
;
Fig. 68.
Outer Region of the Neck. Upper Cervical Ganglia Sympathetic.
The head of a male, aged
A
window has
/o,
made
is
turned
to the I'ight,
of
and drawn backwards.
Platysma and External Jugular Vein have been removed, the Sterno-Cleido- Mastoid Muscle and Internal Jugular Vein drawn forwards, and the Trapezius pulled backwards. The Thoracic Duct is white, the Sympathetic Chain and, its Ganglia are or ange (by mistake, the Spinal Accessory Nerve has been drawn superficial to the Great Auricular Nerve: it should be the reverse). large
In
Hg.
been
in the skin, the
67, the parts are in their natural position; in this figure, the
deeper
have been exposed by drawing the superficial muscles apart; the Internal Jugular Vein, which really lies external to the Carotid Artery, has been pulled inwards, the Sympathetic Chain begins with the Upper Cervical Ganglion which is Vs^h inch, long, and 0.3 inch, broad its upper end lies opposite the transverse process of the 2nd or 3rd Cervical Vertebra; its lower end, opposite the 4th, 5th or 6th Cervical Vertebra. At its lower end is seen the sympathetic chain which goes to the Inferior Cervical Ganglion (cf. Fig. 70). This Ganglion varies in size and may form one mass with the ist Dorsal Ganglion, it lies on the head of the St rib at its point of articulation with the body of the ist Dorsal Vertebra. The sympathetic chain frequently forms a loop around the Subclavian Artery (Ansa of ViEUSSENS). Between the Upper and Lower Cervical Ganglia Ues the middle Cervical Ganglion in front of the Inferior Thyreoid Artery, which may also be surrounded by a loop of S3'mpathetic fibres. The Sympathetic Chain lies behind the Carotid Artery, and is fixed to the Vertebral Column and the Prestructures
;
I
vertebral Muscles.
same way
It
therefore does not
as the Vagus.
When
trouble about the Sympathetic
to
Vagus
in the ligature
move
with the Carotid Sheath,
ligaturing the Carotid Artery, there
is
in the
no need
but one has to take care not to include the
with the Artery.
The Sympathetic is, therefore, in a well protected position, and rarely damaged in accidents, or during operations (removal of tumours). In recent years, the Sympathetic has been divided and more or less removed (Superior Cervical Ganglion etc.) for Epilepsy, Glaucoma and Gr^WE's disease. The Sympathetic can be exposed by a longitudinal incision along the anterior border of the SternoMastoid Muscle; the Carotid Artery, Internal Jugular Vein and Vagus are drawn is inconvenient, because the thin-waUed much distended held by the retractor. If one operated along the posterior border of the Sterno-Mastoid drawing the muscle with the vein inwards, more room is obtained
This proceeding
aside.
vein
is
downwards on to the clavicle, the lower CerviGanglion can also be removed, after having freed the clavicular head of the Sterno-Mastoid from its attachment. The latter operation, however, is difficult, because the Vertebral Vessels may lie up against the Ganglion near the Apex
if
the incision has been continued
cal
of the Pleura
(cf.
Fig.
This incision
70). is
This should on no account be injured.
the best for ligaturing the Vertebral Artery before
enters the foramen in the transverse processes of the Cervical Vertebrae.
it
, ;
Larynx from behind -
Fig. 69.
From
Goitre.
body of an old woman, the enlarged Thyreoid Gland (Goitre) was
the
removed with
Larynx and
the
the Trachea,
and hardened
Formalin ; only a
in
small portion of the Oesophagus remains; the posterior wall of the Larynx
The Parathyreoids are or an ge,
dissected. left
of the Thyreoid
lobe
Gland
The Recurrent Laryngeal Nerve has been drazvn
more
to
The topographical
clearly
position
Fig. 60 indicates those structures
The topographical enters the
relations
at
of
is
show
its
around
on both
aside,
Gland
which must be divided
sides, in order
in
is
shewn
causes paralysis of the Vocal Cords.
Fig.
in
6.
exposure of the gland.
where the Superior Thyreoid Artery
(cf.
Fig.
The
66).
removal of
difficulty in
Recurrent Lar3mgeal Nerve, injury
to avoid the
its axis.
branches.
the Thyreoid
the point
gland, are most important
the Thyreoid Gland
The larger
the lymphatic glands, red.
caiised the Trachea to rotate
is
This nerve ascends
to
which
groove between
in the
the Trachea and Oesophagus, supplies these structures and enters into the formation of the
Oesophageal Plexus (Plexus Gulae).
It
then follows the Inferior Thyreoid
— more often —
Artery, in some cases running upwards in front of the Artery, or it
passes between
few cases behind
its
branches
this vessel,
at
the
point
of
bifurcation
;
it
avoid inclusion with the Ugature for the Artery.
its
terminal branches;
ends
lies
always closely applied to the Thyreoid Gland.
the removal of the gland, the nerve must be freed, and great
Constrictor Muscle and
onl}'
at
It
supplies the muscles of
then passes under the Inferior
the Crico-Thyreoid articulation
by dividing
Galen
—
Ansa Galeni
the Larynx, except the Crico-Thyreoid.
into
—
,
the other
This muscle (cf.
whilst the bulk of that nerve pierces (internal branch) the Thyreo-hyoid
is
Fig. 66),
Membrane mucous
together with the Superior Thyreoid Artery and supplies the lar3mgeal sensation. practical importance are the Parathyreoid Glands.
or the seat of a tumour, they
Usually, their position
but there
For
care taken, to
supplied by the External branch of the Superior Laryngeal Nerve
Of great
a
one of these joins the descending branch of the Superior
Laryngeal Nerve, thus forming the loop of
membrane with
in
may be
may is
as
cause great diagnostic
shewn
When
enlarged
difficulties.
in the figure near the Thyreoid
Gland
Parathyreoids anywhere between the frenum of the tongue and
the h3?oid bone, and between the lower border of the Mandible, the Clavicle and the Trapezius Muscle.
Epit;inttis
Greater Cornu of Hyoid Hone Lateral Thyreohyoid LiRainent Cuiu'iforni
Internal llraneh of Superior Larj-ngeal Xcrvc
( '.iitihij;*'
Superior Thyreoid Vessels Superior Tlu'reoid Vein
External Branch of Superior
Laryngeal Nerve
Corn iculo -Pharyngeal Ligament .\iiastoniosis
Ncr\e
to
between Superior and
Transverse Arytenoid
Muscle
Inferior Laryngeal Nerves
(AnsaGAi-ENi) Posterior Crico-Arytenoid Muscle
Inferior
Horn
Criroid f:.rtilage
of Thyreoid
Cartilage Posterior Superior Parathyreoid
(Inferior*
Anterior Branch of Inferior Recurrent) Laryngeal Nerve
Body
Recurrent L.iryngi
Inferior Laryngeal Artery
Nerve Inferior Thyreoid Artery
Inferior Thyreoid Artery
Deep Cervical (Thyreoid) Lgl.
_
Tracheal Nerve
Middlr Tl.vr.oid
Anterior Inferior Parathyreoid Body Posterior Inferior
Parathyreoid
Body
(_)csophagus
Oesophageal Nerves Inferior Thyreoid
Tracheal Ner\*e
Deep Cervical Lymphati
Vein
Right Inferior (Recurrent) Laryngeal Nerve
Glands Left Lateral Lobe of Thyreoid Gland ((ioitrei
Inferi
Fig. 69.
Rebmau
Limited, Loiulon.
Laiynx from behind
—
Thyreoid ^'eins
Goiti-e
RebiiKiu Com|iany,
New
York.
V.-ins
jth
Svmp;ithetic ViiRus Xcrvc' Chain Vertebral Artery
Loiiniis
Ci-rvical
C"l!i
Vertebra
Muscle
Rectus Capitis Anticus Muscle
Pbrcnic Nerve
Transverse Process of 6th Cervical Vertebra (f'liASSAiONAC's Tubercle) Anterior ScalctH- Muscle
ln(eri
1
liyrcoid Artery
Middle Scalene Muscle
Brachial
Pi-
Transverse Artery of Neck Transversalis Coili^
Scalene Tubercle (LiSKKANC) Internal
Mammary
Thoracic Uuct Artery
/
Phrenic Nerve .\pex of Pleura Ki;,'lit
Inttrnal M;inini,My Vi-in
Recurrent Laryngeal irynffcal Nerve Ri^lit
/\ --
Innominate Vein
I
--
\ ~^
'
Innominate Arterv
Trachea
Fig. 70.
Left Inferior (Recurrent! Laryngeal Nerve
Left Innominate Vein
Apex
Oesophagus
Inferior Thyreoid Vein
of the Pleura.
Nat. Size.
Rebmau
Ijimited
London.
Rebuiau Compuiiy,
New
York,
Fig. 70.
Fyom
Apex
of
the Pleura.
of a man, aged 40, both clavicles have been removed, Trachea cut off, and the important vessels and nerves displayed in their relation to the apex of the pleura (which is coloured light blue). On the left side, special attention has been paid to the Veins and the Thoracic Duct; on the neck
and Oesophagus
the right side to the Arteries
and
the Nerves, in particular, to the Sympathetic.
The apex of the Pleura ends exactly at the level of the ist rib. This which forms with the Sternum and ist Dorsal Vertebra the upper aperture of the Thorax, ascends behind, in an oblique direction. The slope of the apex of the pleura, and the lung within it, corresponds to that of the rib mentioned. An instrument, introduced immediately above the first rib, horizontally backwards, will therefore open the pleura. By percussion, one can also prove the presence of resonant lung about one inch above the clavicle. Despite all this, it is wrong to sa)' that the pleural cavity extends everywhere beyond the upper aperture of the thorax. Normally, it passes above the level of that inclined plane only at one spot, at the middle of the ist rib, and only to the extent of V2 inch. Strands of connective tissue keep the apex of the pleura in position this fascia runs from the Cervical Vertebrae and the neck of the first rib to the apical pleura. The large vessels and nerves which pass through the upper aperture of tlie Thorax to the head and the upper limb, and the Nerves which go from the neck to the arm are in close relation with the apex of the Pleura. Internal to the latter, on the right side, the Innominate Artery, on the left, the Subclavian Artery passes. The Innominate Artery bifurcates into Common Carotid and Subrib
;
behind the Sterno-Clavicular articulation or at a higher level. The Subclavian Artery arches over the apex of the Pleura, leaving it at the Scalene Tubercle on the first rib. The Internal Mammary Artery which arises from the cla\'ian either
Subclavian, before is
also
Nerve.
in
relation
The
it
to
passes between the Scalenus Anticus and Medius Muscles, the
Apex
of
the Pleura;
external
to
it
is
the Phrenic
Ganglion (cf. right side of the figure) lies on the apex, between the Longus Colli Muscle and the arch of the Subclavian Artery, in front of which the Vagus descends (also in relation with the apex of the Pleura). Both Innominate Veins, formed by the Internal Jugular and Subclavian Veins are also relations of the apical pleura, on which the Brachial Plexus, external to the Subclavian Artery rests. Lastly, the Pleura lines the inner border of the Scalenus Anticus Muscle where it is attached to the first rib. Disease of the Pleura can, especially on the right side, affect the Recurrent Laryngeal Nerve. The fact that so many structures of vital importance are in close apposition within a small space renders removal of tumours, growing in that region, and ligature of the vessels very difficult and even dangerous. Apart from the possibility of injury to the vessels and nerves in the neighbourhood, there is danger of opening the Pleura. Inferior Cervical
—
—
,
Course of the Main Vessels and Nerves to the Arm.
Fig. 71.
The head
turned
is
the
to
A
Major have been removed.
portion,
origin
its
and
Between the
arm drawn downwards,
from
piece has been excised
and outwards
insertion being thrown inwards
clavicular portion of the Pectoralis
abducted
slightly
The Platysma and the clavicular portion of
and rotated outwards. ralis
the
left,
the Pecto-
sternal
its
respectively.
Major which usually
arises
from the inner half of the Clavicle, and the origin of the Deltoid from the outer third
of that bone,
a
A
Vein
join the Subclavian
if
rated from
its
it
is left
Artery on the
ist rib
without
in
region.
this
Above
Vein, sepa-
is
the its
muscles,
its
the Brachial
the latter are ill-developed.
with
on
lies
The Neuro- Vascular bundle
Major from
Take from
the midpoint of
almost
is
Proceeding
separation
of
the
origin, is necessary.
the arterj'
lies at
a
the upper border of the Pectoralis Minor, the Subclavian Artery gives in our figure: the
the minute Alar Thoracic (Thoracica Suprema). 2
the Clavicle;
this point.
two branches which are not shewn
supply the
The
the
following surface marking can be used for ligature of the Subclavian
finger's breadth interval
off
when
interfering
clavicular portion of the PectoraUs
Artery
into the Axilla.
under
pass
Externally, and partly behind the artery
completely covered by muscles, even
backwards,
Plexus
Brachial
by the Scalenus Anticus Muscle,
this vessel.
to
Fig. 76, text).
cf.
were a bridge!) from the neck
Plexus which soon surrounds
The
which the Cephalic Vein disappears
and
Artery
Vein,
inner aspect, lower down.
directly
in
further details
(for
The Subclavian Clavicle (as
space
Pectoral Muscles run
The
Acromio-Thoracic and
anterior Thoracic Nerves
with the former vessel.
They
which
perforate the
costo-coracoid membrane. Lastly,
there
is
we mention
that
in
our figure
—
and
this is not
uncommon
—
a gap between the sternal and the clavicular portions of the Sterno-Cleido-
Mastoid Muscle
in
which the Internal Jugular Vein
is
visible.
\
KxtHrn;il Jugular Vt-in
Small rccloral
D.-ltuid
.MuvJ
CoracM.iJr.irhial
(inMt iV'ctuial Muscle
Median Xc
Shurt Head nf Biceps
LuuK Head
..f
Biceps
Fig. 71.
Course of Main Vessels and Nerves to the Arm. 7.,
Rebman
Ijimited,
Loudon.
Nat. Size.
Rebm;in Company,
New
York.
S
«1
JO
> B so
c»
5-^ 03
P
cr
3
=r
op
<:
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> 5 3
O.
ft
i=i'
re
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S
Figgs. 73 and 74.
Relation of the Capsule of the Shoulder-Joint to the Upper Epiphyseal Line. After von Brunn.
Fig. 73.
Frontal Section through the right Shoulder-Joint of a boy aged 8 years. Arm abducted to a right angle. Seen from in front.
Ai'm placed horizontally. Above, on
outer side,
tlie
tiie
Capsule of
tiie
Shoulder-Joint does not
extend as far as the Epiphyseal Line, but on the lower aspect the Capsule passes
beyond the Epiphyseal Line on
At .so
the point
marked
that Separation
the inner
to
dark
the thin
*,
of the Epiphysis
line
side of the
neck of the Humerus.
shews how the Capsule
does not necessarily
is
reflected
open the Joint-Cavity.
Horizontal Section through the left Shoulder'- Joint of a boy aged 8 years. Arm abducted to a right angle.
Fig. 74.
Arm the
placed horizontally.
Spine
of the
The
Seen from above.
Scapula and touched
section passed directly below
lower
the
of the Acromion
border
Process.
The
relation
of
the Capsule to
and posterior aspects, as
anterior
extends beyond
Joint-Cavity
from the Articular Cartilage,
this
it
is
the Epiphyseal Line
below
boundary
(cf.
Fig.
13).
is
It
same on the
the is
true
that
the
because the Capsule, arising
(only
attached for some distance to the Cartilage or
is
to the Bone).
The Epiphyseal
Lines, Epiphyseal Boundaries or Epiphyseal Cartilaginous
Discs are of great importance for
many
long bones takes place
if
chiefly,
Residual Cartilage between the Diaphysis process
is
liable to
especially
marked
at
The
reasons.
longitudinal growth of the
not exclusively, at these (shaft)
lines,
and the Epiphysis.
puberty, but on the other hand,
i.
e.
at
This growing it
is
especially
be interfered with during the same period, by inflammation, which
result in the Separation of Diaphysis
is
not so frequent as Inflammatory
Fractures usually occur near, but not
Excision of joints
in
children
of the Epiphyseal Lines.
may
and Epiphysis.
Traumatic Separation of the Epiphysis Separation.
the
(in)
along the Epiphj'seal Lines.
should only be performed with due consideration
Epiphyseal Cartilage
Deltoid iluscle
Clavicle
Humerus
Scapula
Subscapular Muscle
Fig. 73.
Frontal Section through the right Shoulder-Joint of a boy aged 8 years. Arm abducted to a right angle. Nat. Size.
—
After
von Brdnn.
Acromion
'
Scapula
Humerus
Fig. 74.
Horizontal Section through the
left
Shoulder-Joint of a boy aged 8 years.
Arm
abducted to a right angle. Nat. Size. — After von Brunn.
UclmiMn
I^iniitoi],
London.
Rebnian Comp.my,
New
York.
Subdeltoid Deltoid Muscle Bursa Humerus
Coraco-Acromial Ligament
Long Head
of Bic
Coracoid
Muscle
'.
Coracoid
Membrane
CIa\icle
Small Pectoral Muscle Bursa under CoracoBracbialis
Muscle
Humeral Branch of AcromioThoracic Arterj*
CoracoBrachiaiis
Muscle Anterior f-ircuniflex -\rtery
f-oracoBrachialis ^luscle
Great Pectoral Muscle
(
epli;ilic
Vein
Deltoid Muscle
Short
Long Head
Head
of IJiceps
of Biceps
Muscle
Muscle
Vv Tro'hse
Fig. 75.
Anterior Relations of the Shoulder-Joint. Nat, Size.
Rebnian Limited, London.
Rebnian Company,
Now
Yoi'k.
:
Anterior Relations of the Right Shoulder-Joint.
Fig- 75-
Skin and Superficial Fascia over the anterior portion of the Deltoid and the outer portion of the Pectoralis
Major have been removed;
cut below the Shoulder- Joint
and thrown upwards and outwards.
Bursa (pink),
deltoid
the Joint,
and
the Deltoid has been
The Sub-
Sheath of the Biceps (light blue)
the
have been opened.
The middle
third
the Clavicle and
of
Subclavius Muscle, the Coracoid
common
Process with the insertion of Pectoralis Minor Muscle and the
Head
the Coraco-Brachialis and Short
Groove.
Pus
Its
Head
Humerus
into the
Bicipital
Effusion and
the Joint often extend into this sheath.
in
Subdeltoid Bursa,
Distension fibrous of
of the
synovial sheath always communicates with the Joint.
Between the Capsule the
The Long Head
of the Biceps are shewn.
runs through the Shoulder-Joint over the
origin of
of
this
the Shoulder-Joint and the Deltoid Muscle
which, as a rule
Bursa may
easily
the Subdeltoid
stimulate
to the
Capsule and the wall
They
Bursa are called the Coraco- Humeral Ligament.
of protective roof for the Joint an important bursa, the Subacromial Bursa, jV third large bursa lies
The Capsule
is
a kind
found.
between the Scapula and the Subscapularis Muscle
the Bursa Subscapularis usually communicates with the Joint
much
are
by the much-distended Bursa.
in the figure
Humerus
The
fluid in the Shoulder-Joint.
Between the Capsule and the Coraco- Acromial Ligament which forms
of the
lies
does not communicate with the Joint.
,
running from the Coracoid Process
strands
covered
of
of the Shoulder-Joint
is
(cf.
Fig. 121).
it
allows the
wide and loose;
Head
leave the Glenoid Cavity of the Scapula for a distance of as
to
Above,
as one inch.
for the greater part,
is
it
this
Capsule
attached to
Cavity (Glenoid Ligament).
is
tlie
attached to the neck of the Scapula;
fibrcius
The Long Head
ring which deepens
of the Biceps arises
tlie
Glenoid
from the upper
part of the Glenoid Ligament.
The Glenoid
Cavitj'
not directed exactly outward, but
is
somewhat upwards
and forwards.
When Head
of the
at least in
the
arm hangs
vertically
Humerus touches
dead bodies.
distance of 0.15
— 0.25
The
downwards, only the lower portion of the
the Glenoid Cavity articular surface of the Scapula,
highest point of the
Head
of the
Humerus
inch from the highest point of the Joint Cavity.
lies at
a
o o
o
t:
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1^
I'osli-Tiur
I)flt«.i(l
Mu-Jcle
liunuTus
Circumflex Arterv
Circumflex
Nrn-e
Teres ^rinor Muscle
Ucltoid Muscle
PosU-rior Axilliiiy
Lymphatic Glands
Icrcs Minor Muscle
Latissimus Dorsi
Muscle Posterior Cutaneous Branch of
Circumflex Nerve
Outer
Head
Triceps
Jjr'FrOhSe.
Fig. 77.
Posterior Relations of the Shoulder-Joint. Nat. 8ize.
U(.'bin;iii
LimitLMl,
L(-'inlttji.
Ucltmitii
(oinpniiy,
Xrw
York.
of
;
Fig" 11'
Posterior Relations of the Shoulder-Joint.
Skin and Fascia have been removed over the posterior lialf of the Deltoid, of which a large portion has also been cut away.
The Anterior and the Posterior Circumflex Arteries arise, opposite each from the last part of the Axillary Artery and wind round the Surgical Neck of the Humerus, the former from in front, the latter from behind. The Posterior Circumflex Artery passes through the Quadrilateral Space formed by the Teres Minor (above), the Teres Major (below), the Humerus (anteriorly) and the Long Head of the Triceps (posteriorly). It supplies the Teres Minor, Deltoid etc., and ends by anastomosing with the Anterior Circumflex. With it run its 2 Venae Comites of which onh^ the larger is shewn in the figure. Taking a similar course, but somewhat posterior, the Circumflex Nerve passes to innervate the Deltoid and Teres Minor Muscles and the skin over this region. Its large cutaneous branch emerges at the posterior border of the Deltoid Muscle and divides into an ascending and a descending branch. other,
On
ably
the Teres Major, below the Deltoid
is
a lymphatic gland which
constant, — the Posterior Axillar}- Gland (FroHSE) —
we have
,
it is
is
prob-
usually subcutaneous
found deep glands which lie on the blood vessels. Their efferent vessels pass through the triangular space, between the Teres Major, Minor, and Long Head of the Triceps, forwards to the Axilla. On the dorsal aspect of the trunk there are other subcutaneous lymphatic glands which are neither constant in position nor in number (cf. Fig. 145 and text). The Superficial Glands of the Thorax and Abdomen may be divided into in
pathological
cases,
also
Anterior, Posterior and External, according to their position.
Anterior Glands:
Clavicular Glands lying on the Clavicle, above the
Deltoideo-Pectoral Fossa, sometimes also on the origin of the Sterno-Cleido-Mastoid
Muscle.
(Cf.
Fig.
115.)
Internal Pectoral Glands,
usually
at
the level
inner border of the Breast (the blue gland in Fig.
The Xiphoid Gland,
at the
External Glands External Pectoral or
(i.
of the nipple
(cf
.
Figs.
1
1
4
and
of
these
glands
is
rib,
along the
base of the Xiphoid Process
(cf
.
Fig.
1
1
4).
Glands, outside the Nipple, and along
The}- are intermediate glands for the lymphatics 1
Thoraco-epigastric Glands
One
2nd
external to the nipple line):
e.
Paramammary
the outer border of the Breast.
of the
114).
1
5). (i
—
4)
along the External Mammary Vessels. sometimes visible through
nearly always palpable and
the skin.
The most important of these glands are the Thoraco-epigastric. Paramammar}' and Posterior Axillar}'. The subcutaneous position of the first mentioned is especially well noticeable when Langer's Muscle e. a muscular connection (i.
between Latissimus Dorsi and Pectoralis Major) is present. Their efferent vessels run in this case along the free border of the AxiUary Fascia, where it is bounded by that muscle, before they open into the AxiOary Glands. The Shoulder-Joint is accessible for (operations) surgical measures from in front, and from behind. The Circumflex Nerve has, however, to be avoided on the posterior aspect, because injury would produce paralysis and atrophy of the Deltoid Muscle.
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—
Deltoid Muscle
Teres Elinor Miisrle
Posterior Circumflex
Artery
Humerus
Teres Major ^tiiscle
I.ong
Head
of Triceps
Superior Protunda .\rlery
Coraco-Bracbialis Muscle
Brachial Artery
Musculo-Spiral Xerve
Ulna)'
—
Nerve
Tuuer
Head
of
Outer
Head
of Triceps
I'licep;
Musculo-Spiral Groove
Brachialis Anticus Muscle
Cutaneous Branch of Musculo-Spiral Nerve
Musculo-Spiral Nerve
Brachio-Radialis {Supinator Longus)
Muscle
Posterior Branch of
Radial Nerve
Pig. 79.
Outer and Posterior Aspect of Left Arm.
—
Nat. Size.
Fig. 79.
Left Arm, Outer and Posterior Aspect.
Skin and Fascia have been completely removed ; a large piece of the Ottter Head of the Triceps, and the posterior portion of the Deltoid Muscle beloiv have been cut away.
The Long Head of
wards and backwards.
Neck
of the
has been drawn down-
The Venae Comites have been removed.
Below the Shoulder-Joint, from the Surgical
the Triceps
origin
its
anterior aspect backwards,
amund
the
Humerus, between the Teres Minor and Teres Major, the
Posterior Circumflex Vessels pass (the Artery being a branch of the Axillary and
having
2
Venae
The Circumflex Nerve accompanies them
Comites).
the Deltoid and Teres Minor Muscles
Behind the outer border
(cf.
Fig.
tlie
Musculo-Spiral Nerve
and the Superior Profunda Artery, as they wind around the bone Spiral
Groove
Fig. 80).
(cf.
and runs downwards
to
Brachio-Radialis Muscles
The Nerve
for
operations,
Nerve
is
owing in
to the large vessels;
the way,
nerves in the thigh. injured
in
arm
The Anterior and
Osteomyelitis).
fractures,
because Its close
(e.
g.
Internal
are
is
it
not
favourable
for
not a straight one, like that of the
proximity to the bone explains
and why
Humerus
extensive scraping of the surfaces
a serious
is
on the Posterior surface the Musculo-Spiral
course
its
Septum
between the Brachialis Anticus and the This spiral course of the nerve
Fig. 81).
obstacle in extensive operations on the
Musculo-
in the
pierces the External Intermuscular
the forearm, (cf.
supplies
it
77).
Humerus emerge
of the
;
may be
why
it
is
so often
pressed upon by or be embedded in
Callus-formation.
The Ulnar Nerve runs
for a short distance parallel
to the
Long Head
of
the Triceps.
The Superior Profunda Artery anastomosing, by means
of a
Recurrent
Branch, with the Posterior Circumflex Artery, supplies the Triceps and the (nutrient artery)
and divides
into
Humerus
an Anterior and a Posterior Division. The former
accompanies the Musculo-Spiral Nerve and ends by anastomosing with the Radial Recurrent Artery.
The
latter
runs
in
the substance of the
Triceps downwards to the Olecranon where
Recurrent Artery.
it
Inner
Head
of the
anastomoses with the Interosseous
Transverse Section through the Middle
Fig. 80.
A
of
the Right Arm.
from a series of sections taken from a frozen body. This section under surface of a right upper stump, or the upper surface of a left For practical purposes, the former interpretation is to be preferred.
specimen
sliews the
arm.
Note The relation of the Median Nerve to the Brachial Artery the Ulnar Nerve and the Musculo-Spiral Nerve winding round the bone. The External Intermuscular Septum is well displayed; the Internal is not distinctl}' visible in ;
:
this section.
The Flexors (Brachialis Anticus, Biceps and Coraco-Brachialis), are separated from the Extensors (Triceps) by the Intermuscular Septa. The Internal Septum runs along the inner border of the Humerus to the Internal Condyle. The External Septum extends from the insertion of the Deltoid Muscle downwards along the outer border of the shaft of the Humerus to the External Cond3'le. The Internal Septum is really the fibrous continuation of the Coraco-Brachialis (which passes some animals to the Internal Condyle). The enormous Triceps presses these Septa forwards; in this section they are shewn to describe a curve with its convexity directed forwards. Both groups of Muscles thus lie in fibrous sheaths, formed by the Fascia of the arm, the Intermuscular Septa and the Periostium. in
Fig. 81.
Transverse Section through the Lower Third of the Right Arm.
Section through a right
arm hardened
in formalin.
Interpretation similar to
that of the section above (Fig. 80).
Note the differences in shape, size, and position of the various structures, compared with Fig. 80. Shape of the Humerus, of the Biceps, of the Brachialis Anticus, of the Triceps. — Change in the position of the Musculo-Spiral Nerve which has left the bone, of the Ulnar Nerve which has reached the Internal Intermuscular Septum etc. In this figure, all the Fasciae are coloured blue. Thus the continuity of the Intermuscular Septa with the Periosteum, at the outer and at the inner border of the Humerus, and with the Deep Fascia is shewn. The latter binds down the muscles and forms thin fascial septa between them; e. between Biceps, Brachialis Anticus, Coraco-brachialis, and between the 3 heads of the Triceps. The whole arm is enclosed in the Superficial Fascia which is especially strong on the extensor aspect. On the Deep Fascia run, covered by the superficial fascia, the Superficial Veins and Nerves. as
i.
—
Biceps Muscle
jNIedian
Norvc
Internal C"utaTic«»us
Nerve
Hiailiial Artery
Anticiis
l_ir;it"hialis
Muscle
Coraco-Bradiialis
Muscle
Musculu-Spiral Nerve-
l7*3xCJP-r^^ Superior Profunda
j
^,^r__^ I-T."^
'^C^^-^"'^'^
Inner Head ni Triceps Muscle
Arterv
Outer
Head
of Triceps Inferior Profunda Artery
Fig. 80.
Transverse Section tlu'ough the Middle of the (right) Arm. View from
li^low.
Nat. Siz
Biceps
Brachialis Anticus Muscle
Musculo -Cutaneous Nerve Brachial Artcr
Cephalic Vei
Median Nerve
Internal Cutaneous
Ner\e
Bfisilic
Vein
Musculo-Spiral Ncr\c
Great Anastomotic ,\rtery
Internal Intermuscular
Septum Inferior Profunda
Brachio-Radialis (Supinator Longus)
Artery
Muscle
Ulnar Nerve
Posterior Branch of
Radial Nerve Inner
Head
of Triceps
External Intermuscular
Septum
Inner
Head
of Triceps
Long Head
of Triceps
Outer Head of Triceps
Tendon
Fig. 81.
of Triceps
Transverse Section through the Lower Third of the Right Arm. Nat. Size.
KebiiKin Limiteil, Louilon.
Rebmau Company, New
York.
Lesser
Cutaneous Nerve
IiiltTiial
1^
^
Internal Cutancttus
MusculoNerve
I'.ianch nf the
Spiral
Ulnar Nerve
IJasilic
Cephalic Vein
Vein
Median Nerve
Interniil
Cutaneous Nc
Brachial Ailery
Median
Basilic Ve:
Bracbio-Kadialis
Muscle (Supinator
Bicipital Fascia
Longusl
—
Pronator Ratli Teres Muscle
Cutaneous liianch of Musculocutaneous Nerve
- Kadial Artery
Flexor Carpi Radialis Muscle
Se.fethti
Fig. 82.
Left Antecubital Space
~
Superficial Layer.
Nat. Size.
Kebman
Limited, Loudon.
Rebman Company, New York.
Left Antecubital Space.
Fig. 82.
Superficial Layer.
Skin over the knver part of the arm, and over the upper part of the The Superficial Fascia covering the Biceps and forearm has been removed. Tlie
and Nerves have
Superficial Veins
tlie
Fascia and
its
also been taken away,
expansions in the forearm are
but the Bicipital
left intact.
The superficial and broad Bicipital Fascia ends by an expansion into Deep Fascia of the forearm and by blending with the Periosteum of the Ulna. The true Tendon of the Biceps is inserted into the Radius. The Superficial Muscles which arise from the Internal Condyle are intimately connected with the Deep the
Fascia and the Bicipital Fascia in the upper part of the forearm.
At
Superficial Veins.
the upper end of the forearm
2
constant and one
not-constant Veins are found: the Ulnar and Radial Veins, and the Median Vein.
The
latter vein divides into the
Median
Basilic,
and the Median Cephalic Veins, the
former joining the Ulnar forms the Basilic Vein, the
These veins vary.
forms the Cephalic Vein. is
the largest vein in
It
thus forms a
a rule, the
Median
Basilic
Vein
the Antecubital Space, and the most suitable for Phlebotomy.
The Cephalic Vein runs upwards Pectoralis Major
As
joining the Radial
latter
and Deltoid Muscles, collateral
in the
arm and disappears between the
to join the Axillary
venous channel.
The
Vein
Basilic
(cf.
Fig. 75
and
76).
Vein joins the Venae
Comites of the Brachial Artery and then forms the Axillar}' Vein, which, higher up,
becomes the Subclavian
Bicipital
injury
(cf.
AxiUa).
The Median Basilic Vein is separated from the Brachial Artery b}' Fascia. The Arter}^ can therefore be injured in Phlebotomy, and
may be The
2
followed by an Arterio-venous Aneurysm. chief
Cutaneous Nerves of the forearm, the Cutaneous Branch of
the Musculo-Cutaneous Nerve and the Internal Cutaneous Nerve ficial at
the Antecubital Space.
Veins.
Its
than the
the this
trunk and
veins.
its
The
branches
lie
latter in
nerve runs with the Basilic and Ulnar
'/sth
of
The nerve may have divided
pierces the fascia of the arm.
become super-
all
cases at a slightly deeper level
into 2 large branches,
where
it
Fig. 83.
Skin, Superficial,
is
and Deep Fasciae have been
Biceps with Bicipital Fascia,
are exposed:
by Vessels
iiot-covered
and Nerves,
Flexors which arise from
The
Brachialis Anticus
upper portion
is
its
,
as far as
it
Superficial
of the
Pronator Radii
upper portion been
drawn
out-
also displayed.
nerves and veins which have been
to the superficial
cimen, see Fig. 82
has at
ichicli
wards,
(As
the
The following muscles
reinoi'ed.
the Internal Condyle, especially the
The Brachio-Radialis
Teres.
Deep Layer.
Right Antecubital Space.
left in
this spe-
text.)
Brachial Artery runs, accompanied by
its
Venae Comites, along the
inner border of the Biceps, towards the acute angle formed by the Pronator Radii
Teres and the Brachio-Radialis Muscles. the joint
—
it
more
divides into the
than
2/j,th
its
superficial
deeply placed and larger Ulnar Artery. to its Internal ^'ena
In
course,
—
in front of the line of
and smaller Radial, and the more
Internal to the Brachial Artery (or rather
Comes) runs the Median Nerve which may, however,
inch internal to the
vessel.
lie
more
This nerve pierces the Pronator Radii
Teres and supplies the Superficial and the Deep Flexors of the forearm, except the Flexor Carpi Ulnaris and the inner portion of the Flexor Profundus Digitorum (cf.
Fig. 89).
outer border of the Biceps runs, at a deeper level, the Musculo-
Along the Spiral Nerve; this
Muscles
(cf.
Nerve
between the Brachio-Radialis and Brachialis Anticus
Fig. 89).
The mass and the portion rates lower
lies
of
down
of
muscles arising from the Internal Condyle of the Humerus
bone above
it,
and from the deep
into the Pronator Radii Teres
of the outer border of the Radius,
into
fascia of the forearm, sepa-
which
is
inserted at the middle
the Flexor Carpi Radialis going to the
base of the 2nd Metacarpal Bone, into the Palmaris Longus, which present,
and
into the
is
not always
Flexor Carpi Ulnaris, which arises also from the Ulna.
The lymphatic glands
are described in Figs. 89 and
1
1
5 text.
Ccphalit
Win
Deep Cubital Lymphatic Gland Internal Cutaneous Nerve Basilic
Biceps Muscle
Vein
Superficial Cubital
Lymphatic Gland liiiichialis
Median Nerve
Anticus iluscle
Median Cutaneous Branch of Musculo -Cutaneous Nerve
Basilic
Vein
Companion Veins of Brachial Artery
Internal Condyle of
Musculo-Spiral Nerve
Humerus
Deep Portion of Brachialis Anticus
Brachial Artery
Muscle
Brachialis Anticus
Recurrent Tibial Artery
Muscle
Tendon of Biceps
Bicipital Fascia
Posterior Interosseous Nerve
Ulnar Artery
Pronator Radii Teres
Supinator Brevis
Muscle
Muscle
Flexor Carpi RadiaUs
Muscle
Radial Nervt
— Palmaris Longus Muscle Kiidial -Vrtery
Flexor Sublimis Digitorum Muscle
Dr.Frohse Fig. 83.
Right Antecubital Space: Deep Layer. Nat. Size.
Rebman
Limited, London.
Rebman Company, New York.
-
Inner Intcriiiil
Head
nf Triceps
Cutinmus
Xcrvc Ulnar Nerve fireat
Anastomotic Artcrv Biachialis Anticus Muscle IJasilic
Vein
Inferior Profunda
Brachial Artery
Art
^ledian Basilic Vein
Olecranon Bursa
Cntaneous Branch of Musculo -Cutaneous Nerve
lexor Carpi Ulnaris Muscle
Cephalic Vcin-
liicipital
rasi'i.i.
Anterior Ulnar Kei inrcnt .\rterv
Common Ulnar Recurrent -Vrtcry
of Pronator^ Radii Teres Muscle
Ulnar Origin
^ledian Xcrvc
Ciiminon fntiTosseous Arterv
Deep Flexor Muscle
of
Fingers
Humeral Origin of Pronator^ Radii Teres ^luscle
Median Artery
Brachio-Radialis Musclc_ (Supinator Longus)
-Ulnar Vessels Radial Artery
Superficial Flexor Muscle of l-'ingers
Flexor Carpi Radialis
Palmaris Longus Muscle
Dr, Frohse
Fig. 84.
Region
of
Elbow
—
Right
Side.
Nat. Size.
Rebman
Limitefl,
Luinhm.
Rebmiin Conipany,
New
York.
Fig. 84.
Region
of
Elbow
Right Side.
Skin, Superficial Fascia (except the Bicipital Fascia) the Superficial Muscles arising the
from
and
the
upper portions of removed;
the Internal Condyle have been
Pronator Radii Teres, however,
is left intact.
This figure shews the region of the Elbow, the deep layer of the AnteSpace and the upper third of the Forearm, from the inner side. The course of the Ulnar Nerve behind and below the Internal Condyle well displayed. The nerve having pierced the Internal Intermuscular Septum, is comes to lie behind this Septum, often embedded in the Triceps Muscle; then, passing behind the Internal Condyle, it runs between the Humeral and the Ulnar Origins of the Flexor Carpi Ulnaris Muscle. The Ulnar Nerve supplies the Inner Head of the Triceps, and both Heads of the Flexor Carpi Ulnaris, giving off an anastomotic branch to the Median Nerve. In man, only a portion of the Flexor Profundus Digitorum, the slips to the 4th and 5th fingers, are supplied by the Ulnar Nerve. Behind the Olecranon is the subcutaneous bursa which is the bursa most frequently diseased, with the exception of the Patellar Bursa (Miner's Elbow). cubital
Cf. Fig. 86.
There may be a Common Ulnar Recurrent Artery (branch of the Ulnar which divides into Anterior and Posterior Ulnar Recurrent Arteries, or these vessels may come off directly from the Ulnar Artery. The Anterior Ulnar Recurrent Artery anastomoses with the anterior division of the Inferior Profunda and the Anastomotica Magna, both from the Brachial Artery, and the posterior branch with the posterior division of the Inferior Profunda. Artery)
Remarks on
the Mechanics of the
Elbow -Joint.
The
articular surfaces correspond to the type of hinge-surfaces, but not has been suggested that they are analogous to screw surfaces. As a matter of fact, they correspond to neither type, although the Trochlea of the
exactly.
It
Humerus has the shape of a screw a lateral movement of the Ulna does
surface shewing an inclination of 0.15 inch,
not take place during flexion and extension. shews that the axis of rotation varies constantly during movement, and that the change in direction is much greater than a simple screw movement would account for. If the movement were a simple rotation, the Ulna should move on the Humerus with as equal freedom as the Humerus on the Ulna; this is not the case according to Otto FISCHER. This joint has, therefore, been described as a loose-joint, but FISCHER has shewn that during life the cartilaginous coverings of the joint continuously change their position and shape during movement owing to the action of the muscles which press them firmly together, and that the joint is no "loose-joint".
Careful
investigation
—
Fig. 85.
Transverse Section through the Right Elbow-Joint.
The section (through a frozen body) has passed, transversely to the axis of the Humerus, throitgli the Trochlea and Radial Head of the bone, through the base of the Olecranon, and the tip of the Coronoid Process of the Ulna.
The with
its
reader looks at a right forearm from above.
elevated border
lies free;
The Head
the deeper middle portion
is
of the
taken up
Radius b}'
the
head of the Humerus. The strength of the Internal and External Lateral Ligaments, the Bursa over the Olecranon, the position of the LTlnar Nerve behind the Internal Condyle, and the positions of Median Nerve, Brachial Artery and Musculo-Spiral Nerve on the flexor aspect are all worthy of obser\ation. The e. the Brachial Artery divides, as a rule, at the level of the line of the joint level of this figure) into Radial and Ulnar Arteries. Below this level, the lumina of these 2 arteries, one superficial (Radial Artery), and one deep (Ulnar Artery), would appear in a transverse section. When the forearm is extended, the tip of the Olecranon Process (cf. Fig. 86), In lies immediately below a line connecting the 2 Condyles of the Humerus. flexion, it lies at a considerable distance below this line. Dislocation of the Ulna or fracture of the Olecranon Process is present, if the Olecranon lies above this line during flexion of the Forearm. radial
(i.
Fig. 86.
Longitudinal Section through the Left Elbow-Joint.
The Forearm is in the position of almost co7nplete extension. The section passed through the Trochlea of the Humerus, the Greater Sigmoid Cavity of the Ulna and through a portion of the Radius ; it is, therefore, intermediate between a frontal and a sagittal section.
1)
2)
Note: The Subcutaneous Bursa over the Olecranon Process. The Deep Bursa, above the Olecranon Process, situated in front (under cover) of the Triceps, or in the muscle substance, just above the upper recess of the Capsule of the Joint.
3)
The Bursa at The insertion
the Insertion of the Biceps (Bicipital Bursa).
on to the Humerus runs along the upper borders of the 3 fossae which receive the Olecranon (posterior) Coronoid Process (anterior larger) and Head of Radius (anterior smaller). These On the Ulna, the Capsule is attached three fossae are therefore intracapsular. to the border of the cartilage of the Sigmoid Fossa or very near that border. On the Radius, the attachment is in the middle between the lower border of the of the Capsule of the Elbow-Joint
—
Head, and the on the inner.
Bicipital Tuberosity,
—
extending lower down on the outer side than
is very thin, but it is strengthened by anterior and and oblique fibres, and especially by the Lateral Ligaments, an Internal and an External Ligament (cf. Fig. 85). The External Lateral Ligament blends with the Orbicular Ligament, of the Radius, which surrounds the Head of that bone and is attached to the Ulna.
The Capsule
itself
posterior longitudinal
(Continuation next page.)
bi vth
Ml ill
111
il
Vittr\
lend
ii
f
Bittps
\\ith liuisii
Bdsilic \ cin j\1iisiiilo-Spir;il
niiipit
I
il
Nerve
iscia
Brarliio-Radialis Muscle ^Supinator Lonj^isi
Brachinlis Anticus Mn-^cli
"^
Kxtonsor Carpi Radialis Longior Muscle
;^^V7/__'|-' \1 A\
Extensor Carpi Radialis Brevior Muscle
\\
Coronoid Process of
Pronator Radii Teres
Muscle Superficial Flexor
External Lateral rnal Lateral Ligament
If -f-^
Ligament
V j
Hunierub
'Radius
Humeral Head
of Flexor Carpi XJInaris
Ulnar Verve'
Ulnar Head of Flexor Carpi Ulnaris Olecranon Bursa
Fig. 85.
Olecranon
Transverse Section through Right Elbow-Joint. Seen from above.
—
Nat. Hize.
Triceps
Biceps Muscle
Bur^a under Triceps Brachialis Anticus
Bicipital Fascia
(
Merranon Bursa
Internal Cutaneous.
Nerve
Tendon
of Biceps
Radial Artery
Median
Basilic
Vein
Brachio-Radialis Muscle (Supinator T,ongus)
Fig. 86.
Deep Radial
Radius
Bursa under Biceps
Muscle
Longitudinal Section through View from outer
Relnimu Limited, Londou.
Side.
—
(left)
Elbow-Joint.
Nat. Size. Rebiuiui Cuiniiiuiy,
New Ymk.
,
Epiphysis of Inti-rnal
—^ —
VV'^
'
'<*
Humerus
'I,
-m
C'luulyli-
_rartiIagiD(ius End of Olt'cranon Process lying ill the Olecranon Fossa
mM
Epiphysis of Trochlea
'
"^ W
Epiphysis of External Coiuhlc
Epiphysis of Capitellum
I^jiiphysis of
Fig, 87.
LoHfi
Head
of Kadii
Frontal Section through (right) Elbow-Joint of a person aged 19 years. Nat. Size. — After von Brunn.
Head
of Triceps
Biceps
Brachialis Anticus Muscle
Brachio-Radialis (Supinator Longus) Muscle
Epiphysis of Trochlea
Epiphysis of Olecranon
Fig. 88.
Sagittal Section through (left) Elbow-Joint of a child aged 8 years. Nat. Size.
RebmuD
Limited, Lumlon.
—
After
von Brunn.
Rebman Company, New York.
(To Fig.
the
86,
former page.)
The lateral ligaments are very important in relation to the movements They become tense in marked flexion and extension. joint. Synovial
continuations
corresponding to
the
3
fossae
supra)
(vide
of
are
formed by the wall of the Capsule: a large posterior, and 2 smaller anterior conThe one first mentioned is drawn upwards and backwards, during tinuations. extension, thus coming to lie above the Olecranon, between this bone and the the 2 anterior Triceps (cf figure). During flexion, it fills the Olecranon Fossa an opposite movement; thus the Anterior Ulnar Synovial Conprocesses present tinuation (cf. figure) lies in the greater anterior fossa in front of the Trochlea of the Humerus, during extension. During extension a recess of the Capsule analogous to the one above is formed above and behind the Olecranon. the Patella in the knee-joint ;
.
—
—
This cul-de-sac extends higher in the living subject than
which, necessarily, was
The
Joint
drawn
is
shewn
our figure,
in
after death.
most readily accessible from behind:
is
—
in
front
there
are
powerful muscles, and large vessels and nerves to be avoided, behind there is onl}' the Ulnar Nerve. Effusion into the joint bulges most at either side of the Olecranon.
Fig. 87 and 88.
Relation of the Capsule of the Elbow-Joint to the Epiphysial Lines. (After voN Brunn.)
Frontal Section through the Right Elbow-Joint of a person aged 19 years.
Fig. 87.
View from behind.
The
Joint-Cavit}' extends far
the Radius;
beyond the Epiphysial Line
but even here, the Capsule arises
cular Cartilage,
and
is
loosely attached to the
(cf.
of the
Head
of
Shoulder-Joint) from the Arti-
Radius as
lower end of
far as the
the cavity.
Disconnection of the united Epiphyses of the External Condyle and the
Head
Humerus from
the rest of the bone will involve the Jointbe affected if the Epiphysis of the Trochlea were separated at the place where the Trochlea and the Radial Head meet.
Radial
Cavity;
of
the
the latter would
Fig. 88.
also
Sagittal Section
through the Left Elbo^v-Joint of a child aged 8 years.
View from the inner
The boundary of
the Olecranon
line
side.
between the Diaphysis of the Ulna and the Epiphysis
passes across the Joint-Cartilage.
—
The Capsule
also extends
above the line of the Diaphysis of the Humerus: Though fairly strong in front and readily removed as far as the Joint-Cartilage it is firmly attached to the Olecranon Fossa, and very thin, thus defying dissection. Separation of the Epiphyses, fore affect the Joint-Cavity.
—
both of
Humerus and Ulna
—
,
will there-
Right Forearm, Deep Layer: Anterior Aspect.
Fig. 89.
The Fasciae of the Anteciibital Space and of the anterior aspect of the forearm are removed, including the Bicipital Fascia, e. g. of the Sii/)erficial Flexors, only their origin and insertion are left. The Deep Head of the Pronator Radii Teres is intact, and the Brachio-Radialis is drawn outwards.
The Brachial Artery divides into Radial and Ulnar usually in front of The Ulnar Artery runs downwards and inwards, under of muscles which arise from the Inner Condyle of the Humerus; below cover the
the line of the Joint.
the middle (or near the middle) of the forearm,
runs along
it
meets the Ulnar Nerve, which
inner (ulnar) side.
its
The Median Nerve,
as a rule, leaves the vessels in the antecubital space,
and runs downwards between the Superficial the Nerve emerges at the outer border of the Flexor Sublimis Digitorum (or Palmaris Longus, if present), and comes to lie
pierces the Pronator Radii Teres
and Deep Flexors. just
Near the
wrist,
under the Fascia. The Musculo-Spiral Nerve
and divides
into
(i)
lies at
the inner border of the Brachio-Radialis,
the Posterior Interosseous, which supplies the Extensors of the
(cf. Fig. 90) and (2) the Radial Nerve, which accompanies the Radial Artery upper 2/3rds of the forearm, and then passes to the posterior aspect (cf. Fig. 93). The Ulnar Ner\-e having pierced the Flexor Carpi Ulnaris, runs, to the along that muscle. At the junction of the middle and lower i/3rd of the hand, forearm, it gives off the Dorsal Cutaneous Branch for the hand (cf. Fig. 93). The Ulnar Artery and Nerve only accompany each other in the lower i/3rd of the forearm. The Anterior Interosseous Artery, the Radial and Ulnar Recurrent Arteries are shown in the figure; these latter are important for carrying on the collateral circulation on the outer and inner sides of the arm respectively. We make special mention of the Lymphatic Glands in this region about which so little is known; in the Antecubital Space: Superficial, Deep, Posterior Cubital Glands; on the forearm: Radial and Ulnar Glands. When the Palmaris Longus is absent and in some cases also where it is present one can make the following observation. When the hand is flexed upon the forearm, the tendons recede, and thus the Median Nerve comes to lie directly under the fascia, where it can be seen, felt and rolled about. The Ulnar Artery becomes at the same time more deepl}' placed, owing to the relaxation of the Flexor Carpi Ulnaris Muscle. When the hand is extended (dorsiflexed) the Median Nerve slides back into position and the Flexor Carpi Ulnaris presses the Ulnar Artery to the surface. The pulse can now be readily felt by
forearm in the
—
—
placing the finger on the outer side of the tendon of that muscle.
The matism, the is
position of the
etc. is
hand and the fingers
Median Nerve.
in greater peril,
at the
moment
of injury,
trau-
more danger for In Extension the Ulnar Artery (and even the Ulnar Nerve)
therefore most important.
In Flexion,
even when no muscle or tendon
is
there
injured.
is
Basilic
CVpIi.ilic
Vein
Vein Suiierficial Cubital Lgl.
Ctitiineoiis Branrh of Mu>;rti It -Cutaneous Xervr I
Hicops Muscle
Deep Cubital
Brachialis -Vuticus Muscle
llicipital
I,gl.
Brachial Artery
I'"ascia
Posterior Culiitiil C;ianil
Tendon
c»f
Bircps Flrxoi Muscles
Anterior Branch of Ulnar Recurrent Artery
Posterior Interosseous Ner\'
Nerve to Extensor Car] Radialis Brevior Miisr'
Anastomosis between Ulnar ;iik1
"Median Ner\'es
Ra'
<
oninion Ulnar Recurrent
Artery Supinator Brevis MuscI
I'ppcr Belly of Superficial I-'Irxor of Index Finger
Ulnar Head of Pronat. Radii Teres Muscle .
Humeral Head
of Pronatn Radii Teres Muscle
Anterior Interosseous Arteiy
Rndial Nerve
Ulnar Lymphatic Gland
Intermediate Tendon of Superficial Flexor of Index Finger
Brachio-Radialis (Supinator Longus) Muscle
Radial Tymphatic Gland
Median Nerve
Radial Head (to 3rd Finger] of Superficial Flexor Muscle of the Fingers
Dee]j Flexor of Fingers
Anterior Interosseous Nerve. and Artery
Lower V^j^
Radial Artery
Tong Flexor Muscle
of
Belly of Superficial
Flexor of Index Finger
Ulnar Artery
Thumb. Ulnar Nerve
Pronator Quadratus ^fuscle Flexor Carpi Ulnaris Muscle
Palmar Branch of ifedian Nerve
Palmar Cutaneous Branch of —Ulnar Nerve
Tendon
of Flexor Carpi Radialis Muscle
Superficial Flexor Muscle of Fingers
Tendon of Palmaris Longus Muscle
Dorsal Branch
'^'Ci'--^^^***^^'*'^"
Fig. 89.
of
Ulnar Nerve
Dr.Froh se
Right Forearm: Deep Layer.
Anterior Aspect.
—
Nat. Size.
Mcduin Xcrvc l'"l(^xor
r;ilmaris
Lon^ws
Miis< Ir
Superficial Flexor of
Carpi Radialis Muscle
tlio
Finpcrs
Radial Artery
Ulnar Artery
Pronator Radii Teres Muscle TTlnar
Brachio-Radialis (Supinator Longus) Muscle
Nerve
Fli-xor C:irpi Ulnaris
Deep Flexor
('ommon Extensor
of Fingers
Mnsilc
of Fingers
^Xj^s^S^^.?-
Posterior Interosseous Nerve Extensor of 5th Finger
Extensor Carpi Extensor Ossis Metacarpi Pollicis
Uliiari^
Transverse Section at the Junction of the Upper and Middle Thirds of the (right) Forearm.
Fig. 90.
Nat. Size.
Superficial Flexors of Fingers
Deep Flexor of Fingers
3rd, 2nd, (th, 5th
Lougus Muscle Median Nerve Flexor Carpi Radialis MuscU ^.„^ Palniaris
/
,
1
i
Long Flexor
of
Thumb
Radial Artery Cephalic Vein
/^
\
^
^
^^'^'^^'^ V
Q^
/ ^^
X^
/''}}
^^~^
.
.
.
lljndi
,
r^
4^
_-^^^£:^^^ "!
^^
Dors;.!
,.
Branch
r,f
Ulnar Nerve
Posterior L'inar Vein
Q5M Ulna
-
Muscle
/C^!!^^-~^ ^S2Llp* -^^^
Pronator Quadratus Muscle
^
/
^Extensor Carpi Ulnaris
Extensor Carpi Radialis Longior Muscle
\
Extensor Carpi Radialis Brevior Muscle P
Interosseous
Membrane
Extensor Indicis Muscle Extensor of Little Finger Common Extensor of Fingers I
Radius
Long Extensor Muscle of Thumb
Posterior Interosseous
Fig. 91.
s^h)
Xervc
x"N/
Extensor Ossis Metacarpi Pollicis
ami
Ulnar Artery _ __
Brachio-Radialis (Supinator Longus) Muscle
Extensor Primi ^y^ Internodii PoIHcis Muscle
(3rd, 4tli
Elexor Carpi Ulnaris Muscle
j
Nerve
Transverse Section through Lower
End
of (right) Forearm.
Nat. Size.
Rebman
Limited, Lomloii.
Rebman Company, New York.
Fig. 90.
Frozen
Transverse Section through the Right Forearm at the junction of the Upper and Middle Thirds.
Vietv of a Kiglit
sec/ion.
Arm from
beloiv,
or a Left
Arm from
above.
On the Flexor Aspect are to be noted Position of the Palmar Branch of the Radial Ner\e (too large in the figure) under cover of the Brachio-Radialis; position of the Radial Artery between this muscle and the Pronator Radii Teres, about 2/5ths inch INIedian nerve in the middle between the Radial and Ulnar Nerves, from the fascia. Between the Median and Ulnar Nerves is the both deeply embedded in the muscles. Ulnar Artery; the Anterior Interosseous Artery runs very near the Radius. Intermuscular Septa are seen between the superficial and the deep flexors, and between the flexor and the extensor muscles. Dorsal aspect Posterior Interosseous Nerve and Artery between the Supinator Brevis and the Extensors. Near the condyles of the Humerus the special Fasciae blend with the Deep Fascia of the forearm at the middle Y„rd they are separate, thus forming rapidly spreads. simple and suppurative the "Lymph spaces" in which inflammation :
;
;
—
—
Fig. 91.
Frozen
Transverse Section through the Right Forearm at the lower end.
section.
I'ieiu
of a Right
Arm from
beloiv,
or nf a Left
Arm
from above.
Radial Artery, where the pulse can be felt and where the between the skin and the bone, separated from the latter Ulnar Artery usually covered by the Tendon by fibres of the Pronator Quadratus. of the Flexor Carpi Ulnaris; at a deeper level, and more towards the inner (ulnar) side Median Nerve, between the Flexor Carpi Radialis and Flexor lies the Ulnar Nerve Sublimis Digitonmi, usually somewhat covered by the Palmaris Longus (cf. Fig. 95), if this muscle is present and normally developed. Fasciae and Septa are coloured blue in the figure which is a supplement to Figs. 94, 97 and 98 in which the tendon sheaths at the wrist are shown. The separation of the special fasciae and the fascia of the forearm (cf. Fig. 90) The fascia forms well carried out here, although there are no synovial sheaths. is also on the flexor aspect special compartments for the Flexor Carpi Radialis, Flexor Carpi This explains why there are 2 Fasciae in front of the Ulnaris and Palmaris Longus. Ulnar Artery, whilst the Radial Artery lies immediately under the fascia of the forearm. An incision for ligaturing the Ulnar Artery, carried along the border of the Flexor Carpi Ulnaris, divides not only the fascia of the forearm, but a second fascia which becomes This fascia forms the posterior wall of the fascial canal, in which thicker lower down.
Note: Portion
artery
is
of the
generally ligatured,
—
—
the muscle runs.
The Pronator Quadratus is covered by a fascia of its own. It is true that the other Flexor Muscles and the Median Nerve also have their own fasciae, but they are of no practical importance, and one should regard these muscles as lying in a common "Lymph Space" which ends below at the upper limits of the Tendon Sheaths and is bounded on either side by the Septa forming the canals for the 3 muscles mentioned Above, this Lymph Space is continued into the arm, along the Vessels and above. This explains the danger (and also the necessity of making deep incisions) of Nerves. deep suppuration
in
the forearm.
—
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Nerves and Veins on the Dorsum
Fig. 93.
A
the Right Hand.
of
fresh specimen, hi which only the skin has been removed.
(The Veins and
Nerves on the jrd finger have been drawn after RtrD/NGERs Atlas of the Nervous System.)
Nerves: The Dorsum and
the Radial
of the
the
of
Ulnar Nerve.
moreover, there
is,
of fibres occurs
between these
hand
nearl}' always, at least
nerves: this explains wh}- in injury, paralysis
2
The fingers
(2
—
2
dorsal
and
5),
of
one anastomosis, and thus an exchange etc.,
Dorsum
In most cases they divide the
hand equally between them; the axis
dary between the
by Sensory Branches
supplied
Their areae of distribution are not constant;
the loss of sensation ma}' be very slight. of the
is
middle finger being the boun-
of the
areae.
surfaces of the distal phalanges (2nd and 3rd) of the 4 inner of the terminal
phalanx of the thumb are innervated by nerves
running on the palmar surface, thus the Median supplies the 2nd and 3rd phalanges of 3rd fingers completely,
The
and the outer half
of those of the 4th finger.
may
be innervated only by the Radial Nerve; there here,
although
these bodies 'are
usually
Median and Ulnar Nerve
the branches of
also
found on (cf.
many
as to
4)
of
the
because the
the hand,
of b)-
the
Deep Ulnar Nerve.
flows from the fingers on the dorsum through several
Superficial Veins
which begin
at the first
venous channels, the Radial and Posterior Ulnar Veins.
Tendons
palmar surface along
Fig. 95 middle finger).
Dorsal Interossei are supplied, like the Palmar Interossei,
Veins: The blood
be Paccinian Corpuscles
the
There are no Motor Nerves on the Dorsum
(as
thumb may, however,
dorsal surface of the terminal phalanx of the
phalanges into larger
The former
crosses the
Extensor Primi Internodii, Extensor Secundi Internodii, and
Extensor Ossis Metacarpi
Pollicis
(cf.
Fig. 92)
and then runs upwards on the
anterior surface of the limb.
The Veins and Nerves and the Tendons is
are quite superficial,
of the Extensors.
The
formed by transverse and oblique
forearm. text).
e.
they
lie
between the skin
Posterior Annular Ligament
fibres
This fascia becomes very thin
i.
which strengthen the
in the
dorsum
of the
hand
(cf.
figure)
fascia of the (cf.
Fig. 92,
;
Fig. 94.
Tendon Sheaths on the Dorsal Aspect
Skin, Superficial Fascia,
Vessels,
the Right Hand. and Nerves have but supposed to be
except the Radial Artery,
The Posterior Annular Ligament
been removed.
of
is intact,
transparent.
The tendon or synovial sheaths of the Extensor Tendons lie in special compartments between the Periostium of the bones of the forearm and the wrists on one hand, and the Posterior Annular Ligament on the other hand; they e. as far as transverse fibres are present extend upwards as far as this ligament, below, they extend 1^1^/4 inch beyond the ligament. The synovial sheaths may, however, extend higher (^/r.ths inch or more above the highest transverse fibres, vide infra). Starting at the outer (radial) side, and going inwards, we find 6 Compartments and Sheaths for the Tendons of the following muscles: Pollicis, and Extensor Primi Internodii; the 1. Extensor Ossis Metacarpi sheath for the latter muscle is about y.^ inch longer than the sheath for the former. 2. Extensor Carpi Radialis Longior, and Extensor Carpi Radialis Brevior. The latter crosses the Radial E.x. tensors 3. Extensor Secundi Internodii. These three sheaths e. posterior to them. at an acute angle, lying on them, usually communicate, and are to be considered as forming practicall)' one sheath. The two tendons 4. Extensor Communis Digitorum and Extensor Indicis. for the index finger lie in one sheath which communicates with the common sheath for the 3rd, 4th and 5th fingers. The index sheath is, however, shorter. The sheath of this muscle, which sometimes 5. Extensor Minimi Digiti. has two tendons (cf. figure) is usually longer than the others mentioned above. 6. Extensor Carpi Ulnaris, this sheath is quite short, because the muscle ends at the base of the 5th Metacarpal Bone. The broad tendinous slips which connect the tendons to the 2nd, 3rd and i.
i.
4th fingers are remarkable. ation
of
which
is
one
they probably represent the formanalogous to the one on the palmar aspect
Morphologically,
broad aponeurosis,
fully developed.
Subcutaneous Bursae are shewn (cf. figure) on the 2nd and 3rd fingers. They are due to continuous pressure (professional bursae). The Tendon Sheaths accompany the movements of their tendons. The distal ends of those sheaths which belong to tendons inserted into the metacarpal bones, are easily determined. In order to find the distal ends of the others, the fingers should be completely flexed and hardened with injections of Eormalin. The proximal ends were determined, from another specimen, in the dorsiflexed position with extended fingers (cf. the black and red lines above the posterior annular ligament).
The length
Tendon Sheaths
according to the size of the hand. Those of the Extensors of the Carpus are the shortest and of about equal length (Vi5~Vi5 inch). The sheath of the Extensor Communis Digitorum which It is someoften contains several compartments, varies most (3^5 3-/5 inches). of the
varies
—
times longer in small hands than in large ones. largest
sheaths.
Extensor Secundi Internodii,
The weakest tendons have Extensor Primi Internodii,
Extensor Minimi Digiti; their respective lengths are: 2Y5 inches.
— 2%;
2^5
— 2V5;
2^1^
the
and
—
3Vf,
iLxtcnsor liidicis Muscl
Ulna
Extensor C;upi Ulnari:
Extensor Carpi Katlialis Longior Muscle
Muscle
Extensor Minimi Digiti
Extensor Carpi Radialis Brevior Muscle
Muscle
I
Extensor Ossis Metacarpi PoUicis Muscle and Extensor Primi Internodii
Extensor Communis
Dif^torum Muscle
Pollicis
Muscle
Radial Artery -Vbductor Minimi ^luscle
Dij^iti
Extensor Secundi Internodii Pollicis
Muscle
1st
Dorsal Interosseous
Muscle
Subcutaneous Dorsal ^letacarpo-Phalangcal Bursa
Subcutaneous Dorsal Bursa on Index Finger
Fig. 94.
Tendon-Sheaths on Dorsal Aspect of Right Hand. Nat. Size.
Kebman
Limited, Londou.
Rebmau Company, New York.
Flexor Sublimis Digitorum Muscle
Jhisrulo-Cut.iiKdUS XiTVi-
fM\ Flexor Carpi Ulnaris JIuscU^
Palraaris
—
|—r,
W
"
l<'"li''l
^^tTVf
Kadial Artt-ry Pronator
Longus Muscli-
Quatlr.itii^
Miisclf
Flexor Longus PolUcis Muscle
Dorsal Branch of
Ulii;ir
Krrve
Median Nerve Ulnar Artery Flexor Carpi Kadi.ilis Muscle
Ulnar Nerve Extensor Ossis Metacarpi PoHicis Muscle
Annular Ligament
— Deep Branch
of
Sftperficialis V'olac
Artery
Ulnar Nerve Abduct'.r PoUicis
TVriisch-
Transverse Carpal Ligament \
Palmaris Brcvis Muscl
Superficial
Muscubir Branch of Mrdian Nerve
Palmar Arch
l'"lexf>r
Brevis PolUcis
Muscle
Abductor Minimi Digiti Mnscle -Vbductor
I'ollicls
Muscle
4th Lumbricalis Muscle
1st
Dorsal Interosseous
Muscic
Pig. 95.
Palm
of
Hand
(left)
:
Superficial Layer.
Nat. Size.
Rebman
Limited, Luiidon.
Rebman
Coin))aiiy,
New
York.
;
Fig. 95.
Palm
of
Hand
(Left); Superficial Layer.
The Palmar Fascia has been removed almost completely, the Annular Ligament partly, and all the veins have been cut away.
Arteries. At the wrist the Ulnar Arter}' Ligament and the Transverse Carpal Ligament it may, give off the branch which with the Pisiform Bone ;
—
passing to the deeper layers
Nerve
in
lies
between the Annular
at this point
— in
contiguity
deep palmar arch, association with the deep branch of the Ulnar joins the
(Fig. 96).
In the palm of the hand, covered onty by the palmar fascia, lies the Superficial Palmar Arch. This arch is formed by the continuation of the trunk of the Ulnar Artery, and is often completed by an anastomosing branch from the Radial Artery. (Cf. text, Fig. 92.) Nerves. In the lower part of the forearm the Median Nerve lies on the outer aspect of the Palmaris Longus Muscle, or in the case of absence of In the this muscle on the outer side of the Flexor Sublimis Digitorum Muscle. palm of the hand the nerve is more superficial than the tendons. (Cf. Figs. 103, 104.) The Median Nerve supplies the palmar (flexor) aspect of the three outer fingers and the outer border of the fourth finger whereas the Ulnar Nerve supplies the palmar aspect of the fifth finger and the inner border of the fourth finger.
The Median Nerve
supplies the short muscles of the thumb except the Adductor Transversus Muscle and the Adductor Obliquus Muscle; b) the two Outer Lumbricalis Muscles, and a part of the third (which also Bardeleben and Frohse). derives a supply from the Ulnar Nerve The Ulnar Nerve supplies a) a part of the third Lumbricalis Muscle as well as the fourth; b) all the muscles of the little finger; c) all the interosseous muscles; d) the Adductor Transversus Muscle and the x\dductor Obliquus Muscle of the Thumb. When the hand is slightly dorsiflexed (cf. text, Fig. 89) the Ulnar Artery and a part of the Ulnar Nerve are shewn above the Annular Ligament. The Tendons of the Flexor Sublimis Digitorum Muscle are arranged in two layers those to the 3rd and 4th fingers are situated more superficial (cf. Fig. 91), those a) all
—
—
The Median Nerve is contiguous to the 2nd and 5th fingers at a deeper plane. to the tendon of the 3rd finger. The sheath of the Flexor Carpi Radialis Tendon is laid open at its proximal end the Extensor Ossis Metacarpi Pollicis sends a slip to the Abductor Pollicis Muscle. The Thenar Eminence is chiefly composed of muscles whereas ;
is a thick layer of fat containing a cutaneous the Palmaris Brevis Muscle. tense it is very The Palmar Fascia is of great practical importance, and strong, bridging over the space between the Thenar and Hypothenar Eminences its intimate connection with the skin explains why the latter cannot be picked up and why celluhtis of the hand is dangerous. This dense fascia prevents the infective process from spreading towards the surface while the delicate tendonsheaths and the loose tissue which surrounds them affords a favourable means of Injury is well known to produce very free haemorrhage due to the extension. abundant anastomosis in this region. The nerve supply is most complete, numerous Pacinian Corpuscles are
upon the Hypothenar Eminence muscle
—
observed
(cf.
—
Fig. 93).
Palm
Fig. 96.
of
Hand
(Left);
Deep Layer.
In addition to those structures removed in Fig. pj, the distal portions of the Flexor Sublimis Digitorum and flie Flexor Profundus Digitorum (except in connection ivith the little finger) muscles, the Palmaris Longns Muscle, the Superficial Palmar Arch and the deep fascia of the hand have been cut away. A piece of the Abductor Pollicis Muscle has been excised, and the Pronator Quadratus Muscle exposed.
The Deep Palmar Arch formed by with the deep division
the Ulnar Artery
the junction
plane than the flexor tendons and the deep fascia,
between the
superficial
(cf.
Figs. 97
—
The deep
deep branch of lies at a
in
the
deeper middle
"the
palmar aspect
of the
104).
Ulnar Nerve accompanies the deep arch as far Muscle and the ist Dorsal Inter-osseous all the Interosseous muscles, having given off, in the Hypothenar Group of Muscles and the two inner
division of the
Adductor Transversus Muscle, passing on to suppl}^ the fibres to
course,
practicalh',
bones nearer the dorsal than
as the
its
the
arch and the distal border of the carpal bones, on the
bases of the metacarpal
hand
of
Radial Artery
of the
Pollicis
Lumbricalis muscles.
The tendons and (cf.
Figs. g8
—
to the phalanges.
their
sheaths
Most important
loi).
When
phalanx no suture position of flexion;
is
Osseo - Aponeurotic Canal
an
in
these tendons are divided near the base of the terminal
required,
but
run
the relation which the flexor tendons bear
is
as
it
is
quite sufficient
to fix
the finger in the
the division should occur at the intermediate phalanx,
if
suture of the cut ends of the tendon
The Flexor Profundus interphalangeal articulation
;
is
necessary.
perforates the Flexor
Subhmis tendon
at the first
accordingly at this point there are three tendinous
At the base of the first Phalanx (proximal phalanx) there are only two tendons to be sewn together. The flexor tendons are enclosed within a fascial canal and often retract considerablj' towards the muscular portion when divided. The distal end retracts to a marked extent when the injury occurs in extreme strands.
flexion
which
g. when a bottle breaks in the hand). Under such conditions it ma\' be necessary
(e.
is
relatively
thin
at the joints
(where
it
is
to
open up the tendon-sheath
reinforced by a few delicate
transverse and oblique fibres) but dense opposite the shaft of the
first
and second
phalanges. In addition to the sensory communication shown in Fig. 95 as a loop around the Ulnar Artery and the motor communication in the 3rd Lumbrical Muscle, others occur. One inconstant communication occurs between the dorsal branch of the Ulnar Nerve and the branch to the inner aspect of the little finger. Another of greater constancy passes through the Adductor Transversus Pollicis Muscle where becoming more superficial it winds round the Flexor Longus Pollicis Muscle and joins the Muscular branch of the Median Nerve.
Palmaris Longus Muscle Flexor Subliniis Digitonim Muscle y Flexor Sublimis Slip to Index Finger*
Supinator Longus Muscle
^
Radial Artery Flexor Sublimis Slip to Little Finger
-—
Flexor Profundus Digitoruin Muscle
Flexor Carpi Radialis Muscle
Median Nerv;
Pronator Quadratus iluscle
Flexor Longus Pollicis Muscle
Dorsal Branch of Ulnar Ner\-e^ Extensor Ossis Metacarpi Pollicis
Muscle Flexor Carpi TJlnaris Muscle
Abductor Pisiform
Pollicis
Opponens
Deep Branch
of
Muscle
Bone Pollicis
Muscle
Ulnar Artery Muscular Branch of Median Nerve
Deep Branch
Ulnar Nerve
of
Ulead
"'^''^P
Deep Palmar Arch
'
^
of Flexor Brevis Pollicis ^^"^'-"l*^
uper L-rficial)
4th Lumbricalis ifuscle
Flexor Longus Pollicis
Muscle
Palmar and Dorsal Interosseous Muscle Adductor
Pollicis
^ 1st
Lumbricalis Muscle
Muscle Transverse Metacarpal
Ligament 1st
4th Dorsal Inter-
Dorsal Inter-osseous iluscle
osseous Muscle
Division of Flexor Sublimis Digitorum
Flexor Sublimis
Tendon
_
Digitorum Muscle
Flexor Profundus Digitorum iluscle
Chiasma Tendinum
2nd Phalanx of Index Finger
Vincula Tendinum
Flexor Profundus Digitorum Muscle
Fig. 96.
Palm
of
Hand Nat.
Rebmaii Limited, Loudou.
(Left):
Deep Layer.
f^ize.
Rebmau
C'oniiiaiiy,
New Ymk.
Fig. 97.
Palm
of
Hand
(Right) '/j
Robiuan Limited, Londou.
:
Tendon-Sheaths and Large Arteries.
Nat. Size.
Rebman Company, New York.
Palm
Fig. 97.
of
Hand
(Right); Tendon-sheaths and large Arteries.
Palmar
This diagram illustrates the Flexor Tendon-sheaths, the large
more
the
definite
furrows of
of the palm, in addition
the skin
arteries,
to the outlines
of the bones of the hand, as shewn in a skiagram.
The more
definite furrows of the
M or W according
of
to
Palm
of the
hand present the appearance
whether they are viewed from the inner or outer aspect
of the limb.
The
the second upstroke
fingers;
5tli
from the ulnar
of the
lines)
skirts the
around the
runs almost transversely across
(or third line)
or initial downstroke joins the
line,
M, and
third line
whereas the
is
variable
in
its
continuit}'.
is
two upstrokes
The
last
(ist
and
stroke of the
M
the most important guide for the superficial Palmar arch,
and third
first
lines
combined approximately mark the proximal
limitation of tlie tendon-sheaths of the 2nd, 3rd
A g8—
further
description
these
of
and
4tla fingers.
tendon-sheaths
is
found
in
the
text
loi).
The Tendon-sheaths become
A
and
Thenar Eminence.
The
(Figs.
balls of the 3rd, 4th
to the radial side of the hand.
The second 3rd
M curves
upstroke of the
initial
of great importance in inflammatory conditions.
whitlow originating at the proximal phalanx
may
invade the tendon-sheath at
the base of this phalanx and extend to the palm, thus endangering the whole hand.
At there
is
the Osseo-aponeurotic canal completed
formed a constriction
by the
of the tendon-sheaths
conditions as Tuberculosis of the Tendon-sheath
anterior
Annular Ligament
so that in such pathological
and Tenosynovitis the swelling
presents a constriction at the Annular Ligament with an enlargement both above
and below
this structure.
The wrist-joint
fold
between the hand and the forearm corresponds roughly
which extends higher
The groove between corresponds to the is
joint,
the
into
first
the forearm
(proximal)
with
its
convexity upwards.
and second (intermediate) phalanges
but the joint between second and third
situated Vio to V^ inch distal to the groove.
to the
(distal)
phalanges
Figs. 98
Palm
loi.
of
Hand
After JoESSKi. and (Cf.
(Left); Tendon-sheaths.
von Rustih
Fig.
)|
97.)
The tendon-sheaths of the P'lexor Muscles (Flexor Sublimis Digitorum and Flexor Profundus Digitorum; Flexor Longus Pollicis) extend from a distance of a little less than an inch above the Annular ligament far into the palm of the hand. one for the Flexor Sublimis There are generally two tendon-sheaths and Flexor Profundus Digitorum Muscles, another for the Flexor Longus Pollicis Muscle which are frequently in communication.
—
—
The sheath
Flexor Carpi Radialis Muscle extending from the is of but little practical importance. The large flexor tendon-sheath shews after inflation a bulging above the constriction caused b)^ the annular ligament. On the inner side of the hand the sheath extends lower down, and invariably communicates with the sheath for the tendons of the of
the
trapezium to the 2nd Metacarpal bone
little
finger.
In a similar
manner the Sheath
of the Flexor
Longus
Pollicis
extends as
far as the Distal phalanx.
This
is
a ver\' important point of practical application because suppuration
of the sheath of the
thumb
or of the
finger always extends into the main
little
sheaths; this does not occur in the case of the 2nd, 3rd or 4th digits.
Moreover, we have herein an explanation of the extension of Suppuration from the thumb to the little finger and vice versa — the inflammatory process passing from the thumb to the main flexor sheath and into the sheath of the Uttle finger owing to the free communication. The Median Nerve is situated between the main Sheaths and the Annular Ligament whereas the Ulnar Nerve lies superficial to the ligament so that it only comes in close relation with the main sheaths above and below this structure. The Ulnar Artery, not shewn in the figure, lies nearer the Sheaths than the Ulnar Nerve. The Tendons of the Flexor Sublimis and Flexor Profundus muscles lie in common sheaths as they extend down upon the fingers from tlie metacarpophalangeal joints as far as the bases of the terminal phalanges, of the
i.
e.
the insertion
Profundus tendons. Injury,
therefore,
to the terminal
phalanges
distal
to these points
would
not involve the sheaths.
Figs. 99 and 100 depict
.variations which are described by some authors a third sheath being inserted as a wedge, between the two main sheaths at their proximal end When this third sheath becomes markedl}'^ developed (Fig. 100) tlie tendon of the Flexor Profundus passing to the Index
as normal
—
—
finger
is
transmitted through
.
it.
The somewhat complicated arrangement muscles
is
of the tendons of the
long flexor
schematically represented in Fig. 101.
The "Mesotendina" analogous cross-section.
to
the Mesenteric folds, are
shewn
in the
Flexor Longus
I'ollicis
Muscle
Flexor Muscles (Sheath) to Little Finger
Jledian Nerve
Ulnar Nerve
Flexor Carpi Radialis Muscle
Proximal End of Common Synovial Sheath
Fig. 98.
Fig.
98—101.
Fig. 98
Rebmau
Fig. 100.
Fig. 101.
Fig. 99.
Limited, Lomlou.
Palm
of
and 101 /, Nat.
Hand
Size, Fig.
(Left); Teudon-Sheaths. 99 and 100
'/,
Nat. Size.
Rebman Company, New
Ynil-,
1st
5th Mctar.irp;!!
^Ict.itTarpal Boiic
Vnnu
Trapezium Uncifurni
Bone Trapezoid Bone
Cuncifnrm Bone
Pisiform
Bone
Semilunar Bi Triangular
Fibro-Cartilagc
Fig. 102.
—
Horizontal Section through the Articulations.
Rebman
Limited, Loudo
—
Dorsum
of the
Right Hand.
Nat. Hize.
Rcbman Compauy, New York.
Horizontal Section through the
Fig. 102.
Hand;
A
horizontal section
culations ivhich
lie
lias
exposed
lie
independently, viz: a) Cuneiform
The following hand i)
:
Right
of the
Articulations.
from
to vieiu
the dorsal aspect
all the arti-
between the forearm above and the Metacarpal bones below,
but those joints which do not
in the
Dorsum
in the plane
— Pisiform,
of the section have been opened b)
Trapezium
or combination
Joint Cavities
— ist
Metacarpal.
are found
of Joint Cavities
—
Joint between Radius, Scaphoid
&
Semilunar extending almost to the
Cuneiform but separated from the following Articular
Fibro-Cartilage,
"the
joint
by the Triangular
Radio-Carpal Articulation", the Wrist
Joint Proper. 2)
Joint between
Head
of Ulna,
Radius and
Inter-articular Fibro-Cartilage,
"the Inferior Radio-UInar Articulation". 3)
Joint
between the Cuneiform and Pisiform Bones.
4)
Joint
between the Trapezium and the
5)
Joint
between
Metacarpal Bone.
Unciform Bone and the bases of the 4th and 5th
tlie
Metacarpal Bones;
this
Combination of the
6)
ist
may communicate cavities
joint
with the following
between the
(6).
surfaces of the
distal
Scaphoid, Semilunar and Cuneiform Bones, the proximal surface of the
Unciform Bone,
all
the articular surfaces of the
Trapezoid, the inner surface of the Trapezium
2nd and
3rd Metacarpal Bones.
"Intercarpal
Os Magnum and and the bases
the
of the
and Carpo-Metacarpal
Articulation".
The wide extension
of No. 6
forms an important point
in the
spreading
of pathological processes.
The Dorsal and Palmar ligaments so
that
extreme Dorsitlexion
result in a fracture
ligaments. or fibular.)
of the
(Lecomte;
cf.
(e.
g.
as in a
of the Carpal Joints fall
on the hand)
lower end of the radius than
in
are is
very strong
more
likely
to
a rupture of these
the behaviour of the malleoli, in particular the external
Fig. 103.
Transverse Section through Carpus.
Frozen section viewed from
the Fingers.
p'd Metacarpal Bone have been sawn through.
the Styloid Process of the
On
the back
The second row of Carpal Bones and
hand the Extensor Tendons, on the outer
of the
Extensor Ossis Metacarpi and the Extensor Primi Internodii of the
hand the Flexor Tendons are shewn
to the
Bones
of the
side
the
the palm
Pollicis, in
each other and
in their relations to
Hand.
The Concavity
Carpus with the tunnel completed by the Anterior
of the
Annular Ligament are well shewn. Radial
Note:
becoming more
The Median Nerve
Ulnar Artery, and Nerve.
Artery;
approximation to the Flexor
superficial at the wrist, lies in close
Sheath, and directly under the Palmar Fascia.
(Vide Figs. 98 and
Fig. 104.
loi.)
Transverse Section through Palm
Left Hand, seen
Frozen Section.
from
tlie
of
Hand.
fingers.
The Flexor and Extensor Tendons have diverged towards
The median nerve has divided
inner (ulnar) or outer (radial) side.
branches. evident.
The
fleshy
The Radial
either into
the
many
muscles of the Thenar and Hypothenar Eminences are
and
Ulnar Arteries have divided
so
that
the
smaller
branches of the Radial, with the exception of the Princeps PoUicis artery, are scarcely visible
;
the branches of the Ulnar Artery are readily found
the nerves on the
Palmar aspect near the 4th Metacarpal Bone.
The Palmar Fascia which bridges over and Hypothenar Eminences
bound firmly
to
or their sheath,
it
accompanying
is
the
space between the Thenar
of great practical importance,
so that suppuration deep to the fascia,
becomes pent
up,
and deep
incisions
i.
e.
of the
hand
is
well shewn.
(Cf. Foot.)
is
around the Tendons
become necessary
evacuation of the pus.
The concavity
because the skin
for the
Styloid Process of 3rd Metacarpal
/
Trapezoid Bone Klexor Profundus Pigitoruin to Index Finger
Bone
Extensor Indicis INIuscIe
Extensor Carpi Radialis Brevior Muscle
/
Tendon
Os Magnum Extensor Communis Digitorum Muscle
/
Dorsal Branch of Ulnar Nerve
Median Nerve^ Extensor Carpi Radialis Longior^
Unciform Bon
iluscic
Radial Arter>\ Extensor
]\Iiniini
Digiti
Muscle
Flexor Carpi Radialis Muscle
Extensor Sccundi Internodii Pol ids Muscle Flexor Longus Pollicis ilusclc.^
^
I
Flexor Profundus Uigitorum ^luscle
Trapezium
Extensor Carpi Ulnaris Muscle
Abductor Minimi Digiti Muscle
Extensor Primi Tntcrnodii I'ollicis Muscle Superficial Branch ot Radial Nerve Extensor Ossis Metacarpi Pollici: Muscle
Opponens Minimi
-—Ulnar Nerve
^
Tuberosity of Trapcziuni--
Opponcns
Pollicis
Abductor
of
Unciform Bone
Ulnar Nerve
Muscl
I'almaris Brcvis
Anterior Annular Ligament
Fig. 103.
Palmar
Deep Division
Opponens Minimi Digiti Muscle
""Hook
Muscl
Pollicis
—
Digitt iluscle
—
Superficial Division
Muscle
Ulnar Artery
Fasci.
Transverse Section through Carpus (Left): Distal Aspect. Nat. 8ize.
Extensor Indicis ^lusclcajiEj
Deep Palmar Arch
Extensor Tendon to jrd Finger
Deep Division
osseous Muscle Inter-osseous Muscle
Flexor Longus 1st
4th Lumbrical ilusclcs
Dorsal Intcr-osscons Muse
Adductor Tiansversus Muscle I'^xtonsor
Dorsal Branch of Ulnar Nerve
Pollicis
Secundi Internodi
Pollicis
Deep Palmar Fascia
Muscle
Deep Dorsal Fascia
Extensor Primi Internodi Pollicis 1st
Muscle
Extensor Minimi Digiti Jluscle
Metacarpal Bone
Ulnar Artery Branch of Radial Nerve
Superficial
Flexor Profundus Tendon to Little Finger
Princeps Pollicis Artery
Opponens
Pollicis
Opponens Minimi
Muscle // y
Digiti
Abductor ^Minimi Digiti
Flexor Brcvis Pollicis Muscle
Abductor
Pollicis
•^J J
Muscle
Flexor Minimi Digiti Digital Branches of Ulnar
1st
Lumbrical Muscle
Median Nerve
—
Nerve
Digital
Branches
Palmaris Brevis Muscle
Palmar Fascia
Fig. 104.
Transverse Section through Palm of
Hand
(Left)
:
Distal Aspect.
Nat. Size.
Rebmau
Limited, LouiJou.
Rebman Company, New York.
Supra-clavicular
Branches
Supra-clavicular Branches
Posterior Cutaneous Branches of Intercostal
Lateral Cutaneous Branches of Intercostal Nerves
Lateral Cutaneous Bran< hes of Intercostal
Nerves
Nerves (Intercosto-
Humeral Nerve) Cutaneous Branch Circumflex Nerve
»f
Cutaneous Branch of Circumflex Nerve Internal Cutaneous Nerve and Lesser Internal Cutaneous Nerve (Nerve of
Anterior Cutaneous Branches of Intercostal Nerves
Wrisbf.rg)
Internal Cutaneous
Nerve and
Upper External
Lesser Internal Cutaneous Nerve (Nerve of WrisukiiO)
Cutaneous Branch of the Musculo-Spiral
Nerve
Upper External Cutaneous Branch of the Musculo-Spiral Nerve Posterior Division of the Internal
Cutaneous Nerve
Lower External Cutaneous Branch of the MusculoSpiral Nerve
Lower Externa! Cutaneous Branch of the Musculo-Spiral
Nerve
Cutaneous Portion of Musculo-Cutaneous
Cutaneous Portion of Musculo-Cutaneous
Nerve
Nerve Anterior Division of the Internal
Cutaneous Nerve
Palmar Cutaneous Branch of Median Nerve
Palmar Cutaneous Branch of Ulnar Nerve
Radial
Nerve
Ulnar Nerve
^ledian
Nerve
Fig. 105
and 106.
Rpbman
Areae of Distribution of Cutaneous Nerves
Limited, London.
of the "Upper
Extremity (Right).
Rebman Company, New York.
Areae of distribution of Cutaneous Nerves Upper Extremity, (right).
Fig. 105 and io6. of
Outlines of Figs, after Fau's Atlas.
Colours correspond
to those
employed for
the spinal segineiiis in the subsequent figures.
areae of distribution of the nerves of the
Unfortunately the their variations
have not been completely worked
and the Trunk by Frohse and Zander.
For
hmb and
out, as in the case of the
Head
purposes the diagrams
practical
will probabl}' suffice.
The upper The front
Nerves.
part of
Nerves (yellow)
Intercostal
the shoulder
of
the chest
is
the back
,
(green)
supplied
from the Cervical
supplied
is
by the Anterior Branches
The
by the Posterior Branches.
of the
Lateral
Branches suppl\^ the Axilla and even the upper part of the inner aspect of the arm.
When
the
arm
is
supinated the anterior boundary between adjacent areae
of distribution extends
down
tip of the 4th finger.
But the posterior boundar}'
the
arm
the middle of the anterior aspect of the line
runs
down
arm
to the
the middle of
to the 3rd finger.
The following points should be observed — The upper part of the shoulder is supplied :
the Supra -Clavicular
b}-
and Supra-Acromial Branches of the Cervical Plexus.
The lower Below of the
part of the shoulder
this level the
arm corresponding
by the Circumflex.
Musculo-Spiral supplies the skin on the outer aspect
to the area supplied
b\-
the Internal Cutaneous (red)
(A further
and Lesser Internal Cutaneous Nerves on the inner aspect.
branch from the Musculo-Spiral Nerve pleting
— Gegenbaur
tlie
supply of this region.)
On
the inner part of the anterior (flexor)
—
may
surface of
assist
internal in
the forearm
com-
is
to
be found the Internal Cutaneous Nerve, the dorsal branch of which supplies the inner aspect of the posterior (extensor) surface; on the outer aspect of the back of the
forearm the chief nerve
supplied
in the
the
Radial,
by the Musculo-cutaneous Nerve. In the palm of the hand the cutaneous
and Ulnar (brown) finger.
is
is
divided
by a
line
only
a
very small
distribution of the
area being
Median
(violet)
which runs along the axis of the 4th
Median and Ulnar Nerves supply smaU areae On the outer side a small area of the Thenar
Special branches from the
upper part of the Palm.
eminence
is
supplied by the Radial Nerve.
The Dorsum of the hand is supplied equally by Radial and Ulnar Nerves, but where these become wanting in the case of the 2nd, 3rd and 4th fingers, their deficiency is made up by the Median Nerve. (Cf. Fig. 106.)
Cutaneous Nerves, according to their Segmental
Figs. 107 and 108.
(Spinal) Origin.
The nerves distributed to the upper extremit}' are derived from the segments -- 4th Cervical and 2nd Dorsal inclusive. The distribution is such that the upper segments pass to the outer side and the lower the origin of the nerves, the more internal is their distribution. The thick black lines situated on the Anterior and Posterior aspects of the arm indicate the boundary between the rostral and caudal parts of the limb, the correct continuation of this line on to hand
the forearm and
WiCHMANN
not yet defined.
is
that it should continue between the dark-blue and violet areae to the distal end of the ist Metacarpal bone on both the anterior and posterior aspects. The segmentary distribution over the attachment of the limb to the trunk differs in front and behind. The posterior divisions of the Cervical Nerves ramify over the posterior aspect: VIII. C and i. D have, as a rule, no posterior division, so that 2. D follows VII. C; again, i. D has not usually even an anterior division, so that the 2nd intercostal nerve foUows directly upon the Supraclavicular branches is
of opinion
distributed to the chest.
The boundaries between
the intercostal
nerves are diagrammatic
in
the
middle V.f of ^ colour accurately represents the nerve indicated, the upper and lower thirds being the upper and lower association
figure inasmuch
as
only
the
areae of the nerves. less definite than indicated; moreover on the inner side where the red area may more extensive and with the brown may pass even as far as the 4th finger. The following segments correspond to the different nerves.
In the limb the limitations are
there are
be
far
many
IV. C:
V.
C
much
variations particularly
—
the supra-clavicular nerves.
(VI. C):
—
(V. C) VI. C, VII.
—
the cutaneous branches of the circumflex.
C
(VIII. C)
:
-
the cutaneous branches of the Musculo-Spiral.
VI.
C
On
the inner aspect of the limb
:
the cutaneous branches of the Musculo-Cutaneous. the Dorsal Nerves enter
at
the upper
Nerves at the lower. The Intercosto-humeral belongs to the one takes the 2nd Dorsal segment as belonging to this Plexus. The Interna] cutaneous is chiefly derived from i. D and VIII. C. The band (VII. C) gives the boundary between VI. C and VIII. C as these
part, the Cervical
Cervical Plexus violet
if
nerves ramif}' over this area. defined.
The area of the Median and Ulnar Nerves in the hand are not accurately' The dorsal branch of the Ulnar Nerve chiefly contains VII. C the ,
palmar branch VII. C (only represented in the figure) and i. D. The Palmar branches of the Median Nerve correspond to VI. C and VII. C, the digital branches to VI. C, VII. C, VIIL C (the nearer to the inner side, the lower is the origm of the fibres in the cord). The outer side of the 4th finger ma}- even be partially supplied b)' i. D.
Pigs. 109 and no. Nerve-Supply of the Muscles of the Upper Extremity, according to their Segmental (Spinal) Origin.
The segments are given partly according In
the
text,
to
WICHMANN
and BOLK,
Arabic figures represent the Cen'ical Segments,
Roman
the first
Coloiin as in Figs. loy
I.
and
partly after
Dorsal
ZIEHEN.
indicated by n
is
108.
The ventral muscles of the superficial layer of the shoulder-girdle are the SternoMastoid and Pectoralis Major; those of the deep layer the Subclavius and Pectoralis Minor. That portion of the Spinal Accessory Nerve which supplies the Stemo-Mastoid Muscle contains 2. C. and 3. C. The Anterior Thoracic Nerves divide into several branches; the upper segments are for the Pectoralis Major 5. C, 6. C, 7. C. (Clavicular portion 5. C), 8. C. in some cases also supplies the lower segments are for the Pectoralis Minor 7. C, 8. C. ;
the lowest fibres of the Pectoralis Major.
The Nerve to the Subclavius Muscle is composed uf fibres derived from 5. C. and 6. C. The superficial layer of the Extensor Muscles of the Shoulder-Girdle is composed and Latissimus Dorsi in the majorit\- of cases the Spinal Accessor)' Trapezius Muscle contains 2., 3. and 4. C, the long Subscapular Nerve to the Latissimus Dorsi Muscle 6., 7. and 8. C. The other Subscapular Nerves to the Teres Major Muscle 5., 6. (and 7.) C. to the Subscapularis Muscle 5. and 6. C, the Suprascapular Nerve to the Supraspinatus Muscle 5. C, to the Infraspinatus Muscle 5. and 6. C. The deep layer is composed of the Serratus Magnus with Bell's Nerve 5., 6. and 7. C. Levator Scapulae (3.) 4. and 5. C. and the Rhomboid Muscles 5. C, possibly further fibres from 4. C. to the Rhomboideus Minor Muscle. Of the mixed nerves, the Median contains fibres derived from each segment, 5., 6., The motor (though 5. C. probably contains Sensory fibres only). 7., 8. C. and I. D. the Ulnar part of the Musculo-Cutaneous Nerve contains fibres from 5., 6. and 7. C. Nerve usually 7. and 8. C. and I. D. or 8. C. and L D. only. The motor part of the Circumflex 5. and 6. C. The motor part of the Musculo-Spiral (5. C.) 6., 7. and 8. C. Musculo-Cutaneous Nerve: Coraco-Brachialis Muscle 6. and 7. C; Biceps This last named muscle Brachialis Anticus Muscle 5. and 0. C. Muscle 5. and 6. C. has a double Nerve-supply as it also recei\'es fibres from the Musculo-Spiral Nerve (derived from the same segments). Median Nerve: Pronator Radii Teres Muscle 6. and 7. C. Flexor Carpi Palmaris Longus 7. and 8. C. and L D. Flexor Sublimis Radialis 6. and 7. (and 8.) C. Pronator Digitorum 7. and 8. C. and I. D. Flexor Longus Pollicis 6., 7. (and 8.) C. Quadratus (6.) 7. and 8. C. and L D. Muscles of the Thenar Eminence 6. and 7. C. The two outer Lumbrical Muscles are usually considered to be supplied from 8. C. and L D. segments. Ulnar Nerve: Flexor Carpi Ulnaris Muscle (7.) 8. C. and I. D. the outer (radial) portion may also be supplied b\' the Median Nerve (Frohse) thus having a double Nerve-supply, like the following muscle; Flexor Profundus Digitorum (Ulnar and Median) 7., 8. C. and I. D. The deep portion of the Ulnar contains 8. C. and I. D., but chiefly 8. C. at the Hypothenar Eminence even the 7. C. may take part (Bolk). For the Motor Anastomosis between the Ulnar and Median Nerves cf. Figs. 84 and 96. The Circumflex Nerve contains fibres from the 5th and 6th Cervical Segments. The small area of Deltoid Muscle coloured green denotes the probabilit}', as evidenced by The Anterior clinical observations, that fibres from 4. C. supply this portion (Ziehen). part of the Deltoid mav be supplied by the Anterior Thoracic Nerves (Anastomosis with the Circumflex, Frohse). The nerve to the Teres Minor Muscle usually only contains 5. C. for Long Head of Triceps 6., 7. and 8. C. for Outer Head of Triceps 6., 7. (and 8.) C. for Inner Head of Triceps (6.), 7. and 8. C. of
the Trapezius
Nerve
;
to the
;
;
—
—
;
;
;
;
;
;
;
;
;
;
I for
Anconeus
7.
and
8.
C.
Brachio- Radialis (Supinator Longus) 5. and 6. C. Extensor Carpi Radialis Longior and Brevior (5.) 6. and 7. C. Supinator Brevis 5., 6. (and 7.) C. Extensor Communis Digitorum and Extensor Minimi Digiti 6., and 7. and 8. C. Extensor Primi Intemodii Pollicis 6., 7. (and 8.) C. Extensor Indicis 6., 7. and 8. C. Extensor Secundi Internodii Pollicis 6., 7. (and 8.) C. (in Bolk's case 7. C. only)
Thorax and Abdomen.
Fig. III.
The Trunk (Chest)
and the lower
The
divided into two chief divisions; the upper
is
the
is
superficial
line
Abdomen of
is
the
Thorax
(Belly).
separation between these
two regions follows the
lower margin of the bones and cartilages which comprise the thoracic cage, but this surface
marking by no means
indicates the relative size of these cavities.
This curved line only shews the attachment of the base of the diaphragm
which
is
in
constant
movement
so
that
the
capacity of these cavities
varying and the position of the more movable viscera Certain
points and
these regions and
made
ever
alter accordingly.
connecting lines are employed
thereby endeavours are
is
in
order to subdivide
to traverse or
map
out certain
important viscera or visceral domains.
The most important
lines
and regions are marked
black
lines
tinental
and English guides may be pictured.
have been added red
The reader
is
however strongly recommended
plicity of visceral surface
Atlas of
Textbook
lines in order that the
markings
b}'
Anatomy, Cunningham.
QuAlN's Anatomy. Surgical Anatomy,
Deaver.
to the
most important Con-
appreciate the multi-
reference to the following authorities:
Human Anatomy, TOLDT. of
to
in the figure:
.
.
Frontal Section through the Trunk.
Fig. 112.
Frozen Section.
The anterior surface of the second section of a series of VerFrontal Sections seen from in front. The Thoracic and Abdotninal Viscera are in their position at extreme expiration which is never reached during life. Atmospheric pressure has driven the intercostal spaces inwards so that the outlines of Pleura and Lung are undulating. tical
A
shews much better than a transverse section the different from the general (Coelomic) Cavity of the Embryo.
frontal section
cavities derived
The formation Abdominal Cage. 3
As
Cavities.
of
the
There
the pericardium
is
Diaphragm
results in a division into Thoracic and no Thoracic Cavity but a Thoracic Bony pushed downwards from the neck into the Coelom,
is
really
completely independent cavities are estabhshed: i)
Pericardial Cavity, containing the Heart and a part of the large vessels.
2)
Left Pleural Cavity with the Lung.
3)
Right Pleural Cavity with the Lung.
the practice of many anatomists to call the space between the Left and Right Pleural Cavities the Mediastinum, according to this the Heart would in the Mediastinum (Middle). be But if three independent cavities are recognized there remain two spaces communicating above, one in front of and one behind the heart the Anterior Mediastinum and the Posterior Mediastinum The Anterior Mediastinum is further divided by the overlapping right and left pleurae (cf. Fig. 116) between the 2nd and 4th ribs into an upper and lower compartment with free communication. Above the Mediastina communicate freely with the spaces between the structures of the neck. The complementary spaces shewn in the figure between the Thoracic Wall and the Diaphragm are only occupied by the Lung during inspiration. It is
—
—
—
The Pericardium is a closed sac consisting of a visceral layer closely enveloping the heart and the roots of the large vessels and a parietal layer directly continuous with the former but blending with the Mediastinal Pleura, the Diaphragm and the Anterior Thoracic Wall. The Pleural Sacs are two closed cavities, which
at
consisting of a visceral layer
the root of the lung blends with the parietal layer.
This parietal layer
lines the thoracic wall (Costal pleura) — the pericardium — (Pericardial pleura) — the diaphragm — (Diaphragmatic pleura) — and the mediastinum — (Media-
—
stinal pleura)
—
The uppermost above the it
lies
first
part of the pleura which reaches from V2 to 4/5ths inch shewn in the figure because
rib is the Apical Pleura (this is not
behind the plane of
section).
(Vide Figs. 70, 121,
126.)
Fig. 113.
Upper Aperture
of
Thorax.
and 2nd Costal Cartilages and the -muscles The Clavicles and Ribs have been pushed The Pericardium is exposed. The Thymus and
The upper part of the Sternum,
the ist
attached to these have been removed.
down
to
their
full extent.
Thyreoid Glands have been cut away, together with tlie Bronchial Lymphatic The Inferior Thyreoid Vessels are divided and the cervical fascia Glands. dissected away.
The following structures pass upwards or downwards through the superior aperture of the Thorax. Vessels. The right Common Carotid Arterj' rising from the Innominate Artery. The Left Common Carotid a direct branch of the Arch of the Aorta. The Subclavian Arteries at first pass upwards into the neck and then to the Axilla. To the right of the Arch of the Aorta lies the Superior Vena Cava formed by the junction of the Right and Left Innominate Veins, which pass behind the Sterno-Clavicular Articulation and the Manubrium Sterni. The Innominate Veins are formed by the junction of the Internal Jugular and Subclavian Veins. The large veins are situated to the outer side and in front of the main arteries. The Lymphatic Duct (the chief lymphatic channel) after passing upwards in the posterior mediastinum where it is situated between the Aorta, Large Azygos Vein and Oesophagus directs its course away from the Vertebral Column obliquely upwards and to the left side of the neck; here, under cover of the deep cervical fascia it forms an arch and finally opens into the Left Subclavian Vein (cf. Fig. 67). Nerves. The Phrenic Nerve derived from the 3rd, 4th and 5th Cervical Nerves (chiefly the 4th) runs obliquely across the Scalenus Anticus Muscle to the outer side of the Internal Jugular Vein, then behind this vessel between the Subclavian Vein and Artery (Figs. 67 and 70). The Right Phrenic Nerve runs to the outer and anterior aspect of the Vena Cava Superior, between the Pericardium and Mediastinal Pleura, along the right border of the Pericardium to the Diaphragm. (Coronary Ligament of I.iver. Liver and Abdominal Wall.) The Left Phrenic Nerve takes a greater cun'e in its passage from the Neck into the Thorax owing to the asymmetry of the large vessels and is situated on a deeper plane than the right, owing to the rotation of the heart to the left, in its course between the Pericardium and Pleura to the Diaphragm (cf. course of Phrenics in Fig. 122). The Vagus or Tenth Cranial Nerve 'running between the Carotid Artery and Internal Jugular Vein at first passes downwards and slightly backwards but soon inclines forwards to the right and in front of the Right Subclavian Artery, on the left side in front of the Subclavian Artery and Aortic Arch. Both Vagi accompany the Oesophagus in its lower part and through the Oesophageal Opening into the Abdomen on to the walls of the Stomach. The left Vagus merges gradually to the Anterior Aspect whereas the right Vagus becomes directed to the Posterior Aspect of the Stomach; this results from the developmental rotation of the Viscus to the right. From each Vagus is given off a Recurrent Lar}'ngeal Nerve (Motor Nerve to Muscles of the Larynx); the right recurrent nerve looping around the Subclavian Artery whereas the left recurrent ner\'e winds round the Ductus Arteriosus at its connection with the Arch of thePAorta; each nerve ascends upwards by the side of the Trachea (cf. Fig. 6q). Viscera: The Trachea bifurcates opposite the 4th or 5th Dorsal Vertebra into Right and Left Bronchus under cover of the large vessels. The Oesophagus is shewn in the figure to the left of the Trachea.
Thyreoid Cartilage Mertian Vein of Neck
Sternohyoid Muscle
Thyreohyoid Muscle
Omohyoid Muscle
Cricoid Curtilagf
Cricothyreoid Ligament (Ligamentum Conicum)
Cricothyreoid Vessels
,Thyreohyoid Muscle ("ricothyreoid Muscle^
Antnirir jvi^jular Vein
I
Superior Thyreoid Vessels Inferior
Thyreoid Ciland
Thyreoid Vessels
Sternocleido-
mastoid Recurrent Laryngeal
Ncrve
Muscle
^^^-
Middle ThjTeoid Vein Rt-current L;iryngcal N erve
rtirenic
Nerve
Pericardium
-2nd Rib Pectoral is ^lajor Muscle Internal Intercostal
Internal
Muscle
Mammary' Vessels
Body
of
Sternum
Fig. 113.
Upper Aperture
of Thorax.
Nat. Size.
Bebmau
I^imited,
Loudou.
Rebman Company, New York.
j i
/
Kxternal Jijg^ilar Vein
Thoracic Duct
Subclavius ^luscle
Deltoid Musrie
Pectoralis
Minor Musrie
Cepbalit: Vein
Pectoralis
Major
Muscle
T.atissimusDorsi Muscle
]
Teres Major Muscle Intercosto-Humeral Ner\e Subscapularis Muscle
Subscapular Vessels
i
j
I
Long Thoracic Nerve Scrratus
Magnus Muscle
(4th
Rib)
Breast
External ^lainmary Vessels
External (Jblique Muscle uf
Abdomen
toralis
Major Muscle
Sheath of Rectus Abdominis Muscle
"3"i'^'*'^-j-' "^'^
Fig. 114.
Lymphatic Glands connected with the
Mamma
in
an Adult.
Vo Nat. Size.
Rebman
Limited, London.
ReljLuan
Company, New York.
:
Lymphatic Glands connected with the
Fig. 114.
This figure
by side
the
Frohse
not
is
on
the deeper
drawn from a
the Axillary
layer
and
but
is
Lymphatic Glands.)
—
the
breast with
Major Muscle and
Pectoralis
dissection
its
the Clavicle
a diagram constructed
On
It
is
from viany
an Adult.
sources.
bloodvessels
and lymphatics are shewn.
have been removed.
—
The internal
green and
A set
the deep
(Essay
on the
lefit
large part of
of glands are red.
absolutely necessary to adopt a definite and universally applicable classification in order to readily comprehend their distribution. The number
the Axillary Lymphatics
of Glands varies enormously the
in
the right side the superficial layer,
coloured blue, the external not coloured, the intermediate
ot
Mamma
(8
to 43)
and
into these enter the afferent
Lymphatic Vessels from
Thorax and Arm.
Of the afferent lymphatics which come from the Thorax, those from the Mammary Gland have the greater practical importance. A superficial and a deep set, separated by the Intercosto-Humeral Nerve and the External Mammary Vessels can be made out. The first regional gland for the lymphatics of the Breast lies, when the arm is abducted to a right angle, just below the free border of the Pectoralis Major Muscle at the level of the 3rd rib. An inconstant deep gland is sometimes present; this Paramammary Gland is depicted in the figure at the outer border of the beast. By Lesser enlargement of this gland considered characteristic of Syphilis. Usually from the Breast the Lymph passes through i to 4 glands which lie under cover of the Pectoralis Minor Muscle, parallel to the inner side of the Axillary Vein. Subpectoral and Subclavian Glands. Thus it passes through several smaller glands In rare cases, which one should always bear in mind, lymphatic vessels pass between the two pectoral muscles and are associated with an Interpectoral Gland. But the more usual connection lies with the neighbouring External Gland called the Intermediate. Fortunately there seldom exists a direct communication with the deep glands, the Subscapular Glands and thence along the nerve to the Latissimus Dorsi Muscle. When this group becomes affected, the Neuro-Vascular bundle cannot well be left untouched in the course of a operation inasmuch as it is very frequently surrounded by the lymphatics (v. Origin of Subscapular Artery). The lymph from the arm passes usually with the superficial vessels to a gland which lies (cf. Fig.) on the Axillary Vein; thence under cover of the Pectotalis Minor Muscle along the outer side of the vein. A lymphatic channel may accompany the Cephalic Vein and disappear in the Infraclavicular Fossa, between the Deltoid and Pectoralis Major Muscles, to enter a DeltoideoPectoral (Infraclavicular) Gland. The Deep Lymphatics lie partly on the Subscapularis Muscle, partly along the outer Thoracic Wall the Subscapular and Thoracic Glands. Accordingly it becomes advisable to classify the glands of the Axilla in the followis
—
—
ing
way A. Superficial Glands. Pectoral, Intermediate, Brachial, Infraclavicular (Deltoideo-Pectoral). B.
Deep Glands. Subscapular.
To
these regional sets of glands the following intermediate glands have to be added:
Subpectoral, Subclavian and Thoracic. An important variation in the Pectoral Glands
is the presence of an Interpectoral Gland. Apart from the usual lymphatic channels leading to the Axilla there are two (blue) other important 13'mphatic vessels which in obstruction or removal of the former carry lymph from the lower border of the breast to the Umbilicus, or to the Internal Mammary Artery.
From
the
supero-internal
part
of the Breast,
lymphatics
run into the Superficial
Gland whence the lymph may travel into deeper regions. On the other hand, lymphatics may emerge towards the surface and connect the Internal Mammary Lymphatic Glands with the Superficial Glands of the Axilla. (Cf. the transverse black line at the upper border of the Mamma.) Internal Pectoral
o
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Costal Pleur
Upper Lob<
Middle Lobe \rca of Absolute ardiac Dulness
'
Fig. 116.
Boundaries of the Lungs and Pleurae as seen Ai-ea of Absolute Cai'diac Dulness. 7s Nat. Size.
Rebman
Limited, London.
—
fi.'om
in Front.
After Joessel (modified).
RebiiKin
Company, New York.
Boundaries of the Lungs and Pleurae as seen from in front. Area of Absolute Cardiac Dulness.
Pig. Ii6.
The Pleura,
the Diaphragmatic and the Apical Pleura. the reflections of the Pleura, e. the lines upon the which the Costal Pleura becomes the Diaphragmatic
Pleura
Parietal
consists
The knowledge
of
i.
—
cf.
margin
the upper
inwards
downwards
extends from an angle of 45" downwards and the left of the middle line at the angle
inch to
i
Manubrium and Body
of
of Sternum).
slightly
downwards along
From
this point
gradually approaching the middle
in a vertical direction,
at the level of the 5th Costo-Sternal Articulation
line is
Vio^h to
Sternum (Junction
continues
important.
is
of the right costal pleura
ist costal cartilage at
of the
a point
to
—
dotted lines in the figure
The Anterior (Median) Boundary
it
Pleura,
Costal
(including the Pericardial) Pleura
Anterior Thoracic WaU at and the Mediastinal Pleura
of the
the
of
the Mediastinal
from
;
this point its
course
the lower border of the 6th costal cartilage in the
6th intercostal space or along the upper border of the 7th costal cartilage, the
lower
border of which
reaches
it
about
"f an
-ys^J^
inch mesial to
costo-
its
chondral junction.
The
costal
cartilage
the
of
7 th
rib,
lower costal cartilages,
the
like
is
This also applies to an increasing surface of the ribs themselves as we get lower in the series (27,1 inches). The limit of the Pleura crosses the right nipple line (cf. Fig. iii) at the lower margin of the 6th costal almost entirely devoid of Pleura.
down, and the axillary
cartilage or slightly lower
line at the
lower border of the
9th Costal Cartilage.
In
tlie
the Sternal it
upper
part, the left costal pleura takes a similar course;
Angle (LUDWiGs Angle) a
passes so as to often reach the middle
to
pleura of the opposite side;
tlie
downwards
tically
level the
until
it
little
further to
line,
becoming,
from
tlie left;
to
it
crosses
this point
some degree, adherent
for the distance of 2 inches
it
extends ver-
reaches the level of the 4th costal cartilage; at this
margin of the pleura extends obliquely downwards and outwards
whence
to the
curves with
its upper border of the point Cartilage this from concavity inwards to the upper border of the 7th Costal it again follows a similar course to the Right Pleura downwards and outwards; though mesially it does not reach the 7th Costal Cartilage it may extend lower
5th Costochondral Articulation
it
;
down the
externally.
gtli
interspace
The (cf.
left
tlie
axiUary Une at the loth rib or in
The pink area
indicates Absolute Cardiac Dulness
pleura crosses
Fig. 126).
wliich under normal conditions
is
not encroached upon by lung tissue and which
area serves for the exposure of the Pericardium in Pericardiotomy.
and
Cf. Figs.
70
121 for a description of the Apical Pleurae.
The boundaries between tlie The Right Lung has three
different lobes are
lobes
—
shewn
in the figure.
the superior and middle lobes are
separated anteriorly by a fissure which extends to the level of the 4th rib or 1/2
the rib
inch lower.
The boundary between
the middle and inferior lobes
6th intercostal space and extends behind
obUquely downwards
The
Left
Lung
to the
consists
tlie
lies
opposite
anterior extremity of the
lower border of the lung. of 2 lobes
and the
fissure
which separates them
extends from the posterior end of the 4th interspace to the region behind the costal cartilage.
7 th
7 th
Boundaries of Lungs and Pleurae from behind.
Fig. 117.
The Median Boundaries the Costal Pleurae
of the Pleurae posteriorly,
The lower
limit,
i.
continuous with the Diaphragmatic Pleura,
border of the 12th Dorsal Vertebra
this
the lines at which
e.
the Mediastinal Pleurae, run along the
become continuous with
bodies of the Vertebrae.
i.
where the Costal Pleura becomes
e.
is
line
very important.
From
runs horizontally outwards so that
not only the lower rib cartilages but also the bony ribs are free.
which varies much
in
length and
the lower
may even be
absent,
is
The
12th rib,
usually bisected
b}-
this line.
The in Fig.
1 1
difference on the
two
sides in the Axillary Line has
6.
The Apices
of the Pleurae are not visible from behind, because they never
pass up as high as the upper surface of the
The lines,
been mentioned
fissures
ist
Dorsal Vertebra.
between the Upper and Lower Lobes are indicated by black
beginning behind
in
the 3rd intercostal space they run obliquely outwards
and downwards.
But on the right divides the upper lobe into
side
two
a small fissure arises from the main fissure and
—
(the
Superior and Middle I^obes).
Superior Lobe
—7-
-
—
Fissure of Lunj;
Inferior
Lobe
Lcjwer Border of
Lower Border
Fig. 117.
Limited, London.
of Pleura
Boundaries of Lungs and Pleurae, from behind. Vs Nat. Size.
Rebman
Lung
—
Modified after Joessel.
Rcbm.Ti!
Company, New York.
Left Innominate
Vein Right Pleura Voiia
M.mimary
Internal
Arch of Aorta Pulmonary Artery
Cava Superior
1^
V-
I-oft
Auricle
.
Atrium of Right
Ventricle
Auricle
.
;:
;;^ Riyht Ventricle
Right Ventricle
Fig. 118.
rcricardium
Thymus
Pericardium
Left Pleura
Anterior Thoracic Wall and Heai-t in the New-Born. Nat. Size.
Kebman
Limited, London.
Bebinan Company,
New
York.
:
Anterior Thoracic Wall and Heart in the New-Born.
Pig. Ii8.
From
the fresh corpse of a iionnal Foetus
of the Anterior Thoracic The position
soft parts,
tlie
Wall over the Sternum unci Costal Cartilages have been removed.
of the heart and
its
important parts has been determined by Luscmka's method,
6
(by the introduction of
shewn
—
six points
vessels
are fully
and muscles being imagined as transparent.
and
outline of the Pericardium
The
The heart and the great
needles).
the figure, the bones
in
the area
indicated
of Absolute Cardiac Dtdness are yellow.
—
Arabic figures
b}'
The
employed
determine
to
the position of the heart are
the Sternum
close
may be
structure
the Internal
Mammary
to the
the Sternum
margin
right
Reflection
Arch
of the
Pericardium,
Aorta
of
would be
vessels
in
(this last-
the adult
injured, but not so in the child. Cf. Fig.
intercostal
1
19.
space on the right side close to
Right Pleura, Superior Vena Cava, upper border
;
of
pierced by inserting the needle obliquely):
Internal angle of the 2nd
2.
space on the right side close to
intercostal
first
Right Pleura, Right Phrenic Nerve,
:
Vena Cava
Superior
named
angle of the
Internal
1.
Right Auricle.
of
Aperture of Pericardium.
Sternum
angle of 2nd
Internal
3.
Region
;
Cf. Fig.
1
The
20.
Middle
4.
left
left
pleura
line of
Boundary between Middle
5.
Xiphisternum
line
of
at the level
and
Sternum
Lower border
:
left
side
close
to the
pulmonar\- valves being
below and
to
the
right)
opened by the needle.
is
Sternum
right auricle
(the
the Aortic posterior,
;
or at a slightly higher level
lations
of
the
to
on the
.space
and Aortic Valves
of Pulmonar\-
above and
anterior,
intercostal
in the
of the 4th Chondro-sternal
articu-
new-born: Border of Right Pleura,
right ventricle; Tricuspid Valve.
at
the junction
of the
of right ventricle or of
Manubrium with
pericardium, and
the
of the area
Absolute Cardiac Dulness.
Lower border
6.
about the
'
-.th
limit
passed
inch internal to the
between
left
mammary
(red)
the
the
Apex
right
Interventricular
the child;
upper and lower parts of the
wards between
Thymus which
costo-chondral junction
of Heart, or
(blue)
Septum
lies in
tlie
more accurately
Ventricle.
without
This
entering
needle either
Anterior Mediastinum are continuous
front
of the
Pericardium reaches down-
the Parietal pleurae as far as the area of
The Anterior Mediastinum fat,
and
hne:
its
of the Heart. ilie
in
the
through
exactly
chamber
of 5th rib on the left side at
lymphatics and small vessels.
is
filled
Absolute Cardiac Dulness.
up by Thymus, loose connective
tissue,
Anterior Thoracic Wall and Heart in the Adult.
Fig. 119.
hi addition Cartilages
parts covering the Thorax,
the soft
to
and
the junction
of the
named
last
the jrd,
4th, ^th Costal
6th Costal Cartilage
the
ivith
together with the Intercostal muscles lun'e been removed.
Between the (blue) is visible
the Triangularis Sterni Muscle
of
slips
lines of reflection
its
;
Between the 3rd and 4th Costal Cartilages pleurae are in contact with each other, as
left
The
tracted upwards. line,
parietal pleura
the
behind the Sternum are also delineated in
(cf.
Pig.
in blue.
the right and
116)
the adult the Th3'mus has con-
considerably beyond the middle
right pleura ma}' extend
often as far as the left border of the Sternum. Parallel with the borders of the Sternum, at a distance
Mammary
the width of the bone, the Internal
which varies with
Artery, a branch of the Subclavian,
Venae Comites except in the two upper intercostal spaces where there is only one vein. Around the artery lie lymphatic glands, (Sternal and Anterior Mediastinal Glands) more numerous above than below. The Heart in the Adult is more deepl}' situated than in the Newborn
takes
and
its
its
course accompanied
apex
The
b)'
further to the
is
2
left.
Apex
distance from the
(Left \'^cntricle)
to the
nipple
is
2'^l^ths
to
iVsthsinch in the vertical line, and Vjths to if/jth inch in the horizontal direction. (As the Figure is ''/jths nat. size, actual measurements according to the Figure will require multiplication
by
five thirds.)
^\n irregularity in the Costal Cartilage is
shewn
which may even in\olve the
rib
the 4th Costal Cartilage on the right side.
in
The following data connected with the bony Thorax and made out by Bardelebex.
in
particular
the costal cartilages have been In
about 10
The
the Sternum.
other
;
in
60
%
the
"/o
Sth Costal Cartilage,
6th and
on the
7th Costal
left side
between the 5th and 6th Costal close apposition
The and position
40
"/o
sides,
articulates with
with each on the right side, articulations exist The arrangement, together with the usually
articulate
convert the intercostal spaces
in front
of the
slits.
position of the
not absolutely
in
Cartilages.
of the cartilages,
pericardium into narrow
is
and
on both
Cartilages
constant
Apex
—
of the Heart, the Pulmonar}'
quite
apart from
physiological
and Aortic Valves \ariations in form
of the Heart.
The Pulmonary Valves behind the 3rd
usually
left costal cartilage,
lie
opposite
the
2nd
left
interspace or
rarely in the 3rd interspace.
For operations upon the Pericardium the most suitable site is a small is uncovered by pleura. The entrance may be made through the 4th or 5th intercostal space, close to the Sternum, without wounding the pleura; the Internal Mammar}' Artery must always be borne in mind. Removal of a part of the 4th and 5th Costal Cartilages with a small portion of the left Sternum, allows a fair extent of the pericardium to be exposed. area where the pericardium
Stcrno-Mastoid Muscle
^laniibrium
External
Steriii
Intercostal
Muscle
Poctoralis !^^ajor
Muscle
Internal
Mamniary
\'essels
Pectoralis
Minor
Muscle
-r-^;-
^
Triangularis Stern!
Muscle
Xiplmid Process
Diaphragm
External Oblique
Muscle of the Ab.lonu-n
Superior Epigastric Artery
jfr.
^^*^'^'«^'< ^\Rectus Abdominis Muscle
Fig. 119.
Frahse,
Transversalis Abdominis ^[uscle
Anterior Wall of Thorax and Heai-t in the Adult. 7^ Nat. Size.
Rebman
Limited, Lonilon.
Kebuian Conipauy,
New
York.
I,p(t C'arotid
Artery T.eft
Innominate Artery
Subclavian Artery
/
Ductus Arteriosus (BoTAi.Li)
Pulmonary Artery Superior
Vena
C.i
Aortic Semilunar Valves: Left Valv.
Pulmonary Semilunar Valves: Anterior Valve
RJKht Viilve.^
I'o^terior
Valve
ml
Right Coronary Artery
Anterior Cusp (Aortic) of Mitral Valve
Atrium
lA Riglil
AurirUPosterior Cusp
—
Cusps of Tri»:us)jiJ Valve:
(Parietal) of Mitral
Valve
Septal (-usp
'
Posterior Papillary
Anterior Cusp -
Muscle
Posterior Cusp --Inter Ventricular
Septum
Ri^ht Ventriclc-^^
Left Ventricle
Anterior Papillary Muscl
Descending Branch of Left Curonar)' Artery
Fig. 120.
Heart of Adult.
—
(,ardiac
Notch
Ventricles opened.
Nat. Size.
Reliman Limited, Lfiudou.
Reljnian Company,
New
York.
Fig. I20.
Normal
Heart
adult heart liardened in for mot ; the ventricle
the Aortic
and Pulmonary
Left Ventricle
more
is
and
is
to
shew
rotated so that
tlie
to tlie front.
in order to
valves of the heart
opened so as
is
the heart
valves,
serni/iinar
TIte figure is senti-diagrai>unatic
The
Opened.
of Adult, Ventricles
demonstrate more clearly
all th
their relative positions.
figure shews the outer and anterior aspects of the Right Auricle, the
Right Auricular appendage and the opening of the Superior Vena Cava.
Right Ventricle Papillary Muscles, Anterior, Posterior and :
Tendineae,
Chordae
Septal.
Cusps of the Tricuspid valve, one large Anterior, a large Posterior
3
and a small Septal Cu.sp; between the two Ventricles the Inter-Ventricular Septum; on the Anterior aspect of the Heart the inter-ventricular groove, terminating
Descending Branch
the Cardiac Notch, and the
As
in
the Left Coronary Artery.
of
the continuation of the Right Ventricle upwards (the Conus Arteriosus)
has been widely opened and
wall removed, the pulmonary semilunar valves
its left
appear to be completely disconnected from the Right Ventricle, but their relative positions are well shewn, one anterior, one right
and one
Left Ventricle: Papillary Muscles, anterior or
with chordae tendineae attached to the two cusps aortic cusp
and posterior or
and almost
in
anterior or
and posterior or right (right or
the right one extending up into the Aorta
right
are three in number, like the pulmonary, one
and
left,
this
is
due
to
the
is
posterior,
common developmental
Aorta and Pulmonary Artery.
origin of the
The Aortic Valves and
left
of the mitral valve
continuity with the semilunar valve.
The Aortic Valves two are
left cusp),
left.
posterior to the
lie
(cf.
Fig. 119)
more
to the right,
Because the Aortic Valves are situated deepl}' and distance from
at a
lower level
a
considerable
Pulmonar}' Valves. at
the Anterior Thoracic Wall, to obviate the obliterating effect of
the Pulmonar}' Valves the Stethoscope
space close to the Sternum,
i.
e.
is
applied
the point
over the 2nd right Intercostal
where the Aorta
lies
close
to
Anterior Thoracic Wall.
The
Mitral Valvular sound
is
listened for at the
apex of the Heart.
the
)
Fig. 121.
Transverse Section through the Trunk, at the level the 1st and 2nd Dorsal Vertebra.
of
Frozen Section. The section passes through the 2nd Dorsal Vertebra anil the Disc between the 1st and 2nd Dorsal Vertebrae, also through the ist and 2nd Ribs, through the lower part of the Trachea, Thyreoid Gland and Clavicle ; the shoulder-joint on either side and Scapula with their muscles have been cut through. The shoulders ii*erc rather elevated.
The important 1
details are:
—
Apices of Pleurae as seen from below are unequal because the section is not absolutely horizontal (Difference /,„th inch). The Apices of the Lungs separated by the section have been removed. The Subclavian Artery on the left side arching over the Apex of the Lung, and its intimate relation to the 1st rib and the Scalene Muscles is noticed. Course of the Trachea and Oesophagus; the former deviates a little to the right probably' owing to the asymmetry of the Thj'reoid Gland whereas the Oesophagus '
2)
normallj' deviates to the
When
left.
is much enlarged (as in the inhabitants of the Saxony Mountain Districts) it not only surrounds the Trachea, but also touches the Oesophagus and exerts pressure on the Carotid Artery and thin-walled Jugular Vein both vessels being pushed backwards and outwards. 4) The Brachial Plexus, on either side, has been cut through. 51 The Vagus Nerve is situated between the Carotid and Jugular Vessels (cf. Figs. 59, Recurrent Laryngeal Nerve between the Trachea and Oesophagus 61, and 113). (cf. Figs. 69 and 113). The space between the Vertebral Column and the front of the neck is remarkably small for the passage of the important Cervical Structures. Finally, the Tendon of the Long Head of the Biceps is seen in its groove and the subscapular bursa between the Subscapularis Muscle and the scapular or shoulder-joint is shewn.
3)
the Thyreoid Gland
—
Fig. 122.
Frozen Section. Stermtin
is
Transverse Section through the Thorax, at the level gth Dorsal Vertebra.
The
divided
sectio7i is
jitst
made through
the gth
Dorsal Vertebra, the 4th
below the articitlation of the 5th
rib.
As
the
man had
to f}th
of
ribs ; in front the
died from Pneitmonia the
lungs are fully expanded and not in the cadaveric expiratory position.
This figure shews clearly
how
the Thorax
is
occupied
b\'
the 3 cavities (Pericardium con(cf. Fig. 112, Text).
taining the Heart, Pleurae containing the Lungs) and the spaces or Mediastina
The Anterior Mediastinum tissue,
fat
presents a verj* small space occupied by loose connectiveand lymphatic glands, and shews that the pericardium is not completely covered
by Pleura. In the Posterior Mediastinum at some distance to the left of the Vertebral Column descending Aorta is seen, on the right side the Oesophagus with both Vagus Nerves, whereas between the Great and Small Azygos Veins the Thoracic Duct is cut across, posteriorly is the sympathetic cord, and behind the right Vagus nerve is a small lymphatic gland. This figure instinctively shews the position of the Phrenic Nerves between the Pericardium and Parietal Pleurae which is a point of considerable practical importance in Pleurisy.
the
On is
seen.
either side
at
the 7th rib in the Axillar\- line the Interlobar Pulmonary fissure
Oesophagus Recurrent Internal Jugular Vein Laryngeal Scalenus Anticus Muscle ^^^^'^ Trachea 1st Dorsal Subclavian Vein Carotid Artery Vertebra Subclavian Vagus Nerve ThySubclavius Muscle Artery Phrenic reoid Clavicle Cephalic Vein Nerve Gland [
Pectoralis
Major Muscle
'
Brachial Plexus Pectoralis
Coraco-brachialis and Short of Biceps Muscle
Long Head
Minor Muscle
Head
Deltoid Muscle
I
1
I
1st
Rib
of Biceps Muscle
Hull
Sea]
Infraspinatus Musi.li
Serratus ^lagnus ^tuscle
Apex
Apex
of Pic-u
2nd Rib
Fig. 121.
Rhoniboideus Major Muscle
Ti-ansverse Section through the
2nd Dorsal
Trapezius
A''ertebra
Muscle
3rd Dorsal
—
Scon from below.
-;-
N,it.
jrd Rib
Vertebra
at the level of the 1st
Trunk
'
of Pleura
and 2nd Dorsal Vertebra.
Size.
Anterior llediastinum
Atrium Pectoralis
4th
Major iluscle
Pericardial
of.
Right Auricle
Cavity
I
Sternum
j
Internal Maui-
Right
mary Artery
Ventricle
Left Ventricle
Atrium of Left Auricle
Rib
Left Phrenic Ner\'e
Serratus
Magnus Muscle
Latissimus Dorsi Alusde'
^^
Descending Aorta
Oesophagu;
Thoracic Duct
Right Vagus Nerve
oth
Rib
Intercostal
Azj'gosVein
Vein
Fig. 122.
Vertebra
... „ ,, , Splanchnic Nerve and Small Azygos Vein ,
Sympathetic
Transverse Section tlu'ough the Thorax at the level of the Seeu from below.
Rebmau
oth Dorsal
"'^i>
Limited, London.
—
9tii
Dorsal Vertebra.
7a N^at- Size.
Rebman Company, New Yor
r
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1
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tt)
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^
Fig. 124.
Position of Abdominal Viscera, from in front.
Cf. Fi^. Ill
for Topography.
In the right h3-pochondrium lies the Liver wliich even extends further (however, the 12th rib, costal cartilages of gth, loth, th ribs should be excepted). The liver lies in contact with the diaphragm, and indirectly with the Thoracic wall, the lower border of the viscus varies with its size and .shape this depends upon the shape of the Thorax and with respiration. In the nipple line it may correspond to the costal arch or extend below it Vr.t^s to r'-,ths inch). In the Axillary line it reaches to the loth intercostal space or extends ''/jths to rV.-.ths inch lower down. The lower concave surface of the Viscus is in relation with the right kidney, right supra-renal body (cf. Renal Impression Fig. 136) ai.d hepatic flexure of Colon. In the left Hypochondrium lie the Kidney, Suprarenal bod\-. Stomach, Spleen, Splenic Flexure of Colon, Tail of the Pancreas and usually a part of the left lobe of the Liver. This region is occupied bv about -/^rds of the Stomach i. e. Cardia and Fundus. The Cardia lies behind the outer end of the 7th Costal Cartilage, the inner concave surface of the Spleen is in relation with the upper part of the left kidne\', its outer convex surface with the Diaphragm (PhrenicoSplenic ligament), cf. Figs. 125, 126, 136. As a rule the liver does not extend further to the left than the inner half of the 7th Costal Cartilage. The Splenic flexure is anchored bv the Phrenico-colic fold to the loth and iith ribs. This fold also forms a platform upon which the spleen reposes, but this fold becomes stretched when the spleen is enlarged and any alteration occurs in the position of the Colon. The form and size of the Epigastric regions varj' with the individual and the sex the subcostal angle varies widel}' between 30 " and 70 ". The shape of the Xiphoid Process offers many variations, it may be directed forwards, backwards or laterally, presenting an opening, or be bifurcated, curved or crooked. In the Epigastric region are found a part of the Liver. Gall-Bladder, Stomach, Duodenum and Transverse Colon. The lower border of the Liver extends at the 8th costal cartilage bevond the right costal arch and often reaches to a point midway between the Umbilicus and the top of the Xiphoid Process. At the lower border of the Liver near the gth and loth costal cartilages is situated the gall-bladder (cf. Figs. 131 and 132). Behind the Liver are situated: Lesser Curvature of Stomach, Small Omentum. Omental Sac, Aorta, Coeliac Plexus of Sympathetic; a part of the Stomach, (Antrum Pylori) touches the Abdominal Wall. To the right of the Middle line, normally, Transverse Colon as well as Duodenum lie in this region. The former is often curved and extends downwards into the Umbilical region. In some cases it lies wholly outside the Epigastriuin. The Umbilical Region contains a great portion of small intestine (mostly Ileum) which is usually covered by the Great Omentum. The Iliac Region contains the ascending (right) and descending (left) Colon with Small Intestine. The Hypogastric region lodges in its middle, small intestine, bladder (when distended) and uterus (when pregnant) on the right the Appendix and on the left the Sigmoid Flexure. The greater part of the anterior wall of the Bladder is imcovered by Peritoneum (cf. Fig. B): when the bladder is much distended this region corresponds to a Vs^hs to 2 ins. high with a base corresponding to the interval between the 2 pubic spines (about i^l^th inch). Cf. Figs. 143, 144. 1
—
—
;
—
A
1
Gall Bhddei
Descending Colon
Ascending Colon
/
Fig. 124.
Position of
Abdominal Viscera, from in
Va Nat. Size.
Ilolnuan Limited, London.
—
front.
After Luschka.
Rebman Company, New York.
/
Common
Bile
Duct
Pancreas
Descending Colon
Fig. 125.
Ascending Colon
Position of /. /3
Rebman
Limited, London.
Abdominal Viscera, from behind.
Nat. Size.
—
After
Luschka.
Kebman Company, New York.
Position of Abdominal Viscera from behind.
Fig. 125.
Between the Spleen which (cf.
The
rib.
level.
opposite the
lie
front of the
in
due
right kidney,
P)Oth
kidneys
on the
occasionally
are
same
the
at
rarity.
Fig.
(Cf.
the ascending colon with
A
In the
its
—
Mesocolon
Fig.
cf.
by the Duodenum;
its
;
into
is
closely applied to the posterior
of
WlRSUNG) which
(cf.
I""ig.
130, text),
These
is usuall}-
coming from the
left
continuity
the
lower level i.
of the Vertebral
e.
when
Column,
of the left
side
Kidney whereas
135).
upper part
may touch
kidney
head
Its
lines.
abdominal
— extends
to the left
the Suprarenal Gland.
portion
wall, the
is
almost completely
of the
Duodenum which
Duct
of the
Pancreas (Duct
joined by an accessory Du't (Duct of Santorini)
shewn
The ascending Colon in
right
front of the right kidney with the
the Vertical
Common
and the
relations are
the
is
a considerablv
Lumbar Vertebra
intermediate part beiiig indicated by dotted encircled
nth
on either side of the Vertebral Column (yellow^ the
visible
is
it
but rarely
level,
front
in
lies in
in front of the 1st
Kidney and Spleen
figure
and 2nd Lumbar
1st
horseshoe-shaped kidne}-,
to the outer
lies
further details,
(for
The Pancreas as far as the
kidney below
127.)
The descending colon
duodenum above
the
mostly found at a lower
is
at
.situated
the lower ends of the two \-iscera are joined
no great
left
side also in front of the
left
to the size of the I^iver,
without any evidence of undue mobility.
is
left side is situated
and the
12th Dorsal
12th rib,
Sometimes both kidneys are
higher.
on the
ribs
136).
The Kidneys Vertebrae and
and nth
wath the Diaphragm above, and the
lies in relation
and
Figs. 126
level of the 9th
(cf.
is
in
Bile
Duct open.
the figure, which also depicts the
Figs.
120,
129 and
ureter
left
133).
seen on the right, the descending on the
left
(next
Sigmoid Flexure) between the Costal Arch and the Crest of
the Ilium.
The
relations of the
The
last portion
which the Coccyx (Perineal Curve)
lies.
Peritoneum
of the
gut shews the Ampulla of the
Below the
and opens
to the Viscera are described in Fig. 136.
tip of that
bone, the
in the slit-like laterally
Rectum
Rectum passes
compressed Anus.
against
backward
Fig. 126.
The expiration);
lung
left
Lung and
figure shews the
the vault
to the
the pleura,
Left
cf.
Figs. 116
and 117
Side View.
diaphragm during extreme expiration (cadaveric
extends as high as the 4th
same degree.
—
Spleen.
The
—
intercostal space
left
—
of the Lung
fissure
and the
the left boundar\- of
and especially the normal
position of a
normal
Fundus
of the
spleen are shewn.
The
inner concave surface of the spleen
Stomach and the upper part relation with the
The
of the left
kidney
Diaphragm connected with
spleen e.xtends from
(cf.
it
direction, so that the inferior pole points
loth
the Sacro-Sciatic
and the Rectum are
to
which
its
direction in
—
rests
upon
1
spleen
is
is
it
shewn; as the spleen
desirable
to
learn
the
increase in size must extend.
pre\'ents a
solid viscera
—
surface
is
in relation
with the fundus of the Stomach;
permanent enlargement upwards. left kidneA',
affords a gliding surface along
forwards and downwards. is
A normal
ith rib.
Pancreas and ea.sily
left
be pushed
It is
The lower
surface
Supra-renal glands
vertically
downwards,
which the spleen may when enlarged
thus that the anterior
mo.st readily felt at the anterior border of the
loth
—
aside.
The Phrenico-Splenic Ligament prevents expansion it
long axis
a line drawn from the
e.
i.
surface of the spleen
which under normal conditions caimot
but
its
the lower part of the*Sigmoid Flexure
man}' forms of enlargement,
The upper concave this frequently
in
downward and forward
a
towards the Umbilicus.
Foramen
is
visible.
The convex diaphragmatic a viscus subject
iith rib with
in
rib.
Sterno-clavicular articulation to the top of the
Through
the convexity
by the Phrenico-.Splenic Ligament.
does not extend beyond the costo-chondral line
is
Fig. 135),
(cf.
Fig. 125) the 9th to the
corresponding to the long axis of the
left
against the
lies
jjole of iMb.
slide
an enlarged spleen
Vault of Diaphragm
/-?l
—
I
Lower Border in
of
Lung
Expiration
Lower Border
of Lung, during Inspiration
Line of Reflection of Pleura
Spleen
Trausversalis Abditiniuis lluscle
Fig. 126.
Left '/a
Rebmau
Limited, Loudo
iS'at.
Lung and Size.
—
Spleen, lateral view.
After
Luschka. UebuKiu Conijiauv,
New
Yoi'k.
Rectus Abdominis Muscle
Hepatic Duct
Gastroduodenal Artery
Falciform
Ligament of Liver
Right
Caudate
Gastric
Left Gastric
Oesophagus
Lobe
Artery
Artery
(Cardiac End)
Transversalis:
Hepatic Artery
Abdominis' Muscle ]
Parietal Layer of Peritoneum
Gastrosplenic
Ligament
Round Ligament
Peritoneum of
of
Omental Sac
Liver (Obliterated
Umbilical Vein) 7lh l*orlal
Common
Bile
Rib
Vein
Duct
Cystic Duct
Outer Layer of| Peritoneum i
Mesenteric Vein
Jnfciifjr
Transverse Colon Inferior Recess of
Omental Sac
Root of Mesentery llco-Colic Artc-ry
Ileum
Vermiform Appendix superior Haemorrhoidal Artery
Ureter
Ovarian Ligament
Lxtcrnal Iliac
Artery
Round Ligament of Uterus
Deep
Epigastric Vessels
Round Ligament of Uterus
Fig. 127.
Rectus
Limited, London.
Umbilical
Artery
Position of Viscera covered V4
Enbman
Bladder
Abdominis Muscle
.
Uterus
^
.
,^
"^-O^^
by Peritoneum -
Child.
Nat. 8ize.
Ilcbman Company,
New
York.
Fig. 127.
Position of Viscera covered by Peritoneum
—
Child.
Child under one year of age. Anterior abdominal iva/l, Stomach, Jejunum, Ileiiiii, Left portion of Transverse Colon, Sigmoid Flexure, Mesenteries and ivall of Omental Sac, Transverse Mesocolon have been removed. Peritoneum, blue.
Inner layer of Omental Sac, yellow. This figure shews the Abdominal and part of the Pelvic Viscera in situ removal of those mentioned above. The Liver is large, its anterior surface passing beyond the right costal arch throughout its whole extent (reminding one of the arrangement in the Foetus). Of the Viscera the following parts are shewn. Cardiac end of Stomach cut across transversely. Pylorus joining the Duodenum, of which, by removal of the Anterior layer (if the lesser Omentum, the horizontal and commencement of the descending portion with the opening of the Common Bile Duct are shewn. The remaining part is covered by the Transverse Colon. The lumen of the intestine is visible at the Duodeno-jejunal Flexure, below and posterior to which is found the Duodeno-jejunal Fossa. The Ileo-'caecal junction and the Vermiform Appendix are seen in their usual position at a higher level in the child than in the adult. The Ascending Colon which appears rather short in the figure, the right half of the Transverse Colon (lumen owing to line of section), on the left the Splenic Flexure, Descending Colon, and two openings through which the upper and lower extremities of the Sigmoid P'lexure are also visible. On the lower surface of the Liver we find the Gall Bladder and vessels after
entering the Hilum of the Liver,
Forming the
Spleen.
left
inferior
In this instance the
Kidney
the
Bile
Ducts and further to the left the Fossa Duodeno-jejunalis is
boundar}' of the
the Left Colic Artery.
and occup3' normal
is
horseshoe-shaped, but the Ureters are normal
positions, crossing the
External
Iliac vessels
(cf.
Figs. 131, 134,
and disappearing behind the much distended Rectum. By the side of the left Ureter runs the Sujaerior Haemorrhoidal Artery (a branch of the Inferior Mesenteric) to the Rectum. In front of the Rectum is the Uterus, of which the fundus is visible; from either side the round ligament passes to the Inguinal Canal crossing in their course the Deep Epigastric Vessels. The Fallopian Tubes and Ovaries lie on the right side in the true pelvis, on the left side in the false pelvis, either because they have not completely descended, or, more probably, because the much distended Rectum had pushed them upwards. This latter view is supported by the fact that the Fundus Uteri is squeezed in between the Bladder and the left ij^.
137.
14Q.
150)
wall of the pelvis.
In front of the Uterus lies tlie Bladder, bounded anteriorly by the slightly opened Cave of RetziU-S; in this region the Bladder is uncovered by Peritoneum. The Peritoneum which lines all these organs, and encloses them to a greater or lesser degree, has been cut off at the root of the mesentery. (Cf. Fig. 136.)
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Fig. 130.
Woman
Position of the Viscera which
lie
outside the Peritoneum.
The Intestines have been removed from the Cardiac end of to the Rectum. Pancreas and Spleen in normal position. Parietal peritoneum lias been removed in the Abdominal but left in the Pelvic
the
aged
yO.
Stomach down
Cavity.
The median from the Xiphoid to the left side of the Umbilicus below which part the incisions diverge towards the right and left Anterior Superior Iliac The two large upper flaps are further divided into two smaller ones by Spines. incisions running towards the loth ribs. The two Kidneys (practically at the same level, though the left is usually ihe higher, cf. Fig. 125) together with their large arteries from the Aorta are shewn with their veins which enter into the Inferior Vena Cava. At the hilum the Vein is situated in front of the Artery, which has divided into many branches, The
Peritoneal Cavity has been opened in the following way.
incision extends
whereas the Ureter is situated behind. The left Renal Vein passes in front ("ava; the termination of this
left
renal vein
Aorta to join the Inferior Vena and the right vessels are covered by
of the
the head of the Pancreas.
The Pancreas extends
across at the
level
of
the
ist
Lumbar
\'ertebra
from the Right Kidney to the Left, terminating in relation with the Spleen and lying in front of the Aorta and Inferior Vena Cava. Above the Pancreas the Coeliac Axis with its three diverging branches is shewn below the Superior Mesenteric Artery, (the origin of which lies under cover of the gland), at a lower level and to the right is the Middle Colic Artery. To the right of this Artery is the Superior Mesenteric \"ein whereas further to the left Above the Pancreas the Portal Vein can be seen, is the Inferior Mesenteric Vein. cut off at the hilum of the Liver. This vein is fonned by the union of the ;
Splenic and the Superior Mesenteric Veins.
The Ureters passing downwards on
—
the Psoas Muscles
cross the
Iliac
inch above, on the right Vi inch below the origin of the and course along the outer wall of the true pelvis to the Internal Iliac Arterj^ Trigone of the Bladder. In the Male the Ureter crosses the Vas Deferens, passing
Vessels
below
on the
left
^/j
—
Female the Ureter passes below the Uterine ^\rtery. of the A
this duct; in the
To
the
right
large vessels and to the
left of
the Aorta are large lymphatic glands.
The Aorta bifurcates into the Common Iliac Arteries at the lower border of the 4th Lumbar Vertebra. The inlet of the true pelvis is almost completelv filled up by the much distended Rectum (ligatured) and the Uterus (in this instance enlarged) which overUes the Bladder.
(Cf.
Figs.
146
and
147.)
Gall-Bladder, Bile Ducts, and Surrounding Structures
Fig. 131.
Female.
On
of a woman, aged 55, a large window, 57-2 inches long by 4 inches fitroiigh the skin of the right hvpochoiidi'iac region. The window diminished throiigli the deeper layers. The Liver and Gall-Bladder
the body
ivide ivas
made
aperture
is
have been drawn upwards and to the right while the Stomach and Duodenum, have been draivn downwards. By removal of a part of the Anterior layer of the Hepato-diiodenal fold the structures at the iiilum of the Liver have been exposed.
This figure shews the window with its inner boundary situated ^^th inch from the middle Hne. At the margin of the window, especially at the outer margin, the various la^-ers i^f the abdominal wall are to be seen: External Oblique Muscle. at the upper and lower margins Internal Oblique Muscle, Transversalis Muscle the Rectus Muscle and its sheath together with the lumina of the severed ;
—
vessels
which run behind the muscles: Superior Epigastric Branch of the Internal and the Deep Epigastric from the External Artery (cf. Fig. g)
Mammary
1
1
Iliac A^ter}^
and Gall-bladder have been drawn upwards and shew the structures in the Hepato-Duodenal Fold, but the natural position of the GaU-bladder is shewn in Fig. 124. The fundus of this organ, which is normal, extends a little way beyond the lower border of the Liver at the point where this viscus leaves the Co.stal Arch {8th or gth Costal cartilage) and runs obliquely upwards into the epigastric region. The fundus is ^/..th to 2 inches from the middle line so that access is gained to it by a longitudinal incision from the costal arch through or along the In this figtire the Liver
to the right in order to
i
outer border of the Rectus Muscle. In pathological conditions, the gall-bladder may be so shrunken as to be hidden under cover of the li\'er, but when distended or the seat of a neoplasm, it ma)' be easily palpated and even become of such a size as to be mistaken for an
ovarian cyst.
The instance)
of the Gall-bladder varies greatlv from iV.ith inches (as in this It is covered by peritoneum on its free surface inches long. 5V2 Fig. 133). The Gall-bladder is directed backwards and inwards. Its size
to
only (cf. duct (iVsth to iVoths inches long) has always an acute S curve and it joins the hepatic duct at an acute angle (the length of the hepatic duct is one inch). The Hepato-Duodenal Fold forms the Anterior boundary of the Foramen of
WiNSLOW
:
the arrangement of the structures in this fold are
To To
the Right:
Common
Bile Duct.
the Left: Hepatic Artery.
Behind: Portal Vein.
:
—
and Surrounding Structures
Bile Ducts
Gail-Bladder.
Fig. 132.
Male.
As
p
was
cut out
of the right Hypo-chondriac region of the corpse of a robust male.
(Other
in Fig.
i
a large window, 6 inches long and
inches ivide,
9
details as in Fig. i^i.)
The Fundus
No
more
of the Gail-Bladder lies
made
difference dependent on sex could be
All the structures are shewn of normal differently
arranged from Fig.
transverse,
the P3dorus
further on
to
at
is
131
Duodenum
tlie
(cf.
Fig.
Foramen
1
3
more
of
and somewhat
distinctly,
of the Gall-Bladder
Hepato-duodenal
tlie
where
1
than in Fig. 131.
out in the position of the organ.
size,
g. the position
e.
a higher le\el,
Cystic Duct), consequently the
to the side
is
more
extends
does not go beyond the
it
WlXSLOW
fold
in a
is
.somewhat different
position.
The>
two lymphatic glands
seen,
e.
g. a
smaller Cystic at the neck of the
(xall-
Bladder, and a larger Gland of the Portal Vein on the anterior aspect of the Portal
Vein near the Hepatic Duct, are constant.
Another gland may be found lower
down near the Common Bile Duct at the upper border of the Duodenum. It is right to know of these glands, because they become enlarged in chronic inflammation of the Biliary passages and
may become
as to be mistaken
so hard
for
gaU-stones.
The Gall-Bladder which
di\-ides into
is
supplied
by the Cystic Artery
two branches, one running along the
running between, the Gall-bladder and the Liver. in
Cholecystectomy.)
artery
(cf.
Figs. 131
Considerable importance
and
132) which, derived
runs across the anterior aspect of the
is
(a
branch
of the Hepatic)
free surface of, the other
(Both branches need a ligature attached to a small but constant
from the Hepatic or Gastro-duodenal,
Common
Bile-Duct and ramifies on
Duodenum and on the Pancreas. It sends a branch upwards to the which we caU the Accessory C^^stic Artery. It reasonably follows forming Choledochotom\' the operator should look out for
Both figures shew
that,
when
the Liver
is
on the
that
in per-
this artery.
pushed upwards, the Duodenum
and Pylorus drawn downwards, the Bile passages are of the Gall-Bladder,
it,
Gall-Bladder
easily accessible
;
thus removal
opening of the Cystic Duct, and other operations are rendered
possible.
The Common Bile-Duct
lies for
a short
part
of its course
duodenal portion and favourable for surgical measures. the
Duodenum
is
covered by the Pancreas.
(Cf.
Its further
Fig. 133.)
in the
Supra-
course behind
Transversalis Cystic Uuct
Cystic Artery
Hepatic Duct
Portal Vein
Abdominis Muscle
Superior Epigastric Vessels
Left
Lobe
of Liver
Rectus \bdominis Muscle Tr.insversali;
.\bdominis .Muscle
^^ r,.A
=
"b^>5f>^*\^-."VV
Fig. 132.
Gail-Bladder, Bile-Ducts and Surrounding Sti'uctm-es Seen from
Robman
Limited, London.
in front.
—
Nat.
- Male.
iSize.
Rebiuan Company,
New
York.
Vena Cava Central Tendon of Diaphragm
Inferior
,
Kight Auricle
Lung
Pericardium Kight Ventricle Costal Pleura
^ Diaphragm Parietal Peritoneum
I'ortal Vein with Fibrous Capsule (Glissos)
Branch of
Visceral Peritoneum
^
Branch of Hepatic Vein Tendinous intersection n Rectus Muscle
Hilum
of Liver
Hepatic Duct Cystic Duct
Common
Duct
Bile
Gall -Bladder
Vena Cava
Inferior
Foramen of
Wins LOW Portal Vein
Pylorus
Rectus Abdominis
Muscle
Common
Bile-Duct
Pancreatic Duct (WiHsrNf!)
Head
of Pancreas
Umbilicus
Ampulla of Vater '
T .^
ff--
'
/
/
/
~~~'
/""^-
7>^
Transverse
Meesocolon
Inferior Horizontal ntal portion of Duodenum
Peritoneal Ca\'ity
Transverse Colon
Omental Sac
Sacrum 5th
Root
Lumbar Xerve
/
Lumbar
Plexus
Internal
of Mesentery
V
Spermatic Vessels
II
Coniinon Iliac Arterv
Fig. 133.
Subplirenic Space 8.igittal Section,
Rebman
Limited, London.
;
Pelvis of Ureter, seen from the right.
—
Hilum -/a
of Liver, Bile-Ducts.
^^a*- Size.
Rebniaii Cornpanv,
New
York.
;
Sub-Phrenic Space: Pelvis of Ureter, Hilum of Liver;
Fig- 133-
Bile Ducts.
Section passing
Sagittal
Duodenum and
the
indies
I'^lath
Common
The
frozen female body.
of the middle
the right
to
Bile
Duct was exposed
Pancreas.
The Peritoneum
in red.
is
Common
This figure shews with great accuracy the course of the
Duct which
—
Portion iY;,th
is
usually 3 to 4 inches long.
within
lies
—
it
passes
behind the
Retro-Duodenal Portion
The
portion
last
—
i
is
of
Vater
—
is
be divided
at
downwards. freed and
in
portions are both retro-peritoneal.
Supra Duodenal
portion.
left,
Duct from the back, of the
the Pancreatic portion of the
Exposure
Cf. Fig. 129.
as practised b}'
Duct leads
Tuffier,
viz.
(cf.
Fig. 131)
Diaphragm by
Omentum must
structure
this
drawn
Duodenum have been
Duct
is
accessible (Trans-
is
less
commendable. Rupture of Bile.
Liver, Spleen, Stomach, are separ-
this
is
lined
by Peritoneum, and
does not apply to those parts of
which are not covered by Peritoneum but connected with
loose connective tissue.
When
pus spreads into
this
neighbouring organs; Stomach, Gall-Bladder, Appendix, Kidney, or Peritonitis, a
the most
of the Retro-peritoneal portion
ated by a narrow space from the Diaphragm, which
communicates with the Abdominal Cavity:
Fig. 136.)
;
retro-peritoneal exudation
to extensive
The organs below the Diaphragm,
the Liver
(Cf.
cases.
Fig. 132, text.)
(Cf.
Duodenum, and
the
of
some
on the Bile Duct (gall-stonesj
in operations
the upper and descending parts of the
to the
duodenal Choledochotomy).
of this portion
gland to
this
opens into the
upper portion
When
runs
it
the Retro-Duodenal portion the Gastro-Hepatic
the
drawn
groove on
,
it
easily accessible part is the
To expose
a
length
in
Duodenum where
importance
of
in
Y^th inch
i
close to the Pancreatic Duct, or together with
The Retro-Duodenal and Pancreatic This
Duodenum and
inch long.
Pancreatic Portion
side of the descending portion of the
Ampulla
the
Supra-Duodenal
upper part of the
through the substance of the Pancreas or
left
of the
Bile
inch long.
crosses
either
—
Peritoneum of the Hepato-Duodenal fold, and
the
The Duct next
the
upper portion
Its
of a
line
in its course behind
Subphrenic abscess
is
space from in
general
formed.
Accordingly, a Subphrenic abscess ma}' be either Intra- or Extra-peritoneal the latter variety connective-tissue.
is
very Ukel}' to occur (Cf.
Figs. 133
and
if
suppuration extends along the perinephric
136.)
Right Kidney, exposed from behind.
Fig- ^34-
of a male corpse a window-section has been ^ade by removing part of the Latissinms Dorsi, two digitations of the Serrattts Posticus
Oil the right side skin,
and
Inferior, the tendinous origin of the Transversalis Muscle
the fatty tissue
behind the Kidney.
The Kidney
The
Left Kidne\'
forward
is tilted
extends from
^'ertebra to the lower border of the ^'ertebra.
The Right Kidney
The upper
half of the Kidne\'s
to exhibit the hihini.
upper border of the
the
2nd or
to
2th
1
Dorsal
Lumbar
the middle of the 3rd
usually about the space of Y2 ^ vertebra lower.
is
lie
near the pleural cavities from which they
ver\'
are only separated b}' the Diaphragm.
The side;
Kidney
distance from the lower end of the (iV.i^h inch in the male,
varies considerably
and
rYsths inch in the male
Access
—
peritoneally
kidney
to the
is
inch in the female on
the left
obtained by two routes, either from
side).
in front (trans-
Lumbar
or from behind (from the
Fig. 135, text)
cf.
iVr.th
to the crest of the Ilium
inch in the female, on the right
i
region).
B3'
the latter route the surgeon has the ad\antage that in operations upon the kidney the peritoneum Spinalis
deep
Muscle
lumbar
route followed
of the lower
division
after
of the
laj'er
The
not opened.
is
fascia
is
then
at the
is
border of the Sacro-
border of the Latissimus Dorsi, the After division of the Fascia
divided.
TransversaUs and the Renal Fat the lower end of the Viscus
extending the incision upwards injured,
as
of reflection runs
line
its
as far as the
\'ertebra in a horizontal direction of
some length;
If
the bone
is
this case
in
\&cy short the
carried forward
may open
1
from the lower border
outwards across the 12th
the anterior part of the rib i
ith rib
may
easilj^
of the
behind
;
of the rib
lies
if
12th Dorsal
this
bone be
below the
pleura.
be mistaken and thus an incision
Kidney the
and Vein anteriorly affords a great advantage from
In
into the pleura.
For operations near the Pelvis
accessible
exposed.
is
2th rib the Pleura ma}' be slighth'
same advantage
the
situation of the Arter>'
rendering the Pelvis easily
in
applies
to
upper
the
part
of
the Ureter.
The lower as for ligature
of
part of the Ureter
the
upper border of the of the outer
Common
made
Common
2th rib
and middle
aside without
the
1
opening. Iliac
parallel with
Iliac
is
reached
Arterw
obliquely
b}'
"an Oblique lateral incision"
This incision
third of P< >UPART's ligament.
The
is
carried
downwards and forwards
The peritoneum
is
pushed
where
it
crosses
lowest part of the Ureter below
Artery can also be reached extra-peritoneally
and
directly
from the
to the junction
abo\e Poupart's ligament.
b\'
an incision
—
tissinius
Dorsi Muscle
Serratus Posticus Inferior
Muscle
Sacro Spinalis Muscle
;ih
Rib
Right Kidney^-^^g
Inferior
Vena Cava-—_^='
Renal Vessels
-^m
Ureter
a
Ascending C nlon
Quadratus Lumboruni
Muscle
Iliohypogastric
Nerve
Spermatic Vessels
Iliu-inguinal
Superficial
Nerve
Lamella of
Lumbar Fascia
Lateral Cutaneous
Branch
\ Gluteus Maxtmus
Muscle
Gluteus Medius Muscle Origin of Transversalis
External Abdominal Oblique Muscle
Abdominis Muscle
Abdominal Oblique Muscle
Internal
Fig. 134.
Eight Kidney, Exposed from behind. */.
Rebman
Limited, London.
Nat. Size.
Rebman Company, New York.
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Position of the Abdominal Viscera seen from behind: lines
Fig. 136.
of Peritoneal Reflection.
The plaster model by His which has been made from nature Anat.
the form this
Abt,
Phys., Anat.
u.
and position
shews when taken
1878)
of the
Abdominal Organs
model shews the individual
reflection of the Peritoneum,
to pieces
relations
and the
Archiv.
and put together again
various organs,
relations of intra-
the lines of
and extra-peritoneal areae.
Our figure varies slightly from the model by His (cf. Fig. 130). Uncovered by Peritoneum A considerable area of the posterior :
posterior surface
of the Liver,
the
kidneys, F'R-
135
Inferior
surface
anterior
ai^d
The
139).
Vena Cava,
the Pancreas, of the
of of
large
the Kidneys in vessels
Duodenum and
surface of both
with the Pancreas
contact
are also
f.
a beautiful manner; further
in
the
of
(cf.
extra-peritoneal:
—
(cf.
Aorta and
the posterior wall of the greater part of the Ascending Colon
The
and Descending Colon.
posterior aspect of the middle portion
The Caecum
of the lower portion of the Rectum.
toneum except where the Ileum opens
into
its
is
also
and the whole
uncovered
posterior
aspect as
b}'
the peri-
it
becomes
closely applied to the wall of the False Pelvis.
On
rare occasions only does the
Vermiform Appendix Mesenteriolum
The
enveloped
is
in
Caecum
possess a Mesenter}- whereas the
Peritoneum and has
its
own Mesentery
—
—
extra-peritoneal position of the Kidneys,
Ascending and Descending
Colon afford an important means of operating upon these Viscera without opening the peritoneal cavity
(cf.
Fig. 134).
Moreover, as the peritoneum
attached to the anterior surface of the kidney, the kidney
it
Lumbar Colostomy was
only loosely
can be easily detached, and thus
removed without opening the peritoneal
Formerly,
is
cavity.
frequently performed for disease of the
Sigmoid and Rectum.
The absence
of
an important'! relation ^° is
Peritoneum on the posterior surface of the Rectum bears
^^
spread of inflammation.
unfavourable for circular enterorrhaphy
after
This absence of peritoneum
removal of Rectal Carcinoma
because gut surrounded by Peritoneum heals more readily.
Inferior
Vena
Ca,
Caudate Lcjbe iSl'IOKLlUS)
Hepatic Arterj-
Oesophagus Left Triangular Ligament of Liver
Vein
I'ortal
Coiiiinon nilc
Coeliac Axis,
Duct
Suprarenal Body Superior Mesenteric. Artery
^
Foramen
of
WiNSi.ow
Inferior Mesenteric
Vein
Supra- Renal Body
Spleen
Fatty Capsule of
Kidney
Pancreas
"
Right Ivldney
Pancreatic Duct
Duodeno-Jejunal Flexure
Hepatic Flexure of
Colon Left Colic Artery
Inferior Horizontal Portion of Duodenum
Descending Colon Right Ureter
Abdominal AortaInferior
Vena Cava
Inferior Mesenteric
Artery
Ascending Colon
Left Ureter
Left
Common
Iliac
Ileocolic Artery
Vessels
Superior
Haemorrhoidal Vessels
Artery to Appendix
Internal Iliac Vessels
^ Sigmoid Flexure
Fig. 136.
Rebman
Vermiform Appendix
Position of
Model made
Caecum
in
Abdominal Viscera, seen from behind; Lines
Plaster of Paris by
Limited, Loudon.
Stager, Leipzig.
According to
W.
of Peritoneal Reflections. His.
—
7-
Nat. Size.
Rebman Company, New
York.
Rectus Abdominis
Inferior Ileo-
Caeca Fossa I
Anterior Superior Iliac Spine Superficial Epigastric Vessels
Ileum
Ureter
Deep
/
/
Vas Deferens
Ilio-hypogastric
External Iliac Vessels
Nerve Spermatic Vessels
Fig. 137.
Plica Epigastrica
Vermiform Appendix and Caecum. Nat. Size.
Muscle
Epigastric Artery
Vermiform Appendix and Caecum.
Fig' 137-
window has been made 5
In a robust male corpse, a lozenge-shaped
inches
the skin but of a smaller area through the deeper layers
by 4 inches throttgh
of the right Hypogastric and Iliac Regions;
Omentum and
Transverse Colon
are tlirowii upwards.
The Appendix its
higher
at a
is
level,
and more
laterall}^ situated
than usual;
position varies with the degree of distension of the neighbouring intestines.
As
Appendix
the
marked
in
completely enveloped
is
commencement
contrast to the
covered anteriorly whereas posteriorly wall
Peritoneum,
in
of the
its
mobility
Ascending Colon which
very
is
only
is
remains fixed to the posterior abdominal
it
Fig. 136).
(cf.
The Caecum,
usually
inch
2^/r,ths
long,
is
situated
in
the
Right
Iliac
Fossa on the Fascia Iliaca above the outer V2 of PouPART's Ligament; when moderately distended and the neighbouring coils of intestine empty or only distended
slightly
movable
it
ma}-
lie
Coming in
possession
very variable; in
shape
in
may come
in
Abdominal Wall, but
if
more
lower end of the Caecum near the Ileo-Caecal Junction and
own mesentery
its
length
may be
it
Anterior
bent upwards upon the Ascending Colon.
off the
of
the
against
lies
it
the position of the
varies from
it
straight,
i
to
serpiginous, spiral or bent
contact with the Bladder or
Vermiform Appendix
is
10 inches (usual length 3 to 4 inches);
Ovary
upon
itself;
in position
in the true Pelvis,
it
may
it
lie
behind the Ileum or extend up behind the Caecum, Kidney or even the Liver, or Stomach, and extending beyond the middle
base
Its
corresponds to
right Anterior Superior Iliac Spine
The toneum
in
Arteries to relation
tlie
with
Ileum,
line.
Mc BuRNEY's
point
—
midway between
the
and the LTmbilicus.
Caecum and Appendix produce
which small recesses are formed,
e.
g.
folds of Peri-
Superior and
Inferior Ileo-Caecal Fossae.
As
Appendicitis
Appendix are
often
parallel to the outer
is
of frequent occurrence, operations
The usual incision PoUPARX's Ligament;
necessary. V2
of
is
—
made
upon the Vermiform directly
above and
though the viscus can be
reached by an incision along the outer border of the Rectus Abdominis Muscle at the level of the Anterior Superior Iliac Spine.
Pig. 138.
The Hypogastric and male cadaver (aet.
Sigmoid Flexure and Inguinal Canal.
Regions are exposed on the left side of a normal The tipper portion of the Abdominal Wall in this ^8). region has been removed^ and the Ingiiinal Canal dissected ont, the Sigtnoid thrown upwards and inwards, after accurately determining its positum (dotted
—
Iliac
lines).
The Sigmoid Flexure which, variable in length, extends between the Descending Colon attached to the posterior Abdominal Wall and the Rectum attached to the posterior Pelvic Wall is the most movable portion of the
—
—
—
—
large intestine.
The Sigmoid Flexure
usuall}'
possesses a lower
vexity downwards, and an upper (right) curve with are indicated
by the dotted
the figure, a small
lines.
peritoneal
When
its
the Sigmoid
pouch over the
left
(left)
curve with
is
con-
its
convexity upwards.
Such
turned upwards, as in
psoas becomes evident
—
the
Fossa Sigmoidea.
Lying internal to the Psoas Muscle are seen (cf. Fig. 137) the Iliac above the divided Rectus Muscle is seen the Obliterated Hypogastric Artery passing upwards towards the Umbilicus as the lateral vesico-umbilical Vessels;
ligament
in the Plica Umbilicalis.
The
fibres of the External
Oblique Muscle of the
Abdomen
diverge in the
Inguinal Region forming the two pillars of the External Inguinal Ring, so that in the middle line at the Symphysis and the SusLigament of the Penis or even extends beyond the middle line to the Opposite side, whereas the inferior or outer pillar terminates at the Spine of the Pubis. The upper sharp angle of the External Abdominal Ring, and the anterior surface of the cord are covered by the Intercolumnar Fibres (removed in the figure), the function of which is to prevent a wide divergence of the pillars. These intercolumnar fibres are derived from the External Oblique Muscle of the opposite side and terminate by blending with PouPART's Ligament. Accordingly this ligament is formed by the External Oblique Muscles of both sides and represents a tendon which most authors view as a band of connection between two bony points or as the lower border of the External Oblique Muscle. This latter view is probabl}' the more correct but it fails to take into
the upper or inner pillar ends pensor}'
consideration
the connection of this ligament with the Fascia Lata of the Thigh.
Several small Ugaments, of which some have been
named
are connected
with Poupart's Ligament.
There exists, occupying a horizontal position between the Pubis and PouPART's Ligament, a triangular-shaped ligament, with its base directed outwards, which is named GiMBERNAT's Ligament. When this structure is looked at from above and behind it receives the name of CoLLES' Ligament. Its sharp outer edge is sometimes called the Falx Inguinalis (Ligament of Henle). Internal and external to the Deep Epigastric Vessels lie respectively the Internal and External Abdominal Rings between these is Hesselb ach's Ligament. ;
Obliterated Hj-pogastric Artery
Sigmoid Flexure
Spermatic Cord
Pocpart's Ligament
\
Ilio-pubic
Ascending Colon
Band (Colles)
Free Edge o( Gimbernat's Ligament
IHo-bypogastric Nerve Spermatic Vessels
(
Externa! Abdominal Ring
Deep
Internal
Epigastric Artery
Abdominal Ring
Vas Deferens
Hes-^elbacu's Ligament
Fig. 138.
Sigmoid Flexure and Inguinal Canal. Nat. Size.
Rebm.iQ Limited, London.
Rebman Company, New York.
Piiricardial Cavity
Pectoralis
Sternum
bth Costal
5th Costal
Cartilage
Cartilage
Api;x of Heart
Major Musirle 5th
Caudate Lobe
Rib
(Si'igelicis)
Rib
6th
Vena Cava
Inferior
Stoniarli Serratiis
Ma
Muscle ,lli
oth
Kil>
Rib
Latissimus Dorsi
Muscle Ocsoplia^'iis
Supra-ren.il
Fig".
Body
Riffht
Vagus Nerve
nth Dorsal Vertebra
Thoracic Duct
Thnracii
Aorta
Transverse Section through the Trunk at the level of the
139.
—
Seen from below.
Rectus Abdominis Muscle
-/s
Uth
Dorsal Vertebra.
^^^' ^*^^*
Xiphoid Process
Portal Vein
7th Costal Cartilage
Right Hepatic Duct
7th
Rib
Liver
Greater
Omentum
Duodenojejunal Flexure ,
Mtli
Rib
Pancreas
Latissimus Dorsi
Muscle Pleural Cavitj'
Left Kidney
nth Rib
^^^
Supra-renal Body
Fig. 140.
Abdominal Aorta
1st
Inferior
Vena Cava
Transverse Section through the Trunk at the level of the 1st Seen from above.
Rebmau
Lumbar
Vertebra
Limited, J^nnduii.
—
'/-
Nat.
Lumbar
Vertebra.
riize.
Rebman Company, New York.
Fig. 139.
Transverse Section through the Trunk at the level nth Dorsal Vertebra, from below.
of
the
tJie same body as in Figs. 121 and 122. In front the 6th Cliondro-Sternal Articulation is ciit tbrovgli, also the yth, 6th, jtJi, Stli, gt/i, 10th and Jitli ribs; tlie vertebral column is slightly deviated to the right.
Frozen section of
In
Lungs
(in
this
the
section
the
lowest portions of the Thoracic Viscera,
condition of inspiration as in
Fig. 122)
Heart and
and the Abdominal
Viscera,
between these two Liver, Stomach and Spleen are shewn in transverse section groups of viscera lies the diaphragm. The Liver occupies the greatest space, the remaining space is chiefh' occupied by the Stomach, a small area is left by the Liver for the Apex of the Heart, and by the Stomach for the Spleen. The Lungs in their position during inspiration are seen at the periphery. The entrance of the Oesophagus into the Stomach and the numerous broad plications of the Gastric Mucous Membrane are well shewn. Behind the Oesophagus Hes the Aorta at a higher level the Oesophagus occupies the more posterior position while in close relation behind it and in contact with the Vertebral Column are found the large and small Azygos Veins, the Thoracic Duct and the Sympathetic System. ;
;
Fig. 140. Transverse Section through the Trunk at the level of the 1st Lumbar Vertebra. Seen from above.
Frozen section as in Fig. ifg passing through the disc between the 12th Dorsal
and
1st
Lumbar
Vertebra.
space as in Fig. 139, now taking up the space previously occupied by the heart whereas, behind, room is made for the Between this Viscus and the Spleen, right kidney. To the left is the Stomach. the Splenic Flexure has introduced itself extending upwards beyond the plane of
The Liver occupies almost
as
much
the section so that only sections of the Transverse and Descending Colon are seen.
Between the Colon and Stomach a lumen of small intestine is \'isible and between the Colon and Abdominal Wall the Great Omentum. The Pancreas has been cut almost throughout its whole length as it extends horizontally across from Liver to Spleen. The Oblique position of the kidneys is also seen; on either side a "Pleural Space" is found between their upper half and the posterior abdominal wall. The space between the Pancreas and the posterior abdominal wall is occupied by the Left Kidney which has been cut through at its greatest diameter whereas the Right, situated at a lower level, was divided nearer its upper pole. The peculiar shape of the transverse section of the Aorta is due to the origin of the Superior Mesenteric Artery.
Retroperitoneal Lymphatic Glands and Vessels.
Fig. 141.
The whole of the Anterior Abdominal Wall and the lower part of the Anterior Tlioracic Wall have removed in a male infant, 4 weeks old. A small area of peritoneum has been left over the right
been
kidney ;
the Receptactihim Chyli has been
exposed
to
view by cutting away a short piece of the Aorta.
The renal lymphatics are described after Stahr; the lymphatics of the testicle partly after Most and partly after B r u h n s whose description has been adopted for the deep inguinal glands.
Apart from the glands above the fascia lata of the thigh described in Fig. 166, deep consideration both as regional and as intermediate to the deep lymphatic vessels of the lower limb. As a rule, they are small and only 1—4 in number; their efferent vessels run, as shewn in the figure, along the inner border of the Femoral Vein and along the outer and anterior surfaces of the vessels of the thigh into the Pelvis. The former path leads to Cloquet's Gland, the outer tract to a (usually) very large gland just above Pol'Part's Ligament. The large lymphatic vessels (4 to 6) of the testicle have a very long course before they arrive at their regional glands (the lumbar glands:; occasionally, there is an intermediate gland on the course of the Spermatic Vessels (black spot on the right side at the level of the Rectum). The regional glands on the right side are usually at a lower level than on the left side; with the Vas Deferens lymphatic vessels run to the base of the bladder. The lymphatics of the inferior half of the Ureter pass to a Pelvic Gland, those of the superior half to a Lumbar Gland. The Lymphatics of the Kidney form on its surface a network quite distinct from the Stellate Veins of Verheyn. The efferent vessels (2 4) pass with the renal blood-vessels either directly or through an intermediate gland to the group of lymphatic glands situated at the angle formed by the Renal V'eins and the Inferior Vena Cava. When accessory renal vessels are present (cf Fig. 164) lymphatic vessels with a special regional gland usually accompany them (Frohsel As the Peritoneum gives a covering to all the abdominal viscera its lymphatics do not correspond to the limitations of each viscus (cf. peritoneum over right kidney after Stahr who has kindly allowed us to make use of his hitherto unpublished figures). All the lymphatics referred to, as well as those from the Intestine which convey the Chyle, directly or indirectly pass into the Receptaculum which lies behind the Abdominal Aorta and from which the Thoracic Duct leads. The Aorta and Inferior Vena Cava are surrounded by a network of lymphatics and glands. glands
demand
—
General Remarks on Lymphatic Glands. As many
regional glands are secondary to other organs
it remains that only a fewintermediate glands (a collection of lymphoid tissue on the course of a lymphatic vessel) are
purely regional. From pathological observations, lymph nodes or small collections of lymphoid tissue Frohse and Hein have seen in a are frequently found on the course of lymphatic vessels case of Arterio-Venous Aneurj'sm (the injected specimen of an amputated arm) 6 large glands ;
situated along the radial and ulnar arteries.
Hein has
arm a small gland near the ulnar Carcinoma Mammae with lymphatics 4 newly formed glands on the clavicle and in yet another axillary glands on the healthj' side and 31 on the diseased side; — to sum up:
further observed in an apparently healthy
nerve, just below the Elbow-Joint.
obstructed
axillarj-
Frohse found
in
a case of
pathological case 14 pathological conditions favour the new-formation and development of lymphatic glands. In some cases the lymphatic glands are not visible to the naked eye but when injected with
mercury even a gland of the size of a pin's head can be recognized because distended by preventing the passage of mercury.
it
becomes
Mam-
Internal
mary Artery
Pericardium
Diaphragmatic Pleura
Oesophagus
Inferior Phrenic
Artery
Supra-renal
Body Fatt>'
of
Capsule
Kidnev
Lymphatic Plexus Stellate Veins
(Vkkheyn) L2th Dorsal
Nerve Origin of Transversal is
Ab-
dominis !Muscle Inferior Mesenteric Artery Ilio-irguinal
Nerve 4th
Lumbar
Artery External Cutaneous Nerve
Superior Vesical Artery
Deep Circumflex Iliac
Artery
Epigastric and
Obturator Trunk Inferior Epigastric Glands
Falciform Edge of Fossa Ovalis
Fascia Lata
Long Saphenous Vein
Spermatic Cord
Adductor Longus Muscle
Fig. 141.
Reti-operitoneal
Lymphatic Glands and Vessels.
Newborn male Child.
Kebman
Limited, London.
—
Nat. Size.
Kcbman Company, New York.
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Fig. 145.
Back shewing Nerves, Arteries and Lymphatic Glands.
The Skin and Superficial Fascia have been removed from the whole dorsal aspect, extending from Occiput to Sacrum. On the right side the Trapezius, Latissimus Dorsi, Superficial Layer of Lumbar Aponeurosis, Supra- and Infra-Spinatus Fascia wit/i the attachment of the Splenius Capitis Muscle have been cleared aivay. This figure are
is
purposed to shew those lymphatic glands of the back which
known and which receive but scant attention. Trapezius Muscle with 1. Muscles and Nerves.
little
Spinal Accessory (Xlth downwards, Latissimus Dorsi Muscle with its nerve running obliquely downwards and inwards, Levator Anguli Scapulae and Rhomboid Muscles with branches from the Posterior Thoracic Nerve, Supra- and Infra-spinatus Muscles with the Supra-scapular Nerve, Teres Minor and Deltoid Muscles with the Circumflex Nerve, Teres Major Muscle, Subscapular Nerve, Serratus A'lagnus Muscle, Long Thoracic Nerve (of Bell) (v. Figs. 109 and iioj. The Occipital Arter}' (a branch of the External Carotid) be2. Arteries. comes visible, at the attachment of the Sterno-Mastoid and Trapezius, and ramifies over the Occiput. The Posterior Auricular Artery (External Carotid) passes behind the pinna to anastomose with the former. The Transversalis Colli Artery from the Subclavian Arterj' appears in the space between the Levator Anguli Scapulae and Rhomboid Muscles. The Supra-scapular Artery either a direct branch of the Subclavian or a radicle of the Thyreoid Axis or Inferior Thyreoid Artery, accompanies the Supra-scapular Nerve to the Supra- and Infra-spinous Fossae where it anastomoses with the Subscapular Artery from the Axillary. More externally the Posterior Circumflex Artery accompanies the CircumIn close flex Nerve as it winds around the Surgical Neck of the Humerus. contiguity to Bell's Nerve is found the Long Thoracic Artery (inconstant). LTpon Cranial)
Nerve running almost
vertically
Dorsum of the Trunk proper only small arteries are found because the Dorsum the Trunk like the extensor aspects of the limbs receives its blood from the ventral or flexor aspect. At the point of emergence of the Occipital 3. Lymphatic Glands. Behind the Pinna accompanying the Arterj' a few Occipital Glands are found. Posterior Auricular Artery and 13'ing over the tendinous attachment of the SternoCleido-Mastoid is a posterior Auricular Gland which should be called the Superior Posterior Auricular Gland so as to distinguish it from a deeper gland which lies Deeply situated behind the Mastoid Process, in contact with the Muscle itself. and under cover of the Splenius and close to the Occipital Artery Ues a deep the of
Mastoid Gland (cf. Fig.). The subcutaneous glands along the upper border of the Trapezius and near the Vertebral Column are not particularly marked in the figure. They may be called the Superior and Inferior Subcutaneous Nuchal Glands. At the level of the 7th Cervical Vertebra lies the Superior Superficial Dorsal Gland; the Inferior Superficial Dorsal Gland lies along the outer border of the Latissimus Dorsi at the level of the ist or 2nd Lumbar Vertebra. At the Clavicular Origin of the Deltoid is the Superficial Clavicular Gland, whereas more deeply situated near the Suprascapular Artery and at the upper border of the Scapula is the Supra-scapular Gland. Deep Dorsal Glands are situated at the upper border of the Rhomboid Muscles; on the Teres Major Muscle is seen the posterior superficial Axillary Gland; a deep gland is situated between the Teres Major, Teres Minor and Triceps Muscles. These glands are not all constant; they may only be found in pathological conditions; such occurrence does not exclude their normal presence as merely elementary.
Occipital
Gland
Occipital Artery
Splenius Capitis et Cervicis Muscle
Deep Mastoid Gland Posterior Auricular Artery
Longissiinus Capitis Muscle Siipt-ro-posterior Auricular
Gland
Rhomboid (Major) Muscle Sterno-Cleido-Mastoid Muscle (Infero -posterior Auricular Gland)
Levator Angtili Scapulae Muscle Trapezius Muscle
Deep Dorsal Gland
Spinal Accessory
nth Xerve.
Superficial Superior Dorsal
Superficial Clavicular
Gland
Gland
Circumflex
/
/
/ ^/OvrSS^ /
/
//ni
Ner\*e
I-""g Head o Triceps Muscl.
}W '/
Deep
Posterior Axillary Gland
Teres Minor Muscle
Infra-spinatus Muscle
Teres Major Muscle
Long Thoracic Nerve (Bell)
Serratus
Magnus Muscle
Superficial Inferior
Dorsal Gland
Longissimus Dorsi Muscle
External IVbdominal Oblique
Serratus Posticus (Inferior)
Muscle
2th
Muscle
Rib
fnternal Abdominal L)blique Muscle iPkti r's Trianglei
Internal
Abdominal
Oblique Muscle Postero -superior Iliac
Spine
Gluteus Medius
Muscle
/
/
I
Gluteus Maxinius
Muscle
'S^^-"
Fig. 145.
I'r.i'rohsc
Back, shewing Nerves, Arteries and Lymphatics. -/,
Nat. Size.
Promontory
Fundus of Uterus
Douglas' Pouch Posterior Fornix of Vagina
Symphysis Pubis
Labium Minus Labium Majus
i^^^-i-'^V
Fig. 146.
Median Section through a Female Pelvis (Bladder and Rectum empty). v.,
Rebman
Liiititcd,
Loudon.
Nat. Size.
Rcbman t'ompany, New York.
Median Section through Female Pelvis Bladder and Rectum
Fig. 146.
;
being empty.
Median section through
the body
of a
woman
aged
In this instance, owing
^o.
either to pathological adhesions or post-mortem changes, the Uterus did not
on the Bladder,
directly
it
drawn forward
has, therefore, been
lie
into the position
of anteversion and anteflexion in accordance with the general investigations
upon living
When is
the bladder
is
subjects.
empty the normal
anteverted (virgins) and anteflexed (women)
e.
i.
the Uterus
Whether
aspect of the bladder (B. Schultze).
superior lie
position of the uterus during life
between the Uterus and Bladder or whether other
have not
on the postero-
lies
coils of
varieties
small intestine
we
normally exist
definitely decided.
As
the bladder becomes distended the Uterus
is
pushed upwards and
backwards.
The course its
of the
Vagina
is
S-shaped, like the
Urethra.
Into
upper cul-de-sac the Cervix Uteri protrudes, thus forming an Anterior and
Posterior Fornix of which the latter
is
separated from the Pouch of
The empty bladder evidences a
An
Uterus.
slight impression
to the
body
of the
(iVsth inch long) enters the bladder at an acute angle.
The Peritoneum does not extend
Rectum
due
"uterine impression" can also be recognized on the distended bladder.
The S-shaped Urethra
Coccyx).
DOUGLAS by
(Operation route.)
V25th inch.
the
Rectum and
(3rd Sacral
so far
Segment) as upon
its
down on
the posterior aspect of
Anterior Aspect
(ist
Segment
of
Levator Ani, External and Internal Anal Sphincter Muscles are shewn
in the figure.
Lastly the extremity of the Dural Sac of the Spinal Cord ating at the level of the 2nd
Segment
of the
Sacrum.
is
seen termin-
I
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43 (U
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43
External Female Genital Organs.
Fig. 148.
The Labia have been drawn apart in order ticular, the
skin
is
closed in Virgins
to the
when
meet, but behind they are lost
these Labia
well-covered
usually
Vestibule.
Vestibule and, in par-
the
openings of the ducts of Bartholini's Glands.
The Labia Majora corresponding
Rima Pudendi which
shew
to
(Vulva.)
with
Scrotum
of
the male limit the
the thighs are adducted; in front
They
near the Anus.
are folds of
and large sebaceous glands, and contain
hair
large Veins.
The Labia Minora
are separated by a sulcus from the Labia Majora
outer surfaces are covered with skin, their inner surfaces with
continuous with that of the Vestibule.
join
below the
Clitoris
the Penis of the Male
being
merge
visible.
into
The
and form the Frenum. is
usually rudimentary,
posterior ends of
the Labia Majora, or
limits the Vestibule is
mucous membrane
In front the Labia Minora bifurcate, the
portions of either side unite to form the Prepuce of the Clitoris,
outer
posteriorly.
may
At
their
;
The its
Clitoris
unite
which corresponds
extremity (Glans
the Labia Minora
the inner to
alone
Clitoridis)
vary much, they
may
together and form an arch which
the posterior junction
of the Labia
Minora
situated the Fossa Navicularis.
In the
angle between the Labium Minus and the
Hymen
opening of the duct of Bartholini's or Duverney's Gland.
Hymen and the Clitoris
a vertical
In
is
situated the
front
of
the
about midway between the posterior limit of the Vaginal Orifice and is
slit,
situated the Urethral Orifice
semilunar or
/\
which may be of
different shapes:
—
-shaped.
The projection of mucous membrane behind this — Lingula Urethrae VON Bardeleben — is correspondingly pointed or rounded off. The Hymen a reduplication of the mucous membrane at the entrance of the Vagina varies much in shape though generally crescentic from side to side with the broad part of the crescent posterior in situation (prior to Defloration);
it
may be annular, or fimbriated, even double or fenestrated. During "Defloration" hymen is usually torn and heals with cicatrices. Fresh lacerations occur
the
during the
first
labour,
these lead to the formation of Carunculae Myrtiformes.
;
Fig. 149.
Pelvic Organs of
Female seen from above and
in front.
Ureter.
Woman aged
50.
Left Appendages
upwards and
its
removed as far as the Rectum, Uterus retroverted The Right Fallopian Tube is drawn of Uterus removed. fimbriated extremity thrown upwards oi'er the brim of the Intestines
The Abdominal Opening of the Fallopian Tube and the Ovarian Fossa are thus exposed; the ovary is somewhat drawn upwards by the tube. On the left side the peritoneum covering tlie important vessels and nerves has true pelvis.
but the portion forming the posterior layer of the Broad Ligament has been preserved intact and the round ligament retained in situ. On the left side the Lymphatic Glands are exposed and their corresponding imaginary been removed,
situations on
the right
By Waldeyer the following fossae:
the
Round Ligament
side are depicted through the transparent peritoneum.
wall of the true pelvis has been divided into
the lateral
Paravesical, Obturator, Hypogastric (Para-Iliac) (in
the Male
—
Vas Deferens) and
bounded by
the Ureter.
When
the Bladder is empty the Paravesical Fossa is divided into an and posterior part by the Transverse Vesical Fold; the anterior part belongs more to the Anterior Abdominal Wall, the posterior part can be fully seen when the Uterus is retroverted. The Obturator Fossa in the depth of which the Obturator Vessels and Nerve run over the surface of the Obturator Internus Muscle contains the Ovarian Fossa which may be a simple groove or a deep alcove against which the lateral half of the Ovary lies while its posterior border remains free and rounded. The Ovary lies on the Uterine Artery touching the Ureter: according to the size of this organ and the position of the Internal Iliac Vessels it reaches or extends beyond the Internal Iliac Vessels, as far as the lower border of the anterior
External
Iliac
Vein.
The most
posterior
fossa
is
the H3'pogastric (Para-Iliac) Fossa in which
the Pyriformis Muscle and on this muscle the Sacral Plexus are found.
The Ureter
Common
generally enters the True Pelvis at the bifurcation
of
the
Artery passing over the External Iliac Vessels and the UmbilicoVesical Trunk to lie between the Internal Iliac Vessels and the Uterine Artery and covered for some distance by the broad ligament and the Vessels to the AppendIn this part of its course the Ureter lies directly under the Peritoneum. ages. Further forwards, in front of the Broad Ligament, the Uterine Artery crosses over and in front of the Ureter as it leaves the pelvic wall and approaches the Vaginal Portion of the Uterus. It is at the level of the Internal Os (where the Uterine Artery bifurcates Waldeyer) that the Uterine Artery crosses the Ureter. The Ureter comes very near the Vaginal Portion of the Uterus (cf. dotted line) as it curves round it laterally to open into the bladder. The Ureter is only separated from the Vaginal Portion of the Uterus by the vessels in the cellular tissue of the Parametrium (Branches of the Uterine Artery and Utero-Vaginal Venous Plexus). On its outer side lies the Vesicovaginal Venous Plexus. These Plexuses communicate freely so that the Ureter is embedded in a venous plexus. Iliac
—
Bifurcation Inferior
t»f
Aorta
Superior IIaeui(»rrlioidal Arterv
Vena Cava
/ Ovarian Vessels
Syiiip;ilhetic
^
Chain
f
Ovarium Artery
Common
Iliac Vessels
Ureter
Genito-Crural Nerve
Middle Sacral Vessels
Fossa Hypojfastrica
iWaldevek)
(Para-iliac Fossii)
iDisc between — Promontory 5th Lumbar and 7th Sacral '
>bliir;itor F<.)ssa
Vertebra)
(Waloryki;
Internal Iliac Vessels
Uterine Arterv
--
Ureter
Ovary
-Viiipiilta
External Iliac Vessels
—
Obtmatur Artery
—
Uterine Artery
uf
Falloi'Ian Tube
Round Ligament
Posterior Layer of the Broad Ligament
of Uterus
Obturator Nerve
Posterior Fossa ParaVesicalis (WALDElTEtt)
Superior Vesical Superior Vesical
Arterv
Artery *
'<
minion Trunk of
Deep
Middle Vesical Artery
Epigastric and
(Vesico -Vaginal)
Obturator Arteries
L'^tero -Vagina I
Transverse Vesical Fold
(Walueyeu)
Vesico- Vaginal Venous Plexus
Anterior Fossa ParaVesicalis
Venous
Plexus
(Waldeyer) Obliterated Hjijogastric
Artery
Linea Alba
Symphysis Pubis
Fig. 149.
Pelvic Organs of Female, seen from above and in front 7,,
Rcbman
Limited, London.
Ureter.
Nat. Size.
Rt'Ijuiiin
Ciiiiipiuiy.
New
York.
Lateral
I
line
S.icr.'il
Art (TV
Pustcni- Superior
Spine .interior lirancli of 3r(l SatTiil
Nerve Anterior Brani:h of .)tli Sacral
Nerve 2nd Posterior S.uTiil
eritoneum
Koraineii
I
Pouch of
Doroi.AS) il
adder
Keclo* Vesica Fascia
I
Great) Sciatic
Nerve Small SacroSciatic
Perinaeal
Ligament
Raph^
Posterior Scrotal Branch of the Perinaeai Nerve (of Internal Pudic)
^^^'^•^*
.*!). .-^
-
Fig. 150.
Pelvic Organs of Male, exposed from behind, V, Nat. Size.
Rebman
Limited, London.
RebmjiQ Company,
New
York.
Fig. 150.
Male Pelvic Organs, exposed from behind.
The Ghiteus Maximus is detached from the Posterior Inferior }^. Spine downwards and the Erector Spinae divided transversely at thin level. The Sacrum has been sawn through between the 2nd and p-d Sacral Foramina, the Coccyx between the Jst and srid Segments ; the different layers liave then been successively exposed: Rectum, Bladder, Peritoneum, Vas Deferens, Male aged Iliac
Seminal Vesicle and Ureter. On the right side the Great Sacro-Sciatic Ligament has been cut short and the Ischiorectal Fossae cleared out on both sides.
The
in the
figure
particularly
shews the
different
layers
through
which the
Rectum or deeper parts. Removal of the lower part of the Sacrum can be carried out, as shewn figure, without any great damage. The nerve supply of the Rectum and
Surgeon cuts
Bladder
is
in
order to reach the
chiefly derived
from
tlae
3rd Sacral Nerve.
There
is
no
risk of
opening
the Dural Sac which usually terminates at the lower part of the 2nd segment of the Sacrum.
Deep
to the
Sacrum
lie
the middle and lateral Sacral Vessels; next
the Rectal Fascia (yellow) and before reaching the longitudinal muscles of the
Rectum a
thick layer of
fat, in
which
lie
the Superior Haemorrhoidal Vessels and
the Lymphatic Glands of the Meso-Rectum, has to be divided.
According
to the
degree of distension the Rectum may occupy the whole of the Recto- Vesical Pouch or leave on either side a peritoneal space (light -blue). The lower boundarj' at which the peritoneum is reflected on the Rectum is about 3 inches above the
Anus. Below this level operations on the Rectum can be performed without opening the Peritoneum. In front of the Rectum merely separated by Recto-Vesical Fascia is the Bladder, the base of which is laterally and inferiorly covered by the Ampulla of the Vas Deferens and the Seminal Vesicles. In the angle between these structures lies the Ureter (green), this can be exposed by removing a layer of fatty tissue rich in the vascular anastomoses of the numerous branches of the Inferior Vesical Vessels
(cf.
Fig. 161).
The arrangement
of the muscles bounding the Ischio-Rectal Fossa is to be seen as well as their relation to the lesser Sacro-Sciatic Ligament and the Coccygeus Muscle; a small gap engages one's attention (through which a Hernia of the Floor of the Pelvis may occur), next the Levator Ani Muscle and finall}the External Anal Sphincter (cf. Fig. 153). The Internal Pudic Vessels and Nerve wind round the Spine of the Ischium and run under cover of the Obturator Fascia forwards and downwards. These structures therefore do not re-enter the pelvis through the Sciatic Foramen as usually stated but remain separated by the muscular floor of the pelvis. Neither do these structures pass into the Ischio-Rectal Fossa but remain in Alcock's Canal which is a re-duplication of the Fascia covering the Obturator Internus Muscle on the outer wall of this fossa.
Median Section through Male
Fig. 151.
Pelvis.
Frozen section through the body of a robust elderly man. The Rectum was much distended by faeces which were removed after the section had been hardened; the Bladder contained frozen urine which melted as the section thaived.
The parietal layer of Peritoneum lining the Anterior Abdominal Wall can be traced over the summit and posterior aspect of the Bladder to be reflected on to the anterior surface of the Rectum at the level of the lower border of the 4th segment of the Sacrum. This point, of great surgical importance (for the removal of Tumours) is situated 3 inches above the Anus (length of Index Finger). The Peritoneum now continues upwards as far as the 2nd or ist segment of the Sacrum. Between the Anterior Abdominal Wall and the Peritoneum a space is formed when the Bladder is distended (Space of Retzius) because the peritoneum being adherent to the Bladder is pushed upwards as this organ rises out of the
Between the Rectum and the Bladder, close to the middle line this is partly shewn in the section. Ampulla of the Vas Deferens The Rectum when filled with faeces is chiefly distended above the 3rd or Anal Pelvis (Fig. 144). is
—
situated the
portion (Ampulla Recti)
so
that
the organs which
lie
in
front
of this part are
pushed upwards.
Below the Ampulla
of the
Vas Deferens
Prostate; the remainder of this gland lies in
rr>unded
by the
Prostatic
lies
front
the posterior portion of the of the Urethra,
and
is
sur-
Venous Plexus.
is thickened and presents marked rugae The Urethra on emerging from -the Bladder passes through the Prostatic portion Prostatic Sinus or Verumontanum — this portion is usually one inch or a little more in length, though in cases of Hypertroph}' of the Prostate The next segment of or a greatly distended Rectum this ma}- be exceeded. the Urethra is known as the Membranous portion — according to Waldeyer
In this specimen the Bladder Wall
on
its
inner surface.
—
the upper and larger part of this should be called the Muscular portion because it derives both circular and longitudinal segment is almost one inch. The Urethra at this situation forms a curve at an angle of 90 degrees which often obstructs the passage of the point of a catheter. The distal segment is 6 to 8 inches long and extends from the Anterior layer of the triangular ligament to the end of the Penis, lying between the Corpora Cavernosa it is surrounded by a delicate erectile tissue (the Corpus Spongiosum) which is enlarged posteriorly to form the Bulb and anteriorl)' to form the Glans Penis. The Corpora Cavernosa arise on either side of the ascending Ramus of the Pubis and tenninate as cones at the level of the Slight!}Coronar}' Sulcus of the Glans Penis by which they are covered. posterior to the slit-like external urinar}^ orifice the Urethra widens into the Fossa Xavicularis. The Glans may or may not be covered by a Prepuce according to size, age, habits, etc. (Phimosis, Paraphimosis, Circumcision cf. Fig. 5 2 and Text). As the position of the testicles is not quite symmetrical, the Septum of the Scrotum has not been divided but the left testicle within its Tunica Vaginalis has been cut obhquely. it
is
fibres.
surrounded by muscles from which
The length
of
this
—
1
i
IVfillK
.umi.y „f
Dun
t
S
/
^^
f
,,-\
,•?
=
Vns Deferens (Ampulla Aiiiimlla of
Roctum
—
^C. Levator .Vni Muscle
Deep Transverse iiacal
Pcri-
Muscle (Transversus Perlnaei)
^
Bulb uf Urottr.i
Fig. 151.
Median Section through Male
Pelvis.
V, Nat. Size.
Rebman
Limited, Loncion.
Rebman Company, New York.
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«-4.
Frontal Section through Male Pelvis. Levator Ani Muscle.
^ig- 153-
Frozen
section.
made almost
Through
the body of a
parallel with
Male of middle age a
section lias been
so that the plane of section is not
the pelvic axis,
accurately frontal.
This figure short description
necessary.
is
B
The Bladder section, visible
intended to complete the series Figs. 151 and 152; only a
is
with
its
overlying peritoneum
above the black hnes which dehneate the peritoneum.
All other structures except the parts of the thigh of
below the
Very felt
a frontal plane,
in
last
Rectum and
to
these
i.
e.
(cf.
the folds of the buttocks and
lower part of the Bladder, Ampullae Fig.
151)
the Seminal Vesicles and
mentioned the Rectal Wall.
instructive
is
the divided Obturator Internus Muscle,
which can be
bulging on examination of the Female Pelvis, and especially the direction of
the Levator the
lie
Vasa Deferentia, external
directly
in front of the plane of
is,
White
round sidered
it
Ani which line
upper border of the Obturator Internus from
and approaches the Rectum
and terminate consist
to
arises at the
of
in a
funnel-shaped manner to sur-
in the
External Anal Sphincter.
many
parts.
At
the
This muscle
commencement
of
may be
the funnel
conit
is
markedly thickened (Constrictor of the Vagina).
Near the Obturator Internus Muscle are situated the Internal Pudic Vessels and Nerve
(cf.
side of the
Rectum
The
Fig. 154)
last
covered by Fascia (not seen
the figure).
are seen the Ischio-Rectal Fossae filled with
part of the
Rectum
onl}'
as
it
viewed from behind.
On
either
fat.
runs obliquely downwards and
backwards has been cut through; the upper part section as
in
lies
in
front of the plane of
Extern;!! Iliac
\'eiii
Obturator Artery
—
Hip-Joint
—
Obturator Nerve
Deferens * \
Ureter Vesica! Plexus of Veins
Ampulla of Vas Deferens
Obturator Internus
Ampulla
of
—^^
^/~*:-fWt
t
—y^~rpW3 S
Seinina! ^'esI(lt
|
_
" ff^KV
.
g
Rectum
Levator Ani ^Muscle
Ischio-Roctal Fossa
Tuber Isch
Gluteus Afaximu^ ilusc!!
Fig. 153.
Frontal Section through Male Pelvis Seen from behind.
Rinjman
Limileil, Loiulon.
—
-/s
—
Levator Ani Muscle.
Nat. Size.
Rcbmaii Company,
New
York.
0>rpu.'i Sponjjii'Siim
Perinaeal Ner\'e (Posterior Scrotal Branches)
^ ^\
Posterior Scrotal Vessels
Long Pudendal Xerve
Raphe between
Biillx
Cavernosus Muscles
Left Ischio -Cavernosus irusctc
Deep Transverse I'ennaeal Miiscic Minpressor Urethrae
(.oininunication with
Obturator Vein
Vessels to the
Obturator Fascia
Eulb
^(Alcock's Canal)
Central Point of Perinaeiini
Superficial
Perinaeal
^ Brcinch of Internal
\riidi ...
Superficial
Piidic
'Iransverstt J'crinae-'tl
Muscle Recurrent Gluteal
Branches of Small Sciatic
Xen*e -
f 'rvu-i'EK's
Gland
Dorsal Ner\'e of Penis
Perinaeal Vessel: and Xer\'e I
Inferior
Haemorrhoidal
Vessels and Nerve
Parietal Layer of Pelvic Fascia
Levator Ani Muscle
Externa! Anal Sphincter
Internal
Anal Sphincter Tip of Coccj-x
Coccj'geus Muscle
Gluteus Maximus Muscle
Fig. 154.
Ano-Coccygeal Ligament
Male Pei-inaeum,
Superficial Layer.
Nat. Size.
Bebmau
Limited, London.
Eebman
Conij>any,
New
York.
Male Perineum.
Fig. 154.
I.
Superficial Layer.
The Superficial Fascia and Vessels of the Perineum with the Ischio-Rectal fat
The Superficial Fibres of
have been removed. been the
cut
away
in order to
right side the nerves
shew more
and
the
External Sphincter Ani have Levator Ani Muscle.
distinctly the
have been dissected out; on the
vessels
On
left side
a deeper dissection, with exposure of Cowper's Gland, has been carried out
and Nerves.
after partial removal of Vessels
The connection
of the Sphincter
Ani and Bulbo-Cavernosus Muscles shews
the crossing over of the anterior fibres in the middle of
the
Perineum, where these muscles
attached.
The connection between
merely indicated
in this figure
(cf.
join,
the
line.
At
the central point
Transverse Perineal Muscle
is
Levator Ani Muscles
is
the Sphincter and
Fig. 153).
The Ischio-Cavernosus Muscles
arising
from the descending rami of the
Pubis envelop the Corpora Cavernosa; the Bulbo-Cavernosus Muscles, united by a median raphe,
The
lie in
contact with the Corpus Spongiosum.
Superficial Fascia of the
Perineum
(as far as it exists)
and the Fascia
covering the Levator Ani Muscles (Anal Fascia) have been removed. covering the Obturator Internus Muscle
The
Superficial
(the terminal
Branch
shewn
is
in Sagittal Section
Arteries of the Perineum arise from
The Fascia (cf.
Fig. 153).
the Internal Pudic
of the Internal Iliac Artery):
Haemorrhoidal
1.
Inferior
2.
Superficial Perineal,
i
—
3 small
branches to Anus.
runs transversely across either superficial or deep to
the Transversus Perinaei.
Both these 3.
arteries are direct
branches of the Internal Pudic Artery.
Terminal Branches of the Internal Pudic Artery: a)
Artery Artery
b)
to to
Bulb,
giving
off
(Ilth, Illth,
of the
(or Clitoris).
Perineum are branches
IVth Sacral) which divide into
and a Deep Branch.
and the
Cowper's Gland.
Dorsal Artery of the Penis
The Nerves
the Transverse Perineal Artery
2
of the Internal Pudic
main branches, the Superficial Perineal
Both nerves are mixed, the Deep Branch
the Dorsal Nerve of the Penis.
Nerve
is
continued as
,
Male Perineum.
Fig- 155'
Tlie
Perineum
is
II.
Recto-Urethral Muscle.
exposed by a U'ianguUw
Nerves have been completely removed.
Anal Sphincter
tlie
The
section.
iviiidoiv
Prostate.
Vessels
By dividing and throwing back
Recto-Urethral Muscle
and the
been exposed to view and the
lias
Prostate exhibited by separation of some of the thin fibres of the Levator Ani. In front of the anteriorly versely,
the divided Superficial
the narrow space between
in
between these
which blends,
Anal Sphincter
them deeper
fibres
fibres are
which pass
shewn trans-
forward the retracted fibres of the l.evator Ani Muscle;
further
anteriorly,
Anus
fibres
and the Central point stretches the Recto-Urethral Muscle
posteriorly,
witli the
and
with the Levator Ani Muscle and the Rectal Wall,
Transverse Perineal Muscle, the Raphe and the fibres of the
Bulbo-Cavernosus Muscles as well as the Membranous Portion (Waldeyer) of the Urethra. to view.
On
either side of the Recto-Urethral
Muscle the Prostate
is
exposed
(This dissection can be carried out in the course of operations.)
In the triangle between the Superficial Transverse Perineal Muscle
and
the Pubic Angle, the superficial fascia of the Perineum which covers the Ischio-
and Bulbo-Cavernosus Muscles
is
seen on
the
right
side.
On
the
left side
the
fascia has been removed so that the muscles mentioned and the superficial layer of the triangular ligament are exposed.
The ment
is
Superficial Fascia
an Aponeurosis
(v.
is
a true superficial
Bardeleben).
fascia,
but the triangular liga-
IUilb()-{_avernnsiis
Raphe between
Muscle
Bulbo-(.'a\ernosiis
Muscles Tscli
io-Cavernosus
Muscle
Superficial Layer of
Triangular Ligament Superficial Transverse Perina,eal
Central Point of Periniieiim
Muscle Guthrie's Muscle (Recto-Uretliial
Muscled
Prostate
Levator Ani Muscle
Deep part of Externa! Anal Sphincter
Fig. 155. Male Perinaeuin. II.
Recto-TJrethral Muscle.
Prostate.
Nat. Size.
Reliinnn
I/iinitcil
LuikIi.ii.
Rcl)iii:in
('iiiiipany,
New
Yurk.
Artcrv to the Bulb
Fig. 156.
Male Perinaeum.
Siihiirethral filanfl )(!o\vi'KK*s
III.
Gland)
Cowper's Glands with their Ducts.
Nat. Size.
Relmian Limiteil,
Lniicioii.
Rebm.iii Comiiaiiy,
Ntw
Yoik.
Fig.
156.
Male Perineum.
Ducts.
The
Vessels
III.
Terminal Branches
and Nerves
liave been cut
COWPER's Gland with
Prostate.
away
so as to exhibit the course of the Artery to the
its
Bulb and
Ani and Sphincter Ani Muscles which This figure
Glands and their
is
their ducts
diameter
is
from the middle z
fibres
given
line
f(ir
the
and
1
fibres
center
hmien
their
3V5ths inches
'/jth to
0.0 1
of the Levator
it.
in
CowPER's
length; whereas
inch.
themselves, not always symmetrical, are situated about V5 inch
on either side of the membranous portion of the Urethra between
layers of the triangular ligament, near of
Ducts of Cowpbrs
the demonstration of the position of
which vary from
0.02 inch
The Glands
the
muscles and laid open
The Prostate has been exposed by removal of the
Glands.
part of the Peri-
in the posterior
The Corpus Spongiosum has been denuded of
neum.
Pudic Artery.
of Internal
the Compressor
is
posterior border
and between the
These glands are lobulated or mulberry-
Urethrae.
shaped, hard, almost white in colour, about
Yi;
to
-/d
inch long.
The}' belong to
the racemose type of glands and vary according to the individual and age but are frequentty unobserved
The Artery two vessels between the
(cf.
2
owing
the Bulb
to incomplete dissection.
branch of the Internal Pudic) consisting
of
Fig. 154), supplies the Bulb, Prostate
and the structures which
lie
layers of the triangular ligament,
Compressor Urethrae Muscle,
to
Membranous Portion
of Urethra,
as the Glans Penis.
At
(a
e. g.
CowPER's Gland and Corpus Spongiosum
this point
it
as far
anastomoses with the Dorsal Artery of the
Penis and through this with the Arteries of the Corpora Cavernosa.
Male Perineum.
Fig- 157'
Ampulla
IV. Urogenital Triangle.
of
Rectum.
the triangular ligament is exposed on the left side by remov-
The deep layer of
ing the superficial layer of the triangular ligament and the Corpus Spongiosum
Cowper's Gland,
as far as the middle line; the Urethra,
nosum and In
Muscle
(the
Dorsal Artery of the Penis have, however, been preserved.
the
front
Corpus Caver-
the left
the
of
Muscle
Transverse Perineal Muscle,
Waldeyer)
the Urogenital Triangle of
of
the Compressor Urethrae
shewn.
is
This
muscle arising from the bony margin of the Pelvis (Ischium and Pubis) and the fibrous portion
the Ischio-Cavernosus Muscle, passes to join
of
opposite side in the middle
line.
The
Cowper's Glands and Duct which
outlines of the
are not exposed
its
fellow of the
Bulb are delineated
by the
dissection
in
(cf.
blue;
Fig. 156)
are also indicated.
Anteriorly the Compressor Urethrae Muscle verse Pelvic Ligament which
Waldeyer
ligament.
emerging through the
this
figure
is
to
do,
accumulate
if
as an aponeurotic covering of
this
the
Preurethral Ligament;
fibres near the anterior border of the
off the artery to the
is
seen
;
this vessel a
Corpus Cavernosum.
Compressor Urethrae branch of the Internal
The
chief object of
give an idea of the position and size of the Ampulla of the
Rectum when distended
Anus and which
named
has
Muscle, the Dorsal Artery of the Penis
Pudic soon gives
connected with the Trans-
blending together of the superficial and deep layers of the
the muscle or as a triangular
may be looked upon
is
is
(red).
Rectum which
lies
above the
capable of considerable distension faeces may, and frequently
the bowel
the Ischio-Bulbosus
In this part of the
is
is
not emptied.
shewn between the
On
the right side an abnormal Muscle
Ischio-
and Bulbo-Cavernosus Muscles.
I)(irs;il
Artery of
Penis and ^Vrtery to
(_'<.)rpus
Cavornosum .Superficial
Layer of Trianfjuiar
Ligament
Deep Transverse Perinacal Muscle it'onipressnr
I'rethrac
Musclel IrreguNir
Muscle
frnin
(
owi'Ek's (ilaud
Ischium tu
Bulb
'•J'rt
Levator Ani Muscle
Perinaeal Artery
/
Superficial Transverse Perinaeal Muscle
External Anal Sphincter
Anus
Fig, 157.
h^e
Male Perinaeum. IV.
Central Point of Perinaeum
Tiro-Genital Triangle.
Ampulla
of
Rectum.
Nat. Size.
Rebman
Limited, London.
Rebman Company, New York.
Dfirsal Artery -
i
-
«>f
Duct
of Cowi'Bk's
Penis
Gland
'idiiprfs-sor
L'rcHir.'ic Musi'It;
Superficial
Transverse Pcrinacal Muscles
I'K. state
\'.is
Di-fcrens i.Vmpulla)
Seminal i Vesicle Recto- Vesica
I
Pouch
Inter-ampullary Muscle Inter-anipullary Triangle (Base of Bladder
Rectum
Fig. 158.
Male Perinaeum. V.
(cut across)
Prostate, Seminal Vesicles, TJrethra in its course through
the TJro-Genital Triangle. Nat. Size.
Rebman
Limited, London.
Rebmim Company, New
York.
Male Perineum. V. Prostate, Seminal Vesicles, COWPER's Glands, Urethra passing through the Urogenital Triangle.
Fig. 158.
Anus and surrounding Ani Muscle
parts
—
Ani completely and
the Sphincter
—
partially (window- section)
have been removed; Prostate, Seminal
Bladder and Douglas' Pouch are partly exposed from below and in
Vesicles,
front, also
Perineum
central point of the
tlie
in
front of the Prostate Gland.
Coccyx forwards
the Tip of the
Passing from
to the anterior
the cut Levator Ani Muscle the following parts are seen in order:
through the
Section
Rectum,
Interampullary Triangle
Ampullae
Next
neum
with
Peritoneum
directly in front,
which
At
is
Muscle
;
attention
is
Membranous
called
and Ischio-Urethral Muscle; by ;
J.
anteriorly.
lie
the
Between
to
Henle
(Compressor Urethrae).
Cowper's Glands.
of
Kalischer's Urogenital Sphincter Muscle
many
anatomical and physiological relations.
Johannes Muller
portion of the Urethra,
GUTHRiE's muscle
as
Urethral Muscle
on either side
whereas further forward are exhibited to view the Urethra
various times this has been described by
thral
Transverse
the Prostate Gland with the central point of the Peri-
is
very variable, yet possesses
strictor of the
Bladder;
the base of the
and the accessory glands entering the Ducts Special
of
the Prostate the Interampullary Muscle runs transversely.
order
in
—
margin
Douglas' Pouch, Waldeyer's
of
Vasa Deferentia with the Seminal Vesicles
of the
named and
the last
the Levator
;
Arnold
as the Ure-
by Cruveilhler as the Transverse Urethral
Krause and Kohlrausch
associates
Cf. the
by Fr.
as the Con-
it
with the
next figure.
as the Transverse
Deep Transverse
Perineal Muscle
Fig-
Male Perineum.
J^SQ-
VI. Pubic Region.
Levator Ani Muscle.
The Levator Ani Muscle has been exposed, a part of the Urethra below at which
Ligament has been removed.
traverses the Triangular
it
are preserved but
The
vessels
except the Dorsal Nerve of the Penis, Jiave been
nerves,
tJie
the point
cut away.
This figure shews ahnost the complete surface of the Levator Ani Muscle with
different
its
which traverse
it
and the incomplete gap
parts
have been preserved on
which the Coccygeus bears
relation
regarded as a part)
to this
Recto-Urethral Muscle
of
of
Waldeyer)
Between to the
this
(cf.
muscle
(of
Posteriorly
which
it
in the anterior part of the
the close
should be
really
of its fibres
Levator Ani, the
the Compressor Urethrae Muscle encircling
Fig. 155),
whereas others pass transversely across
The Transverse
can be seen.
it
ment
by some
side.
left
of the veins
seen.
is
Furthermore through the gap
the Urethra
the
Some
anteriorly.
in front
Pelvic Ligament (or the Pre-urethrae Liga-
runs across in front of a gap
(for
the transmission of veins).
ligament and the Suspensory Ligament of the Penis which
lower border of the Symphysis,
is
situated the
gap
is
attached
for the passage of the
superficial vessels of the Penis.
The Dorsal the Dorsal Vein
lumen
of
if
the
mucous
where folds,
it
passes through the triangular ligament
in
the Corpus
is
which become obliterated during the passage
an instrument, be neglected.
embedded ation
seen to have bifurcated into Left and Right branches.
of the Urethra,
circular
or
is
Arteries of the Penis are seen anastomosing in this figure, and
almost
of urine
In this Distal portion of the Urethra as
Spongiosum the Lumen
is
more
oval.
between the Corpus Spongiosum and Corpora Cavernosa
is
The
it
is
Here the separmost
distinct.
Urethra lAnteiior Segment') Fampinifortii Plcsiis
Corpus Cavernosum
\
Art^iy to Corpus Cavernosum Dorsal Nerve of Penis
Fascia of Penis
Dorsal Artery of Penis (Anastomosis)
Dorsal Vein of Penis Posterior Scrotal Arterv
jUpper portion of Superficial Layer of Triangular Ligament
Transverse Fibres of (Compressor Urethrac iluscle
Internal Pudic
Perinaeal Artery
Inferior
Fig. 159.
Coccygeus Muscle
Haemorrhoidal Artery
Male Perinaeum. VI.
Pubic Region.
Levator Ani Muscle.
Nat. Size.
Rebmau
Limited, Londou.
Kebiuau Company,
New
York.
Vein
Upp^r portion of Super-
Dorsal
Vein Bulbo-Civcrnosus
^lii*iclc
hcial
of Clitoris
Layer of TrianLigament Uulhits Vcstibuli
giilar
Long Pudendal Nerve Kxti-rnal Tudic
Vein
PoufAitr's Ligament
Obturator Xerv Xervc
I
(-(MiiiiuiiULatidn with tjbtui.ititr
Vein
\
>eep Transverse
rerinaeal ^luscle
(Compressor Urethrae)
Posterior Labial Arterv
Sciatic
Artery
I'yriforinis
Muscle
Nerve
to Obturator
Internus
Sciata Artery
Gluteal Arterv
Internal Pudir Arterv
Great Sacro-Sciatic Ligament
CoCLygeus Muscle Superficial Transverse Perinaeal
'\Um\e
I'turyy
Barth'olini's
Levator Ani Muscle
Gland
Fig. 160.
Female Perinaeum. Nat. Size.
Eebmau
Limited, LoiiUuu.
Rebmau Company, New York.
Fig. i6o.
Female Perineum.
Body of a Young Female. The skin and Superficial Fascia, except of the Mons Veneris, have been removed On the right side the superficial, on the left side the deep layer of the Perinetim is shewn: on both sides the Os Innominatum is exposed: on the right the Great Sacra-Sciatic Ligament is preserved. Vessels and Nerves are entirely preserved on the right side, but only partly on the left.
The
chief difference
the following
:
between the Male and Female Perineum consists
in
—
Instead of the small urethral aperture in the triangular ligament of the Male, there exists in
the Female, a inuch
wider opening for the Vestible.
Whereas
the Corpora Spongiosa are joined in the Male to form the Corpus Spongiosum, the corresponding parts in the bule.
So
either
side:
Female remain
as the Bulb of the VestiFemale remain distinct on the Male, they come together in a median raphe. A
that the Bulbo-cavernosus Muscles
whereas
in
distinct,
in
the
connection of the superficial fibres of the Bulbo-Cavernosus, with the Sphincter
Ani
The Bulbs lie on either These Bulbs of the A'estibule contain large quantities of Blood, so that injury to them (e. g. during labour), may produce serious haemorrhage. From these there extends forwards a Venous (like
a figure
8),
is
likewise present in the Female.
side of the Vestibule at the base of the Labia Minora.
Plexus which, near the Frenum of the
Clitoris,
passes into
the deeper
tissues
communicating at its mesial aspect with the Veins of the Clitoris (particularly those of the Glans of the Clitoris). The Corpora Cavernosa of the Clitoris are much smaller than the Bulbs of the Vestibule or of the corresponding parts in the Male. The}' arise from the descending Ramus of tlie Pubis on either side, and unite under the Suspensory Ligament to form one shaft (divided by an imperfect septum); the Clitoris is curved with its concavity downwards and backwards, so that its extremit}', the Glans, points towards the Vestibule. Many minute veins of the Glans unite to form the Dorsal Vein of the Clitoris, which opens under the Suspensory Ligament into the Pubic Plexus. at
(Cf.
the side
of the Clitoris
Male.)
The Bulb of the Vestibule having a position different from the corresponding parts in the male, the glands, corresponding to CowPER's Glands, i. e. Bartholixi's Glands lie internally and behind the Bulbus Vestibuli. The Pubic Arch being much wider, and the Ischio-Cavernosus Muscle less developed in the Female, the Urogenital Triangle is larger than in the Male. In Virgins, the muscles in the subpubic region are well developed. During labour. the Vestible and surrounding parts are stretched to a maximum and even frequently torn, so that a perfect restitution to the normal state never occurs. The ^'^estibule and neighbouring parts remain stretched after labour, so that the muscles become .smaller and degenerated, or replaced by connective tissue and fat. The "True Perineum" which lies between the Vestibule and Vagina in front, the Anus and Rectum behind, is neither broad nor strong. "Rupture of the Perineum" is therefore a frequent occurrence during labour. It falls to the duty of the Obstetrician and Gynaecologist, to prevent this rupture by appropriate mechanical intervention, to detect injuries and to suture them, and to cure Recto^'aginal Fistulae.
a>
> a CO «i
4) Vl
xn
^Vbilouiinal A<»rta
4tli
laiiiibiii
Irunk
Vertebra
I'soas ^lusclo
ol Syiiipi'tlietic
I
>i-cp
I-ayer of
J.iiinbar
Fascia
Inferior ^rtsenteric Plexii:
Aortic Plexus
Sijjmtiid Flexure-
Anterior
(iiir.il
1st SiUTiil
Xrr\c-
Gangli'in
Frankel's Recto-Vesical
Ganglion FHAKKEL'sGreat Vesico-Semioal
Ganglion Frankrl's Small Vesico-Seminal
Ganglitm Fkankri/s Seminal Ganglion
Vas Deferens
Great SacroSciatic
Ligament
Internal Pudlc Vessels and
Adductor Muscles
Nerves
Obturator Externus Muscle
Spine
Obturator
Fig. 162.
Membrane
Organs of the Male Pelvis, seen from the iModified after
Rebman
Limited, Loudou.
Max
Frajstkel.
left side.
—
Isrliiiim
(Obturator Internus Muscle
Hamstring Muscles
Tuberosity of Ischium
(if
Nerves
to the
Seminal Vesicles.
Va N^'- Size.
Rt'linian ('omiiriny,
Nuw
Yoik.
Fig. 162. Organs of Male Pelvis, seen from the left side. Nerves to the Seminal Vesicles. Modified after Max Frankel.
made through
of a male pelvis. The of the Ischium and Horizontal Ramus of the Pubis; this gives a view from the left side of the Viscera and Nerves —. Most of the Blood Vessels have been its Pelvis, removed.
A
section has been
sagittal
the left half
section passes through Sacro-Iliac Articulation, Tuberosity
—
The
name
Inferior Mesenteric Sympathetic Plexus runs
the Aorta around which
to
continued
into
it
lies
ist
of this
forms the Abdominal Aortic Plexus, this
the Hypogastric Plexus lying in
Rectum. A little lower down which is connected with the
from the Artery
is
front of the upper part of the
the large RectoA''esical Ganglion of
Sacral Ganglion
by a large nerve.
Frankel From
this
or 3 branches pass to a yet larger Ganglion (Great Vesico-Seminal Ganglion). Some of the branches of the Recto-Vesical Ganglion go to the Plexus surrounding the Rectum. Several small branches pass from the Pudic Plexus to the Great 2
Vesico-Seminal Ganglion and a delicate twig to the Seminal Vesicle directly. Several large and small branches pass from the Great Vesico Seminal Ganglion, one group runs in front of the Ureter, supplying it and terminating in the Posterior Wall of the Bladder, where they either run superficially for some distance, or penetrate at once into the Muscular Coats; another group runs
downwards;
directly
it
contains filaments to the Bladder and the
Seminal Vesicle, amongst these
of the
the Vesical Orifice of the Ureter. glion
pass to the
around
Upper
pole of
is
Upper Border
a thicker branch which ramifies around
which leave the Ganthe Seminal Vesicle and form a large plexus
The bulk
of the fibres
it.
Below the Great Vesico-Seminal Ganglion lies the Small Vesico-Seminal Ganglion, directly behind and internal to the Vesical Orifice of the Ureter. The roots of this Ganglion are derived directly from the Recto-Vesical Ganglion but there also exists a connection with the Great Vesico-Seminal (janglion. Fibres are distributed directly to the Ureter and Vas Deferens, a few run behind the Ureter to the Fundus of the Bladder, while 2 or 3 larger branches go to the upper pole of the Seminal Vesicle, here they anastomose with the fibres from the
Great Vesico-Seminal Ganglion. very careful dissection exposes two strata of nerves (not seen in the figure), an upper going directly to the Prostate, and a lower lying on the Seminal
A
X'esicle.
found part
2
Both layers anastomose with each other. In this lower stratum, Frankel other small ganglia which he calls Seminal Ganglia. From the lower
of the
Hypogastric Plexus fibres also run
Johannes MCller
called
(in
directl\' to
the Seminal Vesicles.
1835) this part of the Plexus "the Inferior
Hypogastric Plexus"'. Max Frankel proposes to divide this into a Superior, a Middle and an Inferior Haemorrhoidal Plexus. The latter would be applied to the Plexus on the Rectum below the Levator Ani.
.
Fig. 163.
A
large ivindoiv
lias
Gluteus Medius and
Gluteal Region.
been cut out of
Gluteus Maxhntis Muscle;
tlie
from
the
the Pyriformis Muscles, smaller pieces have been removed.
Under an extremely thick layer of superficial fascia, lies the Gluteus Maximus Muscle, which covers nearly the whole of the Gluteal Region. The following bony prominences can be
felt:
the Crest of the Ilium, the Great Tro-
chanter and with less ease, because covered by the Gluteus Maximus, the TuberoThe upper and outer part of this muscle passes over the sity of the Ischium. outer aspect of the Great Trochanter and is inserted into the Fascia posterior and
A
Trochanteric Bursa placed within the superficial fascia is The Gluteus Maximus covers important vessels and nerves; at the upper rare. border of the Pyriformis Muscle, emerging with it through the Great SacroOutside Sciatic Foramen, is the Gluteal Artery, a branch of the Internal Iliac. Lata.
Superficial
and soon divides into 5 — 7 branches to the Glutei Muscles. A large branch (Superficial Branch) becomes more superficial by emerging between the Gluteus Medius and Pyriformis Muscle, to run under cover of the Gluteus Maximus. Another large branch (Deep Branch), runs between the Gluteus Medius and the Gluteus Minimus, this divides into a Superior and an Inferior Branch, the former of which follows the middle curved line. Deep the Pelvis,
the trunk of this vessel
is
short,
to these vessels lies the Superior Gluteal Nerve.
Hernia
At
this point a variety of Sciatic
may occur. At the lower
border of the Pyriformis Muscle, the Great Sciatic Nerve emerges at a point corresponding to the junction of the inner and middle thirds of a line drawn from the Great Trochanter of the Femur to the Tuberosity of
At
the Ischium. Sciatic
and
Nerve
is
superficial
the lower
border of the Gluteus
easily exposed, fascia;
at
because at
a lower level
Maximus Muscle,
this point,
it
is
it
is
the Great
only covered by skin
covered by the long head of the
Biceps Muscle.
Great Sciatic Nerve, lies the Sciatic Artery, a slightly Gluteal Artery. This vessel gives off the Companion Between the Sciatic Artery and the Great Sciatic Arterj' to the Sciatic Nerve. the Inferior Gluteal Nerve lies the Nerve to the Gluteus Maximus Muscle, Internal to the
smaller
vessel
than
the
—
Nerve
—
Most of
the
internally,
the Internal Pubic Artery emerges
Pyriformis Muscle, and
smaller Sacro-Sciatic Ligament
after
crossing the Spine
re-enters
the Pelvis
of
at the
lower border
the Ischium
through
or the
the Sacro-Sciatic
Foramen, but does not enter the Pelvic Cavity (cf. Fig. 150). A second variety of Sciatic Hernia may protrude below the Pyriformis Muscle, where the structures mentioned leave the Pelvis; a third variety may occur at the Lesser Sacro-Sciatic Foramen. The Hip-Joint lies under cover of the Pyriformis Muscle in front of the Obturator Internus and Externus Muscles, and in consequence is scarcely accessible from behind. An important Bursa lies between the Tuberosity of the Ischium and the soft parts over it, e. g. the Sciatic Bursa.
—
Latissimus Dorsi Muscle
External Oblique Muscle of Abdomen Internal Oblique ^Muscle of Abdomen (Pktit's Triangle)
Layer of
Superficial
Lumbar Aponeurosis Gluteus Medius Muscle
Posterior Superior Iliac
Spine
Gluteus Maximus Muscle
—
^:-
Gluteus Medius Muscle Gluteal Artery with its
Deep Division dividing into Superior and Inferior Branches
Pyriformis Muscle
Gluteus ifinimus Muscli-
Great Sciatic Nerve Sciatic Arterv
luternal Pudic Ner\'e
Small Sacro-Sciatic Ligament
Branch of
Sciatic
Artery perforating
Ligament Internal Pudic Artery
Nerve to Obturator Intemus Muscle Small Sciatic Nerve Inferior Gluteal
Nerve
Bursa between Trochanter and Gluteus Maximus
__
_.
Gemellus Inferior
Great Sacro-Sciatic
Ligament Tuberosity of Ischium
Companion Artery Sciatic Nerve
of
Quadratus Femoris Muscle Recurrent Gluteal Branches of Small Sciatic
-
-^
Nerve
Iliotibial
Band
Semitendinosus Muscle
Long Head
of Biceps
Muscle
-^iS"
Fig. 163.
Gluteal Region.
74 Nat. Size.
Rebmau
Limited, Lontlou.
Rebmau Company, New York.
» a •V
c cr o oo
o
Frontal Section through the (Right) Hip-joint.
Fig. 165.
This front,
of
secfioti
not quite vertical, but
is
downwards and backwards.
all the large joints in the body,
Access
Socket of the
which
this
in
joint
is
with
filled
is
is
covered on
situation
there
are
fat.
At
this
disease,
point,
—
In front
.
Neck
in
muscles.
it
The
fewer Vessels and Nerves.
is
very
ring,
—
and
thin,
which may subsequent!}' extend
Capsule of the joint extends on to the Femur, parts
from above and
most deeply situated
all sides by thick
bony wall
the
deepened by a dense fibrous
is
the
incompletely covered by cartilage at the Fossa Acetabuli
allows of perforation by
The Socket
and
is
obtained more easily from the outer side over the Great Tro-
is
chanter, because
directed obliquely
is
The Hip-joint
easily
the Pelvis.
in
the Glenoid Ligament.
to a
The
varying extent at different
reaches the Intertrochanteric Line, behind
it
inserted on
is
Femur, about Va^h inch below the middle of the neck, so that to the a considerable part of the Neck lies within the Capsule and fractures of the of the
Femur may in front,
consequently^ be completely Intra-Capsular.
owing
to the
The Capsule
the Antero-Inferior Iliac Spine and the bone internal to
with
which
Ligament,
blends,
it
the
lie
2
to
the Intertrochanteric Line.
Tendons
of
origin
of the
over the Capsule
this,
Superficial
to
between the axis
of the shaft
the Neck)
Femur
the
of
133", the
and the axis
varies
from
average being
116'-'
125".
BiGELOW's
Rectus Femoris Muscle which
arise from the Antero-inferior Spine and the brim of the Acetabulum.
about 120" to
.strongest
is
IHo-Femoral Ligament (Bertini, Bigelow) which passes, from
neck (Angle
of the
The angle
of inclination of
(MIKULICZ) but
to
138°
As
a rule the longer the neck,
is
usually
the
greater the angle.
The
architecture of the cancellous tissue
briefly as follows:
is
A
pressure
system of Cancelli converges from the surface, commencing at right angles to the surface on
the
inner side;
a traction
system crosses the former
at right angles,
forming arches, which run from the outer compact tissue with their convexity directed
upwards
portions of the
to
neck.
the
middle and lower parts of the head, and the adjacent
The
third (muscular traction) system begins at the Great
Trochanter at right angles with the insertion
of
muscles into
inwards forming arches with their convexity' directed upwards: the former at an angle of 45", together with the vertical
plane of compact bone
Femoral el
which Merkei.
first set,
calls
this
this
it,
and passes
system crosses
forms the strong
the Femoral Spur (Calcar
Iliacus
Muscle Anterior Crural Nerve Psojis
Muscle
External Iliac Artery Gluteus Minimus Muscle
External Iliac Vein
'iliileiis
Meilius Muscl
Gluteus ilaxinius Muscle
Ligamentum Teres
Obturator Tnternus
Bursa over the Trochanter
Muscle
Tuberosity of Ischium
Femur
Fig. 165.
Frontal Section through the Hip-Joint; Right Seen from
Kebman
Limited, London.
in
front.
—
7:i
side.
Nat. Size.
Rebman Company, New York.
r
Inguinal Region; 2nd Layer. Opening).
Fig. 167.
man aged
Specimen from a
Glands have been removed.
—
Fascia in one region
^^.
Fossa Ovalis (Saphenous
Skin, Siihcittaneotis
The Lymphatic
the Cribriform Fascia
—
and Lymphatic
Tissue
whicli perforate the
Deep
have also been removed.
The
Vessels
Fossa ovalis {Saphenous Opening) and above the Femoral Vein, the " Infindibuliform ,
Process" (Waldeyer) derived
from
the Transversalis Fascia are shewn.
Not only the Aponeurosis proper Muscle but etc.,
also
may be
the Fascia Lata and
of
the
External Abdominal Oblique
the Fascia covering' the Pectineus Muscle
looked upon as tendinous expansions of
animals, but also
in
man,
this
The
in
muscle extends directly or indirectly on to the
made tense in all External Oblique Muscle. Below PoUPART's Ligament, Thigh.
Not only
Muscle.
this
Fascia Lata can be
bodies by special
pulling on
the
arrangements occur
which have been produced by the passage of the Vessels through the Fascia.
The a
like
thigh,
ment
usual
tense
given
is:
The Fascia Lata which envelopes
membrane, divides below the inner part
2
PouPART's Liga-
layers.
PART's Ligament; over the Femoral Vein and internal forated
of
the
The Deep Layer blends with the Ilio-Pectineal Fascia, and upwards behind the Vessels. The Superficial Layer is attached to Pou-
into
passes
description
at
many
points,
(Cribriform Fascia).
to
it,
this
fascia
per-
is
through which Superficial Vessels enter the deep layers
When
this fascia is
removed together with the subjacent
fat,
The lower margin of this opening is always sharp (the Falciform Margin); over this the Long Saphenous Vein passes to open into the Femoral Vein. The upper and outer margin which can be dissected out is attached above to Poupart's Ligament, and partly to Gimbernat's Ligament. The Saphenous Opening is merel}' intended for the transmission of vessels comparable to many other openings in
a groove
is
exposed; Fossa Ovalis or Saphenous Opening.
superficial fasciae, is
through which veins pass; with
this difference that the
opening
too large for the vein.
The
—
on the inner
side.
External Pudic Vessels; above. Superficial Epigastric Vessels; on the outer
side,
Superficial Vessels
which pierce
the Superficial Circumflex Iliac Vessels. origin
this
Like
Fascia are
all
:
vessels situated
from a large artery or near their opening into a large
vessels bleed furiously
when
cut.
close to their
vein,
these small
Inguinal Region, 3rd Layer. Triangle.
Fig. i68.
Spermatic Cord.
SCARPA'S
Male, aged ^J. The Fascia Lata and tlie Lymphatics of t/ie Groin have been removed. The Aponeurosis of the Exter>ial Abdominal Oblique Muscle (and the External Abdominal Ring) has been slit np and the chief constituents of the
Spermatic Cord dissected
out.
When the Fascia Lata which stretches across the Inguinal Region has been removed, a triangular space with its base directed upwards, and its apex
—
—
downwards Scarpa's Triangle is exposed. The upper boundary area is PouPART's Ligament; the internal, Adductor Longus Muscle, which
of this
arising
bone below the Pubic Spine, runs outwards and downwards, to be inserted into the middle third of the middle lip of the Linea Aspera the external, Sartorius Muscle, which arising below the Antero-Superior Spine of the Ilium descends obliquely inwards and downwards, over the Internal Condyle of the Femur, to be inserted on the inner surface of the Tibia as far down as the Crest from
the
;
of the Tibia.
In
this
Anterior Crural Nerve and the main
Triangle, the
The Femoral Artery
vessels
are
under Poupart's Ligament, at the between the Anterior Superior Iliac mid-point Spine, and the Symphysis Pubis, and passes almost vertically downwards. At the ligament, the Femoral Artery can be readily compressed by digital pressure against the horizontal ramus of the Pubis. In Scarpa's Triangle, the Femoral Artery gives off posteriorly, the Deep Femoral Artery, apart from the smaller branches, Fig. 167 Superficial Epigastric, Superficial External Pudic and Superficial Circumflex Iliac Arteries As the Deep Femoral Artery is a branch of large size, tliere occurs at its origin, V2 inch below Poupart's Ligament, a sudden diminution in the calibre of the Superficial Femoral Artery. The Femoral Vein lies to the inner side of the Artery and is enclosed in This Vein receives the Long its sheath, but soon passes behind the Artery. Saphenous Vein, which passes over the margin of the Fascia (see Fig. 167). Internal to the Vein, is situated the Crural Ring (see Fig. 170). The space below the ring. between the Adductor Longus, P'emoral Vein, and Pectineus Muscle is filled up with fat and deep lymphatic glands. The Anterior Crural Nerve appears in the Muscular Compartment under Poupart's Ligament, and lies about -/f,ths inch external to the Artery in Scarpa's Triangle. This nerve disappears under cover of the Sartorius Muscle and divides into branches which supply the skin on the Anterior Aspect of the thigh, the Sartorius and the Quadriceps Extensor. Deep to the Vessels and the Nerve lie the Ilio-Psoas and exposed.
lies
directly
—
—
.
i
—
—
Pectineus Muscles.
At
the
Apex
of
Scarpa's Triangle, the Sartorius passes obliquely over
This muscle has, therefore, to be drawn aside
the vessels.
further course of both Artery
The
in
order to expose the
and Vein.
Vas Deferens Spermatic Artery and the Pampiniform Plexus of Veins, Cremasteric Vessels to the coverings of the Cords. The Cremasteric Vein is of importance because it alwa3's communicates with the Pampiniform Plexus, though it opens into the Deep Epigastric \^ein figure also shews the constituents of the Spermatic Cord
with the Vessels to the
(Collateral
^"as,
Venous Channel).
:
Inguinal Region, 4th Layer.
Fig. 169.
Hernial Orifices, Iliac Bursa.
Male aged 60. The Spermatic Cord has been drawn out of the Inguinal Canal and cut off. Vas Deferens (blue). Fascia of Penis is opened up and the Dorsal Vessels and Nerves are exposed. External part of Fascia Lata has been removed. Anterior Crural and External Cutaneous Nerves have been lopped off short. A piece has been cut out of the Ilio-Psoas to expose the Iliac Bursa (pink). The Pelvis and Head of the Femur are indicated in dotted lines. The dotted ellipse over the Head of the Femur indicates the position and size of the communication between the Iliac Bursa and the Hip-faint (in this case). Immediatelv external to the Common Femoral Artery, but on a slightly deeper plane, are the Ilio-Psoas Muscle and the Anterior Crural Xerve. very large bursa (Iliac Bursa) separates the Ilio-Psoas Muscle from the Horizontal Ramus of the Pubis and the Capsule of the Hip-Joint whereby the Muscle pla}'s over the edge of the bone without friction. The Capsule of the
A
Hip-Joint
is
weak
in
is
of practical
10)
This Bursa swollen
at its point of contact with the Iliac Bursa,
there exists a communication between these
(I
the
may extend some
importance
difficulty
of
in
2
and
in
some cases
cavities.
distance into the Pelvis which occurrence
connection with primary disease of this Bursa.
diagnosis
arises
When
between enlarged l\-mphatic glands,
aneurysm of the Femoral Artery, or disease of the Hip. An accurate anatomical knowledge of this bursa is the only clue to a correct diagnosis. Again inflammation ma\' spread from the Hip-Joint into the Bursa, via a direct communication, b}' piercing the thin septum, and further extend into the Pelvis. The figure also shews the important relations of the Hernial Orifices. The fibres of the External Abdominal Oblique Muscle diverge at an acute angle, and form the 2 pillars of the External Abdominal Ring. The Internal Pillar ends in the middle line (or reaches to the opposite side) at the Symphj'sis Pubis by sending fibres into the Suspensory Ligament of the Penis. The Outer Pillar is The angle between the diverging fibres chiefly inserted into the Pubic Spine. and the anterior aspect of the cord are covered by intercolumnar fibres which hold the two pillars together. Poupart's Ligament is a thickened fibrous cord or rather a tendon or tendinous cord (the lower border of the External Abdominal Oblique Muscle).
From the External PiUar and PoUTART's Ligament which are blended many fibres spread in various directions, and to some of these names have been applied. The fibrous mass which stretches across to the Fascia covering together,
near the Spine of the Pubis, and forming a triangular ligament with the base pointing outwards has been called GiMBERNAT's Ligament
the Pectineus Muscle,
(Fig. 170). The fibres directed upwards and backwards to reach the bone, have been called the Ilio-Pubic band. Both ligaments are usuallj- blended together. These structures are not constant, and their descriptions are most variable.
Externiil Abflmnin.il Obiiiiiic Mus(_le
Tensor Muscle of Fascia L;ita
Anterior Superior Iliac'Spine External Cutaneous Nerve Iliacus
Muscle
Rectus Pernor is Muscle Ilio-Femoral
Band (Bkrtini)
Anterior Crural Nerve Ilio-Pectineal Fascia
Bursa Iliaca
Femoral Vessel
Internal
Abdominal
Oblique Muscle
Femoral Rin;
Ilio-Pubic
—
Band
Fascia covering Pectineus Muscle
Deep Femoral Artery
,
Spermatic Cord. (Vas Deferens; Inferior Horn of Fossa Ovalis (Saphenous Opening}
External Circumflex. Artery
Dorsal Vein of Penis Superficial Femoral Artery
Long Saphenous Vein Superficial Dorsal Vein of Penis
Fascia Lata Sartorius Muscle
Fig. 169.
Inguinal Region,
left side,
4th Layer.
Hernial
Oriiices.
Bursa
Iliaca.
V^ Nat. Size.
Rebmau Limited
Londou.
Rebman Company, New Yoik.
Rectus Kfmi>ris Muscle (llutrus Mctlius ;ind Kxteriiiil
Minimus Muscles
Abdominal Oblique Muscle
Anterior Inferior Iliac Spine Internal
Abdominal Oblique Muscle
Transversalis
Abdominis Muscle
Ilio-Psoas Muscle
Anterior Crural Nerve
Head
of
Femur
liio-Pectineal Bursa
Fascia Transversalis Extcrnil Inguin
Deep
Epiga'^tric
il
Fossa
Vrtcrj
Internal Inguinal Fossa
Cremaster Muscle Obturator Artery,
Femoral Ring
Gimbgrhat's Ligament ^~„:^^^
.-x
Pectineus Muscle
Ilio-Pectlneal
Edge
Eminence
—-^
of Glenoid Fossa
Obturator Canal Posterior Division of
Obturator Nerve Obturator Extemus Muscle Anterior Division of Obtiu-ator Nerve Adtluctor Brevis Muscle Internal Circumflex Vessels Ilio-Psoas Muscle
Pectineus Muscle
Adductor Longus Muscle
Deep Femoral
Vessels
Superficial Femoral Vessels
Long Saphenous Nerve
Sartorius Muscle
Long Saphenous Vein Dr. Ir^si.
Rectus Femoris Muscle
Fig. 170.
Inguinal Region,
left side,
Hip-joint.
Great Trochanter
External Vastus Muscle
Sth Layer. Subperitoneal Hernial Obturator Region.
Orifices.
7, Nat. Size.
Rebraan Limited, Loudon.
Rebman Company, New York.
Fig. 170. Inguinal Region, left side, 5th layer. Subperitoneal Hernial Orifices. Hip-Joint. Obturator Region.
The Inguinal Region and neighbouring parte have been exposed layer by layer in an adult male; above Poupart's Ligament the Subperitoneal Hernial Orifices are exposed. At the level of Poupart's Ligament Muscles and Vessels are cut across so that the Muscular Compartment and the Vascular Compartment (opening for Femoral Hernia) are seen. Below the Ligament on the inner side a piece of the Pectineus has been cut out so that the opening of the Obturator Canal (external opening of Obturator Hernia) is shewn; on the outer side the Hip-foint has been exposed and the joint cavity widely opened. immediately external to the Artery but on a much deeper plane. The Anterior Crural Xerve lies almost o\er the middle of the Head of the Femur. The Head of the Femur can onl}' be felt from in-front, in
The
ver}'
Hip-Joint
thin people.
lies
So that owing
large vessels, the Hip-Joint
The
is
to its
deep situation and
not \ery easih' accessible from
its
in
proximity to the front.
and External Circumflex Arteries, of considerable size, are given off from the Deep F'emoral Artery, but one of them, occasionally both, may come off from the Common or Superficial Femoral Artery. Internal to the vessels is a landmark of some importance. If the Pectineus Muscle be removed the External Obturator Muscle is exposed as it arises from the outer surface of the Obturator Foramen and the Obturator Membrane, and runs outwards to the Digital Fossa. The Membrane closes the Obturator Foramen except at its anterior and external angle; here a small gap hardly Vo^h inch in hernia may protrude diameter allows the Obturator Vessels and Nerve to pass. — position proves Hernia its the difficulty of Obturator through the orifice diagnosis, and its close proximity to the Obturator Nerve sometimes causes pain The in the area of distribution of the nerve owing to pressure by the Hernia. figure also shews structures passing under PouPART's Ligament which together with the upper border of the Pelvis forms a large slit-like space divided into two compartments by the Iho-Pectineal F"ascia. This fascia, which is derived from the Fascia covering the Iliacus Muscle and accompanied the Ilio-Psoas down to the Lesser Trochanter of the Femur, is firmly attached to the Ilio-Pectineal Eminence. In the outer compartment is the Ilio-Psoas Muscle with the Anterior Crural Nerve embedded in its anterior surface. In the inner compartment are Between the Femoral Vein and the Large Vessels and the Pectineus Muscle. the outer margin of Gimbernat's Ligament there remains a small space filled by loose connective-tissue; this is the Femoral Ring, the most important spot at which the Peritoneum can readily be pushed forward and give rise to a Femoral Hernia. Here we find situated the Deep Inguinal Lymphatic Glands, one of which goes by the name of Cloquet's Gland. A Femoral Canal does not exist (as a preformed Canal) in normal subjects. It is the result of the descent of a Femoral Hernia. Internal
—
A
c
o H
OS -*J
I^ong Saplienous
I^'ppcr pnrt of Sartorius F(-iTH»r;il
Muscle
Vein
Vein accompanyintr the Femoral Vein
Superficial f-.rarilK ^r.lS.Ie
Fascia Lata
IIl'xter*s (Adductor)
Seiiiiinembranosu^
Canal
Muscle
Tendon of Adductor
Magnus Opening
in
Adductor
Ma^us Saphenous Xervc
Poplitt-al
Artery
Anastomotica ^fagna Arter>'
Popliteal Vein
Vein accompanying the Popliteal Vein
Short Saphenous Vein
Intfrnal Vastus
Muscle
Adductor Tubercle on Inner Condyle of Femur
Semitendinosus Muscle.
Long Saphenous Vein
Sartorius \fust:l
loner Head of Gastrocnemius Muscl
Saphenous Nerve
Fig. 173. Hunter's Canal and Popliteal Space, left side, seen from the inner side. (Jobeet's Fossa.) 7, Nat. Size.
Rebmau
Limiteil,
I^udon.
Eebman
C'omp.iny,
New
York.
Hunter's Canal and
Fig. 173.
(JOBERT's Fossa.)
side.
Left
Leg of a
Popliteal Space seen from the inner
A
girl aged 75 years.
piece has been
out of the Sartorius
citt
Muscle. part of the thigh the Femoral Artery
In the upper
down
aspect of the limb, lower In
aspect.
Artery
it
on the inner side and
is
course the Artery crosses the
its
and
lies internal
superficial
approaches the inner side of the
to the
shaft,
Femur
head
at
on
its
posterior
an acute angle. Above the
of the
and gets on
hes on the anterior
finally
to
bone but subsequently its
posterior surface.
it
The
is almost in a line drawn vertically downwards whereas the Femur is oblique, thus the crossing is brought about. Above the Artery is in front of the Adductors but as these muscles, e. g.
course of the Artery axis of the
Adductor Longus and Adductor Magnus, are inserted by a broad
Pectineus,
membranous tendon along
the entire length of the Linea Aspera from the Lesser
Trochanter as far down as the Inner Condj'le, the Artery mu.st pierce in
order to reach the posterior surface.
Below the apex
Canal. torius
Muscle and
of the thigh
it
rests
reaches
of
This occurs
Scarpa's Triangle the Artery
Hunter's Canal which
At
is
tendon
Adductor or HuNTER's is
covered by the Sar-
upon the Adductor Longus Muscle.
spreading from the Adductor Longus and Muscle.
in the
this
About the middle
formed by a strong Aponeurosis
Magnus Muscles over
the Vastus Internus
the end of this canal the artery pierces the Adductor Tendon.
This
canal bounded in front by the Aponeurosis mentioned, behind by the Adductor
Longus and Magnus
is
about
2
inches long and terminates at the junction of the
middle and lower thirds of the thigh.
The Long Saphenous Nerve
enters the
canal with the Artery but perforates, in conjunction with the Great Anastomotic
Artery, the Anterior wall of this Canal about
its
middle.
Two
accompanA'ing
Veins pass through the Canal with the Arter}': of these veins, one diminutive.
the insertion
The
3
of the
Perforating Branches of the
Adductors
in a similar
is
usually very
Deep Femoral Artery
perforate
way, to gain the posterior aspect of
the Thigh.
For operations
—
e.
g. in cases of
exposure of the Femur throughout internall}'
its
and lower down the
vessels.
On
the
extent,
and anteriorly the large vessels are
the upper cul-de-sac of the Knee-joint
or Nerves.
Acute Osteomyelitis
may be
in
outer side
— is
which require
chosen because
the way; on the anterior aspect
injured, posteriorly the Sciatic
the outer side
there
Nerve
are no important Vessels
Figs. 174 and 175. Transverse Sections through the of the
Thigh
at the
end
upper and middle thirds.
Frozen Section. Three powerful groups of muscles surround the thigh and enclose it so completely that the Great Trochanter and the Condyles alone remain subcutaneous. In front, the Quadriceps Extensor (Rectus arising from the Anterior Inferior Spine of the Acetabulum, Vastus Internus, Vastus Externus and between these the Crureus arising from the Femur); internally, the Adductors (Adductor Brevis, Adductor Longus, Adductor Magnus, Pectineus and Gracilis) arising from the
and brim
behind,
Pelvis;
the Flexors (Biceps, Semimembranosus, Semitendinosus) arising
from the Tuberosity
the Ischium
of
with the
exception of the Short
Head
of
the Biceps.
The Extensors
increase in mass as far as the lower
third
because they until they
from the Femur. The Adductors merely form a tendon at the Knee-joint. The Flexors are reinforced by the Short Head of the Biceps and diverge at the Popliteal Space to the outer and diminish
receive fibres
regularly
inner sides respectively.
A
very strong fascia surrounds the muscles of the thigh enclosing them fascia the muscles protrude through the slit,
so tightly that after division of the
The fascia is strongest on the outer side because it receives the tendinous expansion of the Tensor of the Fascia of the Thigh, and of the Gluteus Maximus. From the Fascia two membranous Septa stretch to the bone, thus like a hernia.
z groups: the External Septum extending from the great Trochanter along the outer Hp of the Linea A.spera down to the External Condyle; the Internal Septum from the Lesser Trochanter along the inner lip to the Tendon
dividing the muscles into
Adductor Magnus. The figures shew the different positions of the Femoral Artery. In V\g. 174 it Hes just above the slit in the Adductor on the inner side, and slightly anterior to the Bone. In Fig. 175 it has already reached the posterior aspect of the Bone. The Deep Femoral Artery is still visible as a large vessel It diminishes in Fig. 174 between the Adductor Longus and Adductor Magnus. rapidly in size by giving off the Perforating Arteries. While the Anterior Crural Nerve divides rapidly into its branches so much so that the main trunk is no longer evident in our figures, the Sciatic Nerve remains distinct on the back of the thigh, being well surrounded by fat and lying in the triangular space between the Adductors and the already diverging Flexors. In Fig. 175 the nerve has already divided into External and Internal Popliteal of the
Nerves, which, however,
lie
in
close apposition.
The Adductors and Flexors
are less distinctly
The
separated from each other
throughout its course a formed by the .splitting of the Superficial layer of the Fascia. This statement holds good also for the Gracilis and Rectus in the upper part of than they are from the Extensors.
Sartorius has
special canal,
the thigh.
b}-
pus.
bouring
The thin special fasciae of the F"lexors and Adductors are easily perforated They are practically lymph spaces between the muscle.s and their neighparts.
RiTtiis Kcnioris
Muscle
Internal Vastus Muscle
fa
f
1
.ml Artery
]
1
All
L
Long-US Muscle
r
t
^ Saphenous Vein
External Vastus Muscle
Gr
Muscle
cilis
A.Miirlni- Ma^jnus
Luny
Ile.i.l nl"
Muscle
Hic.ps
Sciatic N'erve
Semimembranosus Muscle
',
Semitendinosus
IVIuscle
Transverse Section through the Junction of Upper and
Fig. 174.
Middle thirds of the (right) Thigh. Seen from
Rcttiis
Periusteimi uf
lielow.
—
-/a
i^'At.
Size.
Fcmoris MiiscK-
Femur
Mus(
ExtcriKil Vastus
Intern
il
\' istus
Muscle
_^
Fascia L; tl
Vdductur ^lagiius Muscle
/o ^ ^/^
^
// /
External Intermuscular Septum
il
r,
/
^
/
^
\
\^
Int rnal Intermuscular
Septum
Femoral Artery Short Head nf Biceps
Muscle
Saphenous Xeive
Extern;il Popliteal
-^
_ \\j'
(Peroneal) Nerve
Hunter's Canal
uTTi^ Sartnrius Muscle
Internal Popliteal (Tibial)
Nerve
L ng
Saphenous Vein
Cr icilis Muscle Long Head
of Biceps Muscle
Semimembranosus Muscle
Semitendinosus Muscle
Femoro- Popliteal Vessels
(cf.
Toldt, Note
Small Sciatic Nerve
Fig. 175.
Transverse Section through the Junction of Lower and Middle thirds of the (right) Thigh. Vb Nat. Size.
Kebniau
Llinitod,
Loiidtm.
Rebmun
(.'oiiipaiiy,
New
York.
313)
ExtiTiial liitermusciil.
Septum Superior Pmirh of Joint
Fasciii Liitii
Internal Vastus
Muscle^
Superior lixtern;il Articular Artery
Subcutaneous Prepatellar Bursa
Subfascial Prepatellar Bursa
External Condyle
Tendon of Poplitcus Muscle
Alar Linanient External Semilunar^ Cartilage Inferior External Articular Artery Ilio-Tibial
Band Tibiu-Eilnilar Articulation
Biceps Muscle
Peroneal Nerve
Deep
Infrapatellar
tExt. Popliteal)
Bursa of
Patellar Ligament'
Outer Head Gastrocnemius
Muscle Soleus Muscle
Anterior Tibial Muscle
Common
Peroneus Longus
Extensor of
Muscle
Toes
:.^s^,^.viv,^^
Fig. 176.
Left Knee-Joint aiid Surrounding Structures.
Seeu from the outer
Kebman
Limited, Londou.
(leftj
side.
—
^4 ^^^' S^^^-
Robman Couipauy, New York.
Left Knee-joint and Surrounding Parts.
Fig. 176.
Seen from the
outer side.
Preparation made from a female aged 75 years.
Plaster of Paris had been Boundaries of the Joint-Cavity (pink) ; the TibiaFibular Articulation which does not communicate with the knee-joint, dark red. injected into
tlie
Knee-Johit.
around
The lower parts of Vastus Externus and Biceps Muscles have been removed; the attachment of
The independent
biirsae
Band and
Ilio-Tibial
The Fascia Lata and
which
of the thigh
the Gluteus
Maximus Muscle;
practically always
One
to the Tibia,
it,
is
Laterally
fibres of
The
figure
the case in serous, purulent
A
tense effusion pushes the Patella and the that,
under these conditions,
not in contact with the underlying bones but rides
is
the fluid.
some
and blends with
and of the upper cul-de-sac, which
distended as
Extensor Tendon away from the bones, so
the Patella
Maissiat,
of
observes that the greatest extension of the joint
possible in the forward direction.
Common
Cavit}'
communicates with
or haemorrhagic exudations.
no great degree of bulging
Synovial Cavity does not reach far ;
Band
checks Adduction of the Thigh.
It
shews the extent of the Knee-joint
slit
continuous with the Fascia enclosing the
Band runs down
this
the Capsule of the Knee-joint.
is
is
derived from the Tensor of the Fascia of the Thigh and
is
the
into the Tibia are preserved.
reinforced by a broad strand of fibres the Ilio-Tibial
is
the
of the Biceps into the Head of the Fibula
insertion
the
and
leg,
the knee-joint (blue).
eitlier
is
possible,
or dances on
because the
firstly,
upwards or downwards over the
joint-
secondly, because the extremely strong lateral ligaments are tightly stretched.
Posteriorly
around the Condyles of the Femur, the capsule
In addition to the Prepatellar Bursa
deep Infrapatellar Bursa, which
lies
(cf.
is
more
explanation to Fig.
extensible.
and the
181),
between the Tibia and the Ligament
of the
is
shewn lying be-
tween the Biceps Tendon and the External Lateral Ligament.
Like the bursa
Patella,
the almost constant External Inferior Bicipital Bursa
above mentioned,
this
never communicates with the Knee-joint.
Further, the vessels which take part in the anastomosis on the outer side of the knee-joint are visible.
The blood-supply
much
pressure
On
(e.
g. in
of the Anterior
kneeling)
is
side, the
Anastomosis which
is
of the Joint
which has
to
bear
abundant.
the inner side, the Superior
on the outer
Aspect
and
Inferior Internal Articular Arteries,
Superior and Inferior External Articular Arteries, form the reinforced
by the Great Anastomotic Artery,
and
the
Recurrent Tibial Artery.
The Anastomosis partly deep
is
partly superficial
between the Patella and the Skin,
between the Tendons and the Ligaments.
Fig. 177. Sagittal Section through the Knee-joint during Extension.
Frozen Section ilirough the External Condyle of the Femur and the Tibia; the Patella
not cut along
is
The Knee-joint its
easily
is
accessible from
and Vessels. This Synovial Cavity
The Patella,
if
on account of
joint
of the
insertion
extends highest
we
far
in front
or either side,
on
onl)'
as
the largest in the body; moreover,
it
is
the
various Intrinsic Ligaments. is 1^/4
on
different
all
to 2V4 inch,
sides.
The
joint-cavity
above the margin
of
the
take into account the Subcrureal Bursa, which nearly always com-
On
both sides
reaches close to the line of the limit of the
Thus the
extent.
is
its
Capsule
as
front,
in
municates with the Joint.
upper
greatest longitudinal axis.
do we find large muscles and between them important Nerves
posterior surface,
most complex
its
(cf
.
Fig.
1
Condyles of the Femur, below anterior
the insertion of the Capsule
80),
joint, posteriorly, it
extends upwards as far as the it
follows the Tibia to a lesser
and posterior surfaces of the Femoral Condyles are
within the Synovial Sac, but not so their lateral surfaces.
The
anterior wall of the Capsule
Quadriceps; between
is
formed above by the Tendon of the
tendon and the anterior surface of the Femur there
this
always a Bursa which
is
of importance
children, but invariably in adults (98 %)'
because
it
by a more
of a director in the figure), with the Joint-Cavity.
communicates, occasionally or less wide opening
Accumulations of
Below the
spot.
border
fluid
point of insertion
of the posterior surface of this bone. this
bone
to the
account of This
is
of
the
its
upper cul-de-sac of the
Quadriceps Extensor
to the
upper
formed by the cartilaginous covering
The Ligamentum
Tubercle of the Tibia.
the deep Infra-patellar Bursa
tlie
within the Knee-joint cause bulging at this
of the Patella, the wall of the joint is
border of
Patellae attaches the lower
Between
it
and the Tibia
lies
which does not communicate with the Joint on
being separated by a large Synovial-fold
— Plica Synovialis Patellaris.
attached to the Intercondylar Fossa (Crucial Ligaments) by sagittal fibres.
Between the Tibia and the Femur, the External Semilunar Cartilage seen in the figure, is
in
course
This Bursa may, therefore, be
regarded as a part of the Joint-Cavity, and be called Knee-joint.
(cf.
is
its
inner concave margin
is
sharp,
firmly connected with the capsule of the joint.
its
is
external convex margin
Quadriceps Extensor
Subcrureus iluscle
Popliteal .Vitciy .
-
Internal I'opliteal
^-'
'
ii
Bursa under Quadriceps Extensor
Xer
Prepatellar Bursafc
- Patellar
External SeniilunaaCartilage
Ligament
Ligamcntuin Mucusum
utellar
Giistrocnemius ituscle
Bursa
Fibul,
Anterior Tibial Artery
Fig. 177.
Sagittal Section through the (left) Knee-Joint during extension. Seen from the inner
Rebman
Limited, Loiidou.
(right) side.
—%
N^at. Size.
Kebmau Comjiany, New York.
fctus Fcnioris
Superior Puuth of
Muscle
Subcriireus Muscli-
Jnml
TcnJun of Quadrict'ps Extt-nsor
Jntcrnal Vastus
Patelli
Muscle Short Head of Biceps Musdc
Subfascial Prcp.itolliir
Bursa
SubfuUneous Pr4i>atellar
Bursa
Kxtrrn.il I'opliU-al
Anterior Crucial
(Peroneal) Nerve
Ligament External Semilunar Cartilage
Popliteal Vessels
Liga men turn
Internal Popliteal (Tibial) Nei-vc
Mucosum Popliicus Muscle
Short Saphenous Vein
Ligamcntum Patellae
~
Intfrnal Sural
Cutaneous Nerve
Deep Bursa under
Patella
Gaslrocni-
Subcutiint-ous Bursa
Soleus Muscle
o^ tr.
Tubercle of Tibia Peroneal .\rtery
Posterior Tibial Muscle
Interosseous
Membrane
Anterior Tibial Muscle
Pig. 178.
Sagittal Section through the^deft) Knee-Joint during flexion. Seen from the outer
Kcbiiuin LiniUcd, Ixiudon.
(left)
side.
—
Vi Nat. Size.
Rebnian Company, Nch
York.
.
Sagittal Section through the Left Knee-joint during
Fig. 178.
Flexion.
made from a man aged 82
This preparation was into
limb,
t/ie
and
On
that position.
Formal was
years.
the knee, forthwith, flexed to its
utmost
the section was made without and a high amputation through the right leg
the following day
In spite of advanced age
ivds quite
injected
was kept
limit,
in
freezing. this joint
normal.
In contrast with the extended position (Fig. 177) this figure indicates the relations during
extreme
the middle of the joint, in
As
flexion.
the section has been carried almost through
a larger part of the Intrinsic Ligaments
As
the Patella
is
by the Ligament
fixed
Patella leaves the Anterior Surface of the lie is
is
shewn than
Fig. 177.
in front of the Joint-slit,
which
it
of the Patella to the Tibia,
Femur during
and comes
flexion,
does not cover during extension.
the to
The Capsule To such
folded backwards, and the Vessels and Nerves are extremely bent.
frequent bandings of an imperfect elastic arterial tube, of the
not-uncommon
aneurysm of the Popliteal Artery.
the figure exhibits the Anterior
:
this
is
attributed the
Of the
2
main cause
Crucial Ligaments,
extends from the depression
in front of the
Spine of the Tibia (Anterior Intercondylar Fossa) upwards, outwards and back-
wards
Crucial Ligament, Patellaris
fills
is
Condyle;
of the External
to the inner side
its
function,
check excessive rotatory movements.
to
up the space between the
Patella,
like the Posterior
The
Plica Synovialis
Articular Surface of the Tibia,
and the Crucial Ligaments.
One is
of the
most striking changes which occurs
relaxation of the External Lateral
Attached
to the
Femur
Ligament
—
in this joint
this is not
Ligaments. joints, (e.
g.
A
which
leg.
its
—
becomes tense
relaxed and allows
complexity. Contrary to the other large
have a free joint cavity or are
at the outset traversed
Shoulder, by tendon of biceps. Hip-joint by
of this joint contains
is
the figure
These movements, however, are limited by the Crucial
glance at the figure shews
either
it
during flexion,
in
eccentric to the axis of flexion, this ligament
during extension and prevents rotation, but during flexion
inward rotation of the
seen
Ligamentum
by one tendon
Teres), the interior
a complicated arrangement of ligaments which lead to the
formation of numerous pouches.
In cases of suppuration
in the Knee-joint,
purulent products, therefore, tend to remain in these recesses and only removed with difficulty.
clefts,
the
and are
o .4
m Ok
o 0)
a
•-»
c -
Prepatellar lUirsa
Patella l,i(»;imentuiii
Aliicosum
]()int-Caps\ile
Internal Lateral
Ligament
Vr- External Lateral
Ligament
- Anterior Crucial Ligament Po^iterior r'nu'ial Tajjainent
^^IJircps ^Iiisrlc Sarl»)rius
Muscl External
Cirarilis
MuslIc
Muscle and Bursa
Internal
Head
of Gastrocnemius
Rebman
Head
cd
Gastrornemius Musrle
cans Tibialis
Muscle
Transverse Section through the right Knee-Joint. Seen from above.
Figs.
al
Ramus Con mun
Nerve
Internal Popliteal Nerve \ Popliteal Vein
Semitendinosus Muscle
Fig. 181.
Extcn
\r
\ Seniinieniliianosus
Piiplite.il
182 and 183.
Limited, Londou.
—
'/lo
^^^- Size.
Lymphatics of the Popliteal Space.
%
Nat. Size.
Rebman Company, New York.
Fig. i8i.
Transverse Section through the Knee-joint. Frozen Section.
This frozen section shews the Prepatellar Bursa (Subcutaneous and Subfascial Comanterior to these, the Retinacula of the Patella, which strengthen the Capsule. These Retmacula become of importance in Fracture of the Patella. When the Patella is broken transversely, the functional impairment of the Extensor Apparatus will depend on the extent of the destruction of these Retinacula. partments), the lateral ligaments and
Figs. i8a and 183. Fig. 1^2.
From a man aged
Lymphatics 41 years.
—
of the Popliteal Space.
Fig. 183.
From a -woman aged 60
rears.
Normally there occur in the Popliteal Space more Lymphatic Glands than are usually stated (3—5); they are easily overlooked on account of their small size and the difficulty of their dissection in fat subjects. They ma}' be divided into three groups (of at least one gland each'i a Superficial group between the External Saphenous Vein and External Popliteal Nerve, separated from the latter by a thin fascia — the Superficial Popliteal Gland. The greater number lie close to the Popliteal Vessels under cover of the Internal Popliteal Nerve the Deep Popliteal Glands. Variable in position is a gland below the vessels which receives the bulk of the lymphatics of this space; whereas the Afferent Lymphatic Vessels to the different groups of glands are fairly constant, there is much variation in the Efferent Vessels. Therefore :
—
different cases are depicted.
Fig. 182, large Lymphatics, accompanying the Short Saphenous Vein, join the Gland; one Efferent Lymphatic extends upwards with the Femoro-popliteal Vein, another Efferent Lymphatic divides and joins the Articular Gland, which thus becomes a secondary gland to the Superficial as well as to the Deep Gland and the Lymphatics of the Joint. The large Efferent Vessel opened, in this instance, into the Efferent Tract (first mentioned), of the Superficial Gland and extended upwards as a stray vessel, to 4 inches beyond the figure, under cover of the fascia. After piercing the fascia it divided into 5 branches, and after a curved course opened into the Lower Internal Group of the Superficial Inguinal Glands. The arrangement of the Lymphatics in Fig. 183 is similar. The Afferent Vessels join, in this case, to form a thick trunk which passes with the Popliteal Vein through the opening in the Adductor Magnus. Between these two extremes there are endless variations, both paths being used in equal or unequal proportions at the same time. We are not satisfied of the presence of a third path; if such were emploj'ed it would, theoretically, lead along the Great Sciatic Nerve to the Pelvic Glands. The Lymphatics of the lower extremity begin at the foot and follow, in front and on the inner side, the Long Saphenous Vein; on the posterior aspect they partly pass over the Popliteal Space and go to the inner side; partly, as shewn in the figure, to the Popliteal Space, under the fascia, accompanying the Short Saphenous Vein. So that these Lymphatics may reach the Deep Inguinal Gland by following the Popliteal and Femoral Vessels, or join the Superficial Inguinal Glands after having pierced In
Superficial
the fascia. In Fig. 183, the Bursa in connection with the Semimembranosus Muscle has been opened and the Bursa under the Inner Head of the Gastrocnemius is shewn projected through that Muscle. Both communicate at the red spot which is marked by a f. We were unable in these cases and in 8 others, to shew any communication between these Bursae and the Knee-joint. It,
therefore,
seems doubtful whether
this
Bursa communicates
(in "j.^rd
or
'/.,
of
all
cases), with the Joint as is stated in the books.
Weak in
of
the removal its wall.
spots in the Capsule favour the perforation backwards in pathological cases; of Hygromata,
the joint
is
frequently
opened on account of the tenuity
Popliteal Space.
Fig. 184.
The immediate
continuation of the Fascia Lata
On
the Fascia of the leg.
this lies
is
becomes
Fascia which, after covering the Popliteal Space,
known
the Short Saphenous Vein which sinks into
the Popliteal Space and opens into one of the Popliteal Veins.
Space
this fascia, the Popliteal
is
exposed.
This space
is
Head
way
In this
a
lozenge-shaped space
which contains, well surrounded by
The most
superficial structure
is
or above
almost
into Internal
Communicating
its
The
division
While the
downwards
the middle
in
Internal
Tibial
at
about
Nerve passes
Popliteal
the External runs
line,
of
the Great
of
and External Popliteal Nerves, has occurred
the middle of the thigh.
verticall}'
(void
which traverses the
the Internal Popliteal Nerve
Branch, under cover of the Gastrocnemius Muscle.
Nerve
formed
is
the Large Vessels and Nerves.
fat,
space almost vertically, to di.sappear, after giving off
Sciatic
of the Fibula,
side inserted into the Crest of
emerge the two converging heads
the Tibia), while out of the depth of the space,
muscles),
After removal of
formed by the diverging
Flexors of the leg (Biceps on the outer side inserted into the
Semimembranosus and Semitendinosus on the inner of the Gastrocnemius.
as the Popliteal
directly continuous with
downwards and
outwards along the inner border of the Biceps Muscle.
Somewhat i.
internal
the largest of the
e.
closely
bound down
2
and on a deeper plane
to the
Artery
b}'
is
connective-tissue.
The Artery
deeper plane and more towards the middle of the space, fat,
Tibia
closely applied to the capsule of the joint.
it
is
72 inch thick,
line, lies
of the Knee-joint,
somewhat it
is
it
this
vein
lies at
a
is
still
here separated by
from the Femur; near the articular surfaces of the
a layer of
the middle
the Popliteal Vein,
situated
accompany the Artery;
or 3 Veins which
to the outer side
could only be
wounded
(cf.
Now
the artery, having left
In cases of Excision
Fig. 181).
at this spot.
Its
branches are the
Superior and Inferior Internal and External Articular Arteries and the Azygos Articular Artery which pierces the posterior
Close to the Internal Popliteal Nerve,
may (cf.
lie
subcutaneously on the
fascia,
waU is
of the Capsule.
a small L)'mphatic Gland: another
but there
are rarely
Figs. 182, 183).
This figure also shews the Bursa under the Inner
cnemius Muscle, which may communicate with the Knee-joint
and
ever more than 4
Head
of
the Gastro-
(Fig. 179). (Cf. Figs. 182
183, Text.)
This
is
of importance, because this
which needs removal.
It
operation on this Bursa.
is,
Bursa may be the seat
of a
Hygroma
therefore, possible to infect the Knee-joint during an
—
f
iitJincoiis
Branch of Small Sciatic
Ubtur; irator Nerve
New
|
Superficial Popliteal IvVniphatic Gland
Sartorius ilu
Femoro-Pnplitcal Vein (Tributary of tlie Short Saphenous Vein)
Gracilis Muscle
Semi tend ndinosus ^Tustle
— -
Kxternal Popliteal Ner\'e
Pupliteal Vessels
Internal Popliteal
Semiinembranitsus
Pljmtaris Muscle
Muscle Bursa between Internal of Gastrocnemius and Semimembranosus
-
Head
Biceps Muscle
Ramus T.onfj
Nerve
Sapliennus Nerve
Coninninicans Tibialis
Short Saphen<^»us Vein I^ong Saphenous Vi-in
Internal
Head
External of
Head
of
Gastrocnemius
Gastrocnemius
Ramus Communicans
Small Sciatic Nerve
Fibularis
JJr.Ffohsr-.
Fig. 184.
Popliteal Space on the right side. '/j,
r{i'lun;ui
Limit cil, Lomloii.
Nat. Size.
Rebnian Compiiny,
Now
York.
Anterior Tibial Miiscif
Common
Interosseous Mcmbr;inc
Kxti-nsor Afusrlr of FinKc
Posterior Tibial Muscle
/ Tibia
Anterior Tibial Artery
Anterior Tibial
N
Posterior Tibial Arterv
Musrtilo-Cutaneous XcrvtPostr-rior Tibial
Nerv
Pi-roneus Brevis Miiscl<
PuplitPiis Miis
A^':^
:'-^-''r\<'^-.-
-" <
^*
^-^]
i-""K s,.,,i„.„„us v,-i„
J^ong Saphrnous Nerve
Ramus Communirans Fibular is
Sulcus Muscif
Muscular Vein (Varicose Vein
'\
Inlcrnal Ileail of Gastr«»rnemius
Ramus fommunicans
Muscle
Tibial
Plantaris Muscle
Short Saphenous Vein
Fig*.
185.
Fascia of Leg.
Transverse Section through the right Leg at the Junction of Tipper and Middle thirds. Seen from bolow.
—
Nat. Size.
Anterior Tibial Artery-
Anterior Tibial Muscle
I-ong Extensor
Anterior Tibia
I.onj;
Extensor of the I-oiifj
Saphenous Vein
Tibia
Anterior Peroneal Artery
Piistorior Tibial
Fibula
Long Flexor
Peroneus T-ongus Muscle
Muscle
of the Toes
Posterior Tibial Artery isterior Tibial
Nerve
Poroneus Brevis Muscl
Short Saphenous Vein
Long Flexor
Tendo
Fig. 186.
of the Big-Toe
Achillis
Transverse Section through the right Leg neai- the Ankle. Seen from below.
Ktbin.m Limited, London.
—
Nat. Size. Rebnian Company,
Npw
York.
Figs. 185
and 186. Transverse Sections through the Leg at the beginning of the middle third and near the ankle.
Frozen Sections.
limb,
The Fasciae (blue) in Fig. 185, shew that on the Anterior aspect the Extensor Group of Muscles arise from fascia; on the Posterior
of the
aspect
from the Fascia enveloping the limb, and forming a special canal for the Short Saphenous Vein the particular Fasciae of the Muscles are represented. At a higher level this Fascia is continuous on the flexor aspect with muscular attachments: on the outer side, with tlie expansion of the Biceps Tendon internalh' with the expansion of the Sartorius, Gracilis and Semitendinosus Tendons. The circumference of the leg diminishes below the middle as the muscles ;
become
tendinous, thus near the ankle there are practical^ only tendons and bones.
the Long Saphenous Vein on the inner, and on the posterior surface are observed. The Fascia, which is a continuation of the Fascia Lata, is only interrupted by the Anterior Surface of the Tibia as it becomes intimtitely blended with the Periosteum. On the Antero-external aspect the Fascia sends a septum to the Fibula, which sepadeep la3'er passes transversely rates the Peroneal Muscles from the Extensors. In the subcutaneous tissue,
the Short Saphenous Vein
A
across from
the Posterior Siu-face of the Tibia to the outer surface of the Fascia,
this layer lies
deep
to the Soleus
and Gastrocnemius Muscles, which
it
separates
from the still more deeply situated Flexors. Above the ankle this layer is very strong and binds the Flexors down to the Bone; the Tendo Achillis becomes more prominent near the Os Calcis. The space formed in this way is filled by large pads of fat. The Internal Surface of the Tibia is palpable throughout its whole extent being only covered by skin and thin superficial fascia. The other surfaces of this triangular prism of bone are covered b}' muscles. The Fibula is completely surrounded by muscles except the Head and a triangular surface above the External Malleolus which are subcutaneous. The bond of union between the Tibia and Fibula is very firm. The upper Tibio-Fibular Articulation allows of scarcely anj' movement; this joint may communicate with the Bursa under the Popliteus Muscle and indirectly with the Kneejoint. Lower down these two bones are held together by a very strong Interosseous Membrane, whereas in the lower tliird, the union is 3'et more firm. Near the ankle, so firmly are these bones held together, that they may be viewed as one while the Inferior Tibio-Fibular Articulation is rather to be considered as an excavation of the Ankle-joint, than as an independent joint. In the upper third of the leg, of the 2 most important vessels which require ligation, the Anterior Tibial Artery is easily found on the Posterior Surface of external to this is the tlie Posterior Tibial Muscle in the Neuro- Vascular Bundle ;
Peroneal Arterv.
On
window has
side a larger
the outer
have been removed from
been cut out of the fascia; portions
Long Extensor Long and Short Peroneal Muscles,
the following muscles: Anterior Tibial,
Long Extensor of
of the Toes,
External Popliteal Nerve.
Outer Aspect of Leg.
Fig. 187.
the
Big
so that portions of the Tibia
The Anterior Aspect
of the
Toe,
and Fibtda have been exposed.
Leg
is
occupied
the Extensor Muscles of
b\'
covered
the Anterior Tibial
the Foot; the External Surface of the Tibia
is
Muscle and the Long Extensor of the Toes.
About the middle
Long Extensor
of the leg,
Big Toe appears between these two muscles and
of the
Tendons pass under the Annular Ligament, on
the
relations
b)'
to
the
in these
Dorsum
the
of
the Foot.
On
the outer side,
the
Peroneal Muscles which arise from the Fibula
2
pass down, as tendons, behind the Outer Malleolus. are
on the Flexor Aspect
of the leg pass
anterior aspect routes.
The Anterior
of the Interosseous first
all
(cf.
large
joints).
to the front
The
large Vessels and Nerves
Their branches to supply the
from the Popliteal Space
various
b}'
Tibial Artery passes directly forwards over the upper
Membrane, and runs downwards upon
this
Membrane
margin
lying at
between the Anterior Tibial Muscle and Long Extensor Muscle of the Toes,
then between the former and the
Long Extensor Muscle
of the
Big Toe. In the
tendon crosses the Artery obliquely, so that finally the Artery
lower third
this
reaches the
Dorsum
of the
Foot by passing below the Anterior Annular Ligament
between the Long Extensor Muscles
The External
Popliteal
of the
Toes and Big Toe.
Nerve takes quite a
the Great Sciatic Nerve at or above
the middle
coming
different course,
of the thigh
off
nerve passes
this
towards the outer boundary of the Popliteal Space and perforating the Long Peroneal Muscle winds around the head of the Fibula and appears on the anterior aspect of the Leg.
In
branch; the former
and pierces the deep Leg, whence
it
The Anterior
Tibial
its
—
runs
course this nerve divides into a Superficial and a
Deep
Musculo-Cutaneous Nerve supplies the Peroneal Muscles
fascia at the junction of the
down
to
the
Dorsum
middle and lower thirds of the
of the
Foot as a Cutaneous Nerve.
Nerve passes obliquely through the Origin
of
the
Long
Extensor Muscle of the Toes, and runs downwards on the outer side of the Artery; lower internal to
it
down
the Nerve
at the ankle-joint.
crosses in front of the Artery
In
its
course
it
and
lies
antero-
supplies the three Extensors on
the front of the Leg.
The
position of the External Popliteal
the Fibula requires great
Nerve passing round the head
of
care in operations on the upper end of the Fibula
because a deep longitudinal incision would divide the nerve.
lentlon of Ouadriceps Muscle
Slu.rt
Head
..{
\t-^A
Biceps Muscle
Loiijj
He.ul of Bleep
Outer Head of Gastrocnemius, Muscle (Tendon of Origin)
Head
IVmoiicus
.jf
Band
Patella
:\IiiSLle
lixternal Popliteal
riio-Tibi.il
7
Xer
Ligament of Patella
Insertit.n of Bicei)s into Tibia
Fibula
Lonj< Extensor Muscle of Toi-s
Upper portion of Anterior
Lmigus Muscl
Tibial
Muscle
Outer
Head
of Gastrocnemius Muscle
Tendinous Arch for Antcrio Tibial Nerve
Sulcus Muscl
Anterior Tibial Arterv
Superior portion of Long Extensor of Big-Toe
^lusculo-Cutaneous Nerve (Branch to Peroneus Brevisl
Interosseous ifembrane
Pernneus Brevis Muscle
Periosteum (Fascia of Leg)
Ramus Communicans
Fibularis
Inferior portion of Long Extensor of Big-Toe
Lower
Peroneus Longus Muscle
part of Anterior Tibial Muscle
jir
Right Leg.
Outer Side.
% Rebman
Limited, London.
Long Extensor
Lower
Anterior Intermuscular Septum
Fig. 187.
part of
Muscle of Toes
Vrohf^
I
External PopHteal Nerve.
Nat. Size.
Rebmnn Company, New
Vo,k.
Sliort SapbeiKiiis
H.-auof
of
Ciastrocncmius / -
„
Vessels to Outer ,
Head
-^•^;
Gastrocnemius IVipIitcal
Head
Outer
Vein
Br;inrlics to Innci
of
Gastrocnemius
//
uniotor
Vci
Xerv
Dbliquc Popliteal Inttrnal Popliteal
Ligament
Nerve
(Semimenibranttsuy
Inferior External
Inferior Internal Articular Arter\
Articular Artery popliteus
Gracilis Muscle
Kainus Communicans Bursa under
Fibular is
Semimembranosus Kcr\e
to Suk'us
Neixe
to Posterior Tibial
Internal Lateral
Muscle
Muscle
Ligament
lixternal Popliteal
Fascia covering Popliteus
Long Saphenous Nerve
Ramus {.Jiminuinican:
Xervc
Si.l.iis
Must
Xcive
to Posterior Tibial
le
Muscle
Peroneal Aili-n
Posterior Tibial ^Vrtery
Upiui Ner\c' tit Long Flexoi of Big-Toe
Superior Branch tu Long Flexor of Toes
Posterior Tibial Muscle
Long Flexor Muscle
Long Flexor Muscle
Peroncus Longus Muscle
of
Big-Toe
of
Toes
Inferior
Branch
to
Long Lower Nerve
Flexor of Toes and
Ltmg
Muscular Vein (Varicose
Soleus Muscle
Vein)
Tendon of Gastrocnemius
Short Saphenous Vein
Muscle
Fig. 188.
to
Flexor of Big-Toe
Vasomotor Branch
Right Leg
fi'om behind:
Deep Layer.
Internal Popliteal Nerve.
V, Nat. Size.
Rebnian Limited, Loudon.
Kobjiiun Coni|iaiiy,
New
York.
Fig. i88.
Posterior Aspect of Leg.
Deep Layer, Internal Popliteal
Nerve.
tlie Superficial Fascia, a large piece has been cut out of the Gastrocnemius and Soletis Muscles, the heads of origin of the Gastrocnemius have been thrown outwards. By further removal of the Deep Fascia, the large Vessels and Nerves have been exposed. An incision through the fascia covering the Popliteus Muscle has exposed the Bursa under the Semimembranosus Muscle.
After removal of
The arrangement
muscles on the back of the leg is very simple: a Superficial Layer formed by the Gastrocnemius, Soleus and the slender Plantaris; a Deep Layer formed by the Posterior Tibial, Long Flexor of Toes and Long Flexor of Big-Toe. On this latter group lie the important Nerves and Arteries, which are quite separated from the Superficial Layer of muscles by the Deep Fascia of the the
Leg
Superficial
(v.
of the
Figs. 185, 186).
Muscles,
loose
Between the Deep Fascia
connective
tissue,
favourable
to
of the leg
the
spread
and of
Cellulitis is found.
In order to allow the vessels and nerves, leaving the Popliteal Space, to reach the deep aspect of the superficial muscles an aponeurotic opening is formed by the Soleus i. e. an arch is thrown across from its Tibial to its Fibular Origin
under which the above mentioned structures pass. At the lower border of the Popliteus Muscle, the Popliteal Artery divides into Anterior and Posterior Tibial Arteries (occasionally this division takes place at a higher level). The Anterior Tibial Artery (the smaller branch), passes directly over the upper border of the Interosseous Membrane to the Anterior Aspect of the Leg the Posterior Tibial Artery passes under the arch of the Soleus, approaches the inner side of the limb and lies in its outer third under the skin between the Tendons on the Long Flexor of the Big-Toe and the Long Flexor of the Toes; ;
together with these tendons of the foot.
The
it
chief branch
passes behind the Internal Malleolus into the sole this vessel is the Peroneal Artery which runs
from
outwards through the arch of the Soleus, under cover of the Fibular origin and the muscular belly of the Long Flexor of the Big Toe, to near the ankle where it emerges and terminates by giving off a Perforatmg Branch to the Anterior Tibial Artery and a large Communicating Branch (sometimes double) to the Posterior Tibial Artery or the outer side of the heel. The Posterior Tibial Nerve runs along the outer side of the Artery, and after giving off numerous branches, passes with it under the Internal Annular
Ligament to the sole of the foot. Deeply situated on the Interosseus Membrane lies the Posterior Tibial Muscle. As the Tibia is subcutaneous throughout its whole length, the structure The Fibula is readily exposed of the leg is convenient for extensive operations. taken in the neighbourhood must be after removal of the Soleus Muscle, but care of
its
head
to avoid injury to the External Popliteal Nerve.
Synovial Sheaths of the Tendons behind the Internal
Fig. 189.
Malleolus.
The Tendu AchUlis, Plantar Fascia, a large part of the Abductor Muscle of the Big Toe, the Short Flexor of the Toes and the Deep Fascia of the Leg have The Annular Ligament has been dissected out and the Tendon-
been removed.
sheaths distended with Gelatin.
Strong Septa extend from the Internal Annular Ligament surface of the Tibia, so that the
by synovial sheaths.
Tendons run
The Sheath
to the posterior
in Osteo-aponeurotic Canals, enclosed
of the Posterior Tibial
Tendon commences two
inches above the tip of the Internal Malleolus and reaches as far as the insertion
Tendon
of this
on the bony
into the
communicating with
little
Immediately behind
this
its
upper end
lies
inserted obliquely on the tendon,
is
as muscle fibres are inserted into
leaving
its
further
downwards
sheath and rarely
Long Flexor Muscle
the Sheath of the
This sheath extends to a higher level up
the Foot.
and
Scaphoid Bone, so as to extend a
aspect of the tendon.
the leg than
posterior
the
of
former
border free as long
it.
The sheath ends at the level of the Astragalo-Scaphoid Joint. Still nearer the Os Calais is the Sheath of the Long Flexor of the Big-Toe separated from the Long Flexor of the Toes by a space occupied by the Posterior Tibial Nerve and Vessels on their way to the sole of the foot. This sheath commences one inch above the Tip First Metatarsal Bone.
the Big-Toe crosses the
with the
latter,
the
of the Malleolus
far as the base of the
At the point where the Tendon of the Long Flexor of Long Flexor of the Toes and has a band of communication
Tendons
still
remain within their proper sheaths, but these
sheaths communicate with each other
Toe
and may reach as
;
in
many
cases the
Long Flexor
of the Big-
without synovial covering at the point of crossing.
is
Like the tendon-sheaths
in
the hand, these sheaths are of importance in
connection with the spreading of inflammatory processes from the foot to the leg
and vice disease
versa.
may
Moreover, as they pass over the Capsule of the Ankle-joint
perforate
these Sheaths
and extend
to
the Ankle-joint
or in
the
reverse direction.
At with
the toes the Flexor Tendons,
one important difference;
Central Synovial Sheaths.
at
the
like
those of the Hand, have sheaths
toes they
never communicate with the
Gastrdcneinius Muscle
Sulcus ilusclc
Long Flexor Muscle
of Uic Toes
Peroneal Muscles Posterior Tibial Muscle
Lun^' Flexor of the Biy-Tot-
Tcndo
-^MM
Aehillis
-
—— i
-
Internal Malleolus
Internal Lateral
Ligament
Abductor Muscle of the Big-Toe Short Flexor MuscKr of the Toes luberclc of Scaphoid Bone Accessorius
Long
Mustr
Flexor Muscle
of the Toes
Abtluctur iiud Flexiir Muscle of the Little Toe
Fig. 189.
Abductor Muscle the Big-Toe
Tendon Sheaths behind the Internal Malleolus. '/,
llebman Liiniled,
of
Loiiiluu.
Nat. 8ize.
RebiiiMii
Comiiany,
New
York.
of Ucii ^l)^•tp Lay«
I-'asciii
LonK Flexur Muscle
of
the Big-Toe
Posterior Tibial Artery
Posterior Tibial
Tendon
Nerve
of Plaiitaris
Muscle
\^ ^^
Bur>;i
under Tendi'
A(hilli^
Internal Annular
Ligament
Fig. 190.
Region
of (right) Internal Malleolus
from behind.
Nat. Size.
Kebman
Limited, London.
Rebman Company, New York.
Region behind the Internal Malleolus.
Fig. 190.
Right Leg of a girl aged 75 years. The region around the Internal Malleolus is exposed in layers. ^ windows have been made in the Deep Fascia and Internal
Annular Ligament.
The Long Saphenous Vein runs in the Superficial Fascia as far as the accompanied by the Long Saphenous Nerve. The Fascia of
Internal Malleolus
the
Leg
is
strengthened behind the Internal Malleolus by thick bands of fibres
which radiate from the Malleolus towards the inner surface of the Os Calcis and
—
Plantar Fascia
under which
This Ligament forms a bridge
the Internal Annular Ligament.
Flexor Tendons, Nerves and Vessels pass to the sole of the
tlie
Nearest to the Internal Malleolus under this fascia and
Tendon
neurotic Canal the
Tendon
The Tendon
of the Toes.
the Posterior Tibial Vessels
Toes and the Long Flexor
strong
foot.
Apo-
passes, next to this the
muscle crosses the
of this
Leg from within outwards.
Posterior Tibial Muscle in the
Nextly,
Muscle
of the Posterior Tibial
Long Flexor
of the
in a
of the
lie
Big Toe so
between the Long Flexor of the the
that, for ligature of this vessel,
mid-point between Internal Malleolus and Tendo Achillis serves as the landmark. Directly posterior to the Artery
minal branches. to this this is
of the
—
is
the Posterior Tibial Nerve or
Internal and External Plantar Nerves.
and extending as
far
back as the
Tendo
found the Tendon of the Plantaris which
Os
Calcis,
is
— is
The space
posterior
occupied by
fat;
in
inserted into the posterior part
along side of the Tendo Achillis.
By pushing
the Vessels and Nerves forwards, the posterior segment of the
Ankle-joint can be reached.
middle of the
Achillis
ter-
its
The Long Flexor
Between
joint.
this
of the
Big Toe passes over the
and the other tendons, posterior
to the
Inner
Malleolus on the one side and the Peroneal Tendons behind the outer Malleolus
on the other joint,
side, the
because
it
is
Capsule of the Joint
may bulge
not strengthened at these points.
tirpation of the Capsule in Tuberculosis, the joint
arrangement
is
(cf.
Fiy. 193), there
is,
filled out.
It
accessible from behind.
however, the difference
deeper position, the swelling of the joint
extensive.
For operations, such as Ex-
The
analogous with that on the Anterior Aspect of the joint near the
Extensor Tendons its
is
in cases of effusion into the
becomes
visible
when
is
that,
owing
only noticed posteriorly
the hollow next to the
Tendo
to
when
Achillis
is
^
1
—
4>
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Frontal Section through the (Right) Ankle-joint.
Fig. 197.
As
Frozen Section.
did not pass directly
the section
External Malleolus some tissue was removed in order
The
form a socket which
to
a lower level than the
upwards between the lower ends of these bones
the joint cavity extends
;
forming a recess caUed the Inferior Tibio-Fibular Articulation. Astragalus the Capsule
Astragalus).
Astragalus
By may
this
does
only
arrangement
extend
the Capsule
a considerable
of the
portion
and behind, so as
in
to
The lies at
Os
Neck
of
the the
Coris
form folds (vide Fig. 199) but on either side
to the
Os
Calcis:
the
Astragalus and
Anterior and Posterior Astragalo-Fibular Ligaments and
the Calcaneo-Fibular Ligaments
Astragalus and
of
Dorsal and Plantar Flexion, the capsule
Deltoid Ligament extending from the Internal Malleolus Tali, the
cartilages
neck
of the foot.
strong tense ligaments attach the Malleoli to the Astragalus and
Sustentaculum
the Tibia and
the
to
enter the joint cavity in extreme dorsi-flexion
responding to the free movements loose in front
To
attached along the border of the articular
is
the anterior surface
(on
of the
expose this prominence.
of their Malleoli
The External Malleolus extends
grips the Astragalus. Internal
means
Tibia and Fibula by
the tip
t/irotigh
to
extending from the External Malleolus
to
the
Calcis respectively.
ankle-joint
is
therefore not easily accessible from the side; behind,
a considerable depth under the
Fig. 190).
Its anterior aspect,
accessible
(cf.
Tendo
Achillis,
but can be reached
on either side of the Extensor Tendons,
is
it
(cf.
the i^ost
Fig. 193).
This figure also shews the position of the Peroneal Muscles enveloped in their sheaths
below the Outer Malleolus and the position
The
inner side.
Posterior
Tibial
now
Internal and External Plantar Branches which are position
than the
tip of
but
Calcis, the Posterior
this lies at a slightly
higher level
by the Interosseus Ligament
(v.
which
Joint
Fig. 199)
is
not
is
separated
from the
an independent joint
a part of the Astragalo-Scaphoid Articulation, whereas the Posterior Calcaneo-
Astragaloid Articulation If
;
the External Malleolus.
The Anterior Calcaneo-Astragaloid Posterior
on the
lying in a well-protected
between muscles. Between the Astragalus and the Os
Calcaneo-Astragaloid Articulation can be seen
is
of the Flexors
Artery and Nerve have already divided into
swollen
it
is
quite independent
and
liable to
independent affections.
bulges forwards and outwards to point anteriorly at the Tip of the
External Malleolus.
The movements of Abduction and Adduction are limited at this joint. The inner border of the foot is arched and does not touch the ground.
Transverse (Frontal) Section through the Anterior Part
Fig. 198.
of the Tarsus.
Frozen Section.
The Foot
is
arched both Antero-posteriorly and Transversely. The Trans-
verse Arch, shewn in the figure, begins posteriorly where the
Sustentaculum Tali forms a semicircle
A whereas
further forward
little
Calcis with
its
Fig. 197).
the Scaphoid and Cuboid Bones form
front of these the arch
in
(v.
Os
becomes more
an arch,
Cuneiform Bones
definite as the
with their broad Dorsal and narrow Plantar Surfaces closely resemble the stones of an arch.
The Longitudinal Arch is still more pronounced in the Metacarpal Bones. The Plantar Vessels and Nerves run forward under cover of this arch which them from pressure (due
serves to protect
to the
weight of the body).
Longitudinal (Sagittal) Section through the Foot.
Fig. 199.
Frozen Section carried through the middle of the Tibia and the
oitter
part
of the 2nd Toe. This figure shows the Longitudinal Arch w^hich inner side.
The
inner tubercle of the
Bone form the PiUars less
curved; here
Bone.
of this
The Astragalus forms
the
Calcis
On
Arch.
Anterior Pillar
its
Os is
is
most marked on the
and the head of the
ist
Metatarsal
the outer side of the Foot the arch
is
formed by the base of the 5th Metatarsal
Keystone
Strong ligaments bind
of this Arch.
together the bones on their Plantar Aspect and firmly brace up the arch; the Plantar Fascia stretched across from the Inner Tubercle of the
Heads
of the Metatarsal
Mention must
Bones
also
acts
Calcis to the
Uke a bowstring.
be made of the assistance rendered by the Tendon
and other Muscles
the Posterior Tibial
Os
in
keeping up the Arch.
This figure further shews: a Bursa (alwa3's present) between the
and Tendo AchiUis. Fascia
is
rarely
The
(A Bursa between the Tendo AchiUis and the
met
Os
Calcis
Superficial
with.)
cavity of
the
ankle-joint
extends backwards
Posterior Calcaneo-Astragaloid Articulation.
the Astragalo-Scaphoid Joint. This explains
forming Chopart's
of
disarticulation,
easily
In front
why
it
is
nearlj'
as
the
as
the
Vsths inch distant from
inexperienced persons,
open
far
ankle-joint
when
instead
of
per-
the
Astragalo-Scaphoid Articulation.
The is
figure shews also that the Posterior Calcaneo-Astragaloid Articulation
a complete
Articulation.
joint,
whereas the anterior
is
merely a part of the Astragalo-Scaphoid
>^
a> a>
P
o o
O 02 04 a>
bo
^^
.
Mnsnilo-Cutanrous;
Nerve
Anterior Tibial ^^us«lc
T-ong Saphenous Vein.
Superior (Vertical)
Annular Ligament
Saphenous
X
— Short Saphenous Vein
Limp Extensor Muscle of the
Tots
Annnlar Ligament Short Saphenous Xervc
Short Extensor Muscle of the Toes
Anterior Tibial Xerve-
Dorsal Arterv nf Foot
Peroncus Tcrtius Muscle
Plantar Arch
Dorsal Venous Arch of Foot
1st
Dorsal (Metatarsal) Artery
Fig. 193.
Region of
AnMe
and Dorsum of Foot.
Nat. Size. Reliman Limited,
Ix)ikIoii.
Rebman
Comp.^iny,
New
Yuik.
^ig- 193'
Region
of the
Ankle and Dorsum
of Foot.
Left.
Preparation from a girl aged 75 years. The Fascia of the Leg and Dorsum of the Foot has been removed, but the Superficial Veins and the Anterior Anmilar Ligament have been preserved.
The open network
which occurs in this situation, conVenous Plexus which terminates on the inner side in the Long Saphenous Vein, and on the outer side in the Short Saphenous Vein. The Fascia extending from the leg to the foot is considerably strengthened above and over the ankle by the Superior and Anterior Annular Ligaments. The latter is formed by a series of fibres which run from the Internal Malleolus outwards and downwards to the outer border of the foot, these fibres are crossed by another tains little
fat,
but
is
of superficial fascia
rich in a
which run frorn the inner border of the External Malleolus. These no independent structures but thickenings of the Fascia; they can only
series of fibres
fibres are
be displayed
artificially
(cf.
Fig. 193).
The Extensor Muscles
present the same relations as in the Leg.
inner side, the Anterior Tibial Muscle the
first
is
On
inserted into the Scaphoid and base
the of
Long Extensor of the Big Toe next the Long Extensor of the Toes
Metatarsal Bone, externally to this the
runs to the terminal phalanx of the Big Toe,
and
Peroneus Tertius (Third Peroneal) Muscle to Arising from the first part of the upper and outer surface of the Os Calcis, deep to the Tendon of the Long Extensor of the Toes, lies the Short Extensor of the Toes, with its obliquely directed tendons which blend with the Long Extensor Tendons to form the dorsal aponeurosis of the toes. Between the Metatarsal Bones appear the Dorsal Interosseous Muscles. At the mid-point between the 2 Malleoli and between the tendons of the Long Extensors of the Toes and Big Toe is situated the Anterior Tibial Artery in its continuation below the Anterior Annular Ligament it is called the Dorsal Artery of the Foot which runs over the middle Cuneiform Bone onwards into the 1st interosseous space, where it anastomoses with the External Plantar Artery. The Anterior Tibial Artery gives off to each Malleolus a Malleolar the Dorsal Artery of the Foot, to both inner and outer sides of the Branch Foot a Tarsal Artery. The Anterior Tibial Nerve generally on the inner side of the Dorsal Artery of the Foot, supplies tlie Short Extensor Muscle of the Toes and gives a Cutaneous Nerve to the contiguous sides of the Big Toe and the 2nd Toe. On either side of the Extensor Tendons and between the tendinous bundle and each Malleolus is a space of considerable importance, because at these points the Capsule of the Joint is only covered by Skin and Superficial Fascia without any accessory strengthening fibres. At no other place is the joint so exposed or so readily accessible. Moreover by a bulging of these spaces an effusion into the joint will be first observed. to the 4 outer Toes,
lastly the
the Tubercle of the 5th Metatarsal Bone.
;
—
—
,
Outer Side
Fig. 194.
Preparation from a girl aged /j years.
of (Left) Foot.
The Fascia over
Dorsum of
the
the
Foot has been removed with preservation of the Annular Ligament, Superficial Veins and Nerves. slieivn
Fascial
The
Over the External Malleolus,
a small Subcutaneous Bursa.
The Peroneal Tendons
behind the External Malleolus side
Peroneal Muscles are
the
Synovial Sheaths of Peroneal Muscles
Superficial Fascia behind the External Malleolus
Saphenous Vein and Nerve. is
Bands which bind down
(Retinacnla Peroneorum).
pin k.
contains the Short V2 to Yj cases), there
(in
are held within their grooves
strong bands similar to those on the inner
b}'
which are derived from the Anterior Annular Ligament.
Without these
ligaments a displacement of these tendons over the Malleoli would be of frequent
These bands, the Superior and Inferior Peroneal Bands are thickenings
occurrence.
The Superior Band runs from
of the fascia.
the lower part of the outer surface of the
the outer
Os
Long Peroneal and deep to this the tendon The Inferior Peroneal Band, more distally Malleolus to the outer surface of the Os Calcis
muscles, of which the Short Peroneal
of
the Malleolus to it
runs from the Tip of
situated,
a
:
Septum separates
in
a
common
Peroneal
bifurcated:
Band and
the upper bifurcation
Long Peroneal
lies
Muscle, extends
1^/4
The upper end
with the posterior
of the sheath enclosing the
Chopart's
The lower end
of the
new sheath which comes almost
cation
into contact with the
between them never occurs.
thin that
easil}'
is
it
By
this route
perforated
by
first
sheath; a
it
Long
receives
communi-
Nevertheless, the intervening septum
is
so
pus.
an Abscess of the sole of the foot
Again; the relation of the Peroneal Sheaths
into the leg. for example,
sheath of
Joint but the sheath of the
Peroneal passes beyond as far as the groove on the Cuboid Bone, here a
point,
inches above the tip of the Malleolus; the
sheath for the Short Peroneal to a less height. the Short Peroneal Muscle extends to
this
under cover of the Superior
the lower bifurcation comes into relation
border of the Inferior Peroneal Band.
two
sheath while in the
groove directly behind the External Malleolus, but above and below is
these
lies anteriorly.
Both the Peroneal Tendons are enclosed
the sheath
the tendon
of the Short Peroneal Muscle.
of the
the
side
and has under
Calcis
tuberculosis of this joint to extend
to
may
easily
Chopart's
up the leg
spread up
Joint allows,
after perforating
the
tendon sheaths.
At
the
Tendons are reason of this
Ankle such easy means
closely is
for extension are not found, although the
applied to the joint behind the External Malleolus.
The
explained by the definite separation which the strong Calcaneo-
Scaphoid Ligament secures.
Short Saphenous Ner\
t-
Short Saphenous Vein
Peroncus Longus Muscle Peroneus Brevis Muscle Miisciilo-Ciitancous
Xcrve External Malleolus
Upper part of External Annular Ligament (covering
Anterior Tibial Muse
I.on{?
the Peroneal Muscles)
Extensor Muscle of the Big- Toe
Lower
1
Annular lAntcriorl Ligament
part of External
Annular Ligament
1
(covering the Peroneal Muscles)
Tendon Sheath of Peroneus Longus Muscle Dorsal Arterv of Foot
Abductor Muscle of the Little-Toe
Short Extensor Muscie of the Big-Toe
Muscle Toes
Slidft Extensor
of the
:
Tertius Muscle
Anterior Tibial Nerve
Dorsal Venous Arch of Foot
1st
Dorsal (Metatarsal) Arterv
Fig. 194.
Outer side of the /.J
Robinaii Limited, Lnndnii.
(left)
Foot.
Nat. Size.
K('l)iii:in
r
Ncu" York.
Subcutanetiiis Bursa nver Internal Malleolus
Subcutaneous Bursa over Kxternal MallcoUis
Tendon-Sheath of Anterior
-\nnular \Anteriori Ligament
Tibial \fusclc
Tendon-Sheath of Long Extensor Muscle of the Biff-Toe
Tendon-Sheath of Peroneus Tertius Muscle
Tendon-Sheath of the Long Extensor Muscle of the Toes
Bursa under the Tendon of the Anterior Tibial Muscle
Short Extensor Muscle
Peroneus Tertius Muscle
of the Big-Toe
1st
Accessory Tendon-Sheath
\\
of T-onp Extensor Muscle of the Big-Toe
1st
I
-
(I
ji
'n
i
cndon-Sheath of the Extensor Muscle of the Big-Toe
'ii.rt
Short Extensor Muscle of
Dorsal Interosseous
the Toes
Muscle
2nd Accessory TendonSheath of Long Extensor Muscle of the Big-Toe
Metatarso- Phalangeal Bursa
Toe
of the 5th
Metatajso-Phalangeal Bursa
Intermetatarso-Phalangeal
of the Big-Toe
Bursae
Subcutaneous Bursa over Subcutaneous Bursa over Dorsum of the Big-Toe
Fig. 195.
Dorsum
Dorsum
of (left) Foot
of 3rd
Toe
shewing Muscles and Tendon-Sheaths.
7, Nat. Size. Keldiiaii
IJuiiled, J.ominn.
Kt-biiKcii
Oujiijauy,
New
Yurk.
Dorsum
Fig. 195.
of (Left)
Foot with Muscles and Tendon-sheaths.
The Fascia of the Dorsum of the Foot has been removed except
The Tendon-sheaths have been opened except
and Anterior Annular Ligaments.
the cul-de-sac at their extremities, the length of
which
indicated by an arrow.
is
The Superior and Anterior Annular Ligaments keep during movements at the ankle;
in position
separate compartment for each tendon with
avoid any
its
arrangement
own
of
the Anterior Tibial Muscle
Intermalleolar-Line (between the tips of the
Chopart's
The Sheath
Joint.
^4 inch above
A
this
the Extensor-Tendons is
perfected by a
sheath in order to
special
friction.
The Sheath the
the Superior
the
of the
commences
second and even a third Synovial Sheath
may be
the Big
of
down
Intermalleolar-Line and extends
inches above
and ends usually
Malleoli)
Long Extensor
21/2
to
at
Toe begins
LiSFRANC's
Joint.
present (Fig. 195) in connection
with this tendon.
The Long Extensor a
common
Tibial
A Bursa
is
to the
which
arises
in
the Sinus Tarsi assists in keeping
place under the Annular Ligament.
found between
Many
the sheath of the Anterior
middle of the External Cuneiform Bone.
sling-like ligament
these tendons in
Toes and the Third Peroneal Muscle occupy
commences lower down than
sheath which
and extends
of the
this
Ligament and the Neck
other Synovial Sacs
may be
present:
Sometimes an extensive
of the Astragalus.
those between
the heads of
the Metatarsal Bones (Intermetatarso-phalangeal Bursa) are quite frequent.
Whenever
tendons pass over bony prominences, small synovial sacs are placed to act like cushions; even where the Lumbrical Muscle winds around the shaft of the
phalanx these are found. pressure of skin
Again Subcutaneous Bursae occur whenever there
against bone especially under "Corns"'.
Malleoli are fairly constant as well of the
I
St
first
as those on
The Bursae over
the lateral aspect of the
and 5th Metatarsal Bones, and those over the Heads
is
the
Heads
of the ist Phalanges.
;
Fig. 196.
Dorsum
with Tendon-sheaths. Arteries and
of (Left) Foot,
Bones projected on to the Skin.
This
is
a reconstructed figure: The outlines are taken from a young individual
the bones are
of a corresponding size; moreover in comparison with several
other specimens
of the Arteries and Tendon-sheaths have been
position
the
relatively determined.
This figure
(cf.
Fig. 97)
has been
constructed to shew the relation of
Arteries and Tendon-sheaths to Bones and Joints. indicate the position of deeper structures, to
be taken as the
reliable points.
In the
Hand
furrows and folds
but in the Foot bony prominences are
Along the inner
the Tubercle of the
border,
Scaphoid, on the outer side the Tuberosity of the 5th Metatarsal Bone are plainly
The Tarso-Metatarsal
evident.
Articulation (LlSFRANC's Joint)
is
Immediately proximal to the tuberosity of the 5th Metatarsal Bone the other point lies
1
'/2
is
the one point,
A
inches distal to the tubercle of the Scaphoid.
line joining these 2 points indicates the line of the joint.
The Mid-Tarsal
determined thus:
Joint
is
(Cf.
Fig.
curved
20.)
determined by connecting on the inner border
a point V^rd inch proximal to the Tubercle of the Scaphoid, on the outer border V5 inch proximal to the Tuberosity relations joint
which the extremities
space can be
made
The
of the 5th Metatarsal.
of the
Tendon-sheaths bear
out directly in most cases
by
figure shews the
to these lines.
The
feeling at Vs^ds to Vsth
jnch above the tip of the Inner Malleolus the Anterior Border of the Articular
Surface of the Tibia where Synovial Bursae see Fig.
muscles.
it
is
only covered by skin and tendons.
(For certain
197.)
Frequently a Bursa
bone where
it
is
placed between a tendon and
acts as a cushion
when pressed
its
insertion into the
against the bone by the opposing
Consider, from this point of view, the bursa over the Internal Cuneiform
Bone, which
lies
into the Internal
under the Anterior Tibial Muscle close Cuneiform and the
ist
Metatarsal Bones.
to its point of insertion
|
Perforating llranch ni Peroneal Artery
-Vutcrior Tibial Artery
—
Anterior Jntern.il Malleolar Artery
Tendon-Sheath of J-ong Extensor Muscle of the Toes
Tendon-Sheath of Posti-riur Tibial Muscle
Tendon-Sheath of Peroneus Brevis Muscle
Tendon -Sheath of
Anteri|
Tendon-Sheath of Peroneus Longus Muscle
External Tarsal Artery
Tendon-Sheath of Long Extensor Muscle of the Big-Toe
Internal Tarsal Artery
IJiiisa
External Malleolar Artery
Dorsal Artery of Eoot
under Tcnilini of Anterior Tibial Muscle
Metatarsal Artery
Transverse Metatarsal Artery
Deep Branch
Posterior Perforating Branch
passing to the Plantar Arch
Internal Plantar Artery
Dorsal Digital Artery
Fig. 196.
^Vnterior Perforating
—
Dorsum
Dorsal Digital Artery
of Foot
with Tendon-Sheaths, Arteries and Bones.
(Projection on to the surface.) ^-
Rebinan
Liiiiited,
Louiion.
Branch
Left side.
Nat. Size. Robinnii (.'imipniiy.
New
Yurk.
Inti-rn^il
Malleol
a his
Posterior Tibial
Muscl
Kxti-inul Matlrulus
Interosseous Ligament
Long Flexor
iluscle of the Toes
Peroneus Brevis Muscle
Internal Plantar Ner\'e
Lonff Flexor iluscie of the Big-Toe
Pcroneus L
Accessory Muscle External Plantnr Nerve
Calcaneus
Abductor Muscle of the Big- Toe
Short Flexor Muscle of the
Abductor Muscle of
Toes
Fig. 197.
the Little-Tue
Frontal Section through the (right) Ankle-Joint. iSeen
Robmau
Limited, London.
from behind.
Nat. Size.
Rebmau Company, New
York.
Long Extensor Muscle
Miihllc Cuneiform B.iniSliort Extensor
Muscle
L.nig Kxtensor Muscle
.if
<.f
the
the Toes
Toes
of the
Big-Toe Anterior lIl.iM Nerve
Dorsal Artei-y of Foot.
|
i
\
Bone
Internal Cuneiform
External Cuneiform
Tendon
A
Long Flexor Muscle
of the
Bone
of the
Toes \
lUerior
Tibial
Muscle
portion of Adductor Muscle of the Big-Toe
)bli(iue
Peroneus Lougus Muscle iTlterual
Plantar Artery
Cuboid Abductor Muscle of the Big-Toe Short Flexor Muscle of_/ the Toes Jtli
/
I^ong and Short Elexors ..1 the Big-Toe
/
Metatarsal Bnn. '-
External Plantar Ner\e and Vessels
t)pposing iluscle
Internal Plantar
I^lant.ir
Nerve
h'ascia
iif
Little-T.ie
Abductor and Short Flexor Muscle of the Little-Toe
Fig. 198.
Frontal Section through the Anterior Part of the Tarsus. fSepii
from
in
front.
—
Nat
tfi/.f.
Anterior Tibial Muscle Accessor)- Muscle
Scaphoid Postenoi libial Muscle
Long
E\ten->or
Muscle uf the Big-Tu
Internal Cuneiform
Bone
Peroneus Longus Muscle 1st Metataisal Bone Short Extensor Muscle uf the Big-Toe Interosseous Muscle
Lumbrical Muscles Transverse Adductor of the Big-Toe
2nd Metatarsal Bone
Fig. 199.
Sagittal Section through the (right) Foot. Seen from the outer
Rebmaii Limited, London.
side.
—
7.,
Nat. Size.
Ilebmau Comijany,
New
York.
Flexor Muscles of
I
}rt\
Ti'e
Subiut.incous Met;it;irso. Phiilangeal Bursa uf the Little- Toe
Interosseous Muscles
Pl.iiit.ir
Arch
Abductor Muscle of the Big-Toe
Tenth 'H of Pcroneus
Lungus Muscle
Long Flexor Muscle of the Big- Toe I'eroncus Brevis Muscle
Long Flexor Muscie
of the Toes
Internal Plantar
Cuboid
Ner\e
Internal Plantar Artery
External Plantar Ner\'e
Pcroneus Longus Muscle
External Plantar .Vrlcry
Accessory Muscle
Os
Calcis
Tcndo
Fig. 200.
Horizontal Section through the (right) Foot, near the 7:,
Rebmau
Achillis
Limited. London.
sole.
Nat. Size.
Rebnuin Company, N'e« York.
Fig. 200. Horizontal Section through the (Right) Foot near the Sole.
The
Frozen Section.
distal lutlf
of
Bone has been freed
^th Metdtarsal
tlie
by
dissection.
The
result of the arching
of the foot
is
only by a few points of the skeleton of the
Tubercle of the Os Calais the
5tli
Metatarsal Bone;
;
foot,
namely;
on the outer side
in front
the inner side: the
<:in
that the body-weight
though many consider that owing
:
Head
to the mobilit\-
—
H.
VON Meyer
the 3rd Metatarsal
received
behind; the Inner
the Head, also the base of of the
of this
Metatarsal Bone
ist
bone the head
2nd Metatarsal Bone should be looked upon as the supporting to
is
point.
Bone should be viewed
as
of the
According the point of
support as the other bones only serve for the purpose of preventing the foot from
However
capsizing to either side. heel,
outer margin of foot, balls
normally;
when
The this
this ma\'
of toes
be, foot-prints teach us that onl)' the
and toes themselves, touch the ground
the inner margin meets the ground
section
arrangement.
shews
definitely
we have
by the
the share taken
The Metatarsal Bones
lie
to deal with Fiat-Foot.
different
at different levels;
bones
in
the heads of the
inner three have been divided by the section which passes throughout the length of the 4th
and only through the base
half has been freed
In
the
by
figure
of the 5th Metatarsal
(of
which
its
distal
dissection). is
seen the Bursa on the outer aspect of the Little
opposite the Metatarso-phalangeal Articulation the outer margin of the foot
is
;
this the
Toe
most prominent point on
frequently the seat of a corn produced
by pressure
from the boot. Inflammation readily reaches is
this
Bursa whence
often in communication with the Bursa.
it
spreads to the joint which
Tarsal and Metatarsal Articulations.
Fig. 201.
The preparation
The
to
thoroughly expose the joints has been removed
minimmn
witli
a
chisel.
Tarsal Bones articulate with each other, with the Bones of the
and with the Metatarsal Bones, forming as a rule
some are
Side.
of a frozen foot in extreme plantar flexion; the
is
of tissue necessary
Right
simple (where
verj'
onl)-
two
8 separate joint-cavities of
articular surfaces take part
in
the
Leg
which joint),
others are very complicated (where several joint-spaces combine to form one jointcavit}'
by communication).
articulation into the
In the latter
communicating
disease spreads rapidly
case,
whereas disease of a simple
joints
from one
cavit}'
mav
remain localized.
The 1.
separate joint-cavities are:
Ankle-joint, between the Astragalus, Tibia and Fibula with an
upward
recess between the Tibia and Fibula.
and Os
2.
Posterior Calcaneo-Astragaloid Joint (Fig. 199).
3.
Articulation between the A.stragalus on the one
Calcis on the other
hand
(Fig.
The Head
199).
hand with the Scaphoid
of the Astragalus lies in
a socket formed by the Scaphoid, Calcaneo-Scaphoid Ligament and the Anterior
Part of the 4.
lies
Os
Calcis.
Joint between
Os
Calcis
and Cuboid; the inner
exactly opposite the outer end of the former
cuboid Ligament. The foot can be the Astragalus and It is to
disease,
Os
(3)
easily disarticulated at this
Calcis being left behind.
be noticed that
this joint
extremitj^
consists
one may be affected without the
of
2
of this joint
separated only by the Calcaneo-
S-shaped articulation
(Disarticulation after
Chopart.)
separate joint-cavities so that, in
other.
5.
Small Articulation between the Cuboid and External Cuneiform.
6.
Verj' complex Joint-cavit}'
between Scaphoid and the
3
Cuneiforms,
between the contiguous Cuneiforms, between the Middle and External Cuneiforms
and the bases
of the
2nd and 3rd Metatarsals and between the bases of these
Metatarsals.
between
Metatarsal and the Internal Cuneiform.
7.
Joint
8.
Joint between the Cuboid and the 4th and 5th Metatarsals.
The
joints
ist
between the
5
Metatarsals on the one hand and the 3 Cuneiforms
and the Cuboid on the other form a curved
line
which
proximal projection of the 2nd Metatarsal to the extent of of the Metatarsals after
LiSFRANC can be performed
is
only interrupted by the
^/jths inch.
at this line.
Disarticulation
1st
Dorsal Interosseous
Muscle
1st
Metatarsal Bone
Line of LisffailC'^ Articulation Internal Cuneiform
Bone Cuneiform Bone
Middle Cuneiform Bone
ty of 5th Metatarsal
Bone LisfranC's Articulation Tuberosity of Scaphoid
Chopart's Articulation Line of Chopart's Articulation
Astragalus
Tibia
Fig. 201.
Tarsal and Metatarsal Joints exposed from above on the right side. 7, Nat. Size.
Rebman
Limited, Loudon.
Rebnian Company,
New
York.
posterior Branches of
Lumbar Nerves Anterior Branches of
Lumbar
Nf*rvf^ .
Lateral Branches of
Lumbar Nerves Hio-Hj-piiffastric
Xcrve Posterior Branches of
Lumbar Nerves and first 3
Sacral Ner\-es
Genital Branch of GcnitoCniral Ncr\'e
Remrrent Branches of Small Sciatic Nerve Crural Branch of GenitoCrural Nen*c
External Cutaneous Nerve
External Cutiineous Ner\'.
Small Sciatic Ncr\-c
Middle and Internal Cutaneous Nerves
(
*btnrator
Obturator Nerve
Nerve
-
Long Saphenous Nerve
-
External Popliteal Nerve
I-onn Saphenous Ncrvr
Short Saphenous Nen^e
External Popliteal Nerve
External Calcanean Nerve
Musculo -Cutaneous Nerve Internal Calcanean Nerve
Anterior Tibial Ner\'e
—
Internal Plantar Nerve
External Plantar Nerve
Short Saphenous Nerve
^r-
Fig. 202 and Fig. 203.
r
fee.
Ai'eae of Distiibution of the Cutaneous Nerves of the
lower Exti'emity.
Right
side.
Vs Nat. Size.
Rebman Limited London.
Rebman Company, Neu York.
Areae
and 203.
Figs. 202
of the
of distribution of the
Lower Extremity. Right
Outlines partly after Fau's Atlas.
Areae of Nerves are partly diagrauuitatic.
Colours are chosen in the order of segmentation ill
accord with the colours
Cutaneous Nerves
Side.
those for the
Lumbar Plexus
are
two following figures, for the segments
the
tised, in
:
of the cord.
The Cutaneous Nerves of the Lower Extremity require thorough re-investigation, far more than those of the Upper Limb. The upper quarter of the thigh is supplied by the following Cutaneo-sensory Nerves:— Outer third, Ilio-hypogastric Middle, Crural Branch of Genito-Crural;
(red);
These
Genito-Crural. small
areae, supplied
2
area near the Scrotum
supplied
in
Genital Branch
Middle and Internal Cutaneous; l^ateral
of
by the same nerve, are yellow; only a
The remainder
is
supplied b)^
of the Anterior Surface
outer third, by the External Cutaneous, internal to
its
The two
third.
on separation of the thighs)
(visible
the Perineal Branch of the Small Sciatic. is
Inner
this,
by the
innermost part, by the Obturator Nerve.
at its
Nerves extend on
to the posterior aspect
which
is
chiefly
supplied by the Small Sciatic Nerve.
The
Gracilis
is
not often
perforated
b}'
the Cutaneous Branch
of
the
Obturator; this Nerve usualh' winds round the border of the Adductor Longus
Muscle and thus comes nearly alwaj's
Gracilis.
It lie
near the
Long Saphenous Nerve
composed
of fibres
The Brjmches reaches
nerve
after
piercing the fascia, so that this Nerve
is
from the Internal Cutaneous as well as from the Obturator Nerve.
inner surface of the
Leg
is
entirely supplied
of the Anterior Crural Nerve, namel}', the
down
Border of the
to the surface at the Anterior
anastomoses with the Internal Cutaneous Nerve and comes to
Long Saphenous Nerve which
as far as the inner border of the foot,
and so becomes the longest
other parts of the Foot and
All
in the bod}'.
Great Sciatic Nerve and
its
by the Terminal Sensor}'
Leg
are
supplied
by the
branches.
In the Leg, the Internal and External Popliteal Nerves apportion the skin
between each In
the
other, the
Foot,
the
former taking the middle of the
Dorsum belongs
to
calf,
the latter the outer side.
the External Popliteal,
the Sole to the
Internal Popliteal.
At
the Heel,
mentioned.
The area
the
Internal
and External Calcanean Branches should be
of the Internal Plantar corresponds to the distribution of the
Median, that of the External Plantar to the Ulnar
The supply Hand.
of the
Dorsum
of the
in
the hand.
Foot exhibits no
similarity to that of the
Besides the Superficial Nerves a Deep Branch from the Anterior Tibial
Nerve has
to
and 2nd Toes.
be considered
in its
supply to the contiguous margins of the Big
;
Fig. 204. Innervation of the Skin and Muscles of the Lower Limb according to their Segmental Origin from the Cord Anterior Aspect. :
FAV's Atlas;
Outlines modified after
WiCIIMAMJV
Nen>e-siipplv after
modifications stiggestea
ivitji
Lumbar, Roman
bv
Ziehen.
As
each plexus has only 5 segtnents the fundamental colours of the Spectrum
In
text Arabic figures
the
Yellow, Blue and Green and
and
limb
of the leg
Line luhich,
doivnwajds
obliijuelv
the
Black
are employed.
the so-called A.xial
ru7!7iing
indicate
and
the Internal Malleolus
to
appears at the outer side
the thigh,
in
Segments.
Red, Orange,
boundary betiveen trunk
represent the
lines
iiivisible
the Sacral
encircling
the
latter.
The Segmental Distribution of the Nerves in the Lower Extremity is more comthan in the Upper Limb. Li man the distribtition of both Motor and Sensory
plicated
Nerves has not been properly determined.
This figure
intended to contrast the Cutaneous
is
Suj^ply with the Muscular.
Naturally
Nerves are
the
and
or Extensor Nerves,
intu Dorsal
and External
Apart from these, special
Popliteal.
well as the Flexor Nerves)
(as
will
divided
being the Anterior Crural
and Internal
the Obturator
the latter
the Muscles of the Pelvic Girdle
be
to
the former
Ventral or Flexor Nerv^es,
Popliteal,
branches
be considered
for
in
tlie
In this figure onlv the Extensor Nerves will be described.
next figure.
The
Anterior Crural Nerve corresponds
more
the Radial; this divides into a branch to the Iliacus
to the
Musculo-Cutaneous than to
Fig.
105), the Anterior Di\'ision
(cf.
(mixed) which supplies the Sartorius and Pectineus, and the Posterior Division (also mixed)
which supplies the Quadriceps Extensor Group of Muscles.
These muscles correspond Sartorius 2 (2)
3
and 3
Rectus Femoris
:
the following spinal segments,
to 2,
and 4
3
Vastus Internus
;
and
2
Pectineus 2 and 3 3 (and 4), Crureiis
and 4; Subcrureus 3 and 4; Vastus Externus 3 and 4. The Sensory Portion of the Nerve is formed by the Middle and Internal Cutaneous
(Anterior Divisions) and
Nerve (Posterior
communication to the Obturator Nerve, by the Long Saphenous
its
Of Leg and
Division).
from
these, the former supply the thigh chiefly
and
2
3,
formed from 3 and particularly 4. The External Cutaneous Nerve (a modified lateral branch of the Lumbar Nerves)
the latter supplies the
contains
i,
and 3;
2
is
may be
Posterior Branch
its
contains the Crural Branch
Anterior Branch
which also contain
This
ventral elements).
constant relation between the fibres which
The
remarks
following
External Popliteal Nerve
Muscle
(4)
5.
—
:
4.
The
slip
At the
5.
I
:
and 4
;
On
and
foot
whole of the Dorsum 3
(4)
5.
5.
I.
2,
Head
4.
the
of Biceps 5.
Long Extensor 4.
5. 5.
neither
and
3
internal
(the
constant,
with
Anterior Tibial
I.
not
connection
Short
:
is
receives from
m
from the muscle to the Big Toe
Sensorv part
and backward,
Motor part
nerve
it
made
Short Peroneal Muscle
I.
Extensor of the Big Toe 5. I;
are
a trochanteric branch; occasionally
of the Genito-Crural
twigs
there
is
its
of
any
4.
incompletely
studied
Long Peroneal Toes 4. 5. I. Long (II).
I.
of the
Short Extensor of the Toes
(I). I.
the outer side of the leg from above and in front,
downwards
II.
and Anterior Tibial Nerve)
(iNIusculo-Cutaneous of the
Foot contains:
on the Dorsum proper
4.
5.
I
;
on the inner
on the outer
side,
.side,
I
5.
I
and
II.
The
according to Paterson,
and
II.
External Oblique Miisclo of
Abdomen Rectus Abdominis
Lumbar
i
^TT
Tensor lensor of F Fascia of Thifjh
;^4
Pyraniidalis
Lumbar
Antcriiir Tibial ^Tustlr
Long
Pcrnnciis
Iiitoinal
Head
Long Extensor
of Gastrocnemius
of the Toes
Luinbiir <
Soleus
Long Flexor
\'ertical
^Vfuscle of the
Toes
Portion of Anterior
Annular Ligament
Anterior Annular Ligament
r.v-v-*v. »v-\
Fig. 204.
Dr. IrjJiSv. ftc.
Nerve-Supply of the Skin and Muscles of the Lower Limb theii- Segmental (Spinal) Origin. Anterior Aspect.
according to
Vs Nat. Size.
Rebmaii
T.iinited,
Londou.
Rebm.in Company,
New
Ynik.
L;iti>siiiius
Dorsi
External Oblique Muscle of Abdomen
(Uuteus Medius
Lumbar
I
Sacral TTI, Ventral
Branch Sacral III, Dorsal
Maxinuis
(iluteiis
Branch
Lumbar
IT
S;ural lA'
Sacral
\' -|-
Coccj'geus
Nerve
External Vastus
Adductor M;i{rnu
Gr;i fills
Lumbar
I
Scniitendinnsus
Sacral III
IIe;id
cif
Rirops
Lumbar
III
Seminicnibr;in'
Lumbar IV Kxteriiiii
Ile.id of
Gastrocnemius
Internal
Head
of
launbar
\'
Gastrocnemius
Sacral IT
Soleus
^^- —
JJr.
Trohsc.f"'^-
Nerve-Supply of the Skin and Muscles of the Lower Limb according to theii' Segmental (Spinal) Origin. Posterior Aspect.
Pig. 205.
Vs Nat. Size.
Rebman
Limited, Londou.
Rebman Company, New York.
;
Fig. 205. Innervation of the Skin and Muscles of the Lower Limb according to their Segmental Origin from the Cord: Posterior Aspect.
remarks made in connection
TJie preliniinarY
line
(difficult
to
the continuation
of the A.xial Line
back of the thigh
shewn
is
runs on the posterior aspect of the leg limb the distribution
more
still
is
Group
on
runs
line
anterior
the
boundary
Tlie
tin's fiiriire.
uptvards
On
the
because
asfn-ct,
it
the back of the the
Gluteal Region
muscles of the
on
Inner Malleolus,
after encircling the
and a
dorsal
haiie
to
be
Ventral Group.
and Quadratus Femoris Muscles belong
Gemelli
Group
the Extensor
to
:
This
this figure.
heloiv,
the neii'es of the
Intermis Muscle,
Obturator
to
not been especially indicated but
lias
reach the inner side of the thigh.
to
divided into a Dorsal
the Flexor
Limb
romplicatcd than
and
neroes of the Plexus enter in,
in
204 a[>plv
J^io.
the
and
Crest of the Ilium
the
to
will)
and
between the Trunk
define}
to
belong, in front the Psoas Group, behind the
Gluteal Muscles, Tensor of the Fascia of the Thigh and the P3Tiformis.
The
following
the segmental relation
is
Obturator Intemus 5.
Gemellus Inferior
I.
5.
Tensor I.
2.
of the Fascia
3.
2.
i.
3.
supplied
is
Thigh
of the
Iliacus
(4),
by
4.
5.
I.
4.
2.
b}-
the Quadratus
of
4.
5.
I.
Lumborum
(4).
The Motor part and Foot: Long Head of and Semimembranosus
of the Internal Popliteal supplies the Muscles of the Thigh,
Biceps
4.
I;
5.
4. 5.
I
(or according to Boi.k
for the
deep Flexors
chiefl}'
5.
I,
(II).
I.
5.
Adductor Longus
2
and
Sensory part
Nerve
I
Internal Plantar 5
Nerve are
like
:
and
II I,
Nerve
its
the External
and
I
the motor fibres derived from
is
3.
and
3
(2)
I.
They
are
4.
II,
(and
To
5).
the Internal Plantar
2.
are divided
4.)
chiefly
3
Gracilis
composed of I. II, on the
and
colour (indicative of the
ist
2.
II
3.
and
(and III
2.
3.
— 4.
4). ;
Internal
sole of the foot the
Fibres of the Obturator
4.
of the Sacral
derived
from
Nerves and the Coccygeal II
and III (yellow).
the other colours
Coccygeal Nerve should have been put
as follows:
Adductor Brevis
4.
3.
The Cutaneous
II.
2.
other nerves take part in the supply of this area,
The red
5.
(3)
are generally accepted:
(II)
I
continuation also I and
Over the Sacrum the Dorsal Branches
for the
(2.
Pectineus (exceptionally)
and
5.
Leg
Semitendinosus
II);
II.
the Small Sciatic Nerve
Nerve must be mentioned.
4.
terminal branches contain
and
Adductor Magnus
4.
3.
—
and
I
of the Obturator
fibres
Obturator Externus 3 and
Popliteal
The
the External mostly
The motor
and
I
Adductor Magnus (hamstring portion)
the Superficial Muscles of the Calf and the Popliteus
Red
4.
two go together).
Medius and Minimus
Portion
Iliac
Quadratus
(Ill),
II.
I.
last
belong to the Extensor Group.
4.
3.
II.
I.
5.
5.
two and the
(so that the first
Psoas and Psoas Minor Gluteus Maximus
Gemellus Superior
(Ill),
11.
I.
I.
5.
.4.
As
Green, Blue and
in.
segment of
a
new
plexus) has been omitted
to avoid complexity in the figure.
On
the
superficial to the
outer side
of the
Hip
it
is
necessary
to
remember
the Ilio-hypogastric
Fascia covering the Gluteus Medius Muscle (Schwalbe).
Printed by
Hermann
Pohle, Jena.
Germany.
— 2932.
^
UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles
----c=:r-'
'83
