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LANDMARKS AND SURFACE MARKINGS 
 OF THE HUMAN BODY 
 
 V 
 
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Verj-eoral border 
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 liifrdspindtus--. 
 
 I'/Dorsdl ^ 
 
 ? srerno- 
 
 Hamstrings -^ 
 
 Gastrocnemius 
 
 
 ulnaris ' 
 
 Tennnr Fasciae kmoris 
 Gluteal cleft 
 
 Gluteal Fold 
 
 Popliteal space 
 
 -Ilio -tibial band 
 Biceps Femoris 
 
 External saphenous 
 vein 
 
 -External saphenous vein 
 ,'Fibula 
 
 I'endo Actiilles 
 
LANDMARKS AND 
 
 SURFACE MARKINGS OF 
 
 THE HUMAN BODY 
 
 BY 
 
 L. BATHE R^AWLING 
 
 M.B., B.C. (Cant.), F.R.C.S. (Eng.) 
 
 Surgeon with charge of Out-Patients, Demonstrator of Practical and Operativh 
 
 Sui;GERy, late Senior Demonstrator of Anatomy at St. Bartiiolomew's 
 
 Hospital ; late Assistant-Slrgeon to the German' Hospital, Dai.ston ; late 
 
 Hunterian Professor. Royai, College of Surgeons, England, etc. 
 
 WITH THIRTY-ONE ILLUSTRATIONS 
 
 FIFTH EDITION 
 
 PAUL B. HOEBER 
 
 69, EAST 59TH STREET 
 
 NEW YORK 
 
o. -. 
 
 ^•^ce; ^ 
 
 Printed in England, 1912 
 
PREFACE 
 TO THE FIFTH EDITION 
 
 From the fact that the fourth edition was disposed of 
 within one year, it would appear to me obvious that but 
 little alteration or addition is necessitated for this edition ; 
 the text has been adhered to, but the illustrations have 
 been improved. 
 
 L. BATHE RAWLING. 
 
 1 6, Montagu Street, 
 PoRTMAN Square, W. 
 1912 
 
CONTENTS 
 
 CHAPTER I 
 
 PAGE 
 
 THE HEAD AND NECK - - • - - - 1 
 
 CHAPTER II 
 THE UPPER EXTREMITY - - - • - - 19 
 
 CHAPTER III 
 
 THE THORAX - - - - - - * 34 
 
 CHAPTER IV 
 THE ABDOMEN - - - - - - "49 
 
 CHAPTER V 
 
 THE LOWER EXTREMITY - - • - - - 70 
 
 APPENDIX 
 
 THE LENGTH OF VARIOUS PASSAGES, TUBES, ETC. - - 86 
 
 THE WEIGHT OF SOME ORGANS - - - - - 88 
 
 THE OSSIFICATION AND EPIPHYSES OF THE BONES OF THE 
 
 UPPER AND LOWER EXTREMITIES - - • - 89 
 
 INDEX - • - - - - - - 92 
 
ILLUSTRATIONS 
 
 I and 2. Cranio-cerebral Topography 
 3 and 4. The Side of the Neck 
 
 5. The Front of the Neck 
 
 6. The Front of the Arm and Forearm 
 
 7. The Elbow and Back Region 
 
 8. The Elbow Region .... 
 
 9. The Veins of the Arm and Forearm 
 10 and II. The Palm of the Hand 
 
 12. The Back of the Wrist 
 
 13. The Back of the Arm and Forearm 
 
 14. The Shoulder and Arm 
 
 15. The Heart, Great Vessels, Kidney, and Ureter 
 16 and 17. The Pleural Sacs, Lungs, etc. 
 
 18. The Abdominal and Thoracic Planes 
 
 19. The Alimentary Canal ... 
 
 20. The Liver, Anterior Abdominal Wall, etc. 
 21 to 24. The Thigh and Leg 
 
 25 and 29. The Region of the Ankle and Foot 
 
 To face p. 
 
 4 
 
 I4» 15 
 
 18 
 
 20 
 
 23 
 24 
 24 
 26 
 28 
 30 
 31 
 36 
 41,42 
 
 50 
 56 
 62 
 
 70,74 
 77-80 
 
 viii 
 
LANDMARKS AND SURFACE 
 MARKINGS OF THE HUMAN BODY 
 
 CHAPTER I 
 THE HEAD AND NECK 
 
 Cranio-cerebral Topography 
 
 Only those surface markings will be given which are of 
 practical value, and, as far as possible, each landmark will 
 be rendered independent of any other, as by such means 
 any given structure can be rapidly depicted on the surface, 
 the important question of time and of space rendering the 
 more complicated systems, in which it is necessary to map 
 out a network of intersecting lines in order to fix the 
 position of any single structure, of little surgical value. 
 It is necessary, however, to recognize first certain impor- 
 tant bony points, etc. 
 
 The nasion, situated at the base of the nose at the 
 Fig. i., 1. central point of the naso-frontal suture. 
 
 The inion, or external occipital protuberance, 
 Fig. i., 2. a projection, variable in size, which can be 
 readily felt on the occipital bone, immediately 
 above the nuchal furrow. 
 
 A line uniting these two points over the vertex of the 
 skull corresponds in direction to the mesial longitudinal 
 fissure of the brain, to the upper attached margin of the 
 
 I 
 
2 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 falx cerebri, and to the stiperior longitudinal venous sinus. 
 
 This sinus originates in the region of the foramen caecum, 
 
 just anterior to the crista galli, and broadens out 
 
 rapidly as it passes backwards towards the internal 
 
 occipital protuberance, which lies at the same level as 
 
 the previously mentioned external protuberance. It then 
 
 turns sharply to the right, forming the right lateral sinus^ 
 
 The left lateral sinus derives its blood mainly from the 
 
 straight sinus, which receives, at the anterior margin of the 
 
 tentorium cerebelli, the great vein of Galen, the main 
 
 efferent trunk of the deep nuclear cerebral veins. The 
 
 line drawn as above from the nasion to the inion also 
 
 corresponds in direction to the occasionally persistent 
 
 metopic suture between the two halves of the frontal bone, 
 
 and to the sagittal suture between the two parietal bones. 
 
 The frontal bone is separated off from the two parietal 
 
 bones by the coronal suture, and the point of junction of 
 
 the coronal and sagittal sutures is known as the bregma, 
 
 the site of the foetal anterior fontanelle, an opening which 
 
 is normally closed by the end of the second year. Between 
 
 the parietal and occipital bones the lambdoid suture lies ; 
 
 and at the junction of the sagittal and lambdoid sutures 
 
 the posterior fontanelle is situated, closed at or soon after 
 
 birth. The point of junction of the last two 
 Fig. i., 13. . ^ •* 
 
 sutures is known as the lambda. This point 
 
 lies about 2| inches above the inion or external occipital 
 
 protuberance. About i inch from its posterior superior 
 
 angle, and close to the sagittal suture, the parietal bone 
 
 is perforated by a small foramen, and a line uniting the 
 
 two foramina crosses the sagittal suture at a point known 
 
 as the obelion. The parietal bone is outwardly bulged at 
 
 a point rather above its centre, forming: the 
 Fig. i., 11. , . '^ 
 
 parietal eminence, especially marked in the foetal 
 
THE HEAD AND NECK 3 
 
 skull, and indicating the point at which the single ossific 
 
 nucleus makes its appearance. 
 
 Turning now one's attention to the lateral aspect of the 
 
 skull, the inferior temporal crest should be ex- 
 Fig, i., 6. . . ^ 
 
 amined. This crest crosses the parietal bone 
 
 rather below the junction of the middle and lower thirds, 
 cutting off the vault proper above from the temporal fossa 
 below\ The ridge is often so feebly developed in this 
 region that it may be necessary to verify its position by 
 tracing it backwards from the region of the external 
 angular frontal process, at which level the crest is always 
 well marked. The temporal muscle arises from the inferior 
 temporal crest and from the temporal fossa below, whilst 
 the overlying fascia, the temporal fascia, gains 
 attachment to the superior temporal crest — a 
 feebly developed ridge which runs above and parallel to 
 the inferior crest. To avoid confusion, it is perhaps 
 necessary to add that the inferior temporal crest is quite 
 distinct from the infratemporal crest, which forms the 
 lower margin of the temporal fossa, and separates off that 
 fossa from the zygomatic fossa. 
 
 The external angular frontal process articulates with 
 
 the frontal process of the malar bone, and 
 
 the articulation between the two processes is 
 
 easily felt at the upper and outer border of the orbital 
 
 cavity. 
 
 The malar tubercle, a small prominence to be felt 
 
 alone: the posterior border of the frontal pro- 
 Fig i 12. 
 
 ' * cess of the malar bone, a short distance below 
 
 the fronto-malar suture. 
 
 The zygomatic process of the temporal bone should be 
 
 traced backwards towards the ear, and an examination of 
 
 the skull will show that this process divides in front of the 
 
 I — 2 
 
4 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 ear into three roots, the anterior merging into the eminentia 
 articularis, the middle helping in the formation of the 
 post-glenoid process, whilst the posterior or upper root 
 Fig. ii., 13,14 sweeps backwards above the external auditory 
 Fig. I., 17. meatus to become continuous with the supra- 
 meatal and supramastoid crests, and to blend with 
 the posterior curved end of the temporal crest. The 
 suprameatal crest is of special surgical importance, as it 
 forms the upper boundary of Macewen's suprameatal 
 triangle, and also indicates fairly accurately the lower 
 level of the cerebrum in this situation. 
 
 The lateral sinus describes a gentle curve from the 
 Fig. i., 16. external occipital protuberance to the upper 
 Fig. ii., 9. ^^^ posterior part of the base of the mastoid 
 process, finally curving downwards towards, though not 
 reaching to, the apex of that process. The degree of 
 upward curve is subject to a good deal of variation, 
 and the sinus frequently presents a lesser upward con- 
 vexity than was the case in the specimen from which 
 the illustration was taken. 
 
 The lower limit of the cerebrum can, with sufficient 
 Fig. i., 17, accuracy, be mapped out in the following 
 
 '•7, 17. manner: A point is taken in the median 
 antero-posterior line about | inch above the nasion, and 
 from this point a line is drawn outwards which lies about 
 I inch above, and follows the curve of the upper border 
 of the orbit. This line is carried backwards as far as 
 the level of the external angular frontal process, then curv- 
 ing upwards and backwards towards the Sylvian point (see 
 next page). The temporo-sphenoidal lobe sweeps now 
 downwards and forwards towards the posterior border of 
 the malar bone, and then lies practically on a level with 
 the upper border of the zygoma. At and behind the ear 
 
FIG. I. 
 
 1. The nasion. 
 
 2. The inion. 
 
 3. The mid-point between nasion and inion. 
 
 4. The Rolandic fissure. 
 
 5. The superior temporal crest. 
 
 6. The inferior temporal crest. 
 
 7. The Sylvian point. 
 
 8. The anterior horizontal limb of the Sylvian fissure. 
 
 9. The vertical limb of the Sylvian fissure. 
 
 10. The posterior horizontal limb of the Sylvian fissure. 
 
 11. The parietal prominence. 
 
 12. The malar tubercle. 
 
 13. The lambda. 
 
 14. The first temporo-sphenoidal sulcus, 
 
 15. The external parieto-occipital sulcus. 
 
 16. The lateral sinus. 
 
 17. 17, 17. The level of the base of the cerebrum. 
 
 18. The external auditory meatus. 
 
 19. 19. Reid's base line. 
 
CRANIO-CEREBRAL TOPOGRAPHY 
 
 I'IG. I. 
 
 To face p. 4. 
 
FIG. II. 
 
 /, I. Reid's base line. 
 
 2. 2. A line parallel to the above at the level of the supra- 
 
 orbital margin. 
 
 3. The middle meningeal artery. 
 
 4. The anterior branch. 
 
 5. 5, 5. The three sites for trephination. 
 
 6. The posterior branch. 
 
 7. The site for trephination. 
 
 8. The point for trephining to reach the descending horn 
 
 of the lateral ventricle. 
 
 9. The lateral sinus. 
 
 10. The inion. 
 
 11. The mastoid process. 
 
 12. Macewen's suprameatal triangle. 
 12a. The mastoid antrum. 
 
 12b. The facial nerve. 
 
 13. The suprameatal and supramastoid crests. 
 
 14. 14. The temporal crest. 
 
 15. The temporal fossa. 
 
 16. The external angular frontal process. 
 
 17. The tendo-oculi attachment, 
 
 18. The lachrymal groove. 
 
CRANIO-CEREBRAL TOPOGRAPHY 
 
 FIG. TI. 
 
 To follow Fit;. /. 
 
THE HEAD AND NECK 5 
 
 the cerebrum lies flush with the suprameatal and supra- 
 mastoid crests, and subsequently follows the curve of the 
 lateral sinus from the base of the mastoid process to the 
 external occipital protuberance. 
 
 The lateral sinus is, to a large extent, walled in by the 
 tentorium cerebelli, a membrane separating the cerebrum 
 and cerebellum one from the other. The sinus curve, 
 therefore, corresponds not only to the position of the lateral 
 sinus, but also represents the outer attachment of the 
 tentorium cerebelli, and the interval between the cerebrum 
 above and the cerebellum below. 
 
 Reid's base line is drawn backwards from the lower 
 r:\rr ; 1Q border of the orbit to the middle of the external 
 
 r ig. I., !», 
 
 IS- auditory meatus, and, when further produced, 
 
 '^" "■' ' ■ the line will be found to fall just below the 
 level of the inion, and to lie almost entirely below the 
 level of the lateral sinus. This line is utilized by some 
 surgeons in trephining the skull, distances being measured 
 along this line and points taken above or below, according 
 to the seat of the lesion. 
 
 The Sylvian point represents the site of divergence of 
 the three limbs of the Sylvian fissure. It lies 
 i:^ inches behind the external angular frontal 
 process, and i^ inches above the upper border of the 
 zygoma. The main posterior horizontal limb of the 
 Fig. i., 10, Sylvian fissure passes backwards and upwards 
 ^^- from the Sylvian point to a second point 
 
 situated f inch below the most prominent part of the 
 parietal bone. 
 
 The vertical limb is directed upwards for about f inch, 
 whilst the anterior horizontal limb passes for- 
 wards for about the same distance. 
 The Sylvian point corresponds also to the anterior pole 
 
 Fig. i, 7. 
 
6 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 of the island of Reil and to the middle cerebral artery, as 
 that vessel lies deeply embedded in the anterior part of 
 the Sylvian fissure. 
 
 To mark out the external parieto-occipital fissure and the 
 Fig. i. 12- first temporo-sphenoidal or parallel sulcus, it is 
 ^^- necessary to find two bony points — the malar 
 
 tubercle and the lambda. A line uniting these two 
 points corresponds in its posterior part to the external 
 parieto-occipital sulcus, and in its middle third to the 
 first temporo-sphenoidal sulcus. 
 
 The Rolandic fissure. — Take a point \ inch behind the 
 
 centre of a line drawn across the vertex of the 
 Fig. i., 4. 
 
 skull from the nasion to the inion, and from 
 this point draw a line downwards and forwards for 3I 
 to 4 inches, at an angle of 67^° (three-quarters of a right- 
 angle) to the median antero-posterior line. In front of 
 this sulcus is the precentral or ascending frontal con- 
 volution, an area better known as the Rolandic or motor 
 area. The main centres here situated correspond, from 
 above downwards, to the movements of the lower extremity, 
 upper extremity and face of the opposite side of the body. 
 The superior temporal crest cuts across the Rolandic line 
 
 . . at the junction of its lower and middle thirds, 
 
 i-ig. I., 5. 
 
 It may be regarded as the line of demarcation 
 
 between the upper extremity area above and the face area 
 
 below. 
 
 On the left side of the head, that part of the brain which 
 
 is included in the obtuse angle between the anterior and 
 
 ^. . posterior horizontal limbs of the Sylvian fissure is 
 
 Fig. I. "" -^ 
 
 known as Broca's area (the motor speech centre). 
 
 The middle meningeal artery, a branch of the internal 
 
 maxillary, enters the skull through the foramen spinosum, 
 
 and divides, after a short and variable course across the 
 
THE HEAD AND NECK 7 
 
 middle fossa of the skull, into two main trunks. The seat 
 
 of bifurcation usually corresponds to a point 
 Fig. ii., 3. 
 
 just above the centre of the zygoma. 
 
 The anterior branch is not only the larger of the two, 
 
 .. , but it is also more liable to injury, since it is 
 Fig. II., 4. •' •" 
 
 protected in the temporal region by a com- 
 paratively thin osseous barrier. 
 
 Fig. ii., 5, The danger zone in the course of this branch 
 ' may be mapped out by taking three points : 
 
 (i) I inch behind the external angular frontal process, 
 and I inch above the zygoma. 
 
 (2) ij inches behind the external angular frontal process, 
 and i^ inches above the zygoma. 
 
 (3) 2 inches behind the external angular frontal process, 
 and 2 inches above the zygoma. 
 
 A line uniting these three points indicates, therefore, 
 that part of the anterior division of the middle meningeal 
 artery which is most liable to injury. 
 
 The anterior division of the vessel will be exposed by 
 trephining over any of these three points, but it is generally 
 preferable to choose the highest point, as by such means 
 the posterior border of the great wing of the sphenoid is 
 avoided ;* and, as an additional reason, it should be 
 added that, in the position of points i and 2, the artery 
 frequently runs in an osseous canal. After trephining over 
 the upper point, the bone can be chipped away in a down- 
 ward and forward direction, if such an exposure of the 
 artery is deemed necessary. 
 
 The posterior branch of the artery passes almost 
 Fig. ii., 6. 
 
 horizontally backwards, parallel to the zygoma 
 and to the supramastoid crest, and it can be exposed 
 
 ♦ N.B. — This point will be better understood by reference to the 
 base of the skull. 
 
8 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 by trephining over a point where a vertical Hne drawn 
 
 upwards from the posterior border of the 
 Fig. ii., 7. . 
 
 mastoid process cuts another Hne drawn back- 
 wards from the supra-orbital margin parallel to Reid's 
 base line. 
 
 The lateral ventricles. — The descending cornu of the 
 
 lateral ventricle may be tapped by trephining 
 
 I5 inches above Reid's base line and ij inches 
 behind the external auditory meatus. The trocar should 
 be directed towards the summit of the opposite ear, the 
 ventricle being reached within 2 inches from the surface 
 (Keen). 
 
 The basic fosses. — "There is no external sign to indicate 
 the situation of the fossae of the skull. In general, how- 
 ever, it may be said that the anterior fossa extends as far 
 back as the anterior end of the zygoma ; that the middle 
 fossa lies between this and the mastoid process, and 
 the posterior includes all the base behind the process" 
 (Eisendrath). 
 
 The mastoid antrum may be exposed by trephining 
 Fig. ii. 12a. ^^ Macewen's suprameatal triangle, a space which 
 '^' "•' 'is bounded above by the backward continua- 
 tion of the upper root of the zygoma (the supramastoid 
 crest), behind by a vertical line drawn upwards from 
 the posterior border of the external auditory meatus, 
 and below and in front by the suprameatal spine, a 
 prominent bony process which assists in the formation of 
 the posterior superior quadrant of the external auditory 
 meatus. In this triangle there is usually a well-marked 
 depression, the suprameatal fossa. The supramastoid 
 crest not only indicates the uppermost possible limit of 
 the mastoid antrum, but, as has already been stated, 
 it corresponds also to the level of the base of brain in 
 
THE HEAD AND NECK g 
 
 this situation. The crest, therefore, represents the level 
 
 of the tegmen antri, and, in mastoid explora- 
 
 ■' ■ tions, the scene of operation must be confined to 
 
 an area below this crest. In the adult the antrum usually 
 
 lies at a depth of | to f inch from the surface. 
 
 The lateral sinus lies posterior and nearer to the surface, 
 Fig. ii., 9. whilst the facial nerve pursues its course in front 
 ig. II., 12b. ^^^ Qj^ ^ deeper plane. 
 
 The parotid gland occupies the space which is bounded 
 
 above by the zygomatic arch, behind by the 
 Fig. iii., 5. . , , , 
 
 auricle and the mastoid process, and below by 
 
 a line drawn from the angle of the jaw to the apex of the 
 mastoid process. In front, the gland extends a variable 
 distance over the anterior surface of the masseter muscle. 
 This muscle passes downwards and backwards from the 
 lower border of the zygomatic arch to be attached to the 
 outer surface of the descending ramus and angle of the 
 lower jaw. When the teeth are clenched, the anterior 
 border of the muscle is easily defined, a well-marked line 
 of demarcation being so formed between the masseter 
 muscle behind and the buccinator in front. 
 
 Stejisen's duct, the duct of the parotid gland, corresponds 
 to the middle third of a line drawn from the 
 lower border of the tragus of the ear to a point 
 situated half-way between the ala of the nose and the 
 red line of the upper lip. At the anterior border of the 
 masseter muscle the duct dips inwards, through the 
 buccinator muscle, to open on the buccal mucous mem- 
 brane, opposite the second molar tooth of the upper jaw. 
 The transverse facial artery, a branch of the superficial 
 temporal, runs inwards parallel to and imme- 
 diately below the zygoma, lying above the level 
 of Stensen's duct. 
 
10 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 The facial nerve, after emerging from the stylo-mastoid 
 
 foramen, curls round the condyle of the jaw, 
 
 ' ' and traverses the substance of the parotid 
 
 gland, in which part of its course it divides into numerous 
 
 branches. The general transparotid course of the nerve 
 
 and the direction of its buccal branch may be indicated 
 
 by a line drawn forwards parallel to and below Stenson's 
 
 duct from the lobule of the ear. 
 
 The inferior dental nerve may be exposed by trephining 
 
 over the ascending ramus of the lower jaw, 
 
 '' ' midway between the anterior and posterior 
 
 borders, and on a level with the last molar tooth. In 
 
 this manner, the nerve, accompanied by the corresponding 
 
 artery, is exposed as it enters the inferior dental canal. 
 
 The tonsil corresponds in position to a point situated 
 
 just above and in front of the angle of the 
 Fig. iv.,3. . 
 
 lower jaw. 
 
 The borders of the hony orbit. — The following bones assist 
 in the formation of the orbital margin : 
 Above, the frontal bone. 
 
 Externally, the external angular frontal process and the 
 malar bone. 
 
 Below, the malar bone and the superior maxilla. 
 Internally, the nasal process of the superior maxilla 
 and the internal angular frontal process. 
 
 The tendo oculi and nasal duct. — By alternate forcible 
 closure and opening of the lids, the internal 
 '^" "" ' tarsal ligament, or tendo oculi, can be felt 
 passing to its insertion into the nasal process of the 
 superior maxilla. Immediately below the tendon, at the 
 junction of the inner and lower walls of the 
 orbital cavity, is the depression for the lachry- 
 mal sac, which sac narrows below into the nasal duct. 
 
THE HEAD AND NECK II 
 
 The duct passes downwards, backwards and slightly out- 
 wards, to open into the anterior part of the inferior meatus 
 of the nose under cover of the inferior turbinated bone. 
 The duct is about ^- inch long. 
 
 The supra- orbital, infra-orbital, and mental foramina. — 
 Figs, iii., At the junction of the inner and middle thirds 
 ^■' ■ of the supra-orbital margin, the supra-orbital 
 notch or foramen may be felt, and a line drawn down- 
 w^ards from this foramen through the interval between the 
 two lower bicuspid teeth will pass through both infra- 
 orbital and mental foramina. The former foramen lies 
 ^ to I inch below the orbital margin, whilst the latter (in 
 the adult) lies midway between the alveolar and inferior 
 borders of the lower jaw. 
 
 The frontal sinuses are very variable in extent. They 
 occupy the space between the inner and outer tables of 
 the frontal bone, above the base of the nose and above 
 the inner half of the supra-orbital margin. The sinus 
 communicates with the nasal cavity by means of a narrow 
 channel, the infundibulum, which opens into the middle 
 meatus of the nose under cover of the middle turbinated 
 bone, on a level with the inner margin of the palpebral 
 fissure. 
 
 The antrum of Highmore usually occupies the greater 
 part of the interior of the superior maxilla, and opens into 
 the hiatus semilunaris, a depression which lies under cover 
 of the middle turbinated bone. The opening is, however, 
 situated at so high a level that pus only escapes into the 
 nose when the antrum is practically full. Two teeth are, 
 on the other hand, closely related to the antrum — namely, 
 the second bicuspid and the first molar — the sinus 
 usually extending downwards in the interval between 
 the two labial and single palatal fangs of the latter 
 
: middle meatus. 
 
 12 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 tooth. The removal of either of these teeth, followed 
 up by any necessary upward boring, will efficiently drain 
 the sinus. 
 
 The sinus may also be drained by everting the upper 
 lip and puncturing the outer wall through the canine 
 fossa, a depression lying above the canine tooth. 
 
 The sphenoidal sinus occupies the greater part of the 
 body of the sphenoid, and opens into the spheno-ethmoidal 
 recess, a space lying above and behind the superior 
 turbinated bone. 
 
 The sinuses of the nose and their efferent channels : 
 
 The sphenoidal sinus = spheno-ethmoidal recess. 
 
 The posterior ethmoidal cells = superior meatus. 
 
 The anterior ethmoidal cells 
 
 The middle ethmoidal cells 
 
 The frontal sinus 
 
 The antrum of Highmore 
 
 The nasal duct = inferior meatus. 
 
 The Triangles of the Neck. 
 
 The lateral aspect of the neck is divided by the sterno- 
 
 mastoid muscle into two triangles — anterior and posterior. 
 
 The anterior triangle is bounded in front by the middle 
 
 line of the neck, behind by the anterior border 
 
 of the sterno-mastoid muscle, and above by the 
 
 lower border of the ramus of the jaw. 
 
 The space so marked out is divided into three smaller 
 triangles by the digastric muscle and by the anterior belly 
 of the omo-hyoid : 
 
 (i) The submaxillary triangle, above the digas- 
 Fic iv. 17» 
 
 trie muscle, containing the submaxillary gland. 
 
 (2) The muscular triangle, anterior to the 
 Fig. iv., 19. 
 
 omo-hyoid muscle. 
 
THE HEAD AND NECK I3 
 
 (3) The carotid triangle, bounded above by the posterior 
 belly of the digastric, behind by the anterior 
 '' ' border of the sterno-mastoid muscle, and in 
 front by the anterior belly of the omo-hyoid. In this tri- 
 angle the common carotid bifurcates, and the external 
 carotid gives off most of its branches. 
 
 The posterior triangle is bounded in front by the 
 posterior border of the sterno-mastoid, behind by the 
 Fig. iv., 15, anterior border of the trapezius, and below by 
 ^^ the middle third or fourth of the clavicle. The 
 
 triangle is subdivided by the posterior belly of the omo- 
 hyoid, which cuts off the small subclavian triangle below 
 from the more extensive occipital triangle above. 
 
 The Vessels and Nerves. 
 
 The carotid arteries correspond in direction to a line 
 
 from the sterno-clavicular joint to the hollow 
 
 "S- '"•. • between the angle of the jaw and the mastoid 
 
 process. The common carotid usually bifurcates at the 
 
 level of the upper border of the thyroid cartilage (fourth 
 
 p;«r ::: in cervical vertebra), the external carotid subse- 
 r ig. III. I i\j, 
 
 '^- quently lying superficial to and slightly to the 
 
 inner side of the internal carotid. The omo-hyoid muscle 
 (upper belly) crosses the common carotid at the level of 
 the cricoid cartilage, and in this situation the artery may 
 be compressed against the prominent anterior tubercle 
 of the transverse process of the sixth cervical vertebra 
 (Chassaignac's tubercle). 
 
 The superior thyroid artery arises from the external 
 
 carotid in the carotid triangle, immediately above the 
 
 level of the upper border of the thyroid carti- 
 
 F'g- '"•. 12. j^g^^ ^^j^ turning downwards under cover of 
 
 the anterior belly of the omo-hyoid muscle, is directed 
 
 2 
 
14 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 towards the apex of the lateral lobe of the thyroid 
 gland. 
 
 The lingual artery arises midway between the level of 
 the upper border of the thyroid cartilage and the great 
 Fig. iii., 13. cornu of the hyoid bone, and enters the sub- 
 Fig, v., 7. maxillary triangle by passing deep to the 
 posterior belly of the digastric muscle. The artery so 
 gains the upper border of the hyoid bone, and runs in- 
 wards for a short distance parallel to that bone under 
 cover of the hyo-glossus muscle. 
 
 The facial artery arises opposite the great cornu of the 
 
 hyoid bone, and also enters the submaxillary triangle by 
 
 passing deep to the posterior belly of the digas- 
 Fig. iii 14 
 
 ■' " trie. In this triangle the artery lies deeply 
 
 embedded in the substance of the submaxillary salivary 
 gland, and then enters on its facial course by curling round 
 the inferior border of the lower jaw immediately anterior 
 to the masseter muscle, about i| inches in front of the 
 angle of the jaw. The vessel then passes upwards towards 
 the inner canthus of the eye, there terminating as the 
 " angular artery." 
 
 The occipital artery arises from the outer side of the 
 external carotid artery in the upper part of the carotid 
 triangle, and passes upwards and backwards, 
 under cover of the posterior belly of the digas- 
 tric muscle, towards the interval between the mastoid 
 process and the transverse process of the atlas. At the 
 apex of the posterior triangle the artery is joined by the 
 great occipital nerve (posterior primary division of the 
 second cervical nerve), the two structures then passing 
 upwards on to the vault of the skull. 
 
 The posterior auricular irtery arises from the external 
 carotid, immediately above the posterior belly of the 
 
THE SIDE OF THE FACE AND NECK 
 
 FIG. III. 
 
 1. The supra-orbital foramen. 13. The 
 
 2. The infra-orbital foramen. 14. The 
 
 3. The mental foramen. 15. The 
 
 4. The zygoma. 16. The 
 
 5. The parotid gland. 17. The 
 
 6. The transverse facial artery. pi 
 
 7. Stensen's duct. iS. The 
 
 8. The facial nerve. 19. The 
 
 9. The common carotid artery. 20. The 
 
 10. The external carotid artery. 21. The 
 
 11. The internal carotid arter}'. 22. The 
 
 12. The superior thyroid artery. 23. The 
 
 lingual artery. 
 
 facial artery. 
 
 interna] jugular vein. 
 
 external jugular vein. 
 
 upper limit of the brachial 
 
 exus. 
 
 subclavian artery. 
 
 clavicle. 
 
 manubrium sterni. 
 
 gladiolus sterni. 
 
 angle of Ludwig. 
 
 first costal cartilage. 
 
 To face Fi^. IV.,pfi. 14, 15. 
 
THE SIDE OF THE FACE AND NECK 
 
 F^IG. 
 
 1. The inferior maxilla. 
 
 2. The inferior rlental nerve. 
 
 3. The tonsil. 
 
 4. The transverse process of the 
 
 atlas. 
 
 5. 5. The spinal accessory nerve. 
 
 6. The sterno-mastoifl muscle. 
 
 7. The upper limit of the brachial 
 
 plexus. 
 H. The third part of the sulj- 
 
 clavian artery. 
 9. Tlie clavicle. 
 
 IV. 
 10. 
 
 The clavicular head of the 
 sterno-mastoid muscle. 
 
 The sternal head of the sterno- 
 mastoid muscle. 
 
 The digastric muscle. 
 
 The omohyoid muscle. 
 
 The trapezius muscle. 
 
 The posterior trianjj^le. 
 
 The carotid trian,i(le. 
 
 The submaxillary triangle. 
 
 Tlie subclavian triangle. 
 
 The muscular triangle. 
 
 To face lut;. ///.,//. 14, 15. 
 
THE HEAD AND NECK I5 
 
 digastric muscle, and passes backwards parallel to the 
 upper border of that muscle, through the lower 
 '^" '^' part of the parotid gland, to the depression 
 between the cartilage of the concha of the ear and the 
 mastoid process. Here the artery is joined by the posterior 
 auricular nerve — a branch of the facial. 
 
 The superficial temporal artery arises in the substance of 
 the parotid gland as one of the two terminal branches of 
 the external carotid. It crosses the base of the zygomatic 
 process of the temporal bone, immediately in front of the 
 tragus of the ear, and is accompanied by the auriculo- 
 temporal nerve, a sensory branch of the third division of 
 the fifth cranial nerve. 
 
 The subclavian artery (cervical course) is represented by 
 Fig. iii. 18. ^ curved line from the sterno-clavicular joint 
 Fig. IV., 8. ^y ^]^g mid-point of the corresponding clavicle, 
 the convexity of the line extending upwards into the 
 supraclavicular fossa about f to i inch above the clavicle. 
 In marking out this vessel, the shoulders should be well 
 depressed. 
 
 The artery passes behind the scalenus anticus muscle, 
 the second part of the artery being covered by that muscle. 
 The outer border of the scalene muscle usually corresponds 
 to the outer border of the sterno-mastoid muscle, and 
 consequently the third part of the subclavian artery is 
 represented by that part of the curve which 
 ig. IV., . j.^^ between the outer border of the sterno- 
 mastoid muscle and the mid-point of the clavicle. 
 
 The subclavian artery ends anatomically at the outer 
 border of the first rib. 
 
 The external jugular vein is formed just behind the angle 
 of the jaw by the junction of the posterior division of the 
 temporo-maxillary trunk with the posterior auricular vein. 
 
 2 — 2 
 
l6 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 The vessel so formed passes downwards and backwards, 
 superficial to the sterno-mastoid muscle, to- 
 wards the middle of the clavicle, above which 
 bone the vein pierces the deep fascia to join the subclavian 
 vein. 
 
 The internal jugular vein runs parallel and external to 
 the internal and common carotid arteries, and 
 ' ' therefore presents a similar surface marking to 
 that already given for those arteries. 
 
 The vagus nerve passes downwards in the carotid sheath, 
 behind and between the carotid arteries and the internal 
 jugular vein. 
 
 The cervical sympathetic trunk also lies in the line of the 
 carotid arteries, being placed behind the carotid sheath. 
 The superior cervical ganglion is situated in front of the 
 transverse processes of the second and third cervical 
 vertebrae ; the middle ganglion overlies the corresponding 
 process of the sixth vertebra ; whilst the inferior ganglion, 
 which is frequently fused with the first thoracic, lies 
 behind the first part of the subclavian artery, between 
 the transverse process of the seventh cervical vertebra 
 and the neck of the first rib. 
 
 The phrenic nerve is formed below the level of the hyoid 
 Fig. iv. (un- bone by branches from the anterior primary 
 between divisions of the third, fourth and fifth cervical 
 nerves, and passes downwards and slightly 
 inwards towards the sternal end of the clavicle. At the 
 level of the cricoid cartilage the nerve lies midway between 
 the anterior and posterior borders of the sterno-mastoid 
 muscle. 
 
 The spinal accessory nerve crosses the transverse process 
 of the atlas, a bony prominence to be felt immediately 
 below and in front of the apex of the mastoid process. 
 
THE HEAD AND NECK I7 
 
 The nerve enters the substance of the sterno-mastoid 
 Fig. iv., 4, ^^ ^^^ junction of the upper and second quar- 
 
 5. 5. ters along the anterior border of the muscle, 
 emerging from the posterior border of the muscle at 
 the junction of the upper and middle thirds. The point 
 of emergence is, however, subject to some variation, and 
 the nerve may enter the posterior triangle of the neck at 
 a somewhat lower level, pursuing subsequently a down- 
 ward and backward course towards the anterior border 
 of the trapezius muscle, beneath which muscle it sinks.* 
 
 The superficial cervical plexus. — Take a point midway 
 along the posterior border of the sterno-mastoid muscle, 
 and from this point draw three lines : 
 
 1. Upwards towards the lobe of the ear = the great 
 auricular nerve (2 and 3 C). 
 
 2. Upwards along the posterior border of the sterno- 
 mastoid muscle = small occipital nerve (2 C). 
 
 3. Forwards towards the middle line of the neck = the 
 transverse cervical nerve (2 and 3 C.)- 
 
 By producing these three lines in a downward direc- 
 tion, the descending branches of the plexus are roughly 
 indicated. 
 
 Thus the great auricular produced = the supraclavicular 
 nerve; the small occipital produced = the suprasternal 
 nerve ; the transverse cervical produced = the supra- 
 acromial nerve. The three descending trunks are derived 
 from the third and fourth cervical nerves, and all the 
 branches of this plexus arise from the anterior primary 
 divisions of their respective nerves. 
 
 * Another surface-marking for the spinal accessory nerve. — Draw ;i 
 line from a point midway between the tip of the mastoid process and 
 the angle of the jaw to the middle of the posterior border of the 
 sterno-mastoid muscle, and thence across the posterior triangle to the 
 anterior border of trepezius. 
 
l8 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 The brachial plexus. — The upper limit of the nerve- 
 Fig, iii., 17. trunks which form this plexus is represented 
 '^' '^■' ■ by a line drawn from the mid-point between 
 the anterior and posterior borders of the sterno-mastoid 
 muscle at the level of the cricoid cartilage to a second 
 point situated just external to the mid-point of the clavicle. 
 The lowest cord lies behind the third part of the sub- 
 clavian artery. 
 
 The rinia glottidis, which in its front part is laterally 
 
 bounded by the true vocal cords, lies opposite 
 
 Fiff V 10 . . 
 
 the mid-point along the anterior border of the 
 
 thyroid cartilage. 
 
 The epiglottis, though fixed below to the thyroid angle 
 immediately above the point of attachment of 
 " the true vocal cords, extends upwards to above 
 the level of the body of the hyoid bone, 
 
 A suicidal cut-throat frequently involves the thyro-hyoid 
 space, and the epiglottis may be severed from its thyroid 
 attachment. 
 
 The isthmus of the thyroid gland crosses the trachea 
 Fig. v., 12. about I to f inch below the cricoid cartilage. 
 Fig. V. The structures in the middle line of the neck : 
 
 (i) Passing down from the jaw to the body of the hyoid 
 bone, the two genio-hyoid muscles lie each side of the 
 middle line. They are placed, however, deep to the mylo- 
 hyoid muscles, which are directed downwards and inwards 
 to the m.edian raphe and to the body of the hyoid bone. 
 (2) The body of the hyoid bone. (3) The thyro-hyoid 
 space. (4) The thyroid cartilage. (5) The crico-thyroid 
 space. (6) The cricoid cartilage. (7) The upper two or 
 three tracheal rings. (8) The isthmus of the thyroid gland, 
 (g) The trachea. (10) The suprasternal notch. 
 
THE FRONT OF THE NECK 
 
 FIG. V. 
 
 1. The supra-orbital foramen. 
 
 2. The infra-orbital foramen. 
 
 3. The mental foramen. 
 
 4. The j<enio-hyoifl muscle ((leej) 
 
 to the mylo-hyoid muscle). 
 
 5. The digastric muscle. 
 
 6. The mylo-hyoiil muscle. 
 
 7. The liNO-glossus muscle. 
 <S. The liyoid bone. 
 9. The epiglottis. 
 
 10. The thjroid cartilage. 
 
 11. u. The trachea. 
 
 12. The thyroid isthmus. 
 
 13. The sternum. 
 
 To /ace p. 18. 
 
CHAPTER II 
 THE UPPER EXTREMITY 
 
 In this chapter, and in that on the lower extremity, the 
 reader's attention is mainly directed to those bony promi- 
 nences and muscular or tendinous elevations which lie in 
 the region of the joints, since these form the more 
 important landmarks which aid in the representation of 
 the arteries, nerves, etc., of the limbs. The muscular 
 masses, which complete the symmetry of the arm or leg 
 between the joints, are only mentioned where necessary, a 
 fair general knowledge of the anatomical structure of the 
 body being assumed. 
 
 The shoulder region. — The acromial process, the spine 
 of the scapula and the clavicle, being subcutaneous 
 throughout their whole length, can readily be palpated 
 from end to end. The clavicle should first be examined 
 from its blunted sternal extremity to the acromio-clavicular 
 joint. The inner third of the shaft is rounded and 
 presents a marked forward convexity, whilst the outer 
 third of the bone is flattened from before backwards and 
 shows a concave anterior border. At the outer end of the 
 bone a slight elevation can usually be felt on the superior 
 surface, and immediately external to this is the acromio- 
 clavicular joint, the long axis of which lies in the antero- 
 posterior direction, 
 
 »9 
 
20 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 The acromial spine is narrow at about its centre, 
 
 broadening out towards the vertebral border of the 
 
 scapula, and forming there a smooth triangular 
 
 Fig. xiii., 1. ,.,,.,, ,. ^ 
 
 surrace, over which glides the tendinous part or 
 the trapezius. Externally, the spine terminates in the 
 upward curved acromial process, at the anterior 
 '' " border of which an oval facet is situated for 
 articulation with the clavicle. The supra- and infra- 
 spinatus muscles fill up the depressions or fossae which lie 
 in relation to the spine of the acromion. 
 
 The clavicle is also bounded above and below by 
 depressions, little evident in fat subjects, but most marked 
 when, as the result of pathological or physiological condi- 
 tions, fat is feebly represented. The supra- 
 ' clavicular or subclavian triangle is dealt with 
 in the first chapter. The mfraclavicular space is bounded 
 above by the clavicle, below by the clavicular head of the 
 pectoralis major muscle, internally by the costal cartilage 
 of the first rib, and externally by the anterior border of the 
 deltoid muscle. The floor is formed by the subclavius 
 muscle and the costo-coracoid membrane. In the outer 
 
 part of the space the coracoid process may be 
 Ficr, vi 3. 
 
 '' ' felt, the apex of the process lying under cover 
 
 of the anterior border of the deltoid muscle. In favourable 
 cases, the pulsation of the axillary artery (Part I.) may be 
 detected below the clavicle, as this vessel runs downwards 
 from the outer border of the first rib. The bulky 
 '' ' deltoid muscle, arising from the clavicle and from 
 the acromial process and spine, is, so to speak, pushed 
 outwards by the underlying head and great tuberosity 
 of the humerus, so producing the normal rounded appear- 
 ance of the shoulder. This outward displacement of the 
 muscle is taken advantage of by Hamilton in the diag- 
 
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 nerv 
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 leve 
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 radia 
 radia 
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 03 t; o '-' b '-' 
 
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THE UPPER EXTREMITY 21 
 
 nosis of a dislocation of the shoulder-joint, as, after such 
 an injury, the humerus is drawn inwards by the pectoralis 
 major, latissimus dorsi and other muscles to such a degree 
 that a ruler placed along the outer side of the arm will be 
 in contact with the acromion process and the external 
 humeral condyle at one and the same time. In the 
 normal condition, this is not possible. 
 
 To measure the length of the humerus, the tape-measure 
 Fig. xiv., 4, should be carried from the lower margin of the 
 acromial process to the external condyle of the 
 humerus. The lesser tuberosity of the humerus is always 
 difficult to identify, but it can usually be distinguished 
 lying rather below the mid-point of a line uniting the 
 coracoid process and the great tuberosity of the humerus, 
 the arm being well everted and the elbow in contact with 
 the side of the body. 
 
 Between the two tuberosities is the bicipital groove, in 
 which runs the long tendon of the biceps muscle. The 
 groove may be represented by a line, about 2 inches long, 
 which runs downwards from the tip of the acromial 
 process, parallel to the long axis of the humerus. 
 
 The upper epiphysis of the humerus includes the head 
 and both tuberosities, and the epiphysial line runs trans- 
 versely, at right angles to the long axis of the humerus, at 
 the lower border of the great tuberosity. 
 
 The axilla. — To examine this space, the elbow should 
 be supported, and the patient instructed to relax all 
 muscles. The anterior wall is formed by the major and 
 minor pectoral muscles, and by the costo-coracoid mem- 
 brane The pectoralis major alone forms the anterior 
 fold of the axilla, and does not extend as far 
 '^" ^' ' downwards as the posterior fold, whilst its 
 rounded appearance results from the twisting of the fibres 
 
22 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 of the pectoral muscle before their insertion into the outer 
 bicipital ridge. The posterior wall is formed mainly by 
 the subscapularis muscle overlying the ventral surface of 
 the scapula, the axillary border of which bone can be made 
 out by deep palpation from the inferior angle below to the 
 head above. The rounded posterior fold of the axilla results 
 from the fact that the latissimus dorsi curls round the 
 Fig. vi.,9. teres major muscle from behind forwards in 
 Fig. XIII., 7. Qj-fjgi- ^o reach its insertion into the floor of the 
 bicipital groove. The narrow outer boundary of the axilla 
 corresponds to the upper part of the shaft and to the head 
 of the humerus, and in this situation, in a well-developed 
 arm, two prominent longitudinal folds are seen, 
 the anterior of which corresponds to the coraco- 
 brachialis and biceps (short head) muscles, whilst the 
 Fig. vi., 1 - more posterior fold results from the projection 
 of the neuro-vascular bundle. The head of the 
 humerus and of the scapula can be felt at the upper and 
 posterior part of the axilla, the second rib on the inner 
 side, and the coracoid process in front. The head of the 
 humerus looks in the same direction as the internal 
 condyle of the humerus. The inner wall of the axilla is 
 formed by the upper part of the lateral wall of the thorax, 
 which is here clothed by the serrations of the serratus 
 magnus muscle. 
 
 The axillary lymphatic glands are arranged in three main 
 groups, all converging towards the apex of the axilla : 
 
 (a) The pectoral set, running upwards and outwards 
 under cover of the outer border of the pectoral muscles 
 and draining the anterior and lateral aspects of the chest- 
 wall and the abdomen above the level of the umbilicus. 
 
 (b) The subscapular set, running upwards along the 
 axillarv border of the subscapularis muscle, and draining 
 
6-5li 
 
 K^ 0) ^ J3 
 
 I— 1 
 
 > 
 
 < . 
 
 f) 
 
 
 1— 1 
 
 w . 
 
 Ph 
 
 ffi S 
 
 £H 
 
 S 5 2' 
 
 O rt- 
 
 K 1) (LI 0) 
 
THE UPPER EXTREMITY 23 
 
 the lateral and posterior aspect of the chest above the 
 level of the umbilicus. 
 
 (c) The brachial and axillary set, running upwards in 
 the line of the axillary vessels, and draining the whole of 
 the upper extremity. 
 
 The elbow region. — When the forearm is extended, a 
 pjg. yjj line joining the internal and external condyles 
 of the humerus cuts across the tip of the ole- 
 cranon process, which bony prominence lies w^ell to the 
 inner side of the mid-point of the intercondyloid line. 
 When the forearm is flexed, the olecranon moves down- 
 wards, and by uniting the three bony points a triangle is 
 Fig. xiii. formed. Immediately below the external con- 
 
 ^' ^- dyle the head of the radius is felt " lying in the 
 
 valley behind the supinator longus " (Holden). The 
 humero-radial articulation is transverse, but the humero- 
 ulnar articulation slopes obliquely downwards and 
 inwards, and consequently, whilst the external condyle is 
 about f inch above the humero-radial joint, the internal 
 condyle lies rather more than i inch above the line of the 
 humero-ulnar articulation. 
 
 The junction of the dtaphysis and lower epiphysis of the 
 humerus corresponds to a transverse line drawn across 
 the humerus immediately above the tips of the condyles. 
 The bony points on the outer side of the joint are generally 
 obscured in those cases where there is considerable effusion 
 into the elbow-joint, the synovial membrane bulging out- 
 wards below the external condyle of the humerus and 
 between that process and the olecranon process. Under 
 similar conditions, there is also an outward projection of 
 the synovial membrane between the olecranon and the 
 internal condyle of the humerus, obscuring the deep 
 depression that normally exists in that situation — a de- 
 
24 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 pression at the base of which the ulnar nerve can be rolled 
 beneath the finger. 
 
 In front of the elbow is the antecuhital triangle, the base 
 
 of which corresponds to a line drawn across the 
 
 ■' ■ front of the elbow between the two humeral 
 
 condyles, whilst the inner and outer boundaries are formed 
 
 Fig. viii., respectively by the pronator radii teres and 
 
 supinator longus muscles. This triangular 
 
 space is vertically subdivided by the biceps 
 
 '' ' tendon, on either side of which a depression 
 
 exists, the inner and outer bicipital sulci. In the outer 
 
 sulcus the musculo-spiral nerve divides into its 
 
 '^" ^'"■' ■ two terminal branches, radial and posterior 
 
 interosseous, whilst the median nerve and the brachial 
 
 pj yjjj artery lie in the inner sulcus, the artery inter- 
 
 ^' ^' mediate between the tendon and the nerve. 
 
 The artery and nerve are, however, obscured in the lower 
 
 part of the inner sulcus by the overlying bi- 
 
 ig. VIII., . ^jpj^g^j fascia, which can be traced inwards 
 
 to the pronator region, whilst its upper free margin 
 
 presents a well - marked crescentic edge which looks 
 
 upwards and inwards. 
 
 The superficial veins in front of the bend of the elbow 
 
 are arranged in the form of a letter M, the 
 
 '^' "^' radial, median and ulnar veins being received 
 
 from below, whilst two main efferent vessels, the cephalic 
 
 and the basilic, carry the blood upwards, The 
 
 ' ' ■' ■ basilic vein passes upwards in the superficial 
 
 fascia, along the inner side of the arm, and pierces the 
 
 deep fascia about half-way between the axilla and the 
 
 internal condyle, and at the foramen so pro- 
 
 ' '^'' ' duced in the deep fascia the internal cutaneous 
 
 nerve emerges to become superficial. The epitrochlear 
 
> 
 
 C 
 W 
 
 w 
 

 . •'- l> ;-. 
 
 ^ 
 
 S -^ J3 rt 
 
 >^ 
 
 
 
 
 
 
 
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 P^P S cfl a, 
 
 
 
 
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 THE UPPER EXTREMITY 25 
 
 gland lies in close connection with the median basilic or 
 
 basilic veins above and in front of the internal 
 Fig. ix., 11. J , 
 
 condyle. 
 
 The cephalic vein can be traced upwards along the outer 
 
 side of the arm as far as the groove between 
 Fie. ix, 4. . 
 
 the deltoid and pectoralis major muscles. In 
 
 the interval between these two muscles the vein lies 
 
 embedded, and eventually pierces the costo- 
 
 ' ■ coracoid membrane in the infraclavicular region 
 
 to open into the axillary vein. 
 
 The Region of the Wrist and Hand. 
 Two tendons only are conspicuous at the front of the 
 Fig. X., wrist — the palmaris longus in the middle line, 
 ^' '■ and the flexor carpi radialis to the outer side 
 
 of the palmaris longus. The flexor carpi ulnaris can, 
 however, be distinguished by palpation along the ulnar 
 Fig. X., border of the forearm, and can be traced down- 
 4-. 5. wards to its insertion into the pisiform bone. 
 
 Between the palmaris longus and the flexor carpi ulnaris 
 the main mass of the flexor sublimis digitorum lies. Two 
 transverse creases are seen in this situation, the 
 upper of which roughly corresponds to the level 
 of the radio-carpal joint, whilst the lower represents almost 
 exactly the upper limit of the anterior annular ligament. 
 Just external to where the flexor carpi radialis tendon 
 cuts across the two transverse creases there is a 
 ' ' depression, in the floor of which the lower end 
 of the radius and the tubercle of the scaphoid bone may 
 be felt. The radial artery crosses this space in a down- 
 ward and outward direction. The trapezium 
 lies at the lower limit of the depression, imme- 
 diately below and external to the scaphoid tuberosity. 
 
26 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 The prominent pisiform bone can be distinguished by 
 
 tracing downwards the tendon of the flexor 
 
 '' ' carpi ulnaris muscle, and posterior to this bone 
 
 both cuneiform and unciform bones are situated. A finger's 
 
 breadth below and external to the pisiform 
 
 bone deep palpation will verify the position of 
 
 the hook of the unciform bone. 
 
 The anterior annular ligament is attached to four bony 
 
 points, two on the radial side, the scaphoid 
 
 tubercle and the ridge on the trapezium, and 
 
 two on the ulnar side, the pisiform and the hook of the 
 
 unciform. The upper limit of the ligament corresponds 
 
 to the lower of the two transverse creases in 
 
 front of the wrist, whilst the inferior limit of the 
 
 ligament lies about f inch below. 
 
 The flexor synovial sheaths. — The flexor longus pollicis, 
 the flexor sublimis and the flexor profundus 
 '^' '■ digitorum all pass beneath the anterior annular 
 ligament. In this situation the flexor sublimis consists of 
 four tendons, of which the medius and annularis lie super- 
 ficial to the tendons which pass to the index and little 
 fingers. The profundus consists of two parts only, 
 the tendon to the index-finger being alone differentiated 
 off from the main mass. Beneath the ligament these 
 tendons are surrounded by two synovial sheaths, one for 
 the flexor longus pollicis and one for the remaining tendons 
 plus the median nerve. The sheaths extend upwards 
 about I inch above the upper limit of the ligament, and 
 therefore the same distance above the lower transverse 
 pj ^j crease in front of the wrist. The flexor longus 
 
 ®' pollicis sheath is continued downwards to the 
 
 insertion of the tendon into the distal phalanx of the 
 thumb. The main sheath broadens out below the liga- 
 
FIG. X. 
 
 1. The flexor carpi radialis. 
 
 2. The palmaris longus. 
 
 3. The ulnar artery. 
 
 4. The flexor carpi ulnaris. 
 
 5. The pisiform bone. 
 
 6. The transverse creases of the wrist. 
 
 7. The superficial branch of the ulnar artery. 
 
 8. The deep branch of the ulnar artery. 
 
 9. The superficial palmar arch. 
 ID. The deep palmar arch. 
 
 11. The digital branches of the superficial palmar arch. 
 
 12. The superficialis volee. 
 
 FIG. XI. 
 
 1. The pisiform. 
 
 2. The unciform. 
 
 3. The trapezium. 
 
 4. The scaphoid tuberosity. 
 
 5. The anterior annular ligament. 
 
 6. 6. The flexor longus pollicis sheath. 
 
 7. 7. The main flexor synovial sheath. 
 
 8. The distal flexor synovial sheaths. 
 
 9. The continuation of the main sheath along the little finger. 
 
THE UPPER EXTREMITY 27 
 
 ment, and though generally continued onwards to the end 
 Fie xi. 7 o^ ^^^ little finger, the major portion terminates 
 
 ^' ®" at the level of the upper transverse crease of 
 
 the palm. The flexor tendons to the fore, middle and ring 
 fingers also possess more distally distinct synovial sheaths, 
 Fig. xi. 8 which extend from the terminal phalanges 
 
 ^' °' of the fingers upwards to the necks of the 
 
 metacarpal bones, a level corresponding roughly to the 
 lower transverse crease of the palm. 
 
 A distance of ^ inch separates the main synovial sheath 
 above from the more distal segments below. 
 
 On the outer side of the wrist the most marked feature 
 is the " anatomical snuff-box," a space bounded on the 
 radial side by the tendons of the extensor ossis metacarpi 
 and primi internodii pollicis muscles, and on the ulnar side 
 by the tendon of the extensor secundi internodii pollicis. 
 
 In the floor of the space the styloid process of the radius 
 is felt, this prominence lying fully j inch below the level 
 of the corresponding process of the ulna, and also on a 
 slightly more anterior plane. Immediately below the 
 radial styloid process the scaphoid bone lies, most pro- 
 minent when the hand is well adducted. Below this, again, 
 the trapezium and the bases of the first and second meta- 
 carpals are to be felt. 
 
 On the dorsum of the hand there is a well-marked 
 elevation, most noticeable when the wrist is fully flexed, 
 due to the projection of the bases of the second and third 
 metacarpal bones, the styloid process of the latter bone 
 being especially prominent. 
 
 Immediately above this elevation there is a depression 
 where the tendons of the extensor carpi radialis longior 
 and brevior are felt as they pass to their insertion into 
 the bases of the second and third metacarpal bones. 
 
 3 
 
28 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 Near the middle of the posterior aspect of the lower end 
 
 of the radius a tubercle can generally be dis- 
 
 ■' ■ tinguished, the radial Uihercle, separating the 
 
 extensor secundi internodii pollicis on the inner side from 
 
 the tendon of the extensor carpi radialis brevior, which 
 
 'ies more external. 
 
 The posterior annular ligament, about f inch broad, 
 extends from the lower part of the outer border 
 * ' of the radius to the styloid process of the ulna 
 and the carpal bones below the ulna. The ligament has, 
 therefore, a downward and inward direction, and beneath 
 it pass the extensor tendons. These occupy distinct com- 
 partments, and possess synovial sheaths as under : 
 
 I. One compartment and synovial sheath for the 
 extensor ossis metacarpi and extensor primi 
 internodii pollicis. 
 
 2. One for the extensor carpi radialis longior 
 Fig. xii., 3. J , 
 
 and brevior. 
 
 3. One for the extensor secundi internodii 
 Fig. xii., 5. ,,. . 
 
 pollicis. 
 
 4. One for the extensor communis digitorum 
 Fig. xii., 6. , • T • 
 
 and extensor mdicis. 
 
 Fig. xii., 7. 5. One for the extensor minimi digiti. 
 
 6. One for the extensor carpi ulnaris. The 
 Fig. XII., 8. g^|.g^^ Qf ^]^g synovial sheaths is indicated in 
 the diagram, where the radial artery is also depicted as it 
 Pior vi; crosses the " anatomical snuff-box " towards 
 
 V Ig. XII ., 
 
 ^' '°- the base of the first interosseous space, at 
 which level the vessel dips down between the two heads 
 of the first dorsal interosseous muscle to complete the deep 
 palmar arch. 
 
THE BACK OF THE WRIST 
 
 FIG. XII. 
 
 I. 
 
 4- 
 
 2,3 
 
 9- 
 lo. 
 
 The posterior annular ligament. 
 The rarlial tubercle. 
 
 5-8. The compartments and synovial sheaths of the 
 extensor tendons (see text). 
 The radial artery, crossing the " anatomical snuff-box." 
 The base of the first interosseous space. 
 
 To face p. 
 
the upper extremity 2g 
 
 Vessels, etc., of the Upper Extremity. 
 
 The axillary artery extends from the outer border of 
 the first rib to the lower margin of the 
 
 Fig. vi., 5. 
 
 teres major muscle. When the arm is held 
 
 out at right angles to the long axis of the body, and 
 
 the palmar surface of the hand turned upwards, the 
 
 artery corresponds in direction to a line drawn from the 
 
 middle of the clavicle to the junction of the anterior and 
 
 middle thirds of the outer axillary wall at the outlet of 
 
 that space. At its termination the artery and the accom- 
 
 pj yj panying nerves — the neuro-vascular bundle — 
 
 10-13. form a projection which lies behind that due to 
 
 the coraco-brachialis and biceps (short head) muscles. 
 
 The artery is divided into three parts by the 
 Pi ST. vi . 4» 
 
 pectoralis minor muscle, which muscle can be 
 
 represented by a triangle, the base corresponding to the 
 
 anterior extremities of the third, fourth and fifth ribs, 
 
 whilst the apex is situated at the end of the coracoid process. 
 
 The brachial artery. — The arm and forearm being held 
 
 in the position already indicated as necessary 
 
 ^ " 'in order to map out the axillary artery, the 
 
 brachial artery corresponds to a line drawn from the outer 
 
 wall of the axillary outlet at the junction of its anterior 
 
 and middle thirds to the mid-point in front of the bend of 
 
 the elbow at the level of the head of the radius. 
 
 '^' ^'■' At the last point the artery bifurcates into 
 
 radial and ulnar arteries. 
 
 The radial artery extends from the middle of the bend 
 
 Fig. vi., 17. ^^ ^^^ elbow at the level of the head of the 
 
 radius to the radial side of the tendon of the 
 
 FifiT* xii. 
 
 9, 10. ' flexor carpi radialis muscle just above the base 
 of the thumb. The artery then crosses the " anatomical 
 
 3—2 
 
30 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 snuff-box " towards the base of the first interosseous 
 space. 
 
 The ulnar artery in the lower two-thirds of its course 
 accompanies and hes to the radial side of the 
 ulnar nerve (see " ulnar nerve in the forearm,''^ 
 p. 32). The upper third of its course is represented by a 
 line which passes obliquely upwards and outwards to the 
 middle of the bend of the elbow at the level of the head of 
 the radius. 
 
 The superficial palmar arch is formed by the anastomosis 
 Fie. X 7 ^^ ^^^ superficial division of the ulnar artery 
 
 9' '2. vv'ith the superficialis volse, or with some other 
 branch of the radial artery. The convexity of the arch 
 looks towards the fingers, and lies on a level with the 
 lower border of the outstretched thumb. Occasionally 
 the arch extends lower down, reaching as far as the upper 
 of the two transverse creases on the palmar aspect of the 
 hand. 
 
 The deep palmar arch, formed by the anastomosis of the 
 Fig. X. 8 radial artery with the deep branch of the ulnar, 
 ^°" lies about one finger's breadth above the level 
 of the superficial palmar arch. 
 
 The digital branches of the superficial palmar arch pass 
 
 downwards in the intervals between the meta- 
 
 '^" ^'' ' carpal bones to within ^ inch of the digital 
 
 clefts, where the vessels bifurcate to run along the 
 
 adjacent sides of the fingers. 
 
 The circumflex nerve and the posterior circumflex artery 
 pj j(jjj__ 3_ both pass backwards through the quadrilateral 
 Fig. VI., 7. muscular space, and curl round the surgical 
 neck of the humerus towards the outer and front aspect 
 of the shoulder region. The artery anastomoses with the 
 anterior circumflex artery, and the level of the arterial 
 
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 w 
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 S '^ 
 
 
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 "H.S 
 
 
 ti !^ 
 
 cy. 
 
 
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 7^ "^ 
 
 
 
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 rt 
 
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 cB cs o -S aj 
 
 1» 1> <U UJ c^ 
 
 H H H ? H 
 
 ■- N rO "^ "O 
 
THE SHOULDER AND ARM 
 
 FIG. XIV. 
 
 1. The clavicle. 
 
 2. The acromion process. 
 
 3. The external condyle of the humerus. 
 
 4. 4. Hamilton's line. 
 
 5. The deltoid muscle. 
 
 6. 6. The musculo-spiral nerve. 
 
 To face p. 31. 
 
THE UPPER EXTREMITY 3I 
 
 circle so formed, and of the posterior circumflex nerve, 
 may be represented by a line drawn at right angles to the 
 shaft of the humerus from a point just above the centre 
 of the deltoid muscle. 
 
 The miisculo-cutancous nerve usually pierces the inner 
 aspect of the coraco-brachialis muscle about i to 2 inches 
 below the coracoid process. It then runs downwards and 
 outwards, deep to the biceps muscle, towards the outei 
 bicipital sulcus, at which level it becomes cutaneous. 
 The course of the nerve in the arm can, therefore, be 
 roughly indicated by a line from the coracoid process 
 above to the outer bicipital sulcus below. 
 
 The mtisculo-spiral nerve, accompanied by the anterior 
 branch of the superior profunda artery, pierces 
 Fig. xiv. 6, the external intermuscular septum of the arm, 
 from behind forwards, at the junction of the 
 upper and middle thirds of a line drawn from the insertion 
 of the deltoid muscle to the external condyle of the 
 humerus. Below this point the nerve passes downwards 
 and inwards to the outer bicipital sulcus, where it bifurcates 
 into its two terminal branches. Above the point at which 
 the nerve pierces the external intermuscular septum, the 
 course of the nerve may be represented by a curved line 
 drawn upwards and inwards to the junction of the upper 
 arm with the posterior fold of the axilla. 
 
 The radial nerve, a branch of the musculo-spiral, arises 
 Fig. vi., 16 ^^ the outer bicipital sulcus, and passes vertically 
 ig. XIII., '0(jown the forearm, accompanying, and lying to 
 the outer side of, the radial artery in its middle third. 
 At the junction of the middle and lower thirds of the fore- 
 arm, the nerve turns round the outer border of the radius 
 under cover of the supinator longus tendon, to be dis- 
 tributed to the back of the wrist and hand. 
 
32 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 The posterior interosseous nerve arises from the musculo- 
 
 r-- ••• n spiral in the outer bicipital sulcus, and curls 
 Fig. XIII., 9. ^ r ' 
 
 round the neck of the radius in the substance 
 of the supinator brevis muscle, emerging from the posterior 
 border of that muscle 2 inches below the head of the 
 radius. It then passes vertically down the posterior aspect 
 of the forearm, lying about midway between the inner and 
 outer borders, and terminating in a gangliform enlarge- 
 ment at the posterior aspect of the wrist. 
 
 The median nerve in the arm. — This nerve accompanies 
 Fig vi 11 t^^ brachial artery, and therefore presents a 
 similar surface marking. It is necessary, how- 
 ever, to bear in mind that the nerve crosses the artery super- 
 ficially from above downwards and from without inwards. 
 The median nerve in the forearm passes vertically down- 
 wards from the inner bicipital sulcus to the 
 front of the wrist, there lying to the ulnar side 
 of the flexor carpi radialis and under cover of the palmaris 
 longus tendon. The nerve then passes under the anterior 
 annular ligament to the palm. 
 
 The ulnar nerve in the upper third of the arm lies along 
 
 the inner side of the brachial artery. It then 
 
 '^' ^'■' ■ leaves that vessel, and, accompanied by the 
 
 inferior profunda artery, passes downwards and backwards 
 
 to reach the hollow between the internal condyle and the 
 
 olecranon process. 
 
 The ulnar nerve in the forearm corresponds in direction 
 
 to a line drawn from the internal condyle of the 
 
 'g- VI., . ]^^j_^gj-^g ^Q ^]^g radial side of the pisiform bone. 
 
 In front of the wrist the nerve lies to the radial side of 
 the tendon of the flexor carpi ulnaris muscle, and subse- 
 quently passes superficial to the anterior annular ligament 
 to its palmar distribution. 
 
THE UPPER EXTREMITY 33 
 
 The palmar fascia is triangular in shape, the apex being 
 attached to the anterior annular ligament between the 
 thenar and hypothenar eminences, whilst the base corre- 
 sponds to the proximal ends of the four inner fingers. 
 
 The Creases of the Palm and Fingers. 
 
 The upper transverse crease on the palmar aspect of 
 the hand lies just below the normal limit of the superficial 
 palmar arch, but at the level of the lower limit of the 
 main flexor synovial sheath. The lower crease crosses 
 the necks of the metacarpal bones, and corresponds to 
 the upper limit of the distal flexor synovial sheaths. 
 
 The metacarpo-phalangeal joints lie about half-way 
 between the distal crease of the palm and the proximal 
 crease of the fingers. The middle and distal creases 
 on the palmar aspect of the fingers correspond fairly 
 accurately to the respective interphalangeal joints. The 
 " knuckles " are formed by the heads of metacarpal 
 bones. 
 
CHAPTER III 
 THE THORAX 
 
 The majority of the thoracic viscera are depicted on the 
 surface in relation to the costal cartilages, ribs and inter- 
 costal spaces, and it is therefore necessary to lay stress on 
 certain important points : 
 
 1. That the twelve ribs are divided into two groups : 
 {a) True ribs, seven in number, articulating by means of 
 their costal cartilages with the mesial sterno-xiphoid bone ; 
 (b) False ribs, five in number, all falling short of the middle 
 line, the upper three attached to the costal cartilage of the 
 rib above, the lower two not articulating with the trans- 
 verse process of the corresponding vertebra, and the 
 anterior extremities not attached to the costal cartilage 
 of the rib above. These last two ribs are therefore known 
 as " floating ribs." 
 
 2. That the first rib lies mainly under cover of the 
 
 clavicle, but that its costal cartilage can gener- 
 ig. 111., . ^jj^ ^^ palpated with ease as it lies below the 
 
 sternal end of the clavicle. 
 
 3. That the first interspace which can be felt to the 
 outer side of the sternum is the first interspace. This 
 axiom may appear at first sight to be quite unnecessary, 
 but it is in reality not uncommon for students to regard 
 the first space which can be felt as the second interspace. 
 
 34 
 
THE THORAX 
 
 35 
 
 4. That the second costal cartilage articulates in front 
 Fig. iii.. at the angle of Ludwig with the adjoining parts 
 
 of the manubrium and gladiolus. 
 
 5. That the seventh costal cartilage articulates with 
 
 the adjoining parts of the gladiolus and xiphoid 
 cartilage. 
 
 6. That the anterior extremity of the ninth costal 
 
 cartilage corresponds almost exactly to the 
 
 PifiT. XX. 
 
 point where the linea semilunaris cuts the 
 costal arch. 
 
 7. That the twelfth rib is liable to great variation in 
 size, frequently being so insignificant that it cannot be 
 felt at all. It is, therefore, often advisable to count from 
 above in fixing any particular rib. 
 
 8. That the intercostal spaces, in consequence of the 
 downward and forward obliquity of the ribs, are wider in 
 front than behind. 
 
 The female mamma, when well developed, extends up- 
 wards to the second rib, inwards to the outer border of 
 the sternum, downwards to the sixth or seventh rib, and 
 outwards to the mid-axillary line. The true glandular 
 substance is, however, less regular in disposition, pro- 
 longations passing in various directions. Of these, the 
 most important is the so-called " axillary prolongation," 
 which is directed upwards and outwards along the anterior 
 fold of the axilla. 
 
 The nipple usually corresponds to the fourth mterspace 
 
 It is variable in position, and not infrequently 
 
 '^' ^'^' overlies the fourth rib. In the female the nipple 
 
 lies just below, and external to, the apex or central point 
 
 of the breast. 
 
 Fig XV The heart lies opposite the middle four dorsal 
 
 ''^- vertebrae, and the projection of its anterior 
 
36 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 surface upon the front of the chest wall may be indicated 
 in the following manner. 
 
 Take the following four points : 
 
 1. The lower border of the second left costal cartilage 
 about I inch from the left border of the sternum. 
 
 2. The upper border of the third right costal cartilage 
 ^ to I inch from the right border of the sternum. 
 
 3. The lower border of the sixth right costal cartilage 
 f inch from the right border of the sternum. 
 
 4. The fifth left interspace i^- inches below and just 
 internal to a line drawn vertically downwards from the 
 nipple. If any abnormality exists with regard to the 
 position of the nipple, this last point may be fixed with 
 greater accuracy by taking a point in the fifth left inter- 
 space nearly 4 inches from the middle line. 
 
 The apex beat — the point of maximum impulse of the 
 left ventricle against the chest wall — lies in the 
 ' ' fifth left interspace I5 inches below and ^ inch 
 internal to the nipple, or 3J inches from the middle line. 
 The position of the apex beat, therefore, does not exactly 
 represent the outermost limit of the left ventricle. The 
 above four points should now be joined in the following 
 manner : 
 
 Points I and 2 by a straight line. 
 
 Points 2 and 3 by a curved line, the heart reaching 
 the greatest distance from the middle line, I5- inches, in 
 the fourth interspace. 
 
 Points 3 and 4 by a line presenting a slight downward 
 convexity, and cutting across the middle line in close 
 relation to the xiphisternal junction. 
 
 Points I and 4 by a line presenting a fairly well marked 
 convexity to the left. In the illustration this line is 
 drawn rather too straight. 
 
FIG. XV. 
 
 N.B. — 111 this and in other figures in which the costal cartilages are 
 depicted the numbered references do 7iot refer to the corresponding 
 cartilages. These are numbered for general convenience only. 
 1-4. The four points of the heart. 
 
 5. The auricular area. 
 
 6. The ventricular area. 
 
 7. The left ventricle. 
 
 8. The apex beat. 
 
 9. The pulmonary valve. 
 
 10. The pulmonary artery. 
 
 11. The aortic valve. 
 V2. The mitral valve. 
 
 13. The tricuspid valve. 
 
 14. The ascending aorta. 
 
 15. The aortic arch. 
 
 16. The innominate artery. 
 
 17. The right and left common carotid arteries. 
 
 18. The right and left subclavian arteries. 
 
 19. The right and left subclavian veins. 
 
 20. The right and left internal jugular veins. 
 
 21. The right and left innominate veins. 
 
 22. The superior vena cava. 
 
 23. The inferior vena cava. 
 
 24. The abdominal aorta. 
 
 25. The cceliac axis. 
 
 26. The superior mesenteric artery. 
 
 27. The renal arteries. 
 
 28. The inferior mesenteric artery. 
 
 29. The common iliac arteries. 
 
 30. The internal iliac arteries. 
 
 31. The external iliac arteries. 
 
 32. The kidney. 
 
 33. The ureters. 
 
 34. The ovary. 
 
THE HEART, GREAT VESSELS, KIDNEY, AKD 
 URETER 
 
 FIG, XV. 
 
 To Jace p, 36. 
 
THE THORAX 37 
 
 A line joining Points i and 3 divides this cardiac area 
 
 into two parts, which roughly correspond to 
 
 the aurictdar area above and to the right, and 
 
 the ventricular area below and to the left. This 
 RifiT, XV. 6. 
 
 ventricular area is occupied mainly by the 
 
 right ventricle, whilst a narrow strip along 
 ig. XV., . ^^^ j^^^ border represents that part of the left 
 ventricle which comes to the surface. 
 
 The four points given above for marking out the pro- 
 jection of the heart on the anterior thoracic wall may be 
 simplified by taking and joining the following four points : 
 
 1. The upper border of the third right chondro-sternal 
 junction. 
 
 2. The lower border of the second left chondro-sternal 
 junction. 
 
 3. The lower border of the sixth right chondro-sternal 
 junction. 
 
 4. The position of the apex beat. 
 
 By uniting these four points, the heart is mapped out 
 for most practical purposes with sufiicient accuracy. 
 
 The Valves of the Heart. 
 
 1. The pulmonary valve is situated at the highest level, 
 
 and lies opposite the upper border of the third 
 Fig. XV., 9. j^£^ costal cartilage, close to its junction with 
 the sternum. 
 
 2. The aortic valve lies just below and internal to the 
 
 pulmonary valve at the lower border of the 
 Fig. XV., II. ^j^.^^ ^^^^ costal cartilage at its junction with 
 
 the sternum. 
 
 3. The mitral or left auriculo- ventricular valve is situated 
 
 behind the left half of the sternum at the level 
 Fig. XV., 12. ^^ ^^^ fourth chondro-sternal junction. 
 
38 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 4. The tricuspid or right auriculo-ventricular valve Hes 
 Fig. XV., very obhquely behind the sternum at the level 
 of the fourth interspace and the anterior extremi- 
 ties of the fifth costal cartilages, extending downwards and 
 to the right almost as far as the sixth chondro-sternal 
 junction. 
 
 The Aorta and other Vessels, etc. 
 
 The ascending aorta, 2 to 2^ inches long, arises behind 
 
 Fig. XV., the left border of the sternum at the level of 
 
 the third costal cartilage, and passes upwards 
 
 and to the right towards the right border of the sternum 
 
 at the level of the second costal cartilage. 
 
 The aortic arch is directed backwards and to the left, 
 Fig. XV., the upper limit lying about i inch below the 
 suprasternal notch, or half-way between that 
 notch and the angle of Ludwig. The arch becomes the 
 descending aorta at the left side of the lower part of the 
 body of the fourth dorsal vertebra. 
 
 The descending thoracic aorta, 7 to 8 inches long, passes 
 onwards through the posterior mediastinum, and pierces 
 the diaphragm at the level of the twelfth dorsal vertebra. 
 The site of diaphragmatic perforation is represented on the 
 surface by a point situated just to the left of the middle 
 line, two fingers' breadth above the transpyloric plane.* 
 
 The innominate artery, ij to 2 inches long, arises from 
 Fig. XV. the aortic arch in the middle line i inch below 
 
 ^^" the suprasternal notch, and passes upwards and 
 
 to the right to the right sterno-clavicular articulation, at 
 which level it bifurcates into its two terminal branches. 
 
 The left common carotid (thoracic course) arises from 
 
 * Any "planes" mentioned in this chapter will be explained in the 
 chapter on the abdomen. 
 
THE THORAX 39 
 
 the aortic arch on a posterior plane to, and slightly to 
 Fig. XV., th^ ^sft of, the trunk of the innominate artery, 
 and passes upwards and to the left to the left 
 sterno-clavicular articulation. 
 
 The left subclavian artery (thoracic course) arises from 
 Fig. XV., ^^^ aortic arch on a posterior plane to, and 
 
 ^^- slightly to the left of, the thoracic part of the 
 
 left common carotid artery, and passes almost vertically 
 upwards behind the left border of the sternum to the left 
 sterno-clavicular joint. 
 
 The superior mediastinum is bounded above by the plane 
 
 of the thoracic inlet and below by a plane which 
 
 passes backwards from the angle of Ludwig in 
 
 front to the lower border of the fourth dorsal vertebra 
 
 behind (Ludwig's plane). 
 
 The pulmonary artery arises opposite the upper border 
 pj j^y of the third left costal cartilage at its junction 
 
 '°- with the sternum, and passes backwards and 
 
 slightly upwards to its bifurcation, which takes place 
 opposite the second left costal cartilage. 
 
 The internal mammary artery arises from the first part 
 of the cervical course of the subclavian 
 ig. XX., . g^j-^gj-y^ ^^^ passes almost vertically downwards 
 behind the corresponding sterno-clavicular joint. In its 
 further thoracic course, the artery lies ^ inch external 
 to the outer border of the sternum, bifurcating opposite 
 Fig. XX., the sixth costal cartilage or the sixth interspace 
 
 ®' '°- into the musculo-phrenic and superior epigastric 
 arteries. The former vessel curves outwards, following the 
 line of the costal arch, whilst the latter passes onwards to 
 enter the sheath of the rectus abdominis muscle. 
 
 The left innominate vein, 3 inches long, is formed 
 opposite the left sterno-clavicular joint, and passes to the 
 
40 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 right, slightly overlapping the upper part of the aortic 
 Fig. XV. arch, and occupying the greater part of the 
 space between the summit of the arch below 
 and the suprasternal notch above. 
 
 The right innominate vein is formed at the right sterno- 
 Fig. XV , clavicular joint, and passes obliquely down- 
 
 21 
 
 wards and inwards to meet the corresponding 
 vein of the opposite side at the lower border of the first 
 right costal cartilage close to its junction with the sternum. 
 
 The superior vena cava, formed by the junction of the 
 ' Fig. XV., above two veins, is directed almost vertically 
 
 ^^' downwards from the lower border of the first 
 
 right costal cartilage close to its junction with the 
 sternum, to open into the right auricle of the heart at the 
 level of the upper border of the third right chondro- 
 sternal junction. 
 
 The inferior vena cava enters upon its short intrathoracic 
 Fig. XV., course by passing through the quadrate opening 
 
 ^"^" of the diaphragm at the level of the eighth 
 
 dorsal vertebra, opening into the right auricle of the heart 
 opposite the fifth right interspace and the adjoining part 
 of the sternum. 
 
 The vena azygos major drains the whole thoracic wall, 
 except the first space on the right side and the upper three 
 spaces on the left. It opens into the superior vena cava 
 at the level of the lower part of the second right inter- 
 space, curling round the root of the right lung in order to 
 reach its destination. 
 
 The main aortic intercostal vessels occupy the subcostal 
 groove of a rib as they pass round the chest wall, lying 
 between the corresponding vein above and the nerve 
 below. 
 
the thorax 4i 
 
 The Pleura and Lungs. 
 
 I. The pleural sacs. — When the shoulders are depressed, 
 
 Fig. xvi., 5. the two clavicles lie practically at right angles 
 
 ig. XVII., 4. ^Q ^]^g j^j^g g^j^-g q£ ^]^g body, and in this position 
 
 the apices of the pleural sacs extend into the supra- 
 clavicular region, lying about i^ inches above the clavicle 
 under cover of the clavicular head of the sterno-cleido- 
 mastoid muscle. 
 
 The anterior margin of each sac sweeps downwards and 
 inwards behind the corresponding sterno-clavicular joint, 
 the two sacs converging towards the angle of Ludwig, at 
 which level they meet one another just to the left of the 
 middle line. They then pass vertically downwards parallel 
 to one another as far as the level of the fourth chondro- 
 sternal junction. 
 
 The right sac passes onwards in the same straight line 
 to the sixth or seventh chondro-sternal articulation, and 
 then sweeps round the anterior, lateral, and posterior 
 aspects of the chest wall, cutting across — 
 
 (i) The upper part of the eighth costal cartilage in the 
 lateral vertical line ; 
 
 (2) The tenth rib in the mid-axillary line ; 
 
 (3) The eleventh rib in the line of the inferior angle of 
 the scapula ; 
 
 (4) The twelfth rib at the outer border of the erector 
 spinae muscle. 
 
 The obliquity of the twelfth rib causes the pleura to fall 
 below the level of the inner half of the rib, the pleura 
 in this last part of its course being directed inwards 
 towards the spine of the twelfth dorsal vertebra. 
 
 The left pleura, from the level of the fourth left chondro- 
 sternal articulation, sweeps obliquely outwards and down- 
 
 4 
 
42 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 wards behind the costal cartilages of the fifth, sixth and 
 seventh ribs to the eighth costal cartilage in the lateral 
 vertical plane. Beyond this point the left pleura follows 
 the same general direction as the right sac, descending, 
 however, to a slightly lower level. 
 
 The lowest limit reached by the two pleural sacs is 
 situated in the mid-axillary line, the sacs there cutting 
 across the tenth rib about 2 inches above the costal 
 margin, which is in this situation usually represented by 
 the tip of the eleventh rib. 
 
 Difficulty is sometimes experienced in endeavouring to 
 verify the position of the twelfth dorsal spine, and in such 
 cases the pleural reflection behind the mid-axillary region 
 may be represented by a line which passes almost trans- 
 versely backwards toward the median posterior line from 
 the tenth rib in the mid-axillary line. 
 
 The two sacs are for the most part separated from one 
 
 another by the width of the vertebral bodies — 
 
 " * about i| inches. In the lower part of the 
 
 posterior mediastinum, however, the right sac approaches 
 
 the median line. 
 
 2. The lungs may be mapped out in part by lines similar 
 
 to those given for the pleural sacs. The apex of the 
 
 ■ R upper lobe of each lung extends into the supra- 
 
 Fig. xvii., clavicular region, and the anterior margins 
 5. 
 
 converge towards the angle of Ludwig, cutting 
 
 obliquely across the corresponding stern o-clavicular joint. 
 
 The two anterior borders do not, however, meet at the 
 
 angle of Ludwig, for the right lung on reaching the middle 
 
 line passes vertically downwards as far as the level of the 
 
 sixth or seventh chondro-sternal junction, whilst the left 
 
 lung runs down behind the left border of the sternum to 
 
 the junction of the fourth costal cartilage with the sternum. 
 
THE PLEURAL SACS, LUNGS, ETC. 
 
 FIG. XVI I, 
 
 1, I. The spinal dural sheath. 
 
 2, The spinal cord. 
 
 3, The filiun tenninale. 
 
 4, 4. The pleune. 
 
 5, 5. The lunj^s. 
 
 6, 6. The main oblique fissures of 
 
 the lunj^s. 
 
 7, 7. The apex of the lower lobe 
 
 of the lunjis. 
 
 8, 8. The roots of the lun;<s, 
 
 » The transvcTse processes of .l.e first and second lun.bar vertebra: should be dr.wu in such 
 .-I manner as to come into contact with the inner border oi the kidney. To/ace p. 42 
 
 The spleen. 
 
 The left kiilney in Morris's 
 
 quadrilateral.* 
 The ureter. 
 The liver. 
 
 The descending colon. 
 The rectum. 
 The posterior superior diac 
 
 spine. 
 
THE THORAX 43 
 
 The right lung, from the level of the sixth or seventh 
 chondro-sternal junction, sweeps outwards, cutting across — 
 (i) The sixth costal cartilage in the lateral vertical line 
 
 (2) The eighth rib in the mid-axillary line ; 
 
 (3) The tenth rib in the line of the inferior angle of the 
 scapula, and finally passing inwards towards the tenth 
 dorsal spine. 
 
 The left lung, from the outer border of the sternum at 
 the level of the fourth chondro-sternal articulation, passes 
 outwards for a short distance along the lower border of the 
 fourth costal cartilage, and then turns downwards and 
 inwards in a curved direction to the sixth costal cartilage 
 in the lateral vertical plane. The lung then sweeps round 
 the chest wall, following a course similar to that already 
 indicated as pursued by the right lung, the left lung lying, 
 however, at a slightly lower level. 
 
 Stress should, perhaps, be laid on the fact that, as the 
 lower border of each lung sweeps round the antero-lateral, 
 lateral, and posterior aspects of the chest wall, from the 
 sixth costal cartilage in front to the tenth dorsal spine 
 behind, the course pursued is practically transverse to the 
 long axis of the body. 
 
 It will be convenient to here put in a tabulated manner 
 the comparative lower levels of the right pleura and lung. 
 Starting in each case at the right chondro-sternal junction, 
 the pleura and lung may be represented by lines which 
 traverse the chest wall, cutting across the 
 
 (i) Lateral vertical line at the eighth costal cartilage 
 (pleura) — sixth costal cartilage (lung). 
 
 (2) Mid-axillary line at the tenth rib (pleura)— eighth 
 
 rib (lung). 
 
 (3) Scapular line at the eleventh rib (pleura)— tenth 
 
 rib (lung). 
 
 4—2 
 
44 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 (4) And sweeping in towards the twelfth dorsal spine 
 (pleura) — tenth dorsal spine (lung). 
 The numbers to be remembered are, therefore, 6, 8, 10, 
 II, and 12 for the pleura, and 6, 6, 8, 10, 10 for the lung. 
 
 On the left side, the levels are similar with two main 
 exceptions — {a) the lung and pleura sweep outwards so as 
 to leave a part of the heart uncovered (see " superficial 
 cardiac dulness"), {b) both lung and pleura descend to a 
 slightly lower level. 
 
 The Lower Limit of the Lung, the Pleura, and the Liver 
 in the Right Mid-axillary Line. 
 
 (i) The lung corresponds to the eighth rib. 
 
 (2) „ pleura „ „ tenth rib. 
 
 (3) „ liver ,, „ costal margin, or even 
 
 lower. 
 
 The fissures of the lungs. — The main fissure of each lung 
 Fie. xvi. 7. ^^ indicated by a carved line which starts behind 
 Fig. XVII., 6. ^^ the level of the second dorsal spine, the apex 
 of the main lower lobe of each lung, therefore, being 
 situated immediately below and external to this dorsal 
 spine. When the arms fall naturally to the side of the 
 body, the line representing the main fissure cuts across the 
 infraspinous surface of the scapula, and crossing then the 
 fifth rib in the mid-axillary line, terminates in front at 
 the inferior border of the lung at the level of the sixth 
 chondro-costal junction. When the arms are extended 
 above the head, the inferior angle of the scapula slides 
 upwards and outwards on the chest wall. In this position 
 the main fissure is represented by a line from the second 
 dorsal spine which passes downwards and outwards to the 
 inferior angle of the scapula, and then forwards to the 
 termination of the fissure at the inferior border of the lung. 
 
THE THORAX 
 
 45 
 
 The smaller or upper fissure of the right lung separates 
 
 off from the main fissure in the mid-axillary line, and passes 
 
 almost transversely forwards alone: the lower 
 Fig. XVI., 8. J b 
 
 border of the fourth rib and costal cartilage to 
 
 the anterior border of the lung. It is thus manifest that 
 
 the anterior aspect of the chest, above the level of the sixth 
 
 costal cartilage, corresponds to the upper two lobes of the 
 
 right lung and to the upper lobe of the left lung, whilst 
 
 the posterior aspect of the chest below the level of the 
 
 second dorsal spine corresponds to the right and left main 
 
 lower lobes. 
 
 The apices of the upper and lower lobes. — It will be here 
 in place to again lay stress on the fact that the apex of the 
 upper main lobe lies about i inch above the clavicle in the 
 supraclavicular fossa, under cover of the clavicular head 
 of a well-developed sterno-cleido-mastoid muscle, and 
 Fie xvi. ^hat the apex of the lower lobe lies immediately 
 Fig. XVII., 7. |-)giQ^ ^j^(j external to the spine of the second 
 dorsal vertebra. 
 
 The roots of the lungs lie opposite the spines of the fourth, 
 fifth, and sixth dorsal vertebrae, and the bodies 
 
 PifiT. xvii, 8. 
 
 'of the fifth, sixth, and seventh vertebrae. They 
 may be so represented, lying also midway between the 
 median posterior line and the vertebral border of the 
 scapula, the arms hanging loosely from the shoulders. 
 
 The areas of deep and superficial cardiac dulness. — 
 
 I. The area of deep cardiac dulness, quadrate in form. 
 
 Fig. XV., corresponds to the complete area already 
 
 mapped out as representing the projection of 
 
 the heart on to the anterior aspect of the chest wall. 
 
 2. The area of superficial cardiac dulness, more or less 
 triangular in shape, corresponds to that part of the heart 
 which is not covered by the thin anterior margin of the 
 
46 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 lung. This area can, with sufficient accuracy, be defined 
 pj j^yj ^0 3-S a triangular space, the left border being 
 Fig. XV. formed by a line from the fourth left chondro- 
 
 sternal articulation to the apex beat of the heart in 
 the fifth left interspace, the right border by a line which 
 passes downwards along the middle of the sternum from the 
 level of the anterior extremities of the fourth to the seventh 
 costal cartilages, and the base by a line which passes out- 
 wards from the level of the seventh costal cartilage to the 
 position of the apex beat. 
 
 A reference to Figs. xiv. and xv. will make it evident 
 thai paracentesis of the pericardium can be performed, without 
 injury to pleura or lung, in the fifth left intercostal space. 
 The internal mammary artery runs vertically downwards 
 about I inch from the outer border of the sternum, and 
 the needle should, therefore, be inserted through the fifth 
 intercostal space about i inch from the outer border 
 of the sternum. 
 
 The trachea and bronchi. — The trachea, 4I- inches long, 
 
 commences immediately below the cricoid 
 Fig. xvi., 1. . 
 
 cartilage, on a level with the sixth cervical 
 
 vertebra, and passing downwards through the superior 
 
 mediastinum, bifurcates opposite the level of the lower part 
 
 of the bod}^ of the fourth dorsal vertebra (Ludwig's plane). 
 
 The two bronchi diverge, the left being the longer 
 
 Fig. xvi., 2, ^^"^ ^hs narrower. The tendency of foreign 
 
 ' bodies to pass more frequently into the right 
 
 bronchus is explained by the fact that the septum between 
 
 the two bronchi is placed to the left of the middle line of 
 
 the trachea. The right bronchus, previous to the giving- 
 
 off of the eparterial bronchus, is less obliquely inclined 
 
 than the left bronchus, though subsequently it follows 
 
 much the same course. 
 
THE THORAX 47 
 
 The greater obliquity of the left bronchus accounts also 
 for the fact that the left pulmonary artery tends to lie at 
 the higher level, whilst the right pulmonary artery lies 
 below the level of the corresponding bronchus. 
 
 The oesophagus, 9 inches long, also commences at the 
 Fig. xix., level of the cricoid cartilage, and passing 
 
 '' ^' downwards through the superior and posterior 
 
 mediastina, pierces the diaphragm at the level of the 
 tenth dorsal vertebra, entering the stomach at the level 
 of the eleventh vertebra. 
 
 The entrance of the oesophagus into the stomach may 
 be indicated by taking a point on the seventh left costal 
 cartilage f inch away from the left side of the xiphisternal 
 junction. 
 
 The thoracic duct, 15 to 18 inches long, commences 
 
 as the receptaculum chyli, a spindle-shaped sac which lies 
 
 opposite the bodies of the first and second 
 Fig. XX., 5. 11- 
 
 lumbar vertebrae, and between the thoracic 
 
 aorta on the left and the vena azygos major on the right. 
 It may be represented on the surface by an oval enlarge- 
 ment placed just to the right of the middle line, occupying 
 the upper two-thirds of the space between the transpyloric 
 (first lumbar) and subcostal (third lumbar) planes. 
 
 The efferent duct pierces the diaphragm through the 
 
 aortic orifice opposite the twelfth dorsal vertebra, 
 
 Fig. XX., 6. J u u 
 
 and passes almost vertically upwards through 
 
 the posterior mediastinum, just to the right of the middle 
 line, as far as the lower part of the fourth dorsal vertebra 
 (Ludwig's plane). The duct now crosses behind the 
 oesophagus to the left of the middle line, and then again 
 passes vertically upwards through the superior medias- 
 tinum and into the neck as far as the level of the 
 transverse process of the seventh cervical vertebra. 
 
48 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 Finally, the duct curls outwards and downwards to open 
 
 into the angle between the internal jugular and 
 FifiT. XX., 7. 
 
 subclavian veins of the left side. The duct 
 
 drains the whole of the lymphatic area of the body, except 
 
 the right side of the head and neck, the right arm, the 
 
 right side of the thorax and the convexity of the liver, the 
 
 lymphatics from these regions draining into a smaller duct 
 
 which opens into the angle between the right internal 
 
 jugular and subclavian veins. 
 
CHAPTER IV 
 
 THE ABDOMEN 
 
 The anterior aspect of the trunk (i.e., thorax and abdomen) 
 
 Fig. xviii., ^^ divisible into right and left halves by a median 
 
 ' vertical plane from the middle point at the 
 
 suprasternal notch above to the symphysis pubis below. 
 
 Each half is again divided by a lateral vertical plane which 
 
 Fig. xviii., is drawn parallel to the median plane, half-way 
 4 4 
 ' ' between that plane and the anterior superior 
 
 iliac spine. Prolonged downwards, this lateral plane crosses 
 Poupart's ligament rather nearer to the inner than to the 
 outer end. Prolonged upwards, it crosses the clavicle 
 about midway between the median point at the supra- 
 sternal notch and the acromio-clavicular joint. 
 
 That part of the lateral vertical plane which traverses 
 the mammary region is sometimes called the " mammary 
 plane," that part which crosses the clavicle the " clavicular 
 plane," and the downward prolongation which cuts across 
 Poupart's ligament the " Poupart plane." 
 
 The clavicular, mammary, and Poupart planes are, 
 however, continuous, and they together form the lateral 
 vertical plane, which is chosen in preference to the mid- 
 Poupart plane of many anatomists, since it is measured 
 from the median plane to a fixed bony point. Two vertical 
 planes only will be consequently retained in the subdivision 
 of the anterior aspect of the trunk, the median and lateral 
 vertical planes. 
 
 49 
 
50 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 The median plane can be bisected by a horizontal plane 
 
 which is on the same level as the body of the first lumbar 
 
 vertebra. This plane so constantly cuts across the pyloric 
 
 end of the stomach that it is called the transpyloric plane, 
 
 and it w^ill be found that not only does this 
 Fig. xviii. 
 
 plane lie half-way between the suprasternal 
 
 notch and the symphysis pubis, but that it also lies 
 
 midway between the umbilicus and the sterno-xiphoid 
 
 junction. It is, therefore, not necessary to expose the 
 
 whole of the anterior aspect of the trunk in order to 
 
 verify the position of the transpyloric plane, a plane of the 
 
 greatest value in defining the position of several abdominal 
 
 viscera.* 
 
 The point at which the median vertical and transpyloric 
 
 planes intersect has been suitably called the 
 Fig. xviii., 1. 
 
 "central point," and the point of intersection 
 
 of the lateral vertical and transpyloric planes may be 
 
 tentatively called the " lateral central " or 
 Fig. xviii., 2. 
 
 " paracentral " point. This latter point usually 
 
 corresponds to the anterior extremity of the ninth costal 
 
 cartilage. 
 
 The distance between the " central point " and the top 
 
 of the symphysis pubis is bisected by a horizontal plane 
 
 which passes through the tubercles of the iliac 
 Fig. xviii. 
 
 crests, the intertuhercular plane, a plane corre- 
 sponding to the level of the body of the fifth lumbar 
 vertebra. It has also been suggested that the distance 
 between the " central point " and the suprasternal notch 
 should likewise be bisected by a plane, the thoracic plane, 
 which crosses the gladiolus at the level of some part of 
 
 * N.B. — Most of the "planes " mentioned in the text were first put 
 forward by Dr. C. Addison, Lecturer and Senior Demonstrator of 
 Anatomy, St. Bartholomew's Hospital, to whom the credit is due. 
 
THE ABDOMINAL AND THORACIC PLANES 
 
 Level of hard palate = first cervical. 
 
 Level of free margin of upper teeth = second cervical. 
 
 Level of hyoid bone = second to third cervical. 
 
 Level of upper part of thyroid cartdage = fourth cervical. 
 
 Level of cricoid caitilage = sixth cervical. 
 
 Supra- 
 sternal 
 plane 
 
 Lud wig's 
 
 plane "^ 
 
 Thoracic 
 plane 
 
 Sterno- 
 
 xiphoid 
 
 plane 
 
 Transpyloric 
 
 plane < 
 
 Subcostal 
 plane ^ 
 
 Umbilical <- 
 plane 
 
 Intertuber- 
 cular plane ** 
 
 Spinous _. 
 plane 
 
 Disc 
 between 
 2 and 3 D. 
 
 Disc 
 _^ Ijetwcen 
 4 and 5 D. 
 
 Disc 
 between 
 9 and 10 D. 
 
 Below sacral 
 promontory 
 
 FIG. XVII r. 
 
 1, The central point. 
 
 2, 2. The latc-rril central or paracentral point. 
 
 3, 3. The median vertical plane. 
 
 4, 4. The lateral vertical plane. 
 
 5, 5. The niid-I'ou])art point. 
 
 6, 6. The pubic spines. 
 
 To /ace />• 50- 
 
THE ABDOMEN 5I 
 
 the anterior extremities of the fourth costal cartilages. 
 
 This plane is, however, of little value, and is 
 Fig. xviii. 
 
 merely mentioned as completing the sym- 
 metrical subdivision of the median vertical plane into 
 four equal parts. 
 
 The following planes are, therefore, chosen as the most 
 scientific in the subdivision of the anterior aspect of the 
 trunk : 
 
 Two vertical planes — (i) The median ; (2) the lateral. 
 
 Three transverse planes — (i) The intertubercular; (2) the 
 transpyloric ; (3) the thoracic. 
 
 Two important points are also named — (i) The central 
 point ; (2) the lateral central point. 
 
 The abdominal regions mapped out by the intersection 
 of the transpyloric and intertubercular planes with the 
 lateral vertical planes receive the same nomenclature as in 
 the older methods of regional subdivision of the abdomen. 
 These regions are nine in number : 
 
 I. Right hypochondriac. 2. Epigastric. 3. Left hypo- 
 chondriac. 4. Right lumbar. 5 Umbilical. 
 Fig. xviii. •,*<-. tt 
 
 6. Left lumbar. 7. Right iliac. 8. Hypo- 
 gastric. 9. Left iliac. 
 
 Other Transverse Planes, with their Correspond- 
 ing Vertebral Levels. 
 (a) The suprasternal plane, on a level with the disc 
 
 between the second and third dorsal vertebrae. 
 RicT. xviii. 
 
 (b) Ludwif!;'s plane (junction of manubrium 
 
 and gladiolus), on a level with the disc between the fourth 
 
 and fifth dorsal vertebrae. 
 
 (c) The sterno-xiphoid plane (junction of sternum and 
 
 xiphoid cartilage), on a level with the disc between the 
 
 ninth and tenth dorsal vertebra;. 
 
52 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 (d) The subcostal plane, on a level with the lower part of 
 the third lumbar vertebra. 
 
 (e) The umbilical plane, on a level with the disc between 
 the third and fourth lumbar vertebrae. 
 
 (/) The spinous plane, drawn between the two anterior 
 superior iliac spines, and usually falling below the level of 
 the sacral promontory. 
 
 The linec^ semilunares correspond to the outer border 
 
 Fiff. XX. o^ the rectus abdominis muscle, and extend, 
 
 '^' with a slight outward convexity, from the pubic 
 
 spine below to the tip of the ninth costal cartilage above 
 
 (the lateral central point). 
 
 The linec^ transverse^ result from the tendinous inter- 
 Fie. XX. 13 sections in the rectus abdominis muscle. They 
 13, 13. g^j-g three in number, and are situated — (i) at 
 the level of the umbilicus; (2) midway between the 
 umbilicus and the xiphoid cartilage ; (3) immediately 
 below the xiphoid cartilage. 
 
 The semilunar fold of Douglas, representing the lower 
 
 limit of the posterior lamella of the rectus 
 Fig. XX., 14. ^ 
 
 sheath, lies about half-way between the um- 
 bilicus and the upper border of the pubic symphysis. 
 The umbilicus usually lies i to i^- inches above the 
 
 intertubercular plane, and corresponds to the 
 Fig. xviii. 
 
 level of the disc between the third and fourth 
 
 lumbar vertebrae. The umbilicus is, however, so incon- 
 stant in position that the umbilical plane is rejected as 
 often as possible in favour of a more definite and scientific 
 plane. 
 
 The iliac spines and crest. — When the body is in the 
 Figs xxii dorsal recumbent position, the anterior superior 
 
 ^'^"'- iliac spine is usually visible to the eye, and no 
 palpation is needful in order to fix its position. In the 
 
THE ABDOMEN 53 
 
 obese, however, it is generally necessary to trace forward 
 the iliac crest to its anterior termination. By tracing the 
 iliac crests in a backward direction the " iliac tubercles " 
 will be found, lying about 2 to 2^ inches behind the 
 anterior superior spines, and a line uniting these two 
 tubercles (the intertubercular plane) corresponds to the 
 level of the fifth lumbar vertebra. Still further backward, 
 the posterior superior iliac spines will be found at the 
 Fig. xvii posterior termination of the iliac crest. A line 
 ' which joins the posterior superior iliac spines 
 
 cuts across the spine of the second sacral vertebra. 
 
 The pubic spine lies at the outer limit of the pubic crest. 
 Fig. xviii., Iri the male, it is advisable to invaginate the 
 Fie xxii scrotum in order to locate the position of this 
 
 2i 2. spine ; whilst in the female, owing to the 
 
 prominence of the mons veneris, it is usually necessary 
 to abduct the thigh, to feel for the rounded tendon of the 
 adductor longus muscle, and to trace this tendon up to 
 its origin from a depression on the pubic bone, which is 
 situated immediately below and internal to the pubic 
 spine. 
 
 In the erect position of the body the symphysis pubis 
 is nearly horizontal, the inner or pelvic surface looking 
 upwards and only slightly backwards, whilst the external 
 surface faces downwards and a little forwards. The pubic 
 crest is therefore practically directed forwards and the 
 pubic arch backwards. A knife inserted horizontally 
 backwards immediately above the pubic symphysis would 
 pass above the upper limit of the prostate gland and below 
 the promontory of the sacrum ; whilst if directed hori- 
 zontally backwards below the symphysis pubis, it would 
 pierce the prostate near its centre and pass below the level 
 of the tip of the coccyx. 
 
54 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 The inguinal canal. — In the adult this canal is about 
 Fig. XX., 19, ij inches long, and extends from the internal 
 Fig XX. 17 to t^^ external abdominal rings. The internal 
 ^^- abdominal ring, a funnel-shaped prolongation of 
 
 the transversalis fascia, is situated f inch above the mid- 
 point of Poupart's ligament. The external abdominal ring, 
 Fig. XX., 18, formed by the splitting of the aponeurosis of 
 the external oblique muscle, is triangular in 
 shape, the base directed downwards and inwards and 
 opening up immediately above the pubic spine, whilst the 
 apex is directed upwards and outwards. 
 
 Petifs triangle. — This triangle is bounded in front by 
 the posterior border of the external oblique, and behind 
 by the anterior border of the latissimus dorsi muscle, 
 whilst the base is formed by part of the iliac crest. The 
 external oblique is inserted into the anterior half of the 
 iliac crest, and the base of the triangle corresponds to 
 I to 2 inches of the bone behind the mid-point of the 
 crest. The triangle is subject to great variation in size, 
 the two bounding muscles converging rapidly above to 
 form the apex of the triangle. The floor is formed by the 
 internal oblique muscle. 
 
 The Alimentary Canal. 
 
 The stomach. — Capacity about 2 pints. The cardiac 
 orifice lies opposite the eleventh dorsal vertebra, 
 ■' ' and is situated about 4 inches away from the 
 surface. It corresponds in position to a point on the 
 seventh costal cartilage | inch away from the outer 
 border of the sterno -xiphoid junction. The seventh 
 costal cartilage is the lowest of the series of cartilages 
 which articulate in front with the mesial sterno-xiphoid 
 bar, and forms, therefore, the upper lateral boundary of 
 
THE ABDOMEN 55 
 
 the epigastric triangle. The pyloric orifice hes opposite 
 
 the first lumbar vertebra, and corresponds in 
 Fip- xix 3 • • 
 
 ■' ■ position to a point in the transpyloric plane 
 
 just to the right of the middle line. 
 
 The lesser curvature is represented by a curved line, con- 
 vexity to the left, uniting the above two points. The 
 greater curvature, in the moderately distended condition of 
 the stomach, ascends to the lower border of the left fifth 
 costal cartilage and rib, lying immediately above and 
 behind the apex of the heart. Sweeping then downwards, 
 the greater curvature usually cuts the left costal margin at 
 some part of the ninth costal cartilage, and finally curves 
 
 upwards and inwards to the pylorus. The 
 Fig. XX., 1. . . . . 
 
 upper limit of the fundus of the stomach corre- 
 sponds to the level of the left dome of the diaphragm. 
 
 The duodenum. — Total length, about lo inches. Part i 
 Fig. xix., 4, ^2 inches; part 2 = 3 to 4 inches; part 3 = 4 to 
 ' ^' 5 inches. 
 
 The pyloric orifice of the stomach lies opposite the first 
 lumbar vertebra, and the first part of the duodenum is 
 directed backwards, with a slight inclination upwards, to 
 the right side of the body of the first lumbar vertebra. 
 
 Part 2 descends, on the right side of the median vertical 
 plane, from the level of the first lumbar vertebra (trans- 
 pyloric plane) to the level of the third lumbar vertebra 
 (subcostal plane). The third part of the duodenum passes 
 almost transversely across the middle line at the level 
 of the subcostal plane, and having reached the left 
 Fig xix., side of the middle line, ascends sharply to 
 
 ^' the duodeno-jejunal flexure, which is placed on 
 
 a level with the second lumbar vertebra, just below the 
 transpyloric plane, and i to i^ inches to the left of the 
 middle line. The duodenum is subject to great variation 
 
FIG. XIX. 
 
 1, I. The oesophagus. 
 
 2. The stomach. 
 1.. The pylorus. 
 
 4, 4, 4. The three parts of the duodenum. 4'- The pancreas. 
 :;'. The duodeno-jejunal flexure. 
 
 6. The attachment of the mesentery of the small intestine. 
 
 7. The ileo-csecal valve. 
 
 8. The caecum. 
 
 9. The vermiform appendix. 
 
 10. The ascending colon. 
 
 11. The hepatic flexure. 
 
 12. The splenic flexure. 
 
 13. The descending colon. 
 
 14. The iliac colon. 
 
 15. The ilio-pelvic colon. 
 
 16. The gas tro -hepatic omentum. 
 17 The foramen of Winslow. 
 
 18. The common bile-duct. 
 N.B.— The transverse colon has been intentionally omitted. 
 
THE ALIMENTARY CANAL 
 
 FIG. XIX. 
 
 a, a, and a', a' = \.\\q lateral vertical planes. 
 
 b, h. The transpyloric plane. 
 
 c, c. The subcostal ]>lane. 
 
 d, d. The intertubercular plane. 
 
 To /ace p. 56. 
 
THE ABDOMEN 57 
 
 The vermiform appendix. — The opening of the appendix 
 Fig. xix., ^"t° the caecum is situated just below and 
 
 ®- internal to the junction of the right lateral 
 
 vertical and intertubercular planes, at the top right-hand 
 corner of the hypogastric region. The surface marking of 
 the csecal orifice of the appendix does not coincide with 
 McBurney's point, which is situated at the junction of 
 the outer and middle thirds of a line drawn from the 
 right anterior superior iliac spine to the umbilicus. This 
 point represents the usual seat of maximum pain on 
 palpation in an attack of appendicitis. The appendix 
 is usually 3 to 4 inches long, and, according to Testut, 
 is in 40 per cent, of cases directed downwards and 
 inwards, overhanging the pelvic brim, whilst in 26 per 
 cent, of cases only is it directed upwards and inwards 
 (towards the spleen). Stress should be laid on the fact 
 that the ileo-caecal valve and the caecal orifice of the 
 appendix are both situated on the postero-internal aspect 
 of the caecum. 
 
 The ascending colon passes upwards from the level of 
 Fig. xix., the intertubercular plane to the upper part of 
 the ninth right costal cartilage, the gut there 
 turning on itself to form the hepatic flexure. In its 
 upward course the ascending colon lies almost entirely 
 to the right of the right lateral vertical plane. 
 
 The transverse colon extends from the hepatic flexure on 
 Fie xix ^he right to the splenic flexure on the left. The 
 
 "• former flexure corresponds to the ninth costal 
 
 cartilage, whilst the latter reaches upwards as high as the 
 eighth. In between these two points the gut varies greatly 
 in direction in different subjects. Most commonly the 
 gut passes almost transversely from one side to the other, 
 crossing the middle line at about the level of the second 
 
 5-2 
 
58 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 lumbar vertebra. It also crosses the second part of the 
 Fiff. xix., duodenum, and lies, therefore, usually above 
 the umbilical plane. In the diagram the two 
 flexures are dep cted, but the intervening portion of the 
 gut has been intentionally omitted. 
 
 The descending colon passes almost vertically downwards 
 Fig. xix., from the region of the splenic flexure to the 
 level of the posterior part of the iliac crest, below 
 which level it becomes known as the iliac colon. The 
 descending colon lies wholly to the left of the left lateral 
 vertical plane. 
 
 The operation of lumbar colotomy is now seldom 
 Fig. xvii., performed, but it is nevertheless necessary to 
 indicate the position of the descending colon 
 on the posterior aspect of the trunk. It corresponds in 
 direction to a line drawn vertically upwards to the tip of 
 the last rib, from a point situated J inch behind the mid- 
 point along the iliac crest between the anterior and 
 posterior superior iliac spines. 
 
 The iliac and pelvic colon. — Between the termination 
 of the descending colon at the level of the iliac crest, and 
 the beginning of the rectum proper at the level of the 
 third piece of the sacrum, the large gut describes so varied 
 a course that no definite detailed account can be given of 
 its surface marking. It may, however, be briefly described 
 Fig. xix., 3-S passing downwards and inwards from the 
 
 ^'*' level of the iliac crest, parallel to Poupart's 
 
 ligament, as far as the left side of the pelvic brim (the 
 iliac colon). The gut then forms a great loop (the pelvic 
 Fig. xix., colon), which sweeps over to the right side of 
 the pelvic brim, turning on itself to become the 
 rectum at the level of the third sacral vertebra. 
 
 The rectum. — A line which unites the two posterior 
 
THE ABDOMEN 
 
 59 
 
 superior iliac spines crosses the spinous process of the 
 Fig. xvii., second sacral vertebra. The rectum begins at 
 the level of the third sacral vertebra, and may 
 be indicated on the surface by drawing in the gut as 
 starting about ^ to f inch below the above-mentioned line, 
 and extending downwards, following the curves of the 
 sacrum and coccyx, to the anal orifice, which is placed 
 about 2 inches below the level of the tip of the coccyx. 
 The dura mater enclosing the spinal cord (see ^^ spinal 
 cord'') reaches downwards to the level of the 
 third sacral vertebra. The spinal dura, there- 
 fore, terminates at the same level as the rectum begins, a 
 point to be borne in mind in those operations carried out 
 in the sacral region for the exposure of a growth involving 
 the gut in the neighbourhood of the ilio-pelvic and rectal 
 junction. 
 
 The Kidney 
 
 {Length, 4^ inches; breadth, 2 J inches; thickness, 
 
 1 1 inches; weight, 4I ounces). 
 
 {a) Anterior surjace marking. — The two kidneys are 
 Fig. XV. obliquely placed in such a manner that the 
 
 ^^- superior poles lie i| to 2 inches, and the inferior 
 
 poles 2h to 3 inches, distant from the middle line. The 
 left kidney lies at a slightly higher level than its fellow, 
 and the hilum is placed just below and in-ternal to the 
 junction of the transpyloric and left lateral vertical 
 planes ; or, in other words, the hilum of the left kidney lies 
 just internal to the anterior extremity of the ninth costal 
 cartilage. The upper pole lies half-way between the sterno- 
 xiphoid and transpyloric planes, whilst the lower pole 
 corresponds to the subcostal plane. The right kidney does 
 not ascend to quite such a high level, and the inferior pole 
 
60 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 lies opposite the umbilical plane. The hilum of this kidney 
 also lies just below the level of the hilum of the opposite 
 kidney. 
 
 (b) Posterior surface marking — Morris's quadrilateral. — 
 Fig. xvii. Two vertical lines are drawn at a distance of 
 
 '^- I inch and 3^ inches respectively from the 
 
 median posterior line, and two horizontal lines are drawn 
 outwards at the level of the spinous processes of the 
 eleventh dorsal and third lumbar vertebrae. In the quadri- 
 lateral so marked out, the kidneys are drawn, care being 
 taken to place the long axis of each kidney in the required 
 oblique direction. 
 
 The Ureters 
 
 {Length, 10 inches'). 
 
 (a) Anterior surface marking. — The ureter passes nearly 
 Fig. XV. vertically downwards from the hilum of the 
 kidney (just below and internal to the junction 
 of the transpyloric and lateral vertical planes), and dips 
 into the true pelvis in close relation to the bifurcation 
 of the common iliac artery. This vessel bifurcates into 
 internal and external iliacs at the junction of the upper 
 and middle thirds of a line drawn from a point ^ inch 
 below and to the left of the umbilicus (the aortic bifurca- 
 tion) to a second point situated half-way between the 
 anterior superior iliac spine and the symphysis pubis. 
 This apparently complicated surface marking for the ureter 
 will be rendered more easy by a reference to the diagram. 
 The right ureter generally dips into the pelvis just below 
 the bifurcation of the common iliac artery. 
 
 (&) Posterior surface marking. — The course of the ureter 
 Fig. xvii. on the posterior aspect of the trunk can be 
 
 ^^' represented by a line drawn vertically upwards 
 
THE ABDOMEN 6l 
 
 from the posterior superior iliac spine to the level of the 
 spinous process of the second lumbar vertebra. 
 
 The ovary lies in the angle between the internal and 
 Fig XV external iliac arteries, immediately below the 
 pelvic brim and anterior to the ureter. 
 
 The urachus is directed upwards from the apex of the 
 Fig. XX. bladder, at the upper border of the pubic 
 
 '^" symphysis, to the umbihcus. 
 
 Abdominal Vessels. 
 
 The abdominal aorta. — The thoracic aorta enters the 
 Fig. XV., abdominal cavity by passing beneath the middle 
 
 ^^" arcuate ligament of the diaphragm at the level 
 
 of the twelfth dorsal vertebra. The vessel then changes 
 its name, and the abdominal aorta passes vertically 
 downwards as far as the left side of the body of the fourth 
 lumbar vertebra, at which level it bifurcates into the two 
 common iliac arteries. The course of the vessel may be 
 mapped out on the surface by taking a point about two 
 fingers' breadth above the transpyloric plane and slightly 
 to the left of the middle line, and by drawing a line verti- 
 cally downwards to a second point situated ^ inch below 
 and to the left of the umbilicus. 
 
 The first large vessel which arises from the abdominal 
 p;o- vw aorta is the cceliac axis. This trunk is given off 
 
 ^^- at the level of the twelfth dorsal vertebra, and 
 
 divides, after a course of about ^ inch, into three main 
 trunks— the hepatic, splenic, and coronary or gastric 
 arteries. 
 
 The superior mesenteric (level of disc between the twelfth 
 Fig. XV., dorsal and the first lumbar vertebrae) follows 
 
 ^^- next, springing from the anterior aspect of the 
 
 aorta immediately above the transpyloric plane. 
 
62 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 The renals (level of the first lumbar vertebra) pass out- 
 Fig. XV., wards from the lateral aspect of the aorta 
 
 immediately below the level of the trans- 
 pyloric plane. 
 
 The inferior mesenteric (level of the third lumbar 
 Fig. XV., vertebra) arises from the left side of the main 
 
 trunk at about the level of the subcostal plane. 
 The common iliac artery corresponds to the upper third 
 Fig. XV. of a line drawn from a point | inch below and 
 
 to the left of the umbilicus to a second point 
 situated half-way between the anterior superior iliac spine 
 Fig. XV. 3-^d the symphysis pubis. The external iliac 
 
 artery corresponds in direction to the lower 
 two-thirds of this line. 
 
 The deep epigastric artery is given off from the external 
 Fig. XX., ili^-c just as that vessel passes under Poupart's 
 
 ligament half-way between the anterior superior 
 iliac spine and the symphysis pubis. The epigastric artery 
 then passes upwards and inwards along the inner side 
 of the internal abdominal ring towards a point situated 
 ^ inch to I inch outside the umbilicus, entering the 
 rectus sheath at the level of the semilunar fold of 
 Douglas. 
 
 This vessel forms the outer boundary of Hesselbach's 
 Fig. XX., triangle, the inner boundary of this space being 
 
 formed by the linea semilunaris of the same 
 side, and the base by Poupart's ligament. Each triangle 
 is vertically subdivided into two parts by the obliterated 
 hypogastric artery, on either side of which herniae may 
 protrude. 
 
 The inferior vena cava is formed by the junction of the 
 two common iliac veins on the right side of the body of 
 the fifth lumbar vertebra, about i inch below and | inch 
 
FIG. XX. 
 
 1. I. The diaphragm. 
 
 2. The liver. 
 
 3. The gall-bladder. 
 
 4. The ligamentum teres. 
 
 5. The receptaculum chyli. 
 
 6. The thoracic duct. 
 
 7. The venous termination of the duct. 
 
 8. The internal mammary artery. 
 
 9. The superior epigastric artery. 
 ID. The musculo-phrenic artery. 
 
 11. The rectus abdominis muscle. 
 
 12, 12. The linse semilunares. 
 I3> I3» 13- The linse transversae. 
 
 14. The semilunar fold of Douglas. 
 
 15. The nrachus. 
 
 16. Hesselbach's triangle. 
 
 17. 17. The internal abdominal ring. 
 
 18. 18. The external abdominal ring. 
 
 19. 19. The inguinal canal. 
 
 20. The deep epigastric artery. 
 
THE LIVER, ANTERIOR ABDOMINAL WALL, ETC. 
 
 riG. XX, 
 
 'I'o/ncc />. 62. 
 
THE ABDOMEN 63 
 
 to the right of the umbilicus. The vein passes upwards 
 Fig. XV., ^^ pierce the quadrate opening of the diaphragm 
 at the level of the eighth dorsal vertebra, 
 entering the right auricle of the heart opposite the fifth 
 right interspace and the adjoining part of the sternum. 
 
 The Liver. 
 
 The anterior border can be mapped out by drawing a 
 
 curved line from a point in the fifth left 
 F iff XX 2 
 
 interspace 3^^ inches from the middle line (the 
 position of the apex of the heart), the line cutting the 
 left costal margin at the tip of the eighth costal cartilage 
 and the right costal margin at the tip of the ninth costal 
 cartilage. Between these two latter points, the anterior 
 border of the liver crosses the middle line half-way between 
 the umbilicus and the sterno-xiphoid junction ( = trans- 
 pyloric plane), whilst a notch to the right of the middle 
 line indicates the hepatic attachment of the 
 ig. XX., . ^j-^^jjjgjjf^^jj^ teres, which passes from that notct 
 downwards and inwards to the umbilicus. 
 
 Beyond the tip of the ninth right costal cartilage the 
 
 anterior border of the liver follows the lower limit of the 
 
 costal arch, descending sometimes even below that level, 
 
 Fig. xvii., and after cutting across the twelfth rib, ascends 
 
 '^- towards the level of the eleventh dorsal spine. 
 
 The iippcr limit of the liver is indicated by a line starting 
 
 as before in the fifth left interspace 3J inches 
 
 '^' '''^' from the middle line, and ascending slightly as 
 
 it passes to the right. This line cuts across the sixtii 
 
 Fig. xvii, t"'??^* chondro-sternal articulation, the upper 
 
 ^2- ' border of the right fifth costal cartilage in the 
 
 right lateral vertical plane, the sixth rib in the mid-axillary 
 
64 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 line, sweeping thence just below the angle of the scapula 
 towards the eighth dorsal spine. 
 
 The gall-bladder. — The fundus projects from under the 
 
 anterior border of the liver in the angle between 
 
 *' ' the tips of the ninth and tenth costal cartilages 
 
 and the outer border of the rectus abdominis muscle. 
 
 The diaphragm. — On ordinary inspiration the right dome 
 
 of the diaphragm corresponds in level to the 
 
 *' ' lower part of the fourth right interspace, whilst 
 
 the left dome ascends to the lower part of the fifth left rib 
 
 and costal cartilage. 
 
 The Common Bile-du-ct, etc. 
 
 The gastro-hepatic omentum, passing upwards from the 
 Fig. xix. lesser curvature of the stomach to the trans- 
 verse fissure of the liver, presents a free edge, 
 which looks downwards and to the right, and which forms 
 the anterior boundary of the foramen of Winslow, the 
 pj ^^^^ channel of communication between the greater 
 
 '^* and the lesser peritoneal sacs. The free edge 
 
 of this omentum further contains (between its two layers 
 of peritoneum) three important structures : 
 
 1. The common bile-duct to the right. 
 
 2. The hepatic artery to the left. 
 
 3. The portal vein behind and between the two former 
 structures. 
 
 In mapping out any of these structures, it is, therefore, 
 advisable to first draw in the lesser curvature of the 
 stomach, the pylorus, the three parts of the duodenum, 
 and the pancreas. The pylorus occupies such a definite 
 position in the transpyloric plane that all these structures 
 are easily and quickly drawn in. The free margin of the 
 lesser omentum should be represented as a curved line 
 
THE ABDOMEN 65 
 
 passing upwards and to the right for i^ to 2 inches from 
 the duodeno-pyloric junction. The portal vein is formed 
 behind the head of the pancreas by the union of the 
 superior mesenteric and splenic veins, and passes up- 
 wards to the transverse fissure of the Hver behind the 
 first part of the duodenum, and in the free edge of the 
 lesser omentum. 
 
 The hepatic artery, a branch of the coeliac axis, passes 
 upwards from the upper border of the first part of the 
 duodenum, in the free edge of the lesser omentum, to the 
 transverse fissure of the liver. 
 
 The common bile-duct is 3 inches long, and is formed 
 Fie xix ^y ^^^ union of the hepatic and cystic ducts. 
 
 '^' It passes downwards in the free edge of the 
 
 gastro-hepatic omentum, behind the first part of the 
 duodenum, behind the head of the pancreas, and opens 
 on the inner and posterior aspect of the second or 
 descending part of the duodenum. 
 
 The Spleen, 
 
 The long axis of the spleen corresponds to the tenth 
 Fig. xvii., "b, and the viscus extends upwards to the 
 
 ^- upper border of the ninth rib, and downwards 
 
 to the lower border of the eleventh rib. The upper and 
 inner pole lies i^ to 2 inches away from the tenth dorsal 
 spine, whilst the lower or anterior pole reaches as far 
 forwards as the mid-axillary line. 
 
 The Spinal Cokd. 
 
 The spinal cord extends from the foramen magnum to 
 
 the lower border of the first lumbar vertebra 
 
 Fi|' xvii , (transpyloric plane). The cord follows the 
 
 curves of the vertebral column, and presents 
 
66 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 also two enlargements, the intumescentia cervicalis and 
 
 lumbalis. The former swelling lies between the third 
 
 cervical and second dorsal vertebrae, the latter between the 
 
 ninth and twelfth dorsal vertebrae. Near its termination 
 
 the cord tapers away as the conus medullaris. 
 
 The filum terminale, the prolongation of the cord, is 
 
 continued onwards from the lower part of the 
 Fig. vii., 7. 
 Fig. xvii., body of the first lumbar vertebra to near the 
 
 tip of the coccyx, at which level it blends with 
 
 the periosteum lining that bone. 
 
 The theca vertebralis, or dural sheath, extends as low 
 
 Fig. vii., 6. as the third sacral vertebra, at which level it is 
 Fid xvii. 
 
 1, 1, ' pierced by the filum terminale. 
 
 A line uniting the two posterior superior iliac spines 
 
 .. ,_ cuts across the second sacral spine, and the 
 Fig. vii., 10. . . 
 
 Fig. xvii., dural sac, therefore, terminates about | inch 
 
 below the level of this interspinous line. At the 
 
 third month of intra-uterine life the cord extends the 
 
 whole length of the vertebral canal, whilst at birth it 
 
 reaches as low down as the third lumbar vertebra. 
 
 A reference to Fig y will show that cerebro-spinal fluid 
 
 might be withdrawn from the thecal canal anywhere 
 
 between the termination of the cord at the level of the 
 
 transpyloric plane and the base of the sacrum. A line 
 
 drawn across the back, at right angles to the long axis of 
 
 the body, at the level of the highest part of the iliac crests, 
 
 cuts across the median posterior line at the level of the 
 
 interspace between the laminae of the second and third or 
 
 third and fourth vertebrae. It is at this point, or rather to 
 
 one side of this point, that lumbar puncture is carried out. 
 
THE ABDOMEN 67 
 
 THE PERINEUM. 
 
 A brief account only will be given, as, though the 
 landmarks are most important, the tendency is great to 
 drift into the question of surgical applied anatomy, a pitfall 
 which the writer is most anxious to avoid. 
 
 The perineum is, in shape, roughly quadrilateral, the 
 lateral boundaries being formed in front by the diverging 
 rami of the pubis and ischium, and behind by the ischial 
 tuberosity and the gluteus maximus muscle. The anterior 
 and posterior angles of the space are formed respectively 
 by the symphysis pubis and the tip of the coccyx. The 
 subpubic angle is obtuse in the female and acute in the 
 male. In the female, also, the ischial tuberosities are 
 further apart and slightly everted. The perineum is 
 divided into two areas by a line drawn between the 
 anterior part of the ischial tuberosities, thus forming — 
 
 {a) The genital area. 
 (6) The rectal area. 
 
 This transverse line passes about i inch in front of the 
 anus, and represents the level of the two transverse perinei 
 muscles, the posterior border of the triangular ligament, 
 and the line along which Colles's fascia is reflected round 
 the posterior border of the two transverse perinei muscles 
 to become continuous with the posterior border of the 
 triangular ligament. The " central tendinous point of the 
 perineum " corresponds to the middle of this line, and 
 forms the point of attachment of several muscles. 
 
 {a) The genital area.~ln the male, this area is divided 
 into two lateral triangles by the median antero-posterior 
 prominence of the bulb of the penis (corpus spongiosum). 
 The two crura of the penis (corpora cavernosa) diverge as 
 
68 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 they pass backwards towards the tuberosity of the ischium, 
 and the main pudic vessels He under cover of these 
 erectile organs. The triangle is completed behind by 
 the transversus perinei muscle. All the above-mentioned 
 erectile structures and muscles lie superficial to the 
 triangular ligament. 
 
 In the female, this area is practically cut into two lateral 
 triangles by the orifice of the vagina, each side of which 
 lies the bulb of the vestibule, an organ of erectile tissue, 
 corresponding developmentally to the male corpus spon- 
 giosum. More superficially, the two labia majora converge 
 towards the mons veneris in front, whilst, on the mesial 
 aspect of the labia majora, the labia minora converge 
 towards the clitoris, between which body and the vaginal 
 margin a smooth triangular space exists, the vestibule. 
 At the junction of the vagina and the vestibule the urethra 
 opens. 
 
 Vaginal examination. — Passing along the posterior vaginal 
 wall the finger enters the superior fornix, the upper part 
 of which is in direct relation with the peritoneal cavity 
 (Douglas's pouch). Along the anterior wall the smaller 
 anterior fornix is first encountered, this cul-de-sac not 
 being directly related to the peritoneal cavity, and imme- 
 diately above this the as uteri may be examined. Bi- 
 manually, much information can usually be gained with 
 regard to the size and position of the uterus, the condition 
 of the uterine appendages, the contents of Douglas's 
 pouch, etc. 
 
 (6) The rectal area. — This area is divided into two 
 lateral parts by a line drawn from the " central point of 
 the perineum " to the tip of the coccyx, and the examining 
 fingers may, in thin subjects, be made to sink deeply 
 into each lateral recess (the ischio-rectal fossae), being 
 
THE ABDOMEN 69 
 
 then in relation with the rectum and levator ani muscle 
 on the inner side, the ischial tuberosity and the obturator 
 internus muscle on the outer side, the transverse perinei 
 muscle in front, and the gluteus maximus and great sacro- 
 sciatic ligament behind. 
 
 Rectal examination. — If the forefinger be gently inserted 
 into the rectum, definite resistance is offered by the 
 external and internal sphincters, the latter aided by 
 contraction of the levator ani muscle Further on the 
 finger enters the dilated ampuUary portion of the rectum, 
 meeting, perhaps, further obstruction from Houston's 
 valves. When insinuated as far as possible, the palmar 
 aspect of the distal phalanx will, in the male, be in contact 
 with the vasa deferentia and the vesiculse seminales, the 
 middle phalanx with the prostate gland, and the proximal 
 phalanx with the sphincters, which intervene between the 
 finger and the triangular ligament and the spongy and 
 membranous parts of the urethra. Posteriorly, the hollow 
 of the sacrum and the coccyx can be fully explored. It 
 is most important to bear in mind that the peritoneum 
 is reflected from the rectum on to the upper third of the 
 vagina in the female, and on to the vesiculce seminales, 
 about I inch above the upper limit of the prostate gland, in 
 the male. 
 
 In children, since the true pelvis is but little developed 
 and the later pelvic viscera are practically abdominal, a 
 rectal examination enables one to explore all the lower 
 abdominal viscera, including the bladder. 
 
FIG. XXI. 
 
 1. The iliac crest. 
 
 2. The posterior superior iliac spine. 
 
 3. The sacrum. 
 
 4. The second sacral spine. 
 
 5. The coccyx. 
 
 6. The pyriformis muscle. 
 
 7. The ischial tuberosity. 
 
 8. The sciatic artery and the ischial spine. 
 
 9. The great trochanter of the femur. 
 
 10. The gluteal artery. 
 
 11. Nelaton's line. 
 
 12. The great sciatic nerve. 
 
 13. The internal popliteal nerve. 
 
 14. The external popliteal nerve. 
 
 15. The biceps tendon. 
 
 16. The semimembranosus muscle. 
 
 17. The semitendinosus muscle. 
 
 18. The outer head of the gastrocnemius muscle. 
 
 19. The inner head of the gastrocnemius muscle. 
 
 20. The posterior tibial artery and nerve. 
 
 21. The external saphenous vein. 
 
THE BACK OF THE THIGH AND LEG 
 
 no. xxr. 
 
 To /are f>. 70, 
 
FIG. XXII. 
 
 1. The iliac crest. 
 
 2. The pubic spine. 
 
 3- Poupart's ligament. 
 
 4. The anterior crural nerve. 
 
 5. The common femoral artery. 
 
 6. The common femoral vein. 
 
 7. The crural canal. 
 
 8. The superficial femoral artery. 
 
 9. Vastus externus. 
 
 10. Vastus internus. 
 
 11. The upper limit of the synovial membrane of the 
 
 knee-joint. 
 
 12. The patella. 
 
 13. The ligamentum patellae. 
 
 14. The tubercle of the tibia. 
 
 15. The internal tuberosity of the tibia. 
 
 16. The external tuberosity r>'"the tibia. 
 
 17. The head of the fibula. 
 
 18. The internal saphenous vein. 
 
 19. The anterior tibial artery. 
 
 20. The anterior tibial nerve. 
 
 21. The musculo-cutaneous nerve. 
 
 22. The dorsalis pedis artery. 
 
 23. The dorsal venous arch. 
 
THE FRONT OF THE THIGH AND LEG 
 
 ]'I(>. XXII. 
 
 To follow I'ig. XXI. 
 
THE LOWER EXTREMITY " 71 
 
 which becomes less marked when, as the result of disease 
 or disuse, the gluteus maximus undergoes atrophic 
 changes. The fold of the nates does not correspond to 
 Fig. xxi. *^^ ^°^^^ border of the gluteus maximus muscle, 
 as it crosses almost transversely the lower 
 oblique fibres of that muscle. This fold also becomes less 
 distinct when the glutei muscles degenerate. The head 
 and neck of the femur form with the shaft of that bone 
 an angle of 125 to 130 degrees. 
 
 Nelaton's line.—" If in the normal state you examine 
 Fig. xxi., 11. the relation of the great trochanter to the other 
 ' 5. '""■' bony prominences of the pelvis, you will find 
 that the top of the great trochanter corresponds to a line 
 drawn from the anterior superior iliac spine of the ilium 
 to the most prominent point of the tuberosity of the 
 ischium. This line also runs through the centre of the 
 acetabulum. The extent of displacement in dislocation or 
 in fracture is marked by the projection of the trochanter 
 behind and above this line " (Nelaton). 
 
 Bryant's triangle. — When the patient is in the dorsal 
 Fig. xxiii., recumbent position, draw a line round the 
 
 * body at the level of the anterior superior 
 
 iliac spine, and from this line drop a perpendicular to the 
 top of the great trochanter. To complete the triangle, 
 draw a line from the anterior superior iliac spine to the 
 top of the trochanter. When the trochanter is displaced 
 upwards the perpendicular line is diminished in length as 
 compared with the sound side, and when it undergoes 
 a backward displacement the spino-trochanteric line is 
 relatively increased in length. 
 
 (6). — Anterior and internal aspect. The lower extremity 
 is demarcated from the abdomen by a well-marked furrow, 
 the inguinal groove. This corresponds to the situation 
 
72 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 of PouparVs ligament, the recurved lower border of the 
 obliquus externus abdominis muscle. This ligament, as 
 it passes from the anterior superior iliac spine to the 
 pubic spine of the same side, forms the upper boundary 
 of Scarpa's triangle, a space which is best demonstrated 
 Fig. xxiv., when the thigh is flexed, abducted, and everted. 
 ' The sartorius muscle is then thrown into action 
 
 and the outer boundary of the space so shown. If the 
 hand be now placed on the upper and inner aspect of 
 the thigh and the limb be sharply adducted, a rounded 
 tendon at once becomes noticeable. This is the adductor 
 longus, which forms the inner boundary of Scarpa's triangle. 
 
 The outwardly directed adductor longus and the 
 inwardly curving sartorius converge to form the apex of 
 the triangle. 
 
 The floor of the space is formed from without inwards 
 by the iliacus, psoas, pectineus and adductor longus 
 muscles. In the superficial fascia which overlies this 
 region, numerous lymphatic glands are situated, and it 
 will here be convenient to briefly discuss their general 
 arrangement. The superficial lymphatic glands are placed 
 in three main groups : 
 
 (i) The oblique or inguinal glands, running parallel to 
 and below Poupart's ligament, and draining the anterior 
 aspect of the abdomen below the level of the umbilicus, 
 the lower half of the side and back, the gluteal region, 
 and the upper and outer part of the thigh. 
 
 (2) The vertical or femoral glands, running with the long 
 internal saphenous vein, and draining the greater part of 
 the inner aspect of the foot, leg, and thigh. 
 
 (3) The pubic glands, situated below and external to the 
 pubic spine, and draining mainly the external genitals, 
 perineum, and anus. 
 
THE LOWER EXTREMITY 73 
 
 The deep fascia presents an opening, the saphenous 
 Fig. xxii., 8. opening, for the transmission of the long 
 ig. XXIV., 9. saphenous vein to the common femoral vein. 
 This foramen is oval in shape, being i inch long and | to 
 f inch broad, the long axis vertical. The central point 
 of the opening is situated i^ inches below and i^- inches 
 external to the pubic spine. 
 
 Beneath the deep fascia overlying Scarpa's triangle, 
 certain important structures are situated, such as the 
 common, superficial femoral, and profunda femoris 
 arteries, the corresponding veins, and the anterior crural 
 nerve. These will all be dealt with later, the femoral 
 rmg alone needing here further definition. 
 
 The femoral ring, through which a femoral hernia 
 Fig. xxii., 7. commonly escapes from the abdominal cavity. 
 Fig. XXIV., 8. jjgg ijgiow the inner part of Poupart's ligament, 
 and external to the pubic spine. A good way to define the 
 ring with precision is that recommended by Holden : 
 " Feel for the pulsation of the common femoral artery, 
 allow ^ inch on the inner side for the femoral vein, then 
 comes the femoral ring." The crural or femoral ring 
 presents the following boundaries : To the inner side is 
 Gimbernat's ligament ; to the outer side is the femoral 
 vein ; in front is Poupart's ligament ; behind is the 
 pectineus muscle and the horizontal ramus of the os 
 pubis. 
 
 Hunter's canal, a more or less triangular muscular 
 Fig. xxiv., channel for the transmission of the superficial 
 femoral artery, occupies the middle third of the 
 antero-internal aspect of the thigh. During forcible con- 
 traction of the thigh muscles, Scarpa's triangle may be 
 seen to be continued downwards as a shallow depression 
 between the extensor and adductor muscles, this furrow 
 
74 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 corresponding to the position of the canal in question. 
 The anatomical boundaries of the canal are (i) vastus 
 internus externally, (2) adductor longus and magnus 
 behind, (3) sartorius and a strong fascial band between 
 the adductors and vastus internus in front and internal. 
 
 The canal transmits the superficial femoral vein and 
 artery, the long internus saphenous nerve (anterior crural), 
 and the nerve to the vastus internus (anterior crural). 
 
 In order to compare the length of the lower extremities 
 the limbs should be placed parallel to one another, and 
 the tape-measure carried from the anterior superior iliac 
 spine to the tip of the internal malleolus of the tibia of 
 Fig. xxiv., the same side. The distance between these 
 ^®- two points may be subdivided, if necessary, by 
 
 marking out, on the inner aspect of the knee, the trans- 
 Fig, xxiv., verse line which indicates the level of the 
 femoro-tibial articulation. The lengths of the 
 femur and of the tibia are thus separately estimated. 
 The region of the knee. — The biceps tendon forms the 
 upper and outer boundary of the popliteal 
 space, and under cover of this tendon, on its 
 inner or popliteal aspect, a cord-like structure is felt, the 
 external popliteal or peroneal nerve This intimate 
 relation of tendon and of nerve must be remembered in 
 Fig. xxi., 14. the operation of tenotomy of the biceps tendon 
 ig. xxiii., . j£ ^]^g biceps tendon be now traced downwards 
 the head of the fibula is reached, this process lying below, 
 external, and on a posterior plane to the outer tuberosity 
 of the tibia. The styloid process of the head 
 of the fibula projects upwards from the 
 posterior part of the head, and in front of this the rounded 
 long external lateral ligament of the knee-joint can be 
 traced upwards to its femoral attachment. In front of 
 
FIG. XXIII. 
 
 1. The iliac crest. 
 
 2. The anterior superior iliac spine. 
 
 3. Poupart's ligament. 
 
 4. Bryant's triangle. 
 
 5. Nelaton's line. 
 
 6. The great trochanter. 
 
 7. The ilio-tibial band. 
 
 8. The outer tibial tuberosity. 
 
 9. The head of the fibula. 
 
 10. The biceps tendon. 
 
 11. The peroneal nerve. 
 
 12. 12. The anterior tibial nerve. 
 
 13. The musculo-cutaneous nerve. 
 
 14. 14. The anterior tibial artery. 
 
 15. The dorsalis pedis artery. 
 
 16. The external saphenous vein. 
 
 17. The venous arch. 
 
THE SIDE OF THE THIGH AND LEG 
 
 riG. XXIII. 
 
 To /ace /. 74. 
 
FIG. XX I V. 
 
 1. The anterior superior iliac spine. 
 
 2. The pubic spines. 
 
 3. The sartorius muscle. 
 
 4. The adductor longus muscle, 
 
 5. The anterior crural nerve. 
 
 6. The common femoral artery. 
 
 7. The common femoral vein. 
 
 8. The femoral ring. 
 
 9. The saphenous opening. 
 
 10. 10, 10. The internal or long saphenous vein. 
 
 1 1 . The profunda femoris artery. 
 
 12. The superficial femoral in Scarpa's triangle. 
 
 13. The superficial femoral in Hunter's canal. 
 
 14. The adductor magnus tendon. 
 
 15. The adductor tubercle. 
 
 16. The lower epiphysial line of the femtir. 
 
 17. The line of the knee-joint. 
 
 18. The gracilis, sartorius, and semitendinosus 
 
 muscles. 
 
 19. The internal saphenous nerve. 
 
 20. The posterior tibial artery. 
 
 21. The internal plantar artery. 
 
 22. The external plantar artery. 
 
 23. The anterior tibial nerve. 
 
THE SIDE OF THE THIGH AND LEG 
 
 I'IG. XXIV. 
 
 To follow Fig. XXI 1 1 
 
THE LOWER EXTREMITY 
 
 75 
 
 the biceps tendon there is a depression which is bounded 
 
 anteriorly by the broad iHo-tibial band. Two 
 Fig. XXIII., 7. 
 
 well-marked tendons bound the popliteal space 
 on the upper and inner side, the semimembranosus and 
 semitendinosus. The latter is the more external, the 
 Fig. xxi., more superficial, and the narrower, and the 
 
 '^' '^- long rounded tendon can be traced some 
 distance up into the thigh. The semimembranosus 
 tendon lies to the inner side of the semitendinosus and 
 on a deeper plane. The broad tendon can be traced 
 downwards to its insertion into the inner and posterior 
 aspect of the internal tuberosity of the tibia. On the 
 inner aspect of the knee the tendon of the gracilis muscle 
 and the lower part of the sartorius muscle form a fairly 
 well-marked prominence, the individual muscles being, 
 however, usually incapable of clear definition owing to 
 their flattened shape. Between these tendons and the 
 prominent vastus internus muscle a depression exists, and 
 Fig. xxi v., by deep palpation the adductor magnus tendon 
 may be felt lying under cover of the inner 
 margin of the vastus internus muscle. By tracing this 
 Fig. xxiv., tendon downwards to its insertion the adductor 
 Fie xxiv i'^ibercle is reached. This tubercle corresponds 
 
 '^- also to the level of the lower epiphysial line of 
 
 the femur. 
 
 The sartorius and gracilis muscles, though not easily 
 defined on the inner side of the knee, form, together with 
 Fig xxiv the semitendinosus muscle, a fairly well-marked 
 
 '®- elevation below the internal tuberosity of the 
 
 tibia, which is directed downwards, forwards, and outwards. 
 
 The ligamentum patellae narrows off as it passes from 
 Fig. xxii., the inferior border of the patella to the tibial 
 
 '^- tuberosity, and on each side of the ligament 
 
76 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 depressions exist, in the lower part of which the inner and 
 outer tuberosities of the tibia are readily felt. 
 
 The prepatellar bursa extends from the middle of the 
 patella to the tibial tubercle. Laterally, the bursa falls 
 just short of the patellar border. 
 
 The synovial membrane of the knee-joint extends upwards 
 Fig. xxii., about three fingers' breadth above the upper 
 border of the patella when the leg is in the 
 extended position, reaching up under the vastus internus 
 to a slightly higher level than on the other side. Laterally, 
 the synovial membrane extends to near the inner and 
 outer margins of the femoral condyles, whilst the lower 
 limit is situated just above the tubercle of the tibia. 
 When the joint is distended with fluid the outline of the 
 joint cavity becomes marked, and the depressions which 
 normally exist each side of the patellar ligament become 
 obliterated. 
 
 The ankle and foot. — The external malleolus projects 
 Fig. xxvii. about I inch below the internal, and also lies 
 
 '' ^" on a more posterior plane. The ankle-joint 
 
 corresponds in level to a point about ^ inch above the 
 tip of the internal malleolus. 
 
 About I inch below and ^ inch in front of the styloid 
 process of the external malleolus is the peroneal tubercle, 
 Fig. XXV. which separates the peroneus brevis above from 
 
 ^^' the longus below. The two peronei tendons, 
 
 when traced upwards, are found to pass behind the 
 external malleolus. About i inch in front of the peroneal 
 cubercle is the prominent styloid process of the base of 
 Fig. XXV., the fifth metatarsal bone, to which the pero- 
 
 '^- neus brevis is attached. Between the peroneal 
 
 tubercle and the base of the fifth metatarsal bone the 
 cuboid bone may be felt, grooved on its outer and under 
 
FIG. XXV. 
 
 Internal Aspect of Foot and Anki;,e. 
 
 1. The tibialis anticus. 
 
 2. The internal malleolus. 
 
 3. The tibialis posticus. 
 
 4. The tubercle of the scaphoid. 
 
 5. The flexor longus digitorum. 
 
 6. The sustentaculum tali of the os calcis. 
 
 7. The flexor longus hallucis. 
 
 8. The tendo Achillis. 
 
 9. The head of the astragalus. 
 
 10. The joint between the scaphoid and the internal cuneiform. 
 
 11. The joint between the first metatarsal bone and the internal 
 
 cuneiform. 
 
 12. The metatarso-phalangeal joint. 
 
 External Aspect ok Foot and Ankle. 
 
 13. The external malleolus. 
 
 14. The head of the astragalus. 
 
 15. The head of the os calcis. 
 
 16. The peroneus tertius. 
 
 17. The base of the fifth metatarsal bone. 
 
 18. The peroneus brevis. 
 
 19. The peroneus longus. 
 
 20. The peroneal tubercle of the os calcis. 
 
 21. The tendo Achillis. 
 
 22. The extensor longus digitorum. 
 
H 
 O 
 O 
 
 Q 
 
 < 
 < 
 
 o 
 
 »— I 
 
 o 
 
 / 
 
THE LOWER EXTREMITY 77 
 
 aspect by the peroneus longus tendon. The tendon 
 
 crosses the plantar aspect of the foot in a forward and 
 
 inward direction, to be inserted into the outer aspect of the 
 
 base of the first metatarsal bone. Immediately in front of 
 
 the external malleolus there is a well-marked 
 FisT XXV . 
 
 depression, which is bounded in front by a 
 
 prominence due to the fleshy mass of the extensor brevis 
 
 digitorum, and above by the tendon of the peroneus 
 
 tertius. 
 
 If the floor of this depression be examined. 
 Fist. XXV 14 
 
 ' ' the head of the astragalus will be felt above and 
 
 to the inner side, and the head of the os calcis 
 
 ' ■ below and to the outer side. 
 
 Between the two malleoli in front of the ankle-joint 
 
 four tendons can be felt. The most prominent and the 
 
 innermost is the tendon of the tibialis anticus 
 
 '^ ^ ' ■ muscle. External to this follow the extensor 
 
 longus hallucis, the extensor longus digitorum 
 
 '^' ^^^ and the peroneus tertius. When the foot is 
 
 well extended, the head of the astragalus can also be 
 
 identified lying under cover of the extensor tendons. 
 
 Immediately below the internal malleolus is the susten- 
 
 pj j^^y ^ Q taculum tali, grooved on its under aspect by the 
 
 Fig. XXV., 7. flgxor longus hallucis tendon, and between the 
 
 Fig XXV , sustentaculum and the internal malleolus the 
 
 ^' ^- tibialis posticus and flexor longus digitorum 
 
 pass. 
 
 The tibialis posticus tendon can be traced upwards 
 
 behind the internal malleolus and downwards 
 
 Fig. XXV., 3. ^^ ^^^ scaphoid tuberosity, to which process 
 
 the tendon gains its main attachment. In 
 
 Fig. XXV., 4. ^^^^^ ^^ ^^^ internal malleolus there is another 
 
 depression, which lies below the line of the tibialis 
 
 7-2 
 
78 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 anticus tendon, and here the head of the astragalus can 
 
 again be felt, especially prominent when the 
 
 Fig. XXV., 1. £qq^ jg ^g|2 everted. About i inch below 
 
 Fig. XXV., 9. and in front of the internal malleolus the 
 Fie XXV 4 tuberosity of the scaphoid bone forms the 
 most prominent bony point on the inner side 
 of the foot, and a line which joins the tip of the internal 
 malleolus, the head of the astragalus, and the scaphoid 
 tubercle, normally presents a slight upward convexity. 
 
 In flat-foot, the head of the astragalus undergoes a 
 downward displacement, and the line uniting the three 
 bony points becomes straight, or even downwardly 
 convex. 
 
 A line drawn almost transversely across the foot from 
 
 a point just behind the scaphoid tubercle indicates the 
 
 level of the mid-tar sal joint. 
 
 Fig. XXV., Ij^ front of the scaphoid tuberosity, the in- 
 
 _.^°' ^^" ternal cuneiform and the first metatarsal bones 
 Fig. XXV,, 
 
 ''' ^2- may be located and verified. 
 Behind the ankle-joint, the tendo Achillis is placed, 
 Pior vvx/ the tendon being at its narrowest at a point 
 
 r ig. XXV., 
 
 ^' ^'- about i^ inches above its insertion into the 
 posterior part of the os calcis. When distended with 
 fluid, the synovial membrane of the ankle-joint bulges 
 outwards, so as to obliterate the depressions that normally 
 lie between the tendo Achillis and the two malleoli. 
 
 The anterior annular ligament of the ankle. — The upper 
 
 portion of this ligament, about i inch broad, 
 
 ig. XXVI., . gj^^gj^^g transversely across the ankle from 
 
 tibia to fibula. It presents two compartments only, 
 
 one for the tibialis anticus, and one for 
 
 Ig. XXVI., . ^j^^ remaining extensor tendons. The former 
 
 tendon alone possesses a synovial sheath. 
 
THE REGION OF THE ANKLE AND FOOT 
 
 FIG. XX VI. 
 
 1. The internal malleolus. 
 
 2. The external uialleoliis. 
 
 3. The transverse band of the anterior annular li,<(anient. 
 
 4. The Y-shaped band of the anterior annular ligament. 
 
 5. The head of the os caicis and the extensor brevis digitorum. 
 
 6. The tibialis anticus synovial sheath. 
 
 7. The extensor longus hallucis synovial sheath. 
 
 8. The exten.sor longus digitorum and peroneus tertius 
 
 synovial sheath. 
 
 To /ace />. 78. 
 
THE REGION OF THE ANKLE AND FOOT 
 
 FIG. XXVII. 
 
 1. The transverse band. 
 
 2, 3. The upper and lower hml s of the Y-shaped part of the 
 
 anterior annular ligament. 
 
 4. The tibialis anticus synovial sheath. 
 
 5. The internal malleolus. 
 
 6. The internal annular ligament. 
 
 7. The tibialis posticus synovial sheath. 
 
 S. The flexus longus digitoruni synovial sheath. 
 9. The flexor longus hallucis synovial sheath. 
 
 To face p. 79. 
 
THE LOWER EXTREMITY 79 
 
 The lower portion of the ligament is Y-shaped, the 
 Fig. xxvi.,4. single limb arising from the upper and outer 
 ig. XXVI., 5. aspect of the head of the os calcis in close 
 connection with the origin of the extensor brevis digitorum 
 muscle. The upper limb of the divided portion becomes 
 attached to the internal malleolus, whilst the lower limb 
 sweeps over to the scaphoid tuberosity and to the inner 
 side of the foot. The extensor communis digitorum and 
 Fig. xxvi., the peroneus tertius pass under the single 
 
 go 
 
 ' ■ undivided limb, and possess in this situation 
 a common synovial sheath ; whilst the extensor longus 
 Fig. xxvi , hallucis and the tibialis anticus pass through 
 separate compartments in each limb of the 
 divided portion of the ligament, and each tendon in so 
 doing is surrounded by a synovial sheath, that enveloping 
 the tibialis anticus tendon being continuous with the 
 sheath already alluded to as enclosing the tendon under 
 the transverse portion of the ligament. 
 
 The internal annular ligament is triangular in shape, the 
 Fig xxvii apex being attached to the internal malleolus, 
 
 ®' and the base to the lower margin of the os 
 
 calcis. From the deep aspect of the ligament septa are 
 given off which form separate compartments for the 
 Fig. xxvii., passage of the tendons of the tibialis posticus, 
 ^' ^' ^ flexor longus digitorum, and flexor longus 
 hallucis muscles, each tendon having its own synovial 
 sheath. These three sheaths extend for about i inch 
 above the upper limit of the annular ligament; and 
 although the sheath enveloping the tibialis posticus 
 reaches almost as far forwards as the scaphoid tuberosity, 
 the other two sheaths usually terminate about ^ inch 
 p. below the inferior margin of the ligament. 
 
 3, 3, 3, 3. Thg flexor longus hallucis and flexor longus 
 
8o HUMAN LANDMARKS AND StlRfACE MARKINGS 
 
 digitorum have, again, distinct synovial sheaths just before 
 their insertion into the distal phalanges of the toes, these 
 sheaths, however, being very variable, and rarely extending 
 further backwards than the heads of the metatarsal bones. 
 The external annular ligament is less definite in shape, 
 and can only be described as a broad band passing from 
 the external malleolus to the lower margin of the os calcis. 
 Fig. xxviii., Beneath it two tendons pass, the peroneus 
 ' ^' longus and brevis. These two tendons possess 
 
 a common synovial sheath, which extends upwards 2 to 
 3 inches above the tip of the external malleolus, and 
 downwards as far as the " peroneal tubercle," where the 
 sac divides into two, one part accompanying the peroneus 
 brevis to near the base of the fifth metatarsal bone, the 
 other extending forwards to the outer and under aspect of 
 the cuboid bone. The peroneus longus is also usually 
 enclosed in a synovial sheath in the last inch or so of its 
 course, previous to its insertion into the outer aspect of 
 the base of the first metatarsal bone. 
 
 The Vessels and Nerves of the Lower 
 Extremity. 
 
 The gluteal artery emerges from the great sacro-sciatic 
 
 notch, above the pyriformis muscle, at the 
 
 '' ' junction of the inner and middle thirds of a 
 
 line drawn from the posterior superior iliac spine to the 
 
 top of the great trochanter of the femur of the same side. 
 
 The sciatic artery may be ligatured at a point which lies 
 
 just external to the junction of the middle and 
 
 ig. XXI., . jQ.^gj. ^]-ii]-ds of a line drawn from the posterior 
 
 superior iliac spine to the outer part of the ischial 
 
 tuberosity of the same side. This line also cuts across 
 
1^ 5 n o 
 
 X 2 
 
 
 
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 r2 "5 
 
 ^ D ^ 
 
 
 6 
 
 
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 3 1^ 
 
 if! ■J'l 
 
 !/■; ^_ 
 
 ij <*. 
 
 be o 
 
 c 
 
 
 P rt 
 
 > o 
 
 "5 — 
 
 
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 ttJ V 
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 c3 oj 
 
 
 
 >- ^ 
 
 ;-< u 
 
 t- Jll 
 
 "5 i1 
 
 
 oj aj 
 
 <U V 
 
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 Ji <U 
 
 1-1 
 
 a Ph 
 
 P. P. 
 
 (Li OJ 
 
 5 ii 
 
 V 
 
 (U OJ 
 
 i> (U 
 
 ^ -15 
 
 "3 r5 
 
 •*-* 
 
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 H H 
 
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 -t I/O yD I - 
 
THE LOWER EXTREMITY 8l 
 
 the posterior inferior iliac spine and the tip of the ischial 
 spine, whilst the internal pudic artery hes immediately 
 internal to the seat of election for ligation of the sciatic 
 artery. 
 
 The common and superficial femoral arteries. — With the 
 thigh flexed, everted, and slightly abducted, 
 these vessels correspond in direction to a line 
 drawn from a point midway between the anterior superior 
 iliac spine and the symphysis pubis to the adductor 
 tubercle of the femur below. 
 Fig. xxiv., The upper i^ inches of this line = the common 
 
 ^' femoral artery, 
 
 pj j^j^jy The upper third = the common and super- 
 
 ^> '2. ficial femoral arteries in Scarpa's triangle. 
 Fig xxiv The upper two-thirds = the complete common 
 
 6, 12, 13. and superficial femoral arteries. 
 Fio- vviv The middle third = the superficial femoral 
 
 '3- artery in Hunter's canal. 
 
 The popliteal artery enters the upper angle of the 
 popliteal space (from the inner side) by passing between 
 the femur and the adductor magnus tendon. The vessel 
 at first passes obliquely outwards and downwards to the 
 mid-point of the space, and then changes direction by 
 passing vertically downwards as far as the lower border 
 of the popliteus muscle, at which level it bifurcates into 
 anterior and posterior tibial arteries. The point of bifur- 
 cation corresponds to the level of the tubercle of the tibia. 
 
 The anterior tibial artery. — The course of this vessel 
 Fig. xxii., "i^'Y be indicated by a line drawn from a point 
 Fig^xxiii i^s^ below the level of the tibial tubercle, and 
 14, 14. midway between "the outer tuberosity of the 
 tibia and the head of the fibula, to a second point in front 
 of the ankle midway between the two malleoli, at which 
 
82 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 level the artery lies between the tendons of the extensor 
 longus hallucis and longus digitorum muscles. 
 Fig. xxii. The anterior tibial artery is continued on- 
 
 pj j^'j^jjj wards as the dorsalis pedis as far as the base of 
 the first interosseous space. 
 The posterior tibial artery starts at the lower border of 
 Fig. xxi., the popliteus muscle as one of the terminal 
 branches of the popliteal artery. It can be 
 represented by a line which starts at the inferior angle of 
 the popliteal space, on a level with the tubercle of the 
 tibia, and which passes downwards and inwards to the 
 mid-point between the posterior border of the internal 
 malleolus and the inner border of the os calcis. At this 
 level it lies under cover of the internal annular liga- 
 ment, and bifurcates in this situation into the internal and 
 Fig. xxiv., external plantar arteries. Behind the internal 
 20 22. malleolus the posterior tibial artery lies between 
 the tendons of the flexor longus hallucis and longus digi- 
 torum muscles, but on a slightly superficial plane. 
 
 The internal plantar artery passes forwards to the 
 cleft between the first and second toes, whilst 
 ' ' the more important external plantar artery is 
 first directed forwards and outwards towards the base of 
 the fifth metatarsal bone, and then, changing direction, 
 passes forwards and inwards to the base of the 
 ig. xxix., . ^^^^ interosseous space, forming in this latter 
 part of its course the deep plantar arch. It anastomoses 
 with the dorsalis pedis artery, which dips downwards be- 
 tween the two heads of the first dorsal interosseous muscle. 
 The external saphenous vein arises from the outer side of 
 Fig. xxiii., the venous arch on the dorsum of the foot, 
 '^' ^^' passing upwards behind the external malleolus 
 and along the outer and back part of the leg to the middle 
 
THE LOWER EXTREMITY 83 
 
 of the popliteal space, where it pierces the deep fascia to 
 Fig. xxi., open into the popliteal vein. It is accompanied 
 in the greater part of its course by the external 
 saphenous nerve, which extends forwards on the outer side 
 of the foot as far as the tip of the little toe. 
 
 The internal saphenous vein arises from the inner side of 
 Fig. xxiv., the venous arch found on the dorsum of the 
 ' ' ^ foot. It passes upwards in front of the internal 
 malleolus, along the inner side of the leg and knee, behind 
 the internal condyle of the femur, and its further upward 
 course in the thigh is indicated by a Ime drawn from the 
 adductor tubercle to the saphenous opening. Attention 
 has previously been drawn to the elevation below the 
 internal tuberosity of the tibia which is formed by the 
 sartorius, gracilis and semitendinosus muscles, and below 
 this prominence the saphenous vein is accompanied by 
 the internal saphenous nerve, a branch of the deep division 
 of the anterior crural. The saphenous nerve runs down 
 the leg with the vein, in front of the internal malleolus of 
 Fig xxiv t^^ tibia, and extends as far forwards as the 
 ^^ ball of the great-toe. In the thigh the nerve 
 
 crosses in front of the superficial femoral artery from with- 
 out inwards, and accompanies that artery throughout the 
 whole length of Hunter's canal. 
 
 The anterior crtiral nerve emerges from under cover of 
 
 Poupart's ligament, about half-way between 
 
 ig. xxiv., . ^j^^ anterior superior iliac spine and the pubic 
 
 spine. The nerve lies nearly ^ inch external to the 
 
 common femoral artery, and the same distance external 
 
 to the femoral sheath. 
 
 The great sciatic nerve makes its exit from the pelvis 
 
 through the great sacro-sciatic notch below 
 
 '6 XX'- > ^j^g pyriformis muscle. The nerve emerges 
 
04 HUMAN LANDMARKS AND SURFACE MARKINGS 
 
 from under cover of the lower border of the gluteus 
 maximus muscle just to the inner side of the mid-point 
 between the ischial tuberosity and the great trochanter 
 of the femur. The nerve corresponds in direction to the 
 upper two-thirds of a line drawn downwards from the 
 above point to the middle of the popliteal space below. 
 At the junction of the middle and lower thirds of the 
 thigh the great sciatic nerve divides into its two terminal 
 branches, internal and external popliteal. 
 
 The small sciatic nerve lies in the same line as the great 
 sciatic, but extends downwards as far as the inferior angle 
 of the popliteal space. 
 
 The internal popliteal nerve crosses the popliteal artery 
 
 superficially from without inwards ; its onward 
 
 " continuation, the posterior tibial nerve, and the 
 
 two terminal branches of the posterior tibial nerve, the 
 
 internal and external plantars, all have the same surface 
 
 marking as the corresponding arteries. Two 
 Fiff. xxi 20 
 
 '' ' points, however, need to be borne in mmd : 
 
 first, the posterior tibial nerve crosses the corresponding 
 
 artery superficially from within outwards and downwards 
 
 and, secondly, the internal plantar nerve is relatively 
 
 much more important than the corresponding artery. 
 
 The external popliteal or peroneal nerve was last seen to lie 
 Fig. xxi., under cover of the biceps femoris tendon at the 
 Fie' xxiii upper and outer boundary of the popliteal space. 
 
 10., 11. 'pjjg nerve follows the tendon downwards to the 
 head of the fibula, and curls round to the antero- external 
 Fie; xxiii. aspect of the leg about I inch below the head 
 
 12, 13. q{ ^]^g^^ bone, dividing there into its two ter- 
 minal branches, anterior tibial and musculo-cutaneous. 
 
 The anterior tibial nerve passes downwards and inwards 
 to join the corresponding artery, lying external to the 
 
THE LOWER EXTREMITY 85 
 
 upper third of the artery, superficial to the middle third, 
 Fig. xxii., ^^^ external again to the lower third. The 
 
 ^°" nerve extends forwards along the outer side 
 
 Fig. xxiii., ^^ ^^^ dorsalis pedis artery as far as the cleft 
 between the first and second toes, the con- 
 tiguous sides of which toes it supplies. 
 
 The nmsctilo-cutaneous nerve, running down in the sub- 
 Fig, xxii., stance of the peronei muscles, becomes cuta- 
 pj j^j^jjj neous below the middle of the leg. It then 
 ^^ passes obliquely downwards and inwards across 
 
 the anterior annular ligament, to be distributed to the 
 greater part of the dorsum of the foot. 
 
APPENDIX 
 
 THE LENGTH OF VARIOUS PASSAGES, 
 TUBES, ETC. 
 
 The spinal cord, i6 to i8 inches. 
 
 The trachea, 4^ inches. 
 
 The right bronchus, i inch. 
 
 The left bronchus, i| to 2 inches. 
 
 The pharynx, 4I inches. 
 
 The oesophagus, g to 10 inches.* 
 
 The stomach : 
 
 Capacity, about 2 pints. 
 
 Length, 10 inches. 
 
 Width, 4 to 5 inches. 
 Duodenum, 8 to 10 inches. 
 Bile-duct, 3 inches. 
 Small intestine, 23 feet. 
 
 Jejunum, upper two-fifths. 
 
 Ileum, lower three-fifths. 
 Appendix, 3 to 4 inches. 
 Caecum, 2| inches. 
 Ascending colon, 8 inches. 
 Transverse colon, 20 inches. 
 Descending colon, 4 to 6 inches. 
 
 * The distance from the teeth to the cardiac orifice of the stomach 
 is about 16 to 17 inches. 
 
 86 
 
APPENDIX 
 
 Iliac colon, 5 to 6 inches. 
 
 Pelvic colon, 16 to 18 inches. 
 
 Rectum, 5 to 6 inches. 
 
 Anal canal, i to ij inches. 
 
 Crural canal, ^ inch. 
 
 Inguinal canal, i|- inches. 
 
 Receptaculum chyli, i to 2 inches. 
 
 Thoracic duct, 16 to 18 inches. 
 
 Kidney, 4^ inches by 2^ inches by i^ inches. 
 
 Ureter, 10 inches. 
 Male urethra, 8 to 10 inches. 
 Prostatic, i to li inches. 
 Membranpus, anterior wall, | inch. 
 „ posterior wall, | inch. 
 
 Spongy and penile, 6 to 8 inches. 
 Testis, ii inches by i inch by f inch. 
 Seminiferous tubules, 2 to 3 feet. 
 Canal of the epididymis, ig to 20 feet. 
 Vas deferens, 16 to 18 inches. 
 Ovary, i inch by | inch. 
 Fallopian tubes, 4 to 4^ inches. 
 Uterus, 3 inches by 2 inches by i inch. 
 Vagina, anterior wall, 3 inches. 
 ,, posterior wall, 4 inches. 
 Female urethra, i to i| inches. 
 
 87 
 
APPENDIX 
 
 THE WEIGHT OF SOME ORGANS. 
 
 The brain : Male, 50 ounces ; female, 45 ounces. 
 
 The lungs : Together, 42 ounces ; right, 22 ounces ; 
 left, 20 ounces. 
 
 The heart : Male, 10 to 12 ounces ; female, 8 to 
 10 ounces. 
 
 The liver, 50 to 60 ounces. 
 
 The kidneys, 4I ounces. 
 
 The suprarenals, i to 2 drachms. 
 
 The prostate, 6 drachms. 
 
 The testis, 6 to 8 drachms. 
 
 The ovary, i to 2 drachms. 
 
 The spinal cord, i| ounces. 
 
 The pancreas, 2 to 4 ounces. 
 
 The spleen, 7 ounces. 
 
APPENDIX 89 
 
 THE OSSIFICATION AND EPIPHYSES OF THE BONES 
 OF THE UPPER AND LOWER EXTREMITIES. 
 
 Certain epiphyses and epiphysial Hnes have been alluded to in the 
 text, and the following table, compiled from Gray's " Anatomy," has 
 consequently been appended • 
 (a) The Upper Extremity ; 
 T/ie clavicle : 
 
 I centre for the shaft (in membrane) in the fourth to fifth 
 
 week (i.u.l.).* 
 I centre for the sternal end in the eighteenth to twentieth 
 year. 
 
 Union between the two in the twenty-fifth year. 
 TAe scapula : 
 
 I centre for the body in the eighth week (i.u.l.). 
 I centre for the coracoid process in the first year. 
 
 1 centre for the base of the coracoid\ 
 
 process I between the fifteenth 
 
 2 centres for the acromial process y and eighteenth 
 I centre for the vertebral border years. 
 
 I centre for the inferior angle 
 Tkc humerus : 
 
 I centre for the shaft in the eighth week (i.u.l.). 
 I centre for the head in the first year. 
 I centre for the great tuberosity in the third year. 
 1 centre for the small tuterosity in the fourth year. 
 
 Head and tuberosities unite together in the fifth year' 
 
 and with the shaft in the twentieth year. 
 I centre for the internal condyle in the fifth year. 
 1 centre for the trochlear in the twelfth year. 
 I centre for the capitellum in the second year. 
 I centre for the external condyle in the thirteenth year. 
 The last three unite together to form an epiphysis, 
 
 which unites with the shaft in the seventeenth year, 
 
 the internal condylejoining separately in the eighteenth 
 
 year. 
 The radius and ulna : 
 
 I centre for the shaft of the radius in the eighth week 
 
 (i.u.l.). 
 I centre for the shaft of the ulna in the eighth week 
 
 (i.u.l.). 
 
 * i.u.l. = intra-uterine life. 
 
go APPENDIX 
 
 I centre for the lower end of the radius in the second year 
 
 — union at twenty. 
 I centre for the lower end of the ulna in the fourth year — 
 
 union at twenty. 
 I centre for the upper end of the radius in the fifth year — 
 
 union at sixteen. 
 I centre for the upper end of the ulna in the tenth year — 
 union at sixteen. 
 The carpus : 
 
 All the bones are cartilaginous at birth. The first centre 
 of ossification appears in the os magnum and the last 
 in the pisiform. 
 T/ie metacarpus and phalanges : 
 
 I centre for the shaft of the metacarpal and the shaft of 
 
 the phalanx in the eighth week (i.u.L). 
 I centre for the head of the metacarpal bone and the base 
 of the phalanx in the third year. 
 
 Union between diaphyses and epiphyses in the 
 twentieth year. 
 
 The thumb metacarpal is an exception to the rule, a 
 well-marked epiphysis always appearing at the base. 
 This bone, therefore, resembles a phalanx in its mode 
 of ossification, though an epiphysis is not infrequently 
 seen at the head of the bone also. 
 {B) The Lower Extremity : 
 The OS innominatum : 
 
 Three main primary centres for ilium, ischium, and 
 pubis, appearing respectively in the second, third, and 
 fourth months (i.u.l.). The three parts of the bone 
 are separated at first by the Y-shaped acetabular 
 cartilage. 
 
 Five secondary centres appear about puberty for the 
 crest, symphysis pubis, anterior inferior iliac spine, 
 ischial tuberosity, and the acetabular cartilage. These 
 unite at about the twenty-fifth year. 
 The femur : 
 
 I centre for the shaft in the fifth week (i.u.l.). 
 
 I centre for the lower end in the ninth month (i.u.l.) — 
 
 union with shaft in the twentieth year. 
 I centre for the head in the first year — union with shaft in 
 
 the eighteenth year. 
 I centre for the great trochanter in the fourth year. 
 I centre for the small trochanter in the fourteenth year. 
 The patella : 
 
 I centre in the third year. 
 
APPENDIX gi 
 
 The tibia and fibula : 
 
 I centre for the shaft of the tibia in the seventh week 
 (i.u.l.). 
 
 I centre for the shaft of the fibula in the eighth week 
 (i.u.l.)- 
 
 J centre for the upper end of the tibia in the first year- 
 union at twenty. 
 
 I centre for the upper end of the fibula in the fourth year 
 — union at twenty-five. 
 
 1 centre for the lower end of the tibia in the second year 
 — union at eighteen. 
 
 I centre for the lower end of the fibula in the second 
 year — union at twenty. 
 The tarsus : 
 
 The OS calcis, astragalus and cuboid alone have centres 
 of ossification at birth, these appearing respectively in 
 the sixth, seventh, and ninth months. The os calcis 
 possesses a secondary centre, appearing about the 
 tenth year, for its posterior surface. 
 The metatarsus and phalanges : 
 
 Centres appear as in metacarpus, etc. 
 
INDEX 
 
 Abdominal aorta, 6i 
 
 plaues, 50 
 
 regions, 51 
 Acromial spine and process, 19, 20 
 Acromio-clavicular joint, 19 
 Adductor magnus tendon, 75 
 
 tubercle, 75 
 Anal canal, length of, 87 
 " Anatomical snufF-box," 27, 28, 29 
 Ankle region, 76 
 Antecubital space, 24 
 Anterior annular ligament(ankle), 
 
 7S 
 Anterior annular ligament (wrist), 
 
 25, 26 
 Anterior crural nerve, 83 
 
 tibial artery, 81 
 
 tibial nerve, 84 
 
 triangle of neck, 12 
 Antrum of Highmore, 11 
 Aortic arch, 38 
 
 intercostals, 40 
 
 valve, 37 
 Apex beat, 36 
 Apices of lung, 45 
 Appendix, 57 
 
 length of, 86 
 Ascending aorta, 38 
 
 colon, 57 
 
 length of, 86 
 Astragalus, 77 
 Auricular area, 37 
 Auriculo-temporal nerve, 15 
 Axilla, 21 
 Axillary artery, 20, 29 
 
 lymphatics, 22 
 
 Base of brain, 4 
 Basic fossae, 8 
 Basilic vein, 24 
 Biceps femoris, 74 
 
 humeri, 21, 24 
 Bicipital fascia, 24 
 
 groove, 21 
 
 sulci, 24 
 Bile-duct, 64 
 
 length of, 86 
 Bony points of elbow, 23 
 Brachial artery, 24, 29 
 
 plexus, 17 
 
 Bregma, 2 
 Broca's area, 6 
 Bronchi, 46 
 
 length of, 86 
 Bryant's line and triangle, 71 
 Bulb of penis, 67 
 
 of vestibule, 67 
 
 Caecum, 56 
 
 length of, 86 
 Canal of epididymis, 87 
 Cardiac orifice, 54 
 Carotid arteries, 13 
 
 triangle, 13 
 
 tubercle, 13 
 Central point, 50 
 
 tendinous point of perineum, 
 67,68 
 Cephalic vein, 24, 25 
 Cerebellum, 5 
 Cerebrum, 4 
 
 Cervical sympathetic, 16 
 Circumflex nerve and artery, 30 
 Clavicle, 19 
 Clitoris, 68 
 Coeliac axis, 61 
 Colles's fascia, 67 
 Common bile-duct, 64, 65 
 
 carotid artery, 38 
 
 femoral artery, 81 
 
 iliac artery, 62 
 Conus meduUaris, 66 
 Coraco-brachialis fold, 22, 29 
 Coracoid process, 20 
 Coronal suture, 2 
 Coronary artery, 61 
 Creases of palm and fingers, 33 
 
 of wrist, 25 
 Cricoid cartilage, 18, 47 
 Crura of penis, 67 
 Crural canal, 73 
 
 length of, 87 
 Cuboid bone, 76 
 Cuneiform bone, 26 
 Curvatures of stomach, 56 
 
 Deep cardiac dulness, 45 
 epigastric artery, 62 
 palmar arch, 30 
 plantar arch, 82 
 
 92 
 
INDEX 
 
 93 
 
 Deltoid, 20 
 Descending aorta, 38 
 
 colon, 58 
 
 length of, 87 
 Diaphragm, 64 
 Digital arteries, 30 
 Dorsalis pedis artery, 82 
 Douglas's fold, 43, 53 
 
 pouch, 68 
 Duodeno-jejunal fold, 55 
 Duodenum, 55 
 
 length of, 86 
 Dura mater, 59, 66 
 
 Elbow region, 23 
 
 Epiglottis, 18 
 
 Epiphyses, 89 
 
 Epiphj'sial line of humerus, 21, 23 
 of femur, 75 
 
 Epitrochlear gland, 25 
 
 Extensor tendons of foot, 64 
 of wrist, 28 
 
 External abdominal ring, 54 
 angular frontal process, 3 
 annular ligament (foot), 80 
 carotid arter}', 10 
 iliac artery, 62 
 jugular vein, 15 
 lateral ligament (knee), 74 
 parieto-occipital fissure, 6 
 plantar artery and nerve, 82, 
 
 84 
 popliteal nerve, 74, 84 
 saphenous vein and nerve, 
 82.83 
 
 Facial artery, 14 
 
 nerve, 9, 10 
 Fallopian tubes, length of, 87 
 False ribs, 34 
 Falx cerebri, 2 
 
 Female urethra, length of, 87 
 Femoral canal and ring, 73 
 Fibula, 74 
 
 Filum terminale, 66 
 First costal cartilage and rib, 34 
 First interspace, 34 
 p-issures of lung, 44 
 Flexor carpi radialis, 25, 29 
 ulnaris, 25 
 
 sublimis, 25, 26 
 
 synovial sheaths, 26, 27 
 Floating ribs, 34 
 Fontanelle, anterior, 2 
 
 posterior, 2 
 p-QOt region, 76 
 Foramen of Winslow, 64 
 Fornices of vagina, 68 
 Frontal sinus, 11 
 
 Gall-bladder, 64 
 Gastro-hepatic omentum, 64 
 
 Genital area, 67 
 Gluteal arter}-, 60 
 Gluteus maximus, 70 
 Gracilis, 75 
 Great auricular nerve, 17 
 
 occipital nerve, 14 
 
 sciatic nerve, 83 
 
 Hamilton's test, 20 
 Hand region, 25 
 Heart, 35 
 Hepatic artery, 61, 64, 65 
 
 flexure, 57 
 Hesselbach's triangle, 62 
 Hip region, 70, 71 
 Houston's valves, 68 
 Humerus, head of, 20, 22 
 Hunter's canal, 73 
 
 Ileo-c£ecal valve, 56 
 Iliac colon, 58 
 
 length of, 87 
 
 crest, 52 
 
 spines, 52, 53 
 
 tubercles, 53 
 Ilio-pelvic colon, 58 
 length of, 87 
 Ilio-tibial band, 75 
 Inferior dental nerve and artery, 
 10 
 
 mesenteric artery, 62 
 
 temporal crest, 3, 4 
 
 vena cava, 40, 62 
 Infraclavicular space, 20 
 Infra-orbital foramen, 11 
 Inguinal canal, 54 
 
 length of, 87 
 
 groove, 71 
 Inion, I 
 Innominate artery, 38 
 
 veins, 39, 40 
 Intercostal space, 35 
 Internal abdominal ring, 54 
 
 annular ligament (foot), 79 
 
 carotid artery, 13 
 
 jugular vein, 16 
 
 mammary arterj', 39 
 
 plantar artery and nerve, 82, 
 84 
 
 popliteal nerve, 84 
 
 pudic artery, 81 
 
 saphenous nerve, 83 
 vein, 83 
 Intertubercular plane, 50, 53 
 Ischial spine, 81 
 
 tuberosity, 70 
 Ischio-rectal fossa.', 68 
 Island of Rtil, 5 
 
 Kidney, 59 
 
 length and weight of, 87 
 8—2 
 
94 
 
 INDEX 
 
 Knee region, 74 
 Knuckles, 33 
 
 Labia majora and minora, 67 
 
 Lachrymal sac, 10 
 
 Lambda, 2 
 
 Lambdoid suture, 2 
 
 Larjmx, 18 
 
 Lateral sinus, 2, 4, 5, 9 
 
 ventricles, 8 
 
 vertical plane, 49 
 Length of femur and tibia, 74 
 
 of humerus, 21 
 Ligamentum patellae, 75 
 
 teres, 63 
 Lines semilunares, 52 
 
 transversae, 52 
 Lingual artery, 14 
 Liver, 63 
 
 weight of, 88 
 Ludv^fig's angle, 35 
 
 plane, 51 
 Lumbar puncture, 66 
 Lungs, 42 
 
 weight of, 88 
 
 Macewen's triangle, 4, 8 
 Malar tubercle, 3 
 Mamma, 34 
 Masseter muscle, 9 
 Mastoid antrum, 8 
 McBurney's point, 57 
 Median nerve, 24, 32 
 
 vertical plane, 49 
 Mental foramen, 1 1 
 Mesentery of small intestine, 56 
 Mesial fissure of brain, i 
 Metacarpo-phalangeal joint, 33 
 Metopic suture, 2 
 Middle cerebral artery, 5 
 
 meningeal artery, 6, 7 
 Mid-tarsal joint, 78 
 Mitral valve, 37 
 Mons veneris, 67 
 Morris's quadrilateral, 60 
 Muscular triangle, 12 
 Musculo-cutaneous nerve (arm), 3 1 
 
 (leg), 85 
 Musculo-phrenic artery, 39 
 Musculo-spiral nerve, 24, 31 
 
 Nasal duct, 10 
 
 Nasion, i 
 
 Natal fold, 71 
 
 Nelaton's line, 71 
 
 Ninth costal cartilage, 35, 50, 59 
 
 Nipple, 35 
 
 Obelion, 2 
 Occipital artery, 14 
 nerve (great), 14 
 (small), 17 
 
 CEsophagus, 47 
 Olecranon, 23 
 Omo-hyoid muscle, 13 
 Orbit, boundaries of, i o 
 Os calcis, 77 
 Os uteri, 68 
 Ovary, 61, 87, 88 
 
 Palmar fascia, 33 
 Palmaris longiis, 32 
 Pancreas. 56 
 
 weight of, 88 
 Paracentesis of pericardium, 46 
 Paracentral point, 50 
 Parietal eminence, 2 
 Parieto-occipital sulcus, 6 
 Parotid gland, 9 
 Pectoralis major and fold, 21 
 
 minor, 29 
 Pelvic colon, 58 
 
 length of, 87 
 Pericardium, 46 
 Perineum, 67 
 Peroneal nerve, 74, 84 
 
 tendons, 76, 80 
 
 tubercle, 76, 80 
 Petit' s triangle, 54 
 Pharynx, 1 1 
 
 length of, 86 
 Phrenic nerve, 16 
 Pisiform bone, 25, 26 
 Plantar arch, 82 
 Pleura, 41 
 Popliteal artery, 81 
 
 space, 74 
 Portal vein, 64 
 
 Posterior annular ligament 
 (wrist;, 28 
 
 auricular artery and nerve, 14 
 
 inferior iliac spine, 81 
 
 interosseous nerve, 24. 32 
 
 superior iliac spine, 53 
 
 tibial artery I and nerve, 82, 84 
 
 triangle, 13 
 Poupart's ligament, 71 
 Prepatellar bursa, 76 
 Prostate gland, 53 
 
 weight of, 88 
 Pubic spine, 53 
 Pudic vessels, 67 
 Pulmonary artery, 39 
 
 valve, 37 
 Pylorus, 55 
 Pyriforrais muscle, 80 
 
 Radial artery, 25, 28, 29 
 
 nerve, 24, 31 
 
 tubercle, 28 
 Radius, 23 
 
 Receptaculum chj-li, 47, 87 
 Rectal area, 67, 68 
 
 examination, 69 
 
INDEX 
 
 95 
 
 Rectum, 58 
 
 length of, 87 
 Reid's base line, 5 
 Renal artery, 62 
 Rima glottidis, 18 
 Rolandic area, 6 
 
 fissure, 6 
 Roots of lung, 45 
 
 Sagittal suture, 2 
 Saphenous opening, 73 
 Sartorius, 75 
 Scalenus anticus, 15 
 Scaphoid bone (carpus), 25 
 
 (tarsus), 77, 78 
 Scarpa's triangle, 72 
 Sciatic artery, So 
 nerve (great), 83 
 
 (small), 84 
 Semilunar fold of Douglas, 52 
 Semimembranosus, 75 
 Seminiferous tubules, length of, 
 
 87 
 Semitendinosus. 75 
 Shoulder region, 19 
 Sinuses of nose, 12 
 Small intestine, 56 
 
 occipital nerve, 17 
 
 sciatic nerve, 84 
 Sphenoidal sinus, 12 
 Spinal accessory nerve, 16 
 
 cord, 65 
 
 length and weight, 86, 
 88 
 Spinous plane, 52 
 Spleen, 65 
 Splenic artery, 61 
 
 flexure, 57 
 Stenson's duct, 9 
 Sterno-mastoid, 12 
 Sterno-xiphoid plane, 52 
 Stomach, 54 
 Styloid process of radius and 
 
 ulna, 27 
 Subclavian artery, 15, 39 
 
 triangle, 13 
 Subcostal plane. 52 
 Submaxillary gland and triangle, 
 
 12 
 Subpubic angle, 67 
 Superficial cardiac dulness, 45 
 
 cervical plexus, 17 
 
 femoral artery, 81 
 
 lymphatics of arm, 22 
 of leg, 72 
 
 palmar arch, 30 
 
 temporal artery, 15 
 Superior epigastric artery, 39 
 
 longitudinal sinus, 2 
 
 mediastinum, 39 
 
 mesenteric artery, 61 
 
 temporal ciest, 3, 6 
 
 Superior thyroid artery, 13 
 
 vena cava, 40 
 Supra-acromial nerve, 17 
 Supraclavicular nerve, 17 
 Suprameatal crest and spine, 3, 8 
 
 fossa, 8 
 Supra-orlDital foramen, 11 
 Suprarenals, weight of, 88 
 Suprasternal nerve, 17 
 
 plane, 52 
 Sustentaculum tali, 77 
 Sylvian fissure, 5 
 
 point, 5 
 Sympathetic chain and ganglia, 
 
 16 
 Symphysis pubis, 53 
 Synovial membrane of knee, 76 
 
 sheaths of ankle, 78, 79 
 of wrist (extensor), 28 
 (flexor), 26 
 
 Tegmen antri, 9 
 Temporo-spheuoidal sulcus, 6 
 Tendo Achillis, 78 
 
 oculi, 10 
 Tendons of ankle region, 76 
 
 of wrist, 25 
 Tentorium cerebelli, 5 
 Testis, length and weight, 87, 88 
 Theca vertebralis, 66 
 Thoracic aorta, 38 
 
 duct, 47 
 
 plane, 50 
 Thyroid isthmus, 18 
 Tibial tuberosities, 74 
 Tibialis anticus, 77 
 
 posticus, 77 
 Tonsil, 10 
 Trachea, 18 
 
 Transpyloric plane, 50, 55 
 Transverse cervical nerve, 17 
 
 colon, 57, 86 
 
 creases of palm, 33 
 of wrist, 25 
 
 facial arter}', 9 
 Transversus perinei, 67 
 
 process of atlas, 16 
 Trapezium, 25 
 Triangles of neck, 12 
 Triangular ligament, 67 
 Tricuspid valve, 38 
 Trochanter of femur, 70 
 True riVjs, 34 
 Tuberosities of humerus, 20 
 
 of tibia, 74 
 
 Ulnar artery, 24, 30 
 
 nerve, 32 
 Umbilical plane, 52 
 Umbilicus, 52 
 Unciform bone, 26 
 Urachus, 61 
 
96 
 
 INDEX 
 
 Ureter, 60, 87 
 Urethra, male, 87 
 
 female, 87 
 Uterus, dimensions of, 87 
 
 Vagina, examination of 68 
 
 dimensions of, 87 
 Vagus nerve, 16 
 Valves of heart, 37 
 Veins of elbow, 24 
 
 Vena azygos major, 40 
 Ventricular area, 36 
 Vermiform appendix, 57 
 Vestibule, 68 
 Vocal cords, 18 
 
 Wrist -joint, 25 
 Wrist region, 25 
 
 Zygomatic process, 3 
 
 H. K. LEWIS, 136, GOWER STREET, LONDON, W.C. 
 
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Rawling 
 
 QM551 
 
 R19 
 
 1915 
 
 Landmarks and surface markings 
 of the human bod./'. 
 
 

 
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